309-008-0800 Conduct of Certification Reviews (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 History: BHS 11-2018, amend filed 05/10/2018, effective 05/10/2018 MHS 15-2017, temporary amend filed 12/01/2017, effective 12/01/2017 through 05/29/2018 MHS 4-2017, f. 5-23-17, cert. ef. 6-1-17 MHS 30-2016(Temp), f. 12-30-16, cert. ef. 1-1-17 thru 6-29-17 MHS 16-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 6-2016(Temp), f. 6-28-16, cert. ef. 7-1-16 thru 12-27-16