W. Va. Code R. § 65-7-4 - Certificate of Need Application

4.1. An application for a certificate of need shall be on forms approved by the board. The applicant shall submit the original and three (3) copies of the application to the board. The application shall have a verification signed by the Chief Executive Officer and the person or persons who prepared the application.

4.2. The application shall, at a minimum, include the following:

4.2.a. The identification of the applicant;

4.2.b. A copy of the governing body's approval of the proposal and its written authorization empowering specified individuals to sign the application and to act on its behalf;

4.2.c. A description of the project;

4.2.d. A timetable for implementation of the project, including the projected date for incurring the obligation for any capital expenditure;

4.2.e. A documented analysis of the need of the population to be served by the project, including the medically underserved, and the extent to which the proposed service will be accessible to the population;

4.2.f. Policies for patient admission and provision of fully or partially uncompensated care;

4.2.g. A documented analysis of alternatives considered by the applicant;

4.2.h. A documented analysis of the proposal's relationship to the existing health care system, including providers of direct, ancillary, and support services and health professional training programs in the area in which services are to be provided, and, when applicable, the extent to which the proposal will meet the needs of those training programs;

4.2.i. An analysis of the relationship of the proposal to the applicant's long-range plan on file with the board;

4.2.j. A documented analysis of the proposal's relationship to the state health plan;

4.2.k. An analysis of the extent to which competition allocates services of the type being proposed and promotes quality assurance, cost effectiveness and accessibility;

4.2.l. An analysis of the relationship of the proposal to the most recent statements of deficiencies and plans of corrections from surveys conducted by accreditation organizations and other federal, state and local inspection agencies, as well as copies of those survey reports or portions of the reports as may be required by the board;

4.2.m. Documentation of the availability of resources, including health care providers, management personnel and funds for capital and operating needs;

4.2.n. Copies of existing or proposed policies with respect to employment of facility staff and, where applicable, admission to medical staff membership;

4.2.o. A preliminary financial feasibility study which includes an analysis of historical and projected utilization, charges, sources of revenue, statements of revenues and expenses, a statement of changes in fund balance, a statement of cash flows, balance sheets, and a statement of the specific assumptions upon which the feasibility study was based;

4.2.p. Documentation of existing or proposed mechanisms for soliciting consumer input into the applicant's decision-making process;

4.2.q. In the case of construction projects, a documented analysis of the cost and methods of the proposed construction, including provisions for energy conservation and the probable impact of the proposed construction on the applicant's cost of providing health services;

4.2.r. If applicable, a documented analysis of the needs or circumstances of entities such as health professional schools, multi-disciplinary clinics and specialty centers which provide a substantial portion of their services to individuals not residing in the health service area in which they are located or in adjacent health service areas;

4.2.s. If applicable, a documented analysis of the needs and circumstances of research projects; and

4.2.t. If applicable, a documented analysis of the need and circumstances of health maintenance organizations.

Notes

W. Va. Code R. § 65-7-4