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