Current through Vol. 41, No. 13, March 15, 2024
(a)
Site reviews. The following conditions will apply to site visits
and other related certification reviews conducted by ODMHSAS.
(1) Initial, renewal or follow-up site
reviews, based on the current certification status of the applicant, will be
scheduled and conducted by designated representatives of the ODMHSAS at each
location or site of the applicant. ODMHSAS may conduct virtual site visits at
its discretion.
(2) ODMHSAS may
require materials be submitted to Provider Certification, in a form determined
by ODMHSAS, prior to on-site visits to verify compliance with applicable Core
Organizational Standards, Core Operational Standards, and/or Quality Clinical
Standards.
(3) One or more site
review(s) may be conducted to determine compliance with prior deficiencies as
well as with standards not applicable during the prior certification visit(s).
(4) A minimum number of consumer
records, as determined by ODMHSAS, shall be made available for review to
determine compliance with applicable Quality Clinical Standards. For
organizations unable to provide the required minimum of records, the current
certification status, including a Permit for Temporary Operations, will be
allowed to expire. ODMHSAS may require review of additional consumer records to
assure a representative sample of records is evaluated to determine compliance
with Quality Clinical Standards.
(5) A Site Review Protocol shall be completed
during each certification review. Protocols shall contain the current ODMHSAS
Standards and Criteria applicable to the facility.
(A) A facility must be prepared to provide
evidence of compliance with each applicable standard.
(B) In the event the reviewer(s) identifies
some aspect of facility operation that adversely affects consumer safety or
health, the reviewer(s) shall notify the facility director and appropriate
ODMHSAS staff. An immediate suspension of certification may be made by the
Commissioner of ODMHSAS.
(b)
Accreditation status. The
ODMHSAS may accept accreditation granted by The Joint Commission (TJC), the
Commission on Accreditation of Rehabilitation Facilities (CARF), or the Council
on Accreditation of Services for Families and Children, Inc. (COA), as
compliance with certain specific ODMHSAS standards. For such accreditation to
be considered, the facility shall make application and submit evidence to the
ODMHSAS of current accreditation status and scope. This evidence shall include
documentation of the program or programs included in the most recent
accreditation survey, including survey reports of all visits by the accrediting
organization, any reports of subsequent actions initiated by the accrediting
organization, any plans of correction, and the dates for which the
accreditation has been granted. ODMHSAS may, at its discretion, conduct
additional compliance monitoring and verification of standards deemed compliant
based upon accreditation status.
(c)
Deficiencies. A deficiency
shall be cited for each rule not met by the facility.
(d)
Report to applicant and plan of
correction.
(1) During the course of
the certification process, and prior to determination of certification status,
ODMHSAS staff shall report the results of the certification review to the
facility. The facility shall receive written notice of the deficiencies in a
Certification Report in accordance with
450:1-9-7,
450:1-9-7.1,
and
450:1-9-7.2.
(2) The facility may be required to submit a
written plan of correction as determined by
450:1-9-7,
450:1-9-7.1,
and
450:1-9-7.2.
Approval of the plan of correction by Provider Certification may be required
before a final report of findings can be presented to ODMHSAS or the
Board.
(3) If a request for a
revised plan of correction is necessary, the facility must submit an acceptable
plan of correction within the required time frame to continue the certification
process. Failure to submit a timely and adequate revised plan of correction
shall result in either a notice of denial of the application, expiration of
certification, or revocation of the certification status, as
applicable.
(e)
Notification of consideration and possible action for
certification.
(1) After consideration
of materials requested by ODMHSAS pursuant to certification procedures, and
completion of the necessary review(s), ODMHSAS staff shall prepare a report
that summarizes findings related to compliance with applicable certification
standards.
(2) Reports regarding
applications for Permits for Temporary Operations and Certifications will be
forwarded to the ODMHSAS Board, and/or the Commissioner or designee.
(3) Reports for individual certification
applications will be handled in accordance with procedures outlined in OAC
450:21, OAC 450:50, OAC 450:53, or OAC 450:75.
(4) Prior to the ODMHSAS staff's presentation
of its report related to the applicant's certification to the Board or the
Commissioner or designee, the ODMHSAS staff shall notify the applicant of:
(A) the findings included in the report, and
(B) the date and time of the Board
meeting at which the facility's certification will be considered, if applicable
.
(5) Achievement of
certain scores is a prerequisite for consideration of a specific certification
status but may not be the sole determinant. Individual deficiencies that meet
the criteria in
450:1-9-9
may be grounds for suspending or revoking certification or denying applications
for certification.
(6)
Consideration of certification may be deferred while additional information
regarding a facility's compliance status is reviewed.
(7) The minimum conditions for compliance
that must be verified by ODMHSAS for consideration of a certification status
shall be stipulated in 450:1-9-5.7.
(f)
Recommendations for revocation of
certification. In the event ODMHSAS cannot verify compliance with
applicable certification standards in accordance with 450:1-9-5.7, except for
Permits for Temporary Operations, ODMHSAS shall forward recommendation for
revocation of certification to the Commissioner or designee. If the
Commissioner or designee approves a recommendation to revoke certification, an
individual proceeding shall be initiated pursuant to Subchapter 5. Applicants
unable to demonstrate compliance with standards required for Permit for
Temporary Operation are not subject to the provisions for revocation and are
simply denied the Permit as stipulated in
450:1-9-7.
Added at 27 Ok Reg 2200, eff 7-11-10 ; Amended at 30 Ok
Reg 1402, eff 7-1-13
