Targeted Review and Self-assessment Process

(1) A provider with a two-year license is eligible to renew that license through the targeted review and self-assessment process both of which are required. The targeted review is conducted by the Department and the self-assessment is conducted by the provider. (2) In a targeted review, the Department shall conduct a survey in accordance with 115 CMR 8.03(4) to review all critical indicators and the licensure indicators that were not met by the provider in its previous survey and shall conduct a certification review only if a full certification survey is required under 115 CMR 8.05(1). (3) In a self-assessment, the provider shall review, using the self-assessment guidelines established by the Department, all licensure indicators. The provider shall also review those certification indicators that were not met in its previous survey unless the Department is conducting a full certification survey pursuant to 115 CMR 8.06(2). Upon completion of the self-assessment, the provider shall submit to the Department its ratings of all indicators reviewed together with a detailed and comprehensive description of the provider's on-going quality assurance system and self-assessment process. The submission must include the evidence used by the provider to justify its rating for each indicator reviewed. (4) Where an indicator is rated by both the Department and provider, the Department's rating shall be the determinative rating. (5) The Department shall review the adequacy of the provider's quality assurance system and self-assessment. Ratings from the targeted review and self-assessment will be combined to determine in accordance with 115 CMR 8.04 the licensure level for the provider. The provisions of 115 CMR 7.03(5) through (10) shall apply to the targeted review and self-assessment process. (6) Providers issued a two-year license through the targeted review and self-assessment process shall be subject to a full licensure and certification survey at their next survey cycle. (7) The Department may require a full licensure and certification survey when there has been a change in circumstance since the provider's previous survey. A change in circumstance includes, but is not limited to, change in leadership of the provider, merger or consolidation of the provider with another provider, increase in incidents, restraints, or substantiated investigations, contract performance issues, and the addition of services not reviewed through the previous survey.