197.150. Procedures for compliance, requirements.
Procedures for compliance, requirements.
197.150. The department shall require that each hospital, ambulatorysurgical center, and other facility have in place procedures for monitoringand enforcing compliance with infection control regulations and standards.Such procedures shall be coordinated with administrative staff, personnelstaff, and the quality improvement program. Such procedures shall include,at a minimum, requirements for the facility's infection control program toconduct surveillance of personnel with a portion of the surveillance to bedone in such manner that employees and medical staff are observed withouttheir knowledge of such observation, provided that this unobservedsurveillance requirement shall not be considered to be grounds forlicensure enforcement action by the department until the departmentestablishes clear and verifiable criteria for determining compliance. Suchsurveillance also may include monitoring of the rate of use of hand hygieneproducts.
(L. 2004 S.B. 1279)