House File 13 - Introduced HOUSE FILE 13 BY GRABER , HOLT , GOLDING , STONE , A. MEYER , MOMMSEN , DUNWELL , FISHER , COLLINS , MOORE , GUSTOFF , CARLSON , JENEARY , VONDRAN , WULF , BRADLEY , SHERMAN , KNIFF MCCULLA , DEYOE , WILLS , RINKER , JOHNSON , BODEN , GUSTAFSON , NORDMAN , SORENSEN , GEHLBACH , KAUFMANN , FRY , YOUNG , HENDERSON , WILZ , WOOD , SIEGRIST , OSMUNDSON , WINDSCHITL , GRASSLEY , BOSSMAN , and GERHOLD A BILL FOR An Act relating to rural emergency hospitals, including 1 licensing requirements and fees, making penalties 2 applicable, providing emergency rulemaking authority, and 3 including applicability and effective date provisions. 4 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 5 TLSB 1084YH (8) 90 pf/rh

H.F. 13 Section 1. Section 135B.1, Code 2023, is amended by adding 1 the following new subsections: 2 NEW SUBSECTION . 5. “Rural emergency hospital” means a 3 facility that provides rural emergency hospital services in 4 the facility twenty-four hours per day, seven days per week; 5 does not provide any acute care inpatient services with the 6 exception of any distinct part of the facility licensed as a 7 skilled nursing facility providing posthospital extended care 8 services; and meets the criteria specified in section 135B.1A 9 and the federal Consolidated Appropriations Act, Pub. L. No. 10 116-260, §125. 11 NEW SUBSECTION . 6. “Rural emergency hospital services” 12 means the following services provided by a rural emergency 13 hospital that do not exceed an annual per patient average of 14 twenty-four hours in such a rural emergency hospital: 15 a. Emergency department services and observation care. 16 For purposes of providing emergency department services, an 17 emergency department of a rural emergency hospital shall 18 be considered staffed if a physician, nurse practitioner, 19 clinical nurse specialist, or physician assistant is available 20 to furnish rural emergency hospital services in the facility 21 twenty-four hours per day. 22 b. At the election of the rural emergency hospital, with 23 respect to services furnished on an outpatient basis, other 24 medical and health services as specified in regulations adopted 25 by the United States secretary of health and human services. 26 Sec. 2. Section 135B.2, Code 2023, is amended to read as 27 follows: 28 135B.2 Purpose. 29 The purpose of this chapter is to provide for the 30 development, establishment and enforcement of basic standards 31 for the care and treatment of individuals in hospitals and 32 rural emergency hospitals and for the construction, maintenance 33 and operation of such hospitals, which, in the light of 34 existing knowledge, will promote safe and adequate treatment 35 -1- LSB 1084YH (8) 90 pf/rh 1/ 11

H.F. 13 of such individuals in such hospitals, in the interest of the 1 health, welfare and safety of the public. 2 Sec. 3. Section 135B.3, Code 2023, is amended to read as 3 follows: 4 135B.3 Licensure. 5 No person or governmental unit, acting severally or jointly 6 with any other person or governmental unit shall establish, 7 conduct or maintain a hospital or rural emergency hospital in 8 this state without a license. 9 Sec. 4. NEW SECTION . 135B.3A Rural emergency hospital 10 licensure. 11 1. The department shall adopt rules pursuant to chapter 12 17A to establish minimum standards for the licensure of rural 13 emergency hospitals consistent with the federal Consolidated 14 Appropriations Act, Pub. L. No. 116-260, §125, and with 15 regulations issued by the United States secretary of health and 16 human services for rural emergency hospitals. 17 2. To be eligible for a rural emergency hospital license, a 18 facility shall have been, on or before December 27, 2020, one 19 of the following: 20 a. A licensed critical access hospital. 21 b. A general hospital with not more than fifty licensed 22 beds located in a county in a rural area as defined in section 23 1886(d)(2)(D) of the federal Social Security Act. 24 c. A general hospital with no more than fifty licensed beds 25 that is deemed as being located in a rural area pursuant to 26 section 1886(d)(8)(E) of the federal Social Security Act. 27 Sec. 5. Section 135B.4, Code 2023, is amended to read as 28 follows: 29 135B.4 Application for license. 30 Licenses shall be obtained from the department. 31 Applications shall be upon forms and shall contain information 32 as the department may reasonably require, which may include 33 affirmative evidence of ability to comply with reasonable 34 standards and rules prescribed under this chapter . Each 35 -2- LSB 1084YH (8) 90 pf/rh 2/ 11

H.F. 13 application for license shall be accompanied by the license 1 fee, which shall be refunded to the applicant if the license 2 is denied and which shall be deposited into the state treasury 3 and credited to the general fund if the license is issued. 4 Hospitals and rural emergency hospitals having fifty beds or 5 less shall pay an initial license fee of fifteen dollars; 6 hospitals of more than fifty beds and not more than one hundred 7 beds shall pay an initial license fee of twenty-five dollars; 8 all other hospitals shall pay an initial license fee of fifty 9 dollars. 10 Sec. 6. Section 135B.5, subsection 1, Code 2023, is amended 11 to read as follows: 12 1. Upon receipt of an application for license and the 13 license fee, the department shall issue a license if the 14 applicant and hospital facilities comply with this chapter , 15 chapter 135 , and the rules of the department. Each licensee 16 shall receive annual reapproval upon payment of five hundred 17 dollars and upon filing of an application form which is 18 available from the department. The annual licensure fee shall 19 be dedicated to support and provide educational programs on 20 regulatory issues for hospitals and rural emergency hospitals 21 licensed under this chapter . Licenses shall be either general 22 or restricted in form. Each license shall be issued only 23 for the premises and persons or governmental units named in 24 the application and is not transferable or assignable except 25 with the written approval of the department. Licenses shall 26 be posted in a conspicuous place on the licensed premises as 27 prescribed by rule of the department. 28 Sec. 7. Section 135B.5A, Code 2023, is amended to read as 29 follows: 30 135B.5A Conversion of a hospital relative to certain 31 hospitals . 32 1. A conversion of a long-term acute care hospital, 33 rehabilitation hospital, or psychiatric hospital as defined by 34 federal regulations to a general hospital or to a specialty 35 -3- LSB 1084YH (8) 90 pf/rh 3/ 11

H.F. 13 hospital of a different type is a permanent change in bed 1 capacity and shall require a certificate of need pursuant to 2 section 135.63 . 3 2. A conversion of a critical access hospital or general 4 hospital to a rural emergency hospital or a conversion of a 5 rural emergency hospital to a critical access hospital or 6 general hospital shall not require a certificate of need 7 pursuant to section 135.63. 8 Sec. 8. Section 135B.7, Code 2023, is amended to read as 9 follows: 10 135B.7 Rules and enforcement. 11 1. a. The department, with the approval of the state 12 board of health, shall adopt rules setting out the standards 13 for the different types of hospitals and for rural emergency 14 hospitals to be licensed under this chapter . The department 15 shall enforce the rules. 16 b. Rules or standards shall not be adopted or enforced 17 which would have the effect of denying a license to a hospital , 18 rural emergency hospital, or other institution required to be 19 licensed, solely by reason of the school or system of practice 20 employed or permitted to be employed by physicians in the 21 hospital, rural emergency hospital, or other institution if the 22 school or system of practice is recognized by the laws of this 23 state. 24 2. a. The rules shall state that a hospital or rural 25 emergency hospital shall not deny clinical privileges to 26 physicians and surgeons, podiatric physicians, osteopathic 27 physicians and surgeons, dentists, certified health service 28 providers in psychology, physician assistants, or advanced 29 registered nurse practitioners licensed under chapter 148 , 30 148C , 149 , 152 , or 153 , or section 154B.7 , solely by reason of 31 the license held by the practitioner or solely by reason of 32 the school or institution in which the practitioner received 33 medical schooling or postgraduate training if the medical 34 schooling or postgraduate training was accredited by an 35 -4- LSB 1084YH (8) 90 pf/rh 4/ 11

H.F. 13 organization recognized by the council on higher education 1 accreditation or an accrediting group recognized by the United 2 States department of education. 3 b. A hospital or rural emergency hospital may establish 4 procedures for interaction between a patient and a 5 practitioner. The rules shall not prohibit a hospital or 6 rural emergency hospital from limiting, restricting, or 7 revoking clinical privileges of a practitioner for violation 8 of hospital rules, regulations, or procedures established 9 under this paragraph, when applied in good faith and in a 10 nondiscriminatory manner. 11 c. This subsection shall not require a hospital or rural 12 emergency hospital to expand the hospital’s current scope of 13 service delivery solely to offer the services of a class of 14 providers not currently providing services at the hospital 15 or rural emergency hospital . This section shall not be 16 construed to require a hospital or rural emergency hospital 17 to establish rules which are inconsistent with the scope of 18 practice established for licensure of practitioners to whom 19 this subsection applies. 20 d. This section shall not be construed to authorize the 21 denial of clinical privileges to a practitioner or class of 22 practitioners solely because a hospital or rural emergency 23 hospital has as employees of the hospital or rural emergency 24 hospital identically licensed practitioners providing the same 25 or similar services. 26 3. The rules shall require that a hospital or rural 27 emergency hospital establish and implement written criteria 28 for the granting of clinical privileges. The written criteria 29 shall include but are not limited to consideration of all of 30 the following: 31 a. The ability of an applicant for privileges to provide 32 patient care services independently and appropriately in the 33 hospital or rural emergency hospital . 34 b. The license held by the applicant to practice. 35 -5- LSB 1084YH (8) 90 pf/rh 5/ 11

H.F. 13 c. The training, experience, and competence of the 1 applicant. 2 d. The relationship between the applicant’s request for the 3 granting of privileges and the hospital’s or rural emergency 4 hospital’s current scope of patient care services, as well as 5 the hospital’s or rural emergency hospital’s determination of 6 the necessity to grant privileges to a practitioner authorized 7 to provide comprehensive, appropriate, and cost-effective 8 services. 9 4. The department shall also adopt rules requiring 10 hospitals and rural emergency hospitals to establish and 11 implement protocols for responding to the needs of patients who 12 are victims of domestic abuse, as defined in section 236.2 . 13 5. The department shall also adopt rules requiring 14 hospitals and rural emergency hospitals to establish and 15 implement protocols for responding to the needs of patients who 16 are victims of elder abuse, as defined in section 235F.1 . 17 Sec. 9. Section 135B.7A, Code 2023, is amended to read as 18 follows: 19 135B.7A Procedures —— orders. 20 The department shall adopt rules that require hospitals 21 and rural emergency hospitals to establish procedures for 22 authentication of all verbal orders by a practitioner within 23 a period not to exceed thirty days following a patient’s 24 discharge. 25 Sec. 10. Section 135B.8, Code 2023, is amended to read as 26 follows: 27 135B.8 Effective date of rules. 28 Any hospital or rural emergency hospital which is in 29 operation at the time of promulgation of any applicable 30 rules or minimum standards under this chapter shall be given 31 a reasonable time, not to exceed one year from the date of 32 such promulgation, within which to comply with such rules and 33 minimum standards. 34 Sec. 11. Section 135B.9, Code 2023, is amended to read as 35 -6- LSB 1084YH (8) 90 pf/rh 6/ 11

H.F. 13 follows: 1 135B.9 Inspections and qualifications for hospital and rural 2 emergency hospital inspectors —— protection and advocacy agency 3 investigations. 4 1. The department shall make or cause to be made inspections 5 as it deems necessary in order to determine compliance with 6 applicable rules. Hospital and rural emergency hospital 7 inspectors shall meet the following qualifications: 8 a. Be free of conflicts of interest. A hospital or rural 9 emergency hospital inspector shall not participate in an 10 inspection or complaint investigation of a hospital or rural 11 emergency hospital in which the inspector or a member of the 12 inspector’s immediate family works or has worked within the 13 last two years. For purposes of this paragraph, “immediate 14 family member” means a spouse; natural or adoptive parent, 15 child, or sibling; or stepparent, stepchild, or stepsibling. 16 b. Complete a yearly conflict of interest disclosure 17 statement. 18 c. Biennially, complete a minimum of ten hours of continuing 19 education pertaining to hospital or rural emergency hospital 20 operations including but not limited to quality and process 21 improvement standards, trauma system standards, and regulatory 22 requirements. 23 2. In the state resource centers and state mental health 24 institutes operated by the department of human services, the 25 designated protection and advocacy agency as provided in 26 section 135C.2, subsection 4 , shall have the authority to 27 investigate all complaints of abuse and neglect of persons 28 with developmental disabilities or mental illnesses if the 29 complaints are reported to the protection and advocacy agency 30 or if there is probable cause to believe that the abuse has 31 occurred. Such authority shall include the examination of all 32 records pertaining to the care provided to the residents and 33 contact or interview with any resident, employee, or any other 34 person who might have knowledge about the operation of the 35 -7- LSB 1084YH (8) 90 pf/rh 7/ 11

H.F. 13 institution. 1 Sec. 12. Section 135B.12, Code 2023, is amended to read as 2 follows: 3 135B.12 Confidentiality. 4 The department’s final findings or the final survey findings 5 of the joint commission on the accreditation of health care 6 organizations or the American osteopathic association with 7 respect to compliance by a hospital or rural emergency hospital 8 with requirements for licensing or accreditation shall be made 9 available to the public in a readily available form and place. 10 Other information relating to a hospital or rural emergency 11 hospital obtained by the department which does not constitute 12 the department’s findings from an inspection of the hospital 13 or rural emergency hospital or the final survey findings of 14 the joint commission on the accreditation of health care 15 organizations or the American osteopathic association shall 16 not be made available to the public, except in proceedings 17 involving the denial, suspension, or revocation of a license 18 under this chapter . The name of a person who files a complaint 19 with the department shall remain confidential and shall not 20 be subject to discovery, subpoena, or other means of legal 21 compulsion for its release to a person other than department 22 employees or agents involved in the investigation of the 23 complaint. 24 Sec. 13. Section 135B.14, Code 2023, is amended to read as 25 follows: 26 135B.14 Judicial review. 27 Judicial review of the action of the department may be sought 28 in accordance with chapter 17A . Notwithstanding the terms of 29 chapter 17A , the Iowa administrative procedure Act, petitions 30 for judicial review may be filed in the district court of the 31 county in which the hospital or rural emergency hospital is 32 located or to be located, and the status quo of the petitioner 33 or licensee shall be preserved pending final disposition of the 34 matter in the courts. 35 -8- LSB 1084YH (8) 90 pf/rh 8/ 11

H.F. 13 Sec. 14. Section 135B.15, Code 2023, is amended to read as 1 follows: 2 135B.15 Penalties. 3 Any person establishing, conducting, managing, or operating 4 any hospital or rural emergency hospital without a license 5 shall be guilty of a serious misdemeanor, and each day of 6 continuing violation after conviction shall be considered a 7 separate offense. 8 Sec. 15. Section 135B.16, Code 2023, is amended to read as 9 follows: 10 135B.16 Injunction. 11 Notwithstanding the existence or pursuit of any other 12 remedy, the department may, in the manner provided by law, 13 maintain an action in the name of the state for injunction 14 or other process against any person or governmental unit to 15 restrain or prevent the establishment, conduct, management or 16 operation of a hospital or rural emergency hospital without a 17 license. 18 Sec. 16. Section 135B.20, subsection 3, Code 2023, is 19 amended to read as follows: 20 3. “Hospital” shall mean means all hospitals and rural 21 emergency hospitals licensed under this chapter . 22 Sec. 17. Section 135B.33, subsection 1, unnumbered 23 paragraph 1, Code 2023, is amended to read as follows: 24 Subject to availability of funds, the Iowa department of 25 public health shall provide technical planning assistance to 26 local boards of health and hospital or rural emergency hospital 27 governing boards to ensure access to hospital such services in 28 rural areas. The department shall encourage the local boards 29 of health and hospital or rural emergency hospital governing 30 boards to adopt a long-term community health services and 31 developmental plan including the following: 32 Sec. 18. Section 135B.34, subsection 7, Code 2023, is 33 amended to read as follows: 34 7. For the purposes of this section , “comprehensive 35 -9- LSB 1084YH (8) 90 pf/rh 9/ 11

H.F. 13 preliminary background check” : 1 a. “Comprehensive preliminary background check” means the 2 same as defined in section 135C.1 . 3 b. “Hospital” means a hospital or rural emergency hospital 4 licensed under this chapter. 5 Sec. 19. EMERGENCY RULEMAKING AUTHORITY. The department 6 may adopt emergency rules under section 17A.4, subsection 3, 7 and section 17A.5, subsection 2, paragraph “b”, to implement 8 the provisions of this Act and the rules shall be effective 9 immediately upon filing unless a later date is specified in the 10 rules. Any rules adopted in accordance with this section shall 11 also be published as a notice of intended action as provided 12 in section 17A.4. 13 Sec. 20. APPLICABILITY. This Act applies to a facility 14 that was, on or before December 27, 2020, a general hospital 15 with no more than fifty licensed beds, located in a county in a 16 rural area as specified in section 135B.3A, as enacted in this 17 Act, with a population between thirty thousand and thirty-five 18 thousand according to the 2020 federal decennial census, 19 operating under a valid certificate of need on and prior to 20 September 1, 2022. Notwithstanding any provision to the 21 contrary, and in accordance with section 135B.5A, as amended 22 in this Act, the conversion of a general hospital as specified 23 under this section to a rural emergency hospital under this 24 Act shall not be subject to certificate of need requirements 25 pursuant to section 135.63. 26 Sec. 21. EFFECTIVE DATE. This Act, being deemed of 27 immediate importance, takes effect upon enactment. 28 EXPLANATION 29 The inclusion of this explanation does not constitute agreement with 30 the explanation’s substance by the members of the general assembly. 31 This bill provides for state licensure of rural emergency 32 hospitals. Under the federal Consolidated Appropriations Act 33 of 2021 (federal Act), rural emergency hospitals (REHs) were 34 established as a new provider type. Effective January 1, 2023, 35 -10- LSB 1084YH (8) 90 pf/rh 10/ 11

H.F. 13 REHs will be eligible to enroll in Medicare and to receive an 1 enhanced reimbursement rate for eligible services consisting 2 of the outpatient prospective payment system rate plus a 5 3 percent add-on and a fixed monthly payment. In order to be 4 classified as an REH under the federal Act, a facility must 5 meet certain requirements, including applicable state licensing 6 requirements. The bill provides a process for such licensure. 7 The bill provides emergency rulemaking authority to 8 implement the bill. 9 The bill includes applicability provisions. The bill 10 applies to a facility that was, on or before December 27, 2020, 11 a general hospital with no more than 50 licensed beds, located 12 in a county in a rural area as specified in the bill with a 13 population between 30,000 and 35,000 according to the 2020 14 federal decennial census, operating under a valid certificate 15 of need on and prior to September 1, 2022. Notwithstanding 16 any provision to the contrary, the conversion of the specified 17 general hospital to a rural emergency hospital shall not be 18 subject to certificate of need requirements. 19 The bill takes effect upon enactment. 20 -11- LSB 1084YH (8) 90 pf/rh 11/ 11