The Occupational Safety and Health Administration (OSHA) mandates that employers protect workers from hazards associated with bloodborne pathogens, such as Hepatitis B and the Human Immunodeficiency Virus (HIV). Employers whose workers have occupational exposure to blood or other potentially infectious materials (OPIM) must establish a written Exposure Control Plan (ECP). The ECP is the central document outlining the employer’s strategy to minimize or eliminate exposure risks and ensure compliance.
Defining the Exposure Control Plan
The Exposure Control Plan (ECP) is a written program required by OSHA under the Bloodborne Pathogens Standard (29 CFR 1910.1030). This document details the procedures and protocols an employer implements to protect employees who have occupational exposure to blood or OPIM. Occupational exposure is defined as reasonably anticipated skin, eye, mucous membrane, or parenteral contact with these infectious materials resulting from an employee’s duties.
The ECP applies to employees whose job tasks involve this potential contact, including healthcare workers, first responders, and certain custodial staff. The plan systematically identifies and mitigates the risks of bloodborne disease transmission through controls and work practices. It ensures that compliance methods, such as universal precautions and engineering controls, are clearly documented and understood by all affected personnel.
The Mandatory Annual Review Schedule
Employers must review and update their Exposure Control Plan at least once every calendar year. This annual review is the minimum mandatory frequency required by the OSHA Bloodborne Pathogens Standard. The scheduled update ensures the plan remains effective and accurately reflects current workplace conditions and procedures.
The annual requirement is a substantive review process, not just re-stamping the date. This assessment ensures all components are up-to-date and account for any changes in job classifications, procedures, or available technology over the preceding year. Maintaining this schedule demonstrates a consistent commitment to worker safety.
Situational Triggers Requiring Immediate Updates
While the annual review is the minimum requirement, the ECP must also be reviewed and updated “whenever necessary” to reflect changes in the workplace. These situational triggers necessitate an immediate revision outside of the yearly schedule to maintain the plan’s accuracy and effectiveness. A key trigger is the introduction of any new or modified task or procedure that affects occupational exposure.
For instance, if a facility adopts a new method for handling contaminated laundry or introduces a different medical procedure, the ECP must be revised to incorporate specific control measures for that new task. Similarly, creating new job classifications or revising existing positions that now involve occupational exposure requires an immediate update. These revisions ensure employees are protected by the most current protocols.
Key Elements of the Annual Review Process
The annual review must include a detailed and documented consideration of new technology that can eliminate or reduce occupational exposure. Mandated by the Needlestick Safety and Prevention Act, the most significant component is the active evaluation of safer medical devices. Employers must document their annual consideration and implementation of appropriate, commercially available, and effective sharps with engineered sharps injury protections and needleless systems.
The process also requires the employer to solicit input from non-managerial employees responsible for direct patient care and potentially exposed to sharps injuries. This frontline worker feedback is essential for identifying, evaluating, and selecting effective engineering and work practice controls practical for the specific work environment. Additionally, the review must include an updated exposure determination that lists all job classifications and procedures where occupational exposure occurs, ensuring no at-risk employee is overlooked.
Implementation and Record-Keeping Requirements
Following any update, the revised ECP must be effectively communicated to all employees with occupational exposure. This communication includes providing updated training that covers new procedures, devices, or changes to the plan’s provisions. Training must be provided at no cost to the employee and during working hours.
Specific record-keeping requirements accompany the ECP to demonstrate compliance. The employer must maintain the written ECP itself, ensuring it is accessible to employees and available to OSHA upon request. Additionally, employers must maintain a confidential sharps injury log, which records accidental needlestick incidents, including the device type, brand, location, and description of the event. Training records, including dates, content summaries, and trainer names, must also be maintained for three years.
Penalties for Non-Compliance
Failing to adhere to the ECP review and update requirements can result in significant financial and legal consequences for the employer. OSHA frequently cites employers for outdated or non-compliant Exposure Control Plans under the Bloodborne Pathogens Standard. The agency issues citations based on the severity and nature of the violation, classifying them as serious, other-than-serious, or willful.
A serious violation, issued when there is a substantial probability that death or serious physical harm could result, carries a maximum penalty exceeding $15,000 per violation. Willful violations, where an employer knowingly disregards the standard, have a maximum financial penalty surpassing $150,000 per violation. Failure to maintain an adequate plan also increases legal liability should an employee contract an illness or suffer an injury due to a preventable exposure incident.