Section He-M 1002.19 - Required Forms(a) Applicants or community residences applying for an initial or renewal certification shall complete and submit the form entitled "Request for Certification of Community Residence and/or Individual Day Provider" (August 2019 edition) and shall affirm to the following: "I swear or affirm that the information provided on this application is accurate to the best of my knowledge and belief. I believe that this residence/community participation service program is in full compliance with the statutes and regulations governing these services. I understand that providing false information shall be grounds for denial, suspension or revocation of this certification."
(b) Applicants applying for emergency certification shall: (1) Complete and submit the form entitled "Emergency Certification for Community Residences - 3 or Fewer Beds" (November 2019 edition); (2) Attach to the emergency certification form a current copy of the floor plan and emergency evacuation plan; and(3) Include a signature from the executive director of the responsible CMHP that verifies that the appropriate staff determined that the home meets the requirements of He-M 1002, and He-M 1202, as applicable and certify to the following: "I certify that:
a. (Individual's name), born on (Date of Birth), needed immediate placement on (Date of Placement) to protect his/her health and safety because (Explain Reasons) .b. There is no condition within the above residence that would pose a health or safety threat to the client.c. This residence is in full compliance with the statutes and regulations governing community residences." (c) Forms completed in accordance with (a) or (b) above shall be submitted to: Department of Health and Human Services
Office of Legal and Regulatory Services
Health Facilities Administration
129 Pleasant Street
Concord NH 03301
N.H. Admin. Code § He-M 1002.19
Amended by Volume XXXIX Number 16, Filed April 18, 2019, Proposed by #12742, Effective 3/20/2019, Expires 9/16/2019.Amended by Volume XXXIX Number 50, Filed December 12, 2019, Proposed by #12916, Effective 11/16/2019, Expires 11/16/2029.