YMCA of Greater Kalamazoo

1001 W. Maple Street

Kalamazoo, Michigan 49002

Blood-borne Pathogens Exposure Control Plan

The YMCA of Greater Kalamazoo is committed to providing a safe and

healthful work environment for our entire staff. In pursuit of this goal, the
following exposure control plan (ECP) is provided to eliminate or minimize
occupational exposure to blood-borne pathogens in accordance with OSHA
standard 29 CFR 1910.1030, “Occupational
Exposure to Blood-borne Pathogens.”

The ECP is a key document to assist our association in implementing and

ensuring compliance with the standard, thereby protecting our employees.
This ECP includes:

▪ Determination of employee exposure

▪ Implementation of various methods of exposure control, including;
Universal Precautions
Engineering and work practice controls
Personal Protective Equipment
Housekeeping

▪ Hepatitis B Vaccination
▪ Post-exposure evaluation and follow-up
▪ Communication of hazards to employees and training
▪ Recordkeeping
▪ Procedures for evaluating the circumstances surrounding exposure
incidents

Implementation methods for these elements of the standard are

discussed in the subsequent pages of this ECP.

DEFINITIONS
Amniotic Fluid is the serous fluid in which the embryo is suspended within
the amnion.
Blood is human blood, human blood components, and products made from
human blood.
Blood-borne Pathogens are pathogenic microorganisms that are present
in human blood and can cause disease in humans.
Contaminated means the presence of human blood, human blood
components, and products made from human blood, or other human body
fluids, unfixed tissues or organs, and HIV tissue cultures.

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Contaminated Sharps are blood-borne-pathogen-contaminated objects
that can penetrate the skin including but not limited to needles, scalpels,
broken glass, exposed ends of dental wires, and broken capillary tubes.
Decontamination is the use of physical or chemical means to remove,
inactivate, or destroy blood-borne pathogens on a surface or item to the
point where they are no longer capable of transmitting infectious particles
and the surface or item is rendered safe for handling, use, or disposal.
Engineering Controls are controls that isolate or remove the blood-borne
pathogen hazards from the workplace.
Epidemiology is the study of the factors controlling the presence or
absence of a disease or pathogen.
Exposure Incident is a specific eye, mouth, mucous membrane, non-
intact skin, or parenteral contact with blood or other potentially infectious
materials from the performance of an employee’s duties.
Hepatitis B (HBV) is a highly contagious virus that infects hundreds of
thousands of Americans each year. It enters the bloodstream and silently
invades liver cells. In the mildest case, one may not be aware of the virus –
it can be gone in six months. Some people become carriers for life infecting
others while in more severe cases the disease may lead to liver cancer and
death.
Hepatitis C (HBC) is another form of the hepatitis virus, which can cause
serious human disease
Human Immunodeficiency Virus is a lentivirus (a member of the
retrovirus family) that can lead to acquired immunodeficiency syndrome
(AIDS), a condition in humans in which the immune system begins to fail,
leading to life-threatening opportunistic infections (HIV) also referred to as
AIDS.
HBV Immunization is a preventative series of immunizing shots given to
help prevent contracting Hepatitis B.
Non-Infectious Body Fluids include feces, saliva (considered potentially
infectious during dental procedures), urine, vomit, nasal secretions, sweat,
and tears. Noninfections body fluids become contaminated if commingled
with potentially infectious body fluids.
Occupational Exposure is a reasonably anticipated eye, mouth, mucous
membrane, non-intact skin, or parenteral contact with blood or other
potentially infectious materials from the performance of an employee’s
duties.
Pericardial Fluid is the serous fluid that fills the pericardial cavity and
protects the heart from friction.
Peritoneal Fluid is the serous fluid of the smooth transparent serous
membrane that lines the cavity of the abdomen.
Pleural Fluid is serous fluid in the pleural cavity.
Potentially Infectious Body Fluids include blood, semen, vaginal
secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid,
peritoneal fluid, amniotic fluid, saliva in dental procedures, and all body

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 fluids in situations where it is difficult or impossible to differentiate between
body fluids.
Parenteral - any piercing of the mucous membranes or the skin barrier
through such events as needle sticks, human bites, cuts, and abrasions.
Personal Protective Equipment (PPE) – A series of protective devices
that, when utilized properly, will help to minimize accidental exposure to
BBPs. These include, but are not limited to eyeglasses with side shields or
goggles, latex gloves, lab coat, and possibly a surgical mask or respirator.
Synovial Fluid - a transparent viscid lubricating fluid secreted by a
membrane of an articulation, bursa, or tendon sheath.
Universal Precautions are a set of precautions designed to prevent the
transmission of human immunodeficiency virus (HIV), hepatitis B virus
(HBV), and other blood-borne pathogens by the use of protective barriers
such as gloves, gowns, aprons, masks, or protective eyewear whenever
handling or being potentially exposed to blood or other potentially infectious
body fluids.
Work Practice Controls are controls that reduce the likelihood of
exposure by altering the manner in which a task is performed.

PURPOSE

The purposes of this exposure control plan:

1. To eliminate or minimize employee occupational exposure to blood or

other body fluids.
2. To identify employees occupationally exposed to blood or other potentially
infectious materials (OPIM) in the performance of their regular job duties.
3. To provide employees exposure to blood and OPIM information and
training. A copy of this plan is available to all employees of the YMCA of
Greater Kalamazoo at the Human Resources office and Front Desk.
4. To comply with OSHA Blood-borne Pathogens Standard.

EMPLOYEE EXPOSURE DETERMINATION

The YMCA of Greater Kalamazoo has performed an exposure determination

for all common job classifications that may be reasonably anticipated to incur
occupational exposures to blood or other potentially infectious materials
(OPIM). This exposure determination is made without regard to use of
personal protective equipment (PPE).

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The following is a list of all job classifications at our facility in which all
employees have occupational exposure:

Job Title Department/Location Task/Procedure

Custodial/Maintenance Staff Maintenance Dept. Laundry/ Cleaning
Lifeguards Aquatics Dept. Pool maintenance
Childcare Early Leaning Dept. Education

The following is a list of job classifications in which some employees at our

establishments have occupational exposure. Included is a list of tasks and
procedures, or groups of closely related tasks and procedures, in which
occupational exposure may occur for these individuals:

Job Title Task/Procedure

MOD Staff Administering CPR/First Aid
School Age Childcare Staff Administering CPR/First Aid
Aquatic Staff Administering CPR/First Aid
Group Exercise Staff Administering CPR/First Aid
Wellness Floor Staff Administering CPR/First Aid
Gymnastics Staff Administering CPR/First Aid
Youth Sports Staff Administering CPR/First Aid
Tot Spot Administering CPR/First Aid

COMPLIANCE METHODS

Universal Precautions
This association embraces “Universal Precautions,” which is a method of
infection control that requires the employer and employee to assume that all
human blood and specified human body fluids are infected with blood-borne
pathogens. Where it’s difficult or impossible to identify body fluids, all are to
be considered potentially infections.

Engineering Controls and Work Practices

The following engineering and work practice controls will be used by all
employees to eliminate or minimize occupational exposures at all
facilities:

Engineering Controls
▪ Contaminated disposable sharps will be disposed of in an appropriate
sharps container.
▪ Any contaminated materials (i.e. towels, paper products) will be disposed
of appropriately or in a red biohazard bag for regulated waste that are in
each of our Blood-borne Pathogens Infection Control Kits (BBP kits)

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Personal Protective Equipment (PPE)
Each department head is responsible for ensuring and issuing appropriate,
readily accessible PPE, without cost to the employees. Hypoallergenic gloves,
glove liners, powder less gloves, or similar alternatives shall be readily
accessible to employees who are allergic to the gloves normally provided.
BBP kits have the necessary PPE’s and they are on top of all our Cintas First
Aid cabinets, at all of our Child Care Sites, Pools, Camp and Janitor’s room.

▪ Gloves – If an employee is expected to have hand contact with blood or

other potentially infectious materials or contaminated surfaces, he or she
will be required to wear gloves. Single use gloves cannot be washed or
decontaminated for reuse. Use gloves when handling any items
contaminated with blood or other potentially infectious materials (OPIM)
or when cleaning surfaces contaminated with blood of other potentially
infectious materials (OPIM)

▪ Eye, Face and Body Protection- Employees will wear eye and mouth
protection such as goggles and masks, glasses with solid side shields, and
masks or chinlength face shields when splashes, sprays, splatters, or
droplets of potentially infectious materials pose a hazard through the
eyes, nose or mouth.

More extensive coverings such as gowns, aprons, surgical caps and

hoods, and shoe covers or boots are needed when gross contamination is
expected.

Work Practice Controls

▪ Employees will wash hands immediately or as soon as feasible after
removing gloves or other PPE.
▪ Employee will remove PPE after it becomes contaminated and before
leaving the work area.
▪ Employees will dispose of contaminated items appropriately.
▪ Flush eyes and mucous membranes immediately after potential
contamination with blood or other potentially infectious materials (OPIM).
▪ Clean surfaces with an appropriate disinfectant if contaminated.

Housekeeping
Work surfaces shall be cleaned and appropriately decontaminated with an
appropriate disinfectant in all of the following instances:
▪ When surfaces are overtly contaminated.
▪ Immediately when blood or other potentially infectious materials is
spilled.
▪ At the end of the work shift if the surface may have become contaminated
since the last cleaning.

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Contaminated Laundry
▪ Laundry that is or may be soiled with blood or other potentially infectious
material shall be treated as if it were contaminated and shall be handled
as little as possible with a minimum of agitation.
▪ Employer will ensure that all contaminated laundry is cleaned and
laundered in such a way that any blood-borne pathogens present are
inactivated or destroyed.
▪ Employer shall ensure that laundry workers wear protective gloves and
other appropriate personal protective work clothing while handling
contaminated laundry.
▪ Contaminated laundry will be placed and transported in bags or as
appropriate.
▪ In most cases, laundry such as towels, will be cleaned or disposed of as
appropriate.

Regulated Waste
▪ All regulated waste that is being disposed of shall be placed in closable,
leakproof containers or bags that are labeled or color-coded. If outside
contamination is likely to occur, a second leak-proof container or bag that
is closable and labeled or color-coded shall be placed over the outside of
the first and closed to prevent leakage during handling, storage, and
transport.
▪ Immediately after use, contaminated sharps shall be disposed of in
closable, leakproof, puncture-resistant, disposable containers that are
labeled or colorcoded. These containers shall be located in the immediate
area of use or where sharps are likely to be found.

HEPATITIS VACCINATION
Each department supervisor will provide training to their employees on
Hepatitis B vaccinations, addressing safety, benefits, efficacy, methods of
administration, and availability.

The Hepatitis B series is available at no cost after initial employee training

and within 10 days of initial assignment to all employees identified in the
exposure determination section of this plan. Vaccination is encouraged
unless: 1) documentation exists that the employee has previously received
the series; 2) antibody testing reveals that the employee is immune; or 3)
medical evaluation shows that vaccination is contraindicated.

However if the employee declines the vaccination, the employee must sign a
declination form. Employees who decline may request and obtain the
vaccination at a later date at no cost. Documentation of refusal of the
vaccination is kept at the Human Resources office.

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Vaccination will be provided by:
Woodbridge Occupational Health Clinic
Borgess at Woodbridge Hills, North Campus
7901 Angling Road, Portage, MI 49024
(269) 324.8426
(269) 324.8445 Fax
M-F 8 a.m.-4:30 p.m.

Following the medical evaluation, a copy of the health care professional’s

written opinion will be obtained and provided to the employee within 15 days
of completion of the evaluation. It will be limited to whether the employee
requires the hepatitis vaccine and whether the vaccine was administered.

POST-EXPOSURE EVALUATION AND FOLLOW-UP

Should an exposure incident occur, contact your supervisor and human
resources. An immediately available confidential medical evaluation and
follow-up will be conducted by Woodbridge Occupational Health Clinic
Borgess at Woodbridge Hills, North Campus
Following initial first aid (clean the wound, flush eyes or other mucous
membrane, etc.), the following activities will be performed:

▪ Document the routes of exposure and how the exposure occurred.

▪ Identify and document the source individual (unless the employer can
establish that identification is infeasible or prohibited by state or local
law).
▪ Obtain consent and make arrangements to have the source individual
tested as soon as possible to determine HIV, HCV and HBV infectivity;
document that the source individual’s test results were conveyed to the
employee’s health care provider.
▪ If the source individual is already knows to be HIV, HCV, and/or HBV
positive, new testing need not to be performed.
▪ Assure that the exposed employee is provided with the source individual’s
test results and with information about applicable disclosure laws and
regulations concerning the identity and infectious status of the source
individual (e.g. laws protecting confidentiality)
▪ After obtaining consent, collect exposed employee’s blood as soon as
feasible after exposure incident, and test blood for HBV and HIV
serological status.
▪ If the employee does not give consent for HIV serological testing during
collections of blood for baseline testing, preserve the baseline blood
sample for at least 90 days; if the exposed employee elects to have the
baseline sample tested during this waiting period, perform testing as soon
as feasible.

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ADMINISTRATION OF POST EXPOSURE EVALUATION AND FOLLOW-UP
The Human Resources department ensures that health care professional(s)
responsible for employee’s hepatitis B vaccinations and post-exposure
evaluation and follow-up are given a copy of OSHA’s blood-borne pathogens
standard.

The Human Resources department ensures that the health care professional
evaluating an employee after an exposure incident receives the following;
▪ A description of the employee’s job duties relevant to the exposure incident
▪ Route(s) of exposure
▪ Circumstances of exposure
▪ If possible, results of the sources individual’s blood test
▪ Relevant employee medical records, including vaccination status

Human Resources provides the employee with a copy of the evaluating

health care professional’s written opinion within 15 days after completion of
the evaluation.

PROCEDURES FOR EVALUATING THE CIRCUMSTANCES

SURROUNDING AN EXPOSURE INCIDENT
The department’s supervisor will review the circumstances of all exposure
incidents to determine:

▪ Engineering controls use at the time

▪ Work practices followed
▪ A description of the device being used (including type and brand)
▪ Protective equipment or clothing that was used at the time of the
exposure incident (gloves, eye shields, etc)
▪ Location of the incident
▪ Procedure being performed when the incident occurred
▪ Employee’s training

The Human Resources department will record all percutaneous injuries from
contaminated sharps in a Sharps Injury Log.

COMMUNICATION OF HAZARDS TO EMPLOYEES & TRAINING

Labels & Signs
The Facilities Director shall ensure that biohazard labels are on each
container of regulated waste or other potentially infectious materials. Labels
shall also be affixed to any other containers used to store, transport, or ship
other potentially infectious materials.

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The labels shall be fluorescent orange or orange-red, and shall include the
universal biohazard symbol. Red bags or containers with the universal
biohazard symbol may be substituted for labels. However, regulated wastes
must be handled in accordance with the rules and regulations of the entity
with jurisdiction.

Training
All employees who have occupational exposure to blood-borne pathogens
receive initial and annual training conducted by their Department’s
Supervisor and on our Risk Management training site.

All employees who have occupational exposure to blood-borne pathogens

receive training on the epidemiology, symptoms, and transmission of blood-
borne pathogens diseases. In addition, the training program covers, at a
minimum, the following elements:

▪ A copy and explanation of the OSHA blood-borne pathogen standard. An

explanation of our ECP and how to obtain a copy
▪ An explanation of methods to recognize tasks and other activities that
may involve exposure to blood and OPIM, including what constitutes and
exposure incident.
▪ An explanation of the use and limitations of engineering controls, work
practices, and PPE
▪ An explanation of the types, uses, location, removal, handling,
decontamination, and disposal of PPE
▪ An explanation of the basis of PPE selection
▪ Information on the hepatitis B vaccine, including information on its
efficacy, safety, method of administration, the benefits of being
vaccinated, and that the vaccine will be offered free of charge
▪ Information on the appropriate actions to take and persons to contact in
an emergency involving blood or OPIM.
▪ An explanation of the procedure to follow if an exposure incident occurs,
including the method of reporting the incident and the medical follow-up
that will be made available
▪ Information on the post-exposure evaluation and follow-up that the
employer is required to provide for the employee following an exposure
incident.

RECORDKEEPING
Training Records

The YMCA of Greater Kalamazoo shall maintain training records for three
years from the date of training. Records shall be kept in their employee’s file,
and shall include:

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 • the dates of the training sessions;
• an outline describing the material presented;
• the name and qualification of person conducting the training; and
• the names and job titles of all persons attending the training sessions.

Employee training records are provided upon request to the employee or the
employee’s authorized representative within 15 working days. Such requests
should be addressed to the Human Resources Department.

Medical Records
Medical records are maintained for each employee with occupational
exposure in accordance with 29 CFR 1910.1020, “Access to Employee
Exposure and Medical Records.”

The Human Resources Department is responsible for maintenance of the

required medical records. These confidential records are kept in a separate
medical record file behind the employee’s personnel file for at least the
duration of employment plus 30 years.

Employee medical records are provided upon request of the employee or to

anyone having written consent of the employee within 15 working days.
Such requests should be sent to the Human Resources Department.

Sharps Injury Log

The YMCA of Greater Kalamazoo maintains a log of all sharps injuries and
retains the information for five years. It may be viewed at the Human
Resources office. This log is reviewed as part of the annual program
evaluation and maintained for at least five years following the end of the
calendar year covered. If a copy is requested by anyone, it must have any
personal identifiers removed from the report.

OSHA Recordkeeping
An exposure incident is evaluated to determine if the case meets OSHA’s
Recordkeeping Requirements (29 CFR 1904). This determination and the
recording activities are done by the Human Resources Department.

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 SHARPS INJURY LOG
FOR
YMCA of Greater Kalamazoo

department
type and
where
date brand of how incident occurred
incident
device
occurred

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Hepatitis B Vaccine Declination Form
The following statement of declination of the hepatitis B vaccine must be
signed by an employee who:
▪ Chooses not to accept the vaccine.
▪ Has had appropriate training regarding hepatitis B, hepatitis B
vaccination, the efficacy, safety, method of administration and benefits of
vaccination, given free of charge to the employee.
▪ This statement is not a waiver; employees can request and receive the
hepatitis B vaccination at a later date if they remain occupationally at risk
for hepatitis B.

An employer cannot require:

 Employees to waive liability in order to receive the vaccine.
 Participation in pre-screening as a prerequisite for receiving the vaccine.

Hepatitis B Vaccine Declination Form

I understand that due to my occupational exposure to blood or other

potentially infectious materials 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 may continue to be at risk of acquiring
hepatitis B, a serious disease, unless I have previously been
vaccinated. If in the future I continue to have occupational exposure
to blood or other potentially infectious materials and I want to be
vaccinated with hepatitis B vaccine, I may receive the vaccination
series at no charge to me.

Employee Name __________________________________________

Employee __________________________________________
Signature

Date ________________

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 Annual Review

This Plan was reviewed on:

The previous review was on:

The reason for the review was (mark appropriate)

 annual review
 new or modified task(s) – list
_____________________________________________________
The review considered the following technological changes that are
commercially available and effective might eliminate or reduce exposure to
BBP since the previous review:

<List all considered new devices designed to eliminate or minimize

occupational hazard note if implemented, provide reason if not>

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