# COMAR Title 10 — Maryland Department of Health

## Subtitle 52 — Preventive Medicine

### Chapter 11 — Universal Infection Control Precautions

**Authority:** Health-General Article, §§18-102, 19-319(h), 19-3A-02(9) and (10), 19-705.3; Health Occupations Article, §§1-207, 4-313(d),4-315, 6-205, 6-312, 6-505, 7-205, 7-316, 8-205, 8-316, 8-506, 14-205, 14-404, 14-415, 14-506, 15-205, 15-314, 16-205, 16-312, and 16-404; Annotated Code of Maryland

**Administrative History:** Effective date: February 14, 1994 (21:3 Md. R. 194)

**Administrative History:** Regulation .02B amended effective October 27, 2003 (30:21 Md. R. 1529)

**Administrative History:** Regulation .03C amended effective October 27, 2003 (30:21 Md. R. 1529)

**Administrative History:** Regulation .04B amended effective October 27, 2003 (30:21 Md. R. 1529)

#### Regulation .01 Scope.

*COMAR 10.52.11.01*

A. These regulations apply to any of the following individuals when the individual is involved in patient care activities:

  (1) Acupuncturist;

  (2) Dental hygienist;

  (3) Dentist;

  (4) Electrologist;

  (5) Employee of a health care facility;

  (6) Employee of a health care professional;

  (7) Mortician;

  (8) Nurse;

  (9) Physician;

  (10) Physician assistant; and

  (11) Podiatrist.

B. These regulations apply to any health care facility or private professional office where a health care worker is involved in patient care activities.

#### Regulation .02 Definitions.

*COMAR 10.52.11.02*

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

  (1) “Assisted living facility” has the meaning for assisted living program stated in Health-General Article, §19-1801, Annotated Code of Maryland.

  (2) “Day care center for adults” has the meaning stated in Health-General Article, §14-301, Annotated Code of Maryland.

  (3) “Freestanding birthing center” has the meaning stated in Health-General Article, §19-3B-01, Annotated Code of Maryland.

  (4) “Freestanding medical facility” has the meaning stated in Health-General Article, §19-3A-01, Annotated Code of Maryland.

  (5) Health Care Facility.

    (a) “Health care facility” means a location where health care is provided, including:

      (i) Assisted living facility;

      (ii) Day care center for adults;

      (iii) Freestanding birthing center;

      (iv) Freestanding medical facility;

      (v) Health maintenance organization;

      (vi) Hospital;

      (vii) Managed care organization;

      (viii) Nursing home; and

      (ix) Related institution.

    (b) “Health care facility” does not include a private professional office.

  (6) “Health care professional” means an individual who is licensed or certified under one or more of the following titles of Health Occupations Article, Annotated Code of Maryland:

    (a) Title 4 Dentistry;

    (b) Title 6 Electrologists;

    (c) Title 7 Morticians;

    (d) Title 8 Nurses;

    (e) Title 14 Physicians;

    (f) Title 15 Physician Assistants; and

    (g) Title 16 Podiatrists.

  (7) “Health care worker” means an individual who is:

    (a) A health care professional;

    (b) An employee of a health care professional; or

    (c) An employee of a health care facility.

  (8) “Health maintenance organization” has the meaning stated in Health-General Article, §19-701, Annotated Code of Maryland.

  (9) “Hospital” has the meaning stated in Health-General Article, §19-301, Annotated Code of Maryland.

  (10) “Managed care organization” has the meaning stated in Health-General Article, §15-101, Annotated Code of Maryland.

  (11) “Nursing home” means either:

    (a) A comprehensive care facility, as defined in COMAR 10.07.02.01B(6); or

    (b) An extended care facility, as defined in COMAR 10.07.02.01B(12).

  (12) “Patient care activity” means an action performed by a health care worker for a patient which could result in one or more of the following:

    (a) Blood or body fluids of the patient touching non-intact skin or mucous membrane of the health care worker;

    (b) Blood or body fluids of the health care worker touching nonintact skin or mucous membrane of the patient;

    (c) Percutaneous contact of the health care worker with the blood or body fluids of the patient; or

    (d) Percutaneous contact of the patient with the blood or body fluids of the health care worker.

  (13) “Private professional office” means a location which is not a part of a health care facility where a health care professional provides services to the public on a regular basis.

  (14) “Related institution” has the meaning stated in Health-General Article, §19-301, Annotated Code of Maryland.

  (15) “Universal precautions” has the meaning stated in COMAR 10.06.01.02B(10).

#### Regulation .03 Compliance Requirements for an Individual.

*COMAR 10.52.11.03*

An individual who is performing patient care activities shall:

A. Comply with the principles of universal precautions;

B. If necessary, make an emergency exception to the use of universal precautions in a situation when failure to provide immediate care could result in serious harm to or death of a patient; and

C. Comply with current professional standards of patient care with regard to disinfection and sterilization of reusable devices used in patient care procedures, including:

  (1) Prohibiting the reuse of single use needles; and

  (2) Properly disposing of needles and other sharps devices.

#### Regulation .04 Compliance Requirements for a Health Care Facility.

*COMAR 10.52.11.04*

A. A health care facility shall:

  (1) Adopt, implement, and enforce a policy that:

    (a) Requires the use of universal precautions by medical staff and employees engaged in patient care activities,

    (b) Permits an individual to make an emergency exception to the use of universal precautions, at the individual's discretion, in a situation where failure to provide immediate care could result in serious harm to or death of a patient, and

    (c) Requires compliance with current professional standards of patient care with regard to disinfection and sterilization of reusable devices used in patient care procedures; and

  (2) Display the version of the notice “We Take Precautions for You” specified in Table A, shown in §B of this regulation, at the entrance to the health care facility.

B. Table A.

#### Regulation .05 Compliance Requirements for Health Care Professional with Private Professional Office.

*COMAR 10.52.11.05*

A. A health care professional who practices in a private professional office shall:

  (1) Ensure that an individual who performs patient care services in the professional's office:

    (a) Complies with the principles of universal precautions,

    (b) Is permitted to make an emergency exception to the use of universal precautions, at the individual's discretion, in a situation where failure to provide immediate care could result in serious harm to or death of a patient, and

    (c) Complies with current professional standards of patient care with regard to disinfection and sterilization of reusable devices used in patient care procedures; and

  (2) Except as provided in §C of this regulation, display the version of the notice “We Take Precautions for You” specified in Table B shown in §B of this regulation.

B. Table B.

C. A health care professional not listed in Table B is not required to post the notice “We Take Precautions for You”.