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DHHS POLICIES AND PROCEDURES

_______________________________________________________________________________________________________________

Section V:

Human Resources

Title:

Safety and Benefits

Chapter:

Safety and Health Inspections

Current Effective Date:

5/1/09

Revision History:

5/1/09, 4/1/04, 7/1/03

Original Effective Date:

10/1/02

_______________________________________________________________________________________________________________

Purpose

To establish a series of internal safety and health inspections for buildings owned, operated, or controlled by the department, in order to efficiently and effectively address safety and occupational health issues, hazards and deficiencies.

Policy

Division/Facility/School Directors shall ensure all inspections are performed as required by Joint Commission, NC Fire Code, OSHA 1910/1926 General Industry and Construction Standards and this policy to maintain a safe and healthy workplace.

Definitions (also see DHHS Policy: Establishment of the Safety and Health Program Definitions Section)

  1. Safety and Health Deficiencies - Conditions and/or practices which do not comply with the requirements of Safety and Health policies, procedures or regulations.


  2. Unsafe Practices - Any action or procedure that creates or exposes employees to risk of injury or occupational illness, or that may result in damage to department-owned or other property.

Implementation

  1. The division/facility/school director shall ensure a system of safety and health self-inspections to ensure workplaces and conditions are free of recognized hazards likely to cause death, serious injury, or occupational illnesses; and to ensure compliance with all applicable safety and health regulations.

    1. The division/facility/school Safety and Health Director shall conduct comprehensive safety and occupational health inspections of all division/facility/school buildings no less than once each year, to identify and document safety and health deficiencies to employees, clients, and visitors; and observe the implementation and effectiveness of Safety and Health policies and procedures.


    2. Each division/facility/school Safety and Health Committee, during the Quarterly Safety Committee Meeting, shall review the results of the completed monthly and quarterly inspections of division/facility/school buildings, to ensure the maintenance of safe conditions and to identify and address newly created deficiencies in a timely manner.


    3. Each facility/school Safety and Health Director shall ensure targeted monthly and quarterly workplace safety inspections for each building within the facility are completed and documented for review at the facility/school Safety Committee meetings. Target safety issues are those that are easily affected by day to day facility operations, by staff and visitors (i.e. fire exits/fire extinguishers blocked, holiday decorations, use of unauthorized electrical cords and appliances, improper storage. etc).


    4. Each Division Safety Representative shall perform a monthly and quarterly workplace safety inspection for each building within the division to identify and document safety compliance. These inspections shall be documented on the monthly and quarterly workplace safety inspection checklists, as developed by the DHHS Safety & Benefits Office.


    5. Division Safety Representatives shall submit the completed monthly and quarterly workplace safety inspection reports to the DHHS Safety & Benefits Office no later than the 10th of the month following the month of the inspection. Large divisions with multiple buildings and various locations may consolidate these reports prior to submitting.


    6. Each employee shall have the opportunity to report safety and health deficiencies and unsafe practices to the Safety Program Manager, division/facility/school Safety and Health Director/Safety Representative, or any Safety and Health Committee with no resulting discrimination, reprisal, or punishment.


    7. Each identified deficiency shall be recorded, logged, prioritized, and tracked until the deficiency is corrected.


    8. The division/facility/school Director shall be provided with relevant information about identified deficiencies and a recommended means of correction, and shall; with the assistance of the division/facility/school Safety and Health Director/Safety Representative, develop and implement a plan of action to abate the identified deficiencies. Upon request from the division/facility/school Director or division/facility/school Safety and Health Director, the Safety Program Manager shall assist in the development of the corrective action plan.


    9. Each division/facility/school Safety and Health Committee shall, as part of the inspection review process, review all previously identified deficiencies and shall report the progress of correction to the division/facility/school director.


    10. Each supervisor/manager shall take the responsibility for the necessary actions for the control and correction of each identified deficiency in their respective areas as outlined in the correction action plan, and shall ensure that supervised employees take the necessary actions within the time limits as set in the corrective action plan.


    11. The Safety Program Manager should conduct comprehensive reviews of each division/facility/school at least once every three (3) years, to ensure the adequate implementation of Safety and Health program and to gauge the effectiveness of the Safety and Health Program.

  2. Regulatory Agency Inspection: The department shall submit to and participate in inspections by duly authorized agents of federal and state regulatory agencies with jurisdiction over state-owned and/or operated buildings.

    1. North Carolina Department of Labor, Division of Occupational Safety and Health (NCDOL-OSH) Inspections.

      1. The Safety and Health Director, and/or Division Safety Representative shall be immediately notified of the arrival of a Compliance Safety and Health Officer from the North Carolina Department of Labor, Division of Occupational Safety and Health (OSH).


      2. The Safety and Health Director, and/or site Safety Representative shall immediately notify the DHHS Safety Program Manager at (919) 733-2662 of the presence of an OSH Compliance Officer at the facility. A DHHS Safety and Benefits Office Representative, as scheduling permits, shall come to the location to assist with the inspection and will remain onsite until the inspection is completed.


      3. The on-site Office Supervisor/Manager, the Safety and Health Director, and/or Division Safety Representative shall immediately meet with the OSH Compliance Officer for the opening conference. If the inspection is at a satellite office, the supervisor/manager at that site shall assume this responsibility and immediately notify the Division Safety Representative who shall notify the DHHS Safety Program Manager at (919) 733-2662.


      4. The DHHS Representatives shall examine the Compliance Officer's credentials and business card to ensure the individual is an NC DOL OSHA Compliance Officer.


      5. The DHHS Representatives shall record the nature and scope of the inspection as described by the Compliance Officer and where applicable, examine the provided documentation. If not provided, the DHHS Representatives should request this before the opening conference is concluded. Nature and scope of the inspection will be one of the following categories:

        1. General Schedule - a comprehensive, wall-to-wall inspection of all buildings and employee work areas within Division offices. Documentation consists of a computer printout or webpage listing the establishment, address, SIC code and nature.


        2. Employee Complaint - a limited inspection of specific violations alleged by the complaining employee, plus any violations in plain sight of the Compliance Officer during the inspection. Documentation consists of an official DOL complaint form listing the alleged violations and locations, with the employee's name removed.


        3. Referral - a limited inspection of specific violations alleged by another regulatory agency, plus any violations in plain sight of the Compliance Officer during the inspection. Documentation consists of an official DOL referral form listing the alleged violations and locations.


        4. Fatality/Catastrophe - a limited investigation of conditions and events leading up to, involved in and resulting from an employee death or the job-related hospitalization of three or more employees, plus any violations in plain sight of the Compliance Officer during the investigation. Documentation consists of an official DOL form describing the fatality/catastrophe event and listing the date.


        5. Public Way Observation - a limited inspection of any serious violations (where the most severe accident that could reasonably occur from a violation would require medical attention greater than first aid) observed by the Compliance Officer from a state road or right-of-way, plus any violations in plain sight of the Compliance Officer during the inspection. There is no documentation for this type of inspection.


        6. Special Emphasis - a limited inspection of conditions covered by a Federal or State special emphasis program, plus any violations in plain sight of the Compliance Officer during the inspection. There is no documentation for this type of inspection.

      6. If the Compliance Officer does not provide official credentials or required inspection documentation and/or does not specifically state the nature and scope of the inspection, the DHHS Representative shall immediately suspend the opening conference and contact the supervisor of the appropriate bureau chief of the North Carolina Department of Labor, Division of Occupational Safety and Health, to verify that this individual is a bona fide Compliance Officer and that the inspection is lawful. No permission to conduct an inspection should be given until this verification is successful.

        1. Eastern North Carolina – 919-662-4597


        2. Western North Carolina – 336-731-2400

      7. The Safety and Health Director, and/or site Safety Representative shall provide the Compliance Officer with the division/facility/school, North Carolina Unemployment Insurance ID number, copies of the Division office OSHA 300 logs and summaries for the preceding five years and the current year to date and any other documentation and records requested by the Compliance Officer.


      8. Upon conclusion of the opening conference, the Compliance Officer will conduct the walk around inspection.


      9. The following individuals should accompany the Compliance Officer during the walk around.

        1. The Safety and Health Director, and/or site Safety Representative, equipped with a notepad, a camera and necessary recording media.


        2. A maintenance representative, and/or a member of the staff, equipped with keys to all areas and rooms within the establishment.


        3. The supervisor/manager assigned to the area currently being inspected.


        4. The DHHS, Safety and Benefits Office Representative, once he/she arrives at the facility.

      10. The Compliance Officer should be allowed to inspect any area, equipment, or room he/she desires without interference.


      11. The Safety and Health Director, and/or site Safety Representative should, however, notify the Compliance Officer when areas are encountered which are not utilized by staff, confidential, or where the inspection process could seriously disrupt critical work activities and of known hazards which could endanger the Compliance Officer or DHHS employees.


      12. If the Compliance Officer wishes to inspect areas where confidential records are used or stored and/or locations where the privacy or confidentiality could be compromised, the Safety and Health Director, and/or site Safety Representative should ensure that the supervisor/manager responsible for such areas is present during that portion of the inspection and should request that the Compliance Officer delay until that person is present.


      13. The Compliance Officer should be allowed to take any photograph he/she desires to document alleged violations. The Safety and Health Director and/or the Safety Representative shall ensure that the contents of the photos do not violate patient, client, or individual’s privacy.

        1. The Safety and Health Director, and/or Division Safety Representative should take a photograph for every photograph taken by the Compliance Officer, at the same angle and distance.


        2. A written record of the location and the hazard of every alleged violation recorded by the Compliance Officer shall be documented during the walk around inspection. This process is necessary to begin mitigating hazards prior to receipt of the official NCDOL-OSH report which may take 10 to 14 days to receive depending upon the scope of the inspection and to prepare for future proceedings regarding the inspection by responsible parties. The Compliance Officer is not required to provide a written summary of findings at the closing conference.

      14. The Compliance Officer should be allowed to privately interview any employee he/she desires without interference.


      15. The Safety and Health Director, and/or site Safety Representative shall inform the employee that the Compliance Officer has the authority to conduct this interview. The employee has the right to speak truthfully, have a supervisor/manager present during the interview and that it is unlawful for anyone in DHHS to take any discriminatory or punishing action against the employee for cooperating with the Compliance Officer.

        1. If necessary, the DHHS Representative shall ensure an office or other private location is provided for the interview.


        2. The Safety and Health Director, and/or site Safety Representative shall record the name of each employee interviewed and where obvious, the alleged violation to which the employee appears to be exposed.

      16. Should the walk around extend over one day, DHHS Representatives shall make themselves available to continue the walk around, on the dates and times indicated by the Compliance Officer. Should scheduling conflicts arise with any DHHS Representative, an alternate individual shall be identified to take the place and responsibilities of the conflicted representative.


      17. The Safety and Health Director, and/or site Safety Representative should provide to maintenance personnel a copy of the alleged violations identified by the Compliance Officer each day. Where such actions do not critically impact the maintenance department's ability to provide for the continued function and safety, or unless specifically countermanded by the Safety and Health Director, maintenance personnel should:

        1. Correct each alleged deficiency as identified by the Compliance Officer.


        2. Inspect areas of the establishment not yet inspected, to locate similar conditions and correct them. No documentation should be made of these corrections.


        3. The Safety and Health Director, site Safety Representative, and/or DHHS Safety & Benefits Office Representative shall photograph the corrected condition. The photograph (s) shall be provided as soon as possible to the Safety and Health Director, site Safety Representative, or DHHS Safety & Benefits Manager, who will provide a copy to the Compliance Officer.

      18. Upon completion of the walk around inspection, the Compliance Officer will conduct a closing conference.

        1. The Director, Manager or Supervisor onsite, the Safety and Health Director, and/or Site Safety Representative, the DHHS Safety and Benefits Office Representative, the Maintenance Representative and any other individual deemed appropriate by any of these individuals should attend the closing conference. If these individuals are not available at the close of the walk around, the DHHS Representative should negotiate with the Compliance Officer to postpone the closing conference to a date and time when all persons are available.


        2. The Compliance Officer will provide a verbal list of alleged violations, which the DHHS Representative recording the Compliance Officers inspection shall check against his/her list compiled during the walk around.


        3. The Director, Manager or Supervisor on site, Safety and Health Director, and/or Site Safety Representative, and/or the DHHS Safety and Benefits Office Representative should identify to the Compliance Officer the identified alleged violations that were corrected prior to the closing conference and provide photograph evidence where available. DHHS Representatives should not provide photographic evidence of corrections made to alleged violations the Compliance Officer identified during the walk around, but did not identify during the closing conference or for violations found as a result of maintenance inspections of other areas that were not identified by the Compliance Officer.


        4. Where in the opinion of the Safety and Health Director and/or Division Safety Representative and/or the Maintenance Representative the correction of any alleged violation will exceed one month from the date of the closing conference, these individuals should explain the reasons to the Compliance Officer and request a reasonable timeframe for correction.


        5. The attending members of the closing conference should not dispute any alleged violation listed by the Compliance Officer or engage in argument with him/her. The attending members should not indicate acceptance of any alleged violation as a citation.

      19. After completion of the closing conference:

        1. The DHHS Safety and Benefits Office Representative and the Safety and Health Director, site Safety Representative, with the assistance of the Maintenance Representative and other staff, will gather and record evidence to support or refute the alleged violations and to estimate the severity and probability of each alleged violation deemed accurate.


        2. The DHHS Safety Program Manager shall consult with the Assistant Attorney General assigned to this case on possible defenses to citations.


        3. The Maintenance Representative shall continue to correct alleged violations deemed accurate, photograph the corrected condition and submit the photograph to the Safety and Health Director/Safety Representative.


        4. The Division Safety and Health Director shall be provided the official citations resulting from this inspection, the same day they are received via certified mail.


        5. The Safety and Health Director and/or site Safety Representative shall immediately notify and fax a copy of the citations to the Safety Program Manager.


        6. The Safety and Health Director and/or site Safety Representative shall, within one (1) working day of receipt, post a copy of the citations in a location or locations where all employees of the establishment have ready access to view them.


        7. Within two (2) working days of receipt, the Safety Program Manager shall consult with the Assistant Attorney General, the Director, manager or supervisor and the Safety and Health Director or site Safety Representative to determine if an informal conference or formal contestment should be pursued.


        8. The Safety Program Manager in consultation with the Assistant Attorney General shall take responsibility for pursuing any contestments to issued citations and/or penalties.


        9. The Safety Program Manager shall keep the Director, site supervisor/manager and Safety and Health Director or site Safety Representative appraised of all activities and results.


        10. The Safety and Health Director or site Safety Representative shall ensure that documentation required by safety information from NCDOL-OSH that is required to be posted is properly posted for the perusal of the employees.


        11. Each Final Order (citations that are not contested or that are not vacated via contestment) should be added to the division/facility/school Safety Committee's meeting agenda and future inspection documentation and tracked through the monthly/quarterly inspection process until corrected.
    2. Fire Marshals

      1. The Safety and Health Director and/or site Safety Representative shall be immediately notified of the arrival of a fire marshal or DOI inspector.


      2. The Safety and Health Director and/or site Safety Representative should insure that the inspector has the authority to conduct an inspection of the establishment.

        1. The North Carolina Department of Insurance, State Fire Marshall's Office has sole responsibility for inspection of state-owned establishments, but has the authority to inspection leased spaces as well.


        2. The local government fire marshal and building inspector has authority to inspect leased spaces, but not state-owned establishments.

      3. If the inspection is justified, the inspector should be accompanied by the Safety and Health Director /or site Safety Representative, a member of maintenance with keys to all areas and rooms and the supervisor/manager responsible for each area being inspected.


      4. Upon receipt of the written results of the inspection, the violations should be added to the division/facility/school safety committee's meeting agenda and future inspection documentation and tracked through the monthly/quarterly inspection process until corrected.

    3. Other Regulatory Agencies

      1. Inspections by regulatory agencies with authority to issue citations and penalties should be conducted by Procedures 2.A., adjusting for the agency conducting the inspection.


      2. Inspections by regulatory agencies that do not issue citations and penalties should be conducted by Procedures 2.B.

        Employee exposure and/or environmental tests that are deemed necessary to establish, measure, or correct a deficiency but are beyond the abilities of division/facility/school staff to perform shall be coordinated through the Safety Program Manager.

    4. The Safety Program Manager shall develop specific operating procedures for the implementation of this policy.


    5. The division/facility/school shall develop division/facility/school specific operating procedures for the implementation of this policy.

References

  1. North Carolina General Statutes, Section 143, Article 63, 143-582(1)


  2. North Carolina Administrative Code: 25 NCAC 1N.0105(a), 0106(5) and (6)


  3. North Carolina State Employees' Workplace Requirements Program for Safety and Health, Section 2
    1. Policy 2.2, Requirements 1.c., 1.g., 1.h., 5.c., and 8.a.
    2. Policy 2.9

For questions or clarification on any of the information contained in this policy, please contact Human Resources. For general questions about department-wide policies and procedures, contact the DHHS Policy Coordinator.


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