Chapter 10: Exposure Control Plan

This document serves as the written procedures Blood-borne Pathogens Exposure Control Plan (ECP) for The University of Mary Washington. These guidelines provide policy and safe practices to prevent the spread of disease resulting from handling blood or other potentially infectious materials (OPIM) during the course of work.

This ECP has been developed in accordance with the OSHA Blood-borne Pathogens Standard, 29 CFR 1910.1030. The purpose of this ECP includes:

  • Eliminating or minimizing occupational exposure of employees to blood or certain other body fluids.
  • Complying with OSHA’s Blood-borne Pathogens Standard, 29 CFR 1910.1030.
  • All employees that may be exposed to blood or other potentially infectious materials as a part of there job duties are included in this plan.

Administrative Duties
The Director of EM& Safety, is responsible for developing and maintaining the program. A copy of the plan may be reviewed by employees. It is located in Physical Plant Facility, Safety Office. In addition, UMW, Safety Department is responsible for maintaining any records related to the Exposure Control Plan. This is current as of August 20,2004

If after reading this program, you find that improvements can be made, please contact the Director, EH & Safety. We encourage all suggestions because we are committed to the success of our written ECP. We strive for clear understanding, safe behavior, and involvement from every level of the company.

Exposure Determination
We have determined which employees may incur occupational exposure to blood or OPIM. The exposure determination is made without regard to the use of personal protective equipment (i.e., employees are considered to be exposed even if they wear personal protective equipment).

Job Classes: Global Risk of Exposure

This exposure determination is required to list all job classifications in which all employees may be expected to incur such occupational exposure, regardless of frequency. At UMW the following job classifications are in this category:

  1. House Keepers
  2. Plumbers
  3. Law Enforcement Employees
  4. Safety Division Employees
  5. Resident Life Employees
  6. Health Care Workers
  7. Lab Workers and Assistants

Job Classes: Function-Specific Risk of Exposure

In addition, we have identified job classifications in which some employees may have occupational exposure. Not all employees in these categories are expected to have exposure to blood or OPIM. Therefore, tasks or procedures that would cause occupational exposure are also listed to further specify which employees have occupational exposure. The job classifications and associated
tasks for these categories are as follows:

  • Housekeeping – within the scope of normal procedures as well as emergency cleaning.
  • Plumbers – within the normal scope of work in relationship to sewage
  • Residence Life Employees – within the normal scope of work.
  • Police Dept. – within the normal scope of work.
  • Jepson Science Center – within the scope of work
  • Safety Division – within the scope of work

Compliance Strategies
This plan includes a schedule and method of implementation for the various requirements of the standard.

Universal precautions techniques developed by the Centers for Disease Control and Prevention (CDC) will be observed at UMW to prevent contact with blood or OPIM. All blood or OPIM will be considered infectious regardless of the perceived status of the source individual.

Engineering and Work Practice Controls
Engineering and Work Practice Controls will be used to eliminate or minimize exposure to employees at UMW. Where occupational exposure remains after institution of these controls, employees are required to wear personal protective equipment. At this facility the following engineering controls are used:

  • Placing sharp items (e.g., needles, scalpels, etc.) in puncture-resistant, leak proof, labeled containers.
  • Performing procedures so that splashing, spraying, splattering, and producing drops of blood or OPIM is minimized.
  • Removing soiled PPE as soon as possible.
  • Cleaning and disinfecting all equipment and work surfaces potentially contaminated with blood or OPIM. Note: We use a solution of 1/4 cup chlorine bleach per gallon of water (10% bleach solution).
  • Thorough hand washing with soap and water immediately after providing care or provision of antiseptic towelettes or hand cleanser where hand washing facilities are not available.
  • Prohibition of eating, drinking, smoking, applying cosmetics, handling contact lenses, and so on in work areas where exposure to infectious materials may occur.
  • Use of leak-proof, labeled containers for contaminated disposable waste or laundry.
  • The employer shall ensure that employees who have contact with contaminated laundry wear protective gloves and other appropriate personal protective equipment.
  • Disposal containers will be discarded by contractual services when they reach 75% capacity.
  • No medical waste is treated at the University of Mary Washington.

The above controls are examined and maintained on a regular schedule.

Hand washing Facilities
Hand washing facilities are available to employees who have exposure to blood or OPIM. Sinks for washing hands after occupational exposure are near locations where exposure to blood-borne pathogens could occur.

Hand washing facilities are located through out campus.

Supervisors make sure that employees wash their hands and any other contaminated skin after immediately removing personal protective gloves, or as soon as feasible with soap and water.

Supervisors also ensure that if employees’ skin or mucous membranes become contaminated with blood or OPIM, then those areas are washed or flushed with water as soon as feasible following contact.

Employees may not bend, recap, remove, shear, or purposely break contaminated needles and other sharps. If a procedure requires that the contaminated needle be recapped or removed and no alternative is feasible, then that employee must recap or remove the needle by using a mechanical
device or a one-hand technique. At UMW recapping or removal is not permitted. Retractable syringes are encouraged to be used.

Handling Contaminated Needles and Other Sharps

The procedure for handling contaminated sharps is:

  • Contaminated sharps are discarded immediately or as soon as possible in containers that are closeable, puncture resistant, leak proof on sides and bottom, and labeled or color coded.  These containers may be obtained at the University Health Center, 1st floor Lee Hall.
  • During use, containers for contaminated sharps shall be easily accessible to personnel and located as close as possible to the immediate area where sharps are used or can be reasonably anticipated to be found (e.g., first aid stations).
  • The containers are kept upright throughout use and replaced routinely and not allowed to be overfilled. Capacity is estimated at 75%. They are to be returned to the Health Center for disposal.
  • When moving containers of contaminated sharps from the area of use, the containers are closed immediately before removal or replacement to prevent spills or protrusion of contents during handling, storage, transport, or shipping.
  • The containers are placed in a secondary container if leakage of the primary container is possible. The second container shall be closeable, constructed to contain all contents and prevent leakage during handling, storage and transport, or shipping. The se
    cond container
    shall be labeled or color coded to identify its contents.
  • Reusable containers shall not be opened, emptied, or cleaned manually or in any other manner which would expose employees to the risk of percutaneous injury.

Work Area Restrictions
In work areas where there is a reasonable likelihood of exposure to blood or OPIM, employees are not to eat, drink, apply cosmetics or lip balm, smoke, or handle contact lenses. Food and beverages are not to be kept in refrigerators, freezers, shelves, cabinets, or on counter tops or bench tops where blood or OPIM are present.

Mouth pipetting/suctioning of blood or OPIM is prohibited. All procedures involving blood or other potentially infectious materials will be conducted in a manner which will minimize splashing, spraying, splattering, and generation of droplets of blood or OPIM. Methods employed at this facility to accomplish this goal are:

Wearing proper personnel protective equipment, using universal precautions

Personal Protective Equipment
All personal protective equipment (PPE) used at this facility is provided without cost to employees. PPE is chosen based on the anticipated exposure to blood or OPIM. The protective equipment is considered appropriate only if it does not permit blood or OPIM to pass through or reach the employees’ 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.

UMW makes sure that appropriate PPE in the all sizes is readily accessible at the work site or is issued without cost to employees by:

  • Safety Office
  • Storeroom
  • House Keeping Supervisors

We purchase (when consumable), clean, launder, and dispose of personal protective equipment as needed, all garments which are penetrated by blood shall be removed immediately or as soon as feasible. All PPE will be removed prior to leaving the work area. When PPE is removed, it shall be placed in an appropriately designated area or container for storage, washing, decontamination or disposal.

Employees must remove all garments which are penetrated by blood immediately or as soon as possible.

They must remove all PPE before leaving the work area. When PPE is removed, employees place it in a designated container for disposal, storage, washing, or decontamination.

Employees must wear gloves when they anticipate hand contact with blood, OPIM, non-intact skin, and mucous membranes; when performing vascular access procedures, and when handling or touching contaminated items or surfaces.

Disposable gloves used at this facility are not to be washed or decontaminated for re-use and are to be replaced as soon as practical when they become contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised.

Utility gloves may be decontaminated for re-use provided that the integrity of the glove is not compromised.

Utility gloves will be discarded if they are cracked, peeling, torn, punctured, or exhibit other signs of deterioration or when their ability to function as a barrier is compromised.

Hypoallergenic gloves, glove liners, powder less gloves, or other similar alternatives shall be readily accessible to those employees who are allergic to the gloves normally provided. UMW encourages the use of nitrile gloves by all employees to avoid latex alergy issues.

Eye and Face Shields
Employees must wear masks in combination with eye protective devices, such as goggles or glasses with solid side shield, or chin length face shields, whenever splashes, splatter, or droplets of blood or OPIM may be generated and reasonably anticipated to contaminate eye, nose, or mouth. Those situations and the corresponding eye and face protection are indicated with the possibility of severe contamination.

Handling Regulated Wastes
When handling regulated wastes, other than contaminated needles and sharps, we make sure it is:

  • Placed in containers which are closeable, constructed to contain all contents, and prevent fluid leaks during handling, storage, transportation, or shipping.
  • Labeled or color coded and closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping.
  • If outside contamination of the regulated waste container (other than contaminated sharps containers) occurs, it shall be placed in a second container. The second container shall be: – Closeable; – Constructed to contain all contents and prevent leakage of fluids during handling,
    storage, transport or shipping. – Labeled or color-coded in accordance with 29 CFR 910.1030 (g)(1)(i) of this standard; and – Closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping.

Note: Disposal of all regulated waste is in accordance with applicable Unites States, state and local regulations. All medical waste at UMW is handled and disposed of by contracted services.

Handling Contaminated Laundry

Laundry contaminated with blood or OPIM is handled as little as possible. Such laundry is placed in appropriately marked (biohazard labeled, or color coded red bag) bags at the location where it was used. Such laundry is not sorted or rinsed in the area of use.

Note: When Body Substance Isolation or Universal Precautions is used in the handling of all laundry (i.e. all laundry is assumed to be contaminated) no labeling or color-coding is necessary if all employees recognize the hazards associated with the handling of this material.

This facility does not follow Universal Precautions in the handling of all laundry, therefore, contaminated laundry must be placed in bags or containers which are labeled or color-coded.

Information and Training
The University of Mary Washington ensures that blood-borne pathogens trainers are knowledgeable in the required subject matter. We make sure that employees covered by the blood-borne pathogens standard are trained at the time of initial assignment to tasks where occupational exposure may occur, and every year thereafter by the following methods:

  • Information and training. (i) Employers shall ensure that all employees with occupational exposure participate in a training program which must be provided at no cost to the employee and during working hours.

Training is tailored to the education and language level of the employee, and offered during the normal work shift. The training will be interactive and cover the following:

  • The standard and its contents.
  • The epidemiology and symptoms of blood-borne diseases.
  • The modes of transmission of blood-borne pathogens.
  • UMW Blood-borne Pathogen ECP, and a method for obtaining a copy.
  • The recognition of tasks that may involve exposure.
  • The use and limitations of methods to reduce exposure, for example engineering controls, work practices and personal protective equipment (PPE).
  • The types, use, location, removal, handling, decontamination, and disposal of PPEs.
  • The basis of selection of PPEs.
  • The Hepatitis B vaccination, including efficacy, safety, method of administration, benefits, and that it will be offered free of charge.
  • The appropriate actions to take and persons to contact in an emergency involving blood or OPIM.
  • The procedures to follow if an exposure incident occurs, including the method of reporting and medical follow-up.
  • The evaluation and follow-up required after an employee exposure incident.
  • The signs, labels, and color coding systems.

Additional training is provided to employees when there are any changes of tasks or procedures affecting the employee’s occupational exposure. Employees who have received training on blood-borne pathogens in the 12 months preceding the effective date of this plan will only receive training in provisions of the plan that were not covered.

Training records shall be maintained for three years from the date of training. The following information shall be documented:

  • The dates of the training sessions;
  • An outline describing the material presented;
  • The names and qualifications of persons conducting the training;
  • The names and job titles of all persons attending the training sessions.

Medical records shall be maintained in accordance with OSHA Standard 29 CFR 1910.20. These records shall be kept confidential, and must be maintained for at least the duration of employment plus 30 years. The records shall include the following:

  • The name and social security number of the employee.
  • A copy of the employee’s HBV vaccination status, including the dates of vaccination.
  • A copy of all results of examinations, medical testing, and follow-up procedures.
  • A copy of the information provided to the healthcare professional, including a description of the employee’s duties as they relate to the exposure incident, and documentation of the routes of exposure and circumstances of the exposure.

Employee medical records pertaining to BBP standard are held at the UMW Student Health Center. All employee records shall be made available to the employee in accordance with 29 CFR 1910.20. All employee records shall be made available to the Assistant Secretary of Labor for the Occupational Safety and Health Administration and the Director of the National Institute for Occupational Safety and Health upon request.

Transfer of Records
If this facility is closed or there is no successor employer to receive and retain the records for the prescribe period, the Director of the NIOSH shall be contacted for final disposition.

Evaluation and Review
This program and its effectiveness is reviewed every year and updated as needed.

Hepatitis B Vaccination Program
The University offers the Hepatitis B vaccine and vaccination series to all employees who have occupational exposure to blood-borne pathogens, and post exposure follow-up to employees who have had an exposure incident.

All medical evaluations and procedures including the Hepatitis B vaccine and vaccination series and post exposure follow up, including prophylaxis are:

  • Made available at no cost to the employee.
  • Made available to the employee at a reasonable time and place.
  • Performed by or under the supervision of a licensed physician or by or under the supervision of another licensed healthcare professional.
  • Provided according to the recommendations of the U.S. Public Health Service.

All laboratory tests are conducted by an accredited laboratory at no cost to the employee. Hepatitis B vaccination is made available by contacting the Safety Office and scheduling with the Mary Washington College Heath Center.

  • After employees have been trained in occupational exposure (see Information and Training).
  • Within 10 working days of initial assignment.
  • To all employees who have occupational exposure unless a given employee has previously received the complete Hepatitis B vaccination series, antibody testing has revealed that the employee is immune, or the vaccine is contraindicated for medical reasons.

Participation in a pre-screening program is not a prerequisite for receiving Hepatitis B vaccination. If the employee initially declines Hepatitis B vaccination but at a later date while still covered under the standard decides to accept the vaccination, the vaccination will be made available. All employees who decline the Hepatitis B vaccination offered must sign the OSHA-required waiver indicating their refusal.

If a routine booster dose of Hepatitis B vaccine is recommended by the U.S. Public Health Service at a future date, such booster doses will be made available.

Post-Exposure Evaluation and Follow-up
All exposure incidents are reported, investigated, and documented. When the employee is exposed to blood or OPIM, the incident is reported to UMW, Safety Office at 540-654-2108. When an employee is exposed, he or she will receive a confidential medical evaluation and follow-up, including at least the following elements:

  • Documentation of the route of exposure, and the circumstances under which the exposure-occurred.
  • Identification and documentation of the source individual, unless it can be established that identification is infeasible or prohibited by state or local law. State or local laws affecting the investigation or documentation of exposure incidents are:
  • The source individual’s blood shall be tested as soon as feasible and after consent is obtained in order to determine HBV and HIV infectivity. If consent is not obtained, ? establishes that legally required consent cannot be obtained. When the source individual’s consent is not required by law, the source individual’s blood, if available, will be tested and the results documented.
  • When the source individual is already known to be infected with HBV or HIV, testing for the source individual’s known HBV or HIV status need not be repeated.
  • Results of the source individual’s testing are made available to the exposed employee, and the employee is informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual.

Collection and testing of blood for HBV and HIV serological status will comply with the following:

  • The exposed employee’s blood is collected as soon as possible and tested after consent is obtained;
  • The employee will be offered the option of having their blood collected for testing of the employee’s HIV/HBV serological status. The blood sample will be preserved for up to 90 days to allow the employee to decide if the blood should be tested for HIV serological status.

All employees who incur an exposure incident will be offered post-exposure evaluation and follow-up according to the OSHA standard. All post exposure follow-up will be performed by Fredericksburg Medical Walk in Center, Dr. Sharma, MD.

The healthcare professional responsible for the employee’s Hepatitis B vaccination is provided with the following:

  • 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 route of exposure and circumstances under which exposure occurred.
  • Results of the source individuals blood testing, if available.
  • All medical records relevant to the appropriate treatment of the employee including vaccination status.

The University of Mary Washington obtains and provides the employee with a copy of the evaluating healthcare professional’s written opinion within 15 days of the completion of the evaluation.

The healthcare professional’s written opinion for HBV vaccination must be limited to whether HBV vaccination is indicated for an employee, and if the employee has received such vaccination.

The healthcare professional’s written opinion for post-exposure follow-up is limited to the following information:

  • A statement that the employee has been informed of the results of the evaluation.
  • A statement that the employee has been told about any medical conditions resulting from exposure to blood or OPIM which require further evaluation or treatment.

Note: All other findings or diagnosis shall remain confidential and will not be included in the
written report.

Labels and Signs
Biohazard labels are affixed to containers of regulated waste, refrigerators and freezers containing blood or OPIM, and other containers used to store, transport or ship blood or OPIM. The universal biohazard symbol is used. The label is fluorescent orange or orange-red. Red bags or containers may
substituted for labels.

Blood products that have been released for transfusion or other clinical use are exempted from these labeling requirements.


A.) Hep B Declination Form

B.) Most FAQ, OSHA Gov’t Printing Office

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