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Forms

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Updates from the Office of Developmental Programs (ODP) for Intermediate Care Facility (ICF) providers:

Please find the Instructions for the ID-46 Cost Report forms, which were emailed previously. Also available is a checklist for completion prior to submission.  A few items to note:

INSTRUCTIONS

  • PDF file contains a Table of Contents on page 2.
  • Document is organized into these major categories:
    • General Instructions/Regulations — Pages 3–4
    • Timing/Requirements for Submission — Pages 4–5
    • Overall Instructions for ID-46 Excel File — Pages 5–7
    • Detailed Instructions for Each Schedule — Pages 8–46
    • Submission Procedures — Pages 47–48
    • Post Submission Procedures — Pages 49–50
    • Appendices — Pages 51–73
  • Within Adobe Acrobat, if you click on the Bookmark symbol in the left margin, all headings throughout the document will appear in a list that is ‘clickable’ so you can jump directly to points of interest and minimize scrolling. An alternate method to display Bookmarks: View > Show/Hide > Navigation Panes > Bookmarks.

CHECKLIST

  • May be completed by clicking on Blue fields within Adobe Acrobat.
  • Items required to be submitted with cost report, along with requested syntax for file names, are listed on pages 4 & 5.

All cost reports and supporting documentation must be submitted via email for FY 2021/22 by 9/30/2022 with:
Subject line: ‘Cost Report Submission – provider name’
To: ODP

If you encounter any problems or have any questions, please contact Pamela Gilbert or Steve Evitts.

Pamela S. Gilbert | Fiscal Manager
PA Department of Human Services | Office of Developmental Programs
Bureau of Financial Management and Program Support

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Photo by Markus Winkler on Unsplash

Message from the Bureau of Human Services Licensing (BHSL) regarding the renewals of assisted living residences (ALR) and personal care homes (PCHs) license renewals:

Due to staffing issues, BHSL Licensing Administration is currently experiencing a delay in processing renewals 130 days in advance of expiration. In most cases, Licensing Administration is issuing the license in the month that it expires.

If your license has expired and you have not yet received your renewal, please contact Licensing Administration at 717-705-0383 or via email directly so that your renewal can be expedited. Any Certificates of Compliance that have or will be expired on or before August 31, 2022, have been emailed to the email addresses we have on file. We are currently working on the September expiration dates. To expedite the process, you will be receiving your Certificate of Compliance electronically. It is being sent to the email address(es) as noted on your renewal application. If changes to your email address(es) are needed at any time throughout the year, please send a notification email here and to your regional office.

The Certificate of Compliance may also be printed from the Provider Directory, which is updated when the Certificate of Compliance is issued via email. It can be found by searching the name of your home here. Select the Certificate hyperlink in the License Status & License # column of your directory listing.

Please be reminded that if you have not received your approval letter from BEO, you will need to submit a Civil Rights Attestation electronically. You can find the form here. The Attestation may be submitted via email ONLY if you had previously submitted the CRCQ without receiving a letter of approval from the BEO. It should be emailed here. Any email correspondence sent to Licensing Administration should have this format in the subject line: LICENSE #, NAME OF HOME, DESCRIPTION OF CONTENTS, i.e.: 123450 – ABC Personal Care Home – Attestation.

When submitting the Civil Rights Compliance Attestation with the renewal application and renewal application fee, they must submitted in one mailing via physical mail to:

Via USPS:

DHS/BHSL
Room 623
PO Box 2675
Harrisburg, PA 17105-2675                               

Or via courier:

DHS/BHSL
Health & Welfare Building Rm 623
625 Forster Street
Harrisburg, PA 17120  

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The Pennsylvania Department of Human Services (DHS) has released a new Civil Righters Compliance (CRC) process for all facilities licensed by DHS. This process is effective Monday, August 22, 2022.

There are two changes to the Civil Rights Compliance process. First, there is a new Civil Rights Compliance form when submitting a new licensing application. There is also a new Civil Rights Compliance Attestation form when submitting a licensing renewal application. Second, the process of submitting the form has changed.

If your license is issued by…  Submit your application AND your
CRC form (if new license)
or CRC Attestation (if license renewal) to:
The Bureau of Adult Residential Licensing RA-PWLICADBHSLPRO@pa.gov
The Office of Children, Youth, and Families RA-PWLICADOCYFPRO@pa.gov
The Office of Mental Health and Substance Abuse Services RA-PWLICADOMHSASPRO@pa.gov
The Office of Developmental Programs* RA-odplicensing@pa.gov
The Office of Child Development and Early Learning*

 

*Licensees who use CLS or PELICAN to submit renewal applications must submit the attestations by email. The attestations are not part of the electronic CLS/PELICAN renewal application process.

 Child care providers should include their MPI number in the subject line and email the appropriate regional office:

Northeast Region

Central Region
Counties:  Dauphin, Cumberland, Lancaster, York, Adams, Lebanon and York

Counties:  Snyder, Perry, Juniata, Centre, Mifflin, Tioga, Lycoming, Northumberland, Union and Clinton

South Region
The Office of Child Development and Early Learning*

 

*Licensees who use CLS or PELICAN to submit renewal applications must submit the attestations by email. The attestations are not part of the electronic CLS/PELICAN renewal application process.

 Western Region
Counties:  Allegheny, Armstrong, Beaver, Butler, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Venango, Warren, Washington and WestmorelandCounties:  Bedford, Blair, Cambria, Franklin, Fulton, Huntingdon and Somerset

Entities seeking a new license will utilize a Civil Rights Compliance (CRC) form (HS 2126). This form must be included in the packet submitted as part of any new license request. The new application, supporting documents, and CRC form must be emailed to the DHS office that issues your license; the email address can be found in the chart above. Entities licensed by OCDEL or ODP who use CLS or PELICAN to submit new applications must submit the form by email. The CRC forms are not part of the electronic CLS/PELICAN new application process. The CRC form for new applications can be found at here.

For licensing renewals, a licensee will now submit a CRC Attestation form (HS 2125). The Attestation form must be submitted as part of a renewal licensing application. The renewal notice will still be sent out 130 days prior to expiration. The renewal application and attestation must be emailed to the DHS office that issues your license; the email address can be found in the chart above. Entities licensed by OCDEL or ODP who use CLS or PELICAN to submit renewal applications must submit the attestations by email. The attestations are not part of the electronic CLS/PELICAN renewal application process. The CRC form for new applications can be found at here.

The DHS Bureau of Equal Opportunity currently issues you a letter verifying that a facility is in compliance with applicable civil rights laws. With the new process, a letter from BEO will no longer be sent out to licensed entities. Instead, the issuance of the new license or renewal license will indicate that your CRC form or Attestation form submission was approved. If there are issues and/or questions on the submitted CRC or Attestation form, a staff member from DHS will contact you.  

The new process is effective on Monday, August 22, 2022. Existing licensees and applicants must begin following the new process on or before that date. 

If you have any questions about the new process, please contact the applicable DHS office using the emails shown above or your respective RCPA Policy Director.

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