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Oregon Bulletin

November 1, 2011

 

Oregon Health Authority,
Office for Oregon Health Policy and Research
Chapter 409

Rule Caption: Temporary Adoption of Patient-Centered Primary Care Home Program Rules.

Adm. Order No.: OHP 6-2011(Temp)

Filed with Sec. of State: 9-29-2011

Certified to be Effective: 10-1-11 thru 3-15-12

Notice Publication Date:

Rules Adopted: 409-055-0000, 409-055-0010, 409-055-0020, 409-055-0030, 409-055-0040, 409-055-0050, 409-055-0060, 409-055-0070, 409-055-0080

Subject: The Oregon Health Authority, Office for Oregon Health Policy and Research is adopting temporary administrative rules for the Patient-Centered Primary Care Home (PCPCH) Program. The rules implement PCPCH standards, reporting, and recognition process and other applicable mandates of ORS 442.210, which was enacted by the 74th Legislative Assembly and 2011 Oregon Laws, Chapter 602 (HB 3650) enacted by the 75th Legislative Assembly. These proposed rules are intended to fulfill the mandates by prescribing the standards used for practices to quality as PCPCHs, the reporting requirements for PCPCHs, and the process used to recognize PCPCHs.

      These temporary rules are available on the OHPR website: http://www.oregon.gov/OHA/OHPR/rulemaking/index.shtml.

      For hardcopy requests, call: (503) 373-1574.

Rules Coordinator: Zarie Haverkate—(503) 373-1574

409-055-0000

Scope

These rules (OAR 409-055-0000 to 409-055-0080) establish the Patient-Centered Primary Care Home Program and define criteria that the Authority shall use to recognize and verify status as PCPCHs. The PCPCH is a model of primary care that has received attention in Oregon and across the country for its potential to advance the “triple aim” goals of health reform: a healthy population, extraordinary patient care for everyone, and reasonable costs, shared by all. PCPCHs achieve these goals through a focus on wellness and prevention, coordination of care, active management and support of individuals with special health care needs, and a patient and family-centered approach to all aspects of care. PCPCHs emphasize whole-person care in order to address a patient and family’s physical and behavioral health care needs.

Stat. Auth.: ORS 413.042, 442.210 & 2011 OL Chapter 602 (HB 3650)

Stats. Implemented: ORS 413.042, 442.210 & 2011 OL Chapter 602 (HB 3650)

Hist.: OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12

409-055-0010

Definitions

The following definitions apply to OAR 409-055-0000 to 409-055-0080:

(1) “Administrator” means the administrator or designee of The Office for Oregon Health Policy and Research as defined in ORS 442.011.

(2) “Authority” means the Oregon Health Authority.

(3) “CHIPRA Core Measure Set” means the initial core set of children’s health care quality measures released by the Centers for Medicare and Medicaid Services in 2009 for voluntary use by Medicaid and CHIP programs.

(4) “NCQA” means National Committee for Quality Assurance.

(5) “Office” means The Office for Oregon Health Policy and Research.

(6) “Patient Centered Medical Home (PCMH)” means a practice or provider who has been recognized as such by the National Committee for Quality Assurance.

(7) “Patient-Centered Primary Care Home (PCPCH)” means a health care team or clinic as defined in 2011 OL Chapter 602 (HB 3650), meets the standards pursuant to OAR 409-055-0030, and has been recognized through the process pursuant to OAR 409-055-0040.

(8) “Personal Health Information” means demographic information, medical history, test and laboratory results, insurance information and other data that is collected by a health care professional to identify an individual and determine appropriate care.

(9) “Practice” means an individual, facility, institution, corporate entity, or other organization which supplies health care services or items, also termed a performing provider, or bills, obligates and receives reimbursement on behalf of a performing provider of services, also termed a billing provider (BP). The term provider refers to both performing providers and BP(s) unless otherwise specified.

(10) “Program” means Patient-Centered Primary Care Home Program.

(11) “Program website” means http://www.oregon.gov/ OHA/OHPR/ HEALTHREFORM/PCPCH/index.shtml.

(12) “Provider” means an individual, facility, institution, corporate entity, or other organization which supplies health care services or items, also termed a performing provider, or bills, obligates and receives reimbursement on behalf of a performing provider of services, also termed a billing provider (BP). The term provider refers to both performing providers and BP(s) unless otherwise specified.

(13) “Recognition” means the process through which the Authority determines if a practice has met the Oregon Patient-Centered Primary Care Home Standards.

(14) “Recognized” means that the Authority has affirmed that a practice meets the Oregon Patient-Centered Primary Care Home Standards.

(15) “Tier” means the level of Patient-Centered Primary Care Home at which the Authority has scored a practice.

(16) “Verification” means the process that Office for Oregon Health Policy and Research shall conduct to ensure that a practice has submitted accurate information to the Authority for purposes of Patient-Centered Primary Care Home recognition.

Stat. Auth.: ORS 413.042, 442.210 & 2011 OL Chapter 602 (HB 3650)

Stats. Implemented: ORS 413.042, 442.210 & 2011 OL Chapter 602 (HB 3650)

Hist.: OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12

409-055-0020

Program Administration

(1) The Program is intended to ensure that there is a uniform process for recognizing PCPCHs throughout the State of Oregon in order to support primary care transformation.

(2) The Office shall recognize practices as PCPCHs upon meeting defined criteria through the Program.

(3) The Office shall administer the Program, including data collection and analysis, recognition, and verification that a practice meets the defined PCPCH criteria. The Office may also provide technical assistance as is feasible.

(4) The Office may contract for any of the work it deems necessary for efficient and effective administration of the Program.

Stat. Auth.: ORS 413.042, 442.210 & 2011 OL Chapter 602 (HB 3650)

Stats. Implemented: ORS 413.042, 442.210 & 2011 OL Chapter 602 (HB 3650)

Hist.: OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12

409-055-0030

Recognition Criteria

(1) The PCPCH measures are divided into “Must-Pass” measures and other measures that place the practice on a scale of maturity or ‘tier’ that reflect basic to more advanced PCPCH functions.

(2) Must-Pass and Tier 1 measures focus on foundational PCPCH elements that should be achievable by most practices in Oregon with significant effort, but without significant financial outlay.

(3) Tier 2 and Tier 3 measures reflect intermediate and advanced functions.

(4) Except for the 10 Must-Pass measures, each measure is assigned a point value corresponding to the Tier. For a practice to be recognized as a PCPCH, it must meet the following point allocation criteria:

(a) Tier 1: 30–60 points and all 10 Must-Pass Measures

(b) Tier 2: 65–125 points and all 10 Must-Pass Measures

(c) Tier 3: 130 points or more and all 10 Must-Pass Measures

(5) A practice’s point score shall be calculated through the recognition process pursuant to OAR 409-055-0040.

(6) See Table 1 for a detailed list of Measures and corresponding point assignment.

(7) See Tables 2.A and 2.B for a detailed list of the PCPCH Quality Measures referred to in Table 1, 2.A) Performance & Clinical Quality Improvement, 4.A) Personal Clinician Assigned, and 4.D) Personal Clinician Continuity.

(8) Data specifications for the measures listed in Table 2 shall be available on the Program website.

(9) Quantitative data shall be aggregated at the practice level, not the individual patient level, and there may not be any transfer of any personal health information.

(10) Measure specification, thresholds for demonstrating improvement, and benchmarks for quantitative data elements shall be developed by the Office and made available on the Program website.

(11) NCQA recognition will be acknowledged in the Authority’s Patient Centered Medical Home (PCMH) recognition process.

(12) Depending on the version of NCQA recognition that was used, practices seeking Oregon PCPCH recognition must attest to being a NCQA recognized PCMH and submit additional information.

(13) Additional required elements are listed in Table 3 for PCMH practices using 2008 NCQA criteria and Table 4 for PCMH practices using 2011 NCQA criteria.

(Tables: Tables reference are available from the agency.)

Stat. Auth.: ORS 413.042, 442.210 & 2011 OL Chapter 602 (HB 3650)

Stats. Implemented: ORS 413.042, 442.210 & 2011 OL Chapter 602 (HB 3650)

Hist.: OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12

409-055-0040

Recognition Process

(1) The Office shall develop a web-based reporting process where practices or other entities on behalf of the practice shall submit data per OAR 409-055-0030. Based on the data submitted by a practice and the criteria in OAR 409-055-0030, the Office shall assign a Tier level to each recognized practice.

(2) The Office shall keep instructions for submitting data posted on the Program website.

(3) Practices shall be notified of a PCPCHs Tier score within 60 days of complete data submission.

(4) Practices must file a request for review with the Program within 180 days if the practice disagrees with the calculated Tier score.

(5) PCPCHs must renew their recognition annually. If during this time, a PCPCH believes that it has made progress and should be recognized at a higher tier, it may request its tier status to be reassessed not more than once every six months.

(6) Recognition requests may be sent to: PCPCH@state.or.us or Office for Oregon Health Policy and Research, Attn: Patient-Centered Primary Care Home Program, General Services Building, 1225 Ferry Street SE, 1st Floor, Salem, OR 97301.

Stat. Auth.: ORS 413.042, 442.210 & 2011 OL Chapter 602 (HB 3650)

Stats. Implemented: ORS 413.042, 442.210 & 2011 OL Chapter 602 (HB 3650)

Hist.: OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12

409-055-0050

Data Reporting Requirements for Recognized PCPCHs

(1) In order to be recognized as a PCPCH, a practice must attest to meeting certain standards as well as submit quantitative data elements as described in Tables 1 and 2.

(2) The attestation shall be submitted via the web-based process pursuant to OAR 409-055-0040.

(3) Recognized PCPCHs shall be scored and tiered pursuant to OAR 409-055-0030.

(4) Attestation data must be submitted by PCPCHs once every three years as a part of the recognition renewal process.

(5) Part of the recognition process shall also include submission of quantitative data about the practice or the practice’s patient population.

(6) Quantitative data shall be submitted via the web-based reporting process.

(7) Quantitative data elements selected from Table 2 must be submitted by recognized PCPCHs annually.

(8) If approved by the practice and the Authority, other entities may submit information on behalf of a practice.

(9) Specific data elements required for PCPCH recognition shall be posted on the PCPCH Program website.

(10) The Authority shall have discretion to make exceptions to the reporting requirements above for practices collecting data elements outside of those on Table 2 for the purpose of quality improvement activities.

(Tables: Tables reference are available from the agency.)

Stat. Auth.: ORS 413.042, 442.210 & 2011 OL Chapter 602 (HB 3650)

Stats. Implemented: ORS 413.042, 442.210 & 2011 OL Chapter 602 (HB 3650)

Hist.: OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12

409-055-0060

Compliance and Enforcement

(1) The Office shall conduct a random audit of a select percentage of PCPCH applicants to verify reported attestation and quantitative data elements for the purposes for confirming recognition and Tier level.

(2) Practices selected for verification shall be notified no less than 30 days prior to the scheduled audit.

(3) Verification may include an audit of practice process as well as medical chart review.

(4) If the Office finds that the practice is not in compliance with processes as attested to, the Office shall work with the practice to move into compliance.

(5) If a practice fails to move into compliance within 180 days of identification of non-compliance with attested information, the Office shall amend the practice’s PCPCH recognition to reflect the appropriate Tier level

Stat. Auth.: ORS 413.042, 442.210 & 2011 OL Chapter 602 (HB 3650)

Stats. Implemented: ORS 413.042, 442.210 & 2011 OL Chapter 602 (HB 3650)

Hist.: OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12

409-055-0070

Insurance Carrier and Managed Care Plan Communication

(1) The Office shall develop a system for making recognized PCPCH Tier status available to insurance carriers and managed care organizations.

(2) The Office shall maintain and update monthly the recognized PCPCH Tier status lists.

Stat. Auth.: ORS 413.042, 442.210 & 2011 OL Chapter 602 (HB 3650)

Stats. Implemented: ORS 413.042, 442.210 & 2011 OL Chapter 602 (HB 3650)

Hist.: OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12

409-055-0080

Reimbursement Objectives

(1) One objective of these standards is to facilitate appropriate reimbursement for PCPCHs consistent with their recognized Tier levels. The standards and Tier recognition process established in this rule are consistent with statutory objectives to align financial incentives to support utilization of PCPCHs, in recognition of the standards that are required to be met at different Tiers.

(2) Managed care plans and insurance carriers may obtain from the Office the Tier level recognition of any practice.

(3) Within applicable programs, the Authority shall develop and implement reimbursement methodologies that reimburse practices based on recognition of Tier level, taking into consideration incurred practice costs for meeting the Tier criteria.

Stat. Auth.: ORS 413.042, 442.210 & 2011 OL Chapter 602 (HB 3650)

Stats. Implemented: ORS 413.042, 442.210 & 2011 OL Chapter 602 (HB 3650)

Hist.: OHP 6-2011(Temp), f. 9-29-11, cert. ef. 10-1-11 thru 3-15-12

 

Rule Caption: Amendments to Health Care Acquired Infection Reporting and Public Disclosure Rules.

Adm. Order No.: OHP 7-2011

Filed with Sec. of State: 9-30-2011

Certified to be Effective: 10-1-11

Notice Publication Date: 8-1-2011

Rules Amended: 409-023-0000, 409-023-0010, 409-023-0012, 409-023-0015

Rules Repealed: 409-023-0000(T), 409-023-0010(T), 409-023-0012(T), 409-023-0015(T)

Subject: The Oregon Health Authority, Office for Oregon Health Policy and Research is implementing amendments to the health care acquired infection (HAI) reporting. The rules implement the health care acquired infection (HAI) reporting, public disclosure, and other applicable mandates of ORS 442.420 and Ch. 838 § 1-6 and 12, enacted by the 74th Legislative Assembly. These rules set forth e the HAIs that are reported, how they are reported, the health care facilities that report them, and how they are publicly disclosed.

Rules Coordinator: Zarie Haverkate—(503) 373-1574

409-023-0000

Definitions

The following definitions apply to OAR 409-023-0000 to 409-023-0035:

(1) “Administrator” means the administrator of the Office for Oregon Health Policy and Research as defined in ORS 442.011, or the administrator’s designee.

(2) “ASC” means ambulatory surgical center as defined in ORS 442.015(3) and that is licensed pursuant to ORS 441.015.

(3) “CBGB” means coronary bypass graft surgery with both chest and graft incisions, as defined in the NHSN Manual.

(4) “CDC” mean the federal Centers for Disease Control and Prevention.

(5) “CDI” means Clostridium difficile infection as defined in the NHSN Manual.

(6) “CLABSI” means central line associated bloodstream infection as defined in the NHSN Manual.

(7) “CMS” mean the federal Centers for Medicare and Medicaid Services.

(8) “COLO” means colon procedures as defined in the NHSN Manual.

(9) “Committee” means the Health Care Acquired Infections Advisory Committee as defined in notes following ORS 442.851 relating to Health Care Acquired Infections.

(10) “Dialysis facility” means outpatient renal dialysis facility as defined in ORS 442.015(20).

(11) “Follow-up” means post-discharge surveillance intended to detect CBGB, COLO, HPRO, HYST, KRPO, and LAM surgical site infection (SSI) cases occurring after a procedure.

(12) “HAI” means health care acquired infection as defined in notes following ORS 442.851 relating to Health Care Acquired Infections.

(13) “Health care facility” means a facility as defined in ORS 442.015(10).

(14) “Hospital” means a facility as defined in ORS 442.015(13) and that is licensed pursuant to ORS 441.015.

(15) “Hospital Inpatient Quality Reporting Program” means the initiative administered by CMS and formerly referred to as RHQDAPU.

(16) “HPRO” means hip prosthesis procedure as defined in the NHSN Manual.

(17) “HYST” means abdominal hysterectomy procedure as defined in the NHSN Manual.

(18) “ICU” means an intensive care unit as defined in the NHSN Manual.

(19) “KPRO” means knee prosthesis procedure as defined in the NHSN Manual.

(20) “Lab ID” means laboratory-identified event as defined in the NHSN Manual.

(21) “LAM” means laminectomy procedure as defined in the NHSN Manual.

(22) “LTC facility” means long term care facility as defined in ORS 442.015(16).

(23) “MDS” mean the Centers for Medicare and Medicaid Services’ minimum data set nursing home resident assessment and screening tool, version 2.0 or its successor, including but not limited to manuals, forms, software, and databases.

(24) “Medical ICU” means a non-specialty intensive care unit that serves 80% or more adult medical patients.

(25) “Medical/Surgical ICU” means a non-specialty intensive care unit that serves less than 80% of either adult medical, adult surgical, or specialty patients.

(26) “NHSN” means the CDC’s National Healthcare Safety Network.

(27) “NHSN Inpatient” means a patient whose date of admission to the healthcare facility and the date of discharge are different days as defined in the NHSN Manual.

(28) “NHSN Manual” means the Patient Safety Component Protocol of the NHSN manual, version March 2009 or its successor, as amended, revised, and updated from time to time.

(29) “NICU” means a specialty intensive care unit that cares for neonatal patients.

(30) “Office” means the Office for Oregon Health Policy and Research.

(31) “Oregon HAI group” means the NHSN group administered by the Office.

(32) “Overall-facility wide” means data is collected for the entire facility as defined in the NHSN Manual.

(33) “Patient information” means individually identifiable health information as defined in ORS 179.505(c).

(34) “Person” has the meaning as defined in ORS 442.015(21).

(35) “Procedure” means an NHSN operative procedure as defined in the NHSN Manual.

(36) “Provider” means health care services provider as defined in ORS 179.505(b).

(37) “QIO” means the quality improvement organization designated by CMS for Oregon.

(38) “RHQDAPU” means the Reporting Hospital Quality Data for Annual Payment Update initiative administered by CMS.

(39) “SCIP” means the Surgical Care Improvement Project.

(40) “SCIP-Inf-1” means the HAI process measure published by SCIP defined as prophylactic antibiotic received within one hour prior to surgical incision.

(41) “SCIP-Inf-2” means the HAI process measure published by SCIP defined as prophylactic antibiotic selection for surgical patients.

(42) “SCIP-Inf-3” means the HAI process measure published by SCIP defined as prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac patients).

(43) “SCIP-Inf-4” means the HAI process measure published by SCIP defined as cardiac surgery patients with controlled 6 a.m. postoperative serum glucose.

(44) “SCIP-Inf-6” means the HAI process measure published by SCIP defined as surgery patients with appropriate hair removal.

(45) “SCIP-Inf-9” means urinary catheter removed on postoperative day 1 or postoperative day 2 with day of surgery being day zero.

(46) “SCIP-Inf-10” means the HAI process measure published by SCIP defined as surgery patients with perioperative temperature management.

(47) “Specialty ICU” mean an intensive care unit with at least 80% of adults are specialty patients including but not limited to oncology, trauma, and neurology.

(48) “SSI” means a surgical site infection event as defined in the Patient Safety Component Protocol of the NHSN manual, version January 2008.

(49) “Staff” means any employee of a health care facility or any person contracted to work within a health care facility.

(50) “State agency” shall have the meaning as defined in ORS 192.410(5).

(51) “Surgical ICU” means a non-specialty intensive care unit that serves 80% or more adult surgical patients.

Stat. Auth.: ORS 442.420 &OL 2007, Ch. 838 § 1-6 & 12

Stats. Implemented: ORS 179.505, 192.410, 192.496, 192.502, 441.015, 442.011, 442.400, 442.405, & OL 2007, Ch. 838 § 1-6 &12

Hist.: OHP 1-2008, f. & cert. ef. 7-1-08; OHP 1-2009, f. & cert. ef. 7-1-09; OHP 4-2010, f. 6-30-10, cert. ef. 7-1-10; OHP 4-2011(Temp), f. 7-28-11, cert. ef. 8-1-11 thru 1-25-12; OHP 7-2011, f. 9-30-11, cert. ef. 10-1-11

409-023-0010

HAI Reporting for Hospitals

(1) Hospitals shall begin collecting data for HAI outcome and process measures for the HAI reporting program for services provided on and after January 1, 2009, except:

(a) NICU shall begin collecting data for HAI outcome and process measures for the HAI reporting program for services provided on and after January 1, 2010.

(b) Hospitals shall report the SCIP-Inf-6 process measure for the HAI reporting program for services provided on and after January 1, 2010.

(c) Hospitals shall report the SCIP-4-Inf and SCIP-10-Inf process measures for services provided on and after January 1, 2011.

(d) Hospitals shall report the NHSN Inpatient COLO, HPRO, HYST, and LAM outcome measures for services provided on and after January 1, 2011.

(e) Hospitals shall report facility-wide NHSN Inpatient CDI data using the Lab-ID method for CDI in NHSN for services provided on or after January 1, 2012.

(f) Hospitals shall report SCIP-Inf-9 performance measures for services provided on or after January 1, 2012.

(2) Reportable HAI outcome measures are:

(a) SSIs for NHSN Inpatient CBGB, COLO, HPRO, HYST, KPRO, and LAM procedures.

(b) CLABSI in medical ICUs, surgical ICUs, and combined medical/surgical ICUs.

(c) NHSN Inpatient CDI facility-wide.

(3) The infection control professional (ICP), as defined by the facility, shall actively seek out infections defined in sections (2)(a) and (b) of this rule during a patient’s stay by screening a variety of data that may include but is not limited to:

(a) Laboratory;

(b) Pharmacy;

(c) Admission;

(d) Discharge;

(e) Transfer;

(f) Radiology;

(g) Imaging;

(h) Pathology; and

(i) Patient charts, including history and physical notes, nurses and physicians notes, and temperature charts.

(4) The ICP shall use follow-up surveillance methods to detect SSIs for procedures defined in section (2)(a) of this rule using at least one of the following:

(a) Direct examination of patients’ wounds during follow-up visits to either surgery clinics or physicians’ offices;

(b) Review of medical records, subsequent hospitalization records, or surgery clinic records;

(c) Surgeon surveys by mail or telephone;

(d) Patient surveys by mail or telephone; or

(e) Other facility surveys by mail or telephone.

(5) Others employed by the facility may be trained to screen data sources for these infections, but the ICP must determine that the infection meets the criteria established by these rules.

(6) The HAI reporting system for HAI outcome measures shall be NHSN. Each Oregon hospital shall comply with processes and methods prescribed by CDC for NHSN data submission. This includes but is not limited to definitions, data collection, data reporting, and administrative and training requirements. Each Oregon hospital shall:

(a) Join the Oregon HAI group in NHSN.

(b) Authorize disclosure of NHSN data to the Office as necessary for compliance of these rules including but not limited to summary data and denominator data for all SSIs, the annual hospital survey and data analysis components for all SSIs, and summary data and denominator data for all medical ICUs, surgical ICUs, and combined medical/surgical ICUs.

(c) Report its data for outcome measures to NHSN no later than 30 days after the end of the collection month. The NHSN field “Discharge Date” is mandatory for all outcome measures.

(7) Each hospital shall report on a quarterly basis according to 409-023-0010(1) the following HAI process measures:

(a) SCIP-Inf-1;

(b) SCIP-Inf-2;

(c) SCIP-Inf-3;

(d) SCIP-Inf-4;

(e) SCIP-Inf-6;

(f) SCIP-Inf-9; and

(g) SCIP-Inf-10.

(8) The reporting system for HAI process measures shall be the Hospital Inpatient Quality Reporting Program, formerly referred to as the RHQDAPU program as configured on July 1, 2008. Each Oregon hospital shall:

(a) Comply with reporting processes and methods prescribed by CMS for the RHQDAPU program. This includes but is not limited to definitions, data collection, data reporting, and administrative and training requirements; and

(b) Report data quarterly for HAI process measures. Data must be submitted to and successfully accepted into the QIO clinical warehouse no later than 11:59 p.m. central time, on the 15th calendar day, four months after the end of the quarter.

(9) For NICUs, the HAI reporting system for outcome measures shall be NHSN. Each Oregon hospital with a NICU shall comply with processes and methods prescribed by NHSN for the CLABSI reporting including but not limited to definitions, data collection, data submission, and administrative and training requirements. Each Oregon hospital shall:

(a) Authorize disclosure of NHSN data to the Office as necessary for compliance with these rules, including but not limited to facility identifiers.

(b) Submit NICU data to be NHSN according to the NHSN Manual.

(10) Each hospital shall complete an annual survey, as defined by the Office, of influenza vaccination of staff and submit the completed survey to the Office. The survey shall include but not be limited to questions regarding influenza vaccine coverage of facility staff:

(a) Number of staff with a documented influenza vaccination during the previous influenza season.

(b) Number of staff with a documented medical contraindication to influenza vaccination during the previous influenza season.

(c) Number of staff with a documented refusal of influenza vaccination during the previous influenza season.

(d) Facility assessment of influenza vaccine coverage of facility staff during the previous influenza season and plans to improve vaccine coverage of facility staff during the upcoming influenza season.

Stat. Auth.: ORS 442.420 & Notes following ORS 442.851

Stats. Implemented: ORS 442.405 & Notes following ORS 442.851

Hist.: OHP 1-2008, f. & cert. ef. 7-1-08; OHP 1-2009, f. & cert. ef. 7-1-09; OHP 4-2010, f. 6-30-10, cert. ef. 7-1-10; OHP 4-2011(Temp), f. 7-28-11, cert. ef. 8-1-11 thru 1-25-12; OHP 7-2011, f. 9-30-11, cert. ef. 10-1-11

409-023-0012

HAI Reporting for Ambulatory Surgery Centers

(1) Each ASC shall complete a survey of evidenced-based elements of patient safety performance as defined by the Office.

(2) The survey shall be submitted annually by each ASC to the Office no later than 30 days after receipt of survey.

(3) Starting with the 2011-2012 influenza season, each ASC shall complete an annual survey, as defined by the Office, of influenza vaccination of staff and submit the completed survey to the Office. The survey shall include but not be limited to questions regarding influenza vaccine coverage of facility staff:

(a) Number of staff with a documented influenza vaccination during the previous influenza season.

(b) Number of staff with a documented medical contraindication to influenza vaccination during the previous influenza season.

(c) Number of staff with a documented refusal of influenza vaccination during the previous influenza season.

(d) Facility assessment of influenza vaccine coverage of facility staff during the previous influenza season and plans to improve vaccine coverage of facility staff during the upcoming influenza season.

Stat. Auth.: ORS 442.420(3)(d) & OL 2007, Ch. 838 § 1-6 and 12

Stats. Implemented: ORS 442.405 & OL 2007, Ch. 838 § 1-6 and 12

Hist.: OHP 1-2009, f. & cert. ef. 7-1-09; OHP 4-2011(Temp), f. 7-28-11, cert. ef. 8-1-11 thru 1-25-12; OHP 7-2011, f. 9-30-11, cert. ef. 10-1-11

409-023-0015

HAI Reporting for Other Health Care Facilities

Dialysis facilities shall begin collecting data for the HAI reporting program for services provided on and after January 1, 2013 pursuant to rules amended no later than July 1, 2012.

Stat. Auth.: ORS 442.420(3)(d) & OL 2007, Ch. 838 § 1-6 and 12

Stats. Implemented: ORS 442.405 & OL 2007, Ch. 838 § 1-6 and 12

Hist.: OHP 1-2008, f. & cert. ef. 7-1-08; OHP 1-2009, f. & cert. ef. 7-1-09; OHP 4-2011(Temp), f. 7-28-11, cert. ef. 8-1-11 thru 1-25-12; OHP 7-2011, f. 9-30-11, cert. ef. 10-1-11

Notes
1.) This online version of the OREGON BULLETIN is provided for convenience of reference and enhanced access. The official, record copy of this publication is contained in the original Administrative Orders and Rulemaking Notices filed with the Secretary of State, Archives Division. Discrepancies, if any, are satisfied in favor of the original versions. Use the OAR Revision Cumulative Index found in the Oregon Bulletin to access a numerical list of rulemaking actions after November 15, 2010.

2.) Copyright 2011 Oregon Secretary of State: Terms and Conditions of Use

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