Chapter 5123:2-4 Accreditation Requirements for County Boards

5123:2-4-01 County board accreditation.

(A) The purpose of this rule is to define the procedures the department will follow to implement an accreditation system as required by section 5126.081 of the Revised Code. Implementation of the accreditation system is intended to ensure that county boards are in compliance with federal and state statutes and rules.

(B) Definitions

(1) "Accreditation requirements" and "requirements for accreditation" mean the criteria adopted by the department that measure county boards' compliance with federal and state statutes and rules.

(2) "Accredited" means the department has conducted and completed an on-site review of the board and has determined the board to be in compliance with the requirements for accreditation.

(3) "Administrative receiver" means an entity designated by the department to administer the board's programs and services.

(4) "Board" or "county board" means a county board of mental retardation and developmental disabilities established under Chapter 5126. of the Revised Code.

(5) "Comprehensive review" means an on-site review conducted by representatives of the department at the board and includes every program and service provided directly or through contract by the board. The purpose of the review is to measure the board's compliance with the department's requirements for accreditation.

(6) "Contractor" means an entity under contract with the board to administer the board's programs or services.

(7) "Day" means a calendar day, unless otherwise identified as a business day. A "business day" means Monday through Friday, excluding any days designated as a state holiday.

(8) "Department" means the Ohio department of developmental disabilities.

(9) "Domain" means a compilation of requirements that are categorically similar in their management and implementation.

(10) "Draft interim summary" means the report sent by the department to the superintendent of the county board and the board president that identifies the areas of noncompliance as identified by the accreditation team during the pre-survey and on-site review.

(11) "Interim review" means a review of a board conducted by representatives of the department during the effective dates of the accreditation period.

(12) "Plan of correction" means the county board's written response to the items of noncompliance identified through the department review process and submitted to the county board in the review report. The plan of correction will identify the methods, responsible parties, and timelines within which these items will be addressed and/or corrected.

(13) "Qualified entity" means a person or organization other than the affected county board that has demonstrated the necessary knowledge and skills to effectively manage areas out of compliance that were identified by the accreditation team.

(14) "Review report" means the official description of the county board's status in relation to its compliance with accreditation requirements as determined through a review process.

(C) Accreditation domains and requirements

The following criteria comprise the domains that will determine the compliance of county boards with accreditation requirements:

(1) Health, safety, and welfare domain and requirements

(a) The county board ensures the compliance of board-operated services and those provided by contract agencies with all applicable health and safety requirements in federal and state statutes and rules.

(b) The county board ensures that employees of the board and their contract agencies are appropriately registered, certified, and/or licensed in accordance with all applicable federal and state statutes and rules.

(c) The county board ensures compliance with all applicable federal and state statutes and rules regarding background investigation requirements for any applicant for employment with the board in any position and for persons employed in direct service positions by contract agencies of the county board.

(d) The county board ensures compliance with all applicable requirements in federal and state statutes and rules permitting board workers to perform delegated nursing tasks, inclusive of giving or applying prescribed medications.

(e) The county board implements a system of reporting, investigating, tracking, and monitoring all major unusual incidents and unusual incidents in accordance with all applicable federal and state statutes and rules.

(f) In accordance with all applicable federal and state statutes and rules, the county board develops and implements written policies and procedures that:

(i) Support and assist individuals receiving services from the county board or its contract agencies;

(ii) Reduce behaviors that place individuals or others at physical risk; and

(iii) Protect individuals from harm to self or others by creating safeguards for their health and safety and the health and safety of others.

(2) Rights domain and requirements

In accordance with all applicable federal and state statutes and rules,

(a) The county board uses an administrative resolution of complaints process to resolve complaints involving the programs, services, policies, or administrative practices of the county board or the agencies acting under contract with the board;

(b) The county board implements a system and safeguards to preserve confidentiality of information for individuals served.

(c) The county board ensures the provision and documentation of case management and service coordination; and

(d) The county board promotes the dignity and protects the rights of individuals served.

(3) Service planning and delivery domain and requirements

In accordance with all applicable federal and state statutes and rules,

(a) The county board maintains, lists, and verifies the changing needs and preferences of individuals waiting for all services, programs, and supports offered to eligible individuals by the board or its contract agencies when resources are lacking to meet these needs;

(b) The county board provides early intervention services to eligible individuals;

(c) The county board ensures the provision of supported living to eligible individuals;

(d) The county board ensures the provision of services and supports to eligible adults;

(e) The county board complies with all home and community-based services (HCBS) waiver requirements and assurances;

(f) The county board ensures that transportation services and options are available to all eligible individuals; and

(g) The county board uses a planning process to identify service needs and to determine program goals.

(4) Administration domain and requirements

(a) The county board utilizes the Ohio eligibility determination instrument (OEDI) or the children's Ohio eligibility determination instrument (COEDI) for the purpose of determining the eligibility of individuals for services provided directly by the board or its contract agencies in accordance with all applicable federal and state statutes and rules.

(b) The county board members serve in accordance with all applicable federal and state statutes and rules.

(c) In accordance with all applicable federal and state statutes and rules, the county board monitors contract agencies providing services and supports to ensure their compliance with all applicable federal and state statutes and rules.

(d) In accordance with all applicable federal and state statutes and rules, the county board reports accurate information in response to the department's requests, including completion of individual information forms.

(e) The county board establishes an ethics council or policy to address direct service contracting issues in accordance with all applicable federal and state statutes and rules.

(f) The county board seeking reimbursement from the community alternative funding system (CAFS) adheres to all applicable federal and state statutes and rules.

(g) The county board ensures that family resource services are available to assist individuals and families in accordance with all applicable federal and state statutes and rules.

(h) The county board complies with all applicable Title XX requirements in federal and state statutes and rules.

(i) The county board completes preadmission screening and resident review for mental retardation and developmental disabilities (PASRR-MR/DD) evaluations and submits data to the department in a timely manner, provides specialized services to eligible residents of nursing facilities, and arranges for the relocation of eligible individuals who are placed inappropriately in nursing facilities in accordance with all applicable federal and state statutes and rules.

(D) Accreditation reviews

(1) The department shall conduct reviews of the county boards to determine compliance with department accreditation requirements.

(a) Following initial accreditation, the department shall conduct a comprehensive review not less than one time prior to the date the board's accreditation is scheduled to expire.

(b) The department may conduct other reviews and investigations as necessary to ensure compliance with accreditation requirements.

(c) The department may conduct interim reviews of any new program or service initiated by the board after its most recent review.

(2) The department shall notify the board prior to conducting any type of review unless serious health and safety issues, as defined by the department, exist within the programs and services offered by the board.

(a) The notification for a comprehensive review will include a list of documents to be submitted by the board to the department and timelines for their submittal prior to the scheduled review date.

(b) Failure of the board to provide requested documents to the department in accordance with identified timelines may result in a finding of noncompliance with the related requirement(s).

(c) The department shall notify the board at least forty-five days prior to initiating a comprehensive review and no less than forty-eight hours prior to initiating an interim review.

(d) The department shall invite the submission of comments by constituents and contracting entities regarding the board's efficiency and effectiveness in complying with the requirements for accreditation.

(3) An exit conference may be held on-site at the conclusion of a comprehensive review but shall be held no more than five business days following the completion of the on-site review. By mutual agreement between the department and the superintendent of the board, the exit conference may be scheduled more than five business days after completion of the on-site review.

(a) Exit conferences shall be conducted by the department with the president of the board or another board member serving as the president's designee, the superintendent of the board, and any other staff members and/or officials the board invites.

(b) The purpose of the exit conference is to provide the board with an oral summary of the board's compliance status with the requirements for accreditation. Any finding(s) of noncompliance with accreditation requirements shall be presented at the exit conference.

(4) The department shall order the board to immediately correct any issues determined by the department to represent a serious threat to the health and safety of individuals participating in the programs and services offered by the board. If the board fails to correct health and safety violations identified, the department may implement administrative intervention, including appointment of an administrative receiver.

(5) The department shall provide, by certified mail, a draft interim summary of its findings to the superintendent and the board president no later than thirty days following the exit conference.

(E) Noncompliance with accreditation requirements

(1) The department shall identify violations of specific requirements in the draft interim summary and the review reports prepared for the board.

(2) The board shall have the opportunity to dispute any of the information contained in the draft interim summary. Disputes must be in writing and sent by the board to the department within ten days by certified mail following receipt of the draft interim summary. The draft interim summary shall remain a draft and not a public record under section 149.43 of Revised Code until the review report is released in accordance with paragraph (D)(3) of this rule.

(a) The board shall submit to the department the specific items in the draft interim summary that are disputed, the reason for the board's disagreement, and any substantiating information.

(b) The department shall respond in writing to the superintendent and the board president by certified mail within fifteen days following receipt of the disputed findings and shall indicate the disposition of the contested citations.

(c) The department's response shall be reflected in the review report.

(3) The department shall send the review report to the board president and the superintendent within sixty days of the exit conference when the draft interim summary is not disputed, or within seventy-five days of the exit conference when responding to contested citations contained in the draft interim summary.

(4) The review report shall contain a recommended term of accreditation, which shall be awarded upon timely and proper submittal of the plan of correction by the board.

(5) The department may grant the board a decision abeyance of up to ninety days to take appropriate action to correct citations that will prevent the board from achieving a minimum of one year accreditation.

(6) The county board shall submit to the department the written plan of correction within forty-five days of receipt of the review report. The department may deny accreditation for failure of a board to submit a plan of correction by the specified date contained within the review report.

(a) A copy of the board's resolution approving the plan of correction shall be forwarded to the department with the plan of correction. The superintendent shall also sign the resolution as an indication of concurrence.

(b) Within thirty days of receipt of the board's plan of correction, the department shall forward to the board written approval or disapproval of the plan of correction.

(c) The board shall initiate implementation of the plan of correction immediately upon notification by the department that the plan of correction has been approved.

(d) If the entire plan or a portion(s) of the plan of correction developed by the board is disapproved, the department shall inform the board of the reasons for the disapproval. The department shall grant the board an opportunity to submit a revised plan of correction within fifteen days of the board's receipt of rejection of the plan of correction unless the health, safety, and welfare requirements are involved. If the board has not met the requirements contained within the health, safety, and welfare domain, as determined by the department, the department shall issue an order denying accreditation.

(e) The department may conduct follow-up reviews to ensure the board's compliance with requirements for accreditation.

(F) Accreditation of a board

(1) The department shall issue a certificate of accreditation once it is determined that the board is in compliance with the department's accreditation requirements.

(2) Accreditation may be granted for periods up to five years, and may be renewed.

(3) The term of accreditation granted to a board shall be dependent upon the degree of compliance with accreditation requirements contained within the domains established by the department's accreditation unit.

(a) A board shall be granted a one-year accreditation when compliance with requirements contained within the health, safety and welfare domain are determined by the department to have been achieved.

(b) A board shall be granted a two-year accreditation when compliance is determined by the department with requirements identified in paragraph (F)(3)(a) of this rule and also selected requirements within the rights, service planning and delivery, and administration domains.

(c) A board shall be granted a three-year accreditation when compliance is determined by the department with requirements identified in paragraphs (F)(3)(a) and (F)(3)(b) of this rule and additional requirements contained within the rights, service planning and delivery, and administration domains not already included in paragraph (F)(3)(b) of this rule.

(d) A board shall be granted a four-year accreditation when compliance is determined by the department with requirements identified in paragraphs (F)(3)(a) to (F)(3)(c) of this rule and the remaining requirements not already included in paragraphs (F)(3)(b) and (F)(3)(c) of this rule contained within the rights, service planning and delivery, and administration domains.

(e) A board shall be granted a five-year accreditation when the department determines compliance with requirements identified in paragraph (F)(3)(d) of this rule and one of the following:

(i) The department determines compliance with best practice standards established by the department in accordance with section 5126.082 of the Revised Code; or

(ii) The department determines that the board has maintained either accreditation from the commission on accreditation of rehabilitation facilities (CARF) or the accreditation council (AC) for no less than a three-year period prior to the accreditation on-site review in program and service areas designated by the department.

(G) Issuance of an order denying accreditation

(1) The department shall issue an order proposing to deny or rescind accreditation in conformance with division (D) of section 5126.081 of the Revised Code only after the board has exhausted all opportunities afforded by the department to correct deficiencies as defined in paragraph (E) of this rule.

(2) Simultaneously, by certified mail, the department shall notify the following officials in the county of its order proposing to deny and/or rescind accreditation: The members of the board of county commissioners, the probate judge, the county auditor, the president of the board or another board member serving as his or her designee, and the superintendent of the board.

(3) The order shall identify the matters in which the board is not in compliance with accreditation requirements, and the responsibilities of the board to contract under division

(E)(1) of section 5126.081 of the Revised Code to have the programs and services administered by another party or become subject to administrative receivership under division

(E)(2) of section 5126.081 of the Revised Code.

(H) Appointment of administrative receivers or contractors

(1) The board shall be given the option by the department of contracting for the administration of programs and services subject to the approval of the director with one or more accredited county board(s) or a qualified entity.

(2) The board shall execute the contract option with another approved entity within thirty days following receipt of the department's notice of the order proposing to deny or rescind accreditation.

(3) If a board does not contract the administration of programs and services identified not in compliance with accreditation requirements within thirty days of receiving the order, the department shall take action to appoint an administrative receiver.

(4) In accordance with division (E)(2) of section 5126.081 of the Revised Code, the department may appoint management personnel from other county boards, employees of the department, or persons from other entities as administrative receiver. Persons from other entities may be appointed only when no qualified department employees or board personnel are available.

(I) Duties of administrative receivers or contractors

(1) The administrative receiver shall assume full administrative responsibility for the programs and services identified not in compliance with the requirements for accreditation.

(2) When the board enters into a contract, the board, by formal resolution, shall grant the contractor full administrative authority according to division (E)(1) of section 5126.081 of the Revised Code for the program(s) and service(s) that the contractor will administer.

(3) The administrative receiver or contractor shall develop a plan of correction to remediate the programs and services identified not in compliance that caused the department to deny or rescind accreditation.

(a) Within ninety days of appointment, the administrative receiver or contractor shall submit to the department for review a plan of correction accepted by the board that specifically addresses those areas not in compliance with the requirements for accreditation.

(b) The department shall respond in writing within thirty days indicating approval or disapproval of the submitted plan of correction.

(c) If the department approves the plan, the administrative receiver or contractor and the board shall commence action to implement the plan immediately.

(d) If the plan of correction developed by the administrative receiver or contractor is disapproved, the department shall inform the administrative receiver or contractor and the board of the reasons for the disapproval and may grant the board and administrative receiver or contractor an opportunity to submit a revised plan of correction.

(e) If the department grants the board and administrative receiver or contractor an opportunity to submit a revised plan of correction, it shall be received by the department no later than thirty days following notification of disapproval.

(4) The administrative receiver or contractor shall report to the department any findings pertaining to issues or circumstances beyond the control of the board and resulting in the likelihood that compliance with the requirements for accreditation cannot be achieved unless the issues or circumstances are remedied.

(5) The administrative receiver or contractor may at any time request the department to conduct a review to determine:

(a) If the board is in compliance with accreditation requirements; and

(b) If the board is capable of assuming its duties to administer designated programs and services.

(6) When, as a result of a review by the department, the board is found to be in compliance with requirements, the department shall reverse its order proposing to deny or rescind accreditation, and issue evidence of accreditation to the board.

(J) Reimbursement of contractor and/or administrative receiver expenses

(1) The board shall reimburse the contractor or administrative receiver for all reasonable expenses, including amounts for time worked, travel, and related expenses.

(2) The board, with department approval, shall negotiate with the contractor to determine allowable costs for services rendered.

(3) The department and the administrative receiver shall negotiate to determine allowable costs for services rendered when any administrative receiver is appointed by the department.

(4) Department employees shall not be additionally reimbursed by the board for their time worked, if appointed by the department as the contractor or administrative receiver.

(K) A contractor or administrative receiver that has assumed the administration of a board's programs and services has the right to authorize the payment of bills in the same manner that a board may authorize payment of bills under Chapter 5126. and section 319.16 of the Revised Code.

(L) Appealing a department decision

(1) A board may appeal the department's decision regarding a proposed denial or rescission of accreditation or refusal to reverse a denial of accreditation by filing a complaint as outlined under section 5123.043 of the Revised Code and rule 5123:2-17-01 of the Administrative Code.

(2) All board appeals to the department shall be in writing and shall be submitted within thirty days of the receipt of the department's written notification of intention to issue a denial or rescission of accreditation or refusal to reverse a denial of accreditation.

(3) Once the department receives an appeal from the board, the procedures and timelines noted in rule 5123:2-17-01 of the Administrative Code shall be followed.

(4) If in its appeal, the department agrees the board can assume its duties in compliance with the department's requirements for accreditation, the department shall:

(a) Reverse its order denying or rescinding accreditation or refusing to reverse a denial of accreditation; and

(b) Issue accreditation to the board.

(5) If the board does not appeal in accordance with paragraphs (L)(1) and (L)(2) of this rule, the department's order proposing to deny or rescind accreditation or refusing to reverse a denial of accreditation shall become effective thirty days after the board receives the department's written notification of the order.

(6) The department shall issue all notices pertaining to accreditation to the members of the board of county commissioners, the probate judge, the county auditor, the president of the board or another board member serving as his or her designee, and the superintendent of the board.

(M) Board annual self-audits

The board shall conduct annual self-audits using the department's designated format to evaluate its compliance with department standards. Self-audits are subject to review by the department during the accreditation process.

Eff 4-12-01
Rule promulgated under: RC Chapter 119.
Rule authorized by: RC 5123.04 , 5126.081
Rule amplifies: RC 5123.04 , 5126.08 , 5126.081 , 5126.082
RC 119.032 REVIEW DATE: April 12, 2006