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7.13.04 Open Door Art Studio & Gallery – Exposure Control Plan for Bloodborne Pathogens


  • Blood means human blood, human blood components, and products made from human blood.
  • Bloodborne Pathogens are pathogenic microorganisms present in human blood and can cause disease in humans.  These pathogens include but are not limited to, Hepatitis B virus HBV and human immunodeficiency virus HIV
  • Contaminated means the presence of the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface
  • Contaminated Laundry means laundry which has been soiled with blood or other potentially infectious materials or may contain sharps
  • Contaminated Sharps means any contaminated object that can penetrate the skin including but not limited to needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires
  • Decontamination means the use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point  where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal
  • Exposure Incident means a specific eye, mouth, other mucous membrane non-intact skin, or parenteral contact with blood or other potentially  infectious materials that result from the performance of an employee’s duties
  • Occupational Exposure means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties
  • Other Potentially Infectious Materials means:
    • The following human body fluids:  semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid amniotic fluid, saliva in dental procedures, and any body fluid that is visibly contaminated with blood and body fluids in situations where it is difficult or impossible to differentiate between body fluids
    • Any unfixed tissue or organ (other than intact skin) from a human (living or dead)
    • HIV – containing all or tissue cultures, organ cultures, and HIV or HBV-containing culture medium or other tissues from experimental animals infected with HIV or HBV
  • Parenteral means piercing mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts, and abrasions
  • Personal Protective Equipment is specialized clothing (aprons) or equipment worn (gloves, googles) by an employee for protection against a hazard
  • Regulated Waste means liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials
  • Universal Precaution is an approach to infection control.  According to the concept of universal precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.

Employee Occupational Exposure Determination by the Job Classification:

  • Medical Services Coordinator
  • RN
  • Direct Support Professionals
  • QIDP
  • Maintenance Technicians
  • Housekeeping
  • Transportation
  • Dietitian
  • Recreation Assistants

Classifications Where Some Risk of Occupational Exposure May Occur:

  • Executive Director
  • Designee
  • QIDP
  • Social Worker
  • Human Resources
  • Lead DSP
  • Bookkeeper
  • Individual Payee Specialist

Tasks or Procedures where Occupational Exposure Occurs, but is not limited to, Those Individuals Listed in the Above Section of this Plan:

  • Drawing Blood
  • Insertion of catheters
  • Injections
  • Glucose sticks
  • Transporting specimens to a laboratory
  • Feeding tubes
  • Changing dressings
  • CPR
  • Accidents/injuries
  • Personal hygiene tasks with residents
  • Cleaning the whirlpool
  • Housekeeping tasks

Tasks or Procedures where Occupational Exposure Could Occur to Those Individuals Listed in the Above Section of this Plan:

  • Medical emergency and those staff that are present and assist
  • An employee/or individual could fall and sustain a laceration while out at an activity away from the location.
  • An individual could sustain an injury, causing a laceration while in the office area
  • An individual could choke while eating candy from the vending machine
  • An individual could have a seizure while waiting for the bus

Engineering Controls:

  • Policy on Sharps
  • Hazards Communication Program
  • Housekeeping Policies
  • Hand washing Facilities
  • Food Policy
  • Personal Protective Equipment

Method of Compliance:

Ensure all employees follow these policies:

  1. Reporting of Communicable Disease – see P&P 6.01.
  2. New admissions surveillance for communicable diseases P&P 6.02.
  3. Management of communicable diseases in Personnel P&P 6.03.
  4. Hand washing P&P 6.05.
  5. Mask Technique P&P 6.06.
  6. Gowning Technique P&P 6.07.
  7. Clean glove technique P&P 6.08.
  8. Hepatitis A & B including post-exposure prophylaxes P&P 6.13.
  9. Universal precautions P&P 6.14 and P&P 6.14.1.
  10. Waste Management P&P 6.15.
  11. Drawing blood and transportation of specimens P&P_____

Employee immunization HBV and post-exposure follow-up refer to P&P 6.13.  Employee waiver for immunization refer to P&P 6.13.1.

Communication of Bloodborne Pathogen Hazards to Employees:

  1. Orientation of all new employees within 10 days of employment
  2. All employees will be in-serviced annually
    • This method of in-service training will be completed on an annual basis each year prior to June 4 and all new employees will receive orientation prior to completing 10 working days.
  3. Training information will be precisely recorded:
    • Dates of training sessions
    • Content of training session
    • Names and qualifications of persons conducting the training
    • Names and job titles of all persons attending the training sessions
  4. Training records shall be maintained for three years from the date on which the training occurred.

Signed by:

Rebecca Sharp Porter
Chief Executive Director

Last Revised: 10/10/23

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