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Oklahoma Administrative Code (Last Updated: March 11, 2021) |
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TITLE 450. Department of Mental Health and Substance Abuse Services |
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Chapter 1. Administration |
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Subchapter 9. Certification and Designation of Facility Services |
SECTION 450:1-9-7.3. Additional certification procedures
Latest version.
- (a) 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.(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 one or more 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), the Council on Accreditation of Services for Families and Children, Inc. (COA), or the American Osteopathic Association (AOA) as compliance with certain specific ODMHSAS standards. For such to be considered, the facility shall make application and submit evidence to the ODMHSAS of current accreditation status. 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.(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 450:1-9-7.3.(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 450:1-9-7.3. 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 Permit for Temporary Operations will be forwarded to the ODMHSAS Board, the Commissioner, or designee.(3) Reports for all other Certification applications will be forwarded to the ODMHSAS Board for consideration or in accordance with procedures outlined in 450:21, 450:22, or 450:50.(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 application, and the certification will be considered.(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 450:1-9-5.1.(f) Recommendations for revocation of certification. In the event ODMHSAS can not verify compliance with applicable certification standards in accordance with 450:1-9-5.1, 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.