(1) "Comprehensive survey," a planned, on-site survey of an agency, by a team of representatives from the department for the purposes of evaluating compliance with the standards for accreditation renewal and assessing the quality of services provided;

(2) "Plan of correction," a plan created by an agency to organize the process of making improvements in clinical or administrative practice, in order to address issues that are identified by the department and require corrective action or improvement to meet the requirements of this article;

(3) "Probation," a status of restricted accreditation of an agency that fails to follow the requirements for accreditation;

(4) "Revocation," the permanent withdrawal of an alcohol or other drug abuse agency's accreditation by the department;

(5) "Root cause analysis," a process to identify the fundamental reason for a failure or an inefficiency of process that allowed for a mistake, including the occurrence or possible occurrence of a sentinel event, to determine how to change procedures so mistakes are less likely, and then make the change; and

(6) "Suspension," the temporary withdrawal of an agency's accreditation by the department.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25, 34-20A-27.

Law Implemented: SDCL 34-20A-27, 34-20A-44.

67:61:02:02. Access by the department. The department shall monitor each agency for continued compliance with this article, regardless of the term of an agency's accreditation certificate. An agency is subject to review, with or without notice, by the department. An agency shall provide the department with complete access to all clients and staff, and to all client, staff, financial, and administrative program records needed to determine whether the agency meets the requirements of SDCL chapter 34-20A and this article. The requirements for the department to review and copy records are those contained in 42 C.F.R. Part 2, in effect on January 18, 2017.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25, 34-20A-27.

Law Implemented: SDCL 34-20A-27, 34-20A-44, 34-20A-44.1.

67:61:02:03. Accreditation of agencies by service classification. An agency that provides substance use disorder services may apply for accreditation by the department. An agency shall comply with the rules in this article that apply to service classifications for which the accreditation is granted. An agency may apply for one or more of the following service classifications:

(1) Prevention;

(2) Outpatient services including early intervention programs, outpatient treatment programs, and intensive outpatient treatment programs;

(3) Day treatment program;

(4) Clinically-managed, low-intensity residential program;

(5) Clinically-managed, residential detoxification program; and

(6) Medically-monitored, intensive inpatient treatment program.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25, 34-20A-27.

Law Implemented: SDCL 34-20A-27.

67:61:02:04. Application for accreditation. An agency seeking to operate an accredited alcohol, other drug, or gambling program shall submit an application for accreditation to the department. The department shall return and not consider an incomplete application submitted by an agency. The department shall make accreditation application forms available upon request to an agency seeking initial accreditation or seeking to add a new level of care to a current accreditation.

If an agency is seeking the renewal of an accreditation, the department must provide the necessary application forms to the agency at least sixty days before the expiration of the agency's current accreditation.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25, 34-20A-27.

Law Implemented: SDCL 34-20A-27.

67:61:02:05. Policies and procedures subject to approval. All agency policies and procedures must comply with and carry out the requirements of article 67:61 and are subject to the approval of the department as part of the accreditation process.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25, 34-20A-27.

Law Implemented: SDCL 34-20A-27.

67:61:02:06. Provisional accreditation and comprehensive survey. The department may grant provisional accreditation to an agency seeking accreditation for the first time or to an agency previously accredited to regain accreditation. A provisional accreditation certificate may only be issued upon submission of a completed application and a preliminary comprehensive survey by the department to determine compliance with this article and the requirements of SDCL chapter 34-20A.

A provisional accreditation expires after six months and may not be extended except with the approval of the department. An extension under this section may not exceed three months. The department shall conduct a follow-up, comprehensive survey, prior to the expiration of the agency's provisional accreditation, to determine if the requirements of SDCL chapter 34-20A and this article have been met. At that time, the department shall:

(1) Grant a one-year accreditation certificate for a new agency;

(2) Grant accreditation up to the end date of the original certification for a currently accredited agency who wants to change the level of care for which they are currently accredited; or

(3) Deny accreditation.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25, 34-20A-27.

Law Implemented: SDCL 34-20A-27.

67:61:02:07. Extension of accreditation period. The department may extend the period of accreditation to accommodate department on-site scheduling delays. No extension may exceed a period of one year beyond the certificate expiration date.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25, 34-20A-27.

Law Implemented: SDCL 34-20A-27.

67:61:02:08. Renewal of accreditation - Comprehensive survey. Each agency currently accredited by the department shall participate in a comprehensive survey to determine compliance with the requirements of this article and SDCL chapter 34-20A prior to the renewal of accreditation. The department shall notify the agency of the date of the comprehensive survey.

The department shall determine whether, based on the survey, the agency complied with SDCL chapter 34-20A and this article, within ninety days of the comprehensive survey. The determination must be based on the evaluation of each component of the accreditation application and materials reviewed. As a result, the department may:

(1) Issue a three-year accreditation certificate, if an agency is in compliance with ninety percent or more of the requirements and submits a plan of correction that is approved by the department and addresses all areas of noncompliance;

(2) Issue a two-year accreditation certificate, if an agency is in compliance with seventy to eighty-nine percent of the requirements and submits a plan of correction that is approved by the department and addresses all areas of noncompliance;

(3) Place an agency on probation for not more than six months, if an agency is in compliance with less than seventy percent of the requirements. If the agency successfully completes a plan of correction approved by the department, addresses all areas of noncompliance, and attains at least seventy percent during a comprehensive survey at the end of the probationary period, the department must issue a one-year accreditation certificate; or

(4) Deny accreditation if the agency fails to substantially comply with the requirements of SDCL chapter 34-20A and this article or fails to submit a plan of correction approved by the department.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25, 34-20A-27.

Law Implemented: SDCL 34-20A-27.

67:61:02:09. Comprehensive survey report -- Plan of correction. The department shall, within thirty days following the comprehensive survey, report its findings to the agency. If an agency is not in compliance with this article and SDCL chapter 34-20A, the department must notify the agency of the areas of noncompliance in the accreditation report. In response to any areas of noncompliance, the agency must submit a plan of correction to the department within thirty days of receiving the accreditation report. The plan must include the action to be taken to correct the areas of noncompliance and the date the action is to be completed. The plan of correction is subject to acceptance or rejection, in whole or in part, by the department. The department shall, within thirty days of receiving the plan of correction, notify the agency of the department's decision regarding approval or disapproval of the plan and the accreditation status of the agency. The department may conduct a follow-up review of the agency to evaluate the corrections. Failure to submit a plan of correction or failure to have the plan of correction approved by the department will result in probation, suspension, or revocation of accreditation.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25, 34-20A-27.

Law Implemented: SDCL 34-20A-27, 34-20A-44.

67:61:02:10. Reasons for placing an agency on probation. The department may place an agency on probation if the department determines:

(1) The agency is in compliance with less than seventy percent of the requirements of this article and SDCL chapter 34-20A;

(2) The agency failed to follow through with the plan of correction to address the areas of noncompliance noted by the department in the accreditation report;

(3) The agency has serious infractions of this article that affect the overall continuity of care or safety of clients;

(4) The agency falsified information provided to the department for accreditation or funding purposes;

(5) The agency participated in, condoned, or permitted illegal acts;

(6) The agency participated in, condoned, or permitted fraud, deceit, or coercion;

(7) The agency failed to comply with licensing and other standards that are required by federal or state laws, rules, or regulations; state and federal confidentiality laws; and this article; and the noncompliance results in practices that are detrimental to the welfare of a client; or

(8) The agency refused to allow the department access for a comprehensive survey, a complaint review, or any necessary follow-up review.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25, 34-20A-27.

Law Implemented: SDCL 34-20A-27.

67:61:02:11. Probation procedures. If the department determines there is sufficient cause to place an agency on probation:

(1) The department must send the agency written notice of probationary status and areas of noncompliance;

(2) The agency must develop and submit a plan of correction, pursuant to § 67:61:02:09, within thirty days of the receipt of the notice of probationary status; and

(3) Within five business days after receiving the plan of correction, the department must notify the agency of the department's decision to approve or deny the plan of correction.

The department must conduct a site visit, at least once during the probationary period, to monitor the agency's progress on the plan of correction.

At the end of the probationary period, the department shall conduct a comprehensive survey of the agency and grant a one year accreditation certificate, provided the agency has obtained at least seventy percent compliance during the final comprehensive survey; suspend the agency's accreditation; or revoke the agency's accreditation.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25, 34-20A-27.

Law Implemented: SDCL 34-20A-27.

67:61:02:12. Suspension or revocation procedures. The department shall provide written notice to an agency of the department's intent to suspend or revoke the agency's accreditation.

The suspension or revocation is effective fifteen days after receipt of the notice. The notice must contain the reason for the department's action, describe the process by which the agency may request reconsideration by the department, and describe the appeal process.

An agency's request for reconsideration must be in writing and be received by the department within fifteen days from the date the agency received the notice of suspension or revocation.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25, 34-20A-27.

Law Implemented: SDCL 34-20A-27.

Cross Reference: Acceptance of new clients prohibited, § 67:61:02:13.

67:61:02:13. Acceptance of new clients prohibited. An agency that has been placed on probation or whose accreditation has been suspended is prohibited from accepting new clients until the department approves the plan of correction.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25, 34-20A-27.

Law Implemented: SDCL 34-20A-27.

67:61:02:14. Delay in meeting requirements. The department may grant an agency a delay in meeting the requirements of this article to avoid undue hardship on the agency if the department determines that allowing a delay would be in the best interest of the agency's clients.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 27A-5-1.

Law Implemented: SDCL 27A-3-1, 27A-5-1.

67:61:02:15. Denial of accreditation. If the department denies the accreditation of an agency, the department must send notice of the denial to the agency by certified mail, return receipt requested, within sixty days of the final review. The notice of denial must inform the agency that the denial is effective fifteen days after receipt of the notice.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25, 34-20A-27.

Law Implemented: SDCL 34-20A-27.

67:61:02:16. Reconsideration of application for accreditation. An agency may request that the department reconsider an application. The request must be in writing and sent within fifteen days after receipt of the denial of accreditation.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25, 34-20A-27.

Law Implemented: SDCL 34-20A-27.

67:61:02:17. Appeal procedure. An agency may appeal to the secretary of the department any denial, revocation, or suspension of certification, or placement on probation by the department. An appeal under this section must be sent by certified mail within fifteen days after receipt of notification of the department's action and must include a request for a fair hearing pursuant to SDCL chapter 1-26.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25, 34-20A-27.

Law Implemented: SDCL 34-20A-27.

Cross Reference: Fair hearings, chapter 67:17:02.

Rule 67:61:02:18 Time and place of hearing.

67:61:02:18. Time and place of hearing. A fair hearing by an impartial hearing officer shall be held within 45 days after the department receives a request for a fair hearing. The hearing officer shall set a time and place for the hearing at the earliest reasonable time. The hearing officer may continue the hearing at the request of any party involved and upon agreement by the parties to a specific extension of time.

Source: 43 SDR 80, effective December 5, 2016.

General Authority: SDCL 34-20A-27.

Law Implemented: SDCL 34-20A-27.

67:61:02:19. Accreditation certificate nontransferable. A certificate issued by the department applies only to the applicant agency, the original facilities, and program classifications for which the certificate was issued. The agency shall notify the department in writing within thirty days before a change of ownership, facility, or program for a determination on continued accreditation. A new application for accreditation must be filed if there is a change of ownership, facility, or program.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25, 34-20A-27.

Law Implemented: SDCL 34-20A-27.

67:61:02:20. Changes requiring notification. An accredited agency shall notify the department before a change in the agency director, a reduction in services provided by the agency, or the impending closure of the agency. Upon receiving a notification under this section, the department must make a determination on the agency's continued accreditation.

An accredited agency shall give the department thirty days' written notice of closure. The agency shall provide the department with written documentation outlining the manner in which safe storage of financial records will be provided, for at least six years from the date of closure, and safe storage of client case records will be provided, for at least six years from the date of closure, as required by 42 C.F.R. § 2.19, in effect on October 1, 1999.

The department may assist in arranging for the continuation of services to clients by another accredited agency before the closing.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25, 34-20A-27.

Law Implemented: SDCL 34-20A-27.

67:61:02:21. Event notification. Each accredited agency shall make a report to the department within twenty-four hours of any: death not primarily related to the natural course of the client's illness or underlying condition, permanent harm to a client, or severe temporary harm to a client, and any intervention required to sustain life to a client.

The agency shall submit a follow-up report to the department within seventy-two hours and must include:

(1) A written description of the event;

(2) The client's name and date of birth; and

(3) Immediate actions taken by the agency.

Each agency shall develop a root cause analysis policy and procedures to utilize in response to any event requiring notification.

Each agency shall report to the department, as soon as possible, any fire with structural damage or in which injury or death occurs; any partial or complete evacuation of the agency resulting from natural disaster; any loss of utilities, including electricity, natural gas, and phone lines; and any loss of an emergency generator, fire alarms, sprinklers, and other critical equipment necessary for operation of the agency for more than twenty-four hours.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25, 34-20A-27.

Law Implemented: SDCL 34-20A-27.

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