HFEL Licensing Amendment Process (12/18/2013)
Receive Amendment
Application
Scan application and
deliver original to
Licensing admin 1
Team Secretary
Licensing (admin
1)1
Facility
Mailroom
Phase
Provide additional
information to
analyst
Receive Amendment
Application
Log receipt into
HFEL licensing
database
Respond to
completeness
questions
Begin amended
operations
Assign to
appropriate regional
review team2
Receive and log
receipt in personal
log3
Review amendment
Is the application
complex?4
N
Draft cover letter
and prepare
amended license
Update ASPEN with
amended license
informatio11
Contact licensing to
draft approval letter
and amended
license
Contact facility with
approval
Assign to analyst
Y
Team Leader
Refer to team leader
Assign to a review team
Review application
and assign to analyst
Contact facility for
additional
information
Survey
NJ Agencies
Team analyst
Y
Comments:
1. There are two admins for acute care who can function interchangeably with one another.
2. There are three separate teams covering north, central, and south New Jersey.
3. There is no standard format for the personal logs. Could be paper or electronic.
4. The team secretary can refer any application to the team leader
5. There is no standard format for the personal logs. Could be paper or electronic.
6. Other state agencies may include medicaid, DCA, or any agency with a vested interest. It is at the analysts interpretation of
regulation which agencies need to be contacted.
7. Surveys in progress or planned may not be in ASPEN yet. Some survey reports may require a week or so to complete and enter into
ASPEN
8. 2-3 cycles of completeness questions may occur, and the process may take several months.
9. The team composes a large printout packet with all of the completeness questions, answers, the application, and any other relevant
documents for review by survey. It is sent via intraoffice mail.
10. The facility should have followed the instructions set out by the team, therefore there should not be any significant deviations that
would cause survey to reject the facility.
11. Licensing enters the amended license information: date, changes in ownership, changes in service, address, etc. – whatever
changes had been approved.
Receive and log
amendment
application5
Review amendment
application
More info
needed from
facility?
N
Info needed
from other state
agencies?6
N
Is survey
approval
required?
Y
Y
Contact other state
agencies for
assistance
Contact survey for
approval
N
Review facility
history in ASPEN for
past compliance
Contact survey for
any complaints,
reportable events,
or survey issues not
in ASPEN7
Draft completeness
questions letter and
mail to facility8
Receive and review
responses to
completeness
questions
Any additional
questions?n
N
Gather all related
documents and send
to survey9
Print out all recs and
approvals10
Y
Provide assistance
to analyst
Survey – provide
approval
Provide most recent
facility history
Receive amendment
packet via intraoffice mail
Conduct survey
Survey – report
findings in ASPEN
Send e-mail to team
with
recommendations
Mail amended
license and cover
letter to facility