Or. Admin. R. 309-019-0240

Current through Register Vol. 63, No. 6, June 1, 2024

Section 309-019-0240 - ACT Failure to Meet Fidelity Standards

(1) If a certified ACT program does not achieve a minimum score of at least 114 on a fidelity review, the following shall occur:

(a) Within 14 calendar days, unless otherwise extended by the Division, the Division, the Division Approved Reviewer, and the ACT program shall meet to discuss the outcome of the failed fidelity review. If a CCO requests to be involved, the host/scheduler shall forward the invite to the CCO.

(b) The Division Approved Reviewer must provide technical assistance for a period of 90 days from the date of the fidelity review publication to address problem areas identified in the failed fidelity review. These areas for Technical Assistance (TA) will include any area that scores a two or below and any sections that do not meet OAR requirements per 309-019-0225 through 0255 or any other applicable statutes, administrative rules, or other regulations;

(c) The Division will extend certification on a temporary basis for 90 days to allow for the technical assistance with anticipation that corrections to program operations will be made.

(d) At the end of the 90-day technical assistance period, The Division Approved Reviewer shall conduct a follow-up re-review to include all TA identified sections per (1)(b) of this rule set.

(e) Within 30 days following the fidelity re-review, the Division Approved Reviewer shall provide a comprehensive amended fidelity report to the Division and the program.

(f) Unless otherwise specified in CCO and program contract, the Program shall send a copy of the amended fidelity re-review report to the appropriate CCO within 7 calendar days following issuance of that amended fidelity re-review report.

(2) If the program achieves a minimum score of 114 or above on the follow-up re-review and meets the requirements of all applicable statutes, administrative rules, or other regulations, the Division shall recertify the program for one year.

(3) The Division may deny, revoke, suspend or place conditions on the programs ACT Certification if the re-review results in a fidelity score of less than 114.

(4) Congruent with the process outlined in section (1) above, if the Division determines a program is not operating in substantial compliance with all applicable statutes, administrative rules or other regulations, the Division may require the program submit a Plan of Correction (POC). The Division shall provide written notice of the requirement to submit a POC and the program shall submit a POC according to the following terms:

(a) The program shall submit a POC to the Division and the appropriate CCO within 30 days of receiving a notice of requirement to submit a POC. The Division may issue up to a 90-day extension to the existing certification to allow the program to complete the POC process; and

(b) The POC shall address each finding of non-compliance and shall include:

(A) The planned action already taken, or to be taken, to correct each finding of non-compliance.

(B) The anticipated or requested timeframe for the completion of each corrective action not yet complete at the time of POC submission to the Division;

(C) A description of and plan for quality assurance activities intended to ensure ongoing compliance; and

(D) The name and role of the individual responsible for ensuring the implementation of each corrective action within the POC.

(c) If the Division finds that clarification or supplementation to the POC is required prior to approval, the Division shall contact the program to provide notice of requested clarification or supplementation, and the program shall submit an amended POC within 14 calendar days of receiving notification.

(d) The program must submit a sufficient POC approved by the Division prior to receiving a certificate. Upon the Division's approval of the POC, the Division shall issue the appropriate certification.

(e) The Division may deny, revoke, suspend, not renew, or place conditions on the program's certification if the program fails to submit an adequate POC within the timeframes established in this rule.

(5) When the Division determines the need to deny, revoke, not renew, or place conditions on the program's certificate issued under these rules, a notice of intent to take action on the certificate shall be issued to the program.

(6) Immediate suspension may occur if the Division finds there is a serious danger to the public health and safety during a specified period of time and/or there is a substantial failure to comply with applicable statutes, administrative rules, or other applicable regulations.

(a) The program may request a contested case hearing to contest the immediate suspension order in accordance with ORS Chapter 183.

(b) Requests for a hearing must be received by the Division within 90 days from the date the immediate suspension order was served on the program personally, or by certified or registered mail.

(7) When the Division issues an Order of Suspension, a notice of intent to revoke, notice of intent to deny an application or notice of refusal to renew the certificate to a program pursuant to these rules, the Division shall offer the program an opportunity for an informal conference. The program shall make its request for an informal conference in writing within 14 calendar days of the issuance of the notice of intent or Order of Suspension.

(a) Upon receipt of a timely written request, the Division shall select a location and time for such conference. Following the conference, the Division may:

(A) withdraw or amend the notice of intent or suspension order; or

(B) not withdraw the notice of intent or suspension order.

(b) the Division shall provide written notice of its decision within 14 calendar days following the informal conference.

(8) A program who is issued a notice of intent to deny, revoke, refuse to renew, or apply a condition on programs certificate under these rules shall be entitled to request a hearing in accordance with ORS Chapter 183.

(9) A Variance per OAR 309-019-0220 and 309-008-1600 is not allowable for failure to meet fidelity for ACT programs. It can be used to substitute and/or contract program core staffing structure per OAR 309-019-0226 (1) & (2), but the request must be done in time of need as a proactive effort of the program to maintain ACT fidelity standards and quality of services.

(a) If a program meets the above criteria and contracts key positions to fulfill the ACT fidelity standards, a Variance must be submitted to Division within 30 calendar days of known agreement and/or contracted position.

(b) A Variance submission must be submitted in at least 60 days prior to scheduled fidelity review; unless there are unforeseen circumstances that result in termination and/or resignation of a core position on the ACT Team. This must be communicated immediately to Division Approved Reviewer and The Division.

(c) If a Variance is needed for this intended purpose, The Division cannot approve for a period that may not exceed approval of 1 year.

Or. Admin. R. 309-019-0240

MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16; MHS 18-2016, f. 11-28-16, cert. ef. 11/30/2016; MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17; MHS 6-2017, f. & cert. ef. 6/23/2017; MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18; MHS 4-2018, amend filed 02/27/2018, effective 3/1/2018; BHS 44-2023, amend filed 12/22/2023, effective 1/1/2024

Statutory/Other Authority: ORS 413.042, 430.256 & 430.640

Statutes/Other Implemented: ORS 428.205 - 428.270, 430.010, 430.205- 430.210, 430.254 - 430.640, 430.850 - 430.955 & 743A.168