5-DHHS26149 Attachment E Facility Org Chart.docx

ATTACHMENT E

RESIDENTIAL FACILITY ORGANIZATION CHART AND ELIGIBILITY FORM #DHHS26149

OFFEROR NAME:

City, State and Zip Code: _________________________________

# of Beds in Facility:

FACILITY CONFIGURATION:

Single Residential Facility: The Offeror owns and operates this residential treatment facility licensed for 16 or fewer beds and it is the only facility owned and operated by the Offeror.

Multiple Residential Facilities/Total Beds 16 or Fewer: The Offeror has multiple residential treatment facilities and the combined total number of licensed beds for ALL facilities is 16 or fewer.

Multiple Residential Facilities/16 or Fewer Beds Each Facility/Facilities Not Closely Located: The Offeror has multiple residential treatment facilities and this facility is NOT located on the same property, on contiguous property, on property that has the appearance of being the same or contiguous property, or on property closely located together with any of the Offeror’s other facilities.

Multiple Residential Facilities/16 or Fewer Beds Each Facility/Facilities on Same Property, Contiguous Property or Property Closely Located Together: The Offeror has multiple residential treatment facilities and this facility IS located on the same property, on contiguous property, on property that has the appearance of being the same or contiguous property, or on property closely located together with other Offeror facilities.

OFFEROR CERTIFICATION:

The Offeror certifies that ALL of the following requirements for organizational and geographical separateness are met for the above-identified facility.

(1) A clinical director may serve more than one facility ONLY if the geographic locations of the facilities are far enough apart that it is NOT FEASIBLE for Clients in the facilities to be combined for any types of programming or activities.

(2) A psychiatrist may serve Clients in more than one facility ONLY if one or the other of the following circumstances applies:

i. The psychiatrist is not an employee or contractor of the Offeror and the psychiatrist is enrolled as an independent Medicaid provider and bills Medicaid directly for mental health services provided to Clients receiving services from the Offeror (e.g., as a pediatrician would do for an eligible Client in the community).

ii The psychiatrist is an employee or contractor of the Offeror and the geographic locations of the facilities are far enough apart that it is NOT FEASIBLE for the Clients in the facilities to be combined for any types of programming or activities.

(1) Clients from each of the Offeror's facilities participate in a separate school program conducted within each of the specific facilities in which the Clients reside or at its own separate off-site location, OR

(2) Clients from each of the Offeror's facilities attend a public school operated by a school district that is also open to students who are not being served in one of the Offeror's facilities, such as at an alternative high school, OR

(3) Clients from each of the Offeror's facilities attend an educational program operated by the Offeror and the educational program operates as a school for the broader community, children from outside of the Offeror's residential facilities also attend, and the teacher is not an employee of the Offeror.

(1) Facility is an individual family home among other individual family homes in a residential neighborhood and each has its own lot, driveway, and separate address.

(2) Facility is a multi-family dwelling among other multi-family dwellings in a residential neighborhood and each has its own lot, driveway, and separate address.

ATTACHMENT

E

RESIDENTIAL

FACILITY

ORGANIZATION

CHART

AND

ELIGIBILITY

FORM

DHHS261

PAGE

OF

Owners, Facility Management Staff, and Direct Care Staff (All categories must be completed.)

Facility Owner(s):

(Required)

Program Director:

Clinical Director:

Administrators: (Required, if different than above)

Facility Clinical Staff: (If not hired/contracted at time of proposal, indicate plan of hiring/contracting staff)

Supervisor(s) of Direct Care Staff:

(If not hired/contracted at time of proposal, indicate plan of hiring/contracting staff)

Direct Care Staff:

(If not hired/contracted at time of proposal, indicate plan of hiring/contracting staff)

Is facility owned or operated under an umbrella organization? _ No Yes If yes, Name of the Umbrella organization: _ Name of the CEO or Equivalent:

REQUIRED SIGNATURE

Name/Title (typed or printed):