415-012-0032 Application Information An applicant for a license shall submit the information listed below on forms provided by the Division: (1) Name and address of the applicant; (2) Name, address, and qualifications of the executive director or administrator; (3) Outline of the staff organization with names and qualifications; (4) Articles of incorporation and bylaws; (5) Names and addresses of the board of directors, sponsors, or advisory boards of the program; (6) Names and addresses of physicians, other professionally trained personnel, medical facilities, and other individuals or organizations with whom the program has a direct referral agreement or is otherwise affiliated; (7) Description of the treatment services provided by the program setting forth program philosophy, goals, objectives, and a description of the treatment methodology for each service element; (8) Materials demonstrating compliance with the administrative rules governing the specific service provided; (9) Materials showing compliance with all related federal, state and local acts, ordinances, rules and amendments such as State Fire Marshal rules, board of health and building zoning codes, and the American Disabilities Act; (10) Materials substantiating compliance with distance requirements subject to ORS 430.590 for programs using methadone to treat opioid addiction. These application procedures apply to new programs and existing programs moving to a new location after 1-14-2013; (11) Materials substantiating compliance with other licensing authorities such as the Child Welfare Division for residential adolescent services or the Drug Enforcement Administration and a federally approved accreditation agency for methadone treatment services; (12) For residential treatment and detoxification facilities, the maximum individual capacity requested; (13) Source of funds used to finance the program such as an annual budget of the organization or a copy of the most current fiscal audit or review; (14) Written evidence of applicable insurance such as liability insurance; (15) Floor plan for the proposed facility; (16) Representative sample individual file; (17) Written nondiscrimination policy including: (a) Explanation of methods used to disseminate the policy; (b) Description of procedures used to communicate with sensory impaired person or persons of limited English proficiency; (c) Written statement about the accessibility of the facility and services for disabled persons; and (d) Written grievance procedure for handling discrimination complaints. (18) Identification of any individual, including stockholders or other legal entities, who have an ownership interest of any person, property or structure representing five percent or more. For purposes of these rules, an individual with a five percent or more ownership interest is presumed to have an effect on the operation of the provider, unless the individual establishes that the individual has no involvement in the operation of the provider; (19) Background information on all licenses, certifications and letters of approval held or previously held by the applicant, or by any owner disclosed under subsection (e) of this rule, to provide care or treatment, or engage in a profession or trade. The list shall include every license, certification and letter of approval, regardless of whether it was issued by the Authority or another regulatory body: (a) The type of license or certification; (b) The name of the issuing regulatory body; (c) The name of the individual or business to whom it was issued; (d) The start and end date of the period of license or certification; (e) A list of the dates of any suspensions, revocations, conditions, penalties, denials, nonrenewal, or other adverse actions initiated or taken on a license or certificate, including documentation of the final resolution of those actions; (f) Disclosure of whether any of the licenses or certificates had expired or were relinquished while a suspension, revocation, condition, penalty, denial, nonrenewal or other adverse action was pending or proposed; and (g) Copies of all current licenses or certificates. (20) Disclosure of any substantiated findings of abuse, neglect, or mistreatment by the applicant, owner, or program staff. Statutory/Other Authority: ORS 413.042 & ORS 430.256 Statutes/Other Implemented: ORS 430.010-430.030, ORS 430.306, ORS 430.397, ORS 430.405, ORS 430.450, ORS 430.630, ORS 430.850 & ORS 443.400 History: ADS 4-2018, amend filed 05/10/2018, effective 05/10/2018 ADS 3-2017, temporary amend filed 12/01/2017, effective 12/01/2017 through 05/29/2018 ADS 4-2013, f. & cert. ef. 5-3-13