Rural Emergency Hospital (REH) Licensure Application

REH License Year: January 1 – December 31


Important! Prior to completing this licensure application, providers are stongly advised to determine their Federal eligibility status by reading the following enrollment information and CMS conditions of participation for Rural Emergency Hospitals.


CMS Memo QSO-23-07-REH - Guidance for Rural Emergeny Hospital Provisions, Conversion Process and Condtions of Participation.


Also read the Minimum Standards of Operation For Mississippi Hospitals, Subchapter 85

Published February 13, 2023.


Effective January 1, 2023, hospitals that were Critical Access Hospitals (CAHs) or rural hospitals with not more than 50 beds, participating in Medicare, as of December 27, 2020, may submit an enrollment application to convert to and enroll in Medicare as a REH.


REHs are eligible to furnish emergency department services, observation care and, if elected by the REH, other specified outpatient medical and health services that do not exceed an annual per patient average length of stay of 24 hours.


REHs are not eligible to provide inpatient services with the exception of post-hospital extended care services furnished in a distinct part unit licensed as a skilled-nursing facility (SNF).


Pilot Freestanding Emergency Rooms and Freestanding Emergency Departments are not eligible to convert to a Rural Emergency Hospital.


License: No person or governmental unit shall establish, conduct, or maintain a hospital in this state without a license.


________________________________________________________________________________________________________________________________________



Documents needed to complete this application: (Upload documents at the end of this application)


  • Completed CMS Exhibit Model Attestation (included in CMS Memo QSO-23-07-REH)


  • Completed CMS Exhibit Model REH Action Plan (included in CMS Memo QSO-23-07-REH)


  • Copy of executed Transfer Agreement(s) with Level I and/or Level II trauma centers as required by 42 CFR § 485.538 Condition of Participation: Agreements.


  • List of Medical Staff members with current appointment / reappointment approval.


  • Attach one (1) true, signed and dated copy of the Bylaws, Rules, and Regulations of the Governing Authority of the hospital.


  • One (1) true, dated copy of Governing Body Minutes related to conversion to a Rural Emergency Hospital.


  • One (1) true, signed and dated copy of any management contract between the Governing Authority and/or owner(s) of the hospital, and the management contract entity, if applicable.


  • One (1) true, signed and dated copy of any Lease Agreement between the Governing Authority and/or Owner(s) of the hospital, and the LESSEE of the hospital, if applicable.


  • If the hospital is owned by an individual, a partnership, or an association, one (1) true, signed and dated copy of the legal instrument that is the legal basis for ownership and/or operation of the hospital to include names of person(s) responsiblke for organizing an entitiy to own and operatie a hospital, e.g., Partnership Agreement, Articles of Association, etc.


  • Upcoming Building / Renovation / Construction Plans


  • Current Emergency Operations Plan Approval Letter from the Mississippi Emergency Healthcare Coalition (MEHC).
 

Certificate of Need

NO Certificate of Need is Required to Convert to a Rural Emergency Hospital

 
 
mm/dd/yyyy
 

Converting to a REH from which facility type:

 
 

SECTION A: FACILITY INFORMATION

 
 

(Enter 6-digit CMS number with no dashes or spaces. e.g., 251XXX)

 
 
 
 
 
 

(If different from Street Address).

 
 
Phone
 
 
 
Phone
 
 

REPORTING PERIOD

 

Begining Date:

 
mm/dd/yyyy
 
 
mm/dd/yyyy
 
 
 
 
mm/dd/yyyy
 
 

OWNERSHIP

As authorized and requirod by SECTION 41-7-171 et seq., & 41-9-1 et seq,, Mississippi Code of 1972, as amended, application is made for license to operate a hospital under the name and at the address shown above. In support of this applioation, the following information and

assurances are given:

 

Select the ownership code of the hospital:

 
 
 
 
 
 
 

CONTROL

 
 
 
 
 
 
mm/dd/yyyy
 
 
mm/dd/yyyy
 
 
 
 
 

MANAGEMENT

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

ACCREDITATIONS AND CERTIFICATIONS

Q. Are REHs eligible to be deemed by a CMS-approved accreditation organization?


A. Yes, REHs are eligible to be deemed by Accrediting Organizations that have a Medicare-approved program for REHs.


As of January 2023, there are not yet any CMS-approved Accrediting Organizations for REHs.

 

Select all that apply"

 
 

Hospital Trustees (Governing Authority)

List all hospital trustees by name and place of residence. If additional entries need to be made, please add them to a document and attach it in the Additional Documents section.


Enter Name, Address, City, State, ZIP, and Telephone Number

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Hospital Organization

 
 
 
 
 
 
 
mm/dd/yyyy
 
 
mm/dd/yyyy
 
 
 

GOVERNING AUTHORITY BYLAWS

 
 
mm/dd/yyyy
 
 
mm/dd/yyyy
 
 
mm/dd/yyyy
 
 
mm/dd/yyyy
 
 

CONSTRUCTION AND FIRE SAFETY

 
 

Upload plans and other supporting documents at the bottom of this form if applicable:

 
 
 

Upload plans and other supporting documents at the bottom of this form if applicable:

 
 

Is the fire alarm system arranged to transmit an alarm automatically to the fire department legally committed to serve the area in which the health care facility is located, by the most direct and reliable method approved by local regulations? (NFPA 101 Section 9.6)

 
 
 
 
 

(NFPA 101 Section 10.2)

 
 
 

Number of hours generator can run with current fuel supply:

 

Mark all that apply:

 
 

Explain what part of the HVAC system actually runs on Generator Backup and what areas of the hospital have partial HVAC service while on generator power.

 
 
 
 
 
 
 
 

If YES, upload a copy at the end of this application. If NO, contact your MSDH Emergency Planner to request a copy.

 
 

MEDICAL STAFF

 
 
 
 
mm/dd/yyyy
 
 
mm/dd/yyyy
 
 
mm/dd/yyyy
 
 
mm/dd/yyyy
 

MEDICAL SPECIALTIES

Enter the NUMBER of Active Associate Medical Staff by specialty (Include Board Certified)

 

Enter the NUMBER of Active Associate Medical Staff by this specialty (Include Board Certified)

 

Enter the NUMBER of Active Associate Medical Staff by this specialty (Include Board Certified)

 

Enter the NUMBER of Active Associate Medical Staff by this specialty (Include Board Certified)

 

Enter the NUMBER of Active Associate Medical Staff by this specialty (Include Board Certified)

 

Enter the NUMBER of Active Associate Medical Staff by this specialty (Include Board Certified)

 

Enter the NUMBER of Active Associate Medical Staff by this specialty (Include Board Certified)

 

Enter the NUMBER of Active Associate Medical Staff by this specialty (Include Board Certified)

 

Enter the NUMBER of Active Associate Medical Staff by this specialty (Include Board Certified)

 

Enter the NUMBER of Active Associate Medical Staff by this specialty (Include Board Certified)

 

Enter the NUMBER of Active Associate Medical Staff by this specialty (Include Board Certified)

 

Enter the NUMBER of Active Associate Medical Staff by this specialty (Include Board Certified)

 

Enter the NUMBER of Active Associate Medical Staff by this specialty (Include Board Certified)

 

Enter the NUMBER of Active Associate Medical Staff by this specialty (Include Board Certified)

 

Enter the NUMBER of Active Associate Medical Staff by this specialty (Include Board Certified)

 

Enter the NUMBER of Active Associate Medical Staff by this specialty (Include Board Certified)

 

Enter the NUMBER of Active Associate Medical Staff by this specialty (Include Board Certified)

 

Enter the NUMBER of Active Associate Medical Staff by this specialty (Include Board Certified)

 

Enter the specialty type for surgeons, e.g., Emergency, Thoracic, General, Orthopedic, etc.

 
 

Other Medical Specialties - e.g., allergy, physical medicine, rehabilitation cardiovascular diseases, dermatology, gastroenterology, pulmonary diseases, nephrology and neurology.

 
 

How many practitioners with Active or Associate admitting privileges were added to the Hospital's medical staff during the reporting period?

 
 
 

Enter the total number of Medical Staff:

 

Enter the number of ACTIVE members:

 

Enter the number of ASSOCIATE members.

 

Enter the number of CONSULTING members:

 
 

PERSONNEL

Report the number of full-time and part-time personnel in the categories specified and as defined below who were on the hospital payroll as of September 30, 2022, EVEN IF YOUR REPORTING PERIOD ENDED ON A DIFFERENT DATE. Full-time personnel are those whose regularly scheduled work-week is 30 hours or more. Part-time personnel are those whose regularly scheduled work-week is less than 30 hours. Exclude private duty nurses, volunteers, and all personnel whose salary is financed entirely by outside research grants. Personnel who work in more than one area should be included only in the category of their primary responsibility and should be counted only once. Include trainees if on the hospital payroll as of September 30, 2022. Include members of religious orders for whom dollar equivalents were reported. If there are staff positions that are shared between the hospital and a nursing home that the hospital may operate (See instruction for K4b), please record these positions as part-time employees. Also, report the number of contracted consultants as of September 30, 2022 They are persons who provide services to your facility, are funded by your facility as contractors, and are not considered regular hospital employees. Include staff from contractual arrangements, nursing registries, temporary agencies, and so forth.

 

Full-time Employees (FT) (30 hours per week or more)

 

Part-Time Employees (PT) (less than 30 hours per week)

 

Full-time Employees (FT) (30 hours per week or more)

 

Part-Time Employees (PT) (less than 30 hours per week)

 

Full-time Employees (FT) (30 hours per week or more)

 

Part-Time Employees (PT) (less than 30 hours per week)

 

    Full-time Employees (FT) (30 hours per week or more)

 

Part-Time Employees (PT) (less than 30 hours per week)

 

Employees (FT) (30 hours per week or more)

 
 

Employees (FT) (30 hours per week or more)

 

Employees (PT) (less than 30 hours per week)

 

Ancillary Personnel. Persons who assist the nursing staff by performing routine duties in caring for patients under the direct supervision of a nurse, including nurses aides, orderlies, attendants, operating room technicians, and so forth.

 

Ancillary Personnel. Persons who assist the nursing staff by performing routine duties in caring for patients under the direct supervision of a nurse, including nurses aides, orderlies, attendants, operating room technicians, and so forth.

 

Full-time Employees (FT) (30 hours per week or more)

 

Part-Time Employees (PT) (less than 30 hours per week)

 

Contracted Consultants (CC)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

SERVICES PROVIDED

 

Select All That Apply

 

Do NOT enter outpatient services here.

 
 

OUTPATIENT SERVICES

The conversion of an eligible facility to an REH allows for the provision of emergency department services, observation care, and additional outpatient medical and health services, if elected by the REH, that do not exceed an annual per patient average length of stay of 24 hours. REHs are prohibited from providing inpatient services, except those furnished in a unit that is a distinct part licensed as a skilled nursing facility to furnish post-hospital extended care services.

 
 
 
 
 

MEDICARE CERTIFICATON OF DISTINCT PART UNITS

A unit designated as a certified distinct part unit (DPU) by the Centers of Medicare and Medicaid Services (CMS).


REHs are not eligible to provide inpatient services with the exception of post-hospital extended care services furnished in a distinct part unit licensed as a skilled-nursing facility (SNF)


eCFR §485.546 Skilled Nursing Facility Distinct Part Unit.

If the REH provides skilled nursing facility services in a distinct part unit, the services furnished by the distinct part unit must be separately licensed and certified and comply with the requirements of participation for long-term care facilities specified in part 483, subpart B.

 
 

CURRENT SKILLED NURSING FACILITY

Complete this section if your hospital currently has a Skilled Nursing Facility (SNF) Distinct Part Unit (DPU). Beds in this unit are licensed acute care bed that have been designated by a hospital to provide SNF services.


Account for all SNF beds set up and staffed for use at the end of the reporting period.


If your hospital does not currently provide SNF services, skip to the next section - Hospital Beds.

 
 
 
 
 
 
 

HOSPITAL BEDS

REHs are not eligible to provide inpatient services with the exception of post-hospital extended care services furnished in a distinct part unit licensed as a skilled-nursing facility (SNF).


All hospital beds not designated to a SNF DPU should be placed in abeyance. Contact the MSDH Office of Health Policy and Planning at (601) 576-7874.

 
 

FINANCES

Revenue

 

Net patient revenue - Reported at the estimated net realizable amounts from patient, third-party payors, and others for services rendered, including estimated retroactive adjustments reimbursement agreements with third-party payors.

 

Tax appropriations - A predetermined amount set aside by the government from its taxing authority to support the operation of the hospital.

 

Other operating revenue - Revenue from services other than health care provided to patients, as well as sales and services to nonpatients. Revenue that arises from the normal day-to-day operations from services other than health care provided to patients. Includes sales and services to nonpatients, and revenue from miscellaneous sources (rental of hospital space, sale of cafeteria meals, gift shop sales). Also include operating gains in this category.

 

Non-operating revenue - Includes investment income, extraordinary gains and other nonoperating gains.

 

Add (a-d) above and enter total:

 

Revenue by Type:

 

Total gross REH revenue - The hospitals full-established rates (charges) for all services rendered to patients utilizing Emergency Services.

 

Total gross outpatient revenue - The hospitals full-established rates (charges) for all services rendered to outpatients.

 

Total gross SNF Unit revenue - The hospitals full-established rates (charges) for all services rendered to patients in a SNF Distinct Part Unit. If No SNF Unit, enter 0

 

Total gross patient revenue - add total gross REH revenue, total gross outpatient revenue, and total gross SNF Unit revenue.

 

EXPENSES

 

Payroll expenses - Include payroll for all personnel including medical and dental residents/interns and trainees.

 

Non-operating revenue - Includes investment income, extraordinary gains and other nonoperating gains.

 

Depreciation expense (for reporting period only) - report only the depreciation expense applicable to the reporting period. The amount also should be included in accumulated depreciation (L5b).

 

Interest expense - Report interest expense for the reporting period only.

 

Supply expense - The net cost of all tangible items that are expensed including freight, standard distribution cost, and sales and use tax minus rebates. This would exclude labor, labor-related expenses and services as well as some tangible items that are frequently provided as part of labor costs.

 
 

Total expenses - Includes all payroll and non-payroll expenses as well as any nonoperating losses. Treat bad debt as a deduction from gross patient revenue and not as an expense.

 

Due to differing accounting standards in use, is bad debt is included in Total Expenses above?

 
 

Uncompensated Care & Provider Taxes

 

Bad debt expense - The provision for actual or expected uncollectibles resulting from the extension of credit. Report as a deduction from revenue.

 

(Revenue forgone at full-established rates. Include in gross revenue). Charity - for purposes of this survey, charity care is measured on the basis of revenue forgone, at full-established rates.

 
 

Medicaid Provider Tax, Fee or Assessment - Dollars paid as a result of a state law that authorizes collecting revenue from specified categories of providers. Federal matching funds may be received for the revenue collected from providers and some or all of the revenues may be returned directly or indirectly back to providers in the form of a Medicaid payment.

 
 

Mark all that apply:

 

REVENUE BY PAYOR

Report total facility gross and net figures

 

Fee for service patient revenue - Do not include Medicaid disproportionate payments

 
 

Add (1a + 1b)

 

Fee for service patient revenue - Do not include Medicaid disproportionate payments

 
 

Add (1c + 1d)

 
 
 
 

Add (2a + 2b)

 
 
 

Medicaid disproportionate share payments DSH minus associated provider taxes or assessments. Report in "Net" only.

 

Medicaid supplemental payments - Not including Medicaid DSH payments (these are supplemental payments the Medicaid program pays the hospital that are NOT Medicaid DSH) and minus associated provider taxes or assessments. Report "Net" only.

 

Add (2c + 2d + 2e + 2f)

 
 
 

NON GOVERNMENT REVENUE

 
 
 
 
 
 
 
 
 

Enter facility total GROSS Revenue (add all GROSS Sections above)

 

Enter facility total NET Revenue (Add all NET sections above)

 
 
 

FIXED ASSETS

 
 
 
 

Gross Square Footage - Include all inpatient, outpatient, office, and support space used for or in support of your health care activities..

 

TOTAL CAPITAL EXPENSES

Capital Expenses - Expenses used to acquire assets, including buildings, remodeling projects, equipment, or property.

 

Include all expenses used to acquire assets, including building, remodeling projects, equipment, or property

 

ENERGY CONSUMPTION

 
 
 

INFORMATION TECHNOLOGY

 

IT Operating expense - Exclude department depreciation and operating dollars paid against capital leases.

 

IT Capital expense - Include IT capital expense for the current year only. Any capital expense that is carried forward from the previous year should be excluded from this figure. Include IT related capital included in the budget of other departments. (I.e. lab, radiology, etc., if known or can be reasonably estimated.) Include the total value of capital leases to be signed in the current year.

 

Number of Employed IT staff (in FTEs). Number of full-time equivalent (FTE) staff employed in the IT department/organization and on the hospital payroll.

 

Total number of outsourced IT staff (in FTEs). I.e. contracted staff.

 

Electronic Health Record - An electronic health record (EHR) integrates electronically originated and maintained patient-level clinical health information, derived from multiple sources, into one point of access. An EHR replaces the paper medical record as the primary source of patient information.

 

* Note: To qualify as a meaningful user for Medicare and Medicaid, a hospital must:


1. possess EHR technology certified against all 24 objectives of meaningful use;


2. meet each of 14 "core" objectives of meaningful use, at least 1 public health objective, and at least 4 additional "menu set" objectives; and


3. report on each of 15 clinical quality measures generated directly from the certified EHR.


* Data will be treated as confidential and not released without written permission, except as required by appropriate state/metropolitan/regional association.

 
 

PRIVILEGED PHYSICIANS

Report the total number of physicians with privileges at your hospital by type of relationship with the hospital.

 

Emergency Medicine - Physicians who provide care in the emergency department.

 

Emergency Medicine - Physicians who provide care in the emergency department.

 

Primary Care - A physician that provides primary care services including general practice, general internal medicine, family practice, general pediatrics, obstetrics/gynecology and geriatrics.

 

Primary Care - A physician that provides primary care services including general practice, general internal medicine, family practice, general pediatrics, obstetrics/gynecology and geriatrics.

 

Radiologist - A physician who has specialized training in imaging, including but not limited to radiology, sonography, nuclear medicine, radiation therapy, CT, MRI.


Pathologist - A physician who examines samples of body tissues for diagnostic purposes.


Anesthesiologist - A physician who specializes in administering medications or other agents that prevent or relieve pain, especially during surgery.

 

Radiologist - A physician who has specialized training in imaging, including but not limited to radiology, sonography, nuclear medicine, radiation therapy, CT, MRI.


Pathologist - A physician who examines samples of body tissues for diagnostic purposes.


Anesthesiologist - A physician who specializes in administering medications or other agents that prevent or relieve pain, especially during surgery.

 

Other Specialist - Other physicians not included in the above categories that specialize in a specific type of medical care.

 

Other Specialist - Other physicians not included in the above categories that specialize in a specific type of medical care.

 

Add all employed physician types in this section

 

Add all cotract physician types in this section

 

ADVANCE PRACTICE REGISTERED NURSES / PHYSICAN ASSISTANTS

 

If "No" skip to Physican Assistant Section. If yes, please report the number of full time, part time, and FTE advanced practice nurses employed or contracted to provide care for patients in your hospital:

 
 
 
 
 

(Please check all that apply):

 

If "No" skip to next section. If yes, please report the number of full time, part time, and FTE Physican Assistants employed or contracted to provide care for patients in your hospital:

 
 
 
 
 

(Check all that apply)

 

SUPPLIMENTAL INFORMATION

 

Satellite Facility (ies). Services are available at a facility geographically remote from the hospital campus.

 
 

Upload any additional purchasing group organization information at the end of the is application.

 
 

Distributor - An entity that typically does not manufacture most of its own products but purchases and re-sells these products. Such a business usually maintains an inventory of products for sales to hospitals and physician offices and others.

 
 
 
 
 
 

(Check all that apply)

 

Enter other social media platforms or services used by your hospital that are not listed above.

 
 
 
 
 
 
 

CONTACT:

 

Name of person completing this application

 
 
 
Phone
 
 

COMPLETING THE APPLICATION PROCESS

Upon completing and submitting this application, you will receive an email from the MSDH Office of Health Facilities Licensure and Certification through DocuSign for your electronic signature. You will receive a copy of the signed application by email.


NO LICENSE FEE WILL BE ASSESSED FOR CONVERSION


For additional information or questions , please contact the MSDH Office of Licensure.


General Number: (601) 364-1100


License Administrator: (601) 364-2722


Fire Safety / Life Safety Code: (601) 364-1111


CLIA  (Laboratory): (601) 364-1115


Criminal History Record Check: (601) 364-1102


Acute Care Survey: (601) 364-2708


Long Term Care (SNF Unit Information): (601) 364-1110

 

Upload the followiing documents to complete your application. Failure to upload required documents may delay processing your application:




  • Copy of executed Transfer Agreement(s) with Level I and/or Level II trauma centers as required by 42 CFR § 485.538 Condition of Participation: Agreements.


  • List of Medical Staff members with current appointment / reappointment approval.


  • Attach one (1) true, signed and dated copy of the Bylaws, Rules, and Regulations of the Governing Authority of the hospital.


  • One (1) true, dated copy of Governing Body Minutes related to conversion to a Rural Emergency Hospital.


  • Attach one (1) true, signed and dated copy of any management contract between the Governing Authority and/or owner(s) of the hospital, and the management contract entity, if applicable.


  • Attach one (1) true, signed and dated copy of any Lease Agreement between the Governing Authority and/or Owner(s) of the hospital, and the LESSEE of the hospital, if applicable.


  • If the hospital is owned by an individual, a partnership, or an association, one (1) true, signed and dated copy of the legal instrument that is the legal basis for ownership and/or operation of the hospital to include names of person(s) responsiblke for organizing an entitiy to own and operatie a hospital, e.g., Partnership Agreement, Articles of Association, etc.


  • Upcoming Building / Renovation / Construction Plans


  • Current Emergency Operations Plan Approval Letter from the Mississippi Emergency Healthcare Coalition (MEHC).
Drop your files here