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Document Citation: 59A-3.250, F.A.C.
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Header:
FLORIDA ADMINISTRATIVE CODE
TITLE 59 AGENCY FOR HEALTH CARE ADMINISTRATION
59A HEALTH FACILITY AND AGENCY LICENSING
CHAPTER 59A-3 HOSPITAL LICENSURE
Date:
08/31/2009
Document:
59A-3.250 Surveillance, Prevention, and Control of Infection.
(1) Each hospital shall establish an infection control program involving members of the organized medical staff, the nursing staff, other professional staff as appropriate, and administration. The program shall provide for:
(a) The surveillance, prevention, and control of infections among patients and personnel;
(b) The establishment of a system for identifying, reporting, evaluating and maintaining records of infections;
(c) Ongoing review and evaluation of all septic, isolation and sanitation techniques employed in the hospital; and
(d) Development and coordination of training programs in infection control for all hospital personnel.
(2) Each hospital shall have written policies and procedures reflecting the scope of the infection control program outlined in subsection (1). The written policies and procedures shall be reviewed at least every two years by the infection control program members, dated at the time of each review, revised as necessary, and enforced.
(3) The policies and procedures devised by the infection control program shall be approved by the governing body, and shall contain at least the following:
(a) Specific policies for the shelf life of all stored sterile items.
(b) Specific policies and procedures related to occupational exposure to blood and body fluids.
(c) Specific policies and procedures related to admixture and drug reconstitution, and to the manufacture of intravenous and irrigating fluids.
(d) Specific policies related to the handling and disposal of biomedical waste in accordance with Chapter 64E-16, F.A.C., May 1995, OSHA 29 CFR Part 1910.1030 Occupational Exposure to Blood Borne Pathogens Final Rule, July 1995, and the Department of Environmental Protection Code Chapter 62-712 on Biomedical Waste, May 1995.
(e) Specific policies related to the selection, storage, handling, use and disposition of disposable items.
(f) Specific policies related to decontamination and sterilization activities performed in central services and throughout the hospital, including a requirement that steam gas (ETO) and hot air sterilizers be tested with live bacterial spores at least weekly.
(g) Specific policies regarding the indications for universal precautions, body substance isolation, CDC isolation guidelines, or equivalent and the types of isolation to be used for the prevention of the transmission of infectious diseases.
(h) A requirement that soiled linen is collected in such a manner as to minimize microbial dissemination into the environment.
(i) A requirement that all cases of communicable diseases as set forth in Chapter 64D-3, F.A.C., be promptly and properly reported in accordance with the provisions of that rule.
(4) The individuals involved in the infection control program shall meet at least quarterly, shall maintain written minutes of all meetings, and shall make a report at least annually to the assigned professional staff and the governing body.
(5) Each hospital shall establish an employee health policy to minimize the likelihood of transmission of communicable disease by both employees and patients. Such policies shall include work restrictions for an employee whenever it is likely that communicable disease may be transmitted until such time as a medical practitioner certifies that the employee may return to work.
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