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Health care facility reporting - 40 Pa. Stat. Ann. § 1303.404

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Nursing homes must electronically report health care-associated infection data on a patient-specific basis to the department of health using nationally recognized standards based on CDC definitions. 

Hospitals must report health care-associated infection data to the CDC and its National Healthcare Safety Network (NHSN).  Each hospital must:

  • Report all components as defined in the NHSN Manual, Patient Safety Component Protocol for all patients throughout the facility on a continuous basis;
  • Report patient-specific data to include patient identification numbers, gender and date of birth;
  • Report data on a monthly basis in accordance with protocols defined in the NHSN Manual as updated by the CDC;
  • Authorize the department, the patient safety authority and the health care cost containment council to have access to the NHSN for facility-specific reports of health care-associated infection data contained in the NHSN database for purposes of viewing and analyzing that data.

Hospitals must have a qualified electronic surveillance system in place that includes the following elements:

  • Extractions of existing clinical data from health care facility systems on an ongoing, constant and consistent basis;
  • Translation from non-standardized laboratory, pharmacy and/or radiology data into uniform information that can be analyzed on a population-wide basis;
  • Clinical support, educational tools and training to ensure that information provided will assist the hospital in reducing the incidence of health care-associated infections in a manner that meets or exceeds benchmarks;
  • Clinical improvement measures designed to provide feedback to health care facility infection control staff; and
  • Collection of data that is patient-specific for the entire facility.


Current as of June 2015