In healthcare, the exposure control plan must be reviewed at least once each year and whenever tasks, roles, or controls change.
Healthcare work touches blood, sharps, and body fluids. A written exposure control plan keeps those risks in check, lays out who falls in scope, and shows what the facility does to cut exposures. The plan is not a binder that sits still. It needs a steady review rhythm and quick edits when work changes. This guide sets a clear schedule, plain triggers, and a practical checklist.
Exposure Control Plan Review Frequency In Healthcare Settings
Here is the short calendar answer. Do a full review every 12 months. Then update on the spot when a change in tasks, procedures, devices, or positions affects exposure risk. That two-part rule fits both large systems and small practices. The annual cycle captures routine tune-ups; the as-needed updates catch real-world shifts between annual dates.
What “Annual” Looks Like In Practice
Pick a fixed month, run a structured review, log findings, and push updates to the controlled plan. Tie training and device checks to the same window so nothing drifts. Pair the review with sharps log trends and device trials to keep engineering controls central.
Annual Review Checklist: Sections And Proof
The checklist below mirrors the typical plan layout. Use it to spot gaps and gather records surveyors expect.
| Plan Section | What To Verify Or Update | Records To Keep |
|---|---|---|
| Exposure Determination | Job titles and tasks with exposure; new roles added this year | Roster, task list, org chart |
| Engineering Controls | Safer devices in use; new tech trialed; removal of outdated models | Device list, trial notes, purchasing files |
| Work Practice Controls | Sharps handling steps, hand hygiene steps, spill response steps | SOPs with revision dates |
| Personal Protective Equipment | Types, sizes, fit, stock levels, points of use | PPE inventory, receipts, photos of stations |
| Hepatitis B Vaccination | Offer path, acceptance/declination logs, post-exposure dosing paths | Consent forms, titer files, declination forms |
| Post-Exposure Care | Immediate steps, source testing, staff testing, follow-up | Exposure packets, clinic referral list |
| Training | Who needs it, content, timing, make-ups for new hires | Sign-ins, LMS pulls, quizzes |
| Sharps Injury Log | Complete entries, trends, root causes, device notes | Log file, trend charts |
| Housekeeping | Decon agents, contact times, waste handling, linen flow | Supplier sheets, route maps |
| Laundry And Waste | Bagging, transport, storage, vendor steps | Contracts, pick-up logs |
| Communication Of Hazards | Labels, signs, color codes, SDS access | Label samples, photo checks |
| Recordkeeping | Where files live, who holds access, retention windows | Index, retention table |
What The Law Says About Frequency
U.S. rules set the floor for timing. The federal bloodborne pathogens standard spells it out: review and update the exposure control plan at least once each year and whenever tasks, procedures, or job roles change in ways that affect exposure. The Needlestick Safety and Prevention Act sharpened the tech focus by calling out safer devices and the review of new engineering controls.
Read the source text here: OSHA 29 CFR 1910.1030 and the federal update here: Needlestick Safety revision. State plans like Cal/OSHA use the same review rhythm with added detail on logs and device trials.
Who Owns The Plan And The Review
Ownership sits with the employer. In day-to-day terms, that means a safety lead, infection prevention lead, lab manager, or a small cross-role team. Pick one named owner for the plan file and one backup. Give them the calendar, the checklist, and the power to request fixes from nursing, the lab, EVS, and purchasing. Loop in a physician leader for needle device choices and post-exposure care steps.
Triggers That Require Off-Cycle Updates
Do not wait for the next annual cycle when work changes midyear. Edit the plan right away when a trigger pops up. Update the plan, tell staff what changed, and refresh the training slides or huddle cards that rely on the plan.
Plan Format And Version Control
Keep one controlled master in a shared drive or policy system. Use a clear file name, a version number, and a change log at the front. Mark each section with a revision date. Keep a pocket copy on the unit if staff do not use the policy system at the bedside. Make the plan easy to reach from training links and QR codes on sharps bins.
Sharps Injury Log: Tie It To The Review
A good plan pulls lessons from the log. Trend where sticks happen, which devices recur, and which shifts see more events. Feed that back into device choices and work practice steps. When you switch to a safer needle, write the decision into the plan and keep the trial notes with the purchasing file.
Training And Plan Changes
Training and the plan move together. Update slides when the plan changes. Use short refreshers in huddles for quick edits and full annual training for deeper changes. New hires need training and vaccination before work with blood or sharps. Keep sign-ins and LMS records aligned with the plan’s version date.
Hepatitis B Offer, PPE, And Work Steps
These parts sit at the core of the plan. Check that the vaccine offer path is live and easy for staff to use. Check that PPE is at points of care, in the right sizes, and stocked. Walk the steps for sharps handling, spills, and waste. Fix what the walk-through reveals and update the plan lines so the paper matches the floor.
Documentation That Surveyors Expect
Auditors and surveyors ask two basic things: what changed and where is the proof. Keep a one-page annual summary that lists edits and the reason for each edit. File meeting notes for device trials and staff input. If a state plan applies, keep the state citation beside the federal one in the header. Store exposure packets and referral lists in a folder staff can reach fast.
Sample Annual Timeline That Works
Month 1: Prep
Set dates, send invites, pull last year’s change log, and export the sharps log. Ask unit leads to send device pain points and any workflow issues that touched sticks or splashes.
Month 2: Field Work
Walk the units, check device makes and models, watch setup and disposal, and snap photos of PPE stations. Visit receiving and waste rooms. Note real steps, not just policy steps.
Month 3: Draft Edits
Update the plan text, swap device names as needed, and add or remove work steps. Align training slides and exposure packets with the same terms used in the plan.
Month 4: Sign-Off And Training
Route the plan to the named owner, the backup, infection prevention, nursing, and the lab. Get sign-off, publish the new version, and run staff updates.
Small Facility Playbook
A small clinic can meet the same bar with a lean setup. Pick one month, use the checklist, and meet for one hour with nursing and the medical lead. Trial one safer device each year. Use a cloud folder with the plan, the log, photos of PPE points, and the change log at the top. Keep the staff list, the vaccine offers, and the training proof in the same folder.
Large System Playbook
Big systems run on scale and alignment. Set a single review window, hand out a shared checklist, and use a standard change log. Ask each site to parse its sharps data and send a summary to the system owner. Use shared device contracts and publish a device matrix so units pick from approved models with safety features.
Common Gaps And Fast Fixes
Outdated Device Names
Plans often carry old brand names long after the bins on the floor change. Cross-check purchasing records and swap names in the plan text.
Missing Staff Input
Front-line input shapes safer picks. Pull feedback from nurses, phlebotomy, and the lab when you trial devices. Store that input with the plan.
Hidden Plan Copy
Staff cannot follow what they cannot find. Add a direct link in the LMS and post a QR code in the clean room and med room.
Training Drift
Slides drift from the plan over time. Align the terms, photos, and steps after each edit so training always matches the plan.
Metrics That Show The Plan Works
Track needle and sharps sticks per 100 FTE, hepatitis B offer acceptance, training on-time rate, and close-out speed for exposure cases. Trend by unit and by device. Use the chart to pick next year’s focus.
Retention And Access Rules
The plan must be accessible to staff. Keep training records and sharps logs per the retention windows in your policy. Link the plan in the policy portal and keep a print copy where regulators can view it on a walk-through. When the plan changes midyear, publish the new version right away.
Quick Reference: Trigger Events And Update Actions
| Trigger Event | Plan Changes To Make | Timing |
|---|---|---|
| New device or safer model | Add to engineering controls; add use steps; retire old device | Before rollout |
| New service line or procedure | Update exposure determination and work steps | Before go-live |
| New job role with exposure | Add to in-scope roles; add training path | Before first shift |
| Exposure incident trend | Add guard steps; change workflow; retrain | Within 30 days |
| Facility move or remodel | Update waste flow, PPE stations, spill kits | Before move |
| Rule or accreditor update | Align terms, logs, device notes, labels | Upon notice |
Why This Schedule Works
The annual cycle sets a steady drumbeat. The trigger list catches change sooner. Together they match how healthcare work shifts through the year. The result is a living document that lines up with how staff work with sharps and body fluids, how devices evolve, and how surveyors check files.