Section 205.550  Infection Control

a)         Each ASTC shall provide a safe and healthful environment that minimizes infection exposure and risk to patients, health care workers and visitors.

b)         Each ASTC shall maintain a written, active and effective facility-wide infection control program.  A system designed for the identification, surveillance, investigation, control, and prevention of infectious and communicable diseases in patients and health care workers shall be included in this program.

c)         The ASTC shall designate a person as a Qualified Infection Control Professional to develop and implement policies governing the control of infectious and communicable diseases.  The means of qualification (i.e., education, training and experience; or certification) shall be documented.

d)         Policies and procedures for the reporting and care of cases of communicable diseases shall comply with the Control of Communicable Diseases Code, the Control of Sexually Transmissible Infections Code, and the Control of Tuberculosis Code.

e)         The ASTC shall consider, select and implement nationally recognized infection control guidelines in developing its infection control program, including the Centers for Disease Control and Prevention publication "Guidelines for Isolation Precautions:  Preventing Transmission of Infectious Agents in Healthcare Settings", "Guidelines for Disinfection and Sterilization in Healthcare Facilities" or "Guide to Infection Prevention in Outpatient Settings:  Minimum Expectations for Safe Care"; or the Association of periOperative Registered Nurses (AORN) publication "Perioperative Standards and Recommended Practices for Inpatient and Ambulatory Centers".

1)         When patients have a communicable disease, or present signs and symptoms suggestive of communicable disease, precautionary measures shall be taken to avoid cross-infection to personnel, other patients and the public.

2)         If an ASTC treats a patient who has a communicable disease, the ASTC shall provide appropriate facilities and equipment for isolation.

3)         Policies and procedures for handling infectious cases shall include orders to the medical, nursing and non-professional staff concerning isolation technique.

4)         The ASTC shall require that all persons who care for patients with or suspected of having a communicable disease, or whose work brings them in contact with materials that are potential conveyors of communicable disease, comply with the ASTC's infection control program to avoid transmission of the disease agent.

f)         The ASTC shall develop and implement comprehensive interventions to prevent and control extensively drug-resistant organisms (XDROs), including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and certain gram-negative bacilli (GNB), that take into consideration guidelines of the Centers for Disease Control and Prevention for the management of XDROs in health care settings, including the "Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings" and "Guidelines for Hand Hygiene in Health-Care Settings".

g)         The ASTC shall comply with 42 CFR 416.43 and 416.51 in developing and maintaining an infection control program. Documentation that the ASTC considered, selected and implemented nationally recognized infection control guidelines in developing its infection control program shall be made available to the Department upon request.

h)         The ASTC shall develop, implement, monitor and enforce a hand hygiene program.

1)         The ASTC shall assess the current practice and compliance, assess current

            hand hygiene products, solicit input from clinical staff, and develop a hand hygiene program for all staff.

2)         All staff (including contractual and medical) shall be educated in the hand hygiene program during initial orientation and at least annually.  This education shall be documented.

3)         The program shall have clear goals that require quantitative, time-specific improvement targets.

4)         The ASTC shall develop and implement ongoing measurement tools to assure compliance with the program.

5)         The results of the monitoring shall be incorporated in the clinical statistical data required in Section 205.620.

i)          Contaminated material shall be handled and disposed of in a manner designed to prevent the transmission of the infectious agent.

j)          Thorough hand hygiene shall be required after touching any contaminated or infected material.

k)         Whenever the Control of Communicable Diseases Code and the Control of Tuberculosis Code require the submission of laboratory specimens for the release of a patient from isolation or quarantine, the specimens shall be submitted to the laboratories of the Illinois Department of Public Health or other laboratory licensed by the Department for the specific tests required.

l)          The ASTC shall establish a systematic plan of checking and recording cases of infection, known or suspected, that develop in the ASTC. The cases shall also be reported to the governing body.  The ASTC shall investigate health care associated infections to determine the causative organism and its possible sources.  The findings and recommendations shall be reported to the medical staff and administration for corrective action.

m)        Policies and procedures related to this Section, and including, but not limited to, the following items, shall be developed:

1)         The isolation of patients with specific and suspected infectious diseases and protective isolation of appropriate patients.

2)         In-service education programs on the control of infectious diseases.

3)         Policies and procedures for isolation techniques appropriate to the diagnosis of the patient, and protective routines for personnel and visitors.

4)         The recording and reporting of all infections of clean surgical cases to the administration and procedures for the investigation of cases.

(Source:  Added at 38 Ill. Reg. 19208, effective September 9, 2014)