Procedures to Obtain Certification

PURPOSE: This rule describes procedures to obtain certification as a provider of individualized supported living (ISL), group home, shared living, employment services, day habilitation, individualized skills development, community networking, out of home respite, and intensive therapeutic residential habilitation services through the home and community-based waivers for individuals with intellectual and developmental disabilities. (1) Under section 630.655, RSMo, the department is mandated to develop certification standards and to certify providers to operate, receive funds from the department, and be eligible for Medicaid reimbursement. However, certification in itself does not constitute an assurance or guarantee the department will fund designated services or programs. (A) A key goal of certification is to enhance the quality of care and life for individuals with a focus on their needs, preferences, and desired outcomes. (B) The primary function of the certification process is assessment of a provider’s compliance with current standards of care and state and federal requirements. A further function is to identify and ensure corrective action is taken for deficiencies identified during the survey process to ensure health and welfare of persons served by the provider. (2) An entity or individual who has received approval to contract with the department and who has successfully enrolled with MO HealthNet as a provider may request to become a provider of certified services by completing an application form as required by the department for this purpose and submitting the application form and other documentation as specified. The completed application is sent to Department of Mental Health, Office of Licensure and Certification, PO Box 687, Jefferson City, MO 65102, fax (573) 751-9207, or emailed to DMH-OLC@dmh.mo.gov. (A) The applicant must submit a current written description of the programs and services for which it is seeking certification by the department. (B) Certification fees are not required. (C) The department reviews a completed application within thirty (30) calendar days of receipt to determine whether the applicant would be appropriate for certification. The department notifies the provider of its determination. A certificate is issued if— 1. The department has determined the application is complete and all necessary documents have been filed with the application; and 2. The department has determined the provider, programs, and services are compliant with state and federal laws and the corresponding rules. (D) A site survey of the applicant will be conducted to determine compliance with standards. (E) Certified providers need to apply for recertification at least sixty (60) calendar days prior to expiration of its existing certificate. Recertification includes a new application and required documentation. (F) Ninety (90) calendar days after its receipt, the department considers any application for certification withdrawn if it is submitted without all the required information and documents. (G) An applicant can withdraw its application at any time during the certification process, unless otherwise required by law. (3) The department conducts site surveys at a provider for the purpose of determining compliance with certification standards, program requirements, and other state and federal regulations. (4) The department recognizes and deems as certified a provider that maintains accreditation under standards for services provided by the department from the Commission on Accreditation of Rehabilitation Facilities (CARF), The Council on Quality and Leadership (The Council), or Joint Commission on Accreditation of Healthcare Organizations (Joint Commission). The deemed provider must— (A) Submit to the department a copy of the most recent accreditation survey report and verification of the accreditation time period and dates within thirty (30) calendar days of receipt from the accreditation agency; (B) Notify the department when the accreditation agency makes a complaint investigation visit within seven (7) calendar days; (C) Notify the department of any changes in accreditation status during the time period of accreditation and resurvey within seven (7) calendar days; and (D) Ensure compliance with all certification rules and regulations pertaining to the service provided, including fire safety regulations; (E) The Division of Developmental Disabilities may conduct a scheduled or unscheduled site survey of an accredited provider at any time to monitor ongoing compliance with the standards and requirements. If any survey finds conditions that are not in compliance with applicable standards, the division may request corrective action steps. (5) Deemed providers are not excluded from monitoring of service delivery by other quality integrated functions within the department. (6) The department provides advance notice and coordinates with the provider to schedule routine, planned surveys. (A) The department notifies the applicant and the division’s regional offices (ROs) regarding survey procedures and a copy of any survey instrument that may be used. Survey procedures include but are not limited to observation and inspection of service sites, interviews with provider staff, individuals being served, and other interested parties, review of provider administrative records necessary to verify compliance with requirements, review of personnel records and service documentation, and observation of program activities. 1. The review of personnel records includes eligibility for employment, documentation of training, and driver’s license related to the billing of service. (B) The applicant agrees, by act of submitting an application, to allow and assist department representatives in fully and freely conducting these survey procedures and to provide department representatives reasonable and immediate access to premises, individuals, and requested information. (C) A provider shall cooperate with the certification process. The provider shall provide information and documentation that is accurate and complete. Actions of the provider, including but not limited to falsification or fabrication of any information used to determine compliance with requirements, may be grounds to deny issuance of or to revoke certification. (7) Surveyor(s) will hold entrance and exit conferences with the provider to discuss survey arrangements and survey findings, respectively. If a surveyor identifies a deficiency that could result in actual jeopardy to the safety, health, or welfare of persons served, the surveyor will not leave the program until an acceptable plan of correction is presented which assures the surveyor that there is no further risk of jeopardy to persons served. The RO will be notified of the conditions that existed and the accepted plan of correction. (8) Within thirty (30) calendar days after the exit conference, the department will provide a written survey report to the provider’s chief executive officer and/or the provider contact on the provider application and the division. (A) The report details all deficiencies identified during the survey. (B) Upon specific request, the provider shall make the report available to the staff, individuals served, and to the public. (9) If deficiencies are identified, the department will include in the survey report a request for the provider to submit a plan of correction. (A) The plan must address each deficiency and specify the method of correction and the final date of correction, including identification of other individuals having the potential to be affected by the same deficient practice, how the provider will monitor its corrective action including the job title of the individual responsible for monitoring compliance on an ongoing basis, and what systemic changes have been put into place to ensure the deficient practice doesn’t occur again. The provider is encouraged to work with the RO to develop a plan of correction. No final date of correction will exceed one hundred eighty (180) calendar days from the exit date of the survey. (B) Within fifteen (15) calendar days after receiving the plan of correction, the department notifies the provider and the division of its decision to approve, deny, or require revisions of the proposed plan. (C) The surveyor assures the plan of correction has been implemented and deficiencies corrected. The department determines if it is necessary for the surveyor to make a return visit to the provider based on the criteria of the plan of correction and will notify the division and ROs of revisit. (D) In the event the provider has not submitted a plan of correction acceptable to the department within sixty (60) calendar days of the original date that written notice of deficiencies was presented by certified mail to the provider, it is subject to expiration of certification. (10) The department sends copies of survey reports, notification about the status of plans of correction, and any other communication relevant to survey to the mailing address and electronic mail address on file in the provider’s application and/or the provider’s chief executive officer. (11) The department may grant certification on a temporary, provisional, conditional, or regular status. (A) Temporary status is granted to a provider if the survey process has not been completed prior to the expiration of an existing certificate and the applicant is not at fault for failure or delay in completing the survey process. (B) Provisional status for a period not exceeding one (1) year is granted to a new provider, a provider which has undergone a change of ownership, or a currently certified provider adding a waivered service based on a review which finds the program in compliance with requirements related to policy and procedure, personnel qualifications and training, and physical plant and fire safety compliance, when applicable, sufficient to begin providing services. Provisional status is effective the date compliance is determined by the Office of Licensure and Certification (OLC) and after the contract with the provider has been executed by the RO. 1. The department shall conduct a comprehensive site survey of the provisionally certified provider and makes further determination of the provider’s certification status no sooner than ninety (90) calendar days after the provider begins providing services to individuals nor later than the expiration date of the provisional certificate. 2. If the provider has begun providing services prior to the expiration of the provisional certificate but for less than ninety (90) calendar days, the OLC director may extend the provisional status for up to one hundred twenty (120) calendar days to allow time for a comprehensive survey to occur. 3. If the provider does not begin serving individuals prior to the expiration date of the provisional certificate, the provisional certificate expires and the provider is required to reapply. 4. If an existing provider of employment services (prevocational services, career planning, job development, and supported employment) wants to add an additional employment service to their certification, the OLC director may waive the provisional certification process and grant regular certification status to the provider for the new service if— A. The provider submits an application for certification for the new service and the department has determined the application is complete, and all necessary documents have been filed with the application; B. All required environmental and fire safety surveys have been completed; C. The provider’s certification survey was completed within the past twelve (12) months; D. The provider is currently in compliance; E. The RO agrees with waiving the provisional process for the new service; and F. The provider has not been on conditional status during the past four (4) years. 5. If an existing provider of day habilitation services wants to add community networking or individual skill development, the OLC director may waive the provisional certification and grant regular certification status to the provider for the new service if— A. The provider submits an application for certification for the new service and the department has determined the application is complete, and all necessary documents have been filed with the application; B. The provider’s certification survey was completed within the past twelve (12) months; C. The provider is currently in compliance; D. The RO agrees with waiving the provisional process for the new service; and E. The provider has not been on conditional status during the past four (4) years. 6. If an existing provider of community networking or individual skill development wants to add community networking or individual skill development to their certification, the OLC director may waive the provisional certification and grant regular certification status to the provider for the new service if— A. The provider submits an application for certification for the new service and the department has determined the application is complete, and all necessary documents have been filed with the application; B. The provider’s certification survey was completed within the past twelve (12) months; C. The provider is currently in substantial compliance; D. The RO agrees with waiving the provisional process for the new service; and E. The provider has not been on conditional status during the past four (4) years. (C) Following the period of provisional status, a regular certificate to provide Medicaid waiver services is awarded to a provider following a comprehensive site survey by the department that determines the provider is in compliance and meets all standards relating to quality of care and the safety, health, rights, and welfare of persons served. If deficiencies are cited during a survey, any and all deficiencies must be corrected prior to the department issuing a certificate. The effective date of the certificate is the date the agency was determined to be in compliance as a result of the comprehensive survey and is effective up to two (2) years. (D) Conditional status is granted to a provider following a site survey by the department that determines there are pervasive and/or significant deficiencies with standards that may affect quality of care to individuals and there is a reasonable expectation the provider can achieve compliance within a stipulated time period. The department considers patterns and trends of performance identified during the site survey. 1. The period of conditional status shall not exceed one hundred eighty (180) calendar days. The department may directly monitor progress, may require the provider to submit progress reports, or both. 2. The department will conduct an additional site survey within the one hundred eighty (180) calendar day review period and make an additional determination of the provider’s compliance with all standards. 3. During the period of conditional status, the department may, at its discretion, take actions per sections (17) and (19) of this rule. 4. At the expiration of conditional status, if the provider is in compliance, the department will issue a certificate with an effective date of the end of the conditional status and expiring two (2) years from the expiration date of the previous certification cycle. (12) The department may investigate any complaint regarding the operation of a certified or deemed certified program or service. If conditions are found that are not in compliance with applicable certification standards, the department may, at its sole discretion, notify the accrediting organization of any concerns. (13) The department may conduct a scheduled or unscheduled site survey of a provider at any time to monitor ongoing compliance with the certification standards. If any survey finds conditions that are not in compliance with applicable certification standards, the department may require corrective action steps and may change the provider’s certification status consistent with procedures set out in this rule. (14) The department certifies only the provider(s) named in the application. The provider(s) may not transfer certification without the written approval of the department. (A) A certificate is the property of the department and is valid only as long as the provider meets standards of care and other requirements. (B) Within seven (7) calendar days of the effective date that a certified provider has a change in accreditation status or discontinues operation, the provider shall provide written notice to the OLC and RO of any such change. (C) Within seven (7) calendar days of the effective date that a certified provider is sold or undergoes a change of ownership, the provider shall submit a written notice to the OLC and the RO of any such change. A change in ownership is considered to have occurred under the following circumstances: 1. A new corporation, partnership, limited partnership, limited liability company, or other entity assumes ownership of the operation; 2. An individual incorporates or forms a partnership; 3. With respect to a certificate holder which is a general partnership, a change occurs in the majority interest of the partners; 4. With respect to a certificate holder which is a limited partnership, a change occurs in the majority interest of the general or limited partners; 5. With respect to a certificate holder which is a corporation, a change occurs in the persons who own, hold, or have the power to vote the majority of any class of stock issued by the corporation; and 6. A certificate holder’s change of Federal Employer Identification Number (FEIN). (D) Providers may not change the premises of a group home, day habilitation program, or onsite employment service site without prior notification to the OLC and RO and approval by DMH and the Missouri Department of Public Safety. (E) A provider must be certified to provide a waivered service prior to providing the service. Any provider that establishes a new program or type of program shall operate that program in accordance with applicable standards. A provisional review, site survey, or comprehensive site survey is conducted as determined by the department. (15) The department may revoke or deny issuance of certification based on a determination that— (A) The nature of the deficiencies results in substantial probability of or actual jeopardy to individuals being served; (B) Serious or repeated incidents of abuse or neglect of individuals being served or violations of rights have occurred; (C) Fraudulent fiscal practices have transpired or significant and repeated errors in billings to the department have occurred; (D) Failure to participate in the certification process in good faith, including falsification or fabrication of any information used to determine compliance with requirements; (E) The nature and extent of deficiencies results in the failure to conform to the certification standards of the program or service being offered; (F) Compliance with standards has not been attained by a provider upon expiration of conditional certification; (G) Failure to allow the surveyors entry into service site areas or to access individuals receiving services; (H) Contract for service delivery has ended with the department; (I) Any provider, or member, partner, administrator, executive director, or program director is found to have disqualifying offense under section 630.170, RSMo, unless an exception has been granted through the DMH Exceptions Committee under sections 630.656 and 630.170, RSMo; or (J) Any provider, or member, partner, administrator, executive director, or program director of a certified agency is found to have ever acted or omitted their duty in a manner which materially and adversely affected the health, safety, welfare, or property of an individual receiving services. (16) If a certified provider discontinues operation as evidenced by the fact that no individual has received a certified service from the provider for the previous twelve (12) months or any time the department is unable to freely gain entry to conduct an inspection, the provider is considered no longer certified. The department notifies the provider in writing that the certificate is void. (17) The department director, at its discretion, may— (A) Place a monitor at a program if there is substantial probability of or actual jeopardy to the safety, health, rights, or welfare of individuals being served. 1. The cost of the monitor is charged to the provider at a rate which will recoup all reasonable expenses incurred by the department. 2. The department shall remove the monitor when a determination is made that the safety, health, rights, and welfare of individuals being served are no longer at risk; (B) Take other action to ensure and protect the safety, health, or welfare of individuals being served; and (C) Initiate additional service delivery review through other quality integrated functions established within the department. (18) A provider which has had certification denied or revoked may appeal in writing to the director of the department within thirty (30) calendar days following notice of the denial or revocation being presented by certified mail to the provider. The director of the department shall conduct a hearing under procedures set out in Chapter 536, RSMo, and issue findings of fact, conclusions of law, and a decision which shall be final. (19) The department has authority to impose administrative sanctions. (A) The department may suspend the certification process pending completion of an investigation when a provider that has applied for certification or the staff of that provider is under investigation for fraud, financial abuse, abuse or neglect of persons served, revocation of persons’ rights without due process, or improper clinical practices. This includes but is not limited to investigations by any state authority for Medicaid audit and compliance, any state authority for child or adult abuse, neglect or financial exploitation, the Health and Human Services Office of Inspector General, or other local, state, or federal law enforcement. (B) The department may administratively sanction a certified provider that has been found to have committed fraud, financial abuse, abuse of persons served, or improper clinical practices, or that had reason to know its staff were engaged in such practices. (C) Administrative sanctions include but are not limited to suspension of certification, clinical utilization review requirements, clinical audit, suspension of new admissions or referrals, implementation of a corrective action plan, denial or revocation of certification, or other actions as determined by the department. (D) The department has the authority to refuse to accept an application for certification from a provider that has had certification denied or revoked or that has been found to have committed fraud, financial abuse, or improper clinical practices, or whose staff and clinicians were engaged in improper practices. (E) A provider which has certification denied or revoked as an administrative sanction may appeal these sanctions pursuant to section (18). (20) A provider may request the department’s exceptions committee waive a requirement for certification if the head of the provider organization provides evidence that a waiver is in the best interests of the individuals it serves. (A) A request for a waiver is in writing and includes justification for the request. (B) The request is submitted to Exceptions Committee, Department of Mental Health, PO Box 687, Jefferson City, MO 65102. (C) The exceptions committee holds meetings in accordance with Chapter 610, RSMo, and responds with a written decision within forty-five (45) calendar days of receiving a request. (D) The exceptions committee may issue a waiver on a time-limited or other basis. (E) If a waiver request is denied, the provider has forty-five (45) calendar days from date of denial to fully comply with the standard unless a different time period is specified by the committee. AUTHORITY: sections 630.050 and 630.655, RSMo 2016.* 45 CFR parts 160 and 164, the Health Insurance Portability and Accountability Act of 1996. Emergency rule filed Feb. 13, 2002, effective March 1, 2002, expired Aug. 27, 2002. Original rule filed Feb. 13, 2002, effective Aug. 30, 2002. Emergency amendment filed April 1, 2003, effective April 14, 2003, expired Oct. 14, 2003. Amended: Filed April 1, 2003, effective Oct. 30, 2003. Rescinded and readopted: Filed June 28, 2023, effective Jan. 30, 2024. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008, and 630.655, RSMo 1980.