(a) As set forth in W.S. § 9-2-2701(c), no program, provider, or facility may receive state funds for substance abuse prevention, early intervention recovery support services, or treatment services unless certified under these rules. Additionally, no substance abuse treatment program may receive court referred or ordered clients unless it is certified under these rules.
(b) All certified substance abuse service providers who are required to be certified shall meet the requirements set forth in these rules. Programs that sub-contract with providers for services must assure that the contractors are in compliance with these rules and thus the program will take full responsibility for these sub-contractors under the program's certification. Programs located outside of Wyoming may be certified, at the discretion of the Division, if they meet the applicable provisions of these rules.
(c) The Division can, under critical issues regarding safety of client, public or staff, conduct unannounced site visits to investigate such occurrences.
(d) If a program has a current recognized national accreditation for substance abuse treatment by specific level of care, applicable portions of this accreditation can be reviewed as part of the certification site visit at the discretion of the Division or its designee, utilizing the following processes. - (i) Applicable portions of the national accredited report by level of service that are congruent with these rules will be accepted in lieu of reviewing documentation for compliance with these rules.
- (ii) Sections that are not congruent with these rules will be reviewed as part of the certification site visit. If Wyoming Standards exceed national accreditation standards, Wyoming Standards will be required and reviewed for compliance.
- (iii) Records will be reviewed for compliance by level of service when national accreditation standards require state compliance for approval under the national standards.
- (iv) Certification reports will reference portions that were viewed as congruent by level of service in the certification report and note compliance.
(e) Any program or provider seeking certification under these rules shall apply to the Division for certification on a form provided by the Division.
(f) Upon receipt of a completed application, the Division shall review the application for compliance with these rules. The review may include an on-site inspection. Within sixty (60) calendar days after receiving the completed application, the Division shall either approve or deny the application. Failure of the Division or its designee to meet this deadline shall not be construed as approval of the application.
(g) An application may be approved subject to conditions provided those conditions are fully set forth in the letter communicating them to the applicant. In the event an application is approved subject to conditions, the applicant must communicate its plan for complying with the condition within fifteen (15) business days of receiving the notification. If the applicant is unwilling to comply with the conditions, the application shall be deemed denied pending further negotiations.
(h) The Division or its designated contractor can conduct on-site certification reviews, including review of organization, personnel, fiscal and clinical records, to assure that programs are meeting compliance. Confidentiality of records will be kept per 42 CFR, Part 2, Federal Confidentiality, and 45 CFR Part 160 and 164, Health Insurance Portability and Accountability Act (HIPAA). The Division may issue a certification for any period not to exceed two (2) years based on compliance level resulting from the on-site certification review. The certification shall remain in effect for the period designated, unless suspended or revoked prior to expiration. Providers seeking renewal will complete a renewal application in a form approved by the Division.
(i) The program shall submit to the Division a written corrective action plan if the provider receives a certification report below the minimum compliance level as determined by Division policy. Other critical issues that put the client, staff or public at risk will result in corrective action even if overall minimum compliance is within the acceptable range. The correction plan must be submitted to the Division within thirty (30) days of receipt of the request from the Division, unless requested in writing sooner.
(j) The Division shall review the corrective action plan and will notify the program of either the acceptance or rejection of the plan. An unacceptable plan must be amended and resubmitted within fifteen (15) business days of date of notice of rejection.
(k) Failure to make corrections pursuant to an approved correction plan may result in appropriate action under Chapter 2, Section 2(m)(ii), of these rules.
(l) Denial/Suspension/Revocation. - (i) The Division may deny an application to issue a certification if an applicant fails to meet all of the requirements of these rules, and may refuse to renew the certification if the applicant no longer meets or has violated any provision of these rules.
- (ii) The Division may at any time upon written notification to a certified program or provider, suspend or revoke the certificate if the Division finds that the provider does not comply with these rules. The notice shall state the reasons for the action and shall inform the certificate holder of actions necessary to remedy the failures and of their right to a hearing under the Wyoming Administrative Procedure Act. In addition to revoking or suspending a certification, the Division may, in its discretion, place a program on probation under a specified, mutually agreeable written correction plan. If another state agency revokes a provider certification/license or terminates their contract, the Division may, after review of the reasons of such action and subsequent on-site investigation, revoke the certification of any services approved by the Division.
- (iii) In the event a certification is suspended or revoked, notice shall be provided promptly by the Division to all courts that may refer persons to that program. Notice of final disposition of the matter shall also be promptly provided to those courts. If the Division denies, refuses to renew, suspends, or revokes a certification, the aggrieved party may request an administrative hearing under the Wyoming Administrative Procedure Act. A request for a hearing must be received by the Division within thirty (30) calendar days of the action from which the appeal is taken. If a timely request for hearing is not received by the Division, no hearing will be available. If a timely request for hearing is received, the action is stayed pending a decision on the appeal, except where the Division finds in writing that the health, safety, or welfare of clients requires that the action take effect immediately.
(m) Complaints. - (i) A complaint may be made by a program director or any person setting forth in writing the act done or omitted by the provider in violation of state and federal law, order, rule, or standard that the Division has jurisdiction over. If the complaint(s) are not under the jurisdiction of the Division, the person making the complaint will be directed to the appropriate authority for review. The complaint shall state the following information: the name, address, and telephone number of the complaining party, and the party, person, or programs the complaint is against; a clear and complete statement of the alleged violation of the law, order, rule or standard complained of, together with the facts which will give the parties a clear and full understanding of the nature of the alleged violation. The allegations may be supported by sworn statements attached to the complaint, a statement of the relief requested, and the signature of the complaining party or his or her attorney.
- (ii) The Division shall establish policies and procedures to ensure that complaints are properly evaluated, documented, acknowledged, and handled in a timely and appropriate manner. The allegations of the complaint shall determine the tasks required and the nature and scope of any investigation that may occur. The order and manner in which information is gathered depends on the type of complaint that is being investigated.
- (iii) The Division, on its own initiative or following the receipt of a complaint, may conduct an investigation of a program. The purpose of an investigation is to endeavor to bring about satisfaction of the complaint and/or violation.
- (iv) Upon initiation of an investigation, the Division shall provide the program director and the board of directors of the program a copy of the complaint and supporting materials in order to allow responding parties the opportunity to provide an informed response to the complaint. The investigation may include on-site inspection and collection of all available pertinent information concerning the operation of the program as it relates to the complaint being investigated. The Division may consult with the program director, the governing body of the program, the staff of the program, clients, parents or guardians of clients, and other pertinent and reliable sources of information about the program.
- (v) The program director and other responding parties shall file a response to the complaint with the Division no later than twenty (20) calendar days after receipt of the complaint. For good cause shown, the Division may extend the time to respond to the complaint.
- (vi) The investigation will begin upon the filing of the response. Within forty-five (45) calendar days of the initiation of an investigation, a preliminary report of the status of the investigation shall be issued to the complaining party and the responding parties. A final report of the investigation shall be issued within one hundred and twenty (120) calendar days of the initiation of the investigation. For good cause shown, the Division may extend the time of the investigation. The Division will provide a status summary every thirty (30) calendar days thereafter to the program director and the board president until the investigation process is complete.
- (vii) After an investigation has been completed, the Division shall notify the program director, board president, if applicable, complaining party, and responding parties of the findings of the investigation. The Division may specify the necessary corrective action and the timeline for completion of the corrective action.