Safety Manual:
Review and Revision Log

Worksite Emergency Plan (Evacuation)

• Changed the title of the Director of CHP to Population Health (page 2).

•  Added “District Office” to “Medical Village Drive” and “Administrative Annex to Grandview Drive” (pages 4, 5, 9, 12, and 16).

•  Changed site coordinators (page 3).

•  Changed the location for evacuation of MVD and added a descriptor for the evacuation of CCHC (page 4).

•  Changed descriptors for emergency shut off valves (page 5) and designated severe weather shelter areas (page 9).

•  Added doors to seal off in case of shelter-in-place (page 12).

•  Added information about procedures for a suspected gas leak (page 13).

•  Changed information about panic buttons (page 17).

•  Updated TOC.

Incident Management

• Added information about safety precautions observed including pre-hire for safety sensitive and post-incident for all positions drug screen (pages 5 and 6). Added Appendix B: information about St. Elizabeth Business Health (page 11).

• Prevention of Tuberculosis (TB) Transmission Plan

• Changed the assessment date from March 2010 to April 2011 (page 7).

•  Added staggered scheduling of TB testing based on birth month (page 9).

•  Updated TOC

Other Sections

• Reviewed – no changes.

Worksite Emergency Plan (Evacuation)

• Added Logo.

• Modified the Severe Weather section (page 8).

Home and Field Visit Safety

• Added Logo.

•  Revised last bullets under “Tips for general planning and preparations” (page 4).

Incident Management

• Added Logo.

•  Revised business hours and added additional location to “Appendix B: Saint Elizabeth Business Health Details” (page 11).

Bloodborne Pathogens (BBP) – Exposure Control Plan

• Added Logo.

•  Removed “Director of Community Health Promotions” from list of positions that usually do not have occupational exposure (page 6).

•  Modified source individual information (pages 18-19).

•  Modified Appendix D: Informed Consent to Blood Testing (page 30).

•  Modified Appendix E: Employee Consent to Blood Testing (page 31).

•  Added Appendix G: Saint Elizabeth Laboratory Requisition Form (#8042)

All Other Sections

• Added Logo.

• Reviewed Remainder – No Changes.

Worksite Emergency Plan (Evacuation)

• Sprinkler Systems – changed “in an arcing pattern” to “to wet materials” (page 7).

• Fire Guidelines – added “in most buildings” to description of pull stations (page 8).

• Hazardous Material-Related Incidents – added more details pertaining to hazardous-material related incidents (page 12).

• Localized Incidents or Threats – added specific language about gunfire/other disturbances and lockdowns (page 16).

• Changed language about panic buttons (page 17).

• Removed review dates from footer.

General Workplace Safety

• Removed review dates from footer.

Home and Field Visit Safety

• Removed review dates from footer.

Bloodborne Pathogens (BBP) – Exposure Control Plan

• Employee Training and Responsibility – changed language to clarify who will coordinate annual updates and track training (page 3).

• Determining Occupational Exposure – updated positions that usually do not have occupational exposure (page 5).

• Engineering Work Practice Controls… - changed “needless” to “needle-less;” changed “safer devices” to “safety devices” in bulleted list (page 8).

• Removed review dates from footer.

Prevention of Tuberculosis (TB) Transmission Plan

• Updated Prevalence Table in Appendix 2 to include 2012 dates (page 13) and adjusted Table of Contents Accordingly.

• Removed review dates from footer.

Hazard Assessment and Personal Protective Equipment

• Moved contact information from Table of Contents Page to “Employee Training and Responsibility” section.

• Added information about shoe covers (pages 9 and 10).

• Removed review dates from footer.

Lockout - Tagout

• Moved contact information from Table of Contents Page to “Employee Training and Responsibility” section.

• Removed review dates from footer.

All Other Sections

Reviewed - no changes

Worksite Emergency Plan (Evacuation)

• Added “In/Out Board or a clear photograph of In/Out Board” and “SDSs” to list of items to take in event of evacuation or shelter (page 3).

• Changed “Administrative Office” to “Administrative Annex” (page 5).

Incident Management

• Updated Supervisor’s procedures for handling employee incidents  (pages 6 and 7).

• Changed Worker’s Comp Contact Information (Appendix A).

• Replaced old Worker’s Comp Form with new one (new contact information) (Appendix D).

Bloodborne Pathogens (BBP) – Exposure Control Plan

• Updated lists of occupational exposures with new position classifications (pages 4 and 5).

Prevention of Tuberculosis (TB) Transmission Plan

• Changed names of Appendices from numerals to letters (all).

• Updated TB Cases and Rates with 2013 data (Appendix B, page 13).

General Workplace Safety

•  Reviewed – No Changes

Home and Field Visit Safety

• Reviewed – No Changes

Worksite Emergency Plan (Evacuation)

• Designated Assembly Areas section, Kenton County Health Center: Changed gray to green after building was painted; Campbell County Health Center: Removed details about the dumpster after the dumpster was removed (Page 4).

• Deleted “kitchen” from eyewash station location of CCHC to correct error (Page 17).

Incident Management

• Updated OSHA’s new reporting requirements effective 1/1/2015 (Pages 6, 7, and 9)

Bloodborne Pathogens (BBP) - Exposure Control Plan

• Updated occupational exposure lists (Pages 4 and 5)

• Changed “Universal Precautions” to “Standard Precautions” as per OSHA’s update in the 1990s (Page 7)

• Changed “body fluids” to “bodily fluids,” “puncture-resistant container” to “sharps container” and made other minor clarifications (throughout).

Hazardous Assessment and PPE

• Added “clothing appropriate for task” to assessment of protection for hand and skin

• Added two criteria to footwear requirements to match dress code guidelines (Page 8)

• Changed “body fluids” to “bodily fluids” and made other minor clarifications (throughout)

• Updated to address Viral Hemorraghic Fever threats after Ebola scare (throughout)

Worksite Emergency Plan (Evacuation)

• Rewrote plan as per instructions received during safety walkthrough with consultants.

Incident Management

• Changed Step 3 of supervisor’s procedure for handling employee incidents to match revision in Personnel Policies (Page 6).

Bloodborne Pathogens (BBP) - Exposure Control Plan

• Corrected clerical errors (Page 3). Moved Environmental Health Worker from List B to List C exposures (Pages 4 and 5). Deleted Health Education Manger (Page 5).

Prevention of Tuberculosis (TB) Transmission Plan

• Added MTB abbreviation (twice on Page 2)

• Added PAPR abbreviation (Page 5); Changed date on risk factor assessment to 2015 (Page 7) 

• Updated TB data in Appendix B (Page 13) with most current data

All

• Changed logo on manual and sample forms in appendices.

Worksite Emergency Plan (Evacuation)

• Deleted references to Maintenance Supervisor (Page 2).

Incident Management

• Revised Appendix C (Page 12); and Appendix J (Page 27) to include forms with new logo and instruction in Appendices C, J, and D (Page 13).

Bloodborne Pahtogens (BBP) Exposure Control Plan

• Updated job titles under Occupational Exposures (Pages 4-5).

Prevention of TB Transmission Plan

• Changed title of keeper of form from “Human Resources Administrator” to “Employee Health Nurse” on (Page 2)

• Updated KY TB Cases and Rates (Appendix B on Page 13); Changed responsibility from “Epidemiology Services” to “Clinical Services (all pages)

Lockout/Tagout

• Deleted references to Maintenance Supervisor (Page 2).

All

• Changed references to “NKIDHD” to “NKY Health”; updated addresses of NKY Health due to move.

Worksite Emergency Plan

• Replaced information for “Medical Village Drive,” “Grandview Drive,” and “Administrative Annex with information for new District Office (Pages 2, 5, 6, 7, 9, 13, 14, 18 and 20)

• Added clarification to sign-in sheets (Pages 3 and 8)

• Updated severe weather guidelines (Page 8); updated hazardous material incident guidelines (Page 12)

• Updated suspicious or dangerous object (Page 16)

• Updated localized incidents or threats (Page 17

• Clarified medical emergencies procedures (Page 19)

Incident Management

• Removed faxing as an option for routine forms to HR (Page 7)

• Changed routing for forms form EPI to EE Health Nurse (Page 8)

• Removed address of third St. Elizabeth Business Health walk-in location (Page 11)

• Clarified instruction Appendix E (Pages 16, 18, and 20).

Bloodborne Pathogens (BBP) Exposure Control Plan

• Moved the following positions from category C to category B exposure: Director of Environmental Health and Safety, Disaster Preparedness Coordinator, Environmental Health Manager, Environmental Health Supervisor, Health Environmentalist, RS (Pages 4 and 5)

• Added sentence about responsibility for purchasing Hep C vaccine (Page 17)

• Deleted details about testing (Page 18)

• Added instruction for form in Appendix C (Page 27)

• Updated address on form in Appendix F (Page 30).

Prevention of Tuberculosis (TB) Transmission Plan

• Added Quantiferon Gold to testing (Pages 2, 4, and 9) 

• Updated site specific protocols to reflect new District Office (Page 7) 

• Updated Appendix B with 2017 KY Tuberculosis case and case rates (Page 13) 

• Replaced form in Appendix E (Page 16)

Hazard Assessment and Personal Protective Equipment (PPE)

• Changed contact information (Page 3); Added to health hazards list (Page 4)

Worksite Emergency Plan

• Updated TOC

• Removed language about designating two assistants for buildings with two or more floors (Page 3)

• Removed reference to “Grandview Drive,” and “Administrative Annex inadvertently left in after 2018 move to new District Office (Page 6) 

• Clarified location of shut off valves (Page 6), severe weather guidelines (Pages 9-10) and hazardous material guidelines (Page 12) 

• Added location of panic button (Page 17) and eyewash station (Page 19) for District Office)

• Added Appendix A for offsite emergency plans (Page 20)

General Workplace Safety

• Updated TOC

• Changed “First Aid” section to “Injuries” and changed language to address all injuries (Page 4)

•  Clarified language in remainder of document

Home and Field Visit Safety

• Changed guidelines for information to leave when making a field visit (Page 4.) Removed reference to land line (Page 6.) Clarified language in remainder of document.

Incident Management

• Changed disclaimer on page 4 to comply with new Workers Comp carrier policies (Page 4)

• Changed instructions to include Employee Incident Report required by NKY Health (Page 6)

• Added contact information for medical case management as per new Workers Comp carrier policies (Page 7)

• Changed instruction in Appendix B for finding locations of St. Elizabeth Business Health (Page 11)

Bloodborne Pathogens (BBP) Exposure Control Plan

• Updated titles in occupational exposure list to reflect updates classifications and re-evaluation of assignment (Pages 4 and 5)

• Updated Appendix B to match current sharp devices form (Pages 27-30)

• Updated Appendix C to match revised MedWatch form (Page 28)

• Updated Appendix G to match revised St. E Lab form (Page 34)

Prevention of Tuberculosis (TB) Transmission Plan

• Updated Appendix B with 2018 KY Tuberculosis case and case rates (Page 13).

Lockout/Tagout

• Revised entire section to be more applicable to office and clinical settings.

Incident Management

• Changed language to be more general to accommodate changing information from Workers’ Comp carrier (Pages 7 and 10).

All Sections

• Changed Header

Worksite Emergency Plan

• Updated TOC. Changed contact from Human Resources Administrator to Environmental Health and Safety (Page 2)

• Changed “bleach wipes” to “disinfectant wipes” (Page 15)

• Added direction for staff to use principles of emergency response training (Page 16)

General Workplace Safety

• Changed contact from Human Resources Administrator to Environmental Health and Safety (Page 1)

• Added “avoid twisting your body” language to lifting and carrying (Page 5)

• Changed “Refrain from” to “Do not” (Page 6). Changed “their” to “your” (Page 6)

Home and Field Visit Safety

• Changed contact from Human Resources Administrator to Environmental Health and Safety (Page 1)

• Changed “all staff members responsible for” to “anyone representing NKY Health on” (Page 2)

•  Updated tips for preparing to visit with a client (Page 3). Updates tips for vehicle safety (Page 4)

Incident Management

• Review only. No changes needed.

Bloodborne Pathogens (BBP) Exposure Control Plan

• Deleted “Health Environmentalist” from Occupational Exposure list (Page 5)

• Corrected clerical errors (throughout)

Prevention of Tuberculosis (TB) Transmission Plan

• Updated storage information for disposable respirators (Page 6)

• Updated site-specific protocols for preventing MTB (Page 7)

• Added PAPRs as an alternative to clinic sites and deleted cultures from home visit sites (Page 8)

•  Updated Appendix B with 2019 KY Tuberculosis case and case rates (Page 13)

Hazard Assessment and Personal Protective Equipment (PPE)

• Added contact information (Page 2)

• Changed “wash hands” to “perform hand hygiene” (Page 7). Corrected misspellings (throughout)

Lockout/Tagout

• Changed contact from Human Resources Administrator to Environmental Health and Safety (Page 1)

• Corrected grammatical errors (Page 3)

ALL

• Moved from .PDF files to pages on Google Sites.

• Sections split into subsections to fit format of sites.

• "Employee" changed to "Staff" when volunteers and supplemental staff are included.

• "Call 911" changed to "Call 9-1-1"

• Clerical, grammatical, and style guide errors corrected.

• Links added. 

BLOODBORNE PATHOGENS (BBP) EXPOSURE CONTROL PLAN

• Changed custodian of employee health records from "Epidemiology" to "Employee Health Nurse" where it was inconsistent.

• Changed language to more clearly describe role of Employee Health Nurse, Supervisor, and Human Resources.

• Forms updated with current versions and moved to central location.

PREVENTION OF TUBERCULOSIS (TB) TRANSMISSTION PLAN

• Forms updated with current versions and moved to central location.

INCIDENT MANAGEMENT

• Changed form names and instructions about submitting forms for the forms that moved from download-and-fill to Google forms that are completed, submitted and routed automatically.

• Detailed review of all sections 

• Home and Field Visits: located info re: off site activities and driving here, re-aligned paragraphs in Home and Field Visits for better flow, tightened language

• Lockout/Tagout: tightened language, allow tags for any powered device

• General workplace safety:  tightened language, re-arranged paragraphs, took "ill" and "illness" out of workplace injury paragraph

• Changed "keeper of training records" from "Human Resources" to "learning management system and/or personnel files"

• For Hazcomm training, changed initial training provided by "Human Resources" to "self-paced orientation site"

• Detailed review of all sections 

• Logout/Tagout and Home and Field Visit sections: Minimal language updates

• General safety: Some language and content updates for clarity

• Worksite Emergencies and TB: Language and content updates to reflect some updates in policy, process, and/or for clarity

• Hazard and PPE and BBP sections: Continuing language, content, formatting updates to reflect updates in policy, process and/or to better clarify said policy or process