O
c
t
o
b
e
r
6
,
2
0
1
5
FRESNO
PIWC 2015
S
P
R
E
WO R KE RS ’ AT
THE
S
E
N
C O M P E N S AT I O N CONFERENCE FRESNO
CONVENTION
T
S
FULL
D AY
CENTER
9th Annual Conference p
i
w
c
f
r
e
s
n
o
.
c
o
m
Table of Contents
1. PIWC Fresno World Series 2. Schedule of Events 3. Exhibitors Map 4. List of Exhibitors 5. Presidents Message – Brian Putnam 6. Platinum Members 7. Mark Pew – PRIUM (bio page) a. Mark Pew bio b. Medical Marijuana – Power Point 8. Keith Wilkinson – Vocational Expert (Bio page) a. Use of Vocational Experts 9. Office of District Attorney a. Sr. Investigator Charles Almaraz (bio page) b. Deputy District Attorney Manny Jimenez (bio page) c. Workers’ Compenation Insurance Fraud (Power Point) 10. Gene Glendenning – Cal/ OSHA (bio page) a. Heat Illness Prevention Training – Power Point b. Cal / OSHA Standards c. Heat Illness Prevention Regulation d. Procedures of Heat Illness Prevention e. Heat Illness Prevention Q&A 11. Professionals In Workers’ Compensation Court a. Walter Newman, MD – The Newman Medical Group (bio page) b. Phil Walker – Work Comp Savings (bio page) c. Phil Walker Bio d. Professionals in Workers’ Compensation Court – Power Point
f. Recipes For Ratings e. Rating Quiz 12. John Paul Beaudoin, PhD – Sierra Valley Medico – bio page a. John Paul Beaudoin, PhD bio 13. The Medical Legal Report a. Michael Gaston – Michael Sullivan & Associates b. Pilar Mitchell – Michael Sullivan & Associates c. The Medical Legal Report – Analyzing Facts and Fiction – Power Point 14. Interacting Within The Interactive Process a. Michael McDonald – The McDonald Law Corp. (bio page) b. Helyn Hoffman – Arthur J. Gallagher c. Interacting Within The Interactive Process – Power Point 15. The State of Cutting Edge Advances in Spinal Technologies and Techniques a. Justin Paquette MD – Paquette Spine Institute – bio page b. Justin Paquette MD bio c. Paquette Spine Institute 16. Employer Roundtable a. David Parker – Parker, Kern, Nard & Wenzel b. David Parker bio c. Martin Acree – Saladino’s Food Service – bio page d. Jan Piel – MV Transportaton – bio page e. Larry Williams – Hall Management Companies – bio page f. Ward Scheitrum – Zacky Farms 17. Ads 18. Parking Map 19. Upcoming Event – Platinum Day At The Races
7:00 - 8:00
Registration, Exhibitor , Continental Breakfast Main Attraction: Stadium Grand Slam
8:00 - 9:00
High Fly, Home Run, or Pop Up? Mark Pew Medical Marijuana in Work Comp
9:00 - 9:15
Exhibitor/Vendors
Break Out Sessions Scouting Report & What To Look For in a 9:15 - 10:00 Vocational Expert?
Keith Wikinson How To Select a Voc Expert
10:00 - 10:15 Break Out Sessions 10:15 - 11:00
11:15 - 11:30 Break Out Sessions 11:30-12:15
12:15-1:15 1:15-1:30 Break Out Sessions 1:30-2:30
Attempting to Steal Home Plate
Charles Almaraz/Manny Jimenez Dealings on Work Comp Fraud
Exhibitor/Vendors Close the Roof It Is Hot Outside
Gene Glendenning Heat Standards
Pre-Season Physical & Changing the Playing Fields
Walt Newman, MD & Phil Walker Professionals in Workers’ Compensation Court
Exhibitor/Vendors Bases are loaded, Two Outs, & Bottom of the 9th
John Paul Beaudoin, PhD Psychoneuroimmunology Managing Stress; Psychological and Mental Health
Commissioner’s Office Report; Change in the Rules
Mitchell/Gaston/Sullivan Medical Legal Report: Writing and Analyzing Facts from Fiction
Lunch Exhibitor/Vendors Avoiding Long Term DL Keeping Within the Foul Lines Michael McDonald/ Helyn Hoffman Interacting Within the Interactive Process
Justin Paquette, M.D. The State of Cutting Edge Advances in Spinal Technologies and Techniques
2:30-2:45
7th Inning Stretch: Refreshments
Owners Box 2:45-4:00 4:00-4:30
Fall Owners Meeting; An Overview of the Big Game
Employer Rountable - David Parker: Moderator
Door Prize Give a Way, Certificate's Distributed
10
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42.
Exhibitors Booth Placement website) (Click on the member name to access
MTI Cypress Care PACBLU myMatrixx Specialized Investigations Learning Services Centre for Neuro Skills Palm Medical Excel One Call Care Medical Todd Olivas & Assoc. Imber Court Reporters CVC Legal Services Definiti Healthcare Sullivan Attorneys Sierra Valley Medico Laughlin, Falbo, Levy & Moresi ADM ExamWorks Medlink Century Pacific Medical Grossman Burn Center Helios GENEX Rene Garza & Assoc. Sacks & Zolonz Resolution Partners ADEPT / Ben Hyatt
15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 43. 44. 45. 46. 47.
Albert Simpkins MD
Castle Copy Hanna Brophy Coventry Wright Lien Assoc. MacroPro Priority Care Solutions
W
elcome to our World Series of Workers Compensation Conference. As you can see, we are working diligently to bring you the best in educational and social events in Central California. This past year we were able to bring back our Holiday Party for the first time in years, have regular half day seminars, and create an all new event of Platinum Day at the Horse Races thanking our Platinum Members for their support throughout the year. We could not put on these great events without the support of our sponsors and we thank each and everyone of you. The Board of Directors of PIWC Fresno are here to serve your needs in an industry we all come from. While I have the pleasure of serving as the Chapter President for 2015, the success of the Chapter would be impossible without the active support and participation of our Board Members, and I would like to recognize them for their service. Because of their hard work all of this is possible. Be sure to thank them when you get a chance. If you are interested in becoming a board member please let me know. I hope you are as excited as I am about this amazing conference that your PIWC board has put together for you today. This is sure to be the best full day conference that Fresno has seen yet. The strength of our organization is premised on the level of involvement by our community. With that in mind, I invite you to call, or e-mail me to share your ideas, thoughts, or feedback to improve our chapter. I will make it a point to ensure that you receive a response to communications you send me.
-Brian Putnam President PIWC Fresno
Platinum Members
(Click on the member logo to access website)
INDUSTRIAL – OCCUPATIONAL SPECIALISTS
MArk Pew PRIUM
Topic: Medical Marijuana in Work Comp
Offers 30 years of experience in property and casualty, technology and healthcare, which extensive knowledge of workers’ compensation managed care. Leads product innovation and marketing at PRIUM, a provider of worker’s compensation medical intervention solutions. Developed PRIUM’s award-winning medical intervention program, which dramatically improves clinical and financial outcomes. Speaks and writes on topics related to opioid abuse, managing prescription drugs, workers’ compensation legislation and the impact on managed care, improving injured worker outcomes, prescribing trends and related issues.Other topics include medicare set-asides, compounded medications, alternative therapies and medical marijuana. Speaking engagements combine industry research, internal analysis and case studies with a touch of humor. Audiences rate them high for their clear descriptions of medical and pharmaceutical cost problems and, more importantly, for their practical and actionable solutions. FRESNO
PIWC 2015
Speaking Contact: Helen King Knight, APR, King Knight Communications, 813-‐690-‐4787,
[email protected]
Bio Mark Pew, Senior Vice President, PRIUM Mark Pew has more than 35 years of experience in the property and casualty, healthcare and technology industries. He created PRIUM’s Medical Intervention Program in 2003, Intervention Triage in 2010, Texas Drug Formulary turnkey solution in 2011, Centers with Standards in 2012, and TaperRx in 2014. From March 2012 thru August 2015, Mark presented educational content 273 times to 16,395 people in 38 states, including 9 national webinars. He serves on the Medical Issues Committee of the International Association of Industrial Accident Boards and Commissions (IAIABC), the Workers’ Compensation Committee for the Self-‐Insurance Institute of America (SIIA), the Medical/Rehab Committee for the Southern Association of Workers’ Compensation Administrators (SAWCA) and the Pharmacy Group for CompSense. Mark is a popular speaker at workers’ compensation conferences around the country as well as individual continuing education venues. He has spoken at the National Workers’ Compensation and Disability Conference, National Rx Drug Abuse Summit, at statewide or self-‐insured conferences in 17 states, and at national and regional association gatherings around the country. A frequent media source for stories on pharmacy and marijuana in workers’ compensation, Mark also writes articles for several publications. He is a regular contributor to Claim Management Magazine, Insurance Thought Leader and LexisNexus. Mark Pew: 678-‐735-‐7309;
[email protected] PRIUM 2805 Peachtree Industrial Blvd., Suite 112 Duluth, GA 30097 Website: www.prium.net Blog: www.priumevidencebased.com linkedin.com/in/markpew Twitter: @RxProfessor
About PRIUM An Ameritox solutions provider, PRIUM sets the industry standard for workers' compensation medical interventions through its ability to secure higher agreement rates and ensure compliance with modified treatment plans. The hallmark of the medical intervention company's success is a collaborative physician engagement process encompassing evidence-‐based medicine, clinical oversight, and jurisdictional guidelines to ensure optimal financial and clinical outcomes. PRIUM eliminates unnecessary treatment through a comprehensive approach that includes complex medical interventions, utilization reviews, and independent medical exams. Based in Duluth, Ga., PRIUM can be reached at www.prium.net or 888-‐588-‐4964. For insight on workers' compensation medical issues, read PRIUM's blog at www.priumevidencebased.com.
www.prium.com
Medical Marijuana
Mark Pew, Senior VP, PRIUM • 35+ years in P&C, 20+ years in Work Comp • Created PRIUM’s Medical Intervention Program in 2003, Intervention Triage in 2010, Texas Closed Formulary turnkey in 2011, Centers with Standards in 2012, TaperRx in 2014 • From March 2012 thru August 2015, Mark has presented educational content 273 times to 16,395 people in 38 states, including 9 national webinars
LinkedIn: markpew Twitter: @RxProfessor
• Published and quoted in CLM Magazine, Risk & Insurance, Business Insurance, workcompcentral, WorkCompWire, Insurance Thought Leadership and others • Member of the IAIABC Medical Issues Committee, SIIA Work Comp Committee, SAWCA Medical / Rehab Committee, CompSense pharmacy group
What is Weed?
What is it? Active Ingredients • 483 known compounds • Primary ingredients are: • THC (tetrahydrocannabinol) – psychoactive (the “high”) • CBD (cannabidiol) – more medical application • Moderates THC • CBN (cannabinol) – weak psychoactive • CBG (cannabigerol) – non-psychoactive, associated with glaucoma • More potent • Up through the 1980’s … < 10% THC • Now … Up to 30% THC … CBD is low or non-existent
http://news.yahoo.com/marijuana-science-why-todays-pot-packs-bigger-punch-155233170.html
• Can be up to 70% in edibles, up to 90% in “dabs”
What is it? The History • Legal and accepted prior to 1937 • George Washington grew hemp as one of his three primary crops • Medical preparations available in pharmacies in the 1850’s • In the 1880’s there were an estimated 500 hashish parlors in NYC • States passed legislation to regulate “poisons” (narcotics, including marijuana) – first was DC in 1906 • Federal Bureau of Narcotics (FBN) created in 1930 • The Marihuana Tax Act of 1937 • Made possession or transfer of cannabis illegal throughout the US under federal law • Required an “excise” tax that was inexpensive but difficult to get • Followed Supreme Court decision on the National Firearms Act • Harry J. Anslinger – head of FBN • With limited budget, used media to exaggerate issues http://en.wikipedia.org/wiki/Legal_history_of_cannabis_in_the_United_States
What is it? Changing Demographics • Pew Research Center national poll in October 2014 • 52% said marijuana should be legal • 45% said marijuana should remain illegal • From 2010 to 2013, favoring legalization increased by 11 points • In 1969, Gallup asked essentially the same question and … • 12% said marijuana should be legal • Pew Research Center national poll in April 2014 • 15% felt marijuana is harmful to health • 69% felt alcohol is harmful to health • 23% felt marijuana is harmful to society • 63% felt alcohol is harmful to society http://www.pewresearch.org/fact-tank/2014/11/05/6-facts-about-marijuana/ http://www.people-press.org/2014/04/02/americas-new-drug-policy-landscape/4-2-14-5/ (Pew Research Center) http://mmjbusinessdaily.com/pew-poll-54-of-american-adults-think-marijuana-should-be-legal/ (Marijuana Business Daily)
Delivery Methods
Delivery Methods Vaporizers • Vaping is the new smoking • Extracts active components without combustion • Nearly eliminates particulate matter or tar • How to get the highest quality vapor: • CBD @ 206.3°C • CBN @ 212.7°C • THC @ 149.3°C Southwest Medical Marijuana Evaluation Center (http://www.evaluationtoday.com/news_medicating_with_marijuana.html)
Delivery Methods Edibles • Edibles • Marijuana butter (“bud butter”) to substitute for standard butter •
http://www.thestonerscookbook.com/how_to_cook_with_weed.php
• But there are complications: 1. Effects take longer to start (processed by digestive system) • So it’s easier to ingest more than appropriate 2. Effects last longer • ~30 minutes for smoking, several hours for edibles 3. Dosage can vary Southwest Medical Marijuana Evaluation Center (http://www.evaluationtoday.com/news_medicating_with_marijuana.html)
Medical Applications
Some say … “medical” marijuana is but a Trojan Horse Do you FEEL better or ARE you better? NOTE: In Colorado, 48.8% of adolescents admitted to substance abuse treatment obtained their marijuana from someone registered to use medically Thurstone C, Lieberman SA & Schmiege SJ, Medical marijuana diversion and associated problems in adolescent substance treatment. Drug Alcohol Dependence 118(2-3):489-492, 2011
Medical Applications FDA’s criteria for “medicine” • To be accepted as medicine, the following criteria must be met: 1. The drug’s chemistry must be known and reproducible 2. There must be adequate safety studies 3. There must be adequate and well-controlled studies proving efficacy 4. The drug must be accepted by qualified experts 5. The scientific evidence must be widely available “Marijuana as Medicine? The science behind the controversy”, Allison Mack & Janet Joy
Medical Applications Risk List Current or past problems with cannabis or other substances Active mental illness Current, past or family history of psychosis Active mood or anxiety disorders Suicidal ideation Women who are pregnant, planning to become pregnant or at high risk of unplanned pregnancy • Anyone under 25 years of age • • • • • •
“How physicians should respond to the new Cannabis Regulations”, The Canadian Journal of Addiction, Meldon Kahan and Sheryl Spithoff
Medical Applications National Institute on Drug Abuse • Clinical trials underway • Autoimmune diseases that weaken the immune system • HIV/AIDS • Multiple sclerosis (MS), causes gradual loss of muscle control • Alzheimer’s disease, causes loss of brain function, affecting memory, thinking, and behavior • Inflammation • Pain • Seizures • Substance use disorders • Mental disorders • Recent animal studies show marijuana can kill certain cancer cells http://www.drugabuse.gov/publications/drugfacts/marijuana-medicine
Medical Applications National Eye Institute • Glaucoma • Studies in the early 1970s showed that marijuana, when smoked, lowered intraocular pressure (IOP) • NEI’s own studies demonstrated that some derivatives of marijuana transiently lowered IOP when administered orally, intravenously, or by smoking, but not when topically applied to the eye • However … • None of the studies demonstrated that marijuana could lower IOP as effectively as drugs already on the market https://www.nei.nih.gov/news/statements/marij
• Anecdote – Would require 6 joints/day for the rest of your life
Medical Applications Top 23 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
It can be used to treat Glaucoma It may help reverse the carcinogenic effects of tobacco and improve lung health It can help control epileptic seizures It also decreases the symptoms of a severe seizure disorder known as Dravet's Syndrome A chemical found in marijuana stops cancer from spreading It may decrease anxiety THC slows the progression of Alzheimer's disease The drug eases the pain of multiple sclerosis Other types of muscle spasms could be helped too It lessens side effects from treating hepatitis C and increases treatment effectiveness Marijuana treats inflammatory bowel diseases It relieves arthritis discomfort It keeps you skinny and helps your metabolism It improves the symptoms of Lupus, an autoimmune disorder While not really a health benefit, marijuana spurs creativity in the brain Marijuana might be able to help with Crohn's disease Pot soothes tremors for people with Parkinson's disease Business Insider Marijuana helps veterans suffering from PTSD “23 Health Benefits Of Marijuana protects the brain after a stroke Marijuana” It might protect the brain from concussions and trauma 4/20/14 • The NFL might allow if proven effective • According to "Real Sports with Bryant Gumbel", 50-60% of NFL players use the drug 21. It can help eliminate nightmares 22. Weed reduces some of the awful pain and nausea from chemo, and stimulates appetite 23. Marijuana can help people trying to cut back on drinking • Counterpoint: Alcohol may cause faster absorption of THC
Medical Applications Prescription Drug Versions • Marinol • Synthetic THC (dronabinol); capsule • Nausea and vomiting for cancer patients, appetite stimulation for AIDS patients, neuropathic pain for MS patients • FDA approved for appetite stimulation (1992), nausea (1985) • Schedule III drug • Cesamet (nabilone) • Synthetic cannabinoid, similar to THC; capsule • Nausea and vomiting for cancer patients • FDA approved originally in 1985, removed from market (to add warnings about potential effects to mental state of patient), reapproved on 5/15/06 • Schedule II drug http://medicalmarijuana.procon.org/view.resource.php?resourceID=000883
Medical Applications The Superstar • Charlotte’s Web • Marijuana extract high in CBD • No psychoactive effect • Administered as an oil (Realm Oil and Alepsia) • Developed in 2011 by the Stanley brothers • Named after 5-year old Charlotte Figi .. • First documented in the 2013 CNN series “Weed” • Born with Dravet Syndrome (epilepsy) • Traditional seizure medications were ineffective • 300 seizures per week • Charlotte’s Web reduced that to 2-3 per month • The emotional hot button driving legalization wikipedia.org/wiki/Charlotte%27s_Web_%28cannabis%29
Medical Applications The Superstar • “Medical expatriates” in Colorado • Moved for access to Charlotte’s Web since it was illegal in their home states • Cost is around $1,000/month • Research shows it’s only effective on 25-30% of patients
Effects
Effects Later Life Outcomes are Dose Dependent % welfare dependent (ages 21-25)
400+ 300 to 399 200 to 299
% Unemployed (ages 21-25)
100 to 199 1 to 99 Never
Mean personal income in thousands of NZ $ at age 25 % gained university degree by age 25
# of occasions using Cannabis ages 14-21
Number of occasions using
Cannabis between ages 14-21
Source: Fergusson and Boden. Addiction, 103, pp. 969-976, 2008 Courtesy of Nora D. Volkow, MD, National Institute on Drug Abuse
Effects Mental and Physical • Marijuana makes us feel good
Business Insider “What Marijuana Does To Your Body And Brain” 4/20/14
•
Dopamine release
•
Especially during adolescence
•
Impacts ability to walk, talk and drive
•
If genetically vulnerable
•
May increase fear, distrust or panic
•
Hallucinations, delusions, loss of personal identity
•
The most important part
•
Sometimes by 20-50 beats/minute
•
Cannabinoid receptors are located where saliva is produced
• Blocks memory formation • Messes with your balance
• Increases the risk of depression (and suicide) • Affects anxiety • Psychosis
• Interrupts REM sleep • Heart rate increase • Dry mouth
Effects The longest-term study to-date • A 20-year study in Australia • Study from 1993-2013 by Dr. Wayne Hall, director of the Centre for Youth Substance Abuse Research at the University of Queensland
•
Five major findings: 1. It’s essentially impossible to overdose • Requires 15-70 grams 2. It doubles the chance of a driving accident • DUI for marijuana not as understood as from alcohol 3. Addiction/dependence can occur • 1 in 10 adults, 1 in 6 adolescents • Strongly associated with use of other illicit drugs 4. Negatively impacts IQ • Only where initiated in adolescence and continued into adulthood 5. Effect on respiratory health is inconclusive • Typically smoke tobacco as well
http://www.fool.com/investing/general/2015/01/11/a-20-year-study-on-marijuana-use-yields-5-surprisi.aspx The entire article - http://onlinelibrary.wiley.com/doi/10.1111/add.12703/abstract
Effects Brain Changes • Casual marijuana use changes the brain • Northwestern Medicine and Massachusetts General Hospital/ Harvard Medical School study on casual use (1-2 times per week) • 20 adults (18-25) who smoked marijuana, 20 who did not • Scientists examined the nucleus accumbens and the amygdala -key regions for emotion and motivation, and associated with addiction -- in the brains of casual marijuana users and non-users • “The more joints a person smoked, the more abnormal the shape, volume and density of the brain regions.” http://www.sciencenewsline.com/articles/2014041523060034.html
Effects What does Healthcare think? • American Medical Association (AMA) • Affirmed on 11/20/13 opposition to legalization of marijuana • “cannabis is a dangerous drug and as such is a public health concern” • “federal efforts to address illicit drug use via supply reduction and enforcement have been ineffective” • “modification of state and federal laws to emphasize public health based strategies to address and reduce cannabis use” • “public health based strategies, rather than incarceration” http://www.usnews.com/news/articles/2013/11/20/ama-reaffirms-opposition-to-marijuana-legalization
Effects What does Healthcare think? • American Society of Addiction Medicine (ASAM) • • • • • • •
Education for patients, health and human services professionals Alcoholism should mean abstinence from marijuana Marijuana dependency is an issue that needs to be treated Medical uses (like Marinol) need to be carefully controlled Smoking is dangerous Continue evidence-based research Physicians should be able to discuss risks and benefits with marijuana as with any other treatment
http://www.asam.org/docs/publicy-policy-statements/1marijuana-5-062.pdf?sfvrsn=0
• “Cannabis is unstable and unpredictable and the drug should be subject to the same standards that apply to other medications. For every disease and disorder for which marijuana has been recommended, there is a better, FDA-approved medication.”
Is marijuana less dangerous than opioids?
Legal Landscape
As perception of risk decreases… (if it’s legal, it can’t be that bad)
Use increases (often by “newbies”)
Not Legal Federal vs. State • Marijuana is illegal at the Federal level • DEA Schedule I controlled substance • Substances in this schedule have no currently accepted medical use in the United States, a lack of accepted safety for use under medical supervision, and a high potential for abuse • Heroin, LSD, peyote, meth, Ecstasy http://www.deadiversion.usdoj.gov/schedules/
• In 2013, DEA requested the FDA evaluate re-scheduling • Study is “ongoing” https://ww3.workcompcentral.com/news/story/id/4ad40fa0f0b7674bd0884294399ad90bf004f354
Not Legal Look the other way – Unofficial • USDOJ Memo to US Attorneys, August 29, 2013 • Urges US Attorneys to exercise their discretion in using federal resources to prosecute individuals using marijuana for medical purposes • Emphasizes federal policy of enforcing CSA (Controlled Substances Act) to prevent: 1. 2. 3. 4.
Distribution of marijuana to minors Revenue to fall into hands of dangerous drug cartels Diverting medical marijuana from legal status to other states State-authorized marijuana activity from being used as a cover for trafficking other illegal drugs 5. Violence in the cultivation and distribution of marijuana 6. Drugged driving and other adverse public health consequences 7. Growing marijuana on public or federal lands
Not Legal Look the other way – Official • 2015 Federal Budget provides protection • US Congress included an amendment that prohibits Department of Justice from using funds to go after state-legal medical cannabis programs • H.R. 83, “Section 538” (specifically lists the states) • President Obama signed it on 12/16/14 • “None of the funds made available in this act to the Department of Justice may be used … to prevent … states … from implementing their own state laws that authorize the use, distribution, possession, or cultivation of medical marijuana.” http://blog.norml.org/2014/12/16/president-to-sign-federal-spending-bill-protecting-state-sanctionedmedical-marijuana-programs/
Not Legal Make it Law • CARERS • Compassionate Access, Research Expansion, and Respect States Act (S.683) • • • •
Introduced on 3/10/15, referred to Committee on the Judiciary • Bipartisan – Rand Paul (R-Kentucky), Kirsten Gillibrand (D-New York), Cory Booker (D-New Jersey) Reclassifies marijuana as a Schedule II drug Allows states to implement regulations as they see fit Enables the Veterans Administration to consider its use
http://www.forbes.com/sites/davidkroll/2015/03/11/is-congress-planning-to-legalizemarijuana/
• H.R. 1538 (identical) introduced on 3/25/15 • •
Referred to the Subcommittee on Crime, Terrorism, Homeland Security, and Investigations Bipartisan –5 Democrats, 4 Republicans
State
Year EffecAve
PaAent Registry? Allow Dispensaries? Specify CondiAons?
Recognize PaAents from other states?
RecreaAonal Adult Use?
Alaska
1999
Yes
No
Yes
Approved Nov 2014, not yet operaAonal
Arizona
2010
Yes
Yes
Yes
Yes
California
2003
Yes
Yes
No
Colorado
2000
Yes
Yes
Yes
No
Yes (Eff. 1/1/14)
ConnecAcut
2012
Yes
Yes
Yes
Delaware
2011
Yes
Yes
Yes
Yes
District of Columbia
2010
Yes
Yes
Yes
Approved Nov 2014, not yet operaAonal
Guam
2014
Yes
Yes
Yes
No
Approved Nov 2014, not yet operaAonal
Hawaii
2000
Yes
No
Yes
Illinois
2013
Yes
Yes
Yes
No
Louisiana
Law signed 6/29/15
Maine
2011
Yes
Yes
Yes
Yes
Maryland
2013
Yes
Yes
Yes
MassachuseWs
2012
Yes
Yes
Yes
Michigan
2008
Yes
No
Yes
Yes
Minnesota
2014
Yes
Yes
Yes
Montana
2011
Yes
No
Yes
No
Nevada
2000
Yes
No
Yes
New Hampshire
2013
Yes
Yes
Yes
Yes, with condiAons
New Jersey
2009
Yes
Yes
Yes
New Mexico
2007
Yes
Yes
Yes
New York
2014
Yes
Yes
Yes
Oregon
2007
Yes
No
Yes
Approved Nov 2014, not yet operaAonal
Rhode Island
2009
Yes
Yes
Yes
Yes
Vermont
2011
Yes
Yes
Yes
Washington
2011
No
Yes
Yes
Yes (Eff. 7/1/14)
Legal Now Overview Medical • 24 states + DC + Guam Recreational • 4 states + DC + Guam (as of 7/1/15) National Conference of State Legislatures http://www.ncsl.org/research/ health/state-medical-marijuan6alaws.aspx
Legal Now Overview State
Year EffecAve
PaAent Registry?
Recognize DefiniAons of Allows for Legal PaAents from Products Allowed Defense other states?
Allow Dispensaries?
Specify CondiAons?
UAB only
Yes
No
Yes
Allowed for Minors
Alabama
2014
Florida
2014
Yes
Yes
Yes
No
Yes
Georgia
2015
Yes
University system
Yes
No
Yes
Yes
Yes
Iowa
2014
Yes
Does not define
Yes
No
Yes
Yes
Yes
Kentucky
2014
No
UniversiAes in KY
Yes
No
No
Mississippi
2014
Ole Miss only
Yes
No
Yes
Yes
Yes
Missouri
2014
Yes
Yes
Yes
No
Yes
Yes
Yes
North Carolina
2014
Yes
University research
Yes
No
Yes
Yes
Yes
Oklahoma
2015
Yes
No
Yes
No
Yes
Yes
Yes
South Carolina
2014
Yes
Yes
Yes
No
Yes
Yes
Yes
Tennessee
2014
Yes
Tenn Tech
Yes
No
Yes
Texas
2015
Yes
Yes
Yes
No
Yes
Yes
Yes
Utah
2014
Yes
Yes
Yes
No
Yes
Yes
Yes
Virginia
2015
No
No
Yes
No
Yes
Yes
Yes
Wisconsin
2013
No
No
Yes
Yes
No
Yes
Yes
Yes Yes
15 states have limited access product laws NOTE: Idaho legislature approved, Governor vetoed in 2015
Legal Now Recreational Use • Alaska and Oregon and DC approved in November 2014 • Alaska (Measure 2) • • •
Passed 53% to 47% Adults 21+ can possess up to 1oz Can grow up to 6 plants
• Oregon (Measure 91) • • • •
Passed 57% to 43% Adults 21+ can have up to 8oz at home and 1oz in public Can cultivate up to 4 plants Effective July 1, 2015
• District of Columbia (Initiative 71) • • • • •
Passed 68% to 31% Possession up to 2oz Cultivation of up to 6 plants U.S. Congress blocked implementation DC ignoring the blockade … Chaos
Remember “Big Tobacco”?
Say hello to “Big Marijuana” April 18-20, 2015 High Times Cannabis Cup
April 20-22, 2015 Marijuana Investor Summit
“Tobacco companies for generations have talked privately about getting into the weed business” “Will Big Tobacco become Big Marijuana?”, USA Today, 4/11/15
Lessons Learned
Colorado Department of Revenue http://www.colorado.gov/cs/Satellite/Revenue-Main/XRM/1251633259746 Statistics and Reports / Marijuana Tax Data (Retail = 3+4+8, Medical = 2)
Lessons Learned $$$$$$$’s Month January 2014 February 2014 March 2014 April 2014 May 2014 June 2014 July 2014 August 2014 September 2014 October 2014 November 2014 December 2014
Retail Tax Medical Tax Original Revenue Revenue 2014 Expectations: (12.9%) (2.9%) $134M in $2,013,576 $913,519 tax+fee revenue $2,212,784 $1,022,176 $3,078,097 $999,900 $3,591,686 $919,982 $3,848,349 $927,330 Total Tax Revenue $4,143,371 $830,861 Jan-Dec 2014 $5,189,191 $838,711 $63,415,383 $5,728,847 $935,807 $5,273,366 $908,630 $5,851,182 $928,329 Total Tax Revenue Jan-May 2015 $5,174,973 $772,472 $44,351,339 $6,422,995 $889,249 Only 10% “medical”
Total $52,528,417 $10,886,966 % of Total 83% 17%
Lessons Learned Oops … Colorado Governor John Hickenlooper (Democrat) On January 23, 2015 on CNBC’s “Squawk Box” • He originally opposed it but it passed 55%-45% •
FYI … He was in the craft brew business
• “If I could've waved a wand the day after the election, I would've reversed the election and said, 'This was a bad idea’ ” • “You don't want to be the first person to do something like this” … “We're starting from scratch” • He tells other governors to “wait a couple of years” because they don't know what the unintended consequences are http://thehill.com/policy/finance/230511-colorado-governor-legalizing-pot-was-bad-idea The full interview - https://www.youtube.com/watch?v=WX8LaCCTBuw
Lessons Learned Unintended Consequences • Colorado • “Surround and Drown” • Hazmat Suits • Underground market still flourishing • Grower can cultivate up to 16 plants per doctor prescription
http://www.washingtonpost.com/news/storyline/wp/2014/07/30/inside-colorados-flourishingsegregated-black-market-for-pot/
• Stoned pets
http://www.usatoday.com/story/news/nation/2014/03/24/marijuana-pot-dogs-edible/6600763/
• Police dogs have to be re-trained • Banks don’t want to process money … “money laundering” (RICO)
Lessons Learned Unintended Consequences • In Washington … • Blueberries - $17,000 per acre • Marijuana - $7,500,000 per acre • What would you grow?
Lessons Learned Capitalism at its best … “Heidi Carney speaks with her husband, Justin Menees, while their daughter, Lexi, 8, sold Girl Scout Cookies outside a marijuana dispensary in Phoenix last week. Girl Scouts seem to be skipping the usual supermarket stops for selling their beloved cookies. A few days after a teenager sold dozens of cookie boxes outside a San Francisco pot dispensary, Menees, 8, will return to Trumed Dispensary in Phoenix on Saturday for the same purpose. Carney, got the idea after hearing about what happened in San Francisco. Susan de Queljoe, a spokeswoman for the Girl Scouts, Arizona Cactus-Pine Council, says this is not something the organization would encourage but that it's up to the parents.”
Implications for Work Comp
Implications Substance Abuse • Tennessee Department of Labor and Workforce Development … • 38-50% of all Work Comp claims are related to substance abuse in the workplace • Why does that matter? • Marijuana accounted for 4.5M of the estimate 7.1M Americans dependent on or abusing illicit drugs • In 2009, approximately 18% of people aged 12 and older entering drug abuse treatment programs reported marijuana as their primary drug of abuse • 61% of persons under 15 reported marijuana as their primary drug of abuse 2010 National Study on Drug Use and Health (NSDUH)
Implications New Mexico • Vialpando v. Ben’s Auto. Servs • • •
NM Court of Appeals in May 2014 required an employer to reimburse an injured worker for medical marijuana The Work Comp statutes allow “reasonable and necessary” for an injured worker’s treatment Even though medical marijuana is not a prescription drug, a “licensed dispensary” could qualify as a “service”, and if that “service” were “reasonable and necessary” …
• Maez v. Riley Industrial • • • • •
NM Court of Appeals in January 2015 confirmed that “medical” marijuana was reasonable and necessary The patient tested positive for recreational use of marijuana while being prescribed a variety of other drugs (including opioids) The physician decided to certify the marijuana use The Court decided that since the physician confirmed its use that it should be deemed “reasonable and necessary” The ultimate patient-directed care
Implications Colorado • Coats v. Dish Network •
• •
A paraplegic telephone customer service representative using "medical" marijuana for spasms in compliance with Colorado’s Medical Marijuana Amendment • Use was off-duty Terminated by Dish Network for testing positive for THC, even though he told them of his use prior to his hire Colorado Supreme Court unanimous decision in June 2015 • Termination was lawful • While “medical” marijuana use is lawful in Colorado, its use violates federal law • According to Colorado’s Lawful Activities Statute, his activities had to be lawful under both state and federal law
Implications More Injuries • From David DePaolo • “According to the National Institute on Drug Abuse, marijuana smokers are more likely than non-marijuana smokers to file workers' compensation claims. For example, a study among postal workers found that employees who tested positive for marijuana on a preemployment urine drug test had 55% more industrial accidents, 85% more injuries, and a 75% increase in absenteeism compared with those who tested negative for marijuana use.” http://daviddepaolo.blogspot.com/2014/03/co-pot-goes-to-court.html http://www.drugabuse.gov/publications/research-reports/marijuana/how-does-marijuana-use-affect-schoolwork-social-life
Implications Drug Free Workplace • Impact on a drug-free workplace? • Workplace safety • Which employee is OK to be stoned at work? • Zero tolerance policy • Marijuana alcohol, illegal drugs, prescription drugs? • Judging intoxication / impairment and causality • 3.1-4.5 ng/mL (oral) and 3.3-4.5 ng/mL (smoked) plasma levels = 0.05 g% blood alcohol concentration • Drug testing policies • Do not remove THC from drug panels • Hiring, Termination and Return to Work policies • Can’t find anyone to fill jobs?
THE QuesAon Presence vs. Impairment
Implications Drug Free Workplace Marijuana -‐ Single Use Marijuana -‐ Regular Use
Urine
Blood
Hair
1-‐7+ days
12-‐24 hours
Doubjul
7-‐100 days
2-‐7 days
Months
Amphetamines
1-‐3 days
24 hours
Months
Cocaine
1-‐3 days
1-‐3 days
Months
Heroin, Opiates
1-‐4 days
1-‐3 days
Months
PCP
3-‐7 days
1-‐3 days
Months
Saliva Not validated (0 -‐24 hours?) Not validated (0 -‐24 hours?) Not validated (0 -‐24 hours?) Not validated (0 -‐24 hours?) Not validated (0 -‐24 hours?) Not validated (0 -‐24 hours?)
http://www.canorml.org/healthfacts/drugtestguide/drugtestdetection.html
Required reading for employers Marijuana in the Workplace: Guidance for Occupational Health Professionals and Employers: Joint Guidance Statement of the American Association of Occupational Health Nurses and the American College of Occupational and Environmental Medicine
Full Report: http://journals.lww.com/joem/Fulltext/2015/04000/Marijuana_in_the_Workplace___Guidance_for.17.aspx
Summary: http://www.lexisnexis.com/legalnewsroom/workers-compensation/b/recent-cases-news-trendsdevelopments/archive/2015/04/24/acoem-guidance-on-marijuana-in-the-workplace-keeping-employers-sane-amidst-thereefer-madness.aspx
In Summary
• Marijuana is not as benign as advocates present • There are medical applications for some conditions using some components • The evidence is still somewhat anecdotal • More research is needed … and going to Schedule II might facilitate • Legalization efforts are well-funded and organized • Judicial reform is necessary • Treatment instead of punishment? • Legalization will have a significant impact on employers, workplaces and Work Comp • Legalization will open a societal Pandora’s Box • It’s about risk management at this point …
Mark Pew Senior Vice President
(678) 735-7309 Office
[email protected] LinkedIn: markpew Twitter: @RxProfessor
PRIUM’s Evidence Based blog www.priumevidencebased.com
keith wilkinson Vocational Expert
Topic: How to Select Voc Experts, LeBeuff, FCE I am a certified vocational expert through the American Board of Vocational Experts. From 1985 through 2007, I worked as a vocational counselor and counseling manager in the California Workers’ Compensation system developing rehabilitation plans and providing job seeking skills training and placement assistance to injured workers. I also conducted job analyses and provided out-of-state rehabilitation services and case management services. I have completed over 300 LeBoeuf/Labor Code §4662 Evaluations and over 500 Diminished Future Earnings Capacity Evaluations for applicant’s and defense attorneys. I have acted as an agreed vocational expert on Le Boeuf/Labor Code §4662 cases 45 times, on DFEC cases 23 times and once as a court appointed expert. I have testified as a Vocational Expert in rebuttal to the Pre SB 899 PDRS (LeBoeuf) and as an expert in rebuttal to the post SB 899 PDRS in DFEC Cases over 100 times since 2003 in Anaheim, Grover Beach, Long Beach, Los Angeles, Marina Del Rey, Oakland, Redding, Riverside, San Bernardino, San Diego, San Francisco, Santa Ana, San Luis Obispo, Santa Monica, and Van Nuys. I have also testified in Superior Court for Family Law and Personal Injury Cases, and in Federal Court for a Personal Injury Case.
FRESNO
PIWC 2015
Use of Vocational Experts For Post January 1, 2013 Cases o Labor Code §4660.1 refers to AMA Guides, 5th Addition regarding Whole Person Impairment. o Because Chapters 1 & 2 of the Guides have been incorporated into California Law, it is necessary to look at a worker’s impairment from a work perspective. o Labor Code §4660.1 (i) requires a comparison of average loss of earnings the permanent disability under the schedule. o The medical community defines the nature and extent of impairment. The Vocational Expert translates what that means for work or, in other words, disability. o The Legislature recognized that Vocational Experts would be used to rebut the schedule by placing them in Labor Code §139.32 (a) (3) (A) (ii) talks about evaluations regarding future earning capacity resulting from an occupational injury or illness.
charles almaraz Office of the District Attorney
Topic: Dealing with Work Comp Fraud Senior Investigator Charles Almaraz has been working in the Fraud Unit since May 2013. He is also fluent in Spanish. Investigator Almaraz has sixteen years of law enforcement experience. He has worked in the Welfare Fraud Unit and the Felony Trial Team. Investigator Almaraz worked as a Deputy Sheriff for eight years before coming to the District Attorney-Public Administrator’s Office.
FRESNO
PIWC 2015
manny jimenez Office of the District Attorney
Topic: Dealing with Work Comp Fraud
Deputy District Attorney Manuel Jimenez was assigned to the Fraud Unit in August 2012. He is also an experienced attorney, who was previously assigned to the Auto Fraud Unit from August 2007 to August 2012.
FRESNO
PIWC 2015
Workers’ Compensation Insurance Fraud
FRESNO COUNTY DISTRICT ATTORNEY’S OFFICE
Description of Unit ■ 2
Deputy District Attorneys ■ 4 District Attorney Investigators ■ 1 Legal Secretary ■ 1 Program Tech
(559) 600-6710 Call Us!
Types of Fraud We Prosecute ■ Applicant
Fraud ■ Employer Fraud ■ Provider Fraud
Applicant Fraud ■ AOE/COE (Arising out of employment and in the course of employment)
■ Malingering ■ Denial
Of Previous Injury ■ Other Lies
Employer Fraud ■ Premium
Fraud ■ Misrepresentations ■ No Worker’s Compensation Insurance
Provider Fraud ■ Double
Billing ■ Overtreatment ■ Kickbacks ■ Other Fraud
Applicant Fraud Statutes ■ California
Insurance Code 1871.4(a)(1)
Fraudulent Material Misrepresentation
■ Penal
Code 118 - Perjury ■ Penal Code 487(a) - Grand Theft ■ Penal Code 550(b)(1) ■ Penal Code 550(b)(3) ■ Burden of Proof
California Insurance Code Section 1871.4 ■ “a
material misrepresentation for the purpose of obtaining worker’s compensation benefits ■ To whom can the lie be made: ■ Doctor ■ Supervisor ■ Claims
Adjuster ■ Investigator
Penal Code 118 – Perjury False statement under oath
Penal Code 550 (b) ■ Present
false claim for benefit under insurance policy
■ Conceal
event that affect’s right to benefit under insurance policy
Penal Code 487(a) ■ Grand
Theft
Penalties
Penalties ■ Ø Ø
■ Ø
■ Ø
■ Ø Ø
Insurance Code 1871.4(a)(1)
Up to one year in county jail (misdemeanor) or up to five years in State Prison (felony) and/or Fine: the greater of $150,000 or double the value of the fraud
Penal Code 118
Up to 4 years in State Prison
Penal Code 487
Up to one year in the County Jail (misdemeanor) or up to 3 years in State Prison (felony)
Penal Code 550(b)(1) and 550(b)(3)
Up to one year in the County Jail (misdemeanor) or up to 5 years in State Prison (Felony) and/or Fine: the greater of $10,000 (misdemeanor)/ $50,000 (felony) or double the amount of the fraud
Indicators of Applicant Fraud ■ ■ ■ ■ ■ ■ ■ ■
No witnesses to alleged injury Injury occurred under unusual circumstances or in an area where applicant would not normally be Applicant’s version of the accident is not credible Applicant gives differing versions of how the injury took place Applicant fails to report the injury timely Applicant’s physical complaints are all subjective in nature Applicant is a new hire Applicant made previous worker’s compensation claims
Indicators of Applicant Fraud ■ ■ ■ ■ ■ ■
Applicant’s job is seasonal or temporary and almost over Job pay rate is low to mid range The alleged injury relates to a preexisting injury or health problem Fellow employee’s state injury is not legitimate Applicant cannot be reached at home during work hours Applicant recently demoted, reprimanded or passed over for promotion
Investigation to Establish Fraud
Employer/Claims Adjuster Role ■ Document
all communication with
claimant ■ Interpreter names/addresses ■ DWC1 ■ Employer’s 1st Report – should be filled out completely
Effective Use of Depositions ■ Questions
must be specific ■ “Since your injury…” ■ Consider video-recording deposition
Effective Use of Depositions
November 9, 1995 – Sub rosa Investigation
January 24, 1996 – Video-recorded Deposition (suspect’s right hand held in a claw entire depo)
Effective Use of Video
Close in time to doctor visit ■ Close in time to depo ■ Activity must be significant ■ Inconsistent with claimant’s representation ■ Quality of video important ■
Reasons for Rejecting Fraud Referrals No false statements ■ No material misrepresentation ■
– Had claimant told the truth, would it make a difference in the benefits received? ■
Dueling doctors
Premium Fraud: The Law ■ Insurance
Code 11880
– State Compensation Insurance Fund ■ Insurance
Code 11760
– Other carriers
Types of Premium Fraud Cash payroll ■ Misclassification of type of work performed ■ Failure to report injuries or reporting them as first aid ■ Purchasing insurance under a new name when there is no change in the control group ■
Premium Fraud: IMPACT ■ Causes
Premium Rates to Rise ■ Creates Unfair Competition ■ Usually not paying other payroll costs – Franchise tax, SDI, UI, SS, Medicare, Fed Tax
Employer Misrepresentations: The Law ■ Insurance
Code 1871.4(a)
■ A
Employer Misrepresentations
person in an authoritative position lies to employee for the purpose of dissuading him or her from filing a workers’ comp claim. REASONS
Employer is not carrying insurance (a misdemeanor under the Labor Code). Employer is trying to keep his experience modifier down. A supervisor is trying to keep his reputation with the employer.
LABOR CODE §3700.5
Failure to obtain Worker’s Compensation Insurance ■
(559) 600-6710 Call Us!
gene glendenning CAL OSHA
topic: Heat standards Eugene Glendenning, Area Manager Cal/OSHA Consultation Service Fresno Area Office Phone (559) 454-1295
Eugene Glendenning has been with the Cal/OSHA Consultation Services Branch since 1979. He is the Area Manager of the Fresno Consultation Area Office. Eugene has also served as the Consultation Services High Hazard Coordinator. Prior to becoming an Area Manager, he has been both a Safety Engineer and an Industrial Hygienist. He is a founding member and past president of the Central Valley Chapter of the American Society of Safety Engineers.
FRESNO
PIWC 2015
Division of Occupational Safety and Health (Cal/OSHA)
2015 HEAT ILLNESS PREVENTION TRAINING
April 2015
Training Goals v Review the regulatory language and heat
illness preventive measures.
v Increase awareness and commitment to safety
and health at the work site.
Heat Illness Prevention Elements Include: v Access to Water v Access to Shade v Weather Monitoring and Acclimatization v High Heat Procedures v Employee and Supervisory Training v Written Procedures Including Emergency
Response
Access to Water v Potable drinking water must be
made available at no cost to the employee.
v Maintain, at all times, sufficient
quantities of pure and cool potable drinking water (i.e. enough to provide at least one quart per employee per hour for the entire shift).
Access to Water v Water must be fit to drink.
Water containers CAN NOT be refilled from non-potable water sources (e.g. irrigation wells, sprinkler or firefighting systems).
v Care must be taken to prevent
contamination of the drinking water supplied to the workers.
Access to Water v Implement and
maintain effective replenishment procedures when beginning the shift with smaller quantities.
Access to Water v Locate the water containers
as close as practicable given the working conditions and layout of the worksite.
v Keep it readily accessible,
move it with the workers!
v Encourage the frequent
drinking of water.
Remind workers not to wait until they are thirsty!
Shade Up:
When the temperature exceeds 80° F v Have and maintain one or
more areas of shade at all times, when employees are present.
v Locate the shade as close
as practical to the area where employees are working.
Shade Up:
When the temperature exceeds 80° F v Provide enough shade to
accommodate the number of employees on recovery or rest periods.
v Provide enough shade to
accommodate the number of employees on meal period who remain on site
v Remember: Access to shade
must be permitted at all times.
Access to Shade, cont. v Encourage employees to take a
cool-down rest in the shade.
v Monitor employees on cool
down rests
v Ask them if they’re
experiencing symptoms of heat illness
v Don’t order back to work until
symptoms abated, allow at least a 5 minute rest
v Take appropriate first aid steps
or emergency response as necessary
Access to Shade, cont. v Shaded area must not cause
exposure to another health or safety hazard. Areas underneath mobile equipment (e.g. tractor), or areas that require crouching in order to sit fully in the shade are not acceptable.
If temperature is below 80° F
v When the temperature does not exceed 80° F,
provide timely access to shade upon request.
When Infeasible or Unsafe
In situations where the employer can demonstrate that it is not safe or feasible to provide shade, an employer can utilize established procedures for providing shade upon request or, for non-agricultural employers, alternative cooling measures that provide equivalent protection.
Monitor the Weather www.nws.noaa.gov
v Instruct supervisors to track
the weather of the job site [by monitoring predicted temperature highs and periodically using a thermometer.]
v Determine, and instruct
supervisors, on how weather information will be used to modify work schedule, increase number of water and rest breaks or cease work early if necessary.
High Heat Procedures Industries covered by this subsection: v Agriculture v Construction v Landscaping v Oil and Gas Extraction v Transportation or delivery of agricultural,
construction materials or other heavy materials.
When the temperature equals or exceeds 95° F You must implement additional preventive measures: v Ensure effective
communication (by voice, observation or electronic means).
When the temperature equals or exceeds 95° F You must implement additional preventive measures: v Observe employees for
alertness and signs and symptoms of heat illness. v Supervisory or designee observation of 20 or fewer
employees
v Mandatory buddy system v Regular communication v Other effective means
When the temperature equals or exceeds 95° F v Designate one or more
employees to call for emergency services
v Give more frequent
reminders to drink plenty of water.
v Hold pre-shift meetings on
prevention
When the temperature equals or exceeds 95° F v For agricultural employers v Temps 95 or above,
ensure employees take a minimum ten minute net preventative cool-down rest every two hours
v Additional ten minute
cool-down rest at end of 8th and 10th hour of work
Emergency Response Procedures v Ensure effective communication v Respond to signs and symptoms of possible heat illness
Ø Supervisor to take immediate, appropriate action Ø If indicators of serious heat illness, implement emergency response procedures Ø Employees exhibiting or reporting signs or symptoms of heat illness shall be monitored and not left alone. Onsite first aid or appropriate emergency medical services shall be offered. Ø Contact emergency medical services and ensure that clear and precise directions to the site can be provided
Address Lack of Acclimatization v As an employer, you are responsible for the working
conditions of your employees, so you must act effectively when conditions result in sudden exposure to heat that your workers are not used to.
v All employees shall be closely observed by a
supervisor or designee during heat waves.
v Employees newly assigned to high heat areas shall
be closely observed by a supervisor or designee for the first 14 days of employment
Address Lack of Acclimatization v Thus, determine how your company will: Ø lessen the intensity and/or shift length of the newly-hired
employees’ work during a two or more week break-in period; Ø modify the work schedule or reschedule non essential duties, during the hot summer months; Ø be extra-vigilant with your employees to recognize immediately symptoms of possible heat illness.
Employee & Supervisor Training Ensure all employees and supervisors: v Are trained before
beginning work that should reasonably be anticipated to result in a heat illness.
Employee Training v The environmental and
personal risk factors for heat illness, as well as the added burden of heat load on the body
Employee Training v Your company’s heat
illness prevention procedures Ø
Including, but not limited to, the employer’s responsibility to provide water, shade, cool-down rests, and access to first aid as well as the employees’ right to exercise their rights under this standard without retaliation
Employee Training, cont. v Importance of frequent
consumption of small quantities of water
v Different types of heat
illness, common signs and symptoms; and appropriate first aid or emergency response
v Knowledge that heat
illness may progress rapidly
Employee Training, cont. v The concept, importance, and methods of
acclimatization
Training must include the importance of acclimatization, how it is developed, and how your procedures address it.
v Importance of immediately reporting signs or
symptoms of heat illness to a supervisor
v Procedures for responding to possible heat
illness
Employee Training, cont. v Procedures to follow when
contacting emergency medical services, providing first aid, and if necessary transporting employees.
v Procedures that ensure clear
and precise directions to the work site, including designating a person to be available to ensure that emergency procedures are invoked when appropriate.
Supervisor Training Supervisors must be trained on the following: v The heat standard requirements v The procedures they must follow to
implement the requirements
v Procedures to follow when a worker exhibits
or reports symptoms consistent with possible heat illness, including emergency response procedures and first aid.
v How to monitor weather reports and how to
respond to hot weather advisories.
Written Procedures v As long as they are effective,
your Heat Illness Procedures can be integrated into the IIPP.
v Maintain the procedures on
site or close to the site, so that it can be made available to employees and representatives of Cal/OSHA upon request.
v Plan in English and the
language understood by the majority of the employees
Written Procedures, cont. Detail how your company will: v Provide access to water & shade. v Monitor the weather. v Institute high heat procedures v Address acclimatization methods and procedures. v Train all employees and supervisors. v Respond to heat illnesses without delay, provide
first aid and emergency services.
v Provide clear and precise directions to the
worksite.
Serious Hazard You risk a serious citation if the outdoor temperature in the work area exceeds 80° F and any of these required elements is not present at the site: v Drinking water v Shade v Trained employees or supervisor v Emergency response procedures
Imminent Hazard Don’t Risk an OPU! You may also risk an Order Prohibiting Use (OPU) and a Serious Citation if the heat and lack of facilities create an imminent hazard. An OPU may be issued if: v The temperature is ≥ 95° and water, shade, training or
emergency procedures are not in place; v The temperature is ≥ 80°, and there is a heat wave, heavy workload or other critical factor putting employees in danger.
An OPU: v Will shut down the operation, and; v Work will not be allowed to resume until the employer
demonstrates that the imminent hazard has been corrected.
For Additional Information Visit the Cal/OSHA Heat Illness Webpage: http://www.dir.ca.gov/DOSH/HeatIllnessInfo.html
Contact us by email:
[email protected]
Heat Illness Materials Multilingual educational materials can be downloaded free from the www.99calor.org website
Cal/OSHA Consultation
STANDARDS PRESENTATION Attachment No. 1 TO Page 1 of 9 CALIFORNIA OCCUPATIONAL SAFETY AND HEALTH STANDARDS BOARD PROPOSED STATE STANDARD, TITLE 8, DIVISION 1, CHAPTER 4 Subchapter 7. General Industry Safety Orders Article 10. Personal Safety Devices and Safeguards Amend Section 3395 to read: Section 3395. Heat Illness Prevention in Outdoor Places of Employment. (a) Scope and Application. (1) This standard applies to all outdoor places of employment. EXCEPTION: If an industry is not listed in subsection (a)(2), employers in that industry are not required to comply with subsection (e), High-heat procedures. (2) List of industries subject to all provisions of this standard, including subsection (e): (A) Agriculture (B) Construction (C) Landscaping (D) Oil and gas extraction (E) Transportation or delivery of agricultural products, construction materials or other heavy materials (e.g. furniture, lumber, freight, cargo, cabinets, industrial or commercial materials), except for employment that consists of operating an air-conditioned vehicle and does not include loading or unloading. (3) This section applies to the control of risk of occurrence of heat illness. This is not intended to exclude the application of other sections of Title 8, including, but not necessarily limited to, sections 1512, 1524, 3203, 3363, 3400, 3439, 3457, 6251, 6512, 6969, 6975, 8420 and 8602(e). NOTE NO. 1: The measures required here may be integrated into the employer's written Injury and Illness Program required by section 3203, or maintained in a separate document. NOTE NO. 2: This standard is enforceable by the Division of Occupational Safety
STANDARDS PRESENTATION Attachment No. 1 TO Page 2 of 9 CALIFORNIA OCCUPATIONAL SAFETY AND HEALTH STANDARDS BOARD PROPOSED STATE STANDARD, TITLE 8, DIVISION 1, CHAPTER 4 and Health pursuant to Labor Code sections 6308 and 6317 and any other statutes conferring enforcement powers upon the Division. It is a violation of Labor Code sections 6310, 6311, and 6312 to discharge or discriminate in any other manner against employees for exercising their rights under this or any other provision offering occupational safety and health protection to employees. (b) Definitions. “Acclimatization” means temporary adaptation of the body to work in the heat that occurs gradually when a person is exposed to it. Acclimatization peaks in most people within four to fourteen days of regular work for at least two hours per day in the heat. “Heat Illness” means a serious medical condition resulting from the body's inability to cope with a particular heat load, and includes heat cramps, heat exhaustion, heat syncope and heat stroke. “Environmental risk factors for heat illness” means working conditions that create the possibility that heat illness could occur, including air temperature, relative humidity, radiant heat from the sun and other sources, conductive heat sources such as the ground, air movement, workload severity and duration, protective clothing and personal protective equipment worn by employees. “Landscaping” means providing landscape care and maintenance services and/or installing trees, shrubs, plants, lawns, or gardens, or providing these services in conjunction with the design of landscape plans and/or the construction (i.e., installation) of walkways, retaining walls, decks, fences, ponds, and similar structures, except for employment by an employer who operates a fixed establishment where the work is to be performed and where drinking water is plumbed. “Oil and gas extraction” means operating and/or developing oil and gas field properties, exploring for crude petroleum or natural gas, mining or extracting of oil or gas or recovering liquid hydrocarbons from oil or gas field gases. “Personal risk factors for heat illness” means factors such as an individual's age, degree of acclimatization, health, water consumption, alcohol consumption, caffeine consumption, and use of prescription medications that affect the body's water retention or other physiological responses to heat.
STANDARDS PRESENTATION Attachment No. 1 TO Page 3 of 9 CALIFORNIA OCCUPATIONAL SAFETY AND HEALTH STANDARDS BOARD PROPOSED STATE STANDARD, TITLE 8, DIVISION 1, CHAPTER 4 “Shade” means blockage of direct sunlight. One indicator that blockage is sufficient is when objects do not cast a shadow in the area of blocked sunlight. Shade is not adequate when heat in the area of shade defeats the purpose of shade, which is to allow the body to cool. For example, a car sitting in the sun does not provide acceptable shade to a person inside it, unless the car is running with air conditioning. Shade may be provided by any natural or artificial means that does not expose employees to unsafe or unhealthy conditions and that does not deter or discourage access or use. “Temperature” means the dry bulb temperature in degrees Fahrenheit obtainable by using a thermometer to measure the outdoor temperature in an area where there is no shade. While the temperature measurement must be taken in an area with full sunlight, the bulb or sensor of the thermometer should be shielded while taking the measurement, e.g., with the hand or some other object, from direct contact by sunlight. (c) Provision of water. Employees shall have access to potable drinking water meeting the requirements of Sections 1524, 3363, and 3457, as applicable, including but not limited to the requirements that it be fresh, pure, suitably cool, and provided to employees free of charge. The water shall be located as close as practicable to the areas where employees are working. Where drinking water is not plumbed or otherwise continuously supplied, it shall be provided in sufficient quantity at the beginning of the work shift to provide one quart per employee per hour for drinking for the entire shift. Employers may begin the shift with smaller quantities of water if they have effective procedures for replenishment during the shift as needed to allow employees to drink one quart or more per hour. The frequent drinking of water, as described in subsection (f)(h)(1)(C), shall be encouraged. (d) Access to shade. (1) Shade required to shall be present when the temperature exceeds 8580 degrees Fahrenheit. When the outdoor temperature in the work area exceeds 8580 degrees Fahrenheit, the employer shall have and maintain one or more areas with shade at all times while employees are present that are either open to the air or provided with ventilation or cooling. The amount of shade present shall be at least enough to accommodate 25% of the number of employees on the shift at any time recovery or rest periods, so that they can sit in a normal posture fully in the shade without having to be in physical contact with each other. The shaded area shade shall be located as close as practicable to the areas where employees are working. Subject to the same
STANDARDS PRESENTATION Attachment No. 1 TO Page 4 of 9 CALIFORNIA OCCUPATIONAL SAFETY AND HEALTH STANDARDS BOARD PROPOSED STATE STANDARD, TITLE 8, DIVISION 1, CHAPTER 4 specifications, the amount of shade present during meal periods shall be at least enough to accommodate the number of employees on the meal period who remain onsite. (2) Shade required to shall be available when the temperature does not exceed 8580 degrees Fahrenheit. When the outdoor temperature in the work area does not exceed 8580 degrees Fahrenheit employers shall either provide shade as per subsection (d)(1) or provide timely access to shade upon an employee's request. (3) Employees shall be allowed and encouraged to take a preventative cooldown rest in the shade for a period of no less than five minutes at a time when they feel the need to do so to protect themselves from overheating. Such access to shade shall be permitted at all times. An individual employee who takes a preventative cool-down rest (A) shall be monitored and asked if he or she is experiencing symptoms of heat illness; (B) shall be encouraged to remain in the shade; and (C) shall not be ordered back to work until any signs or symptoms of heat illness have abated, but in no event less than 5 minutes in addition to the time needed to access the shade. (4) If an employee exhibits signs or reports symptoms of heat illness while taking a preventative cool-down rest or during a preventative cool-down rest period, the employer shall provide appropriate first aid or emergency response according to subsection (f) of this section. Exceptions to subsections (d)(1) and (d)(2): (1) Where the employer can demonstrate that it is infeasible or unsafe to have a shade structure, or otherwise to have shade present on a continuous basis, the employer may utilize alternative procedures for providing access to shade if the alternative procedures provide equivalent protection. (2) Except for employers in the agricultural industry, cooling measures other than shade (e.g., use of misting machines) may be provided in lieu of shade if the employer can demonstrate that these measures are at least as effective as shade in allowing employees to cool. (e) High-heat procedures. The employer shall implement high-heat procedures when the temperature equals or exceeds 95 degrees Fahrenheit. These procedures shall include the following to the extent practicable:
STANDARDS PRESENTATION Attachment No. 1 TO Page 5 of 9 CALIFORNIA OCCUPATIONAL SAFETY AND HEALTH STANDARDS BOARD PROPOSED STATE STANDARD, TITLE 8, DIVISION 1, CHAPTER 4 (1) Ensuring that effective communication by voice, observation, or electronic means is maintained so that employees at the work site can contact a supervisor when necessary. An electronic device, such as a cell phone or text messaging device, may be used for this purpose only if reception in the area is reliable. (2) Observing employees for alertness and signs or symptoms of heat illness. The employer shall ensure effective employee observation/monitoring by implementing one or more of the following: (A) Supervisor or designee observation of 20 or fewer employees, or (B) Mandatory buddy system, or (C) Regular communication with sole employee such as by radio or cellular phone, or (D) Other effective means of observation. (3) Designating one or more employees on each worksite as authorized to call for emergency medical services, and allowing other employees to call for emergency services when no designated employee is available. (4) Reminding employees throughout the work shift to drink plenty of water. (4) Close supervision of a new employee by a supervisor or designee for the first 14 days of the employee's employment by the employer, unless the employee indicates at the time of hire that he or she has been doing similar outdoor work for at least 10 of the past 30 days for 4 or more hours per day. (5) Pre-shift meetings before the commencement of work to review the high heat procedures, encourage employees to drink plenty of water, and remind employees of their right to take a cool-down rest when necessary. (6) For employees employed in agriculture, the following shall also apply: When temperatures reach 95 degrees or above, the employer shall ensure that the employee takes a minimum ten minute net preventative cool-down rest period every two hours. The preventative cool-down rest period required by this paragraph may be provided concurrently with any other meal or rest period required by Industrial Welfare Commission Order No. 14 if the timing
STANDARDS PRESENTATION Attachment No. 1 TO Page 6 of 9 CALIFORNIA OCCUPATIONAL SAFETY AND HEALTH STANDARDS BOARD PROPOSED STATE STANDARD, TITLE 8, DIVISION 1, CHAPTER 4 of the preventative cool-down rest period coincides with a required meal or rest period thus resulting in no additional preventative cool-down rest period required in an eight hour workday. If the workday will extend beyond eight hours, then an additional preventative cool-down rest period will be required at the conclusion of the eighth hour of work; and if the workday extends beyond ten hours, then another preventative cool-down rest period will be required at the conclusion of the tenth hour and so on. For purposes of this section, preventative cool-down rest period has the same meaning as “recovery period” in Labor Code Section 226.7(a). (f) Emergency Response Procedures. The Employer shall implement effective emergency response procedures including: (1) Ensuring that effective communication by voice, observation, or electronic means is maintained so that employees at the work site can contact a supervisor or emergency medical services when necessary. An electronic device, such as a cell phone or text messaging device, may be used for this purpose only if reception in the area is reliable. If an electronic device will not furnish reliable communication in the work area, the employer will ensure a means of summoning emergency medical services. (2) Responding to signs and symptoms of possible heat illness, including but not limited to first aid measures and how emergency medical services will be provided. (A) If a supervisor observes, or any employee reports, any signs or symptoms of heat illness in any employee, the supervisor shall take immediate action commensurate with the severity of the illness. (B) If the signs or symptoms are indicators of severe heat illness (such as, but not limited to, decreased level of consciousness, staggering, vomiting, disorientation, irrational behavior or convulsions), the employer must implement emergency response procedures. (C) An employee exhibiting signs or symptoms of heat illness shall be monitored and shall not be left alone or sent home without being offered onsite first aid and/or being provided with emergency medical services in accordance with the employer’s procedures. (3) Contacting emergency medical services and, if necessary, transporting
STANDARDS PRESENTATION Attachment No. 1 TO Page 7 of 9 CALIFORNIA OCCUPATIONAL SAFETY AND HEALTH STANDARDS BOARD PROPOSED STATE STANDARD, TITLE 8, DIVISION 1, CHAPTER 4 employees to a place where they can be reached by an emergency medical provider. (4) Ensuring that, in the event of an emergency, clear and precise directions to the work site can and will be provided as needed to emergency responders. (g) Acclimatization. (1) All employees shall be closely observed by a supervisor or designee during a heat wave. For purposes of this section only, “heat wave” means any day in which the predicted high temperature for the day will be at least 80 degrees Fahrenheit and at least ten degrees Fahrenheit higher than the average high daily temperature in the preceding five days. (2) An employee who has been newly assigned to a high heat area shall be closely observed by a supervisor or designee for the first 14 days of the employee's employment. (f) (h) Training. (1) Employee training. Effective training in the following topics shall be provided to each supervisory and non-supervisory employee before the employee begins work that should reasonably be anticipated to result in exposure to the risk of heat illness: (A) The environmental and personal risk factors for heat illness, as well as the added burden of heat load on the body caused by exertion, clothing, and personal protective equipment. (B) The employer's procedures for complying with the requirements of this standard, including, but not limited to, the employer’s responsibility to provide water, shade, cool-down rests, and access to first aid as well as the employees’ right to exercise their rights under this standard without retaliation. (C) The importance of frequent consumption of small quantities of water, up to 4 cups per hour, when the work environment is hot and employees are likely to be sweating more than usual in the performance of their duties. (D) The concept, importance, and methods of acclimatization pursuant to the employer’s procedures under subsection (i)(4).
STANDARDS PRESENTATION Attachment No. 1 TO Page 8 of 9 CALIFORNIA OCCUPATIONAL SAFETY AND HEALTH STANDARDS BOARD PROPOSED STATE STANDARD, TITLE 8, DIVISION 1, CHAPTER 4 (E) The different types of heat illness, and the common signs and symptoms of heat illness, and appropriate first aid and/or emergency responses to the different types of heat illness, and in addition, that heat illness may progress quickly from mild symptoms and signs to serious and life threatening illness. (F) The importance to employees of immediately reporting to the employer, directly or through the employee's supervisor, symptoms or signs of heat illness in themselves, or in co-workers. (G)The employer's procedures for responding to signs or symptoms of possible heat illness, including how emergency medical services will be provided should they become necessary. (H) The employer's procedures for contacting emergency medical services, and if necessary, for transporting employees to a point where they can be reached by an emergency medical service provider. (I) The employer's procedures for ensuring that, in the event of an emergency, clear and precise directions to the work site can and will be provided as needed to emergency responders. These procedures shall include designating a person to be available to ensure that emergency procedures are invoked when appropriate. (2) Supervisor training. Prior to supervising employees performing work that should reasonably be anticipated to result in exposure to the risk of heat illness effective training on the following topics shall be provided to the supervisor: (A) The information required to be provided by section (f)(h)(1) above. (B) The procedures the supervisor is to follow to implement the applicable provisions in this section. (C) The procedures the supervisor is to follow when an employee exhibits signs or reports symptoms consistent with possible heat illness, including emergency response procedures. (D) How to monitor weather reports and how to respond to hot weather advisories.
STANDARDS PRESENTATION Attachment No. 1 TO Page 9 of 9 CALIFORNIA OCCUPATIONAL SAFETY AND HEALTH STANDARDS BOARD PROPOSED STATE STANDARD, TITLE 8, DIVISION 1, CHAPTER 4 (i)(3) Heat Illness Prevention Plan. The employer's shall establish, implement, and maintain, an effective procedures for complying with each requirement of this standard required by subsections (f)(1)(B), (G), (H), and (I)heat illness prevention plan. The plan shall be in writing in both English and the language understood by the majority of the employees and shall be made available at the worksite to employees and to representatives of the Division upon request. The Heat Illness Prevention Plan may be included as part of the employer’s Illness and Injury Prevention Program required by section 3203, and shall, at a minimum, contain: (1) Procedures for the provision of water and access to shade. (2) The high heat procedures referred to in subsection (e). (3) Emergency Response Procedures in accordance with subsection (f). (4) Acclimatization methods and procedures in accordance with subsection (g). NOTE: Authority cited: Section 142.3, Labor Code. Reference: Section 142.3, Labor Code
Heat Illness Prevention Regulation Amendments California Code of Regulations, Title 8, Section 3395
Guidance for Employers and Employees on the New Requirements March 23, 2015
Contents INTRODUCTION ................................................................................................................................................................................................................................... 2 (b) DEFINITIONS................................................................................................................................................................................................................................... 2 (c) PROVISION OF WATER.................................................................................................................................................................................................................... 3 (d) ACCESS TO SHADE .......................................................................................................................................................................................................................... 4 (e) HIGH-HEAT PROCEDURES .............................................................................................................................................................................................................. 7 (f) EMERGENCY RESPONSE PROCEDURES .........................................................................................................................................................................................10 (g) ACCLIMATIZATION .......................................................................................................................................................................................................................13 (h) TRAINING .....................................................................................................................................................................................................................................13 (i) HEAT ILLNESS PREVENTION PLAN .................................................................................................................................................................................................15
Page 1
INTRODUCTION Changes to the Cal/OSHA heat illness prevention regulation are expected to go into effect on May 1, 2015. The tables in this document provide guidance to employers and employees on how to implement the new requirements. Please note that this document does not cover all possible situations. For additional information and materials, go to http://www.dir.ca.gov/DOSH/HeatIllnessInfo.html.
(b) DEFINITIONS EXISTING LANGUAGE
AMENDED LANGUAGE
GUIDANCE ON THE NEW REQUIREMENTS
“Shade” means blockage of direct sunlight. One indicator that blockage is sufficient is when objects do not cast a shadow in the area of blocked sunlight. Shade is not adequate when heat in the area of shade defeats the purpose of shade, which is to allow the body to cool. For example, a car sitting in the sun does not provide acceptable shade to a person inside it, unless the car is running with air conditioning. Shade may be provided by any natural or artificial means that does not expose employees to unsafe or unhealthy conditions.
“Shade” means blockage of direct sunlight. One indicator that blockage is sufficient is when objects do not cast a shadow in the area of blocked sunlight. Shade is not adequate when heat in the area of shade defeats the purpose of shade, which is to allow the body to cool. For example, a car sitting in the sun does not provide acceptable shade to a person inside it, unless the car is running with air conditioning. Shade may be provided by any natural or artificial means that does not expose employees to unsafe or unhealthy conditions and that does not deter or discourage access or use.
Shade must be easy for employees to reach. The requirement that shade “not deter or discourage access or use” means that workers should not encounter any obstacles or hazardous or unreasonably unpleasant conditions while moving towards the shade or resting in the shade.
Page 2
Examples: • Employees should not have to cross traffic or waterways to reach the shade. • The shade should not be located next to portable toilet facilities or where employees would sit on wet or muddy ground or come in contact with branches, brush, and thorns.
(c) PROVISION OF WATER EXISTING LANGUAGE
AMENDED LANGUAGE
GUIDANCE ON THE NEW REQUIREMENTS
Provision of water. Employees shall have access to potable drinking water meeting the requirements of Sections 1524, 3363, and 3457, as applicable. Where drinking water is not plumbed or otherwise continuously supplied, it shall be provided in sufficient quantity at the beginning of the work shift to provide one quart per employee per hour for drinking for the entire shift. Employers may begin the shift with smaller quantities of water if they have effective procedures for replenishment during the shift as needed to allow employees to drink one quart or more per hour. The frequent drinking of water, as described in subsection (f)(1)(C), shall be encouraged.
Provision of water. Employees shall have access to potable drinking water meeting the requirements of Sections 1524, 3363, and 3457, as applicable, including but not limited to the requirements that it be fresh, pure, suitably cool, and provided to employees free of charge. The water shall be located as close as practicable to the areas where employees are working. Where drinking water is not plumbed or otherwise continuously supplied, it shall be provided in sufficient quantity at the beginning of the work shift to provide one quart per employee per hour for drinking for the entire shift. Employers may begin the shift with smaller quantities of water if they have effective procedures for replenishment during the shift as needed to allow employees to drink one quart or more per hour. The frequent drinking of water, as described in subsection (f)(h)(1)(C), shall be encouraged.
The purpose of requiring that water be “fresh, pure, suitably cool, and provided to employees free of charge” and “located as close as practicable to the areas where employees are working” is to encourage workers to drink water often and avoid making the workers interrupt their work in order to do so. To ensure that water is fresh, pure, and suitably cool, Cal/OSHA advises employers or supervisors visually examine the water and pour some on their skin.
Page 3
Fresh and Pure Water must be fit to drink (i.e., potable) and free from odors that would discourage workers from drinking the water. If an employer supplies individual water containers, the containers must be clean, and a source of potable water (e.g., a municipal water source) must be readily available. Water from non-approved or non-tested water sources (e.g., untested wells) is not acceptable. If hoses or connections are used, they must be governmentally approved for potable drinking water systems, as shown on the manufacturer’s label. Suitably Cool During hot weather, the water must be cooler than the ambient temperature but not so cool as to cause discomfort. As Close As Practicable to Where Employees Are Working During a Cal/OSHA inspection, the inspector may ask the supervisor to describe the factors the employer considered in deciding where to place water. For example, although it may be impossible or prohibited by law to place water stations within rows of crops where employees are working, it may be possible to place the water stations at the end of rows. Because water containers are smaller than shade structures, they
(c) PROVISION OF WATER EXISTING LANGUAGE
AMENDED LANGUAGE
GUIDANCE ON THE NEW REQUIREMENTS can be placed closer to employees than shade structures can be. Placing water only in designated shade areas or where toilet facilities are located is not sufficient. When employees are working across large areas, water should be placed in multiple locations. For example, on a multi-story construction site, water should be placed in a safely accessible location on every floor where employees are working.
(d) ACCESS TO SHADE EXISTING LANGUAGE
AMENDED LANGUAGE
GUIDANCE ON THE NEW REQUIREMENTS
(1) Shade required to be present when the temperature exceeds 85 degrees Fahrenheit. When the outdoor temperature in the work area exceeds 85 degrees Fahrenheit, the employer shall have and maintain one or more areas with shade at all times while employees are present that are either open to the air or provided with ventilation or cooling.
(1) Shade required to shall be present when the temperature exceeds 85 80 degrees Fahrenheit. When the outdoor temperature in the work area exceeds 85 80 degrees Fahrenheit, the employer shall have and maintain one or more areas with shade at all times while employees are present that are either open to the air or provided with ventilation or cooling.
The trigger temperature for shade being present is reduced from 85 to 80 degrees Fahrenheit. When temperatures exceed 80 degrees, shade structures must be erected if no other shade is readily available.
The amount of shade present shall be
The amount of shade present shall be at
Page 4
Even if temperatures do not exceed 80 degrees, shade must still be available. For employers using shade structures, it is helpful to have the structures erected if the weather is hot enough that the shade can help employees cool off. Employers should monitor predicted weather temperatures in advance (for example, by television or radio or on the Internet) to know when the temperature will probably exceed 80 degrees. Employers are expected to know if the temperature is in fact exceeding 80 degrees at the worksite. “Recovery and rest period” refers to the normal breaks required to be
(d) ACCESS TO SHADE EXISTING LANGUAGE
AMENDED LANGUAGE
GUIDANCE ON THE NEW REQUIREMENTS
at least enough to accommodate 25% of the employees on the shift at any time, so that they can sit in a normal posture fully in the shade without having to be in physical contact with each other. The shaded area shall be located as close as practicable to the areas where employees are working.
least enough to accommodate 25% of the number of employees on the shift at any time recovery or rest periods, so that they can sit in a normal posture fully in the shade without having to be in physical contact with each other. The shaded area shade shall be located as close as practicable to the areas where employees are working. Subject to the same specifications, the amount of shade present during meal periods shall be at least enough to accommodate the number of employees on the meal period who remain onsite.
offered under Industrial Welfare Commission wage orders. The new rules require that enough shade be provided to accommodate all of the employees who are on such a break at any point in time. This does not mean that employers are required to provide enough shade to accommodate all of the employees on the shift at the same time. Employers may, for example, rotate the breaks among employees. They may also erect additional structures on an as-needed basis.
(3) Employees shall be allowed and encouraged to take a cool-down rest in the shade for a period of no less than five minutes at a time when they feel the need to do so to protect themselves from overheating. Such access to shade shall be permitted at all times.
(3) Employees shall be allowed and encouraged to take a preventative cooldown rest in the shade for a period of no less than five minutes at a time when they feel the need to do so to protect themselves from overheating. Such access to shade shall be permitted at all times. An individual employee who takes a preventative cool-down rest (A) shall be monitored and asked if he or she is experiencing symptoms of heat illness; (B) shall be encouraged to remain in the shade; and (C) shall not be
An employee may opt to take a “preventative cool-down rest” in the shade to help the body relieve excess heat. It is crucial that workers not be rushed while taking the cool-down rest.
Page 5
During meal periods, the employer must provide enough shade for all of the employees who choose to remain in the general area of work or in areas designated for recovery and rest periods. Employers may rotate employees in and out of meal periods, as with recovery and rest periods. Employers are not required to provide shade for employees who choose to spend meal periods in their own air-conditioned vehicles. However, employers may not require or pressure employees to eat their lunch in their own vehicles or go off-site to eat.
Water should be available in the rest area so that employees are encouraged to drink more water. The importance of prevention cannot be overstated. Employees who wait until symptoms appear before seeking shade and recovery are at significant risk of developing heat illness. The employee must be monitored during the cool-down rest and asked if he or she is experiencing any symptoms of heat illness including
(d) ACCESS TO SHADE EXISTING LANGUAGE
[None]
AMENDED LANGUAGE
GUIDANCE ON THE NEW REQUIREMENTS
ordered back to work until any signs or symptoms of heat illness have abated, but in no event less than 5 minutes in addition to the time needed to access the shade.
simple fatigue. If any signs or symptoms of heat illness are observed or reported, the employer must not order the employee back to work and must continuously observe the employee until the signs or symptoms have abated. Common early signs and symptoms of heat illness may include, for example, pale skin, heavy sweating, headache, muscle cramps, and fatigue. If no sign or symptom of heat illness is observed or reported, monitoring may be periodic, not continuous.
(4) If an employee exhibits signs or reports symptoms of heat illness while taking a preventative cool-down rest or during a preventative cool-down rest period, the employer shall provide appropriate first aid or emergency response according to subsection (f) of this section.
The terms “preventative cool-down rest” and “preventative cool-down rest period” refer to two different sets of requirements. The requirements for “preventative cool-down rest periods” are set forth in section (e), below. If an employee exhibits or complains of any sign or symptom of heat illness, first-aid procedures should be initiated without delay. Progression to more serious illness can be rapid, and can include altered coordination and speech, mental confusion, unusual behavior, nausea, vomiting, hot dry skin, unusually profuse sweating, loss of consciousness, and seizures. The affected employee may be unable to self-diagnose these problems. If heat illness is suspected, emergency medical personnel should be contacted immediately. No employee with signs or symptoms of heat illness should be left unattended or sent home without being offered on-site first aid or provided emergency medical services, as discussed in subsection (f).
Page 6
(e) HIGH-HEAT PROCEDURES EXISTING LANGUAGE
AMENDED LANGUAGE
GUIDANCE ON THE NEW REQUIREMENTS
The employer shall implement highheat procedures when the temperature equals or exceeds 95 degrees Fahrenheit. These procedures shall include the following to the extent practicable:
The employer shall implement high-heat procedures when the temperature equals or exceeds 95 degrees Fahrenheit. These procedures shall include the following to the extent practicable:
... (2) Observing employees for alertness and signs or symptoms of heat illness.
... (2) Observing employees for alertness and signs or symptoms of heat illness. The employer shall ensure effective employee observation/ monitoring by implementing one or more of the following: (A) Supervisor or designee observation of 20 or fewer employees, or (B) Mandatory buddy system, or (C) Regular communication with sole employee such as by radio or cellular phone, or (D) Other effective means of observation.
During periods of high heat, it is crucial that employees be monitored for early signs and symptoms of heat illness. This helps ensure that sick employees receive treatment immediately and serious illness does not develop. If an employee suffers syncope (fainting), disorientation, loss of consciousness, or other symptoms of heat illness while working unobserved, initial medical treatment may be delayed, with serious or fatal consequences.
(3) Reminding employees throughout the work shift to drink plenty of water.
(3) Designating one or more employees on each worksite as authorized to call for emergency medical services, and allowing other employees to call for emergency services when no designated employee is available.
Page 7
Because each work site is unique, the new provisions give employers options and flexibility in observing and monitoring employees. When employees work in small groups of no more than 20 workers, direct observation by a supervisor or designee may be sufficient. When there are too many employees to allow direct observation, the employer may use the buddy system and pair up employees. With the buddy system, the employer must train the employees to stay in contact, observe each other throughout the day, and immediately report any signs or symptoms of heat illness. For employees who are required to work alone, the employer may communicate with the employee by radio or cell phone in locations where there is adequate coverage. The employee must be contacted regularly and as frequently as possible throughout the day, since an employee in distress may not be able to summon help on his or her own. The new provisions allow employers to use different methods to monitor for heat illness. Whatever method is used, the employer must be able to ascertain the condition of employees at regular intervals and provide emergency services when an employee reports symptoms of heat illness or is unable to respond.
(e) HIGH-HEAT PROCEDURES EXISTING LANGUAGE
AMENDED LANGUAGE
GUIDANCE ON THE NEW REQUIREMENTS
(4) Reminding employees throughout the work shift to drink plenty of water.
All employees must be trained to recognize the signs and symptoms of heat illness and must be allowed to call for emergency medical services when necessary. If, however, all employees in a crew are designated to call for emergency medical services, many will be reluctant to do so. Therefore, employers must specifically assign one or a small number of employees per crew to call for emergency medical services. A designated employee may be either supervisory or non-supervisory.
(4) Close supervision of a new employee by a supervisor or designee for the first 14 days of the employee's employment by the employer, unless the employee indicates at the time of hire that he or she has been doing similar outdoor work for at least 10 of the past 30 days for 4 or more hours per day.
(4) Close supervision of a new employee by a supervisor or designee for the first 14 days of the employee's employment by the employer, unless the employee indicates at the time of hire that he or she has been doing similar outdoor work for at least 10 of the past 30 days for 4 or more hours per day.
See subsection (g), Acclimatization, below.
[None]
(5) Pre-shift meetings before the commencement of work to review the high heat procedures, encourage employees to drink plenty of water, and remind employees of their right to take a cool-down rest when necessary.
Pre-shift meetings are meant to briefly remind supervisors and employees to review high-heat procedures. They are not meant to review every element previously covered in regular training or in orientation. The employer may determine whether the training is required based on the predicted temperature in the area. Topics that should be covered in pre-shift meetings include staying hydrated and taking preventative cool-down rests, identifying the employees who should call for emergency medical services when needed, and how employees will be observed. For employees working
Page 8
(e) HIGH-HEAT PROCEDURES EXISTING LANGUAGE
AMENDED LANGUAGE
GUIDANCE ON THE NEW REQUIREMENTS remotely, the employer may conduct pre-shift meetings by cell phone or radio.
[None]
(6) For employees employed in agriculture, the following shall also apply: When temperatures reach 95 degrees or above, the employer shall ensure that the employee takes a minimum ten minute net preventative cool down rest period every two hours. The preventative cool down rest period required by this paragraph may be provided concurrently with any other meal or rest period required by Industrial Welfare Commission Order No. 14 if the timing of the preventative cool down rest period coincides with a required meal or rest period thus resulting in no additional preventative cool down-rest period required in an eight hour work day. If the workday will extend beyond eight hours, then an additional preventative cool down-rest period will be required at the conclusion of the eighth hour of work; and if the work day extends beyond ten hours, then another preventative cool downrest period will be required at the
Page 9
This subsection applies only to agricultural work sites. When the temperature equals or exceeds 95 degrees, employers must provide one 10-minute “preventative cool-down rest period” every 2 hours. During the first 8 hours of a shift, the cool-down periods may be provided at the same time as the rest periods already required by Industrial Welfare Commission Order No. 14. If employees work longer than 8 hours, the employer must provide an additional 10-minute cool-down rest period every 2 hours. For example, if the shift extends beyond 8 hours, an additional rest period is required at the end of the 8th hour of work. If the shift extends beyond 10 hours, another is required at the end of the 10th hour. Employers must ensure that employees actually take the cool-down rest periods required under this section. Merely offering the opportunity for a break is not enough. Employers are required to provide additional breaks as soon as the temperature equals or exceeds 95 degrees. For example, even if the temperature does not reach 95 degrees until the last half of an 8-hour shift, if the shift will last longer than 8 hours, the employer must ensure that employees take cool-down rest periods starting at the end of the 8th hour of work. Cal/OSHA does not require employers to keep records of the rest
(e) HIGH-HEAT PROCEDURES EXISTING LANGUAGE
AMENDED LANGUAGE
GUIDANCE ON THE NEW REQUIREMENTS
conclusion of the tenth hour and so on. For purposes of this section, preventative cool down rest period has the same meaning as “recovery period” in Labor Code Section 226.7(a).
periods provided under this subsection, but doing so is the best practice and would benefit them.
(f) EMERGENCY RESPONSE PROCEDURES EXISTING LANGUAGE
AMENDED LANGUAGE
GUIDANCE ON THE NEW REQUIREMENTS
[Emergency response procedures were previously required only as an element of training.]
(f) Emergency Response Procedures. The Employer shall implement effective emergency response procedures including:
Emergency medical services must be provided as quickly as possible if an employee suffers heat illness. Establishing emergency response procedures is particularly important at non-fixed or remote work sites or at work sites where access is difficult.
[See above]
(1) Ensuring that effective communication by voice, observation, or electronic means is maintained so that employees at the work site can contact a supervisor or emergency medical services when necessary. An electronic device, such as a cell phone or text messaging device, may be used for this purpose only if reception in the area is reliable. If an electronic device will not furnish reliable communication in the work area, employer will ensure a
If employees cannot reach emergency medical services directly (because cell phone coverage is inadequate, for example), the employer must designate a person who can immediately contact emergency services on behalf of the employees. The employees must be able to reach this person quickly (such as by radio) to request that emergency medical services be summoned.
Page 10
If, however, employees are able to contact emergency medical services directly, they must be allowed to do so in an emergency and not be required to contact a supervisor first.
(f) EMERGENCY RESPONSE PROCEDURES EXISTING LANGUAGE
AMENDED LANGUAGE
GUIDANCE ON THE NEW REQUIREMENTS
means of summoning emergency medical services. [See above]
(2) Responding to signs and symptoms of possible heat illness, including but not limited to first aid measures and how emergency medical services will be provided. (A) If a supervisor observes, or any employee reports, any signs or symptoms of heat illness in any employee, the supervisor shall take immediate action commensurate with the severity of the illness. (B) If the signs or symptoms are indicators of severe heat illness (such as, but not limited to, decreased level of consciousness, staggering, vomiting, disorientation, irrational behavior or convulsions), the employer must implement emergency response procedures. (C) An employee exhibiting signs or symptoms of heat illness shall be monitored and shall not be left alone or sent home without being offered onsite first aid and/or being provided with emergency medical services in accordance with the employer’s procedures.
Page 11
Employers must ensure that supervisors and employees are trained to recognize the signs and symptoms of heat illness, take steps immediately to prevent the progression of heat illness, provide basic first aid (such as cooling towels and shade), obtain emergency medical services, and not allow an employee with signs or symptoms of heat illness to be left alone or sent home without being offered onsite first aid or provided with emergency medical services. Employers, however, are not required to provide medical personnel on site, and supervisors and employees are not expected to have medical expertise to diagnose heat illness.
(f) EMERGENCY RESPONSE PROCEDURES EXISTING LANGUAGE
AMENDED LANGUAGE
GUIDANCE ON THE NEW REQUIREMENTS
[See above]
(3) Contacting emergency medical services and, if necessary, transporting employees to a place where they can be reached by an emergency medical provider.
The employer’s procedures must include contacting emergency medical services when necessary. The procedures must include immediate steps to keep a stricken employee cool and comfortable once emergency service responders have been called. The goal is to stop the rapid progression to more serious illness, which can include mental confusion, loss of consciousness, and seizures. When necessary, employers must be prepared to transport employees safely to a place where they can be reached by an emergency medical provider.
[See above]
(4) Ensuring that, in the event of an emergency, clear and precise directions to the work site can and will be provided as needed to emergency responders.
Page 12
Mobile crews must be provided with a map of their location or detailed directions that can be given to emergency responders.
(g) ACCLIMATIZATION EXISTING LANGUAGE
AMENDED LANGUAGE
GUIDANCE ON THE NEW REQUIREMENTS
[Acclimatization was previously required only as an element of training.]
(g) Acclimatization (1) All employees shall be closely observed by a supervisor or designee during a heat wave. For purposes of this section only, “heat wave” means any day in which the predicted high temperature for the day will be at least 80 degrees Fahrenheit and at least ten degrees Fahrenheit higher than the average high daily temperature in the preceding five days. (2) An employee who has been newly assigned to a high heat area shall be closely observed by a supervisor or designee for the first 14 days of the employee's employment.
Acclimatization is a process by which the body adjusts to increased heat exposure. The body needs time to adapt when working in hotter environments. Employees are more like to develop heat illness if not allowed or encouraged to take it easy when a heat wave strikes or when starting a job that newly exposes them to heat. Acclimatization is fully achieved in most people within 4 to 14 days of regular work involving at least 2 hours per day in the heat.
EXISTING LANGUAGE
AMENDED LANGUAGE
GUIDANCE ON THE NEW REQUIREMENTS
(1) Employee training. Effective training in the following topics shall be provided to each supervisory and nonsupervisory employee before the employee begins work that should reasonably be anticipated to result in
(1) Employee training. Effective training in the following topics shall be provided to each supervisory and non-supervisory employee before the employee begins work that should reasonably be anticipated to result in exposure to the
Employers must train all employees, both supervisory and nonsupervisory, on the policies and procedures established to comply with this regulation.
During heat waves and with new employees, employers must be extravigilant. A supervisor or designee must closely observe employees. Best practices include finding ways to lessen the intensity of employees' work during a heat wave and during 2-week break-in periods of new employees.
(h) TRAINING
Page 13
Training must be provided before the beginning of work involving a risk of heat illness. The training should be provided when an employee is
(h) TRAINING EXISTING LANGUAGE
AMENDED LANGUAGE
GUIDANCE ON THE NEW REQUIREMENTS
exposure to the risk of heat illness:
risk of heat illness:
... (B) The employer's procedures for complying with the requirements of this standard.
... (B) The employer's procedures for complying with the requirements of this standard, including, but not limited to, the employer’s responsibility to provide water, shade, cool-down rests, and access to first aid as well as the employees’ right to exercise their rights under this standard without retaliation.
hired, with refresher training as needed. Training that is given close in time to the hot season is more effective than training given during colder seasons without follow-up refresher training.
(D) The importance of acclimatization. (E) The different types of heat illness and the common signs and symptoms of heat illness.
(D) The concept, importance, and methods of acclimatization, pursuant to the employer’s procedures under subsection (i)(4). (E) The different types of heat illness and, the common signs and symptoms of heat illness, and appropriate first aid and/or emergency responses to the different types of heat illness, and in addition, that heat illness may progress quickly from mild symptoms and signs to serious and life threatening illness.
Page 14
The changes in this subsection include new elements of the content of required training. Cal/OSHA evaluates compliance by examining both content and how it is presented. To be effective, training must be understood by employees and given in a language the employees understand. The test of compliance is whether training has occurred, whether the required content has been provided, and whether the training has been effective in communicating the essentials to employees. To evaluate compliance, Cal/OSHA personnel ask supervisory and nonsupervisory employees about required training elements. The questions are designed to determine whether employees received training through methods generally recognized as effective and whether they understood its content. Inspectors will not expect all answers to be correct but will look for indicators that the employer has made a goodfaith effort to communicate all the essential information. Employers must ensure that their work procedures are consistent with the information provided in the training. Cal/OSHA requires employers to maintain records of the training required in this subsection, as specified in the California Code of Regulations, title 8, section 3203 (Injury and Illness Prevention Program).
(i) HEAT ILLNESS PREVENTION PLAN EXISTING LANGUAGE
AMENDED LANGUAGE
GUIDANCE ON THE NEW REQUIREMENTS
(f)(3) The employer 's procedures for complying with each requirement of this standard required by subsections (f)(1)(B), (G), (H), and (I) shall be in writing and shall be made available to employees and to representatives of the Division upon request.
(i)(3) Heat Illness Prevention Plan. The employer's shall establish, implement, and maintain, an effective procedures for complying with each requirement of this standard required by subsections (f)(1)(B), (G), (H), and (I)heat illness prevention plan. The plan shall be in writing in both English and the language understood by the majority of the employees and shall be made available at the worksite to employees and to representatives of the Division upon request. The Heat Illness Prevention Plan may be included as part of the employer’s Illness and Injury Prevention Program required by section 3203, and shall, at a minimum, contain: (1) Procedures for the provision of water and access to shade. (2) The high heat procedures referred to in subsection (e). (3) Emergency Response Procedures in accordance with subsection (f). (4) Acclimatization methods and procedures in accordance with subsection (g).
The employer must develop, put in writing, and implement effective procedures for complying with the requirements of this standard. A compliant Heat Illness Prevention Plan includes the following: • Procedures for providing sufficient water, as described in subsection (c) • Procedures for providing access to shade, as described in subsection (d) • High-heat procedures in accordance with subsection (e) • Emergency response procedures, outlined in subsection (f) • Acclimatization methods and procedures in accordance with subsection (g)
Page 15
Employees and supervisors must be trained in these procedures so they understand and can implement the employer's plan. The most successful employers teach and make their system work using a teamwork approach. The Heat Illness Prevention Plan must be written both in English and in the language understood by the majority of employees. It must be available to employees at the worksite, as well as to representatives of Cal/OSHA upon request. The plan will be considered available at the worksite if, for example, it can be displayed for employees on a cell phone or other electronic device upon request. The Heat Illness Prevention Plan may be integrated into the employer’s Injury and Illness Prevention Program required under the California Code of Regulations, title 8, section 3203.
EMPLOYER SAMPLE PROCEDURES FOR HEAT ILLNESS PREVENTION April 2015
California employers with any outdoor places of employment must comply with the Heat Illness Prevention Standard - Title 8 California Code of Regulations (T8 CCR) Section 3395. These procedures have been created as a guide to assist employers in crafting their own heat illness prevention procedures, and to reduce the risk of work related heat illnesses among their employees. These procedures are not intended to supersede or replace the application of any other T8 CCR sections, particularly T8 CCR 3203 Injury and Illness Prevention Program (IIPP). T8 CCR 3203 requires an employer to establish, implement, and maintain an effective IIPP. The measures listed here may be integrated into the Employer’s Injury and Illness Prevention Program. The employer must also be aware that other standards apply to Heat Illness Prevention such as the requirement to provide for drinking water, first aid and emergency response. Please note: These procedures describe the minimal steps applicable to most outdoor work settings and are essential to reducing the incidence of heat related illnesses. In working environments with a higher risk for heat illness (e.g., during a heat wave, or other severe working or environmental conditions), it is the employer’s duty to exercise greater caution and additional protective measures beyond what is listed in this document, as needed to protect their employees. To effectively establish your company procedures, carefully review the key elements listed on this document, as well as the examples provided, then develop written procedures applicable to your workplace. The Heat Illness Prevention Plan must be written in English and the language understood by the majority of the employees and must be available at the worksite. Implement and train employees and supervisors on your company procedures and follow-up to ensure your procedures are fulfilled. Furthermore, to successfully tailor these procedures to your work activities, evaluate and consider the individual conditions present at your site (such as, but not limited to): (1) Size of the crew (2) The length of the work-shift (3) The ambient temperature (which can be taken either with the aid of a simple thermometer or by monitoring the weather) (4) The presence of personal protective equipment or additional sources of heat Again, these sample procedures do not include every workplace scenario, so it is crucial that your company evaluate and take into account conditions found in your individual workplace that are likely to cause a heat illness. Mandatory - Requirements for written procedures must also: 1. Identify the designated person(s) that has been assigned the applicable task(s) (e.g. supervisor, foreman, safety coordinator, crew leader). 2. Provide specific details required to carry out the task and ensure that the task is accomplished
EMPLOYER SAMPLE PROCEDURES FOR HEAT ILLNESS PREVENTION successfully (e.g. how many water containers/shade structures, of what size, distance to placement, frequency of water-level replenishment/weather-tracking/water breaks/reminders, etc.). For additional information, see the Enforcement Q&A. 3. Specify how these procedures will be communicated to your employees and in particular to the persons assigned these responsibilities (e.g. via training, meeting), and how it will be ascertained that these company instructions and procedures are followed.
( EMPLOYER’S NAME) The following designated person or persons (Program Administrator Safety Coordinator/ Supervisor/Foreman/Field Supervisor/Crew Leader) have the authority and responsibility for implementing the provisions of this program at this worksite. Name/Title/Phone Number 1. 2. 3. 4. 5. Note: Any of the following items applicable for the provision of water, shade, high heat, acclimatization methods and emergency procedures must have additional language added to provide specifics on how your company intends on implementing these provisions at the job site.
Sample Procedures to Consider for the Provision of Water (include but are not limited to the following):
Drinking water containers (of five to 10 gallons each) will be brought to the site, so that at least two quarts per employee are available at the start of the shift. All workers whether working individually or in smaller crews, will have access to drinking water.
Paper cone rims or bags of disposable cups and the necessary cup dispensers will be made available to workers and will be kept clean until used.
As part of the Effective Replenishment Procedures, the water level of all containers will be checked periodically (e.g. every hour, every 30 min), and more frequently when the temperature rises. Water
2
EMPLOYER SAMPLE PROCEDURES FOR HEAT ILLNESS PREVENTION containers will be refilled with cool water, when the water level within a container drops below 50 percent. Additional water containers (e.g. five gallon bottles) will be carried, to replace water as needed.
Water will be fresh, pure, and suitably cool and provided to employees free of charge. Supervisors will visually examine the water and pour some on their skin to insure that the water is suitably cool. During hot weather, the water must be cooler than the ambient temperature but not so cool as to cause discomfort. Water containers will be located as close as practicable to the areas where employees are working (given the working conditions and layout of the worksite), to encourage the frequent drinking of water. If field terrain prevents the water from being placed as close as possible to the workers, bottled water or personal water containers will be made available, so that workers can have drinking water readily accessible. Since water containers are smaller than shade structures, they can be placed closer to employees than shade structures. Placing water only in designated shade areas or where toilet facilities are located is not sufficient. When employees are working across large areas, water will be placed in multiple locations. For example, on a multi-story construction site, water should be placed in a safely accessible location on every floor where employees are working. All water containers will be kept in sanitary condition. Water from non-approved or non-tested water sources (e.g., untested wells) is not acceptable. If hoses or connections are used, they must be governmentally approved for potable drinking water systems, as shown on the manufactures label. Daily, workers will be reminded of the location of the water coolers and of the importance of drinking water frequently. When the temperature exceeds or is expected to exceed 80 degrees Fahrenheit, brief ‘tailgate’ meetings will be held each morning to review with employees the importance of drinking water, the number and schedule of water and rest breaks and the signs and symptoms of heat illness. Audible devices (such as whistles or air horns) will be used to remind employees to drink water. When the temperature equals or exceeds 95 degrees Fahrenheit or during a heat wave, pre-sift meetings before the commencement of work to encourage employees to drink plenty of water, and remind employees of their right to take a cool-down rest when necessary will be conducted. Additionally, the number of water breaks will be increased. Supervisors/foreman will lead by example and workers will be reminded throughout the work shift to drink water. Individual water containers or bottled water provided to workers will be adequately identified to eliminate the possibility of drinking from a co-workers container or bottle.
3
EMPLOYER SAMPLE PROCEDURES FOR HEAT ILLNESS PREVENTION
Sample Procedures for Access to Shade (include but are not limited to the following):
Shade structures will be opened and placed as close as practical to the workers, when the temperature equals or exceeds 80 degrees Fahrenheit. When the temperature is below 80 degrees Fahrenheit, access to shade will be provided promptly, when requested by an employee. Note: The interior of a vehicle may not be used to provide shade unless the vehicle is air-conditioned and the air conditioner is on.
Enough shade structures will be available at the site, to accommodate all of the employees who are on such a break at any point in time. During meal periods there will be enough shade for all of the employees who choose to remain in the general area of work or in areas designated for recovery and rest periods. (Employers may rotate employees in and out of meal periods, as with recovery and rest periods.) Daily, workers will be informed of the location of the shade structures and will be encouraged to take a five minute cool-down rest in the shade. An employee who takes a preventative cool-down rest break will be monitored and asked if he/she is experiencing symptoms of heat illness and in no case will the employee be ordered back to work until signs or symptoms of heat illness have abated. (see also the section on Emergency Response for additional information) Shade structures will be relocated to follow along with the crew and they will be placed as close as practical to the employees, so that access to shade is provided at all times. All employees on a recovery, rest break or meal period will have full access to shade so they can sit in a normal posture without having to be in physical contact with each other.
In situations where trees or other vegetation are used to provide shade (such as in orchards), the thickness and shape of the shaded area will be evaluated, before assuming that sufficient shadow is being cast to protect employees.
In situations where it is not safe or feasible to provide access to shade (e.g., during high winds), a note will be made of these unsafe or unfeasible conditions, and of the steps that will be taken to provide shade upon request.
For non-agricultural employers, in situations where it is not safe or feasible to provide shade (mobile equipment and vehicle hazards, high winds), a note will be made of these unsafe or unfeasible conditions, and of the steps that will be taken to provide alternative cooling measures but with equivalent protection as shade.
4
EMPLOYER SAMPLE PROCEDURES FOR HEAT ILLNESS PREVENTION
Sample Procedures for Monitoring the Weather (include but are not limited to):
The supervisor will be trained and instructed to check in advance the extended weather forecast. Weather forecasts can be checked with the aid of the internet (http://www.nws.noaa.gov/), or by calling the National Weather Service phone numbers (see CA numbers below) or by checking the Weather Channel TV Network. The work schedule will be planned in advance, taking into consideration whether high temperatures or a heat wave is expected. This type of advance planning should take place all summer long. CALIFORNIA Dial-A-Forecast •
Eureka 707-443-7062
•
Sacramento 916-979-3051
•
Hanford 559-584-8047
•
San Diego 619-297-2107 (#1)
•
Los Angeles 805-988-6610 (#1)
•
San Francisco 831-656-1725 (#1)
Prior to each workday, the forecasted temperature and humidity for the worksite will be reviewed and will be compared against the National Weather Service Heat Index to evaluate the risk level for heat illness. Determination will be made of whether or not workers will be exposed at a temperature and humidity characterized as either “extreme caution” or “extreme danger” for heat illnesses. It is important to note that the temperature at which these warnings occur must be lowered as much as 15 degrees if the workers under consideration are in direct sunlight. Prior to each workday, the supervisor will monitor the weather (using http://www.nws.noaa.gov/ or with the aid of a simple thermometer, available at most hardware stores) at the worksite. This critical weather information will be taken into consideration, to determine, when it will be necessary to make modifications to the work schedule (such as stopping work early, rescheduling the job, working at night or during the cooler hours of the day, increasing the number of water and rest breaks). A thermometer will be used at the jobsite to monitor for sudden increases in temperature, and to ensure that once the temperature exceeds 80 degrees Fahrenheit, shade structures will be opened and made available to the workers. In addition, when the temperature equals or exceeds 95 degrees Fahrenheit, additional preventive measures such as the High Heat Procedures will be implemented.
Sample Procedures for Handling a Heat Wave: For purposes of this section only, “heat wave” means any day in which the predicted high temperature for the day will be at least 80 degrees Fahrenheit and at least ten degrees Fahrenheit higher than the average high daily temperature in the preceding five days.
During a heat wave or heat spike, the work day will be cut short or rescheduled (example conducted at night or during cooler hours). During a heat wave or heat spike, and before starting work, tailgate meetings will be held, to review the company heat illness prevention procedures, the weather forecast and emergency response. In addition, if schedule modifications are not possible, workers will be provided with an increased number of water and rest breaks and will be observed closely for signs and symptoms of heat illness. Each employee will be assigned a “buddy” to be on the lookout for signs and symptoms of heat illness and to ensure that emergency procedures are initiated when someone displays possible signs or symptoms of heat illness.
5
EMPLOYER SAMPLE PROCEDURES FOR HEAT ILLNESS PREVENTION
Sample High Heat Procedures (include but are not limited to): High Heat Procedures are additional preventive measures that this company will use when the temperature equals or exceeds 95 degrees Fahrenheit.
Effective communication by voice, direct observation (applicable for work crews of 20 or fewer), mandatory buddy system, or electronic means will be maintained, so that employees at the worksite can contact a supervisor when necessary. If the supervisor is unable to be near the workers (to observe them or communicate with them), then an electronic device, such as a cell phone or text messaging device, may be used for this purpose if reception in the area is reliable. Frequent communication will be maintained with employees working by themselves or in smaller groups (keep tabs on them via phone or two-way radio), to be on the lookout for possible symptoms of heat illness. The employee(s) will be contacted regularly and as frequently as possible throughout the day, since an employee in distress may not be able to summon help on his or her own. Effective communication and direct observation for alertness and/or signs and symptoms of heat illness will be conducted frequently. When the supervisor is not available, a designated alternate responsible person must be assigned, to look for signs and symptoms of heat illness. If a supervisor, designated observer, or any employee reports any signs or symptoms of heat illness in any employee, the supervisor or designated person will take immediate action commensurate with the severity of the illness (see Emergency Response Procedures). Employees will be reminded constantly throughout the work shift to drink plenty of water and take preventative cool-down rest break when needed.
In addition to the High Heat Procedures listed above, the following High Heat Procedures apply only to agricultural work sites.
When the temperature equals or exceeds 95 degrees, employees will be provided one 10 minute “preventative cool-down rest period” every 2 hours. (During the first 8 hours of a shift, the cool-down periods may be provided at the same time as the rest periods already required by Industrial Welfare Commission Order No. 14.) Employees working longer than 8 hours will be provided an additional 10 minute cool-down rest period every 2 hours. (for example, if the shift extends beyond 8 hours, an additional rest period is required at the end of the 8th hour of work, If the shit extends beyond 10 hours, another is required and the end of the 10th hour, and so on.
All employees will be required to take the cool-down rest periods and merely offering the opportunity for a break is not enough.
Once the temperature equals or exceeds 95 degrees, records will be kept documenting the fact that mandatory cool-down rest periods are provided and taken.
6
EMPLOYER SAMPLE PROCEDURES FOR HEAT ILLNESS PREVENTION
Sample Procedures for Acclimatization (include but are not limited to): Acclimatization is the temporary and gradual physiological change in the body that occurs when the environmentally induced heat load to which the body is accustomed is significantly and suddenly exceeded by sudden environmental changes. In more common terms, the body needs time to adapt when temperatures rise suddenly, and an employee risks heat illness by not taking it easy when a heat wave strikes or when starting a new job that exposes the employee to heat to which the employee’s body hasn’t yet adjusted. Inadequate acclimatization can be significantly more perilous in conditions of high heat and physical stress. Employers are responsible for the working conditions of their employees, and they must act effectively when conditions result in sudden exposure to heat their employees are not used to.
The weather will be monitored daily. The supervisor will be on the lookout for sudden heat wave(s), or increases in temperatures to which employees haven’t been exposed to for several weeks or longer.
During a heat wave or heat spike, the work day will be cut short (example 12 p.m.), will be rescheduled (example conducted at night or during cooler hours) or if at all possible cease for the day.
New employees, or those employees who have been newly assigned to a high heat area will be closely observed by the supervisor or designee for the first 14 days. The intensity of the work will be lessened during a two-week break-in period (such as scheduling slower paced, less physically demanding work during the hot parts of the day and the heaviest work activities during the cooler parts of the day (earlymorning or evening). Steps taken to lessen the intensity of the workload for new employees will be documented.
The supervisor, or the designee will be extra-vigilant with new employees and stay alert to the presence of heat related symptoms.
New employees will be assigned a “buddy” or experienced coworker to watch each other closely for discomfort or symptoms of heat illness.
During a heat wave, all employees will be observed closely (or maintain frequent communication via phone or radio), to be on the lookout for possible symptoms of heat illness.
Employees and supervisors will be trained on the importance of acclimatization, how it is developed and how these company procedures address it.
Sample Procedures for Emergency Response (include but are not limited to):
Prior to assigning a crew to a particular worksite, workers and the foreman will be provided a map of the site, along with clear and precise directions (such as streets or road names, distinguishing features and distances to major roads), to avoid a delay of emergency medical services.
Prior to assigning a crew to a particular worksite, efforts will be made to ensure that a qualified and appropriately trained and equipped person is available at the site to render first aid if necessary.
7
EMPLOYER SAMPLE PROCEDURES FOR HEAT ILLNESS PREVENTION
Prior to the start of the shift, a determination will be made of whether or not a language barrier is present at the site and steps will be taken (such as assigning the responsibility to call emergency medical services to the foreman or an English speaking worker) to ensure that emergency medical services can be immediately called in the event of an emergency. All foremen and supervisors will carry cell phones or other means of communication, to ensure that emergency medical services can be called. Checks will be made to ensure that these electronic devices are functional prior to each shift. When an employee is showing symptoms of possible heat illness, steps will be taken immediately to keep the stricken employee cool and comfortable once emergency service responders have been called (to reduce the progression to more serious illness). Under no circumstances will the affected employee be left unattended. At remote locations such as rural farms, lots or undeveloped areas, the supervisor will designate an employee or employees to physically go to the nearest road or highway where emergency responders can see them. If daylight is diminished, the designated employee(s) shall be given reflective vest or flashlights in order to direct emergency personnel to the location of the worksite, which may not be visible form the road or highway. During a heat wave or hot temperatures, workers will be reminded and encouraged to immediately report to their supervisor any signs or symptoms they are experiencing. Employees and supervisors training will include every detail of these written emergency procedures.
Sample Procedures for Handling a Sick Employee:
When an employee displays possible signs or symptoms of heat illness, a trained first aid worker or supervisor will check the sick employee and determine whether resting in the shade and drinking cool water will suffice or if emergency service providers will need to be called. A sick worker will not be left alone in the shade, as he or she can take a turn for the worse! When an employee displays possible signs or symptoms of heat illness and no trained first aid worker or supervisor is available at the site, emergency service providers will be called. Emergency service providers will be called immediately if an employee displays signs or symptoms of heat illness (decreased level of consciousness, staggering, vomiting, disorientation, irrational behavior, incoherent speech, convulsions, red and hot face), does not look OK or does not get better after drinking cool water and resting in the shade. While the ambulance is in route, first aid will be initiated (cool the worker: place the worker in the shade, remove excess layers of clothing, place ice pack in the armpits and groin area and fan the victim). Do not let a sick worker leave the site, as they can get lost or die before reaching a hospital! If an employee does not look OK and displays signs or symptoms of severe heat illness (decreased level of consciousness, staggering, vomiting, disorientation, irrational behavior, incoherent speech, convulsions, red and hot face), and the worksite is located more than 20 minutes away from a hospital, call emergency service providers, communicate the signs and symptoms of the victim and request Air Ambulance.
8
EMPLOYER SAMPLE PROCEDURES FOR HEAT ILLNESS PREVENTION
Sample Procedures for Employee and Supervisory Training (include but are not limited to): To be effective, training must be understood by employees and given in a language the employees understand. All employers must maintain records of the training showing the date of training, who performed the training, who attended training and subject(s) covered.
Supervisors will be trained prior to being assigned to supervise other workers. Training will include this company’s written procedures and the steps supervisors will follow when employees’ exhibit symptoms consistent with heat illness.
Supervisors will be trained on their responsibility to provide water, shade, cool-down rests, and access to first aid as well as the employees’ right to exercise their rights under this standard without retaliation.
Supervisors will be trained in appropriate first aid and/or emergency responses to different types of heat illness, and in addition, that heat illness may progress quickly from mild symptoms and signs to serious and life threatening illness.
Supervisors will be trained on how to track the weather at the job site (by monitoring predicted temperature highs and periodically using a thermometer). Supervisors will be instructed on, how weather information will be used to modify work schedules, to increase number of water and rest breaks or cease work early if necessary. All employees and supervisors will be trained prior to working outside. Training will include all aspects of implementing an effective Heat Illness Prevention Plan including but not limited to; providing sufficient water, providing access to shade, high-heat procedures, emergency response procedures and acclimatization contained in the company’s written prevention procedures. Employees will be trained on the steps that will be followed for contacting emergency medical services, including how they are to proceed when there are non-English speaking workers, how clear and precise directions to the site will be provided and the importance of making visual contact with emergency responders at the nearest road or landmark to direct them to their worksite. When the temperature is expected to exceed 80 degrees Fahrenheit, short ‘tailgate’ meetings will be held to review the weather report, to reinforce heat illness prevention with all workers, to provide reminders to drink water frequently, to inform them that shade can be made available upon request and to remind them to be on the lookout for signs and symptoms of heat illness. New employees will be assigned a “buddy” or experienced coworker to ensure that they understand the training and follow company procedures.
Resources (include but are not limited to): Heat Illness Prevention Enforcement Q&A Cal/OSHA’s Heat Illness Prevention etool Cal/OSHA’s Heat Illness Prevention Website
http://www.dir.ca.gov/dosh/heatIllnessQA.html http://www.dir.ca.gov/dosh/etools/08-006/index.htm http://www.dir.ca.gov/DOSH/HeatIllnessInfo.html
9
Heat Illness Prevention Enforcement Q&A Updated: April 6, 2015 1. Where and when does this standard apply? This standard applies to all outdoor places of employment. In addition, the following industries are subject to additional requirements in high heat (over 95°F or above) (see Q&A No. 8a and 8b): 1. Agriculture, 2. Construction, 3. Landscaping, 4. Oil and gas extraction, and 5. Transportation and delivery of agricultural products and of construction or other heavy materials (e.g. furniture, lumber, freight, cargo, cabinets, industrial or commercial materials). Cal/OSHA interprets the standard's provisions to apply at all times when employees work outdoors. Some provisions are triggered at specific times, for instance, the shade requirement described in Q&A No. 7 and the High-‐Heat Procedures addressed by Q&A No. 8a. 2. What is meant by "outdoor places of employment"? An outdoor place of employment is best thought of as one that is not an indoor workplace. A workplace with a roof and enclosed sides is generally considered an indoor workplace. For the purposes of this standard, the distinguishing quality of indoor workplaces is that they reduce the risk factors that commonly lead to heat illness. (For information about environmental risk factors for heat illness, see Q&A Nos. 4 and 5.) For example, a building that provides sufficient ventilation and cooling, either by natural or mechanical means, and blocks exposure to direct sunlight will be considered an indoor workplace. Sheds, packing sheds, and partial or temporary structures such as tents, lean-‐tos, and structures with one or more open sides can be either indoor or outdoor workplaces depending on the circumstances. In many cases, these structures may actually be hotter than the environment outside of them because of heating by the sun and conditions inside like limited air circulation or lack of insulation. Cal/OSHA considers a structure in this category to be an outdoor workplace if it does not significantly reduce the net effect of the environmental risk factors that exist immediately outside of the structure. On the other hand, open areas like agricultural fields, forests, parks, equipment and storage yards, outdoor utility installations, tarmacs, and roads are obvious examples of outdoor workplaces. Outdoor
workplaces also include construction sites in which no building shell has been completed and areas of construction sites that are outside of any building shells that may be present. Outdoor areas adjacent to buildings, (e.g., loading docks) are also considered outdoor places of employment if an employee spends a significant amount of time working in them. 3. Are there other regulations that apply to the risk of heat illness? Yes. They include requirements for employers to have an effective Injury and Illness Prevention Program (IIPP) and to provide for drinking water, first aid and emergency response. There are also requirements tailored to specific industrial operations. Areas where these regulations overlap or augment 8 CCR §3395 will be noted in the more specific sections below. Employers should note, however, that 8 CCR §3203 requires an employer to establish, implement, and maintain an effective IIPP. All IIPPs must include effective procedures for hazard identification, evaluation and control, hazard correction, investigation of employee injuries and illnesses, and communication with employees about health and safety matters. All of these requirements apply to the hazards posed by exposure to outdoor heat as well as other hazards. The requirement for effective communication is particularly relevant to heat illness prevention. In evaluating compliance with this requirement, Cal/OSHA determines what the employer does to account for the whereabouts of all employees at appropriate intervals during the work shift and at the end of the shift. This is a critical procedure to follow when the outdoor work environment creates a heat hazard that could result in the collapse of an employee due to heat illness. Indoor heat can be a known hazard in the workplace, and under the obligation of the IIPP, employers are required to inform their employees about the hazard and outline the steps taken to mitigate it. Finally, employers should note that the following standards apply to heat stress or temperature control in specific operations: •
Hazardous waste sites and emergency response: 8 CCR §5192,
•
Working chambers subjected to compressed air: 8 CCR §1230(a), and
•
Building ventilation systems: 8 CCR §5142 and 8 CCR §5143.
4. What are the environmental risk factors for heat illness? 8 CCR §3395 defines environmental risk factors as including "air temperature, relative humidity, radiant heat from the sun and other sources, conductive heat sources such as the ground, air movement, workload severity and duration, protective clothing and personal protective equipment worn by employees." Some of these factors, in particular air temperature, radiant heat, air movement, and conductive heat sources, determine how much an employee's body is heated from external sources. Relative humidity, air movement, protective clothing, and some personal protective equipment affect an employee's ability
to cool through the evaporation of sweat and contact with cooler air. Workload intensity and duration, which can be increased by use of personal protective equipment, add to the employee's heat burden by producing metabolic heat. It is essential and required that supervisors and workers be trained to understand how environmental and personal risk factors, as well as the added burden of heat load on the body caused by exertion, clothing, and personal protective equipment, can increase the risk of heat illness. For example, some employees can be at risk of heat illness even when temperatures are considered mild, if they wear chemical protective clothing such as hazmat suits designed to be impervious to chemical liquids and vapors, or other clothing or body coverings that significantly interfere with the body's ability to dissipate heat compared with normal clothing. Certain water and shade requirements are applicable all year round, but employers should also address the particular hazards presented by these conditions in their Heat Illness Prevention Program. 5. What is the best way to monitor the weather and evaluate the severity of environmental risk factors for heat illness? Some requirements of the standard are triggered by outside temperatures. It is, therefore, critical that employers track the weather and routinely check for approaching heat waves. Heat waves are the primary cause of heat-‐related illnesses and fatalities in the state. For example, according to a study completed by Cal/OSHA in October 2007, the 2006 Cal/OSHA Heat Illness Case Study, 84% of the confirmed occupational heat illnesses in 2006 occurred during the July heat wave. This study also identified the key role that supervisors play in preventing worker fatalities due to heat illness. This finding highlights the value of training supervisors so that they can make the fullest use of their supervisory power to control safety on the job. Knowing how to monitor weather reports, making it a daily practice of doing so, and taking appropriate action in response to predicted hot weather are all an essential part of a supervisor’s training, hence the requirement that this training be provided to all supervisors whose employees perform outdoor work. The National Weather Service forecasts the temperature in various locations in California. Weather forecasts and information are broadcast on NOAA Weather radio and can be accessed at http://www.weather.gov/view/states.php?state=ca&map=on. The supervisor should use a thermometer to keep track of the temperature at the work site on hot days. A simple thermometer available at hardware stores can be used to measure the outdoor ("dry bulb") temperature, as long as it is taken in an area where there is no shade. The temperature measurement must be taken in an area with full sunlight and the bulb or sensor of the thermometer should be shielded from direct contact with sunlight (with the hand or some other object) while taking the measurement. 6. What is considered sufficient access to drinking water?
Adequate water is required at all times, regardless of outdoor temperature and must be made available at no cost to the employee. Water is the body's single best defense against heat other than removing heat exposure itself. In conditions of high heat and strenuous work, the human body can lose over a quart of fluid per hour just by sweating. Continuous replacement of this lost fluid is critical to allowing the body to maintain the life-‐ preserving cooling benefits of perspiration. This is why it is so important to ensure the presence of, ready access to, and consumption of pure, fresh, and cool drinking water. The water must be potable (i.e., fit to drink), fresh, pure, suitably cool, and provided to employees free of charge. Water must be located as close as it is feasible to place it to the areas where employees are working. The purpose of these requirements is to encourage workers to drink water often and avoid making the workers interrupt their work in order to do so. To ensure that water is fresh, pure, and suitably cool, Cal/OSHA advises employers or supervisors to visually examine and smell/taste the water and pour some on their skin. .
When is water fresh and pure?
Water must be potable (i.e., fit to drink) and free from odors that would discourage workers from drinking it. If an employer supplies individual water containers, the containers must be clean, and a source of potable water (e.g., a municipal water source) must be readily available. Water from non-‐ approved or non-‐tested water sources (e.g., untested wells) is not acceptable. If hoses or connections are used, they must be manufacture-‐approved for potable drinking water systems, as shown on the manufacturer’s label. a. When is water suitably cool? Water provided to employees, whether by Igloo or other container, is not required to be maintained at a specific temperature. Rather, the employer should ensure that the water is cooler than the outside temperature (during the summer months) but not so cool as to cause discomfort. In hot weather, it is recommended that employers have ice on hand to keep the water cool. b. When is water as close as practicable to where employees are working? Potable drinking water must always be placed in locations readily accessible to all employees, so that employees can easily drink while working. When an employee has to interrupt work in order to drink, the chances go down that the employee will drink enough water to protect fully against heat illness. Employers are, therefore, encouraged to consider creative means of placing water near working employees (for instance, on harvesting machinery). During a Cal/OSHA inspection, the inspector may ask the supervisor to describe the factors the employer considered in deciding where to place water. For example, although it may be impossible or prohibited by law to place water stations within rows of crops where employees are working, it may be possible to place the water stations at the end of rows. Because water containers are smaller than shade structures, they can be placed closer to employees than shade structures. Placing water only in designated shade
areas or where toilet facilities are located is not sufficient. When employees are working across large areas, water should be placed in multiple locations. For example, on a multi-‐story construction site, water should be placed in a safely accessible location on every floor where employees are working. Employers may supply employees with individual water bottles/containers (preferably insulated) provided hygiene is ensured (i.e., clean bottles for each employee) and a source for water replenishment is readily available. It is not permissible for an employer to require employees to supply their own water or water containers. c. What is the required amount of water and what are "effective procedures for replenishment"? When unlimited drinking water is not immediately available from a plumbed system or otherwise continuously supplied, the employer must provide enough water for every employee to be able to drink one quart of water, or four eight-‐ounce cups, per hour. If an employer chooses not to provide the full-‐shift quantity of drinking water at the start of a work shift (e.g., two gallons per employee for an eight-‐hour shift), the standard requires effective written procedures for drinking-‐water replenishment allowing each employee to drink one quart per hour. In other words, a sufficient quantity of water must always be present and readily accessible allowing every employee to consume at least one quart of water per hour until the water supply has been replenished. A water-‐supply procedure that depends on replenishment during the work shift is out of compliance if it is not reliable. An employer is also out of compliance if at any time drinking water is not available to employees, or if the practice is to wait until the water vessel is empty to replenish it. It is similarly impermissible for an employer to replenish the drinking-‐water supply only when requested by employees. d. What is meant by encouragement to drink water? The standard requires not only that water be provided, but that employers encourage employees to drink it frequently. The importance of this cannot be overstated. Employees are there to work, and many of them may not feel how urgently their bodies need water. The 2006 Cal/OSHA Heat Illness Case Study showed that although 90% of the work sites had drinking water at the site, 96% of the employees suffering from heat illnesses were dehydrated. The tendency of employees to be unaware of and/or not respond to their body’s need to hydrate is an unfortunate but preventable cause of heat illness. In their employee training sessions, employers must stress the importance of drinking water frequently throughout the day, especially in high heat. By removing any barriers that may exist to access, making the access distance as short as reasonable, and making the water station inviting by using ice and shade, employers can actively facilitate and encourage the frequent drinking of water. e. Are there other regulations that apply to the provision of water?
Yes. The following Title 8 standards apply to the provision of drinking water: • Construction: 8 CCR §1524, • Hand labor in agriculture: 8 CCR §3457, • Mining: 8 CCR §6975, and • All other places of employment: 8 CCR §3363. These standards require employers to provide sufficient quantities of drinking water in general in any work environment to which they apply. For employees working in the heat, a minimum of one quart of drinking water per hour must be available to each employee, (e.g., two gallons per employee for an eight-‐hour shift) to replace water lost by sweating. 7. What is considered sufficient access to shade? .
When must shade be provided?
When temperatures exceed 80°F, shade structures must be erected if no other shade is readily available. Even if temperatures do not exceed 80°F, shade must still be available, and it is helpful to have the shade erected if the weather is hot enough that the shade can help employees cool off. Employers should monitor predicted weather temperatures in advance (on television, radio or the Internet) to know when the temperature is likely to exceed 80 degrees. Employers are expected to know if the temperature is in fact exceeding 80 degrees at the work site. a. What are appropriate sources of shade? Shade may be provided by any natural or artificial means that do not expose employees to unsafe or unhealthy conditions. For example, buildings, canopies, lean-‐tos, or other partial or temporary structures that are either ventilated or open to air movement may provide shade. Trees can also provide shade that is superior to artificially provided shade and are accepted as compliant sources of shade if the following conditions are met: 1. the canopy of the trees must be sufficiently dense to provide substantially complete blockage of direct sunlight, and 2. the branches from the trees must not be so low to the ground that employees must crouch or cannot sit up straight without contacting vegetation. Spots of sunlight are acceptable as long as, overall, the shade provides substantially complete blockage of sunlight. Where trees or other vegetation are used to provide shade, the thickness and shape of the canopy must, given the changing angles of the sun, result in a sufficient shadow being cast to protect employees from the sun during the entire shift. The interior of a vehicle may not be used to provide shade unless the vehicle is air-‐conditioned and the air conditioner is operating. Similarly, metal storage sheds and other out-‐buildings do not provide
protection from sunlight which meets the definition of shade unless they provide a cooling environment comparable to shade in open air (i.e., they must be mechanically ventilated or open to air movement). b. When is shade of sufficient quality? Shade is blockage of direct sunlight. Blockage is always sufficient when objects do not cast a shadow in the shaded area. An enclosed area used to provide shade must allow cooling at least comparable to the cooling that would be provided in a shaded unenclosed area in the same location. c. What is acceptable access and location? Shade must be easy for employees to reach and its location must not deter or discourage access or use. Workers should not have to encounter any obstacles or hazardous or unreasonably unpleasant conditions to reach the shade or while resting in it. For example, employees should not have to cross traffic or waterways to reach the shade nor should it be located next to portable toilet facilities or where employees would sit on wet or muddy ground or come in contact with branches, brush, and thorns. The shaded area must let employees assume a comfortable posture and must not cause exposure to another health or safety hazard. Therefore, the shade requirement cannot be met by using areas underneath mobile equipment, like a tractor, or areas that require employees to crouch in order to sit fully in the shade. The shade, whether natural or structural, must be as close as practicable to where employees are working, given the working conditions and layout of the work site. During a Cal/OSHA inspection, the inspector may ask the supervisor to describe the factors the employer considered in deciding where to place shade structures. Because shade is more portable than bathroom facilities, it can and should be placed closer to where employees work. This may involve placing shade structures in multiple areas over large work sites and/or moving the structures as the work area changes (such as movement across fields and rows). When the employer can demonstrate that it is infeasible or unsafe to have a shade structure, or otherwise to have shade present on a continuous basis, the employer may use alternative procedures for providing access to shade as long as the alternative procedures provide equivalent protection. d. How much shade must be available? Employers must ensure there is enough shade for all employees taking a rest and recovery period (breaks) at any one time to sit comfortably and fully in the shade without touching each other. This does not mean that employers are required to provide enough shade to accommodate all of the employees on the shift at the same time. Employers may, for example, rotate the breaks among employees. They may also erect additional structures on an as-‐needed basis. Any such procedure must be clearly and accurately described in the employer's written heat illness prevention procedures. The rules and recommendations described above for breaks also apply to meal breaks. The only difference is that employers are required to provide shade for all employees who choose to remain in
the general area of work or in areas designated for recovery and rest periods. Employers may rotate employees in and out of meal periods, like with recovery and rest periods. Employers are not required to provide shade for employees who choose to spend meal periods in their own air-‐conditioned vehicles. However, employers may not require or pressure employees to eat their lunch in their own vehicles or go off site to eat. e. What if it is unsafe to provide a shade structure? When the employer can demonstrate that a shade structure would be unsafe or infeasible, then the employer may provide alternate access to shade that provides equivalent protection. For example, it may be unsafe to erect a shade structure near the edge of a trench or ravine, or when high winds run the risk of causing a shade structure placed near workers to blow away and hit them. Furthermore, establishing a shade structure on a continuous basis may be infeasible for employees who constantly move from site to site (e.g., meter readers or irrigation installers). In these cases, the employer must document this determination and specify what alternatives to shade will be provided to afford equivalent protection. f.
When may employers use cooling measures other than shade?
Nonagricultural employers may provide cooling measures other than shade if they can demonstrate that the alternative is at least as effective as shade. For example, misting machines are acceptable when the employer can demonstrate that they are at least as effective as shade at allowing the body to cool. g. What are the requirements for encouraging workers to rest in the shade? The employer is required to allow and encourage employees to take a cool-‐down rest in the shade for a period of no less than five minutes at a time when they feel the need to do so to protect themselves from overheating. It is crucial that workers not be rushed while taking the cool-‐down rest, since the purpose of the cool-‐down rest in the shade is to reduce heat stress on the employee; waiting until symptoms appear before seeking shade and recovery creates a significant risk of developing heat illness. Shade removes sunlight as a source of heat, and since people produce more metabolic heat while working, resting out of direct sunlight reduces heat stress while also reducing the heart rate. Encouraging employees to take a cool-‐down rest in the shade is of primary importance particularly for employees who are paid on a piece-‐rate basis, as they would be less inclined to use this preventive rest. Water should be available in the rest area so that employees are encouraged to drink more water. The employee must be monitored during the cool-‐down rest and asked if he or she is experiencing any symptoms of heat illness, including simple fatigue. If any signs or symptoms of heat illness are observed or reported, the employer must not order the employee back to work and must continuously observe the employee until the signs or symptoms have abated. Common early signs and symptoms of heat
illness may include pale skin, heavy sweating, headache, muscle cramps, and fatigue. If no sign or symptom of heat illness is observed or reported, monitoring may be periodic, rather than continuous. If an employee exhibits or complains of any sign or symptom of heat illness, first-‐aid procedures should be initiated without delay. Progression to more serious illness can be rapid and can include altered coordination and speech, mental confusion, unusual behavior, nausea, vomiting, hot dry skin, unusually profuse sweating, loss of consciousness, and seizures. The affected employee may be unable to self-‐ diagnose these problems. If heat illness is suspected, emergency medical personnel should be contacted immediately. No employee with signs or symptoms of heat illness should be left unattended or sent home without being offered onsite first aid or provided emergency medical services, as discussed in subsection (f) of 8 CCR §3395 (see Q&A No.9). "Preventative cool-‐down rest periods" at agricultural work sites are discussed in subsection (e) of 8 CCR §3395 (see Q&A No.8d). 8. What are high-‐heat procedures and what industries are required to comply with this subsection? The following industries, in addition to the elementary provisions of this standard, are subject to the requirements for high-‐heat procedures: •
Agriculture,
•
Construction,
•
Landscaping (except for employment by an employer who operates a fixed establishment where the work is to be performed and where drinking water is plumbed),
•
Oil and gas extraction, and
•
Transportation (except for employment that consists of operating an air-‐conditioned vehicle and does not include loading and unloading).
When the temperature equals or exceeds 95 degree Fahrenheit, employers listed in the industries noted above shall implement the high-‐heat preventive procedures listed in subsection (e) of 8 CCR §3395 and described just below: e. How should employers monitor employees during high heat? During periods of high heat, it is crucial that employees be monitored for early signs and symptoms of heat illness to help ensure that sick employees receive treatment immediately and progression to serious illness is arrested. If an employee suffers syncope (fainting), disorientation, loss of
consciousness, or other symptoms of heat illness while working unobserved, initial medical treatment may be delayed, serious or fatal injury. Because each work site is unique, the new provisions give employers options and flexibility in observing and monitoring employees. When employees work in small groups of no more than 20 workers, direct observation by a supervisor or designee may be sufficient. When there are too many employees to allow direct observation, the employer may use the buddy system and pair up employees. With the buddy system, the employer must train the employees to stay in contact, observe each other throughout the day, and immediately report any signs or symptoms of heat illness. For employees who are required to work alone, the employer may communicate with the employee by radio or cell phone, provided there is adequate coverage. The employee must be contacted regularly and as frequently as practicable throughout the day, since an employee in distress may not be able to summon help on his or her own. Employers may use different methods to monitor for heat illness. Whatever method is used, the employer must be able to ascertain the condition of employees at regular intervals and provide emergency services when an employee reports symptoms of heat illness or is unable to respond. f.
Who should be authorized to call for emergency services?
All employees must be trained to recognize the signs and symptoms of heat illness and must be allowed to call for emergency medical services when necessary. If, however, all employees in a crew are designated to call for emergency medical services, many will be reluctant to do so. Therefore, employers must specifically assign one or a small number of employees per crew to call for emergency medical services. A designated employee may be either supervisory or non-‐supervisory. g. When pre-‐shift meetings are required, what should they cover? Pre-‐shift meetings are meant to provide supervisors and employees with a brief review of high-‐heat procedures. The meetings are not meant to review every element previously covered in regular training or in orientation. The employer may determine whether the training is required based on the predicted temperature in the area. Topics that should be covered in pre-‐shift meetings include staying hydrated and taking cool-‐down rests, identifying the employees who should call for emergency medical services when needed, and how employees will be observed. For employees working remotely, the employer may conduct pre-‐shift meetings by cell phone or radio. h. When are preventative cool-‐down rest periods required in agriculture? When the temperature equals or exceeds 95 degrees, employers must provide one ten-‐minute "preventative cool-‐down rest period" every 2 hours. During the first 8 hours of a shift, the cool-‐down periods may be provided at the same time as the rest periods already required by Industrial Welfare Commission Order No. 14 (8 CCR §11140).
If employees work longer than 8 hours, the employer must provide an additional 10-‐minute cool-‐down rest period every 2 hours. For example, if the shift extends beyond 8 hours, an additional rest period is required at the end of the eighth hour of work. If the shift extends beyond 10 hours, another is required at the end of the tenth hour. Employers must ensure that employees actually take the cool-‐down rest periods required under this section. Merely offering the opportunity for a break is not enough. Employers are required to provide additional breaks as soon as the temperature equals or exceeds 95 degrees. For example, even if the temperature does not reach 95 degrees until the last half of an eight-‐ hour shift, the employer must ensure that employees take cool-‐down rest periods starting at the end of the eighth hour of work if the shift will last longer than eight hours. Cal/OSHA does not require employers to keep records of breaks issued under this section, but doing so is the best practice and would benefit them. 9. What emergency response procedures must an employer implement? The importance of rapidly and effectively obtaining emergency medical services in the event of a serious injury or illness cannot be overstated. Particularly at nonfixed work sites or at sites that are difficult to access, the employer, having evaluated whether the work site is served by the 911 system, needs to be ready to contact and communicate with emergency responders. Emergency medical services must be provided as quickly as possible if an employee suffers heat illness. The employer’s procedures must include contacting emergency medical services when necessary, as well as taking immediate steps to keep a stricken employee cool and comfortable once emergency service responders have been called. The goal is to stop the rapid progression to more serious illness, which can include mental confusion, loss of consciousness, and seizures. As a result, employers must ensure that supervisors and employees are trained to recognize the signs and symptoms of heat illness, take steps immediately to prevent the progression of heat illness, provide basic first aid (such as cooling towels and shade), obtain emergency medical services, and not allow an employee with signs or symptoms of heat illness to be left alone or sent home without being offered onsite first aid or provided with emergency medical services. Employers, however, are not required to provide medical personnel on site, and supervisors and employees are not expected to have medical expertise to diagnose heat illness. Establishing emergency response procedures is particularly important at non-‐fixed or remote work sites or where access is difficult. If employees cannot reach emergency medical services directly (because cell phone coverage is inadequate, for example), the employer must designate a person who can immediately contact emergency services on behalf of the employees. The employees must be able to reach this person quickly (such as by radio) to request that emergency medical services be summoned. If, however, employees are able to contact emergency medical services directly, they must be allowed to do so in an emergency and must not be required to contact a supervisor first.
Employers must be prepared to transport employees safely to a place where they can be reached by an emergency medical provider where necessary. Mobile crews must be provided with a map of their location or detailed, clear, and precise directions that can be given to emergency responders. Employers should also be aware that the following title 8 regulations require first aid and emergency responses in specific industries: •
Construction: 8 CCR §1512,
•
Agriculture: 8 CCR §3439,
•
Logging and sawmills: 8 CCR §6251,
•
Petroleum drilling and production: 8 CCR §6511-‐6512,
•
Petroleum refining, transportation and handling: 8 CCR §6767
•
Tunneling: 8 CCR §8420-‐8421,
•
Telecommunications: 8 CCR §8602(e), and
•
All other places of employment: 8 CCR §3400.
10. What is acclimatization, and how should employers address it under the heat-‐illness prevention standard? Acclimatization is a process by which the body adjusts to increased heat exposure. The body needs time to adapt when working in hotter environments. Employees are more like to develop heat illness if they are not allowed or encouraged to take it easy when a heat wave strikes or when starting a job that newly exposes them to heat. Acclimatization is fully achieved in most people within 4 to 14 days of regular work involving at least 2 hours per day in the heat. During heat waves and with new, unacclimatized employees, employers must be especially vigilant. A supervisor or designee must closely observe employees. Best practices include finding ways to lessen the intensity of employees' work during a heat wave and during two-‐week break-‐in periods of new employees. For purposes of this section, "heat wave" means any day in which the predicted high temperature for the day will be at least 80 degrees Fahrenheit and at least ten degrees Fahrenheit higher than the average high daily temperature for the preceding five days. 11. How is training evaluated for compliance with the standard? Employers must train all employees, both supervisory and nonsupervisory, on the policies and procedures established to comply with this regulation. Training must be provided before the beginning of work involving a risk of heat illness. This means that at a minimum training should be provided when an employee is hired, with refresher training as needed. Training that is given close in time to the hot
season is more effective than training given during colder seasons without follow-‐up refresher training. As a best practice, some employers use a daily "tailgate meeting" approach, starting out each work day with a brief safety reminder about issues considered particularly relevant to the work to be performed that day. The basic test of training is its effectiveness. Cal/OSHA evaluates compliance by examining both content and how it is presented. To be effective, training must be understood by employees and given in a language the employees understand. The test of compliance is whether training has occurred, whether the required content has been provided, and whether the training has been effective in communicating the essentials to employees. To evaluate compliance, Cal/OSHA personnel ask supervisory and nonsupervisory employees about required training elements. The questions are designed to determine whether employees received training through methods generally recognized as effective and whether they understood its content. Inspectors will not expect all answers to be correct but will look for indicators that the employer has made a good-‐faith effort to communicate all the essential information. Employers must ensure that their work procedures are consistent with the information provided in the training. Cal/OSHA requires employers to maintain records of the training required in this subsection, as specified in 8 CCR §3203 (on Injury and Illness Prevention Programs). There are additional topics that supervisors must be trained on, and the importance of supervisory training cannot be overstated. The 2006 Cal/OSHA Heat Illness Case Study showed that 63% of the supervisors of employees who died from heat stroke had not been trained in the prevention of heat illnesses. In addition to the elements required for employee training, the supervisor’s training must include: •
Complete mastery of the training content provided to the employees,
•
The procedures the supervisor must follow to implement the company’s Heat Illness Prevention Plan (see Q&A no. 12),
•
The procedures to follow when an employee exhibits or reports symptoms consistent with possible heat illness, including which steps to follow to provide first aid and immediate medical treatment,
•
How to monitor weather reports and how to respond to hot weather advisories.
All employees and supervisors must be trained on every detail of the employer's emergency response procedures. 12. What written procedures should an employer develop to comply with the requirements of this standard?
The employer must develop, put in writing, and implement effective procedures for complying with the requirements of this standard. A compliant Heat Illness Prevention Plan (HIPP) includes the following subsections of 8 CCR §3395: •
Procedures for providing sufficient water, as described in subsection (c),
•
Procedures for providing access to shade, as described in subsection (d),
•
High-‐heat procedures in accordance with subsection (e),
•
Emergency response procedures, outlined in subsection (f), and
•
Acclimatization methods and procedures in accordance with subsection (g).
Employees and supervisors must be trained in these procedures so they understand and can implement the employer's plan. The most successful employers teach and make their system work using a teamwork approach. The HIPP must be written both in English and in the language understood by the majority of employees. It must be available to employees at the work site, as well as to representatives of Cal/OSHA upon request. The plan will be considered available at the work site if, for example, it can be displayed for employees on a cell phone or other electronic device upon request. The HIPP may be integrated into the employer’s Injury and Illness Prevention Program required under 8 CCR §3203. 13. Where can I get more information on heat illness? Numerous resources and heat illness publications can be found online at this link: http://www.dir.ca.gov/dosh/HeatIllnessInfo.html
Walter Newman M.D. The Newman Medical Group Topic: Professionals in Workers’ Compensation Court
Dr. Walter Newman is the principal of The Newman Medical Group, Occupational Health Services . Dr. Newman is a graduate of Stanford University and received his M.D. from UCSF. He did residency training in Family Medicine at the Stanford/San Jose program and completed the Mini-Residency in Occupational Medicine at UCSF. Dr. Newman is currently Associate Clinical Professor of Medicine at Stanford University. His clinical activities have included consulting services and direct patient care to over 100 companies throughout California. Currently, the majority of his clinical focus is Monterey Mushrooms, where he serves as Chief Health Officer for over 3,500 farm workers and their families. Dr Newman is also Medical Director of the Robert F. Kennedy Trust for farm workers. FRESNO
PIWC 2015
phil walker Work Comp. Savings
Topic: Professionals In Workers’ Compenation court Phil Walker is a Professional Speaker, Teacher, and National Trial Counsel for California workers’ compensation and Longshore defense based in San Francisco, California. For 34 years, he has represented California’s largest airlines, shipyards, steel companies, retailers, universities, and insurers in workers’ compensation and Longshore matters. Phil served as House Counsel for US Steel, General Counsel for New York City’s largest residential real estate firm--Insignia Douglas Elliman, and Managing Attorney for Fireman’s Fund Insurance Company. He was a Partner with Laughlin, Falbo, Levy & Moresi. Phil is a member of the Bars of California, New York, and the District of Columbia. He was educated at Vanderbilt University, where he studied creative writing and public speaking, and Washington & Lee Law School. Phil has been a national legal columnist for Genre Magazine and host of his own television show in San Francisco. He appeared as “the Clerk of Court” with Gene Hackman in Class Action. Phil is the author of The AMA Guides Made Simple, Keynote Speaker for the American College of Occupational and Environmental Medicine Annual Meeting, and Featured Speaker at the SEAK National Workers’ Compensation Law Conference.
FRESNO
PIWC 2015
PHIL NEAL WALKER www.philwalker.do
[email protected] Cell: 415-816-3527
Biographical Highlights Who's Who (Cambridge) Who's Who Among Executives and Professionals Martindale--Hubbell AV-Rated Attorney (highest rating by fellow attorneys) Principal and Expert: Phil Walker Workers' Compensation Savings Principal, Phil Neal Walker Law Corporation Principal and Instructor, Phil Walker Presents Trial Counsel, California Workers' Compensation (34 yrs. experience) Phil Neal Walker Law Corporation 250 King Street, Suite 414 San Francisco, CA 94107 877-774-5550, 415-295-4447 www.philnealwalkerlaw.com
[email protected]
Trial Counsel, US Longshore & Harbor Workers' Compensation Act (34 years experience) Author, The AMA Guides Made Simple! [Fifth Edition] (2008) Expert Witness, The AMA Guides [5th Edition] Nationally-recognized Expert on The AMA Guides to the Evaluation of Permanent Impairment [5th Edition] National Speaker and Instructor "Everything You Need to Know About The AMA Guides" "Winning in California Workers' Compensation" "Secrets of America's Most Successful Companies in Workers' Comp" "The Coming Storm--The End of Pensions, Social Security, Medicare And the Future of Workers' Comp" Featured Speaker and Instructor American College of Occupational and Environmental Medicine (Keynote Speaker--Annual Meeting) California Orthopedic Association California Workers' Compensation Institute (Keynote Speaker) Signal Mutual National Longshore Conference New York University Stern School of Business SEAK Forensic Seminars (General Session Speaker) Forensic Expert Witness Association (Keynote Speaker) (Please see www.askphilwalker.com for additional Speeches) EDUCATION Washington & Lee University Law School, J.D. 1981 Law Review Constitutional Moot Court Team Winner, AmJur Award in Corporate Law Vanderbilt University, BA (English, Creative Writing) 1977 Freshman Class President Founder, The Original Cast Founder, The Wild Bunch EMPLOYMENT General Counsel, Insignia Douglas Elliman (New York) Managing Attorney, Fireman's Fund (San Francisco) Phil Neal Walker Law Corporation 250 King Street, Suite 414 San Francisco, CA 94107 877-774-5550, 415-295-4447 www.philnealwalkerlaw.com
[email protected]
Partner, Laughlin, Falbo, Levy & Moresi (San Francisco) House Counsel, USX Corporation (US Steel) (Western US) Law Clerk, US Army Judge Advocate General's Corps (Fort Gordon) FILM, TELEVISION, THEATER, AND PRINT Clerk of Court, Class Action with Gene Hackman (Film) Host and Creator, "Out and Beyond with Phil Walker" (Television) Founder and Director, The Young Turks Acting Troupe (Theater) National Legal Columnist, Genre Magazine (Print) WEBSITES: www.askphilwalker.com (for additional information) www.philnealwalkerlaw.com (for additional information) SUMMARY Phil Walker is a Professional Speaker, Teacher, and National Trial Counsel for California workers’ compensation and Longshore defense based in San Francisco, California. For 34 years, he has represented California’s largest airlines, shipyards, steel companies, retailers, universities, and insurers in workers’ compensation and Longshore matters. Phil served as House Counsel for US Steel, General Counsel for New York City’s largest residential real estate firm--Insignia Douglas Elliman, and Managing Attorney for Fireman’s Fund Insurance Company. He was a Partner with Laughlin, Falbo, Levy & Moresi. Phil is a member of the Bars of California, New York, and the District of Columbia. He was educated at Vanderbilt University, where he studied creative writing and public speaking, and Washington & Lee Law School. Phil has been a national legal columnist for Genre Magazine and host of his own television show in San Francisco. He appeared as “the Clerk of Court” with Gene Hackman in Class Action. Phil is the author of The AMA Guides Made Simple, Keynote Speaker for the American College of Occupational and Environmental Medicine Annual Meeting, and Featured Speaker at the SEAK National Workers' Compensation Law Conference. Phil Neal Walker Law Corporation 250 King Street, Suite 414 San Francisco, CA 94107 877-774-5550, 415-295-4447 www.philnealwalkerlaw.com
[email protected]
Welcome to
"Professionals in Worker's Compensation Court"
Walter Newman, M.D. Court Clerk, Bailiff and Story Teller
The Honorable Phil Walker, J.D. Presiding Judge
Attorney Representing Plaintiff and Litigants
Barrister Sebastian Huerta
Attorney Representing Defendants and Employers
Barrister Tammy Cramer
Court Reporter and Story Teller
Walt Newman, M.D.
Adjunct Associate Professor of Medicine, Stanford University
PRESIDING JUDGE FOR PROFESSIONALS IN WORKERS' COMPENSATION COURT
THE HONORABLE PHIL WALKER, J.D.
None of the participants in this presentation (Mr. Huerta, Ms. Cramer, Dr. Newman or Mr. Walker) have a conflict of interest disclosure concerning this presentation.
Jimenez vs Globe Oil
Juan Jimenez is a 42 year old field contract worker for Globe Oil in its Coalinga Oil Field. He has worked as a contract employee for 3 years without any lost work time or apparent illness.
Mr. Jimenez applies to be a full time benefited employee at Globe Oil.
In the course of the post offer physical examination, Mr. Jimenez reveals to the company physician that he has Chronic Hepatitis C.
The examining physician reviews the essential job functions of "Oil Field Worker" and determines that the fumes from the Coalinga field could cause a worsening or exacerbation of the Hepatitis C.
The physician in his postoffer report states: "Avoid exposure to hydrocarbon fumes at work" Globe Oil determines it cannot reasonably accommodate the restrictions and the offer of employment is rescinded.
Mr. Jimenez consults a labor attorney who refers him to several medical experts on liver disease and toxicology.
All experts agree there is no chance of worsening of the Hepatitis C from an occupational or environmental work exposure.
Mr. Jimenez sues Globe Oil in PIWC Court under the Americans with Disabilities Act for wrongful failure to hire.
Attorney Huerta representing Jimenez & Attorney Cramer representing Globe Oil
In the Case of Jimenez vs Globe Oil
We now poll you, the jury
Sullivan vs Dr. Kravitz
Mr. Steve Sullivan is a 34 year old office worker who sustained an uncomplicated lifting injury at work. No prior history of back injuries.
The employee was initially treated at an urgent care center with physical therapy and ibuprofen.
Modified duty was recommended but the employer could not accommodate this, so he was placed on total temporary disability.
Mr. Sullivan's symptoms persisted so he went to a chiropractor for 15 visits.
Again, no improvement.
His TPA referred him to Dr. Kravitz for a one time Independent Medical Exam (IME).
Dr. Kravitz reviewed all of Mr. Sullivan's records, MRI's and X-rays, took a thorough medical history and did a thorough exam.
Dr. Kravitz opined no further chiropractic care was indicated and that Mr. Sullivan was fit for duty as an office worker.
Diagnosis: Degenerative Disc Disease, moderate, multi level
Mr. Sullivan returned to his office work, which required occasional lifting up to 20 pounds.
Symptoms persisted for 8 months after Dr. Kravitz' IME.
After 8 months of back pain, Sullivan consulted a neurosurgeon who recommended immediate and urgent multiple level fusion.
The multi-level back fusion failed and Sullivan became addicted to Oxycontin.
After several months of Oxycontin use, Sullivan died of Oxycodone overdose (Coroner's report).
In PIWC Court, the widow and child sued Dr. Kravitz (IME) and his wife for $1.25 million dollars for wrongful death.
(Other treating physicians and chiropractors were also sued)
Attorney Huerta representing Sullivan Widow and Child & Attorney Cramer representing Dr. and Mrs. Kravitz
In the Case of Sullivan family vs Dr. and Mrs. Kravitz We now poll you, the jury
Bettencourt vs Central Coast Clinic
Joe Bettencourt is a 55 year old construction worker for ABC Construction Pismo Beach Area.
Mr. Bettencourt developed acute low back pain after prolonged use of a jack hammer.
He was interviewed and examined at The Central Coast Industrial Clinic.
He was found to be in moderate distress. Patient had difficulty getting on an off exam table. No red flags. No radicular symptoms.
The diagnosis was "moderately severe low back strain" and treatment was:
a) Physical therapy b) Modified Duty c) Ibuprofen
The clinic doctor explained that x-rays and MRI were not indicated and were not considered "best practice" per the ACOEM Guidelines.
Patient Bettencourt seemed perturbed. At his initial evaluation, 48 hours post injury, he stated:
"I want an MRI to be sure there's nothing wrong."
Patient was treated with therapy for about 8 weeks. His symptoms began to worsen. He developed shooting pain into his right leg, weakness and objective reflex weakness on the right.
8 weeks post injury, Central Coast Clinic doctor requested MRI, on a routine bases.
One month after the clinic's imaging request, the MRI was approved and was scheduled (3 months after initial injury).
The MRI revealed a large L5-S1 right disc herniation.
The clinic doctor requested referral to spine neurosurgeon Dr. Graves…
....and 4 months post injury the referral was authorized and examination scheduled.
The exam by Dr. Graves revealed an antalgic gait, weakness in the right leg, absent knee and ankle jerk reflexes and numbness.
Spine Surgeon Graves was quite perturbed and told Bettencourt: “You waited too long to see me. Your surgical outcome is not going to be good.”
“With these findings, an MRI should have been done right away and prompt surgical referral made.”
“Those clinic GP's just don't know how to treat spine injures, do they!”
Bettencourt underwent a multilevel cage fusion procedure, requiring extensive hospitalization, rehabilitation, pain management and morphine pump placement.
Mr. Bettencourt sued The Physicians of Central Coast Clinic for medical malpractice in PIWC Court for delay in diagnosis and treatment, and pain and suffering.
He appeared in court, in his wheelchair, accompanied by his care giver. Morphine pump was delivering medication.
Damages sought: $ 3 million
Attorney Huerta representing Bettencourt & Attorney Cramer representing Central Coast Clinic
In the Case of Bettencourt vs Central Coast Clinic We now poll you, the jury
Special thanks to
Sebastian Huerta, Tammy Cramer and "Judge" Phil Walker, J.D. Slides formatted by Amanda Dao, (Undergraduate, U.C. Davis)
"Professionals in Worker's Compensation Court" was conceived and produced by
Walt Newman, M.D.
Past-President, & Board Chair, Western Occupational and Environmental Medical Association (WOEMA)
[email protected]
408-226-5400
RECIPES FOR RATINGS
1.
2.
THE "0% WPI" RATINGS A.
FIBROMYALGIA:
0% WPI
P. 569
B.
THORACIC OUTLET SYNDROME
0% WPI
P. 569
C.
MYOFASCIAL PAIN SYNDROME
0% WPI
P. 569
D.
TENDINITIS OF UPPER EXTREMITY
0% WPI
P. 507
E.
EPICONDYLITIS (MEDIAL OR LATERAL WITHOUT SURGERY) 0% WPI
P. 507
ADD-ON FOR PAIN: A.
3.
UP TO 3% WPI
0 - 3% WPI
P. 584, 5b
READ IT OFF A CHART A.
HEARING LOSS
P. 250
B.
LOWER EXTREMITY (DIAGNOSIS BASED ESTIMATES)
P. 546-7
1.
P. 546
Meniscectomy
1
4.
Ligaments
P. 546
3.
Hip replacement
P. 546
4.
Knee replacement
P. 546
5.
Pelvic Fracture
P. 546
RANGE OF MOTION (ARM/LEG) A.
2.
SHOULDER 1.
Use a goniometer
P. 475,476, 478
2.
Measure the patient's following 6 motions in both right and left shoulders. Take at least 2 measurements. Write all measurements down. a.
Flexion
P. 475
b.
Extension
P. 475
c.
Abduction
P. 476
d.
Adduction
P. 476
e.
Internal Rot
P. 478
f.
External Rot
P. 478
g.
2 measurements at a 2
h.
3.
minimum
P. 20
Ensure the 2 measurements fall within 10% of each other
P. 20
i.
Use the highest ("maximum") of the measurements
j.
Write all measurements down
Take the maximum measurement in each of the 6 motions above and calculate the UE impairment % per the charts at pp. 476, 477, 479.
p. 474
P. 476, 477, 479
4.
Add up the UE% impairment values for the 6 measurements.
P. 479, 2
5.
Convert the total UE to WPI by using conversion chart at p. 439
P. 439
Calculate the impairment, if any, in the uninjured shoulder, using the same method shown above.
P. 453
6.
a.
Subtract impairment found in uninjured shoulder from impairment found in injured shoulder
P. 453: "If a contralateral 'normal' joint has a less than average mobility, the impairment value(s) corresponding to the uninvolved joint can serve as a baseline and are subtracted from the
P. 475, 476, 478
3
P. 453
calculated impairment for the involved joint." B.
ELBOW (SAME PROCEDURE AS ABOVE)
C.
WRIST (SAME PROCEDURE AS ABOVE)
D.
KNEE 1.
Turn to p. 537 of AMA Guides, Table 17-10 "Knee Impairment"
2.
Measure:
P. 470 474 P. 466 470
Flexion
P. 537
Flexion Contracture
P. 537
Varus
P. 537
Valgus
P. 537
3.
Take 3 measurements at a minimum. Use the maximum.
P. 533
4.
Apply the measurements to p. 537, Table 17-10 to get WPI% or (LE%). a.
5.
P. 453
If you get LE%, go to page 527, Table 17-3, to convert to WPI.
The Lower Extremity chapter does not have a provision indicating that the uninjured knee should be measured as well as the injured 4
P. 527
and that any impairment in the uninjured knee should be subtracted out (like the Upper Extremity chapter has at p. 453). However, you could argue, by analogy, that the same should apply to the lower extremity. You would argue application of p. 453 "by analogy."
5.
E.
ANKLE (FOLLOW SAME PROCEDURE NOTED FOR ABOVE)
P. 537
F.
HIP (FOLLOW SAME PROCEDURE NOTED FOR ABOVE)
P. 537
DRE (DIAGNOSTIC RELATED ESTIMATES) RATINGS (70% OF AMA GUIDES) A.
P. 453
LUMBAR SPINE 1.
Turn to p. 384, Table 15-3.
2.
Check to see which of the following you have (you will find this info in the Physical Exam section of the medical report) a.
Muscle Spasm
b.
Muscle Guarding
c.
Asymmetric Loss of Motion
d.
Non-verifiable radicular root pain 5
P. 384
e.
3.
Radiculopathy (this means pain, numbness, or tingling in one of the nerve pathways shown on p. 377) 1)
Sensory loss
2)
Loss of reflexes
3)
Loss of strength
4)
Atrophy in one leg
f.
Loss of motion segment integrity
g.
Imaging study showing herniated disc (any torn or ruptured disc; any bulging disc 4 mm or greater)
h.
Electrodiagnostic study
i.
X-ray showing loss of motion segment integrity
j.
Compression fracture
Then, turn to p. 384, Table 15-3, and place Applicant in one of the 5 DRE classes based on the findings: a.
b.
Class I:
0% WPI
None of the findings under paragraph 2 above
P. 384
Class II:
P. 384
5 - 8% WPI
ANY OR ALL OF THE
P. 384
6
FOLLOWING: 1)
Muscle spasm
2)
Muscle Guarding
3)
Asymmetric loss of motion
4)
Nonverifiable radicular root pain
OR 5)
Imaging study showing herniated disc with complaints of radiculopathy at side and level that would be expected; radiculopathy has now gone away
OR 6) c.
Class III: 1)
1 - 24% Compression Fracture 10 - 13% WPI
Radiculopathy verified by any of the following: a)
Electrodiagnostic testing
b)
Sensory loss
c)
Loss of reflexes
d)
Loss of strength
e)
Atrophy in one leg
7
P. 384
OR 2)
Herniated disc (i.e. disc which is torn, ruptured, or bulging 4 mm or greater) with radiculopathy (i.e. pain, numbness, or tingling in a known nerve pathway per p. 377)
OR 3)
Patient had surgery for radiculopathy and now has no symptoms of radiculopathy
OR 4) d.
25 - 50% compression fracture
CLASS IV:
20 - 23% WPI
1)
One-level fusion
2)
Loss of motion segment integrity by x-ray as defined on p. 384, Table 15-3
P. 384
OR 3) e.
51 - 100% Compression Fracture with no neurological compromise
CLASS V:
25 - 28% WPI
1)
One-level fusion + radiculopathy
2)
Loss of motion segment integrity by x-ray as defined on p. 384, Table 15-3 + radiculopathy
OR
8
P. 384
2) 4.
B.
51 - 100% Compression Fracture with one-sided neurological compromise
Then, turn to p. 4, Table 1-2, List of ADL's. a.
Identify which, if any, of the 8 ADL's are impacted by the lumbar spine problems.
b.
Each DRE Class has a range, for example, DRE II is 5 - 8% WPI. 1)
If Lumbar spine problems cause minimal or no impact on ADL's, give Applicant lowest number in the range, per p. 5 of AMA Guides P. 4, 5
2)
If Lumbar spine problems cause moderate impact on ADL's, give Applicant medium number in the range, per p. 5 of AMA Guides P. 4, 5
3)
If Lumbar spine problems cause maximum or high impact on ADL's, give Applicant highest number in the range, per p. 5 of AMA Guides P. 4, 5
CERVICAL SPINE 1.
Turn to p. 392.
P. 392
2.
Read the Classes for DRE rating. [ Note: Classes are different for cervical versus lumbar spine)
3.
Place Applicant in a class using same procedure as outlined above.
4.
Use ADL's to determine where to 9
place patient in the range. C.
THORACIC SPINE 1.
6.
Use same procedure as Cervical Spine.
P. 386 P. 4,5
D.
HIGH BLOOD PRESSURE/HYPERTENSION
P. 66
E.
CORONARY HEART DISEASE
P. 36
F.
CARDIOMYOPATHY
P. 47
G.
ARRHYTHMIAS
P. 56
H.
GASTROESOPHAGEAL REFLUX DISEASE (GERD)
P. 121
I.
CONSTIPATION, IRRITABLE BOWEL SYNDROME
P. 128
NERVE RATINGS 1.
Find the nerve you are dealing with for upper extremity (p. 486-490) or lower extremity (p. 551)
2.
Upper extremity, turn to p. 492. Lower extremity, turn to p. 552, Table 17-37
3.
On the chart at p. 492 (upper extremity) or p. 552 (lower extremity), find column for: a.
P. 4,5
Sensory Deficit or pain 10
b. 4.
Motor Deficit
Find the nerve you are dealing with [for example: in carpal tunnel, we deal with median nerve below mid-forearm], find the UE% for sensory deficit and the UE% for motor deficit. [Example: Median nerve below midforearm: Sensory deficit: 39% UE Motor deficit: 10% UE.
5.
Turn to p. 482. Perform the following tests: (you can find this in Physical Exam section of medical report) a.
Monofilament testing or light touch testing
AND b. 6.
Two-point discrimination.
Then, place in one of the following grades based on results of testing in paragraph 5: Grade 5:
0% sensory deficit
Normal monofil/light touch Normal two-point discrim Grade 4:
1 - 25% Sens deficit
Abnormal monofil/light touch Normal two-point discrimination
11
Grade 3:
26 - 60% sens deficit
Abnormal monofil/light touch Abnormal two-point discrimination 7.
Once you have the grade, select a % of sensory deficit within the range (NOTE: Doctor can select any percentage he wants within the range.] a.
8.
That will be your % of sens. deficit.
Multiply the % of sens deficit x the value you got for sensory deficit for the nerve per p. 492. [Example: median nerve below mid-forearm per p. 492 = 39% UE for sensory deficit.] [Example: If doctor finds 25% sens deficit for median nerve below mid-forearm, formula becomes: 25% sens deficit x 39% UE (per p. 492) = 9.75% UE rounds up to 10.0% UE
9.
Then, turn to p. 484, to grade motor deficit [Note: "motor deficit" means "loss of strength." a.
Doctor grades strength in fingers which have the median nerve below mid-forearm going into them."
b.
Per p. 484, Grades are: Grade 5:
0% motor deficit
Full strength Grade 4:
1 - 25% motor deficit
Some strength
12
Grade 3:
26 - 50% motor deficit
No strength c.
Place the patient in a grade based on the strength.
d.
Then, once placed in grade, select a motor deficit % within the range.
e.
Multiply the motor deficit % x the value for motor deficit for the nerve per p. 492. [Example: If doctor found "some strength" in muscles ennervated by median nerve, he would place in Grade 4, 1 - 25% motor deficit. Doctor then selects a percentage in this range. If Dr. selected 25%, the equation becomes: 25% motor def x 10% UE (per p. 492 for motor deficit) = 2.5% UE rounds up to 3.0% UE
10.
Then, combine the UE% for sensory and motor: Sensory: 25% sens def x 39% UE = 10% UE Motor: 25% mot def x 10% UE = 3% UE COMBINE: 10 C 3 = 13% UE.
14.
Convert UE% to WPI per p. 439 for upper extremity and per p. 527 for Lower Extremity. [Example: 13% UE = 8% WPI per p. 439]
15.
CARPAL TUNNEL SPECIAL NOTE: A.
YOU MUST HAVE A POSITIVE ELECTRODIAGNOSTIC TEST (EMG AND/OR NERVE 13
CONDUCTION STUDY) TO DIAGNOSE AND RATE CARPAL TUNNEL SYNDROME (P. 492 AND 493)
7.
CRPS (Complex Regional Pain Syndrome) A.
P. 492, 493
P. 496
UPPER EXTREMITY 1.
Turn to p. 496, Table 16-16.
2.
Patient must have at least 8 of the findings observed by the physician at the same time to get the diagnosis of CRPS.
3.
P. 496
Then, rate in one of 2 ways: a.
Upper Extremity Chapter 1)
Rate range of motion
COMBINE WITH
b. B.
2)
Rate sensory and motor deficits under nerve rating
3)
Convert result to WPI per p. 439
Neurology chapter, p. 343, Table 13-22
LOWER EXTREMITY 14
P. 343
1.
Turn to p. 553.
P. 553
2.
NOTE: Lower extremity does not require the patient to have the 8 findings present at the same time as the upper extremity chapter does at p. 496. You can argue this by analogy: ANALOGY: Patient must have at least 8 of the findings observed by the physician at the same time to get the diagnosis of CRPS, by analogy to Upper Extremity Chapter.
3.
Then, rate in one way: a.
8.
P. 496
Neurology chapter, p. 336, Station and Gait Disorders
P. 336
SLEEP DISORDER 1.
Turn to p. 317, Table 13-4.
2.
To be rated using this chart, the patient MUST have the following: a.
A formal sleep study which diagnoses excessive daytime sleepiness
P. 317
One of the neurological conditions listed on p. 317
P. 317
AND b. AND c.
The Neurological Disorder must 15
be proven by tests.
9.
SEXUAL DYSFUNCTION A.
MALE 1.
TURN TO P. 156, TABLE 7-5
2.
Determine which of these the patient has:
3.
a.
Erection
b.
Ejaculation
c.
Sensation
d.
No sexual function possible
4.
5.
P. 156
Turn to Table 7-5: Place in a class like any DRE Rating. a.
P. 305
Use ADL's to determine where in the range the patient falls.
SPECIAL NOTE 1: ADJUST FOR AGE A.
ONCE YOU HAVE THE WPI%, INCREASE BY 50% FOR MEN UNDER 40
B.
ONCE YOU HAVE THE WPI%, DECREASE BY 50% FOR MEN OVER 65.
SPECIAL NOTE 2: MAKE SURE TESTS 16
P. 4,5 P. 157
DONE
P. 157
A.
Penile Tumescence study
B.
Doppler ultrasound penile blood flow eval
C.
Dynamic Cavernosometry and cavernosography
D.
Angiography
10. SPINE RANGE OF MOTION 1.
Use this method when you have any of the following (p. 380, lower right paragraph 4): A.
Fusion at 2 or more levels in the same spinal region
B.
Fractures at 2 or more levels in the same spinal region
C.
Radiculopathy in the same spinal region which is: 1.
Bilateral (i.e., on both sides)
OR 2. D.
At 2 or more levels on the same side
Radiculopathy which is caused by: 1.
Stenosis
OR
17
P. 380
2. 2.
Recurrent disc herniation.
Then, a Spinal ROM rating has 3 parts: Disorder, Motions, and Nerve a.
Disorder: Turn to p. 404 1)
b.
Find the disorder you have
Motion: Turn to pp. 405-417, find the Motion charts for Lumbar, Thoracic, or Cervical 1)
Use an inclinometer
2)
Measure the following motions [EXAMPLE: LUMBAR SPINE: Sacral Flexion True Lumbar Flexion True Lumbar Extension Right lateral bending Left Lateral Bending.
3)
Turn to the charts at p. 407 and 409. Calculate the impairment using the motions you have. a)
c.
Add these impairments together to get a total WPI for "Motion."
Nerve: Turn to p. 424, find the nerve you are dealing with 18
d.
1)
Grade the sensory deficit per p. 482
2)
Grade the motor deficit per p. 484
3)
COMBINE those impairment numbers. [NOTE: THE IMPAIRMENT % ON P. 424 ARE LE% AND UE%. CONVERT TO WPI PER P. 439 FOR UE OR P. 527 FOR LE.
Then, COMBINE TO GET TOTAL: 1)
DISORDER WPI%
2)
MOTION WPI%
3)
NERVE WPI% COMBINE FOR TOTAL:
________WPI%
11. GRIP STRENGTH Grip strength is only used to rate 2 conditions under the AMA Guides. A.
MUSCLE RUPTURE IN ARM LEAVING PALPABLE DEFECT (EXAMPLE: BICEPS TENDON RUPTURE)
P. 508
B.
EPICONDYLITIS WITH SURGERY (MEDIAL OR LATERAL)
P. 507
C.
NOTE: GRIP STRENGTH IS NEVER USED WITH CARPAL TUNNEL
P. 494
P. 494: "In compression neuropathies, additional impairment values are not given for decreased grip strength."
19
Carpal tunnel syndrome is a "compression Neuropathy."
12. PSYCH
A.
AMA GUIDES not used to rate Psych
B.
Use the "GAF Score." 1.
Find GAF Score.
2.
Go to workcompcentral.com. a.
Select Rating Calculator
b.
Select Psych injury. 1)
Input GAF score
2)
Calculator will convert to WPI.
20
NAME: ______________________________ TOTAL CORRECT:
____________
TOTAL ANSWERED:
____________
PERCENT CORRECT:
____________
AMA GUIDES ASSESSMENT WHERE ARE YOU NOW? 1.
What is the maximum WPI% permitted as an add-on for pain?
_________
2.
On what page in the AMA Guides does this info appear?
_________
3
4.
If the underlying WPI% is 0% WPI, what is the maximum add-on for pain permitted by DEU? What is the WPI % for the following: Fibromyalgia
5.
_________
_________
On what page in the AMA Guides does this appear?
1
_________
NAME: ______________________________ TOTAL CORRECT:
____________
TOTAL ANSWERED:
____________
PERCENT CORRECT:
____________
AMA GUIDES ASSESSMENT WHERE ARE YOU NOW? 1.
What is the maximum WPI% permitted as an add-on for pain?
_________
2.
On what page in the AMA Guides does this info appear?
_________
3
4.
If the underlying WPI% is 0% WPI, what is the maximum add-on for pain permitted by DEU? What is the WPI % for the following: Fibromyalgia
5.
_________
_________
On what page in the AMA Guides does this appear?
1
_________
6.
Thoracic Outlet Syndrome On what page in the AMA Guides does this appear?
7. 8.
On what page in the AMA Guides does this appear?
10.
On what page in the AMA Guides does this appear?
12.
On what page in the AMA Guides does this appear?
_________________________ On what page in the AMA Guides does this appear?
15.
19.
_________
What are the two situations under the AMA Guides where grip strength is used for rating. a.
18.
_________
Myofascial pain syndrome
13.
17.
_________
Epicondylitis (medial or lateral)
11.
16.
_________
Tendinitis of Upper Extremity
9.
14.
_________
b.
_________
_________________________ On what page in the AMA Guides does this appear?
Applicant has undergone a partial medial meniscectomy. What is the WPI%? On what page in the AMA Guides does this appear? 2
_________ _________ _________
20.
Applicant has 30% binaural hearing loss. What is the WPI%? On what page in the AMA Guides does this appear?
21. 22.
23.
Applicant has suffered injury to the right shoulder and has the following motion measurements. What is his WPI%? Motion
Right
Left
Flex
140/138/136
180/180/180
Ext
30/28/29
50/50/50
Abd
180/180/180
180/180/180
Add
20/22/20
40/40/40
Int. Rot.
63/60/59
90/90/90
Ext. Rot.
20/70/45
90/90/90
Applicant has suffered injury to the right knee. He has the following measurements. What is his range of motion? Motion
Right
Left
Flexion
100/98/100
120/120/120
Flex. Contracture 0/0/0 24. 25.
__________ __________
__________
__________
0/0/0
On what page in the AMA Guides does this appear? Applicant has a herniated disc at L4-5 of 6 mm 3
__________
per mri with radiating pain in the L5 distribution of right leg. He undergoes a laminectomy at L4-5. After surgery, all symptoms and pain go away. After surgery, the lumbar spine problems create no impact on any activities of daily living. What is his WPI%?
__________
On what page in the AMA Guides does this appear?
__________
26. 27.
Applicant has a 40% compression fracture at L1-2. The compression fracture produces maximum impact on his ADL's and limits him to the maximum degree in all ADL's.
28.
What is his WPI%?
__________
29.
Where does the info on how impact on ADL's affects the rating appear in the AMA Guides?
__________
30.
Applicant has a right carpal tunnel syndrome which is confirmed by EMG. Applicant has the following findings: a.
Abnormal monofilaments (maximum)
b.
Normal two-point discrimination
c.
No impairment in strength in muscles ennervated by median nerve.
What is his WPI?
__________
31.
On what page in the AMA Guides do you find the value for the median nerve below mid-forearm?
32.
On what page in the AMA Guides do you find the grading for sensory
4
deficit? 33.
34.
__________
On what page in the AMA Guides do you find the grading for motor deficit?
__________
The patient is diagnosed with CRPS in the right arm. He has the following findings: CRPS right arm is swollen and warmer than left arm. No other symptoms.
35.
What is his WPI?
__________
36.
On what page in the AMA Guides does that information appear?
__________
37.
Applicant is diagnosed with sleep apnea. No formal sleep study is done. What is his WPI?
38. 39.
__________
On what page in the AMA Guides does that information appear?
__________
Applicant is a male. He is diagnosed with impotence as a result of work injury. He is 20 years old. No testing is done. What is his WPI?
__________
40.
On what page in the AMA Guides does that information appear?
__________
41.
Applicant takes non-steroidal antiinflammatories for his industrial low back injury. He is diagnosed with gastroesophageal reflux disease from the NSAIDS. His weight has remained the same from before the injury to the date of diagnosis.
5
What is his WPI?
__________
42.
On what page in the AMA Guides does that information appear? (2 possible answers)
__________
43.
Applicant has a fusion of the lumbar spine at L3-4 and L4-5. After the fusion, he has no radiculopathy. His measurements are: Motion Sacral Flexion
50/49/48
True Lumbar Flexion
30/31/29
Extension
20/21/20
Right lateral
25/25/25
Left lateral
25/25/25 What is his WPI%?
__________
44.
On what page in the AMA Guides do you find the WPI for his fusions?
__________
45.
On what pages in the AMA Guides do you find the WPI for his motions?
__________
46.
On what pages in the AMA Guides do you find the WPI for his nerve?
__________
6
John Paul Beaudoin Phd Sierra Valley Medico
Topic: Psychoneuroimmunology Managing Stress; Psychological and Mental Health I specialized as Clinical and Qualified Medical Examiner (Forensics) Psychologist. What is a Psychologist? Psychologists are professionals who focus on patients’ mental and emotional health. Unlike psychiatrists, psychologists are not typically physicians, but they usually hold a Ph.D. or other advanced academic degree. Patients may see a psychologist for a variety of issues, such as eating disorders, anxiety, depression or poor impulse control. Treatment options can include counseling or psychotherapy, although psychologists cannot prescribe medication. There are two branches of psychology: applied psychology, which refers to clinical practitioners who deal with patients; and research psychology, which involves the scholarly study and/or teaching about the human mind (such as cognition and behavior). My main office is in Pacific Grove, Ca., with 10 satellite office in Ca., 3 of which are with Sierra Valley Medico, Inc.
FRESNO
PIWC 2015
JOHN-PAUL BEAUDOIN, PhD Licensed Clinical Psychologist State Appointed Qualified Medical Examiner EDUCATION
1970–1974
BA Theology, University of Portland, Portland, OR
1974–1978
Yale University, New Haven, CT, M Div. Psychology and Religion
1978–1984
Clinical Psychology, The Wright Institute, Berkeley, CA
LICENSURE
California PSY #13842 California QME #93452
PRACTICE
QME, AME, IME, CONSULT, SECOND OPINION
EXPERIENCE
2008-Present 1994-Present 2001-2003 2000-Present 2000-Present 2000-2003 2000-2003 1997-2003 1996-1998 1995-1998 1989-1994 1984-1988 1983
PUBLICATIONS AND PAPERS
“Projected Phantasies of the Deaf: A Psychoanalytic and Cross-Culture Perspective” Dissertation Abstracts, Copyright 1984, Ann Arbor, MI
Sierra Valley Medico, Inc. Private Practice, Clinical Psychologist Central Coast Pain Management, Monterey, CA Monterey Pines Skilled Nursing Facility, Monterey, CA Monterey Convalescent, Monterey, CA Katherine Health Center, Salinas, CA Sunbridge Care Center, Watsonville, CA Sunbridge Care Center, Monterey, CA Canterbury Woods, Pacific Grove, CA Pacific Grove Convalescent, Pacific Grove, CA Private Practice with Stephen R. Berlin, Ph.D., Pacific Grove, CA Community Hospital of the Monterey Peninsula, Monterey, CA Langley-Porter Psychiatric Institute, Center of Deafness, San Francisco, CA
“Stress Management: New Findings in Psychoneuroimmunology” Intellectual Property Law Association annual meeting October 1995, Anaheim, CA Revised Psychoneuroimmunology paper San Francisco Intellectual Property Law Association annual seminar and annual meeting, April 1996, San Jose, CA LOCATIONS
FRESNO 7033 N Fresno Street, Suite 201, Fresno, CA 93720
(559) 435-5581
MERCED 3351 ‘M’ Street, Suite 230, Merced, CA 95348
(209) 383-4485
SAN LUIS OBISPO 620 California Boulevard, Suite Q, San Luis Obispo, CA 93401
(805) 543-5581
Sierra Valley Medico, Inc. • 7033 N Fresno Street, Suite 201, Fresno, CA 93720 • 559 435-5581 • 559 435-5583 fax • www.sierravalleymedico.com
Updated 03/16/10
Michael gaston Michael Sullivan & Assoc.
Topic: Medical Legal Report: Writing and Analyzing Facts from Fiction Mr. Gaston, Managing Partner of the Orange and Fresno offices, represents insurance carriers, self-insured employers and public entities in all aspects of workers’ compensation defense. Previously, as an Associate Attorney for the firm, he led and coordinated the closure of 40% of the workers’ comp cases for K-Mart/Sears that had been unresolved for as long as 15 years.
He began his legal career as a Paralegal in the Los Angeles office, responsible for conducting research and witness investigations, reviewing medical records, preparing petitions and facilitating the completion of discovery.
Before joining Michael Sullivan & Associates, Mr. Gaston was a Middle School Instructor, teaching algebra, history, language arts, religious studies and physical education for the Diocese of Orange. As a Nuclear Machinist’s Mate for the U.S. Navy, he was responsible for the operation, maintenance and repair of steam plants on nuclear-powered submarines, served as an instructor for officers and enlisted men and supervised 25 sailors. Mr. Gaston received his Juris Doctor degree from Southwestern Law School in Los Angeles in the two-year accelerated SCALE program. He received his undergraduate degree from California State University, Fullerton.
FRESNO
PIWC 2015
pilar mitchell Michael Sullivan & Assoc.
Topic: Medical Legal Report: Writing and Analyzing Facts from Fiction
Ms. Mitchell, Supervising Attorney in the Fresno office, manages the staff and cultivates client relations while overseeing all aspects of the firm’s workers’ compensation defense cases for the Central Valley WCAB. Previously, Ms. Mitchell was Associate Attorney in the firm’s Westlake Village office, representing insurance carriers, self-insured employers and public entities in all aspects of workers’ compensation. Before joining Michael Sullivan & Associates, Ms. Mitchell was an Associate Attorney with Newhouse and Creager in Calabasas, working on workers’ compensation defense and appearing before WCABs throughout Southern California, and an Associate Attorney with Shatford Law in Pasadena, representing workers’ compensation plaintiffs. As an Intern with Shatford, she worked in business and family law, civil litigation, real estate and personal injury. As a Document Reviewer with Munger Tolles, & Olson in Los Angeles, Ms. Mitchell assisted in complex litigation for a major investment company. She was a Law Clerk/ Paralegal with the Law Office of Bruce T. McIntosh in Pasadena, drafting documents and attending court hearings and negotiations, and an Intern with Shegerian & Associates in Santa Monica, working in employment law. Ms. Mitchell worked as a Summer Clerk in the Office of the San Bernardino County District Attorney, researching complex cases and drafting documents. As a Student Intern at the Legal Aid Foundation of Los Angeles, she assisted low-income clients and translated for Spanish speakers. Ms. Mitchell received her Juris Doctor degree from the University of Kansas School of Law, and her undergraduate degree from Pepperdine University in Malibu. Ms. Mitchell speaks fluent Spanish.
FRESNO
PIWC 2015
1
■
■
■
The firm provides high-quality litigation in defense of workers’ compensation claims, employment issues and insurance litigation. Offices in Los Angeles, Orange, San Diego, Westlake Village, Inland Empire, Bay Area, and Central Valley. Author of Sullivan on Comp, which covers the complete body of California workers' compensation law.
2
Michael Gaston ¢ Orange & Fresno Offices ¢ 714-202-3440 ' ¢
[email protected] * ¢
Pilar Mitchell ¢ Fresno Office ¢ 559-785-6001 ' ¢
[email protected] * ¢
3
¢
¢
¢
¢
Discuss the basic elements of a sound medical report. Discuss what constitutes substantial medical evidence, and what you can do to make sure your reports are considered substantial. Go over some common scenarios that you will deal with in your P&S reports. Questions are encouraged.
4
¢
¢
¢
The primary treating physician (PTP) is the physician primarily responsible for managing the care of an employee. The primary treating physician must render opinions on all medical issues necessary to determine eligibility for compensation. The PTP is responsible for, among others, the following: ¢
Creating a treatment plan and requesting authorization for treatment.
¢
Referring the employee to other specialist, if necessary.
¢
Reporting an employee’s eligibility for temporary disability.
¢
Reporting whether an employee may return to modified duty.
¢
Reporting when an applicant is P&S and then reporting permanent impairment. 5
¢
¢
¢
¢
¢
¢
Unless there is an objection by either party, a PTP’s opinion will be controlling if it is considered substantial medical evidence. If there is a dispute over an request for treatment, it will generally be resolved by the UR/IMR processes. If there is a dispute over other issues (e.g., disability status, work restrictions, compensable consequence injury, or permanent disability), then the dispute will be resolved by an AME/QME. A claims adjuster must make decisions on all aspects of a claim based on the PTP’s reporting. Following receipt of a P&S report, the parties must make decisions on returning the applicant to work and possibly settling the claim. Therefore, it is very important for PTP’s to produce reports which will be considered substantial evidence. 6
CCR 10606 provides that medical reports should include: ¢
The date of the examination
¢
The history of the injury
¢
The patient’s complaints
¢
A list of all information receive or relied on for the formulation of the opinion
¢
Findings on examination
¢
A diagnosis
¢
An opinion on the nature, extent, and duration of disability and work limitations, if any 7
¢
The cause of disability
¢
Treatment indicated, including past, continuing and future care
¢
An opinion on whether or not PD has resulted from the injury, and whether or not it is stationary, and if stationary, a description of the disability with a complete evaluation
¢
Apportionment of disability, if any
¢
The reasons for the opinion
¢
A signature
Failure to include all of these requirements will not render a report inadmissible but will be considered in weighing the value of the report.
8
In order to be considered substantial evidence, a report: ¢
Must be based on reasonable medical probability
¢
Must not be speculative
¢
Must not be erroneous
¢
Must not be based on inadequate medical history or examination
¢
Must not be based on an incorrect legal theory
¢
Must not be conclusory
¢
Must not be beyond the physician’s expertise
We will go over these ideas in the upcoming slides.
9
¢
¢
¢
¢
¢
A medical opinion only needs to be based on “reasonable medical probability.” It doesn’t need to be based on scientific certainty. It is sufficient if an opinion is “reasonable” or “probable,” i.e., more than merely possible. Doctors are expected to assess all of the facts of a case and to provide their expert opinions. It is helpful if you state that your opinion is based on “reasonable medical probability,” but that alone is not enough. Generally, whether a doctor’s opinion is based on reasonable medical probability depends on how effectively the doctor explains the opinion.
10
¢
¢
¢
¢
¢
A medical opinion must be based on a factual or medical basis, rather than speculation. An opinion based on reasonable medical probability is supported by known facts; a speculative opinion is not. In a sense, all medical reports are speculative. When a doctor apportions 30% of an injury to nonindustrial factors, it is somewhat of a guess. Using medical judgment to come up with an approximate percentage of apportionment does not make it speculative. But, it is the doctor’s ability to support that opinion with facts that makes the opinion substantial evidence.
11
¢
¢
¢
It is permissible to apportion based on: ¢
A review of diagnostic testing
¢
Known facts from your evaluation
¢
A review of medical records
So long as you adequately explain the factual or medical basis for your opinion, it will be considered substantial evidence. It is not permissible to apportion to “prior nonindustrial injuries” if you have no evidence of any.
12
¢
¢
¢
¢
¢
A medical opinion may be insubstantial if it is found to be erroneous. This can happen when a doctor offers an opinion which is invalidated by diagnostic testing. For example, if a doctor offer an opinion on PD to the spine, but fails to review diagnostic testing which shows that the condition was worse than reported, the opinion could be considered insubstantial. Don’t ignore previously performed diagnostic tests. Explain how the testing supports your opinion. If you need diagnostic testing to offer an informed opinion, don’t be afraid to ask for it.
13
¢
¢
¢
¢
¢
Just like a report can be insubstantial if it is erroneous, it can be insubstantial if it is based on an inadequate medical history or examination. This commonly happens when an applicant gives a doctor a false medical history. This is where review of medical records becomes important. If an applicant provides a medical history that is inconsistent with prior records, point that out in your report. Explain how the inaccurate history given by the applicant does or does not affect your opinion.
14
¢
¢
¢
¢
¢
A medical opinion is not substantial evidence if it is based on a misunderstanding of applicable legal standards. Doctors are expected to understand the terms “permanent disability,” “temporary disability,” “permanent and stationary” or “maximum medical improvement,” and “apportionment.” For example, it would be improper to report that an applicant is P&S solely because he or she has been returned to modified duty. P&S status refers to medical rehabilitation from an injury, not the ability to work. Per CCR 10152, "A disability is considered permanent when the employee has reached maximal medical improvement, meaning his or her condition is well stabilized, and unlikely to change substantially in the next year with or without medical treatment."
15
¢
¢
¢
¢
¢
A medical opinion is not substantial evidence if a doctor fails to explain the underlying basis for his or her conclusions. This is the single most important factor in determining whether a doctor’s opinion will be considered substantial evidence. A medical report should explain the reasoning for a conclusion in layman’s terms as much as possible. Because doctors do not testify at workers’ compensation trials, the parties and the WCAB need to understand the basis for the opinion. A good and thorough explanation for an opinion will obviate the need for a supplemental report and possibly a deposition.
16
¢
¢
¢
¢
¢
¢
A medical opinion is not substantial evidence it is extended beyond the range of the physician’s expertise. For example, an orthopedic surgeon’s opinion that the applicant has a compensable psychiatric injury would not be substantial. If there are issues beyond a doctor’s expertise, the doctor should request a consultation in the appropriate specialty. As a doctor, you would be in the best position to know whether a condition is within your expertise. If another specialist is required, the key again is to explain the reasoning for the referral. If you are the PTP, it would then be your duty to review the specialist’s opinion and then comment and incorporate the report.
17
Whether an injury is AOE/COE may be: ¢
¢
A medical issue – Are the applicant’s lower back problems caused by cumulative trauma or a pre-existing condition? A legal issue – Did the applicant’s injury while driving to work occur in the course of employment?
18
¢
If AOE/COE is a medical issue, it must be resolved by a physician.
¢
AOE/COE is commonly a medical issue for the following:
¢
¢
¢
Cumulative trauma claims
¢
Psychiatric claims
¢
Internal medical claims (hypertension, gastrointestinal issues)
¢
Occupational diseases (cancer, asbestosis)
If AOE/COE is a medical issue, it is the doctor’s duty to take a full and accurate history, and make a determination on causation based on reasonable medical probability. A doctor must explain how and why a worker’s condition is or is not related to the employment.
19
¢
¢
¢
¢
¢
¢
If AOE/COE is a legal issue, your job as a doctor is simply to treat the injury until it is denied by the insurer. For example, if an applicant is injured while driving to work, then his/her claim is potentially barred by the going and coming rule. While the claim is being investigated, LC 5402(c) requires an employer to provide up to $10,000 in medical care until the employer denies the claim. So, even if there is an issue over whether the injury is compensable, medical treatment should be provided until the claim is denied. Leave it up to the lawyers to determine whether the claim is compensable. If you are advised that the claim is denied, you should discontinue treatment at that point.
20
¢
¢
¢
Many times, an applicant will claim injury to multiple body parts as a result of an industrial injury. When you first treat an applicant, it is important that you report what body parts are claimed to be injured. Take a history from the applicant and determine whether it is medically probable for the mechanism of injury to cause injury to all of the body parts. Explain why or why not.
21
¢
¢
¢
¢
¢
In workers’ compensation, subsequent injuries which are caused by an industrial injury are also compensable. If an applicant claims injury to a new body part months or years after the initial injury, assess whether the new body part is causally related to the original injury. Take a complete history of the newly claimed body part (e.g. subsequent injuries, when did the symptoms begin, what was the applicant doing when the symptoms commenced.) Not all subsequently claimed body parts relate to the original injury. If you do not believe that the add-on body part is related to the original injury, you must properly explain your opinion.
22
¢
¢
¢
¢
¢
When an industrial injury lights up, aggravates, or accelerates a preexisting disease or condition, the injury is compensable. An exacerbation occurs when an industrial injury has caused a temporary flare-up of the pre-existing disease or condition. The employer must treat the pre-existing disease or condition during the temporary flare-up. After the temporary flare-up subsides, the employer is no longer required to treat the pre-existing disease or condition. An aggravation occurs when an industrial injury has permanently worsened a pre-existing disease or condition. If there is a permanent aggravation of a pre-existing disease or condition, then not only is the employer liable for any disability caused by the employment, but is also fully liable for continuing medical treatment of the condition.
23
¢
¢
¢
¢
¢
If a pre-existing disease or condition is permanently aggravated by an industrial injury, the applicant’s permanent disability may be apportioned to the pre-existing non-industrial factors. That is, the employer is not liable for the PD caused by the pre-existing factors and you should apportion appropriately. However, if industrial factors contribute even 1% to the need for medical treatment, the employer is fully liable for the total cost of medical treatment. The employee must still prove that the pre-existing condition was exacerbated or aggravated by an industrial injury. It up to a doctor to determine whether there is an exacerbation or aggravation. A doctor’s opinion on this issue must be substantial evidence.
24
¢
¢
¢
¢
¢
A PTP’s duties include reporting whether an employee is temporarily disabled. Temporary disability is total if the employee cannot return to any kind of work during the recovery period. Temporary disability is partial when the employee can perform some work, but not full normal duties. If you believe that an employee can only perform “modified duty” or “light duty,” be specific with your work restrictions. Employers rely on a doctor’s work restrictions to determine whether an employee’s usual work falls within the restrictions or to determine whether another position is available.
25
¢
¢
¢
¢
¢
Medical care under the workers’ compensation system is generally based on the Medical Treatment Utilization Schedule (MTUS). The MTUS is composed mostly of the ACOEM Guidelines, but also includes other guidelines. The MTUS is presumptively correct on the extent and scope of medical treatment. Utilization review (UR) and independent medical review (IMR) are the processes used to determine whether a request for treatment falls within the MTUS. Per LC 4604.5(a), the MTUS may be rebutted by a preponderance of scientific medical evidence establishing that variance from the MTUS is reasonably required to cure or relieve the applicant from the effects of the injury.
26
¢
¢
¢
¢
¢
In order to request authorization for medical treatment, a DWC Form RFA must be completed. The RFA form must be accompanied by documentation substantiating the need for medical treatment. Explain why the applicant needs the requested Because of the UR/IMR scheme, a physician’s course of care is generally limited to what is allowable under the MTUS. But, if a doctor presents other scientific literature showing that the proposed course of care is reasonable, then the MTUS may be rebutted. Also, pursuant to Dubon II, if a UR decision is untimely, the WCAB retains jurisdiction to award treatment so long as the request is supported by “substantial medical evidence.”
27
¢
¢
¢
Therefore, it is always a good idea justify the needed for the requested treatment in a report. It may persuade the claims adjuster to authorize the treatment without sending the request to UR. Or, the UR doctor may be persuaded by PTP’s rationale for the requested treatment.
28
¢
¢
¢
¢
For injuries on or after Jan. 1, 2005, permanent disability is rated using the AMA Guides. Under the AMA Guides, a physician performs an evaluation to determine the whole person impairment (WPI) for the injured applicant’s medical condition(s). After considering various factors such as the applicant's history, the physical examination and test results, the physician must compare the medical findings for the applicant's condition with the impairment criteria listed in the AMA guides. The report should include a summary list of the impairments and impairment ratings by percentage, together with a calculation of the final WPI, and a statement of the rationale underlying the WPI opinion.
29
¢
¢
¢
¢
Almaraz/Guzman is the name commonly given to the WCAB decisions involving two consolidated cases: Almaraz v. Environmental Recovery Services and Guzman v. Milpitas Unified School District. The WCAB’s en banc decision in Almaraz/Guzman was affirmed by the Court of Appeal in Milpitas Unified School District v. WCAB (Guzman) (2010) 187 Cal.App.4th 808. Under Almaraz/Guzman, the whole person impairment (WPI) portion of the schedule may be rebutted by evidence within the "four corners" of the AMA guides. A physician may utilize any chapter, table or method in the AMA Guides to assess WPI when those pertaining to an injury do not accurately describe the injured employee's impairment.
30
¢
¢
¢
¢
¢
¢
When should a doctor address Almaraz/Guzman in an MMI report? Almaraz/Guzman does not allow a doctor to conduct a fishing expedition through the AMA Guides simply to achieve a desired result. For example, a doctor shouldn’t use Almaraz/Guzman just because an applicant would have received a higher PD award under the old schedule. Doctors are expected to use their clinical judgement on whether a scheduled rating accurately reflects an applicant’s impairment. The key to applying Almaraz/Guzman is to explain why departure from the impairment percentages is necessary and how the doctor arrived at a different rating. Cases involving Almaraz/Guzman generally boil down to whether a doctor properly explains why use a different part of the AMA Guides more accurately reflects an applicant’s impairment.
31
¢
¢
¢
Although SB 863 made changes to PD for injuries on or after Jan. 1, 2013, Almaraz/Guzman still applies. LC 4660.1(h) states, "In enacting the act adding this section, it is not the intent of the Legislature to overrule the holding in Milpitas Unified School District v. Workers' Comp. Appeals Bd. (Guzman) (2010) 187 Cal.App.4th 808." So, for injuries arising on or after Jan. 1, 2013, a physician still may utilize any chapter, table or method in the AMA Guides to assess an injured worker's whole person impairment, provided that his or her opinion is supported by substantial evidence.
32
¢
¢
¢
¢
¢
Since 2004, LC 4663(a) requires apportionment to be based on “causation.” LC 4664(a) states, “The employer shall only be liable for the percentage of permanent disability caused by the injury arising out of an in the course of employment.” Apportionment may be based on pathology and asymptomatic prior conditions. In fact, the WCAB has held that a doctor who refuses to find apportionment solely because the applicant did not have significant pre-injury medical treatment or disability would not be substantial evidence. Such an opinion would be based on an incorrect legal theory. This was required under the old law, but not the current law.
33
¢
¢
¢
¢
The key to any apportionment opinion is the doctor’s explanation. For example, suppose a doctor apportions 50 percent of a back disability to an industrial injury and 50 percent to degenerative disc disease. The doctor should explain how and why the disability is causally related to the industrial injury and how and why the injury is responsible for about 50 percent of the disability. The doctor should also explain the nature of the degenerative disk disease, how and why it is causing permanent disability at the time of the evaluation, and how and why it is responsible for about 50 percent of the disability.
34
¢
¢
¢
¢
¢
Suppose an applicant has arthritis in the knee and gets a total knee replacement which removes the arthritis. Does apportionment apply? Although there is some dispute over this at the WCAB, all of the recent decisions would allow apportionment. As explained in Williams v. WCAB (2008) 74 CCC 88 (writ denied), “[W]hen the medical evidence establishes that a combination of factors results in the need for surgery and consequent permanent disability, causation of the permanent disability lies with all the factors, even pathology removed by the surgery.” It is appropriate to apportion to the arthritis, even if it is removed by surgery, so long as the arthritis contributed to the need for surgery. The doctor needs to explain how the pre-existing arthritis contributed to the need for surgery.
35
§
Questions?
§
Contact Information: § §
[email protected] [email protected]
36
Michael Mcdonald McDonald Law Corp.
Topic: Interacting within the interactive process Michael G. McDonald is the founder of McDonald Law Corporation in Concord, California. Mr. McDonald graduated from Marquette University in Milwaukee, Wisconsin. He received his law degree from California Western School of Law in San Diego, California. Mr. McDonald has over 27 years of California Workers’ Compensation law experience, is a Judge Pro Tem for the Workers’ Compensation Appeals Board, and is a certified specialist in Workers’ Compensation by the California Board of Legal Specialization of the State Bar of California. Mr. McDonald’s firm concentrates its practice in the areas of Workers’ Compensation defense, including 132a, Serious and Willful claims, and subrogation. Mr. McDonald is a lecturer for ExecuSummit, Council on Education in Management, Lorman Education Services, CWCDAA Annual Conferences, and various employer organizations concerning Workers’ Compensation issues, teaches Insurance Education Association classes, and has authored articles for Quinlan Publishing of New York, GetMedlegal.com, wcezine.com and Skeet Shooting Magazine. He is the past President of the Northern California Workers’ Compensation Defense Attorneys’ Association, serves on the California Workers’ Compensation Defense Attorneys’ Association Board of Directors, member of the Concord and California Chambers of Commerce, as well as several Industrial Claims Associations. He is also past President of the Bay Point Rod and Gun Club and has served on the United Sportsmen Incorporated Board of Directors. Mr. McDonald’s honors include receiving the Reginald Heber Smith Fellowship, awarded by Legal Services Corporation (1985), being named to the International Who’s Who of Entrepreneurs (2001), and the Northern California Super Lawyers List (2007, 2009).
FRESNO
PIWC 2015
McDONALD LAW CORPORATION
MICHAEL G. McDONALD is the founder of McDonald Law Corporation in Concord, California. Mr. McDonald graduated from Marquette University in Milwaukee, Wisconsin. He received his law degree from California Western School of Law in San Diego, California. Mr. McDonald has over 27 years of California Workers’ Compensation law experience, is a Judge Pro Tem for the Workers' Compensation Appeals Board, and is a certified specialist in Workers’ Compensation by the California Board of Legal Specialization of the State Bar of California. Mr. McDonald’s firm concentrates its practice in the areas of Workers’ Compensation defense, including 132a, Serious and Willful claims, and subrogation. Mr. McDonald is a lecturer for ExecuSummit, Council on Education in Management, Lorman Education Services, CWCDAA Annual Conferences, and various employer organizations concerning Workers’ Compensation issues, teaches Insurance Education Association classes, and has authored articles for Quinlan Publishing of New York, GetMedlegal.com, wcezine.com and Skeet Shooting Magazine. He is the past President of the Northern California Workers' Compensation Defense Attorneys’ Association, serves on the California Workers’ Compensation Defense Attorneys’ Association Board of Directors, member of the Concord and California Chambers of Commerce, as well as several Industrial Claims Associations. He is also past President of the Bay Point Rod and Gun Club and has served on the United Sportsmen Incorporated Board of Directors.
Corporate Office Bay Area 1800 Sutter Street, Suite 300 Concord, CA 94520-‐2556 Voice: (925) 363-‐4380 E-‐mail:
[email protected]
PLEASE REPLY TO OUR CORPORATE OFFICE
www.mcdonaldlawcorp.com Fax: (925) 363-‐4352
Los Angeles Area Office Voice: (657) 333-0630 Central Valley/Sacramento Office Voice: (916) 201-‐2450 South Bay/San Jose Office
Voice: (408) 315-‐5941
McDonald Law Corporation Statement of Practice (Continued)
Mr. McDonald's honors include receiving the Reginald Heber Smith Fellowship, awarded by Legal Services Corporation (1985), being named to the International Who's Who of Entrepreneurs (2001), and the Northern California Super Lawyers List (2007, 2009).
helyn hoffman Arthur J. Gallagher Topic: Interacting within the interactive process Bio- Helyn Hoffman- WCCP/CPDM Senior Claims Consultant Arthur J. Gallagher I provide over 30 plus years of National and International experience in Claims Management, Risk Management, Human Resources, and ADADisability Management from such organizations as Coca-Cola Enterprises, Kaiser- Health Organizations, Macy*s California, Non Profit Specialty Health Care Organizations, Specialty Retail Stores and the International chain of Whole Foods Markets. Positions I have held range from Managers of Claims to Director of Human Resources, Safety Risk Officer to HR Employee Relations Representative. I have been so fortunate to have been included in this great organization of AJG a year ago and I am continuing my passion of claims management for our clients. The most exciting aspect of my position at AJG claims management is the ability to service my clients from a National Multi State point of view; with expertise in the state of CA. I provide all aspects of claims management from reporting claims, file reviews, to claim resolutions/settlements. I served several years as the president of DMEC/ Risk Management of NCA Chapter and Instructor of the prestige IEA (Insurance Education Association)teaching WC Claims Management, Legal Updates, Return to Work Programs including Leave Absence Management ADA issues to Employers, Adjusters, Attorneys, Claims Specialists, etc… for over 7 years. FRESNO
PIWC 2015
Friend or Foe -‐ Return to Work or not within the claims process
Presented by: Michael G. McDonald, Esq. McDonald Law Corporation Helyn Hoffman Arthur J. Gallagher
Michael G. McDonald, Esq.
Founder: McDonald Law Corpora3on Education: Marquette University, Milwaukee, WI (BA 1980); California Western
School of Law, San Diego, CA (JD 1985) Member: Diablo Valley Industrial Claims Assn; Valley Industrial Claims Assn;
Professionals in Workers’ Compensation; California Chamber of Commerce Director: California Workers’ Compensation Defense Attorneys Association;
President: NCWCDAA 2009-‐2011 Accomplishments: Recipient of the Reginald Heber Smith Fellowship; named
to the 2007, 2009 Northern California Super Lawyers list; Bd of Directors: CWCDAA; Certified Specialist in Workers’ Compensation by the State Bar of California Instructor: Insurance Education Association; Lecturer: Lorman
Education Services; Council on Education in Management www.mcdonaldlawcorp.com
Helyn Hoffman – WCCP/CPDM
Senior Claims Consultant: Arthur J. Gallagher & Co. I provide over 30 plus years of National and International experience in Claims Management,
Risk Management, Human Resources, and ADA-‐ Disability Management from such organizations as Coca-‐Cola Enterprises, Kaiser-‐ Health Organizations, Macy*s California, Non Profit Specialty Health Care Organizations, Specialty Retail Stores and the International chain of Whole Foods Markets.
Positions I have held range from Managers of Claims to Director of Human Resources, Safety
Risk Officer to HR Employee Relations Representative. I have been so fortunate to have been included in this great organization of AJG a year ago and I am continuing my passion of claims management for our clients. The most exciting aspect of my position at AJG claims management is the ability to service my clients from a National Multi State point of view; with expertise in the state of CA. I provide all aspects of claims management from reporting claims, file reviews, to claim resolutions/settlements.
I served several years as the president of DMEC/ Risk Management of NCA Chapter and
Instructor of the prestige IEA (Insurance Education Association)teaching WC Claims Management, Legal Updates, Return to Work Programs including Leave Absence Management ADA issues to Employers, Adjusters, Attorneys, Claims Specialists, etc… for over 7 years.
Chemistry of TIAP Summary of the AB2222 Communication -‐ The Three C program Defining the Interactive Process Triggers of TIAP -‐ Known and Unknown Accommodations -‐ Leave of Absence Direct Job Placement WC Voucher Mod/Alt Employment Alternative Community Employment Separation of Employment -‐ Not Termination www.mcdonaldlawcorp.com
Summary of AB2222 CA bill in effect 01/01/2001 – expanding the scope of
disabilities, entitled to protection under the agencies of “FEHA” and the Unruh Act Employers are expected to engage under AB2222 in the interactive process under this law. Employers will be liable to liability under failing to engage AB2222 allows the difference of CA law to ADA Key words in AB2222 limit to substantially limited Knowing the term disabled is broader in scope; implied, presented and applied. www.mcdonaldlawcorp.com
The Three C Program Communication: Consistency, Continuity and Caring Documented Dialogs; All parties included and clearly
heard, timelines with agreed upon outcomes Good faith actions of all parties; ER, EE and medical Provider – caring to a positive outcome Forms: Medical Authorization Release, standard approved and legally review TIAP documents( launching pad will be the DOL forms) “SME”-‐ always include your subject matter expert in this process (HR, Claims, Managers to Safety) www.mcdonaldlawcorp.com
TIAP: The Interac3ve Process What is the interactive process? Understanding the interactive process within the Workers’
Compensation system – AB2222 Objectives/Outcomes of the TIAP (Interactive Process) Defined roles and expectations of all the persons in TIAP Face-‐to-‐face meetings & documentation of TIAP Temporary to Permanent Return to Work within TIAP Settlements, Accommodations and closing the file Laws that intersect with TIAP and WC:ADA (amended ADAAA-‐2008), FMLA, FEHA and all local policies. www.mcdonaldlawcorp.com
Interac3ve Process: Simply Defined This is a process in which Employers and Employees
(Applicants) engage in a dialog (verbal, written or third party) about limitations, conditions, modifications of the essential functions of one’s job description of employment. This process can apply to Applications in process; this can apply to established employees (hired) and exiting employees on a path of retirement to Workers’ Compensation claims to non-‐industrial claims made. www.mcdonaldlawcorp.com
Triggers of Interac3ve Process ER Triggers
Employee Actions
Information received formally
Employee requests a meeting to
from a MD regarding claim conditions/restrictions of employment Request of accommodations from the EE (verbal or written) Requests for dialog from legal entity; Attorney IN HR process problems/ concerns are reviewed with employee
discuss accommodations. This includes: leave of absence, partial work schedules, location, telecommute are just some forms of employment accommodation Employee requests accommodations during HR review of performance, attendance in addition interpersonal relationships
www.mcdonaldlawcorp.com
Work Within the Interac3ve Process Goal of TIAP: Gainful Return To Work Employers must demonstrate the process without
prejudice in the following way:
1. Face-‐to-‐face meetings with employee: 2 persons preferred 2. Written documentations (letters) supporting the meeting’s
documentations that demonstrate reframing of meeting and defined plans of actions with timelines and expectations of each person 3. Follow up on all communications in a written diary format -‐ email, phone calls, Skype, etc…
www.mcdonaldlawcorp.com
Accommoda3ons under TIAP Once notification is received that your employee has a
condition or restriction of employment, you may start the interactive process. In some cases, placing an employee on a leave of absence is the first option and is viewed as a form of accommodation. This will afford you some time to review medical provider notes and review an employment accommodation. The accommodation can include the following: a partial work schedule, location/position/schedule change, alternative community work, etc… www.mcdonaldlawcorp.com
Accommoda3ons-‐TRTW Temp to Perm Accommodating modified duty under a claim not only
reduces your TTD claim exposure, it supports the TIAP program of accommodation. This can be on temporary restrictions within an agreement and a specific time frame based on a medical provider note to permanent restrictions based on an MMI report. Temporary -‐ No greater than 90 days in duration and the TRTW must be able to support and medically demonstrate sustained improvement of the condition of employment. www.mcdonaldlawcorp.com
Interac3ve -‐ MMI-‐Perm Employers need to start on the interactive process with
the Injured Worker during the injury -‐ awareness of potential restrictions leading to permanent conditions or restrictions of employment. If IW is no longer an employee, you will be asked to support the questions “if it were not for” could you have accommodated the restrictions? If this process took place, you would have met the expectation. Documentation of the following will be the requirement: Job Description( RU-‐91) last known note. www.mcdonaldlawcorp.com
Modified Alterna3ve Employment In the TIAP process, you will need to work closely with your hiring
persons in addition to managers of departments/locations of your employment. Search your open positions, in addition to positions that the IW is a proper candidate for accommodations could meet with or without restrictions. You are not required to create a position or create undue hardship upon the business. Define all your modifications/restrictions (last known note) of the IW usual and customary job; match up on Technical, Educational, location and certifications, etc… If placement fits, you will be in the process Mod/Alt -‐normal company transfer will take place. Provide copies of this transfer /accommodation to your claims adjuster. www.mcdonaldlawcorp.com
Alterna3ve Community Placement Temporary accommodations can go beyond your employment doors
– Goodwill, local schools, Red Cross, National Guard, etc… In many cases, the IW will be placed in Community Service positions during temporary restrictions as the form of accommodations. These accommodations for the IW will support gainful return to work. In addition, IW can be paid up to 85%. Forms needed: TRTW agreement form, Medical provider note (in some states, you will be required to have MD approval) IW can option out – TTD will stop if it is a clear offer of TRTW IW will need to be placed on a LOA to support accommodation and TIAP can continue to take place to separation if warranted www.mcdonaldlawcorp.com
Direct Job Placement In many cases, the IW will be placed in Community
Service positions during temporary restrictions accommodations and some of these positions will evolve into a permanent opportunity. Once this is established; you will need to have a
resignation from IW regarding current employment. Coordinate with this agency or alternate employment a copy of the acceptance of employment document and process your documents to the claims adjuster for file notes of alternate employment. www.mcdonaldlawcorp.com
WC Voucher LC § 4658.5; 8 CCR 10133.53: Injuries Occurring between
01/01/04 -‐ 12/31/12 ($4,000 -‐ $10,000)
www.mcdonaldlawcorp.com
WC Voucher (Post 01/01/13) LC § 4658.7; 8 CCR 10133.34: Injuries Occurring On or After 01/01/13
($6,000) unless P&S and PPD exists Offer of Reg, Mod/Alt work made no later than 60 days after CA receipt of FIRST P&S report from either a PTP or AME/QME
On Form 10133.36 Physician to discuss work capacities/restrictions and activities compatible with physical requirements of JA CA SHALL forward the form to the employer for the purpose of fulling informing the Employer of work capacities/ restrictions for potential reg/mod/alt work www.mcdonaldlawcorp.com
WC Voucher (Post 01/01/13) LC § 4659.7 Offer of employment to last at least 12 months (Regulation 10133.35) SJDB voucher shall be offered to the IW within 20 days of expiration of time to make offer of employment $6,000
Includes up to $1,000 to purchase computer Includes up to $500 of miscellaneous expenses without need for itemization Unable to settle voucher www.mcdonaldlawcorp.com
Issues Duty of CA to obtain RTW/Voucher Report Failure to Inform Employer of work capacities Duty to Investigate Documentation Failure Good Faith Participation in TIAP AA jump in on it: 132a to S &W, etc… Civil Liability issues Employment Audits Insurance Rates increase, EMR rates increase www.mcdonaldlawcorp.com
Separa3on vs Termina3on Separation of employment is a mutual agreement of
resignation of employment (moving, retirement, gainful alternative employment) Termination of employment is usually under a non-‐voluntary exit of employment( performance, HR good faith actions; PP) Process of choice in claims management: Separation. Complete interactive process in addition with a voluntary resignation www.mcdonaldlawcorp.com
Termina3on in claims-‐interac3ve Termination in the claims process is the most difficult
for employers and claims adjusters -‐ IW’s will usually seek out/obtain legal counsel and start the medical and legal aspects of the claim all over again. If a termination occurs for good faith action (positive drug tests, altercations, unsafe acts, etc…) it may not result in claim closure, denial or stop the medical train; however, it will reduce the exposure of the interactive process of non-‐accommodation. Documentation www.mcdonaldlawcorp.com
Case examples TIAP Vanderheiden v. City of Alameda
(06/02/09) 1st DCA unpublished Firefighter since 1989 Co-‐worker splashed bodily fluids into his mouth and eye from suspected hepatitis patient Resulted in arguments, complaints, union intervention, police report Relationship with co-‐workers deteriorated and he was put on leave due to concern about mental state; directed to seek treatment www.mcdonaldlawcorp.com
Vanderheiden v. City of Alameda (cont.) Plaintiff filed suit alleging discriminatory
discharge, failure to accommodate, failure to engage in interactive process City filed for Summary Judgment Plaintiff failed to engage in interactive process He failed to request reasonable accommodation He failed to produce evidence he was not disabled and
capable of performing essential duties of job www.mcdonaldlawcorp.com
Vanderheiden (cont.) Trial court found in City favor Court of Appeal reversed Sufficient evidence existed of discriminatory discharge Factual question as to whether City engaged in Interactive Process Question of fact about ability to perform essential job functions
www.mcdonaldlawcorp.com
Case Raine v. City of Burbank nd (01/25/06) 2 DCA 1995 Police Officer sustained a torn meniscus, which
made running, jumping, kneeling and lifting difficult He was assigned to a light duty front desk position while he was recovering In 2002, his physician advised City he was unable to perform essential job duties of a PO. City engaged in interactive process: No positions available but he could change status to police technician www.mcdonaldlawcorp.com
Raines v. City of Burbank (Cont.) Appeals Court noted the front desk assignment would
require City to create a new sworn officer position Unreasonable to create a new position when the front desk position was reserved for civilian personnel, without altering PO status and salary No vacant position existed for Raines
www.mcdonaldlawcorp.com
Cuielle:e v. City of Los Angeles nd (04/22/11) Published 2 DCA Police Officer injured on duty He requested desk assignment upon return from
medical leave City provided desk job in warrants section, a common practice WC Award of 100% City informed him he was not allowed to work a week after the 100% rating www.mcdonaldlawcorp.com
Cuielle:e v. City of Los Angeles (cont.) Court held the 100% rating obtained in a WC
proceeding was not a legitimate, non-‐discriminatory reason for the adverse work action Trial Court erred in failing to properly instruct jury on ability to perform essential job duties of PO with or w/o reasonable accommodation City failed to engage in Interactive Process
www.mcdonaldlawcorp.com
Cuielle:e v. City of Los Angeles (cont.) Decision affirmed with costs to Plaintiff Practice of placing injured POs in permanent, light
duty positions amounts to a reasonable accommodation Plaintiff could perform essential job functions of a desk for fugitive warrants
www.mcdonaldlawcorp.com
Gambini vs. Total Renal Care Mental illness of acceptance ADA matter led to
performance/employment conduct termination Federal Trial Court upheld termination Federal Appellate Court overturned the termination Held opinion: Firing-‐Termination of an employee for misconduct/performance caused by a known disability is the same as firing an employee for having the disability ? -‐ If the employee discloses a disability and any aspect (behavior-‐performance) is part of the disability, the EE/ER must enter into TIAP www.mcdonaldlawcorp.com
Wills v. Superior Court of Orange County (2011) Bipolar disorder Employer written policy against verbal threats, threatening
conduct and violence in workplace IW threatened to add Anaheim PD employees to her “Kill Bill” list Listed employee discussed a restraining order; others perceived the list and statements as threats IW argued conduct part of disability Employer argued IW violated written policy prohibiting workplace violence and threats www.mcdonaldlawcorp.com
Wills v. Sup. Court Court held EEOC “Enforcement Guidance on the ADA and
Psychiatric Disabilities” did not prevent employer from disciplining an employee for threats or violence in the workplace ADA does not require ignoring misconduct that will endanger others, even if the misconduct is a result of disability Employer must be able to show Policy is enforced consistently Discipline of disabled employee not any more harsh than those of non-‐disabled employees www.mcdonaldlawcorp.com
Difference between Gambini and Wills Gambini did not involve threats of violence Throwing paper at supervisor and shouting
profanities were not threats of violence Hint: Document Environmental factors C0-‐worker concerns Behavioral tendencies
www.mcdonaldlawcorp.com
Tips for Avoiding Liability Have written policies and consistently apply them Centralize and focus on your decision making Have a process/system in place to track, record and
preserve all accommodations including the process of TIAP Good faith on all parties participation is mandatory TIAP may be required several times during the course of a given injury as conditions of employment change based on accepted medical conditions of employment. www.mcdonaldlawcorp.com
Par3cipate in the Process Make it simple and transparent Practice your Three C concept Follow up and follow through -‐ timelines Clearly state in the offer whether the assignment is
temporary or permanent, document all aspects of the offer as if it was a new hire on board Make an effort to find an alternative position that accommodates the restrictions without undue hardships in costs to morale www.mcdonaldlawcorp.com
Ques3ons? www.mcdonaldlawcorp.com
[email protected]
Bay Area • (925) 363-‐4380 Central Valley • (916) 201-‐2450 South Bay • (408) 315-‐5941 Los Angeles Area • (657) 333-‐0630
WE ARE PLEASED TO ANNOUNCE THE OPENING OF OUR LOS ANGELES AREA OFFICE MCDONALD LAW CORPORATION PROUDLY SERVICES ALL VENUES STATEWIDE
Ques3ons?
www.ajgrms.com Helyn_Hoff
[email protected]
Phone: (415) 288-‐1625
Justin Paquette M.D. Paquette Spine Institute
Topic: The State of cutting edge advances in spinal technologies and techniques Justin Paquette, MD specializes in cervical, thoracic and lumbar spinal disorders, minimally invasive and neuronavigation-assisted spine surgery, adult and pediatric spinal deformity, scoliosis, motion preservation technology, artificial discs and other non-fusion surgeries, endoscopic spinal surgery, spinal tumor management, spine trauma and complex spine reconstruction, peripheral nerve decompression and reconstruction, as well as non-operative spine management such as injections. Dr. Paquette’s current research projects involve stem cell technology and research, the effects of spinal fluid dynamics on the development of idiopathic scoliosis and biomechanical parameters of biological cervical plates as compared to standard anterior cervical plates. In addition, he has researched long term effects of adult deformity surgery and has written articles for several publications, including NeuroReport. He consults for several companies creating advanced technology for the use of spinal surgeries such as tools, plates, screws, instrumentation and innovative devices for the use of spine stabilization and preservation of motion. He serves as a traveling instructor for advanced surgical techniques and motion preservation technologies and has been a national speaker for current research and surgical techniques in Boston, Los Angeles, Phoenix, Las Vegas, Jamaica, orange County, Pennsylvania and San Diego. Dr. Paquette has also been interviewed for multiple medical television programs including shows on E! Entertainment and Lifetime. Dr. Paquette received his bachelors of science in biology, psychology and cognitive science from Vassar College. He received his masters in neuroscience and neurology from the Boston University School of Medicine and received his medical degree from Albany Medical College. After an internship in general surgery at Beth Israel Deaconess Medical Center at Harvard University, he completed a residency in neurosurgery at Harvard and the Tufts–New England Medical Center. He subsequently completed a comprehensive spine surgery fellowship at Cedars-Sinai Medical Center in Los Angeles. He has spent time studying advanced spinal endoscopic approaches in Phoenix, Arizona and has had additional training in pediatric scoliosis surgery at Children’s Hospital at the University of Miami and Children’s Hospital at San Diego. He currently runs a spine fellowship at Silver Lake Hospital. He currently practices in several locations from Northern to Southern California.
FRESNO
PIWC 2015
OUR LOCATIONS
A WORD FROM DR. PAQUETTE
Dr. Paquette accepts all patient referrals including private insurance, workmans’ compensation and personal injury. He provides complex neurosurgical spine care through offices in the following areas:
“The most important aspect of my professional life is an unwavering commitment to the welfare of my patients. As such I will take the time to address each patient’s problems, questions and concerns in order to devise a logical and thoughtful approach to their treatment.” - Dr. Justin D. Paquette
•
Beverly Hills
•
Pasadena
•
Downtown Los Angeles
•
Riverside
•
Fresno
•
Roseville
•
Monrovia
•
Sacramento
•
Newport Beach
•
San Bernardino
•
Orange County
•
San Diego
•
Palm Desert
•
San Fernando Valley
•
Palmdale
•
Visalia
“OPERATING WITH THE GOAL OF BEING THE LEAST INVASIVE BUT THE MOST EFFECTIVE”
TESTIMONIALS “THANK YOU DR. PAQUETTE!! To all of those perspective clients who have been searching for the “Right Surgeon,” look no further because you have found him! Dr. Paquette has given me a second chance to live a quality life again, once back on October 13, 2007 and most recently, September 17, 2010...” -M.W. “Dr. Paquette and his staff are very positive. Every time I call I am able to talk to someone right away or they return my call the same day. Knowing that I can reach Dr, Paquette or his staff and get any answers I need is important to me. Dr. Paquette
spine institute 8670 Wilshire Boulevard, Suite 206 Beverly Hills, California 90211 (855) A-Z-S-P-I-N-E (297-7743) (310) 659-2915 x 107
DON’T LET SPINE RELATED PAIN STOP YOU FROM ENJOYING LIFE
HOURS OF OPERATION Monday through Friday 8:30 AM to 5:00 PM 24 Hour Answering Service Available Through Both of the Numbers Above.
has a very positive approach with his patients.
spine institute
That positive attitude from Dr. Paquette always makes me as a patient feel good...” - L.B. www.justinpaquette.com
www.justinpaquette.com
SURGERY TECHNIQUES Dr. Paquette has extensive experience in the diagnosis and treatment of complex spinal disorders of the cervical, thoracic, lumbar, sacral and coccyx regions of the body, including the spinal cord and nerves. The following are a partial list of conditions we routinely treat. If you do not see the condition that you are looking for please contact our office or visit our website for more information. • Chiari
Malformations
• Compression • Correction
of Failed Spinal Surgeries
• Degenerative
ABOUT DR. PAQUETTE Dr. Paquette completed a triple major at Vassar College in Poughkeepsie, NY after which he spent one year in post-graduate research on primate frontal lobe function at Yale University. He holds a Master’s Degree from Boston University School of Medicine with a published thesis in the early detection and treatment of Huntington’s Disease. He attended Albany Medical College where he published works on novel drug therapies for stroke treatment. He completed his neurosurgical residency at Harvard and Tufts Medical Universities followed by a complex spine fellowship at Cedars-Sinai medical Center at Los Angeles. He has been treating patients in private practice for the past six years.
Fractures – Osteoporosis Disc Disease
SURGERY TECHNIQUES AND SPECIALTIES • Artificial
Disc and Non-Fusion Technologies
• Complex
Spinal Reconstruction
• Computer
Assisted Navigation
• Endoscopic
and Laser Assisted Surgery
• Microscopic
Approaches
• Minimally • Novel
Invasive Spinal Surgery
Approaches to Spinal Fusion
• Outpatient • Scoliosis
Spinal Surgery
and Spinal Deformity Correction
• Stem
Cell Technology in Spinal Fusion and Disc Regeneration
• Hereditary
Spinal Disorders
NON-SURGICAL TECHNOLOGIES
• Herniated
Discs Cervical, Thoracic & Lumbar
• Epidural
• Hyperhydrosis
– Sweaty Palms
• Kyphosis-Forward
Spinal Imbalance
• Median
Nerve Compression – Carpal Tunnel Syndrome
• Scoliosis • Spinal
Deformities
• Spinal
Infections
• Spinal
Stenosis
• Spinal
Trauma
• Tumors
of the Spine & Spinal Cord
• Ulnar
Never Compression – Cubital Tunnel Syndrome
• Vascular
Malformations of the Spine
spine institute www.justinpaquette.com
Lumbar
Spinal Injections – Cervical Thoracic &
• Facet
Joint Injections – Cervical Thoracic & Lumbar
• Pain
Management
• Trigger
Point Injections
WE CAN HELP RELIEVE YOUR PAIN - SO YOU CAN GET BACK TO LIVING.
CURRICULUM VITAE
Justin Paquette, M.D.
8670 Wilshire Blvd. Ste. 200 Beverly Hills, CA 90211 Tel: (310) 870-7123 Fax: (310) 652-2501 ______________________________________________________________________________________________________
EDUCATION: Undergraduate:
Bachelors of the Science in Biology/Psychology and Conjunctive Science, 1989-1993 Vassar College Poughkeepsie, NY
Graduate:
Masters of Neuroscience/Neurology, 1994-1996 Boston University School of Medicine, Boston, MA Masters Thesis: 1998 Volumetric MRI, 99 M-TC HMPAO SPECT, neuropsychologic and neurologic assessment of asymptomatic gene positive Huntington’s disease patients.
Medical School:
Doctor of Medicine, 1996-2000 Albany Medical College Albany, NY
POST GRADUATE TRAINING: Internship:
Internship, General Surgery, 2000-2001 Harvard University/Beth Israel Deaconess Medical Center Boston, MA
Residency:
Neurosurgery Residency, 2001-2005 Residency Training Program Harvard/Tufts/New England Medical Center Boston, MA
Research:
Frontal Lobe Function in Subhuman Primates, 1993-1994 Dr. Goldman-Rakic, Yale University New Haven, CT
Fellowship:
Spine Surgery Fellowship, 2005-2006 Cedars-Sinai Institute for Spinal Disorders Cedars-Sinai Medical Center Los Angeles, CA
1
2/18/2015
WORK HISTORY: August 2008-Present
Neurosurgeon Paquette Spine Institute (Private practice) 8670 Wilshire Blvd Ste 200 Beverly Hills, CA 90211
June 2005-August 2008
Neurosurgeon Cedars Sinai Institute for Spinal Disorders Los Angeles, California
CLINICAL INVESTIGATION PROTOCOLS Investigator: Comparison of interater reliability on PACS scoliosis imaging and the impact on diagnosis in operative planning. Cedars Sinai Institute for Spinal Disorders, Los Angeles, CA, 2005-present. Investigator: Comparison of biomechanical parameters of biological cervical plate as compared to standard anterior cervical plates. Cedars Sinai Institute for Spinal Disorders, Los Angeles, CA, 2005-present. Investigator: Long term outcomes in complex thoracolumbar adult deformity correction. Cedars Sinai Institute for Spinal Disorders, Los Angeles, CA 2005-present. HONORS AND AWARDS 1989 Woodstock Academy Valedictorian PUBLICATIONS: 1.
Kimelberg HK, Feustel PJ, Jin Y, Paquette J, Boulos A, Keller RW, Tranmer B: Acute treatment with tamoxifen reduces ischemic damage following middle cerebral artery occlusion. Neuroreport 11(12):2675-2679, August 2000.
ABSTRACTS: 1.
Boulos A, Rutledge E, Paquette J, Yi Qiang J, Feustel P, Kimelberg HK, Tranmer B, Popp JA: Tamoxifen excitatory amino acid release in vitro and provides neuroprotections in vivo. January 31, 1999.
2.
Boulos A, Rutledge E, Paquette J, Yi Qiang J, Feustel P, Kimelberg HK, Tranmer B, Popp JA: Tamoxifen excitatory amino acid release in vitro and provides neuroprotection in vivo. American Association of Neurological Surgeons, new Orleans, LA 1999.
3.
David CA, Riesenberger R, Zerris V, Paquette J: relationship between plasma brain natriuretic peptide and cerebral vasospasm after aneurismal subarachnoid hemorrhage. Feburay 1, 2005.
CEDARS SINAI MEDICAL CENTER TALKS 1. 2. 3. 4. 5. 6. 7.
Minimally invasive spine surgery and neuronavigation History of spinal instrumentation Case presentation of ankylosing spondilitis Current state of the art in cervical spine surgery Pathology and treatment of vertebral artery Adult Idiopathic deformity Cervical Artificial disc technology 2
2/18/2015
8. Community lectures – “treatment for neck & cervical problems” 9. Community lectures – “current treatment for low back pain” 10. Ankylosing Spondilitis Association Meeting – “current surgical treatment for complex” Grand Rounds (Cedars) 1. Vertebral Artery Surgical Pitfalls and Salvages 2. Advances in Scoliosis Treatment 3. New technology in Neuro-navigation and Spine Surgery 4. Pedicle Subtraction Osteotomies 5. Motion Preservation Technologies TRAVELING INSTRUCTOR AND SPEAKER 1. 2.
Minimally invasive transforminal interbody fusion Lumbar motion preservation technology/surgeries
MEDIA INTERVIEWS/PROGRAMS 1. 2. 3.
Lifetime Network- Leon Smith story E-Entertainment- Celebrity brushes with death Boston Globe- Neurosurgical deep brain stimulation
INVITED SPEAKER JAMAICA 1. 2.
Thoracic pedicle screws (state of the art) Advances in treatment of occipital cervical meningiomas.
PRESENTATIONS Depuy Spine – West Coast Deformity Masters Meeting 1. Current Concepts 2. Difficult Cases TRAINING Depuy Spine – Posterior Cervical Training cadaver Course, Las Vegas INTRAMURAL LECTURES AND CONFERENCES Cedars-Sinai Institute for Spinal Disorders Back Pain Conference (Community Lecture), Los Angeles, CA, August, 2005. Fifth Annual Symposium on Current Concepts in Spinal Disorders, Las Vegas , NV , February 3-4, 2006 . State of the art in minimally invasive spinal surgery Neck Pain Explained: Cedars-Sinai Institute for Spinal Disorders Neck Pain Conference February 3, 2007 Surgical Indications for Interventional Injections, Sixth Annual Symposium on Current Concepts in Spinal Disorders, Las Vegas, NV, March 1-3, 2007. Surgical Workup of Lumbar Deformity: A Case Illustration, Cedars-Sinai Institute for Spinal Disorders Ankylosing Spondylitis Conference March 17, 2007
3
2/18/2015
david parker Parker, Kern, Nard & Wenzel
Employer roundtable
Mr. Parker is an attorney and shareholder with the firm of Parker, Kern, Nard & Wenzel. He is a member of the California State Bar as well as the District of Columbia, Washington D.C. Bar. His primary areas of practice include workers’ compensation and employment defense, often advising employers on cross-over employment litigation and issues ranging from reasonable accommodation to risk management and self-insurance. He earned his B.A. degree from California State University, Fullerton and his J.D. degree from University of Pacific, McGeorge School of Law. Mr. Parker has extensive experience representing clients before the Workers’ Compensation Appeals Board from discovery through trial and appeal. He has handled the defense of wide- ranging, complex workers’ compensation litigation including catastrophic multiple-party pesticide over spray claims, asbestosis cases and workers’ compensation fraud cases. Mr. Parker is a frequently requested speaker on labor, employment and workers’ compensation issues. He is currently an instructor for the Insurance Education Association and has lectured extensively on worker’s compensation fraud to the California District Attorney’s Association, a statewide organization of prosecuting attorneys. Mr. Parker is an active member of the California Workers’ Compensation Defense Attorneys Association and a former board member of the Fresno Industrial Claims Association (acting as its legal advisor). He is also a regular contributor to the Valley Ag Safety Newsletter, a publication of Valley Agricultural Services.
FRESNO
PIWC 2015
David H. Parker
Mr. Parker is an attorney and shareholder with the firm of Parker, Kern, Nard & Wenzel. He is a member of the California State Bar as well as the District of Columbia, Washington D.C. Bar. His primary areas of practice include workers’ compensation and employment defense, often advising employers on cross-over employment litigation and issues ranging from reasonable accommodation to risk management and self-insurance. He earned his B.A. degree from California State University, Fullerton and his J.D. degree from University of Pacific, McGeorge School of Law.
Focus of Practice
General Business and Corporate Matters, Employment and Workers’ Compensation Defense
Bar Admissions California, 1991
Education
J.D., McGeorge School of Law, 1991 B.A., California State University Fullerton, 1987
Professional and Civic Involvement State Bar of California
District of Columbia, Washington D.C. United States District Court, Eastern District American Bar Association - Member 2009 Fresno County Bar Association Los Angeles County Bar Association Fresno Industrial Claims Association (FICA), Former Legal Advisor, 1997-2000 Chairman, Fresno County Bar-Client Relations Committee California State Bar Delegate - 1994 to 1997 California Workers’ Compensation Defense Attorneys Association (Chairman, Membership Committee - 1996) Staff Instructor, Insurance Education Association (IEA) 1998 - Present Board Member Valley Public Radio, KVPR, April 12, 2006 Present Phi Delta Phi Legal Fraternity Former Member, California State Bar Resolutions Committee 2003 - 2005 Valley Performing Arts Council - Former Board Member
Mr. Parker has extensive experience representing clients before the Workers’ Compensation Appeals Board from discovery through trial and appeal. He has handled the defense of wideranging, complex workers’ compensation litigation including catastrophic multiple-party pesticide over spray claims, asbestosis cases and workers’ compensation fraud cases. Mr. Parker regularly advises employers on the complexities of reasonable accommodation and modification of employment as required by State and Federal statutes. He is committed to assisting employers in implementing effective safety and risk management programs to control frequency and severity of loss in the workplace. Mr. Parker has maintained a lifelong commitment to civic involvement in addition to his legal practice. He currently serves the Fresno County Bar Association as Chairman of the client relations committee and formerly served the State Bar of California as a member of the Resolutions Committee. He currently serves the community as a Board Member of Valley Public Radio, KVPR, and formerly served as a Board Member for the Valley Performing Arts Council, a non-profit organization committed to providing local grade school students with exposure to the classical performing arts. Mr. Parker is a frequently requested speaker on labor, employment and workers' compensation issues. He is currently an instructor for the Insurance Education Association and has lectured extensively on worker's compensation fraud to the California District Attorney's Association, a statewide organization of prosecuting attorneys. Mr. Parker is an active member of the California Workers' Compensation Defense Attorneys Association and a former board member of the Fresno Industrial Claims Association (acting as its legal advisor). He is also a regular contributor to the Valley Ag Safety Newsletter, a publication of Valley Agricultural Services.
martin acree Saladino’s Food Service
Employer roundtable
Marty Acree, HR Manager for Saladino’s Foodservice. Marty began the workers’ compensation part of his career when he joined Industrial Indemnity as a Loss Control Consultant in 1986. Over nearly 30 years, he has worked for carriers, brokers and employers providing safety and claims management services. Marty holds his ARM and WCCP designations, as well as a BA from Fresno Pacific and an MBA from Columbia Southern. Marty transitioned from Safety to HR with Saladino’s, and oversees all work comp claims. Marty Acree, HR Mgr 559-271-3721
FRESNO
PIWC 2015
Jan peil M V Transportation
Employer roundtable
CA Work Comp Supervisor MV Transportation
Jan Piel supervises and manages work comp claims in California for MV Transportation, one of the nation’s largest transit and paratransit companies, for the past 8 years. In California, MV has over 60 locations and approximately 8,000 employees with an average of 450 open work comp claims every year. Jan works closely with adjusters, attorneys, doctors, vendors and location personnel to ensure claims are handled swiftly and cost effectively. She has been instrumental in instituting safety policies and procedures at MV locations nationwide. She has provided training and solutions to location management on how to handle, manage and reduce claims. Before starting with MV Transportation, Jan was a Senior Adjuster with Crawford & Company/Broadspire for over 23 years. FRESNO
PIWC 2015
larry willams Hall Management Companies
Employer roundtable
Born and raised in Fresno, CA. a graduate of Clovis West High School & an attendee of Long Beach State University. I’ve been in the Safety business for the last 20 years. Starting off with being a Kern County Fire Fighter for five years, then going back into my first love, Construction. I was the Safety & Service Manager for Williams Scotsman, Inc. in both Fresno & Bakersfield, CA. where I supervised two crews of service technicians and several outside contractors. There we refurbished modular office buildings and classrooms, which were distributed all over central California. I was there for nine years. I left there and went to Alvarado Group Services where I was an inspector for Highlands Energy Services, where I followed up on crews who had weatherized homes under the contracts of PGE & SoCal Gas. I saw the need for Safety where it had been basic and/or non-existent and with my knowledge of Safety and its demands, I was promoted to Safety Director for all five of Alvarado’s companies (2 energy weatherization, 2 commercial construction and 1 residential construction). After being there for just over two years, construction diminished and business slowed down and I was laid off as were many others at the company. I was then introduced to Agriculture Labor and Earl Hall of Hall Management Companies. I’ve been working for them now for 3 years. I am the Executive Risk & Safety Director for over 20,000 employees throughout California. I’ve now found a new love in the world of Agriculture and Safety. I’ve been able to utilize my knowledge to train Safety Supervisors in the ways of Ag Safety so that they can in turn train the massive workforce that we have day in and out. My goal is to maintain a safe workplace and keep an informed workforce of the dangers that lurk within.
FRESNO
PIWC 2015
ward scheitrum Zacky Farms
Employer roundtable
Ward Scheitrum, HR/Safety Director for Zacky Farms and Lead Faculty Area Chair (LFAC) for the University of Phoenix. Ward completed an MBA at CSU, Fresno and his DBA at Walden University. He holds the following designations; ARM, CSP, CPEA, SPHR-CA, CSMS, and CPEA. Ward has worked in Worker’s Compensation and Loss Control since 1983. He is a lead faculty instructor for University of Phoenix and teaches business (Bachelors and MBA level classes). Ward served as President for the American Society of Safety Engineers and President for the Central Valley Safety Society. Ward also served as President for the Central California SHRM and was the State Director for the California State Council of SHRM.
FRESNO
PIWC 2015
AOE/COE INVESTIGATIONS Too many questions and not enough time? Our skilled claims investigators know that you want more than just a recorded statement — you want an investigation with the right questions asked and the facts revealed. Allow the APEX Claims Team to take care of your AOE/COE investigations so that you can sit back, relax, and know that everything you need is being handled the correct way, the first time around. Standard AOE/COE investigations include: Preliminary background report
In addition to AOE/COE investigations, our Claims Team can also assist with:
In-person recorded statements
Disability management interviews
Use of bi-lingual investigators (Spanish and Korean) at no additional charge.
Doctor video showings
Rush case handling, at no additional charge
Expanded medical canvass (11 facility searches)
14-day turnaround
Medical records retrieval
Updates within 24 hours of obtaining statements
Police/accident report retrieval
Complimentary medical canvass (5 facility searches)
Verbatim transcription
Document signing with provided notary
Detailed investigation report with pertinent files attached (original documents mailed) Direct communication with investigator
888.900.2739 TOLL-FREE APEXPI.com
SURVEILLANCE INVESTIGATIONS Effective investigations start with communication and at APEX, communication never stops. Our surveillance investigators continually stay in contact with in-office and support staff to ensure that all investigative needs are met. When you allow APEX to handle your surveillance needs, you can expect that our investigators have the experience, training, and excellent communication skills necessary to conduct a superior investigation. Standard surveillance investigation services include: Preliminary background report
In addition to standard surveillance investigations, our investigators can also assist with:
Daily case updates
Activity checks
Access to CaseLink, giving you the ability to view case materials 24/7
Alive and well checks Court appearances, when needed
14-day turnaround 24-hour rush case handling, when needed GPS-tracked investigators Nationwide coverage Our commitment to quality, including clear, steady video Detailed investigation report with pertinent files attached
888.900.2739 TOLL-FREE APEXPI.com
Workers’ Compensation Defense Law firm since 1943
Hanna Brophy is Proud to Support the PIWC Work Comp World Series
Make Hanna Brophy Part of Your Team! Workers’ Comp Defense Serious & Willful Misconduct Public Employees Retirement System (CalPERS) Labor Code Section 132a Cal OSHA Defense & Litigation Workers’ Comp Subrogation Civil Insurance Defense & Litigation 15 Offices Throughout California: Bakersfield Fresno Los Angeles Oakland Orange Redding Riverside Sacramento Salinas San Diego San Francisco San Jose Santa Rosa Stockton Van Nuys
Bakersfield Office 1800 30th Street Suite 210 Bakersfield, CA 93301 t 661-397-1212
Fresno Office 1141 West Shaw Ave Suite 101 Fresno, CA 93711 t 559-435-9823
General Information: 510-839-1180 Web Referrals & Information: www.hannabrophy.com
UNMATCHED SKILL NATIONWIDE SCOPE ENDURING RELATIONSHIPS
Imber Court Reporters is large and experienced enough to handle all of your needs—and small enough to make you feel like you’re our only client. Relationships that last Because we’re court reporter owned and operated, we understand your needs inside and out. You’ll always receive extraordinary service and competitive rates—plus quality, accuracy and professionalism that are second to none.
Services that shine COURT REPORTING. Our reporters deliver a quality and service advantage you’ll notice from the very first assignment. More than 100 expert reporters statewide A national network covering every major metropolitan area Competitive pricing Scheduling online and by fax, phone or email Confirmation of all services the day before Depositions with full-size transcripts, condensed transcript/word index booklet and scanned exhibits Fast, on-time turnaround—even on expedited orders ° ° ° ° ° ° °
CONFERENCE ROOMS. We provide state-of-the-art conference rooms in our Valencia headquarters—and in dozens of premier locations up and down the state. Name the city—anywhere—and we’ll find and schedule the perfect room. VIDEO SERVICES. Our skilled video professionals use the latest digital technology. You can receive your legal video in any format—from standard DVD to video synchronized to transcript. INTERPRETING SERVICES. We work with the nation’s finest interpreting agencies to provide one-call service anywhere. Our interpreters are experienced and accredited in more than 140 languages. We’ll handle every detail and provide an interpreter that’s perfect for your assignment.
“I CAN’T IMAGINE USING ANOTHER COURT REPORTING FIRM…”
Technology that delivers IMBER OFFICE. Whenever, wherever you need case or account information, Imber Office is open for business. It’s powerful, user friendly and easy on the environment. ° Log in from your computer or mobile device. ° Get instant access to your transcripts, exhibits, calendar, orders and account information. ° Send requests, attach documents, get answers. DIGITAL TRANSCRIPTS. Our digital transcripts with secure digital signatures are efficient, easy to work with and kinder to the environment. We provide digital transcripts in a wide range of file formats, including PDF, ASCII, DOC and E-Transcript.
Let’s get started We believe long-term relationships are the foundation of lasting success. Try us and see what it’s like to have a court reporting agency that works with you as a true partner. Tell us what you need, and we’ll deliver—every time.
GET THE APP! Our Imber Office app brings the power and convenience of Imber Office to your iPhone, iPad or Android device. Download it from the App Store or Google Play.
CERTIFICATIONS
Certified Shorthand Reporter—CSR State Women’s Business Enterprise—WBE Local Small Business Enterprise—LSBE Small Business Enterprise—SBE Community Business Enterprise—CBE Very Small Business Enterprise—VSBE Central Contractor Registration—CCR
CORPORATE HEADQUARTERS Imber Court Reporters Inc. 27959 Smyth Drive Valencia, California 91355
Phone: 661.295.4678 Toll free: 800.719.3376 Fax: 661.295.4679 Web: imbercourtreporters.com
Servicing All Venues Statewide BAY AREA CONCORD OFFICE (925) 363-4380 Oakland San Francisco Santa Rosa
“Large Enough to Serve You; Small Enough to Know You” MLC specializes in Workers' Compensation Defense, Appeals and Subrogation matters, is committed to cost-effective representation and strives to provide the highest quality legal service to our clients.
SOUTH BAY SAN JOSE OFFICE (408) 315-5941 Salinas San Jose CENTRAL VALLEY SACRAMENTO OFFICE (916) 201-2450 Sacramento Stockton Redding SOUTHERN CALIFORNIA LOS ANGELES OFFICE (657) 333-0630 All venues
In today’s competitive environment, McDonald Law Corporation champions conservative fees, while maintaining our reputation for zealous advocacy, reliability and integrity.
Corporate Office – Phone: (925) 363-4380 * Fax: (925) 363-4352
WE ARE IN THE CENTRAL VALLEY 5200 N. Palm Ave., Suite 211 Fresno, CA 93704 t: 559.785.6000 f: 559.785.6001
With seven offices in California, attorneys from Michael Sullivan & Associates serves venues from Santa Rosa to San Diego. Los Angeles
Westlake Village
Inland Empire
400 Continental Blvd. Suite 250 El Segundo, CA 90245 t: 310.337.4480 f: 310.337.4486
30699 Russell Ranch Rd. Suite 200 Westlake Village, CA 91362 t: 818.338.4000 f: 818.338.4001
3602 Inland Empire Blvd. Suite C-315 Ontario, CA 91764 t: 909.694.1444 f: 909.694.1445
Orange County
San Diego
Bay Area
2100 W. Orangewood Ave. Suite 200 Orange, CA 92868 t: 714.202.3440 f: 714.202.3444
7801 Mission Center Ct. Suite 245 San Diego, CA 92108 t: 619.757.2750 f: 619.757.2755
2000 Powell St. Suite 500 Emeryville, CA 94608 t: 510.858.7777 f: 510.858.7778
sullivanattorneys.com
Why “Sullivan on Comp”? “Sullivan on Comp” is the most comprehensive treatise available on California workers’ compensation law. It is written for attorneys, claims adjusters, employers and anyone else that needs current, complete, and easily accessible information on this body of law.
9 GET CLEAR ANSWERS.
Tired of treatises that like to sound smart but don’t really answer your question? “Sullivan on Comp” is written with a deliberate emphasis on clarity.
9 GET ALL THE ANSWERS.
“Sullivan On Comp” is the most complete discussion of California workers’ compensation in existence. There is nothing else like it.
9 FIND YOUR ANSWERS.
“Sullivan On Comp” is user friendly with a separate volume for each subject.
9 BE UP TO DATE.
The subscription, in addition to annual written updates, includes access to “Sullivan on Comp” on WorkCompCentral, which is simply always up to date.
Place your order today! Call WorkCompCentral at 805.484.0333 or visit www.4ullivaO0O$PNQDPN.
J
t s u
$
Morse, Giesler, Callister, Karlin & Hiura go beneath the surface using both intuition and investigation to ensure a satisfactory outcome. We listen to our clients and provide the legal services they expect. The partners, having over 100 years of combined workers’ compensation experience, understand the importance of providing timely and proficient service to our clients. We believe it is crucial to return phone calls promptly and respond to correspondence on a timely basis. Our file handling results in the speedy resolution of files, on average within 18 months. Morse, Giesler, Callister, Karlin & Hiura has offices in Glendale, Ontario, West Los Angeles, Orange County, San Diego, Sacramento, and the Bay Area, covering all workers’ compensation Boards statewide. Attorney caseloads are carefully monitored to be sure that premium service is provided to our clients. We know the law and how to apply it.
California Workers’ Compensation Defense Firm ·Sacramento 916-568-2800 ·San Mateo 650-378-8535 ·Ontario 909-296-4200 ·Glendale 818-649-3200 -Orange 657-235-5120 ·San Diego 858-869-2669 -West Los Angeles 818-649-3200
Fall is Here "The creation of a thousand forests is in one acorn." — Ralph Waldo Emerson
• • • • • •
Complex Care & Home Health Services Durable Medical Equipment &Supplies Transportation & Language Services Air Ambulance & Medical Escort Diagnostic Imaging Services Dental & Hearing Programs 800•553•2155
www.mtiamerica.com
FRESNO (559) 449-8170 Nancy Tholen, Managing Partner Tamanee A. Armstrong Jeffry B. Diamond Leslie E. Gomes Bryce Y. Hatakeyama Joseph A. Igoa Jere E. Mealer David R. Montano Richard L. Morris Katrina R. Pickett Brock L. Roverud BAKERSFIELD (661) 328-0224 Bruce Wade, Senior Managing Partner Pamela L. Goe Andrea L. Lopez Tara H. Morse Kenneth W. Scott STOCKTON (209) 476-8491 Paula White, Senior Managing Partner Maribeth Arendt Jeremiah J. Brasher H. Nila Dhugga James N. Fischer Lawrence R. Moore Timothy C. Nelson Amy E. Olson Amber D. Price Mary Anne Violanti CHICO (530) 243-1133
[Since 1949]
Law Offices of Mullen & Filippi, LLP The Leader in Worker’s Compensation Defense Law MAIN AREAS OF PRACTICE Mullen & Filippi is proud of the legal services it provides to public and private employers, insurance carriers, and third party administrators in a variety of practice areas, including: Workers' Compensation, Employment Law, Subrogation, Third-Party Liability Defense Claims and the coordination of multi-forum litigation. WORKSHOPS Our thorough and timely workshops are valued by industry insiders throughout California - and available in your office to save time and resources.
LOS ANGELES (310) 606-8805
SEMINARS
OAKLAND (510) 444-1532
Mullen & Filippi is committed to providing relevant information to all California employers and insurers who have a vested interest in workers' compensation law. We are known throughout the state for having extensive educational seminars, held in northern and southern California, at least three times a year. These are attended by a lengthy who's who list of industry managers and specialists. We also conduct customized on-site workshops not just for clients, but for any stakeholder in the workers' compensation community.
ORANGE (714) 221-8336 REDDING (530) 243-1133 RIVERSIDE (951) 823-8858 SACRAMENTO (916) 442-4503 SAN DIEGO (619) 961-1193 SAN FRANCISCO (415) 835-7540 SAN JOSE (408) 287-3831 SANTA ROSA (707) 542-4600 VAN NUYS (818) 780-0400
WEB SITE - Visit us today at www.mulfil.com Our Web site has become an important destination for perusing current and critical information in the field. You will find plenty of articles, briefs, legal links – even a powerful compensation calculator. Mullen & Filippi – for more than 65 years, the California leader in workers’ compensation law.
DENTAL + DOCTOR
DIAGNOSTICS EQUIPMENT + DEVICES HOME HEALTH + COMPLEX CARE PHYSICAL THERAPY
TRANSPORT + TRANSLATE
A Fully Integrated Service Approach A comprehensive solution to simplify the integration of services for complex claims.
Client/Payor
PCS Nurse Case Manager
Injured Worker PCS Care Coordinator
Treating Physician
Nurse Case Manager collaborates with all parties to seamlessly execute the treatment plan
DME Home Health Diagnostic Imaging Modifications Transportation & Translation Pharmacy TOLL FREE: 866-932-5779 PRIORITYCARESOLUTIONS.COM
SIERRA VALLEY MEDICO, INC. LOCATIONS & PROVIDERS
7033 N. Fresno St Suite 201, Fresno, CA 93720 (559) 435-‐5581 2020 17th Street, Suite 2016, Bakersfield, CA 93301
(661) 322-4101 3351 “M” Street, Suite 230, Merced, CA 95348 (209) 383-4485 1400 Florida Avenue, Suite 108, Modesto, CA 95351 (209) 523-5581 300 E. Mineral King Avenue, #110, Visalia, CA 93291 (559) 734-3931 10 Harris Court St. A1, Monterey, CA 93940 (800) 800-0667 860 Oak Park Blvd. #201, Arroyo Grande, CA 93420 (805) 543-‐5581 620 California Blvd., #Q, San Luis Obispo, CA 93401 (805) 543-‐5581 1200 N. Ventura Road, Suite F, Oxnard, CA 93030 (800) 800-‐0667 8929 University Cntr Ln # 207, San Diego, CA 92122 (800) 800-0667
Harvey L. Alpern, M.D. - Internal Medicine John G. Dallas, M.D. – Orthopaedic Mark Howard, M.D – Orthopaedic Jeffrey M. Lundeen, M.D. – Orthopaedic Alice Martinson, M.D. – Orthopaedic Mohinder Nijjar, M.D. – Orthopaedic David G. Surdyka, M.D. – Orthopaedic
John-Paul Beaudoin, M.Div.,Ph.D,- Psychology Scott A. Graham, M.D. – Orthopaedic Michael G. Klassen, M.D. – Orthopaedic Craig R. MacClean, M.D. – Orthopaedic Ernest B. Miller, M.D. – Orthopaedic Lee J. Piatek, M.D. – Orthopaedic Shen Ye Wang, M.D. – Neuropathology
*** ANOTHER NEW OFFICE *** 1505 SHEPARD DRIVE SUITE 204 SANTA MARIA, CA 93454
• Lien defense from MPN Control to IBR disputes • Lien negotiation & resolution • Bill Review • Certified Expert Witness • Walk through Services Our hearing representatives are: -‐Denise Wright -‐Donna Soto
-‐Armando Sandoval
We bring over 45 years combined experience in all areas of Defense representation and look forward to working with you
[email protected]
Representing Employers in Workers’ Compensation Cases Fresno
Bakersfield
Stockton
Bishop
Oakland
Sacramento
Salinas
San Jose
San Luis Obispo
Santa Barbara
“The aggressive problem-solving tactics utilized by Yrulegui & Roberts are very effective in reducing our workers’ compensation costs. “ Chris Elliott, Claims Manager - Harris Ranch
5250 N. Palm Avenue, Suite 402 Fresno, CA 93704 (559) 222-0660 • Fax (559) 222-2880 www.rjylaw.com
Workers’ Compensation Defense Subrogation Serious & Willful Misconduct 132a Employer Defense and Cal OSHA Defense
To avoid delays on “O” Street please use alternate exits on Tulare Street or Van Ness Avenue from Highway 41 *Parking fees may vary per parking lot.
Tulare St. Exit From Hwy 41
Santa Fe Ave
City Hall
5
6
4
Premiere Event Parking
Convention Saroyan Center Theatre
3
Valdez Hall
9
N St.
Selland Arena
Double Tree Hotel Mono St.
Inyo
Tulare St.
Kern
8 Fresno St.
1
2
Chukchansi Park
L St. Van Ness Ave. From Hwy 41
Broadway St.
H St.
Capacity
Parking Management
1- Premiere Event Parking FCEC Parking Lot 2- Premiere Event Parking City of Fresno Garage 3- Double Tree Hotel Garage 4, 5 & 6- Civic Center Square Lots 7- Pavilion Parking Lot 8- Tower Garage
“O” Street
485
Fresno Convention & Entertainment Center
559.445.8100
“O” Street & Inyo Street
1500
SP+ Parking
559.264.2425
“L” Street
300
Double Tree Hotel
559.268.1000
Inyo Street
300
Civic Center
559.485.4700
“N” Street
470
ABM
559.264.5648
“L” Street
100
SP+ Parking
559.264.2425
9- Spiral Garage
Inyo Street
591
SP+ Parking
559.264.2425
Parking Operator
559.252.6464
Parking Meters
559.621.7275
Highway Exits:
Entrance
M St.
Fulton St. From Hwy 99
Parking
O St. From Hwy 41
Ventura Ave.
Capitol
7
P St.
Phone
Southbound Highway 41: Tulare Street; “O” Street; Van Ness Ave Northbound Highway 41: Van Ness Ave Southbound or Northbound Highway 99: Ventura Ave