|Form #||Item #||Description||Check List|
|HS 200 ||||Licensing & Certification Application [H&S Code Section 1748(b) & 1749(a)(3)] |
Note: Please read the instructions on the HS 200 form prior to completion of the form. The items listed below are the most common items that are not completed correctly – however, these are not all of the items listed on each form.
Amount of fee enclosed [H&S Code, Section 1748(a)]
- A fee is also required for additional hospice sites.
|A.4.c||Change of Location|
- A licensed hospice and a separately licensed HHA cannot share the same space but CAN be in the same building with a different address, phone number, staff, etc.
|A.9.||Age range of clients|
- Age range needed especially for pediatric hospice.
|A.10.||Days and hours of operation |||
|B.1||Licensee’s name |
- The licensee’s formal organization name must be consistent throughout all documents.
Submit an organization chart/flow chart if the owner is a profit or nonprofit corporation, limited liability company (LLC), or general partnership. The organization chart needs to display the following:
- Applicant’s owners, directors, board members, corporate officers, LLC members/managers, and partners.
Note: Submit the HS 215A form for each of these individuals.
- Parent company of applicant, if applicable, and all of the licensed agencies/facilities they are operating – see B.6.
|B.5.a.||Licensee’s "other" facility involvement|
- Answer all aspects of the question.
|B.5.b.||Revocation, suspension, etc. action |
- If applicable to the licensee, submit the information requested.
|B.6.||Subsidiary (Parent Company) Information|
If there is a “subsidiary” (parent company) submit:
- An organization chart with the parent company name.
- A listing of all owners, directors, board members, corporate officers, LLC members/managers, and partners of the parent company. [H&S Code Section 1265(i)]
- A listing of all facilities the parent company is operating.
|C.1.b||"Interim" Management Company Agreement |
- Note if CHOW: If there is an "interim" Management Company Agreement, between the current and the prospective licensee, submit a signed and dated copy of Agreement.
|C.2.||Name of "Proposed" and "Current" Agency |
- Enter both hospice names if this is a CHOW.
- The applicant may insert the corporate name if there is no hospice name.
|C.3.||Address of "Proposed" Facility, Agency, or Clinic |
- The additional hospice site addresses must be listed after the parent address. They do not need a separate license [H&S Code Section 1748(a)].
|C.6.b||Director of Nursing and Date of Hire |
- Submit their resume. (SQHC, Section 5.3, Director of Patient Care Services)
- List all individuals having 5% or more ownership, unless "nonprofit."
|Property Ownership |
- Submit a copy of the Grant Deed, Bill of Sale, Lease, Sublease, or Rental Agreement between the owner of the property and the proposed licensee.
|F.1.||Signature [H&S Code Section 1749(a)(3)] |
- Original "signature" is required and MUST be signed by the applicant (not the Administrator unless the owner is the Administrator).
|Hospice Svs||||Hospice Services|
- Must provide, or make provisions for the basic services listed below: (H&S Code Sections 1749(b)(1) through (b)(7) and SQHC, Section 2.1. Services Provided)
- Skilled nursing services
- Social services/counseling services
- Medical direction
- Bereavement services
- Volunteer services
- Inpatient care arrangements
- Home health aide services
- Note: All services provided by the additional hospice sites and parent hospice [H&S Code Section 1746(n)].
- Note: Services for additional Sites have to be the same as their parent [H&S Code Section 1746(k)].
|DO to review|
|CMS 417||||Hospice Request for Certification in the Medicare Program |
- If this freestanding hospice is licensed "only," the only reason this form is being requested is for the listing of the types of services.
- Complete this form as indicated.
|Geog. Areas||||Geographic Areas of Hospice |
- Submit web-based map reflecting the distance between the parent ant the additional hospice site, if this is an additional hospice site.
- Additional hospice sites cannot establish a new additional site outside of the hospice’s approved geographic service area.