The hospital shall provide an area for the cleaning, disinfection, packaging, sterilization, storing and distribution of medical/surgical patient care supplies.
01.
Service Areas. The service shall be separated into the following areas:
a. Receiving and cleaning of contaminated supplies; and
b. Assembly area (packaging); and
c. Sterilization area; and
d. Sterile and nonsterile storage area.
02.
Equipment and Supplies. Autoclaves, sterilizers, and other equipment shall be available to meet the needs of the hospital.
03.
Policies and Procedures. Policies and procedures established for processing and reprocessing of all instruments and supplies shall be approved by the infection control committee and must include the following:
a. Method of cleaning all equipment; and
b. A listing of contents of package and material to be used for all items autoclaved or sterilized; and
c. Procedure for operation of autoclaves and sterilizers; and
d. Policy regarding shelf life of all types of packages; and
e. Policy regarding expiration dates of packages; and
f. Procedure for conducting daily check of thermometers, and recordings; and
g. Determination of temperature, time, pressures, and humidity for autoclaves and sterilizers; and
h. Procedure for recall and disposal or reprocessing; and
i. Policy regarding maximum size and weight of packs; and
j. Procedure for biological (spore) check of gas sterilizers, each load; and
k. Procedure for biological (spore) check of autoclave at least monthly; and
l. Policy establishing aeration periods for various kinds of materials that are gas sterilized; and
m. Procedure for cleaning and disinfection of all items that are not sterilized; and
n. Procedure for cleaning and sanitizing equipment and surfaces (housekeeping); and
o. Policy establishing that all water issued for respiratory therapy shall be sterile; and
p. Written infection control procedure; and
q. Procedure for the control of water used for respiratory therapy if that service is not responsible.
04.
Inservice/Continuing Education. Documentation of all orientation and educational programs for each employee shall be present at the facility.
