Section 448.810a - Reliance on national accreditation organizations for hospitals(a) Report of other agencies.--After a provider has been licensed or approved to operate a hospital for at least three years under this or a prior act, no portion of which has been pursuant to a provisional or other restricted license, if requested by the facility, the department shall rely on the report of an acceptable accreditation organization authorized pursuant to this section and section 806.(b)Application and approval process.--An accreditation organization shall apply to the department for approval. Prior to approval, the department shall: (1) determine that the standards of the accreditation organization are equal to or more stringent than existing licensure survey requirements;(2) evaluate the survey process of the accreditation organization to ensure the integrity of the survey process; and(3) enter into a written agreement with the accreditation organization that includes requirements for: (i) notice of all surveys ;(ii) sharing of complaints and other relevant information;(iii) participation of the department in accreditation organization activities if determined to be appropriate by the department;(iv) protection of the confidentiality of medical and personal records;(v) all licensure surveys of deemed hospitals shall be based on the standards established by the national accreditation organization and State law; and(vi) any other provision necessary to ensure the integrity of the accreditation and survey process.(c) Finding of substantial compliance of hospital.--(1) If an approved accreditation organization has issued a final report finding a hospital to be in substantial compliance with the accreditation organization's standards, the department shall accept the report as evidence that the hospital has met the department's licensure requirements and shall grant the hospital deemed status, if the hospital provides a copy of the final report to the department within ten business days of the hospital receiving it from the approved accreditation organization. The final report must have been issued no more than one year prior to the expiration date of the hospital's license.(2) A hospital that receives anything less than full accreditation shall be subject to full licensure survey by the department.(d)Reports to department.-- (1) The department shall, in accordance with department practice, make a final report of an approved accreditation organization immediately available to the public.(2) A preliminary or final report of an approved accreditation organization shall not be admissible as evidence in a civil action or proceeding.(e)Inspection by department.--The department may inspect an accredited hospital to: (1) follow up on a systemic concern or event identified by an approved accreditation organization or by report filed by the facility;(2) investigate a complaint;(3) validate the findings of an approved accreditation organization that determined that a hospital is in compliance with conditions of participation issued by the Centers for Medicare and Medicaid Services and State licensure requirements; or(4) comply with the request of any Federal or State regulatory entity.(f) Department participation or observation of surveys by accreditation organization.-- -The department may participate in or observe a survey of a hospital conducted by an approved accreditation organization. (g)Actions by the department on accreditation organization's failure to meet obligations.-- (1) Upon determination by the department that an approved accreditation organization has failed to meet its obligations under this section, the department shall have 30 days from the time it notifies the accreditation organization to resolve any issues that are resulting in the accreditation organization not meeting its obligations.(2) If, after 30 days, the department and the accreditation organization have not reached an agreement that brings the accreditation organization back into compliance with this act, the department shall provide notice in the Pennsylvania Bulletin that it intends to take action to withdraw the approval of the accreditation organization, list the reasons the action is being taken, make available the accreditation organization's response to the department and receive public comment regarding the decision for a period of not less than 30 days.(3) If, after the conclusion of the public comment period, the department's determination is that the approved accreditation organization has failed to meet its obligation under this section, the department may withdraw approval of the accreditation organization granted under sections 806 and 810 and immediately terminate the agreement between the department and the accreditation organization.(4) Any hospital that has achieved deemed status as a result of being accredited by the accreditation organization terminated by the department shall keep the deemed status until the end of the current licensure period. To renew a license, the hospital shall either be accredited by another department-approved accreditation organization or shall be subject to the department's licensure regulations as provided for in section 806(i)(2).Added by P.L. 422 2013 No. 60,§ 5, eff. 1/5/2014.