Based on level of readiness designation, Certified Community Behavioral Health Clinics (CCBHC) will receive the following certification types:

1. (1) Full certification is given when CCBHC receives level of readiness designation of “ready to certify”. Full certification is effective for 3 years.

   1. (a) Prior to certification, the CCBHC will have 30 calendar days to submit a Site Improvement Plan (SIP) to address areas of deficiency. The SIP must include a plan to achieve compliance which must not to exceed a duration of 3 years.

      1. (A) When access or care to persons served is a serious issue, the CCBHC site may be given a much shorter period to initiate SIPs, and this condition may be established, in writing, as part of the Authority findings
      2. (B) If the Authority identifies an issue that places a person served in imminent risk to health or safety, the Authority may require immediate response based on risk.
   2. (b) The Authority will review the SIP, seek clarifying or additional information from the CCBHC site as needed, and issue a response within 30 calendar days of receipt.
   3. (c) The Authority will take steps to monitor the CCBHC site’s implementation of the SIP as part of performance monitoring, including but not limited to annual check-ins over a 3-year period.

2. (2) Provisional certification is given when the CCBHC receives a level of readiness designation of “mostly meets, needs support”. Provisional certification is effective for 1 year.

   1. (a) Prior to certification, the CCBHC will have 30 calendar days to submit a Site Improvement Plan (SIP) to address areas of deficiency. The SIP must include a plan to achieve compliance which must not to exceed a duration of 12 months.

      1. (A) When access or care to persons served is a serious issue, the CCBHC site may be given a much shorter period to initiate SIPs, and this condition may be established, in writing, as part of the Authority findings
      2. (B) If the Authority identifies an issue that places a person served in imminent risk to health or safety, the Authority may require immediate response based on risk.
   2. (b) The Authority will review the SIP, seek clarifying or additional information from the CCBHC site as needed, and issue a response within 30 calendar days of receipt.
   3. (c) The Authority will take steps to monitor the CCBHC site’s implementation of the SIP as part of performance monitoring, including but not limited to conducting quarterly check-ins over 12 months.
   4. (d) Following 12 months, if the CCBHC site still fails to meet requirements for full certification, provisional certification will continue for an additional six (6) months of monitoring with quarterly check-ins required;
   5. (e) If deficiencies are resolved, and full certification criteria has been met by the CCBHC at the conclusion of the SIP process, the CCBHC is given full certification.
3. (3) CCBHCs with full certification must submit a recertification application to the Authority in conjunction with their Chapter 309 Division 008 certifications.
4. (4) The Authority will use the level of readiness tool to review each application and verify CCBHC certification.

Statutory/Other Authority

ORS 413.042 & HB 4002 (2024)

Statutes/Other Implemented

ORS 413.042

History

BHS 22-2025, adopt filed 09/30/2025, effective 10/01/2025