Appendix G - Prior Approval Review (PAR) Documents

Section F - Staffing
1. Staffing Chart
List Each Position by Title / Check If
Professional Staff / No. of
FTE’s / Days Worked / Hours/Shift Worked / Estimated Salary
2. Indicate the standard workweek (in hours) of a full-time staff position: / 3. For Team Leader position, indicate percent of Time allocated to administration:
4. Describe how staff supervision will be provided.
Section H - Physical Plant
1.Identification of Applicant
a.Applicant’s Name: Click or tap here to enter text.
b.Applicant’s Address:Click or tap here to enter text.
2.Property Information
  1. Address of Proposed Premises: Click or tap here to enter text.
  1. Owner of Premises:
Name: Click or tap here to enter text.
Address: Click or tap here to enter text. / 3.For Leased Property
  1. Term of Lease Agreement: Click or tap here to enter text.
  1. Effective Date of Lease: Click or tap here to enter text.
  1. Is Lease Renewable: ☐YES ☐NO
  1. Annual Rental Cost per Sq. Ft.
$Click or tap here to enter text.
  1. Approximate Size of Property
Click or tap here to enter text.Sq. Ft. /
  1. Estimated Total Rental Cost per year:
$Click or tap here to enter text.
d.Building Size:
  1. Number of Floors: Click or tap here to enter text.
  2. Total Sq. Ft. in Building: Click or tap here to enter text.Sq. Ft
  3. Identify Floors to be Used:Click or tap here to enter text.
  4. Amount of Space to be Used:Click or tap here to enter text.Sq. Ft.
/
  1. Estimated Applicant’s Cost for Capital Improvement:
$Click or tap here to enter text.
  1. Applicant’s Method of Financing Capital Costs:
☐Included in Lease Agreement
☐Applicant’s Cash Investment
☐Other (specify): Click or tap here to enter text.
  1. Attach Copy of Proposed Lease

  1. Office Space - Submit plan showing room arrangement, dimensions, and proposed use of rooms and space. Describe proposed renovations if applicable.

  1. Certificate of Occupancy - Submit a Certificate of Occupancy or equivalent document from local buildings jurisdiction.

  1. Readiness Review - complete a site visit by OMH Field Office staff prior to issuance of an operating certificate..

Section I - ACT Team Staffing & Recipient Phase-In Plan

Assumptions:

  1. Plan begins when first staff is hired,
  2. No more than 8new enrollments per month for the 68 recipient team until model capacity 68 is reached,
  3. Staff is to receive ACT training within first two months.

Plan must include:

  1. Number of active recipients at time of licensing to remain in program & confirmation that they meet ACT admission criteria,
  2. Number of planned new enrollments per month,
  3. Number of active recipients at time of licensing to be discharged from program & confirmation that they do not meet ACT

Admission criteria.

Starting Month: ______Pre-License Caseload: ______# to remain enrolled: ______# to be discharged: ______

Phase-in month / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14
Existing Staff
Staff hiring
New Recipient
Enrollment
Recipients to be
Discharged
Projected
Medicaid Revenue
Staffing Model / Actual Staffing at
Time of Licensing / Staffing Needs and Planned
Date to Hire / Date Planned to Achieve Competencies**
S/A Employment Family
1 FT Team Leader (50% counted in
clinical staff ratio)
.5 Psychiatrist for every 50 clients
1 FTE Nurse for every 50 clients,
including at least 1 FTE RN
MH Professionals
PEER/Paraprofessionals
Program Assistant (Support)

*68 Recipient Team 8.68 Total Staff (minimum)