D.C. Mun. Regs. tit. 22, r. 22-A3401
The Department shall utilize the certification process to thoroughly evaluate the applicant's capacity to provide high quality MHRS in accordance with this regulation and the needs of the District's behavioral health system.
No person or entity shall provide MHRS unless certified by the Department. Each applicant seeking certification as an MHRS provider shall submit a certification application to the Department. An MHRS provider seeking renewal of certification shall submit a certification application at least ninety (90) calendar days prior to the termination of its current certification. The existing certification of an MHRS provider that has submitted a timely application for renewal of certification shall continue until the Department renews or denies renewal ofthe certification.
Certification shall be considered terminated if the MHRS provider:
Upon receipt of a certification application, the Department shall review the certification application to determine if it is complete. If a certification application is incomplete, the Department shall return the incomplete certification application to the applicant. An incomplete certification application shall not be regarded as a certification application. Absent good cause, a provider's failure to submit a complete certification application within ninety (90) calendar days prior to expiration of the current certification shall be deemed a voluntary relinquishment of certification and trigger the Department's closure protocol.
Following the Department's acceptance of the certification application, the Department shall determine whether the applicant's services and activities meet the certification standards described in this chapter. The Department shall schedule and conduct an on-site survey of the applicant's services to determine whether the applicant satisfies the certification standards. The Department shall have access to all records necessary to verify compliance with certification standards and may conduct interviews with staff, others in the community, and consumers.
The Department may conduct an on-site survey at the time of certification application or certification renewal, or at any other time during the period of certification.
Applicant or MHRS provider interference with the on-site survey, submission of false or misleading information, or lack of candor by the applicant or provider shall be grounds for an immediate suspension of any prior certification or denial of a new certification application.
A Statement of Deficiency ("SOD") is a written notice to an applicant or existing MHRS provider identifying non-compliance with certification standards. The intent of the SOD is to provide:
The Department will not normally issue an SOD to applicants who fail to demonstrate compliance with the standards. The Department will normally consider the applicant's failure to comply with the initial certification requirements as evidence that the applicant is ill-prepared to assume the responsibilities of providing MHRS to District residents and deny the application.
When utilized, the SOD shall describe the areas of non-compliance, suggest actions needed to bring operations into compliance with the certification standards, and set forth a timeframe of no more than ten (10) business days for the applicant or existing MHRS provider's submission of a written Corrective Action Plan ("CAP").
The issuance of an SOD is a separate process from the issuance of a Notice of Infraction ("NOI"). NOIs shall be issued promptly upon observation of violations of this chapter, especially when they are recurrent, endanger consumer or staff health or safety, or when there is a failure to comply with core requirements of this chapter.
The Department is not required to utilize the SOD process. It may immediately deny certification or proceed with decertification.
An applicant or certified MHRS provider's CAP shall describe the actions to be taken and specify a timeframe for correcting the areas of non-compliance. The CAP shall be submitted to the Department within ten (10) business days after receipt of the SOD from the Department, or sooner if specified in the SOD.
The Department shall notify the applicant or the certified MHRS provider whether the provider's CAP is accepted within ten (10) business days after receipt.
The Department may only issue certification after the Department verifies that the applicant or the certified MHRS provider has remediated all of the deficiencies identified in the CAP and meets all the certification standards.
A determination to grant full certification to a provider shall be based on the Department's review and validation of the information provided in the application, as well as facility survey findings, any CAP, and the provider's compliance with this chapter.
The Department shall certify an applicant and recertify a Mental Health Rehabilitation Services (MHRS) provider that demonstrates substantial compliance with this chapter, for a time period that runs concurrently with the applicant or provider's accreditation period. Certification shall start from the date of issuance of certification by the Department, subject to the provider's continuous compliance with all certification standards. Certification shall remain in effect until it expires, is renewed, is revoked, or is voluntarily relinquished. The certification shall specify:
The Department may grant provisional certification to an MHRS applicant or provider that has demonstrated substantial compliance with this chapter, has met initial requirements for the evidence-based practice certification process (if applicable), and has received provisional accreditation from the Commission on Accreditation of Rehabilitation Facilities, The Joint Commission, or the Council on Accreditation.
Provisional certification shall expire upon termination of the provider's provisional accreditation period(s) unless revoked in accordance with §§ 3403.
Certification is not transferable to any other organization.
Prior to adding an MHRS service during the term of certification, the MHRS provider shall submit a certification application describing the service. Upon determination by the Department that the service is in compliance with certification standards, the Department may certify the MHRS provider to provide that service.
Nothing in these rules shall be interpreted to mean that certification is a right or an entitlement. Certification as an MHRS provider depends upon the Director's assessment of the need for additional providers and availability of funds. An individual or entity that applies for certification during an open application period as published in the District of Columbia Register may appeal the denial of certification under this subsection by utilizing the procedures contained in §§ 3403.2 and 3403.3. The Department shall not accept any applications for which a notice of moratorium is published in the District of Columbia Register.
In the event that a certification application is under review while a moratorium is put in place, the Department will continue to process the application for a time period of no more than thirty (30) calendar days. If, after thirty (30) calendar days, the application is deemed incomplete, the provider will be granted ten (10) business days to resolve all incomplete items. Any items not resolved or provided by the due date will result in the incomplete application being returned to the applicant and the Department will take no further action to issue certification. The applicant shall then wait until the moratorium is lifted in order to submit any subsequent certification applications.
The MHRS provider shall notify the Department in writing thirty (30) calendar days prior to implementing any of the following operational changes, including all aspects of the operations materially affected by the changes:
MHRS providers shall forward to the Department within thirty (30) calendar days all inspection reports conducted by an oversight body and all corresponding corrective actions taken regarding cited deficiencies.
MHRS providers shall immediately report to the Department any criminal allegations involving provider staff.
D.C. Mun. Regs. tit. 22, r. 22-A3401