Loading
The Oregon Administrative Rules contain OARs filed through July 15, 2014
 
QUESTIONS ABOUT THE CONTENT OR MEANING OF THIS AGENCY'S RULES?
CLICK HERE TO ACCESS RULES COORDINATOR CONTACT INFORMATION

 

OREGON HEALTH AUTHORITY,
PUBLIC HEALTH DIVISION

 

DIVISION 18

DISEASE REPORTING

333-018-0000

Who is Responsible for Reporting

(1) Each health care provider knowing of or attending a human case or suspected human case of any of the diseases, infections, or conditions listed in OAR 333-018-0015 shall report such cases as specified. Where no health care provider is in attendance, any individual knowing of such a case shall report in a similar manner. An individual required to report reportable diseases who is unsure whether a case meets the definition of a suspect case as that is defined in OAR 333-017-0000 should err on the side of reporting if the suspected disease, infection, or condition is one that:

(a) Is required to be reported immediately or within 24 hours under OAR 333-018-0015;

(b) Is highly transmissible; or

(c) Results in serious or severe health consequences.

(2) Each health care facility, where more than one health care provider may know or attend a human case or suspected human case, may establish administrative procedures to ensure that every case is reported.

(3) Each licensed laboratory shall report human test results as specified in OAR 333-018-0015(5). When more than one licensed laboratory is involved in testing a specimen, the laboratory that is responsible for reporting the test result directly to the health care provider that ordered the test shall be responsible for reporting.

(4) Each veterinary laboratory or licensed laboratory shall report animal test results as specified in OAR 333-018-0017. When more than one laboratory is involved in testing a specimen, the laboratory that is responsible for reporting the test result directly to the licensed veterinarian or client of record caring for the animal shall be responsible for reporting.

Stat. Auth.: ORS 413.042, 433.004 & 437.010
Stats. Implemented: ORS 433.004 & 437.030
Hist.: HD 15-1981, f. 8-13-81, ef. 8-15-81; HD 4-1987, f. 6-12-87, ef. 6-19-87; HD 29-1994, f. & cert. ef. 12-2-94; OHD 3-2002, f. & cert. ef. 3-4-02; PH 5-2010, f. & cert. ef. 3-11-10; PH 7-2011, f. & cert. ef. 8-19-11

333-018-0005

To Whom Reports Shall Be Made

(1) In general, if the patient is an Oregon resident, reports shall be made to the local public health administrator for the patient's place of residence.

(2) In lieu of reporting to the local public health administrator, with the consent of the local public health administrator and the Authority, reports may be made directly to the Authority (for example, via electronic reporting).

(3) In urgent situations when local public health staff are unavailable, case reports shall be made directly to the Authority.

(4) Where the case is not an Oregon resident, reports shall be made either to the patient's local public health authority (if the patient resides in the United States) or directly to the Authority.

(5) In lieu of reporting to the local public health administrator, with the consent of the local public health administrator, licensed laboratories shall report directly to the Authority’s HIV Program:

(a) All tests indicative of and specific for HIV infection as required by OAR 333-018-0015;

(b) All CD4+ T-lymphocyte counts; and

(c) All HIV viral load tests.

Stat. Auth.: ORS 431.110, 433.001, 433.004, 433.006
Stats. Implemented: ORS 431.110, 433.001, 433.004, 433.006, 433.106
Hist.: HD 15-1981, f. 8-13-81, ef. 8-15-81; HD 20-1985(Temp), f. & ef. 9-30-85; HD 4-1987, f. 6-12-87, ef. 6-19-87; HD 15-1988, f. 7-11-88, cert. ef. 9-1-88; HD 13-1990(Temp), f. 5-25-90, cert. ef. 8-1-90; HD 5-1991, f. 3-29-91, cert. ef. 4-1-91; HD 10-1991, f. & cert. ef. 7-23-91; HD 29-1994, f. & cert. ef. 12-2-94; OHD 22-2001, f. & cert. ef. 10-19-01; OHD 3-2002, f. & cert. ef. 3-4-02; PH 11-2005, f. 6-30-05, cert. ef. 7-5-05; PH 1-2007, f. & cert. ef. 1-16-07; PH 7-2011, f. & cert. ef. 8-19-11; PH 16-2013, f. 12-26-13, cert. ef. 1-1-14

333-018-0010

Form of the Report

(1) A health care provider required to report reportable diseases under ORS 433.004 and these rules shall submit to the local public health administrator a report that includes but is not limited to:

(a) The identity, address, and telephone number of the person reporting;

(b) The identity, address, and telephone number of the attending health care provider, or other treating health care provider if any;

(c) The name of the person affected or ill, that person's current address, telephone number, and date of birth;

(d) The diagnosed or suspected disease, infection, or condition; and

(e) The date of illness onset.

(2) A licensed laboratory required to report reportable diseases under ORS 433.004 and these rules shall submit to the local public health administrator a report that includes but is not limited to:

(a) The name and telephone number of the reporting laboratory;

(b) The name, gender, age or date of birth, the address and county of residence of the person from whom the laboratory specimen was obtained, if known;

(c) The date the specimen was obtained;

(d) The name, address and telephone number of the health care provider of the person from whom the laboratory specimen was obtained;

(e) The name or description of the test;

(f) The test result; and

(g) Information required by the Authority’s Manual for Mandatory Electronic Laboratory Reporting, if electronic reporting is required under OAR 333-018-0013.

(3) Reportable disease reports shall be made in the following manner:

(a) Reports for diseases or suspected diseases that are immediately reportable under OAR 333-018-0015 shall be submitted orally, by telephone, with a follow-up written report via facsimile.

(b) Reports for diseases or suspected diseases that are required to be reported within one to seven days under OAR 333-018-0013 shall be submitted in writing via facsimile or by other means approved by the local public health administrator, consistent with the need for timely reporting as provided in OAR 333-018-0015.

(c) Electronically, if required by OAR 333-018-0013.

(4) If requested by a local public health administrator or the Oregon Public Health Division, health care providers and licensed laboratories shall provide additional information of relevance to the investigation or control of reportable diseases or conditions (for example, reported signs and symptoms, laboratory test results (including negative results), potential exposures, contacts, and clinical outcomes).

Stat. Auth.: ORS 413.042 & 433.004
Stats. Implemented: ORS 433.004
Hist.: HD 15-1981, f. 8-13-81, ef. 8-15-81; HD 4-1987, f. 6-12-87, ef. 6-19-87; HD 13-1990(Temp), f. 5-25-90, cert. ef. 8-1-90; HD 5-1991, f. 3-29-91, cert. ef. 4-1-91; HD 10-1991, f. & cert. ef. 7-23-91; HD 29-1994, f. & cert. ef. 12-2-94; OHD 3-2002, f. & cert. ef. 3-4-02; PH 11-2005, f. 6-30-05, cert. ef. 7-5-05; PH 5-2010, f. & cert. ef. 3-11-10; PH 7-2011, f. & cert. ef. 8-19-11; PH 16-2013, f. 12-26-13, cert. ef. 1-1-14

333-018-0013

Electronic Laboratory Reporting

(1) A licensed laboratory that, pursuant to ORS 433.004 and OAR chapter 333, division 18, sends an average of greater than 30 records per month to the local public health administrator shall electronically send all reportable disease data to the Authority in accordance with the standards set forth in the Authority’s Manual for Mandatory Electronic Laboratory Reporting, dated February 2009, and incorporated by reference.

(2) Prior to reporting data electronically, a licensed laboratory shall seek and obtain approval from the Authority for its electronic reporting, in accordance with the Authority’s Manual for Mandatory Electronic Laboratory Reporting.

(3) A licensed laboratory that fails to seek approval from the Authority for electronic reporting or fails to obtain approval within one year from seeking approval from the Authority may be subject to civil penalties in accordance OAR 333-026-0030.

(4) A licensed laboratory that is required to report data electronically shall have a state-approved continuity of operations plan for reporting continuity in the event of emergency situations disrupting electronic communications. At least two alternative methodologies should be incorporated, such as facsimile, mail, or courier service.

(5) A licensed laboratory required to report data electronically shall participate fully in Oregon’s Data Quality Control program, as specified in the Authority’s Manual for Mandatory Electronic Laboratory Reporting.

(6) Electronic reports shall meet the reporting timelines in OAR chapter 333, division 18.

Stat. Auth.: ORS 413.042 & 433.004
Stats. Implemented: ORS 433.004
Hist.: PH 5-2010, f. & cert. ef. 3-11-10; PH 7-2011, f. & cert. ef. 8-19-11

333-018-0015

What Is to Be Reported and When

(1) Health care providers shall report all human cases or suspected human cases of the diseases, infections, microorganisms, and conditions specified below. The timing of health care provider reports is specified to reflect the severity of the illness or condition and the potential value of rapid intervention by public health agencies.

(2) When local public health administrators cannot be reached within the specified time limits, reports shall be made directly to the Authority, which shall maintain an around-the-clock public health consultation service.

(3) Licensed laboratories shall report all test results indicative of and specific for the diseases, infections, microorganisms, and conditions specified below for humans. Such tests include but are not limited to: microbiological culture, isolation, or identification; assays for specific antibodies; and identification of specific antigens, toxins, or nucleic acid sequences.

(4) Human reportable diseases, infections, microorganisms, and conditions, and the time frames within which they must be reported are as follows:

(a) Immediately, day or night: Bacillus anthracis (anthrax); Clostridium botulinum (botulism); Corynebacterium diphtheriae (diphtheria); novel influenza; Yersinia pestis (plague); poliomyelitis; rabies (human); measles (rubeola); Severe Acute Respiratory Syndrome (SARS) and infection by SARS coronavirus; rubella; variola major (smallpox); Francisella tularensis (tularemia); Vibrio cholerae O1, O139, or toxigenic; hemorrhagic fever caused by viruses of the filovirus (e.g., Ebola, Marburg) or arenavirus (e.g., Lassa, Machupo) families; yellow fever; intoxication caused by marine microorganisms or their byproducts (for example, paralytic shellfish poisoning, domoic acid intoxication, ciguatera, scombroid); any known or suspected common-source outbreaks; any uncommon illness of potential public health significance.

(b) Within 24 hours (including weekends and holidays): Haemophilus influenzae (any invasive disease; for laboratories, any isolation or identification from a normally sterile site); Neisseria meningitidis (any invasive disease; for laboratories, any isolation or identification from a normally sterile site); pesticide poisoning.

(c) Within one local public health authority working day: Bordetella pertussis (pertussis); Borrelia (relapsing fever, Lyme disease); Brucella (brucellosis); Campylobacter (campylobacteriosis); Chlamydophila (Chlamydia) psittaci (psittacosis); Chlamydia trachomatis (chlamydiosis; lymphogranuloma venereum); Clostridium tetani (tetanus); Coxiella burnetii (Q fever); Creutzfeldt-Jakob disease and other transmissible spongiform encephalopathies; Cryptococcus (cryptococcosis), Cryptosporidium (cryptosporidiosis); Cyclospora cayetanensis (cyclosporosis); bacteria of the Enterobacteriaceae family found to be non-susceptible to third-generation cephalosporins and to carbapenem antibiotic (other than ertapenem); Escherichia coli (Shiga-toxigenic, including E. coli O157 and other serogroups); Giardia (giardiasis); Grimontia spp.; Haemophilus ducreyi (chancroid); hantavirus; hepatitis A; hepatitis B (acute or chronic infection); hepatitis C; hepatitis D (delta); hepatitis E; HIV infection (does not apply to anonymous testing) and AIDS; death of a person <18 years of age with laboratory-confirmed influenza; lead poisoning; Legionella (legionellosis); Leptospira (leptospirosis); Listeria monocytogenes (listeriosis); mumps; Mycobacterium tuberculosis and M. bovis (tuberculosis); nonrespiratory infection with nontuberculous mycobacteria; Neisseria gonorrhoeae (gonococcal infections); pelvic inflammatory disease (acute, non-gonococcal); Plasmodium (malaria); Rickettsia (all species: Rocky Mountain spotted fever, typhus, others); Salmonella (salmonellosis, including typhoid); Shigella (shigellosis); Taenia solium (including cysticercosis and undifferentiated Taenia infections); Treponema pallidum (syphilis); Trichinella (trichinosis); Vibrio spp.; Yersinia (other than pestis); any infection that is typically arthropod vector-borne (for example: babesiosis, California encephalitis, Colorado tick fever, dengue, Eastern equine encephalitis, ehrlichiosis, Heartland virus infection, Kyasanur Forest disease, St. Louis encephalitis, West Nile fever, Western equine encephalitis, etc.); a human bitten by any other mammal; and hemolytic uremic syndrome.

(d) Within seven days: Any blood lead level tests including the result.

(5) Licensed laboratories shall report, within seven days, the results of all tests of CD4+ T-lymphocyte absolute counts and the percent of total lymphocytes that are CD4 positive, and HIV nucleic acid (viral load) tests.

Stat. Auth.: ORS 413.042, 433.004 & 433.006
Stats. Implemented: ORS 433.004 & 437.010
Hist.: HD 15-1981, f. 8-13-81, ef. 8-15-81; HD 20-1985(Temp), f. & ef. 9-30-85; HD 4-1987, f. 6-12-87, ef. 6-19-87; HD 15-1988, f. 7-11-88, cert. ef. 9-1-88; HD 13-1990(Temp), f. 5-25-90, cert. ef. 8-1-90; HD 5-1991, f. 3-29-91, cert. ef. 4-1-91; HD 10-1991, f. & cert. ef. 7-23-91; HD 9-1992, f. & cert. ef. 8-14-92; HD 29-1994, f. & cert. ef. 12-2-94; OHD 22-2001, f. & cert. ef. 10-19-01; OHD 3-2002, f. & cert. ef. 3-4-02; PH 11-2005, f. 6-30-05, cert. ef. 7-5-05; PH 7-2006, f. & cert. ef. 4-17-06; PH 13-2006(Temp), f. 6-27-06, cert. ef. 7-1-06 thru 12-27-06; PH 19-2006, f. & cert. ef. 9-13-06; PH 11-2007(Temp), f. & cert. ef. 8-22-07 thru 2-18-08; PH 13-2007, f. & cert. ef. 11-7-07; PH 8-2009(Temp), f. & cert. ef. 9-1-09 thru 2-26-10; PH 5-2010, f. & cert. ef. 3-11-10; PH 7-2011, f. & cert. ef. 8-19-11; PH 16-2013, f. 12-26-13, cert. ef. 1-1-14

333-018-0017

Reporting of Veterinary Diseases

(1) Laboratories shall report to the Oregon Public Health Division all test results indicative of and specific for the following diseases, infections, microorganisms, and conditions, within the following time frames, as follows:

(a) Immediately, day or night: anthrax, rabies, and plague;

(b) Within one day: psittacosis, leptospirosis, Q fever, and tularemia; and

(c) Within one week: Baylisascaris, Borrelia burgdorferii, campylobacteriosis, Cryptococcus, Cryptosporidium, Escherichia coli O157:H7, giardiasis, lymphocytic choriomeningitis, methicillin-resistant Staphylococcus aureus, Rocky Mountain spotted fever, salmonellosis, toxoplasmosis, West Nile virus, yersiniosis; and any other disease that could potentially be a zoonotic illness.

(2) “Test” as used in this rule, includes but is not limited to:

(a) Microbiological culture, isolation, or identification;

(b) Assays for specific antibodies; and

(c) Identification of specific antigens, toxins, or nucleic acid sequences.

Stat. Auth.: ORS 413.042 & 433.004
Stats. Implemented: ORS 433.004
Hist.: PH 5-2010, f. & cert. ef. 3-11-10

333-018-0018

Submission of Isolates to the Public Health Laboratory

Licensed laboratories are required to forward aliquots or subcultures of the following to the Oregon State Public Health Laboratory:

(1) Suspected Neisseria meningitidis and Haemophilus influenzae from normally sterile sites.

(2) Suspected Shiga-toxigenic Escherichia coli (STEC), including E. coli O157; Salmonella spp., Shigella spp., Vibrio spp., Grimontia spp., Listeria spp., Yersinia spp.; Mycobacterium tuberculosis and M. bovis from any source.

(3) Serum that tests positive for IgM antibody to hepatitis A virus.

(4) Serum that tests positive for IgM core antibody to hepatitis B virus.

(5) All cryptococcal isolates.

(6) All isolates of the Enterobacteriaceae family resistant to third-generation cephalosporins and non-susceptible to any carbapenem antibiotic other than ertapenem.

(7) For persons under the age of 18 who died with laboratory-confirmed influenza: respiratory specimens or viral isolates, any Staphylococcus aureus isolates, and, after consulting with the Oregon Public Health Division, autopsy specimens.

Stat. Auth.: ORS 413.042, 433.004 & 438.450
Stats. Implemented: ORS 433.004 & 438.310
Hist.: HB 248, f. 6-30-70, ef. 7-25-70; HD 28-1988, f. & cert. ef. 12-7-88; HD 20-1994, f. & cert. ef. 7-20-94; HD 6-1995, f. & cert. ef. 9-13-95; OHD 11-2001, f. & cert. ef. 5-16-01, Renumbered from 333-024-0050(5); OHD 3-2002, f. & cert. ef. 3-4-02; PH 11-2005, f. 6-30-05, cert. ef. 7-5-05; PH 28-2006, f. 11-30-06, cert. ef 12-18-06; PH 5-2010, f. & cert. ef. 3-11-10; PH 7-2011, f. & cert. ef. 8-19-11; PH 16-2013, f. 12-26-13, cert. ef. 1-1-14

333-018-0020

Reports from Local Public Health Administrators

(1) The local public health administrator shall notify the Authority immediately of any reported cases of the following diseases and conditions: anthrax, botulism (foodborne), cholera, diphtheria, marine intoxications, measles, pesticide poisoning, plague, poliomyelitis, rabies; any uncommon illness of potential public health significance; any outbreak of disease.

(2) Animal bites that have been investigated by the local public health administrator and for which testing of the biting animal for rabies has been deemed unnecessary need not be reported to the Authority.

(3) For other reportable diseases and conditions, the local public health administrator shall notify the Authority no later than the end of each business week of all cases reported during that week. Reports shall be made by means approved by the Authority and in a format approved by the Authority.

Stat. Auth.: ORS 431.110, 431.120, 433.004, 437.010, 616.010 & 624.005
Stats. Implemented: ORS 433.004 & 437.010
Hist.: HD 15-1981, f. 8-13-81, ef. 8-15-81; HD 12-1983, f. & ef. 8-1-83; HD 4-1987, f. 6-12-87, ef. 6-19-87; HD 29-1994, f. & cert. ef. 12-2-94; OHD 3-2002, f. & cert. ef. 3-4-02; PH 7-2011, f. & cert. ef. 8-19-11; PH 16-2013, f. 12-26-13, cert. ef. 1-1-14

333-018-0035

Procedures Involving Emergency Response Employees

(1) Each person or local government employing persons to render emergency care shall designate a contact person or "designated officer" to receive reports from the local public health administrator made under ORS 433.006. The employer shall assure that the designated officer has sufficient training to carry out the duties as described below, which shall include appropriate procedures for follow-up after occupational exposures to specific diseases as specified below in section (2) and section (6).

(2) Sections (3) through (5) apply only to the following subset of reportable diseases: meningococcal disease, infectious pulmonary or laryngeal tuberculosis, diphtheria, plague (Yersinia pestis), rabies, hemorrhagic fevers (for example, Lassa, Marburg, and Ebola).

(3) Health care providers and health care facilities shall, when reporting this subset of diseases, determine and include as part of their report whether or not an emergency care provider was involved in pre-hospital care for this disease.

(4) Health care providers and facilities shall report to the local public health administrator and may relay the diagnosis of these diseases directly to the emergency care providers or the designated officer specified below in section (5), but shall not disclose the identity or addresses of the person having the disease or otherwise refer specifically to the person.

(5) Upon receiving a report of a reportable disease as defined in section (2) above, the designated officer shall notify all out-of-hospital caregivers, including but not limited to: first responders, emergency medical technicians, paramedics, firefighters, law enforcement officers, corrections officers, probation officers, or other current or former personnel of the employer who may have been exposed to the reportable disease. The designated officer shall inform the personnel only of the reportable disease and the fact of possible exposure and the appropriate follow-up procedures. The designated officer shall not inform the personnel of the identity or addresses of the individual having the reportable disease or otherwise refer specifically to the individual having the reportable disease.

(6) In the event of an occupational exposure to a bloodborne pathogen as defined by ORS 433.060, the designated officer shall also assist the exposed worker as defined in ORS 433.060 in implementing the provisions of ORS 433.065 through ORS 433.080 and associated Authority rules (chapter 333, division 22). These rules include provisions for determining HIV, hepatitis B and hepatitis C status of the source patient and soliciting HIV testing after an occupational exposure.

Stat. Auth.: ORS 433.045 - 433.080 & 431.110
Stats. Implemented: ORS 433.006 & 433.065
Hist.: HD 15-1981, f. 8-13-81, ef. 8-15-81; HD 12-1983, f. & ef. 8-1-83; HD 4-1987, f. 6-12-87, ef. 6-19-87; HD 29-1994, f. & cert. ef. 12-2-94; HD 8-1997, f. & cert. ef. 6-26-97; OHD 15-2001, f. & cert. ef. 7-12-01, Renumbered from 333-018-0023; OHD 3-2002, f. & cert. ef. 3-4-02; PH 7-2011, f. & cert. ef. 8-19-11; PH 16-2013, f. 12-26-13, cert. ef. 1-1-14

Health Care Acquired Infection Reportingand Public Disclosure

333-018-0100

Definitions

The following definitions apply to OAR 333-018-0100 through 333-018-0145:

(1) "Adult ICU" means all specialty and non-specialty intensive care units that care for adults as defined in the NHSN Manual.

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

(3) "Authority" means the Oregon Health Authority.

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

(5) "CAUTI" means catheter-associated urinary tract infection as defined in the NHSN Manual.

(6) "CDC" means the federal Centers for Disease Control and Prevention.

(7) "CDI" means Clostridium difficile infection as defined in the NHSN Manual.

(8) "CLABSI" means central line associated bloodstream infection as defined in the NHSN Manual.

(9) "CMS" means the federal Centers for Medicare and Medicaid Services.

(10) "Collection Month" means the month in which an infection was identified.

(11) "COLO" means colon procedures as defined in the NHSN Manual.

(12) "Committee" means the Health Care Acquired Infections Advisory Committee established in section 4, chapter 838, Oregon Laws 2007.

(13) "Dialysis facility" means outpatient renal dialysis facility as defined in ORS 442.015.

(14) "Dialysis Event" means an event that occurs in individuals who receive dialysis as defined by the NHSN Manual.

(15) "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.

(16) "HAI" means health care acquired infection as defined in section 2, chapter 838, Oregon Laws 2007.

(17) "Health care facility" means a facility as defined in ORS 442.015.

(18) "Hospital" means a facility as defined in ORS 442.015 and that is licensed pursuant to ORS 441.015.

(19) "Hospital Inpatient Quality Reporting Program (HIQRP)" means the initiative administered by CMS that provides a financial incentive to hospitals to report designated quality measures, mandated by section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003.

(20) "HPRO" means hip prosthesis procedure as defined in the NHSN Manual.

(21) "HYST" means abdominal hysterectomy procedure as defined in the NHSN Manual.

(22) "ICU" means an intensive care unit as defined in the NHSN Manual.

(23) "KPRO" means knee prosthesis procedure as defined in the NHSN Manual.

(24) "Lab ID" means laboratory-identified event as defined in the NHSN Manual.

(25) "LAM" means laminectomy procedure as defined in the NHSN Manual.

(26) "LTCF" means a long term care facility as defined in ORS 442.015.

(27) "MDS" means the CMS minimum data set nursing home resident assessment and screening tool.

(28) "Medical ICU" means a non-specialty intensive care unit in which at least 80 percent of patients served are adult medical patients.

(29) "Medical/Surgical ICU" means a non-specialty intensive care unit in which less than 80 percent of patients served are adult medical, adult surgical, or specialty patients.

(30) "MRSA" means methicillin-resistant Staphylococcus aureus as defined in the NHSN Manual.

(31) "NHSN" means the CDC’s National Healthcare Safety Network.

(32) "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.

(33) "NHSN Manual" means the 2014 patient safety component protocols, established by the CDC’s NHSN, which govern the HAIs and other information required by CMS to be reported by health care facilities, found at http://www.cdc.gov/nhsn/Training/patient-safety-component/, and incorporated by reference.

(34) "NICU" means a specialty intensive care unit that cares for neonatal patients.

(35) "Non-specialty ICU" means an intensive care unit in which patients are medical, surgical, or medical/surgical patients.

(36) "Oregon HAI group" means the NHSN group administered by the Authority.

(37) "Overall-facility wide" means data are collected for the entire facility as defined in the NHSN Manual.

(38) "Patient information" means individually identifiable health information as defined in ORS 179.505.

(39) "Pediatric ICU" means a specialty intensive care unit that cares for pediatric patients.

(40) "Person" has the meaning given that term in ORS 442.015.

(41) "Procedure" means an operative procedure as defined in the NHSN Manual.

(42) "Provider" means health care services provider as defined in ORS 179.505.

(43) "QIO" means the quality improvement organization designated by CMS for Oregon.

(44) "SCIP" means the Surgical Care Improvement Project, established through collaborative efforts of the Joint Commission and CMS.

(45) "SCIP-Inf-1" means the HAI process measure defined as prophylactic antibiotic received within one hour prior to surgical incision, published by SCIP effective July 1, 2006.

(46) "SCIP-Inf-2" means the HAI process measure defined as prophylactic antibiotic selection for surgical patients, published by SCIP effective July 1, 2006.

(47) "SCIP-Inf-3" means the HAI process measure defined as prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac patients), published by SCIP effective July 1, 2006.

(48) "SCIP-Inf-4" means the HAI process measure defined as cardiac surgery patients with controlled 6 a.m. postoperative serum glucose, published by SCIP effective July 1, 2006.

(49) "SCIP-Inf-6" means the HAI process measure defined as surgery patients with appropriate hair removal, published by SCIP effective July 1, 2006.

(50) "SCIP-Inf-9" means the HAI process measure defined as urinary catheter removed on postoperative day one or postoperative day two with day of surgery being day zero, published by SCIP effective July 1, 2006.

(51) "SCIP-Inf-10" means the HAI process measure defined as surgery patients with perioperative temperature management, published by SCIP effective July 1, 2006.

(52) "Specialty ICU" means an intensive care unit in which at least 80 percent of adult patients served are specialty patients, including but not limited to oncology, trauma, and neurology.

(53) "SSI" means a surgical site infection event as defined in the NHSN manual.

(54) "Staff" means any employee of a health care facility or any person contracted to work within a health care facility.

(55) "State agency" has the meaning given that term in ORS 192.410.

(56) "Surgical ICU" means a non-specialty intensive care unit in which at least 80 percent of patients served are 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, 442.400, 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; Renumbered from 409-023-0000 by PH 13-2013, f. 12-26-13, cert. ef. 1-1-14; PH 17-2014, f. & cert. ef. 6-9-14

333-018-0105

Review

Unless otherwise directed by the Authority, the committee shall review these rules (OAR 333-018-0100 through 333-018-0145) at least biennially.

Stat. Auth.: ORS 442.420 & 2007 OL Ch. 838 ¦ 1–6 & 12
Stats. Implemented: 2007 OL Ch. 838 ¦ 1–6 & 12
Hist.: OHP 1-2008, f. & cert. ef. 7-1-08; Renumbered from 409-023-0005 by PH 13-2013, f. 12-26-13, cert. ef. 1-1-14

333-018-0110

HAI Reporting for Hospitals

(1) Hospitals must report to the Authority the following HAIs:

(a) SSIs for HPRO, LAM, CBGB and KPRO procedures.

(b) SSIs for inpatient COLO and HYST;

(c) MRSA bacteremia lab ID events;

(d) CLABSI in:

(A) Adult, pediatric, and neonatal ICUs; and

(B) On or after January 1, 2015, all adult, pediatric, medical, surgical, and medical/surgical wards.

(e) Inpatient CDI facility-wide, excluding neonatal and well-baby units;

(f) CAUTI in:

(A) Adult and pediatric ICUs; and

(B) On or after January 1, 2015, all adult and pediatric medical, surgical, and medical/surgical wards; and

(2) Hospitals must report to the Authority all fields required to be reported by NHSN in accordance with the NHSN manual, including discharge dates.

(3) A hospital must report the information required in section (1) of this rule to the Authority no later than 30 days after the end of the collection month.

(4) A hospital must have an infection control professional (ICP) who actively seeks out HAIs required to be reported under this rule by screening a variety of data from various sources that may include but are 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.

(5) An ICP shall use follow-up surveillance methods to detect SSIs for procedures listed in section (1) 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.

(6) A hospital may train others employed by the facility to screen data sources for these infections required to be reported in section (1) of this rule but the ICP must determine that the infection meets the criteria established by these rules.

(7) Hospitals that report the information in subsection (1)(a) to (e) of this rule through NHSN in order to meet CMS reporting requirements, may, in lieu of reporting this information directly to the Authority, permit the Authority to access the information through NHSN. A hospital that permits the Authority to access the information through NHSN must:

(a) Join the Oregon HAI group in NHSN;

(b) Authorize disclosure of NHSN data to the Authority as necessary for compliance with 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 adult, pediatric and neonatal ICUs; and

(c) Permit the Authority to access data reported through NHSN dating back to when reporting was first required by CMS for the different HAIs.

(8) All hospitals must report to the Authority on a quarterly basis the following HAI process measures, including but not limited to definitions, data collection, data reporting and training requirements:

(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.

(9) Hospitals that report the information in section (8) of this rule to CMS or the Joint Commission do not have to provide the information directly to the Authority; the Authority will access the information through CMS or the Joint Commission. If a hospital is not reporting the information in section (8) of this rule to CMS or the Joint Commission, in accordance with CMS or Joint Commission reporting requirements, it must provide the information to the Authority no later than on the 15th calendar day, four months after the end of the quarter.

Stat. Auth.: ORS 442.420 & 2007 OL Ch. 838 ¦ 1–6 & 12
Stats. Implemented: ORS 442.405 & 2007 OL 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; Renumbered from 409-023-0010 by PH 13-2013, f. 12-26-13, cert. ef. 1-1-14; PH 17-2014, f. & cert. ef. 6-9-14

333-018-0115

HAI Reporting for Ambulatory Surgery Centers

All Ambulatory Surgical Centers must complete the Evidence-Based Elements of Patient Safety Performance (EBEPSP) Survey provided by the Authority, annually, no later than 30 days after receipt of the survey.

Stat. Auth.: ORS 442.420 & 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; Renumbered from 409-023-0012 by PH 13-2013, f. 12-26-13, cert. ef. 1-1-14; PH 17-2014, f. & cert. ef. 6-9-14

333-018-0120

HAI Reporting for Long Term Care Facilities

(1) All LTCFs must report urinary tract infections to the Authority except as provided in subsection (b) of this section.

(a) A LTCF must report infections to the Authority in the same manner established by MDS, including but not limited to reporting definitions, data collection, data submission, and administrative and training requirements.

(b) If a LTCF reports infections in accordance with MDS to CMS, the LTCF is not required to report that information directly to the Authority; the Authority will access the information through CMS.

(2) All LTCFs must submit the Evidence-Based Elements of Patient Safety Performance Survey to the Authority annually, no later than 30 days after receipt of the survey.

(3) All LTCFs must submit the Infection Prevention Program Survey to the Authority annually, no later than 30 days after receipt of the survey.

Stat. Auth.: ORS 442.420 & 2007 OL Ch. 838 ¦ 1–6 & 12
Stats. Implemented: ORS 442.405 & 2007 OL Ch. 838 ¦ 1–6 & 12
Hist.: OHP 1-2009, f. & cert. ef. 7-1-09; Renumbered from 409-023-0013 by PH 13-2013, f. 12-26-13, cert. ef. 1-1-14; PH 17-2014, f. & cert. ef. 6-9-14

333-018-0125

HAI Reporting for Other Health Care Facilities

(1) All dialysis facilities shall report dialysis events to the Authority.

(2) A dialysis facility that reports dialysis events to NHSN may, in lieu of reporting the information directly to the Authority, permit the Authority access to NHSN.

(3) All Inpatient Rehabilitation Facilities (IRF) shall report to the Authority CAUTIs for adult and pediatric wards.

(4) The reporting system for IRFs shall be NHSN.

(5) IRFs that report information in order to meet CMS reporting requirements, may, in lieu of reporting information directly to the Authority, permit the Authority to access the information through NHSN. An IRF that permits the Authority to access the information through NHSN must:

(a) Join the Oregon HAI group in NHSN;

(b) Authorize disclosure of NHSN data to the Authority as necessary for compliance with 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 adult, pediatric and neonatal ICUs; and

(c) Permit the Authority to access data reported through NHSN dating back to when reporting was first required by CMS for the different HAIs.

Stat. Auth.: ORS 442.420 & 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; Renumbered from 409-023-0015 by PH 13-2013, f. 12-26-13, cert. ef. 1-1-14; PH 17-2014, f. & cert. ef. 6-9-14

333-018-0127

Annual Influenza Summary

Each hospital, ASC, LTCF and IRF must submit an annual survey to the Authority, no later than May 31, on a form prescribed by the Authority, regarding influenza vaccination of staff. Facilities must report at least the following information:

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

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

(3) Number of staff with a documented refusal of influenza vaccination during the previous influenza season; and

(4) 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 & OL 2007, Ch. 838 ¦ 1-6 and 12
Stats. Implemented: ORS 442.405 & OL 2007, Ch. 838 ¦ 1-6 and 12
Hist.: PH 17-2014, f. & cert. ef. 6-9-14

333-018-0130

HAI Public Disclosure

(1) The Authority shall disclose to the public facility-level and state-level HAI outcomes quarterly.

(2) The Authority may disclose state-level and facility-level HAI data, including but not limited to observed frequencies, expected frequencies, proportions, and ratios.

(3) The Authority shall summarize HAI data by facilities subject to this reporting in an annual report. The Authority shall publish the annual report no later than April 30 of each calendar year.

(4) The Authority shall disclose data and accompanying explanatory documentation to facilities and the general public.

(5) The Authority may use statistically valid methods to make comparisons by facility, and to state, regional, and national statistics.

(6) The Authority shall provide a maximum of 30 calendar days for facilities to review facility-reported data prior to public release of data.

(7) The Authority shall provide facilities the opportunity to submit written comments and may include any submitted information in the annual report.

(8) Pending recommendations from the committee, the Authority may publish additional reports intended to serve the public’s interest.

Stat. Auth.: ORS 442.420 & 2007 OL Ch. 838 ¦ 1–6 & 12
Stats. Implemented: ORS 442.405, 192.496, 192.502, 192.243, 192.245 & 2007 OL Ch. 838 ¦ 1–6 & 12
Hist.: OHP 1-2008, f. & cert. ef. 7-1-08; Renumbered from 409-023-0020 by PH 13-2013, f. 12-26-13, cert. ef. 1-1-14; PH 17-2014, f. & cert. ef. 6-9-14

333-018-0135

HAI Data Security

The Authority shall undertake precautions to prevent unauthorized disclosure of the raw data files. These precautions include but are not limited to:

(1) Storing the raw data files on the internal storage hardware of a password-protected personal computer that is physically located within the Authority;

(2) Restricting staff access to the raw data files;

(3) Restricting network access to the raw data files; and

(4) If applicable, storing patient information within a strongly-encrypted and password-protected virtual drive or using other methods to reliably achieve the same level of security.

Stat. Auth.: ORS 442.420 & 2007 OL Ch. 838 ¦ 1–6 & 12
Stats. Implemented: ORS 192.496, 192.502 & 2007 OL Ch. 838 ¦ 1–6 & 12
Hist.: OHP 1-2008, f. & cert. ef. 7-1-08; Renumbered from 409-023-0025 by PH 13-2013, f. 12-26-13, cert. ef. 1-1-14; PH 17-2014, f. & cert. ef. 6-9-14

333-018-0140

Prohibited Activities

Unless specifically required by state or federal rules, regulations, or statutes, the Authority is prohibited from:

(1) Disclosing individually identifiable patient, health care professional, or health care facility employee information;

(2) Intentionally linking or attempting to link individual providers to individual HAI events; and

(3) Providing patient-level or provider-level reportable HAI data to any state agency for enforcement or regulatory actions.

Stat. Auth.: ORS 442.420 & 2007 OL Ch. 838 ¦ 1–6 & 12
Stats. Implemented: ORS 192.496, 192.502 & 2007 OL Ch. 838 ¦ 1–6 & 12
Hist.: OHP 1-2008, f. & cert. ef. 7-1-08; Renumbered from 409-023-0030 by PH 13-2013, f. 12-26-13, cert. ef. 1-1-14

333-018-0145

Compliance

(1) Health care facilities that fail to comply with these rules or fail to submit required data shall be subject to civil penalties not to exceed $500 per day per violation.

(2) The Authority shall annually evaluate the quality of data submitted, as recommended by the committee.

Stat. Auth.: ORS 442.445 & 442.420
Stats. Implemented: ORS 442.445
Hist.: OHP 1-2008, f. & cert. ef. 7-1-08; Renumbered from 409-023-0035 by PH 13-2013, f. 12-26-13, cert. ef. 1-1-14

The official copy of an Oregon Administrative Rule is contained in the Administrative Order filed at the Archives Division, 800 Summer St. NE, Salem, Oregon 97310. Any discrepancies with the published version are satisfied in favor of the Administrative Order. The Oregon Administrative Rules and the Oregon Bulletin are copyrighted by the Oregon Secretary of State. Terms and Conditions of Use

Oregon Secretary of State • 136 State Capitol • Salem, OR 97310-0722
Phone: (503) 986-1523 • Fax: (503) 986-1616 • oregon.sos@state.or.us

© 2013 State of Oregon All Rights Reserved​