S.P.A.R.E. Policies Bloodborne

Scroll down or click on the title to see the policy:

• IFC‐07, Exposure Control of Bloodborne Pathogens

POLICY/PROCEDURE Cornerstone

Title: Exposure Determination for Bloodborne Pathogens Page 1 of 11 IFC-07 Reviewed: 7/17/08, 10/29/09, Revised: 7/17/08, 10/29/09, Effective Date: 7/11/01 9/23/10 9/23/10

VP Approval: Responsible Dept: Quality Section: Infection Control

POLICY Cornerstone Hospice endeavors to eliminate, or minimize occupational exposure to Hepatitis B Virus (HBV), Hepatitis C (HCV), Hepatitis E (HEV), Human Immunodeficiency Virus (HIV), and other bloodborne pathogens by using a combination of engineering and work practice controls, personal protective clothing and equipment, training, medical surveillance, Hepatitis B vaccination, signs and labels, and other provisions.

PROCEDURE A. Exposure Determination: 1. Categories at Risk: Employees are listed in three categories: a. High Risk: Frequent patient contact; medical procedures performed. b. Moderate Risk: Occasional patient contact with or without medical procedures performed. c. No Risk: No patient contact or medical procedures performed.

High Risk Moderate Risk Staff Nurse, RN & LPN Special Program Manager Social Services Manager CNA/HHA Hospice House Charge RN Chaplain On-Call Nurse, RN Hospice House RN Social Services Staff Nurse Clinician Transport Staff Volunteer with direct patient contact Regional Team Manager Housekeeping No Risk Transport Office Staff

2. Not all employees in these categories are at risk all of the time. Any procedure or task listed in attached Tables A & B would expose the above job classifications to bloodborne pathogens, or put the employee at occupational risk.

B. Implementation Schedule and Methodology: OSHA requires that this plan include a schedule and methods of implementation for various requirements of the standard. The following complies with this requirement: 1. COMPLIANCE METHODS a. Standard Precautions will be observed at Cornerstone Hospice in order to prevent contact with blood or other potentially infectious materials. All blood or other potentially infectious material will be considered infectious, regardless of the perceived status of the source individual.

2. ENGINEERING AND WORK PRACTICE CONTROLS a. Engineering and work practice controls will be utilized to eliminate or minimize exposure to employees at Cornerstone Hospice & . Where occupational exposure remains after institution of these controls, personal protective equipment shall also be utilized. At Hospice, the following engineering controls will be utilized: sharps containers, biomedical waste bags, vinyl gloves, disposable barriers, gowns, face masks, goggles, etc. All biomedical waste containers and sharps boxes will have limited access. The waste is to be picked up by an approved contractor on a regular basis, and removed from Hospice premises.

b. Such controls will be examined and maintained on a routine and ongoing basis. 3. HANDWASHING Hospice staff will follow the CDC Guidelines for Hand Hygiene as described in policy IFC-16 4. NEEDLES a. Contaminated needles and other contaminated sharps will not be bent, recapped, removed, sheared or purposely broken. OSHA allows an exception to this if the procedure would require that the contaminated needle be recapped, and no alternative is feasible, and the action is required by the medical procedure. If such action is required, then the recapping of the needle must be done by a mechanical device, or a one-handed “scoop” technique.

POLICY/PROCEDURE Cornerstone Hospice Title: Exposure Determination for Bloodborne Pathogens Page 2 of 11 IFC-07

b. At Cornerstone Hospice, recapping is not permitted. Each needle must be disposed of in a properly labeled sharps container. Hospice does not reuse any sharps or needles. Each nurse is responsible for disposing of the sharps container when it is full in the biohazardous material storage facility, at an

appropriate site. 5. WORK AREA RESTRICTIONS a. In work areas where there is a reasonable likelihood of exposure to blood or other potentially infectious materials (which includes any patient bedroom or bathroom area), employees are not to eat, drink, apply cosmetics or lip balm, smoke or handle contact lenses. Food and beverages are only to be kept in the kitchen or dining area, and are not to be consumed by employees in the patient

rooms. b. Food and drink must NOT be kept in refrigerator, freezers, and cabinets or on counter tops where

blood, biologicals, or other potentially infectious materials are present. 6. SPECIMENS a. Specimens of blood or other potentially infectious materials will be placed in a container which prevents leakage during the collection, handling, processing, storage, and transport of the specimens. Standard precautions will be used in the handling of all specimens. All specimen containers will be recognizable as containing specimens in accordance with the OSHA Standard regarding the labeling of biohazardous waste.

7. PERSONAL PROTECTIVE EQUIPMENT a. All personal protective equipment used at this facility will be provided without cost to employees. Personal protective equipment will be chosen based on the anticipated exposure to blood or other potentially infectious materials. Training in the use of PPE is required during orientation and

annually thereafter. b. The protective equipment will be considered appropriate only if it does not permit blood or other potentially infectious materials to pass through or reach the employee’s clothing, skin, eyes, mouth, or other mucous membranes, under normal conditions of use, and for the duration of time which the

protective equipment will be used. c. Protective clothing will be provided through the Supply Supervisor and will be specific for the anticipated exposure. Gloves, isolation gowns, face masks, and protective eyewear will be available in the Medical Supply Room in each facility. They may also be ordered from the Medical Supply

Provider. d. Gloves shall be worn where it is reasonably anticipated that employees will have hand contact with blood, other potentially infectious materials, non-intact skin, and/or mucous membranes. Disposable gloves are not to be washed or decontaminated for re-use. They are to be replaced as soon as practical when they become contaminated, torn, punctured, or when their ability to function as a barrier is compromised. e. Isolation gowns, masks in combination with eye protection devices, such as goggles or glasses with solid side shields, or chin length face shields, are required to be worn whenever splashes, spray, splatter, or droplets of blood or other potentially infectious materials may be generated, and eye, nose or mouth contamination can reasonably be anticipated. 8. HOSPICE HOUSE LAUNDRY PROCEDURES a. Laundry contaminated with blood or other potentially infectious materials will be handled as little as possible. Disposable gowns are not to be washed or laundered for re-use, but are to be disposed of

immediately. b. All employees who handle contaminated laundry will utilize personal protective equipment to prevent contact with blood or other potentially infectious materials. c. Contaminated laundry will be picked up and processed by contracted laundry companies. 9. HEPATITIS B VACCINE a. All employees will receive training on the safety, benefits, efficacy, methods of administration, and availability of the vaccine during orientation. Employees who have been identified as having risk of exposure to blood or other potentially infectious materials will be offered the Hepatitis B Vaccine, at no cost to the employee. New employees who have recently completed the vaccination series within the recommended window may elect to have antibody testing performed to determine immunity

status. If the employee does not have sufficient immunity, the Hepatitis B Vaccine will be offered.

POLICY/PROCEDURE Cornerstone Hospice Title: Exposure Determination for Bloodborne Pathogens Page 3 of 11 IFC-07

b. All employees will complete the Acknowledgement of Hepatitis B Information and Response to Hepatitis B Vaccination (Form #4035 Attachment A) and their choices recorded in the Employee

data base.

c. The employee will be given the opportunity to accept or decline the Hepatitis B Vaccine. d. Employees who decline the Hepatitis B Vaccine will sign a waiver which uses the wording in Appendix A of the OSHA Bloodborne Standard. Employees who initially decline the vaccine, but who later wish to accept, may then have the vaccine provided at no cost.

10. POST-EXPOSURE EVALUATION AND FOLLOW-UP a. An employee, who suffers a blood or body fluid exposure, should immediately flush the site with water or decontaminate with soap and water. The incident shall be reported as soon as possible to their immediate supervisor and the Human Resources Department. All employees who incur an exposure incident will be offered post-exposure evaluation and follow-up, in accordance with the OSHA Bloodborne Pathogen Standard.

b. The follow-up will include the following: i. The employee/supervisor will document the route of exposure, and the circumstances related to the incident on an Incident Report. ii. If possible, the identification of the source individual and also if possible, the HIV/HBV status of the source individual will be determined. The blood of the source individual will be tested for HIV/HBV infectivity, if the HIV/HBV status is not already known. The source individual will sign consent to be tested. (Form 4040 Attachment B) iii. Results of testing of the source individual will be made available to the exposed employee, with the exposed employee informed about the applicable laws and regulations concerning disclosure of the identity and infectivity of the source individual. iv. After the exposed employee receives appropriate education and counseling and gives informed consent,(Form 2033 Attachment C), a baseline HIV/HBV will be drawn. Repeat testing will be performed at three months, six months, nine months and again at 12 months. If baseline testing is declined by the exposed employee, source testing will not be performed. v. The employee will be offered post-exposure prophylaxis in accordance with the current recommendations of the US Public Health Service. vi. The employee will be given appropriate counseling concerning precautions to take during the period after the exposure incident. The employee will also be given information on what potential illnesses to watch for, and to report any related experiences to the appropriate personnel. vii. All pertinent documentation of the exposure will be filed in the employee’s health file. viii. The Human Resources Department and the Compliance Department, in conjunction with the employee’s supervisor, will ensure the employee obtains counseling, blood work, or other necessary post-exposure follow-up, from Hospice’s Workers Compensation physician.

11. TRAINING a. Training for all employees will be conducted, prior to initial assignments and annually thereafter. This training will target tasks where occupational exposure may occur. Training for employees will include an explanation of: i. The OSHA Standard for Bloodborne Pathogens. ii. Epidemiology and symptomatology of bloodborne diseases. iii. Modes of transmission of bloodborne pathogens. iv. Cornerstone Hospice Exposure Control Plan. v. Procedures which might cause exposure to blood or other potentially infectious materials at this or other facilities. vi. Control methods which will be used at this or other facilities, to control exposure to blood or other potentially infectious materials. vii. Personal protective equipment available at this facility, and who should be contacted to obtain it. viii. Post-exposure evaluation and follow-up. ix. Signs and labels used at this and other facilities. x. Hepatitis B vaccine program at this facility.

POLICY/PROCEDURE Cornerstone Hospice Title: Exposure Determination for Bloodborne Pathogens Page 4 of 11 IFC-07

12. RECORD KEEPING a. Hospice records on Employee Health and Worker’s Compensation claims will be maintained by the HR Department. b. The OSHA Log will be maintained by Human Resources to record any needle sticks from contaminated sharps. c. Incident Reports will be maintained by the Compliance Department. d. Training records and SPARE packets will be maintained by the Education Department.

13. EVALUATION OF THE INCIDENT a. The Risk Manager will review the circumstances of all exposure incidents to determine: 1. Why the exposure occurred 2. If procedures were being followed 3. If procedures, protocols or training changes are required.

POLICY/PROCEDURE Cornerstone Hospice Title: Exposure Determination for Bloodborne Pathogens Page 5 of 11 IFC-07

APPENDIX A DEFINITION OF TERMS:

TERM DEFINITION Blood Human blood, human blood components and products made from human blood. Bloodborne Pathogenic micro-organisms that are present in human blood and can cause disease in humans. Pathogens These pathogens include, but are not limited to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV). Communicable A disease which may be transmitted directly or indirectly from one person to another. Disease: Contagious A disease conveyed easily to others. Disease: Contaminated The presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface. Decontamination The use of physical or chemical means to remove micro-organisms but not necessarily all microbial forms (e.g., bacterial endospore) on inanimate objects. Disinfect To inactivate virtually all recognized pathogenic micro-organisms but not necessarily all microbial forms (e.g., bacterial endospore) on inanimate objects. Engineering Controls that isolate or remove the hazard from the workplace. Controls Exposure A specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood, or Incident other potentially infectious materials that result from the performance of an employee’s duties. Infection A disease state resulting from pathogens in or on the body. Infectious Any disease caused by a growth or pathogen. May or may not be contagious. Disease Laundry Laundry which has been soiled with blood or other potentially infectious materials or may contain sharps. Non-Pathogens A germ or micro-organism which does not normally cause disease. Occupation-al Reasonably anticipated skin, eye, mucous membrane or parenteral contact with blood or other Exposure potentially infectious materials that may result from the performance of an employee’s duties. This definition excluded incidental exposures that may take place on the job, and that are neither reasonable nor routinely expected and that the worker is not required to incur in the normal course of employment Organism Any living thing, plan or animal. (May be one cell or many cells.) Other Potentially 1. The following body fluids: , vaginal secretions, cerebrospinal fluid, synovial fluid, Infectious pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, and any body fluid Materials that is visibly contaminated with blood. (OPIMs) 2. Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and 3. HIV or HBV containing cell or tissue cultures, organ cultures, and culture medium or other solutions; and blood, organs or other tissues from experimental animals infected with HIV or HBV. Pathogen A disease-producing micro-organism. (Only seen with a microscope.) Personal Protective Specialized clothing or equipment worn by an employee for protection against a hazard. Equipment Portal of Entry The point at which organisms (germs) enter a host (body). Potentially Blood and blood products, all contaminated sharps, all tissue specimens, all operating room wastes, Infectious Waste Class IV isolation wastes, wastes related to Creutzfeldt-Jakob Disease, all laboratory wastes contaminated with blood and body fluids, and all wastes heavily contaminated with blood. Reservoir A natural habitat for the growth and multiplication of micro-organisms. Source Any individual, living or dead, whose blood, body fluids, tissues, or organs may be a source of Individual exposure to the employee. Examples include, but are not limited to, and patients, clients in institutions for the mentally retarded, trauma victims, clients of drug and alcohol treatment facilities, residents of and homes, human remains prior to embalming, and individuals who donate or sell blood or blood components. Sterilize The use of physical or chemical procedure to destroy all microbial life including highly resistant bacterial endospore.

POLICY/PROCEDURE Cornerstone Hospice Title: Exposure Determination for Bloodborne Pathogens Page 6 of 11 IFC-07

TERM DEFINITION Standard CDC recommendations for substances such as urine, feces, sweat, vomitus, nasal discharge, tears, Precautions saliva (except during dental work), that does not include viable blood. Standard Precautions combine and Body Substance Isolation (BSI). A method of infection control in which all human blood, semen, saliva (from dental work), vaginal fluids, , amniotic fluid, fluids around the brain, spine, lungs, joints, and abdomen, and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens. Vehicle The means of transmitting organisms’ modes of transmission - routes organism used to infect. Work Practice Controls that reduce the likelihood of exposure by altering the manner in which a task is performed. Controls

POLICY/PROCEDURE Cornerstone Hospice Title: Exposure Determination for Bloodborne Pathogens Page 7 of 11 IFC-07

APPENDIX B PPE Precautions for High Risk Procedures – Table A

CLINICAL STAFF GOGGLES/ POTENTIAL TASKS GOWNS GLOVES COMMENTS MASKS CONTAMINATION Bladder irrigation No No Yes Urine instillation. Cleaning of blood Yes, if Yes if Yes Use a solution of 1 part bleach and body fluid splashing is soiling is utility Blood, OPIM and 10 parts water for cleaning. spills. likely likely gloves Catheter care. No No Yes Urine Catheterization. No No Yes Urine Should be an aseptic procedure. Chemstick / Used articles shall be disposed of No No Yes Blood Accucheck in proper containers. Yes if Colostomy/ Plastic aprons are recommended No soiling Yes Feces Ileostomy care: to protect personal clothing. likely Yes if Yes if Plastic aprons are recommended Colostomy/Irrigation splashing is soiling is Yes Feces to protect personal clothing. likely likely. Cultures/obtaining. No No Yes Exudate Diabetic Urine No No Yes Urine Testing All articles soiled with blood or OPIM should be placed in an Disposal of Yes if impervious bag before removal contaminated No soiling is Yes Blood, OPIM from room. If articles are soiled articles likely. with infective materials, labeling or color coding must be completed on the bags. Central or Yes if peripheral line No soiling is Yes Blood Should be a sterile procedure. dressing. likely. Dressing change (including dressing Yes if soiling/ Yes if Follow requirements for change/wound splashing is soiling is Yes Blood, OPIM Transmission-Based Precautions, cleaning as part of likely. likely. if appropriate. procedure.) Yes if Yes if Plastic aprons are recommended Enemas splashing is soiling is Yes Feces to protect personal clothing. likely. likely. Yes if Removal of fecal No soiling is Yes Feces impaction. likely. Yes if Gloves are mandatory to prevent Urine, feces, vaginal Incontinent care No soiling is Yes contamination from build-up drainage likely. under fingernails.

Should be an aseptic procedure. Administering IV. No No Yes Blood

If linen is contaminated with Yes if infectious material, if must be Handling used No soiling Yes Blood, OPIM bagged before removal from the laundry/linen. likely room and properly labeled. See policy regarding linen handling. Insertion/removal of Nasal secretions and No No Yes Use aseptic technique. NG tube. saliva POLICY/PROCEDURE Cornerstone Hospice Title: Exposure Determination for Bloodborne Pathogens Page 8 of 11 IFC-07

Yes if Yes if soiling / Oral hygiene. splashing is Yes Blood, OPIM splashing likely is likely Aseptic no-touch technique Measuring output No No Yes Urine, blood, OPIM should be used. See comments under “Urinary” Table A. Yes if soiling / Urine, vaginal Perineal Care No Yes splashing secretions, feces is likely If care includes removal of Yes if invasive procedure devices, Postmortem care. No soiling is Yes Blood, OPIM follow specifics for that likely procedure. Measuring a rectal No No Yes Feces temperature.

Yes, if Yes if Specimens, splashing is soiling is Yes Blood collecting blood. likely. likely.

Yes if Yes, if Specimens, soiling / splashing is Yes Saliva collecting sputum. splashing likely. is likely

Specimens, No No Yes Stool collecting stool.

Specimens, No No Yes Urine collecting urine Yes if splashing is Gloves should be worn on both likely or if hands. Plastic aprons are resident/patient Yes if Suctioning nasal, Sputum, saliva, blood, recommended. Follow has a soiling is Yes oral and tracheal. OPIM requirements for Transmission- suspected or likely. Based Precautions, if known appropriate. respiratory infection. Suppository - No No Yes Feces insertion of Yes if Topical medication No soiling Yes Exudate administration. likely. Yes, if splashing is likely or if Yes if resident/patient soiling / Tracheal care. Yes Sputum has suspected splashing or known is likely. respiratory infection.

Yes if Yes, if soiling / Vaginal douche: splashing is Yes Vaginal secretions splashing likely. is likely.

POLICY/PROCEDURE Cornerstone Hospice Title: Exposure Determination for Bloodborne Pathogens Page 9 of 11 IFC-07

Housekeeping/Hospice House Staff

GOGGLES/ POTENTIAL TASKS GOWNS GLOVES COMMENTS MASKS CONTAMINATION Cleaning of body Yes, if Yes, fluids, spills and/or No soiling is utility Blood, OPIM Refer to Nursing - Category I. splashes. likely. gloves Rubber/utility gloves should be Cleaning Yes if used for all procedures resident/patient No splashing Yes Blood, OPIM recommending glove use in this toilets. is likely category. Yes, if Yes, if Cleaning room of No soiling is soiling is Blood, OPIM discharge. likely likely Cleaning room of Yes, if Yes, if transmission-based No soiling is soiling is Blood, OPIM precautions. likely likely Rubber/utility gloves should be Handling soiled No No Yes Blood, OPIM worn when there is obvious dishes and utensils. soiling of the dishes. Handling soiled feeding syringes. No No Yes Saliva, blood

Yes, if Yes, Handling used splashing is plastic Yes Blood, OPIM Rubber gloves should be worn. laundry/ linen likely aprons

PPE Precautions for Moderate Risk Procedures – Table B

CLINICAL STAFF

GOGGLES/ POTENTIAL TASKS GOWNS GLOVES COMMENTS MASKS CONTAMINATION No, unless an Application of Ace bandage: No No open Blood, OPIM lesion is present If resident/patient requires Answering a call light: No No No None specific procedure, follow identified policy. Precautions not necessary unless open Back rub: No No No None lesions are present.

Yes if If resident/patient is Bath care including Yes if soiling/ identified in Transmission- complete/partial bed bath, No splashing Blood, OPIM splashing is Based Precautions, follow shower or tub bath is likely likely specific policy. Yes if Gloves are recommended Bed making, unoccupied Urine, feces, No No soiling is if a bed is made after an and occupied. blood, OPIM likely incontinent episode. Yes, if Bedpan, urinal, bedside No No soiling is Blood, OPIM commode: likely Mouth piece should be Respiratory Bronchoinhalers No No Yes cleaned before returning secretions to medication cart. POLICY/PROCEDURE Cornerstone Hospice Title: Exposure Determination for Bloodborne Pathogens Page 10 of 11 IFC-07

Gloves may be desired as Yes if Cleaning beside table/ over cleaning fluids may be No No soiling is Blood, OPIM bed table. harsh to the skin. likely

Yes if Blood, OPIM Compress application: No No soiling is

likely

Yes if Wipe from inner to outer Eye care: No No soiling is Exudate canthus. likely Hand-washing must be Eye drop administration: No No Yes Tears and Exudate completed before and after procedure. Ear care: No No No None Yes if Hand-washing must be Feeding a resident: No No soiling is Saliva completed before and likely after procedure. Procedure must be Yes if completed by a licensed Feeding with a syringe: No No soiling is Saliva nurse. Hand washing likely must be completed before and after procedure. Hair care: No No No None Injections: No No Yes Blood Use aseptic technique. Gloves are recommended Meal service and pick up: No No No None if there is visible soiling on the dishes. Nail care: No No No None Equipment should be If contact cleaned, dried and Yes if with oral Respiratory covered between uses. If Nebulizer IPPB Treatment: splashing is No secretion secretions resident/patient is being likely. s treated for infection follow precautions identified. Nose drops, instillation: Use no-touch aseptic No No Yes Nasal secretions techniques. Follow proper hand- washing procedure after Oral medication and No No No None direct contact with administration: resident/patient or secretions. If resident/patient is being treated for a respiratory Oxygen administration: No No No None infection, follow the Transmission-Based Precautions identified. Passing/serving drinking No No No None water: Protective devices or No No No None restraints: Range of motion: No No No None Single use razors should be disposed of in impervious container and Shaving: No No Yes Blood, OPIM head of electric shaver must be sanitized per procedure between resident’s/patient’s use. Vital signs: No No Yes if Blood, OPIM See Category I - POLICY/PROCEDURE Cornerstone Hospice Title: Exposure Determination for Bloodborne Pathogens Page 11 of 11 IFC-07

soiling is Measuring Rectal likely. Temperature. If resident/patient is being treated for an infection, follow those Transmission-Based Precautions. Yes if Weighing the resident/ No No soiling is Blood, OPIM patient: likely.

House keeping/Hospice House Staff

GOGGLES POTENTIAL TASKS GOWNS GLOVES COMMENTS / MASKS CONTAMINATION Yes if Employees may wear Yes if soiling soiling/ Cleaning baseboards: No Blood, OPIM utility gloves as cleaning is likely. splashing materials are harsh. is likely. See above. Yes if

Cleaning dining rooms, soiling/ No No None tables and chairs: splashing

is likely.

Utility gloves if Cleaning equipment: No No Blood, OPIM See above soiling is likely Utility gloves if Cleaning food carts: No No Blood, OPIM See above soiling is likely Utility gloves if Cleaning public bathroom: No No Blood, OPIM See above soiling is likely If using pressure washers, Yes if protective equipment Cleaning wheelchairs: No No soiling is Blood, OPIM should be worn to protect likely. from spray. Staff must exercise Disposal of trash: No No No None caution for inadvertent sharps disposal. Yes if Floor care: No No soiling is Blood, OPIM likely. Keep linen covered while Handling, storage and transporting and distribution of laundry and No No No None distributing to prevent linen. unintentional soiling. Inventory of personal No No No None effects: Yes if soiling is Maintenance procedures: No No Blood, OPIM likely

Utility gloves may be worn Washing walls: No No No None as cleaning materials are harsh to the skin. Washing windows: No No No None See above

Acknowledgement of Hepatitis B Information and Response to Hepatitis B Vaccination

I have received and read the following information forms: (Please retain these two specified forms for your future reference) • “Hepatitis B and Its Implication for Healthcare Workers” • CDC Publication (Vaccine Information Sheet): “Hepatitis B Vaccine – What You Need To Know” I understand the following: 1. Hepatitis B Vaccine (HBV) is specific for infection caused by the Hepatitis B virus and does not immunize for any other infections or other types of hepatitis. 2. Certain healthcare workers are considered to be at risk for exposure to the Hepatitis B virus if, through the scope of their duties, they are exposed to blood, body fluids, or other infectious material. Occupational exposure is defined by OSHA as “reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of one’s duties.” 3. While Hepatitis B infection can occur from causes other than occupational exposure, Cornerstone Hospice (CH) provides Hepatitis B Vaccine to eligible staff for the sole purpose of minimizing the risk for infection associated with work-related exposures only. 4. Administration of the full three-dose regimen to those in occupational risk groups has substantially reduced the incidence of Hepatitis B infection in these groups. There is insufficient data regarding the vaccine’s effectiveness in preventing disease when given after exposure to the virus. 5. The vaccine may cause none, some, or all of the side-effects set forth in the CDC Publication, “Hepatitis B Vaccine – What You Need To Know.” CH will not be responsible for any costs associated with treatment of possible side effects from the vaccine. 6. If occupationally eligible for HBV, the vaccine will be provided at no cost to the eligible employee. Likewise, labwork that is recommended to check antibody levels (Hepatitis B Surface Antibody/HBsAb) will be done at no cost. 7. Should I elect to receive HBV, I will be given written notice of the recommended dosing schedule when I receive the first dose of vaccine. Once notified, it is my responsibility to make arrangements to receive subsequent doses and titers as recommended. 8. My participation in this immunization program is entirely voluntary and I am free to withdraw from vaccinations, or to decline associated labwork, without any effect on my employment at CH. 9. If I decline HBV and/or subsequent doses, I can reverse this decision at any time, as long as I remain on staff at CH and while my duties place me at risk for occupational exposure to the Hepatitis B virus. 10. I may contact appropriate and qualified staff at CH at any time to answer questions regarding Hepatitis B issues and vaccine. At my discretion, my personal physician will serve as an additional resource in this regard. If requested, I will provide medical information to appropriate CN staff regarding Hepatitis B issues - before, during, or after administration of vaccine doses. 11. If applicable, I will make every reasonable effort to provide to CH any, and all, documentation of previous HBV doses and/or titer (HBsAb) results. I will submit this information to CH prior to the first day of employment, or at a later date if I then become eligible for Hepatitis B Vaccine. 12. My signature below reflects my review, understanding, and agreement of all items specified on this document.

Please check the appropriate boxes. Sign and date below. □ My job and duties at CH do not expose me to blood, body fluids, and/or other infectious materials as an occupational risk for Hepatitis B infection. As such, I am ineligible to receive Hepatitis B Vaccine from CH. □ I understand the purpose and potential risks of the Hepatitis B Vaccine. My job at CH qualifies as an occupational risk for Hepatitis B infection. I wish to receive the Hepatitis B Vaccine. □ After careful consideration, I decline to receive Hepatitis B Vaccine from CH. By declining, I understand that I remain at risk to acquire Hepatitis B infection through my duties at CH. (See Item 9. above) □ I have completed the three-dose series of Hepatitis B Vaccine prior to employment at CH. Before your first day of work, provide documentation of doses or note approximate date of vaccine completion here: ______□ Following completion of the Hepatitis B Vaccine series, I had a titer (HBsAb) done. The results of this titer were (Check one): Positive/Immune ___ Negative ___ Unknown ___ Provide documentation of your titer. Send or FAX prior to your first day of work. □ I have completed the Hepatitis B Vaccine Series in the last two months and I am requesting a HBsAb titer to be drawn to determine my immunity status.

REMARKS: ______

______Signature of Employee Printed Name Date

Form #4035 (12/08)

We have requested that you have your blood tested because an employee has had an exposure to your blood or body fluids. If you agree, your blood will be drawn and tested to rule out the presence of Human Immunodeficiency Virus or the Hepatitis Virus.

HIV is believed to be the virus which causes acquired immunodeficiency syndrome (AIDS). Testing is now available which can, with a reasonable degree of accuracy, detect the presence of HIV antibodies in the blood. You should be aware of the following before you agree to be tested: ƒ The testing will be repeated if the first test is positive. A more sophisticated test will be done if the second is positive as well. It probably means you have been exposed to HIV if that test is also positive. However, the possibility of false positive or even false negative results cannot be excluded. ƒ A positive result does not mean you have AIDS or you will necessarily develop AIDS or any AIDS-related illness. It does mean you are presumed to have been exposed to the virus and therefore are capable of transmitting the virus to others.

Hepatitis Virus is the virus that causes Hepatitis infection. Testing is now available which can, with a reasonable degree of accuracy, detect the presence of hepatitis antibodies in the blood. You should be aware of the following before you agree to be tested: ƒ A positive test result does not mean that you have Hepatitis, or that you will necessarily develop Hepatitis. It does mean that you are presumed to have been exposed to the virus, and therefore, are capable of transmitting the virus to others.

You will be referred to an appropriate counseling resource to assist you in understanding the significance of this outcome if you have a positive test result.

═══════════════════════════════════════ I have read the above and have had the opportunity to ask questions. I understand that if I consent to testing, the consent applies to any follow-up test as indicated.

I ACCEPT testing (Check here and sign below)

______Signature of Patient or Legal Representative / Relationship to Patient Date

______Signature of Hospice Representative Date

PATIENT CONSENT Patient Name: FOR BLOOD TESTING Medical Record #: Team:

White- Chart (Form # 4040 1/10)

You have the option of having your blood tested because you have had an exposure to a patient who could have AIDS or be positive for HIV or Hepatitis antibodies or have an unknown status. Your blood will be drawn for testing now, in six weeks, three months, six months and again in 12 months if you agree to testing.

HIV is believed to be the virus which causes acquired immunodeficiency syndrome (AIDS). Testing is now available which can, with a reasonable degree of accuracy, detect the presence of HIV antibodies in the blood. You should be aware of the following before you agree to be tested: ƒ The testing will be repeated if the first test is positive. A more sophisticated test will be done if the second is positive as well. It probably means you have been exposed to HIV if that test is also positive. However, the possibility of false positive or even false negative results cannot be excluded. ƒ A positive result does not mean you have AIDS or you will necessarily develop AIDS or any AIDS- related illness. It does mean you are presumed to have been exposed to the virus and therefore are capable of transmitting the virus to others. ƒ If you have any questions, please ask your physician or call the Florida AIDS Hotline (800 FLA-AIDS)

Hepatitis B Virus is the virus that causes Hepatitis B infection. Testing is now available which can, with a reasonable degree of accuracy, detect the presence of HBV antibodies in the blood. You should be aware of the following before you agree to be tested: ƒ A positive test result does not mean that you have Hepatitis B, or that you will necessarily develop Hepatitis B. It does mean that you are presumed to have been exposed to the virus, and therefore, are capable of transmitting the virus to others.

You will be referred to an appropriate counseling resource to assist you in understanding the significance of this outcome if you have a positive test result.

═══════════════════════════════════════ I have read the above and have had the opportunity to ask questions. I have received a copy of the CDC Brochure Exposure to Blood – What Healthcare Personnel Need to Know. I understand that if I consent to testing, the consent applies to the follow-up test as indicated. I understand that I may be jeopardizing any claim to a work related exposure if I refuse to be tested.

ACCEPT testing REJECT testing (Check here and sign below) (Check here and sign below)

______(Employee) (Employee)

______(Date) (Date)

______(Witness) (Witness)

______(Date) (Date)

EMPLOYEE CONSENT POST-EXPOSURE Employee Name: Team:

White - Employee Health File Yellow - Employee’s Copy (Form #2033 Rev. 9/09)