1. (a) Facilities shall submit HAI and designated PAE data required by this section to NHSN or its successor.
2. (b) Facilities shall comply with the process prescribed by NHSN or its successor to allow the department access to HAI and designated PAE data as specified in §§200.3 - 200.7 of this title.

3. (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(1) and (11) of this title (relating to Definitions) shall have its own facility identification number.

   1. (1) CMS certified health care facilities shall use the CMS-assigned provider number.
   2. (2) If a facility has multiple campuses or a hospital and ambulatory surgical center are 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 or its successor.
   3. (3) The relationship between CMS-assigned and NHSN-assigned facility identifiers and the name and license number of the facility is public information.
4. (d) The department shall notify the facility contact by email 90 calendar days in advance of any change in requirements for reporting HAI and designated PAE data.

5. (e) Facilities shall report HAI data on patients identified with a surgical site infection associated with a procedure listed in §200.4 of this title (relating to Which Events to Report).

   1. (1) If the facility treating the patient performed the procedure, the facility shall report the infection to NHSN or its successor according to the surveillance methods described by NHSN or its successor and this chapter.
   2. (2) If the facility treating the patient did not perform the surgery, 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 SSI and designated PAE and shall report the infection to NHSN or its successor according to the surveillance methods described by NHSN or its successor and this chapter.

Source Note:The provisions of this §200.3 adopted to be effective May 4, 2011, 36 TexReg 2729; amended to be effective August 7, 2012, 37 TexReg 5793; amended to be effective April 21, 2013, 38 TexReg 2363.