410 IAC 15-1.5-2 Infection control

Sec. 2. (a) The hospital shall provide a safe and healthful environment that minimizes infection exposure and risk to patients, health care workers, and visitors. (b) There shall be an active, effective, and written hospital-wide infection control program. Included in this program shall 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 shall have a method for identifying and evaluating trends or clusters of nosocomial infections or communicable diseases. (d) A person qualified by training or experience shall be designated 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 executive nurse shall do the following: (1) Be responsible for the implementation of successful corrective action plans in affected problem areas. (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 hospital shall establish an infection control committee to monitor and guide the infection control program in the facility as follows: (1) The infection control committee shall be a hospital or medical staff committee that meets at least quarterly, with membership that includes, but is not limited to, the following: (A) The person directly responsible for management of the infection surveillance, prevention, and control program. (B) A representative from the medical staff. (C) A representative from nursing service. (D) A representative from administration. (E) Consultants from other appropriate services within the hospital, as needed. (2) The chairman should be a person with interest or experience in infection control. (3) The infection control committee responsibilities shall include, but not be limited to, the following: (A) Establishing techniques and systems for identifying, reviewing, and reporting infections in the hospital. (B) Recommending corrective action plans on identified problems, reviewing outcomes, and assuring resolution. (C) Reviewing employee exposure incidents and making appropriate recommendations to minimize risk. (D) Reviewing and recommending changes in procedures, policies, and programs which are pertinent to infection control. These include, but are not limited to, the following: (i) Sanitation. (ii) Universal precautions, including infectious waste management. (iii) Cleaning, disinfection, and sterilization. (iv) Aseptic technique, invasive procedures, and equipment usage. (v) Reuse of disposables. (vi) An isolation system. (vii) A system, which complies with state and federal law, to monitor the immune status of health care workers exposed to communicable diseases. (viii) An employee health program to determine the communicable disease history of new personnel as required by state and federal agencies. (ix) Requirements for personal hygiene and attire appropriate for work settings. (x) A program of food preparation and storage for all personnel involved in food handling which includes, but is not limited to, the following: (AA) Storage of employee food in patient refrigerators. (BB) Medications in nutrition refrigerators. (CC) Refrigerator and freezer temperature monitoring. (xi) A program of linen management for personnel involved in linen handling.