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PCA Provider Checklist

  1. Participate in MN Department Of Human Services "Steps For Success" program (offered three times per year).
  2. Register your home care business through the Minnesota Secretary of State.
  3. Obtain Federal  Tax ID Number (IRS), State Tax ID Number (MN Department of Revenue)
  4.   Obtain Liability Insurance,  Worker Compensation Insurance, Fidelity Bond and Surety Bond.   
  5.   Pay application fee (currently $688.00).
  6.   Complete PCA Provider Application including the name and license number of the Qualified Professional you have on staff. 
  7.   When application is approved, you will receive a "Welcome Letter" from the Department of Human Services (DHS) with your Provider Number.
  8.   Send person in charge of billing to state training (offered monthly).
  9.   You will need a Policies and Procedures manual  which explains compliance with all state regulations.
  10.   You will need forms to document your business and the services you provide to each client.
  11. Prepare to hire PCA employees.
  12. Accept clients to your PCA company.
  13. Establish billing system with MNITS (state payment system).
  14. Schedule PCAs to provide care for your clients.
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Comprehensive License Checklist

  1.   Register your home care business with the Minnesota Secretary of State.
  2.   Obtain Federal  Tax ID Number (IRS), State Tax ID Number (MN Department of Revenue) and, optionally, NPI number.
  3.   Obtain Worker Compensation insurance.  
  4.   Complete the application forms.  NOTE: Must have Registered Nurse named on the application.
  5.   Send check for $4200.00 made out to "MN Department of Health" with your completed application.
  6.   Background studies will be done on all owners and managers once the application is received.
  7.   License will be issued within 90 days of submitting a completed application.
  8.   Notify MN Department of Health within 5 days after admitting first client.
  9.   License will be temporary for one year.  You will receive a permanent license after successful completion of the survey for compliance.
  10. Note:  Cannot apply for Medicare Certification with a temporary license.
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245D License Checklist

  1. Register your home care business with the Minnesota Secretary of State.
  2. Obtain Federal  Tax ID Number (IRS), State Tax ID Number (MN Department of Revenue).
  3. Obtain Worker Compensation  insurance. 
  4. Complete the 245D Pre-Application worksheet. Be sure to click on "Applicant Agreement and Verification and Affidavit of Authorized Agent " in Step 10. C to download the form.  Fill it out and have it notarized
  5. Apply for 245D License from DHS online or contact us to apply for you once Steps 1, 2 and 3 above are completed.  (There is a consultation fee for this.) The License cost is $500.00.
  6. When license is approved, one must get liability insurance, Waiver 101 Training, and complete Provider Enrollment (Cost is $688) to be eligible for payments for providing services.
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Basic License Checklist

  1.   Register your home care business with the Minnesota Secretary of State.
  2.   Obtain Federal  Tax ID Number (IRS), State Tax ID Number (MN Department of Revenue), and, optionally, NPI number.
  3.   Obtain Worker Compensation insurance.
  4.   Complete the application forms.
  5.   Send check for $2100.00 made out to "Commissioner of Finance, Treasury Department" with your completed application.
  6.   Background studies will be done on all owners and managers once the application is received.
  7.   License will be issued within 90 days of submitting a completed application.
  8.   Notify MN Department of Health within 5 days after admitting first client.
  9.   License will be temporary for one year.  You will receive a permanent license after successful completion of the survey for compliance.
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Assisted Living License Checklist

  1. You need to have a house in order to apply for an Assisted Living license.  The address of the house will be the address on the license.  You cannot change the address once the application has been submitted.- If you have less than 5-bedrooms, you will not be able to take clients on a CADI or BI waiver.
    - You can only provide care for clients aged 55 and older.
    - You can accept clients who are Private Pay (aged 55 and older).
    - For clients over age 65, the only payer (other than Private Pay) is Elderly Waiver.
  2. Provide the address of the house and other mailing addresses as appropriate.
  3. Register your company with the Secretary of State.  Provide a copy of the Certificate of Organization (3-page document).
  4. Register for a Federal Tax ID (EIN) number from the IRS.  Provide a copy of the SS-4 Form.
  5. Apply for a MN Tax ID from the MN Department of Revenue.  Provide the MN Tax ID number.
  6. Provide the name, home address, phone, email address, title and % of ownership for all owners.
  7. Provider the name, home address, phone, email address and copy of license of the Assisted Living Director.
  8. Provide the name, home address, phone, email address and copy of license of the Nursing Supervisor.
  9. Provide an Organization Chart.
  10. Provide a written Description of Business.
  11. Provide a Certificate of Liability assigned to the address of the house showing that you have Worker Comp insurance.
  12. Provide a Certificate of Liability assigned to the address of the house showing that you have General Liability insurance.
  13. Provide blueprints of the house (these must be computer generated and scalable) which include the square footage, number of bedrooms, a plan for each floor showing doors, windows, stairs, walls, location of smoke alarms in each bedroom and other rooms and location of fire extinguishers. (Note:  alarms must be interconnected so that when one alarm goes off, they all go off.)
  14. Provide blueprint of the kitchen that shows location of the appliances (sink, refrigerator, microwave, stove, etc.)  Blueprint should show location of smoke alarm and fire extinguisher.
  15. Written description of the appliances (MDH is looking for evidence that appliances have been NSF, ETL or EPH approved.  If you do not find that approval, you need to list the make, model and year of the appliance.)
  16. Written description of ALL SURFACES in the kitchen (countertops, walls, ceilings, floors) describing the surface type (wood, laminate, linoleum, tile, metal).  MDH needs to know it is washable, able to be cleaned.
  17. You must submit a proposed menu for at least one week.
  18. Complete the Uniform Disclosure of Assisted Living Services and Amenities (UDALSA) form:  www.health.state.mn.us/facilities/regulation/assistedliving/docs/forms/udalsa.pdf
  19. Complete the Assisted Living License application.
  20. Provide verification that the owner has read the regulations and the Signature of the Owner.

 

ALL OF THESE DOCUMENTS MUST BE PRESENT BEFORE AN APPLICATION CAN BE SUBMITTED.  YOU MUST READ THE REGULATIONS FOR THE LICENSE AND SIGN THAT YOU HAVE READ THEM.

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