Form 445099 Branch Questionnaire - Illinois

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State of Illinois
Illinois Department of Public Health
Branch Questionnaire
Questionnaire for determining licensure branch office status
Name of agency
Address
City
State
Zip Code
License number
The purpose of these questions is to evaluate the agency's overall management ability in the areas of supervision,
coordination of services, effectiveness of communication systems, organizational staffing practice and service delivery
logistics to determine if a proposed satellite office should be designated as a branch. Your responses to the following items
will be considered for the "desk audit" review and will be confirmed at the next on-site visit.
1. Describe the reason for the new branch location. Describe what type of services will be provided at the location? (i.e-
intake referrals, staff training, and or workers assignments etc.). If additional space is needed, please attach another
page. List the current number of clients being served currently under your license.
2. What is the address of the proposed satellite office?
Address
County
Phone Number
City
State
Zip Code
Is the proposed satellite office located on the premises of another business? If so, please name.
3. Is the location from which the satellite provides services within a portion of the total geographic service area served by
the parent agency or will service area be added?
Form Number (445099)
Page 1 of 5
State of Illinois
Illinois Department of Public Health
Branch Questionnaire
Questionnaire for determining licensure branch office status
Name of agency
Address
City
State
Zip Code
License number
The purpose of these questions is to evaluate the agency's overall management ability in the areas of supervision,
coordination of services, effectiveness of communication systems, organizational staffing practice and service delivery
logistics to determine if a proposed satellite office should be designated as a branch. Your responses to the following items
will be considered for the "desk audit" review and will be confirmed at the next on-site visit.
1. Describe the reason for the new branch location. Describe what type of services will be provided at the location? (i.e-
intake referrals, staff training, and or workers assignments etc.). If additional space is needed, please attach another
page. List the current number of clients being served currently under your license.
2. What is the address of the proposed satellite office?
Address
County
Phone Number
City
State
Zip Code
Is the proposed satellite office located on the premises of another business? If so, please name.
3. Is the location from which the satellite provides services within a portion of the total geographic service area served by
the parent agency or will service area be added?
Form Number (445099)
Page 1 of 5
State of Illinois
Illinois Department of Public Health
Branch Questionnaire
4. What geographic area will be served by the proposed satellite? Is it limited to patients served by a health facility?
5. What is the mileage and estimated travel time between the parent agency office and the satellite office? (Note any
unusual road conditions or terrain variations.)
6. What is the staffing pattern (number and type of employees) at the parent agency office and satellite office? Also list
services provided and indicate whether they are provided directly, through a contract or both.
7. Describe how administration is shared between the parent agency and the satellite office.
8. Are the staff at the satellite office employees of the parent agency? If not, please explain.
9. Where will personnel records be maintained and how will payroll be processed for the satellite office?
Form Number (445099)
Page 2 of 5
State of Illinois
Illinois Department of Public Health
Branch Questionnaire
10. Is the direct supervision at the satellite location the same as that at the parent office? Explain.
11. Is a designated supervisor available to the satellite location during all hours of operation?
12. What is the planned frequency of visits by the parent agency to the satellite location?
13. Does your agency provide services under contract with the Illinois Department of Aging (Community Care Program),
Department of Human Services( Department of Rehabilitation Services) and or Veterans Affairs? If yes, list the number of
clients currently being served under each applicable program.
14. Will patients be accepted and plans of service formulated at the satellite office or at the parent agency office?
Describe the process.
Form Number (445099)
Page 3 of 5
State of Illinois
Illinois Department of Public Health
Branch Questionnaire
15. Where will the client records for the satellite office be maintained?
16. At either or both locations, are client records maintained in accordance with accepted professional standards?
Explain.
17. Do the records contain all necessary information to identify the clients and describe the service plan and care
rendered? Are the records safe-guarded against loss and unauthorized use? Explain
18. Are the client records for satellite office reviewed by the parent agency? How often?
19. How and who will perform the every 90 day supervisory visit for the clients at the branch location?
20. How will the client billing for care provided from the branch be processed?
Form Number (445099)
Page 4 of 5
State of Illinois
Illinois Department of Public Health
Branch Questionnaire
21. How does the parent agency provide procedural guidance, supervision and orientation/inservice training for the
satellite staff?
22. Are copies of policy and procedure manuals located at the satellite offices?
23. Are copies of completed and signed contracts for services by arrangement or direct contract workers available in the
branch office?
24. How is the communication system between the parent agency and satellite office designed to provide for timely
exchange of information?
Submitted by
Signature of Administrator
Date
Submit by Email
Form Number (445099)
Page 5 of 5

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