New Hampshire § 151-33 - Section 151:33 Hospitals, End-Stage Renal Dialysis Centers, Nursing and Other Residential Care Facilities, New Hampshire Veterans' Home, Assisted Living Residences, and Ambulatory Surgical Facilities Required to Report.

§ 151-33. Section 151:33 Hospitals, End-Stage Renal Dialysis Centers, Nursing and Other Residential Care Facilities, New Hampshire Veterans' Home, Assisted Living Residences, and Ambulatory Surgical Facilities Required to Report.

I. Any hospital licensed pursuant to this chapter shall maintain a program capable of identifying and tracking infections for the purpose of reporting under this section. Such program shall have the capacity to identify the following elements: (a) The specific infectious agents or toxins and site of each infection; (b) The clinical department or unit within the facility where the patient first became infected or was first diagnosed; and (c) The patient's diagnoses at time of admission and any relevant specific surgical, medical, or diagnostic procedure performed during the current admission. II. (a) Hospitals shall initially identify, track, and report infections to include: (1) Central line related bloodstream infections; (2) Catheter associated urinary tract infections; and (3) Surgical wound infections. (b) Hospitals shall also initially identify, track, and report process measures including coverage rates of influenza vaccination for health care personnel and patients/residents. II-a. Any ambulatory surgical facility licensed pursuant to this chapter shall maintain a program capable of identifying and tracing infections for the purpose of reporting under this section. Such program shall have the capacity to identify the following elements: (a) Surgical wound infections. (b) Surgical antimicrobial prophylaxis. (c) Coverage rates of influenza vaccination for health care personnel. II-b. Any end-stage renal dialysis center licensed pursuant to this chapter shall maintain a program capable of identifying and tracking infections for the purpose of reporting under this section. Such program shall have the capacity to identify the following elements: (a) Positive blood culture. (b) Vascular access site infection. (c) Intravenous antimicrobial start time. (d) Coverage rates of influenza vaccination for health care personnel. II-c. Any nursing and residential care facility licensed pursuant to this chapter, the New Hampshire veterans' home established under RSA 119:1, or any assisted living residence licensed under RSA 161-J shall maintain a program capable of identifying and tracking the coverage rates of influenza vaccination for health care personnel. Nothing in this section shall be construed to mandate or require influenza vaccination for health care personnel or patients/residents. III. Subsequent to the initial requirements identified in paragraphs II, II-a, or II-b, the department shall, from time to time, require the tracking and reporting of other types of infections and measures when reporting protocols are identified by the department, that occur in hospitals, end-stage renal dialysis centers, and ambulatory surgical facilities in consultation with technical advisors, which shall include the Centers for Disease Control and Prevention (CDC), Centers for Medicare and Medicaid Services (CMS) Hospital Inpatient Quality Reporting Program, and the National Quality Forum, who are regionally or nationally-recognized experts in the prevention, identification, and control of health care associated infections and the reporting of performance data. All required tracking and reporting of other types of infections and measures shall be consistent with the requirements supported by the CDC, CMS Hospital Inpatient Quality Reporting Program, or the National Quality Forum. IV. The commissioner of the department shall adopt rules, pursuant to RSA 541-A, for hospital, end-stage renal dialysis center, nursing and residential care facility, the New Hampshire veterans' home, assisted living residence, and ambulatory surgical facility identification, tracking, and reporting of infections, measures, and/or coverage rates of influenza vaccinations as required in this section which shall be consistent with the recommendations of recognized centers of expertise in the identification and prevention of infections including, but not limited to the National Healthcare Safety Network and the Healthcare Infection Control Practices Advisory Committee of the Centers for Disease Control and Prevention or its successor, The Joint Commission, the Centers for Medicare and Medicaid Services, the Hospital Quality Alliance, the National Quality Forum, and the New Hampshire health care quality and safety commission under RSA 151-G. V. Each hospital, end-stage renal dialysis center, nursing and residential care facility, the New Hampshire veterans' home, assisted living residence, and ambulatory surgical facility shall regularly report to the department hospital, end-stage renal dialysis center, nursing and residential care facility, the New Hampshire veterans' home, assisted living residence, and ambulatory surgical facility acquired infections and the infection data it has collected and/or coverage rates of influenza vaccinations as required in this section. Such reporting shall be done in the manner directed by the department in accordance with rules adopted pursuant to RSA 541-A. The commissioner shall establish data collection and analytical methodologies that meet accepted standards for validity and reliability. In no case shall the frequency of reporting be required to be more frequently than once every 3 months, and reports shall be submitted not more than 60 days after the close of the reporting period.