PURPOSE: This rule describes procedures to obtain certification as Alcohol and Drug Abuse Programs, Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), Compulsive Gambling Treatment Programs, Substance Abuse Traffic Offender Programs (SATOP), Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric Rehabilitation Programs (CPRP), and Psychiatric Outpatient Programs.

1. (1) Under sections 630.655, 630.010, and 376.779.3 and 4, RSMo, the department is mandated to develop certification standards and to certify an organization’s level of service, treatment or rehabilitation as necessary for the organization to operate, receive funds from the department, or participate in a service network authorized by the department and eligible for Medicaid reimbursement. However, certification in itself does not constitute an assurance or guarantee that the department will fund designated services or programs.

   1. (A) A key goal of certification is to enhance the quality of care and services with a focus on the needs and outcomes of persons served.
   2. (B) The primary function of the certification process is assessment of an organization’s compliance with standards of care. A further function is to identify and encourage developmental steps toward improved program operations, client satisfaction and positive outcomes.

2. (2) An organization may request certification by completing an application form, as required by the department for this purpose, and submitting the application form, and other documentation, as may be specified, to the Department of Mental Health, PO Box 687, Jefferson City, MO 65102.

   1. (A) The organization must submit a current written description of those programs and services for which it is seeking certification by the department.
   2. (B) A new applicant shall not use a name which implies a relationship with another organization, government agency or judicial system when a formal organizational relationship does not exist.

   3. (C) Certification fees are not required, except for the Substance Abuse Traffic Offender Program (SATOP). A nonrefundable fee of one hundred twenty-five dollars ($125) is required upon initial application. Renewal fees are as follows:

      1. 1. A fee of one hundred twenty-five dol-

lars ($125) is required if the aggregate number of individuals being served in the SATOP program(s) during the preceding state fiscal year was less than two hundred fifty (250) individuals;

1. 2. A fee of two hundred fifty dollars

($250) is required if the aggregate number of individuals being served in the SATOP program(s) during the preceding state fiscal year was at least two hundred fifty (250) but no more than four hundred ninety-nine (499); or

1. 3. A fee of five hundred dollars ($500)

is required if the aggregate number of individuals being served in the SATOP program(s) during the preceding state fiscal year was at least five hundred (500). 9 CSR 10-7

1. (D) The fee schedule may be adjusted annually by the department.
2. (E) The department will review a completed application within thirty (30) calendar days of receipt to determine whether the applicant organization would be appropriate for certification. The department will notify the organization of its determination. Where applicable, an organization may qualify for expedited certification in accordance with subsections (3)(B) and (C) of this rule by submitting to the department required documentation and verification of its accreditation or other deemed status.
3. (F) An organization that wishes to apply for recertification shall submit its application forms to the department at least sixty (60) days before expiration of its existing certificate.
4. (G) An applicant can withdraw its application at any time during the certification process, unless otherwise required by law.

1. (3) The department shall conduct a site survey at an organization to assure compliance with standards of care and other requirements. The department shall determine which standards and requirements are applicable, based on the application submitted and the on-site survey.

   1. (A) The department shall conduct a comprehensive site survey for the purpose of determining compliance with core rules and program/service rules, except as stipulated in subsections (3)(B) and (C).

   2. (B) The department shall conduct an expedited site survey when an organization has attained full accreditation under standards for behavioral healthcare from the Commission on Accreditation of Rehabilitation Facilities (CARF), Joint Commission on Accreditation of Healthcare Organizations (JCAHO), or the Council on Accreditation of Services to Families and Children (COA).

      1. 1. The survey shall monitor compliance

with applicable program/service rules promulgated by the department.

1. 2. The survey shall not monitor core

rules, except for those requirements designated by the department as essential to—

1. A. Providing and documenting ser-

vices funded by the department or provided through a service network authorized by the department;

1. B. Assuring the qualifications and

credentials of staff members providing these services;

1. C. Protecting the rights of individuals

being served, including mechanisms for grievances and investigations; and

1. D. Funding, contractual, or other

legal relationship between the organization and the department.

1. (C) The department shall grant a certificate, upon receipt of a completed application, to an organization which has attained full accreditation under standards for behavioral healthcare from CARF, JCAHO or COA; does not provide methadone treatment; does not receive funding from the department; and does not participate in a service network authorized by the department.

   1. 1. The organization must submit a copy

of the most recent accreditation survey report and verification of the accreditation time period and dates.

1. 2. The department shall review its cate-

gories of programs and services available for certification and shall determine those which are applicable to the organization. The department, at its option, may visit the organization’s program site(s) solely for the purpose of clarifying information contained in the organization’s application and its description of programs and services, and/or determining those programs and services eligible for certification by the department.

1. (4) The department shall provide advance notice and scheduling of routine, planned site surveys.

   1. (A) The department shall notify the applicant regarding survey date(s), procedures and a copy of any survey instrument that may be used. Survey procedures may include, but are not limited to, interviews with organization staff, individuals being served and other interested parties; tour and inspection of treatment sites; review of organization administrative records necessary to verify compliance with requirements; review of personnel records and service documentation; observation of program activities; and review of data regarding practice patterns and outcome measures, as available.
   2. (B) The applicant agrees, by act of submitting an application, to allow and assist department representatives in fully and freely conducting these survey procedures and to provide department representatives reasonable and immediate access to premises, individuals, and requested information.
   3. (C) An organization must engage in the certification process in good faith. The organization must provide information and documentation that is accurate, and complete. Failure to participate in good faith, including falsification or fabrication of any information used to determine compliance with requirements, may be grounds to deny issuance of or to revoke certification.
   4. (D) The surveyor(s) shall hold entrance and exit conferences with the organization to discuss survey arrangements and survey findings, respectively. A surveyor shall immediately cite any deficiency which could result in actual jeopardy to the safety, health or welfare of persons served. The surveyor shall not leave the program until an acceptable plan of correction is presented which assures the surveyor that there is no further risk of jeopardy to persons served.

   5. (E) Within thirty (30) calendar days after the exit conference, the department shall provide a written survey report to the organization’s director and governing authority.

      1. 1. The report shall note any deficiencies

identified during the survey for which there was not prompt, remedial action.

1. 2. The organization shall make the

report available to the staff and to the public upon request.

1. 3. Where applicable, the department

shall send a notice of deficiency by certified mail, return receipt requested.

1. (F) Within thirty (30) calendar days of the date that a notice of deficiency is presented by certified mail to the organization, it shall submit to the department a plan of correction.

   1. 1. The plan must address each deficien-

cy, specifying the method of correction and the date the correction shall be completed.

1. 2. Within fifteen (15) calendar days after

receiving the plan of correction, the department shall notify the organization of its decision to approve, disapprove, or require revisions of the proposed plan.

1. 3. In the event that the organization has

not submitted a plan of correction acceptable to the department within ninety (90) days of the original date that written notice of deficiencies was presented by certified mail to the organization, it shall be subject to expiration of certification.

1. (5) The department may grant certification on a temporary, provisional, conditional, or compliance status. In determining certification status, the department shall consider patterns and trends of performance identified during the site survey.

   1. (A) Temporary status shall be granted to an organization if the survey process has not been completed prior to the expiration of an existing certificate and the applicant is not at fault for failure or delay in completing the survey process.

   2. (B) Provisional status for a period of one hundred eighty (180) calendar days shall be granted to a new organization or program based on a site review which finds the program in compliance with requirements related to policy and procedure, facility, personnel, and staffing patterns sufficient to begin providing services.

      1. 1. In the department’s initial determina-

tion and granting of provisional certification, the organization shall not be expected to fully comply with those standards which reflect ongoing program activities.

1. 2. Within one hundred eighty (180) cal-

endar days of granting provisional certification, the department shall conduct a comprehensive or expedited site survey and shall make a further determination of the organization’s certification status.

1. (C) Conditional status shall be granted to an organization which, upon a site survey by the department, is found to have numerous or significant deficiencies with standards that may affect quality of care to individuals but there is reasonable expectation that the organization can achieve compliance within a stipulated time period.

   1. 1. The period of conditional status shall

not exceed one hundred eighty (180)-calendar days. The department may directly monitor progress, may require the organization to submit progress reports, or both.

1. 2. The department shall conduct a fur-

ther site survey within the one hundred eighty (180)-day period and make a further determination of the organization’s compliance with standards.

1. (D) Compliance status for a period of one

1. (1) year shall be awarded to an organization which, upon a site survey by the department, is found to meet all standards relating to quality of care and the safety, health and welfare of persons served. A two (2)-year time period of certification may be granted when an organization achieves compliance for three

2. (3) consecutive surveys with no deficiencies related to quality of care and the safety, health and welfare of persons served.

   1. (E) For organizations that have attained full accreditation under standards for behavioral healthcare from CARF, JCAHO, and COA, and that receive an expedited site survey from the department, compliance status from the department shall be for a period of time equal to the length of the accreditation received from the accrediting entity.
3. (6) The department may investigate any written complaint regarding the operation of a certified program or service.
4. (7) The department may conduct a scheduled or unscheduled site survey of an organization at any time to monitor ongoing compliance with these rules. If any survey finds conditions that are not in compliance with applicable certification standards, the department may require corrective action steps and may change the organization’s certification status consistent with procedures set out in this rule.

5. (8) The department shall certify only the organization named in the application, and the organization may not transfer certification without the written approval of the department.

   1. (A) A certificate is the property of the department and is valid only as long as the organization meets standards of care and other requirements.
   2. (B) The organization shall maintain the certificate issued by the department in a readily available location.
   3. (C) Within seven (7) calendar days of the time a certified organization is sold, leased, discontinued, moved to a new location, has a change in its accreditation status, appoints a new director, or changes programs or services offered, the organization shall provide written notice to the department of any such change.
   4. (D) A certified organization that establishes a new program or type of program shall operate that program in accordance with applicable standards. A provisional review, expedited site survey or comprehensive site survey shall be conducted, as determined by the department.

6. (9) The department may deny issuance of and may revoke certification based on a determination that—

   1. (A) The nature of the deficiencies results in substantial probability of or actual jeopardy to individuals being served;
   2. (B) Serious or repeated incidents of abuse or neglect of individuals being served or violations of rights have occurred;
   3. (C) Fraudulent fiscal practices have transpired or significant and repeated errors in billings to the department have occurred;
   4. (D) Failure to participate in the certification process in good faith, including falsification or fabrication of any information used to determine compliance with requirements;
   5. (E) The nature and extent of deficiencies results in the failure to conform to the basic principles and requirements of the program or service being offered; or
   6. (F) Compliance with standards has not been attained by an organization upon expiration of conditional certification.

7. (10) The department, at its discretion, may—

   1. (A) Place a monitor at a program if there is substantial probability of or actual jeopardy to the safety, health or welfare of individuals being served.

      1. 1. The cost of the monitor shall be

charged to the organization at a rate which recoups all reasonable expenses incurred by the department.

1. 2. The department shall remove the

monitor when a determination is made that the safety, health and welfare of individuals being served is no longer at risk.

1. (B) Take other action to ensure and protect the safety, health or welfare of individuals being served.

1. (11) An organization which has had certification denied or revoked may appeal to the director of the department within thirty (30) calendar days following notice of the denial or revocation being presented by certified mail to the organization. The director of the department shall conduct a hearing under procedures set out in Chapter 536, RSMo and issue findings of fact, conclusions of law and a decision which shall be final.

2. (12) The department shall have authority to impose administrative sanctions.

   1. (A) The department may suspend the certification process pending completion of an investigation when an organization that has applied for certification or the staff of that organization is under investigation for fraud, financial abuse, abuse of persons served, or improper clinical practices.
   2. (B) The department may administratively sanction a certified organization that has been found to have committed fraud, financial abuse, abuse of persons served, or improper clinical practices or that had reason to know its staff were engaged in such practices.
   3. (C) Administrative sanctions include, but are not limited to, suspension of certification, clinical utilization review requirements, suspension of new admissions, denial or revocation of certification, or other actions as determined by the department.
   4. (D) The department shall have the authority to refuse to accept for a period of up to twenty-four (24) months an application for certification from an organization that has had certification denied or revoked or that has been found to have committed fraud, financial abuse or improper clinical practices or whose staff and clinicians were engaged in improper practices.
   5. (E) An organization may appeal these sanctions pursuant to section (11).

3. (13) An organization may request the department’s exceptions committee to waive a requirement for certification if the head of the organization provides evidence that a waiver is in the best interests of the individuals it serves. 9 CSR 10-7

   1. (A) A request for a waiver shall be in writing and shall include justification for the request.
   2. (B) The request shall be submitted to Exceptions Committee, Department of Mental Health, PO Box 687, Jefferson City, MO 65102.
   3. (C) The exceptions committee shall hold meetings in accordance with Chapter 610, RSMo and shall respond with a written decision within forty-five (45) calendar days of receiving a request.
   4. (D) The exceptions committee may issue a waiver on a time-limited or other basis.
   5. (E) If a waiver request is denied, the exceptions committee shall give the organization forty-five (45) calendar days to fully comply with the standard, unless a different time period is specified by the committee. AUTHORITY: sections 630.050 and 630.055, RSMo 2000.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed Sept. 25, 2002, effective April 30, 2003. *Original authority: 630.050, RSMo 1980, amended 1993, 1995 and 630.055, RSMo 1980.