197.154. Regulation review and update required, standards.

Regulation review and update required, standards.

197.154. No later than July 1, 2005, the department shall review andupdate its current regulations governing hospital and ambulatory surgicalcenter infection control programs. Such standards shall be based uponnationally recognized standards and shall include, but not be limited to,standards for:

(1) Maintaining databases to be used for infection tracking;

(2) Developing hospital protocols related to aseptic technique andinfection control practices including but not limited to hand washing,isolation, and other infection control policies;

(3) Developing appropriate corrective action plans and follow-ups forany deficiencies identified in hospital infection control practices;

(4) Conducting root cause analysis and follow-up of sentinel events,as defined by the Joint Commission on Accreditation of HealthOrganizations, attributable to nosocomial infections; and

(5) Ensuring that hospital and ambulatory surgical center policiesand medical staff bylaws are in place to promote and enforce compliancewith infection control policies.

(L. 2004 S.B. 1279)