Fla. Admin. Code Ann. R. 59A-3.250 - Surveillance, Prevention, and Control of Infection
(1) Each hospital shall establish an
infection control program involving members of the organized medical staff, the
nursing staff, other professional staff as appropriate, and administration. The
program shall comply with the requirements in sections
381.0098 and
395.1011, F.S. and shall provide
for:
(a) The surveillance, prevention, and
control of infections among patients and personnel;
(b) The establishment of a system for
identifying, reporting, evaluating and maintaining records of
infections;
(c) Ongoing review and
evaluation of all septic, isolation and sanitation techniques employed in the
hospital; and,
(d) Development and
coordination of training programs in infection control for all hospital
personnel.
(2) Each
hospital shall have written policies and procedures reflecting the scope of the
infection control program outlined in subsection (1). The written policies and
procedures shall be reviewed at least every two years by the infection control
program members, dated at the time of each review, revised as necessary, and
enforced.
(3) The policies and
procedures devised by the infection control program shall be approved by the
governing board, and shall contain the following:
(a) Specific policies for the shelf life of
all stored sterile items.
(b)
Specific policies and procedures related to occupational exposure to blood and
body fluids.
(c) Specific policies
and procedures related to admixture and drug reconstitution, and to the
manufacture of intravenous and irrigating fluids.
(d) Specific policies related to the handling
and disposal of biomedical waste as required by chapter 64E-16, F.A.C., OSHA 29
CFR Part 1910.1030, Bloodborne Pathogens.
(e) Specific policies related to the
selection, storage, handling, use and disposition of disposable
items.
(f) Specific policies
related to decontamination and sterilization activities performed in central
services and throughout the hospital, including a requirement that steam gas
(ETO) and hot air sterilizers be tested with live bacterial spores at least
weekly.
(g) Specific policies
regarding the indications for universal precautions, body substance isolation,
CDC isolation guidelines, or equivalent and the types of isolation to be used
for the prevention of the transmission of infectious diseases.
(h) A requirement that soiled linen is
collected in such a manner as to minimize microbial dissemination into the
environment.
(i) A requirement that
all cases of communicable diseases as set forth in chapter 64D-3, F.A.C., be
promptly and properly reported as required by the provisions of that
rule.
(4) The individuals
involved in the infection control program shall meet at least quarterly, shall
maintain written minutes of all meetings, and shall make a report at least
annually to the assigned professional staff and the governing board.
(5) Each hospital shall establish an employee
health policy to minimize the likelihood of transmission of communicable
disease by both employees and patients. Such policies shall include work
restrictions for an employee whenever it is likely that communicable disease
may be transmitted until such time as a medical practitioner certifies that the
employee may return to work.
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