Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 675 - Nursing and Specialized Facilities › Subchapter 3 - Licenses › Section 310:675-3-5.1 - Description of forms

Current through Vol. 41, No. 20, July 1, 2024
(a) The forms used
				to apply for a facility license are the following.
(1) The License Application for a Nursing or
				Specialized Facility (Form 953-A) requires: identification of the type of
				license; the name and address of the facility; the administrator's name; the
				number and type of beds; the applicant's name; confirmation of changes in the
				owner, lessee, manager or any person or entity disclosed pursuant to
				310:675-3-1.1(e);
				a zoning statement for new facilities; and an oath affirming the truth,
				correctness and completeness of the information provided.
(2) The Disclosure Statement of Owner, Lessee
				and Manager for a Nursing or Specialized Facility (Form 953-B) requires: the
				names and types of legal entities for the owner, lessee and manager; name,
				address and tax identification number for any person or entity disclosed
				pursuant to
				310:675-3-1.1(e);
				and an oath affirming the truth, correctness and completeness of the
				information provided.
(3) The
				Detail Attachment (Form 953-C) supplements the Disclosure Statement (Form
				953-B) and requires the names and addresses for the following as applicable:
(A) All shareholders owning 5% or more of a
				corporate entity and all officers of a corporate entity;
(B) All partners of a general
				partnership;
(C) All general
				partners and all limited partners that own 5% or more of a limited
				partnership;
(D) All members that
				own 5% or more of a limited liability company and all managers of a limited
				liability company;
(E) All
				beneficiaries that hold a 5% or more beneficial interest in a trust and all
				trustees of the trust;
(F) All
				persons or entities that own a 5% or more interest in a joint
				venture;
(G) All persons or
				entities that own a 5% or more interest in an association;
(H) The owners holding a 5% or more interest
				of any other type of legal entity; and
(I) Any other person holding at least a five
				percent (5%) interest in any entity which owns, operates, or manages the
				facility.
(J) As a substitute to
				submitting a Disclosure Statement and Detail Attachment, if the owner, lessee
				and/or manager is an entity that is publicly traded and is required to file
				periodic reports under the Securities and Exchange Act of 1934, or is a wholly
				owned subsidiary of such a publicly held company, the applicant may submit the
				applicable portions of the most recent annual and quarterly reports required by
				the Securities and Exchange Commission (SEC). The applicant shall include an
				index reflecting where each item of information required to be disclosed
				pursuant to the Disclosure Statement and Detail Attachment may be located in
				the SEC filings. Submission of the complete SEC filing is not required. Only
				those portions applicable to the Disclosure Statement and Detail Attachment are
				to be submitted.
(K) The required
				disclosure shall also be made by all persons or entities with an ownership
				interest in any entity required to be disclosed in paragraphs (A) through (I)
				of this section that is equal to a 5% or more indirect ownership interest in
				the owner, lessee and/or manager. The disclosure shall be made at each level of
				the organization to the extent required by this subsection.
(L) For purposes of subsection (K), the
				percentage of indirect ownership interest in the owner, lessee and/or manager
				is determined by multiplying the percentages of ownership in each entity. For
				example, if A owns 10 % of the stock in a corporation that owns 80 % of the
				applicant for license, A's interest equates to an 8 % indirect ownership
				interest in the applicant and must be reported. Conversely, if B owns 80
				percent of the stock of a corporation that owns a 5% interest of the stock of
				the applicant, B's interest equates to a 4% indirect ownership interest in the
				applicant and need not be reported.
(4) The Affirmation Attachment (Form 953-D)
				supplements the Disclosure Statement (Form 953-B) and requires the following:
				the names and addresses of individuals, members, officers and/or registered
				agents required to be disclosed for the applicant pursuant to
				310:675-3-5.1(a)(3); and an affirmation from each of the above concerning their
				age, character and health.
(5) The
				Staffing Projection and Professional Certification for a Nursing or Specialized
				Facility (Form 953-E) requires: a projected staffing pattern; and a
				certification from the director of nursing, the physician on call for medical
				emergencies, and the pharmacist providing consultation and emergency pharmacy
				services.
(6) The Periodic Report
				for Suspended License (Form 953-F) requires: the name and address of the
				facility; the applicant's name and address, contact person and address; report
				of progress in reopening the facility; request for extension based on
				extenuating circumstances; and an oath affirming the truth, correctness and
				completeness of the information provided.