Use this SOP to maintain required infection-control devices, supplies, protective practices, cleaning, sterilization, housekeeping, and waste handling in every patient-care area.

šŸ“š Resources Needed

  • A sink in every patient-care area, preferably with 4ā€“6-inch wing-tip faucet handles or hands-free controls

  • Antibacterial soap, paper towels, and an appropriate garbage receptacle

  • Disposable gloves and gloves designed to withstand instrument-cleaning procedures

  • Protective eyewear or masks with eye shields, protective masks, and disposable fluid-resistant gowns

  • Sharps containers

  • Cleaning solutions appropriate to the level of contamination and compliant with applicable guidelines

  • A 10% bleach solution mixed daily or a germicidal solution effective against tuberculosis, hepatitis, and HIV

  • A heat or heat-pressure sterilizer, including an autoclave, for non-disposable critical instruments

  • Hepatitis B vaccination-status or vaccine-declination records for personnel with occupational exposure to bloodborne pathogens

  • The Handling and Control of Infections/Biohazardous Wastes procedures

āœ… Before You Start

  • Confirm the required infection-control devices and supplies are available in every patient-care area.

  • Assess the planned procedure for possible exposure of the eyes, face, mouth, nose, clothing, arms, or other exposed body parts to potentially contaminated substances.

  • Select the required eye protection, mask, gloves, and fluid-resistant gown before the procedure begins.

  • Confirm any 10% bleach solution intended for use was mixed that day.

  • Identify whether any reusable instrument is a critical instrument that has penetrated soft tissue or bone or contacted mucous membranes.

šŸš€ Tips & Tricks

  • Keep handwashing supplies, disposable gloves, protective equipment, sharps containers, and waste receptacles stocked near the point of care.

  • Mark the preparation date on daily-mixed bleach solution so staff can verify it is current.

  • Separate potentially contaminated instruments and waste from clean items to help prevent cross-contamination.

šŸ“˜ Instructions

Step 1: Maintain Infection-Control Devices And Supplies

  • Provide adequate infection-control devices and supplies in all patient-care areas.

  • Each patient-care area must include a sink, preferably with 4ā€“6-inch wing-tip faucet handles or hands-free controls; antibacterial soap; paper towels; an appropriate garbage receptacle; disposable gloves; and a sharps container.

Step 2: Maintain Hepatitis B Vaccination Records

  • Offer the Hepatitis B vaccine and any necessary booster, in accordance with Cal/OSHA requirements, to all personnel who have occupational exposure to bloodborne pathogens.

  • Keep documentation of each affected team member's vaccination status or vaccine declination on file.

Step 3: Use Required Personal Protective Equipment

  • Wear protective eyewear or a mask with an eye shield during procedures in which exposure to potentially contaminated substances is likely.

  • Wear a protective mask during procedures when the face, mouth, or nose may be splashed with potentially contaminated substances.

  • Wear a disposable, protective, fluid-resistant gown during procedures when clothing may be contaminated with blood or body fluids.

  • Ensure the gown covers the arms and all exposed body parts.

Step 4: Perform Required Hand Hygiene

  • Wash hands whenever gloves are removed.

  • Wash hands after any direct patient contact or indirect contact with blood or any body substance.

  • Use antibacterial soap in special areas, before performing invasive techniques, and after any exposure to blood or body fluid.

Step 5: Handle And Clean Contaminated Items

  • Handle potentially contaminated instruments carefully while wearing gloves designed to withstand the cleaning procedures.

ā€¢  Clean instruments, equipment, and environmental surfaces with solutions appropriate to the level of contamination and that meet applicable guidelines.

Step 6: Sterilize Critical Instruments

  • Treat an instrument as critical when it has penetrated soft tissue or bone or has come in contact with mucous membranes.

  • If a critical instrument is not disposable, sterilize it in a heat or heat-pressure sterilizer, including an autoclave.

Step 7: Disinfect Touch And Splash Surfaces Immediately

  • Treat a surface as a touch and splash surface when it is exposed to splatter of blood or body fluids contaminated by treatment personnel.

  • Immediately disinfect the surface with either a 10% bleach solution mixed daily or a germicidal solution effective against tuberculosis, hepatitis, and HIV.

Step 8: Prevent Cross-Contamination

  • Use appropriate housekeeping techniques to prevent cross-contamination.

Step 9: Dispose Of Potentially Contaminated Waste

  • Dispose of potentially contaminated waste according to the Handling and Control of Infections/Biohazardous Wastes procedures.

šŸ›  Troubleshooting

Required Supplies Are Missing From A Patient-Care Area

Do not begin the procedure until the required sink access, soap, paper towels, garbage receptacle, disposable gloves, sharps container, and procedure-specific protective equipment are available.

Potentially Contaminated Material Splashes A Surface

Disinfect the affected touch or splash surface immediately with daily-mixed 10% bleach solution or a germicidal solution effective against tuberculosis, hepatitis, and HIV.

A Reusable Critical Instrument Cannot Be Sterilized

Do not reuse the instrument. A non-disposable critical instrument must be sterilized in a heat or heat-pressure sterilizer, including an autoclave, before reuse.

Vaccination Documentation Is Missing

Confirm the Hepatitis B vaccine and any necessary booster were offered in accordance with Cal/OSHA requirements, then obtain and retain the vaccination-status or declination documentation.

āœ… Completion Check

  • Every patient-care area has the required sink, soap, paper towels, garbage receptacle, disposable gloves, and sharps container.

  • Personnel with occupational exposure to bloodborne pathogens were offered the Hepatitis B vaccine and necessary booster, and vaccination or declination documentation is on file.

  • Personnel used protective eyewear or a mask with an eye shield, a protective mask, and a disposable fluid-resistant gown whenever the applicable exposure risk existed.

  • Protective gowns covered the arms and exposed body parts.

  • Hands were washed after gloves were removed and after direct patient contact or indirect contact with blood or any body substance.

  • Antibacterial soap was used in special areas, before invasive techniques, and after exposure to blood or body fluid.

  • Potentially contaminated instruments were handled with cleaning-resistant gloves, and instruments, equipment, and environmental surfaces were cleaned with appropriate compliant solutions.

  • Non-disposable critical instruments were sterilized in a heat or heat-pressure sterilizer, including an autoclave.

  • Touch and splash surfaces were disinfected immediately with daily-mixed 10% bleach solution or an effective germicidal solution.

  • Appropriate housekeeping techniques were used to prevent cross-contamination.

  • Potentially contaminated waste was disposed of according to the Handling and Control of Infections/Biohazardous Wastes procedures.

References

CalOptima Health Facility Site And Medical Record Review Audit Packet: Infection Control Procedures, page 59

Source Protocol Revision: Apr 29, 2026

Internal readiness SOP only; the full CalOptima, Cal/OSHA, infection-control, sterilization, and biohazardous-waste requirements control.