All right, good morning, everyone. Thank you for attending our AM session. I'm John Piacentino, Acting Associate Director for Science at NIOSH. It's my distinct pleasure to introduce my colleagues from the Occupational Safety and Health Administration. I'd like to introduce you to Dr. Yasmin Daniels and Dr. James Klyza. They work in the Directorate of Enforcement Program at the Occupational Safety and Health Administration, and this morning, they're going to share with us their experience during OSHA's Coronavirus Disease 2019 National Emphasis Program. So thank you very much for attending, and thank you both for attending our conference. Good morning. Thank you for that wonderful introduction. So my name, again, is Dr. Yasmin Daniels, and I will be discussing the enforcement guidance and inspection outcomes in healthcare for OSHA's Coronavirus Disease 2019 National Emphasis Program, and I'm sure if you're sitting here, most of you may be somewhat familiar with OSHA's COVID-19 NEP, as we call it. So I may say NEP or National Emphasis Program throughout this talk, and I use that interchangeably. Before I begin, I would like to read this disclaimer that in the past 24 months, neither myself or Dr. Klyza have had any financial relationships with any of ACOEM's ineligible companies. The opinions, findings and conclusions presented by the speakers, us, are not necessarily those of the Occupational Safety and Health Administration, and all of the raw data in this presentation is available publicly. Over the last few years, OSHA has learned a lot about the hazards associated with working with COVID-19. Although COVID-19 has a different impact than it did two years ago, and employers have more controls in place, it may still be a workplace threat in some places. COVID-19 has impacted every aspect of our lives and brought challenges to employers, workers and their families and communities. These impacts were felt in all industries and in every workplace, but as you will see later in this presentation, the hazard was most prevalent in the healthcare industry. OSHA continues to update its guidance based on the latest scientific information and CDC guidance. OSHA has issued compliance and enforcement guidance to assist employers throughout the pandemic, beginning with the Interim Enforcement Response Plan, which has been updated several times to reflect changes within public guidance and to align with CDC's guidance. The COVID-19 NEP, or National Emphasis Program, which has also been updated since its initial issuance in March of 2021. The COVID-19 Healthcare Emergency Temporary Standard, which we all know has been withdrawn except for the record-keeping portions. And for a brief three-month period in 2022, OSHA issued a focused healthcare initiative, which focused on follow-up and monitoring inspections in healthcare establishments where workers were at heightened risk for contracting the virus. This initiative is now archived. Also, many of the resources that OSHA already had available for the healthcare community, even prior to the pandemic, were useful sources of guidance during the pandemic. Here's a quick look at just some of these resources, all of which are accessible on OSHA's Healthcare Safety and Health Topics page. So as you can see on the screen, there are lots of resources spanning from dentistry to healthcare facilities and professionals. And all of these, the links have been provided for all of these. So if you do have access to the SwapCard app, we do provide copies of our slides there for your information. The COVID-19 NEP joined OSHA's 10 other active National Emphasis Programs. The goal of any NEP is to reduce workplace deaths, injuries, and or illnesses. Not all National Emphasis Programs have a specific goal. For example, the amputations NEP. But some National Emphasis Programs do have an inspection goal, such as the heat NEP and silica NEP. The goal of the COVID-19 NEP has been to continue performing a high percentage of COVID-19 inspections, which for us was about 5% of the total national office inspection goal for OSHA, as we had been doing during the first year of the COVID-19 pandemic prior to the NEP. There are only a few National Emphasis Programs covering industries within healthcare. The COVID-19 NEP covers 11 healthcare industries listed in Appendix A of the COVID-19 NEP. The silica and heat NEPs each include one healthcare industry among other non-healthcare industries which are not listed here. So if you look here, the silica NEP covers offices of dentists and the heat NEP covers nursing care facilities, skill care nursing facilities. In addition to its National Emphasis Programs, OSHA also has initiatives specifically targeting healthcare, which are highly focused and sometimes very short term. This first memorandum, the inspection guidance for inpatient healthcare settings, establishes guidance for inspections conducted in inpatient healthcare settings with North American Industries codes covering hospitals, nurses, and residential care facilities. All such inspections, whether they be programmed or unprogrammed, cover the following five focus hazards. These are musculoskeletal disorders relating to patient care and resident handling, workplace violence, bloodborne pathogens, tuberculosis, and slips, trips, and falls. The second, which is the COVID-19 focused healthcare initiative, was a three-month initiative focused only on follow-up and monitoring inspections within high-risk sectors of healthcare, such as hospitals and skill care employers. And I mentioned this before in my previous slides, this initiative is now archived. OSHA also has regional and local emphasis programs with similar goals of reducing workplace deaths and injuries and or illnesses within high hazard industries. So these are not national emphasis programs, but they are developed based on the local knowledge by regional offices. Regions 2, 6, 7, and 8 all have programs that target individual healthcare industries, among other industries that are not listed here. For example, Region 2 has a health high hazard top 50 emphasis program. It's a regional emphasis program that covers offices of dentists. Region 6 has a health hazard in the healthcare industry emphasis program, which covers freestanding ambulatory surgical centers and urgent care centers, and so on and so forth. In case you're wondering, OSHA's current regulatory agenda consists of a handful of rulemakings related to occupational medicine. It not only includes the occupational exposure to COVID-19 in healthcare settings, but it also includes an infectious disease rule, workplace violence in healthcare, heat illness prevention, and medical surveillance updates to the silica and lead standards. This presentation will not focus on rulemaking, but instead we will discuss outcome-based metrics of the COVID-19 National Emphasis Program. And if you'd like to stay up to date on these rules, please visit reginfo.gov. Many of OSHA's COVID-19 resources have been archived with the waning pandemic and in light of information from CDC and FDA, which have removed the need for OSHA's regulatory protection enforcement discretion. Therefore, where respiratory supplies and services are readily available, OSHA has ceased to exercise enforcement discretion for temporary noncompliance of certain paragraphs of the respiratory protection standard. The agency also no longer exercises enforcement discretion of the requirements in other healthcare standards and has rescinded its previous temporary enforcement discretion memorandum. The full list of archived resources can be found under the news update section of our coronavirus safety and health topics page. And we've also provided the link for everyone's information. So now it's time to focus just on the COVID-19 NEP after providing all of the background. In January of 2021, President Biden directed the Secretary of Labor, acting through the Assistant Secretary of Labor for OSHA, to launch this National Emphasis Program to better focus OSHA's enforcement efforts related to COVID-19 on hazardous conditions that put the largest number of workers at serious risk and on employers that engage in retaliation against employees who complain about unsafe or unhealthful conditions or exercise rights under the act. The NEP provided an inspection goal for each region to continue performing at least 5% of COVID-19 inspections as they did during the first year of the pandemic prior to the NEP in responding to things like complaints, fatalities, and referrals. The COVID-19 NEP was designed to prioritize healthcare inspections because that is where the hazard was found to be prevalent. The highest priority was given to fatality inspections and then to other unprogrammed inspections, such as complaints and referrals, and then to follow-up and programmed inspections related to COVID-19 hazards in accordance with our field operations manual. If potential COVID-19 hazards were apparent during non-COVID inspections, a compliance officer could have covered COVID-19 as part of their inspection scope or they could have made a referral. So why did OSHA prioritize or target healthcare in its COVID-19 NEP? Healthcare had consistently led OSHA's COVID-19 complaints. Both in 2021, just before the NEP, and even in 2022, healthcare complaints were among the highest compared to any other industry. Many of OSHA's unprogrammed inspections, which were already being prioritized, were within the healthcare industry. The National Emphasis Program also advised area offices to rely predominantly on NICs within the healthcare industries based on their local knowledge. So local knowledge could have included records showing high rates of infection, information obtained from commercial directories, referrals from local health departments, and from other federal agencies with joint jurisdiction. OSHA used additional enforcement data, such as referrals, hazard alert letters, fatalities and catastrophes, inspections, violations, to determine its national emphasis targeting and we did not just rely on the number of complaints. You'll see that in the next slide. I also would like to note that not all of the top essential industries are listed on this slide here, in this table. For example, postal services were also among the top essential industries with high numbers of complaints. However, this table does accurately reflect that healthcare was the leader among all other industries in the number of complaints that we did receive. When looking at six different OSHA enforcement categories, such as complaints, fatalities and catastrophes, referrals, inspections, COVID-19 related hazards, and hazard alert letters, healthcare industries, which are listed here in this table by their NICs codes, were among the top 10 industries with the highest number of workers performing tasks associated with exposures to SARS-CoV-2. In generating our targeting list for our NEP, non-healthcare industries were also included in the rankings. But as you can see from these tables, healthcare industries did dominate several of the six enforcement categories. So here's a look at what these targeting tables actually looked like in our NEP. The targeted industries are listed within Appendix A, Tables 1 and 2 of the COVID-19 NEP. So as I mentioned before, both healthcare and non-healthcare industries are being targeted because they were both among the top enforcement categories. Table 1 represents the industries within healthcare and Table 2 represents the industries that are not within healthcare. Some of the industries in Appendix A were on our annual appropriations exemption list issued January 2021, such as offices of physicians, offices of dentists and home healthcare services. This means that although these industries were still subject to health inspections, any apparent safety inspections or safety violations of establishments with 10 or fewer employees within these industries would not be cited or referred for later inspection unless such violations created an imminent danger. We later saw that the Bureau of Labor Statistics data, particularly the respiratory illness incidence rates, supported our rationale for generating the National Emphasis Program's targeting list. Healthcare industries led all other industries in overall injuries and illnesses, pictured on the left here. And there's a similar industry trend for respiratory illness incidence, pictured on the right. My colleague, Dr. Klyza, will be going a bit further into the healthcare data later on in this presentation. So here's a case study where an OSHA compliance officer found that employees at a health clinic in New York conducted COVID-19 testing by using nasal swabs on unmasked individuals who had signs and symptoms of COVID-19. Employees did approximately 300 tests a day. These employees were provided and required to wear N95 respirators. The employer, however, did not provide medical evaluations and did not fit test their employees. And OSHA, therefore, issued the employer a serious violation. OSHA later re-inspected and found similar respiratory protection hazards, and the employer issued a willful violation to the employer. The citations were contested, and eventually they were settled at a repeat violation with the initial penalty amount still being held. The hazards were also abated by the employer. The staffing agency which had employees working at that host employer site, they were also cited. OSHA has issued temporary worker bulletins that mention respiratory protection as well as blood-borne pathogens, among other topics. More information about temporary workers can be found on OSHA's temporary worker webpage. Speaking of respiratory protection violations, we found that the most frequently cited standard from fiscal year 2020 to fiscal year 2022 was respiratory protection. This list of top 10 violations remained relatively unchanged from the start of the pandemic in 2020 all the way to 2022. Within the respiratory protection standard, medical evaluations, fit testing, written programs, training, and record-keeping were among the top provisions that were cited. In all, OSHA issued approximately 1,400 COVID-19-related citations to employers since the beginning of the pandemic through the end of 2022, aided by the National Emphasis Program's additional emphasis on enforcement and compliance. Our enforcement data also revealed that most of the COVID-19-related fatalities occurred for those healthcare industries that we had been targeting within the National Emphasis Program. There was an overall decrease in the number of healthcare-related fatalities after the National Emphasis Program became effective from about 70 percent before to about 30 percent after the NEP became effective, but this could have also been impacted by an increasing worker vaccination rates and infection-acquired immunity. This also showed that our targeted healthcare industries had been capturing primary healthcare workers who were exposed to COVID-19 hazards. Another aspect of President Biden's orders was that the COVID-19 NEP have an added focus on anti-retaliation. After the COVID-19 NEP became effective, we saw an overall decrease in the total number of COVID-19 whistleblower complaints, and the majority of whistleblower complaints within the healthcare industry were merit and awarded. So we're going to go to another case study. Here's one such case involving an inspection of a dental facility in Texas. There was a period during the pandemic where dental practices reduced the types of procedures being conducted, especially those with the potential to produce aerosols. When things began to open up again, employees returning to work voiced concerns about their safety and were fired for raising these concerns with the employer. An OSHA whistleblower complaint was filed and found to be a merit case. OSHA determined that the owners discriminated against their employees for exercising their rights to express concerns about their safety and health. The employees were awarded back wages as a result of being fired for raising safety and health concerns. And in case you're interested in any of these two case studies, there were OSHA news releases that were published for both of those, and they're available on our public page under the news release sections. So here are some lessons that we learned from the COVID-19 NEP. Our COVID-19 NEP provided us with these valid lessons, that the NEP effectively targeted industries where the largest number of workers were at serious risk for exposure to COVID-19, but it also showed us that most of the at-risk industries were within healthcare. When targeted, several outcomes, for example, fatalities, decreased primarily within healthcare. My colleague, Dr. Kleisel, will be diving a little bit further into the data covering this. The office, the Directorate of Enforcement Programs within OSHA, which is where we work, we're still currently evaluating data from the NEP to determine whether to continue our national emphasis program for COVID or to expire it. And finally, in addition to all of the COVID-19 guidance that we've been providing, there still may be questions from the healthcare community regarding COVID-19 worker protection and OSHA enforcement. OSHA has already been responding to some of these, and inquiries can continue to be submitted to us through our electronic correspondence, using the web-based form from the OSHA Contact Us page, or they can be mailed to us using the address on screen. At this time, I would like to pass it over to my colleague, Dr. Kleiser, to continue the rest of this presentation. And I would love to take questions that you may have at the end of his talk. Thank you. Hi, everyone. My name is Dr. Jim Kleiser. I studied epidemiology for my PhD. And that's basically the direction I went in as far as the descriptive statistics here. Just simple lines, not so much a regression or anything here. But these are enumerating. These are common metrics for OSHA performance on enforcement. And these are basically the average total violations per inspection here in navy blue. We're pretty much remaining about constant from 17 to 22. Not really a large trend there. But if you look in orange, respiratory protection is what that stands for. That standard, there was a peak in 2020 in violations, clearly. These are the average number of violations per inspection. I had to do it in a log 10 scale, though, to get all the lines to fit within the same grid. If you look at total record keeping or 1904 violations, that was common also in that time period. Peaked in 2020, as did the hazard alert letters there in green. Basically to explain briefly, this data only represents inspections for the 23 target NAICS codes that Dr. Daniels explained to you. Eleven of those were healthcare related. They're targeted as higher risk places under pandemic conditions, the essential industries, as they're called. Other ones include meat packing, some construction related corrections, the postal service, as Dr. Daniels mentioned, warehousing, temp agencies, et cetera. So the primary and most common violations we would get were either record keeping or respiratory protection and the average inspection. Those are the ones you'd run into the most. Record keeping, of course, are the 300 logs for recording the injury illnesses. They're work related, primarily despite, I would assume, a safe assumption would be primarily pandemic driven. Also reporting such injury illnesses. I'll get more into this a little bit later on the next slide. Gravity metrics. Basically in English, gravity is the severity of any violation you would receive from an ocean inspection. If you look at the average total serious and other than serious gravity level, those really aren't changing that much over time. However, if you look at the repeat violations, as Yasmin gave an example of a repeat, there was originally a willful. Those did peak. And more likely reasons were because of the focused healthcare initiative, where they're reinspecting the employers of healthcare variety for a second visit to see how they're performing. A repeat is where they had prior inspections with violations at their site. A repeat is a second inspection observed where the same violations are present. A willful is where the inspection had sufficient evidence to indicate an intent or disregard or indifference to the OSHA standard regulations. Respiratory protection and its subparagraphs. This is that same peak you saw in orange on the previous slide, but this is the blue line here represents all violations of respiratory protection peaking in 2020 again. All of these are the subparagraphs of that same standard. So you notice it's the practice, written program, selection of the proper respiratory protection, whether it's medical evaluations, fit testing, all of the subparagraphs of relevance. 5A1s, which are the general duty clause under the OSHA Act, and also hazard alert letters which are basically a warning letter in a way based upon general duty where there wasn't sufficient evidence to lead to a violation of 5A1. Typically with the 5A1 violation, there's no existing standard for that particular hazard, in this case SARS-CoV-2, for the hazard to the employee that's considered work-related. It is an employer responsibility under the OSHA Act to provide a workplace free from recognizable hazards to that employee. The hazard must exist, it is recognized by the employer or their industry. The hazard is likely to cause death or serious harm to the employee, and there's a feasible means to evade such a hazard. So as you can see, the hazard alert letters did peak at that time period. It was difficult on average to get the 5A1 general duty violations to occur at a higher rate like that. Record keeping. As I talked about earlier, 1904 violations of record keeping peaked in 2020. Basically two basic types, reporting, which would be basically the employer is required to report hospitalizations, amputations, or loss of eye of an employee with a work-related injury or illness within 24 hours of the event. They're also required to report a fatality of an employee with a work-related fatality within eight hours of the event once they're aware of it. As far as recording, recording would be like the OSHA 300 logs, the recording violations here, OSHA 300 logs or equivalent like the workers' comp records. Personal protective violations largely declined. These are all other personal protective equipment aside from like the N95s, the respirators and such. Under the respiratory standard, this would be other things like gloves and garments and such to protect you from the hazard. If you look here, though, you see that hazard assessments were peaking in 22. Most likely the reason for that would be because of the novel hazard of SARS-CoV-2 at the time period and the employer failed to address the appropriate hierarchy of controls for the hazards, engineering, administrative, and personal protective equipment for the hazard of SARS-CoV-2. Fatality investigations. If you notice in 2020, 61% roughly of all investigations that OSHA did of those 23 NAICS codes were fatality investigations. 21 dropped to 19% and then down to 1.4 or so in 22. So they declined over time. Most likely common sense reasons, the hazard of the pandemics was being addressed as best we could with vaccination and precautionary measures. Incompliance inspections. In 2020, 60% were incompliant, 21 if you look, 69%, and it went up as high as 76% in 22. A likely reason for such would be that basically no violations are observed in an inspection, an incompliance inspection. So the increasing rates are more likely due to the measures taken to address the pandemic. And also employers, initially it was a novel hazard in 2020, but over time learned how to address the issue and so when OSHA would return, they were compliant by then because they found means, suitable means to mediate the hazards. Failure to evade metrics. If you notice, before the NEP, roughly 13% of inspections had a failure to evade. Failure to evade means basically that an employer had a violation in an inspection but did not correct the hazard to the employees within the allotted deadline after the inspection. If you notice, after the NEP, the rate dropped seriously down to roughly 7.7%. Most likely for similar reasons, the employers got more familiar with the hazard and how to address it correctly. Vital statistics data from the CDC. This is when a little more p-value oriented analysis rather than descriptive statistics were being done. This is the death certificate data that I'm sure pretty much everybody is familiar with that CDC provides. I downloaded it from 2020. That was all that was available at the time for the pandemic. And of course, it gives a lot of demographics. They're redacted, of course, but they also give your industry and your occupation. So basically what I did was, initially it was a simple analysis of variance, a univariate regression, where the only X variable, independent variable, was time, the month of 2020 in the pandemic. Healthcare worker, which is the Y axis, number of fatalities with COVID as the underlying cause of death. On this one, everybody that qualified as a healthcare worker on their death certificate coded with the census code for their occupation. So it could be any kind of job under healthcare, anything from a housekeeping staff all the way up to the administrator that runs the show at a particular location. So if you look at this line here, it was basically the line that fit the scatterplot. And basically the slope was 192 per month healthcare workers of any kind that died during that year of 2020. That's the line that best fits the data. The reason that I started with something like this is there's some during inspections and such, there was some, it was a bit of an argument whether the COVID cases or fatalities from work for healthcare workers were work related. And that was often argued with. So this is one thing you can see that there's a definite trend, there's a pretty severe trend for that job. Then I did use the same data and ran logistic regressions. The first one here is it's with the same data. I used age, gender, month, same months that for 2020 and the same definition for healthcare worker. So if you notice healthcare workers, their odds were 1.07 was their odds ratio in an adjusted model and a broad scope definition for healthcare worker, meaning anybody that defined in the census code as a healthcare worker. And so even though it would dilute the results, you still see significant results. The month, if you solve the equation for October, that's a continuous variable. The month of October was roughly 4.5 was the odds of dying of COVID as your underlying cause in 2020. Gender, if you invert this, females had a protective effect. If you invert it, the males were a 1.2 where their odds ratio of dying versus a female age. If you solve for say age 61 on this equation, your odds are 1.96 for each year you get older. Basically the population that I had was age 1865 for the death certificates of the healthcare workers. So I compared them versus every other occupation of that age group. Another one where I, same data, month, gender, age, identical, but I did hospitals, those coded under industry as a hospital worker or long-term care as a nursing home. Basically the hospitals, similar result, 1.09 for their odds ratio. So 1.09 and long-term care significantly higher, 1.26 was their odds ratio for long-term care risks. The solutions for month, gender, and age were pretty much the same as the other model. I just stratified it differently. The next thing I did was a structural equation modeling, a path model to explore the transmission dynamics using the CMS data sets for nursing homes in the United States that fall under Medicare and Medicaid. The pandemic data that I used was from 5, 2020 to August of 22. I also used census data, USA FACS data for the morbidity and mortality, CDC data for vaccination and CMS data for specifics on each individual nursing home covered by their jurisdiction in the United States. This is the path model. This is all one equation. I did it using the structural equation modeling system on the program called SAS, model 9.4. It's called a PROC CALIS is what you run to do this. This is all one equation. So basically how it works is for each week of the pandemic, it has an effect on each of these variables here. Inverse correlations are where you see the dotted line. So as each week goes by in the pandemic, staff shortages decreased in each nursing home. Vaccination rate of the staff increases, staff shortages go down. Staff COVID rate goes down when vaccination goes up. State vaccination decreases state COVID rate, resident rate. Vaccination decreases their COVID rate, right? The lines that are solid are direct correlations. So you can see as each week goes by, vaccination goes up, COVID goes up, resident COVID goes up, and such. So that's basically how the model works. Excuse my voice, I'm sorry, I have a really hoarse voice today. Basically that's the idea of the model and how they work. It's been done, these structural equation models have existed for a long time. They invented these in the early 1900s. It was, who is it, like Spearman, Wright, Pearson, Hotelling. Those are some of the famous statisticians of their day that developed this. This is not very commonly used in epidemiology. It's used in social, mostly other social sciences. This is an interesting way to see the effects. It's a common sense model. The results of it fit with pre-existing research. These are the data sources that we used. Rather than internal, OSHA enforcement data you can get to on this site. Population trends from CDC, COVID-19 rates, and morbidity and mortality, CMS data, vital stats, BLS data that Dr. Daniels is demonstrating, and population density data. Because that's also a risk factor, as I'm sure everybody knows too, as far as the denser the population in an area, it seemed to correlate with higher rates. That's basically it. Does anybody have any questions? A question if you were able to analyze health care settings that were part of the voluntary protection program, how they may have done versus just those that aren't in that. I'm sorry, I'm deaf in one ear. Could you say the last part, the health care settings that were? Voluntary protection program, or VPP sites, versus the non-VPP sites. To be honest, sir, let me put it to you this way. The analysis we did, the evaluation that this is a condensed version of, was roughly, I think it was 130 pages of analysis. But what you're saying is something that we did not get the opportunity to do. And that's a very good idea, by the way. Great. And then, when could a compliance officer actually evaluate a site? If you have to kind of be safe for the actual officer to go and inspect, if the hazard's still there, they probably shouldn't be investigating at that time. Any comments on that? You want to explain? I'll talk. You can just share it. You can go first, if you want. Thank you for the question. That was actually one of a big concern for us, especially at the beginning of the pandemic when we had not as much guidance out. So OSHA does take very seriously the compliance officer safety. And we didn't mention this before, but Dr. Kleiser and myself are actually former compliance officers. So we understand the risks that exist going out into an environment where you're unsure of what the hazards are, even how you may be exposed to them. So in cases where a compliance officer were to, like in the beginning of the pandemic, especially going into a healthcare setting, we had guidance encouraging them to conduct interviews by phone, maybe from a parking lot or a room that was big enough to maybe have them on one end and the worker on the other end. But in no cases did we guide or encourage compliance officers to go into patient settings. So if they were entering a healthcare facility and there was a patient who did have signs and symptoms or may have been positive for COVID-19, the compliance officer was not allowed to go in there and they would have to find a different area within the building and or outside of the building to conduct their inspection. And there were, in some limited cases, OSHA did allow, and this was based on, I believe, the local office's discretion. They did allow some remote inspections. So that was something that was also a part of our enforcement. And I think Dr. Kleisel wanted to add something to that also. Thank you. One thing, if Dr. Daniels didn't mention it, we also before, because I was doing inspections during the pandemic before I transferred over to the national office, was that we did JHAs, job hazard analyses. We did it at length the day before you go to any site, and it would be site specific in as much detail as we had the luxury of using. Um, Mike Pronto, Naples, Italy have been stationed overseas throughout the pandemic, but OSHA still often ties into us since we are still U. S. Affiliated two questions. First one is, how did the Supreme Court's decision to block the emergency temporary standard on mandatory vaccines for companies with more than 100 people sort of shift OSHA's approach both short term and or what's ahead? Long term. Second question. Um, in Europe, they basically most countries just slapped what they call FFP twos or nine and 95 equivalents on the society. Um, that seemed to work very well, but we couldn't do that because we couldn't enroll standing up an R. P. P. And get it to everywhere. I wondered if how good is the data on the entirety of the program? Or if you took an approach where you just employers gave everybody and then 95. Um, do you guys have any data on whether that might be more either temporary approach or or longer term? So I think I got the first question. I mean, I may need you to clarify the second question at the end. But as far as the, um, the emergency temporary standard, how that potentially impacts, I think, us moving forward or what we have currently. Um, so the Cove in 19 national emphasis program is still currently active. Um, just so everyone everyone knows. And so we're in the process of evaluating the data to understand whether or not, um, we it will expire or we will continue it. So typically, national emphasis programs, they expire after about a year. That's sort of on average. And then at the end of that 12 month program, we look at all of the data. We look at the hazards. We look at the industries that have been targeted, and we see if it needs to be renewed or continued. Um, as far as if whether or not the the E. T. S. or, you know, whatever had been sort of revoked, um, affects us moving forward regarding the N. E. P. It at this point, I can't say that it does. We're sort of evaluating that independently as far as, you know, a standalone emphasis program. But depending on what the outcome is, because we do have a, you know, a rule that's sort of still in the work, so we don't really know what the outcome of that's going to be just yet. Eso perhaps, depending on what that is, we may get further direction from our front office to potentially, you know, pause the N. E. P. U. Or cancel it. So I can't say for sure where we're going. But I think for us, Jim and myself immediately, we've been assigned just evaluating the N. E. P. And so it's sort of being on standby for whatever whatever direction they would like us to go. And so the second question, I think I just need a little clarification. So in Europe, they basically put in 90 fives on entire countries with zero respiratory protection, zero fit testing. And you saw I mean, some of its source control, but you saw numbers come down across since vaccines were delayed in many European countries, maybe U. K. The exception in U. S. We were about 4 to 6 months behind. I guess my question is, as OSHA wrote, those regs looks at the data. How strong is it on the entirety of the program? And when you have something like a pandemic, um, would that be an alternative approach or has OSHA considered that as an alternative approach that would be faster when you do not have the bandwidth to stand up respiratory protection programs throughout society? Yeah, that's a That's a good question. And thanks for sharing that information. I didn't realize that that's what was happening outside of the U. S. And so if I understand correctly, you're saying that they sort of decided to put in 90 fives on everyone, and they saw that that significantly helped to reduce. Correct. At least at least the nation of Italy. I mean, most of most of the European Union changing region did that in a majority of countries. Yeah. So I'll just start off by saying, um, and I don't know if you meant this, but we specifically focus on just the working population. So as far as you know, just the community, the general community, we can't really we can't really enforce that in the community. But I will say that during the pandemic, we did notice that there were lots of supply shortages, as I'm sure everyone is aware of. And so it would not have probably been feasible to throw a 95 on everyone because of that reason. And that was also another reason that OSHA did put in place a lot of enforcement discretion. And so it pertained to like things like fit testing. There were shortages with regards to the actual respirators being available, as well as things to test the employees for fit testing and to perform medical evaluations. And so some of the enforcement discretion. So OSHA never. And I think this may have been a misconception among several industries. But there was this question that came in a lot about OSHA sort of relaxing their enforcement of the fit testing. So OSHA did not necessarily relax their enforcement. What we did was we exercise enforcement discretion for the annual fit testing. So OSHA does have still and always has had a requirement to fit test employees initially whenever an employee is provided with a tight fitting respirator. And so that's never gone away. It's never been relaxed. There's never been any enforcement discretion pertaining to that. It's only for the annual fit testing when the employee was using, you know, the same or similar respirator. Sometimes there were limited resources, especially brought on by the pandemic. So I think I can't speak for what the agency is going to do with future pandemics. I mean, it I think it's great that the data showed that the you know, the number of infections perhaps decreased by using utilizing that method. But I it would be interesting to see how that pairs with OSHA's policies of continuing to, you know, have compliance with the requirements under the respiratory protection standards, such as having a fit test for everyone. If we do decide, you know, if the nation does decide to throw it and 95 on everyone in the workplace because of this, you know, data from externally, are we going to have the resources to now have fit testing for everyone? And also, you know, there are cases where people are not medically clear to wear those things. So without having those things, we may be inducing other risks onto these workers who may have pre existing conditions that prevent them from wearing, you know, tight fitting respirators. So these are some of the concerns that I can think of. But as far as like, you know, if the agency would do something like that, I can't say I don't know. It makes total sense. The data is available, you know, throughout Europe and sort of that we had the perverse, uh, outcome because we were in Europe working under OSHA standards. And so our employees were the only ones not wearing it. 95 is not wearing FFP twos because we couldn't stand up the respiratory protection program to allow it in our lives. If you can't do that, you can't put, you know, FFP two. So it was it was actually making it less protective for the workers. That's interesting. Thank you for sharing that. Hi. Just a quick, quick question. Um, what could you give us some examples or the scope of the type of penalties that organizations incurred for noncompliance? Did you want to take that? Um, I can. So, um, the scope and type of penalties. Um, so there was a case study that I showed you. Let's see if I can go back to that. I believe it was this one. So this was, um, an example of a an inspection that happened in New York where, um, employees were swabbing, um, patients who showed signs and symptoms of Cove in 19 and they were doing something like 300 swabs a day. And so OSHA initially conducted an inspection here. And found that these employees were asked to wear and 95 respirators. But the employer was not fit testing them and not providing them with medical evaluations. And so OSHA issued a serious violation or serious citation. And then OSHA went back because I believe it may have been a complaint that was made. So they went back later on, um, and found the same types of hazards occurring. So in that case, there was a repeat violation. And so let's see if I remember correctly. A serious violation is we have publications. I believe they recently went up and I don't have the numbers sort of at the forefront of my brain right now. But if you have the data, the dated numbers like the listens before erased. It was 20 for serious. Um, 50 for repeat 70 for willful. Yeah. So at least we know the order of magnitude. So serious is sort of like it's a serious violation. But serious is a little bit lower in penalty amount than a repeat. And then a willful is probably the highest that you would probably be issued. And so with this case, for example, they initially got a serious penalty. And so when OSHA went back and found that the conditions were the same and the employer was exposing them to similar hazards, OSHA issued a willful because they did find intentional as Dr Kleiser explained, intentional disregard or plain indifference to the standard. And so during settlement is when they sort of reduced the penalty to a repeat, which I believe they sort of settled at the penalty being the same, but the seriousness of the penalty being downgraded from a willful to a repeat. So hopefully that gives a little bit of an example. But OSHA does have our our penalty amounts are public. We do have those posted on our website if you're interested, and maybe even after if you want to exchange contact info, we can send you a link to that as well. Hi, my name is Tony Waldrop and, uh, so I was a deputy commander at a level one trauma center in the military. I'm in the Air Force. Um, I'd like to ask, it seemed like there is a correlation there that you're drawing between excess deaths in hospital employees and the potential relation of the violations of the respiratory protection program. But I'd be interested in knowing or seeing data comparisons between hospital employee deaths and programs that actually were not cited or did not violate the respiratory protection programs. Um, because it seemed to me it's hard to control for that. The excess deaths there, it's hard to relate that directly to the respiratory protection program, whether you're falling or not, because many of those folks were essential employees coming to work every day. Whereas in certain locations, people were still decided to stay home. And these folks, while they were at work, were respiratory fitted in my hospital, 10 care folks. But they still got COVID because they were out at Walmart, picking up food and stuff like that. So it'd be interesting to see a little bit more detail and relationship into that regard. Okay, I'm sorry, my deaf ear. No, he was just saying it would be interesting to see a little bit more detail about the correlation between the program, the COVID-19, um, you know, respiratory violations and the ones that were non programs. So, okay, yeah, that is a good idea, sir. I'm not sure. I don't think I went on that stratifying that way, but that is a good idea. Thank you. So, hi, thanks for showing this data. I think it's great. It was very enlightening. One of the things I was struck by is the number of fatalities and the number of complaints in the health care sector. I'm rich stockings. I work mostly in oil and gas, but some other industry sectors. And I'm wondering, you may or not know, is OSHA contemplating any additional regulatory action targeted at health care because of the sort of massive number of people that were impacted and the relative ineffectiveness of their protective programs? Thank you for the question. Um, I'm going to go back. So there are some current OSHA rule makings. Um, and I don't know if your questions specifically pertain to, like, related to COVID-19. But as far as the future of OSHA enforcement regard related to COVID-19, we do have the COVID-19 in health care rule that's still currently being reviewed. And I don't have the status of that currently because it's not sort of in our office. There are several stages to these rules being finalized and approved. But we do have other rules that are also in the works specifically related to occupational medicine, so IE health care. And that includes the infectious diseases rule, workplace violence in health care rule, heat illness prevention, which does pertain to some health care workers, as well as medical surveillance updates of our silica and health standards. So as far as any future direction, these are the things that we're focused on specifically related to the health care industry. I hope that answered the question. Hi. Um, good morning. That was a really interesting presentation. Thank you. I'm Rebecca Guest from New York City, um, medical center in New York City. I have a question. Having sort of lived through this, um, recently, although it doesn't seem that recent, thankfully, does OSHA consider actual local conditions such as access to masks and access to people to do respiratory fit testing when making a determination of a violation. And I mentioned that because, you know, there were certainly areas in New York City that did not have access to proper respiratory protection, did not have a supply and did not have a supply of employees, um, to actually do respiratory fit testing and do the things that needed to be done. So when making a determination, I wonder if Ocean considers those actual local conditions. Yeah, go ahead. Um, not specific to New York. I handled. I was in Region two when I was a compliance officer, which covers New Jersey, you know, in New York, New York State and generally area. Also, Puerto Rico. For some reason, I don't understand. But, um, as far as what you're saying that the area director, the area director who is in charge of that location of an OSHA office has the authority. Even the system area directors can make these suggestion based upon the circumstances for if to what degree the citation will go. And you see where I'm going. You may still get the violation, but it may be a serious instead of a repeat of willful. Or it could mean other than serious even. Or it could be lowered down, depending on what if you work with the area office, that's usually the best approach to have. And then that usually helps your situation. And they're more understanding. If you make them cognizant of the facts like you're bringing out. No, I appreciate that. And that did not apply to my medical center. Thankfully, we had better resources. But I do know that less, um, well supplied. You know, there were certain areas in New York City where I have colleagues working that that did not have what was needed. And so the news news was scary. It was very frightening, and it wasn't willful lack of compliance. And I just wanted to add one more thing if I could add to that. Um, so I mentioned in the presentation that OSHA had OSHA issued several enforcement discretion memos. And I think that the general idea with a lot of these memos was that OSHA was looking for employers to exercise good faith efforts. And you'll see that word repeated in a lot of our enforcement discretion memos. So in the case where, you know, employers had absolutely no access, and let's say a compliance officer is inspecting that particular establishment, and they've done, you know, all the different things and asking and asking the employer, What steps did you take to acquire your respirators? And, you know, there's several levels of documentation that go through these inspections, not just asking one question. The employer says no, and then automatically they get a citation. So, you know, they interview employees. They do walk throughs. They look at their inventory. You know, they look at correspondence that they made with suppliers and like, you know, that kind of thing. So if the employer did show good faith efforts to acquire these things and to protect their employers, they're like Dr. Kleiser said, there are certain things that can be applied to and, you know, reduced as far as a penalty goes or even a violation goes. So we did have these enforcement discretion memo guidances available during, you know, during the height of the pandemic. And I hope again it, you know, it kind of sometimes varies from region to region because they do have discretion. They have to go. It's sort of a case by case basis, and it also depends on the circumstances of that particular inspection because not every inspection is the same and not all of the establishments have the same exact, you know, protocols in place. So yeah, it really would just depend. Thank you. I really appreciate that. And that's that's good to hear. You're welcome. I have a few questions. Um, the OSHA ETS, which was not enforced formally, but it's still recommended. Is it still recommended by OSHA for Covid? So the ETS, um, the currently what we are enforcing are the record keeping portions of the ETS. Um, I believe if if the employer has things in place, sort of like the Covid 19 plan and some of the things that the ETS did recommend, and you're including that as part of your infection control plan, then by all means, you know, but it's not something that we are actively enforcing as you as you stated correctly. Yes. And so does that also include the mini respirator program? Because that was a substandard to the fit testing rule. So is that still something that that employers need to support their employees who choose to wear a respirator that it's not required for their job, but that's what they're choosing to provide them that guidance regarding seal checks and that kind of thing. Yes. So I think that the mini respirator program is sort of like complimentary to our standard respiratory protection program. So I don't believe that we would come out and actually enforce that the employer do that. But if there are components of the mini respiratory protection program that do correlate to what we already have in place as far as part of our bigger respiratory protection program, and I wholeheartedly support, um, you know, supporting that support that. Sorry. But I would I would not say that, you know, having a mini respiratory protection program would therefore be in compliance with our standalone respiratory protection program because that's not an accurate statement that I would make. And then one last question about not so serious violations. How long are those are those posted on for public viewing on your website? And how long those stay on there? Um, that's a good question. So on our public page, um, we have, um, sort of an index, an A to Z index, and that's the quickest way that I can think of getting access to it. And when you go into that, you can click on, let's say, eat, which will take you to establishment search. And so that's one of the most public places that you can find any company that's been issued any violation, and you can even narrow down, I think, by year. As far as how far back that goes, I'm not sure, Jim, if you know how far back he he's more of a data guy, so he'll know how far back that stays on our website. But if you type in the establishment name, it actually will tell you exactly all of the violations that were issued under that particular inspection. Um, so we'll let's let me turn it over to Jim. Sorry. Um, if you look at this link right here, this is the historical OSHA data. It's some things are updated daily on it from 1970. The OSH Act to now it's redacted, so there aren't like individuals names aren't on it. So but names of establishments are this is the history of OSHA data. So anybody has access to it, but very few people use it, to be honest. But this is what I used. All this data right here is all public access. Anybody can use it. So but what you're saying specifically enforcement data that's right here is, you know, thank you. There are no questions. Thank you very much.

Occupational Safety and Health Administration

Coronavirus Disease 2019 National Emphasis Program

enforcement efforts

healthcare settings

respiratory protection

hazard assessments

violations

healthcare worker fatalities

OSHA rulemakings

worker protection