Notice of Mandatory Requirement to Submit Four-Year
Renewal of Licensee Background Check Information
PDF Version of DQA 08-015
(PDF, 37 KB)
Notice of Mandatory Requirement to Submit Four-Year Renewal
of Licensee background Check Information
This memo serves as official notice to entity license holders/legal
representatives that the Division of Quality Assurance (DQA) is now
conducting the required four-year renewal of licensee background checks.
Response Required to Complete Four-Year Renewal Process
Regardless of when you last submitted an application for licensure,
certification or registration, if you wish the license approval to continue,
you must submit the completed forms for the required four-year renewal
process.
Pursuant to 50.065(6)(am), Stats. and HFS 12.05, Wis. Admin. Code,
failure to comply with any provision of background information gathering
requirements subjects entities to certain sanctions, including denial,
revocation, non-renewal, or suspension of regulatory approval.
As the license holder/legal representative, you must comply with the
requirements of this notice by June 30, 2008. Access the DQA
Regulated Entity Background Check Process web page at http://dhfs.wisconsin.gov/caregiver/fouryear.htm
to obtain the necessary forms for the Existing License Holder Four-Year
Renewal Background Check Process.
Step 1
Identify the appropriate person(s) who must complete the Background
Information Disclosure (BID) and BID Appendix forms:
-
License Holder or Legal
Representative - An individual, or legal representative for an
organization that does not have a single owner who has regulatory
approval to operate any entity regulated by DQA, whether or not
the person has regular, direct contact with clients.
-
Principal officers, corporation or
board members of the business organization, if those persons
have regular, direct contact with clients.
-
Nonclient residents - Individuals
who are ten years of age and older, who are not clients, but who
reside at the entity if those persons have regular, direct contact
with clients.
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Step 2
As the license holder or legal representative, you must ensure that
you, your appropriate board members who have client contact and your
nonclient residents who are ten years of age and older do the
following:
- Complete a new Background Information Disclosure (BID)
form, HFS-64 (Rev. 02/08). Do not send copies of prior background
check forms or results of earlier background checks.
-
Complete a Background Information
Disclosure Appendix form, HFS-69 (Rev. 01/08)
- If you are the license holder or legal representative for
multiple facilities, you may submit one BID and one BID
Appendix, if you check the box in Section 3 of the BID Appendix;
and
- Attach a list of all DQA-regulated facilities, including the
Facility Name, Facility Address (Street, City, State, Zip Code),
Facility license or certification number (if known), and
facility type for each license, certification, or registration.
For a list of facilities on record for your organization, e-mail
a request to DHFSCaregiverPilot@wisconsin.gov.
The request must include the license holder or legal
representative's name and the organization or corporation name.
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Step 3
Submit all forms with an $8.00 processing fee for each person,
payable by check to the "Division of Quality Assurance":
4-Year Entity Background Checks
Office of Caregiver Quality
PO Box 2969
Madison, WI 53701-2969
The processing fee is required, unless it was paid the as part of
an initial DQA program application in 2008. If you are unsure if you
meet this exemption, include the fee. The fee will be returned if
Department records indicate it is not necessary.
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Submit to the Department only the forms and fee for the license holder
or legal representative, appropriate board members, and non-client residents
by June 30, 2008. Do not submit forms for employees to DQA.
Caregiver Background Check Resources
See the website at http://dhfs.wisconsin.gov/caregiver/index.htm
for more information, including background check forms, rules and
regulations, and contact information. There are a variety of useful tools on
the Caregiver Program website including:
If you have any questions, contact the Office of Caregiver Quality via
e-mail at DHFSCaregiverPilot@wisconsin.gov
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