New Mexico Administrative Code › Title 7 - HEALTH › Chapter 20 - MENTAL HEALTH › Part 11 - CERTIFICATION REQUIREMENTS FOR CHILD AND ADOLESCENT MENTAL HEALTH SERVICES › Section 7.20.11.14 - PROGRAM SURVEYS, INVESTIGATIONS, AND REPORTS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Application for certification, whether
				initial or renewal, constitutes permission for entry into, and surveys of a
				program by the authorized LCA representatives at reasonable times while the
				application is pending.
B. LCA
				surveyors may enter the premises of an agency at any time and review any and
				all records of medicaid recipients, CYFD custody clients and agency staff; the
				LCA may conduct interviews with staff and/or clients in programs that are
				certified or required to be certified, whether or not an application for
				certification has been made, for the purpose of determining compliance with
				these certification requirements.
C. The LCA may conduct a survey(s) to
				assess/monitor progress with correction of violations found on previous
				surveys; or to investigate complaints or allegations of abuse, neglect or
				exploitation. The LCA may also conduct inquiry into matters of potential health
				and/or safety risk to clients as identified in serious incident reports or
				other information received by the LCA.
D. Findings made by the LCA during on-site
				surveys or investigations described in these certification requirements may
				result in changes of certification status, sanction(s), suspension, revocation,
				non-renewal, or denial of certification in accordance with all of the
				guidelines governing such actions as defined in these certification
				requirements.
E. When certification
				on-site surveys are conducted concurrently with licensing on-site surveys and
				there are violations found of both licensing and certification requirements
				that do not directly overlap, the LCA may issue a single report citing
				deficiencies with reference to both licensing and certification
				requirements.
F. When, during a
				certification survey, the LCA finds a violation(s) of these certification
				requirements that also constitute(s) a violation(s) of the licensing
				regulations of the department, the LCA may issue a single report addressing the
				violation(s) with reference to certification requirements only.
G. REPORTS:
(1) The LCA issues a written report of the
				findings for all required certification surveys within 30 business days of
				completion of the survey.
(2) When
				a survey is conducted for purposes of investigation, the LCA issues a report in
				instances of partial or fully substantiated complaint(s)/allegation(s) within
				30 business days of the completion of the investigation.
(3) When a survey is conducted for purposes
				of investigation and the complaint(s)/allegation(s) are unsubstantiated, the
				LCA issues a letter indicating that the complaint was not substantiated, but
				does not issue a report.
(4) When a
				survey is conducted for the purposes of inquiry into questions of compliance
				arising from incident reports or other reports, the LCA may issue a report of
				any findings of noncompliance. If such a report is issued, it will be issued
				within 30 calendar days after completion of the survey.
(5) When a survey is conducted for purposes
				of following-up a monitoring plan, the LCA issues a follow up letter
,
but does not issue a report unless information obtained during such a
				visit indicates the need for a full program review and/or additional
				investigation(s).
(6) When a survey
				is conducted for purposes of technical assistance, the LCA does not issue a
				report.
(7) A report of a survey or
				investigation may be combined with a notice of contemplated action or notice of
				emergency sanction.