Current through Register Vol. 63, No. 9, September 1, 2024
(1) The Division shall employ review
procedures deemed adequate to determine applicant or provider compliance with
applicable administrative rules, statutes, other applicable regulations, and as
necessary, contractual obligations. These procedures may include but are not
limited to:
(a) Entry and inspection of any
service delivery location;
(b)
Document review; and
(c) Interviews
with or a request for completion of a questionnaire by individuals
knowledgeable about the provider or applicant. Individuals interviewed may
include program staff, managers, governing or advisory board members, allied
agencies, individuals, their family members, and significant others.
(2) Program staff must cooperate
with the Division during a certification review.
(3) Within 30 days following the completion
of each discretionary review, the Division may at its discretion issue a report
and require a Plan of Correction (POC) congruent with section (4) of this
rule.
(4) Within 30 days following
the completion of each initial or renewal certification review, the Division
shall issue a report that includes:
(a) A
statement of any deficiency including a description of the review findings
related to non-compliance with applicable administrative rules, statutes, other
applicable regulations, and any required corrective actions where
applicable;
(b) Pursuant to a
certification review when the Division determines a provider or applicant is
not operating in substantial compliance with all applicable statutes,
administrative rules, and other regulations, and the POC process is
appropriate, the Division may require the provider or applicant to submit a
POC. The Division shall provide written notice of the requirement to submit a
POC, and the provider or applicant shall prepare and submit a POC according to
the following terms:
(A) The provider or
applicant shall submit the POC to the Division within 30 days of receiving the
statement of deficiency. The Division may issue up to a 90-day extension to the
existing certification to allow the provider or applicant to complete the POC
process;
(B) The POC shall address
each finding of non-compliance and shall include:
(i) The planned action already taken or to be
taken to correct each finding of non-compliance;
(ii) The anticipated or requested timeframe
for the completion of each corrective action not yet complete at the time of
POC submission to the Division;
(iii) A description of and plan for quality
assurance activities intended to ensure ongoing compliance; and
(iv) The name of the individual responsible
for ensuring the implementation of each corrective action within the POC.
(c) If the
Division finds that clarification or supplementation to the POC is required
prior to approval, the Division shall contact the provider or applicant to
provide notice of requested clarification or supplementation, and the provider
or applicant shall submit an amended POC within 14 calendars days of
notification;
(d) The provider
shall submit a sufficient POC approved by the Division prior to receiving a
certificate. Upon the Division's approval of the POC, the Division shall issue
the appropriate certification;
(e)
The Division may deny, revoke, not renew, or place conditions on an applicant
or provider's certification if the provider fails to submit an adequate POC
within the timeframes established in this rule.
Statutory/Other Authority: ORS
179.040,
179.505, ORS
413.042,
413.032-413.033,
426.072,
426.236,
426.500,
430.010,
430.021,
430.256,
430.357,
430.560,
430.640,
430.870 &
743A.168
Statutes/Other Implemented: 413.520, 426.060, 426.140,
430.010, 430.254, 430.335, 430.590, 430.620 &
430.637
