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Abduction (Sentinel Event 7B)

Facilities must report abduction of a patient/resident of any age, including removal of a patient/resident, who does not have decision-making capacity, without specific notification and approval by staff even when the person is otherwise authorized to be away from the setting.

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Abortion

Physician or member of staff must report each abortion performed.

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Abuse, Neglect, Exploitation, Isolation, or Abandonment of Older or Vulnerable Person

Any licensed health care professional or hospital personnel who in a professional or occupational capacity knows or has reasonable cause to believe that an older person (elder abuse) or vulnerable person has been abused, neglected, exploited, isolated or abandoned shall report the abuse or neglect.

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Adverse Action Against Provider

Hospitals must report professional review action, based on reasons related to professional competence or conduct, adversely affecting clinical privileges for a period longer than 30 days; or voluntary surrender or restriction of clinical privileges while under, or to avoid, investigation.

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Adverse Reaction to Vaccines (VAERS)

Healthcare providers are required by law to report to VAERS: Any adverse event listed in the VAERS Table of Reportable Events Following Vaccination that occurs within the specified time period after vaccination An adverse event listed by the vaccine manufacturer as a contraindication to further doses of the vaccine Healthcare providers are strongly encouraged to report: Any […]

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Air Embolism - Death/Serious Injury (Sentinel Event 2C)

Facilities must report patient death or serious injury associated with intravascular air embolism that occurs while begin cared for in a healthcare setting, excluding those associated with neurosurgical procedures known to present a high risk of intravascular air embolism. Intended to capture high-risk procedures, other than neurosurgical procedures, that include, but are not limited to, […]

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Annual Financial Audit

Hospitals must file a copy of their annual financial audit conducted by an independent auditor, with the Division of Health Care Financing and Policy (DHCFP). 

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Artificial Insemination with Wrong Sperm or Egg (Sentinel Event 4G)

Facilities must report artificial insemination with the wrong donor sperm or wrong egg.

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Birth Defects/Adverse Birth Outcomes

Chief administrative officer of each hospital must prepare and make available list of patients who are under the age of seven and have one or more birth defects, as well as patients discharged with adverse birth outcomes.

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Blindness

Hospitals, medical clinics, and similar institutions must report information on persons who are blind or night-blind or whose vision is severely impaired; or whose vision has been restored.

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Burn - Death/Serious Injury (Sentinel Event 5C)

Facilities must report patient or staff death or serious injury associated with a burn incurred from any source in the course of a patient care process in a healthcare setting, including operating room flash fires (second-degree), hot water, sunburn in the patient with decreased ability to sense pain, and smoking in the patient care environment.

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Burns (NRS629)

Every provider of health care must report second or third degree burns to 5% or more of the body; burns to the upper respiratory tract or laryngeal adema resulting from inhalation of heated air; or burns which may result in death to the local fire department (counties w/populations > 45,000) or to the Nevada State […]

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Cancer Registry (Nevada Central Cancer Registry)(NCCR)

Hospitals, medical laboratories and other facilities that provide screening, diagnostic or therapeutic services to patients with respect to cancer and other neoplasms shall report information on cases of cancer and other neoplasms, which are specified by the State Board of Health as subject to reporting, to the system.

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CARA Plan of Care/Neonatal Abstinence Syndrome (CARA/CAPTA)

A provider of health care who delivers or provides medical services to an infant in a medical facility and who knows or has reasonable cause to believe that the infant was born with a fetal alcohol spectrum disorder, is affected by prenatal substance abuse or is experiencing symptoms of withdrawal from a substance as a […]

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Certificate of Birth

If a birth (incl. a stillbirth) occurs in a hospital or the mother and child are immediately transported to a hospital, the person in charge of the hospital or his or her designated representative shall obtain the necessary information, prepare a birth certificate, secure the signatures required by the certificate and file it within 10 […]

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Change in Administrator, Ownership, or Transfer of Property.

A medical facility must notify the Division of Public and Behavioral Health within 10 days of a change in the administrator of the facility or if there is a transfer of the real property on which the facility is located. If there is a change in ownership, address, or service provided, the Division must be […]

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Child Abuse, Neglect, or Endangerment

Any licensed health care professional or hospital personnel who has reasonable knowledge to believe that a child under 18 has been abused or neglected shall report the abuse or neglect. Additionally, if the reporter has reason to believe that a newborn infant has been affected by a fetal alcohol spectrum disorder or prenatal substance abuse […]

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CMS Occupational Mix Survey

Critical Access Hospitals (CAHs) are not required to complete the CMS Occupational Mix Survey. CMS collects this data every 3 years for an occupational mix adjustment to the wage index.

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Communicable Diseases

A provider of health care who knows of, or provides services to, a person who has or is suspected of having a communicable disease (including animal bites and vaccine reactions) shall report that fact to the health authority in the manner prescribed by the regulations of the Board. A laboratory director shall, in the manner […]

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Community Paramedicine

Each holder of a permit to provide community paramedicine services in Nevada must report quarterly on the types of services provided including the number of patients to whom a service has been provided, the impact of providing community paramedicine services, a description of the quality improvement program and program to prevent waste, fraud, and abuse, […]

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Complications from Abortion

Must report number of patients admitted for hospital care for a complication which resulted from an abortion.

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Congenital Heart Disease

For hospitals who regularly offer obstetric services (not only on emergency basis), attending physician must examine infants and report any cases of congenital heart disease.

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Consultation by Unlicensed Physician

Any physician licensed in this State shall notify the Board if any unlicensed physician comes into this State for consultation with or assistance to the physician licensed in this State and specify the date of the consultation or assistance, whether the unlicensed physician has provided such consultation or assistance, or both, to the licensed physician […]

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Contaminated Drugs, Devices, or Biologics - Death/Serious Injury (Sentinel Event 2A)

Facility must report patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the healthcare setting, including contaminants in drugs, devices, or biologics regardless of the source of contamination and/or product. Intended to capture contaminations that can be seen with the naked eye or with use of detection […]

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Controlled Substance Prescriptions

Each person registered pursuant to chapter 453 of NRS to dispense a controlled substance listed in schedule II, III, IV or V for human consumption shall, not later than the end of the next business day after dispensing a controlled substance, upload information to the database. The requirements of this subsection do not apply if […]

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COVID-19 Capacity and Utilization

Hospitals must report capacity and utilization data in order to assist the White House Coronavirus Task Force in tracking the movement of the virus, and to facilitate planning, monitoring, and resource allocation during the COVID-19 Public Health Emergency.

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COVID-19 Cases

Reporting of all COVID-19 cases and test results is required under Nevada's communicable disease reporting statutes and regulations as an "extraordinary occurrence of illness". 

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COVID-19 Deaths

All providers of health care, health care facilities, medical examiners, coroners and funeral homes must report immediately to their local and state health department, each death that is caused by, associated with or related to COVID-19 infection consistent with the CDC criteria. This includes information on the immediate cause of death, such as a heart […]

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COVID-19 Multisystem Inflammatory Syndrome in Children (MIS-C)

Reporting of MIS-C associated with COVID-19 is required under Nevada's communicable disease reporting statutes and regulations as an "extraordinary occurrence of illness". The case definition of MIS-C is: an individual aged <21 years presenting with fever, laboratory evidence of inflammation, and evidence of clinically severe illness requiring hospitalization, with multisystem (>2) organ involvement (cardiac, renal, […]

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COVID-19 Nursing Home Cases

CMS is requiring facilities to report COVID-19 cases in their facility to the CDC National Health Safety Network (NHSN) on a weekly basis. CDC and CMS will use information collected through the new NHSN Long-term Care COVID-19 Module to strengthen COVID-19 surveillance locally and nationally; monitor trends in infection rates; and help local, state, and […]

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COVID-19 Outbreak in Skilled Nursing Facility

Skilled nursing facilities must report any outbreaks of COVID-19 immediately, and continue reporting until there are no new cases. An outbreak is defined as any new occurrence in residents or staff.

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COVID-19 Patients Waiting for Discharge

Hospitals are requested to complete a daily log on patients that need to be discharged to a lower level of care in order to help track the COVID-19 bed crisis throughout the State of Nevada.

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COVID-19 Provider Relief Funds

Provider Relief Fund (PRF) recipients that received one or more payments exceeding $10,000 in the aggregate from the PRF will be required to report to HHS demonstrating their compliance with the terms and conditions which they agreed to.

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COVID-19 Skilled Nursing Facility Daily Census Survey

Nevada skilled nursing facilities are required to complete a daily census survey under a directive from the State's Chief Medical Officer. The State will use this information for internal dashboards that will merge with data provided by the hospitals.  State health officials hope that having this data will help to organize transitions and tell the […]

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COVID-19 Skilled Nursing Facility Daily Status Survey

Skilled Nursing Facilities in Nevada must complete a COVID-19 Daily Status Survey via a link sent in an email from the Division of Public and Behavioral Health (DPBH).

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COVID-19 Skilled Nursing Facility Nevada Health Alert Network (NVHAN) (EMResource)

Effective 7/15/20, Nevada’s Chief Medical Officer, Dr. Ihsan Azzam, is requesting that all skilled nursing facilities participate in the Nevada Health Alert Network (NVHAN). It is understood during this time of crisis that skilled nursing facilities are extremely busy taking care of residents; therefore, in addition to general demographics the only information being requested is: […]

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COVID-19 Test Results

Laboratories who are processing and testing samples from Nevada residents are required under severe penalties to report all COVID-19 test results to the Division of Public and Behavioral Health within 24 hours from analysis through an established reporting method.

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COVID-19 Vaccine Aggregate Data

Facilities administering the COVID-19 vaccine will need to enter certain aggregate and other information into the REDCap system in addition to the data entered into WebIZ. More information will be posted here as it becomes available.

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Device Failure - Death/Serious Injury (Sentinel Event 2B)

Facilities must report patient death or serious injury associated with the use or function of a device in patient care, in which the device is used or functions other than as intended, whether or not the use is intended or described by the device manufacturer's literature. Includes, but is not limited to, catheters, drains, and […]

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Discharge to Unauthorized Person (Sentinel Event 3A)

Facilities must report discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person. Release to “other than an authorized person” includes removing the patient/resident without specific notification and approval by staff, even when the person is otherwise authorized. Examples of individuals who do not have […]

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Dosimetry
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Duty of Mental Health Professionals Concerning Threats (a.k.a. "Duty to Protect" or Tarasoff Provision)

If a patient communicates an explicit threat of imminent serious physical harm or death to a clearly identified or identifiable person and, in the judgment of the mental health professional, the patient has the intent and ability to carry out the threat, the mental health professional shall apply for the emergency admission of the patient […]

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Electric Shock - Death/Serious Injury (Sentinel Event 5A)

Facilities must report patient or staff death or serious injury associated with an electric shock in the course of a patient care process in the healthcare setting, excluding events involving patients during planned treatments such as electric countershock/elective cardioversion. Intended to capture patient death or injury associated with unintended electric shock during the course of […]

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Elopement - Death/Serious Injury (Sentinel Event 3B)

Facilities must report patient death or serious injury associated with patient elopement (disappearance), excluding events involving competent adults with decision-making capacity who leave AMA or voluntarily leave without being seen. The term “elopement” and “competent” adult should be interpreted in accordance with prevailing legal standards in applicable jurisdictions. Of note, an assessment that identifies patients […]

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Employee Fatality, Serious Work Related Injuries and Illnesses (OSHA 300 Log and Annual Summary)

Employers must notify NVOSHA of all workplace accidents involving an employee fatality or fatalities within 8 hours after learning of the accident. Employers must report to NVOSHA all inpatient hospitalizations of one or more employees, amputations of a part of an employee’s body or an employee’s loss of an eye within 24 hours after learning of the hospitalization, amputation […]

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Epilepsy

If a physician determines that a patient's epilepsy severely impairs the ability to safely operate a motor vehicle, the physician shall sign a written statement verifying that the physician informed the patient and provide a copy of the signed statement to the patient and to the DMV. (Note: State Board of Health defines this reportable […]

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Exposure to Infectious Disease (Public Employees Not Patients)

If a medical facility makes a determination that the emergency response employee (ERE) involved has been exposed to an infectious disease, the medical facility shall conduct the test and, in writing, notify the appropriate persons including the designated officer who submitted the request.

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Failure to Communicate Test Results - Death/Serious Injury (Sentinel Event 4I)

Facilities must report patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results. Includes events where failure to report increased neonatal bilirubin levels result in kernicterus. Examples of serious injury are a new diagnosis, or an advancing stage of an existing diagnosis (e.g., cancer). Failure to […]

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Fall - Death/Serious Injury (Sentinel Event 4E)

Facilities must report patient death or serious injury associated with a fall while being cared for in a healthcare setting. Includes but is not limited to fractures, head injuries, and intracranial hemorrhage. Of note, an assessment that identifies patients at “risk” of fall, findings of risk accompanied by organizationally defined measures to be taken when […]

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Financial Statements

A hospital or Intermediate Care Facility (incl. Distinct Part Long-Term Care) must file a balance sheet detailing the assets, liabilities and net worth of the institution for its fiscal year; and a statement of income and expenses for the fiscal year, with the Division of Health Care Financing and Policy (DHCFP).

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Fire or Disaster

An Intermediate Care Facility (Incl. Distinct Part Long-Term Care) must report the occurrence of a fire or disaster to the Bureau of Health Care Quality and Compliance (HCQC) within 24 hours.

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Firearm/Knife Wounds

Every provider of health care to whom any person comes or is brought for treatment of an injury which appears to have been inflicted by means of a firearm or knife, not under accidental circumstances, shall promptly report the person’s name, if known, his or her location and the character and extent of the injury […]

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Healthcare-Associated Infections (HAI)

Each medical facility and facility for skilled nursing which provided medical services and care to an average of 25 or more patients during each business day in the immediately preceding calendar year shall, within 120 days after becoming eligible, participate in the secure, Internet-based surveillance system established by the Division of Healthcare Quality Promotion of […]

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Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS)

The director or other person in charge of a medical laboratory shall report as required by this section the results of any test confirming the presence of the human immunodeficiency virus (HIV) or antibodies to the human immunodeficiency virus (HIV); or if the test was conducted to monitor the progression of a human immunodeficiency virus […]

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Impersonation of Healthcare Provider (Sentinel Event 7A)

Facilities must report any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider, including those without licensure to provide the care given, and those with licensure who represent themselves and act beyond the scope of their licensure.

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Indebtedness Statements, Policies, and Plans (District Hospitals)

District hospitals are required to submit an annual statement of current and contemplated general obligation debt and special elective taxes, statement of debt management policy, plan for capital improvement or alternate statement and certain information regarding chief financial officer.

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Injuries/Illnesses contracted during public health emergency or other health event

To the extent feasible, every provider of health care to whom any person comes or is brought for the treatment of an injury which the provider concludes was inflicted during the existence of a state of emergency or declaration of disaster or an illness which the provider concludes was contracted during a public health emergency […]

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Insufficient Malpractice Insurance Coverage

A practitioner licensed pursuant to chapters 630 to 640 of NRS who does not have insurance covering liability for a breach of his or her professional duty toward a patient shall report to the board which issued the practitioner’s license.

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Intra- or Post-operative Death (Sentinel Event 1E)

Facilities must report intraoperative or immediately postoperative death in an ASA Class I patient, including all ASA Class I patient deaths in situations where anesthesia was administered; the planned surgical procedure may or may not have been carried out. Immediately post-operative means within 24 hours after surgery or other invasive procedure was completed or after […]

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Introduction of Metallic Object into MRI Area - Death/Serious Injury (Sentinel Event 6A)

Facilities must report death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area, including retained foreign objects, external projectiles, and pacemakers.

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Judicial action against employee of SNF

Facilities for skilled nursing must report any judicial action taken against an employee or former employee of the facility which would indicate that the employee is unfit to be employed as a member of the staff of a facility for skilled nursing.

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Lead (Pediatric Lead Levels)

Qualified laboratories, offices of providers, and medical facilities shall report any result of a blood test for lead screening obtained by using a capillary specimen and which indicates an amount of lead in the blood that is greater than the amount designated by the Council of State and Territorial Epidemiologists.

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Lost Biological Specimen - Death/Serious Injury (Sentinel Event 4H)

Facilities must report patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen, including events where specimens are misidentified, where another procedure cannot be done to produce a specimen, and including progression of an undiagnosed disease or threat of disease that changes the patient's risk status for life, requiring monitoring […]

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Maternal Labor or Delivery - Death/Serious Injury (Sentinel Event 4C)

Facilities must report maternal death or serious injury associated with labor or delivery in a pregnancy while being cared for in a healthcare setting. Includes events that occur within 42 days post-delivery. Excludes deaths from pulmonary or amniotic fluid embolism, acute fatty liver of pregnancy, or cardiomyopathy.

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MBQIP - Antibiotic Stewardship

Part of the Medicare Beneficiary Quality Improvement Project (MBQIP), within the Patient Safety/Inpatient domain, the Antibiotic Stewardship measure assesses the core elements of hospital antibiotic stewardship programs: leadership, accountability, drug expertise, action, tracking, reporting, and education.

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MBQIP - Emergency Department Transfer Communication (EDTC)

Part of the Medicare Beneficiary Quality Improvement Project (MBQIP), the Emergency Department Transfer Communication (EDTC) quality measure is National Quality Forum (NQF) endorsed (NQF #291), and relevant to small rural hospitals. This measure is being implemented by critical access hospitals (CAHs) in the Medicare Beneficiary Quality Improvement Project (MBQIP) because small rural hospitals frequently transfer […]

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MBQIP - HCP/IMM-3: Influenza Vaccination Among Healthcare Personnel

(Note: Formerly OP-27) Part of the Medicare Beneficiary Quality Improvement Project (MBQIP), within the Patient Safety/Inpatient domain, CAHs must report on the influenza vaccination data for HCP physically working in the inpatient and outpatient hospital units for at least one working day between October 1 through March 31, regardless of clinical responsibility or patient contact. […]

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MBQIP - Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Part of the Medicare Beneficiary Quality Improvement Project (MBQIP), the intent of the HCAHPS initiative is to provide a standardized survey instrument and data collection methodology for measuring patients’ perspectives on hospital care. While many hospitals have collected information on patient satisfaction, prior to HCAHPS there was no national standard for collecting or publicly reporting […]

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MBQIP - OP-18: Median Time from ED Arrival to ED Departure for Discharged ED Patients

Part of the Medicare Beneficiary Quality Improvement Project (MBQIP), within the Outpatient domain, CAHs must report on the average time patients spent in the emergency department before being sent home. Reducing the time patients remain in the emergency department (ED) canimprove access to treatment and increase quality of care, potentially improves access to care specific to the […]

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MBQIP - OP-2: Fibrinolytic Therapy Received Within 30 Minutes

Part of the Medicare Beneficiary Quality Improvement Project (MBQIP), within the Outpatient domain, CAHs must report on time-to-fibrinolytic therapy, which is a strong predictor of outcome in patients with AMI.

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MBQIP - OP-22: Patient Left Without Being Seen

Part of the Medicare Beneficiary Quality Improvement Project (MBQIP), within the Outpatient domain, CAHs must report on the percentage of patients who left the emergency department before being seen. Reducing patient wait time in the ED helps improve access to care, increase capability to provide treatment, reduce ambulance refusals/diversions, reduce rushed treatment environments, reduce delays in […]

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MBQIP - OP-3: Median Time to Transfer to Another Facility for Acute Coronary Intervention

Part of the Medicare Beneficiary Quality Improvement Project (MBQIP), within the Outpatient domain, CAHs must report on the median number of minutes before outpatients with chest pain or possible heart attack who needed specialized care were transferred to another hospital. The early use of primary angioplasty in patients with STEMI results in a significant reduction in […]

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Medicaid Hospital Admission, Discharge or Death

Hospitals must report whenever a hospital admission, discharge or death of a Nevada Medicaid patient occurs.

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Medical Certificate of Death

Physician or APRN last in attendance must sign medical certificates of death, including stillbirth within 48 hours. The funeral director or person acting as undertaker shall present the completed certificate of death to the local registrar within 72 hours after the occurrence or discovery of death.

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Medical Malpractice of Osteopathic Physician or Physician Assistant

An osteopathic physician or physician assistant shall report to the Board any action for malpractice when receive a summons; any claim for malpractice submitted to arbitration or medication; any settlement, award, judgment, or other disposition of any action or claim; and any sanction imposed which are reportable to the NPDB.

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Medical Malpractice of Physician

A physician shall report to the Board any action for malpractice when receive a summons; any claim for malpractice submitted to arbitration or medication; any settlement, award, judgment, or other disposition of any action or claim; and any sanction imposed which are reportable to the NPDB.

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Medicare Cost Report

Hospitals must file a copy of the Medicare Cost Report, with the Division of Health Care Financing and Policy (DHCFP).

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Medication Error - Death/Serious Injury (Sentinel Event 4A)

Facilities must report patient death or serious injury associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration). Excludes reasonable differences in clinical judgment on drug selection and dose. Includes, but is not limited to, death or serious injury […]

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Mental Health Crisis Hold (L2K) Reporting via Bitfocus

In September 2018, NRHP, DPBH and Bitfocus developed a legal hold reporting form for use by NRHP members as part of a pilot program to track legal holds and address the delays in placement of these patients.

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Mental Health Crisis Holds (Legal hold, Legal 2000, L2k)

Hospitals must report the number of applications for emergency admission received by the hospital quarterly. Within 48 hours of receiving an application for emergency admission, and within 48 hours of discharging a patient from an emergency admission, hospitals must report certain information to the Division. 

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Minimum Data Set (MDS)

The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes.  This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems.  Care Area Assessments (CAAs) are part of this process, and provide […]

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Mistreatment, Neglect, Abuse, Injuries of Residents

A Long Term Care (LTC) facility shall ensure that all crimes or alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result […]

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Neonate Labor or Delivery - Death/Serious Injury (Sentinel Event 4D)

Facilities must report death or serious injury of neonate associated with labor or delivery in a pregnancy. Includes, for the office-based surgery, birthing center or “home” setting, unplanned admission to an inpatient setting within 24 hours of delivery. Unplanned admission to other than the birth setting should be verified with the identified birth setting.

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Nevada Healthcare Quarterly Reports (NHQR) (CHIA)

Hospitals and Intermediate Care Facilities (incl. Distinct Part Long-Term Care) must submit quarterly utilization and financial reports to DHCFP via the Nevada Healthcare Quality Reporting portal.

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NRHP QI - Age Appropriate Vital Signs within 20 Minutes of Discharge from Emergency Department

NRHP member facilities report on this quality indicator developed by the NRHP Risk Manager Work Group, which tracks whether patients in the Emergency Department had their vital signs checked and documented within 20 minutes of being discharged.

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NRHP QI - Physician Compliance with Opioid Prescribing Requirements (AB 474)

NRHP member facilities report on this quality indicator developed by the NRHP Risk Manager Work Group, which tracks compliance with the opioid prescribing requirements as determined by AB 474 in the 2017 Legislative Session.

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NRHP QI - Prompt Communication of Critical Lab Values to Appropriate Healthcare Professional

NRHP member facilities report on this quality indicator developed by the NRHP Risk Manager Work Group, which tracks the number of prompt (within one hour) person-to-person communications of critical lab values per the hospital's policy.

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Nurse Conduct

Any personnel of a medical facility shall report in writing to the Executive Director of the Board any conduct of a licensee or holder of a certificate which constitutes a violation of the provisions of Chapter 632 (the Nevada Nurse Practice Act).

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Nursing Facility Census

All Medicaid participating Nursing Facilities must report census information monthly including the number of vacant beds available for resident occupancy.

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Operating Budget

Hospitals must file a copy of their proposed operating budget for the fiscal year, with the Division of Health Care Financing and Policy (DHCFP). 

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Ophthalmia Neonatorum (ON)

Providers, hospitals, and anyone knowing the condition exists must immediately report cases of ophthalmia neonatorum (ON). The report must be signed by the parent or guardian.

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Osteopathic Physician or Physician Assistant Conduct

Any medical facility that becomes aware that a person practicing osteopathic medicine or practicing as a physician assistant has, is or is about to become engaged in conduct which constitutes grounds for initiating disciplinary action shall file a written complaint with the Board. Any hospital, clinic or other medical facility must report any change in […]

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Overdoses (Opioids)

The Nevada State Board of Health has approved final regulations to implement the provisions of Assembly Bill 474, the Controlled Substance Abuse Prevention Act. The regulations now lay out procedures for reporting cases or suspected cases of drug overdose to the State of Nevada's Chief Medical Officer. A provider of health care shall report the […]

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Patient Death Associated with Restraint or Seclusion

Hospitals must report deaths associated with the use of seclusion or restraint.

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Patient Safety Checklists

On or before July 1 of each year, the Patient Safety Committee of a medical facility shall submit a report to the Director of the Legislative Counsel Bureau for transmittal to the Legislative Committee on Health Care. The report must include information regarding the development, revision and usage of the patient safety checklists and patient […]

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Patient Suicide, Attempted Suicide or Self-Harm (Sentinel Event 3C)

Facilities must report patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting. Excludes deaths resulting from self-inflicted injuries that were the reason for admission/presentation to the healthcare facility.

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Payroll Based Journal (PBJ)

Under the ACA, long term care facilities must submit information about staff working in direct care. This includes agency and contract staff. Direct care staff are defined by the CMS as anyone that uses interpersonal contact or is involved in residential care management to provide care and services that allows the recipients to attain or […]

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Physical Assault - Death/Serious Injury (Sentinel Event 7D)

Facilities must report death or serious injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare setting. Language and definitions may vary based on state statute; however, the principle and intent remain regardless of language required based on jurisdiction.

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Physician or Physician Assistant Conduct

Any medical facility that becomes aware that a physician, perfusionist, physician assistant or practitioner of respiratory care is or is about to become engaged in conduct which constitutes grounds for initiating disciplinary action shall file a written complaint with the Board. Any hospital, clinic or other medical facility must report any change in privileges while […]

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Positive COVID-19 Test Following Second Dose of Vaccine

Facilities must inform DPBH staff immediately if a resident or staff tests positive two weeks or more following their second dose of the COVID-19 vaccine.

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Pressure Ulcers (Sentinel Event 4F)

Facilities must report any stage 3, stage 4 and unstageable pressure ulcers acquired after admission/presentation to a healthcare setting, excluding progression from stage 2 to stage 3 if stage 2 was recognized upon admission, and excludes pressure ulcers that develop in areas where deep tissue injury is documented as present on admission/presentation.

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Preventable/Inheritable Disorders in Infants

If the examination and tests reveal the existence of preventable/inheritable disorders or conditions in an infant, the provider or hospital attending or assisting at the birth of the infant shall report to the State's Chief Medical Officer, and local county health officers. Upon notification by the State Public Health Laboratory that a test is abnormal […]

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Promoting Interoperability Programs (PIP) & Electronic Health Records - Meaningful Use (EHR-MU)

In 2011, CMS established the Medicare and Medicaid EHR Incentive Programs (now known as the Promoting Interoperability Programs) to encourage eligible professionals (EPs), eligible hospitals, and CAHs to adopt, implement, upgrade (AIU), and demonstrate meaningful use of certified electronic health record technology (CEHRT). The program consisted of three stages and by using certified EHR technology, the provider must […]

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Quality Payment Program (QPP) & Merit-Based Incentive Payment System (MIPS)

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, created the Quality Payment Program (QPP). The QPP streamlined multiple quality programs under the Merit-based Incentive Payment System (MIPS) including existing payment programs that ended 12/31/18: (1) Physician Quality Reporting System (PQRS); (2) Value-based Payment Modifier (VBM); and (3) Medicare Electronic Health Record (EHR) Incentive […]

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Restraints - Death/Serious Injury (Sentinel Event 5D)

Facilities must report patient death or serious injury associated with the use of physical restraints or bedrails while being cared for in a healthcare setting. Intended to capture instances where physical restraints are implicated in the death, e.g., lead to strangulation/entrapment, etc.

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Retention of Foreign Object (Sentinel Event 1D)

Facilities must report unintended retention of foreign object in a patient after surgery or other invasive procedure. Includes medical or surgical items intentionally placed by provider(s) that are unintentionally left in place. Excludes a) objects present prior to surgery or other invasive procedure that are intentionally left in place; b) objects intentionally implanted as part […]

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Rural Health Clinic (RHC) Provider Relief Funds (PRF)

All Rural Health Clinics (RHCs) who received and accepted the Rural Testing Relief Fund Payment must report monthly the number of COVID-19 tests collected system wide (across all entities associated with the RHC's Tax Id Number (TIN)) and the number of positive COVID-19 Tests as required by the Terms and Conditions of accepting the payment.

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Sentinel Event Annual Summary Report

Each medical facility shall provide to the Division, in the form prescribed by the State Board of Health, a summary of the reports submitted by the medical facility regarding sentinel events during the immediately preceding calendar year.

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Sentinel Events in LTC

The following sentinel events apply to the long-term care setting. Please click on the links to view the reporting requirements: 1A. Surgery or other invasive procedure performed on the wrong site 1B. Surgery or other invasive procedure performed on the wrong patient 1C. Wrong surgical or other invasive procedure performed on a patient 2A. Patient […]

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Sentinel Events Involving Death

The following sentinel events involve death. Please click on the links to view the reporting requirements: 1E. Intraoperative or immediately postoperative/postprocedure death in an ASA Class I patient 2A. Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the healthcare setting 2B. Patient death or serious injury […]

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Sexual Abuse/Assault (Sentinel Event 7C)

Facilities must report sexual abuse/assault on a patient or staff member within or on the grounds of a healthcare setting. Language and definitions may vary based on state statute; however, the principle and intent remain regardless of language required based on jurisdiction.

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Sexual Offense Against a Child

A person who knows or has reasonable cause to believe that another person has committed a violent or sexual offense against a child who is 12 years of age or younger shall report to a law enforcement agency. Note: You do not need to make a duplicate report if you already reported under NRS 432B.220.

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Sickle Cell Disease (Sickle Cell Anemia Registry)(SCR)

Hospitals and providers who diagnose or provide treatment of sickle cell disease and its variants must report information regarding patients, including usage of and access to health care services.

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Stoppage of Medically Necessary Procedures

All NV hospitals must report to the Division of Public and Behavioral Health (DPBH) within 24 hours of any decision or intent to stop medically necessary procedures and provide the dates that the stoppage will remain in effect.

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Surgery or Procedure on Wrong Patient (Sentinel Event 1B)

Facilities must report surgery or other invasive procedure performed on the wrong patient, defined as any surgery or invasive procedure on a patient that is not consistent with the correctly documented informed consent for that patient. Surgery or other invasive procedure includes, but is not limited to, endoscopies, lens implants, lesion removal, injection into joints. […]

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Surgery or Procedure on Wrong Site (Sentinel Event 1A)

Facilities must report any surgery or other invasive procedure performed on the wrong site, defined as any surgery or other invasive procedure performed on a body part or site that is not consistent with the correctly documented informed consent for that patient. Surgery or other invasive procedure includes, but is not limited to, endoscopies, lens […]

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Syndromic Surveillance

The health authority may require an emergency facility or a health care provider to report information to the system for syndromic reporting and active surveillance during a major event or if the health authority determines that the reporting is otherwise appropriate and necessary to monitor the public health in this State.

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Trauma Registry (Nevada Trauma Registry) (NTR)

Hospitals shall submit quarterly reports of patients treated by hospital for trauma (any acute injury which involves a significant risk of death or the precipitation of complications or disabilities.

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UB04 (CHIA)

Hospitals must report patient discharge billing data.

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Unsafe Administration of Blood - Death/Serious Injury (Sentinel Event 4B)

Facilities must report patient death or serious injury associated with unsafe administration of blood products, including hemolytic reactions and administering blood or blood products a) to the wrong patient, b) that are the wrong type, or c) that have been improperly stored or handled.

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Unsafe FDA-Regulated Medical Devices and Drugs

Facilities are required to report when it receives information that reasonably suggests that a medical device has (or may have) caused or contributed to a serious injury or death of a patient or employee of the facility. The FDA receives voluntary reports on other serious adverse event, product quality problem, product use/medication error, or therapeutic inequivalence/failure that […]

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Unusual or Excessive Loss or Disappearance of Products

If a pharmacy becomes aware of any unusual or excessive loss or disappearance of a product that is a precursor to methamphetamine while the product is under the control of the pharmacy, the pharmacy must make an oral and written report to the NV Department of Public Safety.

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VaccineFinder

COVID-19 vaccine supply must be entered into VaccineFinder by all registered providers on a daily basis. Once there is widespread availability of the vaccine, the system will help the public search for provider locations offering vaccination near them.

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WebIZ (Immunization Information System) (IIS)

Any provider who administers any immunization to a child or adult shall report information concerning the person and the immunization provided to the Department for inclusion in the Immunization Information System (WebIZ).

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Workplace Violence

Hospitals must report incidents of workplace violence that involve the use of physical force against an employee or other provider of care by a patient or a person accompanying a patient; involves the use of a firearm or other dangerous weapon; or presents a realistic possibility of death or serious physical harm.

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Wrong or Contaminated Gas (Sentinel Event 5B)

Facilities must report any incident in which systems designed for oxygen or other gas to be delivered to a patient contain no gas, the wrong gas, or are contaminated by toxic substances. Intended to capture events in which the line is attached to a reservoir distant from the patient care unit or in a tank […]

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Wrong Surgical Procedure (Sentinel Event 1C)

Facilities must report wrong surgical or other invasive procedure performed on a patient, or any surgical procedure performed incorrectly, defined as any surgical or other invasive procedure performed on a patient that is not consistent with the correctly documented informed consent for that patient. Surgery or other invasive procedure includes, but is not limited to, […]

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DISCLAIMER
Although many of these requirements apply to individual medical professionals and other types of hospitals and health care facilities, the information is presented solely to support Critical Access Hospitals. The reporting requirements and legal mandates on this site are not an exhaustive list and Nevada Rural Hospital Partners, Inc. bears no responsibility or liability for any hospitals' or providers' failure to comply with Federal or State laws or regulations.