APPENDICES
Appendix A: Voluntary Agency Licensing Residential Program Proposal RequiredDocumentation
Appendix B: Budget Forms
APPENDIX A: Voluntary Agency Licensing Residential Program Proposal Required
Documentation
Voluntary Agency Licensing
Residential Program Proposal Required Documentation Checklist
Name of Agency______
Name of Facility______
Requested ActionApproval of Incorporation OR Operating Certificate
Program Type______
Note:If the program intends to serve children with identified OMRDD, OMH or OASAS service needs, consultation with the appropriate agency should occur as needed.
Site Address______
Contact Person______
Telephone Number______
E-mail Address______
Submission DateM [__][__] D [__][__] Y [__][__] OCFS Reviewer______
INTRODUCTIONItem / Submitted / Approved / NA / On File
General Philosophy and Purpose
Mission Statement
Need for Program
AGENCY ORGANIZATION
Note: Board member information is required for approval of incorporation.
If board member information has changed, submit corrected information at this time.
Item / Submitted / Approved / NA / On File
Corporate Structure
Summary Description
Dated Copy of Current or Revised Bylaws
General Organizational Structure
Proposed Organization Chart
Proposed Job Descriptions
Proposed Program Policy Manual
Personnel
List Current Or Proposed Employees By:
Title
Number
Education
Certificate or License
Start Date of Employment for Proposed Staff
Salaries/Fringe Benefits
Item / Submitted / Approved / NA / On File
For Residential Staff, Identify:
Number of Staff for Each Job Title
Qualifications of Staff for Each Job Title
Staffing Pattern
Responsibilities of Staff, Including Supervisory Structure
Personnel Policy Manual
Recruitment and Hiring Practices Including:
Individual Personnel File Documentation
Resume (including education and work history)
Contacted References
SCR Database Check Result
Current Medical Examination (including TB test results)
Verification/Statement of Criminal History Check
Verification of Participation in Required, Ongoing Training
New Staff Orientation Outline
In-Service Training Outline
Description of Training Programs
Past Year Dates
Proposed Program Changes and Upcoming Schedule
Policy on Advanced Education and Certification
Employee Evaluation Procedures (with forms/criteria attached)
SERVICES PLANNING
Item / Submitted / Approved / NA / On File
Admissions
Criteria for Admissions
Anticipated Referral Sources and Method of Referral
Criteria for Selection
Initial Treatment Planning Procedure
Includes Identification of Permanency Goal and Plan
Procedure & Schedule for Review of Treatment Plans(Routine & Emergency)
Discharge Planning
Criteria
Procedures
Aftercare Services
Record Keeping
Policy
Procedures
Content and Format (copies of all forms)
Confidentiality
HEALTH SERVICES PROGRAM
Note: If a discrete Medicaid rate is being requested, an application for such must be obtained from the OCFS Regional Office. Documentation for this section may be used in determining the requested Medicaid rate.
Item / Submitted / Approved / NA / On File
Clinical Services
Psychiatric Services
Number and Qualifications of Staff
Methods Used
Responsibilities
Size of Caseload
Frequency and Length of Contact with Child
Nature of Contact with Children
Types of Records and Location
Psychological Services
Number and Qualifications of Staff
Methods Used
Responsibilities
Size of Caseload
Frequency and Length of Contact with Child
Nature of Contact with Children
Types of Records and Location
Social Work Services
Number and Qualifications of Staff
Methods Used
Responsibilities
Size of Caseload
Frequency and Length of Contact with Child
Nature of Contact with Children
Types of Records and Location
Services to Families
Medical Services
Numbers and Qualifications of Staff
Responsibilities of Staff
Methods Used
Size of Caseload (Ratio)
Frequency and Length of Contact with Each Child
Nature of Contact with Children
Types of Records Maintained and Location
HIV Policy
Item / Submitted / Approved / NA / On File
Medication Policy
Storage of Medication
Procedure for Administration of Medication
Documentation of Medication Administered
EDUCATION PROGRAM PLAN
Item / Submitted / Approved / NA / On File
Off-Campus Program
Plan for Coordination with LocalSchool District
Plan for Coordination with HomeSchool District
On-Campus Program
Copy of License/Certification from NYS Education Department
Summer Program Description
RESIDENTIAL PROGRAM
Item / Submitted / Approved / NA / On File
Daily Activities Schedule for Each Unit or Program
Staff Responsible for Activity Plan and Schedule
Staff Responsible for Implementation
Written Discipline Policy (Including Procedures for Ensuring Staff are Trained and Aware of Policy and Techniques)
Corporal Punishment
Physical Restraint Plan
Agency Policy on Use of Restraint
Restraint Technique Used (if any)
Documentation of Staff Training on Restraint
Written NYSOCFS Regional Office Approval of Restraint Plan (must be current)
Use of Isolation
Deprivations or Loss of Privileges
Procedures to Prevent an AWOL
Procedures Initiated Following an AWOL
Procedures to Prevent Assaults
Procedures Initiated Following an Assault
Procedures to Prevent Presence of Illegal Substances
Procedures Initiated Following Presence of Illegal Substances
Copies of Forms Used to Document Unusual Incidents
Policy on Personal Hygiene
Clothing
Purchase Responsibility and Method
Storage
Laundry
Item / Submitted / Approved / NA / On File
Money and Other Personal Property
Allowances
Accountability for Money
Regulations Regarding Use of Money
Statement and Policy Regarding Religious Training/Opportunity for Worship
Opportunity for Work Experience
Availability
On-Grounds
Off-Grounds
Supervision
Pay
Community Involvement
Description of Opportunities
Anticipated Frequency
Recreation Program and Plan
If Staff Other Than Noted in Staff Section, Provide Number and Qualifications of Staff
Types of Activities
Schedule of Activities
If Different, Summer Schedule of Daily Activities
NUTRITION AND FOOD SERVICES
Item / Submitted / Approved / NA / On File
Number and Qualifications of Staff
Menu Planning Procedure
Inventory and Purchase Procedure
Food Preparation Procedure
Sanitation Procedure
Serving Procedure
Client Involvement in Food Service Procedures
Snack Policies
Nutrition Education
SAFETY
Item / Submitted / Approved / NA / On File
Disaster Preparedness Policy and Plan
Emergency Evacuation Procedures
Staff Training Plan
APPENDIX B: Budget Forms
BUDGET FORMS
(Rev. 1/8/02)
Agency Name:Program Name:
Location:
Budget Type: / Start-up (up to six months)
Operational
Budget Period:
FORMS:
- Summary of Personnel Costs
- Personal Narrative
- Contractual/Consultant
- Travel Costs
- Equipment
- Supplies
- Other Expenses
I
Summary of Personnel Costs
Position/Title / Annual Salary / % of Time / Total Cost1. Personnel Total
2. Fringe Benefits Total / EnterRate:
3. Total Personal Services Costs
** The figures in the column are for comparison purposes only. It may not exactly equal the Total Cost figure.
Personal Narrative
BudgetNarrative:Attachadescriptionoftherole/responsibilityofeachpersonincludedabove.
1.Title:
EnterRole/ResponsibilityBelow
2.Title:
EnterRole/ResponsibilityBelow
3.Title:
EnterRole/ResponsibilityBelow
4.Title:
EnterRole/ResponsibilityBelow
5.Title:
EnterRole/ResponsibilityBelow
7.Title:
EnterRole/ResponsibilityBelow
8.Title:
EnterRole/ResponsibilityBelow
9.Title:
EnterRole/ResponsibilityBelow
10.Title:
EnterRole/ResponsibilityBelow
12.Title:
EnterRole/ResponsibilityBelow
13.Title:
EnterRole/ResponsibilityBelow
14.Title:
EnterRole/ResponsibilityBelow
15.Title:
EnterRole/ResponsibilityBelow
f
16.Title:
EnterRole/ResponsibilityBelow
17.Title:
EnterRole/ResponsibilityBelow
18.Title:
EnterRole/ResponsibilityBelow
19.Title:
EnterRole/ResponsibilityBelow
20.Title:
EnterRole/ResponsibilityBelow
Contractual/Consultant
Item / TotalCostsTotalContractual/ConsultantCosts
EnterBudgetNarrativeBelow:
Travel Costs
Item / TotalCostsTotalTravelCosts
EnterBudgetNarrativeBelow
Item / TotalCostsTotalEquipmentCosts
EnterBudgetNarrativeBelow:
Item / TotalCostsTotalSupplyCosts
EnterBudgetNarrativeBelow:
Confidential Draft 1.23.18
Item / TotalCostsTotalOtherExpenses
EnterBudgetNarrativeBelow