Current through Register No. 40, October 3, 2024
(a)
Each applicant for a license shall comply with the requirements of RSA 151:4II,
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 ACS to be newly licensed:
"I certify that I have notified the public of 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 ten (10) business days prior to the filing of this
application";
c. For any
ASC to be newly licensed and to be located within a radius of fifteen (15)
miles of a hospital 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 fifteen (15) miles of a hospital 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 ten (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 ASC;
(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 corporation; or
c.
"Certificate of Trade Name" if a sole proprietorship or if otherwise
applicable;
(4) The
applicable fee in accordance with
RSA 151:5, 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 name and
qualifications of the ASC administrator and medical director;
(6) Copies of applicable licenses and/or
certificates for the ASC administrator and medical director;
(7) 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, Saf-C 6000, and
as amended pursuant to
RSA 153:5,
I by the state fire marshal with the board of
fire control, including but not limited to the ambulatory health care occupancy
chapter of NFPA 101 as adopted by the commissioner of the department of safety,
and local fire ordinances applicable for an ASC; and
b. For a building under construction, the
written approvals required by He-P 812.04(a) shall be submitted at the time of
the application based on the local official's review of the building plans and
upon completion of the construction project;
(8) If the ASC uses a private water supply,
documentation that the water supply has been tested in accordance with RSA 485
and
Env-Dw
702.02, 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
the medical director, as 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
#5514, eff 11-25-92; amd by #6530, eff 6-27-97; amd by
#6895, INTERIM, eff 11-26-98, EXPIRED: 3-26-99; paragraph (e) EXPIRED:
6-27-05
