4-003.02A
Licensee
Responsibilities: Licensees must submit a written application to
the Department. The licensee may construct an application or obtain an
application form from the Department. The licensure application must include:
1. Full name of the assisted-living facility
to be licensed, street and mailing address, telephone and facsimile number, if
any;
2. Type of assisted-living
facility to be licensed;
3. Name of
the administrator;
4. Name and
address of the assisted-living facility owner(s);
5. Ownership type;
6. Mailing address for the
owner(s);
7. The preferred mailing
address for the receipt of official notices from the Department;
8. List of names and addresses of all persons
in control of the assisted-living facility. The list must include all
individual owners, partners, limited liability company members, parent
companies, if any, and members of boards of directors owning or managing the
operations and any other persons with financial interests or investments in the
assisted-living facility. In the case of publicly held corporations, the
individual owners listed must include any stockholders who own 5% or more of
the company's stock;
9. The legal
name of the individual or business organization (government, corporation,
partnership, limited liability company or other type) to whom the license
should be issued and a statement that the individual or organization accepts
the legal responsibility for compliance with these regulations;
10. Applicant's federal employer
identification number, if not an individual;
11. Applicant's social security number if the
applicant is an individual. To ensure social security numbers are not part of
public records and are used only for administrative purposes, applicants may
submit social security numbers in a separate document;
12. Number of beds;
13. Signature(s) of:
a. The owner, if the applicant is an
individual or partnership;
b. Two
of its members, if the applicant is a limited liability company;
c. Two of its officers, if the applicant is a
corporation; or
d. The head of the
governmental unit having jurisdiction over the assisted-living facility to be
licensed, if the applicant is a governmental unit;
14. Occupancy certificates issued by the
State Fire Marshal or delegated authority dated within the 18 months prior to
the license expiration date;
15.
Required licensure fee specified in 175 NAC 4-004.09; and
16. If applicable, the disclosure information
required by
Neb. Rev. Stat.
§§
71-516.01 to
71-516.04,
the Alzheimer's Special Care Disclosure Act. The following information must be
submitted:
a. The Alzheimer's special care
unit's written statement of its overall philosophy and mission which reflects
the needs of residents afflicted with Alzheimer's disease, dementia, or a
related disorder;
b. The process
and criteria for placement in, transfer to, or discharge from the
unit;
c. The process used for
assessment and establishment of the plan of care and its implementation,
including the method by which the plan of care evolves and is responsible to
changes in condition;
d. Staff
training and continuing education practices;
e. The physical environment and design
features appropriate to support the functioning of cognitively impaired adult
residents;
f. The frequency and
types of resident activities;
g.
The involvement of families and the availability of family support programs;
and
h. The costs of care and any
additional fees.
4-003.02B
Department
Responsibilities: The Department will:
1. Send a notice of expiration and an
application for renewal to the licensee's preferred mailing address not later
than 30 days prior to the expiration date. The licensure renewal notice
specifies:
a. Date of expiration;
b. Fee for renewal;
c. License number; and
d. Name and address of the assisted-living
facility.
2. Issue a
renewal when it determines that the licensee has submitted a completed
application;
3. Send to each
licensee that fails to renew its license a second notice, which is the final
notice and specifies that:
a. The licensee
failed to pay the renewal fee or submit an application or both;
b. The license has expired;
c. The Department will suspend action for 30
days following the date of expiration;
d. Upon receipt of the renewal fee and
completed renewal application, the Department will issue the renewal license;
and
e. Upon failure to receive the
renewal fee and completed renewal application, the license will be
lapsed.
4. Place the
assisted-living facility license on lapsed status for nonpayment of fees if the
licensee fails to renew the license. During this time, the assisted-living
facility may not operate. The license remains in lapsed status until it is
reinstated.