§ 1187.172. Contents and submission of bed requests.
(a) Required contents. An applicant’s bed request must contain the following information:
(1) Ownership information.
(i) The applicant shall provide the name and address of each person who is any of the following:
(A) The applicant and a description of the applicant’s involvement in the proposed project.
(B) The legal entity of the subject facility.
(C) An owner of the subject facility.
(D) A related party involved in the proposed project and a description of the related party’s involvement with the project.
(ii) For each person identified, the applicant shall specify whether:
(A) The person is a spouse, parent, child or sibling of another person identified.
(B) During the 3-year period preceding the bed request, the person is or was an owner of a nursing facility, whether or not located in this Commonwealth, and, if so, the name and address of each of the nursing facilities.
(2) Project overview.
(i) The applicant shall provide an overview of the proposed project which includes a description of the population and primary service area the applicant intends to serve.
(ii) The applicant shall include a narrative and supporting documentation addressing each criterion in § § 1187.175 and 1187.176 (relating to criteria for the approval of bed transfer requests; and criteria for the approval of bed requests other than bed transfer requests), as applicable, and indexed to the criterion being addressed.
(3) Financial information.
(i) The applicant shall provide a feasibility or market study and financial projections prepared for the project that identify the following:
(A) Project costs.
(B) Sources of project funds.
(C) Projected revenue sources by payor type.
(D) Specific assumptions used and expected occupancy rates by payor type.
(ii) The applicant shall provide independent audited or reviewed financial statements of the subject facility for the most recent year prior to the fiscal year in which the bed request is filed. If the financial statements are not available for the subject facility, the applicant shall provide independent audited or reviewed financial statements of the legal entity or parent corporation of the subject facility for the most recent year prior to the fiscal year in which the bed request is filed.
(4) Compliance history. For each person identified in the ownership information section of the bed request as specified under paragraph (1), an applicant shall specify whether or not any of the following applies, and, if so, the applicant shall attach copies of all documents relating to the applicable action, including notices, orders or sanction letters received from the Federal Centers for Medicare and Medicaid Services or any state Medicaid, survey or licensing agency:
(i) The person is currently precluded or, at any time during the 3-year period preceding the bed request, was precluded from participating in the Medicare Program or any State Medicaid Program.
(ii) The person is or, at any time during the 3-year period preceding the date of the bed request, was a party to, or the owner of a party to a corporate integrity agreement with the Department or the Federal government.
(iii) The person owned, operated or managed a nursing facility, including the subject facility, and, at any time during the 3-year period preceding the date of the bed request, one of the following applies:
(A) The facility was precluded from participating in the Medicare Program or any State Medicaid Program.
(B) The facility had its license to operate revoked or suspended.
(C) The facility was subject to the imposition of civil monetary penalties, sanctions or remedies under State or Federal law for resident rights violations.
(D) The facility was subject to the imposition of remedies based on the failure to meet applicable Medicare and Medicaid Program participation requirements, and the facility’s deficiencies were graded as immediate jeopardy to resident health and safety.
(E) The facility was designated a special focus facility by the Federal Centers for Medicare and Medicaid Services, indicating a poor performing facility.
(5) Certification and authority.
(i) A bed request shall be signed by the applicant.
(ii) The applicant shall certify that the representations made and the information provided in the bed request are true and correct to the best of the applicant’s knowledge, information and belief.
(iii) If the applicant is a person other than the legal entity of the subject facility, the applicant shall certify that the applicant is authorized to submit the bed request on behalf of the legal entity and that the legal entity has reviewed and approved the contents of the bed request.
(b) Optional information. In addition to the required content specified under subsection (a), an applicant may include in its bed request whatever information the applicant feels is relevant to or supports its bed request.
(c) Submission. An applicant shall submit an original and two copies of its bed request to the Department.
Cross References This section cited in 55 Pa. Code § 1187.174 (relating to information and data relevant to bed requests); 55 Pa. Code § 1187.175 (relating to criteria for the approval of bed transfer requests); and 55 Pa. Code § 1187.176 (relating to criteria for the approval of bed requests other than bed transfer requests).
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