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 450:1-9-7 - Procedures for completion of the Permit for Temporary Operations certification process

Universal Citation: OK Admin Code 450:1-9-7

Current through Vol. 42, No. 7, December 16, 2024

(a) Completion of the certification process for a Permit for Temporary Operations will be done in cooperation between the applicant and ODMHSAS staff, and consists of the following:

(1) Each organization pursuing ODMHSAS certification shall initially apply for a Permit for Temporary Operations, with the exception of special circumstances specified in 450:1-9-5.7(a)(2).

(2) Upon receipt of an application ODMHSAS will provide all applicants for a Permit for Temporary Operations a document listing the Core Organizational Standards, Core Operational Standards and Quality Clinical Standards required for a Permit for Temporary Operations. For facilities or programs that have provided clinical services for 30 days or longer, at the time of the initial application, ODMHSAS may also review applicable Quality Clinical Standards.

(3) The application, including required documentation of policies and procedures, shall be reviewed for completeness by ODMHSAS staff. If the application is deemed complete, a site review of the facility or program will be scheduled and completed. Failure to provide required materials within 60 days of receipt of the application will result in a denial of the application.

(4) Any deficiencies of applicable Core Organizational Standards and Core Operational Standards, and Quality Clinical Standards if applicable, cited as a result of the site visit or review(s) of documents requested by ODMHSAS will be identified and a report will provided to the facility by ODMHSAS within five (5) working days of the site visit unless precluded by extenuating circumstances.

(5) The facility will have ten (10) working days from receipt of the deficiency report to correct deficiencies related to Core Organizational and Core Operational Standards categorized as Necessary Standards. The facility will have five (5) working days from receipt of the report to submit a plan of correction related to cited deficiencies in standards categorized as Critical Standards. ODMHSAS may conduct an additional site visit(s) to verify proof of compliance with any deficiencies cited in the initial review. Compliance with all Critical Standards for which the facility was not compliant upon the initial review must be demonstrated through a follow up site visit or review.

(6) If any pending deficiencies in Core Organizational Standards and Core Operational Standards are identified following this ten (10) day correction period, the program will have five (5) additional working days from receipt of any subsequent report to correct and verify compliance with any pending deficiencies.

(7) The following additional procedures will apply to programs or facilities reviewed for Quality Clinical Standards pursuant to an application for Permit for Temporary Operation as referenced in 1-9-7 (2) above.
(A) The facility will also have ten (10) working days from receipt of the report to submit a plan of correction related to cited deficiencies in Quality Clinical Standards categorized as Necessary Standards. The facility will have five (5) working days from receipt of the report to submit a plan of correction related to cited deficiencies in Quality Clinical Standards categorized as Critical Standards. The plan of correction will indicate the earliest date by which ODMHSAS should schedule an additional site visit or documentation review to determine compliance with Quality Clinical Standards for which deficiencies were cited but not more than twenty (20) working days from receipt of report as referenced in (5) above. Compliance with all in Quality Clinical Standards categorized Critical Standards for which the facility was not compliant upon the initial review must be demonstrated through a follow up review.

(B) Any deficiencies of applicable standards identified during the follow up review referenced in (A) above will be identified by ODMHSAS and included in a report provided to the facility by ODMHSAS within three (3) working days of the site visit or review unless precluded by extenuating circumstances. Facilities for which ODMHSAS cannot determine compliance with all pending Clinical Standards categorized as Critical Standards during the follow up site visit or review referenced in (A) above may request ODMHSAS to complete one additional site visit or review prior to the finalization of a certification report. Facilities desiring this additional review must do so in writing to ODMHSAS within three (3) working days of receipt of the follow up report referenced in (A) above and indicate the earliest date by which ODMHSAS should schedule the final review but not more than fifteen (15) working days from receipt of report as referenced in (A) above. If the applicant fails to demonstrate compliance with all Quality Clinical Standards categorized as Critical Standards during the additional site visit or review, the application will be denied.

(8) Facilities for which ODMHSAS can verify substantial compliance with applicable Critical and Necessary Core Organizational Standards, Core Operational Standards, and Quality Clinical Standards during the initial review, and subsequently submit required plans of correction and demonstrate compliance with all Critical Standards within the timeframes specified in (5) through (7) above may be considered for Permit for Temporary Operation in accordance with guidelines established in 450:1-9-5.7.

(9) Anytime, during the process outlined above, ODMHSAS may request one or more written plan(s) of correction in a form and within a timeframe designated by ODMHSAS.

(10) Failure of any applicant for a Permit for Temporary Operation to demonstrate compliance with applicable standards within timeframes stipulated in (5) through (7), shall result in a notice of denial of the application for a Permit for Temporary Operations

(b) Additional certification procedures related to a Permit for Temporary Operations.

(1) Re-application for a Permit can be accepted no sooner than six months after issuance of a notification of denial.

(2) If an applicant fails a second time to satisfy requirements for a Permit for Temporary Operations as stipulated in 450:1-9-7(a)(8), ODMHSAS can accept an additional re-application no sooner than twelve (12) months from time of the issue of the second notification of denial.

(3) Organizations granted a Permit for Temporary Operations must achieve a subsequent level of ODMHSAS certification prior to the expiration of a Permit for Temporary Operations. Failure to do so will result in a cancellation by ODMHSAS of the Permit for Temporary Operations. ODMHSAS will provide notice of the cancellation and stipulate to the organization that it is must discontinue services subject to any statutory provisions that mandate the applicable ODMHSAS Certification. Re-application for a Permit for Temporary Operations, following a cancellation by ODMHSAS or by the organization to which a Permit was issued, may occur after six months and in accordance with the requirements of 450:1-9-7 and 450:1-9-12.

Added at 11 Ok Reg 3335, eff 7-5-94 ; Amended at 13 Ok Reg 2209, eff 7-1-96 ; Amended at 14 Ok Reg 1906, eff 5-27-97 ; Amended at 16 Ok Reg 1466, eff 7-1-99 ; Amended at 17 Ok Reg 2120, eff 7-1-00 ; Amended at 18 Ok Reg 521, eff 10-13-00 (emergency); Amended at 18 Ok Reg 2649, eff 7-1-01 ; Amended at 19 Ok Reg 1346, eff 7-1-02 ; Amended at 20 Ok Reg 2100, eff 7-1-03 ; Amended at 21 Ok Reg 1724, eff 7-1-04 ; Amended at 22 Ok Reg 2099, eff 7-1-05 ; Amended at 23 Ok Reg 1941, eff 7-1-06 ; Amended at 24 Ok Reg 2554, eff 7-12-07 ; Amended at 27 Ok Reg 2200, eff 7-11-10 ; Amended at 30 Ok Reg 1400, eff 7-1-13

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