1. (a) Applicants or community residences applying for an initial or renewal certification shall complete and submit the form entitled “Request for Certification of Community Residence and/or Individual Day Provider” (August 2019 edition) and shall affirm to the following:

   “I swear or affirm that the information provided on this application is accurate to the best of my knowledge and belief. I believe that this residence/community participation service program is in full compliance with the statutes and regulations governing these services. I understand that providing false information shall be grounds for denial, suspension or revocation of this certification.”

2. (b) Applicants applying for emergency certification shall:

   1. (1) Complete and submit the form entitled “Emergency Certification for Community Residences - 3 or Fewer Beds” (November 2019 edition);
   2. (2) Attach to the emergency certification form a current copy of the floor plan and emergency evacuation plan; and

   3. (3) Include a signature from the executive director of the responsible CMHP that verifies that the appropriate staff determined that the home meets the requirements of He-M 1002, and He-M 1202, as applicable and certify to the following:

      1. a. (Individual’s name), born on (Date of Birth), needed immediate placement on (Date of Placement) to protect his/her health and safety because (Explain Reasons).
      2. b. There is no condition within the above residence that would pose a health or safety threat to the client.
      3. c. This residence is in full compliance with the statutes and regulations governing community residences.”

      “I certify that:

3. (c) Forms completed in accordance with (a) or (b) above shall be submitted to:

   Department of Health and Human Services

   Office of Legal and Regulatory Services

   Health Facilities Administration

   129 Pleasant Street

   Concord NH 03301

Source. #9894-B, eff 3-25-11; ss by #12742, INTERIM, eff 3-20-19, EXPIRED: 9-16-19 New. #12916, eff 11-16-19