Chapter 18 - Alcohol/Substance Abuse

Title	Section
GENERAL	3-18.1
Purpose	3-18.1A
Goals	3-18.1B
Objectives	3-18.1C
Policy	3-18.1D
Eligibility	3-18.1E
Provision of Services	3-18.1F
STAFF RESPONSIBILITIES AND OPERATING RELATIONSHIPS	3-18.2
Headquarters	3-18.2A
Area Office	3-18.2B
Service Unit	3-18.2C
CONTRACT/GRANT PROGRAM STAFF RESPONSIBILITIES AND OPERATING RELATIONSHIPS	3-18.3
Contractor	3-18.3A
Alcoholism/Substance Abuse Program Director	3-18.3B
Program Staff	3-18.3C
TECHNICAL ASSISTANCE	3-18.4
ADMINISTRATIVE/MANAGEMENT	3-18.5
Purpose	3-18.5A
Goals	3-18.5B
Objectives	3-18.5C
Management Aspects	3-18.5D
CLIENT SERVICES	3-18.6
Substance Treatment Services	3-18.6A
Intake/Admission	3-18.6B
Individual Treatment Plan-Client Staffing	3-18.6C
Required Medical Screening of Clients	3-18.6D
Psychological Assessment	3-18.6E
Social Assessment	3-18.6F
Referral Process	3-18.6G
Client Rights	3-18.6H
Spiritual Guidance/Counseling	3-18.6I
Counseling Services	3-18.6J
Discharge Services	3-18.6K
Medication Control	3-18.6L
Recreational Health Promotion/Disease Prevention Services	3-18.6M
Aftercare/Follow-up Services	3-18.6N
CONTINUUM OF CARE SERVICES	3-18.7
Written Plan	3-18.7A
Documentation	3-18.7B
Agreements	3-18.7C
Review	3-18.7D
EXCEPTION/VARIANCE	3-18.8
QUALITY ASSURANCE PLAN FOR SUBSTANCE ABUSE PROGRAMS	3-18.9
Purpose	3-18.9A
Objectives	3-18.9B
Quality Assurance Program Methodology	3-18.9C
SERVICES	3-18.10
Purpose	3-18.10A
Detoxification Units	3-18.10B
Primary Residential Treatment	3-18.10C
Outpatient Care	3-18.10D
Service Unit/Tribal Services: Rehabilitation and Aftercare Program for Adolescents	3-18.10E
Group Home	3-18.10F
Halfway House	3-18.10G
Transitional Living Center	3-18.10H
Youth Primary Residential Treatment	3-18.10I
Women and Children Program	3-18.10J
Drop-In Center (General Program Description)	3-18.10K
HEALTH PROMOTION/DISEASE PREVENTION	3-18.11
Purpose	3-18.11A
Goals	3-18.11B
Basic Concepts and Definitions	3-18.11C
School-Based Prevention	3-18.11D
Community-Based Prevention	3-18.11E

Attachments	Description
I	Glossary of Terms
II	Memorandum of Agreement Between Indian Health Service and the Bureau of Indian Affairs published in the Federal Register on March 6, 1987
III	Public Law 99-570, Section 4230, "Indian Health Service Reports"
IV	HHS Transmittal 87.01 (8/25/87): Policy on Smoking in HHS Occupied Buildings and Facilities
V	Indian Health Service Non-Smoking Policy (2/17/87)

3-18.1  GENERAL

1. PURPOSE This Chapter establishes general policy, staff responsibilities, operating relationships, standards, and guidelines for the development of alcoholism/substance abuse treatment and prevention services supported or administered by Indian Health Service (IHS).  These programs may be administered by contracts or grants with Indian tribal governments or urban Indian authorities, or administered through an IHS Area Office or Service Unit.  Included within the scope of this Chapter are policies and guidelines for the development and operation of Youth Primary Residential Treatment Centers (YPRT) authorized by Public Law (P.L.) 99-570, the "Anti-Drug Abuse Act of 1986" October 27, 1986, as amended.
2. GOALS
   1. In accordance with the IHS goal of elevating the health status of the American Indian and Alaska Native to the highest level possible, the Alcoholism and Substance Abuse Program Branch (ASAPB) will attempt to lower the incidence and prevalence of alcohol abuse and alcoholism among American Indians and Alaska Natives to a level at or below that of the general population in the U.S. within a 15-year period.
   2. The ASAPB will assist American Indian and Alaska Native groups through school/community-based planning to establish effective programs of prevention, treatment, and rehabilitation for persons suffering from or afflicted with problems arising from alcoholism/substance abuse. Included is the development of YPRTs in each IHS Area.
3. OBJECTIVES
   1. Reduce years of productive life lost due to alcoholism/substance abuse by 5 percent per year (5 year goal is 25 percent).
   2. Guide the development of a comprehensive, effective prevention and intervention program with emphasis on Indian youth and family.
   3. Guide the development of a comprehensive, effective network of Indian community based treatment services for the alcohol/substance abuser and his/her family.  Such a network will include emergency, inpatient, and outpatient services.
   4. Guide the development of a comprehensive, effective network of Indian community-based rehabilitative services for the alcohol/substance abuser and his/her family.  Such a network will include quarter-way, halfway, and domiciliary facilities as well as outreach and aftercare services.
   5. Develop a series of well-designed, culturally relevant, appropriate research projects on alcoholism/substance abuse among American Indians and Alaska Natives.
   6. Promote medical and social detoxification services within each Area serviced by IHS.
4. POLICY
It is the policy of IHS to: (1) assure that within available resources a comprehensive program for alcoholism/substance abuse prevention, treatment, and rehabilitation is developed for each Indian community; (2) assure that within those resources, eligible patients or clients, regardless of sex or age, have access to and are provided either directly or under contract or grant, high quality medical treatment and high quality services for alcoholism/substance abuse as defined in the Glossary; and, (3) evaluate and to monitor program performance of IHS-supported alcoholism/substance abuse programs.
5. ELIGIBILITY Determination of eligibility for services from IHS or at IHS expense is made on an individual basis in accordance with established criteria found in the IHS Manual Part 2, Chapter 1, Section 2, Persons to Whom Services May be Provided (or Current IHS Policy on Eligibility}.  Exceptions are allowed when services are provided through contracts or grants for community alcoholism/substance abuse programs which have been transferred to the IHS pursuant to P.L. 94-437, the "Indian Heath Care Improvement Act," as amended.  In this instance, the clients/recipients/patients will be those clients described in the contract or grant.
6. PROVISION OF SERVICES Preventive services, treatment and supportive/rehabilitation services, as described in the Glossary, will, to the extent that such services are available, be made available, directly or indirectly under contract or grant, to all those eligible.  Treatment and rehabilitation services based in regional and community facilities shall be family oriented.

3-18.2  STAFF RESPONSIBILITIES AND OPERATING RELATIONSHIPS

1. HEADQUARTERS
   1. The IHS Headquarters Alcoholism/Substance Abuse Program Branch Chief is responsible for:
      1. Coordinating program activities with the Director, Division of Clinical and Preventive Services, Office of Health Programs.
      2. Planning, directing, and evaluating the implementation of Indian community alcoholism/substance abuse programs.
      3. Assuring the coordination of Indian community alcoholism/substance abuse programs with the Indian tribal program directors, IHS Headquarters and Area line staff, and other interested Federal and non-Federal agencies and institutions.
      4. Recommending program or policy changes as a result of analyzed data, recommendations from operational levels, and research results.
      5. Systematically monitoring services through use of an approved data system.
      6. Disseminating information to Congress and the American people based on program evaluation results and other reports.
   2. The Headquarters Chief Medical Officer and the Headquarters Physician Advisor for Alcoholism/Substance Abuse Programs, through the Area Chief Medical Officers, are responsible for:
      1. Assuring that alcoholism/substance abuse services are of the highest quality, consistent with recognized patient care standards, and are provided in an ethical fashion with respect for the rights and dignity of the patient.
      2. Assuring the development and maintenance of standards for the training of health professionals.
      3. Assuring the monitoring of quality, appropriateness, and effectiveness of medical and ancillary treatment for alcoholism/substance abuse and related conditions.
      4. Encouraging the development of appropriate research into alcoholism/substance abuse and its related conditions.
2. AREA OFFICE
   1. The IHS Area Director and IHS Area Coordinator are responsible for:
      1. Assuring that within available resources a comprehensive program for alcoholism/substance abuse prevention, treatment, and rehabilitation is developed that provides for regional youth treatment and broad based rehabilitation services for each Indian community.
      2. Assuring the development and implementation of policies and procedures to guide the operation of these programs.
      3. Assuring that alcoholism/substance abuse programs are monitored and that programs so monitored are effectively evaluated with approved instruments.
      4. Assuring that contracts or grants with appropriate representatives of urban programs or tribal councils are negotiated and developed in accordance with current IHS contracting or granting authority.
   2. The Area Chief Medical Officer is responsible to the Headquarters Chief Medical Officer and the IHS Area Director for:
      1. Assuring that Area clinical alcoholism/substance abuse and treatment/rehabilitation services are of the highest quality, consistent with recognized patient care standards, and are provided ethically with respect for the rights and dignity of the patient.
      2. Assuring the development and maintenance of standards for the training of Area medical professionals and other community health care providers in the provision of clinical alcoholism/substance abuse and treatment/rehabilitation services.
      3. Assisting in the planning of services to be provided and monitoring their quality, appropriateness, and effectiveness.
   3. The IHS Area Alcoholism/Substance Abuse Coordinator is the principal advisor to the IHS Area Director or his/her designee and is responsible for:
      1. Reviewing, coordinating, and when appropriate, assisting in the development of proposals from Indian tribes or organizations to the IHS for alcoholism/substance abuse program activities.
      2. Assuring that all contracts or grants are responsive to community needs, the Tribal Action Plan (TAP), and IHS standards.
      3. Coordinating the development, implementation, revision, and integration of Area activities for the prevention and treatment of alcoholism/substance abuse, utilizing the continuum of care concept.
      4. Coordinating his/her activities with those of the Area Chief Medical Officer or the Area Director's designee.
      5. Assuring the coordination of Indian community alcoholism/substance abuse programs with interested Federal and non-Federal agencies and institutions.
      6. Providing technical assistance to IHS Service Units, tribes, or organizations in their implementation of IHS standards for alcoholism/substance abuse prevention, treatment, rehabilitation and supporting services.
      7. Assuring that written contract reporting requirements include the use of the approved data system (Alcoholism Treatment Guidance System or Chemical Dependency Management Information System) for the purpose of collecting client/patient specific data for treatment in planning, case management, and reflecting all alcoholism and substance abuse program efforts.  Manuals governing the use of the data system are maintained in each IHS Area Office.
      8. Developing administrative mechanisms for monitoring alcoholism/substance abuse program services to clients and reporting results obtained to the Area Director or his/her designee and/or IHS Headquarters.
      9. Assuring that Indian community alcoholism/substance abuse treatment/prevention programs are evaluated in the manner established by the Chief, Alcoholism and Substance Abuse Program Branch, IHS.
      10. Providing training programs for Service Units, community health care providers and Alcoholism/Substance Abuse Program staff.
      11. Providing consultation to Area; tribal, and other community resource agencies, assuring effective prevention, intervention, and other treatment approaches to overcome alcoholism/substance abuse problems.
      12. Providing consultation on alcoholism/substance abuse program services to the Area Director or the Area Director's designee.
   4. The IHS Area Intervention Team is responsible to the Area Alcoholism/Substance Abuse Program Coordinator and is responsible for:
      1. Serving those patients who meet the requirements of P.L. 99-570, the Anti-Drug Abuse Act of 1986, as amended, and who are eligible for the service of IHS.
      2. Monitoring and providing technical assistance to the rehabilitation and aftercare program in each Service Unit or tribal program.
      3. Monitoring to assure appropriate placement in the treatment continuum for adolescents needing treatment for alcoholism/substance abuse.
      4. Monitoring to assure that rehabilitation and aftercare staff provide services for families of adolescents in treatment.
      5. Monitoring to assure development and implementation of aftercare services at the community level for all adolescents who receive treatment for alcoholism/substance abuse under P.L. 99-570 resources.
      6. Monitoring to assure that all clients are properly evaluated and staffed, and that appropriate treatment plans have been developed.
      7. Providing rehabilitation and aftercare staff with appropriate training to carry out their responsibilities under P.L. 99-570.
      8. Assisting the rehabilitation and aftercare staff with prevention (psychological enhancement) activities for the Native communities in cooperation with the Tribal Coordinating Committees (TCC).
      9. Coordinating with local TCC to ensure response to community needs in the implementation of the P.L. 99-570.
      10. Coordinating with the local TCC to ensure implementation of a quality assurance program within the rehabilitation and aftercare program.
      11. Recording all Area Intervention Team activities on the appropriate Management Information System of the Alcoholism/Substance Abuse Program.
      12. Assisting in the annual evaluation of the rehabilitation and aftercare program.
      13. Assuring all records and charts at the local rehabilitation and aftercare programs are maintained in storage for five (5) years after discharge of clients.
   5. The IHS Project Officer is responsible to the Area Alcoholism/Substance Abuse Program Coordinator and Contracting Officer for the administration of the contract or grant including:
      1. Reviewing, assessing, and understanding the general and specific terms of the contract.
      2. Maintaining a contract file on all matters affecting the contract, whether initiated by the Contracting Officer, the Contractor, or Project Officer.
      3. Reviewing and recommending for approval all invoices for payment under the contract as well as other progress or financial reports, requests for modifications, waivers, subcontracts, or property acquisitions.
      4. Advising and reporting to the Contracting Officer on the progress of the work.
      5. Monitoring the Contractor's technical progress, including the surveillance and assessment of performance, and recommending changes in requirements as the need arises.
      6. Making site visits as necessary to report on contractor performance, comparing actual performance with scheduled performance.
      7. Assisting the Contractor in the resolution of problems encountered in the performance of the contract.
      8. Keeping the Contracting Officer fully informed of any difficulties in the administration or performance of the work contracted for, and attempting to remedy the problems or referring the matter to the Contracting Officer in order to protect the rights of the Government.
3. SERVICE UNIT
   1. The Service Unit Director is responsible to the Area Director for:
      1. Cooperating in the development and planning of a comprehensive community alcoholism/substance abuse service delivery system.
      2. Negotiating an annual Memorandum of Agreement or Master Action Plan with the tribal council, specifying the responsibilities of the tribe and IHS with respect to mutually acceptable program and liaison activities.
      3. Performing tasks as required to implement the policies of the Area Director or IHS policy.
      4. Designating a person on his/her staff who will serve as the liaison with the representative of the community in the Alcoholism/Substance Abuse Program.
      5. Reporting as required by P.L. 99-570; Section 4214, Social Services Reports (b), Referral of Data as amended.
      6. Designating a person on his/her staff who will serve as a representative on the TCC in the development and implementation of the Tribal Action Plan.
   2. The Service Unit Clinical Director is responsible to the Area Chief Medical Officer and the Service Unit Director for:
      1. Assuring the planning of clinical alcoholism/substance abuse and treatment/rehabilitation services within the Service Unit.
      2. Assuring that all alcoholism/substance abuse related accidents and illnesses are documented.
      3. Monitoring the clinical alcoholism/substance abuse and treatment/rehabilitation services.  This includes oversight and evaluation of the quality, appropriateness, and effectiveness of these services to assure that they are of the highest quality, culturally relevant, consistent with recognized patient care standards, and respectful of the rights and dignity of the patient.
      4. Instituting corrective actions where deficiencies are noted.
      5. Assuring the development of standards for the training of medical health care professionals for the provision of clinical alcoholism/substance abuse and treatment/rehabilitation services.
   3. The IHS Service Unit Alcoholism Program Coordinator is responsible to the Service Unit Director for:
      1. Assessing IHS alcoholism/substance abuse program needs.
      2. Representing the IHS Service Unit in activities with the local Tribal Health Authority related to alcoholism/substance abuse program development issues.
      3. Monitoring the progress of alcoholism/substance abuse program activities to assure that proper quantity and quality of services are provided to patients.

3-18.3  CONTRACT/GRANT PROGRAM STAFF RESPONSIBILITIES AND OPERATING RELATIONSHIPS Unless otherwise specified, the term contractor will refer to a tribal government or urban board of directors responsible for a program supported by IHS funds (contract or grant).

1. THE CONTRACTOR IS RESPONSIBLE FOR:
   1. Participating in the development of a Tribal Action Plan pursuant to P.L. 99-570, Section 4203, Purpose, and Section 4206, Tribal Action Plans, as amended.
   2. Assuring that alcoholism/substance abuse services are of the highest quality consistent with recognized health care standards and provided with respect for the rights and dignity of the client.
   3. Assuring that all services are developed in response to community needs.
   4. Assuring that all services are appropriately documented and reported in compliance with contract/grant requirements.
   5. Assuring that program activities are appropriately modified as a result of evaluation assessments.
   6. Assuring that program services are developed and provided in conformity with minimum national or applicable State/tribal standards, whichever is the most thorough and comprehensive to assure quality and effective services/operations.
2. THE ALCOHOLISM/SUBSTANCE ABUSE PROGRAM DIRECTOR IS RESPONSIBLE FOR:
   1. Assessing community needs for alcoholism/substance abuse prevention, treatment, and rehabilitation services in coordination with the service delivery system.
   2. Planning, directing, and implementing alcoholism/substance abuse prevention, treatment, and rehabilitation services in response to needs, contract/grant requirements, periodic evaluation results, and current treatment trends in service delivery.
   3. Reporting services delivered as required by the IHS data system manual (Alcoholism Treatment Guidance System; Chemical Dependency Management Information System).
   4. Coordinating the completion of any modifications to the contract or the scope of work with relevant authorities.
   5. Assisting in the negotiation of memoranda of agreement for services as required by the service delivery system.
   6. Determining needs for technical assistance and requesting assistance as necessary to support program activities.
   7. Participating in IHS evaluation processes.
   8. Assuring the completeness and accuracy of all records, reports, and record systems as they pertain to program administration and client services.
   9. Coordinating services and available resources to promote the continuum of care.
   10. Complying with minimum national, State, or tribal standards and/or licensure requirements for staff and program operations.
3. PROGRAM STAFF ARE REQUIRED TO:
   1. Provide services to the defined population and implement activities as required by the scope of work.
   2. Maintain current case and/or other program records/logs/files in which services/activities are appropriately documented.
   3. Comply with standards for counselor performance including those related to confidentiality.
   4. Improve skills through the use of continuing education resources.
   5. Carry out the requirements of their job descriptions.
   6. Attain skill levels identified for basic and advanced certified counselor categories.

3-18.4  TECHNICAL ASSISTANCE All questions regarding interpretation and/or implementation, or requests for technical assistance incidental to this issuance should be addressed to the local IHS Area Alcoholism/Substance Abuse Coordinator. 3-18.5  ADMINISTRATIVE/MANAGEMENT

1. PURPOSE It is the purpose of this section to provide guidelines for the development of responsive alcoholism/substance abuse prevention, treatment, or rehabilitation program activities in the community.
2. GOALS
   1. To establish minimum requirements for the management of alcoholism/substance abuse program services.
   2. To develop a uniform service delivery system.
   3. To ensure that quality services are provided to clients of IHS-funded alcoholism/substance abuse programs.
3. OBJECTIVES While the alcoholism/substance abuse service needs of tribes and urban communities may differ, the major objective of this section is to provide criteria for development of quality programs responsive to community needs.  This section identifies tasks for the governing body, qualifications for various positions, general program objectives, staff development requirements, personnel requirements, fiscal requirements, and other structural issues that must be met for the successful development and maintenance of the program. Adherence to standards listed herein is required.  Local programs may establish additional criteria, as policy and procedure manuals are completed for program components.
4. MANAGEMENT ASPECTS Definition:  A collection of supportive and directive elements within a quality program, required for the successful delivery of quality services within a community.  The absence of any element will result in the delivery of a service that is of a lesser quality.
   1. Governing Body
      1. The governing body shall be a duly constituted tribal (*Indian community) governing entity such as a tribal council or committee delegated the authority consistent with P.L. 94-437 (Indian Health Care Improvement Act) in the spirit of P.L. 93-638 (Indian Self-Determination Act): P.L. 99-570, Section 4203 (3) definition; a non-profit, profit, not for profit corporation, that can be construed as an Indian controlled corporation, or a legally constituted Indian body managed by a board of directors.
         
         1. IHS facilities and programs will be duly constituted in accordance with IHS policy and directives and managed by IHS staff.
      2. The governing body shall:
         1. Provide evidence that the governing body is representative of and accountable to the Indian community, or, in the case of IHS programs, provide such representation and accountability to the local community governing body as required by IHS policy and directives.
         2. Adopt rules and policies which define powers and duties of the governing body, its committees and program administrator.  In the case of IHS-managed programs, the relationship to the governing body shall be defined, and in Memorandum of Understanding.
         3. Be responsible for complying with all funding source requirements.
         4. Insure program capability to provide quality services that are appropriate and adequate to clients through the availability of sufficient resources such as, but not limited to, the following:  funds, supplies, equipment, facilities and professional staff.
         5. Insure appropriate expenditure of funds.
         6. Insure proper use of staff time and establish a process for evaluating performance.
      *  Indian:  Term used to indicate American Indian, Alaska Native or Aleut people indigenous to the North American continent.
      3. The ongoing responsibilities of the governing body shall include, but not be limited to, the following activities:
         
         1. The governing body shall oversee the development of a policy manual which provides for program management, operation, board authority, regulation, principles, philosophy, and overall goals upon which the program is established.
            1. This manual shall be reviewed and updated annually.
            2. This manual shall be made available to all staff and to any individual or group upon request.
            3. Special attention shall be given to this manual to insure compliance with tribal, local, State, and Federal rules and regulations, and to provide a protocol for safety and well-being of all clients and staff.
         2. The governing body shall establish an advisory committee specifically knowledgeable about Indian alcoholism/substance abuse.  The committee shall be composed of a majority of Indian people.
         3. The governing body shall establish an organizational structure, formally documented in an organizational chart, which accurately depicts lines of authority and reporting relationships within the program.
         4. The governing body shall implement personnel management policies that promote staff, program and community development.
         5. The governing body shall utilize the expertise of the alcoholism/substance abuse program administrator or director in formulating policy for the program.
         6. The governing body shall provide guidelines for assuring the safety and well-being of all clients and staff.
      4. The governing body shall be responsible for all personnel in the program and have written policies that include details for administration of programs, staffing requirements, position descriptions, and qualifications.
   2. Advisory Committee
      
      1. Advisory committee membership shall be comprised of representatives of the Indian population to which services are targeted and shall have written procedures governing their operations.
      2. The alcoholism/substance abuse program administrator shall be an ex officio member of the advisory committee.
      3. The duties of the advisory committee shall include, but not be limited to, the following:
         
         1. Review and comment on program policies and procedures.
         2. Participation in planning and evaluation of staff development activities.
         3. Review and comment regarding the development of program goals and objectives.
         4. Advise the alcoholism/substance abuse program administrator on selection of facilities.
         5. Advocacy on the behalf of the program, clients, and community.
         6. Participation in eliciting the aid of community resources in supporting program objectives.
         7. Participation in problem solving between program and community.
         8. Assisting the governing body in defining the alcoholism/substance abuse problem within Indian communities.
      4. The advisory committee shall develop and submit recommendations for review and implementation by the governing body.
      5. The governing body shall determine the number and composition of the advisory group.
      6. The advisory committee shall meet not less than quarterly and shall keep written minutes of their meetings.  These minutes will include, but not be limited to, the following:
         1. Date.
         2. Names of members attending.
         3. Topics discussed.
         4. Recommendations made.
         5. Follow-up.
   3. Program Administrator/Director
      1. The program administrator shall be appointed by the governing body and shall be directly responsible to that body.
         1. The program administrator shall demonstrate qualifications necessary for assumption of authorities and duties necessary to administer the program.
         2. The program administrator shall be responsible for the overall management of the program as an agent of the governing body.
         3. The responsibilities of the program administrator shall include, but not be limited to, the following:
            
            
            1. Budget development and financial reports.
            2. Recruitment and direction of the staff when appropriate.
            3. Preparation, presentation, and implementation of long and short-term plans for the governing body.
            4. Preparation of reports describing program operations.
            5. Preparation of evaluation reports.
            6. Organization and administration of the project.
            7. Delegation of duties and establishment of a formal means of accountability of all staff and personnel.
            8. Establishment and documentation for governing board approval of specific program goals and objectives for the current year.
            9. Establishment and maintenance of a policy and procedure manual that is revised and reviewed annually.
            10. Development of a written evaluation plan based on the goals and objectives of the program.  An annual review and updating of this evaluation is required.  General guidance for the evaluation plan is as follows:
                
                
                1. Assess the attainment of the program goals and objectives.
                2. Document program achievements not related to original goals and objectives.
                3. Assess the utilization of staff and program resources.
                4. Provide operational definitions.
                5. Ensure the availability of the evaluation plan to all personnel.
                6. Assure that all reporting requirements stipulated in the contract are fulfilled.
            11. All staff with youth shall have a background investigation completed to determine past history of sexual or child abuse.
      2. Qualifications
         
         
         1. The director of a large community program who functions solely as the program administrator shall have:  two years academic course work with a concentration in management; a minimum of one year management experience in alcoholism/substance abuse programs, and a basic understanding of alcoholism and substance abuse through completion of an academic course in Alcohol 101.  This position is subject to the key personnel clause.  Currently employed program directors who do not meet these criteria will have three years from the date of publication of these Standards to complete a program to meet these criteria.  Those hired after that date must meet these criteria.
         2. The director of a large or small community program who functions as the program administrator and a clinician shall have: two years academic course work with a concentration in management; a minimum of one year management experience in alcoholism/substance abuse programs, and shall meet the requirements for national, Area or State certification/licensure: certified advanced training in counseling techniques with the chemically dependent, including theories, modalities, techniques, and practices; some treatment experience with adults and adolescents. This position is subject to the key personnel clause. Currently employees program directors who do not meet these criteria will have three years from the date of publication of these Standards to complete a program to meet these criteria. Those hired after that date must meet these criteria.
         3. The administrator of a YPRT must have: a master's degree in a behavioral science; three years administrative experience and two years counseling experience in an adolescent treatment program or equivalent training and experience acceptable to the Area Alcoholism/Substance Abuse Program. This position is subject to the key personnel clause.
         4. Program administrators shall be sensitive to the diversity of Indian cultures as well as have a well-rounded knowledge of alcoholism/substance abuse.  Program administrators shall have at least a master's degree in administration, psychology, social work, education, or nursing and, when required, has appropriate license. Experience may be substituted for a professional degree if carefully evaluated, justified, and documented by the governing body.  In programs primarily serving children or adolescents, the program administrator shall have appropriate professional qualifications and experience including previous administrative responsibility in a program for children or adolescents.
         5. Program administrators must affirm in writing that his/her employment performance has not been impaired by alcoholism/substance abuse over the past 3 years.
   4. Treatment Coordinator The treatment coordinator shall be responsible for treatment operations of the program.
      
      
      1. The treatment coordinator shall report directly to the program administrator the results of treatment techniques used within the program.
      2. The treatment coordinator shall directly supervise all treatment personnel; i.e., counseling staff and adjunct therapy staff, including volunteers.
      3. The treatment coordinator shall supervise the development of all treatment plans and conduct a monthly review of the status of all clients of the program.
      4. The treatment coordinator shall be a fully certified alcoholism/substance abuse counselor. In addition to meeting the general requirements of number 5 below, the treatment coordinator shall demonstrate a minimum of forty (40) hours of additional training in supervision and case management.
      5. The treatment coordinator/supervisor working in the YPRT must have certification/licensure as an alcoholism/substance abuse counselor; certified advanced training in counseling techniques with the chemically dependent, including theories, modalities, techniques and practices: some treatment experience with adults and adolescents and at least three years experience supervising others in the performance of their duties, two years of which was in youth alcoholism/substance abuse treatment. An advanced degree alone is not sufficient.
      6. Upon initial hire, the treatment supervisor, if recovering from alcoholism or drug dependency, must affirm in writing that his/her employment performance has not been impaired by alcoholism/substance abuse over the past 3 years.
      7. All staff working with youth shall have a background investigation completed to determine past history of sexual or child abuse.
   
   
   5. The Rehabilitation Staff The rehabilitation staff shall have written job descriptions which describe their specific day-to-day duties and responsibilities.
      
      
      1. The rehabilitation staff shall be sensitive to Indian cultures and be knowledgeable about alcoholism/substance abuse.
      2. The rehabilitation staff shall have demonstrated basic knowledge in the following areas:
         
         
         1. Life-style and language of the target population.
         2. The physiological, psychological, behavioral, and social variables of alcohol and other substance abuse.
         3. Theories and issues in alcoholism/substance abuse including different counseling methodologies and treatment techniques.
         4. Community resources.
         5. Interviewing, casework, psychosocial and emotional development, and family and community systems and therapies.
         6. Laws, regulations, political issues, and public policy related to alcoholism/substance abuse and its treatment.
         7. The goals, philosophy, policies, and procedures under which the project operates.
      
      
      3. The rehabilitation staff shall meet the requirements for national, Area, or State certification/licensure as an alcoholism/substance abuse counselor unless their job is in another specialty. Then staff shall meet certification/licensure requirements of the specialty.
      4. Upon initial hire, the rehabilitation staff, if recovering from alcoholism or drug dependency, must affirm in writing that his/her employment performance has not been impaired by alcoholism/substance abuse over the past 2 years.
   6. Prevention Staff Qualifications
      
      
      1. The prevention staff shall have sufficient training and skills to enable them to organize and conduct both large and small-scale community activities.  They must be familiar with health promotion and disease prevention goals, objectives, and methods; have knowledge and skill in health education practices, principles, and techniques; have a thorough knowledge of teaching methods; be able to speak to large and small groups; be able to develop and utilize media resources such as TV, radio, newspaper, etc., and conduct awareness, prevention, and public relations activities; be knowledgeable of and able to apply health promotion/disease prevention evaluation techniques and methods to evaluate the effectiveness of health promotion and disease prevention activities. A master?s degree in health education or related area, a bachelor's degree with one year of health education and related health promotion/disease prevention experience, or an equivalent training and experience accepted by IHS is required.
      2. All staff working with youth shall have a background investigation completed to determine past history of sexual or child abuse.
   7. Youth Primary Residential Treatment Center Staff
      1. Counselor II in YPRTs shall have certification/licensure as an alcoholism/substance abuse counselor and two years counseling experience in an alcoholism/substance abuse program or counseling agency. One year of the counseling experience must have been with youths with alcoholism/substance abuse problems and must have provided an opportunity to demonstrate knowledge of counseling theory, techniques and practices specific to Indian adolescents.
      2. Counselor I shall have certification or licensure as an alcoholism/substance abuse counselor, but will not be required to have experience beyond that needed for certification or licensure.
      3. Counselor interns must be enrolled in a course of study leading to certification or licensure and upon placement or hire must, if recovering, affirm in writing that his/her employment performance has not been impaired by alcoholism/substance abuse over the past year.
      4. Intake specialists in the YPRTs shall have certification/licensure as an alcoholism/substance abuse counselor and three years counseling experience in an alcoholism/substance abuse program, one of which demonstrates techniques and practices specific to adolescents.
      5. Family therapists in YPRTs shall have professional training and certification as a family therapist; three years counseling experience in an alcoholism/substance abuse program, one of which demonstrates the ability to use advanced counseling theories, techniques and practices with families.
      6. Recreation therapists in the YPRTs shall have a degree in recreation therapy and registration, certification or licensure as a recreation therapist and three years experience working in a recreation program which required the ability to practice at an advanced level; one year of work experience that demonstrated the ability to conduct treatment planning with individuals and monitor performance against objectives; have knowledge of arts, games, crafts, and activities and have the ability to implement and supervise crafts, games, and activities: and one year of training and experience in alcoholism/substance abuse treatment for adolescents.
      7. Recreation technicians in the YPRTs shall have one year experience in a recreation program, with demonstrated ability to work under supervision and implement a treatment plan; knowledge of recreation theory, techniques and practices; the ability to supervise games and activities as a part of a treatment plan; and six months experience working with alcoholism and substance abuse program clients.
      8. The education specialist acts as a liaison between the youth's home school, Bureau of Indian Affairs (BIA) or State teachers at the YPRT Center, and the youth; obtains educational assessment from the home school, works with YPRT Center teachers in assessing educational needs and making an individualized educational plan; and tutors youth as individuals and in groups in accordance with the educational plan. A master's degree in special education with two years teaching experience is desirable, but a bachelor's degree, a teaching certificate, and a student teaching placement or equivalent supervised teaching experience with children who have special education needs are acceptable. One year of individualized tutoring for children with special education needs may be substituted for the required teaching experience. Awareness of the special needs of alcoholism/substance abuse program clients is required.
      9. The aftercare specialist shall have certification/licensure as an alcoholism/substance abuse counselor; advanced knowledge of relapse prevention, community and family systems, resources, resource development and utilization; and two years of related work experience. Additional behavioral health training is desirable.
      10. Nurses must possess either an R.N. or L.P.N. degree in accordance with their job descriptions; must have a thorough knowledge of the physiological, psychological, behavioral, and social variables of alcohol and other substance abuse including theories and issues in alcoholism/substance abuse and familiarity with alcoholism/substance abuse counseling methodologies and treatment techniques; and must possess a valid state license to practice nursing.
      11. Non-professionally trained counseling staff shall provide counseling under the guidance of professionally trained counseling supervisors.
      12. All staff working with youth shall have a background investigation completed to determine past history of sexual or child abuse.
   8. Impaired Employment Performance
      1. Each program administrator applicant must affirm in writing that his/her employment performance has not been impaired by alcoholism/substance abuse over the past 3 years.
      2. Upon initial hire, the treatment supervisor, if recovering from alcoholism or drug dependency, must affirm in writing that his/her employment performance has not been impaired by alcoholism/substance abuse over the past 3 years
      3. Each alcoholism/substance abuse counselor applicant must affirm in writing that his/her employment performance has not been impaired by alcoholism/substance abuse over the past 2 years.
      4. The governing body shall determine that trainee applicants/interns must affirm in writing that his/her employment performance has not been impaired by alcoholism/substance abuse over the past year and shall serve a probation period of 1 additional year.
   9. The Support Staff The support staff (e.g. cooks, custodians, clerks, house parents, and all other ancillary staff) shall have appropriate training and experience for their positions and understand the philosophy underlying alcoholism/substance abuse treatment and the need for confidentiality. Those whose duties require direct contact with clients (such as house parents), must possess this knowledge as a condition of employment. Others, such as secretaries, cooks and custodians may be provided training within the first 90 days of employment.
   10. Volunteer Services
       1. In programs where volunteer services are utilized, the objectives and scope of volunteer service are clearly stated in writing. An orientation program is conducted to familiarize volunteers with the program's goals and services and to provide appropriate clinical orientation regarding the program's patients.
       2. The orientation program includes explanation of at least the following:
          
          
          1. The importance of maintaining confidentiality and protecting patients' rights.
          2. The procedures for responding to unusual events and incidents.
          3. The program's channels of communication and the distinctions between administration and clinical authority and responsibility.
          4. Volunteer activity records and reports contain information that can be used to evaluate the effectiveness of the volunteer services.
          5. All staff working with youth shall have a background investigation completed to determine past history of sexual or child abuse.
   11. Compensation and Fringe Benefits The program shall have a written salary schedule covering all positions and describing all compensation and fringe benefits.
       1. The project shall have a minimum health insurance plan for all employees.
       2. The compensation and fringe benefits shall meet all Federal, State, and local regulations for a project of this type.
   12. Treatment Philosophy
       1. The program recognizes alcoholism/substance abuse as both a treatable illness and a social problem amenable to preventive intervention and treatment.
       2. The program is committed to work with other national, State, local, and tribal agencies to provide a comprehensive range of prevention, outreach, treatment, habilitative, and rehabilitative services to the alcoholism/substance abuse client and family.  (Documented Affiliation Agreements with agencies providing the following services are maintained if the services are not provided directly by the program: detoxification, primary residential care, halfway house care, outpatient treatment, medical care, social services, and legal services provided by the courts and law enforcement agencies.)
       3. The client shall be treated with respect and not labeled as a "drunk" or "addict", but as a person suffering from the disease of alcoholism or drug abuse.
       4. The client shall be viewed and treated as an individual.
       5. Culturally oriented services shall be available and provided where deemed appropriate and necessary.
       6. The client is entitled to confidentiality and this will be respected by the staff at all times.
       7. The program's rehabilitative activities shall be designed with sensitivity to the cultural values and beliefs of Indian people.
       8. Treatment goals shall be written and clearly understood by both the client and the staff. Such goals will be developed with participation of the client.
       9. The program shall provide a supportive atmosphere reinforcing abstinence through a process of living together with others who value abstinence and who govern their lives in accordance with rules that sustain an alcohol/substance abuse-free life-style.
       10. The supportive environment allows individuals to be themselves within the context of their own life-styles and culture and gives them the support necessary to continue without dependence on chemical supports.
       11. The treatment process is designed to promote the development of knowledge and problem-solving skills to combat drug dependency.
   13. Program Objectives
       1. The facility shall have written program objectives reviewed and approved by the governing body prior to implementation.
       2. The program objectives shall include, but not be limited to, the following:
          
          
          1. The evaluation and appropriate treatment of people who have experienced problems with alcohol and/or other drug use and either want to live a drug-free life-style or have been ordered to treatment by competent legal authority.
          2. The enhancement of individual dignity and the protection of the legal rights of all clients.
          3. The employment of competent staff whose members subscribe to professional ethics and standards in their discipline.
          4. Adherence to the non-discriminatory practices in the delivery of services.
          5. The integration of program services with other community resources in response to community needs.
          6. Enhancement of program effectiveness through an ongoing evaluation of treatment activities.
   14. Staff Development
       1. There shall be written policies and procedures establishing a staff development program. These shall be reviewed and approved by the governing body.
       2. The staff development program (It is recommended that staff development activities be conducted by accredited educational or training authorities.) shall include, but not be limited to, the following:
          
          
          1. On-the-job training.
          2. In-service education.
          3. Orientation for new staff.
          4. Opportunities for continuing job-related education.
       3. A systematic assessment of program needs shall be made to determine what individual staff training is necessary to achieve program goals and objectives. The results of this assessment shall be documented.
       4. An individual shall be assigned the responsibility for supervising staff development activities. This individual shall convene quarterly staff meetings to provide staff development activities. Minutes of such meetings shall be taken and recorded.
       5. The staff development supervisor shall meet regularly with staff members to insure that training activities are suited to individual needs. A record of meetings, findings, and training will be maintained to ensure accountability.
       6. A systematic assessment of program needs shall be made to determine if individual staff training is accomplished in accordance with program goals and objectives.
       7. The program administrator shall conduct an annual review of all staff development assessment reports and staff development activities. There shall be documentation verifying the program administrator has reviewed such reports and approved these activities.
   15. Client Records Client Information System
       1. A Management Information System approved by IHS shall be utilized by all IHS-funded alcoholism/substance abuse programs.
       2. There shall be written policies and procedures consistent with the Federal, State, local, and tribal regulations governing data collection.
       3. There shall be a record-keeping system that allows for the efficient retrieval of data needed to measure program performance.
       4. Only individuals with a "need-to-know" shall have access to any client files or records as defined by 42 CFR Part 2. "If a portion of a health or medical record indicates a diagnosis, prognosis, referral, or treatment of alcohol or drug abuse, then the Confidentiality of Alcohol and Drug Abuse Patient Records Regulations, 42 CFR Part 2 apply. In general under these regulations, the only disclosure of a diagnosis, prognosis, referral or treatment of alcohol or drug abuse which may be made without patient consent are: (1) to meet medical emergencies (42 CFR Part D, Sec. 2.51), (2) for research, audit, evaluation and examination (42 CFR Part D, Sec. 2.52, 2.53, 2.54, and 2.56), (3) for supervision and regulation of narcotic maintenance and detoxification programs (42 CFR 2.61-2.67), and (4) pursuant to a qualified service organization agreement, as defined in 42 CFR 2.11. In all other situations, written consent of the patient is required prior to disclosure of alcohol or drug information."
       5. A list of all individuals having access to client files shall be maintained and the individual who has control of all client records shall monitor this activity.
       6. There shall be written policies and procedures relating to the Freedom of Information Act and Confidentiality Act and how each is applicable to the treatment program.
       7. The client shall have the right to view his/her files and records under the supervision of treatment personnel in accordance with the procedures mandated in PRIVACY ACT PROCEDURES For IHS Medical Records Staff, all Other Persons Who Work in IHS or Contract Hospitals and Clinics and IHS Contractors Using IHS Medical Records, U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES, Public Health Service, IHS.
   16. Evaluation Research
       1. There shall be written policies and procedures that allow ongoing evaluative research within the program. Evaluative research shall monitor ongoing program activity.
       2. There shall be documentation of program effectiveness with respect to American Indian people.
       3. There shall be written documentation that knowledge gained from evaluative research will be utilized to improve program activities.
       4. All evaluative research reports shall present data and information understandably and in a manner useful to staff members who serve in management and decision-making capacities.
       5. There shall be written policies and procedures that will require signed informed consent for all evaluative research especially when such activities involve clients in treatment which may place the client at risk.
       6. Written policies and procedures shall require that when research findings are made public, care shall be taken to insure the confidentiality of the individual(s)/tribe(s) involved.
   17. Facilities
       1. The program's policies and procedures governing the use, furnishing, and decoration of its facilities shall be consistent with the program's treatment philosophy.
       2. There shall be written policies and procedures for controlling the purchase, storage, distribution, and inventory of equipment and supplies.
       3. The physical health and safety features of the facility shall conform to requirements of Federal, State and local authorities having jurisdiction.
       4. There shall be written records of inspections by Federal, State, and local authorities having jurisdiction. These written records shall be maintained by the administration.
       5. There shall be documentation of programs planned for daytime, evenings, and weekends consistent with the needs of the patient for social, educational, and recreational activities.
       6. There shall be documentation that the facility's environment is consistent with client needs and that the environment contributes to the development of therapeutic relationships. This documentation will be reviewed during the semi-annual review.
       7. The alcoholism/substance abuse program shall establish an environment that enhances the positive self-image of the patient and maintains human dignity through facility construction, personal hygiene, sleeping areas, clothing, sanitation, and furnishings.
       8. There shall be written plans and procedures established for meeting potential emergencies such as fire and natural disasters. These plans and procedures shall be posted in a highly visible location.
       9. Evacuation drills shall be conducted by staff on a quarterly basis and documented in a record for that purpose.
   18. Personnel Management The development of personnel management components shall include, but not be limited to, the following:
       1. Written policies and procedures describing the program's practices and procedures that shall include, at a minimum, the following:
          1. Verification that personnel policies and procedures are implemented.
          2. Documentation verifying that personnel policies and procedures are reviewed and updated at least annually.
          3. Policies defining wage and salary scales.
          4. Personnel records on each staff member.
          5. Documentation of Standards of job performance.
       2. Written job descriptions for all positions and documentation that personnel policies comply with Federal, State, local, and tribal regulations on fair employment.
       3. Established procedures for program orientation of new staff members.
       4. Written policies and procedures regarding confidentiality of personnel records.
       5. A semi-annual assessment of the program as to the adequacy and appropriateness of program services and personnel.
   19. Fiscal Management
       1. Program staff in charge of disbursing funds should be bonded for the protection of employees and continued program security. This bonding shall include all individuals who have authority to sign checks or perform other accounting activities.
       2. There shall be a written plan for obtaining financial resources for the total program.
       3. No single agent of the program shall have the authority to originate and complete documents that result in payment. Checks shall be reviewed and signed by at least two (2) authorized individuals to avoid unauthorized payments by an individual.
       4. There shall be procedures to document in-kind contributions received by the program.
       5. There shall be written policies and procedures governing the control of inventory to include product selection, evaluation, supply, storage, and distribution.
       6. An annual budget shall be reviewed and approved by the governing body prior to the beginning of each fiscal year of operation.
       7. Revisions of the budget and authorization to reallocate funds shall be reviewed and approved by the governing body.
       8. There shall be a fiscal management system based on cost-accounting procedures which should include, but not be limited to, the following:
          
          
          1. Fiscal experience and current financial position of the program.
          2. The rationale for determining the direct and indirect cost of program expenses.
          3. Documentation describing the mechanism used to determine the basis for allocating cost (a cost allocation formula).
          4. A reporting mechanism that describes the fiscal performance of the program (the relationship of the budget with actual expense to include both revenues and expenses by category).
          5. An income and expense report for each individual funding source where the program has more than one source of funds.
          6. A consolidated statement showing total receipts and expenditures.
       
       
       9. All financial statements and reports shall be made available to the governing body and to staff who participate in budget preparation and who have fiscal management responsibilities.
       10. An audit of the program's financial record may be instituted by IHS. The IHS shall provide funding or audit resources for all audits initiated by IHS. Programs may have private CPA firms audit their books at no cost to IHS.
       11. There shall be written policies and procedures for the control of all accounts receivable for handling cash, credit arrangements, discounts, write-offs, and billings.
       12. When clients are charged for services, a written fee schedule shall be provided. Policies on fees shall be approved by the governing body.
       13. There shall be documentation verifying compliance with established fiscal policies and procedures as set forth by the governing body.
       14. An insurance policy covering the material resources of the program and comprehensive liability covering the governing body and the program staff members shall be provided.
       15. The budget categories expenses by the types of services or program shall be provided.
       16. The program shall have written policies and procedures for inventory control, including purchasing authority and procedures, product selection and evaluation, and supply storage and distribution.
   20. Food Services:  Applies to all Residential Programs and Drop-in Centers
       1. The treatment program shall have a designated food service coordinator who is knowledgeable about dietetic services (may be part-time) and is preferably a Certified Dietetic Manager.  This person may be appointed by assignment, memorandum of agreement, or contract.
       2. The food service coordinator shall prepare written policies and procedures including, but not limited to, the following:
          
          
          1. Standards for nutritional care - diet menus and meal order, nutrition screening and referral criteria.
          2. Safety, sanitation, and waste disposal.
          3. Preparation of food items.
          4. Personal hygiene standards - health code, infection control, and cleaning schedule.
          5. Purchasing of food and equipment.
          6. Receiving, storing, handling, and preserving of food and non-food items.
          7. Preparing and transporting food for out-of-facility food services.
          8. Standards of inspection and verification of compliance with Federal, State, local, and tribal laws and regulations.
          9. Record-keeping for the effective management of dietetic operations.
          10. Use of specialized dietetic services for special dietary needs - diet menus and meal orders.
          11. Orientation of new employees and staff development.
       
       
       3. Residential treatment programs shall provide 24-hour care and will have a written plan that indicates the food services available to clients.
       4. Each client of a residential treatment program shall have his/her nutritional needs assessed and such assessment shall become a part of the client's case record.
       5. In the residential treatment program, the nutritional assessment shall include, but not be limited to, the following:
          
          
          1. Brief history regarding diet.
          2. Special diet requirement, if necessary.
          3. Indication of any nutritional deficiencies.
          4. Proposed dietetic treatment plan signed and dated by the food service coordinator.
       
       
       6. The residential treatment program shall conduct a final nutritional assessment of each client prior to release from the program.  The assessment shall be signed, dated and filed in the client's case record.
       7. In the residential treatment program, the nutrition and dietetic elements shall be monitored to comply, at a minimum, with the following:
          
          
          1. Menus are planned in accordance with the current recommended dietary allowance standards as published by the National Research Council.
          2. Meals are served at regular and reasonable times.
          3. Menus are approved by the Area dietician/nutritionist, considering preference of the Indian people being served as well as specialized dietary needs of individuals; i.e., diabetes, diets, etc.
          4. Mealtimes are of sufficient duration to allow a relaxed atmosphere.
          5. No more than 14 hours shall elapse between evening meals and breakfast meals.
          6. Studies are conducted at least quarterly to determine of type and quality of food is acceptable.
       
       
       8. The food service coordinator shall prepare quarterly dietetic progress reports which may include such data as:
          
          
          1. Utilization rates regarding regular and special meals.
          2. Results of any inspection conducted by Federal, State, local, and tribal health authorities.
          3. Budget projections and a report of expenditures; e.g., cost per serving which includes raw food cost, cost of supplies, freight, employee costs, etc.

3-18.6  CLIENT SERVICES

1. ALCOHOLISM/SUBSTANCE ABUSE TREATMENT SERVICES
   1. Residential treatment programs shall provide patients with a minimum number of treatment hours as listed in the following components:
      
      
      1. Primary Residential Treatment (PRT), an intensive treatment program, shall provide each patient with a minimum of 48 hours per week of structured and planned activities designed to build and develop the patient's ability to cope with problems of alcoholism and substance abuse.  (See description of requirements for PRT in Standards 3-18.10C).
      2. The YPRT, an intensive treatment program, shall provide each patient with a minimum of 58 hours per week of structured and planned activities designed to build and develop patient's ability to cope with problems of alcoholism and substance abuse.  (See description of requirements of YPRT in Standards 3-18.10I.
   2. Intermediate Care (Recovery House or Halfway House) shall be a residential program for patients requiring moderately structured living agreements and continued counseling therapy.  (See detailed description of Intermediate Care Program in Standards 3-18.10E and Standards 3-18.10F.
   3. Women and Children Program, an intensive treatment program, shall provide each patient with a minimum of 48 hours per week of structured and planned activities designed to build and develop patient's ability to cope with problems of alcoholism and substance abuse.  (See description of requirements for Women and Children in Standards 3-18.105J.
   4. Outpatient counseling shall be provided at a frequency determined by the program director and treatment coordinator to meet the requirements of the population served.
   5. Group Home Program, a residential program to facilitate the rehabilitation of the alcohol/substance abuser by placing the patient in an organized therapeutic environment.  Outpatient counseling shall be provided at a frequency determined by the outpatient component director and treatment coordinator to meet the requirements of the population served.
2. INTAKE/ADMISSION
   1. The program shall have clearly stated written eligibility criteria for admission to the program.
   2. The program shall have written policies and procedures governing and defining the intake process to include, but not limited to, the following:
      
      
      1. Statistical and demographic data required on intake.
      2. Procedures followed upon accepting referrals.
      3. Procedures for referral from community resources.
      4. Type of information to be gathered prior to admission.
      5. Medical, psychological, and social assessments for admission into a YPRT or other treatment programs.
      6. Procedures for crisis management.
   3. The client or applicant shall have the right to withhold any information that is not absolutely necessary to the treatment process or to the operation of the program.
   4. Treatment programs shall use standardized forms for recording intake information.
   5. The intake process shall include, but not be limited to the following items of orientation of the client:
      
      
      1. The general nature and goals of the program.
      2. Explanation of treatment costs if applicable.
      3. Overview of the hours when services are available.
      4. Rules governing client conduct.
      5. Infractions that could lead to discharge from the program or other disciplinary actions.
      6. Review of forms that are to become a part of the client's case record.
      7. Patient rights.
3. INDIVIDUAL TREATMENT PLAN-CLIENT STAFFING
   1. A written treatment plan shall be developed and recorded in the client's records.  This treatment plan shall be developed as soon after the client's admission as possible within the following time frame:  within 72 hours of admission an interim treatment plan will be developed and implemented; a comprehensive treatment plan will be developed and implemented within 10 days of admission.  The plan shall be developed by an interdisciplinary team comprised of at least two individuals.  The team shall consist, at a minimum, of an alcoholism/substance abuse counselor and a primary care provider (physician, nurse, nurse practitioner, clinical pharmacist, or physician assistant), or a mental health worker, or a social services worker.
      1. At a YPRT, the treatment plan shall be developed by an interdisciplinary team of no less than four professionals.  The team shall consist of, at a minimum, a primary care provider (physician, nurse, nurse practitioner, clinical pharmacist, or physician assistant), an alcoholism/substance abuse counselor, a mental health worker, and a social services worker/family therapist.
   2. The treatment plan shall include, but not be limited to, the following:
      
      
      1. Problems and diagnoses identified shall be listed and written in clearly understandable terms.
      2. Treatment goals shall be written in terms of measurable behavior.
      3. The treatment plan shall define the services to be provided to the client, therapeutic activities in which the client is expected to participate, and when these services will be provided.
      4. The plan shall designate the team of staff members to be involved in the client's treatment.
      5. The treatment plan shall be prepared in partnership with the client, reviewed with the client at least monthly (every two weeks in programs of 60 days or less), and revised as often as necessary.
      6. The treatment plan shall be written in a manner understandable to the client.
      7. Progress notes shall be recorded in the case file indicating the client's progress towards established goals.
      8. Progress notes shall be dated and signed by the individual making the entry.
      9. Treatment goals shall be established and identified on short and long-term bases: e.g., those that can be addressed while at the Center and those that will need to be addressed in an aftercare plan.  All goals and problems shall be addressed.
         1. Short-term goals shall include the most immediate needs of the client entering the program; i.e., need for medical attention, contact with family, nutritional needs, etc.
         2. Long-term goals shall address activities needed to maintain social and psychological functioning in the community.  This may include such activities as family therapy, vocational rehabilitation, individual therapy, and learning of coping skills.
      10. Remedial measures and changes will be recorded in the progress notes and treatment plan as they occur indicating the change and the reason for the change.
      11. Involvement of the family in treatment planning directly or through collaborative efforts with the community-based program is a required activity of the YPRT.  This activity must be documented and include the family's perception of the client's problem as an integral part of the assessment/treatment plan.
      12. There shall be documented justification when identified clinical problems/needs of the client are not addressed.
      13. All goals will be stated in terms that are specific, measurable, specify a completion or progress date, and clearly specify the roles of the client, counselor, family, and others involved.
4. REQUIRED PHYSICIAN ASSESSMENT OF CLIENTS
   1. Prior to admission to a residential treatment program a medical examination by a qualified physician shall be conducted.  Results of the medical history, physical examination, and appropriate laboratory tests shall be forwarded to the Center prior to admission.  If the medical examination is completed more than one week prior to admission, it shall be updated by the originating physician or medical facility to be current within one week.
   2. Information from the medical examination shall be used in the development of the individualized treatment plan and to ensure that adequate follow-up services are provided.
   3. Clients admitted to PRT Centers shall receive a physical examination and be medically evaluated within 24 hours of admission to the treatment program.  This evaluation will be reviewed by a physician who will provide or order any other medical services that may be indicated including services listed under 3-18,10(B).  This shall include a medical history and a physical examination if the client has not had one, or if the current physical examination is over one week old, and the medical history and physical examination cannot be obtained in D(1) above.
   4. Those programs serving youth shall have a growth and development history completed.
   5. A nutritional assessment shall be completed by a registered dietitian/nutritionist.
5. PSYCHOLOGICAL ASSESSMENT
   1. Prior to or within one week of admission to a residential treatment program, a psychological assessment shall be conducted, documented, and submitted as part of the referral process on all clients which shall include, but is not limited to, the following:
      
      
      1. A mental status examination including immediate recall and recent and remote memory.
      2. A determination of current and past psychiatric/psychological abnormality.
      3. A determination of any degree of danger to self or others.
      4. A neuropsychological assessment, if indicated by the psychiatric/psychological assessment.
         1. Special emphasis is placed on cognitive functioning, including any learning impairment that might influence diagnosis and treatment.
   2. The psychological/emotional assessment shall be reviewed by appropriate professional individuals.  The assessment may be done by qualified personnel other than psychologists or psychiatrists (e.g., social workers, chemical dependency counselors, etc.) if approved and monitored by the appropriate professional mental health personnel.
   3. The process and results of the assessment shall be documented in the patient's record.
   4. There shall be a written individualized and updated treatment plan based on the results of the psychological/emotional assessment.
   5. Clients shall participate in the development of the updated treatment plan based on its objectives.
   6. There shall be documentation that, to the extent resources are available, psychological/emotional evaluation recommendations are implemented as soon as the medical conditions of the client permit.
6. SOCIAL ASSESSMENT
   1. Within the first five days of treatment a social assessment shall be made and documented.
   2. The results of the social assessment shall be made available to the interdisciplinary staffing team and incorporated into the treatment plan.
   3. The social assessment includes, but is not limited to, the following:
      
      
      1. The family's history of alcoholism and other drug dependence.
      2. The client's educational level, vocational status, and job performance history.
      3. The client's social support networks, including family and peer relationships.
      4. The client's sexual history, including sexual abuse (either as the abuser or the abused) and orientation.
      5. The client's perception of his strengths and weaknesses.
      6. The client's leisure, recreational, and vocational interests and hobbies.
      7. The client's daily activity patterns, including those that support and those that are alternatives to alcohol/drug dependence.
      8. The social influences on the client and the client's identity, including values and beliefs.
      9. The client's own perception of his dependence.
      10. The client's ability to participate with peers in programs and social activities.
      11. Interviews of family members and significant others, as available, with the client's written or verbal permission.
      12. Legal problems, if applicable.
      13. Spiritual, cultural, and religious perceptions, influences, and needs as expressed by the client.
   4. Family status and an assessment of the family's capacity and interest in participating in ongoing services for the client.  The staff shall ensure that the client's family will be involved in the assessment and treatment processes.
7. REFERRAL PROCESS
   1. Treatment programs shall have written policies and procedures that describe requirements for referrals and a written plan that delineates the conditions for referral to other programs or agencies.
   2. The written policies and procedures shall include a mechanism by which a client can be referred or request a referral to another community provider.
   3. Upon referral, there shall be written evidence of the rationale for referral and to whom the referral was made.
   4. Programs to which referrals are made shall be contacted by the alcoholism/substance abuse treatment program to establish a procedure to facilitate the referral process, and, if appropriate, the return of the client for treatment for substance abuse.  The YPRT will discharge clients to the appropriate community-based resources for aftercare services as well.
8. CLIENT RIGHTS
   1. The program shall have written policies and procedures designed to enhance the dignity of all clients and to protect their human rights.
   2. The written policies and procedures shall include, but not be limited to, the following:
      
      
      1. There shall be a procedure established to inform all clients of their legal and human rights.
      2. Prior to the use of medications or medically related procedures, the client shall give his/her consent in writing.  A medical policy shall be written and made a part of the policy and procedure manual.
      3. Provisions shall be made for the client to receive visitors at the treatment facility.
      4. Visitation shall be conducted so as to minimally disrupt the client's usual activities and treatment program.
      5. The inpatient treatment program shall provide to the client some means of communication with persons outside the program; if possible, there should be some provision for private telephone conversation with family and friends.
      6. The client should be allowed to send and receive mail.
   3. Termination For Cause. There shall be written policies and procedures for discharging clients who fail to comply with the rules of the program.
      1. The written policies and procedures shall include, but not be limited to, the following:
         
         
         1. Type of infraction that led to discharge.
         2. Who has authority to discharge clients.
         3. Evidence of prior notification of the client.
         4. A process for appeal or review of a discharge decision or other disciplinary action.
9. SPIRITUAL GUIDANCE/COUNSELING
   1. Spiritual guidance and counseling shall be made available to all clients upon request,
   2. The client will be allowed to choose a spiritual counselor of his/her own persuasion.   The Center will make reasonable effort to provide the counselor of the client's choice or a substitute of the same persuasion if the client approves.
   3. The client's cultural, spiritual, and religious beliefs and desires will be respected in all instances.  Under no circumstances will the client be placed under any pressure to follow or conform to specific practices or beliefs other than his/her own.  Only general principles of spirituality and a belief in a higher power will be included in the program.
10. COUNSELING SERVICES
    1. All clients shall receive individual counseling to deal with the problems deemed most important by the client and the treatment team.
    2. Counselors trained in alcoholism/substance abuse counseling shall provide individual counseling to all the clients.
    3. Group counseling shall be made available to every individual in treatment and be mandatory for inpatient clients.
    4. Group and individual counseling shall be used to help the client develop coping skills.
11. DISCHARGE SERVICES
    1. The treatment program shall have a written policy concerning the discharge of clients.
    2. When a client is discharged, the following shall be documented:
       
       
       1. The proposed aftercare plan to include, but not limited to, halfway house or other residential treatment needed, outpatient and community counseling, Alcoholics Anonymous (AA) or other group sessions, and all other needs identified in the treatment goals and objectives.
       2. A discharge summary describing the reason for discharge.
       3. An individual status report which indicates the client's progress toward goals and objectives achieved.
       4. An assessment of the client's alcoholism/substance status at discharge.
       5. Identification of the program or counselor to whom the client is discharged.
    
    
    3. The client shall be informed as to how he/she may reestablish contact with the program in times of crisis.
    4. The client shall be informed as to the frequency with which the program will attempt to contact him/her for follow-up.
    5. No client shall be discharged without a written plan delineating how he/she is going to proceed over the next 30 days.
    6. Referrals made (documented and discussed with the client) to halfway houses, other residential treatment, or community or other aftercare facilities.
    7. In the discharge planning process, rehabilitation and aftercare staff at the Service Unit level shall be involved in the treatment planning process.
12. MEDICATION CONTROL
    1. The program shall have written policies and procedures defining qualifications for program staff members who dispense and administer medications or otherwise provide medical services on orders from qualified physicians.
    2. These written policies shall be approved by the governing body.
    3. In accordance with Federal and State laws, the treatment program shall maintain prescription orders, narcotic records, and inventory control records for at least five years.
    4. If medications are administered by treatment staff, they shall be under the supervision of a licensed physician, registered nurse, or licensed practical nurse or nurse practitioner.
    5. Medication orders shall be written only by licensed physicians.
    6. The program shall have available at all times an updated list of staff members authorized to administer medications.
    7. Keys to the locked cabinets and rooms shall be available within the facility at all times.
13. RECREATIONAL ACTIVITIES
    1. The treatment program shall have a written plan describing the recreational activities in which the clients may participate.
    2. Recreational activities shall include physical exercise as well as other organized indoor and outdoor activities.  Physical exercise shall be mandatory in all inpatient treatment facilities.
    3. The recreational activities shall take into account the cultural/ethnic background and the physical condition and disabilities of the individual clients in the program.
    4. There shall be a treatment staff member that is specifically assigned to develop recreational activities for the clients.  Where available, the services of a qualified recreational therapist should be used for diagnostic planning and individual client evaluation.
    5. Considering that nicotine is an addictive drug, all programs shall be smoke-free.  (Per HHS Transmittal 87.01 dated 08/25/87 and IHS Non-Smoking Policy dated 02/17/89).
14. AFTERCARE/FOLLOW-UP SERVICES
    1. There shall be written policies and procedures pertaining to the follow-up of all clients.
    2. The policies and procedures shall provide a plan noting information that will enhance the client's long-term. treatment program.  This plan should note long-term effects on the client.
    3. The written aftercare plan shall describe the services to be provided to clients returning to their respective communities during the aftercare period (the period following discharge).
    4. The written plan shall include intervals in which the aftercare/follow-up shall occur with each client.
    5. The plan shall be developed in partnership with the client and where appropriate, his/her family, prior to completion of treatment.  The client shall be informed prior to discharge as to the nature of the aftercare/follow-up services and the rationale behind the process.  A review of accomplishments made during treatment will be conducted with the client at the time of discharge.
    6. A written consent statement signed by the client indicating willingness to participate in aftercare/follow-up shall be obtained at the time of discharge.
    7. Clients may be asked to complete research forms that may be a part of an aftercare/follow-up plan.
    8. The Area Intervention Team Aftercare Specialists shall be notified when a client is discharged from an inpatient program.
    9. Aftercare/follow-up services provided by community support systems shall continue as long as necessary and be a requirement for each community wishing to place an individual into treatment.
    10. The date, method and results of any aftercare/follow-up attempts shall be entered into the client's records and shall be signed by the individual making the entry.
    11. If follow-up information cannot be obtained, the reasons shall be entered into the client's record.
    12. The aftercare/follow-up of the individual shall be consistent with the treatment philosophy of the program.
        
        
        1. Program follow-up shall not infringe on a client's rights to privacy or other human rights.
        2. The aftercare/follow-up shall be used to enhance the effectiveness of the program in meeting client needs.
        3. The aftercare/follow-up should be used as a longitudinal evaluation of the program's ability to provide services.

3-18.7  CONTINUUM OF CARE SERVICES

1. WRITTEN PLAN A written plan shall be developed specifying how private and public human service agencies serving the same target population will be involved in both early identification, access, and entry into the alcoholism/substance abuse service delivery system.
2. DOCUMENTATION There shall be written documentation maintained by the program verifying referral and provision of community and other services to the clients.
3. AGREEMENTS Formal agreements shall be made with agencies within the community capable of providing support services to clients.
4. REVIEW The community service network shall be reviewed annually by the governing body to ensure that all potential service providers have been contacted and program clients have been made aware of their services.

3-18.8  EXCEPTION/VARIANCE

1. THE IHS MAY GRANT EXCEPTIONS TO THESE STANDARDS based on demonstrated lack of program or community resources.
   1. Exceptions shall not be granted which are judged to be detrimental to the health or safety of the clients and program.
   2. The program seeking an exception shall submit, in writing, the reasons the requirement cannot be currently met and a plan to achieve compliance with the excepted standard.
2. THE PROGRAM MAY RECEIVE APPROVAL FOR A VARIANCE TO THESE STANDARDS based on the demonstrated increases in program effectiveness through the use of alternate standards by submitting a written plan.

3-18.9  QUALITY ASSURANCE PLAN FOR ALCOHOLISM/SUBSTANCE ABUSE PROGRAMS

1. PURPOSE The quality Assurance Plan for alcohol/substance abuse treatment and prevention is a mechanism to enhance patient care through objective assessment of patient care and the resolution of identified problems.
2. OBJECTIVES
   1. The IHS-funded alcoholism/substance abuse programs shall initiate and maintain a Quality Assurance Program consistent with IHS policies and guidelines.
   2. The IHS-funded contractors shall assure delivery of the highest quality of care possible to patients with alcoholism/substance abuse problems consistent with resources available and within achievable goals.
   3. The IHS-funded contractors shall develop and implement activities within the Quality Assurance Program to monitor the delivery of treatment/prevention services.
   4. The IHS-funded contractors shall provide for the integration of the various service disciplines, such as medical care, mental health, social services, health education, law enforcement, education systems, and other local resources with the alcoholism/substance abuse program activities.
   5. The IHS-funded contractors shall provide a system of non-biased auditing of individuals and program activities to identify existing problems with the delivery of services.
   6. The IHS-funded contractors shall provide a system to assure that periodic follow-up activities are maintained for the correction of identified program problems.
3. QUALITY ASSURANCE PROGRAM METHODOLOGY All activities of the Quality Assurance Program shall be consistent with IHS policies and guidelines.
   1. Authority
      1. The Director of the Area Alcoholism/Substance Abuse Program has the authority and responsibility to administer the Quality Assurance Plan for his/her program components.
      2. The individual assigned the responsibility of Quality Assurance Officer shall be responsible for the following activities:
         
         
         1. Development and implementation of a plan as required by IHS policy.
         2. Strict adherence to requirements of the plan.
         3. Provision of administrative support for the implementation of the Quality Assurance Plan.
   2. Quality Assurance Committee
      
      
      1. The thrust of a Quality Assurance Program shall be to provide a rational basis to determine the quality of care being provided clientele and the total effectiveness of the treatment and/or prevention program
      2. To assist in the accomplishment of goals of the Quality Assurance Program, each program site shall develop and maintain a Quality Assurance Committee with the following suggested composition, as appropriate:
         1. P.L. 93-638 Alcoholism/Substance Abuse Program:
            
            
            1. Alcoholism/substance abuse program director or representative;
            2. Governing board representative;
            3. Service Unit Director or urban health board representative, as appropriate;
            4. IHS-Service Unit Medical Officer;
            5. Mental Health representatives;
            6. Social Services - IHS/BIA/Tribe representatives;
            7. Community Health Representatives;
            8. IHS Health Educator;
            9. BIA Superintendent or representative;
            10. Law enforcement/court system representative;
            11. Education system representative; and
            12. Other representatives as deemed necessary by program governing board.
         2. IHS facilities will have a Quality Assurance Committee consisting of those members prescribed under IHS policies and directives which will also include the alcoholism/substance abuse coordinator.
   3. Quality Assurance Process
      
      
      1. The Quality Assurance Committee shall develop and institute a patient satisfaction questionnaire to be implemented as a quarterly function.
      2. The Quality Assurance Committee shall review the results of the quarterly patient satisfaction survey within 30 days following the end of each quarter.  The survey results shall be utilized to identify barriers to the effective and efficient delivery of alcoholism/substance abuse services.
      3. Service Unit rehabilitation and aftercare staff, along with program staff, shall review case records of five active clients monthly to determine quality of treatment being administered.
      4. The IHS program evaluation protocol implemented within the program shall be reviewed for completeness, adequacy, and accuracy by the Quality Assurance Committee.
      5. Information collected shall be evaluated to determine quality of care and total effectiveness of the alcoholism/substance abuse program in meeting community needs, including contract compliance efforts or lack of efforts.
      6. The quality assurance process shall assess compliance to IHS alcoholism/substance abuse program standards, safety standards, fire prevention and medical and other emergency plans, and sanitation, environmental safety and handicapped facilities requirements.
      7. The Quality Assurance Committee shall establish a plan for identifying and eliminating program deficiencies.  This plan will be submitted to the appropriate governing body for approval.
      8. The Quality Assurance Committee shall periodically review the progress or lack of progress being made in the identification and elimination of program deficiencies.
      9. The professional staff shall participate in determining what qualifications (training, experience, and documented competence) are required for assuming specific clinical service responsibilities.
      10. It is recommended that the Committee meet quarterly, but it must meet not less than semi-annually.  Minutes of the activities of the Quality Assurance Committee shall be taken and kept current.
   4. Semi-Annual Quality Assurance Report
      1. The Chairperson of the Quality Assurance Committee shall assume the responsibility for preparing and dispatching a quality assurance report at least quarterly to the following:
         
         
         1. One copy to the governing body.
         2. One copy to each member of the Alcoholism/Substance Abuse Quality Assurance Committee.
         3. One copy to the Area Alcoholism/Substance Abuse Committee.
         4. One copy to the Service Unit Director.
      2. Other copies will be distributed as deemed necessary by the Alcoholism/Substance Abuse Program Director.
      3. The Alcoholism/Substance Abuse Program Office shall maintain a copy of that report in its files.

3-18.10  SERVICES

1. PURPOSE Alcohol and substance abuse have been recognized as a major Indian health problem.  The first clear policy statements on this problem were set down in the summary report of the IHS Task Force on Alcoholism (1969/1972). The Task Force developed several excellent recommendations, but there was no mechanism within the IHS to assure the implementation of these recommendations.  However, the passage of the Indian Health Care Improvement Act of 1976 (P.L. 94-437) made possible the establishment of the Office of Alcoholism Programs (now the Alcoholism and Substance Abuse Program Branch).  Subsequently, the Alcoholism and Substance Abuse Program Branch developed the goals and objectives listed under 3-18.1(B) and (C).
2. DETOXIFICATION UNITS
   1. Medical Detoxification Unit Definition:  General Program Description A facility for individuals under the influence of alcohol and/or other drugs who have concurrent health problems which require immediate medical attention.  Individuals are admitted for the purpose of undergoing withdrawal from alcohol and/or other drugs while under the supervision of medical staff who intervene in potentially life-threatening situations.  As soon as the individual's physical or emotional condition permits, motivational counseling is begun to facilitate entry into a treatment program for behavior change and the development of life skills.
      1. Standards
         
         
         1. All medical detoxification programs shall be located within a PHS Hospital or a licensed contract hospital and may be inpatient or outpatient at the discretion of the physician.
         2. A licensed physician shall be a member of the staff.
         3. The medical detoxification program shall have a 24-hour day, 7-day week, supervision by competent medical personnel (e.g., registered nurses, licensed practical nurses, interns, aides).
         4. Each client shall have a medical examination including, at a minimum, those items required under accreditation standards such as the Joint Commission on the Accreditation of Healthcare Organizations (JCAHCO) or the Commission for the Accreditation of Rehabilitation Facilities.  The examination shall be made by competent medical staff and shall be documented.  A medical history shall be a part of the client's medical records.
         5. Appropriate medical laboratory tests, including tests for communicable diseases when indicated, shall be administered as directed by the attending physician.
         6. Emergency medical services shall be available for clientele of the medical detoxification program.
         7. All clientele shall receive, at a minimum, one (1) hour of motivational counseling by a qualified alcoholism/substance abuse counselor during the detoxification period to motivate the client to seek treatment and work towards a sober life-style.
         8. All clientele shall be made aware of alcoholism/substance abuse rehabilitation resources available within the community.
   2. Social Detoxification Unit Definition:  General Program Description A facility where individuals are admitted for purposes of undergoing withdrawal and/or to reduce the onset of physical impairment and emotional dysfunction due to alcoholism/substance abuse.  Staff in these facilities are trained to monitor the physical and emotional status of the individuals during withdrawal, identify withdrawal symptoms that are potentially life-threatening and make appropriate medical referrals.  They are also trained to provide motivational counseling to facilitate the problem drinker's entry into a treatment program for behavioral change and the development of life and coping skills.  This service is not designed for those individuals who have concurrent health problems which require immediate attention.  Social detoxification may take place in a community, tribal, contract, or IHS facility.  The use of IHS facilities is encouraged when space is available.
      
      
      1. Standards
         
         
         1. Social (non-medical) detoxification shall be used for intoxicated clients who are not at acute medical risk.
         2. The social detoxification program shall be housed in a facility which conforms to physical, sanitary, and safety features as required by the appropriate governmental jurisdiction (Federal, State or local).
         3. To insure that the patients receive a safe detoxification, the social detoxification program shall employ staff who are qualified to care for the intoxicated individual, provide 24-hour care, and who meet all State or other jurisdictional standards.
         4. The social detoxification program shall provide for emergency medical backup on a 24-hour basis.
         5. All clients shall be medically screened by a physician, physician's assistant, or other licensed practitioner under the supervision of a physician for potential medical problems requiring medical detoxification.  This shall be done prior to admission or within 24 hours following admission to the social detoxification center.
3. PRIMARY RESIDENTIAL TREATMENT Definition:  General Program Description Primary Residential Treatment (PRT) is a non-medical, residential intensive treatment program designed to facilitate the rehabilitation of the alcoholism/substance abuser by placing the client in a highly structured therapeutic environment.  The therapeutic environment of the PRT is a short-term (generally 30-60 days), highly structured program including diagnostic services, individual and group counseling, alcoholism/substance abuse education, psychological self-awareness, decision-making skills development, and building self-esteem.  The PRT provides group support sessions, cultural, social and recreational programs within the therapeutic environment. Alcoholism/substance abuse are recognized as both a treatable illness and a social problem amenable to prevention and treatment through a coordinated multi-disciplinary effort.  The alcoholism/substance abuse program efforts must be sensitive to the unique cultural background, promote the dignity of individuals under treatment and protect the legal rights of all its clients.  All program staff shall demonstrate competence in subscribing to professional standards in the treatment of alcoholism/substance abuse. The confidentiality of all clients shall be respected among and between the staff.  The program will be designed to meet the cultural and human needs of Indian people.  Awareness of these needs will be facilitated through active involvement by the professional staff in the Indian community. This community involvement will also enhance the house resident's access to support services within the Indian community.
   1. Standards - Inpatient Treatment (Intensive Primary Care) The treatment program shall have a written plan which shall include, but not be limited to, the following:
      
      
      1. Alcoholism/substance abuse are recognized as both a treatable illness and a social problem amenable to prevention and treatment, through a coordinated multi-disciplinary inter-agency effort.
      2. Treatment programs are committed to work with tribal, Federal, State, and third party agencies to provide a comprehensive range of prevention, outreach, treatment, and rehabilitative services to alcoholism/substance abuse clients and their families.
      3. Alcoholism/substance abuse programs shall operate to promote the dignity of all its clients and to protect their legal and human rights.
      4. Counseling staff shall provide both individual and group counseling sessions.
      5. In order to ensure appropriate and acceptable alcoholism/substance abuse program activities, staff must develop the programs in collaboration with the Indian community.
      6. Confidentiality of all clients shall be respected and guarded at all times.
      7. Based on the diagnostic assessment of the client, there shall be a written, individual treatment plan developed by a staffing team comprised of at least two individuals.  The team shall consist of, at a minimum, of an alcoholism/substance abuse counselor and a primary care provider (physician, nurse, nurse practitioner, clinical pharmacist, or physician assistant), or a mental health worker, or a social worker.
         
         
         1. The treatment plan shall delineate those services required for the clients, including medical services.
         2. The treatment plan shall be evaluated periodically but not less frequently than every 14 days.
         3. All treatment activity shall be documented in client charts.
         4. Each treatment plan shall contain at least two treatment goals, one of which shall be sobriety.  The goals shall have specific target dates and measurable outcomes.
         5. Treatment goals for each individual client shall be stated and clearly understood by everyone involved.
         6. Each treatment plan shall contain short and long term treatment goals.
         7. All treatment plans shall be developed with active participation by the client, and where appropriate, his/her family.
      8. The staff shall ensure that the client's family will be involved in the assessment and treatment processes by indicating family status and an assessment of the family's capacity and interest in participating in ongoing services for the client.
      9. Residents shall have access to culturally relevant ceremonies that will be beneficial to their treatment (e.g., sweat lodge, traditional dances, etc.).
      10. Overall program philosophy shall dictate specific provisions for individual rights with regard to culture, language. religion, and tribal affiliation.
      11. All residential treatment programs shall maintain continuous 24-hour in-house supervision of clients by program staff.  This is not to be construed as any form of resident/peer supervision in place of program staff.
      12. The PRT program shall have specific written program objectives and policies, including measurable results expected from program activity.  The written program objectives shall address the standards as identified in Administrative/Management Section, 3-18.5 of this Chapter.
      13. The PRT program component shall have written descriptions of the organization to include, but not limited to, the following:
          
          
          1. A written outline of the PRTs interrelationship to other components and community resources.
          2. Written authority and responsibilities of program staff.
          3. Personnel policies shall be described in accordance with the Administrative/Management Section, 3-18.5 of this Chapter.
          4. Written plans shall include lines of authority, including those relating to the parent agency.
          5. The role of the component director and other staff shall be delineated in accordance with IHS Administrative Standards.
      14. The PRT component shall have written procedures for the treatment of alcoholism/substance abuse clientele.  This written plan shall be in accordance with the Administrative/Management Section, 3-18.5.
      15. There shall be written procedures describing, in detail, the performance of each of the following treatment elements to clients of the PRT component.  All these elements shall be performed weekly.
          
          
          1. A total of at least 48 hours of treatment activity shall be included in the program.
          2. A minimum of 10 hours of individual and group counseling therapy shall be included in the treatment program.
          3. The plan shall include a minimum of 6 hours of group support, such as AA.
          4. A minimum of 12 hours of alcohol/substance abuse education shall be given to clientele weekly.
          5. Clients shall receive a minimum of 8 hours education in development of decision-making skills, coping skills, and psychological enhancement.
          6. Clients shall be given a minimum of 6 hours per week of recreation/physical activity.
          7. A minimum of 6 hours of spiritual activities, including at least 2 hours of cultural activities will be made available to clients.
          8. Activities which cover two or more areas can be applied to meeting the requirements for both areas (e.g., the individual and group counseling are part of the 48 treatment hours; AA can meet group support and spirituality if the theme stressed spirituality).
      16. The facility shall be maintained within accepted sanitary and safety standards as established by appropriate jurisdiction.
      17. Food shall be prepared, stored and served in accordance with Federal, State, tribal, or local standards.
      18. An acceptable case load (number of clients per counselor) will be established to ensure the delivery of quality treatment services.
4. OUTPATIENT CARE PROGRAM Definition:  General Program Description The outpatient care program is a program for individuals and families who are in need of therapeutic and supportive counseling and referral services but do not require residential treatment.  Persons may have had their primary treatment experience in another component or may begin treatment in the community outpatient care inpatient.  The outpatient care program provides diagnostic services, therapeutic intervention, individual, peer and group counseling, and referral to appropriate resources.  A rehabilitation plan tailored to needs of clients is negotiated and developed upon intake.  The individual treatment plan is implemented to facilitate the development of new life skills and to eliminate alcoholism/substance abuse and other destructive behavior. Rehabilitation and aftercare is usually defined as that portion of the plan and services provided starting with discharge from an inpatient or residential facility.  It includes halfway houses, foster homes, and other residential services following primary residential treatment, as well as outpatient treatment. These community outpatient care services may also be the appropriate component for the initial treatment.
   1. Standards The following standards shall be applicable to all IHS-funded alcoholism/substance abuse programs having outpatient components.
      1. All clients discharged from inpatient facilities such as PRTs, detoxification, and halfway houses, are required to have a plan to participate in community rehabilitation and aftercare.
      2. At a minimum, community outpatient care services shall provide 2 hours of service twice a week, for 6 weeks, and at least 2 hours once a week thereafter for 2 years.
      3. Counselors are required to evaluate the effectiveness of community outpatient care services semi-annually for a period of no less than 2 years to determine that client needs are adequately met.
      4. Alcoholism/substance abuse programs having an outpatient care component shall have a written plan describing in detail:
         1. Program goals and objectives.
         2. Methodology of providing outreach, referral, family, aftercare, and preventive services.
         3. Treatment procedures to be used in providing services.
         4. Scope of population to be served.
      5. The written plan shall include a definition of the roles and responsibilities of staff assigned to rehabilitation and aftercare activities.
      6. The written plan shall include specifications for the lines of authority of staff assigned.
      7. The written plan shall include development of an admissions procedure for the component.
      8. The written plan shall include the development of an Intake Committee which shall have the responsibility for establishing, staffing, and monitoring the appropriate treatment plan for the clients, to assure the proper utilization of available resources, and to promote quality of services.
      9. The written plan shall include the provisions for the immediate evaluation and/or assessment of client needs regarding alcoholism/substance abuse related problems.  Based on the diagnostic assessment of the client, there shall be a written, individual treatment plan developed by a staffing team comprised of at least two individuals.  The team shall consist of, at a minimum, an alcoholism/substance abuse counselor, and a primary care provider (physician, nurse, nurse practitioner, clinical pharmacist, or physician assistant), or a mental health worker, or a social worker.
         1. The treatment plan shall delineate those services required for the clients, including medical services.
         2. The treatment plan shall be evaluated periodically but not less frequently than every 14 days.
         3. All treatment activity shall be documented in client charts.
         4. Each treatment plan shall contain at least two treatment goals, one of which shall be sobriety.  The goals shall have specific target dates and measurable outcomes.
         5. Each treatment plan shall contain short and long term treatment goals.
         6. All treatment plans shall be developed with active participation by the client, and where appropriate, his/her family.
      10. The written plan shall delineate a methodology of providing medical evaluations by qualified medical personnel of alcoholism/substance abusers who are accepted into the outpatient care program.  All medical evaluations and services shall be documented in the client's files.
      11. The written plan shall contain provisions for the documentation of social-psychological evaluations of individuals referred for alcoholism/substance abuse problems.  The social-psychological evaluation shall include:
          
          
          1. Social information.
          2. Social-economic status.
          3. Family relationships.
          4. Cultural background.
          5. Drinking/substance use history.
          6. Present emotional state.
          7. Other factors pertinent to the client's alcoholism/substance abuse problem including those found in 3-18.6N Client Services.
      12. The written plan shall include provisions for the referral of clientele to other resources.  The written plan shall delineate responsibilities for client advocacy and follow-up on referrals to forestall the referral-rejection process.
      13. The written plan shall include procedures for patient discharge and subsequent aftercare activities.  The records of the client shall be documented regarding all activities.
      14. The written plan shall delineate the component's working relationship with other community resources.  Written affiliation agreements shall be maintained on an annual basis.
      15. The counseling staff of the aftercare program shall meet the minimum State or other acceptable certification or licensing standards.
      16. In meeting the requirements of an alcoholism/substance abuse counselor, the aftercare program director shall possess education/training and experience in alcoholism/substance abuse counseling.
      17. The written plan shall contain details of training provisions for staff assigned to the program.  All training received by the staff shall be documented and maintained in their respective personnel files.
      18. The written plan shall delineate responsibilities for record-keeping, case management, confidentiality of records and client information.
      19. Information and data will be maintained to provide for the annual evaluation of the component.
      20. Facilities for the aftercare program shall meet Federal, State, and local licensing laws and regulations concerning space, equipment, and supplies.  Fire and sanitation codes shall be met.
      21. The staff shall ensure that the client's family will be involved in the assessment and treatment processes by including family status and an assessment of the family's capacity and interest in participating in ongoing services for the client.
      22. The written plan shall delineate how the assigned staff shall maintain contact with the client in aftercare service.
      23. The written plan shall delineate-the preventive intervention activities (school/community-based) and linkages to be undertaken to enhance the aftercare services.
      24. The aftercare program shall have office space available for private counseling sessions and facilities for group activities.
5. SERVICE UNIT/TRIBAL SERVICES:  REHABILITATION AND AFTERCARE PROGRAM FOR ADOLESCENTS Definition: The rehabilitation and aftercare program for adolescents is a program for individuals and families who are in need of therapeutic and supportive counseling and referral services after discharge from an inpatient or residential facility.  Persons may have their primary treatment experience in another component or may begin treatment in the community rehabilitation/aftercare component.  It includes, halfway houses, foster homes, and other residential services following treatment.  These community rehabilitation and aftercare services may also be the appropriate component for the initial treatment.  The rehabilitation and aftercare program provides diagnostic services, therapeutic intervention, individual, peer, and group counseling, and referral to appropriate resources.  A rehabilitation plan tailored to needs of clients is negotiated and developed upon intake.  The individual treatment plan is implemented to facilitate the development of new life skills and to eliminate alcoholism/substance abuse and other destructive behavior. The major goal of these services is to maintain and build on progress attained during the primary treatment phases in assisting the adolescent to alter abusive life-style behaviors identified as self-defeating and "at-risk," including the abusive use of drugs, alcohol, and inhalants.  A second major goal of aftercare services is to address barriers that exist, facilitate healing processes and develop healthy levels of communication, support, understanding, security, and responsibility.  The tribal program in developing and carrying out aftercare activities, shall be guided by the following scope:
   1. Standards The following standards shall be applicable to all IHS-funded alcoholism/substance abuse programs providing adolescent rehabilitation and aftercare services to tribes under P.L. 99-570, the "Anti-Drug Abuse Act of 1986," as amended, or having rehabilitation/aftercare for youth.
      1. All clients discharged from inpatient facilities such as PRTs, detoxification, and halfway houses, are required to have a plan to participate in community rehabilitation and aftercare.
      2. An effort shall be made to provide aftercare services to all adolescent clients returning to the tribal community upon discharge.  These efforts will include parental contacts to obtain consents for release of information and to negotiate an aftercare agreement.  These efforts shall also include development of affiliation agreements with county and State agencies, and other programs who may assume or be a participant in aftercare services toward the objectives of coordinating aftercare planning, establishing a local case manager per case, and ensuring service coverage of all adolescent clients.
      3. Counselors are required to evaluate the effectiveness of community rehabilitation/aftercare services semi-annually for a period of no less than 2 years to determine that client needs are adequately met.
      4. All adolescents discharged from a primary treatment program (residential or outpatient) shall have an aftercare treatment plan developed within two weeks before discharge.
         1. The treatment plan shall be developed in cooperation with other program staff including the primary residential treatment program, local agencies, tribal programs, and tribal or IHS health programs.
         2. The treatment format must include coverage and assessment in the following areas to be considered acceptable:
            1. Family status and an assessment of the family's capacity and interest in participating in ongoing services for the adolescent client.  The staff shall ensure that the client's family will be involved in the assessment and treatment processes.
            2. Identification of peer group relationships and the strength and/or weaknesses of these associations, with options for addressing this area.
            3. School status and identification of any special learning problems obtained through psychological testing, school records or other data, and a plan to address educational issues identified through this process.  The factor of school support should be addressed and include the client, parents, and school staff as participants.
            4. An assessment of social level of functioning with identification of developmental delays, self-esteem issues, special social skills objectives, and personal talents that can be built upon to enhance social functioning, improve self-confidence and promote personal satisfaction levels.
            5. Identification of physical handicaps that would impact on treatment progress or require consideration of other options for treatment.
            6. Assessment of cultural/spiritual attitudes, values, and factors of self-identity which may be critical to personal growth and development.  The treatment plan should outline the options which are locally available to enhance growth in this area and whether options considered are consistent with parental beliefs and those of the adolescent client.
            7. Assessment of vocational/occupational needs and potentials and options locally available to promote development in this area.  Options selected shall reflect parental and adolescent participation in discussion and selection.
            8. Other community and/or environmental factors not covered previously which are identified as significant to the continuing treatment process.
      5. A register system of case finding and identification shall be established and maintained to portray all adolescent referral dispositions.
         1. Development of this system shall include cases referred by other tribal programs, tribal health departments, mental health and social service programs; and shall also include an activity directed at identifying adolescent cases referred into primary treatment from other agencies such as county social services, State and county mental health, private agencies, schools and parochial institutions.
      6. Alcoholism/substance abuse programs having a rehabilitation and aftercare component shall have a written plan describing in detail:
         1. Program goals and objectives.
         2. Methodology of providing outreach, referral, family, aftercare, and prevention services.
         3. Treatment procedures to be used in providing services.
         4. Scope of population to be served.
      7. The written plan shall include a definition of the roles and responsibilities of staff assigned to rehabilitation and aftercare activities.
      8. The written plan shall include specifications for the lines of authority of staff assigned.
      9. The written plan shall include development of an admission procedure for the component.
      10. The written plan shall include the development of an Intake Committee which shall have the responsibility for establishing, staffing, and monitoring the appropriate treatment plan for the clients, to assure the proper utilization of available resources, and to promote quality of services.
      11. The written plan shall include provisions for the immediate evaluation and/or assessment of client's needs regarding alcoholism/substance abuse related problems.  In cooperation with the client, a treatment plan shall be developed and documented in the client's record.  All treatment goals developed shall include specific target dates for completion.
      12. The written plan shall delineate a methodology of providing-medical evaluation by qualified medical personnel of alcohol/substance abusers who are accepted into the rehabilitation and aftercare program.  All medical evaluations and services shall be documented in the client's files.
      13. All treatment plans must be documented in a client record system.
          1. The active client case file must be current and must include progress notes on all contacts and other activities related to the treatment plan.
          2. Summary statements on progress shall be completed at the end of 30, 60, and 90 days following discharge from primary residential treatment; six months, and every six months thereafter, as long as the client remains in an active service status. These summary statements should be specific to show progress or lack of progress in the identified problem areas of school, peers, family, social/cultural/spiritual relationships; and shall be specific as to any relapse factors.  If the client has reentered primary treatment, a halfway house, or has left the community, this information must be documented.
      14. The tribal rehabilitation/aftercare component and staff assigned to carry out the defined aftercare activities must maintain an awareness of community resources that are lacking or deficient in ensuring a quality opportunity for continuing client recovery.  Staff shall endeavor to bring these areas to the attention of other program staff, tribal officials (including the local TCC), and participate in planning directed toward development of resources and enhancement of deficient resources.
      15. A special focus of aftercare activity on behalf of adolescents is the development of support groups that strengthen and facilitate the recovery process. Peer groups that impact negatively on adolescent clients are to be identified with efforts directed toward use of alternative groups or efforts directed (through referral) toward involving these group members in treatment, awareness, and education.
      16. Aftercare staff are responsible for intervention activities for cases where relapse indicators are present, and are responsible as the case manager in facilitating a reentry into primary treatment or other residential programs.  The standard is one of consulting and coordinating with other local staff to carry out crisis assessments and to develop feasible options of intervention within a timely and protective format.
      17. Aftercare staff consult and assign tasks to ensure appropriate involvement of all other community-based professional and paraprofessional staff in planning and carrying out continuing treatment for adolescent clients.  The appropriate roles are consultation and the assignment of tasks to ensure a necessary level of service and to prevent service breakdowns or service gaps from occurring.  As primary case managers for adolescent clients, aftercare staff must commit time and effort to organizing other community staff around aftercare objectives and specific treatment efforts.
      18. All rehabilitation and aftercare programs for adolescents are expected to establish "Alumni" support groups to assist the discharged clients in maintaining sobriety. It is expected that all rehabilitation and aftercare programs for adolescents shall develop and implement a tracking system to have contact with clientele for a minimum of two years to enhance follow-up services.
      19. All IHS-funded rehabilitation and aftercare programs for adolescents shall abide by the IHS Acquired Immune Deficiency Syndrome (AIDS) and Human Immuno-deficiency Virus (HIV) policies and procedures.
      20. In those cases where sexual abuse of clientele is suspected or identified, program staff shall report all incidents to the appropriate authorities.  Programs shall include in the treatment plan long term physical, social and mental health treatment for sexual abuse.
      21. The counseling staff of the aftercare program shall meet the minimum State or other acceptable certification or licensing standards.
      22. In meeting the requirements of an alcoholism/substance abuse counselor, the aftercare program director shall possess education/training and experience in alcoholism/substance abuse counseling.
      23. Information and data will be maintained to provide for the annual evaluation of the component.
6. GROUP HOME Definition:  General Program Descriptions A "Group Home" is a non-medical residential program designed to facilitate the rehabilitation of the alcoholism and substance abuser by placing the client in an organized therapeutic environment.  The treatment program of the "Group Home" should be a Pre-Post Treatment Component (PPTC) designed to provide assessments, motivational counseling, temporary holding facility until a YPRT center has an opening, and provides transitions of clients from YPRTs back to their home environments. The Group Home can serve as a facility for five to eight clients who require removal from their homes and are participating in intensive outpatient treatment.  If a client feels he/she is relapsing, entry into the "Group Home" with appropriate short-term treatment is acceptable. Group Homes cannot be considered detention or emergency shelter centers.  The Group Home preparatory activity will enable the clients to better acclimate to the treatment program of a YPRT. The Group Home is a vital link in the aftercare process and will serve as a transitional center for clientele who are returning from YPRTs to their home environments. In addition, a selecting process to eliminate those individuals who are not motivated for treatment would be used for admission to the group home program.  The Group Home placement would be a motivating factor which would prepare the client to complete the YPRT or the Intensive Outpatient Components. An effective Group Home will increase the client's choices of maintaining sobriety.
   1. Standards A Group Home component shall have specific written program objectives and policies including measurable results expected from program activity.  The written program objectives shall address substance abuse standards.
   2. The Group Home component shall have a written description of program protocol to include:
      1. Description of goals and objectives of the Group Home component.
      2. Description of the authority and responsibilities of program staff (including those relating back to the parent agency and/or governing body).
      3. Definitional description of the role of the house-parents in the overall treatment process.
      4. Written protocol which delineates the safety and well-being of the clientele.
      5. Written procedures describing in detail the following required treatment activities in the Group Home components:
         1. The Group Home shall provide a structured living environment for the substance abuse clientele.
         2. The Group Home shall serve as a preparatory activity to enable the client to acclimate to the treatment in a YPRT.
         3. The Group Home shall serve as a selecting or assessment process to assure that clients are referred to appropriate treatment reserves.
         4. The Group Home may serve as a residential center for those receiving treatment from the outpatient program.
         5. The Group Home may serve as a transitional program to facilitate clients returning from YPRT and involvement with the aftercare program.
         6. The Group Home will provide assessments, motivational counseling, individual and group counseling, support system awareness, living skills development, psychological enhancement, and substance abuse education.
         7. Most of the services provided by the Group Home shall be provided by resources external to the Group Home.
         8. The Group Home parents are expected to be qualified to present motivational counseling, provide substance abuse education and serve as supervisors of clientele activities.
         9. In addition, Group Home parents will provide the clientele with access to support groups such as AA, Alanon, Narcotics Anonymous (NA), etc.
   3. Based on the diagnostic assessments of the rehabilitation, aftercare, and Service Unit staff, there shall be an individualized treatment plan developed by the interdisciplinary team.
   4. The Group Home staff shall maintain the IHS Management Information System in place by the Area Offices.
   5. The staff of the Group Home shall have, at a minimum, a pair of house parents.
   6. Counseling staff can be employed if an outpatient staff or rehabilitation and aftercare staff are not available to provide the treatment program counseling and other services.
7. HALFWAY HOUSE Definition:  General Program Description A halfway house is a non-medical, residential treatment program designed to facilitate the rehabilitation of the alcoholism/substance abuser by placing the client in an organized therapeutic environment.  The therapeutic environment of the halfway house provides diagnostic services, individual and group counseling, group support sessions, and vocational and/or employment services.  The therapeutic environment includes structured social and recreational activities designed specifically for the residents of the program.  Clients who are detoxified and have adequate knowledge of facts and skills taught in the PRT are suitable for admission to a halfway house.  The halfway house program is designed to assist the client to develop and practice independent living skills needed to function in a sober life-style.
   1. Standards
      1. The halfway house component shall have specific written program objectives and policies, including measurable results expected from program activity.  The written program objectives shall address the Administrative/Management Section, 3-18.5 of this Chapter.
      2. The Halfway House component shall have a written description of the organization, to include:
         1. A documentation of the component's working relationship with other components and community resources.
         2. A description of the authority and responsibility of program staff.
         3. Personnel policies and procedures described in accordance with the Administrative/Management Section, 3-18.5 of this chapter.
         4. Written plans shall indicate the lines of authority including those relating back to the parent agency and/or governing body.
         5. The role of the component director and other staff delineated in accordance with the Administrative/Management Section, 3-18.5 of this Chapter.
      3. The halfway house treatment component shall have written procedures for all aspects of the treatment process for the alcoholism/substance abuser.  This written plan shall address all standards for residential treatment, as found in the Administrative/Management Section, 3-18.5 of this Chapter.
      4. There shall be written procedures describing in detail the following required weekly treatment for clients in the halfway house treatment component:
         1. A minimum of 30 hours of treatment activity shall be provided to clients in addition to employment (training) activities.
         2. A minimum of 10 hours of individual and group counseling therapy shall be provided to the clientele.
         3. The plan shall include a minimum of 4 hours of group support sessions, such as AA.
         4. A minimum of 8 hours of alcoholism/substance abuse education shall be provided to the clientele.
         5. A minimum of 40 hours of client activity shall be devoted to employment preparation and/or training and actively seeking employment.  After employment or entry into a paid training program, a maximum stay in the halfway house of 8 weeks is recommended.  Efforts should be made not to exceed 90 days in the halfway house component.
         6. Those persons employed shall be required to attend treatment sessions during evenings or on weekends.
         7. Clients shall be given at least 2 hours of supervised recreation/physical activities.
         8. At a minimum, 4 hours of spiritual activities will be available to clientele.
         9. Activities which fit into two or more categories can be applied to both categories (e.g., the individual and group counseling can be applied to the 30-hour treatment requirement; AA can be applied to group support and spirituality if spirituality was the main theme of the AA meeting).
      5. Based on the diagnostic assessment of the client, there shall be a written, individual treatment plan developed by a staffing team comprised of at least two individuals.  The team shall consist of, at a minimum, an alcoholism/substance abuse counselor and a primary care provider (physician, nurse, nurse practitioner, clinical pharmacist, or physician assistant), or a mental health worker, or a social services worker/family therapist.
         1. The treatment plan shall delineate those services required for the clients, including medical services.
         2. The treatment plan shall be evaluated periodically but not less frequently than every 14 days.
         3. All treatment activity shall be documented in client charts.
         4. Each treatment plan shall contain at least two (2) treatment goals, one of which shall be sobriety.  The goals shall have specific target dates and measurable outcomes.
         5. Each treatment plan shall contain short and long-term treatment goals.
         6. All treatment plans shall be developed with active participation by the client, and, where appropriate, his/her family.
      6. Fifty percent (50%) of all clients completing the treatment plan shall have achieved all the established short term goals and those long-term goals that can be completed while the client is in the halfway house program.
      7. Each client (except those refusing services, or leaving against advice) shall have an aftercare plan developed 7 days prior to discharge from the component
      8. Clients who successfully complete the treatment plan shall receive one (1) follow-up visit within 30 days of discharge from treatment.
      9. Confidentiality of all records shall be maintained at all times.  See Administrative/Management Section, 3-18.5 of this Chapter for additional criteria for confidentiality of records.
      10. The facility shall be maintained within acceptable sanitary and safety standards as established within the Administrative/Management Section, 3-18.5 of this Chapter.
      11. Food shall be prepared, stored, and served in accordance with Federal, State, tribal, or local standards.
      12. All IHS-funded, alcoholism/substance abuse programs having this component shall establish "alumni" support groups to assist discharged clients in maintaining sobriety.  It is expected that all Halfway House programs shall develop and implement a tracking system to have contact with clients for a minimum of two years to enhance follow-up services.
      13. All IHS-funded Halfway House program shall abide by the IHS AIDS and HIV policies and procedures.
      14. In those cases where sexual abuse of clients is suspected or identified, program staff shall report all incidents to the appropriate authorities.  Programs shall include in the treatment plan long-term physical, social and mental health treatment for the sexual abuse.
8. TRANSITIONAL LIVING CENTER Definition:  General Program Description Transitional Living Center (TLC) is a non-medical, residential, intensive treatment program designed to facilitate the rehabilitation of the alcoholism/substance abuser by placing the client in a highly-structured, therapeutic environment.  The therapeutic environment of the TLC is a short-term (generally 60 days) highly-structured program including diagnostic services; individual and group counseling; alcoholism/substance abuse education: psychological self-awareness:  decision-making skills development; and building self-esteem.  The program provides group support sessions, cultural, social, and recreational programs within the therapeutic environment.  The TLC does not include vocational training and work placement services.  Community involvement will enhance the TLC aftercare program.
   1. Standards The treatment programs shall have a written treatment plan which shall include, but not be limited to, the following:
      1. The delineation of the multi-disciplinary inter-agency effort to be undertaken including Federal, State, and third party agencies to provide a comprehensive range of prevention, outreach, treatment, and rehabilitative services.
      2. Alcoholism/substance abuse programs shall be operated in such a manner that they promote the individual's dignity and culture, and protect the legal rights of all its clients.
      3. Counseling staff shall be accessible for both individual and group counseling sessions.
      4. In order to ensure appropriate and acceptable alcoholism/substance abuse activities, staff must develop the programs in collaboration with the Indian community.
      5. A written procedure for admission to the component shall be developed and kept current.  The admission criteria shall include a recommendation that the client shall have completed a PRT program.
      6. The component shall have a written procedure for the treatment of alcoholism/substance abuse clientele.  This written plan shall be in accordance with the Administrative/Management Section, 3-18.5 of this Chapter.
      7. There shall be a written procedure describing in detail how the clients will be given the following types of treatment, all of which shall be given on a weekly basis.
         1. A total of at least 36 hours of treatment activity per week shall be included in the program.
         2. A minimum of 6 hours each week of individual and group counseling therapy shall be included in the treatment program.
         3. The plan shall include a minimum 6 hours per week of group support; e.g., AA (step work is encouraged).
         4. Clients will be given a minimum of 6 hours of alcohol education each week.
         5. Clients shall receive a minimum of 6 hours education per week in decision-making skills, coping skills, psychological enhancement, relapse prevention, anger control, and step work.
         6. Clients shall be given a minimum of 6 hours per week of recreational/physical activity.
         7. A minimum of 6 hours of spiritual activities each week including at least 2 hours of cultural activities will be available to clients.
         8. Activities which meet requirements in more than one area can be used to meet the standards for all areas to which they apply.
      8. Based on the diagnostic assessment of the client, there shall be a written, individualized treatment plan developed by a staffing team comprised of at least two individuals.  The team shall consist, at a minimum, of an alcoholism/substance abuse counselor and a primary care provider (physician, nurse, nurse practitioner, clinical pharmacist, or physician assistant), or a mental health worker, or a social services worker.  The staff shall ensure that the client's family will be involved in the assessment and treatment processes and include family status and an assessment of the family's capacity and interest in participating in ongoing services for the client.
         1. The treatment plan shall delineate those services required by the client, including medical services.
         2. The treatment plan shall be evaluated periodically but not less frequently than every 30 days.
         3. All treatment activity shall be documented in client charts.
      9. Confidentiality of all clients shall be respected and guarded at all times.
      10. Treatment goals for each individual client shall be stated and clearly understood by everyone involved.
      11. Residents shall have access to culturally relevant activities that will be beneficial to their treatment.
      12. Overall program philosophy shall accommodate specific provisions for individual rights with regard to culture, language, and religion.
      13. All residential treatment programs shall maintain continuous 24-hour in-house supervision of clients by program staff.  This is not to be construed as any form of resident/peer supervision in place of program staff.
      14. The facilities for housing the TLC shall meet appropriate tribal, State, and Federal regulations on fire, safety, environmental, food service, sanitation and building codes.
      15. The TLC component shall have specific written program objectives and policies, including measurable results expected from program activity.  The written program objectives shall address the Administrative/Management Section, 3-18.5 of this Chapter.
      16. Emergency medical care shall be available from community resources for all clientele of the program.
      17. A licensed physician shall be on call and available as needed within a reasonable period of time.
9. YOUTH PRIMARY RESIDENTIAL TREATMENT Definition:  General Program Description The YPRT is a non-medical, residential intensive treatment program designed to facilitate the rehabilitation of youth by placing the client in a highly structured therapeutic environment.  The primary focus of the YPRT is alcoholism/substance abuse.  The therapeutic environment of the YPRT is a short term (generally 30-60 days), highly structured program including diagnostic services, individual, family, and group counseling, alcoholism/substance abuse education, psychological self-awareness, decision-making skills development, and building self-esteem.  The YPRT provides group support sessions, cultural, social and recreational programs within the therapeutic environment. Alcoholism/substance abuse are recognized as both a treatable illness and a social problem amendable to prevention and treatment through a coordinated multi-disciplinary effort.  The alcoholism/substance abuse program efforts must be sensitive to the unique cultural background, promote the dignity of individuals under treatment and protect the legal rights of all its clients.  All program staff shall demonstrate competence by subscribing to professional standards in the treatment of alcoholism/substance abuse. The confidentiality of all clients shall be respected among and between the staff.  The program will be designed to meet the cultural and human needs of Indian people.  Awareness of these needs will be facilitated through active involvement by the professional staff in the Indian community. This community involvement will also enhance the house residents access to support services within the Indian community.
   1. Standards-Youth Residential Treatment (Intensive PRT).  The YPRT program shall have written protocol which includes, but shall not be limited to, the following:
      1. Alcoholism/substance abuse is recognized as both a treatable disease and a social problem amenable to prevention and treatment through a coordinated multi-disciplinary inter-agency effort.
      2. Treatment programs are committed to work with tribal, State, Federal and third party agencies to provide a comprehensive range of prevention, outreach, treatment, and rehabilitative services to alcoholism/substance abuse.
      3. Alcoholism/substance abuse programs shall operate to promote and protect the dignity, culture and the legal and human rights of all its clients.
      4. The YPRT program shall have written program policies, procedures and measurable objectives to define results expected from program activity.  The written program objectives shall address the standards as identified in Administrative/Management Section, 3-18.5 of this Chapter.
      5. The YPRT program component shall have written descriptions of the organization to include, but not be limited to, the following:
         1. A written outline of the YPRTs interrelationship to other components and community resources.
         2. Written authority and responsibilities and program staff.
         3. Personnel policies directed in accordance with Administrative/Management Section, 3-18.5 of this Chapter.
         4. Written plans to include lines of authority, including those relating to the parent agency.
         5. The role of the component director and other staff that are delineated in accordance with IHS Administrative Standards.
      6. A description of treatment methods employed by the program shall be maintained.
      7. Overall program philosophy shall dictate specific provisions for individual rights with regard to culture, language, religion, and tribal affiliation.
      8. A fire, safety, and disaster plan shall be maintained and updated on an annual basis.
      9. Dietary and nutritional policies shall be developed and implemented.  Confidentiality of all clients shall be respected and guarded at all times.
      10. All counselors shall be qualified and certified as alcoholism/substance abuse counselors.  Those not certified as alcoholism/substance abuse counselors shall be certified within one year from their initial employment.
      11. All new patients entering the program shall receive orientation to the program and expectations.  In addition, a patient shall be assigned to the new patient to assist in adjusting to the treatment environment.
      12. All staff members other than alcoholism/substance abuse counselors shall be provided with training in alcoholism/substance abuse and basic counseling techniques so that their interactions with clients will maximally contribute to the rehabilitation process.  All staff shall receive training in human growth and development including abnormal and deviant behavior and dual diagnosis issues.
   2. The YPRT shall be located where supportive services are readily available.  This includes access to IHS or tribally-operated direct health care systems and contract health services for routine and emergency medical care; psychological and/or psychiatric services including consultation and assessments from licensed psychologists or social workers; educational resources: vocational rehabilitation, assessment, and placement; other State and Federal resources; housing for visiting family: staff trainees: space for training purposes: and support for cultural involvement.
   3. Sufficient space shall be allocated to meet minimum residential treatment facility or equivalent requirements in the State where located.  The facility shall be so licensed.  Currently functioning facilities who do not meet the criterion will have two years from the date of publication of these Standards to obtain licensure.  Those opening after that date must meet the criterion.
   4. The basis for admission shall be:
      1. The client is assessed by a local multi-disciplinary team as deemed appropriate for inpatient treatment.
      2. The community staffing teams concur that inpatient treatment is necessary and appropriate.
      3. The final approval for admission will rest with each Area YPRT.
   5. Intake information shall include at a minimum:
      1. A completed physical examination within 1 week of admission.
      2. Social, psychological, legal, and educational background.
      3. Alcohol/substance use history, including chemical use and details of use.
      4. Family history including functioning of family relationship.
      5. Relationship with family members.  The staff shall ensure that the client's family will be involved in the assessment and treatment processes including a family status and an assessment of the family's capacity and interest in participating in ongoing services for the client.
      6. Written plan specifying the extent of family involvement.
   6. Within 5 days of admission the client shall be:
      1. Oriented to his/her rights, responsibilities, treatment processes, physical plant, location, and staff.
      2. Interviewed by the intake specialist, family therapist, recreation therapist, alcoholism/substance abuse counselor, educational specialist, and significant staff to determine initial treatment needs.
      3. The total intake/client evaluation process will take no more than five working days.
   7. An interdisciplinary committee of at least four (4) persons will be established to:
      1. Review admission data.
      2. Assign a committee member to assume primary responsibility for the client's quality treatment.
      3. Establish a treatment plan.
      4. Conduct a case conference review on a weekly basis including observations from other staff members (cooks, attendants, etc.) to provide opportunities for a modified treatment plan as required.
   The committee shall consist of, at a minimum, a primary care provider (physician, nurse, nurse practitioner, clinical pharmacist, or physician assistant), an alcoholism/substance abuse counselor, a mental health worker, and a social services worker/family therapist.
   8. Treatment Standards:
      1. Counseling staff shall provide individual, family, and group counseling sessions.  Professionally trained staff shall direct specialist groups such as anger control, stress management, relapse prevention and other psychological enhancement activities.
      2. In order to ensure appropriate and acceptable alcoholism/substance abuse activities staff must develop the programs in collaboration with Indian community resources.
      3. Confidentiality (42 CFR-Subpart 2) of all clients shall be respected and guarded at all times.
      4. Treatment goals for each individual client shall be stated and clearly understood.
      5. Residents shall have access to culturally relevant ceremonies that will be beneficial to their treatment (e.g., sweat lodge, traditional dances, etc.).  For those clients who request Native practitioners, this service shall be available on a referral basis and compatible with the program schedule.
      6. Overall program philosophy shall dictate specific provisions for individual rights with regard to culture, language, religion, and tribal- affiliation.
      7. All residential treatment programs shall maintain continuous 24-hour in-house supervision of clients by program staff.  This is not to be construed as any form of resident/peer supervision in place of program staff.
      8. The YPRT program shall have specific written program objectives and policies, including measurable results expected from program activity.  The written program objectives shall address the standards as identified in the Administrative/Management Section, 3-18.5 of this Chapter, and the provisions of P.L. 99-570, as amended.
      9. The YPRT program component shall have written descriptions of the organization to include, but not limited to, the following:
         1. A written outline of the YPRTs interrelationship to other components and community resources.
         2. Written authority and responsibilities of program staff.
         3. Personnel policies shall be described in accordance with the Administrative/Management Section, 3-18.5 of this Chapter.
         4. Written plans shall include lines of authority including those relating to the parent agency.
         5. The role of the component director and other staff shall be described in accordance with the Administrative/Management Section 3-18.5 of this Chapter.
      10. The YPRT component shall have written procedures for the treatment of alcoholism/substance abuse clientele.  This written plan shall be in accordance with the Administrative/Management Section 3-18.5 of this Chapter.
      11. The YPRT program is to be co-ed, treating boys and girls.
      12. There shall be written procedures describing in detail, treatment elements for the various groupings of youth.  Each treatment element shall be adjusted to meet the specific need of each age grouping which is defined as follows:  6 to 12: 13 to 17; and 18 to 24 years of age.  The weekly treatment schedule shall include, but will not be limited to, the following:
          1. A total of at least 58 hours of treatment or supervised activity shall be included in the program.
          2. A minimum of 10 hours of individual and group counseling therapy shall be included in the treatment program.
          3. The plan shall include a minimum of 6 hours of group support, such as AA, NA, Alateen, Children of Alcoholics (COA), Alateen, etc.
          4. A minimum of 12 hours of alcohol/substance abuse education shall be given to the clientele weekly.
          5. Clients shall receive a minimum of 8 hours education in decision-making skills, coping skills, and psychological enhancement.
          6. Clients shall be given a minimum of 6 hours per week of recreational/physical activity.
          7. A minimum of 6 hours of spiritual activities including as least 2 hours of cultural activity weekly will be available to clients.
          8. Activities which cover two or more areas can be applied to meeting the requirements for both areas (e.g., the individual and group counseling are part of the 58 treatment hours:  AA can meet group support and spirituality requirement if the theme stressed is spirituality).
          9. The activities will include:
             1. Counseling/treatment therapy (individual and group therapy).
             2. Life Skills Development:
                1. Positive attitude development.
                2. Decision-making skills.
                3. Self-awareness/self-control.
                4. Anger control.
                5. Survival/coping skills.
                6. Loss of a meaningful relationship.
                7. Physical and mental development.
                8. Health promotion/disease prevention, including sexually transmitted diseases.
                9. Stress Management.
             3. Alcoholism/Substance Abuse Education:
                1. Use of structured programs such as Here's Looking at You, Year 2000, Project Charlie, Beginning Alcohol and Addictions Basic Education Studies (BABES), etc.
             4. Academic Education Assistance: Youth in school are usually in need of assistance to meet the demands of education.  The following is recommended for the clients of school age:
                1. How to study effectively.
                2. How to effectively read.
                3. How to use the library and tutorial resources.
                4. Using the computer to study.
             5. Recreation and Social Skills Development.
             6. Community Re-entry Training (relapse prevention).
          10. Clients shall receive a minimum of 10 hours per week or the minimum local State mandated hours of supervised elementary/secondary education activities.  The education program shall be age group specific curriculum adhering to local school district requirements.  In the event a client has completed the secondary education, a form of vocational training will be arranged.
          11. Family therapy shall be made available to families of clientele of the YPRT.
      13. Based on the diagnostic assessment of the client, there shall be a written, individualized treatment program developed by an interdisciplinary committee consisting of at least four individuals.  The committee shall consist of, at a minimum, a primary care provider (physician, nurse, nurse practitioner, clinical pharmacist, or physician assistant), an alcoholism/substance abuse counselor, and a mental health worker or a social service worker/family therapist.
          1. The treatment plan shall delineate those services required for the client, including medical and mental health services.
          2. The treatment plan shall be evaluated periodically but not less frequently than every 2 weeks.  Each client shall be staffed by 2 staff members and all findings shall be documented in the progress notes.
          3. All treatment activity shall be documented in client charts.  After discharge, client charts shall be maintained in storage for a minimum of 5 years.
      14. Each treatment plan for patients shall contain at least two treatment goals.  The goals shall be time specific and measurable, with defined responsibilities for staff.
      15. Each treatment plan shall contain short and long-term treatment plans.
      16. The aftercare staff shall be involved in aftercare planning for all patients, including those refusing services.  The referring outpatient/rehabilitation and aftercare staff shall maintain contact with the treatment process of all patients referred to YPRTs.  The YPRTs should utilize the Outpatient Care staff in working with the families when planning aftercare activities.
      17. The client's attendance at scheduled therapeutic/educational sessions shall be considered a required activity; that is, therapy is not optional at the choice of the client.  Exceptions may be made by the treatment supervisor in consultation with the lead therapist.
      18. Residents of the YPRT will assist in food service and housekeeping activities as a part of their program of recovery.
   9. A centralized-controlled file system shall be maintained to ensure confidentiality and accountability for each client.  The individual treatment folder shall contain the following pertinent information: admission data, assessments, treatment plan, aftercare plan, and correspondence.  All file cabinets shall have locks and the rooms containing the file cabinets shall be locked when unattended.  All client/patient charts shall be retained in storage for 5 years after discharge.
   10. The client's attendance at scheduled therapeutic/educational sessions shall be considered a required activity; that is, therapy is not optional at the choice of the client.  Exceptions may be made only by the treatment supervisor in consultation with the lead therapist.
   11. Visitational leave from the Center to the home community may or may not be considered a therapeutic process;  that is, a leave request shall be evaluated by the head therapist in consultation with the family through a home visit made by a community worker.  Visitational leave will be granted on a case by case basis.  Alternately, family visitation may be arranged at the center in addition to, in preparation for, or in place of a home visit.  During the first two weeks of treatment, only emergency leave will be granted.
   12. Substance abuse, especially in the case of alcohol abuse, shall be considered strongly suggestive of family involvement with substances.  The lead therapist shall maintain contact with the community-based program during the course of treatment to assess the extent of family alcoholism/substance abuse and to determine the status of family wellness for discharge planning purposes.
   13. Discharge planning shall be considered as beginning on admission to the Center since most often the client/patient will return to the community.  Accordingly, family and community relationships are important factors in the development of aftercare plans with community-based programs.  At a minimum, the Rehabilitation and Aftercare staff shall be involved two weeks prior to discharge.  A discharge summary shall be delivered to the local program within one week after discharge.  The discharge process shall be monitored by the Area Intervention Team.
   14. Special Consideration:
       1. Security:  The adolescents in particular require security measures to reduce the chances that the patients will "run away."  The YPRT shall have procedures which give program staff direction in the following:
          1. Group control:  The staff shall have procedures available to direct their activities in safeguarding the clientele/patients from intrusion into their space.
          2. Clients are to be monitored constantly so that chances for "run away" are minimized.
          3. Once it has been determined that patients have "run away," program protocol should direct the staff to do the following:
             1. Safeguard patients who remain in the facility.
             2. Notify appropriate staff, law enforcement agencies, referral agencies, and parents (if appropriate).
          4. Detection devises:
             1. TV cameras should monitor the hallways and all exits.  In some instances the outside of the building should have TV surveillance.   TV cameras are not to be used to monitor client/patient room activities, but shall monitor the halls and exits.
             2. Motion detectors should be in place at all exits, activated during the "off hours."
          5. Procedures shall describe how clientele are to be transported to internal and external resources so that the client receives maximum safeguards from possible violence.  At least two individuals shall escort clients to all activities.  In no circumstances shall a male staff member transport a female patient alone or a female staff member with a male patient alone.
          6. Sexual Encounters: The program shall develop procedures to assure clientele/patients are safeguarded from sexual exploitation.  The procedures shall include detailed instructions on the following factors:
             1. If a client has been assaulted or an attempted assault has been committed, a detailed procedure shall be maintained on how to handle the patient; i.e., how to safeguard the client who has been assaulted (or attempted) and provide short-term treatment and/or support.
             2. The procedure shall detail action to be taken if the person(s) committing the assault is a client.
             3. If the person committing the assault is an employee, procedures shall be developed to assure that the employee is removed immediately from the YPRT.  The appropriate law enforcement agency will be notified, as well as appropriate tate and Federal officials.
          7. Personnel Issues:  All staff employed to serve the youth shall be interviewed and their background checked by the employing agency to ensure that the prospective employee does not have a current or previous charge(s) of sexually deviate behavior on record.  Procedures should describe the processing of the personnel check so that the rights of all potential employees are safeguarded, but that an appropriate check of facts is completed.
          8. Kitchens need to be secure.  Knives and other potential weapons need to be locked during off-duty hours.  Vinegar and other hazardous household items shall be secured.
10. WOMEN AND CHILDREN PROGRAM Definition:  General Program Description A Women and Children Program is a non-medical, residential, intensive treatment program designed to facilitate the rehabilitation of the alcoholic/substance abusing woman with children by placing her and her dependent children in an organized, therapeutic environment.  The therapeutic environment is a short-term (generally 45 to 90 days) highly-structured program which provides diagnostic services, individual and group counseling, alcoholism/substance abuse education, psychological self-awareness , decision-making skill development, and building self-esteem.  The program provides group support sessions, parenting skill classes, child and family counseling and activities.  Additional pertinent topics and activities shall be provided to the mother and her children to enhance the development of skills to overcome the alcoholism/substance abuse and its effects on the family and other aspects of life; and to become functional individuals, parents, family and community members.
    1. Standards
       1. The Women and Children program component shall conform to the Primary Residential Treatment Standards (3-18.10J).
       2. Women and children shall be admitted only as family units: e.g., a woman must be accompanied by at least one child, the child shall not be admitted without the mother or guardian.
       3. Children shall be 12 years of age or younger.  Older children may be admitted to the program under special situations after being properly assessed by the local referral source and with the concurrence of the treatment team.  Older children in need of residential treatment shall be referred to an adolescent treatment program.
       4. Child care and activities will be available for the children.
          1. Child care shall be provided according to the following ratio for age of children:
             1. 0-3 years (36 months) = 1 worker/5 children.
             2. 3-5 years = 1 worker/8 children.
             3. 6-12 years = 1 worker/10 children
          2. Nursery facilities will be available for those children under the age of 3 years.
       5. All school age youth shall be enrolled in an accredited educational program.
       6. Treatment planning shall provide for treatment of the family as a unit as well as its individual members including both the mother and the children who are assessed to be in need of treatment.  Assessment and counseling shall be available and provided to children in need.
       7. Family unit treatment plans shall be individualized and written upon completion of individual evaluations.  Treatment plans shall be implemented within five working days from intake.
       8. Based on the diagnostic assessment of the family unit, there shall be an individualized treatment plan developed by an interdisciplinary team of at least three individuals.  The team shall consist, at a minimum, of an alcoholism/substance abuse counselor, and a primary care provider (physician, nurse, nurse practitioner, clinical pharmacist, or physician assistant), a mental health worker, or a social service worker/family therapist. The staff shall ensure that the client's family will be involved in the assessment and treatment processes by including family status and an assessment of the family's capacity and interest in participating in ongoing services for the client.
       9. Treatment activities shall consist of the following at a minimum:
          1. Initial interview.
          2. Intake process.
          3. Orientation.
          4. Individual counseling.
          5. Group counseling.
          6. Family counseling.
          7. Parenting classes.
          8. Self-help groups (AA, Alatot, NA, Adult COA, etc.)
          9. Aftercare and relapse prevention.
          10. Traditional support groups.
          11. Accredited, appropriate school for children.
          12. Recreation and alternate activities.
          13. Specialized individual counseling and groups for pertinent special topics.
          14. Employment counseling.
       10. Medical services and treatment shall be available to the clients.  A medical screening of both the mother and children shall be part of the screening/intake process.
       11. Residents of the recovery program are functional and will assist in food service and housekeeping activities as a part of their recovery program.
       12. Staff shall be fully trained and accredited in their field.  In addition, all staff not directly involved in alcoholism/substance abuse activities shall be trained in alcoholism/substance abuse.  All counseling and professional staff shall be certified in alcoholism/substance abuse counseling.
       13. Staff members shall be knowledgeable in use of resources and referral processes (e.g., AFDC, Employment Security, Food Stamps, WIC, Headstart, Vocational Rehabilitation, etc.) and shall counsel and assist clients in applying for and obtaining needed resources.
       14. In remote areas, the Area Intervention Team and/or local Rehabilitation and Aftercare staff shall coordinate telephone contacts with family units.  In some instances, regional and/or community family groups shall be established to initiate a local family focused program.
       15. All IHS-funded alcoholism/substance abuse programs having this component shall establish "alumni" support groups to assist discharged clients in maintaining sobriety.  It is expected that all Women and Children programs shall develop and implement a tracking system to have contact with clientele for a minimum of two years to enhance follow-up services.
       16. All IHS-funded Women and Children programs shall abide by the IHS AIDS and HIV policies and procedures.
       17. In those cases where sexual abuse of clientele is suspected or identified, program staff shall report all incidents to the appropriate authorities.  Programs shall include in the treatment plan long term physical, social and mental health treatment for the sexual abuse.
11. DROP-IN CENTER
    1. A Drop-In Center is a non-medical, non-residential facility serving individuals who are considered at high risk of becoming alcoholism/substance abusers and who incur physical impairments or emotional dysfunction due to alcoholism/substance abuse.  The drop-in center provides a program of activities designed as an alternative to alcoholism/substance abuse.  The drop-in center program provides motivational counseling, referrals to community resources, nourishment, temporary shelter, first aid, social and recreational activities.  The program provides referral for detoxification and treatment of alcoholism/substance abuse.
       1. Type A:  Small Rural/Reservation/Urban Drop-In Centers for smaller communities will be integrated with the "Outpatient" components.  The focus of the staff will vary depending upon the emphasis of the Drop-In Center's program.  If the Drop-In Center is functioning as a gathering place for youth, the emphasis of the program will be on education, psychological enhancement and supervised community recreation activities.  If the Drop-In Center's emphasis is on serving as a referral center and providing temporary shelter, the program should provide at least one daily meal and have a staff that is aware of community resources.  The use of part-time and volunteer help is important in the operation of a small Drop-In Center component.
       2. Type B:  Large Urban/Reservation The Type B Drop-In Center component is designed for large populations and should be staffed independently of the Outpatient component.  Urban and reservation communities may, however, have different emphasis for their programs.  One community may emphasize prevention activities, another may provide some direct services and referrals, and others may add meals, sleeping, and personal hygiene facilities in an effort to refer those in need to appropriate treatment programs.  All Drop-In Centers shall provide motivational counseling.
       3. Type C:  Special Emphasis Education and Recreational Activities The Type C Drop-In Center is designed to provide a special emphasis in education and recreational activities as a diversion from alcoholism/substance abuse activities.
    2. The following standards shall be applicable to all IHS-funded alcoholism/substance abuse programs having a drop-in center component, including Type A, B, and C above:
       1. Alcoholism/substance abuse programs having a Drop-In Center component shall have a written plan describing:
          1. Program goals/objectives.
          2. Methodology of providing drop-in services.
          3. Scope of activity.
       2. The written plan shall include a definition of the roles and responsibilities of individuals assigned Drop-In Center activities.
       3. The written plan shall include specifications for the lines of authority for Drop-In Center activity.
       4. The written plan shall include the development of an advisory committee which shall have the responsibility for advising and establishing the appropriate Drop-In Center Program, proper utilization of available resources, and to assure quality of services provided.
       5. The written plan shall delineate the interrelationship of the component and its personnel with other resources in the community.  Written affiliation agreements shall be maintained on an annual basis.
       6. The written plan shall provide for documentation of correspondence and activities with referral agencies.
       7. The written plan shall delineate responsibilities for record keeping, center supervision, and confidentiality of records.
       8. The written plan shall provide for the evaluation of the Drop-In Center component each program year.
       9. The written plan shall include a provision for the continued in-service training of Drop-In Center personnel.
       10. The Drop-In Center program shall be housed in a facility which conforms to physical, sanitary, and safety features as required by appropriate governmental jurisdiction (Federal, State, tribal and local).
       11. During hours of activity the Drop-In Center shall be staffed by qualified personnel, minimum of one staff person for each 25 clients.  Volunteers may be used to meet this requirement if a paid qualified staff member is on site.  It is recommended that Drop-In Centers be open 40 hours or more per week, with an emphasis on services in the late afternoon, evenings, and weekends.
       12. Whenever a Drop-In Center serves meals to clientele, the food shall be prepared in a sanitary manner.  The Area Nutritionist shall review and approve the dietary plan.  The kitchen shall meet all sanitary and safety standards of the tribal, State or Federal Government (see Section I).
       13. The Drop-In Center shall have staff available to provide a minimum of 1 hour of motivational counseling daily.
       14. The Drop-In Center shall provide a minimum of 1 hour of alcoholism/substance abuse education within the center daily.
       15. The Drop-In Center program shall employ staff who are qualified to provide alcoholism/substance abuse information and referrals, motivational counseling, social, and recreational activities.  All staff shall be required to be annually certified in first aid and CPR.

3-18.11  HEALTH PROMOTION/DISEASE PREVENTION

1. PURPOSE This section sets forth the goals, basic concepts and definitions, standards, and reporting format to achieve the major health promotion/disease prevention initiatives of the IHS and the Department of Health and Human Services.
2. GOALS
   1. To lower the rate of new cases of alcoholism/substance abuse within the targeted communities by promotive and/or proactive intervention approaches.
   2. To achieve by 2000 the Department's health promotion/disease prevention objectives.
3. BASIC CONCEPTS AND DEFINITIONS PREVENTION is a broad term that generally encompasses primary, secondary, and tertiary prevention. PRIMARY PREVENTION encompasses activities directed toward specifically identified vulnerable high risk groups (children of alcoholic/substance abuse parents, students enrolled in schools with a high rate of substance abuse, etc.) for whom measures can be taken to avoid the onset of a predetermined disorder.  They are primarily educational in nature rather than clinical. Primary prevention efforts are directed toward promotive or proactive interventions focusing on the development of positive, adaptive, and adjustive capabilities and skills.  Programs for the health promotion and/or disease prevention fall within the domain of primary prevention and are largely educational, and may include activities that reinforce concepts taught. In essence, promotive/proactive efforts carry the promise of helping IHS staff and communities focus on the key objective of decreasing the incidence of new cases in alcoholism and substance abuse in high risk population groups. SECONDARY PREVENTION OR INTERVENTION includes activities that seek to detect alcoholism/substance abuse-related problems in the early stages and to intervene in such a way as to reduce the severity of the disorder.  Intervention efforts are action-oriented and provide Indian communities the opportunities for the development of appropriate and effective programs targeted to specific groups (e.g., youth, women, etc.) to decrease the incidence of alcoholism/substance abuse. TERTIARY PREVENTION occurs once a disorder manifests clinically diagnosable signs and symptoms and is, by definition, oriented toward treatment and rehabilitation.  The goal of such activities is to minimize, insofar as is possible, long-term after-effects and the recurrence of the disorder. Primary and secondary prevention in alcoholism/substance abuse are the most specific of the terms and, from the programmatic standpoint, the most realistic and achievable. In developing the standards on primary prevention programs, several qualities are necessary, that is, they must: 1) be mass or group-oriented, not targeted to individuals; 2) be directed to "well" people, not to the already affected, although targets can appropriately include those, who by virtue of life circumstances or recent experiences, are known to be at risk for adverse outcomes; and 3) strengthen physical and psychological health.
4. SCHOOL-BASED PREVENTION A School-Based Prevention (SBP) program has several key elements: 1) identifies group(s) within the targeted school(s) who are at risk of developing problems related to alcoholism/substance abuse based on current epidemiological data; 2) develops collaboratively with BIA, public schools, Indian tribes, students and other appropriate sources, preventive intervention alcoholism/substance abuse educational curricula that are culturally relevant, acceptable and appropriate to the targeted groups (Headstart-grade 12); 3) provides accurate information and access to available educational media resources (films, community cable TV, audio visual, radio, etc.) to increase awareness among the affected student population and families regarding alcoholism/substance abuse; and 4) all these activities (items 1-3 above) shall be done in conjunction with the BIA and/or public schools.
   1. Standards (BIA School-Based) The following standards shall be applicable to all IHS-funded alcoholism/substance abuse programs having a prevention program (BIA school-based).  State-funded public and other non-IHS funded schools serving Indian children will be encouraged to follow these or similar standards.  At the minimum, they should seek tribal input for all programs serving Indian students.
      1. The SBP programs shall have specific written program descriptions.  For the purpose of ensuring uniformity and the collection of pertinent data, the "Primary Prevention Reporting Form" will be utilized.  In preparing the report, it is mandated that each primary prevention activity address the following critical areas:
         1. Epidemiological data utilized to identify high risk group(s).
         2. Target group(s) served.
         3. Program objectives.
         4. Methods to be employed; e.g., collaboration with BIA, Project Charlie, BABES, Fetal Alcohol Syndrome (FAS), frequency of program, etc.
         5. Pre/post evaluation.  Specify outcome measures/indicators; e.g., percent decrease in school drop-outs, truancy; percent who felt strongly that program enhanced their coping skills, how to say "NO", etc.
      2. All SBP programs shall provide a program of instruction regarding alcoholism/substance abuse to students in Headstart, kindergarten, and grades 1 through 12.
      3. All SBP programs shall include family participation in the instructions related to alcoholism/substance abuse to students in Headstart, kindergarten, and grades 1 through 12.
      4. In collaboration with BIA, the SBP program shall assist in training programs for CHRs, health aids, tribal judges, police and others as needed, funded under the Act of November 2, 1921, (25 U.S.C.13) and P.L. 99-570, as amended.  It shall include not less than 80 hours of instruction in (1) crisis intervention and family relations; (2) youth alcoholism/substance abuse; and (3) the causes and effects of FAS.
      5. All SBP Programs shall present or coordinate the presentation of one (1) training session of FAS for the student body each school term.
      6. The SBP Programs shall present one (1) educational session to be targeted to child/parent relationships and the effects of alcoholism/substance abuse on family relationships.
      7. The SBP Programs shall provide at a minimum 5 hours of alcoholism/substance abuse education for the students during the school term.
      8. The SBP Programs shall present alcoholism/substance abuse education programs to BIA dorm staff, teachers, professional staff, school administrators, security, student governing body, and IHS clinic staff serving students.
      9. The SBP Programs shall include in their program activities the following:
         1. History of alcoholism among American Indians/Alaska Natives.
         2. Physical and emotional effects of alcoholism/substance abuse.
         3. Self-awareness and culture identity issues.
         4. Values and attitude clarification.
         5. Peer pressure and decision-making,
         6. Effective communication.
         7. Family bonding and enrichment.
         The above activities may be provided directly by prevention program staff or by other resources.
      10. In order to ensure accountability of the SBP programs, all IHS-funded SBP programs should integrate the management of the programs into the BIA school administration system.
      11. Staffing and facilities shall be in compliance with IHS Standards as found in the Administrative/Management Section, 3-18.5 of this Chapter.
      12. All personnel issues, including training, shall be in accordance with IHS Standards as found in the Administrative/Management Section, 3-18.5 of this Chapter.
      13. All social and recreational activities shall contain alcoholism/substance abuse prevention intervention activities (education, counseling, or psychological enhancement activities).
5. COMMUNITY-BASED PREVENTION Community-Based Prevention (CBP) programs have several key elements: 1) identify group(s) within the community who are at risk of developing problems related to alcoholism/substance abuse based on current epidemiological data; 2) develop, collaboratively with community leaders, tribal officials, tribal/community police and judges, key community resources, IHS and BIA representatives, promotive or proactive interventions to prevent the onset of alcoholism/substance abuse; and 3) provide accurate information and access to available educational media resources (films, community cable TV, audio visual, radio, etc.) to increase awareness among the affected community group(s) and families regarding alcoholism/substance abuse.
   1. Standards: The following standards shall be applicable to all IHS-funded alcoholism/substance abuse CBP Programs:
      1. The CBP Programs shall have specific written program descriptions.  For the purpose of ensuring uniformity and the collection of pertinent data, the "Primary Prevention Reporting Form" will be utilized.  In preparing the report, it is mandated that each primary prevention activity address the following critical areas:
         1. Epidemiological data utilized to identify high risk group(s).
         2. Target group(s) served.
         3. Program objectives.
         4. Methods to be employed.
         5. Pre/post evaluation measures.
      2. All CBP programs shall be reviewed and approved annually by a committee from the community to be served.  Included on the committee for the primary prevention program shall be representative(s) from the targeted high risk group(s), community leaders, tribal officials, tribal/community police and judges, IHS and BIA representatives
      3. All CBP programs shall present or coordinate the presentation of one (1) training session on FAS every six months in the community being served.
      4. All CBP programs shall, at a minimum, present one (1) educational session on child/parent relationships annually.
      5. All CBP programs shall provide, at a minimum, 8 hours of preventive intervention activities per month.  These activities should be based on current knowledge and techniques regarding alcoholism/substance abuse.
      6. All social and/or recreational activities supported by the CBP programs shall include alcoholism/substance abuse preventive intervention activities: e.g., building self-esteem, mutual-help, self-help, group counseling, etc.
      7. Staffing of preventive intervention programs shall be in accordance with IHS Standards as found in the Administrative/Management Section, 3-18.5 of this Chapter.
      8. Facilities utilized by the CBP programs shall be in compliance with IHS Standards as found in the Administrative/Management Section, 3-18.5 of this Chapter.
      9. All personnel issues, including training activities and/or requirements shall be in accordance with IHS Standards as found in the Administrative/Management Section, 3-18.5 of this Chapter.
      10. All CBP programs shall provide or coordinate with appropriate agencies to provide the following educational program activities for the Indian community being served:
          1. Decision-making skills development.
          2. Alcoholism/substance abuse education.
          3. Effective parenting.
          4. Awareness of community resources.
          5. Single parenting activities.
          6. Building self-esteem and coping skills.
          7. Family bonding and enrichment.
          8. Developing mutual-help and self-help groups.
          9. Creating and implementing health promotion/disease prevention activities.