Oklahoma Administrative Code
Title 450 - Department of Mental Health and Substance Abuse Services
Chapter 1 - Administration
Subchapter 9 - Certification and Designation of Facility Services
Section 450:1-9-5.7 - Types and duration of certification status for facilities and programs

Universal Citation: OK Admin Code 450:1-9-5.7

Current through Vol. 41, No. 13, March 15, 2024

(a) The ODMHSAS may grant the following types of certification for the durations specified below.

(1) Permit for Temporary Operations. A Permit for Temporary Operations may be granted upon ODMHSAS's verification that the organization has substantially complied with Core Organizational Standards and Core Operational Standards applicable to the type of services for which Certification is sought. A Permit for Temporary Operations allows for the organization to begin operations so that compliance with Quality Clinical Standards may be assessed by the Department.
(A) A Permit for Temporary Operations will be granted for six (6) months and will expire upon subsequent certification achieved by the organization or upon a determination by ODMHSAS that the organization is not in substantial compliance with Quality Clinical Standards.

(B) Organizations shall notify ODMHSAS in writing no later than fourteen (14) calendar days after initiating clinical services in order to begin the compliance review of Quality Clinical Standards. Failure to provide such notification within the required timeframe may result in immediate termination of the Permit for Temporary Operation.

(C) A Permit for Temporary Operations may not be renewed. ODMHSAS may extend a Permit for Temporary Operations for no more than ninety (90) days in the event of extenuating circumstances as determined by ODMHSAS.

(D) Organizations that do not achieve subsequent Certification after obtaining a Permit for Temporary Operations must wait a minimum of ninety (90) days before making re-application.

(2) Probationary Certification. Probationary Certification may be awarded for a one (1) year period by ODMHSAS in cases where a program or facility has changed majority ownership or majority board composition but operations of the program or facility continue. Such programs or facilities must provide ODMHSAS with documentation of any changes in policies, procedures, personnel, services, and other documentation as requested by ODMHSAS. Upon determination by ODMHSAS that the program or facility meets the requirements of 450:1-9-5.7(a)(3) prior to expiration of the Probationary Certification, the program or facility may obtain applicable Certification.

(3) Certification. ODMHSAS may award Certification for a one (1) year or two (2) year period beyond the period approved for a Permit for Temporary Operations or as a renewal of a previously awarded Certification in accordance with applicable chapters as stipulated in 450:1-9-5 and when ODMHSAS determines that the organization has met substantial compliance with applicable standards. To qualify for Certification, programs must meet the following:
(A) Demonstrate compliance with a minimum of ninety percent (90%) of all Critical Standards as identified in the ODMHSAS Provider Certification Manual on the initial site review, file an acceptable plan of correction in the required timeframe addressing standards for which compliance was not achieved on the initial site review, and demonstrate compliance with one hundred percent (100%) of all Critical Standards after the initial site review.

(B) Demonstrate compliance with a minimum of seventy-five percent (75%) of all Necessary Standards as identified in the ODMHSAS Provider Certification Manual on the initial site review and file an acceptable plan of correction in the required timeframe addressing standards for which compliance was not achieved on the initial site review. ODMHSAS may verify compliance with standards identified in the plan of correction at its discretion.

(C) Programs with fewer than five (5) active cases for which clinical records could be reviewed must meet the requirements in (B) above, but can be considered for no more than a one (1) year certification.

(D) Community Residential Mental Health Programs can be considered for no more than a one (1) year certification.

(E) Programs awarded a Probationary Certification are not eligible for Certification under the conditions described in 450:1-9-5.7(3) until all conditions of 450:1-9-5.7(2) have been satisfied.

(F) Programs found to have initiated operations prior to the awarding of a Permit for Temporary Operations for the services for which certification is statutorily required shall obtain the necessary Permit for Temporary Operations to continue operations. Subsequently, these programs will be eligible for Certification for a one (1) year period only for the first two (2) years of Certification. Programs that fail to obtain the necessary Permit for Temporary Operations shall be required to cease operations.

(4) Certification with distinction. Certification with Distinction may be awarded for up to three (3) years by ODMHSAS in accordance with applicable chapters as stipulated in 450:1-9-5 for programs seeking renewal of previously awarded certification when ODMHSAS verifies all of the following minimal conditions are satisfied:
(A) Programs must have provided services with an approved ODMHSAS Certification as described in 450:1-9-5.7(a)(3) for one (1) year or longer in addition to the time services were provided under an approved Permit for Temporary Operations.

(B) Programs must demonstrate compliance with a minimum of ninety percent (90%) of all Critical Standards as identified in the ODMHSAS Provider Certification Manual on the initial site review, file an acceptable plan of correction in the required timeframe addressing standards for which compliance was not achieved on the initial site review, and demonstrate compliance with one hundred percent (100%) of all Critical Standards after the initial site review.

(C) Programs must demonstrate compliance with a minimum of eighty-five percent (85%) of all Necessary Standards as identified in the ODMHSAS Provider Certification Manual on the initial site review and file an acceptable plan of correction in the required timeframe addressing standards for which compliance was not achieved on the initial site review. ODMHSAS may verify compliance with standards identified in the plan of correction at its discretion.

(D) ODMHSAS may refund certification renewal application fees for organizations that demonstrate 100% compliance with all standards (i.e. Core Organizational Standards, Core Operational Standards, and Quality Clinical Standards) during the initial renewal site visit and review.

(E) Community Residential Mental Health Programs can be considered for no more than a one (1) year Certification with Distinction.

(F) Programs awarded a Probationary Certification are not eligible for Certification under the conditions described in 450:1-9-5.7(4) until all conditions of 450:1-9-5.7(2) have been satisfied.

(5) Certification with special distinction. Certification with Special Distinction may be awarded for up to three (3) years by ODMHSAS in accordance with applicable chapters as stipulated in 450:1-9-5 for programs seeking renewal of previously awarded certification when ODMHSAS verifies all of the following minimal conditions are satisfied.
(A) The program must meet all conditions for Certification with Distinction as outlined in 450:1-9-5.7(a)(4); and,

(B) The program has attained national accreditation (COA, CARF, or TJC) for the services to which ODMHSAS Certification applies.

(C) Certification with Special Distinction will be reduced by ODMHSAS to Certification with Distinction by ODMHSAS if during the certification period for which the Special Distinction was approved, the program fails to maintain national accreditation status.

(D) ODMHSAS may refund certification renewal application fees for organizations that demonstrate 100% compliance with all standards (i.e. Core Organizational Standards, Core Operational Standards, and Quality Clinical Standards) during the initial renewal site visit and review.

(E) Community Residential Mental Health Programs can be considered for no more than a one (1) year Certification with Special Distinction.

(F) Programs awarded a Probationary Certification are not eligible for Certification under the conditions described in 450:1-9-5.7(a)(4) until all conditions of 450:1-9-5.7(a)(2) have been satisfied.

(b) Permits for Temporary Operations granted to applicants for initial certification of a facility, location, or level of service shall be for a period of six (6) months and shall become effective immediately upon approval by the ODMHSAS Board, the Commissioner or designee.

(c) Certification, other than Permits for Temporary Operations, granted to an applicant shall become effective the first day of the month following the date of the action by the Board, provided however, the Board may waive this requirement and make the Certification effective immediately.

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