Administrative Reconsideration-for purposes of this Chapter, also known as an informal reconsideration.
Class A Violation-a violation of a rule or regulation that creates a condition or occurrence relating to the maintenance and/or operation of a facility which results in death or serious harm to the resident(s), patient(s), or client(s). Examples of class A violations include, but are not limited to:
1. acts or omissions by an employee or employees of a facility that either knowingly or negligently resulted in the death of the resident(s), patient(s), or client(s); or2. acts or omissions by an employee or employees of a facility that either knowingly or negligently resulted in serious harm to the resident(s), patient(s), or client(s). Class B Violation-a violation of a rule or regulation in which a condition or occurrence relating to the maintenance and/or operation of a facility is created which results in the substantial probability of death or serious physical or mental harm to the resident(s), patient(s), or client(s). Examples of class B violations include, but are not limited to:
1. medications or treatments improperly administered or withheld;2. lack of functioning equipment necessary to care for a patient or client;3. failure to maintain emergency equipment in working order;4. failure to employ a sufficient number of adequately trained staff to care for resident(s), patient(s), or client(s); or5. failure to implement adequate infection control measures.Class C Violation-a violation of a rule or regulation in which a condition or occurrence relating to the maintenance and/or operation of a facility creates a potential for harm by directly threatening the health, safety, or welfare of the resident(s), patient(s) or client(s). Examples of class C violations include, but are not limited to:
1. failure to perform treatments as ordered by the physician, including the administration of medications;2. improper storage of poisonous substances;3. failure to notify the physician and family of changes in the condition of a patient or client;4. failure to maintain equipment in working order;5. inadequate supply of needed equipment;6. lack of adequately trained staff necessary to meet the resident(s), patient(s), or client(s)' needs;7. failure of a regulated entity to display on its premises at least one sign, which is at least 18 inches tall by 18 inches wide and written in the English language with letters that are not less than one-square-inch in size, in a conspicuous location in a publically-accessible area;8. failure by a regulated entity to develop a workplace violence prevention plan that includes, as a minimum, all of the following resources: a. resources for ongoing education on the issue of workplace violence;b. resources for prevention of workplace violence; andc. resources on responding to incidents of workplace violence and debriefing with respect to such incidents and responses thereto;9. failure by a regulated entity to have a healthcare workplace violence prevention plan that addresses and encompasses all of the following: a. personnel education and policies requiring all healthcare workers who provide direct care to resident(s), patient(s), or client(s) to receive, at least annually, education and training in a format that provides an opportunity for interactive questions and answers with a person knowledgeable about the workplace violence prevention plan. The education and training delivered pursuant to a workplace violence prevention plan that covers topics including but not limited to all of the following: i. how to recognize the potential for violence to occur;ii. when and how to seek assistance to prevent or respond to violence;iii. how to report violent incidents to law enforcement; andiv. resources available to employee or employees for coping with incidents of workplace violence.b. a system for responding to and investigating violent incidents and situations involving violence; andc. a system for regularly, and not less than annually, assessing and improving upon factors that may contribute to or help in preventing workplace violence. The system must address, without limitation, all of the following aspects of the workplace:i. staffing, including staffing patterns that may contribute to, or be insufficient to address, the risk of violence;ii. sufficiency of security systems including alarms, emergency response systems, and availability of security personnel;iii. job design, equipment, and facilities; andiv. security risks associated with particular units of the workplace, areas of the regulated entity's facility with uncontrolled access, late night, or early morning shifts, and areas surrounding the facility such as employee or employees' parking areas;10. failure by a regulated entity to orient all permanent and temporary employee or employees of the entity's workplace violence prevention plan;11. failure by a regulated entity to maintain its workplace violence prevention plan in effect at all times; or12. failure by a regulated entity to protect resident(s), patient(s), or client(s) from personal exploitation including, but not limited to, sexual conduct involving facility staff and the resident(s), patient(s), or client(s). Class D Violation-a violation of a rule or regulation related to administrative and reporting requirements that do not directly threaten the health, safety, or welfare of the resident(s), patient(s), or client(s), or the safety of its employee or employees through workplace violence. Examples of class D violations include, but are not limited to:
1. failure to submit written reports of accidents;2. failure to timely submit a plan of correction;3. falsification of a record;4. failure to maintain the resident(s), patient(s), or client(s)' financial records as required by rules and regulations;5. failure by a regulated entity to maintain and make available to its employee or employees, a written safety and security plan; or6. a regulated entity taking retaliatory action against a person who, in good faith:a. reports an allegation or instance of workplace violence;b. seeks assistance and intervention from local emergency services or law enforcement when a violent incident occurs; orc. reports to law enforcement a crime or allegation involving workplace violence at the regulated entity's facility. Clientan individual receiving services from a health care facility.
CMS - the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services.
Department or DHH - the Louisiana Department of Health and Hospitals.
Desk Review - Health Standards Section's (HSS) procedure for conducting administrative reconsiderations of sanctions in which a panel of HSS employees, who were not involved in the decisions to cite the deficiencies that were the basis of the sanction or impose the sanction, reviews the documentation submitted by the facility and the information on which the sanction was based and determines whether the sanction was appropriate. Oral presentations are not scheduled unless requested.
Devolutive Appeal - an appeal that does not suspend the execution of the administrative sanction pending the outcome of the appeal.
Division of Administrative Law (DAL) - the Louisiana Department of State Civil Service, Division of Administrative Law, or its successor.
Department or LDH-the Louisiana Department of Health.
Employee-for purposes of this Chapter, a person who performs a job or task for the healthcare provider. An employed person may be permanent, temporary, or contracted.
Healthcare Facility or Facility-any healthcare provider or entity licensed or certified by LDH, including all regulated entities, as defined by R.S. 40:2199.12, under the regulatory jurisdiction of LDH. In other laws, statutes and regulations, this entity may be referred to as a provider, agency, clinic, residential unit, or home. A healthcare facility shall include, but not be limited to a/an:
2. adult brain injury facility;3. adult day health care agency;4. adult residential care provider (ARCP);5. ambulatory surgical center;6. case management agency;7. behavioral health service provider;8. crisis receiving center;9. emergency medical services provider;10. end stage renal disease (ESRD) treatment facility;11. forensic supervised transitional residential and aftercare facility;12. free-standing birth center;13. supplier of portable x-ray services;14. home and community-based services (HCBS) provider;18. intermediate care facility for persons with developmental disabilities (ICF-DD);19. mental health clinic;20. mental health center;21. mental health rehabilitation agency;22. non-emergency medical transportation agency;24. nurse staffing agency;26. pain management clinic;27. pediatric day healthcare (PDHC) facility;28. psychiatric residential treatment facility (PRTF);29. substance use/addiction treatment facility;30. therapeutic group home (TGH); and31. any other program licensed or certified by LDH. HSS-the LDH Health Standards Section. HSS - the Department of Health and Hospitals, Office of Management and Finance, Health Standards Section.
Licensee - the person, partnership, company, corporation, association, organization, professional entity, or other entity to whom a license is granted by the licensing agency, and upon whom rests the ultimate responsibility and authority for the conduct of, and services provided by the facility.
Louisiana Administrative Procedure Act (APA) - R.S. 49:950 et seq.
New Admission - any individual admitted to a facility or a new client receiving services from the facility after the facility receives notice of the sanction and on or after the effective date of the sanction as listed in the sanction notice. A client who was admitted prior to the effective date of the sanction and taking temporary leave before, on or after the effective date of the sanction is not considered a new admission upon return to the facility.
Repeat Violation - either of the following:
1. the existence of the violation is established as of a particular date and it is one that may be reasonably expected to continue until corrective action is taken. The department may elect to treat the cited continuing violation as a repeat violation subject to appropriate sanction for each day following the date on which the initial violation is established until such time as there is evidence that the violation has been corrected; or2. the existence of a violation is established and another violation that is the same or substantially similar to the cited violation occurs within 18 months. The second and all similar violations occurring within an 18-month time period will be considered as repeat violations and sanctioned accordingly.Regulated Entity-any licensed healthcare facility as defined by R.S. 40:2199.12.
Sanction - any adverse action imposed on a facility by the department pursuant to its statutory or regulatory authority for a violation of a statute, law, rule or regulation. For purposes of this Rule, sanction does not include the following:
1. any adverse action that may be applied to a facility by the statewide management organization of the Louisiana Behavioral Health Partnership or its successor, or by a contracted coordinated care network with the Bayou Health program or its successor;2. any adverse action that may be applied to a facility by an agency of the federal government or another state agency;4. an immediate jeopardy determination. Secretary-the secretary of LDH or his/her designee.
Workplace Violence-violent acts, including battery or the intentional placing of another person in reasonable apprehension of sustaining battery, directed toward persons at work or on duty with their employment.
La. Admin. Code tit. 48, § I-4603
Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 39:3077 (November 2013), Amended LR 491215 (7/1/2023).AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2009.11, 40:2009.23, 40:2199 and 40:2199.1.