NAC449.61254. Further review or on-site inspection for failure to comply with provisions or for excessive rate of mortality; notice; plan for compliance.

     1. If the review conducted pursuant to NAC 449.6125 discloses that the hospital is not in full compliance with the provisions of NAC 449.612 to 449.61256, inclusive, or if a facility’s adjusted rate of mortality, after considering the factors enumerated in NAC 449.61252, is considered excessive, the Division may, at the expense of the hospital, require:

     (a) A second review; or

     (b) An on-site inspection,

Ê conducted by one or more of the persons specified in NAC 449.61208. When the Division has completed its final review or inspection pursuant to this subsection, it shall notify the hospital in writing of the violations and the recommendations for improvements in the hospital’s service made by the person or persons who conducted the review or inspection pursuant to this subsection.

     2. Within 30 days after it receives the notice, the hospital shall reply to the Division in writing, indicating the measures to be taken to achieve compliance with the provisions of NAC 449.612 to 449.61256, inclusive, and to carry into effect the recommendations made by the person or persons who conducted the review or inspection pursuant to subsection 1.

     3. If the Division determines that the hospital’s plan is satisfactory, all of the corrective actions proposed by the hospital must be completed within 90 days after the Division has received the plan. After that time, the Division may require another review of the hospital pursuant to NAC 449.6125 or a review or inspection conducted pursuant to subsection 1 of this section.

     (Added to NAC by Bd. of Health, eff. 8-31-89; A by R107-98, 3-18-99)