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.
Communicable disease reporting in compliance with section 5111 of the code, MCL
333.5111, and the communicable and related diseases rules,
(c) An ongoing program to prevent, control,
and investigate healthcare associated infections.
Implementation of healthcare associated
infections risk mitigation including, but not limited to, all of the following:
(i) Monitoring personnel hand
(ii) Monitoring infections
caused by organisms that are multidrug-resistant.
(iii) Monitoring device-associated
(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
(viii) Monitoring sterilization and
disinfection practices and reporting failures.
(ix) Monitoring cleaning procedures used in
patient care areas.
surgical services in accordance with standards of care for all of the
(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
(C) Skin antisepsis