Washington Administrative Code › Title 246 - Health, Department of › HEALTH INFORMATION › Chapter 246-440 - Health care-associated infections reporting › Section 246-440-100 - Hospital reporting requirements for health care-associated infections

Current through Register Vol. 24-14, July 15, 2024
The purpose of this section is to establish data collection
				  and submission requirements for health care-associated infections at hospitals.
				  This type of data provides evidence-based information measures to reduce
				  hospital-acquired infections.
(1) A
				hospital must routinely collect and submit data related to health
				care-associated infections to the National Healthcare Safety Network (NHSN) of
				the United States Centers for Disease Control and Prevention (CDC) in
				compliance with
				RCW
				 43.70.056.
(2) A hospital that is licensed under chapter
				70.41 RCW and is also an acute care hospital under
				42 U.S.C.
				1395ww(c)(1)(A), a
				rehabilitation hospital under
				42 U.S.C.
				1395ww(d)(1)(B)(ii), a
				cancer hospital under
				42 U.S.C.
				1395ww(d)(1)(B)(v), or a
				critical access hospital under
				42 U.S.C.
				1395i-4 must collect and submit data as
				required by the Centers for Medicare and Medicaid Services (CMS) for quality
				reporting programs or projects listed in Table 1 of this section.
(3) A hospital that is certified as a
				critical access hospital may also voluntarily submit optional data requirements
				in Table 2 of this section. Submission of optional data is voluntary and is
				beneficial for understanding health care-associated infection rates at these
				hospitals. A hospital that submits optional data under this section must submit
				data on all the optional reporting categories found in Table 2.
(4) All data collected under this section
				must be collected and submitted in accordance with CDC NHSN's definitions,
				methods, requirements, and procedures found at
www.cdc.gov/nhsn/
.
Table 1
National Health Safety Network Health Care-Associated
				  Infection Reporting Requirements for Hospitals Centers for Medicare and
				  Medicaid Services (CMS), January 2019
Hospital Type (CMS Reporting Program or
						  Project)
Reporting Requirement (Health Care-Associated
						  Infection Event)
Reporting Specifications (if any)
Acute Care Hospital (CMS Hospital
						  Inpatient Quality Reporting (IQR) Program authorized by
						  42 U.S.C.
						  1395ww(b)(3) (B)
						  (viii))
Central line-associated blood stream infection
Adult, pediatric and neonatal intensive care units,
						  medical, surgical, and medical/surgical wards
Catheter-associated urinary tract infection
Adult and pediatric intensive care units, medical,
						  surgical, and medical/surgical wards
Surgical site infection - Colon procedure
Inpatient procedures
Surgical site infection - Abdominal hysterectomy
						  procedure
Inpatient procedures
MRSA bacteremia LabID Event
Facility-wide Inpatient (FacWideln)
Clostridioides
(FKA Clostridium)
difficile
LabID Event
Facility-wide Inpatient (FacWideln)
Health care personnel flu vaccination
All inpatient health care personnel
Rehabilitation Hospital (CMS Inpatient
						  Rehabilitation Facility Quality Reporting (IRFQR) Program authorized by
						  42 U.S.C.
						  1395ww(j)(7))
Catheter-associated urinary tract infection
All adult and pediat-ric inpatient rehabilitation
						  locations
Clostridioides
(FKA Clostridium)
difficile
LabID Event
Facility-wide Inpatient (FacWideln)
Health care personnel flu vaccination
All inpatient health care personnel
Cancer Hospital (CMS PPS-Exempt Cancer
						  Hospital Quality Reporting (PCHQR) Program authorized by
						  42
						  U.S.C. 1395cc(k))
Central line-associated blood stream infection
All bedded inpatient locations
Catheter-associated urinary tract infection
All bedded inpatient locations
Surgical site infection - Colon procedure
Inpatient procedures
Surgical site infection - Abdominal hysterectomy
						  procedure
Inpatient procedures
MRSA bacteremia LabID Event
Facility-wide Inpatient (FacWideln)
Clostridioides
(FKA Clostridium)
difficile
LabID Event
Facility-wide Inpatient (FacWideln)
Health care personnel flu vaccination
All inpatient health care personnel
Critical Access Hospital (CMS Core
						  Member Beneficiary Quality Improvement Project (MBQIP) Measures authorized by
						  42 U.S.C.
						  1395i-4)
National Health Safety Network Annual Hospital Survey
						  (Antimicrobial stewardship)
Health care personnel flu vaccination
Required of all Inpatient health care personnel
Table 2
Optional Reporting
Hospital Type (CMS Reporting Project)
Optional Reporting (Health Care-Associated
						  Infection Event)
Critical Access Hospital - (CMS
						  Additional Member Beneficiary Quality Improvement Project (MBQIP) Measures
						  authorized by
						  42 U.S.C.
						  1395i-4)
Central line-associated blood stream infection
Catheter-associated urinary tract infection
Surgical site infection - Colon procedure
Surgical site infection - Abdominal hysterectomy
						  procedure
MRSA bacteremia LabID Event
Clostridioides
(FKA Clostridium)
difficile
LabID Event