(a) All facilities regulated under this article shall:

1. (1) implement and enforce a program for the prevention of circumstances which could result in an employee or patient/client becoming exposed to significant risk body substances which could put them at significant risk of HIV infection during the provision of services, as defined in sections 63.1 and 63.9 of this Title. Such a program shall include:

   1. (i) use of scientifically accepted protective barries during job-related activities which involve, or may involve, exposure to significant risk body substances. Such preventive action shall be taken by the employee with each patient/client as an essential element for the prevention of bidirectional spread of HIV;
   2. (ii) use of scientifically accepted preventive practices during job-related activities which involve the use of contaminated instruments or equipment which may cause puncture injuries;
   3. (iii) training at the time of employment and yearly staff development programs on the use of protective equipment, preventive practices, and circumstances which represent a significant risk for all employees whose job-related tasks involve, or may involve, exposure to significant risk body substances;
   4. (iv) provision of personal protective equipment for employees which is appropriate to the tasks being performed; and
   5. (v) a system for monitoring preventive programs to assure compliance and safety;

2. (2) implement and enforce a policy/procedure for the management of individuals who are exposed to significant risk body substances under circumstances which constitute significant risk of transmitting or contracting HIV infection. The policy/procedure shall include:

   1. (i) a system for reporting to a designated individual in the facility exposure thought to be a circumstance which constitutes significant risk of transmitting or contracting HIV infection;

   2. (ii) evaluation of the circumstances of a reporting exposure and services for providing follow-up of the exposed individual which includes:

      1. (a) medical and epidemiological assessment of the individual who is the source of the exposure, where that individual is known and available;
      2. (b) if indicated epidemiologically, HIV counseling and voluntary testing of the source individual. Disclosure of the HIV status of the source individual can be made with the express written consent of the protected individual, or a person authorized pursuant to law to consent to health care for the protected individual if such person lacks capacity to consent, or pursuant to court order, if the HIV status is not known to the exposed individual;
      3. (c) appropriate medical follow-up of the exposed individual;
   3. (iii) assurances for protection of confidentiality for those involved in reported exposures.