Ind. Admin. Code tit. 410, r. 15-2.5-1 – Infection control program

Sec. 1. (a) The center shall provide a safe and healthful environment that minimizes infection exposure and risk to patients, health care workers, and visitors.

(b) The center shall maintain a written, active, and effective center-wide infection control program. Included in this program must be a system designed for the identification, surveillance, investigation, control, and prevention of infections and communicable diseases in patients and health care workers.

(c) The infection control program must identify and evaluate trends or clusters of center generated infections or communicable diseases.

(d) The center shall designate a person qualified by training or experience as responsible for the ongoing infection control activities and the development and implementation of policies governing control of infections and communicable diseases.

(e) The chief executive officer, medical staff, and nursing manager shall:

(1) be responsible for the implementation of successful corrective action plans in affected problem areas and ensure that infection control policies are followed; and
(2) provide for appropriate infection control input into plans for renovation and new construction to ensure awareness of federal, state, and local rules that affect infection control practices as well as plan for appropriate protection of patients and employees during construction or renovation.

(f) The center shall establish a committee to monitor and guide the infection control program in the center as follows:

(1) The infection control committee shall be a center or medical staff committee, that meets at least quarterly, with membership that includes, but is not limited to, the following:
1. (A) The person directly responsible for management of the infection surveillance, prevention, and control program as established in subsection (d).
2. (B) A representative from the medical staff.
3. (C) A representative from the nursing staff.
4. (D) Consultants from other appropriate services within the center as needed.
(2) The infection control committee responsibilities must include, but are not limited to, the following:
1. (A) Establishing techniques and systems for identifying, reviewing, and reporting infections in the center.
2. (B) Recommending corrective action plans, reviewing outcomes, and assuring resolution of identified problems.
3. (C) Reviewing employee exposure incidents and making appropriate recommendations to minimize risk.
4. (D) Written reports of quarterly meetings.
5. (E) Reviewing and recommending changes in procedures, policies, and programs which are pertinent to infection control. These include, but are not limited to, the following:
  1. (i) Sanitation.
  2. (ii) Universal precautions, including infectious waste management.
  3. (iii) Cleaning, disinfection, and sterilization.
  4. (iv) Aseptic technique, invasive procedures, and equipment usage.
  5. (v) Reuse of disposables.
  6. (vi) A patient isolation system.
  7. (vii) A system, which complies with state and federal law, to monitor the immune status of health care workers exposed to communicable diseases.
  8. (viii) An employee health program to determine the communicable disease history of new personnel as well as an ongoing program for current personnel as required by state and federal agencies.
  9. (ix) Requirements for personal hygiene and attire that meet acceptable standards of practice.
  10. (x) A program of linen management.

(g) Sterilization of equipment and supplies must be provided, within the scope of the service offered, in accordance with acceptable standards of practice or manufacturer's recommendations and applicable state laws and rules, 410 IAC 1-4. Sterilization services must be directed by a qualified person or persons and must provide for the following:

(1) Biological indicators must be used to check sterilization processes at least monthly. Chemical sterilizing indicators must be used to check the sterilizing process of individual packs.
(2) Written policies and procedures must be available and followed by personnel responsible for sterilizing equipment and supplies, including, but not limited to, the following:
1. (A) Minimum time and temperature for processing various size bundles and packs.
2. (B) Instructions for loading, operating, cleaning, and maintaining sterilizers.
3. (C) Instructions for cleaning, packaging, storing, labeling, and dispensing of sterile supplies.
4. (D) Procedure for maintaining and recording the particular sterilizing cycle.
5. (E) Sterilization of heat labile reusable equipment.
(3) Records of results must be maintained and evaluated periodically in accordance with 410 IAC 15-2.4-2 to include, but not be limited to, the following:
1. (A) Records of recording thermometers or a daily record of the sterilizing cycle (date, time, temperature, pressure, and contents) for each sterilizer load.
2. (B) Results of biological indicators used in testing the sterilizing processes.

(h) Environmental surfaces and equipment not requiring sterilization which have been contaminated by blood or other potentially infectious materials shall be cleaned then decontaminated in accordance with acceptable standards of practice and applicable state laws and rules, 410 IAC 1-4.

(i) The center, whether it operates its own laundry or uses outside laundry service, shall ensure that the laundry process complies with a recognized laundry standard as follows:

(1) Clean linen must be separated from soiled linen at all times as follows:
1. (A) Contaminated linens must be clearly identified and bagged.
2. (B) Clean linen must be covered during transit, and separate containers or carts must be provided for transporting thereof.
(2) Central clean linen storage space must be provided as follows:
1. (A) If commercial laundry services are utilized:
  1. (i) a soiled linen collection room must be provided; and
  2. (ii) a hand washing facility is required in each area where unbagged soiled linen is handled.
2. (B) If laundry is processed in the center:
  1. (i) a laundry processing room must be provided;
  2. (ii) clean linen storage and mending must be separated from soiled linen handling and storage; and
  3. (iii) employee hand washing facilities shall be available in each room where clean or soiled linen is processed and handled.

(Indiana Department of Health; 410 IAC 15-2.5-1; filed Dec 1, 1999, 3:44 p.m.: 23 IR 786; errata filed Feb 15, 2000, 8:05 a.m.: 23 IR 1657; readopted filed Jul 15, 2005, 8:00 a.m.: 28 IR 3661; readopted filed Jul 14, 2011, 11:42 a.m.: 20110810-IR- 410110253RFA; readopted filed Sep 13, 2017, 4:08 p.m.: 20171011-IR-410170339RFA; readopted filed Nov 28, 2023, 12:13 p.m.: 20231227-IR-410230639RFA)