PURPOSE: This rule specifies the requirements for infection control practices in a hospital.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

1. (1) There shall be an active multidisciplinary infection control committee responsible for implementing and monitoring the infection control program. The committee shall include, but not be limited to, the infection control officer, a member of the medical staff, registered professional nursing staff, quality improvement staff and administration. This program shall include measures for preventing, identifying, and investigating healthcare-associated infections and shall establish procedures for: collecting data, conducting root cause analysis, reporting sentinel events, and implementing corrective actions. These measures and procedures shall be applied throughout the hospital, including as a part of the employee health program.
2. (2) The infection control committee shall conduct an ongoing review and analysis of healthcare-associated infections (HAI) data and risk factors. Priorities and goals related to preventing the acquisition and transmission of potentially infectious agents will be established based on risks identified.
3. (3) Hospitals shall implement written policies and procedures outlining infection control SENIOR SERVICES

measures. These measures shall include, but are not limited to, a hospital-wide hand hygiene program that complies with the October 25, 2002 Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Health-Care Settings, which is incorporated by reference in this rule. A copy of the CDC Guideline for Hand Hygiene in Health-Care Settings may be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. This rule does not incorporate any subsequent amendments or additions. At a minimum, the program shall require every health care worker to properly wash or sanitize his or her hands immediately before and immediately after each and every episode of patient care. Procedures shall include, at a minimum, requirements for the facility’s infection control program to conduct surveillance of personnel in accordance with section 197.150, RSMo. Surveillance procedures may also include monitoring the employees’ and medical staff’s use of hand hygiene products. A mechanism approved by the hospital infection control committee for reporting and monitoring patient and employee infections shall be developed for all patient care and support departments in the hospital.

1. (4) Orientation and ongoing education shall be provided to all patient care and patientcare support personnel on the cause, effect, transmission, prevention and elimination of infections. Records of employee attendance shall be retained and available for inspection. A mechanism for monitoring compliance with infection control policies and procedures shall be coordinated with administrative staff, personnel staff and the quality improvement program.
2. (5) Infection control committee meetings shall be held quarterly. Minutes shall be retained.
3. (6) There shall be an annual review and evaluation of the quality of the infection control program.

AUTHORITY: sections 192.006 and 197.080, RSMo 2000 and 197.150 and 197.154, RSMo Supp. 2007.* This rule previously filed as 19 CSR 30-20.021(5)(B). Original rule filed June 27, 2007, effective Feb. 29, 2008.

*Original authority: 192.006, RSMo 1993, amended 1995; 197.080, RSMo 1953, amended 1993, 1995; 197.150, RSMo 2004; and 197.154, RSMo 2004.