Policy required document Workplace
Bloodborne Pathogens Exposure Control Plan
The Exposure Control Plan is the written program OSHA requires from any employer whose workers can reasonably expect contact with blood or other potentially infectious materials.
It lists the job classifications and tasks with exposure, states how the employer will follow the standard's methods of compliance (universal precautions, engineering and work practice controls, PPE, housekeeping), lays out hepatitis B vaccination and post-exposure follow-up, and describes the sharps injury log and how sharps devices are evaluated.
It is one of the few OSHA written programs with an explicit annual review requirement, and the only one that requires documented input from front-line staff on device selection. Home health, hospice, dental, behavioral health with medical staff, tattoo studios, and any workplace with designated first aid responders are in scope.
Accreditors survey against it and OSHA cites it heavily in health care.
Obligation ledger
Who requires it, and what each one says.
| Source | Applies when | What it requires | Status |
|---|---|---|---|
| OSHA Bloodborne pathogens, exposure control plan 29 CFR 1910.1030(c)(1) | Any employee has occupational exposure | A written plan with the exposure determination, schedule and method of implementing each compliance paragraph, and the procedure for evaluating exposure incidents; accessible to employees. Legally required. | Mandatory |
| OSHA Bloodborne pathogens, annual review and device input 29 CFR 1910.1030(c)(1)(iv) and (v) | Always | Review and update at least annually and whenever tasks or positions change; document annual consideration of safer medical devices; solicit and document input from non-managerial employees who handle sharps. Legally required. | Mandatory |
| OSHA Bloodborne pathogens, training and records 29 CFR 1910.1030(g)(2), (h) | Always | Training at assignment and annually; medical records kept for employment plus 30 years; training records with dates, content summary, trainer and attendees kept three years; sharps injury log for employers who keep an OSHA 300 log. Legally required. | Mandatory |
| Needlestick Safety and Prevention Act Pub. L. 106-430; 66 FR 5318 (Jan 18, 2001) | Always | Added the safer-device review, front-line input, and the sharps injury log to the standard. Legally required (now embedded in 1910.1030). | Mandatory |
| Home health and hospice accreditation (ACHC, CHAP) ACHC HH and HSP standards; CHAP Standards of Excellence; 42 CFR 484.70 infection control | You seek deemed status accreditation | Written infection prevention and control program, which surveyors read together with the OSHA ECP; personnel files show BBP training and hepatitis B vaccination status or declination. Accreditor expectation grounded in the CoP. | Implied |
Required sections
- Exposure determination: job classifications with exposure for all employees, and classifications with some exposure plus the tasks involved (1910.1030(c)(2))
- Schedule and method of implementation for: methods of compliance (d), HIV/HBV research labs (e) if applicable, hepatitis B vaccination and post-exposure evaluation (f), communication of hazards and training (g), recordkeeping (h)
- Universal precautions statement and engineering and work practice controls (d)(1) to (d)(2)
- Personal protective equipment provision, use, cleaning and disposal (d)(3)
- Housekeeping, regulated waste, laundry (d)(4)
- Hepatitis B vaccination offered within ten working days of assignment; declination form text from Appendix A (f)(2)
- Post-exposure evaluation and follow-up procedure, including source individual testing and the healthcare professional's written opinion (f)(3) to (f)(5)
- Procedure for evaluating the circumstances of an exposure incident (c)(1)(ii)(C))
- Annual review of safer medical devices and documentation of that review (c)(1)(iv)(B))
- Solicitation of non-managerial employee input on device selection, documented in the plan (c)(1)(v))
- Labels and signs (g)(1)
- Training program content and annual schedule (g)(2)
- Sharps injury log maintenance and privacy (h)(5), for employers required to keep injury records
- Plan review date and revision history (c)(1)(iv))
What the examiner asks for
What changed
Change log.
Frameworks
Where this document is required.
Who looks at it
Where this document gets checked.
No one certifies a document like this on its own. It is read during the audits and inspections below, and by the agency behind each rule.
| Where it is looked at | Who looks at it |
|---|---|
| ACHC/CHAP | ACHC and CHAP surveyors employed or contracted by each accreditor, typically clinicians with home care or hospice experience. Surveys for Medicare deemed programs are unannounced |
| CARF | CARF surveyors, who are peer professionals employed in accredited or comparable organizations, trained and assigned by CARF. Surveys are scheduled and on site for two to three days |
| ISNetworld/Avetta | Platform reviewers (ISN's RAVS team, Avetta's review specialists) grading documents against client and regulatory checklists; hiring clients may additionally audit contractors in the field. No independent certification or accreditation exists |
| OSHA written programs | OSHA compliance safety and health officers, or State Plan inspectors (government inspection). No certification exists; voluntary recognition programs such as VPP and SHARP involve OSHA or consultation program evaluation |
Who helps write it
Consultants.
Firms that name these standards in their own material.
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Where it lives
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From the publisher
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Questions
What people ask.
Our staff only give first aid occasionally. Are we in scope?
If you designate employees as first aid responders as part of their job, yes. OSHA's 1993 compliance policy allows some flexibility on when the hepatitis B vaccine is offered for collateral-duty first aiders, but the written plan and training still apply.
What does the annual review have to show?
A dated record that the plan was reviewed, that safer sharps devices available on the market were considered, and that non-managerial employees with sharps exposure were asked for input. Inspectors look for the date and the input record, not just a revised cover page.
Can we use a template?
OSHA publishes a model plan. The exposure determination and the device review must be specific to your workplace, which is where templates fail inspection.
How long do we keep training records?
Three years from the training date. Medical records, including vaccination and post-exposure records, for the duration of employment plus 30 years.
Who owns this site?
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