Chapter 3793:5-1 General Provisions

3793:5-1-01 Prevention Standards - Certification Process.

(A) The purpose of this rule is to state the procedures that an agency must follow in order to receive alcohol and other drug prevention certification by the Ohio department of alcohol and drug addiction services.

(B) The provisions of this rule are applicable to all alcohol and other drug (AOD) prevention programs that include a facility or entity where a primary function of the facility/entity is the delivery of alcohol and other drug prevention programming and services. For the purposes of this rule, the words program, facility and/or entity shall be referred to as "agency".

(C) The provisions of this rule are not intended to regulate agencies and institutions with their own set of regulatory requirements and where the delivery of alcohol and other drug prevention programming and services is not a primary function of the agency. The Ohio department of alcohol and drug addiction services recognizes the extensive research which validates that effective alcohol and other drug prevention requires a multifaceted approach involving multiple sectors of the community. Many sectors of the community play a contributing role to ensure a comprehensive multifaceted and multiple sector approach in the delivery of effective alcohol and other drug prevention programming and services. Therefore, the following entities are not defined as alcohol and other drug prevention programs and the provisions of this rule are not applicable:

(1) Educational entities under the jurisdiction of the Ohio department of education;

(2) Educational entities under the jurisdiction of the Ohio board of regents;

(3) Law enforcement and judicial entities;

(4) ODADAS Certified Driver Intervention Programs;

(5) Agencies that are only engaged in information dissemination;

(6) Agencies where the delivery of alcohol and other drug prevention programming and services is not a primary function of the agency; and

(7) Agencies whose sites are physically located outside of the State of Ohio.

(D) Prevention Standards definitions:

(1) Alcohol and other drug prevention" focuses on preventing the onset of AOD use, abuse and addiction. AOD prevention includes addressing problems associated with AOD use and abuse up to, but not including assessment and treatment for substance abuse and dependence. AOD prevention is a proactive multifaceted, multi-community sector process involving a continuum of culturally appropriate prevention services which empowers individuals, families and communities to meet the challenges of life events and transitions by creating and reinforcing conditions that impact physical, social, emotional, spiritual, and cognitive well-being and promote safe and healthy behaviors and lifestyles. AOD prevention is a planned sequence of activities that, through the practice and application of evidence based prevention principles, policies, practices, strategies and programs, is intended to inform, educate, develop skills, alter risk behaviors, affect environmental factors and/or provide referrals to other services.

The term Alcohol and Other Drugs (AOD) includes, but is not limited to the following drugs of abuse - alcohol, tobacco, illicit drugs, inhalants, prescription and over-the-counter medications.

Culturally appropriate means the service delivery systems respond to the needs of the community being served as defined by the community and demonstrated through needs assessment activities, capacity development efforts, policy, strategy and prevention practice implementation, program implementation, evaluation, quality improvement and sustainability activities.

Evidenced Based Prevention means the prevention policies, strategies, programs and practices are consistent with prevention principles found through research to be fundamental in the delivery of prevention services; the prevention policies, strategies, programs and practices have been identified through research to be effective; the service delivery system utilizes evaluation of its policies, strategies, programs and practices to determine effectiveness; the service delivery system utilizes evaluation results to make appropriate adjustments to service delivery policies, strategies, programs and practices to improve outcomes.

(a) Prevention Service Categories by Population Served:

(i) Universal Prevention Services: Services target everyone regardless of level of risk before there is an indication of an AOD problem;

(ii) Selected Prevention Services: Services target persons or groups that can be identified as "at risk" for developing an AOD problem:

(iii) Indicated Prevention Services: Services target individuals identified as experiencing problem behavior related to alcohol and other drug use to prevent the progression of the problem. These services do not include clinical assessment and/or treatment for substance abuse and dependence.

(b) Prevention Service Delivery Strategies:

(i) Information Dissemination is an AOD prevention strategy that focuses on building awareness and knowledge of the nature and extent of alcohol and other drug use, abuse and addiction and the effects on individuals, families and communities, as well as the dissemination of information about prevention, treatment and recovery support services, programs and resources. This strategy is characterized by one-way communication from source to audience, with limited contact between the two;

(ii) Alternatives are AOD prevention strategies that focus on providing opportunities for positive behavior support as a means of reducing risk taking behavior, and reinforcing protective factors. Alternative programs include a wide range of social, recreational, cultural and community service/volunteer activities that appeal to youth and adults;

(iii) Education is an AOD prevention strategy that focuses on the delivery of services to target audiences with the intent of affecting knowledge, attitude and/or behavior. Education involves two-way communication and is distinguished from information dissemination by the fact that interaction between educator/facilitator and participants is the basis of the activities. Activities affect critical life and social skills including decision making, refusal skills, critical analysis and systematic judgment abilities;

(iv) Community-Based Process is an AOD prevention strategy that focuses on enhancing the ability of the community to provide prevention services through organizing, training, planning, interagency collaboration, coalition building and/or networking;

(v) Environmental prevention is an AOD prevention strategy that represents a broad range of activities geared toward modifying systems in order to mainstream prevention through policy and law. The environmental strategy establishes or changes written and unwritten community standards, codes and attitudes, thereby influencing incidence and prevalence of alcohol and other drug use/abuse in the general population;

(vi) Problem Identification and Referral is an AOD prevention strategy that refers to intervention oriented prevention services that primarily targets indicated populations to address the earliest indications of an AOD problem. Services by this strategy focus on preventing the progression of the problem. This strategy does not include clinical assessment and/or treatment for substance abuse and dependence.

(2) "Alcohol and other drug prevention program" means an agency that owns and/or has administrative responsibility for the operation and delivery of alcohol and other drug prevention programming and services as a primary function of the agency.

(3) "Consumer" means a person who receives alcohol and/or other drug prevention services.

(4) "Executive director" means an individual responsible for the day-to-day operations of an agency.

(5) "Governing authority" means an individual, board or other entity that has ultimate responsibility for the management, operation and control of the agency as designated by laws, by articles of incorporation, by another written document which creates or governs the operations of an agency or by ownership of assets or a sole proprietorship.

(6) "Natural environment" includes, but is not limited to locations where a consumer lives, works or attends school.

(7) "Primary Function" means the agency owns and/or has administrative responsibility for the operations and delivery of alcohol and other drug prevention programming and services and the agency's official documents such as but not limited to by-laws, articles of incorporation, policies or mission/purpose documents include statements that reflect the same.

(a) Where the primary function of the agency is in question, the Ohio department of alcohol and drug addiction services certification specialists will determine if an agency meets the definition of program and primary function through the review of the agency's official documents and alcohol and other drug prevention programming and services in consultation with the county Alcohol, Drug Addiction and Mental Health Services or Alcohol Drug Addiction Services Board Executive Director and the executive director of the agency being considered for prevention certification.

(b) Ohio department of alcohol and drug addiction services certified treatment agencies that also provide alcohol and other drug prevention programming and services must apply for prevention certification.

(8) "Site" means the agency's primary place for delivering prevention services or the administrative office if prevention services are provided in the consumer's natural environment.

(9) "Volunteer" means an uncompensated individual involved in the on-going provision of prevention services. This definition does not apply to volunteers whose sole purpose is to perform administrative functions or other ancillary activities that may include, but are not limited to, chaperoning a single event, assisting in or serving food at events, performing administrative support duties, etc.

(10) "Variance" means written permission granted by the Ohio department of alcohol and drug addiction services to an agency to be exempted from or meet a modified requirement of a rule or specific provision of a rule of the Administrative Code or other certification standard. The department will track all approved variances as a means to identify opportunities for continuous improvement to these rules.

(E) Each agency, except government owned agencies, shall be registered to do business in Ohio with the Ohio Secretary of State and shall have on file a copy of this registration.

(1) If the agency is a non-profit organization, the agency shall submit an application for continued existence to the Ohio Secretary of State as required by statute. The agency shall have on file a copy of the approved statement of continued existence for the corporation approved by the Ohio Secretary of State.

(2) If the agency is owned by an out-of-state corporation, the agency shall have on file a copy of the license to do business in Ohio which is issued by the Ohio Secretary of State.

(F) Procedure for processing an application for certification: For agencies not currently certified as an AOD prevention provider.

(1) Any Ohio alcohol and other drug prevention agency subject to or seeking prevention certification pursuant to division (A) of section 3793.06 of the Revised Code shall apply to the Ohio department of alcohol and drug addiction services by filing an application that includes, but is not limited to, the following information for each site to be certified by the department:

(a) Name, address, telephone number and county of each site to be certified by the Ohio department of alcohol and drug addiction services. The client's natural environment (e.g. school, home, job and family services agency) is not considered a site and therefore would not be certified.

(b) Business hours of operation for the agency.

(c) The alcohol and other drug prevention services the agency provides.

(d) Copy of an Ohio food services operator's license if required by the Ohio Department of Health.

(e) Copy of an occupancy and use certificate issued by the division of construction compliance of the Ohio department of commerce or issued by an Ohio certified building department of a municipal corporation, township or county which has been established in conformity with law for the purpose of enforcing the "Ohio Basic Building Code" for the location where prevention services will be provided except for those locations considered as the consumer's natural environment.

(f) Copy of a current annual fire inspection by an Ohio certified fire authority or by the division of the state fire marshal of the Ohio department of commerce for the location where services will be provided except for those locations considered as the consumer's natural environment.

(g) A copy of the owner's current registration for doing business in Ohio that has been filed with the Ohio secretary of state.

(h) If the owner is an out-of-state corporation, a copy of the license from the Ohio secretary of state for doing business in Ohio.

(i) If the owner is a non-profit organization, a copy of the approved statement of continued existence approved by the Ohio Secretary of State.

(j) Agencies requesting a variance or an extension of a variance for one or more of the certification standards shall include a copy of the request with the certification application. Each variance request shall be prepared and submitted in accordance with this rule.

(k) The application shall be signed and dated by the executive director, CEO or president of the organization.

(2) Upon receipt of an application, the Ohio department of alcohol and drug addiction services shall review the materials to determine if they are complete.

(a) If an application is incomplete, the department shall notify the applicant of corrections or additions needed and/or may return the materials to the applicant.

(b) The department's return of the materials to the applicant or failure of the department to take further action to issue a certificate shall not constitute denial of an application for certification.

(3) Upon acceptance of an application the Ohio department of alcohol and drug addiction services shall contact the agency to schedule an on-site inspection.

(a) The department shall send the agency a letter confirming the date of the on-site inspection.

(b) The department shall notify, in writing, the applicable alcohol and drug addiction services board or the alcohol, drug addiction and mental health services board of the date of the on-site inspection.

(4) The Ohio department of alcohol and drug addiction services shall conduct an on-site inspection at the time of application, with official written notice to the agency, or at any other time for cause as determined by the department, with or without official written notice to the agency.

(5) The Ohio department of alcohol and drug addiction services shall have access to all agency records related to prevention services. The department may conduct interviews with members of the agency's governing authority, prevention staff, others in the community and/or consumers with the consumers' permission.

(6) The Ohio department of alcohol and drug addiction services shall prepare a follow-up inspection report for the on-site inspection of the prevention agency.

(a) The inspection report shall cite any standards with which the agency was not in compliance at the time of the on-site inspection.

(b) The Ohio department of alcohol and drug addiction services shall provide a copy of the on-site inspection report to the agency and to the applicable alcohol and drug addiction services board or the alcohol, drug addiction and mental health services board.

(c) Agencies shall correct deficiencies identified during a certification inspection conducted by the Ohio department of alcohol and drug addiction services and documentation of correction of the deficiencies shall be sent to the department within the time frame specified in the follow-up inspection report.

(7) The Ohio department of alcohol and drug addiction services shall issue a certificate to each applicant complying with the certification standards.

(a) Certificates for the provision of prevention services shall not exceed three years.

(b) The department shall provide the agency with the original certificate, and provide a copy of the certificate to the applicable alcohol and drug addiction services board or the alcohol, drug addiction and mental health services board.

(c) The prevention agency shall display the certificate in a prominent location.

(G) Conditional certification.

(1) Conditional certification may be granted by the Ohio department of alcohol and drug addiction services to enable the agency to obtain consumers, to establish and maintain activity/consumer records, to implement quality improvement activities and/or to correct deficiencies identified during an on-site certification inspection.

(2) The Ohio department of alcohol and drug addiction services may issue a conditional certification for a maximum period of ninety days.

(a) Conditional certifications expire on the last day of a calendar month.

(b) Failure to comply with the terms of the conditional certification may result in a non-certified status.

(H) Relocation of a certified agency shall render the certification void. Void certificates shall be returned to the Ohio department of alcohol and drug addiction services.

(1) An agency shall submit an application for certification of a new site to the Ohio department of alcohol and drug addiction services at least thirty days prior to relocation to avoid possible non-certified status of the agency.

(2) Upon acceptance of an application, the Ohio department of alcohol and drug addiction services may conduct an on-site inspection of the new site for compliance with certification standards for physical plant and safety and any other certification standards deemed appropriate by the Ohio department of alcohol and drug addiction services.

(3) Certificates issued as a result of a relocation of an agency shall have the same expiration date as the certification of the original agency site.

(I) Procedure for renewal of prevention certification for currently certified prevention agencies:

(1) Any Ohio alcohol and other drug prevention agency seeking renewal of prevention certification pursuant to Division (A) of Section 3793.06 of the Revised Code shall submit a renewal application, upon receipt, to the Ohio department of alcohol and drug addiction services that includes, but is not limited to, verification of the following information for each site to be certified by the department.

(a) Name, address, telephone number, and county of each site to be certified by the Ohio department of alcohol and drug addiction services. A location which would be considered the consumer's natural environment (e.g. school, home, job and family services agency) is not considered a site and need not be certified.

(b) Business hours of operation for alcohol and other drug prevention services.

(c) The alcohol and other drug prevention services provided.

(d) Copy of a current annual fire inspection by an Ohio-certified fire authority or by the division of the State Fire Marshal of the Ohio Department of Commerce for the location where services will be provided.

(e) Agencies requesting a variance or an extension of a variance for one or more of the prevention certification standards shall include a copy of the request with the certification application. Each variance request shall be prepared and submitted in accordance with this rule.

(f) An assurance statement, signed and dated by the executive director, CEO or president of the organization, which states that the agency shall comply with the prevention certification standards for each certified site for the duration of its three-year certification period.

(g) The application shall be signed and dated by the executive director, CEO or president of the organization.

(2) Upon receipt of a renewal application, the Ohio department of alcohol and drug addiction services shall review the materials to determine if they are complete.

(a) If an application is incomplete, the department shall notify the applicant of corrections or additions needed and/or may return the materials to the applicant.

(b) The department's return of the materials to the applicant or failure of the department to take further action to issue a certificate shall not constitute denial of an application for certification.

(3) Upon approval of the renewal application, the department shall issue a certificate valid for up to a three-year period beginning from the date of issue.

(a) The department shall provide the agency with the original certificate and provide a copy of the certificate to the applicable alcohol and drug addiction services board or the alcohol and drug addiction and mental health services board.

(b) The prevention agency shall display the certificate in a prominent location.

(4) The Ohio department of alcohol and drug addiction services shall contact the agency to schedule an on-site inspection within the three-year certification period. Reviews will be scheduled with a minimum 90-day notice.

(a) The department shall send the agency a letter confirming the date of the on-site inspection.

(b) The department shall notify, in writing, the applicable alcohol and drug addiction services board or the alcohol, drug addiction and mental health services board of the date of the on-site inspection.

(5) The Ohio department of alcohol and drug addiction services shall conduct an on-site inspection within the three-year certification period with official written notice to the agency, or at any other time for cause as determined by the department, with or without official written notice to the agency.

(6) The Ohio department of alcohol and drug addiction services shall have access to all prevention related records to verify compliance with certification standards. The department may conduct interviews with members of the agency's governing authority, prevention staff, others in the community and/or consumers with the consumers' permission.

(7) The Ohio department of alcohol and drug addiction services shall prepare a follow-up inspection report for the on-site inspection.

(a) The inspection report shall cite any prevention standards with which the agency was not in compliance at the time of the on-site inspection.

(b) The Ohio department of alcohol and drug addiction services shall provide a copy of the on-site inspection report to the agency and to the applicable alcohol and drug addiction services board or the alcohol, drug addiction and mental health services board.

(c) Agencies shall correct deficiencies identified during a certification inspection conducted by the Ohio department of alcohol and drug addiction services. Documentation of correction of the deficiencies shall be sent to the department within the time frame specified in the follow-up inspection report.

(J) The Ohio department of alcohol and drug addiction services certifies sites. Each prevention certification issued by the department is for a specific address. Certificates are not transferable to any other agency or to other agency sites.

(K) Variances.

(1) The Ohio department of alcohol and drug addiction services may grant a variance from any certification standard, or portion thereof, for the period during which the certification is in effect.

(2) Requests for variances of certification standards shall be in writing to the Ohio department of alcohol and drug addiction services and shall include:

(a) The administrative rule number and standard for which a variance is sought.

(b) The rationale for requesting the variance.

(c) Documentation by the agency that assures the Ohio department of alcohol and drug addiction services that the quality of services and consumer safety shall not be jeopardized if the variance is granted.

(d) The consequences of not receiving approval of the requested variance.

(3) The Ohio department of alcohol and drug addiction services shall issue a written statement to the agency granting or denying a request for variance of certification standards. A copy of the written statement shall be provided to the applicable alcohol and drug addiction services board or alcohol, drug addiction and mental health services board.

(4) The agency shall maintain a file copy of all requests for variances and the approval or denial of the requests for the period during which the certification is in effect.

(L) The Ohio department of alcohol and drug addiction services may deny or revoke certification for one or more of the following reasons:

(1) The agency fails to comply with any certification standard;

(2) The agency misuses or fails to properly account for the disbursement of state or federal funds;

(3) The agency knowingly provides false information to: the Ohio department of alcohol and drug addiction services, an alcohol and drug addiction services board or an alcohol, drug addiction and mental health services board or other entity;

(4) The agency knowingly permits an employee to falsify any records pertaining to the consumer;

(5) The agency is aware of an employee, volunteer or students who has abused or neglected a consumer and has failed to take appropriate disciplinary or legal action to correct the situation;

(6) The agency fails to provide access to its records as requested by the Ohio department of alcohol and drug addiction services.

(7) Denial, revocation or termination would be in the best interest of the citizens of Ohio.

(M) The Ohio department of alcohol and drug addiction services shall give the agency written notice by certified mail, return receipt requested, if it intends to deny or revoke certification. The notice shall include:

(1) The standard(s) with which the agency was found to be in non-compliance and/or other reason(s) for the action.

(2) The section(s) of the law or rule(s) involved.

(3) A statement informing the agency that it is entitled to a hearing if it requests it within thirty days of the time of the mailing of the notice.

(4) A statement that at the hearing, the agency's representative may appear in person and/or be represented by its attorney or may present its position, arguments or comments in writing and at the hearing it may present evidence and examine witnesses appearing for and against it. A copy of the notice shall be mailed to the attorney or other representative of record representing the agency.

(N) If an agency requests a hearing, the Ohio department of alcohol and drug addiction services shall set the date, time and place for the hearing within fifteen days, but not earlier than seven days, after the agency has requested a hearing unless otherwise agreed upon by both the department and the agency. A copy of the hearing notice shall be mailed to the agency's representative or its attorney.

(1) The Ohio department of alcohol and drug addiction services shall conduct the adjudication hearing following the procedures in section 119.09 of the Revised Code and among other things may appoint a referee or hearing examiner to conduct the proceedings and make recommendations as appropriate.

(2) The Ohio department of alcohol and drug addiction services shall provide the agency a certified copy of its decision by certified mail, return receipt requested.

(3) If the Ohio department of alcohol and drug addiction services' decision after the hearing is to deny or revoke certification, the agency shall be informed of its right to appeal and file its notice of appeal of the decision within fifteen days of the mailing of the notice of the department's order.

(4) If the agency decides to appeal the Ohio department of alcohol and drug addiction services' decision, the agency shall appeal the order of the department to the court of common pleas of the county in which the agency's place of business is located. The agency's notice of appeal is to be filed with the department and must state the order appealed from and the grounds of the appeal. A copy of the agency's appeal must be filed with the court of common pleas in the county in which the appeal is being filed.

(5) Within thirty days after receipt of a notice of appeal, the Ohio department of alcohol and drug addiction services shall send to the common pleas court a complete record of the proceedings in the case by certified mail, return receipt requested.

(O) Any person who violates the provisions of these rules shall be subject to the penalties provided in section 3793.99(B), (C), and (D) of the Revised Code.

(P) Sanction:

(1) Any agency which has had its certification revoked pursuant to this rule shall not be eligible to apply to the Ohio department of alcohol and drug addiction services for certification for at least five years from the date of revocation without the written consent of the department.

(2) Any agency which has been denied certification pursuant to this rule shall not be eligible to apply to the Ohio department of alcohol and drug addiction services for certification for at least three years from the date of denial without the written consent of the department.

(Q) Certification shall be considered void and invalid if an agency: fails to reapply, voluntarily relinquishes certification, moves to another location, goes out of business or is sold or otherwise conveyed to another entity.

(R) The agency shall immediately notify the Ohio department of alcohol and drug addiction services and the applicable alcohol and drug addiction services board or alcohol, drug addiction and mental health services board in writing of any changes in its operations that affect the agency's continued compliance with the department's certification requirements.

(S) All agencies shall be in compliance with all applicable federal, state and local laws and regulations.

(T) Agencies providing alcohol and other drug prevention services, as defined in this rule, will have three years from the effective date of this rule to make application and become certified by the Ohio department of alcohol and drug addiction services.

Effective: 10/01/2006
R.C. 119.032 review dates: 09/30/2011
Promulgated Under: 119.03
Statutory Authority: 3793.02(D) , 3793.06
Rule Amplifies: 3793.06

3793:5-1-02 Prevention Standards - Governing Authority.

(A) The purpose of this rule is to state the governing authority requirements that an agency must meet in order to receive alcohol and other drug prevention certification by the Ohio Department of Alcohol and Drug Addiction Services.

(B) The provisions of this rule are applicable to all alcohol and other drug prevention programs that include a facility or entity where a primary function of the facility/entity is the delivery of alcohol and other drug prevention programming and services. For the purposes of this rule, the words program, facility and/or entity shall be referred to as "agency".

(C) Prevention Standards definitions:

(1) "Alcohol and other drug prevention" focuses on preventing the onset of AOD use, abuse and addiction. AOD prevention includes addressing problems associated with AOD use and abuse up to, but not including assessment and treatment for substance abuse and dependence. AOD prevention is a proactive multifaceted, multi-community sector process involving a continuum of culturally appropriate prevention services which empowers individuals, families and communities to meet the challenges of life events and transitions by creating and reinforcing conditions that impact physical, social, emotional, spiritual, and cognitive well-being and promote safe and healthy behaviors and lifestyles. AOD prevention is a planned sequence of activities that, through the practice and application of evidence based prevention principles, policies, practices, strategies and programs, is intended to inform, educate, develop skills, alter risk behaviors, affect environmental factors and/or provide referrals to other services.

The term Alcohol and Other Drugs (AOD) includes, but is not limited to the following drugs of abuse - alcohol, tobacco, illicit drugs, inhalants, prescription and over-the-counter medications.

Culturally appropriate means the service delivery systems respond to the needs of the community being served as defined by the community and demonstrated through needs assessment activities, capacity development efforts, policy, strategy and prevention practice implementation, program implementation, evaluation, quality improvement and sustainability activities.

Evidenced Based Prevention means the prevention policies, strategies, programs and practices are consistent with prevention principles found through research to be fundamental in the delivery of prevention services; the prevention policies, strategies, programs and practices have been identified through research to be effective; the service delivery system utilizes evaluation of its policies, strategies, programs and practices to determine effectiveness; the service delivery system utilizes evaluation results to make appropriate adjustments to service delivery policies, strategies, programs and practices to improve outcomes.

(a) Prevention Service Categories by Population Served:

(i) Universal Prevention Services: Services target everyone regardless of level of risk before there is an indication of an AOD problem;

(ii) Selected Prevention Services: Services target persons or groups that can be identified as "at risk" for developing an AOD problem;

(iii) Indicated Prevention Services: Services target individuals identified as experiencing problem behavior related to alcohol and other drug use to prevent the progression of the problem. These services do not include clinical assessment and/or treatment for substance abuse and dependence;

(b) Prevention Service Delivery Strategies:

(i) Information Dissemination is an AOD prevention strategy that focuses on building awareness and knowledge of the nature and extent of alcohol and other drug use, abuse and addiction and the effects on individuals, families and communities, as well as the dissemination of information about prevention, treatment and recovery support services, programs and resources. This strategy is characterized by one-way communication from source to audience, with limited contact between the two;

(ii) Alternatives are AOD prevention strategies that focus on providing opportunities for positive behavior support as a means of reducing risk taking behavior, and reinforcing protective factors. Alternative programs include a wide range of social, recreational, cultural and community service/volunteer activities that appeal to youth and adults;

(iii) Education is an AOD prevention strategy that focuses on the delivery of services to target audiences with the intent of affecting knowledge, attitude and/or behavior. Education involves two-way communication and is distinguished from information dissemination by the fact that interaction between educator/facilitator and participants is the basis of the activities. Activities affect critical life and social skills including decision making, refusal skills, critical analysis and systematic judgment abilities;

(iv) Community-Based Process is an AOD prevention strategy that focuses on enhancing the ability of the community to provide prevention services through organizing, training, planning, interagency collaboration, coalition building and/or networking;

(v) Environmental prevention is an AOD prevention strategy that represents a broad range of activities geared toward modifying systems in order to mainstream prevention through policy and law. The environmental strategy establishes or changes written and unwritten community standards, codes and attitudes, thereby influencing incidence and prevalence of alcohol and other drug use/abuse in the general population;

(vi) Problem Identification and Referral is an AOD prevention strategy that refers to intervention oriented prevention services that primarily targets indicated populations to address the earliest indications of an AOD problem. Services by this strategy focus on preventing the progression of the problem. This strategy does not include clinical assessment and/or treatment for substance abuse and dependence.

(2) "Alcohol and other drug prevention program" means an agency that owns and/or has administrative responsibility for the operation and delivery of alcohol and other drug prevention services as a primary function of the agency.

(3) "Deemed Status" means that on-site review by the Ohio department of alcohol and drug addiction services of certain sections of the administrative code shall be waived for those agencies that own or operate a treatment program currently certified under Agency Rule 3793:2-1-08.Designatedsections of this rule shall be deemed for an agency not certified by ODADAS which has received national accreditation that included the prevention services, and demonstrates that the deemed sections within this rule are consistent with the national accreditation.

(4) "Executive Director" means an individual responsible for the day-to-day operations of an agency.

(5) "Governing Authority" means an individual, board or other entity that has ultimate responsibility for the management, operation and control of the agency as designated by laws, by articles of incorporation, by another written document which creates or governs the operations of an agency by ownership of assets or a sole proprietorship.

(6) "National Accreditation" means an organization that is recognized nationally as an accreditation body, including but not limited to, Commission on Accreditation of Rehabilitation Facilities (CARF), Council on Accreditation for Children and Family Services (COA), Joint Commission of Accreditation of Healthcare Organizations (JCAHO).

(7) "Primary Function" means the agency's owns and/or has administrative responsibility for the operation and delivery of alcohol and other drug prevention programming and services and the agency's official documents such as but not limited to by-laws, articles of incorporation, policies or mission/purpose documents include statements that reflect the same.

(a) Where the primary function of the agency is in question, the Ohio department of alcohol and drug addiction services certification specialists will determine if an agency meets the definition of program and primary function through the review of the agency's official documents and alcohol and other drug prevention programming and services in consultation with the county Alcohol, Drug Addiction and Mental Health Services or Alcohol Drug Addiction Services Board Executive Director and the executive director of the agency being considered for prevention certification

(b) Ohio department of alcohol and drug addiction services certified treatment agencies that also provide alcohol and other drug prevention programming and services must apply for prevention certification

(8) "Student" means an individual enrolled in an educational institution and supervised by an individual qualified to provide prevention services pursuant to Agency Level 3793:5-1-05.

(9) "Volunteer" means an uncompensated individual involved in the on-going provision of prevention services. This definition does not apply to volunteers whose sole purpose is to perform administrative functions or other ancillary activities that may include, but are not limited to, chaperoning a single event, assisting in or serving food at events, performing administrative support duties, etc.

(D) Deemed status shall be granted to waive sections of the Administrative Code if the agency that owns or operates a treatment program(s) with current certification from the Ohio Department of Alcohol and Drug Addiction Services under Agency Level 3793 of the Administrative Code or has achieved national accreditation as defined in this rule. Deemed provisions include: (E), (F), (G), (H), (I), (J), (K) and (L) of this rule.

(E) Each agency, including government-owned agencies, shall have on file a copy of the signed W-9 form, request for taxpayer identification number and certification.

(F) Each agency shall have a governing authority.

(1) The governing authority for a corporation shall be a board of directors/trustees.

(2) The governing authority for a partnership shall be the partners as specified in their registration with the Ohio Secretary of State.

(3) The governing authority for a limited liability company shall be the members as specified in their registration with the Ohio Secretary of State.

(4) The governing authority for a government organization shall be the appointing authority of a department, division, bureau or other government office.

(5) The governing authority for a sole proprietorship is the sole proprietor.

(G) Each agency whose governing authority is a board of directors, shall have written policies, code of regulations and/or by-laws that include but are not limited to the following:

(1) Procedure for selecting members of the governing authority.

(2) Statement of the number of members of the board of directors needed for a quorum at meetings of the board of directors.

(3) Provisions for guarding against the development of, and prohibiting the existence of, a conflict of interest between a member of the board of directors and the agency.

(4) Provisions for orienting new members of the board of directors.

(H) Each agency (corporation, partnership, limited liability company, sole proprietorship and/or government organization) shall have written policies, code of regulations, articles of incorporation and/or by-laws, as applicable, stating the responsibilities of the governing authority and shall maintain documentation that includes, at a minimum, the following:

(1) Establishing the duties and responsibilities of the staff member responsible for the overall day-to-day operation of the alcohol and other drug prevention services, if applicable.

(2) Selecting a staff member responsible for the overall day-to-day operation of the alcohol and other drug prevention services, if applicable.

(3) Conducting meetings of the governing authority at least quarterly and maintaining minutes of these meetings, if applicable.

(4) Approving the prevention services that the agency will provide, if applicable.

(5) Approving and revising, as necessary, the agency's policies for operating prevention services, if applicable.

(6) Approving an annual budget for prevention services, if applicable.

(7) Reviewing the annual audit report of the agency conducted in accordance with this rule, if applicable.

(8) Reviewing the agency's annual quality improvement plan, if applicable.

(I) The agency shall maintain a roster of the members of the board of directors and their professional affiliations, if applicable.

(J) Each agency shall have a current table of organization that:

(1) Reflects the relationship of the agency to the governing authority.

(2) Reflects each position, including employees, contract staff, students and volunteers who provide prevention services for the agency.

(3) Includes the date and original signature of the Chief Executive Officer or Executive Director of the agency.

(K) The governing authority is responsible for ensuring that the agency is operated in accordance with the following:

(1) All applicable federal and state laws, regulations and rules, to include non-discrimination provisions for employment and services provided.

(2) Local ordinances and regulations.

(3) Local zoning regulations.

(4) Agency policies and procedures as required by this rule.

(L) The governing authority shall be responsible for ensuring that there is protection through liability insurance, malpractice insurance and/or other insurance for the governing authority and the prevention agency's staff.

Effective: 10/01/2006
R.C. 119.032 review dates: 09/30/2011
Promulgated Under: 119.03
Statutory Authority: 3793.02(D) , 3793.06
Rule Amplifies: 3793.06

3793:5-1-03 Prevention Standards - Administration.

(A) The purpose of this rule is to state the administration requirements that an agency must meet in order to receive alcohol and other drug prevention certification by the Ohio Department of Alcohol and Drug Addiction Services.

(B) The provisions of this rule are applicable to all alcohol and other drug prevention programs that include a facility or entity where a primary function of the facility/entity is the delivery of alcohol and other drug prevention programming and services. For the purposes of this rule, the words program, facility and/or entity shall be referred to as "agency".

(C) Prevention Standards definitions:

(1) "Accessibility" means ease of obtaining services.

(2) "Alcohol and other drug prevention" focuses on preventing the onset of AOD use, abuse and addiction. AOD prevention includes addressing problems associated with AOD use and abuse up to, but not including assessment and treatment for substance abuse and dependence. AOD prevention is a proactive multifaceted, multi-community sector process involving a continuum of culturally appropriate prevention services which empowers individuals, families and communities to meet the challenges of life events and transitions by creating and reinforcing conditions that impact physical, social, emotional, spiritual, and cognitive well-being and promote safe and healthy behaviors and lifestyles. AOD prevention is a planned sequence of activities that, through the practice and application of evidence based prevention principles, policies, practices, strategies and programs, is intended to inform, educate, develop skills, alter risk behaviors, affect environmental factors and/or provide referrals to other services.

The term Alcohol and Other Drugs (AOD) includes, but is not limited to the following drugs of abuse - alcohol, tobacco, illicit drugs, inhalants, prescription and over-the-counter medications.

Culturally appropriate means the service delivery systems respond to the needs of the community being served as defined by the community and demonstrated through needs assessment activities, capacity development efforts, policy, strategy and prevention practice implementation, program implementation, evaluation, quality improvement and sustainability activities.

Evidenced Based Prevention means the prevention policies, strategies, programs and practices are consistent with prevention principles found through research to be fundamental in the delivery of prevention services; the prevention policies, strategies, programs and practices have been identified through research to be effective; the service delivery system utilizes evaluation of its policies, strategies, programs and practices to determine effectiveness; the service delivery system utilizes evaluation results to make appropriate adjustments to service delivery policies, strategies, programs and practices to improve outcomes.

(a) Prevention Service Categories by Population Served:

(i) Universal Prevention Services: Services target everyone regardless of level of risk before there is an indication of an AOD problem;

(ii) Selected Prevention Services: Services target persons or groups that can be identified as "at risk" for developing an AOD problem;

(iii) Indicated Prevention Services: Services target individuals identified as experiencing problem behavior related to alcohol and other drug use to prevent the progression of the problem. These services do not include clinical assessment and/or treatment for substance abuse and dependence.

(b) Prevention Service Delivery Strategies:

(i) Information Dissemination is an AOD prevention strategy that focuses on building awareness and knowledge of the nature and extent of alcohol and other drug use, abuse and addiction and the effects on individuals, families and communities, as well as the dissemination of information about prevention, treatment and recovery support services, programs and resources. This strategy is characterized by one-way communication from source to audience, with limited contact between the two;

(ii) Alternatives are AOD prevention strategies that focus on providing opportunities for positive behavior support as a means of reducing risk taking behavior, and reinforcing protective factors. Alternative programs include a wide range of social, recreational, cultural and community service/volunteer activities that appeal to youth and adults;

(iii) Education is an AOD prevention strategy that focuses on the delivery of services to target audiences with the intent of affection knowledge, attitude and/or behavior. Education involves two-way communication and is distinguished from information dissemination by the fact that interaction between educator/facilitator and participants is the basis of the activities. Activities affect critical life and social skills including decision making, refusal skills, critical analysis and systematic judgment abilities;

(iv) Community-Based Process is an AOD prevention strategy that focuses on enhancing the ability of the community to provide prevention services through organizing, training, planning, interagency collaboration, coalition building and/or networking;

(v) Environmental prevention is an AOD prevention strategy that represents a broad range of activities geared toward modifying systems in order to mainstream prevention through policy and law. The environmental strategy establishes or changes written and unwritten community standards, codes and attitudes, thereby influencing incidence and prevalence of alcohol and other drug use/abuse in the general population;

(vi) Problem Identification and Referral is an AOD prevention strategy that refers to intervention oriented prevention services that primarily targets indicated populations to address the earliest indications of an AOD problem. Services by this strategy focus on preventing the progression of the problem. This strategy does not include clinical assessment and/or treatment for substance abuse and dependence.

(3) "Alcohol and other drug prevention program" means an agency that owns and/or has administrative responsibility for the operation and delivery of alcohol and other drug prevention programming and services as a primary function of the agency.

(4) "Deemed Status" means that on-site review by the Ohio Department of Alcohol and Drug Addiction Services of certain sections of the administrative code shall be waived for those agencies that own or operate a treatment program currently certified under Agency Rule 3793:2-1-08.Designatedsections of this rule shall be deemed for an agency not certified by ODADAS which has received national accreditation that included the prevention services, and demonstrates that the deemed sections within this rule are consistent with the national accreditation.

(5) "Documented Alcohol and other drug prevention experience" means the experience determined by the agency or its governing authority as sufficient in meeting the requirements of the standards and in the delivery of effective prevention services. Documentation shall include employment application, resume and/or other documentation deemed appropriate by the agency or its governing authority.

(6) "National Accreditation" means an organization that is recognized nationally as an accreditation body, including but not limited to, Commission on Accreditation of Rehabilitation Facilities (CARF), Council on Accreditation for Children and Family Services (COA), Joint Commission of Accreditation of Healthcare Organizations (JCAHO).

(7) "Natural environment" includes, but is not limited to locations where a consumer lives, works or attends school.

(8) "Primary Function" means the agency owns and/or has administrative responsibility for the operations and delivery of alcohol and other drug prevention programming and services and the agency's official documents such as but not limited to by-laws, articles of incorporation, policies or mission/purpose documents include statements that reflect the same.

(a) Where the primary function of the agency is in question, the Ohio department of alcohol and drug addiction services certification specialists will determine if an agency meets the definition of program and primary function through the review of the agency's official documents and alcohol and other drug prevention programming and services in consultation with the county Alcohol, Drug Addiction and Mental Health Services or Alcohol Drug Addiction Services Board Executive Director and the executive director of the agency being considered for prevention certification.

(b) Ohio department of alcohol and drug addiction services certified treatment agencies that also provide alcohol and other drug prevention programming and services must apply for prevention certification.

(9) "Site" means the prevention program's primary place for delivering prevention services or the administrative office if prevention services are provided in the consumer's natural environment.

(10) "Student" means an individual enrolled in an educational institution and supervised by an individual qualified to provide prevention services pursuant to Agency Level 3793:5-1-05.

(11) "Volunteer" means an uncompensated individual involved in the on-going provision of prevention services. This definition does not apply to volunteers whose sole purpose is to perform administrative functions or other ancillary activities that may include but are not limited to chaperoning a single event, assisting in or serving food at events, performing administrative support duties, etc.

(D) Deemed status shall be granted to waive sections of the Administrative Code if the agency that owns or operates a treatment program(s) with current certification from the Ohio Department of Alcohol and Drug Addiction Services under Agency Level 3793 of the Administrative Code or has achieved national accreditation as defined in this rule. Deemed provisions include: (G), (H), (L), (M), (N), (P), and (Q) of this rule. If the prevention site to be certified is located at the same address as the certified treatment program site, then (O) may be deemed.

(E) Prevention agencies granted deemed status under the provisions of paragraph (D) of this rule shall maintain agency fiscal records (i.e. ODADAS 047 form) which identify prevention-related fiscal activity.

(F) The Ohio Department of Alcohol and Drug Addiction Services reserves the right to revoke deemed status for a prevention agency in the event that the treatment program under which it is deemed receives non-certified status from the Ohio Department of Alcohol and Drug Addiction Services.

(G) Fiscal Administration:

(1) The agency shall have an annual budget, which identifies prevention services estimated revenues and expenditures, that has been approved by the governing authority before the beginning of the agency's fiscal year. Minutes of the governing authority shall reflect approval.

(2) The agency shall prepare monthly financial statements reflecting prevention related activities. Minutes of the governing authority shall reflect that the monthly financial statements have been reviewed and approved by the governing authority.

(3) Each agency shall account for funds in a manner that readily identifies revenues by each separate funding source and expenditures for prevention services. Each agency shall also account for funds in compliance with rules and regulations required by applicable funding sources.

(4) Where applicable, each agency 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.

(5) Agencies 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 agencies receiving state and other public-funding.

(H) Personnel Policies and Procedures:

(1) Each agency 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:

(a) 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.

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

(c) Policy prohibiting sexual harassment.

(d) Employment recruitment and selection process.

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

(f) Annual performance evaluation of each employee.

(g) Employee grievance procedure.

(h) Staff development.

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

(j) Standards of acceptable behavior for all employees.

(k) Policy for reporting consumer abuse/neglect.

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

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

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

(o) Policy and procedures for each employee to review his/her own personnel file and procedures for doing this.

(p) Procedure that states that employment applicants shall be informed of the rules and regulations governing fair employment practices, that the applicants right to privacy shall be respected, and that the results of inquiries shall be treated in confidence by the agency.

(q) Policy and procedures on confidentiality and how to maintain consumer records.

(I) Personnel Files:

(1) A personnel file shall be maintained for each employee, adult volunteer and student conducting prevention services. Personnel files shall contain, at a minimum, the following when applicable:

(a) Employment application and/or resume.

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

(c) Verification or copies of current professional licenses and/or certifications and/or registrations from professional regulatory boards in Ohio of each alcohol and other drug prevention service provider. If verification by a staff member of the agency 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 certification/license. The staff member verifying the credential must date and sign the verification document.

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

(e) Position description.

(f) Annual performance evaluation.

(g) 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).

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

(i) Personnel policies and procedures.

(ii) Procedures for reporting suspected child abuse and/or neglect, consistent with section 2151.42.1 and 2151.421 of the Revised Code, rule 5101:2-34-06 of the Administrative Code.

(iii) Consumer rights policy.

(iv) Consumer grievance procedure.

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

(J) A position description shall be established for each employee of the agency. 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).

(K) Contract alcohol and other drug prevention service providers and/or supervisory personnel of prevention service providers shall meet the same qualifications required of agency employees providing the same prevention services.

(L) Consumer Behavioral Interventions:

(1) Agencies shall have a policy on consumer behavioral interventions that includes, but is not limited to, the following:

(a) A statement that the use of all cruel and unusual punishments and practices including, but not limited to physical or verbal abuse is prohibited.

(b) A statement indicating what types of interventions shall be employed.

(c) A statement that isolation in a locked, unmonitored room shall not occur.

(d) A statement that behavioral intervention shall only be administered by the staff member responsible for the overall day-to-day operation of the alcohol and other drug prevention services, supervisors or prevention employees with direct care responsibilities who have been trained in the agency's approved behavioral interventions policy and procedures.

(M) Agencies Serving Children and Adolescents:

(1) Each alcohol and drug prevention agency serving children and/or adolescents shall have a policy which states the following:

(a) Each employee and/or contract staff hired after the effective date of this rule and/or adult volunteer and students utilized in positions which are responsible for the daily direct care or supervision of children and/or adolescents shall:

(i) Be at least eighteen years of age.

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

(b) The policy shall state that a prospective employee, adult volunteer or student has not pled guilty to nor been convicted of any of the offenses listed in Agency level 5101:2-5-09 (K) except as provided in 5101:2-5-09 (J).

(c) The policy shall state that the agency shall require that criminal records checks on prospective employees, adult volunteers and students 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).

(N) Other Administrative Requirements:

(1) Each agency that prepares and/or serves meals as part of its daily scheduled activities shall operate its dietary services in accordance with laws, regulations and/or ordinances of the Ohio Board of Dietetics, Ohio Department of Health and/or local health department.

(2) Each agency that permits consumers to medicate themselves shall have written policies and/or procedures for self-medication.

(3) Each agency shall have a plan that includes the stated goal that the agency will address the need for culturally specific and relevant services for ethnic minorities, deaf or hearing impaired and others.

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

(5) Each agency shall maintain a consumer 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 and other drug prevention services.

(6) Each agency shall maintain a financial management information system which meets specifications established by the department for collecting financial information related to alcohol and other drug prevention services.

(7) Each agency shall participate in information surveys conducted or sponsored by the Ohio Department of Alcohol and Drug Addiction Services.

(8) Each agency shall have policies and procedures regarding communication assistance for limited-English proficient consumers, family members or significant others as required by State and Federal law.

(9) Each agency shall have policies and procedures regarding auxiliary aids for sensory-impaired consumers, family members or significant others, including the sight and hearing impaired, as required by State and Federal law.

(O) Each agency shall identify a location (street address, city and county) as the primary place for conducting prevention services. This standard does not prohibit alcohol and other drug prevention services from being provided in the natural environment of a consumer, including, but not limited to, place of residence, work place or school.

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

(2) The agency shall have on file a copy of a "certificate of use and occupancy" for each certified site where alcohol and other drug prevention services are provided in accordance with the Ohio Basic Building Code and rule 4101:2-1-27 of the Administrative Code.

(3) The agency 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 certified site where alcohol and other drug prevention services are provided.

(4) The agency shall have a fire and evacuation plan posted at each certified site where alcohol and other drug prevention services are provided.

(5) If the certified site has a swimming pool used by prevention services consumers, the agency shall maintain documentation to reflect that the swimming pool is being maintained in compliance with the requirements of Chapter 3749.04 of the Revised Code.

(6) A certified site is prohibited from using freestanding wood burning stoves or unvented kerosene, gas or oil heaters where services are provided.

(7) Each certified 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 administrator.

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

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

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

(d) The certified site shall have at least one drinking fountain that is handicapped accessible.

(e) The certified site shall have at least one telephone that is handicapped accessible.

(P) Each agency shall have written policies and/or procedures for universal infection control for each certified site.

(1) Each agency shall provide training and education on infection control to all employees, volunteers and students who provide prevention services.

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

(Q) Each agency 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. Each agency shall have procedures for transporting consumers to other organizations, when necessary.

(R) Closing a certified prevention site or discontinuing alcohol or other drug prevention services:

(1) If an agency voluntarily closes its alcohol and other drug prevention site or discontinues the provision of alcohol or other drug prevention services, it shall give a thirty-day advance written notice to each of its current consumers, including parents/guardians of children receiving recurring services, which specifies the date that the site will close or the date that the alcohol or other drug prevention services will no longer be provided.

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

(i) Division of Quality Improvement, Ohio Department of Alcohol and Drug Addiction Services responsible for certification.

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

(b) If an agency terminates all prevention services, a close-out audit shall be conducted which meets the Ohio Department of Alcohol and Drug Addiction Services guidelines and federal office of management and budget circulars.

Effective: 10/01/2006
R.C. 119.032 review dates: 09/30/2011
Promulgated Under: 119.03
Statutory Authority: 3793.02(D) , 3793.06
Rule Amplifies: 3793.06

3793:5-1-04 Prevention Standards - Quality Assurance and Improvement.

(A) The purpose of this rule is to state the quality assurance and improvement requirements that an agency must meet in order to receive alcohol and other drug prevention certification by the Ohio Department of Alcohol and Drug Addictions Services.

(B) The provisions of this rule are applicable to all alcohol and other drug prevention programs that include a facility or entity that operates such a program where a primary function of the facility/entity is to provide alcohol and other drug prevention services as defined in this rule. For the purposes of this rule, the word agency shall refer to a program, facility or entity.

(C) Prevention Standards definitions:

(1) "Alcohol and other drug prevention" focuses on preventing the onset of AOD use, abuse and addiction. AOD prevention includes addressing problems associated with AOD use and abuse up to, but not including assessment and treatment for substance abuse and dependence. AOD prevention is a proactive multifaceted, multi-community sector process involving a continuum of culturally appropriate prevention services which empowers individuals, families and communities to meet the challenges of life events and transitions by creating and reinforcing conditions that impact physical, social, emotional, spiritual, and cognitive well-being and promote safe and healthy behaviors and lifestyles. AOD prevention is a planned sequence of activities that, through the practice and application of evidence based prevention principles, policies, practices, strategies and programs, is intended to inform, educate, develop skills, alter risk behaviors, affect environmental factors and/or provide referrals to other services.

The term Alcohol and Other Drugs (AOD) includes, but is not limited to the following drugs of abuse - alcohol, tobacco, illicit drugs, inhalants, prescription and over-the-counter medications.

Culturally appropriate means the service delivery systems respond to the needs of the community being served as defined by the community and demonstrated through needs assessment activities, capacity development efforts, policy, strategy and prevention practice implementation, program implementation, evaluation, quality improvement and sustainability activities.

Evidenced Based Prevention means the prevention policies, strategies, programs and practices are consistent with prevention principles found through research to be fundamental in the delivery of prevention services; the prevention policies, strategies, programs and practices have been identified through research to be effective; the service delivery system utilizes evaluation of its policies, strategies, programs and practices to determine effectiveness; the service delivery system utilizes evaluation results to make appropriate adjustments to service delivery policies, strategies, programs and practices to improve outcomes.

(a) Prevention Service Categories by Population Served:

(i) Universal Prevention Services: Services target everyone regardless of level of risk before there is an indication of an AOD problem;

(ii) Selected Prevention Services: Services target persons or groups that can be identified as "at risk" for developing and AOD problem;

(iii) Indicated Prevention Services: Services target individuals identified as experiencing problem behavior related to alcohol and other drug use to prevent the progression of the problem. These services do not include clinical assessment and/or treatment for substance abuse and dependence.

(b) Prevention Service Delivery Strategies:

(i) Information Dissemination is an AOD prevention strategy that focuses on building awareness and knowledge of the nature and extent of alcohol and other drug use, abuse and addiction and the effects on individuals, families and communities, as well as the dissemination of information about prevention, treatment and recovery support services, programs and resources. This strategy is characterized by one-way communication from source to audience, with limited contact between the two;

(ii) Alternatives are AOD prevention strategies that focus on providing opportunities for positive behavior support as a means of reducing risk taking behavior, and reinforcing protective factors. Alternative programs include a wide range of social, recreational, cultural and community service/volunteer activities that appeal to youth and adults;

(iii) Education is an AOD prevention strategy that focuses on the delivery of services to target audiences with the intent of affection knowledge, attitude and/or behavior. Education involves two-way communication and is distinguished from information dissemination by the fact that interaction between educator/facilitator and participants is the basis of the activities. Activities affect critical life and social skills including decision making, refusal skills, critical analysis and systematic judgment abilities;

(iv) Community-Based Process is an AOD prevention strategy that focuses on enhancing the ability of the community to provide prevention services through organizing, training, planning, interagency collaboration, coalition building and/or networking;

(v) Environmental prevention is an AOD prevention strategy that represents a broad range of activities geared toward modifying systems in order to mainstream prevention through policy and law. The environmental strategy establishes or changes written and unwritten community standards, codes and attitudes, thereby influencing incidence and prevalence of alcohol and other drug use/abuse in the general population;

(vi) Problem Identification and Referral is an AOD prevention strategy that refers to intervention oriented prevention services that primarily targets indicated populations to address the earliest indications of an AOD problem. Services by this strategy focus on preventing the progression of the problem. This Strategy does not include Clinical Assessment and/or treatment for substance abuse and dependence.

(2) "Alcohol and other drug addiction program" means an agency that owns and/or has administrative responsibility for the operation and delivery of alcohol and other drug prevention programming and services as a primary function of the agency.

(3) "Consumer" means a person who receives alcohol and/or other drug prevention services.

(4) "Deemed Status" means that on-site review by the Ohio Department of Alcohol and Drug Addiction Services of certain sections of the administrative code shall be waived for those agencies that own or operate a treatment program currently certified under Agency Rule 3793:2-1-08.Designatedsections of this rule shall be deemed for an agency not certified by ODADAS which has received national accreditation that included the prevention services, and demonstrates that the deemed sections within this rule are consistent with the national accreditation.

(5) "Governing Authority" means an individual, board or other entity that has ultimate responsibility for the management, operation and control of the prevention program as designated by laws, by articles of incorporation, by another written document which creates or governs the operations of a prevention program or by ownership of assets or a sole proprietorship.

(6) "Major Unusual Incident" means, but is not limited to, the following:

(a) Death or serious injury or a consumer, employee, contract staff member, volunteer or student when the person is on the agency's premises, performing tasks for the agency or participating in prevention services.

(b) Any allegation of physical, sexual or verbal abuse of a consumer.

(c) Any allegation of staff neglect of a consumer.

(7) "National Accreditation" means an organization that is recognized nationally as an accreditation body, including but not limited to, Commission on Accreditation of Rehabilitation Facilities (CARF), Council on Accreditation for Children and Family Services (COA), Joint Commission of Accreditation of Healthcare Organizations (JCAHO).

(8) "Student" means an individual enrolled in an educational institution performing an internship or field placement, and supervised by an individual qualified to provide prevention services pursuant to 3793:5-1-05.

(9) "Volunteer" means an uncompensated individual involved in the on-going provision of prevention services. This definition does not apply to volunteers whose sole purpose is to perform administrative functions or other ancillary activities that may include but are not limited to, chaperoning a single event, assisting in or serving food at events, performing administrative support duties, etc.

(D) Deemed status shall be granted to waive sections of the Administrative Code if the prevention provider is owned by an agency that owns a treatment program(s) with current certification from the Ohio Department of Alcohol and Drug Addiction Services under Agency Level 3793 of the Administrative Code or has achieved national accreditation as defined in this rule. Deemed provisions include: (E1), (E2), (E3), (F) and (H) of this rule.

(E) Each agency shall establish and implement a written quality improvement plan updated annually and approved by the governing authority that includes, at a minimum, the following:

(1) Designation of a committee or staff member for coordinating the agency's quality assurance and improvement activities.

(2) Provisions for informing the agency's governing authority of the findings of quality assurance and improvement activities.

(3) Provisions for monitoring correcting actions directed by the governing authority.

(4) Provisions for evaluating consumer satisfaction and use of findings for improvement of the prevention services provided by the agency.

(5) A description of how prevention quality improvement activities are integrated into the agency's overall management.

(F) Each agency shall have a written risk management plan for conducting risk management activities. Risk management means a planned approach for the purpose of safeguarding potential risks in terms of hazardous working conditions, fire and safety conditions, major unusual incidents and financial risk. The plan shall include, at a minimum, the following:

(1) Plan objectives.

(2) Structure and process for implementing the risk management plan:

(a) Identification of staff responsible for implementing and coordinating risk management activities.

(b) Functional duties and responsibilities of designated staff; staff may also assume other organizational functions.

(3) Scope and content of the risk management activities that include, at a minimum, the following:

(a) A policy to safeguard against potential hazardous working conditions for staff, consumers and visitors to the certified site, including physical plant conditions and fire safety considerations.

(b) Provisions for conducting risk management activities shall be developed, to include, at a minimum, the following:

(i) Reporting, reviewing and monitoring all of the major unusual incidents such as death or injury to a consumer or staff, sexual/physical abuse of a consumer or staff member or a significant disruption of services.

(ii) Reporting, reviewing and monitoring of significant financial loss to the agency, as determined in the risk management plan.

(iii) Linkage of risk management activities to quality assurance activities, including, at a minimum, ongoing formal communication between staff responsible for both activities, joint reporting to the governing authority and accountability for corrective action(s).

(c) An emergency medical plan shall be posted in an area accessible to staff at all times.

(G) All major unusual incidents shall be reported in writing to the Ohio Department of Alcohol and Drug Addiction Services and to the applicable alcohol and drug addiction services board or alcohol, drug addiction and mental health services board within seventy-two hours of the reported incident or such other time as agreed upon between the parties. Reports shall not include consumer identifying information unless the consumer has given written consent to release information in compliance with 42 C.F.R., Part 2. Each agency shall have written criteria for conducting reviews of major unusual incidents that include, but are not limited to, the following:

(1) Death or serious injury or a consumer, employee, contract staff member, volunteer or student when the person is on the agency's premises, performing tasks for the agency or participating in prevention services.

(2) Any allegation of physical, sexual or verbal abuse of a consumer.

(3) Any allegation of staff neglect of a consumer.

(H) Each agency shall maintain documentation for the quality assurance, risk management and quality improvement activities that it conducts.

Effective: 10/01/2006
R.C. 119.032 review dates: 09/30/2011
Promulgated Under: 119.03
Statutory Authority: 3793.02(D) , 3793.06
Rule Amplifies: 3793.06

3793:5-1-05 Prevention Standards - Provision of Services.

(A) The purpose of this rule is to state the service provision requirements that an agency must meet in order to receive alcohol and other drug prevention certification by the Ohio Department of Alcohol and Drug Addiction Services.

(B) The provisions of this rule are applicable to all alcohol and other drug prevention programs that include a facility or entity where a primary function of the facility/entity is the delivery of alcohol and other drug prevention programming and services. For the purposes of this rule, the words program, facility and/or entity shall be referred to as "agency".

(C) Prevention Standards definitions:

(1) "Alcohol and other drug prevention" focuses on preventing the onset of AOD use, abuse and addiction. AOD prevention includes addressing problems associated with AOD use and abuse up to, but not including assessment and treatment for substance abuse and dependence. AOD prevention is a proactive multifaceted, multi-community sector process involving a continuum of culturally appropriate prevention services which empowers individuals, families and communities to meet the challenges of life events and transitions by creating and reinforcing conditions that impact physical, social, emotional, spiritual, and cognitive well-being and promote safe and healthy behaviors and lifestyles. AOD prevention is a planned sequence of activities that, through the practice and application of evidence based prevention principles, policies, practices, strategies and programs, is intended to inform, educate, develop skills, alter risk behaviors, affect environmental factors and/or provide referrals to other services.

The term Alcohol and Other Drugs (AOD) includes, but is not limited to the following drugs of abuse - alcohol, tobacco, illicit drugs, inhalants, prescription and over-the-counter medications.

Culturally appropriate means the service delivery systems respond to the needs of the community being served as defined by the community and demonstrated through needs assessment activities, capacity development efforts, policy, strategy and prevention practice implementation, program implementation, evaluation, quality improvement and sustainability activities.

Evidenced Based Prevention means the prevention policies, strategies, programs and practices are consistent with prevention principles found through research to be fundamental in the delivery of prevention services; the prevention policies, strategies, programs and practices have been identified through research to be effective; the service delivery system utilizes evaluation of its policies, strategies, programs and practices to determine effectiveness; the service delivery system utilizes evaluation results to make appropriate adjustments to service delivery policies, strategies, programs and practices to improve outcomes.

(a) Prevention Service Categories by Population Served:

(i) Universal Prevention Services: Services target everyone regardless of level of risk before there is an indication of an AOD problem;

(ii) Selected Prevention Services: Services target persons or groups that can be identified as "at risk" for developing and AOD problem;

(iii) Indicated Prevention Services: Services target individuals identified as experiencing problem behavior related to alcohol and other drug use to prevent the progression of the problem. These services do not include clinical assessment and/or treatment for substance abuse and dependence.

(b) Prevention Service Delivery Strategies:

(i) Information Dissemination is an AOD prevention strategy that focuses on building awareness and knowledge of the nature and extent of alcohol and other drug use, abuse and addiction and the effects on individuals, families and communities, as well as the dissemination of information about prevention, treatment and recovery support services, programs and resources. This strategy is characterized by one-way communication from source to audience, with limited contact between the two.

(ii) Alternatives are AOD prevention strategies that focus on providing opportunities for positive behavior support as a means of reducing risk taking behavior, and reinforcing protective factors. Alternative programs include a wide range of social, recreational, cultural and community service/volunteer activities that appeal to youth and adults.

(iii) Education is an AOD prevention strategy that focuses on the delivery of services to target audiences with the intent of affection knowledge, attitude and/or behavior. Education involves two-way communication and is distinguished from information dissemination by the fact that interaction between educator/facilitator and participants is the basis of the activities. Activities affect critical life and social skills including decision making, refusal skills, critical analysis and systematic judgment abilities.

(iv) Community-Based Process is an AOD prevention strategy that focuses on enhancing the ability of the community to provide prevention services through organizing, training, planning, interagency collaboration, coalition building and/or networking.

(v) Environmental prevention is an AOD prevention strategy that represents a broad range of activities geared toward modifying systems in order to mainstream prevention through policy and law. The environmental strategy establishes or changes written and unwritten community standards, codes and attitudes, thereby influencing incidence and prevalence of alcohol and other drug use/abuse in the general population.

(vi) Problem Identification and Referral is an AOD prevention strategy that refers to intervention oriented prevention services that primarily targets indicated populations to address the earliest indications of an AOD problem. Services by this strategy focus on preventing the progression of the problem. This Strategy does not include Clinical Assessment and/or treatment for substance abuse and dependence.

(2) "Alcohol and other drug prevention program" means an agency that owns and/or has administrative responsibility for the operation and delivery of alcohol and other drug prevention programming and services as a primary function of the agency.

(3) "Deemed Status" means that on-site review by the Ohio Department of Alcohol and Drug Addiction Services of certain sections of the administrative code shall be waived for those agencies that own or operate a treatment program currently certified under Agency Rule 3793:2-1-08.Designatedsections of this rule shall be deemed for an agency not certified by ODADAS which has received national accreditation that included the prevention services, and demonstrates that the deemed sections within this rule are consistent with the national accreditation.

(4) "Documented Alcohol and other drug prevention experience" means the experience determined by the agency or its governing authority as sufficient in meeting the requirements of the standards and in the delivery of effective prevention services. Documentation shall include employment application, resume and/or other documentation deemed appropriate by the agency or its governing authority.

(5) "National Accreditation" means an organization that is recognized nationally as an accreditation body, including but not limited to, Commission on Accreditation of Rehabilitation Facilities (CARF), Council on Accreditation for Children and Family Services (COA), Joint Commission of Accreditation of Healthcare Organizations (JCAHO).

(6) "Primary Function" means the agency owns and/or has administrative responsibility for the operations and delivery of alcohol and other drug prevention programming and services and the agency's official documents such as but not limited to by-laws, articles of incorporation, policies or mission/purpose documents include statements that reflect the same.

(a) Where the primary function of the agency is in question, the Ohio department of alcohol and drug addiction services certification specialists will determine if an agency meets the definition of program and primary function through the review of the agency's official documents and alcohol and other drug prevention programming and services in consultation with the county Alcohol, Drug Addiction and Mental Health Services or Alcohol Drug Addiction Services Board Executive Director and the executive director of the agency being considered for prevention certification.

(b) Ohio department of alcohol and drug addiction services certified treatment agencies that also provide alcohol and other drug prevention programming and services must apply for prevention certification

(7) "Student" means an individual enrolled in an educational institution and supervised by an individual qualified to provide prevention services pursuant to Agency Level 3793:5-1-05.

(8) "Volunteer" means an uncompensated individual involved in the on-going provision of prevention services. This definition does not apply to volunteers whose sole purpose is to perform administrative functions or other ancillary activities that may include, but are not limited to, chaperoning a single event, assisting in or serving food at events, performing administrative support, etc.

(D) Deemed status shall be granted to waive sections of the Administrative Code if the agency that owns or operates a treatment program(s) with current certification from the Ohio Department of Alcohol and Drug Addiction Services under Agency Level 3793 of the Administrative Code or has achieved national accreditation as defined in this rule. Deemed provisions include: (N) of this rule.

(E) Each agency shall have written policies and/or procedures for prevention services that include, at a minimum, the following:

(1) Description for each of the prevention services provided.

(2) Criteria for identifying target populations for receipt of prevention services.

(3) Procedures for processing requests for receipt of prevention services from other entities.

(F) Each agency shall have a designated staff member who is responsible for the overall day-to-day operation of the alcohol and other drug prevention services. This staff member shall be directly responsible to the governing authority or to the Executive Director of the Agency or designee of the governing authority.

(G) The staff member responsible for the overall day-to-day operation of the alcohol and other drug prevention services hired on or after the effective date of this rule shall meet one of the following qualifications:

(1) Certified Prevention Specialist I (OCPS I) certified by the Ohio Chemical Dependency Professionals Board.

(2) Certified Prevention Specialist II (OCPS II) certified by the Ohio Chemical Dependency Professionals Board.

(3) Registered Applicant, with the Ohio Chemical Dependency Professionals Board, for certification as a Prevention Specialist.

(4) Licensed Chemical Dependency Counselor II, with documented alcohol and other drug prevention experience, licensed by the Ohio Chemical Dependency Professionals Board.

(5) A Licensed Chemical Dependency Counselor III, with documented alcohol and other drug prevention experience, licensed by the Ohio Chemical Dependency Professionals Board.

(6) A Licensed Independent Chemical Dependency Counselor, with documented alcohol and other drug prevention experience, licensed by the Ohio Chemical Dependency Professionals Board.

(7) Certified Chemical Dependency Counselor III-E, with documented alcohol and other drug prevention experience, certified by the Ohio Chemical Dependency Professionals Board.

(8) Certified Chemical Dependency Counselor III, with documented alcohol and other drug prevention experience, certified by the Ohio Chemical Dependency Professionals Board.

(9) Certified Chemical Dependency Counselor II, with documented alcohol and other drug prevention experience, certified by the Ohio Chemical Dependency Professionals Board.

(10) Certified Chemical Dependency Counselor I, with documented alcohol and other drug prevention experience, certified by the Ohio Chemical Dependency Professionals Board.

(11) Licensed Professional Clinical Counselor, with documented alcohol and other drug prevention experience, who is licensed by the State of Ohio Counselor and Social Worker Board.

(12) Licensed Professional Counselor, with documented alcohol and other drug prevention experience, who is licensed by the State of Ohio Counselor and Social Worker Board.

(13) Licensed Independent Social Worker, with documented alcohol and other drug prevention experience, who is licensed by the State of Ohio Counselor and Social Worker Board.

(14) Licensed Social Worker, with documented alcohol and other drug prevention experience, who is licensed by the State of Ohio Counselor and Social Worker Board.

(15) Certified Health Education Specialist, with documented alcohol and other drug prevention experience, who is certified by the National Commission on Health Education Credentialing.

(16) Registered Nurse, with documented alcohol and other drug prevention experience, who is registered with the Ohio Nursing Board.

(17) School Educator and/or Counselor, with documented alcohol and other drug prevention experience, who is certified or licensed by the Ohio Department of Education.

(18) Physician with documented alcohol and other drug prevention experience.

(19) Psychologist with documented alcohol and other drug prevention experience.

(H) An individual hired on or after the effective date of this rule to direct the overall day-to-day operations of the alcohol and other drug prevention services who possesses certification/licensure but is not an OCPS I, II or is not a registered Ohio Certified Prevention Specialist applicant must participate in 12 hours of alcohol and other drug prevention-specific continuing education every two years.

(I) The staff member responsible for the overall day-to-day operations of the alcohol and other drug prevention services may be a volunteer if the individual meets the qualifications in accordance with this rule.

(J) The position description of the staff member responsible for the overall day-to-day operation of the alcohol and drug prevention services shall, at a minimum, include the following responsibilities:

(1) Directing the day-to-day operations of the prevention services.

(2) Implementing the policies and procedures of the prevention services.

(3) Ensuring that the agency is operating in accordance with the Ohio Department of Alcohol and Drug Addiction Services' prevention certification standards.

(K) Prevention services shall be provided by individuals, hired on or after the effective date of this rule, shall have one or more of the following registrations, certifications and/or licenses from professional regulatory entities in Ohio:

(1) Certified Prevention Specialist I certified by the Ohio Chemical Dependency Professionals Board.

(2) Certified Prevention Specialist II certified by the Ohio Chemical Dependency Professionals Board.

(3) Registered Applicant, with the Ohio Chemical Dependency Professionals Board, for certification as a Prevention Specialist.

(4) Licensed Chemical Dependency Counselor II, with documented alcohol and other drug prevention experience, licensed by the Ohio Chemical Dependency Professionals Board.

(5) Licensed Chemical Dependency Counselor III, with documented alcohol and other drug prevention experience, licensed by the Ohio Chemical Dependency Professionals Board.

(6) Licensed Independent Chemical Dependency Counselor, with documented alcohol and other drug prevention experience, licensed by the Ohio Chemical Dependency Professionals Board.

(7) Certified Chemical Dependency Counselor III-E, with documented alcohol and other drug prevention experience, certified by the Ohio Chemical Dependency Professionals Board.

(8) Certified Chemical Dependency Counselor III, with documented alcohol and other drug prevention experience, certified by the Ohio Chemical Dependency Professionals Board.

(9) Certified Chemical Dependency Counselor II, with documented alcohol and other drug prevention experience, certified by the Ohio Chemical Dependency Professionals Board.

(10) Certified Chemical Dependency Counselor I, with documented alcohol and other drug prevention experience, certified by the Ohio Chemical Dependency Professionals Board.

(11) Licensed Professional Clinical Counselor, with documented alcohol and other drug prevention experience, who is licensed by the State of Ohio Counselor and Social Worker Board.

(12) Licensed Professional Counselor, with documented alcohol and other drug prevention experience, who is licensed by the State of Ohio Counselor and Social Worker Board.

(13) Licensed Independent Social Worker, with documented alcohol and other drug prevention experience, who is licensed by the State of Ohio Counselor and Social Worker Board.

(14) Licensed Social Worker, with documented alcohol and other drug prevention experience, who is licensed by the State of Ohio Counselor and Social Worker Board.

(15) Certified Health Education Specialist, with documented alcohol and other drug prevention experience, who is certified by the National Commission on Health Education Credentialing.

(16) Registered Nurse, with documented alcohol and other drug prevention experience, who is registered with the Ohio Nursing Board.

(17) School Educator and/or Counselor, with documented alcohol and other drug prevention experience, who is certified or licensed by the Ohio Department of Education.

(18) Physician with documented alcohol and other drug prevention experience.

(19) Psychologist with documented alcohol and other drug prevention experience.

(20) An individual hired to provide prevention services on or after the effective date of this rule who is not an Ohio-Certified Prevention Specialist or who does not possess another certification/license with documented alcohol and other drug prevention experience, shall apply to become a registered applicant within thirty days of the effective date of hiring.

(L) An individual hired to provide prevention services on or after the effective date of this rule who possesses certification/licensure but not an OCPS I, II or is not a registered OCPS applicant must participate in 20 hours of AoD prevention-specific continuing education every two years.

(M) Volunteers and students:

(1) Each Agency is required to and must demonstrate that volunteers and students have been trained to perform the prevention activities they are engaged in.

(2) Volunteers under 18 and students providing direct consumer services must do so in the presence of an adult staff member.

(3) If volunteers under 18 and students provide alcohol and other drug prevention services, they shall be supervised by an individual who meets supervisory requirements in accordance with this rule.

(4) If the agency utilizes volunteers and students, it shall have written policies and/or procedures for volunteers that include, at a minimum, the following:

(a) Identifying the duties that may be performed by volunteers and students.

(b) Recruiting and selecting volunteers and students.

(c) Orienting volunteers and students to the policies and procedures of the agency that are relevant to their duties.

(d) Training volunteers and students on their duties.

(e) Evaluating the performance of volunteers and students.

(f) Terminating the services of volunteers and students.

(5) Volunteers and students under 18 must have written permission from a parent/guardian to perform prevention activities.

(6) Agencies utilizing adult volunteers and students 18 and over involved in the ongoing provision of prevention services with children and/or adolescents shall require a criminal record check conducted by the Bureau of Criminal Identification and Investigation (BCII) and, if the prospective volunteer/student does not demonstrate that he/she has been a resident of Ohio for the preceding five years, by the Federal Bureau of Investigation (FBI).

(N) All staff shall be familiar with the consumer rights policy and consumer grievance procedure. There shall be documentation in each employees personnel file, including contract staff, adult volunteers and students that he/she has received a copy of the consumer rights policy and the consumer grievance procedure and has agreed to abide by them.

Effective: 10/01/2006
R.C. 119.032 review dates: 09/30/2011
Promulgated Under: 119.03
Statutory Authority: 3793.02(D) , 3793.06
Rule Amplifies: 3793.06

3793:5-1-06 Prevention Standards - Activity/Consumer records.

(A) The purpose of this rule is to state the activity/consumer records requirements that an agency must meet in order to receive alcohol and other drug prevention certification by the Ohio Department of Alcohol and Drug Addiction Services.

(B) The provisions of this rule are applicable to all alcohol and other drug prevention programs that include a facility or entity where a primary function of the facility/entity is the delivery of alcohol and other drug prevention programming and services. For the purposes of this rule, the words program, facility and/or entity shall be referred to as "agency".

(C) Prevention Standards definitions:

(1) "Alcohol and other drug prevention" focuses on preventing the onset of AOD use, abuse and addiction. AOD prevention includes addressing problems associated with AOD use and abuse up to, but not including assessment and treatment for substance abuse and dependence. AOD prevention is a proactive multifaceted, multi-community sector process involving a continuum of culturally appropriate prevention services which empowers individuals, families and communities to meet the challenges of life events and transitions by creating and reinforcing conditions that impact physical, social, emotional, spiritual, and cognitive well-being and promote safe and healthy behaviors and lifestyles. AOD prevention is a planned sequence of activities that, through the practice and application of evidence based prevention principles, policies, practices, strategies and programs, is intended to inform, educate, develop skills, alter risk behaviors, affect environmental factors and/or provide referrals to other services.

The term Alcohol and Other Drugs (AOD) includes, but is not limited to the following drugs of abuse - alcohol, tobacco, illicit drugs, inhalants, prescription and over-the-counter medications.

Culturally appropriate means the service delivery systems respond to the needs of the community being served as defined by the community and demonstrated through needs assessment activities, capacity development efforts, policy, strategy and prevention practice implementation, program implementation, evaluation, quality improvement and sustainability activities.

Evidenced Based Prevention means the prevention policies, strategies, programs and practices are consistent with prevention principles found through research to be fundamental in the delivery of prevention services; the prevention policies, strategies, programs and practices have been identified through research to be effective; the service delivery system utilizes evaluation of its policies, strategies, programs and practices to determine effectiveness; the service delivery system utilizes evaluation results to make appropriate adjustments to service delivery policies, strategies, programs and practices to improve outcomes.

(a) Prevention Service Categories by Population Served:

(i) Universal Prevention Services: Services target everyone regardless of level of risk before there is an indication of an AOD problem;

(ii) Selected Prevention Services: Services target persons or groups that can be identified as "at risk" for developing an AOD problem;

(iii) Indicated Prevention Services: Services target individuals identified as experiencing problem behavior related to alcohol and other drug use to prevent the progression of the problem. These services do not include clinical assessment and/or treatment for substance abuse and dependence.

(b) Prevention Service Delivery Strategies:

(i) Information Dissemination is an AOD prevention strategy that focuses on building awareness and knowledge of the nature and extent of alcohol and other drug use, abuse and addiction and the effects on individuals, families and communities, as well as the dissemination of information about prevention, treatment and recovery support services, programs and resources. This strategy is characterized by one-way communication from source to audience, with limited contact between the two;

(ii) Alternatives are AOD prevention strategies that focus on providing opportunities for positive behavior support as a means of reducing risk taking behavior, and reinforcing protective factors. Alternative programs include a wide range of social, recreational, cultural and community service/volunteer activities that appeal to youth and adults;

(iii) Education is an AOD prevention strategy that focuses on the delivery of services to target audiences with the intent of affection knowledge, attitude and/or behavior. Education involves two-way communication and is distinguished from information dissemination by the fact that interaction between educator/facilitator and participants is the basis of the activities. Activities affect critical life and social skills including decision making, refusal skills, critical analysis and systematic judgment abilities;

(iv) Community-Based Process is an AOD prevention strategy that focuses on enhancing the ability of the community to provide prevention services through organizing, training, planning, interagency collaboration, coalition building and/or networking;

(v) Environmental prevention is an AOD prevention strategy that represents a broad range of activities geared toward modifying systems in order to mainstream prevention through policy and law. The environmental strategy establishes or changes written and unwritten community standards, codes and attitudes, thereby influencing incidence and prevalence of alcohol and other drug use/abuse in the general population;

(vi) Problem Identification and Referral is an AOD prevention strategy that refers to intervention oriented prevention services that primarily targets indicated populations to address the earliest indications of an AOD problem. Services by this strategy focus on preventing the progression of the problem. This strategy does not include clinical assessment and/or treatment for substance abuse and dependence.

(2) "Alcohol and other drug prevention program" means an agency that owns and/or has administrative responsibility for the operation and delivery of alcohol and other drug prevention programming and services as a primary function of the agency.

(3) "Consumer" means a person who receives alcohol and/or other drug prevention services.

(4) "Primary Function" means the agency owns and/or has administrative responsibility for the operations and delivery of alcohol and other drug prevention programming and services and the agency's official documents such as but not limited to by-laws, articles of incorporation, policies or mission/purpose documents include statements that reflect the same.

(a) Where the primary function of the agency is in question, the Ohio department of alcohol and drug addiction services certification specialists will determine if an agency meets the definition of program and primary function through the review of the agency's official documents and alcohol and other drug prevention programming and services in consultation with the county Alcohol, Drug Addiction and Mental Health Services or Alcohol Drug Addiction Services Board Executive Director and the executive director of the agency being considered for prevention certification.

(b) Ohio department of alcohol and drug addiction services certified treatment agencies that also provide alcohol and other drug prevention programming and services must apply for prevention certification.

(5) "Volunteer" means an uncompensated individual involved in the on-going provision of prevention services. This definition does not apply to volunteers whose sole purpose is to perform administrative functions or other ancillary activities that may include, but are not limited to, chaperoning a single event, assisting in or serving food at events, performing administrative support duties, etc.

(D) Documentation of Prevention Services:

(1) Each agency shall maintain documentation for prevention services provided, which shall include, at a minimum, the following:

(a) Date the prevention service was provided.

(b) Location where the prevention service was provided.

(c) Approximate number of consumers who received the prevention service.

(d) Types of prevention strategies/services provided.

(e) Description of activities conducted.

(f) Signature of an individual who is qualified to provide prevention services in accordance with this rule.

(E) Consumer Records.

(1) Each agency that maintains individual consumer records shall have written policies and/or procedures for maintaining uniform consumer records that includes, at a minimum, the following:

(a) Confidentiality of consumer records that includes, at a minimum, the following statements:

(i) Staff shall not convey to a person outside of the agency that an individual attends or received services from the agency or disclose any information identifying a consumer as an alcohol or other drug prevention services consumer unless the consumer consents in writing for the release of information, the disclosure is allowed by a court order, or the disclosure is made to a qualified personnel for a medical emergency, research, audit or program evaluation purposes.

(ii) Federal laws and regulations do not protect any threat to commit a crime, any information about a crime committed by a consumer either at the agency or against any person who works for the agency.

(iii) Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.

(b) Access to consumer records by consumers, staff and others.

(c) Release of consumer information.

(d) Storage of consumer records that requires consumer records be maintained in accordance with 42 C.F.R., part 2, confidentiality of alcohol and drug abuse consumer records.

(2) Destruction of activity/individual consumer records to include the requirement that records be maintained for at least three years from the final date of delivery of prevention services. Consumer records shall be destroyed to maintain consumer confidentiality as required by state and federal law.

(F) To release information on an individual consumer, disclosure of client information forms shall be completed and shall include the following information as required by 42 C.F.R., part 2:

(1) Name of the agency making the disclosure.

(2) Name or title of the individual or the name of the organization to which the disclosure is to be made.

(3) Name of the consumer.

(4) Purpose of the disclosure.

(5) Type and amount of information to be disclosed.

(6) Original signature of the consumer or person authorized to give consent.

(7) Date consumer or other authorized person signed the form.

(8) Statement that the consent is subject to revocation at any time except to the extent the agency or person who is to make the disclosure has already acted in reliance on it.

(9) The date, event or condition upon which the consent will expire, unless revoked before that specified time.

(G) Each disclosure made with the consumer's written consent must be consistent with 42 C.F.R. part 2, by including the following written statement: "This information has been disclosed to you from records protected by federal confidentiality rules. The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R., part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client."

(H) If an agency maintains electronic records, the agency must be able to produce hard copies of consumer records upon legally valid requests and have a written policy and procedure indicating how consumer original signatures and staff original signatures are obtained and verified for documentation.

(I) If an agency discontinues operations or is taken over or acquired by another entity, it shall comply with 42 C.F.R., part 2, subsection 2.19 which governs the disposition of records by discontinued programs.

Effective: 10/01/2006
R.C. 119.032 review dates: 09/30/2011
Promulgated Under: 119.03
Statutory Authority: 3793.02(D) , 3793.06
Rule Amplifies: 3793.06

3793:5-1-07 Prevention Standards - Consumer Rights and Grievances.

(A) The purpose of this rule is to state the consumer rights and grievances requirements that an agency must meet in order to receive alcohol and other drug prevention certification by the Ohio Department of Alcohol and Drug Addiction Services.

(B) The provisions of this rule are applicable to all alcohol and other drug prevention programs that include a facility or entity where a primary function of the facility/entity is the delivery of alcohol and other drug prevention programming and services. For the purposes of this rule, the words program, facility and/or entity shall be referred to as "agency".

(C) Prevention Standards definitions:

(1) "Alcohol and other drug prevention" focuses on preventing the onset of AOD use, abuse and addiction. AOD prevention includes addressing problems associated with AOD use and abuse up to, but not including assessment and treatment for substance abuse and dependence. AOD prevention is a proactive multifaceted, multi-community sector process involving a continuum of culturally appropriate prevention services which empowers individuals, families and communities to meet the challenges of life events and transitions by creating and reinforcing conditions that impact physical, social, emotional, spiritual, and cognitive well-being and promote safe and healthy behaviors and lifestyles. AOD prevention is a planned sequence of activities that, through the practice and application of evidence based prevention principles, policies, practices, strategies and programs, is intended to inform, educate, develop skills, alter risk behaviors, affect environmental factors and/or provide referrals to other services.

The term Alcohol and Other Drugs (AOD) includes, but is not limited to the following drugs of abuse - alcohol, tobacco, illicit drugs, inhalants, prescription and over-the-counter medications.

Culturally appropriate means the service delivery systems respond to the needs of the community being served as defined by the community and demonstrated through needs assessment activities, capacity development efforts, policy, strategy and prevention practice implementation, program implementation, evaluation, quality improvement and sustainability activities.

Evidenced based prevention means the prevention policies, strategies, programs and practices are consistent with prevention principles found through research to be fundamental in the delivery of prevention services; the prevention policies, strategies, programs and practices have been identified through research to be effective; the service delivery system utilizes evaluation of its policies, strategies, programs, and practices to determine effectiveness; the service delivery system utilizes evaluation results to make appropriate adjustments to service delivery policies, strategies, programs and practices to improve outcomes.

(a) Prevention Service Categories by Population Served:

(i) Universal Prevention Services: Services target everyone regardless of level of risk before there is an indication of an AOD problem;

(ii) Selected Prevention Services: Services target persons or groups that can be identified as "at risk" for developing and AOD problem;

(iii) Indicated Prevention Services: Services target individuals identified as experiencing problem behavior related to alcohol and other drug use to prevent the progression of the problem. These services do not include clinical assessment and/or treatment for substance abuse and dependence.

(b) Prevention Service Delivery Strategies:

(i) Information Dissemination is an AOD prevention strategy that focuses on building awareness and knowledge of the nature and extent of alcohol and other drug use, abuse and addiction and the effects on individuals, families and communities, as well as the dissemination of information about prevention, treatment and recovery support services, programs and resources. This strategy is characterized by one-way communication from source to audience, with limited contact between the two;

(ii) Alternatives are AOD prevention strategies that focus on providing opportunities for positive behavior support as a means of reducing risk taking behavior, and reinforcing protective factors. Alternative programs include a wide range of social, recreational, cultural and community service/volunteer activities that appeal to youth and adults;

(iii) Education is an AOD prevention strategy that focuses on the delivery of services to target audiences with the intent of affection knowledge, attitude and/or behavior. Education involves two-way communication and is distinguished from information dissemination by the fact that interaction between educator/facilitator and participants is the basis of the activities. Activities affect critical life and social skills including decision making, refusal skills, critical analysis and systematic judgment abilities;

(iv) Community-Based Process is an AOD prevention strategy that focuses on enhancing the ability of the community to provide prevention services through organizing, training, planning, interagency collaboration, coalition building and/or networking;

(v) Environmental prevention is an AOD prevention strategy that represents a broad range of activities geared toward modifying systems in order to mainstream prevention through polity and law. The environmental strategy establishes or changes written and unwritten community standards, codes and attitudes, thereby influencing incidence and prevalence of alcohol and other drug use/abuse in the general population;

(vi) Problem Identification and Referral is an AOD prevention strategy that refers to intervention oriented prevention services that primarily targets indicated populations to address the earliest indications of an AOD problem. Services by this strategy focus on preventing the progression of the problem. This Strategy does not include Clinical Assessment and/or treatment for substance abuse and dependence;

(2) "Alcohol and other drug prevention program" means an agency that owns and/or has administrative responsibility for the operation and delivery of alcohol and other drug prevention programming and services as a primary function of the agency.

(3) "Consumer" means a person who receives alcohol and/or other drug prevention services.

(4) "Deemed Status" means that on-site review by the Ohio Department of Alcohol and Drug Addiction Services of certain sections of the administrative code shall be waived for those agencies that own or operate a treatment program currently certified under Agency Rule 3793:2-1-08.Designatedsections of this rule shall be deemed for an agency not certified by ODADAS which has received national accreditation that included the prevention services, and demonstrates that the deemed sections within this rule are consistent with the national accreditation.

(5) "National Accreditation" means an organization that is recognized nationally as an accreditation body, including but not limited to, Commission on Accreditation of Rehabilitation Facilities (CARF), Council on Accreditation for Children and Family Services (COA), Joint Commission of Accreditation of Healthcare Organizations (JCAHO).

(6) "Primary Function" means the agency owns and/or has administrative responsibility for the operations and delivery of alcohol and other drug prevention programming and services and the agency's official documents such as but not limited to by-laws, articles of incorporation, policies or mission/purpose documents include statements that reflect the same.

(a) Where the primary function of the agency is in question, the Ohio department of alcohol and drug addiction services certification specialists will determine if an agency meets the definition of program and primary function through the review of the agency's official documents and alcohol and other drug prevention programming and services in consultation with the county Alcohol, Drug Addiction and Mental Health Services or Alcohol Drug Addiction Services Board Executive Director and the executive director of the agency being considered for prevention certification.

(b) Ohio department of alcohol and drug addiction services certified treatment agencies that also provide alcohol and other drug prevention programming and services must apply for prevention certification.

(7) "Volunteer" means an uncompensated individual involved in the on-going provision of prevention services. This definition does not apply to volunteers whose sole purpose is to perform administrative functions or other ancillary activities that may include, but are not limited to, chaperoning a single event, assisting in or serving food at events, performing administrative support duties, etc.

(D) Deemed status shall be granted to waive sections of the Administrative Code if the agency that owns or operates a treatment program(s) with current certification from the Ohio Department of Alcohol and Drug Addiction Services under Agency Level 3793 of the Administrative Code or has achieved national accreditation as defined in this rule. Deemed provisions include: (E) and (F) of this rule.

(E) Consumer Rights:

(1) Each agency shall have the following:

(a) Consumer rights policy that lists verbatim all of the consumer rights identified in this rule.

(b) Consumer grievance procedure.

(c) Policy for maintaining for at least two years from resolution, records of consumer grievances that include, at a minimum, the following:

(i) Copy of the grievance.

(ii) Documentation reflecting process used and resolution/remedy of the grievance.

(iii) Documentation, if applicable, of extenuating circumstances for extending the time period for resolving the grievance beyond twenty-one calendar days.

(2) The rights of consumers shall be stated verbatim according to this rule and shall include, but not be limited to, the following:

(a) The right to be treated with consideration and respect for personal dignity, autonomy and privacy.

(b) The right to be informed of available prevention services.

(c) The right to give consent or to refuse any service.

(d) The right or freedom from unnecessary physical restraint or seclusion.

(e) The right to be advised and the right to refuse observation by others and by techniques such as one-way vision mirrors, tape recorders, video recorders, television, movies and photographs.

(f) The right to confidentiality of communications and personal identifying information within the limitations and requirements for disclosure of consumer information under state and federal laws and regulations.

(g) The right to have access to one's own consumer record in accordance with agency procedures.

(h) The right to be informed of the reason(s) for terminating participation in agency services.

(i) The right to be informed of the reason(s) for denial of an agency service.

(j) The right not to be discriminated against for receiving services on the basis of race, ethnicity, age, color, religion, sex, sexual orientation, socio-economic status, national origin, disability or HIV infection, whether asymptomatic or symptomatic, or aids.

(k) The right to know the cost of services, if applicable.

(l) The right to be informed of all consumer rights.

(m) The right to exercise one's own rights without reprisal.

(n) The right to file a grievance in accordance with agency procedures.

(o) The right to have oral and written instructions concerning the procedure for filing a grievance.

(3) The agency's consumer rights policy and the consumer grievance shall be posted in a place accessible by consumers at each certified site.

(4) All staff involved with the operation of an alcohol and other drug prevention services shall be familiar with the consumer rights policy and consumer grievance procedure. There shall be documentation in each employee's personnel file, including contract staff, adult volunteers and students that he/she has received a copy of the consumer rights policy and the consumer grievance procedure and has agreed to abide by them.

(F) Consumer Grievance Procedures:

(1) Each agency shall have a consumer grievance procedure that has provisions, for, at a minimum, the following:

(a) Requirements that the grievance must be in writing.

(b) Requirement that the grievance must be dated and signed by the consumer or the individual filing the grievance on behalf of the consumer.

(c) Requirement that the grievance include the date, approximate time, description of the incident and names of individuals involved in the incident/situation being grieved.

(d) Statement to whom the consumer is to give the grievance.

(e) Statement that the agency will make a resolution decision on the grievance within twenty-one calendar days of receipt of the grievance. Any extenuating circumstances indicating that this time period will need to be extended must be documented in the grievance file and written notification given to the consumer.

(f) Designation of staff who will be available to assist a consumer in filing of a grievance.

(g) Statement that a consumer has the option to file a grievance with outside organizations, that include, but are not limited to, the following, with the mailing address and telephone numbers for each stated:

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

(ii) Ohio Department of Alcohol and Drug Addiction Services.

(iii) Ohio legal rights services.

(iv) U.S. Department of Health and Human Services, Civil Rights Regional Office in Chicago.

(h) Requirement that a written acknowledgement of receipt of the grievance be provided to each grievant. Such acknowledgment shall be provided within three working days from receipt of the grievance. The written acknowledgment shall include, at a minimum, the following:

(i) Date grievance was received.

(ii) Summary of grievance.

(iii) Overview of grievance investigation process.

(iv) Timetable for completion of investigation and notification of resolution.

(v) Agency contact name, address and telephone number.

Effective: 10/01/2006
R.C. 119.032 review dates: 09/30/2011
Promulgated Under: 119.03
Statutory Authority: 3793.02(D) , 3793.06
Rule Amplifies: 3793.06