1 BUREAU OF HEALTH FACILITY REGULATION Licensure Application Form

BUREAU OF HEALTH FACILITY REGULATION Licensure Application Form Residential Treatment Center for Children and Adolescents I. FACILITY IDENTIFICATION 57 Name of Center (as it will appear on license) License # Client Code/File Number Street Address (location) Licensee/Owner (name of corp., partnership, individual, etc) FL City Telephone Number State Zip Code Address/PO Box (mailing) City Telephone Number Fax Number State Zip Code E-mail Address II. APPLICATION TYPE Under the authority of Chapter 394, Florida Statutes, and Chapter 65E-9 Florida Administrative Code, application is hereby made to operate a Residential Treatment Center for Children and Adolescents. A. Application is for (check one): 1. 2. 3. 4. 5. 6. Initial License License Renewal. Current expiration date _______ mm/dd/yy Change of Licensed Operator. Change of Capacity. Change of Service. Effective date _______ Current capacity _______ Effective date _______ List service changes on a separate sheet and submit with application. _________________________ Change of Center’s Name. Prior name B. Residential Treatment Center is for (check all that apply) 1. 2. C. Children through age 12 Adolescents ages 13 through 17 Center is to be licensed as a Therapeutic Group Home AHCA FORM 3180-5004 (Rev 6/2008) 1 III. LICENSE FEE/CAPACITY (There is a maximum capacity of 12 beds for Therapeutic Group Homes). is attached. Applications submitted without fee will be returned. A. Number of Beds to be licensed B. A check in the amount of $ The license fee is $230 per bed. (There is no fee for a capacity reduction. For capacity expansions filed other than when the license is being renewed, pay for the additional beds only.) IV. OWNERSHIP INFORMATION A. Complete the following for the Licensee/Owner identified in Section I: FL Department of State Corporate ID Number: B. Type of Ownership (choose one) C. Officers Names and Addresses President Vice-president Secretary Treasurer D. Provide the full name and address of additional individuals having at least 5 percent ownership interest Attach additional sheets, if necessary Not for Profit Federal Tax ID number: For Profit Name Address Percent Name Address Percent Name Address Percent Name Address Percent V. ACCREDITATION A. Accreditation (check one) Not Accredited THE JOINT COMMISSION CARF COA NCQA If accredited, provide a copy of the full accreditation report including award letter, accreditation certificate, and any follow up letters/reports to or from the accrediting body. Please review Chapter 394.741, F.S. for additional information. For Renewals, only submit any additional documentation to or from the accrediting organization that has not been previously submitted, such as follow up letters. If a new accreditation period has begun, please submit all accreditation information. Accreditation period effective date __________ and end date __________ AHCA FORM 3180-5004 (Rev 6/2008) 2 VI. USE OF RESTRAINTS Yes No. Are restraints used by the facility? Note: Any facility using restraints must comply with standards established by the Centers for Medicare and Medicaid Services (CMS). The Agency for Health Care Administration will monitor the facility's use of restraints. VII. CO-LOCATION OF OTHER PROGRAMS WITH THE RTC List any other programs that are to be co-located with the RTC: ____________________________________________ _______________________________________________________________________________________________ Note: Advance written approval must be received from the local DCF Children's Mental Health office and from AHCA's Hospital and Outpatient Services Unit prior to co-locating any other program with the RTC. Children from another program are not permitted to co-mingle or share common spaces at the same time as the children residing in the RTC. VIII BACKGROUND SCREENING _________________________________________________ _________________________________________________ A. Name of Administrator: B. Name of Financial Officer: Note: Florida Department of Law Enforcement (FDLE) and Federal Bureau of Investigation (FBI) background screening is required for the Administrator and Financial Officer. Applications will not be approved without satisfactory screening results provided to the Agency. Screening will be repeated every 5 years. If one or both screenings were completed within the last 5 years, please include a copy of the screening results with the application. If the Agency must conduct the required background screening, payment should be included to pay the screening costs. The total cost for both screenings is $43.25 per person. This fee may be added to the license fee check, if desired. 1. Has the administrator been terminated, permanently suspended, or excluded from Medicare or Medicaid in any state or been employed by a corporation, business or professional association that has been suspended or excluded from Medicaid or Medicare in any state? Yes No. 2. Has the financial officer been denied enrollment, or been suspended or excluded from Medicare or Medicaid in any state or been employed by a corporation, business, or professional association that has been suspended or excluded from Medicaid or Medicare in any state? Yes No. 3. If "Yes" to either 1. or 2. above, provide a description and explanation of any denial, exclusion, permanent suspension, or termination from the Medicare or Medicaid program. Proof of compliance with the requirements for disclosure of ownership and controlling interest under the Medicare or Medicaid program may be accepted in lieu of this submission. Use back page or extra sheet, if needed. 4. Has any member of the Board of Directors, corporate officers, or individuals who own 5 percent or more of the Facility been convicted of any Level 2 offense in Chapter 435, Florida Statutes? If so, provide a description and explanation of the conviction on a separate page. Yes No. AHCA FORM 3180-5004 (Rev 6/2008) 3 IX. AFFIDAVIT Under the authority of Chapter 394, Florida Statutes, and Chapter 65E-9, Florida Administrative Code, this application is being made to obtain a license to operate a Residential Treatment Center for Children and Adolescents at the street address indicated on this application. I certify that the information contained in this application is true, correct, and complete. If this application is approved, I agree that all services rendered by the facility shall conform to applicable federal, state, and local laws. I understand that falsification of information in this application or a violation of applicable laws and administrative rules will constitute grounds for action against the facility's license. _____________________________________ Signature of Administrator ____________ Date ____________________________________ Print or Type Administrator's Name NOTARY: STATE OF FLORIDA, COUNTY OF ____________________________ Swor n to (o r a ffi rme d) a nd s ubscr ib ed b e for e me this _____ da y of ________________________ 2 0_____ , b y ________________________________________________. ( N ame o f Ap p lic ant) (Affix notary seal or stamp below) ________________________________________________________ Signature of No tar y Pers ona l l y kn own to me _____, OR pro duce d id en ti fic a ti on _____ T ype o f Iden ti fica tion p rod uced __________________________________ (Do not list the person's ID #) ___________________________________________ Contact person for questions regarding the application. _______________________________ Phone number SEND THE COMPLETED APPLICATION TOGETHER WITH A CHECK MADE PAYABLE TO THE AGENCY FOR HEALTH CARE ADMINISTRATION FOR THE TOTAL NUMBER OF BEDS FOR WHICH LICENSURE IS REQUIRED TO: Agency For Health Care Administration Hospital And Outpatient Services Unit 2727 Mahan Drive, Mail Stop 31 Tallahassee, Fl 32308 Incomplete Applications Will Be Returned For Completion. AHCA FORM 3180-5004 (Rev 6/2008) 4