Missouri Department of Social Services

Children's Division

Residential Program Unit

THE FOLLOWING DOCUMENTS MUST ACCOMPANY YOUR APPLICATION FOR LICENSURE:

1.	Evidence of compliance with local building and zoning requirements;

2.	A floor plan of the proposed site in which the specific use of each room is identified;

3.	A signed copy of the civil rights agreement (See Form RPU-32);

4.	A chart depicting the agency's organizational structure and lines of supervision;

5.	Written policies and procedures established by the board of directors which clearly set forth the authority and the responsibilities delegated to the executive director;

6.	A copy of the articles of incorporation;

7.	A copy of the bylaws;

8.	A copy of the board roster including the addresses of all officers;

9.	A proposed budget for a period of not less than one (1) year;

10.	Verification of not less than three (3) month's operating capital;

11.	A written intake policy;

12.	Written identification of specific program models or designs which shall include the methods of care and treatment to be provided;

13.	Job title, job description and minimum qualifications for all staff;

14.	A projected staffing plan for the anticipated capacity;

15.	Written child abuse and neglect reporting policy;

16.	Written personnel practices, including staff training and orientation;

17.	Annual written plan for staff training;

18.	Written discipline policy;

19.	Written visitation policy;

20.	Written health care policy;

21.	Written restraint policy which shall include identification of all methods to be used and documentation of training utilizing a recognized restraint training program;

22.	A needs assessment conducted and submitted as evidence of need for the type and scope of program proposed. This assessment shall include, at a minimum, an identification and survey of potential referral sources, existing resources and unmet community needs;

23.	Evidence of compliance with fire safety requirements of the State Fire Marshall;

24.	Documentation that the agency's water supply and sewage disposal system is currently in compliance with the requirements of the Department of Health if not an approved public source;

25.	Verification of a physical examination for all staff working directly with children completed by a licensed physician, certified nurse practitioner, advanced practice nurse in a collaborative agreement with a licensed physician or a registered nurse who is under the supervision of a licensed physician, shall be submitted within thirty (30) days of initial licensure using the form prescribed by the division. (Attached is Form RPU-10, Personnel Report-Residential Treatment Agency to report this information);

26.	Verification of a check of the Family Care Safety Registry (FCSR) for all staff and volunteers working directly with children (See attached RPU-10 to report this information);

27.	Verification of the education and experience for all administrative and professional staff. Submit a copy of the resume for all administrative and professional staff;

28.	Written description of the recreational program, and the manner in which staff are qualified and prepared to create, organize and supervise them;

29.	A copy of the Personnel Manual for the Agency;

30.	A copy of the Program Manual for the Agency;

31.	For any agency operating a swimming pool on grounds, documentation that the pool is operated and maintained in accordance with all applicable local ordinances and/or state guidelines;

32.	Documentation that each facility’s food service is currently in compliance with the requirements of the Department of Health or any local applicable ordinance;

33.	Written volunteer policies;

34.	Written policy for the use of visiting resources;

35.	Written confidentiality policy;

36.	Written policy for the use of locked isolation;

37.	Written instructions for fire and other emergency evacuations;

38.	Written description of the agency's religious requirements and practices; and

39.	Written policies governing the use of psychotropic medication.

SPECIFIC TO MATERNITY CARE:

1.	Written description of the program;

2.	Written financial policies and expectations;

3.	Written plan for all deliveries.

Please contact Residential Program Unit, (573) 751-4954, if you have any questions regarding the above information.

Return the completed form and attached information to:

Residential Program Unit

Children's Division

P. O. Box 88

Jefferson City, Missouri 65103

(REV. 06-14)