10A NCAC 13B .5102. POLICY AND PROCEDURES

(a)  Each facility department or service shall establish and maintain written infection control policies and procedures.  These shall include but are not limited to:

(1)           the role and scope of the service or department in the infection control program;

(2)           the role and scope of surveillance activities in the infection control program;

(3)           the methodology used to collect and analyze data, maintain a surveillance program on nosocomial infection, and the control and prevention of infection;

(4)           the specific precautions to be used to prevent the transmission of infection and isolation methods to be utilized;

(5)           the method of sterilization and storage of equipment and supplies, including the reprocessing of disposable items;

(6)           the cleaning of patient care areas and equipment;

(7)           the cleaning of non-patient care areas; and

(8)           exposure control plans.

(b)  The infection control committee shall approve all infection control policies and procedures.  The committee shall review all policies and procedures at least every three years and indicate the last date of review.

(c)  The infection control committee shall meet at least quarterly and maintain minutes of meetings.

 

History Note:        Authority G.S. 131E-79;

Eff. January 1, 1996.