Rhode Island Department of Health Center for Health Systems Policy and

Regulation Three Capitol Hill, Room 410 Providence, RI 02908-5097 Phone: (401)222-2788 Fax: (401) 222-3017

Letter of Intent Form (Version A2.A5.20t5) applicants must file a Letter of Intent (LOI) on this form 45 days prior filing a Certificate of Need (CON) application. In order to be eligible to file a CON application in the 10 June 2016 batch, a LoI must be frled with this office by no later than 26 April 2016. A11

Please submit three paper copies of the LOI to: Center for Health Systems Policy and Regulation Rhode Island Department of Health 3 Capitol Hill, Room410 Providence, Rhode Island A2908 Please submit one electronic copy of the LOI to: [email protected],gsv Please direct any questions to the Center for Health Systems Policy and Regulation at

(40I) 222-

2788.

1.

Brief Descriptive Title of Proposal: Certified Home Healthcare Agency to provide Nursing, Physical Therapy, Occupational Therapy, and Speech Therapy with concentration on community dwelling seniors and individuals with disability that are at high risk for hospitalization due to changes in physical and medical conditions.

2.

Information for the Applicant(s):

Name: Visitine Rehab and Nursing Services Address: 30 Cumberland St. Woonsocket, Rl I

J.

Information for the Facility (if different from applicant):

Name: Visitins Rehab and Nursins Servrces Address: 30 Cumberland St. Woonsocket, RI 4.

Information of the Chief Executive Officer:

Teleohone: 508-272-0037

Name: Gregory Stelmach Address: 80 Chace Farm Rd. Swansea, MA02777

E-mail: gstelmach@,visitingrehabservices.com Fax number 774-244-4404 Information for the person to contact regarding this proposal: Name:

Telephone:

same as above

44dt.rs Fax number:

E-mail:

Certihed Home Healthcare Agency to provide Nursing, Physical Therapy, Occupational Therapy, and Speech Therapy with concentration on community dwelling seniors and individuals with disability that ate at high risk for hospitalization due to changes in physical and medical conditions.

7.

a. Capital Cost of Proposal: $30,000.00

b. First Full Year Operating Cost of Proposal: $106,280.00 8. Month and year the proposai wouid be implemented: January 2017

9. Will you be requesting: Expeditious review: Yes

No X

Acceierated review: Yes

NoX

If Yes, please complete Appendix A

10. Select the licensure category that best describes the facility:

[--l

Freestanding ambulatory surgical center

i-f-l

Home Nursing Care Provider

1

1. Please

identiff the tax status of the facility:

_

non-profit X_for-profit

-other 12. Please check each and every category that describes this proposal.

A. _X_ construction, development or establishment of a new healthcare facility; B. _acapital expenditure for: 1. _ health care equipment in excess of $2,451,805; 2. _ construction or renovation of a health care facility in excess of $5,720,877; 3. _an acquisition by or on behalf of a health care facility or HMO by lease or rlnnofinn. uvt lqrtvrr,

4. _ C. _

acquisition of an existing health care facility, if the services or the bed capacity of the facility will be changed; any capital expenditure which results in an increase in beci capacity of a hospital and inpatient rehabilitation centers (including drug and/or alcohol abuse treatment centers);

D. E. _ F. _ G. _ H. _

arry capital expenditure which results in an increase in bed capacity of a nursing facllity in excess of 10 beds ar l}Yo of facility's licensed bed capacity, which ever is greater, and for which the related capital expenditures exceed $2,000,000 the offering of a new health service with annualized costs in excess of $ 1,634,536; predevelopment activities not part of a proposal, but which cost in excess of $5,720,877; establishment of an additional inpatient premise of an existing inpatient health care facility or a surgicenter premises of a health care facility; tertiary or specialty care services: full body MRI, CT, cardiac catheterization, positron emission tomography, linear accelerators, open heart surgery, organ transplantation, and neonatal intensive care services. Or, expansion of an existing rcrtiary or specialty care service invoiving capitai andJor operating expenses for additional equipment or facilities;

i3. For each single piece of tertiary or specialty care equipment regardiess of cost and healthcare equipment in excess of $2,383,575, provide the following: Tvoe:

Manufacturer's Name:

Model Name & Number:

Cost:

14. Please indicate the financing mix for the capital cost of this proposal. NOTE: the Health Services Council's policy requires a minimum 20Yo equity invesiment in CON projects (33o/o equity minimum for equipment-related proposals).

Terms (Yrs.)

lnterest Amount

Source

lquitv* )ebt**

B

30"000

10001

B

ease'^

TOTAL

*

Rate

Percent

030,000

o,/ ,/(

o/t

o/ /1

o/<

100"/,

Equrty means non-debt funds contributed towards the capital cost of an acquisition or project r,vhich are free and clear of any repayment obligation or liens against assets, and that result in a like reduction in the portion of the capital cost that is required to be financed or mortgaged (R23-1s-CON).

** If debt andlor lease financing

is indicated, please complete Appendix B.

15. Wiil zoning approval be required

as part

NoX

of this proposal: Yes

this proposal involves new construction or expansion of patient occupancy, that will require an appraved plan for water supply and se.wage disposal from the state an#cr NoX municipal authority : Yes

16. Will

Please have the appropriate individual attest to the following: e le. accJlrale and, t rug. " information conteined in this form is

Signed and dated by

6tl 'fuf'u

"l

hereby certifu that the

President or Chief Executive Officer