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CODE OF MARYLAND REGULATIONS
TITLE 10. DEPARTMENT OF HEALTH AND MENTAL HYGIENE
SUBTITLE 07. HOSPITALS
CHAPTER 02. COMPREHENSIVE CARE FACILITIES AND EXTENDED CARE FACILITIES
Date:
08/31/2009
Document:
.21 Infection Control Program.
A. Infection Control Program. The facility shall establish, maintain, and implement an effective infection control program that:
(1) Investigates, controls, and prevents infections in a timely manner through a system that enables the facility to:
(a) Analyze patterns of infected individuals;
(b) Analyze changes in prevalent organisms;
(c) Analyze increases in the rate of infection; and
(d) Obtain surveillance data for the prevention and control of additional cases;
(2) Determines the procedures, such as appropriate precautions, that are to be applied to an individual resident;
(3) Maintains a record of infections in the facility, and the corrective actions that were taken related to infections; and
(4) Monitors and evaluates the:
(a) Effectiveness of the infection control program by surveying rates of infection, especially of those residents who have an especially high risk of infection; and
(b) Effective implementation of the policies and procedures that are outlined in § F(1) of this regulation.
B. The facility shall assign at least one individual with education and training in infection surveillance, prevention, and control to be responsible for approving actions to prevent and control infections.
C. Effective January 1, 2005, the facility's infection control coordinator shall attend a basic infection control training course that is approved by the Office of Health Care Quality and the Office of Epidemiology and Disease Control Program for the Department.
D. The facility shall have mechanisms for communicating the results of infection control activities to employees, and the individual or individuals who are responsible for improving the facility's performance.
E. The facility's communication mechanism shall ensure that the administrator, director of nursing, and the medical director receive and address reports of infection control findings and recommendations in a timely manner.
F. Infection Control Policies and Procedures.
(1) The infection control program shall establish written policies and procedures to investigate, control, and prevent infections in the facility including policies and procedures to:
(a) Identify facility-associated infections and communicable diseases in accordance with COMAR 10.06.01;
(b) Report occurrences of certain communicable diseases and outbreaks of communicable diseases to the local health department in accordance with COMAR 10.06.01 and Health-General Article, § 18-202, Annotated Code of Maryland;
(c) Institute appropriate infection control steps when an infection is suspected or identified in order to control infection and prevent spread to other residents;
(d) Perform surveillance of residents and employees at appropriate intervals to monitor and investigate causes of infection, facility-associated and community acquired, and the manner in which it was spread;
(e) Train employees about infection control and hygiene including:
(i) Hand hygiene;
(ii) Respiratory protection;
(iii) Soiled laundry and linen processing;
(iv) Needles, sharps, or both;
(v) Special medical waste handling and disposal; and
(vi) Appropriate use of antiseptics and disinfectants.
(f) Train and monitor employee application of infection control and aseptic techniques; and
(g) Review the infection control program at least annually and revise as necessary.
(2) The facility shall provide information concerning the communicable disease status of any resident being transferred or discharged to any other facility, including a funeral home.
(3) The facility shall obtain information concerning the communicable disease status of any resident being transferred or discharged to the facility.
G. Preventing Spread of Infection.
(1) The facility shall assess any residents with signs and symptoms of an infectious illness for the possibility of transmission to another resident or employee.
(2) The facility shall take appropriate infection control steps to prevent the transmission of a communicable disease to residents, employees, and visitors as outlined in the following guidelines:
(a) Guideline for Isolation Precautions in Hospitals; and
(b) Guideline for Infection Control in Health Care Personnel.
(3) The facility shall prohibit employees with a communicable disease or with infected skin lesions from direct contact with residents or their food if direct contact could transmit the disease.
(4) The facility shall require employees to perform hand hygiene after each direct resident contact for which hand hygiene is indicated by accepted professional practice.
(5) The facility shall handle, store, process, and transport linens so as to prevent the spread of infection.
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