La. Admin. Code tit. 48 § I-4577

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-4577 - Infection Control

A. The ASC shall maintain an infection control program that minimizes infections and communicable diseases through prevention, investigation and reporting of infections. This program shall include all contracted services and those services provided under a use agreement.

B. The ASC shall provide a functional and sanitary environment for the provision of surgical or endoscopy services, if provided, by adopting and adhering to professionally accepted standards of practice. The ASC shall have documentation that the infection control program was considered, selected and implemented based on nationally recognized infection control guidelines.

C. The infection control program shall be under the direction of a designated and qualified professional. The ASC shall determine that the individual selected to lead the infection control program has had documented training in the principles and methods of infection control. The individual shall maintain his/her qualifications through ongoing education and training, which can be demonstrated by participation in infection control courses or in local and national meetings organized by a nationally recognized professional infection control society.

D. The ASC shall develop, with the approval of the medical director and the governing body, policies and procedures for preventing, identifying, reporting, investigating, controlling and immediately implementing corrective actions relative to infections and communicable diseases of patients and personnel. At a minimum, the policies shall address:

1. hand sanitizers and hand hygiene;

2. use of all types of gloves;

3. surgical scrub procedures;

4. linen cleaning and reuse;

5. waste management;

6. environmental cleaning;

7. reporting, investigating and monitoring of surgical infections;

8. sterilization and cleaning procedures and processes;

9. single use devices;

10. disinfecting procedures and processes;

11. breaches of infection control practices; and

12. utilization of clean and dirty utility areas.

E. The ASC shall have policies and procedures developed and implemented which require immediate reporting, according to the latest criteria established by the Centers for Disease Control, Office of Public Health and the Occupational Safety and Health Administration (OSHA), of the suspected or confirmed diagnosis of a communicable disease.

F. The ASC shall maintain an infection control log of incidents related to infections. The log is to be maintained within the ASC for a minimum of 18 months.

G. Any employee with a personal potentially contagious/ or infectious illness shall report to his/her immediate supervisor and/or director of nursing for possible reassignment or other appropriate action to prevent the disease or illness from spreading to other patients or personnel.

1. Employees with symptoms of illness that have the potential of being potentially contagious or infectious (i.e. diarrhea, skin lesions, respiratory symptoms, infections, etc.) shall be either evaluated by a physician and/or restricted from working with patients during the infectious stage.

H. Provisions for isolation of patients with a communicable or contagious disease shall be developed and implemented according to ASC policy and procedure.

I. Provisions for transfer of patients from the ASC shall be developed and implemented according to ASC policy and procedure.

J. The ASC shall develop a system by which potential complications/infections that develop after discharge of a patient from the ASC are reported, investigated and monitored by the infection control officer.

K. Procedures for isolation techniques shall be written and implemented when applicable.

L. The ASC shall have a written and implemented waste management program that identifies and controls wastes and hazardous materials to prevent contamination and the spread of infection within the ASC. The program shall comply with all applicable laws and regulations governing wastes and hazardous materials and the safe handling of these materials.

La. Admin. Code tit. 48, § I-4577

Promulgated by the Department of Health, Bureau of Health Services Financing, LR 431752 (9/1/2017).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2131-2141.