1. (1) Pursuant to Section 26B-7-221, each facility required to report data on the incidence and rate of healthcare associated infections, including any ambulatory surgical facility, general acute hospital, specialty hospital, end stage renal disease facility, or any facility required by CMS, as mandated by CMS to the NHSN shall:

   1. (a) share data with the Department by joining the Department NHSN Group, UDOH HAI (ID# 17686);
   2. (b) confer rights to the Department in NHSN;
   3. (c) exclude patient identifiers unless necessary for reporting requirements and data validation; and
   4. (d) follow CMS rules and NHSN protocols for defining terms and criteria for reporting infection data.

2. (2) Any facility required to report data to NHSN shall confer rights to the Department for all reported data elements, except for patient identifiers unless necessary for reporting requirements, including for data validation, for the following conditions:

   1. (a) central line associated bloodstream infections (CLABSI);
   2. (b) catheter associated urinary tract infections (CAUTI);
   3. (c) surgical site infections from procedures on the colon and abdominal hysterectomy;
   4. (d) methicillin-resistant Staphylococcus aureus bacteremia;
   5. (e) Clostridioides difficile infection of the colon; and
   6. (f) any other health care associated infections reported to NHSN as required by CMS.

KEY: quality improvement, patient safety, health care, infection controls

Date of Last Change: September 28, 2023

Notice of Continuation: November 3, 2022

Authorizing, and Implemented or Interpreted Law: 26B-1-202; 26B-7-202; 26B-7-207; 26B-7-221