Bloodborne Pathogens Exposure Control Plan template

2. Responsibilities

• Plan administrator ([name/role]): keeps this plan current, runs the annual review and the safer-device evaluation, arranges training, vaccination, and post-exposure follow-up, and maintains the records.
• Managers and supervisors: make sure the controls, PPE, and sharps containers in their area are in place and used, release staff for training and vaccination appointments, and act on exposure reports at once.
• Employees with occupational exposure: follow the work practices and PPE rules in this plan, complete training, and report every exposure incident and sharps injury immediately. No exposure is too small to report.
• [Occupational health provider / licensed healthcare professional]: provides hepatitis B vaccination and post-exposure evaluation and follow-up, and the written opinions the standard requires.

3. Exposure determination

The standard requires a written exposure determination, made without regard to the use of personal protective equipment: an employee who would be exposed without gloves counts as exposed, even if they always wear gloves. {{org.name}}'s determination is below, and it is updated whenever jobs, tasks, or procedures change.

• Job classifications in which all employees have occupational exposure: [e.g. registered nurses, phlebotomists, dental hygienists, laboratory technicians].
• Job classifications in which some employees have occupational exposure: [e.g. housekeeping, laundry, maintenance, designated first aid responders].
• For each classification on the "some employees" list, the tasks and procedures in which occupational exposure occurs: [e.g. cleaning blood spills, handling contaminated laundry, emptying sharps containers, giving first aid].

4. Universal precautions, engineering and work practice controls

Universal precautions apply at {{org.name}}: all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens, and where body fluid types cannot be told apart, all body fluids are treated as potentially infectious. Engineering and work practice controls come first; where exposure remains after them, PPE is also used, as paragraph (d)(2)(i) of the standard requires.

• Engineering controls in use: [sharps disposal containers, self-sheathing needles, sharps with engineered sharps injury protections, needleless systems, other devices]. They are examined and maintained or replaced on [schedule], so their effectiveness is checked rather than assumed.
• Contaminated needles and other contaminated sharps are not bent, recapped, or removed. The only exceptions are the ones the standard allows (no alternative is feasible, or a specific medical or dental procedure requires it), and then only by a mechanical device or a one-handed technique: [list any approved procedures]. Shearing or breaking contaminated needles is prohibited.
• Sharps containers are closable, puncture resistant, leakproof on the sides and bottom, and labeled or color-coded. They are kept upright, as close as feasible to where sharps are used, and replaced routinely before they overfill: [fill line/frequency].
• Hands are washed immediately or as soon as feasible after removing gloves or other PPE. Skin is washed with soap and water, or mucous membranes flushed with water, immediately or as soon as feasible after contact with blood or OPIM. Handwashing facilities are at [locations]; where they are not feasible, [antiseptic hand cleanser with clean towels / antiseptic towelettes] are provided, followed by soap and running water as soon as feasible.
• No eating, drinking, smoking, applying cosmetics or lip balm, or handling contact lenses in work areas where there is a reasonable likelihood of occupational exposure, and no food or drink kept where blood or OPIM are present. Break and food areas: [designated areas].
• Procedures involving blood or OPIM are performed so as to minimize splashing, spraying, spattering, and droplets. Mouth pipetting or suctioning is prohibited. Specimens go in containers that prevent leakage, labeled or color-coded as the standard requires.
• Equipment that may be contaminated is examined before servicing or shipping and decontaminated as necessary. Where that is not feasible, a label states which portions remain contaminated, and affected employees, the servicer, or the manufacturer are told before handling.

5. Personal protective equipment

Where there is occupational exposure, {{org.name}} provides appropriate PPE at no cost to employees, in the appropriate sizes, readily accessible at [locations] or issued to employees. Under the standard, PPE is "appropriate" only if it does not permit blood or OPIM to pass through to or reach the employee's work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of use. The PPE matrix by task is at [location].

• Gloves when hand contact with blood, OPIM, mucous membranes, or non-intact skin can be reasonably anticipated, when performing vascular access procedures, and when handling or touching contaminated items or surfaces. Disposable gloves are replaced as soon as practical when contaminated, or as soon as feasible when torn, punctured, or no longer a barrier, and are never washed or decontaminated for reuse. Hypoallergenic gloves, glove liners, or powderless gloves are available to employees allergic to the gloves normally provided: [location].
• Masks in combination with eye protection (goggles or glasses with solid side shields), or chin-length face shields, whenever splashes, spray, spatter, or droplets may be generated and eye, nose, or mouth contamination can be reasonably anticipated.
• Gowns, aprons, lab coats, or similar protective clothing in occupational exposure situations, chosen for the task and the degree of exposure anticipated; and surgical caps or hoods and/or shoe covers or boots where gross contamination can reasonably be anticipated.
• A garment penetrated by blood or OPIM is removed immediately or as soon as feasible. All PPE is removed before leaving the work area and placed in [designated area/container] for storage, washing, decontamination, or disposal.
• {{org.name}} cleans, launders, disposes of, repairs, and replaces PPE at no cost to employees. Contaminated PPE is not taken home to wash.
• If an employee briefly declines PPE in the rare and extraordinary circumstances the standard describes, [name/role] investigates and documents the circumstances to see whether changes can prevent it happening again.

6. Housekeeping, regulated waste, and laundry

The worksite is kept clean and sanitary to the written cleaning schedule at [location], which sets the cleaning and decontamination method for each area by location, type of surface, type of soil, and the tasks performed there. The standard requires this schedule.

• Contaminated work surfaces are decontaminated with [approved disinfectant] after procedures are completed; immediately or as soon as feasible after overt contamination or any spill of blood or OPIM; and at the end of the shift if they may have become contaminated since the last cleaning.
• Reusable bins, pails, and cans likely to become contaminated are inspected and decontaminated on [schedule], and immediately or as soon as feasible when visibly contaminated.
• Broken glassware that may be contaminated is never picked up directly with the hands: use [brush and dustpan / tongs / forceps].
• Regulated waste goes in containers that are closable, constructed to contain all contents and prevent leakage of fluids, labeled or color-coded, and closed before removal. It is disposed of through [licensed waste contractor] in line with applicable federal, state, and local regulations.
• Contaminated laundry is handled as little as possible with a minimum of agitation, bagged or containerized where it was used and not sorted or rinsed there, and carried in bags or containers labeled or color-coded as the standard requires. Wet laundry likely to soak through goes in bags that prevent soak-through and leakage. Anyone handling it wears gloves and other appropriate PPE.

7. Hepatitis B vaccination

The hepatitis B vaccine and vaccination series are made available at no cost to every employee with occupational exposure, after they have received the training on the vaccine described below and within 10 working days of initial assignment. The exceptions are the ones the standard gives: the employee has already received the complete series, antibody testing shows they are immune, or the vaccine is contraindicated for medical reasons. Vaccination is performed by or under the supervision of a licensed physician or other licensed healthcare professional, through [provider], at a reasonable time and place.

• Participation in a prescreening program is never a condition of receiving the vaccine.
• An employee who declines the vaccine signs the statement in Appendix A to the standard, as paragraph (f)(2)(iv) requires. Completed statements are kept at [location/system].
• An employee who declines at first but later decides to accept the vaccine, while still covered by the standard, is offered it at that time.
• If the U.S. Public Health Service recommends a routine booster dose in future, it is made available on the same no-cost terms.
• The healthcare professional responsible for vaccination is given a copy of the standard. {{org.name}} obtains their written opinion, limited to whether vaccination is indicated and whether the employee has received it, and gives the employee a copy within 15 days of the evaluation being completed.

8. Exposure incidents: what to do

1. 1Immediately wash the affected skin with soap and water, or flush the eyes, nose, or mouth with water.
2. 2Report the exposure to [name/role, phone] straight away. The evaluation is made available immediately after a report, and some post-exposure treatment is time-sensitive, so reporting is minutes, not the end of the shift.
3. 3The supervisor records the route of exposure and the circumstances, and identifies the source individual where that is feasible and not prohibited by state or local law.
4. 4The exposed employee goes to [occupational health provider / emergency department] for a confidential medical evaluation and follow-up, at no cost to them.
5. 5Sharps injuries are entered in the sharps injury log the same day: [log location].
6. 6[Name/role] evaluates the circumstances of the incident (the device, the task, the controls, the training) and records what changes as a result.

9. Post-exposure evaluation and follow-up

Following a report of an exposure incident, {{org.name}} makes a confidential medical evaluation and follow-up immediately available to the exposed employee, at no cost, performed by or under the supervision of a licensed physician or other licensed healthcare professional, and following U.S. Public Health Service recommendations current at the time. Laboratory tests are conducted by an accredited laboratory at no cost to the employee. As paragraph (f)(3) of the standard requires, the evaluation includes at least:

• Documentation of the route(s) of exposure and the circumstances under which the exposure incident occurred.
• Identification and documentation of the source individual, unless that is infeasible or prohibited by state or local law, and testing of the source individual's blood for HBV and HIV infectivity as the standard sets out. The results are made available to the exposed employee, who is told about the laws on disclosing the source individual's identity and infectious status.
• Collection and testing of the exposed employee's blood for HBV and HIV serological status, after consent. If the employee consents to blood collection but not yet to HIV testing, the sample is preserved for at least 90 days.
• Post-exposure prophylaxis when medically indicated, as recommended by the U.S. Public Health Service; counseling; and evaluation of reported illnesses.
• The evaluating healthcare professional is given a copy of the standard, a description of the employee's duties as they relate to the incident, the documentation of route and circumstances, the source individual's test results if available, and the relevant medical records, including vaccination status.
• The employee receives a copy of the healthcare professional's written opinion within 15 days of the evaluation being completed. The opinion is limited to confirming that the employee has been informed of the results and told about any medical conditions resulting from the exposure that need further evaluation or treatment; all other findings stay confidential.

10. Labels and signs

• Warning labels bearing the biohazard legend go on containers of regulated waste, refrigerators and freezers containing blood or OPIM, and other containers used to store, transport, or ship them. Labels are fluorescent orange or orange-red, or predominantly so, with lettering and symbols in a contrasting color.
• Red bags or red containers may be used instead of labels.
• Labels are affixed as close as feasible to the container by string, wire, adhesive, or another method that prevents their loss or unintentional removal.
• Labels on contaminated equipment also state which portions of the equipment remain contaminated.
• Label and red-bag supplies are kept at [location], and [name/role] checks containers and fridges in each area [frequency].

11. Information and training

Every employee with occupational exposure is trained at no cost and during working hours: at the time of initial assignment to tasks where occupational exposure may take place, and at least annually after that, within one year of their previous training. Additional training is given when new or modified tasks or procedures affect an employee's occupational exposure. Material is appropriate in content and vocabulary to each employee's educational level, literacy, and language, and the trainer is knowledgeable in the subject as it relates to this workplace: [trainer name and qualifications]. The training covers at least:

• An accessible copy of the regulatory text of the standard and an explanation of its contents.
• A general explanation of the epidemiology and symptoms of bloodborne diseases, and of the modes of transmission of bloodborne pathogens.
• This exposure control plan and how to get a copy of it.
• How to recognize tasks and other activities that may involve exposure to blood and OPIM, and the use and limitations of engineering controls, work practices, and PPE.
• The types, proper use, location, removal, handling, decontamination, and disposal of PPE, and the basis for selecting it.
• The hepatitis B vaccine: its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination are offered free of charge.
• What to do and whom to contact in an emergency involving blood or OPIM; the procedure to follow if an exposure incident occurs, including how to report it and the medical follow-up available; and the post-exposure evaluation and follow-up {{org.name}} provides.
• The signs, labels, and color coding the standard requires.
• An opportunity for interactive questions and answers with the person conducting the training. A recorded video with nobody to ask does not provide it.

12. Records and review

This plan is reviewed and updated at least annually, and whenever new or modified tasks and procedures affect occupational exposure or new or revised positions have occupational exposure. Each review reflects changes in technology that eliminate or reduce exposure, and documents the consideration and implementation of appropriate commercially available and effective safer medical devices: [devices evaluated, decision, and date]. Non-managerial employees responsible for direct patient care who are potentially exposed to injuries from contaminated sharps are asked for their input on identifying, evaluating, and selecting engineering and work practice controls, and that request is documented here: [how and when input was sought, and from whom]. Owner: [name/role]. Next review due: [date].

• Medical records: an accurate record for each employee with occupational exposure, kept under 29 CFR 1910.1020, with the employee's name, hepatitis B vaccination status (including the dates of all vaccinations and any records on their ability to receive the vaccine), the results of examinations, medical testing, and follow-up, the employer's copy of the healthcare professional's written opinion, and the information given to the healthcare professional. Kept confidential, not disclosed without the employee's express written consent except as the standard or other law requires, and kept for at least the duration of employment plus 30 years. Held by: [occupational health provider / location].
• Training records: the dates of the sessions, the contents or a summary, the names and qualifications of the trainers, and the names and job titles of everyone attending, kept for 3 years from the date of the training at [system/location].
• Sharps injury log: required of every employer that must keep an injury and illness log under 29 CFR part 1904 ([applies / does not apply] here). The log of percutaneous injuries from contaminated sharps records at least the type and brand of device, the department or work area, and how the incident happened; it protects the injured employee's confidentiality; and it is kept for the period 29 CFR 1904.33 requires. Kept at: [location/system].
• Availability: all of these records are made available to OSHA and NIOSH on request; training records to employees and their representatives on request; and medical records to the employee they concern, and to anyone with that employee's written consent.