HSC §1288.6: (a) (1) Each general acute care hospital, in collaboration with infection prevention and control professionals, and with the participation of senior health care facility leadership shall, as a compone

(a) (1) Each general acute care hospital, in collaboration with infection prevention and control professionals, and with the participation of senior health care facility leadership shall, as a component of its strategic plan, at least once every three years, prepare a written report that examines the hospital’s existing resources and evaluates the quality and effectiveness of the hospital’s infection surveillance and prevention program. (2) The report shall evaluate and include information on all of the following: (A) The risk and cost of the number of invasive patient procedures performed at the hospital. (B) The number of intensive care beds. (C) The number of emergency department visits to the hospital. (D) The number of outpatient visits by departments. (E) The number of licensed beds. (F) Employee health and occupational health measures implemented at the hospital. (G) Changing demographics of the community being served by the hospital. (H) An estimate of the need and recommendations for additional resources for infection prevention and control programs necessary to address the findings of the plan. (3) The report shall be updated annually, and shall be revised at regular intervals, if necessary, to accommodate technological advances and new information and findings contained in the triennial strategic plan with respect to improving disease surveillance and the prevention of HAI. (b) Each general acute care hospital that uses central venous catheters (CVCs) shall implement policies and procedures to prevent occurrences of health care associated infection, as recommended by the Centers for Disease Control and Prevention intravascular bloodstream infection guidelines or other evidence-based national guidelines, as recommended by the advisory committee. A general acute care hospital that uses CVCs shall internally report CVC associated blood stream infection rates in intensive care units, utilizing device days to calculate the rate for each type of intensive care unit, to the appropriate medical staff committee of the hospital on a regular basis.