Survey Application ORGANIZATION INFORMATION

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1 ORGANIZATION TO BE SURVEYED Survey Application ORGANIZATION INFORMATION Organization/Unit Name Acronym Federal Tax Identification Number La Frontera Inc. Hope Center Hope Center Organization Website (Example: Telephone (Example: ) Fax (Example: ) Street Address (no P.O. Box) 260 South Scott Avenue Suite Number, Floor, or Department City State/Province/Territory Zip/Postal Code Tucson AZ County/Municipality Pima Country US ORGANIZATION CHARACTERISTICS Total annual operating revenue for the Annual operating revenue for the organization being surveyed programs seeking accreditation Fiscal Year End 9,402,923 1,060,181 06/30 Locale Urban Ownership Type Private, not for profit Type of Government Entity Description Other Ownership Description Other Government Entity Description CORPORATE STRUCTURE 1. Is your organization a unit or department within a larger entity (i.e., not a distinct legal entity and has the same federal tax identification number as the larger entity)? Yes Name of larger entity Street Address (no P.O. Box) Suite Number, Floor, or Department La Frontera Center, Inc. 502 West 29 th Street City State/Province/Territory Zip/Postal Code Tucson AZ Country Briefly describe the larger entity and how your programs fit into its operations. 2. If your organization is a unit or department within a larger entity, is the larger entity a subsidiary of a parent company (i.e., a distinct legal entity with a separate federal tax identification number from the parent company)? 1 of 13

2 Name of Parent Company Street Address (no P.O. Box) Suite Number, Floor, or Department City State/Province/Territory Zip/Postal Code Country Federal Tax Identification Number 3. If your organization is not a unit or department within a larger entity, is it a subsidiary of a parent company (i.e., a distinct legal entity with a separate federal tax identification number from the parent company)? Name of Parent Company Street Address (no P.O. Box) Suite Number, Floor, or Department City State/Province/Territory Zip/Postal Code Country Federal Tax Identification Number SIGNIFICANT CHANGES/EVENTS Indicate if your organization experienced any significant changes or events in the past year for the programs seeking accreditation. Change/Event Type Yes/ Explanation Change in leadership Change in ownership Relocation of accredited program/service or organization itself Change in mailing and/or addresses Significant reorganization of personnel Expansion, reduction, or elimination of program, service, or site Severe financial distress Merger or consolidation Joint Venture or acquisition involving accredited programs/services Investigations Material litigation Catastrophes Sentinel events CMS Sanctions, bans on admissions, fines, penalties, or loss of programs SOURCES OF FUNDING/REFERRAL Category Funding Referral Name of Funding/Referral Source Managed Care PPO no info Medicaid/MediCal/AHCCCS Medicare 2 of 13

3 OTP organizations must list a State Methadone Authority contact. If your organization is using the CARF-CCAC standards manual as the primary manual for the survey, funding/referral references are not required. FUNDING/REFERRAL Reference #1 Title First Name Middle Initial Ms. Barbara Last Name Suffix (Jr., Sr., etc.) Credentials Stuart Work Telephone Extension Address barbara.stuart@azdhs.gov Job Title Program Manager and State Opioid Treatment Authority (SOTA) Organization Name AZ Department of Health Services Mailing Address Address Line 2 Address Line E. Highland Suite 100 City State/Province/Territory Zip/Postal Code Phoenix AZ County/Municipality Maricopa Country US 3 of 13

4 CONTACT INFORMATION SURVEY KEY CONTACT Title First Name Middle Initial Ms. Carmen Last Name Suffix (Jr., Sr., etc.) Credentials Calderon MPA Job Title Executive Director/CEO Address Work Telephone Extension Fax ORGANIZATION INFORMATION Same as Organization to Be Surveyed CONTACT INFORMATION ACCREDITATION LIAISON Same as Survey Key Contact Title First Name Middle Initial Ms. Melody Last Name Suffix (Jr., Sr., etc.) Credentials Chimes Job Title Director, Human Resources and Facilities Address Work Telephone Extension Fax ORGANIZATION INFORMATION Same as Organization to Be Surveyed CONTACT INFORMATION AFTER-HOURS CONTACT Same as Survey Key Contact After-Hours Telephone of 13

5 CONTACT INFORMATION TRAVEL & LODGING CONTACT Same as Survey Key Contact Title First Name Middle Initial Ms. Teri Last Name Suffix (Jr., Sr., etc.) Credentials Lagunas Job Title Administrative Assistant Address Work Telephone Extension Fax ORGANIZATION INFORMATION Same as Organization to Be Surveyed INFORMATION & OUTCOMES MANAGEMENT (IOM) CONTACT CONTACT INFORMATION Same as Survey Key Contact 5 of 13

6 PERSONNEL STATISTICS AND DEMOGRAPHICS Information reported below is for all programs seeking accreditation and should be reported in numbers (not percentages). Total Full-Time Equivalent (FTE) Personnel Actual number of direct-services personnel Employees Contracted Personnel 22 2 Volunteers Total Direct-Services Personnel 0 24 PERSONS SERVED Information reported below is for all programs seeking accreditation and should be reported in numbers served annually (not percentages). Total Number of Persons Served Annually 455 Race/Ethnicity Number of Persons Served Other Race/Ethnicity Description African American/Black 150 Asian 50 White 105 Hispanic/Latino (Ethnicity) 100 Native (American or Alaskan) 5 Gender Number of Persons Served Female 220 Male 225 Age Number of Persons Served Other Age Description (Adult) (Adult) (Adult) 55 If you are using the aging services, CARF-CCAC, medical rehabilitation, or vision rehabilitation services standards manual, you need not complete the following grid. If you are using the business and services management networks standards manual, complete this grid only if you are seeking accreditation for programs/services that you provide directly. Other Characteristics of Persons Served Number of Persons Served Other Description Alcohol and/or Other Addictions 400 Developmental Disabilities 10 Dual Diagnosis AOD/DD 5 Dual Diagnosis AOD/MH 57 Dual Diagnosis MH/DD 2 HIV positive/aids 4 Homeless Individuals 7 Mental Disorders 21 Physical Disabilities 11 Unemployed/Underemployed 39 Visual Impairments 2 Additional information regarding the community, population, or cultures you serve that would be helpful. 6 of 13

7 STANDARDS MANUAL Primary Standards Manual 2014 Opioid Treatment Program INFORMATION FOR SCHEDULING COLLABORATIVE/RELATED SURVEYS CARF/Joint Commission Collaborative Survey Are there any other surveys that should be considered when scheduling this survey? CCAC/EAGLE Collaborative Survey If yes, please describe. CONFLICTS OF INTEREST Have any CARF International surveyors served as consultants to your organization in the last four years? Yes Would surveyors from any specific states/provinces/territories represent a conflict of interest? (DMEPOS surveys, choose N/A option.) If yes, please list names. Don Jorgensen, Ph.D. If yes, please list the states/provinces/territories. Would you accept one team member being assigned to your survey from your own state/province/territory? (DMEPOS surveys, choose N/A option.) Are there any organizations/suppliers considered to be in direct competition with your organization? Are there any geographical areas outside of your state/province/territory from which referrals or significant funding is received? (DMEPOS surveys, choose N/A option.) Are any of your organization's employees current or former CARF International surveyors? Are there any other potential conflicts of interest to avoid? If yes, please list the organizations/suppliers. If yes, please list the geographical areas. If yes, please list names. If yes, please specify. AIRPORT INFORMATION Nearest/Most Convenient Airport Name and City Distance/Time from Hotels Other tes/instructions Tucson International 9 miles/25 minutes OTHER SURVEY LOGISTICS Will the organization provide transportation between locations for the survey team? Provide any additional information that may assist us in arranging your survey logistics. 7 of 13

8 PROGRAMS TO BE SURVEYED PROGRAMS TO BE SURVEYED The grid below identifies the program(s) that are a part of this survey. Program Outpatient Treatment Opioid Treatment Program Adults 8 of 13

9 OPIOID TREATMENT PROGRAM INFORMATION OPIOID TREATMENT PROGRAM STANDARDS MANUAL Outpatient Treatment Opioid Treatment Program Adults Total Number of persons served annually Direct-services personnel in full-time equivalents (FTEs) Does this program provide medication services, including handling, prescribing, dispensing, and/or administration of medications? Yes Does this program use seclusion or restraint? 9 of 13

10 LOCATIONS FOR SURVEY LOCATIONS FOR SURVEY Contact us if changes to locations visited during the survey are necessary. The grid below identifies the location(s) that are required to be visited during this survey. Refer to each location page for details about programs to be surveyed at the location. Location Name Street Address City State/Province/Territory La Frontera, Inc. Hope Center 260 South Scott Street Tucson AZ 10 of 13

11 LOCATION INFORMATION Location Name La Frontera Inc. Hope Center Street Address (no P.O. Box) 260 South Scott Street LOCATION Suite Number, Floor, or Department Does this location operate solely as an administrative site? City State/Province/Territory Zip/Postal Code Tucson AZ County/Municipality Country Telephone Pima US Is this location acting as the survey headquarters? Yes Distance from survey headquarters Miles or kilometres? Direction from survey headquarters Do you want this location's address and Describe any accessibility issues at phone number to be published in our the location. Location Type listings of accredited organizations? ne Owned/leased Yes Days and Hours of Operation Other Other Days/Hours Description M-Th 5am-3:30pm; F5am-12; Sa 7-10am Direct-service personnel in full-time Average number of persons served equivalents (FTEs) at this location for daily at this location for the programs the programs seeking accreditation seeking accreditation STAFF MEMBER RESPONSIBLE FOR OPERATIONS Same as Survey Key Contact PROGRAMS AT THIS LOCATION The grid below identifies the program(s) to be surveyed at this location. Program Outpatient Treatment Opioid Treatment Program Adults OPIOID TREATMENT PROGRAM DETAILS If this site has a mobile unit, where is it Type of OTP Dispensing Location Does this site have a mobile unit? housed? Clinic Program Sponsor First Name Last Name Job Title Sharon McRae-Perez OTP Services Director Work Telephone Extension Address smcrae@lafrontera.org 11 of 13

12 OTP Medical Director First Name Last Name Job Title John Lankton Medical Director Work Telephone Extension Address License Number AZ Identify in the grid below any current program licensure or certification. Licensure/Certification Type License/Certification Number Expiration Date CSAT AZ10111M 11/30/2017 DEA RE /31/ of 13

13 OTHER INFORMATION GROUPS Entities this organization is a member of or affiliated with are listed below. Group AATOD (American Association for the Treatment of Opioid Dependence) APA (Psychiatric) (American Psychiatric Association) APA (Psychological) (American Psychological Association) MHCA (Mental Health Corporations of America) SURVEY ACCESSIBILITY What files or documents do you keep or have available in electronic format? File/Document Policies and Procedures Does CARF International need to provide an interpreter for the survey team to conduct the survey? Description electronic If yes, specify language(s). In what primary language are your organization documents written? English If other, specify language. 13 of 13

Survey Application ORGANIZATION INFORMATION. Organization/Unit Name Acronym Federal Tax Identification Number

Survey Application ORGANIZATION INFORMATION ORGANIZATION TO BE SURVEYED Organization/Unit Name Acronym Federal Tax Identification Number The Arbors Community TAC Organization Website (Example: www.carf.org)