1. 1. An infection control program that meets the requirements of this Section is established under the direction of an individual qualified according to policies and procedures;

2. 2. An infection control program has a procedure for documenting:

   1. a. The collection and analysis of infection control data,
   2. b. The actions taken relating to infections and communicable diseases, and
   3. c. Reports of communicable diseases to the governing authority and state and county health departments;
3. 3. Infection control documents are maintained for at least 12 months after the date of the document;

4. 4. Policies and procedures are established, documented, and implemented:

   1. a. To prevent or minimize, identify, report, and investigate infections and communicable diseases that include:

      1. i. Isolating a patient;
      2. ii. Sterilizing equipment and supplies;
      3. iii. Maintaining and storing sterile equipment and supplies;
      4. iv. Using personal protective equipment such as gowns, masks, or face protection;
      5. v. Disposing of biohazardous medical waste; and
      6. vi. Moving and processing soiled linens and clothing;

   2. b. That specify communicable diseases, medical conditions, or criteria that prevent an individual, a personnel member, or a medical staff member from:

      1. i. Working in the hospital,
      2. ii. Providing patient care, or
      3. iii. Providing environmental services;

   3. c. That establish criteria for determining whether a medical staff member is at an increased risk of exposure to infectious tuberculosis based on:

      1. i. The level of risk in the area of the hospital premises where the medical staff member practices, and
      2. ii. The work that the medical staff member performs; and
   4. d. That establish the frequency of tuberculosis screening for an individual determined to be at an increased risk of exposure;

5. 5. Tuberculosis screening is performed for a personnel member or medical staff member:

   1. a. On or before the date the personnel member or medical staff member begins providing services at or on behalf of the hospital, and
   2. b. As part of a tuberculosis infection control program according to R9-10-113;

6. 6. Soiled linen and clothing are:

   1. a. Collected in a manner to minimize or prevent contamination,
   2. b. Bagged at the site of use, and
   3. c. Maintained separate from clean linen and clothing and away from food storage, kitchen, or dining areas;
7. 7. A personnel member washes hands or uses a hand disinfection product after each patient contact and after handling soiled linen, soiled clothing, or potentially infectious material;

8. 8. An infection control committee is established according to policies and procedures and consists of:

   1. a. At least one medical staff member,
   2. b. The individual directing the infection control program, and
   3. c. Other personnel identified in policies and procedures; and

9. 9. The infection control committee:

   1. a. Develops a plan for preventing, tracking, and controlling infections;
   2. b. Reviews the type and frequency of infections and develops recommendations for improvement;
   3. c. Meets and provides a quarterly written report for inclusion by the quality management program; and
   4. d. Maintains a record of actions taken and minutes of meetings.

An administrator shall ensure that:

Historical Note

Adopted effective February 23, 1979 (Supp. 79-1). Section repealed; new Section made by final rulemaking at 8 A.A.R. 2785, effective October 1, 2002 (Supp. 02-2). Section R9-10-230 renumbered to R9-10-233; new Section R9-10-230 renumbered from R9-10-229 and amended by exempt rulemaking at 19 A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). Amended by exempt rulemaking at 20 A.A.R. 1409, pursuant to Laws 2013, Ch. 10, § 13; effective July 1, 2014 (Supp. 14-2). Amended by final expedited rulemaking at 28 A.A.R. 1113 (May 27, 2022), with an immediate effective date of May 4, 2022 (Supp. 22-2).