Additional Required Documents for CHOW

• Criminal Background Checks (new owners) completed by a LSP authorized agency
• Proof of Financial Viability
  • Verification of assets equal to $100,000 or the cost of 3 months operation, whichever is less; or
  • Letter of credit equal to $100,000, or the cost of 3 months of operation
• General & Professional Liability Insurance at least $300,000
• Worker’s Compensation Insurance
• The days of operation (outpatient only)
• Articles of Incorporation/ Articles of Organization
• Submission of a key personnel change form for any change in director or nursing director

• Criminal background checks for all owners
• Proof of Financial Viability: a. A letter of credit issued from a federally insured, licensed lending institution in the amount of at least $100,000 or the cost of three months of operation, whichever is less; or b. affidavit of verification of sufficient assets equal to $100,000 or the cost of three months' operation, whichever is less
• Secretary of State Articles of Incorporation
• Proof of general liability insurance of at least $300,000 per occurrence
• Proof of workers' compensation insurance as required by state law
• Proof of professional liability insurance of at least $100,000 per occurrence/$300,00 per annual aggregate, or proof of self-insurance of at least $100,00, along with proof of enrollment as a qualified healthcare provider with the Louisiana Patient's Compensation Fund (PCF):
  • If the ARCP is self-insured and is not enrolled in the PCF, professional liability limits shall be $1,000,000 per occurrence/$3,000,000 per annual aggregate
  • NOTE: LDH/HSS shall specifically be identified as the certificate holder on any policies and any certificates of insurance issued as proof of insurance by the insurer or producer (agent)
• Office of Public Health Plan Review Approval – See “Residential Plan Review Packet” – Website:  OPH Plan Review Questionnaire

• OSFM- LDH Plan Review Approval Letter (DH-##-##### project number)
• Cautionary Codes accompanying the Plan Review letter
• Attestation for compliance with Plan Review cautionary items
• OSFM onsite approval 
• OPH onsite approval
• Floor Plan
• Organizational chart
• Medical Director’s name
• Criminal Background Checks: Owners, managing employees and those in direct care with minors completed by a LSP authorized agency
• Line of Credit at least $50,000
• General & Professional Liability Insurance at least $500,000
• Worker’s Compensation Insurance
• CLIA certificate (if applicable)
• Proof of registration/status with the La. Secretary of State
• Lease Agreement or letter indicating ownership; identify areas that are subleased

• CMS 3427 ESRD Application and Survey and Certification Report
• Management agreement (if applicable)  
• LSC Attestation Form
• Lease Agreement/Letter from Lessor

Please complete the following steps for FNR CHOW:

• Complete the application
• Upload proof of the change of ownership, which must show the seller's or transferor's intent to relinquish the FNR approval. 
  • The Change of Ownership documentation should include the following additional required document : 
    • Letter relinquishing all FNR rights of the current owner
• Pay the FNR fee.
• Do not attach the FNR initial application or the program's license application packet. 

• CHOW Checklist – please complete and return with packet
• Disclosure of Ownership (HSS-1513L) 
• LTC Facility App for Medicare/Medicaid Form (CMS 671) 
• Intentions Regarding  Medicare Certification / Agreement (HSS-NH-15)
• Health Insurance Benefits agreement (CMS 1561) –– 3 copies, sign each with original signature
• Assurance of Compliance Portal - OCR

The Nursing Home license is not transferable; therefore, another licensing application and fee must be submitted.

The fee of $600.00 plus $5.00 per room must be in the form of a company check, certified check, or money order made payable to: Louisiana Department of Health.

If more than one CHOW occurs, the fee is applicable to each.