Free License Application for Nursing Home, Facility for the Developmentally Disabled, or Institute for Mental Disease-F-62019 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62019 (Rev. 07/08)

STATE OF WISCONSIN

FOR OFFICE USE ONLY License Number License Fee

LICENSE APPLICATION FOR NURSING HOME, FACILITY FOR THE DEVELOPMENTALLY DISABLED, OR INSTITUTE FOR MENTAL DISEASE

Caregiver Background Fee License Type Effective Date Expiration Date

Type of Facility
Nursing Home Facility for the Developmentally Disabled Institute for Mental Disease

Type of Application
Initial Change of Ownership Replacement Facility

Completion of this form is required by Chapter 50.50.03(3)(b), Wis. Stats., and HFS 132.14(2) and HFS 134.14(1), Wis. Admin. Code. The department will not issue a license until the applicant has supplied all requested information. The personally identifiable information collected on this form will be used to determine licensure eligibility and for statistical information and for no other purpose.

RETURN THE COMPLETED APPLICATION TO: Division of Quality Assurance Bureau of Technology, Licensing and Education P.O. Box 2969 Madison, WI 53701-2969 I. GENERAL INFORMATION
Name ­ Facility Previous Name (if applicable) Street (physical) Address City Mailing Address (if different from physical address) City Telephone Number FAX Number E-mail Address State Zip Code County State Zip Code

Level of License
A. B. C. D. HFS 132 Skilled Care ­ Nursing Home Intermediate Care ­ Nursing Home Skilled Care ­ Institute for Mental Disease (IMD) Intermediate Care ­ Inst. for Mental Disease (IMD) HFS 134 E. Facility for the Developmentally Disabled

Licensed Bed Capacity

Fiscal Year End Date

Type of Certification
Medicare (Title XVIII) Medicaid (Title XIX) Medicare and Medicaid (Dual Certification) Distinct Part Fully Participating State Licensed only (no certification)

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II. ADMINISTRATION A. Administrator
Status: Permanent Acting (temporary and unlicensed) Interim (temporary and licensed) QMRP (only if facility is licensed as an FDD for 16 or fewer beds)
Name ­ Administrator License Number Begin Date

Indicate if the administrator is also the designee (person authorized to accept personal service and receive registered and Yes No certified mail.) If "No," complete the Designee section. B. Designee
Name ­ Designee Title Begin Date

C. Director of Nursing
Name ­ Director of Nursing Status Begin Date

Permanent

Acting (temporary)
Begin Date

D. Medical Director
Name ­ Medical Director

III. OWNERSHIP INFORMATION A. Applicant / Licensee [person(s) or business entity having the authority to direct the management or policies of the facility]
Name ­ Applicant Street (physical) Address City Mailing Address (if different from physical address) City Telephone Number Contact Person Fax Number State Zip Code County State Zip Code County

E-mail Address Telephone Number

B. Type of Organization (Check type of ownership.)
Governmental City County State Federal City / County Tribal Proprietary Sole Proprietary Partnership Corporation Limited Liability Company Limited Liability Partnership Trust Voluntary Non-Profit Corporation Church Association Church / Corporation Private Non-Profit Limited Liability Company Limited Liability Partnership Trust

C. Interested Parties
List all names, principal business addresses, and the percentage of ownership interest of all officers, directors, stockholders owning 5% or more of stock, members, partners, and all other persons having authority or responsibility for the operation of the organization. For non-profit organizations or governmental organizations, list the names and principal business address of all officers, directors, and board members. Attach additional pages if necessary.

F-62019 (Rev. 07/08) Name Street Name Street Name Address Name Address Name Address Name Street Name Address Title City Title City Title City Title City Title City Title City Title City

Page 3 Ownership Percentage State Zip Code

Ownership Percentage State Zip Code

Ownership Percentage State Zip Code

Ownership Percentage State Zip Code

Ownership Percentage State Zip Code

Ownership Percentage State Zip Code

Ownership Percentage State Zip Code

D. Ownership Operation Building Land

The licensee owns the: Yes Yes Yes No No No

NOTE: If the licensee is not the owner of the operation, building, or land, complete the following section or sections as appropriate. D1. Owner of the: Operation Building Land
Name ­ Owner of the Operation or Operation, Building, and Land Street (physical) Address City Mailing Address (if different from physical address) City Telephone Number Contact Person Fax Number State Zip Code E-mail Address Telephone Number County State Zip Code County

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Type of Organization (Check type of ownership.)
Governmental City County State Federal City / County Tribal Proprietary Sole Proprietary Partnership Corporation Limited Liability Company Limited Liability Partnership Trust Voluntary Non-Profit Corporation Church Association Church / Corporation Private Non-Profit Limited Liability Company Limited Liability Partnership Trust

Interested Parties
List all names, principal business addresses, and the percentage of ownership interest of all officers, directors, stockholders owning 5% or more of stock, members, partners, and all other persons having authority or responsibility for the operation of the organization. For non-profit organizations or governmental organizations, list the names and principal business address of all officers, directors, and board members. Attach additional pages if necessary.
Name Address Name Address Title City Title City Ownership Percentage State Zip Code

Ownership Percentage State Zip Code

D2. Owner of the:

Building

Land

Name ­ Owner of the Building or Building and Land Street (physical) Address City Mailing Address (if different from physical address) City Telephone Number Contact Person Fax Number State Zip Code County State Zip Code County

E-mail Address Telephone Number

Interested Parties
List all names, principal business addresses, and the percentage of ownership interest of all officers, directors, stockholders owning 5% or more of stock, members, partners, and all other persons having authority or responsibility for the operation of the organization. For non-profit organizations or governmental organizations, list the names and principal business address of all officers, directors, and board members. Attach additional pages if necessary.
Name Street Name Street Title City Title City Ownership Percentage State Zip Code

Ownership Percentage State Zip Code

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D3. Owner of the:
Name ­ Owner of the Land Street (physical) Address City

Land

State

Zip Code

County

Mailing Address (if different from physical address) City Telephone Number Contact Person Fax Number State Zip Code E-mail Address Telephone Number County

Interested Parties
List all names, principal business addresses and the percentage of ownership interest of all officers, directors, stockholders owning 5% or more of stock, members, partners, and all other persons having authority or responsibility for the operation of the organization. For nonprofit organizations or governmental organizations, list the names and principal business address of all officers, directors and board members. Attach additional pages if necessary.
Name Street Name Street Title City Title City Ownership Percentage State Zip Code

Ownership Percentage State Zip Code

D4. Subsidiary / Parent Information
a. Is the applicant a subsidiary company, either wholly or partially owned by another organization or business? Yes No

If "Yes," provide the following information:
Legal Business Name ­ Parent Company DBA (Doing Business As) Type of Ownership Address Contact Person City Telephone Number State Zip Code

b.

Is the applicant affiliated with any subsidiaries in the health care field in this state or any other state? Yes · · No

If "Yes," provide one of the following: Names and addresses of all subsidiaries owned by the parent company, in this state or any other state, (relationship type: nursing homes, home health agencies, hospices, hospitals, rehabilitation facilities, etc.) Organizational chart exhibiting the legal business names and, if applicable, the dba name of all the subsidiaries currently owned by the parent company in the health care field in this state or any other state, (relationship type: nursing homes, home health agencies, hospices, hospitals, rehabilitation facilities, etc.) Complete annual report to shareholders.

·

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D5. Chain Organization
Is the applicant under the control of a chain organization? Yes No

Chain organization is defined as multiple providers, and / or suppliers owned, leased, or through any other devises, controlled by a single business entity (defined as chain home office.) Each entity in the chain may have a different owner but the "home office" maintains uniform procedures in each facility for handling utilization review, reimbursement, handling admissions, also maintains and controls centrally, provider/suppliers cost reports, etc. In addition, a chain facility would not necessarily be a subsidiary of the parent corporation but the chain facility or facilities could be owned by different subsidiaries of the same corporate parent.
Name ­ Chain Organization

If the applicant/licensee is a Limited Liability Company (LLC) or Limited Liability Partnership (LLP): Provide the names and addresses of all LLC's, LLP's or any other type of entity that any of the member(s) of the applicant are also members, officers, directors and/or board members. Provide an organizational chart exhibiting the legal business names of any and all subsidiaries, LLC's, LLP's involved with this applicant and its members.

IV. FIT AND QUALIFIED
The following information will be used to determine if the applicant meets the fit and qualified requirements under Chapter 50, Wis. Stats.: A. Has the applicant, any of the interested parties and/or any of the members of a LLC / LLP, been affiliated in the past five years with a hospice (HSP), a home health agency (HHA), a residential care facility, e.g., Community Based Residential Facility (CBRF), Adult Family Home (AFH), or a health care facility (HCF), e.g., hospital, nursing home or facility for the developmentally disabled in the State of Wisconsin or in any other state? Yes No

IF THE ANSWER IS "YES," complete all information in the section below. Use the facility abbreviations (in parenthesis) from above to identify the type of facility. IF THE ANSWER IS "NO," complete questions A ­ I.
Facility Name and Address City and State Type of Health Care Provider Owner / Operator / Mgr. Vendor / Provider No. Dates of Affiliation

B.

Has any adverse action initiated by any state licensing agency resulted in the denial (D), suspension (S), or revocation (R) of a license? Yes No

If "Yes," complete the following table. Use abbreviations to describe the type of adverse action and refer to the previous page for abbreviations for type of health care provider.
Facility Name and Address City and State Type of Health Care Provider Type of Adverse Action Effective Dates of Adverse Action

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C. Has any adverse action initiated by a state or federal agency based on non-compliance resulted in civil money penalties (CMP), termination of provider agreement (TPA), suspension of payments (SOP), or the appointment of temporary management of the facility (TMF)? Yes No

If "Yes," complete the following table. Use abbreviations to describe the type of adverse action and refer to the previous page for abbreviations for type of health care provider.
Facility Name and Address Location of State Federal or State Type of Health Care Provider Type of Adverse Action Effective Dates of Adverse Action

D. Has the applicant, any of the interested parties and/or any of the members of a LLC / LLP, ever had a denial, suspension, enjoining or revocation of a health care provider license, in this state or any other state, as defined in Chapter 146.81, Wis. Stats., or any conviction for providing health care without a license? Yes If "Yes," explain. No

E.

Has the applicant, any of the interested parties and/or any of the members of a LLC / LLP, ever been convicted of a crime involving neglect or abuse of patients, or involved in assaultive behavior, wanton disregard for the health and safety of others, or any act of elder abuse under Chapter 46.90, Wis. Stats. Yes If "Yes," explain. No

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F.

Has the applicant, any of the interested parties and/or any of the members of a LLC / LLP, ever been convicted of a crime related to the delivery of health care services or items? Yes If "Yes," explain. No

G. Has the applicant, any of the interested parties and/or any of the members of a LLC / LLP, ever been convicted of a crime involving controlled substances under Chapter 161, Wis. Stats.? Yes If "Yes," explain. No

H. Has the applicant, any of the interested parties, and/or any of the members of a LLC / LLP had any prior circumstances that resulted in bankruptcy or in the closing of a hospice, home health agency, or an inpatient health care facility, e.g., nursing home or hospital, or the relocation of its patients or residents? Yes If "Yes," explain. No

I.

Identify the other types of providers owned by the applicant / licensee. If more than two, check here and attach additional pages.

Name ­ Provider City State Zip Code

Relationship Type (nursing home, home health agency, community based residential facility, hospital, hospice) Name ­ Provider City State Zip Code

Relationship Type (nursing home, home health agency, community based residential facility, hospital)

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V. FINANCIAL RESPONSIBILITY
The questions in this section are to be answered ONLY by the applicant / licensee. A. Has the applicant / licensee, any of the interested parties and/or any of the members of a LLC / LLP, been adjudicated bankrupt? Yes No

If "Yes," explain on a separate page. Provide the dates, court , and disposition of each action. B. Are there any unsatisfied judgements against the applicant / licensee, any of the interested parties and/or any of the members of a LLC / LLP? Yes No

If "Yes," explain on a separate page. Provide the names and addresses of creditors, amounts. and the reasons for nonpayment. C. Does the applicant / licensee, any of the interested parties and/or any of the members of a LLC / LLP, owe any debts that are 90 days past due? Yes No

If "Yes," explain on a separate page. Provide the names and addresses of creditors, amounts, and reasons for non-payment. D. Are there any liens filed against the applicant / licensee, any of the interested parties and/or any of the members of a LLC / LLP, or their property? Yes No

If "Yes," explain on a separate page. E. Estimated average gross annual revenues from all sources. Round to the nearest thousand dollars.

Daily Rate: Title XIX Private Pay Other Other Revenues TOTAL

$ $ $ $ $

F.

Estimated annual costs. Round to the nearest thousand dollars.

Operating Expenses Capital Outlays TOTAL

$ $ $

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G. HFS 132.14(3)(a)4(c), Wis. Admin. Code, requires the applicant to have sufficient financial resources to permit operation of the facility for six (6) months. This amount is one-half of the figure shown in your answer to question F. (estimated annual costs). NOTE: Daily rate charges are automatically taken into consideration. · Complete the following HCF projected financial statement forms F-01022 A - E, located in the DHS Forms Library at http://dhs.wisconsin.gov/forms/DHCFnum.asp F-01022 A F-01022 B F-01022 C F-01022 D F-01022 E · Instructions for Projected Financial Statements Projected Income Statement Projected Cash Flow Related Party Transactions Projected Balance Sheet

Include the following information (if applicable): 1. 2. 3. Certified statement of line of credit; or Personal financial statement along with a signed affidavit committing personal resources or a copy of the corporation's annual report along with a signed affidavit committing corporate resources; or Other financial documentation to support sufficient resources to cover operating losses.

H. Do you have any other commitments to transfer residents from other facility closings or phasedowns? Yes No

If "Yes," explain on a separate page. I. Provide projected patient days, by month and by type of payer, for the first six months of operation. J. Provide the following, if applicable. · · · · Explain large variances in the projected revenues and/or expenses from those of the current operator's latest cost report. Explain changes in occupancy rate or mix from those of the current owner's latest cost report. Provide proof of commitment of mortgages when the purchase of the real estate is involved in the change of ownership. Evidence of commitment of a working capital loan and/or a line of credit from the financial institution providing financing.

VI. APPLICANT / LICENSEE
If the applicant/licensee has never been licensed to operate a nursing home in Wisconsin, we request that you respond to the following: 1. 2. Provide resumes for each officer (if the applicant is a corporation), or each partner (if partnership) or member (if limited liability company), etc. to assist the Department in determining the applicant's ability to operate a long term care facility. Is your licensed Nursing Home Administrator (NHA) in good standing in Wisconsin? What nursing facilities has this individual directed and what time periods and bed size? What accomplishments has the NHA achieved?

VII. MANAGEMENT COMPANY
A. Is the operation of the facility under a management contract? Yes No

If "yes," provide the following information regarding any management company retained to operate this facility or program. Type of Management Company:
Name - Management Company Name - Contact Person Address City Telephone Number State Zip Code

Corporation

Partnership

LLC

Other

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B.

Identify officers, directors, trustees or supervisors of the management company. Attach additional pages if necessary.
Title City Title City State Zip Code State Zip Code

Name Address Name Address

C. Identify other facilities the management company has owned, operated or managed in the last 5 years. Attach additional pages if necessary.
Name Address Dates of Involvement Name Address Dates of Involvement Name Address Dates of Involvement City State Zip Code City State Zip Code City State Zip Code

D. While managing any of the above facilities identified in item C.: 1. Has any adverse action initiated by any state licensing agency resulted in the denial (D), suspension (S), or revocation (R) of a license? Yes No

If "Yes," complete the following table. Use abbreviations to describe the type of adverse action and refer to page 6 for abbreviations for type of health care provider.
Facility Name and Address City and State Type of Health Care Provider Type of Adverse Action Effective Dates of Adverse Action

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2.

Has any adverse action been initiated by a state or federal agency based on non-compliance resulted in civil money penalties (CMP), termination of provider agreement (TPA), suspension of payments (SOP), or the appointment of temporary management of the facility (TMF)? Yes No

If "Yes," complete the following table. Use abbreviations to describe the type of adverse action and refer to page 6 for abbreviations for type of health care provider.
Facility Name and Address City and State Type of Health Care Provider Type of Adverse Action Effective Dates of Adverse Action

E. If there is a management company involved, how will you monitor the success of this management company in complying with HFS 132, Wisconsin Administrative Code, and CFR (Code of Federal Regulation)? Provide resumes for each individual of the management company who will exercise operational or managerial control in the long term care facility. F. Attach a copy of the signed contract with the management company.

VII. CONTACT PERSON
Identify the person responsible for completing this application and who can be contacted if we have questions.
Name Telephone Number FAX Number Title Date Application Completed

VIII. ATTESTATION I attest, under penalty of law, that the information provided above is truthful and accurate to the best of my knowledge and that knowingly providing false information or omitting information may result in a fine of up to $10,000 or imprisonment not to exceed 6 years, or both (per Chapter 946.32, Wis. Stats.).
SIGNATURE (FULL) ­ Applicant (Potential Licensee)
Title ­ Applicant Name - Applicant's (Print or type.)

Date Signed

NOTE: The Management Company cannot attest to or sign on behalf of the applicant (potential licensee).