N.M. Code R. § 7.7.2.22

Current through Register Vol. 35, No. 11, June 11, 2024

Section 7.7.2.22 - INFECTION CONTROL

A. Program. The hospital shall have an infection control program designed to reduce the number of infections, including nosocomial infections, within the hospital.

B. Program Approval.

(1) Purpose: The governing body or medical staff shall approve an infection control program to carry out surveillance and investigation of infections in the hospital and to implement measures designed to reduce these infections to the extent possible.

(2) Responsibilities: The infection control program shall:

(a) establish techniques and systems for discovering and isolating infections occurring in the hospital;

(b) establish written infection control policies and procedures, which govern the use of aseptic technique and procedures in all areas of the hospital;

(c) establish a method of control used in relation to the sterilization of supplies and solutions; there shall be a written policy requiring identification of sterile items and specified time periods in which sterile items shall be reprocessed;

(d) establish policies specifying when employees or persons providing contractual services with infections or contagious conditions, including carriers of infectious organisms, shall be relieved from, or reassigned duties, until there is evidence that the disease or condition poses no significant risk to others;

(e) at least annually assess effectiveness of the infection control process; and

(f) establish effective guidelines for the disposition of infectious materials in accordance with the local, state and federal guidelines.

C. Education: The hospital shall provide training to all appropriate hospital personnel on the epidemiology, etiology, transmission, prevention and elimination of infection, as follows:

(1) aseptic technique: all appropriate personnel shall be educated in the practice of aseptic techniques such as hand-washing and scrubbing practices, standard precautions, personal hygiene, masking and dressing techniques, disinfecting and sterilizing techniques and the handling and storage of patient care equipment and supplies, to include the handling of needles and sharp instruments; and

(2) orientation and in-service: new employees shall receive appropriate orientation and on-the- job training, and all employees shall participate in a continuing in-service program; the participation shall be documented.

D. General Infection Control Provisions.

(1) There shall be regular inspection and cleaning of air intake sources, screens and filters, with special attention given to high risk areas of the hospital as determined by the infection control committee.

(2) A sanitary environment shall be maintained to avoid sources and transmission of infection.

(3) Proper facilities shall be maintained, and techniques used, for disposal of infectious wastes, as well as sanitary disposal of all other wastes.

(4) Hand-washing facilities shall be provided in patient care areas for the use of hospital personnel.

(5) Sterilizing services shall be available at all times.

(6) Soiled linen shall be contained and secured at the point generated. It can be transported to a designated area or cleaning facilities. No special precautions beyond the standard precautions are necessary. Soiled bed linen shall be placed immediately in a container available for this purpose and sent to the laundry promptly.

(7) Tuberculosis exposure control plan.

(a) A program to minimize the risk of infectious tuberculosis among or between health care workers, patients, or visitors and others shall be developed.

(b) This program shall include: a comprehensive facility-wide risk assessment, early identification, isolation, and treatment of potentially infectious tuberculosis patients, effective engineering controls to prevent the spread, and reduce the concentration of, infectious droplet nuclei, a written, respiratory protection program to protect health care workers from exposure, education, counseling, and screening processes for health care workers.

E. Reporting Disease: Hospitals shall report cases and suspected cases of notifiable conditions as listed in 7.4.3.13 NMAC to the New Mexico department of health pursuant to New Mexico regulations governing the control of disease and conditions of public health significance, New Mexico department of health, 7.4.3 NMAC or any superceding regulation.

F. Policies and Procedures. There shall be written policies and procedures pertinent to care of patients with communicable diseases that shall include standard precautions.

(1) These policies and procedures shall be developed by administrative, medical, and nursing staff.

(2) The policies and procedures shall be applicable within the hospital, designed to ensure safe and adequate care to patients, safety to hospital employees, and consistent with applicable laws and regulations.

(3) Policies shall be made known to, and readily available to all hospital employees as well as the medical and nursing staff, and shall be followed in the care of patients, and shall be kept current by periodic review and revision.

N.M. Code R. § 7.7.2.22

7.7.2.22 NMAC - Rp, 7.7.2.22 NMAC, 06-15-04; A, 03-15-06