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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State of Alaska Department of Health & Social Services
Home Health Agency Licensure Application
Page 2 of 13Form # HHA 1001
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
Page 3 of 13Form # HHA 1001
State of Alaska Department of Health & Social Services
Home Health Agency Licensure Application
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.
Page 4 of 13Form # HHA 1001
State of Alaska Department of Health & Social Services
Home Health Agency Licensure Application
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
State of Alaska Department of Health & Social Services
Home Health Agency Licensure Application
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.
Page 6 of 13Form # HHA 1001
State of Alaska Department of Health & Social Services
Home Health Agency Licensure Application
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
Page 7 of 13Form # HHA 1001
State of Alaska Department of Health & Social Services
Home Health Agency Licensure Application
Drop-down List
Legal Name and Address of Organization
Drop-down List
Legal Name and Address of Organization
Drop-down List
Legal Name and Address of Organization
Drop-down List
Legal Name and Address of Organization
Drop-down List
Legal Name and Address of Organization
X. GEOGRAPHICAL SERVICE AREA (Please describe the geographical service area of the agency)
Page 8 of 13Form # HHA 1001
State of Alaska Department of Health & Social Services
Home Health Agency Licensure Application
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
Page 9 of 13Form # HHA 1001
State of Alaska Department of Health & Social Services
Home Health Agency Licensure Application
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
Page 10 of 13Form # HHA 1001
State of Alaska Department of Health & Social Services
Home Health Agency Licensure Application
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
DirectOther Contract
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
Page 11 of 13Form # HHA 1001
State of Alaska Department of Health & Social Services
Home Health Agency Licensure Application
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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:
Page 13 of 13Form # HHA 1001
State of Alaska Department of Health & Social Services
Home Health Agency Licensure Application
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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