0940-05-16-.15
Hospital Central Sterile Supply And Control
Cite as Tenn. Comp. R. & Regs. 0940-05-16-.15
(1)
Sterilizing equipment must be under the supervision of a qualified individual. This qualification
consists of a working knowledge of basic bacteriology and principles of sterilization gained
through education and experience.
(2)
Sterilizer function must be checked by bacterological, mechanical and chemical indicators.
(3)
Autoclave functions will be monitored daily by use of mechanical and chemical indicators.
Autoclaves equipped with vacuum pumps must be monitored once daily with an appropriate
test to verify proper mechanical function. Biological testing must be conducted a minimum of
once weekly using a heat-resistant, spore-forming organism.
MINIMUM PROGRAM REQUIREMENTS FOR
CHAPTER 0940-05-16
MENTAL HEALTH HOSPITAL FACILITIES
(4)
Ethylene oxide sterilizers must be checked with mechanical and chemical indicators to verify
proper operation of the sterilizer. In addition, each cycle of the sterilizer must be tested with a
suitable bacteria.
(5)
All bacteria must be cultured at the temperature recommended by the supplier.
(6)
Precautions must be taken so that soiled supplies cannot contaminate sterile supplies. Sterile
supplies must be packaged and stored in a manner that will protect the sterility of the
contents. There must be separation between decontamination and preparation areas.
(7)
Infection control policies and procedures must be developed pertaining to the control of
infection by screening and treatment of sick employees and orientation of all central supply
personnel in aseptic techniques and in the prevention of contamination through the handling,
cleaning and sterilizing of contaminated supplies and equipment.
(8)
All packages or containers must be appropriately labeled. If processed by sterilizing, the label
must remain legible. In addition, the label must contain an expiration date.
(9)
A written policy governing expiration dates and procedures for collecting out-of-date or
recalled supplies must be formulated.
(10) Storage must be provided for keeping equipment and supplies in a clean, convenient and
orderly manner.
(11) In lieu of closed storage spaces, dust covers sealed to exclude outside air may be used.