Exposure prevention, sharps safety, immediate response, medical follow-up, training, and recordkeeping

Applies To	Besa Health \| 218 W 4th Street, Santa Ana, CA 92701
Plan Administrator	Mike Yang, DO
Backup Administrator	Matthew Ehorn
Effective Date	March 2026
Review Cycle	At least annually and whenever tasks, positions, devices, incidents, or requirements change
Next Scheduled Review	March 2027

Purpose

Besa Health establishes, implements, and maintains this plan to eliminate or minimize employee exposure to blood and other potentially infectious materials. Universal Precautions apply to every patient and every source of blood or other potentially infectious material, regardless of known infection status.

The Rules Everyone Must Know

Bring the lab cart into the procedure area before any blood draw or other procedure involving a sharp. The cart's sharps container must be upright, secured, open, and within immediate reach.
Activate the engineered safety feature and discard the sharp immediately. Never carry an exposed contaminated sharp to another room or leave it on a tray.
Wear gloves whenever contact with blood, non-intact skin, contaminated items, or specimens is reasonably anticipated. Add goggles, a mask, and a gown whenever splashing may occur.
Report every needlestick, cut, splash to the eyes, nose, or mouth, or contact with non-intact skin immediately to Mike Yang, DO and Matthew Ehorn.

Exposure is a medical urgency: perform first aid at once, go to Room 3, and begin confidential medical evaluation without delay. Do not wait for the end of the shift or for source-patient test results.

Plan Administration And Responsibilities

The written plan is available to employees in the Besa Health Knowledge Base and may be reviewed during working hours without charge. Mike Yang, DO owns the plan; Sheyanne Espiritu, FNP serves as backup. Matthew Ehorn coordinates vaccination offers and, with Mike Yang, maintains required confidential exposure records.

Role	Responsibility
Mike Yang, DO	Administer and approve the plan; receive exposure reports; provide or arrange immediate evaluation; lead incident review; approve corrective actions; and ensure annual review.
Sheyanne Espiritu, FNP	Serve as backup plan administrator and carry out the administrator's duties when Dr. Yang is unavailable.
Matthew Ehorn	Offer and coordinate Hepatitis B vaccination; maintain confidential vaccination and exposure records with Dr. Yang; support training and external-care authorization.
Medical Assistant	Move and position the lab cart; check the sharps container during room reset; stock PPE; manage red-bag waste; clean and disinfect assigned areas; and report any deficiency.
Clinical Staff	Follow Universal Precautions, use safety-engineered devices and PPE, discard sharps immediately, report exposures, and participate in safety-device review.
Housekeeping And Administration	Follow this plan when assigned cleanup, waste, first-aid, or exposure-response duties and avoid handling blood or regulated waste unless trained and equipped.

Exposure Determination

Exposure determinations are made without considering personal protective equipment. The following classifications and tasks reflect Besa Health's current operations.

Exposure Category	Job Classifications	Tasks Or Circumstances
All employees in classification	Physician; Nurse Practitioner; Physician Assistant; Medical Assistant	Blood draws; wound care; dressing changes; specimen handling; disposal of contaminated sharps; cleanup of blood or other potentially infectious material.
Some employees in classification	Housekeeping	Cleaning a blood spill; handling contaminated surfaces or regulated waste; encountering contaminated broken glass or a discarded sharp.
Some employees in classification	Administration	Providing first aid; assisting with an exposure response; entering the MA room or handling regulated waste only when specifically assigned and trained.

New or modified positions, tasks, and procedures must be evaluated before assignment and added to this plan when occupational exposure is reasonably anticipated.

Key Definitions

Blood means human blood, blood components, and products made from human blood.
Other potentially infectious materials, or OPIM, include specified human body fluids, any visibly bloody body fluid, unfixed human tissue, and other materials covered by Cal OSHA Title 8 Section 5193.
An exposure incident is specific contact of the eyes, mouth, other mucous membrane, non-intact skin, or a puncture with blood or OPIM while performing work duties.
A sharp is any object reasonably capable of penetrating skin and causing an exposure, including needles, lancets, scalpels, capillary tubes, and contaminated broken glass.

Engineering And Work Practice Controls

Universal Precautions And Hand Hygiene

Treat all human blood and OPIM as infectious. Exam-room sinks, soap, and single-use towels are the primary handwashing facilities. Wash hands immediately after removing gloves and as soon as feasible after contact. Flush eyes and mucous membranes with water immediately after contact. Hand sanitizer does not replace washing after visible contamination.

Safety Engineered Devices

Use needleless systems and sharps with engineered sharps-injury protection whenever feasible and effective for the procedure. The safety feature must be activated immediately after use. Non-managerial employees who perform direct patient care must participate in identifying, evaluating, and selecting safety devices and work-practice controls. Mike Yang documents this input during the annual plan review and whenever a new device, procedure, or incident prompts reevaluation.

Review device type and brand, ease of activation, visibility of activation, patient safety, and whether the device protects before, during, and after disposal.
Document why a safety-engineered option is not used when a patient-safety determination or objective product evaluation supports an exception.
Review exposure incidents and the frequency of use of involved device types and brands to identify prevention opportunities.

Lab Cart And Sharps Container

The clinic's only sharps container is mounted or secured upright on the lab cart. The lab cart must accompany every procedure involving a sharp and must be positioned as close as feasible to the person using the device.
If the cart and usable sharps container cannot be brought within immediate reach before the procedure begins, stop and obtain an approved disposal setup before using the sharp.
The Medical Assistant checks the container during each room reset and before the cart is used again. Replace it if damaged, leaking, unsecured, contaminated on the outside, or at the manufacturer's fill line.
Never recap, bend, shear, break, remove, or pass a contaminated needle by hand. A one-handed scoop or mechanical device may be used only when a specific procedure requires recapping or removal and no feasible alternative exists.
Never reach into, open, empty, clean, compress, or shake a sharps container. Close a full container and place it in the designated secure medical-waste storage area in the MA room for vendor pickup.
Contaminated broken glass must be handled with tongs, forceps, a brush, and dustpan, never by hand, and placed in the sharps container if the item can puncture skin.

One-container control: a contaminated sharp must never be carried from the procedure area to find the lab cart. Position the cart first, then begin the procedure.

Specimens And Contaminated Equipment

Collect specimens in closed containers that prevent leakage. Place a leaking, externally contaminated, or puncture-prone primary container into a labeled, leak-resistant and, when needed, puncture-resistant secondary container before storage or transport. Examine contaminated equipment before servicing or shipment; decontaminate it when feasible and attach a biohazard label describing any portion that remains contaminated.

Work Area Restrictions

Do not eat, drink, smoke, apply cosmetics or lip balm, handle contact lenses, or store food in areas where blood or OPIM may be present. Mouth pipetting and suctioning are prohibited. Perform procedures to minimize splashing, spraying, splattering, and droplet generation.

Personal Protective Equipment

Besa Health provides required PPE in appropriate sizes at no cost. Select PPE based on the reasonably anticipated route and amount of exposure. Remove PPE before leaving the work area, dispose of it in the appropriate waste stream, and perform hand hygiene.

PPE	Location	Required Use
Disposable gloves	Each exam room; reserve stock in the MA room	Blood draws; wound care; dressing changes; specimen handling; blood-spill cleanup; contact with contaminated items or non-intact skin.
Masks	Each exam room and the MA room	Use with eye protection when splashes, sprays, or droplets may reach the nose or mouth.
Goggles	Protective Equipment bag in the MA room	Use when blood or OPIM could splash or spray toward the eyes.
Disposable gowns	MA room	Use when clothing or exposed skin could be contaminated during wound care, spill cleanup, or another splash-prone task.

Replace disposable gloves immediately if torn, punctured, contaminated, or compromised. Never wash or reuse disposable gloves.
Remove a garment penetrated by blood immediately or as soon as feasible and place it in the correct red-bag waste container.
Disposable PPE must be discarded after use. If reusable goggles are supplied, disinfect them according to the manufacturer's instructions before returning them to the Protective Equipment bag. Employees must never take contaminated items home for cleaning.

Housekeeping And Decontamination

Maintain the clinic in a clean and sanitary condition. The Medical Assistant performs clinical-area decontamination; trained housekeeping staff perform assigned environmental cleaning. Work surfaces must be decontaminated after a procedure, immediately after visible contamination or a spill, and at the end of the work period when contamination may have occurred.

Use CaviWipes according to the exact product label. Pre-clean visible soil when required, use enough wipes to keep the surface visibly wet for the label's full contact time, allow the surface to dry, and never mix disinfectants.
Wear gloves and add goggles, a mask, and a disposable gown when the spill presents splash or clothing-contamination risk.
Confine the area, absorb the material, collect sharps mechanically, disinfect from the cleaner outer edge toward the center, and place cleanup waste into the correct sharps or red-bag container.
Inspect and decontaminate reusable bins and receptacles when visibly contaminated and at the frequency needed to keep them sanitary. Do not pick up contaminated broken glass by hand.
Besa Health does not process contaminated laundry. If reusable contaminated laundry is introduced, this plan must be updated before use.

Regulated Waste

Place non-sharp regulated waste in a closable, leak-resistant biohazard container lined with a red biohazard bag. Red-bag supplies, the active red-bag container, and the designated secure medical-waste storage area are in the MA room. Keep containers upright, closed when not in use, labeled, and secured from unauthorized access.

California Medical Waste Disposal provides pickup upon request. Matthew Ehorn or the designee requests pickup early enough to prevent overfilling and to remain within all applicable storage-time limits. Release waste only to an authorized transporter, verify the service record, and retain tracking documents under the clinic's medical-waste procedure.

Hepatitis B Vaccination

Matthew Ehorn ensures that the Hepatitis B vaccination series is offered to every employee with occupational exposure after required training and within 10 working days of initial assignment, at no cost and at a reasonable time and place. Prescreening cannot be required as a condition of receiving the vaccine.

No new offer is required when records show a completed series, documented immunity, or a medical contraindication determined by a licensed healthcare professional.
An employee who declines must sign the mandatory declination statement in Appendix A. An employee who later accepts while still covered may receive the series at no cost.
Vaccination and immunity records are confidential medical records maintained by Matthew Ehorn and Mike Yang, DO.

Exposure Incident Response

Act immediately: an exposure incident includes a needlestick or other puncture, a splash to the eyes, nose, or mouth, or contact of blood or OPIM with non-intact skin.

Step 1 Stop And Perform First Aid

Wash needlesticks and cuts with soap and water. Flush the nose, mouth, and affected skin with water. Irrigate eyes with clean water or saline. Do not scrub aggressively, squeeze a puncture wound, or apply bleach or caustic agents.

Step 2 Report The Exposure

Immediately notify both Mike Yang, DO and Matthew Ehorn. Report before leaving the worksite unless emergency transport is required.

Step 3 Go To Room 3

Room 3 is the clinic's immediate first-aid and initial assessment location. Mike Yang, DO evaluates or arranges evaluation without delay. The employee may decline evaluation by the employer-provider.

Step 4 Obtain Independent Or After-Hours Care

If Dr. Yang is unavailable, it is after hours, or the employee requests an independent evaluator, go immediately to Concentra East Edinger and Lyon, 1619 E Edinger Avenue, Santa Ana, CA 92705, telephone 714-542-8904. Occupational injury care is listed as available 24 hours a day, 7 days a week. Call ahead when feasible, but do not delay urgent care.

Step 5 Document Without Delaying Care

Document the route of exposure, circumstances, device type and brand, procedure, protective mechanism status, body part, work area, and available source-person information. Preserve the device information without handling the contaminated sharp again.

Step 6 Begin Confidential Medical Follow Up

Besa Health makes the evaluation, accredited laboratory testing, counseling, indicated prophylaxis, and follow-up available at no cost and at a reasonable time and place. The evaluating clinician follows current U.S. Public Health Service recommendations.

Medical Evaluation Requirements

Identify and document the source individual unless infeasible or prohibited. Obtain legally required consent and arrange source testing for HBV, HCV, and HIV as soon as feasible. Do not delay indicated HIV PEP while awaiting results.
Offer the exposed employee prompt baseline collection and testing for HBV, HCV, and HIV after consent. If baseline blood is collected but HIV testing is declined, preserve the sample for at least 90 days as required by Cal OSHA.
The evaluating clinician determines HBV vaccine or HBIG needs from the employee's vaccine-response status and source status; follows current CDC testing guidance for HCV; and evaluates HIV PEP urgently under current occupational guidance.
Provide counseling, follow-up testing, and evaluation of reported illnesses. The National Clinician Consultation Center PEPline is available to clinicians at 1-888-448-4911.
Provide the evaluator with the regulation, the employee's relevant duties, route and circumstances, available source results, and relevant vaccination records.
Obtain the limited healthcare professional written opinion and give a copy to the employee within 15 days after the evaluation is completed. All other diagnoses and findings remain confidential.

Incident Evaluation And Corrective Action

Mike Yang, DO reviews each exposure promptly with the exposed employee and appropriate non-managerial clinical staff. The review must not delay medical care and must protect employee confidentiality.

Determine how and why the incident occurred, including staffing, workflow, cart placement, device selection, safety-feature activation, PPE, training, environment, and patient-safety factors.
Determine whether a needleless system, different safety-engineered device, administrative control, work-practice control, PPE change, or additional training could have prevented the incident.
Implement and document corrective action. Update this plan before affected work resumes when the review identifies a deficient control.
Use incident information and the frequency of use of involved sharp types and brands during annual device review. Solicit and document active input from non-managerial employees who perform direct patient care.

Sharps Injury Log

A Sharps Injury Log is required for every exposure incident involving a sharp. Matthew Ehorn and Mike Yang maintain it confidentially and record the incident within 14 working days after it is reported. Do not include the injured employee's name in the log.

Required Field	What To Record	Control
Incident timing	Date and time of exposure	Record within 14 working days
Sharp	Type and brand of device	Do not handle the used device again to obtain information
Employee and location	Job classification; department or work area	Exclude employee name
Procedure and event	Procedure being performed; how the incident occurred; body part involved	Use factual, nonjudgmental language
Safety mechanism	Whether present and activated; whether injury occurred before, during, or after activation	Record employee observations
Prevention input	How an engineered, administrative, or work-practice control might have prevented the injury	Include exposed employee's opinion

Other Required Records

Record	Retention And Control
Employee medical records	Keep confidential for employment plus 30 years under Cal OSHA. Include vaccination status, evaluation and testing results, limited written opinions, and information supplied to the evaluator.
Training records	Keep for 3 years. Include date, content or summary, trainer names and qualifications, and attendee names and job titles.
Sharps Injury Log	Keep for 5 years from the exposure incident and make available as required while protecting injured-employee confidentiality.
Annual plan and device review	Keep completed review documentation with the current and superseded plan, including direct-care employee input, devices considered, decisions, and corrective actions.
OSHA injury records	Evaluate each work-related exposure separately for OSHA 300 recordability and workers' compensation reporting; these records do not replace the Sharps Injury Log.

Training And Communication

Bloodborne-pathogen training is part of employee onboarding and is required before an employee performs a task with occupational exposure. Covered employees repeat training at least annually and receive additional training when new tasks, devices, or controls affect exposure. Training is provided during working hours and at no cost.

Besa Health uses assigned courses and quizzes. The program must also provide an opportunity for interactive questions and answers with a person knowledgeable about the standard and Besa Health's work practices. Employees may direct questions to Mike Yang, DO or the designated knowledgeable trainer.

Required Training Content

An accessible copy and explanation of Cal OSHA Title 8 Section 5193; bloodborne-disease epidemiology, symptoms, and transmission
Besa Health's exposure determination, this plan, where to obtain it, and the tasks that may involve blood or OPIM
Engineering controls, the lab-cart sharps process, work-practice controls, their limitations, and prohibited practices
PPE selection, location, proper use, removal, disposal, hand hygiene, decontamination, and regulated-waste handling
Hepatitis B vaccination benefits and the no-cost offer
Emergency contacts, immediate first aid, Room 3, Concentra referral, medical follow-up, and Sharps Injury Log reporting
Biohazard labels and color coding, employee rights, record confidentiality, and an interactive question-and-answer opportunity

Annual Review And Change Control

Mike Yang, DO reviews and updates this plan at least annually and sooner when necessary. Sheyanne Espiritu, FNP completes the review when acting as backup.

☐ New or modified tasks, procedures, positions, or exposure conditions

☐ New technology and commercially available needleless systems or sharps with engineered injury protection

☐ Direct-care employee input on device selection and work practices

☐ All exposure incidents, Sharps Injury Log trends, device types and brands, and frequency of use

☐ Changes in PPE, lab-cart placement, housekeeping, waste service, post-exposure care, training, or legal requirements

☐ Any information showing that the plan or a control is deficient

Annual Review Record

Review Item	Decision Or Action	Owner And Completion Date
Direct-care employee input	Record participating employees by job title and summarize device or work-practice feedback.	Mike Yang, DO / MM/DD/YYYY
Safety-device evaluation	List devices considered, objective criteria, selection, and any patient-safety exception.	Mike Yang, DO / MM/DD/YYYY
Incident and trend review	Summarize de-identified findings, frequency-of-use review, and corrective actions.	Mike Yang, DO / MM/DD/YYYY
Plan update and communication	Identify revisions, retraining, and the date the updated plan became accessible.	Mike Yang, DO / MM/DD/YYYY

Immediate Exposure Checklist

☐ Stop work and wash or flush the exposed area immediately.

☐ Notify Mike Yang, DO and Matthew Ehorn immediately.

☐ Go to Room 3 for first aid and initial assessment.

☐ Go to Concentra East Edinger and Lyon if Dr. Yang is unavailable, after hours, or an independent evaluation is requested.

☐ Do not delay indicated HIV PEP while awaiting source testing.

☐ Document the route, circumstances, device, procedure, work area, body part, and source information without delaying care.

☐ Arrange confidential source and employee testing with required consent and provide the evaluator with required information.

☐ Complete the Sharps Injury Log within 14 working days when a sharp was involved.

☐ Provide the employee the limited healthcare professional written opinion within 15 days after the evaluation is completed.

☐ Review causes, obtain employee input, implement corrective action, and update training or this plan when needed.

Appendix A Hepatitis B Vaccine Declination

The following statement is mandatory for an employee who declines the offered Hepatitis B vaccination:

I understand that due to my occupational exposure to blood or OPIM I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease.

If in the future I continue to have occupational exposure to blood or OPIM and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.

Employee Name
Employee Signature
Date
Received By	Matthew Ehorn or designee

References And Adoption

This is Besa Health's site-specific operational control plan. It incorporates the topics in the CalOptima binder sample on pages 75 through 92 while applying current California requirements and current clinical guidance. Licensed healthcare professionals must use the recommendations current at the time of an exposure rather than relying on a fixed medication regimen in this document.

Plan Approval And Implementation

By signing below, the approving leaders confirm that the listed controls are available to affected employees and that the plan will be reviewed at least annually.

Pre-Implementation Verification

☐ The lab cart and its sharps container can be positioned within immediate reach before every procedure involving a sharp.

☐ Exam-room and MA-room PPE supplies are stocked, including goggles in the Protective Equipment bag.

☐ The spill kit, red-bag container, and regulated-medical-waste storage area in the MA room are ready for use.

☐ California Medical Waste Disposal pickup-on-request instructions and current contact information are available to responsible staff.

☐ Concentra East Edinger and Lyon will accept Besa Health work-injury authorizations, including after-hours exposures.

☐ Onboarding training, interactive questions, Hepatitis B vaccine offers, and confidential exposure-record procedures are active.

Approval

Role	Name And Signature	Date
Approving Provider	Mike Yang, DO / Signature	MM/DD/YYYY
Plan Administrator Backup	Matthew Ehorn / Signature	MM/DD/YYYY

Required Review Triggers

Review and update this plan sooner than the scheduled annual review whenever a new or modified task, procedure, device, job classification, exposure incident, regulatory requirement, waste vendor, or post-exposure provider may affect occupational exposure or the controls described here. Obtain and document input from non-managerial direct-care employees when evaluating engineering and work-practice controls.

Implementation note: Before signature, confirm that the lab cart can be positioned within immediate reach for every sharp procedure, that Concentra will accept Besa Health work-injury authorizations, and that California Medical Waste Disposal pickup can always occur within applicable storage limits.

Bloodborne Pathogen Exposure Control Plan