Hospital Certificate Of Approval Page 4
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18F-62092 (Rev. 07/08)
Page 4
Emergency services (organized)
Physical therapy services
Home care program
Post-operative recovery rooms
Hospice
Psychiatric services
Inpatient surgical services
Radiology services (diagnostic)
Intensive care unit
Radiology services (therapeutic)
Laboratory services (clinical)
Rehabilitation services
Laboratory services (anatomical)
Respiratory care services
Long term care unit
Self care unit
Neonatal nursery
Shock trauma
Nuclear medicine services
Social services
Obstetrics
Speech pathology services
Occupational therapy services
Other
(Specify.):
I. STAFFING
Indicate number of full-time (FT) and part-time (PT) employees. Attach additional pages, if necessary.
FT
PT
FT
PT
1. Chief Executive Officer
8. Pharmacy
*2. Nurse Administrator, RN
9. Dietary
*3. Nurse Supervisor
10. Laboratory
*4. Registered Staff Nurses
11. Housekeeping
*5. LPN Staff Nurses
12. Maintenance Personnel
6. Nurse Aides
13. Laundry Personnel
7. Medical Records
14. Other
(Specify.)
* Under 2, 3, 4, and 5, report only those registered or licensed nurses with a current registration or license number.
Report all other nurses under number 6.
II. PLANT DESCRIPTION AND SPACE USE
Not required for facilities that already have departmentally approved plans.
A. DESCRIPTION OF FACILITY [DHS 124.27, 42 CFR 485.623(a)]
Attach plans or drawings for each floor of the building occupied by the existing hospital and identify:
1. Life Safety Code Plans
(a) Exiting
(b) Fire barriers
(c) Smoke barriers
(d) Horizontal exits
(e) Exit passage ways
(f) Vertical shafts
(g) Linen and trash chutes, and
(h) Additional relevant information.
2. Building Information
(a) Construction type
(b) Age of existing building segments
(c) Additional relevant information
(d) Local zoning compliance statement
3.
Existing Space Description
(a) Current room/space use
(b) Identification of hazardous areas protected by rated fire resistive partitions
(c) Other relevant information.
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