Table of Contents
Chapter 17 - Residential Licensing
- 17.01 Initial Licensing Process Effective 10/1/23
- 17.02 Initial Licensing Review Effective 10/1/23
- 17.03 Verification of Qualified Residential Treatment Program (QRTP) Designation Effective 10/1/23
- 17.04 Rate Setting Effective 7/1/22
- 17.05 Residential Licensing Waiver and Variance Effective 10/1/23
- 17.06 Residential Licensing Denials Effective 11/1/23
- 17.07 Residential License Revocation Effective 1/1/23
- 17.08 Referral Holds Effective 7/1/22
- 17.09 Termination of Residential Contract Effective 12/01/23
- 17.10 Root Cause Analysis Effective 11/1/23
- 17.11 Annual Review for Licensed and/or Contracted Agencies Effective 7/1/22
- 17.12 Relicensure Application Process Effective 7/1/22
- 17.13 Review for Licensing Action Effective 7/1/22
- 17.14 Institutional Reports Effective 7/1/22
- 17.15 Visits to DCS-Licensed Residential Facilities Effective 2/1/23
Tools:
- Annual Review Tool - Available from the Residential Licensing Unit (RLU)
- Comprehensive Review Tool - Available from the RLU
- Contracted Agency Review Tool - Available from the RLU
- ESC Only Review Tool - Available from the RLU
- Non-Contracted Agency Review Tool - Available from the RLU
- Indiana Practice Model
- Indiana Transparency Portal
- State Department of Health: Health Care Engineering Program
- State Department of Health: DCS Residential Facility Compliance
- Vendor Profile Attachments Provider Quick Start Guide
Forms:
- Application for License to Operate a Children's Group Home (GH), Child Caring Institution (CCI), or a Private Secure Facility (PSF) Indiana Code (IC) 31-27-3 or 31-27-5 (SF45158)
- Application for Private Secure Facility, Child Caring Institution, or Group Home Waiver/Variance (SF57073)
- Automated Direct Deposit Authorization Agreement (SF47551)
- Background Check Review Summary - Available from the RLU
- Checklist for Initial Licensure - Available from the RLU
- Contract Request Form - Available from the Contract Specialist Supervisor
- Cost Report - Available from the RLU
- Health Care Program - Child Caring Institutions, Private Secure Facilities, Group Homes, and Emergency Shelters (S45879)
- Indiana Administrative Code (IAC) Checklist for Residential Licensing - Available from the RLU
- Information Systems Access and Use Agreement KidTraks User Agreement (SF56798)
- Notice of Annual Contracted Residential Review - Available from the RLU
- Notice of Background Check Review - Available from the RLU
- Notice of Comprehensive Contracted Residential Review - Available from the RLU
- Notice of Non-Contracted Residential Review - Available from the RLU
- Notice of Termination of Contract - Provided by the RLU
- Notice of Waiver/Variance Application - Approval: Provided by the RLU
- Notice of Waiver/Variance Application - Denial: Provided by the RLU
- Nutrition Program - Child Caring Institutions, Private Secure Facilities, Group Homes, and Emergency Shelters (SF46683)
- Personnel Checklist - Available from the RLU
- Plan of Correction (POC) Request - Available from the RLU
- Preliminary Report of Alleged Institutional Child Abuse or Neglect (310A) (SF49459)
- Qualified Residential Treatment Program (QRTP) Attestation Worksheet - Provided by the RLU
- Qualified Residential Treatment Program (QRT) Designation Attestation (SF53038)
- Rate Letter - Available in the case management system
- Relicensure Application Review Checklist - Available from the RLU
- Request for Administrative Hearing - Residential License Denial or Revocation (SF57115)
- Residential Licensing - Child Caring Institution (CCI) Staffing (SF57092)
- Residential Licensing: Exit Report and Narrative - Available from the RLU
- Residential Licensing - Group Home (GH) Staffing (SF57091)
- Residential Licensing - Private Secure Facility (PSF) Staffing (SF57090)
- Residential Licensing Inquiry (SF57093)
- Residential Treatment Services Provider (RTSP) and Child Placing Agency (CPA) Rates Administrative Review Request (SF55061)
- Site Visit Form - Available from the RLU
- W-9 and Direct Deposit Form Instructions
- W-9 and Direct Deposit Form Q & A
- W-9 Request for Taxpayer Identification Number and Certification