6 Colo. Code Regs. § 1011-1 Chapter 04, pt. 5

Current through Register Vol. 47, No. 20, October 25, 2024

Part 5 - HOSPITAL OPERATIONS

5.1 Materials Management Services

(A) All hospitals shall provide materials management services with facilities for receiving, processing, storing, and dispensing supplies and equipment for all departments/services of the hospital.

(B) Materials management services shall be overseen by a person who is competent in materials management, supply processing, and control methods to ensure integrity of the system is maintained throughout receiving, cleaning, processing, storing, and issuing supplies.

(C) Sufficient supporting personnel shall be assigned to the service and be properly trained in materials management services.

(D) Written policies and procedures shall be established for all functions of the materials management services.

(E) At a minimum, the policies and procedures shall address: obtaining, cleaning, processing, storing, and issuing supplies, and the training and supervision of personnel.

5.2 Environmental Services

(A) Each hospital shall establish organized environmental services, to ensure the hospital environment is clean and sanitary.

(B) Environmental services shall be overseen by a person competent in environmental sanitation and management.

(C) Written policies and procedures shall be established and implemented for cleaning the physical plant and equipment.

(D) The policies and procedures shall be designed to prevent and control infection. At a minimum, the policies and procedures shall address:

(1) Cleaning schedules,

(2) Cleaning methods,

(3) The proper use and storage of cleaning supplies,

(4) Hand washing, and

(5) The supervision and training of environmental services personnel.

(E) Dry dusting and sweeping are prohibited.

(F) Suitable equipment and supplies shall be provided for cleaning of all surfaces. Such equipment shall be maintained in a safe, sanitary condition.

(G) Carts used to transport rubbish and refuse shall be constructed of impervious materials, shall be enclosed, and shall only be used for this purpose.

5.3 Facility Services

(A) The grounds, physical plant, equipment, and furnishings shall be hazard free and in good repair.

(B) The hospital shall provide facility maintenance services, which shall be responsible for the upkeep of the hospital's grounds, physical plant, equipment, and furnishings.

(C) The building and mechanical programs shall be overseen by a qualified person informed in the operations of the hospital and in the building structures, their component parts, and facilities.

(D) The hospital shall implement written policies and procedures to keep the entire hospital in good repair and to provide for the safety, welfare, and comfort of the occupants of the building(s).

(E) Physical Plant Maintenance

(1) Inspections and maintenance shall be conducted of physical plant systems including, but not limited to, the electrical system, emergency power generators, water supply, and ventilation.

(2) Inspection and maintenance shall be conducted in accordance with written maintenance schedules.

(3) Records shall be maintained showing the date of inspection and maintenance and action taken to correct any deficiencies.

(F) Equipment Maintenance

(1) Inspections and preventive maintenance shall be conducted of equipment, including equipment used for direct patient care, to ensure that it is in good working order.

(2) Preventive maintenance shall be conducted in accordance with written maintenance schedules.

(3) Preventive maintenance includes, but is not limited to: routine inspections, cleaning, testing, and calibrating in accordance with manufacturers' instructions, or if there are not manufacturers' instructions, as specified by the hospital's written policies and procedures.

(4) A hospital may, under certain conditions, use equipment maintenance activities and frequencies that differ from those recommended by the manufacturer. Hospitals that choose to employ alternate maintenance activities and/or schedules must develop, implement, and maintain a documented alternate equipment maintenance program to minimize risks to patients and others in the hospital associated with the use of hospital or medical equipment.

(G) Records shall be maintained showing the date of maintenance and action taken to correct any deficiencies.

(H) Insect, Pest, and Rodent Control

(1) The hospital shall develop and implement written policies and procedures for the effective control and eradication of insects, pests, and rodents.

(2) Pesticides shall not be stored in patient or food areas and shall be kept under lock.

(3) Only properly trained, responsible personnel shall be allowed to apply insecticides and rodenticides.

5.4 Waste Disposal Services

(A) The hospital shall provide for the safe disposal of all types of waste products.

(B) Infectious waste disposal shall be overseen by a person qualified by education, training, competencies, and/or experience in the principles of infectious waste management.

(C) All personnel shall wash their hands thoroughly after handling waste products.

(D) The hospital shall develop and implement written policies and procedures to ensure the safe disposal of waste products.

(E) The policies and procedures shall address, at a minimum, the following:

(1) The discharge of all sewage into a public sewer system;

(2) Garbage and refuse;

(a) All garbage and refuse, not treated as sewage, shall be collected and stored in covered containers.

(b) All garbage and refuse shall be removed from the hospital premises as frequently as necessary to prevent nuisance or health hazards.

(3) Infectious waste; and

(a) Infectious waste shall be handled and disposed of in accordance with the requirements of Section 25-15-401, et. seq., C.R.S.

(4) Biological non-infectious waste.

(F) In-facility refuse containers shall be kept clean, and single-service liners shall be used when appropriate to the container.

(G) Each hospital shall have a sufficient number of watertight containers with tight fitting lids, to hold all refuse that accumulates between collections.

(H) Containers used for storing or holding refuse waiting for collection must be enclosed.

(I) Accumulated waste material shall be removed from the building at least daily.

(J) All external rubbish and refuse containers shall be impervious and tightly covered.

5.5 Linen and Laundry Services

(A) The hospital shall provide linen and laundry services, directly or by contract, to ensure the proper laundering of washable goods and a sufficient supply of clean linen.

(B) Linen and laundry services shall be overseen by a person qualified by education, training, competencies, and/or experience.

(C) The hospital shall develop and implement policies and procedures for the collection, processing, distribution, and storage of linen.

(D) Clean linen shall be stored and distributed to the point of use in a way that minimizes microbial contamination from surface contact or airborne particles.

(E) Soiled linen shall be collected at the point of use and transported to the soiled linen holding room in a manner that minimizes microbial dissemination.

(F) Laundering shall be conducted in accordance with manufacturers' instructions regarding the washing machine and the cleaning agent used.

(G) Only commercial laundry equipment shall be used to process hospital linen and laundry.

6 CCR 1011-1 Chapter 04, pt. 5