Policies and Procedures

(A) Each health care facility shall develop and implement written policies and procedures for complying with the provisions of M.G.L. c.111, § 111C and 105 CMR 172.000. (B) Such policies and procedures at a minimum shall address the following: (1) Identification of the person(s) authorized to receive the Unprotected Exposure Form; Identification of the person(s) qualified to determine whether or not the reported unprotected exposure is capable of transmitting a bloodborne infectious disease dangerous to the public health as defined in 105 CMR 172.001; Identification of the authorized person(s) responsible for notifying the designated infection control officer for the care providers who have sustained an exposure that in the opinion of the health care facility is capable of transmitting an infectious disease dangerous to the public health; Identification of the person(s) qualified to recommend the appropriate precautions, instructions and other advice to be given to the designated infection control officer for the care provider(s) who has sustained an exposure(s) to an infectious disease dangerous to the public health; (5) Maintenance of the confidentiality of the Unprotected Exposure Form and of the identity of the patients and care providers; and (6) Procedures to ensure that all reasonable efforts will be made to inform the patient of his or her diagnosis of an infectious disease dangerous to the public health prior to informing, within the time frame set forth in 105 CMR 172.000, the designated infection control officer for the care provider who has sustained an exposure to an infectious disease dangerous to the public health.