16 Del. Admin. Code § 6001-IV-19.0

Current through Register Vol. 28, No. 7, January 1, 2025

Section 6001-IV-19.0 - Council on Accreditation (COA)

19.1 Deemed Status Categories

19.1.1 Programs with Three-Year or Four-Year Accreditation may qualify for a 2 year license.

19.1.2 Programs that are accredited as part of a merger, consolidation or acquisition must submit verification that COA will extend accreditation to the new entity.

19.2 Notification of Audit:

19.2.1 Programs must inform DSAMH of all COA visits whether announced or unannounced. The Quality Assurance Unit should be notified in writing of a scheduled visit no less than 30 days prior to the visit. The Quality Assurance Unit should be notified by phone or email of an unannounced visit within 24 hours of the first day of the visit.

19.3 Reporting to DSAMH

19.3.1 Programs must notify DSAMH of any immediate threat to life that is discovered by COA during the visit within 24 hours of the day the threat to life is discovered.

19.3.2 Programs must report all other hazardous or emergency situations to DSAMH within 24 hours accompanied by the investigation report; action plan and action plan follow up activity reports prepared according to COA guidelines.

19.3.3 Programs must submit to DSAMH any corrective action to address hazardous or emergency situations at the same time they are submitted to COA.

19.3.4 Programs must submit to DSAMH any other correspondence required by COA during the course of the Accreditation period and/or between each COA review.

19.4 Deemed Status Revocation

19.4.1 DSMAH can revocate Deemed Status standing at any time, but specifically when:

19.4.1.1 A program is unsuccessful in receiving Three-Year or Four-Year Accreditation from COA;

19.4.1.2 In response to a hazardous or emergency event;

19.4.1.3 When reporting to DSAMH does not occur in accordance with the time table established above;

19.4.1.4 Following a survey by DSMAH when it is determined that the program is not operating under the COA guidelines and/or DSAMH licensure standards.

19.4.2 Once revoked, a program must wait 1 year before reapplying for Deemed Status. DSAMH must conduct a full site review before restoring Deemed Status.

19.5 Program Exemptions:

19.5.1 Programs are exempt from the Division of Substance Abuse and Mental Health standards for Substance Abuse Treatment Programs with the exception of:

19.5.1.1 Standards Applicable to all Programs:

19.5.1.1.1 Section § 5.0: Programs with Deemed status must be in compliance with the following subsections of section 5.0:

19.5.1.1.1.1 Subsection § 5.1.3.1;

19.5.1.1.1.2 Subsections § 5.1.6.3.5.3, § 5.1.6.3.5.5, § 5.1.6.3.5.6, § 5.1.6.3.5.7, § 5.1.6.3.5.8, § 5.1.6.3.5.9;

19.5.1.1.1.3 Subsection § 5.1.6.4;

19.5.1.1.1.4 Subsection § 5.1.6.5;

19.5.1.1.1.5 Subsection § 5.1.7.4.

19.5.1.1.2 Section § 6.0: Programs must be in compliance with all of section § 6.0.

19.5.1.1.3 Section § 8.0: Programs with Deemed Status are exempt from sub-section 8.1.2.1.1 of section 8.0. When client records are reviewed, DSAMH will accept documents in section 8.1.2 in the format accepted by COA. Programs must be in compliance with all other subsections of section § 8.0.

19.5.1.1.4 Section § 9.0: Programs must be in compliance with standard § 9.1.5: "smoke free facility".

19.5.1.2 Standards Applicable to Specific Settings and Modalities

19.5.1.2.1 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-19.0

14 DE Reg. 471 (11/01/10)