Adult Brain Injury

Initial Licensure

Checklist for Initial Licensure- Adult Brain InjuryA completed initial license application packet for an ABI facility shall be submitted to, and approved by, LDH prior to an applicant providing adult brain injury services.  An applicant shall submit a completed initial licensing packet to LDH, which shall include:

1. a completed Adult Brain Injury licensure application (HSS Form)
2. a non-refundable licensing fee of $250 (plus $250 for each offsite location) (Payment Procedure)
3. a copy of the approval letter of the architectural facility plans from the Office of the State Fire Marshal (OSFM) Health Care licensing plan review internet site - http://sfm.dps.louisiana.gov/pr_healthcare.htm  OSFM plan review contact information: Phone 225-925-4920 or Fax 225-925-4414
4. a copy of the on-site inspection report with approval for occupancy by the Office of the State Fire Marshall (residential and outpatient facilities only) 
5. a copy of the health inspection report with approval of occupancy from the Office of Public Health (residential and outpatient facilities only)
6. a copy of a statewide criminal background check conducted by the Louisiana State Police, or its authorized agency, on all owners. (Criminal Background Check website)
7. proof of financial viability as evidenced by one of the following:
   1. verification of sufficient assets equal to $100,000 or the cost of 3 months of operation, whichever is less; or
   2. a letter of credit from a federally insured,  licensed lending institution in the amount equal to $100,000 or the cost of 3 months operation, whichever is less;
8. proof of general and professional liability insurance of at least $300,000;
9. proof of worker’s compensation insurance; 
10. if applicable, clinical laboratory improvement amendments (CLIA) certificate;
11. disclosure of ownership and control information; 
12. a readable 11x17 minimum copy floor sketch of the premises to be licensed, including room usage and dimensions (residential and outpatient only);
13. a copy of the articles of organization or articles of incorporation; 
14. qualifications for program director & director of nursing

If the initial licensing packet is incomplete, the department will notify the applicant of the missing information and the deadline to submit the additional requested information.  If the additional requested information is not submitted to the department within 90 days of notification, the application will be closed.

Re-Licensure

In order to renew a license, the ABI facility shall submit a completed license renewal application packet to the department at least 30 days prior to the expiration of the existing current license.

The license renewal application packet shall include:

1. a completed ABI licensure application (HSS Form)

2. a non-refundable licensing fee of $250 (plus $250 for each offsite location) (Payment Procedure)

3. a copy of the on-site inspection report with approval for occupancy by the Office of the State Fire Marshall (residential and outpatient facilities only)

4. a copy of the health inspection report with approval of occupancy from the Office of Public Health (residential and outpatient facilities only)

Failure to submit to the department a completed license renewal application packet prior to the expiration of the current license will result in the voluntary surrender of the ABI facility license.

Entity or dba/trade Name Change Process 

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 specifics of the change that has occurred and the effective date of that change;
2. a completed license application (HSS Form);
3. the fee of $25, (HSS Payment Procedure); and
4. a copy of documents or articles of incorporation from the Secretary of State’s Office indicating the change. 

Geographic Address Change

Please submit the following to complete this process:

1. a “letter of intent” describing the specifics of the change (address changed from and to) that has occurred and the effective date of that change;
2. a completed license application (Form);
3. the fee of $250 (plus $250 for each offsite location) (Payment Procedure);
4. a copy of the approval letter of the architectural facility plans from the Office of the State Fire Marshal (OSFM) Health Care licensing plan review internet site - http://sfm.dps.louisiana.gov/pr_healthcare.htm OSFM plan review contact information: Phone 225-925-4920 or Fax 225-925-4414
5. a copy of the on-site inspection report with approval for occupancy by the Office of the State Fire Marshall (residential and outpatient facilities only)
6. a copy of the health inspection report with approval of occupancy from the Office of Public Health (residential and outpatient facilities only);
7. disclosure of ownership and control information; and
8. a readable  11x17 minimum copy floor sketch of the premises to be licensed, including room usage and dimensions (residential and outpatient only).

Once this information is received and approved, the LDH Health Standards Section must conduct an onsite physical environment inspection before final approval can be given for the provider to move into the new location. 

Key Administrative Personnel Change

Any change regarding the facility’s key administrative personnel shall be reported in writing to the department with five working days of the change.

Key administrative personnel include the:

1. facility director; or
2. director of nursing

These key administrative personnel changes should be reported by completing and submitting the following HSS form: HSS Key Personnel Change Form

Mailing Address, Email, Phone, or Fax Number Change

Please submit a written notification to the department of any mailing address, email, phone, or fax number changes for the facility.

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 and entity name of the previous and the new owner, the effective date of transfer of ownership, address and phone number)
2. *A diagram showing the ownership structure “before” and “after” the change
3. *Copy of the executed Bill of Sale
4. *HSS Forms
5. *855A/B approval letter for the following providers: Home health, hospice, hospitals, RHCs, ASCs,   

         ESRDs, portable x-ray, community mental health 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 documents are also needed:

1. Does your facility have a CLIA Certificate? If yes, contact the CLIA program by clicking here.
2. *Licensing Fee: Click here for the link for the Health Standards Fee Schedule

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

Additional Documents Required:

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