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Title: Section 793.6 - Infection Control

Effective Date


793.6 Infection Control. The hospice must: 

(a) implement and enforce an agency wide program for the surveillance, identification, prevention, control and investigation of infectious and communicable diseases, which could result in staff, volunteers, visitors, or patients and family members becoming exposed to such communicable diseases or infections. Such a program shall include: 

(1) policies and procedures for maintaining and documenting an effective infection control program in all settings where patients reside, including but not limited to protocols for addressing patient care issues and prevention of infection related to airborne pathogens, infusion therapy, urinary tract care, respiratory tract care, wound care and multi-drug resistant organisms;  

(2) following accepted standards of practice to prevent transmission of infections and communicable disease;  

(3) monitoring staff for compliance with hospice policies and procedures related to infection control;  

(4) protocols for educating staff, contracted personnel, patients, families and other caregivers in infectious disease transmission, standard precautions and the prevention and control of infection; and 

(5) a specific program for protecting patients, staff and families from bi-directional spread of HIV and other blood borne pathogens, as specified in subdivision (b) of this section. 

(b) assure that a program be implemented and enforced for the prevention of circumstances which could result in staff, including housekeeping, direct care staff and volunteers, or patients and family members becoming exposed to significant risk body substances which could put them at significant risk of HIV infection, as defined in section 63.1 of this Title, or other blood borne pathogen infection, during the provision of services. Such a program shall include: 

(1) use of scientifically accepted protective barriers during job-related activities which involve, or may involve, exposure to significant risk body substances. Such preventative action shall be taken by the staff with each patient and shall constitute an essential element for the prevention of bi-directional spread of HIV or other blood borne pathogens.  

(2) use of scientifically accepted preventive practices during job-related activities which involve the use of contaminated instruments or equipment which may cause puncture injuries; 

(3) training at the time of employment and yearly staff development programs on the use of protective equipment, preventive practices, and circumstances which represent a significant risk for all employees whose job-related tasks involve, or may involve, exposure to significant risk body substances; 

(4) provision of personal protective equipment for staff which is appropriate to the tasks being performed; and 

(5) a system for monitoring preventive programs to assure compliance and safety. 

(c) implement and enforce a policy/procedure for the management of individuals who are exposed to significant risk body substances under circumstances which constitute significant risk of transmitting or contracting HIV or other blood borne pathogen infection. The policy/procedure shall include: 

(1) a system for reporting to a designated individual in the hospice any exposure thought to represent a circumstance which constitutes significant risk of transmitting or contracting HIV or other blood-borne pathogen infection; 

(2) evaluation of the circumstances of a reported exposure and services providing follow-up of the exposed individual which includes: 

(i) medical and epidemiological assessment of the individual who is the source of the exposure, where that individual is known and available; 

(ii) if indicated epidemiologically, HIV or other blood-borne pathogen counseling and voluntary testing of the source individual. Disclosure of the HIV status of the source individual can be made, consistent with Article 27-F of Public Health Law and Part 63 of this Title, with the express written consent of the protected individual, or a person authorized pursuant to law to consent to health care for the protected individual if such person lacks capacity to consent, or pursuant to court order, if the HIV status is not known to the exposed individual;  

(iii) appropriate medical follow-up of the exposed individual; and 

(iv) assurances for protection of confidentiality for those involved in reported exposures. 


VOLUME E (Title 10)