Section 1303.403 - Infection control plan(a) Development and compliance.--Within 120 days of the effective date of this section, a health care facility and an ambulatory surgical facility shall develop and implement an internal infection control plan that shall be established for the purpose of improving the health and safety of patients and health care workers and shall include: (1) A multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility:(i) Medical staff that could include the chief medical officer or the nursing home medical director.(ii) Administration representatives that could include the chief executive officer, the chief financial officer or the nursing home administrator.(iii) Laboratory personnel.(iv) Nursing staff that could include a director of nursing or a nursing supervisor.(v) Pharmacy staff that could include the chief of pharmacy.(vi) Physical plant personnel.(vii) A patient safety officer.(viii) Members from the infection control team, which could include an epidemiologist.(ix) The community, except that these representatives may not be an agent, employee or contractor of the health care facility or ambulatory surgical facility.(2) Effective measures for the detection, control and prevention of health care-associated infections.(3) Culture surveillance processes and policies.(4) A system to identify and designate patients known to be colonized or infected with MRSA or other MDRO that includes:(i) The procedures necessary for requiring cultures and screenings for nursing home residents admitted to a hospital.(ii) The procedures for identifying other high-risk patients admitted to the hospital who necessitate routine cultures and screening.(5) The procedures and protocols for staff who may have had potential exposure to a patient or resident known to be colonized or infected with MRSA or MDRO, including cultures and screenings, prophylaxis and follow-up care.(6) 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.(7) A required infection-control intervention protocol which includes:(i) Infection control precautions, based on nationally recognized standards, for general surveillance of infected or colonized patients.(ii) Intervention protocols based on evidence-based standards.(iii) Isolation procedures.(iv) Physical plant operations related to infection control.(v) Appropriate use of antimicrobial agents.(vi) Mandatory educational programs for personnel.(vii) Fiscal and human resource requirements.(8) The procedure for distribution of advisories issued under section 405(b)(4) so as to ensure easy access in each health care facility for all administrative staff, medical personnel and health care workers.(b) Department review.--No later than 14 days after implementation of its infection control plan, a health care facility and an ambulatory surgical facility shall submit the plan to the department. The department shall review each health care facility's and ambulatory surgical facility's infection control plan to ensure compliance under the Health Care Facilities Act and section 408(3) . If, at any time, the department finds that an infection control plan does not meet the requirements of this chapter or any applicable laws, the health care facility or ambulatory surgical facility shall modify its plan to come into compliance.(c) Notification.--Upon submission to the department of its infection control plan, a health care facility and an ambulatory surgical facility shall notify all health care workers, physical plant personnel and medical staff of the facility of the infection control plan. Compliance with the infection control plan shall be enforced by the facility. 2002 , March 20, P.L. 154, No. 13, § 403, added 2007, July 20, P.L. 331, No. 52, §1, effective in 30 days [ 8/20/2007].