Ambulatory Surgical Facility Infection Control Plan Guidelines

Under Act 52 of 2007, ambulatory surgical facilities are required to develop and implement an internal infection control plan. This infection control plan must include the following:  

  1. A multidisciplinary committee (see below)
  2. Measures to detect, control, and prevent health care related infections
  3. Surveillance processes and policies
  4. A system to identify and designate patients known to be infected with methicillin resistant staphylococcus aureus (MRSA) or another multi-drug resistant organism (MDRO)
  5. Procedures and protocols for staff who may have had potential exposure to a patient known to be infected with MRSA or MDRO, including cultures, screenings, prophylaxis and follow-up care
  6. An outreach process for notifying a receiving health care facility or an ASF of any patient known to be colonized prior to transfer within or between facilities
  7. An infection-control intervention protocol 

The required infection protocol must be based on nationally recognized standards for surveillance of infected patients, have intervention protocols based on evidence-based standards and isolation procedures, describe physical plant operations related to infection control, appropriate use of antimicrobial agents, mandatory education programs for employees, and any fiscal and human resource requirements. 

There also must be a procedure to ensure the distribution of any Patient Safety Authority advisories issued so that the information is available to all administrative staff and health care providers within the facility. 

As part of the infection control plan, a multidisciplinary committee needs to be assembled and should include the following individuals: 

  1. Medical staff, which could include the chief medical officer
  2. Chief executive officer or chief financial officer
  3. Laboratory personnel
  4. Nursing staff, which could include the director of nursing or a nursing supervisor
  5. Pharmacy staff, which could include the chief of pharmacy
  6. Physical plant personnel
  7. A patient safety officer
  8. A member from the infection control team,which could include an epidemiologist
  9. A member of the community, as long as they are not an agent, employee, or contractor of the ASF 

Once completed, and no later than 14 days after implementation, the facility’s infection control plan needs to be submitted to the Department of Health at the following address for review and to ensure compliance under the Health Care Facilities Act.   

Pennsylvania Department of Health
Healthcare Associated Infection Prevention Section
Room 932, Health and Welfare Building
7th and Forster Streets
Harrisburg, PA  17120
Attn:  William Cramer 

If the department determines that the infection control plan does not meet the requirements of the law, the facility will be required to modify its plan to come into compliance. At the latest, the facility’s infection control plan must be submitted to the department on or before Dec. 31, 2007.   

The department will review each facility’s infection control plan to ensure compliance with the Health Care Facilities Act and with the requirements of Act 52. If, at any time, the department finds that an infection control plan does not meet the applicable requirements, the facility shall modify its plan to come into compliance. 

After submission to the department, the facility must notify all health care workers, physical plant personnel, and medical staff of the infection control plan. Compliance with the facility’s infection control plan is to be enforced by the facility.

Last Updated: 8/12/2008
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