Statutes, codes, and regulations
Delaware Administrative Code
Title 16 - Health and SafetyDepartment of Health and Social ServicesDivision of Substance Abuse and Mental HealthSubstance Abuse Facility Licensing Standards
Part IV - Deemed Status
Section 6001-IV-17.0 - Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)

16 Del. Admin. Code § 6001-IV-17.0

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Current through Register Vol. 28, No. 7, January 1, 2025
Section 6001-IV-17.0 - Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)
17.1 Deemed Status Categories:
17.1.1 Programs with Full Accreditation may qualify for a 2 year license.
17.1.2 Programs that are accredited as part of a merger, consolidation or acquisition must submit verification that JCAHO will extend accreditation to the new entity.
17.2 Notification of Audit:
17.2.1 Programs must inform DSAMH of all JCAHO visits whether announced or unannounced. The Quality Assurance Unit shall be notified in writing of a scheduled visit no less than 30 days prior to the visit. The Quality Assurance Unit shall be notified by phone or email of an unannounced visit within twenty-four (24) hours of the first day of the visit.
17.3 Reporting to DSAMH
17.3.1 Programs must notify DSAMH of any immediate threat to life that is discovered by JCAHO during the visit within 24 hours of the day that the threat to life is discovered.
17.3.2 Programs must report all sentinel events to DSAMH within twenty-four (24) hours accompanied by the root cause analysis, action plan and action plan follow up activity reports prepared according to JCAHO guidelines.
17.3.3 Programs must submit to DSAMH any corrective action to address sentinel events at the same time they are submitted to JCAHO.
17.3.4 Programs must submit to DSAMH any other correspondence required by JCAHO during the course of the Accreditation period and/or between each JCAHO review.
17.4 Deemed Status Revocation
17.4.1 DSAMH can revocate Deemed Status standing at any time, but specifically when:
17.4.1.1 A program is unsuccessful in receiving Accreditation, or Provisional Accreditation from JCAHO;
17.4.1.2 In response to a sentinel event;
17.4.1.3 When reporting to DSAMH does not occur in according with the time table established above;
17.4.1.4 Following a survey by DSMAH when it is determined that the program is not operating under the JCAHO guidelines and/or DSAMH licensure standards.
17.4.2 Once revoked, a program must wait one (1) year before reapplying for Deemed Status. DSAMH must conduct a site review before restoring Deemed Status.
17.5 Program Exemptions:
17.5.1 Programs are exempt from the Division of Substance Abuse and Mental Health standards for Substance Abuse Treatment Programs with the exception of:
17.5.1.1 Standards Applicable to all Programs:
17.5.1.1.1 Section § 5.0:
17.5.1.1.1.1 Subsection § 5.1.2.1;
17.5.1.1.1.2 Subsection § 5.1.4;
17.5.1.1.1.3 Subsection § 5.1.7.1;
17.5.1.1.1.4 Subsection § 5.1.7.2;
17.5.1.1.1.5 Subsection § 5.1.7.3;
17.5.1.1.1.6 Subsection § 5.1.8;
17.5.1.2 Section § 6.0: Programs must be in compliance with all of section § 6.0.
17.5.1.3 Section § 8.0: Programs with Deemed Status are exempt from sub-section § 8.1.2 of section § 8.0. When client records are reviewed, DSAMH will accept documents in section § 8.1.2. In the format accepted by JCAHO. Programs must be in compliance with all other subsections of section § 8.0.
17.5.2 Section § 9.0: Programs with Deemed Status are exempt from all standards in section § 9.0. with the exception of § 9.1.5. "smoke free facility".
17.6 Standards Applicable to Specific Settings and Modalities
17.6.1 Programs must be in compliance with all standards specific to the modality for which the program is being licensed.

16 Del. Admin. Code § 6001-IV-17.0

12 DE Reg. 464 (10/01/08)
14 DE Reg. 471 (11/01/10)