Ohio Department Of Alcohol And Drug Addiction Services

Prevention Certification Checklist 1

OHIO DEPARTMENT OF ALCOHOL AND DRUG ADDICTION SERVICES DIVISION OF QUALITY IMPROVEMENT

PREVENTION CERTIFICATION REVIEW CHECKLIST

Per OAC 3793:5-1-01(F) and ORC 3793.06, I certify that there is a completed application for certification or re- certification in this file. ______Review’s Initials Date

Review Date(s):______Reviewer(s):______

______

Owner: ______

Address: ______Deemed Status: ______CARF City/State/Zip Code: ______JCAHO ______COA County: ______ODADAS

Telephone #: ______

Program staff/others present at exit interview: (please print name and title)

Revised on 3-3-2011 Prevention Certification Checklist 2

3793:5-1-02 Governing Authority Par. Applicability Description Compliance Y/N/D or Comments Documentation N/A (F) All Agencies Governing authority responsible Articles of for overall operations of Incorporation/Partnership prevention agency Agreements/LLC Registration with State of Ohio (G)(1) Agencies Procedure for selecting Written policies, code of with Board members of the governing regulations and/or by- of Directors authority laws (G)(2) Agencies Number of Board members Written policies, code of with Board needed for a quorum at regulations and/or by- of Directors meetings laws (G)(3) Agencies Provisions for guarding Written policies, code of with Board against/prohibiting conflict of regulations and/or by- of Directors interest between Board member laws and agency (G)(4) Agencies Provisions for orienting new Written policies, code of with Board board members regulations and/or by- of Directors laws (H)(1) All Agencies Written policies, code of Written policies, code of regulations, articles of regulations, articles of incorporation and/or bylaws incorporation and/or by- stating (documentation laws maintained ) responsibilities of governing authority include: Establishing duties and responsibilities of staff member responsible for overall day-to- day operation of AoD prevention services

3793:5-1-02 Governing Authority (cont.) Par. Applicability Description Compliance Y/N/D or Comments Documentation N/A (H)(2) All Agencies Selecting a Written policies, code staff of regulations, articles member of incorporation and/or responsibl by-laws e for overall day-to-day operation of AoD prevention services (H)(3) All Agencies Conductin Written policies, code g and of regulations, articles maintainin of incorporation and/or g by-laws documenta tion of at least quarterly meetings of the governing authority (H)(4) All Agencies Approving Written policies, code prevention of regulations, articles services of incorporation and/or by-laws (H)(5) All Agencies Approving/ Written policies, code

revising of regulations, articles policies for of incorporation and/or operating by-laws prevention services (H)(6) All Agencies Approving Written policies, code annual of regulations, articles budget for of incorporation and/or prevention by-laws services (H)(7) All Agencies Reviewing Written policies, code annual of regulations, articles audit of incorporation and/or report by-laws (I) All Agencies Roster of Current roster of Board members of of Board of Directors/professional Directors affiliations or Partners and their profession al affiliations (J)(1) All Agencies Current Relationship reflected Table of in Table of Organizati Organization on that reflects relationshi p of agency to governing authority

3793:5-1-02 GOVERNING AUTHORITY (CONT.) Par. Applicability Description Compliance Y/N/D or Comments Documentation N/A (J)(2) All Agencies Reflects Each position reflected each in Table of position Organization including employees , contract staff, students and volunteers (J)(3) All Agencies Includes Date/original signature date and included original signature of CEO or Executive Director (L) All Agencies Governing Copy of insurance authority policies responsibl e for Verification in ensuring personnel files when protection applicable through liability insurance, malpractic e insurance

and/or other insurance for governing authority and prevention agency staff

3793:5-1-03 ADMINISTRATION Par. A Description Compliance Y/N Comments p Documentation /D p or li N/A c a b il it y (H)(1)(a) A Assurance of non- Written P and P ll discrimination against any To include all elements A person or group on the basis of g race, ethnicity, age, color, e religion, sex, national origin, n sexual orientation or disability c in the recruitment/ selection/ i promotion/ evaluation or e retention of employees s volunteers (H)(1)(b) A Provisions for providing cultural Written P and P

ll sensitivity training to staff A g e n c i e s

3793:5-1-03 ADMINISTRATION (CONT.) Par. A Description Compliance Y/N/ Comments p Documentation D or pl N/A ic a bi lit y (H)(1)(c) A Policy prohibiting sexual Written Policy ll harassment A g e n ci e s (H)(1)(d) A Employment Written P and P ll recruitment/selection process A g e

n ci e s (H)(1)(e) A Provisions for Written P and P ll promotion/discipline/termination A of employment g e n ci e s (H)(1)(f) A Annual performance evaluation Written P and P ll of each employee A g e n ci e s (H)(1)(g) A Employee grievance procedure Written P and P ll A g e n ci e s (H)(1)(h) A Staff development Written P and P ll

A g e n ci e s (H)(1)(i) A Employee benefits Written P and P ll A g e n ci e s (H)(1)(j) A Standards of acceptable Written P and P ll behavior for all program A employees g e n ci e s (H)(1)(k) A Reporting consumer Written Policy ll abuse/neglect A g e n ci e

(H)(1)(l) A Overtime and compensatory Written P and/or P ll time policies/procedures A g e n ci e s (H)(1)(m) A Policy ensuring that copy of Written P and P ll agency’s personnel A policies/procedures is available g to each employee e n ci e s (H)(1)(n) A Procedure for notifying Written P and P ll employees of changes in A personnel policies/procedures g e n ci e s (H)(1)(o) A Policy for each employee to Written P and P ll review his/her own personnel A file and procedures for doing g this

e n ci e s

3793:5-1-03 ADMINISTRATION (CONT.) Par. A Description Compliance Y/N Comments p Documentation /D p or li N/A c a b il it y (H)(1)(p) A Procedure re: employment Written P and P ll applicants and fair employment A practices, right to privacy and g confidentiality e n c i e s (H)(1)(q) A Policy/procedures on Written P and P ll confidentiality and how to A maintain consumer records g e

n c i e s (L)(1)(a) A Policy on consumer behavioral Written Policy and ll interventions that includes, but Statement A is not limited to: the use of all g cruel and unusual punishments e and practices including, but not n limited to physical or verbal c abuse is prohibited i e s (L)(1)(b) A Statement indicating what types Written Statement ll of interventions will be A employed g e n c i e s (L)(1)(c) A Statement that isolation in a Written Statement ll locked, unmonitored room shall A not occur g e n c i

3793:5-1-03 ADMINISTRATION (CONT.) Par. A Description Compliance Y/N/ Comments p Documentation D or p N/A li c a b ili t y (M)(1)(a) A Policy stating: employee or Written Policy g contract staff hired after e 10/1/2006 and/or n volunteers/students in positions c responsible for daily direct care i or supervision of e children/adolescents shall: be s at least 18 years of age and s possess a high school e diploma/equivalency certificate r v i n g c

h il d r e n a n d / o r a d o l e s c e n t s (M)(1)(b) A Prospective employee/adult Written Policy g volunteer or student has not e pled guilty to/been convicted of n any of the offenses listed in c Agency level 5101:2-5-09(K) i except as provided in 5101:2-5- e 09(J) s s e r

v i n g c h il d r e n a n d / o r a d o l e s c e n t s (M)(1)(c) A Agency shall require criminal Written Policy g records checks on employees, e adult volunteers, students by n the BCII and, if current Ohio c residency is less than 5 years, i by the FBI

e s s e r v i n g c h il d r e n a n d / o r a d o l e s c e n t s (N)(2) A Policy/procedures for self Written P and P

g medication e n c i e s t h a t p e r m it c li e n t s t o s e lf - m e d i c a

3793:5-1-03 ADMINISTRATION (CONT.) Par. Applicability Description Compliance Y/N/D or Comments Documentation N/A (N)(4) All Agencies Each Written P and P agency shall have a written P/P for handling cases of consumer abuse and/or neglect by employees , contract staff, students and volunteers that includes notifying appropriat e profession al regulatory boards and

law enforceme nt authorities when applicable (N)(8) All Agencies Policies/pr Written P and P ocedures for providing communic ation assistance for limited- English proficient consumers /family members/s ignificant others at no additional cost (N)(9) All Agencies Policies/pr Written P and P ocedures for providing auxiliary aids for sensory- impaired consumers

/family members/s ignificant others at no additional cost (P) All Agencies Each Written P and P program shall have written P/P for universal infection control for each certified site

(P)(2) All Agencies P/P for Written P and P reporting communic able diseases in accordanc e with OAC 3701- 3

3793:5-1-04 QUALITY ASSURANCE AND IMPROVEMENT Par. Applicability Description Compliance Y/N/D or Comments Documentation N/A

(E) All Agencies Establish and implement a Current QI plan written QI plan, updated annually & approved by Board meeting minutes governing authority, that indicate approval of includes plan (E)(1) All Agencies Designation of committee/staff Designation in plan member for coordination QA/QI activities (E)(2) All Agencies Provisions for informing Designation in plan governing authority of QA/QI activities (E)(3) All Agencies Provisions for monitoring Designation in plan corrective actions directed by the governing authority (E)(4) All Agencies Provisions for evaluating Designation in plan consumer satisfaction and use Documentation of how of findings for improvement of consumer satisfaction prevention services provided by evaluated agency (E)(5) All Agencies Description of how prevention Designation in plan QI activities are integrated into agency’s overall management (F) All Agencies Written risk management plan Written plan that includes, at a minimum: (F)(1) All Agencies Plan objectives Designation in plan (F)(2) All Agencies Identification of staff Designation in plan (a) responsible for implementing and coordinating risk management activities

3793:5-1-04 QUALITY ASSURANCE AND IMPROVEMENT (CONT.) Par. Applicability Description Compliance Y/N/D Comments

Documentation or N/A (F)(2)(b) All Agencies Functional duties and responsibilities of staff (F)(3)(a) All Agencies Policy to safeguard against potential hazardous working conditions, including physical plant conditions and fire safety considerations (F)(3)(b) All Agencies Risk management activities to include:  reportin g, reviewi ng, monitori ng all MUI’s  reportin g, reviewi ng, monitori

ng significa nt financia l loss to the progra m

(F)(3)(b) All Agencies Linkage of risk Designation in plan (iii) management activities to quality assurance activities, including, at a minimum, ongoing formal communication between staff responsible for both activities, joint reporting to the governing authority and accountability for corrective action(s) (G) All Agencies All MUI’s Designation in plan reported in writing to Verify in records Dept/ADAS/AD

AMHS Board w/in 72 hours

3793:5-1-04 QUALITY ASSURANCE AND IMPROVEMENT (CONT.) Par. Applicability Description Compliance Y/N/D or Comments Documentation N/A (G)(1) All Agencies Criteria for Designation in plan MUI’s include: Death/seri ous injury to consumer/ employee/ contract staff/volunt eer/student on agency’s premises, performing tasks for the agency, participatin g in prevention services (G)(2) All Agencies Any Designation in plan allegation of physical/se xual/verbal

abuse of consumer (G)(3) All Agencies Any Designation in plan allegation of staff neglect of a consumer (H) All Agencies Document Documentation ation of maintained QA/risk manageme nt/QI activities

3793:5-1-05 PROVISION OF SERVICES Par. Applicability Description Compliance Y/N/D or Comments Documentation N/A (E)(1) All Agencies Each Written P and/or P agency shall have written policy and/or procedures for prevention services that include, at a minimum, the

following: description for each prevention service provided (E)(2) All Agencies Criteria for Written P and/or P identifying target population s for receipt of prevention services

3793:5-1-05 PROVISION OF SERVICES (CONT.) Par. A Description Compliance Y/N/ Comments p Documentation D or p N/A li c a b ili t y (E)(3) A Procedures for processing Written procedures ll requests for receipt of A prevention services from other g entities e n c

i e s (M)(4)(a) A If agency utilizes Written P and/or P ll volunteers/students, it shall A have written policies and/or g procedures that include, at a e minimum, the following: n identifying the duties that may c be performed by i volunteers/students e s (M)(4)(b) A Recruiting and selecting Written P and/or P ll volunteers/students A g e n c i e s (M)(4)(c) A Orienting volunteers/students to Written P and/or P ll the policies/procedures of the A agency that are relevant to their g duties e n c i e s

(M)(4)(d) A Training volunteers/students on Written P and/or P ll their duties A g e n c i e s (M)(4)(e) A Evaluating the performance of Written P and/or P ll volunteers/students A g e n c i e s (M)(4)(f) A Terminating the services of Written P and/or P ll volunteers/students A g e n c i e s

3793:5-1-06 ACTIVITY/CONSUMER RECORDS Par. App Description Compliance Y/N/ Comments lica Documentation D or bilit N/A y (E)(1)(a)(i) All Staff shall not convey to a Stated verbatim in the Age person outside of the agency written P and/or P ncie that an individual attends or s received services from the agency or disclose any information identifying a consumer as an alcohol or other drug prevention services consumer unless the consumer consents in writing for the release of information, the disclosure is allowed by a court order, or the disclosure is made to a qualified personnel for a medical emergency, research, audit or program evaluation purposes (E)(1)(a)(ii) All Federal laws and regulations Stated verbatim in the Age do not protect any threat to written P and/or P ncie commit a crime, any s information about a crime committed by a consumer either at the agency or against any person who works for the agency

(E)(1)(a)(iii) Federal laws and regulations do Stated verbatim in the not protect any information about written P and/or P suspected child abuse or neglect from being reported under state law to appropriate state or local authorities. (E)(1)(b) All Access to consumer records Written P and/or P Age by consumers, staff and ncie others s

3793:5-1-06 ACTIVITY/CONSUMER RECORDS (CONT.) Par. A Description Compliance Y/N Comments p Documentation /D p or li N/A c a b il it y (E)(1)(c) A Release of consumer Written P and/or P ll information A g e n c i e s

(E)(1)(d) A Storage of consumer records Written P and/or P ll that requires consumer records A be maintained in accordance g with 42 C.F.R., part 2, e confidentiality of alcohol and n drug abuse consumer records c i e s (E)(2) A Destruction of activity/individual Written P and/or P ll consumer records to include A the requirement that records be g maintained for a least 3 years e from the final date of delivery of n prevention services. Consumer c records shall be destroyed to i maintain consumer e confidentiality as required by s state and federal law (H) A Able to produce hard copies of Written P and P g consumer records upon legally e valid requests and have a Hard copy produced while n written P&P re: how on site c consumer/staff original i signatures are obtained/verified e s t h a t m

a i n t a i n

e l e c t r o n i c c o n s u m e r r e c o r d s

3793:5-1-07 CONSUMER RIGHTS AND GRIEVANCES Par. A Description Compliance Y/N/ Comments p Documentation D or p N/A li c a b il it y (E)(1)(c) A Policy for maintaining for at Written Policy ll least 2 years from resolution, A records of consumer grievances g that include: e (i) copy of the grievance n (ii) documentation c reflecting process i used and e resolution/remedy s (iii) documentation of extenuating circumstances for extending resolution beyond 21 calendar days

(E)(2)(a) A The rights of consumers Verbatim ll include: A The right to be treated with g consideration and respect for e personal dignity, autonomy and n privacy c i e s (E)(2)(b) A The right to be informed of Verbatim ll available prevention services A g e n c i e s (E)(2)(c) A The right to give consent or to Verbatim ll refuse any service A g e n c i e s (E)(2)(d) A The right or freedom from Verbatim ll unnecessary physical restraint A or seclusion

g e n c i e s

(E)(2)(e) A The right to be advised and the Verbatim ll right to refuse observation by A others and by techniques such as g one-way vision mirrors, tape e recorders, video recorders, n television, movies and c photographs i e s

3793:5-1-07 CONSUMER RIGHTS AND GRIEVANCES (CONT.) Par. Applicability Description Compliance Y/N/D or Comments Documentation N/A (E)(2)(f) All Agencies The right to confidentiality of Verbatim communications and personal identifying information within the limitations and requirements for disclosure of consumer information under state and federal laws and regulations (E)(2)(g) All Agencies The right to have access to Verbatim one’s own consumer record in accordance with agency

procedures (E)(2)(h) All Agencies The right to be informed of the Verbatim reason(s) for terminating participation in agency services (E)(2)(i) All Agencies The right to be informed of the Verbatim reason(s) for denial of an agency service (E)(2)(j) All Agencies The right not to be Verbatim discriminated against for receiving services on the basis of race, ethnicity, age, color, religion, sex, sexual orientation, socio-economic status, national origin, disability or HIV infection, whether asymptomatic or symptomatic, or AIDS (E)(2)(k) All Agencies The right to know the cost of Verbatim services, if applicable (E)(2)(l) All Agencies The right to be informed of all Verbatim consumer rights

3793:5-1-07 CONSUMER AND GRIEVANCES (CONT.) Par. Applicability Description Compliance Y/N/D or Comments Documentation N/A (E)(2) All Agencies The right to Verbatim (m) exercise one’s own rights without reprisal (E)(2)(n) All Agencies The right to Verbatim file a grievance in

accordance with agency procedures (E)(2)(o) All Agencies The right to Verbatim have oral and written instructions concerning the procedure for filing a grievance (F)(1)(a) All Agencies Consumer Written Procedure grievance procedure has provisions for: requirement that the grievance must be in writing (F)(1)(b) All Agencies Requirement Written Procedure that the grievance must be dated and signed by the consumer or individual filing

grievance on behalf of the consumer

(F)(1)(c) All Agencies Requirement Written Procedure that grievance include date, approximate time, description of incident and names of individuals involved in incident/situat ion (F)(1)(d) All Agencies Statement to Written Procedure whom the consumer is to give the grievance (F)(1)(e) All Agencies Statement Written Procedure that the agency will make a resolution decision on the grievance w/in 21 calendar days of receipt; extenuating circumstance

s indicating need for extension must be documented in file and written notification given to consumer

3793:5-1-07 CONSUMER AND GRIEVANCES (CONT.) Par. Applicability Description Compliance Y/N/D or Comments Documentation N/A (F)(1)(f) All Agencies Designated Written Procedure staff available to assist consumer in filing grievance (F)(1)(g) All Agencies Statement Written Procedure that consumer Addresses and phone has option to #s included in file procedure grievance w/outside organization s including: i) ADAM HS/A DAS Board

(ii) ODADAS (iii) Ohio Legal Rights (iv) U.S. Dept. of HHS, Civil Rights Regional Office/Chi cago

(F)(1)(h) All Agencies Requirement Written that written Acknowledgement acknowledg ement of receipt of grievance is provided to each grievant w/in 3 working days and includes: (i) D at e gri ev an ce

re ce iv ed (ii) Su m m ar y of gri ev an ce (iii) O ve rvi e w of gri ev an ce in ve sti ga tio n pr oc es

s (iv) Ti m et ab le for co m pl eti on of in ve sti ga tio n an d no tifi ca tio n of re so lut io n (v) Ag

en cy co nt ac t na m e/ ad dr es s/ ph on e #

Revised on 3-3-2011