Eastern Florida State College Health Sciences Operations Manual

Transcription

1 Eastern Florida State College Health Sciences Operations Manual Sub-Section: Title: Student Criminal History Checks in Health Sciences Date Adopted: July 18, 2006 Updated : March 2011/October 9, 2012 Health Sciences and Nursing programs will enact appropriate operational procedures to support the Eastern Florida State College Procedure Criminal History Checks. Operational Procedure: In accordance with Administrative Rule 6HX , the Health Sciences and Nursing programs of Eastern Florida State College will ensure that the applicants to various Health Sciences and Nursing programs receive any required background screening. 1

2 Eastern Florida State College, Health Sciences & Nursing Programs Procedures Criminal Background Checks and Drug Screening Effective May 01, 2009 (Updated October 9, Criminal Background Check (CBC) and Drug Screen (DS) Procedure RATIONALE: Certain criminal offenses preclude students from participating in patient care. In addition, some professional licensure boards prohibit licensure for those convicted of specific offenses. Thus, students from professional programs are subject to the statutory and/or regulatory requirements independently imposed by law, or as required by affiliating entities. Students must meet any and all requirements of the clinical facility, which may be more extensive than required by Eastern Florida State College (EFSC) This procedure is designed to provide a safe environment for patients, visitors, faculty, employees and students at Eastern Florida State College, Health Sciences Institute and its affiliated institutions. Certified criminal background checks (CBCs) and Drug Screens (DS) allow the Health Sciences Institute programs to evaluate whether students possess the character and fitness to participate in clinical education activities. The Health Sciences Institute and Institute of Nursing Programs do not guarantee that state licensure boards will ultimately issue a license to an individual with or without a criminal record. CRIMINAL BACKGROUND CHECK (CBC) Prospective Students: Prospective students seeking admission to the Health Sciences or Institute of Nursing programs will be informed of this procedure and its requirements will be posted on the admissions website. New Students: Students admitted to any Health Sciences Institute or Institute of Nursing programs will be informed of these requirements at the time of conditional acceptance. At this time the student will be required to complete a criminal background check and authorize release of the results to appropriate academic and/or clinical personnel. A successful criminal background check will be considered a condition of acceptance and it must be completed prior to the start of classes. Enrolled Students: Students currently enrolled in Health Sciences Institute or Institute of Nursing programs will be required to complete a successful criminal background check and authorize release of the results to 2

3 appropriate academic and/or clinical personnel before starting their clinical rotation. Any disruption in enrollment may require the student to undergo an additional criminal background check. Students will be required to report any criminal convictions subsequent to completion of the initial criminal background check. Failure to comply with this procedure will preclude participation in clinical rotations. As a result, the student will not be able to complete the requirements of the educational program and will result in dismissal from the program DRUG SCREEN (DS) Prospective Students: Prospective students seeking admission to the Health Sciences or Institute of Nursing programs will be informed of this procedure, and its requirements will be posted on the admissions website. New Students: Students admitted to any Health Sciences or Institute of Nursing programs will be informed of this procedure and its requirements at the time of conditional acceptance. At this time the student will be required to complete a drug screen and authorize release of the results to appropriate academic and/or clinical personnel. The drug screen check will be considered a condition of acceptance and it must be completed prior to the start of classes. Enrolled Students: Students currently enrolled in Health Sciences or Institute of Nursing programs will be required to complete a successful drug screen and authorize release of the results to appropriate academic and/or clinical personnel before starting their clinical rotation. Any disruption in enrollment may require the student to undergo an additional criminal background check and drug screening. Failure to comply with this procedure will preclude participation in clinical rotations. As a result, the student will not be able to complete the requirements of the educational program and will result in dismissal from the program Students may be required to undergo additional CBCs and/or DSs during their tenure as a Health Sciences Institute or Institute of Nursing student, as deemed necessary by the academic and/or clinical facility. The cost of all CBCs and DSs shall be the responsibility of the student. Further, the student will be responsible for completing all CBCs and DSs in a timely manner. Failure to comply with this procedure will result in dismissal from the student s program. Failure of either the CBC or DS will result in dismissal from the student s program. Decisions are subject to right of appeal. Results of all background checks and drug screens will be privileged and confidential, will be maintained in a secure electronic file on the vendors secured site, and shall not be released or otherwise disclosed to any person or agency, other than (1) individuals involved in Health Sciences or Institute of Nursing programs admissions and student services; (2) persons who have a legitimate need to know, as determined by Dean, Health Sciences Institute or Institute of Nursing; (3) upon direction of a court order; (4) any affiliated entity providing clinical training; or, (5) with the written consent of the student. Records will be maintained on students until graduation or end of matriculation. 3

4 PROCEDURES Criminal Background Check: 1. Prospective students for any of the Health Sciences or Nursing programs will be notified through the admissions web page, that if admitted they would be required to complete a criminal background check and authorize release of the results to appropriate academic and/or clinical personnel after admission. 2. Students accepted for conditional admission will be notified that matriculation is contingent upon the evaluation and acceptable outcome of all required CBCs. 3. Students will be notified verbally, by letter or of the deadline for completion. EFSC will provide students with the name of vendor with which the Health Sciences Institute or Institute of Nursing has established reporting relationship. Students will be given instructions on obtaining and reporting the results of their CBC. Students will be responsible for all costs associated with completion of a criminal background check. 4. The program manager will have access to the results that will be maintained on a secured electron site maintained through the vendor. Level II Background results will be sent to one designated individual in each institute. 5. In the event a record of conviction is found, the record will be screened as to severity by the vendor and the program manager will be notified, who will then notify the student. At that time, the student will be denied admission or dismissed from the program. *Students claiming inaccuracies in their CBC will be referred to the entity completing the initial CBC for procedures as required by the Fair Credit Reporting Act. CRIMINAL BACKGROUND CHECK REPORTING CRITERIA: Some criminal offenses preclude students from participating in patient care. In addition, some professional licensure boards include specific offenses which constitute those crimes for which licensure are prohibited. Major offenses are those that indicate clear potential threat or harm to the community and constitutes an automatic failure of the CBC. Prospective students with any of these offenses will be denied admission into any programs in the Health Sciences or Nursing programs, and students currently enrolled in any programs will be dismissed from that program. Prior to entry into any Health Sciences or Nursing Programs, the prospective student and/or applicant will be required to complete the Criminal Background Check. All felony cases listed below will be posted are the ones stated by Florida Statutes as of August The new law has created changes as to the length of time one may apply to be licensed in the State of Florida. The variable is the degree of the felony as well as the law that was applied at the time of conviction. Eastern Florida State College will not be held responsible to interpret the new laws. We will hold to the statement that the student is responsible for clearing their way to apply to the State for licensing. 4

5 We made up that form that they had to sign understanding they may not be licensed in the State of Florida, but we have allowed them to continue in the program. How does this affect them, and does it mean for us to reimburse their tuition, financial aid, books etc, if we enforce this now. If they are grandfathered in and you have permitted them in the course that would be done on an individual basis. The background policy states that they can be dropped at any time if they are convicted of a felony. Assault and related offenses when resulting in a felony Battery and related offenses when resulting in a felony Arson, Attempted Arson Child abuse, aggravated child abuse, neglect of a child, exploitation of a child Endangering the welfare of a child Theft and related offenses resulting in a felony Contributing to the delinquency or dependency of a child Fraud Credit Card Crimes; Credit Card Fraud, Credit Card Theft, Illegal use a Credit Card Hate Crimes and related offenses Sale, Distribute, Deliver of controlled substances and related offenses when resulting in a felony Possession of a controlled substance when resulting in a felony Animal Abuse Kidnapping, False Imprisonment Killing of an unborn child by injury to the mother Lewd and Lascivious Behavior when resulting in a felony Murder, Maiming, Manslaughter, Attempted Murder, Attempted Maiming, Attempted Manslaughter Malicious Wounding, Unlawful Wounding Obscene literature Prohibited acts of persons in familial or custodial authority Prostitution, Sexual Solicitation Rape, Sexual Abuse, Sexual Assault, Incest Sexual Misconduct Sexual Assault, Sexual Battery and other Sexual Offenses Robbery and related offenses resulting in a felony Vehicular Homicide, Vehicular Assault, Hit and Run Breaking and Entering Weapon Crimes and related offenses Embezzlement Additionally, such students must not have been judicially determined to have committed abuse or neglect against a child as defined in Florida Statutes (F.S. 3901(2) and (47); must not have a confirmed report of abuse, neglect, or exploitation as defined in F. S (6), or abuse or neglect as defined in F.S (6), which has been uncontested or upheld under F. S or F. S ; must not have a proposed confirmed report that remains unserved and is maintained in the central abuse registry and tracking system pursuant to F.S (2)(c); and has not committed an act that constitutes domestic violence as defined in F.S

6 If a student does not have any of the offenses listed above on their record, but does have a record of other types of convictions; an administrative review must occur between the Dean of Health Sciences Institute/ Institute of Nursing and the program manager prior to final admission into the program. An administrative review is a review of the conviction record and the factors listed below. The program manager will meet with the Dean, Health Sciences Institute or Institute of Nursing to conduct the administrative review as follows: The Dean of Health Sciences Institute/Institute of Nursing, and program manager will review the criminal history background check and discuss the factors listed below: o o o o o o o o o Applicant s age at the time the offense was committed; Mitigating factors at the time the offense was committed; Number of offenses for which the individual was convicted; (We will address any student with several misdemeanors and advise them that it could affect their ability to be hired by an agency and it will be noted in Banner that this conversation was held. ) Documentation of efforts and success at rehabilitation; The amount of time since the offense was committed; The likelihood the offense will be repeated; Individual s employment related references (history) since committing the offense; The relationship between the program and the offense committed; The training, structure and supervision available in the program. After evaluation of the listed factors above, the Dean, Health Sciences Institute or Institute of Nursing will make a recommendation regarding program entry. PROCEDURES Drug Screening: 1. Prospective students for any of the Health Sciences or Institute of Nursing programs will be notified through the admissions web page that, if accepted, they will be required to complete a drug screen and authorize release of the results to appropriate academic and/or clinical personnel. 2. Students accepted for conditional admission will be notified that matriculation is contingent upon the evaluation and acceptable outcome of all required drug screens. 3. Students will be notified verbally and by letter or of the deadline for completion of the drug screening. The School will provide students with instructions on obtaining an authorized drug screen. Students will be responsible for all costs associated with completion of a drug screen. 4. The program manager will have access to the results that will be maintained on a secured electronic site maintained through the vendor. 5. In the event that a student fails a drug screen, the program manager will notify the Dean and the student. Students may also be notified directly by the vendor. At that time, the student will be denied admission or dismissed from the program. *Students claiming inaccuracies in their DS will be referred to the vendor and/or authorized laboratory completing the drug screen. 6

7 *Refer to Eastern Florida State College Student Handbook for Student Code of Conduct Policies The Board of Nurse Examiners for the State of Florida may require documentation from individuals who have been convicted of a crime before granting the privilege of sitting for the licensure examination. Other areas of concern include substance abuse, mental health treatment, and any disability that might adversely affect the safe practice of professional nursing. The Board may deny sitting for licensure if doing so is seen to be in the best interest of society. The programs that require background screening include all Health Sciences Institute programs; associate degree nursing, transitional nursing, practical nursing, nursing assistant, emergency medical technicians, paramedics and Continuing Education for nurse refresher classes. In addition, certain clinical experiences at facilities outside Eastern Florida State College are necessary for progression in and graduation from Allied Health programs. Some clinical facility sites may require additional criminal background checks on students prior to permitting them to be assigned for educational purposes. Some professional licensing, registration, or certification boards also require further information from individuals who have been convicted of a crime in connection with their determination of the eligibility of an application for licensure, registration, or certification or even for the privilege of sitting for licensure, registration or certification examination. Other areas of concern may involve substance abuse and mental health. 7

8 Eastern Florida State College Health Sciences Operations Manual Section: Sub-Section: Title: Financial Management Title: Daily accounting systems-cosmetology Date Adopted: JULY 18, 2006; Updated: March 2011/October 2012 The purpose of this operational procedure is to ensure consistent management of receipts in clinical settings in Cosmetology. I. Physical Controls/Security: Only authorized staff members will utilize the cash drawer. Students, if allowed access to the cash drawer, will do so only under the direct visual supervision of the authorized staff member. Only authorized staff members will be allowed to void computer transactions. Separate reconciliation of cash drawers is required of each staff member. Security will be maintained in the cashier station by locking the area when not directly supervised and by the use of a door alarm to alert any staff/faculty to the entrance of any individual from outside the building. Deposits will be made daily after reconciliation of receivables. Verification of deposits will be maintained by security and the authorized staff member. 8

9 Health Sciences Institute/Institute of Nursing Adjunct Faculty Checklist Instructors Name: (please print) Teaching/Learning/Supervisor orientation: Instructor received textbook(s) and supplemental materials: Instructor received course objectives and plans for each course he/she is teaching Instructor understands syllabus submission procedures and requirements Instructor understands ADA section 508 compliance and resources available to assist Instructor understands release of student information, FERPA Instructor understands grade and attendance reporting procedures and requirements Orientation with Administrative Support Instructor received EFSC Faculty Handbook inserts Instructor received campus-specific information, including a campus map and safety procedures Instructor received identification badge, library card and parking sticker instructions send to Security with completed Vehicle Record Sheet after Orientation call Security to be sure available. Instructor received information on procedure to open locked classrooms Instructor understands paycheck distribution procedures (rate of pay, when, and how) Instructor has received ID Number: B 9

10 Instructor has received initial PIN Number: Birthday in format MMDDYY Instructor s credentialing has been confirmed per from HR. Instructor has received training on logging into BANNER WEB for attendance and grade reporting Instructor has received training and instructions for account. User Name: Password: Address: ANGEL training scheduled via I have reviewed the preceding information and have had the opportunity to ask questions. Instructor s Signature Date Administrative Support s Signature Date Program Manager Date 10

11 Eastern Florida State College Health Sciences Procedure Manual Section: Sub Section: Title: Human Resources Adjunct Faculty Credentialing Date Adopted: JULY 18, 2006; Updated : March 2011/October 9, 2012 The purpose of this procedure is to define the steps required for the receipt, processing and credentialing of adjunct faculty in Health Sciences. Responsibilities of Administrative Support Staff: 1. Receive application from HR and forward to Dean for review. 2. Schedule interviews as directed by the Dean and program manager. 3. After candidates are interviewed, complete the Human Resources Credentialing Application form with demographic information, education, work experiences, licenses and certifications. 4. Complete telephone reference checks on final candidates. 5. After interviews are complete, print the credential sheet from Knowledge Tree which is to be completed before they begin teaching assigned classes. 6. After signature of the Dean copy entire packet and send original to Human Resources. 7. After approval from credentialing officer, prepare and file packet in faculty folders. Responsibilities of Dean: 1. Review application for appropriateness. Ensure interviews are scheduled with appropriate program managers. 2. Ensure credentialing forms are complete. 3. Ensure credentialing forms are signed and forwarded to Human Resources. 4. Upon Human Resources approval, notify program manager and administrative support. New full time faculty participates in the Collegewide mentor program. Contact will be made by Dr. Katina Gothard who is responsible for this program 11

12 Eastern Florida State College Health Sciences Procedure Manual Section: Sub-Section: Title: Infection Control Title: Storage of Food Items Date Adopted: JULY 18, 2006 Updated: March 2011 The purpose of this policy to define the storage of food items in Health Sciences Institute and Institute of Nursing faculty/staff break room. No food items or utensils may be stored under any sink. Refrigerators should be cleaned out weekly on Thursdays. Any personal items not labeled with name and date will be discarded. Each refrigerator should have a LOG on it, proving it was looked at with the date and the cooling temperature. Items containing MAYO should be looked at very closely. Outdated items should be thrown away. 12

13 Eastern Florida State College Health Sciences Procedure Manual Section: Institute for Continuing Education Title: Procedure for Faculty and Staff Sub-Section: Title: Participation in Continuing Education Date Adopted: JULY 18, 2006 Updated: October 2012 In support of the Eastern Florida State College procedure 309.6, the Health Sciences Institute and Institute of Nursing will make continuing education non-credit professional development activities available to full time faculty and full time or regular part time staff. 1. The American Heart Association (AHA) courses: Contact Kate Cunningham for AHA: Participation is for tuition only. Textbooks, lab fees and supplies are not included. 3. Acceptance is not automatic due to the expenses associated with some courses. 4. Departments or divisions of the college may order customized training for groups of employees subject to the approval of the Dean, Health Sciences Institute/ Institute of Nursing. 13

14 Eastern Florida State College Health Sciences Procedure Manual Section: Sub-Section: Title: Admission to Health Sciences Programs Title: Immunization and CPR Requirements in Health Sciences/Nursing Date Adopted: JULY 18, 2006/ Reviewed and updated October 9,2012 Health Sciences Campus will enact appropriate operational procedures to support the Eastern Florida State College Procedure Release of Student Records and Procedure 410 Release of Student Records. Operational Procedure: After acceptance into the specific Health Sciences and Nursing programs, each student will be required to have an immunization record on file and CPR certification. Forms will be submitted to the secure online database where they are reviewed by the appropriate program manager. Should the student have religious or medical reasons for not having immunizations documentation must be presented to the Program Manager as to why they do not have the required immunizations. CPR Certification will be the American Heart Association Healthcare Provider. No other card will be accepted 14

15 Eastern Florida State College Health Sciences Procedure Manual Section: Title: Safety Sub-Section: Title: Storage and Disposal of Hazardous Material Date Adopted: JULY 18, 2006 The purpose of this procedure to define the storage and disposal of hazardous materials in Health Sciences or Nursing programs. 1. Health Sciences will follow the general college procedures for the storage and disposal of hazardous materials. 2. Aerosol cans and batteries will be separated from routine trash for disposal as hazardous material. Notify Security for removal. 3. Appropriate containers for collection and transportation of hazardous materials will be available at each appropriate location. 4. Flammable chemicals will be stored in fire retardant lockers when not in use. 5. When chemicals are to be removed from the building, the area will request a hazardous materials pick up from Security and will attach an MSDS sheet to each chemical container for disposal. The chemicals will be removed by the Security personnel or designated Bio-hazardous waste removal vendors contracted by the college. 6. Each department will maintain appropriate MSDS forms in their respective area. Due to the continuing changes in the types and numbers of materials used in this facility, the following list of MSDS sheets may not be complete. If any MSDS sheet is needed, please go online and look up the material or product at one of the sites listed below. -msdssearch.com -SIRI.uvm.edu/msds 7. A listing of chemicals held in Health Sciences and Nursing programs will be maintained in the administrative offices for Health Sciences Institute and the Institute of Nursing. Additional Website information:

16 Eastern Florida State College Health Sciences Procedure Manual Section: Sub-Section: Title: Office Management Title: Key Management Date Adopted: 2006/October 2012 JULY 18, In order to maintain a balance between security and access to classroom and office space, the following procedure will be enacted: All requests for keys must be submitted to the building coordinator. Requests for keys will receive final approval from the (Health Sciences) Dean, Health Sciences Institute. When key requests are approved, the building coordinator will submit a work order. When locksmith delivers the key it is attached to a Personnel Key Information Issuing Sheet. The Key holder will complete the form and the white sheet is returned to the locksmith for further disposition. The key holder is will be issued the pink sheet and the yellow sheet will be filed in the key holder s folder. Keys will be issued to full time faculty based on their specific access needs. For example, full time faculty teaching in building 20 will be given keys to access those classrooms in building 20 only. If there is an occasional need for the faculty member to teach in another classroom, security should be notified to unlock the building/classroom. Keys may be issued to part time faculty. Part time faculty will need to contact the Health Sciences Institute office for classrooms in building 20 and Security for classrooms in other buildings. The Health Sciences Institute office will offer coverage until the start of evening classes, Monday through Thursday. Adjunct faculty requiring assistance with copying material, access to computers or scantron scoring should notify the Administrative Assistant in the Health Sciences/Nursing Institute Copy machines and computer access are also available in the adjunct office of Building and Building

17 Eastern Florida State College Bloodborne Pathogen Exposure Control Plan 17

18 HISTORY Implementation: 1992 Dr. J. Sidlowski, Bruce Brown Reviewed: 1998 Program Coordinators Policy and Procedures Committee Reviewed/Revised: Fall 2000 for Compliance with 1999 OSHA Standards: Holly Kahler, Rita Hallock, Claudia Campbell (Health Sciences Campus OSHA & Safety Committee) Revised: Spring 2001; Holly Kahler, Rita Hallock, Claudia Campbell (Health Sciences Campus OSHA & Safety Committee) Approved: Summer 2001; Holly Kahler, Rita Hallock, Claudia Campbell (Health Sciences Campus OSHA & Safety Committee) Reviewed/Revised: Fall 2001; Holly Kahler, Rita Hallock, Claudia Campbell (Health Sciences Campus OSHA & Safety Committee), Barry Inman, BA/BS, CIC, CHE (Brevard County Health Dept.) Approved: Fall 2001; Eastern Florida State College Cabinet Reviewed/Revised: Fall 2002; Holly Kahler, Rita Hallock, Claudia Campbell (Health Sciences OSHA & Safety Committee), Barry Inman, BA/BS, CIC, CHE (Brevard County Health Dept.) Reviewed/Revised: Fall 2003; Dr. Holly Kahler, Rita Hallock, Claudia Campbell, Judy Campbell, Dr. Janice Grumbles, Anthony Misco, Dr. Dennis Connaughton, Dr. Barbara Ake, Judy Capps, Linda Miedema (Health Sciences OSHA Committee), Barry Inman, BA/BS, CIC, CHE (Brevard County Health Dept.) Reviewed/Revised: Summer 2004: Members of Health Sciences Campus OSHA Committee: Judy Capps, Dr. Janice Grumbles, Dr. Holly Kahler, Krista Matheny, Linda Miedema, Anthony Misco Reviewed/Revised: Fall 2005; Dr. Holly Kahler, Rita Hallock, Claudia Campbell, Dr. Laura Earle, Dr. Barbara Ake, Judy Capps, Linda Miedema, Dr. Ethel Newman, (Health Sciences OSHA Committee), Barry Inman, BA/BS, CIC, CHE (Brevard County Health Dept.) Reviewed/Revised: Fall 2006: Health Sciences OSHA Committee: Dr. Barbara Ake, Dr. Holly Kahler, Linda Miedema, Claudia Campbell, Dr. Ethel Newman, Dr. Laura Earle, Robin Pollard Reviewed/Revised: Fall 2007: Health Sciences OSHA Committee: Dr. Barbara Ake, Dr. Holly Kahler, Linda Miedema, Claudia Campbell, Dr. Ethel Newman, Dr. Laura Earle, Debra Ramirez Reviewed/Revised: Fall 2008: Health Sciences OSHA Committee: Dr. Holly Kahler, Dr. Laura Earle, Debra Ramirez, Donna Hamilton, Kris Hardy, Dr. Kathinka Babb Reviewed/Revised: Fall 2009: Health Sciences OSHA Committee: Dr. Holly Kahler, Dr. Laura Earle, Debra Ramirez, Donna Hamilton, Kris H Reviewed/Revised: Fall 2013: Health Sciences OSHA Committee: Dr. Laura Earle, Donna Hamilton, Kris Hardy, Kate Cunningham 18

19 TABLE OF CONTENTS Purpose 5 Definitions. 5 SECTION I: EXPOSURE DETERMINATION Bloodborne Pathogens 7 Rabies 8 SECTION II: METHODS OF MIMIMIZING EXPOSURE Standard Precautions 10 Engineering Controls 11 Work Practices Controls 13 Personal Protective Equipment 15 Housekeeping Controls 16 Biohazardous Waste Control 18 SECTION III: HEPATITIS B VACCINATION, POST EXPOSURE EVALUATION AND FOLLOW-UP MEDICAL RECORD KEEPING HBV Vaccination 19 Post Exposure Protocol 19 Post Exposure STEP-BY-STEP Instructions 19 Phone Number Resources 20 SECTION IV: INFORMATION AND TRAINING Responsibility 22 Training Topics 22 Program Methods and Schedule 23 Training Records 23 SECTION V: PLAN MANAGEMENT Annual Training and Review 23 Availability of Plan to Employees 23 Responsibilities 23 APPENDICES A. EFSC Accident/Incident Occupational Exposure Report(s) 25 B. Sharps Injury Incident Report.. 26 C. Sharps Injury Log 31 D. Consent Form for Source Patient 32 E. Consent Form for Exposed Person 34 F. Declination of Hepatitis B Vaccination 36 G. Bloodborne Pathogens Plan Confirmation Document 38 H. A Checklist for Implementing The Plan 40 PAGE 19

20 I. OSHA Compliance Inspection Checklist 42 J. Dental Unit Waterline Maintenance 44 K. Disposal of Radiologic Chemicals and Lead Foils.. 47 L. Disposal and Reverse Distribution of Pharmaceuticals 50 M. Secondary Labeling of Containers.. 52 N. Rabies and Zoonotic Diseases 54 PURPOSE: The purpose of this Exposure Control Plan is to provide guidelines for minimizing or eliminating occupational exposure of employees and students of the Health Sciences Institute to blood and other potentially infectious materials. DEFINITIONS: Bloodborne Pathogens means: Pathogenic microorganisms that may be present in human blood and body fluids and can cause disease in humans. These pathogens include Hepatitis B virus (HBV), Hepatitis C virus (HCV), and the Human Immunodeficiency Virus (HIV), which may result in AIDS. Hepatitis B Virus (HBV): An acute or chronic, viral liver disease. Hepatitis B is the most contagious form of viral hepatitis. Hepatitis C Virus: A contagious viral liver disease. Hepatitis C can cause severe liver damage. Human Immunodeficiency Virus: The virus that causes AIDS. Acquired Immune Deficiency Syndrome (AIDS): AIDS destroys the human immune system and is the final and most severe stage of the HIV virus. Zoonotic diseases are any diseases that may be transmitted from animals to humans or from humans to animals. Exposure may occur from any body fluid including blood, saliva, urine or feces. Zoonotic diseases include Rabies, Leptospirosis, tick-borne diseases (Lyme disease, Rocky Mountain Spotted Fever, Ehrlichia), parasitic diseases, tuberculosis and Psitticosis. Exposure Incident means: A specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that occurs during the performance of an employee s or student 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 or student s duties. Source Individual: Any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the employee. Exposed Individual: Any individual who has been exposed to a potential blood borne pathogen. 20

21 Post-Exposure Prophylaxis (PEP): A treatment given immediately following exposure to bloodborne pathogens to prevent infection. This may include vaccinations, immunoglobulin injections or other treatments depending on the pathogen. Personal Protective Equipment (PPE): Safety equipment that a person wears or uses to prevent injury in the workplace. Standard Precautions: Refer both to safeguards taken to ensure protection of the HCW from bloodborne pathogens and to protect patients/clients from those same pathogens. This includes the use of appropriate PPE, proper handling of sharps and appropriate hand washing and disinfection of surfaces and instruments. It also includes following the proper procedures if exposure occurs and reporting incidents in a timely fashion. Standard Precautions are also to be implemented to prevent exposure to zoonotic diseases. Other Potentially Infectious Material (OPIM) means: 1. Blood, all body fluids WITH VISIBLE BLOOD, secretions, excretions, mucous membranes, and non-intact skin; 2. Any unfixed tissue or organ (other than intact skin) from a human (living or dead); 3. Blood, organs, and tissues from cultures and solutions containing HIV, HBV, or HCV. Regulated Waste means: 1. Liquid blood, semi-liquid blood, or other potentially infectious materials; 2. Contaminated items that would release blood or other potentially infectious materials in a liquid blood or semi-liquid state if compressed; 3. Items that are caked with dried blood or other potentially infectious materials that are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials. 21

22 SECTION I: EXPOSURE DETERMINATION BLOODBORNE PATHOGENS (HIV, HBV, HCV) Category I Following is a list of occupational training programs in the Health Sciences Institute & Institute of Nursing in which all Health Sciences clinical or lab instructors, staff, or students have occupational exposure to Bloodborne Pathogens: Cosmetology, Nail Specialist, Esthetician Dental Assisting Dental Hygiene Emergency Medical Services Emergency Medical Technology Fire Science Technology Medical Assisting Medical Laboratory Technology Nursing ADN Paramedic Patient Care Technician Phlebotomy Practical Nursing LPN Surgical Technology Transitional Programs Category II Following is a list of occupational training areas in the Health Sciences Institute in which some employees or students have occupational exposure to Bloodborne pathogens. Radiography Technology Veterinary Technology Physical Education Instructors, staff and students Maintenance * Security * Clerical Staff in clinical/lab facility *These employees are covered by Eastern Florida State College, Collegewide Bloodborne Pathogen and Exposure Control Plan. The tasks, which gave the potential for exposure to Bloodborne Pathogens, are: Aggression Control Direct Patient/ Client Physical Contact 22

23 CPR and First Aid Procedures Handling Biohazardous/ Biomedical Waste Specimen handling Maintenance Housekeeping (contracted services responsible for training and tracking of employees) Part-time, temporary, contract and per diem employees are covered by this Exposure Control Plan and will be categorized according to their job requirements. Employees without patient/ client contact or exposure to clinical/ lab facilities will not be categorized. RABIES VIRUS Category 1 Following is a list of occupational training areas in the Health Sciences Institute in which all employees or students may have occupational exposure to Rabies virus: Veterinary Technology Category 2 Following is a list of occupational training areas in the Health Sciences Institute in which some employees may have occupational exposure to Rabies virus: Security The tasks, which gave the potential for exposure to Rabies virus, are: Stray animal/wildlife rescue Direct Patient/Client physical contact and restraint CPR and First Aid Procedures Handling Biohazardous/Biomedical Waste Specimen handling (nervous tissue, cerebrospinal fluid) 23

24 SECTION II: METHODS OF MINIMIZING EXPOSURE Program Administration: The Health Science OSHA Committee is responsible for the implementation of the ECP (Exposure Control Plan). The OSHA Committee will maintain, review, and update the ECP annually and include new or modified tasks and procedures when necessary. Those employees who are determined to have occupational exposure to blood or other potentially infectious materials (OPIM) must and will comply with the procedures and work practices outlined in this ECP. The OSHA Committee will monitor all programs, courses, and personnel which utilize personal protective equipment (PPE), engineering controls (e.g., sharps containers), labels, and red bags as required by the standard. The individual programs will ensure that adequate supplies of the aforementioned equipment are available in the appropriate sizes at the appropriate locations. This OSHA Committee will provide oversight of this provision by performing periodic inspections. The OSHA Committee will be responsible for ensuring that appropriate employee immunization and OSHA training records are maintained. The OSHA Committee will perform periodic inspections of laboratory facilities. EFSC Human Resources will be responsible for training, documentation of training, and making the written and online ECP available to all employees. STANDARD PRECAUTIONS: All employees will utilize standard precautions. EXPOSURE CONTROL PLAN: Eastern Florida State College is committed to providing a safe and healthful work environment for our entire staff and students. In pursuit of this goal, this ECP is provided to eliminate or minimize occupational exposure to bloodborne pathogens in accordance with OSHA standard 29 CFR , Occupational Exposure to Bloodborne Pathogens. This ECP is a key document to assist with organization, implementation and ensuring compliance with the standard, thereby protecting our employees and students. 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 any member of the OSHA Committee or by accessing the material via the Health Sciences website or Human Resources. OSHA Committee names and contact information is provided to all affected employees. If requested, HR will provide an employee with a written copy of the ECP free of charge within 15 days of request. The ECP is also provided on the institution's web site. 24

25 Students are also provided information on OSHA and Standard Precautions before any course work or lab involvement where bloodborne or zoonotic disease pathogens are utilized or present. Students may be tested on this material in exam format at any time during their education. The OSHA Committee is responsible for reviewing and updating the ECP to reflect any new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure. The following methods of implementation have been developed to minimize or eliminate occupational exposure: Implementation of Standard Precautions Establishment of Engineering Controls Implementation of Work Practice Controls Use of Personal Protective Equipment Proper Handling and Disposal of Biohazardous Waste Implementation of Maintenance Procedures A. Standard Precautions: Employees shall adhere to the practice of Standard Precautions (bloodborne disease control). Standard Precautions define all blood; all body fluids, secretions, excretions, mucus membranes, and non-intact skin (except sweat) as potentially infectious. As part of Standard Precautions the Health Sciences Institute shall practice the following infection control measures: Change gloves multiple times during the care of one patient/client, if necessary. To prevent cross contamination of different body sites, and before and after any direct patient/student/client contact: If hands have NOT been soiled, alcohol containing antiseptic hand cleanser or antiseptic wipes may be used. If hands have been soiled by visible blood, body fluids or other substances, soap and water scrub MUST be used. Before and after each shift and on leaving or entering the operatory after visiting a restroom, a 90-second soap and water scrub should be performed in order to ensure antisepsis. Change gloves if they become torn, or if they contact infectious material. Change gloves immediately before contact with mucous membranes or non-intact skin when working on multiple sites on a patient s (or student s) body to avoid cross contamination. All employees and students will wash hands and utilize PPE when handling any other regulated waste such as soiled utility gloves, laundry, bandages, gauze, etc. All employees and students will use appropriate germicidal disinfectants on surfaces or equipment to minimize or omit transmission of infectious material in any areas mentioned where there is exposure to bloodborne pathogens in Section I, Category I. Utility gloves are provided for employees and students, housekeeping and/or other staff and should be checked for cracks before each use and replaced as necessary. 25

26 Hypoallergenic gloves, glove liners, powder and latex free gloves are available to all employees and students in all health care locations and labs. B. Engineering Controls Engineering controls and work practice controls will be used to prevent or minimize exposure to bloodborne pathogens. The specific engineering controls and work practice controls are listed below: 1. Handwashing Facilities: a. Definition: Handwashing facilities shall include a sink, liquid soap, running water and disposable towels. b. Handwashing facilities shall be available for use by instructors, staff and students in all health care clinics or labs. c. Handwashing facilities are available in each building of each campus located in both female and male restrooms on both first and second floor locations. Note: in Cocoa Campus Bldg 17, the restrooms are only located on the first floor. d. If handwashing facilities are not available, antiseptic hand cleanser will be available. The use of antiseptic hand cleanser is not a substitute for handwashing and should be followed by regular handwashing as soon as a facility is available. 2. Emergency Eye Wash Stations and Showers: a. Eye Wash Station Definition: Any suitable liquid used to rinse the eyes (e.g., sterile physiological saline or sterile water) with pressure and force against the eyeball to remove foreign objects or for irrigation purposes. 1. All Health Sciences laboratories contain either plumbed or 15 minute eye wash stations. 2. The eye wash stations are evaluated and inspected annually for cracks, mold, plumbing, cloudy solution, frozen, or those exposed to heat that may scald the user. 3. Incidents are handled using self-contained or 15 minute eye wash stations while the affected individual is in transit to the emergency shower or medical facility. 4. Signage indicating the location of eyewash station will be prominently displayed. Eye Wash Stations: , ,20-124A, ,20-111B, , , b. Emergency Showers Definition - individually plumbed facility with appropriate floor drainage to be used for rinsing of chemicals from the body in an emergency fashion. 1. Emergency showers must be checked annually for patency, leaks and adequate drainage. 2. Incidents of superficial exposure to biohazardous chemicals will necessitate showering to remove the chemical from the skin until transfer to an emergency facility. Showers: , , Sharps Containers: a. Definition of Sharps Disposal Containers: Rigid, leak-proof, puncture-resistant on the sides and bottom and labeled with Bio-Hazard warning labels and /or red in color. 26

27 b. Definition of Sharps: Scalpels, needles, razor blades, glass carpules or ampules, vials, capillary tubes and lancets, microscope slides, cover slips, or any item where there is a potential for puncture. c. Sharps containers shall be placed in all health care labs, clinics, and any work area where sharps are utilized. d. Sharps disposal containers are inspected and maintained or replaced by the appropriate and named faculty, coordinator, or other assigned and qualified individual every month or when the appropriate lab sessions convene or whenever necessary to prevent overfilling. This organization adheres to the procedure of filling a sharp disposal container only ¾ full. If a Sharps disposal container has been in use for an entire Fall or Spring semester it should also be replaced even if <75% full. Sharps containers should be sealed, taped and labeled with the point of origin, the start date and end dates, and initials of person performing action. Containers should be transferred to the appropriate location on each campus and placed in the Biohazard Waste containers. See appendix A for location of Biohazard Waste containers and storage sites. e. The OSHA Committee will identify the need for changes in engineering controls and work practices through review of OSHA records, employee interviews, and annual or semiannual inspections. f. New procedures and products are evaluated regularly by core personnel in lab settings through literature review and supplier information, and new products are considered. 4. Leak Proof Containers: a. Specimens used for teaching purposes are contained in leak proof containers. Both faculty and students are instructed in the use of all leak proof containers. *SEE BIOMEDICAL WASTE PLAN(S) FOR DISPOSAL OF SHARPS 5. Containers for Other Regulated Waste: a. Other regulated waste shall be placed in a red bag at the point of origin. Red bags shall be placed in puncture resistant containers for transfer to the biomedical waste storage area. Puncture resistant cardboard boxes are provided to each laboratory along with the appropriate red biohazard bags. b. Secondary Containers If outside contamination of the primary red bag occurs, that container shall be placed within a second red bag, which prevents leakage during handling and storage. *SEE BIOMEDICAL WASTE PLAN(S) FOR DISPOSAL OF OTHER REGULATED WASTE 6. Safety Devices: a. Devices which are appropriate for employees to use to prevent injury and exposure to biohazardous fluids include the following items: Disposable Safety Pipettes, Needle Stick Protector, Recapping Devices, and Safety Needle where applicable. C. Work Practice Controls: 27

28 In addition to engineering controls, the work practice controls described below have been implemented to minimize exposure to bloodborne pathogens. 1. Handwashing is required in this facility and employees and students have been instructed in this procedure and know where facilities are located. Employees shall wash their hands with soap and running water as soon as possible after removal of gloves or other personal protective equipment. An employee shall wash hands and any other skin with soap and water for a minimum of 90 seconds before and after each shift and as soon as feasible following patient contact and immediately following any procedure. Should handwashing facilities be unavailable, the employees/students must use alcohol based antiseptic hand cleanser to prevent cross contamination of patients. If hands are visibly soiled, handwashing with soap and water must be performed. Handwashing facilities are located within 100 feet of clinical and lab settings. 2. Recapping of sharps and bending and breaking of needles is prohibited in this facility. Employees and students have been trained in these procedures. If needles must be recapped, it is done: With a one-handed scoop (passive recapping) -or- A recapping safety device is used 3. Disposal of sharps: After use, all sharps will be placed in the appropriate receptacles for reprocessing or disposal. The containers meet the requirements as outlined in the OSHA regulations for Engineering/Work Practice Controls. Employees and students are trained in these procedures, and have been instructed not to overfill containers. 4. Mechanical or hand held suction pipettes are required in this facility where appropriate. Blood and other potentially infectious materials are handled with care in this facility. Employees and students using pipettes have been trained in these procedures. 5. Eating, drinking, smoking, applying cosmetics and handling contact lenses is prohibited in this facility in work or lab areas where there is any risk of occupational exposure. Employees and students receiving a splash in the eye should remove any contact lenses and dispose of them. They should not rinse and replace the contact lens. Employees and students have been informed of this rule. 6. Storage of food and drink is prohibited in places where other potentially infectious materials are kept. This applies to refrigerators, freezers, shelves, cabinets, countertops and bench tops. Food and drink consumption is prohibited in all laboratory areas. Employees and students have been informed of this standard. 7. Leak-proof containers are used for all specimens in the teaching laboratories. See Engineering Controls for specific details. 8. Equipment that may become contaminated is inspected for blood or other potentially infectious materials on a regular basis and decontaminated if necessary. a. Equipment should be inspected, cleaned and disinfected after each patient/client to prevent cross-contamination. b. Non-Sterile Equipment that has sat idle for longer than 48 hours should be inspected, cleaned and disinfected prior to use on a patient/client. 28