908 KAR 1:380. Licensing procedures and standards for the operation of alcohol and other drug abuse prevention programs

Link to law: http://www.lrc.ky.gov/kar/908/001/380.htm
Published: 2015

      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.)
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