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Thursday, March 5, 2020

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A Senior’s Guide to Successful Downsizing in Retirement

Downsizing can be a stressful process. This is especially true if you’ve lived in the same home for decades, as sorting through a lifetime’s worth of belongings can be completely overwhelming! Fortunately, planning ahead will help make the downsizing process as effortless as possible. So, take a look through the following resources for help cutting back your belongings and choosing a new place to call home.

Is Downsizing Right for You?
Before you start paring down your possessions and hunting for a smaller home, make sure downsizing is the right move.

Decluttering Room by Room
Decluttering your home in sections will make the process much more manageable.

Choosing a New Neighborhood
Research different places you would like to live and pay special attention to the cost of living, healthcare availability, and recreational opportunities.

Budgeting for Hidden Expenses
Leave room in your budget for hidden expenses like moving costs and real estate agent fees.

Preparing yourself for a downsizing move is a complex process. Don’t jump into this big decision without thinking through your options carefully! Ensure downsizing is right for you, research different retirement locations, and make sure your budget will cover all of the expenses associated with selling and buying a home. Good planning will save you from downsizing regret!

Tuesday, October 8, 2019

Change of Ownership (CHOW) is a process that must be followed to transfer the ownership from one party to another.


Congregate Living Health Facility Change of Ownership (CHOW) Process

This document is meant to be an aid for CAHSAH members to use to help them during the

Change of Ownership (CHOW) process. It should supplement the information, forms, and

paperwork you receive from your local Department of Health Services (DHS) district licensing

and certification office. 

Remember: even though there are certain forms and regulations that

mandate the CHOW, that this process is dynamic and fluid and is subject to delays because of

workload, individual differences between staff in your local DHS district office, and filling out

forms incorrectly. Make sure to start with ample time to avoid surprises in your planning process.

Helpful Tips on the CHOW:

· You should make sure that the organization you are going to purchase has a licensed

Congregate Living Health Facility in good standing and that there are no conditions still unaddressed from a previous

survey before you purchase (or at least know that they don’t before you purchase). 


Because when you buy Congregate Living Health Facility, you inherit that facility's history,

record and provider number. Their history becomes your history regardless if you have only

owned them for a short time.

· You do have the option of terminating the provider number and establishing a new one, but

this could take extra three months of processing time. When you terminate and take on a new

provider number, you can not bill while you are waiting for the new provider number.

You can also not bill retroactively. Many providers think they can bill while they are waiting

for a new provider number, and they are often surprised when their claims get denied. This

should be taken into consideration when you are making this decision. Call your DHS district

office and ask about this issue.

· DHS has indicated that, if you are taking on the provider number of the Congregate Living

Health Facility you are purchasing, you can start billing through a Management Agreement

between the borrower and seller. Make sure to run this by your district office before you start

billing to make sure that it is acceptable. There are risks involved in not waiting for the

CHOW to be approved.

· Always remember to keep a copy of all forms you fill out. Sometimes DHS and CMS lose

documents and it is very handy and time-saving to have copies of these documents.

· If you have any questions regarding change of ownership paperwork and requirements, you

should work with your DHS, Licensing and Certification Office. The phone number and

information for your local district DHS L&C office can be found here:

You should get on a first name basis with the

analyst who is processing your Change of Ownership paperwork. This DHS L&C staff person

will be the most important person in the process and can assist you with all your questions.

Additionally, attached to this document is a copy of a Change of Ownership Letter that you

can use to understand what DHS will ask from you. We recommend you start a few months

before you know that you need to start billing, so you can have all your paperwork approved.

· Time Frame: This entire process from start to finish, generally takes 60-90 days (assuming

you submit paperwork for FI, and DHS at the same time and you submit your paper work


What is a Change of Ownership?

State regulations require that you file a change of ownership, per Title 22, Section 74667, in the

following circumstances:




(a) Changes Requiring New Application. An application shall be submitted to the Department

within 10 working days whenever a change of ownership occurs. A change of ownership shall

be deemed to have occurred where, among other things, when compared with the information

contained in the last approved license application of the licensee, there has occurred a transfer

of 50 percent or more of the issued stock of a corporate licensee, a transfer of 50 percent or

more of the assets of the licensee, a change in partners or partnership interests of 50 percent or

greater in terms of capital or share of profits, or relinquishment by the licensee of the

management of the Congregate Living Health Facility

(b) Changes Requiring Written Notice. The licensee shall, within 10 days, notify the Department

in writing of the following:

(1) Change of name of Congregate Living Health Facility;

(2) Change of location and/or address of Congregate Living Health Facility;

(3) Change in the licensing information required by subsection (a) of Section 74661.

(4) Change of the mailing address of the licensee;

(5) Change in the principal officer (chairman, president, general manager) of the governing

board. Such written notice shall include the name and principal business address of each

new principal officer;

(6) Change of the administrator including the name and mailing address of the administrator,

the date the administration assumed office and a brief description of qualifications and

background of the administrator.

(7) Change of Director of Patient Care Services including the name and mailing address of

the Director of Patient Care Services, the date the Director of Patient Care Services

assumed office and a brief description of qualifications and background of the Director of

Patient Care Services Administrator, the date the administration assumed office, and a brief

description of qualifications and background of the administrator.

(8) Addition or deletion of services.

Change of Ownership Process:

To do a Change of Ownership there are three entities involved: The Fiscal Intermediary (FI),

Department of Health Services (DHS), Licensing and Certification, District Office (the one with

where your parent Congregate Living Health Facility is located), and the Centers for Medicare

and Medicaid Services


I. Fiscal Intermediary (FI) Involvement:

* Fill out the 855A Application, the Application for Health Care Providers that will Bill

Medicare Fiscal Intermediaries, if you plan on billing for Medicare services. Read the

instructions, it specifically states what to do if you are doing a CHOW. The FI just checks it to

make sure that the financials of the corporation are sound and accurate and reports this to both

CMS and DHS. It depends on the FI. Some FIs send a copy to both to CMS and DHS District

Office. Another FIs send it just to DHS and DHS sends to CMS. CMS will need this approval

before they can process the CHOW. Once the FI approves or denies the CHOW, they are no

longer involved in the process. Time frame: up to 60 days depending on workload. You should

receive the form from your DHS L&C office. However, if you need it, the 855 A form can be

found here:


II. DHS Involvement

You should write to the DHS and request the CHOW application packet. We strongly recommend

that you work through the DHS office, so you can be on record as starting the CHOW process

and get all the official forms and paperwork from your district DHS L&C office, as well as

establish contact with a DHS employee. However, if you want to download or review copies of

these forms, you can by going to (Note:

at this time, Congregate Living Health Facility forms are combined with nursing home forms.)

The attached sample letter from DHS L&C Alameda is an example of a letter you would receive

with all of the forms and information attached. Call (916) 641-5795 and ask for the DHS example

letter in hot file L6.

Much like a new Congregate Living Health Facility, the following are the forms required for a


HS 200 – Application for a facility license;

HS 215 – Applicant Information;

HS 308 – Designation of Administrative Responsibility

HS 309 – Administrative Organization

A check for the license fee payable to the Department of Health Services

HS 310 – Date of Ownership Change

HS 690 – Assurance of Compliance

MC 803 – Medi-Cal Provider Data Form

HCFA 1513 – Ownership and Control Interest Disclosure Statement

HCFA 1561 – Health Insurance Benefits Agreement (two copies)

HCFA 1572 – Copy of Federal Survey Report Form (retain for your information)

HCFA 2572 – Statement of Financial Solvency*

DHS 1051 Civil Rights Compliance Review

HS 413 – Intermediary Preference*


* If a nonprofit organization, a copy of IRS Letter of Determination of Nonprofit


* A copy of State Franchise Tax Board Letter of Determination of Nonprofit status;

* If the owner is a corporation, a copy of the Articles of Incorporation as filed with

the Secretary of State, State of California, or if the owner is a partnership, a signed

copy of the Partnership Agreement;

* Evidence of possession of the property (lease, rental agreement, deed, bill of sale)

* Notice – Relative to Effective Date of Provider Agreement;

* Office of Civil Rights Letter;

* A copy of any management agreement(s) signed and dated by both parties;

* A copy of instructions on the Implementation of Patient Self-Determination

Provision of OBRA 90 (No need to return);

* CMS 855A Medicare General Enrollment-Health Care Provider/Supplier

Application – Mail original to the intermediary (as explained above) and provide

DHS with a copy.

* Evidence of adequate capitalization to fund the business for three (3) months

without Medicare/Medi-Cal reimbursement. Initial HHA’s are required to have a

capitalization plan that satisfies the federal requirement (90 days) as referenced in

the July 31, 1998 Federal Register, Volume #63, Number 147.


For a CHOW, You must also do the following:

1. A letter from the current licensee to the Department with a copy of the letter to the new

licensee stating that the present license will be relinquished to the Department for

cancellation upon issuance of a new license.

2. A letter from the new licensee to the Department stating where stored patient medical

records will be maintained, and that they will be made available to the previous licensee.

3. A copy of any management agreements signed and dated by both parties.

DHS Recommendation Process: Once you submit the paperwork to DHS, then they will review

and make a recommendation and forward their recommendation to CMS regarding the CHOW.

CMS, more than likely, will approve whatever DHS recommends. DHS indicated that if they

have a lot of concerns about the Congregate Living Health Facility, they will also do a change of

ownership survey. Time Frame: Depends on the workload in each district office. It is best to call

DHS and ask them how long it would take them to process your CHOW.

III. CMS Involvement – Final Approval of the CHOW

Generally, per DHS, CMS doesn’t care about the change of ownership and usually accepts the DHS

recommendation. CMS tends to be more concerned with changes of address rather than

ownership. However, CMS does make the final determination regarding the CHOW and will

send an effective date of the change of ownership along with a contact letter to the Congregate

Living Health Facility notifying the Congregate Living Health Facility that they have been

approved or denied.

If you also will bill for Medi-Cal services, then CMS will also send a transmittal (in-house form)

to the State DHS, Provider Certification Office (in Sacramento), to the Provider Enrollment

Branch to make sure that you get authorized to process Medi-Cal claims. This letter will let

Medi-Cal know that your CHOW has been approved with a certain effective date and that your

Congregate Living Health Facility will be receiving payment for Medi-Cal.

Tuesday, March 26, 2019

Can various types of medical gas cylinders be stored comingled in the same storage room?

Medical Gas Cylinder Storage

Our explainationis as follows:

NFPA 99 does not prohibit various medical gas cylinders from being stored in the same room as long as flammable and non-flammable gasses are not comingled.  Typical medical gases whose storage can be comingled with oxygen include: Carbon Dioxide, Medical Air, Nitrogen, Nitrous Oxide, Helium, Argon, and Xenon. All criteria as specified in EC.02.05.09 applies as well as NFPA 99-2012 requiring full and empty cylinders to be segregated from each other.

As previously indicated, non-flammable medical gas cylinders cannot be comingled with; flammable materials, cylinders containing flammable gases, or containers containing flammable liquids. Typical flammable gases may include but are not limited to: Acetylene, Butane, Ammonia, Ethane, and Propane.  This prohibition is outlined in NFPA 99-2012;

Medical gas cylinders are also not allowed to be stored in an enclosure containing motor driven devices with the exception of cylinders intended for instrument air reserve headers that must comply with NFPA 99-2012; This reference can be found at NFPA 99-2012;  
The only other item that you must be aware of is that the storage unit storing these cylinders must be vented to the outside atmosphere.  And  you must chain the cylinders in two different areas, the top and the bottom of the cylinder.  Not touching one another, unable to clash should there be an earthquake.  And on the outside of the storage unit, there must be the signage that denotes the type of gases that are in the storage unit.  It must be posted to the outside door.  


Monday, March 4, 2019

New a solution for your outdoor generator needs with your Congregate Living Health Facility?

We have a great solution for your generator needs!

This company does the generator and installation very well, we have used them for several of our clients and their reviews of the process was better than perfect.  Cannot beat that, right?


Here is their link:

Give them a ring and they will come and do a free assessment to determine your size and ideal location.  It is really that easy!

Monday, February 25, 2019

Some good questions were recently asked of us, here are the responses to them.

Are curtains only required if it's a shared room?

Do trash cans in the bedroom need a lid? 

How many fire extinguishers shoukd we have in a 2500 sq. ft. Facility?

Are we required to have a sample medical record chart?

Do we need a stationary bike in a rehab room? We already have dumbells and parallel bars. 

Do we need a Pulmonary doctor?
we responded with:

correct curtains only if it is shared.  privacy is maintained with the door closed

trash can should always have lids.

it is one extinguisher per 600 sq ft.  roughly, you will need 4 rounded off to the lowest or you can round up to the five

samples medical record yes.

equipment for the rehab room is based on your type of patients you will admit.  based on your type, I would summons the PT company or person you are contracting with and have them prepare you a document of what your basic needs are for a rehab room in your facility.  since you are not a PT professional, I always err on the side of caution in making sure you have a professional do the assessment for you. With the state, you want to provoke their happiness with you in how you are going about and doing this like the rehab room.  getting a PT to prepare your order for equipment is the right way to do this and by doing this, you are demonstrating that you have the knowledge and understanding to realize you are not a multi-trained person in all fields of medicine and that you know how and when to ask for professional assistance.  in your governing body minutes, you should document this as an event of new business to gain time and points should you not have everything in from ordering should they come while you wait for back orders.

Ideally, your medical director would be a pulmonary doctor if you planned on having trached patients.  If not pulmonary then definitely a hospitalist.  But, again we are back to the basic question of what does your patient look like on paper.  

Saturday, January 12, 2019

Top Three areas keeping you from healthcare accreditation with your congregate

CLHFs (congregate living health facility) have become high on the scale for private insurers to want to deny claims submitted for reimbursements. So, as history has shown before, one of the ways that the private payers sit longer on their monies is to deny the claims based on the fact that the facility is unaccredited.

Joint Commission and CIHQ are the only two organizations thus far that offer a program for CLHFs, and while working on a facility and its accreditation, I became aware of these top three areas CLHFs struggle with in achieving compliancy to these.

These are the top three issues:

Often times when staff take care of patients that are on the vent, along with the trachs that they have, nursing staff will provide care to these patients that encompass many tasks. Tasks that range from changing the trach tube, suctioning, changing out equipment tubing, and an array of other tasks that are often times defined as "ventilator services". This goes without saying that this can ease the nightmare of additional documentation for the staff, which is fine so long as there has been a definition to the terms of ventilator services. "Ventilator Services Provided" is often the term used, and the terms that need to be defined in the nursing policy for the facility. A simple definition of what services it is that have been provided allows then the staff to continue to offer the abbreviated version of these services condensed into just these three words for simplex documentation.

The next area problematic has to do with the initial nursing assessment that is to be done within 24 hours of admission for new admits. In processing the new admission, it is common that the LVN will do an assessment of the patient in preparing the paperwork, she/he then assesses and then signs the document with time and date. But, here lies the problem: LVNs cannot make assessments of patients. This assessment is outside their scope of practice. So, the quick and easy work around this problem is for the RN to come review the patient, assess the patient, and determine if she/he agrees with the LVN documentation. If he/she does agree with it, then he/she will need to countersign the LVN signature with a new date and time, which must also be within the first 24 hours of admission.

The 3rd area has to do with the credentials verification and processing of your Medical Director and any other physicians, PA, RNPs that make rounds and take care of the patient in your facility. The primary source verification is the website of which you would verify their licenses, printing up the verification sheet for proof that you have checked their licenses. The second source verification is the verification through the AMA for the physicians. You need to have an account with AMA and pay the $40.00 per query. The query you run is the second source of verification that you need to run and print up for their credentials verification folders.

These resolutions to these three problems can be your sure win to assisting you at getting closer to that procurement of your accredited status for CLHF.

Photo via   Pexels A Senior’s Guide to Successful Downsizing in Retirement Downsizing can be a stressful process. This is especia...