(1) Each health care facility covered under the scope of this chapter must develop and implement a written hazardous drugs control program. Elements of the hazardous drugs control program may be located in other documents such as the employer's accident prevention program or other policies and procedures as long as they are referenced in the program. The hazardous drugs control program must, at a minimum, include the following:

(a) A written inventory of hazardous drugs in the workplace.

(b) A current hazard assessment for hazardous drugs for which there is reasonably anticipated occupational exposure.

(c) Hazardous drugs policies and procedures including, but not limited to:

(i) Engineering controls (equipment use and maintenance).

(ii) Personal protective equipment.

(iii) Safe handling practices (receiving and storage, labeling, preparing, administering, and disposing of hazardous drugs).

(iv) Cleaning, housekeeping, and waste handling.

(v) Spill control.

(vi) Personnel issues (such as exposure of pregnant workers).

(vii) Training.

(2) A standard or universal precautions approach to managing occupational exposure to hazardous drugs is recommended by NIOSH; however, due to the variety of factors that affect occupational exposure some health care facilities may find it more effective to institute precautions based on exposure risk. For example a tiered approach that effectively matches precautions to the nature of exposure may be used including, but not limited to, handling, storing, cleaning, preparing and engineering controls.

(3) Review and update the written hazardous drugs control program annually and whenever changes that affect occupational exposure occur, such as introduction of a new hazardous drug, or a change in handling practices.

(4) Seek and consider input from employees who may be exposed to hazardous drugs as a result of the performance of their duties regarding the quality and effectiveness of the hazardous drugs control program.