In accordance with 105 CMR 158.005, an existing Adult Day Health program operating prior to January 2, 2015, shall submit an application for an original license prior to May 1, 2015, and this application shall have the effect of a license until acted upon by the Department.  In order to comply with this regulation, an existing Adult Day Health program must submit an application containing the items in column A, on or before May 1, 2015.  The remaining items supporting the application, as described in column B, must be submitted on or before June 1, 2015.

 

A

B

 May 1, 2015June 1, 2015
1. Application ChecklistMust be submitted, and note all items included in 5/1/2015 submission.No need to resubmit with supporting materials.
2. Initial Licensure/Suitability/ Notice of Intent to Acquire FormCompleted form with option for delayed submission of supporting documents below, as applicable.No need to resubmit with supporting materials.
  • Local Fire Inspection Certificate (Question B3)
Certificate must be submitted OR documentation of a good faith effort on the part of the applicant to obtain the certificateCertificate must be submitted by this date.
  • Local Certificate of Occupancy (Question B4)
Certificate must be submitted OR documentation of a good faith effort on the part of the applicant to obtain the certificateCertificate OR documentation from city or town that certificate is not available must be submitted by this date.
  • Application Fee (Question B5)
N/AN/A
  • CORI Release Forms (for all individual owners, corporate officers, directors, members of the board of trustees, and individuals listed as having a 5% or greater ownership interest in any entity listed in Questions C3 and C4)
All required CORI forms (per Sections C.3 and C.4) may be submitted by this date. (See (1) below)All required CORI forms (per Sections C.3 and C.4) must be submitted by this date. (See (1) below)
  • Listing or Resume (for all individual owners, corporate officers, directors, members of the board of trustees, and individuals listed as having a 5% or greater ownership interest in any entity listed in Question E1)
Prior healthcare ownership information (per Section E.1) may be submitted by this date. (See (2) below)Prior healthcare ownership information (per Section E.1) must be submitted by this date. (See (2) below)
  • Documentation of pending change of ownership – if applicable
Must be submitted by this date – only if applicable. 

3. Additional Disclosure Form – if applicable under Initial Licensure/Suitability Form

(Questions E2, F1, G1 or G2)

Must be submitted by this date – only if applicable. 
4. Program Capacity FormMust be submitted by this date. 
  • Schematic Floor Plan
Must be submitted by this date. (See Figure A below) 

5. Clinical Attestation Form

Completed form with option for delayed submission of supporting documents below, as applicable.No need to resubmit with supporting materials.
  • ADH Approved Tests Request Form – if applicable
Must be submitted by this date (if applicable). 
  • CMS Form 116 – if applicable
Must be submitted by this date (if applicable). 
  • Board of Health Kitchen Approval – if applicable under 105 CMR 158.045(A)(9)
Certificate must be submitted OR documentation of a good faith effort on the part of the applicant to obtain the certificateCertificate must be submitted by this date.
  • Waiver Request(s) – one form per request if applicable
As applicable, waiver requests must be filed with sufficient time to allow the Department to consider and approve the request by January 2, 2016.As applicable, waiver requests must be filed with sufficient time to allow the Department to consider and approve the request by January 2, 2016.
  • Plan for Compliance (Existing Programs Only) – if applicable
Must be submitted and include, at minimum, a description of a provisional plan of action. (See (3) below)A complete plan of action must be submitted by this date. (See (4) below)

5. HCFRS Enrollment Forms

  
  • HCFRS Enrollment Form A – VG Services Agreement
Must be submitted by this date. 
  • HCFRS Enrollment Form B – VG Access Administrator
Must be submitted by this date. 
  • HCFRS Enrollment Form C – HCFRS Facility Agreement
Must be submitted by this date. 
  • HCFRS Enrollment Form D – HCFRS User Agreement
Must be submitted by this date. 
  1. Signed CORI release forms must be submitted as supporting materials to the application for all corporate officers and directors, all board officers and directors, or all members of any other form or governing body.  All required CORI forms should be submitted at one time.
  2. If a member of the governing body has owned or operated a health care facility in the preceding 10 years, a chart, or other well-organized listing, of such ownership or operation must be submitted. If a member of the governing body has not had such ownership or operation interest, a resume must be submitted.  Required prior ownership information should be submitted at one time.
  3. This description, DUE ON MAY 1st, should provide an indication of a program’s areas of non-compliance, and a brief identification of the program’s intent to come into compliance or seek a waiver.

    For example: “In order to come into full compliance with the ADH regulations by January 2, 2016, [Name of ADH Program] plans to add a toilet, install handrails and seek a waiver from 105 CMR 158.042(C)(8)(d).”
  1. A plan of action, DUE ON JUNE 1st, need not detail each individual step that a program will take to achieve compliance, but should provide the Department with an overall understanding of the requirements not met together with major milestones and target dates for achieving compliance.

    For example: “[Name of Program] will hire an architect to draw plans to expand one of two bathrooms to accommodate another toilet by July 1, 2015; will hire a contractor to complete bathroom construction by September 1, 2015; will purchase and install handrails in the main corridor by September 1, 2015; and will file a waiver request from 105 CMR 158.042(C)(8)(d) by October 1, 2015.”

The application packet submitted on or before May 1, 2015 must include a statement clearly indicating who the applicant is, where the program is located, and a statement describing the supporting documentation that is NOT included, but which will be provided on or before June 1, 2015.

All remaining supporting documentation must be provided to the Department at one time, on or before June 1, 2015, together with a statement describing what is being provided. An applicant must not submit its remaining information to the Department piecemeal.

Figure A. Sample schematic floor plan with instructions for rectangular room.

Step 1 – Make a drawing (by hand or electronically) of the floorplan in the room you are measuring. It doesn't have to be to scale, but the more accurate it is, the more useful it will be for recording purposes.

Step 2 – Measure the shortest width and length in the room.

Step 3 – Multiply the width and the length to get the main area measurement.

Step 4 – Calculate the area of individual recesses.

Step 5 – Add all of the areas together to get the total floor area.

Figure A. Sample schematic floor plan with instructions for rectangular room

The schematic floor plan submitted with the Program Capacity Form must include:

  • Labeling of all rooms for use (e.g., nurse’s office, activity room, rest area, etc.)
  • Dimensions (length and width) of each room/space, including non-participant areas (closets, storage areas, corridors, lobby and similar areas). The square footage of non-participant areas will not be counted toward space requirements for purposes of calculating capacity, and must be deducted from the gross square footage.
  • Indication of which toilets are handicapped accessible.
  • Indication of separate space, as necessary, for therapeutic activities for participants with advanced dementia.

New programs anticipating opening after January 2, 2015, must obtain a license from the Department before beginning operation.