§16B-3-5a. Accreditation reports accepted for periodic license inspection.

Notwithstanding any other provision of this article, a periodic license inspection shall not be conducted by the Office of Health Facility Licensure and Certification for a hospital if the hospital has applied for and received an exemption from that requirement: Provided, That no exemption granted diminishes the right of the Office of Health Facility Licensure and Certification to conduct complaint inspections.

The Office of Health Facility Licensure and Certification shall grant an exemption from a periodic license inspection during the year following accreditation if a hospital applies by submitting evidence of its accreditation by the Joint Commission on Accreditation of Health Care Organizations or the American Osteopathic Association, or any accrediting organization approved by the Centers for Medicare and Medicaid Services, and submits a complete copy of the accrediting organization’s accreditation report.

If the accreditation of a hospital is for a period longer than one year, the Office of Health Facility Licensure and Certification may conduct at least one license inspection of the hospital after the first year of accreditation and before the accreditation has expired and may conduct additional license inspections if needed. Hospitals receiving a three-year accreditation shall conduct annual self-evaluations using the current year accreditation manual for hospitals unless the Office of Health Facility Licensure and Certification informs the hospital that the hospital will be inspected by the Office of Health Facility Licensure and Certification. Hospitals are not required to conduct self-evaluations for any calendar year during which they are inspected by the Office of Health Facility Licensure and Certification. These self-evaluations shall be completed and placed on file in the hospital by March 31 of each year. Hospitals shall make the results of the self-evaluation available to the Office of Health Facility Licensure and Certification upon requested.

Accreditation reports filed with the Office of Health Facility Licensure and Certification shall be treated as confidential in accordance with §16B-3-10 of this code.