Current through Register Vol. 50, No. 9, September 20, 2024
A. Initial Survey.
An initial on-site survey will be conducted to assure compliance with all
hospice minimum standards.
1. Within 90 days
after submitting its application and fee, the hospice shall complete the
application process, shall become operational to the extent of providing care
to only two outpatients, shall be in substantial compliance with applicable
federal, state, and local laws, and shall be prepared for the initial survey.
If the applicant fails to meet this deadline, the application shall be
considered closed and the agency shall be required to submit a new application
packet including the license application fee.
2. The hospice agency that applies for an
inpatient facility license shall not provide care to patients in the agencys
inpatient hospice facility setting prior to the initial survey and achieving
inpatient facility licensure.
3.
The initial survey will be scheduled after the agency notifies the department
that the agency had become operational and is ready for the survey as provided
in §8205.
A 1
4. If, at the initial licensing survey, the
agency is in substantial compliance with all regulations, a full license will
be issued.
5. If, at the initial
licensure survey, an agency has more than five violations of any minimum
standards or if any of the violations are determined to be of such a serious
nature that they may cause or have the potential to cause actual harm, LDH
shall deny licensing.
B.
Licensing Survey. An unannounced on-site visit, or any other survey, which may
include home visits, may be conducted periodically to assure compliance with
all applicable federal, state, and local laws and/or any other
requirements.
C. Follow-up Survey.
An on-site follow-up may be conducted whenever necessary to assure correction
of violations. When applicable, LDH may clear violations at exit interview
and/or by documentation review.
D.
Statement of Deficiencies
1. The department
shall issue written notice to the agency of the results of any surveys in a
statement of deficiencies, along with notice of specified timeframe for a plan
of correction, if appropriate.
2.
Any statement of deficiencies issued by the department to a hospice agency
shall be available for disclosure to the public 30 calendar days after the
agency submits an acceptable plan of correction of the deficiencies or 90
calendar days after the statement of deficiencies is issued to the agency,
whichever occurs first.
E. Complaint Investigations
1. The department shall conduct complaint
investigations in accordance with
R.S.
40:2009.13 et seq.
2. Complaint investigations shall be
unannounced.
3. Upon request by the
department, an acceptable plan of correction shall be submitted by the agency
for any complaint investigation where deficiencies have been cited. Such plan
of correction shall be submitted within the prescribed timeframe.
4. A follow-up survey may be conducted for
any complaint investigation where deficiencies have been cited to ensure
correction of the deficient practices.
5. The department may issue appropriate
sanctions, including but not limited to, civil fines, directed plans of
correction, provisional licensure, denial of license renewal, and license
revocation for non-compliance with any state law or regulation.
6. The departments surveyors and staff shall
be given access to all areas of the hospice agency and all relevant files
during any complaint investigation. The departments surveyors and staff shall
be allowed to interview any agency staff or patient as necessary or required to
conduct the investigation.
F. Unless otherwise provided in statute or in
this Chapter, the hospice agency shall have the right to an informal
reconsideration for any deficiencies cited as a result of a survey or an
investigation.
1. Correction of the deficient
practice, of the violation, or of the noncompliance shall not be the basis for
the reconsideration.
2. The
informal reconsideration of the deficiencies shall be submitted in writing
within 10 calendar days of receipt of the statement of deficiencies, unless
otherwise provided for in these provisions.
3. The written request for informal
reconsideration of the deficiencies shall be submitted to the Health Standards
Section.
4. Except as provided for
complaint surveys pursuant to
R.S.
40:2009.11 et seq., and as provided in this
Chapter for license denials, revocations, and denial of license renewals, the
decision of the informal reconsideration team shall be the final administrative
decision regarding the deficiencies. There is no administrative appeal right of
such deficiencies.
5. The agency
shall be notified in writing of the results of the informal
reconsideration.
6. The request for
an informal reconsideration of any deficiencies cited as a result of a survey
or investigation does not delay submission of the required plan of correction
within the prescribed timeframe.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
40:2181-2191.