A Hospital Operating License permits an agency or facility to provide health care diagnostic and therapeutic services under the supervision of an organized medical staff. A valid state license is required prior to providing care to any clients. 

This tool helps healthcare organizations manage compliance by identifying gaps in policies and procedures and creating a plan for remediation. It includes a customizable Hospital Standards Compliance Assessment Workbook with clear questions correlated to each EP. 


The Hospital license requires the hospital to follow certain regulations. Among others, the hospital must have a system for coding and indexing medical records in order to make them easily retrievable by diagnosis or procedure. The hospital must also keep patient records confidential and allow access only to authorized individuals. In some instances, however, the hospital may be required to disclose information about patients to law enforcement authorities. 

Lastly, the hospital must make sure that its physicians have current licensure and a valid medical board certification. The hospital must also have a credentialing committee that acts quickly and expeditiously when it receives an application for privileges by a licensed physician, podiatrist or dentist. 

The hospital must also have a procedure for modifying or revoking the clinical privileges of an advanced practice nurse or physician assistant. The procedure must include procedural rights for the advanced practice nurse or physician assistant, such as a hearing and written notice of the hospital’s decision. 


The purpose of state licensure is to protect the public by establishing minimum standards of competency. Licensing boards generally accomplish this by requiring education, assessing character and testing through examinations. 

Health professionals often seek independent certifications that validate their knowledge and expertise in a specific content area. They also work in institutions subject to organizational accreditation. These levers, along with licensure, play an important role in shaping how educational institutions and employers promote the development of lifelong learning skills. 

The committee believes that geographic licensure and scope-of-practice laws need a closer examination to make sure they do not hinder the full realization of the promise of optimum patient care provided through interdisciplinary teams and informatics. This will require additional study and coordination among professional boards. 


No person, firm, partnership, association, corporation or other entity shall establish, operate, conduct and maintain a hospital for the hospitalization and nursing care of human beings in this thanh lap trung tam ngoai ngu State without first obtaining from the department a license to do so. This includes a general, critical access or psychiatric hospital. 

Prior to the commencement of construction, a hospital must file plans and specifications with the department. These must include an architect’s certification that the plans are prepared in accordance with state and local codes, zoning ordinances and building standards. 

The department reviews all CON applications, including those for changes in ownership and new construction/additions. Projects eligible for limited review do not require a recommendation from the PHHPC and include proposals with total project costs less than $6 million ($15 million for hospitals) with certain requests. 


Hospitals must be compliant with the various regulatory bodies that oversee healthcare. Non-compliance can lead to fines, recoupments and other penalties that can damage an organization’s reputation. It also puts patients at risk of not receiving the best care, which can impact their health. 

The Department must formally notify the hospital and any affected health systems agency of any finding that would require the commissioner to take action to revoke, suspend or limit the facility’s operating certificate. The notice must specify the reason and the time frame for a public hearing. 

The hospital must have a well-organized medical staff and governing body that is accountable for the quality of the hospital’s patient care. The hospital must also provide discharge planning evaluations for patients at an early stage of the hospital stay or upon request of a patient, a person acting on their behalf or the physician. 


Hospitals need to keep their state licenses up-to-date. They also need to perform background checks that are specially designed for the healthcare industry. These include criminal checks, identity verification, sex offender status checks and more. Using background checks designed for the healthcare industry helps ensure that your hospital’s employees meet rigorous standards and provide high levels of care. 

Staffing top-of-license benefits both healthcare organizations and employees. When nurses, CNAs, RNs and MAs are practicing at the top of their licenses, hospitals experience higher employee engagement, reduced missed care, better patient outcomes and lower labor costs. 

Each hospital and clinc’s Operating Certificate includes information on the number of licensed beds and services available at the facility. It also identifies extension clinics operated by the hospital or clinc.