Section He-P 802.04 - Initial License Application Requirements(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 hospital or special health care service 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 facility 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. section 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. section 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 hospital; (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," where applicable; (4) List of affiliated or related parties; (5) The applicable fee 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";(6) A resume identifying the name and qualifications of the administrator and medical director;(7) Copies of applicable licenses, certificates, or both, for the administrator and medical director;(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 time of the application based on the local official's review of the building plans and their final inspection upon completion of the construction project; (9) If the hospital 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 public water supply is used, a copy of a water bill; (10) A written statement from the applicant, proposed licensee, administrator, and medical director stating that he or she: a. Does not have a felony conviction in this or any other state; b. Has not been convicted of a sexual assault, other violent crime, assault, fraud, abuse, neglect or exploitation or pose a threat to the health, safety or well-being of a patient in this or any other state; c. Does not have any permanent restraining or protective orders against the applicant, licensee, or administrator; d. Has not had a finding by the department or any administrative agency in this or any other state for assault, fraud, abuse, neglect, or exploitation of any person in this or any other state; and (11) If any of the items in (10) above have occurred, the individual shall include a detailed explanation of the circumstances surrounding the occurrences; and (12) The results of a criminal records check from the NH department of safety for the applicant(s), licensee if different than the applicant, administrator, and medical director. (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 (c) If a hospital has not previously performed a special health care service but plans to do so, the hospital shall complete a new application including all of the above application requirements and any information required under He-P 802.38, He-P 802.39, and He-P 802.40. (d) A previously operating special health care service, which means a special health care service as defined by RSA 151:2-e that was being offered by a hospital prior to July 1, 2016 and has continued to be offered since July 1, 2016, shall not require additional licensure separate from the hospital license but shall still comply with RSA 151 and all applicable He-P 802 provisions.N.H. Admin. Code § He-P 802.04
#2044, eff 6-3-82; ss by #3193, eff 1-28-86, EXPIRED: 1-28-92; ss by #5317, EMERGENCY, eff 1-29-92, EXPIRED 5-28-92
New. #5846, eff 6-22-94, EXPIRED: 6-22-00
New. #9580, eff 10-24-09
Amended by Volume XXXVII Number 45, Filed November 09, 2017, Proposed by #12407, Effective 10/24/2017, Expires 4/22/2018.Amended by Volume XLI Number 6, Filed February 11, 2021, Proposed by #13166, Effective 1/28/2021, Expires 1/28/2031.