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INITIAL HOME HEALTH AGENCY APPLICANT LICENSURE PROCESS

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INITIAL HOME HEALTH AGENCY APPLICANT LICENSURE PROCESS Powered By Docstoc
					HOME HEALTH AGENCY
APPLICATION FOR CHANGE OF OWNERSHIP
Under the authority of Chapter 400, Part III, Florida Statutes (F.S.), and 59A-8, Florida Administrative Code
(F.A.C.), this application is being made for a new license due to the pending change in ownership of a home
health agency.

S.408.803 (5), F.S., defines a change of ownership as: “’Change of ownership’ means an event in which the licensee
changes to a different legal entity or in which 45 percent or more of the ownership, voting shares, or controlling interest in
a corporation whose shares are not publicly traded on a recognized stock exchange is transferred or assigned, including
the final transfer or assignment of multiple transfers or assignments over a 2-year period that cumulatively total 45 percent
or greater. A change solely in the management company or board of directors is not a change ownership.

Section 400.471(8), F.S., requires that when transferring the ownership of a home health agency or incorporating, an
application for a license must be submitted at least 60 days before the effective date of the change. Failure to comply will
result in an administrative fine of $50 per day not to exceed $500.

(1) HOME HEALTH AGENCY’S NEW INFORMATION
HHA License #                    Medicare # [refer to item (21)]                  Medicaid # [refer to item (20)]


Name of Agency                                                                               Telephone Number

Street Address                                                                               Fax

City                                                         County                          State          Zip Code

E-mail Address

Mailing Address (if different from above)


City                                                             State                               Zip Code


(2) AGENCY RELOCATION AND COMPLIANCE WITH LOCAL ZONING
 Has the office moved or will it move from its current licensed location?
       YES    NO     If yes, state the date of relocation __________________________ and enclose the following:
          A report or letter from the local government zoning office that the building is zoned appropriately for use
           as a home health agency and evidence of legal right to occupy the office such as a lease, deed, rental
           agreement or contract. Refer to s.408.810 (6), F.S.

(3) NEW OWNERSHIP (individual or entity that will directly own the home health agency)
Name                                                                              Telephone Number

Street Address                                                                               Fax

City                                                         County                          State          Zip Code

                                                             E-mail Address
Check the appropriate type:
For Profit:             Not for Profit:           Employer Identification #
 Corporation            Charitable Organization
 Partnership            Church
 Limited Liability Co.  Hospital District       Anticipated date of transfer of ownership
 Individual             Other
 Other
(4) HOME HEALTH AGENCY’S CURRENT INFORMATION [if different from information in item (1) above]


AHCA 3110-1012 July 05                                                                                              Page 1 of 7
HHA License #                                   Medicare #                            Medicaid #

Name of Agency                                                                                        Telephone Number

Street Address                                                                                        Fax

City                                                  County                 State                    Zip Code

Mailing Address (if different from above)

City                                                                State                             Zip Code


(5) CURRENT OWNERSHIP (individual or entity that directly owns the home health agency)
Name                                                                                Telephone Number

Address                                                                                               Fax

City                                                  County                 State                    Zip Code


(6) IDENTIFY THE PRINCIPALS OF THE NEW OWNERSHIP:
President (full legal name)       Individual Address                                                           Phone

Vice President

Secretary

Treasurer

Partner

Partner


(7) FOR-PROFIT ENTITIES
List individuals and/or legal entities who have at least 5% financial interest in the entity listed in item (2) above.
If legal entities are listed, include individuals and/or legal entities who have at least 5% financial interest in those entities.
Add an attachment page and/or organizational chart, if necessary.
Name (full legal)                             Individual Address                                                      % Interest




(8) NON-PROFIT ENTITIES
Do Board members serve on a volunteer basis?              YES       NO 
If yes, enclose Voluntary Board Member Affidavit signed by each volunteer board member.



AHCA 3110-1012 July 05                                                                                                 Page 2 of 7
(9) FOR ALL OWNERSHIPS
(a) Enclose the following signed documents (include notarization, if required):
     AHCA Form 3100-0008, Affidavit of Compliance with Background Screening Requirements (for administrator)
     AHCA Form 3110-0001 Dec 06 Affidavit of Good Moral Character (for alternate administrator)
     AHCA Form 3110-1014 Dec 06, Affidavit of Compliance with Screening Requirements
(b) Have any members of the Board of Directors, officers or individuals having 5% or more financial interest
    been convicted of any level 2 offense, pursuant to s. 435.04, F.S.? (These offenses are listed on AHCA Form
    3100-0008 Affidavit of Compliance with Background Screening Requirements) YES  NO 
    If yes, enclose the following information: the full name of the person, the position held and a description/
    explanation of their conviction(s) of any level 2 offenses. If the person has received an exemption from
    disqualification for this offense, please include a copy.
(c) Has the applicant, owner or any individual having 5% or more financial interest been excluded, suspended,
    terminated or involuntarily withdrawn from participation in Medicare, Medicaid in any state or any other governmental
    or private health care/insurance program? YES  NO 
    If yes, enclose the following information: the full name of the person, the position held and a description/
    explanation of any exclusions, permanent suspensions, terminations or involuntary withdrawals from any of the
    above listed programs. Proof of compliance with the requirements for disclosure of ownership and control interest
    under the Medicare or Medicaid programs may be accepted in lieu of this submission.
(d) Has the applicant, owner or any individual having 5% or more financial interest previously been found by any
    licensing, certifying or professional standards board to have violated the standards or conditions that relate to home
    health-related licensure or certification, or to the quality of home health-related services provided? YES  NO 
   If yes, enclose the following information: the full name of the person, the position held and a written description/
   explanation of any violations and the actions taken by the relevant board.

(10) ENCLOSE THE FOLLOWING ITEMS:
 (a) Copy of signed & dated asset purchase agreement indicating that a change of ownership is pending.
 (b) Copy of signed closing document (bill of sale) showing the date of the transfer of ownership.
      (This document is not required initially and may be submitted after the date of the transfer.)
 (c) Completed Financial Schedules 1 through 7, compiled by a certified public accountant, and proof of
      assets as required by s. 400.471(3), F.S. and 59A-8.004(5), F.A.C. See financial schedules and instructions
      AHCA Form 3110-1012 Dec 04.
  (d) Check and enclose copies of all that are appropriate to the new ownership:

         Articles of Incorporation. (corporations)

         Current Bylaws. (corporations)

         Partnership Agreement. (partnerships and limited partnerships)

         Company organizational papers. (limited liability companies, other)

         Certificate of Status or Authorization as filed with the Florida Department of State, Division of Corporations.

         Certificate of Foreign Incorporation as filed with the Florida Department of State, Division of Corporations, if
              applicable. (corporations established in another state)

         Affidavit of Fictitious Name as filed with Division of Corporations, if home health agency will operate under a
               name other than the name of the partnership or corporation.

         Proof of federal employer identification number from the Internal Revenue Service (required).

(11) INSURANCE
Enclose proof of the following current insurance coverage in an amount of not less than $250,000 per claim as
required by s. 400.471(6), F.S.:
    (a) Malpractice insurance as defined in s. 624.605(1)(k), F.S.; AND
    (b) Liability insurance as defined in s. 624.605(1)(b), F.S.
Proof of insurance must specify the home health agency’s new name and street address

AHCA 3110-1012 July 05                                                                                            Page 3 of 7
(12) IS THIS AGENCY TO BE MANAGED BY SOMEONE OTHER THAN THE APPLICANT?
 YES  NO  If yes, provide the name, address and phone number for the management company:



(13) HOURS OF OPERATION
Indicate the regular business hours of this agency by listing the time the agency office will open for business and
the time it will close [59A-8.003(10)(a), F.A.C., requires that an agency be open for 8 consecutive hours per day,
Monday through Friday between the hours of 7 a.m. and 6 p.m., excluding legal and religious holidays]:

Time will open ________ a.m.          Time will close ________ p.m.         Days of the Week ________________________
Indicate if the agency will have a 24-hour on-call system (required for agencies offering skilled services).
YES  NO 

(14) GEOGRAPHIC SERVICE AREA - List each county in which the agency expects to provide services. Counties
must be within a single AHCA area.
 1                                                            9
 2                                                           10
 3                                                           11
 4                                                           12
 5                                                           13
 6                                                           14
 7                                                           15
 8                                                           16
AHCA Area 1: Escambia, Okaloosa, Santa Rosa, Walton; Area 2: Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes,
Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, Washington. Area 3: Alachua, Bradford, Citrus, Columbia,
Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, Union. Area 4: Duval,
Baker, Clay, Flagler, Nassau, St. Johns, Volusia. Area 5: Pasco, Pinellas. Area 6: Hardee, Highlands, Hillsborough,
Manatee, Polk. Area 7: Brevard, Orange, Osceola, Seminole. Area 8: Charlotte, Collier, DeSoto, Glades, Hendry, Lee,
Sarasota. Area 9: Indian River, Martin, Okeechobee, Palm Beach, St. Lucie. Area 10: Broward. Area 11: Dade,
Monroe.
(15) SATELLITE OFFICE
WILL THIS AGENCY OPERATE A SATELLITE OFFICE? A satellite office is a secondary office in the same county as
the main office, operating under the auspices of the main office’s license. Refer to 59A-8.003(7), F.A.C., for requirements.
YES  NO  If yes, list address(es) below:
(a) Street Address

   City

(b) Street Address

    City

Attach information on any additional sites. Satellite offices must meet same requirements as in item (2).
(16) DROP-OFF SITE
WILL THIS AGENCY OPERATE A DROP-OFF SITE? A drop-off site may be located in any county within the licensed
geographic service area. This is merely a workstation for direct care staff. Neither billing nor prospective patient contact is
allowed. Refer to 59A-8.003(8), F.A.C., for further requirements. YES  NO  If yes, list address(es) below:
(a) Street Address

   City

(b) Street Address

   City

Attach information on any additional sites.
AHCA 3110-1012 July 05                                                                                             Page 4 of 7
(17) SERVICES TO BE PROVIDED
Indicate services to be provided by checking direct and/or contract in the table below:
  “Direct employees” are those for whom the agency pays withholding taxes. State rules require that a licensed-only agency
  provide at least one of the services listed below by direct employees. If providing nursing services, some of the service
  must be provided by a direct employee, as required in state law, s. 400.487(5), F.S. Federal regulations require that
  Medicare and Medicaid agencies provide one of the skilled services (*) below entirely by direct employees. Medicaid does
  not include Medical Social Services as a home health agency service.
Service                                    Direct Contract         Service                                   Direct Contract
Nursing (*)                                                        IV Therapy
Physical Therapy (*)                                               Homemaker, Companion
Speech Therapy (*)                                                 Nutritional Guidance
Occupational Therapy (*)                                           Appliance and Equipment
Respiratory Therapy                                                Medical Social Services (*)
Home Health Aide (*)                                               Other:
(18) PROVIDE THE FOLLOWING INFORMATION ON ADMINISTRATIVE PERSONNEL:
                                                                                             Status:         Florida License
              Full Name                                    Job Title                    Part-time, Full-time or Registration
                                                                                            or Contract          Number
                                                     Administrator (*)

                                                  Director of Nursing (*)
                                                    Financial Officer
                                        (person responsible for financial operation)
                                                Alternate Administrator (*)

Enclose resume for positions marked with (*), if there will be a change from the currently approved individual.
(a) Has either the Administrator or Financial Officer been excluded, suspended, terminated or involuntarily withdrawn
    from participation in Medicare, Medicaid in any state or any other governmental or private health care insurance
    program?         YES  NO 
    If yes, enclose the following information: the full name of the person, the position held and a description and
    explanation of any exclusions, permanent suspensions, terminations or involuntary withdrawals from any of the above
    listed programs. Proof of compliance with the requirements for disclosure of ownership and control interest under the
    Medicare or Medicaid programs may be accepted in lieu of this submission.

(b) Has either the Administrator or Financial Officer previously been found by any licensing, certifying or professional
    standards board to have violated the standards or conditions that relate to home health-related licensure or certification,
    or to the quality of home health-related services provided? YES  NO 
    If yes, enclose the following information: the full name of the person, the position held and the standards or
    conditions found to have been violated and the date.
(19) PROVIDE THE FOLLOWING INFORMATION ON SERVICE PERSONNEL:
     “Direct employees” are those for whom the agency pays withholding taxes. Entries should match those listed in (17).
                                                                                If sub-contracted from another agency,
                                                 # Direct    # Contracted
                 Personnel                                                           write name(s) of agency below
                                               employees      employees
                                                                                  (enclose additional pages if needed).
Licensed Nurses
Physical Therapists & PT Assistants
Speech Therapists
Occupational Therapists & OT Assistants
Respiratory Therapists
Home Health Aides & CNAs
Homemakers / Companions
Medical Social Services
Nutritional Guidance
Medical Equipment & Supplies
Other:



AHCA 3110-1012 July 05                                                                                            Page 5 of 7
(20) FOR MEDICAID AGENCIES ONLY
Medicaid numbers are not transferable. Contact the Medicaid fiscal intermediary, ACS State Healthcare,
at (800) 377-8216 or at the web site http://floridamedicaid.acs-inc.com to obtain an application for a change of ownership.

If the home health agency is currently enrolled in any Medicaid Waiver programs, contact the department, agency or
organization that enrolled the agency in the waiver and inform them of the change of ownership.
(21) FOR MEDICARE CERTIFIED AGENCIES ONLY
(a) Federal approval - The U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services
     (CMS) requires Medicare certified home health agencies to submit an application for change of ownership. To obtain
     an application (CMS 855), contact the appropriate Medicare fiscal intermediary or access the CMS web site at
     http://www.cms.hhs.gov/CMS/Forms/CMSForms/list.asp..
(b) If the new ownership does not intend to assume the same Medicare provider number, CMS requires advance
     written notification at least 45 days prior to the effective date of the change of ownership. Mail notification to:
              REGIONAL ADMINISTRATOR
              DEPARTMENT OF HEALTH AND HUMAN SERVICES
              CENTERS FOR MEDICARE AND MEDICAID SERVICES
              61 FORSYTH ST STE 4 T20-DMSO
              ATLANTA GA 30303-8909

    Please attach a copy of the notification to this application.
(c) Check the Medicare agency type below that describes how the home health agency will operate once the
    change of ownership is approved and provide the information requested under that status:

   Parent Agency - a Medicare certified agency with its own, independent provider number.

      If this agency operates a Sub-Unit, list the name, address and Medicare number:

      ___________________________________________________________________________________________


      If this agency operates any Branches (licensed & unlicensed), list the names, addresses and Medicare numbers:

      ___________________________________________________________________________________________

      ___________________________________________________________________________________________

      ___________________________________________________________________________________________


   Sub-Unit Agency - a separately licensed, semi-autonomous agency related to the parent agency; the agency
    independently meets the conditions of participation and has its own sub-unit provider number.

      List the name, address and Medicare number of the Parent agency:

      ___________________________________________________________________________________________


   Branch Agency - a separately licensed agency that operates under a parent or sub-unit’s control and provides
    services under the controlling agency’s Medicare provider number.

      List the name, address and Medicare number of the controlling Parent agency:

      ___________________________________________________________________________________________


(22) OUTSTANDING FINES ASSESSED OF THE CURRENTLY LICENSED HOME HEALTH AGENCY
    s. 400.471(12), F.S., states AHCA may not issue a license to a home health agency that has any unpaid fines
    assessed.
Are there any outstanding fines assessed by Final Order from AHCA? YES  NO 

 If yes, please complete the following for each separate fine (attach additional information as needed):


AHCA 3110-1012 July 05                                                                                          Page 6 of 7
                                            Date of final order or AHCA complaint #
(a) Fine amount $

                                            Date of final order or AHCA complaint #
(b) Fine amount $


s. 408.831(2), F.S., requires the transferor to pay any fines owed AHCA prior to issuance of license certificate.

(23) FEES FOR LICENSE AND BACKGROUND SCREENING                                            FEE(S) ENCLOSED:

Change of Ownership Licensing (license expires 2 years from the date it is issued)        [ ] $1,660.00
New Administrator Background Screening:
  Enclose completed fingerprint card* and $47 fee                                        [ ] $    47.00
  Enclose copy of screening results if already screened – no fee
New Financial Officer Background Screening:
  Enclose completed fingerprint card* and $47 fee                                        [ ] $    47.00
  Enclose copy of screening results if already screened – no fee

Total amount enclosed (include check or money order made payable to AHCA)                    $
* Contact the Home Care Unit for fingerprint card and instructions. Contact information below.

(24)
STATE OF FLORIDA
COUNTY OF _______________________

                                                        AFFIDAVIT

I, _______________________________ hereby swear or affirm that the information provided in this application, including
its attachments, is true and correct and will comply with administrative and procedural requirements.



                                                                  Signature of Applicant (Owner or officer)


                                                                  Title

This person is personally known to me ____ or produced the following identification ___________________________
Subscribed and sworn to or affirmed before me this _____day of ________________________.
                                                                      (Month & Year)

                                                          Notary State Seal:
Notary Public (Type or Print Name)



Notary Public (Signature)
                                                 RETURN THIS COMPLETED FORM WITH FEES TO:
                                                           AHCA HOME CARE UNIT
                                                           2727 MAHAN DRIVE – MAIL STOP 34
My Commission Expires
                                                           TALLAHASSEE FL 32308
                                                 Questions? Contact Licensed Home Health Programs Unit at
                                                 http://ahca.myflorida.com
                                                 or (850) 414-6010.




AHCA 3110-1012 July 05                                                                                              Page 7 of 7

				
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