Current through Register Vol. 24-18, September 15, 2024
The licensee shall:
(1) Establish and implement an effective
hospital-wide infection control program, which includes at a minimum:
(a) Written policies and procedures
describing:
(i) Types of surveillance used to
monitor rates of nosocomial infections;
(ii) Systems to collect and analyze data;
and
(iii) Activities to prevent and
control infections;
(b)
A review process, using definitions and criteria established by the infection
control committee, to determine if staff and patient infections are
nosocomial;
(c) A system for
reporting communicable diseases consistent with chapter 246-100 WAC,
Communicable and certain other diseases;
(d) A procedure for reviewing and approving
infection control aspects of policies and procedures used in each area of the
hospital;
(e) A procedure to
monitor the physical environment of the hospital for situations which may
contribute to the spread of infectious diseases;
(f) Provisions for:
(i) Providing consultation regarding patient
care practices, equipment and supplies which may influence the risk of
infection;
(ii) Providing
consultation regarding appropriate procedures and products for cleaning,
disinfecting and sterilizing;
(iii)
Providing infection control information for orientation and in-service
education for staff providing direct patient care;
(iv) Making recommendations, consistent with
federal, state, and local laws and rules, for methods of safe and sanitary
disposal of:
(A) Sewage;
(B) Solid and liquid wastes; and
(C) Infectious wastes including safe
management of sharps;
(g) Identifying specific precautions to
prevent transmission of infections; and
(h) Coordinating employee activities to
control exposure and transmission of infections to or from employees and others
performing patient services;
(2) Assign one or more individuals to manage
the infection control program with documented qualifications related to
infection surveillance, prevention, and control, including:
(a) Education;
(b) Training;
(c) Certification; or
(d) Supervised experience;
(3) Designate an infection control
committee, comprised of the individual or individuals assigned to manage the
program and multidisciplinary representatives from the professional staff,
nursing staff and administrative staff, to:
(a) Oversee the program;
(b) Develop a committee-approved description
of the program, including surveillance, prevention, and control
activities;
(c) Delegate authority,
approved in writing by administrative and professional staff, to institute
surveillance, prevention, and control measures when there is reason to believe
any patient or staff may be at risk of infection;
(d) Meet at regularly scheduled intervals, at
least quarterly;
(e) Maintain
written minutes and reports of findings presented during committee meetings;
and
(f) Develop a method for
forwarding recommendations to the professional staff, nursing, administration,
and other committees and departments as appropriate.
Statutory Authority: Chapter 71.12 RCW and RCW 43.60.040.
95-22-013, § 246-324-100, filed 10/20/95, effective
11/20/95.
