The organization should work with their designated Certifying State Agency (CSA) to complete the steps for relocating a CSP servicing location.
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, then DHS serves as the designated CSA. If more than 50% of the funding source for community mental health treatment, for a CSP site, is from DCFS, then 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.
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 steps that a CSP organization must take to relocate a provisionally or fully certified CSP servicing location. Services may not be provided at the relocated site, and be reimbursed, until the site has been certified in accordance with Rule 132 standards. This certification includes the relocated site having a State Fire Marshal inspection completed and passed.
1. CSP Notifies CSA of Site Relocation
Written notification of the CSP site relocation must be submitted to the designated CSA, DHS-DMH-PACE at DHS.DMHProviderAssist@illinois.gov or DCFS-IPI at DCFS.Medicaid@illinois.gov. The notification should include the:
- Employer Identification Number (EIN)/Tax Identification Number (TIN) of the CSP
- Address of the current servicing location
- Address of the new servicing location
- Primary contact name and title
- Primary contact email address and telephone number
- Attestation that the policies and procedures in effect at the relocated site shall be in compliance with Rule 132 standards for a CSP
- Whether or not a State Fire Marshal inspection has been conducted at the relocated site (a relocated site must satisfactorily pass an inspection prior to being approved for provisional certification)
- If a State Fire Marshal inspection has not been conducted at the relocated site, the Fire Inspection Request Form needs to be completed and submitted with the notification (form obtained by contacting the designated CSA, DHS-DMH-PACE at DHS.DMHProviderAssist@illinois.gov or DCFS-IPI at DCFS.Medicaid@illinois.gov)
- If a State Fire Marshal inspection has been conducted at the relocated site within the last two (2) years and passed, a copy of the inspection report must be submitted
If questions regarding the notification or completion of the Fire Inspection Request Form, contact the designated CSA at the email address above.
2. DHS-BALC Notified of Site Relocation (applies only when DHS is the designated CSA)
When DHS is the designated CSA, DHS-DMH-PACE shall review the information received from the CSP and, if complete, forward the documents to DHS-BALC.
3. 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 relocated 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.
4. 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.
5. Provisional Certificate Issued
A Provisional Certificate shall be issued by the designated CSA, DHS-BALC or DCFS-IPI, to the organization for the relocated CSP site upon receipt of documentation evidencing that the relocated site has successfully passed the Office of the State Fire Marshal fire clearance requirements and DMH/IPI site visit.
The Provisional Certificate shall allow for the operation of the relocated 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-BALC is the designated CSA, DHS-BALC shall also forward a copy of the Provisional Certificate to DHS-DMH-PACE.
6. 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 CSP site relocation by forwarding Form 1, if applicable, Form 2 and a copy of the Provisional Certificate. Program Manager, upon receipt of the Provisional Certificate, shall reach out to the relocated CSP site to ensure that the site is becoming operational within the twelve (12) month provisional time frame.
7. 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.
- 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, the designated CSA should be contacted, 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 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.
8. Full Certificate Issued
If the organization is found to be in compliance with Rule 132 standards at the site visit as outlined in Step 7, a Full Certificate shall be issued by the 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.
When DHS is the designated CSA, DHS-BALC shall also forward a copy of the Full Certificate to DHS-DMH-PACE.
9. Bureau of Community Programs Notified (applies when DHS is the designated CSA)
When DHS is the designated CSA, DHS-DMH-PACE Unit shall forward a copy of the Full Certificate to the respective Program Manager.
