Current through Register Vol. 49, No. 9, September, 2024
Attachment for Item 12
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Arkansas Department Of Health Bureau Of Alcohol And
Drug Abuse Prevention
LICENSURE STANDARDS MANUAL
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 in September 1, 1989. The manual was again revised and
implemented on July 1, 1995 and again on July 1, 1996 as a licensure manual.
The standards specified in this manual are effective July 1, 1997.
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 four 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).
(4) Application for licensure
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 (CARP).
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.
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, die
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. 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 $75.00 application fee.
Step 3 Development of the schedule and requirements for the
review of the program;
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 licensure survey process (when applicable).
Step 6 Submission to the ADAP, by the program, of the $1,500
Licensure Review fee for first time applicants.
Step 7 Formal on-site review by the ADAP Standards Review
Team.
Step 8 Report by ADAP Standards Review Team and recommendations
to ADAP Office of Program Compliance.
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 a Licensure follow-up review.
STANDARDS REVIEW TEAM
The members of the Standards Review Team (SRT) 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
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2
|
(a) The ADAP. One member will be designated as "team
leader."
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1
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(b) Administrative/Director from another treatment
facility (as selected by the ADAP Office of Program Compliance
Director).
|
|
1
|
(c) Counselor/Clinician from another treatment facility
(as selected by the ADAP Office of Program Compliance Director.
|
|
|
(d) Other representatives as deemed appropriate by the
ADAP Office of Program Compliance.
|
The program to be reviewed will be notified prior to the
on-site visit as to the composition of its Standards Review Team. If, for a
valid reason, the program objects to a particular team member, a different
member can be selected by the ADAP Office of Program Compliance.
The minia: m requirements for the Administrator/Director/SRT
Member from another treatment program are:
(a) A minimum of Two (2) years experience in
their current position.
(b)
Currently employed by a program licensed by the 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/SRT Member
from another treatment program are:
(a)
Qualification as a Certified Alcohol and Drug Abuse Counselor (CADC).
(b) Be currently employed in a
clinical/counseling capacity with a minimum of two (2) years
experience.
(c) Currently employed
by a facility licensed 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.
s
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.
1997
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 as determined
by ADAP staff, that is applicable at the time of initial review, then ADAP can
issue a six (6) month provisional license. No later than six (6) months after
the according of the provisional license, a follow up review, with a full SRT,
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
Dispersion
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 Treating,.
Program Standards. The licensure review and the Methadone
Standards review can be performed at the same time.
Licensure Under Previous
Standards
All programs currently licensed 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 ADAP
staff and representatives of organizations previously specified. Minimally, the
ADAP shall triennial, 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,
interviews with staff and clients (in accordance with confidentiality
standards) and interviews with various community agencies/individuals.
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
discussions of 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 licensure 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, and conduct pernio reviews to
determine a program's ongoing compliance with the standards. 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 die 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:
(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 Office
of Program Compliance Director 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. A three year license will not be accorded to a
program that receives a provisional license, even if the follow up review
determines that all applicable mandatory standards and at least 80% of the
applicable non-mandatory standards are in compliance.
One-Year License - A one year license can be accorded
to a program that previously held a provisional license if all applicable
mandatory standards and at least 80% of all applicable mandatory standards are
in compliance. Any program that must have a follow-up licensure review
performed, even if the review determines that all applicable and at least 80%
of the applicable mandatory standard are in compliance, shall receive no
greater than a one year license.
Six Month (Provisional) License - A Six Month
license can be accorded to currently licensed programs that do not meet the
criteria necessary for a three year or one 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 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 year
license, then the program will not be allowed to operate as a substance
abuse/addition 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, 1997" as
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 require 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 Treatment and Prevention Committee of the
Alcohol and Drug Abuse Coordinating Council, Freeway Medical Center, Suite 907,
5800 West 10th Street, little Rock, AR 72204, postmarked within twenty (20)
working days after the formal decision of the Director of The Office of Program
Compliance has been mailed to the program. The Chairperson of the committee
will then include this appeal on the agenda for the next regularly scheduled
meeting of said Committee. Representatives of the program will meet with that
Committee to discuss the points in question. The representatives will notify
the ADAP in writing of their decision within fifteen (15) working days of that
meeting. The Director of the Office of Program Compliance shall notify the
program of the Committee's final decision within ten (10) working days.
NON APPLICABLE STANDARDS FOR INITIAL REVIEW FOR
PROVISIONAL LICENSURE
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A-5-B
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B-7
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C-l-c
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C-2
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|
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C-3
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|
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C-5-a thru-c
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C-6-a thru -d
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D-3
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D-9
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D-14-b thru -d
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n
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A-3-a thru n
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n
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A-4
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n
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A-5
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ii
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A-6
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n
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B-l
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n
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B-2
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n
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B-3
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n
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B-4-a thru e
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n
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B-5-a thru d
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n
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B-6
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n
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C-l
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n
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C-2
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u
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C-3
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ii
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C-4
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h
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C-5
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ii
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C-7
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ii
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D-l-a thru j
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n
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D-2
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n
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D-3
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n
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D-4
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n
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D-5-a thru d
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n
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D-6
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ii
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D-7
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ii
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D-8
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ii
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3-1-a thru n
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ii
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E-6
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n
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F-4
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n
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G-2-a thru e
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n
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H-8
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n
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N-l-b
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n
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N-2-a thru c
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LICENSURE STANDARDS QUESTIONNAIRE
PART I
(Management And Administration Component)
Instructions:
Circle Your
Level Of Compliance
C - Compliance N - Non-Compliance N/A - Non-Applicable
* Asterisks denote mandatory
standards
A.
Governing Authority1. There is a
governing authority which has the ultimate authority for the overall operation
of the program and which is one of the following:
a. a public organization (C N N/A)*;
or
b. a private, non-profit
organization. (As verified by Articles of Incorporation submitted to the
Arkansas Secretary of State). (C N N/A)*
2. Written documentation includes the means
by which the governing authority provides for:
a. the election or appointment of its
officers and members; (C N N/A)*
b.
the orientation of new board members and any subsequent board training; (C N
N/A)*
c. the appointment of
committees necessary to effect the discharge of its responsibilities, (C N
N/A)*
d. the scheduling of
meetings, (C N N/A)*
e.
determination of quorum requirements;(C N N/A)*
f. keeping minutes of all meetings. (As
verified in corporation by-laws). (C N N/A)*
3. The minutes of the meetings of the
governing authority include at least:
a.
date(s)ofthemeeting(s); (C N N/A)*
b. names of the members attending; (C N
N/A)*
c. topics discussed; (C N
N/A)*
d. decisions reached and
actions taken; (C N N/A)*
e. target
dates for implementation and recommendations; (C N N/A)*
f. executive director's or other program
reports. (C N N/A)*
4.
The governing authority, for the alcohol or drug program:
a. delegates a chief executive officer who is
not a member of the governing authority, (C N N/A)*
b. delegates authority and responsibility to
the chief executive for the management of the program in accordance with
established policy. (As verified in the by-laws). (C N N/A)*
5. The governing authority has:
a. authorized compilation and distribution of
a policy and procedures manual that describes the regulations, principles, and
guidelines that determine the alcohol and/or other drug program's operations;
(C N N/A)*
b. reviewed and updated
this policy manual as needed but at least annually; (As verified in Board
minutes).(C N N/A)*
c. made
available this policy manual to all alcohol or drug program staff (As verified
by signed receipt or route slip); (C N N/A)*
d. made available this policy manual to the
public upon request; (C N N/A)*
e.
made every effort to maintain policies that are in compliance with local, state
and federal laws and regulations and documented that these efforts have been
done. (C N N/A)*
6.
During the exit interview process, as described in the Licensure Procedures, at
least 25% of the program's governing authority and/or its full executive
committee are present. (C N N/A)*
B.
Program Planning/Evaluation
Programs that have currently successfully completed an ADAP RPP
or Progress Report meet the criteria set forth in items Bl, B2 and B3.
1. The program has conducted, or has
available to it, a needs assessment for the population to be served. (C N
N/A)
2. Based upon the needs
assessment, an Annual Program Plan is developed which includes:
a. a written statement of the program's goals
and objectives; (C N N/A)
b. a
written plan for implementation of these goals and objectives; (C N
N/A)
3. The alcohol or
drug abuse treatment program has developed a written evaluation plan based on
the goals and objectives of the program: (C N N/A)
The evaluation plan does include operational definitions of
criteria to be applied in determination of achievements of established goals,
objectives and mechanism for:
4. The periodic assessing of the progress
toward the attainment of the program's goals and objectives: (C N
N/A)
5. documentation of program
achievements not related to original goals and objectives: (C N N/A)
6. assessing the effective utilization of
staff and program resources toward the attainment of the program's goals and
objectives: (C N N/A)
7. The
evaluation plan is reviewed and updated at least annually. (As verified in
Board minutes): (C N N/A)
There is documentation verifying:
8. The implementation of the evaluation plan:
(C N N/A)
9. That the results of
the evaluation process become part of the ongoing planning process: (C N
N/A)
10. That the results of the
evaluation process are made available to all personnel: (C N N/A)
C.
FiscaJ Management
1. There is a written budgetary plan:
a. which includes a statement of expected
financial resources and expenditures for the program during the current fiscal
year: (C N N/A)*
b. for obtaining
future financial resources including a system to secure additional treatment
funding sources such as insurance, employee assistance programs, or client self
pay: (C N N/A)*
c. which is
reviewed and approved at least annually by the governing authority; (C N
N/A)*
d. the budget is reviewed and
approved by the governing authority prior to the beginning of its fiscal year:
(C N N/A)*
2. Any
revisions of the written, program-oriented budget during the fiscal year of
operation are reviewed and approved by the governing authority: (C N
N/A)*
3. Any rebudgeting of funds
during the fiscal year is in accordance with changing program needs, and the
rationale for the change and the change is documented: (C N N/A)*
4. The program maintains a current written
schedule of rate and charge policies which:
a.
has been approved by the governing authority (C N N/A)
b. is immediately accessible to all concerned
program personnel and individuals served by the program: (C N N/A)*
5. The fiscal management system
maintains a reporting mechanism which:
a. is
prepared and submitted to the governing authority at least quarterly; (C N
N/A)*
b. is responsive to the
reporting requirements established by the ADAP; (C N N/A)*
c. includes a series of financial reports
including at least, a Variance Report and balance sheet, published at least
quarterly, which specifies the amount budgeted, the amount spent, and the
explanation of any variances; (C N N/A)*
6. The fiscal management system has an annual
audit of financial operations which:
a. is
performed by an independent certified public accountant; (C N N/A)*
b. provides a Financial Statement based on
the results of that audit; (C N N/A)*
c. is reviewed and approved by the governing
authority; (C N N/A)*
d. the annual
independent audit is completed and available to the program within 120 days of
the end of the audit period. (C N N/AJ
7. The program has liability insurance that
provides for the protection of the physical and financial resources of the
program, coverage of the building and equipment, and coverage of its clients,
staff and general public. If part of a governmental agency, in lieu of
liability insurance, the program has other appropriate means of protection for
the items specified above.
(C N N/A)
D.
Employment and Personnel
Practices1. The program has written
personnel policies and practices which:
a.
includes an Equal Employment Opportunity (EEO) Affirmative Action
Plan; (C N N/A)*
b.
applies to both clients and individuals employed by the program and
those working under the supervision of individuals employed by the program; (C
N N/A)*
c.
includes a Statement of Compliance with Title VI/ Title VII of the 1964 CivU
Rights Law and a description of the policy and procedures used to follow the
guidelines of the Equal Employment
Opportunities Commission (EEOC) currently in force: (C
N N/A)*
d.
a Statement of Compliance with Title WTitle VII of the 1964 Civil
Rights Law and a description of the program's policies and procedures used to
demonstrate compliance with the guidelines of the Equal Employment
Opportunities commission (EEOC) must he prominently displayed within the
program an copies be made available upon request(C N WA)*
e.
includes an employee grievance
procedure which is reviewed, updated and approved annually by the Board of
Directors. (C N N/A)*
2. The program maintains written job
descriptions for all staff, including volunteers, that include at least:
a. qualifications; (C N N/A)*
b. reporting supervisor; (C N N/A)*
c. positions supervised(C N N/A)*
d. duties and responsibilities. (C N N/A)*
The program has documentation that:
3. Each job description is
reviewed and updated as needed for continuing appropriateness; (C N
N/A)*
4. All personnel meet all of
the local, state, or federal legal requirements for their positions (e.g.,
licensing, certification); (C N N/A)*
5. A policy has been developed which
addresses alcohol and other drug use by program staff. (C N N/A)*
6. The written personnel policies and
practices include a mechanism for evaluation of personnel performance on at
least an annual basis; (C N N/A)*
7. The mechanism for evaluation of personnel
performance does require a written report and requires documentation that the
evaluation is reviewed with the employee. (C N N/A)*
8. The written personnel policies and
practices does include a mechanism consistent with due process for suspension
and dismissal of an employee for cause. (C N N/A)*
9. There is documentation that any wages paid
to clients engaged in vocational training or work within the program are in
accordance with local, state, and/or federal requirements. (C N N/A)*
10. There is a personnel record kept on each
employee containing at least:
a. job
description; (C N N/A)*
b.
application and/or resume; (C N N/A)*
c. license/certification, where applicable;
(C N N/A)*
d. annual employee
evaluation; (C N N/A)*
e.
verification of academic records (when required by job descriptions); (C N
N/A)*
f. verification of references
or rationale as to why verification was not performed. (C N N/A)*
11. Employee records are stored in
a secure and confidential place. (C N N/A)*
12. An employee or his authorized
representative shall be allowed to inspect, under supervision, his permanent
record upon request, except for information collected in confidence either
before January 1, 1975, or by the specific waiver of the employee.
(C N N/A)*
13. An employee assistance program has been
developed and implemented for program staff. (C N N/A)
14. The program has established an
appropriate staff development plan for all members of the treatment staff*
which:
a. includes an orientation program for
each staff person; which includes a documented review of the Agency's policies
and procedures; (C N N/A)
b.
includes a training program based upon the identified needs of the persons and
the designated staff development representative (needs are identified and
documented annually); (C N N/A)
c.
there is documentation of the staff person's involvement in the plan; (C N
N/A)
d. documents staff development
opportunities made available and staff participation in them;
(C N N/A)
E.
Physical Plant
1. The physical facilities of the program:
a. is structurally sound and the program has
current valid certifications of applicable building, fire, safety and health
inspections of its facilities; (C N N/A)*
b. provides sufficient privacy to maintain
confidentiality of the communication between counselor and client:
(C N N/A)*
2. If the program uses space provided by
another organization, there is a written agreement specifying the terms of such
usage.
(C N N/A)
3. The program has a written internal
disaster plan, including evacuation plan, which includes the training of staff
in disaster and evacuation procedures and the documented rehearsal of the plan
at least quarterly. (C N N/A)
4.
Firearms, or other dangerous weapons, shall not be allowed within the
physical plant of the program. Persons with a "Concealed Handgun License" shall
not be allowed to bring a firearm into the Program's physical plant. However,
law enforcement or security personnel, in performance of their duties, may
carry firearms within the Program's physical plant. (C N N/A)*
PART
II
(Program Services)
Standards Applicable to All
Programs/Services
A.
Intake and Assessment
1. There are
clearly stated written criteria for determining the eligibility of individuals
for admission. (C N N/A)*
2. The
program has written policies and procedures governing a uniform intake process
that defines:
a. the types of information to
be gathered on all clients prior to admission; (C N N/A)*
b. procedures to be followed when accepting
referrals from outside agencies or organizations;
(C N N/A)*
c. procedures to follow when referring
individuals to services other than at the program; (C N N/A)*
d. the types of records to be kept on all
clients.
(C N N/A)*
3. The following information is collected and
recorded on standardized formats developed by the program on all clients and is
part of the client's case record;
(Note: Intake standards
designated with (AE) are not required if an ASI is administered and
properly completed).a.
identifying information which includes name, address, telephone number,
and guardianship of client (for minors), social security number, and
confirmation of identity. (C N N/A)*
b. demographic information which includes
date of birth, sex, race or ethnic origin; (C N N/A)*
(AE)
c. name,
address and phone number of referral source; any conditions or stipulations of
the referral; or information needs of the referral source
(C N N/A)*
d. presenting problems; (C N N/A)*
e. alcohol and/or other drug abuse history;
(C N N/A)* (AE)
f.
family history; (C N N/A)* (AE)
g. educational status and history; (C N N/\)*
(AE) h. vocation/employment status and history;
(C N N/A)* (AE) i. legal history; (C N N/A)*
(AE) j. medical and health history; (C N N/A)* k.
psychological/psychiatric treatment history;
(C N N/A)* (AE) 1. any other relevant
information which will assist in
formulating an initial assessment of the client.
(C N N/A)* m. a financial evaluation to include insurance
coverage.
(C N N/A)*
4. Each new admission, readmission or
transfer admission is interviewed and the interview is documented. (C N
N/A)*
5. When a client refused to
divulge information and/or follow the recommended course of treatment, this
refusal is noted in the case record. (C N N/A)*
6. During the intake process, documentation
is made that an effort has been made to have the client understand policies and
procedures, services available, costs, clients rights, and program rules. (C N
N/A)*
7. There are written policies
and procedures for emergency admissions. (C N N/A)*
B.
Treatment Plans
1. Based upon the initial assessment, an
individualized written treatment plan is reviewed and approved by one of the
following: a Physician, Psychologist,
Certified Alcohol and Drug Abuse
Counselor (as recognized by the Arkansas Substance Abuse Certification Board or
as recognized by the ICRC).
(C N N/A)*
2. An initial treatment plan must be
developed upon intake, and delineates the client's immediate needs and actions
required to meet those needs. (C N N/A)*
3. A comprehensive treatment plan must be
developed no later than seven days after the admission date for residential
programs and twenty-one days for outpatient programs. (C N N/A)*
4. The individualized treatment plan
minimally contains:
a. a clear and concise
statement of the client's current strengths and needs; (C N N/A)*
b. a clear and concise statement of the goals
the client is attempting to achieve; (C N N/A)*
c. type and expected frequency of therapeutic
activities in which the client is participating; (C N N/A)*
d. the staff person(s) responsible for the
client's treatment. (C N N/A)*
5. Comprehensive Treatment Plans are:
a. Developed in partnership with the client;
(C N N/A)*
b.
Reviewed
and/or modified no later than every seven (7) days from the onset of the
comprehensive plan in the residential environment; (C N
N/A)*
c.
Reviewed
an/or modified no later than every thirty (30) days from the onset of the
comprehensive plan in the outpatient and other modalities (except aftercare);
(C N N/A)*
d. Unless
medically contraindicated, detoxification based treatment plans must be
reviewed no later than every seven (7) days. (C N N/A)*
6. The use of abstract terms, technical
jargon, and slang are avoided in the treatment plan; the treatment plan is
written in a manner readily understandable to the average client; and the
program provides the client with a copy of fie initial treatment plan and all
subsequent revisions upon request by the client. (C N N/A)*
7. The program has established policies and
procedures for the treatment planning process (C N N/A)*
C.
Progress Notes
1. A client's progress and current status in
meeting the goals set in the treatment plan, as well as efforts by staff
members to help the client achieve these stated goals, is recorded in the
client's case record following each therapeutic session, or as indicated in the
treatment plan. (C N N/A)*
2. All
progress notes are: dated and signed, including staff title. (C N
N/A)*
3. Progress Notes in the
client's case records are a description of the actual behavioral observation.
(C N N/A)
4 The use of abstract
terms, technical jargon, or slang are avoided in progress notes. (C N N/A)
5. On client's receiving services
from an outside resource, the program attempts to secure a written copy of
status reports and other needed client records from that resource. (C N
N/A)
6. The program has developed a
uniform progress note format that all treatment staff uses. (C N N/A)
7. Outpatient Progress Notes must include the
length of time involved in the treatment session. (C N N/A)*
D.
Confidentiality and
Client Rights1. A client's written
authorization does appear on a consent form which contains, when completed:
a. the name of the program which is to make
the disclosure; (C N N/A)*
b. the
name or title of the person or organization to which disclosure is to be made;
(C N N/A)*
c. the name of the
client; (C N N/A)*
d. the purpose
or need for the disclosure; (C N N/A)*
e. the extent or nature of information to be
disclosed; (C N N/A)*
f. The date
or condition on which the consent will expire; (C N N/A)*
g.
A statement, when applicable, as
to the client's
right to revoke the consent(not retroactively) or, for
those clients mandated into treatment by the criminal justice system, a
statement that the consent cannot be revoked by the client; (C N
N/A)
h. the date
on which the consent is signed; (C N N/A)
i. the signature of the client; (C N
N/A)*
j. parental and/or witness
signature, when appropriate. (C N N/A)*
2. When appropriate, a written notice of
prohibition on redisclosure accompanies or follows a disclosure with consent in
accordance with the above standards and federal regulations (42 CFR Part 2). (C
N N/A)*
3. A summary of the Federal
Confidentiality Law is provided to the client at the time of admission or to
the applicant at the time of assessment. (C N N/A)*
4. Every authorization for release of
information becomes part of the client's permanent case record. (C N
N/A)*
5. There is reason to believe
that the following conditions have been met in obtaining a client's written
consent for release of information: (C N N/A)*
a. the client is informed, in a manner that
assures his or her understanding of the specific type of information that has
been requested, as well as the benefits and disadvantages of releasing the
information, if know; (C N N/A)*
b.
the client is informed of the purpose or need for the information; (C N
N/A)*
c. treatment services are not
contingent upon the client's decision concerning authorization for the release
of information; (C N N/A)*
d. the
client gives his or her consent freely and voluntarily; (C N N/A)*
5. There is reason to believe that
all policies related to confidentiality are being applied even after an
applicant or client has terminated active involvement with the program.
(C N N/A)*
6. In a life-threatening situation, or where
an individual's condition or situation precludes the possibility of obtaining
written consent, the program does allow for the release of pertinent medical
information to the medical personnel responsible for the individual's care
without a client or applicant's authorization, and without the authorization of
the executive director or his or her designee, if obtaining such authorization
would cause an excessive delay in delivering treatment to the individual.
(C N N/A)*
7. When information has been released without
the individual's authorization under these standards, there is reason to
believe that the staff member responsible for the release of information enters
into the individual's case record all details pertinent to the transaction,
including at least: the date the information was released; persons to whom the
information was released; the reason the information was released; the nature
and details of the information given. (C N N/A)*
8. There is reason to believe that as soon as
possible after the release of information, the client or applicant is informed
that such information was released. (C N N/A)*
9. The program has written procedures for
responding to requests for confidential client information when presented with
telephone inquiries, written inquiries, subpoenas, court orders, search
warrants, arrest warrants, and for reporting child abuse.
(C N N/A)*
10. There are written policies and procedures
for the protection of a client's privacy with regard to program visitors which
requires that: (C N N/A)*
a. the clients are
informed in advance of scheduled visitations; (C N N/A)*
b. visitations are conducted so as to
minimally interrupt the client's usual activities and therapeutic programs. (C
N N/A)*
11. There are
procedures to inform all clients of their legal and human rights and
documentation of the implementation of these procedures. (C N N/A)*
12. There are written policies and procedures
for reviewing and responding to client's communications (e.g., opinions,
grievances) which require the delineation of the means by which clients are
familiarized with these policies and procedures.
(C N N/A)*
a.
the grievance procedures establish specific steps that client's must complete
within the program. (C N N/A)*
b.
the grievance procedure shall
tell clients that they can submit a grievance directly to the Bureau of Alcohol
and Drug Abuse Prevention; if after the program's process proves to be
unsatisfactory. (C N N/A)*
c.
provide pens, paper, envelopes,
postage, and access to a telephone for the purpose of filing a
grievance,
(C N N/A)*
d.
a reasonable specific deadline
for completing the process and the address and telephone number of the Bureau
of Alcohol and Drug Abuse Prevention. (C N N/A)*
13. There is a client handbook which is made
available to each client of the program. (C N N/A)*
14. This handbook includes the following:
a. written statement of the services provided
by the program and a description of the kinds of problems and types of clients
the program can or cannot serve; (C N N/A)*
b. written statement describing admission
procedures; (C N N/A)*
c. written
statement describing living conditions and standards of behavior expected of
clients;
(C N N/A)*
d. there is documentation that each client of
the program has a handbook made available to them and has been familiarized
with the contents of such handbook. (C N N/A)*
15. There are written policies and procedures
which allow clients access to legal representation. (C N N/A)*
16. There are written policies and procedures
for the provision of services related to AIDS/HTV, sexually transmitted
diseases, Tuberculosis, Hepatitis and other infectious diseases.
(C N N/A)*
£. Client Records
1. There is a case record for each client
that contains: (C N N/A)*
a. results of all
examinations, tests, and intake and assessment information and any
interpretation of these results; (C N N/A)
b. reports from referring sources; (C N
N/A)*
c. treatment plans; (C N
N/A)*
d. medical history and
medication records. Medication records must document the medication, dosage,
route of administration, frequency of administration, the name of the
prescribing physician, the time and date the dosage was taken, and the full
signature of the staff person administering the medication. This documentation
applies to bom prescription and nonprescription medications. Non-medical
programs cannot administer medications but do witness the client's taking of
the medication with the same documentation. (C N N/A)*
e. reports from outside resources, which
shall include the name of the resource and date of the report. These reports
shall be signed by the person making the report or by the program staff member
receiving the report; (C N N/A)*
f.
case conference and consultation notes, including the date of the conference or
consultation, recommendations made, and actions taken;
(C N N/A)*
g. correspondence related to the client,
including all letters, and dated notations of telephone conversations relevant
to the client's treatment: (C N N/A)*
h. consents for releases of information and
copies of, or documentation of, information which was released. (C N
N/A)*
i. progress notes. Entries
shall be filed in
chronological order and shall include the date any relevant
observations were made, the date the entry was made, and the signature and
staff title of the individual rendering service; (C N N/A)*
j. records of services provided. Summaries of
services provided shall be sufficiently detailed to identify the types of
services the client has received and action taken to address specific problems
identified. General terms such as "counseling" and "activities" shall be
avoided in describing services;(C N N/A)*
k. aftercare plans (when appropriate); (C N
N/A)*
1. discharge summary which minimally
documents the reason for discharge, responses to treatment goals, any
readmission conditions and the date and time of discharge; (C N N/A)*
m.
There shall be
evidence that client records are reviewed at no longer than every seven (7)
days to ensure proper and timely completion of the records. (C N
N/A)*
n.
Active
clients cases are giv?z a review by
counseling staff "staffing" at least weekly. The
staffing will focus on each active client's progress in treatment, future
client treatment and any changes in the client's treatment plan. (C N
N/A)*
2. There are written policies and procedures
governing the compilation, access storage, dissemination, retention, and the
proper disposal of individual client case records. (C N N/A)*
3. The written policies and procedures ensure
that:
a. the program exercises its
responsibility for safeguarding and protecting loss, tampering, or unauthorized
disclosure of information, and that the file cabinets are marked
CONFIDENTIAL;
(C N N/A)*
b. content and format of client records are
kept uniform; (C N N/A)*
c. entries
in the client case record are signed and dated; (C N N/A)*
d. client case records are maintained in
accordance with federal or state regulations, whichever time frame is longer.
(C N N/A)*
4. The
program provides adequate physical facilities for the storage, processing, and
handling of client case records by means of suitable, locked, secured rooms or
file cabinets. (C N N/A)*
5. Client
case records are readily accessible to those individuals specifically
authorized by program policy. (C N N/A)*
6. Client case records are marked
"CONFfflENTIAL" or bear a similar cautionary statement; (C N
N/A)*
F.
Referral, Public Information and Outreach
1. The program has written referral policies
and procedures which facilitate referrals between the program and other service
providers in such a manner so as to ensure continuity of care and these are
current (dated no longer than 2 yr. prior to the Licensure review). (C N
N/A)*
2. Written referral
agreements document at least;
a. the services
the resource agrees to provide; (C N N/A)
b. the duration of the agreement; (C N
N/A)
c. the procedures to be
followed in making referrals; (C N N/A)
d. a statement of conformity to federal,
state and program confidentiality requirements. (C N N/A)
3. The program maintains a current (dated nc
'"r.ger than 2 years prior to the Licensure review) list of appropriate
resources available within the service area which contains at least:
a. the name and location of the resources; (C
N N/A)
b. the types of services
provided by the resource. (C N N/A)
4. There is written documentation of requests
for services and responses made to those requests, including, when appropriate,
responses by a provider to whom an individual has been referred. (C N
N/A)
5. The program provides Public
Information and Outreach activities which include: (C N N/A)*
a. the program's philosophy and goals of
Public Information and Outreach; by the program. (C N N/A)*
6. The program has policies that
specify who is responsible for the public information and outreach activities,
how such activities are documented, and who is responsible for the compilation
of such documentation. (C N N/A)*
G.
Aftercare
1. The program has written policies and
procedures to assure the provision of aftercare services, where needed. These
services are designed to support and increase the gains made to date in the
treatment process. (C N N/A)*
2.
Aftercare plans include:
a. an assessment of
the client's current status, to include accomplishments and needs; (C N
N/A)*
b. a statement of the
aftercare goals; (C N N/A)*
c. the
date of review; (C N N/A)*
d. the
individuals involved in the review; (C N N/A)*
e. any, when appropriate, updating or
modification of the aftercare goals. (C N N/A)*
H. Emergency
1. The program does provide 24-hour
availability of emergency services including adequate provisions for handling
special and difficult circumstances, when it is determined that an emergency
exists. (C N N/A)*
2. The program
maintains a publicly listed and publicized telephone number through which
emergency care is available at all times. (C N N/A)*
3. Medical coverage is readily available for
emergency services at all times. (C N N/A)*
4. Evaluation and treatment services are
available outside the program's facilities if needed in emergency situations.
(C N N/A)*
5. The management for emergency services is
structured as to provide timely response to requests for emergency services.
(C N N/A)*
6. The program has at least one staff person
present at all times who maintains a valid certification in First Aid,
including but not limited to CPR. (C N N/A)
7. The program, and any satellite facilities,
maintain suitably stocked first aid kits. (C N N/A)
8.
The program has documentation
that demonstrates compliance with the ADAP "Incident Reporting Policy". (C N
N/A)*
I.
Intensive Outpatient
1.
There are Intensive Outpatient
services available for clients who need a more intensive
treatment program than that provided in outpatient while not needing the
24-hour supervision found in inpatient or residential services. (C N
N/A)*
2. The facilities used for
Intensive Outpatient programs are adequate and
appropriate for the program provided.
(C N N/A)*
3. The facilities are readily available to
the public and, if possible, are located close to public transportation. (C N
N/A)*
4. At least one treatment
staff member is present at all times when the Intensive
Outpatient program is operating. (C N N/A)*
5. A minimum of four and one-half (4 1/2)
hours structured treatment is provided daily in the day treatment environment.
(C N N/A)*
J.
Outpatient
1. There are outpatient services available
which provide a variety of diagnostic and primary alcohol and/or drug abuse
treatment services on both a scheduled and non-scheduled basis in a
nonresidential therapeutic setting, and services provided by the outpatient
component include, but are not necessarily limited to the following: (C N N/A)*
a. case management; (C N N/A)*
b. orienting clients to the program's
operations and procedures; (C N N/A)*
c. interviewing applicants and clients for
diagnostic purposes; (C N N/A)*
d.
conducting individual, group or family counseling sessions; (C N
N/A)*
e. informing clients of
program and community resources; (C N N/A)*
f. making referrals to appropriate outside
agencies or individuals; (C N N/A)*
g. crisis intervention; (C N N/A)*
h. interdisciplinary treatment services; (C N
N/A)*
i. serving as a resource for
clients. (C N N/A)*
2.
Hours of operation are scheduled to make outpatient services accessible to
clients and the general public; and during hours which the program does not
operate, are conspicuously displayed so as to communicate those hours to the
public. (C N N/A)*
K.
Residential
1. There are
residential services available which provide services seven (7) days per week,
24 hours per day. (C N N/A)*
2.
There are written policies regarding the use of alcohol and/or drugs in the
facility. (C N N/A)*
3. Residential
Treatment provides for a minimum of five (5) hours daily (Monday through
Friday) of structured treatment.
(C N N/A)*
4. All clients of the residential program are
active participants in the therapeutic program. (C N N/A)*
5. There are written policies and procedures
for communications with family and significant others outside the program which
require:
a. clients are allowed to conduct
private telephone conversations with family and significant others, unless
justified in the client's case record and explained to the client; (C N
N/A)*
b. clients are allowed to
send and receive mail in uncensored condition. Mail may be inspected in the
presence of a staff member. (C N N/A)*
6. There is an area provided in which clients
can meet with outside community service providers who assist in fulfilling the
goals and objectives of the client's individual treatment plan. (C N
N/A)*
7. At least one treatment
staff member is present at all times.
(C N N/A)*
8. There is at least one treatment staff
member for every 25 residents of the residential program at all times. (C N
N/A)*
9. There is documentation of
planned programs, consistent with the needs of the clients, for social,
educational, and recreational activities for all clients for daytime's,
evenings, and weekends. (C N N/A)*
L.
Detoxification
1. Medically supervised (Residential or
Social setting) detoxification shall include a bed, oral intake of fluids,
three meals a day, and the taking of vital signs (temperature, pulse,
respiration rate, blood pressure), fluid and food intake a minimum of one time
every six (6) hours or more often as indicated by the client's condition, for a
minimum of seventy two (72) hours. There shall be documentation in the client's
case record verifying each vital sign and fluid and food taken during the
client's stay in detoxification. (C N N/A)*
2. While a client is in a medically
supervised detoxification component, qualified (registered and/or licensed
practical nurses) nursing staff member(s) must be present to monitor the
client's convalescence on a twenty-four (24) hour basis. (C N N/A)*
3. There shall be documentation that staff
members assigned to a medically supervised detoxification component are
knowledgeable about die physical signs of withdrawal, the taking of vital signs
and the implication of those vital signs, and emergency procedures. (C N
N/A)*
4. Medical support shall be
available and consist of the following;
a.
Licensed physician providing supervision of detoxification; (C N
N/A)*
b. Qualified service
agreement with a hospital or a licensed physician with admitting privileges to
a hospital; (C N N/A)*
c. A written
plan for emergency procedures approved by a licensed physician; and (C N
N/A)*
d. Supplies, as designated by
the written emergency procedure, readily assessable to the staff.
(C N N/A)*
The following Standards apply to those programs that are
Regional Alcohol and Drug Detoxification Programs (RADD).
5. The program is responsible for
providing detoxification services for its assigned catchment area. (C N
N/A)*
6. The program dedicates at
least three (3) staff members to be trained as Regional Detoxification
Specialists to evaluate admissions (C N N/A)*
7. The program maintains adequate liability
insurance. (C N N/A)*
8. If the
program is not hospital based, then it shall contract with a hospital licensed
as a critical care facility. (C N N/A)*
9. The program is responsible for all
individuals committed under applicable substance abuse commitment laws for its
assigned catchment area. (C N N/A)*
10. The program has performed sufficient
outreach and referral activities necessary to educate judges, prosecuting
attorneys, law enfcT-.ement personnel, community service providers, substance
abuse treatment programs, and the public as to the operations of the RADD
program. (C N N/A)*
11. The program
has procured an agreement with the local community mental health center (as
certified by the Division of Mental Health Services) and other appropriate
agencies, to provide consulting services for dual diagnosed applicants or
clients. (C N N/A)*
12. Each RADD
program shall have at least one staff member who is a certified CPA and First
Aid instructor. (C N N/A)*
M.
Transitional living Centers
(Chemical Free Living Center)
1.
Transitional Living Centers shall comply with all applicable local fire, health
and safety codes. (C N N/A)*
2. All
Transitional Living Center clients shall be active participants in an
outpatient (or more intensive) substance abuse treatment program. (C N
N/A)*
3. Transitional Living
Centers shall maintain policies forbidding the use of alcohol and/or any drug
not prescribed by a licensed medical doctor. (C N N/A)*
N.
Dietary Services
1. There is a written plan describing the
organization and delivery of the program's food service. (C N N/A)*
There is documentation that:
a. the dietary services comply with all
applicable federal, state, and local sanitation and safety laws and
regulations; (C N N/A)*
b. a
minimum of three meals per day are provided to each resident; (C N
N/A)*
c. meals adhere to menus
reviewed and approved by an Arkansas Licensed Dietitian. (C N N/A)*
2. Food is served:
a. in an appetizing and attractive manner; (C
N N/A)
b. at realistically planned
mealtimes; (C N N/A)
c. in a
congenial and relaxed atmosphere. (C N N/A)
3. Menu considerations are made for special
dietary needs due to confirmed medical or religious requirements. (C N N/A)
COMPLIANCE RATIO
|
|
Standards in Compliance
|
Standards Non-applicable
|
Total Possible
|
|
M
|
NM
|
M
|
NM
|
M
|
NM
|
|
|
PARTI
|
|
|
|
|
|
|
|
A.
|
Governing Authority
|
|
|
|
|
22
|
0
|
|
B.
|
. Program Planning/ Evaluation
|
|
|
|
|
0
|
11
|
|
C.
|
Fiscal Management
|
|
|
|
|
13
|
3
|
|
D.
|
Employment/ Personnel
|
|
|
|
|
24
|
5
|
|
E.
|
Physical Plant
|
|
|
|
|
3
|
2
|
|
|
PART II
|
|
|
|
|
|
|
|
A.
|
Intake & Assessment
|
|
|
|
|
22
|
0
|
|
B.
|
Treatment Plans
|
|
|
|
|
13
|
0
|
|
C.
|
Progress Notes
|
|
|
|
|
3
|
4
|
|
D.
|
Confidentiality & Client Rights
|
|
|
|
|
37
|
2
|
|
E.
|
Client Records
|
|
|
|
|
22
|
1
|
|
F.
|
Referral, Public Information and Outreach
|
|
|
|
|
4
|
7
|
|
G.
|
Aftercare
|
|
|
|
|
6
|
0
|
|
H.
|
Emergency
|
|
|
|
|
6
|
2
|
|
I.
|
Day Treatment
|
|
|
|
|
5
|
0
|
|
J.
|
Outpatient
|
|
|
|
|
11
|
0
|
|
K.
|
Residential
|
|
|
|
|
10
|
0
|
|
L.
|
Detoxification
|
|
|
|
|
15
|
0
|
|
M.
|
Transitional Living Centers
|
|
|
|
|
3
|
0
|
|
N.
|
Dietary Services
|
|
|
|
|
4
|
4
|
|
SUPPLEMENTAL
|
|
|
|
|
24
|
4
|
|
TOTAL
|
|
----
|
----
|
|
227
|
45
|
Percentage Mandatory in Compliance________
Non-Mandatory_________
SUPPLEMENTAL ADMINISTRATIVE
QUESTIONNAIRE
STANDARDS FOR PRIVATE-FOR-PROFIT (NON-MEDICAL MODEL
PROGRAMS)
A.
General Standards
1. The purpose of the organization should be
clearly stated in appropriate publications for distribution to staff, those
served, referral and payment sources, and interested public. The purposes
stated in these documents may use more common language than the legalistic or
professional terminology used in a charter or program evaluation system. These
purposes statements should, however, not be inconsistent with the purposes as
established in the organization's legal documents. The statements of the
organization's purposes should be sufficiently broad as to allow for
modification and/or expansion of the program in response to community needs or
the needs of those served, and yet specific enough to give direction to the
organization's efforts. For program evaluation, purpose statements should
describe in general terms who is served, the services provided, and the goals
of the organization. (C N N/A)*.
2. The organization must comply with the laws
and regulations of all government and legally authorized agencies under whose
authorities it operates. These include, but are not limited to, those regarding
equal employment opportunity, safety, and affirmative action. (C N
N/A)*
3. The chief executive should
control the operation of the organization through day-to-day decision making,
authorization of expenditures, and other procedures in accordance with the
program's established policies. (C N N/A)*
4. The names and addresses of all owners or
general or limited partners should be disclosed. In the case of corporations,
the names and addresses of officers and directors should be made known. (C N
N/A)*
5. The purposes of the
organization, their relation to the needs of those served, and the degree of
fulfillment of the purposes should be reviewed and evaluated at least annually
by its staff, chief executive officer, and when applicable, governing body.
(C N N/A)*
6. All personnel employed by the program must
meet the legal requirements of their positions. (C N N/A)*
7. A system to verify the credentials of
staff, consultants, and volunteers providing professional services must be
established. (C N N/A)*
8. Job
descriptions should be established for all personnel, including volunteers with
ongoing involvement and should be relevant to the organization. Each job
description should set forth the qualifications, reporting supervisor,
position(s) supervised, and duties. Each job description should be dated and
periodically reviewed for continuing appropriateness; a copy should be provided
to the individual involved. (C N N/A)*
9. Written agreements should be obtained when
clinical and/or medical services are provided outside the program. The nature
and extent of actual involvement by individuals utilized through consultation
or affiliation arrangements should be documented. (C N N/A)*
10. Employment operating policies include,
but are not limited to:
a. Any probationary
period and provision for periodic evaluation. (C N N/A)*
b. Conduct and general regulations. (C N
N/A)*
c. Hours of work, holidays,
vacation, leave of absence. (C N N/A)*
d. Promotion policy. (C N N/A)
e. Grievance procedures. (C N N/A)*
f. Disciplinary action. (C N N/A)*
g. Method and period of wages. (C N
N/A)*
h. Fringe benefits (the
availability of insurance, health
care, employee assistance programs, etc.)
(C N N/A)* i. Meals, housing, transportation, etc. (C N N/A)*
j. The organization's position with regard to
malpractice liability coverage. (C N N/A)*
11. Personnel policies should be
reviewed and adapted on an as needed basis. (C N N/A)*
12. The chief executive should establish
procedures which assure that staff understand the personnel policies. (C N
N/A)*
13. There should be personnel
and other records which contain the information necessary to carry out the
personnel management function, including, but not limited to: application,
evidence of current licensure where applicable, reports of performance
evaluation, authorizations for deductions, authorizations to enter benefit
programs, salary and position changes, and other information required by law or
organization policy. In a publicly operated facility or a rehabilitation unit
of a larger entity, such information should be obtained but may be retained
elsewhere. (C N N/A)*
14. The
organization should not discriminate with regard to employment, promotion, pay,
or place or work because of race, creed, national origin, sex, disability, or
age. (C N N/A)*
15. The immediate
supervisor should conduct a job performance evaluation, at least annually, for
each staff member on a regular basis, and should document the results, review
them with the staff person, and include them in the personnel file.
(C N N/A)*
16. Staff growth and development related to
the attainment of the organization's goals and objectives should be encouraged
and supported through:
a. The planned conduct
of interdisciplinary and unit inservice training programs or which agenda are
prepared. Inservice training programs are necessary for each service unit in
order to maintain staff competency and to provide for growth and development. A
variety of techniques should be utilized, such as staff meetings focused upon
theoretical concepts or analysis of representative programs, training films,
guest speakers, review of literature, etc. (C N N/A)
b. Ready access to relevant professional
reference materials. (C N N/A)
c.
The establishment to the extent possible, of affiliations with universities and
colleges to provide internship programs for the disciplines represented in the
organization. Internship programs are a part of essential training for all
professional disciplines. As such, they provide the student with guided,
progressive contact with those served in an actual work setting. They also
provide contacts with professional training institutions which stimulate and
assist staff in keeping abreast of current professional developments. The
planning and curriculum of an internship program is developed customarily
between the organization and the specific institution which has agreed to enter
into such an arrangement. (C N N/A)
B.
Fiscal Management
1. Financial operations must conform to
applicable legal
requirements and be based upon sound financial planning and
prudent management. (C N N/A)*
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 sufficient 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 advice,
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.
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.
Intensive Outpatient-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 or structured treatment
daily.
May-Term in the interpretation of a standard to reflect an
acceptable method that is recognized but no 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 that provides
treatment services.
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 f 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, altering 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 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 prnpram and an outside
resource.
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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 Licensure is completed by the treatment
program prior to the on-site visit.
The Licensure Standards Manual is comprised of three major
sections.
(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 program).
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 Section 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 annually and put into
this present edition and format. This present edition was promulgated for
implementation on July 1, 1997.
APPLICATION FOR LICENSURE
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