In December 1991, the Occupational Safety and Health Administration (OSHA) published a new rule regarding exposure to blood borne pathogens.  The purpose of this rule is to identify actions employers need to take for their employees who have potential occupational exposure to blood during performance of routine work duties.

The greatest risk of exposure to blood during the performance of routine work duties is found within the health care setting.  Mains'l Services, Inc.'s workplace, a residential setting for people with developmental disabilities and related conditions does not pose the same type of exposures.  The primary tasks of all employees of Mains'l Services is to offer training, assistance, and supervision to the people we serve.  Only as a collateral or incidental duty are employees expected to render first aid or be exposed to blood or body fluids which may present possible exposure to a blood borne pathogen

Mains'l Services, Inc. is committed to providing a safe workplace and implements all OSHA recommended procedures that minimize occupational exposure.  Mains'l Services also educates its employees about universal precautions that should be observed to prevent contact with blood or other potentially infectious materials.  In addition to preventive measures and education, Mains'l also provides access to treatment following an exposure incident at no charge to employees.

The policies and procedures supporting this policy on Blood Borne Pathogens are designed to meet compliance with OSHA standards.

It is the responsibility of Mains’l Services to determine the specific policies and procedures used in each individual program and their compliance to rules and regulations.  It is also the responsibility of Mains’l Services to make adjustments in the policies and procedures in the event rules and regulations are changed or reinterpreted.


The first step in determining work place exposure to blood borne pathogens is through the development of an Exposure Control Plan (see attached.)  The Exposure Control Plan is designed to eliminate or minimize employee exposure to blood borne pathogens.  The Exposure Control Plan must contain:

I.    Exposure Determination
II.    Schedule and Method of Implementation for:
    A.    Methods of Compliance
    B.    Hepatitis B Vaccine and Post Exposure Follow Up
    C.    Communication of Hazards to Employees
    D.    Record Keeping
III.    Procedure for Evaluation of Circumstances Surrounding Exposure Incidents

The Exposure Determination (see Exposure Control Plan - Section I) is a site specific document completed by the Manager with the assistance of the Senior manager.  Its purpose is to delineate all tasks and procedures which may present an occupational exposure.  Because the primary tasks of all employees of Mains’l Services, Inc. is to offer training, assistance, and supervision to the people we serve, tasks posing an occupational exposure are considered collateral duties and are not regarded as primary job assignments.  The completed Exposure Determination for each site is maintained in the policy manual at the site.   The entire Exposure Control Plan, including the Exposure Determination, is reviewed and updated at least annually and whenever necessary to reflect new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure.

The Exposure Control Plan also contains a Schedule and Methods of Implementation for A) the OSHA recommended methods of compliance including the concept of universal precautions, engineering and work practice controls, personal protective equipment and general housekeeping standards, B) Hepatitis B Vaccine and Post Exposure Follow Up, C) Communication of Hazards to Employees, and D) Record Keeping.  

Using the Universal Precautions approach, Engineering and Work Practice Controls, Personal Protective Equipment and general housekeeping standards are in place in all sites as deemed necessary.  (see Exposure Control Plan - Section IIA.)   Information about the aforementioned topics is contained in the “Control of Infection and Communicable Disease” Training module and provided during the first 60 days of employment to new employees and immediately to current employees.  

The Infection Control Plan is found within the Mains’l Policy Manual as an attachment to the Exposure 
Control Plan and incorporates related procedures addressing the universal precautions of hand washing, use of gloves, general cleaning procedures, and laundry procedure. 

The Schedule and Methods of Implementation also pertain to the administration of the Hepatitis B vaccine and Post Exposure Evaluation and Follow Up.  Pursuant to the OSHA modification of Hepatitis B vaccination requirements, employees who have occupational exposure as a “collateral duty” need not be offered the vaccine until an exposure incident has occurred.  (An exposure incident is defined as a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral (skin piercing) contact with blood or other potentially infectious materials that results from the performance of an employee’s duties).  Any unvaccinated person who has rendered assistance in any situation involving the presence of blood or other potentially infectious material, regardless of whether an actual exposure incident as defined by the OSHA standard has occurred, will be offered the vaccine.  The procedure following an exposure incident is delineated in the Exposure Control Plan - Section IIB.  New employees are instructed in the procedures during initial orientation and current employees are informed of the procedures during the training conducted by the Managers. 

The Schedule and Methods of Implementation also pertain to the communication of hazards to employees.  Warning labels and signs are not deemed necessary in the residential programs in which the employees of Mains’l work.  Occupational exposures only occur as collateral duties of employees and training is provided in infection control, universal precautions, personal protective equipment including the use of gloves, general work practice controls such as hand washing, and general housekeeping standards.

As mentioned throughout this procedure, comprehensive training is provided to all employees of Mains’l Services, Inc.  The training module includes all the elements recommended in the OSHA standard (see Exposure Control Plan - Section IIC.)   New employees receive training within the first sixty days of employment and the training will be reviewed annually for all employees, within one year of previous training.

Finally, the Schedule and Method of Implementation applies to record keeping (see Exposure Control Plan - Section IID.)  If an occupational exposure occurs, Mains’l Services will establish and maintain an accurate medical record for each employee with an occupational exposure.  The medical records will be confidential and will include all information as stipulated in the OSHA regulations.  Training records are maintained and contain all information as stipulated in the OSHA regulations.

The last component of the Exposure Control Plan is the procedure for evaluation of circumstances surrounding exposure incidents.  Following an exposure incident, the senior manager will review all documentation of the route(s) of exposure and the circumstances under which the exposure occurred and make recommendations to prevent future exposure incidents (See Exposure Control Plan - Section III).  The report will be reviewed by the Health Services Director who will make necessary changes or revisions to policy and procedure.

Internal Controls: 

OSHA Rule on Blood Borne Pathogens: 1910.1030 of Title 29 of the Code of Federal Regulations