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 |
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 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
| A-5-B |
| B-7 |
| C-l-c |
| C-2 |
| C-3 |
| C-5-a thru-c |
| C-6-a thru -d |
| D-3 |
| D-9 |
| D-14-b thru -d |
n | A-3-a thru n |
n | A-4 |
n | A-5 |
ii | A-6 |
n | B-l |
n | B-2 |
n | B-3 |
n | B-4-a thru e |
n | B-5-a thru d |
n | B-6 |
n | C-l |
n | C-2 |
u | C-3 |
ii | C-4 |
h | C-5 |
ii | C-7 |
ii | D-l-a thru j |
n | D-2 |
n | D-3 |
n | D-4 |
n | D-5-a thru d |
n | D-6 |
ii | D-7 |
ii | D-8 |
ii | 3-1-a thru n |
ii | E-6 |
n | F-4 |
n | G-2-a thru e |
n | H-8 |
n | N-l-b |
n | N-2-a thru c |
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)*; orb. 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/EvaluationPrograms 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 Management1. 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/AJ7. 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 EmploymentOpportunities 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 Plant1. 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 Assessment1. 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 Plans1. 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 Notes1. 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'sright 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 bycounseling 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 Outreach1. 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. Aftercare1. 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 Outpatient1. 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. Outpatient1. 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. Residential1. 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. Detoxification1. 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 Services1. 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 Standards1. 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 Management1. 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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007.25.97 Ark. Code R. 002