SECTION 310:667-39-8. Infection control program

(a)   General. The CAH shall establish an infection control program to provide a sanitary environment and avoid sources and transmission of infections. The program shall include written policies and procedures for identifying, reporting, evaluating and maintaining records of infections among patients and personnel. The program shall provide an ongoing review and evaluation of all aseptic, isolation and sanitation techniques employed in the hospital and coordinate training programs in infection control for all personnel.

(b)   Infection control committee. The CAH may establish an infection control committee (or equivalent) or this function may be fulfilled by the medical and professional committee of the whole. The committee shall meet at least quarterly.

(c)   Policies and procedures review.

(1)   The infection control committee shall evaluate, revise as necessary, and approve the type and scope of surveillance activities utilized at least annually.

(2)   Infection control policies and procedures shall be reviewed periodically and revised as necessary, based on current scientific knowledge, accepted practice guidelines, and applicable laws and regulations.

(d)   Policies and procedures content. The policies and procedures outlined for the infection control program shall be approved by the infection control committee and contain at least the following:

(1)   A requirement that a record of all reported infections generated by surveillance activities include the identification and location of the patient, the date of admission, onset of the infection, the type of infection, the cultures taken, the results of cultures when known, any antibiotics administered and the physicians or practitioners responsible for care of the patient.

(2)   Specific policies related to the handling and disposal of biomedical waste.

(3)   Specific policies and procedures related to admixture and drug reconstitution, and the manufacture of intravenous and irrigating fluids.

(4)   Specific policies regarding the indications for and types of isolation to be used for each infectious disease. These policies shall incorporate the concepts of Standard Precautions and the recommended transmission-based categories of Contact, Airborne, and Droplet isolation procedures as deemed appropriate by the medical and professional staff.

(5)   A definition of nosocomial infection.

(6)   Designation of an infection control officer, who coordinates the infection control program.

(7)   Policies for orienting new employees and an ongoing continuing education program for currently employed personnel concerning infection control. Written documentation shall be maintained indicating new employees have completed orientation and that all current personnel have attended continuing education.

[Source: Added at 12 Ok Reg 1555, eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 17 Ok Reg 692, eff 12-16-99 (emergency); Amended at 17 Ok Reg 2992, eff 7-13-00; Amended at 20 Ok Reg 1664, eff 6-12-03]