SAMPLE WRITTEN PLAN

This is a sample written Exposure Control Plan provided only as a guide to assist in complying with 29 CFR 1910.1030, OSHA's Bloodborne Pathogens standard.  It is not intended to supersede the requirements detailed in the standards.  You need to review the standard for particular requirements which are applicable to your specific situation.  Note that this sample program does not include provisions for HIV/HIB laboratories and research facilities which are addressed in the standards. If you operate this type of facility, you need to include provisions as re­quired by the standard. Employers will need to delete or add information relevant to your particular facility in order to develop an effective, comprehensive exposure control plan. Note that the exposure control plan is expected to be reviewed at least on an annual basis and updated when necessary. 

This material and safety and health consultation services are provided at no cost to owners, proprietors, and managers of small businesses by the Illinois Onsite Safety & Health Consultation Program, Industrial Services Division, Department of Commerce and Economic Opportunity under a program funded largely by the Occupational Safety and Health Administration (OSHA), an agency of the U.S. Department of Labor.

 

ONSITE SAFETY & HEALTH CONSULTATION PROGRAM

Illinois Department of Commerce & Economic Opportunities

Industrial Services Division

100 West Randolph, Suites 3-400 Chicago, Illinois 60601

Phone:  312/814-2337    Fax: 312/814-7238    TDD:  800/419-0667

 


BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN

TABLE OF CONTENTS 

 

A. Exposure Determination.......................................................................................................... 3  

B. Implementation Schedule & Methodology.............................................................................. 4 

C. Hepatitis B Vaccine & Post-Exposure Evaluation & Follow-up  ...................................... 12 

D. Interaction with Health Care Professionals ......................................................................... 14 

E. Information and Training ....................................................................................................... 15 

F. Recordkeeping ...................................................................................................................... 15 

G. Dates, Evaluation and Review ............................................................................................. 17 

Appendices

Statement of Declination

Sample Exposure Incidence Report

Sample Training Outline

Sample Sharps Injury Log

BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN

 

FACILITY NAME: _________________________________________

 

We have developed this Exposure Control Plan (ECP) to elimin­ate or minimize employee occupational exposure to blood or other body fluids, and to comply with OSHA’s Bloodborne Pathogens standard, 29 CFR 1910.1030. Employees covered by the bloodborne pathogens standard receive an explanation of this ECP during their initial training session. It is also reviewed in their annual refresher training. All employees have an opportunity to review this plan at any time during their work shifts. If requested, we will provide an employee with a copy of the ECP free of charge and within 15 days of the request.

 

 ____________________ is the Program Administrator responsible for the implementation of the Exposure Control Plan (ECP). The Program Administrator will maintain, review and update the ECP at least annually, and whenever necessary to include new or modified tasks or procedures. The Program Administrator is also responsible for:

 


•                     Maintaining and providing all necessary personal protective equipment (PPE), engineering controls, labels and red bags.

•                     Ensuring that adequate supplies of equipment are available in the appropriate sizes.

•                     Ensuring that all new recommendations or changes are effectively implemented.

•                     Ensuring that all medical actions required are performed and that appropriate employee health and OSHA records are maintained.

•                     Training, documentation of training and making the written ECP available to employees, OSHA and NIOSH representatives.

•                     Recordkeeping

 

A.   Exposure Determination. Those 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. The job classifications where all employees have occupational exposure are:

 

Job Title

Department/Location

 

 

 

 

 

 

 

 

           

Job classifications where some employees have occupational exposure is below. This list includes all full-time, part-time, contract and per diem employees. 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 Classification

Department/Location

Tasks/Procedures

Example: Janitor

Example: Maintenance

Example: Handling Regulated Waste

 

 

 

 

 

 

 

B. Implementation Methods & Controls

 

1.      Universal Precautions. Universal precautions are used in order to prevent contact with blood or other potentially infectious materials (OPIM).  All blood or other potentially infectious material are considered infectious regard­less of the perceived status of the source individual.

 

2.      Text Box: List engineering controls, such as non-glass capillary tubes, SESIPs, needleless systems, sharps containers, sinks for washing hands, etc. that you provide.Engineering Controls and Work Practices. Engineering and work practice controls are used to eliminate or minimize exposure to employees at this facility. Where occupational exposure remains after institution of these controls, personal protective equipment is also used. Specific engineering controls and work practice controls used are listed.

 

Text Box: List scheduled maintenance such as daily or weekly. Also, who has the responsibility to review the effectiveness of the individual controls, such as the supervisor for each department. Example: Sharps disposal containers are inspected and maintained or replaced by _________ every _______ or whenever necessary to prevent overfilling.

 

 

  


Controls listed are examined and maintained on a regular schedule. The schedule for reviewing the effectiveness of the controls is as follows:

 

Text Box: List scheduled maintenance such as daily or weekly. Also, who has the responsibility to review the effectiveness of the individual controls, such as the supervisor for each department. Example: Sharps disposal containers are inspected and maintained or replaced by ______ every ____ of whenever necessary to prevent overfilling.

 

 

  

 

We identify the need for changes in engineering control and work practices; we evaluate new procedures or new products regularly. Both front line workers and management officials are involved in this process.

 

Text Box: List how you intend to do this. Examples: review of OSHA records, employee interviews, committee activities, etc.; describe the process, literature reviewed, supplier info, products considered; describe how employees will be involved in the selection and review procedures.     

 

  

 

Hand washing facilities are available and readily accessible to employees who incur expo­sure to blood or other potentially infectious materials. At this facility, hand washing facilities are located:

 

Text Box: List locations, such as patient rooms, procedure area. If hand washing facilities are not feasible, you are required to provide either an antiseptic cleanser in conjunction with a clean cloth/paper towels or antiseptic towelettes. If these alternatives are used then the hands are to be washed with soap and running water as soon as feasible. Employers who must provide alternatives to readily accessible handwashing facilities should list the location, task, and responsibilities to ensure maintenance and accessibility of these alternatives.

 

 

 

 

  

 

After removal of personal protective gloves, employees wash hands and any other potentially contaminated skin area immediately or as soon as feasible with soap and water. If employees incur exposure to their skin or mucous membranes then those areas are washed or flushed with water as soon as feasible following contact.

 

3.   Needles . Contaminated needles and other contaminated sharps will not be bent, recapped, removed, sheared or purposely broken. 

 

If recapping or needle removal is required, then the recapping or removal of the needle must be done by the use of a mechanical device or a one_handed technique.  At this facility recapping or removal is only permitted for the following procedures:

 

Text Box: List the procedures and also list the mechanical device to be used or alternately if a one-hand technique is used.

 

  

4.   Containers for Reusable Sharps . Contaminated sharps that are reusable are placed after use into appropriate sharps containers. The sharps containers are leak proof, puncture resistant and labeled with a biohazard label.

 

Text Box: List here where sharps containers are located as well as who has responsibility for removing sharps from containers and how often the containers are checked to remove the sharps.

 

  

5.   Work Area Restrictions . Employees may not eat, drink, apply cosmetics or lip balm,

smoke, or handle contact lenses in any work area where there is a reasonable likelihood of exposure to blood or OPIM. Food and beverages are not to be kept in refrigerators, freezers, shelves, cabinets, or on counter tops or bench tops where blood or OPIM are present.  

All procedures are conducted in a manner which will minimize splashing, spraying, splattering and generation of droplets of blood or other potentially infectious materials.  Methods which are employed to accomplish this goal are:  

Text Box: List methods, such as covers on centrifuges, usage of dental dams if appropriate, etc.

 

 

6.   Specimens. Specimens of blood or OPIM are placed in a container which prevents leakage during the collection, handling, processing, storage and transport of the specimens. Any specimens which could puncture a primary container are placed within a secondary container which is puncture resistant.

Text Box: List here how this are carried out, e.g., which specimens, if any, could puncture a primary container, which containers can be used as secondary containers and where the secondary containers are located.

 

  

If outside contamination of the primary container occurs, the primary container is placed within a secondary container which prevents leakage during the handling, processing, storage, transport or shipping of the specimen.

Text Box: Note that the standard provides for an exemption for specimens from the labeling/color coding requirement of the standard provided that the facility utilizes universal precautions in the handling of all specimens and the containers are recognizable as containing specimens. This exemption applies only while the specimens remain in the facility. If the employer chooses to use this exemption, then it should be stated here.

 

 

  

7.   Contaminated Equipment . Equipment which has become contaminated with blood

or other potentially infectious materials is examined prior to servicing or shipping and decontaminated as necessary unless the decontamination of the equipment is not feasible.  

Text Box: List here any equipment which it is felt can not be decontaminated prior to servicing or shipping.

  

 

8.   Personal Protective Equipment . The required personal protective equipment is

provided to employees at no cost to them. Appropriate PPE in a variety of sizes is readily accessible at the work site or is issued to employees. Hypoallergenic gloves, glove liners, powderless gloves, or other similar alternatives are readily accessible to those employees who are allergic to the gloves normally provided.

 

Training in the use of PPE is provided and covers the appropriate PPE for the tasks or procedures employees perform. Types of PPE available to employees are as follows. 

Text Box: List how the clothing are provided to employees, e.g., who has responsibility for distribution, etc. and also list which procedures would require the protective clothing and the type of protection required, this could also be listed as an appendix to this program. The employer could use a personal protective equipment task checklist as follows: · Gloves · Utility Gloves · Examination Gloves · Lab Coat · Face Shield · Clinic Jacket · Protective Eyewear (with solid side shield) · Surgical Gown · Shoe Covers · Other PPE (list)

 

 

 

 

 

 

 

  

 

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 any garment contaminated by blood or OPIM in such a way as to avoid contact with the outer surface.

 

All employees are expected to use the required personal protective equipment (PPE). An employee who temporarily and briefly declines to use PPE must report to the immediate supervisor (i.e., it was the employee's professional judgment that in the specific instance its use would have prevented the delivery of healthcare or posed an increased hazard to the safety of the worker or co-worker).  When the employee makes this judgment, the supervisor will investigate and document the cir­cumstances in order to determine whether changes can be instituted to prevent such occurrences in the future.

 

All personal protective equipment is cleaned, laundered and disposed of at no cost to employees.  All repairs and replacements are made at no cost to employees.

 

All garments which are penetrated by blood must be removed immediately or as soon as feasible. All personal protective equipment must be removed prior to leaving the work area. The following protocol has been developed so that equipment is left at the work area and is not taken home.

 

Text Box: List where employees are expected to place the personal protective equipment upon leaving the work area, and other protocols, etc.

  

 

 

Disposable gloves used at this facility are not to be washed or decontaminated for re-use and are to be replaced as soon as practical when they become contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised. Utility gloves may be decontaminated for re-use provided that the integrity of the glove is not compromised. Utility gloves are discarded if they are cracked, peeling, torn, punctured, or exhibit other signs of deterioration or when their ability to function as a barrier is compromised.

 

9.   Housekeeping. This facility is cleaned and decontaminated according to the following schedule (list area and schedule):

 

Area

Schedule

Cleaner

Example: Contaminated work surfaces