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
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 Technology, Licensing & Education, 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. HFS 124.29, for review and approval by the department
(refer to Subchapter V - Physical Environment, HFS 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 of state
institutions.
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 Form (F82064)
- This 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.
- Complete and return
the entire form, including any necessary attachments, for each signatory
and other members identified as having access to clients the entity
serves.
- Forms may be duplicated or copies can be obtained from the
Department's Caregiver Forms website or the Department's
main form site.
Caregiver Background Check Fees
A provision in this law also allows DHFS to assess fees for conducting
background and criminal history checks of license holders/applicants.
Entities may incur additional costs when it is necessary for the
department to follow up with federal and local law enforcement, other
agencies, or other states for additional information.
The current fee for government agencies requesting criminal history
record checks by the Department of Justice (Wisconsin Statute 165.82) is
$5.00 per individual.
In addition, the department's current fee for
processing background and criminal history checks of license
holders/applicants is $3.00 per individual.
The total criminal history
record check and processing fee is $8.00 per individual. Payment for the
Caregiver Background Check must be submitted separately from the required
licensure fee and made payable to the Division of Quality Assurance.
Licensure Application
A. Complete application packet. Make sure application is
signed.
Submit completed application to:
Division of Quality Assurance
Bureau of Technology, Licensing & Education
P.O. Box 2969,
1 W. Wilson St. Rm. 950
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 HFS 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 HFS 124.05.
2. Medical staff bylaws including the various committees. For
information of what the bylaws shall include, please refer to Subchapter
III, HFS 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. (HFS 124.05(3)).
4. The name and qualifications of the registered nurse who will direct
the nursing service and the designee. (HFS 124.13)
5. The registered nurse staff pattern for 24-hour registered nurse
coverage seven days per week, including names and registration number. (HFS
124.13)
6. The name of the qualified medical record administrator or accredited
record technician and the number of hours on duty. (HFS 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. (HFS 124.15)
8. The name and qualifications of the registered dietitian who will
direct the dietary service, including the number of hours on duty. (HFS
124.16)
9. Names of staff pathologist and hours on duty, or name of qualified
physician, or name and qualifications of laboratory specialist. (HFS
124.17)
10. Policies and procedures governing medical care provided in the
emergency
service. (HFS 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. (HFS 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 HFS 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: August 20, 2008 |
