1. (1) If a Certified or Provisional Status ACT program does not achieve the minimum fidelity rating per their geographical service area based on OAR 309-019-0235 the following shall occur:

   1. (a) Within 14 calendar days, unless otherwise extended by the Division, the Division Approved Reviewer will coordinate & host a meeting with The ACT Program and the Division Designee, to discuss the outcome of the fidelity review and collectively develop a technical assistance plan.
   2. (b) If a CCO requests to be involved, the host/scheduler shall forward the invite to the CCO timely.

   3. (c) The technical Assistance (TA) plan must include all items within the fidelity comprehensive report that received a rating of a two or below in the following subscale categories:

      1. (A) Operations and Structure,
      2. (B) Core Practices Subscale,
      3. (C) Evidence-Based Practices Subscale and
      4. (D) Person-Centered Planning & Practices Subscale.
   4. (d) If the Division has identified any non-compliance or other regulatory violations per OAR’s 309-019-0225 through 0255 or any other applicable statutes, administrative rules, or other regulations, these items will be added to the TA plan as addendum items by the Division Designee and/or the Division Licensing and Certification;
2. (2) The Division Approved Reviewer must provide technical assistance for a period of 90 calendar days from the date of the fidelity review publication to address areas identified in the technical assistance plan.
3. (3) The Division will extend certification on a temporary basis for the 90 days period to ensure there are no impacts to billing during the technical assistance period with anticipation that corrections to program operations will be made.
4. (4) At the end of the 90-day technical assistance period, The Division Approved Reviewer shall conduct a follow-up re-review which will include only the identified subscale topics identified within the TA Plan created within this rule set in addition to the Core Team Subscale section to verify integrity and intent to implement the other subscale items on fidelity scale.

5. (5) Within 30 calendar days following the fidelity re-review, the Division Approved Reviewer shall provide a comprehensive amended fidelity report to the Division and the ACT program.

   1. (a) If the ACT Program currently serves participants who are members of a CCO, unless otherwise specified in a private contract with that CCO, the ACT Program shall send a copy of the amended fidelity re-review report to the appropriate CCO within 7 calendar days following issuance of that amended fidelity report.
   2. (b) If the ACT Program achieves the minimum rating or higher per OAR 309-019-0235 on the fidelity re-review and all other applicable statutes, administrative rules, or other regulations, the Division can approve the program for ACT Accreditation for two-years of original fidelity month.

6. (6) If a Provisional Status Provider per OAR 309-019-0233 does not achieve the minimum fidelity rating on their first fidelity review, the provider has seven calendar days to communicate to the Division one of the following:

   1. (a) Accept conclusion and reapply for Provisional Status;
   2. (b) Appeal the conclusion in writing on their agency letter head with date stamp to the Division Designee and request a re-assessment.
   3. (c) No longer publicize or in any way promote agency as an ACT accredited service provider and agree to follow all necessary steps per OAR 309-019-0250 Transitions to lower level of care or care coordinate transfer of clients to a neighboring accredited ACT Team.
7. (7) Re-Reviews for Provisional Providers must occur within 45 calendar days of appeal receipt by the Division.
8. (8) The Division may deny, revoke, suspend or place conditions on the programs ACT Accreditation if the re-review results in a rating that is below 2.5 out of 5 or the Division has identified a regulatory non-compliance issue per certificate of approval.

9. (9) Congruent with the process outlined in section (1) above, if the Division determines a program is operating outside of compliance with all applicable statutes, administrative rules or other regulations, the Division may require the program to submit a Plan of Correction (POC). The Division shall provide written notice of the requirement to submit a POC and the program shall submit a POC according to the following terms:

   1. (a) The program shall submit a POC to the Division and the appropriate CCO within 30 days of receiving a notice of requirement to submit a POC. The Division may issue up to a 90-day extension to the existing certification to allow the program to complete the POC process; and

   2. (b) The POC shall address each finding of non-compliance and shall include:

      1. (A) The planned action already taken, or to be taken, to correct each finding of non-compliance.
      2. (B) The anticipated or requested timeframe for the completion of each corrective action not yet complete at the time of POC submission to the Division;
      3. (C) A description of and plan for quality assurance activities intended to ensure ongoing compliance; and
      4. (D) The name and role of the individual responsible for ensuring the implementation of each corrective action within the POC.

10. (10) If the Division finds that clarification or supplementation to the POC is required prior to approval, the Division shall contact the program to provide notice of requested clarification or supplementation, and the program shall submit an amended POC within 14 calendar days of receiving notification.

    1. (a) The program must submit a sufficient POC approved by the Division prior to receiving a certificate. Upon the Division’s approval of the POC, the Division shall issue the appropriate certification.
    2. (b) The Division may deny, revoke, suspend, not renew, or place conditions on the program’s certification and or accreditation if the program fails to submit an adequate POC within the timeframes established in this rule.
11. (11) When the Division determines the need to deny, revoke, not renew, or place conditions on the program’s accreditation issued under these rules, a notice of intent to take action on the accreditation shall be issued to the program.

12. (12) Immediate suspension may occur if the Division finds there is a serious danger to the public health and safety during a specified period of time and/or there is a substantial failure to comply with applicable statutes, administrative rules, or other applicable regulations.

    1. (a) The program may request a contested case hearing to contest the immediate suspension order in accordance with ORS Chapter 183.
    2. (b) Requests for a hearing must be received by the Division within 90 days from the date the immediate suspension order was served on the program personally, or by certified or registered mail.

13. (13) When the Division issues an Order of Suspension, a notice of intent to revoke, notice of intent to deny an application or notice of refusal to renew the certificate to a program pursuant to these rules, the Division shall offer the program an opportunity for an informal conference. The program shall make its request for an informal conference in writing within 14 calendar days of the issuance of the notice of intent or Order of Suspension.

    1. (a) Upon receipt of a timely written request, the Division shall select a location and time for such conference. Following the conference, the Division may:

       1. (A) withdraw or amend the notice of intent or suspension order; or
       2. (B) not withdraw the notice of intent or suspension order.
    2. (b) the Division shall provide written notice of its decision within 14 calendar days following the informal conference.
14. (14) A program who is issued a notice of intent to deny, revoke, refuse to renew, or apply a condition on programs certificate under these rules shall be entitled to request a hearing in accordance with ORS Chapter 183.
15. (15) A Variance per OAR 309-019-0220 and 309-008-1600 is not an allowable avenue in response to an agency’s inability to meet minimum fidelity rating for ACT service accreditation and may only be used for ACT Programs within context of OAR 309-019-0241.

Statutory/Other Authority

ORS 413.042, 430.256 & 430.640

Statutes/Other Implemented

ORS 428.205 - 428.270, 430.010, 430.205- 430.210, 430.254 - 430.640, 430.850 - 430.955 & 743A.168

History

BHS 29-2025, amend filed 12/29/2025, effective 01/01/2026
BHS 17-2025, amend filed 06/25/2025, effective 06/29/2025
BHS 32-2024, temporary amend filed 12/27/2024, effective 01/01/2025 through 06/29/2025
BHS 44-2023, amend filed 12/22/2023, effective 01/01/2024
MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018
MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18
MHS 6-2017, f. & cert. ef. 6-23-17
MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17
MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16
MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16