I. INTRODUCTION:

The purpose of this Exposure Control Plan is to eliminate or minimize employee occupational exposure to blood or certain other bodily fluids to comply with the OSHA Bloodborne Pathogens Standard, 29 CFR 1910.1030.

Protecting employees from occupational exposures to disease-causing viruses and bacteria has become an extremely significant issue in many work places. Work situations which present the possibility for contact with blood, body fluid, or biological agents pose infectious disease risks. For example, the Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV) are pathogens that are transmitted through blood and other body fluids.

Several safety studies have been conducted which have focused on the transmission of diseases through occupational exposures. Many of these studies have focused on occupational exposures to Human Immunodeficiency Virus, because individuals who contract this virus later develop Acquired Immune Deficiency Syndrome (AIDS). A few of the published cases are described in the following paragraphs for the purpose of providing examples of occupational exposures to bloodborne pathogens.

Case 1. A hospital worker sustained accidental self-inflicted injection of "several milliliters of blood while obtaining blood in a vacuum collection tube from an AIDS patient." The worker subsequently sero-converted to an HIV-antibody positive status and has since developed AIDS.

Case 2. A U.S. Navy hospital corpsman punctured his fingertip while disposing of a phlebotomy needle from a patient (who was later diagnosed with AIDS). The Corpsman remained HIV-negative for 6 months before sero-converting to a HIV-positive status.

Case 3. A laboratory worker who handled HIV-concentrated materials tested sero-positive for the virus. The worker did not recall any direct skin exposure, but did report having dermatitis of the arm. The worker also reported instances of handling materials while wearing gloves which had pinholes and tears.

To address the hazards associated with occupational exposures to disease-causing agents, the Federal Occupational Safety and Health Administration (OSHA) issued a final rule which covers all employees who may be exposed to bloodborne pathogens through work-related contact with blood or other potentially infectious materials. Employers at ANY facility who have workers who handle, or who have the potential to come into contact with blood, other body fluids which may contain bloodborne pathogens, or contaminated items, must comply with this regulation.

II. BACKGROUND INFORMATION:

Prior to the promulgation of the Bloodborne Pathogen Standard, OSHA had no specific regulation designed to control or reduce occupational exposures to bloodborne viruses. Subsequently, OSHA relied on general occupational standards for regulatory guidance on issues pertaining to biological hazards.

In 1983 OSHA issued a set of voluntary guidelines designed to reduce the risk of occupational exposure to the Hepatitis B Virus. The Hepatitis B Virus has long been recognized as a pathogen capable of causing serious illness and death. The voluntary guidelines, which were sent to employers in the healthcare industry, included a description of the disease, recommended work practices, and recommendations for use of the Hepatitis B Vaccine.

In 1986, The American Federation of State, County and Municipal Employees requested that OSHA issue a standard which mandated that employers implement the work practice guidelines developed by the Center for Disease Control and amend the Hazard Communication Standard to require training for employees exposed to infectious diseases. Also in that year, several agencies (the Service Employees International Union, the National Union of Hospital and Healthcare Employees, and the Drug, Hospital and Healthcare Union) petitioned the agency to promulgate a standard to protect healthcare workers by adopting the voluntary guidelines as regulatory requirements.

In 1987 in response to these requests, OSHA published an Advance Notice of Proposed Rule-making. Another motivation for OSHA’s notice of proposed rule-making publication was the result of studies which focused on the Human Immunodeficiency Virus (HIV). Though the transmission of the Human Immunodeficiency Virus is considerably less efficient than Hepatitis B Virus, occupational contact with Human Immunodeficiency Virus became a significant concern because exposure to Human Immunodeficiency Virus apparently leads to the development of Acquired Immune Deficiency Syndrome (AIDS).

The final standard, published in 1991, is based on the written and oral comments received during public hearings from employees, labor union representatives, members of trade and professional organizations and other affected groups.

III. OCCUPATIONS AT RISK:

The reason that the Bloodborne Pathogen Standard impacts so many diverse fields becomes obvious after analyzing work-related duties to determine where the potential for exposure to bloodborne pathogens occurs.

The Occupational Safety and Health Administration (OSHA) requires employers to determine which employees may, through the performance of their regular responsibilities, be exposed to blood or other potentially infectious substances. In accordance with OSHA regulations, the exposure determination should be made assuming that the employee is not using personal protective equipment. Employers are required to list all job categories in which an employee MAY BE exposed to such infectious substances regardless of frequency. Monmouth University has determined that employees in the following positions may be exposed to blood or other potentially infectious materials:

Athletic Trainers, Coaches, and Fitness Trainers
Custodians
Fire and Safety Personnel
Groundskeepers
Health Center Personnel Physicians, Nurses, & Administrative Staff)
Lifeguards
Physical Education Faculty
Plumbers
Police Officers
Residential Life Administrative Staff
School For Children Employees
Service Response Personnel

Custodial Staff, Groundskeepers, Service Response Personnel and Plumbers may manage wastes containing contaminated items, or clean toilets, sinks, and other areas which are potentially contaminated with infectious materials.

Through the Human Immunodeficiency virus does not readily survive in environments such as toilets, sinks, and linens the Hepatitis B Virus is viable in conditions which immediately destroy other bloodborne pathogens. Custodial staff, police officers, and lifeguards must protect themselves from exposures to body fluids and potentially infectious materials.

School for Children and Health Center staff always face the possibility of contact with blood or other body fluids whenever they handle students. Because these employees have the opportunity for direct contact with blood or other body fluids, they are at risk for contracting the Human Immunodeficiency Virus, Hepatitis B, and other bloodborne pathogens.

Police Officers, Residential Life Staff, Fitness Trainers, Athletic Trainers and Coaches, Physical Education Faculty and lifeguards also have the potential to be exposed to bloodborne pathogens when they treat or assist accident victims or people experiencing medical difficulties. Waste removal personnel may handle containers of potentially infectious materials. Police officers, in the line of duty, may be exposed to contaminated drug paraphernalia or come into contact with people who are injured or who, through violence, present an exposure risk.

IV. SCOPE AND APPLICATION:

This standard applies to all employees at Monmouth University who in the performance of their responsibilities may come in contact with blood or other potentially infectious material.

Responsibility:

Department Heads and Supervisors are directly responsible for the safety of those they supervise. They are accountable to senior management for all safety issues concerning the workers they supervise. Some of their responsibilities are:

Ensuring workers know and adhere to the procedures defined in this Exposure Control Plan.

Ensuring that protective equipment is available, and in good working order and is used when necessary.

Performing regular hygiene, housekeeping and equipment maintenance inspections.

Determining required levels of personal protective equipment; and immediately informing the Director of Affirmative Action, Human Relations and Compliance when an employee has been exposed to potentially infectious materials.

Ensuring that new employees do not perform any tasks where there is a potential for exposure until the employee has completed Bloodborne Pathogens training.

Ensuring that employees, under their supervision, complete the annual refresher training.

Monmouth University will provide the safest work environment possible, however, employees are expected to:

Avoid unsafe practices.
Follow all prescribed safety procedures.
Report all unsafe conditions to their Department Head or Supervisor.
Label containers and samples containing potentially infectious materials appropriately
Be familiar with all hazards in their work area, biological or otherwise
Utilize all protective equipment provided and practice good hygiene

V. OVERVIEW OF STANDARD REQUIREMENTS:

One of the requirements of the Bloodborne Pathogen Standard is that employees be informed of the contents of the regulation. The following sections review some of the most important elements of the Bloodborne Pathogen Standard.

A. Universal Precautions

Universal precautions will be observed at the University in order to attempt to prevent contact with blood or other potentially infectious materials. The principle of universal precautions is a conservative approach to infectious control. Simply, the concept of Universal Precautions is:

ALL HUMAN BLOOD AND CERTAIN BODY FLUIDS ARE TREATED AS IF THEY ARE KNOWN TO BE INFECTIOUS FOR HIV, HBV, AND OTHER BLOODBORNE PATHOGENS.

Employees at Monmouth University must practice this approach whenever they handle blood, body fluids, or other potentially infectious materials. By making this assumption, employees will avoid all contact with potentially contaminated items by following standard safety precautions, using proper safety controls, and wearing appropriate personal-protective equipment.

The advantages in this approach are obvious. Employees who come in contact with people or who handle blood, blood products, or other body fluids often have no idea whether they may be exposed to viruses. For example, source individuals (any individual, living or dead, whose blood or other potentially infectious fluids may be a source of occupational exposure to the employee) may show no obvious symptom of carrying the virus. Unconscious accident victims will not be able to inform rescue units of their medical status. Vials of blood or blood products may not have appropriate warning labels, or these items may not have been tested for bloodborne pathogens. Waste containers may hold needles, personal-hygiene items, or other contaminated waste. Using Universal Precautions takes the guesswork out of how to respond to potential exposure situations safely.

B. Engineering and Work Practice Controls

It is the University’s policy to use engineering controls and work practices to eliminate or minimize employee and student exposure to bloodborne pathogens. Personal protective equipment must be worn when the potential for occupational exposure remains after these controls have been implemented.

Engineering controls are those devices which isolate or remove the bloodborne pathogen hazards from the work place. These engineering controls are routinely examined as part of an inspection program. The table below lists the engineering controls, which have been implemented, where appropriate, to protect employees from potential exposure situations. This table also provides information on the inspection schedule for these controls.

Engineering Controls and Inspection Schedule
 

The following sections describe the engineering controls and work practices, which should be practiced by University employees.

Hand-Washing Facilities and Eye-Wash Stations:

Hand-washing facilities and eye-wash stations, which are readily accessible, have been made available to all employees, in accordance with the Federal standard.

Employees must wash their hands at these facilities every time they come in contact with items containing or contaminated with potentially infectious agents.

Where the construction of hand-washing facilities is not feasible, Monmouth University will provide an antiseptic hand cleanser. Employees must wash their hands with running water as soon as possible after using these antiseptic cleansers.

Site Locations of Hand-Washing Facilities:

In every Rest Room, Laboratories, School for Children, Health Center, Residence Halls, Monmouth University Police and Safety Department, all other permanent buildings and the William Boylan Gymnasium.

Site Locations of Eye-Wash Stations:

• Facilities Management in the hallway near the time clock.
• Auto Mechanics Shop on the wall between the second and third garage door (eyewash and shower).
• Edison Science Building boiler room in corridor between lab doors 7 & 8 (eyewash and shower).
• Edison Science Building, Rooms 213, 232, 235, 238, 238A (eyewash and shower).
• Student Center boiler room just down form the stairs near the elevator.
• Wilson Hall first landing of west staircase (MU photographer lab eyewash bottle station).
• Health Center Room 2
• Gym trainer room, on the north wall.
• Art workshop, A-1, near sink in the south room
• 600 Building, Room 608

Safe Work Practices:

Safe Work practices are defined as those procedures which have been developed by Monmouth University to reduce or eliminate employee exposures to bloodborne pathogens during the execution of their work tasks.

Employees should understand these procedures fully, and they must implement these practices when appropriate.

The Importance of Avoiding Routine Exposures:

A majority of biological contaminations are the result of small sprays, splashes or mists. Most of these contaminations do not cause an immediate, adverse health effect. Therefore, many workers do not fully appreciate the hazards they face during the completion of certain work tasks. Employees must realize that one accidental exposure to bloodborne pathogens can result in serious health effects. All the procedures described in this Exposure Control Plan and associated training program must be strictly followed by employees.

Basic Hygiene:

The following basic hygiene procedures are mandatory under the Bloodborne Pathogen Standard, 29 CFR 1910.1030. These procedures have been implemented by the University and must be followed by employees who may be exposed to bloodborne pathogens.

All procedures involving blood or other potentially infectious materials shall be performed in such a manner to prevent or minimize splashing, spraying, spattering, and generation of droplets of these substances. Employees must wash their hands immediately after removal of gloves or other personal protective equipment (or as soon as feasibly possible).

If accidental skin contamination occurs, the area should be washed with copious amounts of soap and water for 15 minutes. If the eyes or mucous membranes are accidentally contaminated, they should be flushed with water for at least 15 minutes. All accidental exposures must be immediately reported to the employee’s immediate supervisor as soon as possible.

Additional Safe-Work Procedures:

Loose hair and clothing should be confined when in work areas where potential exposure to bloodborne pathogens may occur. Horseplay and other behavior which might confuse, startle, or distract workers will not be tolerated.

All areas of potentially exposed skin shall be washed before leaving the work area. Water and a mild soap, or an antiseptic cleanser, should be used for skin cleansing.

Solvents are not to be used as skin cleansers. They remove the natural protective oils from the skin and can cause irritation and inflammation.

Employees with acne, dermatitis, open wounds, or other skin problems,should be extremely cautious when involved in potential exposure situations. Employees with skin problems should review safe work procedures with their supervisors.

Contaminated Needles and Other Sharps Handling Procedures:

The following procedure regarding handling sharps is mandatory under the Bloodborne Pathogen Standard. These procedures have been adopted by the University and must be followed by employees who may be exposed to bloodborne pathogens.

Contaminated needles and other contaminated sharps shall not be bent or recapped. Contaminated needles and other contaminated sharps will not be removed, bent, or recapped unless it is done by using a mechanical device or a one-handed technique. Shearing or breaking of contaminated needles is forbidden.

Contaminated, reusable sharps must be placed in appropriate containers immediately after use (or as soon as reasonably possible) until properly processed. These containers must be puncture resistant, labeled (and/or color coded) in accordance with the Federal standard. All sharps containers must be leak-proof on the sides and bottoms. (See Monmouth University Regulated Medical Waste Program for disposal of sharps.)

Site Locations of Sharps Containers:

1. Health Center in each of the four examining rooms and in the pharmacy.

2. Boylan Gymnasium in the Sports Medicine Facility.

3. Edison Science Building, second floor, Room 223 (locked in office).

Actions Prohibited in Work Areas:

The following work area policies are mandatory under the Bloodborne Pathogen Standard, 29 CFR 1910.1030. These procedures have been adopted by the University and must be followed by employees who may be exposed to bloodborne pathogens.

Eating, drinking, smoking and applying cosmetics is forbidden in areas where there is a reasonable possibility of occupational exposure to potentially infectious materials.

Food and beverages must not be kept in refrigerators, freezers, shelves, cabinets, or on bench-tops where blood or other potentially infectious materials are present. Mouth pipetting or suctioning of blood or other potentially infectious materials is prohibited.

Employee Exposure Situations and Safe Work Practices:

Since medical history and examinations cannot reliably identify all persons infected with bloodborne pathogens, precautions must be used by employees to prevent any contact with blood and body fluids. This approach, which is recommended by the Center for Disease Control, is referred to as "Universal Blood and Body Fluid Precautions" or "Universal Precautions."

The following safe work practices for exposed and potentially exposed workers are advocated by the Center for Disease Control:

1. All exposed and potentially exposed workers will use appropriate barrier precautions to prevent skin and mucous membrane exposure when contact with blood and body fluids is anticipated.

2. Gloves must be worn when touching blood, body fluids, mucous membranes, or non-intact skin.

3. Gloves must be worn when handling items or surfaces contaminated with blood or body fluids.

4. Masks and protective eyewear or face shields should be worn during procedures that are likely to generate droplets of blood or other body fluids in order to prevent exposures of the mucous membranes of the mouth, nose and eyes.

5. Gowns or aprons should be worn during procedures that are likely to generate splashes of blood or other bodily fluids.

6. Hands and other skin surfaces should be washed immediately and thoroughly with water and antiseptic cleanser if contaminated with blood or other bodily fluids.

7. Hands should be immediately washed after gloves are removed.

8. Employees must take precautions to prevent injuries caused by needles, scalpels and other sharp instruments or devices during or after medical procedures, when cleaning instruments and during disposal of used needles.

9. To prevent needle-stick injuries, needles should not be recapped, purposely bent or broken by hand, removed from disposable syringes or otherwise manipulated by hand.

10. After they are used, disposable syringes, needles, scalpel, blades and other sharp items must be placed in puncture-resistant containers for disposal. These containers should be as close as practical to the area where disposable sharps are used.

11. Mouthpieces, resuscitation bags or other ventilation devices should be available for use in areas in which the need for resuscitation procedures is reasonably anticipated.

12. Healthcare workers who have exuding lesions or weeping dermatitis must refrain from handling patients and patient-care equipment until the condition is resolved.

13. Pregnant employees should review safe work procedures with supervisors and Human Resources.

Containerization Procedures:

The following containerization procedures are mandatory under the Bloodborne Pathogen Standard, 29 CFR 1910.1030. These procedures are described in the Monmouth University Regulated Medical Waste Program.

Specimens of blood or other potentially infectious materials shall be placed in containers which prevent leakage during collection, handling, processing, storage, transport or shipping. These containers must be closed prior to being stored, transported or shipped. Containers for storage, transport or shipping will be labeled in accordance with the standard and the Monmouth University Regulated Medical Waste Program.

Special Note: According to the Federal standard, facilities that utilize Universal Precautions in the handling of all specimens, the labeling/color-coding of specimen containers is not necessary if these containers are easily recognizable as holding potentially infectious agents. This exemption only applies while such containers remain within the facility. Labeling/color-coding is mandated for those containers when they leave the facility. However, it is prudent practice to label ALL containers with the contents of the container and their associated hazard.

If outside contamination of the primary container occurs (or if specimens contained within the primary container could puncture that container), the primary container must be placed within a secondary container which prevents leakage during handling, processing, storage, transport or shipping. The secondary container has to be puncture-resistant and labeled/color-coded under the requirements of the standard.

Equipment-Handling Procedures:

The following equipment-handling procedures are mandatory under the Bloodborne Pathogen Standard, 29 CFR 1910.1030. These procedures have been adopted by the University and must be followed by employees who may be exposed to bloodborne pathogens.

Equipment which may become contaminated with blood or other potentially infectious materials will be examined prior to servicing or shipping and will be decontaminated, when necessary.

A label prepared in accordance with the Federal standard and the section on labels in this document will be attached (if necessary) to the equipment, stating which portions remain contaminated. Designated employees of the University will ensure that appropriate hazard information is conveyed to all affected employees, as well to servicing and repair representatives.

Special Procedures for Glassware:

The following procedures are prudent practices and are not mandated by the Federal standard. Nonetheless, they are required by the University.

1. Accidents involving glassware are a significant cause of injuries in laboratories and related facilities. Broken glassware should be swept up. It should not be picked up by hand.

2. Glassware should be handled carefully and stored properly.

3. Damaged items need to be repaired or discarded.

4. Hand protection must be worn when inserting rubber stoppers or corks into glassware, or when placing rubber tubing on glass hose connections.

5. Proper instruction on the use of specialized glassware must be obtained.

6. Equipment must be used only for its intended purpose.

7. Employees should ask their supervisors if they are unsure how to handle equipment or if they feel items are not being used properly.

Working Alone and Unattended Operations

The following procedures are prudent practices and are not mandated by the Federal standard. Nonetheless, they should be followed by all University employees.

1. Employees should not work alone in a laboratory if the procedure being conducted is hazardous.

2. If employees must work alone, due to the constraints of an experiment or analysis, they should:

(a) Review the operations with their supervisor to determine if the operations can be conducted alone safely.

(b) Arrange to have Police personnel or another employee check them on a regularly scheduled basis when they work alone.

3. If a reaction or other operation is to be unattended for any length of time, employees must:

(a) Leave on the lights in the work place.

(b) Place an appropriate sign on the door; and

(c) Provide for containment of the materials being used, should an event such as a power failure occur.

Universal Personal Protective Equipment Policy

Monmouth University provides, at no cost to the employee, appropriate personal protective equipment for personnel who may be exposed to bloodborne pathogens. The following lists the personnel protective clothing available at the University and how to obtain these supplies:
 

Gloves:

The routine use of gloves is one of the most basic safety procedures used to protect employees from the hazards associated with infectious agents. Gloves must be worn whenever there is an opportunity for hand-contact with blood, blood products, mucous membranes, non-intact skin and other potentially infectious materials or contaminated items and surfaces.

Disposable Gloves:

Disposable gloves (such as surgical or examination gloves) should be replaced promptly if they are torn, punctured or their ability to function as a protective barrier is compromised in any way. Disposable gloves should not be washed or decontaminated for re-use. They should be properly discarded in compliance with the University Policy on Disposal of Regulated Medical Waste.

Gloves That Are Re-Used:

Utility gloves (gloves designed for more than a single use) may be decontaminated for re-use if the integrity of the glove is not compromised. Prior to use, to ensure that these gloves have no leaks, employees should blow air into the glove; seal the glove at the neck; and, determine if there is a release of air from holes in the glove. Utility gloves must be discarded if they are cracked, peeling, torn, punctured or exhibit other signs of deterioration.

Hypoallergenic Gloves:

Hypoallergenic gloves, glove liners, powderless gloves or other similar protective gear are available to employees who are allergic to the gloves normally provided. Employees who require such items should contact their supervisor.

Face Protection:

Masks, in combination with eye protection devices (i.e. goggles, safety glasses with shields, face shields) must be worn when splashes, spray, splatter or droplets of blood or other potentially infectious materials may be generated and contamination of the eyes, nose or mouth can be reasonably anticipated.

Other Protective Apparel:

Gowns, aprons, lab coats or other similar outer garments should be worn in occupational exposure situations. The type of garment should be selected based on the he degree of anticipated exposure. Employees should contact their supervisor if they have any questions concerning the type of personal protective apparel appropriate for certain job tasks. Such clothing will not be worn outside of designated work areas.

If protective clothing is penetrated by blood or potentially infectious materials, these items must be removed immediately (or as soon as feasible). All personal protective equipment should be removed prior to leaving the work area. Laundering, disposal, repair and/or replacement of this equipment will be done at no cost to the employee.

For routine work situations, closed toe shoes should be worn at all times.

According to the Federal standard, the employee may temporarily and briefly decline to use this equipment when, in the employee’s professional judgment, its use prevents the delivery of healthcare or poses an increased hazard to the employee or co-worker. However, when this happens, the circumstances shall be thoroughly investigated in order to determine whether a change can be made to better address the matter.

University Schedule for Cleaning and Method of Decontamination:

Effective housekeeping is essential to minimize all occupational hazards. Good housekeeping is critically important to protect workers from the hazards associated with potentially infectious agents. This section is dedicated to describing the pertinent housekeeping procedures at this facility.

Monmouth University strives to maintain its work sites in a clean and sanitary condition. To do so, a rigorous cleaning schedule for the various work areas which contain potentially infectious materials has been instituted. The following describes the cleaning protocol used at the University.

Housekeeping Procedures for Equipment:

The following housekeeping procedures for equipment are mandatory under the Bloodborne Pathogen Standard, 29 CFR 1910, 1030. These procedures have been implemented by the University and must be followed by employees who may be exposed to bloodborne pathogens.

Decontamination of Equipment:

All equipment and working surfaces will be decontaminated after contact with blood or other potentially infectious materials. Work surfaces will be washed with disinfectant after completion of procedures which lead to contamination of these surfaces.

Work surfaces will be cleaned at the end of the work shift when operations conducted during the shift involve potentially infectious materials. Protective coverings, such as plastic wrap, aluminum foil, or imperviously-backed absorbent paper used to cover equipment and surfaces must be replaced as soon as feasible when they become overtly and contaminated or at the end of the work shift. All bins, pails, cans, and similar receptacles intended for reuse which may be expected to become contaminated with blood or other potentially infectious materials will be routinely inspected, cleaned, and decontaminated whenever they become visibly contaminated.

Housekeeping Procedures for Waste Materials:

The following housekeeping procedures for waste materials are mandatory under Bloodborne Pathogen Standard, 29 CFR 1910. 1030. These procedures have been implemented by the University and must be followed by employees who may be exposed to bloodborne pathogens.

[A] Housekeeping Procedures for Sharps:

Broken glassware which may be contaminated should never be picked up directly with the hands. A brush and dustpan, tongs or forceps should be used to clean up broken glassware. Employees are required to wear gloves every time they clean- up broken glassware.

[B] Waste Sharps:

Contaminated sharps must be discarded immediately after use. Containers for waste sharps shall be:

Closable.
Puncture Resistant.
Leak-proof on sides and bottom.
Labeled/color-coded according to the Federal standard and the chapter on labels in this document.
Easily accessible to personnel (i.e. found close to the work areas where potentially infectious materials are handled).
Maintained upright throughout use.
Disposed of monthly unless disposal required more frequently.

When moving containers of contaminated sharps from the area of use, the containers will be closed immediately prior to removal to prevent the accidental release of contents or placed in a secondary container if leakage is possible. This secondary container must be closable, constructed to contain all contents and prevent leakage during handling, storage, transport or shipping, and labeled/color- coded according to the Federal standard and the section designated "Label Requirements" in this document. (See Monmouth University Regulated Medical Waste Program).

[C] Containers for Other Potentially Infectious Wastes:

Containers for other potentially infectious wastes generated during procedures conducted at Monmouth University must be:

Closable.
Constructed to contain all contents and prevent leakage of fluids during handling, storage, transport or shipping;
Labeled/color-coded according to the Federal standard and the section entitled "Label Requirements" in this document; and
Closed prior to removal to prevent the accidental release of materials.

If outside contamination of the waste container occurs, the primary container will be placed in a secondary container. The secondary container must be closable, constructed to contain all contents and prevent leakage during handling, storage, transport or shipping, labeled/color-coded according to the Federal standard and the section designated "Label Requirements" in this document, and closed prior to removal to prevent the accidental release of materials (see Monmouth University Regulated Medical Waste Program).

[D] Housekeeping Procedures for Laundered Items:

Contaminated laundry will be handled as little as possible with a minimum of agitation. Contaminated laundry will be containerized in the area of use and shall not be sorted or rinsed in the location of use. Wet laundry which presents a potential leak problem will be placed in leak-proof containers. Contaminated laundry will be placed in containers which are labeled/color-coded according to the Federal standard and the section on labels in this document.

Special Note: According to the Federal standard, facilities that utilize Universal Precautions in the handling of all soiled laundry, the labeling/color-coding of laundry containers is not necessary if alternative labeling or color-coding permits all employees to recognize Universal Precautions must be used with these items. This exemption only applies while such containers remain within the facility. Labeling/color-coding is mandated for those containers when they leave the facility. However, it is prudent practice to label ALL containers with the contents of the container and their associated hazard.

Employees who have contact with contaminated laundry must wear gloves and other appropriate personal protective equipment, as deemed necessary for the safe handling of laundry. Employees should contact their supervisor if they have any questions concerning the type of personal protective apparel appropriate for certain job tasks.

VI. EMPLOYEE EXPOSURE DETERMINATION

The purpose of the "Employee Exposure Determination" is to make employees aware that:

They may be exposed to bloodborne pathogens during the performance of certain work tasks.

Specific job-related duties place them at risk for exposures to potentially infectious materials.

They should not perform these tasks until they have received Bloodborne Pathogens training and they have been offered the opportunity to receive Hepatitis B vaccination.

They must review safety information and safe-work procedures specific to the duties they are performing and the type of pathogens to which they may be exposed.

They should assess their health status (i.e. if they have open wounds, whether they have had vaccinations for Hepatitis B) before performing duties that could place them at risk of receiving an exposure to bloodborne pathogens.

Employee Exposure Determination: Medical Staff - Physicians, Nurses, Etc.
 

The following safe work practices apply to the general duties associated with physician-care, nursing and other medical activities.

1. Follow Universal Precautions at all times.

2. Protective eyewear or face shield should be worn for invasive procedures that commonly result in the generation of droplets, splashing of blood, other body fluids or bone chips.

3. If a glove is torn, the glove must be removed and replaced promptly.

4. If needle-stick or other instrument-related injury occurs, the needle or instrument involved in the incident should be removed from the sterile field.

Employee Exposure Determination: Custodial Employees
 

The following safe work practices apply to the general duties associated with custodial employee activities.

1. Custodial employees must wear waterproof gloves and eye protection whenever they clean toilets, bathrooms and other facilities.

2. Custodial employees should not handle discarded needles, syringes and other potentially contaminated sharps. If they encounter a situation where needles, syringes or other potentially contaminated sharps are present, they should contact their supervisor immediately.

3. Custodial employees must wear gloves whenever they handle or expect to handle discarded condoms, sanitary napkins and other similar items.

4. Surfaces and items contaminated with blood or other body fluids should be cleaned with a bleach solution (1:10 to 1:100 dilution of household bleach) or approved disinfectant.

Employee Exposure Determination: Service Response Personnel, Groundskeepers
 

The following safe work practices apply to the general duties associated with Service Response Team and Groundskeeper activities:

1. Protective gloves must be worn whenever trash and recyclable items are handled.

2. Discarded needles, syringes and other potentially contaminated sharps should not be handled. If a situation is encountered where needles, syringes or other potentially contaminated sharps are present, the supervisor should be contacted immediately.

3. Waterproof gloves must be worn whenever discarded condoms, sanitary napkins and other similar items are handled.

4. Employees’ hands should be washed immediately after removing waterproof gloves.

Employee Exposure Determination: Plumbers
 

The following safe work practices apply to the general duties associated with Plumbers’ activities:

1. Plumbers must wear waterproof gloves whenever they unclog toilets, sinks and shower drains or when they handle or expect to handle discarded condoms, sanitary napkins and other similar items.

2. Plumbers must wear waterproof gloves when handling items or surfaces obviously contaminated with blood or body fluids.

3. Plumbers must wear protective eyewear or face shield and protective, waterproof clothing when splashing of contaminated liquids is anticipated.

4. Plumbers should not handle discarded needles, syringes and other potentially contaminated sharps. If they encounter a situation where needles, syringes or other potentially contaminated sharps are present, they should contact their supervisor immediately.

5. Employees’ hands should be washed immediately after removing waterproof gloves.

6. Clothing which becomes contaminated with blood or other body fluids during repair work should be removed immediately (or as soon as possible) and separated from other clothing until properly laundered.

Employee Exposure Determination: Fire and Safety Personnel
 

The following safe work practices apply to the general duties associated with Fire and Safety activities:

1. Fire and Safety personnel must wear protective gloves whenever they handle regulated medical wastes or bio-hazardous materials.

2. Fire and Safety personnel must take precautions to prevent injuries caused by needles, syringes and other sharp objects. Fire and Safety personnel should always pay attention to their hands whenever they handle discarded needles, syringes and other sharp objects. Whenever Fire and Safety personnel encounter a situation where needles, syringes or other potentially contaminated sharps are present, they should always wear protective gloves and whenever feasible, use hemostats to pick-up sharps and place them into appropriate sharps containers.

3. Fire and Safety personnel must wear waterproof gloves whenever they expect to handle materials.

4. Employees’ hands should be washed immediately after removing waterproof gloves.

5. Clothing which becomes contaminated with blood or other body fluids during transport or retrieval of Regulated Medical Wastes or bio-hazardous materials should be removed immediately (or as soon as possible) and separated from other clothing until properly laundered.

Employee Exposure Determination: Police Officers
 

The following safe work practices apply to the general duties for employees of the Police Department:

1. Gloves must be worn by law enforcement employees whenever they anticipate touching blood, body fluids, mucous membranes or non-intact skin while they conduct their operations.

2. Gloves must be worn when handling items or surfaces obviously contaminated with blood or body fluids.

3. Hands and other skin surfaces should be washed immediately and thoroughly with water and antiseptic cleanser if contaminated with blood or other body fluids.

4. Hands should be immediately washed after gloves are removed.

5. Employees must take precautions to prevent injuries caused by needles, syringes and other sharp objects. Law enforcement employees should always pay attention to their hands whenever they handle needles, syringes and other sharp objects.

6. Mouthpieces, resuscitation bags, or other ventilation devices should be available to those officers who may reasonably be expected to perform CPR.

7. Clothing which becomes contaminated with blood or other body fluids during operations should be removed immediately (or as soon as possible) and separated from other clothing until properly laundered.

8. Areas and equipment which become contaminated with blood or other body fluids should be cleaned immediately with a bleach solution (1:10 to 1:100 dilution of household bleach).

9. Pregnant employees should review safe work procedures.

10. Whenever employees handle uncooperative individuals, they should attempt to keep the individual’s back towards themselves. This way, the opportunity to be bitten is minimized because the individual is facing away from the the employee. Employees should always endeavor to obtain additional assistance whenever they handle an uncooperative individual.

Employee Exposure Determination: Sports Team Coaches/Trainers, Fitness Trainers, and Physical Education Faculty
 

The following safe work practices apply to the general duties associated with Team Sports Coaches/Trainers.

1. Gloves must be worn by Coaches/Trainers whenever they anticipate touching blood, body fluids, mucous membranes or non-intact skin while they provide first aid or CPR procedure.

2. Gloves must be worn when handling items or surfaces obviously contaminated with blood or body fluids.

3. Hands and other skin surfaces should be washed immediately and thoroughly with water and antiseptic cleanser if contaminated with blood or other body fluids.

4. Hands should be immediately washed after gloves are removed.

5. Employees must take precautions to prevent injuries caused by needles, syringes and other sharp objects.

6. Mouthpieces, resuscitation bags, or other ventilation devices should be available to those employees who may reasonably be expected to perform CPR.

7. Clothing which becomes contaminated with blood or other body fluids during responses should be removed immediately (or as soon as possible) and separated from other clothing until properly laundered.

8. Areas and equipment which become contaminated with blood or other body fluids should be cleaned immediately with a bleach solution (1:10 to 1:100 dilution of household bleach).

9. Pregnant employees should review safe work procedures with Medical Department personnel.

Employee Exposure Determination: Lifeguards
 

The following safe work practices apply to the general duties associated with lifeguarding:

1. Follow universal and standard precautions at all times.

2. Mouthpieces, resuscitation bags should be available to lifeguards.

3. Gloves must be worn when handling items or surfaces contaminated with body fluids.

4. All contaminated equipment should be cleaned immediately.

Employee Exposure Determination: School for Children Employees
 

The following safe work practices apply to the general duties associated with School for Children Employees.

1. Follow Universal Precautions at all times.

2. Gloves must be worn by School for Children employees whenever they anticipate touching blood, body fluids, mucous membranes or non-intact skin.

3. Gloves must be worn when handling items or surfaces obviously contaminated with blood or body fluids.

4. Hands and other skin surfaces should be washed immediately and thoroughly with water and antiseptic cleanser if contaminated with blood or other body fluids.

5. Hands should immediately be washed after gloves are removed.

6. Employees must take precautions to prevent injuries caused by sharp objects.

7. Clothing which becomes contaminated with blood or other body fluids during responses should be removed immediately (or as soon as possible) and separated from other clothing until properly laundered.

8. Areas and equipment, which become contaminated with blood or other body fluids, should be cleaned immediately with a bleach solution (1:10 to 1:100 dilution of household bleach).

9. School must wear gloves for Children Employees whenever they anticipate touching blood, body fluids, mucous membranes or non-intact skin while they provide first aid or CPR procedure.

10. Mouthpieces, resuscitation bags, or other ventilation devices should be available to those employees who may reasonably be expected to perform CPR or First Aid.

11. Pregnant employees should review safe work procedures with Medical Department personnel.

Employee Exposure Determination: Residential Life Staff
 

The following safe work practices apply to the general duties associated with Residential Life staff activities.

1. Residential Life staff should immediately contact University Police if they encounter any of these situations and wait for direction from the University Police and the Residential Life Administrator on call.

2. Residential Life staff should not handle discarded needles, syringes, condoms, feminine sanitary items and other potentially contaminated materials in the residence halls. If they encounter a situation where needles, syringes or other potentially contaminated materials are present, they should contact the University Police and the Residential Life Administrator on-duty.

3. Residential Life staff should contact the University Police and Facilities Management when they encounter vomit, human waste or other potentially infectious fluids and materials in the residence halls.

VII. HEPATITIS B VACCINE AND POST-EXPOSURE EVALUATION AND FOLLOW-UP

Monmouth University shall make available the Hepatitis B Vaccination series to all employees who may be exposed through their occupation, and post exposure follow-up to employees who have had an exposure incident.

The Director of Affirmative Action, Human Relations and Compliance shall ensure that all medical evaluations and procedures including the Hepatitis B Vaccine and vaccination series and post exposure follow-up, including prophylactics are:

1. Made available at no cost to the employee.

2. Made available to the employee at a reasonable time and place.

3. Performed by or under the supervision of a licensed physician or by or under the supervision of another licensed healthcare professional.

4. Provided according to the recommendations of the U.S. Public Health Service.

All laboratory tests shall be conducted by an accredited laboratory at no cost to the employee.

Hepatitis B Vaccination

The Director of Affirmative Action, Human Relations and Compliance is responsible for monitoring the Hepatitis B vaccination program. We have made arrangements with the Health Center to provide this service.

Hepatitis B vaccination shall be made available after the employee has received the training in occupational exposure (see information and training) unless the employee has previously received the complete Hepatitis B vaccination series, antibody testing has revealed that the employee is immune, or the vaccine is contraindicate for medical reasons.

Participation in a pre-screening program shall not be 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 shall then be made available.

All employees who decline the Hepatitis B vaccination offered shall 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 shall be made available.

VIII. POST EXPOSURE EVALUATION AND FOLLOW-UP

All exposure incidents shall be reported, investigated and documented. When the employee incurs an exposure incident, it shall be reported to the Director of Affirmative Action, Human Relations and Compliance.

Following a report of an exposure incident, the exposed employee shall immediately receive a confidential medical evaluation and follow-up including at least the following elements:

1. Documentation of the route of exposure, and the circumstances under which the exposure incident occurred;

2. Identification and documentation of the source individual, unless it can be established that identification is infusible or prohibited by state or local law.

3. 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, the Director of Affirmative Action, Human Relations and Compliance shall establish 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, shall be tested and the results documented.

4. When the source individual is already known to be infected with HBV or HIV, testing for the source individual’s know HBV or HIV status need not be repeated.

5. Results of the source individual’s testing shall be made available to the exposed employee, and the employee shall be 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:

1. The exposed employee’s blood shall be collected as soon as feasible and tested after consent is obtained;

2. The employee will be offered the option of having their blood collected for testing of the employees HBV/HIV 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 in accordance with the OSHA standard. All post exposure follow-up will be performed by the medical facility listed at the back of this plan.

Information Provided to the Healthcare Professional

The Director of Affirmative Action, Human Relations and Compliance shall ensure that the healthcare professional responsible for the employee’s Hepatitis B Vaccination is provided with the following:

1. A copy of 29 CFR 1910.1030;

2. A written description of the exposed employee’s duties as they relate to the exposure incident;

3. Written documentation of the route of exposure and circumstances under which exposure occurred;

4. Results of the source individuals blood testing, if available;

5. All medical records relevant to the appropriate treatment of the employee including vaccination status.

Healthcare Professional’s Written Opinion

The Director of Affirmative Action, Human Relations and Compliance shall obtain and provide the employee with a copy of the evaluating healthcare professional’s written opinion within 5 days of the completion of the evaluation.

The healthcare professionals written opinion for HBV vaccination shall 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 shall be limited to the following information:

1. A statement that the employee has been informed of the results of the evaluation;

2. A statement that the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation or treatment.

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

IX. LABELS AND SIGNS

The Associate Vice President of Facilities Management or designee shall ensure that biohazard labels shall be affixed to containers of regulated waste.

The universal biohazard symbol shall be used. The label shall be fluorescent orange or orange-red.

Red bags or containers may be substituted for labels. However, regulated waste must be handled in accordance with the rules and regulations of the organization having jurisdiction and in compliance with University Policy.

X. TRAINING AND RECORDKEEPING

Information Training

The Director of Affirmative Action, Human Relations and Compliance shall ensure that training is provided to employees at the time of initial assignment to tasks where occupational exposure may occur, and that it shall be repeated within twelve months of the previous training. Training shall be tailored to the education and language level of the employees and offered during the normal work shift. The training will be interactive and cover the following:

1. A copy of the standard and an explanation of its contents.

2. A discussion of the epidemiology and symptoms of bloodborne diseases.

3. An explanation of the modes of transmission of bloodborne pathogens.

4. An explanation of the Monmouth University Bloodborne Pathogen Exposure Control Plan and a method for obtaining a copy.

5. The recognition of tasks that may involve exposure.

6. An explanation of the use and limitations of methods to reduce exposure, for example engineering controls, work practices and personal protective equipment (PPE).

7. Information on the types, use location, removal, handling, decontamination and disposal of PPEs.

8. An explanation of the basis of selection of PPEs.

9. Information on the Hepatitis B vaccination, including efficacy, safety, method of administration, benefits and that it will be offered free of charge.

10. Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials.

11. An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting and medical follow-up.

12. Information on the evaluation and follow-up required after an employee exposure incident.

13. An explanation of the signs, labels and color coding systems.

The person conducting the training shall be knowledgeable in the subject matter.

Employees who have received training on bloodborne pathogens in the twelve months preceding the effective date of this policy shall only receive training in provisions of the policy that were not covered.

Additional training shall be provided to employees when there are any changes of tasks or procedures affecting the employee’s occupational exposure.

Recordkeeping:

Medical Records (exposure incidents):

The Director of Affirmative Action, Human Relations and Compliance is responsible for maintaining medical records as indicated below. These records will be kept at the Office of Human Resources.

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:

1. The name and social security number of the employee.

2. A copy of the employee’s HBV vaccination status, including the dates of vaccination.

3. A copy of all results of examinations, medical testing and follow-up procedures.

4. 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.

Training Records

The Director of Affirmative Action, Human Relations and Compliance is responsible for maintaining the following training records. These records will be kept at the Office of Affirmative Action, Human Relations and Compliance.

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

1. The dates of the training sessions.

2. An outline describing the material presented.

3. The names and qualifications of persons conducting the training.

4. The names and job titles of all persons attending the training sessions.

Availability of Records

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 proscribed period, the Director of the NIOSH shall be contacted for final disposition.

Evaluation and Review

The Director of Affirmative Action, Human Relations and Compliance is responsible for annually reviewing this program and its effectiveness and for updating this program as needed.

XI. GLOSSARY

The following is a summary of important terms which can be found in the OSHA Bloodborne Pathogen Standard and reference materials that are provided to employees as part of this Company’s information and training programs. Supervisors and employees members may wish to review and become familiar with these definitions.
 

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