New Jersey Department of Health

Office of Certificate of Need and Healthcare Facility Licensure

P.O. Box 358

Trenton, NJ 08625-0358

INSTRUCTIONS FOR COMPLETING THE

APPLICATION FOR THE ADDITION OF LONG-TERM CARE BEDS

(PURSUANT TO N.J.S.A. 26:2H-7.2)

Please submit a cover letter, including a detailed project narrative, as well as scaled plans of the entire facility. Indicate where the new beds will be located. Plans should be submitted with ALL applications, regardless of whether renovations will be required. Label all rooms according to use (i.e., dining room, resident room, activity room, etc.) and indicate room numbers of resident rooms.

Checks should be made payable to “Treasurer, State of New Jersey.”

Forward completed applications to:

Mailing Address:

New Jersey Department of Health

Office of Certificate of Need and Healthcare Facility Licensure

P. O. Box 358

Trenton, NJ 08625-0358

Overnight Services (DHL, FedEx, UPS):

New Jersey Department of Health

Office of Certificate of Need and Healthcare Facility Licensure

25 South Stockton Street, 2nd Floor

Trenton, NJ 08608-1832

To obtain additional information regarding the application process, please call:

609-292-6552	Team A: for facilities located in Bergen, Hudson, Mercer, Morris, Passaic, Somerset, Sussex and Warren Counties

609-633-9042	Team B: for facilities located in Burlington, Gloucester, Hunterdon, Middlesex, Monmouth and Ocean Counties

609-292-7228	Team C: for facilities located in Atlantic, Camden, Cape May, Cumberland, Essex, Salem and Union Counties

New Jersey Department of Health

Office of Certificate of Need and Healthcare Facility Licensure

P. O. Box 358

Trenton, NJ 08625-0358

APPLICATION FOR THE ADDITION OF LONG-TERM CARE BEDS

(PURSUANT TO N.J.S.A. 26:2H-7.2)

1.	Name of Facility
2.	Name of Licensed Operator/Owner
3.	Facility Street Address
4.	City	5.	State	6.	Zip Code
7.	County
8.	Application Fee Amount

($1500 plus $15 per additional bed):	Check Number	Check Date
9.	Name of Facility Representative	10.	Telephone Number
11.	Current Number of Licensed Long-Term Care Beds
12.	Were any of the above referenced long-term care beds approved through a previous Add-a-Bed Application, pursuant to N.J.S.A. 26:2H-7.2?	No	Yes

If Yes, Number of Beds	Date Approved
13.	Does the facility currently have any waivers of building requirements?	No	Yes

If Yes, please cite specific waivers:

14	Number of Additional Long-Term Care Beds Requested
15.	Identify the proposed location of the additional beds, including the floor, wing, and room numbers:
16.	Does the facility have any three or four-bedded rooms?	No	Yes

If Yes, please describe the facility’s plan to reduce the capacity of all rooms to a maximum of two beds:
17.	Will this project require renovation and/or construction?	No	Yes

18.	Does the facility have adequate dining and recreation space for the additional beds, in accordance with Section 8.3.A of the AIA Guidelines?	No	Yes

19.	Does the facility maintain a minimum of one bathtub or shower for every 20 residents, not otherwise served by bathing facilities in resident rooms?	No	Yes
Name of Individual Completing Form	Title
Signature	Date

LCS-5 (Instructions)

MAY 16

APPLICATION FOR THE ADDITION OF LONG-TERM CARE BEDS

(Continued)

LCS-5

MAY 16	Page 2 of 2 Pages.

MAY 16	Page 1 of 2 Pages.

LCS-5, Application for Addition of LTC Beds

LCS-5, CN, Certificate of Need, Healthcare facility Licensure, licensure, licensing, LTC beds, LTC

EWhite

2004-05-05

NJDOH