Arkansas Administrative Code
Agency 007 - Arkansas Department of Health
Division 25 - Bureau of Alcohol and Drug Abuse Prevention
Rule 007.25.95-003 - Licensure Standards Manual for Substance Abuse/Addiction Treatment Programs
Current through Register Vol. 49, No. 9, September, 2024
The Bureau of Alcohol and Drug Abuse Prevention (ADAP) developed this Manual to help clarify the various elements of the Licensure process. This manual is to be used as the measurement tool to determine compliance with the Licensure Standards for Alcohol and Drug Abuse Treatment Programs in Arkansas. As pointed out in these standards, the passage of Act 644 of 1977, by the Arkansas State Legislature, created the Office on Alcohol and Drug Abuse Prevention (ADAP). Furthermore, Act 597 of 1989 delegated the ADAP as the sole agency responsible for accrediting all alcohol and/or other drug treatment programs. Duties and responsibilities included, in part, the development and promulgation of standards, rules and regulations for licensure of alcohol and drug abuse prevention, treatment and rehabilitation programs/facilities within the State. In 1995, Act 173 changed the Accreditation process to a Licensure process.
It was in response to state and federal legislation, as well as to the changing needs of the alcohol and drug abuse treatment programs and the public at large, that the accreditation standards were implemented. The standards were adopted and implemented on January 1, 1983 and a revised manual was put into effect on September 1, 1989. Those standards, remained in effect until the adoption of this Licensure Manual effective July !, 1995.
This Licensure Standards Manual is to be used as a guide to the Licensure process and includes the Procedures for Licensure, the Licensure Standards Questionnaire, and the Supplemental Administrative Questionnaire. The purpose of the licensure review is to determine the extent of compliance with those minimal standards by the program being reviewed.
ABSTRACT
Two documents constitute the Licensure Standards Manual for Substance Abuse Treatment Programs in Arkansas. Those two documents are:
(1) The Licensure Manual; and
(2) Application for Licensure.
The Application for Licensure is completed by the treatment program prior to the on-site visit.
The Licensure Standards Manual consists of three major sections. Those sections are:
(1) Procedures for Licensure;
(2) Licensure Standards Questionnaire; and the
(3) Supplemental Administrative Questionnaire (to be used in reviewing non-medically based private-for-profit programs).
The Procedures for Licensure is used as a guide to the Licensure Process. It explains the process for treatment programs in the State of Arkansas and for the Standards Review Team.
The Licensure Standards Review Questionnaire is used as the measurement tool to determine the program's level of compliance as well as being the document describing the Licensure Standards.
The Supplemental Administrative Questionnaire replaces Part I, Sections A through D of the Standards Review Questionnaire. It is to be used in reviewing programs that are not licensed for Substance Abuse Services by the Arkansas Department of Health, Bureau of Health Resources ( for Hospital based programs), or Accredited for Substance Abuse Services by the Joint Commission for the Accreditation of Health Care Organizations (JCAHO), or Accredited for Substance Abuse Services by the Commission for the Accreditation of Rehabilitation Facilities (CARF). Programs administered by the Department of Defense and/or the Veterans Administration are not required to be licensed by the ADAP, but may voluntarily seek licensure. Programs certified by the Arkansas Department of Human Services, Division of Mental Health Services (DMHS), and providing alcohol and/or other drug abuse treatment services, will be considered licensed provided that the ADAP is involved in the DMHS certification review. The ADAP participation in the DMHS reviews will focus on the substance abuse services provided by the program under review.
The above documents were revised from the Standards in effect January 1, 1983 and September 1, 1989. Beginning on June 30, 1994 the standards were revised and put into this present edition and format. This present edition was promulgated for implementation on July 1, 1995.
PROCEDURES FOR LICENSURE
Licensure of an alcohol or drug abuse treatment program is required of any such organization which is operating or seeking to operate a program in the State of Arkansas. Upon implementation of the standards, the ADAP will provide to each of the programs, known to be operating within Arkansas, a Licensure Standards Manual. In order to provide for an even distribution of the reviews of the programs, the ADAP will contact the Executive Director of each of the programs.
A schedule for the entire licensure process will be developed by mutual cooperation for each program. For those programs certified with the Division of Mental Health Services, the schedule will be developed in cooperation with that Division. The entire licensure process for a program is shown below, with explanatory comments following.
Step 1 - Program notified by ADAP of upcoming Licensure Review and need to complete Application for Licensure.
Step 2 - Receipt by ADAP of program's completed Application for
Licensure and payment of the $250.00 application fee.
Step 3 - Development of the schedule and requirements for the review of the program; and
Step 4 - Review of pertinent information received from the program by the
ADAP. If necessary, review of any additional information requested following the initial review of Step 3.
Step 5 - Written confirmation and notification by the ADAP to include:
(a) timetable developed in Step 1;
(b) members of the Standards Review Team for that program; (see Standards Review Team Member Selection Process);
(c) and costs (e.g., fees) to the program for the Accreditation Survey Process (when applicable).
Step 6 - Submission to the ADAP, by the program, of the $1,500 Licensure
Review fee.
Step 7 - Formal on-site review by the ADAP Standards Review Team.
Step 8 - Report by ADAP Standards Review Team and recommendations to
ADAP Treatment Services Director.
Step 9 - Formal report to the program with the type of license awarded,
findings, and recommendations of the ADAP Standards Review Team.
Step 10 - (When applicable) responses to program's appeal and/or scheduling of Licensure follow-up review.
STANDARDS REVIEW TEAM
The members of the Standards Review Team for each program will consist of members who participate in the formal on-site review. The Standards Review Team will be composed of representatives from:
(# of Voting Members)Organization
2 (a) The ADAP One member will be designated as "team leader."
1 (b) Administrative/Director from another treatment facility (as selected by the ADAP Treatment Services Director).
1 (c) Counselor/Clinician from another treatment facility (as selected by the ADAP Treatment Services Director).
(d) Other representatives as deemed appropriate by the ADAP Treatment Services Director.
The program to be reviewed will be notified prior to the on-site visit as to the composition of its Standards Review Team. I£ for a valid reason, the program objects to a particular team member, a different member can be selected by the ADAP Treatment Services Director.
The minimum requirements for the Administrator/Director from another treatment program are:
(a) A minimum of Two (2) years experience in their current position.
(b) Currently employed by a program accredited by ADAP, with no current serious administrative deficiencies.
(c) Not be a former employee or client of the program to be reviewed.
(d) Not be currently employed by a program that operates in the same ADAP catchment area as the program under review and/or in competition with the program for funding.
The minimum requirements for the Counselor/Clinician from another treatment program are:
(a) Qualification as a Certified Substance Abuse Counselor (CSAC).
(b) Be currently employed in a clinical/counseling capacity with a minimum of two (2) years experience.
(c) Currently employed by a facility accredited by ADAP with no current serious clinical/client care deficiencies.
(d) Not be in violation of counselor ethics or be under investigation for violation of counselor ethics.
(e) Not be a former employee or client of the program under review.
(f) Not be employed by a program that operates in the same ADAP catchment area as the program under review, or be in competition with the program for funding.
OTHER ISSUES REGARDING LICENSURE
ADOLESCENT TREATMENT PROGRAMS
Whenever Alcohol and/or other Drug Abuse Treatment Programs seek licensure under the Department of Human Services - Division of Children and Family Services (DCFS), the ADAP, whenever feasible, will coordinate with DCFS to provide for a DCFS Standards Review Team (SRT) member. If DCFS representation on the Licensure Standards Review is not feasible, then the program seeking licensure under DCFS regulations will submit to those processes mandated by DCFS.
Program Commencing Operations After July 1, 1995
Prior to the actual provision of alcohol and/or drug abuse treatment services, the program seeking licensure, and/or required to receive a licensure review, will complete all steps specified in the application process. If the program seeking licensure has not yet provided treatment services, the standards listed on page NA-1 are non-applicable during the initial review. If the program under review meets the required level of compliance that are applicable, at the time of initial review, the SRT can recommend a six (6) month provisional license. No later than six (6) months after the according of the provisional license, a follow-up review will be performed to determine the program's level of compliance with all applicable standards, including those listed on page NA-1. If the program under review meets the necessary level of compliance, then the SRT can recommend licensure in line with the levels of licensure specified in this manual.
Methadone and LAAM Dispension
Any program in Arkansas that intends to dispense Methadone and/or LAAM must meet the standards set forth in this manual and those standards found in the Methadone/LAAM Maintenance Treatment Program Standards. The licensure review and the Methadone Standards review can be performed at the same time.
Accreditation Under Previous Standards
All programs currently accredited by the ADAP prior to the implementation of the licensure standards will be considered as licensed. The scheduling of a program's licensing review will not change.
ON-SITE REVIEW
The formal on-site review will be made by at least two (2) ADAP staff and representatives of organizations previously specified. Minimally, the ADAP shall triennially, with a six-month extension period, inspect the facilities and review the policies and procedures utilized by each program. The examination and review will include case record audits, program record audits, and interviews with staff and clients (in accordance with confidentiality standards).
The on-site review will be made in order to verify information previously submitted and to allow an opportunity for the on-site members of the Standards Review Team to review the program from that perspective. The length of the on-site review will vary with the size and complexity of the program.
Prior to the exit interview, there will be a meeting of the Standards Review Team members. In this meeting, each member will present his findings on the area(s) assigned him/her. This is to include areas considered as strengths, weaknesses, deficiencies and/or in non-compliance, as well as his/her decision about each item of the Standards as found in the part(s) of the questionnaire assigned to him/her.
Following the presentation of all of the team members and the discussionsof the findings, a composite questionnaire will be completed which will reflect the final decision for each item of the questionnaire. This composite will then be used to determine the type of accreditation recommended by the Standards Review Team, as per majority vote.
EXIT INTERVIEW
After the above meeting, the Standards Review Team will meet (exit interview) with the Executive Director, Program Director, and the President of the Program's Governing Authority.
During this meeting, the team members will present the review findings and the type of licensure to be recommended for the program. The purpose of this meeting will be to discuss and clarify the findings and recommendations with full opportunity for the exchange of additional information in rebuttal of any adverse findings and/or recommendations noted by the team members. Based upon the discussion and clarification in the above meeting, the Standards Review Team will determine if changes are necessary in their findings and/or recommendations and to make those changes as indicated.
After the Executive Exit Interview, an exit interview will be held with the Executive Director, Governing Authority and appropriate staff for the purpose of summarizing the Licensure Standards process, findings of the Review, and to make appropriate recommendations for correction of non-compliant standards and/or to make recommendations for program improvements. It should be noted that 25% of the Governing Authority and/or the Governing Authority's entire Executive Committee must be present during this exit interview.
In addition to the Licensure Review, the ADAP will, at least annually, perform a client record (case) review, a billing-to-services review (for ADAP funded Programs) and a Title XX Review (for those Programs receiving Title XX Substance Abuse Treatment funds). The ADAP shall also conduct at least one unannounced review annually. The unannounced review will focus on those areas in which the licensed program has had difficulty maintaining compliance with the standards and/or to review complaints filed against the program. Programs licensed to dispense Methadone and/or LAAM will receive an unannounced review at least quarterly. The primary purpose of the unannounced reviews at the Methadone/LAAM programs is to determine the program's ongoing compliance with Methadone/LAAM specific standards. In addition, the ADAP will periodically contact the clients of Methadone/LAAM programs to aid in the determination of compliance with Methadone/LAAM specific standards.
The ADAP reserves the right to revoke the license of any program found to not be in compliance with the standards. The ADAP also reserves the right to conduct a full, licensure review prior to the expiration of the program's current license.
LICENSURE REPORT
Following the on-site review, each team member will submit to the team leader a formal written report within fifteen (15) working days after the last day of the on-site review. This report should follow the outline below:
(1) Program reviewed;
(2) Date(s) on-site review;
(3) Name of team member and organization represented;
(4) Area(s) reviewed by team member;
(5) Findings to include areas considered as strengths, weaknesses, deficiencies, and/or in non-compliance, recommendations for improvement; and
(6) Recommendation for type of licensure to be awarded program based upon the questionnaire completed by team member and which'is to be attached to the written report.
Within thirty (30) working days of the last day of the on-site review, a formal written report will be written by the team leader and forwarded with the licensure notice and the composite completed questionnaire to the program.
This time frame should be maintained even if all materials from the team members have not been received. In that event, the team leader will write the formal report based upon materials available.
Based upon these reports and recommendations, the ADAP Director of Treatment Services shall award the program the appropriate type of licensure.
TYPES OF LICENSE
THREE-YEAR LICENSE
Three-year License will be awarded when a program has complied with all applicable mandatory standards and at least 80% of all other standards.
ONE-YEAR LICENSE
One-year License will be awarded when a program has complied with all applicable mandatory standards and 70%-79% of all other applicable standards.
SIX MONTH (Provisional) LICENSE
A Six Month License can be accorded to currently accredited or licensed programs that do not meet the criteria necessary for a one or three year license. The six month period is provided to allow the program time to make efforts to bring those failed standards into compliance that would allow a one or three year license. A follow up review will be performed at the end of the six month period and if the program fails to" meet the level of compliance that would allow a one or three year license, then the program will not be allowed to operate as a substance abuse/addiction treatment program. The program can request that the follow up review be performed prior to the end of the six month period.
A six month license can also be accorded to a program as specified under "Programs Commencing Operations after July 1, 1995" previously addressed in this manual.
NON-LICENSED
Programs receiving a non-licensed status will not be eligible for funding through ADAP or through funding sources which requires licensure by ADAP. Also, programs that receive a non-licensed status will not be allowed to operate as an alcohol and/or other drug abuse treatment facility in the State of Arkansas.
APPEAL PROCESS
If, for any reason, a program does not agree with the licensure decision, the program may appeal as follows: Written notification must be received by the Chairperson of the ADAP Authority, Freeway Medical Center, Suite 907, 5800 West 10th Street, Little Rock, Arkansas 72204, postmarked within twenty (20) working days after the formal decision of the Director of Treatment Services has been mailed to the program. The Chairperson of the ADAP Authority will then include this appeal on the agenda for the next regularly scheduled meeting of said Authority. Representatives of the program will meet with that Authority to discuss the points in question. The ADAP Authority will notify the ADAP in writing of their decision within fifteen (15) working days of that meeting. The ADAP Director shall notify the program of the Authority's final decision within ten (10) working days.
NON-APPLICABLE STANDARDS FOR INITIAL REVIEW FOR PROVISIONAL LICENSURE
I-A-5-b
I-B-a
I - C-l-c
I - C-2
I - C-3
I - C-5-a thru c
I - C-6-a thru d I-D-3 I-D-9
I_D-14-bthrud IE - A-3-a thru m n - a-4
H - A-5 H-A-6
n-B-i n-B-2 n-B-3
II - B-4-a thru e H - B-5-a thru d n-B-6 n-c-i n-c-2 n-c-3 n-c-4 n-c-5 n-c-7
n-D-l-athruj n - d-2 n - d-3 n-D-4
II - D-5-a thru d n-D-6 n - d-7 n - d-8
II-E-l-a thrum
E-E-6
H-F-4
E - G-2-a thru e
H - M-l-b n - M-2-a thru c
LICENSURE STANDARDS QUESTIONNAIRE PART I (MANAGEMENT AND ADMINISTRATION COMPONENT)
SUPPLEMENTAL ADMINISTRATIVE QUESTIONNAIRE
STANDARDS FOR PRIVATE-FOR-PROFIT (NON-MEDICAL MODEL PROGRAMS)
DEFINITIONS
(Relative to ADAP Licensure Standards)
Admission The point in an alcohol or drug abuser's relationship with the program at which the intake process has been completed and the individual is entitled to receive services.
Affiliation Agreement A written agreement between the governing authority of the program and another organization under the terms of which specified services, space and/or personnel are provided to one organization by the other, but without exchange of moneys.
Aftercare The component of the treatment program which assures the provision of continued contact with the client following the termination of services from a primary care modality, designed to support and to increase the gains made to date in the treatment process. Aftercare plan development should start prior to discharge but is not implemented until discharge.
Alcohol and/or Drug Abuser/Addict An abuser is a person who voluntarily uses alcohol or other drugs in such a way that his or her social or economic functioning is disrupted. An addict is a person who is physically and/or psychologically dependent on alcohol and/or other drugs and has little or no control over the amounts consumed, leading to substantial health endangerment, and/or social functioning disruption and/or economic functioning disruption.
Applicant Any individual who has applied for admission to a program but is not yet admitted to the program.
Assessment The process of collecting significant data to enable evaluation of an individual's strengths, weaknesses, problems and needs so that a treatment plan can be developed.
Certified Substance Abuse Counselor An individual recognized by the Arkansas
Substance Abuse Certification Board as being a Certified Substance Abuse Counselor.
Client An individual who has an alcohol or drug abuse problem, for whom intake procedures have been completed, and who is admitted to the program.
Counselor An individual who, by virtue of education, training or experience, provides treatment, which includes advise, opinion, or instruction to an individual or in a group setting to allow opportunity for a person to explore his or her problems related directly or indirectly to alcohol and/or drug abuse or dependence.
Day-Treatment The process of providing treatment services in a partial (less than twenty-four hours) residential setting and consisting of at least four and one-half (4 1/2) hours of structured treatment daily.
Detoxification The withdrawal of a person from a physiologically addicting substance.
Documentation Provision of written, dated and authenticated evidence (signed by person's name and title) to substantiate compliance with standards, e.g., minutes of meetings, memoranda, schedules, notices, announcements.
Emergency Admission An admission that does not meet the intake process due to the extreme nature of the circumstances involved.
Emergency Care A network of services that provides all persons having acute problems related to alcohol and/or drug use and abuse readily available diagnosis and care, as well as appropriate referral for continuing care after emergency treatment.
Executive Director The individual appointed by the governing authority to set in its
(his/her) behalf in the overall management of the alcohol or drug abuse treatment program.
Fiscal Management System Procedures that provide management control of the financial aspects of program operations. Such procedures include cost accounting, program budgeting, materials purchasing, and client billing standards.
Follow-Up The process of determining the status of an individual at a determined point in time past discharge.
Governing Authority That person or persons with the ultimate authority and responsibility for the overall operation of the program.
Inpatient Care The process of providing care to persons who require twenty-four hour supervision in a hospital or other suitably equipped medical setting as a result of acute or chronic medical and/or psychiatric illness associated with alcohol and/or drug abuse.
Intake The process of collecting and assessing information to determine the appropriateness of admitting or retaining an individual in an alcohol or drug abuse treatment program.
May Term in the interpretation of a standard to reflect an acceptable method that is recognized but not necessarily preferred.
Outpatient Program A non live-in program offering treatment or rehabilitation services to alcohol or drug abusers on a scheduled or non-scheduled basis.
Primary Care Modality All components of the treatment program, excluding aftercare.
Program An individual, partnership, corporation, association, government subdivision or public or private organization.
Program Component A category into which a specific group of interrelated services can be classified, e.g., outpatient care.
Progress Note That portion of the client's case which describes the progress of the client and his (her) current status in meeting the goals set in the treatment plan, as well as describing the efforts of staff members to help the client achieve those stated goals. Progress notes also include documentation of those events and activities related to the client's treatment.
Outreach. Public Education and Information The dissemination of relevant information specifically aimed at increasing the awareness, receptivity, and sensitivity of the community and stimulating social action to increase the services provided for people with problems associated with the use of alcohol and/or drugs. It also includes the process of reaching into a community systematically for the purpose of identifying persons in need of services, alerting individuals and their families as to the availability of services, locating additional services, and enhancing the entry into the service delivery system.
Referral Agreement A written document defining a relationship between the program and an outside resource for the provision of client services not available within the alcohol or drug abuse treatment program.
Rehabilitation The restoration of a client to the fullest physical, mental, social,
vocational and economic usefulness of which he or she is capable. Rehabilitation may include, but is not limited to, medical treatment, psychological therapy, occupational training, job counseling, social and domestic rehabilitation and education.
Residential Program A twenty-four hour, non-medical, live-in facility offering treatment and rehabilitation services to facilitate the alcohol or drug abuser's ability to live and work in the community.
Shall Term used to indicate a mandatory statement, the only acceptable method under the present standards.
Should Term used in the interpretation of a standard to reflect the commonly accepted method, yet allowing for the use of effective alternatives.
Staff Any individual who provides services to the program on a regular basis as a paid employee or as a volunteer.
Standards Specifications representing the minimal characteristics of an alcohol or drug abuse treatment program which are acceptable for the accreditation of a program.
Substance Abuse Treatment A process whereby services are provided to an individual with the intent of the cessation of harmful or addictive use of alcohol and/or other drugs. Treatment must include, but should not be limited to, counseling. Treatment promotes the ultimate goal of the individual reaching their fullest physical, mental, social, vocational and economic capabilities possible.
Treatment Plan A written plan developed after assessment, which specifies the goals, activities and services appropriate to meet the objective needs of the client.
Treatment Program Any program that delivers alcohol and/or drug abuse services to a defined client population.
Treatment Staff That group of personnel of the alcohol or drug abuse treatment program which is directly involved in client care or treatment.
Update A dated and signed review of a report, plan or program with or without revision.
Working Agreement A written contract, letter of document, or other document that defines the relationship between a program and an outside resource.
ARKANSAS DEPARTMENT OF HEALTH
BUREAU OF
ALCOHOL AND DRUG ABUSE PREVENTION
APPLICATION FOR LICENSURE
FOR
ALCOHOL AND / OR DRUG ABUSE TREATMENT PROGRAMS
July 1, 1995
ABSTRACT
Two documents constitute the Licensure Standards Manual for Alcohol and Other Drug Abuse Treatment Programs in Arkansas,
Those two documents are:
(1) The Licensure Manual; and
(2) Application for Licensure.
The Application for Licensu're is completed by the treatment program prior to the on-site visit.
The Licensure Standards Manual is comprised of three major sections.
Those sections are:
(1) Procedures for Licensure;
(2) Licensure Standards Questionnaire; and the
(3) Supplemental Administrative Questionnaire (to be used in reviewing non-medically based private-for-profit programs).
The Procedures for Licensure is used as a guide to the Licensure Process. It explains the process for treatment programs in the State of Arkansas and for the Standards Review Team.
The Standards Review Questionnaire is used as the measurement tool to determine the program's level of compliance as well as being the document describing the Standards. The Supplemental Administrative Questionnaire replaces Sections A through D of the Standards Review Questionnaire. It is to be used in reviewing programs that are not licensed by the Arkansas Department of Health, Bureau of Health Resources or certified by the Division of Mental Health Services, or accredited by the Joint Commission on the Accreditation Healthcare Organizations, or Accredited by the Commission for the Accreditation for Rehabilitation Facilities or the Department of Defense or Veterans Administration, and does not hold an IRS non-profit status.
The above documents were revised from the Standards in effect since January 1, 1983 and again revised on September 1, 1989. Beginning in January 1994 the standards were revised and put into this present edition and format. This present edition was promulgated for implementation on July 1, 1995.
Bureau of Alcohol and Drug Abuse Prevention
Division of Treatment Services
Freeway Medical Center, Suite 907
5800 West 10th Street
Little Rock, Arkansas 72204
(501) 280-4500
