DHS ARMHS Application Checklist .us



DHS ARMHS Application ChecklistAPPLICATION SUBMISSION INSTRUCTIONSUse the following checklist to ensure that you have all of the necessary attachments for your adult rehabilitative mental health services (ARMHS) application. FORMCHECKBOX Each attachment is clearly labeled in the upper right corner (example B1a, B1b, B1c). FORMCHECKBOX Attachments are labeled according to content (example: Attachments A1-A8, B1-C2) FORMCHECKBOX Submit attachments in the following order:Signed Application (DHS-7181)Signed Certification Requirements (DHS-7181A)Application Attachments (A-1 to D-6)Signed Branch Office Application – if applicable (DHS-7181C)**Ensure you are using the most current version of the application by checking the links above.AGENCY INFORMATIONAgency Name: FORMTEXT ?????Date Received: FORMTEXT ?????Date Reviewed: FORMTEXT ?????Is the application attached: FORMCHECKBOX Yes – DHS-7181 is attached FORMCHECKBOX No Current application? FORMCHECKBOX Yes FORMCHECKBOX NoRevision Date: 06/27/2017Digital application format? FORMCHECKBOX Yes FORMCHECKBOX No Is the application missing any required information? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, what? FORMTEXT ?????Are branch office locations identified on the application? FORMCHECKBOX Yes – DHS-7181C is attached FORMCHECKBOX NoIs the certification requirements attached: FORMCHECKBOX Yes – DHS-7181A is attached FORMCHECKBOX NoCurrent Cert Requirements? FORMCHECKBOX Yes FORMCHECKBOX NoRevision Date: 03/15/2016 Provider Type: FORMCHECKBOX 1. County or tribe; or private provider – CARF (Commission on Accreditation of Rehabilitation Facilities) Accredited Behavioral Healthcare or Certified Community Mental Health Center FORMCHECKBOX 2. Private provider – nonprofit or for profitProvider Type(see above)AttachmentItem #ARMHS RequirementsYesNoSection A: Can the organization suppor the implementation of ARMHS?1, 2A – 1 Organizational Chart & Summary FORMCHECKBOX FORMCHECKBOX 2 A – 2Minnesota Secretary of State Certificate of Incorporation FORMCHECKBOX FORMCHECKBOX 1, 2A – 3Hours of operation for ARMHS FORMCHECKBOX FORMCHECKBOX 1, 2A – 4 – if applicableLegal, signed copy of Subcontractors Agreement(s) FORMCHECKBOX FORMCHECKBOX 1, 2A – 5 ARMHS Quality Assurance Plan FORMCHECKBOX FORMCHECKBOX 1, 2A – 6 Internal Policies and Procedures FORMCHECKBOX FORMCHECKBOX 1, 2A – 7 Grievances/Complaints Procedure FORMCHECKBOX FORMCHECKBOX Section B: Does the organization fit into or add to the local mental health system?1, 2B – 1 Experience in providing adult mental health services FORMCHECKBOX FORMCHECKBOX 1, 2B – 2 Description of ARMHS FORMCHECKBOX FORMCHECKBOX 1, 2B – 3 Collaboration Planning FORMCHECKBOX FORMCHECKBOX 1, 2B – 4 Enhancement to local mental health system FORMCHECKBOX FORMCHECKBOX 1, 2B – 5 Culturally specific services FORMCHECKBOX FORMCHECKBOX Section C: Does organization ensure the State they can provide the ARMHS the person needs?1, 2 C – 1Clinical Supervision Plan FORMCHECKBOX FORMCHECKBOX 1, 2 C – 2Difference between Practitioner and Rehabilitation Worker FORMCHECKBOX FORMCHECKBOX 1, 2 C – 3Difference between Certified Peer Special I and II FORMCHECKBOX FORMCHECKBOX Section D: Link between medical necessity of ARMHS and recovery–oriented needs of person1, 2D – 1Completed Mock Recipient FileA diagnostic assessment (DA)A functional assessment (FA)A level of care utilization system (LOCUS)An interpretive summaryAn individual treatment plan (ITP) which includes:Two rehabilitative goals, and no more than three objectives per goal.At least one intervention for each objectiveProgress Note(s) that includes all goals and objectives identified in the ITP FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Training – Check Pathlore1, 2 MH131AAdmin Staff, ARMHS Info Session <Enter person’s name/date> FORMCHECKBOX FORMCHECKBOX 1, 2MH131CClinical Staff 1, ARMHS Info Session <Enter person’s name/date> FORMCHECKBOX FORMCHECKBOX 1, 2MH621-628, 630, 631Clinical, Online Trainings FORMCHECKBOX FORMCHECKBOX 1, 2MH131CClinical Staff 2, ARMHS Info Session <Enter person’s name/date> FORMCHECKBOX FORMCHECKBOX 1, 2MH621-628, 630, 631Clinical, Online Trainings FORMCHECKBOX FORMCHECKBOX Provider Type(see above)AttachmentItem #ARMHS RequirementsYesNoBranch Office Requirements Checklist and Training1, 2 Office 1 – if applicableAttachments 1 – orgizational chartAttachment 2 - clinical supervision plan FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 1, 2MH131CClinical Staff 1, ARMHS Info Session <Enter person’s name/date> FORMCHECKBOX FORMCHECKBOX 1, 2MH621-628, 630, 631Clinical, Online Trainings FORMCHECKBOX FORMCHECKBOX 1, 2MH131CClinical Staff 2, ARMHS Info Session <Enter person’s name/date> FORMCHECKBOX FORMCHECKBOX 1, 2MH621-628, 630, 631Clinical, Online Trainings FORMCHECKBOX FORMCHECKBOX ................
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