State of Wyoming– Department of Health Ph: 307-777-7123
Aging Division Fax: 307-777-7127
Healthcare Licensing and Surveys Web: https://www.health.wyo.gov/aging/hls
6101 Yellowstone Road, Suite 186C Email:
Cheyenne WY 82002
PSYCHIATRIC HOSPITAL
LICENSE APPLICATION
Fees: / Initials, Change in Ownership, Annual Renewal(Anything marked in 1a thru 1c below)
Accredited:
Without Swing Beds $100 With Swing Beds $200
Non-Accredited:
0 – 50 Beds $100 151 – 200 Beds $400
51 – 100 Beds $200 201 or more Beds $500
101 – 150 Beds $300 / Changes
(Anything marked in 1d thru 1h below)
$50
Make Payment to: Treasurer, State of Wyoming
FOR DEPARTMENTAL USE ONLY
Fee Paid / Old # / Appl Approved
Check # / New #
If we have questions/concerns regarding the information provided on this application, whom should we contact?
Person’s Name: Phone Number:
EMail:
(Licenses will NOT be sent in hard copy, but sent electronically via email to the address in #9 below.)
GENERAL APPLICATION INFORMATION
1. Type of Application: (check one)
Rev. 01/11/2017 Page 1 of 11
a. Initial Application
b. Change in Ownership Effective Date of Change:
Accepting assignment of the existing provider agreement Yes No
c. Annual Renewal
d. Change in Main Physical Location Effective Date of Change:
e. Change, Addition or Removal of Ancillary Location Effective Date of Change:
f. Change or Addition in Services Effective Date of Change:
Details:
g. Change in Facility Name (put new name in #2) Effective Date of Change:
Old Name:
h. Change in Beds Effective Date of Change:
Old # of Beds: New # of Beds:
2. Facility Name: (This is how it will appear on your license.)
FACILITY NAME:
3. Physical Facility Full Address: (Main location. Include city, st., zip.)
4. Mailing Address: (If different than #3. Include city, st., zip)
5. County:
6. Fiscal Year End Date: (Cost Reporting End Date)
7. Phone:
8. Fax:
9. Email: (This will be used for all official correspondences, survey results, etc. Only one address per provider.)
PROVIDER DETAILS
10. Are you a Medicare/Medicaid Certified Provider? Yes No
a. If yes, what is your CMS Certification Number (CCN):
b. If no, are you planning on applying for Medicare/Medicaid Certification? Yes No
11. National Provider Identifier number (NPI):
12. Federal Employer Tax ID number (EIN):
13. Does the healthcare facility have in place a documented quality management function to evaluate and improve patient/resident/client care and services? Yes No
14. Number of licensed beds:
15. Number of observation beds:
16. Number of operating rooms:
17. Number of endoscopy procedure rooms:
18. Number of cardiac catheterization procedure rooms:
FACILITY NAME:
19. Do you currently have a “deemed” status with one of the nationally recognized accrediting organizations below? Yes No
(You can belong to an accrediting organization but not be deemed. Deemed status means you have requested and received approval from Centers for Medicare and Medicaid Services (CMS) to accept the accrediting organization’s survey process instead of using the State Survey Agency for certification.)
a. If yes, what approved accrediting organization do you belong to:
(Check one:) TJC AOA DNV
b. If no, are you in the process or plan to become deemed within the next 12 months? Yes No
c. Date of Last Accrediting Survey: (You must submit copy of the survey results with this application.)
20. Admission & Occupancy Data: (Use period from April 1 previous calendar year through March 31 current calendar year. Example of calculations at end of application.) (Only required on annual renewal applications.)
i. Annual Admissions:
ii. Actual Total Patient Days of Care: (total daily census for the year)
iii. Available Total Patient Days of Care: (# of licensed beds X # of days in year)
iv. Occupancy Rate Percentage: (actual total patient days of care ÷ available total patient days of care)
21. If you provide swing bed services, you must complete occupancy data on swing beds. (Only required for renewal applications.)
v. Annual Swing Bed Admissions:
vi. Actual Total Swing Bed Patient Days of Care: (total daily census for the year)
vii. Available Total Swing Bed Patient Days of Care: (# of licensed beds X # of days in year)
viii. Swing Bed Occupancy Rate Percentage: (actual total patient days of care ÷ available total patient days of care)
22. Specialized Units: (check as appropriate)
Rev. 04/01/2017 Psychiatric Hospital License Application Page 11 of 11
Alzheimer Unit
PPS Psychiatric Unit
PPS Rehabilitation Unit
Substance Abuse Unit
Special Care Unit
Other
FACILITY NAME:
23. Services Provided: (Check as appropriate. See list of service description in Attachment B.)
Rev. 04/01/2017 Psychiatric Hospital License Application Page 11 of 11
Alcohol and/or Drug Services
Anesthesia Services
Audiology
Burns Care Unit
Cardiac Catheterization Laboratory
Cardiac-Thoracic Surgery
Chemotherapy Services
Chiropractic Services
CT Scanner
Dental Services
Dietetic Services
Emergency Department (Dedicated)
Extracorporeal Shock Wave Lithotripter
Gerontological Specialty Services
ICU-Cardiac (non-surgical)
ICU-Medical/Surgical
ICU-Neonatal
ICU-Pediatric
ICU-Surgical
Laboratory-Clinical
Magnetic Resonance Imaging
(MRI)
Obstetric Services
Occupational Therapy Services
Operating Rooms
Ophthalmic Surgery
Optometric Services
Organ Transplant Services
(Non Medicare-certified)
Orthopedic Surgery
Outpatient Services
Pediatric Surgery
Pharmacy
Physical Therapy Services
Positron Emission Tomography Scan
Post-Operative Recovery Rooms
Psychiatric Services-Emergency
Psychiatric-Child/Adolescent
Psychiatric-Forensic
Psychiatric-Geriatric
Psychiatric-Adult Inpatient
Psychiatric-Outpatient
Radiology Services-Diagnostic
Radiology Services-Therapeutic
Reconstructive Surgery
Respiratory Care Services
Rehab Services – Inpatient
Rehab Service – Outpatient
Renal Dialysis (Acute Inpatient)
Social Services
Speech Pathology Services
Surgical Services-Inpatient
Surgical Services-Outpatient
Swing Bed Services
Trauma Center (Designated)
Transplant Center (Medicare Certified)
Urgent Care Center Services
Rev. 04/01/2017 Psychiatric Hospital License Application Page 11 of 11
24. In accordance with W.S. 35-2-910(c), does the Hospital provide for the review of professional practices in the hospital for the purpose of reducing morbidity and mortality and for the improvement of the care of patients in the hospital? This review shall include but not be limited to:
(a)The quality and necessity of the care provided to patients as rendered in the hospital;
(b)The prevention of complications and deaths occurring in the hospital;
(c)The review of medical treatments and diagnostic and surgical procedures in order to ensure safe and adequate treatment of patients in the hospital; and
(d)The evaluation of medical and health care services and the qualifications and professional competence of persons performing or seeking to perform those services.
The review shall be performed according to the decision of a hospital's governing board by:
(a)A peer review committee appointed by the organized medical staff of the hospital;
(b)A state, local or specialty medical society; or
(c)Any other organization of physicians established pursuant to state or federal law and engaged by the hospital for the purposes of W.S. 35-2-910(c).
Yes No
FACILITY NAME:
PERSONNEL
25. Name/Title of person in charge of facility, agency, or clinic (CEO):
26. Name of Administrator/Director:
a. Professional License Type:
b. Professional License Number:
27. Name of Director of Nursing/Nursing Supervisor:
a. Professional License Type:
b. Professional License Number:
28. Name of Medical Director (if applicable):
a. Professional License Type:
b. Professional License Number:
29. Name of Maintenance Director (if applicable)
a. Contact phone number:
LOCATIONS/BUILDINGS
30. Main Building Location (You must attach a current floor plan with areas clearly identified.)
a. Property Ownership: Own Rent Lease
b. Physical Address: (Include city.)
c. Services at this location:
d. Date services began at this location:
e. Is there a current construction or remodel project going on at this location? Yes No
f. If yes, list HLS project numbers:
31. Number of ancillary locations under the CCN in 10a.
a. An attestation is attached at the end of the application form. You must complete a form for EACH of these locations.
FACILITY NAME:
OWNER/OPERATOR
32. Ownership type (check one) (This is the owner of the healthcare facility provider – not the owner of property/physical structure.)
a. Sole Proprietor/Individual
b. Partnership
c. Profit Corporation
d. Nonprofit Corporation
e. Limited Liability Company
f. Governmental: City County Hospital District State
g. Other:
33. Ownership Name:
34. Mailing Address:
35. Phone:
36. Contact person:
37. Contact person’s email:
38. List all officers and titles below: or List attached.
a.
b.
c.
d.
e.
39. Has the owner ever had a license to operate a healthcare facility or agency providing healthcare services in this or any other state denied, suspended, revoked or otherwise terminated for cause? Yes No
a. If yes, explain:
40. Is the healthcare facility operated or managed by a business entity other than the owner listed in #32 above?
Yes No
a. If yes, Operating Entity Name:
b. Mailing Address:
c. Phone:
d. Contact Person’s Name:
e. Contact Person’s Email:
FACILITY NAME:
41. Has the operator ever had a license to operate a healthcare facility or agency providing healthcare services in this or any other state denied, suspended, revoked or otherwise terminated for cause? Yes No
a. If yes, explain:
42. Did you read and understand the healthcare facility licensure requirements (W.S. 35-2-901 and 902 et seq) outlined at the end of this application? Yes No
ATTESTATION
Ancillary or Locations Not Within the Main Building
(ONLY COMPLETE FOR EACH ADDITIONAL LOCATION IDENTIFIED IN #31)
FACILITY NAME:
Ancillary Location Name:
Ancillary Location Address (BE SPECIFIC: SUITE #, ETC.):
Please attach a copy of the organization chart that identifies where this ancillary location fits into your organization.
# of Highway Miles from Main Hospital:
# of Radius Miles from Main Hospital:
List all of the services you provide at this ancillary location:
Are the employees at this ancillary location employees of the hospital?
YES NO
Are these employees under the supervision of a hospital employee?
YES NO
Are these services under the supervision of your organized medical staff?
YES NO
How are referrals made to this location?
Are services billed as a hospital service (hospital’s provider number)?
YES NO
If No, are these services billed under a private clinic or physician/specialists provider number?
YES NO
Name of Person Completing this form:
Title:
Date:
FACILITY NAME:
SIGNATURE
Wyoming Statutes requires signature by two (2) officers of the organization, or a signature of all managing agents. If signed by managing agents, copies must be attached of company documents indicating the individuals signing are managing agents for the company.
I have read the contents of this application. My signature legally binds the facility’s agreement to abide by the rules promulgated by the Stat of Wyoming for this category of healthcare facility and do hereby state the information provided on this application is true to the best of my knowledge and belief.
The facility further understands the facility is responsible for admitting and retaining only those persons who qualify for this category of healthcare facility as defined in the applicable rule and facility policies and procedures. The facility agrees to allow authorized representative of the Wyoming Department of Health, upon presentation of proper identification, to request and/or enter the facility at any time without a warrant, any facility records and documentation as necessary to ascertain compliance with State licensing laws and rules promulgated by the Wyoming Department of Health.
Application must have original signatures of two officers as listed in the ownership section above. In most cases, a CEO, CFO, Administrator, or Director signature will not be accepted.
Signature #1______
Printed Name:
Title:
Date:
Signature #2______
Printed Name:
Title:
Date:
LICENSE STATUTETITLE 35 / PUBLIC HEALTH AND SAFETY
CHAPTER 2 / HOSPITALS, HEALTH CARE FACILITIES AND HEALTH SERVICES
ARTICLE 9 / LICENSING AND OPERATIONS
352901.Definitions; applicability of provisions.
(a)As used in this act:
(i)"Acute care" means short term care provided in a hospital;
(ii)"Ambulatory surgical center" means a facility which provides surgical treatment to patients not requiring hospitalization and is not part of a hospital or offices of private physicians, dentists or podiatrists;
(iii)"Birthing center" means a facility which operates for the primary purpose of performing deliveries and is not part of a hospital;
(iv)"Boarding home" means a dwelling or rooming house operated by any person, firm or corporation engaged in the business of operating a home for the purpose of letting rooms for rent and providing meals and personal daily living care, but not habilitative or nursing care, for persons not related to the owner. Boarding home does not include a lodging facility or an apartment in which only room and board is provided;
(v)"Construction area" means thirty (30) highway miles, from any existing nursing care facility or hospital with swing beds to the site of the proposed nursing care facility, as determined by utilizing the state map prepared by the Wyoming department of transportation;
(vi)"Department" means the department of health;
(vii)"Division" means the designated division within the department of health;
(viii)"Freestanding diagnostic testing center" means a mobile or permanent facility which provides diagnostic testing but not treatment and is not part of the private offices of health care professionals operating within the scope of their licenses;
(ix)Repealed By Laws 1999, ch. 119, § 2.
(x)"Health care facility" means any ambulatory surgical center, assisted living facility, adult day care facility, adult foster care home, alternative eldercare home, birthing center, boarding home, freestanding diagnostic testing center, home health agency, hospice, hospital, freestanding emergency center, intermediate care facility for people with intellectual disability, medical assistance facility, nursing care facility, rehabilitation facility and renal dialysis center;
(xi)"Home health agency" means an agency primarily engaged in arranging and directly providing nursing or other health care services to persons at their residence;
(xii)"Hospice" means a program of care for the terminally ill and their families given in a home or health facility which provides medical, palliative, psychological, spiritual and supportive care and treatment. Hospice care may include shortterm respite care for nonhospice patients, if the primary activity of the hospice is the provision of hospice services to terminally ill individuals and provided that the respite care is paid by the patient or by a private third party payor and not through any governmental third party payment program;