Download 10 NYCRR 405.11 NEW YORK CODES, RULES AND

10 NYCRR 405.11
NEW YORK CODES, RULES AND REGULATIONS
TITLE 10. DEPARTMENT OF HEALTH
CHAPTER V. MEDICAL FACILITIES
SUBCHAPTER A. MEDICAL FACILITIES--MINIMUM STANDARDS
ARTICLE 2. HOSPITALS
PART 405. HOSPITALS--MINIMUM STANDARDS
10 NYCRR § 405.11 (2012)
§ 405.11 Infection control
The hospital shall provide a sanitary environment to avoid sources and transmission of nosocomial infections and
of communicable diseases which may lead to morbidity or mortality in patients and hospital personnel. The
hospital shall establish an effective infection control program for the prevention, control, investigation and
reporting of all communicable disease and increased incidence of infections, including nosocomial infections,
consistent with current acceptable standards of professional practice. The hospital-wide infection control program
shall be reviewed as frequently as necessary but not less than once per year, and updated as necessary to promote
optimal effectiveness.
(a) Organization. The hospital shall designate an infection control professional who is responsible for the
development and implementation of a hospital-wide infection control program. This individual shall be qualified by
training in infection surveillance, prevention and control and also have knowledge or job experience in
epidemiological principals, infectious diseases and infection control practices.
(b) Nosocomial surveillance, prevention and control. The hospital-wide infection control program shall include
processes designed to reduce the risk of endemic and epidemic nosocomial infections and communicable diseases
in patients and hospital personnel. Such processes shall include methods to:
(i) collect and analyze surveillance data including case findings and identification of epidemiologically important
nosocomial infections and communicable disease;
(ii) prevent or reduce the risk of nosocomial infections; and
(iii) control the spread of infection and communicable diseases and epidemiologically important organisms.
(c) Reporting of infections and communicable diseases. There shall be written policies and procedures for
identifying, reporting and investigating infections, and communicable disease of patients and hospital personnel
both community acquired and nosocomial. The professional responsible for the hospital-wide infection control
program shall report to the Department of Health, in a manner specified by the Commissioner of Health, any
increased incidence of nosocomial infections, as designated in section 2.2 of this Title and defined by the
Department, or nosocomially acquired communicable disease designated in section 2.1 of this Title. This individual
shall also report, immediately, the presence of any communicable disease as defined in Section 2.1 of this Title, to
the city, county, or district health officer.
(d) Integration with the quality assurance program. The professional responsible for the hospital-wide infection
control program shall ensure that all hospital infection control activities are integrated with the quality assurance
program required by Section 405.6 of this Part, including identification, assessment and correction of problems
related to infection and communicable disease control.
(e) Infection control education. The hospital shall require compliance with written requirements for orientation
and ongoing education programs that are relevant to the hospital's infection control program for all personnel
whose activities are such that they are at risk of directly or indirectly contributing to the transmission of infection
or communicable disease from or to patients, other health care personnel or themselves.
(f) Corrective action plans. The hospital shall be responsible for the implementation of acceptable corrective action
plans related to infection control and resulting from problems identified through quality assurance or regulatory
oversight activities and the professional responsible for the hospital-wide infection control program shall report to
the chief executive officer progress in correcting identified problems.