Mercury Healthcare International Health Facility Inspection Checklist for Medical Tourism and Health

Mercury Healthcare International, Inc.

Maria K Todd Consultant, Speaker, Author, Patient Advocate, www.twitter.com/@AskMariaTodd http://MariaTodd.com

Mercury Healthcare International, Inc. Hospital Inspection Checklist for Medical Tourism and Health Travel Person conducting the inspection __________________________ Date ______________________

Facility Name and Details Name _______________________________________________________ Address________________________________________________ City ___________________ State _______ Country _______ Postal Code _____ Telephone: ______________________ Fax: ___________________________ Website URL: ___________________________________________________ Corporate Affiliation (chain/ brand) _____________________________________ Year established: _________ Date of last accreditation survey* __________________

Medical Travel Department Coordinator

General Description Name of Manager ________________________ Telephone _________________ Email address: __________________________ FAX: _____________________ VOIP Contact (Skype, WhatsApp, or similar) ________________________________

Primary Business Development Contact Name ______________________________Title _______________________ Email Address: ________________________ Telephone ___________________

Remittance Information Address to mail payments: ___________________________________________ Wire transfer details: ______________________________________________ To whom should Guarantee of Payment letters be directed: ______________________ Accounts Receivable Manager Name: ____________________________________ Accounts Receivable Manager Telephone: ______________ FAX: _______________ Accounts Receivable Manager Email: ____________________________________

Commissioning Details Facility is commissioned to operate as ___Acute Care Hospital ___ Outpatient Only ____ Inpatient Rehabilitation Center ____Outpatient Rehabilitation ___Psychiatric Inpatient ____ Long Term Care ___Hospice ___Transient Dialysis ___Urgent Care

___Polyclinic Licensing Authority Name: ___________________________________________ Licensing Authority Address: __________________________________________ Licensing Authority Telephone: _________________ FAX: ____________________ Focal Point for Verifications: ___________________________________________

Management Details President / CEO / Director General: ____________________________________ Telephone: ______________________ Email: ___________________________ Chief Medical Officer: _______________________ Specialty: _________________ Telephone: ______________________Email: ___________________________ Director of Nursing ________________________ Degree: __________________ Telephone: ______________________ Email: ___________________________

Patient Care Area # Private Rooms _________ # Operating Theaters _______ # ICU Beds ___________ # Critical Care Beds _______ # OP Surgery Observation Beds____ #Trauma Stations ____ # Pediatric Beds ____ # Burn Care Beds _____ # Transient Dialysis Stations ______ Average Daily Inpatient Census ____________

Medical Traveler Readiness Do all rooms have free Internet WiFi access for patients? _____ Do all rooms have television controlled by each patient? ______ How many television channels available to patients in hospital beds? ____ How many channels broadcast in English around the clock? _______ Do all rooms have dual signage including English language translation on emergency exit routes, patient fall prevention instructions, etc? _____ Are there rooms especially designated for medical travelers? _____ Qty: _________ Do each of these rooms have companion sleeping accommodations? _____ Is 24/7 meal service available for patient and companion? ____ Is the dietitian available to consult with the patient in English? ____ Are meals available with the following options: (circle available) Vegan Diet, Vegetarian Lacto/Ovo, Halal Preparation, Kosher Preparation, Other? ____________ Is there a telephone in each room for each patient? _____ Is the telephone enabled for international outgoing calls? ____ Is the telephone enabled for outgoing mobile phone calls? _____ Are there dialing instructions in English and other relevant languages located in the room for patients who wish to place a call from the telephone in their room? ____ Is there a patient guidebook that provides details about how everything works and whom to call for assistance located in the room printed in English and other relevant languages?

Charges What is the average daily rate for semi-private standard room and board in the hospital? ____ What is the average daily rate for private standard room and board in the hospital? ____ Are independent doctors able to compete on price when offering services to medical travel patients? ___________ Does facility offer upgraded medical traveler accommodations? _____ If yes, attach details.

Does the facility charge different prices to foreign patients? ______ If yes, why? _____________________________________________________

Nursing Services Are home care nurses available to visit the patient at a hotel if necessary? ____ % of nurses fluent in spoken and written English ___ % of nurses fluent in spoken and written Arabic ____ % of nurses fluent in spoken and written Russian____ % of nurses fluent in spoken and written Mandarin ____ % of nurses fluent in spoken and written Spanish ____ % of nurses fluent in spoken and written French____ % of nurses fluent in spoken and written German ____ Medical/Surgical floor Nurse to patient ratio _____ ICU/CCU Nurse to Patient Ratio Are all nurses who care for patients Registered Nurses or higher? _____ Are nursing notes and daily progress notes maintained in English? _____ Medical Staff # Full Time Active Medical Staff? __________ Are the physicians: ____ employed by the hospital ____ independent ____ Combination Are Credentialing and Privileging Procedures in accordance with JCI Standards or Equivalent? ____ Initially, how many physicians will be ready to participate in our medical tourism program? _____ Attach detailed list by name and specialty with contact details

Medical Records Systems Medical Records Software programs/platforms in use _________________________ Radiology PACS system? _____ Computerized Physician Order Entry? _______ Privacy and Security Encrypted? _________ Are the following Medical Records documented in English or other relevant languages? ____ If no, are they translated within 24 hours? ______ Initial History and Physical Operative Note ____ Consultant Reports ____ Discharge Summary _____

Attending Physician Progress Notes _____ Diagnostic Studies yes no Patient and Insurance Invoices yes no Therapist Notes ____ Diagnostic Studies _____ Patient and Insurance Invoices ______ Written Patient Training and Discharge Follow-up Care Instructions in English or other relevant languages? __________ All follow up patient written communications in English? ______

Quality, Outcomes and Satisfaction Monitorin Does the facility monitor Clinical Outcomes and Patient Satisfaction after departure? ______ If yes, how? _______________ How often is follow up conducted? _______________

Marketing and Promotion Patient Marketing Brochures and Website in English or other relevant languages? ________ Does the facility have a promotion video in English or other relevant languages? _________

Special Capabilities In which specialties does the hospital excel or have advanced capabilities? (Attach list with average # of cases in each specialty per day/week/month

Concierge Handling Does the hospital have established affiliations with a local concierge service for patient meet and greet on arrival and transfer back to the airport at departure?

Does the hospital verify driving history, insurance and accident records of the drivers it uses to transport patients? ______

Hotel /Accommodation Partnerships Does the hospital maintain collaboration partnerships with hotels, spas and other accommodation outlets? _______________ (Attach a list with details, contact focal points, average rates, limitations or specializations)

General Description Facility is primarily engaged in providing, by or under the supervision of physicians, to inpatients: bed and board, nursing services and other related services, hospital and surgical facilities and medical social services as are ordinarily furnished by the hospital for the care and treatment of inpatients, and such drugs, biologicals, supplies, appliances, and equipment, for use in the hospital, as are ordinarily furnished by such hospital for the care and treatment of inpatients; and such other diagnostic or therapeutic items or services, furnished by the hospital or by others under arrangements with them made by the hospital, as are ordinarily furnished to inpatients either by such hospital or by others under such arrangements.

Level(s) of Care (check all that apply) Acute Care: diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons Rehabilitation: services for the rehabilitation of injured, disabled, or sick persons Long-term Care: extended care services furnished to an inpatient of a skilled nursing facility including but not limited to nursing services performed by or under the supervision of registered professional nurses, bed and board, physical and/or occupational therapy or speech-language pathology services furnished by the skilled nursing facility or by others under

arrangements with them made by the facility; medical social services; such drugs, biologicals, supplies, appliances, and equipment, furnished for use in the skilled nursing facility, as are ordinarily furnished by such facility for the care and treatment of inpatients; medical services provided by an intern or resident-in-training of a hospital with which the facility has in effect a transfer agreement, under a teaching program of such hospital, and other diagnostic or therapeutic services provided by a hospital with which the facility has such an agreement in effect; and such other services necessary to the health of the patients as are generally provided by skilled nursing facilities, or by others under arrangements with them made by the facility.

Psychiatric Services: treatments and services for addiction recovery, medical detoxification, behavioral health services, eating and other disorders furnished to inpatients and/or partially-hospitalized patients.

Ambulatory / Same-Day Surgery Center: a facility where surgeries and other procedures are performed but the patient is discharged on the same day.

Academic Medical Center: a facility that operates a recognized and accredited intern or a resident-in-training teaching program IDTF: An independent diagnostic testing facility where imaging or laboratory or other diagnostic tests are performed that is independent from an inpatient facility.

Qualifications The facility maintains electronic medical records on all patients for a period of at least seven years. In the case of minors, records are maintained until their 26th birthday.

Electronic medical records are maintained in a secure encrypted server Copies of electronic medical records and images, reports, diagnostic studies, operative reports, admission and discharge summaries, physician and nursing notes are available to the patient or the patient's designee at no charge upon written request Bylaws are in effect with respect to its staff of physicians and other licensed and certified practitioners with privileges at the facility.

Credentialing and privileging policies, standards and primary source verification procedures are published and implemented. Privileges are granted by criteria-based core privileging for each specialty. Such criteria-based cor privileging incorporates predefined criteria in conjunction with clinically-realistic, well-defined, written core privileges. The term “core privileges� refers to those clinical activities within a specialty or subspecialty that any appropriately trained, actively practicing practitioner with good references would be competent to perform. In addition, the core must be defined based on the uniqueness of the practitioners who hold clinical privileges within a specialty or subspecialty and those services or procedures that a hospital or healthcare organization can support. In other words, the core should reflect what the majority of practitioners within a specialty or subspecialty are currently performing at that organization. In the criteria-based core privileging approach, practitioners who meet predefined criteria are eligible to apply for core privileges, and those who can document additional training and experience may request special (or noncore) privileges. If a practitioner meets criteria to request core privileges and the practitioner’s requests are supported by references attesting to his or her current clinical competence, privileges may be granted. Procedures requiring specialized training or experience beyond the predefined criteria for the core would be applied for and granted separately. The same is true for the privilege of performing what would otherwise be a basic procedure in a new or an unusual fashion (performing surgery by using a robot instead of a hand held scalpel). Special/noncore privileges nearly always correspond to one of the following: New advances in technology (i.e., introduction of new equipment or techniques) High-risk/problem-prone, volume sensitive diagnoses or procedures that would not be automatically incorporated within the core Scope of practice that may cross specialty lines Services, treatments, or procedures that take additional knowledge, skill sets, judgment, or ability to manage complications beyond those obtained in a residency program or those which require continuous performance of the procedure to maintain proficiency.

Written and implemented policies require that every patient be assigned to the service of a physician or qualified clinical psychologist with respect to such services.

The inpatient facility provides 24-hour nursing services rendered or supervised by a registered professional nurse, and has a registered professional nurse on duty at all times. For acute care hospitals, in general medical / surgical nursing areas, the patient to nurse staffing ration is no more than 4:1. In more intensive care settings, the ratio of patients to nurse is no more than 2:1.

Accreditation* The hospital is currently accredited by a program of the country in which such institution is located or comparable approval standards of such accreditor that is itself accredited by the International Society of Quality (ISQua) or ISO 9001:2018.

Accreditation or Certification by the Global Healthcare Resources' Accreditation (GHA) Program or from TEMOS, or MTQua or other such proprietary accreditation and certification programs not recognized by ISO or ISQua are not recognized accreditors for the purpose of this criteria.

Post-hospital extended care services

The facility offers post-hospital extended care services: extended care services furnished an individual after transfer from a hospital in which he was an inpatient for not less than 3 consecutive days before his discharge from the hospital in connection with such transfer. For purposes of the preceding sentence, items and services shall be deemed to have been furnished to an individual after transfer from a hospital, and he shall be deemed to have been an inpatient in the hospital immediately before transfer therefrom, if he is admitted to the skilled nursing facility (A) within 30 days after discharge from such hospital, or (B) within such time as it would be medically appropriate to begin an active course of treatment, in the case of an individual whose condition is such that skilled nursing facility care would not be medically appropriate within 30 days after discharge from a hospital; and an individual shall be deemed not to have been discharged from a skilled nursing facility if, within 30 days after discharge therefrom, he is admitted to such facility or any other skilled nursing facility.

The facility offers home-health or hotel-based services which includes the following items and services furnished to an individual, who is under the care of a physician, by a home health agency or by others under arrangements with them made by such agency, under a plan (for furnishing such items and services to such individual) established and periodically reviewed by a physician, which items and services are provided on a visiting basis in a place of residence used as such individual’s home or hotel or other temporary accommodation — (1) part-time or intermittent nursing care provided by or under the supervision of a registered professional nurse; (2) physical or occupational therapy or speech-language pathology services; (3) medical social services under the direction of a physician; (4) to the extent permitted in regulations, part-time or intermittent services of a home health aide who has successfully completed a training program approved by the Secretary; (5) medical supplies (including catheters, catheter supplies, ostomy bags, and supplies related to ostomy care, and a covered osteoporosis drug (as defined in subsection (kk)), but excluding other drugs and biologicals) and durable medical equipment and applicable disposable devices while under such a plan; in the case of a home health agency which is affiliated or under common control with a hospital, medical services provided by an intern or resident-in-training of such hospital, under a teaching program of such hospital; and any of the foregoing items and services which are provided on an outpatient basis, under arrangements made by the home health agency, at a hospital or skilled nursing facility, or at a rehabilitation center which meets such standards as may be prescribed in regulations, and— the furnishing of which involves the use of equipment of such a nature that the items and services cannot readily be made available to the individual in such place of residence, or which are furnished at such facility while he is there to receive any such item or service, but not including transportation of the individual in connection with any such item or service.

Other Medical and Health Services (check all that apply) Physician servicesservices and supplies (including drugs and biologicals which are not usually self-administered by the patient) furnished as an incident to a physician’s professional service, of kinds which are commonly furnished in physicians’ offices and are commonly either rendered without charge or included in the physicians’ bills Services and supplies (including drugs and biologicals which are not usually self-administered by the patient) furnished as an incident to a physician’s professional service, of kinds which are commonly furnished in physicians’ offices and are commonly either rendered without charge or included in the physicians’ bills Hospital services (including drugs and biologicals which are not usually self-administered by the patient) incident to physicians’ services rendered to outpatients and partial hospitalization services incident to such services.

Diagnostic services furnished to an individual as an outpatient by a hospital or by others under arrangements with them made by a hospital, and ordinarily furnished by such hospital (or by others under such arrangements) to its outpatients for the purpose of diagnostic study.

Outpatient physical therapy services and outpatient occupational therapy services Dialysis services, supplies and equipment, outpatient dialysis support services, and institutional dialysis services and supplies, and, for items and services, including such renal dialysis services such as vascular access or erythropoietin administration furnished to an individual with acute kidney injury.

Antigens prepared by or under the supervision of a licensed physician with full, unrestricted privileges of the facility Blood clotting factors for hemophilia patients to control bleeding without medical or other supervision, and items related to the administration of such factors.

Prescription drugs used in immunosuppressive therapy furnished, to an individual who receives an organ transplant Certified nurse-midwife services Qualified psychologist services Clinical social worker services Prostate cancer screening tests Oral drugs prescribed for use as an anticancer chemotherapeutic agent for a given indication, and containing an active ingredient (or ingredients), which is the same indication and active ingredient (or ingredients) as a drug that cannot be selfadministered Colorectal cancer screening tests Diabetes outpatient self-management training services Oral drug(s) prescribed for use as an acute anti-emetic used as part of an anticancer chemotherapeutic regimen if the drug is administered by a physician (or as prescribed by a physician)— (i) for use immediately before, at, or within 48 hours after

the time of the administration of the anticancer chemotherapeutic agent; and (ii) as a full replacement for the anti-emetic therapy which would otherwise be administered intravenously.

Screening for glaucoma Medical Nutrition Therapies (enteral or parenteral) Preventive physical examinations Cardiovascular screening blood tests Diabetes screening tests Intravenous immune globulin for the treatment of primary immune deficiency diseases Ultrasound screening for abdominal aortic aneurysm as a result of an initial preventive physical examination or for an individual with a contributory or familial history of abdominal aortic aneurysm or who has risk factors for abdominal aortic aneurysm Items and services furnished under a cardiac rehabilitation program or under a pulmonary rehabilitation program Kidney disease education services Personalized prevention plan services Home infusion therapy services Diagnostic x-ray testing including mammography Diagnostic laboratory tests and other diagnostic tests including exam or manipulation under anesthesia X-ray, radium, and radioactive isotope therapy, including materials and services of technicians Rapid detox services Application or changes of surgical dressings, splints, casts, or other devices used for reduction of fractures and dislocations Durable medical equipment and supplies Ambulance services where the use of other methods of transportation is contraindicated by the individual's condition, including medical evacuation by airlift Prosthetic devices other than dental which replace all or a part of an internal body organ, (including colostomy bags and supplies related to colostomy care, including replacement of such devices, and including one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens Leg, arm, back, and neck braces, and artificial legs, arms, and eyes, including replacements if required because of a change in the patient’s physical condition Pneumococcal vaccine and its administration and influenza vaccine and its administration; and/or hepatitis B vaccine and its administration, furnished to an individual who is at high or intermediate risk of contracting hepatitis B Services of a certified registered nurse anesthetist Extra-depth shoes with inserts or custom molded shoes with inserts for an individual with diabetes, if— (A) the physician who is managing the individual’s diabetic condition (i) documents that the individual has peripheral neuropathy with evidence of callus formation, a history of pre-ulcerative calluses, a history of previous ulceration, foot deformity, or previous amputation, or poor circulation, and (ii) certifies that the individual needs such shoes under a comprehensive plan of care related to the individual’s diabetic condition Screening pap smear and screening pelvic exam Bone mass measurement Dental and oromaxillofacial surgery or treatments, including procedures and treatments to the temporomandibular joint, dental implant services, periodontal (gum) disease procedures, and other dental or orthodontic services

Pricing practices Prices charged are not prejudiced on the basis of the patient's race, color, national origin, citizenship, age, disability, religion, language proficiency, sex or source of payment.

Gender identity

Sex is defined to include gender identity, which refers to an individual's internal sense of gender, whether or not that gender is the same as the gender the individual was assigned at birth. Facility treats all individuals consistent with their preferred or declared gender identity.

Language fluency and assistance Automated translation is not permitted unless reviewed and edited as needed by a qualified, certified medical translator Required language assistance is available in a timely manner and provided through a qualified translator or interpreter.

Reliance on unqualified staff or persons accompanying an individual with LEP for interpretation does not constitute adequate language assistance.

The facility has implemented a written language access plan that facilitates its ability to meet their obligations, such as addressing how the entity will determine an individual's primary language, identifying a service for accessing qualified interpreters when the need arises, types of language assistance services that may be required under particular circumstances and documents for which translations should be routinely available.

Access by disabled persons Facilities are required to provide disabled individuals with accessible buildings and facilities.

Disabled individuals are provided with effective communication, such as through auxiliary aids and services, which includes the provision of qualified interpreters, qualified readers, audio recordings and Braille materials.

All health programs or activities provided through electronic and information technology, such as online booking and electronic billing, must be made available to individuals with disabilities.

Specific accessibility standards set forth in the Web Content Accessibility Guidelines (WCAG) 2.0. provide text alternatives for any non-text content, creating content that can be presented in different ways and making it easier for users to see and hear content.

Facilities and clinics have made reasonable modifications to avoid discrimination based on disability, except where modifications would fundamentally alter the nature of the health program or activity.

Security Measures The facility has written and implemented procedures for all of the following: Active Shooter Shelter-in-Place Chemical, biological, radiological, nuclear and explosive (CBRNE) events refer to the uncontrolled release of chemicals, biological agents or radioactive contamination into the environment or explosions that cause widespread damage Fires and explosions Climate change, natural disasters, and changes in average weather conditions or in more extreme weather events which would give rise to closures, rescheduling of elective admissions, patient evacuation, and other unforeseen interruptions of elective health services Healthcare surges Decontamination Infections disease outbreaks Mass Fatalities Planning that could overload facility capabilities and elective admissions and scheduled surgery appointments Loss of utilities and life support services Prescription medication dispensing (Pixys or similar locked and controlled access) Release of and access to patient information by authorized personnel and limited to the minimum necessary Disaster preparedness procedures and periodic testing and drill simulations Disaster recovery procedures and periodic testing and simulations Distance to nearest fire department ______________

Distance to the nearest police substation ___________

Professional Liability / Censure Clients, Insurers and Employers often inquire about professional liability matters in case of an unanticipated negative outcome. How are these matters dealt with? ____________________________________________________________ Describe what happens in the event of the death of a medical traveler? ____________________________________________________________ Has the corporation, an officer or board member or physician or nurse ever been convicted of a crime, including assault, insurance fraud, embezzlement, pilferage, or other crimes?

Has the facility's state license (if applicable) ever been denied, suspended or revoked for any reason? ___________ Has the facility's Drug Dispensing or Controlled Dangerous Substances certificate ever been denied, suspended or revoked for any reason? __________ Has the facility ever been subjected to sanctions by a Professional Review Organization, a Government Program or a ThirdParty Payer or regulatory agency? ________ Has the facility ever been required to pay back a sum of money equivalent to over $1,000 USD to a payer for inappropriate billing practices? ________

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