STATE OF WASHINGTON

DEPARTMENT OF SOCIAL AND HEALTH SERVICES
Aging and Long-Term Support Administration

PO Box 45600, Olympia, Washington98504-5600

Important Notice--Please Read Carefully

Initial License or

Initial License with Medicaid Contract

Nursing Home License Application Packet

Dear Applicant:

The Department of Social and Health Services (DSHS) issues licenses to individuals and entities to operate a nursing home. Nursing home licenses are issued to the licensee (operator) and are not transferable as part of the business (RCW 18.51.050). The licensee/operator is ultimately responsible for the daily operational decisions of the nursing home and the care of the residents. DSHS must approve a new licensee before a new license is issued.

The Nursing Home License Fee is $359 per bed. Enclose a check or money order made payable to Washington State Treasurer with the application. If no check is included, the application will not be processed and will be returned to the applicant. (see WAC 388-97-560 (2) and (4))

DSHS and the Department of Health, Construction Review (DOH-CRS) each have a role in the licensing of prospective nursing homes. All facilities not currently licensed must submit construction documents for review and approval prior to licensure or commencing construction. All construction information must be submitted and approved by DOH-CRS, and construction completed before a nursing home license inspection can be scheduled by DSHS (Residential Care Services field unit). Nursing home license applications and DOH-CRS applications may be processed simultaneously.

Please note that RCW 74.46.660 requires that any nursing home applying to participate in the Medicaid payment system must obtain and maintain Medicare certification, under Title XVIII of the Social Security Act, 42 U.S.C. Sec. 1395, as amended, for a portion of the facility's licensed beds.

The Centers for Medicare & Medicaid Services (CMS) administers the Medicare program, and works in partnership with the States to administer Medicaid. CMS is responsible for quality standards in health care facilities through its survey and certification activity and maintains oversight of the survey and certification of nursing homes.

A Fiscal Intermediary (FI) is a private company that has a contract with Medicare to pay Medicare Part A and some Medicare Part B bills. The FI determines and processes claims for reimbursement under Medicare. The FI reviews and processes the CMS 855A Medicare General Enrollment Health Care Provider / Supplier Application. Once processed, the FI makes its recommendation to accept or deny acceptance of the applicant into the Medicare program. However, CMS makes the final decision.

Please note that the department will not perform a certification inspection until the Fiscal Intermediary (FI) makes its recommendation to CMS.

Applications are processed on a first come, first served basis and may take longer than 60 days to process. Incomplete applications will be returned without action.

The enclosed nursing home initial license application packet includes:

  • Notice to All Applicants
  • Frequently Asked Nursing Home Questions
  • Resource Information for Licensed Nursing Home Providers
  • Application Instructions
  • Nursing Home License Application – Initial License or Initial License with Medicaid contract
  • Lease or Operating Agreement Attestation form
  • Individuals Affiliated with Applicant Supplemental Information form
  • Management Agreement Attestation form
  • Financial Attestation form
  • Agreement Not to Enter Facility form
  • Consent (Authorization) to Release and/or Use Confidential Information form
  • Real Property and/or Building Related to Financing and/or Insurance Attestation form
  • Checklist
  • Residential Care Services (RCS) Information
  • In addition, you must download the current Background Authorization forms from the NH Applications page at under “Related Materials”.

If you intend to enroll in Medicare or Medicare and Medicaid, the following must be completed, signed, and submitted to this office with the nursing home license application. All forms must have original signatures. The forms are available on the Internet using the links below. Please note that these forms will not be forwarded to CMS unless all forms and attachments are submitted by the applicant. This may affect the proposed licensing date.

  • CMS 1561 - Health Insurance Benefit Agreement (submit 2 originals)
  • CMS-671 - Long Term Care Facility Application for Medicare and Medicaid Form
  • Expression of Intermediary Preference Form (included in this application packet)
  • Office for Civil Rights (OCR) Clearance Package

The CMS 855A “Application for Health Care Providers That Will Bill Medicare Fiscal Intermediaries” form must be completed to enroll in Medicare. The 855A form is available directly from your fiscal intermediary or at This form must be completed, signed, and submitted directly to your fiscal intermediary. Do not submit it to this office.

The applicant (licensee) must purchase a surety bond or an approved alternative to assure protection of residents’ personal funds deposited with the facility, including deposits and prepayments. (see 42 CFR 483.10 (c), WAC 388-97-07015 (6), and WAC 388-96-366 (6))

Please review all documents to assure they are complete and that all requested and applicable information is provided. Incomplete applications will not be processed and will be returned to the applicant. This may cause a problem with the anticipated opening date.

Make a complete copy of all of your application materials for your files. Mail the completed nursing home application, required documents, attachments and license fee to:

For US Mail:For Federal Express or UPS:

DSHS Aging & Long-Term SupportDSHS Aging & Long-Term Support

Residential Care ServicesResidential Care Services

Attn: Business Analysis & Applications UnitAttn: Business Analysis & Applications Unit

P.O. Box 456004450 10th Avenue SE

Olympia, WA98504-5600Lacey, WA 98503

If you have any questions, please call the Business Analysis and Applications Unit at (360) 725-2420.

Cover Letter – Initial License Application – NHPage 1 of 2

October 2013

STATE OF WASHINGTON

DEPARTMENT OF SOCIAL AND HEALTH SERVICES
Aging and Long-Term Support Administration
PO Box 45600, Olympia, Washington98504-5600

NOTICE TO ALL APPLICANTS

Please be aware that:

  • The applicant will not be licensed to operate the facility as a nursing home until and unless the department’s application review process is complete and licensure is approved. The applicant may not admit any residents needing or requesting nursing home services or begin operation of the facility as a nursing home until and unless the department approves licensure. Operating the nursing home without a license is a crime and violates RCW 18.51.050 and WAC 388-97-550.
  • If the applicant begins operating the facility as a nursing home without department licensure approval it is a misdemeanor which may be referred to law enforcement, and the department may impose sanctions against the applicant, including license denial (RCW 18.51.054, RCW 18.51.060, WAC 388-97-570 and WAC 388-97-630).
  • If the applicant applies for a contract with the state to provide nursing facility Medicaid eligible individuals, please note that the applicant (facility) may not accept Medicaid residents until the applicant has been licensed and has either (1) accepted assignment of the former licensee’s Medicaid contract or (2) has received its own certification (RCW 74.46.660).
  • If the applicant accepts Medicaid residents prior to Medicaid certification, the facility will not be authorized to receive payment for services provided before the contract approval date and other sanctions may apply including denial of the contract.

Notice to All Applicants – NHPage 1 of 1

10/01/04

Frequently Asked NH Questions

What is a nursing home?

A nursing home is defined as any home, place or institution which operates or maintains facilities providing convalescent or chronic care, or both, for a period in excess of twenty-four consecutive hours for three or more patients not related by blood or marriage to the operator, who by reason of illness or infirmity, are unable properly to care for themselves. Convalescent and chronic care may include but not be limited to any or all procedures commonly employed in waiting on the sick, such as administration of medicines, preparation of special diets, giving of bedside nursing care, application of dressings and bandages, and carrying out of treatment prescribed by a duly licensed practitioner of the healing arts. It may also include care of mentally incompetent persons. (RCW 18.51.010)

“Nursing home” does not include (1) general hospitals or other places which provide care and treatment for the acutely ill and maintain and operate facilities for major surgery or obstetrics, or both; or (2) any assisted living facility, guest home, hotel or related institution which is held forth to the public as providing, and which is operated to give only board, room and laundry to persons not in need of medical or nursing treatment or supervision except in the case of temporary acute illness. (RCW 18.51.010)

What is the difference between a nursing home, nursing facility, and skilled nursing facility?

A nursing home is any facility licensed to operate under Chapter 18.51 RCW.

A nursing facility or “Medicaid-certified nursing facility” is a nursing home that has been certified to provide nursing services to Medicaid recipients under Section 1919(a) of the Federal Social Security Act.

A skilled nursing facility or “Medicare-certified skilled nursing facility” is a nursing home that has been certified to provide nursing services to Medicare recipients under Section 1819(a) of the Federal Social Security Act.

I am constructing a new NH. How do I start the licensing process?

Before beginning the construction process, contact Department of Health, Certificate of Need (DOH-CON), to determine whether there is a need for additional nursing home beds in the county.

New construction requires approval from the Department of Health, Construction Review Services (DOH-CRS). Contact DOH-CRS for review of all new boarding home construction. The application is available at Write to: Department of Health, Construction Review Services, P.O. Box 47852, Olympia, WA98504-7852. Phone: (360) 236-2944. Fax: (360) 236-2901. Email: . CRS approval must be obtained before a nursing home license can be issued. The nursing home application may be submitted prior to obtaining CRS approval.

I want to remodel my nursing home. How do I start?

Remodels require approval from the Department of Health, Construction Review Services (DOH-CRS). Contact DOH-CRS for review of all nursing home construction. Write to: Department of Health, Construction Review Services, P.O. Box 47852, Olympia, WA98504-7852. Phone: (360) 236-2944. Fax: (360) 236-2901. Email: . CRS approval must be obtained before the remodeled area may be used.

Remodels also require approval from Department of Health, Certificate of Need (DOH-CN) when there is any capital expenditure exceeding the one million dollar threshold adjusted for inflation (currently $1.2 million). Any change in the number of licensed beds requires DOH-CN approval. Contact DOH-CN for review of your project. Write to: Department of Health, Certificate of Need, P.O. Box 47852, Olympia, WA98504-7852. Phone: (360) 236-2955. Fax: (360) 236-2901.

How long will it take to process my NH license application?

Each nursing home application is unique. Because of this, it is impossible to predict how long the licensing process will take. Currently, the application process may take as long as 90 days from the time a complete application is received.

What is the license fee for a NH license?

The license fee is $359 per licensed bed. The fee is calculated by multiplying the number of licensed beds by $359. For initial applications, this fee is due when the application is submitted.

No fee is required for change of ownership or Medicaid contract applications.

Is the nursing home license fee refundable?

The nursing home license fee is not refundable under WAC 388-97-550 (4).

How do I request a nursing home license and/or Medicaid contract application?

You may obtain a nursing home license or Medicaid contract application by calling the Business Analysis and Application Unit at (360) 725-2420. Nursing home license and contract applications are available at this website.

When does a Change of Ownership (Licensee) occur?

A change of ownership occurs when there is a substitution, elimination, or withdrawal of the Licensee or a substitution of control of the Licensee. See WAC 388-97-585 for examples.

What is “Control” of the Licensee?

Control, when used in the context of a Change of Ownership (Licensee), means the possession, directly or indirectly, of the power to direct the management, operation, and policies of the Licensee, whether through ownership, voting control, by agreement, by contract or otherwise.

What does an Owner of five percent (5%) or more of the current licensee, the proposed licensee, or the assets of a nursing home mean?

An Owner of five percent (5%) or more of the current licensee, the proposed licensee, or the assets of a nursing home means:

  • In a sole proprietorship, the owner, or if owned by community property, the owner and the owner’s spouse.
  • In a corporation, the owner of at lease five percent (5%) of the capital stock of the corporation.
  • In other business entity types, the owner of a beneficial interest in at least five percent (5%) of the capital assets of the entity.

What is a management agreement?

A management agreement is a written, executed, agreement between the Licensee and another individual or entity regarding the provision of certain services in a nursing home.

What is a Manager?

A manager is the individual or entity providing the services under the management agreement.

What is an initial nursing home license?

An initial nursing home license is the first nursing license issued to the individual or entity legally responsible for the daily operations and decisions of the nursing home and grants the individual or entity the right to operate a licensed nursing home at a specific location.

What are nursing home license renewals?

Nursing home license renewals are subsequent licenses granted to an existing Licensee to continue operating a licensed nursing home at a specific location.

What is a Temporary Manager?

A Temporary Manager is an individual or entity appointed by the department to oversee the operation of the nursing home to ensure the health and safety of its residents, pending correction of deficiencies or closure of the facility.

What is Receivership?

Receivership is established by a court action and results in the removal of a nursing home’s current licensee and the court appointment of a substitute licensee to temporarily operate the nursing home.

How can I become a Temporary Manager and/or Receiver?

Individuals, partnerships, corporations, or other entities interested in being appointed as a temporary manager or receiver must complete and submit the required application. You may obtain a nursing home Temporary Manager or Receiver application by calling the Business Analysis and Applications Unit at (360) 725-2420.

What is a surety bond?

A surety bond is a formal pledge made to secure resident funds against loss and guarantees to the resident that the facility will compensate the resident for any loss of funds managed by the facility. The facility is required to purchase a surety bond or an alternate assurance or security such as an assignment of time deposit. A surety bond or acceptable alternate must protect the full amount of residents’ funds deposited with the facility

I need to complete a Change of Ownership (Licensee) license application. Which Change of Ownership (Licensee) application do I use?

If you do not currently operate a licensed nursing home in the State of Washington, fill out and submit a completed Change of Ownership (Licensee) “Long” application.

If you currently operate a licensed nursing home in the State of Washington or if you are an affiliate of an entity currently licensed to operate a nursing home in Washington, fill out and submit a completed Change of Ownership (Licensee) “Abbreviated” application. (An “affiliated entity” is an entity that is owned by a licensed entity, holds interest in a licensed entity, or is a subsidiary of a licensed entity).

If you currently operate a licensed nursing home in the State of Washington, intend to submit license applications to operate several additional facilities, and the applicant will be the same on all applications, fill out and submit a completed Change of Ownership (Licensee) “Long” application for one of the facilities. Submit a completed Change of Ownership (Licensee) “Short” application for each additional facility. All applications must be submitted simultaneously.

If you do not know which Change of Ownership (Licensee) application to use, call the Business Analysis and Applications Unit at (360) 725-2420.

I am the 100% owner of a “for profit” corporation that is licensed to operate a nursing home. I want to change from a corporation to a limited liability company (LLC). I will remain the 100% owner. Do I need to submit an application?

You will need to fill out and submit a completed Change of Ownership (Licensee) “Short” application.

If you do not know which Change of Ownership (Licensee) application to use, call the Business Analysis and Applications Unit at (360) 725-2420.

The 25% owner of a “for profit” corporation wants to sell the 25% interest to the remaining owners. There will be no change in the person with control over all operational decisions. Do I need to submit an application?

You need to notify the Business Analysis and Applications Unit (BAAU), in writing, which owner is selling, what percentages will be distributed to the each of the remaining parties, and when this sale will take place. In addition, you need to submit an ownership diagram or a list showing all parties with ownership in the corporation. However, under these circumstances, an application is not required.

If this sale is the only sale of interest in the corporation within the past twenty-four (24) months, the above notice will suffice. However, if within a continuous twenty-four (24) month period, fifty percent (50%) or more of the corporation is transferred through one or more transactions to:

  • A different party (e.g. new or former shareholders); or
  • An individual or entity that had less than a five percent (5%) ownership interest in the corporation at the time of the first transaction.

If this transaction is determined to be a Change of Ownership (Licensee), but do not know which Change of Ownership (Licensee) application to use, call the Business Analysis and Applications Unit at

(360) 725-2420.

How do I apply for a Medicaid contract to provide services to residents who are eligible for Medicaid?

For initial nursing home license applications, fill out and submit a completed Nursing Home License Application – Initial License, along with the applicable license fee.