Licensure

(a) Application for licensure. (1) No person or entity shall operate a hospital without first obtaining a license from the Department. The license is not transferable or assignable. (2) The applicant shall file a licensure application in a timely manner. The application shall be on forms provided by the Department, with a check of $10.00 for each census bed, crib and bassinet, payable to the Oklahoma State Department of Health. (3) The entity responsible for operation of the hospital and appointment of the medical staff shall be considered the applicant for the license. This entity may be a lessee if the hospital is leased and the lessee is the operating entity. For the purposes of licensure, a company providing administrative management of a hospital, which functions by contract with the governing body of the hospital, shall not be considered the entity responsible for operation. (4) An application is not considered to be filed unless it is accompanied by the application fee. (b) Application filing. An initial license application or renewal application shall be filed as follows: (1) The application for an initial license for a new hospital shall be filed prior to or at the time final drawings for construction are OAC 310:667 OKLAHOMA STATE DEPARTMENT OF HEALTH 5 September 13, 2019 submitted to the Department for review which shall be at least thirty (30) days before a hospital begins operation. (2) The application for an initial license for a change of ownership or operation, shall be filed at least thirty (30) days before the transfer. The sale of stock of a corporate licensee, where a majority of the governing body does not change, is not considered a change of ownership or operation. The sale or merger of a corporation that owns an operating corporation that is the licensed entity shall not be considered a change of ownership unless a majority of the governing body is replaced. (3) The application for renewal of a license of an existing hospital shall be filed at least thirty (30) days before the expiration date of the current license. (c) Where to file. The application and the license fee shall be delivered or sent to the Department. The effective date shall be the date the application and fee are received. (d) Forms. The applicant for a license shall file application forms as follows: (1) For an initial license of a new hospital, or for an existing hospital following a change in ownership or operation, the applicant shall file these forms: Application for License to Operate a Hospital or Related Institution; Board of Directors Information Sheet; and Designation of Licensed Beds Form. (2) For renewal of a current license, the applicant shall file the Application for License to Operate a Hospital or Related Institution; Board of Directors Information Sheet; Designation of Licensed Beds Form; and a Fire Inspection Report For Hospitals. (e) Description of forms. The forms used to apply for a hospital license are the following: (1)The Application For License to Operate Hospital or Related Institution (Form 920) requests: identification of the type of license requested; the name and address of the hospital; the name and address of the operating entity; the number of beds and bassinets; the ownership of the building and grounds; the applicant's name; the chief executive officer/administrator's name; attachment for credentialed staff; and an affidavit attesting the signature of the applicant. (2) The Board of Directors Information Form (Form 929) requests: The names and addresses of the Board of Directors for the hospital. (3) The Designation of Licensed Beds Form (Form 929) requests: A listing of the types of beds operated by the hospital and a total of the beds. (4) The Fire Inspection Report for Hospitals (Form 928) requests: a check list of the annual inspection conducted by the local fire marshal. (f) Eligibility for license. (1) Hospitals making appropriate application that have been determined to be compliant with these standards are eligible for a license. (2) A hospital may operate inpatient and outpatient facilities under one (1) license as a hospital campus as long as the following requirements are met: (A) The facilities shall be separated by no more than fifty (50) OAC 310:667 OKLAHOMA STATE DEPARTMENT OF HEALTH 6 September 13, 2019 miles. This requirement may be waived if the services of the facilities are totally integrated through telecommunication or by other means. (B) The facilities are operated by the same governing body with one administrator. (C) The medical staff for all facilities is totally integrated so that any practitioner's privileges extend to all facilities operated under the common license. (3) An outpatient facility located at a different address from a hospital is eligible to be licensed as part of the hospital but is not required to be licensed. (4) Each hospital shall participate in a functioning regional system of providing twenty-four (24) hour emergency hospital care approved by the Commissioner of Health in consultation with the Oklahoma Trauma Systems Improvement and Development Advisory Council. Participation in a regional system may include active participation of the hospital in the provision of emergency services based upon the system plan, participation of the hospital's medical staff in the provision of emergency services at other hospitals in the system based on the system plan, or payment into a fund to reimburse hospitals providing emergency services in the system. (5) If an area of the state fails to develop a functioning regional system of providing twenty-four (24) hour emergency hospital care necessary to meet the state's needs for trauma and emergency care as established by the state-wide trauma and emergency services plan, the Commissioner of Health, in consultation with the Oklahoma Emergency Response Systems Development Advisory Council, shall develop a system for the area. Each hospital located in the area shall participate as specified by the system plan for that region. (g) Regional system of emergency hospital care. (1) In counties and their contiguous communities with populations of 300,000 or more, a functioning regional system of providing twenty- four (24) hour emergency hospital care shall include definitive emergency care for all clinical categories specified in OAC 310:667- 59-7. In these regions, a functioning system shall only transfer emergent patients out of the system when treatment or diagnostic services are at capacity unless the patient has a special treatment need not normally provided by the system. Transfers out of the system may occur based upon the patient or the patient's legal representative's request or based upon a special circumstance for the transfer. (2) In counties and communities with populations of less than 300,000, a functioning regional system of providing twenty-four (24) hour emergency hospital care shall include definitive care based upon the classification of hospital's emergency services in the region as specified in OAC 310:667-59-7. Transfers out of the regional system may be based upon lack of diagnostic or treatment capability or capacity. A functioning system shall not permit emergent patient transfers out of the system if the system has the capability and capacity to provide care unless the patient or patient's legal representative requests the transfer. (3) A functioning regional system of providing twenty-four (24) hour emergency hospital care shall demonstrate compliance with OAC OAC 310:667 OKLAHOMA STATE DEPARTMENT OF HEALTH 7 September 13, 2019 310:667-1-3(g)(1) or (2) through system continuous quality improvement activities. Activities shall include monitoring of patient transfers and corrective actions when inappropriate transfers are identified. Special circumstance patient transfers shall be identified and reviewed through continuous quality improvement activities. (h) Quality indicators. The Department, with the recommendation and approval of the Hospital Advisory Council, shall establish quality indicators to monitor and evaluate the quality of care provided by licensed hospitals in the state. (1) The quality indicators shall focus on the following measurement areas: (A) Acute myocardial infarction (including coronary artery disease); (B) Heart failure; (C) Community acquired pneumonia; (D) Pregnancy and related conditions (including newborn and maternal care); (E) Surgical procedures and complications; (F) Patient perception measures such as satisfaction surveys; and (G) Ventilator-associated pneumonia and device-related blood stream infections for certain intensive care unit patients in acute care hospital settings. (2) The quality indicators in use shall be periodically evaluated and revised as health care quality issues are identified and others are resolved. (i) Data submission requirements. (1) The Department shall define the parameters and scope of each quality indicator, the beginning and ending dates of the period when each indicator will be in effect, how the indicator will be measured, any inclusionary or exclusionary criteria, and the frequency and format of how the data shall be reported. (2) Each hospital shall report applicable data related to these indicators to the Department in the specified format and within required time frames.