Delaware Health and Social Services Division of Developmental Disabilities Services Office of the Director APPLICATION FOR AUTHORIZATION OF DAY AND RESIDENTIAL SERVICE PROVIDER Division of Developmental Disabilities Services Marianne Smith, Director Revised 5/24/07 PROCESS OVERVIEW INTRODUCTION Pursuant to Section 6981(e), Title 29 of the Delaware Code, the Division of Developmental Disabilities Services (DDDDS) has established a process for the authorization of service providers that elect to be considered for selection to provide day and/or residential services for people who are eligible to receive said services from the DDDS. DAY AND RESIDENTIAL SERVICE PROVIDERS MUST BE AUTHORIZED BY THE DDDS TO CONTRACT WITH THE DDDS. (1) Authorization - The process by which a service provider becomes eligible to be considered for selection to provide day and/or residential services for people with mental retardation/developmental disabilities who receive said services from the DDDS. Initial authorization is valid for twelve calendar months from the time a provider becomes authorized by the DDDS. (2) Letter of Interest - The document by which an authorized provider makes known their desire to be considered to provide day and/or residential services for a specific individual, or group of individuals. The Letter of Interest precludes the need for a provider to resubmit information that was required for initial authorization. PROCESS How to become an authorized provider: The interested agency must fill out and submit an Application for Annual Authorization of Day and Residential Service Provider AUTHORIZATION The Authorized Provider classification that is issued by the DDDS is the prerequisite authorization that must be acquired by any agency, business, or individual* that intends to be considered for selection to provide day and/or residential services for people who are eligible to receive services from the DDDS. It is the authorized provider’s responsibility to reapply for authorized provider status prior to the end of the initial twelve-month period of authorization, and every year thereafter, in order to remain authorized. The DDDS will not notify providers of impending expiration of authorized status. The DDDS will authorize/not authorize providers on the basis of information submitted via the Application for Annual Authorization of Day and Residential Service Provider. Authorized providers will be assigned a classification (i.e., day, residential, or both), and notified of their status, in writing, by the DDDS within 10 business days of a determination. An applicant may request a review of the outcome of their application for authorized provider status by sending a written request to the Director within five business days of receipt of the Division’s notification. The DDDS will maintain a Directory of Authorized Day and Residential Service Providers that lists agencies, businesses, and individuals* that are qualified to be considered for selection to provide day and/or residential services for people who receive services from the DDDS. The Directory will be posted on the DDDS website, and available for review at the Office of the Director. With the exception of basic contact information, all other information submitted by providers via the application process will remain confidential to the fullest extent of the law. * Does not apply to individuals who wish to become Foster Care Providers. LETTER OF INTEREST Whenever an individual or group of individuals who are eligible to receive services from the DDDS need day and/or residential services, the DDDS will publish a Request for Service for Letters of Interest specific to the service needs of said individual(s). The Request for Service will include information about the services needs, date/time/place of a mandatory Request for Service meeting, and any other particulars deemed necessary by the DDDS. A prospective service provider must be authorized by the DDDS via the annual authorization process to submit a Letter of Interest. HOWEVER, AN APPLICANT MAY SUBMIT AN APPLICATION FOR AUTHORIZATION OF DAY AND RESIDENTIAL SERVICE PROVIDER AND A LETTER OF INTEREST AT THE SAME TIME. GENERAL INFORMATION (1) The Application for Authorization of Day and Residential Service Provider may be obtained by calling the Office of the Director of the Division of Developmental Disabilities Services at (302) 744-9600, or by visiting the DDDS website at www.state.de.us/dhss/ddds/index.html (2) Applicants are cautioned to answer all questions, and submit any ancillary documents with the application as requested. An incomplete application may result in a delay or denial of authorization. (3) Completed applications (pages 5 thru 8) should be mailed to: The Division of Developmental Disabilities Services Woodbrook Professional Center 1056 South Governors Avenue, Suite 101 Dover, DE 19904 ATTN: APS Committee (4) Faxed applications will not be accepted. (5) An Authorized Provider shall report to the DDDS any material changes that could adversely affect the provider’s authorized status within ten days of the material change. Notification must be submitted to the DDDS in writing and signed by the provider/provider’s legal designee. Delaware Health and Social Services Division of Developmental Disabilities Services Office of the Director Application for Authorization Of Day and Residential Service Provider Submitted by (contact person): Provider Name and Address: Principal Office Location: Phone Number: FAX Number: Email Address: Website Address: Delaware Business License Number: Federal E.I. Number: Please indicate if either of the following authorizations (through the Office of Minority and Woman Business Enterprises) applies to your business: Minority-Owned Business Enterprise? (please circle one) Yes Authorization No. ___________________________ No Women-Owned Business? (please circle one) Yes Authorization No. ___________________________ No If you answered NO to either of the above, and your business is eligible to be authorized as either through the Office of Minority and Women Business Enterprises, you are encouraged to apply for said authorization. For more information, please visit www.state.de.us/omwsbe/. Authorization Evaluation Criteria Complete all sections. If something is not available, enter ?N/A? in the applicable section. Mission Statement and Philosophy of Service: What are the mission, history, and philosophy that underlie your delivery of services? Programs, Services, and Performance: 1. Describe the types of programs and services offered, and populations served. 2. Specifically describe your past experience in providing services to persons with developmental disabilities. Additionally, describe your service delivery for this population. 3. Summarize the most recent Consumer/Family Satisfaction Survey. 4. Summarize the most recent Staff Satisfaction Survey. 5. What are your rates regarding (a) staff vacancies and (b) staff training compliance? 6. Submit as enclosures: A. Three letters of reference from organizations that can attest to the current quality of your delivery of services B. One sample of a consumer service plan C. One copy of your quality improvement/strategic plan Health and Safety: 1. List all of your national or other accreditations. 2. List and explain any programs or services that you offer that are under any probationary or other problematic status. 3. List the current licensing authorizations you hold in the state in which you are incorporated. 4. List and explain any suspension or revocation of service licenses or authorizations. 5. List and explain any current or pending litigation. 6. Submit as enclosure: D. One copy of your Emergency Operation Plan (EOP) Policies, Procedures, and Quality Assurance: 1. Describe your quality assurance system. 2. Submit as enclosures: E. One copy of Rights Policy F. One copy of Abuse/Neglect Policy G. One copy of Risk/Incident Management Policy H. One copy of Appeals Process I. One copy of Training Policy Business Practices: 1. Describe your governing body. 2. Submit a copy of your Table of Organization. 3. Describe your internal auditing system, including audit schedules. 4. What is your current Authorized Medicaid Provider status? 5. Describe your ability to initiate and deliver HCBS waiver services on an ongoing basis. 6. Describe your pre-employment screening criteria and process. 7. Submit as enclosure: J. Notarized letter from a CPA firm attesting to the nature of your 1) historical and current financial management practices, 2) debt to income liquidity ratio, and 3) possession of a 60-day cash reserve. K. Notarized copy of certificate of insurance. L. Submit a copy of your Business Plan NOTE: THE STATE RESERVES THE RIGHT TO CONTACT ANY APPLICANT TO DISCUSS OR REQUEST ADDITIONAL INFORMATION REGARDING ANY ASPECT OF THIS APPLICATION ACQUISITION OF AUTHORIZED PROVIDER STATUS DOES NOT GUARENTEE THAT A AUTHORIZED PROVIDER WILL BE SELECTED TO PROVIDE SERVICES (I.E., ISSUED A CONTRACT) 8