197.154.  Regulation review and update required, standards. — No later than July 1, 2005, the department shall review and update its current regulations governing hospital and ambulatory surgical center infection control programs.  Such standards shall be based upon nationally recognized standards and shall include, but not be limited to, standards for:

  (1)  Maintaining databases to be used for infection tracking;

  (2)  Developing hospital protocols related to aseptic technique and infection control practices including but not limited to hand washing, isolation, and other infection control policies;

  (3)  Developing appropriate corrective action plans and follow-ups for any deficiencies identified in hospital infection control practices;

  (4)  Conducting root cause analysis and follow-up of sentinel events, as defined by the Joint Commission on Accreditation of Health Organizations, attributable to nosocomial infections; and

  (5)  Ensuring that hospital and ambulatory surgical center policies and medical staff bylaws are in place to promote and enforce compliance with infection control policies.