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Executive Office of Elder Affairs - Assisted Living Application

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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EXECUTIVE OFFICE OF ELDER AFFAIRS
Assisted Living Certification Unit
www.mass.gov/elder
APPLICATION FORM FOR ASSISTED LIVING CERTIFICATION
Initial Renewal* Other
A. GENERAL INFORMATION
The Applicant hereby submits this notarized Application for Certification to advertise, operate
and maintain an Assisted Living Residence in accordance with Chapter 354 of the Acts of 1994
(M.G.L. c. 19D, s. 4 et seq.). An Applicant as defined in 651 CMR 12.02 is any person or a legal
entity applying to Elder Affairs for original Certification or for renewal of Certification as a
Sponsor of an Assisted Living Residence. A person applying on behalf of an entity shall answer
on behalf of the entity.
1.
Assisted Living Residence for Which Renewal of Certification is sought
Name of Assisted Living Residence
Address of Assisted Living Residence
Executive Director/Manager’s Name
Executive Director/Manager’s Email Address
Telephone Number of Assisted Living Residence
Fax Number
Name of the Management Company & Address, (if applicable)
Assisted Living Residence Website
to
1
*651 CMR 12.03(2)(g) Applications for renewal Certification must also include a
statement that the data required by 651 CMR 12.04(13), information documenting all
substantial changes to the operating plan prior to the effective date, and all other information
required by EOEA, have been submitted.
Beginning and ending dates of the Sponsor’s fiscal year:
Last Updated 6/1/2018
UNIT CONFIGURATION
TOTAL number of Units proposed:
*
*Note: this number should equal the total of A and B above; confirm this number is correct
T
RADITIONAL AL UNITS PROPOSED
Unit Type # Units by Type
Single Occupancy:
Double Occupancy:
TOTAL (
A):
SPECIAL CARE RESIDENCE(SCR) UNITS PROPOSED
# Units per SCR
Unit Breakdown
1
st
SCR
2
nd
SCR 3
rd
SCR 4
th
SCR
Single Occupancy:
Double Occupancy:
Total Each SCR:
TOTAL All SCRs (B):
2. Certification Registration (Choose one: Individual or Co-Owners, Corporation, Partnership
or Other Entity, or Trust)
Individual or Co-Owners
Owner’s Name: First, Initial (if used), Last
Owner’s Address
Name of the Leasee or Mortgagee, if applicable
Leasee’s or Mortgagee’s Address
Owner’s Telephone # Owner’s Social Security #
Co-Owner’s Name: First, Initial (if used), Last
Co-Owner’s Address
Co-Owner’s Telephone # Co-Owner’s Social Security #
Last Updated 6/1/2018
2
0
0
0
0
0
0
Corporation, Partnership or Other Entity
Corporation Non- Profit Profit
Un-incorporated Assoc. Partnership Other
(Please Identify)
Name of Corporation or other Entity
Address of Corporation or Entity
Corporation or Entity Telephone #
Date and Place of Incorporation or Formation of Entity
Federal Taxpayer Identification #
Name of person making Application on behalf of Entity
Address of person making Application on behalf of Entity
Telephone # of person making Application
Trust
Name of Trust Agreement
Trustee’s Name
Trustee’s Address
Federal Taxpayer Identification #
Email Address
Name of Corporate Contact Person Email Address
B. SUITABILITY STANDARDS
Any Applicant for initial Certification or for renewal of Certification as a Sponsor who knowingly
or willfully makes or causes to be made a false statement or representation on this statement may be
prosecuted under applicable state laws. If you need additional space, please attach additional sheets
to the Application and reference the Application section and sub-section.
1. List the names and addresses of each officer, director or trustee of the Applicant.
Name Address
2. List the names and addresses of limited partners or shareholders of the Applicant or
Sponsor with more than twenty five percent interest in the Assisted Living Residence being
certified.
Name Address
3. For each individual listed in section 1 or 2 above, list all multifamily housing or health care
facilities or providers in the Commonwealth or in other states in which he or she has been or
is an officer, director, trustee, or general partner.
Name Address
4
Last Updated 6/1/2018
4. For each individual listed in section 1 or 2 above, list the names and addresses of those who
have, within the five years before the date of this application, directly or indirectly had an
ownership interest in one or more of the following entities:
a. Hospital, clinic, long term care facility, mammography facility, institutions for unwed
mothers, out of hospital dialysis unit, hospice program, bacteriological laboratory, blood
bank, or other entity licensed by the Massachusetts Department of Public Health under
M.G.L. c. 111;
b. Medical provider licensed under other applicable state statutes; including facility, halfway
house or treatment program unit for alcoholism licensed under M.G.L. c. 111B, ambulance
service licensed under M.G.L. c. 111C, clinical laboratory licensed under M.G.L. c. 111D,
and drug rehabilitation facility licensed under M.G.L. c. 111E; or,
c. Home health agency in Massachusetts certified under Title XVIII of the Social Security
Act, as amended.
Name
Address
5. For each individual listed in section 4 above, list the name and address of the applicable
entities in which there was an ownership interest during the applicable period.
6. With respect to each licensed or certified entity named in section 5 above and within such
five year period, the Applicant shall furnish a written statement from the Massachusetts
Department of Public Health that such licensed or certified entity has:
a. Substantially met applicable criteria for licensure or certification; and,
b. If applicable, has corrected all cited deficiencies without delicensure or decertification
being imposed.
(Attach separat
ely.)
5
Name
Address
Last Updated 6/1/2018
C. STATEMENT
Each Applicant shall respond to the following questions. If the answer to any of the following
questions is yes, please explain in the space provided below or attach a statement explaining the
issue and the current status with any state, local or federal agency or court of law. If additional
information concerning the matter is necessary, you will be so notified in writing.
1. Has the Applicant ever directly or indirectly had an ownership interest in an entity licensed
by the Massachusetts Department of Public Health under M.G.L. c. 111, or a medical
provider licensed under M.G.L. c. 111B, 111C, 111D or 111E or a home health agency
certified under Title XVIII of the Social Security Act, as amended, that:
a. Has been the subject of a patient care receivership action?
Yes No
b. Has ceased to operate such an entity as a result of a settlement agreement arising from a
decertification action?
Yes No
c. Has ceased to operate such an entity as a result of a settlement agreement in lieu of a patient care
receivership?
Yes No
d. Has ceased to operate such an entity as a result of a delicensure action or involuntary termination
of participation in either the Medical Assistance program under Title XIX of the Social Security
Act, as amended, or the Medicare Program under Title XVIII of the Social Security Act?
Yes No
e. Has been the subject of a substantiated case of patient abuse or neglect involving material failure
to provide adequate protection or services for the Resident in order to prevent such abuse or
neglect?
Yes No
f. Has over the course of its operation been cited for repeated, serious and willful violations of rules
and regulations governing the operation of said health care facility that indicate a disregard for
Resident safety and an inability to responsibly operate an Assisted Living Residence?
Yes No
6
Last Updated 6/1/2018
2. Has the Applicant ever been found in violation of any local, state or federal statute,
regulation, ordinance or other law by reason of that individual’s relationship to an Assisted
Living Residence?
Yes No
If response is yes, please explain:
3. I (We), the Applicant have sufficient personal knowledge and information to affirm that the
ownership entity governing the Assisted Living Residence for which I (we) seek certification is
in sound fiscal condition and is maintaining sufficient cash flows and reserves to operate and
maintain the Assisted Living Residence and all Resident service expenses at this time and
upon commencement of operations.
Yes No
If response is no, please explain:
4. I (We), the Applicant affirm that the Assisted Living Residence for which certification is
sought meets all applicable local, state, and federal statutes, regulations, ordinances or other
laws including, but not limited to, the federal Americans with Disabilities Act and the Fair
Housing Amendments Act, the Massachusetts Architectural Access Board regulations, State
Sanitary Code, State Building Code, fire safety regulations, and other regulations affecting the
health, safety or welfare of Residents and staff.
Yes No
7
Last Updated 6/1/2018
D. CHECK LIST
1. Application Form
2. $200 Application Fee, made payable to “The Commonwealth of Massachusetts”
3. Operating Plan*
*NOTE: Applicants for re-certification are only required to submit documents listed
below if they have been revised since obtaining certification approval from Elder
Affairs. If changes have been made, please submit an updated version of the document
which highlights the revisions.
a. The location of Units and Special Care Units, common spaces, and egresses by floor (may
attach a floor plan)
b. The fee structure for lodging, meals and services
c. The type and extent of services to be offered, arrangements for providing such services,
including third party contracts, and linkages with hospital and nursing facilities
d. A Medication Policy for each of the following:
a. Self-Administered Medication Management (SAMM)
b. Limited Medication Administration ( LMA)
c. As needed medication (PRN)
d. Controlled Substance Management, required under 651 CMR 12.04(14)
e. A means for Residents to communicate urgent or emergency needs, and a plan to provide
timely assistance to them
f. The number of staff to be employed in the operation of the Assisted Living Residence and
their minimum qualifications and responsibilities
g. A copy of the Residency Agreement
h. A copy of all required current building, fire safety, and locally approved state sanitary code
certificates and permits
i. Procedures for notification of a Resident and his or her representative when, due to changes
in the Resident’s service needs, the Assisted Living Residence is no longer an appropriate
environment
j. A copy of the quality improvement and assurance program required under 651 CMR
12.04(10)
8
Last Updated 6/1/2018
Last Updated 6/1/2018
k. A copy of the disaster and emergency preparedness plan required under 651 CMR 12.04(11)
l. A copy of the communicable disease control plan required under 651 CMR 12.04(12)
m. Policies and procedures designed to ensure a safe environment for all Residents
4. Individual Service Plan Form
5. Assessment Form
6. Resident Satisfaction Survey Form
7.
Printed Marketing Mat
erials*(inclusive of current rental and service fees)
*NOTE: Prior to receiving certification, all advertisements must disclose
“Pending EOEA certification” in a minimum 14 point font size.
8. Disclosure of Rights and Services (see 651 CMR 12.08(3))
9. Resident Handbook (if applicable)
REMAINDER OF PAGE INTENTIONALLY
LEFT BLANK
9
Last Updated 6/1/2018
SPECIAL CARE RESIDENCE ONLY
Applicants proposing a Special Care Residence (SCR) must submit the following additional
information.*
*NOTE: Applicants for re-certification are only required to submit documents listed
below if they have been revised since obtaining certification approval from Elder
Affairs. If changes have been made, please submit an updated version of the document
which highlights the revisions.
The SCR Operating Plan must include the following:
1. A brief description of type of Special Care Residence or the population characteristics
to be served by the SCR
2. A floor plan of the building indicating which area(s) comprise the SCR
(if the entire building will be a SCR, indicate “N/A” here)
3. A description of how the SCR will meet the specialized needs of its Resident population,
including those who may need assistance in directing care due to cognitive or other
impairments. The description must include the following elements:
a. Physical design of the structure and the units
b. Physical environment
c. Specialized safety features, including the Residence’s policy on ensuring Resident safety
during power outages or other situations when the locking or unlocking mechanisms of the
doors may not work
d. Enrichment activities
e. Staff training
f. 24-hour emergency preparedness plan based upon the anticipated needs of the occupants of
the Special Care Residence
4. A copy of all policies and procedures related to the design and operation of a SCR
required under 651 CMR 12.04(5) including, at a minimum, the following:
a. Policies and procedures to assess and reduce the risk of potential hazards in the physical
environment related to the special characteristics of the population
b. Policies and procedures for the Special Care Residence that address unsafe Resident
behaviors such as wandering, and verbally or physically aggressive behavior including
coercive or inappropriate sexual behavior
c. Policies and procedures governing the transition of Residents moving in or out of the
Special Care Residence
d. A 24-hour preparedness plan based on the assessed needs of each occupant of the Special
Care Residence for emergency assistance. This plan must also include appropriate
method(s) to provide the necessary assistance.
10
Last Updated 6/1/2018
E. SIGNATURE AND SEAL
1. I, , being first duly sworn on oath depose and say
that the statements contained in this Application are true, complete and correct to the best of my
knowledge.
2. Pursuant to M.G.L. c. 62C, s. 49A, I hereby certify under the penalties of perjury that I, and the
entity on behalf of which I am signing, have complied with all laws of the commonwealth relating
to taxes, reporting of employees and contractors, and withholding and remitting child support.
Type or Print Name of Applicant (Individual, Corporation, or Trust)
____________________________________________________
Signature of Person Authorized to sign for Applicant (Officer, Trustee or Individual)
Subscribed and sworn to before me on this ________ day of ________, 20___.
My Commission expires:
_____________________, 20___.
(Seal)
Notary Public
This Application for Renewal of Certification will not be issued unless this certification clause is
signed and notarized by the Applicant, and the Application includes all required information,
attachments and statements, and fee payments.
Your Social Security number/Federal Taxpayer identification number will be furnished to the
Massachusetts Department of Revenue to determine whether you have met tax filing or tax
payment obligations. Applicants who fail to correct any non-filing or delinquency will be
subject to suspension or revocation of Certification. This request is made under the authority of
M.G.L. c. 62C s. 49A.
APPLICATION SUBMISSION:
In accordance with the regulations (651 CMR 12.03(2), every Application shall be notarized and
signed under the pains and penalties of perjury by the Applicant. Except as set forth in 651 CMR
12.03(8), Change of Ownership shall be submitted to EOEA at least 60 days prior to the date the
Applicant plans to commence operation of the Assisted Living Residence.
A completed application and $200.00 Application fee, made payable to the Commonwealth
of Massachusetts to:
The Executive Office of Elder Affairs
Assisted Living Certification Unit
One Ashburton Place 5
th
Floor
Boston, MA 02108
11
____________________________________________________
Last Updated 6/1/2018
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Completed 10 May 2020

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