Accreditation as Evidence for Meeting Licensing Requirements

PURPOSE: This rule establishes the procedures to be followed in order for an organization to qualify for a license under sec tions 210.481 through 210.511, RSMo, by the agency being ac credited by Council on Accreditation of Services for Children and Families, Inc., the Joint Commission on Accreditation of Healthcare Organizations, or the Commission on Accreditation of Rehabilitation Facilities (accreditation bodies). (1) Purpose and Scope. This regulation applies to Licenses is sued to individuals or organizations which are accredited by an accrediting body. (2) Definitions. For the purpose of this regulation, the defi nitions set forth in section 210.481, RSMo, and the following definitions shall apply: (A) “Accrediting body” shall mean the Council on Accreditation of Services for Children and Families, Inc., the Joint Commission on Accreditation of Healthcare Organizations, or the Commission on Accreditation of Rehabilitation Facilities; (B) “Individual or organization” shall mean any adult person, corporation, partnership, religious denomination, religious or ganization, or organized group of human beings; and (C) “Prima facie evidence” means evidence that will establish a fact or sustain a decision unless contradictory evidence is produced. (3) The Children’s Division shall accept accreditation by an accrediting body as prima facie evidence that the individual or organization meets the requirements for a license to operate a foster home, residential care facility, or child placing agency in accordance with the applicable provisions of sections 210.481 to 210.511, RSMo. The division will accept accreditation for purposes of documenting eligibility for license or relicensure. However, any individual or organization whose license is based upon accreditation must still fully comply with all of the requirements of licensure (including full compliance with all federal, state, and local health and safety codes) as if not ac credited for the duration of the license to maintain the license. The safety and welfare of children served by the individual or organization shall be the paramount consideration in all licensing decisions. If a service or program, including, but not limited to, child placing, maternity, infant/toddler, residential treatment, and intensive residential treatment in residential child care, is not accredited by the accrediting body, then the organization must apply for and meet all licensing require ments as for the unaccredited program or service. (4) Application and Reapplication for License for Accredited Individual or Organizations. (A) The individual or organization applying for licensure as an accredited individual or organization shall present to the division with its application for licensure or relicensure all of the following: 1. A copy of the individual or organization’s official final accreditation report and accreditation certificate from the ac crediting body establishing that the individual or organization is accredited in good standing for the period of time covered by the license; 2. A list of operating sites which includes the capacity served, the gender served, and the ages served by that organi zation. This list shall be updated if there is a change in operat ing sites by the individual or organization; 3. A copy of the accrediting body’s official standards and policies for accreditation; 4. A copy of any corrective action documents or other notices from the accrediting body regarding areas of non-com pliance or required improvement or monitoring; 5. Any documentation required at initial licensure or re-licensure as stated in chapters 13 CSR 35-71 (for residential treatment agencies) and 13 CSR 35-73 (for child placing agen cies), including, but not limited to, agency policies, procedures, organizational charts, budgets, staff training records, and per sonnel records verifying compliance with background check requirements; and 6. Any and all other information and documentation that the division may determine is reasonably necessary to verify that the individual or organization is accredited in good stand ing and otherwise meets all of the requirements for licensure. (B) The division in its discretion may conduct on-site visits to verify compliance with licensure requirements before a license is issued. (C) The division shall examine the areas that the organization is applying for a license. The division then may issue a corre sponding license for those areas in which the organization is accredited. The license shall be valid for the period of time up to two (2) years (or such other time as may be specifically authorized or required by statute), or when the organization’s accreditation expires, whichever is shorter. (D) If the individual or organization’s accreditation expires during the term of the license, the division may issue a provi sional license pursuant to section 210.486, RSMo, for a period of time not to exceed six (6) months upon the individual or organization showing that— 1. The individual or organization is still in good standing with the accrediting body, the re-accreditation process is being diligently pursued, and accreditation is expected within six (6) months of the date the accreditation expired. The division may, at its discretion, request a letter of good standing from the accrediting body; 2. The individual or organization otherwise demonstrates the potential capacity to meet full requirements for licensure; and 3. The division director is satisfied that the operation of the foster home, residential care facility, or child placing agency provisionally licensed is not detrimental to the health and safety of the children being served. (E) The division may deny the issuance of a license to, or may suspend or revoke the license of, any individual or organiza tion which fails to provide information that the division may require to establish eligibility for licensure. (F) The individual or organization seeking licensure under this section shall have the responsibility to apply for accred itation and/or re-accreditation in a timely manner to ensure compliance with all deadlines set out in this section and other applicable laws. (5) Information Sharing. (A) The individual or organization shall notify the division immediately of any sentinel event, any critical incident as required in 13 CSR 35-71.070, any unusual event as required in 13 CSR 35-73.050, and of any suspension, limitation, including but not limited to required corrective action or monitoring, or revocation of accreditation. The procedures and requirements for reporting shall be the same for non-accredited, licensed individuals, and organizations as provided in chapters 13 CSR 35-71 and 13 CSR 35-73. (B) Sentinel events are those events which the accrediting body requires the individual or organization to report to the accrediting body as a condition of accreditation, but shall at a minimum include the following: 1. A death of a child in one (1) of the individual’s or orga nization’s facilities; 2. A serious emotional or physical injury of a child in one (1) of the individual’s or organization’s facilities. For purposes of this regulation, a serious emotional or physical injury occurs when it is medically reasonable or necessary for a child to ob tain professional medical intervention as a result of something that happens to the child while placed with the individual or organization; 3. A child elopes from the individual’s or organization’s facility; 4. A fire in a location routinely occupied by children, which requires the fire department to be called; 5. An allegation or report of physical abuse, sexual abuse, emotional abuse, or neglect of a child pertaining to the indi vidual or organization, or an employee, contractor, subcontrac tor, volunteer, or officer of the individual or organization; 6. An employee is terminated from employment in rela tion to the safety and care of children; 7. There is any change in the chief executive officer; 8. There is a lawsuit filed against the individual or organi zation by or on behalf of a person who is or was in the individ ual’s or organization’s care; 9. Any known criminal charges are filed against the indi vidual, facility, organization, any resident of the facility, or any employee or volunteer of the individual or organization who has contact with children; 10. When the individual or organization is not in com pliance with any of the criteria for accreditation, including maintaining the required level of services and staffing levels, for more than three (3) consecutive days; or 11. Whenever a child attempts to harm him/herself or oth ers, including suicide attempts. (C) The individual or organization shall notify the division of the entrance, exit, and any performance review meetings of the accrediting body which are held in conjunction with the accreditation of the organization. The division has a right to attend any or all of these meetings between the organization and the accrediting body. (6) The division may make such inspections and investigations as it deems necessary to ensure that the individual or organi zation continues to meet the requirements of licensure, for in vestigative purposes involving reports of alleged child abuse or neglect, and to address a complaint concerning the health and safety of children which the individual or organization serves. (7) Any individual or organization who is aggrieved by a deci sion of the division to deny, revoke, or suspend a license based upon an organization’s accreditation standing under this sec tion may either— (A) Seek administrative review following the procedures set forth in 13 CSR 35-71.030 for residential treatment agencies or 13 CSR 35-73.017 for child placing agencies; or (B) Apply for licensure as an unaccredited individual or or ganization. AUTHORITY: sections 207.020, 210.506, and 660.017, RSMo 2016, and section 210.112.8, RSMo Supp. 2021.* This rule originally filed as 13 CSR 35-50.010. Emergency rule filed Dec. 23, 2004, effective Jan. 2, 2005, expired June 30, 2005. Original rule filed Dec. 23, 2004, effective June 30, 2005. Emergency amendment filed June 11, 2021, effective July 1, 2021, expired Feb. 24, 2022. Moved to 13 CSR 35-35.140 and amended: Filed June 11, 2021, effective Jan. 30, 2022. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986, 1993, 2014; 210.112, RSMo 2004, amended 2005, 2011, 2018, 2020; 210.506, RSMo 1982, amended 1993, 1995; and 660.017, RSMo 1993, amended 1995.