Addendum To Initial Licensure Application For New Construction (and/or additions) Of Inpatient Hospice Facilities

Initial Licensure Requirements for *New Construction of Inpatient Hospice Facilities.

*New Construction includes an addition to existing building which will affect patient care or treatment areas of the hospice inpatient facility.

Completed pdficon.gif (914 bytes)Initial License Application: The applicant must submit a completed Initial License Application and the following information required and documentation as required in pdficon.gif (914 bytes)175 NAC 16, Section 003.01B:

  • List of names and addresses of all persons in control of the service. The list must include all individual owners, partners, limited liability company members, parent companies, and members of boards of directors owning or managing the operations and any other persons with financial interests or investments in the service. In the case of publicly held corporations, the individual owners listed must include any stockholders who own 5% or more of the company’s stock. 175 NAC 16, Section 003.01B
  • Copy of the registration as a foreign corporation filed with the Nebraska Secretary of State, if applicant is a foreign corporation. 175 NAC 16, Section 003.01B
  • Required licensure fee specified in pdficon.gif (914 bytes)175 NAC 16, Section 004.10.
  • Number of Beds;
  • Construction Plans/Schematic Plans: must be completed in accordance with The Engineers and Architects Regulation Act, pdficon.gif (914 bytes)Neb. Rev. Stat. §§ 81-3401 to 81-3455, and  175 NAC 16, Section 003.01B #15-19, and must include the following:
  1. Project name; description of the project with quantity and floor area information on bed, care, treatment, bathing, toileting, dining and activity locations; building systems; medical equipment, street address; and contact person;
  2. Site plan, floor plans, elevations, wall and building sections, construction details, plumbing and electrical diagrams, construction component schedules;
  3. Complete list of names, titles and telephone numbers of other authorities reviewing or inspecting the construction;
  4. Certification/Approval of Construction Plans from a licensed architect or engineer, that the construction plans and any revisions meet the requirements of Physical Plant Construction Standards, pdficon.gif (914 bytes)175 NAC 16, Section 007;
  5. Upon Department request, any additional information that maybe required for review, such as structural and mechanical calculations, electrical system calculations, and product and equipment information.
  6. Planned occupancy date;
  7. Copies of zoning approval from the relevant jurisdiction; and
  8. Occupancy certificates issued by the State Fire Marshal or delegated authority.
  • On site inspection of physical plant after construction is complete and the issuance of a completion/approval Certificate by the State Architect. pdficon.gif (914 bytes)175 NAC 16, Sections 005.03 A, A1, B, B1 & B2.

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