house of sakhi - hospital license application

8/9/2019 House of Sakhi - Hospital License Application

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Joint Commission InternationalAccreditation

Survey Application

for

HOSPITALS

Effective: January 2010Revised: 10 February 2010


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Hospital Survey Application Page 2of 26

HH OOSSPPIITTAALL AACCCCRREE DDIITTAATTIIOONN SSUURRVVEE YY AAPPPPLLIICCAATTIIOONN

PART 1

Check the type of survey you are applying for:

IN ITIAL ACCREDITATIO N TRIE NNIAL ACCREDITATION

FOR IN ITIAL SURVEY APPLICANTS: If you have provided clinical services for less than a year,please provide the date that your organization began providing clinical services.

04/ 23/ 2010dd / mm / yyyy

I . APPLICANT INFORMATION

A. Demographics

1. Organization N ame: (The entry text below, as entered, will be used for your certificates. Only a max imum

length of 60-characters is allowed.)

RACHEL SAKHI ATTORNEY

2. Facility Address:

5225 FIGUEROA MOUNTAIN ROAD[street number and name]

[P.O. Box]

LOS OLIVOS, CALIFORNIA[city/ province and/ or state]

93441[postal/ zip code]

UNITED STATES OF AMERICA[country]

www.p4style.us[website address]

3. Main Telephone Number:805 294 32

[country code] [city code] [number]


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4. Ownership:HJTT % RACHEL SAKHI[Owner Name/ Parent Company]

Choose applicable Ownership Type from the list below.private / non-government

public / governmental

public / private mix

governmental / military

Other

Mailing Address: (if different from above)5225 FIGUEROA MOUNTAIN ROAD[street number and name]

[P.O. Box]

LOS OLIVOS, CA[city/ province and/ or state]

93441[postal/ zip code]

USA[country]

5. Ownership Primary Contact:

Name: Dr. Rachel Lynne-Sakhi[Mr./ Mrs./ Miss/ Ms./ Dr.]

Title: Registered Agent

E-mail: [email protected]

Tel: 805 294 32[country code] [city code] [number]

Fax:[country code] [city code] [number]


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B. Organization Contacts

6. Staff Information: Fill in the names, titles, telephone numbers and email addresses for the individuals listed below

Chief Executive Officer: (or equivalent)Name: Dr. Rachel Lynne-Sakhi

[Mr./ Mrs./ Miss/ Ms./ Dr.]

Title: Chairwoman & President



Fax:

[country code] [city code] [number]

Individual responsible for Medical services(or equivalent)Name: Dr. Rachel Lynne-Sakhi






Individual responsible for Nursing services(or equivalent)Name: Dr. Rachel Lynne-Sakhi







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Accreditation Survey Coordinator: (provide contact information)Name: Dr. Rachel Lynne-Sakhi






7. Individual responsible for completing this application

If this individual is the same as an individual listed above, add only their nameName: Dr. Rachel Lynne-Sakhi






8. Individual responsible for processing invoices and payments:Name: Dr. Rachel Lynne-Sakhi


Title: Medical Director





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C. General Information

9. Are there laws or regulations requiring your organization to have a current operating permitor license?

Yes* No

a) * If yes, please submit a copy of the permit or license along with this application. Theapplication cannot be accepted until a copy of the license is received.

b) If no, please name the government agency that grants your organization the authority tooperate and provide services

10. Are you applying as a hospital that is located within another hospital?

Yes No

If yes, what is the name of the hospital in which you are located?

11. Please provide your usual hours of operation, and provide information on any dailyreligious observances, staff functions, etc. that will need to be part of the survey agenda andactivities of the survey team.

Regular Business Hours

12. In the box below check any changes that you anticipate will happen within the next 12months related to the applicant organization and give a brief description of what willchange.

Check Type of Change Description

Ownership Change of Ownership of Property

Clinical Medical Services (new services or expansion ofservices)

Establishment of Clinical Medical Services

Organization Management Integration of Organization Management

Patient Care Buildings (new or renovations planned) Establishment & Infrastructure Installation of PatientCare Building (Renovations & New Construction)


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13. In what language is the medical record documentation written?

English & Spanish

14. In what language are the policies, procedures, and committee minutes written?

English & Spanish

15. In what language is patient care conducted?

English or the Primary Language.


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16. Site Demographics and Building Codes: Specific information is required in order to assist inthe development of the on-site survey agenda. The information needed includes the location(s),distance(s), and occupied areas (square meters) of the organization's physical layout (both on themain campus and/ or off campus locations) where the health care services are provided. Also

needed are the local or national codes under which the buildings were designed and are beingmaintained, and the approximate age of each site. Please fill in the information on this form. Listeach building separately: See Addendum on page 19for additional form(s).

Building Name Address:

Include num ber, street,and city

Is this building locatedon the Main campus oris it an additional site?

(check box)

If an additional site:include Kilometersfrom main campus

Parcel # TBD; Zone TBD Main campus N/ A

Additional site

Building Code(s) followed:

None

Age of building:Area - square meters:


Additional site


None



Additional site


None



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PART 2I . ORGANIZATIONAL DESCRIPTION

A. In-patient Services

21. Total number of beds: As Needed

22. Total number of holding or observing beds: As Needed

23. Average daily in-patient census: To Be Determined

24. Emergency room annual visits: On Demand

25. Does the organization conduct or participate in any research or clinical trials?

Yes No

If yes, please list the research or clinical trials currently underway.To Be Determined/ As per Schedule

26. Does the organization serve as a site for training health care students or residents?

Yes No

If yes, please check the type of students who are on-site and list the number of students on-site annually.

Type of Student Number on-siteAnnually

Medical students

Dental students

Medical Residents

Nursing students

Allied health students (PT , OT, RT, dietitian)

Other To Be Determined




27. List the top five primary patient discharge diagnosis and the top five surgical proceduresperformed. Enter the information in the table provided below.

Top Five Primary DischargeDiagnoses

Top Five SurgicalProcedures

To Be Determined To Be Determined






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29. In-Patient Care Units/ Wards: Using the table below please list each Inpatient Care Unit/ Wardincluding the additional information requested. See the example in the first two lines.

NOTE: List each patient unit/ ward separately. The survey team needs to know each area thathouses patients in order to select those areas that will be visited during tracer methodology sessions.

Include patient care units located at the main site as well as any areas that are separate from thehospital. If you need an additional form please click on this link to down load an additional form.Download and complete as many forms as necessary and submit all completed forms with yourapplication. See Addendum on page 19for additional form(s).

Please check the last column only if anesthesia/ sedation is administered in the location listed. Ifyou need the Joint Commission International Accreditations definition of Anesthesia andSedation1.

Name ofUnit/ Ward

AverageDaily

Census

Type ofCare Given

Floor Building N ame Check here if Anesthesia /

SedationAdministered

Example: Ward A 32 Surgical Intensive Care 3 Main site

Example: Ward B7 10 Mental Health 2 Building C

1

The administration to an individual, in any setting, for any purpose, by any route, medication to induce a partial or total loss of sensation for the

purpose of conducting an operative or other procedure.


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30. List the type of surgical/ operating room theaters, the number you have, and the building inwhich they are located.(Include all locations and buildings where surgery is provided, such as obstetrics operating theater, general operating theater,

cardiac operating theater, pediatric operating theater, outpatient operating theater, and so on.)

Operating Theater Number Building Name

31. List Non-clinical H ospital Departments or Services. (non-clinical services that support the hospital such ashuman resources, housekeeping, dietary, information systems, finance)

32. List any contracted services.Contracted services are defined as services provided through a written agreement with another organiz ation, agency, or individual,

the agreement specifies the services or personnel to be provided on behalf of the applicant organiz ation. For ex ample, a hospital

may contract with another organization for services such as pathologists, physical therapists, reading x -rays, dietary emergencyroom physicians, medical specialists.

Name of contracted organization Services provided


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B. Out Patient Services

33. List Outpatient Units, the number of annual visits, and the type of service provided.(E x ample: Surgical clinic, 150 visits per month, pre and post operative procedure evaluation and treatment).

NOTE: See Addendum on page 19 for additional form(s).

Name of OutpatientUnit or Clinic

Numberof Annual

Visits

Type ofCare Given

Floor Building N ame Anesthesia / Sedation

Administered

Sample: Surgery Clinic 5 Pre and post operativeprocedure evaluation

and treatment

1 Building G

Sample: BehavioralHealth Outpatient Clinic

10 Mental Health 1 Main Site

Total Number ofAnnual Visits

0


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PART 3I . ADDITIONAL SERVICES

A. Medical Transport

34. Do you own and operate a medical transport service that provides Emergency MedicalTransport Services to the community?

Yes If you answered Y es, continue to # 35 and # 36 below.

No If you answered N o, please sk ip to section B

35. Number of medical transports per year. ON DE MAND

36. Does the medical transport service use advanced life support/ paramedics?

Yes

No

B. H ome Care Services

37. Does your organization provide services in an ind ividuals home?

Yes If you answered yes, please complete # 38 through # 40

No If you answered no, go to Part IV

38. Average number of individuals visited in the home per day. ON DEMAND

39. Total number of home visits made per year. ON DEMAND

40. Please indicate the type of care provided in the patients home:(check all that apply)

Home Health (nursing service)Personal Care and supportHome Medical EquipmentHome PharmacyHospice Service/ Palliative Care in the homeOther (please specify) TBD


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PART 4I . SCHEDULING AND TRAVEL (Section Must Be Completed In Full)

A. Scheduling

41. Please indicate three months in which the organization could have the survey scheduled.

Month Year

05 2010

06 2010

07 2010

42. Please indicate up to a MAXIMUM of five other weeks during the year to avoid scheduling

a survey, if preferred months cannot be accommodated.

FromDD/ MM/ YY

ToDD/ MM/ YY

08/ 01/ 10 08/ 30/ 10

09/ 01/ 10 09/ 27/ 10

10/ 01/ 10 10/ 31/ 10

11/ 01/ 10 11/ 31/ 10

12/ 01/ 10 12/ 31/ 10

B. Traveling Instructions

43. Air Transportation: Please indicate the airport(s) nearest to your organization that the surveyorsshould fly into.Sycamore Valley Airfield

44. Ground Transportation: Please provide travel directions from airport to hotel.

Please provide the following to assist the surveyors in making their ground transportationarrangements.

From Airport to H otel: Recommended method of transport (taxi, car service, etc)

From H otel to Airport: Recommended method of transport (taxi, car service, etc)


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From H otel to Organization: Recommended method of transport (taxi, car service, etc)

Please provide travel direction from hotel to organization.

Surveyor Assembly: Location to which surveyors should go. (building name and/ or number anddoor entrance, if applicable)

Assembly Point at organization when surveyors arrive.

45. Recommended Hotel Accommodations: (high-speed internet access is required)Please recommend two to three business hotels near your organization that have high-speed internet access.High-speed internet access is required for the surveyors to complete the survey report each evening. If

possible, please include the Marriott, Hilton or Intercontinental hotel nearest to your organization, as thesehotels provide preferred rates for the surveyors. If your organization has a preferred rate with business hotelsnear your organizations, please include the specific information and directions for obtaining the preferredrates for surveyors.

H otel N ame Address/ Web site Distance to hospital Telephone/ Fax(please include countryand city code)

Kilometers Phone:

Travel time Fax:

Kilometers Phone:

Travel time Fax:

Kilometers Phone:

Travel time Fax:

Kilometers Phone:

Travel time Fax:

Kilometers Phone:

Travel time Fax:

NOTE: For insurance/ security purposes the survey team is required to make travelreservations through JCI's travel agent.


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46. Please enter any comments or other information you feel may be pertinent for surveyorstraveling to your survey.

47. Date application completed: 04/ 23/ 2010dd / m m / yyyy


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PART 5

I. AUTH O RIZATION

The undersigned makes request to Joint Commission International for an accreditation survey of theApplicant Organization named below. By signing this document we hereby provide accurate and truthfulinformation within this application. Also, by signing this document, we hereby authorize JCI to obtain anyrecords and reports about this organization that may be available from other agencies and/ or organizationsthat may be pertinent to the survey.

I am authorized to make this agreement on behalf of:

Name of Applicant Organization: RACHEL SAKHI ATTORNEY

Name: Rachel Sakhi

Title: Authorized Representative

Signature:

Date: April 23, 2010

I have also included a copy of the organ izations license (Part I Section C)

Signature

Return Completed Application long with any Additional Forms Usedby FAX or EMAIL to:

Joint Commission International AccreditationFax: +1 630 268 2996

ORE-mail: [email protected]


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ADDENDUM(S)SEE FOLLOWING PAGES


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Additional Form(s): # 16




(check box)


Main campus N/ A

Additional site


None


Main campus N/ A

Additional site


None


Main campus N/ A

Additional site


None


Main campus N/ A

Additional site


None



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Additional Form(s): # 16




(check box)


Main campus N/ A

Additional site


None


Main campus N/ A

Additional site


None


Main campus N/ A

Additional site


None


Main campus N/ A

Additional site


None



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Additional Form(s): # 29 In-Patient Care Units/ Wards

Name ofUnit/ Ward

AverageDaily

Census

Type ofCare Given






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Additional Form(s): # 29 In-Patient Care Units/ Wards

Name ofUnit/ Ward

AverageDaily

Census

Type ofCare Given






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Additional Form(s): # 33 Out-Patient Services


Numberof Annual

Visits

Type ofCare Given


Administered

Sample: Surgery Clinic 5 Pre and post operativeprocedure evaluationand treatment

1 Building G




0


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Additional Form(s): # 33 Out-Patient Services


Numberof Annual

Visits

Type ofCare Given


Administered

Sample: Surgery Clinic 5 Pre and post operativeprocedure evaluationand treatment

1 Building G




0

house of sakhi - hospital license application

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