Section 5122-25-04 - Certification procedure for deemed status(A) Any provider subject to or seeking certification under this rule shall apply to the department by filing an application. (1) A provider that has received accreditation for one or more of the services in which it is seeking certification, and is applying for deemed status from the department according to rule 5122-25-02 of the Administrative Code shall file an application that includes:(a) Identifying information including:(i) Legal name as filed with the Ohio secretary of state, including any fictitious name ("doing business as") if applicable;(ii) Addresses and telephone numbers at which the applicant operates and address for legal notice and correspondence. Each provider shall have at least one physical site that is certified. A location which would be considered the client's natural environment (e.g. school, home, job and family services agency) is not considered a site and need not be certified;(iii) Governing structure and the names and contact information of the governing body, board of directors, LLC members or similar body;(iv) Name and e-mail address of executive director, chief executive officer or president; and(v) Name and e-mail address of designated provider contact person who shall be the primary contact on behalf of the provider;(vi) Current and previous history of state agency licensure and certification;(vii) Whether the provider is requesting certification to provide mental health services, addiction treatment services, or services to both populations;(viii) A list of services according to Chapter 5122-29 of the Administrative Code to be provided during the term of certification;(ix) Number of beds for each residential and withdrawal management substance use disorder services location; (x) A description of the provider's purpose, mission and goals if a provider is applying for its first certification; and,(xi) Other information or material if requested by the department to determine the applicants services meet certification standards.(b) Upon request of the department, the following corporate information. Before requesting this information, the department shall first attempt to obtain the information from the Ohio secretary of state website:(i) Identification of the statutory corporate agent for service; and(ii) If an out-of-state corporation, a copy of the certificate from the Ohio secretary of state, of registration to do business in Ohio.(c) For any site which has not been approved or accredited by the provider's accrediting body, copies of approved physical inspections, either initial or renewal, for each building owned or leased, including: (i) A building inspection by a local certified building inspector or a certificate of occupancy issued by the department of industrial relations, to be re-inspected whenever there are major alterations or modifications to the building or facility. An additional building inspection shall be required for any major change in the use of space that would make the facility subject to review under different building code standards;(ii) Approved fire inspection conducted within the previous twelve months, which shall be free of deficiencies, and was conducted by a certified fire authority, or where there is none available, by the division of the state fire marshal of the department of commerce;(iii) Water supply and sewage disposal inspection for facilities in which these systems are not connected with public services to certify compliance with rules of the department of health and any other state or local regulations, rules, codes or ordinances;(iv) Current boiler certificate of operation, if applicable; (v) Current elevator permit, if applicable; and,(vi) Food service license or permit, if required by the department of health.(d) The applicable non-refundable certification fee as provided for in rule 5122-25-08 of the Administrative Code for services which are not accredited, if applicable.(e) Documentation of any existing waivers or variances from the department regarding the certification standards, and justification if the provider is seeking their renewal.(f) Notification if the provider uses seclusion or restraint as defined in rule 5122-26-16 of the Administrative Code.(g)If a provider is seeking certification for supplemental behavioral health services as defined in rule 5122-29-27 of the Administrative Code, that are funded in whole or in part by a board, and for which there are no specific certification standards, the name of the service, a brief description of the service, and a letter of approval from the board shall be submitted.(h) The documentation required in paragraph (I) of rule 5122-25-02 of the Administrative Code, unless it has already been submitted and deemed status approved by the department.(i) Driver intervention programs shall include: (i) The total number of hours of operation, including the total number of program hours;(ii) If services are provided at a camp, a copy of the "Permission to Operate a Camp" issued by the local county/city health department pursuant to rule 3701-25-02 of the Administrative Code.(iii) If services are provided at a hotel or motel, a copy of the hotel/ motel license from the division of the state fire marshal of the Ohio department of commerce will be accepted in lieu of a copy of a occupancy and use certificate and annual fire inspection. (j) Documentation requested by the department for any service not included under the deemed status provision of rule 5122-25-02 of the Administrative Code.(B) Upon receipt of an application, the department shall review the materials to determine if they are complete. If an application is incomplete, the department shall notify the applicant of corrections or additions needed, and may return the materials to the applicant. Incomplete materials shall not be considered an application for certification, and return of the materials or failure to issue a certificate shall not constitute a denial of an application for certification.(C) Following the department's acceptance of materials as a complete application, the department shall determine whether the applicant's services and activities meet certification standards. The process for such a determination consists of the following: (1) For a provider applying for deemed status, the department shall review the application materials, and issue the certification for services covered under deemed status without further evaluation of the services, except that the department may conduct an on-site survey or otherwise evaluate the provider for cause, including complaints made by or on behalf of consumers and confirmed or alleged deficiencies brought to the attention of the department.(2) For services not included in a provider's deemed status approval, the department may schedule and conduct an on-site survey of or otherwise evaluate the applicant's services and activities. If conducting an on-site survey, the department shall send the provider a letter confirming the date of the on-site survey, and notify, in writing, the applicable board of the date of the on-site survey. At least thirty days before a scheduled survey date, the applicant shall post notices of the survey date and of the opportunity for the public to participate in a public information interview during the survey. Such notices shall be posted in public areas, on bulletin boards near major entrances, and in treatment or residential areas of the applicant.
The department shall have access to all written, electronic and recorded records to verify compliance with certification standards as established by department rules. The department may conduct interviews with members of the provider's governing authority, staff, others in the community and clients with the client's permission.
Exit interviews with provider staff shall be conducted during routine initial and renewal on-site surveys.
(D) The department may conduct an on-site survey or otherwise evaluate a provider applying for or granted deemed status at any time based on cause, including complaints made by or on behalf of consumers and confirmed or alleged deficiencies brought to the attention of the director. The department may or may not notify a provider in advance of a survey conducted for cause. The department shall have access to all written, electronic and recorded records or media to verify compliance with certification standards as established by department rules. The department may conduct interviews with members of the provider's governing authority, staff, others in the community and clients with the client's permission.
(E) An applicant that fails to comply with any or all of the certification standards applicable to the agency shall receive a written statement from the department citing items that are not in compliance.(1) This statement shall describe the deficiencies, actions needed for correction, and a time frame for the provider to submit a written plan of correction.(2) The provider's plan of correction shall describe the actions to be taken and shall specify a time frame for correction of deficiencies.(F) If a provider adds a service or activity subject to certification during the term of certification, the provider shall submit: (1) For a provider applying for deemed status, the documentation required in paragraph (K) of rule 5122-25-02 of the Administrative Code. Upon determination by the department that the provider has obtained appropriate behavioral health accreditation, the department will certify the provider to provide that service or activity.(2) Interim certification application process: (a) The department shall review the application materials for compliance with Chapters 5122-26 to 5122-29 of the Administrative Code.(b) The department may conduct an on-site inspection of the physical plant environment if the location is not accredited by the accrediting body.(c) The provider must demonstrate clinical readiness to meet the documentation requirements of Chapter 5122-27 of the Administrative Code by demonstrating it has acquired an electronic health record system that supports documentation to meet these requirements and/or providing samples of paper forms.(d) A provider that fails to respond to a request to submit additional documentation or a request to submit a corrective response (e.g. corrective action plan or plan of correction) within ninety days shall automatically be considered to have withdrawn its application. If the provider wishes to seek certification, it shall file a new initial application.(3) Initial full certification application process: (a) Review the application materials for compliance with Chapters 5122-26 to 5122-29 of the Administrative Code.(b) For an initial certification only, a provider that fails to respond to a request to submit additional documentation or a request to submit a corrective response (e.g. corrective action plan or plan of correction) within ninety days shall automatically be considered to have withdrawn its application. If the provider wishes to seek certification, it shall file a new initial application.(c) The department shall schedule and conduct an on-site survey prior to the expiration date of an interim certificate issued in accordance with paragraph (F)(2) of this rule and paragraph (F)(2)(a) of rule 5122-25-05 of the Administrative Code unless the provider has obtained accreditation for the service that includes an on-site survey by the accrediting body to review the provision of the service.(d) The department may schedule and conduct an on-site survey or otherwise evaluate the applicant's services and activities if a provider is seeking any other initial certification.(e) If conducting an on-site survey, the department shall send the provider a letter confirming the date of the on-site survey, and notify, in writing, the applicable board of the date of the on-site survey.(f) At least thirty days before a scheduled survey date, the applicant shall post notices of the survey date and of the opportunity for the public to participate in a public information interview during the survey. Such notices shall be posted in public areas, on bulletin boards near major entrances, and in treatment or residential areas of the applicant.(g) The department shall have access to all written, electronic and recorded records to verify compliance with certification standards as established by department rules. The department may conduct interviews with members of the provider's governing authority, staff, others in the community and clients with the client's permission.(h) Exit interviews with provider staff shall be conducted during routine initial and renewal on-site surveys. (G) If a provider adds a new location during the term of certification, the provider shall submit either the documentation required in paragraph (A)(1)(c) of this rule, or evidence that the site has been approved by its accrediting body. Upon determination by the department that the site is in compliance with certification standards, the department will certify the provider to provide services at that location. (1) The following services are site specific, meaning that a provider must request certification at each specific location:(a) Residential and withdrawal management substance use disorder provided in accordance with rule 5122-29-09 of the Administrative Code.(b) Driver intervention program provided in accordance with rule 5122-29-12 of the Administrative Code.(2) A provider may provide any currently certified service not included in paragraph (G)(1) of this rule at any certified location. (H) Each agency shall submit an application for certification renewal no fewer than ninety days prior to the expiration of the current certificate.(I) A provider that has not previously notified the department that it utilizes seclusion and restraint must do so and submit any documentation requested by the department to verify its compliance with the Administrative Code prior to utilizing these measures. A provider shall not utilize seclusion restraint without written acknowledgment from the department that it is authorized to do so.Ohio Admin. Code 5122-25-04
Effective: 10/31/2019
Five Year Review (FYR) Dates: 2/1/2021
Promulgated Under: 119.03
Statutory Authority: 5119.36
Rule Amplifies: 5119.36
Prior Effective Dates: 01/01/2004, 07/01/2009, 11/24/2011, 10/01/2012, 02/01/2016