Current through September 21, 2024
(a) As set forth in W.S. §
9-2-2701(c), no program,
provider, or facility may receive state funds for substance abuse prevention,
early intervention recovery support services, or treatment services unless
certified under these rules. Additionally, no substance abuse treatment program
may receive court referred or ordered clients unless it is certified under
these rules.
(b) All certified
substance abuse service providers who are required to be certified shall meet
the requirements set forth in these rules. Programs that sub-contract with
providers for services must assure that the contractors are in compliance with
these rules and thus the program will take full responsibility for these
sub-contractors under the program's certification. Programs located outside of
Wyoming may be certified, at the discretion of the Division, if they meet the
applicable provisions of these rules.
(c) The Division can, under critical issues
regarding safety of client, public or staff, conduct unannounced site visits to
investigate such occurrences.
(d)
If a program has a current recognized national accreditation for substance
abuse treatment by specific level of care, applicable portions of this
accreditation can be reviewed as part of the certification site visit at the
discretion of the Division or its designee, utilizing the following processes.
(i) Applicable portions of the national
accredited report by level of service that are congruent with these rules will
be accepted in lieu of reviewing documentation for compliance with these
rules.
(ii) Sections that are not
congruent with these rules will be reviewed as part of the certification site
visit. If Wyoming Standards exceed national accreditation standards, Wyoming
Standards will be required and reviewed for compliance.
(iii) Records will be reviewed for compliance
by level of service when national accreditation standards require state
compliance for approval under the national standards.
(iv) Certification reports will reference
portions that were viewed as congruent by level of service in the certification
report and note compliance.
(e) Any program or provider seeking
certification under these rules shall apply to the Division for certification
on a form provided by the Division.
(f) Upon receipt of a completed application,
the Division shall review the application for compliance with these rules. The
review may include an on-site inspection. Within sixty (60) calendar days after
receiving the completed application, the Division shall either approve or deny
the application. Failure of the Division or its designee to meet this deadline
shall not be construed as approval of the application.
(g) An application may be approved subject to
conditions provided those conditions are fully set forth in the letter
communicating them to the applicant. In the event an application is approved
subject to conditions, the applicant must communicate its plan for complying
with the condition within fifteen (15) business days of receiving the
notification. If the applicant is unwilling to comply with the conditions, the
application shall be deemed denied pending further negotiations.
(h) The Division or its designated contractor
can conduct on-site certification reviews, including review of organization,
personnel, fiscal and clinical records, to assure that programs are meeting
compliance. Confidentiality of records will be kept per 42 CFR, Part 2, Federal
Confidentiality, and 45 CFR Part 160 and 164, Health Insurance Portability and
Accountability Act (HIPAA). The Division may issue a certification for any
period not to exceed two (2) years based on compliance level resulting from the
on-site certification review. The certification shall remain in effect for the
period designated, unless suspended or revoked prior to expiration. Providers
seeking renewal will complete a renewal application in a form approved by the
Division.
(i) The program shall
submit to the Division a written corrective action plan if the provider
receives a certification report below the minimum compliance level as
determined by Division policy. Other critical issues that put the client, staff
or public at risk will result in corrective action even if overall minimum
compliance is within the acceptable range. The correction plan must be
submitted to the Division within thirty (30) days of receipt of the request
from the Division, unless requested in writing sooner.
(j) The Division shall review the corrective
action plan and will notify the program of either the acceptance or rejection
of the plan. An unacceptable plan must be amended and resubmitted within
fifteen (15) business days of date of notice of rejection.
(k) Failure to make corrections pursuant to
an approved correction plan may result in appropriate action under Chapter 2,
Section 2(m)(ii), of these rules.
(l) Denial/Suspension/Revocation.
(i) The Division may deny an application to
issue a certification if an applicant fails to meet all of the requirements of
these rules, and may refuse to renew the certification if the applicant no
longer meets or has violated any provision of these rules.
(ii) The Division may at any time upon
written notification to a certified program or provider, suspend or revoke the
certificate if the Division finds that the provider does not comply with these
rules. The notice shall state the reasons for the action and shall inform the
certificate holder of actions necessary to remedy the failures and of their
right to a hearing under the Wyoming Administrative Procedure Act. In addition
to revoking or suspending a certification, the Division may, in its discretion,
place a program on probation under a specified, mutually agreeable written
correction plan. If another state agency revokes a provider
certification/license or terminates their contract, the Division may, after
review of the reasons of such action and subsequent on-site investigation,
revoke the certification of any services approved by the Division.
(iii) In the event a certification is
suspended or revoked, notice shall be provided promptly by the Division to all
courts that may refer persons to that program. Notice of final disposition of
the matter shall also be promptly provided to those courts. If the Division
denies, refuses to renew, suspends, or revokes a certification, the aggrieved
party may request an administrative hearing under the Wyoming Administrative
Procedure Act. A request for a hearing must be received by the Division within
thirty (30) calendar days of the action from which the appeal is taken. If a
timely request for hearing is not received by the Division, no hearing will be
available. If a timely request for hearing is received, the action is stayed
pending a decision on the appeal, except where the Division finds in writing
that the health, safety, or welfare of clients requires that the action take
effect immediately.
(m)
Complaints.
(i) A complaint may be made by a
program director or any person setting forth in writing the act done or omitted
by the provider in violation of state and federal law, order, rule, or standard
that the Division has jurisdiction over. If the complaint(s) are not under the
jurisdiction of the Division, the person making the complaint will be directed
to the appropriate authority for review. The complaint shall state the
following information: the name, address, and telephone number of the
complaining party, and the party, person, or programs the complaint is against;
a clear and complete statement of the alleged violation of the law, order, rule
or standard complained of, together with the facts which will give the parties
a clear and full understanding of the nature of the alleged violation. The
allegations may be supported by sworn statements attached to the complaint, a
statement of the relief requested, and the signature of the complaining party
or his or her attorney.
(ii) The
Division shall establish policies and procedures to ensure that complaints are
properly evaluated, documented, acknowledged, and handled in a timely and
appropriate manner. The allegations of the complaint shall determine the tasks
required and the nature and scope of any investigation that may occur. The
order and manner in which information is gathered depends on the type of
complaint that is being investigated.
(iii) The Division, on its own initiative or
following the receipt of a complaint, may conduct an investigation of a
program. The purpose of an investigation is to endeavor to bring about
satisfaction of the complaint and/or violation.
(iv) Upon initiation of an investigation, the
Division shall provide the program director and the board of directors of the
program a copy of the complaint and supporting materials in order to allow
responding parties the opportunity to provide an informed response to the
complaint. The investigation may include on-site inspection and collection of
all available pertinent information concerning the operation of the program as
it relates to the complaint being investigated. The Division may consult with
the program director, the governing body of the program, the staff of the
program, clients, parents or guardians of clients, and other pertinent and
reliable sources of information about the program.
(v) The program director and other responding
parties shall file a response to the complaint with the Division no later than
twenty (20) calendar days after receipt of the complaint. For good cause shown,
the Division may extend the time to respond to the complaint.
(vi) The investigation will begin upon the
filing of the response. Within forty-five (45) calendar days of the initiation
of an investigation, a preliminary report of the status of the investigation
shall be issued to the complaining party and the responding parties. A final
report of the investigation shall be issued within one hundred and twenty (120)
calendar days of the initiation of the investigation. For good cause shown, the
Division may extend the time of the investigation. The Division will provide a
status summary every thirty (30) calendar days thereafter to the program
director and the board president until the investigation process is
complete.
(vii) After an
investigation has been completed, the Division shall notify the program
director, board president, if applicable, complaining party, and responding
parties of the findings of the investigation. The Division may specify the
necessary corrective action and the timeline for completion of the corrective
action.
