Hospice

Initial Licensing

Hospice facilities shall be licensed by the Louisiana Department of Health (LDH). LDH is the only licensing authority for hospice facilities in the State of Louisiana. It shall be unlawful to operate a Hospice facility without possessing a current, valid license issued by LDH. Once a license has been issued, it shall be valid until its expiration date unless otherwise revoked, suspended, or terminated.

Effective March 20, 2012, Facility Need Review approval is required for initial licensure, change of address and change of ownership.

Initial License Application
Letter of Intent

Required Documentation

The provider must submit a Letter of Intent to HSS via e-mail.  Required documents may be submitted with the Letter of Intent.
Below is a list of documents that are required for Initial License Application of a Hospice:

1. a copy of the approval letter of the architectural facility plans from the LDH Department of Engineering and Architectural Services (if an inpatient facility)
2. a copy of the approval letter of the architectural facility plans from the Office of the State Fire Marshal (if an inpatient facility)
3. a copy of the on-site inspection report with approval for occupancy by the Office of the State Fire Marshal (if an inpatient facility)
4. a copy of the health inspection report with approval of occupancy from the Office of Public Health (if an inpatient facility)
5. a copy of criminal background checks on all owners and the administrator
6. Line of Credit ($75,000) from a federally insured lending agency 
7. proof of general and professional liability insurance of at least $300,000
8. proof of worker’s compensation insurance
9. if applicable, a Clinical Laboratory Improvement Amendments (CLIA) certificate or CLIA certificate of waiver;
10. a completed disclosure of ownership and control information form
11. a floor sketch or drawing of the premises to be licensed (if an inpatient facility)
12. qualifications for the Administrator, Director of Nursing, and Medical Director
13. a copy of the Articles of Incorporation
14. Intermediary Preference/Fiscal Year End Date form
15. Form CMS-417 Hospice Request for Certification in the Medicare Program
16. Form CMS-1561 Health Insurance Benefit Agreement (three copies with original signatures)
17. Completed License Application form

Add a Branch

If you are interested in adding a branch, please:

1. Complete the Branch application form
2. Submit a non-refundable $300.00 fee (per branch)
3. Complete the CMS 855A form & submit to the Fiscal Intermediary (FI)

Change of Name

According to the minimum licensing regulations, notification of changes such as name and address must be provided to the department in writing or by facsimile within 24 hours of the occurrence. 

A change in the name of the licensed provider requires that HSS be notified. The provider shall submit a new license application showing that the transaction being requested is a name change. A fee of $25 will be required to print a new license.

Please submit the following to complete this process:

1. A “letter of intent” describing the change that has occurred and the effective date of that change
2. A completed license application (HSS Form)
3. A fee of $25, (HSS Payment Procedure); and
4. A copy of the articles of incorporation from the Secretary of State’s Office indicating this change.

The provider must submit a notice of the name change to the FI according to their process. The Health Standards Section cannot complete the process until receipt of the 855A form from the FI.

Change of Address

According to the minimum licensing regulations, notification of changes such as name and address must be provided to the department in writing or by facsimile within 24 hours of the occurrence. 

All providers having a change of address shall submit:

1. A “Letter of Intent” describing the change that has occurred and the effective date of that change.
2. A completed license application (HSS Form)
3. A fee of $600 (HSS Payment Procedure)
   1. If the parent moves, the fee is $600 plus $300 for each alternative delivery site.
   2. If an alternative delivery site moves, the fee is $300.
   3. If more than one alternative delivery site moves, the fee is $300 per branch.
4. A Hospice provider undergoing a change of location within a 50-mile radius of the licensed geographic location shall submit a written attestation of the change of location and the department shall reissue the Facility Need Review (FNR) approval with the name and new location; and

The provider must submit the notice of the change of address to the FI according to their process. The Health Standards Section cannot complete the process until receipt of the 855A form from the FI

Change of Ownership Information

Providers must complete this document when they have a change in their ownership structure. This document would be used for both a change of ownership (CHOW) as defined by state and/or federal regulations, or a change of ownership information (CHOI) that does not meet the state and/or federal regulations CHOW definition.

For Health Standards to make a CHOW/CHOI determination, all providers must submit the following documents:

1. Letter of Intent (including d/b/a (doing business as) and entity name of the previous and the new owner, the effective date of change of ownership, address and phone number).
2. A diagram showing the ownership structure “before” and “after” the change
3. Copy of the executed legal transaction documents (Bill of Sale, lease, etc.)
4. CHOW/CHOI License Application
5. Change of Ownership Application
6. 855A/B approval letter for the following Medicare Certified providers: Home Health, hospice, hospitals, RHCs, ASCs, ESRDs, portable x-ray, community mental health, CORF, Nursing Facilities, and OPT.

Note: If this action is a CHOI, the documents above are the only documents you need to submit, however the Department may, at its discretion, request additional documentation in support of the CHOI. If so, you will be contacted for any of said additional documents.There is no fee for a CHOI. 

If this action is a CHOW, the following are also needed:

1. Does your facility have a CLIA Certificate? If yes, you may also be required to complete a CHOW for CLIA. 

2. Licensing Fee: Click here for the link for the Health Standards Fee Schedule 

Note: The fee for a CHOW is usually the same as a license renewal unless the facility is making additional changes. For providers completing an acquisition/merger, please contact the program desk for assistance.

Additional Documents Required:

1. License Application Emergency Preparedness Addendum form (HSS Form)
2. Form CMS-417 Hospice Request for Certification in the Medicare Program: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS417.pdf
3. Form CMS-1561 Health Insurance Benefit Agreement (submit 3 forms each with original signatures, sign in the 3^rd section as the successor if accepting provider agreement): https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS1561.pdf
4. Documentation showing the seller’s or transferor’s intent to relinquish the FNR approval
5. Completion of a new FNR application (HSS Form) and $200 non-refundable FNR fee
6. Documentation of qualifications for administrator, director of nursing, & medical director
7. Line of Credit from a federally insured, licensed lending agency for at least $75,000
8. Proof of general and professional liability insurance, and worker’s compensation of at least $300,000.  The certificate holder shall be the Department of Health. 
9. Proof of criminal background check (CBC) on the administrator and all owners.  If a  corporation, submit proof of CBC on all Board of Directors and principal owners.
10. Articles of Incorporation/Articles of Organization
11. Electronic verification from the Office of Civil Rights (OCR) of successful submission of the attestation:http://www.hhs.gov/civil-rights/for-providers/clearance-medicare-providers/index.html
12. Disclosure of any financial and/or familial relationship with any other entity receiving third party payor funds, or any entity which has previously been licensed in Louisiana
13. If any owners of the disclosing entity are also owners (Proprietorship, Partnership, or Board Member) of other licensed health care facilities, please submit a list of the names, addresses, and provider numbers for those facilities. 

For all other Change of Ownership Information, please contact the HSS Ownership Group

Change of Key Personnel

A change in key personnel, such as the Administrator or Director of Nursing, requires that the provider notify HSS so that the provider's records can be updated as all communications regarding the agency will be directed to the Administrator and/or Director of Nursing. Notification shall be made using the HSS Key Personnel Change form.