Free Hospital Certificate of Approval Application-F-62092 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62092 (Rev. 07/09)

STATE OF WISCONSIN Chapter 50.35, 50.498, and 946.32, Wis. Stats. FOR DQA OFFICE USE ONLY COA Number COA Fee Caregiver Background Fee Effective Date

HOSPITAL CERTIFICATE OF APPROVAL APPLICATION
TYPE OF APPLICATION Initial Change of Ownership

Hospitals are required to complete this form per Chapter 50.35, Wis. Stats. Failure to complete this form may result in nonissuance of a hospital certificate of approval. The personally identifiable information collected on this form will be used to determine licensure eligibility and for statistical information and for no other purpose. Collection of the applicant's social security number (SSN) or federal employer identification number (FEIN) is required by Chapter 50.498, Wis. Stats. Failure to supply the number may result in denial of the application. The number will be disclosed only to the Department of Revenue for use in collection of tax delinquencies.

Return the completed application to: Division of Quality Assurance Bureau of Technology, Licensing and Education PO Box 2969 Madison WI 53701-2969 Questions about completion of this application may be directed to the Bureau of Technology, Licensing and Education at 608266-7297.

I. GENERAL INFORMATION
A. HOSPITAL LOCATION
Name ­Facility Previous Hospital Name (if applicable) Street (physical) Address Mailing Address City Telephone Number Fax Number County E-mail Address State Zip Code Initial Begin Date (at present location)

B. CHANGE OF OWNERSHIP List the previous owner's name, Certificate of Approval (COA) number, and Medicare and Medicaid numbers.
Name ­ Previous Owner Previous COA Number Medicare Number - Previous Owner Medicaid Number - Previous Owner

F-62092 (Rev. 07/08)

Page 2

C. TYPE OF HOSPITAL General Special Chemical Dependency / Alcohol Children's Maternity Rehabilitation Psychiatric Orthopedic Surgical
Name - Fiscal Intermediary

Critical Access Hospital (CAH) Long Term Acute Care Hospital Located Within Another Hospital Other (Specify.)

Fiscal Year End Date

D. TYPE OF CERTIFICATION Applying for: Medicare (Title XVIII) Medicaid (Title XIX) E. ACCREDITATION STATUS Non Accredited Applying for Accreditation with: JCAHO AOA Program JCAHO Other Medicare and Medicaid State Licensed Only (no TXIX / TXVIII certification)

Complete the following for CHANGE OF OWNERSHIP applications only. Currently Accredited Deemed F. BED CAPACITY Indicate the total number of beds requested for those categories that apply.
General Acute Beds Accredited by Accreditation Begin Date Accreditation End Date

JCAHO

AOA

Other
Deemed Begin Date Deemed End Date

Breakdown
TOTAL Psychiatric Beds Psychiatric Beds *PPS Psychiatric Beds

TOTAL Rehabilitation Beds Chemical Dependency / Alcohol Beds TOTAL BEDS

Rehabilitation Beds

*PPS Rehabilitation Beds

* PPS (Prospective Payment System) excluded psychiatric beds and PPS excluded rehabilitation beds must have prior approval from the Centers for Medicare and Medicaid Services (CMS). If you are adding new PPS excluded psychiatric or rehabilitation beds, you must include a copy of the CMS approval letter with this application.
Total Number of Acute Care Beds

If Critical Access Hospital (CAH): G. OFFSITE LOCATIONS Yes
Name of Off-Site Street (Physical) Address City Services Provided

Are swing bed services provided?

Yes

No

No

Attach additional pages, if necessary.
Type of Provider Telephone Number State Zip Code Number of Beds

F-62092 (Rev. 07/08)

Page 3

Name of Off-Site Street (Physical) Address City Services Provided State Zip Code

Type of Provider Telephone Number Number of Beds

Name of Off-Site Physical Address City Services Provided State Zip Code

Type of Provider Telephone Number Number of Beds

Check here

if a change of ownership or more offsite locations are being applied for or have been approved by the Centers for Medicare and Medicaid Services (CMS), and attach a separate listing.

The listing should include all required information for each component that is not located on the hospital's premises and that will be billed under the hospital's Medicare provider number. Also, describe the services that will be provided and the number of beds if overnight inpatient services will be provided. Provide a copy of CMS' approval letter for each offsite location. Off-site locations that meet the definition of a hospital as described at Chapter 50.33(2), Wis. Stats., and DHS 124.02(6), Wis. Admin. Code, must be licensed separately. H. SERVICES PROVIDED BY THE HOSPITAL Check the type of services that will be provided. Attach additional pages if necessary. Place a "1" if service will be provided directly by hospital staff and a "2" if the service will be provided by contracting with another provider of service. If services will be provided both directly and by contract, insert a "3."
Check if Provided Enter 1, 2, or 3 Service Check if Provided Enter 1, 2, or 3 Service

Acute renal dialysis Alcohol and/or drug services Anesthesia services Blood bank Burn care unit Chiropractic services Coronary care unit Dental services Dietetic services

Open heart surgery facilities Operating rooms Optometric services Organ bank Organ transplant services Outpatient services Outpatient surgery unit Pediatric services Pharmacy

F-62092 (Rev. 07/08)

Page 4

Emergency services (organized) Home care program Hospice Inpatient surgical services Intensive care unit Laboratory services (clinical) Laboratory services (anatomical) Long term care unit Neonatal nursery Nuclear medicine services Obstetrics Occupational therapy services I. STAFFING

Physical therapy services Post-operative recovery rooms Psychiatric services Radiology services (diagnostic) Radiology services (therapeutic) Rehabilitation services Respiratory care services Self care unit Shock trauma Social services Speech pathology services Other (Specify.):

Indicate number of full-time (FT) and part-time (PT) employees. Attach additional pages, if necessary. FT 1. *2. *3. *4. *5. 6. 7. Chief Executive Officer Nurse Administrator, RN Nurse Supervisor Registered Staff Nurses LPN Staff Nurses Nurse Aides Medical Records PT 8. 9. 10. 11. 12. 13. 14. Pharmacy Dietary Laboratory Housekeeping Maintenance Personnel Laundry Personnel Other (Specify.) FT PT

* Under 2, 3, 4, and 5, report only those registered or licensed nurses with a current registration or license number. Report all other nurses under number 6.

II. PLANT DESCRIPTION AND SPACE USE
Not required for facilities that already have departmentally approved plans. A. DESCRIPTION OF FACILITY [DHS 124.27, 42 CFR 485.623(a)] Attach plans or drawings for each floor of the building occupied by the existing hospital and identify: 1. Life Safety Code Plans (a) (b) (c) (d) (e) (f) (g) (h) Exiting Fire barriers Smoke barriers Horizontal exits Exit passage ways Vertical shafts Linen and trash chutes, and Additional relevant information.

2. Building Information (a) (b) (c) (d) 3. Construction type Age of existing building segments Additional relevant information Local zoning compliance statement

Existing Space Description (a) Current room/space use (b) Identification of hazardous areas protected by rated fire resistive partitions (c) Other relevant information.

F-62092 (Rev. 07/08)

Page 5

4.

Proposed Use of Rooms / Space within the Hospital

5. ADA (Americans with Disabilities Act) Accessibility Plan (a) Parking (b) Access routes (c) Toilet rooms for public, staff, and patients indicating if ADA accessible (d) Additional relevant information Answer each of the following questions by checking the "Yes" or "No" boxes.
Yes No

1-a. Are building alterations and remodeling proposed? 1-b. If YES, attach plans or drawings indicating the areas of remodeling. SEE item B.2. 2-a. Will the building have a mixed occupancy? 2-b. If YES, identify all classifications and locations on the drawings or plans requested above. 3-a. Has the JCAHO (Joint Commission on the Accreditation of Healthcare Organizations), or the State approved any Life Safety Code variances or waivers? 3-b. If YES, attach a copy of the award letter and waivers that have been approved. 4-a. Are all patients/clients/residents capable of leaving the building on their own? 4-b. If NO, are there instances when four (4) or more staff dependent patient/clients/residents are present in the building at the same time? 5. Is the building equipped with a fire alarm system?

6-a. Is there an interconnected smoke detection system? 6-b. If YES, is the smoke detection system throughout the building, i.e., in all areas, common areas and work spaces, whether occupied or not. in limited areas. (Identify locations on drawings.) 7-a. Is there an approved and supervised automatic sprinkler system? 7-b. If YES, is the automatic sprinkler system throughout the building, i.e., in all areas throughout the building. in limited areas. (Identify locations on drawings.)
ENTER NUMBER BELOW.

8.

Indicate the number of building stories. 8-a. 8-b. Above ground, including the exit level. Below the ground level of the exit.

B.

PROPOSED USE OF IDLE SPACE

Use of idle space requires considerable study to determine how the facility can be sectioned-off for new services, renters, or types of uses, etc. The direction and scope of renovations must be in compliance with LIFE SAFETY CODES. Applicant is strongly urged to seek expert advice, e.g., an engineering consultant, to determine which space to declare idle. Renovation cost may be a factor to consider before applying for hospital licensure status. 1. Explain how you will utilize the idle space, e.g., rental to outside groups, expansion of outpatient services, integration of existing or new health care services. Attach narrative.

F-62092 (Rev. 07/08)

Page 6

2. If applicable, provide a description of construction considerations and time frame for the renovations described in the table above. Attach only one narrative covering all proposed building changes. NOTE: You must contact the Division of Quality Assurance prior to initiating all physical plant and environment renovations. The Plan Approval Application (form F-62333) can be obtained at http://dhs.wisconsin.gov/forms/DQAnum.asp or by calling (608) 264-9838. III. ADMINISTRATION A. HOSPITAL ADMINISTRATOR / CHIEF EXECUTIVE OFFICER (CEO)
Name - Administrator / CEO Title Male Female Status Interim Acting Permanent Begin Date

Is the Administrator / CEO in charge of more than one facility?
If Yes, Name of Facility and City

Yes

No
Type of Provider

Education
Name of School / College / University Address Name of School / College / University Address Years Attended Diploma / Degree / Year Years Attended Diploma / Degree / Year

Work Experience
Employer Address Position Dates

Attach a resume and a copy of the professional license, if applicable, for the administrator, managing employee, and medical director which includes their educational and work experience. B. PERSON IN CHARGE IN ABSENCE OF ADMINISTRATOR / CEO (SUBSTITUTE ADMINISTRATOR)
Name Begin Date

Title

Education
Name of School / College / University Address Name of School / College / University Address Years Attended Diploma / Degree / Year Years Attended Diploma / Degree / Year

F-62092 (Rev. 07/08)

Page 7

Work Experience
Employer Address Position Dates

C. MEDICAL DIRECTOR
Name ­ Medical Director Male Female Status Interim Acting Permanent Begin Date

Title

Is the Medical Director in charge of more than one facility? Education
Name of School / College / University Address Name of School / College / University Address

Yes

No

Years Attended Diploma / Degree / Year Years Attended Diploma / Degree / Year

Work Experience
Employer Address Position Dates

D. NURSE ADMINISTRATOR (DIRECTOR OF NURSING)
Name Begin Date

E. NAME OF PERSON IN CHARGE OF EACH DEPARTMENT
Dietary Service Medical Records

IV. OWNERSHIP A. APPLICANT (OWNER) Identify person(s) or business entity having the authority to direct the management or policies of the facility.
Name ­ Applicant (owner) Street (Physical) Address Mailing Address (if different from physical address) City Fax Number Contact Person Title ­ Contact Person Telephone Number State Zip Code County FEIN or SSN

E-mail Address Telephone Number

F-62092 (Rev. 07/08)

Page 8

Holding (i.e., what the owner owns): B. TYPE OF ORGANIZATION Check type of ownership.
Governmental City County State Federal City / County Tribal

Operations

Building

Land

Proprietary Sole Proprietary Partnership Corporation Limited Liability Company Limited Liability Partnership Trust

Voluntary Non-Profit Corporation Church Association Church / Corporation Private Non-Profit Limited Liability Company Limited Liability Partnership Trust

If Incorporated, Date Incorporated

C. INTERESTED PARTIES List all names, principal business addresses and the percentage of ownership interest of all officers, directors, stockholders owning 5% or more of stock, and members, partners, and all other persons having authority or responsibility for the operation of the organization. For non-profit organizations or governmental organizations, list the names and principal business address of all officers, directors, and board members. Attach additional pages if necessary.
Name Address City Name Address City Name Address City Name Address City Name Address City State Zip Code State Title Begin Date Ownership Percentage Zip Code State Title Begin Date Ownership Percentage Zip Code State Title Begin Date Ownership Percentage Zip Code State Title Begin Date Ownership Percentage Zip Code Title Begin Date Ownership Percentage

F-62092 (Rev. 07/08)

Page 9

D. OTHER PROVIDERS Identify other providers that are licensed and / or Medicare certified, located in Wisconsin, and are owned or operated by the applicant / owner under the exact same owner name. If more than two, check here
Name ­ Provider City State Zip Code

and attach additional pages.

Relationship Type (nursing home, home health agency, community based residential facility, hospital) Name ­ Provider City State Zip Code

Relationship Type (nursing home, home health agency, community based residential facility, hospital)

E. SUBSIDIARY / PARENT INFORMATION 1. Is the applicant a subsidiary company, either wholly or partially owned by another organization or business? Yes No

If "Yes," provide the following information:
Legal Business Name ­ Parent Company DBA (Doing Business As) Type of Ownership Mailing Address City Contact Person State Telephone Number Zip Code

2. Is the applicant affiliated with any subsidiaries in the health care field in this state or any other state? Yes No

If Yes, provide one of the following: Names and addresses of all subsidiaries owned by the parent company, in this state or any other state, (relationship type: nursing homes, home health agencies, hospices, hospitals, rehabilitation facilities, etc.) Organizational chart exhibiting the legal business names and, if applicable, the DBA name of all the subsidiaries currently owned by the parent company in the health care field in this state or any other state, (relationship type: nursing homes, home health agencies, hospices, hospitals, rehabilitation facilities, etc.) Complete annual report to shareholders.

F-62092 (Rev. 07/08)

Page 10

F. CHAIN ORGANIZATION Is the applicant under the control of a chain organization? Yes No

Chain organization is defined as multiple providers, and/or suppliers owned, leased, or through any other devises, controlled by a single business entity (defined as chain home office). Each entity in the chain may have a different owner but the "home office" maintains uniform procedures in each facility for handling utilization review, reimbursement, handling admissions, also maintains and controls centrally, provider/suppliers cost reports, etc. In addition, a chain facility would not necessarily be a subsidiary of the parent corporation but the chain facility or facilities could be owned by different subsidiaries of the same corporate parent.
Name ­ Chain Organization

G. FIT AND QUALIFIED The following information will be used to determine if the applicant meets the fit and qualified requirements under Chapter 50, Wis. Stats. 1. Has the applicant been affiliated in the past five years with a hospice (HSP), a home health agency (HHA), a residential care facility, e.g., Community Based Residential Facility (CBRF), Adult Family Home (AFH), or a health care facility (HCF), e.g., hospital, nursing home, or facility for the developmentally disabled in the State of Wisconsin or in any other state? Yes No

IF THE ANSWER IS "YES," complete all information in the section below. Use the facility abbreviations (in parenthesis) from above to identify the type of facility. IF THE ANSWER IS "NO," complete only questions 4 ­14 of this section.
Facility Name and Address City and State Type of Health Care Provider Owner / Operator / Mgr. Vendor / Provider No. Dates of Affiliation

2.

Has any adverse action initiated by any state licensing agency resulted in the denial (D), suspension (S), or revocation (R) of a license or approval? Yes No

If "yes," please complete the following table. Use abbreviations to describe the type of adverse action and refer to G.1. (above) for abbreviations for type of health care provider.
Type of Health Care Provider Effective Dates of Adverse Action

Facility Name and Address

City and State

Type of Adverse Action

F-62092 (Rev. 07/08)

Page 11

3.

Has any adverse action initiated by a state or federal agency based on non compliance resulted in civil money penalties (CMP), termination of provider agreement (TPA), suspension of payments (SOP), or the appointment of temporary management of the facility (TMF)? Yes No

If "yes," please complete the following table. Use abbreviations to describe the type of adverse action and refer to G.1. (above) for abbreviations for type of health care provider.
Facility Name and Address City and State Federal or State Type of Health Care Provider Type of Adverse Action Effective Dates of Adverse Action

4. Has the applicant ever had a denial, suspension, enjoining, or revocation of a health care provider license, in this state or any other state, as defined in Chapter 146.81, Wis. Stats., or any conviction for providing health care without a license? Yes If "yes," explain. No

5. Has the applicant ever been convicted of a crime involving neglect or abuse of patients, or involved in assaultive behavior, wanton disregard for the health and safety of others, or any act of elder abuse under Chapter 46.90, Wis. Stats.? Yes If "yes," explain. No

F-62092 (Rev. 07/08)

Page 12

6. Has the applicant ever been convicted of a crime related to the delivery of health care services or items? Yes If "yes," explain. No

7.

Has the applicant ever been convicted of a crime involving controlled substances under Chapter 161, Wis. Stats.? Yes If "yes," explain. No

8.

Has the applicant had any prior financial failure that resulted in bankruptcy or in the closing of a hospice, home health agency or an inpatient health care facility, e.g., nursing home or hospital, or the relocation of its patients or residents? Yes If "yes," explain. No

9.

Has the applicant/owner been adjudicated bankrupt? Yes No

If "yes," explain on a separate page. Provide the dates, court, and disposition of each action. 10. Are there any unsatisfied judgments against the applicant/owner? Yes No

If "yes," explain on a separate page. Provide the names and addresses of creditors, amounts, and the reasons for non-payment. 11. Does the applicant / owner owe any debts that are 90 days past due? Yes No

If "yes," explain on a separate page. Provide the names and addresses of creditors, amounts, and reasons for non-payment. 12. Does the applicant / owner plan to provide care to patients who are unable to pay for service? Yes 13. No

Attach proof of sufficient resources as may be necessary to operate the facility for at least 90 days. Proof of sufficient financial resources should include income / expense statements.

14. Financial References This question is to be completed by the applicant. Include at least one bank. Attach additional pages, if necessary

F-62092 (Rev. 07/08) Name Address City Name Address City State Zip Code State Zip Code Telephone Number Telephone Number

Page 13

H. OWNER OF BUILDING / LAND If the building, land, or building and land, is owned by an entity (i.e., corporation, partnership, individual, etc.) other than the applicant / owner, complete this section. If the owner of the land is another entity, also complete Section I. Holding:
Name Mailing Address City County State

Building

Land
Telephone Number Fax Number Zip Code

Type Of Organization Check type of ownership.
Governmental City County State Federal City / County Tribal Proprietary Sole Proprietary Partnership Corporation Limited Liability Company Limited Liability Partnership Trust Voluntary Non-Profit Corporation Church Association Church / Corporation Private Non-Profit Limited Liability Company Limited Liability Partnership Trust

Interested Parties Definition: Interested parties are (1) persons or business entities having ownership interest of 5% or more, (2) partners if the entity is a partnership, (3) officers and directors if the entity is a corporation, and (4) if the entity is either governmental or non-profit, interested parties are the officers and directors. If there is a separate listing already in existence, and that listing contains all the required information, attach a copy of that listing to this application. If a complete listing is attached, completion of this portion of the application will be considered satisfied.
Name Address City Name Address State Title Begin Date Zip Code Title Begin Date Ownership Percentage

F-62092 (Rev. 07/08) City Name Address City Name Address City Name Street City State Zip Code State Title Begin Date Zip Code State Title Begin Date Zip Code State Title Begin Date Zip Code

Page 14 Ownership Percentage

Ownership Percentage

Ownership Percentage

Ownership Percentage

I. OWNER OF LAND Complete this section if the owner of the land is not the same entity as the owner of the operation or the owner of the building. Holding:
Name Mailing Address City County State

Land
Telephone Number Fax Number Zip Code

Type of Organization Check type of ownership.
Governmental City County State Federal City / County Tribal Proprietary Sole Proprietary Partnership Corporation Limited Liability Company Limited Liability Partnership Trust Voluntary Non-Profit Corporation Church Association Church / Corporation Private Non-Profit Limited Liability Company Limited Liability Partnership Trust

Interested Parties Definition: Interested parties are (1) persons or business entities having ownership interest of 5% or more, (2) partners if the entity is a partnership, (3) officers and directors if the entity is a corporation, and (4) if the entity is either governmental or non-profit, interested parties are the officers and directors. If there is a separate listing already in existence, and that listing contains all the required information, attach a copy of that listing to this application. If a complete listing is attached, completion of this portion of the application will be considered satisfied.
Name Title

F-62092 (Rev. 07/08) Address City Name Address City Name Address City Name Address City Name Address City State Zip Code State Title Begin Date Zip Code State Title Begin Date Zip Code State Title Begin Date Zip Code State Title Begin Date Zip Code Begin Date

Page 15

Ownership Percentage

Ownership Percentage

Ownership Percentage

Ownership Percentage

Ownership Percentage

V. LEASE AGREEMENT Is there a lease agreement?
Name Mailing Address City State Zip Code Lease Agreement End Date

Yes

No

If "yes," list the name and address of the lease holder.

VI. MANAGEMENT COMPANY A. MANAGEMENT CONTRACT Is the operation of the facility under a management contract? Yes No

If "yes," provide the following information regarding any management company retained to operate this facility or program.
Type of Management Company

Corporation
Name ­ Management Company Name ­ Contact Person Address

Partnership

Individual

Government

Telephone Number

F-62092 (Rev. 07/08) City State Zip Code

Page 16

B. OFFICERS, DIRECTORS, TRUSTEES, OR SUPERVISORS OF THE MANAGEMENT COMPANY Identify officers, directors, trustees, or supervisors of the management company. Attach additional pages if necessary.
Name Address City Name Address City State Zip Code Title State Zip Code Title

C. OTHER MANAGEMENT COMPANY FACILITIES Identify other facilities the management company has owned, operated, or managed in the last five years. Attach additional pages, if necessary.
Name Address City Dates of Involvement Name Address City Dates of Involvement Name Address City Dates of Involvement State Zip Code State Zip Code State Zip Code

D. ADVERSE ACTIONS The following questions refer to any of the facilities identified in item C.

F-62092 (Rev. 07/08)

Page 17

1. Has any adverse action initiated by any state licensing agency resulted in the denial (D), suspension (S), or revocation (R) of a license? Yes No

If "yes," please complete the following table. Use abbreviations to describe the type of adverse action and refer to IV.G.1. for abbreviations for type of health care provider.
Facility Name and Address City and State Type of Health Care Provider Type of Adverse Action Effective Dates of Adverse Action

2. Has any adverse action been initiated by a state or federal agency based on noncompliance resulted in civil money penalties (CMP), termination of provider agreement (TPA), suspension of payments (SOP), or the appointment of temporary management of the facility (TMF)? Yes No

If "yes," please complete the following table. Use abbreviations to describe the type of adverse action and refer to IV.G.1. for abbreviations for type of health care provider.
Facility Name and Address City and State Type of Health Care Provider Type of Adverse Action Effective Dates of Adverse Action

E. COPY OF MANAGEMENT CONTRACT Attach a copy of the signed contract with the management company.

VII. CONTACT PERSON
Identify the person responsible for completing this application and who can be contacted to address questions.
Name ­ Contact Person (Print.) Telephone Number Fax Number Title Date Application Completed

VIII. DESIGNEE
Identify the person authorized to accept personal service and receive registered and certified mail. Is the administrator also the Designee?
Name ­ Designee

Yes

No
Title

If "no," provide the following information.

F-62092 (Rev. 07/08)

Page 18

IX. ATTESTATION
The Management Company CANNOT attest to or sign on behalf of the applicant (Owner). I understand, under penalty of law, that the information provided above is truthful and accurate to the best of my knowledge and that knowingly providing false information or omitting information may result in a fine of up to $10,000 or imprisonment not to exceed six years, or both, per Chapter 946.32, Wis. Stats.
SIGNATURE - Applicant's (Owner's) Legal Representative
Name (Print or type.) - Legal Representative Date Signed

Title ­ Legal Representative

RETURN THE COMPLETED APPLICATION TO: Division of Quality Assurance Bureau of Technology, Licensing and Education PO Box 2969 Madison WI 53701-2969