An administrator shall ensure that:
1. An infection control program that meets
the requirements of this Section is established under the direction of an
individual qualified according to policies and procedures;
2. An infection control program has a
procedure for documenting:
a. The collection
and analysis of infection control data,
b. The actions taken relating to infections
and communicable diseases, and
c.
Reports of communicable diseases to the governing authority and state and
county health departments;
3. Infection control documents are maintained
for at least 12 months after the date of the document;
4. Policies and procedures are established,
documented, and implemented:
a. To prevent or
minimize, identify, report, and investigate infections and communicable
diseases that include:
i. Isolating a
patient;
ii. Sterilizing equipment
and supplies;
iii. Maintaining and
storing sterile equipment and supplies;
iv. Using personal protective equipment such
as gowns, masks, or face protection;
v. Disposing of biohazardous medical waste;
and
vi. Moving and processing
soiled linens and clothing;
b. That specify communicable diseases,
medical conditions, or criteria that prevent an individual, a personnel member,
or a medical staff member from:
i. Working in
the hospital,
ii. Providing patient
care, or
iii. Providing
environmental services;
c. That establish criteria for determining
whether a medical staff member is at an increased risk of exposure to
infectious tuberculosis based on:
i. The level
of risk in the area of the hospital premises where the medical staff member
practices, and
ii. The work that
the medical staff member performs; and
d. That establish the frequency of
tuberculosis screening for an individual determined to be at an increased risk
of exposure;
5. Tuberculosis screening is
performed:
a. As part of a tuberculosis
infection control program that complies with the Guidelines for Preventing the
Transmission of Mycobacterium tuberculosis in Health-care Settings according to
R9-10-113(2) ; or
b. Using a screening method
described in R9-10-113(1), as follows:
i. For a personnel member, on or
before the date the personnel member begins providing services at or on behalf
of the hospital and at least once every 12 months thereafter or more frequently
if the personnel member is determined to be at an increased risk of exposure
based on the criteria in subsection (4)(c);
ii. Except as required in
subsection (4)(d), for a medical staff member, at least once every 24 months;
and
iii. For a medical staff member at
an increased risk of exposure based on the criteria in subsection (4)(c), at
the frequency required by policies and procedures, but no less frequently than
once every 24 months;
5. Tuberculosis screening is performed for a
personnel member or medical staff member:
a.
On or before the date the personnel member or medical staff member begins
providing services at or on behalf of the hospital, and
b. As part of a tuberculosis infection
control program according to
R9-10-113 ;
6. Soiled linen and clothing are:
a. Collected in a manner to minimize or
prevent contamination,
b. Bagged at
the site of use, and
c. Maintained
separate from clean linen and clothing and away from food storage, kitchen, or
dining areas;
7. A
personnel member washes hands or uses a hand disinfection product after each
patient contact and after handling soiled linen, soiled clothing, or
potentially infectious material;
8.
An infection control committee is established according to policies and
procedures and consists of:
a. At least one
medical staff member,
b. The
individual directing the infection control program, and
c. Other personnel identified in policies and
procedures; and
9. The
infection control committee:
a. Develops a
plan for preventing, tracking, and controlling infections;
b. Reviews the type and frequency of
infections and develops recommendations for improvement;
c. Meets and provides a quarterly written
report for inclusion by the quality management program; and
d. Maintains a record of actions taken and
minutes of meetings.
