HSC §1288.9: By January 1, 2009, the department shall do all of the following: (a) Require each general acute care hospital to develop, implement, and periodically evaluate compliance with policies and procedures

By January 1, 2009, the department shall do all of the following: (a) Require each general acute care hospital to develop, implement, and periodically evaluate compliance with policies and procedures to prevent secondary surgical site infections (SSI). The results of this evaluation shall be monitored by the infection prevention committee and reported to the surgical committee of the hospital. (b) Require each general acute care hospital to develop policies and procedures to implement the current Centers for Disease Control and Prevention guidelines and Institute for Healthcare Improvement (IHI) process measures designed to prevent ventilator associated pneumonia. (c) During surveys, evaluate the facility’s compliance with existing policies and procedures to prevent HAI, including any externally or internally reported HAI process and outcome measures.