Assisted Living, News

Housekeeping for senior living (Part 3): Exposure control plan

In Part 2 of this series we covered safety tips for sharps management in a senior living facility. Part 3 will discuss explain what an exposure control plan is and what should be included, taken from Disaster Planning, Infection Control, and OSHA Compliance: A Toolkit for Senior Living, written by Karen T. Stratoti, RN, BSN, LNHA, CALA.

The Occupational Safety and Health Administration (OSHA) defines the exposure control plan (ECP) as the employer’s written program that outlines the protective measures an employer will take to eliminate or minimize employee exposure to blood and other potentially infectious materials (OPIM). It’s important to note that missing the ECP annual review is one of the most common OSHA citations.

The ECP must contain, at a minimum, the following:

  • An exposure determination that identifies job classifications and, in some cases, tasks and procedures where there is occupational exposure to blood and OPIM;
  • Procedures for evaluating the circumstances surrounding an exposure incident; and
  • A schedule of how and when other provisions of the standard will be implemented, including methods of compliance, communication of hazards to employees, and recordkeeping.

Recordkeeping requirements for exposed employees

OSHA has several requirements regarding recordkeeping for incidents of exposure, including:

Training records. Training records must be completed for each employee when training is done. Senior living facilities should check their individual state mandates to determine how long these records must be kept for.

The training records must include the:

  • Dates of the training sessions
  • Contents or a summary of the training sessions
  • Names and qualifications of persons conducting the training
  • Names and job titles of all persons attending the training sessions

Employee training records must be provided upon request to the employee or the employee’s authorized representative within 15 working days. Such requests should be addressed to the administrator or executive director of the facility.

Medical records. Medical records must be maintained for each employee with occupational exposure, in accordance with OSHA. OSHA mandates that administrators keep the medical records of any employee who may have been exposed for at least the duration of employment, plus 30 years. This time frame is dependent on your individual state’s OSHA requirements.

The administrator/executive director is responsible for maintaining employees’ medical records. Employees may request their employee medical records in writing, and they must be given to said employee within 15 working days of the request. Such requests should be sent to the administrator/executive director.

OSHA recordkeeping. An exposure incident must be evaluated to determine if the case meets OSHA’s Injury and Illness Recordkeeping and Reporting Requirements, found at This determination and the recording activities should be completed by the administrator/executive director.

Sharps injury log. A sharps injury log must be established and maintained for recording percutaneous (through the skin) injuries from contaminated sharps. The log should include:

  • Type and brand of device involved in the injury
  • The unit or work area where the exposure occurred
  • An explanation of how the incident occurred

The log must be recorded and maintained to protect the confidentiality of the injured employee. OSHA’s 300 Log of Work-Related Injuries and Illnesses may be used to record this information. Injury and illness recordkeeping forms 300, 300A, and 301 can be accessed and printed from OSHA’s webpage at The administrator/executive director is responsible for the maintenance of the sharps injury log.