Purpose and Objective 

The company is committed to providing a safe and healthy workplace. The following Bloodborne Pathogen Program is provided to help ensure that employees have instructions and reference materials to aid in protecting themselves and others.  Proper use and application of these principles will help to minimize or eliminate risk of exposures in accordance with OSHA 29 CFR 1910.1030, “Occupational Exposure to Bloodborne Pathogens.” 

Definitions 

Biological Hazard: Any viable infectious agent that presents a potential risk to human health. 

Bloodborne pathogens: Microorganisms that are present in blood and can cause diseases, such as human immunodeficiency virus (HIV) and hepatitis B (HBV), which are spread through contact with infected blood or blood products. 

Contaminated: The presence or reasonably anticipated presence of blood or other potentially infectious materials. 

Decontamination: The use of known methods to remove or destroy bloodborne pathogens to the point where they are no longer capable of transmitting infectious particles. 

Engineering Controls: Controls such as self-sheathing needles or sharps disposal containers that isolate or remove the bloodborne pathogens hazard. 

Exposure Incident: A specific incident in which blood or other potentially infectious materials may have come into contact with an employee’s eyes, mouth or other non-skin area during an employee’s duties. 

HBV: Hepatitis B virus. 

HIV: Human immunodeficiency virus. 

Licensed Healthcare Professional: A person whose legally permitted scope of practice allows him or her to independently perform the duties of a health care professional and who has obtained a license or certificate indicating his or her competence to practice in the field. 

Medical Wastes/Infectious Wastes: Blood, blood products, bodily fluids, any waste from human and animal tissues; tissue and cell cultures; human or animal body parts removed by means of surgery or autopsy. 

PPE: Equipment worn by an employee to protect themselves from workplace hazards (examples: hard hats, gloves, safety glasses). 

Source Individual: An individual whose blood or other potentially infectious materials may be a source of occupational exposure to an employee. 

Sterilize: The use of a physical or chemical procedure to destroy all microbial life including highly resistant bacterial endospores. 

Universal Precautions: Preventing exposure to bloodborne pathogens by assuming all blood and bodily fluids to be potentially infectious and taking appropriate protective measures. 

Work Practice Controls: Also known as “Administrative Controls.” Controls that reduce the likelihood of exposure by altering the manner in which a task is performed. 

Responsibilities 

Management 

Management will be responsible for implementing, supporting, and enforcing this program. 

Supervisors are responsible for leading the program implementation and for ensuring that the safe work practices in this program are utilized. Supervisors must also ensure exposure control in their work areas. 

The manager of the Bloodborne Pathogen Program is responsible for the overall development, implementation, and continuous improvement of this program at all company locations. 

Employees are responsible for using the knowledge gained in training, including: 

• Identifying tasks that pose a risk of occupational exposure to bloodborne pathogens 
• Conducting work in accordance with company procedures 
• Utilizing universal precautions 
• Practicing proper hygiene to prevent exposures 

General Work Procedures 

Protecting employees from bloodborne pathogens is a critical part of an effective safety and health program. In order to do so, there must be training to ensure that employees understand how to recognize risk factors and that they understand the controls put in place to reduce risk. Any time employees will interact with bloodborne pathogens, it is critical that they receive the tools and training to be safe and successful. 

All employees must follow the following procedures for controlling exposure to bloodborne pathogens: 

• Supervisors must ensure that affected employees are trained in proper work practices, universal precautions, the use of personal protective equipment (PPE), and proper cleanup and disposal techniques. 
• The company will provide readily accessible hand washing facilities for employees and will ensure that, after a potential exposure event, employees are instructed to wash their hands and any other potentially exposed area with soap and water. 
• Engineering controls will be examined and maintained on a regular schedule to ensure their effectiveness. 
• The company will provide resuscitation equipment and other ventilation equipment to eliminate the need for direct mouth-to-mouth contact for employees whose jobs would require them to perform resuscitation and first aid. 
• Eating, drinking, smoking and applying contact lenses or cosmetics will be prohibited in areas where exposure to bloodborne pathogens is possible. Do not store food and drinks in refrigerators or cabinets where potentially infectious materials are stored. 
• Wear disposable latex or vinyl gloves if: 
• You have cuts, abrasions, chapped hands, dermatitis, or similar conditions. 
• You are examining a patient with an open skin wound and active bleeding. 
• You are handling blood, blood products, or body secretions. 
• Wear gowns, aprons, or lab coats whenever there is a possibility that bodily fluids could splash on an employee. 
• Wash your hands as soon as possible after handling potentially infectious materials and after removing protective clothing and equipment. 
• Remove all protective equipment when leaving the work area and if the equipment is contaminated. 
• Place protective equipment in a proper storage container for washing, decontamination, or disposal. 
• Remove contaminated clothing before entering other areas of a building or leaving a building. 

Medical Waste 

• Separate all medical and infectious waste, except for sharp objects, from other waste at the point of origin and place it in double, disposable red bags with “Biohazard” and “Infectious Waste” labels. 
• Place all “sharps,” such as needles, scalpels, and razor blades or broken glass, in puncture-proof, leak-proof, labeled or color-coded containers for proper disposal. 
• Place all infectious waste in leakproof bins or barrels marked “Biohazard” and “Infectious Waste.” These will be collected by a licensed infectious-waste removal company. 
• Disinfect contaminated reusable equipment before washing for reuse. Decontaminate reusable glassware in a 1-to-9 bleach solution before rinsing and acid washing and then sterilize the glassware in an autoclave. 
• Decontaminate floors and other surfaces with a 1-to-9 bleach solution as well. 

Universal Precautions 

In situations in which there is exposure potential, all bodily fluids will be considered infectious and precautions will be taken for infectious diseases. This is known as taking universal precautions. 

Engineering Controls 

Engineering controls will be used where applicable to prevent or minimize exposure to bloodborne pathogens. Consideration and implementation of appropriate, commercially-available, effective and safer medical devices will be documented annually. 

Administrative Controls 

The company will provide hepatitis B vaccinations to employees who are covered under this program and who choose to be vaccinated. The company will document that it offered the vaccine to covered employees, as well as any employee’s decision to accept or decline the vaccine, and the date of vaccination if accepted by an employee. 

Employees must: 

• Take part in evaluating the exposure determination due to the nature of their jobs as shown in Appendix B 
• Use bleach to disinfect any potentially contaminated area 
• Apply bleach with single-use gloves and allow it to sit for 15 minutes 
• Place any single-use gloves that have been contaminated in a biohazard garbage bag and cover 
• Dispose of the biohazard bag according to company procedures outlined in this plan 
• Utilize handwashing facilities as soon as feasible after removal of gloves or other PPE 
• Disposal containers for sharps should be inspected and maintained as well as replaced when necessary to avoid overfilling 

Personal Protective Equipment 

In the event of the need to exercise precautions, personal protective equipment (PPE) used at the ​facility or site​ will be provided to employees. PPE will be chosen based on the anticipated exposure. The PPE will be considered appropriate only if it does not permit fluids to break the barrier potentially exposing employees. Training in the proper use of PPE for specific tasks will be provided initially and annually thereafter for affected employees. 

Any employees using PPE must use the following precautions: 

• Wash hands immediately or as soon as feasible after removing gloves or other PPE. 
• Remove PPE after it becomes contaminated and before leaving the work area. 
• Used PPE may be disposed of in appropriate containers. 
• Wear appropriate gloves when it is possible that there may be hand contact with blood or other bodily fluids or when touching potentially contaminated materials.  Replace gloves immediately if torn, punctured, contaminated or if there is the potential that they have been compromised through other means. 
• Remove and dispose of PPE immediately after use and remove it prior to leaving the work area. 

The procedure for handling used PPE is that it will be immediately disposed of after use in approved bloodborne pathogen containers. 

Housekeeping 

The company will maintain its worksites in clean and sanitary conditions. This will include a written housekeeping schedule which specifies the method for decontamination. Regulated waste will be disposed of in containers which are closable, constructed to contain all contents and prevent leakage, appropriately labeled or color-coded and closed prior to removal to prevent spillage.   

Post-Exposure Evaluation 

Should an employee exposure incident occur, contact the Bloodborne Pathogen Program Manager immediately.  A confidential medical evaluation and follow-up will be conducted as soon as possible by a licensed health care professional.  Following initial first aid, these activities must be performed: 

• Document the routes of exposure and how the employee exposure or potential exposure occurred.  See Appendix C. 
• Identify the source individual if possible. 
• Obtain consent and make appointments to have the exposed employee tested as soon as possible for HIV, HCV and HBV infectivity. 
• The source individual’s test results should also be communicated to the employee’s health care provider.  If the source individual is known to be HIV, HCV and/or HBV positive, new testing need not be performed. 
• Assure that the exposed employee is provided with the source individual’s test results and with information about applicable laws and regulations. 
• Once the employee who was potentially exposed has consented to testing, conduct testing as soon as feasible after the exposure incident for HBV and HIV. 
• If the employee does not give consent, preserve a baseline blood sample for 90 days.  If the employee elects to have the baseline sample tested during this period, testing should be conducted as soon as feasible. 

Reporting and Follow-up 

Any employee who has suffered a cut, needle stick or mucous membrane exposure to another person’s bodily fluids, or who has been exposed to human blood and blood products, must report the incident immediately to the company (nurse, physician, health and safety director). An employee covered under this program, or an employee acting as a “Good Samaritan,” who has been exposed on the job to HIV, HAV, HBV or HCV, will be tested at the time of exposure to determine if the virus has been transmitted. The employee will be retested at 6 weeks, 12 weeks and 6 months after exposure. All testing will be performed at company expense. 

The company will also contact the exposure source and request that person to be tested at company expense. The testing for this person is not mandatory, however, and refusal will not affect his or her employment. Test results will be provided to source and exposed employees within 5 business days of their receipt. Confidentiality will be maintained for both the exposed employee and the exposure source during all phases of the post-exposure program. 

Training 

The company will provide training on the exposure risks of bloodborne pathogens by a qualified individual to any employee whose assigned job duties include first aid, HAZMAT response, custodial work (such as cleaning restrooms) or any other position where exposure potential must be considered. 

All employees in affected jobs will receive initial training upon being hired and yearly thereafter. The training will include: 

• Company policy 
• Methods of warnings (signs, labels, etc.) 
• Types and transmission of bloodborne pathogens 
• OSHA requirements 
• Universal precautions 
• Use and limitations of personal protective equipment (PPE) as well as PPE selection 
• Medical waste disposal procedures 
• Post-exposure treatment and procedures 
• HBV vaccinations 

Recordkeeping 

The company will maintain all exposure reports, training, and vaccination records. OSHA requires that records be kept for the duration of employment plus 30 years except for training records which must be kept for 3 years. Hepatitis B or HIV contracted on the job will be recorded on the OSHA 300 log as an illness. Exposure to bloodborne pathogens from contact with “sharps” will be recorded on the OSHA 300 log if a doctor prescribes treatment with gamma globulin, HBV immune globulin or HBV vaccine. All recordkeeping shall be kept in accordance with OSHA 29 CFR 1910.1020. 

Training records shall be kept for each employee after training is completed. The records will include: 

• Dates of training sessions 
• Contents or a summary of the training session 
• Names and qualifications of trainers 
• Names and job titles of training attendees 

Records will also be kept for any employee exposure in accordance with 29 CFR 1910.1020.  This should include: 

• The name and social security number of the employee 
• A copy of the employee’s hepatitis B vaccinations 
• A copy of results of examinations, medical testing, and follow-up 
• A copy of the licensed healthcare professional’s written opinion 
• A copy of the information provided to the licensed healthcare professional 

The company will ensure that employee medical records are kept confidential and that they are not disclosed or reported without the employee’s express written consent. 

Appendix

Appendix A – Employee Exposure Potential Determination 

Job Title:

1. Housekeeping
2. First Responders
3. Safety

Department/Location 

1. Custodial and HR
2. Plant
3. Plant

Tasks with exposure potential 

1. ​​​​Cleaning public restrooms, picking up trash​ 
2. Performing first aid 
3. Performing first aid 

Note: Part-time, temporary and contract employees are covered by the Bloodborne Pathogens Program.

Appendix B – Administration of Post-Exposure Evaluation and Follow-up 

The Bloodborne Pathogen Program Manager will ensure that licensed health care professionals conducting the employee’s hepatitis B vaccination and post-exposure evaluation and follow-up are given a copy of OSHA’s bloodborne pathogens standard. 

The Bloodborne Pathogen Program Manager will ensure that the health care professional evaluating an employee after a potential exposure incident receives the following information: 

• Routes of exposure 
• Circumstances of exposure 
• Results of the individual’s blood test (if possible) 
• Any relevant employee medical records including vaccinations 

In addition, the Bloodborne Pathogen Program Manager will be responsible for providing the employee with a copy of the evaluating health care professional’s written opinion within 15 days after the evaluation is complete. 

Appendix C – Form for Evaluating an Exposure Incident 

1. ​​Name of responsible person or department ​ will investigate the incident to determine: 
2. ​​Name of involved employee ​was the employee involved in the exposure incident. 
3. What engineering controls were in use at the time? 
4. Work practices or procedures that were followed: 
5. A description of route of exposure (device being used, tool, etc.): 
6. PPE used at the time: 
7. Location of incident: 
8. Description of work being performed: 
9. Employee’s training: 

Appendix D – Hepatitis B Vaccine Declination (Mandatory) 

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

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        Employee Signature Date 

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Employee name (print)