LAC 48:I.6779. General Provisions

A. The FSBC shall have policies and procedures, approved and implemented by the clinical staff and governing body, that address provisions for: 1. sanitizing, disinfecting, and sterilizing supplies, equipment, and utensils; and 2. the safe use of cleaning supplies and solutions that are to be used and the directions for use, including: a. terminal cleaning of the birthing rooms; and b. cleaning of the birthing rooms between delivery procedures. B. Policies and procedures shall be developed, implemented, and approved by the FSBC’s governing body for the types and numbers of sterilizing equipment and autoclaves sufficient to meet the sterilization needs of the FSBC. 1. Procedures for the proper use of sterilizing equipment for the processing of various materials and supplies shall be in writing, according to manufacturer’s recommendations, and readily available to personnel responsible for the sterilizing process. 2. All sterilization monitoring logs shall be maintained within the FSBC for a minimum of 18 months. C. All steam sterilizing equipment shall have live bacteriological spore monitoring performed at a frequency according to the manufacturer’s instructions. 1. If tests are positive, a system shall be in place to recall supplies that have tested substandard in accordance with the FSBC’s policies and procedures set forth by the FSBC’s governing body. D. All ethylene oxide sterilizing equipment shall have live bacteriological spore monitoring performed with each load and according to manufacturer’s recommendation. There shall be ventilation of the room used for this sterilization to the outside atmosphere. There shall be a system in place to monitor trace gases of ethylene oxide with a working alert system which is tested and documented daily.