Hospital Infection Control

(1) Infection control policies must be developed that include infection control orientation to protect the hospital employees and patients from cross contamination. The policies must ensure the following: (a) Isolation of infectious patients from other patients or staff; and (b) Isolation techniques to include gowns, masks and gloves as needed in transporting of infectious patients to and from the Radiology service. (2) Disinfection of use area and equipment in accordance with infection control policies must be accomplished when infectious patients have been served. (3) It must be the duty of the Chief Executive Officer or Administrator to assure that an infection control committee including members of the medical staff, nursing staff and administrative staff develop guidelines and techniques for the prevention, surveillance, control and reporting of hospital infections in accordance with hospital rules and regulations. Duties of the committee must include the establishment of: (a) Written infection control measures; (b) Techniques and systems for discovering and reporting infections in the hospital; (c) Written procedures governing the use of aseptic techniques and procedures in all areas of the hospital; (d) Written procedures concerning food handling, laundry practices, disposal of environmental and patient wastes, traffic control and visiting rules in high risk areas, sources of air pollution and routing culturing of autoclaves and sterilizers; MINIMUM PROGRAM REQUIREMENTS FOR CHAPTER 0940-05-16 MENTAL HEALTH HOSPITAL FACILITIES (e) A method of control used in relation to the sterilization of supplies and water and a written policy requiring sterile supplies to be reprocessed at specific time periods; (f) Formal provisions to educate and orient all appropriate personnel in the practice of aseptic techniques, such as handwashing and scrubbing practices, proper grooming, masking and dressing care techniques, disinfecting and sterilizing techniques and the handling and storage of patient care equipment and supplies; and (g) Measures which control the indiscriminate use of preventive antibiotics in the absence of infection and the use of antibiotics in the presence of infection based on necessary cultures and sensitivity tests.