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

1. (1) There shall be an active multidisciplinary infection prevention and control committee responsible for implementing and monitoring the infection prevention and control program for patients and staff. 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, reporting, and investigating healthcare-associated infections and shall establish procedures for collecting data, participating in root cause analysis, and implementing corrective actions as relevant to infection prevention and control. These measures and procedures shall be applied throughout the hospital.
2. (2) The infection prevention and control committee shall conduct an ongoing review and analysis of healthcare-associated infections
3. (HAI) data and risk factors. Priorities and goals related to active surveillance, monitoring, reporting, and preventing the acquisition and the acquisition and transmission of potentially infectious agents will be established based on risks identified.
4. (3) Hospitals shall implement written policies and procedures outlining infection prevention and control measures. These measures shall include, but are not limited to, a hospital-wide hand hygiene program. This program must comply with current national standards endorsed by Centers for Disease Control and Prevention (CDC) or World Health Organization guidelines. At a minimum, the program shall require every healthcare worker to properly wash or sanitize his or her hands immediately before and immediately after having direct contact with a patient. Procedures shall include, at a minimum, requirements for the facility’s infection prevention and 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.
5. (4) All areas of the hospital shall have a process for reporting patient and employee infections. A process for monitoring compliance with infection prevention and control policies and procedures shall be coordinated with the infection prevention and control committee.
6. (5) Infection prevention and control committee meetings shall be held at least quarterly. Minutes shall be retained per hospital policy.
7. (6) There shall be a process for the review and evaluation on a regular basis of the quality and scope of the infection prevention and control program.

AUTHORITY: section 192.006, RSMo 2000, and sections 197.080, 197.150, and 197.154, RSMo Supp. 2013.* This rule previously filed as 19 CSR 30-20.021(5)(B). Original rule filed June 27, 2007, effective Feb. 29, 2008. Amended: Filed Dec. 31, 2013, effective Aug. 30, 2014. *Original authority: 192.006, RSMo 1993, amended 1995; 197.080, RSMo 1953, amended 1993, 1995; 197.150, RSMo 2004; and 197.154, RSMo 2004.