DHS ARMHS Application Checklist

APPLICATION SUBMISSION INSTRUCTIONS

Use the following checklist to ensure that you have all of the necessary attachments for your adult rehabilitative mental health services (ARMHS) application.

Each attachment is clearly labeledin the upper right corner (example B1a, B1b, B1c).

Attachments are labeled according to content (example: Attachments A1-A8, B1-C2)

Submit attachments in the following order:

  1. Signed Application (DHS-7181)
  2. Signed Certification Requirements (DHS-7181A)
  3. Application Attachments (A-1 to D-6)
  4. Signed Branch Office Application – if applicable (DHS-7181C)

**Ensure you are using the most current version of the application by checking the links above.

AGENCY INFORMATION

Agency Name:

Date Received:Date Reviewed:

Is the applicationattached: Yes – DHS-7181 is attached No

Current application? Yes NoRevision Date: 06/27/2017

Digital application format? Yes No

Is the application missing any required information? Yes No

If yes, what?

Are branch office locations identified on the application?

Yes – DHS-7181C is attached No

Is the certification requirements attached: Yes – DHS-7181A is attached No

Current Cert Requirements? Yes NoRevision Date: 03/15/2016

Provider Type: 1. County or tribe; or private provider – CARF (Commission on Accreditation of Rehabilitation Facilities) Accredited Behavioral Healthcare or Certified Community Mental Health Center

2. Private provider – nonprofit or for profit

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Provider Type
(see above) / Attachment
Item# / ARMHS Requirements /

Yes

/

No

Section A: Can the organization suppor the implementation of ARMHS?
1, 2 / A – 1 / Organizational Chart & Summary
2 / A – 2 / Minnesota Secretary of State Certificate of Incorporation
1, 2 / A – 3 / Hours of operation for ARMHS
1, 2 / A – 4– if applicable / Legal, signed copy of Subcontractors Agreement(s)
1, 2 / A – 5 / ARMHS Quality Assurance Plan
1, 2 / A – 6 / Internal Policies and Procedures
1, 2 / A – 7 / Grievances/Complaints Procedure
Section B: Does the organization fit into or add to the local mental health system?
1, 2 / B – 1 / Experience in providing adult mental health services
1, 2 / B – 2 / Description of ARMHS
1, 2 / B – 3 / Collaboration Planning
1, 2 / B – 4 / Enhancement to local mental health system
1, 2 / B – 5 / Culturally specific services
Section C: Does organization ensure the State they can provide the ARMHS the person needs?
1, 2 / C – 1 / Clinical Supervision Plan
1, 2 / C – 2 / Difference between Practitioner and Rehabilitation Worker
1, 2 / C – 3 / Difference between Certified Peer Special I and II
Section D: Link between medical necessity of ARMHS and recovery–oriented needs of person
1, 2 / D – 1 / Completed Mock Recipient File
  1. A diagnostic assessment (DA)
  2. A functional assessment (FA)
  3. A level of care utilization system (LOCUS)
  4. An interpretive summary
  5. An individual treatment plan (ITP) which includes:
  6. Two rehabilitative goals, and no more than three objectives per goal.
  7. At least one intervention for each objective
  8. Progress Note(s) that includes all goals and objectives identified in the ITP

Training – Check Pathlore
1, 2 / MH131A / Admin Staff, ARMHS Info Session <Enter person’s name/date>
1, 2 / MH131C / Clinical Staff 1, ARMHS Info Session <Enter person’s name/date>
1, 2 / MH621-628, 630, 631 / Clinical, Online Trainings
1, 2 / MH131C / Clinical Staff 2, ARMHS Info Session <Enter person’s name/date>
1, 2 / MH621-628, 630, 631 / Clinical, Online Trainings
Provider Type
(see above) / Attachment
Item # / ARMHS Requirements /

Yes

/

No

Branch Office Requirements Checklist and Training
1, 2 / Office 1 – if applicable / Attachments 1 – orgizational chart
Attachment 2 - clinical supervision plan
1, 2 / MH131C / Clinical Staff 1, ARMHS Info Session <Enter person’s name/date>
1, 2 / MH621-628, 630, 631 / Clinical, Online Trainings
1, 2 / MH131C / Clinical Staff 2, ARMHS Info Session <Enter person’s name/date>
1, 2 / MH621-628, 630, 631 / Clinical, Online Trainings

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