3793:2-1-03 Program administration.

(A) The purpose of this rule is to state the minimum program administration requirements that a program must meet in order to be certified or licensed by the Ohio department of alcohol and drug addiction services as an alcohol and drug addiction outpatient treatment program, residential treatment program, ambulatory or sub-acute detoxification program or licensed as an opioid agonist program.

(B) The provisions of this rule are applicable to all of the following Ohio alcohol and drug addiction programs, public and private, regardless of whether they receive any public funds that originate from and/or pass through the Ohio department of alcohol and drug addiction services, in accordance with division (A) of section 3793.06 of the Revised Code:

(1) Alcohol and drug addiction outpatient treatment programs.

(2) Alcohol and drug addiction residential treatment programs.

(3) Opioid agonist programs.

(4) Alcohol and drug addiction ambulatory detoxification programs.

(C) Deemed status shall be granted to waive paragraphs of the Administrative Code if the program:

(1) Is certified/licensed by the Ohio department of mental health. Deemed provisions include paragraphs (M), (N), (Q), (U) and (Y) of this rule.

(2) Is licensed by the Ohio department of jobs and family services. Deemed provisions include paragraphs (L) and (R) of this rule.

(D) The provisions of this rule are not applicable to the following programs:

(1) Alcohol and other drug prevention programs.

(2) Alcohol and drug addiction sub-acute detoxification and acute hospital detoxification programs.

(3) Criminal justice therapeutic community programs.

(4) Treatment alternatives to street crime programs.

(5) Driver intervention programs.

(E) Each program shall have a program director (or other similar title) who is responsible for the overall day-to-day operation of the alcohol and drug addiction program.

(F) The qualifications for an alcohol and drug addiction program director shall include at least the following knowledge and skills requirements:

(1) Bachelor's degree and a minimum of five years' experience in alcohol and other drug addiction services or an allied profession to include a minimum of two years as a supervisor or

(2) Minimum of six years' experience in alcohol and other drug addiction services or an allied profession to include a minimum of three years as a supervisor or

(3) Minimum of five years business administration experience to include a minimum of two years as a supervisor.

(G) The program shall have an annual revenue and expenditure budget that has been approved by the governing authority before the beginning of the program's fiscal year. Minutes of the governing authority shall reflect that approval.

(H) The program shall prepare monthly financial statements reflecting the financial position of the program. These statements shall be brought to the attention of the governing authority. Minutes of the governing authority shall reflect that the monthly financial statements have been brought to the attention of the governing authority.

(I) Each program shall account for funds in compliance with rules and regulations required by applicable funding sources.

(J) Where applicable, each program shall ensure that federal, state and local funds are spent in accordance with grant agreements, assurances, contracts and federal cost principles as each requirement relates to the source of funds and the funding agency.

(K) Programs that receive funds that originate from and/or pass through the alcohol, drug addiction and mental health services board, the alcohol and drug addiction services board and/or the Ohio department of alcohol and drug addiction services shall have an audit/review conducted in accordance with the department's financial and compliance audit guidelines for alcohol and other drug addiction programs and agencies receiving state and other funding.

(L) Programs that do not receive funds that originate from and/or pass through the alcohol, drug addiction and mental health services board, the alcohol and drug addiction services board and/or the Ohio department of alcohol and drug addiction services shall, at a minimum, have an audit/review conducted in accordance with generally accepted auditing standards. Programs may utilize additional standards as designated by their funding entities as long as the required audits meet these minimum standards.

(M) Each program shall have policies and procedures regarding communication assistance for limited-English proficient clients, family members or significant others as required by state and federal law.

(N) Each program shall have policies and procedures regarding auxiliary aids for sensory-impaired clients, family members or significant others, including the sight and hearing impaired as required by state and federal law.

(O) Each program shall establish and maintain written personnel policies and procedures that comply with relevant federal, state and local statutes and regulations including, at a minimum, the following:

(1) Assurance of non-discrimination against any person or group of persons on the basis of race, ethnicity, age, color, religion, sex, national origin, sexual orientation or disability in the recruitment, selection, promotion, evaluation or retention of employees or volunteers.

(2) Provisions for providing cultural sensitivity training to staff.

(3) Policy prohibiting sexual harassment.

(4) Employment recruitment and selection process.

(5) Provisions for promotion, discipline and termination of employment.

(6) Annual performance evaluation of each employee.

(7) Program employee grievance procedure.

(8) Staff development.

(9) Employee benefits (e.g. retirement plans, annuities, insurance, sick leave, vacation leave and other leave).

(10) Standards of acceptable behavior for all program employees.

(11) Overtime and compensatory time policies and/or procedures.

(12) Policy ensuring that a copy of the program's personnel policies and procedures is available to each employee.

(13) Procedure for notifying employees of changes in personnel polices and procedures.

(14) Policy permitting each employee the right to review his/her own personnel file and procedures for doing this.

(15) Procedure that states that employment applicants shall be informed that the program follows the rules and regulations governing fair employment practices, that the applicant's right to privacy shall be respected, and that the results of inquiries shall be treated in confidence by the program.

(16) Policy prohibiting an individual from supervising any person closely related by blood, marriage or other significant relationship including business associate.

(a) "Closely related by blood or marriage" is defined to include, but is not limited to, spouse, children (whether dependent or independent), parents, grandparents, siblings, aunts, uncles, in-laws, steps and other persons related by blood or marriage who reside in the same household.

(b) "Significant relationship" means persons living together as a spousal or family unit when not legally married or related where the nature of the relationship may impair the objectivity or independence of judgment of one individual working with the other.

(c) "Business associates" are defined as parties who are joined together in a relationship for business purposes or acting together to pursue a common business purpose or enterprise.

(d) "Supervision" means the direct ability or power to effectively recommend the hire, suspension, layoff, promotion, discharge, reward or discipline of a person.

(P) A personnel file shall be maintained for each employee, contract staff, volunteer and student intern conducting program activities. Personnel files shall contain, at a minimum, the following when applicable:

(1) Employment application and/or resume.

(2) Copy of notification of hiring, to include starting date, position and starting salary or wage for those employees hired after the effective date of this rule.

(3) Verification or copies of current professional licenses and/or certifications and/or registration from professional regulatory boards in Ohio of each alcohol and drug addiction service provider. If verification by a staff member of the organization is used in lieu of a copy of the credential, each verification must include the employee's name, social security number, name of regulatory board in Ohio which issued the certification/license, certification/license number and expiration date of the license. The staff member verifying the credential must date and sign the verification document.

(4) The personnel file of each alcohol and drug services provider and supervisor shall include documentation of education, training and experience to demonstrate competency in providing and/or supervising alcohol and drug addiction services.

(5) Position description.

(6) Annual performance evaluation.

(7) Documentation that the employee has reviewed and agreed to abide by the federal regulations on the confidentiality of alcohol and drug abuse patient records (Title 42, Code of Federal Regulations, part 2).

(8) Documentation to reflect that the employee has received a copy of the following and has agreed to abide by each of them:

(a) Program's personnel policies and procedures.

(b) Program's client abuse/neglect policy.

(c) Program's client rights policy.

(d) Program's client grievance procedure.

(9) For contract staff, a signed copy of his/her contract with the program.

(Q) A position description shall be established for each employee of the program. Each position description shall include, at a minimum, the following:

(1) Job title.

(2) Supervisor to whom the person holding this position is responsible.

(3) Duties/responsibilities.

(4) Minimum qualifications for the position (knowledge/skills).

(5) Credentials and academic requirements, if applicable.

(6) Subordinates (positions supervised by person holding this position).

(R) Each alcohol and drug addiction program serving children and/or adolescents shall have a policy which states the following:

(1) Each employee and/or contract staff hired after June 13, 2004 and/or volunteer and student intern utilized in positions which are responsible for the direct care or supervision of children and/or adolescents shall:

(a) Be at least twenty-one years of age.

(b) Possess a high school diploma or equivalency certificate.

(c) Meet the policies set forth in paragraphs (R)(2) and (R)(3) of rule 3793:2-1-03 of the Administrative Code.

(2) The policy shall state that a prospective employee, volunteer or student intern has not pled guilty to nor been convicted of any of the offenses listed in paragraph (I) of rule 5101:2-5-09 of the Administrative Code. A prospective employee, adult volunteer or student intern convicted of or who has pleaded guilty to an offense listed in paragraph (I) of rule 5101:2-5-09 of the Administrative Code may be hired by an agency if the conditionsas provided in paragraph (H) of rule 5102:2-5-09 of the Administrative Codehave been met.

(3) The policy shall state that the agency shall require that criminal records checks on employees, volunteers and student interns be conducted by the bureau of criminal identification and investigation (BCII) and, if the prospective employee does not demonstrate that he/she has been a resident of Ohio for the preceding five years, by the federal bureau of investigation (FBI).

(S) Each alcohol and drug addiction residential or halfway house program for adults that includes child care shall have a policy which states that:

(1) Each employee, contract staff, volunteer or student intern which is responsible for the direct care of children shall:

(a) Be at least eighteen years of age and

(b) Possess a high school diploma or equivalency certificate.

(2) The policy shall state that a prospective employee, adult volunteer or student intern has not pled guilty to nor been convicted of any of the offenses listed in paragraph (I) of rule 5101:2-5-09 of the Administrative Code. A prospective employee, adult volunteer or student intern convicted of or who has pleaded guilty to an offense listed in paragraph (I) of rule 5101:2-5-09 of the Administrative Code may be hired by an agency if the conditionsas provided in paragraph (H) of rule 5101:2-5-09 of the Administrative Code have been met.

(3) The policy shall state that the agency shall require that criminal records checks on prospective employees, adult volunteers and student interns be conducted by the bureau of criminal identification and investigation (BCII) and, if the prospective employee does not demonstrate that he/she has been a resident of Ohio for the preceding five years, by the federal bureau of investigation (FBI).

(T) Each program shall have an affirmative action plan that includes the stated goal that the program will attempt to have staff who reflect, as nearly as possible, the racial composition of its service area.

(U) Each program shall have a plan that includes the stated goal that the program will address the need for culturally specific and relevant programming for ethnic minorities, deaf or hearing impaired and others:

(V) Each program shall have a written policy or procedure for handling cases of client abuse and/or neglect by employees, contract staff, student interns and volunteers that includes notifying appropriate professional regulatory boards and law enforcement authorities when applicable.

(W) Each alcohol and drug addiction treatment program shall:

(1) Maintain a client information system which meets specifications established by the Ohio department of alcohol and drug addiction services for collecting socio-demographic information and data on alcohol/drug addiction services provided by the program.

(2) Maintain a financial management information system which meets specifications established by the department for collecting financial information related to alcohol/drug addiction services provided by the program.

(3) Participate in information surveys conducted or sponsored by the Ohio department of alcohol and drug addiction services.

(X) Each program shall identify a location (street address, city and county) as a primary place for conducting business. This standard does not prohibit alcohol and drug addiction services from being provided in the natural environment of a client, for example, place of residence, work place or school.

(1) Each agency shall designate a safety officer who will be responsible for ensuring that each program site is in compliance with the physical plant and safety requirements of this rule.

(2) The program shall have on file a copy of a "certificate of use and occupancy" for each program site where alcohol and drug addiction services are provided in accordance with the Ohio basic building code and rule 4101:2-1-27 of the Administrative Code.

(3) The program shall have on file a copy of the report of an annual fire inspection by a certified fire authority, or where none is available, by the division of the state fire marshal of the Ohio department of commerce, for each program site where alcohol and drug addiction services are provided.

(4) The program shall have a fire and evacuation plan for each program site where alcohol and drug addiction services are provided.

(5) If a program has a swimming pool, the program shall maintain documentation to reflect that the swimming pool is being maintained in compliance with the requirements of section 3749.04 of the Revised Code.

(6) A program is prohibited from using freestanding wood burning stoves or unvented kerosene, gas or oil heaters at its site.

(7) The program shall have sufficient office space to allow privacy between a counselor and a client.

(8) Each program site shall meet, at a minimum, the following handicapped accessibility requirements, or have on file a copy of a plan for meeting these requirements that has been approved by the Ohio department of alcohol and drug addiction services' equal employment opportunity regional program administrator.

(a) Entrances, hallways, spaces where services are provided and office space for employees shall be handicapped accessible.

(b) The programs shall have at least one handicapped accessible bathroom.

(c) Residential treatment programs shall have handicapped accessible shower facilities.

(d) The program shall have designated handicapped parking space(s) based on the Americans with Disabilities Act accessibility guidelines.

(e) At least one drinking fountain that is handicapped accessible shall be available.

(f) At least one telephone that is handicapped accessible shall be available.

(Y) Each program shall have written policies and/or procedures for universal infection control for each program site.

(1) Each program shall provide training and education on infection control to all employees, contract staff, student interns and volunteers.

(2) Each program shall have a written policy and/or procedure for the reporting of communicable diseases in accordance with Chapter 3701-3 of the Administrative Code.

(Z) Each program shall be in compliance with the Federal Department of Transportation Omnibus Transportation Testing Act of 1991 and the Drug-Free Workplace Act of 1988 regarding federal drug-free workplace regulations, when applicable.

(AA) Closing a program:

(1) If a program certified/licensed by the Ohio department of alcohol and drug addiction services voluntarily closes its alcohol and drug addiction program, it shall give a thirty-day advance written notice to each of its current clients which specifies the date that the program will close.

(a) A copy of this notice shall be placed in each client's clinical record.

(b) A copy of this notice shall be sent to the:

(i) Unit of the Ohio department of alcohol and drug addiction services responsible for compliance and certification/licensure of programs.

(ii) Applicable alcohol and drug addiction services board or alcohol, drug addiction and mental health services board.

(c) A program close-out audit shall be conducted which shall meet the Ohio department of alcohol and drug addiction services' guidelines and federal office of management and budget circulars.

(2) If it appears that a client will require ongoing alcohol and drug addiction services after the projected closing date of the program, the program shall:

(a) Refer the client to another program certified by the Ohio department of alcohol and drug addiction services for alcohol and drug addiction services or to an individual in private practice who is qualified to provide the services needed.

(b) Have documentation to ascertain that the program has accepted the client for admission. (A progress note by a case manager or clinician stating the date, time and place that the client is scheduled for an intake interview will meet the requirements of this standard).

(3) If a client is a minor, the program shall:

(a) Send a thirty-day advance notice, which specifies the date that the program will close to the minor client's parent or legal guardian and to the minor in accordance with section 3719.012 of the Revised Code.

(b) Refer the client to another program which offers the appropriate level of care and is certified by the Ohio department of alcohol and drug addiction services for alcohol and drug addiction services, or to an individual in private practice who is qualified to provide the services needed.

(c) Have documentation to ascertain that the program has accepted the client for admission. (A progress note by a case manager or clinician stating the date, time and place that the client is scheduled for an intake interview will meet the requirements of this standard).

(BB) Each organization that owns and/or operates an alcohol and drug addiction program shall be in compliance with all applicable federal, state and local laws and regulations in addition to the requirements of agency-level 3793 of the Administrative Code.

(CC) A program certified as an alcohol and drug addiction outpatient or residential treatment program or detoxification program by the Ohio department of alcohol and drug addiction services or licensed as a opioid agonist program at the time of the effective date of this rule shall remain certified/licensed until the expiration of its current certification/licensure. If it wants to continue to operate as an alcohol and drug addiction outpatient, residential treatment, detoxification program or opioid agonist program, it is required to apply to the department for program certification/licensure in accordance with this rule and rule 3793:2-1-01 of the Administrative Code.

Effective: 02/14/2011
R.C. 119.032 review dates: 11/10/2010 and 07/15/2015
Promulgated Under: 119.03
Statutory Authority: 3793.02(D) , 3793.06
Rule Amplifies: 3793.06
Prior Effective Dates: 7/1/91, 7/1/2001, 11/17/2005, 7/1/2006