Form DHS-3610A-ENG "Children's Therapeutic Services and Supports (Ctss) Provider Assurance Statements" - Minnesota

What Is Form DHS-3610A-ENG?

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

Form Details:

  • Released on December 1, 2018;
  • The latest edition provided by the Minnesota Department of Human 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 DHS-3610A-ENG by clicking the link below or browse more documents and templates provided by the Minnesota Department of Human Services.

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Download Form DHS-3610A-ENG "Children's Therapeutic Services and Supports (Ctss) Provider Assurance Statements" - Minnesota

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Clear Form
DHS-3610A-ENG
12-18
BEHAVIORAL HEALTH
Children's Therapeutic Services and Supports (CTSS)
Provider Assurance Statements
The provider entity's chief executive officer or president must initial these CTSS assurance statements on each page
and sign on the last page.
The provider organization agrees to do the following:
• Deliver services as required by
Minnesota Statutes, section 256B.0943
(CTSS statute)
• Maintain a policies and procedures manual that minimally includes the following:
• Provider agency organizational structure and process to notify DHS of changes
• Provider entity governing structure
• Identification of designated authority who has responsibility for establishing policy and maintaining quality
operations
• Code of ethics
• Procedures for investigating, reporting and acting on violations of ethical conduct standards
• Procedures for investigating, reporting and acting on violations of data standards
• Procedures for conducting criminal background studies
• Policy for cultural competence plan
• Policy for the retention and destruction of mental health records
• Policy for reporting and acting on unusual incidents (such as; serious injury or illness, victimization or abuse
involving recipient, missing persons, inappropriate recipient and staff contact)
• Policy and procedures to ensure physical safety of child and others
• Policies and procedures regarding use of restraint or seclusion include: description of who may use restrictive
procedures, type and frequency of staff training, when those procedures may be used, documentation of
request to and approval by mental health professional for use of restrictive procedures, reporting
requirements for use of restrictive procedures and regular, systematic review of patterns of use of restrictive
procedures
• The provider must have written policies and procedures that it reviews and updates every three years and
distributes to staff initially and upon each subsequent update.
• Submit information required by the state in a timely fashion, including future changes to administrative
requirements.
• Maintain all necessary records required by federal and state laws, rules and policies.
• Comply with laws and rules to be an enrolled Medicaid provider.
• Maintain recipient files and personnel files in safe, confidential and secure location.
• Maintain fiscal procedures, including internal fiscal control practices and a process for collecting revenue that is
compliant with federal and state laws.
• Cooperate with the certification, re-certification and any de-certification actions by DHS or representatives of DHS.
• Employ or contract with mental health staff that meet the statutory qualifications of a mental health professional
or practitioner or mental health behavioral aide (MHBA), if applicable, and have the pre-service and continuing
education specified in statute.
PROVIDER NAME
AUTHORIZED INITIALS NPI
Page 1 of 2
Clear Form
DHS-3610A-ENG
12-18
BEHAVIORAL HEALTH
Children's Therapeutic Services and Supports (CTSS)
Provider Assurance Statements
The provider entity's chief executive officer or president must initial these CTSS assurance statements on each page
and sign on the last page.
The provider organization agrees to do the following:
• Deliver services as required by
Minnesota Statutes, section 256B.0943
(CTSS statute)
• Maintain a policies and procedures manual that minimally includes the following:
• Provider agency organizational structure and process to notify DHS of changes
• Provider entity governing structure
• Identification of designated authority who has responsibility for establishing policy and maintaining quality
operations
• Code of ethics
• Procedures for investigating, reporting and acting on violations of ethical conduct standards
• Procedures for investigating, reporting and acting on violations of data standards
• Procedures for conducting criminal background studies
• Policy for cultural competence plan
• Policy for the retention and destruction of mental health records
• Policy for reporting and acting on unusual incidents (such as; serious injury or illness, victimization or abuse
involving recipient, missing persons, inappropriate recipient and staff contact)
• Policy and procedures to ensure physical safety of child and others
• Policies and procedures regarding use of restraint or seclusion include: description of who may use restrictive
procedures, type and frequency of staff training, when those procedures may be used, documentation of
request to and approval by mental health professional for use of restrictive procedures, reporting
requirements for use of restrictive procedures and regular, systematic review of patterns of use of restrictive
procedures
• The provider must have written policies and procedures that it reviews and updates every three years and
distributes to staff initially and upon each subsequent update.
• Submit information required by the state in a timely fashion, including future changes to administrative
requirements.
• Maintain all necessary records required by federal and state laws, rules and policies.
• Comply with laws and rules to be an enrolled Medicaid provider.
• Maintain recipient files and personnel files in safe, confidential and secure location.
• Maintain fiscal procedures, including internal fiscal control practices and a process for collecting revenue that is
compliant with federal and state laws.
• Cooperate with the certification, re-certification and any de-certification actions by DHS or representatives of DHS.
• Employ or contract with mental health staff that meet the statutory qualifications of a mental health professional
or practitioner or mental health behavioral aide (MHBA), if applicable, and have the pre-service and continuing
education specified in statute.
PROVIDER NAME
AUTHORIZED INITIALS NPI
Page 1 of 2
• Provider entity will be responsible for oversight of their partners and will assume full professional responsibility
for them.
• Document staff qualifications and training in personnel files.
• Conduct required criminal background studies of staff and volunteers prior to the provision of direct care and
document results in each individual's personnel file.
• Ensure that clinical supervisor meets professional and Medical Assistance standards.
• Maintain written clinical policies and procedures manual with at least the following topics covered:
• Diagnostic assessment
• Individual treatment plan development
• Clinical supervision
• Service delivery
• Individual treatment plan review
• Individual behavior plan, if applicable
• Individual education plan (IEP), if applicable
• Deliver services as needed and within each individual provider's areas of competence, and scope of practice.
• Provide services consistent with Minnesota's Mental Health System of Care principles.
• Integrate evidence based practices.
• Incorporate family involvement and cultural competency into policy development, implementation and evaluation
of programs and service.
• Provide services based on the individual's needs and preferences, which are medically necessary, and vary in
frequency, flexibility, and place of service dependent upon individual treatment plan and client input.
• Provide services consistent with all applicable federal and state laws and regulations.
By signing this provider certification requirements document, I acknowledge as the provider entity's chief executive
officer or president, that failure to meet these requirements may be cause for decertification or denial of certification
as a CTSS provider.
NAME OF PERSON SIGNING (print name)
TITLE
SIGNATURE
DATE
PROVIDER NAME
AUTHORIZED INITIALS NPI
Page 2 of 2
DHS-3610A-ENG 12-18
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