Health care regulations are always changing, and ensuring that your organization both understands and complies with requirements is an ongoing task. From CHNA reports to long-term care regulations, the INCompliance team can help walk you through the details.

The IRS rules allow some flexibility. In most cases, it should be defined geographically (zip codes, counties, MSAs, etc.), but in special circumstances (e.g., children’s hospitals, cancer hospitals, specialty units) may also be described by patient populations. Should include not only those the hospital would like to serve, but those available to serve (including through emergency department). Often, this will be the hospital’s service area which is generally a geographic area comprising 75 percent of the admissions.

Data for the CHNA should include federal, state and local sources and identify the following:

• Current and projected service area population and demographic information
• Existing hospital services
• Other health care providers and resources in the service area
• Health Professional Shortage Areas within the service area
• Health conditions of the area population

Data can be obtained from a variety of sources, including the following:

• State Health Department
• Community Health Rankings and Roadmaps
• Community Commons
• HRSA Data Warehouse
• Kids Count Data Center

The following organizations or groups may be considered for community input:

• Associations – Ohio Hospital Association, Children’s Hospital Association, regional hospital associations
• Consumers and individuals residing in the community
• Local business owners
• Physicians – both those on the medical staff and perhaps those who are not
• Local Departments and organizations – Job and Family Services, ADMHS Board, FQHCs, County Health Department, Aging, school districts, United Way

One way to gather, assess and use community input is to form a group of interested stakeholders from both within and outside of the hospital (could be called an “Advisory Council”) to assist with considering the data and input and identifying and prioritizing needs.

The hospital should review each significant need and consider the following:

• The burden, scope, severity or urgency of the need
• Estimated feasibility and effectiveness of possible interventions
• Health disparities associated with the need
• The importance the community places on the need
• Whether the need can be addressed alone or does it require partnering with another organization
• Whether the hospital has the capabilities and resources (e.g., skills, funding, knowledge) to address the need
• Services the hospital has that can help address the need
• Whether the hospital can change current business practices to help address the need

For each significant need addressed in a CHNA, the implementation strategy should include the following:

• Action steps
• Anticipated impact
• Programs and resources to commit to addressing the need
• Planned collaborations

While those may be a resource considered as a part of the CHNA, it is extremely unlikely that those activities followed the steps and included the level of external input required for CHNAs.

All significant needs are not required to be addressed. The implementation strategy must address each significant health need, indicating whether the need is one the hospital will address or not. If the need is not being addressed by the hospital, indicate the reason (e.g., limited resources, lacking expertise, etc.).

We assist in the conversion of space for nursing home and assisted living use. We can advise on space requirements, timing of notifications and notice requirements, and survey process.

We assist you in meeting licensure requirements and waiver regulations for participation in an assisted living waiver program. We can help with conversion of space and prepare notification filings to initiate licensure, certification under a waiver program and, if necessary, survey processes.

Our Certificate of Need expert was director of Ohio’s Certificate of Need program before joining our team. She will prepare and submit your Certificate of Need application and support you throughout the process, including support for administrative hearings.

We assist you in meeting licensure and certification requirements throughout the planning and implementation of bed sales and acquisitions, ensuring that the beds remain “valid” throughout the process. Serving as your liaison with Ohio Department of Health (ODH), we will prepare notification filings to initiate licensure, certification and survey processes.

Do you need additional long-term care beds? Are you struggling with low occupancy rates? We bring providers together to relocate beds to areas where they can be better utilized to enhance operations. We assist you by negotiating terms for bed transaction agreements and ensuring your interests are met throughout the process. Specifically, we provide:

• Preparation of Certificate of Need application
• A plan review to address licensure requirements
• Consultation on staffing requirements
• Preparation of variance requests
• Preparation of requests for a change in licensed capacity
• Interaction with the ODH throughout the licensure process
• Nursing Home Certification
• Franchise Permit Fee (Bed Tax) information
• Identify market value for bed operating rights

Our nursing home consultant will ensure that your interests are met during negotiations for allocation of the franchise permit fee associated with bed sales and acquisitions. We also advise on the optimal time for de-licensure of beds being relocated and the licensure of beds at the receiving facility to minimize your franchise permit fee liability.

Our director of regulatory services has worked with experts to develop rules for the Health Care Services (HCS) program, covering cardiac catheterization, open heart surgery, radiation therapy and pediatric intensive care unit services.

She developed and implemented the HCS program for the ODH and was the program’s administrator from its inception in 1997 through 2009. We can assist with the following:

• Initiating a new health care service
• Discontinuing an existing health care service
• Interpreting regulations and evaluating compliance
• Changing the scope of service or service level designation
• Preparing waiver and variance request for requirements not met or met in an alternative manner
• Conducting service review to evaluate compliance

Our director of regulatory services has 28 years of involvement with hospital registration as a program administrator with the ODH. Additionally, our director has provided consultation to the ODH regarding registration policy and rules and can help ensure that your registration is accurate. If you are having registration issues, we can work with the ODH to resolve problems and correct mistakes.