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6.10 – Exposure Control Plan


Open Door 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 blood-borne pathogens in accordance with OSHA standard 29 CFR 1910.1030, “Occupational Exposure to Blood-borne 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
  • Procedures for evaluating circumstances surrounding exposure incidents
  • COVID-19 Coronavirus vaccination education

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

Program Administration

  • Medical Services Manager is responsible for implementation of the ECP.  The Infection Control Committee will maintain, review, and update the ECP at least annually, and whenever necessary to include new or modified tasks and procedures
  • 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.
  • Each department of Open Door 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
  • The Medical Services Manager 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.
  • Human Resources Department will be responsible for training, documentation or training, and making the written ECP available to employees, OSHA, and NIOSH representatives


  • Blood means human blood, human blood components, and products made from human blood
  • Bloodborne Pathogens means pathogenic micro-organisms that are present in human blood and can cause disease in humans.  These pathogens include but are not limited to Hepatitis B virus HBV and human immunodeficiency virus HIV.
  • Contaminated means the presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface
  • Contaminated Laundry means laundry which has been soiled with blood or other potentially infectious materials or may contain sharps.
  • Contaminated Sharps means any contaminated object that can penetrate the skin including but not limited to needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires
  • Decontamination means the use of physical or chemical means to remove, inactivate or destroy blood-borne pathogens on a surface or item to the point where they are no  longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use or disposal
  • Exposure Incident means a specific eye, mouth, other mucous membrane non-intact skin or parenteral contact with blood or other potentially infectious materials that result from performance of an employee’s duties
  • Occupational Exposure means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that my result from the performance of an employee’s duties
  • Other Potentially Infectious Materials means:
    • The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood and body fluids in situations where it is difficult or impossible to differentiate between body fluids
    • Any unfixed tissue or organ (other than intact skin) from a human (living or dead)
    • HIV – containing all or tissue cultures, organ culture, and HIV or HBV containing culture medium or other tissues from experimental animals infected with HIV or HBV.
  • Parenteral means piercing mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts and abrasions.
  • Personal Protective Equipment is specialized clothing (aprons) or equipment worn (gloves, goggles)by an employee for protections against hazard
  • Regulated Waste means liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.
  • Universal Precautions is an approach to infection control.  According to the concept of universal precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV and other blood borne pathogens

Employee Exposure Determination

All staff employed by Open Door is at risk of occupational exposure.

Methods of implementation and control

Universal Precautions

All employees will utilize universal precautions.

Exposure Control Plan

Employees covered by the blood-borne pathogens standard receive an explanation of the 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 the Medical Services Coordinator.  If requested, we will provide an employee with a copy of the ECP free of charge and within 15 days of the request.  Infection Control Committee is responsible for reviewing and updated 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 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:

  • Reporting of communicable disease – see P&P 6.01
  • New admissions surveillance for communicable disease  – see P&P 6.02
  • Management of communicable disease in personnel – see P&P 6.03
  • Hand washing  – see P&P 6.05
  • Mask Technique – see P&P 6.06
  • Gowning Technique – see P&P 6.07
  • Clean glove technique  –  see P&P 6.08
  • Hepatitis A & B including post-exposure prophylaxes – see P&P 6.13
  • Universal precautions – see P&P 6.14 and P&P 6.14.1
  • Waste Management – see P&P 6.15
  • Respiratory Protection Program- see P&P 6.16

Sharps disposal containers are inspected and maintained or replaced by the nursing staff/designee

This organization identifies the need for changes in engineering controls and work practices and work practices through review of OSHA records, employee suggestions, safety recommendations and new federal regulations.

We evaluate new procedures and new products regularly by review in department meetings, review of new regulations – state and federal

Both front-line workers and management officials are involved in this process in the following manner:  New safety/OSHA recommendations are reviewed in Department Representative Meetings

The Chairperson for the Department Representative Meeting and Infection Control Committee are responsible for ensuring that these recommendations are implemented.

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 the nursing department.

The types of PPE available to employees are as follows:  Gloves, hypoallergenic gloves, masks, eye shields, gowns, etc.

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 will be disposed of in appropriate containers
  • 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.
  • 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:  Policy 6.14 Universal Standard Precautions; Policy 6.06 Mask technique, Policy 6.07 Gowning technique, Policy 6.16 Respiratory Protection Plan.


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 container is:  Refer to Policy 6.15 Waste Management.

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


The following labeling methods are used in this facility:

Equipment to be Labeled                        Label Type (Size, color)

Step-on Metal Trash Can                          Small red bag, biohazard label

Large Trash Can                                     Large red bag, biohazard label

All staff are responsible for ensuring that warning labels are affixed or red bags are used as required if regulated waste or contaminated equipment is generated within the facility.

Hepatitis B Vaccination

The Human Resources Department 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 after 30 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 or refusal of the vaccination is kept in the employee’s medical file.

Vaccination will be provided by the Open Door nurse.

COVID 19 Vaccination

During orientation and at least annually, all employees will receive education and training on current COVID-19 preventative measures. Open Door will provide any updated bulletins regarding CMS and OSHA recommendations regarding COVID-19 vaccination and prevention.

Post-Exposure evaluation and follow-up

Should an exposure incident occur, contact the Medical Services Manager or the Executive Director.

An immediately available confidential medical evaluation and follow-up will be conducted by Medical Director.  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 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 know 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 a 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

Medical Services Manager 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 OHSA’s blood-borne pathogens standard.

Medical Services Manager/Executive Director ensure 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

Medical Services Manager/Executive Director 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

The Infection Control Committee and Steering Committee Meeting will review the following 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)
  • A 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

The Departmental Supervising Licensed Nurse will record all percutaneous injuries form contaminated sharps in a Sharps Injury Log.

If revisions to the ECP are necessary the Medical Services Manager/Executive Director will ensure that appropriate changes are made.  (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 receive initial and annual training conducted by the Human Resources Department (attach a brief description of their qualification).  All employees who have occupational exposure to blood-borne pathogen disease.  In addition, the training program covers, at a minimum, the following elements:

  • A copy and explanation of the OSHA blood-borne pathogen standard
  • Education of COVID prevention measures and vaccination recommendations
  • 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, 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 the Corporate Office, 540 Industrial Mile Road, Columbus Ohio 43228


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

The training records include:

  • The dates of the training sessions
  • The contents or 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:  Human Resource Department, Open Door Corporate Office, 540 Industrial Mile Rd, Columbus, Ohio 43228

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”

The Human Resources Department is responsible for maintenance of the required medical records.  These confidential records are kept in the file room at the corporate office 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 the Human Resource Compliance Manager.

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 the Associate Director/Employee Benefits Coordinator

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:

  • Date of injury
  • 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 a personal identifiers removed from the report.

Signed by:

Rebecca Sharp Porter
Chief Executive Director

Last Revised: 5/11/2023

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