Bloodborne Pathogens Exposure Control Plan

Sample Written Program

This sample Bloodborne Pathogens program is provided by the Missouri On-Site Safety and Health Consultation Program.  In order to comply with OSHA’s standard for Bloodborne Pathogens, 29 CFR 1910.1030, this written program must be site specific.  Modify the template to reflect the policies and procedures at your company.  Since OSHA regulations set minimum requirements, you may choose to add additional information to your site specific program. There is no requirement to follow this sample and its use does not guarantee compliance with the OSHA standard.

To prepare your plan, please follow these steps:

1. Read the Bloodborne Pathogens Standard 29 CFR 1910.1030

2. The following information may be useful in developing your program:

3. Add information to make it site specific to your company.

4. For clarification or assistance, contact the Missouri On-Site Safety and Health Consultation Program at 573-522-SAFE.

 

Bloodborne Pathogens Exposure Control Plan

(To customize, please complete and remove the highlighted areas of the program)

 

Date Created:

Date Reviewed:

1. Company Policy

(Name of Company) is committed to providing a safe and healthful work environment for our entire staff.  In pursuit of this goal, the following exposure control plan (ECP) is provided to eliminate or minimize occupational exposure to bloodborne pathogens in accordance with OSHA standard 29 CFR 1910.1030, “Occupational Exposure to Bloodborne Pathogens.”  The ECP is a key document to assist our organization 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 exposure incidents

 

Implementation methods for these elements of the standard are discussed in the subsequent pages of this ECP.

2. Program Administration

(Name of person or job title) is responsible for the implementation of the ECP.

(Name of person or job title) will maintain, review and update the ECP at least annually and whenever necessary to include new or modified tasks and procedures.

Employees who are determined 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 person or job title) will provide and maintain all necessary personal protective equipment (PPE), engineering controls (e.g., sharps containers), labels and red bags as required by the standard.

(Name of person or job title) will ensure that adequate supplies of the aforementioned equipment are available in the appropriate sizes.

(Name of person or job title) will be responsible for ensuring that all medical actions required by the standard are performed and that appropriate employee health and OSHA records are maintained.

(Name of person or job title) will be responsible for training, documentation of training and making the written ECP available to employees, OSHA and NIOSH representatives.

3. Employee Exposure Determination

The following is a list of all job classifications at our establishment in which all employees have occupational exposure: (Use as many lines as necessary).

 

Job Title

Department/Location

(Ex: 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: (Use as many lines as necessary).

Job Title

Department/Location

Task/Procedure

(Housekeeper)

(Environmental Services)

(Handling Regulated Waste)

 

 

 

 

 

 

 

 

 

 

NOTE: Part-time, temporary, contract and per diem employees are covered by the Bloodborne Pathogens standard. The ECP should describe how the standard will be met for these employees.

4. Methods of Implementation and Control

Universal Precautions

All employees will utilize universal precautions.

Exposure Control Plan

Employees covered by the Bloodborne Pathogens standard will receive an explanation of this ECP during their initial training session. It will also be reviewed in their annual refresher training.  All employees can review this plan at any time during their work shifts by contacting (Name of person or job title).  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 person or job title) is responsible for reviewing and updating the ECP annually or more frequently if necessary to reflect any new or modified tasks and procedures that affect occupational exposure and to reflect new or revised employee positions with occupational exposure.

5.  Engineering Controls and Work Practices

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

(For example: non-glass capillary tubes, SESIPs, needleless systems)

 

 

Sharps disposal containers are inspected and maintained or replaced by (Name of person or job title) whenever necessary to prevent overfilling.

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

We evaluate new procedures and new products regularly by (Describe the process, literature reviewed, supplier info, products considered)

Both front-line workers and management officials are involved in this process in the following manner: (Describe employees' involvement)

(Name of person or job title) is responsible for ensuring that these recommendations are implemented.

6. Personal Protective Equipment (PPE)

PPE is provided to our employees at no cost to them. Training in the use of the appropriate PPE for specific tasks or procedures is provided by (Name of person or job title).   

The types of PPE available to employees are as follows:

(gloves, gowns, eye protection, etc.)

 

 

PPE is located (Location) and may be obtained through contacting (Name of person or job title).  (Specify how employees will obtain PPE and who is responsible for ensuring that PPE is available.)

All employees using PPE must observe the following precautions:

  • Wash hands immediately or as soon as feasible after removing 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 is 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 or 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 procedure by title or number and last date of review; include how and where to find decontaminate face shields, eye protection, resuscitation equipment)

 

7. Housekeeping

Regulated waste is placed in containers which are closable, constructed to contain all contents and prevent leakage, appropriately labeled or color-coded (see the following section “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 procedure by title or number and last date of review)

 

 

The procedure for handling other regulated waste is: (May refer to specific 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 appropriately labeled or color coded.  Sharps disposal containers are available at (Locations)  They will be placed in locations that are easily accessible and as close as feasible to the immediate area where sharps are used.

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

Broken glassware that may be contaminated is only picked up using mechanical means, such as a brush and dustpan.

 

8. Laundry

The following contaminated articles will be laundered by this company:

 

 

Laundering will be performed by (Name of person or job title or department).   

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 (specify either red bags or bags marked with the biohazard symbol) for this purpose
  • Wear the following PPE when handling and/or sorting contaminated laundry: (List appropriate PPE).

 

9. Labels

The following labeling methods are used in this facility:

 

Equipment to be Labeled

Label Type

(EX: contaminated laundry)

(red bag)

(ES: Specimens)

(biohazard label)

 

 

 

 

 

(Name of person or job title) is responsible for ensuring that 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 (Name of person or job title) if they discover regulated waste containers, refrigerators containing blood or OPIM, contaminated equipment, etc., without proper labels.

 

10. Hepatitis B Vaccination

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

The hepatitis B vaccination series is available at no cost after initial employee training and within 10 days of initial assignment to all employees identified in the exposure determination section of this plan. Vaccination is encouraged unless: 1) documentation exists that the employee has previously 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 declines the vaccination, the employee must sign a declination form. Employees who decline may request and obtain the vaccination at a later date at no cost.

Documentation of refusal of the vaccination is kept at (Location). Vaccination will be provided by (List health care professional responsible for this part of the plan).

Following the medical evaluation, a copy of the health care professional’s written opinion will be obtained and provided to the employee within 15 days of the completion of the evaluation. It will be limited to whether the employee requires the hepatitis vaccination and whether the vaccine was administered.

 

11. Post-Exposure Evaluation and Follow-Up

Should an exposure incident occur, contact (Name of person or job title).

An immediately available confidential medical evaluation and follow-up will be conducted by (Name of licensed health care professional).

Following 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 (e.g., 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

 

12. Administration of Post-Exposure Evaluation and Follow-Up

(Name of person or job title) ensures that the 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 Bloodborne Pathogens standard.

(Name of person or job title) 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
  • If possible, results of the source individual’s blood test
  • Relevant employee medical records, including vaccination status

 

(Name of person or job title) will provide the employee with a copy of the evaluating health care professional’s written opinion within 15 days after completion of the evaluation.

13. Procedures for Evaluating the Circumstances Surrounding an Exposure Incident

(Name of person or job title) 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 (including type and brand)
  • 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

 

(Name of person or job title) will record all percutaneous injuries from contaminated sharps in a Sharps Injury Log.

If revisions to this ECP are necessary (Name of person or job title) will ensure that appropriate changes are made. (Changes may include an evaluation of safer devices, adding employees to the exposure determination list, etc.)

14. Employee Training

All employees who have occupational exposure to bloodborne pathogens receive initial and annual training conducted by (Name of person or job title). (Attached is a brief description of their qualifications.)

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

  • A copy and explanation of the OSHA bloodborne pathogen 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 (Location).

15. Recordkeeping

Training records are completed for each employee upon completion of training. These documents will be kept for at least three years.

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 person or job title).

16. 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 person or job title) is responsible for maintenance of the required medical records. These confidential records are kept in (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 person or job title).

17. OSHA Recordkeeping

Exposure incidents will be 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 person or job title).

18. Sharps Injury Log

In addition to the 1904 Recordkeeping Requirements, all percutaneous injuries from contaminated sharps are also recorded in a Sharps Injury Log. All incidences must include at least:

  • Type and brand of the device involved (syringe, suture needle)
  • Department or work area where the incident occurred
  • Explanation of how the incident occurred
     

This log is reviewed as part of the annual program evaluation and maintained for at least five years following the end of the calendar year covered. If a copy is requested by anyone, it must have any personal identifiers removed from the report.

 

SHARPS INJURY LOG

 

FACILITY NAME:

 

CALENDAR YEAR:

 

LOG ADMINISTRATOR:

 

 

           
 

 

DATE*

INCIDENT LOCATION

(e.g.  Department)

WORK AREA

INCIDENT DESCRIPTION

(e.g. How incident occurred)

TYPE/BRAND DEVICE INVOLVED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 

*Optional Entry

 

 

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: ______________________________

 

Date: __________________________________

 

 

 

 

Bloodborne Pathogens/Exposure Control Plan Training Roster

Training Performed By:

 

Employee Name

Employee Signature

Training Date