Section 441.24.5. Accreditation.

The commission shall make all decisions involving issuance, denial, or revocation of accreditation. This accreditation shall delineate all categories of service the organization is accredited to provide. Although an organization may have more than one facility or service site, the commission shall issue only one accreditation notice to the organization, except as provided in paragraph 24.5(5)“f.”

         24.5(1) Organizations eligible for accreditation. The commission accredits the following organizations:

            a.               Case management providers.

            b.               Community mental health centers.

            c.               Supported community living providers.

            d.               Mental health service providers.

         24.5(2) Application and renewal procedures. An applicant for accreditation shall submit Form 470-3005, Application for Accreditation, to the Division of Behavioral, Developmental, and Protective Services, Department of Human Services, Fifth Floor, Hoover State Office Building, 1305 East Walnut, Des Moines, Iowa 50319-0114.

            a.               The application shall be signed by the organization’s chief executive officer and the chairperson of the governing body and shall include the following information:

             (1)             The name and address of the applicant organization.

             (2)             The name and address of the chief executive officer of the applicant organization.

             (3)             The type of organization and specific services for which the organization is applying for accreditation.

             (4)             The targeted population groups for which services are to be provided, as applicable.

             (5)             The number of individuals in each of the targeted population groups to be served, as applicable.

             (6)             Other information related to the standards as requested by division staff.

            b.               Organizations that have received an initial 270-day accreditation and have not provided services by the end of the 270 days shall have their accreditation lapse for that specific service. This lapse of accreditation shall not be considered a denial. New applications may be submitted that include the waiting list of individuals to be served along with specific timelines of when the services will begin.

            c.               An organization in good standing may apply for an add-on service.

         24.5(3) Application review. Upon receipt of an application, Form 470-3005, the division shall review the materials submitted to determine whether the application is complete and request any additional material as needed. Survey reviews shall commence only after the organization has submitted all application material.

            a.               For a new organization, staff may initially conduct a desk audit or on-site visit to review the organization’s mission, policies, procedures, staff credentials, and program descriptions.

            b.               The division shall review organizational services and activities as determined by the accreditation category. This review may include audits of case records, administrative procedures, clinical practices, personnel records, performance improvement systems and documentation, and interviews with staff, individuals, boards of directors, or others deemed appropriate, consistent with the confidentiality safeguards of state and federal laws.

            c.               A team shall make an on-site visit to the organization. The division shall not be required to provide advance notice to the provider of the on-site visit for accreditation.

            d.               The on-site team shall consist of designated members of the division staff. At the division’s discretion, the team may include provider staff of other providers, individuals, and others deemed appropriate.

            e.               The team shall survey the organization and the services indicated on the accreditation application in order to verify information contained in the application and ensure compliance with all applicable laws, rules, and regulations. At the time of a one-year recertification visit, the team shall review the services that did not receive three-year accreditation.

            f.                The team shall review case records and personnel records to see how the organization implements each of the indicators in the standards. If the documentation is not found in the records, the organization shall show, at the time the division staff is on site, documentation of how the indicator was accomplished.

            g.               When an organization subcontracts with agencies to provide services, on-site reviews shall be done at each subcontracting agency to determine if each agency meets all the requirements in this chapter. The accreditation is issued to the organization.

            h.               At the end of the survey, the team leader shall lend an exit review. Before the close of the on-site review, the organization must provide the team leader any documentation that demonstrates how the organization has met these standards for services.

            i.                The accreditation team leader shall send a written report of the findings to the organization within 30 working days after completion of the accreditation survey.

            j.                Organizations required to develop a corrective action and improvement plan pursuant to subrule 24.5(4)“a” shall submit the plan to the division within 30 working days after the receipt of a report issued as a result of the division’s survey review. The action plan shall include specific problem areas cited, corrective actions to be implemented by the organization, dates by which each corrective measure shall be completed, and quality assurance and improvement activities to measure and ensure continued compliance.

            k.               Quality assurance staff shall review and approve the corrective action and improvement plan before making an accreditation recommendation to the commission.

            l.                The division shall offer technical assistance to organizations applying for first-time accreditation. Following accreditation, any organization may request technical assistance from the division to bring into conformity those areas found in noncompliance with this chapter’s requirements. If multiple deficiencies are noted during a survey, the commission may also require that technical assistance be provided to an organization, as staff time permits, to assist in implementation of an organization’s corrective action plan. Renewal applicants may be provided technical assistance as needed, if staff time permits.

         24.5(4) Performance outcome determinations. There are three major areas addressed in these standards: policies and procedures, organizational activities, and services, as set forth in rules 441—24.2(225C), 24.3(225C), and 24.4(225C). Each rule contains standards, with a performance benchmark and performance indicators for each standard. Each of the applicable standards for the three areas (policy and procedures, organizational activities, and services) shall be reviewed.

            a.               Quality assurance staff shall determine a performance compliance level based on the number of indicators found to be in compliance.

             (1)             For service indicators, if 25 percent or more of the files reviewed do not comply with the requirements for a performance indicator, then that indicator is considered out of compliance and corrective action is required.

             (2)             Corrective action is required when any indicator under policies and procedures or organizational activities is not met.

            b.               In the overall rating, the performance rating for policy and procedures shall count as 15 percent of the total, organizational activities as 15 percent of the total, and services as 70 percent of the total.

             (1)             Each of the three indicators for policy and procedures has a value of 5 out of a possible score of 15.

             (2)             Each of the 34 indicators for organizational activities has a value of .44 out of a possible score of 15.

             (3)             Each service has a separate weighting according to the total number of indicators applicable for that service, with a possible score of 70, as follows:

Service	Number of indicators	Value of each indicator
Case management	51	1.37
Day treatment	48	1.46
Intensive psychiatric rehabilitation	51	1.37
Supported community living	45	1.55
Partial hospitalization	48	1.46
Outpatient psychotherapy and counseling	35	2.00
Emergency	8	8.75
Evaluation	4	17.50

            c.               Quality assurance staff shall determine a separate score for each service to be accredited. When an organization offers more than one service under this chapter, there shall be one accreditation award for all the services based upon the lowest score of the services surveyed.

         24.5(5) Accreditation decisions. The division shall prepare all documents with a final recommendation regarding accreditation to be presented at the commission meeting. The division shall mail to all commission members summary reports of the on-site service review or desk review and a final recommendation concerning accreditation on each application to be processed at the next commission meeting.

If the commission approves accreditation, Form 470-3006, Notice of Action-Approval, shall be issued which states the duration of the accreditation and the services that the organization is accredited to provide. If the commission denies or revokes accreditation, Form 470-3008, Notice of Action-Denial, shall be issued which states the reasons for the denial.

            a.                Initial 270-day accreditation. This type of accreditation may be granted to a new organization. The commission shall base the accreditation decision on a report by the division that:

             (1)             The organization has an approved policies and procedures manual that includes job descriptions.

             (2)             Staff assigned to the positions meet the qualifications in the standards and the policies and procedures of the organization.

            b.                Three-year accreditation. An organization or service is eligible for this type of accreditation if it has achieved an 80 percent or higher performance compliance level. The organization may be required to develop and submit a plan of corrective action and improvement that may be monitored either by written report or an on-site review.

            c.                One-year accreditation. An organization is eligible for this type of accreditation when multiple and substantial deficiencies exist in specific areas causing compliance levels with performance benchmarks and indicators to fall between 70 percent and 79 percent, or when previously required corrective action plans have not been implemented or completed. The organization must submit a corrective action plan to correct and improve specific deficiencies and overall levels of functioning. Quality assurance staff shall monitor this plan through on-site reviews, written reports and the provision of technical assistance.

            d.                Probational 180-day accreditation. An organization is eligible for probational 180-day accreditation instead of denial when the overall compliance level is from 60 to 69 percent, and pervasive and serious deficiencies exist; or when corrective action plans previously required as a result of a one-year accreditation have not been implemented or completed. The commission may downgrade organizations with a one-year or three-year accreditation to the probational 180-day accreditation when one or more complaints are founded.

All deficiencies must be corrected by the time of the follow-up on-site survey at the conclusion of the provisional period. After this survey, the organization shall meet the standards for accreditation for a one-year accreditation, or the commission shall deny accreditation.

            e.                Add-on service accreditation. When the on-site review of the add-on service results in a score comparable to the overall organization’s score at the time of the most recent accreditation, the organization shall have the add-on accreditation date coincide with the overall accreditation date of the organization. If the add-on service on-site review results in a lower score and lower accreditation decision, division staff shall conduct another on-site review for that add-on service when the add-on service accreditation expires.

            f.                 Special terms.

             (1)             When an organization subcontracts with more than one agency, the length of accreditation shall be determined individually.

             (2)             The accreditation period for services that have deemed status according to rule 24.6(225C) shall coincide with the period awarded by the national accrediting body or the certification for home-and community-based services.

             (3)             New or add-on services that meet the requirements for accreditation shall receive an initial 270-day accreditation for that individual service. The term of accreditation shall be determined individually. At the time of recertification of the new add-on service, recommendation may be made to coincide with the term of accreditation for the other services of that organization that are accredited by the commission.

             (4)             An organization must notify the division when there are changes in its ownership, structure, management, or service delivery.

            g.                Extensions. The division may grant an extension to the period of accreditation if there has been a delay in the accreditation process that is beyond the control of the organization, the division, or the commission; or the organization has requested an extension to permit the organization to prepare and obtain approval of a corrective action plan. The division shall establish the length of the extension on a case-by-case basis.

            h.                Denial of accreditation. An emergency commission meeting may be called to consider denial or revocation of accreditation.

             (1)             Accreditation shall be denied when there are pervasive and serious deficiencies that put individuals at immediate risk or when the overall compliance level falls to 59 percent or below. Under such circumstances no corrective action report shall be required.

             (2)             When one or more complaints are received, quality assurance staff shall complete an investigation and submit a report to the commission. If any of the complaints are substantiated and the commission determines that there is a pervasive or serious deficiency, the commission may deny accreditation.

             (3)             An organization whose accreditation has been denied or revoked shall not be approved for any service for at least six months from the notice of decision denying or revoking accreditation.

             (4)             If the organization disagrees with any action or failure to act in regard to the notice of decision to deny accreditation to the organization, the organization has the right to appeal in accordance with 441—Chapter 7.

         24.5(6) Nonassignability. Accreditation shall not be assignable to any other organization or provider. Any person or other legal entity acquiring an accredited facility for the purpose of operating a service shall make an application as provided in subrule 24.5(2) for a new certificate of accreditation. Similarly, any organization having acquired accreditation and desiring to alter the service philosophy or transfer operations to different premises must notify the division in writing 30 calendar days before taking action in order for the division to review the change.

         24.5(7) Discontinuation.

            a.                Discontinued organization. A discontinued organization is one that has terminated all of the services for which it has been accredited. Accreditation is not transferable between organizations.

             (1)             An organization shall notify the division in writing of any sale, change in business status, closure, or transfer of ownership of the business at least 30 calendar days before the action.

             (2)             The organization shall be responsible for the referral and placement of individuals using the services, as appropriate, and for the preservation of all records.

            b.                Discontinued service. An organization shall notify the division in writing of the discontinuation of an accredited or certified service at least 30 calendar days before the service is discontinued.

             (1)             Notice of discontinuation of a service shall not be initiated during the 30 days before the start of a survey. Once a survey has begun, all services shall be considered in determining the organization’s accreditation score.

             (2)             The organization shall be responsible for the referral and placement of individuals using the services, as appropriate, and for the preservation of all records.