5122-25-02 Accreditation and deemed status.

(A) A provider seeking certification for one or more of the following services may attain appropriate behavioral health accreditation, which includes an accrediting body survey of the actual provision of services, prior to submitting an application for certification:

(1) Behavioral health counseling and therapy service as defined in rule 5122-29-03 of the Administrative Code;

(2) Mental health assessment service as defined in rule 5122-29-04 of the Administrative Code;

(3) Pharmacologic management service as defined in rule 5122-29-05 of the Administrative Code;

(4) Partial hospitalization service as defined in rule 5122-29-06 of the Administrative Code;

(5) Crisis intervention mental health service as defined in rule 5122-29-10 of the Administrative Code;

(6) Community psychiatric supportive treatment (CPST) service as defined in rule 5122-29-17 of the Administrative Code;

(7) Intensive home based treatment (IHBT) service as defined in rule 5122-29-28 of the Administrative Code;

(8) Assertive community treatment (ACT) service as defined in rule 5122-29-29 of the Administrative Code;

(9) Outpatient treatment program as defined in rule 5122-29-34 of the Administrative Code;

(10) Sub-acute detoxification as defined in rule 5122-29-37 of the Administrative Code; or,

(11) Prevention services as defined in rule 5122-29-20 of the Administrative Code.

(B) Behavioral health accreditation referenced in paragraph (A) of this rule shall be obtained from one or more of the following accrediting bodies, with the exception of sub-acute detoxification, which shall obtain accreditation in accordance with paragraph (D) of this rule:

(1) The joint commission;

(2) Commission on accreditation of rehabilitation facilities;

(3) Council on accreditation; or,

(4) Other behavioral health accreditation as determined by the director.

(C) A provider seeking certification for both alcohol and other drug (AoD) services and mental health services under deemed status must ensure the accrediting body reviews or accredits the provision of both AoD and mental health services.

(D) A provider seeking certification for acute hospital detoxification as defined in rule 5122-29-37 of the Administrative Code shall attain hospital accreditation and a provider seeking certification for sub-acute hospital detoxification may attain appropriate behavioral health accreditation from the joint commission, healthcare facilities accreditation program, DNV healthcare inc, or the commission on accreditation of rehabilitation facilities prior to submitting an application for certification.

(E) The department may:

(1) Add the names of other accrediting bodies to those listed in paragraphs (B) and(D) of this rule if it determines that such bodies meet its accreditation requirements.

(2) Likewise, the department may delete the names of accrediting bodies from those listed in paragraphs (B) and (D) of this rule if it determines that such bodies no longer meet its accreditation requirements.

A provider accredited by a body the department chooses to delete from those listed in paragraphs (B) and (D) of this rule shall remain certified until its current accreditation expires. If a provider wishes to retain certification after that time, it must attain accreditation from a body recognized by the department or undergo the non-deemed status certification process in accordance with rule 5122-25-03 of the Administrative Code.

(F) A provider granted deemed status in accordance with rule 5122-25-04 of the Administrative Code shall maintain its accreditation throughout its term of certification. Should a provider choose to not submit a renewal application to its accrediting body, the provider shall immediately notify the department and will be subject to a full certification survey. A provider granted deemed status that fails to immediately notify the department that it did not submit a timely renewal application to its accrediting body may be subject to certification revocation in accordance with Chapter 119. of the Revised Code.

(G) The provider shall inform the department, the appropriate boards, and local client advocacy groups in writing of its accreditation survey date at least thirty days prior to the beginning of a scheduled accreditation survey, or when the provider is given less than thirty days notice of a scheduled survey, within seven days of receiving notice from the accrediting body. A provider undergoing an unannounced or unscheduled accreditation survey shall inform the department within seven days after the conclusion of the unannounced or unscheduled accreditation survey.

(H) The department shall accept the provider's appropriate behavioral health accreditation or hospital accreditation, when applicable, as evidence of compliance with the services identified in paragraphs (A) and (C) of this rule and Chapters 5122-26 to 5122-28 of the Administrative Code.

The following standards are exempted from the statement in paragraph (H) of this rule:

(1) Rule 5122-26-13 of the Administrative Code (incident notification); and,

(2) Rule 5122-29-33 of the Administrative Code (health home service for persons with serious and persistent mental illness). This paragraph shall no longer be exempted from deemed status effective January 1, 2017.

(I) The department shall only grant deemed status for services which are accredited. The department may grant partial deemed status to a provider when:

(1) The provider has accreditation for some, but not all, of the services listed in paragraphs (A) and (C) of this rule; or,

(2) The agency is applying for certification to provide both AoD and mental health services, but the accrediting body has not reviewed or accredited the provision of both.

(J) The department shall accept a provider's accreditation, certification, or recognition as required by paragraph (F) of rule 5122-29-33 of the Administrative Code in lieu of promulgating standards for the provision of integrated physical health and behavioral health care as part of the health home service for persons with serious and persistent mental illness rule.

(K) A provider applying for deemed status by the department must submit the most recent copy of the following:

(1) Each of the accrediting body's survey reports, and any modifications made to the survey report if applicable;

(2) Certificate, license or plaque awarded by the accrediting body; and,

(3) Accreditation award notification letter if requested by the department.

(L) A provider must notify the department within ten days of any change to its accreditation status, by providing a copy of the accreditation status change notification.

(1) Should a provider's accreditation status be granted as or modified to probation, stipulations, conditional, provisional, deferral, preliminary denial or other similar status, the department may ask for additional documentation until such time as full accreditation status is restored. Full accreditation status means the accrediting body has issued an accreditation decision of "accredited" or "accreditation" without additional conditions or modifiers other than three-year or one-year accreditation.

(2) Should a provider's accreditation be denied, suspended or revoked by the accrediting body, the department shall withdraw deemed status and the provider shall be subject to a full certification survey or certification revocation in accordance with Chapter 119. of the Revised Code.

(M) The department may conduct surveys or review documentation of a sample of providers having achieved appropriate behavioral health accreditation in order to evaluate whether the accreditation processes used by the organizations are consistent with service delivery models the director considers appropriate for mental health services. The department will communicate to an accrediting organization any identified concerns, trends, needs, and recommendations. The department shall have access to all records necessary to evaluate the accrediting body processes, but may not conduct a survey or request documentation under this paragraph for the purpose of determining compliance with certifications standards.

Effective: 2/1/2016
Five Year Review (FYR) Dates: 06/29/2015 and 02/01/2021
Promulgated Under: 119.03
Statutory Authority: 5119.36
Rule Amplifies: 5119.36
Prior Effective Dates: 10/1/2003, 3/25/2004. 11/15/2004, 7/1/2005, 1/9/2006, 8/23/2007, 7/1/2009, 7/1/2013