(A) Any provider subject to or seeking
certification under this rule shall apply to the department by filing an
application.
(1) A provider that has
received accreditation for one or more of the services in which it is seeking
certification, and is applying for deemed status from the department according
to rule 5122-25-02 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) Addresses and
telephone numbers at which the applicant operates and address for legal notice
and correspondence. Each provider shall have at least one physical site that is
certified. 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;
(iii) Governing structure
and the names and contact information of the governing body, board of
directors, LLC members or similar body;
(iv) Name and e-mail address of executive director, chief
executive officer or president; and
(v) Name and e-mail address of designated provider contact
person who shall be the primary contact on behalf of the provider;
(vi) Current and previous history of state agency licensure
and certification;
(vii) Whether the provider is requesting certification to
provide mental health services, addiction treatment services, or services to
both populations;
(viii) A list of services according to Chapter 5122-29 of the
Administrative Code to be provided during the term of
certification;
(ix) Number of beds for each residential and withdrawal
management substance use disorder services location;
(x) A description of the provider's purpose, mission
and goals if a provider is applying for its first certification; and,
(xi) Other information or material if requested by the
department to determine the applicants services meet certification
standards.
(b) Upon request of the department, the following corporate
information. 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
provider'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) Approved fire
inspection conducted within the previous twelve months, which shall be free of
deficiencies, and was conducted by a certified fire authority, or where there
is none available, by the division of the state fire marshal of the department
of commerce;
(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;
(iv) Current boiler
certificate of operation, if applicable;
(v) Current elevator
permit, if applicable; and,
(vi) Food service license or permit, if required by the
department of health.
(d) The applicable non-refundable certification fee as
provided for in rule 5122-25-08 of the Administrative Code for services which
are not accredited, if applicable.
(e) Documentation of any existing waivers or variances from
the department regarding the certification standards, and justification if the
provider is seeking their renewal.
(f) Notification if the provider uses seclusion or
restraint as defined in rule 5122-26-16 of the Administrative
Code.
(g) If a provider is seeking certification for supplemental
behavioral health services as defined in rule 5122-29-27 of the Administrative
Code, that are funded in whole or in part by a 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 board shall be
submitted.
(h) The documentation required in paragraph (I) of rule
5122-25-02 of the Administrative Code, unless it has already been submitted and
deemed status approved by the department.
(i) Driver intervention programs shall
include:
(i) The total number of
hours of operation, including the total number of program hours;
(ii) If services are
provided at a camp, a copy of the "Permission to Operate a Camp"
issued by the local county/city health department pursuant to rule 3701-25-02
of the Administrative Code.
(iii) If services are
provided at a hotel or motel, a copy of the hotel/motel license from the
division of the state fire marshal of the Ohio department of commerce will be
accepted in lieu of a copy of a occupancy and use certificate and annual fire
inspection.
(j) Documentation requested by the department for any
service not included under the deemed status provision of rule 5122-25-02 of
the Administrative Code.
(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 may return the materials to the applicant.
Incomplete materials 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, 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 a provider
applying for deemed status, the department shall review the application
materials, and issue the certification for services covered under deemed status
without further evaluation of the services, except that the department may
conduct an on-site survey or otherwise evaluate the provider 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 services not
included in a provider's deemed status approval, the department may
schedule and conduct an on-site survey of or otherwise evaluate the
applicant's services and activities.
If conducting an on-site survey, the department
shall send the provider a letter confirming the date of the on-site survey, and
notify, in writing, the applicable board of the date of the on-site survey. At
least thirty days before a scheduled survey date, the applicant shall post
notices of the 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.
The department shall have access to all
written, electronic and recorded records to verify compliance with
certification standards as established by department rules. The department may
conduct interviews with members of the provider's governing authority,
staff, others in the community and clients with the client's
permission.
Exit interviews with provider staff shall be
conducted during routine initial and renewal on-site surveys.
(D) The department may conduct an on-site survey or otherwise
evaluate a provider 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 or may not notify a provider in advance of a survey conducted for
cause.
The department shall have access to all written,
electronic and recorded records or media to verify compliance with
certification standards as established by department rules. The department may
conduct interviews with members of the provider's governing authority,
staff, others in the community and clients with the client's
permission.
(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 provider to submit a written plan of correction.
(2) The provider's
plan of correction shall describe the actions to be taken and shall specify a
time frame for correction of deficiencies.
(F) If a provider adds a service or
activity subject to certification during the term of certification, the
provider shall submit:
(1) For a provider
applying for deemed status, the documentation required in paragraph (K) of rule
5122-25-02 of the Administrative Code. Upon determination by the department
that the provider has obtained appropriate behavioral health accreditation, the
department will certify the provider to provide that service or
activity.
(2) Interim certification
application process:
(a) The department shall review the application materials
for compliance with Chapters 5122-26 to 5122-29 of the Administrative
Code.
(b) The department may conduct an on-site inspection of the
physical plant environment if the location is not accredited by the accrediting
body.
(c) The provider must demonstrate clinical readiness to
meet the documentation requirements of Chapter 5122-27 of the Administrative
Code by demonstrating it has acquired an electronic health record system that
supports documentation to meet these requirements and/or providing samples of
paper forms.
(d) A provider that fails to respond to a request to submit
additional documentation or a request to submit a corrective response (e.g.
corrective action plan or plan of correction) within ninety days shall
automatically be considered to have withdrawn its application. If the provider
wishes to seek certification, it shall file a new initial
application.
(3) Initial full
certification application process:
(a) Review the application materials for compliance with
Chapters 5122-26 to 5122-29 of the Administrative Code.
(b) For an initial
certification only, a provider that fails to respond to a request to submit
additional documentation or a request to submit a corrective response (e.g.
corrective action plan or plan of correction) within ninety days shall
automatically be considered to have withdrawn its application. If the provider
wishes to seek certification, it shall file a new initial
application.
(c) The department shall schedule and conduct an on-site
survey prior to the expiration date of an interim certificate issued in
accordance with paragraph (F)(2) of this rule and paragraph (F)(2)(a) of rule
5122-25-05 of the Administrative Code unless the provider has obtained
accreditation for the service that includes an on-site survey by the
accrediting body to review the provision of the service.
(d) The department may schedule and conduct an on-site
survey or otherwise evaluate the applicants services and activities if a
provider is seeking any other initial certification.
(e) If conducting an on-site survey, the department shall
send the provider a letter confirming the date of the on-site survey, and
notify, in writing, the applicable board of the date of the on-site survey.
(f) At least thirty days before a scheduled survey date,
the applicant shall post notices of the 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.
(g) The department shall have access to all written,
electronic and recorded records to verify compliance with certification
standards as established by department rules. The department may conduct
interviews with members of the provider's governing authority, staff,
others in the community and clients with the client's permission.
(h) Exit interviews with provider staff shall be conducted
during routine initial and renewal on-site surveys.
(G) If a provider adds a new location
during the term of certification, the provider shall submit either the
documentation required in paragraph (A)(1)(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 provider to provide services at that
location.
(1) The following
services are site specific, meaning that a provider must request certification
at each specific location:
(a) Residential and withdrawal management substance use
disorder provided in accordance with rule 5122-29-09 of the Administrative
Code.
(b) Driver intervention program provided in accordance with
rule 5122-29-12 of the Administrative Code.
(2) A provider may
provide any currently certified service not included in paragraph (G)(1) of
this rule at any certified location.
(H) Each agency shall submit an application for certification
renewal no fewer than ninety days prior to the expiration of the current
certificate.
(I) A provider that has not previously
notified the department that it utilizes seclusion and restraint must do so and
submit any documentation requested by the department to verify its compliance
with the Administrative Code prior to utilizing these measures. A provider
shall not utilize seclusion restraint without written acknowledgment from the
department that it is authorized to do so.
