Or. Admin. Code § 309-019-0240 - [Effective 6/29/2025] 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.
Notes
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
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