Department of Mental Health, Retardation and Hospitals
Division of Behavioral Healthcare
Licensing Rules and Regulations Deeming Protocol

  1. The Department will annually determine which regulations shall be considered for deemed status
    • The determination will be made by the Deeming Committee
    • The determination will be finalized and publicized by the end of the first quarter of the calendar year.
    • A distinction shall be made between those JCAHO, CARF and COA eligible standards that may be considered for deeming.
  2. A letter stating which standards shall be deemed will be sent to the Executive Directors of all the licensed organizations
    • The information will also be posted on the Department's website
  3. The Executive Director of an accredited organization will designate the request for deemed status on the application for licensure.
    • If the organization requests deemed status, the complete accreditation report shall be submitted with the license application
    • Should an accredited organization not opt to request deemed status, an explanation of that decision shall accompany the application for licensure.
    • In order for deemed status to be granted for designated regulations, the organization, depending on its accrediting body, must be in "Conformance," "Full Standards Compliance," or "Full Compliance."
  4. When the accreditation report is received by the Licensing Office it will be forwarded to designated persons in the Division of Behavioral Healthcare.
    • Such persons will review the report, and will make a written recommendation regarding deemed status to the Administrator of the Licensing Office
    • If a decision is made by the Division of Behavioral Healthcare to not grant deemed status, the Licensing Office will notify the organization immediately
    • Departmental decisions regarding deeming are made at the discretion of the Department and are not subject to appeal
    • Decisions regarding deeming may be revoked for cause at any time
  5. Those regulations that have been deemed will not be subject to review during the subsequent biennial licensing survey
  6. The organization's deemed status will be in effect until the next accreditation review by the accrediting body

October 2004