Utah Department of Administrative Services Division of Administrative Rules

Utah Administrative Code

The Utah Administrative Code is the body of all effective administrative rules as compiled and organized by the Division of Administrative Rules (Subsection 63G-3-102(5); see also Sections 63G-3-701 and 702).

NOTE: For a list of rules that have been made effective since April 1, 2014, please see the codification segue page.

NOTE TO RULEFILING AGENCIES: Use the RTF version for submitting rule changes.

R386. Health, Disease Control and Prevention, Epidemiology.

Rule R386-705. Epidemiology, Health Care Associated Infection.

As in effect on April 1, 2014

Table of Contents

R386-705-1. Authority and Purpose.

This rule establishes data sharing requirements for health care associated infections and for influenza vaccination of health care workers. It is authorized by Utah Code Sections 26-1-30(2), 26-6-3, 26-6-7, and 26-6- 31.

R386-705-2. Definitions.

For purposes of this rule:

(1) "Ambulatory surgical center" or "ASC" is as defined in Utah Code Section 26-21-2.

(2) "Department" means the Utah Department of Health.

(3) "End stage renal disease facility" is as defined in Utah Code Section 26-21-2.

(4) "General acute hospital" is s defined in Utah Code Section 26-21-2.

(5) "Health care facility" is as defined in Utah Code Section 26-21-2.

(6) "Health care workers" or "HCW"s include, but are not limited to, personnel such as physicians, nurses, nursing assistants, therapists, technicians, dental personnel, pharmacists, laboratory personnel, autopsy personnel, contractual staff not employed by the health care facility, and persons (e.g., clerical, dietary, housekeeping, maintenance, and volunteers) not directly involved in patient care, but potentially exposed to infectious agents that can be transmitted to and from employees of a healthcare facility.

(7) "Specialty hospital" is as defined in Utah Code Section 26-21-2.

R386-705-3. Health Care Associated Infections Reporting.

(1) Pursuant to Utah Code Section 26-6-31, facilities required to report data on the incidence and rate of health care associated infections as mandated by the Center for Medicare and Medicaid Services (CMS) to the National Healthcare Safety Network (NHSN) in the Centers for Disease Control and Prevention (CDC) shall:

(a) Share data with the Department by joining the Department NHSN Group, UDOH HAI (ID# 17686), and confer rights to the Department in NHSN. All data shared with the Department under this rule shall exclude patient identifiers unless necessary for reporting requirements and data validation.

(b) Follow CMS rules and NHSN protocols for defining terms and criteria for reporting infection data.

(2) Facilities required to share data submitted to NHSN with the Department include:

(a) Ambulatory surgical facilities;

(b) General acute hospitals;

(c) Specialty hospitals;

(d) End stage renal disease facilities; and

(e) Any other facilities as required by CMS.

(3) Facilities required to report data to NHSN shall confer rights to the Department for all reported data elements, except for patient identifiers unless necessary for reporting requirements, including for data validation, for the following conditions:

(a) Central line associated bloodstream infections (CLABSI);

(b) Catheter associated urinary tract infections;

(c) Surgical site infections from procedures on the colon and abdominal hysterectomy;

(d) Methicillin-resistant Staphylococcus aureus bacteremia;

(e) Clostridium difficile infection of the colon; and

(f) Any other health care associated infections reported to NHSN as required by CMS.

R386-705-4. Influenza Vaccination Rate Reporting.

(1) Each licensed hospital and licensed long term care facility shall report its influenza vaccination rates for the current influenza season by January 31.

(2) Reports of influenza vaccination rates shall include the total number of HCWs and the number of those workers who are documented to have received an influenza vaccine for the current influenza season.

(a) Licensed hospitals that report HCW influenza vaccination data to NHSN may confer rights to the Department to HCW influenza vaccination data (excluding any patient identifiers) to fulfill this reporting requirement.

(b) Licensed hospitals that do not confer rights to the Department for HCW influenza vaccination data through NHSN shall report HCW influenza vaccination data online to the Department through the Utah Facility Online Reporting System (UFORS). Facilities may contact the Bureau of Epidemiology at (801) 538-6191 with questions about UFORS, to report a problem, or to obtain instructions for using the system.

(c) Influenza vaccination rates reported to UFORS shall be measured using complete enumeration of all HCWs in the facility during the season and the number of them who were vaccinated during that season.

(d) Licensed long term care facilities shall report HCW influenza vaccination data according to requirements in Utah Administrative Code R432-40, the Long-Term Care Facility Immunizations Rule.

R386-705-5. Health Care Associated Infection Prevention.

Each facility required to share data with the Department as described in R386-705-3 shall implement processes to prevent the incidence of health care associated infections.

(1) The processes shall include at least one intervention that is proven by scientifically valid means to be effective in health care associated infection prevention. Interventions that have been recommended by an accepted health authority, including the CDC, or the federal Hospital Infection Control Practices Advisory Committee (HICPAC), meet this requirement.

(2) The facility shall have a system to monitor these processes and shall make information about them available upon request.

R386-705-6. Attestation Required.

Each facility required to share data with the Department as described in R386-705-3 and R386-705-4 shall attest to the implementation and effectiveness of its health care infection prevention program, as described in R386- 705-5, and its systems for reporting, as required by this rule, once every three years.

R386-705-7. Penalties.

An entity that violates any provision of this rule may be assessed a penalty as provided in Utah Code Section 26-23-6.


quality improvement, patient safety, health care, infection controls

Date of Enactment or Last Substantive Amendment

December 21, 2012

Notice of Continuation

December 7, 2012

Authorizing, Implemented, or Interpreted Law

26-1-30(2); 26-6-3; 26-6-7; 26-6-31

Additional Information


For questions regarding the content or application of rules under Title R386, please contact the promulgating agency (Health, Disease Control and Prevention, Epidemiology). A list of agencies with links to their homepages is available at http://www.utah.gov/government/agencylist.html or from http://www.rules.utah.gov/contact/agencycontacts.htm.