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HomeMy WebLinkAboutACHA FORMAPPLICATION CHECKLIST Health Care Licensing Application Adult Family Care Home This application is for licensure to operate an Adult Family Care Home as described in Chapter 429, Florida Statutes (F.S.). Applications must be received at least 60 days prior to the expiration of the current license to avoid a late fine. If the renewal application is received by the Agency less than 60 days prior to the expiration date, it is subject to a late fee as set forth in statute. The applicant will receive notice of the amount of the late fee as part of the application process or by separate notice. The application will be; withdrawn from review if all the required documents and fees are not included with this application or received within 29 days of an omission notice. Forms listed below maybe obtained from the website: http://abca.m florida.com/MCHQ/COREBILL/INDEX SHTML. Send completed applications to: Agency for Health Care Administration, Assisted Living Unit, 2727 Mahan Drive, Mail Stop 30, .Tallahassee, FL 32308. A. ALL Applications must include: /The biennial licensure fee of $226.34 - Please make check or money order payable to the Agency for Health Care Administration (AHCA). All fees are nonrefundable. (VOTE. starter checks and temporary checks are not accepted. Health Care Licensin A licatio _ a pp n, Adult Famlly Care Homes, AHCA Form 3180-1022 All social security numbers must be entered on the Health Care Licensing Application Addendum, AHCA Form 3110-1024. The Addendum must accompany all initial applications and renewal applications that have changes in the financial interests since the last application for this license. Complete the information that is applicable; write "NA" on the items that are not applicable, sign, date and send with the application Level 2 background screening for the Owner and all household members/relief staff is required ev y 5 years. Please check all boxes below that apply to this application: The Owner and/or ❑ household members/relief staff submitted a Level 2 screening through a LiveScan vendor approved to submit fingerprint requests through the Florida Department of Law Enforcement (FDLE). For more information regarding LiveScan vendors please see the Agency's background screening website at: http://ahca.myflorida. com/MCHQ/Central_ServicesB ackground_Screening/index.shtml. All screening results must be sent to the Agency for Health Care Administration (Agency) for review and eligibility determinations. If you choose to use a LiveScan source other than the Agency's contracted vendor you must provide the following ORI EAHCA020Z and identify. the Agency for Health Care Administration as the recipient of the screening results to ensure the results are reviewed by the Agency. If th Agency does not receive the result, additional screening and fees may be required. The, Owner and/or ❑ household members/relief staff do not have access to a Florida LiveScan vendor and will submit a fingerprint card (you must obtain a fingerprint card from the Agency. To request a fingerprint card please contact the Agency's Background Screening AHCA Form 3180-1022, Revised January 2014 Section 59A-35.060(1), Florida Administrative Code INSTRUCTION CHECKLIST Form available at: http://ahca.myflorida.com/MCHO/COREBILL/UNDEX.SHTML Section at (850)412-4503 or email bgscreen(cDahca.myflorida.com.). The fingerprint card ;st'Te submitted to: he Agency's contracted vendor, Cogent Systems, along with a fee of $80.25 ($64.50 for the screening + $15.75 processing fee). The fingerprint card must be filled out completely and the fingerprints taken by law enforcement personnel or individual trained in processing fingerprints. Return the completed card to: Cogent Systems Attn: Fingerprint Card Scan Florida 5025 Bradenton Ave Suite A Dublin, OH 43017 ❑ Another LiveScan vendor authorized to provide services in Florida that is equipped to transmit the images of the fingerprints from the fingerprint card electronically. This requires special equipment and not all LiveScan vendors have this ability. You may find LiveScan vendor contact information on the FDLE website: http://www.fdle.state.fl. us/Content/Criminal-H istory/Livescan-Service-Providers-and- Device-Vendors. aspx#Top. ❑ Proof of Level 2 screening within the previous 5 years for the Owner and/or ❑ all household members/ relief staff from the Agency, the Department of Children and Families, Department of Health, Agency for Persons with Disabilities or Department of Financial Services (if the applicant has a certificate of authority to operate a continuing care retirement community) is included with this application. An Affidavit of Compliance with Background Screening Requirements, AHCA Form 3100-0008, is also enclosed. B. Additional Information needed for INITIAL Applications: *ocal Zoning Form for Assisted Livina and Adult Family Care Homes, AHCA Form 3180-1021 ❑ 5cpr6munity Residential Home Affidavit of Compliance EO"A Fire Inspection Report from the local fire authority. ❑ R idential Group Care Inspection Report, DH Form 4029 Pr of of the licensee's right to occupy the home to include a copy of the applicant's driver's ZA 'ense and a lease, sublease agreement, or proof of Homestead Exemption FCH Income & Expense Statement, AHCA Form 3180-1017, September 1996 C. Change During License Period: Request to increase/decrease number of licensed beds: ❑ Complete and submit sections 1, 2 and 9 of the Health Care Licensing Application, Adult Family Care Homes, AHCA Form 3180-1022 AHCA Form 3180-1022, Revised January 2014 Section 59A-35.060(1), Florida Administrative Code INSTRUCTION CHECKLIST Form available at: htto://ahca.mvflorida.com/MCHO/COREBILL/INDEX.SHTML ❑ $25.00 fee for replacement license/reissue of license due to change during licensure period. Please make check or money order payable to the Agency for Health Care Administration (AHCA). All fees are nonrefundable All forms can be obtained from the website at http://ahca.myflorida.conVMCHQ/COREBILL/INDEX SHTML RETU cy for Health Care Administration, Assisted Living Unit, 2727 Mahan Drive, Mail Stop #30, IMPORTANT NOTE FOR RENEWALS: Applications must be received at the address above at least 60 days in advance of expiration of registration. NOTE: If you have additional questions after reviewing the application forms and the AHCA web site: http://ahca-.myflorida.com/MCHQ/Health_Facility_Regulation/Assisted_Living/afc.shtml, please call the Assisted Living Unit staff at (850)412-4304. Staff will be happy to answer questions, but cannot walk you through the application forms. Filling out the forms is part of your responsibility as an applicant. The Agency's role in this process is to evaluate your application and, if there are items missing from your application once received, send you a letter that gives you another chance to complete the application successfully. If you need help in filling out the application forms, we would advise you to seek help from an attorney or a consultant. A fee of $25.00 will be charged for a replacement license that occurs before the expiration of the license. Notice: If you are a Medicaid provider, you may have a separate obligation to notify the Medicaid program of a name/address change, change of ownership or other change of information. Please refer to your Medicaid handbooks for additional information about Medicaid program policy regarding changes to provider enrollment information. The Agency for Health Care Administration scans all documents for electronic storage. In an effort to facilitate this process, we ask that you please place checks, money orders and fingerprint cards on top of the application and paperclip everything together. Please do not staple or bind documents submitted to the Agency. AHCA Form 3180-1022, Revised January 2014 Section 59A-35.060(1), Florida Administrative Code INSTRUCTION CHECKLIST Form available at: http://ahca.mvflorida.conVMCHO/COREBILL/fNDEX.SHTML AHCA USE ONLY: File #: Application #: Check #: Check Amt: Batch #: Health Care Licensing Application ADULT FAMILY CARE HOME Under the authority of Chapters 408 Part II and 429 Florida Statutes (F.S.) and Chapter 59A-35, an application is hereby made to operate an adult family care home as indicated below: 1. Provider / Licensee Information A. Provider Information —please complete the following for the Adult Family Care Home name and location. Provider name, address and telephone number will be listed on htt ://www.floridahealthfinder. ov/ License # (for renewal & change National Provider Medicare # (CMS Medicaid # of ownership applications) Identifier (NPI) (if applicable) CCN) Name of Adult F mily Care Home Applic nt/Licensee Street Address (physical locat�l of busi ss) City � Co t // �• n' Zc�`7 Telephone Number Fax Number E-mail Address Provider Website (I 2- 52 Ca 2� 1 m eeu �chr� c �c ailing Address or Same as above (All mail will be sent to this location) 0 J� City F-L, PIeraf,, Slate %211 Contact P rs, oSor this ap�il�ay�on CAntact Tel hone Nuunber 76 Contact e-mail address or ❑ Do not have i ,(NOTE: e-mail 1���GG�Un Mai �cce By providing your e-mail address you agree to t from the Agency �J e-mail correspondence p p 9 Y Do you Le'Own or ❑ Rent the property Do you live in the Adult F ily Care Home? for the Adult Family Care Home listed ff Yes ❑ No above? AHCA Form 3180-1022, Revised January 2014 Section 59A-35.060(1), Florida Administrative Code Page 1 of 5 Form available at: ham://ahca.mvflorida.com/MCHO/COREBILUfNDEX.SHTML B. -Licensee Information — please complete the following for the person seeking to operate the Adult Family Care Home Licensee Name Federal Employer Identification / pl Number (EIN) Mailing A dressA— City S. � IPW4 Telephone Number Fax Number E-mail Address ��cp3t m ccu-"ern� A D . 60k of Licensee (check one): For Profit ❑ Partnership ® Individual ❑ Other 2. Application Type and Fees Indicate the type of application with an 'X." Applications will not be processed if all applicable fees are not included. All fees are nonrefundable. Renewal applications must be received 60 days prior to the expiration of the license to avoid a late fine. If the renewal application is received by the Agency less than 60 days prior to the expiration date, it is subject to a late fee as set forth in statute. The applicant will receive notice of the amount of the late fee as part of the application process or by separate notice. APPLICATION TYPE: .® Initial Licensure ❑ Renewal Licensure ❑ Change during Ilcensure period — Increase/Decrease in # of beds Proposed Effective Date: Total number of residents (1 to 5) for which you are applying? NOTE. Each AFCH must have at least one licensed space designated for an OSS (optional state supplementation) recipient. Per Florida Statute 429.67(8), adult foster homes or assisted living facilities that are converting to an AFCH that were licensed prior to January 1, 1994 are exempt from this requirement. Action Fee TOTAL FEES LICENSE FEE (Initial or Renewal): $226.34 $ 226,511 Change During Licensure Period/Replacement License $ 25.00 $ OD TOTAL FEES INCLUDED WITH APPLICATION: j $_�G Please make check ormoney order payable to the Agency for Health Care ,Administration (AHCA) NOTE: Starter checks and temporary checks are not accepted. AHCA Form 3180-1022, Revised January 2014 Section 59A-35.060(1), Florida Administrative Code Page 2 of 5 Form available at: htto://ahca.myflorida.com/MCHO/COREBILUfNDEX.SHTML J. Kequired Disclosure For the owner/operator listed in this application, the following disclosures are required: Has any individual listed in this application been convicted of any level 2 offense pursuant to subsection 408.809(1)(d) Florida Statutes? (These offenses are listed on the Affidavit of Compliance with Background Screening Requirements, AHCA Form #3100-0008.) YES EJ NO ❑ If yes, enclose th following information: The full legal name of the 'n idup aid the osition held ❑ A description/exp anatlon o the convic lor�- If the individual has received an exemption from disqualification for the offense, include a copy. Has any individual listed in this application been excluded, suspended, terminated or jvoluntarily withdrawn from participation in Medicare or Medicaid in any state? YES ❑ NO © If yes, enclose the following information: ❑ The full legal name of the individual and the position held ❑ A description/explanation of the exclusion, suspension, termination or involuntary withdrawal. 4. Provider Fines and Financial Information Pursuant to subsection 408.831(1)(a), Florida Statutes, the Agency may take action against the applicant, licensee, or a licensee which shares a common controlling interest with the applicant if they have failed to pay all outstanding fines, liens, or overpayments assessed by final order of the agency or final order of the Centers for Medicare and Medicaid Services (CMS), not subject to further appeal, unless a repayment plan is approved by the agency. Are there any incidences of outstanding fines, liens or overpayments as described above? YES ❑ NO If yes, please complete the following for each incidence (attach additional sheets if necessary): Amount: $ assessed by: ❑ Agency for Health Care Administration ❑ CMS Date of related inspection, application or overpayment period if applicable: Due date of payment: Is there an appeal pending from a Final Order? YES ❑ NO ❑ Please attach a copy of the approved repayment plan if applicable. AHCA Form 3180-1022, Revised January 2014 Section 59A-35.060(1), Florida Administrative Code Page 3 of 5 Form available at: http://ahca.mvflorida.con/MCHo /COREBILL/INDEX_SHTML 5. 'Other Household Members List each household member residing at the AFCH addressed. Do not list AFCH residents. Full Name Date of Birth Relationship to Provider MM~I� NOTE. Household members include adults who are permanently or regularly present in the home for more than a few hours at a time. A person shall be considered a household member even though the person has another residence if the person is in a position of familial authority or perceived familial authority. 6. Designated Relief Person Provide the following information for each designated relief person. You must have at least one designated relief person. Attach additional sheets if there are more than 2 relief persons. a DateBirt `e• e e e e •- �N � ..�L/Lb�tl•1IwKwrG�iir�is INS ��i '-r'�.��.� • / r.�'i %�Lllf:.i_ 'f ,�' —11,aI 0IIII Z `F.'ni�—�i_ .Y�:} W615pf2 OhdiL Mac &hu -%;- 7. Staff Person(s) 6,a1,Vgj1705f, P. , z, Fz- r 3 q9 $3 e, Ole Lcik-a� Dr, r Provide the following information for each staff person. Attach additional sheets if there are more than 2 staff persons. _ Z34 Full Name Date of Birth Street Address City County - Zip Telephone Number Lana- 1) 2- 54110 84r n -A,gree 65 - /-Ue.le Bw4rlz AHCA Form 3180-1022, Revised January 2014 Section 59A-35.060(1), Florida Administrative Code Page 4 of 5 Form available at: htto://ahca.mvflorida.com/MCHO/COREBILL/rNDEX.SHTML 8. Types of Services Provided Please indicate which of the following services your AFCH will provide if needed by the resident. Check all that apply. PERSONAL CARE SERVICES (ADLs): [� Eating [v]� Bathing NURSING SERVICES: [v�Administration of Medication Dressing [�Toileting [a' Grooming [v]� Walking ❑ Other Nursing Services: NOTE: The provider, relief person or staff ` per son must be licensed as a physician; nurse, or physician's assistant to administer medication or provide other nursing services. 9. Affidavit I, l 5A.,_ MOT.�-�/�e. , hereby swear or affirm, under penalty of perjury, that the statements in this application are true and correct. I hereby attest that all employees required by law to undergo background screening have met the minimum standards or are awaiting screening results. l gn tyre of Licens e or Authorized Representative Title Date Notice: If you are a Medicaid provider, you may have a separate obligation to notify the Medicaid program of a name/address change, change of ownership or other change of information. Please refer to your Medicaid handbooks for additional information about Medicaid program policy regarding changes to provider enrollment information. RETURN THIS COMPLETED FORM WITH FEES AND ALL REQUIRED DOCUMENTS TO: AGENCY FOR HEALTH CARE ADMINISTRATION ASSISTED LIVING UNIT 2727 MAHAN DR., MS 30 TALLAHASSEE FL 32308-5407 Questions? Review the information available at http://ahca.mvflorida.com/ or contact the Agency at (850) 412-4304 AHCA Form 3180-1022, Revised January 2014 Section 59A-35.060(1), Florida Administrative Code Page 5 of 5 Form available at: hq:Hahca.mvflorida.com/MCHO/COREBILUFNDEX.SHTML