administrative policy - resources.ssmhealth.com

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Printed copies are for reference only. Please refer to the electronic copy for the latest version.

Administrative Policy

TITLE:

COVID-19 Plan for Ambulatory Settings

OUTCOME STATEMENT:

To ensure the safety of staff who may be in contact with COVID positive patients and Patients Under Investigation for COVID-19 (PUI), and to ensure compliance with the OSHA COVID-19 Emergency Temporary Standard (OSHA ETS) in place for healthcare.

SCOPE:

This policy is applicable to all SSM Health ambulatory settings including clinics, ambulatory surgery centers and SSM Health retail pharmacies located within an ambulatory setting. This plan does not apply to healthcare support services which are not performed in a healthcare setting (non-health care office settings) and pharmacies in retails settings.

FILE MAINTENANCE INFORMATION:

Original Effective Date: 7/6/2021 Revision Dates: 7/14/2021; 8/2/2021 Review Dates: Author(s): Multi- Disciplinary Team, Diana Quinn Body or Person Last Approved: Multi- Disciplinary Team, Diana Quinn This plan and the links contained therein are subject to modification

DEFINITIONS:

See OSHA ETS in the attachment for definitions.

PROCESS:

I. Plan Overview

A. Policies and procedures related to COVID-19 are located on the COVID-19 intranet site as Taskers. These Taskers supersede policies and procedures on related topics but only for issues dealing with COVID-19 positive patients and persons under investigation.

B. SSM Health has multiple workplaces that are substantially similar, and therefore has developed a single COVID-19 plan for the substantially similar workplaces, with site-specific considerations included in the table below.

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Facility Location Wisconsin Dean Medical Group clinics Dean Medical Group Ambulatory Surgery Centers Dean Medical Group Therapy Services Dean Retail Services Monroe Clinics St. Clare Clinics Fond du Lac Regional Clinic and Agnesian HealthCare Enterprises

Oklahoma Healthplexes SSM Health Medical Group at St. Anthony Clinics SSM Health Medical Group at St. Anthony Shawnee Clinics SSM Health Medical Group and Midwest Clinics Missouri SSM Health Medical Group – St. Louis SSM Health Medical Group – Southern Illinois SSM Health Medical Group – Mid Missouri

II. Roles and Responsibility

A. SSM Health’s goal is to prevent the transmission of COVID-19 in the workplace(s). Managers as well as non-managerial employees are all responsible for supporting, complying with, and providing recommendations to further improve this COVID-19 plan.

B. The COVID-19 Safety Coordinator(s), listed below, implements and monitors this COVID-19 plan. The COVID-19 Safety Coordinator(s) has SSM Health’s full support in implementing and monitoring this COVID-19 plan and has authority to ensure compliance with all aspects of this plan.

COVID-19 Safety Coordinator(s)

Name Title/Region Contact Information (office location, phone, email address)

Diana Quinn WI Regional Director of Environmental Safety and Emergency Preparedness

1808 W. Beltline Hwy, Madison WI 53715 608-294-6276 Cell: 608-575-8812 [email protected] Emergency 24/7 Hotline: 608-250-1139

Lori Mertens-Pellitteri

WI Environmental Safety & Emergency Preparedness Manager

1808 W. Beltline Hwy, Madison WI 53715 608-280-4477 Cell: 608-444-2040 [email protected] Emergency 24/7 Hotline: 608-250-1139

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C. SSM Health and the COVID-19 Safety Coordinator(s) will continue to work cooperatively with non-managerial employees to conduct a workplace-specific hazard assessment and in the development, implementation, and updating of this COVID-19 plan.

III. Hazard Assessment- Identification and Evaluation of COVID-19 Hazards A. SSM Health conducted a COVID-19 hazard assessment, and continue to monitor and reassess,

through various means. SSM Health sought input in this assessment with non-management staff input.

B. All employees’ potential workplace exposures to persons at, or who may enter, our workplace were evaluated. All persons will be considered potentially infectious.

C. Areas were assessed for the need for additional barriers and other protections where people may congregate, or come in contact with one another, regardless of whether employees are performing an assigned work task or not. For example: meetings, entrances, bathrooms, hallways, aisles, walkways, elevators, break or eating areas, cool-down areas, and waiting areas. See appendix A.

D. For areas where direct patient care is conducted an assessment was made for the appropriate precautions and PPE. The Infection Control Guidance provides appropriate PPE in accordance with the OSHA ETS.

E. SSM Health monitors applicable orders and general and industry-specific guidance from OSHA, and the local health department related to COVID-19 hazards and prevention.

F. SSM Health evaluates existing COVID-19 prevention controls in our workplace and the need for different or additional controls.

G. SSM Health conducts periodic inspections, as needed, to identify unhealthy conditions, work practices, and work procedures related to COVID-19 to ensure compliance with our COVID-19 policies and procedures.

H. SSM Health regularly reviews the hazard assessment for any changes of potential risk to employees and to review the effectiveness of this program.

IV. Patient screening and management A. Limited points of entry have been established B. Patients and visitors are screened upon entry. C. Patients and visitors point of entry are limited and monitored.

Steven Miller OK Regional Director of Environmental Safety and Emergency Preparedness

1000 N. Lee Oklahoma City, Ok 73102 Phone: 405-272-6898 Cell: 405-694-1586 [email protected]

Azar Doyle Environmental Health and Safety: Missouri and Illinois

1015 Corporate Square Suite 160 St. Louis, MO 63132 O: 314.989.2278 [email protected]

John O’brien Missouri Regional Director of Environmental Safety and Emergency Preparedness

1015 Corporate Square Drive St. Louis, MO 63132 Direct: 314-989-2895 Cell: 314-393-0222 Emergency 24/7 Hotline: 314-989-3900 [email protected]

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D. Patients and visitors are screened with the following questions: 1. Have you been exposed to someone with COVID-19 in the past 14 days? 2. Have you been diagnosed with COVID-19 in the past ten (10) days? 3. Do you have a fever and/or the following symptoms?

a. New or worsening cough b. Worsening shortness of breath c. Fatigue/malaise d. Headache e. Loss of taste/smell

E. Patients and visitors must wear a tight-fitting mask (surgical, droplet or cloth). F. Maintain limited visitors per policy. G. Telehealth services are available when appropriate.

V. Standard and transmission-based precautions A. Currently, SSM Health utilizes regional-or ministry-based policies to dictate transmission-based

precautions. 1. System Policy: https://ssmhc.policytech.com/dotNet/documents/?docid=72215 2. Health at Home: https://ssmhc.policytech.com/dotNet/documents/?docid=73556 3. St. Louis Region: https://ssmhc.policytech.com/dotNet/documents/?docid=5214 4. MCH: Transmission-based:

https://ssmhc.policytech.com/dotNet/documents/?docid=75963 5. SAF/WMH/RMC: Standard & Transmission-based:

https://ssmhc.policytech.com/dotNet/documents/?docid=36103 6. SAF/WMH/RMC) for standard precautions only

https://ssmhc.policytech.com/dotNet/documents/?docid=37883 7. Standard (WMH): https://ssmhc.policytech.com/dotNet/documents/?docid=79709 8. SMM: Transmission-based:

https://ssmhc.policytech.com/dotNet/documents/?docid=79170 9. SMJN: Standard & Transmission-based:

https://ssmhc.policytech.com/dotNet/documents/?docid=6753 10. DMG/Therapy Services: Standard & Transmission-based:

https://ssmhc.policytech.com/dotNet/documents/?docid=67499 11. SCB: Standard: https://ssmhc.policytech.com/dotNet/documents/?docid=49419 12. WI ASC: Standard & Transmission-based:

https://ssmhc.policytech.com/dotNet/documents/?docid=64292 13. Agnesian Work & Wellness (at RMC) only: Standard:

https://ssmhc.policytech.com/dotNet/documents/?docid=33546 14. St. Francis Home Standard & Transmission-based:

https://ssmhc.policytech.com/dotNet/documents/?docid=29708 15. Villa Loretto: Transmission-based (only related to GI illness):

https://ssmhc.policytech.com/dotNet/documents/?docid=65849 16. General Standard & Transmission-based:

https://ssmhc.policytech.com/dotNet/documents/?docid=65890 17. Dean Medical Group: Standard and Transmission based Precautions:

https://ssmhc.policytech.com/dotNet/documents/?docid=67499

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B. For precautions specific to COVID-19, the taskers developed and disseminated by System Incident Command supersede any guidance in standard policy.

VI. Personal protective equipment A. In workplace settings where an employee has exposure to people classified as PUI or COVID-19-

positive, SSM Health will provide “high droplet” PPE, which includes a NIOSH-approved respirator, gown, gloves, and eye protection, in accordance with the OSHA ETS.

B. In settings where healthcare services are provided, SSM Health will provide each employee at that location with a surgical or medical procedure (droplet) mask in accordance with the OSHA ETS.

A. The Infection Prevention Resource Guide (IPRG) contains details on this topic and can be accessed here. This tasker is currently under development,. Please return to this site in the near future.

C. NOTE: the IPRG contains the other “terms” of the ETS such as: a face mask must be changed at least once daily, and when soiled or damaged, and more often as necessary and must be worn over the nose and mouth etc.

VII. Aerosol-generating procedures (AGP) on a person with suspected or confirmed COVID-19 B. For any AGP, all patient care with exposure to a PUI or COVID-19 positive patient, will require

“high droplet” PPE, which includes a NIOSH-approved respirator, gown, gloves, and eye protection.

C. The IPRG can be accessed here.

VIII. Physical distancing A. Social distancing is mentioned throughout the IPRG in many contexts, such as waiting rooms,

cafeterias, work gatherings, and indoor & outdoor social gatherings. B. The IPRG contains details on this topic and can be accessed here.

IX. Cleaning and disinfection A. SSM Health follows CDC’s guidelines for cleaning and disinfection. SSM Health has chosen

appropriate cleaners and disinfectants for hospital / healthcare use and is diligent in reviewing and following manufacturer’s instructions for use. High-touch surfaces, and other surfaces are cleaned frequently and at least once a day. Alcohol-based hand rub used throughout the system meets or exceeds 60% alcohol. There is guidance throughout the IPRG for cleaning in various areas and upon surfaces and equipment.

B. The IPRG contains details on this topic and can be accessed here.

X. Health screening and medical management A. Health screening is provided to all employees via use of the Employee Access Screening tool.

This screening tool can be accessed here B. In accordance to Employee Health processes employees are required to report any illness or

symptoms consistent with COVID-19 to Employee Health services. C. The Employee Health nurse will follow the symptomatic algorithm to determine work restriction

and provide direction for appropriate medical follow up. D. Employee Health Registered Nurse will contact all COVID-19 positive employees with further

guidance, education and isolation instructions.

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E. Following our risk stratification guidelines employees who fall into the appropriate risk level will be contacted by Employee Health for contact tracing. Based on the employee information the Employee Health RN will direct the employee to appropriate follow up and testing, if required.

F. Management and removal from the work place is managed by the asymptomatic and symptomatic algorithms as outlined in the COVID-19 Preparedness: Employee Health Management System Playbook. Employee may return to when they meet the criteria as out lined in the asymptomatic and symptomatic algorithms as outlined in the COVID-19 Preparedness: Employee Health Management System Playbook. Employees can reach out to their local Employee Health staff for information in the Employee Health Playbook

G. Medical Removal Protection benefits H. SSM Health will comply with the Medical Removal Protection (MRP) benefits requirements.

OSHA’s ETS applies to employees who work at patient care sites, including home health. When an employee has been removed from the workplace and is not working remotely or in isolation, SSM Health will apply the following pay practices:

ETS Removal Scenario

What to Do Compensation & Benefits Recording in Workday

Employee COVID + (Work-Related)

• Notify your manager and Employee Health immediately. Employee or manager are required to complete an employee event report in the online portal. “Report an Event” link is located on SSM Intranet Homepage.

• Work with Employee Health and your assigned Worker’s Compensation Partner for your test results and post result instructions.

• Talk with your manager about any remote or isolation work opportunities during the quarantine period.

Covered Workers’ Compensation Claims receive the following benefits:

• Paid Time Off (PTO) will be applied for quarantine dates prior to the COVID test date and applicable jurisdictional waiting period dates (typically first three days). If PTO is not available Emergency Temporary Standard (ETS) time will be paid for the quarantine dates and waiting period dates.

• Lost time benefits, after the appropriate waiting period days, will be paid per jurisdictional requirements by SSM’s appropriate vendor. SSM will supplement the lost time benefits, when necessary, with PTO (if available) or ETS (if PTO is not available) up to the employee’s regular salary up to $1400/wk. per the ETS pay requirement. The supplemental pay will be

• If you are working remotely or isolated, normal clocking applies using the TIME app or SSM Health time clock. If you are not able to work remotely or isolated, during the quarantine period while waiting for test results, contact your assigned Workers’ Compensation Partner. If your claim is determined to be covered, Workers’ Compensation Partner will provide Leave of Absence information to Sedgwick. If your claim is determined to not be covered, follow instructions below under “Non-Occupational” scenario.

• Workers’ Compensation Partner will enter appropriate time coding for covered Workers’ Compensation claims. “PTO” will be entered for quarantine dates prior to COVID test date and applicable waiting period dates. If no PTO available, “ETS” will be entered.

• Supplemental pay will be entered by the SSM Workers’ Compensation Partner for the

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provided during the period of time the ETS requires an employee be removed from work.

• Reasonable and necessary medical expenses related to COVID-19 will be covered by the Worker’s Compensation program. All employee benefits will continue during this period.

applicable period of time. PTO (if available) will be utilized. If no PTO, ETS will be applied to provide the supplemental pay. See employer’s obligation information below.

• Lost time dates after ETS RTW criteria is met will be paid by SSM’s Workers’ Compensation Vendor at the applicable jurisdiction benefit rates.

• Manager should review employees time prior to time submission deadlines and notify the assigned Workers’ Compensation Partner if he/she believes time entry is missing or incorrect.

Employee COVID + (Non-Occupational)

• Notify your manager and Employee Health immediately; contact Sedgwick by phone or online portal to initiate a request for a Leave of Absence and potentially a Short-Term Disability (STD).

• Provide copy of your COVID+ test results to Sedgwick.

• Talk with your manager about any remote or isolated work opportunities during the quarantine period.

• You will receive your regular rate of pay for time worked.

• Paid Time Off will be used up to your FTE during the quarantine days prior to test date and applicable 7-day elimination period prior to Short-Term Disability benefits being applicable. If PTO is not available; ETS time will be applicable and only applied to meet the ETS pay requirement of providing employee’s regular salary up to $1400/wk pay requirement.

• PTO & ETS hours will be paid at your regular rate of pay.

• Short-Term Disability benefits will be supplemented, when necessary, to meet the required OSHA COVID-19 pay requirement. PTO will be utilized (if available). If no PTO available, ETS will be utilized.

• Approved STD dates outside the pay requirements of OSHA’s ETS will be paid

• If you are working remote or isolated, normal clocking applies using the TIME app or SSM Health time clock.

• If you are not able to work remotely or isolated, for dates prior to your COVID test, SSM Health Leave of Absence Partner will apply PTO up to FTE for applicable dates. If no PTO is available, ETS time will be applied.

• If you test positive, you will be paid Short -Term Disability following a 7 - calendar day elimination period. SSM Leave of Absence Partner will apply -PTO (if available) up to FTE for applicable elimination period days. If no PTO, ETS will be applied by SSM Leave of Absence Partner.

• SSM Leave of Absence Partners will apply supplemental pay benefits, when applicable, to meet the OSHA ETS pay requirement of providing regular salary up to $1400/wk.

• Manager should review employees time prior to time submission deadlines and notify SSM Leave of Absence Partner if he/she believes

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based on the normal STD policy.

• COVID-19 testing will be provided at no cost to the employee.

time entry is missing or incorrect.

Employee has been told by health care provider they are suspected to have COVID 19

Work Related:



• A covered Workers’ Compensation claim requires a COVID+ test result.

Talk with your manager about any remote work or isolation work opportunities during the quarantine period.

Non-Occupational:

• Notify your manager and Employee Health immediately; contact Sedgwick by phone or online portal to initiate a request for a Leave of Absence and potentially a Short-Term Disability (STD).

• Provide medical documentation to

• Covered Workers’ Compensation Claim receives the compensation & benefits outlined in the “COVID+ (Work-Related) scenario above.

• Approved Short-Term Disability Claim receives the compensation & benefits outlined in the “COVID+ (Non-Occupational)

• Leave of Absence with no corresponding STD claim requires use of available PTO up to FTE. If PTO is not available, ETS will be applicable providing regular pay or $1400/wk. per ETS pay requirement for the required dates.

• Covered Workers’ Compensation Claim – see recording information provided in “COVID+ (Work-Related) scenario above.

• Approved Short-Term Disability Claim – see recording information provided in “COVID+ (Non-Occupational) scenario above.

• Leave of Absence without an associated STD or workers’ compensation claim, SSM Leave of Absence Partner will enter PTO up to employee’s FTE.. If no PTO is available, ETS pay will be applied to provide employee’s regular salary up to $1400/wk per the OSHA ETS pay requirement.

• Manager should review employees time prior to time submission deadlines and notify the assigned Leave of Absence Partner if he/she believes time entry is missing or incorrect.

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Sedgwick to support disability.

Talk with your manager about any remote or isolated work opportunities during the quarantine period.

Recent loss of taste and/or smell, with no other explanation or is experiencing both fever and new unexplained cough with shortness of breath

Work Related:



• A covered Workers’ Compensation claim requires a COVID+ test result.

Talk with your manager about any remote work or isolation work opportunities during the quarantine period.

Non-Occupational:

• Notify your manager and Employee Health immediately; contact Sedgwick by phone or online portal to initiate a request for a Leave of Absence and potentially a Short-Term

• Covered Workers’ Compensation Claim receives the compensation & benefits outlined in the “COVID+ (Work-Related) scenario above.

• Approved Short-Term Disability Claim receives the compensation & benefits outlined in the “COVID+ (Non-Occupational)

Leave of Absence with no corresponding STD claim requires use of available PTO up to FTE. If PTO is not available ETS will be applicable providing regular pay or $1400/wk. per ETS pay requirement for the required dates.

• Covered Workers’ Compensation Claim – see recording information provided in “COVID+ (Work-Related) scenario above.

• Approved Short-Term Disability Claim – see recording information provided in “COVID+ (Non-Occupational) scenario above.

Leave of Absence without an associated STD or workers’ compensation claim, SSM Leave of Absence Partner will enter PTO-ETS up to employee’s FTE. If no PTO available, ETS pay will be applied to provide employee’s regular salary up to $1400/wk. per OSHA ETS pay requirements.

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Disability (STD). • Provide medical

documentation to Sedgwick to support disability.

Talk with your manager about any remote or isolated work opportunities during the quarantine period.

Employee is required to be notified by the employer of close contact in the workplace to a person who is COVID 19 positive unless the employee has been fully vaccinated against COVID or had COVID 19 & recovered w/in the past 3 months with no symptoms listed in #3

• Notify your manager and Employee Health immediately. Employee or manager are required to complete an employee event report in the online portal. “Report an Event” link is located on SSM Intranet homepage.


• SSM Workers’ Compensation Partner will notify Sedgwick of the employee’s Leave of Absence.

• Talk with your manager about any remote or isolation work opportunities during the quarantine period.

• Paid Time Off (PTO) will be applied for quarantine dates prior to being eligible to return to work per OSHA COVID-19 ETS

• If PTO is not available ETS will be applicable

• If employee tests positive; see scenario “COVID Positive -Work Related” for applicable pay benefits.

• If you are working remotely or isolated, normal clocking applies using the TIME app or SSM Health time clock. If you are not able to work remotely or isolated, during the quarantine period, contact your assigned Workers’ Compensation Partner.

• SSM Workers’ Compensation Partner will provide Leave of Absence information to Sedgwick.

• Workers’ Compensation Partner will enter appropriate time coding, PTO-ETS or ETS for applicable quarantine dates.

• Manager should review employees time prior to time submission deadlines and notify the assigned Workers’ Compensation Partner if he/she believes time entry is missing or incorrect.

The above pay practices align with the following requirements for employees who work in patient care sites under OSHA’s COVID-19 ETS:

1. Employers must continue to provide the benefits to which the employee is normally entitled and pay the employee the same regular pay the employee would have received had the employee not been absent from work, up to $1,400 per week per employee.

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2. Employer’s obligation to provide paid medical removal benefits ends when an employee meets the return-to-work (i.e. is no longer likely infectious) based on CDC guidelines, even if the employee is experiencing persistent debilitating effects of the disease and is unable to work for that reason.

3. The employer’s payment obligation is reduced by the amount of compensation the employee receives from any other source, such as a publicly or employer-funded compensation program (e.g., paid sick leave, administrative leave), for earnings lost during the period of removal or any additional source of income the employee receives that is made possible by virtue of the employee’s removal.

XI. Vaccination A. SSM Health requires all employees to receive the COVID-19 vaccination as part of a multi-

layered infection control approach. Leaders are required to receive their first dose of vaccine by July 31, 2021 and all other team members by September 1, 2021. Employees working at patient care sites, will be provided reasonable time and paid leave, using PTO if available, for vaccination and any side effects experienced following vaccination as described below.

B. Vaccination Available At Normal Work Location: Employees working at a location which offers the vaccination should receive the COVID-19 vaccination at their normal work location during their work hours. The employee should remain clocked in and will be paid regular time.

C. Vaccination Not Available At Normal Work Location: Employees should partner with their manager to receive the vaccine during their normal work hours, or before or after their scheduled work time, and will be paid regular time (typically up to one hour) for travel and vaccination time.

D. Employees who experience vaccination side effects: Employees who experience side effects are required submit an employee event report. The employee event online reporting portal can be accessed by clicking on the “Report an Event” icon located on the SSM Health Intranet Homepage. If the employee is off work and unable to enter the event, the employee’s manger is responsible for entering an employee event report on behalf of the employee.

E. Approved workers’ compensation claims related to vaccination side effects will receive the following pay benefits: 1. Paid Time Off - Emergency Temporary Standard (PTO-ETS) will be applied for applicable

jurisdictional waiting period days; typically, three days. If PTO is not available, ETS time will be applicable.

2. Paid time (ETS) will be applicable for lost time dates following the applicable waiting period dates.

3. Workers’ Compensation Partner will enter appropriate time coding in Workday. 4. Manager should review employees time prior to time submission deadlines and notify the

assigned Workers’ Compensation Partner if he/she believes time entry is missing or incorrect.

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XII. Anti-retaliation SSM Health encourages employee participation in creating a safe and healthy work environment. SSM Health strictly prohibits retaliation against any employee asserting a right to protections under the COVID-19 plan or for engaging in activity required under this Plan. Employees will be informed of their rights under this Plan and the prohibition on retaliation when they participate in training.

XIII. Requirements implemented at no cost to employees SSM Health will comply with the provisions of OSHA’s COVID-19 ETS at no cost to its employees, with the exception of any employee self-monitoring conducted under the Health Screening and Medical Management section of this plan.

XIV. Reporting, Recordkeeping, and Access

SSM Health has a policy containing information on how to report information about COVID-19 cases in our workplace to the local health department whenever required by law, and provide any related information requested by the local health department.

A. SSM Health will maintain a COVID-19 log of all reported employee activity utilizing the pandemic tracker. The Employee Health nurse will capture all required data, maintaining and updating the log as needed. This log will be maintained securely by Employee Health.

B. Employee Health will provide discrete data as outlined as need for authorized and approved requesters.

XV. Reporting COVID- fatalities and hospitalizations to OSHA

A. Our SSM Health policy “OSHA Reporting of Serious Injury” provides information on how to report information regarding serious work-related illness, injury or death. This would include instances that fit criteria with COVID-19 employee cases.

B. Refer to SSM Health OSHA Reporting Policy (https://ssmhc.policytech.com/dotNet/documents/?docid=80453)

XVI. Mini-respiratory protection program A. SSM Health employees who are required to wear a respirator must be enrolled in the full SSM

Health System Respiratory Protection Program (RPP) and must continue to comply with the policy and utilize SSM Health approved and provided respirators. (https://ssmhc.policytech.com/dotNet/documents/?docid=65949)

B. SSM Health allows employees to wear their own (employee-provided) respirator but only in place of a facemask. Personal respirators may not be used when a respirator is part of the required PPE. Personal respirators are also not allowed if an employee was previously disqualified from respirator use based on the medical evaluation. The Employee must notify their manager prior to use of any personally-supplied respirators. Employees must do the following before using a personal respirator:

1. Read and follow all instructions provided by the manufacturer on use, maintenance, cleaning and care, and warnings regarding the respirator’s limitations.

2. Keep track of your respirator so that you do not mistakenly use someone else’s respirator. 3. Do not wear your respirator where other workplace hazards (e.g., chemical exposures)

require use of a respirator.

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For more information about using a respirator, see OSHA’s Respiratory Protection Safety and Health topics page: www.osha.gov/respiratory-protection

C. Training and Documentation for Employee-Provided respirator: When the employee notifies the manager that they will be using an employee-provided respirator instead of a facemask, the manager will then provide a copy of the instructions (Appendix B) to the Employee.

D. This tasker is currently under development,. Please return to this site in the near future.

XVII. Engineering Controls - physical barriers and ventilation A. SSM Health will ensure that each employee is separated from all other people in the workplace

by at least 6 feet when indoors, unless it can be demonstrated that such physical distance is not feasible for a specific activity.

B. SSM Health utilizes physical barriers for situations where we cannot maintain at least six feet between individuals (this is not required in direct patient care areas or resident rooms). Physical barriers are placed at workstations, outside of direct patient care areas, (e.g., entryway/lobby, check-in desks, triage, hospital pharmacy windows, bill payment) where employees are not separated from all other people by at least 6 feet of distance. SSM Health conducted an initial assessment to ensure the appropriate barriers are in place as required. See Appendix A for a sample template.

C. SSM Health maximizes, to the extent feasible, the quantity of outside air for our buildings with mechanical or natural ventilation systems. See SSM Health System Policy: Room Air Parameters for Critical and Non-Critical Areas (https://ssmhc.policytech.com/dotNet/documents/?docid=69268)

D. SSM Health conducted an initial assessment to ensure the ventilation is running as required by the OSHA ETS. See Appendix A for a sample template.

XVIII. Training SSM Health provides effective training that includes:

A. Our COVID-19 policies and procedures, as outlined in the SSM Health Infection Prevention Resource Guide, to protect employees from COVID-19 hazards. This includes:

1. Our COVID-19 policies and procedures on patient screening and management (housed within the Patient Care – Screenings and Algorithms intranet site)

2. Tasks within the workplace that could result in COVID-19 infection (housed within the COVID-19: Patient Care intranet site)

3. Our COVID-19 policies and procedures designed to prevent the spread of COVID-19 that are applicable to the employee’s duties (housed within SSM Health Infection Prevention Resource Guide as well as the COVID-19: Patient Care intranet site)

4. Our COVID-19 policies and procedures for cleaning and disinfection (housed within SSM Health Infection Prevention Resource Guide)

B. A detailed COVID-19 PPE plan (located within the SSM Health Infection Prevention Resource Guide as well as demonstrated in the video modules: CDC Donning & Doffing PPE – Example 1, CDC Donning & Doffing PPE – Example 2, and CDC Donning & Doffing with Reuse PPE for Southern Illinois Ministries)

C. Information regarding COVID-19-related benefits, housed in the COVID-19 HR Polices landing page, to which the employee may be entitled under applicable federal, state, or local laws. This includes:

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D. The fact that (as noted in the eLearning modules released in February 2020: Coronavirus Disease 2019 (COVID-19) , Coronaviruses , and Coronavirus Infections – More Than Just the Common Cold):

1. COVID-19 is an infectious disease that can be spread through the air. 2. COVID-19 may be transmitted when a person touches a contaminated object and then

touches their eyes, nose, or mouth. 3. An infectious person may have no symptoms.

E. Methods of physical distancing of at least six feet and the importance of combining physical distancing with the wearing of face coverings as outlined in the SSM Health Infection Prevention Resource Guide.

F. The importance of frequent hand washing with soap and water for at least 20 seconds and using hand sanitizer when employees do not have immediate access to a sink or hand washing facility, and that hand sanitizer does not work if the hands are soiled – as discussed in the mandatory eLearning module Infection Prevention & Control: Breaking the Chain of Infection

G. Proper use of face coverings and the fact that face coverings are not respiratory protective equipment - face coverings are intended to primarily protect other individuals from the wearer of the face covering as outlined in the SSM Health Infection Prevention Resource Guide and summarized in the Cloth Masks section of the Infection Prevention PPE Guidelines landing page.

H. COVID-19 symptoms, and the importance of obtaining a COVID-19 test and not coming to work if the employee has COVID-19 symptoms as outlined in the COVID-19 Employee Health landing page.

I. Training developed by the Clinical Education department (utilizing evidence-based research and CDC guidelines and in collaboration with subject matter experts in other disciplines such as infection prevention, sterile processing, and regulatory) which includes:

1. Initial training for staff that encompasses all the above and concludes with an interactive question and answer session (either in groups or individually) by leaders (or other personal knowledgeable in the covered subject) within the employee’s work unit.

2. Immediate and effective additional training each time changes occur to the employee’s risk of contracting COVID-19, polices or procedures are altered, or a gap in knowledge around COVID-19 training or related skills has been identified

3. Deployment plans are created based on the significance of the change and include just-in-time training in huddles, eLearning modules, presentation or video with return demonstration, etc.)

4. Guidance to reach out to Clinical Education or Employee Heath for additional questions. Additionally, an email address has been supplied for further questions [email protected]

DOCUMENTATION:

REFERENCES:

OSHA COVID 10 Emergency Temporary Standard 29 CFR 1910. Subpart U: 1910.502, 1910.504, 1910.505 and 1910.509 Appendix A: Physical Barrier and Ventilation assessment template

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Appendix B

Hazard Assessment

Medical Record pick-up desks

Insurance/payment/complaint desks

Check-in/Check-out desks

Retail check-out counters

Registration areas

Triage desks

Information desk

Deli check-out

Reception desks

Concierge desk

Valet desk

Sliding windows have physical barrier

(i) Physical barriers . At each fixed work location outside of direct patient care areas (e.g., entryway/lobby, check-in desks, triage, hospital pharmacy windows, bill payment) where each employee is not separated from all other people by at least 6 feet of distance, install cleanable or disposable solid barriers, except where the facility can demonstrate it is not feasible. The barrier must be sized (e.g., height and width) and located to block face-to-face pathways between individuals based on where each person would normally stand or sit. The barrier may have a pass-through space at the bottom for objects and merchandise. Note to paragraph (i): Physical barriers are not required in direct patient care areas or resident rooms.

Place Yes/No/NA; initials; date. For any "N", place a comment where the

additional Physical Barrier is needed

Site

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SSM Health employees who wish to use a respirator instead of a facemask and who are not enrolled in the full SSM Health System RPP may provide their own respirators (N95 filtering facepiece types, elastomeric, CAPR, or PAPR) for voluntary use, except those individuals who were previously disqualified from respirator used based on the medical evaluation. Respirators can be an effective method of protection against COVID–19 hazards when properly selected and worn. Respirator use is encouraged to provide an additional level of comfort and protection for workers even in circumstances that do not require a respirator to be used. However, if a respirator is used improperly or not kept clean, the respirator itself can become a hazard to the worker. You should do the following:

(1) Read and follow all instructions provided by the manufacturer on use, maintenance, cleaning and care, and warnings regarding the respirator’s limitations.

(2) Keep track of your respirator so that you do not mistakenly use someone else’s respirator.

(3) Do not wear your respirator where other workplace hazards (e.g., chemical exposures) require use of a respirator

For more information about using a respirator, see OSHA’s respiratory Protection Safety and Health topics page: www.osha.gov/respiratory-protection

Employee Name: __________________________________________

Employee ID: _____________________________________________

Day training received: ______________________________________

Manager Signature: ________________________________________

Managers SHOULD maintain training documentations.

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Attachment- OSHA COVID-19 ETS with the definitions. See OSHA 1910.505: COVID-19 Emergency Temporary Standard for definitions. You can access that link here.

administrative policy - resources.ssmhealth.com

Documents