Initial Licensure

Initial Licensure. For initial licensure, an applicant shall be in compliance with all requirements, as outlined in these regulations, and must submit documents, included but not limited to, those outlined below: 1. A completed/signed application, on forms as designated by MSDH. All information submitted on the application forms, or by request for additional information, shall be accurate and current at the time of filing; 2. A non-refundable application/processing fee in an amount set by the Board and made payable to the Mississippi State Department of Health, by business check, money order, or by electronic means. The fee is non-refundable. 3. A Licensing Fee in an amount set by the Board and made payable to the Mississippi State Department of Health by business check, money order, or by electronic means. The fee is non-refundable. 4. Certificates/letters of approval from the local zoning authority indicating that the location of the Pediatric Skilled Nursing Facility conforms to local zoning ordinances, if applicable; 5. Certificates/letters of approval from the local/regional/state Fire Marshal that the Pediatric Skilled Nursing Facility is in compliance with all applicable fire safety standards; 6. Evidence that the Pediatric Skilled Nursing Facility water and sewer systems have been approved by the Mississippi State Department of Health; 7. Copy of the Health Inspection report/approval from the MSDH, office of public health. 8. Certificate of Occupancy; 9. Clinical Laboratory Improvement Amendments (CLIA) certificate or CLIA certificate of waiver. 10. Proof of general and Professional Liability Insurance in the amount of at least $300,000.00 including Workman’s Compensation Insurance; 11. Articles of Incorporation, Disclosure of Ownership and Control Information; 12. Proof of financial viability/contingency plan demonstrating evidence that the applicant processes assets sufficient to establish and sustain all components of a Pediatric Skilled Nursing Facility to meet the provisions as outlined in these regulations while operating and/or during extraordinary circumstances including but not limited to audited financial statements, an established line of credit issued from a federally insured institution in the amount of at least $100,000.00, a projected twelve (12) month statement of operations and a projected first twelve months statement of cash flow. The requesting Pediatric Skilled Nursing Facility shall provide evidence of the referenced above review in the form of a certified affidavit or statement resultant of a review from an independent certified public accountant firm. 13. That the center is located within 20 miles or 30 minutes (whichever is greater) of an Emergency Department that has capabilities to handle pediatric emergencies; 14. The name of the Pediatric Skilled Nursing Facility’s administrator, manager or supervisor, the name and license number of the Medical Director and Director of Nursing along with proof of available licensed and supportive personnel who will have responsibility for any part of the care given to Pediatric Skilled Nursing Facility’s clients; as well as proof of ancillary support services such as dietary, housekeeping, maintenance and other personnel either directly or contractually secured to support the Pediatric Skilled Nursing Facility on a daily basis; 15. The names and titles of personnel who have been affiliated, during the preceding five (5) years with any other Pediatric Skilled Nursing Facility, through ownership or employment, and the listing of names and addresses of the appropriate Pediatric Skilled Nursing Facility for each. This information shall be provided for the applicant: administrator, manager or supervisor, and all licensed nurses; and 16. Floor sketch or drawing of premises to be licensed, letter of intent and functional plan. 17. Lead Testing Reports. The exterior playground shall be soil tested for lead contamination; soil samples shall be taken from a minimum of four remote locations around the playground and submitted to a certified lead testing laboratory for analysis. If the building was constructed before 1965, a lead hazard screen or lead-based paint risk assessment shall be done by an individual or company certified as a Lead Risk Assessor by the Mississippi Department of Environmental Quality (MDEQ). 18. Asbestos Testing Report. An asbestos survey shall be performed on all existing structures to be converted into a Pediatric Skilled Nursing Facility to assure compliance with Air Emission Regulations for the Prevention, Abatement, and Control of Air Contaminates-APC S-1-Section 8 (state regulation) and National Emission Standards for Hazardous Air Pollutants (NESHAP) – 40CFR Part 62, Subpart M (federal regulation).