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Florida Administrative Code (Last Updated: November 11, 2024) |
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59. Agency for Health Care Administration |
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59A. Health Facility and Agency Licensing |
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59A-5. Ambulatory Surgical Center Licensure |
1(1) Each center shall establish an Infection Control Program involving members of the medical staff, nursing staff, other professional and administrative staff as appropriate. The program shall provide for:
30(a) The surveillance, prevention, and control of infection among patients and personnel;
42(b) The establishment of a system for identification, reporting, evaluating and maintaining records of infections;
57(c) Ongoing review and evaluation of aseptic, isolation and sanitation techniques employed by the center; and,
73(d) Development and coordination of training programs in infection control for all center personnel.
87(2) Each center shall have written policies and procedures reflecting the scope of the infection control program outlined in subsection (1). The written policies and procedures shall be reviewed at least every two years by the infection control program members, dated at the time of each review, revised as necessary, and enforced.
139(3) The policies and procedures devised by the infection control program shall be approved by the governing board, and shall contain at least the following:
164(a) Specific policies for the shelf life of all stored sterile items.
176(b) Specific policies and procedures related to occupational exposure to blood and body fluids.
190(c) Specific policies related to the handling and disposal of biomedical waste in accordance with Chapter 64E-16, F.A.C. and, OSHA 21029 CFR Part 1910.1030, 214Bloodborne Pathogens.
216(d) Specific policies related to the selection, storage, handling, use and disposition of disposable items.
231(e) Specific policies related to decontamination and sterilization activities performed at the center, including but not limited to a requirement that steam, gas (ETO) and hot air sterilizers be tested with live bacterial spores at least weekly.
268(f) Specific policies regarding the indications for universal precautions, body substance isolation, CDC isolation guidelines, or equivalent and the types of isolation to be used for the prevention of the transmission of infectious diseases.
302(g) A requirement that soiled linen be collected in such a manner as to minimize microbial dissemination into the environment.
322(h) A requirement that all cases of communicable diseases as set forth in Chapter 64D-3, F.A.C., be promptly and properly reported in accordance with the provisions of that rule;
351(4) The individuals involved in the infection control program shall meet at least quarterly, shall maintain written minutes of all meetings, and shall make a report at least annually to the quality assurance committee and the governing board.
389(5) Each center shall establish an employee health policy to minimize the likelihood of transmission of communicable disease by both employees and patients. Such policies shall include, but not be limited to, work restrictions for an employee whenever it is likely that communicable disease may be transmitted, until such time as a medical practitioner certifies that the employee may return to work.
451Rulemaking Authority 453395.1055 FS. 455Law Implemented 457395.1055 FS. 459History–New 6-14-78, Formerly 10D-30.11, Amended 2-3-88, Formerly 10D-30.011, Amended 11-13-95, 2-23-16.
