Licensure and Medicare / Medicaid Certification for
Hospitals
NOTE
TO APPLICANTS: INITIAL SURVEYS FOR MEDICARE PARTICIPATION:
S&C Memo
08-03: Initial Surveys for New
Medicare Providers (PDF,
103 KB)
IMPORTANT NOTE TO APPLICANTS: Interim
Survey Guidance (PDF 29 KB)
Forms and Documents (below):
Forms and Documents
The following forms and documents can be located on the web sites
listed below.
The applicant will need to complete the Hospital Certificate
of Approval Application along with the following forms and send to the
Bureau of Health Services, Division of Quality
Assurance.
NOTE: Before the start of any construction or remodeling project, plans
for the construction or remodeling must be submitted to the department,
pursuant to s. DHS 124.29, for review and approval by the department
(refer to Subchapter V - Physical Environment, DHS 124, Wisconsin
Administrative Code).
For more information regarding physical environment,
contact the Bureau of Health Services, Division of Quality Assurance, at (608)
264-7748 or see Plan Review website.
Caregiver Background Check Information
Under Chapter 50 of the Wisconsin Statutes [s.50.065] the department is
required to perform background checks on license holders/applicants,
non-clients who reside at the entity, and on employees/staff.
Where the applicant is a corporation or other similar legal body, the
applicant must identify by name
the other members of the corporation or other legal body, in addition to
the signatories on the
application, who legally make up the body to which a license or
certification or other such similar
regulatory approval is issued.
The applicant shall designate for each, who
will or will not have access
to clients the entity serves. The department will do background checks on
all signatories on the
application, and on the other members identified on the application.
Background Information Disclosure (BID) Form (F-82064)
The BID form gathers
information as required by the Wisconsin Caregiver Background Check Law to
help employers and governmental regulatory agencies make hiring,
licensing, certification or registration decisions.
Refer to the
Caregiver Background Check Process web page for information for
completing the BID form for Licensee Applicants/License Holder
Background Checks.
Also review information on the requirement for Employee Background
Checks found on the
Caregiver Background Check Process web page.
Licensure Application
A. Complete application packet. Make sure application is
signed.
Submit completed application to:
Division of Quality Assurance
Bureau of Health Services
P.O. Box 2969,
1 W. Wilson St. Rm. 455
Madison, WI 53701-2969
B. Chapter 50 of the Wisconsin Statutes [s.50.135(2)(a)] requires that the
fee for an inpatient health care facility except a nursing home is $18.00
per bed.
C. Wisconsin Administrative Code, Chapter DHS 124, General and Special
Hospitals, sets forth certain minimum requirements to be met. In order
that we have a complete application, please submit the following
supplemental information:
1. Copy of the hospital articles of incorporation, and the bylaws
written in accordance with DHS 124.05.
2. Medical staff bylaws including the various committees. For
information of what the bylaws shall include, please refer to Subchapter
III, DHS 124.12(5)(b). Please also provide the names of the active
physician staff.
3. Written policies established by governing board on patients rights
and responsibilities. (DHS 124.05(3)).
4. The name and qualifications of the registered nurse who will direct
the nursing service and the designee. (DHS 124.13)
5. The registered nurse staff pattern for 24-hour registered nurse
coverage seven days per week, including names and registration number.
(DHS
124.13)
6. The name of the qualified medical record administrator or accredited
record technician and the number of hours on duty. (DHS 124.14)
7. The name of the staff or consulting pharmacist who will direct the
pharmacy or drug room and the number of hours on duty. (DHS 124.15)
8. The name and qualifications of the registered dietitian who will
direct the dietary service, including the number of hours on duty. (DHS
124.16)
9. Names of staff pathologist and hours on duty, or name of qualified
physician, or name and qualifications of laboratory specialist. (DHS
124.17)
10. Policies and procedures governing medical care provided in the
emergency
service. (DHS 124.24)
11. The name and qualifications of the social worker who will direct
the social work service and the number of hours on duty. (DHS 124.25)
12. Provide schematic plans, which shall include at least the following
adjunct service facilities:
a. a clinical laboratory
b. a blood bank
c. diagnostic x-ray facilities available in the hospital building proper
or in an adjacent clinic or medical facility that is readily accessible
to
the hospital patients, physicians and personnel
d. a medical library
13. If the hospital will be classified as a special hospital that
primarily provides psychiatric care to inpatients and outpatients, the
following additional requirements need to be submitted:
a. Medical record policies documenting the degree and intensity of the
treatment provided to individuals who are furnished services.
b. Documentation regarding treatment plans and staffing that meets the requirements in DHS 124.26(3).
For assistance in completing forms for hospital licensure and
certification, please call Hospital Licensing Specialist at
(608) 266-7297. Questions regarding the Conditions of Participation survey
process should be directed to the Bureau of Health Services at (608)
266-7881.
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Last Revised:
April 04, 2013 |
