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 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 NEWCC 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.";
c. For any
NEWCC to be newly licensed and 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) :
"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."; and
d. For facilities to be licensed under the
listed categories:
"I understand that, in accordance with
RSA 151:4, III(a) (7)
, this facility cannot be licensed pursuant
to He-P 802, 806, 810, 811, 812, 816, 823, or 824 if it is 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) , until
the Commissioner makes a determination that the proposed new facility will not
have a material adverse impact on the essential health care services provided
in the service area of the critical access hospital. I also understand that if
the Commissioner is not able to make such a determination, the license will not
be issued.";
(2)
A floor plan of the prospective NEWCC;
(3) If applicable, proof of authorization
from the New Hampshire secretary of state to do business in 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 company; or
c.
"Certificate of Trade Name," where applicable;
(4) The applicable fee, in accordance with
RSA 151:5 II, XI 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";
(5) A resume
identifying the qualifications of and copies of applicable licenses for the
NEWCC administrator and medical director;
(6) Copies of applicable licenses and/or
certificates for the NEWCC administrator and Medical Director;
(7) Written local approvals as follows:
a. 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;
2. The building
official verifying that the applicant complies with all applicable state and
local building codes and 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, Saf-C 6000 under RSA 153, and as
amended pursuant to
RSA 153:5,
I, by the state fire marshal with the board
of fire control, including the applicable chapter of NFPA 101 and local fire
ordinances and including but not limited to business or ambulatory health care;
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 on-site inspection of the construction
project;
(8) If the
NEWCC uses a private water supply, documentation that the water supply has been
tested in accordance with RSA 485 and
Env-Dw
702.02 and
Env-Dw
704.02 or, if a public water supply is used, a copy of
a water bill; and
(9) The results
of a criminal records check from the NH department of safety for the
applicant(s), licensee if different than the applicant, the administrator and
medical director for which the application is submitted.
(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
#2349, eff 4-28-83; ss by #3193, eff 1-28-86; ss by
#5317, EMERGENCY, eff 1-29-92, EXPIRED: 5-28-92
