Wash. Admin. Code § 246-440-100

Current through Register Vol. 24-21, November 1, 2024

Section 246-440-100 - Hospital reporting requirements for health care-associated infections

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 atwww.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

Wash. Admin. Code § 246-440-100

Adopted by WSR 14-16-056, Filed 7/30/2014, effective 8/30/2014

Amended by WSR 19-22-075, Filed 11/5/2019, effective 1/1/2020