(a) The Division shall conduct a biennial on-site evaluation of the program to ensure that the program is in substantial compliance with these standards. - (i) The Division shall provide the program with at least forty-five (45) days' written notice prior to the date scheduled for the on-site review, except as pursuant to subsection (c) of this Section.
- (ii) The Division shall provide the program with a copy of the applicable Standards and a written format upon which the on-site review shall be based.
- (iii) The on-site review personnel team shall consist of representative(s) of the Division and may also include mutually agreed upon mental health and substance abuse professionals and other appropriate persons.
- (iv) During an on-site visit, the review and evaluation team shall provide administrative and program consultation as requested by the program.
- (v) There shall be an entrance conference that shall include the executive director and an exit conference that shall review significant items and shall be held at a mutually agreed time and shall include the executive director and representation from the governing body.
- (vi) The Division shall prepare a report of the findings of the review and shall send a copy to the chairperson of the governing body and to the executive director of the program within 45 days after the last day of the on-site review. The report shall contain at least the following information:
- (A) Required actions for the program to take in order to comply with standards for which deficiencies were found;
- (B) Specifications and conditions prescribed for any standard or standards for which the Division has granted a waiver or variance.
- (C) Documentation that any required actions from the previous site visit have or have not been resolved.
(b) The program shall provide for review a representative sample of client records, program records, financial statements, and other documents needed by the Division to make its determinations, including any information that may have changed since the time the program's application(s) was submitted. - (i) Records or materials not related to compliance with these Standards, Division Rules, statutes, and the program's contract with the Division will not be reviewed.
- (ii) The program may elect, but is not required, to cover any client identifying information in clinical records to be reviewed.
- (iii) When client identifying information is not covered, the program shall have the reviewer(s) sign an oath of confidentiality for any information in clinical records.
(c) In addition to the on-site evaluation conducted pursuant to subsection (a) of this Section, the Division may: - (i) Upon a written notice that outlines the issues related to compliance, conduct other on-site evaluations of the program necessary to determine continued compliance with these Standards and other applicable requirements; or
- (ii) Conduct other on-site evaluations to determine the continued capability of the program to provide services.
(d) The Division shall offer education and consultation on these Standards to the executive director and/or to the governing body when the program has an interim executive director or a new executive director.
048-10 Wyo. Code R. § 10-1