INSTRUCTIONS FOR

COMPLETION OF CERTIFICATE OF NEED APPLICATION

FOR DESIGNATION AS A PERINATAL FACILITY

SECTION I. GENERAL REQUIREMENTS

1.	CERTIFICATE OF NEED

A.	PRE-SUBMISSION

Prior to the preparation of the application materials, it is strongly recommended that the applicant discuss the proposed designation with the Maternal and Child Health Consortium for the region, and staff of the New Jersey Department of Health. All information provided on the application shall be in accordance with N.J.A.C. 8:33, N.J.A.C. 8:33C and N.J.A.C. 8:43G.

B.	SUBMISSION - NEW JERSEY DEPARTMENT OF HEALTH

Submit one completed application in electronic media and 35 paper copies (no binders please) of the application forms and all required documentation to:

Mailing Address:

New Jersey Department of Health

Office of Certificate of Need and Healthcare Facility Licensure

P. O. Box 358

Trenton, NJ 08625-0358

Overnight Services (DHL, FedEx, UPS):

New Jersey Department of Health

Office of Certificate of Need and Healthcare Facility Licensure

25 South Stockton Street, 2nd Floor

Trenton, NJ 08608-1832

Applications must be submitted in conjunction with all other regional applications for facilities in accordance with the provisions set forth at N.J.A.C. 8:33C-1.1 et seq.

C.	SIGNATURE

All applications must be signed by the current Chief Administrative Officer or Board Chairman of the Hospital.

D.	FILING FEE

All applications must be accompanied by a certified check, cashier's check, or money order made payable to "Treasurer, State of New Jersey." Failure to submit the appropriate fee at the time of filing may result in rejection of the application.

Application Fee:

$7,500 (Projects $1,000,000 or less)

$7,500 + 0.25% of Total Project Cost (Projects greater than $1,000,000)

E.	COMPLETENESS

1.	ALL QUESTIONS REQUIRE AN ANSWER AND MUST BE COMPLETELY FILLED OUT.

2.	Certificate of Need forms must be filed in sequential order. Do not re-number pages.

3.	All exhibits must be identified as noted herein and attached to the back of the Certificate of Need Application form and referenced to the corresponding item in the appropriate section.

4.	Identify each response in the narrative section by question number and respond in sequential order. All additional supporting documentation must be attached to the back of the Certificate of Need form after the exhibits, in Section titled "Appendix".

5.	Only complete applications will be processed [N.J.A.C. 8:33-4.5(a)]. Failure to submit all required information and documentation and/or to follow the steps outlined herein when the Certificate of Need is filed may result in a determination that the application is incomplete and, as such, may not be accepted for processing.

F.	MODIFICATION

No application may be altered or modified by an applicant after the deadline date for application submission. Additional information shall be permitted only in direct response to written questions submitted to the applicant by the New Jersey Department of Health.

2.	MATERNAL AND CHILD HEALTH SERVICES

Application for perinatal designation will result in on-site verification of services and documentation. Questions regarding service delivery, site visits, and designation process should be directed to:

New Jersey Department of Health

Maternal, Child and Community Health Services

PO Box 364

Trenton, NJ 08625-0364

609-292-5616

3.	STATE HEALTH PLANNING

Need projections are based on bed need formulas contained in N.J.A.C. 8:33C and are published in the relevant CN call.

4.	LICENSING

Licensing manuals for hospital-based services may be obtained from the New Jersey Department of Health, Office of Certificate of Need and Healthcare Facility Licensure (609-292-8773) or online at the Department website at www.nj.gov/health.

5.	FINANCIAL

Applicants should contact the New Jersey Department of Health, Health Care Financing Systems (609‑984‑6298) to obtain information with regard to financial requirements.

6.	CONSTRUCTION

Applicants should contact the New Jersey Department of Community Affairs, Health Plans Review Program (609-633-8153) to obtain information regarding construction requirements.

New Jersey Department of Health

Office of Certificate of Need and Healthcare Facility Licensure

PO Box 358

Trenton, NJ 08625-0358

APPLICATION FOR CERTIFICATE OF NEED FOR DESIGNATION AS A PERINATAL FACILITY

INSTRUCTIONS:

All applicants must complete SECTION I, which begins on Page 1 and continues through Page 6,

and SECTION VI, which begins on Page 15. Applicants for the following designations must ALSO complete the appropriate Section indicated:

Community Perinatal Center-Intermediate	SECTION II, Page 7

Community Perinatal Center-Intensive	SECTION III, Page 8

Regional Perinatal Center	SECTION IV, Page 10

Neonatal Services as a Part of a

Specialty Acute Care Children's Hospital	SECTION V, Page 13

SECTION I

Name of Facility

Date of Application

Location Address

Mailing Address, If Different

Name of Contact Person

Telephone Number

Fax Number

Email Address

Name of Consortium of Which Facility is a Member

Source of Data

3-Year Trend 1-Year
Previously Approved Designation

Designation Requested

Community Perinatal Center-Birthing	Community Perinatal Center-Intensive

Community Perinatal Center-Basic	Regional Perinatal Center

Community Perinatal Center-Intermediate	Specialty Acute Care Children's Hospital
Number of Licensed Beds (Entire Facility)

Type of Hospital

Public	Private
Description of the Service Area (include a copy of a map showing the service area):

Services Provided

Medical/Surgical	Pediatrics	Critical Care (Adult)	Critical Care (Neonatal)

Obstetrics/Gynecology	Psychiatric	Critical Care (Pediatric)

Population Served for Perinatal/Obstetric Service:
Race Breakdown:
White:
Black:
Asian:
Native American:
Other:
Ethnicity Breakdown:
Hispanic:
Non-Hispanic:
Percent of Payer Mix:
Private Insurance:
Managed Care Program (e.g., HMO/PPO):
Medicaid:
Self-Pay:
Charity Care:
Age by Percent:
Less than 5 Years:
5 - 18 Years:
19 - 44 Years:
45 - 65 Years:
65+ Years
Sex by Percent:
Male:
Female:
Describe any other unique population characteristics in your regional area:

OUTPATIENT DATA
Healthstart Participation:
PEDIATRIC
PRENATAL
a. Is Hospital a Healthstart Provider?	Yes No
Yes No
b. If Yes, Provider Number:
c. If No, is Application Pending?	Yes No
Yes No
d. If Yes, Date of Application *
(* Provide copy of Healthstart Application with CN Application)
AMBULATORY SERVICES
Prenatal and Postpartum Services:
Days of Operation:
Hours of Operation:
Staffing (Number of FTE's):
RN's:
LPN's:
Social Service Personnel:
Nutritionists:
Nurse Practitioners:
Certified Nurse Midwives:
Family Practice Physicians:
Obstetricians:
Location: On-Site Satellite
Location, If Off Site:
Number of Unduplicated Patients Served:
% of Referrals:
To Home Follow-Up:
To WIC:
To High-Risk OB:
To Family Planning:
% Returning for Postpartum Services:
Number of Visits:
Percent of Payer Mix:
Private Insurance:
Managed Care Programs (e.g., HMO/PPO):
Medicaid:
% Healthstart:
Self-Pay:
Charity Care:
High-Risk Consultation/Services Available (describe where located, name of provider, and hours available for consultation):
AMBULATORY SERVICES, CONTINUED
Pediatric Services:
Days of Operation:
Hours of Operation:
Staffing (Number of FTE's):
RN's:
LPN's:
Social Service Personnel:
Nutritionists:
Nurse Practitioners:
Pediatricians:
Family Practice Physicians:
Location: On-Site Satellite
Location, If Off Site:
Number of Unduplicated Patients Served:
% of Referrals:
To Home Visit:
To WIC:
To Early Intervention:
Number of Visits:
Percent of Payer Mix:
Private Insurance:
Managed Care Programs (e.g., HMO/PPO):
Medicaid:
% Healthstart:
Self-Pay:
Charity Care:
High-Risk Consultation/Services Available (describe where located, name of provider, and hours available for consultation):
CONSULTANT SERVICES
Consultant Services Available:
On-Site	By Phone	24-Hour
Registered Dietician/Nutritionist	Yes	No	Yes	No	Yes	No
Geneticists/Genetic Counselors	Yes	No	Yes	No	Yes	No
Social Workers	Yes	No	Yes	No	Yes	No
Public Health Nurses	Yes	No	Yes	No	Yes	No
Physician Specialists	Yes	No	Yes	No	Yes	No
Lactation Consultants	Yes	No	Yes	No	Yes	No
INPATIENT DATA * (Report Previous Two (2) Years Separately)
Number of Deliveries Per Year:

Number of Pediatric Admissions:

Unit	Number of Licensed/ Approved Beds/ Bassinets	Patient Days	Occupancy Rate	Average Daily Census	Transfer

In	Transfer

Out	Total Number

of Beds/ Bassinets Requested	Number of Increase/

Decrease In Unit Size
Labor
Delivery
Recovery
LDR
Postpartum
LDRP
Newborn
Intermediate
Intensive Unit
* If Certificate of Need is for relocation of beds in a Health System, provide above data for each site separately.
Have any construction Certificates of Need been approved for your facility for the above services?
Yes No If Yes, include copies of blueprints.
a.	Is construction underway or to commence shortly?
Yes No
b.	Specify:
Are any construction Certificates of Need pending approval for your facility for the above services?
Yes No
a.	Specify:
Will the designation requested in this application require any new construction which will require a Certificate of Need?
Yes No
Does the facility currently meet all construction standards for the designation being requested?
Yes No
Will the requested bassinets be accommodated in existing space without physical plant/space waivers?
Yes No N/A – No bassinets requested
RESIDENCY PROGRAMS
Does your facility have residency programs in the following areas:
Obstetrics:	Yes	No	If Yes, Number of Current Residents:
Pediatrics:	Yes	No	If Yes, Number of Current Residents:
Family Practice:	Yes	No	If Yes, Number of Current Residents:
Description of Physical Plant for the Above-Mentioned Units and Surgical Suite for C-Sections.

Are all staffing requirements met for the type of designation for which you are applying?

Yes No

a.	If No, explain:

SECTION II

TO BE COMPLETED BY FACILITIES APPLYING FOR DESIGNATION AS A

COMMUNITY PERINATAL CENTER

-INTERMEDIATE
Number of Maternal-Fetal Transports Made:

Number of Neonatal Transports Made:

Staff Requirements (available on a 24-hour basis and able to arrive within 30 minutes or in hospital):

Obstetrician or Obstetric Resident with Three (3) Years of Training	Yes	No

Pediatrician with Training and Experience in Neonatal Medicine	Yes	No

Anesthesiologist/Nurse Anesthetist	Yes	No

Registered Nurse (clinical responsibility)	Yes	No

Registered Nurse Staff Ratio:

Newborn (Includes Licensed Nurses) 1:8	Yes	No

Intermediate 1:4	Yes	No
Attach copies of the following documentation:

1.	Copy of Perinatal Record Utilized by Providers

2.	Copy of Criteria for Transfer

3.	Copy of Letters of Agreement with Maternal-Fetal and Neonatal Transports

4.	Copy of Contracts with All Required Staff, Including Written Policy for Arrival Time
Describe home follow-up services for women and infants:

Describe family planning services:

SECTION III

TO BE COMPLETED BY FACILITIES APPLYING FOR DESIGNATION AS A

COMMUNITY PERINATAL CENTER

-INTENSIVE
Number of Maternal-Fetal Transports Made:

Number of Neonatal Transports Made:

Number of Neonatal Transports Accepted:

Staff Requirements

Available on a 24-hour basis and able to arrive within 30 minutes or in hospital):

Obstetrician	Yes	No

Neonatologist	Yes	No

Anesthesiologist with Special Training in Care of Neonates	Yes	No

Registered Nurse (clinical responsibility)	Yes	No

Available on a 24-hour basis and able to arrive within 30 minutes or in hospital):

Neonatologist, Neonatal Fellow or Pediatrician with Training in Neonatal Medicine	Yes	No

Registered Nurse Staff Ratio:

Newborn (Includes Licensed Nurses) 1:8	Yes	No

Intermediate 1:4	Yes	No

Intensive 1:2	Yes	No
Does your facility have a Neonatal Transport Team?

Yes No

If Yes, describe team members and vehicles:

Attach copies of the following documentation:

1.	Copy of Perinatal Record Utilized by Providers

2.	Copy of Criteria for Transfer

3.	Copy of Letters of Agreement with Maternal-Fetal and Neonatal Transports Made Out of Facility

4.	Copy of Contracts with All Required Staff, Including Written Policy for Arrival Time

5.	Copy of Letters of Agreement for Neonatal Transports Accepted
SECTION III, CONTINUED

TO BE COMPLETED BY FACILITIES APPLYING FOR DESIGNATION AS A

COMMUNITY PERINATAL CENTER

-INTENSIVE
Describe home follow-up services for women and infants:

Describe family planning services:

Describe provision or arrangements for high-risk infant screening and tracking program:

SECTION IV

TO BE COMPLETED BY FACILITIES APPLYING FOR DESIGNATION AS A

REGIONAL PERINATAL CENTER
Number of Maternal-Referrals (include co-managed or delivered at the RPC even if delivered by referring Obstetrician):

Number of Neonatal Transports Accepted:

Number of Low Birthweight Infants (<2500 grams) Managed in Preceeding 2 Years:

Number of Very Low Birthweight Infants (<1500 grams) Managed in Preceeding 2 Years:

Number of Neonatal Transports Accepted:

Percentage of Transports for the Region:

Attach copies of the following documentation:

1.	Copy of Perinatal Record Utilized by Providers

2.	Copy of Letters of Agreement with Maternal-Fetal and Neonatal Transports Accepted and Back Transports of Infants

3.	Copy of Contracts with All Required Staff, Including Written Policy for Arrival Time

4.	Copy of Contracts with Subspecialists, Including Written Policy for Arrival Time
Describe outreach and educational activities to professionals within the region (attach additional documentation if needed):

Describe follow-up home care services for high-risk women and infants:

SECTION IV, CONTINUED

TO BE COMPLETED BY FACILITIES APPLYING FOR DESIGNATION AS A

REGIONAL PERINATAL CENTER
Describe family planning services:

Describe high risk infant screening and tracking program:

Staff Requirements

Available on a 24-hour basis and able to arrive within 30 minutes:

Perinatologist	Yes	No

Neonatologist	Yes	No

Anesthesiologist with Special Training in Care of Neonates	Yes	No

Perinatal Clinical Specialist (with Master’s in MCH)	Yes	No

Available on a 24-hour basis, present in hospital:

Obstetrician	Yes	No

Neonatologist, Neonatal Fellow or Pediatrician with Training in Neonatal Medicine	Yes	No

Registered Nurse Staff Ratio:

Newborn (Includes Licensed Nurses) 1:8	Yes	No

Intermediate 1:4	Yes	No

Intensive 1:2	Yes	No
SECTION IV, CONTINUED

TO BE COMPLETED BY FACILITIES APPLYING FOR DESIGNATION AS A

REGIONAL PERINATAL CENTER
How long has the board certified perinatologist been on staff?
Years	Months
Does your facility have 24-hour consultation capabilities with subspecialists?

Yes No
Does your facility have antenatal testing capability?

Yes No

a.	If yes, describe all components and follow-up procedures:

Does your facility have a high-risk prenatal clinic under the direction of a board certified perinatologist?

Yes No

a.	If yes, give location:

Does your facility have a maternal-fetal transport team?

Yes No

a.	If yes, describe team members and vehicle used:

b.	Describe reasons for any maternal-fetal transports out of your facility:

Does your facility have a neonatal transport team?

Yes No

a.	If yes, describe team members and vehicle used:

b.	Describe reasons for any neonatal transports out of your facility:

SECTION V

TO BE COMPLETED BY FACILITIES APPLYING FOR DESIGNATION OF

NEONATAL SERVICES AS PART OF A

SPECIALTY ACUTE CARE CHILDREN’S HOSPITAL
Number of Low Birthweight Infants (<2500 grams) Managed in Past 2 Years:

Number of Very Low Birthweight Infants (<1500 grams) Managed in Past 2 Years:

Number of Neonatal Transports Accepted:

Attach copies of the following documentation:

1.	Copy of Contracts with All Required Staff, Including Written Policy for Arrival Time

2.	Copy of Letters of Agreement with Regional Perinatal Centers and All Acceptable Community Perinatal Centers Within the Region

3.	Copy of Contracts with Subspecialists, Including Written Policy for Arrival Time
Staff Requirements

Board Certified Neonatologist (available ona 24-hour basis, present in the hospital)	Yes	No

Perinatal Clinical Nurse Specialist	Yes	No

Registered Nurse (clinical responsibility)	Yes	No

Registered Nurse Staff Ratio:

Intermediate 1:4	Yes	No

Intensive 1:2	Yes	No
Does your facility have a neonatal transport team?

Yes No

a.	If yes, describe team members and vehicle used:

SECTION V, CONTINUED

TO BE COMPLETED BY FACILITIES APPLYING FOR DESIGNATION OF

NEONATAL SERVICES AS PART OF A

SPECIALTY ACUTE CARE CHILDREN’S HOSPITAL
Describe outreach and educational activities to professionals within the region (attach additional documentation if needed):

Describe high-risk infant screening and tracking program:

Describe subspecialty services available for neonates (e.g., ECMO, transplant surgery, etc.):

SECTION VI

TO BE COMPLETED BY ALL APPLICANTS
CERTIFICATION BY APPLICANT
I certify that by applying for the perinatal designation specified above in this application, all of the information provided in this application is true and correct to the best of my knowledge and ability.

I further certify that I have read and understand all the requirements of this designation as specified in N.J.A.C. 8:33C and N.J.A.C. 8:43G and that this facility meets all of those requirements for service.
Name of Individual Completing Form

Title

Signature

Date

APPLICATION FOR CERTIFICATE OF NEED FOR DESIGNATION AS A PERINATAL FACILITY

(Continued)

CN-4 (Instruction)

JUL 12	Page 2 of 2 Pages.

NOV 16	Page 1 of 2 Pages.

INSTRUCTIONS FOR

COMPLETION OF CERTIFICATE OF NEED APPLICATION

FOR DESIGNATION AS A PERINATAL FACILITY

NOV 16	Page 2 of 2 Pages.

CN-4

NOV 16	Page 15 of 15 Pages.

CN-4, Application for Certificate of Need for Designation as a Perinatal Facility

CN-4, Certificate of Need, Perinatal Facility, Application, CN,

EWhite

2014-10-30

NJDOH