Section He-P 803.04 - 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 nursing home 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 nursing home to be newly licensed and to be located within a radius of 15 miles of a hospital certified as a critical assess 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) A floor plan of the prospective nursing home;(3) If applicable, proof of authorization from the New Hampshire secretary of state to do business in the state of 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; orc. "Certificate of Trade Name," where applicable;(4) List of affiliated or related parties;(5) The applicable fee in accordance with RSA 151:5, IV, 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";(6) A resume identifying the qualifications of the nursing home administrator;(7) Copies of licenses for the nursing home administrator;(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; and4. 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; andb. 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 onsite inspection of the construction project;(9) If the nursing home uses a private water supply, documentation that the water supply has been tested in accordance with RSA 485, Env-Dw 702.02, Env-Dw 704.02, or if a public water supply is used, a copy of a water bill;(10) The results of a criminal records check from the NH department of safety for the applicant(s), licensee if different than the applicant, medical director, administrator, and any officer, director, shareholder, or general or limited partner thereof, as applicable;(11) The previous 5 years of regulatory compliance history of the prospective licensee in providing long term care in New Hampshire, including by compliance with applicable statutes and regulations governing the operation of long term care facilities;(12) The previous 5 years of regulatory compliance history of the prospective licensee in providing long term care in states other than New Hampshire, if any, including compliance with the applicable statutes and regulations governing the operation of long term care facilities in said states; and(13) Any waiver requests if 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
N.H. Admin. Code § He-P 803.04
Amended by Volume XXXIX Number 06, Filed February 7, 2019, Proposed by #12721, Effective 1/29/2019, Expires 7/29/2019.Amended by Volume XXXIX Number 37, Filed September 12, 2019, Proposed by #12860, Effective 8/28/2019, Expires 8/28/2029.Amended by Volume XLI Number 36, Filed September 9, 2021, Proposed by #13246, Effective 8/4/2021, Expires 8/4/2031