Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.106 - HEALTH CARE FACILITIES › Subchapter 37.106.1 - Certificate of Need › Rule 37.106.137 - ANNUAL OPERATIONAL REPORTS BY HOSPITALS AND CRITICAL ACCESS HOSPITALS

Current through Register Vol. 13, July 5, 2024
(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.