organizations have similarly long recognized the importance of
vaccinating employees to prevent illness. This is particularly true in
healthcare industries, where employees are more regularly at risk of
occupational exposure to transmissible diseases. For example, the
Advisory Committee on Immunization Practices (ACIP), which reviews
evidence of risk and vaccine effectiveness, recommends vaccinating
healthcare employees against numerous diseases, including influenza,
another viral disease spread through droplet transmission (Shefer et
al., November 25, 2011). Similarly, both HICPAC and the American
Hospital Association have encouraged and endorsed vaccination programs
or policies for healthcare workers. CDC, WHO, and the National
Academies of Science, among others, have all acknowledged that broad
vaccination of all people for COVID-19, in combination with other
public health measures, is a critical tool that can be used to address
the pandemic (CDC, April 29, 2021; WHO, January 8, 2021; NASEM, 2020).
    Any vaccines offered to employees must be demonstrated to be safe
and effective. Fortunately, over the course of the pandemic, there have
been extensive efforts to develop COVID-19 vaccines. As discussed in
greater detail in Grave Danger (Section IV.A. of the preamble), there
are presently three COVID-19 vaccines authorized for emergency use by
the FDA in the United States: the Pfizer-BioNTech COVID-19 vaccine, the
Moderna COVID-19 vaccine, and the Janssen Biotech, Inc. Johnson and
Johnson COVID-19 vaccine, each recommended for use by ACIP in persons
at least 12 years of age and older for the Pfizer-BioNTech vaccines or
18 years of age and older for the Moderna and Johnson and Johnson
(Janssen) vaccines (Oliver et al., December 18, 2020; Oliver et al.,
January 1, 2021; FDA, April 9, 2021; FDA, April 1, 2021; FDA, February
26, 2021; FDA, May 10, 2021). In determining whether to grant EUA for a
new COVID-19 vaccine, the FDA considers several statutory criteria
provided in section 564 of the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 360bbb-3). In evaluating an EUA request, FDA considers, among
other things, the totality of scientific evidence available to
determine if it is reasonable to believe that the vaccine may be
effective (i.e., an efficacy of at least 50%) in preventing COVID-19
and that the known and potential benefits of the vaccine, when used to
prevent COVID-19, outweigh the known and potential risks of the vaccine
(FDA, April 9, 2021; FDA, April 1, 2021; FDA, February 26, 2021). The
product manufacturer must also demonstrate quality and consistency in
manufacturing. Accordingly, any COVID-19 vaccine that receives an EUA
from the FDA--including the Pfizer-BioNTech vaccine, Moderna vaccine,
the Johnson and Johnson (Janssen) vaccine, and any future vaccine that
receives such an authorization after the issuance of this ETS--has been
shown to be sufficiently safe and effective.
    All three vaccines that have been authorized to date, including the
Pfizer-BioNTech, Moderna, and Johnson & Johnson (Janssen) vaccines,
have been found to be highly effective for the appropriate ages (Oliver
et al., December 18, 2020; Oliver et al., January 1, 2021; Polack et
al., December 31, 2020; FDA, December 17, 2020; FDA, December 10, 2020;
FDA, February 26, 2021). The vaccines were also found to be effective
in preventing disease that is severe or requires hospitalization. The
evidence

available at this time, however, does not yet establish that the
vaccines eliminate the potential for asymptomatic COVID-19 development;
rather, fully vaccinated people are less likely to have asymptomatic
infection or transmit SARS-CoV-2 to others (CDC, May 14, 2021). All
three authorized vaccines have met the authorization standard for
safety, with the majority of adverse effects observed to be mild or
moderate in severity and transient, including: fatigue; headache;
chills; muscle pain; joint pain; lymphadenopathy (swelling or
enlargement of lymph nodes) on the same side as the injection; and
injection site pain, redness, and swelling (CDC, December 13, 2020;
CDC, December 20, 2020; CDC, May 14, 2021; Oliver et al., December 18,
2020; Oliver et al., January 1, 2021; Polack et al., December 31, 2020;
FDA, December 17, 2020; FDA, December 10, 2020; FDA, February 26,
2021).
    Further, as discussed more extensively in the Summary and
Explanation (Section VIII of the preamble) requirement for paid time
off for vaccination, vaccination can only function as an effective
control if workers have access to it. Additional explanation of the
importance of removing barriers to controls is also discussed in
Summary and Explanation (see discussion of requirements that employees
receive protections of the ETS at no cost, as well as requirements for
paid time off for vaccination, both in Section VIII of the preamble).
Vaccination References
Centers for Disease Control and Prevention (CDC). (2020, December
13). Local reactions, systemic reactions, adverse events, and
serious adverse events: Pfizer-BioNTech COVID-19 vaccine. https://www.cdc.gov/vaccines/covid-19/info-by-product/pfizer/reactogenicity.html. (CDC, December 13, 2020).
Centers for Disease Control and Prevention (CDC). (2020, December
20). Local reactions, systemic reactions, adverse events, and
serious adverse events: Moderna COVID-19 vaccine. https://www.cdc.gov/vaccines/covid-19/info-by-product/moderna/reactogenicity.html. (CDC, December 20, 2020).
Centers for Disease Control and Prevention (CDC). (2021, April 12).
Benefits of getting a COVID-19 vaccine. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/vaccine-benefits.html. (CDC, April
12, 2021).
Centers for Disease Control and Prevention (CDC). (2021, April 27).
Updated Healthcare Infection Prevention and Control Recommendations
in Response to COVID-19 Vaccination. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-after-vaccination.html.
(CDC, April 27, 2021).
Centers for Disease Control and Prevention (CDC). (2021, April 29).
FAQ ``Why would a vaccine be needed when we can do other things . .
.?. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/faq.html.
(CDC, April 29, 2021).
Centers for Disease Control and Prevention (CDC). (2021, May 14).
Interim clinical considerations for use of COVID-19 vaccines
currently authorized in the United States. https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fvaccines%2Fcovid-19%2Finfo-by-product%2Fpfizer%2Fclinical-consideratio%E2%80%A6. (CDC, May 14, 2021).
Dooling, K et al., (2020, December 22). The Advisory Committee on
Immunization Practices' updated interim recommendation for
allocation of COVID-19 vaccine--United States, December 2020. MMWR
Rep 2021; 69: 1657-1660. DOI: http://dx.doi.org/10.15585/mmwr.mm695152e2. (Dooling et al., December 22, 2020).
Food and Drug Administration (FDA). (2020, December 10). FDA
briefing document. Pfizer-BioNTech COVID-19 Vaccine. https://www.fda.gov/media/144245/download. (FDA, December 10, 2020).
Food and Drug Administration (FDA). (2020, December 17). MRNA-1273
sponsor briefing document (Moderna). https://www.fda.gov/media/144453/download. (FDA, December 17, 2020).
Food and Drug Administration (FDA). (2021, February 26). FDA
Briefing Document: Janssen Ad.COV2.S Vaccine for the Prevention of
COVID-19. (FDA, February 26, 2021)
Food and Drug Administration (FDA). (2021, April 1). Moderna COVID-
19 vaccine. https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/moderna-covid-19-vaccine. (FDA,
April 1, 2021).
Food and Drug Administration (FDA). (2021, April 9). Pfizer-BioNTech
COVID-19 vaccine. https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/pfizer-biontech-covid-19-vaccine. (FDA, April 9, 2021).
Food and Drug Administration (FDA). (2021, May 10). Pfizer-BioNTech
COVID-19 vaccine EUA Letter of Authorization Reissued. https://www.fda.gov/media/144412/download. (FDA, May 10, 2021).
National Academy of Sciences, Engineering, and Medicine (NASEM).
(2020). Framework for equitable allocation of COVID-19 vaccine.
https://www.nap.edu/download/25917. (NASEM, 2020).
Oliver, S et al., (2020, December 18). The Advisory Committee on
Immunization Practices' interim recommendation for use of Pfizer-
BioNTech COVID-19 vaccine--United States, December 2020. MMWR Rep
2020; 69: 1922-1924. DOI: http://dx.doi.org/10.15585/mmwr.mm6950e2.
(Oliver et al., December 18, 2020).
Oliver, S et al., (2020, December 20). The Advisory Committee on
Immunization Practices' interim recommendation for use of Moderna
COVID-19 vaccine--United States, December 2020. MMWR Rep 2021; 69:
1653-1656. DOI: http://dx.doi.org/10.15585/mmwr.mm695152e1. (Oliver
et al., January 1, 2021).
Polack, F et al., (2020). Safety and efficacy of the BNT162b2 mRNA
Covid-19 vaccine. New England Journal of Medicine, 383(27), 2603-
2615. doi: 10.1056/nejmoa2034577. (Polack et al., December 31,
2020).
Shefer, A. et al., (2011, November 25). Immunization of health-care
personnel: Recommendations of the Advisory Committee on Immunization
Practices (ACIP). MMWR Recommendations and Reports 60(RR07); 1-45.
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6007a1.htm. (Shefer et
al., November 25, 2011).
World Health Organization (WHO). (2021, January 8). COVID-19
vaccine. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/covid-19-vaccines. (WHO, January 8, 2021).

O. Training

    The CDC has determined that training is a necessary component of a
comprehensive control plan for COVID-19. The WHO has also determined
that training is an important control strategy for COVID-19 (WHO, May
10, 2020). When providing guidance for employers, the CDC has said that
employees need to be educated on steps they can take to protect
themselves from potential COVID-19 exposures at work. Employers
informing employees of the hazards to which employees may be exposed
while working is a cornerstone of occupational health and safety (OSHA,
2017). Employees play a particularly important role in reducing
exposures because appropriate application of work practices and
controls limit exposure levels. Employees therefore need to be informed
of the grave danger of COVID-19, as well as the workplace measures
included in their employers' COVID-19 plans because those measures are
necessary to reduce risk and provide protection to employees. Employees
must know what protective measures are being utilized and be trained in
their use so that those measures can be effectively implemented.
    Training has been shown to be an effective tool to reduce injury
and illness (Burke et al., February 2006), but training is even more
critical when the workplace hazard includes the potential transmission
of the potentially deadly SARS-CoV-2 virus from one employee to
another: One improperly trained employee could increase risk for that
employee and for all of that employee's contacts, including coworkers.

Therefore, training is an essential component of a layered approach to
minimizing the risk of contracting COVID-19 in the workplace.
    Training and education provide employees and managers an increased
understanding of existing safety and health programs. A thorough
understanding of these programs is necessary so employees can more
effectively contribute to their development and implementation.
Training provides employers, managers, supervisors, and employees with
the knowledge and skills needed to do their work safely and to avoid
creating hazards that could place themselves or others at risk, as well
as awareness and understanding of workplace hazards and how to
identify, report, and control them. Specialized training can address
unique hazards.
    Because OSHA has long recognized the importance of training in
ensuring employee safety and health, many OSHA standards require
employers to train employees (e.g., the Bloodborne Pathogen standard at
29 CFR 1910.1030(g)(2)). When required as a part of OSHA standards,
such as is required by this ETS, training helps to ensure that
employees are able to conduct work in a safe and healthful manner
(OSHA, April 28, 2010). Training is essential to ensure that both
employers and employees understand the sources of potential exposure to
COVID-19 and control measures to reduce exposure to the hazard.
    Employee comprehension is critical to ensuring that training is an
effective control. If training information is not presented in a way
that all employees understand, the training will not be effective.
Employers must thus consider language, literacy, and social and
cultural appropriateness when designing and implementing training
programs for employees (O'Connor et al., 2014). Additionally, if
employers do not offer training to employees in a convenient manner,
employees may be less likely to participate in the training. Therefore,
to be effective, training must be offered during scheduled work times
and at no cost to the employee. This will ensure that all employees
will have the time and financial resources to receive training. This is
also consistent with other OSHA standards. For example, the Bloodborne
Pathogen standard requires training be provided at no cost and during
working hours (Sec.  1910.1030(g)(2)(i)) and in a manner employees
understand (Sec.  1910.1030(g)(2)(vi)).
    Research dating back to the 1980s has found ``overwhelming
evidence'' of the effectiveness of training programs on employee
knowledge (NIOSH, 1998), as well as employee behaviors (NIOSH, January
2010). With enhanced knowledge of safety and health hazards and
controls, employees can implement safer work practices. This can result
in reductions in workplace-related illnesses (Burke et al., February
2006).
    The CDC has stated that information on workplace policies should be
communicated clearly, frequently, and via multiple messages (CDC, March
8, 2021). Training and education on safe work practices and controls
should be used to raise awareness among employees. Emphasizing the
effectiveness of these workplace controls helps to counteract
misinformation. Additional training, such as on PPE and infection
control policies and procedures, should be given to employees in those
workplaces where there is a high risk of exposure to COVID-19 (WHO, May
10, 2020).
    Scientific research and case studies have further reinforced the
importance of training in responding to the COVID-19 pandemic.
Researchers found that a COVID-19 outbreak was effectively contained as
a result of prompt implementation of infection control measures,
including early in-person education of employees on the signs,
symptoms, and transmission of COVID-19 (Hale and Dayot, August 13,
2020). Knowledge of PPE was markedly improved following training on PPE
for healthcare employees in China during the COVID-19 pandemic (Tan et
al., June, 2020).
    Training has been widely recognized as a key component of
occupational safety and health. Even though the body of scientific
evidence on the importance of training during the COVID-19 pandemic is
limited given its ongoing nature, the evidence that does exist only
further emphasizes the important role of training in protecting the
health and safety of employees. As such, OSHA has concluded that
training is necessary to ensure proper implementation of the employer's
COVID-19 plan and all other control measures, and that such training
will reduce incidence of COVID-19 illness both on its own and when
complemented by other measures as part of a multi-layered strategy to
minimize employee exposure to the grave COVID-19 danger.
References
Burke, M.J. et al., (2006, February). Relative effectiveness of
worker safety and health training methods. American Journal of
Public Health 96: 315-324. (Burke et al., February 2006).
Centers for Disease Control and Prevention (CDC). (2021, March 8).
Guidance for Businesses and Employers Responding to Coronavirus
Disease 2019 (COVID-19). https://www.cdc.gov/coronavirus/2019-ncov/community/guidance-business-response.html. (CDC, March 8, 2021).
Hale, M. and Dayot, A. (2020). Outbreak Investigation of COVID-19 in
Hospital Food Service Workers. American Journal of Infectection
Control. S0196-6553(20)30777-X. https://doi.org/10.1016/j.ajic.2020.08.011. (Hale and Dayot, August 13,2020).
National Institute for Occupational Safety and Health (NIOSH).
(1998, June). Assessing Occupational Safety and Health Training: A
literature review, June 1998. https://www.cdc.gov/niosh/docs/98-145/pdfs/98-145.pdf?id=10.26616/NIOSHPUB98145. (NIOSH, June 1998).
National Institute for Occupational Safety and Health (NIOSH) (2010,
January). A systematic review of the effectiveness of training and
education for the protection of workers, January 2010.https://
www.cdc.gov/niosh/docs/2010-127/pdfs/2010-127.pdf. (NIOSH, January
2010).
O'Connor, T. et al., (2014). Occupational safety and health
education and training for underserved populations. New
Solutions24(1): 83-106. (O'Connor et al., 2014).
Occupational Safety and Health Administration (OSHA). (2010, April
28). Training Standards Policy Statement. https://www.osha.gov/dep/standards-policy-statement-memo-04-28-10.html.(OSHA, April 28,
2010).
Occupational Safety and Health Administration (OSHA). (2017).
Workers' Rights. https://www.osha.gov/sites/default/files/publications/osha3021.pdf.(OSHA, 2017).
Tan, W. et al., (2020, June). Whole-process emergency training of
personal protective equipment helps healthcare workers against
COVID-19: Design and effect. Journal of Occupational and
Environmental Medicine 62: 420-423. DOI: 10.1097/
JOM.0000000000001877. (Tan et al., June, 2020).
World Health Organization(WHO).(2020, May 10). Considerations for
public health and social measures in the workplace context of COVID-
19: Annex to Considerations in adjusting public health and social
measures in the context of COVID-19, May 2020. https://www.who.int/publications-detail-redirect/considerations-for-public-health-and-social-measures-in-the-workplace-in-the-context-of-covid-19.(WHO,
May 10, 2020).

VI. Feasibility

A. Technological Feasibility

    This section presents an overview of the technological feasibility
assessment for OSHA's Emergency Temporary Standard (ETS) for COVID-19.
The ETS has four sections: Healthcare (29 CFR 1910.502); Mini
Respiratory Protection Program (29 CFR 1910.504); Severability (29 CFR
1910.505); and Incorporation by

Reference (29 CFR 1910.509). The ETS applies to all settings where any
employee provides healthcare services or performs healthcare support
services. The settings covered by the ETS are listed in Table VI.A.-1.
[GRAPHIC] [TIFF OMITTED] TR21JN21.001

    The mini respiratory protection program section supplements the ETS
to provide additional protection to workers in appropriate cases. The
healthcare and mini respiratory protection program sections of the ETS
will be discussed below. It is not necessary to discuss the
severability or incorporation by reference sections, as those sections
do not by their own terms impose any requirements that raise issues of
technological feasibility.
    Technological feasibility has been interpreted broadly to mean
``capable of being done'' (Am. Textile Mfrs. Inst. v. Donovan, 452 U.S.
490, 509-510 (1981)). A standard is technologically feasible if the
protective measures it requires already exist, can be brought into
existence with available technology, or can be created with technology
that can reasonably be expected to be developed, i.e., technology that
``looms on today's horizon'' (United Steelworkers of Am., AFL-CIO-CLC
v. Marshall, 647 F.2d 1189, 1272 (D.C. Cir. 1980) (Lead I); Amer. Iron
& Steel Inst. v. OSHA, 939 F.2d 975, 980 (D.C. Cir. 1991) (Lead II);
American Iron and Steel Inst. v. OSHA, 577 F.2d 825 (3rd Cir. 1978)).
Courts have also interpreted technological feasibility to mean that a
typical firm in each affected industry or application group will
reasonably be able to implement the requirements of the standard in
most operations most of the time (see Public Citizen v. OSHA, 557 F.3d
165 (3d Cir. 2009); Lead I, 647 F.2d at 1272; Lead II, 939 F.2d at
990).
    OSHA's assessment focuses on the controls required by the ETS that
stakeholders may believe raise issues of technological feasibility.
These controls include the implementation of a COVID-19 plan and
healthcare-specific good infection control practices, as well the
following controls: Physical distancing; physical barriers; and
ventilation.\26\ As discussed below, OSHA's finding of technological
feasibility is supported by a large number of COVID-19 transmission
prevention plans and best practice documents it reviewed, as well as
physical distancing scenarios and a job matrix it developed, across the
healthcare sector.
---------------------------------------------------------------------------

    \26\ As will be discussed later in this assessment, there are no
technological feasibility barriers related to compliance with other
requirements in the ETS (e.g., facemasks, respirators, cleaning and
disinfection, health screening and medical management, employee
notification).
---------------------------------------------------------------------------

    While OSHA focuses on certain types of evidence in specific parts
of the analysis, much of the evidence supports other discrete findings
made by OSHA. Thus, for example, while OSHA focuses on its review of
plans and best practice documents in establishing the feasibility of
developing and implementing a COVID-19 plan, that evidence also
supports the feasibility of implementing healthcare-specific good
infection control practices, physical distancing and physical barriers,
and ventilation.
    In addition, this analysis discusses only a few examples of the
plans and best practice documents it reviewed, does not recount every
element of the

plans and best practice documents that it reviewed, and does not
recount all details of the scenarios and job matrix it developed. OSHA
based its technological feasibility assessment on all the evidence in
the docket, and not just the select portions discussed here. The
discussion below is merely illustrative of the full complement of
evidence reviewed to demonstrate that employers have implemented the
controls required by the ETS.
    Finally, OSHA's finding of technological feasibility should not be
read to indicate that individual plans or best practice documents OSHA
reviewed are ETS-compliant, that lack of inclusion of a control in a
plan or document indicates the control is infeasible, that the use of a
barrier by employers in a given situation indicates that physical
distancing was not feasible in that situation, or that a particular
control used (e.g., a plastic sheet or curtain used as a physical
barrier) is compliant with the ETS's requirements. The plans and best
practice documents are intended to show two things: (1) That developing
plans to address COVID-19 in various workplaces is both common and
feasible, and (2) that the controls required by the ETS have been
implemented and are feasible in the healthcare settings. The specifics
of the plans may vary, but the ETS COVID-19 plan requirements are
written as performance requirements that provide sufficient flexibility
to ensure that it is feasible for employers to develop and implement
such a plan, including appropriate controls, for any given healthcare
workplace.
I. The ETS's Approach to Employee Protection
    The ETS generally includes provisions that are based on and in
accordance with applicable CDC and other well-established guidelines
for good infection control practices relevant to the exposures
encountered by employees during their job tasks. For example, the ETS
requires the employer to develop and implement policies and procedures
to adhere to Standard and Transmission-Based Precautions. As discussed
in detail in the Need for Specific Provisions (Section V of the
preamble, these requirements are consistent with well-established CDC
and other guidelines that are routinely followed by employers subject
to the ETS. That the ETS is based on CDC and other guidelines or
practices that are well established and have been routinely followed by
many employers both before and during the pandemic is compelling
evidence supporting OSHA's finding of technological feasibility.
    Moreover, as described in more detail in the Need for Specific
Provisions (Section V of the preamble), COVID-19 transmission control
practices work best when used together, overlapping their protective
impact. To this end, the COVID-19 ETS provides a multilayered approach
in which a combination of control measures must be implemented to
minimize the risks of exposure to COVID-19. Thus, to effectively reduce
the risk, employers must ensure that they follow all requirements of
the ETS that are feasible. As discussed in the Need for Specific
Provisions (Section V of the preamble), the OSHA regulatory text
reflects a multilayered strategy by requiring employers to implement
multiple mitigation strategies with several layers of controls to lower
the risks of exposure and reduce the spread of disease. Utilizing
overlapping controls in a layered approach better ensures that no
inherent weakness in any one approach results in an infection incident.
OSHA emphasizes that the infection control practices required by the
ETS work best when used together, layering their protective impact
(Garner, 1996; Rusnak et al., September 2004; Miller et al., 2012; WHO,
2016). For example, in addition to requiring employers to ensure that
employees engage in physical distancing, wear facemasks and follow
healthy hand hygiene practices, employers must ensure the use of
physical barriers at fixed work locations outside of direct patient
care areas where 6 feet of physical distancing is not feasible and
ensure adequate building ventilation. No one measure can prevent
transmission by itself, but several layers combined can significantly
reduce the overall risk of COVID-19 transmission (e.g., a facemask
alone will not be enough to prevent the spread of COVID-19 without
physical distancing and other controls (Akhtar et al., December 22,
2020)).
    Implementing multiple mitigation strategies is even more necessary
to reduce the risk, because it will not be feasible to apply every
control in every workplace situation. Thus, the ETS employs strategies
to ensure that employees will be protected even when a particular
control is not feasible. As discussed below, OSHA concludes that this
multilayered approach to employee protection is feasible based on its
review of commonly implemented healthcare-specific good infection
control practices contained in nationally recognized infection control
practices like CDC guidelines, employer plans, best practice documents,
scenarios, and a job matrix that show these precautions are already in
place or can be readily implemented by typical firms in the healthcare
sector.
    OSHA emphasizes, finally, that although the ETS takes a
multilayered approach to employee protection, it also establishes how
and when controls must be used. For example, physical barriers are
required only where physical distancing is not feasible because, as
OSHA discusses in depth in Need for Specific Provisions (Section V of
the preamble), physical barriers work by preventing droplets from
traveling from the source (i.e., an infected person) to an employee,
and are particularly critical when physical distancing of 6 feet is not
feasible because most COVID-19 transmission occurs via respiratory
droplets that are spread from an infected individual during close
(within 6 feet) person-to-person interactions.
a. COVID-19 Plans
    Paragraph (c) of the ETS requires the employer to develop and
implement a COVID-19 plan that includes policies and procedures to
minimize the risk of transmission of COVID-19, as reflected in
paragraphs (d) through (n) in the ETS. These provisions are summarized
in Table VI.A.-2 below, and are discussed in detail in Need for
Specific Provisions and Summary and Explanation (Sections V and VIII of
the preamble, respectively).

[GRAPHIC] [TIFF OMITTED] TR21JN21.002

    OSHA conducted a search for existing COVID-19 plans and best
practices developed by employers, trade associations, and other
organizations and posted on their publicly available websites. OSHA's
search revealed 77 plans and best practice documents from companies and
trade associations in the Health Care and Social Assistance industry
sector that address COVID-19 hazards using the multilayered approach
and controls required by the ETS. To the extent individual plans are
not discussed specifically below, a breakdown with the name of the
company or organization, a description of the contents, and a link to
the plan can be found in the COVID-19 Plans by NAICS spreadsheet (ERG,
February 9, 2021).
    Based on its review of these plans, OSHA concludes that it is
feasible for employers in typical firms in the healthcare sector to
comply with the requirements in the ETS for a COVID-19 plan.\27\ Below,
OSHA highlights the elements of a few of the plans and best practice
documents it reviewed. In each case, OSHA presumes that an organization
believes that the particular approaches contained in the organization's
own documents are technologically feasible.
---------------------------------------------------------------------------

    \27\ As stated, OSHA located 77 plans in the Health Care and
Social Assistance industry sector. Some of these plans do not
address protections that are covered by the ETS (i.e., they do not
cover settings where any employee provides healthcare services or
healthcare support services). OSHA relied on these particular plans
to draw its conclusion that it is feasible for employers in typical
firms in the healthcare sector to comply with the requirements in
the ETS for a COVID-19 plan, but only to the extent they address the
implementation of controls to protect workers in job categories
commonly found in workplaces where healthcare services and
healthcare support services are provided (e.g., public facing
employees, general office workers).
---------------------------------------------------------------------------

ETS Workplace-Specific Hazard Assessments Required by Different
Healthcare Organizations
    Paragraph (c)(4)(i) of the ETS requires healthcare employers to
conduct a workplace-specific hazard assessment to identify potential
workplace hazards related to COVID-19. The workplace-specific hazard
assessment requirements are discussed in detail in Need for Specific
Provisions and Summary and Explanation (Sections V and VIII of the
preamble, respectively).
    OSHA conducted a search for existing COVID-19 plans and best
practices developed by employers, trade associations, and other
organizations and posted on their publicly available websites and found
that many required employers to conduct a workplace hazard assessment
to determine the COVID-19 exposure risks to employees. While the
specifics of the assessments may not mirror the full requirements for
OSHA's COVID-19 plans, those hazard assessments indicate and provide
additional support for OSHA's determination that it is feasible for
healthcare employers to design and implement COVID-19 plans. The best
practices also indicate that it is feasible for healthcare employers to
have policies and procedures to regularly check on the proper
implementation of

controls, which corresponds to OSHA's requirement that employers
regularly re-assess the COVID-19 plan to ensure that it is updated and
useful.
    The Santa Clara Valley Medical Center (SCVMC) is a 574-bed acute
care, fully accredited public teaching hospital affiliated with
Stanford University Medical School and provides a full range of
inpatient, emergency rehabilitation, neonatal, intensive care, high-
risk maternity care, psychiatry, pediatric intensive care, and burn
intensive care services. The ambulatory outpatient services include
both primary and specialty clinics located not only at SCVMC, but also
at satellite facilities located throughout the area (SCVMC, December 1,
2020).
    The SCVMC plans reviewed includes guidelines for COVID-19 exposure
and risk assessment, contact tracing, testing, and return to work for
their employees (SCVMC, December 1, 2020). Furthermore, the COVID-19
plan includes a policy outlining the worker exposure evaluation process
to be conducted by each department and each ambulatory care clinic that
is part of the SCVMC network. The assessment of exposure risk is
required for all individuals working in the SCVMC hospitals and clinics
including employees, volunteer, staff, physicians, contract personnel,
or other workers. The assessment required by the COVID-19 plan should
evaluate physical distancing, period or duration of exposure, as well
as the implementation of controls such as facemasks and respiratory
protection, and other PPE necessary to protect employees from COVID-19
exposure.
    OSHA also reviewed the COVID-19 plan for Michigan Medicine, one of
the largest fully accredited academic medical centers in Michigan made
up of the University of Michigan health system and medical school. The
Michigan Medicine COVID-19 plan includes specific requirements for each
department to conduct employee COVID-19 job hazard assessments to
evaluate and mitigate the risk of COVID-19 for University of Michigan
workers (Michigan Medicine U-M, May 18, 2021).
    The U-M COVID-19 plan also requires each department to create a
departmental specific COVID-19 work plan for its area to document their
COVID-19 employee job hazard assessment and plan. The plan also
provides departments with resources to develop and implement the
required COVID-19 employee job hazard assessment as well as a
departmental COVID-19 work plan including blank templates for both. The
hazard assessment and subsequent plan required by each department must
evaluate and address for each employee, the ability to maintain
physical distance from all other persons, employee requirements for
facemasks, respiratory protection, and other PPE, hand hygiene and
respiratory etiquette, workplace cleaning and disinfection within the
department or unit. The requirements of the job hazard assessment cover
employees, vendors, contractors, and all other workers performing task
in the department.
    Additionally, OSHA reviewed the COVID-19 plan of Johns Hopkins
Medicine, which is made up of the Johns Hopkins University Health
System with six academic and community hospitals, four suburban health
care and surgery centers, over 40 patient care locations, and a home
care group that offers an array of health care services. The Johns
Hopkins Medicine COVID-19 plan includes requirements that assess the
COVID-19 transmission hazards in the workplace to determine the proper
implementation of controls (Johns Hopkins Medicine, 2021). The plan
also includes policies and procedures to implement a daily COVID-19
safety audit program. Each day, the COVID-19 safety auditor ensures
every hospital, outpatient clinic and care center is practicing proper
masking, physical distancing, handwashing and disinfection of
frequently touched surfaces. As with the SCVMC example, this supports
the feasibility of regular reassessments that employers will need to
conduct for their COVID-19 plans.
    Based on its review of these plans, OSHA concludes that it is
feasible for employers in typical firms in the healthcare sector to
comply with the requirements in the ETS for a COVID-19 workplace-
specific hazard assessment.
ETS Controls Are Included in Best Practices Recommended by Healthcare
Professional Associations
    Some of OSHA's evidence that the COVID-19 plan, distancing,
barriers, and ventilation modifications are feasible for healthcare
employers is that such measures, or substantially similar measures, are
already recommended by some of the largest professional associations in
the healthcare industry.
    The American Society for Health Care Engineering (ASHE) is the
largest professional membership group of the American Hospital
Association. The ASHE is comprised of over 12,000 professionals who
design, build, maintain, and operate healthcare facilities. ASHE
members include health care facility managers, control specialists, and
others. ASHE has developed best practices for minimizing the risk from
COVID-19. These best practices can be, and have been, used by ASHE
members' organizations to develop their individual plans. (ASHE,
December 23, 2020)
    The ASHE best practices are a collection of strategies which can be
implemented to reduce the spread of COVID-19. The ASHE best practices
recommend a multilayered control strategy. ASHE states that healthcare
organizations are working to maintain physical distance of at least six
feet and one way that this has been achieved is by scheduling check-in
times to limit occupancy as well as other controls such as floor
markings. When physical distancing is not feasible, employers have
installed physical barriers, such as clear, acrylic plexiglass or
vinyl, along with requiring face masks. ASHE also states that
healthcare organizations have taken a combination of approaches for
cleaning and disinfection, such as cleaning workstations including
high-touch surfaces daily. ASHE also discusses health screening and
medical management. According to ASHE, some healthcare organizations
have implemented self-screening policies and procedures, including, for
example, having employees certify that they have not displayed symptoms
or been in recent contact with someone that has tested positive for
COVID-19. Finally, the ASHE best practices recommend ensuring that
ventilation systems are working properly, including ensuring that all
negative pressure spaces including AIIRs are properly maintained, and
that the circulation of outdoor air is increased as much as possible.
The ASHE best practices also provide employers with steps to verify
that CDC recommended guidelines for air changes and time required for
contaminate removal based on air changes are followed.
    The American Health Care Association and the National Center for
Assisted Living (AHCA/NCAL), an association representing long term and
post-acute care providers, with more than 14,000 member facilities
including non-profit and proprietary skilled nursing centers, assisted
living communities, sub-acute centers and homes for individuals with
intellectual and development disabilities, has also developed best
practices for minimizing the risk from COVID-19 (AHCA/NCAL, 2021).
Similar to the ASHE best practices and other plans and best practice
documents that were reviewed, the AHCA/NCAL best practices contain many
of the controls that are required

by the ETS. Also similar to the ASHE and other best practice documents,
the AHCA/NCAL membership can use the AHCA/NCAL best practices to
develop their individual plans. For example, the AHCE/NCAL best
practices recommend implementing controls to maintain physical distance
including rearranging offices and workstations as needed, posting signs
and floor markers, and limiting the number of individuals permitted in
the workplace. In addition, the AHCA/NCAL best practices recommend the
use of facemasks and increased cleaning and disinfection. The best
practices also contain recommendations on health screening and medical
management. Members have implemented recommendations on self-
questionnaire policies and procedures for employees and all other
individuals before they can enter the site, including, for example,
recommendations on having employees certify that they have not
displayed symptoms or been in recent contact with someone that has
tested positive for COVID-19. The AHCE/NCAL best practices also contain
recommendations on conducting contact tracing while protecting the
employee's identity, and engaging in facility-wide protocols to protect
other employees.
    The New Mexico EMT Association (NMEMTA) is a professional
organization supporting emergency medical technicians and others
serving the public in the emergency services sector (NMEMTA, March 29,
2020). Similar to other best practice documents that were reviewed, the
NMEMTA best practices contain many of the controls that are required by
the ETS and recommend a multilayered approach to infection control.
Furthermore, NMEMTA members can use this guidance to develop their
individual plans. The NMEMTA best practices recommend implementing
physical distancing controls when responding to an emergency as well as
when transporting patients. For example, NMEMTA provides guidance on
limiting the number of responders by implementing policies for
coordinating with dispatchers prior to initial assessment, and
additional work practices such as using radio communications to
minimize the number of responders on scene. Additionally, the NMEMTA
best practices recommend policies and procedures to limit the number of
EMS workers in the ambulance and provide guidance on installing
physical barriers to separate the driver from the treatment area of the
ambulance. The NMEMTA best practices also recommend policies for
requiring the proper PPE and respiratory protection for EMS employees
as well as for placing facemasks on patients and family members
traveling in the ambulance.
    The National Association for Home Care & Hospice (NAHC) is a
nonprofit organization that represents the nation's 33,000 home care
and hospice organizations. NAHC also advocates for the more than two
million nurses, therapists, aides, and other caregivers employed by
such organizations to provide in-home services to some 12 million
Americans each year who are infirm, chronically ill, or disabled (NAHC,
March 3, 2020). NAHC developed best practices for home health and
hospice employers. The NAHC best practices recommend a multilayered
infection control plan to protect employees from COVID-19. These best
practices include strategies for maintaining physical distance,
including ways to limit instances where caregivers are within 6 feet of
other persons. For example, the NAHC best practices contain policies
for requiring household members to stay in separate rooms of the home
as much as possible and to maintain at least 6 feet of distance from
the caregiver when they must be in the same room. In addition, the best
practices recommend procedures to ensure the home space has good air
flow via an HVAC system or by opening windows and doors during the
visit. The best practices also provide guidance on implementing
protocols for performing hand hygiene and cleaning and disinfection of
the workspace, tools, equipment and other high touch surfaces. The best
practices also recommend requirements for the use of facemasks,
respirators, and other PPE for home health and hospice caregivers,
patients, and members of the household during the home visit.
Additionally, the best practices provide strategies for the
implementation of patient telehealth, as well as self-screening before
visits to prevent employee exposure to known or suspected COVID-19
patients without taking appropriate precautions (e.g., PPE and
respirators).
Examples of Existing Healthcare Employer Plans and Controls
    OSHA also reviewed a number of existing plans prepared by hospitals
and other healthcare providers that also illustrate that employers in
the healthcare sector have implemented a multilayered approach to
protect their workers from COVID-19. MedStar Health, a not-for-profit
community health system comprised of physician offices, urgent care
centers, regional ambulatory care centers, and 10 community hospitals,
has developed and implemented a COVID-19 plan (MedStar, May 5, 2021).
The plan adopts a multilayered approach to protect workers from COVID-
19 across MedStar's facilities and contains many of the provisions also
required by the ETS. For example, MedStar requires controls to ensure
physical distancing, including, for example, restricting the entry of
visitors and non-essential employees to reduce occupancy. Additionally,
MedStar requires the use of facemasks by employees, patients, and
visitors. MedStar also requires employees to self-screen and monitor
for signs and symptoms of COVID-19 and for visitors to utilize the
telephone triage system when scheduling visits to isolate known or
suspected cases of COVID-19 infection. Finally, MedStar requires
cleaning and disinfection of the workplace daily, as well as hand
hygiene protocols before, during, and after all appointments and
procedures.
    Other employer plans reviewed also adopt a multilayered approach to
COVID-19 protection (see, e.g., Cambridge Health Alliance, 2021; Johns
Hopkins Medicine, 2021; HCA Healthcare, 2021; Dignity Healthcare,
2021). With respect to physical distancing, employer plans include
strategies to reduce and restrict occupancy at facilities. For example,
employers have implemented staggered shifts for employees, as well as
teleworking arrangements, to help reduce occupancy and ensure physical
distancing. Employers have also expanded remote telemedicine
consultations so fewer patients with non-emergency conditions need to
visit hospitals and other facilities where patient care occurs to
receive medical care. In this respect, where video conferencing systems
cannot be used, employers have used other virtual options, such as
online secured patient portals with chat and messaging features, to
reduce the occupancy of healthcare facilities. Employers have also
implemented telephone triage systems, and, in this way, patients
identified as low risk for COVID-19 can be cared for virtually, if
appropriate, while patients identified as higher risk for COVID-19 can
be routed to the appropriate care. In addition, employers have reduced
or completely eliminated patient visiting hours for those patients with
suspected or confirmed COVID-19. Finally, employers have installed
floor markings as visual cues to stay six feet apart throughout the
facility, including common areas such as waiting rooms and cafeterias,
spaced public seating six

feet apart, and limited the number of people in a space, whenever
possible.
    The employer plans cited above also include policies and procedures
for the installation of physical barriers to protect workers outside of
direct patient care areas when physical distancing may not be possible
at all times. For example, some hospitals have installed physical
barriers at checkpoints, to protect security guards, as well as at
reception desks and patient/visitor information counters, to protect
the employees working there, from exposure to visitors, patients, and
co-workers.
    The employer plans reviewed also include policies and procedures
for the use of facemasks. Moreover, the plans include policies on
increased cleaning and disinfection. For example, the plans include
requirements that surfaces and equipment are thoroughly cleaned and
disinfected daily using products that are effective against COVID-19.
The plans also include policies on maintaining HVAC systems and using
system filters with a MERV rating of 13 or higher, as well as polices
for pre-screening patients and employees for COVID-19 (including
requirements for self-questionnaires designed to identify anyone who
has or is suspected to have COVID-19 before their arrival at the
facility).
    OSHA has determined that developing a COVID-19 plan, as required by
the ETS, is feasible based on the evidence that employers in the health
care sector have developed plans that address many of the requirements
of the ETS. Additionally, national trade associations and other
organizations in the health care sector have developed best practices
to aid in the development of these plans (ERG, February 9, 2021). As
discussed in the Summary and Explanation (section [VIII]), the plan
must address the hazards identified per the hazard assessment required
by paragraph (c)(4) of the ETS and the employer must do regular
inspections to ensure ongoing effectiveness of the plan and update as
needed.
b. Implementation of Good Infection Control Practices
    The ETS contains four provisions for good infection control
practices, each of which is discussed in detail in Need for Specific
Provisions and Summary and Explanation (Sections V and VIII of the
preamble, respectively):
    Sec.  1910.502(d)--Patient screening and management. The purpose of
this provision is to limit contact with potentially infectious persons
by, for example, requiring screening and triage of everyone entering a
healthcare setting and limiting and monitoring points of entry to the
setting.
    Sec.  1910.502(e)--Standard and transmission-based precautions. The
ETS requires that, in settings where healthcare services, healthcare
support services, are provided, the employer must develop and implement
policies and procedures to adhere to Standard and Transmission-Based
Precautions. Standard and Transmission-Based Precautions are
established and commonly used practices for reducing the risk of
transmission of infectious agents such as COVID-19.
    Sec.  1910.502(f)--Personal protective equipment (PPE). The ETS
requires employers to provide and ensure employees use facemasks or
respirators in specified situations, and also requires the use of other
PPE, such as gloves and eye protection, in appropriate circumstances.
    Sec.  1910.502(g)--Aerosol-generating procedures on a person with
suspected or confirmed COVID-19. Because aerosol-generating procedures
are known to be high risk activities for exposure to respiratory
infections such as COVID-19, the ETS contains special requirements to
address this hazard. For example, the employer must limit the number of
employees present during the procedure to only those essential for
patient care and procedure support.
    Some of these controls are obviously feasible simply because of the
nature of the control. The process of screening, for example, can
typically be accomplished simply through questioning, so there are no
technological feasibility barriers to implementing those controls. To
support its assessment of the technological feasibility of other
controls in the ETS, OSHA reviewed evidence that shows that the
healthcare-specific good infection control practices identified in
Sec.  1910.502(d) through (g) are commonly implemented by employers who
have employees in healthcare settings. This evidence includes: CDC
infection control guidance documents, many of which are COVID-19
specific; regulations issued by the Centers for Medicare & Medicaid
Services (CMS); and accreditation of these settings by The Joint
Commission; and OSHA's Bloodborne Pathogens (BBP) Standard, 29 CFR
1910.1030. For example, Sec.  1910.502(e) requires compliance with the
CDC's Standard and Transmission-Based Precautions. As detailed below,
OSHA can show that this is technologically feasible by demonstrating
that at least some hospitals and other healthcare settings follow these
precautions (thereby showing it is capable of being done and can be
implemented in other healthcare settings).
    To demonstrate that, OSHA points to two reasons why healthcare
employers comply with these precautions. First, OSHA's BBP standard
already requires hospitals and other healthcare facilities to implement
a parallel framework, often with similar systems and controls, to
comply with many of the same precautions. Even where the requirements
for some controls must be implemented somewhat differently under this
ETS than under the BBP standard, OSHA is not aware of technological
feasibility challenges that arise from these differences. For example,
a hospital's COVID-19 plan will be different from its BBP Exposure
Plan, but the planning process will already be familiar to the hospital
and there should be enough similarities in the construction of plans
identifying and addressing hazards that there will not be any
feasibility issues with formulating the COVID-19 plan.
    Second, healthcare employers must have an infection control program
that includes Standard and Transmission-Based Precautions to be
eligible for certain government funds (CMS distribution of Medicare and
Medicaid funds) or accreditation (The Joint Commission). CMS
regulations only cover providers that accept or collect payments from
Medicare or Medicaid. Compliance with the CMS regulations is generally
validated through periodic accreditation surveys of facilities by CMS-
approved accreditation organizations, including The Joint Commission,
state survey agencies, and other accrediting organizations (e.g.,
Accreditation Association for Ambulatory Health Care (AAAHC)). CMS and
The Joint Commission reliance on largely the same criteria as this ETS
means that the technological feasibility of the ETS is supported by
those hospitals and other healthcare settings who do have to comply by
proving that the requirements are capable of being done.\28\
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    \28\ OSHA notes that its assessment in this section addresses
only whether the ETS is technologically feasible. The fact that many
health care facilities have already implemented some version of the
controls required by the ETS does not mean that there is no need for
the ETS to apply to healthcare. Again, CMS regulations only cover
providers that accept or collect payments from Medicare or Medicaid.
In addition, OSHA has in place enforcement mechanisms that CMS does
not have and that would work in concert with CMS to achieve a
greater level of compliance. For example, OSHA can respond to
complaints, conduct random unannounced inspections, and conduct
worksite inspections in response to complaints filed by workers. As
described elsewhere in this preamble, the ETS is necessary to
address the grave danger posed by COVID-19. See Rationale for the
ETS, Grave Danger and Need for the ETS (Section IV of the preamble).

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CDC Infection Control Guidance Documents
    The CDC has issued infection control guidance, listed in Table
VI.A.-3, that apply to the following settings and industry groups:
Hospitals and ambulatory care, plasma and blood collection facilities
and dialysis facilities, home health care, emergency responders and
prehospital care, autopsies, long-term care, and dental and oral care.
These guidelines provide infection-control recommendations for use in
the settings covered by the ETS (listed in Table VI.A.-3). The guidance
provides recommendations for implementing policies and practices to
minimize the risk of exposure to respiratory pathogens, and many are
recently issued guidelines specific to COVID-19.
BILLING CODE 4510-26-P
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BILLING CODE 4510-26-C
    The CDC guidelines in Table VI.A.-3 are commonly implemented,
longstanding, and essential elements of infection control in healthcare
settings (i.e., the settings listed in Table VI.A.-1), evidenced by the
CDC's 2007 Guideline for Isolation Precautions: Preventing Transmission
of Infectious Agents in Healthcare Settings (Item 8 in Table VI.A.-3,
above), which incorporates Standard and Transmission-Based Precautions
into its recommendations. This 2007 Guideline updated 1996 guidelines,
which introduced the concept of Standard Precautions, and also noted
the existence of infection control recommendations dating back to 1970.
    The implementation of the CDC guidelines is also evidenced by
regulations issued by the Centers for Medicare & Medicaid Services
(CMS) that apply to settings in Table VI.A.-1 and the accreditation of
settings in Table VI.A.-1 by The Joint Commission, as described below.
    OSHA notes that guidelines that are grouped with one setting in
Table VI.A.-1 may apply to other settings as well. For example, the
Interim Infection Prevention and Control Recommendations for Healthcare
Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (Item
1 in Table VI.A.-3) applies to Emergency Medical Personnel, Home Health
Care, and Long-Term Care, in addition to applying to Hospitals and
Ambulatory Care.\29\
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    \29\ The guidance is applicable to all U.S. settings where
healthcare is delivered, and defines ``healthcare setting'' as
places where healthcare is delivered. According to the guidance,
this includes acute care facilities, long-term acute care
facilities, inpatient rehabilitation facilities, nursing homes and
assisted living facilities, home healthcare, vehicles where
healthcare is delivered (e.g., mobile clinics), and outpatient
facilities, such as dialysis centers, physician offices, and
others.'' Moreover, the guidance defines ``healthcare personnel,''
or HCP, as all paid and unpaid persons serving in healthcare
settings who have the potential for direct or indirect exposure to
patients or infectious materials, including body substances (e.g.,
blood, tissue, and specific body fluids); contaminated medical
supplies, devices, and equipment; contaminated environmental
surfaces; or contaminated air. According to the guidance, HCP
include emergency medical service personnel, nurses, nursing
assistants, home healthcare personnel, physicians, technicians,
therapists, phlebotomists, pharmacists, students and trainees,
contractual staff not employed by the healthcare facility, and
persons not directly involved in patient care, but who could be
exposed to infectious agents that can be transmitted in the
healthcare setting (e.g., clerical, dietary, environmental services,
laundry, security, engineering and facilities management,
administrative, billing, and volunteer personnel).

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CMS Regulations That Condition Participation in Medicare and Medicaid
on Implementation of Nationally Recognized Infection Control Guidelines
    The Centers for Medicare & Medicaid Services (CMS) administers
healthcare programs for the elderly (Medicare) and needs-based state
programs that help with medical costs (Medicaid). As a condition for
participation in Medicare or Medicaid, medical providers must comply
with regulations issued by the Department of Health and Human Services
(DHHS), 42 CFR Pts. 400-699. A number of these regulations, which apply
to a broad spectrum of the settings listed in Table VI.A.-1, condition
participation in Medicare and Medicaid on the implementation of
nationally recognized infection control practices like the CDC
guidelines listed in Table VI.A.-3. The applicable CMS regulations are
summarized in Table VI.A.-4.
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BILLING CODE 4510-26-C
Accreditation by The Joint Commission
    Founded in 1951, The Joint Commission is an independent, not-for-
profit organization that accredits and certifies more than 22,000
healthcare organizations and programs in the United States (The Joint
Commission, 2021a). Joint Commission accreditation and certification is
recognized nationwide as a symbol of quality that reflects an
organization's commitment to meeting certain performance standards.
Joint Commission standards are the basis of an objective evaluation
process that can help healthcare organizations measure, assess and
improve performance. The standards focus on important patient,
individual, or resident care and organization functions that are
essential to providing safe, high-quality care (The Joint Commission,
2021b). To maintain accreditation, organizations undergo an on-site
survey by a Joint Commission survey team at least every three years
(laboratories are surveyed every two years). In these surveys, The
Joint Commission monitors compliance with its standards for the
implementation of good infection control and biosafety practices
(including, for example, adherence to Standard and Transmission-Based
Precautions, as recommended by the CDC Guidelines in Table VI.A.-3)
(The Joint Commission, 2021c). The Joint Commission offers
accreditation for the following settings (many of which are contained
in Table VI.A.-1) (The Joint Commission, 2021c):
     Ambulatory care facilities;
     Critical access hospitals;
     Behavioral health care;
     Hospitals;
     Home care services;
     Nursing care centers; and
     Office-based surgery centers.
OSHA's Bloodborne Pathogens Standard, 29 CFR 1910.1030
    Employers subject to the ETS have also been subject to requirements
in the Bloodborne Pathogens (BBP) standard for 30 years, since it was
promulgated in 1991. As the BBP standard was promulgated, OSHA found
``with

respect to the technological feasibility of the standard that its
provisions permit practical means to reduce the risk now faced by those
employees working with blood and other infectious materials and that
there do not appear to be any major obstacles to implementing the
rule.'' (56 FR 64004, 64039 (Dec. 6, 1991)). OSHA's finding of
technological feasibility during the BBP standard rulemaking is
additional evidence that there are no technological feasibility
barriers to complying with the ETS.
    For example, Standard Precautions, which are required by the ETS,
are similar to, but more extensive than, ``Universal Precautions'',
which are required by the BBP standard to prevent contact with blood or
other potentially infectious materials (see definitions in the BBP
standard). The BBP standard defines ``Universal Precautions'' as an
approach to infection control wherein all human blood and certain human
body fluids are treated as if known to be infectious for HIV, HBV, and
other bloodborne pathogens. Standard Precautions were developed to
integrate principles of Universal Precautions into broader principles
pertaining to routes of exposure other than the bloodborne route, such
as via the contact, droplet, or airborne routes. For example, although
the BBP standard might not apply, Standard Precautions would be
utilized when workers are exposed to urine, feces, nasal secretions,
sputum, vomit, and other body fluids, and also when workers are exposed
to mucous membranes and non-intact skin. Using Standard Precautions
when there is exposure to these materials, it should be assumed that
the materials potentially contain infectious agents that could be
transmitted via the contact, droplet, or airborne routes. Standard
Precautions not only include the infection control methods specified as
Universal Precautions (e.g., hand hygiene, the use of certain types of
PPE based on anticipated exposure, safe injection practices, and safe
management of contaminated equipment and other items in the patient
environment), but also include, for example, respiratory and cough
etiquette. The respiratory and cough etiquette and other additional
controls for Standard Precautions are minor expansions on the Universal
Precautions already applicable to most healthcare facilities, and OSHA
is not aware of any technological barriers for employers subject to the
ETS.
    In addition to the above requirements, the BBP standard contains
requirements for an exposure control plan, engineering and work
practice controls, hand hygiene, personal protective equipment,
housekeeping (e.g., cleaning and decontamination), and vaccination,
which all have corollaries in the ETS. While there are differences
between the BBP standard and the ETS, there is overlap. For example,
although the requirements for a COVID-19 plan in the ETS are different
than those for the exposure control plan required by the BBP standard,
the process for developing and implementing these plans should be
similar. Based on this overlap, there should not be any technological
feasibility barriers to complying with the corollary provisions in the
ETS.
c. Physical Distancing and Physical Barriers
    Physical Distancing: The ETS (paragraph (h)) requires the employer
to ensure that each employee is separated from all other people by at
least 6 feet unless the employer can demonstrate that such physical
distancing is not feasible for a specific activity, and that, when the
employer establishes it is not feasible for an employee to maintain a
distance of at least 6 feet from all other people, the employer must
ensure that the employee is as far apart from all other people as
feasible.
    Physical Barriers: The ETS (paragraph (i)) requires that at each
fixed work location outside of direct patient care areas where an
employee is not separated from all other people by at least 6 feet of
distance, the employer must install cleanable or disposable solid
barriers, except where the employer can demonstrate it is not feasible
(or the paragraph (a)(4) exception for vaccinated employees applies).
    As discussed above, OSHA reviewed a number of plans and best
practice documents developed and employed by the healthcare sector to
reduce the risk of COVID-19 exposure. These plans included
recommendations and requirements for the implementation of physical
distancing and physical barriers in the settings covered by the ETS.
These plans and best practice documents provide strong evidence that it
is technologically feasible to implement these controls in the
healthcare sector. Moreover, OSHA developed physical distancing
scenarios and a job matrix spreadsheet, discussed below, which also
provide strong evidence that the implementation of physical distancing
and physical barriers is technologically feasible in the healthcare
sector.
Physical Distancing Scenarios
    OSHA developed ``physical distancing'' scenarios for a variety of
workplaces covering a wide range of situations to describe the controls
that have been put in place to maintain not only physical distancing
but also 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), as well as other
controls required by the ETS as part of a multilayered strategy to
reduce or eliminate the transmission of SARS-CoV-2. As OSHA discusses
in more depth below, these scenarios are based primarily on COVID-19
plans developed by employers.
    OSHA uses these scenarios (and by extension the plans on which they
are based) to support its feasibility determination regarding the
physical distancing and physical barrier requirements of the ETS, and
also to show that other controls required by the ETS are being, or can
be implemented, by typical employers across affected workplaces.
    OSHA also uses these scenarios to explore ways to mitigate the
remaining risk of exposure when it is infeasible to comply with the
requirements for physical distancing. While this portion of the
analysis falls outside the pure examination of the technological
feasibility of the required controls, it is intended to demonstrate the
steps that employers are expected to take to reduce exposure risk. Some
of the plans that OSHA consulted in developing these scenarios include
examples of controls that would not meet the requirements of the ETS,
but OSHA has attempted to incorporate some of these examples into the
scenarios while noting that some of the controls may only be used when
the other controls are infeasible.
    Thus, for example, some scenarios describe the use of both physical
distancing and physical barriers by employers. OSHA's description of
the scenarios below should not be read to mean that OSHA sanctions the
use of physical barriers in lieu of physical distancing, when physical
distancing is feasible. For an in-depth discussion on the rationale
underlying OSHA's rulemaking decisions, please see Need for Specific
Provisions (Section V of the preamble).
    As another example, some scenarios describe facemasks, ventilation,
and other controls required by the ETS as additional controls when
physical distancing is not feasible. But these controls are not
alternatives to physical distancing under the ETS. Again, physical
distancing (or physical barriers at fixed workstations outside of
direct patient care areas, when physical distancing is not feasible)
must be

implemented alongside these controls under the ETS as part of a
multilayered approach to infection control.
    Finally, OSHA emphasizes that physical distancing is feasible for
the vast majority of situations employers may face in their daily job
duties. There are a select number of situations where physical
distancing is not feasible, and for these situations, employers must
implement physical barriers if feasible at fixed work locations outside
of direct patient care areas. And, again, employers must implement the
other controls as required by the standard (e.g., facemasks, and
respirators, cleaning and disinfection, health screening and medical
management, employee notification).
    In reviewing the record, OSHA found that, while exposure to COVID-
19 can occur from contact with co-workers or the public as part of
healthcare workers' job duties in a wide range of workplaces covered by
the ETS, many of the processes and controls used to minimize risk are
the same or similar.
    The physical distancing scenarios OSHA's contractor--a safety and
health subject matter expert--developed include examples of policies
and procedures implemented to maintain physical distancing, physical
barriers, and other controls based on a review of guidance and existing
pandemic plans and other sources. This information was supplemented
where needed with additional internet searches, for instance, from news
articles, industry surveys, or articles in industry publications that
demonstrate how companies in different industries have been
implementing physical distancing. The contractor also relied on its
professional expert judgment (ERG, February 25, 2021). The scenarios
identify groups of workers who face similar work situations with regard
to physical proximity (within 6 feet) of another person (e.g.,
visitors, members of the public), and for whom the same or similar
precautions to limit physical proximity can be implemented. In this
respect, some of the evidence on which OSHA relies in this assessment
(with respect to the offices, law enforcement, security guards, and
protective services, home healthcare, personal care, and companion
service providers, and postmortem services scenarios) rely on plans and
best practices from both industries affected by this ETS and other
industries not affected by the ETS. In analyzing the evidence of
physical distancing and barriers across multiple industry sectors, OSHA
observed that the feasible methods of implementing physical distancing
and physical barriers for employees with similar exposures was similar
regardless of industry (for example, employing physical distancing and
barriers to protect administrative and clerical staff, receptionists,
those who are exposed to human remains, and those who enter personal
residences to provide care). To this end, OSHA's assessment of the
feasibility of implementing physical distancing and physical barriers
in the healthcare section is based on evidence from other industries to
the extent that workers share similar job roles and perform similar job
tasks such that the feasibility of distancing and barriers would be the
same in either case.
    OSHA also developed a job matrix spreadsheet to identify groups of
workers facing similar work situations. To develop this spreadsheet,
OSHA first found and reviewed 418 plans from employers representing
various separate 3-digit North Industry Classification System (NAICS)
codes, and 286 best practice documents from trade associations and
other organizations covering 46 3-digit NAICS codes (ERG, February 9,
2021). As part of the review, OSHA included plans and best practices
from industries outside of healthcare to clearly demonstrate the
feasibility of implementing a multilayered approach to COVID-19
infection control (including facemasks and the installation of physical
barriers where distancing is not feasible) for similar work situations.
    Next, OSHA identified unique job categories across the industry
sectors with many categories present across multiple NAICS codes. These
job categories were cross-referenced with the scenarios to develop the
job matrix spreadsheet (February 25, 2021). This job matrix spreadsheet
was used to identify job categories facing similar situations regarding
the ability to maintain physical distance with coworkers and/or members
of the public. OSHA expects that, for these situations, employers can
implement the same or similar precautions, for not only limiting
physical proximity, but also for the other multilayered controls
required by the ETS. Workers with public-facing job duties, such as
receptionists and security guards, share many of the same or similar
exposure control challenges, and employers of these job categories over
a wide variety of industry sectors have implemented similar
multilayered controls such as physical distancing, the installation of
barriers, requirements for face masks, and hand hygiene, among others,
as discussed below (February 25, 2021). OSHA concludes, based on the
job matrix that evidence of feasibility for one scenario also
establishes feasibility for other scenarios to the extent job
categories cut across scenarios.
    The scenarios OSHA developed for the healthcare sector are listed
in Table VI.A.-5.

[GRAPHIC] [TIFF OMITTED] TR21JN21.008

    Below, OSHA highlights some of the elements of these scenarios and
portions of the job matrix on which it relied. In the discussion below,
OSHA will first describe some of the types of jobs workers conduct in
most workplaces in the scenarios discussed (or across scenarios to the
extent this is supported by the job matrix), and identify some of the
unique work processes that are already conducted in a physically
distanced manner or that can be easily modified to avoid or reduce
physical proximity for each scenario discussed (or, as applicable,
across scenarios). OSHA then describes some of the discrete activities
where physical contact with others (i.e., the public or other workers)
may be necessary or unavoidable, along with the precautions and
controls that can still feasibly be implemented for the scenarios (or,
as applicable, across scenarios) as part of a multilayered approach to
protection, such as facemasks, ventilation, and the use of physical
barriers.
    In this respect, OSHA's analysis found employers have implemented
physical barriers at fixed work locations outside of direct patient
care areas (e.g., entryway/lobby, check-in desks, triage, hospital
pharmacy windows, bill payment). Physical barriers are required as part
of the multi-layered approach to infection control that is at the heart
of the ETS. As discussed more fully in the Need for Specific Provisions
(Section V of the preamble), physical barriers, when properly
installed, are effective at intercepting respiratory droplets and
minimizing the risk of exposure to COVID-19, especially in areas where
employees cannot maintain a minimum of 6 feet of distance from
coworkers, customers, and members of the general public.
    The ETS does not specify the type of material that must be used for
physical barriers, but the material must be impermeable to infectious
droplets that are transmitted when an infected individual is sneezing,
coughing, breathing, talking, or yelling. In addition, physical
barriers must be made from materials that can be easily cleaned and
disinfected unless in lieu of cleaning the employer may opt to replace
the barrier. Using replaceable materials would allow an employer to
dispose of and replace barriers between uses, instead of cleaning and
disinfecting more permanent barriers. The effective design and
implementation of physical barriers will differ among workplaces based
on job tasks, work processes, and even potential users. Physical
barriers must be designed, constructed, and installed to prevent
droplets from reaching employees when they are in their normal sitting
or standing location relative to the workstation. For example, under
the provision, plastic sheeting can qualify as a physical barrier only
in situations where it is fixed in place and blocks face-to-face
pathways of air between the users on either side while those workers
are performing all of their assigned tasks.
    Examples of physical barriers across a variety of workplaces are
discussed in the scenarios below. Further considerations for the design
and implementation of physical barriers to properly block face-to-face
pathways of breathing zones, including whether plastic sheeting, films,
curtains, and other non-rigid materials are acceptable materials, as
well as installation, are discussed in the summary and explanation of
Physical Barriers.
    Employers subject to the ETS share a common challenge: Finding ways
to limit physical proximity (of less than 6 feet) between each worker
and other workers, as well as visitors and other non-employees in the
workplace. In the limited situations where physical distancing is not
feasible, employers often face similar challenges and employ similar
solutions in designing and installing physical barriers to help protect
their employees, even though the types of products or services they
offer or the work they do vary. For example, employers often install
physical barriers with a pass-through space at the bottom.
    A barrier is thus an effective tool in helping to protect a
security guard at a check point at a hospital's entrance, a
receptionist in the billing department, and any other public-facing
employee. Physical barriers have also been installed to shield
healthcare workers and others from individuals with suspected or
confirmed COVID-19 (for example in triage areas of an emergency
department). Employers have also installed barriers between urinals and
sinks in restrooms both as separations between persons using the
facility and as a splash guard (ERG, February 9, 2021; ERG, February
25, 2021).
    As the assessment below makes clear, OSHA has found no feasibility
issues with the implementation of physical distancing or physical
barriers in typical operations in the healthcare sector.
General Office Settings
    General office settings are common across a number of industry
sectors, and many healthcare facilities have areas

with administrative offices similar to general office settings. OSHA
developed a physical distance scenario for offices by identifying
industry sectors where office worksites are common. OSHA found that
employers have successfully implemented a variety of physical
distancing measures (measures to keep people 6 feet apart) by
incorporating administrative and engineering controls for the various
job categories that work in offices such as supervisors and managerial
staff, administrative and clerical staff, and receptionists.
    Administrative and clerical workers are a common job category
within office worksites across a wide variety of industries. In
addition to the offices scenario, administrative and clerical workers
were identified in a number of other physical distancing scenarios
including: Law enforcement, security guards, and protective services;
postmortem care; and long-term care (although OSHA believes
administrative and clerical workers likely work within most scenarios,
given that administrative and clerical work is usually necessary
regardless of industry sector).
    A number of strategies for maintaining physical distancing as part
of a multilayered approach have been implemented for administrative and
clerical staff, including establishing remote work, altering the work
environment to limit the number of chairs and workstations, relocating
workers to locations that ensure proper physical distancing, and
arranging visitor seating areas to be at least 6 feet away from
employees' desks. Employers can also adopt telehealth services to
completely isolate clerical and administrative staff from the patients,
clients, and other people they might otherwise be interacting with in
person. Meetings can be conducted virtually, or conference tables and
chairs can be relocated to areas of the office where physical
distancing can be ensured. Employers may also establish occupancy
limits for certain rooms (e.g., bathrooms, breakrooms, elevators,
lunchrooms, and changing areas), stagger breaks to limit the number of
workers on break at the same time, and use signs and markings to
communicate occupancy limits and to remind workers to keep 6 feet
apart. Shared equipment, such as copiers or printers, can also be
located more than 6 feet apart so that different employees can use that
equipment at the same time without having to be close to each other.
    OSHA notes that many supervisors and managers (e.g., hospital
administrators) have many of the same types of exposures as
administrative and clerical staff. They commonly work in communal
office areas, engage in collaborative group work, and hold office
meetings in conference rooms. Moreover, as supervisors and managers,
they implement the physical distancing strategies described above for
the facilities where they work, and not just to apply to administrative
and clerical staff.
    While receptionists are a common job category within office
worksites, they are also employed in a variety of industry sectors.
Receptionists are public-facing employees and their jobs include tasks
which routinely put them in contact with the public, such as greeting
and directing patients and families appropriately, responding to
inquiries, coordinating with first responders or law enforcement,
working with patients to process medical billing and paperwork, and
maintaining security and telecommunications systems.
    OSHA identified a number of physical distancing strategies that
have been commonly used to increase physical distancing for
receptionists. When telework is not possible, employers have eliminated
reception seating areas, closed lobbies, and required patients and
visitors to phone or text ahead for entry into the workplace. In
addition, signs and floor marks indicating 6-foot spaces where lines
can form in reception areas have been found to help maintain physical
distance between visitors and receptionists. When limiting access to
reception areas is difficult, employers have reduced occupancy by only
allowing seating at every other chair in waiting areas. Touchless or
remote payment and scheduling options have been successfully used to
limit face-to-face interactions with customer clients.
    As discussed above there are many options of potential controls to
provide physical distancing for supervisors and managers,
receptionists, administrative and clerical workers, and other office
workers who work in office settings. However, there may be limited
instances where employees might be unable to physically distance all of
the time. As part of a multilayered approach to transmission control,
physical barriers have been installed in office settings across all
industry sectors. For example, workers in office settings (e.g.,
medical billing and financial service, transcription, and medical
records departments) often spend the majority of the day at their desks
or other fixed workstations. For these situations, employers have
installed plexiglass barriers or partitions between workstations and
between public-facing staff and patients, families, customers, clients,
and other non-employees. At public facing workstations, physical
barriers with small openings have been installed to enable the passing
of paperwork and payment machines, for example. Under the ETS, when it
is not feasible for employees to be properly distanced from each other,
barriers must also be installed between the employees.
Law Enforcement, Security Guards, and Protective Services
    A physical distance scenario developed particularly for law
enforcement, security guards, and protective services identified a
number of industry sectors where job categories within the scenario are
common. OSHA found that employers of security guards have successfully
implemented a variety of physical distancing controls to maintain 6
feet of physical distance from other people.
    Common physical distancing controls for security guards include
staggering work shifts and limiting or ending in-person meetings. The
use of walk-through metal detectors instead of hand-held wands and
electronic mobile credentials to avoid the need for security officers
to physically check individuals have also been implemented (if wands
are used, the person being wanded should face away from the security
guard). Electronic mobile credentials can also be centrally managed
from a remote location, limiting the need for personnel to visit
badging offices. Employers have utilized signs, floor markings, and
ropes to mark a 6-foot distance around security guard stations to
remind people who are standing in line to maintain appropriate distance
from the security officer and other people in line.
    As part of a multilayered approach to transmission control,
employers have also installed physical barriers to protect these
workers when they are at fixed workstations. Across healthcare
workplaces, employees working in security checkpoints are commonly
unable to maintain physical distance from non-employees who need to be
checked-in or are waiting in line (for example, during identification
screenings at hospital entrances). In such circumstances, the
installation of barriers helps protect security personnel interacting
with the public.
Emergency Medical Services
    OSHA developed a physical distancing scenario for Emergency Medical
Service (EMS) organizations. EMS workers cover a number of job
categories including emergency medical

technicians (EMTs), paramedics, and cross-trained firefighters serving
in the capacity of paramedics or EMTs.
    OSHA identified a number of common physical distancing controls
implemented by EMS providers, which limit the number of onsite workers
within physical proximity of patients and others, and also limit crowd
size during emergency response. First, to limit the number of EMS
workers that respond to a call to those absolutely necessary, EMS
employers have implemented polices to coordinate with the emergency
response operator (e.g., the 911 operator/dispatcher) on how many EMS
responders are needed. Also, employers have implemented policies to
ensure that the emergency response operator coordinates with law
enforcement to disburse or move unnecessary people before the ambulance
arrives. Additionally, employers have instituted work practices where
one EMS worker conducts the initial patient evaluation and performs
medical treatment, remaining in radio communication with the other EMS
worker, who will enter to assist only if necessary. EMS employers have
also instituted policies to limit the number of workers in the
ambulance to those who are medically necessary and to encourage family
members to follow the ambulance in their own vehicle rather than riding
in the ambulance.
    EMS workers cannot always avoid proximity to coworkers or patients
during some operations including, for example, engaging in emergency
medical care, transporting patients in ambulances, and transferring
patients to healthcare facilities. When EMS workers respond to an
emergency, they are involved in evaluating and treating the patient
onsite before transporting the patient as necessary. EMS workers may
need to work as a team in order to perform some tasks (e.g., while
performing cardiopulmonary resuscitation (CPR) and using a bag valve
mask also known as an Ambu bag). In addition, arriving EMS workers
could be within 6 feet of people at the site, including family members
and the general public who may have gathered.
    Employers of emergency medical services (EMS) workers have
installed physical barriers to protect their workers in at least some
of these situations. For example, physical barriers are often installed
between the workstations of emergency response operators, who assist in
coordinating the response to emergency situations (e.g., for the EMS
system or the public health system, and in 911 call centers or
healthcare facilities). Employers have also installed physical barriers
between the treatment compartment of ambulances and the driver's
compartment to protect drivers and other workers who need not be
exposed to patients.
    OSHA also identified a number of strategies that have been used by
EMS providers as part of a multilayered approach to infection control.
Employers have implemented policies for requiring employees to wear
appropriate respiratory protection and other PPE, placing a face
covering or facemask on the patient when possible, and requiring family
members to wear face coverings or leave the area while EMS workers
respond to emergencies in patient homes. In addition, employers have
instituted protocols for moving a patient with confirmed or suspected
COVID-19 outside or in a more ventilated area for treatment where
medically possible (note that the ETS requires healthcare workers to
wear respirators when treating a patient who is confirmed or suspected
to have COVID-19 as well as when they are exposed to aerosol-generating
procedures conducted on a patient who is confirmed or suspected to have
COVID-19).
    In some situations, EMS workers might need to ride in the cab
within 6 feet of each other as well as the patient being transported.
In these situations, overlapping controls, such as requiring all EMS
workers in the patient compartment to wear appropriate PPE and to wash
their hands or use an alcohol-based hand sanitizer that contains at
least 60% alcohol, have been implemented. Moreover, as stated, where
feasible, physical barriers can be constructed to isolate the driver's
cab from the rear patient care area. In addition, patients riding in
the rear compartment can wear a face covering and face shield, when
possible, or at least a face shield when a face covering is not
possible. Employers have also established procedures to open outside
air vents in the cab and turn on the rear exhaust ventilation fans to
the highest setting to create a pressure gradient toward the patient
area.
    It is also common that EMS operations must quickly return an
ambulance to service after responding to an emergency involving, or
transporting patients who are, COVID-19 positive. In such
circumstances, multiple EMS workers must often concurrently participate
in cleaning and disinfection of the patient area in the ambulance. In
these situations, employers have used outdoor cleaning areas or indoor
exhaust ventilation, in addition to following widely-established
polices requiring PPE and face coverings.
Long-Term Care
    Long-term care employers operate nursing homes, retirement
communities, assisted living facilities, and intermediate and
continuing care facilities. There are a wide range of job titles for
workers in this industry including healthcare providers (e.g.,
physicians, nurses, nurses' assistants, orderlies, physical,
occupational, and speech therapists, personal care aides, and
psychiatric aides), as well as support staff (e.g., facility
administration, reception, engineering and maintenance, housekeeping,
laundry, food service, transportation, pharmacy, and security).
    OSHA identified a number of physical distancing strategies that
have been implemented in various areas of long-term care facilities
such as reception areas, waiting rooms, dining rooms, and common areas.
These strategies include: Restricting the number of visitors; limiting
access to the residential area to essential workers (i.e., maintenance
workers performing non-critical tasks and staff performing billing
services would not be granted access); increasing the number of meal
services; limiting the number of residents in the dining area at one
time; and providing room service.
    Although physical distancing can be feasibly maintained most of the
time, there are some situations where workers in long-term care
facilities cannot always avoid physical proximity with residents,
visitors, or co-workers. Long-term care employers have installed
physical barriers to protect employees in many of these situations. For
example, resident care and front desk staff may need to be within 6
feet of visitors during visitor check-in or when providing information
or assistance, and administrative staff may have a central counter for
information and resources for residents. In these situations, employers
have installed physical barriers between workstations and visitor or
resident areas. Food servers and aides may need to be within 6 feet of
a resident when serving food, servicing or clearing buffet food lines,
and when providing assistance. In these situations as well, employers
have installed physical barriers between employees and residents.
    Healthcare providers may also need to provide care or therapy in
resident rooms or other care/therapy areas. As part of a multilayered
approach to infection control, some employers have required workers
caring for residents to wear a gown, safety glasses, gloves, and either
a surgical mask or N95 respirator (depending on whether the worker is

providing care to residents with suspected or confirmed COVID-19, for
example). Also, in accordance with American Health Care Association/
National Center for Assisted Living (AHCA/NCAL) recommendations,
employers have, to the extent possible, reduced the frequency of
routine procedures, such as taking vital signs and weights, and have
also required residents to wear a face covering when staff enter their
rooms or when receiving care/therapy from a healthcare provider, unless
they are medically unable to do so. Many employers have also
implemented cohorting procedures for staff and patients (i.e.,
assigning staff to specific residents and only those residents) while
minimizing staff working across units (AHCA and NCAL, April 21, 2020).
Home Healthcare, Personal Care, and Companion Service Providers
    OSHA developed a physical distancing scenario for organizations
that visit private residences to provide healthcare services and health
care support services. Employers in this industry use a wide range of
job titles for their workers including professional home healthcare
practitioners (e.g., physicians, nurses, medical technicians); personal
care providers (e.g. self-care aides); and other workers who offer
companion services for disabled persons, the elderly, and persons
diagnosed with intellectual and developmental disabilities.
    To help ensure physical distancing, employers in this industry have
switched to virtual services when possible by determining whether some
clients' needs can be met through telehealth or with online technology,
such as video conferencing. Many physical distancing strategies have
also been implemented by employers of this sector when services must be
conducted at a patient's private residence. These include implementing
protocols for workers to maintain 6 feet of distance from clients and
other household members, and for workers providing service in teams to
maintain 6 feet of distance from each other, as much as possible while
they perform their work. Employers have also implemented procedures to
instruct all people within the household (other than the direct client
receiving services) to go to another room, or at a minimum, maintain at
least 6 feet of distance from workers.
    Workers performing in-home healthcare or personal care services
cannot always feasibly maintain 6 feet of physical distance from their
clients or co-workers. In these situations, companies have successfully
implemented a multi-layered suite of controls such as requiring all
workers to wear facemasks, respiratory protection, or other PPE, and
requiring patients and members of households to self-screen for COVID-
19 before the visit. Also employers have required all workers to wash
their hands or use an alcohol-based hand sanitizer that contains at
least 60% alcohol before and after each visit, and have implemented
administrative controls such as assigning workers to ``bubbles'' or
cohorts to reduce the number of other individuals with whom a worker
comes in physical proximity. Finally, employers have taken steps to
ensure that private residences have adequate airflow by way of either
an HVAC system or open windows and doors.
Postmortem Services
    OSHA developed a physical distancing scenario to address the
conduct of autopsies. Jobs involved in conducting medical autopsies
generally fall within the following categories; medical examiners,
forensic pathologists, and autopsy technicians who examine bodies
postmortem; and administrative and clerical staff who may be essential
for support purposes.
    The postmortem care industry has implemented a variety of physical
distancing controls to prevent physical proximity (within 6 feet) of
other people when performing autopsies. Physical distancing controls
for these situations are meant to keep professional healthcare
practitioners and, in some cases guests (e.g., law enforcement, family
members of the deceased), at least 6 feet apart. These strategies
include posting reminders of the need to maintain at least 6 feet of
physical distance from other persons, where possible, training workers
on proper physical distancing relative to other workers and guests, and
establishing work schedules (e.g., alternating days, extra shifts) that
reduce the total number of workers in a facility at any given time. In
addition, many employers require workers to limit the number of staff
in the prep/exam room at any given time to the minimum number
necessary.
    In workplaces where autopsies are performed, physical proximity
cannot always be avoided. In these situations, facilities have
successfully implemented a multi-layered suite of controls, such as
wearing appropriate PPE, to protect workers from other people (e.g.,
guests or other staff) during postmortem medical examination, for
example. Physical barriers have also been installed in other areas
where physical distancing may be difficult to maintain including, at
reception counters, in restrooms, in consultation rooms, and in
offices, for example.
Summary of Feasibility Challenges for Distancing and Physical Barriers
    While OSHA strongly emphasizes the use of physical distancing and
physical barriers, it recognizes that there are a few situations where
employers have found that it is not feasible to implement either or
both. Physical distancing and physical barriers may not be feasible
during direct patient care, including the conduct of Emergency Medical
Services (EMS) while treating a patient in the back of an ambulance,
for example. Physical barriers may also be infeasible where they
obstruct an emergency egress path or interfere with a facility's fire
safety systems (e.g., fire alarm notification devices, fire sprinklers,
fire pull stations).
    OSHA emphasizes a multilayered approach for employers to protect
their workers: Physical distancing and, if necessary, physical barriers
at fixed work locations outside of direct patient care areas must be
used in conjunction with other controls, such as facemasks, hand
hygiene, and ventilation, and not as the sole means of control. When
confronting the rare situations where both physical distancing and
physical barriers are not feasible, employers can still implement the
remaining layers of overlapping controls, including facemasks, hand
hygiene, and ventilation, required by the standard to reduce the risk
of COVID-19 transmission.
    Based on the evidence that physical distancing and physical
barriers are already being implemented across a broad range of
healthcare settings, OSHA concludes that it is feasible to implement
the ETS's requirements for physical distancing and for physical
barriers at fixed work locations outside of direct patient care areas
(e.g., entryway/lobby, check-in desks, triage, hospital pharmacy
windows, bill payment). In the few cases where physical distancing and
physical barriers are both not feasible, work can be conducted to
maintain as much distance as possible, and the additional controls such
as facemasks, ventilation, and hygiene required by the ETS will still
provide some measure of protection.
d. Ventilation
    Ventilation systems are another necessary part of a multilayered
strategy to control transmission of COVID-19 (CDC, March 23, 2021). As
will be discussed in more detail below, the

ability of heating, ventilation, and air conditioning (HVAC) systems to
reduce the risk of exposure depends on many factors, including design
features, operation and maintenance practices, and the quality and
quantity of outdoor air supplied to the space. Paragraph (k) of the ETS
require employers who own or control buildings or structures with
existing heating, ventilation, and air conditioning (HVAC) systems to
ensure that: (1) Each HVAC system is used in accordance with the HVAC
manufacturer's instructions and its design-specifications; (2) the
amount of outside air circulated through its HVAC system and the number
of air changes per hour (ACHs) are maximized to the extent appropriate;
(3) all air filters are rated Minimum Efficiency Reporting Value (MERV)
13 or higher, if compatible with the HVAC system (or, alternatively,
rated at the highest compatible filtering efficiency); (4) all air
filters are maintained and replaced as necessary; and (5) all outside
air intake ports are clean, maintained, and cleared of any debris that
may affect the function and performance of the HVAC system. Moreover,
where an employer has an existing airborne infection isolation room
(AIIR), the employer must maintain and operate it in accordance with
its design and construction criteria.
    In the remainder of this section, OSHA discusses how employers can
comply with these requirements and then draws its conclusion on
technological feasibility.
Using HVAC Systems in Accordance With Manufacturer's Instructions and
Design Specifications
    To meet the ETS's requirements, employers must verify that the
system is functioning as designed. Because each building and its
existing HVAC systems will be different, the employer might need to
consult a professional engineer or HVAC specialist to determine the
best way to maximize the system's ventilation and air filtration
capabilities for each specific room in the building and thereby ensure
the system is operating according to design specifications.
    The American Society of Heating, Refrigeration and Air Conditioning
Engineers (ASHRAE) Standard 180-2018 Standard Practice for Inspection
and Maintenance of Commercial Building HVAC Systems provides guidance
on preventive maintenance for HVAC systems, including checklists that
employers can use to verify the system is operating as designed
(ASHRAE, June 11, 2018). Additional guidance can be found in CDC's
Guidance for Businesses and Employers Responding to Coronavirus Disease
2019 (COVID-19) (CDC, March 8, 2021), and the ASHRAE Guidance for Re-
Opening Buildings (ASHRAE, October 5, 2020).
    Healthcare settings have additional HVAC design parameters for
meeting specifications for directional airflow and relative pressure
differentials. For example, according to ASHRAE's Standard 170
Ventilation of Health Care Facilities, ventilation systems that provide
air movement from clean areas (e.g., nursing stations) to potentially
contaminated areas (e.g., patient airborne infection isolation rooms)
are recommended for preventing airborne transmission. Thus, the air
pressure of the room or space would be maintained at a negative
pressure relative to the hallways and surrounding spaces. This means
that when the door is opened, potentially contaminated air or other
dangerous particles from inside the room will not flow outside into
non-contaminated areas. (ASHRAE, 2017). Normally functioning existing
isolation rooms should already be able to serve this function because
Joint Commission accreditation and Centers for Medicare & Medicaid
Services (CMS) regulations have requirements for negative pressure
airborne infection isolation rooms design.
Using AIIRS in Accordance With Design and Construction Criteria
    AIIRs are designed to prevent the transmission of airborne
transmissible agents to areas outside a patient's room. These rooms
have a high air exchange rate and are under negative air pressure,
meaning that the room air has a slight negative pressure compared to
the surrounding rooms. The high air exchange rate (at least 12 air
changes per hour (ACH) for new construction or renovation, 6 ACH
otherwise) helps change the room air frequently and reduces (but does
not eliminate) buildup of airborne disease agents, such as the virus
that causes COVID-19. The negative air pressure differential (0.01 inch
of water [2.5 Pa]) helps reduce the chance that the remaining airborne
virus will exit the room door and contaminate air in adjacent hallways.
An anteroom is a beneficial room feature that helps further isolate the
AIIR from the adjacent hallway. When the AIIR has an anteroom, the
AIIR's air pressure should be negative to the anteroom, while the
anteroom air pressure should be negative to the adjacent hallway. This
arrangement means air from the hallway will flow into the anteroom each
time the door is opened, and air from the anteroom will flow into the
AIIR--minimizing the amount of airborne disease agents (virus) that
exits the room. ASHRAE Standard 170, Ventilation of Health Care
Facilities offers detailed guidance for designing and operating AIIRs
(ASHRAE, 2017).
Maximizing Outside Air Circulated Through HVAC System(s) and the Number
of Air Changes per Hour (ACHs) to the Extent Appropriate
    Building HVAC systems are designed to draw in a certain amount of
outdoor air into the building to maintain indoor air quality. By
introducing fresh air into the building, HVAC systems can prevent the
buildup of airborne contaminants through dilution.
    The introduction of outdoor air into the building can also help
limit the potential for the virus that causes COVID-19 to accumulate in
the building. The more outdoor air the HVAC system is capable of
drawing into the building, the greater the impact may be on limiting
the potential for the virus to accumulate. Maximizing the amount of
outdoor air introduced to the system can be achieved by fully opening
the building's outdoor air intake dampers; however, this may introduce
other indoor air quality or comfort concerns resulting from humidity,
temperature extremes, or outdoor pollution. Employers should work with
building managers or HVAC professionals to adjust the HVAC system to
bring in as much outdoor air as possible, while taking into
consideration outdoor pollution levels and ensuring that the HVAC
system is capable of maintaining building temperature and humidity
levels within acceptable occupant comfort ranges. OSHA notes that it
does not expect employers to reconfigure duct work to comply with this
provision. When maximizing the outside air, employers should take into
account not to draw in air from potential pollution sources such as
smoking areas, loading docks, vehicle traffic areas, or active
construction zones, or air being re-entrained from the building exhaust
itself.

    Balancing refers to the process of measuring the air flow through
the supply ducts and adjusting the dampers to provide an even
distribution of air through the HVAC system duct work and supply vents.
According to ASHRAE Standard 111 Measurement, Testing, Adjusting, and
Balancing of Building HVAC Systems, testing and balancing an HVAC
system provides the means to determine and monitor system performance.
Proper balancing ensures that outdoor air brought into the building
will be evenly supplied to all areas of the building and limit the
potential for ventilation dead zones or stagnant air to accumulate
(ASHRAE, October 31, 2017).
    In addition to considering the factors discussed above with respect
to maximizing outside air, employers must also consider how to maximize
ACHs. ACHs are a measure of the air volume that is added to or removed
from a space in one hour divided by the volume of the space. The more
frequently the air within that space is replaced per hour, or the more
ACHs, the more the overall potential concentration of COVID-19 in the
work environment will be reduced. Building owner/operators or employers
can seek assistance from HVAC professionals on maximizing ACHs based on
the workspace and the design capabilities of the HVAC system(s)
(ASHRAE, 2017).
Using Air Filters Rated MERV 13 or Higher, if Compatible With the HVAC
System(s), or, Alternatively, to the Highest Compatible Filtering
Efficiency
    Building HVAC systems are equipped with air filters that remove
particles from recirculated air streams before returning the air to
occupied spaces. Air filters are available in a variety of materials
such as pleated paper, cloth, woven fiberglass, and polyester. A
filter's efficiency is measured by the fraction of particles the filter
is able to remove from the air stream. The higher the filter's
efficiency the better it is at removing particles from the air. There
are several systems for rating filter efficiencies. The most common is
the MERV rating system, which was developed by ASHRAE.
    Many existing HVAC systems are designed and installed to operate
with filters ranging from MERV 6 to MERV 8. MERV 8 filters are only
about 20 percent efficient in removing particles in the 1 [micro]m to 3
[micro]m size range (the size range of concern for aerosol droplets
containing the virus that causes COVID-19). Employers and building
managers can improve this efficiency by upgrading to MERV 13 or higher
filters, to the extent those filters are currently compatible with
system components (e.g., filter housing slot type, size, and shape).
MERV 13 filters are at least 85 percent efficient at capturing
particles in the 1 [micro]m to 3 [micro]m size range. Increasing filter
efficiency, however, can increase pressure drop across the filters
leading to increased fan energy use, reduced airflow rates, and or/
issues controlling indoor temperature and humidity levels. As a result,
employers and building owners may need to consult an HVAC professional
to optimize filter efficiency consistent with their HVAC system's
capabilities.
Maintaining and Replacing All Air Filters as Necessary
    The required frequency for changing filters will vary depending on
the characteristics of the HVAC system, and therefore the ETS does not
specify a frequency for filter changing.
Ensuring All Outside Air Intake Ports Are Clean, Maintained, and
Cleared of Any Debris That May Affect the Function and Performance of
the HVAC System(s)
    To comply with this provision, a visual inspection of the outside
air intakes, which can be accomplished as part of a routine maintenance
program, is required.
Additional Ventilation Measures
    A note to the ETS's ventilation requirements provides that, in
addition to the requirements for existing HVAC systems and AIIRs, all
employers should also consider other measures to improve ventilation in
accordance with CDC guidance. Below are some additional measures that
an employer should consider to increase total airflow supply to
occupied spaces:
     Disabling demand-control ventilation (DCV) controls that
reduce air-supply based on temperature or occupancy;
     Using natural ventilation (i.e., opening windows if
possible and safe to do so) to increase outdoor air dilution of indoor
air when environmental conditions and building requirements allow;
     Running the HVAC system at maximum outside airflow for 2
hours before and after occupied times;
     Generating clean-to-less-clean air movements, re-
evaluating the positioning of supply and exhaust air diffusers and/or
dampers, and adjusting zone supply and exhaust flow rates to establish
measurable pressure differentials;
     Requiring that staff work in ``clean'' ventilation zones
and not in higher-risk areas (e.g., visitor reception) to the extent
feasible;
     Using portable high-efficiency particulate air (HEPA) fan/
filtration systems to help enhance air cleaning especially in higher-
risk areas; and
     Ensuring exhaust fans in restroom facilities are
functional and operating at full capacity when the building is
occupied.
    The terms of the ETS make clear that there are no technological
hurdles to compliance with its ventilation requirements. First, the
ventilation requirements apply only to existing systems. A note in the
ETS emphasizes that the requirements do not require installation of new
HVAC systems or AIIRS, or upgrades of existing systems to replace or
augment functioning systems. Therefore, the ventilation requirements do
not raise the questions of feasibility typically associated with
employers needing to install new engineering controls to come into
compliance with a new standard.
    Second, the HVAC requirements apply only to employers who own or
control buildings or structures. Thus, for example, the requirements do
not apply to employers who lease space and do not control the building
or structure, and the ETS does not raise questions as to how these
employers would comply with the ventilation requirements.
    Third, employers covered by the general section are required only
to ensure that HVAC systems operate with a sufficient filter (MERV-13
where possible) in accordance with manufacturer's instructions and
design specifications, and only in a manner that is appropriate for the
system using methods that are compatible with the system, and that
AIIRs are maintained and operated in accordance with their design and
construction criteria. As such employers are not required by the ETS to
modify their HVAC systems or AIIRs in any manner, only to ensure that
they are operating as designed, which negates questions as to how the
employer would make modifications.
    Fourth, a number of the plans, best practice documents, and
scenarios discussed above reference HVAC systems and ventilation. The
use of HVAC systems to manage building air filtration and circulation
of fresh air as part of overlapping controls to address the COVID-19
hazard illustrate that there is no technological feasibility barrier to
compliance with the ETS's ventilation requirements in typical firms in
all affected industries. The ETS's filter requirements are inherently
technologically feasible because they only require the installation of
the

maximum filter that is compatible with the applicable HVAC system.
    The design and complexity of HVAC systems can vary widely depending
on a range of factors including the use, size, and age of the building,
and, as discussed, deciding on the maximum appropriate amount of
outside air to circulate through the HVAC system(s) and number of ACHs
can be a complex task. However, larger buildings have dedicated
facilities management staff who are responsible for regular ventilation
system maintenance and adjustment and will have the prerequisite
experience to evaluate the capabilities of the HVAC system, while in
other cases, employers may need to consult with an HVAC professional to
ensure that facilities HVAC is functioning in accordance with the HVAC
manufacturer's instructions and the design specifications of the HVAC
system(s). Based on these factors, OSHA concludes that there are no
technological barriers to compliance with the ETS's ventilation
requirements.
e. Other Provisions
    There are no technological feasibility barriers related to
compliance with other requirements in the ETS (e.g., facemasks, and
respirators, cleaning and disinfection, health screening and medical
management, employee notification). Indeed, as explained above, many of
the plans, best practice documents, and scenarios reviewed by OSHA
indicate that these controls have been implemented by employers across
industry sectors as part of a multilayered approach to protecting
workers from the COVID-19 hazard. OSHA highlights a few of the ETS's
other requirements below, but only to point out administrative issues
that will be explored in more depth in other sections of the preamble.
     Facemasks. The ETS requires employers to provide, and
ensure that employees wear, facemasks that are FDA-cleared, authorized
by an FDA EUA, or offered or distributed as described in an FDA
enforcement policy. Facemasks that meet these requirements are
currently widely available.
     There may be situations where wearing a facemask presents
a hazard to an employee of serious injury or death (e.g., arc flash,
heat stress, interfering with the safe operation of equipment). The
relevant section of the Summary and Explanation provides further
discussion on this topic.
     Respirators. As noted in Need for Specific Provisions and
Summary and Explanation (Sections V and VIII of the preamble,
respectively), the increased need for respirators by healthcare workers
during the pandemic has resulted in shortages of N95 filtering
facepiece respirators (FFRs). The ETS addresses these shortages by
encouraging employers to use not only N95 FFRs, but also other
respirators such as elastomeric respirators and powered air-purifying
respirators (PAPRs), where feasible. For further details, see paragraph
(f) of the ETS, as well as relevant sections of Need for Specific
Provisions and Summary and Explanation.
     Notification. Paragraphs (l)(2) and (l)(3) of the ETS
contain COVID-19-connected notification requirements for both the
employer and the employee. OSHA identifies no technological feasibility
issues in connection with the ETS's notification requirements. It is
the employer's responsibility to ensure that appropriate instructions
and procedures are in place so that designated representatives of the
employer (e.g., managers, supervisors) and employees conform to the
rule's requirements.
    There are also no technological barriers to compliance with the
mini respiratory protection program section of the ETS. That section
requires employers, many of whom have never developed or implemented a
respiratory protection program under the Respiratory Protection
standard, 29 CFR 1910.134, to develop and implement one if their
employees wear respirators. However, the mini respiratory protection
program section will require a program that is far less extensive, and
thus easier to comply with, than what is required under 29 CFR
1910.134. For example, the mini respiratory protection program section
will not require quantitative fit testing or medical evaluations
regarding employees' ability to use respirators, both of which are
required under 29 CFR 1910.134. Therefore, OSHA concludes that
compliance with the mini respiratory protection program section does
not raise issues of technological feasibility. OSHA discusses the
administrative cost of complying with the mini respiratory protection
program section in its economic feasibility analysis.
II. Conclusions
    OSHA has reviewed the requirements imposed by the ETS and has
determined that achieving compliance with the rule is technologically
feasible for typical operations in the settings that are covered by the
ETS. In reaching this determination, OSHA reviewed evidence that shows
that healthcare-specific good infection control practices are routinely
implemented by employers who have employees in covered settings. This
evidence includes: Readily available CDC infection control guidance
documents, many of which are COVID-19 specific; regulations issued by
the Centers for Medicare & Medicaid Services (CMS), compliance with
which is typically required for accreditation of these settings by The
Joint Commission; and the application of similar requirements in OSHA's
Bloodborne Pathogens Standard, 29 CFR 1910.1030.
    OSHA's assessment also analyzed the technological feasibility of
complying with the requirements of the ETS for developing a COVID-19
Plan: Maintaining physical distancing; installing physical barriers;
and ensuring existing ventilation systems are operating as designed. As
noted, the ETS requires employers to develop and implement a COVID-19
plan through a multilayered approach to addressing the spread of COVID-
19 by taking feasible measures to reduce or eliminate the transmission
of COVID-19. This includes requirements for employers to implement
procedures to ensure employees maintain at least 6 feet of physical
distancing from others to the extent feasible and, when distancing is
not feasible, to install physical barriers, again to the extent
feasible. It also allows flexibility in the material of barriers.
    OSHA recognizes that sometimes it may not be feasible to implement
either physical distancing or physical barriers for particular work
activities, but even if this is the case, employers must still protect
their employees through the other provisions of the flexible
multilayered approach required by the ETS. The regulatory text allows
for alternatives in some situations, and OSHA has identified a variety
of alternatives that it believes would be technologically feasible in
those situations most of the time. As explained, there are no
technological feasibility barriers related to compliance with
requirements in the ETS for facemasks and respirators, cleaning and
disinfection, health screening and medical management, or employee
notification. Based on the combination of OSHA's evaluation of
technological feasibility of controls in the various scenarios
examined, OSHA finds that the ETS is technologically feasible.
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