3793:2-1-04 Quality assurance and improvement.

(A) The purpose of this rule is to state the minimum quality assurance and improvement requirements that a program must meet in order to be certified or licensed by the Ohio department of alcohol and drug addiction services to provide alcohol and drug addiction services.

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

(1) Alcohol and drug addiction outpatient treatment programs.

(2) Alcohol and drug addiction residential treatment programs.

(3) Opiod agonist programs.

(4) Alcohol and drug addiction ambulatory detoxification programs.

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

(1) Alcohol and drug prevention programs.

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

(3) Criminal justice therapeutic community programs.

(4) Treatment alternatives to street crime programs.

(5) Driver intervention programs.

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

is certified/licensed by the Ohio department of mental health. Deemed provision includes paragraph (F) of this rule.

(E) Each program 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 program's quality assurance and improvement activities.

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

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

(4) Provisions for conducting completeness of client records review at least quarterly.

(5) Provisions for conducting peer review. Peer review means an evaluation of the clinical pertinence and appropriateness of services delivered. Peer review shall be conducted by staff who are qualified to provide the same alcohol and drug addiction services under review. Peer review shall occur at least quarterly and shall determine the following:

(a) Assessments were thorough, complete and timely.

(b) Treatment plan problems, goals and objectives were based on the results of the assessment.

(c) Services were related to the treatment plan goals and objectives.

(d) Documentation accurately reflects the services that were provided.

(6) Assurance that any service provider cannot review his/her own client records for quality assurance and improvement activities.

(7) Provisions for conducting activities to determine that the client's admission to, continued stay and discharge from the program is appropriate based on the Ohio department of alcohol and drug addiction services' protocols for levels of care (youth and adult) for publicly funded clients, including, at a minimum, the methodology, frequency and content of these activities.

(8) Procedures for conducting waiting list management activities, including: identification of pregnant women, intravenous drug users, non-emergency status clients and clients with medical and/or psychiatric emergencies, maintaining contact with clients, policy and procedures for removing clients from the waiting list and procedures for notifying referral sources of the client's waiting list status.

(9) Provisions for conducting client satisfaction surveys to include, at a minimum, the following:

(a) Survey to be conducted on an annual basis.

(b) Satisfaction protocols, including provisions for the opportunity for all clients to participate and provisions for anonymity in survey participation, data collection, analysis and reporting of findings.

(c) Satisfactions measures, including accessibility (timeliness of appointments), appropriateness (responsiveness to client needs), cultural competency (of staff providing services), recommendation of services to others and overall satisfaction.

(d) Use of findings for improvement of the services provided by the program.

(10) Provisions for conducting referral source satisfaction surveys which shall include, at a minimum, the following:

(a) Survey to be conducted on an annual basis.

(b) Satisfaction protocols, including reasonable attempts to contact a sample of referral sources, data collection, analysis and reporting of findings.

(c) Satisfaction measures, including access (ease of referral), program information (general information about the program), client information (feedback about client) and overall satisfaction.

(d) Use of findings for improvement of the services provided by the program.

(11) A description of how quality improvement activities are integrated into the entity's overall management.

(F) Each program 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 and 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 the staff designated; 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, clients and visitors to the program, including physical plant conditions and fire safety considerations.

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

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

(ii) Reporting, reviewing and monitoring of significant financial loss to the program, 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 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. Each program 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 of a client, employee, contract staff member, volunteer or student intern when the person is on the program's premises, performing tasks for the program or participating in program activities.

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

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

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

Effective: 02/14/2011
R.C. 119.032 review dates: 11/10/2010 and 07/15/2015
Promulgated Under: 119.03
Statutory Authority: 3793.02 , (D), 3793.06 , 3793.11
Rule Amplifies: 3793.06
Prior Effective Dates: 7/1/91, 7/1/01, 11/17/05