Printable Maryland Rsa Template

INSTRUCTIONS FOR COMPLETION OF RESIDENTIAL SERVICE

AGENCY (RSA) LICENSURE APPLICATION

A Residential Service Agency (RSA) is a business that employs or contracts with individuals to provide at least one home health care service for compensation to an unrelated sick or disabled individual. This application is to receive a state license for a RSA from the Maryland Department of Health, Office of Health Care Quality (OHCQ). The RSA program is NOT a Medicare program. Current regulations for the RSA program can be found in Code of Maryland Regulations (COMAR)

10.07.05.For more information relating to RSAs visit the OHCQ Residential Service Agency Dashboard at

https://app.smartsheet.com/b/publish?EQBCT=85e22fc816cc4cc0a30f1b5a41f5146e

APPLICATION FOR INITIAL LICENSE PROCESS

To apply, first download the application onto your computer. You will be able to complete the application electronically or you can print it out and hand write the information into each appropriate section. Additional information for each required section can be found below.

REQUIRED SECTIONS

Please complete each section based on the following information:

Section 1 - General Information: Detail your agency’s information including: The legal agency name, trading name (Doing Business As (DBA)), agency’s email, phone number, fax number, agency’s business address (for the physical location), mailing address (if different from the business address), agency’s license number, agency’s FEIN (Federal Employer Identification Number), agency administrator, agency after hours emergency contact information, and agency’s business hours. Please note, for agencies with multiple locations provide the address and contact information for the agency’s main office. Branch office location information will be collected in Section 7.

Section 2 - Ownership: Include information related to your agency’s ownership: type of business organization of disclosing entity (sole proprietorship, partnership (including LLP), limited liability company (LLC), and corporation), name and address of ownership, the name, title, address and percentage of the agency owned by each owner, the agency’s president (if Corporation) or manager’s (if LLC) name, contact information, and address, and FEIN (Federal Employer Identification Number). If the ownership is a corporation, provide the date of Articles of Incorporation. If ownership is LLC provide the date of Articles of Organization.

Section 3 - Background: Respond “yes” or “no” to the background questions listed in Section 3 of the application. For Section 3 Questions 1 through 3 that you have answered “yes”, provide a detailed explanation (including: dates, type of license, agencies, violations, or offenses).

Section 4 – Worker’s Compensation: First identify if the agency has employees. If the agency has employees, provide the agency’s worker’s compensation insurance policy number, binder number, name of insurance company, policy’s effective date, and the policy’s expiration date. Additionally, attach a copy of the agency’s worker’s compensation insurance policy to the application (This can be added to the application electronically as an attachment). If your agency does not have workers’ compensation insurance AND does not have any employees, submit a Letter of Exemption (sole proprietorships or partnerships) or Certificate of Compliance (corporations or LLCs) from the Certificate of Compliance Coordinator at the Workers’ Compensation Commission. Additional information can be found under the Resource Links section of the OHCQ RSA Dashboard (see link above).

Section 5 – RSA Services: For this section please select all of the home care services to be

provided. The home care services include: Durable Medical Equipment (DME), Durable Medical Equipment with Oxygen, Therapy Services including speech therapy, occupational therapy, and physical therapy, Medical Social Services, Nutritional Services, Intravenous therapy, Skilled Nursing and Aides Only, Ventilator Services, or Skilled Nursing. If you selected the “Skilled Nursing and Aides Only” service, please provide the level of home care services that your agency will be providing. The levels include: 1. Level One: RN supervision of Aides without medication management, 2. Level Two: RN supervision of Aides with medication management, or 3. Level Three: Complex care provided by RN, LPN, and RN supervision of Aides (e.g. Wound Care, Tube Feeding, Trach Care, Vent Management, Intravenous or Related Therapies, etc.). Next, select if the agency is “for profit” or “not-profit”. Finally, list the types of complex care that will be provided by your agency.

Section 6 – Addendum – Branch Offices: “Branch office” means a satellite office of an RSA that is operated by the same person, corporation, or other business entity that manages the parent RSA, and has the same name of the parent RSA:

1.Ownership tax identification number as the parent business entity;

2.Upper-level management;

3.Policies and procedures; and

4.Provides services within the same geographic area served by the parent business entity.

Provide your agency’s licensed name and license number. Select “yes” if your agency operates any branch offices. Select “no” if your agency does not operate any branch offices. If you answered “yes”, provide the address and phone number for each of the agency’s branch offices.

Section 7 - Affidavit: If the program is going to be in more than one applicant’s name, each applicant’s signature is required. Provide the signature of each applicant, his/her title, and the date the application was signed by that applicant. This signator agrees under the penalties of perjury that the information given in this application is true. This applicant’s signature also certifies that your agency follows the administrative and procedural requirements pertaining to the Code of Maryland Regulations (COMAR) 10.07.05. Additionally, you are accepting responsibility to notify OHCQ if there are any future substantive changes in the agency and operation, and that written notice will be given before the effective date of the change. The signators also swear and affirm that each applicant is over the age of 21, is fully competent, and understands the terms of this application.

REQUIRED DOCUMENTATION

In addition to a completed application, additional supporting documents are required to finalize your application. See below for a list of additional documents that are required for each RSA licensure type.

1.An organizational chart that includes all positions with the name of the person in that position.

2.Policies and procedures as required by COMAR 10.07.05.

3.A business plan as required by COMAR 10.07.05.

4.A sample personnel file.

5.Sample patient files for adult and pediatric patients (if applicable).

Suggested Format for Writing Policy and Procedure Statements: When developing your agency’s policies and procedures, the following elements are recommended:

1.Date of approval by governing body.

2.Title or subject of the policy. (Example: Employee Orientation)

3.Policy statement. Describe the agency’s policy on the subject. (Example: All employees shall receive orientation prior to assuming responsibilities for the position.)

4.Purpose of the policy. Describe why the subject is important. (Example: To assure staff understand and comply with all agency policies and procedures.)

5.Procedures. Define who, when, and where. (Example: Who will be responsible? What materials will be used?

How will participation in orientation be documented?)

Suggested Format for Writing Job Descriptions: When developing your agency’s job descriptions, the following elements are recommended:

1.Date of approval by governing body.

2.Position title. (Example: Nursing Supervisor)

3.Position to which this job title reports. (Example: Reports to Director of Nursing)

4.Qualifications. Educational and experience requirements. (Example: Graduation from accredited school of nursing. Number of years of home health experience. Number of years of supervisory experience.)

5.Credential requirements. (Example: Current license in the State of Maryland) Job responsibilities. List the tasks that the person in this position would have to perform. (Example: Perform annual performance evaluations on all licensed nurses and home health aides. Participate in quality assurance activities.)

APPLICATION FINALIZATION

Electric Submission: To submit the completed application and all supporting documentation electronically to OHCQ, visit the OHCQ RSA Dashboard and click on the RSA Licensure Application Form (https://app.smartsheet.com/b/form/26fb6697dcc841b7ae8fde911eec9b05). Complete the form with the following information: Name of RSA, type of RSA, contact information for the agency’s contact person including: Name, Position, email address, phone number, and secondary phone number. Next, upload the following documents to the form:

1.Completed application

2.Organizational chart

3.Policies and procedures

4.Sample personnel file

5.Sample patient file for adult and pediatric patients

6.Business Plan - Scope of services

7.Worker's compensation documentation

Finally, select the “Attestation” box confirming that all the information in the application and supporting documents are correct and true. If you would like to have a copy of the form and attachments sent to your email, please select the “Send me a copy of my responses”. It is recommended that you keep a copy of your responses and documents for your own records. Once your application is submitted you will receive email updates regarding your pending application. The total processing time of the application should take 2 to 3 months after all documents are received.

Paper Submission: To submit a hard copy of the application and supporting documents please

return in person or via mail to the following address: Ambulatory Care Program, Office of Health Care Quality, Bland Bryant Building, Spring Grove Hospital Center, 55 Wade Avenue, Catonsville, MD 21228. Once submitted the application is submitted it will take 6 or more months to process.

LICENSE NOTIFICATION

All application notifications and process updates will be made by email. If no email is provided there may be an additional three-month delay in processing your application.

Once your application has been approved, a formal approval or denial letter will be mailed to your agency from OHCQ through the mail. If your agency is approved, an operating license will be sent to your agency with effective date.

ADDITIONAL INFORMATION

To add services to your RSA you must submit a new application to the OHCQ for review and approval with required updates to the policies and procedures. This process can take up to 3 to 4 months if submitted electronically, and up to 6 months if submitted on paper.

If you do not intend to continue with your license, you must return your operating license to OHCQ.

An unannounced on-site survey of your facility may be performed at any time to determine compliance with RSA requirements. Visit the OHCQ RSA Dashboard for additional information regarding survey activities and procedures.

If you are operating an unlicensed RSA program, your Medicaid provider number and reimbursement are in jeopardy of termination.

RSA HOTLINE

In accordance with State regulations, the State of Maryland has established a RSA Hotline. The purpose of the Hotline is:

To receive complaints about local RSAs; To receive questions about local RSAs; and

To lodge complaints concerning the implementation of advance directives.

The Hotline number is 800-492-6005. Voice messages can be left on the Hotline number. Written complaints may be submitted to the address at the end of the instructions or via the OHCQ RSA Dashboard at https://app.smartsheet.com/b/home?lx=WI2JkCnlI1Ng9CuRw1DP7ynUXphoZCJbZcV5Sw9 DPzI

QUESTIONS

Please visit the OHCQ RSA Dashboard

(https://app.smartsheet.com/b/home?lx=WI2JkCnlI1Ng9CuRw1DP7ynUXphoZCJbZcV5Sw9DPzI) or contact 410-402-8267 or additional information and questions related to this application.

MARYLAND DEPARTMENT OF HEALTH (MDH)

OFFICE OF HEALTH CARE QUALITY (OHCQ)

RESIDENTIAL SERVICES AGENCY (RSA) APPLICATION FOR LICENSURE

1. GENERAL INFORMATION

2.OWNERSHIP (Type of business organization of disclosing entity)

NAME(S), TITLE(S), AND ADDRESS(ES) OF OWNER(S) AND PERCENTAGE OWNED IF 2% OR MORE

(Attach additional pages if needed.)