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 or Health Care License" (December 2018 edition)
which is 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
HCSPA 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 HCSPA 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.";
(2) 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. A certificate of authority, if a
corporation;
b. A certificate of
formation, if a limited liability company; or
c. A certificate of trade name, where
applicable;
(3) The
applicable fee in accordance with
RSA 151:5 if HCSPA
serves less than 10 clients or $250 fee if HCSPA serves more than 10 clients,
in accordance with
RSA 151:5 payable in
cash in the exact amount of the fee or, if paid by check or money order, the
exact amount of the fee made payable to the "Treasurer, State of New
Hampshire";
(4) A resume
identifying the qualifications for the HCSPA administrator;
(5) Written local approvals as follows:
a. For the proposed licensed premises, 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, as
adopted by the commissioner of the department of safety under RSA 153, and as
amended pursuant to
RSA
153:5,I, by the state fire
marshal with the board of fire control and local fire ordinances applicable for
a business; and
b. For a
building under construction, the written approvals required by a. above shall
be submitted at the time of the application based on the local official's
review of the building plans and again upon completion of the construction
project; and
(6) If the
HCSPA 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, a copy of a water
bill; and
(7) The results of a
criminal records check from the NH department of safety for the applicant(s),
licensee, and administrator.
(b) The applicant shall mail or hand-deliver
the documents to:
Department of Health and Human Services
Health Facilities Administration
129 Pleasant Street
Concord, NH 03301
