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 450:1-9-7.1 - Procedures for completion of additional certification processes subsequent to a Permit for Temporary Operations

(1) No later than ninety (90) days prior to the expiration of a Permit for Temporary Operation, ODMHSAS will notify the facility of necessary records and documentation to verify compliance with applicable Quality Clinical Standards for Certification. The facility shall provide the required materials within thirty (30) days of notification from ODMHSAS.

(2) A site review of the facility or program will be scheduled and completed once the necessary records and documentation have been received.

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

(4) The facility will have ten (10) working days from receipt of the deficiency report to correct deficiencies related to 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. ODMHSAS may conduct an additional site visit(s) to verify proof of compliance. Compliance with all Quality Clinical Standards categorized as Critical Standards for which the facility was not compliant upon the initial review must be demonstrated through a follow up review.

(5) If any pending deficiencies in Quality Clinical 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.

(6) Facilities for which ODMHSAS cannot determine compliance with all Quality Clinical Standards categorized as Critical Standards during the follow up site visit or review may request ODMHSAS to complete one additional site visit or review prior to the finalization of a 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 and indicate the earliest date by which ODMHSAS should schedule the final review but not more than fifteen (15) working days from receipt of the follow up report. If the applicant fails to demonstrate compliance during the additional site visit or review, the application for subsequent certification shall be denied, and the Permit for Temporary Operations will expire.

(7) Facilities for which ODMHSAS can verify substantial compliance with applicable Critical and Necessary Quality Clinical Standards during the initial review, and subsequently submit required plans of correction and demonstrate compliance with all Critical Quality Clinical Standards within the timeframes specified in (4) through (6) above may be considered for Certification in accordance with guidelines established in 450:1-9-5.7.

(8) 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.

(9) Failure of any applicant to demonstrate compliance with standards within the timeframes specified in (4) through (6) above shall result in denial of the application for subsequent certification and the Permit for Temporary Operations will expire.