ࡱ> c 3 bjbjʉʉ  ffWSVV%%&&&4C&C&C&h&,LC&K^?_?_?_cc c$>jQ&c cccc%%?_?_:}}}c%R?_&?_}c}}p %"=?_0fghi%^N<o6==&Q8cc}cccccKvfccccccccccccccccV a$: North Carolina Department of Health and Human ServicesFor Official Use OnlyDivision of Health Service RegulationLicense # IF MERGEFIELD LICNO="" " ______________" MERGEFIELD LICNOH0019 ______________Medicare #  MERGEFIELD provnum Acute and Home Care Licensure and Certification SectionFID #: MERGEFIELD FIDRegular Mail: 1205 Umstead Drive 2712 Mail Service CenterPC ___________ Date _____________Raleigh, North Carolina 27699-2712Overnight UPS and FedEx only: 1205 Umstead DriveRaleigh, North Carolina 27603Telephone: (919) 855-4620 Fax: (919) 715-3073License Fee:  MERGEFIELD totlicfee  2020 HOSPITAL LICENSE RENEWAL APPLICATION Legal Identity of Applicant: MERGEFIELD LICENSEE (Full legal name of corporation, partnership, individual, or other legal entity owning the enterprise or service.) Doing Business As (d/b/a) name(s) under which the facility or services are advertised or presented to the public: PRIMARY: IF MERGEFIELD FACILITY="" "________________________________________________________________________" MERGEFIELD FACILITYAdventHealth Hendersonville________________________________________________________________________ Other: IF MERGEFIELD OBN1="" "________________________________________________________________________" MERGEFIELD OBN1Park Ridge Health________________________________________________________________________ Other: IF MERGEFIELD OBN2="" "________________________________________________________________________" MERGEFIELD OBN2Park Ridge Hospital________________________________________________________________________ Facility Mailing Address: IF MERGEFIELD FADDR1="" "Street/P.O. Box: ________________________________________________" MERGEFIELD FADDR1100 Hospital DriveStreet/P.O. Box: ________________________________________________  MERGEFIELD FADDR2 IF MERGEFIELD FCITY="" "City: ______________________" MERGEFIELD FCITYHendersonvilleCity: ______________________, IF MERGEFIELD FSTATE="" " State: ________" MERGEFIELD FSTATENC State: ________ IF MERGEFIELD FZIP="" " Zip: __________________________________________________" MERGEFIELD FZIP28792 Zip: __________________________________________________ Facility Site Address: IF MERGEFIELD SADDR="" "Street: ________________________________________________" MERGEFIELD SADDR100 Hospital DriveStreet: ________________________________________________IF MERGEFIELD SCITY="" "City: ______________________" MERGEFIELD SCITYHendersonvilleCity: ______________________, IF MERGEFIELD SSTATE="" " State: ________" MERGEFIELD SSTATENC State: ________ IF MERGEFIELD SZIP="" " Zip: ________" MERGEFIELD SZIP28792 Zip: ________County: MERGEFIELD FCOUNTYTelephone:IF MERGEFIELD FPHONE="" "(____) ___________" MERGEFIELD FPHONE(828)684-8501(____) ___________Fax:IF MERGEFIELD FFAX="" "(____) ___________" MERGEFIELD FFAX(828)687-0729(____) ___________ Administrator/Director: IF  MERGEFIELD ADMFULLNAM ="" "_____________________________________"  MERGEFIELD ADMFULLNAM Jimm Bunch_____________________________________ Title: IF  MERGEFIELD ADMPOSITIO="" "_____________________________________"  MERGEFIELD ADMPOSITIOCEO_____________________________________ (Designated agent (individual) responsible to the governing body (owner) for the management of the licensed facility) Chief Executive Officer: ____________________________________ Title: ________________________ (Designated agent (individual) responsible to the governing body (owner) for the management of the licensed facility) Name of the person to contact for any questions regarding this form: Name: _____________________________________________________ Telephone: ____________________ E-Mail:  IF  MERGEFIELD FEMAIL <> "" " MERGEFIELD FEMAIL " "______________________________________________________" ______________________________________________________ For questions regarding this page, please contact Azzie Conley at (919) 855-4646. In accordance with Session Law 2013-382 and 10A NCAC 13B .3502(e) on an annual basis, on the license renewal application provided by the Division, the facility shall provide to the Division the direct website address to the facilitys financial assistance policy. This Rule applies only to facilities required to file a Schedule H, federal form 990. Please use Form 990 Schedule B and/or Schedule H as a reference. Please provide the main website address for the facility: ______________________________________________________________________________ In accordance with 131E-214.4(a) DHSR can no longer post a link to internet Websites to demonstrate compliance with this statute. Please provide the website address and/or link to access the facilitys charity care policy and financial assistance policy: ______________________________________________________________________________________ Also, please attach a copy of the facilitys charity care policy and financial assistance policy: Feel free to email the copy of the facilitys charity care policy to: DHHS.DHSR.Hospital.CharityCare.Policy@dhhs.nc.gov. Please provide the following financial assistance data. All responses can be located on Form 990 and/or Form 990 Schedule H. Contribution, Gifts, Grants and other similar Amounts (Form 990; Part VIII 1(h))Annual Financial Assistance at Cost (Form 990; Schedule H Part I, 7(a)(c))Bad Debt Expense (Form 990; Schedule H Part III, Section A(2))Bad Debt Expense Attributable to Patients eligible under the organization's financial assistance policy (Form 990; Schedule H Part III, Section A(3)) AUTHENTICATING SIGNATURE: this attestation statement is to validate compliance with GS 131E-91 as evidenced through 10A NCAC 13B .3502 and all requirements set forth to assure compliance with fair billing and collection practices. Signature: ______________________________________________________Date:_________________________ Print Name of Approving Official: _______________________________________________________________ For questions regarding NPI contact Azzie Conley at (919) 855-4646. Primary National Provider Identifier (NPI) registered at NPPES __________________________________ If facility has more than one Primary NPI, please provide ______________________________________ List all campuses as defined in NCGS 131E-176(2c) under the hospital license. Please include offsite emergency departments  Name(s) of Campus: Address: Services Offered: Please attach a separate sheet for additional listings ITEMIZED CHARGES: Licensure Rule 10A NCAC 13B .3110 requires the Applicant to provide itemized billing. Indicate which method is used: _____a. The facility provides a detailed statement of charges to all patients. _____ b. Patients are advised that such detailed statements are available upon request. Ownership Disclosure (Please fill in any blanks and make changes where necessary). 1. What is the name of the legal entity with ownership responsibility and liability? Owner:IF MERGEFIELD OWNCONAME="" "_______________________________________________________" MERGEFIELD OWNCONAMEFletcher Hospital Inc_______________________________________________________Street/Box:IF MERGEFIELD OWNADDR1="" "_______________________________________________________" MERGEFIELD OWNADDR1100 Hospital Drive_______________________________________________________City: IF MERGEFIELD OWNCITY="" "___________________" MERGEFIELD OWNCITYHendersonville___________________ State: IF MERGEFIELD OWNSTATE="" "____" MERGEFIELD OWNSTATENC____ Zip: IF MERGEFIELD OWNZIP="" "____________" MERGEFIELD OWNZIP28792____________Telephone:IF MERGEFIELD OWNPHONE="" "(____) ___________" MERGEFIELD OWNPHONE(828)684-8501(____) ___________ Fax: IF MERGEFIELD OWNFAX="" "(____) ___________" MERGEFIELD OWNFAX(828)687-0729(____) ___________CEO:IF MERGEFIELD SROFFICER="" "_______________________________________________________" MERGEFIELD SROFFICERJimm Bunch, CEO_______________________________________________________ Is your facility part of a Health System? [i.e., are there other hospitals, offsite emergency departments, ambulatory surgical facilities, nursing homes, home health agencies, etc. owned by your hospital, a parent company or a related entity?] Yes No If Yes, name of Health System*: __________________________________________________ * (please attach a list of NC facilities that are part of your Health System) If Yes, name of CEO: ___________________________________________________________ a. Legal entity is: IF  MERGEFIELD ownnfprof  = "False" " X For Profit" " For Profit"  For Profit IF  MERGEFIELD ownnfprof  = "True" " X Not For Profit" " Not For Profit"  Not For Profit b. Legal entity is:IF MERGEFIELD OWNOWNTYPE="CORP" " X Corporation" " Corporation" Corporation IF MERGEFIELD OWNOWNTYPE="LLP" " X LLP" " LLP" LLPIF MERGEFIELD OWNOWNTYPE="PART" " X Partnership" " Partnership" PartnershipIF MERGEFIELD OWNOWNTYPE="PROP" " X Proprietorship" " Proprietorship" ProprietorshipIF MERGEFIELD OWNOWNTYPE="LLC" " X LLC" " LLC" LLCIF MERGEFIELD OWNOWNTYPE="GOVMT" " X Government Unit" " Government Unit" Government Unit c. Does the above entity (partnership, corporation, etc.) lease the building from which services are offered? IF  MERGEFIELD ownbldown ="" " Yes X No"" X Yes No" Yes _ No If "Yes", name of building owner:  MERGEFIELD ownbldown  2. Is the business operated under a management contract? IF MERGEFIELD MGMTCONAME="" " Yes X No" " X Yes No" Yes _ No If Yes, name and address of the management company. Name:IF MERGEFIELD MGMTCONAME="" "_________________________________________________________________________" MERGEFIELD MGMTCONAMEWake Forest Bajptist Medical Center_________________________________________________________________________Street/Box:IF MERGEFIELD MGMTADDR1="" "_________________________________________________________________________" MERGEFIELD MGMTADDR110th Fl, Janeway Business Developem_________________________________________________________________________ MERGEFIELD MGMTADDR2City:IF MERGEFIELD MGMTCITY="" "______________________" MERGEFIELD MGMTCITYWinston Salem______________________ State: IF MERGEFIELD MGMTSTATE="" "____________" MERGEFIELD MGMTSTATENC____________ Zip: IF MERGEFIELD MGMTZIP="" "____________" MERGEFIELD MGMTZIP27157____________Telephone:IF MERGEFIELD MGMTPHONE="" "(____) ___________" MERGEFIELD MGMTPHONE(704)355-2000(____) ___________ 3. Vice President of Nursing and Patient Care Services: IF MERGEFIELD VPNURSING="" "_______________________________________________________________________________" MERGEFIELD VPNURSINGError! MergeField was not found in header record of data source._______________________________________________________________________________ 4. Director of Planning: _______________________________________________________________ Facility Data A. Reporting Period. All responses should pertain to the period October 1, 2018 to September 30, 2019. B. General Information. (Please fill in any blanks and make changes where necessary.) For B and C, submit one record for the licensed hospital. DO NOT SUBMIT SEPARATE RECORDS FOR EACH CAMPUS. 1. Admissions to Licensed Acute Care Beds: include only admissions to beds in category D-1 (a q) on page 6; exclude responses in categories D-2 D-8 on page 6; exclude normal newborn bassinets; exclude swing bed admissions.2. Discharges from Licensed Acute Care Beds: include only discharges from beds in category D-1 (a q) on page 6; exclude responses in categories D-2 D-8 on page 6; exclude normal newborn bassinets; exclude swing bed admissions.3. Average Daily Census: include only admissions to beds in category D-1 (a q) on page 6; exclude responses in categories D-2-D-8 on page 6; exclude normal newborn bassinets; and exclude swing bed admissions.4. Was there a permanent change in the total number of licensed beds during the reporting period? Yes No If Yes, what was the number of licensed beds at the end of the reporting period? If Yes, please state reason(s) (such as additions, alterations, or conversions) which may have affected the change in bed complement:5. Observations: Number of patients in observation status and not admitted as inpatients, excluding Emergency Department patients.6. Number of unlicensed Observation Beds  Designation and Accreditation 1.Are you a designated trauma center?___Yes___No Designated Level #______2.Are you a critical access hospital (CAH)? ___Yes___No3.Are you a long term care hospital (LTCH)? ___Yes___No4.Is this facility TJC accredited?___Yes___No Expiration Date:____________5.Is this facility DNV accredited?___Yes___No Expiration Date:____________6.Is this facility AOA accredited?___Yes___No Expiration Date:____________7.Are you a Medicare deemed provider?___Yes___No D. Beds by Service (Inpatient Do Not Include Observation Beds or Days of Care) Please provide a Beds by Service (p. 6) for each hospital campus (see G.S. 131E-176(2c)) Please indicate below the number of beds usually assigned (set up and staffed for use) to each of the following services and the number of census inpatient days of care rendered in each unit. If your facility has a Nursing Facility unit and/or Adult Care Bed unit please complete the supplemental packet for Skilled Nursing Facility beds. Licensed Acute Care Beds Campus if multiple sites: ____________________________Licensed Beds as of 9/30/2019Operational Beds as of 9/30/2019Inpatient Days of CareIntensive Care Units1. General Acute Care Beds/Days a. Burn (for DRGs 927, 928, 929, 933, 934, and 935 only) b. Cardiac c. Cardiovascular Surgery d. Medical/Surgical e. Neonatal Beds Level IV* (Not Normal Newborn) f. Pediatric g. Respiratory Pulmonary h. Other (List)Other Units i. Gynecology j. Medical/Surgical (Exclude Skilled Nursing swing-beds) k. Neonatal Level III* (Not Normal Newborn) l. Neonatal Level II* (Not Normal Newborn) m. Obstetric (including LDRP) n. Oncology o. Orthopedics p. Pediatric q. Other, List: Total General Acute Care Beds/Days (a through q)MERGEFIELD HGENLIC2. Comprehensive In-Patient RehabilitationMERGEFIELD REHABHLIC3. Inpatient HospiceMERGEFIELD HOSLIC4. Substance Abuse / Chemical Dependency TreatmentMERGEFIELD SALIC5. PsychiatryMERGEFIELD PSYLIC6. Nursing FacilityMERGEFIELD NFTOTAL7. Adult Care HomeMERGEFIELD HATOTAL8. OtherMERGEFIELD OTHRHLIC9. Totals (1 through 8)MERGEFIELD TOTALBEDS *Neonatal service levels are defined in 10A NCAC 14C .1401. If this hospital is designated as a swing-bed hospital by Centers for Medicare & Medicaid Services (CMS): 10. Number of Swing Beds11. Number of Skilled Nursing days in Swing Beds Reimbursement Source. (For Inpatient Days, show Acute Inpatient Days only, excluding normal newborns.) Campus if multiple sites: _________________________________________________ Primary Payer SourceInpatient Days of Care (total should be the same as D.1.a q total on p. 6)Emergency Visits (total should be the same as F.3.b. on p. 8)Outpatient Visits (excluding Emergency Visits and Surgical Cases)Inpatient Surgical Cases (total should be same as 9.e. Total Surgical Cases-Inpatient Cases on p. 12)Ambulatory Surgical Cases (total should be same as 9.e. Total Surgical Cases-Ambulatory Cases on p. 12)Self PayCharity CareMedicare* Medicaid*Insurance*Other (Specify)TOTAL * Including any managed care plans. Services and Facilities 1.Obstetrics Number of Infantsa. Live births (Vaginal Deliveries)b. Live births (Cesarean Section)c. Stillbirths Number of Roomsd. Delivery Rooms - Delivery Only (not Cesarean Section)e. Delivery Rooms - Labor and Delivery, Recoveryf. Delivery Rooms LDRP (include in Item D.1.m on Page 6) g. Number of Normal Newborn Bassinets (Level I Neonatal Services) _______________ Do not include in section D. Beds by Service on Page 6 2. Abortion Services Number of procedures per Year _______________ (Feel free to footnote the type of abortion procedures reported) 3. Emergency Department Services Total Number of ED Exam Rooms: ______________. Of this total, how many are: a.1. # Trauma Rooms_________________ a.2. # Fast Track Rooms_______________ a.3. # Urgent Care Rooms______________ b. Total Number of ED visits for reporting period: ____________________ c. Total Number of admits from the ED for reporting period: __________________ d. Total Number of Urgent Care visits for reporting period: __________________ e. Does your ED provide services 24 hours a day 7 days per week? ____ Yes ____ No If no, specify days/hours of operation: _______________________________________________ _______________________________________________________________________________  f. Is a physician on duty in your ED 24 hours a day 7 days per week? ____ Yes ____ No If no, specify days/hours physician is on duty:  4. Medical Air Transport: Owned or leased air ambulance service: a. Does the facility operate an air ambulance service?___ Yes ___ Nob. If Yes, complete the following chart. Type of AircraftNumber of AircraftNumber OwnedNumber LeasedNumber of TransportsRotaryFixed Wing 5. Pathology and Medical Lab (Check whether or not service is provided) a. Blood Bank/Transfusion Services ___ Yes ___ Nob. Histopathology Laboratory ___ Yes ___ Noc. HIV Laboratory Testing ___ Yes ___ No Number during reporting period HIV Serology ____________ HIV Culture ____________d. Organ Bank ___ Yes ___ Noe. Pap Smear Screening___ Yes ___ No 6. Transplantation Services - Number of transplants TypeNumberTypeNumberTypeNumbera. Bone Marrow-Allogeneicf. Kidney/Liverk. Lungb. Bone Marrow-Autologousg. Liverl. Pancreasc. Corneah. Heart/Liverm. Pancreas/Kidneyd. Hearti. Heart/Kidneyn. Pancreas/Livere. Heart/Lungj. Kidneyo. Other Do you perform living donor transplants? ____ Yes ____ No 7. Telehealth/Telemedicine* Check the appropriate box for each service this facility provides or receives via telehealth/telemedicine. A service may apply to more than one category. Check all that applyServiceProvide service to other facilities via telemedicineReceive service from other facilities via telemedicineEmergency Department ((Imaging ((Psychiatric ((Alcohol and/or substance use disorder (other than tobacco) services((Stroke((Other services(( * Telehealth/telemedicine is defined by the U.S. Health Resources & Services administration as the use of electronic information and telecommunication technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health, and health administration. Technologies include video conferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications. 8. Specialized Cardiac Services (for questions, call Healthcare Planning at 919-855-3865) a. Open Heart Surgery Open Heart SurgeryNumber of Machines/ProceduresNumber of Heart-Lung Bypass Machines Total Annual Number of Open Heart Surgery Procedures Utilizing Heart-Lung Bypass MachineTotal Annual Number of Open Heart Surgery Procedures done without utilizing a Heart-Lung Bypass MachineTotal Open Heart Surgery Procedures (2. + 3.) 8. Specialized Cardiac Services continued (for questions, call Healthcare Planning at 919-855-3865) b. Cardiac Catheterization and Electrophysiology Cardiac Catheterization, as defined in NCGS 131E-176(2g) Diagnostic Cardiac Catheterization**Interventional Cardiac Catheterization*** Number of Units of Fixed Equipment Number of Procedures* Performed in Fixed Units on Patients Age 14 and youngerNumber of Procedures* Performed in Fixed Units on Patients Age 15 and older Number of Procedures* Performed in Mobile UnitsDedicated Electrophysiology (EP) EquipmentNumber of Units of Fixed EquipmentNumber of Procedures on Dedicated EP Equipment *A procedure is defined as one visit or trip by a patient to a catheterization laboratory for a single or multiple catheterizations. Count each visit only once, regardless of the number of diagnostic, interventional, and/or EP catheterizations performed during that visit. For example, if a patient has both a diagnostic and an interventional procedure in one visit, count it as one interventional procedure. ** a cardiac catheterization procedure performed for the purpose of detecting and identifying defects or diseases in the coronary arteries or veins of the heart, or abnormalities in the heart structure, but not the pulmonary artery. 10A NCAC 14C .1601(9) *** a cardiac catheterization procedure performed for the purpose of treating or resolving anatomical or physiological conditions which have been determined to exist in the heart or coronary arteries or veins of the heart, but not the pulmonary artery. 10A NCAC 14C .1601(16) Number of fixed or mobile units of grandfathered cardiac catheterization equipment owned by hospital (i.e., equipment obtained before a CON was required): ______________ For questions, please contact Healthcare Planning and Certificate of Need at 919-855-3873. CON Project ID numbers for all non-grandfathered fixed or mobile units of cardiac catheterization equipment owned by hospital: ____________________________________________________________________________________________ ____________________________________________________________________________________________ Name of Mobile Vendor, if not owned by hospital: ______________________________________________ Number of 8-hour days per week the mobile unit is onsite: ______________8-hour days per week. (Examples: Monday through Friday for 8 hours per day is 5 8-hour days per week. Monday, Wednesday, & Friday for 4 hours per day is 1.5 8-hour days per week) 9. Surgical Operating Rooms, Procedure Rooms, Gastrointestinal Endoscopy Rooms, Surgical and Non-Surgical Cases and Procedures NOTE: If this License includes more than one campus, please copy pages 11-13 (through Section 9-g) for each site. Submit the Cumulative Totals and submit a duplicate of pages 11-13 for each campus. Campus if multiple sites: _________________________________________________ Surgical Operating Rooms A Surgical Operating Room is defined as a room used for the performance of surgical procedures requiring one or more incisions and that is required to comply with all applicable licensure codes and standards for an operating room (G.S. 131E-146(1c)). These surgical operating rooms include rooms located in both Obstetrics and surgical suites. Type of RoomNumber of RoomsDedicated Open Heart Surgery Dedicated C-SectionOther Dedicated Inpatient Surgery (Do not include dedicated Open Heart or C-Section rooms)Dedicated Ambulatory SurgeryShared - Inpatient / Ambulatory SurgeryTotal of Surgical Operating Rooms Of the Total of Surgical Operating Rooms, above, how many are equipped with advanced medical imaging devices (excluding mobile C-arms) or radiation equipment for the performance of endovascular, cardiovascular, neuro-interventional procedures, and/or intraoperative cancer treatments? Your facility may or may not refer to such rooms as hybrid ORs. Gastrointestinal Endoscopy Rooms, Procedures, and Cases Report the number of Gastrointestinal Endoscopy rooms and the Endoscopy cases and procedures performed during the reporting period, in GI Endoscopy Rooms and in any other location. Total Number of Licensed Gastrointestinal Endoscopy Rooms: __________________ GI Endoscopies*PROCEDURESCASESTOTAL CASESInpatientOutpatientInpatientOutpatientPerformed in Licensed GI Endoscopy RoomsNOT Performed in Licensed GI Endoscopy RoomsTOTAL CASES must match total reported on Page 27 (Patient Origin GI Endoscopy Cases) (*As defined in 10A NCAC 14C .3901 Gastrointestinal (GI) endoscopy procedure means a single procedure, identified by CPT code or [ICD-10-PCS] procedure code, performed on a patient during a single visit to the facility for diagnostic or therapeutic purposes. Procedure Rooms (Excluding Operating Rooms and Gastrointestinal Endoscopy Rooms) Report rooms, which are not licensed as operating rooms or GI endoscopy rooms, but that are used for performance of surgical procedures other than Gastrointestinal Endoscopy procedures. Total Number of Procedure Rooms: ___________________ Campus if multiple sites: _________________________________________________ Non-Surgical Cases by Category Enter the number of non-surgical cases by category in the table below. Count each patient undergoing a procedure or procedures as one case regardless of the number of non-surgical procedures performed. Categorize each case into one non-surgical category the total number of non-surgical cases is an unduplicated count of non-surgical cases. Count all non-surgical cases, including cases receiving services in operating rooms or in any other location. Non-Surgical CategoryInpatient CasesAmbulatory CasesEndoscopies OTHER THAN GI Endoscopies Performed in Licensed GI Endoscopy Rooms NOT Performed in Licensed GI Endoscopy RoomsOther Non-Surgical CasesPain ManagementCystoscopyYAG LaserOther (specify) Surgical Cases by Specialty Area Enter the number of surgical cases performed in licensed operating rooms only, by surgical specialty area. Count each patient undergoing surgery as one case regardless of the number of surgical procedures performed while the patient was having surgery. Categorize each case into one specialty area the total number of surgical cases is an unduplicated count of surgical cases. Count all surgical cases performed only in licensed operating rooms. The total number of surgical cases should match the total number of patients listed in the Patient Origin Tables on pages 28 and 29. Surgical Specialty AreaInpatient CasesAmbulatory CasesCardiothoracic (excluding Open Heart Surgery) Open Heart Surgery (from 8.(a) 4. on page 9)General SurgeryNeurosurgeryObstetrics and GYN (excluding C-Sections) OphthalmologyOral Surgery/DentalOrthopedicsOtolaryngologyPlastic SurgeryPodiatryUrologyVascularOther Surgeries (specify)Number of C-Sections Performed in Dedicated C-Section ORs Number of C-Sections Performed in Other ORsTotal Surgical Cases Performed Only in Licensed ORs Number of surgical procedures performed in unlicensed Procedure Rooms: _____________ Campus if multiple sites: _________________________________________________ For questions regarding this page, please contact Healthcare Planning at 919-855-3865. g. Average Operating Room Availability and Average Case Times Based on your facilitys experience, please complete the table below by showing the averages for all licensed operating rooms in your facility. Healthcare Planning uses this data in the operating room need methodology. Average case times should be calculated, not estimated. When reporting case times, be sure to include set-up and clean-up times. Average Hours per Day Routinely Scheduled for Use Per Room*Average Number of Days per Year Routinely Scheduled for UseAverage Case Time ** in Minutes for Inpatient CasesAverage Case Time ** in Minutes for Ambulatory Cases * Use only Hours per Day routinely scheduled when determining the answer. Example: A facility has 3 ORs: 2 are routinely scheduled for use 8 hours per day, and 1 is routinely scheduled for use 9 hours per day. 2 rooms x 8 hours = 16 hours 1 room x 9 hours = 9 hours Total hours per day 25 hours 25 hours divided by 3 ORs = 8.3 Average Hours per day Routinely Scheduled for Use Per Room ** Case Time = Time from Room Set-up Start to Room Clean-up Finish. Definition 2.4 from the Procedural Times Glossary of the AACD, as approved by ASA, ACS, and AORN. NOTE: This definition includes all of the time for which a given procedure requires an OR. It allows for the different duration of Room Set-up and Room Clean-up Times that occur because of the varying supply and equipment needs for a particular procedure. For questions regarding this page, please contact Healthcare Planning at 919-855-3865. Definition of Health System for Operating Room Need Determination Methodology Submit one record for the licensed hospital. DO NOT SUBMIT SEPARATE RECORDS FOR EACH CAMPUS. The Operating Room need determination methodology uses the following definition of health system that differs from the definition on page 4 of the License Renewal Application. (Note that for most facilities, the health system entered here will be the same health system entered on page 4, but it may not be. Please read this definition carefully.) A health system includes all licensed health service facilities located in the same county that are owned or leased by: the same legal entity (i.e., the same individual, trust or estate, partnership, corporation, hospital authority, or the State or political subdivision, agency or instrumentality of the State); or the same parent corporation or holding company; or a subsidiary of the same parent corporation or holding company; or a joint venture in which the same parent, holding company, or a subsidiary of the same parent or holding company is a participant and has the authority to propose changes in the location or number of ORs in the health service facility. A health system consists of one or more health service facilities. Based on the above definition, is this facility in a health system? ______ Yes ______ No If so, name of health system: _________________________________________________________________ 20 Most Common Outpatient Surgical Cases - Enter the number of surgical cases performed only in licensed operating rooms and / or licensed endoscopy room by the top 20 most common outpatient surgical cases in the table below by CPT code. Count each patient undergoing surgery as one case regardless of the number of surgical procedures performed while the patient was having surgery. Submit one record for the licensed hospital. DO NOT SUBMIT SEPARATE RECORDS FOR EACH CAMPUS. CPT CodeDescriptionCases29827Arthroscopy, shoulder, surgical; with rotator cuff repair29880Arthroscopy, knee, surgical; with meniscectomy (medial and lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed29881Arthroscopy, knee, surgical; with meniscectomy (medial or lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed42820Tonsillectomy and adenoidectomy; younger than age 1242830Adenoidectomy, primary; younger than age 1243235Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)43239Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple43248Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with insertion of guide wire followed by dilation of esophagus over guide wire43249Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with balloon dilation of esophagus (less than 30 mm diameter)45378Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure)45380Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple45384Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery45385Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique62311Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal)64483Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or computed tomography); lumbar or sacral, single level64721Neuroplasty and/or transposition; median nerve at carpal tunnel66821Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (e.g., YAG laser) (one or more stages)66982Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage66984Extracapsular cataract removal with insertion of intraocular lens prosthesis (stage one procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification)69436Tympanostomy (requiring insertion of ventilating tube), general anesthesia 10. Imaging Procedures a. 20 Most Common Outpatient Imaging Procedures Enter the number of the top 20 common imaging procedures performed in the ambulatory setting or outpatient department in the table below by CPT code. Submit one record for the licensed hospital. DO NOT SUBMIT SEPARATE RECORDS FOR EACH CAMPUS. CPT CodeDescriptionProcedures70450Computed tomography, head or brain; without contrast material70486Computed tomography, facial bone; without contrast material70551Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material 70553Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material followed by contrast material(s) and further sequences71020Radiologic examination, chest; two views, frontal and lateral71250Computed tomography, thorax; without contrast material(s)71260Computed tomography, thorax; with contrast material(s)71275Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing72100Radiologic examination, spine, lumbosacral; two or three views72110Radiologic examination, spine, lumbosacral; minimum of four views72125Computed tomography, cervical spine; without contrast material72141Magnetic resonance (e.g., proton) imaging, spine cervical without contrast material 72148Magnetic resonance (e.g., proton) imaging, spine lumbar without contrast material 73221Magnetic resonance (e.g., proton) imaging, upper joint (e.g. shoulder, elbow, wrist) extremity without contrast material 73630Radiologic examination, foot; complete, minimum of three views73721Magnetic resonance (e.g., proton) imaging, lower joint (e.g. knee, ankle, mid-hind foot, hip) extremity without contrast material74000Radiologic examination, abdomen; single anteroposterior view74176Computed tomography, abdomen and pelvis; without contrast material74177Computed tomography, abdomen and pelvis; with contrast material(s)74178Computed tomography, abdomen and pelvis; with contrast material(s) followed by contrast material  Instructions for Hospitals with multiple campuses: For MRI Services, (Sections 10b-10e, pp 17-18), do not provide cumulative/combined data for all campuses. Provide data for individual campuses only. b. MRI Procedures Indicate the number of procedures performed on MRI scanners (units) operated during the 12-month reporting period at your facility. For hospitals that use equipment at multiple sites/campuses, please copy the MRI pages and provide separate data for each site/campus. Campus if multiple sites: ___________________________ ProceduresInpatient Procedures*Outpatient Procedures* TOTAL ProceduresWith Contrast or SedationWithout Contrast or SedationTOTAL InpatientWith Contrast or SedationWithout Contrast or SedationTOTAL OutpatientFixedMobile (performed only at this site )TOTAL*** An MRI procedure is defined as a single discrete MRI study of one patient (single CPT-coded procedure). An MRI study means one or more scans relative to a single diagnosis or symptom. ** Totals must be greater than or equal to the totals in the MRI Patient Origin Table on page 30 of this application. Note: Healthcare Planning and Certificate of Need may request CPT codes for MRI procedures if further clarification is needed. c. Fixed MRI Scanners Indicate the number of MRI scanners (units) operated during the 12-month reporting period at your facility. For hospitals that operate medical equipment at multiple sites/campuses, please copy the MRI pages and provide separate data for each site/campus. Campus if multiple sites: ______________________________ Fixed ScannersNumber of UnitsNumber of fixed MRI scanners-closed, including open-bore scanners (do not include any Policy AC-3 scanners)Number of fixed MRI scanners-open (do not include any Policy AC-3 scanners)Number of Policy AC-3 MRI scanners used for general clinical purposesTotal Fixed MRI Scanners Number of grandfathered fixed MRI scanners on this campus: ___________ For questions, please contact Healthcare Planning and Certificate of Need at 919-855-3873. CON Project ID numbers for all other fixed MRI scanners on this campus: ______________________________________ ___________________________________________________________________________________________ d. Mobile MRI Services Campus if multiple sites: ___________________________________ During the reporting period, Did the facility own one or more mobile MRI scanners? ____ Yes ____ No If Yes, how many? ________ Of these, how many are grandfathered? _______ CON Project ID numbers for non-grandfathered mobile scanners owned by facility: ________________________________________________________________________ Did the facility contract for mobile MRI services? ____ Yes ____ No If Yes, name of mobile vendor: ___________________________________________________ e. Other MRI Patients served on units listed in the next table should not be included in the MRI Patient Origin Table on page 30 of this application. For hospitals that operate medical equipment at multiple sites/campuses, please copy the MRI pages and provide separate data for each site/campus. Campus if multiple sites: ______________________________________________ Other ScannersUnitsInpatient Procedures*Outpatient Procedures* TOTAL ProceduresWith Contrast or SedationWithout Contrast or SedationTOTAL InpatientWith Contrast or SedationWithout Contrast or SedationTOTAL OutpatientOther Human Research MRI scannersIntraoperative MRI (iMRI)* An MRI procedure is defined as a single discrete MRI study of one patient (single CPT coded procedure). An MRI study means one or more scans relative to a single diagnosis or symptom. f. Computed Tomography (CT). Campus if multiple sites: _______________________________ How many fixed CT scanners does the hospital have? _______________ Does the hospital contract for mobile CT scanner services? ____ Yes ____ No If yes, identify the mobile CT vendor ________________________________ Complete the following table for fixed and mobile CT scanners. Type of CT ScanFIXED CT Scanner # of ScansMOBILE CT Scanner # of Scans1Head without contrast2Head with contrast3Head without and with contrast4Body without contrast5Body with contrast6Body without contrast and with contrast7Biopsy in addition to body scan with or without contrast8Abscess drainage in addition to body scan with or without contrastTotal g. Positron Emission Tomography (PET). Campus if multiple sites: _______________________ Number of UnitsNumber of Procedures*InpatientOutpatientTotalDedicated Fixed PET ScannerMobile PET ScannerPET pursuant to Policy AC-3Other PET Scanners used for Human Research only* PET procedure means a single discrete study of one patient involving one or more PET scans. PET scan means an image-scanning sequence derived from a single administration of a PET radiopharmaceutical, equated with a single injection of the tracer. One or more PET scans comprise a PET procedure. The number of PET procedures in this table should match the number of patients reported on the PET Patient Origin Table on page 31. For questions, please contact Healthcare Planning and Certificate of Need at 919-855-3873. CON Project ID numbers for all non-grandfathered fixed PET scanners on this campus: ____________________ _________________________________________________________________________________________ Does the hospital own a mobile PET scanner that performed procedures on this campus? ____ Yes ____ No If Yes, enter the CON Project ID number(s) for the mobile scanner(s): ____________________________ If No, name of Mobile PET Provider, if any: _________________________________________________ h. Other Imaging Equipment. Campus if multiple sites: ________________________________ Number of UnitsNumber of ProceduresInpatientOutpatientTotalUltrasound equipmentMammography equipmentBone Density EquipmentFixed X-ray Equipment (excluding fluoroscopic)Fixed Fluoroscopic X-ray EquipmentSpecial Procedures/ Angiography Equipment (neuro & vascular, but not including cardiac cath.)Coincidence CameraMobile Coincidence Camera. Vendor:SPECT Mobile SPECT. Vendor:Gamma CameraMobile Gamma Camera. Vendor:Proton Therapy equipment i. Lithotripsy. Campus if multiple sites: ______________________________________________ Number of UnitsNumber of ProceduresLithotripsy Vendor/OwnerInpatientOutpatientTotalFixedMobile 11. Linear Accelerator Treatment Data (including Cyberknife & Similar Equipment) Campus if multiple sites: ___________________________________ CPT CodeDescription# of ProceduresSimple Treatment Delivery77401Radiation treatment delivery77402Radiation treatment delivery (<=5 MeV)77403Radiation treatment delivery (6-10 MeV)77404Radiation treatment delivery (11-19 MeV)77406Radiation treatment delivery (>=20 MeV)Intermediate Treatment Delivery77407Radiation treatment delivery (<=5 MeV)77408Radiation treatment delivery (6-10 MeV)77409Radiation treatment delivery (11-19 MeV)77411Radiation treatment delivery (>=20 MeV)Complex Treatment Delivery77412Radiation treatment delivery (<=5 MeV)77413Radiation treatment delivery (6-10 MeV)77414Radiation treatment delivery (11-19 MeV)77416Radiation treatment delivery (>= 20 MeV)Other Treatment Delivery Not Included Above77418Intensity modulated radiation treatment (IMRT) delivery and/or CPT codes 77385 and/or 77386 and/or G601577372Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session~ linear accelerator77373Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractionsG0339(Image-guided) robotic linear accelerator-based stereotactic radiosurgery in one session or first fractionG0340(Image-guided) robotic linear accelerator-based stereotactic radiosurgery, fractionated treatment, 2nd-5th fractionIntraoperative radiation therapy (conducted by bringing the anesthetized patient down to the LINAC)Pediatric Patient under anesthesiaLimb salvage irradiationHemibody irradiationTotal body irradiationImaging Procedures Not Included Above77417Additional field check radiographsTotal Procedures Linear AcceleratorsGamma Knife Procedures77371Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of one session~ multisource Cobalt 60 based (Gamma Knife)Total Procedures  Gamma Knife 11. Linear Accelerator Treatment Data continued Campus  if multiple sites: ___________________________________ a. Number of patients who received a course of radiation oncology treatments on linear accelerators (not the Gamma Knife). Patients shall be counted once if they receive one course of treatment and more if they receive additional courses of treatment. For example, one patient who receives one course of treatment counts as one, and one patient who receives three courses of treatment counts as three Number of Patients ________ (This number should match the number of patients reported in the Linear Accelerator Patient Origin Table on page 32.) b. TOTAL number of Linear Accelerators: ________ Of the TOTAL above, Number of Linear Accelerators configured for stereotactic radiosurgery: ________ Number of CyberKnife Systems: ________ Number of other specialized linear accelerators: ________ c. Number of Gamma Knife units ________ d. Number of treatment simulators ________ (machine that produces high quality diagnostic radiographs and precisely reproduces the geometric relationships of megavoltage radiation therapy equipment to the patient.(GS 131E-176(24b))) e. Number of grandfathered Linear Accelerators ________ For questions, please contact Healthcare Planning and Certificate of Need at 919-855-3873. f. CON Project ID numbers for all non-grandfathered Linear Accelerators: ___________________________ ________________________________________________________________________________________ 12. Additional Services: Submit one record for the licensed hospital. DO NOT SUBMIT SEPARATE RECORDS FOR EACH CAMPUS. a. Check each Service provided: (for dialysis stations, show number of stations) 1. Cardiac Rehab Program (Outpatient)(5. Rehabilitation Outpatient Unit(2. Chemotherapy(6. Podiatric Services(3. Clinical Psychology Services(7. Genetic Counseling Service (4. Dental Services(8. Inpatient Dialysis Services ( If number 8 is checked, enter number of dialysis stations: __________ b. Hospice Inpatient Unit Data: Hospital-based hospice units with licensed hospice beds. List each county served and report all patients by county of residence. Use each patient's age on the admission day to the Licensed Hospice Inpatient Unit. For age categories count each inpatient client only once. County of Residence Age 0-17 Age 18-40  Age 41-59  Age 60-64  Age 65-74  Age 75-84  Age 85+  Total Patients Served Total Days of Care  DeathsOut of StateTotal All Ages c. Psychiatric and Substance Use Disorder Units If the psychiatric unit has a different name from the hospital, please indicate: ___________________________________________________________ If address is different from the hospital, please indicate: ____________________________________________________________ 3. Director of the above services. ____________________________________________________________ Indicate the Location of Services in the Service Categories charts below. If it is in the hospital, include the room number(s). If it is located at another site, include the building name, program/unit name and address. Service Categories: All applicants must complete the following table for all mental health services which are to be provided by the facility. If the service is not offered, leave the spaces blank. Psychiatric Services Rule 10A NCAC 27G Licensure Rules for Mental Health Facilities Location of ServicesBeds Assigned by Age< 66-1213-17Total 0-1718 & upTotal Beds.1100 Partial hospitalization for individuals who are acutely mentally ill..1200 Psychosocial rehabilitation facilities for individuals with severe and persistent mental illness.1300 Residential treatment facilities for children and adolescents who are emotionally disturbed or have a mental illness.1400 Day treatment for children and adolescents with emotional or behavioral disturbances.1500 Intensive residential treatment facilities for children & adolescents who are emotionally disturbed or who have a mental illness.5000 Facility Based Crisis Center Rule 10A NCAC 13B Licensure Rules Mental Health Location of ServicesBeds Assigned by Age< 66-1213-17Total 0-1718 & upTotal Beds.5200 Dedicated inpatient unit for individuals who have mental disorders Substance Use Disorder Services Rule 10A NCAC 27G Licensure Rules for Substance Abuse Facilities Location of ServicesBeds Assigned by Age< 66-1213-17Total 0-1718 & upTotal Beds.3100 Nonhospital medical detoxification for individuals who are substance abusers.3200 Social setting detoxification for substance abusers.3300 Outpatient detoxification for substance abusers.3400 Residential treatment/ rehabilitation for individuals with substance abuse disorders .3500 Outpatient facilities for individuals with substance abuse disorders.3600 Outpatient narcotic addiction treatment.3700 Day treatment facilities for individuals with substance abuse disorders Rule 10A NCAC 13B Licensure Rules for Hospitals Location of ServicesBeds Assigned by Age< 66-1213-17Total 0-1718 & upTotal Beds.5200 Dedicated inpatient hospital unit for individuals who have substance use disorders  Patient Origin - General Acute Care Inpatient Services In an effort to document patterns of utilization of General Acute Care Inpatient Services in North Carolina hospitals, please provide the county of residence for each patient admission to your facility. Submit one record for the licensed hospital. DO NOT SUBMIT SEPARATE RECORDS FOR EACH CAMPUS. Must match number of admissions on page 5, Section B-1. CountyNo. of AdmissionsCountyNo. of AdmissionsCountyNo. of Admissions 1. Alamance 37. Gates 73. Person 2. Alexander 38. Graham 74. Pitt 3. Alleghany 39. Granville 75. Polk 4. Anson 40. Greene 76. Randolph 5. Ashe 41. Guilford 77. Richmond 6. Avery 42. Halifax 78. Robeson 7. Beaufort 43. Harnett 79. Rockingham 8. Bertie 44. Haywood 80. Rowan 9. Bladen 45. Henderson 81. Rutherford 10. Brunswick 46. Hertford 82. Sampson 11. Buncombe 47. Hoke 83. Scotland 12. Burke 48. Hyde 84. Stanly 13. Cabarrus 49. Iredell 85. Stokes 14. Caldwell 50. Jackson 86. Surry 15. Camden 51. Johnston 87. Swain 16. Carteret 52. Jones 88. Transylvania 17. Caswell 53. Lee 89. Tyrrell 18. Catawba 54. Lenoir 90. Union 19. Chatham 55. Lincoln 91. Vance 20. Cherokee 56. Macon 92. Wake 21. Chowan 57. Madison 93. Warren 22. Clay 58. Martin 94. Washington 23. Cleveland 59. McDowell 95. Watauga 24. Columbus 60. Mecklenburg 96. Wayne 25. Craven 61. Mitchell 97. Wilkes 26. Cumberland 62. Montgomery 98. Wilson 27. Currituck 63. Moore 99. Yadkin 28. Dare 64. Nash100. Yancey 29. Davidson 65. New Hanover 30. Davie 66. Northampton101. Georgia 31. Duplin 67. Onslow102. South Carolina 32. Durham 68. Orange103. Tennessee 33. Edgecombe 69. Pamlico104. Virginia 34. Forsyth 70. Pasquotank105. Other States 35. Franklin 71. Pender106. Other 36. Gaston 72. Perquimans Total No. of Patients Patient Origin Emergency Department Services In an effort to document patterns of Emergency Department Services in North Carolina hospitals, please provide the county of residence for all patients served in your facility by your Emergency Department. Submit one record for the licensed hospital. DO NOT SUBMIT SEPARATE RECORDS FOR EACH CAMPUS. The total number of patients from this chart must match the number of Emergency Department visits provided in Section F.(3)(b): Emergency Department Services, Page 8. CountyNo. of PatientsCountyNo. of PatientsCountyNo. of Patients 1. Alamance 37. Gates 73. Person 2. Alexander 38. Graham 74. Pitt 3. Alleghany 39. Granville 75. Polk 4. Anson 40. Greene 76. Randolph 5. Ashe 41. Guilford 77. Richmond 6. Avery 42. Halifax 78. Robeson 7. Beaufort 43. Harnett 79. Rockingham 8. Bertie 44. Haywood 80. Rowan 9. Bladen 45. Henderson 81. Rutherford 10. Brunswick 46. Hertford 82. Sampson 11. Buncombe 47. Hoke 83. Scotland 12. Burke 48. Hyde 84. Stanly 13. Cabarrus 49. Iredell 85. Stokes 14. Caldwell 50. Jackson 86. Surry 15. Camden 51. Johnston 87. Swain 16. Carteret 52. Jones 88. Transylvania 17. Caswell 53. Lee 89. Tyrrell 18. Catawba 54. Lenoir 90. Union 19. Chatham 55. Lincoln 91. Vance 20. Cherokee 56. Macon 92. Wake 21. Chowan 57. Madison 93. Warren 22. Clay 58. Martin 94. Washington 23. Cleveland 59. McDowell 95. Watauga 24. Columbus 60. Mecklenburg 96. Wayne 25. Craven 61. Mitchell 97. Wilkes 26. Cumberland 62. Montgomery 98. Wilson 27. Currituck 63. Moore 99. Yadkin 28. Dare 64. Nash100. Yancey 29. Davidson 65. New Hanover 30. Davie 66. Northampton101. Georgia 31. Duplin 67. Onslow102. South Carolina 32. Durham 68. Orange103. Tennessee 33. Edgecombe 69. Pamlico104. Virginia 34. Forsyth 70. Pasquotank105. Other States 35. Franklin 71. Pender106. Other 36. Gaston 72. Perquimans Total No. of Patients Patient Origin Gastrointestinal Endoscopy (GI) Cases In an effort to document patterns of utilization of Gastrointestinal Endoscopy Services in North Carolina hospitals, please provide the county of residence for each GI Endoscopy patient served in your facility. Count each patient once regardless of the number of procedures performed while the patient was receiving GI Endoscopy Services. However, each admission for GI Endoscopy services should be reported separately. Submit one record for the licensed hospital. DO NOT SUBMIT SEPARATE RECORDS FOR EACH CAMPUS. The Total from this chart should match the total GI Endoscopy cases reported on the Gastrointestinal Endoscopy Rooms, Procedures, and Cases table on page 11. CountyNo. of PatientsCountyNo. of PatientsCountyNo. of Patients 1. Alamance 37. Gates 73. Person 2. Alexander 38. Graham 74. Pitt 3. Alleghany 39. Granville 75. Polk 4. Anson 40. Greene 76. Randolph 5. Ashe 41. Guilford 77. Richmond 6. Avery 42. Halifax 78. Robeson 7. Beaufort 43. Harnett 79. Rockingham 8. Bertie 44. Haywood 80. Rowan 9. Bladen 45. Henderson 81. Rutherford 10. Brunswick 46. Hertford 82. Sampson 11. Buncombe 47. Hoke 83. Scotland 12. Burke 48. Hyde 84. Stanly 13. Cabarrus 49. Iredell 85. Stokes 14. Caldwell 50. Jackson 86. Surry 15. Camden 51. Johnston 87. Swain 16. Carteret 52. Jones 88. Transylvania 17. Caswell 53. Lee 89. Tyrrell 18. Catawba 54. Lenoir 90. Union 19. Chatham 55. Lincoln 91. Vance 20. Cherokee 56. Macon 92. Wake 21. Chowan 57. Madison 93. Warren 22. Clay 58. Martin 94. Washington 23. Cleveland 59. McDowell 95. Watauga 24. Columbus 60. Mecklenburg 96. Wayne 25. Craven 61. Mitchell 97. Wilkes 26. Cumberland 62. Montgomery 98. Wilson 27. Currituck 63. Moore 99. Yadkin 28. Dare 64. Nash100. Yancey 29. Davidson 65. New Hanover 30. Davie 66. Northampton101. Georgia 31. Duplin 67. Onslow102. South Carolina 32. Durham 68. Orange103. Tennessee 33. Edgecombe 69. Pamlico104. Virginia 34. Forsyth 70. Pasquotank105. Other States 35. Franklin 71. Pender106. Other 36. Gaston 72. Perquimans Total No. of Patients Patient Origin Inpatient Surgical Cases In an effort to document patterns of Inpatient utilization of Surgical Services in North Carolina hospitals, please provide the county of residence for each inpatient surgical patient served in your facility. Count each inpatient surgical patient once regardless of the number of surgical procedures performed while the patient was having surgery. However, each admission as an inpatient surgical case should be reported separately. Submit one record for the licensed hospital. DO NOT SUBMIT SEPARATE RECORDS FOR EACH CAMPUS. The Total from this chart should match the Total Inpatient Cases reported on the Surgical Cases by Specialty Area table on page 12. CountyNo. of PatientsCountyNo. of PatientsCountyNo. of Patients 1. Alamance 37. Gates 73. Person 2. Alexander 38. Graham 74. Pitt 3. Alleghany 39. Granville 75. Polk 4. Anson 40. Greene 76. Randolph 5. Ashe 41. Guilford 77. Richmond 6. Avery 42. Halifax 78. Robeson 7. Beaufort 43. Harnett 79. Rockingham 8. Bertie 44. Haywood 80. Rowan 9. Bladen 45. Henderson 81. Rutherford 10. Brunswick 46. Hertford 82. Sampson 11. Buncombe 47. Hoke 83. Scotland 12. Burke 48. Hyde 84. Stanly 13. Cabarrus 49. Iredell 85. Stokes 14. Caldwell 50. Jackson 86. Surry 15. Camden 51. Johnston 87. Swain 16. Carteret 52. Jones 88. Transylvania 17. Caswell 53. Lee 89. Tyrrell 18. Catawba 54. Lenoir 90. Union 19. Chatham 55. Lincoln 91. Vance 20. Cherokee 56. Macon 92. Wake 21. Chowan 57. Madison 93. Warren 22. Clay 58. Martin 94. Washington 23. Cleveland 59. McDowell 95. Watauga 24. Columbus 60. Mecklenburg 96. Wayne 25. Craven 61. Mitchell 97. Wilkes 26. Cumberland 62. Montgomery 98. Wilson 27. Currituck 63. Moore 99. Yadkin 28. Dare 64. Nash100. Yancey 29. Davidson 65. New Hanover 30. Davie 66. Northampton101. Georgia 31. Duplin 67. Onslow102. South Carolina 32. Durham 68. Orange103. Tennessee 33. Edgecombe 69. Pamlico104. Virginia 34. Forsyth 70. Pasquotank105. Other States 35. Franklin 71. Pender106. Other 36. Gaston 72. Perquimans Total No. of Patients Patient Origin Ambulatory Surgical Cases In an effort to document patterns of Ambulatory utilization of Surgical Services in North Carolina hospitals, please provide the county of residence for each ambulatory surgery patient served in your facility. Count each ambulatory patient once regardless of the number of procedures performed while the patient was having surgery. However, each admission as an ambulatory surgery case should be reported separately. Submit one record for the licensed hospital. DO NOT SUBMIT SEPARATE RECORDS FOR EACH CAMPUS. The Total from this chart should match the Total Ambulatory Surgical Cases reported on the Surgical Cases by Specialty Area table on page 12. CountyNo. of PatientsCountyNo. of PatientsCountyNo. of Patients 1. Alamance 37. Gates 73. Person 2. Alexander 38. Graham 74. Pitt 3. Alleghany 39. Granville 75. Polk 4. Anson 40. Greene 76. Randolph 5. Ashe 41. Guilford 77. Richmond 6. Avery 42. Halifax 78. Robeson 7. Beaufort 43. Harnett 79. Rockingham 8. Bertie 44. Haywood 80. Rowan 9. Bladen 45. Henderson 81. Rutherford 10. Brunswick 46. Hertford 82. Sampson 11. Buncombe 47. Hoke 83. Scotland 12. Burke 48. Hyde 84. Stanly 13. Cabarrus 49. Iredell 85. Stokes 14. Caldwell 50. Jackson 86. Surry 15. Camden 51. Johnston 87. Swain 16. Carteret 52. Jones 88. Transylvania 17. Caswell 53. Lee 89. Tyrrell 18. Catawba 54. Lenoir 90. Union 19. Chatham 55. Lincoln 91. Vance 20. Cherokee 56. Macon 92. Wake 21. Chowan 57. Madison 93. Warren 22. Clay 58. Martin 94. Washington 23. Cleveland 59. McDowell 95. Watauga 24. Columbus 60. Mecklenburg 96. Wayne 25. Craven 61. Mitchell 97. Wilkes 26. Cumberland 62. Montgomery 98. Wilson 27. Currituck 63. Moore 99. Yadkin 28. Dare 64. Nash100. Yancey 29. Davidson 65. New Hanover 30. Davie 66. Northampton101. Georgia 31. Duplin 67. Onslow102. South Carolina 32. Durham 68. Orange103. Tennessee 33. Edgecombe 69. Pamlico104. Virginia 34. Forsyth 70. Pasquotank105. Other States 35. Franklin 71. Pender106. Other 36. Gaston 72. Perquimans Total No. of Patients Patient Origin - MRI Services In an effort to document patterns of utilization of MRI Services in North Carolina, hospitals are asked to provide county of residence for each patient served in your facility. Submit one record for the licensed hospital. DO NOT SUBMIT SEPARATE RECORDS FOR EACH CAMPUS. The total number of patients reported here should be equal to or less than the total number of MRI procedures reported in the MRI Procedures table. on page 17. CountyNo. of PatientsCountyNo. of PatientsCountyNo. of Patients 1. Alamance 37. Gates 73. Person 2. Alexander 38. Graham 74. Pitt 3. Alleghany 39. Granville 75. Polk 4. Anson 40. Greene 76. Randolph 5. Ashe 41. Guilford 77. Richmond 6. Avery 42. Halifax 78. Robeson 7. Beaufort 43. Harnett 79. Rockingham 8. Bertie 44. Haywood 80. Rowan 9. Bladen 45. Henderson 81. Rutherford 10. Brunswick 46. Hertford 82. Sampson 11. Buncombe 47. Hoke 83. Scotland 12. Burke 48. Hyde 84. Stanly 13. Cabarrus 49. Iredell 85. Stokes 14. Caldwell 50. Jackson 86. Surry 15. Camden 51. Johnston 87. Swain 16. Carteret 52. Jones 88. Transylvania 17. Caswell 53. Lee 89. Tyrrell 18. Catawba 54. Lenoir 90. Union 19. Chatham 55. Lincoln 91. Vance 20. Cherokee 56. Macon 92. Wake 21. Chowan 57. Madison 93. Warren 22. Clay 58. Martin 94. Washington 23. Cleveland 59. McDowell 95. Watauga 24. Columbus 60. Mecklenburg 96. Wayne 25. Craven 61. Mitchell 97. Wilkes 26. Cumberland 62. Montgomery 98. Wilson 27. Currituck 63. Moore 99. Yadkin 28. Dare 64. Nash100. Yancey 29. Davidson 65. New Hanover 30. Davie 66. Northampton101. Georgia 31. Duplin 67. Onslow102. South Carolina 32. Durham 68. Orange103. Tennessee 33. Edgecombe 69. Pamlico104. Virginia 34. Forsyth 70. Pasquotank105. Other States 35. Franklin 71. Pender106. Other 36. Gaston 72. Perquimans Total No. of Patients Patient Origin PET Scanner In an effort to document patterns of utilization of PET Scanners in North Carolina, hospitals are asked to provide county of residence for each patient served in your facility. This data should only reflect the number of patients, not number of scans and should not include other radiopharmaceutical or supply charge codes. Submit one record for the licensed hospital. DO NOT SUBMIT SEPARATE RECORDS FOR EACH CAMPUS. Please count each patient only once. The number of patients in this table should match the number of PET procedures reported in the Positron Emission Tomography (PET) table on page 19. CountyNo. of PatientsCountyNo. of PatientsCountyNo. of Patients 1. Alamance 37. Gates 73. Person 2. Alexander 38. Graham 74. Pitt 3. Alleghany 39. Granville 75. Polk 4. Anson 40. Greene 76. Randolph 5. Ashe 41. Guilford 77. Richmond 6. Avery 42. Halifax 78. Robeson 7. Beaufort 43. Harnett 79. Rockingham 8. Bertie 44. Haywood 80. Rowan 9. Bladen 45. Henderson 81. Rutherford 10. Brunswick 46. Hertford 82. Sampson 11. Buncombe 47. Hoke 83. Scotland 12. Burke 48. Hyde 84. Stanly 13. Cabarrus 49. Iredell 85. Stokes 14. Caldwell 50. Jackson 86. Surry 15. Camden 51. Johnston 87. Swain 16. Carteret 52. Jones 88. Transylvania 17. Caswell 53. Lee 89. Tyrrell 18. Catawba 54. Lenoir 90. Union 19. Chatham 55. Lincoln 91. Vance 20. Cherokee 56. Macon 92. Wake 21. Chowan 57. Madison 93. Warren 22. Clay 58. Martin 94. Washington 23. Cleveland 59. McDowell 95. Watauga 24. Columbus 60. Mecklenburg 96. Wayne 25. Craven 61. Mitchell 97. Wilkes 26. Cumberland 62. Montgomery 98. Wilson 27. Currituck 63. Moore 99. Yadkin 28. Dare 64. Nash100. Yancey 29. Davidson 65. New Hanover 30. Davie 66. Northampton101. Georgia 31. Duplin 67. Onslow102. South Carolina 32. Durham 68. Orange103. Tennessee 33. Edgecombe 69. Pamlico104. Virginia 34. Forsyth 70. Pasquotank105. Other States 35. Franklin 71. Pender106. Other 36. Gaston 72. Perquimans Total No. of Patients Patient Origin Linear Accelerator Treatment In an effort to document patterns of utilization of linear accelerators in North Carolina, hospitals are asked to provide the county of residence for patients served on linear accelerators in your facility. Report the number of patients who receive radiation oncology treatment on equipment (linear accelerators, CyberKnife, but not Gamma Knife) listed in Section 11 of this application. Patients shall be counted once if they receive one course of treatment and more if they receive additional courses of treatment. For example, one patient who receives one course of treatment counts as one, and one patient who receives three courses of treatment counts as three. Submit one record for the licensed hospital. DO NOT SUBMIT SEPARATE RECORDS FOR EACH CAMPUS. The number of patients reported here should match the number of patients reported in Section 11.a. on page 21 of this application. CountyNo. of PatientsCountyNo. of PatientsCountyNo. of Patients 1. Alamance 37. Gates 73. Person 2. Alexander 38. Graham 74. Pitt 3. Alleghany 39. Granville 75. Polk 4. Anson 40. Greene 76. Randolph 5. Ashe 41. Guilford 77. Richmond 6. Avery 42. Halifax 78. Robeson 7. Beaufort 43. Harnett 79. Rockingham 8. Bertie 44. Haywood 80. Rowan 9. Bladen 45. Henderson 81. Rutherford 10. Brunswick 46. Hertford 82. Sampson 11. Buncombe 47. Hoke 83. Scotland 12. Burke 48. Hyde 84. Stanly 13. Cabarrus 49. Iredell 85. Stokes 14. Caldwell 50. Jackson 86. Surry 15. Camden 51. Johnston 87. Swain 16. Carteret 52. Jones 88. Transylvania 17. Caswell 53. Lee 89. Tyrrell 18. Catawba 54. Lenoir 90. Union 19. Chatham 55. Lincoln 91. Vance 20. Cherokee 56. Macon 92. Wake 21. Chowan 57. Madison 93. Warren 22. Clay 58. Martin 94. Washington 23. Cleveland 59. McDowell 95. Watauga 24. Columbus 60. Mecklenburg 96. Wayne 25. Craven 61. Mitchell 97. Wilkes 26. Cumberland 62. Montgomery 98. Wilson 27. Currituck 63. Moore 99. Yadkin 28. Dare 64. Nash100. Yancey 29. Davidson 65. New Hanover 30. Davie 66. Northampton101. Georgia 31. Duplin 67. Onslow102. South Carolina 32. Durham 68. Orange103. Tennessee 33. Edgecombe 69. Pamlico104. Virginia 34. Forsyth 70. Pasquotank105. Other States 35. Franklin 71. Pender106. Other 36. Gaston 72. Perquimans Total No. of Patients Patient Origin - Psychiatric and Substance Use Disorder Submit one record for the licensed hospital. DO NOT SUBMIT SEPARATE RECORDS FOR EACH CAMPUS. Complete the following table below for inpatient Days of Care for beds reported under Section .5200 on pages 23-24. Days of care reported here must match days of care reported on page 6 (D-4 and D-5). County of Patient OriginPsychiatric Treatment Days of CareSubstance Use Disorder Treatment Days of CareAge < 6Age 6-12Age 13-17Age 18 +TotalAge < 6Age 6-12Age 13-17Age 18 +TotalExample: Wake5830 43 102 12  1. Alamance 2. Alexander 3. Alleghany 4. Anson 5. Ashe 6. Avery 7. Beaufort 8. Bertie 9. Bladen 10. Brunswick 11. Buncombe 12. Burke 13. Cabarrus 14. Caldwell 15. Camden 16. Carteret 17. Caswell 18. Catawba 19. Chatham 20. Cherokee 21. Chowan 22. Clay 23. Cleveland 24. Columbus 25. Craven 26. Cumberland 27. Currituck28. Dare 29. Davidson30. Davie 31. Duplin 32. Durham 33. Edgecombe34. Forsyth 35. Franklin 36. Gaston 37. Gates 38. Graham 39. Granville 40. Greene 41. Guilford 42. Halifax 43. HarnettContinued on next page County of Patient OriginPsychiatric Treatment Days of CareSubstance Use Disorder Treatment Days of CareAge < 6Age 6-12Age 13-17Age 18 +TotalAge < 6Age 6-12Age 13-17Age 18 +Total 44. Haywood 45. Henderson 46. Hertford 47. Hoke 48. Hyde 49. Iredell 50. Jackson51. Johnston 52. Jones 53. Lee 54. Lenoir 55. Lincoln 56. Macon 57. Madison 58. Martin 59. McDowell 60. Mecklenburg 61. Mitchell 62. Montgomery 63. Moore64. Nash65. New Hanover 66. Northampton 67. Onslow 68. Orange 69. Pamlico 70. Pasquotank 71. Pender 72. Perquimans 73. Person 74. Pitt 75. Polk 76. Randolph 77. Richmond 78. Robeson79. Rockingham80. Rowan 81. Rutherford 82. Sampson 83. Scotland 84. Stanly 85. Stokes 86. Surry 87. Swain 88. Transylvania 89. Tyrrell 90. Union 91. Vance 92. WakeContinued on next page County of Patient OriginPsychiatric Treatment Days of CareSubstance Use Disorder Treatment Days of CareAge < 6Age 6-12Age 13-17Age 18 +TotalAge < 6Age 6-12Age 13-17Age 18 +Total 93. Warren 94. Washington 95. Watauga 96. Wayne 97. Wilkes 98. Wilson 99. Yadkin100. Yancey101. Other States102. Other TOTAL This license renewal application must be completed and submitted to the Acute and Home Care Licensure and Certification Section, Division of Health Service Regulation prior to the issuance of a 2020 hospital license. AUTHENTICATING SIGNATURE: The undersigned submits application for the year 2020 in accordance with Article 5, Chapter 131E of the General Statutes of North Carolina, and subject to the rules and codes adopted thereunder by the North Carolina Medical Care Commission (10A NCAC 13B), and certifies the accuracy of this information. Signature: ____________________________________________Date:_________________________ PRINT NAME OF APPROVING OFFICIAL _________________________________________________________________ Please be advised, the license fee must accompany the completed license renewal application and be submitted to the Acute and Home Care Licensure and Certification Section, Division of Health Service Regulation, prior to the issuance of a hospital license. North Carolina Department of Health and Human Services Division of Health Service Regulation Acute and Home Care Licensure and Certification Section Regular Mail: 1205 Umstead Drive 2712 Mail Service Center Raleigh, North Carolina 27699-2712 Overnight UPS and FedEx only: 1205 Umstead Drive Raleigh, North Carolina 27603 Telephone: (919) 855-4620 Fax: (919) 715-3073For Official Use Only License # IF MERGEFIELD LICNO="" " ___________________" MERGEFIELD LICNOH0019 ___________________ NF Provider #  MERGEFIELD nfprov  FID # : MERGEFIELD FID Hospital: IF MERGEFIELD FACILITY="" "" MERGEFIELD FACILITYAdventHealth Hendersonville NURSING CARE FACILITY/UNIT BEDS 2020 Annual Data Supplement to Hospital License Application To be completed by each hospital reporting Nursing Facility/Unit Beds as part of its total licensed capacity. A separate form should be completed for each site. Legal Identity of Applicant: IF  MERGEFIELD LICENSEE ="" "________________________________________________________________________"  MERGEFIELD LICENSEE Fletcher Hospital, Incorporated________________________________________________________________________ (Full legal name of corporation, partnership, individual, or other legal entity owning the enterprise or service.) Doing Business As (name(s) under which the facility or services are advertised or presented to the public): PRIMARY: IF MERGEFIELD FACILITY="" "________________________________________________________________________" MERGEFIELD FACILITYAdventHealth Hendersonville________________________________________________________________________ Other: IF MERGEFIELD OBN1="" "________________________________________________________________________" MERGEFIELD OBN1Park Ridge Health________________________________________________________________________ Other: IF MERGEFIELD OBN2="" "________________________________________________________________________" MERGEFIELD OBN2Park Ridge Hospital________________________________________________________________________ Facility Mailing Address: IF MERGEFIELD FADDR1="" "Street/P.O. Box: ________________________________________________" MERGEFIELD FADDR1100 Hospital DriveStreet/P.O. Box: ________________________________________________  MERGEFIELD FADDR2  IF MERGEFIELD FCITY="" "City: ______________________" MERGEFIELD FCITYHendersonvilleCity: ______________________, IF MERGEFIELD FSTATE="" " State: ________" MERGEFIELD FSTATENC State: ________ IF MERGEFIELD FZIP="" " Zip: __________________________________________________" MERGEFIELD FZIP28792 Zip: __________________________________________________ Facility Site Address: IF MERGEFIELD SADDR="" "Street: ________________________________________________" MERGEFIELD SADDR100 Hospital DriveStreet: ________________________________________________ IF MERGEFIELD SCITY="" "City: ______________________" MERGEFIELD SCITYHendersonvilleCity: ______________________, IF MERGEFIELD SSTATE="" " State: ________" MERGEFIELD SSTATENC State: ________ IF MERGEFIELD SZIP="" " Zip: ________" MERGEFIELD SZIP28792 Zip: ________ County: MERGEFIELD FCOUNTY Telephone: IF MERGEFIELD FPHONE="" "(____) ___________" MERGEFIELD FPHONE(828)684-8501(____) ___________ Fax: IF MERGEFIELD FFAX="" "(____) ___________" MERGEFIELD FFAX(828)687-0729(____) ___________ E-mail Address of Administrator: IF MERGEFIELD FEMAIL="" "_________________________________________" MERGEFIELD FEMAILkharris@ucrh.org_________________________________________ National provider identifier (NPI): ____________________________________ 1. Was this facility in operation throughout the entire 12-month reporting period ending September 30, 2019? Yes No If No, for what period was the facility in operation? ____ / ____ / ____ through ____ / ____ / ____ month/day/year month/day/year If No, for what reason was the facility not in full operation during this period? ___________________________ ______________________________________________________________________________________________________________________________________________________________________________________________ 2. Was there a change of ownership anytime between October 1, 2018 and September 30, 2019? Yes No If Yes, what was the date of the change? ____ / ____ / ____ PART A OWNERSHIP DISCLOSURE (Please fill in any blanks and make changes where necessary.) 1. What is the name of the legal entity with ownership responsibility and liability? Owner: IF MERGEFIELD OWNCONAME="" "_______________________________________________________" MERGEFIELD OWNCONAMEFletcher Hospital Inc_______________________________________________________ Street: IF MERGEFIELD OWNADDR1="" "_______________________________________________________" MERGEFIELD OWNADDR1100 Hospital Drive_______________________________________________________ Mailing: ________________________________________________________________ (if different from street) City: IF MERGEFIELD OWNCITY="" "______________________" MERGEFIELD OWNCITYHendersonville______________________ State: IF MERGEFIELD OWNSTATE="" "____________" MERGEFIELD OWNSTATENC____________ Zip: IF MERGEFIELD OWNZIP="" "____________" MERGEFIELD OWNZIP28792____________ Telephone: IF MERGEFIELD OWNPHONE="" "(____) ___________" MERGEFIELD OWNPHONE(828)684-8501(____) ___________ Fax: IF MERGEFIELD OWNFAX="" "(____) ___________" MERGEFIELD OWNFAX(828)687-0729(____) ___________ Senior Officer: IF MERGEFIELD SROFFICER="" "_______________________________________________________" MERGEFIELD SROFFICERJimm Bunch, CEO_______________________________________________________ a. Legal entity is:  IF  MERGEFIELD ownnfprof  = "False" " X For Profit" " For Profit"  For Profit  IF  MERGEFIELD ownnfprof  = "True" " X Not For Profit" " Not For Profit"  Not For Profit Legal entity is: (check ALL that apply) IF MERGEFIELD OWNOWNTYPE="CORP" " X Corporation " "____ Corporation "____ Corporation  IF MERGEFIELD OWNOWNTYPE="LLC" " X LLC " "___ LLC "___ LLC  IF MERGEFIELD OWNOWNTYPE="LLP" " X LLP " "___ LLP "___ LLP IF MERGEFIELD OWNOWNTYPE="PART" " X Partnership " " Partnership " Partnership  IF MERGEFIELD OWNOWNTYPE="PROP" " X Proprietorship "" Proprietorship " Proprietorship  IF MERGEFIELD OWNOWNTYPE="GOVMT" " X Government Unit " " Government Unit " Government Unit  ___ Religious/Fraternal c. Does the above entity (partnership, corporation, etc.) lease the building?  IF  MERGEFIELD ownleasebl  = "False" " Yes X No" " X Yes No"  X Yes No If Yes, name of building owner: IF  MERGEFIELD ownbldown ="" ""  MERGEFIELD ownbldown Alexander Hospital Investors, LLC  2. Is the business operated under a management contract? IF MERGEFIELD MGMTCONAME="" " Yes X No" " X Yes No" Yes X No If Yes, name and address of the management company. Name: IF MERGEFIELD MGMTCONAME="" "_________________________________________________________________________" MERGEFIELD MGMTCONAMEWake Forest Bajptist Medical Center_________________________________________________________________________ Street: IF MERGEFIELD MGMTADDR1="" "_________________________________________________________________________" MERGEFIELD MGMTADDR110th Fl, Janeway Business Developem_________________________________________________________________________ Mailing: _________________________________________________________________________ (if different from street) City: IF MERGEFIELD MGMTCITY="" "______________________" MERGEFIELD MGMTCITYWinston Salem______________________ State: IF MERGEFIELD MGMTSTATE="" "____________" MERGEFIELD MGMTSTATENC____________ Zip: IF MERGEFIELD MGMTZIP="" "____________" MERGEFIELD MGMTZIP27157____________ Telephone: IF MERGEFIELD MGMTPHONE="" "(____) ___________" MERGEFIELD MGMTPHONE(704)355-2000(____) ___________ If this business is a subsidiary of another entity, please identify the parent company below: Name: IF  MERGEFIELD parconame ="" "________________________________________________________________________"  MERGEFIELD parconame Pitt County Memorial Hospital Inc________________________________________________________________________ Street: IF  MERGEFIELD paraddr1="" "________________________________________________________________________"  MERGEFIELD paraddr1 2100 Stantonsburg Road________________________________________________________________________ Mailing ________________________________________________________________________ (if different from street) City: IF  MERGEFIELD parcity="" "______________________"  MERGEFIELD parcityGreenville______________________ State: IF  MERGEFIELD parstate="" "____________"  MERGEFIELD parstate NC____________ Zip: IF  MERGEFIELD parzip ="" "____________"  MERGEFIELD parzip 27835____________ Telephone: IF  MERGEFIELD parphone ="" "(____) ___________"  MERGEFIELD parphone (252)482-8451(____) ___________ Fax: IF  MERGEFIELD parfax ="" "(____) ___________"  MERGEFIELD parfax (____) _______________) Senior Officer: IF  MERGEFIELD parsroffic="" "_______________________________________________________"  MERGEFIELD parsroffic _______________________________________________________ PART B OPERATIONS 1. Facility Personnel a. Administration Name of the Administrator: IF MERGEFIELD ADMFULLNAM="" "____________________________________________________" MERGEFIELD ADMFULLNAMJimm Bunch____________________________________________________ Date Hired As Administrator: IF MERGEFIELD ADMHIRED="" "________________" MERGEFIELD ADMHIRED- - "________________ NC License Number: IF  MERGEFIELD ADMLICNO ="" "_________________" MERGEFIELD ADMLICNOCPA_________________________ b. Nursing Name of the Director: IF MERGEFIELD DONFULLNAM="" "____________________________________________________" MERGEFIELD DONFULLNAMRoland Joy____________________________________________________ Date Hired As D.O.N.: IF MERGEFIELD DONHIRED="" "_____________________" MERGEFIELD DONHIRED- -_____________________ NC License Number: IF MERGEFIELD DONLICNO="" "_________________" MERGEFIELD DONLICNO062097_________________ Medical Director: Name of Medical Director: ____________________________________________________________ IF MERGEFIELD DONFULLNAM="" "____________________________________________________" MERGEFIELD MDRFULLNAM____________________________________________________ Date Hired as Medical Director: ________________________________________________________ Office Address: ____________________________________________________________________ ____________________________________________________________________ Is the facility licensed by the Department of Insurance as a CCRC?  IF  MERGEFIELD category  = "Continuing Care Retirement Community" " X Yes No" " Yes X No"  Yes X No If yes, please answer all items for #3 and #4. If no, please proceed to Part C. Some CCRCs have licensed adult care home beds that are not restricted to individuals contracted with the facility. Do you have unrestricted licensed adult care home beds in your facility? _____Yes _____ No If yes, how many are unrestricted? __________ If yes, how many unrestricted licensed adult care home beds were occupied on September 30, 2019 by individuals NOT contracted with your facility? ____________ Some CCRCs have licensed nursing home beds that are not restricted to individuals contracted with the facility. Do you have unrestricted nursing home beds in your facility? ______Yes _____ No If yes, how many are unrestricted? __________ If yes, how many unrestricted licensed nursing home beds were occupied on September 30, 2019 by individuals NOT contracted with your facility? ____________ PART C PATIENT SERVICES (Please fill in any blanks and make changes where necessary. Check Yes or No.) 1. Was there a change to the licensed bed capacity between Oct 1, 2018 and Sept 30, 2019? Yes No a. If Yes, what was the effective date of the change? ___ /___ /___ b. If Yes, indicate previous number of licensed beds for your nursing home (NH) facility and your adult care home (ACH) facility. ___NH ___ACH 2. Is the facility a Combination Facility, thereby incorporating licensed ACH beds? Yes No If Yes, indicate which rules the facility chooses to apply to the operation of the ACH BEDS (NH rules, ACH rules or both NH & ACH). If both NH & ACH rules are checked, download an ACH Rule Choice checklist from  HYPERLINK "http://www2.ncdhhs.gov/dhsr/nhlcs/forms.html" http://www2.ncdhhs.gov/dhsr/nhlcs/forms.html. Complete and return with the License Renewal Application. This checklist is found under the heading of change of ownership.  FORMCHECKBOX  NH Licensure Rules  FORMCHECKBOX  ACH Licensure Rules 3. Beds By Type (*Must complete Alzheimers Special Care Unit data supplement sheet) a. Nursing Home (NH) Beds (TOTAL) MERGEFIELD NFTOTAL 1. General Nursing Home Beds MERGEFIELD NFGENLIC 2. *Alzheimer's Special Care Unit Beds MERGEFIELD ALZLIC* 3. Ventilator Beds MERGEFIELD VENLIC 4. Traumatic brain injury beds MERGEFIELD TBILIC Are you equipped to accommodate bariatric residents? ____Yes ____No b. Adult Care Home (ACH) Beds (TOTAL) MERGEFIELD HATOTAL 1. General Adult Care Home Beds MERGEFIELD HAGENLIC 2. * Alzheimer's Special Care Unit Beds MERGEFIELD HAALZLIC* Are you equipped to accommodate bariatric residents? ____Yes ____No c. Total Licensed Beds MERGEFIELD TOTALBEDS Total Operational Beds on September 30, 2019 NH ________ ACH ________ Operational Beds means all the licensed beds in the facility that are available for resident/patient use on September 30, 2019. Do not include licensed beds that were not available for use on September 30, 2019 for reasons such as staff shortages, or beds unavailable due to renovations, or second beds located in a room used as a private room. (If you have questions about this item, please call Healthcare Planning at (919) 855-3865.) 4. Nursing Home Bed Certification a. Number of beds certified for Medicare only (Title 18 only)b. Number of beds dually certified for both Medicare & Medicaid (Title 18/19)c. Number of beds certified for Medicaid only (Title 19 only) PART D PATIENT CENSUS If you have questions about the items on this page, please call Healthcare Planning at (919) 855-3865 Important: Report patient census data for September 30, 2019 only. Nursing HomeAdult Care1. Number of patients in facility on September 30, 2019 a. Statistics on Nursing Home Patients on September 30, 2019 by age groups MaleFemale18 - 20 years old21 - 34 years old35 - 54 years old55 - 64 years old65 - 74 years old75 - 84 years old85 years old and olderSubtotalsTotal (Total = subtotal of males + subtotal of females) NOTE: Total for Item # 2a must match the number reported in Item # 1 for Nursing Patients. b. Number of patients in Nursing Home Alzheimers Special Care Unit beds on September 30, 2019  3. a. Statistics on Adult Care Home Residents on September 30, 2019 by age groups MaleFemaleUnder 3535 - 64 years old65 - 74 years old75 - 84 years old85 years old and olderSubtotalsTotal (Total = subtotal of males + subtotal of females) NOTE: Total for Item # 3a must match the number reported in Item # 1 for Adult Care Home Residents. b. Number of residents in Adult Care Home Alzheimers Special Care Unit beds on September 30, 2019  PART E PATIENT UTILIZATION DATA If you have questions about the items on this page, please call Healthcare Planning at (919) 855-3865 1. Beginning Census, Admissions, Discharges, and Deaths by Level of Care Complete the chart below for the reporting period of October 1, 2018 through September 30, 2019.  Patients/ResidentsBeginning Census (Oct. 1, 2018)Admissions (Oct. 1, 2018 - Sept. 30, 2019)Discharges (excluding deaths) (Oct. 1, 2018 - Sept. 30, 2019)Deaths (Oct. 1, 2018 - Sept. 30, 2019)Total* (1) NH Patients(2) ACH Residents *To calculate: Beginning Census + Admissions Discharges Deaths = Total Note: Beginning Census is the number of patients in your facility on October 1, 2018. Admissions is the number of patients admitted from Oct. 1, 2018 through Sept. 30, 2019. Discharges and Deaths are all discharges and deaths from Oct. 1, 2018 through Sept. 30, 2019. 2. Inpatient Days of Care Complete the charts below for the reporting period of October 1, 2018 through September 30, 2019. a. Nursing Home (NH) (1) NH Days reimbursed by Medicare (2) NH Days reimbursed by Medicaid (3) NH Days reimbursed by Private Pay (4) NH Days reimbursed by Other (5) Total { (1) + (2) + (3) + (4) } b. Adult Care Home (ACH) (1) ACH Days reimbursed by Private Pay (2) ACH Days reimbursed by County Special Assistance (3) ACH Days reimbursed by Other (4) Total { (1) + (2) + (3) } Note: Report inpatient days of care as cumulative totals. Example: total number of days reimbursed by Medicare for Patient #1 + total number of days reimbursed by Medicare for Patient #2 + total number of days reimbursed by Medicare for Patient #3 + Continue for each patient in the facility and then repeat for all categories in both tables 2a. and 2b. 3. Counties of Origin for Nursing Home Patients For questions regarding this section, please call Healthcare Planning at (919) 855-3865 Please list in Column B the number of nursing home patients, from that county, who were living in the facility on October 1, 2017. In Column C give the total number of additional nursing home patients, from that county, who were admitted between October 1, 2018 and September 30, 2019. Report patients who were not NC residents on lines 101 through 105. ABCABCABCPermanent County of Residence for Individuals Prior to AdmissionLiving in Facility 10/1/2018Admitted 10/1/2018-9/30/2019Permanent County of Residence for Individuals Prior to AdmissionLiving in Facility 10/1/2018Admitted 10/1/2018-9/30/2019Permanent County of Residence for Individuals Prior to AdmissionLiving in Facility 10/1/2018 Admitted 10/1/2018-9/30/2019  1. Alamance 37. Gates 73. Person 2. Alexander 38. Graham 74. Pitt 3. Alleghany 39. Granville 75. Polk 4. Anson 40. Greene 76. Randolph 5. Ashe 41. Guilford 77. Richmond 6. Avery 42. Halifax 78. Robeson 7. Beaufort 43. Harnett 79. Rockingham 8. Bertie 44. Haywood 80. Rowan 9. Bladen 45. Henderson 81. Rutherford 10. Brunswick 46. Hertford 82. Sampson 11. Buncombe 47. Hoke 83. Scotland 12. Burke 48. Hyde 84. Stanly 13. Cabarrus 49. Iredell 85. Stokes 14. Caldwell 50. Jackson 86. Surry 15. Camden 51. Johnston 87. Swain 16. Carteret 52. Jones 88. Transylvania 17. Caswell 53. Lee 89. Tyrrell 18. Catawba 54. Lenoir 90. Union 19. Chatham 55. Lincoln 91. Vance 20. Cherokee 56. Macon 92. Wake 21. Chowan 57. Madison 93. Warren 22. Clay 58. Martin 94. Washington 23. Cleveland 59. McDowell 95. Watauga 24. Columbus 60. Mecklenburg 96. Wayne 25. Craven 61. Mitchell 97. Wilkes 26. Cumberland 62. Montgomery 98. Wilson 27. Currituck 63. Moore 99. Yadkin 28. Dare 64. Nash100. Yancey 29. Davidson 65. New Hanover 30. Davie 66. Northampton101. Georgia 31. Duplin 67. Onslow102. South Carolina 32. Durham 68. Orange103. Tennessee 33. Edgecombe 69. Pamlico104. Virginia 34. Forsyth 70. Pasquotank105. Other/Unknown 35. Franklin 71. PenderTotal 36. Gaston 72. Perquimans 4. Counties of Origin for Adult Care Home Residents For questions regarding this section, please call Healthcare Planning at (919) 855-3865 Please list in Column B the number of adult care home residents, from that county, who were living in the facility on October 1, 2017. In Column C give the total number of additional adult care home residents, from that county, who were admitted between October 1, 2018 and September 30, 2019. Report patients who were not NC residents on lines 101 through 105. ABCABCABCPermanent County of Residence for Individuals Prior to AdmissionLiving in Facility 10/1/2018Admitted 10/1/2018-9/30/2019Permanent County of Residence for Individuals Prior to AdmissionLiving in Facility 10/1/2018Admitted 10/1/2018-9/30/2019Permanent County of Residence for Individuals Prior to AdmissionLiving in Facility 10/1/2018 Admitted 10/1/2018-9/30/2019  1. Alamance 37. Gates 73. Person 2. Alexander 38. Graham 74. Pitt 3. Alleghany 39. Granville 75. Polk 4. Anson 40. Greene 76. Randolph 5. Ashe 41. Guilford 77. Richmond 6. Avery 42. Halifax 78. Robeson 7. Beaufort 43. Harnett 79. Rockingham 8. Bertie 44. Haywood 80. Rowan 9. Bladen 45. Henderson 81. Rutherford 10. Brunswick 46. Hertford 82. Sampson 11. Buncombe 47. Hoke 83. Scotland 12. Burke 48. Hyde 84. Stanly 13. Cabarrus 49. Iredell 85. Stokes 14. Caldwell 50. Jackson 86. Surry 15. Camden 51. Johnston 87. Swain 16. Carteret 52. Jones 88. Transylvania 17. Caswell 53. Lee 89. Tyrrell 18. Catawba 54. Lenoir 90. Union 19. Chatham 55. Lincoln 91. Vance 20. Cherokee 56. Macon 92. Wake 21. Chowan 57. Madison 93. Warren 22. Clay 58. Martin 94. Washington 23. Cleveland 59. McDowell 95. Watauga 24. Columbus 60. Mecklenburg 96. Wayne 25. Craven 61. Mitchell 97. Wilkes 26. Cumberland 62. Montgomery 98. Wilson 27. Currituck 63. Moore 99. Yadkin 28. Dare 64. Nash100. Yancey 29. Davidson 65. New Hanover 30. Davie 66. Northampton101. Georgia 31. Duplin 67. Onslow102. South Carolina 32. Durham 68. Orange103. Tennessee 33. Edgecombe 69. Pamlico104. Virginia 34. Forsyth 70. Pasquotank105. Other/unknown 35. Franklin 71. PenderTotal 36. Gaston 72. Perquimans PART F CURRENT OPERATING STATISTICS 1. Current Per Diem Reimbursement Rates/Charges. Please state the CURRENT (as of the date the application is signed) basic daily charges/rates for residents or patients in your facility in the following categories of care. For questions please call Certificate of Need (CON) at (919) 855-3873 Private Pay (Usual Customary Charge)Private Room (1 bed/room)Semi-Private (2 beds/room)3 or more beds/roomNursing Home$$$Adult Care Home$$$Special Care Unit (specify)________________$$$Special Care Unit (specify)________________$$$ MedicareCodeRateThree most frequent resource utilization group (RUG) codes and rates paid for them1. $2. $3. $ Medicaid Nursing HomeQuarterly RatesOct.-Dec.Jan.-Mar.Apr.-JuneJuly-Sept.$$$$ Medicaid Nursing Home RateSpecial Care Unit (specify)________________$Special Care Unit (specify)________________$ State/County Special AssistanceRateAdult Care Home$Special Care Unit (specify)________________$Special Care Unit (specify)________________$ Please complete only if applicable: Alzheimers Special Care Unit-Additional ChargeRateNursing Home$Adult Care Home$ PART G ADULT CARE HOME ADDITIONAL INFORMATION For questions please call Healthcare Planning at (919) 855-3865 Please give the number (1, 2, 3, etc.) of adult care home residents currently in facility with a physicians diagnosis of the following: a) Mental Illness (MI) which includes a psychiatric illness but does not include intellectual disability, developmental disability or Alzheimers Disease/Related Dementia. As defined under NC G.S. 122C-3 (21), Mental Illness means, when applied to an adult, an illness which lessens the capacity of the individual to use self-control, judgment and discretion in the conduct of his affairs and social relations as to make it necessary or advisable to be under treatment, care, supervision, guidance or control. Mental illnesses include but are not limited to major depression, schizophrenia, bipolar disorder, obsessive compulsive disorder (OCD), panic disorder, post-traumatic stress disorder (PTSD), and borderline personality disorder. b) Intellectual Disability/Developmental disability (ID/DD) c) Alzheimers Disease or related dementia. If a resident is dually diagnosed, only count the resident once, based on the primary diagnosis. Resident Age - years MI ID/DDAlzheimers/Related Dementia18 - 2021 - 3435 - 5455 - 6465 - 7475 - 8485 or olderTOTAL This license renewal application must be completed and submitted with the license fee to the Nursing Home Licensure and Certification Section, Division of Health Service Regulation prior to the issuance of a 2020 nursing home license. The undersigned submits this application for licensure for the year 2020 (subject to the provision of the Nursing Home Licensure Act, Article 6, Chapter 131E of the General Statutes of North Carolina and to the rules adopted thereunder by the North Carolina Medical Care Commission) and certifies the accuracy of this information. _______________________________________________ ____________________________________ Name of Chief Administrative Officer Title Signature: _________________________________________________________ Date: __________________ (Chief Administrative Officer or Representative)     2020 Renewal Application for Hospital:License No:  MERGEFIELD LICNO  MERGEFIELD FACILITY Facility ID:  MERGEFIELD FID  All responses should pertain to October 1, 2018 through September 30, 2019.  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