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Model Exposure Control Plan

Model Exposure Control Plan

The Model Exposure Control Plan is intended to serve as an employer guide to the Occupational Safety and Health Administration (OSHA) Blood-borne Pathogens standard. A central component of the requirements of the standard is the development of an exposure control plan (ECP).

The intent of this model is to provide small employers with an easy-to-use format for developing a written exposure control plan. Each employer will need to adjust or adapt the model for their specific use.

The information contained in this publication is not considered a substitute for the Occupational Safety Health Act or any provisions of OSHA standards. It provides general guidance on a particular standard-related topic but for specific compliance requirements.

POLICY

The (Facility Name) is committed to providing a safe and healthful work environment for our entire staff. In pursuit of this endeavor, the following exposure control plan (ECP) is provided to eliminate or minimize occupational exposure to blood-borne pathogens in accordance with OSHA standards contained in 29 CFR 1910.1030, "Occupational Exposure to Blood-borne Pathogens". In addition, we will solicit input from non-managerial employees responsible for direct patient care who potentially are exposed to injuries from contaminated sharps in the identification, evaluation, and selection of effective engineering and work practice controls.

The ECP is a key document to assist our firm in implementing and ensuring compliance with the standard, thereby protecting our employees. This ECP includes:

  • Determination of employee exposure
  • Implementation of various methods of exposure control, including:
    • Universal precautions
    • Engineering and work practice controls
    • Personal protective equipment
    • Housekeeping
  • Hepatitis B vaccination
  • Post-exposure evaluation and follow-up
  • Communication of hazards to employees and training
  • Recordkeeping (including a sharps injury log)
  • Procedures for evaluating circumstances surrounding an exposure incident

The methods of implementation of these elements of the standard are discussed in the subsequent pages of this ECP.

PROGRAM ADMINISTRATION

  • __(Name of responsible person or department)__________________ is (are) responsible for the implementation of the ECP. __(Name of responsible person or department)_______________ will maintain, review, and update the ECP at least annually, and whenever necessary to include new or modified tasks and procedures. As part of the annual program review (Name of responsible person or department) will document the solicitation of input from employees responsible for direct patient care who potentially are exposed to injuries from contaminated sharps regarding the identification, evaluation, and selection of effective engineering and work practice controls. Contact location/phone number:____________________________
  • Employees who are discovered to have occupational exposure to blood or other potentially infectious materials (OPIM) must comply with the procedures and work practices outlined in this ECP.
  • (Name of responsible person or department)_____________________ will maintain and provide all necessary personal protective equipment (PPE), engineering controls (e.g., sharps containers), labels, and red bags as required by the standard. __(Name of responsible person or department)______________________ will ensure that adequate supplies of the aforementioned equipment are available in the appropriate sizes. Contact location/phone number: ___________________
  • _(Name of responsible person or department)_______________________ will be responsible for ensuring that all medical actions required are performed and that appropriate employee health and OSHA records are maintained. Contact location/phone number:________________________
  • _(Name of responsible person or department)_____________________ will be responsible for training, documentation of training, keeping the sharps injury log, and making the written ECP available to employees, OSHA, and National Institute of Occupational Safety and Health (NIOSH) representatives. Contact location/phone number:_____________________________

EMPLOYEE EXPOSURE DETERMINATION

The following is a list of all job classifications at our establishment in which all employees have occupational exposure:

  JOB TITLE DEPARTMENT/LOCATION
     
  (Example: Phlebotomists) (Clinical Lab)______________
  _________________________ _________________________

The following is a list of job classifications in which some employees at our establishment have occupational exposure. Included is a list of tasks and procedures, or groups of closely related tasks and procedures, in which occupational exposure may occur for these individuals

JOB TITLE DEPARTMENT/
LOCATION
TASK/
PROCEDURE
(Example:
Housekeeper
Environmental
Services
Handling
Regulated Waste)
_______________ _______________ _______________

Part-time, temporary, contract, and per diem employees are covered by the standard. How the provisions of the standard will be met for these employees should be described in the ECP.

METHODS OF IMPLEMENTATION AND CONTROL

Universal Precautions

All employees will utilize universal precautions.

Exposure Control Plan

Employees covered by the blood-borne pathogens standard will receive an explanation of this ECP during their initial training session. The plan also will 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 (Name of responsible person or department)__________. If requested, we will provide an employee with a copy of the ECP free of charge and within 15 days of the request.

(Name of responsible person or department)_______________ is responsible for reviewing and updating the ECP annually or more frequently, if necessary, to reflect any new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure.

Engineering Controls and Work Practices

Engineering controls and work practice controls will be used to prevent or minimize exposure to blood-borne pathogens. The specific engineering controls and work practice controls used are listed below:

  • (For example: glass capillary tubes in the clinical laboratory, outpatient clinics, and pediatric units)
  • __________________________________________________________
  • __________________________________________________________

Sharps disposal containers are inspected and maintained or replaced by (Name of responsible person or department)_____________________ every (list frequency)______________ or whenever necessary to prevent overfilling.

This facility identifies the need for changes in engineering control and work practices through (Examples: Review of OSHA records, employee interviews, committee activities, etc.)______________________________________________________

We evaluate need procedures or new products by (Describe the process)_______ __________________________________________________________________ __________________________________________________________________

The following staff are involved in this process: (Describe how employees will be involved)__________________________________________________________

(Name of responsible person or department)________________will ensure effective implementation of these recommendations.

Personal Protective Equipment (PPE)

PPE is provided to our employees for free. Training is provided by __(Name of responsible person or department)______________________ in the use of the appropriate PPE for the tasks or procedures employees will perform.

The types of PPE available to employees are as follows:

__(Ex., gloves, eye protection, etc.)___________________________________ __________________________________________________________________ PPE is located ____(List location)_______________________________ and may be obtained through _(Name of responsible person or department)_____(Specify how employees are to obtain PPE, and who is responsible for ensuring that it is available.)

All employees using PPE must observe the following precautions:

  • Wash hands immediately or as soon as feasible after removal of gloves or other PPE.
  • Remove PPE after it becomes contaminated, and before leaving the work area.
  • Used PPE may be disposed of in _____________(List appropriate containers for storage, laundering, decontamination, or disposal.)
  • Wear appropriate gloves when it can be reasonably anticipated that there may be hand contact with blood or OPIM, and when handling or touching contaminated items or surfaces; replace gloves if torn, punctured, contaminated, or if their ability to function as a barrier is compromised.
  • Utility gloves may be decontaminated for reuse if their integrity is not compromised; discard utility gloves if they show signs of cracking, peeling, tearing, puncturing, or deterioration.
  • Never wash or decontaminate disposable gloves for reuse.
  • Wear appropriate face and eye protection when splashes, sprays, spatters, or droplets of blood or OPIM pose a hazard to the eye, nose, or mouth.
  • Remove immediately or as soon as feasible any garment contaminated by blood or OPIM, in such a way as to avoid contact with the outer surface.

The procedure for handling used PPE is as follows: (may refer to specific agency procedure by title or number and last date of review)
____________________________________________________________
____________________________________________________________

(For example, how and where to decontaminate face shields, eye protection, resuscitation equipment)

Housekeeping

Regulated waste is placed in containers which are closable, constructed to contain all contents and prevent leakage, appropriately labeled or color-coded (see Labels), and closed prior to removal to prevent spillage or protrusion of contents during handling.

The procedure for handling sharps disposal containers is: (may refer to specific agency procedure by title or number and last date of review)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

The procedure for handling other regulated waste is: (may refer to specific agency procedure by title or number and last date of review)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Contaminated sharps are discarded immediately or as soon as possible in containers that are closable, puncture-resistant, leak proof on sides and bottoms, and labeled or color-coded appropriately. Sharps disposal containers are available at __________(must be easily accessible and as close as feasible to the immediate area where sharps are used).

Bins and pails (i.e., wash or emesis basins) are cleaned and decontaminated as soon as feasible after visible contamination.

Broken glassware which may be contaminated is picked up using mechanical means, such as a brush and dust pan.

Laundry

The following contaminated articles will be laundered by this company:
________________________ ________________________
________________________ ________________________

Laundering will be performed by _(Name of responsible person or department)_______________________ at (time and/or location).

The following laundering requirements must be met:

  • Handle contaminated laundry as little as possible, with minimal agitation
  • Place wet contaminated laundry in leak-proof, labeled or color-coded containers before transport. Use (red bags or bags purpose.)
  • Wear the following PPE when handling and/or sorting contaminated laundry: (List appropriate PPE)______________________

Labels

The following labeling method(s) is used in this facility:

EQUIPMENT TO BE LABELED LABEL TYPE (size, color, etc.)
(e.g., specimens, contaminated laundry, etc.) (red bag, biohazard label, etc.)
___________________________ ___________________________
___________________________ ___________________________

__(Name of responsible person or department)______________________ will ensure warning labels are affixed or red bags are used as required if regulated waste or contaminated equipment is brought into the facility. Employees are to notify ________________________ if they discover regulated waste containers, refrigerators containing blood or OPIM, contaminated equipment, etc. without proper labels.

HEPATITIS B VACCINATION

(Name of responsible person or department)________________________ will provide training to employees on hepatitis B vaccinations, addressing the safety, benefits, efficacy, methods of administration, and availability.

The hepatitis B vaccination series is available for free after training and within 10 days of initial assignment to employees identified in the exposure determination section of this plan. Vaccination is encouraged unless: 1) documentation exists that the employee previously has received the series, 2) antibody testing reveals that the employee is immune, or 3) medical evaluation shows that vaccination is contraindicated.

However, if an employee chooses to decline vaccination, the employee must sign a Declination Form. Employees who decline may request and obtain the vaccination at a later date free. Documentation of refusal of the vaccination is kept at _______(List location or person responsible for this recordkeeping).

Vaccination will be provided by _(List health care professional responsible for this part of the plan)at (location).

Following hepatitis B vaccinations, the health care professional's Written Opinion will be limited to whether the employee requires the hepatitis vaccine, and whether the vaccine was administered.

POST-EXPOSURE EVALUATION AND FOLLOW-UP

Should an exposure incident occur, contact ____(Name of responsible person) at the following number:_____________________________.

An immediately available confidential medical evaluation and follow-up will be conducted by (Licensed health care professional). Following the initial first aid (clean the wound, flush eyes or other mucous membrane, etc.), the following activities will be performed:

  • Document the routes of exposure and how the exposure occurred.
  • Identify and document the source individual (unless the employer can establish that identification is infeasible or prohibited by state or local law).
  • Obtain consent and make arrangements to have the source individual tested as soon as possible to determine HIV, HCV, and HBV infectivity; document that the source individual's test results were conveyed to the employee's health care provider.
  • If the source individual is already known to be HIV, HCV and/or HBV positive, new testing need not be performed.
  • Assure that the exposed employee is provided with the source individual's test results and with information about applicable disclosure laws and regulations concerning the identity and infectious status of the source individual (i.e., laws protecting confidentiality).
  • After obtaining consent, collect exposed employee's blood as soon as feasible after exposure incident, and test blood for HBV and HIV serological status.
  • If the employee does not give consent for HIV serological testing during collection of blood for baseline testing, preserve the baseline blood sample for at least 90 days; if the exposed employee elects to have the baseline sample tested during this waiting period, perform testing as soon as feasible.

ADMINISTRATION OF POST-EXPOSURE EVALUATION AND FOLLOW-UP

(Name of responsible person or department)________________________ ensures that health care professional(s) responsible for employee's hepatitis B vaccination and post-exposure evaluation and follow-up are given a copy of OSHA's blood-borne pathogens standard.

___(Name of responsible person or department)_____________________ ensures that the health care professional evaluating an employee after an exposure incident receives the following:

  • A description of the employee's job duties relevant to the exposure incident;
  • Route(s) of exposure;
  • Circumstances of exposure;
  • Results of the source individual's blood test, if possible; and
  • Relevant employee medical records, including vaccination status.

__(Name of responsible person or department)__________________ provides the employee with a copy of the evaluating health care professional's written opinion within 15 days after completion of the evaluation.

PROCEDURES FOR EVALUATING THE CIRCUMSTANCES SURROUNDING AN EXPOSURE INCIDENT

(Name of responsible person or department)________________________ will review the circumstances of all exposure incidents to determine:

  • Engineering controls in use at the time
  • Work practices followed
  • A description of the device being used
  • Protective equipment or clothing that was used at the time of the exposure incident (gloves, eye shields, etc.)
  • Location of the incident (O.R., E.R., patient room, etc.)
  • Procedure being performed when the incident occurred
  • Employee's training

If it is determined that revisions need to be made, __(Responsible person or department)___________________ will ensure that appropriate changes are made to this ECP. (Changes may include an evaluation of safer devices, adding employees to the exposure determination list, etc.)

EMPLOYEE TRAINING

All employees who have occupational exposure to blood-borne pathogens will receive training conducted by (Name of responsible person or department). (Attach a brief description of their qualifications.)

All employees who have occupational exposure to blood-borne pathogens will receive training on the epidemiology, symptoms, and transmission of blood-borne pathogen diseases. In addition, the training program covers, at a minimum, the following elements:

  • A copy and explanation of the standard
  • An explanation of our ECP and how to obtain a copy
  • An explanation of methods to recognize tasks and other activities that may involve exposure to blood and OPIM, including what constitutes an exposure incident.
  • An explanation of the use and limitations of engineering controls, work practices, and PPE.
  • An explanation of the types, uses, location, removal, handling, decontamination, and disposal of PPE.
  • An explanation of the basis for PPE selection.
  • Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine will be offered free of charge.
  • Information on the appropriate actions to take and persons to contact in an emergency involving blood or OPIM.
  • An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available.
  • Information on the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident.
  • An explanation of the signs and labels and/or color coding required by the standard and used at this facility.
  • An opportunity for interactive questions and answers with the person conducting the training session.

Training materials for this facility are available at __________________________.

RECORDKEEPING

Training Records

Training records are completed for each employee upon completion of training. These documents will be kept for at least three years at __(Name of responsible person or location of records)______________________.

The training records include:

  • The dates of the training sessions.
  • The contents or a summary of the training sessions.
  • The names and qualifications of persons conducting the training.
  • The names and job titles of all persons attending the training sessions.

Employee training records are provided upon request to the employee or the employee's authorized representative within 15 working days. Such requests should be addressed to _____(Name of Responsible person or department)_______.

Sharps Injury Log

(Name of Responsible person or department) is responsible for maintenance of the Sharps Injury Log for the recording of percutaneous injuries from contaminated sharps. The information in the Sharps Injury Log shall be recorded and maintained in such manner as to protect the confidentiality of the injured employee. The Sharps Injury Log will contain, at a minimum:

  1. The type and brand of device involved in the incident;
  2. The department or work area where the exposure incident occurred; and
  3. An explanation of how the incident occurred.

The Sharps Injury Log will be maintained for the period required by 29 CFR 1904.33.

Annual Review

(Name of Responsible person or department) is responsible for annual ECP review. The review will contain, at a minimum, a discussion of each of the following:

  • Determination of employee exposure
  • Implementation of various methods of exposure control including input from employees responsible for direct patient care who are potentially exposed to injuries from contaminated sharps especially about the following:
    • Universal precautions
    • Engineering and work practice controls
    • Personal protective equipment
    • Housekeeping
    • Hepatitis B vaccination
    • Post-exposure evaluation and follow-up
    • Communication of hazards to employees and effectiveness of employee training
    • Recordkeeping (including the Sharps Injury Log)
    • Procedures for evaluating circumstances surrounding an exposure incident

The completed review will be made available for employee review and will be kept as a permanent attachment in an appendix to the ECP.

Medical Records

Medical records are maintained for each employee with occupational exposure in accordance with 29 CFR 1910.1020, "Access to Employee Exposure and Medical Records."

(Name of Responsible person or department) is responsible for maintenance of the required medical records. These confidential records are kept at ____(List location)________________ for at least the duration of employment plus 30 years.

Employee medical records are provided upon request of the employee or to anyone having written consent of the employee within 15 working days. Such requests should be sent to _(Name of responsible person or department and address)

OSHA Recordkeeping

An exposure incident is evaluated to determine if the case meets OSHA's Recordkeeping Requirements (29 CFR 1904). This determination and the recording activities are done by _(Name of responsible person or department)________.

HEPATITIS B VACCINE DECLINATION (MANDATORY)

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with the hepatitis B vaccine, I can receive the vaccination series at no charge to me.

Signed:__(Employee Name)______________________________

Date:________________________