Dhcs 1737 County-Owned And Operated Provider Self-Survey Form - California - Health And Human Services Agency
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1
2State of California – Health and Human Services Agency
Department of Health Care Services
MHP RE-CERTIFICATION of COUNTY-OWNED AND OPERATED PROVIDERS SELF-SURVEY FORM
COUNTY INFORMATION
County Submitting Form: _________________________
County Code: _____
NPI#: _______________________
No
Is the provider activating any modes?
Yes
Is the provider changing names?
Yes
No
(if yes, please complete page 2, Items C & D.)
PROVIDER INFORMATION
Name: _________________________________________________________
Provider Number: _________________
Address: _______________________________________________
City:____________________
Zip code: ________
SERVICES PROVIDED: (Please check all that apply):
OUTPATIENT
15/01 T1017 - Case Management/Brokerage (Includes Intensive Care Coordination (ICC) T1017 (15/07))
15/30 H2015 - Mental Health Services (Includes Intensive Home Based Services (IHBS) H2015 (15/57))
15/58 H2019 - Therapeutic Behavioral Services
15/60 H2010 - Medication Support
15/70 H2011 - Crisis Intervention
RESIDENTIAL
Number of Beds
05/20 H2013 - Non-Hospital PHF
05/65 H0019- Adult Residential
05/40 H0018 - Crisis Residential
Note: All residential certifications & recertifications require submission of the residential license and be 16 beds or less.
EVALUATION CRITERIA
1.
Regarding written information in English and the threshold languages to assist beneficiaries in
accessing specialty mental health services, at a minimum, does the provider have the following
Yes
No
N/A
information available:
A)
The beneficiary brochure per MHP procedures?
MHP Contract, Exhibit A, Attachment I, § 7A; CCR, Title 9, § 1810.360 (b)(3),(d) and (e)
CCR, Title 9, § 1810.410 (e)(4)
B)
The provider list per MHP procedures?
MHP Contract, Exhibit A, Attachment I, § 7A; CCR, Title 9, § 1810.360 (b)(3),(d)and (e)
CCR, Title 9, § 1810.410 (e)(4)
C)
The posted notice explaining grievance, appeal, and fair hearings processes?
MHP Contract, Exhibit A, Attachment I, § 15A(3)(a)(ii), CCR, Title 9, § 1850.205 (c)(1)(B)
CCR, Title 9, § 1810.410 (e)(4)
D)
The grievance forms, appeal forms, and self-addressed envelopes?
MHP Contract, Exhibit A, Attachment I, § 15A(3)(a)(iii), CCR, Title 9, §1850.205 (c)(1)(C);CCR, Title 9, §1810.410 (e)(4)
2.
Does the space owned, leased or operated by the provider and used for services or staff meet local
fire codes?
(A copy of the most recent fire safety inspection notice from the local fire authority must be
submitted with this form)
MHP Contract, Exhibit A, Attachment I, §4L(2); CCR, Title 9, § 1810.435 (b)(2)
3.
Is the facility and its property clean, sanitary, and in good repair?
MHP Contract, Exhibit A, Attachment I, §4L(3); CCR, Title 9, § 1810.435 (b) (2)
4.
Does the provider have the following policies and procedures:
A) Protected Health Information?
MHP Contract, Exhibit F, CCR, Title 9, §1810.310 (a)(10) CCR, Title 9, §1810.435 (b)(4)
B) Personnel policies and procedures?
MHP Contract, Exhibit A, Attachment I, §4L(5), CCR, Title 9, §1840.314
C) General operating procedures?
MHP Contract, Exhibit A, Attachment I, §4L(5), CCR, Title 9, § 533
D) Maintenance policy to ensure the safety and well being of beneficiaries and staff?
MHP Contract, Exhibit A, Attachment I, §4L(4), CCR, Title 9, § 1810.435(b)(2)
E) Service Delivery Policies?
MHP Contract, Exhibit A, Attachment I, §4L(5), CCR, Title 9, § 1810.209-210 §
1810.212 213 § 1810.225, 1810.227 and 1810.249
DHCS 1737 (Rev. 09/2014)
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