Attachment B STANDARDS FOR THE OPERATION OF CERTIFIED DELAYED ENTRY OF JUDGMENT PROGRAMS (PC 1000)

Transcription

1 STANDARDS FOR THE OPERATION OF CERTIFIED DELAYED ENTRY OF JUDGMENT PROGRAMS (PC 1000) ORANGE COUNTY HEALTH CARE AGENCY ALCOHOL & DRUG ABUSE SERVICES ADMINISTRATION 405 West Fifth Street, Suite 212 Santa Ana, California (714) May 1993 Revised 1994, 1999, 2005 HCA ASR Page 1 of 27

2 TABLE OF CONTENTS I. PURPOSE. 3 II. BACKGROUND.. 3 III. POLICIES IV. REFERRALS... 6 V. MANDATORY PROGRAM ELEMENTS A. ENROLLMENT B. CLIENT INTERVIEW C. FEES.. 7 D. CONSENT TO EDUCATION AND COUNSELING. 8 E. EDUCATION AND COUNSELING ACTIVITIES.. 8 F. DRUG TESTING G. SERVICE PLAN H. TRANSFERS I. EXIT INTERVIEW VI. CLIENT PARTICIPATION REQUIREMENTS. 11 VII. TERMINATION.. 12 A. GROUNDS FOR TERMINATION B. TERMINATION PROCEDURES. 13 VIII. REINSTATEMENT / REENROLLMENT IX. ADMINISTRATION A. CLIENT RECORDS.. 13 B. LESSON PLANS C. URINALYSIS D. STAFF 16 E. FISCAL MANAGEMENT 17 F. REPORTS G. QUALITY ASSURANCE. 18 H. CLIENT RIGHTS.. 18 X. FACILITIES XI. MONITORING EVALUATION AND SANCTIONS HCA ASR Page 2 of 27

3 A. MONITORING B. SANCTIONS XII. PROGRAM FEES XIII. CERTIFICATION AND ENROLLMENT FEES 22 XIV. GENERAL PROVISIONS.. 23 A. POLICIES AND PROCEDURES B. STAFF AVAILABILITY C. RECORDS D. CESSATION OF OPERATION E. NON-DISCRIMINATION IN SERVICES, BENEFITS AND FACILITIES.. 24 F. INDEMNIFICATION AND HOLD HARMLESS CLAUSE G. INSURANCE. 25 H. CERTIFICATION APPLICATION, RENEWAL AND REVOCATION PROCEDURES I. CULTURAL COMPETENCY J NOTICES K. REVISIONS HCA ASR Page 3 of 27

4 I. PURPOSE The purpose of this document is to define the acceptable standards for the effective provision of Penal Code (PC)1000, Deferred Entry Of Judgment, education and counseling services in Orange County. Only providers certified by the Board of Supervisors, upon recommendation by the Health Care Agency (HCA) Alcohol and Drug Abuse Services (ADAS) Court Liaison Services,will be eligible to receive PC 1000 referrals from the Courts. II. BACKGROUND The California State Legislature first passed drug diversion into law in December The intent of the law was to provide drug abuse education and counseling services as an alternative legal action for first-time adult offenders. Offenses and populations qualifying for diversion are outlined in PC 1000 and Health and Safety Code and (possession or use of a controlled substance). In 1997, the State amended the law to change drug diversion to Deferred Entry of Judgment. It is now a post plea program. In lieu of criminal proceedings, defendants may choose to enter a plea of guilty with sentence in abeyance, and enroll in a counseling program. Offenders who successfully complete the counseling program and comply with all requirements of their court order are entitled to have their case dismissed. The law requires the County Drug Program Administrator, with the authority of the Board of Supervisors, to implement a certification procedure for Deferred Entry Of Judgment (PC 1000) services programs. All certifications and recertification shall occur by the authority of the Board of Supervisors. Additionally, the County Drug Program Administrator, in consultation with representatives of the court and the probation department, shall establish and enforce requirements and criteria providing for the effective implementation of PC 1000 programs. This legislation intends for programs to be self-supporting; the cost of the programs incurred is to be absorbed by individuals who enroll. In the County of Orange, CA, the County Drug Program Administrator is the County of Orange, HCA, Behavioral Health Director, or designee. III. POLICIES A. Persons served (clients) are adults referred from the Courts pursuant to of the California Penal Code (PC), who have pleaded guilty with sentence in abeyance contingent upon completion of a program of drug education and counseling. Some clients use drugs on an occasional, experimental basis, while others have a pattern of chronic drug use, dependency or addiction. 3 HCA ASR Page 4 of 27

5 B. Only those providers certified by the Board of Supervisors are eligible to receive referrals from the courts for PC 1000 drug education and counseling services. Courts may make referrals to providers that are not certified, if the courts and the County Drug Program Administrator deem them to be credible and as providing services at no cost to the client. Such programs shall be neither subject to these Standards nor monitored by HCA. C. Program requirements shall consist of thirty-two (32) hours of education and counseling activities, attendance at one (1) self help group meeting per week of scheduled program activity, and monthly drug tests. The thirty-two (32) hours shall include: one (1) hour for a client interview; ten (10) hours of education; twenty (20) hours of individual and/or group counseling; and one (1) hour for an individual exit interview. HCA ADAS Court Liaison Services will provide a list of alternative self-help groups for clients who object to traditional self-help groups. D. Fast track" programs are not allowed. No client shall receive more than four (4) hours of education, counseling, or make-up activities within a period of one (1) week. A minimum of twelve (12) weeks shall be required for a client to progress through the enrollment, education and counseling activities, and completion of the exit interview. E. Each hour of program activity, e.g., client interview, education and counseling, and exit interview, shall consist of sixty (60) minutes. Break times and urinalysis testing shall not count toward program hours. F. To qualify for and maintain certification, providers shall employ at least one licensed clinical staff member (MFT, LCSW, Licensed Clinical Psychologist or Psychiatrist) for review and approval of client service plans and to refer clients for services required existing outside the PC 1000 provider scope of services. G. Providers shall pay a certification fee to HCA for the initial PC 1000 application and annual recertification. This fee covers the County administrative costs to complete the certification and renewal process. The amount of this fee is established by the Board of Supervisors and shall not exceed the actual administrative cost to the County. H. To qualify for certification, providers must offer services at no cost to individuals who are unable to pay as described in Section XII. This includes clients approved for, or in receipt of public assistance, i.e., Temporary Assistance for Needy Families (TANF), Aid to Families with Dependent Children (AFDC), General Relief (GR), Supplemental Security Income (SSI), and Social Security Disability Income (SSDI). 4 HCA ASR Page 5 of 27

6 I. Providers shall pay an Enrollment Fee to HCA on behalf of each non-fee exempt client they admit for services. This fee covers HCA administrative costs associated with monitoring; and is based upon the total number of fee-paying individuals who enter certified PC 1000 programs. This fee is established by the Board of Supervisors and shall not exceed the actual cost to monitor services. This fee is due at the time of enrollment or transfer from another county. This fee shall be factored into the total program cost incurred by the client. J. Clients shall pay the cost of all drug testing. K. Sweat patches may be used as a substitute for urine testing, provided the client is informed in advance of all associated costs. Clients may refuse the use of sweat patches without being penalized by the program, unless court ordered. Court orders for sweat patches shall be documented in the chart in prior to the use of sweat patches. L. HCA will provide a current list of certified PC 1000 providers to the courts. Defendants who are granted Deferred Entry Of Judgment shall attend the certified PC 1000 program of their choice. If the court orders a defendant to attend a specific program, such a referral is outside of the jurisdiction of these Standards. M. Each provider shall establish fees and payment schedules within the context of an open, competitive environment. Fees and sliding scales must reflect the provider s actual costs to deliver services. HCA shall determine if fees are appropriate by reviewing a provider's operating budget. N. Upon court referral of a defendant to a certified PC 1000 provider, it shall be the responsibility of the provider to report client program status directly to the referral source, as outlined in Section IV. O. HCA shall be responsible for monitoring and evaluating certified PC 1000 providers for recertification, as outlined in Section XI, which depends upon provider compliance with these Standards. P. HCA-ADAS Court Liaison Services functions as a liaison between the courts and providers to resolve problems and focus on the overall operation of the PC 1000 programs. Court Liaison Services is not an advocate for providers regarding dealing with the courts. Q. All PC 1000 providers shall observe and adhere to Federal Code of Regulations governing patient confidentiality, as provided in 42 CFR, Part 2 R. Acceptance of applications by HCA for certification for prospective PC 1000 programs or satellites are subject to a request in writing by the Presiding Judge or Supervising Judge of the Justice Center within whose jurisdiction the provider 5 HCA ASR Page 6 of 27

7 intends to operate. The request must document that the demand for services exceeds the current capacity within that jurisdiction. Certification shall occur by approval of the Board of Supervisors as specified in Section XIV.G. IV. REFERRALS The Courts are the referral source for West, Harbor and Harbor/S Justice Centers. HCA Court Liaison Services is the referral source for Central (felony only) and North Justice Centers (felony and misdemeanor). Responsibility for referrals may change if agreed upon by the respective Justice Centers and the Health Care Agency. A. When an individual is granted Deferred Entry Of Judgment, the referral source will explain the PC 1000 provider enrollment process and requirements. B. The referral source provides the defendant with a list of certified PC 1000 providers from which to choose to enroll, unless the court has ordered otherwise. C. The referral source is the primary point of contact for providers pertaining to communication with the Courts regarding client status. V. MANDATORY PROGRAM ELEMENTS A. ENROLLMENT Enrollment is defined as the client and provider having completed, signed and dated, the Enrollment Agreement, Consent to Education and Counseling form, the Consent to Release of Information, Assurances, and Limitations form, the Fee Assessment and Fee Agreement forms, and the Client Interview. All elements of the enrollment process shall be completed on the same day. The client and provider shall sign and date the Consent to Release of Information, Assurances, and Limitations prior to the provider giving any information to the Courts, HCA, any other agency or individual. The Consent to Release of Information, Assurances, and Limitations shall specify the type of information to be released, the person or agency to whom the information is to be released, the purpose of the information, an expiration of the consent, and that HCA/ADAS monitoring staff will review client charts and monitor education or counseling activities. The provider shall complete the applicable referral form to verify that the client has enrolled by the date specified on the referral form or court order. This will be mailed directly to the referral source within five court working days unless the Court specifies otherwise. 6 HCA ASR Page 7 of 27

8 At the time of enrollment, the provider will give the client a list of all his or her scheduled activities, times and locations, and keep a copy in the client s chart. When a provider refers a client back to court, it must send written justification to the judge or Court Liaison Services, within 5 court working days. If the client fails to enroll by the specified date, the provider shall inform the referral source. The provider shall complete the applicable form indicating the client s failure to enroll and mail it to the appropriate referral source within five court workdays. Providers shall not enroll clients who failed to enroll by the specified date. B. CLIENT INTERVIEW The provider shall ensure the client interview shall last a minimum of one (1) hour by documenting the date and times during which the interview took place. The provider shall retain in the client record the following information in order to complete a social history and develop the service plan: 1. Social, economic and family background; 2. Educational history; 3. Employment history; 4. Criminal history; 5. Medical history; 6. Drug/Alcohol use and treatment history. If, during the interview the client is deemed inappropriate for the program, the client shall be referred back to the referral source and written justification mailed to the referral source within five (5) court working days. Examples of acceptable reasons may include: scheduling conflicts, language/cultural differences, or certain prescribed medications. If the provider is unsure about the need to make such a referral, the provider shall contact HCA-ADAS Court Liaison Services Program Evaluation Specialist. C. FEES 7 HCA ASR Page 8 of 27

9 The provider shall use County approved Fee Assessment and Fee Agreement forms to document fees assessed, and payment plan. The client and provider shall sign and date the Fee Assessment and Fee Agreement forms to document agreement to the fees and the importance of adhering to the payment plan. Providers shall refer clients, as appropriate, to apply for public assistance and/or other benefits for which they may be eligible. Should a client be able to provide verifiable documentation, as indicated on the Fee Assessment form, of receiving of public assistance, i.e., Temporary Assistance for Needy Families (TANF), Aid to Families with Dependent Children (AFDC), General Relief (GR), Supplemental Security Income (SSI), or Social Security Disability Income (SSDI), the client shall only be charged County Approved Additional Fees, as indicated on the Enrollment Agreement and Consent to Education and Counseling form. D. CONSENT TO EDUCATION AND COUNSELING The client and provider shall be required to sign and date the Enrollment Agreement and Consent to Education and Counseling form. The provider shall use a County-approved form, addressing the following areas: 1. Program Requirements and Expectations 2. Program Rules and Regulations 3. Program and County Approved Additional Fees 4. Program Goals and Objectives E. EDUCATION AND COUNSELING ACTIVITIES Clients shall begin educational and counseling activities within twenty-one (21) days of enrollment. The provider shall maintain an attendance roster for each education and counseling activity. The roster shall record the date and time the activity begins and ends. The roster shall also identify the topic, facilitator, and be signed by the facilitator and each client. 1. Education Activities All clients must attend a minimum of ten (10) hours of educational activities with no more than fifteen (15) persons per activity. Lesson plans for the ten (10) hours of education shall be written and included in the provider's protocol. Education activities shall be presented in a didactic manner and cover the following topics: i. Physiological and psychological effects of psychoactive substances including: Alcohol, Marijuana, Stimulants, Opioids and Narcotics, 8 HCA ASR Page 9 of 27

10 Depressants, Sedatives and Hypnotics, Psychedelics and Hallucinogens. ii. Risks And Consequences Of Perinatal Drug Exposure iii. HIV, Other Infectious Diseases, And Related Problems (this topic shall consist, at minimum, of a two (2) hour, dedicated educational activity) iv. Twelve (12) Step Approach To Recovery v. Relapse Prevention 2. Counseling Activities All clients shall attend a minimum of twenty (20) hours of group counseling activities with no more than fifteen (15) participants per activity. Counseling activities shall focus on topics pertaining drug use such as progress in recovery, concerns regarding to relapse, personal, family, social, employment, and academic problems. i. At least one counseling activity session shall be dedicated to each of the following skills: a. Decision Making, b. Problem Solving, c. Communication, and d. Relapse Prevention. The client s chart shall contain individual education and counseling activity notes in sufficient detail to behaviorally describe the client s level of participation. The education and counseling notes shall also contain the activity topic, date, facilitators name and signature. If the provider determines that the client requires individual counseling activities, up to six (6) hours of the group counseling activities may be substituted with individual counseling activities. One hour of individual counseling activity will be substituted for two hours of group counseling activity. If the provider determines that the client is inappropriate for group counseling activities and should receive more than six (6) hours of individual counseling, the client may receive the entire required counseling component in individual sessions. Individual sessions may be substituted for group sessions at a ratio of one hour of individual counseling for two hours of group counseling. 9 HCA ASR Page 10 of 27

11 The provider shall maintain individual counseling progress notes in each client's file. Justifications for individual counseling must also be documented in the client's file. F. DRUG TESTING The client s initial drug test shall occur within thirty (30) days of enrollment. Drug testing shall reoccur two (2) more times over the duration of the program. Drug testing shall screen, at minimum, for the following substances: alcohol, marijuana, cocaine, methamphetamine, opiates and benzodiazapines. A provider may increase the frequency of drug testing only to confirm suspected drug or alcohol intoxication during an activity (VII.A.5). Clients shall pay all costs associated with drug testing. Sweat patches may be used for drug testing, provided that the use of sweat patches has been court ordered and documented that the client has been informed in advance of all associated costs. Court orders for sweat patches shall be obtained in advance and documented in the client s file. Written approval shall be obtained in advance for the use of any drug testing method beyond breathalyzers, saliva swabs, urinalysis, or sweat patches from HCA-ADAS Court Liaison Services. If the client has been prescribed medication which may result in a positive drug test, the client shall be immediately placed on an LOA (IX.9.b.i), provided a completed PC 1000 Program Medical Prescription Review form and referred back to court for a medical prescription review. G. SERVICE PLAN The provider shall complete a client s individual service plan within thirty (30) days of enrollment. The service plan shall include goals for recovery, planned actions and target dates to achieve the goals, and progress made towards, or dates the client reaches, the goals. Staff members completing service plans are responsible for recording any observations of symptoms or problems that would necessitate a referral. The counselor, client, and the licensed clinician must sign and date the plan within thirty (30) days of enrollment. The provider shall update the client s service plan upon reinstatement or reenrollment. If thirty (30) days has passed between the termination and the reinstatement / reenrollment dates, the provider shall complete a new individual service plan. 10 HCA ASR Page 11 of 27

12 If at any time during the program a client exhibits symptoms necessitating a referral to a medical or mental health professional, the incident shall be documented in the client s file. The licensed clinician will review the incident the following day, assess and document in the client s chart justification as to whether or not a referral to medical or mental health services was made. H. TRANSFERS Clients may request a transfer from one provider to another provider within California, upon which the client has 21 days to complete the transfer, e.g., enrollment with the prospective or new provider (V.A). Clients requesting transfers shall receive credit for all activities for which they have paid and completed. Providers shall use a County approved form to document the program activities completed by the client. Only HCA approved transfer fees may be charged. Transfers out of state require Court approval. I. EXIT INTERVIEW Prior to program completion, clients shall complete a one (1) hour individual exit interview. The exit interview shall focus on the client s progress toward the service plan goals. The exit interview shall list the beginning and end times, date, and be signed by both the client and provider. The provider shall give the client a copy of the relapse prevention plan and a list of available community resources. All clients shall have completed a one (1) hour client interview, ten (10) hours of education activities, twenty (20) hours of counseling activities, for a total of thirty-one (31) program hours, prior to the exit interview. Exit interviews shall be conducted within thirty (30) days of the last program activity. If the exit interview date will occur after the court mandated completion date, then the provider shall request a completion date extension from the referral source, provided that HCA approves the extension request in advance. Following the exit interview, the provider shall give a completion certificate to the client as evidence to the court of successful program completion. The provider shall notify the referral source in writing of the client s program completion within five (5) court working days. VI. CLIENT PARTICIPATION REQUIREMENTS All clients shall adhere to the following participation requirements. Failure to comply with requirements will constitute grounds for termination of program services and may result in an imposition of sentence. 11 HCA ASR Page 12 of 27

13 A. All clients shall inform the court of their enrollment in a PC 1000 program within five (5) days of enrollment. The provider shall provide the client proof of enrollment for this purpose. B. All clients shall attend and actively participate in all program activities in accordance with the service plan. This includes attendance at one (1) self-help group meeting per week of scheduled program activity. Clients shall not receive program credit for attending more than one self-help meeting per week, unless it is making up a missed meeting; clients shall not receive program credit for attending more than one self-help group per day. C. All clients shall submit to drug testing. Providers shall report all positive drug tests to the court (IX.C.7). D. Clients shall pay all fees to which they agreed, in accordance with the payment schedules determined in Fee Agreement. Failure to pay fees may delay program completion or result in program termination. VII. TERMINATION A. GROUNDS FOR TERMINATION The provider shall terminate a client from program for the following: 1. Failing to adhere to the Fee Agreement. 2. Behavior that disrupts program activities, e.g., violence or threats of violence during educational activities. 3. Absenteeism a. Incurring a third (3 rd ) unexcused absence from educational or counseling activities. b. Incurring a third (3 rd ) unexcused absence from weekly self-help meetings. 4. Termination shall also occur for client failure to obtain a Leave of Absence for any absences beyond those allowed by these Standards. Termination shall also occur for not returning to the program by the LOA expiration date. 5. Testing positive for drug or alcohol use. A drug test determined to have been diluted or adulterated shall be considered a positive drug test. 6. Attending activities while under the influence of alcohol or other drugs, as confirmed by a drug test. 12 HCA ASR Page 13 of 27

14 B. TERMINATION PROCEDURES 1. Upon program termination, the client and referral source shall receive concurrent written notice, e.g., exit report, from the provider explaining the grounds for termination, subsequent return to Court. 2. Termination is final unless the Court orders reinstatement. 3. Providers shall refund to the client within thirty (30) days of termination any fees paid in advance for services not yet received at the time of termination. VIII. REINSTATEMENT / REENROLLMENT A. In the event that the Court refers a client back for reinstatement/reenrollment and thirty (30) days has elapsed following the termination, the provider shall complete an enrollment, (V.A.). If thirty (30) days has not elapsed, the provider need only complete the Enrollment Agreement, Consent to Education and Counseling form, and the Consent to Release of Information, Assurances, and Limitations form. In both cases, unless otherwise specified, the client shall receive credit for sessions already attended prior to the date of termination. B. In the event that the Court refers a client back for reinstatement/reenrollment following a termination due to absenteeism, upon reinstatement/reenrollment, the client shall incur absences as referenced in Section VII.A.3 prior to future terminations for further absenteeism. IX. ADMINISTRATION A. CLIENT RECORDS The provider shall maintain individual records for each client in sufficient detail to document the services received and progress toward service plan goals. Providers shall maintain client records for a minimum of seven (7) years following completion or termination from the program. In addition to any documents previously mentioned in these Standards (Section V), each record shall contain the following documents: 2. Enrollment Forms 3. Client Interview 3. Proof of Enrollment 13 HCA ASR Page 14 of 27

15 The provider shall also provide the client proof of enrollment. Providers shall inform the referral source of client enrollment. Providers shall use the form respective to each referral source. 3. Activity Attendance a. Enrollment Verification - PC 1000 Provider shall be used for referrals received directly from the Probation; b. Court Liaison Referral shall be used for referrals received from the Court Liaison Services. A record of all activities a client attends shall be documented in each client record. Absences and corresponding make-up sessions also shall be documented. 4. Weekly Self-Help Meetings A record of all weekly self-help meetings and dates the client attends shall be documented in the client record on an ongoing basis and submitted to the provider prior to program completion. If the client is unable to provide proof of self-help meeting attendance, it shall be treated as an absence. 5. Fee Payment Documentation A record of all client payments made toward the program fees shall be documented in the client chart at the time of each payment. This shall include the date, amount paid, and the balance forward. 6. Court Referral Form 7. Drug Test Results 8. Proof of Program Completion, Termination, and/or Transfer A copy of the proof of program completion shall also be given to the client. 9. Excused Absences a. Program Activities 14 HCA ASR Page 15 of 27

16 i. Absences from program activities may be excused for family or personal medical emergencies when supported by written documentation. ii. Absences from weekly self-help meetings may not be excused. b. Leave of Absence (LOA) i. The provider shall place the client on a LOA for a period of twenty-one (21) days if the client is to return to court for a medical prescription review. ii. The provider shall require the client request approval in writing and provide written documentation for a LOA for a period of twenty-one (21) days should the client be unable to attend scheduled program activities due to family or personal medical treatment, military service, work-related travel, or incarceration. iii. The provider may place the client on a LOA for a period of twentyone (21) days if the client has completed all program activities, but is unable to pay the balance of program fees at that time. iv. Upon expiration of any LOA or court ruling, whichever comes first, the client expected to return to regular attendance of all program activities. v. Prior to program completion, the provider shall require the client to make up all activities missed due to the LOA. B. LESSON PLANS The provider shall develop lesson plans reflecting the required components for the ten (10) hours of education. Lesson plans shall include the topic and objectives for each component addressed. Provider lesson plans shall be approved by HCA prior to being certified as a PC 1000 provider, and annually as well. C. URINALYSIS Provider staff will observe the following procedure during the collection and handling of urine samples as follows: 1. Label each specimen bottle with the client's name. 2. Record test date. 3. Forward the urine sample to the testing lab within forty-eight (48) hours, when applicable. 15 HCA ASR Page 16 of 27

17 D. STAFF 4. Maintain a copy of all urinalysis results in the client record. 5. Be prepared to testify in court if subpoenaed regarding procedures. 6. Same gender staff must be available to monitor the collection of urine samples if requested. If a program is unable to provide same gender staff upon request, a substitute procedure addressing adequate protection of opposite gender clients shall be submitted to HCA-ADAS Court Liaison Services for approval prior to collecting urine samples. 7. Providers shall report positive test results to the Court within the two (2) court working days. 1. Job Descriptions Staff providing services shall have written job descriptions and resumes that indicate the required education and/or experience necessary to provide quality services. Providers shall obtain HCA approval for any Program Staff, Intern, and Licensed Clinician, as listed below, prior to the provision of PC 1000 services. HCA will cite a provider for any staff not meeting the minimum qualifications; this action may also lead to sanctions. a. Program Staff Counselors shall possess a Bachelor's degree in Social Work, Psychology, Sociology, or other degree in a field related to the treatment of addictions from a four (4) year college or university; a valid CAADAC or Drug and Alcohol Certificate from an accredited college; or a minimum of two (2) years work experience in drug and alcohol treatment providing group or individual counseling. b. Interns Interns may provide services in the program. Intern means a person enrolled in an accredited graduate level program in a behavioral health discipline or a related field, or a student in a Certified Alcohol and Drug Abuse Counselor program. Graduate level Interns may facilitate group or education sessions independently. CAADAC Interns may co-facilitate group sessions in the presence of approved staff. Providers shall submit to HCA 16 HCA ASR Page 17 of 27

18 proof of hours completed prior to hiring an Intern as Program Staff. c. Licensed Clinician 2. Code of Conduct Each provider must have, at a minimum, one licensed clinical staff person, i.e., a licensed MFT, LCSW, a licensed clinical psychologist, or a psychiatrist. The licensed clinician is responsible for maintaining a system of review and referral that results in appropriate treatment for clients with serious mental or medical disorders and problems. Providers shall ensure all staff licenses are available for inspection. A written code of conduct for staff and interns providing PC 1000 services shall be established and address the following: a. Drug free work place b. Personal and business relationships between staff and client, or client s family. c. Prohibition of sexual contact with clients or client s family. d. Conflict of interest e. Duty to report suspicion or evidence of child abuse, elderly abuse or threats to harm others or themselves f. Confidentiality of client information 3. Probation or Parole Requirement Each provider shall have a written policy regarding staff that have been, or are currently on, probation or parole. Staff directly involved with the provision of PC 1000 services shall not have been on probation or parole for any offense at any time during the past two (2) years. E. FISCAL MANAGEMENT 1. Each provider shall have an annual (fiscal year) budget which includes expected income and expense, and that: a. Lists all income by source. 17 HCA ASR Page 18 of 27

19 b. Lists all income and expenses by program service. 2. Each provider shall develop a written fee collection policy, which includes the following information: a. Accountability for all fees collected. b. Statements that services will not be denied due to inability to pay. 3. Each provider shall maintain written policies and procedures, which govern their fiscal management system (e.g., purchasing authority, accounts receivable, cash billings and cost allocation). 4. Personnel responsible for signing checks and performing other accounting activities shall be bonded. Proof of insurance against employee dishonesty may be used as an alternative to bonding. 5. If requested by HCA, the County of Orange fiscal management system shall provide for a certified independent audit of the financial operations of the provider. 6. The provider shall maintain an individual payment card or other individual payment record for each client that shows current and correct assessed fees and any HCA approved additional charges. F. REPORTS Each provider will submit to HCA accurate and timely monthly Provider Status Reports. HCA shall prescribe the format and content of the reports which may include, but are not limited to: Enrollment/Remittance reports; Information on Fee Exempt Clients, Admissions, Completions, Terminations; and problems the provider wishes to bring to the HCA s attention. G. QUALITY ASSURANCE Each provider shall develop and maintain a written policies and procedures manual for quality assurance. The procedures will describe the internal mechanisms implemented to ensure program compliance to all sections of these Standards. This manual shall be made available for inspection. H. CLIENT RIGHTS Providers shall post in a prominent location of the facility and retain in each client record documentation of the following information: 18 HCA ASR Page 19 of 27

20 1. A statement of nondiscrimination regarding the provision of services on the basis of race, ethnic group identification, age, disability, sex, sexual preference, national origin, religion, and mental or physical disability. 2. Client Rights: a. Grievance procedures, including HCA complaint process. b. Appeal process for discharge. c. Program rules and regulations. d. Client fees. e. Access to counseling files. f. Confidentiality of client information. g. Consent to education and counseling. h. Treatment with dignity and respect. i. Freedom from emotional and or physical abuse. X. FACILITIES A. All rooms in which direct client services are provided shall be maintained at a temperature that is appropriate for the season and in compliance with local building codes. B. The County-provided PC 1000 Drug Program Complaint procedure and Notice (regarding fees) shall be displayed in a prominent, public area of the facility and in languages of the populations served by the provider. C. Emergency evacuation plans shall be posted in near the primary exits in all rooms occupied by clients during program activities. D. Fire extinguishers shall be accessible, mounted on the wall, appropriately charged, and have current inspection tags. E. The facility shall be clean in appearance and provide adequate space, ventilation, restrooms, and seating to ensure an appropriate environment for educational and counseling activities. 19 HCA ASR Page 20 of 27

21 F. The facility shall meet ADA (Americans with Disabilities Act) requirements. G. Client records shall be maintained in locked filing cabinets or stored in a in a locked room. XI. MONITORING EVALUATION AND SANCTIONS HCA shall be responsible for monitoring and evaluating certified PC 1000 providers. HCA staff shall conduct site visits at each provider location to monitor and evaluate services, which include the following items: A. MONITORING 1. Monitoring site visits may be announced or unannounced. 2. HCA shall annually evaluate the condition of the facility. 3. HCA shall complete a minimum of one comprehensive program review annually to determine compliance with the Standards, which shall include: a. Review of participant records to evaluate the provision of services and compliance with these Standards. The review may include all or a sample of client records. Providers shall clearly mark and organize PC 1000 records for easy identification. b. Review of administrative records to establish that staff are qualified; appropriate policies and procedures are in implemented; clients are being charged appropriately; and correct financial records of all client payments are maintained. c. An audit debriefing with the executive director or site director to review audit findings. HCA shall confirm findings in a written report of findings to the provider within fifteen (15) days following the audit debriefing. d. Provider shall submit to HCA the required corrective action plan within thirty (30) days of the date of the written report of findings. The corrective action plan shall specify the steps taken to ameliorate the cited areas in sixty (60) days.. 4. HCA shall conduct a follow-up audit to verify that the provider has implemented all necessary corrective actions. 20 HCA ASR Page 21 of 27

22 5. HCA staff shall attend educational and/or counseling activities at each site to evaluate the quality of services. These visits may be unannounced. HCA may also conduct client satisfaction surveys as part of the program audit. B. SANCTIONS Providers found to be in violation of these Standards may be subject to sanctions outlined below: 1. Failure to take corrective action on audit findings within sixty (60) days of the date of the HCA written report, or the date of the follow-up site visit, whichever is later, will result in a notice to suspend certification for one calendar month. The provider may file a written appeal with the Deputy Director of HCA/ADAS or designee. 2. If there is no appeal or the Deputy Director of HCA/ADAS upholds the intended suspension, HCA will remove the provider name from the list of certified PC 1000 providers. The suspension will last for one (1) calendar month beginning the month following the decision. HCA will schedule a compliance review to at the end of the suspension period. 3. If the compliance review reveals continued failure to correct any deficiencies noted during the audit, the suspension will extend for an additional calendar month. 4. If the provider fails to correct deficiencies noted during the audit by the end of the second (2 nd ) month of suspension, HCA may recommend decertification to the Board of Supervisors. The suspension shall continue pending Board action. The provider is not be eligible to reapply for certification for ninety (90) days from the last calendar day of the month during which the Board authorized program decertification. 5. HCA shall automatically recommend to the Board of Supervisors decertification of any provider suspended more than three (3) times in one (1) year. The provider may submit an application for recertification after ninety (90) days from the last calendar day of the month during which the Board authorized the decertification. 6. All reapplications for certification shall be treated as initial applications. A full application fee shall be required by HCA, along with a complete proposal. 7. All new certifications shall require a written request by the Presiding or Supervising Judge within the Justice Center jurisdiction in which the PC 21 HCA ASR Page 22 of 27

23 1000 provider intends to provide services. The assessment must show that demand for services exceeds existing service capacity in the jurisdiction. All initial and recertifications require approval by the Board of Supervisors. XII. PROGRAM FEES All program fee modifications shall be approved by HCA. Providers shall establish fees based on actual costs to provide services. A. To show actual costs, providers shall complete and submit to HCA the PC 1000 Service Provider Client Provider Fee Calculation Worksheet. Provider fees shall correspond to a sliding scale and build in the costs of covering program services and Enrollment fees for all clients, including those who are fee-exempt. B. All providers are required to accept clients who are unable to pay program fees. Non-paying clients are defined as those who are recipients of public assistance including TANF (AFDC), SSI, Social Security Disability Insurance (SSDI), and General Relief. C. In cases where clients state they are indigent, yet they do not meet the criteria listed above, the provider shall refer the client to the appropriate agency(ies) to apply for benefits or assistance. If it is apparent that this process will delay enrollment, then the provider shall instruct the client to return to court to request an extension for the deadline to provide Proof of Enrollment. D. A declaration of unemployment, or having no money, in and of itself, does not qualify a client for fee exempt status. E. In evaluating a client's ability to pay, the financial assessment shall include total household income (excluding the fee-exempt clients defined above). Total family income means income received by the client and income received by any person legally required to support the client (spouse or conservator). Total family income is not considered for fee-exempt clients nor shall fee exempt clients be assessed as having in-kind income for the value of room and board if they live with others. F. Clients shall not perform work for providers as a form of payment. XIII. CERTIFICATION AND ENROLLMENT FEES 22 HCA ASR Page 23 of 27

24 The law provides that the County shall establish fees to recover administrative costs involved in certifying and monitoring PC 1000 programs. For this purpose, each provider shall pay two fees: A. A non-refundable certification fee, payable to the County of Orange, HCA, at the time of initial application and annual recertification. Recertification fees are based on the number of clients a provider received during the year prior to recertification. B. An Enrollment fee for each client who enters a certified program, payable by the provider no later than twenty (20) calendar days after the end of the month of entry. This fee is payable by the provider on behalf of all clients who enter PC 1000 programs. Providers shall not directly charge Enrollment fees to any enrollee; however, the Enrollment fee shall be computed as a cost of doing business when calculating program fees. Enrollment Accounting and Remittances At the time of certification, HCA assigns a four-digit numeric identifier to each provider. Providers shall assign each enrollee name a unique identifying case/account number, preceded by the four-digit provider identifier. Enrollment remittances shall be mailed to HCA no later than the twentieth (20th) calendar day of the month following the month of client provider enrollment. To ensure accurate accounting of fees due, the provider is required to submit with each payment, a completed Confidential PC 1000 Enrollment-Remittance form. This form lists the names and case/account numbers of all individuals who enrolled during the prior month and for whom a payment is being submitted. The total remittance should equal the amount of the current Enrollment fee multiplied by the number of enrollees listed on the form. This form also provides the basis for data entries against which client record information from HCA is ultimately matched. Late payments will be interpreted as a violation of these Standards. Providers who make three (3) late remittances in a calendar year are subject to suspension from the list of certified PC 1000 providers. HCA shall furnish to each provider a supply of the Confidential PC 1000 Enrollment- Remittance forms for use to submit the monthly Enrollment fee payment. The Confidential PC 1000 Enrollment-Remittance form and Enrollment fee remittance shall be mailed to: County of Orange Health Care Agency P. O. Box HCA ASR Page 24 of 27

25 Santa Ana, California (MAKE CHECKS PAYABLE TO THE COUNTY OF ORANGE, HCA. DO NOT SEND OR HAND DELIVER CHECKS TO HCA/ADAS. ALL PAYMENTS SHALL BE MADE USING PROVIDER CHECKS; CLIENT CHECKS WILL NOT BE ACCEPTED.) XIV. GENERAL PROVISIONS A. POLICIES AND PROCEDURES Each provider shall develop written policies and procedures addressing compliance to all Standards contained herein. The policies and procedures shall be approved by HCA as part of the certification process. B. STAFF AVAILABILITY Provider staff shall be available to personally answer the telephone and access charts during normal court and business hours, 8:00 a.m. to 5:00 p.m., Monday through Friday. A voice mail or equivalent system may be used as an alternative if all calls are responded to within 30 minutes between the hours of 8:00 a.m. and 5:00 p.m. during normal court and business hours. Programs using a voice mail or equivalent system are required to send staff members to any program location within 30 minutes if HCA conducts an unannounced audit. C. RECORDS Providers shall have written policies and procedures indicating how client records are stored, secured, and destroyed in accordance with applicable Federal, State, and County regulations. Client records shall be retained for a minimum of seven (7) years. As a contingency to prepare for cessation of a certified PC 1000 service, providers must assure HCA of the accessibility of client records for a period of seven (7) years following the discharge of each client. Providers unable to provide this assurance shall transfer relevant program records to the County of Orange Health Care Agency, Custodian of Records. D. CESSATION OF OPERATION In the event a PC 1000 program ceases operation, the program will remain responsible for ensuring the orderly transfer of clients from the program that is ceasing operation to another certified PC 1000 provider. E. NON-DISCRIMINATION IN SERVICES, BENEFITS AND FACILITIES Providers shall not discriminate in the provision of services, allocation of benefits, accommodation in facilities, employment of personnel, or in any other 24 HCA ASR Page 25 of 27

26 respect, on the basis of ethnic group identification, race, color, creed, ancestry, religion, national origin, sexual preference, sex, age (over 40), marital status, medical condition, or physical or mental handicap and shall comply with all other requirements of law regarding nondiscrimination and affirmative action. Providers shall comply with the provisions of Section 504 of the Rehabilitation Act of 1973 the Americans with Disabilities Act of 1990, as amended, pertaining to the prohibition of discrimination against qualified handicapped persons in all programs or activities. F. INDEMNIFICATION AND HOLD HARMLESS CLAUSE All activities and/or work covered by this Agreement shall be at the risk of provider alone. The provider agrees to defend, indemnify and hold harmless the County of Orange, including all of its Boards, Agencies, Departments, Officers, Employees, Agents and Volunteers, against any and all claims, lawsuits - whether against Provider, County of Orange or others - judgments, demands and liability, including those arising from injuries or death of persons and for damages to property, arising directly or indirectly out of the obligations herein described or undertaken or out of operations conducted or subsidized in whole or in part by Provider, save and except claims or litigation arising through the sole negligence or wrongdoing and/or sole willful misconduct of County of Orange. G. INSURANCE Provider, at its sole cost and expense, shall obtain and maintain in full force during the term of this certification all types of insurance required by law. If staff that write checks are not bonded, the provider will maintain insurance against employee dishonesty. Providers shall also name the County of Orange Health Care Agency as additional insured. H. CERTIFICATION APPLICATION, RENEWAL AND REVOCATION PROCEDURES All providers desiring to provide PC 1000 services in Orange County must complete a formal application packet. Applications will be reviewed and approved by HCA. HCA will recommend certification to the Board of Supervisors of those providers meeting these Standards for the Operation of Certified PC 1000 Providers. Initial and annual certification shall occur by the approval of the Board of Supervisors. Revocation of certification is possible if a provider is out of compliance with these Standards and is unable and/or unwilling to make all required corrections. HCA shall have the authority to suspend certification pending action by the Board of Supervisors as defined in the section XI, B. Sanctions. 25 HCA ASR Page 26 of 27

27 I. CULTURAL COMPETENCY Services shall be provided in a culturally and linguistically appropriate manner. J. NOTICES Notices to and correspondence with HCA, excluding Enrollment remittances payments shall be addressed to: K. REVISIONS Manager County of Orange Health Care Agency Alcohol and Drug Abuse Services Court Liaison Services 405 West Fifth Street, Suite 212 Santa Ana, CA Any revisions of the PC 1000 Provider Standards contained herein shall be addressed in policy letters issued by HCA. 26 HCA ASR Page 27 of 27