Hospital Certificate Of Approval (Page 11 of 18) in pdf

Hospital Certificate Of Approval Page 11

F-62092 (Rev. 07/08)

Page 11

Has any adverse action initiated by a state or federal agency based on non compliance resulted in civil money

penalties (CMP), termination of provider agreement (TPA), suspension of payments (SOP), or the appointment of

temporary management of the facility (TMF)?

Yes

If “yes,” please complete the following table. Use abbreviations to describe the type of adverse action and refer to

G.1. (above) for abbreviations for type of health care provider.

Type of

Federal

Type of Health

Effective Dates of

Facility Name and Address

City and State

Adverse

or State

Care Provider

Adverse Action

Action

4. Has the applicant ever had a denial, suspension, enjoining, or revocation of a health care provider license, in this

state or any other state, as defined in Chapter 146.81, Wis. Stats., or any conviction for providing health care

without a license?

Yes

If “yes,” explain.

5. Has the applicant ever been convicted of a crime involving neglect or abuse of patients, or involved in assaultive

behavior, wanton disregard for the health and safety of others, or any act of elder abuse under Chapter 46.90,

Wis. Stats.?

Yes

If “yes,” explain.

Hospital Certificate Of Approval Page 11