3793:2-1-01 Program certification/licensure process.

 

 

 

3793:2-1-01                 Program certification/licensure process.

 

 

 

(A)   The purpose of this rule is to state the procedures for certification and licensure of alcohol and drug addiction programs in Ohio.

 

(B)   The provisions of this rule are applicable to all of the following Ohio alcohol and drug addiction programs, public and private, regardless of whether they receive any public funds that originate and/or pass through the Ohio department of alcohol and drug addiction services in accordance with division (A) of section 3793.06 of the Revised Code:

 

(1)   Alcohol and drug addiction outpatient treatment programs.

 

(2)   Alcohol and drug addiction residential treatment programs.

 

(3)   Methadone Opioid agonist programs.

 

(4) Ambulatory and sub-acute detoxification programs.

 

(C)  The provisions of this rule are not applicable to the following programs:

 

(1)   Alcohol and drug prevention programs.

 

(2)   Alcohol and drug addiction acute hospital detoxification programs.

 

(3)   Criminal justice therapeutic community programs.

 

(4)   Treatment alternatives to street crime programs.

 

(5)   Driver intervention programs.

 

(6) Programs located outside the State of Ohio.

 

(D)     Procedure  for  processing  an  application  for  program  certification/licensure:  for programs not currently certified and opioid agonist programs.

 

(1)   Any Ohio alcohol and drug addiction outpatient treatment program, residential treatment program or opioid agonist methadone program, ambulatory or sub-acute detoxification program subject to or seeking program certification/licensure pursuant to division (A) of section 3793.06 of the Revised Code shall apply to the Ohio department of alcohol and drug addiction services by filing an application that includes, but is not limited to,

 

 

 

the following information for each program site to be certified/licensed by the department:

(a)  Name,  address,  telephone  number  and  county  of  the  owner  of  the program.

(b)(a) Name, address, telephone number and county of each the program site(s) to be certified by the Ohio department of alcohol and drug addiction services. 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.

(c) Name of program director.

(d)Current table of organization for the alcohol and drug addiction program.

(e)(b) Program and business hours Hours of operation for delivery of alcohol and drug addiction services.

(f)(c) The

Written description for each of the alcohol and drug addiction

services the program provides.

(g) Staff roster of all current employees, contract staff, volunteers and student interns of the alcohol and drug addiction program, that includes first and last names, highest academic degrees and credentials.

(h)(d) Copy of an Ohio food services operator's license if food is prepared and served at the program site to six or more clients required by the Ohio Department of Health.

(i)(e) Copy of an occupancy and use certificate issued by the division of construction compliance of the Ohio department of commerce or issued by an Ohio certified building department of a municipal corporation, township or county which has been established in conformity with law for the purpose of enforcing the "Ohio Basic Building Code" for the location where the program will be conducted.

(j)(f) Copy of a current annual fire inspection by an Ohio certified fire authority or by the division of the state fire marshal of the Ohio department of commerce for the location where services will be provided.

(k)(g) A copy of the owner's program's current registration for doing business

in Ohio that has been filed with the Ohio secretary of state.

(l)(h) If the owner is an out-of-state corporation, a copy of the license from the Ohio secretary of state for doing business in Ohio.

(i) If the program is a non-profit organization, a copy of the approved statement of continued existence approved by the Ohio Secretary of State.

(m) A signed copy of form W-9, request for taxpayer identification number and certification.

(n) A copy of the schedule for services.

(o)(j) Opioid agonist Methadone programs shall submit a signed copy of the current certification from the substance abuse and mental health services administration to use an opioid agonist in the maintenance treatment of opioid addiction.FDA form 2632, application for approval of use of narcotic drugs in a treatment program.

(p) Methadone programs shall submit a copy of FDA form 3633, medical responsibility statement for use of narcotic drugs in a treatment program, for each current program physician.

(q)(k) Residential, and halfway house treatment and sub-acute detoxification programs shall indicate submit the number of alcohol and other drug beds for each type of treatment program.

(r)(l) Programs requesting a variance or an extension of a variance for one or more of the program certification/licensure standards shall include a copy of the request with the program certification/licensure application. Each variance request shall be prepared and submitted in accordance with this rule.

(s)(m) The application shall be signed and dated by the executive program director, CEO or president of the organization.

(2)     Upon receipt of an application, the Ohio department of alcohol and drug addiction services shall review the materials to determine if they are complete.

(a)   If an application is incomplete, the department shall notify the applicant of corrections or additions needed and/or may return the materials to the

applicant.

(b)   The department's return of the materials to the applicant or failure of the department to take further action to issue a certificate/license shall not constitute denial of an application for program certification or licensure.

(3)    Upon acceptance of an application the Ohio department of alcohol and drug addiction services shall contact the program to schedule an on-site inspection of the program.

(a)   The department shall send the program a letter confirming the date of the on-site inspection.

(b)    The department shall notify, in writing, the applicable alcohol and drug addiction services board or the alcohol, drug addiction and mental health services board of the date of the on-site inspection.

(4)    The Ohio department of alcohol and drug addiction services shall conduct an on-site inspection at the time of application, with official written notice to the program, or at any other time for cause as determined by the department to be appropriate, with or without official written notice to the program.

(5)   The Ohio department of alcohol and drug addiction services shall have access to all program-related records to verify compliance with program certification and/or licensure standards as established by department rules. The department may conduct interviews with members of the program's governing authority, program staff, others in the community and/or clients with the clients' permission.

(6)    The Ohio department of alcohol and drug addiction services shall prepare a follow-up inspection report for the on-site inspection of the program.

(a)   The inspection report shall cite any standards with which the program was not in compliance at the time of the on-site inspection.

(b)   The Ohio department of alcohol and drug addiction services shall provide a copy of the on-site inspection report to the program and to the applicable alcohol and drug addiction services board or the alcohol, drug addiction and mental health services board.

(c)       Programs shall correct deficiencies identified during a program certification/licensure inspection conducted by the Ohio department of

alcohol and drug addiction services and documentation of correction of the deficiencies shall be sent to the department within the time frame specified in the follow-up inspection report.

(7)     The Ohio department of alcohol and drug addiction services shall issue a certificate or license to each applicant complying with the program certification or licensure standards.

(a)       Certificates for outpatient and residential treatment programs and ambulatory and sub-acute detoxification residential treatment programs shall not exceed three years.

(b)   Licenses for opioid agonist methadone programs shall be for one year.

(c)   The department shall provide the program with the original certificate or license, and provide a copy of the certificate or license to the applicable alcohol and drug addiction services board or the alcohol, drug addiction and mental health services board.

(d)    The program site shall display the certificate in a prominent location. where services are provided

(8) Certificates and licenses are not transferable to any other program, entity or to other program sites.

(9) Each program shall submit an application for certification or licensure no fewer than sixty days prior to the expiration of the current certification or licensure. The Ohio department of alcohol and drug addiction services is not responsible for ensuring that a program submit an application prior to the expiration of the current certification.

(E) The Ohio department of alcohol and drug addiction services certifies and licenses program sites. Each program certification or license issued by the department is for a specific address.

(F)(E) Conditional program certification/licensure.

(1)      Conditional program certification/licensure may be granted by the Ohio department of alcohol and drug addiction services to enable the program to obtain clients, to establish and maintain client records, to implement quality improvement activities and/or to correct deficiencies identified during an on-site program certification/licensure inspection.

(2)     The Ohio department of alcohol and drug addiction services may issue a conditional program certification/licensure for a maximum period of ninety days.

(a)    Conditional certifications/licensures expire on the last day of a calendar month.

(b)   Failure to comply with the terms of the conditional certification/licensure shall result in a non-certified status.

(G)(F) Relocation of a certified program shall render the certification and/or licensure void. Void certificates/licenses shall be returned to the Ohio department of alcohol and drug addiction services.

(1)   A program shall submit an application for program certification and/or licensure of a new site location to the Ohio department of alcohol and drug addiction services at least thirty days prior to relocation to avoid possible non-certified or non-licensure status of the program.

(2)    Upon acceptance of an application, the Ohio department of alcohol and drug addiction services may conduct an on-site inspection of the new program site location for compliance with certification/licensure standards for physical plant and safety and any other program certification/licensure standards deemed appropriate by the Ohio department of alcohol and drug addiction services.

(3)    Certificates/licenses issued as a result of a relocation of a program site shall have the same expiration date as the certification or licensure of the original program site.

(G) Procedure for renewal of program certification for currently certified programs:

(1) The Ohio Department of Alcohol and Drug Addiction Services will send an application form to the program with information that the department has on file regarding that program. Any Ohio alcohol and drug addiction outpatient, residential treatment program or ambulatory or sub-acute detoxification program seeking renewal of program certification pursuant to Division (A) of Section 3793.06 of the Revised Code shall submit a renewal application, upon receipt, to the Ohio department of alcohol and drug addiction services that includes, but is not limited to, verification of the following information for each program site location to be certified by the department.

(a) Name,  address,  telephone  number,  and  county  of  each  program  site

location to be certified by the Ohio department of alcohol and drug addiction services. 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 be certified.

(b) Program and business hours of operation for alcohol and drug addiction services.

(c) The alcohol and drug addiction services provided.

(d)Copy of a current annual fire inspection by an Ohio-certified fire authority or by the division of the State fire marshal of the Ohio department of commerce for the location where services will be provided.

(e) Residential, halfway house treatment and sub-acute detoxification programs shall indicate the number of alcohol and other drug beds for each type of treatment program.

(f)Programs requesting a variance or an extension of a variance for one or more of the program certification/licensure standards shall include a copy of the request with the program certification/licensure application. Each variance request shall be prepared and submitted in accordance with this rule.

(g) An assurance statement, signed and dated by the executive director, CEO or president of the organization, which states that the agency shall comply with the certification standards as established by department rules for each certified program site location for the duration of its three-year certification period.

(h) The application shall be signed and dated by the executive director, CEO or president of the organization.

(2) Upon receipt of a renewal application, the Ohio department of alcohol and drug addiction services shall review the materials to determine if they are complete.

(a) If an application is incomplete, the department shall notify the applicant of corrections or additions needed and/or may return the materials to the applicant.

(b) The department's return of the materials to the applicant or failure of the department to take further action to issue a certificate shall not constitute denial of an application for program certification.

(3) Upon  approval  of  the  renewal  application,  the  department  shall  issue  a certificate valid for up to a three-year period beginning from the date of issue.

(a) Certificates   for   outpatient,   residential,   ambulatory   and   sub-acute detoxifications programs shall not exceed three years.

(b) The department shall provide the program with the original certificate and provide a copy of the certificate to the applicable alcohol and drug addiction services board or the alcohol and drug addiction and mental health services board.

(c) The program site shall display the certificate in a prominent location where services are provided.

(4) The Ohio department of alcohol and drug addiction services shall contact the program to schedule an on-site inspection of the program within the three-year certification period. Reviews will be scheduled with a minimum 90-day notice.

(a) The department shall send the program a letter confirming the date of the on-site inspection.

(b) The department shall notify, in writing, the applicable alcohol and drug addiction services board or the alcohol, drug addiction and mental health services board of the date of the on-site inspection.

(5) The Ohio department of alcohol and drug addiction services shall conduct an on-site inspection within the three-year certification period with official written notice to the program, or at any other time for cause as determined by the department, with or without official written notice to the program.

(6) The Ohio department of alcohol and drug addiction services shall have access to all program-related records to verify compliance with program certification and/or licensure standards. The department may conduct interviews with members of the program's governing authority, program staff, others in the community and/or clients with the clients' permission.

(7) The Ohio department of alcohol and drug addiction services shall prepare a follow-up inspection report for the on-site inspection of the program.

(a) The inspection report shall cite any standards with which the program was not in compliance at the time of the on-site inspection.

(b) The Ohio department of alcohol and drug addiction services shall provide a copy of the on-site inspection report to the program and to the applicable alcohol and drug addiction services board or the alcohol, drug addiction and mental health services board.

(c) Programs   shall   correct   deficiencies   identified   during   a   program

certification inspection conducted by the Ohio department of alcohol and drug addiction services. Documentation of correction of the deficiencies shall be sent to the department within the time frame specified from the date in the follow-up inspection report.

(H) The Ohio department of alcohol and drug addiction services certifies and licenses program sites. Each program certification or license issued by the department is for a specific address. Certificates and licenses are not transferable to any other program entity or to other program site locations.

(H)(I) Variances.

(1)     The Ohio department of alcohol and drug addiction services may grant a variance from any certification or licensure standard, or portion thereof, for the period during which the certification or licensure is in effect.

(2)   "Variance" means written permission granted by the Ohio department of alcohol and drug addiction services to a program to be exempted from or meet a modified requirement of a rule or specific provision of a rule of the Administrative Code or other program certification/licensure standard.

(3)   Requests for variances of certification or licensure standards shall be in writing to the Ohio department of alcohol and drug addiction services and shall include:

(a)     The administrative rule number and standard for which a variance is sought.

(b)   The rationale for requesting the variance.

(c)     Documentation by the program that assures the Ohio department of alcohol and drug addiction services that the quality of services and client safety shall not be jeopardized if the variance is granted.

(d)  The consequences of not receiving approval of the requested variance.

(4)   The Ohio department of alcohol and drug addiction services shall issue a written statement to the program granting or denying a request for variance of program certification and/or licensure standards. A copy of the written statement shall be provided to the applicable alcohol and drug addiction services board or alcohol, drug addiction and mental health services board.

(5)    The program shall maintain a file copy of all requests for variances and the approval or denial of the requests for the period during which the certification or licensure is in effect.

(I)(J) The Ohio department of alcohol and drug addiction services may deny or revoke certification or licensure for one or more of the following reasons:

(1)   The program fails to comply with any program certification/licensure standard;

(2)   The program misuses or fails to properly account for the disbursement of state or federal funds;

(3)   The program knowingly provides false information to: the Ohio department of alcohol and drug addiction services, an alcohol and drug addiction services board or an alcohol, drug addiction and mental health services board or other entity;

(4)    The program knowingly permits an employee to falsify information on client records;

(5)   The program is aware of an employee who has abused or neglected a client and has failed to take appropriate disciplinary action to correct the situation;

(6)    The program fails to provide access to its records as requested by the Ohio department of alcohol and drug addiction services.

(7)   Denial, revocation or termination would be in the best interest of the citizens of Ohio.

(J)(K) The Ohio department of alcohol and drug addiction services shall give the program written notice by certified mail, return receipt requested, if it intends to deny or revoke certification/licensure. The notice shall include:

(1)    The standard(s) with which the program was found to be in non-compliance and/or other reason(s) for the action.

(2)   The section(s) of the law or rule(s) involved.

(3)   A statement informing the program that it is entitled to a hearing if it requests it within thirty days of the time of the mailing of the notice.

(4)    A statement that at the hearing, the program's representative may appear in person and/or be represented by its attorney or may present its position, arguments or comments in writing and at the hearing it may present evidence and examine witnesses appearing for and against it. A copy of the notice shall be mailed to the attorney or other representative of record representing the program.

(K)(L) If a program requests a hearing, the Ohio department of alcohol and drug addiction services shall set the date, time and place for the hearing within fifteen days, but not earlier than seven days, after the program has requested a hearing unless otherwise agreed upon by both the department and the program. A copy of the hearing notice shall be mailed to the program's representative or its attorney.

(1)    The Ohio department of alcohol and drug addiction services shall conduct the adjudication hearing following the procedures in section 119.09 of the Revised Code and among other things may appoint a referee or hearing examiner to conduct the proceedings and make recommendations as appropriate.

(2)    The Ohio department of alcohol and drug addiction services shall provide the program a certified copy of its decision by certified mail, return receipt requested.

(3)   If the Ohio department of alcohol and drug addiction services' decision after the hearing is to deny or revoke certification or licensure, the program shall be informed of its right to appeal and file its notice of appeal of the decision within fifteen days of the mailing of the notice of the department's order.

(4)     If the program decides to appeal the Ohio department of alcohol and drug addiction services' decision, the program shall appeal the order of the department to the court of common pleas of the county in which it the program's place of business is located. The program's notice of appeal is to be filed with the department and must state the order appealed from and the grounds of the appeal. A copy of the program's appeal must be filed with the court of common pleas in the county in which the appeal is being filed.

(5)    Within thirty days after receipt of a notice of appeal, the Ohio department of alcohol and drug addiction services shall send to the common pleas court a complete record of the proceedings in the case by certified mail,  return receipt requested.

(L)(M) Any person who violates the provisions of these rules shall be subject to the

penalties provided in section 3793.99 of the Revised Code.

(M)(N) Sanction:

(1)   Any program which has had its certification/licensure revoked pursuant to this rule shall not be eligible to apply to the Ohio department of alcohol and drug addiction services for program certification/licensure for at least five years from the date of revocation without the written consent of the department.

(2)   Any program which has been denied certification/licensure pursuant to this rule shall not be eligible to apply to the Ohio department of alcohol and drug addiction services for program certification/licensure for at least three years from the date of denial without the written consent of the department.

(N)(O) Program certification or licensure shall be considered void and invalid if a program: fails to reapply, voluntarily relinquishes the certificate for certification or licensure, moves to another location, goes out of business or is sold or otherwise conveyed to another entity.

(O)(P) The program shall immediately notify the Ohio department of alcohol and drug addiction services in writing of any changes in its operations that affect the program's continued compliance with the department's program certification and licensure requirements.

(P)(Q) All programs shall be in compliance with all applicable federal, state and local laws and regulations.

(Q)(R) Alcohol and drug addiction programs currently certified or licensed by the Ohio department of alcohol and drug addiction services at the time of the effective date of agency-level 3793 of the Administrative Code shall remain certified/licensed until the expiration of their current certification or licensure unless their certification or licensure were to be revoked or terminated in accordance with this rule.

Effective:                                                     06/01/2005

R.C. 119.032 review dates:                         09/01/2005

CERTIFIED ELECTRONICALLY

Certification

02/18/2005

Date

Promulgated Under:                           119.03

Statutory Authority:                           3793.02(D), 3793.06, 3793.11

Rule Amplifies:                                  3793.06, 3793.11

Prior Effective Dates:                         7/1/01