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