RELATES TO: KRS Chapter 13B, 61.870 to 61.884, 194A.005,
194A.070, 209.030, 222.003, 222.005(2), 222.221, 222.990, 223.231,
620.030
NECESSITY, FUNCTION, AND CONFORMITY:
KRS
194A.050 and
222.231
require the Cabinet for Health and Family Services to promulgate administrative
regulations necessary to establish requirements and standards for licensing
alcohol and other drug prevention (AODP) agencies.
KRS
194A.050 requires the secretary to
promulgate, administer, and enforce those administrative regulations necessary
to implement programs mandated by federal law, or to qualify for the receipt of
federal funds and necessary to cooperate with other state and federal agencies
for the proper administration of the cabinet and its programs. This
administrative regulation establishes licensing requirements for AODP.
Section 1. Definitions.
(1) "Alcohol and other drug use prevention
agency" or "AODP" is defined as an agency that develops, provides, and
coordinates prevention services, including training and technical assistance
services, that address substance use and misuse and related
consequences.
(2) "Cabinet" is
defined by
KRS
194A.005.
(3) "Certified prevention specialist" means
an individual who is certified by the Kentucky Certification Board for
Prevention Professionals.
(4)
"Coalition" means a partnership of community stakeholders working to reduce
alcohol, tobacco, and other drug use and misuse problems and related
consequences through community-wide prevention strategies.
(5) "Consumer" means the recipient of
prevention services.
(6)
"Department" means the Department for Behavioral Health, Developmental and
Intellectual Disabilities.
(7)
"International Certification and Reciprocity Consortium" or "ICRC" means the
organization that establishes the standards of practice in addiction
counseling, prevention, and clinical supervision through testing and
credentialing of addiction professionals.
(8) "Kentucky Certification Board for
Prevention Professionals" or "KCBPP" means an ICRC member board that
establishes competency-based certification for prevention specialists that
promotes and maintains integrity and quality of service for alcohol, tobacco,
and other drug prevention.
(9)
"Prevention" means the act of preventing use and misuse of alcohol, tobacco,
and other drugs and the related consequences.
(10) "Prevention Director" means a certified
prevention specialist who manages AODP staff, serves as liaison between the
AODP and the department, and is responsible for developing the annual plan and
budget documents for the AODP.
(11)
"Prevention Specialist " means a paid staff, excluding clerical staff, employed
by an AODP actively involved in the development and implementation of substance
use and misuse prevention services.
(12) "Regional Prevention Center" or "RPC"
means a program funded and licensed by the department for the purpose of
developing, providing, and coordinating prevention training and technical
assistance services that address substance use and misuse and the related
consequences.
Section 2.
Licensing Procedures.
(1) An AODP receiving
remuneration for any prevention program, and any RPC, shall not operate without
first obtaining an AODP license from the cabinet, in accordance with the
procedures of
908
KAR 1:370, unless the AODP is exempted under
KRS 222.003(1)
and (2).
(2) Any AODP operating a program without
first obtaining a license shall be subject to penalties pursuant to
KRS
222.990(2).
(3) An application for licensure,
incorporated by reference in
908
KAR 1:370, shall be submitted in writing to the Office
of Inspector General, 275 East Main Street, Frankfort, Kentucky
40621.
(4) An application for:
(a) Licensure shall be accompanied by a fee
of $155; or
(b) Renewal shall be
accompanied by a fee of eighty (80) dollars.
(5) The license shall remain in effect for
one (1) year from the date of issuance and may be renewed, unless a failure to
comply with licensure standards causes the license to be:
(a) Revoked; or
(b) Suspended.
(6) The license shall be conspicuously posted
in a public area at the AODP and shall indicate the year the license was issued
or renewed.
(7) An application for
licensure or renewal may include an on-site inspection by cabinet
representatives to determine compliance with licensure standards.
(8) The applicant shall provide the cabinet
or its representatives access during normal hours of operation to any area of
the facility and any document needed to complete the inspection.
(9) The cabinet shall notify the AODP in
writing of any violation of licensure standards identified during the
inspection.
(10) The AODP shall
submit to the cabinet a written plan of correction within ten (10) calendar
days of receipt of the notice of violation.
(11) The correction plan shall specify the:
(a) Corrective action to be taken;
and
(b) Date when each violation
shall be corrected.
(12)
The certificate of licensure shall be the property of the cabinet and shall be
returned upon closure or revocation of the license.
(13) The cabinet shall make available to the
public a list of all licensed alcohol and other drug prevention agencies and
may issue revisions and corrections to this list as changes occur.
Section 3. Changes in AODP Status.
(1) An AODP shall notify the cabinet within
ten (10) working days of a change in:
(a)
Name;
(b) Location;
(c) Ownership; or
(d) Discontinuance of services.
(2) If there is a change in AODP
name, ownership, or location, the cabinet may issue a new license for the
remainder of the current licensure period.
Section 4. Physical Plant. There shall be
written housekeeping, sanitation, and maintenance procedures, which shall be
followed at all times to ensure that the AODP shall be clean and in good
repair.
Section 5. Organization and
Administration. Governing body.
(1) An AODP
shall have a governing body with overall authority and responsibility for the
AODP's operation.
(2) The governing
body shall have written documentation to show the AODP is a legal entity in the
Commonwealth of Kentucky by means of a partnership agreement, articles of
incorporation, legislative act, or executive order.
(3) The responsibilities of the governing
body shall be specified in writing and shall include:
(a) Adopting a mission statement that
outlines the AODP's purpose;
(b)
Adopting a conflict of interest policy to govern participation by a governing
body member in a decision that may be influenced by a member's business
interest;
(c) Appointing an
executive director who shall be responsible for the day-to-day operation of the
AODP;
(d) Adopting an
administrative structure and establishing a line of authority for all
prevention programs operated by the AODP;
(e) Documenting administrative structure and
lines of authority on an organizational chart, including the name of each
current governing board member;
(f)
Adopting written policies and procedures to direct administrative and program
functions of the AODP to ensure that sufficient staff and resources are
available for the successful delivery of programs;
(g) Reviewing written prevention policies and
procedures at least every two (2) years and making needed revisions and
incorporating relevant findings of the AODP's quality assurance
system;
(h) Overseeing a system of
financial management and accountability;
(i) Completing an annual training on alcohol
and other drug prevention for members of a multiservice board that provide
oversite to the prevention program; and
(j) Meeting as a whole at least quarterly and
keeping a written record demonstrating the ongoing discharge of its
responsibilities.
Section
6. Staffing and Staff Qualifications.
(1) A prevention specialist shall be
certified by the Kentucky Certification Board for Prevention Professionals and
ICRC as a Certified Prevention Specialist within thirty-six (36) months of
initial employment.
(2) The AODP
shall designate one (1) individual as the prevention director who shall:
(a) Be certified by the KCBPP as a Certified
Prevention Specialist; and
(b)
1. Have a bachelor's degree plus five (5)
years of work experience in prevention or the related fields of health, social
science, marketing, communication, or education; or
2. Have a master's degree with two (2) years
of work experience in prevention or the related fields of health, social
science, marketing, communication, or education.
(3) The AODP shall designate an
individual to serve as an ombudsman who shall be responsible for responding to:
(a) Staff or consumer complaints;
and
(b) Staff or consumer
grievances.
Section
7. Personnel and Employment Practices.
(1) The AODP shall have written policies and
procedures governing employment practices for AODP employees and subcontractors
which shall include:
(a) Protection from
discrimination against any employee or prospective employee based on:
1. Gender;
2. Age;
3. Race;
4. Ethnicity;
5. Religious affiliation; and
6. Disability including prior history of
alcohol or other drug abuse;
(b) Personnel policies addressing:
1. Recruitment;
2. Hiring;
3. Promotion;
4. Discipline; and
5. Termination;
(c) Procedures for conducting background
checks on any individual working with minors to assure that there is no:
1. Record of conviction related to abuse or
molestation of children from the:
a.
Administrative Office of the Courts; or
b. Kentucky State Police; and
2. Individual employed listed on
the central registry established by 922 KAR
1:470;
(d) Procedures for a central registry check
that has been submitted for an individual and is pending, which shall include:
1. Provisional hiring of the individual
pending the results of the registry check;
2. A requirement that the individual shall
not be left unsupervised with a client under eighteen (18) years of age;
and
3. A requirement that the
individual shall be dismissed immediately if the results of the check show the
individual is listed on the central registry;
(e) Procedures ensuring that criminal record
checks as described in paragraph (c) of this subsection shall be completed
annually on a random sample of at least twenty-five (25) percent of all
personnel;
(f) Maintenance of
personnel records for each staff member, which shall contain the following:
1. Application for employment;
2. Job specifications;
3. Written references;
4. Results of background check;
5. Documentation of:
a. Education;
b. Work experience;
c. Training; and
d. Status of professional licensure,
certification, and registration;
6. Salary information;
7. Job performance appraisals;
8. Disciplinary actions;
9. Commendations; and
10. Employee incident reports;
(g) Written job specifications for
all positions identifying the:
1.
Qualifications;
2.
Duties;
3. Reporting supervisor;
and
4. Positions
supervised;
(h)
Explanation of:
1. Employee
benefits;
2. Training and staff
development opportunities;
3.
Safety and work related injury procedures;
4. Employee grievance procedures;
5. Rules of conduct; and
6. Compensation plan;
(i) Information on equal employment
opportunities and affirmative action policies;
(j) A provision for ensuring an alcohol and
drug-free workplace to include actions taken when an employee is involved in
the unlawful manufacture, distribution, possession, or use of alcohol or any
controlled substance at the AODP;
(k) A provision for yearly job appraisal for
each employee, which includes an evaluation based on objective criteria of each
employee's performance in relation to their expected job duties;
(l) Ethical standards identifying acceptable
employee conduct regarding consumers' rights;
(m) Conflict of interest policies governing
dual relationships with other legal entities;
(n) Provisions to assure the confidentiality
of personnel records;
(o) A
provision for providing an employee with access to that employee's personnel
record; and
(p) Provisions for the
storage and retention of personnel records.
(2) A staff member shall be given access to a
copy of the AODP's policies and procedures at the time of employment and shall
be notified of a revision when it is made.
Section 8. AODP Staff Responsibilities.
(1) AODP staff shall:
(a) Provide prevention services, including
training and technical assistance, with a primary content that specifically
addresses substance use and misuse and its related consequences;
(b) Utilize the Substance Abuse and Mental
Health Services Administration (SAMHSA) approved evidence-based decision-making
model for delivery of prevention services;
(d) Utilize evidence-based or
evidence-informed programs and activities in delivery of services.
(2) AODP and staff shall not
provide intervention and recovery programs for persons who are in need of
substance use and misuse treatment.
Section 9. Quality Assurance.
(1) Staff development.
(a) The AODP shall establish a system of
on-going staff development to include training and supervision of all
prevention staff that shall:
1. Be outlined in
the AODP's policies and procedures manual; and
2. Support the attainment of the goals and
objectives of the prevention program.
(b) The AODP shall make required training
available to staff.
(c) The
completion of each training shall be documented in staff personnel records and
shall identify the:
1. Name of the
training;
2. Clock hours earned;
and
3. Dates attended.
(2) Program quality
assurance. The AODP shall have written policies and procedures for assuring the
quality of each program operated by the AODP that shall include the following:
(a) Designation of the 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:
1. Be used for process evaluation;
2. Be used for outcome evaluation;
and
3. Determine the quality of the
service.
Section 10. Consumer Rights. An AODP shall
have written policies and procedures for ensuring the rights of the consumer
that 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 AODP with the name, address, and telephone number of the AODP's
ombudsman;
(3) Assurance of the
confidentiality of consumer's substance use and misuse; and
(4) Posting of the grievance procedure in the
AODP, which shall include at a minimum:
(a)
The period for reviewing and responding to a consumer complaint;
(b) A requirement for documentation of a
grievance in the:
1. Consumer record;
and
2. Central AODP incident file;
and
(c) A requirement
that a grievance alleging abuse or neglect be referred 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
11. 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 provisions of
KRS
61.870 to
61.884.
(3) The cabinet shall conduct an
investigation and inspections based upon a complaint.
Section 12. Denial, Revocation, and
Reapplication. The cabinet shall deny or revoke a license if:
(1) It finds that there has been a failure
with the provisions of this administrative regulation and an acceptable
corrective action plan is not completed;
(2) Access is denied to the cabinet or its
representatives during normal hours of operation to any area of the facility
and any document needed to complete an inspection;
(3) The cabinet finds that the licensee
misrepresented or submitted false information to the cabinet;
(4) The cabinet has probable cause to believe
that continued operation would constitute an immediate danger to the health,
welfare, or safety of clients;
(5)
The AODE fails to comply with the annual renewal process;
(6) An individual having a significant
financial interest in the AODP has, within the seven (7) year period prior to
the application date, had significant financial interest in a facility or
service that was licensed or certified by the cabinet, and the license or
certificate to operate was denied, suspended, revoked, or voluntarily
relinquished as the result of an investigation or adverse action that placed
patients, residents, or clients at risk of death or serious harm;
(7) An individual having significant
financial interest in the AODP has been:
(a)
Previously discontinued or disqualified from participation in any governmental
assistance program due to fraud or abuse of the program; or
(b) The subject of disciplinary action taken
against the individual by a professional licensing board for misconduct related
to endangering a patient or client;
(8) The licensee commits fraud in obtaining a
license or in connection with a service provided; or
(9) The licensee fails to comply with a
cabinet approved corrective action plan.
Section 13. Penalties.
(1) Denial or revocation of a license.
(a) Plan of correction.
1. An AODP shall submit to the cabinet,
within ten (10) calendar days of a notice of a violation, a written plan for
the correction of the regulatory violation.
2. The plan of correction shall be signed by
the AODP's administrator, the licensee, or a person designated by the licensee
and shall specify:
a. The date by which the
violation shall be corrected;
b.
The specific measures utilized to correct the violation; and
c. The specific measures utilized to ensure
the violation will not recur.
3. The cabinet shall review the plan of
correction and notify the AODP in writing of the decision to:
a. Accept the plan;
b. Not accept the plan; or
c. Deny, suspend, or revoke the license for a
substantial regulatory violation in accordance with
KRS
222.231(6).
4. If the cabinet finds the
statement of correction unacceptable, the cabinet shall notify the AODP:
a. Of the specific reasons the plan is
unacceptable; and
b. That an
amended plan of correction is required within ten (10) calendar days of receipt
of the notice by the AODP.
5. The cabinet shall review the amended plan
of correction and notify the AODP in writing of the decision to:
a. Accept the plan;
b. Deny, suspend, or revoke the license for a
substantial regulatory violation; or
c. Require the AODE to submit an acceptable
plan of correction.
6.
An AODP that fails to submit an acceptable amended plan of correction may be
notified that the license will be denied, suspended, or revoked.
(b) Denial of an application for
licensure. If 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 an application for licensure was withdrawn by the AODP.
(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
14. Appeals.
(1) If the cabinet
takes action to deny or revoke an AODP license in accordance with
KRS
222.231(6), the cabinet
shall notify the AODP in writing stating the reason for the adverse action and
the AODP's right to appeal to the cabinet.
(2) The cabinet shall conduct the hearing in
accordance with KRS Chapter 13B.
(3) An AODP that continues to operate after
the closing date established by the secretary, or designee, shall be subject to
action by the cabinet as provided by law.