The Maryland RSA form is an application used to obtain a Residential Services Agency license for skilled nursing and aides in the state of Maryland. This form is essential for agencies looking to provide health care services and must be completed accurately to initiate the licensing process. For those interested in applying, please fill out the form by clicking the button below.
The Maryland Residential Services Agency (RSA) form is a crucial document for individuals and organizations seeking to provide skilled nursing and aide services in the state. This application packet outlines the necessary steps and requirements for obtaining a Residential Services Agency license from the Office of Health Care Quality (OHCQ). Key components include a non-refundable licensure fee of $500, an organizational chart detailing staff positions, and the development of policies and procedures in accordance with state regulations. Additionally, applicants must compile sample personnel and patient files, as well as provide a detailed scope of services, which includes the types of care offered and the geographical areas served. The process also involves an on-site survey to assess compliance with established standards. It is important to note that the issuance of provisional licenses may face delays of up to nine months due to budgetary constraints. This form serves as the foundation for ensuring that agencies meet the necessary qualifications to operate legally and provide quality care to patients in Maryland.
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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
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).
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:
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
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.
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
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
PERCENTAGE
OWNED
NAME OF PRESIDENT (IF CORPORATION) OR MANAGER (IF LLC)
CELL NUMBER
ADDRESS (number, street)
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
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?
Yes
4. WORKERS’ COMPENSATION
Do you have any employees?
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:
2
6. ADDENDUM - BRANCH OFFICES
LICENSED NAME
LICENSE NUMBER
DOES THE AGENCY OPERATE ANY BRANCH OFFICES?
Yes (list all below)
STREET ADDRESS
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
FOR OFFICE USE ONLY
INITIALS
3
This form is applicable not only to new Residential Service Agencies but also to existing agencies that wish to upgrade their licenses.
The $500 application fee is non-refundable, regardless of the outcome of your application.
Medicaid reimbursement is only available once you obtain a full twelve-month license. A provisional license does not qualify you for this.
Once issued, the provisional license cannot be extended under any circumstances, including family emergencies or difficulties in obtaining patients.
You must wait until you receive your provisional license before admitting any patients.
The initial survey is a mandatory step in the licensure process and must be conducted after admitting the required number of patients.
If deficiencies are identified, you are required to submit a written plan of correction within ten working days.
All required policies and procedures must be developed and implemented before submitting your application for licensure.
An organizational chart detailing all positions and personnel must be included with your application. Incomplete submissions may result in denial of licensure.
The timing of the initial survey is determined by the Office of Health Care Quality, based on your readiness and compliance with the outlined requirements.
Filling out the Maryland RSA form can be a straightforward process, but several common mistakes can lead to delays or denials. One significant error is not including the $500 non-refundable licensure fee with the application. This fee is mandatory, and without it, the application will not be processed. Ensure that the payment is attached and that the check or money order is made out correctly to avoid any issues.
Another frequent mistake is failing to provide a comprehensive organizational chart. This chart must include all positions within the agency, along with the names of individuals occupying those roles. Incomplete charts can lead to confusion about the agency's structure and responsibilities, which may result in a denial of the application. Take the time to ensure that the chart is detailed and accurately reflects the personnel in your agency.
Additionally, applicants often overlook the requirement for developing policies and procedures as mandated by COMAR 10.07.05. These documents are essential for demonstrating compliance with state regulations. Inadequate or poorly drafted policies can raise red flags during the review process. It is crucial to invest time in creating thorough policies that meet all regulatory requirements.
Lastly, many applicants neglect to assemble a sample personnel file and a sample patient file. These samples are critical for the on-site survey and must reflect the agency's operational standards. Failure to provide these files can lead to a negative assessment during the initial survey, which may jeopardize the licensing process. Prepare these samples carefully to ensure they meet the expectations of the Office of Health Care Quality.
To begin the process of obtaining a Residential Services Agency (RSA) license in Maryland, you must complete and submit the application packet to the Office of Health Care Quality (OHCQ).
A non-refundable licensure fee of $500 must accompany your application.
It is essential to include an organizational chart that lists all positions along with the names of the individuals filling those roles.
Policies and procedures must be developed as required by the Code of Maryland Regulations (COMAR) 10.07.05.
Sample personnel and patient files should be assembled for both adult and pediatric patients, if applicable.
The Scope of Services provided by your agency needs to be clearly defined, including the geographic area served and accepted referral and payer sources.
Once the application is submitted, be prepared for an on-site survey to evaluate your agency.
After receiving a provisional license, you must admit 3-5 patients within 45 days to maintain your licensing status.
If deficiencies are found during the initial survey, a written plan of correction must be submitted within 10 working days.
Be aware that provisional licenses will not be extended beyond the 90-day expiration date, and you cannot apply for Medicaid reimbursement until a full license is obtained.
When applying for a Residential Services Agency (RSA) license in Maryland, several other forms and documents may be required alongside the Maryland RSA form. Each of these documents plays a crucial role in ensuring compliance with state regulations and in establishing a well-structured agency. Below is a list of commonly used forms and documents that support the licensure process.
Each of these documents is essential for demonstrating compliance and readiness to operate as a Residential Services Agency in Maryland. Ensuring that all forms are accurately completed and submitted can significantly impact the success of the licensure application process.
The Maryland RSA form shares similarities with the Home Health Agency (HHA) application. Both documents require detailed information about the agency's services, organizational structure, and personnel. For instance, both forms mandate the submission of an organizational chart and policies and procedures that comply with state regulations. Additionally, they both include a fee for processing the application and necessitate an on-site survey before a license can be granted. This ensures that both types of agencies meet the necessary health and safety standards before operating.
In the realm of commercial real estate, understanding the various forms and agreements is crucial for success. A Florida Commercial Lease Agreement form, for instance, is a legally binding document that defines the leasing terms for a commercial property. It is imperative for both landlords and tenants to have clarity on expectations and responsibilities, which this agreement facilitates. For those interested in utilizing such a document, further information can be found at https://floridadocuments.net/fillable-commercial-lease-agreement-form, ensuring all parties are well-informed.
Another document comparable to the Maryland RSA form is the Assisted Living Facility (ALF) application. Like the RSA form, the ALF application requires a comprehensive overview of services offered, including the types of care and support provided to residents. Both applications also need a list of personnel and their qualifications, ensuring that staff members are properly trained to deliver care. Furthermore, both forms emphasize the importance of patient rights and necessitate policies that protect those rights, reinforcing the commitment to quality care.
The Nursing Home License application is also similar to the Maryland RSA form. Both documents require a non-refundable application fee and a detailed description of the services to be provided. They both necessitate the assembly of sample patient files and personnel files, which helps demonstrate compliance with state regulations. Additionally, both applications undergo an initial survey process to assess the facility's readiness to provide care, ensuring that all necessary standards are met before a license is issued.
Finally, the Adult Day Care License application bears resemblance to the Maryland RSA form. Both documents require information about the agency's operations, including hours of service and the types of care provided. They also require the submission of an organizational chart and policies that govern the operation of the agency. Both applications focus on the quality of care and necessitate a review of patient rights and internal complaint processes, ensuring that clients receive proper treatment and support.