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Pennsylvania Code




567.1.    Principle.
567.2.    Committee responsibilities.
567.3.    Policies and procedures.


567.11.    Operating suite equipment.


567.21.    Principle.
567.22.    Linen service policy.
567.23.    Clean linen.
567.24.    Soiled linen.


567.31.    Principle.
567.32.    Policies and procedures.
567.33.    Waste disposal.


567.41.    Principle.
567.42.    Policies and procedures.
567.43.    Ventilation system.


567.51.    Water supply.
567.52.    Lighting.
567.53.    Sterilization control.


   The provisions of this Chapter 567 issued under Chapter 8 of the Health Care Facilities Act (35 P. S. § §  448.801a—448.820), specifically sections 448.801a and 448.803; and section 2101(a) and (g) of The Administrative Code of 1929 (71 P. S. §  532(a) and (g)), unless otherwise noted.


   The provisions of this Chapter 567 adopted January 23, 1987, effective March 25, 1987, 17 Pa.B. 376, unless otherwise noted.


§ 567.1. Principle.

 The ASF shall have a sanitary environment, properly constructed, equipped and maintained to protect surgical patients and ASF personnel from cross-infection and to protect the health and safety of patients.


   The provisions of this §  567.1 amended October 22, 1999, effective November 22, 1999, 29 Pa.B. 5583. Immediately preceding text appears at serial page (256588).

§ 567.2. Committee responsibilities.

 The quality assurance committee shall be responsible for:

   (1)  The prevention, control and investigation of infection in the ASF and for assuring the effectiveness of current procedural techniques in all departments.

   (2)  The designation of one full-time or one part-time employe responsible for developing and monitoring the infection control program including, but not limited to:

     (i)   Written standards for ASF sanitation and asepsis.

     (ii)   Procedures and techniques for meeting established sanitation and asepsis standards.

     (iii)   Isolation procedures.

     (iv)   Maintaining records of infections which originate in the ASF among patients and personnel to trace the sources of infection and to identify epidemic situations.

     (v)   Providing assistance in the development of the employe health program of the ASF.

     (vi)   Submitting a copy of pertinent findings and recommendations to the committee.

§ 567.3. Policies and procedures.

 (a)  Only authorized persons, who are properly attired, shall be allowed in the surgical area.

 (b)  Current written policies and procedures to assure definite and valid infection control shall include the following:

   (1)  Medical asepsis.

   (2)  Surgical asepsis.

   (3)  Sterilization and disinfection, including suitable equipment for routine and rapid sterilization.

   (4)  Sterilized materials are packaged, labeled and dated in a consistent manner.

   (5)  Housekeeping.

   (6)  Cleaning of surgical suites prior to each operation.

   (7)  Clean and soiled linen and utility rooms.

   (8)  Linen.

   (9)  Traffic flow patterns.

   (10)  Isolation protocols.

   (11)  Staff health status requirements.

   (12)  Infection control in-service education for personnel.

   (13)  Recording and reporting of potential infection.

   (14)  Bacteriological testing of potential infections, recording results and reporting to the quality assurance committee.

   (15)  Admission criteria for patients with specific or suspected infections.

   (16)  Patient postdischarge investigation.

   (17)  Reporting of communicable diseases as required by §  27.2 (relating to specific identified reportable diseases, infections and conditions).


   The provisions of this §  567.3 amended October 22, 1999, effective November 22, 1999, 29 Pa.B. 5583. Immediately preceding text appears at serial pages (256588) to (256589).


§ 567.11. Operating suite equipment.

 The operating suite shall be adequately equipped with age appropriate equipment for the types of procedures to be performed and the recovery area shall be adequately equipped for the proper care of postanesthesia recovery of surgical patients. All equipment and supplies shall be age and size appropriate for the patients treated. The following equipment shall be available in the operating suite and recovery area.

   (1)  Suitable surgical instruments customarily available for the planned surgical procedure.

   (2)  Emergency call system.

   (3)  Airways, breathing bag and device for the provision of positive pressure rescue breathing.

   (4)  Cardio-pulmonary drugs and intubation equipment.

   (5)  Cardiac monitor and defibrillator.

   (6)  Resuscitator including oxygen and suction equipment.

   (7)  Tracheostomy and necessary pulmonary reexpansion supplies.


   The provisions of this §  567.11 adopted January 23, 1987, effective March 25, 1987, 17 Pa.B. 376; amended July 21, 1989, effective July 22, 1989, 19 Pa.B. 3105; amended October 22, 1999, effective November 22, 1999, 29 Pa.B. 5583. Immediately preceding text appears at serial page (256589).


§ 567.21. Principle.

 An adequate supply of clean linen, sterile linen and disposable materials shall be maintained.

§ 567.22. Linen service policy.

 The ASF shall require the agency providing the linen service to maintain at least the standards outlined in this chapter, and the contract shall so state. The off-premises laundry service shall ensure that clean linen is completely packaged and is protected from contamination upon delivery to the ASF.

§ 567.23. Clean linen.

 Clean linen shall be available to meet the daily and emergency needs of the ASF. Clean linen shall be handled and stored to minimize contamination from surface contact or airborne deposits.

§ 567.24. Soiled linen.

 Soiled linen shall be collected and stored to avoid microbial dissemination into the environment. Soiled linen shall be kept segregated from clean linen. Soiled linen from isolation areas shall be identified and separately bagged. Precautions shall be taken in the subsequent processing of soiled linen from isolation areas to prevent microbial dissemination and infection.


§ 567.31. Principle.

 The facility, the premises and equipment shall be kept clean and free of vermin, insects, rodents and litter.

§ 567.32. Policies and procedures.

 Procedures shall be developed for cleaning and care of equipment, for establishment of cleaning schedules, for cleaning methods and for proper use of cleaning supplies and disposal of waste. Suitable equipment shall be provided to facilitate cleaning.


   The provisions of this §  567.32 amended October 22, 1999, effective November 22, 1999, 29 Pa.B. 5583. Immediately preceding text appears at serial page (256590).

§ 567.33. Waste disposal.

 (a)  Garbage shall be stored in tight, nonabsorbent and readily cleanable containers with tight-fitting lids. Garbage shall be removed from the premises as frequently as necessary to prevent nuisance and shall be disposed of in a manner consistent with Federal and Commonwealth regulations and local codes and ordinances.

 (b)  Refuse shall be stored in covered trash containers prior to removal.

 (c)  Pathological, bacteriological, surgical, gynecological and contaminated waste and similar materials shall be disposed of by a method approved by the Department of Environmental Resources under 25 Pa. Code Chapter 75 (relating to solid waste management) and in compliance with local ordinances.


§ 567.41. Principle.

 The ASF shall be equipped, operated and maintained to sustain its safe and sanitary characteristics and to minimize health hazards in the ASF for the protection of patients and employes.

§ 567.42. Policies and procedures.

 (a)  A schedule of preventive maintenance shall be developed for the physical plant, biomedical and other equipment.

 (b)  Written procedures shall be readily available for employes to follow in the event of a breakdown in equipment, mechanical systems or utilities.

§ 567.43. Ventilation system.

 The ventilation system shall be inspected and maintained in accordance with the written maintenance schedule to ensure that a properly conditioned air supply meeting minimum filtration, humidity and temperature requirements is provided in critical areas such as the surgical and recovery suites under Chapter 571 (relating to construction standards).


§ 567.51. Water supply.

 (a)  Water shall be obtained from a municipal or private water system approved by the Department of Environmental Resources and in compliance with applicable Federal and Commonwealth regulations and local ordinances.

 (b)  Provisions shall be made for an emergency supply of water when the usual source of water is neither usable nor available.

§ 567.52. Lighting.

 Glare-free artificial lighting shall be provided in all areas of the ASF. For current recommendations of lighting levels for ASFs, see the latest edition of the IES, (Illuminating Engineering Society), Lighting Handbook, Application Volume or Lighting for Health Care Facilities. Both documents are published by the IES of North America, 345 East 47th Street, New York, New York 10017.

§ 567.53. Sterilization control.

 There shall be written policies to establish the following:

   (1)  A method of control to assure sterilization of supplies and water.

   (2)  Processing of sterile supplies at specified intervals.

   (3)  Use of disposable equipment.

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