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 450:1-9-7.2 - Procedures for renewal of certification

(1) No later than ninety (90) days prior to the expiration of a current Certification, ODMHSAS will provide the certified facility with a notice of certification expiration and advise the facility that a renewal certification application form must be completed so the organization can be reviewed for consideration for a renewal of certification. Along with the notice of certification expiration, ODMHSAS will provide a document listing Core Organization Standards, Core Operational Standards, and Quality Clinical Standards potentially applicable to the renewed certification.

(2) Each organization desiring to renew Certification must submit a completed certification application form, fees and other required materials in accordance with 450:1-9-6 and at least sixty (60) days prior to the expiration of the current Certification.

(3) In the event an organization, after being notified of the Certification expiration in accordance with (1) above fails to submit the renewal certification application, fees, or other materials as referenced in (2) above, the current Certification will be allowed to expire.

(4) The application 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.

(5) The facility shall provide ODMHSAS documentation regarding its policies and procedures prior to the site review. This documentation may include an attestation that the facility's policies and procedures have not changed since the latest certification review, or a list of which policies and procedures have changed, in lieu of submitting all policies and procedures for review.

(6) Any deficiencies of applicable standards identified as a result of the renewal site visit or subsequent 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 initial renewal site visit unless precluded by extenuating circumstances.

(7) The facility will have ten (10) working days from receipt of the report to correct deficiencies of all Necessary Standards. ODMHSAS may require an additional site visit to verify proof of compliance of Necessary Standards.

(8) The facility will have five (5) working days from receipt of the report to submit a plan of correction related to cited deficiencies in Critical Standards. The plan of correction will indicate the earliest date by which ODMHSAS should schedule an additional review to determine compliance with Critical Standards for which deficiencies were cited but not more than twenty (20) working days from receipt of report as referenced in (6) above. The site visit may or may not be conducted in conjunction with a site visit to verify compliance with pending Necessary Standards. Compliance with all Critical Standards for which the facility was not compliant upon the initial review must be demonstrated through a follow up review.

(9) Any deficiencies of applicable standards identified during the follow up review referenced in (8) 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.

(10) Facilities for which ODMHSAS cannot determine compliance with all Critical Standards during the follow up review may request ODMHSAS to complete one additional 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.

(11) Facilities for which ODMHSAS can verify substantial compliance with Critical and Necessary Standards upon the initial site review and demonstrate compliance with all Critical Standards within the timeframes specified in (7) through (10) above may be considered for Certification renewal in accordance with guidelines established in 450:1-9-5.7.

(12) 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.

(13) If the applicant fails to demonstrate compliance with standards within the timeframes specified in (7) through (10) above, a recommendation to initiate revocation proceedings must be made to the Commissioner or designee. If the Commissioner or designee approves the initiation of revocation proceedings, the provisions of Subchapter 5 will be followed.