In the state of New Jersey, the quest to establish an Adult Day Health Services Facility is guided by comprehensive and stringent regulations, clearly outlined in the HFEL-3 form provided by the New Jersey Department of Health Division of Health Facilities Evaluation and Licensing Office of Certificate of Need and Healthcare Facility Licensure. This critical document serves as a project application that mandates thorough compliance from applicants, ranging from ownership disclosures to operational specifics and facility design requirements. With its mandate for a non-refundable fee, paired with a detailed account of the facility's operational blueprint—including the number of licensed slots requested, the provision of various therapies and services, and the submission of scaled architectural plans—the form exemplifies the meticulous scrutiny applications undergo. This scrutiny extends to the prerequisites for owner and administrator background checks, ensuring that only qualified entities manage such facilities. The crucial inclusion of contact information and the clear stipulation of a 60-day review period underscore the form’s role in ensuring applicants are well informed and prepared for a thorough assessment process. Comprehensiveness and adherence to regulatory codes mark the essence of the HFEL-3 form, embodying the state’s commitment to safeguarding the health and well-being of its aging population through regulated Adult Day Health Services Facilities.
| Question | Answer |
|---|---|
| Form Name | Form Hfel 3 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | hfel 3 cbiu nj department of health form |
New Jersey Department of Health
Division of Health Facilities Evaluation and Licensing
Office of Certificate of Need and Healthcare Facility Licensure
PROJECT APPLICATION FOR AN ADULT DAY HEALTH SERVICES FACILITY
INSTRUCTIONS: Complete all questions directly on this form. Completed application packages, which includes a cover letter and two (2) copies of the project narrative, the fee, and architectural plans are to be sent to:
Assistant Director
Certificate of Need and Healthcare Facility Licensure
New Jersey Department of Health
Mailing Address: |
Overnight Services (DHL, FedEx, UPS): |
PO Box 358 |
171 Jersey Street, Building 5, 1st Floor |
Trenton, NJ |
Trenton, NJ |
A
$10 (per slot) X |
|
(number of slots) = $ |
|
+ $1,500 = $ |
In accordance with N.J.A.C.
Please be advised that incomplete applications will delay the review and approval process. A minimum of 60 days to review your project application is required. You are not authorized to implement any portion of your proposal until you receive written approval from the Certificate of Need and Health Care Facility Licensure Program.
If you have any questions, you may contact the program at (609)
GENERAL INFORMATION
1.Name of Facility
2.Street Address of Facility
3.City, State, Zip
4.County
5.Name of Contact Person for Project Application
6.Email Address
7.Telephone Number
8.Number of licensed adult day health services slots requested:
__________
OWNERSHIP AND DISCLOSURE
9.Identify 100% of the ownership, including the names and home addresses of all principals, (individuals or corporations owning 10% or more), and the percent owned by each. (For nonprofit facilities, provide the names and home addresses of the members of the Board.) An attestation, signed by each individual listed below, that they have read the regulations at N.J.A.C. 8:43F and will comply with them must be included in the application package.
List any ownership interest(s) held by each person in any licensed health care facility in New Jersey or any other state. If
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AUG 12 |
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PROJECT APPLICATION FOR AN ADULT DAY HEALTH SERVICES FACILITY
(CONTINUED)
Name of Facility
OWNERSHIP AND DISCLOSURE, Continued
9.(Continued)
PROGRAM INFORMATION
10. How will the following services be provided? (Check all items that apply)
Occupational Therapy as per N.J.A.C. |
On site |
Physical Therapy as per N.J.A.C. |
On site |
Speech Therapy as per N.J.A.C. |
On site |
Laundry as per N.J.A.C. |
On site |
Meal Preparation as per N.J.A.C. |
On site |
Off site Off site Off site Off site Off site
11. Days and Hours of Operation:
12. Number of Sessions:
13.Scaled architectural floor plans must be submitted, regardless of whether renovation/construction is required, with all rooms in areas clearly labeled with dimensions and their proposed use.
CERTIFICATION: I certify that the information provided in this application is true and correct to the best of my knowledge and belief. I understand and agree not to implement any portion of this proposal prior to receiving written approval from the Certificate of Need and Healthcare Facility Licensure Program.
14. Submitted By (Print)
15. Title
16. Signature
17. Date
FOR STATE USE ONLY
Approved
Yes
No
ID Number
Signature
Date
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AUG 12 |
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