The document outlines an infection control program with the purpose of establishing policies and procedures to minimize exposure to healthcare associated infections. The director of clinical operations is responsible for the program with assistance from an infection control consultant. Goals include educating staff and patients about infection prevention and monitoring for infections to implement control measures. Strategies include identifying infectious exposures, treating patients with antibiotics as ordered, and not treating patients with contagious infections. Surveillance includes notifying the center of post-procedure infections and reporting communicable diseases. Prevention methods incorporate hand washing guidelines, pre-procedure screening, antibiotic delivery, and staff/patient education. The program is evaluated annually and data is reported at meetings.

1. INFECTION CONTROL PROGRAM

2. PURPOSE To establish a program for the development, identification, implementation and review of all Infection Control Policies and Procedures. The Stone Center will maintain and enforce the Infection Control Program to minimize the exposure of patients, staff, physicians and visitors to health care associated infections; and to ensure patient safety as well as a safe environment for patients, staff, physicians and visitors.

3. RESPONSIBILITY The Director of Clinical Operations is responsible for the Infection Control Program The Infection Control Consultant will assist with the development and implementation of infection control policies and procedures The Medical Director and staff will participate in Infection Control activities. Infection Control Committee Meetings will be held quarterly. All infection control activities are reported at regularly scheduled Quality Assurance Meetings, Board Meetings, and Staff Meetings.

4. GOALS Education of our staff and patients about the prevention and identification of infectious diseases Prevention of exposure to infectious diseases and health care associated infections to staff, patients, physicians and visitors Monitor for occurrence of infections and implement appropriate control measures Identify and correct problems related to the Infection Control Program

5. STRATEGIES Identify any potentially infectious exposure or infectious patient On the day of treatment antibiotic therapy will be delivered to patients as ordered Patients suspected of or diagnosed with contagious infections at the time of the pre-procedure call will not be treated at The Center Any patient with a drug resistant bacterial infection (MRSA, VRE ) will need 3 negative cultures before scheduled procedure can be performed

6. STRATEGIES Any patient identified to have an infection will be evaluated and the patient will be referred to the appropriate physician/facility for follow-up. Patients found to have any infectious diseases upon admission to The Stone Center will be isolated. The Infection Control Consultant will be notified to assist with patient transfer and follow-up for employees. The NJDOHSS will be notified if indicated .

7. SURVEILLANCE MD’s will notify the Center of any identified infection in a patient after discharge post procedure. MD’s must complete a Post Procedure Patient Infection Surveillance Form on his/her patient MD’s must report any communicable/infectious disease that he/she may have to the Director of Clinical Operations Communicable/Public Health concerns will be reported to the NJDOHSS. Post Procedure Phone Calls Proper Hand Washing Technique

8. PREVENTION Reduce risk of health care associated infection by providing guidelines on hand washing and standard precautions Review the Infection Control survey results with the staff Screening of patients pre-procedure Delivery of antibiotics to patient as ordered Contagions/communicable diseases are not treated Staff and patient education

9. EVALUATION Any areas that are identified as potential risks for infection or potential risks for infection, will be evaluated and revised as warranted by the QA Committee annually. All aspects of the program will be considered in the evaluation process. Data from the Infection Control Survey, QA Audit Form, Occurrence Screen and Post Procedure Infection Surveillance Form are compiled and reported at Staff Meetings, and to the QA Committee and the Board at regularly scheduled meetings. The Director of Clinical Operations will follow-up on any recommendations