Inspections of facilities — Definitions

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  1. (a) As used in this section:

    1. (1) “Accrediting organization” means an organization that awards accreditation or certification to hospitals or managed care organizations and has been recognized by the Centers for Medicare & Medicaid Services for deemed status, including without limitation The Joint Commission;

    2. (2)

      1. (A) “Hospital” means a facility used for the purpose of providing inpatient diagnostic care or treatment, including general medical care, surgical care, obstetrical care, psychiatric care, and specialized services or specialized treatment that is subject to the rules for hospitals in Arkansas.

      2. (B) “Hospital” does not mean a facility primarily for the provision of long-term care;

    3. (3) “Inspection” means the on-site review of the physical plant and practices as governed by the current rules of hospitals;

    4. (4) “Investigation” means a specific inspection by the Division of Health Facilities Services related to a complaint or complaints; and

    5. (5) “Survey” means the on-site formal review process of a hospital by the division at regular intervals to ensure compliance with applicable rules adopted by the Department of Health.

  2. (b) The department shall make such inspections and surveys as it may prescribe by rule.

  3. (c) Each hospital accredited by an accrediting organization shall be deemed by the department to be licensable without further survey by the personnel of the division if:

    1. (1) The hospital holds current, full accreditation; and

    2. (2) The division receives a copy of the hospital's official accreditation certificate and the complete report issued by an accrediting organization within thirty (30) days of receipt by the hospital from an accrediting organization.

  4. (d) No hospital shall be required to submit accreditation by an accrediting organization, but whenever a hospital does not submit an accreditation certificate, the personnel of the department shall conduct such surveys as are prescribed by rule.

  5. (e)

    1. (1) Nothing in this section shall affect the right of an authorized representative of the department to enter upon or into the premises of a hospital at any time to make an inspection as part of an investigation when the department does so in response to a complaint or specific identifiable information that the hospital is not meeting minimum quality standards.

    2. (2) If the division upon review of an accrediting organization report reasonably determines that a hospital may not be meeting state licensure standards, it may perform a survey of that hospital and take such steps as are necessary to enforce the standards of the department.

  6. (f) A validation survey may be conducted on five percent (5%) of deemed hospitals during any calendar year to determine continued compliance with state rules.

  7. (g) The department shall continue to have authority over new construction, renovations, and alterations of the hospitals as set forth in the current rules.

  8. (h) All hospitals shall notify the division within thirty (30) days when there is a change in accreditation status.

  9. (i) A staff member of the division may accompany an accrediting organization team that conducts any hospital accreditation survey as an ex officio member for the purpose of observation.


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