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For Release:
September 06, 2011

Mary E. O'Dowd, M.P.H.

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DHSS Proposes Amendments, Repeals and New Rules at N.J.A.C. 8:56, Governing Health Care Facility Infection Reporting



         The Office of Health Care Quality Assessment in the Office of the Commissioner in the Department of Health and Senior Services (Department), with the approval of the Health Care Administration Board and in consultation with the Quality Improvement Advisory Committee (QIAC), is proposing Amendments, Repeals and New Rules at N.J.A.C. 8:56, Governing Health Care Facility Infection Reporting.  The notice of proposal appears in the September 6, 2011 issue of the New Jersey Register.  LexisNexis® provides free on-line public access to the New Jersey Administrative Code and the New Jersey Register at


         The administrative rules at N.J.A.C. 8:56 implement the Health Care Facility-Associated Infection Reporting and Prevention Act (Act), P.L. 2007, c. 196, codified at N.J.S.A. 26:2H-12.39 through 12.45.  The Act requires general hospitals licensed in accordance with the Health Care Facilities Planning Act, N.J.S.A. 26:2H-1 et seq. (P.L. 1971, c. 136) to report information related to healthcare-associated infection (HAI) to the Department.  N.J.A.C. 8:56 establishes the system for reporting HAI to the Department, the HAI that is required to be reported, enrollment and training requirements for the reporting system, and data collection and reporting requirements.  N.J.A.C. 8:56 also sets forth the Department’s procedure for determining the HAI data to be reported, availability of the data to the public, and provisions for data accuracy, confidentiality, and enforcement.  


         P.L. 2009, c. 263 extended the HAI reporting requirement to ambulatory surgery facilities.  P.L. 2009, c. 263 requires that ambulatory surgery facilities report to the Department infection related data, as selected by the Commissioner of the Department in consultation with the QIAC.  In order to implement P.L. 2009, c. 263, the Department is proposing substantive and technical amendments, new rules and repeals throughout the chapter.  Noteworthy proposed substantive amendments and new rules include the following:


         • Proposed amendments throughout the chapter to include ambulatory surgery facilities as required reporters of HAI where applicable.

         • A proposed amendment at N.J.A.C. 8:56-1.2 to expand the definition of “health care facility” to include ambulatory surgery facilities that are licensed pursuant to N.J.A.C. 8:43A.

         •  A proposed repeal and new rule at N.J.A.C. 8:56-2.2 that would address the access to HAI data elements in the reporting system that health care facilities are to grant to the Department, as well as continue the standard that information retrieved by the Department from the reporting system is not a government record subject to public access.  P.L. 2011, c. 42 deleted the requirement that access only to information that does not contain patient identifiers be granted to the Department by general hospitals.  Pursuant to P.L. 2011, c. 42, proposed new subsection (a) provides that general hospitals shall grant the Department access to data elements from the reporting system that contains patient identifying information.  Proposed new subsection (b) is consistent with P.L. 2009, c. 263, and only requires ambulatory surgery facilities to grant access to HAI data elements from reporting system to the Department that does not contain patient identifying information. 

         •A proposed amendment at N.J.A.C. 8:56-2.3(c)4i sets forth the confidentiality requirements.          

         •A proposed amendment at N.J.A.C. 8:56-2.4 would add a new subsection, (d), which would provide that data is to be reported within 30 days of the end of each calendar quarter.

         •A proposed amendment at N.J.A.C. 8:56-2.7(c) to state that the Department may conduct an on-site audit of a health care facility’s HAI data elements.


         The public has until November 5, 2011 to comment on the notice of proposal.  Persons wishing to comment on the proposal must submit their comments in writing through regular mail to, Devon L. Graf, Director, Office of Legal and Regulatory Compliance, Office of the Commissioner, Department of Health and Senior Services, PO Box 360, Trenton, NJ 08625-0360.  Written comments on the proposal must be postmarked on or before November 5, 2011, which is the close of the 60-day public comment period.



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