Current through Register Vol. 63, No. 12, December 1, 2024
(1) The Division
shall license a program that meets the definition of a RTF or RTH and
demonstrates compliance with these and all applicable laws and rules. No person
or governmental unit acting individually or jointly with any other person or
governmental unit shall establish, maintain, manage, or operate a program
without a license issued by the Division.
(2) When a program serves or seeks to serve
another category of individuals in addition to adults with a mental health
disorder, the directors of the Authority and the Department shall determine the
department responsible for licensure.
(3) An application for a license must be
accompanied by the required fee and submitted to the Division using the forms
or format required by the Division. The following information must be included
in the application:
(a) Full and complete
information as to the identity and financial interest of each individual,
including stockholders, having a direct or indirect ownership interest of five
percent or more in the program and all officers and directors in the case of a
program operated or owned by a corporation;
(b) Name and resume of the program
administrator;
(c) Physical address
of the setting and mailing address;
(d) Maximum number of individuals to be
served at any one time, their age range and evacuation capability;
(e) Proposed annual budget identifying
sources of revenue and expenses;
(f) Signed criminal record authorizations for
all individuals involved in the operation of the program who contacts the
individuals, including but not limited to caregivers;
(g) Written background information pertaining
to any current or previous licensure or certification by a state agency,
including those licenses or certificates granted to a business or person
affiliated with the business, including:
(A)
Copies of all current licenses or certificates;
(B) Documentation showing the final
disposition of any suspension, denial, revocation, or other disciplinary
actions initiated on any current or previous license or certificate, including
settlement agreements, where applicable; and
(C) Documentation of any substantiated
allegations of abuse or neglect pertaining to the applicant or anyone employed
by or contracted with the applicant.
(h) A complete set of policies and
procedures;
(i) Setting plans and
specifications; and
(j) Other
information the Division may reasonably require.
(4) A complete set of plans and
specifications must be submitted to the Division at the time of initial
application whenever a new structure or addition to an existing structure is
proposed or when significant alterations to an existing facility are proposed.
Plans shall meet the following criteria:
(a)
Plans shall be prepared in accordance with the Building Code and as outlined in
OAR 309-035-0140;
(b) Plans shall be to scale and sufficiently
complete to allow full review for compliance with these rules; and
(c) Plans shall bear the stamp of an Oregon
licensed architect or engineer when required by the Building Code.
(5) Prior to approval of a license
for a new or renovated setting, the applicant shall submit the following to the
Division:
(a) One copy of written approval to
occupy the setting issued by the city or county building codes authority having
jurisdiction;
(b) One copy of the
fire inspection report from the State Fire Marshal or local jurisdiction
indicating that the setting complies with the Fire Code;
(c) When the setting is not served by an
approved municipal water system, one copy of the documentation indicating that
the state or county health agency having jurisdiction has tested and certified
safe the water supply in accordance with OAR chapter 333, Public Health
Division rules to public water systems;
(d) When the setting is not connected to an
approved municipal sewer system, one copy of the sewer or septic system
approval from the Department of Environmental Quality or local jurisdiction.
(6) The following fees
shall be submitted with an initial or renewal application:
(a) The RTF license application fee for
initial or renewal licensing is $60. No fee is required in the case of a
governmentally operated RTF;
(b)
The RTH license application fee for initial or renewal licensing is $30. No fee
is required in the case of a governmentally operated RTH.
(7) A license is renewable upon submission of
a renewal application in the form or format required by the Division and a
non-refundable fee as set out in section (6), except that no fee shall be
required of a governmentally operated program:
(a) Filing of an application for renewal 60
days before the date of expiration extends the effective date of the current
license until the Division takes action upon the renewal application;
(b) The Division shall deny renewal of a
license if the program is not in substantial compliance with these rules or if
the State Fire Marshal or authorized representative has given notice of
noncompliance.
(8) Upon
receipt of an application and fee, the Division shall conduct an application
review. Initial action by the Division on the application shall begin within 30
days of receipt of all application materials. The review shall:
(a) Include a complete review of application
materials;
(b) Determine whether
the applicant meets the qualifications outlined in ORS
443.420 including:
(A) Demonstrates an understanding and
acceptance of these rules;
(B) Is
mentally and physically capable of providing services for
individuals;
(C) Employs or
utilizes only persons whose presence does not jeopardize the health, safety, or
welfare of individuals; and
(D)
Provides evidence satisfactory to the Division of financial ability to comply
with these rules.
(c)
Include a site inspection; and
(d)
Conclude with a report stating findings and a decision on licensing of the
program.
(9) The
Division may elect to deny an application prior to review when:
(a) The applicant has previously had any
action taken on a certificate or license; or
(b) Action taken on a certificate or license
includes denial, suspension, conditions, intent to revoke, or revocation by the
Division, the Authority, the Oregon Department of Human Services, or any other
state agency.
(c) The applicant may
appeal the denial of the application by submitting a request for
reconsideration in writing to the Division within 14 calendar days from receipt
of the denial notice. The Division shall make a decision on the appeal within
30 days of receipt of the appeal. The decision of the Division shall be
final.
(10) The provider
shall submit and complete a plan of correction for each finding of
noncompliance:
(a) If the findings of
noncompliance substantially impact the welfare, health, and safety of
individuals, the provider shall submit a plan of correction that shall be
approved by the Division prior to issuance of a license. In the case of a
currently operating program, the findings may result in suspension or
revocation of a license;
(b) If it
is determined that the findings of noncompliance do not threaten the welfare,
health, or safety of individuals and the program meets other requirements of
licensing, the Division may issue or renew a license with the plan of
correction submitted and completed as a condition of licensing;
(c) The Division shall specify required
documentation and set the timelines for the submission and completion of plans
of correction in accordance with the severity of the findings;
(d) The Division shall review and evaluate
each plan of correction. If the plan of correction does not adequately remedy
the findings of noncompliance, the Division shall require a revised plan of
correction and may apply civil penalties or deny, revoke, or suspend the
license;
(e) The provider owner may
appeal the finding of noncompliance or the disapproval of a plan of correction
by submitting a request for reconsideration in writing to the Division. The
Division shall make a decision on the appeal within 30 days of receipt of the
appeal. The decision of the Division shall be final.
(11) The Division, in its discretion, may
grant a variance to these rules based upon a demonstration by the applicant or
provider that an alternative method or different approach provides equal or
greater program effectiveness and does not adversely impact the welfare,
health, or safety of individuals:
(a) The
provider seeking a variance shall submit in writing an application to the
Division that identifies the section of the rules from which the variance is
sought, the reason for the proposed variance, the proposed alternative method
or different approach, and signed documentation from the CMHP indicating
approval of the proposed variance;
(b) The director or designee shall review and
approve or deny the request for a variance;
(c) The Division shall notify the provider of
the decision in writing within 30 days after receipt of the request. A variance
may be implemented only after receipt of written approval from the
Division;
(d) The provider may
appeal the denial of a variance request by submitting a request for
reconsideration in writing to the Division's Director. The Director shall make
a decision within 30 days of receipt of the appeal. The decision of the
Director shall be final; and
(e) A
variance shall be reviewed by the Division at least every two years and may be
revoked or suspended based upon a finding that the variance adversely impacts
the welfare, health, or safety of the individuals.
(12) Upon finding that the applicant is in
substantial compliance with these rules, the Division shall issue a license:
(a) The license issued shall state the name
of the provider, the name of the program administrator, the address of the
setting to which the license applies, the maximum number of individuals to be
served at any one time and their evacuation capability, the type of program,
and such other information as the Division deems necessary;
(b) A program license shall be effective for
two years from the date issued unless sooner revoked or suspended;
and
(c) A program license is not
transferable or applicable to any setting, location, or management other than
that indicated on the application and license.
(13) The license shall be valid only under
the following conditions:
(a) The provider
may not operate or maintain the program in combination with a nursing facility,
hospital, retirement facility, or other occupancy unless licensed, maintained,
and operated as a separate and distinct part. Each program shall have sleeping,
dining, and living areas for use only by its own individual's caregivers and
invited guests;
(b) The provider
shall maintain the license posted in the setting and available for inspection
at all times; and
(c) A license
becomes void immediately upon suspension or revocation of the license by the
Division or if the operation is discontinued by voluntary action of the
provider or if there is a change of ownership.
(14) Division staff shall visit and inspect
every setting at least once every two years to determine whether it is
maintained and operated in accordance with these rules. The provider or
applicant shall allow Division staff entry and access to the setting and
individuals for the purpose of conducting the inspections:
(a) Division staff shall review methods of
individual care and treatment, records, the condition of the setting and
equipment, and other areas of operation;
(b) All records, unless specifically excluded
by law, shall be available to the Division for review; and
(c) The State Fire Marshal or authorized
representatives shall, upon request, be permitted access to the setting, fire
safety equipment within the setting, safety policies and procedures,
maintenance records of fire protection equipment and systems, and records
demonstrating the evacuation capability of setting occupants.
(15) Incidents of alleged abuse
covered by ORS 430.735 through
430.765 and reported complaints
shall be investigated in accordance with OAR
943-045-0250 through 0370. The
Division may delegate the investigation to a CMHP or other appropriate
entity.
(16) The Division may deny,
suspend, revoke or refuse to renew a license when it finds there has been
substantial failure to comply with these rules or when the State Fire Marshal
or authorized representative certifies that there is failure to comply with the
Fire Code:
(a) In cases where there exists an
imminent danger to the health or safety of an individual or the public, a
license may be suspended immediately; and
(b) The revocation, suspension, or denial
shall be done in accordance with ORS
443.440
(17) The provider shall report promptly to
the Division any significant changes to information supplied in the application
or subsequent correspondence. Changes include but are not limited to changes in
the setting or program name, provider, program administrator, telephone number,
and mailing address. Changes also include but are not limited to changes in the
physical nature of the setting, policies and procedures, or staffing pattern
when the changes are significant or impact the individual's health, safety, or
well-being.
(18) Enforcement of
Home and Community-Based Services and Settings Requirements:
(a) All programs licensed on or after July 1,
2016, shall be in full compliance with all regulatory requirements under these
rules at the time of initial licensure;
(b) All programs licensed prior to July 1,
2016, shall come into compliance with rules as follows:
(A) All programs shall be in full compliance
with these rules no later than January 1, 2017; and
(B) For the rules designated by the Division
to become effective July 1, 2016, the provider shall make measureable progress
towards compliance with those rules. The Division may not issue sanctions and
penalties for failure to meet the rules effective July 1, 2016, or the
obligations imposed by OAR Chapter 411, division 4 until January 1, 2017, if
the provider is making measureable progress towards compliance.
Statutory/Other Authority: ORS
413.042, ORS
443.450 & ORS
443.420
Statutes/Other Implemented: ORS
413.032, ORS
443.400 -
443.465 & ORS
443.991