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Everything You Need to Know About Your Bloodborne Exposure Control Plan

Pretty much every workplace in America falls under the protection of the Occupational Safety and Health Administration (OSHA). They're an enforcement agency that regulates safety standards that keep employees safe. 

Healthcare and dental facilities have risks that require specific policies like hazard communications, medical waste management and your Bloodborne Exposure Control Plan.

These policies must be kept up-to-date with the most recent regulations and include site-specific details. Your exposure control plan and other policies need to be reviewed annually and employee training must be conducted and documented. We see lots of practices that stay very busy and these can get outdated quickly.


Oshaguard exposure control plan


An exposure control plan is required if you have any employee(s) with the risk of exposure to blood or other potentially infectious materials (OPIM). These positions need to be identified in your employee Exposure Determination. Most clinical positions are obvious, but all positions with the risk of exposure need to be identified in your exposure determination. The determination should not be made in regard to the use of PPE. That will be identified in a different portion of your exposure control plan. Job positions would be listed and general tasks and procedures would be identified. Consider all employee's risk even if it's limited. An example might be a receptionist in a small dental practice that helps clean operatories from time to time or a message therapist that might encounter someone with a wound or acne on occasion.

"An employee that only does administrative functions, like billing or scheduling, would not be identified in your exposure determination since there isn't a risk of exposure to bloodborne pathogens."

Any employee with the risk of exposure is afforded the protections outlined in the Bloodborne Pathogen Standard and must follow the policies outlined in your exposure control plan.

Identify Work Practice Controls. Employees should be trained to minimize the risk of exposure to bloodborne pathogens. These fundamentals should be identified in your policies too and include the ways you achieve compliance. Work practice controls typically include practicing Universal Precautions, washing hands after glove removal, not recapping needles and other methods you implement to keep employees safe.

Engineering Controls are used to eliminate or reduce the risk of exposure to blood or OPIM. In addition to training your employees on their use, these need to be identified in your Exposure Control Plan. Examples found in healthcare and dental offices would include recapping devices, evacuation systems for surgical smoke, safety-engineered needles or devices or suction equipment.

OSHA actually amended the Bloodborne Pathogen Standard to require evaluations of safety needles and other devices with built-in engineering controls. Evaluations must be done annually and include non-managerial and front line workers. Be sure to document your evaluations and implement the device if it's deemed safer. If it's not appropriate or there are shortcomings, be sure to list them on the evaluation and continue to look for new products when they're available. Some specialties are much more difficult to actually implement, but it's still important to document annually if it's possible.

Personal Protective Equipment or PPE should be appropriate for the tasks your employees are required to perform. Minimum PPE requirements are identified in your exposure control plan. These minimum requirements must be enforced so it's important to make an informed determination based on the actual risk. Most procedures like injections, cleaning rooms, handling biohazardous waste or wound care might only require gloves, but other procedures like surgery or the use of a handpiece in dentistry might require the use of gloves, mask, eye protection or more.

"List all the procedures and tasks that you perform in your facility and identify the minimum PPE that's required to keep your employees safe."

Employees always have the right to exceed these minimum requirements, but cannot sign a waiver or wear any less then the established minimum requirement.

Housekeeping, Disinfection and Sterilization Protocols should be identified in your exposure control plan. These are based on the current CDC recommendations and should reflect any state requirements. These policies typically identify the type of surface disinfectants you use, high level disinfectants or autoclave use.

Hepatitis B Vaccinations are required to be made available at no-cost to any employee identified in your Exposure Determination. This vaccination policy is outlined in your plan and based on the most current CDC recommendations. Vaccinations must be offered at no charge within 10 days of assignment. It's important to keep proof of Hepatitis B vaccinations for all clinically exposed employees. They can either bring proof of their vaccination or sign a declination form that states they have been vaccinated but don't have a copy of their record. 


Needlestick injury


Post-Exposure Evaluation and Follow-Up procedures are another component of your exposure control plan. Post-exposure evaluation and treatment must be made available at no charge to the employee in the event of a bloodborne exposure incident. Documentation is important and typically includes a healthcare professional's written opinion, testing for HBV, HBC, and HIV (depending on Hepatitis B status), source patient baseline, exposure incident report and the sharps injury log. Employee training should emphasize the importance of reporting an exposure incident as soon as possible.

Annual and New Employee Training Requirements. All employees should be trained prior to any task that could result in exposure to blood or OPIM. Training must be documented at the time of hire and annually thereafter. OSHA training records must be kept for a minimum of three years. Training should be based on the specific risks of your specialty.

If you don't have a current OSHA manual or your policies are outdated, please consider our 2022 OSHA Compliance System for Healthcare or Dentistry. We've provided common-sense, affordable solutions for OSHA and HIPAA for over 25 years. We offer custom OSHA compliance manuals, "Do-it-yourself" systems and in-office consultation and training as well.

Toll-free phone support is always available for our customers. We assist with all your regulatory questions, OSHA inspections, HIPAA audits or abatement.

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