Washington Administrative Code
Title 246 - Health, Department of
FACILITY STANDARDS AND LICENSING
Chapter 246-341 - Behavioral health agency licensing and certification requirements
BEHAVIORAL HEALTH-AGENCY LICENSURE AND CERTIFICATION
Section 246-341-0320 - Agency licensure and certification-On-site reviews and plans of correction

Universal Citation: WA Admin Code 246-341-0320

Current through Register Vol. 24-18, September 15, 2024

Each agency is subject to an initial on-site review and each agency that is not deemed in accordance with WAC 246-341-0310 is subject to routine, ongoing on-site reviews to determine if the agency is in compliance with the minimum licensure and certification standards.

(1) The agency shall participate in an entrance conference conducted by the department review team representative(s) and an on-site review. This may include:

(a) A review of:

(i) Agency policies and procedures;

(ii) Personnel records;

(iii) Individual service records;

(iv) Facility accessibility;

(v) The agency's internal quality management plan, process, or both, that demonstrates how the agency evaluates program effectiveness and individual participant satisfaction; and

(vi) Any other information, including the criteria in WAC 246-341-0335(1)(b), that the department determines to be necessary to confirm compliance with the minimum standards of this chapter; and

(b) Interviews with:

(i) Individuals served by the agency; and

(ii) Agency staff members.

(2) The agency shall participate in an exit conference with the department review team representative(s) at the conclusion of the on-site review which includes a discussion of any findings.

(3) The department will send the agency a statement of deficiencies report that will include instructions and time frames for submission of a plan of correction.

(4) The agency shall correct the deficiencies listed on the plan of correction:

(a) By the time frame agreed upon by the agency and the department review team representative; or

(b) Immediately if the department determines health and safety concerns require immediate corrective action.

(5) On-site reviews of branch sites will occur at the same time as the main site review and take place at the main site location so long as the department can access the following either electronically or by hard copies brought to the main site agency location:

(a) Personnel records of employees hired since the previous review;

(b) A sample of individual service records that reflect the services provided at each branch site location; and

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