016.23.2. Forms

AR ADC 016.23.2Arkansas Administrative CodeEffective: [See Text Amendments] to May 31, 2022

West's Arkansas Administrative Code
Title 016. Department of Human Services
Division 23. Behavioral Health Services
Rule 2. Behavioral Health Agency Certification Manual
Effective: [See Text Amendments] to May 31, 2022
Ark. Admin. Code 016.23.2
016.23.2. Forms
ARKANSAS DEPARTMENT OF HUMAN SERVICES
Accreditation Organization Release of Information Consent
I, CEO (or equivalent) _________________________, hereby consent to the exchange of information between _______________________________________________________ Accrediting Agency and The Arkansas Department of Human Services for the specific purpose of obtaining or sharing information relevant to Behavioral Health Agency Certification.
I consent to information regarding my agency's national accreditation or state certifications being released by facsimile (FAX) __________ Yes __________ No.
I understand that the information I authorize for release may include sensitive information. I understand that a facsimile of this consent is considered as valid as if it were the original.
________________________________________
____________________
Signature of CEO (or equivalent)
Date
________________________________________
____________________
Signature of Witness
Date
Form 200
ARKANSAS DEPARTMENT OF HUMAN SERVICES
BEHAVIORAL HEALTH AGENCY PROVIDER RE-CERTIFICATION
To be submitted to renew DHS Behavioral Health certification after receiving re-accreditation from the national accrediting agency at the time of the new accreditation cycle.
Name of Agency:
_______________________________________________________
Chief Executive Officer (or equivalent): ________________________________________
Corporate Compliance Officer (or equivalent): ___________________________________
Administrative Address: __________________________________________________
Telephone: ___________________________________ Fax: ____________________
E-mail: ____________________________________________________________
1. The provider named above is fully accredited and in good standing with one of the following accreditation organizations. (Please check your accreditation organization)
_____ Joint Commission (J-CO)
_____ Commission on Accreditation for Rehabilitation Facilities (CARF)
_____ Council on Accreditation (COA)
2. Date of most recent survey: ______________________________
3. National Accreditation Period: ____________________ through ____________________
4. The accredited provider is located within the state of Arkansas.
_____ Yes _____ No
Chief Executive Officer (or equivalent) Certification: By my signature I certify that all information contained in this form and in all attachments are correct and complete.
________________________________________
____________________
Signature of Chief Executive Officer (or equivalent)
Date
____________________________________________________________
Name of Chief Executive Officer (or equivalent) typed or printed
Qualifications for Behavioral Health Agency Re-Certification
All of the following information must be attached to Behavioral Health Agency Re-certification form. Applications must be submitted in full. Partial submissions will not be accepted.
1. Latest accreditation survey results. (The entire survey report with a listing of all provider service sites providing outpatient behavioral health services must be included.)
2. Copies of all correspondence and e-mails (e-mails may be copied to DHS) between the agency and the accrediting organization that pertains to the accreditation of the provider's outpatient behavioral health services.
3. A signed agreement that DHS may receive information directly from the accrediting organization regarding the agency's accreditation and any information pertaining to service delivery (BEHAVIORAL HEALTH AGENCY Form 200).
4. All Evidence of Compliance, Measures of Success, Quality Improvement Plans, and any Corrective Action Plans that were required and submitted to the accrediting organization pertaining to outpatient behavioral health services related to the latest accreditation survey.
5. Identify any significant changes (since last certification period) in program resources (i.e. number of sites operated by agency, changes in administrative staff, and number of school-based Mental Health Programs). Please attach additional pages if needed.
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
6. Identify any significant changes (since last certification period) in personnel qualifications and resources (i.e. changes in code of ethics and client grievance policy, changes in how psychological testing services are delivered and changes in the plan for staff training and supervision). Please attach additional pages if needed.
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
7. Identify any significant changes (since last certification period) in the physical plant(s). (i.e. changes in address and phone numbers of service delivery sites, any structural/cosmetic changes). Please attach additional pages if needed.
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
8. Describe any significant changes (since last certification period) in the service delivery plan (i.e. types of services available at each site, changes in the crisis services plan and any plans for expansion or reduction in services). Please attach additional pages if needed.
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Please send a cover letter and all application materials to be re-certified by DHS as an Behavioral Health Agency to the following address:
Department of Human Services
Policy & Certification Office
305 South Palm Street
Little Rock, AR 72205
Form 230
ARKANSAS DEPARTMENT OF HUMAN SERVICES
BEHAVIORAL HEALTH AGENCY ANNUAL REPORTING FORM
State Fiscal Year 20 __________: 7/01/ _____ through 6/30/ _____
Name of Agency:
____________________________________________________________
Chief Executive Officer (or equivalent):
____________________________________________________________
Corporate Compliance Officer (or equivalent):
____________________________________________________________
Clinical Director (or equivalent):
_______________________________________________________
Medical Director
_______________________________________________________
Administrative Address:
____________________________________________________________
____________________________________________________________
Phone Number: _________________________ Fax Number: ______________________________
Contact E-Mail: ____________________________________________________________
Provider Type (please check one): Private Non-Profit Empty Checkbox​ Private For Profit Empty Checkbox​ Public Entity Empty Checkbox​Other
(Specify): ____________________________________________________________
Chief Executive Officer Certification (or equivalent): By my signature I certify that I have reviewed this report and attachments and to the best of my knowledge it represents an accurate report of agency services and resources.
________________________________________
____________________
Signature of Chief Executive Officer (or equivalent)
Date
____________________________________________________________
Name of Chief Executive Officer (or equivalent) typed or printed
THIS REPORT RELATES TO AGENCY WIDE INFORMATION
1. Please include all annual reporting requirements from the accrediting organization. This includes Annual Conformance to Quality Report, Maintenance of Accreditation or Intra-Cycle Monitoring Profile. Please include all correspondence to and from the accrediting organization related to annual reporting requirements.
2. Provider's plans and activities to overcome cultural and linguistic barriers to treatment (Include a brief statement regarding on-going efforts to serve clients from diverse backgrounds as well as those clients that may have physical disabilities.)
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
3. Staff Composition Chart (Please fill out the following chart)
As of the date this report is submitted, report the number of agency employees. Indicate whether the employee is salary (W-2) or contract (1099).
THIS INFORMATION RELATES TO AGENCY WIDE INFORMATION PERSONNEL RESOURCES
TOTAL
W-2
1099
1. Psychiatrist
2. M.D. Non-psychiatrist
3. Psychologist
4. Independently Licensed Clinicians
5. Non-Independently Licensed Clinicians
6. Registered Nurse
7. Qualified Behavioral Health Providers (Including Certified Peer Support Specialist, Certified Youth Support Specialist, Certified Family Support Partners)
8. All other staff not included above
9. Sum of lines 1-7
Form 310
4. Interagency involvement (Please identify all existing formal or informal contracts the agency has with other providers or agencies to provide Outpatient Behavioral Health services. Briefly explain how the agency utilizes and interfaces with other community resources to provide services for the client.)
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
5. Agency wide quality improvement and outcomes activities (Please include agency organizational chart and the outcomes of identified quality improvement efforts to improve client care/outcomes.)
As a part of the outcomes activities report include:
a. Measured outcomes
b. Sample report
c. Collection of outcomes, beginning at the initial behavioral health diagnosis service, which would be completed very close to the client's intake.
PLEASE SUBMIT THIS FORM AND SUPPORTING DOCUMENTATION TO:
Department of Human Services
Policy and Certification
305 South Palm Street
Little Rock, AR 72205
FOR DHS INTERNAL USE ONLY:
1)
Cultural/Linguistic Barriers
Yes ___ No ___
Status: Complete
2)
Staff Composition
Yes ___ No ___
Status: Complete
3)
Interagency Involvement
Yes ___ No ___
Status: Complete
4)
Quality Improvement
Yes ___ No ___
Status: Complete
5)
ACQR MOA PPR
Yes ___ No ___
Comments:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Form 240
ARKANSAS DEPARTMENT OF HUMAN SERVICES
APPLICATION FOR INDIVIDUALLY LICENSED PRACTITIONER
To be completed upon initial application to become certified as an Individually Licensed Practitioner
Name: ____________________________________________________________
Address: ____________________________________________________________
County: ______________________________
Telephone: ___________________________________ Fax: ____________________
E-mail: ____________________________________________________________
Website: ____________________________________________________________
Description of outpatient behavioral health services provided:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Business Hours: ______________________________
Description of how and by whom clients are covered 24 hours a day/7 days a week, addressing crisis services as well as routing services delivery:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Do you provide medication management through your facility?
________________________________________
If not, how is medication management handled for your clients?
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Description of how you will collaborate with other agencies/individuals to facilitate quality and continuity of care for clients:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
________________________________________
_______________
Signature of Individually Licensed Practitioner
Date
________________________________________
Name of Individually Licensed Practitioner
Required Documents to begin processing Independently Licensed Practitioner Certification
All of the following information must be attached to the Independently Licensed Practitioner Certification. Applications not submitted in full will not be processed.
1. Names, credentials and relevant experiences for backup and medication management physicians.
2. Names, credentials and relevant experience of applicant's experience providing behavioral health services.
3. Copies of any affiliation agreements with other agencies/professionals that provide behavioral health services for your clients.
4. Copies of pertinent certifications and/or licenses (i.e. JCAHO, CARF, staff licensure or certification by State boards to practice behavioral health services, etc.). Applicant MUST submit Arkansas licensure which grants the applicant that authority to engage in private/independent practice by the appropriate State Board.
5. Copies of any forms used for documentation (treatment plan, psychosocial history, etc.)
6. Copies of all correspondence and e-mails (e-mails may be copied to the DHS) between the agency and the accrediting organization that pertains to the accreditation of the provider's outpatient behavioral health services.
DHS WILL SCHEDULE AN ONSITE SURVEY WITHIN FORTY-FIVE (45) CALENDAR DAYS OF APPROVING ALL REQUIRED CERTIFICATION DOCUMENTATION.
Please send a cover letter and all application materials to be certified by DHS as an Independently Licensed Practitioner to the following address:
Department of Human Services
Policy & Certification Office
305 South Palm Street
Little Rock, AR 72205
Form 500
ARKANSAS DEPARTMENT OF HUMAN SERVICES
BEHAVIORAL HEALTH AGENCY NEW SITE APPLICATION
Name of Agency:
____________________________________________________________
Chief Executive Officer (or equivalent):
____________________________________________________________
Corporate Compliance Officer (or equivalent):
____________________________________________________________
Administrative Address:
___________________________________
___________________________________
___________________________________
___________________________________
Telephone: ___________________________________ Fax: ___________________________________
E-mail: ____________________________________________________________
NEW SITE PHYSICAL ADDRESS: DATE SITE OPENED:____________________
________________________________________
________________________________________
________________________________________
________________________________________
Telephone: _________________________ Fax Number: ____________________
E-mail: ________________________________________
Chief Executive Officer (or equivalent) Certification: By my signature I certify that I have reviewed this report and attachments and to the best of my knowledge it represents an accurate report of agency services and resources.
_____________________________________________
_______________
Name of Chief Executive Officer (or equivalent) typed or printed
Date
_____________________________________________
Signature of Chief Executive Officer (or equivalent)
PERSONNEL RESOURCES FOR NEW SITE ONLY
SFY2012
(As of the date this report is submitted)
1. Psychiatrists
2. M.D. Non-psychiatrists
3. Psychologists
4. Independently Licensed Clinicians
5. Non-Independently Licensed Clinicians
6. Registered Nurses
7. Qualified Behavioral Health Providers (Including Certified Peer Support Specialist, Certified Youth Support Specialist, Certified Family Support Partners)
8. All other staff not included above
9. Sum of lines 1-8
PROGRAM RESOURCES FOR NEW SITE ONLY
(Round to nearest whole number)
10. Number of counties in service area
11. Number of counties in service area in which agency operates a service site
12. Total number of service sites operated by Agency
13. Average daily clients served by Agency
14. Number of School Based Behavioral Health Programs run by agency
15. Total projected daily average of clients in all school based sites combined
16. Total projected number of clients served in the outpatient clinic
17. Please list other mental health services provided by the organization and provide capacity information, as appropriate (i.e. residential beds, crisis beds, inpatient beds, housing, therapeutic foster care, partial hospitalization, therapeutic communities, etc.)
17.A.
17.B.
17.C
17.D
If more room is needed, please list on a separate page and attach to this report.
CONTACT INFORMATION
18. Contact person regarding this report
19. Telephone number of contact person for this report
20. E-mail address of contact person for this report
PERSONNEL QUALIFICATIONS & RESOURCES
1. Attach administrative structure for the new site/s for which extension of certification is being requested.
2. Attach licenses or certifications and resumes of all administrators of the new site. Include the medical director or consulting psychiatrist information if different from the main office site.
3. Attach any contracts with consulting professionals specific to the new site only if additional to the original certification.
PHSYICAL PLANT [FN1]
1. Attach a list of all new service delivery sites including each site's address (street, city & county), telephone number, fax number, the name of the designated contact person, for each site and that person's email address, the geographic area served by each site and the Outpatient Behavioral Health services available at each site.
2. Attach a photograph of each service delivery site for which you are requesting a certification extension. Include outside entrance to building, staff offices, and waiting area.
SERVICE DELIVERY PLAN THAT IS CURRENTLY IN PLACE FOR EACH NEW SITE
In a narrative report, describe the agency's plan for the provision of services including all requested information in compliance with the current Behavioral Health Agency Certification Policy and Outpatient Behavioral Health Services Medicaid Manual. Please utilize the following format:
1. Type of services available at additional site/s, hours of operation and type of clients served (i.e. children, adults, Seriously Mentally Ill, Seriously Emotionally Disturbed, Juvenile Justice Population, etc.)
2. Provide any information that is specific to the site/s for which certification is being requested that is different from those agency sites already certified by DBHS.
3. Description of agency's crisis services plan that is available at the new site including the policy and procedures for provision of crisis services 24 hours a day 7 days a week.
4. Briefly explain how the new site will utilize and interface with other community resources to provide services for the client.
5. Describe how the new site will be integrated into the Quality Improvement Program of the agency.
ACCREDITATION INFORMATION
I. Attach documentation notifying your accrediting organization of the site/s addition/s and the accrediting organization's acknowledgement of the accreditation extension. Certification extension WILL NOT BE GRANTED until you have the accrediting organization's documentation.
II. Include dates of current accreditation cycle.
Reimbursement by Arkansas Medicaid services shall not occur until the site is certified by the Department of Human Services.
Please send this form along with your application to be certified by DHS as a Behavioral Health Agency to the following address:
Department of Human Services
Policy & Certification Office
305 South Palm Street
Little Rock, AR 72205
Form 250
ARKANSAS DEPARTMENT OF HUMAN SERVICES
APPLICATION FOR PARTIAL HOSPITALIZATION CERTIFICATION
To be completed upon initial application to become certified as a Partial Hospitalization Program
Name of Behavioral Health Agency:
____________________________________________________________
Chief Executive Officer (or equivalent): _____________________________________________
Corporate Compliance Officer (or equivalent): _____________________________________________
Administrative Address: ____________________________________________________________
County: ____________________
Telephone: ___________________________________ Fax: ____________________
E-mail: ____________________________________________________________
Website: ____________________________________________________________
The provider named above shall be certified by the Department of Human Services as a Behavioral Health Agency. A Partial Hospitalization certification will not be issued if the provider is not a part of a DHS certified Behavioral Health Agency. A Certified Behavioral Health Agency can submit one (1) application for multiple Partial Hospitalization sites, with the Personnel Resources to be completed for each site.
Behavioral Health Agency Certification Period: ____________________ through ____________________
As the Chief Executive Officer (or equivalent) of the agency named above, I verify that all information contained in this form and in all attachments is correct and complete.
__________________________________________________
_______________
Signature of Chief Executive Officer (or equivalent)
Date
__________________________________________________
Name of Chief Executive Officer (or equivalent) typed or printed
Required Documents to begin processing Partial Hospitalization Certification
All of the following information must be attached to the Partial Hospitalization Certification. Applications not submitted in full will not be processed.
1. Valid Behavioral Health Agency Certification from the Department of Human Services.
2. Physical Address of all requested Partial Hospitalization sites. An on-site inspection will occur at all sites prior to DHS issuing a certification for a Partial Hospitalization program.
3. Personnel Resources for Each Partial Hospitalization program to be certified.
DHS WILL SCHEDULE AN ONSITE SURVEY WITHIN FORTY-FIVE (45) CALENDAR DAYS OF APPROVING ALL REQUIRED CERTIFICATION DOCUMENTATION.
Please send a cover letter and all application materials to be certified by DHS as a Partial Hospitalization program to the following address:
Department of Human Services
Policy & Certification Office
305 South Palm Street
Little Rock, AR 72205
PERSONNEL RESOURCES FOR EACH INDIVIDUAL PARTIAL HOSPITALIZATION PROGRAM (as of the date this is submitted)
Site Address:
Partial Hospitalization Facility Director:
1. Psychiatrists
2. M.D. Non-psychiatrists
3. Psychologists
4. Independently Licensed Clinicians
5. Non-independently Licensed Clinicians
6. Registered Nurses
7. Qualified Behavioral Health Providers (Including Certified Peer Support Specialist, Certified Youth Support Specialist, Certified Family Support Partners)
8. All other staff not included above
9. Sum of lines 1-8
ARKANSAS DEPARTMENT OF HUMAN SERVICES
BEHAVIORAL HEALTH AGENCY RESOURCE SUMMARY
STATE FISCAL YEAR _______________: 7/01/20 _____ THROUGH 6/30/20 __________
Name of Agency:
____________________________________________________________
Chief Executive Officer (or equivalent):
____________________________________________________________
Corporate Compliance Officer (or equivalent):
_______________________________________________________
Clinical Director (or equivalent):
_______________________________________________________
Medical Director
_______________________________________________________
Administrative Address: ____________________________________________________________
Telephone: ___________________________________ Fax: ______________________________
E-mail: ____________________________________________________________
Provider Type: __________ Private Non-Profit __________ Private For Profit __________ Public Entity
Other (Specify): ____________________________________________________________
Chief Executive Officer (or equivalent) Certification: By my signature I certify that I have reviewed this report and attachments and to the best of my knowledge it represents an accurate report of agency services and resources.
Chief Executive Officer (or equivalent): __________________________________________________
Date: ______________________________
PERSONNEL RESOURCES
SFY __________
(as of the date this report is submitted)
1. Psychiatrists
2. M.D. Non-psychiatrists
3. Psychologists
4. Independently Licensed Clinicians
5. Non-Independently Licensed Clinicians
6. Registered Nurses
7. Qualified Behavioral Health Providers (Including Certified Peer Support Specialist, Certified Youth Support Specialist, Certified Family Support Partners)
8. All other staff not included above
9. Sum of lines 1-8
PROGRAM RESOURCES
(round to nearest whole number)
10. Number of counties in service area
11. Number of counties in service area in which agency operates a service site
12. Total number of service sites operated by Agency
13. Average daily clients served by Agency
14. Number of School Based Behavioral Health Programs run by agency
15. Total projected daily average of clients in all school based sites combined
16. Total projected number of clients served in the outpatient clinic
17. Please list other mental health services provided by the organization and provide capacity information, as appropriate (i.e. residential beds, crisis beds, inpatient beds, housing, therapeutic foster care, partial hospitalization, therapeutic communities, etc.)
17.A.
17.B.
17.C
17.D
If more room is needed, please list on a separate page and attach to this report.
FINANCIAL RESOURCES -- PROJECTED MEDICAID/MEDICARE INCOME
SFY __________
SFY __________
(Projected for current fiscal year -- July 1 through June 30)
18. Total Medicaid revenues
19. Total Medicare revenues
CONTACT INFORMATION
20. Contact person regarding this report
21. Telephone number of contact person for this report
22. E-mail address of contact person for this report
PERSONNEL QUALIFICATIONS & RESOURCES
1. Attach organizational chart for agency making certification application. (Include names of staff for each position)
2. Describe the agency's governing body, to include the makeup of the Board of Directors, and the rules/policies regarding oversight of the executive and administrative staff. Include the coordinated management plan for all operations.
3. Attach policy and procedures related to Code of Ethics and Client Grievance Procedures.
4. Identify one Clinical Director for the entire agency. Include name, credentials, resume and contact information.
5. Attach licenses or certifications and resumes of all administrators, medical director and consulting psychiatrist if medical director is not a psychiatrist.
6. Attach all contracts with consulting professionals.
7. Explain how psychological testing services are delivered. Include names, licenses and any contracts or signed agreements related to psychological services.
8. Attach all existing contracts the agency has with any other providers or agencies (including schools) to provide Outpatient Behavioral Health Services.
9. Attach one job description for Licensed Mental Health Professionals and one for Qualified Behavioral Health Providers.
10. Attach policy for supervision of all direct care staff and the plan for staff training and supervision of those staff whose licensure or certification require professional supervision.
PHYSICAL PLANT(S)
1. Attach a list of all service delivery sites including each site's address (street, city & county), telephone number, fax number, the name of the designated contact person for each site and that person's email address, the geographic area served by each site and the Outpatient Behavioral Health Services available at each site.
2. Submit website if available.
3. Attach a photograph of each service delivery site. Include outside entrance to building, staff offices and waiting area.
4. Describe any projected plan for expansion of the physical plant post Behavioral Health Agency certification. Please include time frames for the expansions.
SERVICE DELIVERY PLAN CURRENTLY IN PLACE FOR EACH SITE
In a narrative report, describe the agency's plan for the provision of services including all requested information in compliance with the current Behavioral Health Agency Certification Policy and Outpatient Behavioral Health Services Medicaid Manual. Please utilize the following format:
I. Type of services available at each site, hours of operation and type of clients served (i.e. children, adults, Seriously Mentally Ill, Seriously Emotionally Disturbed, Juvenile Justice population, school based sites etc.)
II. The number of clients the agency is currently serving. Include the age ranges and total numbers of children (3y/o -- 12y/o), adolescents (13 y/o -- 17y/o) and adults (18y/o -- 21y/o). Also, include the average length of treatment for clients served by the agency.
III. Identify the names and locations of schools where the agency provides services. Include the number of children/adolescents served in each school and specific services that are provided in each school (i.e. individual therapy, group therapy, day treatment case management). If the agency does not currently provide services in school, please identify any plans to do so in the future and the projected number of students anticipated to be treated.
IV. Description of agency's crisis services plan that is available at each site including policy and procedures for provision of crisis services 24 hours a day; 7 days a week.
V. Describe any plans for expansion or reduction in services, as described above, for the current fiscal year.
VI. Treatment Process:
A. Briefly describe the following:
(This item must include a description of the resources and procedures used to ensure the timely delivery of services and the policy addressing family involvement in treatment.)
1. How a client accesses treatment/services
2. Intake/diagnostic process (Include a sample of assessment instrument(s)
3. Treatment planning and review process (Include a sample of Treatment Plan and Treatment Plan Review)
B. Briefly state how Qualified Behavioral Health Providers will be utilized in service delivery including coordination/supervision with clinical staff.
C. Briefly explain how the agency utilizes and interfaces with other community resources to provide services for the recipient.
VII. Substance Abuse Services: Describe in detail substance abuse services provided by the agency, including services for co-occurring disorders.
VIII. Submit plans and activities to overcome cultural and linguistic barriers to treatment.
IX. Quality Assurance & Improvement Efforts:
A. Submit the policy and procedures for the agency's quality assurance committee. Include committee make up, schedule for meetings and procedural activities.
B. Describe any quality improvement efforts the agency has initiated or plans to undertake during the coming fiscal year. Describe the outcomes expected and the methods by which these outcomes will be monitored.
This Behavioral Health Agency Service Resource Summary and Plan of Services should cover the current fiscal year.
Please send this form with your application to be certified by DHS as a Behavioral Health Agency to the following address:
Department of Human Services
Policy & Certification Office
305 South Palm Street
Little Rock, AR 72205
Form 210
ARKANSAS DEPARTMENT OF HUMAN SERVICES
NOTIFICATION FORM FOR CLOSING OR MOVING OF A BEHAVIORAL HEALTH AGENCY SITE
Moving a site constitutes a closing of one site and a move of the program(s), move of existing staff and move of existing client base to another location. If a provider relocates a currently certified site within a fifty (50) mile radius the accrediting agency, DBHS and Medicaid must be notified thirty (30) days prior to that relocation. Neither an on-site survey nor a new Medicaid number is required in order to extend certification to the moved location if within a fifty (5) miles radius.
Name of Agency: _______________________________________________________
Chief Executive Officer (or equivalent): ______________________________
Corporate Compliance Officer (or equivalent): ______________________________
Administrative Address: ____________________________________________________________
____________________________________________________________
Telephone: _________________________ Fax: ______________________________
E-mail: ___________________________________
This is notification that the following site(s) have: __________ moved _____ closed
CLOSING Date of Closing: _________________________
ADDRESS:
_____________________________________________
_____________________________________________
_____________________________________________
MOVING Date of Move: _________________________
PREVIOUS ADDRESS (Include: street, city, county, telephone & fax) NEW ADDRESS
______________________________
_________________________
______________________________
_________________________
______________________________
_________________________
Please attach all documentation to and from your accrediting organization regarding the above information. Certification will not be granted to the new site address until all information from the accrediting organization indicates that the new site address is accredited.
Chief Executive Officer (or equivalent) Certification: By my signature I verify that all information contained in this form and in all attachments is correct and complete.
_____________________________________________
_______________
Signature of Chief Executive Officer (or equivalent)
Date
_______________________________________________________
Name of Chief Executive Officer (or equivalent) typed or printed
1. In addition to this form, please provide any information that is specific to the site/s for which certification is being requested that is different from those agency sites already certified by DHS.
2. Include a photograph of outside entrance to building, staff offices, and waiting area for all new site locations.
Please send this form with required documentation to the following address:
Department of Human Services
Policy & Certification Office
305 South Palm Street
Little Rock, AR 72205
Form 220
ARKANSAS DEPARTMENT OF HUMAN SERVICES
APPLICATION FOR ACUTE CRISIS UNIT CERTIFICATION
To be completed upon initial application to become certified as an Acute Crisis Unit
Name of Behavioral Health Agency:
____________________________________________________________
Chief Executive Officer (or equivalent): _____________________________________________
Corporate Compliance Officer (or equivalent): _____________________________________________
Administrative Address: ____________________________________________________________
County: ____________________
Telephone: ___________________________________ Fax: ______________________________
E-mail: ____________________________________________________________
Website: ____________________________________________________________
The provider named above shall be certified by the Department of Human Services as a Behavioral Health Agency. An Acute Crisis Unit certification will not be issued if the provider is not a part of a DHS certified Behavioral Health Agency. A Certified Behavioral Health Agency can submit one (1) application for multiple Acute Crisis Units, with the Personnel Resources to be completed for each site. Each Acute Crisis Unit site will be individually certified.
Behavioral Health Agency Certification Period: ____________________ through ____________________
As the Chief Executive Officer (or equivalent) of the agency named above, I verify that all information contained in this form and in all attachments is correct and complete.
__________________________________________________
_______________
Signature of Chief Executive Officer (or equivalent)
Date
__________________________________________________
Name of Chief Executive Officer (or equivalent) typed or printed
Required Documents to begin processing Therapeutic Communities Certification [FN1]
All of the following information must be attached to the Acute Crisis Unit Certification. Applications not submitted in full will not be processed.
1. Valid Behavioral Health Agency Certification from the Department of Human Services.
2. Physical Address of all requested Acute Crisis Unit sites. An on-site inspection will occur at all sites prior to DHS issuing a certification as an Acute Crisis Unit.
3. Personnel Resources for each Acute Crisis Unit to be certified.
DHS WILL SCHEDULE AN ONSITE SURVEY WITHIN FORTY-FIVE (45) CALENDAR DAYS OF APPROVING ALL REQUIRED CERTIFICATION DOCUMENTATION.
Please send a cover letter and all application materials to be certified by DHS as an Acute Crisis Unit to the following address:
Department of Human Services
Policy & Certification Office
305 South Palm Street
Little Rock, AR 72205
PERSONNEL RESOURCES FOR EACH INDIVIDUAL THERAPUETIC 1 COMMUNITY1
(as of the date this is submitted)
Site Address:
Therapeutic Communities Facility Director:
1. Psychiatrists
2. M.D. Non-psychiatrists
3. Psychologists
4. Independently Licensed Clinicians
5. Non-independently Licensed Clinicians
6. Registered Nurses
7. Qualified Behavioral Health Providers (Including Certified Peer Support Specialist, Certified Youth Support Specialist, Certified Family Support Partners)
8. All other staff not included above
9. Sum of lines 1-8
Form 330
ARKANSAS DEPARTMENT OF HUMAN SERVICES
APPLICATION FOR BEHAVIORAL HEALTH AGENCY CERTIFICATION
To be completed upon initial application to become certified as a Behavioral Health Agency
Name of Agency: ____________________________________________________________
Chief Executive Officer (or equivalent): _____________________________________________
Corporate Compliance Officer (or equivalent): _____________________________________________
Administrative Address: ____________________________________________________________
County: ____________________
Telephone: ___________________________________ Fax: _________________________
E-mail: ____________________________________________________________
Website: ____________________________________________________________
The provider named above is fully accredited and in good standing with one of the following accreditation organizations. (Please check your accreditation organization)
_____ Joint Commission on Accreditation of Healthcare Organizations (J-CO)
_____ Commission on Accreditation for Rehabilitation Facilities (CARF)
_____ Council on Accreditation (COA)
Date(s) of most recent survey: ______________________________
Accreditation Period: ____________________ through ____________________
The accredited provider is located within the State of Arkansas.
_____ Yes _____ No
As the Chief Executive Officer (or equivalent) of the agency named above, I verify that all information contained in this form and in all attachments is correct and complete.
__________________________________________________
_______________
Signature of Chief Executive Officer (or equivalent)
Date
__________________________________________________
Name of Chief Executive Officer (or equivalent) typed or printed
Required Documents to begin processing Behavioral Health Agency Provider Certification
All of the following information must be attached to the Behavioral Health Agency Certification. Applications not submitted in full will not be processed.
1. Latest accreditation survey results. (The entire survey report covering outpatient behavioral health services must be included.)
2. Copies of all correspondence and e-mails (e-mails may be copied to the DHS) between the agency and the accrediting organization that pertains to the accreditation of the provider's outpatient behavioral health services.
3. A signed agreement that DHS may receive information directly from the accrediting organization regarding the agency's accreditation and any information pertaining to service delivery. (See DHS BEHAVIORAL HEALTH AGENCY Form 200)
4. All Evidence of Compliance, Measures of Success, Performance Improvement Plans, and any Corrective Action Plans submitted to the accreditation organization pertaining to outpatient behavioral health services.
5. Annual Behavioral Health Agency Services and Resource Summary Report with all attachments as designated in the Behavioral Health Agency Services and Resource Summary Form (DHS BEHAVIORAL HEALTH AGENCY Form 210).
DHS WILL SCHEDULE AN ONSITE SURVEY WITHIN FORTY-FIVE (45) CALENDAR DAYS OF APPROVING ALL REQUIRED CERTIFICATION DOCUMENTATION.
Please send a cover letter and all application materials to be certified by DHS as a Behavioral Health Agency to the following address:
Department of Human Services
Policy & Certification Office
305 South Palm Street
Little Rock, AR 72205
Form 100
ARKANSAS DEPARTMENT OF HUMAN SERVICES
APPLICATION FOR BEHAVIORAL HEALTH AGENCY CERTIFICATION [FN1]
To be completed upon initial application to become certified as a Behavioral Health Agency
Name of Agency: ____________________________________________________________
Chief Executive Officer (or equivalent): _____________________________________________
Corporate Compliance Officer (or equivalent): _____________________________________________
Administrative Address: ____________________________________________________________
County: ____________________
Telephone: ___________________________________ Fax: ______________________________
E-mail: ____________________________________________________________
Website: ____________________________________________________________
The provider named above is fully accredited and in good standing with one of the following accreditation organizations. (Please check your accreditation organization)
_____ Joint Commission on Accreditation of Healthcare Organizations (J-CO)
_____ Commission on Accreditation for Rehabilitation Facilities (CARF)
_____ Council on Accreditation (COA)
Date(s) of most recent survey: ______________________________
Accreditation Period: ____________________ through ____________________
The accredited provider is located within the State of Arkansas.
_____ Yes _____ No
As the Chief Executive Officer (or equivalent) of the agency named above, I verify that all information contained in this form and in all attachments is correct and complete.
__________________________________________________
_______________
Signature of Chief Executive Officer (or equivalent)
Date
__________________________________________________
Name of Chief Executive Officer (or equivalent) typed or printed
Required Documents to begin processing Behavioral Health Agency Provider Certification
All of the following information must be attached to the Behavioral Health Agency Certification. Applications not submitted in full will not be processed.
1. Latest accreditation survey results. (The entire survey report covering outpatient behavioral health services must be included.)
2. Copies of all correspondence and e-mails (e-mails may be copied to the DHS) between the agency and the accrediting organization that pertains to the accreditation of the provider's outpatient behavioral health services.
3. A signed agreement that DHS may receive information directly from the accrediting organization regarding the agency's accreditation and any information pertaining to service delivery. (See DHS BEHAVIORAL HEALTH AGENCY Form 200)
4. All Evidence of Compliance, Measures of Success, Performance Improvement Plans, and any Corrective Action Plans submitted to the accreditation organization pertaining to outpatient behavioral health services.
5. Annual Behavioral Health Agency Services and Resource Summary Report with all attachments as designated in the Behavioral Health Agency Services and Resource Summary Form (DHS BEHAVIORAL HEALTH AGENCY Form 210).
DHS WILL SCHEDULE AN ONSITE SURVEY WITHIN FORTY-FIVE (45) CALENDAR DAYS OF APPROVING ALL REQUIRED CERTIFICATION DOCUMENTATION.
Please send a cover letter and all application materials to be certified by DHS as a Behavioral Health Agency to the following address:
Department of Human Services
Policy & Certification Office
305 South Palm Street
Little Rock, AR 72205
Form 100
ARKANSAS DEPARTMENT OF HUMAN SERVICES
APPLICATION FOR THERAPEUTIC COMMUNITIES CERTIFICATION
To be completed upon initial application to become certified as a Therapeutic Community
Name of Behavioral Health Agency:
____________________________________________________________
Chief Executive Officer (or equivalent): _____________________________________________
Corporate Compliance Officer (or equivalent): _____________________________________________
Administrative Address: ____________________________________________________________
County: ____________________
Telephone: ___________________________________ Fax: ____________________
E-mail: ____________________________________________________________
Website: ____________________________________________________________
The provider named above shall be certified by the Department of Human Services as a Behavioral Health Agency. A Therapeutic Communities certification will not be issued if the provider is not a part of a DHS certified Behavioral Health Agency. A Certified Behavioral Health Agency can submit one (1) application for multiple Therapeutic Communities, with the Personnel Resources to be completed for each site.
Behavioral Health Agency Certification Period: ____________________ through ____________________
As the Chief Executive Officer (or equivalent) of the agency named above, I verify that all information contained in this form and in all attachments is correct and complete.
__________________________________________________
_______________
Signature of Chief Executive Officer (or equivalent)
Date
__________________________________________________
Name of Chief Executive Officer (or equivalent) typed or printed
Required Documents to begin processing Therapeutic Communities Certification
All of the following information must be attached to the Therapeutic Communities Certification. Applications not submitted in full will not be processed.
1. Valid Behavioral Health Agency Certification from the Department of Human Services.
2. Physical Address of all requested Therapeutic Communities sites. An on-site inspection will occur at all sites prior to DHS issuing a certification as a Therapeutic Community.
3. Personnel Resources for Each Therapeutic Community to be certified.
DHS WILL SCHEDULE AN ONSITE SURVEY WITHIN FORTY-FIVE (45) CALENDAR DAYS OF APPROVING ALL REQUIRED CERTIFICATION DOCUMENTATION.
Please send a cover letter and all application materials to be certified by DHS as a Therapeutic Community to the following address:
Department of Human Services
Policy & Certification Office
305 South Palm Street
Little Rock, AR 72205
PERSONNEL RESOURCES FOR EACH INDIVIDUAL THERAPUETIC 1 COMMUNITY
(as of the date this is submitted)
Site Address:
Therapeutic Communities Facility Director:
1. Psychiatrists
2. M.D. Non-psychiatrists
3. Psychologists
4. Independently Licensed Clinicians
5. Non-independently Licensed Clinicians
6. Registered Nurses
7. Qualified Behavioral Health Providers (Including Certified Peer Support Specialist, Certified Youth Support Specialist, Certified Family Support Partners)
8. All other staff not included above
9. Sum of lines 1-8
Form 300

Credits

Adopted July 1, 2017.
[FN1]
So in original.
Ark. Admin. Code 016.23.2, AR ADC 016.23.2
End of Document