Missouri Department of Social Services

Children's Division

Residential Program Unit

THE FOLLOWING DOCUMENTS MUST ACCOMPANY YOUR APPLICATION FOR RENEWAL OF LICENSURE:

1.	Verification of a physical examination, 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, for all staff working directly with children utilizing the form prescribed by the division (Attached is Form RPU-10, Personnel Report-Residential Treatment Agency for Children and Youth

2.	A current board roster, including the addresses of all officers

3.	A copy of a current organizational chart

4.	Annual results of a check of the Family Care Safety Registry (FCSR) for all staff and volunteers working directly with children and fingerprint background checks for all staff and volunteers working at the residential site. (See attached RPU-10 to report this information)

5.	Evidence of current compliance with the fire and safety requirements of the State Fire Marshal

6.	A record of monthly drills for fire and emergency evacuations which are held at different times of the day and night

7.	Documentation that each facility's water supply and sewage disposal system is currently in compliance with the requirements of the Department of Health or the Department of Natural Resources if not an approved public source

8.	A copy of a financial review conducted by a certified public accountant

9.	Annual written plan for staff training

10.	A summary of any significant changes to program and copies of any resulting policies or policy changes

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

12.	A copy of the Personnel Manual for the Agency if there have been changes during the licensure period

13.	A copy of the Program Manual for the Agency if there have been changes during the licensure period

14.	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

15.	A copy of the resume for all administrative and professional staff

16.	A copy of the IRS Form 990 for all Not for Profit organizations

17.	Name, phone, and email address of current Reasonable and Prudent Parenting Liaison.

THE FOLLOWING DOCUMENTS OR WRITTEN POLICIES WERE PREVIOUSLY SUBMITTED TO THE LICENSING UNIT ON OR BEFORE THE LAST COMPLIANCE VISIT. IF THEY HAVE BEEN UPDATED, PLEASE SUBMIT THE UPDATED POLICIES:

1.	Written statement of personnel practices

2.	Articles of incorporation

3.	Bylaws

4.	Written intake policy

5.	Written child abuse and neglect reporting policy

6.	Written discipline policy

7.	Written visitation policy

8.	Written health care policy

9.	Written restraint policy which shall include a description of all methods to be used

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

11.	Job descriptions

12.	Written volunteer policies

13.	Written policy for the use of visiting resources

14.	Written confidentiality policy

15.	Written policy for the use of locked isolation

16.	Written instructions for fire and other emergency evacuations

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

18.	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 Licensing Unit, (573) 751-4954, if you have any questions regarding the above information.

Return the completed form and attached information at least thirty (30) days prior to the expiration of the current license to:

Residential Program Unit

Children's Division

P. O. Box 88

Jefferson City, Missouri 65103

(REV 02-19)