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EDMUND G. BROWN JR.
Governor

State of California—Health and Human Services Agency
California Department of Public Health



​Hospice Provider: Initial Licensure or Change of Ownership
Applicant Checklist

The following is a quick reference of some of the questions found on the required forms. It includes the form number, name of form, and an explanation of specific requirements and/or attachments needed for specific forms. This is not an all-inclusive list of the questions that need to be answered so read the questions and instructions on each form.

Note: All forms listed are in PDF format.

Form #​Item #​Description​Check List
HS 200 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​Licensing & Certification Application [H&S Code Sections 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.

 

​A.3.​Amount of fee enclosed [H&S Code Section 1748(a)]
​​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 beconsistent throughout all documents.
​​B.3.​​Owner type

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)]
    Note: Submit the HS 215A form for each of these individuals.
  • 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
  • List the address of the parent hospice first.
  • Note:  A "licensed" HHA and a "licensed" freestanding hospice cannot be located at the same office.
  • Note: A "licensed & certified" HHA and a "certified-only" hospice program can be located in the same office.
​​C.6.a​Name of Administrator and Date of Hire
  • An administrator shall have supervisory or administrative experience in hospice or related health care fields or education in healthcare or administration that meet the requirements of the position. [Standards for Qualify Hospice Care (SQHC) Section 5.1, Administration]
​​C.6.b​Director of Nursing and date of hire
  • Submit their resume. (SQHC, Section 5.3, Director of Patient Care Services)
​​C.7.​Ownership
  • List all individuals having 5% or more ownership, unless "nonprofit."
​D.1.
D.2.
​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).
​HS 215A​ ​ ​ ​​ ​ ​ ​ ​ ​​Applicant Individual Information [H&S Code Sections 1748(b), 1749(a)(1), and 1755(a)]
Note: Please read the instructions on the HS 215A form prior to completion of the form. This form must be completed for the following individuals with original signatures.
​Applicant Organization
  • For each individual having a beneficial interest of  5% or more in the applicant organization (list their ownership percentages) of the applicant organization.
  • For directors, board members, corporate officers, LLC members/managers, and partners of the applicant organization.
​Parent Company
  • For each individual having a beneficial interest of 5% or more in the parent company (list their ownership percentages).
  • For directors, board members, corporate officers, LLC members/managers, and partners of the parent company.
​Management Company
  •  For each individual having a beneficial interest of 5% or more in the parent company (list their ownership percentages).
  • For directors, board members, corporate officers, LLC members/managers, and partners of the parent company.
​Administrator and Designee of the Facility
  • “Resume” for the Administrator
    Note: CAU to compare with qualifications contained in SQHC Section 5.1, Administration
  • Copy of Governing Body signed written statement verifying their appointment.
​Director of Patient Care Services (DPCS) and Designee
  • DPCS and Designee’s "Resume."
  • Copy of DPCS and Designee’s professional license.
​​Sec. D.​Employment/Business Summary
  • A resume or attachment will be acceptable in lieu of Section "D."
​​Sign​Signature
  • Original "signature" is required.
​​Fac Info Sheet​​Facility Information Sheet
If applicable, each individual must complete and submit the “Facility Information Sheet” for each facility and/or agency with which they have a current or past relationship within the last 3 years. The following must be completed for each facility and/or agency:
  • Facility name and address
  • Type of facility
  • Type of business entity (include EIN Number)
  • Individual’s nature and dates of involvement
  • This Sheet must also include any facilities licensed by the California Department of Social Services.
HS 309 1st page ​ ​ ​ ​​​ ​Administrative Organization ​
​2.​Administrator of Corporation or LLC – This is usually the CEO/President.
​3. - 7.​Corporations need to submit:
  • Copy of the Filing Statement from CA Secretary of State (only required if Articles of Incorporation are not endorsed by the CA Secretary of State).
  • Copy of all Articles of Incorporation (endorsed by CA Secretary of State).
  • Copy of By-Laws.

LLCs need to submit:

  • Copy of the Filing Statement from CA Secretary of State (only required if Articles of Organization are not endorsed by the CA Secretary of State).
  • Copy of all Articles of Organization (endorsed by CA Secretary of State).
  • Copy of Operating Agreement.
​9.​Governing Board of Directors
  • Enter the number of board members or LLC members/holders.
  • Submit a list of board of directors or the LLC members/holders.
​10.​Board Officers
  • Enter the names of the board officers or the LLC officers/managers.
​HS 309
2nd page ​ ​ ​ ​
​Organizational Structure ​
​1.​California Out-of-State Corporations, LLC, etc.
  • Submit a copy of the Certificate of Qualification from the California Secretary of State
​3. & 4.​Public Agency
  • Submit a copy of the signed Resolution.
​5.​​Corporations, LLCs, and Partnerships need to complete. N/A for nonprofit.
​Bottom of page​​Partnerships need to submit:
  • A copy of the Partnership Agreement
  • Copy of the California Secretary of State filing, if applicable.
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 a list of geographical areas (including cities, counties & zip codes) to be served. This is required because a provider of Hospice services cannot serve "ALL" of California.
  • So we may verify, the service area documented on page 23 of the CMS-855 application must be submitted.
  • Hospices must obtain prior approval of an expansion of their geographic service area from CMS, and the L&C Program.
  • Note: Submit web-based map reflecting the distance between the parent ant the additional hospice site, if this is an additional hospice site.
  • Note: Additional hospice sites cannot establish a new additional site outside of the hospice’s approved geographic service area.
​​CHOW​Change of Ownership (CHOW)

Submit the following:

  • All of the forms required for an "initial" application
  • A letter from the prospective licensee (to CDPH) stating where the stored patient medical records will be maintained, and that the records will be made available to the previous licensee (SQHC, Section 6.3, B, 3. g.).
  • Copy of "Purchase Agreement" or "Operating Transfer Agreement."


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