California is the only state with a standalone workplace standard for airborne infectious disease, and skilled nursing facilities sit squarely inside it. Title 8, Section 5199, the Aerosol Transmissible Diseases standard, has been on the books since 2009, but many long-term care operators still treat it as something that only applies to acute-care hospitals. It does not. If your facility admits, houses, or transports residents who may have influenza, tuberculosis, COVID-19, measles, or any other disease spread by droplets or airborne particles, Cal/OSHA expects a written program, fit-tested respirators, a vaccination offer, and documented training. Administrators, directors of nursing, and infection preventionists are the people who get asked for these records when an inspector arrives, usually after an employee complaint or a reported outbreak.
Who Section 5199 Covers
The standard applies to workplaces where employees have occupational exposure to aerosol transmissible pathogens. In plain terms, that includes skilled nursing facilities, hospitals, outpatient clinics, home health agencies, hospice, correctional health units, laboratories that handle these pathogens, and emergency medical transport. A skilled nursing facility is not a low-exposure setting. Residents are elderly, frequently immunocompromised, and housed in close quarters. Nursing assistants, LVNs, RNs, respiratory therapists, housekeeping, dietary staff who enter rooms, and maintenance workers can all have occupational exposure.
The standard is separate from and in addition to Section 5193, the bloodborne pathogens standard, and Section 5144, the respiratory protection standard. Many facilities have a bloodborne pathogens exposure control plan and assume it covers airborne disease. It does not, and an inspector will ask for the ATD plan by name.
The Written ATD Exposure Control Plan
The core of Section 5199 is a written Aerosol Transmissible Disease Exposure Control Plan. It must be specific to your facility, reviewed at least annually, and available to employees and their representatives. At a minimum the plan should address:
- A list of job classifications and tasks with occupational exposure
- Source control measures, including screening of residents and visitors for symptoms and the use of masks by symptomatic individuals
- Procedures for identifying, isolating, and either treating or transferring residents who are suspected or confirmed cases
- Engineering and work practice controls, including how airborne infection isolation rooms are used or how residents are transferred to a facility that has them
- Respirator selection, use, and fit testing, coordinated with your Section 5144 respiratory protection program
- Vaccination procedures for employees
- Procedures for reporting and evaluating exposure incidents and outbreaks
- Communication with other employers, including contract staffing agencies, ambulance companies, and outside laboratories
- Training, recordkeeping, and the process for employee involvement in reviewing the plan
A plan downloaded from a template site and left unedited is the most common failure I see. The regulation requires that the plan reflect your actual operation: your census, your layout, your transfer agreements, and the names or titles of the people responsible for each element.
Respirators, Not Just Surgical Masks
Section 5199 requires employers to provide respirators, meaning NIOSH-approved N95 or higher, to employees who enter a room housing a resident with a suspected or confirmed airborne infectious disease, who perform high-hazard procedures such as suctioning or nebulizer treatments on such residents, or who are otherwise exposed under the plan. Surgical masks are source control for the patient, not respiratory protection for the worker.
That triggers the full Section 5144 program: a written respiratory protection program, medical evaluation before first use, annual fit testing, training on donning and doffing and seal checks, and a process for cleaning, storage, and replacement. Facilities that handed out N95s during the pandemic without fit testing or medical clearance were cited in large numbers, and those citations are still being issued.
Under the ATD standard, the employer must also ensure that a supply of respirators is on hand before an outbreak, not ordered after one begins. Document your inventory and your reorder process in the plan.
The Vaccination Offer
The standard requires employers to make certain vaccinations available to employees with occupational exposure, at no cost, during working hours. Seasonal influenza vaccine is the one every SNF must address annually. Other vaccines listed in the standard, such as measles, mumps, rubella, varicella, tetanus-diphtheria-pertussis, and hepatitis B where bloodborne exposure exists, must be offered based on the employee’s exposure and immunity status.
Employees may decline. If they do, the standard requires a signed declination statement using specific language. Keep those declinations with the employee’s medical records, not in the general personnel file. Facilities frequently document that staff were vaccinated but cannot produce declinations for the ones who were not, and that gap is citable.
From the clinical side, our staff nurse points out that vaccination records also serve you during an outbreak investigation. When the county public health department asks which staff were susceptible to measles or varicella, the answer should come out of a file, not a phone survey.
Training That Actually Meets the Standard
Training must occur at the time of initial assignment, annually, and whenever procedures or tasks change. It must be delivered in a way employees understand, in the language of the workforce, and by someone knowledgeable enough to answer questions. Cal/OSHA does not accept a sign-in sheet from a video as proof of training by itself. The training content required by Section 5199 includes:
- An explanation of the standard and where employees can read it
- How aerosol transmissible diseases spread and the signs and symptoms of the diseases the facility is likely to see
- Your facility’s exposure control plan and how to get a copy
- Which tasks carry exposure and the controls that apply to each
- Selection, use, limitations, and care of respirators and other PPE
- The vaccination offer and the benefits of vaccination
- What to do after an exposure incident and how post-exposure evaluation works
- Outbreak procedures and the employee’s role in surveillance
Keep training records for at least three years showing the date, content, trainer, and attendees.
Exposure Incidents and Outbreaks
When an employee is exposed to a resident later confirmed to have an airborne infectious disease, the standard requires that you evaluate the exposure, notify the employee promptly, and offer post-exposure medical evaluation, prophylaxis, and follow-up at no cost. Keep records of the incident, what was offered, and what the employee chose.
If the exposure results in an illness that is work-related and meets recording criteria, it goes on your Cal/OSHA Form 300 under Section 14300. If it results in hospitalization or death, Section 342 requires a report to Cal/OSHA within eight hours. Those reporting obligations apply to infectious illness the same as to a fall.
What to Do Now
- Pull your ATD Exposure Control Plan and check the last review date. If it is more than a year old or was written for a different facility, revise it.
- Confirm that every employee who may enter an isolation room has a current medical evaluation and fit test on file under Section 5144.
- Verify your respirator inventory against your census and document it.
- Audit vaccination records and declination forms for every employee with occupational exposure. Fill the gaps before flu season.
- Review training records for the past twelve months and schedule annual sessions for anyone who is overdue.
- Confirm that your transfer agreements and staffing agency contracts spell out who supplies respirators and training for contract workers.
- Walk the building with your infection preventionist and check that the plan describes the isolation procedures staff actually use.
McNeil Safety Consulting works with skilled nursing and long-term care operators across California to write and audit ATD plans, coordinate respiratory protection programs, and deliver training that satisfies Section 5199. Our staff Licensed Vocational Nurse reviews the clinical elements, including vaccination and post-exposure protocols. Learn more about our infection control services or call (626) 546-9384 to schedule a program review before your next survey or Cal/OSHA visit.
Co-authored with Zennin Sedacey-McNeil, LVN, California Licensed Vocational Nurse, McNeil Safety Consulting.