Current through Register Vol. 46, No. 39, September 25, 2024
(a) Certified
providers of services shall be inspected at least two times per year, once
without prior notice, for compliance with rules, regulations, policies,
procedures and requirements of the office. In the sole discretion of the
office, providers with established records of substantial compliance may be
inspected only once per year, provided such inspection is without
notice.
(b) Activities which shall
constitute inspections for purposes of satisfying the requirements of
subdivision (a) of this section include, but are not limited to:
(1) a recertification review, made pursuant
to this section;
(2) an interim
regulatory compliance review, made pursuant to subdivision (f) of this
section;
(3) an interim or annual
performance review, made pursuant to Office policy;
(4) a focused or targeted review, made
pursuant to Office policy;
(5) a
facilities evaluation, made pursuant to Office policy;
(6) a fiscal audit or review, made pursuant
to Office policy;
(7) corrective
action plan monitoring;
(8) a
cursory on-site visit; and
(9) an
accreditation survey, completed by a nationally recognized accrediting
organization.
(c) Prior
to the expiration of an operating certificate, the office shall conduct a
recertification review for purposes of assessing a provider's compliance with
applicable laws, rules and regulations and to determine the renewal term of the
operating certificate.
(1) Recertification
reviews shall be conducted on an unannounced basis and may include, but not be
limited to, the following areas of review:
(i)
inspection of facility appearance, conditions and general safety;
(ii) evaluation of the governing
authority;
(iii) interviews of
staff and patients/clients;
(iv)
examination of staffing patterns, staff credentials and
qualifications;
(v) compliance with
the requirements of Part 836 of this Title, guidance issued by the Office and
applicable rules and regulations of the Justice Center; and
(vi) such other operating areas or activities
as may be necessary to determine compliance with applicable laws, rules and
regulations.
(2) Fiscal
viability reviews shall include an assessment of the financial information of
the provider of services. Such information shall be submitted in intervals and
in a form prescribed by the Office, for compliance with minimum standards
established by the office, in order to determine the provider's fiscal
capability to effectively support the authorized services.
(3) The specific renewal term shall be based
on the results of the recertification review and fiscal viability review,
utilizing the lowest compliance rating achieved by the provider of services on
either the recertification review or fiscal viability review, except as
otherwise provided in subdivision (i) of this section.
(d) The inspection process shall include
appropriate reporting and corrective action follow-up subsequent to the review,
including the possibility of initiating an unannounced interim inspection which
may encompass the areas of review listed under subdivision (e) of this section,
to assure attention to and correction of cited deficiencies.
(1) Upon completion of an inspection, office
staff shall, within forty-five 45 days of such completion, submit a written
report to the provider of services describing the results of such review,
including each regulatory deficiency identified, if any.
(2) The provider of services shall take all
actions necessary to correct the deficiencies reported. If instructed the
provider of services shall submit a corrective action plan, which is deemed
satisfactory by the Office, within a specified period of time, as directed by
the Office, stating the specific actions taken or planned to achieve compliance
with identified requirements. Any planned actions described in the corrective
action plan must be accompanied with a timetable for their
implementation.
(3) If the provider
of services fails, within the specified or an otherwise reasonable time, to
correct any reported deficiencies, or fails to maintain satisfactory compliance
with applicable laws, rules and regulations, the Commissioner may revoke,
suspend or limit the operating certificate or levy a civil fine for such
failures, in accordance with section
810.16 of this
Part.
(e) The office
shall not perform fiscal viability reviews of governmental agencies or
hospitals authorized by the Office and/or the Department of Health.
(f) Any fines imposed by the Commissioner
against the provider of services must be paid in full before an operating
certificate may be renewed.
