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Exposure Control Plan

Exposure Control Plan


OSHA 1910.1030

Occupational Exposure– reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties.

Responsibility of Organization:

The Organization 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 by 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:

      1. Determination of employee exposure
      2. Implementation of various methods of exposure control, including:
      3. Universal precautions
      4. Engineering and work practice controls
      5. Personal protective equipment
      6. Housekeeping
      7. Hepatitis B vaccination
      8. Post-exposure evaluation and follow-up
      9. Communication of hazards to employees and training
      10. Recordkeeping
      11. Procedures for evaluating circumstances surrounding exposure incidents
      12. Implementation methods for these elements of the standard are discussed in the subsequent pages of this ECP.

Program Administration:

The Administrator is responsible for the implementation of the ECP. The Administrator will maintain, review, and update the ECP at least annually and whenever necessary to include new or modified tasks or procedures.

The Administrator will ensure the provision and maintenance, of an adequate supply of all necessary personal protective equipment (PPE), engineering controls (e.g. sharps containers), labels, and red bags as required by the standard and in appropriate sizes.

The Administrator 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.

The Administrator will be responsible for training, documentation of training, and making the written ECP available to employees, OSHA, and NIOSH representatives.

 Employee Exposure Determination:

  1. The following is a list of all job classifications, whether full-time, part-time or contract positions  at our agency in which employees have occupational exposure:
      • Registered Nurse, Licensed Vocational Nurse
      • Home Health Aides, Companions, and Homemakers, as applicable to the agency
      • Physical Therapists and Physical Therapy Assistants, if applicable to the agency
      • Occupational Therapists and Occupational Therapy Assistants, if applicable to the agency
      • Respiratory Therapists, if applicable to the agency
      • Any other employee that has direct or in-home contact with clients

Methods of Implementation and Control:

  1. Universal Precautions – all employees whether an agency employee or contracted will utilize universal precautions.
  2. Exposure Control Plan – Employees covered by the bloodborne pathogens standard receive an explanation of this ECP during their initial training session. It will also be reviewed in their annual in-service training. All employees can review this plan at any time during their workday by contacting the Administrator or their designee. If requested, we will provide an employee with a copy of the ECP free of charge and within 15 days of request. The Administrator 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.

Engineering Controls and Practices:

Engineering controls and work practice controls will be used to prevent or minimize exposure to bloodborne pathogens.

The agency recognizes the need for changes in engineering controls and practices through a review of OSHA records, employee interviews, and committee activities.

The agency, through both direct care workers and management staff, evaluates new procedures and new products regularly by literature review, supplier information, products considered, and products used. Information is shared with the QAPI Committee and  Administrator, and the Director of Nursing is responsible for ensuring that any new recommendations are implemented.

The specific engineering controls and work practice controls used are listed below:

      1. Puncture-resistant sharps containers – Sharp disposal containers are inspected and maintained or replaced by the Director of Nursing every month and as needed to prevent overfilling.
      2. Non-glass capillary tubes
      3. Safety needles
      4. Antiseptic hand cleanser and/or towelettes
      5. Clean paper towels
      6. Antiseptic hand soap
      7. Prohibiting eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses in work areas where there is a reasonable likelihood of occupational exposure.
      8. Prohibiting food or drink from being stored where blood or other potentially infectious materials are present.
      9. All procedures involving blood or other potentially infectious materials are to be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances.
      10. Prohibiting mouth pipetting of blood or other potentially infectious materials.
      11. Specimens of blood or other potentially infectious materials will be placed in a container that prevents leakage during collection, handling, storage, or transport. If the outside of the specimen container is contaminated then it will be placed in a secondary container. If the specimen could puncture the collection container, then it shall be placed in a secondary puncture-resistant container.
      12. Equipment that may become contaminated with blood or other potentially infectious materials will be decontaminated as necessary and feasible.

Personal Protective Equipment (PPE)

PPE is provided to agency employees at no cost to them. Training in the use of the appropriate PPE for specific tasks or procedures is provided by the Nursing department with oversight by the Director or Nursing.

The following types of PPE are available to employees:

      1. Gloves
      2. Eye protection
      3. Masks (surgical and N95) including face shields
      4. Disposable gowns
      5. Disposable shoe covers

PPE is located in the clean central supply area of the agency which is accessible to all staff during normal work hours and to the on-call staff after normal business hours.

The Director of Nursing is responsible for keeping the clean central supply area stocked and ordering supplies when needed.

All employees using PPE must observe the following precautions:

      1. Wash hands immediately or as soon as feasible after removing gloves or other PPE
      2. Remove PPE after it becomes contaminated and before leaving your work area
      3. Used PPE may be disposed of in a trash receptacle.
      4. Wear appropriate gloves when it is reasonably anticipated that there may be hand contact with blood or other potentially infectious materials 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.
      5. Never wash or decontaminate disposable gloves for reuse.
      6. Wear appropriate face and eye protection when splashes, sprays, spatters, or droplets of blood or other potentially infectious materials pose a hazard to the eye, nose, or mouth.
      7. Remove immediately or as soon as feasible any garment contaminated with blood or other potentially infectious materials in such a way as to avoid contact with the outer surface.
      8. The procedure for handling used PPE (face shields, eye protection) is as follows:

Adhere to recommended manufacturer instructions for cleaning and disinfection. When manufacturer instructions for cleaning and disinfection are unavailable, such as for single-use disposable face shields or goggles, consider:

      1. While wearing a clean pair of gloves, carefully wipe the inside, followed by the outside of the face shield or goggles using a clean cloth saturated with neutral detergent solution or cleaner wipe.
      2. Carefully wipe the outside of the face shield or goggles using a wipe or clean cloth saturated with EPA-registered hospital disinfectant solution.
      3. Wipe the outside of the face shield or goggles with clean water or alcohol to remove residue.
      4. Fully dry (air dry or use clean absorbent towels).
      5. Remove gloves and perform hand hygiene.
      6. Cleaned and disinfected eye protection can be stored onsite, in a designated clean area within the facility.
  1. Regulated waste is placed in closable containers, constructed to contain all contents and prevent leakage, appropriately labeled or color-coded, and closed before removal to prevent spillage or protrusion of contents during handling. See the Hazardous Waste Disposal Policy.
  2. The procedure for handling sharps disposal containers is located in the Hazardous Waste Disposal Policy. Contaminated sharps are discarded immediately or as soon as possible in containers that are closable, puncture-resistant, leakproof on sides and bottoms, and appropriately labeled or color-coded. Sharps disposal containers are available in the dirty supply area.

Hepatitis B Vaccination

The Director Nursing, or designee will provide training to employees on hepatitis B vaccines, 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.
  3. Medical evaluation shows that vaccination is contraindicated.

If the employee declines the vaccination, they 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 in the employee’s personnel file. If the employee chooses to receive the vaccination, they will be referred to the local

health department or other provider that has been arranged by the agency.

If a routine booster dose(s) of the hepatitis B vaccine is recommended by the U.S. Public Health Service at a future date, such booster dose(s) shall be made available to the employee.

Post-Exposure Evaluation And Follow-Up

Should an exposure incident occur, the Director of Nursing or designee will be notified. Following the initial first aid (clean the wound, flush eyes, or another mucous membrane, etc.) the following activities should be performed:

    1. Document the routes of exposure and how the exposure occurred.
    2. Identify and document the source individual (unless the employer can establish that identification is infeasible or prohibited by state or local law).
    3. 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. The source individual will not be charged for testing and the results will be confidential.
    4. If the source individual is already known to be HIV, HCV, and/or HBV positive, new testing need not be performed.
    5. 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).
    6. After obtaining consent, collect the exposed employee’s blood as soon as feasible after the exposure incident, and test blood for HBV and HIV serological status.
    7. If the employee does not give consent for HIV serological testing during the collection of blood for baseline testing, preserve the baseline blood sample for at least 90 days; if the employee elects to have the baseline sample tested during this waiting period, perform testing as soon as feasible.
    8. The agency shall ensure that all laboratory tests are conducted by an accredited laboratory at no cost to the employee.

The Director of Nursing ensures that health professional(s) responsible for the employee’s hepatitis B vaccination and post-exposure evaluation and follow-up are given a copy of OSHA’s bloodborne pathogens standard. The Director of Nursing ensures that the health care professional evaluating the employee after an exposure incident receives:

    1. A description of the employee’s job duties relevant to the exposure incident.
    2. Route(s) of exposure.
    3. Circumstances of the exposure.
    4. If possible, the results of the source individual’s blood test.
    5. Relevant employee medical records, including vaccination status.

The Director of Nursing is responsible for ensuring that the employee receives a copy of the evaluating health professional’s written opinion within 15 days after completion of the evaluation.

The Director of Nursing will review the circumstances of all exposure incidents to determine:

    1. Engineering controls were in use at the time of the incident.
    2. Work practices followed.
    3. A description of the device (if applicable) being used including the type and brand.
    4. Protective equipment or clothing that was used at the time of the exposure incident (gloves, eye shields, etc.)
    5. Location of the incident.
    6. The procedure was performed when the incident occurred.
    7. Employee training.

The Director of Nursing will record all percutaneous injuries from contaminated sharps in the Sharps Injury Log.