Current through Register Vol. XLI, No. 36, September 6, 2024
Section 64-12-3 - State Administrative Procedures3.1. General Licensure Provisions. 3.1.1. A person may not establish, conduct, or maintain in West Virginia any hospital or extended care unit operated in conjunction with a hospital without first obtaining a license. Only one license is required for any person that operates any hospital or extended care unit operated in conjunction with a hospital at the same site.3.1.2. A license is not transferable or assignable.3.1.3. If the ownership of a hospital with a valid unexpired license changes, the new owner shall immediately apply for a new license. The new owner's application for a license has the effect of a valid license for three months from the date the application is received by the Director.3.1.4. Any change in location of the hospital, the total and types of beds or other major changes in the operation of the hospital requires the issuance of a new license.3.1.5. The hospital or extended care unit operated in conjunction with a hospital shall: 3.1.5.a. Notify the Director in writing of any proposed change in the location of the hospital, the total and types of beds or operation of the hospital or extended care unit operated in conjunction with a hospital; and3.1.5.b. Request an application form for a new license.3.2. Application for License. An applicant for license shall complete and submit an application to the department on forms provided by the Director available online at ohflac.wvdhhr.org and shall pay the annual fee as required by W. Va. Code §16-5B-4. The name used on the application forms shall be the legal name of the hospital or extended care unit operated in conjunction with a hospital.
3.3. Issuance of License. 3.3.1. The Director will issue a license if: 3.3.1.a. The hospital or extended care unit operated in conjunction with a hospital is in compliance with this rule and applicable sections of W. Va. Code §16-5B-1, et seq.;3.3.1.b. The hospital or extended care unit operated in conjunction with a hospital is in compliance with the rules of the State Fire Commission;3.3.1.c. The hospital or extended care unit operated in conjunction with a hospital has submitted a complete application with all required documentation; and3.3.1.d. In the case of a project that is subject to review under W. Va. Code §16-2D-1, et seq., the West Virginia Health Care Authority has issued a finding, after a final conformance review, that the completed project conforms to the terms of the certificate of need decision issued for the project.3.3.2. The Director will issue a separate license for each separate and distinct location of the hospital or extended care unit operated in conjunction with a hospital.3.3.3. The license will include: 3.3.3.a. The legal name of the hospital or extended care unit operated in conjunction with a hospital to which it applies;3.3.3.b. The location of the hospital or extended care unit operated in conjunction with a hospital;3.3.3.c. The maximum number of beds classified by type for which it is granted; and3.3.3.d. The date the license is issued and the date the license expires.3.4. Expiration and Renewal of License. 3.4.1. All licenses expire on the thirtieth day of June following the date of their issuance unless continued pursuant to the provisions of W. Va. Code §16-5B-4.3.4.2. Licensed hospitals and extended care units shall annually complete and return to the Director applications for licensure renewal with the required license fee on or before the thirtieth day of April. The Director will provide licensure renewal forms to each licensed hospital and extended care unit by mail or other means he or she may consider proper.3.4.3. The application for license shall specify the hospital's and extended care unit's proposed total bed capacity and the numbers of beds categorized by service provided, excluding bassinets.3.4.4. The Director will renew a license if:3.4.4.a. The hospital or extended care unit operated in conjunction with a hospital is in compliance with subsection 3.3. of this rule;3.4.4.b. The hospital has received approval for all renovations or new building projects from the Director;3.4.4.c. The hospital or extended care unit operated in conjunction with a hospital has submitted the appropriate fee according to the provisions of W. Va. Code §16-5B-4; and3.4.4.d. The hospital has a paternity program as defined in W. Va. Code §16-5B-13.3.5. Inspections. 3.5.1. The Director or his or her designee may enter the premises of any hospital or extended care unit operated in conjunction with a hospital to conduct inspections necessary to determine compliance with this rule.3.5.2. The Director or his or her designee will notify a hospital or extended care unit operated in conjunction with a hospital of any violations of this rule.3.5.3. A periodic licensure inspection is not required by the Department for any hospital that is exempted by the provisions of W. Va. Code §16-5B-5a.3.5.4. The Department will grant an exemption from a periodic licensure inspection in the licensing year following accreditation when a hospital applies for this exemption by submitting with the yearly licensure application a complete copy of the accreditation report from the Joint Commission on Accreditation of Health Care Organization, the American Osteopathic Association, or any accrediting organization approved by the Centers for Medicare and Medicaid Services.3.5.5. No exemption granted diminishes the right of the Department of Health to conduct complaint investigations.3.5.6. If the accreditation of a hospital is for a period longer than one year, the Department may conduct at least one licensure inspection of the hospital after the first year of accreditation and before the accreditation has expired and may conduct additional licensure inspections as considered necessary.3.5.7. A hospital receiving a three-year accreditation shall conduct annual self-evaluation using the current year Accreditation Manual for Hospitals by the thirty-first day of March of each year that an inspection has not occurred.3.5.8. A hospital shall incorporate the results of the self-evaluation in its quality improvement program and make a copy of the self-evaluation available to the Department of Health upon request.3.5.9. A hospital is not required to conduct self-evaluations for any licensing year when they are inspected by the Department.3.5.10. Accreditation reports filed with the Department will be treated as confidential in accordance with W. Va. Code §16-5B-10.3.6. Penalties. 3.6.1. After notice of an opportunity for a hearing, pursuant to the provisions of W. Va. Code §29A-5-1, et seq., the Director may revoke the license of any hospital or extended care unit operated in conjunction with a hospital found in violation of this rule.3.6.2. The licensee shall return a revoked license to the Director immediately upon receiving notice of its revocation. If a hospital or extended care unit operated in conjunction with a hospital voluntarily ceases operation, it shall return its license to the Director.3.6.3. If the Director revokes a license, the Director will consider a new application for a license when evidence has been furnished that the conditions upon which the revocation was based have been corrected.3.7. Miscellaneous Requirements. 3.7.1. A hospital may not change its name without submitting a new licensure application identifying the hospital by the new name. The Director will issue a new license with the hospital identified by the new name.3.7.2. All hospitals and extended care units operated in conjunction with a hospital shall comply with applicable rules of the State Fire Commission, the State Air Pollution Control Commission, and the Department of Environmental Protection Solid or Hazardous Waste Unit.3.7.3. The hospital or extended care unit shall post its license in a conspicuous place on the licensed premises.3.7.4. A hospital shall not admit more patients than the number of beds for which it is licensed except in the case of public catastrophe or emergency and then only as a temporary measure.