Cal. Code Regs. Tit. 22, § 70739 - Infection Control Program
(a) A written hospital infection control
program for the surveillance, prevention and control of infections shall be
adopted and implemented. The program shall include policies and procedures
that:
(1) Define and require methods to handle
all patients, all blood and body fluids and all materials that are soiled with
blood and/or body fluids from all patients. The methods prescribed shall be
designed to reduce the risk of transmission of potentially infectious etiologic
agents from patient to patient and between patient and healthcare worker. The
methods shall include handwashing, the use of gloves, the use of other
barriers, the handling of needles/sharps and the disposal of materials that are
soiled with or contain blood and/or body fluids.
(2) Define practices to reduce the risk of
transmission of airborne infectious etiologic agents including tuberculosis and
addressing the assignment of rooms and/or roommates.
(3) Provide for and document the education of
all personnel.
(A) Each new employee shall
receive training appropriate to his/her job classification and work activities
to acquaint him/her with infection control policies and procedures of the
healthcare facility.
(B) Training
material shall be kept current and conform to new information pertaining to the
prevention and control of infectious diseases. Revised training material shall
be presented to all healthcare workers.
(4) Provide a plan for the surveillance and
control of nosocomial infections including procedures for the investigation and
management of outbreaks.
(5) Define
the equipment, instruments, utensils and disposable materials that are to be
identified as biohazardous.
(b) The oversight of the infection
surveillance, prevention and control program shall be vested in a
multi-disciplinary committee which shall include representatives from the
medical staff, administration, nursing department and infection control
personnel. This committee shall provide advice on all proposed construction and
shall be responsible for the provision of current, updated information on
infection control policy and procedures for the facility.
(c) Hospitals having a licensed bed capacity
of 200 or more shall have a full-time infection control employee who shall
coordinate the activities of the program.
(d) Hospitals having a licensed bed capacity
of 199 or less shall have a designated part-time infection control employee who
shall coordinate activities of the program.
Notes
2. Certificate of Compliance as to 6-15-89 order transmitted to OAL on 10-13-89 and disapproved by OAL on 11-13-89 (Register 89, No. 46).
3. Amendment refiled 11-16-89 as an emergency; operative 11-16-89 (Register 89, No. 46). A Certificate of Compliance must be transmitted to OAL within 120 days or the section will be reinstated as it existed prior to the emergency on 3-16-90.
4. Certificate of Compliance as to 11-16-89 order including amendment of subsections (a)-(d) transmitted to OAL 3-15-90 and filed 4-16-90 (Register 90, No. 17).
Note: Authority cited: Sections 208(a) and 1275, Health and Safety Code. Reference: Section 1276, Health and Safety Code.
2. Certificate of Compliance as to 6-15-89 order transmitted to OAL on 10-13-89 and disapproved by OAL on 11-13-89 (Register 89, No. 46).
3. Amendment refiled 11-16-89 as an emergency; operative 11-16-89 (Register 89, No. 46). A Certificate of Compliance must be transmitted to OAL within 120 days or the section will be reinstated as it existed prior to the emergency on 3-16-90.
4. Certificate of Compliance as to 11-16-89 order including amendment of subsections (a)-(d) transmitted to OAL 3-15-90 and filed 4-16-90 (Register 90, No. 17).
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