The Bureau of Drug and Alcohol Programs (BDAP), Department of Health, has developed a first draft of revised standards and protocols for prevention services. PCPA has participated in he work group with the Department of health to prepare this initial draft. BDAP is requesting comments to the document by May 19, 1999.
Scope
This section establishes the procedures for the issuance of a Certificate of Approval in Prevention to drug and alcohol prevention providers as determined by the Department/Granting Authority.
Policy
a) Persons, partnerships, corporations or other legal entities intending to provide drug and alcohol prevention services utilizing paid or voluntary staff shall be approved, as determined by the Granting Authority.
b) No drug and alcohol prevention provider may receive funds from the Department without a Certificate of Approval in Prevention.
Application for Certificate
a) Persons, partnerships, corporations, or other legal entities intending to provide prevention services shall apply for a Certificate of Approval in Prevention from the Granting Authority. Applications shall be made using prescribed forms and procedures.
b) Certificate shall expire two years from the date of issuance. Prior to the expiration of the certificate, the Granting Authority shall notify the prevention provider of the onsite inspection for the renewal of the Certificate of Approval in Prevention.
c) The Granting Authority will notify the appropriate SCA of applications for and issuance of a Certificate of Approval in Prevention to a provider within the SCA's service area.
Initial Certificate
a) The Granting Authority will issue an initial certificate after an onsite inspection, valid for a specific time period, of no more than six months before a provisional or full certificate can be issued. An initial certificate will be issued when a provider:
1) Has substantially, but not completely complied with applicable requirements for a certificate of approval in prevention.
2) Is complying with a course of correction approved by the Granting Authority.
3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the provider's client.
b) Within 15 working days of the receipt of a deficiency report, a provider shall submit a plan to correct deficiencies noted during the site visit.
c) At the end of a six month period, a provider must qualify for a provisional or full certificate.
Provisional Certificate
a) The Granting Authority will issue a provisional certificate after an onsite inspection, valid for a specific time period of no more than six months when a provider:
1) Has substantially, but not completely complied with applicable requirements for a Certificate of Approval in Prevention.
2) Is complying with a course of correction approved by the Granting Authority.
3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the provider's client.b) Within 15 working days of the receipt of a deficiency report, a provider shall submit a plan to correct deficiencies noted during the site visit.
c) A provisional Certificate of Approval in Prevention may be renewed no more than once.
d) Upon compliance with the requirements, a full certificate of approval will be issued.Full Certificate
a) A Certificate of Approval in Prevention shall be issued when an onsite inspection by the Granting Authority has determined that requirements for the Certificate of Approval in Prevention have been met.
b) A certificate shall indicate the name of the provider, the address of the administrative office, the date of issuance and the expiration date.
c) The current certificate shall be displayed in a public place within the administrative office.
Restrictions on the Certificate of Approval in Prevention
a) A Certificate of Approval in Prevention applies only to the named provider and is not transferable.
b) Utilizing prescribed Granting Authority forms, the holder of the Certificate of Approval in Prevention shall notify the Granting Authority prior to the occurrence of the following conditions:
1) Change in ownership.
2) Change in the name of the provider.
3) Change in the location of the administrative office of the provider.
4) Closing of the provider operations.
c) Failure to notify the Granting Authority may result in the issuance of a provisional certificate and/or a fine.
Right to Enter and Inspect
a) For the purpose of determining continuing conformity of the holder of a Certificate of Approval in Prevention, an authorized representative of the Granting Authority has the right to enter, visit and inspect a provider approved for or applying for a certificate.
b) The Granting Authority representative shall have full and free access to any and all the records necessary to determine provider compliance with these requirements.
c) The Granting Authority representative has the right to interview provider clientele as part of the visitation and inspection process with appropriate client consent.
Notification of Deficiencies
a) The Granting Authority representative shall leave appropriate forms with the provider to address areas of noncompliance with the requirements.
b) These forms shall be completed and submitted to the Granting Authority within 15 working days after the visit.
c) No approval shall be issued until the Granting Authority has approved a plan of corrective action.
Refusal or Revocation of Certificate
a) The Granting Authority may revoke or refuse to issue a Certificate of Approval in Prevention for any of the following reasons:
1 ) Violation of or noncompliance with the requirements.
2) Failure to comply with a plan of corrective action approved by the Granting Authority less the Granting Authority approves an extension or modification of the plan of corrective action.
3) Gross incompetence, negligence or misconduct by the provider.
4) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a Certificate of Approval in Prevention
5) Lending, borrowing or using the Certificate of Approval in Prevention of another provider.
6) Knowingly aiding or abetting the improper granting of a Certificate of Approval in Prevention.
7) Mistreating or abusing individuals to whom services are being rendered.
8) Continued pattern of noncompliance in disregard of these requirements.
9) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public. Applicable to the facility owned or leased by the provide.
10) Unqualified alcohol and other drug prevention service personnel as stated in these requirements.
11) Unqualified prevention service personnel as stated in these requirements supervise alcohol and other drug prevention service staff. (This applies only to project approved agencies and not to small unlicensed providers).
12) Program misuses and/or fails to properly account for the disbursement of state and/or federal funds.
13) Provider knowingly provides the Department and its agents false financial information.
b) If the Granting Authority proposes to revoke or refuse to issue a Certificate of Approval in Prevention, it will give written notice to the provider by certified mail with required return receipt stating:
1) The reasons for the proposed action.
2) The specific time period for the provider to correct the deficiencies. The provider has the opportunity to address the proposed action to the Granting Authority in writing. If the provider does not correct the deficiencies within the specified time period, the Granting Authority will officially notify the provider that it shall revoke or refuse to reissue its certificate of approval and that the provider has a right to a hearing authorized by the Granting Authority. A request to the Granting Authority for a hearing shall be filed in writing within 30 days of receipt of the notification.
Hearings and Appeals
The Granting Authority shall define specific procedures for a hearing and appeals. A copy of the procedures shall be made available to the provider upon application for a Certificate of Approval in Prevention. The Department shall approve the hearing and appeal procedures. Sanctions
a) Any program which has been denied certification or has had its certification revoked pursuant to this rule by the Granting Authority shall not be eligible to apply to the Granting Authority for a Certificate of Approval in Prevention for a minimum of one year from the date of denial or revocation. The maximum time frame will be determined by the Granting Authority based upon the specific nature of the infractions noted in the denial or revocation.
b) Each member of the governing authority of a prevention program which has been denied certification or has had its certification revoked shall not be permitted to serve as a member of a governing authority of a prevention organization for a minimum of one and a maximum of two years from the date of denial or revocation.
c) A program director or other administrators of a prevention program which has been denied certification or has its certification revoked shall not be permitted to be employed in an administrative capacity for a minimum of one and a maximum of two years from the date of denial or revocation.
Governing Authority
a) Each provider shall be registered for doing business in Pennsylvania with the Pennsylvania Department of State and shall have on file a copy of this registration.
b) If the provider is owned by an out of state corporation, the program shall have on file a Certificate of Authority to do business in Pennsylvania issued by the Pennsylvania Department of State.
c) If the provider is a non-profit organization, the program shall have on file the Articles of Incorporation.
d) The provider shall have a federal tax identification number.
e) Each provider shall have a governing authority that has overall responsibility for the operation of its alcohol and other drug prevention program:1) The governing authority for a corporation shall be a board of directors (also known as a board of trustees).
2) The governing authority for a partnership shall be the partners as specified in their registration with the Department of State.
3) The governing authority for a sole proprietorship shall be the proprietor as specified in his/her registration with the Department of State.
4) The governing authority for a joint venture shall be the joint ventures as specified in their registration with the Department of State.
5) The governing authority for a government organization shall be the appointing authority of a department, division, bureau or other government office, which is responsible for the management of the alcohol and other drug prevention or similar programs and has independent authority to hire or terminate staff.
Duties of Governing Authority
The Governing Authority, in conjunction with the program administrator where appropriate, is responsible for insuring that each prevention program shall have written policies, articles of incorporation, and/or bylaws stating the responsibilities of the governing authority. These duties shall include, but are not limited to:
1) Selection of a program administrator as the person officially responsible to the governing authority and establishing duties and responsibilities for the program administrator.
2) Identifying the purpose and philosophy.
3) Describing the organizational structure.
4) Ensuring that an annual performance evaluation is conducted for the program director.
5) Establishing and approving the prevention services that the program will provide.
6) Establishing, approving, and revising as necessary the policies of the prevention program.
7) Approving an annual budget.
8) Approving an annual plan for providing the program's prevention services.
9) Ensuring that the hours of operation for the program accommodate the needs of the program's consumers.
10) Ensuring that all alcohol and other drug prevention services provided and employment practices are in accordance with non-discrimination provisions of all applicable federal and state laws and regulations.
11) Reviewing the financial audit report of the annual independent fiscal audit of the organization.
12) Reviewing the findings of quality assurance and improvement activities of the program.
13) Reviewing the annual management performance report of the program.
14) Ensuring that the provider does not misuse and properly accounts for the disbursement of state and federal funds.
15) Ensuring that the facility operates by a written code of ethics approved by the Granting Authority.
16) Ensuring that services are provided by qualified alcohol and other drug prevention service providers as stated in these requirements.
17) Ensuring that the provider does not provide false financial information.
18) Ensuring that service providers are supervised by qualified alcohol and other drug prevention service supervisors as stated in these requirements.
19) Ensuring that the life and safety of the provider's consumers are not jeopardized by failure of the program to operate its facilities in accordance with the physical plant and safety requirements of this rule. (Subject to removal as a requirement)
Program Administration:
Each prevention provider shall have a program director (or other similar title) who is responsible for the overall day-to-day operation of the alcohol and other drug prevention program. The program director shall be responsible to the governing authority of the organization. If a prevention program is a component of a larger organization, the program director may report to the executive director of the organization, who would report to the governing authority.
a) The program director shall annually review and revise as necessary a written manual delineating program policies and procedures.
b) The program director shall assist the governing authority in formulating policy and shall present the following to the governing authority at least annually:
1) There shall be comprehensive goals and objectives, which include time frames and available resources to include, but not be limited to fiscal, personnel, public relations, training, service delivery and physical plant (as appropriate).
2) Performance report summarizing progress toward meeting goals and objectives at least annually.
Services Management
Each prevention program shall have written policies and/or procedures for prevention programming that includes, but are not limited to the following:
a) Description for each of the prevention services provided by the program.
b) Criteria for identifying target populations for receipt of prevention services.
c) Processing requests for services.
d) Processing referrals for services, where deemed appropriate.
e) Reporting suspected child abuse and/or child neglect.
Fiscal
Base line principles will be written by BDAP fiscal and field input.
Personnel Management
a) Each program shall establish and maintain written personnel policies and procedures that comply with relevant federal, state and local statues and regulations.
b) The Personnel records shall be maintained in a confidential manner and include, but not be limited to:
1 ) Application/resume for employment.
2) Result of reference investigations where applicable.
3) Verification of training experience and professional licensure or registration, where applicable
4) Salary information
5) Job description
6) Work performance evaluation including the following:i) Individual staff performance shall be evaluated at least annually.
ii) The individual shall be informed, by written copy, of their annual evaluation.7) Disciplinary actions
c) There shall be written job descriptions for all staff positions, which shall include, but not be limited to:
1) Job title
2) Tasks and responsibilities of the job
3) Requisite skills, knowledge and experience.
d) The program director shall develop written policies on employee rights and shall demonstrate the program's efforts toward informing staff of the following:
1 ) The employee's right to inspect his or her own records.
2) The employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from their record.
3) The employee's right to submit rebuttal data or memoranda to their own record.
Training
a) The project director shall develop written policies and procedures to provide for ongoing staff training and evaluation.
Documentation shall include, but not be limited to:
1 ) An assessment of staff training needs.
2) Plans for addressing these needs.
3) Mechanism to collect feedback on training completed.
4) An annual evaluation of the overall training completed.
b) All prevention staff, including volunteers, shall receive at a minimum, training appropriate to their job responsibilities, to include current theory, research and best practices.
c) Verification of all training shall be documented and kept on file.
Data Collection
Each prevention provider shall participate in the State's management information system for collecting social-demographic information and data on alcohol and other drug prevention services. In cases where a prevention provider is responsible for conducting a needs assessment, the provider shall maintain all documentation pertaining to the needs assessment process.
Prevention Services Methodologies
Prevention services shall be provided for the general population and those who are at risk for addiction, but are not necessarily in need of treatment. Provider shall deliver services through one or more of the following methodologies:
a) Information Dissemination.
b) Education.
c) Alternatives.
d) Problem Identification and Referral.
e) Community-Based Process.
f) Environmental
Prevention Service Record
a) A prevention provider shall have written policies and/or procedures for storage, retrieval, access and destruction of service records.
b) A provider shall maintain documentation for prevention services provided that includes, but is not limited to:
1 ) Date that the prevention service/activity was provided.
2) Location where the prevention activity was provided.
3) Number of individuals served in each prevention activity.
4) Type of prevention service/activity provided.
5) A description of strategies and activities, to include an outline, syllabus, lesson plan or summary.
6) Signature of the individual who provided the prevention activity.
Quality Assurance and Program Improvement
a) Each prevention provider shall develop and annually review a written plan, policies and/or procedures for conducting quality assurance and improvement activities.
b) Each prevention provider shall conduct quality assurance and improvement activities that shall include, but not be limited to one or more of the following: (new)
1 ) Consumer satisfaction surveys.
2) Peer reviews.
3) Referral source satisfaction surveys.
c) Each prevention provider shall prepare an annual management performance report which shall include, but not be limited to:
1 ) Program goals and objectives.
2) The risk reduction outcome indicators for the prevention services goals and objectives.
3) Discussion of the extent that the prevention service objectives of the provider were or were not achieved.
4) Description of the prevention services provided.
5) The total number of prevention services provided by type of services and Demographic breakdown.
6) prevention strategies relative to the target population.
7) Results of the quality assurance and quality improvement activities.
Evaluation:
a) Providers shall evaluate the effectiveness of their services on individuals and systems by measuring level changes in the following:
1) Awareness
2) Knowledge
3) Attitude
4) Behavior
b) Methodologies used to measure these changes shall include the following:
1) Process Evaluation
steps taken to measure the results of prevention services and planned activities in quantitative and qualitative terms to learn if their intended accomplishments were met.
2) Outcome Evaluation
collecting evidence, resulting from program services, to learn if intended outcomes were achieved.
Note: In BDAP's Performance/Outcomes Prevention model, outcome evaluation is linked to the achievement of measurable objectives.
3) Impact Evaluation
steps taken to assess the broader long-term affects programs have on changing alcohol, tobacco and other drug use measures or in terms of changes in risk or protective factor indicators.
c) Program evaluations shall include the development and reporting of outcome measures related to the demonstration of risk reduction, development of protective factors, asset development and positive individual and/or community behavioral change.
Confidentiality:
A prevention provider shall develop written procedures to ensure the confidentiality of program participants in accordance with federal and state confidentiality regulations.
Consumer Rights:
The provider shall develop policies and procedures which will prohibit discrimination in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
a) Each prevention provider shall have a Consumer Rights Policy that includes, but is not limited to the right to:
1) be treated with consideration and respect for personal dignity, autonomy and privacy,
2) be informed of the reason (s) for terminating participation in a program,
3) have access to one's own consumer file in accordance with program procedures,
4) know the cost of services, if applicable,
5) file a grievance in accordance with procedures defined in these standards.
b) The prevention provider's Consumer Rights Policy shall state that a copy of the Consumer Rights Policy is available to consumer upon request at no charge.
c) A copy of the Consumer Rights Policy shall be posted in a place accessible by the consumers at each program site.
Consumer Grievance
1) Each prevention program shall have a consumer grievance procedure that includes, but is not limited to the following:
a) Statement that the consumer should make an effort to resolve a complaint/grievance with the program staff and/or the program director before submitting a grievance.
b) Requirement that the grievance be in writing.
c) Requirement that the grievance be dated and signed by the consumer (or dated and signed by a person filing the grievance for the consumer).
d) Requirement that the grievance include the date, time, description, and names of the individuals involved in the incident/situation being grieved.
e) Statement that the program is to make a resolution decision of the grievance within thirty calendar days of receipt of the grievance. Any extenuating circumstances indicating that this time period will need to be extended must be documented in the grievance file.
f) Statement that if the griever is not satisfied with the program's remedy for the grievance, she/he may file a grievance with outside organizations, that include, but is not limited to the following. The grievance procedure must specify the name, address, and telephone number of each of the following:
1) Granting Authority
2) Department of Health, Bureau of Drug and Alcohol Programs
2) program's consumer grievance procedure shall state that a copy of the grievance procedure shall be made available to consumers upon request.
3) The program shall have a written policy for maintaining records of consumer grievances that includes, but is not limited to the following:
a) Statement that records of consumer grievances be kept for at least two years.
b) Statement that there will be documentation reflecting resolution/remedy of the grievance.
c) Statement that the record will contain documentation of the extenuating circumstances for extending the time period for resolving the grievance beyond thirty days.
Management Activities
a) A prevention provider shall maintain written documentation of a needs assessment process.
b) A prevention provider shall provide written documentation of interagency coordination which shall include but not be limited to cooperative programming or co-sponsorship of activities or both.
c) The provider shall develop a written policy regarding the screening and utilization of audiovisual and printed materials. Materials shall be previewed before use.