California Code of Regulations
Title 22 - Social Security
Division 5 - Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies
Chapter 1 - General Acute Care Hospitals
Article 7 - Administration
Section 70739 - Infection Control Program

Universal Citation: 22 CA Code of Regs 70739

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

(a) A written hospital infection control program for the surveillance, prevention and control of infections shall be adopted and implemented. The program shall include policies and procedures that:

(1) Define and require methods to handle all patients, all blood and body fluids and all materials that are soiled with blood and/or body fluids from all patients. The methods prescribed shall be designed to reduce the risk of transmission of potentially infectious etiologic agents from patient to patient and between patient and healthcare worker. The methods shall include handwashing, the use of gloves, the use of other barriers, the handling of needles/sharps and the disposal of materials that are soiled with or contain blood and/or body fluids.

(2) Define practices to reduce the risk of transmission of airborne infectious etiologic agents including tuberculosis and addressing the assignment of rooms and/or roommates.

(3) Provide for and document the education of all personnel.
(A) Each new employee shall receive training appropriate to his/her job classification and work activities to acquaint him/her with infection control policies and procedures of the healthcare facility.

(B) Training material shall be kept current and conform to new information pertaining to the prevention and control of infectious diseases. Revised training material shall be presented to all healthcare workers.

(4) Provide a plan for the surveillance and control of nosocomial infections including procedures for the investigation and management of outbreaks.

(5) Define the equipment, instruments, utensils and disposable materials that are to be identified as biohazardous.

(b) The oversight of the infection surveillance, prevention and control program shall be vested in a multi-disciplinary committee which shall include representatives from the medical staff, administration, nursing department and infection control personnel. This committee shall provide advice on all proposed construction and shall be responsible for the provision of current, updated information on infection control policy and procedures for the facility.

(c) Hospitals having a licensed bed capacity of 200 or more shall have a full-time infection control employee who shall coordinate the activities of the program.

(d) Hospitals having a licensed bed capacity of 199 or less shall have a designated part-time infection control employee who shall coordinate activities of the program.

1. Amendment filed 6-15-89 as an emergency; operative 6-15-89 (Register 89, No. 25). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 10-13-89.
2. Certificate of Compliance as to 6-15-89 order transmitted to OAL on 10-13-89 and disapproved by OAL on 11-13-89 (Register 89, No. 46).
3. Amendment refiled 11-16-89 as an emergency; operative 11-16-89 (Register 89, No. 46). A Certificate of Compliance must be transmitted to OAL within 120 days or the section will be reinstated as it existed prior to the emergency on 3-16-90.
4. Certificate of Compliance as to 11-16-89 order including amendment of subsections (a)-(d) transmitted to OAL 3-15-90 and filed 4-16-90 (Register 90, No. 17).

Note: Authority cited: Sections 208(a) and 1275, Health and Safety Code. Reference: Section 1276, Health and Safety Code.

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