State Laws List

Note: A more recent version of this page is available.  Please visit http://haifocus.com/state-healthcare-associated-infection-laws/.  

The following list of healthcare-associated infection (HAI) laws reflects state statutes and administrative regulations as of August 1, 2011.  The list will be updated periodically to reflect current changes in HAI laws.

This information is provided as a reference companion to an article published in the journal Infection Control and Hospital Epidemiology:  J. Reagan and C. Hacker.  Laws Pertaining to Healthcare-Associated Infections: A Review of 3 Legal Requirements.  Infection Control and Hospital Epidemiology, Vol. 33, No. 1: 75-80 (January 2012).

Note to state agency HAI Program Directors:  Please contact Julie Reagan at juliereagan@haifocus.com if the information pertaining to your state is inaccurate or requires updates.  This website, and particularly this webpage, is provided for the use of the public, healthcare professionals, and state and federal agency personnel.  Diligent effort has been taken to make sure the information is as accurate as possible.  Please help to keep the information timely and useful by alerting us of any necessary updates or changes.

For a listing of state acronyms, please see the appendix below this chart.

Updated as of August 1, 2011.

State Are data submission requirements mandatory or voluntary? Does the state HAI law have public reporting provisions? Are facility identifiers required to be included in public reports?
AL

MANDATORY

Ala. Code § 22-11A-114(a) (hospitals required to report data on facility acquired infections).

YES

Ala. Code § 22-11A-117 (department may undertake studies and publish information based on data obtained).

YES

Ala. Code § 22-11A-117 (one of the purposes of studies is to “provide specific comparative health care facility” HAI rates).

AK

N/A (No HAI law)

S.J. Res. No. 19 (2006) (study law only).

N/A N/A
AZ

N/A (No HAI law)

S.B. No. 1356 (2008) (study law only).

N/A N/A
AR

VOLUNTARY

However, MANDATORY data submission is required for facilities participating in the CMS Hospital Inpatient Quality Reporting Program.Ark. Code Ann. § 20-9-1203(a) (health facilities “shall collect data” on HAI rates); § 20-9-1203(b) (health facilities “may voluntarily submit quarterly reports” on HAI rates to the Department of Health;  § 20-9-1203(c) (health facilities participating in the CMS Hospital Inpatient Quality Reporting Program “shall authorize the department to have access to” certain information submitted to NHSN).

YES

Ark. Code Ann. § 20-9-1205 (requires annual report summarizing health facility quarterly reports to be published on department’s website and made available on request).

NO

Ark. Code Ann. § 20-9-1205(a)(1)(B)  (“No health facility-identifiable data shall be included in the annual report, but aggregate statistical data may be included.”); § 1205(f) (“No annual report or other department disclosure shall contain information that identifies or could be used to identify a specific health facility.”).

CA

MANDATORY

Cal. Health & Safety Code § 1288.55(a) (health facilities “shall report” certain HAIs).

YES

Cal. Health & Safety Code § 1288.55(b) (HAI incidence rates shall be posted on department’s website).

YES

Cal. Health & Safety Code § 1288.55(b) (department shall post on website information regarding incidence rate of HAIs acquired at each facility).

CO

MANDATORY

Colo. Rev. Stat. § 25-3-602(1)(a), (3)(a) (health facilities shall collect and shall submit HAI data).

YES

Colo. Rev. Stat. § 25-3-603(1)-(3) (department shall submit annual report to state legislature, post report on website, issue semi-annual bulletins, and publicize the report as widely as practical).

Click here to view Colorado’s January 2012 Annual Report

YES

Colo. Rev. Stat. § 25-3-603(3)(b) (annual report shall compare HAI rates for each individual health facility in the state).

CT

MANDATORY

Conn. Gen. Stat. § 19a-490o(a) (department shall implement the recommendation of HAI committee “with respect to the establishment of a “mandatory reporting system” for HAIs).

YES

Conn. Gen. Stat. § 19a-490o(c) (annual report shall be submitted to the legislature, posted on department’s website and made available to the public).

LAW IS SILENT
DE

MANDATORY

Del. Code Ann. tit 16 § 1003A(b)(1)  (infection control professionals of hospitals shall submit quarterly reports on HAI rates).

YES

Del. Code Ann. tit 16 §1004A(a) (annual report shall be submitted to legislature and published on department’s website).

YES

Del. Code Ann. tit 16 § 1004A(c) (annual report “shall compare” HAI rates to national rates for each individual hospital in the state).

DC

MANDATORY

D.C. Code Ann. § 7-161(d) (mandatory adverse event reporting by healthcare providers and medical facilities); D.C. Mun. Regs. tit 22, § B208.1 (“Each healthcare facility shall report the aggregate number of patients with MRSA bloodstream infections.”).

YES

D.C. Code Ann. § 7-161(c)(8) (annual report shall be published including “summary data of the number and types of adverse events.”).

NO — SUMMARY ONLY

D.C. Code Ann. § 7-161(c)(8) (published annual report is to include summary data by “type of healthcare providers and medical facility”).

FL

MANDATORY

Fla. Stat. § 408.061(1)(a) (data submission by health care facilities on HAIs shall be required).

YES

Fla. Stat. § 408.063(2) (information shall be published and disseminated to the public).

OPTIONAL

Fla. Stat. § 408.063(2) (information shall be published in a manner “which will enhance informed decisionmaking in the selection of health care providers, facilities, and services.  Such publications may identify [certain aspects] for selection and use of health care providers, health care facilities, and health care services and such other information as the agency deems appropriate.”).

GA

N/A (No HAI law)

S. Res. no. 22 (2006) (study law only).

N/A N/A
HI

MANDATORY

H. B. No. 889, section 2 (2011).  Note, mandatory data submission requirements applicable only to CMS certified facilities only.  (“Each health care facility in the State that is certified by the Centers for Medicare and Medicaid Services shall report information about health care-associated infections to the Centers for Disease Control and Prevention’s national healthcare safety network ….”).

YES

H. B. No. 889, section 2(e) (2011) (“The department may issue reports to the public regarding health care-associated infections in aggregate data form to protect individual patient identity.”).

OPTIONAL

H. B. No. 889, section 2(e) (2011) (Reports issued by the department “may identify individual health care facilities.”).

ID N/A (No HAI law) N/A N/A
IL

MANDATORY

210 Ill. Comp. Stat. § 86/25(d) (requires submission of quarterly and annual reports by hospitals).

YES

210 Ill. Comp. Stat.§ 86/30  (department shall submit annual report to legislature and publish on its website).

YES

210 Ill. Comp. Stat. § 86/30 (department shall publish risk-adjusted mortality rates for each hospital); § 86/25(c) (describing required process for public disclosure of comparative hospital information).

IN

N/A (No HAI law)

Ind. Code Ann. §§ 16-40-5-1 to 16-40-5-8 (study law; expired June 20, 2010).

N/A N/A
IA N/A (No HAI law) N/A N/A
KS N/A (No HAI law) N/A N/A
KY N/A (No HAI law) N/A N/A
LA N/A (No HAI law) N/A N/A
ME

MANDATORY

Me. Rev. Stat. Ann. tit. 22 § 8753 (health care facility shall notify division when sentinel event has occurred); 90-590-270 Me. Code R. § 3(A) (each hospital shall report HAI quality metrics data).

YES

Maine Rev. Stat. Ann. tit. 24A § 6951(4) (annual quality reports shall be produced; reports to be made available on publicly accessible website); Me. Rev. Stat. Ann. tit. 22 § 8707 (public access to data); Me. Rev. Stat. Ann. tit. 22 § 8712 (Maine Health Data Organization “shall distribute the reports on a publicly accessible site on the Internet or via mail or e-mail….”); 90-590-120 Me. Code R. (chapter provides for public disclosure of submitted data).

YES

Maine Rev. Stat. Ann. tit. 24A § 6951(4) (Maine Quality Forum  annual quality reports shall include provider-specific information); Maine Rev. Stat. tit. 22 § 8712(3) (annual report shall compare most common diagnosis-related groups and outpatient procedures for all hospitals in the state).

MD

MANDATORY

Md. Code Regs. 10.25.04.02(A) (each hospital shall file data on HAI measures).

YES

Md. Code Ann., Health-General § 19-134(e) (commission may annually publish comparative evaluation of quality of care outcomes and performance measurements of hospitals and ambulatory surgical facilities); Md. Code Regs. 10.25.04.03(A) (summary studies, reports, or other compilations of data submitted are public information); Md. Code Regs. 10.25.04.03(C) (commission shall publish annual results of quality and performance evaluation system).

YES

Md. Code Ann., Health-General § 19-134(e) (annual report is comparative evaluation); Md. Code Regs. 10.25.04.03(C) (annual reports shall be published on a comparative basis and may compare hospital performance to federal public health goals).

MA

MANDATORY

Mass. Ann. Laws ch. 111, § 51H(b) (facilities “shall report” data and information about HAIs); Mass. Code Regs. § 130.1701(B)-(C) (each hospital shall collect and submit data); § 140.309(B)(2) (ambulatory surgery centers shall collect and submit HAI data).

YES

Mass. Ann. Laws ch. 111, § 51H(c) (department shall transmit data collected for publication on consumer health information website).

LAW IS SILENT
MI

N/A (No HAI law)

See however, Mich. Admin. Code r. § 325.172, Rule 2(dddd) (communicable and related diseases rules; “The unusual occurrence, outbreak, or epidemic of any condition, including healthcare-associated infections” is reportable).

 N/A N/A
MN

MANDATORY

Minn. Stat. § 62J.82(Subd. 1)(2) (Minnesota Hospital Association shall develop web-based system for reporting HAI measures); § 62J.82(Subd. 3) (if hospital does not report measures, commissioner of health may bring enforcement action).

YES

Minn. Stat. § 62J.82(Subd. 1) – (Subd. 2) (web-based system for reporting HAI measures available to the public).

YES

Minn. Stat. § 62J.82(Subd. 2) (web site to provide comparative hospital-specific data on HAI public reporting measures).

MS N/A (No HAI law) N/A N/A
MO

MANDATORY

Mo. Ann. Stat. § 192.667(2) (“Hospitals, ambulatory surgical centers, and other facilities shall provide data on required nosocomial infection incidence rates ….”).

YES

Mo. Ann. Stat. § 192.667(8) (“department shall undertake a reasonable number of studies and publish information, including at least an annual consumer guide ….”).

YES

Mo. Ann. Stat. § 192.667(12) (public report shall show nosocomial infection incidence rate for each hospital, ambulatory surgical center, and other facility).

MT N/A (No HAI law) N/A N/A
NE

N/A (No HAI law)

However, providers are required to submit data to a state patient safety organization, not to the Nebraska Department of Health and Human Services.Neb. Rev. Stat. § 71-8717(1)(j) (providers subject to Patient Safety Improvement Act shall report “unanticipated death or major permanent loss of function associated with health care associated nosocomial infection.”); § 71-8714 (data submission is made to a patient safety organization).

N/A N/A
NV

MANDATORY

Nev. Rev. Stat. Ann. § 439.835 (mandatory reporting of sentinel events); § 439.802 (defines facility acquired infections to be reported).

YES

Nev. Rev. Stat. Ann. § 439.840(1)(d) (health division shall prepare annual summary of reports; inclusion on website).Nev. Rev. Stat. § 439A.270(1)(g) (summary report of sentinel events to be included on internet website established for information concerning hospitals and surgical centers for ambulatory patients).*New S.B. 209 (2011) (Health Division shall prepare annual report for inclusion in Internet website).

YES *New    

S.B. 209 (2011), effective prior to October 2011.Note: Former Nev. Rev. Stat. Ann § 439.840(1)(d), (2) provided for summary reports only (health division shall prepare annual summary of reports for inclusion on website; original reports received shall remain confidential).S.B. 209 (2011), which is effective prior to October 2011 amended the law to provide that the annual report prepared by the Health Division “must be reported in a manner that allows a person to compare the information for medical facilities.”

NH

MANDATORY

N.H. Rev. Stat. Ann. § 151:33 (hospitals shall report infections).

YES

N.H. Rev. Stat. Ann. § 151:34(I) (“department shall establish statewide database of all reported infection information”).

YES

N.H. Rev. Stat. Ann. § 151:34(I) (database shall be organized to allow for comparison of individual hospitals).

NJ

MANDATORY

N.J. Stat. Ann. § 26:2H-12.41 (general hospitals shall be required to report to the department HAI process quality indicators and data on infection rates); N.J. Admin. Code § 8:56-2.4(b)(2) (submission of mandatory data elements required); § 8:56-2.6(a)  (each health care facility shall report HAI data).

YES

N.J. Stat. Ann. § 26:2H-12.43 (information shall be made available to public on internet website); N.J. Admin. Code § 8:56-3.1(b) (analysis of quality of care HAI data is to be made available to public).

YES

N.J. Stat. Ann. § 26:2H-12.43 (information made available to public on internet website pursuant to § 26:2H-12.43 is to be formatted to enable comparisons among hospitals); N.J. Admin. Code § 8:56-3.1(a) (“Department shall utilize procedures to allow appropriate comparison of the quality of care related to HAI across health care facilities ….”).

NM

VOLUNTARY

N.M. Stat. Ann. § 24-29-4(A) (requires recruitment of hospitals to participate in HAI surveillance on voluntary basis); § 24-29-6(A) (participating hospitals shall report the incidence of selected indicators).H.J. Mem. No. 67 (2007) (study law only).

YES

N.M. Stat. Ann. § 24-29-6(B) (reports shall be published periodically).

LAW IS SILENT

N.M. Stat. Ann. § 24-29-6(B) (advisory committee shall determine content of public reports).

NY

MANDATORY

N.Y. Public Health Law § 2819(2)(a) (General hospitals “shall maintain a program capable of identifying and tracking [HAIs]” for public reporting.”); § 2819(3) (hospitals “shall regularly report” HAI data).

YES

N.Y. Public Health Law § 2819(4) (commissioner “shall establish” a state-wide database of reported HAI information).

YES

N.Y. Public Health Law  § 2819(4) (state-wide “database shall be organized so that consumers, hospitals, healthcare professionals, purchasers and payers may compare individual hospital experience with that of other individual hospitals as well as regional and state-wide averages and, where available, national data.”).

NC

MANDATORY

H.B. 809 (2011), § 130A-150(c) (“Each hospital,” is subject to the statewide surveillance and reporting system established” … “and shall be responsible for health care-associated infections surveillance and reporting ….”).

YES

H.B. 809 (2011), § 130A-150(d) (“The department shall release to the public aggregated and provider-specific data on health care-associated infections ….”).

YES

H.B. 809 (2011), § 130A-150(c) (Department shall release to the public “provider-specific data ….”).

ND

N/A (No HAI law)

See however, N.D. Admin. Code 33-06-01-01(42) (reportable conditions rules; nosocomial outbreaks in institutions must be reported).

N/A N/A
OH

MANDATORY

Ohio Rev. Code Ann. § 3727.33 (“each hospital shall submit information” showing hospital performance in meeting measures specified under §  3727.41); § 3727.41(A)(1) (director of health shall adopt rules governing hospitals in submission of information under § 3727.33); § 3727.41(B)(1) (rules for submission of information under 3727.33 shall include rules specifying inpatient and outpatient services measures to be used by hospitals); Ohio Admin. Code 3701-14-01 to 3701-14-04 (HAI indicators to be reported listed in DRG reporting requirement rules).

YES

Ohio Rev. Code Ann. § 3727.39(B) (“director shall make submitted information available on an internet” website that is available to the public).

YES

Ohio Rev. Code Ann. § 3727.39(C) (info presented on website “shall be presented” in manner that enables public to compare performance of hospitals in meeting the measures).

OK

MANDATORY

Okla. Stat. tit. 63, § 1-707(C)(2)(c) (advisory council shall have duty and authority to recommend and approve indicators and data submission requirements for hospitals); Okla. Admin. Code § 310:667-1-3(i)(2) (data submission requirements; each hospital “shall report applicable data” to the department).

YES

Okla. Stat. tit. 63, § 1-707(C)(2)(d) (advisory council shall have duty to publish annual report of hospital performance).

YES

Okla. Stat. tit. 63, § 1-707(C)(2)(d) (annual report to include the facility specific quality indicators).

OR

MANDATORY

Or. Rev. Stat. § 442.851, note, section 3(2)(a) (HAI program shall adopt rules to require health care facilities to report HAI measures); Or. Admin. R. 409-023-0010 (hospitals shall collect and report HAI data).

YES

Or. Rev. Stat. § 409.851, note, section 3(6) (rules for public disclosure of reported HAI measures shall be adopted); § 442.851, note, section 6(1), (4) (annual report summarizing health care facility reports submitted shall be prepared; shall be publicized to interested persons).

YES

Or. Rev. Stat. § 442.851, note, section 6(2) (annual report shall compare HAI measures for each health care facility in the state).

PA

MANDATORY

40 Pa. Stat. Ann. § 1303.404(b) (hospitals shall report HAI data).

YES

40 Pa. Stat. Ann. § 1303.304(c)(1), (3) (annual report shall be made available for public inspection and posted on website)

YES

40 Pa. Stat. Ann. § 1303.304(c)(1)(iv) (annual report shall include the “number of serious events and incidents reported by medical facilities on a geographical basis”).

PR

N/A (No HAI law)

However, see Laws of Puerto Rico Ann. § 363 (requires notification of nosocomial infections occurring at Puerto Rico health facilities).

N/A N/A
RI

MANDATORY

R.I. Gen. Laws § 23-17.17-6(a)(9)(ii)(a) (individual hospitals shall collect data on HAIs).

YES

R.I. Gen. Laws § 23-17.17-5(b) (director shall prepare statewide quality performance measure report using data collected; shall be made available to the public).

YES

R.I. Gen. Laws § 23-17.17-5(b) (quality performance measurement report based on data collected shall be made available to the public to show how individual facilities compare).

SC

MANDATORY

S.C. Code Ann. § 44-7-2430(A)-(B) (individual hospitals shall collect data and shall submit reports on HAI rates to the department).

YES

S.C. Code Ann. § 44-7-2440(A) (annual report to be submitted to legislature and published on department website).

YES

S.C. Code Ann. § 44-7-2440(C) (annual reports must compare HAI rates for each individual hospital in the state).

SD

N/A (No HAI law)

See however, S.D. Admin. R.  44:20:01:01(31) (communicable disease rules; nosocomial infections are reportable).

N/A N/A
TN

MANDATORY

Tenn. Code Ann. § 68-11-263(a) (facilities shall join NHSN and submit data).

YES

Tenn. Code Ann. § 68-11-263(b)(2) (department shall post information received from NHSN on department’s web site for public review).

OPTIONAL

Tenn. Code Ann. § 68-11-265 (reports and studies prepared by the department may identify individual healthcare entities).

TX

MANDATORY

Tex. Health & Safety Code Ann. § 98.103 (health care facilities “shall report” certain infections).

YES

Tex. Health & Safety Code Ann. §  98.106(a) (department shall make public summary available).

YES

Tex. Health & Safety Code Ann. §  98.106(b) (public summary must include comparison of infection rates for each health care facility in the state).

UT

MANDATORY

Utah Admin. Code r. §  R386-705-3 (with certain exceptions, all hospitals shall report certain HAIs).

NO N/A
VT

MANDATORY

Vt. Stat. Ann. tit. 18, § 9405b(a)(3) (commissioner shall adopt rules establishing standard format for community reports which shall include measures of HAIs); § 9405b(b) (each hospital shall publish its community report on its website and make paper copies available); 21-040-026 Vt. Code R. § 2(A) (each hospital responsible for publishing community report and making available to commissioner).

YES

Vt. Stat. Ann. tit. 18, § 9405b(c) (Commissioner shall publish community reports provided by hospitals on a public website).

YES

Vt. Stat. Ann. tit. 18, § 9405b(c) (commissioner’s published reports on public website shall include a comparisons of hospitals within same categories of quality and financial indicators).

VA

MANDATORY

Va. Code.  Ann.  § 32.1-35.1 (acute care hospitals shall report information about nosocomial infections); 12 Va. Admin. Code § 5-90-370(B) (acute care hospitals shall collect and submit data).

YES

Va. Code.  Ann.  § 32.1-35.1 (hospital infection rate data is public information that may be released);12 Va. Admin. Code § 5-90-370(C) (infection rate data is releasable upon request).

LAW IS SILENT
WA

MANDATORY

Wash. Rev. Code § 43.70.056(2)(a) (hospitals shall collect and submit HAI data).

YES

Wash. Rev. Code § 43.70.056(2)(b)(ii)(B)  (Washington state hospital association must develop report and publish on its web site).

YES

Wash. Rev. Code § 43.70.056(2)(b)(ii)(B) (public report must compare HAI rates for individual hospitals).

WV

MANDATORY

W. Va. Code § 16-5B-17(d) (hospitals shall report information on HAIs).

YES

W. Va. Code § 16-5B-17(f) (results of collection and analysis of all hospital data shall be provided for public availability).

LAW IS SILENT
WI N/A (No HAI law) N/A N/A
WY N/A (No HAI law) N/A N/A

 

Appendix A.  U.S. State and Territory Abbreviations

AL, Alabama

AK, Alaska

AR, Arkansas

AZ, Arizona

CA, California

CO, Colorado

CT, Connecticut

DC, District of Columbia

DE, Delaware

FL, Florida

GA, Georgia

HA, Hawaii

IA, Iowa

ID, Idaho

IL, Illinois

IN, Indiana

KS, Kansas

KY, Kentucky

LA, Louisiana

MA, Massachusetts

MD, Maryland

ME, Maine

MI, Michigan

MN, Minnesota

MO, Missouri

MS, Mississippi

MT, Montana

NC, North Carolina

ND, North Dakota

NE, Nebraska

NH, New Hampshire

NJ, New Jersey

NM, New Mexico

NV, Nevada

NY, New York

OH, Ohio

OK, Oklahoma

OR, Oregon

PA, Pennsylvania

PR, Puerto Rico

RI, Rhode Island

SC, South Carolina

SD, South Dakota

TN, Tennessee

TX, Texas

UT, Utah

VA, Virginia

VT, Vermont

WA, Washington

WI, Wisconsin

WV, West Virginia

WY, Wyoming