19_Attachment_J-9_BH_Facility_Owner_Chg.doc

Attachment J-9 Behavioral Health Facility Owner Change Attachment J-9 Behavioral Health Facility Ownership Change

DEFENSE HEALTH AGENCY (DHA)

OWNERSHIP CHANGE APPLICATION FOR A TRICARE-CERTIFIED FACILITY

Facility_____________________________________________________________________ Please check one appropriate facility/program:

( Freestanding psychiatric partial hospitalization program (PHP)

( Residential treatment center (RTC)

( Substance use disorder rehabilitation facility (SUDRF)

All applications must be signed and dated by the Chief Executive Officer.

The above-named facility has made an ownership change application to continue to provide care under TRICARE certification. The signee certifies that the information contained in this application is true and accurately represents the above-named facility.

Chief Executive Officer

Date

OWNERSHIP CHANGE APPLICATION FOR A TRICARE-CERTIFIED FACILITY

Instructions: To allow us to process this application, you must complete all sections of the application.

1.0 Identifying Information:

1.1 Provide the full name, address, IRS tax ID or NPI as appropriate, telephone number, facsimile number, e-mail address, and website address for your facility.

Name of facility PRIOR to ownership change

Name of facility AFTER ownership change Effective Date of ownership change

Doing business as (dba) Physical Address of TRICARE certified program* City State

Zip

Mailing Address (if different)

Telephone Number

Facsimile Number E-mail address Website Address

PREVIOUS IRS Tax ID Number (EIN)* or NPI as appropriate NEW IRS Tax ID Number

* Facilities with programs located at multiple locations must submit a separate complete ownership change application for each location.

1.2 Send All Correspondence To:

Point of Contact Name

Title

Street Address

PO Box Number

Facsimile Number

E-Mail Address

1.3 Corporate Ownership: If the new owner of your facility is a corporation, provide the full name, mailing address, telephone number, and IRS tax ID number or NPI as appropriate of the corporate owner or affiliate.

Name of Corporation

Street Address

PO Box Number

Zip Code

IRS Tax ID (EIN) 2.0 Composition of Administration: Provide the names, graduate and post-graduate degrees for the new administrative personnel of this facility.

Chief Executive Officer (CEO)

Degree(s)

Medical Director(s)

Clinical Director(s) (If Applicable)*

*TRICARE standards for PHPs and RTCs require that the clinical director be a psychiatrist or doctoral level psychologist. The medical director may also serve as the clinical director if he/she fulfills the responsibilities of the clinical director as stated in TRICARE standard I.F for RTCs and TRICARE standard I.E for PHPs. TRICARE Standards for SUDRFs require that the clinical director meet one of the following requirements: is a physician with certification by ASAM, is a physician with one year or 1,000 hours of experience in the treatment of psychoactive substance use disorders, or is a psychiatrist or doctoral level psychologist. The medical director may also serve as the clinical director if he/she fulfills the responsibilities of the clinical director as stated in TRICARE standard I.F for SUDRFs.

3.0 Facility Description

3.1 Does the program(s) requesting certification share physical space or program schedules with other programs such as acute care, RTC, inpatient rehabilitation, or substance use partial hospitalization?

( Yes ( No If yes, please describe.

3.2 Program/Unit Information: Complete the table below for each program(s)/units(s) that you are requesting to remain certified under the new ownership.

Program/Unit Name Days of Hours of Capacity* Age Range

Operation Operation M F Total From To

_____________________________________________________________________________* Capacity is defined as the maximum number and mix of patients for whom the program is designed to provide services.

3.3 Specific Requirements for PHPs: PHPs are required to complete section 3.3. RTCs and SUDRFs do not need to complete this section.

PROGRAM REQUIREMENTS

RESPONSE

DOCUMENTATION

LOCATION

Does the facility provide academic educational services?

( Yes* ( No

*If yes, please indicate the number of hours per day of academic education.

Program name ____________________________________ Hours/day___________

Program name____________________________________ Hours/day___________

Program name____________________________________ Hours/day___________

All facilities must respond to the following sections:

3.4 Specialty programs offered: List any specialty tracks that are included within the program(s) requesting certification (example: dual diagnosis track).

4.0 Program Requirements: Check the appropriate response. Your facility must continue to meet TRICARE standards under the new ownership. A “yes” response indicates that your facility has reviewed the TRICARE standards for the facility type for which you are applying, and attests that your program(s) meets these standards. The TRICARE Standards were included for your reference in the application packet. Each requirement below lists the specific standard to which you should refer.

4.1 Program Requirements for All Facilities:

PROGRAM REQUIREMENTS

RESPONSE

a. Does the facility/program have a valid state or ( Yes ( No federal license to operate under the new ownership?

Refer to TRICARE Standard I.B.

b. Does the program(s) comply with all TRICARE

( Yes ( No charting requirements, including weekly notes by the physician or doctoral level psychologist?

Note: Inpatient detoxification programs require daily physician notes.

Refer to TRICARE Standard II.K for all charting requirements

c. Does the facility have a written agreement

( Yes ( No with an ambulance company to provide emergency transportation?

Refer to TRICARE Standard II.M.1

d. Does the facility have a written agreement

( Yes ( No with an authorized hospital for emergency medical/surgical and mental health care?

Refer to TRICARE Standard II.M.1

e. Does the facility make available during service ( Yes ( No hours, either directly or through contractual arrangement, the physical health services necessary for patient evaluation and treatment?

Refer to TRICARE Standard II.M.2

f. When appropriate, does the facility provide, or ( Yes ( No contract for all pharmacy services?

Note: Psychiatric Partial Hospitalization

Programs (PHPs) and Substance Use Partial

Hospitalization Programs (SUPHs) are not required to provide pharmacy services;

PHPs and SUPHs may answer no to this question if patients are responsible for their own medications.

Refer to TRICARE Standard II.M.3

5.0 Documentation Requirements: Please submit the following documents with this ownership change application. We have included a “Documentation Checklist” to assist you in compiling a complete application. Documents may be provided on diskette as computer generated files, or as scanned documents, or you may provide hard copies.

Document A:

TJC Accreditation: RTCs and PHPs must submit documentation to confirm that the TJC has been informed of your ownership change. Submit a copy of the letter from TJC which confirms that they have been notified of your ownership change and that your program remains accredited by the TJC under the Comprehensive Accreditation Manual for Behavioral Health Care. SUDRFs must submit documentation to confirm that TJC or CARF has been informed of the ownership change, and you must submit a copy of the letter from TJC or CARF which confirms that your program remains TJC accredited under the Comprehensive Accreditation Manual for Behavioral Health Care or CARF accredited.

Refer to TRICARE Standard I.B

Note: TRICARE standards require that facilities have TJC accreditation under the Comprehensive Accreditation Manual for Behavioral Health Care. Accreditation under the Comprehensive Accreditation Manual for Hospitals is not sufficient.

Document B:

Provide a copy of the mission statement, philosophy, goals, objectives, and organizational chart under only the new ownership. Refer to TRICARE Standard I.C and I.D

Document C:

Provide resumes or curriculum vitae for the Administrator/Chief Executive Officer, Medical Director(s), and Clinical Director(s), if applicable.

Refer to TRICARE Standards I.D, I.E, and I.F

Document D:

Staffing Table Complete the attached staffing table for each program requesting certification. The staffing table MUST include each staff member’s name, educational degree, position, hours worked per week, program/unit to which staff member is assigned, hours worked on each program, type of license/certification, and license/certification number. Refer to TRICARE Standards II.A and II.B.

Please remember to include all clinical staff, including physicians, nurses, therapists, activity therapists, mental health workers, and teachers. Therapists must be master’s prepared and licensed or certified by the state in which the facility is located. If they are unlicensed, your facility must confirm that the unlicensed therapists are actively working towards licensure and receive weekly, documented supervision with their clinical entries countersigned. Activity therapists must be bachelor’s prepared and licensed or certified nationally or by the state in which the facility is located. Teachers must be bachelor’s prepared and certified by the state in which the facility is located.

RTCs must also include a copy of the RTC nursing schedule for the month prior to the month in which this application is submitted to document that registered nursing coverage is maintained 24 hours per day for the RTC.

Document E:

Provide a program schedule and program narrative for each program requesting certification.

The program schedule must include the names of staff designated to lead each group that is listed on the schedule. Refer to TRICARE Standard II.L

Note: Psychotherapy groups must be provided and must be led by master’s prepared professionals. Activity therapy groups must also be provided. PHPs and RTCs must provide a range of activity therapy groups each week that are led by a bachelor’s prepared certified activity, occupational, or expressive therapist. SUDRFs must provide a range of activity therapy groups that are supervised and directed by a bachelor’s prepared certified activity, occupational, or expressive therapist. RTCs must provide clinical services SEVEN days per week, which must include either an activity therapy group or a psychotherapy group.

Document F:

Provide a copy of the floor plan of the program(s) requesting certification. If the facility is in multiple buildings, clearly designate the buildings by address and location. Label the programs and room space on the floor plan. Refer to TRICARE Standards III.A and III.B

Document G:

Provide any additional information regarding program changes, which have occurred as a result of the ownership change.

STAFFING TABLE

Week Program/

Unit Name Hours/

Program Type of License/

Certification License/

Certification No.

DOCUMENTATION CHECKLIST

We have included this checklist to assist you in compiling a complete application.

TQMC HT9402-15-R-0005, Section J, Attachment J-9 Page 1 of 9 TQMC HT9402-15-R-0005, Section J, Attachment J-9 Page 9 of 9