To obtain and maintain certification to provide domestic violence intervention treatment services, including certification to provide assessments or any level of care, each program is subject to an on-site review to determine if the program is in compliance with the minimum certification standards of this chapter.

(1) For a standard review, a department representative(s) conducts an entrance meeting with the program and an on-site review that may include a review of:

(a) Program policies and procedures;

(b) Direct service staff personnel records;

(c) Participant and victim records;

(d) Written documentation of the program's treatment program;

(e) Attendance sheets and other forms related to the provision of domestic violence intervention treatment services;

(f) The facility where services are delivered and where records are kept;

(g) The program's quality management plan; and

(h) Any other information that the department determines to be necessary to confirm compliance with the minimum standards of this chapter, including but not limited to interviews with:

(i) Individuals served by the program; and

(ii) The program's direct treatment staff members.

(2) The department representative(s) concludes an on-site review, which may or may not happen in the same visit, with an exit meeting that includes, if available and applicable:

(a) A discussion of findings;

(b) A statement of deficiencies requiring corrective action; and

(c) A compliance report signed by the program's designated official and the department representative.

(3) The department requires the program to correct the deficiencies listed on the plan of correction:

(a) By the negotiated time frame agreed upon by the program and the department representative; or

(b) Immediately if the department determines participant or victim health and safety concerns require immediate corrective action.

(4) If the program fails to make satisfactory corrective actions by the negotiated deadline in the compliance report, the department may:

(a) Begin to take progressive action against the program's certification; or

(b) Initiate an investigation of the program.

(5) The department may schedule a follow-up review after a standard review or investigation to ensure all corrective actions have been successfully implemented.