SECTION 354.1070. Definitions

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.

(1) Present on Admission--Present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered present on admission.

(2) Preventable Adverse Event--A serious, clearly identifiable and measurable error in medical care that is of concern to both the public and health care professionals and providers. The Health and Human Services Commission (HHSC) will determine Medicaid preventable adverse events, which may include the following:

(A) a health care-associated adverse condition or event for which the Medicare program will not provide additional payment under a policy adopted by the federal Centers for Medicare and Medicaid Services, which may be referred to as a hospital acquired condition, hospital acquired infection, never event, or National Coverage Determination (NCD).

(B) any other preventable adverse event that causes patient death or serious disability in a health care setting, including an event on the list of adverse events identified by the National Quality Forum.

(3) Potentially Preventable Event--One of, or any combination of, the following events:

(A) Potentially Preventable Admission--An admission of a person to a hospital or long-term care facility that may reasonably have been prevented with adequate access to ambulatory care or health care coordination.

(B) Potentially Preventable Ancillary Service--A health care service provided or ordered by a physician or other health care provider to supplement or support the evaluation or treatment of a patient, including a diagnostic test, laboratory test, therapy service, or radiology service, that may not reasonably be necessary for the provision of quality health care or treatment.

(C) Potentially Preventable Complication--A harmful event or negative outcome with respect to a person, including an infection or surgical complication, that:

(i) occurs after the person's admission to a hospital or long-term care facility; and

(ii) may have resulted from the care, lack of care, or treatment provided during the hospital or long-term care facility stay rather than from a natural progression of an underlying disease.

(D) Potentially Preventable Emergency Room Visit--Treatment of a person in a hospital emergency room or freestanding emergency medical care facility for a condition that could be, or could have been, treated or prevented by a physician or other health care provider in a nonemergency setting.

(E) Potentially Preventable Readmission--A return hospitalization of a person within a period specified by HHSC that results from deficiencies in the care or treatment provided to the person during a previous hospital stay or from deficiencies in post-hospital discharge follow-up. The term does not include a hospital readmission necessitated by the occurrence of unrelated events after the discharge. The term includes the readmission of a person to a hospital for:

(i) the same condition or procedure for which the person was previously admitted;

(ii) an infection or other complication resulting from care previously provided;

(iii) a condition or procedure that indicates that a surgical intervention performed during a previous admission was unsuccessful in achieving the anticipated outcome; or

(iv) another condition or procedure of a similar nature, as determined by HHSC.

Source Note: The provisions of this §354.1070 adopted to be effective September 1, 2010, 35 TexReg 6649; amended to be effective April 21, 2013, 38 TexReg 2315