F 00027 Form PDF Details

A few months ago, I discovered a form on the IRS website that I had never heard of before – Form F 00027. After digging around a bit, I found out that this is the form used by churches and other tax-exempt organizations to apply for exemption from federal income tax. Considering the recent scrutiny of church finances in the media, I decided to take a closer look at Form F 00027 and see what it entails. In this blog post, I will provide an overview of Form F 00027 and explain why churches and other tax-exempt organizations are required to file it.stay informed! Form F 00027 is used by churches and other tax-exempt organizations to apply for exemption from federal income tax. This form is fairly straightforward, consisting of just five sections: organization information, officers/directors, activities, financial data, and miscellaneous information. The most important part of Form F 00027 is Section B (activities), which asks for detailed information about the organization's activitie

QuestionAnswer
Form NameF 00027 Form
Form Length7 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 45 sec
Other namesf csas fill online, csas compliance describe, csas staff 3, wi dhs 7503

Form Preview Example

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Quality Assurance

 

F-00027 (12/2016)

Page 1 of 7

CSAS STANDARDS RECERTIFICATION APPLICATION

DHS 75.03 General Requirements

The goal of this application form is to assure that Community Substance Abuse Service (CSAS) Programs review compliance with DHS 75.03 general requirements, concurrent with applications for CSAS programs. It is anticipated that completion of this form will increase the likelihood of compliance, improve the on-site survey efforts, and decrease the likelihood of a non-compliance citation.

INSTRUCTIONS

The DHS 75.03 general requirements section must be completed at each recertification application and must accompany the specific service applications DHS 75.04 through 75.16, regardless of the number of certifications being sought. Chapter DHS 75, Wisconsin Administrative Code, is available on-line through the Wisconsin Legislature, Revisor of Statutes Bureau, at: http://www.legis.state.wi.us/rsb/code/dhs/dhs075.pdf

•Complete only those sections of 75.03 which pertain to the services requested. (See table on page 6.)

•Complete CSAS Staff Roster(s) for each program type. (See page 7.)

•Providers must remain in compliance with applicable subsections.

•Keep a copy of this application as a baseline from which future developments may be evaluated.

•Applicants are encouraged to use available space or attach addenda to provide information, provide relevant commentary, or to identify questions that will assist you and the surveyor in the review process.

Behavioral Health Certification staff will verify compliance through test and review on-site surveys reviews.

STEPS TO PREPARE FOR ON-SITE SURVEY

Submit completed applications and fees to the appropriate DQA Regional Office, following the instructions provided. Contact information for DQA Regional Offices can be obtained by calling 608-261-0658.

•This application captures an overview of community substance abuse services in a format intended to encourage providers to evaluate and maintain compliance and to initiate plans of correction when needed, prior to Behavioral Health Certification Section (BHCS) surveyor findings or in lieu of citations and Statements of Deficiency.

•Questions are structured to identify program growth or other change from previous certification(s).

•Addenda or other attachments are welcomed where space is insufficient for a full reply.

•A survey will not be scheduled until a DHS 75 CSAS Staff Listing is completed.

•Applications must provide enough information to assure that a meaningful on-site review is likely.

All fees are required in advance of site-visits or approvals

1.Assure that relevant program documentation (including policies, personnel credential files, training records, supervision or collaboration documentation, evaluation reports, and complaint files) are ready for review.

Specific elements of review are identified in DQA publication P-63174, Survey Guide - Behavioral Health Certification for Mental Health and Substance Abuse Services, available at: http://dhs.wisconsin.gov/publications/p6/p63174.pdf

2.Treatments and patient rights will be evaluated on-site through a random sample review of treatment records since the last certification for every applicable program and every clinician.

A sample of discharged or closed client records and other materials will be reviewed. The practice of regular quality assurance reviews of client treatment and case records ensures excellent results. The surveyor may also interview staff or clients to determine program compliance.

3.Applicants must contact the regional health services specialist (surveyor) to schedule an appointment well in advance of the certification end date.

F-00027

Page 2 of 7

CSAS STANDARDS RECERTIFICATION APPLICATION

DHS 75.03 General Requirements

The goal of this application form is to assure that Community Substance Abuse Service Programs review compliance with DHS 75.03, General requirements, concurrent with applications for CSAS programs. It is anticipated that completion of this form will increase the likelihood of compliance, improve the on-site survey efforts, and decrease the likelihood of a non-compliance citation.

ENTITY INFORMATION

Name – Facility

Address – Physical

Certification No.

City

State

Zip Code

County

 

 

 

 

 

 

 

 

 

Mailing Address (if different from above)

 

City

 

 

State

 

Zip Code

 

 

 

 

 

 

 

Telephone No.

Email Address

Do not publish in Provider Directory.

 

Fax No.

Internet Address

Do not publish in Provider Directory.

Name - Contact Person

Telephone No.

Email Address

Do not publish in Provider Directory.

ATTESTATION

I hereby attest that all statements made in this application and in any attachments are true and correct to the best of my knowledge and that I will comply with all laws, rules, and regulations governing alcohol and other drug abuse intervention services.

Name – Director (Print or type.)

Date Application Completed

SIGNATURE – Director (Full Signature)

Date Signed

F-00027

Page 3 of 7

A. Governing Authority

Section 75.03(3)(a-i)

All CSAS Services

This section establishes the requirements for written policies and procedures.

1. Has the program reviewed or re-evaluated its policies and procedures of governing authority?

Yes Enter date of last review:

No

Briefly describe changes in program policies during the past year. (Attach additional pages, as needed.)

B. Personnel

DHS 12-13 and Sections 75.03(4)-(7)

All CSAS Services

(4)

Personnel; requirements for all staff

(6)

Written Verification of Training Assessment and Management of Suicidal Individuals

(5)

Staff development; training needs, plans, and progress

(7)

Confidentiality; policies and affirmations

 

 

 

 

2.Has the program reviewed its staffing policies and personnel requirements, e.g., credentials, staff training plans, confidentiality statements, and DHS 12 caregiver background checks?

Yes Assurance of these requirements will be confirmed on-site.

No However, this agency will review all credentials and completed all caregiver backgrounds before on-site survey is scheduled.

3.Is a DHS 75 CSAS Staff Listing attached to this application?

Yes The recertification survey will not be scheduled without the staff listing.

C. Record Requirements

Sections 75.03(8)-(20)

Applicable Services

By Program Types

(See table on page 6.)

(8)

Patient Case Records

75.06 – 75.15

(9)

Case Records for Emergency Services

75.07 – 75.08

(15)

Progress Notes

76.06 – 75.15

DHS 92 and 94: Patient Rights and Protections

All CSAS services

Initiation / Treatment (See question 6.)

 

(10)

Screening

75.05 – 75.15

(11)

Intake

75.06 – 75.15

(12)

Assessment Process

75.10 – 75.15

(13)

Treatment Planning

75.10 – 75.15

(14)

Staffing Cases

75.06 – 75.15

(15)

Progress Notes

75.06 – 75.15

Discharge and Service Conclusion

 

(16)

Transfer Process

75.06 – 75.15

(17)

Discharge or Termination

75.06 – 75.15

(18)

Referral Process

75.04 – 75.16

(19)

Follow-up Process

75.06 – 75.15

(20)

Service Evaluations

75.04 – 75.15

 

 

4. Are case or treatment record reviews a regular part of the agency’s quality assurance practices?

 

Yes Describe the schedule, participants, and any changes in the process of QA.

 

No

Treatment records are not applicable for 75.04, 75.05, and 75.16 services.

 

F-00027

Page 4 of 7

5.Has the clinic remained in compliance with patient rights, informed consent, confidentiality, and grievance resolution standards (DHS 92 and 94), including documentation?

Yes Describe how the clinic assures compliance with DHS 92 and 94.

No Describe the clinic’s plans for corrective action.

6.Do current practices assure that all elements of client services initiation, assessment, treatment, staffing, and notes, including documentation, are in compliance with administrative code?

Yes Describe how the clinic assures compliance with initiation and treatment documentation.

No

7.Do current practices assure that all elements of client discharge and service conclusion, including documentation, are in compliance with administrative code?

Yes Describe how the clinic assures compliance by documenting discharges and service conclusions. No Describe the clinic’s plans for corrective action.

D. Evaluation

Section 75.03(20)

Services 75.06 – 75.15

8. Programs are required to complete an annual service evaluation which will be reviewed and assured on-site. (See table on page 6.)

Applicable Briefly abstract the latest report on the progress toward meeting goals, objectives, and patient outcomes.

Not applicable

E. Communicable Disease Screening

Section 75.03(21)

Services 75.06 – 75.15

9.Is communicable disease screening conducted and documented in the client case record?

Yes Briefly describe current process and any plans for improvement below.

No

Not applicable

Diseases Screened (Check all that apply.)

Hepatitis B

Hepatitis C

HIV (human immunodeficiency)

STDs (sexually transmitted diseases)

TB (tuberculosis)

F-00027

Optional: How often is staff screened for communicable disease? Screening records will be confirmed in patient treatment and staff records.

Page 5 of 7

Never

F. Unlawful Alcohol or Psychoactive Substance Use

Section 75.03(22)

All services

10. How is staff made aware of this prohibition policy requirement?

Condition of employment

Policy manual review

Other

G. Emergency Shelter and Care

Section 75.03(23)

Services 75.06, 75.07, 75.09 – 75.12, 75.14

11. If this is a residential care program, do you have an emergency plan?

Yes

No Prepare an emergency plan prior to the on-site visit.

Not applicable

H. Reportable Deaths

Section 75.03(24)

Services 75.05 – 75.15

12. Does the program have policies for training staff on reporting certain client deaths?

Yes

No Prepare a policy, as required in Wis. Stat. § 51.64, with staff and record it in their training file.

Not applicable

I. Outpatient Treatment Service

Section 75.13

OPTIONAL

13.Describe innovations the agency has created or employed related to the program or its services. (Attach additional pages, as needed)

14.Describe program needs – problems, supports, or enhancement needs – which your agency has identified, including hiring qualified staff, training availability, or other technical assistance. (Attach additional pages, as needed)

15. Describe special burdens or challenges that the agency faces.

F-00027

 

 

 

 

 

 

 

 

 

 

 

Page 6 of 7

 

 

DHS 75.03 GENERAL REQUIREMENTS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

75.04

75.05

75.06

75.07

75.08

75.09

75.10

75.11

75.12

75.13

75.14

75.15

75.16

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(2)

Certification

X

X

X

X

X

X

X

X

X

X

X

X

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(3)

Governing Authority

X

X

X

X

X

X

X

X

X

X

X

X

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(4)

Personnel

X

X

X

X

X

X

X

X

X

X

X

X

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(5)

Staff Development

X

X

X

X

X

X

X

X

X

X

X

X

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(6)

Training in Mgmt of Suicidal Individuals

X

X

X

X

X

X

X

X

X

X

X

X

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(7)

Confidentiality DHS 92

X

X

X

X

X

X

X

X

X

X

X

X

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(8)

Patient Case Records

 

 

X

X

X

X

X

X

X

X

X

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(9)

Case Records for Emergency Services

 

 

X

X

 

 

 

 

 

 

 

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(10)

Screening

 

X

X

X

X

X

X

X

X

X

X

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(11)

Intake

 

 

X

X

X

X

X

X

X

X

X

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(12)

Assessments

 

 

 

 

 

 

X

X

X

X

X

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(13)

Treatment Plan

 

 

 

 

 

 

X

X

X

X

X

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(14)

Staffing

 

 

X

X

X

X

X

X

X

X

X

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(15)

Progress Notes

 

 

X

X

X

X

X

X

X

X

X

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(16)

Transfer

 

 

X

X

X

X

X

X

X

X

X

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(17)

Discharge or Termination

 

 

X

X

X

X

X

X

X

X

X

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(18)

Referral

X

X

X

X

X

X

X

X

X

X

X

X

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(19)

Follow-up

 

 

X

X

X

X

X

X

X

X

X

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(20)

Service Evaluation

X

X

X

X

X

X

X

X

X

X

X

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(21)

Communicable Disease Screening

 

 

X

X

X

X

X

X

X

X

X

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(22)

Unlawful Substance Use

X

X

X

X

X

X

X

X

X

X

X

X

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(23)

Emergency Shelter and Care

 

 

X

X

 

X

X

X

 

 

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(24)

Death Reporting

 

X

X

X

X

X

X

X

X

X

X

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F-00027Page 7 of 7

DHS 75 COMMUNITY SUBSTANCE ABUSE SERVICES (CSAS) STAFF LISTING

Name - Provider

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Certification No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Functions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

Director

4.

SAC-IT In-training

7. Intermediate/Independent Clinical Supervisor (ICS)

10.

PS-IT

 

 

2. Clinical Substance Abuse Counselor (CSAS)

5.

Clinical Supervisor (CS)

8. Intermediate/Independent Clinical Supervisor (ICS)

11.

Volunteer

 

 

3.

Substance Abuse Counselor (SAC)

6.

CS-IT

9. Prevention Specialist (PS)

 

 

 

 

 

12.

Admin / Mgmt

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Function(s)

 

 

 

 

 

DHS 12 Caregiver Backgrounds

 

 

Name

 

 

Position Description

 

 

Credential /

 

 

Use

 

 

% FTE

 

 

DHS 64

 

DOJ

 

DHS IBIS

Occurred

 

(Last, First)

 

 

 

 

License No.

 

 

numbers

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BID

 

 

Letter

within past

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(mo/yr)

 

 

 

 

 

 

 

 

 

 

 

 

 

listed above.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(mo/yr)

 

 

(mo/yr)

4 Years?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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