Exposure Control Plan (ECP) for Bloodborne
Pathogens Mich. Occupational Health Standard 325.70001 Federal OSHA
(29 CFR 1910.1030)
Exposure Control Plan (ECP) for Bloodborne Pathogens Mich. Occupational Health Standard 325.70001 Federal OSHA (29 CFR 1910.1030)
This document serves as the written procedures Bloodborne Pathogens Exposure Control Plan (ECP) for Hope College. These guidelines provide policy and safe practices to prevent the spread of disease resulting from handling blood or other potentially infectious materials (OPIM) during the course of work.
This ECP has been developed in accordance with the OSHA Bloodborne Pathogens Standard, Michigan Health Standard 325.70001 and Federal OSHA 29 CFR 1910.1030. The purpose of this ECP includes:
- Eliminating or minimizing occupational exposure of employees to blood or certain other body fluids.
- Complying with OSHA's Bloodborne Pathogens Standard, 29 CFR 1910.1030.
The Department of Occupatational Health and Fire Safety is responsible
for developing and maintaining the program. A copy of the plan may be
reviewed by employees. It is located in the Occupational Health and Fire
Safety Office(H&FS). In addition, the H&FS office is responsible for
maintaining any records related to the Exposure Control Plan.
This plan is current as of 1/16/15
If after reading this program, you find that improvements can be made,
please contact the H&FS office. We encourage all suggestions because
we are committed to the success of our written ECP. We strive for clear
understanding, safe behavior, and involvement from every level of the
We have determined which employees may incur occupational exposure
to blood or OPIM. The exposure determination is made without regard to
the use of personal protective equipment (i.e., employees are considered
to be exposed even if they wear personal protective equipment).
Job Classes: Global Risk of Exposure
This exposure determination is required to list all job classifications
in which all employees may be expected to incur such occupational exposure,
regardless of frequency. At this facility the following job classifications
are in this category:
- Athletic Trainers, Athletic Training Students, Life Guards.
- Biology Lab Directors
- Health Clinic Staff
- Housekeeping /Plumbers
- Nursing Faculty, Lab/Media Coordinator, & Student Lab Assistants.
- First Aid /CPR Providers - Campus Safety Officers.
Job Classes: Site Specific Risk of Exposure
The job classifications and associated tasks for these categories are
explained in each departmental policy and procedure. Each of these departments
has a site specific policy which can be obtained from the departmental
representative. They are:
DeVos Field House
|Biology Lab Director
Schaap Science Center
Physical Plant Office
| Lab Coordinator
Schaap Science Center
|Director of Campus Safety
- This plan includes an overview and method of implementation for departmental
site specific requirements of this standard.
- Universal precautions techniques developed by the Centers
for Disease Control and Prevention (CDC) will be observed at
this facility to prevent contact with blood or OPIM. All blood
or OPIM will be considered infectious regardless of the perceived
status of the source individual.
ENGINEERING AND WORK PRACTICE CONTROLS
- Engineering and work practice controls will be used to eliminate
or minimize exposure to employees at this facility. Where occupational
exposure remains after institution of these controls, employees are
required to wear personal protective equipment. At this facility the
following engineering controls are used:
- Placing sharp items (e.g., needles, scalpels, etc.) in puncture-resistant,
leakproof, labeled containers.
- Performing procedures so that splashing, spraying, splattering,
and producing drops of blood or OPIM is minimized.
- Removing soiled PPE as soon as possible.
- Cleaning and disinfecting all equipment and work surfaces potentially
contaminated with blood or OPIM. Note: We use a solution of 1/4
cup chlorine bleach per gallon of water which should be used
to wipe down the surface and allowed to air dry.
- Towelettes or hand cleanser where handwashing facilities are
- Prohibition of eating, drinking, smoking, applying cosmetics,
handling contact lenses, and so on in work areas where exposure
to infectious materials may occur.
- Use of leak-proof, labeled containers for contaminated disposable
waste or laundry.
- Use of protective gloves in all instances of handling raw sewage.
The above controls are examined and maintained on a regular schedule.
Each department containing category A employees has specific departmental
plans, containing specific procedures, planning, and equipment
that shall be consulted and understood by the effected employees
on the above listed controls.
- Handwashing facilities are available to employees who have exposure
to blood or OPIM. Sinks for washing hands after occupational exposure
are near locations where exposure to bloodborne pathogens could occur.
At Hope College handwashing facilities are located:
- In any public restroom located on the campus of Hope College.
- When circumstances require handwashing and facilities are
not available, either an antiseptic cleanser and paper towels
or antiseptic towelettes are provided. Employees must then
wash their hands with soap and water as soon as possible. Employees
can find these hand-washing supplies:
- Supervisors make sure that employees wash
their hands and any other contaminated skin
after immediately removing personal protective
gloves, or as soon as feasible with soap and
that if employees'
skin or mucous
or OPIM, then
as soon as
- Hope College requires that equipment which has become contaminated
with blood or OPIM must be decontaminated before servicing or shipping
as necessary unless the decontamination of the equipment is not feasible.
Our procedures for equipment decontamination are as follows:
- Flush equipment with a bleach/water solution @ 10% Bleach and
allow to air dry.
- Use of other products manufactured to kill HBV or HIV virus.
PERSONAL PROTECTIVE EQUIPMENT
- All personal protective equipment (PPE) used at this facility is
provided without cost to employees. PPE is chosen based on the anticipated
exposure to blood or OPIM. The protective equipment is considered appropriate
only if it does not permit blood or OPIM to pass through or reach the
employees' clothing, skin, eyes, mouth, or other mucous membranes under
normal conditions of use and for the duration of time which the protective
equipment will be used.
- Hope College makes sure that appropriate PPE in the appropriate
sizes is readily accessible at the work site or is issued without
cost to employees by: Contacting the Health and Fire Safety office at X7999
- Synthetic, powder-free gloves, glove liners,
powderless gloves, or other similar alternatives
are readily accessible to those employees who
are allergic to the gloves normally provided.
- We purchase
to the Dow
blood immediately or
- Employees must
are not to
- All bins, pails, cans, and similar receptacles must be inspected and
decontaminated on a regularly scheduled basis: Each department should
include in their site specific plans whom and how often this is to
- Contaminated equipment should be kept separate from other equipment.
Decontamination should be done daily or as needed.
- Additional housekeeping requirements to prevent the spread
of bloodborne pathogens include:
- Broken glassware that may be contaminated shall not
be picked up directly with hands. It shall be cleaned
up using mechanical means and disposed of in closable,
leakproof, puncture-resistant, disposable containers.
HANDLING REGULATED MEDICAL WASTE
Medical Wastes should only be handled by persons who have been trained in the Bloodborne Pathogen Standard. Employees designated with the responsibility of handling medical waste must follow the handling recommendations noted below.
What goes in the red bag?
- Generally, these DO go into a Stericycle red bag:
- Visibly bloody gloves, plastic tubing, or personal protective equipment (PPE)
- Gauze, bandages or other items saturated with blood
- Securely closed disposable sharps containers
- Special handling, marking and local regulations may apply to these:
- Certain pathological waste
- Trace chemotherapy
- These DON’T go in the Stericycle red bag:
- DON’T discard these in the red bag:
- Loose sharps (they go in sharps containers)
- Hazardous and chemical waste
- Radioactive waste
- Fixatives and preservatives
- Biotech or food processing waste that does not contain a potentially infectious agent
- Household waste, food, paper products, and other medical solid waste (unless potentially infectious)
How do I package my red bag medical waste?
Medical waste generators are legally responsible for packaging their waste.
Step 1: Line your container with the red bag prior to use.
Step 2: Tie the bag when the container is full. Each bag must be hand-tied by gathering and twisting the neck of the bag.
Step 3: Secure the lid on the container. Make sure all closure and/or locking mechanisms are engaged. Red bags must not be visible once the container is closed.
Step 4: Check the containers markings. Ensure that federal markings (biohazard symbol, this-side-up-arrows, regulated medical waste, N.O.S., and UN number) are present. Ensure you’re complying with your individual state regulations. If unsure of your state regulations, check with your Stericycle representative: 866.783.9816. Improperly packaged containers or damaged containers will be denied pickup or returned to the customer.
What Goes in the Sharps Disposal Container?
Sharps include, but aren’t limited to, needles, lancets, syringes, broken glass, scalpels, culture slides, culture dishes, broken capillary tubes, broken rigid plastic, and exposed ends of dental wires. Laboratory slides and cover slips contaminated with infectious agents. Our sharps disposal services has a more complete description of sharps waste.
How do I package my sharps waste?
Step 1: Place sharps in a puncture-resistant container designed for sharps waste. Do not allow loose sharps in any waste container other than the sharps container.
Step 2: Securely close the container.
Step 3: Place disposable containers in the red bag waste or schedule for pickup.
When handling regulated wastes, other than contaminated needles and sharps, we make sure it is:
Placed in containers which are closeable, constructed to contain all contents, and prevent fluid leaks during handling, storage, transportation, or shipping. Containers can be obtained from the Health and Fire Safety office. X7999.
Labeled or color coded and closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping.
Note: Disposal of all regulated waste is in accordance with applicable United States, state and local regulations. Regulated medical waste is picked up at the Dow Center Health Clinic, A Paul Schaap Science Center, and the DeVos Field Hse by a licensed medical waste hauler. Hope College uses Stericycle, Inc. 1040 Market St. SW Grand Rapids, MI 49503 to pick-up it's medical waste. Phone (616) 454-9405. All medical pick-ups can be scheduled by calling the Occupational Health and Fire Safety office at X7999.
HANDLING CONTAMINATED LAUNDRY
Laundry contaminated with blood or OPIM is handled as little as possible. Such laundry is placed in appropriately marked (biohazard labeled, or color coded red bag) bags at the location where it was used. Such laundry is not sorted or rinsed in the area of use.
Employees must remove all garments which are penetrated by blood immediately or as soon as possible. They
must remove all PPE before leaving the work area. When PPE is removed, employees place it in a designated
container for disposal, storage, washing, or decontamination. Employees may not bring contaminated laundry
The contaminated laundry must be transported to the Dow Center Equipment Room and turned over to the
Physical Education and Athletic Equipment Manager for washing. The Hope College Athletic Equipment Manager
is Gordon Vander Yacht X7917.
INFORMATION AND TRAINING
- Hope College ensures that bloodborne pathogens trainers are knowledgeable
in the required subject matter. We make sure that employees covered
by the bloodborne pathogens standard are trained at the time of initial
assignment to tasks where occupational exposure may occur, and every
year thereafter by the following methods:
- Video training program
- Supervisor information and training in the work area and review
of site specific policies and procedures.
- Training is tailored to the education and language level
of the employee, and offered during the normal work shift.
The training will be interactive and cover the following:
- The standard and its contents.
- The epidemiology and symptoms of bloodborne diseases.
- The modes of transmission of bloodborne pathogens.
- Hope College Bloodborne Pathogen ECP, and a method
for obtaining a copy.
- The recognition of tasks that may involve exposure.
- The use and limitations of methods to reduce exposure,
for example engineering controls, work practices and
personal protective equipment (PPE).
- The types, use, location, removal, handling, decontamination,
and disposal of PPE
- The basis of selection of PPEs.
- The Hepatitis B vaccination, including efficacy, safety,
method of administration, benefits, and that it will
be offered free of charge.
- The appropriate actions to take and persons to contact
in an emergency involving blood or OPIM.
- The procedures to follow if an exposure incident occurs,
including the method of reporting and medical follow-up.
- The evaluation and follow-up required after an employee
- The signs, labels, and color coding systems.
All trained employees must sign a Document of Training
sign up sheet that is dated and indicates the training
received and the name and title of the instructor. A copy
of this sign up sheet should be filed with the Health and Fire Safey office
at 178 East 11th street Holland, MI 49423. (See Document
of Training record.)
- Additional training is provided to employees
when there are any changes of tasks or procedures
affecting the employee's occupational exposure.
Employees who have received training on bloodborne
pathogens in the 12 months preceding the effective
date of this plan will only receive training
in provisions of the plan that were not covered.
- Training records shall be maintained for three years from the date
of training. The following information shall be documented:
- The dates of the training sessions;
- An outline describing the material presented;
- The names and qualifications of persons conducting the training;
- The names and job titles of all persons attending the training
- Training records shall be kept in the employees file at the
Human Resources Office for three years. A copy of the training
record shall be forwarded to the Occupational Health and Fire
Safety office (See Document of Training Record.)
- Medical records shall be maintained in accordance with OSHA
Standard 29 CFR 1910.20. These records shall be kept confidential,
and must be maintained for at least the duration of employment
plus 30 years. The records shall include the following:
- The name and social security number of the employee.
- A copy of the employee's HBV vaccination status, including
the dates of vaccination.
- A copy of all results of examinations, medical testing,
and follow-up procedures.
- A copy of the information provided to the health care
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.
- Medical records on vaccinations and post exposure follow-ups will be kept at the Dow Center Health Clinic 168 East 13th street Holland, MI 49423, PH 395-7585
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.
HEPATITIS B VACCINATION PROGRAM
- Hope College offers the Hepatitis B vaccine and vaccination series
to all employees who have occupational exposure to bloodborne pathogens,
and post exposure follow-up to employees who have had an exposure incident.
- All medical evaluations and procedures including the Hepatitis
B vaccine and vaccination series and post-exposure follow-up,
including prophylaxis are:
- Made available at no cost to the employee.
- Made available to the employee at a reasonable time
- Hepatitus B Vaccinations at the Holland Medi Center. 616-392-5222 Monday-Friday 7:30 AM to 5:30 PM. Contact the Health and Fire Safety Office for an appointment, X7999 or 616-395-7999
- Post exposure follow-up and prophylaxis at the Holland Medi Center, 335 120th Ave Holland, MI PH 392-5222 6:30 AM to 7:30 PM. After 7:30PM Holland Community Hospital PH394-3202.
- Students (Non-employee) shall go to the Dow Center Health Clinic for post exposure follow-up and prophylaxis. After hour exposures can be treated by contacting the physicians exchange at PH392-8035.
- Performed by or under the supervision of a licensed
physician or by or under the supervision of another licensed
health care professional.
- Provided according to the recommendations of the U.S.
Public Health Service.
- All laboratory tests are conducted by an
accredited laboratory at no cost to the employee.
Hepatitis B vaccination is made available:
- After employees have been trained in
occupational exposure (see Information
- Within 10 working days of initial assignment.
- To all employees who have occupational
exposure unless a given employee has
previously received the complete Hepatitis
B vaccination series, antibody testing
has revealed that the employee is immune,
or the vaccine is contraindicated for
proof of Hepatitis
status is required
to be on file
with the current
a record on
file of their
record. A copy
can be sent
to the Dow
POST EXPOSURE EVALUATION AND FOLLOW-UP
- All exposure incidents are reported, investigated, and documented.
When the employee is exposed to blood or OPIM, the incident is reported
- When an employee is exposed, he or she will receive a confidential
medical evaluation and follow-up.
- Collection and testing of blood for HBV and
HIV serological status will comply with the
- The exposed employee's blood is collected
as soon as possible and tested after
consent is obtained;
- The employee will be offered the option
of having their blood collected for testing
of the employee's HIV/HBV serological
status. The blood sample will be preserved
for up to 90 days to allow the employee
to decide if the blood should be tested
for HIV serological status.
- All Hope
who incur an
will be offered
the OSHA standard.
All post exposure
by the Holland
175 Waverly Road Holland, MI 49423.
The Holland Medi Center is open Monday through Friday from 6:30 AM to 7:30 PM.
Note: All other findings or diagnosis shall remain confidential and will
not be included in the written report.