a) The license applicant shall submit, with the license application, the plan of operation, including, but not limited to, the following components of the facility, respective of the level or levels of service to be provided:

1. 1) A proposal of certification for each level of service to be provided by a facility;
2. 2) A summary of administration requirements as specified in Subpart D;

3. 3) Services and staffing:

   1. A) Clinical level of service and staffing, as appropriate to each level of service provided, and pursuant to the respective level of service requirements in Subpart B;
   2. B) Documentation of the required training for each staffing classification in each level of service; and
   3. C) Any contractual arrangements;
4. 4) Admission process and criteria;
5. 5) Discharge planning and transition process;
6. 6) Network linkages with community-based behavioral health providers;
7. 7) Contents of consumer health and treatment records;
8. 8) Consumer rights and empowerment;
9. 9) Pharmaceutical services and self-medication program;
10. 10) Program space allocation;
11. 11) Restraint and therapeutic separation policies and procedures;
12. 12) Physical plant or buildings, and fire safety;
13. 13) Health services program;
14. 14) Interdisciplinary treatment teams;
15. 15) Psychiatric and psychological services; and
16. 16) Quality improvement plan.

b) The plan of operation shall specify each target population group and service that the facility plans to offer, as referenced in Subpart A. The description shall identify:

1. 1) Eligibility for services;
2. 2) The number of consumers to be served;
3. 3) An identification of the particular needs of the population;
4. 4) How the facility's respective levels of service are designed to meet the needs of the population; and
5. 5) The method and frequency of evaluating consumer progress.

d) The plan of operation shall specify how a facility expects to obtain accreditation via achieving the components in subsections (a), (b) and (c) for each year of provisional licensure. Each provider shall, annually, specify operational benchmarks toward achieving accreditation status for each year of the provisional license period, with the correlating documentation for verification of compliance.

1. 1) During the provisional licensure period, the Department will conduct surveys to determine facility compliance with timetables and benchmarks, and with the facility's provisional licensure application plan of operation. Timetables and benchmarks shall comply with the requirements for accreditation by the national accreditation entities listed in Section 380.730 and shall include, but not be limited to, the following:

   1. A) The training of new and existing staff;
   2. B) The establishment of a data collection and reporting program for the facility's QAPI program, pursuant Sections 380.510 and 380.515; and
   3. C) Compliance with NFPA Chapter 33 and with Section 380.670.
2. 2) As part of the surveys required in subsection (d)(1), the Department will conduct reviews to determine compliance with timetables and benchmarks associated with the accreditation process. Facilities shall meet timetables and benchmarks in accordance with a facility's preferred accrediting entity's conformance standard and recommendations to include, but not be limited to, a comprehensive facility self-evaluation in accordance with one of the established national accreditation programs listed in Section 380.730.
3. 3) Facilities shall submit all reporting and outcome data required by their preferred accrediting entity to the Department upon request.
4. 4) Except for incidents involving the potential for serious harm as described in Section 380.750(c)(5), or death, or a facility's consistent and repeated failure to take necessary corrective actions as described in Section 380.750(c)(6) within 60 days, findings in the facility's root cause analysis and the facility's QAPI program in accordance with Section 4-104(22) of the Act and Section 380.510 shall not be used as a basis for non-compliance.