1. (1) The program shall conduct one on-site verification review of each approved SBHC within one year of application approval to determine compliance with SBHC certification requirements.
2. (2) After the initial on-site verification review, the program shall conduct an on-site verification review every two years for a representative sample of certified SBHCs in each SBHC system.
3. (3) A SBHC will be notified, in writing, no less than 30 days before its scheduled verification review.
4. (4) A SBHC must permit program staff access to the site’s place of business during the review.

5. (5) The verification review must include, but is not limited to:

   1. (a) Review of documents, policies and procedures, and records;
   2. (b) Review of electronic medical record systems, review of electronic health records systems, and review of practice management systems;
   3. (c) Review of data reports from electronic systems or other patient registry and tracking systems;
   4. (d) Interviews with practice management, clinical and administrative staff;
   5. (e) On-site observation of practice staff with at a minimum two school-aged patients, with the consent of the patient, parent, or guardian; and
   6. (f) On-site observation of patient environment and physical environment during business hours.

6. (6) Following a review, program staff may conduct an exit interview with SBHC representative(s). During the exit interview the program staff shall:

   1. (a) Inform the SBHC representative(s) of the preliminary findings of the review; and
   2. (b) Give the SBHC representatives(s) a reasonable opportunity to submit additional facts or other information to the program staff in response to the findings.
7. (7) Within 14 calendar days of the on-site visit program staff must prepare and provide the SBHC with a written report of the findings from the on-site review.
8. (8) If no certification deficiencies are found during the review, the program shall issue written findings to the SBHC indicating no deficiencies were found.

9. (9) If certification deficiencies are found during the on-site review, the program may:

   1. (a) Require corrective actions to be completed within a specified timeline; or
   2. (b) Take action in accordance with OAR 333-028-0250.
10. (10) The program may conduct a review of a certified SBHC without prior notice of any or all selected certification requirements for compliance and perform a verification on-site review of a certified SBHC if the program is made aware of issues of compliance from any source.
11. (11) At any time, a SBHC may request an administrative review of compliance, which includes one on-site visit. The review will be considered a “no penalty” review with the exception of gross violation or negligence that may require site closure or temporary suspension of services.

Statutory/Other Authority

ORS 413.223

Statutes/Other Implemented

ORS 413.223 & 413.225

History

PH 23-2026, amend filed 06/02/2026, effective 07/01/2026
PH 40-2016, f. 12-22-16, cert. ef. 7-1-17
PH 15-2013, f. 12-26-13, cert. ef. 1-1-14