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What are the Components of a Respiratory Protection Program?

September 14, 2020
Compliance, Documentation, Billing, & Coding By Deborah Alexander, Director

The Occupational Safety and Health Administration (OSHA), part of the U.S. Department of Labor, is the governing body entrusted to ensure working individuals have safe and healthy working conditions by establishing and enforcing standards.

The focus of the OSHA Respiratory Protection Program (RPP) standard 29 Code of Federal Regulations (CFR) Part 1910.134 is to protect the staff from exposure to hazardous contaminated air. Maintaining compliance with this standard has come to the forefront during the COVID-19 public health emergency, in particular within the senior living communities. Nursing facilities have been greatly affected by COVID-19, which has infected medically and physically vulnerable patients as well as the staff who care for the them. One critical component of the RPP was the increased need for personal protective equipment (PPE) including N95 Respirators.




What are Key Components of an RPP involving N95 Respirators?

The OSHA RPP standard 29 Code of Federal Regulations (CFR) Part 1910.134 contains the requirements for employees to wear respirators to protect against workplace hazards. The RPP standard contains the following requirements:

  1. Designate a Respirator Program Administrator (RPA)—OSHA requires that a suitably trained individual is responsible for the program. The responsible person may or may not be a health and safety professional. He/she must know the principles of respiratory protection and the authority to implement the plan.
  2. Develop Written Workplace Specific RPP Policy and Procedures—Evaluate the program's effectiveness regularly and modify written operating procedures, as necessary.
  3. Complete a Hazard Assessment–This is to identify and evaluate potential exposures in the workplace that might require respiratory protection. When conducting a hazard evaluation in the healthcare setting, it is essential to consider all job titles, duties, and responsibilities systematically. Who among the staff will have the most exposure to a hazard (e.g., infectious diseases)?
  4. Develop the Respirator Selection–Based on the hazard assessment, determine which types of respirators will be used by specific staff for job titles and specific tasks or procedures. Selected respirators must not hinder the user's ability to see, hear, communicate, and move as necessary to perform the job safely. (Note that both N95 and surgical N95 respirators must be NIOSH certified, but the surgical N95 must also be FDA cleared.)
  5. Conduct Medical Evaluations–A medical evaluation of staff is required before staff are permitted to wear a respirator on the job. Staff are not allowed to wear respirators until a physician or other licensed healthcare professional has determined that they are medically able to do so. The OSHA Respirator Medical Questionnaire is the medical evaluation of choice.
  6. Complete Respirator Fit Testing–This is the most critical part of the RPP because it is the tool utilized to evaluate the fit of the selected respirator model and size to the face of the user. Perform the fit test while the staff is wearing all applicable PPE for actual respirator use, which could interfere with respirator fit. Conduct fit testing at least annually and as needed based on the reasons specified on the OSHA standard. Follow OSHA RPP Appendix A for protocols and exercises that must be followed for Respirator Fit Testing.

Facilities may use either of the following methods, which can be conducted by an outside company/vendor, or staff trained to perform the test:

    • Qualitative Fit Test (QLFT)–This is a pass/fail test that involves the introduction of a harmless odoriferous or irritating substance into the breathing zone around the respirator. Use one of four OSHA-accepted test agents such as Isoamyl acetate (banana smell), Saccharin (sweet taste, or Bitrex (bitter taste, or Irritant smoke (involuntary cough reflex). If the user detects no odor or irritation, this indicates a proper fit.
    • Quantitative Fit Test (QNFT)–Use an instrument to measure leakage around the face seal. It produces a numerical result called a "fit factor," either by generating a test aerosol as a test atmosphere, using ambient aerosol as a test agent, or using controlled negative pressure to measure any leakage. This QNFT offers a more accurate, detailed information on respirator fit.
  1. Perform Staff Training–Perform required staff training for all who will be using a respirator. Training must be comprehensive for the staff to demonstrate a knowledge of the respirator's limitations and capabilities, why the respirator is necessary, and how to inspect, put on and remove, and check respirator seals.
  2. Maintain Recordkeeping–The RPP requires that records be maintained and made available to the staff and OSHA upon request. It includes the RPP Policy and Procedures, the Hazard Assessment and respirator selection, the completed staff OSHA Medical Questionnaire, notes from the medical evaluation and medical clearance by the physician or other health care professional, Respirator Fit Testing Records, and staff training.

Healthcare facilities have been dealing with the supply shortage of PPE since March and staff used any PPE that facility operators managed to acquire. Not everyone can wear an N95 respirator because N95 masks may exacerbate some medical conditions. OSHA has been conducting investigations, giving citations, and penalizing nursing facilities for failure to protect their staff from COVID-19 by not complying with the OSHA Respiratory Protection Program (RPP) standard 29 Code of Federal Regulations (CFR) Part 1910.134. Facility operators must follow OSHA Respiratory Protection Program requirements to establish, implement, and record to support the program.

OSHA released memoranda on March 14, 2020, and April 8, 2020, temporarily suspending the RPP annual Respirator Fit Testing requirements; note OSHA reiterated that facility operators "make a good-faith effort" to comply with the RPP standard. This memoranda supports you if OSHA conducts a survey and your facility has not done a Respirator Fit Testing this year. However, the facility records must support an implemented RPP, including the Respirator Fit Testing done last year.

Not Sure Where to Start?

LW Consulting, Inc. can assist you in getting started with our team of CDC Infection Preventionists, Environmental Services and Respiratory Therapy Services experts.


For more information,  contact Deborah Alexander at 717-213-3122 or email

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