3793:2-1-01 Program certification/licensure process.

(A) The purpose of this rule is to state the procedures for certification and licensure of alcohol and drug addiction programs in Ohio.

(B) The provisions of this rule are applicable to all of the following Ohio alcohol and drug addiction programs, public and private, regardless of whether they receive any public funds that originate and/or pass through the Ohio department of alcohol and drug addiction services in accordance with division (A) of section 3793.06 of the Revised Code:

(1) Alcohol and drug addiction outpatient treatment programs.

(2) Alcohol and drug addiction residential treatment programs.

(3) Opioid agonist programs.

(4) Detoxification programs.

(C) The provisions of this rule are not applicable to the following programs:

(1) Alcohol and drug prevention programs.

(2) Criminal justice therapeutic community programs.

(3) Treatment alternatives to street crime programs.

(4) Driver intervention programs.

(5) Programs located outside the state of Ohio.

(D) Procedure for processing an application for certification/licensure for programs not currently certified and opioid agonist programs.

(1) Any Ohio alcohol and drug addiction outpatient treatment program, residential treatment program, opioid agonist program, or detoxification program subject to or seeking program certification/licensure pursuant to division (A) of section 3793.06 of the Revised Code shall apply to the Ohio department of alcohol and drug addiction services by filing an application that includes, but is not limited to, the following information for each program site to be certified/licensed by the department:

(a) Name, address, telephone number and county of each program site to be certified by the Ohio department of alcohol and drug addiction services. A location which would be considered the client's natural environment (e.g. school, home, job and family services agency) is not considered a site and need not be certified.

(b) Program and business hours of operation for alcohol and drug addiction services.

(c) The alcohol and drug addiction services the program provides.

(d) Copy of an Ohio food services operator's license if required by the Ohio department of health.

(e) Copy of an occupancy and use certificate issued by the division of construction compliance of the Ohio department of commerce or issued by an Ohio certified building department of a municipal corporation, township or county which has been established in conformity with law for the purpose of enforcing the "Ohio Basic Building Code" for the location where the program will be conducted.

(f) Copy of a current annual fire inspection by an Ohio certified fire authority or by the division of the state fire marshal of the Ohio department of commerce for the location where services will be provided.

(g) A copy of the owner's current registration for doing business in Ohio that has been filed with the Ohio secretary of state.

(h) If the owner is an out-of-state corporation, a copy of the license from the Ohio secretary of state for doing business in Ohio.

(i) If the program is a non-profit organization, a copy of the approved statement of continued existence approved by the Ohio secretary of state.

(j) Opioid agonist programs shall submit a copy of the current certification from the substance abuse and mental health services administration to use an opioid agonist in the maintenance treatment of opioid addiction.

(k) List of clinical staff, license number, and licensing body.

(l) Residential, halfway house treatment, detoxification programs shall indicate the number of alcohol and other drug beds for each type of treatment program.

(m) Programs requesting a variance or an extension of a variance for one or more of the program certification/licensure standards shall include a copy of the request with the program certification/licensure application. Each variance request shall be prepared and submitted in accordance with this rule.

(n) The application shall be signed and dated by the executive director, CEO or president of the organization.

(2) Upon receipt of an application, the Ohio department of alcohol and drug addiction services shall:

(a) Notify, in writing, the applicable alcohol and drug addiction services board or the alcohol, drug addiction and mental health services board of the application.

(b) Review the application to determine if it is complete.

(i) If an application is incomplete, the department shall notify the applicant of corrections or additions needed and/or may return the materials to the applicant.

(ii) The department's return of the materials to the applicant or failure of the department to take further action to issue a certificate/license shall not constitute denial of an application for program certification or licensure.

(3) Upon acceptance of an application the Ohio department of alcohol and drug addiction services shall contact the program to schedule an on-site inspection of the program.

(a) The department shall send the program a letter confirming the date of the on-site inspection.

(b) The department shall notify, in writing, the applicable alcohol and drug addiction services board or the alcohol, drug addiction and mental health services board of the date of the on-site inspection.

(4) The Ohio department of alcohol and drug addiction services shall conduct an on-site inspection at the time of application, with official written notice to the program, or at any other time for cause as determined by the department , with or without official written notice to the program.

(5) The Ohio department of alcohol and drug addiction services shall have access to all program-related records to verify compliance with program certification and/or licensure standards as established by department rules. The department may conduct interviews with members of the program's governing authority, program staff, others in the community and/or clients with the clients' permission.

(6) The Ohio department of alcohol and drug addiction services shall prepare a follow-up inspection report for the on-site inspection of the program.

(a) The inspection report shall cite any standards with which the program was not in compliance at the time of the on-site inspection.

(b) The Ohio department of alcohol and drug addiction services shall provide a copy of the on-site inspection report to the program and to the applicable alcohol and drug addiction services board or the alcohol, drug addiction and mental health services board.

(c) Programs shall correct deficiencies identified during a program certification/licensure inspection conducted by the Ohio department of alcohol and drug addiction services and documentation of correction of the deficiencies shall be sent to the department within the time frame specified in the follow-up inspection report.

(7) The Ohio department of alcohol and drug addiction services shall issue a certificate or license to each applicant complying with the program certification or licensure standards.

(a) Certificates for outpatient and residential treatment programs and detoxification programs shall not exceed three years.

(b) Licenses for opioid agonist programs shall be for one year.

(c) The department shall provide the program with the original certificate or license, and provide a copy of the certificate or license to the applicable alcohol and drug addiction services board or the alcohol, drug addiction and mental health services board.

(d) The program site shall display the certificate in a prominent location where services are provided.

(E) Conditional program certification/licensure.

(1) Conditional program certification/licensure may be granted by the Ohio department of alcohol and drug addiction services to enable the program to serve clients, to establish and maintain client records, to implement quality improvement activities and/or to correct deficiencies identified during an on-site program certification/licensure inspection.

(2) The Ohio department of alcohol and drug addiction services may issue a conditional program certification/licensure for a maximum period of ninety days.

(F) Relocation of a certified program shall render the certification and/or licensure void. Void certificates/licenses shall be returned to the Ohio department of alcohol and drug addiction services.

(1) A program shall submit an application for program certification and/or licensure of a new site location to the Ohio department of alcohol and drug addiction services at least thirty days prior to relocation to avoid possible non-certified or non-licensure status of the program.

(2) Upon acceptance of an application, the Ohio department of alcohol and drug addiction services may conduct an on-site inspection of the new program site location for compliance with certification/licensure standards for physical plant and safety and any other program certification/licensure standards deemed appropriate by the Ohio department of alcohol and drug addiction services.

(3) Certificates/licenses issued as a result of a relocation of a program site shall have the same expiration date as the certification or licensure of the original program site.

(G) Procedure for renewal of program certification for currently certified programs:

(1) All programs certified by the department of alcohol and drug addiction services as an outpatient treatment program, residential treatment program, or a detoxification program shall be certified for a certification period not to exceed three years and shall renew upon completion of the assurance statement as indicated in paragraph (G)(3) of this rule.

(2) For programs that have obtained deemed certification pursuant to paragraph 3793:2-1- 01.1 of the Administrative Code, the program shall be certified for the period of their national accreditation, not to exceed three years.

(3) The Ohio department of alcohol and drug addiction services will send each owner an assurance statement for each certified site and for programs that have obtained deemed certification with information that the department has on file . Any Ohio alcohol and drug addiction outpatient, residential treatment program or detoxification program seeking renewal of program certification pursuant to division (A) of section 3793.06 of the Revised Code shall submit an assurance statement signed and dated by the executive director, CEO or president of the organization, and president of the governing authority which states that the agency shall comply with the certification standards as established by department rules for each certified program site location for the duration of its three-year certification period. All assurance statements must be received by the department within thirty days of the beginning of the new certification period and must include:

(a) Any changes to the information supplied by the department regarding that program. Changes include but are not limited to name, address, telephone number, email address, each program site location, program business hours of operation, and the number of alcohol and drug addiction beds if applicable.

(b) Programs requesting a variance or an extension of a variance for one or more of the program certification/licensure standards shall include a copy of the request with the program certification/licensure application. Each variance request shall be prepared and submitted in accordance with this rule.

(4) Failure to comply with the requirements of paragraph (G)(3) of this rule within the specified time frame shall result in the program being placed on conditional status.

(5) The Ohio department of alcohol and drug addiction services shall contact the program to schedule an on-site inspection of the program within the three-year certification period. Reviews will be scheduled with a minimum ninety-day notice.

(a) The department shall send the program a letter confirming the date of the on-site inspection.

(b) The department shall notify, in writing, the applicable alcohol and drug addiction services board or the alcohol, drug addiction and mental health services board of the date of the on-site inspection.

(6) The Ohio department of alcohol and drug addiction services shall conduct an on-site inspection within the three-year certification period with official written notice to the program, or at any other time for cause as determined by the department, with or without official written notice to the program.

(7) The Ohio department of alcohol and drug addiction services shall have access to all program-related records to verify compliance with program certification and/or licensure standards. The department may conduct interviews with members of the program's governing authority, program staff, others in the community and/or clients with the clients' permission.

(8) The Ohio department of alcohol and drug addiction services shall prepare a follow-up inspection report for the on-site inspection of the program.

(a) The inspection report shall cite any standards with which the program was not in compliance at the time of the on-site inspection.

(b) The Ohio department of alcohol and drug addiction services shall provide a copy of the on-site inspection report to the program and to the applicable alcohol and drug addiction services board or the alcohol, drug addiction and mental health services board.

(c) Programs shall correct deficiencies identified during a program certification inspection conducted by the Ohio department of alcohol and drug addiction services. Documentation of correction of the deficiencies shall be sent to the department within the time frame specified from the date in the follow-up inspection report.

(H) The Ohio department of alcohol and drug addiction services certifies and licenses program sites. Each program certification or license issued by the department is for a specific address. Certificates and licenses are not transferable to any other program entity or to other program site locations.

(I) Variances.

(1) The Ohio department of alcohol and drug addiction services may grant a variance from any certification or licensure standard, or portion thereof, for the period during which the certification or licensure is in effect.

(2) "Variance" means written permission granted by the Ohio department of alcohol and drug addiction services to a program to be exempted from or meet a modified requirement of a rule or specific provision of a rule of the Administrative Code or other program certification/licensure standard.

(3) Requests for variances of certification or licensure standards shall be in writing to the Ohio department of alcohol and drug addiction services and shall include:

(a) The administrative rule number and standard for which a variance is sought.

(b) The rationale for requesting the variance.

(c) Documentation by the program that assures the Ohio department of alcohol and drug addiction services that the quality of services and client safety shall not be jeopardized if the variance is granted.

(d) The consequences of not receiving approval of the requested variance.

(4) The Ohio department of alcohol and drug addiction services shall issue a written statement to the program granting or denying a request for variance of program certification and/or licensure standards. A copy of the written statement shall be provided to the applicable alcohol and drug addiction services board or alcohol, drug addiction and mental health services board.

(5) The program shall maintain a file copy of all requests for variances and the approval or denial of the requests for the period during which the certification or licensure is in effect.

(J) The Ohio department of alcohol and drug addiction services may deny or revoke certification or licensure for one or more of the following reasons:

(1) The program fails to comply with any program certification/licensure standard;

(2) The program misuses or fails to properly account for the disbursement of state or federal funds;

(3) The program knowingly provides false information to: the Ohio department of alcohol and drug addiction services, an alcohol and drug addiction services board or an alcohol, drug addiction and mental health services board or other entity;

(4) The program knowingly permits an employee to falsify information on client records;

(5) The program is aware of an employee who has abused or neglected a client and has failed to take appropriate disciplinary action to correct the situation;

(6) The program fails to provide access to its records as requested by the Ohio department of alcohol and drug addiction services.

(7) Denial, revocation or termination would be in the best interest of the citizens of Ohio.

(K) The Ohio department of alcohol and drug addiction services shall give the program written notice by certified mail, return receipt requested, if it intends to deny or revoke certification/licensure. The notice shall include:

(1) The standard(s) with which the program was found to be in non-compliance and/or other reason(s) for the action.

(2) The section(s) of the law or rule(s) involved.

(3) A statement informing the program that it is entitled to a hearing if it requests it within thirty days of the time of the mailing of the notice.

(4) A statement that at the hearing, the program's representative may appear in person and/or be represented by its attorney or may present its position, arguments or comments in writing and at the hearing it may present evidence and examine witnesses appearing for and against it. A copy of the notice shall be mailed to the attorney or other representative of record representing the program.

(L) If a program requests a hearing, the Ohio department of alcohol and drug addiction services shall set the date, time and place for the hearing within fifteen days, but not earlier than seven days, after the program has requested a hearing unless otherwise agreed upon by both the department and the program. A copy of the hearing notice shall be mailed to the program's representative or its attorney.

(1) The Ohio department of alcohol and drug addiction services shall conduct the adjudication hearing following the procedures in section 119.09 of the Revised Code and among other things may appoint a referee or hearing examiner to conduct the proceedings and make recommendations as appropriate.

(2) The Ohio department of alcohol and drug addiction services shall provide the program a certified copy of its decision by certified mail, return receipt requested.

(3) If the Ohio department of alcohol and drug addiction services' decision after the hearing is to deny or revoke certification or licensure, the program shall be informed of its right to appeal and file its notice of appeal of the decision within fifteen days of the mailing of the notice of the department's order.

(4) If the program decides to appeal the Ohio department of alcohol and drug addiction services' decision, the program shall appeal the order of the department to the court of common pleas of the county in which it the program's place of business is located. The program's notice of appeal is to be filed with the department and must state the order appealed from and the grounds of the appeal. A copy of the program's appeal must be filed with the court of common pleas in the county in which the appeal is being filed.

(5) Within thirty days after receipt of a notice of appeal, the Ohio department of alcohol and drug addiction services shall send to the common pleas court a complete record of the proceedings in the case by certified mail, return receipt requested.

(M) Any person who violates the provisions of these rules shall be subject to the penalties provided in section 3793.99 of the Revised Code.

(N) Sanction:

(1) Any program which has had its certification/licensure revoked pursuant to this rule shall not be eligible to apply to the Ohio department of alcohol and drug addiction services for program certification/licensure for at least five years from the date of revocation without the written consent of the department.

(2) Any program which has been denied certification/licensure pursuant to this rule shall not be eligible to apply to the Ohio department of alcohol and drug addiction services for program certification/licensure for at least three years from the date of denial without the written consent of the department.

(O) Program certification or licensure shall be considered void and invalid if a program: fails to follow the procedures for renewal of program certification, voluntarily relinquishes the certificate for certification or licensure, moves to another location, goes out of business or is sold or otherwise conveyed to another entity.

(P) The program shall immediately notify the Ohio department of alcohol and drug addiction services in writing of any changes in its operations that affect the program's continued compliance with the department's program certification and licensure requirements.

(Q) All programs shall be in compliance with all applicable federal, state and local laws and regulations.

(R) Alcohol and drug addiction programs currently certified or licensed by the Ohio department of alcohol and drug addiction services at the time of the effective date of agency 3793 of the Administrative Code shall remain certified/licensed until the expiration of their current certification or licensure unless their certification or licensure were to be revoked or terminated in accordance with this rule.

Effective: 02/14/2011
R.C. 119.032 review dates: 11/10/2010 and 07/15/2015
Promulgated Under: 119.03
Statutory Authority: 3793.02(D) , 3793.06 , 3793.11
Rule Amplifies: 3793.06 , 3793.11
Prior Effective Dates: 7/1/91, 7/1/01, 6/1/05, 11/17/05