Complete Healthcare Compliance Manual

Department Name

Department Physical Address/Location (include suite #)

Street (include Suite #)

City

State

Zip

On Campus __Off Campus

Facility this Department is Provider-Based to

(List hospital names here for reference if necessary)

This is the "facility", "hospital" and/or "main hospital" that the questions throughout the rest of this assessment refer to.

Consider: Is this the most logical hospital affiliation for this department, based on location, etc.?

Dept hours of operation:

Supervisor

Manager

Director

Admin / Exec Director

Operational Owner

Cost Center(s)

Number

Name

Epic Dept #(s) w/Dept Name

Facility under which patients are registered

Physician Supervision Requirement Met By (be as specific as possible)

(Ex: in-clinic physician, PA or ARNP; hospitalist; provider within same bldg; etc.)

(d)(1)

1. Licensing / Credentialling

1. Is the site listed on the hospital's Dept of Health Application?

2. Is this site listed on the Medicare 855A?

(d)(2)(i)

2. Clinical Services Integration

1. Is the Medical Staff privileged at the main hospital?

(d)(2)(ii)

2. Is monitoring and oversight of the dept the same as for other hospital depts? (ex: exec leadership, inf control, quality, etc.)

(d)(2)(iii)

3. Does the dept Medical Director have a reporting relationship to the Chief Medical Officer of the main hospital?

(d)(2)(iv)

4. Does the Medical Staff Committee of the main hospital oversee the medical activities of the dept?

(d)(2)(v)

5. Do the medical records identify the patient as being a patient in the main hospital ?

(d)(2)(vi)

6. Do the clinic patients have access to the full range of services at the main hospital?

(d)(3)

3. Financial Integration

1. Are the dept costs included on the hospital cost report?

(d)(3)

2. Are the income and expenses of the dept shared with the main hospital?

(d)(3)

3. Is the dept on the trial balance of the main hospital?

State Operations Manual § 2026A and CMS rulings not in manual form

4. Building/Space Integration (Provide detailed information for each 'Yes' answer in the Notes section)

1. Is the entrance to the dept shared with any other dept/clinic/service?

2. Does the dept share waiting room space with any other dept/clinic/service?

3. Does the dept share office or front desk space with any other dept/clinic/service at any time day or night? If yes, provide detailed information in notes.

4. Does the dept share staff with any other dept, including registration staff?

(d)(4)

5. Public Awareness / How the Dept is Held Out to the Public as a Dept of the Main Hospital

1. Does the dept signage indicate the name of the hospital?

(d)(4)

2. Take a photo of the clinic sign(s), including sign on outside of building, sign on door, etc.

(d)(4)

3. Do the dept registration documents reference the name of the hospital?

(d)(4)

4. Locate the department/location on the internet (external organizational website). document the naming and description information provided.

(d)(4)

5. If you were a patient, would it be obvious to you that this location is part of the main hospital?