Mich. Admin. Code R. 325.45137 - Ongoing surveillance and prevention program; communicable disease reporting

Current through Vol. 22-05, April 1, 2022

Rule 137. The applicant or licensee shall provide and maintain an ongoing surveillance and prevention program that includes, but is not limited to, all of the following:

(a) An active surveillance program for infection detection through ongoing data collection and analysis that includes patients and personnel who have access to or contact with active patient care areas, and other individuals identified by the health facility or agency policies and procedures.
(b) Communicable disease reporting in compliance with section 5111 of the code, MCL 333.5111, and the communicable and related diseases rules, R 325.171 to R 325.199.
(c) An ongoing program to prevent, control, and investigate healthcare associated infections.
(d) Implementation of healthcare associated infections risk mitigation including, but not limited to, all of the following:
(i) Monitoring personnel hand hygiene.
(ii) Monitoring infections caused by organisms that are multidrug-resistant.
(iii) Monitoring device-associated infections.
(iv) Monitoring antibiotic use.
(v) Monitoring safe practices for injecting medication, saline, or other infusates.
(vi) Monitoring use of disinfectants and germicides in accordance with manufacturers instructions.
(vii) Monitoring use of medical equipment, including air filtration equipment, ultra-violet lights, and other equipment used to control the spread of infectious agents in accordance with manufacturers recommendations.
(viii) Monitoring sterilization and disinfection practices and reporting failures.
(ix) Monitoring cleaning procedures used in patient care areas.
(x) Monitoring surgical services in accordance with standards of care for all of the following:
(A) Appropriate use of antibiotic prophylaxis to prevent surgical site infection, such as protocol to assure that antibiotic prophylaxis to prevent surgical site infection for procedures is administered at the appropriate time, done with an appropriate antibiotic, and discontinued appropriately after surgery.
(B) Aseptic technique practices are used in surgery, including sterilization or high-level disinfection of instruments, as appropriate.
(C) Skin antisepsis methods.


Mich. Admin. Code R. 325.45137
2020 MR 4, Eff. 2/21/2020

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