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Title: Section 405.11 - Infection control

Effective Date


405.11 Infection control. The hospital shall provide a sanitary environment to avoid sources and transmission of nosocomial infections and of communicable diseases which may lead to morbidity or mortality in patients and hospital personnel. The hospital shall establish an effective infection control program for the prevention, control, investigation and reporting of all communicable disease and increased incidence of infections, including nosocomial infections, consistent with current acceptable standards of professional practice. The hospital-wide infection control program shall be reviewed as frequently as necessary but not less than once per year, and updated as necessary to promote optimal effectiveness.

(a) Organization. The hospital shall designate an infection control professional who is responsible for the development and implementation of a hospital-wide infection control program. This individual shall be qualified by training in infection surveillance, prevention and control and also have knowledge or job experience in epidemiological principles, infectious diseases and infection control procedures.

(b) Nosocomial surveillance, prevention and control. The hospital-wide infection control program shall include processes designed to reduce the risk of endemic and epidemic nosocomial infections and communicable diseases in patients and hospital personnel. Such processes shall include methods to:

(i) collect and analyze surveillance data including case findings and identification of epidemiologically important nosocomial infections and communicable disease;

(ii) prevent or reduce the risk of nosocomial infections; and

(iii) control the spread of infection and communicable diseases and epidemiologically important organisms.

(c) Reporting of infections and communicable diseases. There shall be written policies and procedures for identifying, reporting and investigating infections, and communicable disease of patients and hospital personnel, both community acquired and nosocomial. The professional responsible for the hospital-wide infection control program shall report to the Department of Health, in a manner specified by the Commissioner of Health, any increased incidence of nosocomial infections, as designated in section 2.2 of this Title and defined by the department, or nosocomially acquired communicable disease designated in section 2.1 of this Title. This individual shall also report, immediately, the presence of any communicable disease as defined in section 2.1 of this Title, to the city, county, or district health officer.

(d) Integration with the quality assurance program. The professional responsible for the hospital-wide infection control program shall ensure that all hospital infection control activities are integrated with the quality assurance program required by section 405.6 of this Part, including identification, assessment and correction of problems related to infection and communicable disease control.

(e) Infection control education. The hospital shall require compliance with written requirements for orientation and ongoing education programs that are relevant to the hospital's infection control program for all personnel whose activities are such that they are at risk of directly or indirectly contributing to the transmission of infection or communicable disease from or to patients, other health care personnel or themselves.

(f) Corrective action plans. The hospital shall be responsible for the implementation of acceptable corrective action plans related to infection control and resulting from problems identified through quality assurance or regulatory oversight activities and the professional responsible for the hospital-wide infection control program shall report to the chief executive officer progress in correcting identified problems.


VOLUME C (Title 10)