Full Review Process

Information and instructions for health care facilities using the Full Review Process.

The full review process is a 2-part review process in which the licensee and architect submit a set of preliminary plans for first submission. The Division conducts a detailed review of the preliminary plans and sends review comments to the licensee and architect. The licensee and architect are expected to review and incorporate the Division's preliminary plan review comments into the final plans and submit a set of final construction plans. The Division conducts a detailed review of the final construction plans before plan approval is issued.

Common questions

When does the Department use the Full Review Process?

The full plan review process is a time intensive process, so licensees are encouraged to use the self-certification and abbreviated review processes whenever possible. The Department maintains the right to conduct a full plan review on any project submission. Circumstances when the Department conducts a full review of plans include, but are not limited to, one of the following:

  • The facility is a Hospice Inpatient Facility;
  • The facility is converting from one licensed purpose to another purpose (e.g., hospital conversion to long term care);
  • The proposal includes extraordinary waiver requests;
  • The licensee does not or cannot meet the self-certification or abbreviated project eligibility or submission requirements (e.g., no involved architect, incomplete plans or partial submissions, no affidavit);
  • More than one entity is to be licensed by the Department on the proposed premises;
  • The project is selected in the Department's routine sampling to evaluate compliance with construction standards in self-certification and abbreviated project submissions; or
  • The licensee opts for full review.

What materials have to be submitted to the Department for full plan approval?

Preliminary Plans Submission must include:

  • Plan Review Application & Project Information Form - use the Department's form
  • Project Narrative - submit a comprehensive description of the nature of services and scope of construction. Any change in bed complement, service, or existing facility conditions must be fully explained.
  • Statement concerning Determination of Need (DoN): submit a statement indicating that the project conforms to the DoN conditions, if DoN approval is required
  • Capital Cost Estimate Form - use the Department's form
  • Floor Plans of Existing Conditions in currently licensed facilities
  • Preliminary Plans:
    Architectural plans at a scale of at least [1/8" = 1'-0"] including function labels and numbers for all rooms, dimensions indicating the size of all rooms, widths of corridors, partition types, including widths and construction of all partitions
    Site plan & exterior elevations for new buildings or new additions.
  • Phasing plans (minimum scale 1/16"=1'-0"), showing the scope of work within a contained area of the facility for each construction phase in renovations projects. Each phase must be designed so as to minimize disruption of service delivery in areas of the facility which will continue operating during the construction project. Protection barriers between construction areas and the rest of the facility must be specified.

Final Plans Submission must include:

  • Final Construction Plans for the proposed project, including complete architectural, plumbing, mechanical and electrical plans
  • Written Response to the Department's Preliminary Plan Review Comment - respond to each review item
  • Architect's Compliance Checklists (recommended) - submit one for each department or inpatient unit included in the construction or renovation project
  • Physical Plant Waiver Request Form - submit one fully documented form for each waiver requested, if not submitted for preliminary plans submission

Which areas of an existing licensed facility must be upgraded for compliance with current licensure requirements?

Compliance with licensure requirements must be verified and documented within a given project area. Existing licensed conditions outside of the project area will remain acceptable. However, when bed complements are increased, facilities are expected to ensure compliance with square footage minimums and functional area requirements for all functional spaces that are required to support the additional beds.

If the full process is used, when can the licensee begin construction?

Construction must not begin until the facility receives the Department's written plan approval of final construction plans.

What are the timelines for Department full review of projects?

  • Part I - The licensee can expect a Department response within 45-60 days of a complete preliminary plans submission
  • Part II - The licensee can expect a Department response within 45-60 days of a complete final plans submission