Application for Admission to the New Mexico Patients Compensation Fund

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1 Application for Admission to the New Mexico Patients Compensation Fund This application will aid our determination of the appropriate terms of coverage in the New Mexico Patients Compensation Fund (NMPCF) for your hospital or outpatient healthcare facility. This application must be completed in full and signed by an authorized officer of your organization. The information provided in this application will be held in strict confidence. If you have any questions regarding this application, please contact Alan Seeley at (505) or at Please return the completed and signed application to: Alan Seeley Insurance Division New Mexico Public Regulation Commission Physical address: 1120 Paseo de Peralta, 4 th Floor, Santa Fe, NM Mailing address: P.O. Drawer 1269, Santa Fe, NM

2 SECTION I GENERAL INFORMATION A. APPLICANT 1. Legal Name of Facility/Name of Applicant (First Named Insured) 2. Street Address (City) (State) (Zip) 3. Billing Address (City) (State) (Zip) 4. Telephone. ( ) 5. Type of Facility Hospital Outpatient Facility 6. How many years has the facility been in operation? 7. How many years has the facility been under present ownership? 8. Brief Description of Operations: 9. Are any management services provided for others? If YES, please describe: 10. Contact Person: Phone Number: Address: Fax Number: B. GENERAL INFORMATION 1. Facility is: (Check all appropriate boxes) Children s Hospital General Hospital Rehabilitation Hospital Clinic(s) Outpatient Facility Skilled or Extended Care Facility Corporation t for Profit Teaching Hospital Delivery System Network Psychiatric Hospital Tertiary Hospital For Profit Other Specialty (explain) 2

3 2. a. Is the facility accredited by the Joint Commission on Accreditation of Healthcare Organizations? Date of last accreditation: Please attach a copy of the most recent survey. b. Is this facility licensed by the State? Please attach a copy of the most recent survey. c. Is this facility Medicare approved? If NO, please explain: SECTION II COVERAGE INFORMATION A. COVERAGE 1. Current Liability Coverage: (Please attach copy of policy declarations page) a. Carrier: b. Policy Period: c. Deductible: d. Coverage Limits: e. Premium for the Last Five Years: Carrier Year Premium 2. Past Coverage: Has any insurer canceled or declined to issue Professional Liability Insurance for this facility? If YES, please explain on a separate sheet of paper. 3. Loss History: Please attach a loss history for the past five (5) years including the current year and include a breakdown of total incurred losses, paid losses, and outstanding losses separated by year of occurrence for Professional Liability claims. Also attach a loss history in similar format for General Liability claims. Additionally, please provide full details of any claims paid or outstanding during this period in excess of $100,000 (paid) and $50,000 (outstanding). 4. Have all known claims and incidents which may give rise to future claims been reported to past or current insurers? 5. Has the facility conducted a recent review of incidents and other potential claims, and have all been forwarded to the facility s current insurer? If YES, when: By whom: 3

4 6. Has the facility or other associated entity ever lost a license or been placed on probation by any governmental licensing agency? If YES, explain on a separate sheet of paper. 7. Has the facility entered into any joint ventures or limited partnerships? If YES, explain on a separate sheet of paper. 8. a. Does the facility participate in any teaching programs? If YES, please give the type of program, describe the relationship, and who supervises the students: b. Is the program sponsored? If YES, please provide the name of the sponsoring institution: 9. Do you anticipate an expansion of your facility within the next year? 10. Does your facility manage any non-owned entities? If YES, please explain: 11. Are any of the hospital s units or facilities managed by a third party? If YES, please explain and provide a copy of the agreement. 12. Does the facility rent or lease any equipment from others (medical equipment, computers, beds, etc.)? If YES, please describe and indicate the value of the items: 4

5 SECTION II COVERAGE INFORMATION B. PHYSICAL PREMISES a. Beds Hospital Beds Hospital Bassinets Deliveries excluding C Section (Actual Number) Deliveries C Sections (Actual Number) Psychiatric/Substance Abuse Beds Rehabilitation Beds Nursing Home Beds Assisted Living Beds Total Licensed Beds Total Average Annual Occupancy b. Breakdown Hospital Inpatient CURRENT YEAR Estimated Average Annual Occupancy/Visits PRIOR YEARS Acute Care Beds, Cribs, Bassinets: Daily Average Number Occupied Intensive Care Beds: Neonatal Intensive Care Beds: Extended Care Beds: Acute Psychiatric Care Beds: Chemical Dependency Visits: Physical Rehab Visits: Emergency Room Physicians Number of Patients Emergency Visits: Total Number of Visits Department Visits Other Outpatient Visits: Total Number of Visits Counseling: Total Number of Visits Clinics, Dispensaries, Infirmaries Visits Reference Lab: Total Number Home Health Care Visits: Total Number Surgeries: Outpatient Surgeries: Inpatient Deliveries: Total Number Other Hospital 5

6 SECTION III PRACTICE INFORMATION A. PERSONNEL 1. Indicate the number of persons employed by the hospital in each of the following classifications: Certified Registered Nurse Anesthetists Dentists* Emergency Medical Technicians Laboratory or X-ray Technicians Licensed Vocational/Practical Nurses Nurse s Aides Nurse Midwives Nurse Practitioners* Paramedics Registered Nurses Respiratory Therapists Pharmacists Physician Assistants* Physicians & Surgeons* Residents Interns/First Year Residents Other (explain) *Please provide separate listings of names and specialties (and contract, if applicable) for each. 2. Please indicate the number of independent allied staff: Midwives Nurse Anesthetists Nurse Practitioners Physician Assistants Therapists Physicians & Surgeons 3. Please indicate the number of hours worked per week during the current year for each of the following: Certified Midwives CRNAs On-Site Supervision CRNAs On-Site Supervision Dentists NOC (Contracted) Dentists NOC (Employed) Dentists/Oral Surgeons (Employed) Dentists/Oral Surgeons (Contracted) Nurse Practitioner Optometrists Physicians or Surgeons Assistants Podiatrists Major Surgery Podiatrists Surgery Student (CRNAs) Student Nurses Medical Students/Externs 6

7 SECTION III PRACTICE INFORMATION B. SERVICES 1. a. Check all of the following classifications present in hospital and indicate the number of persons employed by the hospital in each classification: Abortion Clinic Emergency Room Nursery Outpatient Surgi- Centers Acute Rehabilitation Extended Care Neonatal Pharmacy Ambulance Service Fitness Wellness Center OB/GYN Blood Bank Burn Units Cardiac Catheterization Centers Health Maintenance Organizations Home Health Care Hospice Off Premises Clinics Off Premises Food Services Off Premises Labs Coronary Care Unit Hospital Foundation Oncology Day Care Inhalation Therapy Open Heart Surgery Physician Hospital Organization or IPA Psychiatric/Chemical Dependency Skilled Nursing Care Surgery Transportation Services (other than ambulance) Trauma Surgery Dental Services Intensive Care Unit Organ Bank Urgent Care Dialysis Mobile Unit (bloodmobiles, mammography, cat scan units, etc.) Organ Transplants Neonatal Intensive Care Physical Therapy Intravenous Therapy Respiratory Therapy Other (explain) b. Are any of these services contracted? If YES, which ones? 2. Indicate the number of exposure units in the current year for the classes noted. Class Units Exposure Units: Current Year Wellness Center Medical/X-ray Laboratory Intravenous Therapy & Dialysis Pharmacy *Receipts *Receipts *Receipts *Receipts Total # employees # *Receipts for services performed for outside firms, not hospital patients. 7

8 SECTION III PRACTICE INFORMATION C. STAFF PRIVILEGES 1. a. Are credentials for new staff members checked and approved prior to granting staff privileges? By whom?: b. How are the applicant s degree(s) and experience verified? 2. Are privileges probationary for at least six months for all new staff members? 3. Do you have any staff members who are not licensed or who have restricted licenses or privileges? If YES, explain on the comment page. 4. a. Do department heads evaluate the work of their staff members? b. Are these evaluations done in writing? c. Is an ongoing medical audit maintained on all staff members clinical work? 5. Are all staff privileges reviewed each year? 6. Do you require all foreign school graduates to be certified by the Educational Council for Foreign Medical School Graduates? 7. Staff members malpractice insurance: a. Are all staff members required to maintain malpractice insurance? b. Is this requirement stated in the staff bylaws? c. What limits are required? d. What evidence of compliance is required? a. Is NMPCF coverage required for eligible staff? Please explain any NO answers on the comment page. 8. Number of staff physicians in each category: Active Consulting Emeritus Assistant Courtesy Probationary 9. Number of physicians assistants 10. Number of certified nurse practitioners D. CONTRACT SERVICES 1. Identify any contracted professional services performed at the hospital: Anesthesia Services Nursing Services Pathology/Laboratory Radiology ER Services Other Services (explain): Please submit a copy of each such contract. 2. Are there any other (professional) service contracts in effect? Describe services: Do you indemnify (hold harmless) the service provider? If YES, submit a copy of the contract. 8

9 SECTION III PRACTICE INFORMATION D. CONTRACT SERVICES (continued) 3. Are there any other source contracts in effect? Please explain: 4. Are contract providers required to carry professional liability or general liability insurance? Limits: E. RISK MANAGEMENT 1. Is there a written, formalized Risk Management Program? 2. Does the Program require periodic recertification for pathogens, HIPAA, disaster, fire, violent attacks? Please provide a copy of the Risk Management Program. F. EMPLOYEES 1. Are licenses and certifications for new (licensed/certified) employees checked prior to hire? 2. Are employees credentials verified in writing? 3. Are probationary and regular performance evaluations done in writing? If YES, please explain: 4. Does every employee receive a copy of their job descriptions and personnel handbook? In NO, please explain: 5. Are employees cross-trained to other units prior to assignment to another unit? Please explain: 6. What percentage of employee shifts are float, per diem or agency assignments over the period of a week? % 7. Are employees trained in the procedure to follow if medical orders are questioned? 8. Is there an employee relations program? 9

10 SECTION IV GENERAL QUESTIONS A. GENERAL QUESTIONS 1. Does another facility provide management services to your hospital? (If YES, please provide name and address of the entity and a copy of contract.) 2. Percent of RN care hours as a total of all nursing care hours: % 3. Percent of contract (agency) RN hours as a total of all nursing care hours: % 4. Licensed Nurse/patient ratio (e.g. 1:X); Surgery: Critical Care: 5. Total number of physicians with hospital privileges: 6. Are all medical staff required to provide a Certificate of Insurance? 7. Any plans to purchase other healthcare facilities? 8. Do you provide telemedicine services? If YES, please describe: B. EMERGENCY DEPARTMENT 1. What percent of Emergency physicians are board certified? % 2. Are all Emergency physicians PAL certified? 3. Are all Emergency physicians ACLS certified? 4. Are all Emergency physicians ATLS certified? 5. Do all discharge instructions contain specific contact information and time frame for follow-up visits? If NO, please explain: 6. Are protocols in place for rapid treatment of high risk presentations? (e.g. chest pain, abdominal pain, pneumonia, children with fever, headache and trauma)? 7. Provide the following annualized data for the past 12 months: a. Average wait time in minutes (arrival to treatment time): Minutes b. Average length of time in ED in hours (arrival to physical discharge): Hours C. RESIDENTS 1. Do you have residents/fellows at your hospital? 2. Does your residency/fellowship program include defined scope of care and supervision requirements for different levels of training? 3. Is the hospital part of an accredited medical school? D. OBSTETRICS 1. Do you provide Obstetrics? 2. Are PALS/NALS/ACLS trained staff present at every delivery? 10

11 E. CREDENTIALING/STAFF PRIVILEGES 1. Does the re-credentialing process include a confirmation of competence regarding procedure specific staff privileges? 2. Do you credential/appoint your physicians every two (2) years? If not, how often? 3. Do you credential/appoint non-physician providers (CRNA, PA, NP, etc.) every two (2) years? If not, how often? 4. Are current Certificates of Insurance kept on file for all medical staff? 5. J.A.C.H.O. Accredited? Date of Last Accreditation: 6. State Certified? Date of Last Certification: SECTION V - SIGNATURE REPRESENTATIONS AND AUTHORIZATIONS I represent that the information provided in this application (and its attachments) is true and that no material facts have been suppressed or misstated. I understand that the information we are providing in this application may materially influence the determination of our surcharges and coverage conditions under the New Mexico Patients Compensation Fund. I further understand that the New Mexico Patients Compensation Fund may terminate any coverage it may provide to us if it discovers any intentional misrepresentations or omissions in this application. Further, I agree to notify the New Mexico Patients Compensation Fund of any material change in the information provided. I am aware that completion of this application does not guarantee coverage for the applicant in the New Mexico Patients Compensation Fund. NOTICE: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD THE NEW MEXICO PATIENTS COMPENSATION FUND FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. (Print/Type Exact Name of Facility) (Date) (Signature of Authorized Officer) (Title) (Printed/Typed Name of Authorized Officer) (Telephone Number) 11

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