Arkansas Administrative Code › Agency 007 - ARKANSAS DEPARTMENT OF HEALTH › Division 25 - Bureau of Alcohol and Drug Abuse Prevention › Rule 007.25.97-002 - Licensure Standards for Alcohol and/or Other drug Abuse/Addiction Treatment Programs

Current through Register Vol. 49, No. 6, June, 2024
Attachment for Item 12
Click
				here to view image
Click
				here to view image
Click
				here to view image
Click
				here to view image
Click
				here to view image
Click
				here to view image
Click
				here to view image
Click
				here to view image
Click
				here to view image
Click
				here to view image
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:
(1) Program reviewed;
(2) Date(s) on-site review;
(3) Name of team member and organization
			 represented;
(4) Area(s) reviewed
			 by team member;
(5) Findings to
			 include areas considered as strengths, weaknesses, deficiencies, and/or in
			 non-compliance, recommendations for improvement; and
(6) Recommendation for type of licensure to
			 be awarded program based upon the questionnaire completed by team member and
			 which is to be attached to the written report.
Within thirty (30) working days of the last day of the on-site
				review, a formal written report will be written by the team leader and
				forwarded with the licensure notice and the composite completed questionnaire
				to the program.
This time frame Should be maintained even if all materials from
				the team members have not been received. In that event, the team leader will
				write the formal report based upon materials available.
Based upon these reports and recommendations, the ADAP 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 Authority
1. 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)*