Section 441.24.6. Deemed status.

The commission shall grant deemed status to organizations accredited by a recognized national, not-for-profit, accrediting body when the commission determines the accreditation is for similar services. The commission may also grant deemed status for supported community living services to organizations that are certified under the Medicaid home- and community-based services (HCBS) mental retardation waiver.

         24.6(1) National accrediting bodies.

            a.               The national accrediting bodies currently recognized as meeting division criteria for possible deeming are:

            1.      Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

            2.      The Commission on Accreditation of Rehabilitation Facilities (CARF).

            3.      The Council on Quality and Leadership in Supports for People with Disabilities (The Council).

            4.      Council on Accreditation of Services for Families and Children (COA).

            b.               The accreditation credentials of these national bodies must specify the type of organization, programs, and services that these bodies accredit and include targeted population groups, if appropriate.

            c.               Deemed status means that the division is accepting an outside body’s review, assessment, and accreditation of an organization’s functioning and services. Therefore, the accrediting body doing the review must be assessing categories of organizations and types of programs and services corresponding to those described under this chapter. An organization that has deemed status must adhere to and be accountable for the rules in this chapter.

            d.               When an organization that is nationally accredited requests deemed status for services not covered by the national body’s standards but covered under this chapter, the division shall accredit those services. Division staff shall provide technical assistance to organizations with deemed status as time permits.

         24.6(2) Application for deemed status.

            a.               To apply for deemed status, the organization shall submit Form 470-3332, Application and Letter of Agreement, and copies of the latest survey report and accreditation certificate, documentation of specific programming policies and procedures for populations being served, and credentials for staff providing services to populations served.

            b.               The division shall not accept an application for deemed status once the division has begun an on-site visit. The organization shall complete the accreditation process.

         24.6(3) Requirements for deemed status. To be eligible for deemed status, the organization shall:

            a.               Be currently accredited by a recognized national accrediting body for services as defined in subrule 24.6(1); or

            b.               Be currently accredited for supported community living under the Medicaid HCBS mental retardation waiver pursuant to 441—subrule 77.37(14). If individuals with mental illness are served, the organization must submit verification of the training and credentials of the staff to show that its staff can meet the needs of the individuals served.

            c.              Require the supported community living staff to have the same supervisor as the HCBS/MR program.

            d.               Require staff for the program being deemed to have the training and credentials needed to meet the needs of the person served.

            e.               Require staff to meet the incident reporting requirements in subrule 24.4(5).

         24.6(4) Granting of deemed status. When the commission grants deemed status, the accreditation period shall coincide with the period awarded by the national accrediting body or the certification for home- and community-based services. However, under no circumstances shall the commission award accreditation for longer than three years.

         24.6(5) Reservations. When deemed status is granted, the commission and the division reserve rights to the following:

            a.               To have division staff conduct on-site reviews for those organizations applying for deemed status which the division has not previously accredited.

            b.               To have division staff do joint site visits with the accrediting body, attend exit conferences, or conduct focused follow-behind visits as determined to be appropriate in consultation with the national accrediting organization and the provider organization.

            c.               To be informed of and to investigate all complaints that fall under this chapter’s jurisdiction according to the process in rule 441—24.7(225C). The division shall report findings to the national accrediting body.

            d.               To review and act upon deemed status when:

             (1)             Complaints have been founded, or

             (2)             The organization’s national accreditation status expires without renewal, or

             (3)             The national accrediting body downgrades or withdraws the organization’s status.

         24.6(6) Continuation of deemed status.

            a.               The organization shall send a copy of Form 470-3332, Application and Letter of Agreement, along with a copy of the application for renewal to the national accrediting body at the same time as application is made to a national accrediting body.

            b.               HCBS staff shall furnish to the division copies of the letter notifying a provider of a forthcoming recertification for organizations deemed for supported community living under the HCBS mental retardation waiver.

            c.               Following the on-site review by a national accrediting body, the organization shall send the division a copy of the cover sheet and the national accrediting body report within 30 calendar days from the date that the organization receives the documents. If a corrective action plan is required, the organization shall send the division a copy of all correspondence and documentation related to the corrective action.

            d.               HCBS staff shall furnish the division with copies of HCBS certification reports and any corrective action required by HCBS within 30 calendar days after HCBS staff complete the report or the organization completes required corrective action.