Questionnaire for a Hospital’s
Off-Site Campus
Hospital License Number: / Hospital Provider Number:
Hospital DBA Name:
Hospital Geographical Address:
Hospital Phone Number:
Hospital Fax Number:
Off-Site Campus Name:
Off-Site Campus Geographical Address:
Off-Site Campus Phone Number:
Off-Site Campus Fax Number:
Is the off-site campus located inside another health care facility? No Yes (include name, address, & type of facility below)
Describe Service
Outpatient Services At This Location / Inpatient Services At This Location / # of Rooms / # of Beds
CMS Definition of Surgical Services:
Surgical and other invasive procedures are defined as operative procedures in which skin or mucous membranes and connective tissue are incised or an instrument is introduced through a natural body orifice. Invasive procedures include a range of procedures from minimally invasive dermatological procedures (biopsy, excision, and deep cryotherapy for malignant lesions) to extensive multi-organ transplantation. They include all procedures described by the codes in the surgery section of the Current Procedural Terminology (CPT) and other invasive procedures such as percutaneous transluminal angioplasty and cardiac catheterization. They include minimally invasive procedures involving biopsies or placement of probes or catheters requiring the entry into a body cavity through a needle or trocar. They do not include use of instruments such as otoscopes for examinations or very minor procedures such as drawing blood.
Surgery is performed for the purpose of structurally altering the human body by the incision or destruction of tissues and is part of the practice of medicine. Surgery also is the diagnostic or therapeutic treatment of conditions or disease processes by any instruments causing localized alteration or transposition of live human tissue which include lasers, ultrasound, ionizing radiation, scalpels, probes, and needles. The tissue can be cut, burned, vaporized, frozen, sutured, probed or manipulated by closed reductions for major dislocations or fractures, or otherwise altered by mechanical, thermal, light-based, electromagnetic or chemical means. Injection of diagnostic or therapeutic substances into body cavities, internal organs, joints, sensory organs, and the central nervous system also is considered to be surgery (this does not include the administration by nursing personnel of some injections, subcutaneous, intramuscular, and intravenous, when ordered by a physician). All of these surgical procedures are invasive, including those that are performed with lasers, and the risks of any surgical procedure are not eliminated by using a light knife or laser in place of a metal knife, or scapel…”.
Will any invasive/surgical procedures be performed at this location?
No
Yes Explain:
Please note surgical procedures must be performed in the appropriate class of operating/procedure room and will thus require a DH plan review by the Office of State Fire Marshal.
Personnel
Please indicate the numbers of each type of staff which will be onsite while patient care is provided
Personnel Type / Yes No / Description (indicate the type of MD, other & whether each will be employees, contracted, privileged or volunteers) / Number On-site
Physicians: / Yes No
RNs: / Yes No
LPNs: / Yes No
Nursing Assistants / Yes No
Other: / Yes No
Other: / Yes No
Other: / Yes No
Other: / Yes No
Other: / Yes No
- Will the off-site campus store medications on its premises? No Yes (If yes, how will the medications be supplied & stored?)
- Will credential files, personnel files, etc. for the staff working at the off-site campus be maintained on the premises of the off-site campus? No Yes (If no, describe where these will be stored and how they can be accessed)
- Will the medical records of the patients seen at the off-site campus be maintained on the premises of the off-site campus? No Yes (Describe the medical storage/ retrieval system and how the patient record will follow the patient to the main campus)
- What arrangements will be made for patients requiring emergency services?(Please do NOT provide an answer such as “call 911” or “transport to nearest emergency room”. You must briefly explain how your policies/procedures will be followed to provide initial care and treatment to persons experiencing emergencies).
- In an emergency situation, will the patient be sent to the main campus of the hospital? Yes No (If the answer is no, where will the patient be sent)
- Will the off-site campus serve the same patient population as the main campus (i.e. open to the general public and serve the same patient population)?
- Describe the catchment area and population being served by the main campus and the off-site campus:
- Will the off-site campus be held out to the public as part of the main campus hospital so that patients recognize what hospital they are entering and being billed for?
- Will the off-site campus and the main campus be financially integrated (e.g. share income and expenses, report cost using the same accounting system for the same cost reporting period)?
Signature
Administrator/Designee Printed Name:
Administrator/Designee Signature: / Date:
HSS-HO-08 (Revised 02/17)