Each site functioning as a CSP, within an organization, must be certified individually. Certification is achieved by the CSP demonstrating compliance with Rule 132 standards.
If 50% or more of the funding source for community mental health treatment, for a CSP site, is from the Illinois Department of Human Services (DHS)-Division of Mental Health (DMH) or if the funding source from both DHS-DMH and the Illinois Department of Children and Family Services (DCFS) are considered equal, DHS serves as the designated Certifying State Agency (CSA). If more than 50% of the funding source for community mental health treatment, for a CSP site, is from DCFS, DCFS serves as the designated CSA. Questions regarding who serves as the designated CSA may be forwarded to DHS-DMH Provider Access, Credentialing, and Enrollment Unit (PACE) at DHS.DMHProviderAssist@illinois.gov or DCFS-IPI at DCFS.Medicaid@illinois.gov.
The organization should work with their designated CSA, DHS or DCFS, to become certified as a CSP. DHS-DMH-PACE and the DHS-Bureau of Accreditation, Licensure and Certification (BALC) shall assist with completion of the requirements if DHS is the designated CSA. The Infant Parent Institute (IPI) shall assist with completion of the requirements if DCFS is the designated CSA.
The following are the certification steps for a new CSP servicing location. Each CSP site, operating under a single Employer Identification Number (EIN)/Tax Identification Number (TIN), must carry out these steps as each CSP site is certified individually.
1. W-9 Certified for the Organization by the Illinois State Comptroller (if not already done)
A W-9 must be certified by the Illinois State Comptroller for the CSP's organizational EIN/TIN. If an organization is in need of having a W-9 certified, the organization should electronically forward a completed W-9 to the designated CSA, DHS-DMH-PACE at DHS.DMHProviderAssist@illinois.gov or DCFS-IPI at DCFS.Medicaid@illinois.gov. The organization shall receive notification once the W-9 is certified.
2. Complete Rule 132 Application
Complete a Rule 132 Application for Certification which may be obtained on the DHS Rule 132 website or by contacting the designated CSA, DHS-DMH-PACE at DHS.DMHProviderAssist@illinois.gov or DCFS-IPI at DCFS.Medicaid@illinois.gov. A Rule 132 Application for Certification shall be issued within ten (10) business days of receipt of an organization's email request.
The designated CSA must be contacted at the email address above to obtain a Fire Inspection Request Form to complete if a State Fire Marshal inspection for the site has not been completed and passed within the last two (2) years. The Fire Inspection Request Form must be submitted with the completed Application for Certification.
If questions regarding the completion of any of the required forms, contact the designated CSA at the email address above.
3. Submit Completed Documents
Submit the completed documents to the designated CSA, DHS-DMH-PACE at DHS.DMHProviderAssist@illinois.gov or DCFS-IPI at DCFS.Medicaid@illinois.gov. The documents forwarded should include the:
- Completed Rule 132 Application for Certification (an application is required for each site)
- Finalized policies and procedures for the site that are in line with Rule 132 guidelines for a CSP (only those policies and procedures related to the areas outlined within the application should be submitted)
- Fire Inspection Request Form (if a State Fire Marshal inspection for the site has been completed and passed within the last two (2) years, the organization should instead submit the Office of the State Fire Marshal report)
- W-9
Submit all documents at one time rather than in intervals. If multiple emails are required for document submission due to the amount of information being forwarded, the emails should be numbered (example 1 of 3, 2 of 3, 3 of 3).
4. Rule 132 Documents Reviewed
A review of the submitted documents shall be conducted by the designated CSA, DHS-DMH-PACE or DCFS-IPI, to validate compliance with Rule 132 standards. This review shall be completed within thirty (30) calendar days of receipt of the documents.
* If the policies and procedures submitted are in line with Rule 132 standards, and all other documents submitted are complete, the certification process shall continue.
When DHS serves as the designated CSA, DHS-DMH-PACE shall forward the documents to DHS-BALC after review and approval.
- If the policies and procedures submitted do not meet the standards established in Rule 132 and/or any of the documents submitted are incomplete, a Notice of Deficiency shall be emailed to the organization's contact person, as listed in the application, within the thirty (30) calendar day time frame. The designated CSA shall offer assistance in correcting the deficiencies identified with this involving ongoing communication, if needed, between the designated CSA and the organization. The organization shall be provided thirty (30) calendar days from the date of the notice to remedy all deficiencies and submit amended/corrected documents.
- If the amended/corrected documents are found to address all the identified deficiencies, the certification process shall continue.
When DHS serves as the designated CSA, DHS-DMH-PACE shall forward the documents to DHS-BALC after review and approval.
o If the organization fails to supply the necessary amended/corrected documents or the supplied amended/corrected documents again fail to meet the Rule 132 standards, the organization shall be notified of their failure to obtain certification as a CSP and the right to appeal pursuant to Rule 132 Section 132.110 Appeal of Certification Determination.
5. Fire Clearance Scheduled
The designated CSA, DHS-BALC or DCFS-IPI, shall request the scheduling of a fire clearance inspection with the Office of the State Fire Marshal if the site has not been inspected within the last two (2) years and the inspection passed.
The designated CSA has no influence over the scheduling of State Fire Marshal inspections.
The designated CSA is not able to answer questions related to fire clearance requirements. If questions regarding fire clearance requirements, contact the Office of the State Fire Marshal at SFMtechservices@illinois.gov.
6. Site visit scheduled.
Site visit will be scheduled by the designated CSA. When DHS serves as the designated CSA, DMH will coordinate the scheduling of the onsite visit. When DCFS serves as the designated CSA, IPI will coordinate the scheduling of the onsite visit. Provider shall ensure the physical environment is conducive to the provision of behavioral health services by being safe, functional, sanitary, and comfortable prior to scheduling the site visit.
7. Provisional Certificate Issued
A Provisional Certificate shall be issued by the designated CSA, DHS-BALC or DCFS-IPI, for the CSP site following the:
- approval of the site's Rule 132 Application for Certification and associated documents
- receipt of documentation evidencing the site's compliance with the Office of the State Fire Marshal's fire clearance requirements
- completion of DMH/IPI site visit and confirmation of meeting requirements
The Provisional Certificate shall allow for the operation of the CSP site effective with the date indicated on the certificate and shall be in effect for twelve (12) months, unless modified by the CSA. The designated CSA shall forward the Provisional Certificate to the organization via email.
If DHS is the designated CSA, DHS-BALC shall also forward a copy of the Provisional Certificate to DHS-DMH-PACE.
8. Bureau of Community Programs Notified (applies when DHS is the designated CSA)
When DHS is the designated CSA, DHS-DMH-PACE shall notify the respective Program Manager of the new provisionally certified CSP site by forwarding a copy of the Provisional Certificate. Program Manager, upon receipt of the Provisional Certificate, shall reach out to the new CSP site to ensure that the site is becoming operational within the twelve (12) month provisional time frame.
9. Site Inspection by the CSA (DHS-BALC or DCFS-IPI)
The designated CSA, DHS-BALC or DCFS-IPI, shall conduct a site inspection within the twelve (12) month provisional certification period and when the site is operational, unless modified by the CSA. The site inspection is conducted to confirm the findings of the provisional certification determination.
- If found to be in compliance, the designated CSA shall notify the CSP within thirty (30) calendar days after the site review and a Full Certificate issued.
- If found to not be in compliance, the designated CSA shall issue the CSP a Notice of Violation within fifteen (15) calendar days after the site review. The organization shall respond to the notice by the due date indicated, by submitting a Plan of Correction, or be subject to loss of certification. The due date for the CSP responding shall be approximately thirty (30) calendar days from the date of the notice.
- If the Plan of Correction submitted is found to satisfactorily address all identified violations, the designated CSA shall notify the CSP within thirty (30) calendar days of the change in certification status from provisional to full certification and a Full Certificate issued.
- If no Plan of Correction is received or if the Plan of Correction submitted is found to not satisfactorily address all the identified violations, the designated CSA shall notify the organization within thirty (30) calendar days of its failure to retain certification and the right to appeal pursuant to Rule 132 Section 132.110 Appeal of Certification Determination. If the designated CSA is DHS, DHS-BALC shall also notify DHS-DMH-PACE of the failure to retain certification who shall in turn notify respective Program Manager. In addition, DHS-DMH-PACE or DCFS-IPI shall notify the Illinois Mental Health Collaborative of any CSP site failing to retain certification.
If questions regarding the site inspection contact the designated CSA, DHS-BALC at DHS.Rule132BALC@illinois.gov or DCFS-IPI at DCFS.Medicaid@illinois.gov.
A site failing to fully operationalize within the twelve (12) month provisional time frame shall result in a meeting being convened by designated CSA Staff. If DHS is the designated CSA, this shall include the DHS-DMH-PACE, DHS-BALC and respective Program Manager. The reason(s) for the site's failure to become operational shall be outlined at the meeting. Based upon the information presented, a final determination shall be made by the designated CSA if the CSP site will or will not be granted an extension to their Provisional Certificate expiration date.
- If a decision is made to extend the Provisional Certificate expiration date, a Continuation letter shall be issued by the designated CSA, DHS-BALC or DCFS-IPI, to the CSP. If DHS is the designated CSA, DHS-BALC shall also forward a copy of the Continuation letter to DHS-DMH-PACE.
- If DHS is the designated CSA, DHS-DMH-PACE shall forward a copy of the Continuation letter to the respective Program Manager.
- If a decision is made by the designated CSA to not extend the Provisional Certificate expiration date, DHS-DMH-PACE or DCFS-IPI shall notify the Illinois Mental Health Collaborative.
10. Full Certificate Issued
If found to be in compliance with Rule 132 standards at the site visit as outlined in Step 9, a Full Certificate shall be issued by the designated CSA, DHS-BALC or DCFS-IPI, which shall remain in effect for three (3) years, unless modified by the CSA. The designated CSA shall forward the Full Certificate to the organization email.
If DHS is the designated CSA, DHS-BALC shall also forward a copy of the Full Certificate to DHS-DMH-PACE.
11. Bureau of Community Programs Notified (applies when DHS is the designated CSA)
When DHS is the designated CSA, DHS-DMH-PACE shall forward a copy of the Full Certificate to the respective Program Manager.
Other:
An organization that wants to withdraw from the certification process at any time should notify the designated CSA, DHS-DMH-PACE at DHS.DMHProviderAssist@illinois.gov or DCFS-IPI at DCFS.Medicaid@illinois.gov.
