Arkansas Administrative Code › Agency 007 - ARKANSAS DEPARTMENT OF HEALTH › Division 25 - Bureau of Alcohol and Drug Abuse Prevention › Rule 007.25.00-001 - Licensure Standards for Alcohol and/or Other Drug Abuse Treatment Programs - Revised 7/1/2000

Current through Register Vol. 49, No. 6, June, 2024
AUTHORITY
The Arkansas Department of Health, Bureau of Alcohol and Drug
				Abuse Prevention (BADAP) is vested by ACA
				20-64-901 et
				seq. with the authority and duty to establish and promulgate rules for
				licensure of alcohol and drug abuse treatment programs in Arkansas. All
				persons, partnerships, associations, or corporations establishing, conducting,
				managing or operating and holding themselves out to the public as alcohol and
				drug abuse treatment programs must be licensed by the Bureau of Alcohol and
				Drug Abuse Prevention, unless expressly exempted from these requirements.
				Programs administered by the Department of Defense and/or the Veterans
				Administration are not required to be licensed by the BADAP, but may
				voluntarily seek licensure.
The Bureau of Alcohol and Drug Abuse Prevention is designated
				as the State Authority governing Methadone/LAAM treatment in Arkansas.
				Treatment programs providing Methadone/LAAM services shall comply with the
				Licensure Standards for Alcohol and/or Other Drug Abuse Treatment Programs, as
				well as applicable federal, state and local laws and regulations including
				those under the jurisdiction of the Food and Drug Administration, and the Drug
				Enforcement Administration.
HISTORY
Act 644 of 1977 created the Arkansas Office on Alcohol and Drug
				Abuse Prevention and charged the office with the responsibility for developing
				and promulgating standards, rules and regulations for accrediting and licensing
				alcohol and drug abuse prevention and treatment programs/facilities within the
				state. Accreditation standards for alcohol and other drug abuse treatment
				programs were implemented in response to state and federal legislation as well
				as the changing needs of the alcohol and drug abuse treatment programs. The
				first Accreditation Standards were adopted and implemented on January 1 1983.
				Act 597 of 1989 delegated the BADAP as the sole agency responsible for
				accrediting all alcohol and other drug abuse treatment programs. Revisions to
				the Accreditation Manual were promulgated on September 1, 1989. Act 173 of 1995
				changed the Accreditation process to a Licensure process. With the advent of
				the 1995 legislation, the Standards were promulgated and implemented as a
				Licensure Manual on July 1, 1995.
The first Methadone Treatment Program Standards were developed
				and promulgated by the Bureau of Alcohol and Drug Abuse Prevention on October
				1, 1993. The Methadone/LAAM Treatment Program Standards were revised to include
				LAAM treatment on July 1, 1997.
ABSTRACT
The Licensure Standards for Alcohol and/or Other Drug Abuse
				Treatment Programs Manual is to be used as a guide to the Licensure process.
				The Manual includes:
(1) Procedures
			 for Licensure
(2) Licensure
			 Standards Review Questionnaire
(3)
			 Application for Licensure
The Application for Licensure is to be completed by all
				programs seeking licensure as an alcohol and/or other drug abuse treatment
				program in Arkansas prior to the on-site visit.
The Procedures for Licensure explains the licensure process for
				treatment programs, the Standards Review Team and other issues regarding
				licensure.
The Licensure Standards Review Questionnaire is used as the
				measurement tool to determine compliance with the Licensure Standards for
				Alcohol and Drug Abuse Treatment.
All standards that are applicable to your program must be
				complied with.
Questions concerning the licensure of alcohol and other drug
				abuse treatment programs in Arkansas may be directed to:
Arkansas Department of Health
Bureau of Alcohol and Drug Abuse Prevention
Director, Office of Program Compliance
5800 W. 10th Street, Suite 907
Little Rock, Arkansas 72204
Phone: 501-280-4500
Fax: 501-280-4519
PROCEDURES FOR LICENSURE
The Bureau of Alcohol and Drug Abuse Prevention (BADAP) of the
				Arkansas Department of Health is vested with the authority and duty to license
				programs in Arkansas. Licensure is required of any organization which is
				operating or seeking to operate an alcohol and other drug treatment program in
				the State of Arkansas. Upon implementation of the standards, the BADAP will
				provide to each of the programs known to be operating within Arkansas, a
				Licensure Standards Manual.
A schedule for the entire licensure process will be developed
				by the BADAP in cooperation with each program. The entire licensure process for
				a program is shown below, with explanatory comments following.
Step 1
a) Programs who
			 are currently licensed shall be notified by BADAP of upcoming Licensure Review
			 and the need to complete an Application for Licensure.
b) First time applicants seeking licensure
			 will submit a completed Application for Licensure to BADAP.
c) Unlicensed alcohol and other drug abuse
			 programs will be notified by BADAP of the need to make Application for
			 Licensure.
Step 2 Receipt by BADAP of the program's completed Application
				for Licensure. First time applicants shall submit a non-refundable $75.00
				application fee.
Step 3 Development of the schedule and requirements for the
				review of the program by the BADAP.
Step 4 Review of pertinent information received from the
				program by the BADAP. If necessary, review of any additional information
				requested following the initial review of Step 3.
Step 5 Written confirmation and notification by the BADAP 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) Costs
			 (e.g., fees) to the program for the licensure survey process (when applicable).
Step 6 Formal on-site review by the BADAP Standards Review
				Team.
Step 7 Submission to the BADAP, by the program, of a $1,500
				nonrefundable Licensure Review fee
for first time
				applicants.
Step 8 Report by BADAP Standards Review Team and
recommendations to the Director of the Bureau of Alcohol and
				Drug Abuse Prevention.
Step 9 Formal report to the program with the type of license
				awarded,
findings, and recommendations of the BADAP 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 BADAP
				reserves the right to adjust the size of the SRT as appropriate to conform to
				the size and complexity of the program under review. The Standards Review Team
				normally will be composed of representatives from:
Number of SRT Members
Organization
2
(a) Two team members from the BADAP. One member will be
						  designated as "team leader."
2
(b) At least two team members from other
treatment facilities as selected by the BADAP. Other
						  representative(s) may be selected as deemed appropriate by the BADAP.
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 from another
				treatment program, the BADAP may select a different member.
The minimum requirements for a SRT Member from another
				treatment program are:
(a) A minimum
			 of three (3) years experience in program administration and/or substance abuse
			 treatment.
(b) Not be a former
			 employee or client of the program to be reviewed.
(c) Currently hold a license or certification
			 that would allow the signing of comprehensive treatment plans as specified in
			 these standards.
Note:
An SRT member reviewing administrative
				functions is not required to hold the credentials specified in item "c"
				above.
OTHER ISSUES REGARDING LICENSURE
Adolescent Treatment
				Programs
Whenever Alcohol and/or other Drug Abuse Treatment Programs
				seek licensure for adolescent services they must comply with the standards set
				forth under this manual. In addition, the program seeking licensure must also
				comply with other applicable regulations mandated by the Department of Human
				Services - Division of Youth Services (DYS). When feasible, the BADAP and DYS
				will perform concurrent licensure reviews.
Programs Commencing Operation After January
				1,1999
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
				BADAP shall review those standards applicable to programs that have not yet
				provided substance abuse treatment. If the program under review meets the
				required level of compliance as determined by BADAP staff, that is applicable
				at the time of initial review, then BADAP can issue a six (6) month operational
				permit. No later than six (6) months after the according of the permit, a
				follow up review, with a full Standards Review Team (SRT), will be performed to
				determine the program's level of compliance with all applicable standards. 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 Levomethadvl Acetate
				Hydrochloride (LAAM)
Any program in Arkansas that intends to dispense Methadone
				and/or l_AAM must meet the standards set forth in this manual and those
				standards and regulations applicable to methadone/LAAM maintenance and
				treatment.
Licensure
Under
Previous
				Standards
All programs currently licensed by the BADAP prior to the
				implementation of these licensure standards will be considered as licensed. The
				scheduling of a program's licensing review will not change. The standards set
				forth in this manual shall apply to all currently licensed programs.
On-Site
Review
A formal on-site review will be made by at least two BADAP
				staff and representatives of organizations as previously specified. Minimally,
				the BADAP shall inspect the facilities prior to the expiration of the program's
				license. The BADAP may extend a program's license for no greater that six
				months due to licensing scheduling. The on site inspection (Licensure Review)
				will use the questionnaire section of this Manual as the primary tool to
				determine compliance with the Licensure Standards. The licensure will include
				examination of program documents and records, client case records, fiscal
				audits, interviews with staff and clients (in accordance with confidentiality
				standards) and interviews with various community agencies/individuals. Other
				sources may be used to determine compliance as applicable. The BADAP reserves
				the right to contact
former clients of the program under review to determine
				compliance with applicable standards.
Prior to the exit interview, there will be a meeting of the
				Standards Review Team members. In this meeting, each member will present
				his/her 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 the decision about each item of the Manual as found in the part(s) of
				the questionnaire assigned.
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 wil! meet
				(exit interview) with the Executive Director, Clinical Director, and a quorum
				of the program's Governing Board.
During this meeting, the team members will present the review
				findings. The purpose of this meeting will be to discuss and clarify the
				findings and recommendations noted by the team members.
Additional Compliance
				Reviews
In addition to the Licensure Review, the BADAP will, at least
				annually, perform a client record (case) review, and conduct periodic reviews
				to determine a program's ongoing compliance with the standards. The BADAP shall
				also perform, at least annually, one unannounced compliance review. 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 BADAP reserves the right to
				contact the clients of licensed programs to aid in the determination of
				compliance with specific standards. BADAP reserves the right to conduct a full
				licensure review prior to the expiration of the program's current license. In
				addition the BADAP reserves the right to use peer reviewers, as it deems
				appropriate, to assist in audits, client records reviews, investigations or
				other monitoring/compliance processes.
Licensure
				Revocation
The BADAP reserves the right to revoke the operational permit
				or license of any program found to not be in compliance with the standards. The
				BADAP shall also reserve the right to revoke the operational permit or license
				of any program found in violation of applicable laws or regulations. The BADAP
				shall reserve the right to revoke the operational permit or license of any
				program that places its staff, clients or the general public in imminent
				peril.
Licensure Report
Following the on-site review, within fifteen (15) working days
				of the last day of the on-site review, a formal written report will be
				completed by the team leader and forwarded with the completed composite
				questionnaire to the program.
Based upon these reports the Director of the Bureau of Alcohol
				and Drug Abuse Prevention shall award the program the appropriate type of
				licensure.
TYPES OF LICENSE
Three-Year License
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				Three-year License wi!i be awarded when a program has complied with all
				applicable standards. A three-year license shall not be accorded to a program
				that receives a follow-up review, even if the follow-up review determines that
				all applicable standards are in compliance.
All standards are
				mandatory.
One-Year License
- A
				one-year license can be accorded to a program that previously held a six-month
				operational permit if all applicable standards are in compliance. Any program
				that must have a follow-up licensure review performed, even if the review
				determines that all applicable standards are in compliance, shall receive no
				greater than a one-year license.
All standards are
				mandatory.
Probationary License
- At
				the BADAP's discretion, a six-month probationary license may be accorded to
				currently licensed programs that do not meet the criteria necessary for
				licensure. The probationary license 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 probationary license 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 treatment program. The program may
				request that the follow-up review be performed prior to the end of the
				probationary license. Programs with a probationary license shall not receive an
				extension.
The Probationary License shall not exceed six months from the
				date of it's issue. Any program issued a probationary license shall submit a
				corrective action plan to the Director of BADAP within thirty (30) calendar
				days from receipt of the Probationary License. Any program receiving a
				Probationary License must bring all applicable failed standards into compliance
				prior to the end of the six month period.
Six-Month Operational Permit
- If the program seeking licensure has not yet provided treatment
				services, the BADAP shall review those standards applicable to programs that
				have not yet provided substance abuse treatment. If the program under review
				meets the required level of compliance as determined by BADAP staff, that is
				applicable at the time of initial review, then BADAP can issue a six (6) month
				operational permit. No later than six (6) months after the according of the
				permit, a follow up review with a full SRT, will be performed to determine the
				program's level of compliance with all applicable standards.
Non-Licensed
- Programs
				failing to comply with all licensure standards, that would allow a one or three
				year license shall, receive a non-licensed status. Programs receiving a
				non-licensed status will not be eligible for substance abuse treatment funding
				through BADAP, or sources which require licensure by the BADAP, nor will they
				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, Alcohol and Drug Abuse Coordinating Council, no
				later that thirty (30) working days after the program's receipt of the
				licensure decision. The appeal must contain:
1. The reason the licensure applicant
			 believes the action was incorrect.
2. The specific outcome requested.
When the written appeal is received," the Chairperson of the
				Alcohol and Drug Abuse Coordinating Council will initiate the appeal
				process.
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PART I
ADMINISTRATIVE OPERATIONS
A.
GOVERNING BOARD
Measurement Criteria
Compliance -
YES
NO
N/A
1. There is a governing board which has the ultimate
						  authority for the overall operation of the program and which is one of the
						  following:
a. A public non-profit organization; or
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b. A private, non-profit organization (As verified by
						  Articles of Incorporation submitted to the Arkansas Secretary of State);
						  or
c. A private, for profit organization (As verified by
						  the Articles of Incorporation submitted to the Arkansas Secretary of
						  State).
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2. Written documentation includes the means by which
						  the governing board provides for all of the following:
a. The election or appointment of its officers and
						  members;
b. The orientation of new board members and any
subsequent board training;
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c. The appointment of committees necessary to effect
						  the discharge of its responsibilities;
d. The scheduling of meetings;
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e. Determination of quorum requirements; and
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f. Keeping minutes of all meetings (As verified in
						  corporation by-laws).
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3. The minutes of the meetings of the governing board
						  include at a minimum:
a. Date(s) of the meeting(s);
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b. Names of the members attending;
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c. Topics discussed;
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d. Decisions reached and actions taken (i.e. approval
						  of budget revisions, evaluation of the Director, changes in policies and
						  procedures);
e. Target dates for implementation and
						  recommendations;
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f. Executive Director's or other program reports;
						  and
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g. The governing board's minutes should be available to
						  staff, persons served and the general public upon request.
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4. The governing board for the alcohol and/or drug
						  program:
a. Delegates a chief executive officer who is not a
						  member of the governing board (applies to nonprofit organizations only);
b. Delegates authority and responsibility to the chief
						  executive officer for the management of the program in accordance with
						  established policy (As verified in the by-laws);
c. Performs an employment evaluation of the program
						  director at least annually.
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5. The governing board 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 abuse treatment program
						  operations;
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b. Reviewed and updated this policy manual as needed
						  but at least annually (as verified in Board minutes);
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c. Made available this policy manual to all alcohol
						  and/or other drug abuse treatment program staff (as verified by signed
						  receiptor route slip);
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d. Made available this policy manual to the public upon
						  reauest: and
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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 performed.
6. At least a quorum of the program's governing board
						  is present during the exit interview process, as described in the Licensure
						  Procedures.
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B.
PROGRAM PUNNING/EVALUATION
1. The program has conducted, or has available to it, a
						  needs assessment for the population to be served and the needs assessment is
						  performed no later than every two years.
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2. Based upon the needs assessment, an Annual Program
						  Plan is developed which includes:
a. A written statement of the alcohol and/or other drug
						  abuse treatment program goals and objectives; and
b. A written plan for implementation of these goals and
						  objectives;
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3. The alcohol and/or other drug abuse treatment
						  program has developed a written evaluation plan based on the goals and
						  objectives of the program. The evaluation plan includes operational definitions
						  of criteria to be applied in determination of achievements of established
						  goals, objectives and mechanism for:
a. The periodic assessing of the progress toward the
						  attainment of the program's goals and objectives;
b. Documentation of program achievements not related to
						  original goals and objectives;
c. Assessing the effective utilization of staff and
						  program resources toward the attainment of the program's goals and
						  objectives;
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d. The evaluation plan is reviewed and updated at least
						  annually (As verified in the Board minutes);
e. There is documentation verifying the implementation
						  of the evaluation plan; and
f. That the results of the evaluation process become
						  part of the ongoing planning process.
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4. That the results of the evaluation process are made
						  available to all personnel (by posting or routing to all staff).
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5. 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.
FISCAL MANAGEMENT
1. There is a written budgetary plan:
a. Which includes a statement of expected financial
						  resources and expenditures for the program during the current fiscal
						  year;
b. The means for obtaining future financial resources
						  including a system to secure additional treatment funding sources (i.e. third
						  party pay, employee assistance programs, or client self pay);
c. That is reviewed and approved at least annually by
						  the governing board; and
d. The projected budget is reviewed and approved by the
						  governing authority prior to the beginning of its fiscal year.
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2. Any revisions of the written, program-oriented
						  budget during the fiscal year of operation are reviewed and approved by the
						  governing board.
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3. The program maintains a current written schedule of
						  rate and charge policies which:
a. Has been reviewed and approved by the governing
						  board, at least annually; and
b. Is immediately accessible to all concerned program
						  personnel and individuals served by the program.
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4. The fiscal management system maintains a reporting
						  mechanism which:
a. Is prepared and submitted to the governing board at
						  least quarterly;
b. Is responsive to the reporting requirements
						  established by the BADAP; and
c. Includes a series of financial reports including at
						  least, a variance report and balance sheet, and income statement that is
						  published at least quarterly.
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5. An annual audit for the fiscal period of the program
						  contract/grant shall be conducted by a Certified Public Account (CPA) and shall
						  be prepared to the generally accepted governmental audit standards as
						  determined by the American Institute of Certified Public Accountants, the
						  Comptroller General of the United States, United States General Accounting
						  Officer (GAO), and the United States Office of Management and Budget
						  (OMB).
6. 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.
7. Each client receives a financial evaluation that
						  includes the amount of all sources of income, as per a specific period (i.e.
						  weekly, every two weeks, bi-monthly, monthly). Sources must include ajl
						  household income (i.e. public assistance, retirement, social security and VA).
						  If specific amounts are unavailable, averages or reasonable estimates may be
						  used. A client's insurance coverage shall be documented, shall include the name
						  of company, policy number, and type of coverage.
D.
EMPLOYMENT AND PERSONNEL PRACTICES
1. The program has written personnel policies and
						  procedures which:
a. Includes an Equal Employment Opportunity (EEO)
						  Affirmative Action Plan;
b. Applies to both persons served by the program and
						  individuals employed by the program and those working under the supervision of
						  individuals employed by the program;
c. Includes a Statement of Compliance with Title
						  Vl/Title VII of the 1964 Civil Rights Law
						  and a description of the policy and procedures used to follow the guidelines of
						  the Equal Employment Opportunities Commission (EEOC) currently in force;
d. A Statement of Compliance with Title Vl/Title 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 be prominently displayed within
						  the program and copies be made available upon request;
e. Includes an employee grievance procedure which is
						  reviewed, updated and approved annually by the Board of Directors; and
f. Documentation of employee grievances shall be
						  confidential and shall be stored separately from personnel records.
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2. The program maintains written job descriptions for
						  all staff, including volunteers, that include at least:
a. Qualifications;
b. Reporting supervisor;
c. Position(s) supervised; and
d. Duties and responsibilities.
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3. All non-certified or non-licensed staff, including
						  volunteers, providing counseling and treatment.related services, shall be
						  registered with the Arkansas Substance Abuse Certification Board (ASCAB).
						  Exception - those staff involved in a internship or practicum from another
						  human services or behavioral discipline.
The program has documentation that:
4. Each job description is reviewed and updated at
						  least annually as needed for continuing appropriateness.
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5. All personnel meet all of the local, state, or
						  federal legal
requirements for their positions (e.g. licensing and
						  certification).
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6. A policy has been developed which addresses alcohol
						  and other drug use by program staff.
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7. The written personnel policies and procedures
						  include a
mechanism for evaluation of personnel performance on at
						  least an annual basis.
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8. The mechanism for evaluation of personnel
						  performance requires a written report and requires documentation that the
						  evaluation is reviewed with the employee.
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9. The written personnel policies and procedures
						  includes a mechanism consistent with due process for suspension and dismissal
						  of an employee for cause.
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10. 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.
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11. There is a personnel record kept on each employee
						  containing at least:
a. Job description;
b. Application and/or resume;
c. License/certification, where applicable;
d. Annual employee evaluation;
e. Verification of academic records (when required by
						  job descriptions); and
f. Verification of references or rationale as to why
						  verification was not performed.
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12. Employee records are stored in a secure and
						  confidential place.
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13. An employee or his authorized representative shall
						  be allowed to inspect, under supervision, his personal record upon
						  request.
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14. An employee assistance policy has been developed
						  and implemented for program staff.
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15. The program has established an appropriate staff
						  development plan for al! employees and volunteers:
a. Includes an orientation program for each staff
						  person; which includes a documented review of the Agency's policies and
						  procedures;
b. Includes a program based upon the identified needs
						  of staff and volunteers (volunteers working less than ten hours monthly are
						  exempt) and designated staff development representative. The needs are
						  identified and documented at least annually.
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c. There is documentation of the staff person's
						  involvement in the plan; and
d. Documents staff development opportunities made
						  available and staff participation in them.
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16. The program shall not use volunteers, students, or
						  interns to supplant services provided. All persons providing services must have
						  a job description as specified in these standards, and shall be directly
						  supervised by a paid staff person.
17. The program shall not use clients to provide any
						  treatment service. This standard also forbids the use of clients to monitor the
						  program during off hours.
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18. A full time program person that is qualified to
						  approve comprehensive treatment plans shall directly supervise each counseling
						  staff.
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19. Any person providing direct treatment services must
						  receive at least one hour of individual supervision or ninety (90) minutes of
						  group supervision weekly. Such supervision must be documented. Persons
						  authorized to approve treatment plans, as specified in this manual, must
						  perform this supervision.
E.
AMERICANS WITH DISABILITIES ACT (ADA)
1. The program shall designate an employee who will
						  monitor the program's compliance with the ADA.
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2. The program shall post the ADA Public Notification
						  in a manner that it is conspicuous to staff, clients and visitors.
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3. The program shall adopt an ADA non-discrimination
						  policy.
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4. The program has conducted an ADA self evaluation
						  plan.
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5. The program shall develop and implement a transition
						  plan which details activities that will bring the program into compliance with
						  the ADA (applicable to new programs). This plan must be completed within 6
						  months of the operation date.
F.
PHYSICAL PLANT
- These standards shall apply to
			 all sites operated by the program regardless of ownership.
1. The physical facilities of the program:
a. Is structurally sound and the program has current
						  valid certifications, which are maintained on site, of applicable building,
						  fire, safety and health and any other applicable inspections of its facilities;
						  and
b. Provides sufficient privacy to maintain
						  confidentiality of the communication between counselor and client.
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2. If the program uses space provided by another
						  organization, there is a written agreement specifying the terms of such
						  usage.
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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 monthly.
4. The Program shall develop written policies and
						  procedures for continued treatment in the event of an emergency or natural
						  disaster.
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5. Firearms, or other dangerous weapons, shall not be
						  allowed within the physical plant operated by the program. Persons with a
						  "Concealed Handgun License" shall not be ailowed 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. Conspicuous warning signs must be posted at all entrances informing
						  staff, volunteers, clients and visitors as to this requirement.
6. The program shall not allow smoking inside any
						  physical plant containing PPWLC clients or their dependents.
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7. The program shall not allow smoking inside any
						  physical plant containing adolescent clients.
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8. The program has at least one staff person present at
						  all time who maintains a valid certification in First Aid, CPR and CPI.
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9. The program, and any satellite facilities, maintain
						  suitably stocked first aid kits.
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10. Private residences shall not be used to provide
						  treatment unless:
a. There is a separate entrance to the area in which
						  services are rendered;
b. Services are provided in an area used exclusively
						  for treatment; and
c. Any private residence used for treatment shall be
						  pre-approved bytheBADAP.
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11. Hours of operation are scheduled to make services
						  accessible to clients and the general public. The hours are posted in such a
						  manner as to allow the viewing of the hours without entering the program. In
						  addition, the program's telephone number shall also be conspicuously
						  displayed.
12. The program shall not operate a new treatment site
						  or make major programmatic changes at a present site without BADAP
						  approval.
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