Sec. 810.14. Inspection and reviews

(a) Certified providers of services shall be inspected at least two times per year, once without prior notice, for compliance with rules, regulations, policies, procedures and requirements of the office. In the sole discretion of the office, providers with established records of substantial compliance may be inspected only once per year, provided such inspection is without notice.

(b) Inspections which qualify toward satisfying the requirements of subdivision (a) of this section include:

(1) a recertification review, made pursuant to subdivisions (c), (d), (e), and (f) of this section;

(2) an interim regulatory compliance review, made pursuant to subdivision (f) of this section;

(3) an annual performance review, pursuant to office policy;

(4) an interim performance review pursuant to office policy; and

(5) an accreditation survey, completed by a nationally recognized accrediting organization.

(c) Prior to the expiration of an operating certificate, the office shall inspect the provider's services for compliance with all applicable laws, rules and regulations to determine the renewal term of the operating certificate.

(d) The specific renewal term shall be based on the results of an on-site recertification review, made pursuant to subdivision (e) of this section, and a fiscal viability review, made pursuant to subdivision (g) of this section, except as otherwise provided in subdivision (i) of this section.

(e) Recertification reviews shall be conducted on an unannounced basis and shall include, but not be limited to, the following areas of review:

(1) on-site inspection of facility appearance, conditions and general safety;

(2) evaluation of the governing authority, with emphasis on its management systems and procedures;

(3) review of patient/client records;

(4) interviews of staff and patients/clients;

(5) examination of staffing patterns and staff qualifications;

(6) analysis of statistical information contained in reports required to be submitted to the office by the provider of services;

(7) a review of compliance with the reporting requirements of the office;

(8) verification of staff credentials and employee or contractor compliance with the provisions of Part 805 of this Title;

(9) compliance with the requirements of Part 836 of this Title and regulations of the Justice Center;

(10) such other operating areas of activities as may be necessary or appropriate to determine compliance with applicable laws and regulations.

(f) The on-site review process shall include appropriate reporting and corrective action follow-up subsequent to the review, including the possibility of initiating an unannounced interim regulatory compliance review which may encompass the areas of review listed under subdivision (e) of this section, to assure attention to and correction of cited deficiencies.

(1) Upon completion of a recertification/interim regulatory compliance review, office staff shall, within 45 days of such completion, submit a written report to the provider of services describing the results of such review, including each regulatory deficiency identified, if any.

(2) The provider of services shall take all actions necessary to correct all deficiencies reported. The provider of services shall submit a corrective action plan, which is deemed satisfactory by the office, within a specified period of time, as directed by the office, stating the specific actions taken or planned to achieve compliance with identified requirements. Any planned actions described in the corrective action plan must be accompanied with a timetable for their implementation.

(3) If the provider of services fails, within the specified or an otherwise reasonable time, to correct any reported deficiencies, or fails to maintain satisfactory compliance with applicable laws, rules and regulations, the commissioner may revoke, suspend or limit the operating certificate or levy a civil fine for such failures, in accordance with section 810.16 of this Part.

(g) Fiscal viability reviews shall include an assessment of the financial information of the provider of services. Such information shall be submitted in intervals and in a form prescribed by the office, for compliance with minimum standards established by the office, in order to determine the provider's fiscal capability to effectively support the authorized services.

(h) Providers of services that fail to meet the office's minimum standards shall be required to submit a financial recovery plan setting forth the specific actions to be taken to meet the minimum standards within a reasonable time frame.

(i) The office shall not perform fiscal viability reviews of governmental agencies or hospitals authorized by the office and/or the Department of Health.

(j) The renewal term of an operating certificate shall be based on the lowest compliance rating achieved by the provider of services on either the recertification review or fiscal viability review.

(k) Renewed operating certificates may be issued for a three month, six month, one year, two year or three year term, depending on the compliance ratings achieved on either the recertification or fiscal viability reviews. In no instance may an operating certificate be issued for a term in excess of five years.

(l) Any fines imposed by the commissioner against the provider of services must be paid in full before an operating certificate may be renewed.