The Maryland RSA form is an application used to obtain a Residential Services Agency license for skilled nursing and aides in Maryland. This form is essential for those looking to provide health care services in a residential setting, ensuring compliance with state regulations. To start the process, fill out the form and submit it along with the required documents.
Click the button below to begin filling out the Maryland RSA form.
The Maryland Residential Services Agency (RSA) form is an essential document for those seeking to establish a licensed agency that provides skilled nursing and aide services. This application packet serves as the starting point for the licensure process, which includes a detailed on-site survey of the agency. Applicants must submit a non-refundable fee of $500 along with several key components: an organizational chart that outlines staff positions, policies and procedures in compliance with state regulations, and sample files for both personnel and patients. Additionally, the form requires a clear description of the scope of services offered, specifying the geographic area served and the accepted referral and payer sources. It is crucial for applicants to understand that the issuance of provisional licenses may experience delays of up to nine months due to budgetary constraints, impacting their ability to operate and receive Medicaid reimbursements. Once the necessary documentation is submitted and approved, the agency must admit a minimum of three to five patients within a specified timeframe to initiate the licensing process fully. Regular follow-ups and compliance checks will ensure that the agency adheres to the required standards, making the RSA form a critical step toward providing quality care in Maryland.
DEPARTMENT OF HEALTH AND MENTAL HYGIENE
Form Approved May 2018
OFFICE OF HEALTH CARE QUALITY
MDH Form AC.APP.1.1.IN.RSAO.2
INSTRUCTIONS FOR COMPLETION OF RESIDENTIAL SERVICE
AGENCY (RSA) LICENSURE APPLICATION
A Residential Service Agency (RSA) is a business that employs or contracts with individuals to provide at least one home health care service for compensation to an unrelated sick or disabled individual. This application is to receive a state license for a RSA from the Maryland Department of Health, Office of Health Care Quality (OHCQ). The RSA program is NOT a Medicare program. Current regulations for the RSA program can be found in Code of Maryland Regulations (COMAR)
10.07.05.For more information relating to RSAs visit the OHCQ Residential Service Agency Dashboard at
https://app.smartsheet.com/b/publish?EQBCT=85e22fc816cc4cc0a30f1b5a41f5146e
APPLICATION FOR INITIAL LICENSE PROCESS
To apply, first download the application onto your computer. You will be able to complete the application electronically or you can print it out and hand write the information into each appropriate section. Additional information for each required section can be found below.
REQUIRED SECTIONS
Please complete each section based on the following information:
Section 1 - General Information: Detail your agency’s information including: The legal agency name, trading name (Doing Business As (DBA)), agency’s email, phone number, fax number, agency’s business address (for the physical location), mailing address (if different from the business address), agency’s license number, agency’s FEIN (Federal Employer Identification Number), agency administrator, agency after hours emergency contact information, and agency’s business hours. Please note, for agencies with multiple locations provide the address and contact information for the agency’s main office. Branch office location information will be collected in Section 7.
Section 2 - Ownership: Include information related to your agency’s ownership: type of business organization of disclosing entity (sole proprietorship, partnership (including LLP), limited liability company (LLC), and corporation), name and address of ownership, the name, title, address and percentage of the agency owned by each owner, the agency’s president (if Corporation) or manager’s (if LLC) name, contact information, and address, and FEIN (Federal Employer Identification Number). If the ownership is a corporation, provide the date of Articles of Incorporation. If ownership is LLC provide the date of Articles of Organization.
Section 3 - Background: Respond “yes” or “no” to the background questions listed in Section 3 of the application. For Section 3 Questions 1 through 3 that you have answered “yes”, provide a detailed explanation (including: dates, type of license, agencies, violations, or offenses).
Section 4 – Worker’s Compensation: First identify if the agency has employees. If the agency has employees, provide the agency’s worker’s compensation insurance policy number, binder number, name of insurance company, policy’s effective date, and the policy’s expiration date. Additionally, attach a copy of the agency’s worker’s compensation insurance policy to the application (This can be added to the application electronically as an attachment). If your agency does not have workers’ compensation insurance AND does not have any employees, submit a Letter of Exemption (sole proprietorships or partnerships) or Certificate of Compliance (corporations or LLCs) from the Certificate of Compliance Coordinator at the Workers’ Compensation Commission. Additional information can be found under the Resource Links section of the OHCQ RSA Dashboard (see link above).
DHMH Form AC.APP.1.1.IN.RSAO.2 (9/13)
Instructions
Section 5 – RSA Services: For this section please select all of the home care services to be
provided. The home care services include: Durable Medical Equipment (DME), Durable Medical Equipment with Oxygen, Therapy Services including speech therapy, occupational therapy, and physical therapy, Medical Social Services, Nutritional Services, Intravenous therapy, Skilled Nursing and Aides Only, Ventilator Services, or Skilled Nursing. If you selected the “Skilled Nursing and Aides Only” service, please provide the level of home care services that your agency will be providing. The levels include: 1. Level One: RN supervision of Aides without medication management, 2. Level Two: RN supervision of Aides with medication management, or 3. Level Three: Complex care provided by RN, LPN, and RN supervision of Aides (e.g. Wound Care, Tube Feeding, Trach Care, Vent Management, Intravenous or Related Therapies, etc.). Next, select if the agency is “for profit” or “not-profit”. Finally, list the types of complex care that will be provided by your agency.
Section 6 – Addendum – Branch Offices: “Branch office” means a satellite office of an RSA that is operated by the same person, corporation, or other business entity that manages the parent RSA, and has the same name of the parent RSA:
1.Ownership tax identification number as the parent business entity;
2.Upper-level management;
3.Policies and procedures; and
4.Provides services within the same geographic area served by the parent business entity.
Provide your agency’s licensed name and license number. Select “yes” if your agency operates any branch offices. Select “no” if your agency does not operate any branch offices. If you answered “yes”, provide the address and phone number for each of the agency’s branch offices.
Section 7 - Affidavit: If the program is going to be in more than one applicant’s name, each applicant’s signature is required. Provide the signature of each applicant, his/her title, and the date the application was signed by that applicant. This signator agrees under the penalties of perjury that the information given in this application is true. This applicant’s signature also certifies that your agency follows the administrative and procedural requirements pertaining to the Code of Maryland Regulations (COMAR) 10.07.05. Additionally, you are accepting responsibility to notify OHCQ if there are any future substantive changes in the agency and operation, and that written notice will be given before the effective date of the change. The signators also swear and affirm that each applicant is over the age of 21, is fully competent, and understands the terms of this application.
REQUIRED DOCUMENTATION
In addition to a completed application, additional supporting documents are required to finalize your application. See below for a list of additional documents that are required for each RSA licensure type.
1.An organizational chart that includes all positions with the name of the person in that position.
2.Policies and procedures as required by COMAR 10.07.05.
3.A business plan as required by COMAR 10.07.05.
4.A sample personnel file.
5.Sample patient files for adult and pediatric patients (if applicable).
Suggested Format for Writing Policy and Procedure Statements: When developing your agency’s policies and procedures, the following elements are recommended:
1.Date of approval by governing body.
2.Title or subject of the policy. (Example: Employee Orientation)
3.Policy statement. Describe the agency’s policy on the subject. (Example: All employees shall receive orientation prior to assuming responsibilities for the position.)
4.Purpose of the policy. Describe why the subject is important. (Example: To assure staff understand and comply with all agency policies and procedures.)
5.Procedures. Define who, when, and where. (Example: Who will be responsible? What materials will be used?
How will participation in orientation be documented?)
Suggested Format for Writing Job Descriptions: When developing your agency’s job descriptions, the following elements are recommended:
2.Position title. (Example: Nursing Supervisor)
3.Position to which this job title reports. (Example: Reports to Director of Nursing)
4.Qualifications. Educational and experience requirements. (Example: Graduation from accredited school of nursing. Number of years of home health experience. Number of years of supervisory experience.)
5.Credential requirements. (Example: Current license in the State of Maryland) Job responsibilities. List the tasks that the person in this position would have to perform. (Example: Perform annual performance evaluations on all licensed nurses and home health aides. Participate in quality assurance activities.)
APPLICATION FINALIZATION
Electric Submission: To submit the completed application and all supporting documentation electronically to OHCQ, visit the OHCQ RSA Dashboard and click on the RSA Licensure Application Form (https://app.smartsheet.com/b/form/26fb6697dcc841b7ae8fde911eec9b05). Complete the form with the following information: Name of RSA, type of RSA, contact information for the agency’s contact person including: Name, Position, email address, phone number, and secondary phone number. Next, upload the following documents to the form:
1.Completed application
2.Organizational chart
3.Policies and procedures
4.Sample personnel file
5.Sample patient file for adult and pediatric patients
6.Business Plan - Scope of services
7.Worker's compensation documentation
Finally, select the “Attestation” box confirming that all the information in the application and supporting documents are correct and true. If you would like to have a copy of the form and attachments sent to your email, please select the “Send me a copy of my responses”. It is recommended that you keep a copy of your responses and documents for your own records. Once your application is submitted you will receive email updates regarding your pending application. The total processing time of the application should take 2 to 3 months after all documents are received.
Paper Submission: To submit a hard copy of the application and supporting documents please
return in person or via mail to the following address: Ambulatory Care Program, Office of Health Care Quality, Bland Bryant Building, Spring Grove Hospital Center, 55 Wade Avenue, Catonsville, MD 21228. Once submitted the application is submitted it will take 6 or more months to process.
LICENSE NOTIFICATION
All application notifications and process updates will be made by email. If no email is provided there may be an additional three-month delay in processing your application.
Once your application has been approved, a formal approval or denial letter will be mailed to your agency from OHCQ through the mail. If your agency is approved, an operating license will be sent to your agency with effective date.
ADDITIONAL INFORMATION
To add services to your RSA you must submit a new application to the OHCQ for review and approval with required updates to the policies and procedures. This process can take up to 3 to 4 months if submitted electronically, and up to 6 months if submitted on paper.
If you do not intend to continue with your license, you must return your operating license to OHCQ.
An unannounced on-site survey of your facility may be performed at any time to determine compliance with RSA requirements. Visit the OHCQ RSA Dashboard for additional information regarding survey activities and procedures.
If you are operating an unlicensed RSA program, your Medicaid provider number and reimbursement are in jeopardy of termination.
RSA HOTLINE
In accordance with State regulations, the State of Maryland has established a RSA Hotline. The purpose of the Hotline is:
To receive complaints about local RSAs; To receive questions about local RSAs; and
To lodge complaints concerning the implementation of advance directives.
The Hotline number is 800-492-6005. Voice messages can be left on the Hotline number. Written complaints may be submitted to the address at the end of the instructions or via the OHCQ RSA Dashboard at https://app.smartsheet.com/b/home?lx=WI2JkCnlI1Ng9CuRw1DP7ynUXphoZCJbZcV5Sw9 DPzI
QUESTIONS
Please visit the OHCQ RSA Dashboard
(https://app.smartsheet.com/b/home?lx=WI2JkCnlI1Ng9CuRw1DP7ynUXphoZCJbZcV5Sw9DPzI) or contact 410-402-8267 or additional information and questions related to this application.
MARYLAND DEPARTMENT OF HEALTH (MDH)
OFFICE OF HEALTH CARE QUALITY (OHCQ)
RESIDENTIAL SERVICES AGENCY (RSA) APPLICATION FOR LICENSURE
1. GENERAL INFORMATION
LEGAL AGENCY NAME
TRADING NAME (DBA)
E-MAIL ADDRESS
PHONE NUMBER
FAX NUMBER
BUSINESS ADDRESS (physical location)
MAILING ADDRESS (if different)
NUMBER, STREET
CITY
STATE
ZIP
COUNTY
LICENSE NUMBER (if applicable)
FEIN NUMBER
NAME OF ADMINISTRATOR (Last, First, Middle Initial)
AFTER HOURS/EMERGENCY CONTACT NUMBER
BUSINESS HOURS (in HH:MM format)
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
FROM:
TO:
2.OWNERSHIP (Type of business organization of disclosing entity)
SOLE PROPRIETORSHIP
PARTNERSHIP
LLC
CORPORATION
NAME
ADDRESS
NAME(S), TITLE(S), AND ADDRESS(ES) OF OWNER(S) AND PERCENTAGE OWNED IF 2% OR MORE
(Attach additional pages if needed.)
NAME AND TITLE
PERCENTAGE
OWNED
NAME OF PRESIDENT (IF CORPORATION) OR MANAGER (IF LLC)
CELL NUMBER
ADDRESS (number, street)
IF CORPORATION, DATE OF ARTICLES OF INCORPORATION:
FEIN
IF LLC, DATE OF ARTICLES OF
ORGANIZATION
DHMH Form AC.APP.1.0 (6/1
1
Last Revised: May 2018
3.BACKGROUND
1.Has any owner, officer, director, agency, or managerial staff had a license revoked, suspended, or denied by the
DHMH within the last five years? No Yes (explain)
2. Does the parent company, owner, agent, officer, or managerial staff own or operate a health carefacility/agency
licensed or surveyed by the OHCQ?
No
Yes (explain)
3. The agency hereby attests that it is in compliance with The Civil Rights Act of 1964; The Rehabilitation Act of
1973; The Americans with Disabilities Act of 1990; and The Drug Free Workplace Act of 1988. No Yes (explain)
4. Have the owners, officers, directors, agents, or managerial staff been convicted of a criminal offense involvingany
program under Title 18, 19, or 20 of the Social Security Act?
Yes
4. WORKERS’ COMPENSATION
Do you have any employees?
If you answered YES, attach a copy of your workers’ compensation insurance policy and complete the following:
POLICY NUMBER
BINDER NUMBER
INSURANCE COMPANY
EFFECTIVE DATE
EXPIRATION DATE
If you answered NO, additional documentation from the Workers’ Compensation Commission must accompany this application (refer to the instruction guide for details).
5. RSA SERVICES
HOME CARE SERVICES TO BE PROVIDED (check all that apply)
Durable Medical Equipment
Medical Social Services
Durable Medical Equipment w/ Oxygen
Occupational Therapy
Intravenous or Related Therapies
Physical Therapy
Skilled Nursing and Aides Only*
Skilled Nursing
Speech Therapy
Ventilator Services
*If you have selected Skilled Nursing & Aides Only please indicate what level of home care services will be provided (check only one level) HOME CARE SERVICES TO BE PROVIDED (check only one level of care)
Level One: RN supervision of Aides without medication management
Level Two: RN supervision of Aides with medication management
Level Three: Complex care provided by RN, LPN and RN supervision of Aides (e.g. Wound Care, Tube Feeding, Trach Care, Vent Management, Intravenous or Related Therapies, etc.)
CATEGORY
Non-Profit
For Profit
LIST THE TYPE(S) OF COMPLEX CARE TO BE PROVIDED BY YOUR AGENCY:
2
6. ADDENDUM - BRANCH OFFICES
LICENSED NAME
LICENSE NUMBER
DOES THE AGENCY OPERATE ANY BRANCH OFFICES?
Yes (list all below)
STREET ADDRESS
MD
7. AFFIDAVIT
I solemnly affirm under the penalties of perjury and upon personal knowledge that the contents of the foregoing application are true. I understand that the falsification of an application for a license may subject me to criminal prosecution, civil money penalties, and/or the revocation of any license issued to me by the DHMH. In addition, knowingly and willfully failing to fully and accurately disclose the requested information may result in denial of a request to become licensed or, where the entity already is licensed, a revocation of that license.
I certify that this agency is in compliance with administrative and procedural requirements pertaining to the Code of Maryland Regulations (COMAR) 10.07.05.
I further certify that I will notify the OHCQ if there are any future substantive changes in agency and operation, and that written notice will be given before the effective date of the change.
I hereby swear and affirm that I am over the age of 21 and I am otherwise competent to sign this Affidavit.
If the program is going to be in more than one applicant’s name, each applicant’s signature is required. required.
SIGNATURE OF APPLICANT
TITLE
DATE
FOR OFFICE USE ONLY
INITIALS
3
Completing the Maryland RSA form is a crucial step in the process of obtaining a Residential Services Agency license. This form requires specific information about your agency, including its structure, services, and personnel. Following the outlined steps will help ensure that your application is complete and submitted correctly.
Once the application is submitted, the next steps involve awaiting approval and preparing for the on-site survey. This survey will assess your agency's readiness to operate and comply with the necessary regulations.
The Maryland RSA form is an application used to obtain a Residential Services Agency (RSA) license for providing skilled nursing and aide services in Maryland. This form is part of the licensure process overseen by the Office of Health Care Quality (OHCQ).
To complete the RSA application, you must submit the following items:
Mail the completed application packet to:
Mrs. Barbara Fagan Program Manager Office of Health Care Quality 55 Wade Avenue, BB Building Catonsville, Maryland 21228
The issuance of provisional licenses can be delayed up to 9 months due to budgetary constraints. After submitting all required documents and receiving written approval, you will be issued a provisional license valid for 90 days. During this time, you must admit 3-5 patients.
If deficiencies are identified during the initial survey, you must submit a written plan of correction (POC) within 10 working days. An unannounced follow-up visit will be scheduled to ensure the POC is implemented. All corrective actions must be completed before the provisional license expires.
No, you cannot apply for Medicaid reimbursement while operating under a provisional license. A full twelve-month license is required for reimbursement eligibility.
The initial survey will review several aspects of your agency, including:
For help with starting a business, you can contact the Maryland Small Business Development Center at 1(877)787-7232. They can provide guidance on business planning and marketing. Additionally, for nurse supervision requirements, reach out to the Board of Nursing at (410) 585-1900 or 1(888)202-9861.
Failing to include the $500.00 non-refundable application fee. This fee is mandatory and must be attached to the application.
Not providing a complete organizational chart. All positions should be listed with the names of the individuals holding those positions.
Omitting required policies and procedures. These must comply with COMAR 10.07.05 regulations.
Neglecting to assemble sample personnel and patient files. This includes files for both adult and pediatric patients if applicable.
Not detailing the scope of services. The application should clearly state the services offered, geographic areas served, and accepted referral and payer sources.
Submitting incomplete or inaccurate information. All sections of the application must be filled out correctly.
Failing to meet the patient admission timeline. Patients must be admitted within 45 days after receiving the provisional license.
Ignoring the follow-up requirements after the initial survey. If deficiencies are found, a written plan of correction must be submitted within 10 working days.
When applying for a Residential Services Agency (RSA) license in Maryland, several additional forms and documents are often required to ensure compliance with state regulations. Understanding these documents is crucial for a smooth application process. Below is a list of commonly used forms and documents that accompany the Maryland RSA form.
Gathering these documents is an essential step in the application process for a Residential Services Agency license in Maryland. Ensuring that each form is complete and accurate will help facilitate a smoother review by the Office of Health Care Quality. Taking the time to prepare these documents thoughtfully can make a significant difference in the success of your application.
The Maryland RSA form shares similarities with the application for a Home Health Agency (HHA) license. Both documents require detailed information about the agency's operations, including an organizational chart and a description of services offered. Just like the RSA form, the HHA application mandates the submission of policies and procedures that comply with state regulations. Both applications also involve a licensing fee and an on-site survey to ensure compliance with health and safety standards before the license can be granted.
Another document akin to the Maryland RSA form is the Assisted Living Facility (ALF) application. Similar to the RSA, the ALF application requires a comprehensive outline of the services provided, including the types of care offered and the geographic area served. Both applications necessitate a review of personnel qualifications and the submission of a sample patient file. The licensing process for both also involves an on-site survey to verify compliance with state regulations, ensuring that the facilities meet the necessary health and safety standards.
The application for a nursing home license is another document that mirrors the Maryland RSA form. Both require a detailed description of services and an organizational structure. Additionally, both documents require a non-refundable application fee and a thorough review of policies and procedures. The nursing home licensing process also includes an on-site survey to assess compliance with state health regulations, similar to the RSA process.
In a similar vein, the application for a hospice license shares key components with the Maryland RSA form. Both applications require a clear outline of services provided and a detailed organizational chart. Furthermore, both require a review of personnel qualifications and adherence to state regulations regarding patient care. The hospice licensing process also includes an on-site survey to ensure compliance with health and safety standards, paralleling the RSA application process.
The application for a behavioral health facility license also resembles the Maryland RSA form. Both documents require comprehensive information about the services offered and the organizational structure of the agency. Additionally, both require the submission of policies and procedures that comply with state regulations. An on-site survey is also part of the licensing process for both, ensuring that the facilities meet the necessary standards for patient care and safety.
Lastly, the application for a substance use treatment facility license is similar to the Maryland RSA form in its requirements. Both applications necessitate a detailed description of services and an organizational chart. Each requires compliance with state regulations through the submission of policies and procedures. The licensing process for both includes an on-site survey to verify adherence to health and safety standards, ensuring the quality of care provided to patients.
When filling out the Maryland RSA form, it is essential to adhere to certain guidelines to ensure a smooth application process. Below is a list of things you should and shouldn't do.
This form can also be used by existing agencies that want to upgrade their licenses. The process is applicable to both new and current Residential Service Agencies.
Reimbursement from Medicaid is not available with a provisional license. A full twelve-month license is required to receive such reimbursement.
The $500 application fee is non-refundable. Agencies should be prepared for this cost before submitting their application.
The process can take time, especially due to budgetary constraints that may delay the issuance of provisional licenses by up to nine months.
Agencies must continue to prepare for the on-site survey and ensure compliance with all requirements during the waiting period.
If deficiencies are identified, agencies must submit a written plan of correction within ten working days. Failure to do so can lead to denial of the license.
Extensions for provisional licenses are not granted under any circumstances. Agencies must complete all corrective actions within the 90-day timeframe.
Developing comprehensive policies and procedures is a critical part of the application process, as required by state regulations.
OHCQ no longer sells the Code of Maryland Regulations (COMAR). Agencies must obtain these regulations through other means, such as local libraries or the Division of State Documents website.
Passing the initial survey requires thorough preparation and compliance with all outlined requirements. Agencies should be proactive in addressing potential deficiencies before the survey occurs.
Complete all required documents before submitting your application. This includes a non-refundable fee of $500, an organizational chart, policies and procedures, and sample patient and personnel files.
After submission, prepare for an on-site survey. This will occur once you have admitted 3-5 patients within 45 days of receiving your provisional license.
Be aware that provisional licenses are temporary and will not be extended. Ensure all corrective actions are completed within the 90-day timeframe.
If deficiencies are found during the initial survey, a written plan of correction must be submitted within 10 working days. Failure to address deficiencies may result in denial of your RSA license.