Alternative Paperwork for Sites Currently Holding AADE Recognition: Initial Or 4-Year Renewal

Alternative Paperwork for Sites Currently Holding AADE Recognition: Initial or 4-Year Renewal Application

Programs holding current AADE recognition, for delivery of DSME, do not need to complete the full DERP application packet(s). Rather, the AADE recognized DSME program must submit the following to SD-DERP, which will satisfy the reporting requirements for SD-DERP recognition. *If your program has Community/Expansion sites or Branch Locations, please be sure to also complete sections at the end of this document.

Step 1 Submit the documentation indicated on the following pages to:

Send application to:

South Dakota Diabetes Education Recognition Program (SD-DERP)

South Dakota Department of Health

Attn: Melissa Coull

1310 Main Ave South, Suite 105

Brookings, SD 57006

Step 2 The application will be reviewed within 6 weeks of receipt

a) Following the Initial/4-year Renewal Application packet review, SD-DERP will either:

a. Grant recognition and schedule a site visit to take place within 90 days from date of initial/renewed recognition

b. Request that the applying program respond to recommendations

c. Request that the applying program re-apply for recognition

b) If the application is incomplete, it will be returned with a request for additional information.

Step 3 A site visit will be conducted within 90 days of the initial/renewed program recognition date to include:

a) Discussion with DSME staff regarding the format of the program, organizational support, resources, referral systems, program availability, and follow-up system.

b) Provide an opportunity for DSME staff to communicate any concerns, needs, etc. to SD-DERP staff.

c) The initial/renewal site visit must take place within 90 days from data of initial/renewed recognition or program recognition may be discontinued.

d) Additional site visits will be conducted, as needed, upon a mutually agreed upon date. Follow up sites visits must take place within 90 days of previous site visit or recognition may be discontinued.

· Recognition is granted for a period of 4 years, upon satisfactory completion of the review process.

· Programs must meet annual reporting criteria and comply with annual site visits to maintain recognition.

· Programs requested to respond to recommendations will be granted a period of 60 days to respond.

· Programs failing to respond to recommendations, within 60 days, will be asked to reapply.

· Programs requested to re-apply may do so at any time.

Alternative Initial/4-Year Renewal Application packet

Program Information:

Date of Report:
Initial Date of Accreditation:
Name of Program:
Sponsoring Agency:
Number of Sites:
Program Coordinator:
Program Coordinator email:
Mailing Address: / Street: Click here to enter text.
City, State, Zip: Click here to enter text.
Program Legal Billing Address:
Program Physical Location Address:
Program NPI Number:
Phone:
Fax:
Application Type: / ☐ Initial application ☐ 4-Year Renewal

*Does the DSME program also have community/expansion sites or branch locations?

☐ Yes

☐ No

If yes, complete the corresponding form at the end of this document.

Staff Information:

Position within DSME Program / Staff Name / Staff Credentials
(RN, RD, R. Ph., PharmD, CDE, BC-ADM)
*List paraprofessionals as well / Date of Hire

Instructions for completing application:

1. Please provide the documentation, indicated on the following pages, in the order presented below. Use the guide to assure all required documentation components are submitted as part of the alternative paperwork, for current AADE recognized sites, making Initial or 4-Year Renewal Application.

2. For each standard, provide the indicated documentation, in the order it is listed.

3. Print the following pages. Check mark the boxes outlined in the Documentation Checklist column to assure all required documentation is submitted.

4. After each page outlining the standard, include the documentation paperwork that speaks to that standard. For example, immediately following the page for Standard 1, include the documentation for organizational chart, program mission and goals, and letter of support. Then proceed to Standard 2, with documentation for Standard 2 immediately following the Standard 2 explanation of required documentation.

5. In addition to the documentation required for Standards 1-10, also submit the following:

Current AADE DEAP letter of approval
Current AADE DEAP Certificate of Accreditation

National Standard / Documentation Checklist for Components of Required Documentation via AADE
For applicant’s use / Documentation Present
For SD-DERP use only
Standard 1 / ☐ DSME/T Organizational Chart including representation of Advisory Group
☐ Program Mission and Goals
☐ Letter of support from your sponsoring organization / ☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
For SD-DERP use only
If standard not met, explain why:
If standard not met, recommendations to meet standard:
National Standard / Documentation Checklist for Components of Required Documentation via AADE
For applicant’s use / Documentation Present
For SD-DERP use only
Standard 2 / ☐ Documented plan for seeking outside input Advisory Group Membership / ☐ Yes
☐ No
For SD-DERP use only
If standard not met, explain why:
If standard not met, recommendations to meet standard:
National Standard / Documentation Checklist for Components of Required Documentation via AADE
For applicant’s use / Documentation Present
For SD-DERP use only
Standard 3 / ☐ Documentation identifying your population
☐ Documented allocation of resources to meet population specific needs. (E.g. room, materials, curriculum staff, support etc.…)
☐ Identification of and actions taken to overcome access related problems as well as communication about these efforts to stakeholders (document in application) / ☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
For SD-DERP use only
If standard not met, explain why:
If standard not met, recommendations to meet standard:
National Standard / Documentation Checklist for Components of Required Documentation via AADE
For applicant’s use / Documentation Present
For SD-DERP use only
Standard 4 / ☐ Program Coordinator Job Description
☐ Program Coordinator Resume reflecting diabetes education experience
☐ Documentation that the Program Coordinator received a minimum of 15 hours of CE credits per year (program management, education, chronic disease care, behavior change) OR credential maintenance (CDE or BC-ADM) / ☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
For SD-DERP use only
If standard not met, explain why:
If standard not met, recommendations to meet standard:
National Standard / Documentation Checklist for Components of Required Documentation via AADE
For applicant’s use / Documentation Present
For SD-DERP use only
Standard 5 / ☐ Job Descriptions for all other Diabetes Education staff (instructors, dietician, community health workers)
☐ Current credential for instructor(s) (including licensure and/or registration proof)
☐ Instructor’s resume is current and reflects their diabetes education experience Proof of Licensure for all other diabetes education staff
☐ Proof of Continuing Education credits related to diabetes for diabetes educators from the past 12 months
☐ There is documentation of successful completion of a standardized training program for CHWs (Training includes scope of practice relative to role in DSME)
☐ Documentation that the CHWs are supervised by, the named diabetes educator(s) in the program
☐ Policy that identifies a mechanism for ensuring participant needs are met if needs are outside of instructor’s scope of practice and expertise / ☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
☐ N/A
☐ Yes
☐ No
☐ N/A
☐ Yes
☐ No
For SD-DERP use only
If standard not met, explain why:
If standard not met, recommendations to meet standard:
National Standard / Documentation Checklist for Components of Required Documentation via AADE
For applicant’s use / Documentation Present
For SD-DERP use only
Standard 6 / ☐ One section or outline of your written curriculum demonstrating integration of AADE7 Self-Care Behaviors. If you are using a pre-published curriculum, you need only include a copy of the cover page / ☐ Yes
☐ No
For SD-DERP use only
If standard not met, explain why:
If standard not met, recommendations to meet standard:
National Standard / Documentation Checklist for Components of Required Documentation via AADE
For applicant’s use / Documentation Present
For SD-DERP use only
Standard 7 / ☐ Education Process Policy from referral to follow up
☐ De-Identified Patient Chart of a real patient that went through the DSME/T program from referral to follow up / ☐ Yes
☐ No
☐ Yes
☐ No
For SD-DERP use only
If standard not met, explain why:
If standard not met, recommendations to meet standard:
National Standard / Documentation Checklist for Components of Required Documentation via AADE
For applicant’s use / Documentation Present
For SD-DERP use only
Standard 8 / ☐ This is incorporated into the de-identified patient chart / ☐ Yes
☐ No
For SD-DERP use only
If standard not met, explain why:
If standard not met, recommendations to meet standard:
National Standard / Documentation Checklist for Components of Required Documentation via AADE
For applicant’s use / Documentation Present
For SD-DERP use only
Standard 9 / ☐ This is incorporated into the de-identified patient chart / ☐ Yes
☐ No
For SD-DERP use only
If standard not met, explain why:
If standard not met, recommendations to meet standard:
National Standard / Documentation Checklist for Components of Required Documentation via AADE
For applicant’s use / Documentation Present
For SD-DERP use only
Standard 10 / ☐ Evidence of aggregate data collected and used for analysis of both behavioral and clinical outcomes is clearly identified at time of application (Table is in the application or you may submit separately). / ☐ Yes
☐ No
For SD-DERP use only
If standard not met, explain why:
If standard not met, recommendations to meet standard:

Additional Required Documentation:

AADE Documents Required by SD-DERP / Documentation Present
For SD-DERP use only
Current AADE DEAP letter of approval / ☐ Yes
☐ No
Current AADE DEAP Certificate of Accreditation / ☐ Yes
☐ No
For SD-DERP use only
If standard not met, explain why:
If standard not met, recommendations to meet standard:

*Complete this section only if the DSME program has community/expansion or branch locations

Definitions of Program Locations under SD-DERP Recognition

Program Main Location

Is the main location for the program
Billing goes through this location
Receives a recognition certificate
The following components/staff are located at this location

o Program Coordinator

o Instructional staff

o Curriculum

o CQI

o Policies & Procedures

o Forms

o Billing

Program’s physical location must be in South Dakota

Community/Expansion Site

A location, other than the main program location, at which the same program is offered
Billing for the DSME services goes through the main location
Do not receive a separate recognition certificate
The following components must be the same as main program location:

o Program Coordinator

o Instructional staff

o Curriculum

o CQI

o Policies & Procedures

o Forms

o Billing

Must be in South Dakota

Branch Location

A location, other than the main program location, that operates semi-independently of the main location
Operates under the main location’s healthcare system
Bills separately from that of the main program location
Receives its own recognition certificate
The following components must be the same as the main program location:

o Program Coordinator

o Advisory group

o Curriculum

o Policies & Procedures

o Forms

Can have different staff delivering the program
Must be in the South Dakota

Table 1: Complete for all community/expansion and branch locations

Name of main program location
Physical address of main program location
Indicate the type of alternate site(s) / ☐ Community/Expansion site
o Physical address ______
o Date site started/will start:______
☐ Branch Location
o Physical address ______
o Branch Location NPI number: ______
o Date site started/will start:______
Staff position within DSME Program
If different than at the main location (excludes Program Coordinator) / Staff Name
If different than at the main location (Excludes {Program Coordinator) / Staff Credentials
(RN, RD, R. Ph., PharmD, CDE, BC-ADM)
*List paraprofessionals as well
If different than at the main location (Excludes Program Coordinator) / Date of Hire
If different than at the main location (excludes Program Coordinator)
☐ Community/Expansion site
o Physical address ______
o Date site started/will start:______
☐ Branch Location
o Physical address ______
o Branch Location NPI number: ______
o Date site started/will start:______
Staff position within DSME Program
If different than at the main location (excludes Program Coordinator) / Staff Name
If different than at the main location (Excludes {Program Coordinator) / Staff Credentials
(RN, RD, R. Ph., PharmD, CDE, BC-ADM)
*List paraprofessionals as well
If different than at the main location (Excludes Program Coordinator) / Date of Hire
If different than at the main location (excludes Program Coordinator)
☐ Community/Expansion site
o Physical address ______
o Date site started/will start:______
☐ Branch Location
o Physical address ______
o Branch Location NPI number: ______
o Date site started/will start:______
Staff position within DSME Program
If different than at the main location (excludes Program Coordinator) / Staff Name
If different than at the main location (Excludes {Program Coordinator) / Staff Credentials
(RN, RD, R. Ph., PharmD, CDE, BC-ADM)
*List paraprofessionals as well
If different than at the main location (Excludes Program Coordinator) / Date of Hire
If different than at the main location (excludes Program Coordinator)

Affirmation: Upon Completion of this application, please read and sign below:

· The administrator responsible for the program verifies that the information included in this application is true and accurate.
· It is the responsibility of the program coordinator to notify appropriate entities and comply with their requirements in order to receive reimbursement.
Name of Person Completing Report: ______
Title of Person Completing Report: ______

Revised December 2015

Alternative Paperwork for Sites with AADE Recognition: Initial or 4-Year Renewal Application | 1