§ 1901. Policy
The purpose of this chapter is to provide for the development, establishment, and
enforcement of standards for the construction, maintenance, and operation of hospitals,
which, in the light of advancing knowledge, will promote safe and adequate treatment
of persons in hospitals. (Amended 1963, No. 154, § 1.)
§ 1902. Definitions
The following words and phrases, as used in this chapter, shall have the following
meanings unless otherwise provided:
(1) “Hospital” means a place devoted primarily to the maintenance and operation of diagnostic
and therapeutic facilities for in-patient medical or surgical care of individuals
who have an illness, disease, injury, or physical disability, or for obstetrics.
(A) “General hospital” is a hospital of which not more than 50 percent of the total patient
days during the year are customarily assignable to the following categories of cases:
chronic, convalescent and rest, drug and alcoholic, epilepsy, developmental and psychiatric
disabilities and mental conditions, and tuberculosis and that provides adequate and
separate facilities and equipment for the performance of surgery and obstetrics, or
either, and for diagnostic X-ray and laboratory services.
(B) “Psychiatric hospital” means a hospital for the diagnosis and treatment of mental
illness.
(C) “Tuberculosis facility” means a hospital (excluding preventoria), or the separate
tuberculosis unit of a general, psychiatric, or chronic disease hospital for the diagnosis
and treatment of tuberculosis.
(D) “Chronic disease facility” means a hospital, or the separate chronic disease unit
of a general hospital, for the treatment of chronic illness, including the degenerative
diseases. The term does not include facilities primarily for the care of individuals
with mental conditions and psychiatric disabilities or tuberculosis, nursing homes,
and institutions the primary purpose of which is domiciliary care.
(E) “Maternity hospital” means a hospital that receives maternity patients exclusively,
for care during pregnancy, during delivery, or within 10 days after delivery.
(F) “Nonprofit hospital” means any hospital owned and operated by a corporation or association,
no part of the net earnings of which is applied, or may lawfully be applied, to the
benefit of any private shareholder or individual.
(G) “Proprietary hospital” means any hospital operated for individual gain or reward.
(H) “Psychiatric facility” means a type of psychiatric hospital, or separate unit of a
general hospital, where patients may obtain diagnostic services and receive intensive
treatment for mental illness and where only a minimum of continued treatment facilities
will be afforded.
(I) The provisions of this subdivision (1) do not apply to any of the following institutions:
(i) nursing and convalescent homes, boarding homes, homes for the aged, nurseries, and
institutions used primarily for domiciliary care;
(ii) any hospital conducted, maintained, or operated by the U.S. government or a duly authorized
agency thereof.
(2) “Person” means any individual, firm, partnership, corporation, company, association,
or joint stock association, and the legal successor thereof.
(3) “Governmental unit” means a state, or political subdivision thereof, or any department,
division, board, or other agency of any of the foregoing.
(4) “Licensing agency” means the Department of Health. (Amended 1959, No. 329 (Adj. Sess.), § 27, eff. March 1, 1961; 1963, No. 154, § 2; 2003, No. 122 (Adj. Sess.), § 141d; 2013, No. 96 (Adj. Sess.), § 96; 2017, No. 113 (Adj. Sess.), § 65; 2023, No. 53, § 76, eff. June 8, 2023.)
§ 1903. License
No person or governmental unit may establish, conduct, or maintain a hospital in this
State without first obtaining a license in accordance with this chapter. (Amended 1963, No. 154, § 3; 2017, No. 113 (Adj. Sess.), § 66.)
§ 1904. Application, fee
(a) An application for a license shall be made to the licensing agency upon forms provided
by it and shall contain such information as the licensing agency reasonably requires.
Each application for license shall be accompanied by a license fee.
(b) Annual license fees.
(1) Base fee of $7,667.00.
(2) Per-bed fee of $25.00.
(3) The base fee for applicants presenting evidence of current accreditation by the Joint
Commission on Accreditation of Health Care Organizations shall be reduced by $2,750.00.
(c) Fees collected under this section shall be credited to a special fund established
and managed pursuant to 32 V.S.A. chapter 7, subchapter 5, and shall be available
to the Department to offset the costs of providing those services. (Amended 1963, No. 154, § 4; 2003, No. 163 (Adj. Sess.), § 2; 2007, No. 76, § 14; 2009, No. 134 (Adj. Sess.), § 26.)
§ 1905. License requirements
Upon receipt of an application for a license and the license fee, the licensing agency
shall issue a license when it determines that the applicant and hospital facilities
meet the following minimum standards:
(1) All hospitals receiving federal aid in their construction and equipment costs shall
comply with Title VI of the Public Health Service Act and with Public Health Service
regulations, Part 53, and with Appendix A of same, as amended.
(2) There shall be full compliance with safety and sanitary standards as required by State
and local building and sanitary codes in order to ensure maximum safety to patients
and the public.
(3) All general hospitals shall provide adequate and separate facilities and equipment
for the performance of surgery and obstetrics, or either, and for diagnostic X-ray
and laboratory services.
(4) Remodeling or expansion of any hospital subject to the provisions of this statute
shall be approved by the licensing agency prior to starting of such remodeling or
expansion, whether or not federal aid is to be requested for the additional projects.
(5) All patients admitted to the hospital shall be under the care of a State registered
and licensed practicing physician as defined by the laws of the State of Vermont.
All hospitals shall use the uniform credentialing application form described in subsection 9408a(b) of this title.
(6) The nursing service of the hospital shall be directed at all times by a registered
professional nurse currently licensed to practice nursing in Vermont.
(7) The care of maternity patients and newborns shall comply with such reasonable regulations
as the licensing agency may establish and thereafter modify in the public interest.
(8) Professional case records shall be compiled for all patients and signed by the attending
physician. These records shall be kept on file for a minimum of 10 years.
(9) Every hospital shall have an organized medical staff of not fewer than three members
that shall meet as often annually as recommended by the Joint Commission on Accreditation
of Hospitals.
(10) All employees shall have a preemployment screening by a licensed physician, licensed
physician assistant, or licensed advanced practice registered nurse who is acting
within his or her scope of practice, or by a designee acting under the direction of
one of these licensed health care professionals. This screening shall include medically
indicated radiological, hematological, biochemical, immunological, or serological
screenings to exclude the presence of a communicable disease prior to employment.
These screenings may be repeated annually as a condition of employment and the results
shall be made available, on request, to the licensing agency for review.
(11) All employees shall have such additional examinations, tests, and immunization treatments
as the licensing agency may determine to be necessary in the public interest.
(12) Accounting records of all operating procedures shall be kept on a monthly basis and
complete operating and financial statements shall be compiled at least once annually
and kept on file for 20 years.
(13) The hospital grounds and buildings shall be subject to inspection by the licensing
agency and other legalized authorities at all times.
(14) A license is not transferable or assignable and shall be issued only for the premises
and persons named in the application.
(15) The licensee shall file an annual report containing such information as the licensing
agency may reasonably require; a copy of the hospital’s annual report to its governing
board shall be provided to the licensing agency within 30 days after publication of
this document.
(16) All new construction involving hospitals and related buildings on hospital premises
shall comply with standards of the State Fire Marshal and the Department of Health,
whether or not federal aid under Title VI of the Public Health Service Act is received
for such construction.
(17) The Department of Health may, when circumstances warrant, issue a temporary license
for such period or periods and subject to such conditions as the Department shall
deem proper, subject to the limitation that such a temporary license shall not be
issued for a total period of more than 36 months. Such circumstances shall include
issues concerning indicators in the hospital’s community report that may result in
the Department’s issuing a license conditioned upon corrective measures or a temporary
license with conditions.
(18) All hospitals shall submit to the licensing agency a plan for implementing the provisions
of section 1852 of this title and a plan for handling patient complaints, which shall become effective upon approval
by the licensing agency. Plans under this subdivision shall include:
(A) the designation of a person or persons qualified as a patient representative;
(B) a method by which each patient shall be made aware of the complaint procedure;
(C) an appeals mechanism within the hospital itself;
(D) a published time frame for processing and resolving complaints and appeals within
the hospital, and notification that further appeals of the hospital’s resolution of
complaints may be made to the licensing agency under chapter 43 of this title; and
(E) periodic reporting to the licensing agency of the nature of complaints filed, and
action taken.
(19) All hospitals shall accept payment for compensation claims of uninsured crime victims
paid for by the Victims Compensation Board established in 13 V.S.A. § 5352 at 70 percent of billed charges and shall not bill any balance to the uninsured crime
victim.
(20) All hospitals shall comply with the rules adopted by the Commissioner pursuant to
section 1914 of this title. License applications shall certify compliance with the rules.
(21) In conducting its reviews, the licensing agency shall evaluate the quality and financial
indicators published by the Commissioner of Health under subsection 9405b(c) of this title.
(22) All hospitals shall provide oral and written notices to each individual that the hospital
places in observation status as required by section 1911a of this title. (Amended 1959, No. 329 (Adj. Sess.), § 27, eff. March 1, 1961; 1963, No. 154, § 5; 1981, No. 238 (Adj. Sess.), § 1; 1985, No. 163 (Adj. Sess.), § 2; 2005, No. 215 (Adj. Sess.), §§ 75a, 323; 2007, No. 27, §§ 2, 3; 2011, No. 78 (Adj. Sess.), § 2, eff. April 2, 2012; 2015, No. 23, § 44; 2015, No. 54, § 4, eff. Dec. 1, 2015; 2015, No. 97 (Adj. Sess.), § 49; 2015, No. 152 (Adj. Sess.), § 4; 2017, No. 113 (Adj. Sess.), § 67; 2017, No. 199 (Adj. Sess.), § 1, eff. May 30, 2018; 2023, No. 6, § 130, eff. July 1, 2023; 2023, No. 53, § 77, eff. June 8, 2023.)
§ 1906. Revocation of license; hearing
The licensing agency, after notice and opportunity for hearing to the applicant or
licensee, is authorized to deny, suspend, or revoke a license in any case in which
it finds that there has been a substantial failure to comply with the requirements
established under this chapter. Such notice shall be served by registered mail or
by personal service setting forth the reasons for the proposed action and fixing a
date not less than 60 days from the date of such mailing or service, at which the
applicant or licensee shall be given opportunity for a hearing. After such hearing,
or upon default of the applicant or licensee, the licensing agency shall file its
findings of fact and conclusions of law. A copy of such findings and decision shall
be sent by registered mail or served personally upon the applicant or licensee. The
procedure governing hearings authorized by this section shall be in accordance with
the usual and customary rules provided for such hearings.
§ 1907. Appeal
Any applicant or licensee, or the State acting through the Attorney General, aggrieved
by the decision of the licensing agency after a hearing, may, within 30 days after
entry of the decision as provided in section 1906 of this title, appeal to the Superior Court wherein the appellant is located. The court may affirm,
modify, or reverse the decision of the licensing agency and either the applicant or
licensee or licensing agency or State may appeal to the Supreme Court for such further
review as is provided by law. Pending final disposition of the matter, the status
quo of the applicant or licensee shall be preserved, except as the court otherwise
orders in the public interest. (Amended 1971, No. 185 (Adj. Sess.), § 185, eff. March 29, 1972; 1973, No. 193 (Adj. Sess.), § 3, eff. April 9, 1974.)
§ 1908. Rules; exceptions
(a) The licensing agency shall adopt and enforce rules and standards with respect to the
different types of hospitals to be licensed under this chapter as may be designed
to further the accomplishment of the purposes set forth in this chapter; such rules
and standards shall be modified, amended, or rescinded from time to time by the licensing
agency as may be in the public interest.
(b) No such rules and standards shall be adopted or enforced that would have the effect
of denying a license to a hospital solely by reason of the school or system of practice
employed or permitted to be employed by physicians therein, provided that such school
or system of practice is recognized by the laws of the State. Provided, however, that
no rule or requirement shall be made under this chapter for any hospital conducted
for those who rely upon treatment by spiritual means or prayer in accordance with
the creed or tenets of any recognized church or religious denomination, except as
to the sanitary and safe condition of the premises, cleanliness of operation, and
its physical equipment. (Amended 2015, No. 23, § 106; 2023, No. 6, § 131, eff. July 1, 2023.)
§ 1909. Inspections
The licensing agency shall make or cause to be made such inspections and investigations
as it deems necessary. If the licensing agency finds a violation as the result of
an inspection or investigation, the licensing agency shall post a report on the licensing
agency’s website summarizing the violation and any corrective action required. (Amended 2019, No. 55, § 2.)
§ 1910. Records
(a) Information received by the licensing agency through filed reports, inspection, or
as otherwise authorized by law shall:
(1) not be disclosed publicly in a manner that identifies or may lead to the identification
of one or more individuals or hospitals;
(2) be exempt from public inspection and copying under the Public Records Act; and
(3) be kept confidential except as it relates to a proceeding regarding licensure of a
hospital.
(b) The provisions of subsection (a) of this section shall not apply to the summary reports
of violations required to be posted on the licensing agency’s website pursuant to
section 1909 of this chapter. (Amended 2019, No. 55, § 3.)
§ 1911. Construction
This chapter shall not be construed in any way to restrict or modify any law pertaining
to the placement and adoption of children or the care of unmarried mothers.
§ 1911a. Notice of hospital observation status
(a)(1) Each hospital shall provide oral and written notice to each Medicare beneficiary that
the hospital places in observation status as soon as possible but not later than 24
hours following such placement, unless the individual is discharged or leaves the
hospital before the 24-hour period expires. The written notice shall be a uniform
form developed by the Department of Health, in consultation with interested stakeholders,
for use in all hospitals.
(2) If a patient is admitted to the hospital as an inpatient before the notice of observation
has been provided, and under Medicare rules the observation services may be billed
as part of the inpatient stay, the hospital shall not be required to provide notice
of observation status.
(b) Each oral and written notice shall include:
(1) a statement that the individual is under observation as an outpatient and is not admitted
to the hospital as an inpatient;
(2) a statement that observation status may affect the individual’s Medicare coverage
for hospital services, including medications and pharmaceutical supplies, and for
rehabilitative or skilled nursing services at a skilled nursing facility if needed
upon discharge from the hospital; and
(3) a statement that the individual may contact the Office of the Health Care Advocate
or the Vermont State Health Insurance Assistance Program to understand better the
implications of placement in observation status.
(c) Each written notice shall include the name and title of the hospital representative
who gave oral notice; the date and time oral and written notice were provided; the
means by which written notice was provided, if not provided in person; and contact
information for the Office of the Health Care Advocate and the Vermont State Health
Insurance Assistance Program.
(d) Oral and written notice shall be provided in a manner that is understandable by the
individual placed in observation status or by his or her representative or legal guardian.
(e) The hospital representative who provided the written notice shall request a signature
and date from the individual or, if applicable, his or her representative or legal
guardian, to verify receipt of the notice. If a signature and date were not obtained,
the hospital representative shall document the reason. (Added 2015, No. 54, § 5, eff. Dec. 1, 2015; amended 2023, No. 6, § 132, eff. July 1, 2023.)
§ 1911b. Workplace violence prevention planning
(a)(1) A hospital licensed pursuant to this chapter shall establish and implement a security
plan for preventing workplace violence and managing aggressive behaviors. Each hospital
shall establish a team for the purpose of providing advice during the development
of the hospital’s security plan. The hospital shall select individuals from the following
groups to serve on its security plan development team:
(A) health care employees providing direct patient care at the hospital;
(B) representatives from the designated agency serving the region where the hospital is
located; and
(C) representatives of relevant law enforcement agencies.
(2) The security plan shall be based on the results of a security risk assessment that
addresses all high-risk areas of the hospital, including the emergency department,
and all patient care areas. The security risk assessment shall be conducted in consultation
with the medical and nursing directors of each department and those hospital employees
supervising other high-risk areas of the hospital. The security risk assessment shall
consider overall patient volume, crime rates in the community, and the availability
of law enforcement to respond to violent incidents at the hospital.
(3) The security plan shall include an option for health care employees who provide direct
patient care to request an identification badge containing only their first name or
their first name and last initial.
(4)(A) The security plan shall require at least one hospital employee trained in de-escalation
strategies to be present at all times in the hospital’s emergency department and all
other patient care areas.
(B) The security plan shall require that a hospital employee trained in trauma-informed
care and victim support serve as a liaison to law enforcement, support victims through
the legal process, and ensure that the response to incidents of violence at the hospital
prioritizes the safety and retention of hospital employees providing health care services
to the extent permitted under State and federal law.
(5) The security plan shall establish training requirements for appropriate hospital employees
on the following:
(A) the culture of safety as determined by the hospital;
(B) response to the presence or use of weapons;
(C) defensive tactics;
(D) de-escalation techniques;
(E) appropriate physical restraint and seclusion techniques;
(F) crisis intervention;
(G) trauma-informed care and strategies;
(H) clinician well-being practices;
(I) presence and intervention of law enforcement; and
(J) safely addressing situations involving patients, family members, or other individuals
who pose a risk of self-harm or harm to others.
(6) The security plan shall include guidelines indicating when a law enforcement officer
should remain with a patient who has demonstrated violence or harm to others. The
guidelines shall be developed jointly by a health care provider representative and
law enforcement.
(7)(A) A hospital shall review and evaluate the security plan developed pursuant to this
subsection annually in conjunction with the data collected pursuant to subdivision
(b)(3) of this section. If necessary, the hospital shall revise the security plan.
(B) The security plan and any annual revisions to the security plan shall be distributed
annually to all hospital employees, volunteers, the hospital’s board of directors,
relevant law enforcement agencies, and any other partners identified by the security
plan development team.
(b)(1) A hospital licensed pursuant to this chapter shall establish and utilize a workplace
violence incident reporting system to document, track, analyze, and evaluate incidents
of workplace violence at the hospital. Data collection through the reporting system
and resulting analysis shall be used to improve workplace safety and to manage aggressive
behaviors, including improvements achieved through continuing education in targeted
areas such as de-escalation training, risk identification, and prevention planning.
(2) All hospital employees shall be notified about the existence of the reporting system
and shall receive training on how to report incidents of workplace violence to the
hospital, hospital security, law enforcement, or any other entity the hospital deems
appropriate.
(3) A hospital shall use its reporting system to track the following:
(A) the number of reported incidents; and
(B) the number of incidents reported to law enforcement.
(c) A hospital shall adopt a policy prohibiting discrimination or retaliation for:
(1) reporting an incidence of workplace violence;
(2) seeking assistance or intervention from the hospital, hospital security, law enforcement,
or any other appropriate entity; or
(3) participating or refusing to participate in an investigation of workplace violence.
(d)(1) A hospital shall post a notice in a conspicuous location, either electronically or
in print, indicating that hospital employees do not tolerate an unsafe work environment
where any type of threatening or aggressive behavior is present. The notice shall
remind hospital patrons of the serious legal consequences of assaulting a hospital
employee.
(2) As used in this subsection, “conspicuous” could include the hospital’s website, waiting
room areas, or any other areas of the hospital that the hospital deems appropriate.
(e) The Agency of Human Services shall collaborate with hospitals to identify incentives,
funding sources, and other means to support the development and operation of workplace
violence prevention programs at hospitals.
(f) Nothing in this section shall require a hospital to make capital investments to implement
its security plan. (Added 2025, No. 9, § 1, eff. July 1, 2025.)