(a) General.

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

   1. (A) Patients;
   2. (B) Healthcare workers; and
   3. (C) Visitors.
2. (2) The facility shall follow standard Centers for Disease Control and Prevention precautions.

3. (3) The administrator shall designate a qualified individual (registered nurse or laboratorian) who shall:

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

4. (4) There shall be policies and procedures establishing and defining the infection control program including:

   1. (A) Definition of nosocomial infections that conforms to the current Centers for Disease Control and Prevention definition;
   2. (B) Measures to identify infections up to thirty (30) days postpartum and investigate and report nosocomial infections, and a system of evaluating and maintaining records of infection among both patients and healthcare workers;
   3. (C) Methods for obtaining reports of infections in patients and healthcare workers in a manner and time sufficient to limit the spread of infections;
   4. (D) Measures for assessing and identifying patients and healthcare workers at risk for nosocomial infections and communicable diseases;
   5. (E) Measures for prevention of infections;
   6. (F) Provisions for education of patients and their families concerning infections;
   7. (G) A plan for monitoring and evaluating all aseptic and sanitation techniques employed within the facility to ensure approved infection control procedures are followed;
   8. (H) Techniques for:

(i) Handwashing;

1. (ii) Scrub techniques;

   1. (iii) Asepsis;

      1. (iv) Sterilization;
      2. (v) Disinfection;
      3. (vi) Housekeeping;
      4. (vii) Linen care;
      5. (viii)

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

1. (ix) Disposal of placenta;

   1. (x) Sharps and needle disposal;

      1. (xi) Separation of clean from dirty process; and
      2. (xii) Other means of limiting the spread of contagion;
   2. (I) A requirement that disinfectants, antiseptics, and germicides be used in accordance with the manufacturer's directions;
   3. (J) Employee health;

   4. (K) Visitation rules. All children under the age of twelve (12) years shall:

      1. (i) Be screened for communicable disease; and
      2. (ii) Not be admitted into the facility if they are obviously ill; and
   5. (L) Guide dogs. No animals except certified dogs for the seeing-impaired will be allowed into the facility.

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

   1. (A) The importance of infection control; and
   2. (B) Each healthcare worker's responsibility in the facility's infection control program.
3. (6) There shall be a plan for each employee to receive annual in-services and educational programs as indicated based on assessment of the infection control process.
4. (7) The infection control officer shall maintain a log of infectious diseases.
5. (8) No item shall be used past the expiration date.
6. (9) One-time patient care items shall not be reused.
7. (10) If sterilization facilities are present, the Association for the Advancement of Medical Instrumentation standards or the Centers for Disease Control and Prevention recommended practices for sterilization in healthcare facilities shall be followed.

(b) Infection Control Committee.

1. (1) There shall be a Professional Review Committee appointed by the governing body to monitor and provide direction for the infection control program:

   1. (A) Administration;
   2. (B) Housekeeping;
   3. (C) Laboratory; and
   4. (D) Nursing.
2. (2) The governing body shall appoint a qualified individual to serve as chair of the Infection Control Committee.

3. (3)

   1. (A) The Infection Control Committee shall meet at least every two (2) months.
   2. (B) Minutes of the meetings shall reflect the Infection Control Committee's actions in monitoring and directing the facility's infection control program.

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

   1. (A) Assist in the development of and approval of all infection control policies and procedures within the facility;
   2. (B) Annually review and approve all infection control policies and procedures within the facility;

   3. (C) Direct all purchases of equipment and/or supplies used for:

      1. (i) Disinfection;
      2. (ii) Decontamination;
      3. (iii) Sanitation; and/or
      4. (iv) Sterilization;

   4. (D) Annually:

      1. (i) Review and approve all products used throughout the facility related to:

(b) (b) Decontamination;

1. (c) (c) Sanitation; and/or

   1. (d) (d) Sterilization; and

      1. (ii) Approve all interim changes;
   2. (E) At each meeting review the results of the biological spore tests on the facility's autoclaves;
   3. (F) Monitor any contractual services relative to infection control (e.g., waste management and laundry) to ensure compliance with all applicable regulations; and

   4. (G) Review any special infection control studies conducted within the facility.

      1. (c) Employee health.

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

   1. (A) Screening healthcare workers for communicable diseases; and
   2. (B) Monitoring healthcare workers exposed to patients with any communicable diseases.

3. (2)

   1. (A) There shall be policies regarding healthcare workers with infectious diseases or carrier states.
   2. (B) The policies shall clearly state when healthcare workers shall not render direct patient care.

   3. (C) Note. Healthcare workers employed by the facility, while affected with any disease in a communicable stage, while a carrier of such diseases, or while afflicted with boils, jaundice, infected wounds, diarrhea, or acute respiratory infections shall not work in any area in any capacity in which there is a likelihood of such person:

      1. (i) Contaminating:

(b) (b) Food contact surfaces;

1. (c) (c) Supplies; or

   1. (d) (d) Any surface with pathogenic organisms; or

      1. (ii) Transmitting disease to:

(b) (b) Facility personnel; or

1. (c) (c) Other individuals within the facility.

2. (3)

   1. (A) There shall be a plan for ensuring that each healthcare worker has measures for prevention of communicable disease outbreaks, especially Mycobacterium tuberculosis (TB).
   2. (B) 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 Healthcare Settings.
3. (4) There shall be a plan for ensuring that all healthcare workers who are frequently exposed to blood and other potentially infectious body fluids are offered immunizations for Hepatitis B.