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016.04.4-19. Administrative Operations (AO)

AR ADC 016.04.4-19Arkansas Administrative CodeEffective: January 1, 2020

West's Arkansas Administrative Code
Title 016. Department of Human Services
Division 04. Division of Behavioral Health
Rule 4. Licensure Standards for Alcohol and Other Drug Abuse Treatment Programs (Refs & Annos)
Effective: January 1, 2020
Ark. Admin. Code 016.04.4-19
016.04.4-19. Administrative Operations (AO)
Currentness
The program shall have written policy and procedures with supporting documentation for all the following:
AO1 Ownership Change. The program shall provide written notification to OADAP at least thirty (30) calendar days prior to any change of name, ownership, location, control of the facility, or make major programmatic changes using the OADAP form (see Addendum 1).
AO2 Access Policy. The program has a policy defining the program's areas that may be accessed by clients and visitors that includes medication areas, dispensing and food preparation areas.
AO3 Directory. The program shall maintain a log of all visitors to the program to protect client confidentiality in accordance with 42 CFR Part 2.
AO4 Tobacco Products. The program shall have a written policy and procedure prohibiting the use of any tobacco products within the facility in accordance with the Arkansas Clean Indoor Act of 2006. If the program provides a designated smoking area it shall be located a minimum of 25 feet from any entrance to the facility and shall not be in a common area that non-smoking individuals must transverse to gain access into the facility. In addition the program shall prohibit the use of alcohol, tobacco and illicit drugs by staff which includes:
a. Providing, distributing, or facilitating the access of tobacco products to clients;
b. Use of tobacco products in the presence of clients or visitors; and
c. Prohibits the public display of tobacco products by staff.
AO5 HIV/AIDS. The Program shall implement a written policy that states the Program shall not deny treatment to a person based on his or her actual or perceived sero status, HIV related condition or AIDS.
AO6 Advertising. The Program shall not use incentives or rewards or unethical advertising practices to attract new clients. This shall not forbid the Program from rewarding clients that maintain exemplary compliance with program rules and their individualized treatment plans.
AO7 Privacy. The private counseling area used provides sufficient privacy to maintain confidentiality of the communication between counselor and client. A private meeting area shall be available for clients to meet with their legal representatives, service providers, family members or persons providing assistance in attaining treatment goals.
AO8 Emergency/Natural Disaster. The program shall develop written policies and procedures for continued safety and treatment of clients in the event of an emergency or natural disaster. Emergency policy and procedures are readily available to all staff; the program has a written internal disaster plan which includes the training of staff in disaster and evacuation procedures, a list of alternate resources and the monthly rehearsal of various disastrous scenarios of the procedure are documented.
AO9 Critical Care Referral. The program will have policies and procedures for referring clients for services needed at a critical care facility.
AO10 Workforce Safety. The program has implemented work practice controls and provided personal protective equipment to reduce exposure to bodily fluids through the normal performance of their duties.
AO11 Infection Control. The Program shall have written policies for infection control, which are in compliance with the Center for Disease Control and Prevention. Guidelines.
AO12 STD Control. The program shall have policies and procedures describing the programs services for HIV/AIDS, Sexually Transmitted Diseases (STDs), Tuberculosis (TB) and Hepatitis to include:
a. The provision of testing and treatment at the program or through a written referral agreement with a medical entity qualified to provide such services;
b. Testing shall be available to all clients upon request;
c. All testing shall be voluntary;
d. All clients shall receive HIV/AIDS, STD, Hepatitis and TB education per admission; and
e. There will be documentation of all above.
AO13 Client Handbook. The Client Handbook shall clearly state that the program shall not be held responsible for any medical costs incurred by clients or children occupying the program and transported to medical appointments. The provider's responsibility is limited to arranging for the clients to access these services and providing transportation for them.
AO14 Grievance Policy. The Program shall have a grievance policy which states that there is a reasonable, specific deadline for completing the grievance process. At the program level, once received, client grievances must be reviewed and a decision reached in accordance of the program's policies and procedures.
Grievances to be reviewed by the governing board shall be heard no later than the board's next scheduled meeting.
AO15 The program will maintain a publicly listed or local telephone number.
AO16 Hours of operation are scheduled to make services accessible to clients and the general public.
AO17 There shall be no less than one (1) staff on duty at all times per twenty-five (25) clients, per physical site. (Not Applicable to Criminal Justice System).
AO18 There shall be no less than one (1) treatment staff per twenty (20) clients during scheduled treatment activities.
AO19 A counselor's caseload shall not exceed the 25 to one (1) client/counselor ratio.
AO20 The program has at least one staff person present during operating hours who maintains a valid certification in First Aid, Cardio-Pulmonary Resuscitation (CPR) and Non-violent Crisis Prevention and Intervention (NCPI). All Specialized Women Services programs will have at least one staff person who is certified in child and infant CPR. This documentation will be verified by the staff member's personnel record.
AO21 The program has procured an agreement with a mental health provider licensed or certified in the State of Arkansas to provide consulting services for dually diagnosed treatment applicants or clients. The agreement must be updated every two years.
AO22 The program maintains a comprehensive resource directory (updated every 2 years) of local community and government agencies within the service area which contains at least:
a. The name and location of the resources;
b. The type of services provided by the resource;
c. The eligibility criteria for the resource; and
d. The phone number(s) and name(s) of the contact person(s).
AO23 Documenting outreach and referral activities necessary to educate judges, prosecuting attorneys, law enforcement personnel, community service providers, substance abuse treatment programs, and the public as to the operations of the program.
AO24 The program will provide written referral to or coordinate introduction of available resources and services through community and government agencies that will assist with specialized needs to maintain a continuum of client care. These agreements shall include:
a. The services the resource agrees to provide;
b. The duration of the agreement;
c. The procedures to be followed in making referral;
d. A statement of conformity to federal, state, and program confidentiality requirements;
e. Date, time and signatures of both parties; and
f. The agreements must be updated every two years.
AO25 Services are available to provide a variety of diagnostic and primary substance abuse treatment on both a scheduled and non-scheduled basis. Services provided by the program include, but are not necessarily limited to the following:
a. Case management;
b. Orientation to the program's operations and procedures;
c. Screening of applicants for substance abuse treatment service for referral, or treatment purposes;
d. Individual, group and family counseling sessions;
e. Crisis intervention; and
f. Interdisciplinary treatment services.
AO26 Residential services are provided seven (7) days per week, 24 hours per day and provide;
a. A minimum of twenty-eight (28) hours of structured treatment weekly
b. A minimum of five (5) hours daily (Monday through Friday) and
c. A minimum of three (3) hours daily on Saturday and/or Sunday.
(See Definitions Section for an explanation of “structured treatment.”)
AO27 Partial day treatment programs provide services at a minimum of four (4) hours per day and at least five (5) days per week.
AO28 Protocol for administrative discharge to include: threats of violence or actual bodily harm, disruptive behavior, sexual misconduct, loitering, sale, purchase or use of drugs or alcohol, continued unexcused absences from counseling.
AO29 When a program determines to administratively discharge a client, the program shall provide a written statement containing:
a. The reason(s) for discharge;
b. Written notice of his or her right to request review of the decision by the Program Director or his or her designee; and
c. A copy of the appeal procedures.

Credits

Adopted Dec. 26, 2010. Amended Jan. 1, 2020.
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 016.04.4-19, AR ADC 016.04.4-19
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