Bloodborne Pathogens Exposure Control Plan s1

Bloodborne Pathogens Exposure Control Plan Office of Environmental Health & Safety Iler 106 201 High Street Farmville, VA 23909 434.395.2940

Revised: February 2014 Standard Operating Guideline # SG-4

Bloodborne Pathogens Exposure Control Plan: Table of Contents Section Page I. Introduction……………………………………………………………………. 2 II. Responsibilities……………………………………………………………...... 2 III. Exposure Determination………………………………………………………. 2 IV. Methods of Implementation and Control……………………………………. 3 a. Universal Precautions…………………………………………………….. 3 b. Engineering Controls and Work Practices……………………………… 3 c. Personal Protection Equipment (PPE)…………………………………… 4 V. Sanitation………………………………………………………………………. 6 VI. Sharps & Regulated Waste Management…………………………………… 7 VII. Hepatitis B Vaccine & Post-Exposure Evaluation and Follow-up…………. 8 VIII. Warning Labels and Signs……………………………………………………. 10 IX. Employee Information and Training…………………………………………. 11 X. Recordkeeping…………………………………………………………………. 12 XI. Plan Review…………………………………………………………………….. 13 XII. Document History……………………………………………………………… 14 XIII. Appendices/Form A. Category 1 – Job Classification expected to incur occupational exposure 15 B. Category 2 - Job classification that may incur occupational exposure…….. 16 C. Sharps Injury Log………………………………………………………………. 17 D. Hepatitis B Vaccine Form………………………………………………………. 18 E. Employee Safety Recommendation Form……………………………………... 19

Version – February 2014 Page 2 I. Introduction:

The following written Bloodborne Pathogens Exposure Control Plan (the Plan) establishes the requirements and procedures necessary to eliminate or minimize employee occupational exposure to pathogenic microorganisms and other infectious materials. The exposure control procedures herein have been developed and implemented to ensure that faculty and staff personnel are knowledgeable of the disease causing pathogens potentially present in human blood (e.g., HBV and HIV) and the specific measures to prevent or limit that exposure.

This Plan is designed and implemented to ensure conformance with the requirements of 29 CFR Part 1910.1030 and to act as a quick reference guide to assist employees conducting first aid and related emergency response or health care activities. A copy of the Plan is available for review during new employee orientation and by any employee during normal working hours in the following locations:

• Office of Environmental Health and Safety • Office of the Director of Facilities Management • Human Resources Department

II. Responsibilities:

Affected Longwood University employees are required to comply with the bloodborne pathogens exposure control procedures and practices contained in this Plan. All duties or activities involving the potential for exposure to blood or other potentially infectious substances must be conducted in complete accord with the requirements and limitations outlined within the Plan.

Violation of any Safety Rule is actionable under the Department of Personnel and Training General Policy 1.60, entitled “Standards of Conduct”.

III. Exposure Determination:

A review of Longwood University personnel duties and responsibilities was conducted in August 2003 to identify those employees that may incur occupational exposure (e.g., specific eye, mouth or other mucous membrane, non-intact skin, or parenteral contact) to blood or other potentially infectious materials (e.g., semen, vaginal secretions, cerebrospinal fluid, amniotic fluid, unidentified body fluid, unfixed human tissue or organ, etc.). The exposure evaluation was conducted without regard to the use of personal protective equipment.

The table contained in Appendix A outlines those employees that may be expected to incur an occupational exposure.

Version – February 2014 Page 3 The table contained in Appendix B outlines those job classifications in which some employees may incur an occupational exposure and their job task and duties.

Note: Part-time, temporary, contract, and per diem employees are covered by the bloodborne pathogens standard.

IV. Methods of Implementation and Control

a) Universal Precautions

Universal precautions shall be observed at all times when the potential for contact with blood or other potentially infectious materials exists. All blood shall be considered infectious regardless of the perceived status of the source individual.

b) Engineering and Work Practice Controls

The following engineering and work practice controls shall be used as a first line of defense to prevent or minimize employee exposure to blood or other potentially infectious materials:

Engineering and Work Practice Controls 1. Needles and other contaminated sharps shall not be bent, recapped or removed and must be placed in a puncture resistant, color-coded/labeled and leak-proof container immediately or as soon as possible after use. 2. Re-usable sharps that are contaminated with blood other potentially infectious substances may not be stored or discarded in a manner that requires the placement of a hand into the containers where they have been placed. 3. Procedures involving the blood or other potentially infectious substances shall be performed in a manner that minimizes splashing, spraying, spattering and the generation of droplets of the substance. 4. Mouth pipetting or suctioning of blood or other potentially infectious substances is strictly prohibited. 5. Specimens of blood or other potentially infectious substances shall be placed in color-coded/ labeled and leak-proof containers for collection, handling, storage, transport and shipment. 6. Broken glassware that may be contaminated with blood or other potentially infectious substances must always be picked up by a mechanical means (e.g., brush, dust pan, tongs, forceps, etc.). 7. Employees must always wash their hands with an antiseptic cleanser immediately after, or as soon as the event allows, removing gloves or other personal protective equipment or any contact with blood or other potentially infectious substances (hand-washing facilities are located throughout the

Version – February 2014 Page 4 campus and antiseptic hand cleansers are maintained with exposure control PPE). 8. Eating, drinking, smoking, applying cosmetics or lip balm or handling of contact lenses is prohibited in areas where there is reasonable likelihood of exposure to blood or other potentially infectious substances. 9. Food or beverages are not to be kept in refrigerators, freezers, shelves or cabinets, or on counter or bench tops, where blood or other potentially infectious substances are present.

Employee implementation and/or adherence to each of the above engineering or work control practices shall be verified via a documented regular inspection of Longwood University first aid or health care facilities and operations, where feasible, conducted by the Environmental Health and Safety Officer.

c) Personal Protective Equipment (PPE)

Where engineering and work control practices fail to eliminate the potential for occupational exposure to blood or other potentially infectious materials, Longwood University employees shall utilize PPE to abate the remaining hazards.

PPE Selection & Use

PPE shall be selected based upon the anticipated means or method of exposure and will be considered appropriate only if it does not allow blood or other potentially infectious substances to pass through or reach the employees’ clothing or result in exposure under normal conditions and duration of use.

Version – February 2014 Page 5 The following table outlines specific types of potential exposure events and the corresponding PPE necessary to eliminate or minimize the exposure hazard:

Exposure Hazard PPE When Use Required 1. Whenever it is reasonably anticipated that hand contact with blood, non- intact skin or organs, mucous membranes, or Disposable physician’s During all general first aid or other potentially infectious examination / surgical or health care assistance materials will occur. general use utility gloves activities 2. When performing vascular access procedures or handling or touching contaminated items or surfaces. 1. Whenever it is reasonably anticipated that face, eye, nose, or mouth contact During all first aid or health Goggles, safety glasses w/ with splashes, spray, care assistance activities side shields and/or chin- splatter, or droplets of involving free-bleeding or length face shield blood or other potentially body fluids expulsion infectious materials will occur 2. Whenever it is reasonably anticipated gross During all first aid or health contamination of body or care assistance activities cloths with blood or other Gown or Apron involving severed arteries, potentially infectious severe lacerations or materials will occur (e.g., amputations autopsies, surgery, amputations, etc.)

NOTE: An exception to the mandatory use of PPE exists whenever it can be verified by a member of management that an employee temporarily and briefly declined to use PPE under rare and extraordinary circumstances in which was the employee’s professional judgment that its use in the specific instance would have prevented the delivery of health care or posed an increased hazard to the safety of the worker or co-worker.

Version – February 2014 Page 6 PPE Availability

All required PPE shall be provided at no cost to affected Longwood University employees and may be obtained from the Departmental Supervisor.

Sufficient sizes and quantity of the above listed PPE shall be maintained in the affected departments at all times to outfit each employee that may be expected to incur an occupational exposure while performing their assigned duties or responsibilities. Hypoallergenic gloves, glove liners, powderless gloves, or other similar alternatives shall be readily accessible to those employees who are allergic to the gloves normally provided.

The Environmental Health and Safety Officer shall inspect on a periodic basis the PPE inventory at each of the indicated storage locations and shall ensure correction, within 72-hours, of any deficiencies noted in the style, size, or quantity of PPE available.

PPE Cleaning, Laundering and Disposal

All re-usable PPE shall be cleaned and laundered, as well as repaired or replaced when discovered to be defective, at no cost to affected Longwood University employees.

All garments that become saturated and/or penetrated by blood or other potentially infectious substances must be removed immediately, or as soon as the incident allows, and prior to leaving the immediate work or incident location. This procedure should be done in such a way as to avoid contact with the outer surface.

All removed PPE shall be immediately, or as soon as the incident allows, placed into proper containers, sealed and relocated to a designated location for storage prior to laundering, decontamination, or disposal.

NOTES: 1) Disposable examination or surgical gloves are not to be decontaminated for re-use and must be discarded after each use event. 2) Reusable utility gloves may be decontaminated for re-use if their integrity is not compromised (e.g., cracked, peeling, torn, punctured or showing other signs of deterioration or inability to function as a barrier).

V. Sanitation

All work or general area surfaces shall be immediately, or as soon as the event allows, decontaminated after completion of procedures or the spill of blood or other potentially infectious substances. Contaminated surfaces shall also be decontaminated at the end of the work shift if the surfaces may have become contaminated since the last cleaning.

Version – February 2014 Page 7 All bins, pails, cans, boxes, or other containers utilized to store blood, other potentially infectious substances, or regulated medical wastes shall be inspected on a regularly scheduled basis by the Environmental Health and Safety Officer for the presence of exterior contamination. Any container observed with exterior blood or other potentially infectious substances shall be immediately decontaminated and over-packed if damaged or leaking.

The Director of Student Health shall ensure that any equipment in the Student Health and Wellness Center that is possibly contaminated with blood or other potentially infectious substances is examined, prior to servicing or off-site shipment, and that all suspect equipment is decontaminated as necessary, unless decontamination is not physically possible. The Environmental Health and Safety Officer will perform this duty in all other areas beyond the Student Health and Wellness Center.

Decontamination of surfaces or equipment shall be achieved via the use of an EPA-registered germicide or bleach and water mixture (1 part bleach to 10 parts water) and a brush, sponge, or sanitary cloths or wipes. Decontamination supplies shall be maintained in each of the locations utilized to house exposure control PPE. The Environmental Health and Safety Officer shall inspect the decontamination supply inventory on a regular basis and ensure correction of any observed decontamination supply deficiencies within 72-hours of the inspection.

VI. Sharps & Regulated Waste Management

a) Sharps

Contaminated needles and other contaminated sharps (e.g., broken glass) may not be purposely broken or sheared and must be placed in designated sharps containers maintained at each of the locations utilized to house exposure control PPE.

Re-capping, bending, or removal of contaminated needles may take place only when required by a medical procedure or no alternative is feasible. If this action is deemed necessary, it must first be approved by a member of Longwood University management and then be conducted by the use of a mechanical device or a one-handed technique. Currently there are no known circumstances or first aid delivery practices existing at Longwood University requiring the bending, re-capping or removal of contaminated needles or other contaminated sharps.

Immediately upon use, or as soon as feasible, contaminated disposable needles and other sharps shall be placed in a closeable, puncture resistant, labeled / color-coded and leak-proof container for storage prior to scheduled off-site shipment for disposal. During use and while in storage, all sharps containers will be maintained in an upright position and not allowed to overfill. Immediately prior to movement or transport, sharps containers shall be closed to prevent spillage or protrusion.

Version – February 2014 Page 8 The Environmental Health and Safety Officer shall inspect all locations where contaminated disposable needles and sharps containers are housed on a regular basis. Any observed leakage will be addressed by the Environmental Health and Safety Officer within 4-hours of the inspection by placing the container in a closeable, labeled / color-coded, leak-proof secondary container capable of holding the entire contents of the original.

b) Regulated Waste

Liquid or semi-solid blood or other potentially infectious materials, including items that could release blood or other potentially infectious substances or that are caked with dried blood (e.g., bandages, wipes or gauze pads), must be placed immediately, or as soon as feasible, in a closeable, labeled / color-coded and leak-proof container for storage prior to scheduled off-site shipment for disposal. Immediately prior to movement or transport, regulated medical waste containers shall be closed to prevent spillage or protrusion.

VII. Hepatitis B Vaccine & Post-Exposure Evaluation and Follow-Up

Longwood University shall make the hepatitis B vaccine and vaccination series available to all employees who have occupational exposure, as well as provide a post-exposure evaluation to all employees who have had an exposure incident.

Human Resources shall ensure that the above medical evaluations and procedures are made available to affected employees at no cost, at a reasonable time and place, and are conducted by or under the supervision of a licensed physician or other licensed health care professional.

a) Hepatitis B Vaccination

The hepatitis B vaccination shall be made available to an affected employee upon receipt of occupational exposure training and within 10 working days of initial assignment to a job classification identified to have occupational exposure to blood or other potentially infectious substances.

NOTES: 1) The hepatitis B vaccination will not be made available to affected employees when it can be documented that the employee has already received the complete hepatitis B vaccination series, if antibody testing has revealed that the employee is immune, or the vaccine is contraindicated for medical reasons. 2) Affected employee participation in a pre-screening program will not be a prerequisite for receiving the hepatitis B vaccination.

Longwood University has selected a doctor to provide the hepatitis B vaccination to all affected employees.

Version – February 2014 Page 9 If an affected employee initially declines the hepatitis B vaccination but at a later date (while still covered by the standard) decides to accept the vaccination, it will then be made available within 10 working days of request. All affected employees who initially decline the hepatitis B vaccination shall be required to sign a waiver indicating their refusal. (See Appendix C for hepatitis B vaccination waiver form.)

In the event that a licensed physician or other licensed health care professional recommends a booster dose of hepatitis B vaccine for an affected employee, it shall be provided within 10 working days of written receipt of the recommendation.

b) Post-Exposure Evaluation and Follow-Up

All Longwood University employees that have incurred an exposure incident shall be offered post-exposure evaluation and follow-up at no cost.

All blood or other potentially infectious substances exposure incidents must be immediately, or as soon as the incident allows, reported to the Environmental Health and Safety Officer for documentation and investigation.

Following notification of an exposure event, the exposed employee must immediately, or as soon as scheduling permits, receive a confidential medical evaluation and follow-up that includes the following elements:

• Documentation of the route of exposure and circumstances under which the exposure incident occurred; • Identification and documentation of the source individual; and • Collection and testing of a sample of the exposed employee’s and source individual’s blood as soon as feasible, upon consent receipt, to determine bloodborne pathogens infectivity.

NOTES: 1) When documentation indicates that the source individual is infected with HBV or HIV, blood testing for that individual’s known HBV or HIV status is not required. 2) If an exposed employee declines the option of blood collection and testing to determine HBV and HIV serological status, a sample shall still be collected as soon as possible and preserved for 90 days to allow the employee to determine if it should be tested for infectivity status.

Results of the source individual’s testing or infectivity status shall be made available to the exposed employee, along with information regarding the laws and regulations concerning disclosure of the identity and infectious status of the source individual.

Longwood University has selected a doctor to provide post-exposure evaluation and follow-up to affected employees. Human Resources shall provide the following information to the Version – February 2014 Page 10 licensed physician or other licensed health care professional conducting the hepatitis B vaccination or post-exposure evaluation:

• A copy of 29 CFR 1910.1030; • A written description of the exposed employee’s duties as they relate to the exposure incident; • Written documentation of the routes of exposure and circumstances under which the exposure occurred; • Results of the source individual’s blood testing (if available); and • All medicals records relevant to the appropriate treatment of the employee, including vaccination status.

Human Resources shall obtain a written copy of the evaluating licensed physician’s or other licensed health care professional’s written opinion within 15 days of completion of the evaluation.

The licensed physician’s or other licensed health care professional’s written opinion for HBV vaccination and post-exposure follow-up will be limited to the following information:

• Whether vaccination is indicated for the exposed employee and whether the employee has received the vaccination; • A statement that the employee has been informed of the results of the evaluation; and • A statement that the employee has been advised about any medical conditions resulting from exposure to blood or other potentially infectious substances that require further evaluation and/or treatment.

VIII. Warning Labels and Signs

The Environmental Health and Safety Officer shall ensure that biohazard labels are utilized in the following instances or circumstances:

• On all refrigerators and freezers containing blood or other infectious substances; and • When color-coded red bags or red containers are not utilized for the storage, transport of shipment of blood, other potentially infectious substances or regulated waste.

NOTE: Containers of blood, blood components or blood products that are labeled as to their contents and have been released for transfusion or other clinical use are exempted from the labeling requirement.

Required labeling must be fluorescent orange or orange-red and include the universal biohazard symbol and the legend BIOHAZARD. In the case of regulated medical waste, the words BIOHAZARDOUS WASTE may be substituted for the BIOHAZARD legend.

Version – February 2014 Page 11 IX. Employee Information and Training

Prior to assuming a position where occupational exposure to blood or other potentially infectious materials may be expected, new or transfer employees of Longwood University shall attend a bloodborne pathogens exposure training session. The Environmental Health and Safety Officer is responsible for organizing and ensuring that the stated training is conducted. The training will consist of one (1) session lasting approximately forty-five (45) minutes.

The format for the initial training program will be:

• Classroom instruction (20 minutes) • Audiovisual (10 minutes) • Comprehension quiz (15 minutes)

The following items shall be covered:

• Review of 29 CFR 1910.30 and the location where it may be accessed; • Review of Longwood University’s Bloodborne Pathogens Exposure Control Plan; • Identification and discussion of pathogenic microorganisms; • Identification of tasks that may involve exposure; • Review of engineering and work practice controls, to include sanitation; • Identification of required PPE and its selection, use, location, removal, handling and decontaminations requirements; • Discussion of hepatitis B vaccination, to include availability and effectiveness; • Review of exposure reporting and post-exposure and follow-up procedures; • Explanation of warning labels and signs, to include color-coded containers; and • Review of employee training requirements.

When there is a change in an employee’s job assignment or duties that affect their potential for occupational exposure to blood or other potentially infectious substances, the Environmental Health and Safety Officer, upon notification by a Department Supervisor or the Human Resources Department, will organize and ensure that update bloodborne pathogens exposure training is provided for the affected employee. The Environmental Health and Safety Officer is responsible for organizing and ensuring that bloodborne pathogens exposure refresher training is conducted annually for all affected Longwood University employees.

Following each initial, update or refresher training session, all attending employees will be required to sign and date a training attendance record.

Version – February 2014 Page 12 X. Recordkeeping

The Environmental Health and Safety Officer shall ensure that all records required under the Bloodborne Pathogens standard are maintained in their designated locations and in their entirety.

a) Medical Records

All medical records related to occupational exposure to blood or other potentially infectious substances for affected employees shall be maintained in the Human Resources Department, via the employee’s personnel file, for their period of employment, plus 30 years.

All medical records shall be maintained in a confidential manner and will not be disclosed without the written approval of the affected employee. The following information shall be included:

• Employee’s name and social security number; • A copy of the employee’s HBV vaccination status, including dates of vaccination and ability to receive vaccination; • A copy of all examination results, medical testing and follow-up procedures; • A copy of information provided to the health care professional, including a description of the employee’s duties that relate to the exposure incident, and documentation of the routes of exposure and circumstances of exposure; and • A confidential copy of the health care professional’s written opinion.

b) Training Records

All affected employee Bloodborne Pathogens Exposure Control Plan information and training records shall be maintained in the Environmental Health and Safety Office for a period of 3 years from the date of the training.

Employee information and training records shall include the following:

• Date of the training session; • An outline of the material presented; • Names and qualifications of the presenters; and • Names and job titles of all employees attending the training session.

Version – February 2014 Page 13 c) Records Availability

Each affected employee’s medical and training records shall be made available for review and/or copying within 15 working days of receipt of written access request.

d) Transfer of Records

Should the facility be closed or cease operations, the Environmental Health and Safety Officer shall notify the Director of the National Institute of Occupational Safety and Health (NIOSH) at least 3 months prior of the event and submit all records to the Director if so requested.

e) Sharps Injury Log

For cases that involve percutaneous injury from contaminated sharps, the Human Resource Department is responsible for maintaining a Sharps Injury Log. Information shall be entered on the log as to protect the confidentiality of the injured employee. At a minimum, log entries shall document the following:

• Date of Injury • Type and brand of the device involved (syringe, needle) • Department or work area where the incident occurred • Explanation of how the incident occurred

This log is reviewed as part of the annual program evaluation and maintained for at least five years following the end of the calendar year covered. If a copy is requested by anyone, it must have any personal identifiers removed from the report.

XI. Plan Review

The Environmental Health and Safety Officer shall review the written Bloodborne Pathogens Exposure Control Plan for Longwood University annually and modify the plan, or provide additional employee training, if deficiencies in compliance with the standard or plan procedures are identified.

Both front-line workers and management officials will evaluate new products and new procedures, identify any need for changes in engineering controls and work practices, and provide a proactive engagement with the EHS Officer throughout the year by completing an Employee Safety Recommendation Form whenever a change can eliminate or reduce exposures to bloodborne pathogens.

Version – February 2014 Page 14 XII. Document History

Version Date Comments July 2003 07/28/2003 Initial BBP Exposure Plan February 2014 02/15/2014 Reviewed and Updated Plan

Version – February 2014 Page 15 Appendix A – Category 1 – Job Classification Expected to Incur Occupational Exposure

At Longwood University, the following job classifications have occupational exposure to blood or other possibly infectious materials during certain tasks or procedures:

Job Classification Police Sergeant Police Investigator Police Officer Director of Student Health Assistant Director of Student Health Advanced Practice Clinicians Trade Tech (Plumbers) Head Athletic Trainer Assistant Athletic Trainer Aquatic & Fitness Instructor Designated First Aid Responders Registered Nurses

Version – February 2014 Page 16 Appendix B – Category 2 – Job Classification That May Incur Occupational Exposure

At Longwood University, the following job classifications may have occupational exposure to blood or other possibly infectious materials during certain tasks or procedures:

Job Classification Tasks/Duties Trades Manager(s) Routine duties where blood or OPIM may be present Director of Public Safety Emergency Response and routine duties where blood or OPIM may be present Environmental Health and Safety Emergency Response and routine duties Officer where blood or OPIM may be present Administrative Assistants (Student Routine duties where blood or OPIM may be Health & Counseling Center) present Sports Coach & Assistants Administering First Aid and/or treatment of athletic injury Residential Ed. Coordinator or Administering Basic First Aid or CPR Residential Assistant until responders arrive. Area Coordinators and/or Floor Administering Basic First Aid or CPR Wardens until responders arrive. Child Development Center Routine duties where blood or OPIM may be present

Version – February 2014 Page 17 Appendix C – Sharps Injury Log

Coverage Period: January to December

Date Date & Type & Department Description of Incident Entere Time of Brand of or Work d Injury Device Area that Injury Occurred

This form shall be retained in the Human Resources Department until December (Five years after the end of the Log Year)

Version – February 2014 Page 18 Appendix D - Hepatitis B Vaccine Form

Instructions: Read the following information and CHOOSE ONE of the three options.

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself.

I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me.

______I do not want the Hepatitis B vaccination series at this time. I have read and understand the above statement.

______I have previously received the Hepatitis B vaccination series. Approx. dates ____

I understand that receiving the Hepatitis B vaccine imposes certain risks upon me as detailed in the Bloodborne Pathogens training seminar. I voluntarily consent to such risks and agree to hold the Longwood University harmless from any and all claims and causes of action for any injury, loss, or damage resulting from such vaccination.

______I do want the Hepatitis B vaccination series at this time. I have read and understand the above statement.

This form shall be kept in the Employee’s file in the Human Resources Department

Name: Date: Signature: Witness Name: Witness Signature:

Version – February 2014 Page 19 Appendix E – Employee Safety Recommendation Form

Department: Date:

Identification of Safety or Health Hazard:

Suggestion for Elimination or Reduction of Safety or Health Hazard:

Do Not Write Below This Line Date Received by EHS&EM Office: Reviewed by: Comments / Action Taken:

Name of Employee submitting form:

Version – February 2014 Page 20