Section R9-10-105. Initial License Application

A.      A person applying for an initial health care institution license shall submit to the Department an application packet that con- tains:

1.        An application in a format provided by the Department including:

a.         The health care institution’s:

i.         Name, street address, mailing address, tele- phone number, and e-mail address;

ii.        Tax ID number; and

iii.      Class or subclass listed in R9-10-102 for which licensing is requested;

b.        Except for a home health agency, hospice service agency, or behavioral health facility, whether the health care institution is located within 1/4 mile of agricultural land;

c.         Whether the health care institution is located in a leased facility;

d.        Whether the health care institution is ready for a licensing inspection by the Department;

e.         If the health care institution is not ready for a licens- ing inspection by the Department, the date the health care institution will be ready for a licensing inspec- tion;

f.         Whether the applicant agrees to allow the Depart- ment to submit supplemental requests for informa- tion under R9-10-108;

g.        Owner information including:

i.         The owner's name, address, telephone number, and e-mail address;

ii.        Whether the owner is a sole proprietorship, a corporation, a partnership, a limited liability partnership, a limited liability company, or a governmental agency;

iii.      If the owner is a partnership or a limited liabil- ity partnership, the name of each partner;

iv.       If the owner is a limited liability company, the name of the designated manager or, if no man- ager is designated, the names of any two mem- bers of the limited liability company;

v.        If the owner is a corporation, the name and title of each corporate officer;

vi.       If the owner is a governmental agency, the name and title of the individual in charge of the governmental agency or the name of an indi- vidual in charge of the health care institution designated in writing by the individual in charge of the governmental agency;

vii.     Whether the owner or any person with 10% or more business interest in the health care institu- tion has had a license to operate a health care institution denied, revoked, or suspended; the reason for the denial, suspension, or revocation; the date of the denial, suspension, or revoca- tion; and the name and address of the licensing agency that denied, suspended, or revoked the license;

viii.    Whether the owner or any person with 10% or more business interest in the health care institu- tion has had a health care professional license or certificate denied, revoked, or suspended; the reason for the denial, suspension, or revoca- tion; the date of the denial, suspension, or revo- cation; and the name and address of the licensing agency that denied, suspended, or revoked the license or certificate; and

ix.       The name, title, address, and telephone number of the owner's statutory agent or the individual designated by the owner to accept service of process and subpoenas;

h.        The name and address of the governing authority;

i.         The chief administrative officer's:

i.         Name,

ii.        Title,

iii.      Highest educational degree, and

iv.       Work experience related to the health care insti- tution class or subclass for which licensing is requested; and

j.         Signature required in A.R.S. § 36-422(B);

2.        If the health care institution is located in a leased facility, a copy of the lease showing the rights and responsibilities of the parties and exclusive rights of possession of the leased facility;

3.        If applicable, a copy of the owner's articles of incorpora- tion, partnership or joint venture documents, or limited liability documents;

4.        If applicable, the name and address of each owner or les- see of any agricultural land regulated under A.R.S. § 3- 365 and a copy of the written agreement between the applicant and the owner or lessee of agricultural land as prescribed in A.R.S. § 36-421(D);

5.        Except for a home health agency or a hospice service agency, one of the following:

a.         If the health care institution or a part of the health care institution is required by this Chapter to comply with any of the physical plant codes and standards incorporated by reference in A.A.C. R9-1-412, doc- umentation of the health care institution's architec- tural plans and specifications approval in R9-10- 104; or

b.        If a health care institution or a part of the health care institution is not required by this Chapter to comply with any of the physical plant codes and standards incorporated by reference in A.A.C. R9-1-412:

i.         One of the following:

(1)     Documentation from the local jurisdiction of compliance with applicable local build- ing codes and zoning ordinances; or

(2)     If documentation from the local jurisdic- tion is not available, documentation of the unavailability of the local jurisdiction compliance and documentation of a gen- eral contractor’s inspection of the facility that states the  facility  is safe for occu- pancy as the applicable health care institu- tion class or subclass;

ii.        The licensed capacity requested by the appli- cant for the health care institution;

iii.      If applicable, the licensed occupancy requested by the applicant for the health care institution;

iv.       A site plan showing each facility, the property lines of the health care institution, each street and walkway adjacent to the health care institu- tion, parking for the health care institution, fencing and each gate on the health care institu- tion premises, and, if applicable, each swim- ming pool on the health care institution premises; and

v.        A floor plan showing, for each story of a facil- ity, the room layout, room usage, each door and each window, plumbing fixtures, each exit, and the location of each fire protection device;

6.        The health care institution’s proposed scope of services; and

7.        The applicable application fee required by R9-10-106.

B.       In addition to the initial application requirements in this Sec- tion, an applicant shall comply with the supplemental applica- tion requirements in specific rules in this Chapter for  the health care institution class or subclass for which licensing is requested.

C.      The Department shall approve or deny an application in this Section according to R9-10-108.

Historical Note

New Section made by final rulemaking at 8 A.A.R. 3559, effective August 1, 2002 (Supp. 02-3). Amended by exempt rulemaking at 19 A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). Amended by exempt rulemaking at

20 A.A.R. 1409, pursuant to Laws 2013, Ch. 10, § 13;

effective July 1, 2014 (Supp. 14-2).