SUBSTANCE ABUSE CERTIFICATION
SUBSTANCE ABUSE SERVICES APPLICATION
ALCOHOLISM AND OTHER DRUG DEPENDENCY
TREATMENT/INTERVENTION LICENSE OR MEDICAID CERTIFICATION This application is for: (check only one) Initial Services Additional Services
PART I: GENERAL INFORMATION -
Required of All Initial Applicants for each Facility ORGANIZATION INFORMATIONComplete Legal Name:
Official Legal Address:
Suite, Floor, Room, P.O. Box No.:
City: State: Zip Code:
Telephone: ( ) County:
Fax: ( ) E-mail Address:
PLEASE SPECIFY:
Government Entity: Federal State County Local
Corporation (Specify Type)- For Profit Not for Profit
Partnership Association Sole Proprietor Other FEIN:
ATTACH PROOF FROM THE SECRETARY OF STATE THAT THE ABOVE ORGANIZATION IS AUTHORIZED TO DO BUSINESS IN ILLINOIS AND IS IN GOOD STANDING, COPY OF ARTICLES OF INCORPORATION, BYLAWS, LETTER OF AGREEMENT OF PARTNERSHIP, ETC., AS APPLICABLE.
ATTACH A COMPLETED SCHEDULE A - OWNERSHIP DISCLOSURE, FOR EACH OWNER OR CONTROLLING PARTY OF THE ORGANIZATION OR CORPORATION (UNLESS SUCH PERSON OWNS LESS THAN 5% STOCK IN THE CORPORATION).
FACILITY - Required of All Initial Applicants and Additional Service Applicants Name:
Address:
AUTHORIZED ORGANIZATION REPRESENTATIVE - Required of All Initial Applicants and Additional Service Applicants
Name:
Address:
Suite, Floor, Room, P.O. Box No.:
City: State: Zip Code:
Title: Telephone: ( )
MANAGEMENT - Required of All Applicants
Specify the names of all board members and the name, address and phone number of the Chairman of the Board.
LEVELS OF CARE, TYPES OF SERVICES AND POPULATIONS SERVED - Required of All Initial Applicants or Additional Service Applicants
Please specify the levels of care and/or types of services provided at the facility or those services, which will be added to an existing license.
Alcoholism and Substance Abuse Treatment Level I (Outpatient)
Level II (Intensive Outpatient)
Level III Subacute (Inpatient Residential) Level III (Residential Extended Care) Level IV
Detoxification – Ambulatory or Clinically Managed Detoxification – Medically Monitored
Detoxification – Medically Managed (Level IV) Methadone used as adjunct to treatment
Adult Adult Adult Adult Adult Adult Adult Adult
Adolescent Adolescent Adolescent Adolescent Adolescent Adolescent Adolescent
Alcoholism and Substance Abuse Intervention DUI Evaluation
Recovery Home
DUI Risk Education Designated Program
Specify fee charged for DUI Evaluation: $ DUI Risk Education: $
Medicaid Certification
Specify DASA or IDPH License Number:
Level I Level II
Level III Subacute (Residential Rehabilitation) Level III Subacute (Day Treatment)
Level III – (Medically Monitored Detoxification)
Level III – (Medically Monitored Detoxification –Hospital Subacute Setting)
Adult Adult Adolescent Adult Adult Adult
Adolescent Adolescent Adolescent Adolescent Adolescent Is the facility JCAHO accredited? Yes No
Is the facility CARF accredited? Yes No Is the facility COA accredited? Yes No
PART II: FACILITY REQUIREMENTS –
Applicable to all substance abuse treatment, DUI evaluation, DUI risk education, Recovery Home, and designated program services license applicants.ATTACH A COPY OF A SCHEDULE C - STATEMENT OF COMPLIANCE AND LIFE SAFETY INSPECTION REPORT COMPLETED BY AN ARCHITECT FOR THE FACILITY SPECIFIED IN THIS APPLICATION.
PART III: REQUIREMENTS –
Policies and Procedures Operating Manual for all services.Professional Staff Requirements - Applicable to all license applicants except Recovery Homes and all Medicaid certification applicants not licensed by the Department.
SUBPART C REQUIREMENTS – ALL LICENSES Section
2060.307 Service Termination/Record Retention 2060.309 Professional Staff Qualifications 2060.311 Staff Training Requirements
2060.313 Personnel Requirements and Procedures 2060.315 Quality Improvement
2060.317 Service Fees
2060.319 Confidentiality – Patient Information
2060.321 Confidentiality – HIV Antibody/AIDS Status 2060.323 Patient Rights
SUBPART D: REQUIREMENTS – TREATMENT LICENSES
SUBSTANCE ABUSE TREATMENT- Required of all applicants for substance abuse treatment and Medicaid certification who do not have a Department license or any applicant who is proposing to add treatment service to an already existing intervention license.
Section
2060.401 Levels of Care - (If Applying for Treatment License) 2060.403 Court Mandated Treatment
2060.405 Detoxification - (As Applicable) 2060.407 Group Treatment
2060.409 Patient Education
2060.411 Recreational Activities - (As Applicable) 2060.413 Medical Services
2060.415 Infectious Disease Control
2060.417 Assessment for Patient Placement 2060.419 Assessment for Treatment Planning 2060.421 Treatment Plans
2060.423 Continued Stay Review
2060.425 Progress Notes and Documentation of Service Delivery 2060.427 Continuing Recovery Planning and Discharge
SUBPART E: REQUIREMENTS – INTERVENTION LICENSES
INTERVENTION LICENSES - Required of all applicants for substance abuse intervention services, as applicable, and for any applicant with a treatment license proposing to add any of the following
intervention services.
Section
2060.503 DUI Evaluation - (As Applicable) 2060.505 DUI Risk Education
2060.507 Designated Program 2060.509 Recovery Homes
PART IV: MEDICAL DIRECTOR -
Applicable to all applicants licensed by the Department for substance abuse treatment and all Medicaid certification applicants not licensed by the Department.ATTACH A COMPLETED SCHEDULE E FOR THE FACILITY’S MEDICAL DIRECTOR AND ANY OTHER PHYSICIAN WHO WILL PROVIDE SUBSTANCE ABUSE TREATMENT SERVICES.
PART V: MEDICAID CERTIFICATION ONLY
Please attach:
documentation that the facility or parent organization has been licensed as applicable for at least two years.
documentation demonstrating two years of experience in providing quality substance abuse services of the kind for which certification is being requested and for the type of population which will be served.
a description of the geographic area served by the program;
a description of the population, including the size of the population, including the age groups, the number of population in need of service;
a description of the current treatment service(s) provided and the number estimated to have Medicaid coverage;
a description of how the addition of Medicaid certification will increase the availability of treatment for those who cannot access it; and
a description of how the organization works with the treatment system to assure that individuals receive services.
a description of the organization that will be operating the program.
documentation that the organization is fiscally solvent.
a description of the facility that will be utilized.
a description of the program and the clients it serves.
utilizing the attached estimated client population grid, provide a projection of the total number of Medicaid clients to be served each month, the average length of stay anticipated and the estimated average per client cost of treatment.
a schedule of specific day, times and places services will be provided.
provide the number and type of people served during the previous two years in the program for which certification is sought and a description of the clients served. (Demographics, gender, drug of choice, Medicaid eligibility, income level and etc.).
a copy of the two most recent utilization review reports.
copy of the organization’s measurable outcome evaluation process for the past two years and statistics on the program’s client outcomes, i.e., statistical data on clients who complete treatment and data from client satisfaction questionnaires.
for any applicant currently funded by the Department, attach evidence of compliance with all applicable Department audit requirements as specified in 89 211 Administrative Code 507.
documentation that the facility is JCAHO accredited, if application is being made by a hospital based program.
PART VI: INTERVENTION LICENSES -
Required of all applicants for substance abuse intervention services, as applicable, and for any applicant with a treatment license proposing to add any of the following intervention services.DUI EVALUATION AND RISK EDUCATION ONLY
RECOVERY HOMES ONLY Please attach:
a description of the structured alcohol and drug free environment that offers regularly scheduled peer-led or community gatherings (self-help groups, etc.) held a minimum of five days per week.
copies of written linkage agreements with substance abuse providers.
a description of the referral network to be utilized by residents for any necessary medical, mental health, vocational or employment resources.
a copy of a budget which specifies monthly operating expenses and demonstrates sufficient income to meet these expenses plus emergency reserve documenting access to a minimum sum equivalent to the total of two months of operating expenses.
documentation of compliance with all applicable zoning and local building ordinances and the provisions specified in Chapter 20 (Lodging or Rooming Houses) of the National Fire ProtectionAssociation’s (NFPA) Life Safety Code of 1994 for any building housing 16 or fewer residents and with the provisions specified in Chapter 17 (Existing Hotels and Dormitories) of the NFPA Life Safety Code of 1994 for any building housing 17 or more residents.
documentation of fire, hazard, liability and other insurance coverages appropriate to the administration of a recovery home.
documentation of employment of at least one full-time Recovery Home Operator who:
1) either:
A) holds clinical certification from IAODAPCA or receive such certification within two years after the date of employment; or
B) has a minimum of 300 hours of education in the field of substance abuse, 50% of which shall have been under clinical supervision of a professional staff as defined in Section 2060.309; and 2) has a minimum of 2,000 hours of work experience or 4,000 hours of volunteer experience in the field
of substance abuse of which 1,500 hours shall have been in direct clinical services; and 3) has two years of continuous sobriety; and
4) has provided three letters of recommendation from substance abuse professional staff as defined in Section 2060.309; and
5) has provided a signed and dated acceptance of the Code of Ethics as established by the Illinois Association of Residential Extended Care Programs (IARECP).
Attach documentation of employment of at least one Recovery Home Manager who:
1) holds certification as a National Certified Recovery Specialist (NCRS) as specified by the Association of Halfway House Alcoholism Programs of North America, Inc., 680 Stewart Avenue, St. Paul, Minnesota 66106 or will receive such certification within two years after the date of employment; or 2) holds certification from IAODAPCA or will receive such certification within two years after the date
of employment; or
3) has one year of continuous sobriety and 60 hours of substance abuse education and training verified by transcripts, certificates of attendance and/or third party signed statements.
Initial Medicaid Certification
Facility Name:
Estimated Client Population Grid
WEEKLY CAPACITY ESTIMATE
Service
Total Program Capacity
Clients in Program Weekly
Number of Medicaid
Clients
Sessions (Individual)
Sessions (Group)
Days of Service
Number of Non-Medicaid
Clients
Sessions (Individual)
Sessions (Group)
Days of Service
Average Cost of Treatment Per Person
Outpatient Adult (Level I)
Outpatient Adolescent (Level I)
Intensive Outpatient Adult (Level II)
Intensive Outpatient Adolescent (Level II)
Residential Rehabilitation Adolescent (Level III)
Day Treatment Adult (Level III)
PART VII: APPLICANT AFFIRMATION -
Required of All ApplicantsThe application must be signed by: at least two corporate officers vested with authority to act on behalf of the corporation, or; if applicant is a partnership or association, by all partners or associates; and by the Chairman of the Board of Directors. Use additional pages as necessary.
By signature below applicant hereby certifies and affirms that there are no current citations for local ordinance violations; that any previous citations have been corrected to the satisfaction of all applicable authorities; and that the premises are in compliance with all applicable state and local codes.
By signature below applicant acknowledges the right of the Department to verify the data supplied in this license application and consents to such inquiries as might be required. It is understood that, confidential information provided in this application or obtained during the course of any inquiry will be used only for the purposes collected and be maintained confidential by the Department, and not re-released except as allowed by law. Any information provided in the application which the applicant believes to be confidential/proprietary information or trade secrets should be clearly marked as such or applicant waives its right to claim confidentiality regarding such.
By signature below applicant certifies and affirms that none of the applicant’s owners, operators or managers have had a federal registration to distribute or dispense methadone, suspended or revoked or had any governmental license relating to the operation of the facility suspended or revoked, or been convicted within the previous two (2) years in any court of law of operating a motor vehicle while under the influence of alcohol or any drug.
By signature below applicant certifies and affirms that the content of this application and attached schedules, affirmations and materials are true and correct. By signature below applicant certifies and affirms that it is in compliance with all applicable provisions of state and federal constitutions, laws, regulations, court rules and judicial orders, including but not limited to:
a) The Illinois Human Rights Act, [775 ILCS 5];
b) The Americans with Disabilities Act of 1990, (42 USC 12101) and the regulations and guidelines;
c) The Environmental Barriers Act [410 ILCS 25] and The Illinois Accessibility Code (71 Ill. Adm.
Code 400);
d) The Age Discrimination Act of 1975; and e) The 1991 Civil Rights Act.
Signature Date Signature Date
Name (Type/Print) Name (Type/Print)
Date Date
SWORN TO AND SUBSCRIBED BEFORE ME THIS DAY OF ,
PART XI: LICENSE FEE INFORMATION
A separate application is required for each facility.
A license application fee of $200 is required for each facility.
NOTE: There is no fee required for Medicaid certification.
No fee of any type is required from any unit of local, state or federal government.
Application fees are due upon application for each facility license. Application fees are not refundable.
Payment shall be made by check or money order made payable to the Department of Human Services
Payment shall not be in the form of U.S. currency, foreign currency, or stamps.
A separate check or money order shall be submitted with each application.
PART XII: MAILING INFORMATION
Please submit the completed application and fee, if applicable, to: