Or. Admin. R. 411-323-0035 - Endorsement

(1) ENDORSEMENT REQUIRED. A person, agency, or governmental unit acting individually or jointly with any other person, agency, or governmental unit intending to operate a program type as defined in OAR 411-323-0020 must be endorsed by the Department under these rules before establishing, conducting, maintaining, managing, or operating a program.
(a) Except as described in OAR 411-450-0070, endorsements are not transferable or applicable to any other program type. Separate endorsements are required for each program type operated by a certified agency. A certified agency intending to operate additional program types once initial endorsement has been issued must apply for an additional endorsement as described in section (3) of this rule.
(b) If required by the program rules, each geographic location where a program operates must be reported by the agency to the Department and to the corresponding CDDP of the geographic location as described in this rule.
(c) The Department issues or renews an endorsement to a certified agency found to be in compliance with these rules, the rules in OAR chapter 411 division 004, and the corresponding program rules. The effective date for each endorsement corresponds with the effective date for the certification of the agency unless sooner revoked or suspended.
(d) If a certified agency fails to provide complete, accurate, and truthful information during the application or renewal process, the Department may delay initial endorsement, deny the application, or revoke or refuse to renew the endorsement of the program.
(e) For the purpose of endorsement, any applicant or person with an ownership interest in a certified agency is considered responsible for acts occurring during, and relating to, the operation of the agency.
(f) The Department may consider the background and operating history of the applicant and each person with an ownership interest when determining whether to issue or renew an endorsement.
(g) A review of the certified agency is conducted by the Department prior to the issuance or renewal of an endorsement.
(2) CURRENT AGENCY ENDORSEMENT.
(a) All certified agencies endorsed to operate a program are endorsed for not more than two years.
(b) A certified agency intending to operate additional program types must apply for endorsement as described in section (3) of this rule.
(c) An agency licensed or certified under OAR chapter 411, division 054 for residential care and assisted living facilities, OAR chapter 309, division 035 for residential treatment facilities and residential treatment homes for adults with mental health disorders, OAR chapter 413, division 215 for child-caring agencies, or OAR chapter 416, division 550 for youth offender treatment foster care, and as may be described in corresponding program rules, does not require additional endorsement as an agency under these rules to deliver services described in the program rules.
(3) INITIAL ENDORSEMENT.
(a) Notwithstanding section (2) of this rule, a certified agency intending to operate a program as defined in OAR 411-323-0020 must apply for initial endorsement and demonstrate to the satisfaction of the Department that the agency is in compliance with these rules, the rules in OAR chapter 411 division 004, and the corresponding program rules.
(b) The certified agency must submit an application to the Department at least 90 calendar days prior to delivering services that identifies the program type that the certified agency intends to operate.
(A) All geographic locations where programs are to be operated must be identified on the application, if required by the program rules.
(B) The completed application must be on a form provided by the Department and must include all information requested by the Department.
(C) Each licensed site or geographic location where direct services are to be delivered must be assigned a Medicaid Performing Provider Number by the Department as described in OAR chapter 411, division 370.
(4) ENDORSEMENT RENEWAL.
(a) To renew endorsement, the certified agency must:
(A) Submit an application to the Department at least 90 calendar days prior to the expiration date of the existing endorsement for the certified agency. The completed application must identify the program type that the certified agency provides and all geographic locations where program services are provided, when required by the program rules. The completed application must be on a form provided by the Department and must include all information requested by the Department.
(B) Demonstrate to the satisfaction of the Department that the certified agency is in compliance with these rules, the rules in OAR chapter 411 division 004, and the corresponding program rules.
(b) Only existing program types are endorsed on renewal. A certified agency requesting to operate additional program types must apply for initial endorsement as described in section (3) of this rule.
(c) An application for renewal filed with the Department before the date of expiration extends the effective date of the existing endorsement until the Department takes action upon the application for renewal.
(d) A certified agency may not operate a program if a renewal application is not submitted to the Department prior to the date the endorsement expires.
(e) Renewal of endorsements for a program is contingent upon the successful renewal of the certificate of the agency.
(5) EXISTING ENDORSEMENT - ADDING A GEOGRAPHIC LOCATION. Adding a geographic location to an existing endorsement must be reported by the agency to the Department and to the corresponding CDDP of the geographic location. The agency must report the additional geographical location on a form provided by the Department at least 30 calendar days prior to delivering services at the additional geographic location.
(6) ENDORSEMENT EXPIRATION. Unless revoked, suspended, or terminated earlier, the effective date of each endorsement corresponds with the effective date of the certification of the agency.
(7) ENDORSEMENT TERMINATION. Endorsement automatically terminates on the date programs are discontinued or agency certification is terminated.
(8) CHANGE OF CERTIFICATION. New endorsement is required upon a change of the certification of an agency. The recertified agency must submit an application for endorsement as described in section (3) of this rule to the Department at least 30 calendar days prior to a change of the certification of the agency including, but not limited to, a change in ownership, legal entity, legal status, or management corporation.
(9) ENDORSEMENT ADMINISTRATIVE SANCTION. An administrative sanction may be imposed for non-compliance with these rules, the corresponding program rules, or the rules in OAR chapter 411 division 004. An administrative sanction on an endorsement includes one or more of the following actions:
(a) A condition as described in section (10) of this rule.
(b) Denial, revocation, or refusal to renew an endorsement as described in section (11) of this rule.
(c) Immediate suspension of an endorsement as described in section (12) of this rule.
(10) ENDORSEMENT CONDITIONS.
(a) The Department may attach conditions to an endorsement that limit, restrict, or specify other criteria for a program. The type of condition attached to an endorsement must directly relate to a risk of harm or potential risk of harm to individuals.
(b) The Department may attach a condition to an endorsement upon any of the following findings:
(A) Information on the application or initial inspection requires a condition to protect the health, safety, or welfare of individuals.
(B) A threat to the health, safety, or welfare of an individual exists.
(C) There is evidence of abuse, neglect, or exploitation.
(D) The agency is not being operated in compliance with these rules, the rules in OAR chapter 411 division 004, or the corresponding program rules.
(c) Conditions that the Department may impose on an endorsement include, but are not limited to, the following:
(A) Restricting the total number of individuals to whom an agency may deliver services.
(B) Restricting the total number of individuals to whom an agency may deliver services based upon the capability and capacity of the agency and staff to meet the health and safety needs of all individuals.
(C) Restricting the type of support and services an agency may deliver to individuals based upon the capability and capacity of the agency and staff to meet the health and safety needs of all individuals.
(D) Requiring additional staff or staff qualifications.
(E) Requiring additional training.
(F) Restricting an agency from allowing a person on the premises who may be a threat to the health, safety, or welfare of an individual.
(G) Requiring additional documentation.
(H) Restricting enrollments into the endorsed program.
(d) The Department shall impose a condition prohibiting new entry or transfer into services provided under an agency endorsement when there is a death of an individual served by the agency that results in a protective services investigation and the agency was responsible for delivering supports to the individual during the time associated with the individual's death.
(A) The agency may accept a new entry or transfer while the condition is in place, if the entry or transfer approval is granted by the Department and the case management entity.
(B) The condition may be terminated:
(i) Following the protective services investigation determination that abuse or neglect was not a factor in the individual's death; or
(ii) At the discretion of the Department upon satisfactory demonstration by the agency that:
(I) There are adequate protections in place to prevent or minimize risk of harm to other individuals receiving the same or similar type of services; and
(II) Entry of additional individuals in services does not negatively impact the agency's ability to safely serve individuals.
(e) NOTICE OF ENDORSEMENT CONDITIONS. The Department issues a written notice to the agency when the Department imposes conditions on the endorsement of a program. The written notice of endorsement conditions includes the conditions imposed by the Department, the reason for the conditions, and the opportunity to request a hearing under ORS chapter 183.
(A) Conditions take effect immediately upon issuance of the written notice of conditions or at a later date as indicated on the notice and are a Final Order of the Department unless later rescinded through the hearing process.
(B) The conditions imposed remain in effect until the Department has sufficient cause to believe the situation that warranted the condition has been remedied.
(f) HEARING.
(A) An agency may request a hearing in accordance with ORS chapter 183 and this rule upon written notice of endorsement conditions. The request for a hearing must be in writing. An agency must request a hearing within 21 calendar days from the receipt of the written notice of conditions.
(B) In addition to, or in lieu of a hearing, an agency may request an administrative review as described in section (13) of this rule. The request for an administrative review must be in writing. The administrative review does not diminish the right of the agency to a hearing.
(C) The Department shall be allowed reasonable requests for setting or postponement of any hearing to allow for the conclusion of a protective services investigation when a condition is imposed related to the protective services investigation.
(g) The agency may send a written request to the Department to remove a condition if the agency believes the situation that warranted the condition has been remedied.
(h) Conditions must be posted with the endorsement in a prominent location and be available for inspection at all times.
(11) ENDORSEMENT DENIAL, REFUSAL TO RENEW, OR REVOCATION.
(a) The Department may deny, refuse to renew, or revoke an endorsement when the Department finds the agency or any person holding 5 percent or greater ownership interest in the agency:
(A) Fails to maintain agency certification as described in OAR 411-323-0030;
(B) Demonstrates substantial failure to comply with these rules, the rules in OAR chapter 411, division 004, or the corresponding program rules such that the health, safety, or welfare of individuals is jeopardized and the agency fails to correct the non-compliance within 30 calendar days from the receipt of the written notice of non-compliance;
(C) Has demonstrated a substantial failure to comply with these rules, the rules in OAR chapter 411, division 004, or the corresponding program rules such that the health, safety, or welfare of individuals is jeopardized;
(D) Has been convicted of any crime that would have resulted in an unacceptable background check upon hiring or authorization of services;
(E) Has been convicted of a misdemeanor associated with the operation of an agency or program services;
(F) Falsifies information required by the Department to be maintained or submitted regarding program services, agency finances, or funds belonging to the individuals;
(G) Has been found to have permitted, aided, or abetted any illegal act that has had significant adverse impact on individual health, safety, or welfare; or
(H) Has been placed on the list of excluded or debarred providers maintained by the Office of the Inspector General.
(b) NOTICE OF ENDORSEMENT DENIAL, REFUSAL TO RENEW, OR REVOCATION. The Department may issue a notice of denial, refusal to renew, or revocation of an endorsement following a Department finding that there is a substantial failure to comply with these rules, the rules in OAR chapter 411, division 004, or the corresponding program rules such that the health, safety, or welfare of individuals is jeopardized, or that one or more of the events listed in subsection (a) of this section has occurred.
(c) HEARING. An applicant for an endorsement or an endorsed agency, as applicable, may request a hearing in accordance with ORS chapter 183, this rule, and ORS 443.440 for a 24-hour residential or host home program, upon written notice from the Department of denial, refusal to renew, or revocation of an endorsement. The request for a hearing must be in writing.
(A) DENIAL. The applicant must request a hearing within 60 calendar days from the receipt of the written notice of denial.
(B) REFUSAL TO RENEW. The agency must request a hearing within 60 calendar days from the receipt of the written notice of refusal to renew.
(C) REVOCATION.
(i) Notwithstanding subsection (ii) of this section, the agency must request a hearing within 21 calendar days from the receipt of the written notice of revocation.
(I) In addition to, or in lieu of a hearing, an agency may request an administrative review as described in section (13) of this rule. The request for an administrative review must be in writing.
(II) The administrative review does not diminish the right of the agency to a hearing.
(ii) An agency endorsed to operate a 24-hour residential program as described in OAR chapter 411, division 325 or a host home program as described in OAR chapter 411, division 348, must request a hearing within 10 calendar days from the receipt of the written notice of revocation.
(12) IMMEDIATE SUSPENSION OF ENDORSEMENT.
(a) When the Department finds a serious and immediate threat to individual health and safety and sets forth the specific reasons for such findings, the Department may, by written notice to the agency, immediately suspend an endorsement without a pre-suspension hearing and the program may not continue operating.
(b) HEARING. The agency may request a hearing in accordance with ORS chapter 183, this rule, and ORS 443.440 for a 24-hour residential or host home program, upon written notice from the Department of the immediate suspension of the endorsement. The request for a hearing must be in writing.
(A) Notwithstanding subsection (B) of this section, the endorsed agency must request a hearing within 21 calendar days from the receipt of the written notice of suspension.
(i) In addition to, or in-lieu of a hearing, the agency may request an administrative review as described in section (13) of this rule. The request for an administrative review must be in writing.
(ii) The administrative review does not diminish the right of the agency to a hearing.
(B) An agency endorsed to operate a 24-hour residential program as described in OAR chapter 411, division 325 or a host home program as described in OAR chapter 411, division 348, must request a hearing within 10 calendar days from the receipt of the written notice of suspension.
(13) ADMINISTRATIVE REVIEW.
(a) Notwithstanding subsection (b) of this section, the agency, in addition to the right to a hearing, may request an administrative review. The request for an administrative review must be in writing.
(b) An agency endorsed to operate a 24-hour residential program as described in OAR chapter 411, division 325 or a host home program as described in OAR chapter 441, division 348, may not request an administrative review for revocation or suspension. An agency endorsed to operate a 24-hour residential program as described in OAR chapter 411, division 325 or a host home program as described in OAR chapter 411, division 348, may request an administrative review for imposition of conditions.
(c) The Department must receive a written request for an administrative review within 10 business days from the receipt of the notice of suspension, revocation, or imposition of conditions. The agency may submit, along with the written request for an administrative review, any additional written materials the agency wishes to have considered during the administrative review.
(d) The determination of the administrative review is issued in writing within 10 business days from the receipt of the written request for an administrative review, or by a later date as agreed to by the agency.
(e) The agency, notwithstanding subsection (b) of this section, may request a hearing if the decision of the Department is to affirm the suspension, revocation, or condition. The request for a hearing must be in writing. The Department must receive the written request for a hearing within 21 calendar days from the receipt of the original written notice of suspension, revocation, or imposition of conditions.
(14) INFORMAL CONFERENCE. Unless an administrative review has been completed as described in subsection (13) of this rule, an applicant or agency requesting a hearing may have an informal conference with the Department.

Notes

Or. Admin. R. 411-323-0035
SPD 19-2011(Temp), f. & cert. ef. 7-1-11 thru 12-28-11; SPD 1-2012, f. & cert. ef. 1-6-12; APD 42-2014, f. 12-26-14, cert. ef. 12/28/2014; APD 25-2016, f. & cert. ef. 6/29/2016; APD 44-2019, amend filed 10/29/2019, effective 11/1/2019

Statutory/Other Authority: ORS 409.050

Statutes/Other Implemented: ORS 427.007 & 430.215

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