Oklahoma Administrative Code › Title 450 - Department of Mental Health and Substance Abuse Services › Chapter 1 - Administration › Subchapter 9 - Certification and Designation of Facility Services › Section 450:1-9-7.2 - Procedures for renewal of certification

Current through Vol. 41, No. 20, July 1, 2024
(a) The following procedures apply to
				organizations previously awarded certification pursuant to 450:1-9-5.7 and
				organizations that have maintained Certification or Certification with
				Commendation awarded by ODMHSAS prior to November 1, 2010. The process outline
				below can result in an entity being awarded Certification, Certification with
				Distinction, or Certification with Special Distinction. The process will be
				done in cooperation between the applicant and ODMHSAS staff, and consists of
				the following:
(1) No later than ninety (90)
				days prior to the expiration of a current Certification, ODMHSAS will provide
				the certified facility with a notice of certification expiration and advise the
				facility that a renewal certification application form must be completed so the
				organization can be reviewed for consideration for a renewal of certification.
				Along with the notice of certification expiration, ODMHSAS will provide a
				document listing Core Organization Standards, Core Operational Standards, and
				Quality Clinical Standards potentially applicable to the renewed
				certification.
(2) Each
				organization desiring to renew Certification must submit a completed
				certification application form, fees and other required materials in accordance
				with
				450:1-9-6
				and at least sixty (60) days prior to the expiration of the current
				Certification.
(3) In the event an
				organization, after being notified of the Certification expiration in
				accordance with (1) above fails to submit the renewal certification
				application, fees, or other materials as referenced in (2) above, the current
				Certification will be allowed to expire.
(4) The application shall be reviewed for
				completeness by ODMHSAS staff. If the application is deemed complete, a site
				review of the facility or program will be scheduled and completed.
(5) The facility shall provide ODMHSAS
				documentation regarding its policies and procedures prior to the site review.
				This documentation may include an attestation that the facility's policies and
				procedures have not changed since the latest certification review, or a list of
				which policies and procedures have changed, in lieu of submitting all policies
				and procedures for review.
(6) Any
				deficiencies of applicable standards identified as a result of the renewal site
				visit or subsequent review(s) of documents requested by ODMHSAS will be
				identified and a report will provided to the facility by ODMHSAS within five
				(5) working days of the initial renewal site visit unless precluded by
				extenuating circumstances.
(7) The
				facility will have ten (10) working days from receipt of the report to correct
				deficiencies of all Necessary Standards. ODMHSAS may require an additional site
				visit to verify proof of compliance of Necessary Standards.
(8) The facility will have five (5) working
				days from receipt of the report to submit a plan of correction related to cited
				deficiencies in Critical Standards. The plan of correction will indicate the
				earliest date by which ODMHSAS should schedule an additional review to
				determine compliance with Critical Standards for which deficiencies were cited
				but not more than twenty (20) working days from receipt of report as referenced
				in (6) above. The site visit may or may not be conducted in conjunction with a
				site visit to verify compliance with pending Necessary Standards. Compliance
				with all Critical Standards for which the facility was not compliant upon the
				initial review must be demonstrated through a follow up review.
(9) Any deficiencies of applicable standards
				identified during the follow up review referenced in (8) above will be
				identified by ODMHSAS and included in a report provided to the facility by
				ODMHSAS within three (3) working days of the site visit or review unless
				precluded by extenuating circumstances.
(10) Facilities for which ODMHSAS cannot
				determine compliance with all Critical Standards during the follow up review
				may request ODMHSAS to complete one additional review prior to the finalization
				of a report. Facilities desiring this additional review must do so in writing
				to ODMHSAS within three (3) working days of receipt of the follow up report and
				indicate the earliest date by which ODMHSAS should schedule the final review
				but not more than fifteen (15) working days from receipt of the follow up
				report.
(11) Facilities for which
				ODMHSAS can verify substantial compliance with Critical and Necessary Standards
				upon the initial site review and demonstrate compliance with all Critical
				Standards within the timeframes specified in (7) through (10) above may be
				considered for Certification renewal in accordance with guidelines established
				in 450:1-9-5.7.
(12) Anytime,
				during the process outlined above, ODMHSAS may request one or more written
				plan(s) of correction in a form and within a timeframe designated by ODMHSAS.
(13) If the applicant fails to
				demonstrate compliance with standards within the timeframes specified in (7)
				through (10) above, a recommendation to initiate revocation proceedings must be
				made to the Commissioner or designee. If the Commissioner or designee approves
				the initiation of revocation proceedings, the provisions of Subchapter 5 will
				be followed.