Current through Reg. 49, No. 38; September 20, 2024
(a) Facilities
shall submit HAI and NHSN-reported PAEs, including whether the HAI or
NHSN-reported PAE contributed to a patient's death to NHSN. Health care
facilities shall report TxHSN-reported PAEs through the TxHSN portal or its
successor.
(b) Facilities shall
comply with the process prescribed by this chapter and NHSN to allow the
department access to HAI data, including whether the HAI contributed to a
patient's death, and/or designated PAE data as specified in §§ 200.3-
200.7
of this title (relating to How to Report; Which Events to Report; Data to
Report; When to Initiate Reporting; and Schedule for HAI and PAE
Reporting).
(c) Facilities shall
use their facility identification number to identify their facility in the
electronic data and correspondence with the department. Each facility meeting
the definition of ambulatory surgical center or general hospital as defined in
§
200.1(2) and
(12) of this title (relating to Definitions)
shall have its own facility identification number.
(1) CMS certified health care facilities
shall use the CMS-assigned provider number.
(2) If a facility has multiple campuses
associated by ownership, each site shall each use a unique CMS provider number.
In the event that a facility is not CMS certified or a facility operates
multiple facilities under one CMS number, the facility shall use the
identification number assigned by NHSN.
(3) The relationship between CMS-assigned and
NHSN-assigned facility identifiers and the name and license number of the
facility is public information.
(d) The department shall notify the facility
contact by email 90 calendar days in advance of any change in requirements for
reporting HAI data, including whether the HAI contributed to a patient's death,
and designated PAE data.
(e)
Facilities shall report PAE data as defined in §
200.4 and
§
200.6
of this title.
(1) For HAI reporting, if the
facility treating the patient performed the procedure, the facility shall
report the infection to NHSN according to the surveillance methods described by
NHSN and this chapter. For NHSN-reported PAE reporting, if the event occurred
in the facility treating the patient, the facility shall report the event to
NHSN according the surveillance methods described by NHSN and this
chapter.
(2) For PAE reporting,
TxHSN-reported PAEs identified at the same facility that the PAE occurred,
shall be reported through the TxHSN portal or its successor as described in
this chapter.
(3) For HAI and
NHSN-reported PAE reporting, if the facility treating the patient did not
perform the procedure, the treating facility shall notify the facility that
performed the procedure, document the notification, and maintain this
documentation for audit purposes. The facility that performed the procedure
shall verify the data related to the infection. The performing facility shall
report the HAI or NHSN-reported PAE to NHSN according to the surveillance
methods described by NHSN and this chapter.
(4) For TxHSN-reported PAEs, if the facility
that identified the PAE is not the facility responsible for the event, the
facility that identified the PAE shall notify the facility where the event
occurred, document the notification, and maintain this documentation for audit
purposes. The facility in which the event occurred shall report the PAE to
TxHSN or its successor according to the methods described by the department and
this chapter.
