2009 Annual Hospitals Report - Nevada State Health Division ...

OVERVIEW
Licensure and Certification
Authority
2009 Annual Hospitals Report
Under the authority of the State Board of Health and the State Health Officer, pursuant to NRS 439 and 449, BHCQC is
responsible for the licensure and certification of healthcare facilities and medical laboratories in Nevada. The mission of
the bureau is:
To protect the safety and welfare of the public by promoting and advocating quality healthcare through licensure,
regulation, enforcement, and education.
Licensure
Statutory and regulatory licensure requirements for health facilities exist at the state level. With the exception of a few
facility types, a state license is required by NSHD before any healthcare facility may begin providing services. To continue
operating, a facility must annually renew its license by December 31 st of each year.
Certification
Although not required to operate, a healthcare facility may seek certification from CMS to qualify for reimbursements
through Medicare and/or Medicaid. However, since initial certification is a low priority for CMS, facilities often opt for
deemed status from an approved accrediting organization. Deemed status simply means that the facility has met the
accrediting body’s standards which are deemed acceptable in lieu of certification.
Nearly all hospitals in Nevada are accredited by a nationally-recognized accrediting body. Accrediting organizations
include the American Osteopathic Association’s Healthcare Facilities Accreditation Program, Det Norske Veritas, and The
Joint Commission. TJC was the primary provider of accreditation in 2009.
State agencies throughout the United States have federal-state agreements to serve as the field agent for CMS. NSHD
has such an agreement and has further delegated the responsibility of conducting the federal certification inspections to
its Health Facilities section, at the request of those wishing to receive reimbursement for providing medical services to
Medicare and/or Medicaid enrollees. In addition to ensuring compliance with federal regulations related to quality of
care, inspectors review life safety code requirements at the facilities to ensure they are in compliance with federal
regulations.
ASPEN
ASPEN is a suite of software applications designed for the federal government by Alpine Technologies. It is used to
collect, track, and manage healthcare provider data. The federal government has contracted with state governments,
including Nevada, to have state personnel, usually through a state agency, conduct federal surveys/inspections and
respond to complaints. All inspections are recorded in ASPEN Central Office, a component of the ASPEN suite. All
complaints are recorded in ASPEN Complaint and Incident Tracking System, another component of ASPEN.
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