Application & Checklist for Hospital EDat an Outpatient-OnlyOffsite Campus (Adding)Page1

Instructions for Completing the Application & Checklist for Hospital EDs at an Outpatient-OnlyOffsite Campus (Adding)

  1. Please fill out all hospital information.
  2. Please identify a designated contact person of the hospital for all information to be communicated through.
  3. Please place all attachments behind this checklist in the order listed on the checklist.
  4. Please submit the packet in its entirety with this checklist on top of all documents.

All packets will be reviewed by the administrative assistant. If the packet is determined to be incomplete, the entire packet will be sent back to the facility for completion. Once a packet is determined to be complete by the administrative assistant, it will be placed in line for processing. Please keep in mind that with the large volume of work being requested by hospitals, the wait time can be lengthy. The forms, fees and information should be submitted to the state office approximately 6 to 10 weeks prior to your anticipated opening date.

The Department of Health and Hospitals shall not process any packet until all forms, required applicable accompanying information and fees are received.

Payment Information
Check or Money Order Number:
Mail Payment & Payment Transmittal Form To / Mail License Application Packet To
DHH Licensing Fee
PO Box 62949
New Orleans, LA 70162-2949 / Department of Health & Hospitals
Health Standards Section
P.O. Box 3767
Baton Rouge, LA 70821-3767


Application Date: / Effective Date:
Administrator:
Administrator Phone:
Administrator Email: / Designated Contact Person:
Designated Contact Phone:
Designated Contact Email:
Hospital Name:
Hospital Address: / Street:
City/State/Zip:
Hospital Phone: / Hospital Fax:
Type of Service (Attach additional documents if you need more space)
Location License Number Where Bed Changes will Occur / Present Bed Capacity / Proposed Bed Capacity / Increase Of: / Decrease Of: / Present Number of Rooms / Proposed Number of Rooms / Increase Of: / Decrease Of:
Offsite campus:
Totals For Entire Hospital
Overall Bed/Room Change
Anticipated Date for the EDAddition:
Letter of Intent (Details of the Room/Bed Change):
  • Do you have FacilityNeed Review Approval:
  • Yes
  • No STOP, GO NO FURTHER, CONTACT
  • Are you adding this at a currently licensed offsite campus:
  • Yes License # of the Offsite Campus where you are adding the ED:
  • No
  • Will you be licensing this campus for the sole purpose of providing an offsite ED:
  • Yes
  • No Explain:
  • Geographical address where ED will be located:
  • Name of the building where the ED will be located:
  • Floor where the ED will be located:
  • ED Room Numbers/Beds (please remember that the room numbers must match the approved floor plans):
  • Provide a description of this action:
  • What was the space used for prior to licensing:
  • Other details:

Compliance with Hospital Conditions of Participation
  • Please describe how the Outpatient-Only Offsite ED complies with Governing Body CoP at 42 CFR 482.12:
  • Please describe how the Outpatient-Only Offsite ED complies with the Medical Staff CoP at 42 CFR 482.22:
  • Please describe how the Outpatient-Only Offsite ED complies with the Nursing Services CoP at 42 CFR 482.23:
  • Please describe how the Outpatient-Only Offsite ED complies with the Emergency Laboratory Services CoP at 42 CFR 482.27(b)(1):
  • Please describe how the Outpatient-Only Offsite ED complies with the Quality Assessment/Performance Improvement CoP at 42 CFR 482.21:
  • Please describe how the Outpatient-Only Offsite ED complies with the Medical Records CoP at 42 CFR 482.24:
  • Please describe how the Outpatient-Only Offsite ED complies with the Infection Control CoP at 42 CFR 482.42:
  • Please describe how the Outpatient-Only Offsite ED complies with the EMTALA CoP at 42 CFR 489.20 and 489.24:

  • Please describe how the Outpatient-Only Offsite ED complies with the requirements at 42 CFR 482.55(a)(2) for the integration with other departments of the hospital to include, but not limited to, the following:
  • Inpatient admissions:
  • Intra-hospital transport of patients from the off-site ED to the main campus consistent with 482.13(c)(2):
  • Organization & Direction of the emergency services at the off-campus location must be by a qualified member of the hospital’s medical staff & under the same overall medical staff direction.
  • Policies & procedures governing medical care provided at the off-campus location must be established by, and remain an ongoing responsibility of the hospital’s medical staff and the off-campus ED operates under the same general policies and procedures as the ED at the hospital’s main campus.
  • Hospital CoPs found in 42 CFR 482.51 through 42 CFR 482.57 governing other optional services the hospital chooses to offer at the off-campus location.
  • Professional staff have clinical privileges at the main campus of the hospital
  • Hospital maintains the same monitoring and oversight of the off-campus ED as it does for any other of its departments.
  • Medical Director of the off-campus ED maintains a reporting relationship to the hospital’s chief medical officer that is similar to that of a department medical director
  • Medical staff committees of the hospital are responsible for medical activities in the off-campus ED
  • The services of the off-campus ED are integrated into those of the hospital’s main campus, and patients of the off-campus ED who require further care have access to all services of the main campus.

Compliance with Hospital Conditions of Participation
  • Will this Outpatient-Only Offsite ED be located on the campus of any other healthcare provider:
  • No
  • Yes If Yes,
  • Name of the other provider:
  • Explain how the Outpatient-Only Offsite ED complies with RS 40:2007 (1):
  • Explain how the Outpatient-Only Offsite ED complies with RS 40:2007 (2):
  • Explain how the Outpatient-Only Offsite ED complies with RS 40:2007 (4) (B):
  • Explain how the Outpatient-Only Offsite ED complies with RS 40:2007 (4) (C):
  • Explain how the Outpatient-Only Offsite ED complies with RS 40:2007 (4) (D):
  • Explain how the Outpatient-Only Offsite ED complies with RS 40:2007 (4) (E):
  • Explain how the Outpatient-Only Offsite ED complies with RS 40:2007 (4) (F):
  • Explain how the Outpatient-Only Offsite ED complies with RS 40:2007 (4) (G):

Compliance with Hospital Conditions of Participation
  • Will this Outpatient-Only Offsite ED be located on the campus of any other healthcare provider:
  • No
  • Yes If Yes,
  • Name of the other provider:
  • Explain how the Outpatient-Only Offsite ED complies with 42 CFR 412.22 (c) (4) (e) (1) (i):
  • Explain how the Outpatient-Only Offsite ED complies with 42 CFR 412.22 (c) (4) (e) (1) (ii):
  • Explain how the Outpatient-Only Offsite ED complies with 42 CFR 412.22 (c) (4) (e) (1) (iii):
  • Explain how the Outpatient-Only Offsite ED complies with 42 CFR 412.22 (c) (4) (e) (1) (iv):
  • Explain how the Outpatient-Only Offsite ED complies with 42 CFR 412.22 (c) (4) (e) (1) (v):
  • Explain how the Outpatient-Only Offsite ED complies with 42 CFR 412.22 (c) (4) (e) (1) (vi) (A):
  • Explain how the Outpatient-Only Offsite ED complies with 42 CFR 412.22 (c) (4) (e) (1) (vi) (B):
  • Explain how the Outpatient-Only Offsite ED complies with 42 CFR 412.22 (c) (4) (e) (1) (vi) (C):
  • Explain how the Outpatient-Only Offsite ED complies with 42 CFR 412.22 (c) (4) (e) (2)
  • Explain how the Outpatient-Only Offsite ED complies with 42 CFR 412.22 (c) (4) (e) (3)
  • Explain how the Outpatient-Only Offsite ED complies with 42 CFR 412.22 (c) (4) (f) (1)
  • Explain how the Outpatient-Only Offsite ED complies with 42 CFR 412.22 (c) (4) (f) (2)
  • Explain how the Outpatient-Only Offsite ED complies with 42 CFR 412.22 (c) (4) (g)
  • Explain how the Outpatient-Only Offsite ED complies with 42 CFR 412.22 (c) (4) (h)

Criteria (Each of these must be attached in order for your application to be processed): / Yes / No / Describe
  1. HSS-HO-050o Application & Checklist for EDs at the Outpatient Only Offsite Campus
/ Attach
  1. Facility Need Review Approval: If you have not completed this then STOP & GO NO FURTHER WITH THIS PACKET. CONTACT .
/ Attach
  1. Office of State Fire Marshal (OSFM) Plan Review Approval Letter for the LDH Plan Review (This letter should be titled “DHH Facility Licensing Recommendation” or have a plan review number starting with “DH” The OSFM can NOT exempt you from this review.
/ Attach
  1. HSS-PR-02 Plan Review Attestation (You must submit this if the Health Facility Plan Review has any comments)
/ Attach
  1. Please have your architect share the plan review on the Office of State Fire Marshall IMS system with LoriGuillory & JennyHaines.
/ Attach
  1. HSS-HO-016b Worksheet for Hospital Beds & Rooms Not Counted in the Licensed Bed Count (for only the unit where the bed changes are occurring)
/ Attach
  1. Site Map showing where the building with the changes is at on the campus relative to other buildings, parking and streets. Please demarcate all buildings on the campus by name and indicate which buildings will be licensed.
/ Attach
  1. Floor Map showing the entire floor of all buildings being licensed. Please demarcate the boundaries of the ED.
/ Attach
  1. 11 x 17 copy of the floor plans for each area changed to include dimensions and identification of service areas (i.e. nurse’s station, dining area, patient room numbers, etc.) once the changes are made. This MUST include the stamp of approval from the Office of State Fire Marshal for the LDH plan review. The number stamped on the floor plans MUST match the number on the letter titled “LDH Facility Licensing Recommendation.”
/ Attach
  1. 11 x 17 copy of the floor plan showing what the areas impacted looked like before the change inclusive of the name/identification of all rooms/spaces.
/ Attach
  1. Office of Fire Marshall Inspection (architectural, fire, & sprinkler) Report Approval (must indicate on the form the areas specified for the changes such as patient room numbers, dining areas, offices, conference rooms, etc.). Please note that the dba name of the offsite campus must be on this form and it must indicate that the ED & support spaces are approved.
/ Attach
  1. Office of Public Health Inspection Report Approval (must indicate on the form the areas specified for the changes such as patient room numbers, dining areas, offices, conference rooms, etc.). Please note that the dba name of the offsite campus must be on this form and it must indicate that the ED & support spaces are approved.
/ Attach
  1. Office of Public Health Retail Food Permit:
/ Attach
  1. Letter on hospital letterhead stating that either the hospital owns the space and it is not leased or subleased to anyone or that the hospital is the owner of the space through a lease/sublease.
/ Attach
  1. HSS-HO-09 Attestation for a Licensed Hospital
/ Attach
  1. Fee of $300.00 for an offsite location

  1. CLIA Approval for Laboratory Services
/ Attach
  1. Board of Pharmacy Approval for Pharmacy Services
/ Attach
  1. DEQ/Physicist Approval for Imaging Equipment
/ Attach
  1. Since Louisiana Hospital Licensing Standards require that an offsite campus be within 50 miles of the hospital’s main campus, please submit documentation showing that offsite campuses are within a 50 mile radius of the hospital’s new main campus. However, if the hospital participates in Medicare/Medicaid, CMS requires that offsite campuses be located within a 35 miles radius of the hospital’s new main campus. You will need to submit documentation showing that each offsite location is within a 35 mile radius of the new main campus location. If this is a Critical Access Hospital, you will need to submit documentation showing that this offsite campus IS NOT within a 35 mile radius of any other hospital’s campus (unless it is a RHC).
/ Attach
  1. Confirmation from the MAC indicating that they have received the CMS 855A (it must be a CMS 855A and no other versions of the CMS 855) add the offsite campus of the hospital along with an exact copy of the CMS 855A that was submitted. Please keep in mind that if the offsite campus has PPS Excluded Psych Unit, PPS Excluded Rehab Unit, SNF Unit, or Swing Bed Status you will need this included in the CMS 855A.
/ Attach
  1. Approved CMS 855A and Summary Letter from the MAC recommending the addition of the new location
/ Attach
  1. Confirmation from the following (if applicable) indicating awareness of the addition: Accrediting Agency.
/ Attach
  1. Please note that an onsite inspection may need to be conducted by Health Standards before this relocation is approved.
/ Attach
Attestation & Signature
I understand that if the agency license is granted, it is granted for one year and shall become void upon change of ownership or change in geographical address. It is my responsibility to notify the Department of Health and Hospitals, Bureau of Health Services Financing, Health Standards Section in writing of any changes in the information provided in this application in a separate packet. I attest that the hospital currently complies with the requirements of the Office of State Fire Marshal and Office of Public Health. I certify that the information herein is true, correct and supportable by documentation to the best of my knowledge. Documentation of the information above is available upon request by the Department of Health and Hospitals.
Authorized Representative’s Printed Name & Title:
Authorized Representative’s Signature: / Date:
For DHH Use Only / Date / Yes / No / Comments
Incomplete Packet Sent Back To Facility along with Instructional Letter
Packet Ready for Program Manager Review
Routed for survey, survey completed & approved
ACO updated (notes, certification kit in 2 or 3 places)
CMS 1539s Distributed
POPS updated (capacity change application)
License & Letter Printed, Emailed & Mailed
Logs Updated
CMS Notified
Prepped & submitted for scanning
Additional Comments:

HSS-HO-050o Rev (10/16)

P.O. BOX 3767 • BATON ROUGE, LOUISIANA 70821-3767

PHONE #: (225) 342 • 0138 • FAX #: (225) 342-0157
“AN EQUAL OPPORTUNITY EMPLOYER”