NOTICE:

The following document is an example only. It can and should be modified for utilization in various institutions.

Purpose

The purpose of this plan is to eliminate or minimize employee exposure to surfaces, equipment, and body fluids that are potentially contaminated with bloodborne pathogens. This plan is designed to comply with 29CFR1910.1030 and will be reviewed and updated annually and as needed. The plan is available for public inspection.

Definitions

Bloodborne Pathogens--pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, Hepatitis B virus (HBV) and Human Immunodeficiency virus (HIV).

Contaminated--presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.

Contaminated Sharps--any contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broke capillary tubes, and exposed ends of dental wires. Decontamination--the use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal. Exposure--reasonably anticipated skin, eye, mucous membrane, or parenteral contact with infectious materials.

Other Potentially Infectious Material--the following human body fluids: semen, vaginal secretions, cerebrospinal fluid synovial, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids.

General Program Management

A. Responsible Persons

There are three "Categories of Responsibility" that are central to the effective implementation of the Exposure Control Plan.

• The Facility Safety Officer and Facility Safety Committee
• Supervisors
• Employees

The following section defines the role of each group in carrying out the plan. (Throughout this written plan employees with specific responsibilities are identified. The Facility Safety Officer is to be notified of any change due to promotions, new employees, or other reasons, so records may be updated.)

1. Facility Safety Officer Responsible for overall management and support of the Bloodborne Pathogens Compliance Program. Responsibilities typically include, but are not limited to:
   1. Overall responsibility for implementing the Exposure Control Plan for the entire facility including planning for the provision of staff training.
   2. Working with administrators and other employees to develop and administer any additional bloodborne pathogens-related policies and practices needed to support the effective implementation of this plan.
   3. Looking for ways to improve the Exposure Control Plan, as well as to revise and update the plan when necessary.
   4. Collecting and maintaining a suitable reference library on the Bloodborne Pathogens Standard and the bloodborne pathogens safety and health information.
   5. Knowing current legal requirements concerning bloodborne pathogens.
   6. Acting as a facility liaison during OSHA inspections.
   7. Conducting periodic audits to maintain an up-to-date Exposure Control Plan.
   The Facility Safety Committee will assist the Facility Safety Officer in carrying out the mandated duties for exposure control.
2. Supervisors
   Supervisors are responsible for exposure control in their respective areas. They work directly with the Safety Officer and the employees to ensure that proper exposure controlprocedures are followed.
3. Employees
   1. Employees have an important role in the bloodborne pathogen compliance program. Assisting in the execution of the Exposure Control Plan rests in their hands.
      Their role will be to do such things as:
      1. Identify tasks performed that have occupational exposure.
      2. Attend bloodborne pathogen training sessions.
      3. Plan and conduct all operations in accordance with the work practice controls.
      4. Develop and practice good hygiene habits.
   2. If any employee, after they have been properly trained, refuses to abide by these regulations in such a way as shall lead to the injury/illness of themselves, or someone else, that employee may be suspended from duties until the next board meeting at which time that employee will be susceptible to termination of employment at the discretion of the board, if intentional negligence is proven.
   3. If any employee, after they have been properly trained, refuses to abide by these regulations and no injury/illness results thereby, they shall be susceptible to the following disciplinary actions:
      • *First occurrence--verbal warning by their immediate supervisor with a written record of the warning signed by both and turned into the administrator’s office.
      • *Second occurrence--written warning to become a permanent part of the employee's records.
      • *Third occurrence--the employee will be immediately suspended from duties for a period of not less than two (2) days and not more than five (5) days, with a written record maintained in the employee's file.
      • * Fourth occurrence--the employee will be immediately suspended from duties until the next board meeting, at which time that employee will be susceptible to termination of employment.
   4. Availability Of The Exposure Control Plan To Employees To help with their efforts, the Exposure Control Plan is available to employees at any time in each building's administrative office. Employees are advised of this availability during their education/training sessions.
   5. Review And Update Of The Plan The Exposure Control Plan will be reviewed and updated according to the following procedures:
      • Annually.
      • Whenever new or modified information is implemented which affect occupational exposure of the employees.

   Procedures to Follow Upon the Report of Bodily Fluids Present

   1. The proper protection equipment will be used in caring for the injured party.
   2. All body fluids will be handled as potentially dangerous substances.
   3. No employees other than those designated in the site specific Exposure Control Plan is expected to perform service when blood or other potentially infectious materials are present.

   Methods of Compliance

   1. General Universal Precautions -- A general rule requires the blood, bodily fluids, and waste products to be treated as if they are infectious. In order to protect themselves, all staff members will follow universal precautions at all times while on duty:
      1. 1. Handle blood and body substance of all people as potentially infectious.
      2. Wash hands thoroughly with soap and running water before and after all person or specimen contact, even when gloves are used.
      3. Wear disposable gloves for all potential contacts with blood and body substance. Discard gloves immediately after each use.
      4. Wear a gown when splashing with blood or body substance is reasonably expected.
      5. Wear protective eyewear and mask if splattering with blood or body substance is possible.
      6. Treat all linen soiled with blood or body substance as infectious.
      7. Change gloves after each contact, as glove integrity cannot be assured with washing and repeated use.
      8. Wear a waterproof dressing and gloves if you have cuts, abrasions, or other lesions.
      9. Clean up and disinfect all spills or contamination immediately using the established procedure in part D.
      10. Discard disposable items including tampons, used bandages, and dressings in non-reusable bags, which line plastic containers, close bags, and discard daily by an appropriate disposal procedure.
      11. Use disposable or utility gloves for general cleaning.
      12. Use disposable gloves for all housekeeping chores involving potential contact with body fluids.
      13. Use protective airway mask when performing CPR.
   2. Engineering And Work Practice Controls-- All practices, equipment, and supplies will be examined, maintained, and updated as needed on a regular schedule. Information on the use of these procedures will be provided to all employees.
      1. Disposal Procedures
         1. Sharps will be placed in an approved sharps container as described in section D. The container will be placed in central double bag/box system for appropriate disposal when moderately full. Sharps will not be reused, recapped, bent, or removed.
         2. Other contaminated disposable items or bodily products will be placed in the central double bag/box system for appropriate disposal on a regular basis. Bio-hazard disposal bags/boxes will be used.
         3. All central bags/boxes used for disposal will be color coded and marked with the appropriate bio-hazard symbol. Collection points will be in areas not generally accessible to all building occupants.
      2. Handwashing Facilities
         1. Each site at which exposure can reasonably be expected will have hand washing facilities with soap and running water within easy access.
         2. Antiseptic towelettes/alcohol gel will be available at each site where a slight potential for contamination exists without hand washing facilities, as well as disinfectant, gloves, first aid supplies, etc.
         3. Signs will be posted to remind employees to wash after each procedure whether gloved or not.
      3. Clean Up Kits For Removing Blood and Bodily Fluids For contamination with larger amounts of bodily fluids such as vomitus, blood, etc., kits will be provided for clean up by designated trained personnel. Training will be provided in the use of kits to custodians and any other personnel designated as responsible for clean up. Other personnel will be instructed not to clean up any blood or body fluids unless designated as part of this plan.
      4. Eating And Food Storage In Areas Where Contamination Exists No eating, drinking, cosmetics application, food storage, etc., will be allowed in areas where contamination or contaminated fluids are present. Additionally, no food will be stored in refrigerators also containing contaminated products.
      5. Marking Of Areas With Contaminated Products All areas and containers with contaminated products will be marked by labels, colors, and signs as described in part VII, Communication Of Hazard.
   3. Personal Protective Equipment
      1. The plan requires all personnel to use gloves when handling any potentially infectious materials, objects, or surfaces.
      2. All staff herein identified as at risk of exposure is provided ample supplies of gloves at no cost to the employee.
      3. Hypoallergenic gloves or liners are available upon request.
      4. Contaminated laundry and clothing will be cleaned either on site (procedures described in part D) or will be double bagged in marked containers and sent out for professional cleaning.
      5. Roll paper and disposable pillowcases impervious to fluid will be used to cover furniture that would not be easily disinfected in areas with high potential for exposure.
   4. Housekeeping--Cleaning after contamination with blood or body fluids
      1. General
         1. All employees must wear disposable gloves and proper protection equipment prior to making any contact with blood or body fluids. This includes, but is not limited to, care and first aid treatment of a person as well as cleaning procedures for objects contaminated with body fluids.
         2. Use only disposable items provided.
         3. Discard disposable articles from each contact or clean up into plastic trash bags that are marked for placement into the biomedical waste bags.
      2. Handwashing
         1. Use soap and running water. Soap helps remove dirt and bacteria.
         2. Rub hands together for fifteen (15) seconds to work up a lather.
         3. Scrub between fingers, knuckles, back of hands, and around nails.
         4. Rinse hands under running water.
         5. Dry hands with paper towel.
         6. Use paper towel to turn off water, then discard in trash. (If you are in an area where water is not available, use the antiseptic towelettes or alcohol gel that are available until you get to running water.)
      3. Floors and all washable surfaces. Use clean up kits. Follow kit instructions. There are some variations in brands but basic principles and steps are the same.
         1. Put on disposable gloves and proper protection equipment.
         2. Cover the fluid (vomitus, blood, or other body fluid) with the absorbent powder. This will absorb 80-90 times its own weight. Allow it to congeal. Pick up the congealed waste matter with the cardboard scoops and put into plastic bag. Put scoops into the bag.
         3. Apply appropriate disinfectant solution evenly over the spill area. Do not spray.
         4. Wipe disinfectant from the spill area with the absorbent towel and place towel and empty bottles into the biohazard bag.
         5. Remove gloves and place into the plastic bag.
         6. Use antiseptic towelette/alcohol gel and wash hands. Place towelette into biohazard bag. Apply gloves.
         7. Wet the area with an appropriate disinfectant and allow to air dry.
         8. If apron is used, fold together so outside is rolled together.
         9. Twist tie around bag and place into biohazard waste bag. Remove gloves and discard in biohazard container.
         10. Wash hands with soap and running water.
      4. For carpet and upholstery
         1. Put on disposable gloves and proper protective equipment. Cover the spot with the absorbent powder and allow time to gel.
         2. Use scoops to pick up congealed material.
         3. Spray the affected area wet with an appropriate disinfectant and allow to stand for 10 minutes.
         4. Use a carpet extractor, filled with an appropriate disinfectant cleaner, to extract the spot and the surrounding area. Allow to stand for 10 minutes.
         5. Spray the affected area with clean water and extract only. Clean the equipment following the BBP Standard and store for next use.
         6. Remove gloves and place in proper bag with congealed material and scoops.
         7. Use towelette/alcohol gel to clean hands and place in plastic bag. Apply gloves.
         8. Tie off bag and place in bio-medical waste bag. Remove gloves.
         9. Wash hands with soap and running water.
      5. Laundry: for towels, crib sheets, cot covers, washcloths, and other washable materials.
         1. Wear disposable gloves and gowns while handling. Rinse items under cold running water.
         2. Place in appropriate plastic bag that can be sealed until it can be put into the washer.
         3. Spray sink with an appropriate disinfectant.
         4. Remove gloves and place into plastic bag.
         5. Wash hands with towelette/alcohol gel and place in plastic bag. Apply gloves. Put bag in bio-medical waste. Remove gloves.
         6. Wash hands.
         7. Wear gloves and any other appropriate personal protective equipment when handling laundry to place into washer.
         8. Follow manufacturer's instructions for laundry detergent.
      6. For washable surfaces such as walls, changing tables, counter tops, desks, etc.:
         1. Apply disposable gloves.
         2. Use clean-up kit if large amounts of fluid need to be congealed.
         3. Follow kit instructions if it is needed.
         4. For small amounts of fluid that need to be cleaned, absorb with a dry towel and place into biohazard bag.
         5. Apply the appropriate disinfectant to the contaminated surface. Wipe the contaminated area with a paper towel. Place the towel in the proper waste bag. Wet the contaminated surface with the proper disinfectant and allow to air dry.
         6. Remove gloves and place into plastic bag.
         7. Use towelette/alcohol gel to clean hands.
         8. Place towlette into plastic bag and apply gloves. Tie off bag.
         9. Discard bag into bio-medical waste bag. Remove gloves and place in biohazard container.
         10. Wash hands with soap and running water.
      7. Small amount of blood on floors in shop areas, etc. may be washed down the floor drain and followed by wetting with an appropriate disinfectant.
      8. Cleaning schedule
         1. Areas in which regular contamination may be expected will be cleaned daily as well as after each known contamination. Cleaning schedule forms will be provided in each of these areas (See Appendix).
         2. All other areas will be cleaned following each known contamination.
      9. Broken glassware
         1. Sweep up all broken glass with broom and dust pan.
         2. Do not pick up any broken glassware with fingers with or without gloves.
         3. If contaminated, dispose of as sharps with appropriate procedure.
         4. If contaminated, disinfect dustpan and broom.
      10. Reusable sharps (medical devices/instruments)
          1. Contaminated, reusable sharps will be decontaminated as soon as possible, according to facility policies and procedures.
      11. Disposable contaminated sharps
          1. Contaminated sharps will be discarded immediately at the site of use in containers that are close-able, puncture resistant, leak proof, and labeled as to use. Secondary containers will be used if initial container is damaged.
          2. Sharps containers will be placed so they are easily accessible to the area of use.
          3. Regular inspections will be scheduled to assure replacement of containers before they are overfull.
      12. Other regulated wastes will be disposed of as described earlier in Disposal Procedures.

   Hepatitis B Vaccine, Post Exposure Reporting, Evaluation and Follow-up

   1. Hepatitis B vaccine will be made available at no cost to all employees in primary jobs within ten days of assignment. Employees, after Bloodborne Pathogen training, will be given a full description of the vaccination series and side effect. They will sign a consent/refusal form (See Appendix). Those consenting will be scheduled and given time off for the vaccination series. Records of the vaccination will be maintained. Appropriate follow up boosters will be scheduled as medically prescribed.
   2. Post Exposure Reporting, Evaluation, And Follow-Up - all employees, whether under the plan or not, are required to report to their supervisor immediately ALL exposures to bodily fluids using Communicable Disease Risk Exposure Report (See Appendix). All reports will be held as confidential. All exposed employees, both under and not under the plan, will receive full follow up.
      1. Follow up to a report of exposure
         1. An exposed employee will be immediately referred to the designated facility healthcare professional for confidential medical evaluation and follow up. The physician will be provide a copy of this plan.
         2. The healthcare professional will inform the employee and, within five (5) days, the facility whether the incident is defined as an exposure under the standard.
         3. If the incident is not defined as an exposure, the employee will be counseled and no further action will be taken. The reporting form with the physician's determination will be placed in the employee's supplemental file.
         4. If there is a defined exposure, the physician will immediately provide follow up activities at no cost to the employee including:
            1. Documentation of the circumstances and routes of exposure.
            2. Identification and documentation of the source individual.
            3. Collection and testing of the source individual's blood with consent, or
            4. Establishment that legally required consent cannot be obtained.
            5. Make available results of these test to the employee.
            6. Testing of the employee's blood per U. S. Public Health Services protocol including immediate, 3-month, 6-month, and 1-year tests.
            7. With employee permission, immediately begin the Hepatitis B vaccination series and within twenty-four (24) hours administer the HBIG inoculation.
            8. Post-exposure prevention treatment and evaluation of reported illnesses.
            9. Appropriate counseling as determined by the healthcare professional.
            10. Any other activities deemed appropriate by the physician.
         5. With the exception of initial determination, no reports will be made by the physician to the facility. The physician will maintain records for the appropriate time. Refer to medical records.
   3. Information And Training
      1. All employees designated as part of this plan will be given complete training at the time of initial assignment and annually thereafter. Training records will be kept for three years.
      2. Training will include:
         1. A copy of the Bloodborne Pathogens Standard.
         2. Epidemiology and symptoms of bloodborne pathogens.
         3. Modes of transmission of bloodborne pathogens.
         4. Our facility's Exposure Control Plan and where employees can obtain a copy.
         5. Appropriate methods for recognizing tasks and other activities that may involve blood and other potentially infectious materials.
         6. A review of the use and limitations of methods that will prevent or reduce exposure, including:
            1. Engineering controls.
            2. Work practice controls.
            3. Personal protective equipment.
         7. Selection and use of personal protective equipment including:
            1. Types available.
            2. Proper use.
            3. Location within the facility.
            4. Removal.
            5. Handling.
            6. Decontamination.
            7. Disposal.
         8. Visual warnings of biohazards within the facility including:
            1. Labels.
            2. Signs.
            3. "Color-coded" containers.
         9. Information on the Hepatitis B vaccine, including its:
            1. Efficacy.
            2. Safety.
            3. Method of administration.
            4. Benefits.
            5. Facility's free vaccination program.
         10. Consent form for Hepatitis B vaccine.
         11. Actions to take and persons to contact in an emergency involving blood or other potentially infectious materials.
         12. The procedures to follow if an exposure incident occurs, including incident reporting.
         13. Information on the post-exposure evaluation and follow up, including medical consultation, that the facility will provide.
         14. Time to answer specific questions/concerns of attendees.
      3. All employees not a part of this plan will be given training in avoiding contamination.
      4. All training will be given at no cost and during work hours.
      5. Should regulations, procedures, or potential for hazard change, update training will be provided.

   RECORDKEEPING

   1. Medical Records
      1. Records concerning Bloodborne Pathogen exposure and follow up will be kept in the personnel office in the employee's confidential supplemental personnel folder. Records will be kept for thirty (30) years following end of employment in accordance with 29CFR 1910.20.
      2. Exposure records include:
         1. Name and social security number.
         2. Copy of employee's Hepatitis B vaccination status and record including dates.
         3. Copy of the results of the follow up examination.
         4. The healthcare professional's written opinion.
         5. A copy of the information provided to the healthcare professional.
      3. All records will be strictly confidential. Only the physician, Facility Safety Officer, appropriate personnel staff member, and those listed in 29CFR 1910.20 will have access to records.
   2. Training Records
      1. Training records will be maintained for at least three (3) years from the training session.
      2. Records will include:
         1. Date of training session.
         2. Contents of the session.
         3. Names and job description of persons attending.
         4. Names and qualifications of trainer(s).
   3. Availability -- Records are available to:
      1. The Facility Safety Officer
      2. Appropriate personnel staff
      3. Appropriate healthcare professionals
      4. Those identified in 29CFR 1910.20
      5. The employee upon request
      6. Anyone with written consent from the employee
   4. Form 200 Reporting -- Actual exposure will be reported on Form 200 if the:
      1. Incident results in loss of consciousness, transfer to another job, or restriction on work
      2. Medical treatment beyond first aid is given
   5. Transfer Of Records
      1. If the employer ceases to do business, records will be passed to its successor.
      2. If there is no successor, the Director of the National Institute for OSHA will be notified three (3) months prior to disposal. At the Director's request, they will be transmitted to the Director's office within three months.

           

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