16 Del. Admin. Code § 3340-8.0

Current through Register Vol. 28, No. 5, November 1, 2024

Section 3340-8.0 - Infection Prevention and Control

8.1 The FSED shall establish and implement an infection prevention and control program which shall be based upon nationally recognized infection prevention/control guidelines/standards (i.e. the Centers for Disease Control and Prevention).

8.2 The FSED must designate in writing, a qualified licensed healthcare professional who will lead the facility's infection prevention and control program. The FSED must determine that the individual has had training in the principles and methods of infection prevention and control.

8.2.1 The individual designated to lead the FSED's infection prevention and control program must develop and implement a comprehensive plan that includes actions to prevent, identify and manage infections and communicable diseases. The plan of action must include mechanisms that result in immediate action to take preventive or corrective measures that improve the FSED's infection control outcomes.

8.3 The FSED must maintain an ongoing program to prevent, control and investigate infections and communicable diseases. As part of this program, the FSED must have an active surveillance program that covers both patients and personnel working in the FSED.

8.3.1 The infection prevention and control program shall include policies and procedures including, but not limited to the following:

8.3.1.1 A system for investigating, reporting and evaluating the occurrence of all infections or diseases which are reportable or conditions which may be related to activities and procedures of the facility and maintaining records for all patients or personnel having these infections, diseases or conditions;

8.3.1.2 Care of patients with communicable diseases;

8.3.1.3 Exclusion from work and authorization to return to work for personnel with communicable diseases;

8.3.1.4 Surveillance techniques to minimize sources and transmission of infection;

8.3.1.5 The collection, storage, handling and disposition of all pathological and infectious wastes within the facility and to be removed from the facility;

8.3.1.6 Sterilization, disinfecting and cleaning practices and techniques used in the facility, including but not limited to:

8.3.1.6.1 Care of utensils, instruments, solutions, dressings, articles and surfaces;

8.3.1.6.2 Selection, storage, use and disposition of disposable and non-disposable patient care items. Disposable items shall not be reused;

8.3.1.6.3 Methods to ensure that sterilized materials are packaged and labeled to maintain sterility and to permit identification of expiration dates;

8.3.1.6.4 Procedures for care of equipment and other devices that provide a portal of entry for pathogenic microorganisms;

8.3.1.6.5 Techniques to be used during each patient contact, including handwashing before and after each patient contact; and

8.3.1.6.6 Criteria and procedures for isolation of patients.

8.3.2 The infection prevention and control program should be specific to each particular area of the FSED.

8.4 The FSED must provide and maintain a functional and sanitary environment to avoid sources and transmission of infections and communicable diseases.

8.5 The FSED's infection prevention and control program must be integrated into its QAPI program. Infection control data and program activities are an ongoing component of the quality improvement program and actions are taken in response to the data analyses to improve the FSED's infection control performance.

8.6 Reportable diseases shall be reported to the Division of Public Health.

8.7 All FSED personnel shall receive orientation at the time of employment and annual in-service education regarding the infection prevention and control program.

8.8 Specific Requirements for COVID-19

8.8.1 Before their start date, all new staff, vendors and volunteers must be tested for COVID-19 in accordance with Division of Public Health guidance.

8.8.2 All staff, vendors and volunteers must be tested for COVID-19 in a manner consistent with Division of Public Health guidance.

8.8.3 The FSED must follow recommendations of the Centers for Disease Control and Prevention and the Division of Public Health regarding the provision of care or services to patients by staff, vendor or volunteer found to be positive for COVID-19 in an infectious stage.

8.9 The FSED shall amend their policies and procedures to include:

8.9.1 Work exclusion and return to work protocols for staff tested positive for COVID-19;

8.9.2 Staff refusals to participate in COVID-19 testing;

8.9.3 Staff refusals to authorize release of testing results or vaccination status to the FSED;

8.9.4 Procedures to obtain staff authorizations for release of laboratory test results to the FSED to inform infection control and prevention strategies; and

8.9.5 Plans to address staffing shortages and FSED demands should a COVID-19 outbreak occur.

16 Del. Admin. Code § 3340-8.0

25 DE Reg. 771( 2/1/2022) (final)