Current through Register No. 40, October 3, 2024
(a)
Each applicant for a license shall comply with the requirements of RSA
151:4II(a), I-I, and submit the following to the department:
(1) A completed application form entitled
"Application for Residential, Health Care License or Special Health Care
Services" (March 2019), signed by the applicant or 2 of the corporate officers,
affirming to the following:
a. "I affirm that
I am familiar with the requirements of RSA 151 and the rules adopted thereunder
and that the premises are in full compliance. I understand that providing false
information shall be grounds for denial, suspension, or revocation of the
license and the imposition of a fine.";
b. For any nursing home to be newly licensed:
"I certify that I have notified the public of the intent to
file this application with a description of the facility to be licensed by
publishing a notice in a newspaper of general circulation covering the area
where the facility is to be located in at least 2 separate issues of the
newspaper no less than 10 business days prior to the filing of this
application."; and
c. For
any nursing home to be newly licensed and to be located within a radius of 15
miles of a hospital certified as a critical assess hospital, pursuant to
42 C.F.R.
485.610(b) and (c):
"I certify that the facility is to be located within a
radius of 15 miles of a hospital certified as a critical access hospital,
pursuant to
42 C.F.R.
485.610(b) and (c), and that
I have given written notice of the intent to file this application with a
description of the facility to be licensed to the chief executive officer of
the hospital by registered mail no less than 10 business days prior to the
filing of this application.";
(2) A floor plan of the prospective nursing
home;
(3) If applicable, proof of
authorization from the New Hampshire secretary of state to do business in the
state of New Hampshire in the form of one of the following:
a. "Certificate of Authority," if a
corporation;
b. "Certificate of
Formation," if a limited liability corporation; or
c. "Certificate of Trade Name," where
applicable;
(4) List of
affiliated or related parties;
(5)
The applicable fee in accordance with
RSA 151:5,
IV, payable in cash or, if paid by check or
money order, the exact amount of the fee made payable to the "Treasurer, State
of New Hampshire";
(6) A resume
identifying the qualifications of the nursing home administrator;
(7) Copies of licenses for the nursing home
administrator;
(8) Written local
approvals as follows:
a. For an existing
building, the following written local approvals shall be obtained no more than
90 days prior to submission of the application, from the following local
officials or if there is no such official(s), from the board of selectmen or
mayor:
1. The health officer verifying that
the applicant complies with all applicable local health requirements and
drinking water and wastewater requirements;
2. The building official verifying that the
applicant complies with all applicable state building codes and local building
ordinances;
3. The zoning officer
verifying that the applicant complies with all applicable local zoning
ordinances; and
4. The fire chief
verifying that the applicant complies with the state fire code,
RSA 153:1,
VI-a, including the health care chapter of
the Life Safety Code 101 and the Uniform Fire Code, NFPA 1, as published by the
National Fire Protection Association and as amended by the state board of fire
control and ratified by the general court pursuant to
RSA 153:5;
and
b. For a building
under construction, the written approvals required by a. above shall be
submitted at the end of construction based on the local official's review of
the building plans and their final onsite inspection of the construction
project;
(9) If the
nursing home uses a private water supply, documentation that the water supply
has been tested in accordance with RSA 485,
Env-Dw
702.02,
Env-Dw
704.02, or if a public water supply is used, a copy of
a water bill;
(10) The results of a
criminal records check from the NH department of safety for the applicant(s),
licensee if different than the applicant, medical director, administrator, and
any officer, director, shareholder, or general or limited partner thereof, as
applicable;
(11) The previous 5
years of regulatory compliance history of the prospective licensee in providing
long term care in New Hampshire, including by compliance with applicable
statutes and regulations governing the operation of long term care
facilities;
(12) The previous 5
years of regulatory compliance history of the prospective licensee in providing
long term care in states other than New Hampshire, if any, including compliance
with the applicable statutes and regulations governing the operation of long
term care facilities in said states; and
(13) Any waiver requests if
applicable.
(b) The
applicant shall mail or hand-deliver the documents to:
Department of Health and Human Services
Office of Legal and Regulatory Services
Health Facilities Administration
129 Pleasant Street
Concord, NH 03301
