(a) Facilities shall submit HAI and NHSN-reported PAEs, including whether the HAI or NHSN-reported PAE contributed to a patient's death to NHSN. Health care facilities shall report TxHSN-reported PAEs through the TxHSN portal or its successor.
(b) Facilities shall comply with the process prescribed by this chapter and NHSN to allow the department access to HAI data, including whether the HAI contributed to a patient's death, and/or designated PAE data as specified in §§200.3 - 200.7 of this title (relating to How to Report; Which Events to Report; Data to Report; When to Initiate Reporting; and Schedule for HAI and PAE Reporting).
(c) Facilities shall use their facility identification number to identify their facility in the electronic data and correspondence with the department. Each facility meeting the definition of ambulatory surgical center or general hospital as defined in §200.1(2) and (12) of this title (relating to Definitions) shall have its own facility identification number.
  (1) CMS certified health care facilities shall use the CMS-assigned provider number.
  (2) If a facility has multiple campuses associated by ownership, each site shall each use a unique CMS provider number. In the event that a facility is not CMS certified or a facility operates multiple facilities under one CMS number, the facility shall use the identification number assigned by NHSN.
  (3) The relationship between CMS-assigned and NHSN-assigned facility identifiers and the name and license number of the facility is public information.
(d) The department shall notify the facility contact by email 90 calendar days in advance of any change in requirements for reporting HAI data, including whether the HAI contributed to a patient's death, and designated PAE data.
(e) Facilities shall report PAE data as defined in §200.4 and §200.6 of this title.
  (1) For HAI reporting, if the facility treating the patient performed the procedure, the facility shall report the infection to NHSN according to the surveillance methods described by NHSN and this chapter. For NHSN-reported PAE reporting, if the event occurred in the facility treating the patient, the facility shall report the event to NHSN according the surveillance methods described by NHSN and this chapter.
  (2) For PAE reporting, TxHSN-reported PAEs identified at the same facility that the PAE occurred, shall be reported through the TxHSN portal or its successor as described in this chapter.
  (3) For HAI and NHSN-reported PAE reporting, if the facility treating the patient did not perform the procedure, the treating facility shall notify the facility that performed the procedure, document the notification, and maintain this documentation for audit purposes. The facility that performed the procedure shall verify the data related to the infection. The performing facility shall report the HAI or NHSN-reported PAE to NHSN according to the surveillance methods described by NHSN and this chapter.
  (4) For TxHSN-reported PAEs, if the facility that identified the PAE is not the facility responsible for the event, the facility that identified the PAE shall notify the facility where the event occurred, document the notification, and maintain this documentation for audit purposes. The facility in which the event occurred shall report the PAE to TxHSN or its successor according to the methods described by the department and this chapter.

Source Note: The provisions of this §200.3 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