Infection control plan - 40 Pa. Stat. Ann. § 1303.403

All health care facilities and ambulatory surgical facilities must develop and implement an internal infection control plan for the purpose of improving the health and safety of patients and health care workers.  The plan must include: 

• Effective measures for the detection, control and prevention of health care-associated infections;
• Culture surveillance processes and policies;
• A system to identify and designate patients known to be colonized or infected with a multidrug-resistant organism (MDRO) that includes the procedures necessary for identifying high-risk patients admitted to the hospital who necessitate routine cultures and screening;
• The procedures and protocols for staff who may have had potential exposure to a patient or resident known to be colonized or infected with an MDRO, including cultures and screenings, prophylaxis and follow-up care;
• An outreach process for notifying a receiving health care facility or an ambulatory surgical facility of any patient known to be colonized prior to transfer within or between facilities; and
• A required infection-control intervention protocol which includes:
  • Infection control precautions based on nationally recognized standards, for general surveillance of infected or colonized patients;
  • Intervention protocols based on evidence-based standards;
  • Isolation procedures;
  • Physical plant operations related to infection control;
  • Appropriate use of antimicrobial agents;
  • Mandatory educational programs for personnel; and
  • Fiscal and human resource requirements.