Reference Document

Refuge House T3C Credentialing Implementation Plan

Refuge House, Inc.
Last updated: July 24, 2026 · Source: plans/Refuge House T3C Credentialing Implementation Plan.md

Refuge House T3C Credentialing Implementation Plan

Leveraging CK Family Services & Existing Infrastructure

I. EXECUTIVE SUMMARY - LEVERAGING EXISTING PARTNERSHIPS

Current Assets Already in Place:

✅ Treatment Directors

✅ Behavioral Support & Mentoring (Dallas)

✅ Licensed Therapists

✅ 24/7 RN Coverage (IDD/Autism)

✅ Crisis Management (Current)

Implementation Strategy:

  1. Maintain existing partnerships (CK Family Services, Superior)
  2. Formalize current crisis management structure
  3. Add night/weekend aides for primary crisis coverage
  4. Develop internal credentialing programs for expansion

II. TREATMENT DIRECTOR ASSIGNMENTS

Organizational Structure:

Dallas Office:

San Antonio Office:

Documentation for Application:

"Refuge House has qualified Treatment Directors currently employed who 
meet all requirements for both service packages. Angel Wolfe, LMSW serves 
as Treatment Director for both Mental & Behavioral Health and 
IDD/Autism in Dallas, and Alia Cepeda, MS, LPC-S serves as Treatment 
Director of Record for both Mental & Behavioral Health and IDD/Autism 
in San Antonio. This ensures 
appropriate clinical oversight and supervision for all specialized 
service packages."

III. BEHAVIORAL SUPPORT SPECIALIST/MENTOR PLAN

A. Dallas - Existing Partnership Model

Current State:

Application Documentation:

"Behavioral Support Specialist/Mentor services in Dallas will be 
provided through our existing partnership with CK Family Services, 
who currently provides these services to our children. This established 
relationship ensures continuity of care and immediate operational 
capacity at Active Interim implementation."

Inactive Interim Tasks:

B. San Antonio - Phased Implementation

Phase 1 (Day 1 Active):

Phase 2 (Months 1-6):

Application Documentation:

"San Antonio will initially utilize existing qualified staff members 
to provide Behavioral Support Specialist/Mentor services, with a 
comprehensive plan to develop an internal credentialing program for 
contracted providers to ensure adequate coverage as census grows."

C. Internal Credentialing Program Development

Timeline for BSS/Mentor Credentialing Program:

Months 1-3 (During Active Interim):

Months 4-6:

Months 7-12:

IV. CRISIS MANAGEMENT STAFF PLAN

A. Current Crisis Management Structure

Existing Coverage Model:

B. Enhanced Crisis Management Implementation

Phase 1: Day 1 Active Interim

New Positions:

Coverage Structure: | Period | Primary Coverage | Backup Coverage | |--------|-----------------|-----------------| | Weekday Days | Case Managers (on-duty) | Supervisor | | Weekday Nights | Night Aide | Case Manager on-call | | Weekends | Weekend Aide | Case Manager on-call | | Holidays | Rotating Aides | Case Manager on-call |

Application Documentation:

"Crisis Management will utilize our existing model where each case 
manager provides crisis response for their caseload, enhanced with 
dedicated Night and Weekend Aides serving as primary crisis response. 
This ensures 24/7 coverage with staff familiar with each child's 
specific needs, maintaining continuity of care during crisis situations."

C. Internal Crisis Management Credentialing Program

Development Timeline:

Months 1-3 (During Active Interim):

Months 4-6:

Months 7-12:

V. LEVERAGING SUPERIOR HEALTHPLAN/STAR HEALTH RESOURCES

A. 24/7 Nurse Line for IDD/Autism RN Requirement

Implementation Strategy:

"24/7 Registered Nurse availability for IDD/Autism Support Services 
will be provided through Superior HealthPlan's STAR Health 24/7 Nurse 
Advice Line (1-866-912-6283), ensuring immediate access to nursing 
consultation for medical concerns, medication questions, and health 
guidance."

Protocols to Develop (Inactive Period):

B. Licensed Therapist Services

Current State:

Documentation for Application:

"Licensed therapy services are currently provided through Superior 
HealthPlan/STAR Health contracted providers who are already serving 
our children. This established network ensures continuity of care 
and meets all T3C therapeutic service requirements."

VI. INACTIVE INTERIM PERIOD (120 DAYS) IMPLEMENTATION TASKS

Month 1: Foundation & Documentation

Week 1-2:

Week 3-4:

Month 2: Policy & Procedure Development

Week 5-6:

Week 7-8:

Month 3: Staff Preparation

Week 9-10:

Week 11-12:

Month 4: Final Preparations

Week 13-16:

VII. ACTIVE INTERIM IMPLEMENTATION PHASES

Phase 1: Day 1 - Month 3 (Foundation)

Immediate Actions:

Dallas Operations:

San Antonio Operations:

Phase 2: Months 4-6 (Development)

Program Development:

Quality Assurance:

Phase 3: Months 7-9 (Expansion)

Scaling Operations:

System Integration:

Phase 4: Months 10-12 (Optimization)

Full Implementation:

VIII. DOCUMENTATION STRATEGIES FOR APPLICATION

A. For Mental & Behavioral Health Package

Section III.B.1 (BSS/Mentor):

Select option (b) - contracting for services
Documentation: 
- Dallas: CK Family Services existing contract
- San Antonio: Plan for initial staff coverage + credentialing program
- Timeline: Immediate for Dallas, phased for San Antonio

Section III.B.2 (Crisis Management):

Select option (a) - using existing staff
Documentation:
- Current case manager on-call model
- Plan to hire Night and Weekend Aides
- Development of credentialing program for expansion

B. For IDD/Autism Package

Treatment Director:

"Refuge House's Treatment Directors meet all qualifications for 
IDD/Autism services. Angel Wolfe, LMSW (Dallas) and Alia Cepeda, 
MS, LPC-S — Treatment Director of Record (San Antonio) each serve 
as Treatment Director for both M&B and IDD/Autism within their 
respective sites, ensuring consistent clinical oversight and 
supervision."

RN Requirement:

"24/7 RN availability through Superior HealthPlan's STAR Health 
Nurse Advice Line, supplemented by Service Coordination for 
complex medical needs."

IX. QUALITY ASSURANCE & MONITORING

A. Service Delivery Metrics

Monthly Monitoring:

Quarterly Reviews:

B. Continuous Improvement Process

Data Collection:

Analysis and Action:

X. RISK MITIGATION STRATEGIES

Potential Challenges & Solutions:

Challenge: CK Family Services capacity limitations

Mitigation:

Challenge: Night/Weekend Aide recruitment delays

Mitigation:

Challenge: Superior nurse line limitations

Mitigation:

Challenge: Census growth exceeding projections

Mitigation:

XI. IMPLEMENTATION CHECKLIST

For Application Submission:

During Inactive Period:

For Day 1 Active:

For Full Credential (Month 10-11):

This implementation plan leverages existing partnerships and infrastructure while building sustainable capacity for T3C service delivery.

© 2026 Refuge House, Inc. · This is a controlled document. Always refer to the current version.