Current through Register Vol. 35, No. 18, September 24, 2024
A.
Program. The hospital shall have an infection control program
designed to reduce the number of infections, including nosocomial infections,
within the hospital.
B.
Program approval:
(1) Purpose:
The governing body or medical staff shall approve an infection control program
to carry out surveillance and investigation of infections in the hospital and
to implement measures designed to reduce these infections to the extent
possible.
(2) Responsibilities: The
infection control program shall:
(a) establish
techniques and systems for discovering and isolating infections occurring in
the hospital;
(b) establish written
infection control policies and procedures, which govern the use of aseptic
technique and procedures in all areas of the hospital;
(c) establish a method of control used in
relation to the sterilization of supplies and solutions; there shall be a
written policy requiring identification of sterile items and specified time
periods in which sterile items shall be reprocessed;
(d) establish policies specifying when
employees or persons providing contractual services with infections or
contagious conditions, including carriers of infectious organisms, shall be
relieved from, or reassigned duties, until there is evidence that the disease
or condition poses no significant risk to others;
(e) at least annually assess effectiveness of
the infection control process; and
(f) establish effective guidelines for the
disposition of infectious materials in accordance with the local, state and
federal guidelines.
C.
Education: The hospital shall
provide training to all appropriate hospital personnel on the epidemiology,
etiology, transmission, prevention and elimination of infection, as follows:
(1) aseptic technique: all appropriate
personnel shall be educated in the practice of aseptic techniques such as
handwashing and scrubbing practices, standard precautions, personal hygiene,
masking and dressing techniques, disinfecting and sterilizing techniques and
the handling and storage of patient care equipment and supplies, to include the
handling of needles and sharp instruments; and
(2) orientation and in-service: new employees
shall receive appropriate orientation and on-the- job training, and all
employees shall participate in a continuing in-service program; the
participation shall be documented.
D.
General infection control
provisions:
(1) There shall be regular
inspection and cleaning of air intake sources, screens and filters, with
special attention given to high risk areas of the hospital as determined by the
infection control committee.
(2) A
sanitary environment shall be maintained to avoid sources and transmission of
infection.
(3) Proper facilities
shall be maintained, and techniques used, for disposal of infectious wastes, as
well as sanitary disposal of all other wastes.
(4) Handwashing facilities shall be provided
in patient care areas for the use of hospital personnel.
(5) Sterilizing services shall be available
at all times.
(6) Soiled linen
shall be contained and secured at the point generated. It can be transported to
a designated area or cleaning facilities. No special precautions beyond the
standard precautions are necessary. Soiled bed linen shall be placed
immediately in a container available for this purpose and sent to the laundry
promptly.
(7) Tuberculosis exposure
control plan.
(a) A program to minimize the
risk of infectious tuberculosis among or between health care workers, patients,
or visitors and others shall be developed.
(b) This program shall include: a
comprehensive facility-wide risk assessment, early identification, isolation,
and treatment of potentially infectious tuberculosis patients, effective
engineering controls to prevent the spread, and reduce the concentration of,
infectious droplet nuclei, a written, respiratory protection program to protect
health care workers from exposure, education, counseling, and screening
processes for health care workers.
E.
Reporting disease: Hospitals
shall report cases and suspected cases of notifiable conditions as listed in
7.4.3.13 NMAC to the New Mexico
health care authority pursuant to New Mexico regulations governing the control
of disease and conditions of public health significance, New Mexico health care
authority, 7.4.3 NMAC or any superceding regulation.
F.
Policies and procedures:
There shall be written policies and procedures pertinent to care of patients
with communicable diseases that shall include standard precautions.
(1) These policies and procedures shall be
developed by administrative, medical, and nursing staff.
(2) The policies and procedures shall be
applicable within the hospital, designed to ensure safe and adequate care to
patients, safety to hospital employees, and consistent with applicable laws and
regulations.
(3) Policies shall be
made known to, and readily available to all hospital employees as well as the
medical and nursing staff, and shall be followed in the care of patients, and
shall be kept current by periodic review and revision.