Maryland Rsa Template in PDF Open Editor

Maryland Rsa Template in PDF

The Maryland Residential Service Agency (RSA) licensure form is a critical step for agencies in Maryland aiming to offer skilled nursing and aide services. This document, overseen by the Maryland Department of Health and Mental Hygiene's Office of Health Care Quality, outlines the necessary requirements and procedures to secure licensure, including a $500.00 non-refundable fee, development of specific policies and procedures, and patient and personnel file assembly. For a seamless process in obtaining your RSA license, follow the instructions carefully and start by clicking the button below.

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Embarking on the journey of setting up a Residential Services Agency (RSA) in Maryland requires a meticulous understanding of the licensing process overseen by the Maryland Department of Health and Mental Hygiene's Office of Health Care Quality (OHCQ). This comprehensive process, aimed at ensuring the highest standards of skilled nursing and aide services, begins with the submission of a detailed application packet. The packet includes a non-refundable $500 licensure fee, an organizational chart highlighting the roles and individuals within the agency, and the development of policies and procedures in alignment with the Code of Maryland Regulations (COMAR) 10.07.05. Applicants must also prepare sample personnel and patient files, outline the scope of services provided, including the geographic area of service, referral sources, and payer sources, to establish a foundation for operational excellence and regulatory compliance. Due to budgetary constraints, the Maryland RSA form clearly outlines the potential delay of up to nine months for the issuance of provisional licenses, emphasizing the importance of readiness and thorough preparation in meeting the stringent requirements set forth for residential service providers. This pathway to licensure not only ensures candidates are well-prepared to offer high-quality care but also sets the stage for eventual full licensure following a rigorous on-site survey and adherence to a detailed plan of correction in response to any identified deficiencies. By navigating this process, applicants take a critical step towards contributing to Maryland’s health care landscape.

Sample - Maryland Rsa Form

DEPARTMENT OF HEALTH AND MENTAL HYGIENE

Form Approved May 2018

OFFICE OF HEALTH CARE QUALITY

MDH Form AC.APP.1.1.IN.RSAO.2

INSTRUCTIONS FOR COMPLETION OF RESIDENTIAL SERVICE

AGENCY (RSA) LICENSURE APPLICATION

A Residential Service Agency (RSA) is a business that employs or contracts with individuals to provide at least one home health care service for compensation to an unrelated sick or disabled individual. This application is to receive a state license for a RSA from the Maryland Department of Health, Office of Health Care Quality (OHCQ). The RSA program is NOT a Medicare program. Current regulations for the RSA program can be found in Code of Maryland Regulations (COMAR)

10.07.05.For more information relating to RSAs visit the OHCQ Residential Service Agency Dashboard at

https://app.smartsheet.com/b/publish?EQBCT=85e22fc816cc4cc0a30f1b5a41f5146e

APPLICATION FOR INITIAL LICENSE PROCESS

To apply, first download the application onto your computer. You will be able to complete the application electronically or you can print it out and hand write the information into each appropriate section. Additional information for each required section can be found below.

REQUIRED SECTIONS

Please complete each section based on the following information:

Section 1 - General Information: Detail your agency’s information including: The legal agency name, trading name (Doing Business As (DBA)), agency’s email, phone number, fax number, agency’s business address (for the physical location), mailing address (if different from the business address), agency’s license number, agency’s FEIN (Federal Employer Identification Number), agency administrator, agency after hours emergency contact information, and agency’s business hours. Please note, for agencies with multiple locations provide the address and contact information for the agency’s main office. Branch office location information will be collected in Section 7.

Section 2 - Ownership: Include information related to your agency’s ownership: type of business organization of disclosing entity (sole proprietorship, partnership (including LLP), limited liability company (LLC), and corporation), name and address of ownership, the name, title, address and percentage of the agency owned by each owner, the agency’s president (if Corporation) or manager’s (if LLC) name, contact information, and address, and FEIN (Federal Employer Identification Number). If the ownership is a corporation, provide the date of Articles of Incorporation. If ownership is LLC provide the date of Articles of Organization.

Section 3 - Background: Respond “yes” or “no” to the background questions listed in Section 3 of the application. For Section 3 Questions 1 through 3 that you have answered “yes”, provide a detailed explanation (including: dates, type of license, agencies, violations, or offenses).

Section 4 – Worker’s Compensation: First identify if the agency has employees. If the agency has employees, provide the agency’s worker’s compensation insurance policy number, binder number, name of insurance company, policy’s effective date, and the policy’s expiration date. Additionally, attach a copy of the agency’s worker’s compensation insurance policy to the application (This can be added to the application electronically as an attachment). If your agency does not have workers’ compensation insurance AND does not have any employees, submit a Letter of Exemption (sole proprietorships or partnerships) or Certificate of Compliance (corporations or LLCs) from the Certificate of Compliance Coordinator at the Workers’ Compensation Commission. Additional information can be found under the Resource Links section of the OHCQ RSA Dashboard (see link above).

DHMH Form AC.APP.1.1.IN.RSAO.2 (9/13)

Instructions

DEPARTMENT OF HEALTH AND MENTAL HYGIENE

Form Approved May 2018

OFFICE OF HEALTH CARE QUALITY

MDH Form AC.APP.1.1.IN.RSAO.2

 

 

Section 5 – RSA Services: For this section please select all of the home care services to be

provided. The home care services include: Durable Medical Equipment (DME), Durable Medical Equipment with Oxygen, Therapy Services including speech therapy, occupational therapy, and physical therapy, Medical Social Services, Nutritional Services, Intravenous therapy, Skilled Nursing and Aides Only, Ventilator Services, or Skilled Nursing. If you selected the “Skilled Nursing and Aides Only” service, please provide the level of home care services that your agency will be providing. The levels include: 1. Level One: RN supervision of Aides without medication management, 2. Level Two: RN supervision of Aides with medication management, or 3. 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.). Next, select if the agency is “for profit” or “not-profit”. Finally, list the types of complex care that will be provided by your agency.

Section 6 – Addendum – Branch Offices: “Branch office” means a satellite office of an RSA that is operated by the same person, corporation, or other business entity that manages the parent RSA, and has the same name of the parent RSA:

1.Ownership tax identification number as the parent business entity;

2.Upper-level management;

3.Policies and procedures; and

4.Provides services within the same geographic area served by the parent business entity.

Provide your agency’s licensed name and license number. Select “yes” if your agency operates any branch offices. Select “no” if your agency does not operate any branch offices. If you answered “yes”, provide the address and phone number for each of the agency’s branch offices.

Section 7 - Affidavit: If the program is going to be in more than one applicant’s name, each applicant’s signature is required. Provide the signature of each applicant, his/her title, and the date the application was signed by that applicant. This signator agrees under the penalties of perjury that the information given in this application is true. This applicant’s signature also certifies that your agency follows the administrative and procedural requirements pertaining to the Code of Maryland Regulations (COMAR) 10.07.05. Additionally, you are accepting responsibility to notify OHCQ if there are any future substantive changes in the agency and operation, and that written notice will be given before the effective date of the change. The signators also swear and affirm that each applicant is over the age of 21, is fully competent, and understands the terms of this application.

REQUIRED DOCUMENTATION

In addition to a completed application, additional supporting documents are required to finalize your application. See below for a list of additional documents that are required for each RSA licensure type.

1.An organizational chart that includes all positions with the name of the person in that position.

2.Policies and procedures as required by COMAR 10.07.05.

3.A business plan as required by COMAR 10.07.05.

4.A sample personnel file.

5.Sample patient files for adult and pediatric patients (if applicable).

DHMH Form AC.APP.1.1.IN.RSAO.2 (9/13)

Instructions

DEPARTMENT OF HEALTH AND MENTAL HYGIENE

Form Approved May 2018

OFFICE OF HEALTH CARE QUALITY

MDH Form AC.APP.1.1.IN.RSAO.2

Suggested Format for Writing Policy and Procedure Statements: When developing your agency’s policies and procedures, the following elements are recommended:

1.Date of approval by governing body.

2.Title or subject of the policy. (Example: Employee Orientation)

3.Policy statement. Describe the agency’s policy on the subject. (Example: All employees shall receive orientation prior to assuming responsibilities for the position.)

4.Purpose of the policy. Describe why the subject is important. (Example: To assure staff understand and comply with all agency policies and procedures.)

5.Procedures. Define who, when, and where. (Example: Who will be responsible? What materials will be used?

How will participation in orientation be documented?)

Suggested Format for Writing Job Descriptions: When developing your agency’s job descriptions, the following elements are recommended:

1.Date of approval by governing body.

2.Position title. (Example: Nursing Supervisor)

3.Position to which this job title reports. (Example: Reports to Director of Nursing)

4.Qualifications. Educational and experience requirements. (Example: Graduation from accredited school of nursing. Number of years of home health experience. Number of years of supervisory experience.)

5.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. (Example: Perform annual performance evaluations on all licensed nurses and home health aides. Participate in quality assurance activities.)

APPLICATION FINALIZATION

Electric Submission: To submit the completed application and all supporting documentation electronically to OHCQ, visit the OHCQ RSA Dashboard and click on the RSA Licensure Application Form (https://app.smartsheet.com/b/form/26fb6697dcc841b7ae8fde911eec9b05). Complete the form with the following information: Name of RSA, type of RSA, contact information for the agency’s contact person including: Name, Position, email address, phone number, and secondary phone number. Next, upload the following documents to the form:

1.Completed application

2.Organizational chart

3.Policies and procedures

4.Sample personnel file

5.Sample patient file for adult and pediatric patients

6.Business Plan - Scope of services

7.Worker's compensation documentation

DHMH Form AC.APP.1.1.IN.RSAO.2 (9/13)

Instructions

DEPARTMENT OF HEALTH AND MENTAL HYGIENE

Form Approved May 2018

OFFICE OF HEALTH CARE QUALITY

MDH Form AC.APP.1.1.IN.RSAO.2

Finally, select the “Attestation” box confirming that all the information in the application and supporting documents are correct and true. If you would like to have a copy of the form and attachments sent to your email, please select the “Send me a copy of my responses”. It is recommended that you keep a copy of your responses and documents for your own records. Once your application is submitted you will receive email updates regarding your pending application. The total processing time of the application should take 2 to 3 months after all documents are received.

Paper Submission: To submit a hard copy of the application and supporting documents please

return in person or via mail to the following address: Ambulatory Care Program, Office of Health Care Quality, Bland Bryant Building, Spring Grove Hospital Center, 55 Wade Avenue, Catonsville, MD 21228. Once submitted the application is submitted it will take 6 or more months to process.

LICENSE NOTIFICATION

All application notifications and process updates will be made by email. If no email is provided there may be an additional three-month delay in processing your application.

Once your application has been approved, a formal approval or denial letter will be mailed to your agency from OHCQ through the mail. If your agency is approved, an operating license will be sent to your agency with effective date.

ADDITIONAL INFORMATION

To add services to your RSA you must submit a new application to the OHCQ for review and approval with required updates to the policies and procedures. This process can take up to 3 to 4 months if submitted electronically, and up to 6 months if submitted on paper.

If you do not intend to continue with your license, you must return your operating license to OHCQ.

An unannounced on-site survey of your facility may be performed at any time to determine compliance with RSA requirements. Visit the OHCQ RSA Dashboard for additional information regarding survey activities and procedures.

If you are operating an unlicensed RSA program, your Medicaid provider number and reimbursement are in jeopardy of termination.

RSA HOTLINE

In accordance with State regulations, the State of Maryland has established a RSA Hotline. The purpose of the Hotline is:

To receive complaints about local RSAs; To receive questions about local RSAs; and

To lodge complaints concerning the implementation of advance directives.

The Hotline number is 800-492-6005. Voice messages can be left on the Hotline number. Written complaints may be submitted to the address at the end of the instructions or via the OHCQ RSA Dashboard at https://app.smartsheet.com/b/home?lx=WI2JkCnlI1Ng9CuRw1DP7ynUXphoZCJbZcV5Sw9 DPzI

QUESTIONS

Please visit the OHCQ RSA Dashboard

(https://app.smartsheet.com/b/home?lx=WI2JkCnlI1Ng9CuRw1DP7ynUXphoZCJbZcV5Sw9DPzI) or contact 410-402-8267 or additional information and questions related to this application.

DHMH Form AC.APP.1.1.IN.RSAO.2 (9/13)

Instructions

MARYLAND DEPARTMENT OF HEALTH (MDH)

OFFICE OF HEALTH CARE QUALITY (OHCQ)

RESIDENTIAL SERVICES AGENCY (RSA) APPLICATION FOR LICENSURE

1. GENERAL INFORMATION

LEGAL AGENCY NAME

 

 

TRADING NAME (DBA)

 

 

E-MAIL ADDRESS

 

 

PHONE NUMBER

FAX NUMBER

BUSINESS ADDRESS (physical location)

 

MAILING ADDRESS (if different)

 

 

NUMBER, STREET

 

 

NUMBER, STREET

 

 

CITY

STATE

ZIP

CITY

STATE

ZIP

COUNTY

 

 

LICENSE NUMBER (if applicable)

FEIN NUMBER

NAME OF ADMINISTRATOR (Last, First, Middle Initial)

AFTER HOURS/EMERGENCY CONTACT NUMBER

BUSINESS HOURS (in HH:MM format)

 

 

 

 

 

 

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

FROM:

 

 

 

 

 

 

 

TO:

 

 

 

 

 

 

 

2.OWNERSHIP (Type of business organization of disclosing entity)

SOLE PROPRIETORSHIP

PARTNERSHIP

LLC

CORPORATION

NAME

 

ADDRESS

 

NAME(S), TITLE(S), AND ADDRESS(ES) OF OWNER(S) AND PERCENTAGE OWNED IF 2% OR MORE

(Attach additional pages if needed.)

NAME AND TITLE

ADDRESS

PERCENTAGE

OWNED

 

NAME OF PRESIDENT (IF CORPORATION) OR MANAGER (IF LLC)

 

PHONE NUMBER

CELL NUMBER

 

 

 

 

 

 

 

 

ADDRESS (number, street)

 

CITY

STATE

ZIP

 

 

 

 

 

 

 

IF CORPORATION, DATE OF ARTICLES OF INCORPORATION:

 

FEIN

IF LLC, DATE OF ARTICLES OF

 

 

 

 

ORGANIZATION

 

 

 

 

 

 

 

DHMH Form AC.APP.1.0 (6/1

1

 

 

Last Revised: May 2018

MARYLAND DEPARTMENT OF HEALTH (MDH)

OFFICE OF HEALTH CARE QUALITY (OHCQ)

3.BACKGROUND

1.Has any owner, officer, director, agency, or managerial staff had a license revoked, suspended, or denied by the

DHMH within the last five years? No Yes (explain)

2. Does the parent company, owner, agent, officer, or managerial staff own or operate a health carefacility/agency

licensed or surveyed by the OHCQ?

No

Yes (explain)

3. The agency hereby attests that it is in compliance with The Civil Rights Act of 1964; The Rehabilitation Act of

1973; The Americans with Disabilities Act of 1990; and The Drug Free Workplace Act of 1988. No Yes (explain)

4. Have the owners, officers, directors, agents, or managerial staff been convicted of a criminal offense involvingany

program under Title 18, 19, or 20 of the Social Security Act?

No

Yes

 

 

 

 

 

4. WORKERS’ COMPENSATION

 

 

 

 

 

 

 

 

 

Do you have any employees?

Yes

No

 

 

If you answered YES, attach a copy of your workers’ compensation insurance policy and complete the following:

POLICY NUMBER

BINDER NUMBER

 

 

 

 

INSURANCE COMPANY

EFFECTIVE DATE

EXPIRATION DATE

If you answered NO, additional documentation from the Workers’ Compensation Commission must accompany this application (refer to the instruction guide for details).

5. RSA SERVICES

HOME CARE SERVICES TO BE PROVIDED (check all that apply)

Durable Medical Equipment

Medical Social Services

Durable Medical Equipment w/ Oxygen

Occupational Therapy

Intravenous or Related Therapies

Physical Therapy

Skilled Nursing and Aides Only*

 

 

 

Skilled Nursing

Speech Therapy

Ventilator Services

*If you have selected Skilled Nursing & Aides Only please indicate what level of home care services will be provided (check only one level) HOME CARE SERVICES TO BE PROVIDED (check only one level of care)

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.)

CATEGORY

Non-Profit

For Profit

LIST THE TYPE(S) OF COMPLEX CARE TO BE PROVIDED BY YOUR AGENCY:

DHMH Form AC.APP.1.0 (6/1

2

Last Revised: May 2018

MARYLAND DEPARTMENT OF HEALTH (MDH)

OFFICE OF HEALTH CARE QUALITY (OHCQ)

6. ADDENDUM - BRANCH OFFICES

 

LICENSED NAME

 

 

LICENSE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOES THE AGENCY OPERATE ANY BRANCH OFFICES?

No

 

Yes (list all below)

 

 

 

 

 

STREET ADDRESS

 

 

CITY

STATE

ZIP

PHONE NUMBER

 

 

 

 

 

 

MD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. AFFIDAVIT

I solemnly affirm under the penalties of perjury and upon personal knowledge that the contents of the foregoing application are true. I understand that the falsification of an application for a license may subject me to criminal prosecution, civil money penalties, and/or the revocation of any license issued to me by the DHMH. In addition, knowingly and willfully failing to fully and accurately disclose the requested information 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 administrative and procedural requirements pertaining to the Code of Maryland Regulations (COMAR) 10.07.05.

I further certify that I will notify the OHCQ if there are any future substantive changes in agency and operation, and that written notice will be given before the effective date of the change.

I hereby swear and affirm that I am over the age of 21 and I am otherwise competent to sign this Affidavit.

If the program is going to be in more than one applicant’s name, each applicant’s signature is required. required.

SIGNATURE OF APPLICANT

TITLE

DATE

 

 

 

SIGNATURE OF APPLICANT

TITLE

DATE

 

 

 

SIGNATURE OF APPLICANT

TITLE

DATE

 

 

 

SIGNATURE OF APPLICANT

TITLE

DATE

 

 

 

FOR OFFICE USE ONLY

INITIALS

DATE

DHMH Form AC.APP.1.0 (6/1

3

Last Revised: May 2018

Document Data

Fact Detail
Governing Regulations Code of Maryland Regulations (COMAR) 10.07.05
Licensure Fee $500.00 non-refundable
License Types Provisional and Full Twelve Month License
Application Requirements Including but not limited to an organizational chart, development of policies and procedures, sample personnel and patient files, and a scope of services
Pre-Licensure Process Submission of application packet, on-site survey post 3-5 admitted patients
Provisional License Validity Period 90 days without extension

How to Write Maryland Rsa

Filling out the Maryland RSA form is a straightforward process, but attention to detail is required to ensure accuracy and compliance with the state's regulations. This form is your initial step towards obtaining a license to operate a Residential Services Agency (RSA) in Maryland, specifically for providing skilled nursing and aide services. After you've completed and submitted this form, an on-site survey of your agency will be conducted, which is a critical step in the licensure process. Remember, thorough preparation and clarity in your application materials can smooth the pathway to obtaining your license. Here are the steps for filling out the form:

  1. Start by entering the official name of your agency and, if applicable, the trading name (dba) of your agency in the designated fields.
  2. Provide the physical address of your agency, followed by the county. If the mailing address is different, include that as well.
  3. List your business phone number and fax number, ensuring they are accurate for future communications.
  4. Fill in the days and hours of operation for your agency to inform the state of your operating schedule.
  5. Include an email address and an emergency/after-hours phone number to facilitate various means of contact.
  6. Identify the agency's administrator by marking the appropriate title (Mr., Ms., Mrs.) and providing the full name.
  7. Attach the non-refundable application fee of five hundred dollars ($500.00) to the application. Payments should be made via check or money order payable to the Maryland Department of Health and Mental Hygiene.
  8. Check the appropriate level of care your agency will provide: Level One for RN Supervision of Aides without Medication Management, Level Two for RN Supervision of Aides with Medication Management, or Level Three for complex care provided by RN, LPN, and RN supervision of aides. Be sure to specify the type(s) of complex care if selecting Level Three.
  9. Indicate the category of your agency (For Profit or Non-Profit) and the type of ownership (Individual/Sole Proprietorship, Partnership, Corporation).
  10. If your agency is a partnership or corporation, list each officer or director and the names of individuals holding 2% or more ownership. Attach an additional sheet if necessary.

After completing the Maryland RSA form, double-check all provided information to ensure its accuracy and completeness before submission. Mail the completed application packet to the address provided in the instructions, including the non-refundable licensure fee, organizational chart, developed policies and procedures, and all other requested documentation. By carefully following these instructions and ensuring all required documents are in order, you're taking an important step towards successful licensure of your Residential Services Agency.

Understanding Maryland Rsa

What is a Residential Service Agency (RSA) License in Maryland?

A Residential Service Agency (RSA) License in Maryland authorizes an agency to provide skilled nursing services and aide services to patients in a residential setting. It's required for any agency offering these services and must be obtained from the Maryland Department of Health and Mental Hygiene Office of Health Care Quality.

How can I apply for an RSA License?

To apply for an RSA License, you must complete the application packet provided by the Maryland Department of Health and Mental Hygiene Office of Health Care Quality. This includes submitting a $500.00 non-refundable licensure fee, an organizational chart, developed policies and procedures as per COMAR 10.07.05 RSA regulations, sample personnel and patient files, and a scope of services document. Completed applications should be mailed to the specified address.

What happens after I submit my RSA License application?

After submitting your application, you need to prepare for an on-site survey from the Office of Health Care Quality (OHCQ), which includes implementing the required policies and procedures and marketing for the required number of clients and personnel. Upon meeting these conditions and submitting further documentation, a 90-day provisional license will be issued. An on-site survey will be conducted once you admit 3-5 patients.

Can I receive Medicaid reimbursement with a provisional license?

No, agencies cannot apply for Medicaid reimbursement with a provisional license. To be eligible for Medicaid reimbursement, an agency must have a full twelve-month license.

What are the next steps if deficiencies are found during the initial survey?

If deficiencies are found during the initial survey, you will need to submit a written Plan of Correction (POC) within 10 working days of receiving the deficiency report. An unannounced follow-up visit will then be scheduled to ensure the POC is implemented correctly. All corrective actions must be completed before the provisional license expires.

What should I do if I want to set up a business for RSA services?

For guidance on setting up a business for RSA services, contact the Maryland Small Business Development Center. They can assist with starting a small business, creating a business plan, and marketing strategies.

What are the requirements for nurse supervision of aides?

The requirements for nurse supervision of certified nursing aides and medicine aides are outlined by the Maryland Board of Nursing (BON). It's recommended to contact the BON directly to understand these requirements fully.

Common mistakes

Filling out the Maryland Residential Service Agency (RSA) license application requires careful attention to detail. With several steps involved in the process, it's easy to overlook certain aspects. Here, we'll highlight six common mistakes that people make when completing the form, to help you avoid them.

  1. Not submitting the $500.00 non-refundable licensure fee. The application process can't begin without this payment, which should accompany your application packet.

  2. Providing an incomplete organizational chart. Each position within your agency must be listed, along with the name of the person filling that role. An incomplete chart can delay your application.

  3. Failing to develop required policies and procedures in compliance with COMAR 10.07.05 RSA regulations. This step is crucial for demonstrating your agency’s readiness to operate within Maryland's legal framework.

  4. Omitting assembly of sample patient and personnel files. These samples, including files for both adult and pediatric patients if applicable, are essential for the Office of Health Care Quality (OHCQ) to evaluate your agency's record-keeping practices.

  5. Not clearly defining the Scope of Services. Your application must detail the services you'll provide, geographic areas served, accepted referral sources, and accepted payer sources. A lack of specificity here can cause delays.

  6. Attempting to purchase COMAR regulations from OHCQ. The instructions specify that OHCQ no longer sells these documents and suggest alternative methods to obtain them. Missing this information can lead to confusion and unnecessary delay.

By paying close attention to these areas, you can streamline the application process for a Residential Service Agency license in Maryland. Remember, every detail counts when it comes to regulatory compliance and obtaining the necessary credentials to operate your agency.

Documents used along the form

When starting or operating a Residential Service Agency (RSA) in Maryland, the journey involves more than just filling out the RSA application. A variety of documents and forms play a crucial role in the setup, operation, and compliance of the agency. These documents are essential for ensuring that your agency operates within the legal framework set by the Maryland Department of Health and Mental Hygiene and other relevant authorities. Here is a closer look at some of the key forms and documents that are often used along with the Maryland RSA form.

  1. State Affidavit: A sworn statement that verifies the accuracy of the information provided in the RSA application and confirms compliance with state regulations.
  2. Organizational Chart: A visual representation of your agency's structure, including departments, roles, and the hierarchy of staff positions.
  3. Policies and Procedures Manual: A comprehensive document that outlines the standard operating procedures, policies, and guidelines for the agency’s operation, in compliance with COMAR 10.07.05 RSA regulations.
  4. Sample Personnel File: An example file that includes all the documentation you are required to maintain for each employee, such as contracts, background checks, qualifications, and training records.
  5. Sample Patient File: A template for maintaining records of each patient’s care, including medical history, care plan, consent forms, and notes on the services provided.
  6. Scope of Services Document: A detailed outline of the services your agency will offer, the geographic areas served, referral sources, and payer sources for those services.
  7. Statement of Readiness: A signed document indicating that your agency has met all the prerequisites outlined by the OHCQ and is ready for the initial survey or inspection.
  8. Licensure/Certification Verification: Documentation verifying the licensure and/or certification of all your medical and professional staff, ensuring they meet state requirements.
  9. Quality Assurance Plan: A document that details the processes your agency will use to monitor, evaluate, and improve the quality of care provided to patients.

Together, these documents form the backbone of your RSA's operational, administrative, and compliance framework. They not only assist in the initial licensure process but also in maintaining a high standard of care and adherence to regulations on an ongoing basis. Proper preparation and maintenance of these forms and documents can significantly streamline the process of starting and running a compliant Residential Service Agency in Maryland.

Similar forms

The Maryland RSA form, short for Residential Services Agency license application, outlines the requirements for operating a healthcare agency that offers skilled nursing and aide services within homes. Its structure and content share similarities with several other types of healthcare and business-related documents. Each of these documents serves a unique purpose but parallels can be drawn in terms of regulatory adherence, operational detailing, and procedural specification.

Business License Application Forms: Like the Maryland RSA form, business license application forms across various industries and states often require detailed information about the company, including operational aspects, ownership details, and the scope of services provided. Both sets of documents serve as formal requests for permission to operate under specific legal and regulatory frameworks. They customarily require the disclosure of the owner's information, business address, and a detailed description of services, ensuring that the entity's operations align with local laws and sectoral guidelines.

Healthcare Facility Licensing Forms: These forms, used by healthcare facilities other than residential service agencies, such as hospitals and outpatient clinics, similarly mandate comprehensive details regarding the facility's operations, services offered, and organizational structure. The parallel lies in the emphasis on the quality of care and safety, with both forms needing detailed policy and procedure outlines, organizational charts, and service scope descriptions. This ensures that the healthcare entity can provide high-quality services within the regulatory confines, emphasizing patient safety and quality assurance.

Home Health Care Application Forms: Similar to the RSA form, home health care application forms focus specifically on agencies providing nursing and aide services in a patient's home. Both necessitate comprehensive descriptions of services, including the types of care provided (e.g., wound care, medication management), the geographic area served, and the staff's qualifications. The key similarity hinges on the requirement to outline how care is administered outside of traditional healthcare facilities, ensuring that patients receive the necessary care in their homes under strict quality and safety standards.

In essence, while the Maryland RSA form is distinctly targeted at residential service agencies, its structure, and the type of information it collects are analogous to various other healthcare and business licensing documents. The core similarity revolves around the necessity for detailed operational, procedural, and service-oriented information, aimed at upholding high standards of quality and regulatory compliance.

Dos and Don'ts

When preparing to fill out the Maryland Residential Services Agency (RSA) application form, there are key steps to follow and pitfalls to avoid to ensure the process is smooth and successful. Here are some crucial dos and don'ts:

  • Do read all instructions carefully before you begin filling out the form. The Office of Health Care Quality (OHCQ) provides specific directions that are essential for a successful application.
  • Do ensure the application packet is complete before submission. This includes the non-refundable licensure fee, organizational chart, policies and procedures, sample files, and the scope of services, among others.
  • Do visit the Division of State Documents website or your local library to obtain a copy of the regulations. As noted, copies of the COMAR will not be available for purchase through OHCQ.
  • Do prepare for the onsite survey by ensuring your agency is ready and in compliance with all specified requirements, such as having the required number of patients and staff.
  • Don't delay the initial preparatory steps. Delays in completing and submitting your application packet or in making the necessary arrangements for the onsite survey can result in significant setbacks.
  • Don't forget to market for the required 3-5 clients and personnel as outlined. Having these elements in place is crucial for proceeding to the provisional license stage.Don't request an extension for the provisional license; as stated, no extensions will be granted for any circumstances. This underscores the importance of meeting all deadlines and requirements within the specified timeframes.

Following these guidelines meticulously can increase the likelihood of obtaining your Residential Services Agency license without unnecessary complications. Always keep open lines of communication with the OHCQ and utilize available resources such as the Maryland Small Business Development Center and the Board of Nursing for additional support and clarification.

Misconceptions

There are several common misconceptions about the Maryland Residential Services Agency (RSA) licensure process based on the provided content of the Maryland RSA form. Understanding these misconceptions is crucial for individuals and entities interested in obtaining a license to operate a residential service agency in Maryland.

  • Misconception 1: The $500 licensure fee is refundable if the application is not approved.
  • Contrary to this belief, the $500.00 fee required with the RSA licensure application is non-refundable regardless of the application's outcome. This fee covers the cost of processing the application and is not contingent on the approval of the license.

  • Misconception 2: Provisional licenses can be extended under certain circumstances.
  • Some applicants may assume that provisional licenses, which are issued for 90 days, can be extended under special circumstances such as family emergencies or difficulty in obtaining patients. However, the Maryland RSA form clearly states that extensions for provisional licenses will not be granted for any reason, emphasizing the importance of meeting all requirements within the initial 90-day period.

  • Misconception 3: It’s possible to apply for Medicaid reimbursement with a provisional license.
  • A common misunderstanding is that agencies with a provisional license can apply for Medicaid reimbursement. In reality, an agency must have a full twelve-month license to be eligible for Medicaid reimbursement. This ensures that only fully licensed and compliant agencies participate in the Medicaid program.

  • Misconception 4: The Office of Health Care Quality (OHCQ) provides copies of the Code of Maryland Regulations (COMAR).
  • Applicants often think that COMAR, which contains the regulations that residential services agencies must follow, can be purchased or directly obtained from the OHCQ. Instead, the OHCQ directs applicants to the Division of State Documents website or other sources to access COMAR, highlighting the need for applicants to independently research and comply with Maryland's health care regulations.

Understanding and clarifying these misconceptions is vital for any entity or individual in the process of applying for a Residential Services Agency license in Maryland. Ensuring adherence to the outlined requirements and regulations is crucial for a successful application.

Key takeaways

When applying for a Residential Service Agency (RSA) license in Maryland, it is essential to carefully follow the guidelines provided by the Office of Health Care Quality (OHCQ) to ensure a smooth and successful application process. Here are four key takeaways to keep in mind:

  • The application packet includes several vital components such as a State Affidavit, a $500.00 non-refundable licensure fee, an organizational chart, and the development of specific policies and procedures in accordance with COMAR 10.07.05 RSA regulations. To move forward with your application, ensure that all pieces are completed in full and submitted as required.
  • Due to budgetary constraints, there may be a delay of up to 9 months in the issuance of Provisional Licenses to new or upgrading Residential Service Agencies. This delay affects the time frame in which an agency can start serving patients under a provisional license, so plan accordingly and keep patients informed about potential wait times.
  • Once your application is approved, you must demonstrate readiness for a provisional license by admitting 3-5 patients within 45 days and undergoing an on-site survey. The provisional license is crucial for moving forward but remember, it cannot be extended beyond its 90-day expiration under any circumstances. This necessitates prompt action in admitting patients and rectifying any deficiencies identified during the survey.
  • A comprehensive preparation for the initial survey is vital. This preparation includes having a detailed quality assurance plan, well-organized patient and personnel files, and clear policies regarding patient rights and complaint handling. Failure to meet these requirements can lead to a denial of licensure, emphasizing the importance of thorough preparation and compliance with OHCQ guidelines.

Understanding and adhering to these key points can significantly impact the success of your licensure application and the operational readiness of your Residential Service Agency. It is also recommended to seek guidance on setting up and managing your business by contacting the Maryland Small Business Development Center and the Board of Nursing for specific nursing supervision requirements.

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