La. Admin. Code tit. 48 § I-8205

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-8205 - Survey

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.

La. Admin. Code tit. 48, § I-8205

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR:15:482 (June 1989), amended LR 24:2260 (December 1998), LR 25:2409 (December 1999), LR 29:2800 (December 2003), Amended by the Department of Health, Bureau of Health Services Financing, LR 44591 (3/1/2018).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2181-2191.