Chap 7 - OSHA Compliance

Risk Categories/Personnel at Risk

OSHA and the Centers for Disease Control recommend that you know your level of risk.

If you are in Category I or II, you must follow universal precautions by using personal protective equipment and clothing.

The following categories of personnel at EMU have been identified as at risk for exposure:

1. Health Services Center personnel

2. Athletic trainer, student trainers and coaches

3. Nursing faculty who supervise students in clinical agencies or the department Demonstration Laboratory, and work-study students assisting in the Lab

4. Biology faculty who supervise students in labs involving finger pricks or venipuncture

5. Custodians

6. Early Learning Center employees

7. Residence life staff, i.e. residence directors

1. Physical Education faculty who teach CPR

2. Faculty who supervise students in social service agencies, i.e., Education and Social Work Departments

3. Early Learning Center work study/student workers

Category III

Any other faculty, employee or student who is exposed to blood, body fluids or human tissue as a result of duties or educational activities at EMU will be covered by these policies.

Bloodborne Pathogens Control Program Policies and Procedures

General Information

This procedure is mandated for all employers and employees by the U.S. Department of Labor in Occupational Safety and Health Act (OSHA) 1910.1030 and by the Commonwealth of Virginia through Virginia Occupational Safety and Health (VOSH). This policy covers certain faculty, administrators, and all other employees of EMU who may be at risk for exposure to bloodborne viruses including the viruses that cause hepatitis and acquired immunodeficiency syndrome (AIDS).

This control program is designed to prevent the spread of hepatitis and AIDS to persons who may come into contact with blood, body fluids and human tissue as a part of their work at EMU. “Exposure incident,” as defined by OSHA, means a specific eye, mouth, other mucous membrane, non intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee’s duties.

OSHA defines “other potentially infectious materials” as human semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult to differentiate between body fluids. All body fluids are considered contaminated until proven otherwise after it is determined that the source was not infected with hepatitis or AIDS. These fluids may then be disposed of in a normal manner.

There is a mandatory requirement that organizations provide employees with training, protective clothing, puncture-proof containers for contaminated needles and other wastes, and a vaccination against hepatitis B. All approved costs, including the vaccinations, will be paid by EMU.

The Human Resources and Health Services Center in cooperation will provide assistance and oversee the Bloodborne Pathogens Control Program.

Universal Precautions

All persons in the primary risk categories ( Categories I & II) shall wear the appropriate personal protective equipment when in situations where they may be exposed. The personal protective equipment should not permit blood, body fluids or human tissue to pass through to the person’s skin, clothing, eyes, mouth or other mucous membranes under normal conditions of use and for the duration of time which the personal protective equipment is used.

Work Practice Controls

The following work area restrictions will apply when blood, body fluids or human tissue is present or likely to be introduced.

1. No food or drink will be consumed or stored. Persons will not apply lip balm or cosmetics nor will contact lenses be handled. There will be no smoking.
   
   

2. Hand washing facilities will be available. When not available, antiseptic towelettes or dry hand wash will be provided.

Contaminated needles and other contaminated sharps will not be bent, recapped, removed, sheared or broken. Sharps will be handled with care to prevent accidental cuts or punctures. Discard immediately in a puncture resistant container.

Broken glassware which may be contaminated will not be picked up directly with the hands. It will be cleaned up with a broom and dust pan.

Specimens of blood or other potentially infectious materials will be placed in containers preventing leakage and labeled “biohazard” material.

Contaminated work areas will be decontaminated with appropriate disinfectant by only the personnel who have been trained and authorized to work with infectious materials.

Mouth pipetting or suctioning of blood or other potentially infectious materials is prohibited. Should mouth-to-mouth resuscitation be required the proper protective equipment will be used.

All bins, pails, cans or similar receptacles will be inspected regularly by the supervisor and decontaminated as soon as feasible.

Information and Training

All employees in the primary risk categories (Categories I & II) will receive training in protecting themselves from exposure to blood, body fluids and other infectious materials. The training will be coordinated by the Health Services Coordinator. Employee records will be maintained by the Human Resources in coordination with the Health Services Center. The training will include:

Vaccinations

All persons identified in Categories I under “Risk Categories/Personnel at Risk” will be offered the Hepatitis B vaccine within 10 working days after they have been assigned work. Medical records concerning the inoculations will be the responsibility of the Health Services Center and will be kept confidential. The person in the above category has four options and these files will be kept in the Human Resources Office. The options are:

1 - to take the vaccination;

2 - to show they have previously received the vaccination;

3 - to take an antibody testing to show they have sufficient immunity;

4 - to decline the vaccination and sign a waiver.

Persons who decline may decide at a later time to undergo the vaccination at no cost to themselves.

Post-Exposure Evaluation and Follow-Up

All employees who experience an exposure incident will be offered a post-exposure evaluation and Hepatitis B Vaccine. Immediately contact the supervisor to determine if the exposure incident is related to bloodborne pathogen standard. The exposed employee or student will be referred to the Health Services Center for medical assessment, treatment and the appropriate follow-up. Related paperwork must be completed within 24 hours of the incident and sent to the Human Resources.

If possible, the source individual’s blood will be tested as soon as feasible in order to determine HBV and HIV infectivity. EMU will pay for the tests and the test results will be kept confidential in the Health Services Center.

The exposed person will have the opportunity to have his/her blood tested for HIV serological status. The blood sample may be retained for 90 days for testing. This person will be given counseling by the Director of Health Services or contracting physician concerning the necessary precautions to practice during the period after the exposure incident. This will include potential illnesses and personal hygiene.

Decontamination

Containers marked as “biohazard” or color coded in red will be used to store contaminated materials. After the materials/equipment are decontaminated they can be treated like any other soiled item.

Clothing and rubber items will be placed in a fluid-proof plastic bag for several days until the blood or body fluid is completely dry. (HBV can survive for at least one week in dried blood). Then the items will be washed or disposed of as trash. Glass and metal will be decontaminated in an autoclave.

Medical Recordkeeping

An accurate confidential medical record will be maintained for each employee with an exposure incident. The records will be maintained for the duration of employment plus 30 years. Employee medical records will be maintained in Health Services Center. Student employee records will be maintained in the Health Services Center.

Responsibility

For the application and enforcement of this mandated policy each vice president and department head is responsible for the areas under their direction. The Human Resources and Health Services Center will facilitate compliance

Confined Space Policy

Purpose-Scope-Goal

The purpose of this policy is to establish requirements and procedures for the safety and health of employees who work in and in connection with Confined Spaces.

This policy provides minimum safety requirements to be followed while entering, exiting and working in confined spaces at normal atmospheric pressure.

Our goal is to identify, eliminate or control and protect employees required to enter a confined space work area.

Definitions

A confined space is any work area which is difficult to enter and exit; not intended for full time occupancy and is poorly ventilated.

A qualified person: a person designated by Eastern Mennonite University, who by reason of training, education and experience is knowledgeable in the operation to be performed and is competent to judge the hazard involved.

(See attached list for more definitions:)

Dangers

• Asphyxiation (lack of oxygen).

• Mechanical (moving machine parts).

• Chemical or poisonous gases.

• Fire or explosion.
  
  

Identification of Hazards

The qualified person shall make employees aware of these locations so employees will prepare themselves prior to entry.

1. Possible contamination by toxic or flammable vapors.

2. Possible oxygen deficiency or excess.

3. Physical hazards

4. Possible leakage of hazardous materials into the spaces.

Review the past or current uses of the confined spaces.

1. If the contents that were stored there before are known-use the Material Safety Data Sheets (MSDS).

2. Check for coatings that could drop hazardous materials or that could decompose at the presence of heat.

Review the entry and exits and the hazards posed by adjacent spaces. The qualified person shall review the biological and the mechanical hazards.

Evaluation of Hazards

Once the qualified person identifies the confined space and reviews the hazards, this person shall conduct a hazard evaluation.

The qualified person shall examine each hazard with respect to:

1. Hazard exposure: how many or which employee shall be exposed.

2. Magnitude of the hazard: how toxic the hazards are, explosions size, etc.

3. Likelihood of hazard occurrence: measure from certain to impossible.

Potential for changing conditions/activities. This includes not only the changes of work in the confined space but also the weather.

Determine how the hazards will be controlled and the need for emergency responses.

Confined Space Evaluation & Procedure

A minimum procedure to follow:

1. Atmospheric Testing should be conducted, prior to entering, by the qualified person.

2. General testing is usually for oxygen content and flammable atmospheres. (Testing equipment shall be approved by the Underwriters Laboratories.)

3. Vertical entry, test various levels of the confined space.

4. Testing sequence should be oxygenated, flammability and toxicity.
   
   

2. Attendant(s) shall be stationed outside the confined space(s).

1. If confined spaces have several entry points one attendant may be utilized, as long as communications can be conducted with workers inside confined space.

2. Selection of communication systems will be up to qualified person: Verbal; Radio; Signaling.

3. Duties of attendants shall be: assist workers in entering confined space, direct workers to exit when dangers occur, initiate evacuation and emergency procedures, monitor any condition changes, and remain at entry until relieved by another attendant.
   
   

Lockout/Tagout systems shall be used to assure the control of the hazards in a confined space. i.e. de-energize the area if electrical hazard present and lock the switches.

1. Ventilate the confined space.

2. Ventilation normally consists of a pre-early purge of several air changes, then continuous introduction of fresh air during occupancy.

3. Natural ventilation maybe acceptable as long as it achieves the same results as the mechanical ventilation.

4. If ventilation is not possible or feasible consider other alternatives such as the Personal Protective Equipment (PPE).
   
   

1. Equipment to be considered is head protection, eye and face protection, hand protection, foot protection, protective clothing, hearing protection, respiratory protection.

2. Qualified person will gather equipment before entering and inform workers to wear equipment as they enter confined space.
   
   

1. Retrieved equipment shall be considered, for entry or rescue. If it’s going to be in the way of entry or can be wavered, however have other equipment to replace this.

2. Fall protection will be placed to protect the public as well as workers, i.e. barricades for the public and fall arresting systems for the workers.
   
   

9. The qualified person shall consider other safeguards such as:

1. Electrical equipment used shall meet National Electric Code (NEC) standards.

2. Other tools and test equipment shall meet Uniform Life Code (ULC) and Factory Mutual System standards.

3. Have ground fault circuit interrupter (GFCI) to assure grounding.
   
   

10. Warning signs and symbols shall be set up in the confined space entrance or area.

11. Training shall be done prior to entry of confined spaces. Training shall include:

1. Explanation of hazards that they will encounter.

2. Reason for proper use and limitations of Personal Protective Equipment (PPE).

3. How to respond to emergencies.

4. Everyone’s duties.

5. How to recognize the hazards.
   
   

12. Training for Atmosphere Monitoring Personnel shall include:

1. Proper use of monitoring equipment.

2. Field calibration.

3. Hazardous contaminants.

4. Conditions which could alter the work.
   
   

14. Training for Emergency response personnel to include the attendant.

1. Be very familiar with rescue plan.

2. Use of emergency rescue equipment.

3. First Aid and CRP.

4. Be very familiar with all confined spaces locations.

Always have available or can be made available certifications of workers. If they are to perform rescue procedures, qualified person may request a demonstration. Periodic Training shall be given to all who enter confined space.

Working in Confined Space

When working in the confined space all workers shall:

1. Follow all recommended procedures. They shall know all correct procedures for all jobs, they shall wear appropriate required protection and safety devices. If respirators are required, then they shall enter with it on.
   
   

2. The qualified person shall make sure the workers are using the right tools and equipment.
   
   

3. Test repeatedly: Test immediately after entering, test while working, test before every new entry (after breaks and lunch) and before ventilating.
   
   

4. Continue Ventilation: Make sure ventilation is adequate for size of confined space.

Revised: 07/20/09

Equipment Lockout/Tagout Policy

Purpose

• This program is in effect during normal operation and during maintenance “down” time.

• Outside contractors must follow EMU lockout procedures.

• The power source of any equipment to be set-up, adjusted repaired, serviced, installed or where maintenance work is to be performed and unintended motion or release of energy would cause personal injury, such a power source SHALL BE LOCKED OUT BY EACH EMPLOYEE DOING THE WORK.

• Safety locks are for the personal protection of the employee and are only to be used for locking out equipment.

• Safety locks, adapters and “Danger Tags” can be obtained from the Assistant Physical Plant Director.

• Equipment locks and adapters can be obtained from the Assistant Physical Plant Director. The sole purpose of the “Equipment” lock and adapter is to protect the equipment during periods of time when work has been suspended or interrupted. The “Equipment” locks are not to be used as a substitute for the employee’s personal safety lock.

• One key of every lock issued shall be retained by the employee to whom it was issued and the only other key to the lock shall be retained by Physical Plant office.

• Employees will receive training in general and specific energy control procedure. Training will be conducted by the Assistant Physical Plant Director.

• This energy control program will be evaluated annually by the Physical Plant Director and training reminders on procedures will be provided to employees.

• Overall responsibility for this program is vested in the office of the Physical Plant Director.

• The Assistant Physical Plant Director shall train new employees and periodically instruct their employees regarding provisions and requirements of this lockout procedure.

• Each supervisor shall effectively enforce compliance of this lockout procedure including the use of corrective disciplinary action where necessary.

• Each supervisor shall assure that the locks and devices required for compliance with the lockout procedure are provided to their employees.

• Prior to repairing, servicing, installing or performing maintenance work on equipment the supervisor shall determine and instruct the employees of the steps to be taken to assure they are not exposed to injury due to unintended machine motion or release or energy.

• Employees shall comply with the lockout procedures.

• Employees shall consult with their supervisor or other appropriate knowledgeable management personnel whenever there are any questions regarding their protection.

• Employees shall obtain and care for the locks and other devices required to comply with the lockout procedures.

• Equipment main disconnect switches shall be turned off and locked in the off position only after the electrical power is shut off at the point of operation control. Failure to follow this procedure may cause arcing, and possibly an explosion.

• A machine connected to over a 110 volt source of power by a plug-in cord shall have a locking device applied to the plug attached to the cord leading to the machine to be considered locked out.

• A machine connected to a 110 volt source of power by a plug-in cord shall be considered locked out if the plug is disconnected and tagged with a “Do Not Start” tag.

• After locking out the power source, the employee shall try the equipment, machine or process controls to ensure no unintended motion will occur or test the equipment, machine or process by use of appropriate test equipment to determine that the energy isolation has been effective.

• When two or more employees work on the same equipment, each is responsible for attaching his/her lock. Safety locks and adapters are to be fixed on levers and switches in the inoperative (off) position.

An employee who is assigned to a job and upon arrival finds an “Equipment Lock.” “Adapter,” and “Danger Tag” affixed to the equipment shall affix his/her personal lock to the “Equipment Adapter.”

• Power may be turned on when it is required to perform tests or adjustments. All of the rules pertaining to removing locks and restoring power shall be followed. The equipment shall again be locked out if it is necessary to continue work after completing the test or adjustments.

• Upon completion of the work, each employee will remove his/her lock, rendering the machine operable when the last lock is removed.

• The employee responsible for removing the last lock, before doing so, shall assure that all guards have been replaced, the equipment is cleared for operation, and appropriate personnel notified that power is being restored. This employee is also responsible for removing the “Equipment” lock and returning it to the Assistant Physical Plant Director.

• Receipt of a written request signed by Assistant Physical Plant Director which shall state the reason the employee is not able to remove the lock.

• The Assistant Physical Plant Director is responsible for making certain all the requirements for restoring power are followed.

Revised: 07/20/09