[Code of Federal Regulations]

[Title 42, Volume 1]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR8.3]



[Page 57-59]

 

                         TITLE 42--PUBLIC HEALTH

 

    CHAPTER I--PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN 

                                SERVICES

 

PART 8_CERTIFICATION OF OPIOID TREATMENT PROGRAMS--Table of Contents

 

                         Subpart A_Accreditation

 

Sec. 8.3  Application for approval as an accreditation body.



    (a) Eligibility. Private nonprofit organizations or State 

governmental entities, or political subdivisions thereof, capable of 

meeting the requirements of this part may apply for approval as an 

accreditation body.

    (b) Application for initial approval. Three copies of an 

accreditation body application form [SMA-163] shall be submitted to 

SAMHSA at rm. 12-105, 5600 Fishers Lane, Rockville, MD 20857, and marked 

ATTENTION: OTP Certification Program. SAMHSA will consider and accept 

the electronic submission of these materials when electronic submission 

systems are developed and available. Accreditation body applications 

shall include the following information and supporting documentation:

    (1) Name, address, and telephone number of the applicant and a 

responsible official for the accreditation body. The application shall 

be signed by the responsible official;

    (2) Evidence of the nonprofit status of the applicant (i.e., of 

fulfilling Internal Revenue Service requirements as a nonprofit 

organization) if the applicant is not a State governmental entity or 

political subdivision;

    (3) A set of the accreditation elements or standards and a detailed 

discussion showing how the proposed accreditation elements or standards 

will ensure that each OTP surveyed by the applicant is qualified to meet 

or is meeting each of the Federal opioid treatment standards set forth 

in Sec. 8.12;

    (4) A detailed description of the applicant's decisionmaking 

process, including:

    (i) Procedures for initiating and performing onsite accreditation 

surveys of OTPs;

    (ii) Procedures for assessing OTP personnel qualifications;

    (iii) Copies of an application for accreditation, guidelines, 

instructions, and other materials the applicant will send to OTPs during 

the accreditation process, including a request for a complete history of 

prior accreditation activities and a statement that all information and 

data submitted in the application for accreditation is true and 

accurate, and that no material fact has been omitted;

    (iv) Policies and procedures for notifying OTPs and SAMHSA of 

deficiencies and for monitoring corrections of deficiencies by OTPs;

    (v) Policies and procedures for suspending or revoking an OTP's 

accreditation;

    (vi) Policies and procedures that will ensure processing of 

applications for accreditation and applications for renewal of 

accreditation within a timeframe approved by SAMHSA; and

    (vii) A description of the applicant's appeals process to allow OTPs 

to contest adverse accreditation decisions.

    (5) Policies and procedures established by the accreditation body to 

avoid conflicts of interest, or the appearance of conflicts of interest, 

by the applicant's board members, commissioners, professional personnel, 

consultants, administrative personnel, and other representatives;

    (6) A description of the education, experience, and training 

requirements for the applicant's professional staff, accreditation 

survey team membership,



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and the identification of at least one licensed physician on the 

applicant's staff;

    (7) A description of the applicant's training policies;

    (8) Fee schedules, with supporting cost data;

    (9) Satisfactory assurances that the body will comply with the 

requirements of Sec. 8.4, including a contingency plan for 

investigating complaints under Sec. 8.4(e);

    (10) Policies and procedures established to protect confidential 

information the applicant will collect or receive in its role as an 

accreditation body; and

    (11) Any other information SAMHSA may require.

    (c) Application for renewal of approval. An accreditation body that 

intends to continue to serve as an accreditation body beyond its current 

term shall apply to SAMHSA for renewal, or notify SAMHSA of its 

intention not to apply for renewal, in accordance with the following 

procedures and schedule:

    (1) At least 9 months before the date of expiration of an 

accreditation body's term of approval, the body shall inform SAMHSA in 

writing of its intent to seek renewal.

    (2) SAMHSA will notify the applicant of the relevant information, 

materials, and supporting documentation required under paragraph (b) of 

this section that the applicant shall submit as part of the renewal 

procedure.

    (3) At least 3 months before the date of expiration of the 

accreditation body's term of approval, the applicant shall furnish to 

SAMHSA three copies of a renewal application containing the information, 

materials, and supporting documentation requested by SAMHSA under 

paragraph (c)(2) of this section.

    (4) An accreditation body that does not intend to renew its approval 

shall so notify SAMHSA at least 9 months before the expiration of the 

body's term of approval.

    (d) Rulings on applications for initial approval or renewal of 

approval. (1) SAMHSA will grant an application for initial approval or 

an application for renewal of approval if it determines the applicant 

substantially meets the accreditation body requirements of this subpart.

    (2) If SAMHSA determines that the applicant does not substantially 

meet the requirements set forth in this subpart. SAMHSA will notify the 

applicant of the deficiencies in the application and request that the 

applicant resolve such deficiencies within 90 days of receipt of the 

notice. If the deficiencies are resolved to the satisfaction of SAMHSA 

within the 90-day time period, the body will be approved as an 

accreditation body. If the deficiencies have not been resolved to the 

satisfaction of SAMHSA within the 90-day time period, the application 

for approval as an accreditation body will be denied.

    (3) If SAMHSA does not reach a final decision on a renewal 

application before the expiration of an accreditation body's term of 

approval, the approval will be deemed extended until SAMHSA reaches a 

final decision, unless an accreditation body does not rectify 

deficiencies in the application within the specified time period, as 

required in paragraph (d)(2) of this section.

    (e) Relinquishment of approval. An accreditation body that intends 

to relinquish its accreditation approval before expiration of the body's 

term of approval shall submit a letter of such intent to SAMHSA, at the 

address in paragraph (b) of this section, at least 9 months before 

relinquishing such approval.

    (f) Notification. An accreditation body that does not apply for 

renewal of approval, or is denied such approval by SAMHSA, relinquishes 

its accreditation approval before expiration of its term of approval, or 

has its approval withdrawn, shall:

    (1) Transfer copies of records and other related information as 

required by SAMHSA to a location, including another accreditation body, 

and according to a schedule approved by SAMHSA; and

    (2) Notify, in a manner and time period approved by SAMHSA, all OTPs 

accredited or seeking accreditation by the body that the body will no 

longer have approval to provide accreditation services.

    (g) Term of approval. An accreditation body's term of approval is 

for a period not to exceed 5 years.



[[Page 59]]



    (h) State accreditation bodies. State governmental entities, 

including political subdivisions thereof, may establish organizational 

units that may act as accreditation bodies, provided such units meet the 

requirements of this section, are approved by SAMHSA under this section, 

and have taken appropriate measures to prevent actual or apparent 

conflicts of interest, including cases in which State or Federal funds 

are used to support opioid treatment services.