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Department Name: | |
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Department Physical Address/Location (include suite #): | |
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Assessment Done By: |
Date: |
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Proximity Designation: On-Campus ______ Off-Campus ______ | |
For the purpose of this assessment, the terms “provider-based” and “facility-based” are synonymous terms meaning a HOSPITAL department.
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Department Information | ||
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List hospital names here for reference if necessary | ||
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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.? | |
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Facility this department is provider-based to (hospital name): | ||
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Department hours of operation: | ||
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Supervisor: | ||
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Manager: | ||
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Director: | ||
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Admin/Executive director: | ||
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Operational owner: | ||
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Cost center(s): |
Number |
Name |
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Epic department number(s) with department name: | ||
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Facility under which patients are registered: | ||
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Physician supervision requirement met by (be as specific as possible): |
(e.g., in-clinic physician, physician assistant, or advanced registered nurse practitioner; hospitalist; provider within same building; etc.) | |
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Notes |
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Checklist A: Requirements for Meeting Provider-Based Status—Use for All Locations (On-Campus and Off-Campus)
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§ 413.65 Reference |
Regulatory Requirement |
Question |
Y/N |
Documentation/Notes |
Met |
Not Met |
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(d)(1) |
1. Licensing/Credentialling |
1. Is the site listed on the hospital’s Department of Health application? | ||||
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2. Is this site listed on the Medicare enrollment form CMS-855A? | ||||||
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(d)(2)(i) |
2. Clinical Services Integration |
1. Is medical staff privileged at the main hospital? | ||||
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(d)(2)(ii) |
2. Are monitoring and oversight of the department the same as for other hospital departments (e.g., executive leadership, information control, quality, etc.)? | |||||
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(d)(2)(iii) |
3. Does the department’s medical director have a reporting relationship to the chief medical officer of the main hospital? | |||||
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(d)(2)(iv) |
4. Does the medical staff committee of the main hospital oversee the medical activities of the department? | |||||
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(d)(2)(v) |
5. Do the medical records identify the patient as being a patient in the main hospital? | |||||
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(d)(2)(vi) |
6. Do the clinic patients have access to the full range of services at the main hospital? | |||||
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(d)(3) |
3. Financial Integration |
1. Are departmental costs included on the hospital cost report? | ||||
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(d)(3) |
2. Are the income and expenses of the department shared with the main hospital? | |||||
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(d)(3) |
3. Is the department on the trial balance of the main hospital? | |||||
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State Operations Manual § 2026A and Centers for Medicare & Medicaid Services (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 department shared with any other department/clinic/service? | ||||
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2. Does the department share waiting room space with any other department/clinic/service? | ||||||
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3. Does the department share office or front desk space with any other department/clinic/service at any time, day or night? If yes, provide detailed information in the Notes section. | ||||||
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4. Does the department share staff with any other department, including registration staff? | ||||||
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(d)(4) |
5. Public Awareness/How the Department Is Held Out to the Public as a Department of the Main Hospital |
1. Does the department signage indicate the name of the hospital? | ||||
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(d)(4) |
2. Take a photo of the clinic sign(s), including sign on outside of building, sign on door, etc. | |||||
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(d)(4) |
3. Do the department registration documents reference the name of the hospital? | |||||
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(d)(4) |
4. Locate the department/location on the internet (external organizational website). Document the naming and description information provided. | |||||
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(d)(4) |
5. If you were a patient, would it be obvious to you that this location is part of the main hospital? |