Medical Waste Industry Insights

Ensure OSHA Compliance: 7 Steps Every Medical Facility Should Take

By David Ryan

What happens if you are stuck with a needle at work? Are your or your employees trained in how to handle such scenarios? And speaking of training, does your facility work with an OSHA trainer who is authorized and well qualified to train your staff?

Are you scratching your head for answers? If so, it’s time to take a closer look at compliance.

Unsure if OSHA regulations even apply? Simply put, ANY organization in the U.S. or any U.S. territory that employs people falls under the jurisdiction of the OSHA standards. So chances are, that means your company. Here we’ll cover six critical steps that help ensure your facility is compliant.

What Is the Purpose of OSHA?

First, let’s cover the basics on OSHA. Federal law requires employers to provide their employees with working conditions that are free of known dangers. The OSH Act created the Occupational Safety and Health Administration (OSHA) to set and enforce protective workplace safety and health standards.

OSHA, then, is an enforcement division of the Department of Labor (DOL) that holds employers to the standards set by law; a federal hammer, if you will, intended to protect an employees’ rights to a safe work environment.  

New amendments to the OSHA laws are added and amended regularly. For example, in the 1980s, when the AIDS epidemic swept the nation and hypodermic needles were washing up on shore, the federal government took action by implementing the Bloodborne Pathogen (BBP) Standard to the OSHA law.

But with laws that are added and amended regularly, how do you know if your facility meets OSHA’s minimum requirements? Help regarding OSHA compliance is available if you need it.


The truth is, nearly 30 years after the creation of OSHA, many healthcare facilities are either not meeting minimum requirements, or are executing them poorly. And that means there is an increased chance of workplace exposure and injury. To ensure your facility doesn’t fall into this category, implement the following.

7 steps for OSHA Compliance

1. Develop an Exposure Control Plan (ECP) 

2 . Determine Occupational Exposure

3. Identify Methods of Control

4. Ensure Employees Have Personal Protective Equipment (PPE)

5. Enforce Proper Management of Regulated Waste and Laundry

6. Vaccines and Post Exposure Evaluation & Injury Logs

7 . Training Employees

Develop an Exposure Control Plan (ECP)

The first step is creating your ECP. Identify an onsite resource who will be responsible for administering the plan. This individual should be named and tasked with being the “program administrator” in the written plan. He or she is responsible for writing the plan and seeing that it is being carried out within the organization.

Determine Occupational Exposure

What is occupational exposure? The legal definition is as follows:

A reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties. CRM 1910.1030 (b)

To accomplish Step 2, identify which individuals have occupational exposure and make a list of what those exposures are. List the title of those with exposure, the tasks that expose them, and what the exposure is.

For example: “Nurse Assistant, handling patients, contact with blood and other potentially infectious materials (OPIM).”

Identify Methods of Control

A method of control or compliance is essentially the steps taken to eliminate or reduce the exposure event. There are multiple levels of control including:

  • Universal Precautions are a method of infectious control in which all human blood and other potentially infectious materials are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens. Basic best practice is to always assume that the blood or other potentially infectious materials are contaminated with a deadly pathogen and approach/treat the situation accordingly.
  • Engineering and work practice controls are the primary methods used to control bloodborne pathogens. Engineering controls remove or eliminate the hazard. For example, a sharps container and retractable syringe are examples of engineering controls that remove the hazard (the contaminated sharp) from the equation. In contrast, work practice controls only reduce the likelihood of an exposure.  

Examples include having hand wash/eyewash stations in the same areas exposure is likely to occur, hanging sharps collection units in locations where they can be reached with minimal handling, and changing sharps containers at or before the fill line to avoid needle sticks caused by overflow.

Ensure Employees Have Personal Protective Equipment (PPE)
PPE is specialized clothing or equipment used by employees to protect against direct exposure to blood or OPIM. In the event a hazard cannot be eliminated or reduced, PPE may be the best way to continue working with the hazard that exists. Employers should ensure employees are using the correct personal protection -- which may include things like eyewear, gloves, special gowns, and facemasks -- so that employees feel safe every day when they come to work.  Note: PPE used should be listed in the ECP and available to employees free of charge.

Housekeeping has a big part in exposure management, Contaminated work surfaces must be cleaned with an appropriate disinfectant. The industry standard is a solution that is 10% bleach.

Enforce Proper Management of Regulated Waste and Laundry

Regulated Medical Waste includes the following:

  • Liquid or semi-liquid blood or OPIM;
  • Contaminated items that would release blood or OPIM in a liquid or semi-liquid state if compressed;
  • Items caked with dried blood or OPIM and are capable of releasing these materials during handling;
  • Contaminated sharps; and pathological and microbiological wastes containing blood or OPIM

Plans for proper waste disposal should be included in the exposure control plan. It’s a good idea to attach a copy of the medical waste contract and packaging requirements to exposure plan as a best practice. Similarly, contaminated laundry should be managed by a company that is licensed and approved to do so. Not all linen companies can accept and disinfect biohazard contaminated linens.

Vaccines and Post Exposure Evaluation & Injury Logs

Vaccines: Certain vaccinations, for example, for Hepatitis B must be:

  • Made available, free of charge
  • at a reasonable time and place
  • within 10 days to employees with occupational exposure
  • Additionally, if the employee refuses the right to the vaccination, a waiver of rights must be signed to confirm that the document was offered.

Post Exposure: In the event an employee is exposed, the exposure plan must address the following post-exposure procedures and documentation including:

  1. The vaccination record from initial hire
  2. Written opinion post-exposure by a healthcare professional (this statement is limited in scope to the fact that the employee has received an evaluation, informed of results, and told of the need if any to further evaluation or treatment.
  3. The records management plan should include a provision to protect the confidentiality of medical records
  4. The records must be kept for up to 30 years after the employee's last date of employment.

Injury Logs: Sharps and exposure logs should be maintained regularly. Healthcare facilities are required to maintain a sharps injury log in addition to their OSHA 300 logs. (Note: Other industries such as Life Sciences may opt to only maintain the OSHA 300 log.) 

Training Employees

Upon every employee’s first hire, training is required for any assignment with occupational exposure and then repeated annually thereafter. This must happen in order to maintain awareness and compliance within the BBP standard. Training must be done according to the following conditions:

  • Training must be performed by and with access to a qualified individual with a thorough understanding of OSHA standards and occupational safety as it relates to the BBP standard.
  • Training must be provided at no cost to employees and during working hours if the employee is not exempt.
  • Training shall include an introduction to OSHA regulations.
  • Training should include a copy of the facility exposure control plan.

Keep in mind that web-based training can be a practical supplement but is not nearly as effective as live training performed onsite by an authorized professional.

Inquire About Compliance Help & Training

All in all, compliance should be viewed as a top priority at your facility. While managing compliance and staying on top of ever-changing regulations may feel like a heavy burden to bear, rest assured that compliance training can simply be a matter of leaning on the experts. If you have any questions or would like to inquire about Training & Compliance programs, just contact us at any time. We look forward to hearing from you!


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