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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.

(g) (i) The hospital shall possess and maintain a supply of all necessary items of personal protective equipment (PPE) sufficient to protect health care personnel, consistent with federal Centers for Disease Control guidance, for at least 60 days by August 31, 2020, and at least 90 days by September 30, 2020, at rate of usage equal the average daily rate that PPE was used between April 13, 2020 and April 27, 2020; provided, however, that upon request the Department may grant an extension of the deadline to October 30, 2020, at its sole and exclusive discretion for having at least a 90 day supply of PPE where the hospital demonstrates, to the Commissioner’s satisfaction, that:

(A) the hospital’s inability to meet this deadline is solely attributable to supply chain issues that are beyond the hospital’s control and purchasing PPE at market rates would facilitate price gouging by PPE vendors; or

(B) the seven-day rolling average of new COVID-19 infections in New York State remains below one and a half percent (1.5%) of the total seven-day rolling average of COVID-19 tests performed over the same period; and there are ten or less states in the United States that have a seven-day rolling average of new COVID-19 infections exceeding five thousand cases.

(ii) Failure to possess and maintain such a supply of PPE may result in the revocation or suspension of the hospital’s license; provided, however, that no such revocation or suspension shall be ordered unless the Department has provided the hospital with a fourteen day grace period, solely for a hospital’s first violation of this section, to achieve compliance with the requirement set forth herein.

(h) COVID-19 and Influenza Confirmatory Testing.

(1) Any patient who is known to have been exposed to COVID-19 or influenza or has symptoms consistent with COVID-19 or influenza shall be tested for both such diseases.

(2) Whenever a person expires while in the hospital, or while en route to the hospital, and in the professional judgment of the attending clinician there is a clinical suspicion that COVID-19 or influenza was a cause of death, but no such tests were performed in the 14 days before death, the hospital shall administer both a COVID-19 and influenza test within 48 hours after death, in accordance with guidance published by the Department. Such tests shall be performed using rapid testing methodologies to the extent available. The facility shall report the death to the Department immediately after and only upon receipt of both such test results through the Health Emergency Response Data System (HERDS). Notwithstanding the foregoing, no test shall be administered if the next of kin objects to such testing. Should the hospital lack the ability to perform such testing expeditiously, the hospital should request assistance from the State Department of Health.


VOLUME C (Title 10)