At least once a year in healthcare, exposure control plans must be reviewed and updated, and sooner when tasks or risks change.
Need a straight answer on review timing? Here it is, plus a no-nonsense guide that shows what to check, who signs off, and how to document it without drama for your team.
How Often Are Exposure Control Plans Reviewed In Healthcare: Rule And Timing
The rule sets a floor, not a ceiling. Healthcare employers review an exposure control plan each year on a 12-month cycle. You also update the plan any time tasks, procedures, or job roles change in ways that affect exposure. That way the plan mirrors reality on the floor, not last year’s habits.
If you run multiple sites, treat the cycle per site. Align the plan year to your training calendar so the update lands before annual refreshers. Pick a month and stick to it so audits never catch you drifting past the window.
| Requirement | What To Verify | Source |
|---|---|---|
| Annual update | Plan reviewed within the last 12 months; date shown on first page and in revision log. | OSHA 1910.1030(c)(1)(iv) |
| Changes in tasks | New or modified procedures reflected in exposure determination and work practices. | OSHA 1910.1030(c)(1)(iv) |
| New positions | Any new role with exposure added, with training and HBV offer captured. | OSHA 1910.1030(c)(1)(iv) |
| Safer devices | Evaluation of engineering controls and safer sharps documented. | Needlestick Safety Act update |
| Employee input | Notes show non-manager staff gave input on device selection. | OSHA 1910.1030(c)(1)(v) |
| Access to plan | Plan is accessible to staff on every shift; location or link listed. | OSHA 1910.1030(c)(1)(iii) |
Plain Language Explanation Of The Rule
The bloodborne pathogens standard spells it out: review the exposure control plan at least once each year and whenever your work changes in ways that affect exposure. Think of a new phlebotomy process, a shift from reusable to single-use instruments, a new clinic line, or a role redesign. Any of those trigger an update now, not next year.
Many teams treat the annual review as a quick calendar chore. That’s where gaps hide. Pull incident data, device trials, and training feedback into the review. If the data says splash risks rose in one unit, your work practices and PPE section should now reflect the fix.
Authoritative Sources You Can Point To
The plain words live in the 1910.1030 bloodborne pathogens standard. OSHA’s enforcement staff also spells out that “annually” means every 12 months and that updates happen when tasks or positions change; see the OSHA enforcement directive.
When To Review Sooner Than Annually
Several moments call for an immediate update. Use this list as a trigger chart.
- New task or procedure: Add the step, the exposure route, and the control you picked.
- New device or control: Document selection, trials, and any training change tied to the control.
- New role with exposure: Add the role to exposure determination and training schedule.
- After an exposure trend: If data shows a spike and you change a process, mirror that change in the plan.
- New site or service line: Write a site-specific section or annex with local hazards and contacts.
- Regulatory or accreditor update: If a rule or survey playbook changes your process, update now.
Who Owns The Review And The Calendar
Pick one owner and list backups by title. In hospitals, Infection Prevention or EHS leads the work, with unit managers and educators feeding in changes. HR owns training records; Supply Chain handles device trials; Risk Management tracks incidents; Employee Health tracks HBV offers and follow-up. That division of labor keeps the plan fresh without last-minute scrambles.
Map the year. A common pattern:
- January–February: Pull last year’s sharps log, incident logs, and device evaluations.
- March: Staff input sessions on tasks and devices; capture notes.
- April: Draft edits; update exposure determination tables and controls.
- May: Legal or compliance review; align with training syllabi.
- June: Leadership sign-off; post the plan; brief managers.
- July–December: Mini-updates when work changes; log each change with a short note.
What The Annual Review Must Include
Start with exposure determination. Confirm which job titles, tasks, and locations involve exposure to blood or OPIM. Then move to controls. Engineering controls come first, like safety-engineered devices or sharps containers. Work practices follow, like no two-handed recapping. PPE comes next, sized and stocked by task.
Training, HBV vaccination, and post-exposure steps round out the plan. Check that training covers new controls and that schedules line up with onboarding and refreshers. Confirm that the HBV offer reaches every employee with exposure and that declination forms sit on file where policy says they belong.
Bring Frontline Staff Into Device Choices
Solicit input from non-manager employees who deliver care. That includes nurses, techs, lab workers, and anyone who handles sharps. Hold short trials, gather comments on ease of use, and keep the notes with your device evaluations. The standard expects this step, and it pays off in safer practice.
Make The Plan Easy To Find
List where the plan lives. A network drive path, an intranet link, and a hard copy at each site handle most needs. New hires should see it during onboarding, and every employee should be able to pull it up on any shift without a hunt.
How To Document The Annual Review
Use a one-page review record attached to the front of the plan. It should show the review date, names and titles involved, summary of changes, and how you shared updates with staff. Keep a short revision log so auditors can trace edits over time. Save meeting notes and device trials in a labeled folder that matches the plan year.
| Field | Why It Matters | Tip |
|---|---|---|
| Review date | Proves the annual cycle stays intact. | Set a recurring calendar hold for the same week each year. |
| Participants | Shows cross-role input and accountability. | List titles, not names, in the template; fill names at review. |
| Summary of changes | Flags edits that affect training or workflow. | Use bullets by unit so managers can brief fast. |
| Device evaluations | Connects safer tech to the plan update. | Link to the trial note and vendor spec used in the choice. |
| Training updates | Ties plan edits to education content and timing. | Add LMS course IDs for quick checks. |
| Communication proof | Shows how staff were told about the change. | Screenshot the intranet post or include the huddle script. |
Common Pitfalls And Fixes
Late review dates. Missed the window? Do the update now and reset the calendar to a date you can keep. Add two reminders and a backup owner.
Copy-paste plans. One size rarely fits all sites. Keep common language, then add site annexes so hazards and contacts match local reality.
Device changes without edits. New needles or collection kits mean a control change. Update the work-practice language the same week the device ships.
Training drift. If work changed, training changed. Sync syllabi and skill checks with the plan during the same meeting.
Poor access. If staff can’t find the plan, surveys go sideways. Put the link on the unit homepage and in the orientation checklist.
Quick Start Template For This Year
- Open last year’s plan and the current incident and sharps logs.
- Mark any new tasks, procedures, roles, sites, or devices since the last review.
- Update exposure determination tables and control language to match the changes.
- Schedule two 20-minute staff input huddles; capture action items and device feedback.
- Confirm training updates, HBV offer coverage, and post-exposure steps.
- Draft the one-page review record; route for sign-off.
- Post the updated plan, push a short briefing to managers, and log the communication.
How This Guidance Was Built
This guide distills plain text from the federal standard and published compliance materials, then adds practical steps that teams can run without extra tools. The goal is a plan that matches daily work, holds up in a survey, and keeps staff safe.
Audit-Ready Evidence To Keep On Hand
Surveyors and inspectors ask for proof. Keep a small packet that you can pull in minutes. Store it with the plan and refresh it during the review.
- Revision log: One line per change with date and short reason.
- Sharps injury log: A summary page with counts and trends for the year.
- Device evaluations: Trial forms or notes that show the safer device choice.
- Training roster: Names, dates, and course IDs tied to the plan year.
- HBV offer records: Proof of offers and declinations for the exposed group.
- Access proof: A screenshot of the intranet location and a photo of the hard copy at one site.
- Communication: The email or huddle script you used to roll out changes.
Small Clinics And Ambulatory Settings
Small teams wear many hats. Keep the plan tight, but do not skip the annual review. A one-page exposure determination by role, a short control section, and a clear post-exposure flowchart hit the basics.
Pick a single binder or a single folder on your shared drive and label it with the plan year. Put the review record up front.
Tips To Keep The Plan Living
- Add a five-minute check to monthly safety rounds. Ask one nurse or tech what changed this month. If the answer points to exposure, start a mini-update.
- Use short change notes. When a unit adopts a safer device, post a two-line intranet note and drop the same text into the revision log.
- Batch minor edits. Small wording fixes can wait for the annual cycle. Changes that touch exposure, training, or devices go in now.
- Keep titles stable. If you rename roles, update exposure determination tables the same day so records line up today.