Ala. Admin. Code r. 580-3-23-.10

Site Visits

This section establishes procedures for certification site visits conducted by the Alabama Department of Mental Health (DMH/MR) Office of Certification. It outlines the timing of site visits relative to Temporary Operating Authority, the Commissioner's options when a program fails to demonstrate substantial compliance, and requirements for debriefing and exit interviews with agency leadership. Operators must be prepared for both scheduled and unannounced visits and have the opportunity to provide compliance documentation within one working day of the exit meeting.

Ala. Admin. Code r. 580-3-23-.10 - Site Visits 

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(1)
 A
 review of administrative requirements as set out in the Alabama Administrative
 Code, Sections 580-2-13, 580-1-2, and 580-5-30, shall be separate from program
 site visits.

(2)
 A site visit is
 conducted prior to the expiration of the Letter of Temporary Operating
 Authority. The Provider may be required to submit additional documents prior to
 the certification site visit. If a program fails to demonstrate substantial
 compliance with minimum Department standards during this site visit, the
 Commissioner, in his/her sole discretion, may: 
 
(a)
 immediately withdraw the program's
 Temporary Operating Authority, taking into consideration the need for
 alternative placement of persons then being served by the program; or

(b)
 extend the Temporary Operating Authority
 to allow the program time to achieve substantial compliance; or

(c)
 place the program in provisional
 certification status.

(3)
 The initial program site visit and/or
 administrative review will be scheduled with the agency. All subsequent program
 site visits will occur in accordance with the period of temporary operating
 authority or certification renewal date and may be unannounced. All subsequent
 administrative reviews will be conducted in accordance with the period of
 temporary operating authority or certification renewal date and with DMH/MR
 policies.

(4)
 At the end of each
 day of the site visit, a debriefing will be held with the agency's executive
 director or his designee and the surveyor to review any problems that may have
 been found that day.

(5)
 At the
 conclusion of the program site visit, preliminary findings are given orally to
 the Agency Director and any selected staff, board members, and representatives
 of consumers and families available for the exit interview.

(6)
 An exit interview will be conducted upon
 the completion of the respective Division's/Office's certification site visit.
 An entity should have the opportunity to clarify or present evidence of
 compliance on issues being cited by the certification site visit team. At the
 exit meeting, the entity should provide documentation/information related to
 specific citations or the entity will be afforded the opportunity to provide
 documentation to demonstrate compliance to the respective division within one
 (1) working day of the exit meeting. 
 
Author:
 DMH/MR Office of Certification

Authority:

Code of Ala.
 1975,

 §
 
22-50-11
.

Notes

Ala. Admin. Code
 r. 
580-3-23-.10

New Rule: Filed October 1,
 2001; effective November 5, 2001. Amended: Filed August 13, 2002; effective
 September 17, 2002. Amended: Filed January 19, 2005; effective February 23,
 2005.

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