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Reporting And Data

Healthcare-Associated Infections (HAI)

Latest Update: August 11, 2020
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Reporting Information

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 the Centers for Disease Control and Prevention of the United States Department of Health and Human Services that integrates patient and health care personnel safety surveillance systems.

Responsible Party

Who Must Report?

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. Note that no Critical Access Hospitals (CAHs) have more than 25 beds and thus would not have an average daily census large enough to be subject to this mandate. However, some distinct-part skilled nursing facilities may qualify for this reporting requirement.

Deadlines

When Do I Report?

Method

How Do I Report?

Division of Public and Behavioral Health via the National Healthcare Safety Network (NHSN).

Contact Information

Public Health Informatics & Epidemiology (OPHIE)
Healthcare Associated Infection Prevention and Control (HAI)
3811 W. Charleston Blvd.
Suite 205
Las Vegas, NV 89102
Phone: (702) 486-3568
Fax: (702) 486-0490

Authority

The legal mandate requiring reporting

NRS 439.847  Participation in surveillance system by medical facilities and facilities for skilled nursing; access, analysis and reporting of information submitted to surveillance system by Division; regulations.

      1.  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 the Centers for Disease Control and Prevention of the United States Department of Health and Human Services that integrates patient and health care personnel safety surveillance systems. As part of that participation, the medical facility or facility for skilled nursing shall provide, at a minimum, the information required by the Division pursuant to this subsection. The Division shall by regulation prescribe the information which must be provided by a medical facility or facility for skilled nursing, including, without limitation, information relating to infections and procedures.

      2.  Each medical facility or facility for skilled nursing which provided medical services and care to an average of less than 25 patients during each business day in the immediately preceding calendar year may participate in the secure, Internet-based surveillance system established by the Division of Healthcare Quality Promotion of the Centers for Disease Control and Prevention of the United States Department of Health and Human Services that integrates patient and health care personnel safety surveillance systems.

NAC 439.935  Participation in National Healthcare Safety Network: Data to be submitted by each type of medical facility or facility for skilled nursing. (NRS 439.847439.890)

 7.  Each facility for skilled nursing that is required to participate in the National Healthcare Safety Network shall, commencing not later than:

     (a) January 1, 2015, submit data to the National Healthcare Safety Network relating to all catheter-associated urinary tract infections.

     (b) October 1, 2015, carry out the Summary Method of the Vaccination Module of the Patient Safety Component of the National Healthcare Safety Network.

     (c) January 1, 2016, carry out the Clostridium difficile infection surveillance option of the Multidrug-Resistant Organism and Clostridium difficile Infection Module of the Patient Safety Component of the National Healthcare Safety Network.

     (d) October 1, 2016, carry out the Influenza Vaccination Module of the Healthcare Personnel Safety Component of the National Healthcare Safety Network.

Each facility for skilled nursing shall continue to report the information required pursuant to this subsection to the National Healthcare Safety Network at the times and in the manner prescribed by the National Healthcare Safety Network for submission of that information.

Notes

Any other pertinent information

A medical facility or a facility for skilled nursing shall report all confirmed and all suspected instances of a facility-acquired infection acquired at another medical facility or facility for skilled nursing to the medical facility or facility for skilled nursing in which the infection was acquired. The medical facility or facility for skilled nursing which reports a confirmed or suspected instance of a facility-acquired infection pursuant to this subsection shall keep a record of that report for not less than 3 years after making such report.

If a medical facility or a facility for skilled nursing participates in the National Healthcare Safety Network, the chief executive officer of the medical facility or facility for skilled nursing, or the officer’s designee, shall, on or before March 1 of each year, submit to the Division a signed statement certifying that the medical facility or facility for skilled nursing has processes in place to ensure that the data relating to facility-acquired infections submitted to the National Healthcare Safety Network is accurate and meets the requirements of NAC 439.900 to 439.945, inclusive.

Current Documents

Documents related to this reporting
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.