10A NCAC 41A .0106 Reporting of Health Care-Associated Infections

(a) The following definitions apply throughout this Rule:

(1) "Hospital" means any facility designated as such in G.S. 131E-76(3).

(2) "National Healthcare Safety Network" is an internet-based surveillance system managed by the Centers for Disease Control and Prevention. This system is designed to be used for the direct, standardized reporting of healthcare quality information, including health care-associated infections, by health care facilities to public health entities.

(3) "Health care-associated infection" means a localized or systemic condition in the patient resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) with no evidence that the infection was present or incubating when the patient was admitted to the health care setting.

(4) "Denominator or summary data" refers to referent or baseline data required to generate meaningful statistics for communicating health care-associated infection rates.

(5) "The Centers for Medicaid and Medicare Services - Inpatient Prospective Payment System (CMS IPPS) rules" are regulations promulgated for the disbursement of operating costs by the Centers for Medicare and Medicaid Services for acute care hospital stays under Medicare Part A based on prospectively set rates for care.

(b) Hospitals shall electronically report all health care-associated infections required by Paragraph (c) of this Rule through the National Healthcare Safety Network and shall make the data available to the Department. Hospitals also shall:

(1) Report all specified health care-associated infections within 30 days following the end of every calendar month during which the infection was identified;

(2) Report all required health care-associated infection denominator or summary data for healthcare-associated infections within 30 days following the end of every calendar month; and,

(3) Comply with all reporting requirements for general participation in the National Healthcare Safety Network.

(c) Except as provided in rules of this Section, hospitals shall report the healthcare-associated infections required by the Centers for Medicare and Medicaid Services listed in the CMS-IPPS rules beginning on the dates specified therein. A summary of the HAI reporting requirements from the current copy of the CMS-IPPS rules may be obtained through the CMS QualityNet site at


The CMS IPPS rules themselves can be obtained from the CMS IPPS website at http://www.cms.gov/AcuteInpatientPPS/IPPS2011/list.asp#TopOfPage and

http://www.cms.gov/AcuteInpatientPPS/FR2012/list.asp#TopOfPage. A copy of the current CMS-IPPS rules, applicable to this section, is available for inspection in the Division of Public Health, 225 N. McDowell Street, Raleigh NC 27601.

(d) Beginning October 1, 2012 and quarterly thereafter, the Department shall release reports to the public on health care-associated infection(s) in North Carolina.


History Note: Authority G.S. 130A‑150;

Temporary Adoption Eff. November 30, 2011;

Eff. October 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 9, 2018.