Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 3
Subtitle 21 - MENTAL HYGIENE REGULATIONS
Chapter 10.21.16 - Community Mental Health Programs - Application, Approval, and Disciplinary Processes
Section 10.21.16.08 - Approval of a Program
Universal Citation: MD Code Reg 10.21.16.08
Current through Register Vol. 51, No. 19, September 20, 2024
A. Approval Without Conditions.
(1) The
Secretary shall grant approval without conditions to a program if, based on an
on-site review, the Department's designated approval unit determines that the
program complies with the requirements for approval.
(2) Unless the program has been granted
deemed status under Regulation .10 of this chapter, within not more than 3
years of the date of the program's last full on-site review, the Department's
designated approval unit shall conduct a full, on-site review of the
program.
(3) Based on the review
conducted under §A(2) of this regulation, the Secretary shall redetermine
the program's approval status according to the provisions of this
chapter.
B. Approval with Conditions.
(1) The Secretary may grant
approval with conditions to a program if, based on an on-site review, the
Department's designated approval unit determines that the program:
(a) Is deficient in one or more of the
requirements under this chapter, COMAR 10.21.17, or the chapter under the
subtitle for the specific program;
(b) Has no deficiencies that constitute a
threat to health, safety, or welfare of the individuals served;
(c) Has documented that the program will
collaborate with the CSA, as required under COMAR
10.21.17.06A;
and
(d) Has submitted an acceptable
program improvement plan within the time frame established under §B(3) of
this regulation.
(2) If
the Secretary grants a program an approval with conditions under §B(1) of
this regulation, the Secretary shall notify the program that the Department's
designated approval unit may conduct a focused review under the provisions of
§B(4) of this regulation.
(3)
Program Improvement Plan (PIP).
(a) Within 10
working days of receipt of the list of deficiencies cited during the on-site
review, the program director shall:
(i) Submit
a proposed PIP that addresses the identified deficiencies to the CSA or lead
CSA; and
(ii) Collaborate with the
CSA or lead CSA to finalize the PIP.
(b) Within 30 calendar days of receipt of the
list of deficiencies cited during the on-site review, the program director
shall submit:
(i) The PIP to the Department's
designated approval unit; and
(ii)
Documentation of the collaboration with the CSA or lead CSA.
(c) Unless an extension has been
granted by the Department's designated approval unit, if a program fails to
submit a completed PIP within the time frames established in §B(3)(a) and
(b) of this regulation, the Secretary may pursue disciplinary action under
Regulation .12C of this chapter.
(4) Focused Review.
(a) For programs that have been granted
approval with conditions, the Department's designated approval unit may conduct
a focused review to:
(i) Reevaluate the
deficiencies cited during the on-site review conducted under §B(1) of this
regulation; and
(ii) Review the
program's progress on the PIP.
(b) Based on the focused review conducted
under §B(4)(a) of this regulation, the Secretary shall redetermine the
program's approval status according to the provisions of this
chapter.
(5) Regular
Program Review.
(a) Within 3 years of the date
of the program's last full on-site review, the Department's designated approval
unit shall conduct a full, on-site review of the program.
(b) Based on the review conducted under
§B(5)(a) of this regulation, the Secretary shall redetermine the program's
approval status according to the provisions of this chapter.
C. Certificate of Approval.
(1) If the Department's designated
approval unit determines that a program is eligible for approval, the Secretary
shall issue a certificate of approval to the program director that specifies
the:
(a) Chapter under which the program has
been approved;
(b) Type of
approval; and
(c) Beginning and
expiration dates of the approval period.
(2) The Secretary shall notify the
Administration, the CSA of the jurisdiction where the program provides
services, the Medical Assistance Program, and the ASO of the program's
approval.
(3) The program director
shall ensure that the certificate of approval is available during the regular
hours of operation.
(4) Sale or
Transfer of Certificate of Approval.
(a) The
Secretary's certificate of approval of a program, issued according to the
provisions of §C(1) of this regulation, is valid only for the program to
which the Secretary's certificate of approval is issued.
(b) A program may not sell, assign, or
transfer a certificate of approval to another program.
D. Extension of Approval Status. The Secretary shall maintain the program's existing approval status if, before the expiration of approval period, the:
(1)
Department's designated approval unit does not complete an on-site review;
or
(2) Department does not reach a
decision regarding approval.
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