Ga. Comp. R. & Regs. 111-8-40-.16

Current through Rules and Regulations filed through December 24, 2024

Rule 111-8-40-.16 - Infection Control

The hospital shall have an effective infection control system to reduce the risks of nosocomial infections in patients, health care workers, volunteers, and visitors.

(a) The hospital shall designate qualified infection control staff to coordinate the infection control program.

(b) The administrative and medical staff of the hospital, as well as staff from appropriate organized services, shall participate in the infection control program.

(c) The infection control program shall function from a well-designed surveillance plan that is based on accepted epidemiological principles, is tailored to meet the needs of the hospital, and includes both outcome and process surveillance methodologies.

(d) The surveillance plan shall require collection of sufficient baseline data on the incidence of nosocomial infections in order that outbreaks can be identified.

(e) The infection control methodologies for effective investigation and control of outbreaks, once identified, shall include at least:

1. The availability of microbiology laboratory capacity to detect and investigate outbreaks;

2. A system for obtaining appropriate clinical specimens for culture;

3. Access to necessary information in order to investigate infectious outbreaks; and

4. Administrative, physician, and nursing support to direct hospital changes to achieve immediate control of outbreaks and for implementation of corrective actions.

(f) The program shall specify policies and procedures for infection control that apply to all areas of the hospital, and these shall include at least the following:

1. The approved hospital isolation system;

2. The approved procedures for handling and disposing of hazardous waste products;

3. The standards for approved cleaning, disinfection, and sterilization of all areas of the hospital;

4. The standards for hand washing and hand antisepsis; and

5. A communicable disease health-screening plan for the hospital that includes required communicable disease activities, immunizations, exposure evaluations, tuberculosis surveillance, and work restrictions. There shall be evidence that the plan was developed in consultation with hospital administration, medical staff, and safety staff.

(g) The infection control program shall have an organized and effective on-going education plan for hospital health care workers and volunteers that includes at least:

1. An orientation plan;

2. A plan for on-going training on isolation precautions, aseptic practices, and prevention of blood and body fluid exposure; and

3. Provision of specially designed training programs that result from outcome and process surveillance data.

(h) The hospital shall designate which departments are responsible for the reporting of communicable diseases as required by law.

(i) The infection control program shall be evaluated at least annually to determine the effectiveness of the program at lowering the risks and improving the trends of nosocomial infections in patients, health care workers, and volunteers. Changes in the infection control program shall reflect consideration of the results of the evaluations.

Ga. Comp. R. & Regs. R. 111-8-40-.16

O.C.G.A. § 31-7-2.1.

Original Rule entitled "Infection Control" adopted. F. Feb. 20, 2013; eff. Mar. 12, 2013.