(a) Procedure if
action based on state requirements. If a Healthcare Facility receives one or
more deficiencies as a result of an inspection, receives mark-ups or comments
on a set of plans, or receives notice of a pending or actual adverse action
from the Department, which action is based solely on state construction
requirements, the following informal procedure may be instituted to resolve the
issue(s) in as expedient a manner as possible:
Initial Meeting:
(i)
The Healthcare Facility, in collaboration with the Department, shall meet
either by telephone, electronically, or in person to discuss the issue(s) and
to determine whether an informal resolution of the issue(s) is possible and
acceptable.
(ii) This initial
meeting shall be conducted as soon as possible on a date acceptable to all
parties.
(iii) The parties may
agree at this initial meeting to another informal meeting between themselves to
resolve the matter between the Department and the Healthcare
Facility.
(iv) If the Healthcare
Facility agrees at this initial meeting to an informal resolution of the issue,
but desires to have an outside entity review the question, the parties each
agree to outline the issue(s) and that party's position on the issue(s) in
writing.
(v) A written statement of
the issue(s) and positions of the parties shall be prepared to send to an
outside entity within ten (10) working days of the meeting at which this
decision was made.
Submit Statement of the Issues and Party Positions to Code
Authority:
(vi) Once this
statement of the issue(s) and the parties' positions are reduced to writing so
that both parties can agree to what is contained in the document, it shall be
submitted by the Department to the applicable Code authority, such as the
International Code Council or the American Institute of Architects, as agreed
upon by the parties.
Code Authority Decision:
(vii) Once the applicable Code authority
renders its decision, and if the decision or interpretation is still
unsatisfactory to the Healthcare Facility, it may request a formal
administrative hearing.
(viii) The
Healthcare Facility shall send a written request for a formal administrative
hearing to the Department no later than ten (10) calendar days after receipt of
the Code authority's decision.
(b) Procedure if action based on federal
requirements. When a Healthcare Facility is seeking federal certification,
federal requirements related to the physical environment, the Life Safety Code,
and all other relevant federal codes will apply. If a Healthcare Facility
receives deficiencies, mark-ups or comments on a set of plans, or notice of
pending adverse action from the Department which action is based solely on
federal construction and/or regulatory requirements, the following informal
procedure may be instituted to resolve the issue(s) in as expedient a manner as
possible:
Initial Meeting:
(i)
The Healthcare Facility, in collaboration with the Department, shall meet
either by telephone, electronically, or in-person to discuss the issue(s) and
to determine whether an informal resolution of the issue is possible and
acceptable.
(ii) This initial
meeting shall be conducted as soon as possible on a date acceptable to all
parties.
(iii) The parties may
agree at this initial meeting to another informal meeting between themselves to
resolve the matter between the Department and the Healthcare
Facility.
(iv) If the Healthcare
Facility agrees at this initial meeting to an informal resolution of the issue,
but desires to have an outside entity review the question, the parties must
each outline the issue(s) and that party's position on the issue(s) in
writing.
(v) A written statement of
the issue(s) and positions of the parties shall be prepared to send to an
outside entity within ten (10) calendar days of the initial meeting.
Submission of Statement of the Issues and Party Positions to
Code Authority:
(vi) Once
this statement of the issue(s) and the parties' positions are
reduced to writing so that both parties can agree to what is
contained in the document, it will be submitted by the Department to the
applicable Code authority.
Code Authority Decision:
(vii) Once the applicable Code authority
renders its decision and if the
decision or interpretation is still unsatisfactory to the
Healthcare Facility, the parties may agree to submit the question to the
Centers for Medicare and Medicaid Services (CMS) within ten (10) working days
of the date of the decision or interpretation from the Department or the Code
Authority.
(viii) Decisions
rendered by CMS are considered final; however, there is a federal appeal
process, pursuant to 42 CFR
498,
et seq.
