SECTION 310:4-1-13. Description of application forms

(a)   The standard application for a certificate of need requires the following:

(1)   The names and addresses of the facility and contact person;

(2)   Disclosure of the applicant's identity and information sufficient for the Department to determine whether the applicant has been convicted of a felony criminal offense related to the operation or management of a long-term care facility [63:1-853(D)(2)(d)], including but not limited to:

(A)   Sworn and notarized statements from the applicant and each person with controlling interest confirming the lack of any such conviction;

(B)   Social security numbers for the applicant and each person with a controlling interest;

(C)   Birth dates for the applicant and each person with a controlling interest;

(D)   Copies of certificates of incorporation, bylaws, articles of organization, company operating agreements, certificates of limited partnership, or equivalent documents maintained pursuant to state or federal law, and any amendments of such documents. Instead of submitting a document that is not a public record previously filed with a local, state or federal government agency, the applicant may submit a sworn and notarized statement that includes all of the following information:

(i)   Name and date of the document;

(ii)   Name and address of each person or entity that has current or proposed interests, responsibilities or participation in the ownership, operation or management of the facility or that otherwise makes or influences any decision relating to expenditures or operations affecting the facility, whether the person or entity is identified in the disclosed document by proper name or by function;

(iii)   Description of the interest, responsibility, and/or nature of participation of each person or entity named pursuant to (a)(2)(D)(ii) of this section; and

(iv)   Location address and telephone number of the place of business in Oklahoma wherein the applicant shall make the document(s) available for inspection by the Department, upon written request by the Department;

(3)   Historical operating and financial information for the applicant and the facility;

(4)   Residents council and family council minutes for the applicant's facilities;

(5)   A detailed description of the project;

(6)   Projections of personnel needs and identification of the medical director;

(7)   Construction and building information;

(8)   Justification of need for the project; and

(9)   Data and projections on financial and economic feasibility, including but not limited to the following as applicable:

(A)   For conventional, bank, seller-carried, third party, or bond financing, a statement of the proposed principal amount, interest rate and repayment terms, and that the applicant has access to the required funds, signed under oath by a representative of the lending institution, seller, third party, or authority;

(B)   For equity financing:

(i)   An attested balance sheet for the applicant that is dated within the past twelve (12) months and that reflects cash or cash equivalents sufficient to fund the project; or

(ii)   A certificate of deposit or other proof that funds are available and have not been pledged for some other purpose.

(C)   For financing or other funding from or guaranteed by a third party that is not duly authorized or chartered as a bank:

(i)   An attested balance sheet, certificate of deposit or other attested proof that is dated within the past twelve (12) months for the third party, unless the third party is a licensed insurer or surplus lines insurer, the United States of America, a state of the United States of America, or an agency or instrumentality thereof; and

(ii)   Copies of organizational documents and contracts necessary to substantiate the relationship between the applicant and the third party.

(b)   The certificate of need application for exemption for a ten (10) bed or ten percent (10%) expansion of a licensed nursing or specialized facility requires the following:

(1)   The names and addresses of the facility and contact person;

(2)   Disclosure of the applicant's identity;

(3)   Historical occupancy information for the facility;

(4)   A detail of the number of beds to be added; and

(5)   The projected capital cost

(c)   The certificate of need application for exemption for facility replacement requires the following:

(1)   The names and addresses of the facility and contact person;

(2)   Disclosure of the applicant's identity;

(3)   A detail of the number of beds to be replaced;

(4)   The projected capital cost;

(5)   A plan for future use of the facility to be replaced; and

(6)   The distance from the current and proposed sites and a map of the area.

(d)   The certificate of need application for facility acquisition requires the following:

(1)   The names and addresses of the facility and contact person;

(2)   Disclosure of the applicant's identity and information sufficient for the Department to determine whether the applicant has been convicted of a felony criminal offense related to the operation or management of a long-term care facility [63:1-853(D)(2)(d), including but not limited to:

(A)   Sworn and notarized statements from the applicant and each person with controlling interest confirming the lack of any such conviction;

(B)   Social security numbers for the applicant and each person with a controlling interest;

(C)   Birth dates for the applicant and each person with a controlling interest;

(D)   Copies of certificates of incorporation, bylaws, articles of organization, company operating agreements, certificates of limited partnership, or equivalent documents maintained pursuant to state or federal law, and any amendments of such documents. Instead of submitting a document that is not a public record previously filed with a local, state or federal government agency, the applicant may submit a sworn and notarized statement that includes all of the following information:

(i)   Name and date of the document;

(ii)   Name and address of each person or entity that has current or proposed interests, responsibilities or participation in the ownership, operation or management of the facility or that otherwise makes or influences any decision relating to expenditures or operations affecting the facility, whether the person or entity is identified in the disclosed document by proper name or by function;

(iii)   Description of the interest, responsibility, and/or nature of participation of each person or entity named pursuant to (d)(2)(D)(ii) of this section; and

(iv)   Location address and telephone number of the place of business in Oklahoma wherein the applicant shall make the document(s) available for inspection by the Department, upon written request by the Department;

(3)   A description of the proposed transaction and a copy of the contract or agreement;

(4)   A plan for operating the facility including identification of the medical director;

(5)The projected capital cost;

(6)   Financial proof of the applicant's ability to complete the acquisition and to continue services and staffing; and

(7)   Residents council and family council minutes for the applicant's facilities.

(e)   The certificate of need notice for a decrease of beds or a change in continuum of care at a psychiatric or chemical dependency treatment facility or unit requires the following:

(1)   The names and addresses of the facility and contact person;

(2)   A description of the change in beds or change in continuum of care; and

(3)   The anticipated date of the decrease or change.

(f)   The certificate of need application for exemption of a management agreement requires the following:

(1)   The names and addresses of the facility, manager and contact person;

(2)   A copy of the executed management agreement that details the manager's responsibilities and duties;

(3)   Disclosure of the applicant's identity and experience that is sufficient to determine if the management entity and any person with a controlling interest has a history of noncompliance;

(4)   Copies of certificates of incorporation, bylaws, articles of organization, company operating agreements, certificates of limited partnership, or equivalent documents maintained pursuant to state or federal law, and any amendments of such documents. Instead of submitting a document that is not a public record previously filed with a local, state or federal government agency, the applicant may submit a sworn and notarized statement that includes all of the following information:

(A)   Name and date of the document;

(B)   Name and address of each person or entity that has current or proposed interests, responsibilities or participation in the ownership, operation or management of the facility or that otherwise makes or influences any decision relating to expenditures or operations affecting the facility, whether the person or entity is identified in the disclosed document by proper name or by function;

(C)   Description of the interest, responsibility, and/or nature of participation of each person or entity named pursuant to (f)(4)(B) of this section; and

(D)   Location address and telephone number of the place of business in Oklahoma wherein the applicant shall make the document(s) available for inspection by the Department, upon written request by the Department; and

(5)   The anticipated date of commencement of the management agreement.

(g)   The certificate of need application for exemption for ownership change or transfer requires the following:

(1)   The names and addresses of the facility and contact person; and

(2)   A description of the transfer and disclosure of persons and entities involved or affected;

(3)   Copies of agreements or contracts by which ownership is changed or transferred; and

(4)   Copies of certificates of incorporation, bylaws, articles of organization, company operating agreements, certificates of limited partnership, or equivalent documents maintained pursuant to state or federal law, and any amendments of such documents. Instead of submitting a document that is not a public record previously filed with a local, state or federal government agency, the applicant may submit a sworn and notarized statement that includes all of the following information:

(A)   Name and date of the document;

(B)   Name and address of each person or entity that has current or proposed interests, responsibilities or participation in the ownership, operation or management of the facility or that otherwise makes or influences any decision relating to expenditures or operations affecting the facility, whether the person or entity is identified in the disclosed document by proper name or by function;

(C)   Description of the interest, responsibility, and/or nature of participation of each person or entity named pursuant to (g)(4)(B) of this section; and

(D)   Location address and telephone number of the place of business in Oklahoma wherein the applicant shall make the document(s) available for inspection by the Department, upon written request by the Department.

(h)   For the purposes of this section, the term "attest" shall have the meanings as defined in 59 O.S. Supp. 2004, Section 15.1A.

[Source: Added at 14 Ok Reg 2247, eff 6-12-97; Amended at 18 Ok Reg 2468, eff 6-25-01; Amended at 19 Ok Reg 2042, eff 6-27-02; Amended at 22 Ok Reg 2363, eff 7-11-05]