RCPA - Rehabilitation and Community Providers Association


OMHSAS Seeking Comments on Accreditation Concept Paper
April 1, 1999

The Office of Mental Health & Substance Abuse Services (OMHSAS) is asking for comments on their workplan to comply with the Governor's Executive Order to consolidate current program regulations and the licensing process.

The Cross Systems Licensing Project (CSLP) was created to improve the human services licensing system within the Department of Public Welfare (DPW), the Department of Aging (DOA), and the Department of Health (DOH). OMHSAS is beginning the process of implementing the steps necessary to require programs under their administrative authority to obtain accreditation by a nationally recognized accreditation program.

The Office of Mental Health & Substance Abuse Services is looking to work collaboratively with the mental health system stakeholders to understand the accreditation process and the implications for Pennsylvania. With this in mind, members comments are requested about the work plan to PCPA no later than Friday, April 9, 1999.

PCPA will organize a work group to review these comments in detail and assist in compiling the comments received by members. If you feel strongly about a particular issue, feel free to send your comments directly to Carol Ward-Colasante at OMHSAS and please send a copy to PCPA as well.

If you are interested in participating in the work group, or if you have any questions, please contact Rebecca Heidenheim at the Association.


In 1995 the Cross-Systems Licensing Project (CSLP) was created to improve the human services licensing system within the Department of Public Welfare (DPW), the Department of Aging (DOA) and the Department of Health (DOH). The CSLP is a group of licensing and policy professionals from programs within these departments with a mission to address the following concerns: inconsistent application of regulations, duplication and overlap of departmental licensing survey visits, inadequate training of licensors and the rigidity of the inspection process. The CSLP's major initiatives include the development of a new Human Service Licensing Statute, development and implementation of an orientation and training program for new and veteran licensing staff, and revision of existing DPW regulations to eliminate or reduce duplication, inconsistency and program quality items and incorporate state-of-the-art health and safety concepts.
Governor's Executive Order 96-01

Consistent with the goals of the CSLP, Governor's Executive Order (EO) 96-01, effective February 6, 1996, required all departments under the jurisdiction of the Governor's Office to develop a plan and schedule to review all existing regulations. EO 96-01 sets forth regulatory review and promulgation principles stating, among other things, that regulations should address a compelling public interest, that the cost of regulations shall not outweigh their benefits and that regulations should address definable public health, safety or environmental risks

The CSLP Regulatory Framework
In adherence to the requirements of EO-96-01, the CSLP reviewed all DPW licensing regulations to recommend the repeal of inappropriate regulations that go beyond health and safety, to strengthen protections where the need exists, to consolidate regulations where appropriate and to maintain regulations that are needed and consistent with the principles of EO 96-01. The CSLP developed a regulatory framework as a product of this review which outlines the recommendations for all DPW existing regulations. The CSLP's first regulatory initiative under the framework was the revision of Chapter 3800, Child Residential and Day Treatment services.

Chapter 3800 Regulations
The CSLP consolidated several similar DPW child and adolescent residential and day treatment programs into the Chapter 3800 regulations. Child and Adolescent Residential Treatment Facilities (RTF) and Child and Adolescent Community Residential Rehabilitation (CRR), both under OMHSAS' authority, are included in the revised 3800 regulations. The CSLP held a three day workgroup in August 1997 which included statewide child and adolescent residential/day treatment stakeholders, as part of the process in drafting the revised 3800 regulations. During the workgroup process, several stakeholders recommended revisions to the regulations (e.g., inclusion of CASSP principles, inclusion of family members in interagency team meetings, etc.) which were not included because the CSLP defined these elements as program standards and not as health and safety. The CSLP referred concerns of this nature to each program office to address.

OMHSAS Response to CSLP
In response to the CSLP and stakeholder concerns, OMHSAS staff began working on a plan to ensure that program quality standards, as well as health and safety standards, were maintained under the administrative authority of the office. In 1997, through the work of a management intern, interviews were conducted with key office and Department staff as a way to identify the implications of the CSLP and options for addressing program standards and assuring quality. Subsequently, an OMHSAS internal program standards workgroup was formed to further review the issues and recommendations. The workgroup reviewed an issues and options paper developed by the management intern, convened meetings with national accreditation entities, cross-walked OMHSAS regulations with accreditation standards, met with DPW legal staff and developed a workplan with recommendations for each OMHSAS program. The workgroup researched and met with representatives of the following accreditation programs:
  • Joint Commission on Accreditation of Healthcare Organizations (JCAIFIO)
  • The Rehabilitation Accreditation Commission (CARF)
  • Council on Accreditation of Services for Families and Children, INC. (COA)
  • The Council on Quality and Leadership in Supports for People with Disabilities (The Council)

In addition, the workgroup also became aware of and will include the American Osteopathic Association (AOA) in our review as a potential accreditation for osteopathic facilities.

Accreditation Recommendation
Based upon the above work, the program standards workgroup recommended that OMHSAS require national accreditation of all licensed/approved programs. Among the reasons for recommending accreditation are:

1) The behavioral health care and managed care industry support national accreditation.
2) The state would only need to conduct one provider site visit for health and safety.
3) Accreditation standards equal or exceed current OMHSAS regulations.
4) Accreditation standards are updated regularly based upon the national state-of-the-art practice/policy unlike OMHSAS regulations which take years to change.
5) OMHSAS would be able to use licensing staff for monitoring behavioral health care contracts.
6) The move toward accreditation is consistent with national trends. At least 28 states have moved partly or wholly toward accreditation.

OMHSAS Licensing/Program Standards Workplan
The program standards workgroup developed a Licensing/Program Standards Overall Workplan which addresses all OMHSAS programs that are either licensed or approved and are governed by regulations or bulletins. The licensing standards portion of the workplan discusses the recommendation made by the CSLP, if applicable. The program standards portion discusses the OMHSAS accreditation recommendation and identifies the steps needed to implement the recommendation. Additionally, each program is ranked as either a high, medium or low priority. The workgroup prioritized Psychiatric Rehabilitation, Child and Adolescent RTF and CRR and Residential Treatment Facilities for Adults (RTFA) as the first services to address.

In order to move forward with the recommendations in the workplan, the program standards workgroup recommended that OMHSAS develop three separate internal workgroups representing each of the prioritized programs. The program standards workgroup also recommended that a steering committee be developed with key OMHSAS staff to address the broad-based issues related to costs and implementation. The co-chairs of the OMHSAS Program Standards presented this workplan to the OMHSAS Executive Staff Council in August, 1998. Shortly thereafter, the Executive Staff Council endorsed the work plan and recommendation to move toward accreditation.
Next Steps

Each of the three internal workgroups met for the first time in February, 1999. Each workgroup is to decide which of the national accreditation programs will be acceptable for each service. In order to make this decision, each workgroup is to crosswalk existing OMHSAS regulations and bulletins with the national accreditation standards. Each workgroup is to decide whether or not the intent of OMHSAS program standards are satisfactorily addressed by the accreditation standards. Each workgroup will present their recommendation to the steering committee. Once feedback is received by the steering committee, each workgroup will need to develop a strategy and timeframes for implementation, a training plan for providers, counties and others and, in some cases, develop steps involved in drafting/issuing interim program standards. Each workgroup will then be expanded to include representatives from various constituent groups.

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