Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 175 - HEALTH CARE FACILITIES AND SERVICES LICENSURE
Chapter 16 - HOSPICE SERVICES
Section 175-16-005 - INSPECTIONS
Universal Citation: 175 NE Admin Rules and Regs ch 16 ยง 005
Current through March 20, 2024
To determine compliance with operational, care, treatment, and physical plant standards, the Department inspects hospices prior to and following licensure. The Department determines compliance through initial on-site inspections, and for inpatient hospice, review of schematic and construction plans and reports of qualified inspectors. Re-inspections are conducted by on-site inspection or review of documentation requested by the Department.
005.01 Initial Inspection
The Department will conduct an announced initial on-site inspection to determine compliance with 175 NAC 16-006 and 16-007. The inspection will be conducted within 30 working days, or later if requested by the applicant, of receipt of a completed application for an initial license. The Department will provide a copy of the inspection report to the hospice within ten working days after completion of an inspection.
005.02 Results of Initial Inspection
16-005.02A When the Department finds that the
applicant fully complies with the requirements of 175 NAC
16-006 and
16-007, the Department will issue a
license.
16-005.02B When the
Department finds that the applicant has complied substantially but has failed
to comply fully with the requirements of 175 NAC
16-006 and
16-007 and the failure(s) would not
pose an imminent danger of death or physical harm to persons residing in or
served by the hospice, the Department may issue a provisional license. The
provisional license:
1. Is valid for up to
one year; and
2. Is not
renewable.
16-005.02C
When the Department finds the applicant has one or more violations that create
no imminent danger of death or serious physical harm and no direct or immediate
adverse relationship to the health, safety, or security of the persons residing
in or served by the hospice, the Department may send a letter to the hospice
requesting a statement of compliance. The letter must include:
1. A description of each violation;
2. A request that the hospice submit a
statement of compliance within ten working days; and
3. A notice that the Department may take
further steps if the statement of compliance is not submitted.
16-005.02D The statement of
compliance must indicate any steps that have been or will be taken to correct
each violation and the estimated time to correct each violation. Based on the
statement of compliance, the Department will take one of the following actions:
1. If the hospice submits and implements a
statement of compliance that indicates a good faith effort to correct the
violations, the Department will issue either a regular license or a provisional
license; or
2. If the hospice fails
to submit and implement a statement of compliance that indicates a good faith
effort to correct the violations, the Department may deny the
license.
16-005.02E When
the Department finds the applicant fails to meet the requirements of 175 NAC
16-006 and
16-007 and the failure(s) would
create an imminent danger of death or serious physical harm, the Department
will deny the license.
005.03 Physical Plant Inspections
For inpatient hospice, the Department will_conduct inspections for conformity with construction plans and compliance with 175 NAC 16-007 at new facilities or new construction prior to use or occupancy.
16-005.03A On-site progress inspections of
the physical plant by qualified inspectors for conformity to construction
documents and compliance with code requirements may occur at any time after
construction has begun and prior to the concealment of essential
components.
16-005.03B The
Department will conduct an on-site final inspection of the physical plant prior
to use or occupancy. In lieu of an on-site final inspection by the Department,
the Department may accept a certification from a licensed architect or engineer
that the physical plant meets the requirements of the Health Care Facility
Licensure Act and 175 NAC 16, and that the hospice is complete and ready for
occupancy in accordance with Department-approved plans. The architect or
engineer may construct a certification form or obtain a certification form from
the Department.
16-005.03B1 The certification
must state:
1. Name of the architect or
engineer;
2. Name of the
professional entity with which he or she is affiliated, if any;
3. Address and telephone number;
4. Type of license held, the state in which
it is held, and the license number;
5. Name and location of the
hospice;
6. Name(s) of the owner(s)
of the hospice;
7. New
construction had the building structure and plumbing rough-in inspected by a
qualified inspector prior to the time these would be concealed and preclude
observation;
8. All new
construction, care and treatment room sizes, bedroom sizes, handrails, grab
bars, hardware, building systems, protective shielding, privacy curtains,
appropriate room finishes, and other safety equipment are completed in
accordance with approved construction plans; and
9. The hospice is furnished, cleaned, and
equipped for the care and treatment to be preformed in compliance with 175 NAC
16-007, and approved for use and
occupancy.
16-005.03B2
The certification must have attached to it:
1. Copies of documents from other authorities
having jurisdiction verifying that the hospice meets the codes specified in 175
NAC
16-007.03A, and
approved for use and occupancy;
2.
Copies of certifications and documentation from equipment and building system
installers verifying that all equipment and systems installed are operating and
approved for use and occupancy; And
3. Schematic floor plans documenting actual
room numbers and titles, bed locations, capacity, and life safety
information.
005.04 Compliance Inspections
The Department may, following the initial licensure of a hospice, conduct an unannounced onsite inspection at any time as it deems necessary to determine compliance with 175 NAC 16-006 and, for an inpatient hospice, 16-007. Any inspection may occur based on random selection or focused selection.
16-005.04A
Random
Selection: Each year the Department may inspect up to 25% of the
hospices based on a random selection of licensed hospices.
16-005.04B
Focused
Selection: The Department may inspect a hospice when the
Department is informed of one or more of the following:
1. An occurrence resulting in patient death
or serious physical harm;
2. An
occurrence resulting in imminent danger to or the possibility of death or
serious physical harm to patients;
3. For inpatient hospice only, an accident or
natural disaster resulting in damage to the physical plant and having a direct
or immediate adverse effect on the health, safety, and security of
patients;
4. The passage of five
years without an inspection;
5. A
complaint alleging violation of the Health Care Facility Licensure Act or 175
NAC 16;
6. Complaints that, because
of their number, frequency, or type, raise concerns about the maintenance,
operation, or management of the hospice;
7. Financial instability of the licensee or
of the licensee's parent company;
8. Outbreaks or recurrent incidents of
physical health problems at an inpatient hospice such as dehydration, pressure
sores, or other illnesses;
9.
Change of services, management or ownership;
10. Change of status of accreditation or
certification on which licensure is based as provided in 175 NAC 16-004.09;
or
11. Any other event that raises
concerns about the maintenance, operation, or management of the
hospice.
005.05 Results of Compliance Inspections
16-005.05A When the inspection reveals
violations that create imminent danger of death or serious physical harm or
have a direct or immediate adverse effect on the health, safety, or security of
persons residing in or served by the hospice, the Department will review the
inspection findings within 20 working days after the inspection. If the
evidence from the inspection supports the findings, the Department will impose
discipline in accordance with 175 NAC 16-008.03.
16-005.05B When the inspection reveals one or
more violations that create no imminent danger of death or serious physical
harm and no direct or immediate adverse effect on the health, safety, or
security of persons residing in or served by the hospice, the Department may
request a statement of compliance from the hospice. The statement of compliance
must indicate any steps that have been or will be taken to correct each
violation and the estimated time to correct each violation. Based on the
statement of compliance, the Department will take one of the following actions:
1. If the hospice submits and implements a
statement of compliance that indicates a good faith effort to correct the
violations, the Department will not take any disciplinary action against the
license; or
2. If the hospice fails
to submit and implement a statement of compliance, the Department will initiate
disciplinary action against the hospice license, in accordance with 175 NAC
16-008.
005.06 Re-inspections
16-005.06A The Department may conduct
re-inspections to determine if a hospice fully complies with the requirements
of 175 NAC
16-006 and
16-007:
1. After the Department has issued a
provisional license;
2. Before a
provisional license is converted to a regular license;
3. Before a disciplinary action is modified
or terminated; or
4. After the
Department receives a statement of compliance or a plan of correction for cited
violations.
16-005.06B
Following a re-inspection, the Department may:
1. Convert a provisional license to a regular
license;
2. Affirm that the
provisional license is to remain effective; or
3. Modify a disciplinary action in accordance
with 175 NAC 16-008.02; or
4. Grant
full reinstatement of the license.
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