37.106.513 INFECTION PREVENTION, CONTROL, AND SAFETY
(1) The outpatient center must maintain an infection control program that seeks to minimize infections and communicable diseases. The outpatient center is responsible for providing a plan of action for preventing, identifying, and managing infections and communicable diseases, and for immediately implementing corrective and preventive measures that result in improvement.
(a) The infection prevention and control program must include documentation that the outpatient center has considered, selected, and implemented nationally recognized infection control guidelines.
(b) The infection prevention and control program is under the direction of a designated and qualified infection control officer who is a licensed health care professional and has training in infection control.
(2) The outpatient center must have written policies that also address cleaning of patient treatment and care areas to include:
(a) cleaning before use; and
(b) cleaning between patients.
(3) The outpatient center will have policies and processes in place for:
(a) the monitoring and documentation of the cleaning, high level disinfection, and sterilization of medical equipment, accessories, instruments, and implants; and
(b) minimizing the sources and transmission of infections, including adequate surveillance techniques.
(4) The outpatient center must designate a safety officer who is responsible for the facility's safety plan.
(5) The outpatient center must have a safety program which addresses the organization's environment of care and safety for all patients, staff, and others. The elements of the safety program include:
(a) a process for identifying hazards, potential threats, near misses, and other safety concerns;
(b) a process for reporting known adverse incidents to proper authorities;
(c) a process for reducing and avoiding medication errors; and
(d) prevention of falls or physical injuries involving patients, staff, and others.
(6) The outpatient center must have a written emergency and disaster preparedness plan. The plan must address both internal and external emergencies and must also address provision for the safe evacuation of individuals during an emergency, especially for individuals who are at greater risk.
(a) The outpatient center must complete a written evaluation of each drill and promptly implement any corrections identified during the drill. This documentation must be on site at the facility for the period of licensure.
(7) The outpatient center must have a policy concerning the training of outpatient center staff in terms of the emergency and disaster plan.
(8) Products, including medications, reagents, and solutions that carry an expiration date are monitored and disposed of accordingly.
(9) Prior to use, appropriate education is provided to intended operators of newly acquired devices or products to be used in the care of patients.
(10) A system must exist for the proper identification, management, handling, transport, storage, and disposal of biohazardous materials and wastes, whether solid, liquid, or gas.