Home Health Agency Licensure Application - Alaska Department of Health ...dhss.alaska.gov/dhcs/Documents/hflc/PDF/Forms/HHA... · · 2018-03-22Home Health Agency . Licensure Application

State of Alaska Department of Health & Social Services

Home Health Agency Initial or Renewal Licensure Application

DUE DATE: 90 DAYS PRIOR TO THE EXPIRATION OF YOUR CURRENT LICENSE (AS 47.32.060) License Number __________________

Department Use Only

Pursuant to the AS 47.32 Licensing Statute and the regulations of the Department of Health & Social Services Home Health Agency Licensing requirements (7 AAC 10 and 7 AAC 12)

Choose One License Expiration Date

Medicare #License #I. TYPE OF LICENSE APPLYING FOR

BEFORE ATTEMPTING TO COMPLETE THE APPLICATION, PLEASE REVIEW THE HOME HEALTH LICENSING RULES AND REGULATIONS. The rules and regulations can be downloaded from links noted in section IX on the last page of this application.

Note: Retain a copy of the application for future reference.

IF YOU DO NOT TYPE THE APPLICATION USING ADOBE AND CHOOSE TO COMPLETE THE APPLICATION IN WRITING, BE SURE TO MAKE NOTE OF DROP-DOWN BOXES TO PROPERLY COMPLETE THIS APPLICATION.

THE DEPARTMENT IS REQUESTING DISCLOSURE OF INFORMATION THAT IS NECESSARY TO ACCOMPLISH THE STATUTORY PURPOSE AS OUTLINED UNDER AS 47.32.040

If Other, ExplainDays of the Week

pmam toBusiness Hours

E-Mail Address for HFL&C Use:

Administration Fax Number for HFL&C Use:

Administration Phone Number for HFL&C Use:

Main Phone Number for Public Use:

Zip CodeStateCity

Premises Located (If different from above):

Zip CodeStateCity

Mailing Address:

Exact Legal Name:

II. NAME AND LOCATION OF HOME HEALTH AGENCY

Fiscal Period (i.e. MONTH/DAY) to (MONTH/DAY)

Page 1 of 13Form # HHA 1001

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Home Health Agency Licensure Application


Other (Explain)

A. Type of Control (check one)III. OWNERSHIP AND ADMINISTRATION

GOVERNMENTAL

NON-PROFIT

PROPRIETARY

(Add appropriate response from drop down box)

AddressName

B. If Individual or Partnership owned (list all persons who own the Home Health Agency)

BusinessName

C. Names under which persons in B. do business (other than this Home Health Agency)

(2) State where Parent Firm or Organization is Incorporated or Registered

(1) Name of Corporation

D. Corporate Ownership

of 13Form # HHA 1001



AddressNameTitle

(3) List title, name and address of each corporate officer

Percent of SharesAddressName of Stockholder

E. List names and address of each shareholder holding more than 5 percent of shares

AddressName of Agent

F. For other than individual ownership, list the name and address of the Alaska agent or the person(s) legallyauthorized to receive service of process for the facility.

(Check here if not applicable)

G. List the names and addresses of all persons under contract to manage or operate the Home Health Agency.




I. If the Home Health Agency has established lines of authority or supervision, please provide an organization chartthat provides that information. (If yes, attach explanation as Exhibit II.)

No

No

No

NoYes

Yes

Yes

Yes4. Administrator or manager of the Hospice

3. Any officer or director of a corporation

2. Any member of a firm or partnership

1. Applicant

H. Have any of the following been convicted of a felony or of two or more misdemeanors involving moral turpitude inthe last five years? (If yes, attach explanation as Exhibit I.)

IV. GOVERNING BODYIdentify the officers of the governing body of your agency. The governing body has legal authority and responsibility for theconduct of the agency.

Office Name Address State ZIP Code

President

Vice President

Secretary

Treasurer

License or Certification Number (if applicable)

Telephone Number

Address

Name

A. Administrator

V. ADMINISTRATION

Does the administrator/agency manager have responsibility for more than one Alaska agency? If yes, list additional license numbers & agency names.

Agency Name License Number

License NumberAgency Name

Form # HHA 1001 Page 5 of 13



C. Medical Social Worker (if applicable)

License Number

License Number

Name

Address

Telephone Number

D. Dietary Therapist (if applicable)

Name

Address

Telephone Number

Registered by

Telephone Number License Number

Address

Name

B. Director of Clinical Services

License Number

License Number

Agency Name

Agency Name

Does the Director of Clinical Services have responsibility for more than one Alaska agency? If yes, list additional license numbers & agency names.

VI. BRANCH OFFICESNote: (1) a branch office is located in the same service area as the parent agency and shares administration, supervision, and services with the parent agency on a daily basis, a branch office is not required to be separately licensed.

Please provide the name and location of any branch offices of the Hospice.

LocationName Medicare Provider #

#

#

#

VII. CLIENT CENSUS INFORMATION (If this is an Initial Application, skip this section)

A. Enter the total number of clients (unduplicated admissions) served during January1st through December 31st of the past calendar year.

B. Indicate by age (years old) categories below, number of clients served in all categories during timeperiod indicated in A.




Average patient count

Highest patient count Lowest patient count

Acute care daysRespite days

Patients Terminated Deceased

DischargedAdmitted during the year

C. During the time period indicated in A please indicate the total number:

Other

Free-Standing Home Health Agency

Hospice Agency

Skilled Nursing Facility

Hospital

VIII. TYPE OF HOME HEALTH AFFILIATION

TOTAL

FEMALE

MALES

TOTALOver 7565-7445-6418-445-17Under 5

IX. AGENCY CONTRACTS

(Add separate sheets if necessary)Please note: SKILLED NURSING may not be contracted unless it is to cover vacations of regular staff or for specialized skills not routinely offered. SKILLED NURSING must be directly provided by the agency plus ONE OTHER RECOGNIZED SERVICE in order to qualify as a home health agency pursuant to Alaska law. If you contract SKILLED NURSING, please provide rationale.

Legal Name and Address of Organization

Drop-down List




Drop-down List


Drop-down List


Drop-down List


Drop-down List


Drop-down List


X. GEOGRAPHICAL SERVICE AREA (Please describe the geographical service area of the agency)




Qualified Person Acting

Actively RecruitingVacancies*

Paid Volunteer

Part Time

Full TimeTitle

*If you indicate a vacancy in any of these, please indicate:A. Actively recruiting ( ) yes ( ) noB. Do you have a qualified person acting in the capacity of each vacancy ( ) yes ( ) no

Indicate the Full Time Equivalents for each of the following as of the completion date of this application:

XI. STAFFING LIST

All Non-Health Professionals and Technical Personnel

All Other Health Professionals and Technical Personnel

Speech Pathologist & Audiologist

Physical Therapist

Occupational Therapist

Dietitian

Personal Care Attendant

Home Health Aide

Nurse Practitioner or Physician Assistant

LPN

Registered Nurse

Director of Clinical Services

NoYesNoYesPhysician on Professional Advisory Committee

Medical Director Yes No Yes No

NoYesNoYesAdministrator

NoYesNoYes

Yes No Yes No

NoYesNoYes

NoYesNoYes

Yes No Yes No

NoYesNoYes

NoYesNoYes

Yes No Yes No

NoYesNoYes

NoYesNoYes

Yes No Yes No

NoYesNoYes

NoYesNoYes

Medical Social Worker




PERCENTAGE iNCOME

100%TOTAL

Other (Grants, Contributions, Bequests, Fund Raising, etc.

Fees from Patients

Other Third Party Payors (Health Insurance, VA, Worker's Comp, etc..)

Medicaid

Part B

Part A

Medicare

SOURCE

XII. SOURCE OF INCOME

D. Date accreditation expires

E. Type of survey

D. Date of last Accrediting Body Survey

NoYes

B. Has the Home Health Agency requested appraisal by an accrediting body?ProvisionalFullNoYes

A. Is the Home Health Agency fully approved by an approved accrediting body?

XIII. ACCREDITATION

NoYes

Does the facility have a system in place for performing criminal background checks in accordance with AS 47.05and 7 AAC 10.900 - 990 through the Alaska Background Check Program (BCP)?

XIV. CRIMINAL BACKGROUND CHECKS

C. Accrediting body




IV Infusion

Personal Care

Medical Equipment

Drugs & Biologicals

Medical Supplies

Speech/Language Pathology

Occupational Therapy

Physical Therapy

PCA Services

Home Health Aide

Short term inpatient (acute)

Short term inpatient (respite)

Dietary Counseling

Bereavement Services

Pastoral Counseling

Social Services

Nursing Services

ContractDirectPhysician Services

Name of Outside ContracteeServices ProvidedService Categories

XV. SERVICES (Attach additional sheets if more space is needed)

Direct Contract

Direct Contract

Direct Contract

Direct Contract

Direct Contract

Direct Contract

Direct Contract

Direct Contract

Direct Contract

Direct Contract

Direct Contract

Direct Contract

Direct Contract

Direct Contract

Direct Contract

Direct Contract

Direct Contract

Service Categories - Contracts must be available for review by Department staff at the time of the licensure survey. Short-term inpatient care can only be provided in a licensed hospital or a skilled nursing facility.

DirectOther Contract



If not, please provide an explanation.

NoYes

DOES THE HOME HEALTH AGENCY MEET ALL THE ABOVE SCOPE OF SERVICE REQUIREMENTS?

7 AAC 12.500. Scope. A public or private entity that is primarily engaged in the provision of skilled nursing care andtherapeutic services, but not the treatment of mental illness, in a patient's home is a home health agency, and must comply with 7 AAC 12.500 - 7 AAC 12.590.

7 AAC 12.505. Home health agency services. (a) A home health agency must provide skilled nursing services and at least one of the following additional services:

(1) physical therapy;(2) occupational therapy;(3) speech therapy; or(4) home health aide services.

(b) A home health agency may provide additional services designed to maintain, improve, or restore a physical or mentalcondition. Additional services must be provided in accordance with generally accepted professional standards and identified in a plan of care established under 7 AAC 12.513. Additional services may include

(1) nursing care under the supervision of a registered nurse;(2) physical, occupational, speech, or respiratory therapy;(3) medical social services;(4) nutrition counseling;(5) home health aide services;(6) personal care services; and(7) medical supplies, other than drugs and biologicals, and the use of medical appliances.

XVI. SCOPE OF SERVICE




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State of AlaskaDepartment of Health & Social Services

Licensure Application

Page 12 of 13 Application 2018

I. Licensure Fee Payment Submission FormRemit this form along with payment see 7 AAC 12.615 for specific fees due

Make checks payable to: State of Alaska - HFLC

Unit: 4011 Fund: 1004 Dept: 06 Appropriation: 062330704 Revenue: 5101

Activity (select one): 4HF0 License Fee 4HF1 Revisit Fee 4HF2 Modification Fee

For State of Alaska accounting use only

Check # Deposit number:

Date received: Deposit date:

Received by: IRIS document code:

Info to TPL for processing:

Return check date:

Reason for return:

Facility Type: Date:

Branch Location (if applicable)

Facility Name:

Facility Location:

Facility Contact:

Contact Number:

License Number:

Licensure Fee:

Provisional Licensure Fee:

Bed Fee (if applicable): Note No. of beds: ( )

Revisit Fee:

Modification Fee:

Total:




Please submit this application to:

[Note: To submit by E-mail, print the document, sign above, and scan to a PDF file. Attach the signed PDF document to an E-mail

and send to the above E-mail address.]

Signature of Administrator or Designee

Date

Administrator or Designee Name

The applicant, or the person authorized to submit the application on behalf of an applicant that is not an individual, declares and certifies that the contents of this application and the information provided with it are true, accurate, and complete.

In addition, the applicant, or the person authorized to submit the application on behalf of an applicant that is not an individual, declares and certifies that he or she has reviewed the regulatory requirements contained in 7 AAC 10.900 - 990 (Barrier Crimes, Criminal History Checks, and Centralized Registry), 7 AAC 10.9500 - 9535 (General Variance), 7 AAC 10.9600 - 9620 (Inspections and Investigations), the applicable requirements of 7 AAC 12.500 - 590 (Home Health Agencies) and the applicable requirements of 7 AAC 12.600 - 990 (General Provisions).

The undersigned gives assurance that the facility is in compliance to the best of his/her knowledge and he/she is prepared for an on-site inspection to validate compliance.

IX. ATTESTATION

Health Facilities Licensing & Certification4501 Business Park Blvd., Suite 24, Bldg. LAnchorage, AK 99503

Phone: (907) 334-2483Fax: (907) 334-2682Email: [email protected]

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