Healthcare Compliance Tips
Bloodborne Pathogens Standard [Healthcare Compliance Tips]
PPE [Healthcare Compliance Tips]
Healthcare Compliance Tips
Bloodborne Pathogens Standard [Healthcare Compliance Tips]
PPE [Healthcare Compliance Tips]

Exposure Control Plan [Healthcare Compliance Tips]

Evaluate your exposure control plan annually.

A written exposure control plan intends to focus on the bloodborne pathogen standard, which guides how to protect your employees from exposure.

It is critical that you research and create procedures that are tailored to your practice.  For example, start by reviewing the type of controls, such as:

  • Engineering controls
    • Examples: How to handle sharps containers, the use of safer medical devices such as needless devices, shielded needle devices, and plastic capillary tubes.
  • Work practice controls
    • Examples: Wearing personal protective equipment, which includes gloves, gowns, caps, or hand washing and preventing re-capping of needles.

You must determine which employees are affected by reviewing the following categories:

  • Category 1:
    • Healthcare workers classified “at risk” for possible occupational exposure to bloodborne pathogens such as HBV, HCV, and HIV. Nurse and doctors are examples of this category.
  • Category 2:
    • Healthcare workers whose jobs do not involve exposure to bloodborne pathogens, but it may require performing unplanned tasks that involve contact with blood or bodily fluids such as non-clinical personnel.
  • Category 3:
    • Any healthcare worker whose job duties do not involve exposure to blood/body fluids.

Other areas that should be considered within the plan are:

  • Housekeeping
    • This includes decontamination and waste.
  • Safe medical devices
    • Implementation and review of safer medical devices are required annually, in which employee input is necessary.
  • Recordkeeping, HBV, and Training
    • Utilize the occupational injuries/illnesses and the sharps log to evaluate post-exposure incidents (and follow-up). *Note: This applies to practices that have 10 or more employees.
    • Review Hepatitis B vaccination requirements and declination forms.
    • Communicate hazards to employees and train.

Your exposure control plan must be completed annually and documented. If you would like more details, OSHA has provided a sample plan to use in your practice immediately.

**The opinions and observations from the group/author are not a promise to exempt your practice from fines and penalties.  Research, modify, and tailor the advice to fit your specialty.


Joi Sherrod, MPH, CPC, CPCO
Joi Sherrod, MPH, CPC, CPCO
Joi is an educator and owner of JNC Healthcare Compliance Group. After working for distinguished academic teaching hospitals and clinics, she is passionate about helping medical, dental, and behavioral health practices rethink healthcare compliance one trend at a time. Contact Joi at