410-2-5-.05. Application For State Health Plan Adjustment

(1) Requirements (a) Applicant Identification. An application for a Plan Adjustment must be filed in accordance with SHPDA Rule 410-1-3-.09, and accompanied by the administrative fee specified in Rule 410-2-5-.04(c)(5). The application must include the name of the applicant, physical address, telephone number, the contact person and mailing address, telephone number, and e-mail address. (b) Project Description. Provide a narrative statement explaining the nature of the request, with details of the plan adjustment desired. (If the request is for additional beds, indicate the number and type, i.e., Psychiatric, Rehabilitation, Pediatric, Nursing Home, etc.) The narrative should address availability, accessibility, cost, quality of the health care in question, and state with specificity the proposed language of the adjustment. (c) Service Area. Describe the geographical area to be served. (Provide an 8½” x 11” map of the service area. The map should indicate the location of other similar health care facilities in the area.) (d) Population Projections. Provide population projections for the service area. In the case of beds for a specific age group, such as pediatric beds or nursing home beds, document the existence of the affected population. An example for nursing home beds is the number of persons 65 and older. The applicant must include the source of all information provided. (e) Need for the Adjustment. Address the current need methodology. If the application is to increase beds or services in a planning area, give evidence that those beds or services have not been available and/or accessible to the population of the area. (f) Current and Projected Utilization. Provide current and projected utilization of similar facilities or services within the proposed service area. (g) If additional staffing will be required to support the additional need, indicate the availability of such staffing. (h) Effect on Existing Facilities or Services. Address the impact this plan adjustment will have on other facilities in the area both in occupancy and manpower. (i) Community Reaction. Give evidence of project support demonstrated by local community, civic and other organizations. (Testimony and/or comments regarding plan adjustment provided by community leaders, health care professionals, and other interested citizens.) (j) Provide any other information or data available in justification of the plan adjustment request.