Hospital Licensing and Compliance: Protecting Patients and Reputation

Hospital Licensing and Compliance: Protecting Patients and Reputation

A Hospital Operating License permits an agency or facility to provide healthcare therapy and diagnostic services under the direction of an organized medical staff. An official state license is required prior to providing treatment to clients.

This program helps healthcare facilities maintain compliance by identifying the gaps in the policies and procedures they use and creating a plan for remediation. It also includes a customizable Hospital Standards Compliance Assessment Workbook with clear questions correlated to the EPs in each.


The Hospital License requires the hospital to follow certain rules. The hospital, among other things, should have a method of the coding and indexing of medical records so as to make them easily retrievable for diagnosis or procedures. Additionally, the hospital must maintain patient records in a secure manner and restrict access restricted to individuals who are authorized. In some instances, however, the hospital may be obligated to divulge information about patients to law enforcement officials.

Lastly, the hospital must ensure that their physicians hold current licenses and valid medical board certification. The hospital must also have a credentialing committee that acts rapidly and promptly whenever it is approached with an application to become a physician from an authorized physician or podiatrist, as well as a dentist.

The hospital must also have a procedure for modifying or revoking the clinical privileges of an advanced practice nurse or physician assistant. The process must contain legal rights to the advanced practitioner medical assistant and nurse, such as a hearing and in writing notice of the hospital’s decision.


The goal of licensure in the state is to protect the public by setting minimum standards of competence. License boards typically accomplish this by mandating education, assessing character and testing with tests.

Health professionals often seek independent accreditations which validate their skills and knowledge specific areas of content. They also work in establishments that require accreditation from the organizational level. These swaying points, in conjunction with licensure, play an important role in shaping how the educational establishments and employers support the cultivation of lifelong learning abilities.

The committee believes that geographic licenses and the scope-of-practice law require a closer examination to make sure that they are not hindering in the realization of the promise of high-quality healthcare for patients through interprofessional teams as well as informatics. This will require additional study and coordination with professional boards.


A person, company, partnership, association, company or any other type of entity can establish, operate, conduct and manage a hospital that is responsible for the treatment and care of any human being in this state, without first seeking approval from the department for the purpose. This would include a general critical access, or psychiatric institution.

Prior to the commencement of construction, a hospital must make plans and specifications available to the department. This must include an architect’s certification that the plans were prepared according to state and local ordinances, codes of zoning and building codes.

The department reviews all CON applications, including those for changes in ownership and new construction/additions. Projects eligible for limited review need not be apposed of the PHHPC and include proposals with total project costs less than 6 million ($15 million in the case of hospitals) with certain requests.


Hospitals have to be in compliance to the different regulatory bodies who oversee the healthcare industry. Infractions can result in penalties, fines and recoupments as well as other penalties that ruin the reputation of an institution. Also, it puts patients in danger of not receiving the highest quality of care. This can impact their well-being.

The Department must notify in writing the hospital and all affected health care system of any finding that would require the commissioner to initiate action to revoke or suspend operational certificate for the hospital. The notice must state the reason and giay phep hoat dong benh vien the time frame for a public hearing.

The hospital has to be equipped with the best medical team and an governing body accountable to ensure the high quality of the medical care provided to patients. Hospitals must also offer discharge planning evaluations for patients who are in the beginning during their hospital stay, or upon the request of the patient, a individual acting on their behalf or their physician.


Hospitals must maintain their state-issued licenses. Additionally, they must conduct background checks specifically developed for the health industry. This includes criminal checks identification verification, sex offenders’ status checks, and much further. Background checks specifically designed for the healthcare industry helps make sure that the employees of your hospital meet rigorous standards and provide excellent levels of healthcare.

A high-quality staffing level benefits both healthcare organizations and employees. If CNAs, nurses, RNs and MAs are practicing in the top tier of their certifications, hospitals enjoy higher employee engagement, reduced the number of missed appointments, superior outcome for patients, and lower cost.

The Operating Certificate provides information regarding the amount of beds with licenses as well as the facilities that are available to patients at the facility. Also, it lists the extensions clinics run by the clinc or the hospital.