SECTION 200.4. Which Events to Report

(a) ICD-CM codes as designated by the federal NHSN shall constitute the definition of events listed in this rule. Facilities shall adapt to changes in ICD-CM specifications as directed by NHSN and the department.

(b) A health care facility shall report HAI data to the department for any HAI occurring in the facility that CMS requires to be reported through NHSN. The HAI data must include the causative pathogen if the infection is laboratory-confirmed. A current list of reportable HAIs can be found at HAITexas.org.

(c) A health care facility shall report each HAI to the department under this section regardless of the facility's participation in Medicare.

(d) Facilities shall report whether the HAI or the NHSN-reported PAE contributed to a patient's death either directly or by exacerbating an existing disease condition which then led to death.

(e) A health care facility shall report any of the following preventable adverse events involving the facility's patient. A current list of reportable PAEs can be found at PAETexas.org.

(1) A health care-associated adverse condition or event for which the Medicare program will not provide additional payment to the facility under a policy adopted by the federal Centers for Medicare and Medicaid Services.

(2) An event included in the list of adverse events identified by the National Quality Forum.

(3) The executive commissioner may exclude an adverse event from the reporting requirement if the executive commissioner, in consultation with the advisory panel, determines that the adverse event is not an appropriate indicator of a preventable adverse event.

(f) Facilities shall also report denominator data as indicated in TxHSN protocols for TxHSN-reported PAEs. For the HAI events identified in this section for calculation of risk adjusted infection rates as required in Texas Health and Safety Code, §98.106(b), NHSN protocols shall be used for the determination of denominator data for HAI and NHSN-reported PAEs. The following facility information shall be entered by the facility for each reporting period.

(1) Number of beds.

(2) Number of surgeries or invasive procedures performed during the reporting period.

(3) Number of patient days.

(g) If a facility has no HAI and/or PAE during the reporting period, facilities shall report this information through NHSN for HAI and NHSN-reported PAEs. Facilities shall report the absence of TxHSN-reported PAEs through the TxHSN portal or its successor.

Source Note: The provisions of this §200.4 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; amended to be effective September 17, 2014, 39 TexReg 7340; amended to be effective January 18, 2015, 40 TexReg 245; amended to be effective January 1, 2020, 44 TexReg 7713