N.Y. Public Health Law Section 2819
Hospital acquired infection reporting

1.

For the purposes of this section, “hospital acquired infection” shall mean any localized or systemic patient condition that:

(a)

resulted from the presence of an infectious agent or agents, or its toxin or toxins as determined by clinical examination or by laboratory testing; and

(b)

was not found to be present or incubating at the time of admission unless the infection was related to a previous admission.

2.

(a) Each general hospital shall maintain a program capable of identifying and tracking hospital acquired infections for the purpose of public reporting under this section and quality improvement.

(b)

Such programs shall have the capacity to identify the following elements: the specific infectious agents or toxins and site of each infection; the clinical department or unit within the facility where the patient first became infected; and the patient’s diagnoses and any relevant specific surgical, medical or diagnostic procedure performed during the current admission.

(c)

The department shall establish guidelines, definitions, criteria, standards and coding for hospital identification, tracking and reporting of hospital acquired infections which shall be consistent with the recommendations of recognized centers of expertise in the identification and prevention of hospital acquired infections including, but not limited to the National Health Care Safety Network of the Centers for Disease Control and Prevention or its successor. The department shall solicit and consider public comment prior to such establishment.

(d)

Hospitals shall be initially required to identify, track and report hospital acquired infections that occur in critical care units to include surgical wound infections and central line related bloodstream infections.

(e)

For hospital acquired infections for which the department requires tracking and reporting as permitted in this section, hospitals shall be required to report a suspected or confirmed hospital-acquired infection associated with another hospital to the originating hospital. Documentation of reporting should be maintained for a minimum of six years.

(f)

Subsequent to the initial requirements identified in paragraph (d) of this subdivision the department may, from time to time, require the tracking and reporting of other types of hospital acquired infections (for example, ventilator - associated pneumonias) that occur in hospitals in consultation with technical advisors who are regionally or nationally-recognized experts in the prevention, identification and control of hospital acquired infection and the public reporting of performance data.

3.

Each hospital shall regularly report to the department the hospital infection data it has collected. The department shall establish data collection and analytical methodologies that meet accepted standards for validity and reliability. The frequency of reporting shall be monthly, and reports shall be submitted not more than sixty days after the close of the reporting period.

4.

The commissioner shall establish a state-wide database of all reported hospital acquired infection information for the purpose of supporting quality improvement and infection control activities in hospitals. The database shall be organized so that consumers, hospitals, healthcare professionals, purchasers and payers may compare individual hospital experience with that of other individual hospitals as well as regional and state-wide averages and, where available, national data.

5.

(a) Subject to paragraph (c) of this subdivision, on or before September first of each year the commissioner shall submit a report to the governor and the legislature, which shall simultaneously be published in its entirety on the department’s web site, that includes, but is not limited to, hospital acquired infection rates adjusted for the potential differences in risk factors for each reporting hospital, an analysis of trends in the prevention and control of hospital acquired infection rates in hospitals across the state, regional and, if available, national comparisons for the purpose of comparing individual hospital performance, and a narrative describing lessons for safety and quality improvement that can be learned from leadership hospitals and programs.

(b)

The commissioner shall consult with technical advisors who have regionally or nationally acknowledged expertise in the prevention and control of hospital acquired infection and infectious disease in order to develop the adjustment for potential differences in risk factors to be used for public reporting.

(c)

(i) No later than July first, two thousand six, the department shall establish a hospital acquired infection reporting system capable of receiving electronically transmitted reports from hospitals. Hospitals shall begin to submit such reports as directed by the commissioner but in no case later than January first, two thousand seven.

(ii)

The first year of data submission under this section shall be considered the “pilot phase” of the statewide hospital acquired infection reporting system. The purpose of the pilot phase is to ensure, by various means, including any audit process referred to in subdivision seven of this section, the completeness and accuracy of hospital acquired infection reporting by hospitals. For data reported during the pilot phase, hospital identifiers shall be encrypted by the department in any and all public databases and reports. The department shall provide each hospital with an encryption key for that hospital only to permit access to its own performance data for internal quality improvement purposes.

(iii)

No later than one hundred eighty days after the conclusion of the pilot phase, the department shall issue a report to hospitals assessing the overall accuracy of the data submitted in the pilot phase and provide guidance for improving the accuracy of hospital acquired infection reporting. The department shall issue a report to the governor and the legislature assessing the overall completeness and accuracy of the data submitted by hospitals during the pilot phase and make recommendations for the improvement or modification of hospital acquired infection data reporting based on the pilot phase as well as share lessons learned in prevention of hospital acquired infections. No hospital identifiable data shall be included in the pilot phase report, but aggregate or otherwise de-identified data may be included.

(iv)

After the pilot phase is completed, all data submitted under this section and compiled in the statewide hospital acquired infection database established herein and all public reports derived therefrom shall include hospital identifiers.

6.

Subject to subdivision five of this section, a summary table, in a format designed to be easily understood by lay consumers, that includes individual facility hospital acquired infection rates adjusted for potential differences in risk factors and comparisons with regional and/or state averages shall be developed and posted on the department’s web site. The commissioner shall consult with consumer and patient advocates and representatives of reporting facilities for the purpose of ensuring that such summary table report format is easily understandable by the public, and clearly and accurately portrays comparative hospital performance in the prevention and control of hospital acquired infections.

7.

To assure the accuracy of the self-reported hospital acquired infection data and to assure that public reporting fairly reflects what actually is occurring in each hospital, the department shall develop and implement an audit process.

8.

For the purpose of ensuring that hospitals have the resources needed for ongoing staff education and training in hospital acquired infection prevention and control, the department may make such grants to hospitals within amounts appropriated therefor.

9.

Individual patient identifying information reported to the department under this section shall be subject to paragraph (j) of subdivision one of § 206 (Commissioner)section two hundred six of this chapter. Regulations under this section shall include standards to assure the protection of patient privacy in data collected and released under this section and standards for the publication and release of data reported under this section.

Source: Section 2819 — Hospital acquired infection reporting, https://www.­nysenate.­gov/legislation/laws/PBH/2819 (updated Sep. 22, 2014; accessed Apr. 20, 2024).

2800
Declaration of policy and statement of purpose 2801
Definitions 2801‑A
Establishment or incorporation of hospitals 2801‑B
Improper practices in hospital staff appointments and extension of professional privileges prohibited 2801‑C
Injunctions 2801‑D
Private actions by patients of residential health care facilities 2801‑E
Voluntary residential health care facility rightsizing demonstration program 2801‑F
Residential health care facility quality incentive payment program 2801‑G
Community forum on hospital closure 2801‑H
Personal caregiving and compassionate caregiving visitors to nursing home residents during declared local or state health emergencies 2802
Approval of construction 2802‑A
Transitional care unit demonstration program 2802‑B
Health equity impact assessments 2803
Commissioner and council 2803‑A
Authority to contract 2803‑AA
Sickle cell disease information distribution 2803‑AA*2
Nursing home infection control competency audit 2803‑B
Uniform reports and accounting systems for hospital costs 2803‑C
Rights of patients in certain medical facilities 2803‑C‑1
Rights of patients in certain medical facilities 2803‑C‑2
Lesbian, gay, bisexual and transgender, and people living with HIV long-term care facility residents’ bill of rights 2803‑D
Reporting abuses of persons receiving care or services in residential health care facilities 2803‑E
Residential health care facilities 2803‑E*2
Reporting incidents of possible professional misconduct 2803‑F
Respite projects 2803‑G
Board of visitors in county owned residential health care facility 2803‑H
Health related facility 2803‑I
General hospital inpatient discharge review program 2803‑J
Information for maternity patients 2803‑J*2
Nursing home nurse aide registry 2803‑K
In-patient nasogastric feeding procedures 2803‑L
Community service plans 2803‑M
Discharge of hospital patients to adult homes 2803‑N
Hospital care for maternity patients 2803‑O
Hospital care for mastectomy, lumpectomy, and lymph node dissection patients 2803‑O‑1
Required protocols for fetal demise 2803‑P
Disclosure of information concerning family violence 2803‑Q
Family councils in residential health care facilities 2803‑R
Dissemination of information about the abandoned infant protection act 2803‑S
Access to product recall information 2803‑T
Preadmission information 2803‑U
Hospital substance use disorder policies and procedures 2803‑V
Lymphedema information distribution 2803‑V*2
Standing orders for newborn care in a hospital 2803‑W
Independent quality monitors for residential health care facilities 2803‑W*2
Disclosure of information concerning pregnancy complications 2803‑X
Requirements related to nursing homes and related assets and operations 2803‑Y
Provision of residency agreement 2803‑Z
Transfer, discharge and voluntary discharge requirements for residential health care facilities 2803‑Z*2
Antimicrobial resistance prevention and education 2804
Units for hospital and health-related affairs 2804‑A
State task force on clinical practice guidelines and medical technology assessment 2805
Approval of hospitals 2805‑A
Disclosure of financial transactions 2805‑B
Admission of patients and emergency treatment of nonadmitted patients 2805‑C
Every private proprietary nursing home having a capacity of eighty patients or more may have a licensed medical doctor in attendance, upo... 2805‑D
Limitation of medical, dental or podiatric malpractice action based on lack of informed consent 2805‑E
Reports of residential health care facilities 2805‑F
Money deposited or advanced for admittance to nursing homes 2805‑G
Maintenance of records 2805‑H
Immunizations 2805‑I
Treatment of sexual offense victims and maintenance of evidence in a sexual offense 2805‑J
Medical, dental and podiatric malpractice prevention program 2805‑K
Investigations prior to granting or renewing privileges 2805‑L
Adverse event reporting 2805‑M
Confidentiality 2805‑N
Child abuse prevention 2805‑O
Identification of veterans and their spouses by nursing homes, residential health care facilities, and adult care facilities 2805‑P
Emergency treatment of rape survivors 2805‑Q
Hospital visitation by domestic partner 2805‑R
Patients unable to verbally communicate 2805‑S
Circulating nurse required 2805‑T
Clinical staffing committees and disclosure of nursing quality indicators 2805‑U
Credentialing and privileging of health care practitioners providing telemedicine services 2805‑V
Observation services 2805‑W
Patient notice of observation services 2805‑X
Hospital-home care-physician collaboration program 2805‑Y
Identification and assessment of human trafficking victims 2805‑Z
Hospital domestic violence policies and procedures 2806
Hospital operating certificates 2806‑A
Temporary operator 2806‑B
Residential health care facilities 2807
Hospital reimbursement provisions 2807‑A
General hospital nineteen hundred eighty-six and nineteen hundred eighty-seven inpatient rates and charges 2807‑AA
Nurse loan repayment program 2807‑B
Outstanding payments and reports due under subdivision eighteen of section twenty-eight hundred seven-c, sections twenty-eight hundred se... 2807‑C
General hospital inpatient reimbursement for annual rate periods beginning on or after January first, nineteen hundred eighty-eight 2807‑D
Hospital assessments 2807‑D‑1
Hospital quality contributions 2807‑DD
Temporary nursing home stability contributions 2807‑E
Uniform bills 2807‑F
Health maintenance organization payment factor 2807‑I
Service and quality improvement grants 2807‑J
Patient services payments 2807‑K
General hospital indigent care pool 2807‑L
Health care initiatives pool distributions 2807‑M
Distribution of the professional education pools 2807‑N
Palliative care education and training 2807‑O
Early intervention services pool 2807‑P
Comprehensive diagnostic and treatment centers indigent care program 2807‑R
Funding for expansion of cancer services 2807‑S
Professional education pool funding 2807‑T
Assessments on covered lives 2807‑U
Transfers for tax credits 2807‑V
Tobacco control and insurance initiatives pool distributions 2807‑W
High need indigent care adjustment pool 2807‑X
Grants for long term care demonstration projects 2807‑Y
Pool administration 2807‑Z
Review of eligible federally qualified health center capital projects 2808
Residential health care facilities 2808‑A
Liability of certain persons 2808‑B
Certification of financial statements and financial information 2808‑C
Reimbursement of general hospital inpatient services 2808‑D
Nursing home quality improvement demonstration program 2808‑E
Residential health care for children with medical fragility in transition to young adults and young adults with medical fragility demonst... 2808‑E*2
Nursing home ratings 2809
Residential health care facilities 2810
Residential health care facilities 2811
Discounts and splitting fees with medical referral services 2812
Construction 2813
Separability 2814
Health networks, global budgeting, and health care demonstrations 2815
Health facility restructuring program 2815‑A
Community health care revolving capital fund 2816
Statewide planning and research cooperative system 2816‑A
Cardiac services information 2817
Community health centers capital program 2818
Health care efficiency and affordability law of New Yorkers (HEAL NY) capital grant program 2819
Hospital acquired infection reporting 2820
Home based primary care for the elderly demonstration project 2821
State electronic health records (EHR) loan program 2822
Residential care off-site facility demonstration project 2823
Supportive housing development program 2824
Central service technicians 2824*2
Surgical technology and surgical technologists 2825
Capital restructuring financing program 2825‑A
Health care facility transformation program: Kings county project 2825‑B
Oneida county health care facility transformation program: Oneida county project 2825‑C
Essential health care provider support program 2825‑D
Health care facility transformation program: statewide 2825‑E
Health care facility transformation program: statewide II 2825‑F
Health care facility transformation program: statewide III 2825‑G
Health care facility transformation program: statewide IV 2825‑H
Health care facility transformation program: statewide V 2826
Temporary adjustment to reimbursement rates 2827
Plant-based food options 2828
Residential health care facilities 2828*2
Essential support persons allowed for individuals with disabilities during a state of emergency 2829
Nursing homes 2830
Surgical smoke evacuation 2830*2
Regulation of the billing of facility fees
Green check means up to date. Up to date

Accessed:
Apr. 20, 2024

Last modified:
Sep. 22, 2014

§ 2819’s source at nysenate​.gov

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