The Vermont Statutes Online

Title 18 : Health

Chapter 043 : Licensing of Hospitals

• § 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.)