New York Codes, Rules and Regulations
Title 10 - DEPARTMENT OF HEALTH
Chapter V - Medical Facilities
Subchapter A - Medical Facilities-minimum Standards
Article 2 - Hospitals
Part 405 - Hospitals-Minimum Standards
Section 405.11 - Infection control
Current through Register Vol. 46, No. 39, September 25, 2024
The hospital shall provide a sanitary environment to avoid sources and transmission of nosocomial infections and of communicable diseases which may lead to morbidity or mortality in patients and hospital personnel. The hospital shall establish an effective infection control program for the prevention, control, investigation and reporting of all communicable disease and increased incidence of infections, including nosocomial infections, consistent with current acceptable standards of professional practice. The hospital-wide infection control program shall be reviewed as frequently as necessary but not less than once per year, and updated as necessary to promote optimal effectiveness.
(a) Organization.
The hospital shall designate an infection control professional who is responsible for the development and implementation of a hospital-wide infection control program. This individual shall be qualified by training in infection surveillance, prevention and control and also have knowledge or job experience in epidemiological principles, infectious diseases and infection control practices.
(b) Nosocomial surveillance, prevention and control.
The hospital-wide infection control program shall include processes designed to reduce the risk of endemic and epidemic nosocomial infections and communicable diseases in patients and hospital personnel. Such processes shall include methods to:
(c) Reporting of infections and communicable diseases.
There shall be written policies and procedures for identifying, reporting and investigating infections, and communicable disease of patients and hospital personnel both community acquired and nosocomial. The professional responsible for the hospital-wide infection control program shall report to the Department of Health, in a manner specified by the Commissioner of Health, any increased incidence of nosocomial infections, as designated in section 2.2 of this Title and defined by the department, or nosocomially acquired communicable disease designated in section 2.1 of this Title. This individual shall also report, immediately, the presence of any communicable disease as defined in section 2.1 of this Title, to the city, county, or district health officer.
(d) Integration with the quality assurance program.
The professional responsible for the hospital-wide infection control program shall ensure that all hospital infection control activities are integrated with the quality assurance program required by section 405.6 of this Part, including identification, assessment and correction of problems related to infection and communicable disease control.
(e) Infection control education.
The hospital shall require compliance with written requirements for orientation and ongoing education programs that are relevant to the hospital's infection control program for all personnel whose activities are such that they are at risk of directly or indirectly contributing to the transmission of infection or communicable disease from or to patients, other health care personnel or themselves.
(f) Corrective action plans.
The hospital shall be responsible for the implementation of acceptable corrective action plans related to infection control and resulting from problems identified through quality assurance or regulatory oversight activities and the professional responsible for the hospital-wide infection control program shall report to the chief executive officer progress in correcting identified problems.
(g)
(1) The hospital shall possess and maintain a supply of all necessary items of personal protective equipment (PPE) sufficient to protect health care personnel, consistent with federal Centers for Disease Control and Prevention guidance, for at least 60 days, by August 31, 2021.
(2) The 60-day stockpile requirement set forth in paragraph (1) of this subdivision shall be determined by the Department as follows for each type of required PPE:
(i) for single gloves, fifteen percent, multiplied by the number of the hospital's staffed beds as determined by the Department, multiplied by 550;
(ii) for gowns, fifteen percent, multiplied by the number of the hospital's staffed beds as determined by the Department, multiplied by 41;
(iii) for surgical masks, fifteen percent, multiplied by the number of the hospital's staffed beds as determined by the Department, multiplied by 21; and
(iv) for N95 respirator masks, fifteen percent, multiplied by the number of the hospital's staffed beds as determined by the Department, multiplied by 9.6.
(3) A hospital shall be considered to possess and maintain the required PPE if:
(i) it maintains all PPE on-site; or
(ii) it maintains PPE off-site, provided that the off-site storage location is within New York State, can be accessed by the hospital within at least 24 hours, and the hospital maintains at least a 10-day supply of all required PPE on-site, as determined by the calculations set forth in paragraph (2) of this subdivision. A hospital may enter into an agreement with a vendor to store off-site PPE, provided that such agreement requires the vendor to maintain unduplicated, facility-specific stockpiles; the vendor agrees to maintain at least a 60-day supply of all required PPE, or a 90-day supply in the event the Commissioner increases the required stockpile amount pursuant to this subdivision (less the amount that is stored on site at the facility); and the PPE is accessible by the facility 24 hours a day, 7 days a week, year round. In the event the Department finds a hospital has not maintained the required PPE stockpile, it shall not be a defense that the vendor failed to maintain the supply.
(iii) Any PPE stored outside of New York State shall not count toward the facility's required 60-day stockpile.
(4) The Commissioner shall have discretion to increase the stockpile requirement set forth in paragraph (1) of this subdivision from 60 days to 90 days where there is a State or local public health emergency declared pursuant to Section 24 or 28 of the Executive Law. Hospitals shall possess and maintain the necessary 90-day stockpile of PPE by the deadline set forth by the Commissioner.
(5) The Department shall periodically determine the number of staffed beds in each hospital. Hospitals shall have 90 days to come into compliance with the new PPE stockpile requirements, as set forth in paragraph (2) of this subdivision, following such determination by the Department. Provided further that the Commissioner shall have discretion to determine an applicable bed calculation for a hospital which is different than the number of staffed beds, if circumstances so require.
(6) In order to maximize the shelf life of stockpiled inventory, providers should follow the appropriate storage conditions as outlined by manufacturers, and providers are strongly encouraged to rotate inventory through regular usage and replace what has been used in order to ensure a consistent readiness level and reduce waste. Expired products should be disposed of when their expiration date has passed. Expired products shall not be used to comply with the stockpile requirement set forth in paragraph (1) of this subdivision.
(7) Failure to possess and maintain the required supply of PPE may result in the revocation, limitation, or suspension of the hospital's license; provided, however, that no such revocation, limitation, or suspension shall be ordered unless the Department has provided the hospital with a fourteen-day grace period, solely for a hospital's first violation of this section, to achieve compliance with the requirement set forth herein.
(8) In the event a new methodology relating to PPE in hospitals is developed, including but not limited to a methodology by the U.S. Department of Health & Human Services, and the Commissioner determines that such alternative methodology is appropriate for New York hospitals and will adequately protect hospital staff and patients, the Commissioner shall amend this subdivision to reflect such new methodology.
