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Self Certification Review Process

Information and instructions for health care facilities using the Self-Certification Review Process.

The Self-Certification review process is intended to be a one-part review. The licensee and architect submit the construction plans, Compliance Checklists, and combined Licensee's and Architect's Affidavit.

The Department of Public Health (DPH) plan approval relies upon the Affidavit, which attests to all of the following items:

  • Compliance with construction standards;
  • The licensee's understanding and agreement that DPH maintains continuing authority to review the plans, inspect the work, withdraw its approval; and
  • The licensee's understanding of the continuing obligation to make any changes required by DPH to comply with the applicable codes and regulations, whether or not physical plant construction or alterations are complete.

DPH bases its review on the Compliance Checklists in lieu of a review of the plans, but reserves the right to conduct a selective review of the plans for certain projects.

Common questions

Which projects qualify for Self-Certification review?

  • Projects that involve patient care areas, and with an estimated project construction cost of less than $2,000,000, qualify for Self-Certification review, with the exception of hospice inpatient facilities and long term care facilities that were not originally designed and constructed in accordance with the 1968 or 1972 edition of DPH construction standards.
  • All projects that involve non-patient care areas in a hospital, clinic, dialysis facility or ambulatory surgery qualify for Self-Certification review regardless of the estimated project construction cost.
  • Projects in long term care facilities involving the renovation of, or addition to, facilities constructed before implementation of the 1968 and 1972, DPH construction standards are not eligible for review under the Self-Certification process and must be submitted for review according to the abbreviated or full review process.
  • Projects involving hospice inpatient facilities are not eligible for review under the Self-Certification process and must be submitted for review according to the full review process.

What documentation must be submitted to DPH for Self-Certification plan approval?

Documentation marked with an asterisk below must be submitted on the forms available on the DPH Plan Review webpage. Please note that the documentation indicated to be submitted as “PDF file on disc” below will be required to be submitted in PDF format after September 1, 2013, and will also be accepted in PDF format before that date. All PDF documents must be converted from original electronic files or scanned from hard copies at a resolution of 300 dpi.

  • Plan Review Application Form* (printed hard copy)
  • Project Narrative (printed hard copy): Comprehensive description of the nature of services, clinical spaces and scope of construction in square feet. Any change in bed complement, service, existing facility conditions and construction phasing must be fully explained.
  • Check for Plan Review Fee: The fee is determined according to the fee schedule included in the Plan Review Application Form.
  • Statement of Determination of Need Compliance (PDF file on disc): Statement indicating that the project conforms to the Determination of Need (DoN) conditions, if DoN approval is required. DoN requirements can be found on the DoN website.
  • Capital Cost Estimate - Form 4* (PDF file on disc): The cost columns under the “Approved Costs” titles are only applicable to DoN projects.
  • Floor Plans of Existing Conditions (PDF files on disc): In the case of renovations, these floor plans must show existing licensed conditions and indicate all room functions in the vicinity of the project area. Existing licensed conditions are intended to include spaces that have received DPH approval in the past according to licensure rules in effect at the time of design and construction.
  • Site Plan (PDF file on disc): In the case of new construction, outside grade, parking, outdoor walkways, and path of handicapped access to the building must be shown.
  • Final Construction Plans (PDF files on disc) for the proposed project, including complete architectural, mechanical, electrical and plumbing plans.
  • Phasing plans (PDF files on disc) 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.
  • Architect's and Licensee's Affidavit* (PDF file on disc) including original architect's stamp and signatures of the Architect and Licensee. Any waiver requests must be listed by regulation section numbers. The RTF version of the form can be used as a word processing document.
  • Architect's Compliance Checklists* (PDF files on disc): Checklist applicable to proposed service must be submitted for each suite, DPH or inpatient unit included in the new construction or renovation project. The RTF version of each checklist can be used as a word processing document.
  • Physical Plant Waiver Request Form* (PDF file on disc): A fully completed, signed and scanned form must be submitted with an attached floor plan in 8½” x 11” format for each waiver requested. The RTF version of the form can be used as a word processing document.

In which format should the plans be submitted?

The plans must be submitted in electronic format as multi-page PDF files, as described below:

  • CAD files for the plans should be converted to PDF files without layers.
  • Each of the major sections (site, architectural, mechanical, electrical & plumbing) should be represented by a single multi-page PDF file that includes 100 pages or less. If one of the major sections includes more than 100 pages, the plans should be grouped by category in two or more multi-page files (e.g. floor plans, interior elevations, architectural details). Plans must not be submitted as individual files or as “zip files.”
  • Each PDF file should be optimized for fast web viewing at a 300 dpi resolution.
  • Each PDF file should be set for default magnification “Fit Page” and for default zoom “Dynamic Zoom.”
  • The PDF files should be compatible with Adobe Acrobat 7.0 Professional.
  • Each page should be bookmarked with plan number & floor location.
  • PDF files should be copied to CD or DVD to be labeled with project name and enclosed in a rigid clear case clipped to application packet.

No printed plans will be accepted.

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 if not associated with required support spaces for direct care clinical space within the project area. However, when bed complements are increased or rooms used for direct clinical care (e.g. exam rooms, treatment rooms, procedure rooms, imaging rooms) are added, facilities are expected to ensure compliance with room sizes and functional area requirements for all functional spaces that are required to support the additional beds or additional direct care clinical space.

If the Self-Certification process is used, when can the licensee begin construction?

Construction must not begin until the facility receives the written DPH plan approval, as required by Massachusetts General Laws.

What are the timelines for DPH review of Self-Certification projects?

Once DPH receives a complete and accurate Self-Certification application, the licensee may expect a response within 30 days. For services that DPH identifies as “low-risk”, the review will be expedited in 14 days or less.