Frequently Asked Questions about Workplace Violence Prevention in Health Care
California Code of Regulations, title 8, section 3342
§ 3342(a).Scope and ApplicationWhat is the implementation schedule for section 3342?
Employers were required to implement the following subsections by April 1, 2017:
(d) Violent Incident Log
Hospital employers were required to implement the following subsection by July 1, 2017:
(g) Violent Incident Reporting to Cal/OSHA
Employers must implement the following subsections by April 1, 2018:
(c) Workplace Violence Prevention Plan
(e) Review of the Workplace Violence Prevention Plan
- Does Cal/OSHA have a model program to comply with section 3342? If not, are there others available?
At this time, Cal/OSHA does not have a model program for workplace violence prevention in health care.
- What model plan can be used by health care facilities to develop their own plan?
Health care facilities may start with Cal/OSHA’s "Guide to Developing Your Workplace Injury and Illness Prevention Program": http://www.dir.ca.gov/dosh/dosh_publications/iipp.html. Facilities can frame the questions in this guide around violence prevention to develop their workplace violence prevention plan.
The following publications may also be useful for health care facilities:
- Cal/OSHA’s "Guidelines for Security and Safety of Health Care and Community Service Workers": http://www.dir.ca.gov/dosh/dosh_publications/hcworker.html
- Cal/OSHA’s "Injury & Illness Prevention Model Program for Workplace Security": http://www.dir.ca.gov/dosh/dosh_publications/iipsecurity.html
- Federal OSHA’s "Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers": http://www.osha.gov/Publications/osha3148.pdf
- Federal OSHA’s "Preventing Workplace Violence: A Road Map for Healthcare Facilities": http://www.osha.gov/Publications/OSHA3827.pdf
- Many medical center campuses are an intertwined grouping of licensed and unlicensed buildings/spaces owned by various entities. Who is responsible for the Plan?
Subsection 3342(a)(1) lists the types of health care facilities, service categories, and operations that are covered by section 3342. Subsection 3342(c) requires each employer that operates a building or space listed under subsection 3342(c) to have its own workplace violence prevention plan. In addition, an employer that that has its own employees working in one of these covered buildings or spaces must also have its own workplace violence prevention plan, even if it does not operate the building or space in question.
A covered building or space where employees of more than one employer work may be covered by the Cal/OSHA multiple-employer worksite regulation (California Code of Regulations, title 8, section 336.10). While all employers are responsible for the safety and health of their own employees, under certain circumstances, an employer in a multiple-employer setting may also have responsibility for the safety and health of employees other than their own. Similarly, in a "dual-employer" setting (where an employee has two employers at the same time), an employer may have responsibility for the health and safety of workers whom it does not employ directly or supervise directly. The responsibilities of employers in multiple-employer and dual-employer settings are set forth in Labor Code sections 6400 and 6401.7; California Code of Regulations, title 8, sections 336.10 and 3203; and case law interpreting and applying these statutes and regulations.
Subsection 3342(c)(3) requires multiple employers within a covered building or space to coordinate implementation of their workplace violence prevention plans to ensure all employers and employees understand their respective roles.
- If a violent incident occurs in a parking lot or on the grounds of a facility covered by section 3342, is it also within the scope of section 3342?
If a parking lot or grounds are on the premises of the health facility, incidents that occur in the parking lot or on the grounds are also within the scope of section 3342. Where the health facility is located on a campus that contains some building that are covered entities and others that are not, the question of whether the incident falls within the scope of section 3342 will depend on the specific facts and circumstances of the incident.
- If a hospital building serves the licensed space but patients or visitors never enter the building, is the building still within the scope of section 3342?
§ 3342(b).DefinitionsAre senior living and long term care establishments considered health facilities?
Adult and senior living establishments are not health facilities and are not covered by section 3342. Senior living facilities that are assisted living facilities or residential care facilities for the elderly are not health facilities as defined in subsection 3342(b). They are regulated by the Department of Social Services, not the Department of Public Health. For descriptions of these facilities, go to http://www.cdss.ca.gov/inforesources/Community-Care/ASCP-Centralized-Application-Units
Long term care establishments are health facilities and are covered by section 3342. Long term care facilities, licensed by the California Department of Public Health (CDPH), include skilled nursing facilities, intermediate care facilities, and congregate living health facilities. These categories of facilities are health facilities, as defined in subsection 3342(b). Licensed long term health facilities are listed at: http://hfcis.cdph.ca.gov/longtermcare/fulllisting.aspx?st=ltc.
The following establishment are defined as health facilities in subsection 3342(b). The facilities marked with asterisks are long term care establishments:
(1) General acute care hospital
(2) Acute psychiatric hospital
(3) Skilled nursing facility*
(4) Intermediate care facility*
(5) Intermediate care facility/developmentally disabled habilitative*
(6) Special hospital
(7) Intermediate care facility/developmentally disabled*
(8) Intermediate care facility/developmentally disabled-nursing*
(9) Congregate living health facility*
(10) Correctional treatment center
(11) Nursing facility*
(12) Intermediate care facility/developmentally disabled-continuous nursing (ICF/DD-CN)*
(13) Hospice facility
The facilities listed above are defined in California Health and Safety Code section 1250: http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=HSC§ionNum=1250 . A description of each of the above long term health facilities shown in bold font is provided by CDPH at http://hfcis.cdph.ca.gov/servicesandfacilities.aspx. Nursing facilities are not described, but are considered a subset of skilled nursing facilities.
- The definition of "workplace violence" includes the threat or use of physical force against an employee that results in, or has a high likelihood of resulting in, injury, psychological trauma, or stress. How does an employer quantifiably or objectively assess if an event had a "high likelihood" of causing injury, psychological trauma, or stress?
The employer should exercise reasonable judgement, in consultation with the employee(s) targeted in the violent incident and employee representatives (if applicable), in determining whether the threat or use of physical force resulted in or had a high likelihood of resulting in injury, psychological trauma, or stress.
§ 3342(c). Workplace Violence Prevention PlanSubsection 3342(c)(10) requires employers to establish procedures to identify and evaluate patient-specific risk factors. What is the relevance of a patient’s psychiatric condition or diagnosis in this evaluation?
Patient-specific risk factors include those listed in subsections 3342(c)(10)(A)–(c)(10)(D). A patient’s condition or diagnosis should be taken into account in the context of the other factors and not isolated from the other factors. The diagnosis of a specific illness with no other indication of violence from other factors does not necessarily indicate an increased risk of violence.
- Subsection 3342(c)(4) requires employers to have effective procedures for obtaining assistance from law enforcement. However, some law enforcement agencies have declined to work cooperatively with health facilities and do not always respond. Will health care employers be cited if a law enforcement agency fails to respond?
Section 3342(c)(4) requires employers to have procedures to obtain assistance from law enforcement agency. Employers are expected to have reasonable procedures in place to obtain assistance from law enforcement and, if the need arises, to make a good faith effort to communicate and work with law enforcement agencies to obtain their assistance. The procedures must be effective only to the extent possible and under control of the employer. Employers will not be held responsible for conduct by law enforcement that is outside the employer’s control.
- What are some examples of past violations and successful solutions to workplace violence hazards?
Cal/OSHA has investigated workplace violence for many years, both in health care and elsewhere. When problems were found during these inspections, violations would typically fall under the communication, assessment, and training requirements of the Injury and Illness Prevention Program regulation, in title 8 section 3203, and requirements regarding Employee Alarm Systems, in title 8 section 6184. Some investigations of high-risk employers resulted in special orders that required those employers to implement a workplace violence assessment, control, and training program. Many elements of the special orders have been incorporated into the new regulation, such as a written violence prevention plan, procedures to identify and evaluate environmental and patient violence risk factors, procedures to correct violence hazards, violent incident recordkeeping, and workplace security training.
Engineering controls included mobile personal alarms, reconfiguration of physical spaces to remove blind spots, placing intake staff behind physical barriers or glass, installing windows or closed-circuit television cameras, and removal or securing of loose equipment that could be used as a potential weapon. Administrative controls included the creation of systems to disseminate behavior risk assessment information to all affected staff, increased staffing of security personnel, implementing buddy systems, alarm testing, and live drills. Compliance officers conducting these investigations were selected for the work and trained on federal OSHA guidance on workplace violence inspection procedures found in CPL 02-01-058, Enforcement Procedures for Investigating or Inspecting Workplace Violence Incidents: http://www.osha.gov/OshDoc/Directive_pdf/CPL_02-01-058.pdf
In addition, federal OSHA published "Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers" (http://www.osha.gov/Publications/osha3148.pdf) that describes many possible engineering, administrative and work practice controls to address workplace violence.
§ 3342(d). Violent Incident Log and § 3342(g) Reporting Violent Incidents1If an incident occurs on a public sidewalk adjacent to a health facility, is the health facility required to record the incident on their violent incident log or report the incident to Cal/OSHA?
If the employee is not working and is not on the premises of the hospital or other health care facility, a violent incident is not required to be recorded or reported under section 3342. If an employee is working in a facility covered by section 3342 and a violent patient forces the employee out of the facility and then attacks the employee on public property, the violent incident is recordable, and in the case of hospitals, may be reportable. Incidents involving health care workers such as emergency medical responders and home health care workers while performing their duties offsite need to be recorded.
- Subsection 3342(g) requires reporting "the use of physical force against an employee by a patient or a person accompanying a patient that results in, or has a high likelihood of resulting in, injury, psychological trauma, or stress, regardless of whether the employee sustains an injury." How do we quantifiably or objectively assess if an event had a "high likelihood" of causing injury, psychological trauma, or stress?
The employer should exercise reasonable judgment, in consultation with the employee(s) targeted in the violent incident and employee representatives (if applicable), in determining whether the use of physical force resulted in or had a high likelihood of resulting in injury, psychological trauma, or stress.
- Are employees required to complete violent incident reports or the employer’s violent incident log?
Subsection 3342(c)(12)(G) requires the employer to solicit information from affected employees after an incident of workplace violence, but the employees are not required to complete a report. Similarly, subsection 3342(d) requires the employer to solicit information from affected employees for the violent incident log, but the employees are not required to fill out the log.
- The definition of workplace violence in subsection 3342(b) states: "The term workplace violence shall not include lawful acts of self-defense or defense of others." Does this exception apply to police actions in responding to incidents of violence?
The exception for lawful self-defense or defense of others applies to everyone, including law enforcement and security personnel. Hospitals are not required to report the lawful use of a Taser or other weapon by on-duty law enforcement or security personnel.
- The Cal/OSHA preregistration letter sent to hospitals2 states that hospitals "must report to DOSH incidents of physical force against an employee by a patient or a person accompanying a patient, as well as all incidents involving the use of a firearm or other dangerous weapon."However, in the regulation, the four types of workplace violence include co-workers and those with no legitimate business at the site. Do we report on all four types of workplace violence as defined in section 3342, or only Type 2 workplace violence and those involving a weapon?
Only those incidents as described in subsections 3342 (g)(1)(A) and 3342(g)(1)(B) must be reported to Cal/OSHA. The Cal/OSHA preregistration letter was correct and consistent with the regulation:
(g) Reporting Requirements for General Acute Care Hospitals, Acute Psychiatric Hospitals, and Special Hospitals.
(1) Every general acute care hospital, acute psychiatric hospital, and special hospital shall report to the Division any incident involving either of the following:
(A) The use of physical force against an employee by a patient or a person accompanying a patient that results in, or has a high likelihood of resulting in, injury, psychological trauma, or stress, regardless of whether the employee sustains an injury;
NOTE: "Injury" as used in subsection (g)(1)(A), means an injury meeting the criteria in Section 14300.7(b)(1).
(B) An incident involving the use of a firearm or other dangerous weapon, regardless of whether the employee sustains an injury.
- Are hospitals required to report violent incidents occurring at off-site clinics on the hospital’s license?
Section 3342(g)(1) requires every general acute care hospital, acute psychiatric hospital and special hospital to report certain violent incidents to Cal/OSHA. In subsection 3342(b), acute psychiatric hospitals and general acute care hospitals (there are no special hospitals in California) are defined as:
"Acute psychiatric hospital" (APH) means a hospital, licensed by the California Department of Public Health as such meeting the definition provided in Health and Safety Code Section 1250(b) or California Code of Regulations, Title 22, Section 71005; and all services within the hospital's license.
"General acute care hospital" (GACH) means a hospital, licensed by the California Department of Public Health as such meeting the definition provided in Health and Safety Code Section 1250(a) or California Code of Regulations, Title 22, Section 70005, and all services within the hospital's license.
The definitions of both types of hospitals include "all services within the hospital’s license." If offsite clinics provide services within a hospital’s license, then a workplace violence incident (meeting the criteria in subsection 3342(g)(1)) occurring at these locations must be reported to the Division.
- Does an animal bite fall within the definition of workplace violence for recording and/or reporting? This situation could arise particularly in the home health setting.
For recording purposes, using an animal as a weapon against an employee performing work within the scope of section 3342 would fall within the definition of "workplace violence" in subsection 3342(b) and would therefore need to be recorded on the violent incident log.
For reporting purposes, using an animal as a weapon against an employee performing work within the scope of section 3342 would fall within the criteria in subsection 3342(g) and would therefore need to be reported to Cal/OSHA, if the employee is employed by or working at a hospital covered by subsection 3342(g).
§ 3342(f). TrainingDoes everyone working in a hospital need to obtain some form of training, or just certain individuals in certain departments?
All employers whose employees perform work within the scope of section 3342 must provide training to employees commensurate with the risk that employees are reasonably anticipated to encounter in their jobs.
The training that is required depends on the duties of the employees:
Subsection Who Must Be Trained Training Requirement 3324(f)(1) All employees One-time initial training on the employer’s workplace violence prevention plan and other topics 3342(f)(1)(B) All employees Additional training when new equipment or work practices are introduced or when a new or previously unrecognized workplace violence hazard has been identified 3342(f)(2) Employees who perform patient contact activities Annual refresher training on the topics included in the initial training and the results of review of the employer’s workplace violence prevention plan 3342(f)(3) Employees who respond to alarms or other notifications of violent incidents whose assignments involve confronting or controlling persons exhibiting aggressive or violent behavior Initial and annual training specific to the safe handling of violent incidents
- Is there a specific class that employees need to take? Is there a requirement on how long the class needs to be?
No specific class and no minimum length of training time are required by section 3342.
A generic training program that does not contain specifics on the employer’s workplace violence prevention program, including site-specific procedures, hazards, and prevention methods, will not meet the requirements of subsection 3342(f). The training should be based on the employer’s assessment of risk factors. The site-specific components of the required initial training are listed in subsection 3342(f)(1)(A)1.
Pre-packaged or commercially produced training programs may be used to supplement site-specific training where they meet the needs identified in the employer’s workplace violence prevention plan.
- Are health care facilities required to train contractors’ employees who are in the health care facility for very short periods of time?
Training of employees is governed by language in subsection 3342(f) requiring employers to provide effective training that addresses the workplace violence risks that employees are reasonably anticipated to encounter in their jobs.
All employers whose employees perform work within the scope of section 3342 are responsible for the safety and health of their own employees. Furthermore, a health care facility employer may be considered a controlling employer (see California Code of Regulations, title 8, section 336.10) that is responsible for safety and health conditions affecting all employees in the health care facility and therefore may be required to ensure that all employees—even those who may be directly employed by another employer—receive the proper training regarding workplace violence prevention.
Employees of other employers who work in a health care facility for short periods with low-risk exposure to violence (such as employees who repair, maintain, or service equipment at a hospital) must be provided with training on the health care facility’s workplace violence prevention plan and the other elements in section 3342(f)(1)(A). The hospital may ensure that these employees receive the proper training by providing the training directly or by arranging for the employee’s primary employer or a contracted third party to provide the training.
Depending on the workplace violence risks that employees are reasonably anticipated to encounter and the frequency and length of time the employees are in present the health care facility, training may be provided in person or through videos, online information, fact sheets, signage, or other means.
- What training must employers provide for implementing the logging, reporting, and recordkeeping requirements prior to April 1, 2018?
The training requirements of section 3342(f) do not become effective until April 1, 2018. However, under subsection 3342(d), employers are required to record certain violent incidents and maintain a violent incident log beginning on April 1, 2017. In addition, under subsection 3342(g), hospital employers must also report certain violent incidents to the Division beginning on July 1, 2017. There are no specific training requirements for the recording and reporting of violent incidents prior to April 1, 2018, but employers must ensure that recording and reporting are performed in compliance with sections 3342(d) and 3342(g).
§ 3342(h). RecordkeepingSection 3342 gives employees the right to access the violent incident log. Must this be the same log that employers are required to produce for Cal/OSHA on request, or can it be abbreviated?
Employees and their representatives have the right to see the complete violent incident log. Under subsection 3342(h)(5), all records required by subsection 3342(h) must be made available to employees and their representatives, on request, for examination and copying.
- Is there a time frame in which the violent incident log must be produced for employees?
Section 33429(h)(5) requires that access be consistent with section 3204(e), which states that the record is to be provided no later than 15 days after the request is made.
1 Additional answers to frequently asked questions for reporting violent incidents is available at: http://www.dir.ca.gov/dosh/documents/hospital-workplace-violence/faq.pdf
2 Cal/OSHA preregistration letter for violent incident reporting sent to all California hospitals on February 1, 2017 http://www.dir.ca.gov/dosh/documents/hospital-workplace-violence/hospital-registration-letter.pdf