State ACH Licensure Forms
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News and Announcements |
Criminal Record Check Program Effective July 1, 2018 Senate Substitute for Senate Substitute for House Bill 2386 (originally HB 2427) passed this legislative session and will become effective 7/1/2018. The bill made changes to the criminal record check laws for Adult Care Homes (K.S.A. 39-970), Home Health Agencies (K.S.A. 65-5117) and HCBS (K.S.A. 39-2009). Effective 07/01/2018, the New Prohibited Offense List which is now identical for Adult Care Homes, Home Health Agencies and HCBS Providers. There are some new offenses while some previously prohibited offenses have been removed. The revised list is posted on the HOC website at www.kdads.ks.gov/hoc
Please visit the Health Occupations Credentialing web page at www.kdads.ks.gov/hoc regularly for updates. As implementation goes forward updates will be posted to the webpage. KDADS looks forward to working with all provider types to assure a smooth transition. Effective 07/01/2017, the updated Home Health Agency Licensure application and information is available here. There are now two classes of HHA Licensure. Please read the information under Home Health Agencies below for more information. |
Effective March 1, 2004 - All Adult Care
Homes (including assisted living/residential health care facilities,
boarding care homes, home plus facilities and adult day care) are
now managed by Kansas Department for Aging and Disability Services
Licensure and Certification and Evaluation Commission
503 S. Kansas Ave
Topeka, KS 66603-3404
Phone: 785-296-4986
FORMS
This page makes available for direct download as Portable Document Format (.pdf) files (see note above) state licensure and related forms and instructions for health care providers regulated by the Health Facilities Program. Additionally this page provides links to Medicare certification forms and related information which may be applicable to health care providers seeking Medicare reimbursement. A general link to forms of the Centers for Medicare & Medicaid Services (formerly Health Care Financing Administration) is as follows: http://cms.hhs.gov/forms/ Links to specific provider/supplier enrollment forms and associated information can be found in the sections below. Please consult appropriate state laws and state regulations as well as federal laws and federal regulations for definitions and other requirements for the provider types discussed on this page. Questions about state licensure/Medicare certification forms for KDHE regulated providers can be directed to: Hospital and Medical Program at 785-296-0127.
Fee Payment
Submission of the Home Health Agency application state licensure form below also requires a fee. KDHE currently accepts only checks or money orders for these fees made payable to Health Facilities Program or KDHE.
Medical Care Facilities: (Hospitals & Ambulatory Surgical Centers) and Hospital Long Term Care Units: (Regulated by the Kansas Department of Health and Environment)
Application Forms:
- Medical Care Facility Licensure Instructions and Application - revised 9-2018
Ambulatory Surgery Center (ASC) Survey Forms:
- Statement of Deficiencies and Plan of Correction Instructions - Health
- Interviews for ASC's
- Surgical and Anesthesia Records
- ASC Entrance Checklist
- ASC Surveyors Worksheet
- Infection Control Surveyor Worksheet
- Appendix L, Interpretive Guidelines for Ambulatory Surgical Centers
Birthing Centers
- Kansas Laws and Regulations of Licensing Birth Centers
- Initial Kansas Birth Center License Application
- Statement of Attestation for Birth Centers
- Adverse Event Report for Birth Centers
- Renewal or Closure of the current Birth Center license
- Birth Center's Change in Ownership Application
Change Forms:
- Request to Change Use of a Required Room (for KDHE regulated long term care units of hospitals)
- “These forms are available and processed through the Kansas Department for Aging and Disability Services (KDADS), please follow this link to obtain the forms and the KDADS contact.” https://www.kdads.ks.gov/
- Request to Change Bed Capacity and/or Location (for KDHE regulated long term care units of hospitals)
- “These forms are available and processed through the Kansas Department for Aging and Disability Services (KDADS), please follow this link to obtain the forms and the KDADS contact.” https://www.kdads.ks.gov/
Reporting Form for Abuse Neglect & Exploitation:
Critical Access Hospital Survey Forms:
- Hospital Restraint/Seclusion Death Report Worksheet - Long Form
- Hospital Restraint/Seclusion Death Report Worksheet - Short Form
- Hospital/CAH Medicare Database Worksheet
- Critical Access Hospital Procedures
- CAH Entrance Conference Information Sheet
- CAH Infection Control Worksheet
- CAH Medical Record Review Worksheet
- CAH Medical Staff Credentialing Personnel Record - Page 1
- CAH Medical Staff Credentialing Personnel Record - Page 2
- CAH Patient Interview Worksheet
- CAH Voluntary Self Review (.xls)
- CAH Appendix W - Survey Protocol, Regulations and Interpretive Guidelines for Critical Access Hospitals and Swing-Beds
- Statement of Deficiencies and Plan of Correction Instructions - Health
General Hospital and Special Hospital Survey Forms:
- Guidelines for the Operation of a Freestanding Emergency Department
- Hospital Restraint/Seclusion Death Report Worksheet - Long Form
- Hospital Restraint/Seclusion Death Report Worksheet - Short Form
- Hospital-Appendix A - Survey Protocol
- Hospital/CAH Medicare Database Worksheet
- Infection Control Worksheet for Hospitals
- Requested Hospital and Medical Staff Documents and Reports
- Entrance Conference Information Sheet
- Medical Record Review Worksheet
- Medical Staff Credentialing Personnel Record - Page 1
- Medical Staff Credentialing Personnel Record - Page 2
- Patient Interview Worksheet
- Statement of Deficiencies and Plan of Correction Instructions - Health
Statement of Deficiency/Plan of Correction Forms and Instructions:
- Statement of Deficiency Instructions for State Agencies
- Instruction Pamphlet
- POC Instructions for Providers & Suppliers
- Providers POC Form
- Sample POC
Medicare Certification Forms:
- For Certification Forms and Information: Send Email Request to: Tamara.Wilkerson@ks.gov, Medicare Certification Coordinator
RISK MANAGEMENT KDHE MEDICAL CARE FACILITIES
Risk Management Reporting Forms:
- Confidential Quarterly Report Form
- 8.15.18
- Facility or Individual Report of Adverse Finding
- 2.6.19
Risk Management Education and Training:
Risk Management Newsletters
- Risk Management Quarterly - August 2015
- Risk Management Quarterly - November 2015
- Risk Management - Winter-Spring 2017
- Risk Management - Summer-Fall 2017
- Risk Management Winter-Spring 2018
Risk Management Helpful Decision Tools:
Risk Management Annual Reports:
- Risk Management KDHE Annual Report - 2003
- Risk Management KDHE Annual Report - 2004
- Risk Management KDHE Annual Report - 2005
- Risk Management KDHE Annual Report - 2006
- Risk Management KDHE Annual Report - 2007
- Risk Management KDHE Annual Report - 2008
- Risk Management KDHE Annual Report - 2009
- Risk Management KDHE Annual Report - 2010
- Risk Management KDHE Annual Report - 2015
- Risk Management KDHE Annual Report - FY 2016-2017
Risk Management Resources for Survey Preparation:
- BHF Regulations for ASC, Hospitals and Risk Management
- Risk Management Statutes and Regulations
- Risk Management ASPEN State Regulation Set: R99
- Risk Management Standard of Care Interpretive Guidelines & Determinations
- Checklist for Risk Management Plan Review
- Risk Management Sample Plan - Revised 8.15.18
- Risk Management Plan Self-Review Tool - Revised 6.1.17
- Risk Management Statement of Deficiencies and Plan of Correction Instructions - Revised 6.1.17
- Emergency Medical Treatment and Labor Act (EMTALA) Education Revised 6.1.17
- Risk Management Education Training Sample Template
HOME HEALTH AGENCIES
Kansas Statutes and Regulations for State Home Health Agency Licensure
Application for State Home Health Agency Licensure
Criminal Record Check (CRC)
- Request CRCs here: https://www.kansas.gov/kdads-criminalhistory/index.do
- New Law Memo
- Revised CRC Prohibited Offenses List with Historical Changes noted eff-07-01-2018 www.kdads.ks.gov/hoc
Reporting Form for Abuse Neglect & Exploitation
- Complaint Process
- HHA Reporting Form
- 04-16-2018
Medicare Certification for Home Health Agencies
- For Certification Forms and Information: Send Email Request to: Tamara.Wilkerson@ks.gov, Medicare Certification Coordinator
Education and Training for OASIS (Typically Certified Only)
- OASIS Training
- HHA Newsletters
- OASIS C-2
- OASIS D
- OASIS-D 2019 All Items Set
- OASIS-D Change Table New Items
- OASIS-D Data Elements Removed
- OASIS D Guidance Manual Errata 8-6-2018
- CMS OASIS Q&A's
- CMS Q&A April 2018
- Can be found at https://qtso.cms.gov/providers/home-health-agency-hha-providers/reference-manuals
- On this website, you will find the master copy of the CMS OASIS Q&As as well as the CMS Quarterly Q&As.
- The Q&As are updated periodically.
- OASIS Guidance Manual
- Expansion of the Home Health One Clinician Convention - August 2017
- Chapters of the manual are important; however, Chapter 3 is a must.
- Related Links
Informal Review Process (IDR) for Certified Home Health Agencies
- Overview of the IDR Process for HHAs
- IDR Definitions and Acronyms
- IDR Instructions and Request Form
- IDR FAQs
Miscellaneous Home Health or Home Care Resources
Other Provider Types Regulated by BHF that do not Require State Licensure:
Comprehensive Outpatient Rehabilitation Facility
End Stage Renal Disease (Dialysis) Facilities
Hospice
Outpatient Provider of Physical Therapy/Occupational Therapy/Speech Pathology Services
Portable X-ray Facility
Rural Health ClinicMedicare Certification Forms:
- For Certification Forms and Information: Send Email Request to: Tamara.Wilkerson@ks.gov, Medicare Certification Coordinator