Section He-C 6355.02 - Application Process(a) A licensed foster family home shall be considered compliant with certification standards when it is determined to be in compliance with He-C 6446.(b) A staffed foster family home shall be considered compliant with certification standards when it is determined to be in compliance with He-C 6355.11 and He-C 6446.(c) Each foster care program shall be determined eligible for certification by demonstrating in its application that it meets the quality and performance certification standards in He-C 6355.(d) Each foster care program applicant shall demonstrate compliance with RSA 170-G:4, XVII, He-C 6380, enrollment and payment requirements, and He-C 6420, Medicaid covered services in residential facilities.(e) Any foster care program as defined in He-C 6355.01(t) above, licensed in accordance with RSA 170-E, He-C 6446 or from another state, that seeks certification in accordance with He-C 6355 shall request application Form 2612 "Certification For Payment Application - Foster Care Program," (January 2015) from DCYF and be supported by a need identified by DCYF in accordance with RSA 170-G:4.(f) The application in (e) above shall be completed, signed and dated by the foster care program's executive director, or designee, affirming or agreeing with all of the following: (1) "I have reviewed the Administrative Rules He-C 6355 and He-C 6446 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 6355 and He-C 6446. I further understand that DCYF has the right to verify information contained in this application."(2) "I attest that the program is in compliance with He-C 6355, He-C 6446 and the applicable Medicaid rules, and that all information provided as part of the application and in the required attachments is true and complete to the best of my knowledge."(3) "I certify that the following pre-employment checks were completed for all staff, and reviewed as required in He-C 6355.04, a criminal record check, a BEAS state registry check, a DCYF central registry check and a NH motor vehicle record check."(4) "I understand and agree to cooperate with a site visit as part of the application process."(5) "The information contained in this application is correct to the best of my knowledge."(g) The completed application in (e) above shall be returned to DCYF within 90 days of receipt.(h) The applicant shall provide the following information with the application in (e) above: (1) A narrative, which shall include: a. A description of the foster care program being proposed, to include any specialized services and the population the program desires to serve;b. The documented need for the program as required by RSA 170-G:4, XVIII;c. A description of how individual needs of children and families will be met, including but not limited to clinical provisions, educational, recreational, independent living, transitional services and case management, as applicable;d. A description of how the program promotes the safety, permanency and well-being of children and families;e. A description of medical services provided or arranged in order to meet the individual needs of children; andf. The quality assurance process that the applicant intends to use for the program, including all supporting documentation.(2) Attachments, which shall include:a. The name, office held, professional affiliation, address and telephone number of each person on the program's board of directors;b. A copy of the program's license issued in accordance with the following: 1.For programs in New Hampshire, a copy of the license issued in accordance with RSA 170-E:31 and He-C 6446; or
2.For programs outside of New Hampshire, documentation from the corresponding state's regulatory agency(ies);
c. A completed Form 2426 "Residential Resource Guide Provider Form," (January 2015);d. A detailed budget describing the costs associated with the delivery of the foster care program; ande. An organizational chart, to include names, titles, and job descriptions of personnel, and the corresponding credentials which document the education and experience requirements in He-C 6355.16, as applicable; and(3) A copy of the program's policies required by He-C 6355.09 and any other policies maintained by the program.(i) If the type of certification being sought in (e) above is for staffed foster family home care, the following additional information shall be included: (1) The name and address of 3 non-family members as references for the director, including the most recent employer, if applicable;(2) The names, addresses, and telephone numbers of the members of the board of directors and advisory board; and(3) Documentation that the residence and staff have met the requirements of He-C 6446.N.H. Admin. Code § He-C 6355.02
Amended byVolume XXXIV Number 33, Filed August 14, 2014, Proposed by #10640, Effective 7/29/2014, Expires7/26/2015.Amended byVolume XXXV Number 10, Filed March 12, 2015, Proposed by #10783, Effective 2/13/2015, Expires2/13/2025.