osha update for long term care facilitiesanha.org/members/documents/anhaosha2012.pdf · relating to...

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OSHA UPDATEFOR LONG TERMCARE FACILITIES

Alabama Nursing Home AssociationMarch 19, 2012

WHO IS OSHA?

Occupational Safety and Health Administration

Created under the OSH Act of 1970 Initiated in 1971 as a Federal Agency Initiated in 1971 as a Federal AgencyPurpose:

...to assure so far as possible every working man and woman in the Nation safe and healthful working conditions and to preserve our human resources...

OFFICE OF INSPECTOR GENERAL (OIG)

Released September 10, 2010

Title: “OSHA NEEDS TO EVALUATE THE

IMPACT AND USE OF HUNDREDS IMPACT AND USE OF HUNDREDS OF MILLIONS OF DOLLARS IN PENALTY REDUCTIONS AS INCENTIVES FOR EMPLOYERS TO IMPROVE WORKPLACE SAFETY AND HEALTH “

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Why OIG conducted the audit??? The objective of this audit was to answer the

question: Has OSHA effectively evaluated the impact of penalty

reduction incentives on workplace safety and health? reduction incentives on workplace safety and health?

The audit covered 49,192 Federal OSHA inspections of non-Federal employers initiated between July 2007 and June 2009.

The inspections resulted in 142,187 citations and $523.5 million in penalties which were reduced by $351.2 million (67 percent).


WHAT OIG FOUND: OSHA has not effectively evaluated the

impact of $351 million in penalty reductions as an incentive for employers e c o s as a ce ve o e p oye s to improve workplace safety and health. Small employers received the largest reductions (78 percent), but generally had the worst safety and health history — more inspections, more fatalities, and more high-gravity serious (likely to cause death) and repeat violations.


Finally…..OSHA Area Directors did not document

the justification for reductions resulting from informal settlement agreements, for g ,an estimated 49 percent of reductions or $31.8 million.

OSHA incorrectly granted history reductions of $1.1 million to employers with prior violations. “

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READ THE FULL REPORT To view the report, including the scope,

methodology, and full agency response, go to:

http://www.oig.dol.gov/public/reports/oa/2010/02-10-201-10105.pdf

NOTE:OSHA’s Dr. David Michaels, PHD responded in

a memo on September 28, 2010.

OSHA SITE SPECIFIC TARGET PROGRAM

2011

EFFECTIVE DATE: September 9, 2011Purpose: OSHA’s Site-Specific Targeting 2011

(SST-11) inspection plan, and replaces (SST 11) inspection plan, and replaces the August 18, 2010 Notice that implemented OSHA’s Site-Specific Targeting 2010 (SST-10) inspection plan.


2011

Cancellations: OSHA Notice 10-06 (CPL 02), Site-Specific Targeting 2010 (SST-10), August 18, 2010.

Expiration Date: One year from the effective date, unless replaced earlier by a new Notice.

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2011

Significant Changes from 2010 Uses CY 2009 injury and illness data to

compile the targeting lists. Changes the establishment employee size Changes the establishment employee size

from 40 to 20. Incorporates a study to determine the

impact of SST inspections on injury/illness rates and compliance for establishments.


2011

Creating the SST-11 Inspection Lists. OSHA focused its data collection

towards establishments that are most likely to be experiencing elevated rates and numbers of occupational injuries and numbers of occupational injuries and illnesses

NOTE: The 2009 injury and illness data that was collected by the 2010 Data Initiative is used in the 2011 Site-Specific Targeting program.


2011

Primary Inspection List for Nursing/Personal Care Facilities Establishments in SIC code 805

with a DART rate at or above 16 0 with a DART rate at or above 16.0, or a DAFWII case rate at or above 13.0 (only one of these criteria must be met).

This is approximately 300 sites

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2011

Primary Inspection List Continued:

Because of the large number of establishments in SIC code 805 that reported high rates in the OSHA reported high rates in the OSHA Data Initiative survey, higher DART and DAFWII rates are used to select a limited number (300 for the SST-11) of the highest rated establishments in this SIC code


2011

SCOPE: Inspections in the SIC code will focus

specifically on ergonomic stressors; exposure to blood and other potentially p p yinfectious materials; exposure to tuberculosis; and slips, trips, and falls.

When additional hazards come to the attention of the compliance officer, the scope of the inspection may be expanded to include those hazards


2011

Scope:When conditions indicate that a General Duty Clause citation relating to ergonomics may be relating to ergonomics may be warranted, the Area Office will contact the Regional Ergonomics Coordinator.

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2011Recordkeeping Rule

The recordkeeping regulation at §1904.40(a) states that once a request is made, an employer must provide the required recordkeeping records within four (4) business hoursAlthough the employer has four hours to provide Although the employer has four hours to provide

recordkeeping records, there is no requirement that compliance officers must wait until the records are provided before beginning the walk-around portion of the inspection

As soon as the opening conference is completed, the compliance officer(s) are to begin the walk-around portion of the inspection


2011

Previous Inspections Establishments will be deleted from the inspection

list if, within 36 months of the creation of the current inspection cycle, one of the following conditions is met:

1 Establishment received a comprehensive safety 1. Establishment received a comprehensive safety inspection;

2. Establishment qualified for a “records only” inspection; or

3. Establishment in SIC code 805 received an inspection that focused on ergonomic stressors relating to resident handling; exposure to blood and other potentially infectious material; exposure to tuberculosis; and slips, trips, and falls.


2011

Inspection Procedures The scope of inspections for nursing and

personal care facilities (SIC code 805) will focus specifically on ergonomic p y gstressors; exposure to blood and other potentially infectious materials;exposure to tuberculosis; and slips, trips, and falls

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2011

Inspection Procedures Continued During inspections under this Notice, the

OSHA-300 Logs for 2008, 2009, and 2010 will be reviewed. The CSHO will calculate the DART rate and the DAFWII case rate for each DART rate and the DAFWII case rate for each of those years.

NOTE: The OSHA-300 Logs for 2011 (and 2012 when applicable) may also be reviewed for possible injuries and illnesses occurring during the year, but are not to be substituted for the calculations below.


2011

Inspection Procedures Continued The CSHO-calculated DART rate for 2009 will be

compared to the DART rate reported by the employer in the OSHA 2010 Data Initiative data collection.

CSHOs will check OSHA-301 Forms, or equivalent, CS Os w c ec OS 30 o s, o eq va e , as they deem appropriate to confirm the OSHA-300 Forms

For “records only” inspections, a partial walkthrough must be conducted to interview employees in order to verify the establishment’s injury and illness experience

Any serious violations that are observed in plain view in the vicinity or brought to the attention of the CSHO must be investigated and may be cited.

OSHA WORKPLACE VIOLENCE DIRECTIVE

DIRECTIVE NUMBER: CPL 02-01-052 EFFECTIVE DATE:

September 8, 2011

SUBJECT: Enforcement Procedures for

Investigating or Inspecting Workplace Violence Incidents

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Purpose and Changes: This instruction establishes general policy

guidance and procedures for field offices to apply when conducting inspections in response to incidents of workplace violence

This is the first instruction on the enforcement procedures for investigations and inspections that occur as a result of workplace violence incident(s) and specifically at worksites in industries that OSHA has identified as susceptible to workplace violence.

It clarifies and expands the Agency’s policies and procedures in this area


HIGHLIGHTS: This directive is not intended to require an OSHA

response to every complaint or fatality of workplace violence or require that citations or notices be issued for every incident inspected or investigated Instead, it provides general enforcement guidance to be

applied in determining whether to make an initial response and/or cite an employer.

Under this directive, inspectors should therefore gather evidence to demonstrate whether an employer recognized, either individually or through its industry, the existence of a potential workplace violence hazard affecting his or her employees


OSHA-Identified High-Risk Industries Healthcare and Social Service Settings

This category covers a broad spectrum of workers who provide healthcare pand social services in psychiatric facilities, hospital emergency departments, community mental health clinics, drug abuse treatment clinics, pharmacies, community-care facilities, residential facilities and long-term care facilities

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Types of Workplace Violence:

1. Type 1—Criminal Intent Violent acts by people who enter the workplace to

commit a robbery or other crime or current or commit a robbery or other crime—or current or former employees who enter the workplace with the intent to commit a crime.

2. Type 2—Customer/Client/Patients Violence directed at employees by customers,

clients, patients, students, inmates or any others to whom the employer provides a service.


Types of Workplace Violence Continued:

3. Type 3—Co-worker Violence against co-workers, supervisors, or

managers by a current or former employee, supervisor, or manager.

4. Type 4—Personal Violence in the workplace by someone who does not

work there, but who is known to, or has a personal relationship with, an employee.


OSHA: Potential Abatement Methods or Recommendations SEE: Healthcare and Social Services

Facilities. (OSHA publication 3148) for complete listingcomplete listing

1. Engineering Controls and Workplace Adaptations to Minimize Risk

2. Administrative and Work Practice Controls to Minimize Risk

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Sample Engineering Controls/ Adaptations Enclose nurses’ stations and install deep

service counters or bullet-resistant, shatter-proof glass in reception, triage and admitting areas or client service roomsareas or client service rooms.

Provide employee “safe rooms” for use during emergencies

Arrange furniture to prevent entrapment of staff.

Provide lockable and secure bathrooms for staff members separate from patient/client and visitor facilities

OSHA WORKPLACE VIOLENCE DIRECTIVE Sample Administrative Control/ Adaptations

Ensure that adequate and properly trained staff is available to restrain patients or clients, if necessary.

Ensure that adequate and qualified staff is available at all times. The times of greatest risk occur during patient transfers, emergency responses, mealtimes and at night

Control access to facilities other than waiting rooms, particularly drug storage or pharmacy areas.

Establish a system—such as chart tags, log books or verbal census reports—to identify patients and clients with assaultive behavior problems. Keep in mind patient confidentiality and worker safety issues. Update as needed. Review any workplace violence incidents from the previous shift during change-in-shift meetings.

OSHA PRESS RELEASE

Release Number: 11-1638-NAT Nov. 9, 2011

Statement from Assistant Secretary of Labor for OSHA on increase of nonfatal increase of nonfatal occupational injuries among health care workers OSHA to focus on improving safety and health at nursing home facilities

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OSHA PRESS RELEASE

WASHINGTON – “The U.S. Department of Labor's Bureau of Labor Statistics today released detailed data on nonfatal occupational injuries and illnesses requiring days away from work in 2010

The incidence rate for health care support workers increased 6 percent to 283 cases per 10,000 full-time workers, almost 2 1/2 times the rate for all private and public sector workers at 118 cases per 10,000 full-time workers”

OSHA PRESS RELEASE

Assistant Secretary for the department's Occupational Safety and Health Administration Dr. David Michaels issued the following statement in response:

"It is unacceptable that the workers who have dedicated their lives to caring for our loved ones when they are sick are the very same workers who face the highest risk of work-related injury and illness. These injuries can end up destroying a family's emotional and financial security. While workplace injuries, illnesses and fatalities take an enormous toll on this nation's economy – the toll on injured workers and their families is intolerable.

OSHA PRESS RELEASE

"The rates of injuries and illnesses among hospital and health care workers underscore OSHA's concern about the safety and health of these workers. OSHA is responding by launching, in the next few months, a National Emphasis , pProgram on Nursing Home and Residential Care Facilities. Through this initiative, we will increase our inspections of these facilities, focusing on back injuries from resident handling or lifting patients; exposure to bloodborne pathogens and other infectious diseases; workplace violence; and slips, trips and falls.

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OSHA PRESS RELEASE

"The workers that care for our loved ones deserve a safe workplace and OSHA is diligently working to

k hi hmake this happen."

COMPLAINT INVESTIGATIONS

Becoming MORE Common Typical Process:

Employer notified by phone of complaint allegations p y y p p g Follow-up in writing faxed (or mailed) to employer Employer investigates and responds to OSHA Complaint advised of employer's response Complaint closed with satisfactory response

INCIDENCE RATES

DART Days Away, Restricted, or Transferred

DAFWII Days Away from Work Injury and Illness

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CURRENT INCIDENCE RATES

SKILLED NURSING (SIC 8051)

RatesDART

(days away, restricted or transfer)

DAFWII (days away from

work injury/illness)

Incident Rate(All recordable

incidents)

Other Recordable

(All other than death, lost time, restricted,

transfer)

National-2009

5.6 2.6 8.9 3.2

Alabama-2007 8.4 5.9 10 1.6

OSHA FINE/PENALTIES

Fiscal year 2010 data for OSHA fines across all sectors of the healthcare industry. Of the $708,314 in fines issued through

inspections, over half was incurred by nursing and personal care facilities.

Nursing and Personal Care Facilities (8051) received $358,560

OSHA FINE/PENALTIES

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OSHA FINE/PENALTIES

Recent Fines in Nursing Homes (12-18 months)

Approx: $49,000 Included a repeat violation from sister facility, p y,

one clinical violation, physical plant

Approx: $18,000 Primarily Recordkeeping and training

documents

Approx: $10,000 91 days after Safe State inspection

RIGHTS AND RESPONSIBILITIES

Employer http://www.osha.gov/Publications/osha3000.ht

ml

E l Employeehttp://www.osha.gov/Publications/3021.html

OSHA AND LIFE SAFETY

• Part Number: 1910 • Part Title: Occupational Safety and Health

Standards • Subpart: E • Subpart Title: Means of Egress • Standard

Number: 1910.35• Title: Compliance with NFPA 101-2000, Life

Safety Code.

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OSHA AND LIFE SAFETY

An employer who demonstrates compliance with the exit route provisions of NFPA 101-2000, the Life Safety Code, will be deemed to be in compliance with the corresponding requirements in §§ 1910.34, 1910.36, and 1910.37. Reference:

[39 FR 23502, June 27, 1974, as amended at 45 FR 60703, Sept. 12, 1980; 53 FR 12121, Apr. 12, 1988; 67 FR 67962, Nov. 7, 2002

GENERAL DUTY CLAUSE

Section 5(a)(1) of the OSH Act requires:

"Each employer shall furnish to each of his employees employment and a place of employment which and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees."

GENERAL DUTY CLAUSE (CONT’D)

The general duty clause is used only where there is no OSHA standard that applies to the particular hazard involved.

Examples of workplace hazards to which the general duty clause may apply include: Ergonomics, Occupational Exposure to TB

and Workplace Violence.

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GENERAL DUTY CLAUSE (CONT’D)

Four elements are required for issuing general duty clause violations:

1. The employer failed to keep the workplace free of a hazard to which employees of that employer where exposed p

2. The hazard was recognized 3. The hazard was causing or was likely to cause

death or serious physical harm 4. There was a feasible and useful method to correct

the hazard

OSHA REQUIRED PROGRAMS

OSHA Requirements That Apply to Most Health Care Employers

The following programs are g p gEXAMPLES of the key OSHA standards that apply to most health care employers:

HAZARD COMMUNICATION

SUMMARY Protection under OSHA's Hazard Communication

Standard (HCS) includes all workers exposed to hazardous chemicals in all industrial sectors. Thi d d i b d i l h This standard is based on a simple concept - that employees have both a need and a right to know the hazards and the identities of the chemicals they are exposed to when working.

They also need to know what protective measures are available to prevent adverse effects from occurring.

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HAZ-COM STANDARD

OSHA Hazard Communications Standard, 29 CFR 1910.1200 Material Safety Data Sheets (MSDS)Material Safety Data Sheets (MSDS)

Responsible PersonReadily Available Locations

Container LabelingResponsible PersonUniversal Labeling System

HAZ-COM TRAINING

An overview of the OSHA hazard communication standard

The hazardous chemicals present at his/her work area wo a ea

The physical and health risks of the hazardous chemicals

Symptoms of overexposure How to determine the presence or release of

hazardous chemicals in the work area

HAZ-COM TRAINING CONT.

How to reduce or prevent exposure to hazardous chemicals through use of control procedures, work practices and personal protective equipment

Steps the company has taken to reduce or prevent exposure to hazardous chemicals exposure to hazardous chemicals

Procedures to follow if employees are overexposed to hazardous chemicals

How to read labels and MSDSs to obtain hazard information

Location of the MSDS file and written Hazard Communication program

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BLOODBORNE PATHOGENS STANDARD

OSHA standard 29 CFR 1910.1030, "Occupational Exposure to Bloodborne Pathogens.“g

Requires: Development, Implementation and

Maintenance of Exposure Control Plan (ECP)

EXPOSURE CONTROL PLAN (ECP)

ECP Inclusions: Determination of employee exposure Implementation of various methods of Implementation of various methods of

exposure control, including:Universal precautionsEngineering and work practice

controlsPersonal protective equipmentHousekeeping

EXPOSURE CONTROL PLAN (ECP)

Hepatitis B vaccination Post-exposure evaluation/follow-up Communication of hazards to employees

and training Recordkeeping Procedures for evaluating circumstances Safer Device Review and Selection

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ELECTRICAL HAZARD STANDARDS

What OSHA standards address electrical safety? Title 29 Code of Federal Regulations (CFR), Part

1910.302 through 1910.308 -- Design Safety Standards for Electrical Systems, and 1910.331 through 1910.335 -- Electrical Safety-Related Work Practices Standards.

OSHA's electrical standards are based on the National Fire Protection Association Standards NFPA 70,National Electric Code, and NFPA 70E, Electrical Safety Requirements for Employee Workplaces.

LOCK-OUT TAG-OUT STANDARD

1910.147(a)(1)(i) This standard covers the servicing and maintenance of machines and equipment in which the unexpectedenergizing or start up of the machines or energizing or start up of the machines or equipment, or release of stored energy could cause injury to employees. This standard establishes minimum performance requirements for the control of such hazardous energy.

LOCK-OUT TAG-OUT

Definition: Lockout/Tagout means that any

energy source, be it electrical, h d li h i l th hydraulic, mechanical or any other source that may cause unexpected movement, must be disengaged or blocked, and electrical sources must be de-energized and locked in the off position

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EMERGENCY ACTION PLAN STANDARD

What is a workplace emergency?

A workplace emergency is an unforeseen situation that threatens your employees situation that threatens your employees, customers, or the public; disrupts or shuts down your operations; or causes physical or environmental damage.

MEDICAL AND FIRST AID

29 CFR 1910.151 Medical services and first aid

To handle potential workplace i j i l t th t injuries, employers must ensure that medical personnel and adequate first aid supplies are available to workers. The selection of these resources must be based on the types of hazards in the workplace.


Procedural, Program, and/or Equipment Requirements Ensure that medical personnel are ready and

available for advice and consultation on the overall employee safety and health condition in the workplaceworkplace.

Provide trained personnel and adequate first aid supplies to render first aid when a medical facility is not in near proximity to the workplace.

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Provide suitable facilities for immediate emergency use if exposure to injurious or corrosive materials is possible. Training Requirements Adequately train personnel

t d t d i i t fi t idexpected to administer first aid.“Eye Wash Stations”

Employees must know your exposures, locations, and accessibility to Stations.


Eyewash Guidelines:

Paragraph (c) of 29 CFR 1910.151 requires the employer to provide

it bl f iliti f i k d hi suitable facilities for quick drenching or flushing of the eyes and body when employees may be exposed to injurious corrosive materials.


Eyewash Continued:

ANSI Z358.1 provides detailed information regarding the installation and operation of emergency eyewash and shower equipment. emergency eyewash and shower equipment.

OSHA therefore, has often referred employers to ANSI Z358.1 as a source of guidance for protecting employees who may be exposed to injurious corrosive materials.

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Eyewash Continued: 29 CFR 1910.151(c) does not provide specific

instruction regarding the installation and operation of emergency eyewash and shower equipment of emergency eyewash and shower equipment. Therefore, it is the employer's responsibility to assess the particular conditions related to the eyewash/shower unit, such as water temperature, to ensure that the eyewash/shower unit provides suitable protection against caustic chemicals/materials to which employees may be exposed.

PERSONAL PROTECTIVE EQUIPMENT

(PPE)

What is personal protective equipment?

Personal protective equipment, or PPE, isdesigned to protect employees from seriousdesigned to protect employees from seriousworkplace injuries or illnesses resulting from:

contact with chemical, radiological, physical, electrical, mechanical, or other workplace hazards


(PPE)

You are required to train employees who are required to wear PPE the following:Proper Use of PPENecessity of PPENecessity of PPEType and application of PPELimitations of PPEDon and adjustment of PPEMaintenance of PPE.

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(PPE)

Personal Protective Equipment (PPE). Employers must perform an assessment of each operation in their workplace to determine if their employees are required to wear PPE. Note that engineering controls and work

practices are the preferred methods for protecting employees ― OSHA generally considers PPE to be the least desirable means of controlling employee exposure.

OTHER OSHA REQUIRED AND/OR

RECOMMENDED PROGRAMS

Additional Hazards may exist in Health Care Facilities that require Health Care Facilities that require further Program Development to comply with OSHA requirements

ERGONOMIC HAZARDS

OSHA issued an ergonomics guideline for the nursing home industry on March 13, 2003. , In order to develop the guidelines OSHA

reviewed existing ergonomics practices and programs, State OSHA programs, as well as available scientific information.

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ERGONOMICS

What does OSHA consider an "ergonomic injury"? Ergonomic injuries are often described by the term "musculoskeletal disorders" or "MSD “"MSDs.“This is the term that refers collectively to a group of injuries and illnesses that affect the musculoskeletal system; there is no single diagnosis for MSDs.

ERGONOMICS CONT.What is the goal of the guidelines?

OSHA recommends that manual lifting of residents be minimized in all cases and eliminated when feasible.

OSHA recommends that employers implement a OSHA recommends that employers implement a systematic process for identifying and resolving ergonomics issues, and incorporate this process into its overall program to recognize and prevent work-related injuries and illnesses.

OSHA recognizes that small nursing homes may not need a formal program to accomplish this goal.

ERGONOMIC QUESTIONS?

Can an OSHA compliance officer cite a nursing home facility for not implementing the guidelines? No. The guidelines are completely voluntary.

How can your get a copy of the guidelines? The guidelines are available for downloading

from OSHA's web site at www.osha.gov.

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WORKPLACE VIOLENCE TRAINING

Training Materials:

OSHA Workplace Violence Prevention Overview Health Care and Social Service W k Workers PowerPoint Presentation

HTML VersionPPT* - 926 KB Handouts [PDF - 188 KB]

OSHA Publication 3148 [PDF - 244 KB]

SLIPS, TRIPS AND FALLS

Possible Solutions : Keep floors clean and dry [29 CFR 1910.22(a)(2)]. In

addition to being a slip hazard, continually wet surfaces promote the growth of mold, fungi, and bacteria, that can cause infections. ,

Provide warning signs for wet floor areas [29 CFR 1910.145(c)(2)].

Where wet processes are used, maintain drainage and provide false floors, platforms, mats, or other dry standing places where practicable, or provide appropriate waterproof footgear [29 CFR 1910.141(a)(3)(ii)].


Possible Solutions Contd. Walking/Working Surfaces Standard requires [29

CFR 1910.22(a)(1)]: Keep all places of employment clean and orderly and in a sanitary condition.

Keep aisles and passageways clear and in good Keep aisles and passageways clear and in good repair, with no obstruction across or in aisles that could create a hazard [29 CFR 1910.22(b)(1)]. Provide floor plugs for equipment, so power cords need not run across pathways.

Keep exits free from obstruction. Access to exits must remain clear of obstructions at all times [29 CFR 1910.36(b)(4

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Additional Information: Walking/Working Surfaces. OSHA

Safety and Health Topics Page. 29 CFR 1910 22 General Requirements CFR 1910.22, General Requirements [Walking/Working Surfaces]. OSHA Standard.

Small Business Handbook. OSHA Publication 2209-02R, (2005). Also available as a 260 KB PDF, 56 pages.

COMPRESSED GASES

Hazards associated with compressed gases include oxygen displacement, fires, explosions, and toxic gas exposures, as well as the physical hazards associated with high

t pressure systems. Special storage, use, and handling precautions

are necessary in order to control these hazards.

SAFETY COMMITTEE Virtually all safety committee activities involve some

combination of the following:

Hazard AssessmentReview, Hands-on Inspections

Incident Review (“near miss”) Incident Review ( near miss )Review and trending of events

Training and EducationReview, revision, development of employee training

Safety ManagementOrganize and make valid recommendations for

management changes

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SAFETY & HEALTH PROGRAM

DEVELOPMENT

Nursing Home eTool http://osha.gov/SLTC/etools/nursinghome/index.html

Th T l dd th f ll i t iThe e-Tool addresses the following topics: Bloodborne Pathogens Ergonomics Dietary Laundry


DEVELOPMENT

E-Tool Inclusions Continued: Maintenance Nurses Station

Ph Pharmacy Tuberculosis Housekeeping Whirlpool/Shower Workplace Violence


DEVELOPMENT

Sample Safety and Health Programs for Small Business (OSHA)

htt // h /SLTC/ t l / f t h lth/http://osha.gov/SLTC/etools/safetyhealth/mod2_sample_sh_program.html

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Michael Arther, NHAMCA Consulting, LLC

michael@mcaconsult [email protected]

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