Exposure Control Program

Reviewed 01/15

Metropolitan Library System is committed to providing a safe and healthful work environment for the entire staff. In pursuit of this endeavor, this Exposure Control Program (ECP) is provided to eliminate or minimize occupational exposure to bloodborne pathogens as required by PEOSH and in accordance with OSHA standard 29 CFR 1910.1030, “Occupational Exposure to Bloodborne Pathogens”.

The ECP is a key document to assist the organization in implementing and ensuring compliance with the standard, thereby protecting the employees and customers. This ECP includes:

Determination of employee exposure
Implementation of various methods of exposure control, including:
1. Universal precautions
2. Engineering and work practice controls
3. Personal protective equipment
4. Housekeeping
5. Hepatitis B vaccination & Hepatitis B vaccination waiver
6. Post-exposure evaluation and follow-up
7. Communication of hazards to employees and training
8. Record keeping
Procedures for evaluating circumstances surrounding an exposure incident

The methods of implementation of these elements of the standard are discussed in the subsequent pages of this ECP.

Program Administration

The Safety Committee is responsible for the implementation of the ECP and will maintain, review, and update the ECP at least annually, and whenever necessary to include the new or modified tasks and procedures. Those employees who are determined to have occupational exposure to blood or other potentially infectious materials (OPIM) must comply with the procedures and work practices outlined in this ECP.

The Manager of Facilities Maintenance will maintain and provide all necessary personal protective equipment (PPE), engineering controls labels, and red bags as required by the standard. The Director of Facilities Maintenance will ensure that adequate supplies of the aforementioned equipment are available in the appropriate sizes.

The Human Resource Department will be responsible for ensuring that all medical actions required are performed and that appropriate employee health and OSHA records are maintained.

The Human Resource Department will be responsible for training, documentation of training, and making the written ECP available to employees, OSHA, and NIOSH representatives.

Employee Exposure Determination

Metropolitan Library System will perform an exposure determination concerning which employees may incur occupational exposure to blood or other potentially infectious materials. The exposure determination is made without regard to the use of personal protective equipment.

The following is a list of all job classifications at our establishment in which employees have potential occupational exposure:

Job Title	Department/Location
Library Staff	Office, Library, restrooms
Facilities Maintenance Staff	Office, Library, restrooms, parking lot

Methods of Implementation and Control

Universal Precautions
1. Universal precautions will be observed at Metropolitan Library System in order to prevent contact with blood or other potentially infectious material. All blood or other potentially infectious material will be considered infectious regardless of the perceived status of the source individual.
2. Exposure Control Plan -- Employees covered by the bloodborne pathogens standard receive an explanation of this ECP during their initial training session. It will also be reviewed in their annual refresher training. All employees have an opportunity to review this plan at any time during their work shifts by contacting the Human Resource Department or Library Managers. If requested, we will provide an employee with a copy of the ECP free of charge and within 15 days of the request.
3. The Safety Committee is responsible for reviewing and updating the ECP annually or more frequently if necessary to reflect any new or modified tasks and procedures that affect occupational exposure and to reflect new or revised employee positions with occupational exposure.
Engineering Controls and Work Practices controls will be utilized to eliminate or minimize exposure to employees and customers.
1. Hand washing facilities are also available to the employees who incur exposure to blood or other potentially infectious materials. OSHA requires these facilities be readily accessible after incurring exposure. At Metropolitan Library System hand washing facilities are located in the restroom. Where hand washing facilities are not feasible, the Standard allows for antiseptic cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes for use. Employees will be required to wash hands with soap and running water as soon as possible. After removal of personal protective gloves, employees will wash hands and any other potentially contaminated skin area immediately or as soon as feasible with soap and water. If employees incur exposure to their skin or mucous membranes then those areas will be washed or flushed with water as appropriate immediately or as soon as feasible following contact.
2. Needles/Other Sharps -- Contaminated needles and other contaminated sharps (i.e. box cutter blades) will NOT be bent, recapped, removed, sheared or purposely broken. All sharps will be disposed of in a proper sharps container. Acceptable sharps disposal containers are puncture resistant with a tight-fitting lid or seal and properly labeled. Sharps will be removed from normal waste containers with mechanical means only.
3. Work Area Restrictions -- In work areas where there is a foreseeable exposure to blood or other potentially infectious materials, 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, on counter tops or bench tops where blood or other potentially infectious material are present. All procedures will be conducted in a manner that will minimize splashing, spraying, splattering and generation of droplets of blood or other potentially infectious materials.
4. Contaminated Equipment -- Equipment that has become contaminated with blood or other potentially infectious material will be examined prior to servicing or shipping and will be decontaminated as necessary or placed in a biohazard bag.
Personal Protective Equipment
1. All personal protective equipment (PPE) used at Metropolitan Library System will be provided at NO COST to employees. Managers will be responsible for purchasing, maintaining, and distributing of all bloodborne personal protective equipment. Personal protective equipment will be chosen based on the anticipated exposure to blood or other potentially infectious material. The protective equipment will be considered appropriate only if it does not permit blood or other potentially infectious material 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 in which the protective equipment will be used. All used personal protective equipment will be disposed in the proper biohazard waste receptacle. All garments that are penetrated by blood will be removed immediately or as soon as feasible. All used personal protective equipment will be removed prior to leaving the work area. Personal protective equipment will be worn by all employees performing the following tasks:
2. Providing First Aid -- Disposable gloves used at Metropolitan Library System are not to be washed or decontaminated for re-use and are to be replaced immediately when they become contaminated or if gloves are torn, punctured, or when their ability to function as a barrier is compromised. Utility gloves may be decontaminated for re-use provided 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. Masks in combination with eye protection devices, such as goggles or glasses with solid side shield, or chin length face shields, are required to be worn whenever splashes, spray, splatter, or droplets of blood or other potentially infectious material may be generated and eye, nose, or mouth contamination can reasonably be anticipated.
Housekeeping
1. The following areas at Metropolitan Library System will be cleaned and decontaminated according to the following schedule:
  1. Any area where an employee has been injured and blood or body fluids are present
  2. Decontamination will be accomplished by utilizing the following materials: 1:10 to 1:100 bleach solution or EPA registered germicides. All contaminated work surfaces will be decontaminated after completion of procedures and immediately, or as soon as feasible, after any spill of blood or other potentially infectious materials, as well as the end of the work shift if the surface may have become contaminated since the last cleaning. All bins, pails, cans, and similar receptacles will be inspected and decontaminated on a regularly scheduled basis and cleaned and decontaminated immediately, or as soon as feasible, upon visible contamination. Any broken glassware that may be contaminated will not be picked up directly with the hands and will only be picked up with tongs, forceps or similar tool.
2. Regulated Waste Disposal
  1. Regulated waste is placed in containers that are closable, constructed to contain all contents and prevent leakage, appropriately labeled DO NOT RECYCLE, or color-coded red or red-orange, and closed prior to removal to prevent spillage or protrusion of contents during handling.
  2. All contaminated sharps are discarded immediately or as soon as feasible in sharps containers that are closable, puncture-resistant, leak proof on sides and bottoms, and labeled DO NOT RECYCLE. These containers are not to exceed 2/3 capacity before proper disposal.
3. Laundry Procedures
  1. Laundry contaminated with blood or other potentially infectious material will be handled as little as possible. Contaminated laundry will be bagged and containerized at the location where it was used and it will not be sorted or rinsed in the location of use. All employees who handle contaminated laundry will utilize personal protective equipment to prevent contact with blood or other potentially infectious material.
  2. Contaminated laundry will be laundered by a professional method. If contaminated laundry is to be cleaned by an outside source, Metropolitan Library System will inform the outside service of the requirements in 29CFR1910.1030 (d).
4. Labels -- The following will be labeled with the proper biohazard markings: Bloodborne Pathogen Kits, Decon Container, Sharps Containers, and Biohazard Bags.
Hepatitis B Vaccination
1. The hepatitis B vaccination series is available at NO COST within ten (10) working days of initial assignment to employees identified in the exposure determination section of this plan. An employee may choose to decline the vaccination; the employee must sign a declination form (waiver). Employees who initially decline the vaccine, but who later wish to have it may then have the vaccine provided at NO COST. The vaccine will be administered by the appropriate medical clinic. The Human Resource Department is responsible for ensuring the vaccine has been offered and waivers signed for each employee. Metropolitan Library System will not make participation in a pre-screening program a prerequisite for receiving Hepatitis B vaccination.
Post-Exposure Evaluation And Follow-Up
1. All exposure incidents will be reported, investigated, and documented. When the employee/customer incurs an exposure incident, it will be reported to the Human Resource Department within 24 hours of the incident. Following a report of an exposure incident, the exposed employee/customer will immediately receive a confidential medical evaluation and follow up.
2. The source individual’s blood will be tested as soon as feasible and after consent is obtained in order to determine HBV and HIV infectiousness. If consent is not obtained, the Human Resource Department will establish that legally acquired consent cannot be obtained. 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.
3. Results of the source individual’s testing will be made available to the exposed employee, and the employee will be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual.
4. Collection and testing of blood for HBV and HIV serological status will comply with the following:
  1. The exposed individual’s blood will be collected as soon as feasible and tested after consent is obtained.
  2. 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. However, if the exposed employee elects to have the baseline sample tested during this waiting period; perform testing as soon as feasible.
  3. The employee will be given appropriate counseling concerning precautions to take during the period after the exposure incident. The employee will also be given information on what potential illnesses to be alert for and to report any related experiences to appropriate personnel.
5. Administration Of Post-Exposure Evaluation And Follow-Up
  1. Information Provided to the Healthcare Professional
    1. The Human Resource Department will ensure that the health care professional responsible for the employee’s Hepatitis B vaccination is provided with the following:
      1. A copy of 29 CFR 1910.1030, Bloodborne Pathogens Standard;
      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; and
      5. All medical records relevant to the appropriate treatment of the employee including vaccination status.
  2. Healthcare Professionals Written Opinion
    1. The Human Resource Department will obtain and provide the employee with a copy of the evaluating health care professional’s written opinion within 15 days of the completion of the evaluation.
    2. The health care professionals written opinion for HBV vaccination will be limited to whether HBV vaccination is indicated for an employee, and if the employee has received such vaccination.
    3. The health care professionals written opinion for post exposure follow-up will be limited to the following information:
      1. Whether the Hepatitis "B" Vaccine is indicated and if the employee has received the vaccine, for evaluation following an exposure incident and the employee has been informed of the results of the evaluation, and
      2. The employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious material. This opinion will not reference any personal medical information.
Communication of hazards to employees and employee training
1. Training for all employees will be conducted prior to initial assignment to tasks where occupational exposure may occur and reviewed annually. The training will include an opportunity for interactive questions and answers with the person conducting the training session.
2. Training for employees will include an explanation of the following:
  1. The OSHA standard for Bloodborne Pathogens;
  2. Epidemiology and symptomatology of bloodborne diseases;
  3. Modes of transmission of bloodborne pathogens;
  4. This exposure control plan. (i.e. points of the plan, lines of responsibility, how the plan will be implemented, etc.);
  5. Procedures that might cause exposure to blood or other potentially infectious materials at this facility;
  6. Control methods and their limitations, which will be used at the facility to control exposure to blood or other potentially infectious materials;
  7. Personal protective equipment available at this facility and who would be contacted concerning information on the types, proper use, location, removal, handling, decontamination, and disposal of personal protective equipment;
  8. Basis for the PPE selection;
  9. Post exposure evaluation and follow-up;
  10. Signs and labels used at the facility;
  11. Hepatitis B vaccine program at the facility, including information on its efficacy, safety, method of administration, the benefits of being vaccinated and that the vaccine and vaccination will be offered at no cost to employees.
  12. Information on the appropriate actions to take, and persons to contact in an emergency involving blood or other potentially infectious materials;
  13. An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available.
Recordkeeping
1. Training Records are completed for each employee upon completion of training. These documents will be kept in the Human Resources Department. The training records include:
  1. Dates of training sessions;
  2. Contents or a summary of the training sessions;
  3. Names and qualifications of persons conducting the training; and
  4. Names of all persons attending the training sessions.
  5. Employee training records are provided upon request to the employee or the employee’s authorized representative within 15 working days. Such requests should be addressed to the Director of Human Resources.
2. Medical Records
  1. Medical records are maintained for each employee with occupational exposure in accordance with 29 CFR 1910.1020, “Access to Employee Exposure and Medical Records”.
  2. The Human Resource Department is responsible for maintenance of the required medical records. These confidential records are kept for at least the duration of employment plus 30 years.
3. OSHA Record keeping
  1. An exposure incident is evaluated to determine if the case meets OSHA’s Record keeping Requirements (29 CFR 1904). This determination and the recording activities are done by the Human Resource Department.
  2. In addition to the Record keeping Requirements, all percutaneous injuries from contaminated sharps are also recorded in the Sharps Injury Log. All incidences must include at least:
    1. Date of the injury
    2. Type and brand of the device involved
    3. Department or work area where the incident occurred
    4. Explanation of how the incident occurred.
    5. The log is reviewed at least annually as part of the annual evaluation of the program and is maintained for at least five years following the end of the calendar year that they cover. If a copy is requested by anyone, it must have any personal identifiers removed from the report.
Procedures For Evaluating The Circumstances Surrounding An Exposure Incident
1. The Safety Committee will review the circumstances of all exposure incidents to determine:
  1. Engineering controls in use at the time;
  2. Work practices followed;
  3. A description of the device being used (including type and brand);
  4. Personal protective equipment or clothing that was used at the time of the exposure incident (gloves, eye shields, etc.);
  5. Location of the incident (Example: Restroom, library, parking lot, etc.);
  6. Procedure being performed when the incident occurred; and employee’s training.
2. The Library Managers will record all percutaneous injuries from contaminated sharps in the Sharps Injury Log.
3. If it is determined that revisions need to be made, the Safety Committee will ensure that appropriate changes are made to this ECP. (Changes may include an evaluation of safer devices, adding employees to exposure determination list, etc.)

Hepatitis "B" Vaccine Declination (Waiver)

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

Attached Files: Exposure Control Program PDF

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