(a) General.

1. (1) The facility shall develop and use a coordinated process that effectively reduces the risk of endemic and epidemic healthcare-associated infections (HAI) in:

   1. (A) Patients;
   2. (B) Healthcare workers; and
   3. (C) Visitors.

2. (2)

   1. (A) There shall be a comprehensive list of communicable diseases for which:

(i) Patients shall be isolated; and

1. (ii) There are visitation restrictions.

   1. (B) The list and other policies and procedures for isolation shall conform to the latest edition of the Centers for Disease Control and Prevention, Atlanta, Georgia guidelines.
2. (3) It shall be the duty of the administrator or his or her designee to report all infectious or communicable diseases in the facility to the Department of Health as required by the Rules Pertaining to Reportable Diseases in Arkansas, 20 CAR pt. 102, Arkansas Code §§ 20-7-109 and 20-7-110, and Centers for Medicare & Medicaid Services mandatory reporting requirements for Medicare-certified facilities.

3. (4) The administrator shall designate a qualified individual who shall:

   1. (A) Coordinate the activities of the Infection Prevention and Control Committee;
   2. (B) Direct surveillance activities;
   3. (C) Ensure policies established by the Infection Prevention and Control Committee are carried out; and
   4. (D) Gather and report data regarding the hospital’s HAI.

4. (5) There shall be policies and procedures establishing and defining the infection prevention and control program to include:

   1. (A) Definitions of HAI and communicable diseases based on the current Centers for Disease Control and Prevention or National Healthcare Safety Network surveillance definitions;

   2. (B)

      1. (i) Performing an annual facility-based risk assessment to determine the infections that are most likely to occur in the facility.
      2. (ii) Infections to be addressed include but are not limited to the following:

(b) (b) Clostridium difficile infection (CDI);

1. (c) (c) Central line-associated bloodstream infection (CLABSI); and

   1. (d) (d) Catheter-associated urinary tract infection (CAUTI).

      1. (iii) Note. The facility’s system for surveillance, calculation, and evaluation of the incidence of HAI within the facility shall conform to National Healthcare Safety Network or Centers for Disease Control and Prevention publications as applicable;
   2. (C) Calculating HAI rates;
   3. (D) Measures for assessing and identifying patients and healthcare workers at risk for HAI and communicable diseases;
   4. (E) Methods for obtaining reports of infections and communicable diseases in patients and healthcare workers in a manner and time sufficient to limit the spread of infection;

   5. (F) A plan for monitoring and evaluating at least the following areas or departments to ensure policies and procedures are followed:

      1. (i) Inpatient and outpatient surgery;
      2. (ii) Delivery;
      3. (iii) Nursery;
      4. (iv) Central sterilization and supply;
      5. (v) Housekeeping;
      6. (vi) Laundry;
      7. (vii) Food and nutrition;
      8. (viii) Laboratory;
      9. (ix) Nursing;
      10. (x) Maintenance;
      11. (xi) Invasive specialty laboratories (special procedures);
      12. (xii) Radiology; and
      13. (xiii) Hemodialysis units;

   6. (G) Measures for prevention of infections including but not limited to:

      1. (i) Intravenous (IV) devices;
      2. (ii) Indwelling urinary catheters;
      3. (iii) Ventilator care;
      4. (iv) Burns; and
      5. (v) Immunosuppressed patients;

   7. (H)

      1. (i) Measures for prevention of communicable disease outbreaks, especially Mycobacterium tuberculosis (TB).
      2. (ii) All plans for the prevention of transmission of TB shall conform to the most current Centers for Disease Control and Prevention Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings;

   8. (I)

      1. (i) Isolation procedures and requirements for:

(b) (b) Patients colonized or infected with resistant organisms;

1. (ii) Procedures shall conform to the most current Centers for Disease Control and Prevention guidelines;

   1. (J) Provisions for education of patients and their families concerning infections and communicable diseases to include:

      1. (i) Hand hygiene; and
      2. (ii) Any isolation precautions;
   2. (K) A plan for monitoring and evaluating all aseptic, isolation, and sanitation techniques employed in the facility to ensure that approved infection prevention and control procedures are followed;

   3. (L) Techniques for:

      1. (i) Hand hygiene, including policies and procedures that reflect facility-selected national guidelines for soap and water as well as alcohol-based hand rub if used;
      2. (ii) Respiratory protection, including policies and procedures that reflect facility-selected national guidelines;
      3. (iii) Asepsis/sterile technique;
      4. (iv) Sterilization;
      5. (v) Sanitary food preparation;
      6. (vi) Disinfection;
      7. (vii) Housekeeping;
      8. (viii) Linen care;
      9. (ix)

(b) (b) Disposal of infectious waste shall conform to the latest edition of the Department of Health Rules Pertaining to the Management of Medical Waste from Generators and Healthcare Related Facilities, 20 CAR pt. 53;

1. (x) Sharps safety;

   1. (xi) Separation of clean from dirty process; and

      1. (xii) Other means of limiting the spread of contagion;
   2. (M) Authority and indications for obtaining microbiological cultures from patients;
   3. (N) Employee health; and

   4. (O) Visitation rules, especially for patients in:

      1. (i) Isolation;
      2. (ii) Critical care;
      3. (iii) Pediatrics; and
      4. (iv) Other special care units, including postpartum care.

2. (6) There shall be an orientation program for all new healthcare workers concerning:

   1. (A) The importance of infection prevention and control; and
   2. (B) Each healthcare worker’s responsibility in the hospital’s infection prevention and control program.
3. (7) There shall be a plan for each employee to receive annual educational programs as indicated based on assessments of the infection prevention and control process.
4. (8) Maintain documentation of reportable diseases.
5. (9) No items shall be used past the expiration date.

(b) Infection Prevention and Control Committee.

1. (1) There shall be a multidisciplinary committee appointed by administration to develop, implement, and monitor direction for the infection prevention and control program based on services impacting the infection prevention and control process.

2. (2)

   1. (A) The medical staff shall appoint a physician to serve as chairperson of the Infection Prevention and Control Committee.
   2. (B) Additional physician members may be appointed.

3. (3)

   1. (A) The Infection Prevention and Control Committee shall meet at least quarterly.
   2. (B) Minutes of the meetings shall reflect the Infection Prevention and Control Committee’s actions in monitoring and directing the hospital’s infection prevention and control program.

4. (4) The Infection Prevention and Control Committee shall fulfill the following responsibilities:

   1. (A) Assist in the development and approval of all infection prevention and control policies and procedures within the facility;
   2. (B) Ensure that an antibiogram is prepared at least annually and compared to the previous one to identify trends;
   3. (C) Monitor any contractual services relative to infection prevention and control (e.g., waste management and laundry) to ensure compliance with all applicable rules;
   4. (D) Review any special infection prevention and control studies conducted within the facility; and

   5. (E) Provide oversight for disinfectants and sterilants.

      1. (c) Employee health.

5. (1)

   1. (A) There shall be policies and procedures for:

      1. (i) Screening healthcare workers for infectious/communicable diseases; and
      2. (ii) Monitoring for healthcare workers exposed to patients with any communicable diseases.
   2. (B) The policies and procedures shall reflect facility-selected national guidelines.

6. (2)

   1. (A) There shall be employee health policies and procedures regarding preventing the transmission of infectious diseases.
   2. (B) The policies and procedures shall reflect facility-selected national guidelines.
7. (3) There shall be policies that clearly state when healthcare workers shall not render direct patient care.

8. (4) There shall be a plan for ensuring that:

   1. (A) Each healthcare worker is free from TB; and
   2. (B) The facility follows the latest tuberculosis screening and tuberculosis prevention guidelines approved by the Department of Health Rules Pertaining to Communicable Disease — Tuberculosis, 20 CAR pt. 103.
9. (5) There shall be a plan for ensuring that all healthcare workers who are exposed to blood and other potentially infectious body fluids are offered immunizations for Hepatitis B.