Mont. Admin. r. 37.106.137

Current through Register Vol. 23, December 6, 2024

Rule 37.106.137 - ANNUAL OPERATIONAL REPORTS BY HOSPITALS AND CRITICAL ACCESS HOSPITALS

(1) Every hospital and critical access hospital shall submit an annual report to the department on a form provided by the department by the deadline specified on the form. The annual reports must be signed by the hospital administrator and must include whichever of the following information is requested on the form:

(a) whether the hospital has received accreditation, and if so, for what period;

(b) beginning and ending dates of the hospital's reporting period, and whether the facility has been in operation for 12 full months at the end of the most recent reporting period;

(c) a discussion of the organizational aspects of the facility, including the following information:

(i) the type of organization or entity responsible for the day-to-day operation of the hospital (e.g., state, county, city, federal, hospital district, church related, nonprofit corporation, individual, partnership, business corporation);

(ii) whether the controlling organization leases the physical plant from another organization, and if so, the name and type of organization that owns the plant;

(iii) any changes in the ownership, board of directors or articles of incorporation during the past year;

(iv) the name of the current chairman of the board of directors;

(v) if the controlling organization has placed responsibility for the administration of the hospital with another organization, the name and type of organization that manages the facility. A copy of the latest management agreement must be provided;

(vi) if the hospital is operated as a part of a multi-facility system (e.g., medical center, chain of hospitals owned by a religious order, etc.) the name and address of the parent organization;

(d) whether the hospital provides primarily general medical/surgical services, or specialty services (specify);

(e) specific facilities and services provided by the hospital, bed capacities for each service (where applicable) , and whether such services are provided full or part-time, by hospital personnel, or by contracting providers;

(f) newborn nursery statistics, including:

(i) number of bassinets set up and staffed;

(ii) total number of births;

(iii) total newborn days;

(iv) neonatal intensive care admissions and inpatient days;

(g) surgery statistics, including:

(i) number of inpatient and outpatient surgery suites;

(ii) number of inpatient and outpatient operations performed;

(iii) number of adult and pediatric open-heart surgical operations performed;

(iv) total adult and pediatric cardiac catheterization and intracardiac and/or coronary artery procedures;

(h) number of beds set up and staffed and total inpatient days (excluding newborns) in each basic inpatient service category;

(i) inpatient statistics, including:

(i) number of licensed hospital beds (excluding bassinets and long-term care beds);

(ii) number of admissions (excluding newborns);

(iii) number of discharges (including deaths);

(iv) number of deaths (excluding fetal deaths);

(v) census on last day of reporting period (excluding newborns);

(j) information on other services, including number of rooms or units, number of inpatient and outpatient procedures, and number of outpatient visits in at least the following areas:

(i) emergency room;

(ii) organized outpatient department;

(iii) x-ray, ultrasound, nuclear medicine, cobalt therapy, CT scans;

(iv) physical therapy;

(v) respiratory therapy;

(vi) renal dialysis;

(vii) other ancillary services;

(k) information on changes in total number of beds during the reporting period;

(l) whether there is a separate long-term care unit, and if so, how many beds;

(m) patient origin data, including every town of origin and number of discharges;

(n) total medicare and medicaid admissions and inpatient days;

(o) size of medical and non-medical staff, including number of active and consulting physicians, medical residents and trainees, registered and licensed professional or vocational nurses, and all other personnel;

(p) name of person to contact in the event the department has questions concerning the information provided in the annual report.

(2) Any facility failing to timely report such information to the department may be subject to corrective action.

Mont. Admin. r. 37.106.137

NEW, 1984 MAR p. 27, Eff. 1/13/84; AMD, 1996 MAR p. 1975, Eff. 7/19/96; TRANS, from DHES, 2002 MAR p. 185; AMD, 2022 MAR p. 57, Eff. 1/15/2022

AUTH: 2-4-201, 50-5-103, 50-5-302, MCA; IMP: 50-5-106, 50-5-302, MCA