What is exposure control?

For over two decades, Pharmacies have been moving beyond dispensing Medication. In many cases, these Pharmacies provide services that may expose their employees to bloodborne pathogens through exposure to blood and other potentially infections material (OPIM).  This potential for exposure creates risks for employees and regulatory responsibility for the Pharmacy to prevent, minimize, and react to potential exposures.  So, OSHA will require you to have an Exposure Control Plan.  Before getting into what an Exposure Control Plan is, we need to discuss services with exposure possibilities and Bloodborne Pathogens.

What types of Services Could Expose my Employee to Bloodborne Pathogens?

There are several services in a Pharmacy that could expose Pharmacy Employees to blood and other potentially infectious material (OPIM).  These services include:

  • Administering vaccines and other injectables
  • Point of Care Testing
  • The returning and processing of rental DMEPOS
  • Patient Assessments for Clinical Services

These services (and others) expose your employees to the potential exposure from the moment of patient contact to the point of cleanup and disposal of any hazardous waste.  When you move through creating your Exposure Control Plan, you will have a general road map of the moments where bloodborne pathogen exposure is possible.  You will use these moments to develop your processes, including policies, engineering controls, personal protective equipment, and training.

What are Bloodborne Pathogens?

A Bloodborne pathogen is an infectious microorganism in the blood and other potentially infectious material (OPIM) that can cause disease in humans.  OSHA  defines bloodborne pathogens in the Bloodborne Pathogen Standard (1910.1030) as:

“Bloodborne Pathogens means pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV).”

Note: COVID-19, due to its highly infectious nature, should also be considered a potential bloodborne pathogen.

What is the Bloodborne Pathogen Standard?

The OSHA Bloodborne Pathogen Standard (1910.1030) is an OSHA requirement that addresses the needs of employers who have employees with potential occupational exposure to blood or other potentially infectious material. The standard requires employers to develop a Bloodborne Pathogen Exposure Control Plan.

What is an Exposure Control Plan?

The Exposure Control Plan is a document created by an employer designed to prevent and minimize the potential for occupational exposure to Bloodborne Pathogens.  In general, the plan is made up of several parts designed to:

  • Determine the possible activities that have the potential for exposure
  • Create Standard Precaution (handle all blood and OPIM as if it is infectious)
  • Create practices to prevent and minimize exposure
  • Explain when and how to use Personnel Protective Equipment (PPE)
  • Address Hepatitis B Vaccinations (paid for by the employer)
  • Educate and train employees on bloodborne pathogens
  • Educate and train employees on the Pharmacy’s Exposure Control plan
  • Address how exposure events are handled
  • Conduct Employee Training on the hazards and your Pharmacy’s Exposure Control Plan
  • Elicit Employee feedback on practices and devices

Do I Need to Train My Employees?

Yes, you need to train your employees annually on possible methods of exposure they need to be aware of and what to do to prevent the potential for exposure as well as what to do if an exposure has occurred.  It is essential to limit the potential for exposure only to employees who have been trained on your Exposure Control Plan.  And when it comes to interaction with the patients, only qualified individuals (as permitted by the State) should be interacting with patients.

You should also document this training and maintain records of the training and the training materials for no less than three years.

Are There Any Other Record-Keeping Requirements?

In addition to the three years of training records, you will need to maintain Medical Records and Records related to Incidents.  Employee Medical Records need to be kept for 30 years from the last date of employment. Documentation related to incidents must be maintained for five years from the end of the calendar year, including incident reports, investigations, OSHA 300, and OSHA 300a forms.  Medical Records must be maintained confidentially.

What About Covid-19?

Having an Exposure Control Plan designed to meet the Bloodborne Pathogen Standard will also provide you with the framework to comply with any State and Federal recommendations and guidelines to protect your employees from COVID-19.

“OSHA’s Bloodborne Pathogens standard (29 CFR 1910.1030) applies to occupational exposure to human blood and other potentially infectious materials that typically do not include respiratory secretions that may contain SARS-CoV-2 (unless visible blood is present). However, the provisions of the standard offer a framework that may help control some sources of the virus, including exposures to body fluids (e.g., respiratory secretions) not covered by the standard. (https://www.osha.gov/SLTC/covid-19/standards.html)”


Yes, you must have a Pharmacy Exposure Control Plan whenever your employees have the potential for occupational exposure to Bloodborne Pathogens.   The Exposure Control Plan protects your employees, your patients and customers, and the Pharmacy business.

The PRS Pharmacy Exposure Control Plan (ECPTrack) is designed to assist Pharmacies with implementing their Exposure Control Plan.  The Program provides Policies, Procedures, Exposure Control Plan, Forms, and Employee Trainings that are required for compliance with the Exposure Control Plan and OSHA Bloodborne Pathogen Standards and will help you meet State and Federal requirements as they relate to COVID-19.

Why Consider PRS for Pharmacy Complinace/Credentialing Needs

NCPA, The Federation of Pharmacy Networks, Pharmacy Buying Groups and Thousands of Pharmacies across the U.S. rely on PRS for their total Pharmacy Regulatory Compliance/Credentialing needs for themselves and their members.

PRS Pharmacy Service’s Compliance Programs are the most endorsed, complete and cost efficient on the market. Need verification? We invite you to call NCPA or the Federation of Pharmacy Networks and ask who they recommend for pharmacy compliance/credentialing. The answer will be PRS Pharmacy Services.

Ask your insurance auditors what they think about PRS Compliance Programs. We have had many, many pharmacy owners tell us when the auditor asks about compliance and finds out PRS is their provider; the compliance part of audit was pretty much over. Actual Auditor quote “if you are using PRS, I know you are compliant and I don’t need to review your programs. PRS is in many other pharmacies I audit and never found an issue.” Many other auditors have made similar comments.

After providing multiple compliance programs to thousands of pharmacies, not one single pharmacy has ever been fined while using PRS’s Compliance/Credentialing Programs. As a pharmacy owner, that you real peace of mind.