Form DHCS3131 "Application for Mental Health Program Approval Short-Term Residential Therapeutic Programs" - California

What Is Form DHCS3131?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2020;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHCS3131 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form DHCS3131 "Application for Mental Health Program Approval Short-Term Residential Therapeutic Programs" - California

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State of California-
Department of Health Care Services
Health and Human Services Agency
APPLICATION FOR MENTAL HEALTH PROGRAM APPROVAL
SHORT-TERM RESIDENTIAL THERAPEUTIC PROGRAMS
Name of Applicant/ Facility Name:
Head of Service:
Facility Address (Street No., Street Name, P.O. Box, Apt. No.):
City:
Mailing Address (if different from above):
City:
County Mental Health Plan:
Zip Code: Telephone:
(
)
Type of Ownership:
☐ Government Entity
☐ Non-Profit Corp.
Total number of beds to be certified:
Number of beds to be certified per facility/house/cottage:
CDSS License Number: _____________
CDSS License date: _____________
Mental Health Contract (MHP) Yes
No
Age Groups to be admitted
:
Medi-Cal Certification
Yes
No
The following i nformation must be submitted along with this application form. Please check each box
to indicate information has been submitted. Note: The Sections listed for each item below refer to the
corresponding Section in STRTP Regulations Version II.
1. Mental Health Program statement that meets the requirements of Section 5.
2. Policies and procedures the facility will utilize to meet the notification requirements
in Section 6.
3. Policies, procedures, and documentation the facility will utilize to meet the
program record and retention requirements in Section 7.
4. Policies, procedures, and documentation the facility will utilize to meet the
mental health assessment requirements in Section 8
5. Policies, procedures, and documentation the facility will utilize to meet the
admission statement requirements in Section 9.
6. Policies, procedures, and documentation the facility will utilize to meet the
requirements for the treatment plan in Section 10.
7. Policies, procedures, and documentation the facility will utilize to meet
the STRTP mental health program progress note documentation requirements
in Section 11.
DHCS 3131 (Revised 2/2020)
Page 1 of 3
State of California-
Department of Health Care Services
Health and Human Services Agency
APPLICATION FOR MENTAL HEALTH PROGRAM APPROVAL
SHORT-TERM RESIDENTIAL THERAPEUTIC PROGRAMS
Name of Applicant/ Facility Name:
Head of Service:
Facility Address (Street No., Street Name, P.O. Box, Apt. No.):
City:
Mailing Address (if different from above):
City:
County Mental Health Plan:
Zip Code: Telephone:
(
)
Type of Ownership:
☐ Government Entity
☐ Non-Profit Corp.
Total number of beds to be certified:
Number of beds to be certified per facility/house/cottage:
CDSS License Number: _____________
CDSS License date: _____________
Mental Health Contract (MHP) Yes
No
Age Groups to be admitted
:
Medi-Cal Certification
Yes
No
The following i nformation must be submitted along with this application form. Please check each box
to indicate information has been submitted. Note: The Sections listed for each item below refer to the
corresponding Section in STRTP Regulations Version II.
1. Mental Health Program statement that meets the requirements of Section 5.
2. Policies and procedures the facility will utilize to meet the notification requirements
in Section 6.
3. Policies, procedures, and documentation the facility will utilize to meet the
program record and retention requirements in Section 7.
4. Policies, procedures, and documentation the facility will utilize to meet the
mental health assessment requirements in Section 8
5. Policies, procedures, and documentation the facility will utilize to meet the
admission statement requirements in Section 9.
6. Policies, procedures, and documentation the facility will utilize to meet the
requirements for the treatment plan in Section 10.
7. Policies, procedures, and documentation the facility will utilize to meet
the STRTP mental health program progress note documentation requirements
in Section 11.
DHCS 3131 (Revised 2/2020)
Page 1 of 3
State of California-
Department of Health Care Services
Health and Human Services Agency
8. Policies, procedures, and documentation the facility will utilize to meet the
trauma-informed response to significant events requirements in Section 11.
9. Policies, procedures, and documentation the facility will utilize to meet the
medication assistance, control and monitoring requirements in Section 12.
10. Provide a detailed description of the specific treatment modalities the facility will utilize to
meet mental health treatment services requirements in Section 13. This description shall
include policies and procedures for ensuring that children receive mental health treatment
services that the facility does not provide directly, including Specialty Mental Health
Services for Medi-Cal beneficiaries and equivalent services for children who are not Medi-
Cal beneficiaries.
11. Policies, procedures, and documentation the facility will utilize to meet the clinical
reviews, collaboration, and transition determination requirements in Section 14.
12. Policies, procedures, and documentation the facility will utilize to meet the transition
determination plan requirements in Section15.
13. Provide documentation indicating that the proposed head of service meets the
qualifications and experience required in Section 16 and will be employed forty hours per
week.
14. Provide staffing patterns. Include an organizational chart, which lists job descriptions,
staff-to-child ratios, functions, and professional licenses, if applicable, of the direct mental
program staff. Include information regarding contractors that will be available to provide
mental health treatment services to children during their stay in the STRTP. Demonstrate
through these documents that the applicant will provide at least one full time equivalent
(FTE) direct service program staff for each 6 children residing in the STRTP which
includes at least one half-time equivalent licensed mental health professional for each 6
children residing in the STRTP. Include the staff qualifications, training, and experience
for each position type required in Section 17.
15. Policies and procedures the facility will utilize to meet the requirement in Section 17 that
the facility has a psychiatrist available to provide psychiatric services as specified.
16. A detailed staff training plan, describing s taff orientation procedures and documentation
the facility will utilize to meet the in-service education required in Section 18.
17. Policies, procedures and documentation the facility will utilize to meet the personnel
record requirements in Section 19.
18. Policies and procedures regarding the utilization of community resources as adjunct
to the facility’s mental health program, if applicable.
DHCS 3131 (Revised 2/2020)
Page 2 of 3
State of California-
Department of Health Care Services
Health and Human Services Agency
Applicant’s Signature:
Title:
Organization:
Date:
Please submit your completed application to:
Delegate County MHP
And to DHCS at:
E-Mail
Attention: STRTP MHPA application
STRTP@DHCS.CA.GOV
Certified Mail
Department of Health Care Services
Continuum of Mental Health Care Section
P.O. Box 997413, MS 2633
Sacramento, CA 95899-7413
DHCS 3131 (Revised 2/2020)
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