Licensure & Certification Application



State of Wyoming–Department of Health Ph: 307-777-7123

Aging Division Fax: 307-777-7127

Healthcare Licensing and Surveys Web:

Hathaway Bldg., Suite 510 Email: wdh-ohls@

2300 Capitol Avenue

Cheyenne WY 82002

PSYCHIATRIC HOSPITAL

LICENSE APPLICATION FOR

ANNUAL RENEWAL

|Fees: |Annual Renewal |This application is not to be used for a new |

| |Are you deemed with an accrediting organization? |provider, change in ownership, or other |

| |If YES = Go to # B If NO = Go to # C |changes; they are to be submitted on a |

| |Do you have swing beds? |separate application form. |

| |If YES owe = $200 If NO owe = $100 | |

| | | |

| |How many total licensed beds? (Only use if A above is No.) | |

| |0-50 Beds = $100 51-100 Beds = $200 | |

| |101-105 Beds = $300 151-200 Beds = $400 201 or| |

| |more Beds = $500 | |

|Make Payment to: Treasurer, State of Wyoming |

|FOR HLS USE ONLY |

|Fee Paid |Appl Approved |

|Check # | |

If we have questions/concerns, regarding the information provided on this application, whom should we contact?

Contact Person’s Name:     Email:      

GENERAL APPLICATION INFORMATION (This is a fillable form. Tab through the document to advance.)

1. Facility Name:

     

NOTE: Hereafter, “facility” will refer to the entity identified in #1.

2. City:      

3. Phone:      

4. Email:      

5. Name of Administrator:      

6. Provide services for: Outpatient only Inpatient only Both in/outpatient

7. Total number of beds to be licensed:      

FACILITY NAME:

8. Specialized Units: (check as appropriate)

Alzheimer Unit PPS Psychiatric Unit

PPS Rehabilitation Unit Substance Abuse Unit

Special Care Unit Other      

9. Services Provided: (Check as appropriate.)

Alcohol and/or Drug Services

Anesthesia Services

Audiology

Burns Care Unit

Cardiac Catheterization Laboratory

Cardiac-Thoracic Surgery

Chemotherapy Services

Chiropractic Services

CT Scanner

Dental Services

Dietetic Services

Emergency Department (Dedicated)

Extracorporeal Shock Wave Lithotripter

Gerontological Specialty Services

ICU-Cardiac (non-surgical)

ICU-Medical/Surgical

ICU-Neonatal

ICU-Pediatric

ICU-Surgical

Laboratory-Clinical

Magnetic Resonance Imaging

(MRI)

Obstetric Services

Occupational Therapy Services

Operating Rooms

Ophthalmic Surgery

Optometric Services

Organ Transplant Services

(Non Medicare-certified)

Orthopedic Surgery

Outpatient Services

Pediatric Surgery

Pharmacy

Physical Therapy Services

Positron Emission Tomography Scan

Post-Operative Recovery Rooms

Psychiatric Services-Emergency

Psychiatric-Child/Adolescent

Psychiatric-Forensic

Psychiatric-Geriatric

Psychiatric-Adult Inpatient

Psychiatric-Outpatient

Radiology Services-Diagnostic

Radiology Services-Therapeutic

Reconstructive Surgery

Respiratory Care Services

Rehab Services – Inpatient

Rehab Service – Outpatient

Renal Dialysis (Acute Inpatient)

Social Services

Speech Pathology Services

Surgical Services-Inpatient

Surgical Services-Outpatient

Swing Bed Services

Trauma Center (Designated)

Transplant Center (Medicare Certified)

Urgent Care Center Services

FACILITY NAME:

10. Admission & Occupancy Data: (Use period from April 1 previous calendar year through March 31 current calendar year. Example of calculations are included in the license application instructions.)

a. Annual Admissions:      

b. Actual Total Patient Days of Care: (total daily census for the year)      

c. Available Total Patient Days of Care: (# of licensed beds X # of days in year)      

d. Occupancy Rate Percentage: (actual total patient days of care ÷ available total patient days of care)      

11. If you provide swing bed services, you must complete occupancy data on swing beds.

a. Annual Admissions:      

b. Actual Total Patient Days of Care: (total daily census for the year)      

c. Available Total Patient Days of Care: (# of licensed beds X # of days in year)      

d. Occupancy Rate Percentage: (actual total patient days of care ÷ available total patient days of care)      

12. Number of Ancillary Locations:      

13. In accordance with W.S. 35-2-910(c), does the Hospital provide for the review of professional practices in the

hospital for the purpose of reducing morbidity and mortality and for the improvement of the care of patients in the hospital? This review shall include but not be limited to:

(a)  The quality and necessity of the care provided to patients as rendered in the hospital;

(b) The prevention of complications and deaths occurring in the hospital;

(c)  The review of medical treatments and diagnostic and surgical procedures in order to ensure safe and adequate treatment of patients in the hospital; and

(d)  The evaluation of medical and health care services and the qualifications and professional competence of persons performing or seeking to perform those services.

The review shall be performed according to the decision of a hospital's governing board by:

(a)  A peer review committee appointed by the organized medical staff of the hospital;

(b)  A state, local or specialty medical society; or

(c)  Any other organization of physicians established pursuant to state or federal law and engaged by the hospital for the purposes of W.S. 35-2-910(c).

Yes No

14. Owner and Operator – Are the owners and operators the same as those listed on the current license?

Yes No

If no, complete the Initial or Change in Ownership License Application form.

FACILITY NAME:

SIGNATURE

I acknowledge the Wyoming Department of Health will be immediately contacted if there is a change in ownership, facility name, address or location, number of licensed beds, or services provided.  I further acknowledge the facility is responsible for admitting and retaining only those individuals who qualify for this category of healthcare facility as defined in the applicable rule and facility policies and procedures

The facility agrees to allow authorized representatives of the Wyoming Department of Health, upon presentation of proper identification, to enter the facility at any time without a warrant, provide access to any facility records and documentation as deemed necessary to ascertain compliance with State licensing laws and rules promulgated by the Wyoming Department of Health.  My signature legally binds the facility’s agreement to abide by the rules promulgated by the State of Wyoming for this category of healthcare facility and I do hereby verify the information provided on this application is true to the best of my knowledge and belief. 

 

Application must be signed.  This can be an Administrator/Director, CEO, CFO, Executive Director, or Owner. 

Signature: _____________________________________________________________________________________

Printed Name:      

Title:      

Date:      

|Submit application via Email to: |

|wdh-ohls@ |

PSYCHIATRIC HOSPITAL FACILITY

LICENSE APPLICATION INSTRUCTIONS

FOR ANNUAL RENEWAL

Important Information:

• The renewal application is a Word fillable form and must be used in print layout view. Tab through the application form to advance in the document.

• Each facility type must be submitted on the appropriate renewal application.

• Payment is still required to be in the form of a check make payable to: Treasurer, State of Wyoming.

o Please ensure the check clearly identifies the facility name in #1 of the renewal application in order for payment to be credited to the proper provider. Each renewal application requires a separate check.

• Renewal applications need to be submitted by Email to wdh-ohls@; submission of hard copies are not needed. When Emailing please use the following subject line:

License Renewal – ABC Care Center [facility name]

• Renewal applications can be signed by the Administrator/Director, CEO, CFO or an Owner.

• Submission of an original signature page is not needed.

For further questions regarding the renewal application process, contact HLS by sending a detailed email (include facility name and facility type) to: wdh-ohls@ or tammy.schmitt@

ADMISSION AND OCCUPANCY CALCULATIONS

|OCCUPANCY RATE % EXAMPLE |

|(April 1 – March 31) |

|x = Determine Actual Total Resident Days of Care |Add up the total daily census for the year. |

| |Apr 1 = 10; Apr 2 = 15; Apr 3 = 15, etc. TOTAL = x |

|y = Determine Available Total Residents Days of Care |Take the number of licensed beds X number of days in calendar year |

| |105 lic beds x 365 days = y (Remember leap year) |

|z = Determine Occupancy Rate Percentage |Actual Total Resident Days of Care ÷ Available Total Residents Days of Care |

| |x ÷ y = z |

|EXAMPLE: |x = 34,659 days (10+15+15+etc.) |

| |y = 38,325 days (105 x 365) |

| |z = 90% (34,659 ÷ 38,325) |

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