Fla. Admin. Code Ann. R. 59A-3.253 - Investigations and License, Life Safety and Validation Inspections
(1) Inspections. The Agency shall conduct
periodic inspections of hospitals in order to ensure compliance with all
licensure requirements in accordance with section
395.0161, F.S.
(2) Non-accredited hospitals. Hospitals which
are not accredited by an accrediting organization shall be subject to a
licensure inspection.
(3) Accredited
hospitals. The Agency shall accept the report of an accrediting organization in
lieu of a licensure inspection for accredited hospitals and for hospitals
seeking accreditation, provided that the standards included in the report
demonstrate that the hospital is in compliance with state licensure
requirements found in chapters 395 and 408, F.S., and chapters 59A-3 and
59A-35, F.A.C., and the hospital does not meet the criteria specified under
subparagraphs (c)1. and 2.
(a) Upon receipt of
the accrediting organization's report, the Agency will review the findings to
determine if the hospital is in compliance with state licensure
requirements.
(b) The Agency shall
notify the hospital within 60 days of the receipt of the accrediting
organization's survey report regarding the Agency's determination of the
hospital's compliance or non-compliance with state licensure
requirements.
(c) Accredited
hospitals shall be subject to a licensure inspection under the following
circumstances:
1. The hospital has been denied
accreditation or has received a provisional or conditional accreditation from
an accrediting organization on its most recent accreditation report, and has
not submitted an acceptable plan of correction to the accrediting
organization;
2. The hospital has
received full accreditation but has not authorized the release of the report to
the Agency, or has not ensured that the Agency received the accrediting
organization's report prior to the Agency scheduling a licensure
inspection.
(4)
Licensure inspection fees. With the exception of state-operated licensed
facilities, the licensure inspection fee shall be $12.00 per hospital bed,
provided that no licensed facility shall be assessed less than $400.00 per
inspection for licensure, and further provided that a separate fee for the
licensure inspection shall be charged for each hospital located on a separate
premises, regardless of its inclusion on a single license.
(5) Life safety inspection fees. With the
exception of state-operated licensed facilities, the fee for a life safety
inspection shall be $1.50 per hospital bed, provided that no licensed facility
shall be assessed less than $40 for a life safety inspection, and further
provided that a separate fee for the life safety inspection shall be charged
for each hospital located on a separate premises, regardless of its inclusion
on a single license. A separate fee for a life safety inspection will not be
assessed when conducted as part of a licensure or a Centers for Medicare and
Medicaid Services certification inspection.
(6) Validation inspections. Each year, the
Agency shall conduct validation inspections on a minimum of five percent of
those hospitals that have undergone a full accreditation inspection from an
accrediting organization to determine ongoing compliance with licensure
requirements.
(a) If the Agency determines,
based on the results of validation inspection findings, that a fully accredited
hospital is not in compliance with licensure requirements, the Agency shall
report its findings to the accrediting organization and shall conduct a full
licensure inspection on that hospital during the following year.
(b) The fee for conducting a licensure
validation inspection shall be the same as that specified for licensure
inspections under subsection (4). A separate fee for a validation inspection
will not be assessed when conducted in conjunction with a Centers for Medicare
and Medicaid Services certification inspection.
(7) Complaint inspections. The Agency shall
conduct investigations of complaints regarding violations of licensure and life
safety standards in accordance with sections
395.0161 and
408.811, F.S. Complaint
investigations will be unannounced. An entrance conference must be conducted
upon arrival, by Agency personnel investigating the complaint, to inform the
hospital's administrator about the nature of the complaint investigation and to
answer questions from hospital staff. An exit conference must be provided at
the conclusion of the onsite investigation to inform the hospital of the scope
of the investigation and to receive any additional information that the
hospital wishes to furnish.
(a) Upon receipt
of a complaint, the Agency shall review the complaint for allegations of
non-compliance with licensure requirements, and shall take the following
action:
1. Complaints involving accredited
hospitals shall be reported to the appropriate accrediting
organization;
2. Complaints
involving Medicare certified hospitals shall be referred to the Centers for
Medicare and Medicaid Services for a determination as to the need for an
investigation under certification standards.
3. Complaints involving diagnostic radiology
equipment or personnel, or biomedical, waste disposal shall be referred to the
Department of Health for investigation.
(b) Upon a determination that investigation
of a complaint is warranted, the Agency shall conduct an
investigation.
(8)
Conformance with accreditation standards. In all hospitals where the Agency
does not conduct a licensure inspection, by reason of the hospital's
accreditation status, the hospital shall continue to conform to the standards
of accreditation throughout the term of accreditation, or shall notify the
Agency of the areas of non-conformance. Where the Agency is notified of
non-conformance, it shall take appropriate action as specified under subsection
(3).
(9) Sanctions. The Agency shall
impose sanctions, in accordance with section
395.1065, F.S., on those
hospitals which fail to submit an acceptable plan of correction or implement
actions to correct deficiencies identified by the Agency or an appropriate
accrediting organization which are specified in an approved plan of correction
or as identified as a result of a complaint investigation.
Notes
Rulemaking Authority 395.1055, 408.819 FS. Law Implemented 395.0161, 395.1055, 395.1065, 408.811 FS.
New 9-4-95, Formerly 59A-3.204 Amended 5-16-06, 10-16-14, 3-19-17.
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