Section He-C 6350.05 - Application Process for Certification and Procedures for Renewal of Certification(a) Any residential treatment program licensed in accordance with RSA 170-E or RSA 151, or from another state, that seeks certification in accordance with He-C 6350 shall request application Form 2601 "Certification for Payment Application - Residential Programs" (July 2018) from DCYF and be supported by a need identified by DCYF in accordance with RSA 170-G:4.(b) The application form in (a) above shall be completed, signed, and dated by the residential treatment program's executive director, or designee, affirming the following: (1) "I have reviewed the Administrative Rules He-C 6350 and He-C 6420 and will adhere to the rules as a certified provider. I authorize the NH Division for Children, Youth and Families (DCYF) to conduct a certification for payment review to determine the program's compliance with Administrative Rules He-C 6350 and He-C 6420. I further understand that DCYF has the right to verify information contained in this application."; and(2) "The information contained in this application is correct to the best of my knowledge."(c) The completed application form in (a) above shall be returned to DCYF within 90 days of receipt.(d) The applicant shall provide the following information with, or in addition to, the application form in (a) above: (1) An electronic copy of the program description, including a description of the services provided to children and their families, as well as a description of the daily milieu, and how the program promotes the safety, permanency, and well-being of children and their families, including any specialized services that are supported by any certifications and/or accreditations;(2) The name, office held, professional affiliation, address, and telephone numbers of each person on the program's board of directors, including whether or not the board member is a present or past recipient of the agency's services;(3) Evidence that the board of directors has approved the certification request which may include, but is not limited to, minutes of the board meeting documenting that the request was approved or a signature of the board's president;(4) The names of the residential staff/child care personnel within the program;(5) A copy of the program's license and/or operational approval, in accordance with the following: a. For programs in New Hampshire, a copy of the license issued in accordance with RSA 170-E:31 or RSA 151:5; orb. For programs outside of New Hampshire, documentation of approval from the corresponding state's regulatory agency(ies) ;(6) A electronic copy of a completed Form 2426 "Residential Resource Guide Provider Form" (January 2015);(7) A copy of the general liability insurance certificate for the program;(8) An organizational chart, personnel titles, job descriptions, and the corresponding credentials which document the education and experience requirements in He-C 6350.11, as applicable. This shall include identification of who in the program is responsible for implementation of reasonable and prudent parent Standard;(9) For programs in New Hampshire which operate and maintain approval as a non-public school per Ed 400 and a private provider of special education per Ed 1100, a copy of their approval from the NH state board of education;(10) For programs outside of New Hampshire with education programs, documentation of educational certification from the corresponding state's regulatory agency(ies);(11) A description of the staff development and training processes; and(12) An electronic copy of the program's policies required by He-C 6350.10 and any other policies maintained by the program.(e) For residential treatment programs that are seeking re-certification, the executive director shall be notified in writing by DCYF of the need to re-apply for certification of the residential treatment program 4 months prior to the expiration date of the current certification.(f) The executive director or designee shall complete, sign, and date Form 2601R "Certification for Payment Renewal Application - Residential Programs" (July 2018), affirming the following: (1) "I have reviewed the Administrative Rules He-C 6350 and He-C 6420 and will adhere to the rules as a certified provider. I authorize the NH Division for Children, Youth and Families (DCYF) to conduct a certification for payment review to determine the program's compliance with Administrative rules He-C 6350 and He-C 6420. I further understand that DCYF has the right to verify information contained in this application."; and(2) "The information contained in this application is correct to the best of my knowledge."(g) The completed application form in (f) above shall be returned to DCYF within 30 days of receipt.(h) The applicant shall provide the following information with, or in addition to, the renewal application form in (f) above: (1) An electronic copy of the updated program description, including a description of the services provided to children and their families, as well as a description of the daily milieu, and how the program promotes the safety, permanency, and well-being for children and families, including any specialized services that are supported by any certifications and/or accreditations;(2) The name, office held, professional affiliation, address, and telephone number of each person on the program's board of directors, including whether or not the board member is a past or present recipient of the agency's services;(3) The names of the residential staff/child care personnel hired since last the certification period;(4) The names of the executive director, assistant director, if applicable, and clinical coordinator, including identification of who in the program is responsible for implementation of reasonable and prudent parent standard;(5) A copy of the program's license and/or operational approval, in accordance with the following: a. For programs in New Hampshire, a copy of the license issued in accordance with RSA 170-E:31 or RSA 151:5; orb. For programs outside of New Hampshire, documentation of approval from the corresponding state's regulatory agency(ies) ;(6) A copy of the general liability insurance certificate for the program;(7) For programs in New Hampshire which operate and maintain approval as a non-public school per Ed 400 and a private provider or special education per Ed 1100, a copy of their approval from the NH state board of education;(8) Programs outside of New Hampshire shall submit documentation of educational certification from the corresponding state's regulatory agency(ies); and(9) Programs in New Hampshire shall submit an electronic copy of completed Form 2450 "Statistics of Residential Programs" (July 2004) .N.H. Admin. Code § He-C 6350.05
#4442, eff 7-1-88; amd by #4906, eff 8-10-90; amd by #5122, eff 4-25-91, EXPIRED 4-25-97
New. #6617, eff 10-25-97; ss by #8453, INTERIM, eff 10-25-05, EXPIRED: 4-23-06
New. #8693, eff 7-27-06
Amended byVolume XXXV Number 06, Filed February 12, 2015, Proposed by #10759, Effective 1/17/2015, Expires1/17/2025.Amended by Volume XXXVIII Number 37, Filed September 13, 2018, Proposed by #12609, Effective 8/23/2018, Expires 8/23/2028.