5122-25-04 Certification procedure.

(A) Any agency subject to or seeking certification shall apply to the department by filing an application.

(1) An agency that has received accreditation and is applying for deemed status from the department according to rule 5122-25-03 of the Administrative Code shall file an application that includes:

(a) Identifying information including:

(i) Legal name as filed with the Ohio secretary of state, including any fictitious name ("doing business as") if applicable;

(ii) Address(es) and telephone number(s) at which the applicant operates and address for legal notice and correspondence;

(iii) Name and e-mail address of executive director, chief executive officer or president; and

(iv) Name and e-mail address of designated agency contact person who shall be the primary contact on behalf of the agency;

(v) A list of services according to Chapter 5122-29 of the Administrative Code to be provided during the term of certification; and

(vi) A description of the agency's purpose, mission and goals if an agency is applying for its first certification.

(b) Corporate information including the following upon request of the department. Before requesting this information, the department shall first attempt to obtain the information from the Ohio secretary of state website:

(i) Identification of the statutory corporate agent for service; and

(ii) If an out-of-state corporation, a copy of the certificate from the Ohio secretary of state, of registration to do business in Ohio.

(c) For any site which has not been approved or accredited by the agency's accrediting body, copies of approved physical inspections, either initial or renewal, for each building owned or leased, including:

(i) A building inspection by a local certified building inspector or a certificate of occupancy issued by the department of industrial relations, to be re-inspected whenever there are major alterations or modifications to the building or facility. An additional building inspection shall be required for any major change in the use of space that would make the facility subject to review under different building code standards;

(ii) Annual approved fire inspection, which shall be free of deficiencies, by a certified fire authority, or where there is none available, by the division of the state fire marshal of the department of commerce; and

(iii) Water supply and sewage disposal inspection for facilities in which these systems are not connected with public services to certify compliance with rules of the department of health and any other state or local regulations, rules, codes or ordinances.

(d) Documentation of any existing waivers or variances from the department regarding the certification standards, and justification if the agency is seeking their renewal.

(e) Notification if the agency uses seclusion and/or restraint or major aversive behavioral interventions in accordance with rule 5122-26-16 of the Administrative Code.

(f) If an agency is seeking certification for other mental health services as defined in rule 5122-29-27 of the Administrative Code, that are funded in whole or in part by a community mental health board, and for which there are no specific certification standards, the name of the service, a brief description of the service, and a letter of approval from the community mental health board shall be submitted.

(g) The documentation required in rule 5122-25-03 of the Administrative Code, unless it has already been submitted and deemed status approved by the department.

(h) Documentation for consideration by ODMH of reciprocity with another state department's licensing, certification/licensure or approval requirements, in accordance with rule 5122-25-03 of the Administrative Code.

(i) Documentation requested by ODMH for any service not included under the deemed status provision of rule 5122-25-03 of the Administrative Code.

(2) An agency that is not requesting deemed status by the department according to rule 5122-25-03 of the Administrative Code shall file an application that includes, but is not limited to:

(a) Identifying information including:

(i) Legal name as filed with the Ohio secretary of state, including any fictitious name ("doing business as") if applicable:

(ii) Address(es) and telephone number(s) at which the applicant operates and address for legal notice and correspondence;

(iii) Governing structure;

(iv) Agency budget;

(v) Table of organization;

(vi) Name and e-mail address of executive director, chief executive officer, or president;

(vii) Name and e-mail address of designated agency contact person who shall be the primary contact on behalf of the agency

(viii) List of qualified providers according to Chapter 5122-29 of the Administrative Code and the services they provide;

(ix) List of services according to Chapter 5122-29 of the Administrative Code to be provided during the term of certification; and

(x) A list of subcontracts with other agencies or organizations that provide mental health services.

(b) Corporate information including the following upon request of the department. Before requesting this information, the department shall first attempt to obtain the information from the Ohio secretary of state website:

(i) A copy of the applicant's articles of incorporation and all amendments;

(ii) Identification of the statutory corporate agent for service; and

(iii) If an out-of-state corporation, a copy of the certificate from the Ohio secretary of state, of registration to do business in Ohio.

(c) Copies of approved physical inspections, either initial or renewal, for each building owned or leased, including:

(i) A building inspection by a local certified building inspector or a certificate of occupancy issued by the department of industrial relations, to be re-inspected whenever there are major alterations or modifications to the building or facility. An additional building inspection shall be required for any major change in the use of space that would make the facility subject to review under different building code standards;

(ii) Annual approved fire inspection by a certified fire authority, or where there is none available, by the division of the state fire marshal of the department of commerce; and

(iii) Water supply and sewage disposal inspection for facilities in which these systems are not connected with public services to certify compliance with rules of the department of health and any other state or local regulations, rules, codes or ordinances.

(d) Documentation of any existing waivers or variances from the department regarding the certification standards, and justification if the agency is seeking their renewal.

(e) Notification if the agency uses seclusion and/or restraint or major aversive behavioral interventions in accordance with rule 5122-26-16 of the Administrative Code; and

(f) Documentation for consideration by ODMH of reciprocity with another state department's licensing, certification/licensure or approval requirements, in accordance with rule 5122-25-03 of the Administrative Code.

(g) If an agency is seeking certification for other mental health services as defined in rule 5122-29-27 of the Administrative Code, that are funded in whole or in part by a community mental health board, and for which there are no specific certification standards, the name of the service, a brief description of the service, and a letter of approval from the community mental health board shall be submitted.

(B) Upon receipt of an application, the department shall review the materials to determine if they are complete. 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. Incomplete materials, including failure to pay the full certification fee, shall not be considered an application for certification, and return of the materials or failure to issue a certificate shall not constitute a denial of an application for certification.

(C) Following the department's acceptance of materials as a complete application, or while awaiting final payment of the full certification fee in accordance with rule 5122-25-08 of the Administrative Code, the department shall determine whether the applicant's services and activities meet certification standards. The process for such a determination consists of the following:

(1) For an agency applying for deemed status, the department shall review the application materials, and issue the certification without further evaluation of the services, except that the department may conduct an on-site survey or otherwise evaluate the agency for cause, including complaints made by or on behalf of consumers and confirmed or alleged deficiencies brought to the attention of the department.

(2) For an agency that has not been granted deemed status by the department according to rule 5122-25-03 of the Administrative Code, the department may schedule and conduct an on-site survey of and/or otherwise evaluate the applicant's services and activities. At least thirty days before a scheduled survey date, the applicant shall:

(a) Notify appropriate community mental health boards and local client advocacy groups in writing of the ODMH survey date; and

(b) Post notices of the ODMH survey date and of the opportunity for the public to participate in a public information interview during the survey. Such notices shall be posted in public areas, on bulletin boards near major entrances, and in treatment or residential areas of the applicant.

(D) The department may conduct an on-site survey or otherwise evaluate an agency applying for or granted deemed status at any time based on cause, including complaints made by or on behalf of consumers and confirmed or alleged deficiencies brought to the attention of the director.

The department may conduct an on-site survey or otherwise evaluate an agency not applying for deemed status at the time of initial application or renewal in accordance with paragraph (C)(2) of this rule, at other times with appropriate notice, or at any time based on cause, including complaints made by or on behalf of consumers and confirmed or alleged deficiencies brought to the attention of the director.

The department shall have access to all records necessary to verify compliance with certification standards applicable to the agency and may conduct interviews with staff, others in the community, and clients with client permission. When scheduling surveys, the department shall notify the appropriate mental health boards(s) and invite their participation, pursuant to division (A)(3) of section 340.03 of the Revised Code. Exit interviews with agency staff shall be conducted during routine initial and renewal on-site surveys.

(E) An applicant that fails to comply with any or all of the certification standards applicable to the agency shall receive a written statement from the department citing items that are not in compliance.

(1) This statement shall describe the deficiencies, actions needed for correction, and a time frame for the agency to submit a written plan of correction.

(2) The agency's plan of correction shall describe the actions to be taken and shall specify a time frame for correction of deficiencies.

(F) If an agency adds a service or activity subject to certification during the term of certification, the agency shall submit:

(1) For an agency applying for deemed status, the documentation required in rule 5122-25-03 of the Administrative Code. Upon determination by the department that the agency has obtained appropriate behavioral health accreditation, the department will certify the agency to provide that service or activity.

(2) For an agency not requesting deemed status, a description of the service or activity and the list of qualified providers. Upon determination by the department that the service or activity is in compliance with certification standards, including conducting an on-site survey, if indicated, the department will certify the agency to provide that service or activity.

(G) If an agency adds a new location during the term of certification, the agency shall submit either the documentation required in paragraph (A)(1)(c) or paragraph (A)(2)(c) of this rule, or evidence that the site has been approved by its accrediting body. Upon determination by the department that the site is in compliance with certification standards, the department will certify the agency to provide any or all of its certified services at that location.

(H) Each agency shall submit an application for certification renewal no fewer than sixty days prior to the expiration of the current certificate.

Effective: 10/01/2012
R.C. 119.032 review dates: 07/17/2012 and 09/30/2017
Promulgated Under: 119.03
Statutory Authority: 5119.61(A) , 5119.611 , 5119.612
Rule Amplifies: 5119.61(A) , 5119.611 , 5119.612
Prior Effective Dates: 1/1/2004, 7/1/2009, 11/24/2011