The licensee shall:

(1) Establish and implement an effective hospital-wide infection control program, which includes at a minimum:

(a) Written policies and procedures describing:

(i) Types of surveillance used to monitor rates of nosocomial infections;

(ii) Systems to collect and analyze data; and

(iii) Activities to prevent and control infections;

(b) A review process, using definitions and criteria established by the infection control committee, to determine if staff and patient infections are nosocomial;

(c) A system for reporting communicable diseases consistent with chapter 246-100 WAC, Communicable and certain other diseases;

(d) A procedure for reviewing and approving infection control aspects of policies and procedures used in each area of the hospital;

(e) A procedure to monitor the physical environment of the hospital for situations which may contribute to the spread of infectious diseases;

(f) Provisions for:

(i) Providing consultation regarding patient care practices, equipment and supplies which may influence the risk of infection;

(ii) Providing consultation regarding appropriate procedures and products for cleaning, disinfecting and sterilizing;

(iii) Providing infection control information for orientation and in-service education for staff providing direct patient care;

(iv) Making recommendations, consistent with federal, state, and local laws and rules, for methods of safe and sanitary disposal of:

(A) Sewage;

(B) Solid and liquid wastes; and

(C) Infectious wastes including safe management of sharps;

(g) Identifying specific precautions to prevent transmission of infections; and

(h) Coordinating employee activities to control exposure and transmission of infections to or from employees and others performing patient services;

(2) Assign one or more individuals to manage the infection control program with documented qualifications related to infection surveillance, prevention, and control, including:

(a) Education;

(b) Training;

(c) Certification; or

(d) Supervised experience;

(3) Designate an infection control committee, comprised of the individual or individuals assigned to manage the program and multidisciplinary representatives from the professional staff, nursing staff and administrative staff, to:

(a) Oversee the program;

(b) Develop a committee-approved description of the program, including surveillance, prevention, and control activities;

(c) Delegate authority, approved in writing by administrative and professional staff, to institute surveillance, prevention, and control measures when there is reason to believe any patient or staff may be at risk of infection;

(d) Meet at regularly scheduled intervals, at least quarterly;

(e) Maintain written minutes and reports of findings presented during committee meetings; and

(f) Develop a method for forwarding recommendations to the professional staff, nursing, administration, and other committees and departments as appropriate.