1. (1) The licensee shall implement a hospital-wide infection control program that includes:

   1. (a) a system for reporting, evaluating, and investigating infections;
   2. (b) an employee health program;
   3. (c) definitions of nosocomial infections;
   4. (d) documented in-service education for departments and services related to infection control;
   5. (e) laboratory services;
   6. (f) methods for isolation depending on the medical condition involved;
   7. (g) orientation of new employees;

   8. (h) preventative, surveillance, and control procedures; and

      1. (i) review and evaluation of aseptic, isolation, and sanitation techniques.
2. (2) The licensee shall incorporate infection control reporting data into the hospital quality improvement plan.

3. (3) The licensee shall ensure that:

   1. (a) reuse data is incorporated into the hospital infection control identification and reporting processes;
   2. (b) reuse data is incorporated into the quality improvement plan;
   3. (c) single-use items may be reused according to hospital policy;
   4. (d) there are specific policies and procedures for each type of reusable item;
   5. (e) there are written infection control policies and procedures for each area of the hospital, including requirements dictated by the physical layout, personnel, and equipment involved; and
   6. (f) there are written policies for the selection, storage, handling, use, and disposition of disposable or reusable items.

KEY: health care facilities

Date of Last Change: June 5, 2026

Notice of Continuation: August 22, 2025

Authorizing, and Implemented or Interpreted Law: 26B-1-202; 26B-2-202; 26B-2-203