908 KAR 1:380. Licensing procedures and standards
for the operation of alcohol and other drug abuse prevention programs.
RELATES TO: KRS 222.211
STATUTORY AUTHORITY: KRS 194.050, 222.211, EO
2004-726
NECESSITY, FUNCTION, AND CONFORMITY: EO
2004-726, effective July 9, 2004, reorganized the Cabinet for Health Services
and placed the Department for Mental Health and Mental Retardation within the
cabinet. KRS
194.050, 222.211 authorize the cabinet to regulate alcohol and other drug abuse
agencies and programs. This administrative regulation provides licensure
requirements and minimum standards for the operation of agencies providing
alcohol and other drug abuse prevention.
Section 1. Definitions. (1) "Agency"
means as defined in KRS 222.005(2).
(2) "Alcohol and other drug abuse" means
as defined in KRS 222.005(12).
(3) "Cabinet" means as defined in KRS
222.005(3).
(4) "Certified chemical dependency prevention
professional" means an individual who is recognized by the Kentucky
Certification Board of Chemical Dependency Professionals, Inc.
(5) "Consumer" means the recipient of
prevention services.
(6) "Legal entity" means a unit other
than a natural person with a separate and distinct independent existence,
having lawful standing in the Commonwealth of Kentucky to function legally, to
sue or be sued and make decisions through agents, by means of a partnership
agreement, articles of incorporation, legislative act, or executive order.
(7) "Outcome evaluation" means an
assessment of ways in which an individual, system, or community participating
in a prevention program has changed as a result of that program.
(8) "Prevention" means as defined in KRS
222.211(1).
(9) "Preventionist" means any individual
or certified prevention professional who receives remuneration for an alcohol
or other drug prevention program.
(10) "Process evaluation" means
describing and documenting what actually was done, how much, when, for whom and
by whom during the course of the program.
(11) "Program" means as defined in KRS
222.005(10).
Section 2. Licensing Procedures. (1) An agency
receiving remuneration for any program shall not operate without first
obtaining from the cabinet an alcohol and other drug abuse prevention license,
unless the agency is exempted under KRS 222.003(1) and (2).
(2) Any agency operating a program without first
obtaining a license shall be subject to the penalties as stated in KRS
222.990(2).
(3) An application for licensure or renewal of
licensure shall be submitted in writing to the Cabinet for Health and Family
Services, Office of Inspector General, Division of Licensing and Regulation,
275 East Main Street, Frankfort, Kentucky 40621, and shall include at a minimum
the agency name and mailing address.
(4) An application for licensure shall be accompanied
by a fee of $155. The license shall remain in effect for one (1) year from the
date of issue and may be renewed. An application for renewal shall be
accompanied by a fee of eighty (80) dollars.
(5) The license shall be conspicuously posted in a
public area at the agency and shall indicate the year the license was issued or
renewed.
(6) An application for licensure and renewal shall
be processed as follows:
(a) The cabinet may conduct an on-site inspection
of each agency to determine compliance with licensure standards;
(b) The agency shall provide representatives of the
cabinet access during normal hours of operation to any document needed to
complete the inspection;
(c) The cabinet shall notify the agency in writing
of any violation of licensure standards identified during the inspection;
(d) The agency shall submit to the cabinet a
written plan of correction within ten (10) days of receipt of the notice of
violation. The plan of correction shall specify the corrective action to be
taken and the date when each violation shall be corrected.
(7) Changes in agency status.
(a) Name change.
1. The agency shall notify the cabinet in writing
within ten (10) calendar days of the effective date of change.
2. The cabinet may issue a new license for the
remainder of the licensure period.
3. The agency shall submit a processing fee of
twenty-five (25) dollars to the cabinet.
(b) Change of location. The agency shall not
deliver services at a new location until an application for licensure
accompanied by a fee of eighty (80) dollars is filed with the cabinet.
(c) Change of ownership. The new owner of the
agency shall submit to the cabinet an application for licensure accompanied by
a fee of eighty (80) dollars within ten (10) calendar days of the effective
date of change.
(d) Discontinuing a program. The agency shall
notify the cabinet in writing within ten (10) calendar days of the effective
date of discontinuance.
(8) The certificate of licensure shall be the
property of the cabinet and shall be returned by the agency to the cabinet upon
closure or revocation of the license.
(9) The cabinet shall make available to the public
a list of all licensed alcohol and other drug prevention agencies. The cabinet
may issue revisions and corrections to this list as changes occur.
Section 3. Physical Plant. There shall be written
housekeeping, sanitation and maintenance procedures which shall be followed at
all times to ensure that the agency shall be clean and in good repair.
Section 4. Organization and Administration. (1)
Governing body.
(a) An agency shall have a governing body with
overall authority and responsibility for the agency's operation.
(b) The governing body shall have written
documentation to show the agency is a legal entity in the Commonwealth of
Kentucky by means of a partnership agreement, articles of incorporation,
legislative act or executive order.
(c) The agency shall maintain written documentation
to show that it has professional liability insurance in the minimum amount of
$100,000 per occurrence;
(d) The responsibilities of the governing body
shall be specified in writing and shall include:
1. Adopting a mission statement that outlines the
agency's purpose;
2. Adopting a conflict of interest policy to govern
participation by a governing body member in a decision which may be influenced
by a member's business interest;
3. Appointing an executive director who shall be
responsible for the day-to-day operation of the agency;
4. Adopting an administrative structure and
establishing a line of authority for all prevention programs operated by the
agency;
5. Documenting administrative structure and lines
of authority on an organizational chart, including the name of each current
governing board member;
6. Adopting written policies and procedures to
direct administrative and program functions of the agency to ensure that
sufficient staff and resources are available for the successful delivery of
programs;
7. Reviewing written prevention policies and
procedures at least every two (2) years making needed revisions and
incorporating relevant findings of the agency's quality assurance system;
8. Overseeing a system of financial management and
accountability;
9. Obtaining agency professional liability
insurance in the amount of $100,000 per occurrence at a minimum;
10. Completing a minimum of two (2) hours of annual
training on alcohol and other drug prevention for a prevention agency, and in a
multiservice agency for that particular component of the board that provides
oversight to the prevention program; and
11. Meeting as a whole at least quarterly and
keeping a written record demonstrating the ongoing discharge of its
responsibilities.
(2) Staffing and staff qualifications.
(a) A preventionist who is actively involved in the
development and implementation of a prevention program shall be certified by
the Kentucky Certification Board for Prevention Professionals as a prevention
professional or become a Kentucky certified prevention professional within
twenty-four (24) months of the effective date of this administrative regulation
or within twenty-four (24) months of employment whichever is longer.
(b) The agency shall designate one (1) or more
individuals as prevention supervisor.
(c) A prevention supervisor shall meet at least one
(1) of the following sets of qualifications:
1. A bachelors degree plus five (5) years of work
experience in prevention or the related fields of health, social science,
marketing, communications or education. Two (2) years of the work experience
shall be in administration; or
2. A masters degree, with two (2) years of work
experience in prevention administration or the related fields of health, social
sciences, marketing, communications or education.
(d) Staff responsible for providing prevention
services within the agency shall be clearly designated.
(e) The agency shall designate an individual as an
ombudsman.
Section 5. Quality Assurance. (1) Staff and
community volunteer development.
(a) The prevention agency shall establish a system
of on-going staff development to include training and supervision of all
prevention staff and community volunteers which shall:
1. Be outlined in the agency's policy and
procedures manual; and
2. Support the attainment of the goals and
objectives of the prevention program.
(b) The prevention agency shall make training
available for administrative staff, all preventionists, and volunteers. The
training shall be in an area that enables a volunteer or staff to carry out
their expected job duties.
(c) Completion of training shall be documented in
the volunteer and staff development files and shall identify the name of the
training, clock hours earned and dates attended.
(2) Program quality assurance. The agency shall
have written policy and procedures for assuring the quality of each program
operated by the agency which shall include the following:
(a) Designation of an individual responsible for
monitoring and evaluating the quality assurance activities;
(b) Description of the range of activities and
services provided in each program;
(c) A statement of intended program outcomes and
indicators of effectiveness; and
(d) Establishment of a mechanism and a schedule for
the collection, organization and analysis of data to be used for the process
evaluation and outcome evaluation of a program to determine the quality of the
service.
Section 6. Personnel and Employment Practices. (1)
The agency shall have written policies and procedures governing employment
practices for agency employees and subcontractors which shall include:
(a) Protection against discrimination of any
employee or prospective employee on the basis of gender, age, race, ethnicity,
religious affiliation, and disability including prior history of alcohol or
other drug abuse;
(b) Provisions for recruiting, selecting,
promoting, disciplining and terminating staff;
(c) Procedures for confirming previous checks or
conducting background checks from the Justice Cabinet for agency staff and
subcontract employees working with minors to assure that there is no previous record
of conviction related to abuse or molestation of children;
(d) Provision for the maintenance of personnel
records for each staff member containing the following:
1. Application for employment;
2. Job specifications;
3. Written references;
4. Results of background check;
5. Documentation of all education, work experience,
training and status of professional licensure, certification and registration;
6. Salary information;
7. Job performance appraisals;
8. Disciplinary action;
9. Commendations; and
10. Employee incident reports.
(e) Written job specifications for all positions
identifying the qualifications, duties, reporting supervisor and positions
supervised;
(f) Explanation of employee benefits, training and
staff development opportunities, safety and work related injury procedures,
employee grievance procedures, rules of conduct and compensation plan;
(g) Information on equal employment opportunities
and affirmative action policies;
(h) A provision for ensuring an alcohol and drug
free work place to include action to be taken when an employee is involved in
the unlawful manufacture, distribution, possession or use of alcohol and any
controlled substance at the agency;
(i) A provision for yearly job appraisal which
includes an evaluation, based on objective criteria of each employee's
performance in relation to their expected job duties;
(j) Ethical standards identifying acceptable
employee conduct regarding consumer's rights;
(k) Conflict of interest policies governing dual
relationships with other legal entities;
(l) Provisions to assure the confidentiality of
personnel records;
(m) A procedure for providing an employee with
access to his personnel record; and
(n) Procedures for the storage and retention of
personnel records.
(2) A staff member shall be given access to a copy
of the agency's policies and procedures at the time of employment and shall be
notified of a revision as it is made.
Section 7. Program Operation and Services. (1) Each
program operated under the authority of the alcohol and other drug prevention
license shall have a program operations manual containing the following:
(a) Philosophy;
(b) Mission statement;
(c) A method for determining the needs of the
population to be served and a program provided in response to an identified
need;
(d) A method for tailoring a program to the
characteristics of a specific target audience including age, gender, drug use
patterns, racial, ethnic and cultural heritage;
(e) A method to be used to review an activity plan,
information, material and curricula prior to use for accuracy, potential
effectiveness and appropriateness in influencing the alcohol and drug use
behavior of the target audience;
(f) A method for soliciting input and involving the
community or identified target audience in planning;
(g) A method for making or receiving a prevention
consumer referral within or outside the agency;
(h) A method for referring or delivering a service
to a consumer having special speech, language, visual or hearing needs;
(i) A method for determining an individual's or
agency's suitability for participation in the prevention program; and
(j) Policies and procedures for setting and
collecting fees.
(2) The prevention agency shall maintain reports
and records documenting the following:
(a) Results of a needs assessment;
(b) Collaboration with a community or other agency;
(c) Material and curricula reviewed;
(d) Program activity or service delivered;
(e) Case management information pertaining to early
intervention and prevention programs directed at a specific audience including
the following:
1. Screening and assessment results;
2. A prevention service provided;
3. Research data showing effectiveness of a
prevention program used for a specific target audience;
(f) A background check conducted on a volunteer
working with a minor to assure that there is no previous record of conviction
related to the abuse or molestation of minors;
(g) Identification of which of the following
prevention strategies was employed:
1. An alternative which provides for the
participation of a target population in an activity that excludes alcohol and
other drug use. Methods shall include involving agency and community members in
the design and provision of constructive and healthy activities that offset the
attraction to or otherwise meets the needs usually filled by alcohol and other
drugs;
2. Community-based process which aims to enhance
the ability of a community member to identify a problem or resource and to
appropriately select the prevention strategy that will more effectively impact
the behavior relating to alcohol and other drug use. Methods shall include
involving the community in planning, organizing, and implementing prevention
programs through interagency collaboration, coalition building, and networking;
3. Consultation which involves an interaction and
contractual relationship between two (2) or more people wherein one who has
special skills or expertise in accomplishing a specific goal provides one who
does not have the same skills or expertise, guidance in the mutual
accomplishment of that goal;
4. Education which involves two (2) way
communication and interaction between the educator or facilitator and the
participant. The method shall include direct training, training of trainers and
training of impactors. This strategy consists of a well-defined, structured
learning process which involves both knowledge and skill development.
Educational programs seek to accomplish the following:
a. Motivate an individual to make a healthy choice
about alcohol and other drug use;
b. Help him develop the competency needed to make a
choice;
c. Prepare him to develop and implement a
prevention program in a particular setting.
5. Public and social policy change which
establishes or changes written or unwritten community standards, codes, and
attitudes, thereby influencing incidence and prevalence of alcohol and other
drug use problems in the general population and creating an environment more
conducive to prevention. Methods shall include changing laws and community
standards to restrict availability and access, price increases and community
wide actions;
6. Information dissemination which is characterized
by limited contact, one (1) way communication of information from the source to
the audience. Methods shall include identification, collection and
dissemination of resource materials, media communication, public speaking and
networking activities Information dissemination programs provide the following:
a. Awareness and knowledge of the nature and extent
of alcohol and other drug use, abuse and addiction;
b. The effect of alcohol or a drug on an
individual, family or community;
c. Information to increase the perception of risk;
and
d. Identification of an available prevention
program or service.
7. Problem identification and referral which is
designed to identify a person who is beginning to experience an alcohol or
other drug problem or those for whom the risk of developing a problem is
particularly high. Methods shall include screening, intensive preventive
education, or referral for a clinical assessment;
(h) Documentation of a consumer referral made and a
source used within or outside the agency;
(i) Process and outcome evaluation results;
(j) A follow-up plan; and
(k) Fee assessment and collection.
Section 8. Consumer Rights. An agency licensed to
provide an alcohol or other drug prevention program shall have written policies
and procedures for ensuring the rights of the consumer which shall include:
(1) An assurance that there shall be no unlawful
discrimination in determining eligibility for admission to a prevention
program;
(2) A statement of consumer rights posted in the
agency with the name, address and telephone number of the agency's ombudsman;
(3) Assurance of the confidentiality of consumer's
alcohol, tobacco, and other drug issues; and
(4) The grievance procedure posted in the agency
which shall include at a minimum:
(a) The time frame for reviewing and responding to
a consumer complaint;
(b) The requirement for the documentation of a
grievance in each consumer record and in a central agency incident file; and
(c) The requirement of referring to the appropriate
authority an allegation of abuse or neglect in accordance with:
1. KRS 209.030 regarding the abuse or neglect of an
adult; and
2. KRS 620.030 regarding the abuse or neglect of a
minor.
Section 9. Complaints. (1) A suspected violation of
a licensure standard shall be reported to the cabinet.
(2) The complainant and information related to a
suspected violation shall be kept confidential and shall not be disclosed
publicly during an investigation. Once the investigation is complete,
disclosure of the information shall be subject to the provision of KRS 61.870
to 61.884.
(3) A complaint received by the cabinet shall be
processed according to the following procedures:
(a) The cabinet may conduct an on-site inspection
to determine if a violation of a licensure standard has occurred; and
(b) The cabinet may conduct an audit of the
agency's financial records in accordance with generally accepted government
auditing standards.
Section 10. Revocation. (1) A violation of a
licensure standard may result in the revocation of a license.
(2) The following violations shall result in the
revocation of a license:
(a) A violation creating an immediate danger to the
prevention consumer;
(b) Fraud in obtaining a license or in connection
with a service provided;
(c) Gross negligence, misconduct or violation of
the ethics code of the Kentucky chemical dependency certification board which
results in revocation of the prevention professional credential;
(d) A conviction of an agency preventionist or
volunteer of a crime related to the abuse, neglect or exploitation of a child
or an adult.
Section 11. Penalties. (1) Denial or revocation of
a license.
(a) Plan of correction. If an agency fails to
submit an acceptable plan of correction within ten (10) calendar days from the
date of a notice of violation, the cabinet shall notify the agency, in
accordance with Section 12 of this administrative regulation, that the license
may be denied thirty (30) calendar days after the date of the notice of denial
or suspension unless:
1. The agency submits an acceptable plan of
correction to the cabinet;
2. The agency requests a hearing in accordance with
Section 12 of this administrative regulation; or
3. The agency notifies the cabinet in writing that
the application for licensure is withdrawn.
(b) Denial of an application for licensure. When an
application for licensure is denied, the legal entity named in the application
may reapply for a license in accordance with Section 2 of this administrative
regulation after a period of:
1. One (1) year from the date of denial; or
2. Thirty (30) days from the date of application
for licensure was withdrawn by the agency.
(2) Reapplication. The legal entity named in the
application may reapply for a license in accordance with Section 2 of this
administrative regulation after a period of one (1) year from the date of
revocation.
Section 12. Appeals. (1) If the cabinet takes
action to deny or revoke an agency license, the cabinet shall notify the agency
in writing stating the reason for the adverse action and the agency's right to
appeal in accordance with KRS 222.231(6).
(2) If the agency believes an action by the cabinet
is unfair, without reason, or unwarranted, the agency may appeal the action in
writing to the Secretary, Cabinet for Health Services, 4th Floor, 275 East Main
Street, Frankfort, Kentucky 40621, within thirty (30) calendar days after
receipt of the notice of action from the cabinet.
(3) Upon receipt of the appeal, the secretary, or
his designee, shall issue a notice of hearing no later than twenty (20) days
before the date of the hearing. The notice of hearing shall comply with KRS 13B.050.
The secretary shall appoint a hearing officer to conduct the hearing in
accordance with KRS Chapter 13B.
(4) The hearing officer shall issue a recommended
decision in accordance with KRS 13B.110. Upon receipt of the recommended order
and following consideration of any exceptions filed pursuant to KRS 13B.110(4),
the secretary shall enter a final decision pursuant to KRS 13B.120.
(5) An agency that continues to operate after the
closing date established by the secretary, or his designee, shall be subject to
legal action by the cabinet as provided by law. (24 Ky.R. 1824; Am. 2131; 2387;
eff. 5-18-98.)
