Form CDC 55.122 CDC 55.122 State Health Department HAI Mandate and Validatyion Surv

Form Approved

OMB No. 0920-0666

Exp. Date: 12/31/2026

www.cdc.gov/nhsn

State Health Department HAI Mandate and Validation Survey

CDC's NHSN will continue to publish data for HAI SIRs and SURs using the 2015 baseline and updated risk adjustment. These data reports will be separated by facility type. This survey asks questions about any mandate(s) and validation efforts that were in place for the 2023 reporting year, for each of the HAI measures covered in the report, by facility type.

Section 1: Contact Information

Name

__________________________________

State/Province

__________________________________

Email Address

_________________________________

Section 2: State Reporting Requirements Section

This section inquires of any state reporting requirements that were in place during the 2023 calendar year. Please indicate the HAI specific requirements and the period they were effecting. These questions will be asked for each HAI measure by location and facility type.

1. Did your state have a reporting requirement (e.g., legislation or policy including reportable conditions) for healthcare facilities to report CLABSI data to NHSN from ANY LOCATION type within the facility (e.g., ICU, Ward, NICU) at any time during 2023 for any of the following facility types? Check all that apply.

   • Acute Care Hospital (ACH)

   • Critical Access Hospital (CAH)

   • Long Term Acute Care Facility (LTAC)

   • Inpatient Rehabilitation Facility (IRF)

   • No reporting mandates (e.g., legislative or state-required mandate) for any facility type

Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).

Public reporting burden of this collection of information is estimated to average 50 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS H21-8, Atlanta, GA 30333, ATTN:  PRA (0920-0666).

CDC 57.122, Rev 1, v12.0

2. Was this CLABSI state reporting requirement (e.g., legislation or policy including reportable conditions) for ANY LOCATION implemented and in effect on January 1, 2023 for any of the following facility types? Check all that apply.

   • Acute Care Hospital (ACH)

   • Critical Access Hospital (CAH)

   • Long Term Acute Care Facility (LTAC)

   • Inpatient Rehabilitation Facility (IRF)

   • No reporting mandates (e.g., legislative or state-required mandate) for any facility types

3. Did your state have a reporting requirement (e.g., legislation or policy including reportable conditions) for healthcare facilities to report CLABSI data to NHSN from adult and/or pediatric ICU (critical care) locations at any time during 2023 for any of the following facility types? Check all that apply.

   • Acute Care Hospital (ACH)

   • Critical Access Hospital (CAH)

   • Long Term Acute Care Facility (LTAC)

   • No reporting mandates (e.g., legislative or state-required mandate) for any facility types

4. Was this CLABSI state reporting requirement (e.g., legislation or policy including reportable conditions) for adult and/or pediatric ICU (critical care) locations implemented and in effect on January 1, 2023 for any of the following facility types? Check all that apply.

   • Acute Care Hospital (ACH)

   • Critical Access Hospital (CAH)

   • Long Term Acute Care Facility (LTAC)

   • No reporting mandates (e.g., legislative or state-required mandate) for any facility types

5. Did your state have a reporting requirement (e.g., legislation or policy including reportable conditions) for healthcare facilities to report CLABSI data to NHSN from WARD locations at any time during 2023 for any of the following facility types? Check all that apply.

   • Acute Care Hospital (ACH)

   • Critical Access Hospital (CAH)

   • Long Term Acute Care Facility (LTAC)

   • No reporting mandates (e.g., legislative or state-required mandate) for any facility types

6. Was this CLABSI state reporting requirement (e.g., legislation or policy including reportable conditions) for WARD locations implemented and in effect on January 1, 2023 for any of the following facility types? Check all that apply.

   • Acute Care Hospital (ACH)

   • Critical Access Hospital (CAH)

   • Long Term Acute Care Facility (LTAC)

   • No reporting mandates (e.g., legislative or state-required mandate) for any facility types

7. Did your state have a reporting requirement (e.g., legislation or policy including reportable conditions) for healthcare facilities to report CLABSI data to NHSN from NICU locations at any time during 2023 for any of the following facility types? Check all that apply.

   • Acute Care Hospital (ACH)

   • No reporting mandates (e.g., legislative or state-required mandate) for any facility types

8. Was this CLABSI state mandate (e.g., legislation or policy including reportable conditions) for NICU locations implemented and in effect on January 1, 2023 for any of the following facility types? Check all that apply.

   • Acute Care Hospital (ACH)

   • No reporting mandates (e.g., legislative or state-required mandate) at any facility types

9. Did your state have a reporting requirement (e.g., legislation or policy including reportable conditions) for healthcare facilities to report CAUTI data to NHSN from ANY LOCATION at any time during 2023 for any of the following facility types? Check all that apply.

   • Acute Care Hospital (ACH)

   • Critical Access Hospital (CAH)

   • Long Term Acute Care Facility (LTAC)

   • Inpatient Rehabilitation Facility (IRF)

   • No reporting mandates (e.g., legislative or state-required mandate) for any facility types

10. Was this CAUTI state reporting requirement (e.g., legislation or policy including reportable conditions) for ANY LOCATION implemented and in effect on January 1, 2023 for any of the following facility types? Check all that apply.

    • Acute Care Hospital (ACH)

    • Critical Access Hospital (CAH)

    • Long Term Acute Care Facility (LTAC)

    • Inpatient Rehabilitation Facility (IRF)

    • No reporting mandates (e.g., legislative or state-required mandate) for any facility types

11. Did your state have a reporting requirement (e.g., legislation or policy including reportable conditions) for healthcare facilities to report CAUTI data to NHSN from adult and/or pediatric ICU (critical care) locations at any time during 2023 for any of the following facility types? Check all that apply.

    • Acute Care Hospital (ACH)

    • Critical Access Hospital (CAH)

    • Long Term Acute Care Facility (LTAC)

    • No reporting mandates (e.g., legislative or state-required mandate) for any facility types

12. Was this CAUTI state reporting requirement (e.g., legislation or policy including reportable conditions) for adult and/or pediatric ICU (critical care) locations implemented and in effect on January 1, 2023 for any of the following facility types? Check all that apply.

    • Acute Care Hospital (ACH)

    • Critical Access Hospital (CAH)

    • Long Term Acute Care Facility (LTAC)

    • No reporting mandates (e.g., legislative or state-required mandate) at any facility types

13. Did your state have a reporting requirement (e.g., legislation or policy including reportable conditions) for healthcare facilities to report CAUTI data to NHSN from WARD locations at any time during 2023 for any of the following facility types? Check all that apply.

    • Acute Care Hospital (ACH)

    • Critical Access Hospital (CAH)

    • Long Term Acute Care Facility (LTAC)

    • No reporting mandates (e.g., legislative or state-required mandate) for any facility types

14. Was this CAUTI state reporting requirement (e.g., legislation or policy including reportable conditions) for WARD locations implemented and in effect on January 1, 2023 for any of the following facility types? Check all that apply.

    • Acute Care Hospital (ACH)

    • Critical Access Hospital (CAH)

    • Long Term Acute Care Facility (LTAC)

    • No reporting mandates (e.g., legislative or state-required mandate) for any facility types

15. Did your state have a reporting requirement (e.g., legislation or policy including reportable conditions) for healthcare facilities to report VAE data to NHSN from ANY LOCATION at any time during 2023 for any of the following facility types? Check all that apply.

    • Acute Care Hospital (ACH)

    • Critical Access Hospital (CAH)

    • Long Term Acute Care Facility (LTAC)

    • No reporting mandates (e.g., legislative or state-required mandate) for any facility types

16. Was this VAE state reporting requirement (e.g., legislation or policy including reportable conditions) for ANY LOCATION implemented and in effect on January 1, 2023 for any of the following facility types? Check all that apply.

    • Acute Care Hospital (ACH)

    • Critical Access Hospital (CAH)

    • Long Term Acute Care Facility (LTAC)

    • No reporting mandates (e.g., legislative or state-required mandate) for any facility types

17. Did your state have a reporting requirement (e.g., legislation or policy including reportable conditions) for healthcare facilities to report VAE data to NHSN from adult and/or pediatric ICU (critical care) locations at any time during 2023 for any of the following facility types? Check all that apply.

    • Acute Care Hospital (ACH)

    • Critical Access Hospital (CAH)

    • Long Term Acute Care Facility (LTAC)

    • No reporting mandates (e.g., legislative or state-required mandate) for any facility types

18. Was this VAE state reporting requirement (e.g., legislation or policy including reportable conditions) for adult and/or pediatric ICU (critical care) locations implemented and in effect on January 1, 2023 for any of the following facility types? Check all that apply.

    • Acute Care Hospital (ACH)

    • Critical Access Hospital (CAH)

    • Long Term Acute Care Facility (LTAC)

    • No reporting mandates (e.g., legislative or state-required mandate) for any facility types

19. Did your state have a reporting requirement (e.g., legislation or policy including reportable conditions) for healthcare facilities to report VAE data to NHSN from WARD locations at any time during 2023 for any of the following facility types? Check all that apply.

    • Acute Care Hospital (ACH)

    • Critical Access Hospital (CAH)

    • Long Term Acute Care Facility (LTAC)

    • No reporting mandates (e.g., legislative or state-required mandate) for any facility types

20. Was this VAE state reporting requirement (e.g., legislation or policy including reportable conditions) for WARD locations implemented and in effect on January 1, 2023 for any of the following facility types (check all that apply)?

    • Acute Care Hospital (ACH)

    • Critical Access Hospital (CAH)

    • Long Term Acute Care Facility (LTAC)

    • No reporting mandates (e.g., legislative or state-required mandate) for any facility types

21. Did your state have a reporting requirement (e.g., legislation or policy including reportable conditions) for acute care hospitals (ACH) to report SSI data to NHSN from any of the following procedure types during 2023? If your state has no mandates, please only respond to the first option.

Procedure	Was this reporting mandate in place at any time during 2023?	This mandate was in effect on January 1, 2023
No reporting mandates for any procedure in place	Yes No	Yes No
AAA	Yes No	Yes No
CARD	Yes No	Yes No
CBGB/CBGC	Yes No	Yes No
CHOL	Yes No	Yes No
COLO	Yes No	Yes No
CSEC	Yes No	Yes No
FUSN	Yes No	Yes No
FX	Yes No	Yes No
HPRO	Yes No	Yes No
HYST	Yes No	Yes No
KPRO	Yes No	Yes No
LAM	Yes No	Yes No
PVBY	Yes No	Yes No
REC	Yes No	Yes No
VHYS	Yes No	Yes No

22. Did your state have a reporting requirement (e.g., legislation or state-required mandate) for critical access hospitals (CAH) to report SSI data to NHSN from any of the following procedure types during 2023? If your state has no mandates, please only respond to the first option.

Procedure	Was this reporting mandate in place at any time during 2023?	Was this reporting mandate in effect on January 1, 2023?
No reporting mandates for any procedure in place	Yes No	Yes No
COLO	Yes No	Yes No
HYST	Yes No	Yes No

23. Did your state have a reporting requirement (e.g., legislation or state-required mandate) for healthcare facilities to report MRSA Bacteremia Laboratory-identified (LabID) Events to NHSN from Facility-wide inpatient locations (FacWideIN) at any time during 2023 for any of the following facility types? Check all that apply.

    • Acute Care Hospital (ACH)

    • Critical Access Hospital (CAH)

    • Long Term Acute Care Facility (LTAC)

    • Inpatient Rehabilitation Facility (IRF)

    • No reporting mandates (e.g., legislative or state-required mandate) for any facility types

24. Was this MRSA Bacteremia LabID Event state mandate (e.g., legislation or state-required mandate) for FacWideIN locations implemented and in effect on January 1, 2023 for any of the following facility types? Check all that apply.

    • Acute Care Hospital (ACH)

    • Critical Access Hospital (CAH)

    • Long Term Acute Care Facility (LTAC)

    • Inpatient Rehabilitation Facility (IRF)

• No reporting mandates (e.g., legislative or state-required mandate) for any facility types

25. Did your state have a reporting requirement (e.g., legislation or state-required mandate) for healthcare facilities to report C. difficile Laboratory-identified (LabID) Events to NHSN from Facility-wide inpatient locations (FacWideIN)  at any time during 2023 for any of the following facility types? Check all that apply.

    • Acute Care Hospital (ACH)

    • Critical Access Hospital (CAH)

    • Long Term Acute Care Facility (LTAC)

    • Inpatient Rehabilitation Facility (IRF)

    • No reporting mandates (e.g., legislation or state-required mandate) at any facility types

26. Was this CDI LabID Event state mandate (e.g., legislation or state-required mandate) for FacWideIN locations implemented and in effect on January 1, 2023 for any of the following facility types? Check all that apply.

• Acute Care Hospital (ACH)

• Critical Access Hospital (CAH)

• Long Term Acute Care Facility (LTAC)

• Inpatient Rehabilitation Facility (IRF)

• No reporting mandates (e.g., legislation or policy) for any facility types

Section 3: Data Validation

This section asks about any validation activities that were conducted during the 2023 calendar year. Please let us know if your validation activities and the period they were effective. These questions will be asked for each HAI measure stratified by facility type.

27. Did your state use the NHSN External Validation Toolkit to perform validation on 2023 NHSN data prior to June 1, 2024?

• Yes

• No

28. Please select the HAI(s) that were validated using the NHSN External Validation Toolkit

• CLABSI

• CAUTI

• SSI-COLO

• SSI-HYST

• MRSA LabID Event

• C. difficile LabID Event

• None

29. Please select the facility type(s) that were validated using the NHSN External Validation Toolkit

• Acute Care Hospital (ACH)

• Critical Access Hospital (CAH)

• Long Term Acute Care Facility (LTAC)

• Inpatient Rehabilitation Facility (IRF)

• None

30. Select the appropriate HAIs and facility types for which you (state health department) or a partner organization have access to 2023 data via NHSN. Check all that apply. If your state has no access to any data listed, please only respond to the first option.

	ACH	CAH	LTAC	IRF
No Access to any of the data listed	□	□	□	□
CLABSI
CAUTI
SSI-COLO
SSI-HYST
MRSA Bacteremia LabID Event
C. difficile LabID Event
VAE

31. Has your state health department or partner organization performed data quality checks on at least 6 months of 2023 NHSN data from any of the following HAIs within any healthcare facility types prior to June 1, 2024? This includes an assessment of outliers, data entry errors, trends, data completeness, etc. Check all that apply. If your state performs no data quality checks for any HAIs listed, please only respond to the first option.

	ACH	CAH	LTAC	IRF
No data quality checks performed for any facility type for HAIs listed below		□	□	□
CLABSI
CAUTI
SSI-COLO
SSI-HYST
MRSA Bacteremia LabID Event
C. difficile LabID Event
VAE

32. Does your state health department or partner organization contact hospitals if outliers, errors, missing data, or incomplete data are found?

• Yes

• No

33. Has your state health department or partner organization completed an external audit (medical record review of any HAI, or a review of laboratory records for MRSA or C. difficile LabID Events) of 2023 NHSN data from any of the following facility types prior to June 1, 2024?

    • Yes

    • No

34. 	ACH	CAH	LTAC	IRF
    No external audit or review completed for any of the HAI's listed below	□	□	□	□
    CLABSI
    CAUTI
    SSI-COLO
    SSI-HYST
    MRSA Bacteremia LabID Event
    C. difficile LabID Event
    VAE

35. Does your state have a mandate (e.g., legislation or policy) to conduct an annual external audit (medical record review of any HAI either onsite or via remote desktop electronic review) of NHSN data for any facility types (ACH, CAH, LTAC, or IRF)?

• No mandate and no external audits are performed on HAI data

• No mandate, the state conducts external audits on an ad hoc basis

• Yes, there is a state mandate to conduct annual external audits

36. Please select the required HAIs for each facility type that had a state mandate (e.g., legislation or policy including reportable conditions) to conduct an external audit of NHSN data during 2023. If your state does not have a mandate to conduct an annual external audit, please skip this question.

	ACH	CAH	LTAC	IRF
CLABSI
CAUTI
SSI-COLO
SSI-HYST
MRSA Bacteremia LabID Event
CDI LabID Event
VAE

If you need space to clarify or comment on any of your survey responses, please do so here:

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