Licensing Management

Program Specific Policy: CORE (Waiver and Behavioral Health)

Subject: Health and Safety

Applicable Standard(s):  N/A

Effective Date: March 1, 2013

Revision History: February 9, 2024

Issue Date: February 9, 2024

Background:

As a long-standing recipient of federal and state funding, Easterseals Louisiana (ESL) provides an array of services and programs which are overseen by governmental agencies. We are required to maintain certain licenses and/or credentialing in order for us to be able to provide these services. ESL’s OAAS/OCDD Waiver Services are licensed by the Louisiana Department of Health (LDH). Additionally, ESL’s Behavioral Health Programs and Services receive funding from a variety of sources (e.g. HUD) and are licensed regionally by LDH. 

Purpose:

To establish a standard procedure for ensuring all ESL facilities, programs, and services (across disciplines), which are required to operate under certain licensing and inspection guidelines, remain in compliance to include, but not limited to application and issuance, site distribution and display, and tracking and timely renewal.

Policy:

Easterseals Louisiana (ESL) maintains the responsibility of providing appropriate evidence of licensing and inspection compliance with all relevant standards, regulations and maintenance requirements established by federal and state regulatory bodies.

Procedure: 

1. Applicable ESL facilities, programs, and services will display and have on file current license and/or inspection certificates for review. Issued certificates may include, but are not limited to those from:

• Louisiana Department of Health

• Office of the State Fire Marshal

• Department of Labor

• Fiscal and Program Review Agencies
  
  

2. License and/or Inspection Certificate information will be reported and updated on a primary spreadsheet, as necessary; and identified by region, program license number, provider identification number, and expiration date. This spreadsheet will be housed in the shared manager’s folder, labeled “Licensing and Inspection Certificates. The Quality Team will perform the tracking and upkeep of the spreadsheet. 

3. ESL’s Quality Team will serve as primary point of contact and designee for tracking and executing the renewal process, to include receiving renewal notification alerts prior to 60-days of expiration.  Therefore, the Quality Team’s Department email will be issued to relevant parties for official communications.

4. In lieu of waiting for notice from Health Standards, beginning no later than 60 days before any program license expires, the Quality Team (QT) rep will contact the applicable Program Director to review the current license, make changes (if applicable) and obtain Fire Marshall inspection and other documents maintained on site and within the quality and compliance site. QT rep will complete the license application and submit along with the supporting documents to the Business Office. QT rep will copy the applicable Program Director and Vice President as an FYI. 

   • The Business Office will prepare/collect necessary administrative documents pertaining to payment for license renewal(s) such as the Disclosure of Ownership Form and the Health Standards Section Payment Transmittal Form and prepare the check for submission.

   • The Business Office will secure the required signature(s) of the CEO on the renewal packet, check, etc.

   • The Business Office will submit the signed application and the payment packet to the required entity/entities and copy the QT @quality@laeasterseals.com

   • The Quality Team will place the completed documents in the Document Repository at Licensing.

   • The goal is to submit the application no later than 30 days prior to expiration of license.

5. Program Directors will be instructed to send the QT a copy of the new license once received. The Quality Team License Renewal tracker will be updated and the license will be placed in the License Folder in the Quality House.  All appropriate parties will have access to retrieve their respective documents for required site visits, required posting in regional offices, or as needed. 

6. Internal and external facility inspections:

   • Internally, ESL’s Quality Team will initiate semi-annual facility inspections, facilitated by ESL’s Program Directors, which shall occur (Spring and Fall) to prevent and identify any issues including but not limited to:

     1. Heating and Cooling Systems

     2. Electrical Systems

     3. Emergency Warning Devices

     4. Walking and Working Surfaces

     5. Ingress and Egress

     6. Recreation/Visitation Areas

     7. Health and sanitation related to food preparation, eating areas and restrooms.

     8. Structural integrity of facility

     9. Storage of Hazardous Materials

     10. Fire Protection Systems Equipment

     11. Air Contaminants and Ventilation

     12. And other areas appropriate to services provided. 

• Inspections are completed electronically.  QT will create the reports and provide recommendations based on a risk and liability analysis.

• Annual Safety Inspections for applicable safety needs (e.g. annual Fire Marshal inspection, Public Health inspection, etc.) will be completed by the relevant  external authority, received in writing with recommendations and followed up by ESL’s Quality Team to ensure action is taken.

Related Documents and Reports:

• License and/or Inspection Certificates Information Spreadsheet

• Semi-Annual Facility Inspection Report