STATE OF MARYLAND
DHMH
Maryland Department of Health and Mental Hygiene
Office of Health Care Quality
Spring Grove Center ● Bland Bryant Building
55 Wade Avenue ● Catonsville, Maryland 21228-4663
Martin O’Malley, Governor –Anthony G. Brown, Lt. Governor – Joshua M. Sharfstein, M.D., Secretary
PLEASE FOLLOW ALL INSTRUCTIONS AS OUTLINED IN THIS LETTER
You have indicated to the Office of Health Care Quality (OHCQ) that you are interested in obtaining a Residential Services Agency (RSA) license for Skilled Nursing and aides. Attached you will find an application packet which includes the State Affidavit. To begin the licensure process, which will include an on-site survey of your agency; the following items must be completed and submitted to OHCQ with your application packet:
$500.00 non refundable licensure fee
An organizational chart that includes all positions with the name of the person in that position.
Development of policies and procedures as required by COMAR 10.07.05, RSA regulations.
Assembly of a sample personnel file.
Assembly of a sample patient file for adult patients and pediatric patients, if applicable.
The Scope of Services to be provided by the agency, including services to be provided, geographic area of services, accepted referral sources, and accepted payer sources.
MAIL COMPLETED APPLICATION PACKETS TO THE ADDRESS BELOW:
Mrs. Barbara Fagan
Program Manager
Office of Health Care Quality
55 Wade Avenue, BB Building
Catonsville, Maryland 21228
PLEASE NOTE: OHCQ WILL NO LONGER HAVE CODE OF MARYLAND REGULATIONS (COMAR) AVAILABLE FOR PURCHASE. TO OBTAIN A COPY OF THE REGULATIONS YOU MAY DO ONE OF THE FOLLOWING:
Visit the Division of State Documents website at www.dsd.state.md.us
Call the Division of State Documents at 410-974-2486 ext. 3876 or 800-633-9657 ext. 3876
Visit your local library (Check online at www.dsd.state.md.us/Depositories.aspx to find the closest location)
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Please be advised, due to Budgetary Constraints, the issuance of Provisional Licenses to new Residential Service Agencies or current Residential Service Agencies that want to upgrade their license will be delayed up to 9 months. If you know of patients that are in need of services please advise them to go to our web site for a listing currently licensed Residential Service Agencies. New Residential Service Agencies or current Residential Service Agencies that want to upgrade their license may forward their policies and procedures and their request, but there will be a delay of up to 9 months.
When you have received the written approval, have implemented the above policies and procedures and marketed for the required 3-5 clients as well as for personnel, you must submit the following:
a.The signed Statement of Readiness;
b.A copy of the signed contract between your company and the
Registered Nurse that you’ve hired;
c.A list of personnel with positions held;
d.Licensure/certification verification for all licensed/certified personnel and
e.A completed organizational chart.
At that point the 90-day Provisional License will be issued. Once you are issued the provisional license, you must admit 3-5 patients who will receive skilled nursing or aide services. You must admit the patients within 45 days. An on-site survey will be conducted by the OHCQ nurse surveyor once you have admitted 3-5 patients, on or after the 45th day.
The provisional license will not be extended beyond the 90-day expiration date. Do not request an extension; extensions for provisional licenses will not be granted for any circumstances (i.e. family emergencies, unable to obtain patients etc.) Also, please note that you can not apply to receive reimbursement from Medicaid with a provisional license; you will need a full twelve month license.
The initial survey will include:
A review of the written policies and procedures for your agency; Observation of clinical record management;
Review of personnel files;
Review of patient rights information provided to patients/representatives; Review of internal complaint documentation;
Review of clinical records; Interviews with agency staff;
Home visits or telephone interviews with patients/representatives; Review of the quality assurance plan and documentation.
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If there are deficiencies identified during the initial survey, you will be required to submit a written plan of correction (POC) within 10 working days of receipt of the written deficiency report. Once the POC is received, an unannounced follow-up visit will be scheduled to monitor the POC implementation. Keep in mind that the temporary license will not be extended, therefore the correction dates must be within the 90 day timeframe to allow time for the follow-up visit.
All corrective action must be completed prior to the expiration date of the temporary license.
If upon receiving written notification from you that you have all of the information described above ready for review and are ready for an initial survey, and it is determined on the initial survey that you do not have and /or are not implementing the required items and policies outlined in this letter, the survey will cease and you will be denied initial licensure.
If there are continuing deficiencies identified, you will be denied a Residential Service Agency license and you would be required to transfer any active patients to another agency.
If you have questions about how to set up a business, it is recommended that you contact the Maryland Small Business Development Center at 1(877)787-7232. This agency can assist in how to start a small business, what goes into a business plan and how to market your small business.
It is recommended that you contact the Board of Nursing (BON) to understand the requirements for nurse supervision of certified nursing aides and medicine aides. The contact information for the BON is (410) 585-1900 or 1(888)202-9861.
Again, please be advised, due to Budgetary Constraints, the issuance of Provisional Licenses to new Residential Service Agencies or current Residential Service Agencies that want to upgrade their license will be delayed up to 9 months.
If you have any questions regarding these instructions, please contact Elaine Horsey at (410)402-8267.
Sincerely,
Barbara Fagan
Program Manager
Ambulatory Care Programs
Office of Health Care Quality
cc:Jane Wessley
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OFFICE OF HEALTH CARE QUALITY
Residential Service Agency Licensure Application
SKILLED NURSING AND AIDES ONLY
Initial Licensure Application
Under the provisions of Code of Maryland Regulations (COMAR) 10.07.05, application is hereby made to operate a Residential Service Agency (RSA) in the State of Maryland.
Official name of agency ___________________________________________________
Trading Name (dba) _____________________________________________________
Agency Address _________________________________________________________
________________________________________ County _______________________
Mailing Address (if different from above) ________________________________________
________________________________________________________________________
Business Phone No. ________________________ Fax No._______________________
Days and Hours of Operation______________________________________________
Email Address__________________________________________________________
Emergency/After Hours Phone Number_____________________________________
Administrator: Mr. Ms. Mrs. ____________________________________________________
See Page Three for information about Branch Offices.
A non-refundable application fee of five hundred dollars ($500.00) is to be attached to the application. Make checks or money orders payable to the Maryland Department of Health and Mental Hygiene.
DHMH 125H
Revised 08/11
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Home Care Services to be provided:
CHECK ONE LEVEL OF CARE TO BE PROVIDED
Level One
_____RN Supervision of Aides without Medication Management
Level Two
_____RN Supervision of Aides with Medication Management
Level Three
_____Complex care provided by RN, LPN and RN supervision of Aides
(e.g. Wound Care, Tube Feeding, Trach Care, Vent Management, Intravenous or Related Therapies, etc.)
List the type(s) of complex care to be provided by your agency: ________________
______________________________________________________________________
Category: |
For Profit ( ) |
Non Profit ( ) |
Type of Ownership:
Individual/Sole Proprietorship
Name of Owner___________________________________________________________
Address of Owner_________________________________________________________
Partnership |
Corporation |
If the applicant is a corporation, or partnership, list each officer or director, and the names of individuals holding 2% or more ownership. (Attach list if necessary)
Name & Title |
Address |
%Owned |
________________________________ |
______________________ |
_______ |
________________________________ |
______________________ |
_______ |
________________________________ |
______________________ |
_______ |
________________________________ |
______________________ |
_______ |
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Branch Office
If applicable, list address (es) of any branch office (s):
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Note: “Branch office” means a satellite office of a RSA that is operated by the same person, corporation or other business entity that manages parent RSA, and that along with the parent RSA has the same:
a.Ownership tax identification number as the parent business entity;
b.Upper-level management;
c.Policies and procedures; and
d.Provides services within the same geographic area served by the parent business entity.
“I, _________________________________, do solemnly declare and affirm under penalties
of perjury that the contents of the foregoing application are true to the best of my knowledge, information, and belief. I understand that the falsification of an application for a license
shall subject me to criminal prosecution, civil money penalties, and/or the revocation of any license issued to me by the Department of Health and Mental Hygiene. ”
_________________________________________
Print Name of Authorized Person
_________________________________________
Signature of Authorized Person
_________________________________________
Title
__________________
Date
By signing this form, the signee indicates full understanding that a violation will constitute grounds for revoking the license to operate a Residential Service Agency in the State of Maryland.
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State of Maryland
Office of Health Care Quality
Residential Service Agency Hotline
In accordance with State regulations, the State of Maryland has established a Residential Service Hotline. The purpose of the Residential Service Agency Hotline is:
-To receive complaints about local residential service agencies -To receive questions about local residential service agencies.
-To lodge complaints concerning the implementation of advance directives.
The hot line is available 24 hours per day, 7 days per week
All voice mail messages will be returned during the next business day. at:
1-800-492-6005
Written complaints may be submitted to:
Barbara Fagan, Program Manager
Office of Health Care Quality
Spring Grove Center
Bland Bryant Building
55 Wade Avenue
Catonsville, Maryland 21228
or
Via our website at:
www.dhmh.state.md.us/ohcq/faq_help/file_a_complaint.htm.
The Office of Health Care Quality may also be reached Monday through Friday from 8 AM to 5 PM at: 410-402-8267.
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STATE AFFIDAVIT
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement
may be prosecuted under applicable State Laws. In addition, knowingly and willfully failing to fully and accurately disclose the information requested may result in denial of a request to become licensed or, where the entity already is licensed, a revocation of that license.
I certify that this agency is in compliance with the administrative and procedural requirements pertaining to COMAR 10.07.05, Regulations governing RSA Agencies, in the areas of written administrative patient care policies and other organizational documentation.
I further certify that I will notify the Office of Health Care Quality if there are any future substantive changes in agency and operation that significantly affect policies and procedure that notice will be given, in writing, before the effective date of the change.
I hereby swear and affirm that I am over the age of 21, I am otherwise competent to sign this Affidavit, and that these statements are true and based upon my personal knowledge.
NAME OF AGENCY:____________________________________________________
________________________________________________________________________
SIGNATURE OF AUTHORIZED OFFICIAL |
TITLE |
DATE |
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STATEMENT OF READINESS FOR A RESIDENTIAL SERVICE AGENCY
PROVISIONAL LICENSE
I, ____________________, have the following items and policies in place:
An organizational chart that includes all positions with the name of the person in that position.
I have hired a registered nurse who will be responsible for the oversight of the skilled nurses and aides. The job description, resume and contract for this person must be submitted prior to receipt of the provisional license.
Policies and procedures as required by COMAR 10.07.05, RSA regulations. A sample personnel file.
Sample patients file for adult patients and pediatric patients, if applicable. Description of the Scope of Services to be provided by the agency, including services to be provided, geographic area of services, accepted referral sources, and accepted payer sources.
I, ______________________, have marketed and I am ready to admit 3 to 5 patients who
require skilled care that will be provided by a certified nursing aide under the supervision of a registered nurse. If I am requesting a Level III license, I am aware that I must have at least one client who has received a medical treatment or procedure ordered by a physician and can only be provided by a RN/LPN.
I, ______________________, understand that if for any reason I am unable to obtain 3 to
5 patients and/or do not demonstrate the ability to operate a Residential Services Agency and do not follow all instructions in this letter, I may be denied initial licensure.
Name of Agency
Signature
Date
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SUGGESTED FORMAT FOR WRITING
POLICY AND PROCEDURE STATEMENTS
DATE OF APPROVAL BY GOVERNING BODY
TITLE OF POLICY OR SUBJECT OF THE POLICY
Example – Employee Orientation
POLICY STATEMENT
Describe what the agency policy is for the subject of the policy
Example – All employees shall receive orientation prior to assuming responsibilities for the position.
PURPOSE OF THE POLICY
Define why it is important to perform orientation –
Example – To assure staff understand and comply with all agency policies and procedures.
PROCEDURE
State how orientation will be conducted – Example – Who will be responsible?
What materials will be used?
How participation in orientation will be documented?
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SUGGESTED FORMAT FOR WRITING
JOB DESCRIPTIONS
DATE OF APPROVAL BY GOVERNING BODY
POSITION TITLE
Example – Nursing Supervisor
POSITION TO WHICH THIS JOB TITLE REPORTS
Example – Reports to Director of Nursing
QUALIFICATIONS
EDUCATIONAL REQUIREMENTS
Example – Graduation from accredited school of nursing
EXPERIENCE REQUIREMENTS
Example - # of years of home health experience
# of years of supervisory experience
CREDENTIAL REQUIREMENTS
Example – Current license in the State of Maryland
JOB RESPONSIBILITIES
List the tasks that the person in this position would have to perform Examples – Perform annual performance evaluations on all licensed nurses and home health aides.
Participate in quality assurance activities.
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Sample Nurse Surveyor RSA Policy Review Sheet
Below you will find some of the items that the Nurse Surveyor will look for in your agency’s policies and procedures.
POLICY AND PROCEDURES 10.07.05.03 (A)(3) Policies provide framework for the delivery of health care services to the patients in a consistent, safe and effective manner.
ADMINISTRATIVE POLICIES
COMAR 10.07.05.01B (4) defines the governing authority for the residential service agency. INCLUDE THIS CITATION IF THERE IS NO DESCRIPTION OF THE GOVERNING AUTHORITY.
10.07.05.03(H)(2)
Inspection. An agency shall keep records and make reports in the manner and form as the Secretary prescribes. Agencies shall ensure that all records are open to inspection by the Department.
USE THIS CITATION IF THE AGENCY REFUSES OR IS RELUCTANT TO PROVIDE REQUESTED DOCUMENTATION
.
03 (A)(3) (a)Scope of services
Must include services to be provided, patient population to be served, geographic area to be served, payer sources accepted May include referral sources.
(l)(i)delineation of services provided by the agency Cross reference this is .03A(3)(a) Scope of services
A(3)(g) & (6)(c,d,e) Billing and service record
Policy should include frequency of billing, information to be included on the bill (type of service provided, dates and times of service, hourly rate and total cost), accepted methods of payment, consequences of non-payment.
.03(A)(6)(c,d,e)
c.statement of liability for cost of services not covered by insurance
d.process for presenting itemized billing statement estimate of costs associated with the services requested
e.estimate of costs associated with the services requested
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03 (A)(3) (h) & (k)(viii) Clinical record maintenance Use cross reference to cite both
Must include at a minimum:
A list of documents to be included in the clinical record; Timelines for the submission of clinical documentation to the office for filing in the clinical record;
Specific timelines for retention of records;
Requirements that clinical documentation be written in ink, signed and dated;
Procedures for thinning records; Protection from loss or misuse;
HIPAA
03 (A)(3)(d)Emergency procedures
Must include patient related ( falls, bleeding, cardiac, mental status changes) and disaster management both in the home (fire, power outage) and external (weather related)
Check agency policy regarding CPR.
(k)(vi)infection control procedures
Reporting patient infections and maintaining records, staff infections, hand washing and glove use, protective equipment use such as aprons and protective eye wear, environmental cleanup, linen washing
(k)(vii) disposal of biomedical waste double bagging, bleach, trash
(k)(xi) maintenance of equipment cleaning, reporting damage or breakdown
(l)Coordination of care when appropriate, including: Review on call policy and procedures and on call logs
under this requirement.
Cite issues related to coordination with other providers such as home health agencies, with physicians, with caregivers and other entities.
Should include after hours on call procedures, and coordination with other providers who may be providing services in the home such as HHAs and hospices or other entities.
(i)notification to the patient of the agency’s responsibilities
include patient rights statement, responsibility to perform complaint investigations.
Might include reference to billing and/or on call
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03A6 (a&b) Provide the patient with
(a)name and phone number of agency contact
(b)name of caregiver referred by the agency to provide services
Check with patient at home visit to determine if they received this information
(m) Quality assurance program
Written plan, data collection, quality indicators, frequency of monitoring, participants in activities, results/actions, reports
03A3(n) A procedure for resolution of complaints, including referral to OHCQ - must provide hotline number, name, address, phone number and contact info.
must inform no disruption of services due to complaint format should be included in sample patient packet
AND
.03 (A)(7) Complaint investigation procedures including mechanism for written complaints, complaint files including source, category, and disposition. Summary reports for QA, OHCQ and public review are developed and made available.
AND
.03(A)(8) If the agency does not conduct a complaint investigation, document its reason and forward the complaint and its reason to the Department (OHCQ).
PATIENT POLICIES
(c)Admission criteria
Must include patient population age range, any disease processes not accepted, any care needs accepted or not such as IV, ventilator, g-tubes, trachs, assessment by RN for both skilled and non-skilled cases, reasons for non-acceptance
(k)(ii)Evaluation of potential patients before acceptance into program
Includes referral/intake screening and initial nursing assessments
(k)(v)Clinical management
Includes obtaining physician orders for care (diagnoses, medications, treatments, frequency of visits), verbal orders, nursing assessments for both skilled and aide only patients,
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documentation requirements for MARs and TARs,
Must include policies and procedures for wound management, pain management, IV management, etc. or the name of the procedure manual to be used by the staff.
(k)(iii)Frequency of patient monitoring
Includes patient reassessment at specified intervals and supervisory visits for the skilled nurses and aides at specified intervals determined by the RSA.
(j) Provision of personal care by HHA
Must include list of services provided by aide, patient
assessments and development of aide assignment, how aide is installed in patient’s home, , aide supervision, aide
documentation, any special qualifications that might be required for patient care, reporting to RN,
May include transportation policies if aide or companion transports the patient.
Should include some restrictions on aide activities such as taking money or other gifts, bringing family members to the home, visiting outside the hours of work.
(e) Administration of drugs –
Aides may not administer medications. Agency must define assistance by aide.
For skilled nurse cases must have policies for assessment, administration and documentation including MARs
If the agency is going to use Medication Technicians must have policies that clearly state understanding of nurse delegation and supervision
(f)Enteral and parenteral nutrition (See also .04 Special Requirements for IV and related therapies) Must have physician orders that include type, amount frequency and route and for IV type of device. Must include management of the device.
(k)(iv)Prep and storage of enteral formulas, IV therapies and
other supplies and equipment (See also .04 Special Requirements for IV and related therapies – any policies specific to these modalities?)
See also .05 and (.03(B)) Special requirements for Provision of Ventilator Services – any policies specific to these modalities? What does agency do if there is equipment failure during hours of care?
(k)(ix)training of patients and (k)(x)training of patient caregivers
assessment of teaching needs, develop teaching plan, teach, evaluate results by demonstration or verbalization
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10.07.05.03B An agency that provides invasive equipment or supplies such as intravenous therapy shall arrange for 24 hour a day equipment maintenance service in case of equipment failure.
10.07.05.04RSA providers of intravenous therapy must meet the special requirements found at 10.07.05.04. Submit policies and procedures that demonstrate these requirements will be met.
PERSONNEL POLICIES
03A3(b) & .03A (4)(d) Skills assessments and skill demonstrations.
Look for policies also for orientation, and periodic performance reviews.
There must be policies about how these will be performed, by whom, and when. Must be done before patient assignment.
Staff must have evidence of skills demonstrations in personnel files. Check personnel files
.03A(4)(a,b,c,e) face to face interviews, verification of past employment, check of character references and verification of licenses
Check personnel files for all staff at initial survey
.03A(5) maintain personnel files for 3 years after termination Need to have policy statement
03 (A)(3)(i)health requirements for employees and contractors Must include TB and Hepatitis B
Must have two step PPD prior to employment
May include pre-employment physical.
May be separate file for health records.
03 (A)(3) (k) (i) Job descriptions and educational requirements for all staff –
Must have JD for each category of employee on organizational chart
Might include in-service requirements.
Staff should sign copy of JD. Check personnel files
03 (A)(3) (k)(xii) responsibilities of licensed health professionals – might include in-service and supervisory requirements. Should be included on job description.
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