§ 8.4 - Accreditation body responsibilities.

§ 8.4 Accreditation body Body responsibilities.

(a) Accreditation surveys and for cause inspections.

(1) Accreditation bodies Bodies shall conduct routine accreditation surveys for initial accreditation, renewal, and continued accreditation of each OTP and then at least every 3 yearsthree years to allow for renewal of certification.

(2) Accreditation bodies Bodies must agree to conduct for-cause inspections upon the request of SAMHSAthe Secretary.

(3) Accreditation decisions shall be fully consistent with the policies and procedures submitted as part of the approved accreditation body Accreditation Body application.

(b) Response to noncompliant programs.

(1) If an accreditation body Accreditation Body receives or discovers information that suggests that an OTP is not meeting Federal opioid treatment standardsapplicable accreditation or certification standards established or authorized under this part, or if a survey of the OTP by the accreditation body otherwise demonstrates one or more deficiencies in the OTP, the accreditation body shall as appropriate either require and monitor corrective action or shall suspend or revoke accreditation of the OTP, as appropriate based on the significance of the deficiencies.

(i) Accreditation bodies shall either not accredit or shall revoke the accreditation of any OTP that substantially fails to meet the Federal opioid treatment standards.

(ii) Accreditation bodies shall notify SAMHSA as soon as possible but in no case longer than 48 hours after becoming aware of any practice or condition in an OTP that may pose a serious risk to public health or safety or patient care.

(iii) If an accreditation body determines that an OTP is substantially meeting the Federal opioid treatment standards, but is not meeting one or more accreditation elements, the accreditation body shall determine the necessary corrective measures to be taken by the OTP, establish a schedule for implementation of such measures, and notify the OTP in writing that it must implement such measures within the specified schedule in order to ensure continued accreditation. The accreditation body shall verify that the necessary steps are taken by the OTP within the schedule specified and that all accreditation elements are being substantially met or will be substantially met.

(2) Nothing in this part shall prevent accreditation bodies from granting accreditation, contingent on promised programmatic or performance changes, to OTPs with less substantial violations. Such accreditation shall not exceed 12 months. OTPs that have been granted such accreditation must have their accreditation revoked if they fail to make changes to receive unconditional accreditation upon resurvey or reinspection.

Accreditation Body demonstrates that such standards are not being met, the Accreditation Body shall, within 60 days following discovery of the non-compliant condition(s) or applicable survey date:

(i) Provide written notice to the OTP that identifies each area of non-compliance, categorizes each non-compliant condition as either “minor” or “significant” as determined by the Accrediting Body, and requires the OTP to take corrective action to address the area(s) of non-compliance within a schedule, not to exceed 180 days, that the Accrediting Body deems appropriate based on the severity of the non-compliant conditions; and

(ii) Provide the Secretary with a copy of the written notice required under paragraph (b)(1)(i) of this section.

(2) Once an Accreditation Body provides an OTP with the notice described in paragraph (b)(1)(i) of this section, it shall verify the implementation of the corrective measures by the OTP within the specified schedule. Within 30 days following the last day of the specified schedule, the Accreditation Body shall provide written notice to the Secretary regarding whether the OTP has implemented the corrective measures.

(3) OTPs that are meeting the requirements of § 8.12, but are only required to correct minor non-compliant conditions shall be granted a three-year accreditation, beginning from the end date of the current and expiring accreditation period. Minor non-compliant conditions, found at the time of the survey that are not resolved, as determined by the Accreditation Body, within the OTP's three-year accreditation period and that remain areas of non-compliance during the OTP's subsequent three-year accreditation renewal survey, shall automatically be categorized as “significant” non-compliant conditions for purposes of the renewal survey and must be corrected in accordance with paragraph (b)(1)(i) of this section.

(4) OTPs that are required to correct significant non-compliant conditions shall be granted a one-year accreditation, beginning from the end date of the current and expiring accreditation period. An OTP's accreditation must be revoked if it fails to correct significant non-compliant conditions within the schedule provided under paragraph (b)(1)(i) of this section. If an Accrediting Body verifies that an OTP has corrected the significant non-compliant conditions identified within the specified schedule, it shall extend the OTP's accreditation period by an additional two years.

(5) In cases of severe non-compliance with the requirements of § 8.12 that pose immediate risks to patient health and safety, the Accreditation Body shall inform the OTP and Secretary within 48 hours and provide a detailed written report of the non-compliance within 5 business days. The Accreditation Body shall give the OTP 30 days from the date of the non-compliance report to correct the non-compliance issue(s). A follow-up survey shall be conducted by the Accreditation Body within 30 days of the expected correction date to ensure successful remediation. Should the OTP not rectify the non-compliance within the 30-day period, the Accreditation Body shall revoke the OTP's accreditation. The Secretary will then make a decision regarding the OTP's certification in accordance with the procedures under § 8.13.

(c) Recordkeeping.

(1) Accreditation bodies Bodies shall maintain, and make available as requested by the Secretary, records of their accreditation activities for at least 5 years from the creation of the record. Such records must contain sufficient detail to support each accreditation decision made by the accreditation bodyAccreditation Body.

(2) Accreditation bodies Bodies shall establish procedures to protect confidential information collected or received in their role as accreditation bodies Accreditation Bodies that are consistent with, and that are designed to ensure compliance with, all Federal and State laws, including 42 CFR part 2.

(i) Information collected or received for the purpose of carrying out accreditation body Accreditation Body responsibilities shall not be used for any other purpose or disclosed, other than to SAMHSA the Secretary or its duly designated representatives, unless otherwise required by law or with the consent of the OTP.

(ii) Nonpublic information that SAMHSA the Secretary shares with the accreditation body Accreditation Body concerning an OTP shall not be further disclosed except with the written permission of SAMHSAthe Secretary.

(d) Reporting.

(1) Accreditation bodies Bodies shall provide to SAMHSA the Secretary any documents and information requested by SAMHSA the Secretary within 5 days of receipt of the request.

(2) Accreditation bodies Bodies shall make submit a summary of the results of each accreditation survey available to SAMHSA upon requestto the Secretary within 90 days following the survey visit. Such summaries shall contain sufficient detail to justify the accreditation action taken.

(3) Accreditation bodies Bodies shall provide SAMHSA upon request the Secretary a list of each OTP surveyed, and the identity of all individuals involved in the conduct conducting and reporting of survey results.

(4) Accreditation bodies Bodies shall submit to SAMHSA the Secretary the name of each OTP for which the accreditation body Accreditation Body accredits conditionally, denies, suspends, or revokes accreditation, and the basis for the action, within 48 hours of the action.

(5) Notwithstanding any reports made to SAMHSA the Secretary under paragraphs (d)(1) through (d)(4) of this section, each accreditation body Accreditation Body shall submit to SAMHSA the Secretary semiannually, on January 15 and July 15 of each calendar year, a report consisting of a summary of the results of each accreditation survey conducted in the past year. The summary shall contain sufficient detail to justify each accreditation action taken.

(6) All reporting requirements listed in this section shall be provided to SAMHSA the Secretary at the address specified in § 8.3(b).

(e) Complaint response. Accreditation bodies Bodies shall have policies and procedures in place to respond to complaints received from SAMHSAthe Secretary, patients, facility staff, and others , within a reasonable period of time but not more than 5 days of 5 business days from the receipt of the complaint. Accreditation bodies Bodies shall also agree to notify SAMHSA within 48 hours the Secretary within 5 business days of receipt of a complaint and keep SAMHSA informed of all aspects of the from a patient, facility, staff or others, and to inform the Secretary of their response to the complaint.

(f) Modifications of accreditation elements. Accreditation bodies Bodies shall obtain SAMHSAthe Secretary's written authorization prior to making any substantive (i.e., noneditorial) change in accreditation elements.

(g) Conflicts of interest. The accreditation body Accreditation Body shall maintain and apply policies and procedures that SAMHSA the Secretary has approved in accordance with § 8.3 to reduce the possibility of actual conflict of interest, or the appearance of a conflict of interest, on the part of individuals who act on behalf of the accreditation bodyAccreditation Body. Individuals who participate in accreditation surveys or otherwise participate in the accreditation decision or an appeal of the accreditation decision, as well as their spouses and minor children, shall not have a financial interest in the OTP that is the subject of the accreditation survey or decision.

(h) Accreditation teams.

(1) An accreditation body Accreditation Body survey team shall consist of healthcare professionals with expertise in drug abuse treatment and, in particular, opioid treatment. The accreditation body OUD treatment. The Accreditation Body shall consider factors such as the size of the OTP, the anticipated number of problemssurvey non-compliance issues, and the OTP's accreditation history , in determining the composition of the team. At a minimum, survey teams shall consist of at least two healthcare professionals whose combined expertise includes:

(i) The dispensing and administration of drugs medications subject to control under the Controlled Substances Act (21 U.S.C. 801 et seq.);

(ii) Medical issues relating to the dosing and administration of opioid agonist treatment medications MOUD for the treatment of opioid use disorderOUD;

(iii) Psychosocial counseling of individuals undergoing opioid receiving OUD treatment; and

(iv) Organizational and administrative issues associated with opioid treatment programsOTPs.

(2) Members of the accreditation team must be able to recuse themselves at any time from any survey in which either they or the OTP believes there is an actual conflict of interest or the appearance of a conflict of interest. Conflict or perceived conflict of interest must be documented by the Accreditation Body and made available to the Secretary.

(i) Accreditation fees. Fees charged to OTPs for accreditation shall be reasonable. SAMHSA the Secretary generally will find fees to be reasonable if the fees are limited to recovering costs to the accreditation bodyAccreditation Body, including overhead incurred. Accreditation body Body activities that are not related to accreditation functions are not recoverable through fees established for accreditation.

(1) The accreditation body Accreditation Body shall make public its fee structure, including those factors, if any, contributing to variations in fees for different OTPs.

(2) At SAMHSAthe Secretary's request, accreditation bodies Accreditation Bodies shall provide to SAMHSA the Secretary financial records or other materials, in a manner specified by SAMHSAthe Secretary, to assist in assessing the reasonableness of accreditation body Accreditation Body fees.