This regulation provides a comprehensive definitions section for Alabama's substance use levels of care chapter, establishing terminology used across all substance use disorder treatment settings governed by the Alabama Department of Mental Health. Defined terms cover clinical concepts, treatment modalities, staff qualifications, documentation requirements, and service types applicable to the full continuum of SUD treatment. Facility operators across all substance use levels of care must apply these definitions when interpreting and complying with the operational standards in this chapter.
View official source580-9-44-.01 Definitions (1) Abstinence - Non-use of any addictive psychoactive substance. (2) Abuse - The willful infliction of physical pain, injury, or mental anguish or the willful deprivation of services necessary to maintain mental and physical health. (3) Activity - The execution of a task or action (a group or individual session) by an individual. (4) Activity Therapy – Structured, object-oriented music, dance, art, social, or play therapeutic activities conducted, not for recreational purposes, by a qualified substance abuse professional to assist a client in developing or enhancing psychosocial competencies, to alleviate emotional disturbances, to change maladaptive patterns of behavior, and/or to assist in restoring the individual to a level of functioning capable of supporting and sustaining recovery. (5) Addiction - A primary, chronic neurobiological disease, with genetic, psychosocial and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. (6) Administer - The direct application of a prescription drug by ingestion or any other means to the body of a client by a licensed practitioner, or by the client at the direction of, or in the presence of, a practitioner. (7) Admission - That point in an individual’s relationship with an organized treatment service when the placement assessment process has been completed and the individual placed in a level of care of the treatment program. (8) Adolescent - An individual aged 13-18. The term also frequently applies to young adults aged 18-21, whose needs dictate admissions to adolescent programs. (9) Advocacy - To advocate for, protect and advance the legal, human and service rights of people. (10) Aftercare - The component of a treatment program which assures the provision of continued contact with the client following the termination of services from a primary care modality, designed to support and to increase the gains made to date in the treatment process. Aftercare plan development should start prior to discharge, but is not implemented until discharge. (11) Aftercare Plan - A written plan that specifies goals to be achieved by a client and/or family involved in the aftercare of the client. (12) Alcoholism - A general but diagnostic term, usually used to describe alcohol dependence, but sometimes used more broadly to describe a variety of problems related to the use of beverage alcohol. (13) Ambulatory Detoxification - Detoxification that is medically monitored but that does not require admission to an inpatient medically or clinically monitored or managed setting. (14) Ancillary Services - Non-substance use related services such as legal, vocational, employment, public assistance, childcare and transportation that may either be essential or incidental to a client’s recovery. (15) ASAM Placement Criteria - ASAM Placement criteria means the most current edition/set of placement criteria for substance abuse patient/clients published by the American Society of Addiction Medicine. (16) Assertive Community Treatment (ACT) - Active outreach to persons, usually with serious and persistent mental illness, who need a support system that facilitates living and functioning adequately in the community. ACT involves comprehensive services designed to engage and retain patients in treatment and assist them in managing daily living, obtaining work, building and strengthening family and friendship networks, managing symptoms and crises and preventing relapse. (17) Basic Living Skills – Scheduled interventions conducted under the supervision of a qualified substance abuse professional to train and assist a client in reestablishing the ability to perform and manage fundamental tasks required for daily living. (18) Behavioral Health Field - A broad array of mental health, substance use, habilitation and rehabilitation services that are utilized to individuals with substance use disorders. The field includes the areas of psychology, social work, counseling and psychiatric nursing. (19) Behavioral Health Screening – A structured interview process conducted by a qualified substance abuse professional, utilizing the DMH/SASD uniform assessment tool, for the purpose of identifying an individual’s presenting needs and establishing a corresponding recommendation for placement in an appropriate level of care. (20) Case Management - The activities guided by a client’s service plan which brings agencies, resources and people together within a planned framework of action toward the achievement of established treatment goals. (21) Central Registry - A system which is used by two (2) or more providers to share information about clients who are applying for or presently involved in detoxification or maintenance treatment using methadone or other opiate replacements, for the purpose of preventing the concurrent enrollment of clients with more than one OMT provider. (22) Certification - The process by which DMH or SASD determines that a provider is qualified to provide treatment or prevention services under applicable State and Federal standards. (23) Chemical Dependency - A generic term relating to psychological or physical dependency, or both, on one or more psychoactive substances. (24) Chemical Restraint - Is the use of any drug to manage a client’s behavior in a way that reduces the safety risk to the client or others or to temporarily restrict the client’s freedom of movement and is not a standard treatment dosage for the client’s medical or psychiatric condition. (25) Child/Adolescent - The period of life of an individual up to the age at which one is legally recognized as an adult according to state or provincial law. (CARF) (26) Child Sitting Services – Care provided for children of clients in treatment during the same time period as the specific occurrence of the parent’s treatment. (27) Client - An individual who receives treatment for alcohol or other drug problems. The terms “client” and “patient” sometimes are used interchangeably, although staff in medical settings more commonly use “patient” while staff of non-medical residential or outpatient settings refer to “clients”. (28) Clinically Managed Services - Services directed by non-physician addiction specialists rather than medical personnel. They are appropriate for individuals whose primary problems involve emotional, behavioral or cognitive concerns, readiness to change, relapse, or recovery environment and whose problems with intoxication/withdrawal or biomedical are minimal or can be managed through separate arrangements for medical services. (29) Clinical Supervision - Intermittent face-to-face contact, provided on or off the site of a service, between a clinical supervisor and treatment staff to ensure that each client has an individualized counseling plan and is receiving quality care. (30) Consultation - A discussion of the aspects of a particular client’s circumstance with other professionals to ensure comprehensive and quality care for the client that isconsistent with the objectives of the client’s treatment plan, or is used to make adjustments to the client’s treatment plan. (31) Continuous Assessment - The term includes but is not limited to review of the individual service plan, client progress reports, etc. The information gained from continuous assessment is used to match an individuals’ need with the appropriate setting, care level and intensity. It is also used to determine an individuals’ need for continued stay, discharge, or transfer to another level of care. (32) Continuing Care - A course of treatment identified in a service plan designed to support the process of recovery that is provided at a frequency sufficient to maintain recovery. The treatment provided is flexible and tailored to the shifting needs of the client and his and her level of readiness to change. (33) Co-Occurring Disorders - Concurrent substance use and mental health disorder found in a single individual. Both conditions are such that they may also exist alone but there is no implication as to one disorder being primary. Other terms used to describe COD include: dual diagnosis, dual disorders, mentally ill chemically addicted (MICA), chemically addicted mentally ill (CAMI), mentally ill substance abusers (MISA), mentally ill chemically dependent (MICD), coexisting disorders, co-morbid disorders, and individuals with co-occurring psychiatric and substance symptomatology (ICOPSS). (34) Continued Stay, Transfer, and Discharge Criteria - Criteria used after the initial assessment to monitor progress during a treatment episode and decide on Level of Care. (35) Counselor - A member of the clinical staff working in a program who is licensed or certified and whose primary duties consist of conducting and documenting services such as counseling, psycho-educational groups, psychosocial assessment, treatment planning and case management. (36) Crisis Intervention - Services that respond to a client’s needs during acute episodes that may involve physical distress, imminent relapse and danger to self and others. (37) Crisis Planning - A process of developing necessary resources to appropriately address and respond to acute needs of a client to include assessing for suicide and homicide ideations or plans. (38) Criteria - Written rules, measures, or factors that help assessors determine where to place a client in care. (39) Dependence - Used in three different ways: (a) physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist; (b) psychological dependence is a subjective sense of need for a specific psychoactive substance, either for its positive effects or to avoid negative effects associated with its abstinence; and (c) one category of psychoactive substance use disorder. (40) Detoxification - The deliberate withdrawal of a person from a specific physiological addicting substance in a safe and effective manner. (41) Detoxification Rating Scales - As needed documentation. For example: clinical institution, withdrawal, assessment (CIWA); clinical opiates withdrawal scale (COWS), etc. (42) Developmental Delay, Prevention Activities, Dependent Child – Structured activities provided by an appropriately credentialed professional for children of clients in treatment, during the same time period as the specific occurrence of the parent’s treatment. These services function to foster healthy psychological, emotional, social and intellectual development of the child. (43) Diagnostic Criteria - Prevailing standards which are used to determine a client’s mental and physical condition relative to their need for substance abuse services, such as those which are described in the current Diagnostic and Statistical Manual of Mental Disorders. (44) Didactic Group - Groups that are designed to teach or lecture. (45) Discharge Planning - The process, beginning at admission of determining a client’s continued need for treatment services and developing a plan to address ongoing client recovery needs once the client has been discharged from a level of care. (46) Discharge Summary - A written narrative of the client’s treatment record describing the client’s accomplishments and problems during treatment, reasons for discharge and recommendations for further services. (47) Discharge/Transfer Criteria - During client assessment, problems and priorities are identified as justifying treatment at a particular level of care. Discharge/Transfer Criteria describe the degree of resolution of those problems and priorities and are used to determine when a client can be treated at a different level of care or discharged from treatment. The appearance of new problems may require services that can be provided effectively only at a more or less intensive level of care. This level of function and clinical severity of a client’s status in each of the six dimensions is considered in determining the need for discharge or transfer. (48) Documentation - Provisions of written, dated and authenticated evidence (signed by person’s name and title) to substantiate compliance with standards (e.g., minutes of meetings, memoranda, schedules, notices, announcement). (49) Drug Intoxication - Dysfunctional changes in physiological functioning, psychological functioning, mood state, cognitive process, or all of these, as a consequence of consumption of a psychoactive substance; usually disruptive, and often stemming from central nervous system impairment. (50) DSM - The most current edition of the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association. References to DSM may be construed to mean the most current edition of the International Classification of Diseases (ICD-10) when appropriate. (51) Dual Diagnosis - Refers to the client who has signs and symptoms of concurrent substance-related and mental disorders. Other terms used to describe such co-occurring disorders include, co-occurring disorders, dual disorders, mentally ill chemically addicted (MICA), chemically addicted mentally ill (CAMI), mentally ill substance abusers (MISA), mentally ill chemically dependent (MICD), coexisting disorders, comorbid disorders, and individuals with co-occurring psychiatric and substance symptomatology (ICOPSS). (52) Dual Diagnosis Capable (DDC) - Treatment programs that address co-occurring mental and substance-related disorders in their policies and procedures, assessment, treatment planning, program content and discharge planning are described as “Dual Diagnosis Capable” DDC. Such programs have arrangements in place for coordination and collaboration with mental health services. They can provide psychopharmacologic monitoring and psychological assessment and consultation, either on site or through coordinated consultation with off-site providers. Program staff are able to address the interaction between mental and substance related disorders and their effect on the client’s readiness to change- as well as relapse and recovery environment issues- through individual and group program content. Nevertheless, the primary focus of DDC programs is the treatment of substance-related disorders. (53) Dual Diagnosis Enhanced (DDE) - Describes treatment programs that incorporate policies, procedures, assessments, treatment and discharge planning processes that accommodate patients who have co-occurring mental and substance related disorders. Mental health symptom management groups are incorporated into addiction treatment. Motivational enhancement therapies specifically designed for those with co-occurring mental and substance-related disorders are more likely to be available (particularly in out-patient settings) and, there is close collaboration or integration with a mental health program that provides crisis backup services and access to mental health case management and continuing care. In contrast to Dual Diagnosis Capable services, Dual Diagnosis Enhanced services place their primary focus on the integration of services for mental and substance-related disorders in their staffing, services and program content. (54) Early Intervention - Services that explore and address any problems or risk factors that appear to be related to the use of alcohol and other drugs and that help the client to recognize the harmful consequences of inappropriate use. Such individuals may not appear to meet the diagnostic criteria for a substance use disorder, but require early intervention for education and further assessment. (55) Emergency Service - A network of services that provides all persons having acute problems related to alcohol and other drug use and abuse readily available diagnosis and care, as well as appropriate referral for continuing care after emergency treatment. (56) Exploitation - An unjust or improper use of another person or their resources for one’s own profit or advantage or for the profit or advantage of another person. (57) Evidence-Based Practice - An approach to mental health care practice in which the clinician is aware of the evidence that bears on his/her clinical practice, and the strength of that evidence. (58) Failure (as in a treatment failure) - Lack of progress and/or regression at any given level of care. These situations warrant a reassessment of the treatment plan, with modifications of the treatment approach. Such situations may require changes in the treatment plan at the same level of care or transfer to a different (more or less intensive) level of care to achieve a better therapeutic response. Sometimes used to describe relapse after a single treatment episode- an inappropriate construct in describing a chronic disease or disorder. (59) Family - Individuals as defined by law, or significant others that claim relationship to the client. A person’s immediate relatives and/or significant others. A term used to describe a person’s parents, spouse, siblings, extended family, guardians, legally authorized representatives, or significant others as identified by the person served. (CARF) (60) Family Counseling – A treatment plan focused on intervention involving a client, his/her family unit and/or significant others, and a mental health/substance abuse professional. Treatment is designed to maximize strengths and to reduce behavior problems and/or functional deficits stemming from the existence of a mental disorder that interferes with a client’s personal, familial, vocational, and/or community adjustment. (61) Flow Sheets - A term usually associated with the field of nursing; Documentation that is required for a patient that assesses their entire day. Components of a flow sheet include: (a) The Master Treatment Problem (MTP Problem). (b) Risk Assessment. (c) Medication Compliance and Response. (d) Subjective & Objective Data. (e) Physical Assessment- Review of Systems. (f) Pain Assessment. (g) Intervention/Education. (h) Response to Intervention. (i) Additional Information. (62) Follow-up - A process used by a treatment provider that will periodically assess the progress of a client who has completed treatment services. (63) Governing Authority - The individuals or group that provides direction, guidance, and oversight, approves decisions specific to the organization and its services. The chief executive or agency director reports to this authority. (64) Grievance - A written expression of dissatisfaction which may or may not be the result of an unresolved complaint. (65) Group Counseling - The application of counseling techniques which involve interaction among members of a group consisting of at least three (3) clients but not more than fifteen (15) with a minimum of one (1) counselor for every fifteen (15) clients. (66) Health Education – A service prescribed to modify assessed alcohol and/or drug use, cognitive, behavioral, emotional, social, and/or psycho-physiological factors relevant to and affecting the client’s physical health problems. This service is provided for individuals who have established illnesses or symptoms. (67) HIV Early Intervention Services – Appropriate pretest counseling for HIV and AIDS. Testing individuals with respect to such disease, including tests to confirm the presence of the disease, tests to diagnose the extent of the deficiency in the immune system, and tests to provide information on appropriate therapeutic measures for preventing and treating the deterioration of the immune system and for preventing and treating conditions arising from the disease. Also, appropriate post-test counseling and therapeutic measures. (68) Human Service Needs Assessment (HSNA) - An assessment of specific human service needs of a client. The systematic determination of the specific needs of each client. Its’ purpose is to comprehensively define the scope of services and the client’s functional levels to develop an individualized case management case plan. It clearly describes the client’s strengths and problem areas. The following key elements make up the HSNA: family relationship, housing, vocational/educational, recreational, transportation, social support, physical, financial and spiritual. (69) Individualized Counseling - Counseling designed to meet a particular client’s needs, guided by a treatment plan that is directly related to a specific, unique client assessment. (70) Individualized Service Plan - The ongoing process by which a clinician and the client identify and rank problems, establish agreed upon goals and decide on the treatment process and resources to be utilized. (71) Intake - The process of collecting and assessing information to facilitate admission of an individual into a substance abuse treatment program. (72) Intake Service - A structured interview process conducted by a trained clinician for the purpose of identifying and evaluating a client’s continued need for treatment or care after diagnostic interview examination, admission and implementation of the initial treatment plan, in a specific level of care. (73) Intensive Case Management - A comprehensive community service that includes evaluation, outreach and support services, usually provided on an outpatient basis. The case manager (management team) advocates for the client with community agencies and arranges services and supports. The case manager may also teach community living and problem-solving skills, model productive behaviors and the client becomes self-sufficient. (74) Intensive Outpatient Treatment - An organized service delivered by addiction professionals or addiction-credentialed clinicians, which provides a planned regimen of treatment, consisting of regularly scheduled sessions within a structured program, for a minimum of nine (9) hours of treatment per week for adults and six (6) hours of treatment per week for adolescents. (75) Interdisciplinary Staff - A group of clinicians trained in different professions, disciplines, or service areas (such as physicians, counselors, psychologists, social workers, nurses and certified substance abuse counselors), who function interactively and interdependently in conducting a client’s diagnostic interview examination, service plan and treatment services. There must be close interaction and integration among the disciplines to ensure that all members of the team interact to achieve team goals. (76) Intervention - A planned interaction with an individual who may be dependent on one or more psychoactive substances, with the aim of making a full assessment, overcoming denial, interrupting drug-taking behavior, or inducing the individual to initiate treatment. Includes activities and strategies that are used to prevent or impede the development or progression of substance abuse problems. (77) Length of Service - The number of days for inpatient care or units/visits for outpatient of service provided to a patient, from admission to discharge, at a particular level of care. (78) Level of Care - The term refers to broad categories of patient placement, which encompass a range of clinical services such as early intervention, detoxification, or Opioid Maintenance Therapy services and levels of care such as intensive outpatient treatment or clinically managed medium intensity residential treatment. (79) Level of Function - An individual’s relative degree of health and freedom from specific signs and symptoms of a mental or substance-related disorder, which determine whether the individual requires treatment. (80) Licensed Independent Practitioner - An individual permitted by law and by the organization to provide care and services, without direction or supervision, within the scope of the individual's license and consistent with individually granted clinical privileges. In Alabama such individuals include: MD, DO, licensed psychologist, licensed professional counselor, licensed certified social worker, licensed marriage and family therapist, Master’s level nurse in psychiatric nursing, certified registered nurse practitioner, and physician assistant. (81) Linkage - Established connections and networks with a variety of agencies, companies and persons in the community that provides linkage that is facilitated between the client and service provider. (CARF) (82) Long-term Detoxification Treatment - Detoxification treatment for a period of more than thirty (30) days but less than one-hundred eighty (180) days. (83) Medical Director - A physician licensed under Alabama law who has been designated to oversee all medical services of a provider and has been given the authority and responsibility for medical care delivered by a provider. This includes ensuring the program is in compliance with all federal, state and local laws and regulations regarding the medical treatment of addiction to an Opioid drug. (84) Medically Managed Treatment - Services that involve daily medical care, where diagnostic and treatment services are directly provided and/or managed by an appropriately trained and licensed physician. (85) Medically Monitored Treatment - Services that are provided by an interdisciplinary staff of nurses, counselors, social workers, addiction specialists and other health care professionals and technical personnel, under the direction of a licensed physician. Medical monitoring is provided through an appropriate mix of direct patient contact, review of records, team meetings, twenty-four (24) hour coverage by a physician, and quality assurance programs. (86) Medical Monitoring - Evaluation, care and treatment by medical personnel who are licensed for clients whose substance abuse and related problems are severe enough to require intensive inpatient treatment using an interdisciplinary team approach. (87) Medical Necessity - Services by a provider to identify or treat an illness that has been diagnosed or suspected. The services are consistent with: (a) The diagnosis and treatment of a condition. (b) The standards of good medical practice. (c) Required for other than convenience. (d) The most appropriate supply or level of service. When applied to inpatient care, the term means: that the needed care can only be safely given on an inpatient basis. (88) Medically Managed Service - Services provided or directly managed by a physician. (89) Medically Monitored Service - Services provided under the direction and supervision of a physician. The physician may or may not directly administer care to the client. (90) Medication Administration – The direct administration of prescribed medication, as according to assessed needs stipulated in a client’s service plan, and observation of the client’s intake of the medication by mouth. (91) Medication Assistant Certified Worker (MAC Worker) – Unlicensed worker that performs basic strategies in assisting with the medication administration process. Must have successfully completed the twenty-four (24) hour MAC 1 & 2 educational program and received a score of ninety (90) or above on the MAC test. (92) Medication Assistant Supervisor Nurse (MAC Nurse) – A registered nurse (RN) or licensed practical nurse (LPN) with a valid Alabama license and employed or contracted by an agency/program certified by the ADMH. Must complete the seven (7) hours training program for MAS nurses and receive a score of ninety (90) or above on the MAS test. (93) Medication Assistance Train-the-Trainer Registered Nurse (MATT RN) – Must be a MAS registered nurse with at least one (1) year of community service. Must also receive additional training beyond the MAS requirement and receive a score of ninety (90) or above on the MATT test. (94) Medication Destruction Record - What it is and what is contained in it. (95) Medication Management - The practice of prescribing and/or dispensing medication by qualified personnel. (CARF) (96) Medication Monitoring - Face-to-face contact between the client and rehabilitative services, or a child and adolescent services/adult protective services professional, pharmacist, RN, or LPN for the purpose of reviewing the overt physiological effects of psychotropic medications; monitoring compliance with dosage instructions; instructing the client and/or caregivers of expected effects of psychotropic medications; assessing the client’s need to see the physician; and recommending changes in the psychotropic medication regimen. (97) Mental Health Consultation – A service aimed at assisting other service agency providers or independent practitioners in providing appropriate services to an identified Medicaid client by providing clinical consultation. Key service functions include written or oral interaction in a clinical capacity in order to assist another provider to meet the specific treatment needs of an individual client and to assure continuity of care to another setting. (98) Modality - A specific type of treatment (technique, method, or procedure) that is used to relieve symptoms or induce behavior change. Modalities of addiction treatment include, for example, detoxification or antagonist medication, motivational interviewing, cognitive behavioral therapy, group therapy, social skills training, vocational counseling and self/mutual help groups. (99) Monitoring - The interaction between the area authority or county program and a provider of public services regarding the functions set forth in the standards. (100) Motivational Enhancement and Engagement Strategies - A patient-centered counseling approach for initiating behavior change by helping patients to resolve ambivalence about engaging in treatment and stopping substance use. This approach employs strategies to evoke rapid and internally motivated change in the patient, rather than guiding the patient stepwise through the recovery process. (Adopted from Principles of Drug Addiction Treatment-A Research Based Guide, National Institute on Drug Abuse, 1999). (101) Neglect - The willful act of withholding or inadequately providing shelter, food, hydration, clothing, medical care and good hygiene. (102) Non-Violent Crisis Intervention - A process of interrupting an action or behavior that is harmful to an individual through the use of techniques that require limited force or action. Mental Health Chapter 580-9-44 Revised 3/17/23 9-44-17 (103) Nurse Delegation Program (NDP) - A general term that refers to the entire system that allows non-licensed persons to assist licensed nursing professionals in the administration of medications in a residential treatment setting. (104) Opioid Agonist Treatment Medication - A prescription medication, such as methadone, Buprenorphine or other substance scheduled as a narcotic under the Federal Controlled Substances Act (21 U.S.C. Section 811) that is approved by the U.S. Food and Drug Administration for use in the treatment of opiate addiction or dependence. (105) Opioid Maintenance - The dispensing of methadone for more than one-hundred eighty (180) days in the treatment of an individual for dependence on opiates. (106) Outpatient Service - An organized non-residential service, delivered in a variety of settings, in which addiction treatment personnel provide professionally directed evaluation and treatment of substance-related disorders. Usually fewer than nine (9) hours. (107) Overdose - The inadvertent or deliberate consumption of a dose much larger than that either habitually used by the individual or ordinarily used for treatment of an illness, and likely to result in a serious toxic reaction or death. (108) Parenting Skills Development – A structured face-to-face encounter facilitated by a trained clinician for the purpose of enhancing the parenting competency of individuals who are parents of dependent children, and who have a substance use disorder. This service may include interactive activities involving the parents’ children. (109) Partial Hospitalization - A generic term encompassing day, night, evening and weekend treatment programs that employ an integrated, comprehensive and complementary schedule of recognized treatments. Commonly referred to as “day treatment.” A partial hospitalization program does not need to be attached to a licensed hospital. (110) Patient - An individual receiving alcohol/other drug treatment. The terms “client”, “patient” and “client” sometimes are used interchangeably and refer to the individual who has completed the screening, behavioral health screening and diagnostic interview examination process and is receiving substance abuse treatment services. (111) Peer Counseling Services – The provision of scheduled interventions by a certified peer counselor, who is in recovery from a substance use or co-occurring substance use and mental illness disorder, to assist a client in the acquisition and exercise of skills needed to support recovery. Services may include activities that assist clients in accessing and/or engaging in treatment and in symptom management, promote socialization, recovery, and self-advocacy, and provide guidance in the development of natural community supports and basic daily living skills. (112) Performance Improvement - A formal method of evaluating the quality of care rendered by a provider and is used to promote and maintain an efficient and effective service delivery system. Performance improvement includes the use of a quality assurance process to ensure that problems, when they occur are corrected appropriately and in a timely manner. (113) Pharmacotherapy - Any treatment of persons served with medications, including methadone or opiate replacement therapies. (114) Physical Restraint - The direct application of physical force to a client without the client’s permission to restrict his or her freedom of movement. (115) Placement Assessment - An interview with the person served to collect information related to his/her history and needs, preferences, strengths and abilities in order to determine the diagnosis, appropriate services and/or referral. (Modified CARF) (116) Prevention - Social, economic, legal, medical and/or psychological measures aimed at minimizing the use of potentially addicting substances, lowering the dependence risk in susceptible individuals, or minimizing other adverse consequences of psychoactive substance use. Primary prevention consists of attempts to reduce the incidence of addictive diseases and related problems in a general population. Secondary prevention aims to achieve early detection, diagnosis and treatment of affected individuals. Tertiary prevention seeks to diminish the incidence of complications of addictive diseases. (117) Program - A generalized term for an organized system of services designed to address the treatment needs of patients. (118) Progress Note - Written entries made by clinical staff in the client record that document progress or lack thereof toward meeting treatment plan objectives, and which generally address the provision of services, the client’s response to those services, and significant events. Progress notes also include documentation of those events and activities related to the client’s treatment. (119) Psychiatric Seclusion - The involuntary confinement of a client alone in a room, from which the client is prevented from leaving for a prescribed period of time in order to control or limit his/her dangerous behavior. (120) Psychoeducation - Individualized instruction and training of the persons served to increase their knowledge and understanding of their psychiatric diagnoses, prognoses, treatment and rehabilitation in order to enhance their acceptance of these psychiatric disabilities, increase their cooperation and collaboration with treatment and rehabilitation, improve their coping skills, and favorably affect their outcomes. Such education should be consistent with the individual plans and be provided with the knowledge and support of the interdisciplinary teams. (CARF) (121) Qualified Case Manager - An individual that possesses a Bachelor of Science degree in a behavioral health field or in nursing and have successfully completed training in a case management curriculum approved by DMH to provide case management services to the identified population being served. (122) Qualified Interpreter: (a) Spoken Language Interpreters must be able to interpret expressively and receptively using specialized vocabularies between two persons speaking two languages. (b) Sign Language Interpreters must meet the expectations of the Spoken Language Interpreter plus be eligible to work in Alabama as specified in Section 34, Chapter 16 of the Code of Alabama, i.e., they must obtain Interpreter licensure. (123) Qualified Person - Any person qualified under applicable law or professional requirement where they exist to perform any function authorized under these rules. Where professional qualifications are not imposed under other law, these rules may permit persons to act as specifically authorized. (124) Qualified Physician - Is a psychiatrist or a licensed physician who has been granted privileges to order seclusion or restraint. (125) Qualified Registered Nurse - Is one who has successfully completed a DMH approved psychiatric management course and who as at least one (1) year psychiatric nursing experience. A Registered Nurse who has been granted privileges to implement seclusion or restraint. (126) Qualified Substance Abuse Professional I (QSAP I) – An individual licensed in the State of Alabama as a Professional Counselor, Certified Social Worker, Psychiatric Clinical Nurse Specialist, Psychiatric Nurse Practitioner, Marriage and Family Therapist, Clinical Psychologist, Physician’s Assistant, Physician and meets the other qualifications as specified in the standards themselves. (127) Qualified Substance Abuse Professional II (QSAP II) – An individual who holds a master’s or bachelor’s degree from an accredited college or university in Psychology, Social Work, Community Rehabilitation, Pastoral Counseling, Family Therapy, or other behavioral health areas that requires equivalent clinical course work and who meets the other qualifications as specified in the standards themselves. (128) Qualified Substance Abuse Professional III (QSAP III) – An individual who has a bachelor’s degree from an accredited college or university in Psychology, Social Work, Community Rehabilitation, Pastoral Counseling, Family Therapy, or other behavioral health area that requires equivalent clinical course work and; who has a minimum of two (2) years full-time paid employment experience providing direct treatment or care for individuals who have substance-related disorders, under the supervision of a QSAP I, and holds a substance abuse counselor certification. (129) Readiness to Change - An individual’s emotional and cognitive awareness of the need to change, coupled with a commitment to change. When applied to addiction treatment it describes the patient’s degree of awareness of the relationship between his/her alcohol or other drug use or mental health problems and the adverse consequences of such use, as well as the presence of specific readiness to change personal patterns of alcohol and other drug use. (130) Recovery Support Services – A range of non-clinical services provided to facilitate the process of recovery from substance use disorders and to promote wellness. These services may be provided prior to, during and after treatment for individuals and their families who have been assessed as having a need for such. (131) Referral - The establishment of a link between a client and another service by providing client authorized documentation to the other service of the client’s need and recommendations for treatment services, and includes follow-up within a given time span as to the disposition of the recommendations. (132) Relapse - Recurrence of psychoactive substance-dependent behavior in an individual who has previously achieved and maintained abstinence for a significant period of time beyond withdrawal. (133) Relapse Prevention - Services designed to support the recovery of the individual and to prevent the recurrence of substance abuse. (134) Resident - A patient in one of the clinically managed, residential levels of care. (135) Residential Detoxification – Detoxification that is medically monitored and requires admission to a Clinically Managed or Medically Monitored Detoxification Program. (136) Restraint: (a) Any manual method used or physical or mechanical device, material, or equipment attached or adjacent to a client’s body that he or she cannot easily remove or that restricts freedom of movement or normal access to one’s body. (b) A drug used to control a client’s behavior when that drug is not a standard treatment for the client’s condition. (c) The use of physical, mechanical, chemical, or other means to temporarily subdue an individual or otherwise limit a person’s freedom of movement. (CARF) (137) Seclusion - The use of a secure, private room designed to isolate a client who has been determined by a physician to pose an immediate threat of physical harm to self or others. Seclusion refers to the placement of a client alone in any room from which the client is physically prevented from leaving. (138) Screening - A process involving a brief review of a person’s presenting problem to determine the person’s appropriateness and eligibility for substance abuse services and the possible level of services require. (139) Sentinel Event - Is an unexpected occurrence involving a child/adolescent receiving treatment for a psychological or psychiatric illness that results in serious physical injury, psychological injury, or death (or risk thereof). Serious Incident/Critical Incident - The occurrence or set of events inconsistent with the routine operation of an approved treatment facility, or the routine care of a client. Serious incidents, sometimes referred to as critical incidents, include but are not necessarily limited to the following: (a) Adverse drug events. (b) Self destructive behavior. (c) Deaths and injuries (including automobile accidents) to the client, client family, staff, and visitors. (d) Medication errors. (e) Neglect or abuse of a client. (f) Fire. (g) Unauthorized disclosure of information. (h) Damage to or theft of property belonging to a client or an approved treatment facility. (i) Other unexpected occurrences. Mental Health Chapter 580-9-44 Revised 3/17/23 9-44-23 (j) Or events potentially subject to litigation. A serious incident may involve multiple individuals or results. (141) Service Plan – A written plan of services, developed by the clinician in conjunction with the client, that addresses the individualized needs of the client through devising plans for services that offer reasonable promise of success and are consistent with the abilities and circumstances of the client. The Service Plan is reviewed regularly by the clinician and client to assess its continued viability and effectiveness while respecting the client’s input and freedom of choice. (142) Setting - A specific place in which treatment is delivered. Settings for alcohol/other drug treatment include hospitals, methadone clinics, community mental health centers and prisons or jails. (143) Severity of Illness - Specific signs and symptoms for which a patient requires treatment, including the degree of impairment and the extent of a patient’s support networks. (144) Short-term Detoxification Treatment -Detoxification treatment for a period not in excess of thirty (30) days. (145) Sign Language Interpreter – The provision of sign language or interpreter services for clients enrolled in a specified level of care by appropriately credentialed professionals. (146) Smoking Cessation – A structured face-to-face encounter provided by trained personnel to assist individuals enrolled in a specific level of care in efforts to stop smoking. (147) Staffing/Case Review - A regularly scheduled review of client’s treatment goals which involve the client’s primary clinical staff person and other persons involved in the implementation of the treatment plan. (148) Staff Member - A person who is directly employed by an organization on either a full- or part-time basis. (CARF) (149) Stages of Change - This refers principally to the work of Prochaska and DiClemente, who described how individuals progress and regress through various levels of awareness of a problem, as well as the degree of activity involved in behavior. While their original work studied individuals who changed from smokers to non-smokers, the concept of stages of change subsequently has been applied to a variety of behaviors. (150) Standards - Specifications representing the minimal characteristics of an alcohol and other drug abuse treatment program, which are acceptable for the licensing of a program. (151) State Opioid Treatment Authority - The Director, or designee, of the State of Alabama DMH Substance Abuse Division’s Treatment Services or its successor. (152) Substance Abuse - Harmful use of a specific psychoactive substance. The term also applies to one category of psychoactive substance-related disorders. While recognizing that “abuse” is part of present diagnostic terminology, ASAM recommends that an alternative term be found for this purpose because of the pejorative connotations of the word “abuse”. (153) Substance Abuse Service Provider - Any entity or person. A public agency, a private for-profit or not-for-profit agency, a person who is in private practice and a hospital either licensed or exempt from licensure that has obtained certification through DMH/SASD to provide substance abuse services at any of the SASD approved levels of care. (154) Substance Dependence - Marked by a cluster of cognitive, behavioral and psychological symptoms indicating that the individual continues to use alcohol or other drugs despite significant related problems. The cluster of symptoms can include tolerance, withdrawal or use of a substance in larger amounts or over a longer period of time than intended; persistent desire or unsuccessful efforts to cut down or control substance use; a great deal of time spent in activities related to obtaining or using substances or to recover from their effects; relinquishing important social, occupational or recreational activities because of substance use; and continuing alcohol or drug use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by such use. (155) Substance Use Disorders - Include Substance Dependence and Substance Abuse, according to the specific diagnostic criteria given in DSM IV. Substance Use Disorders are one of two subgroups (‘substance dependence’ and ‘substance abuse’) of the broader diagnostic category of Substance-Related Disorders. In the ASAM PPC-2R, the specific subgroup or disorder is used in the diagnostic criteria for admission to certain levels of care. (156) Supportive Counseling - Not considered therapy but is provided to clients, or victims, to help them discuss feelings relating to domestic violence, sexual assault or abuse, and other issues that maybe negatively affecting their well-being. It is used to help them identify their strengths and to re-develop feelings of self-worth. The client’s spouse, parents, or other family members may also receive supportive counseling which provides them with an outlet to verbalize their feelings and to develop viable plans for action. (157) Support Services - Those readily available to the program through affiliation, contract or because of their availability to the community at large (example: 911). They are used to provide services beyond the capacity of the staff of the program and which will not be needed by patients on a routine basis or to augment the services provided by staff. (158) The Levels of Care: (a) Level 0.5: Early Intervention: A service for a group of individuals who, for a known reason, are at risk of developing substance-related problems, or for those for whom there is not yet sufficient information to document a substance use disorder. (ASAM PPC-2R). (b) Level I: Outpatient Treatment: Organized services that may be delivered in a variety of settings. Includes professionally directed services provided by addiction or mental health personnel that include evaluation, treatment and recovery services. These services are provided in regularly scheduled sessions and follow a defined set of policies and procedures or medical protocols. (ASAM PPC-2R) (c) Level II: Intensive Outpatient Treatment/Partial Hospitalization: An organized outpatient service that delivers treatment services during the day, before or after work or school, in the evenings, or on the weekends. Includes programs that essentially provide education and treatment components while allowing clients to apply their newly acquired skills within “real world” environments. These programs have the capacity to arrange for medical and psychiatric consultation, psychopharmacological consultation, medication management and 24-hour crisis services. (ASAM PPC-2R) (d) Level III: Residential/Inpatient Treatment: Encompasses organized services provided by addiction and mental health personnel who provide a planned regimen of care in a twenty-four (24) hour live-in setting. Such services adhere to defined policies and procedures. They are located in permanent facilities where clients reside safely. They are staffed for twenty-four (24) hour coverage and self-help groups are available on-site. There are five types of programs located at this level: 1. Level III.01: Transitional Residential Program 2. Level III.1: Clinically Managed Low Intensity Residential Treatment 3. Level III.3: Clinically Managed Medium Intensity Residential Treatment 4. Level III.5: Clinically Managed High Intensity Residential Treatment 5. Level III.7: Medically Monitored Inpatient Treatment (ASAM PPC-2R) (e) Level IV: Medically Managed Intensive Inpatient Treatment: These programs provide a planned regimen of twenty-four (24) hour medically directed evaluation, care and treatment of mental and substance-related disorders in an acute care inpatient setting. They are staffed by addiction- credentialed physicians, psychiatrists and clinicians. Services at this level are delivered under a defined set of policies and procedures and have permanent facilities that include inpatient beds. Level four programs provide care to clients who’s mental and substance-related problems are so severe that they require primary biomedical, psychiatric and nursing care. Treatment is provided twenty-four (24) hours a day and the full resources of a general acute care hospital or psychiatric hospital are available. Treatment is specific to SA or MI disorders but the skills of the interdisciplinary team and the availability of support services allow the conjoint treatment of any co-occurring biomedical condition that needs to be addressed. (ASAM PPC-2R) (159) Timeout - The restriction of a client for a period of time to a designated area from which the client is not physically prevented from leaving for the purpose of providing the client an opportunity to regain self-control. (160) Tolerance - A stage of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drug’s effects over time. (161) Transfer - Movement of the client from one level of service to another, within the continuum of care. The change may take place at the same location or by physically moving the client to a different site for the new level of care. (162) Transfer Summary - A written justification of the circumstances of the transfer of a client from one component to another or from one provider to another. (163) Transitional Hold – A brief physical restraint of an individual that may be face-down for the purpose of quickly and effectively gaining physical control of that individual, or prior to transport to enable the individual to be transported safely. (164) Transitional Residential Treatment – Services directed by persons who specialize in addictions treatment. They are appropriate for persons whose primary problems involve emotional, behavioral or cognitive concerns, readiness to change, relapse potential and recovery environment dictates that these issues can be addressed through arrangements for clinical/medical services with the appropriate living situation. (165) Transportation – Agency provided non-emergency services utilized to transport a client to and from treatment or care, and to and from community-based organizations and activities during the course of treatment or care, as identified in the individual’s service plan. (166) Treatment - The application of professional planned, merged, administered, and/or monitored evidenced-based/best practices and procedures to identify, stabilize, minimize, or alleviate the harmful consequences of substance related disorders and to restore impaired health and functionality relative to the disorders. (167) Treatment Program - Any program that delivers alcohol and/other drug abuse treatment services to a defined client population. (168) Treatment Staff - The group of personnel of the alcohol and other drug abuse treatment program, which is directly involved in client care or treatment. (169) Waiver - The voluntary relinquishment or surrender of some known right or privilege. Waivers are given in writing, listing clearly and unambiguously the full knowledge of what is being waived. They are developed specifically for a particular right, duty, or privilege and cannot be used or applied to other essential functions of a job or activity. All waivers are signed by the appropriate authority. (170) Youth - A person between six (6) and eighteen years (18) of age. (CARF) (171) Meaning of the verbs in the Standards: Attention is drawn to the use of the words “shall”, “should”, and “may” in the SASD Standards: (a) “Shall” is the term used to indicate a mandatory statement, the only acceptable method under these present standards. (b) “Should” is the term used to reflect the most preferable procedure, yet allowing for the use of effective alternatives. (c) “May” is the term used to reflect an acceptable method that is recognized but not necessarily preferred. Authority: Code of Ala. 1975, §22-50-11. History: July 22, 1992. Extended: September 30, 1992. Extended: December 31, 1992. Certified: March 30, 1993. Effective May 5, 1993. Repealed and New Rule: Filed November 19, 2003; effective December 24, 2003. Repealed and New Rule: Filed January 26, 2012; effective March 1, 2012. 580-9-44-.02 Personnel (1) Qualified Treatment Personnel. The entity shall employ qualified and trained personnel to ensure the health, safety, and well-being of its clientele, and to support efficient utilization of its resources. (a) The entity shall develop, maintain, and document implementation of written policies and procedures to ensure that all personnel meet and remain current on credentials required for certification, licensure, and for job performance and service delivery as specified by these rules. (b) Qualified Substance Abuse Professionals (QSAP). The entity shall utilize qualified substance abuse professionals, to provide treatment for individuals with substance related disorders. 1. QSAP I. A Qualified Substance Abuse Professional I (QSAP I) shall consist of: (i) An individual licensed in the State of Alabama as a: (I) Professional Counselor, Graduate Level Social Worker, Psychiatric Clinical Nurse Specialist, Psychiatric Nurse Practitioner, Marriage and Family Therapist, Clinical Psychologist, Physician’s Assistant, Physician; or (ii) An individual who: (I) Has a master’s degree or above from a nationally or regionally accredited university or college in psychology, social work, counseling, psychiatric nursing, or other behavioral health area with requisite course work equivalent to that of a degree in counseling, psychology, social work, or psychiatric nursing, and (II) Has successfully completed a clinical practicum or has six month’s post master’s clinical experience; and (III) Holds a substance abuse counselor certification credential from the Alabama Association of Addiction Counselors, National Association of Alcoholism and Drug Abuse Counselors, Alabama Alcohol and Drug Abuse Association, or International Certification and Reciprocity Consortium/Alcohol and Other Drug Abuse, Inc. which shall be obtained within thirty (30) months of date of hire. (iii) A QSAP I is authorized to provide services as delineated in the most recent version of the ADMH Substance Abuse Services Billing Manual as published and maintained by ADMH. 2. QSAP II. A Qualified Substance Abuse Professional II (QSAP II) shall consist of: (i) An individual who: (I) Has a Bachelor’s Degree from a nationally or regionally accredited university or college in psychology, social work, community, rehabilitation, or pastoral counseling, family therapy, or other behavioral health area that requires equivalent clinical course work, and (II) Is licensed in the State of Alabama as a Bachelor Level Social Worker; or (III) Has a Bachelor’s Degree from a nationally or regionally accredited college or university in psychology, social work, community, rehabilitation, or pastoral counseling, family therapy, or other behavioral health area that requires equivalent clinical course work, and (IV) Holds a substance abuse counselor certification credential from the Alabama Association of Addiction Counselors, National Association of Alcoholism and Drug Abuse Counselors, Alabama Alcohol and Drug Abuse Association, or International Certification and Reciprocity Consortium, or (V) Has a bachelor's degree from a nationally or regionally accredited university or college in psychology, social work, community rehabilitation, pastoral counseling, family therapy, or other behavioral health area that requires equivalent clinical course work and (VI) Obtains a substance use counselor certification credential from the Alabama Association of Addition Counselors, National Association of Alcoholism and Drug Abuse Counselors, Alabama Alcohol and Drug Abuse Association, or International Certification and Reciprocity Consortium within 30 months of hire and (VII) Participates in ongoing weekly supervision from an assigned QSAP I that is documented and appropriately filed in their personnel record for auditing purposes until counselor certification is obtained. (ii) A QSAP II is authorized to provide services as delineated in the most recent version of the ADMH Substance Abuse Services Billing Manual as published and maintained by ADMH. 3. QSAP III. A Qualified Substance Abuse Professional III (QSAP III) shall consist of: (i) An individual who: (I) Has a Bachelor’s Degree from a nationally or regionally accredited university or college in psychology, social work, community, rehabilitation, or pastoral counseling, family therapy, or other behavioral health area that requires equivalent clinical course work, and (II) Participates in ongoing supervision by a certified or licensed QSAP I for a minimum of one (1) hour individual per week until attainment of a substance abuse counselor certification credential from the Alabama Association of Addiction Counselors, National Association of Alcoholism and Drug Abuse Counselors, or Alabama Alcohol and Drug Abuse Association, or International Certification and Reciprocity Consortium/Alcohol and Other Drug Abuse, Inc. which shall be obtained within thirty (30) months of hire. (ii) A QSAP III is authorized to provide services as delineated in the most recent version of the ADMH Substance Abuse Services Billing Manual as published and maintained by ADMH. 4. Qualified Paraprofessionals(QPP). A qualified paraprofessional shall have the following minimum qualifications: (i) A high school diploma or equivalent, and (ii) One (1) year of work experience directly related to job responsibilities and (iii) Concurrent participation in clinical supervision by a licensed or certified QSAP I. (iv) A QPP is authorized to provide services as delineated in the most recent version of the ADMH Substance Abuse Services Billing Manual as published and maintained by ADMH. 5. Peer Support Specialist. A peer support specialist must meet the following minimum qualifications: (i) Certified by ADMH as a Certified Recovery Support Specialist (CRSS) within six (6) months of date of hire, and (ii) Concurrent participation in clinical supervision by a licensed or certified QSAP I. (iii) A Peer Support Specialist is authorized to provide services as delineated in the most recent edition of the ADMH Substance Abuse Services Billing Manual as published and maintained by ADMH. 6. Students who are completing a graduate degree from a regionally accredited university or college in psychology, counseling, social work, or psychiatric nursing may conduct direct services under the following conditions: (i) The student is in a clinical practicum that is part of an officially sanctioned academic curriculum. (ii) The student receives a minimum of one (1) hour per week of direct clinical supervision (face to face) from a licensed or certified QSAP I. (iii) Any written clinical documentation generated by the student must be reviewed and signed by the supervising clinical staff member. (2) Staff Development. The entity shall develop, maintain, and document implementation of written policies and procedures that establish a staff development and training program for all employees, students, and volunteers. This program shall include, at a minimum, the following requirements: (a) Annual Training: During each calendar year, the entity shall provide training for each employee that addresses the following topics: 1. Crisis intervention. 2. Management of disruptive behavior. 3. Suicide prevention/intervention. 4. Confidentiality and privacy of client information. 5. Cultural competency relative to the program’s target population. 6. Infectious disease prevention and management, to include at a minimum: TB, HIV/AIDS, Sexually Transmitted Diseases and Hepatitis. 7. Program policies and procedures. 8. ADMH Administrative Code specific to level(s) of care. (b) First Aid/Cardiopulmonary Resuscitation (CPR) Training. All staff of each substance abuse prevention, treatment, and recovery support program shall obtain, within one (1) month of hire, and continuously, thereafter, current certification in First Aid and CPR. (3) An individual who met the requirements of the Administrative Code 580-9-44-2 Personnel effective March 2012 and was employed prior to the approval of these rules shall be in good standing. Authority: Code of Ala. 1975, §22-50-11. History: New: Filed: July 22, 1992. Extended: September 30, 1992. Extended: December 31, 1992. Certified: March 30, 1993. Effective: May 5, 1993. Repealed and New Rule: Filed January 26, 2012; effective March 1, 2012. Amended: Filed January 8, 2018; effective February 22, 2018. Amended: Filed October 16, 2018; effective November 30, 2018. Amended: Published January 31, 2023; effective March 17, 2023. Amended: Published April 28, 2023; effective June 12, 2023. 580-9-44-.03 Client Rights (Repealed 11/30/18) (Repealed) Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Repealed: Filed October 16, 2018; effective November 30, 2018. 580-9-44-.04 Abuse And Neglect (Repealed 11/30/18) (Repealed) Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Repealed: Filed October 16, 2018; effective November 30, 2018. 580-9-44-.05 Grievances, Complaints And Appeals (Repealed 11/30/18) (Repealed) Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Repealed: Filed October 16, 2018; effective November 30, 2018. 580-9-44-.06 Confidentiality And Privacy (Repealed 11/30/18) (Repealed) Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Repealed: Filed October 16, 2018; effective November 30, 2018. 580-9-44-.07 Seclusion And Restraint (Repealed 11/30/18) (Repealed) Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Repealed: Filed October 16, 2018; effective November 30, 2018. 580-9-44-.08 Child And Adolescent Seclusion And Restraint (Repealed 11/30/18) (Repealed) Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Repealed: Filed October 16, 2018; effective November 30, 2018. 580-9-44-.09 Incident Reporting (Repealed 5/15/20) (Repealed) Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Repealed: Published March 31, 2020; effective May 15, 2020. 580-9-44-.10 Infection Control (Repealed 5/15/20) (Repealed) Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Repealed: Published March 31, 2020; effective May 15, 2020. 580-9-44-.11 Performance Improvement (Repealed 11/30/18) (Repealed) Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Repealed: Filed October 16, 2018; effective November 30, 2018. 580-9-44-.12 Operational Policies And Procedures Manual (Repealed 5/15/20) (Repealed) Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Repealed: Published March 31, 2020; effective May 15, 2020. 580-9-44-.13 Program Description (Repealed 3/17/23) (Repealed) Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Repealed: Published January 31, 2023; effective March 17, 2023. 580-9-44-.14 Level 0.5: Early Intervention (1) Rule Compliance. Each Level 0.5 Early Intervention Program shall comply with the following rules and the rules specified in this chapter. (a) Operational Plan. The entity shall develop, maintain and document implementation of a written operational plan that defines its Level 0.5 Early Intervention Program. The program description shall comply with all of the requirements specified in 580-9-44-.13 and the following additional specifications: 1. Location. The entity shall specifically identify and describe the setting in which Level 0.5 Early Intervention services shall be provided. Services may be provided in any appropriate setting that protects the client’s right to privacy, confidentiality, safety and meets the DMH facility certification standards as appropriate to the location. Service locations may include traditional clinical offices and behavioral health sites, residences, schools, shelters, work sites, community centers and other locations as pre-authorized by DMH. (i) Adolescent Specific Criteria. (I) Location. Shall not provide services in locations that would require shared services or significant contact with individuals receiving treatment for substance use disorders. 2. Admission Criteria. The entity shall develop, maintain, and document implementation of written criteria for admission to its Level 0.5 Outpatient Program, as according to 580-9-44-.13(9), and the following criteria: (i) The entity’s admission criteria shall specify the target population for Level 0.5 services to include, at a minimum, individuals whose problems and risk factors appear to be related to substance use, but do not meet the diagnostic criteria for a substance-related disorder as defined in the current Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. (ii) The entity shall provide written documentation in individual case records that each client admitted to receive Level 0.5 Early Intervention Services meets the most current edition of the ASAM Patient Placement Criteria diagnostic and dimensional criteria for this level of care. (iii) Adolescent Program Specific Criteria. The entity shall provide written documentation in individual case records that each adolescent admitted to receive Level 0.5 Early Intervention services meets the most recent edition of the ASAM Patient Placement Criteria adolescent diagnostic and dimensional criteria for this level of care. 3. Core Services. Each Level 0.5 Early Intervention Program shall demonstrate the capacity to provide a basic level of skilled services appropriate to the needs of its clientele: (i) Screening and assessment sufficient to screen for, and rule in or out, substance-related disorders. (ii) Individual counseling. (iii) Group counseling. (iv) Family counseling. (v) Psychoeducation. (iv) Case Management: (I) Case planning. (II) Linkage. (III) Advocacy. (IV) Monitoring. 4. Service Intensity. The entity shall document that the amount and frequency of services is established on the basis of the unique needs of each client served. 5. Documentation: In addition to meeting the requirements of 580-9-44-.13(21), an individualized progress note shall be recorded for each service provided in Level 0.5. 6. Support Systems. (i) At a minimum, the Early Intervention Program shall develop, maintain and document implementation of written policies and procedures which govern the process used to ensure the availability of and provide referrals as needed for: (I) Treatment of substance use disorders. (II) Medical, psychological or psychiatric services, including assessment. (III) Community social services. (ii) The entity shall maintain up-to-date, written Memorandums of Understanding, Collaborative Agreements or Referral Agreements as applicable. 7. Program Personnel. Each Level 0.5 Early Intervention Program shall employ an adequate number of qualified individuals to carry out personalized care for its clientele and to meet the program’s goals and objectives. (i) Every client in a Level 0.5 Program shall be assigned to a specific Primary Counselor for care management. 8. Training. The entity shall provide written documentation that all Level 0.5 Program personnel satisfy the competency and training requirements as specified in 580-9-44-.02(3). 9. Service Intensity: The entity shall document that the amount and frequency of Level 0.5 Early Intervention Services are established on the basis of the unique needs of each client served. 10. Length of Service: The entity shall provide written documentation that the duration of treatment in each Level 0.5 Program shall vary as determined by: (i) The client’s ability to comprehend the information provided and use that information to make behavior changes; or (ii) The appearance of new problems which require another modality of service. 11. Service Availability: The entity shall provide written documentation describing the process utilized to establish the hours of service availability for its Level 0.5 Early Intervention Program. At a minimum, this process shall: (i) Include consideration of the needs of the target population, including work, school and parenting responsibilities. (ii) Not be based solely on standard eight (8) to five (5), Monday through Friday office hours. Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Amended: Published January 31, 2023; effective March 17, 2023. 580-9-44-.15 Level I: Outpatient Treatment (1) Rule Compliance. Each Level I Outpatient Program shall comply with the following rules and the rules specified in this chapter. (a) Program Description. The entity shall develop, maintain and document implementation of a written operational plan that defines its Level I Outpatient Program. The program description shall comply with all of the requirements specified in 580-9-44-.13. 1. Location. The entity shall specifically identify and describe the setting in which Level I Outpatient Services shall be provided. Services may be provided in any appropriate setting that protects the client’s right to privacy, confidentiality and safety, including but not limited to, traditional clinical offices and behavioral health sites, residences, schools, shelters, work sites, community centers and other locations as pre-authorized by DMH. 2. Admission Criteria: The entity shall develop, maintain and implement written criteria for admission to its Level I Outpatient Program in compliance with the requirements of 580-9-44-.13(9) and the following specifications: (i) The entity’s admission criteria shall specify the target population for the Level I Program, which shall include, at a minimum, individuals whose assessed severity of illness initially warrants this level of care, including but not limited to: (I) Whose progress in a more intensive level of care warrants a step-down to a less intensive level of care. (II) Who are in the early stages of change and who are not yet ready to commit to full recovery. (III) Who are experiencing increased conflict, demonstrating passive compliance or considering leaving treatment. (ii) The entity shall provide written documentation in individual case records that each client admitted to receive Level I Outpatient Services meets: (I) The diagnostic criteria for a substance use disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders. (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (iii) Adolescent Program Specific Criteria: The entity shall provide written documentation in individual case records that each adolescent admitted to receive Level I Outpatient Services meets: (I) The diagnostic criteria for a substance use disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders. (II) The adolescent dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (iv) Co-occurring Disorders Program Specific Criteria: The entity shall provide written documentation in individual case records that each client admitted to receive Level I Outpatient Services in a Co-occurring Enhanced Treatment Program meets: (I) The diagnostic criteria for a substance use and mental illness disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders. (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (v) Women and Dependent Children Program Specific Criteria: The entity shall provide written documentation in individual case records that each client admitted to receive Level I Outpatient Services in a Women and Children Program: (I) Meets the diagnostic criteria for a substance use disorder as defined in the most recent edition Diagnostic and Statistical Manual for Mental Disorders. (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (III) Is pregnant; or (IV) Has care and custody of dependent children; or (V) Has lost custody of dependent children and has the potential for family reunification. 3. Core Services. Each Level I Outpatient Program shall demonstrate the capacity to provide a basic level of skilled treatment services appropriate to the needs of its clientele. (i) At a minimum, the entity shall directly or by referral provide the following core services: (I) Behavioral Health Screening. (II) Individual counseling. (III) Group counseling. (IV) Family counseling. (V) Psychoeducation. (VI) Mental health consultation. (VII) Recovery support services. (VIII) Peer counseling services. (IX) Medication management. (X) Alcohol and/or drug screening/testing. (XI) Smoking cessation. (XII) Sign language interpreter services. (XIII) HIV early intervention services. (XIV) Case management: I. Case planning. II. Linkage. III. Advocacy. IV. Monitoring. (ii) Adolescent Program Specific Criteria: Each Level I Adolescent Outpatient Program shall document the capacity to provide each of the core services and to include activity therapy. (I) Activity therapy. (iii) Co-occurring Disorders Program Specific Criteria: Each level I Co-occurring Disorders Outpatient Program shall document the capacity to provide each of the core services to include basic living skills, crisis intervention services, and intensive case management. (iv) Women and Dependent Children Program Specific Criteria: Each Level I Women and Dependent Children Outpatient Program shall document the capacity to provide each of the core services and/or arrange for the following services: (I) Transportation. (II) Child sitting services. (III) Developmental delay and prevention services. (IV) Activity therapy. (V) Parenting skills development. 4. Therapeutic Component Implementation. The entity shall document implementation of regularly scheduled treatment sessions that are provided in an amount, frequency and intensity appropriate to the client’s assessed needs and expressed desires for care. (i) Service strategies for each Level I Outpatient Program shall include, at a minimum: (I) Implementation of individualized counseling plan strategies. (II) Ongoing individualized assessment services. (III) Motivational enhancement and engagement strategies. (IV) Relapse prevention strategies. (V) Interpersonal choice/decision-making skill development. (VI) Health education. (VII) Random drug screening. (VIII) Family education. (IX) Gender responsive treatment. (ii) Adolescent Program Specific Criteria: Each Level I Adolescent Outpatient Program shall document the capacity to provide the service strategies and the following therapeutic components: (I) Adolescent specific evidence based therapeutic interventions. (II) Client education on key adolescent development issues, including but not limited to, adolescent brain development and the impact of substance use, emotional and social influence on behavior, value system development, puberty/physical development, sexuality and self-esteem. (III) Recreation and leisure time skills training. (IV) Family, community and school reintegration services. (iii) Co-occurring Disorders Program Specific Criteria: Each Level I Co-occurring Disorders Outpatient Program shall document the capacity to provide the service strategies and the following therapeutic components: (I) Groups and classes that address the signs and symptoms of mental health and substance use disorders. (II) Groups, classes, and training to assist clients in becoming aware of cues or triggers that enhance the likelihood of alcohol and drug use or psychiatric decompensation and to aid in development of alternative coping responses to those cues. (III) Dual recovery groups that provide a forum for discussion of the interactions of and interrelations between substance use and mental health disorders. (iv) Women and Dependent Children Program Specific Criteria: Each Level I Women and Dependent Children Outpatient Program shall document the capacity to provide the service strategies and the following therapeutic components: (I) Specific services which address issues of relationships, parenting, abuse, and trauma. (II) Primary medical care, including prenatal care. (III) Primary pediatric care for children. (IV) Therapeutic interventions for children which address their developmental needs and issues of sexual abuse and neglect. (V) Outreach to inform pregnant women of the services and priorities. (VI) Interim services while awaiting admission to this level of care. (VII) Recreation and leisure time skills training. 5. Documentation: An individual progress note shall be recorded for each respective service provided in Level I. 6. Support Systems. Each Level I Outpatient Program shall develop, maintain and document implementation of written policies and procedures which govern the process used to provide client access to support services on site, or through consultation or referral, which shall minimally include: (i) Medical, psychiatric, psychological, laboratory and toxicology services. (ii) Medical and psychiatric consultation shall be available within twenty-four (24) hours by telephone or if in person, within a timeframe appropriate to the severity and urgency of the consultation requested. (iii) Direct affiliation with or coordination through referral to more intensive levels of care and medication management. (iv) Emergency services shall be available by telephone twenty-four (24) hours a day, seven (7) days a week. (v) Mutual self-help groups that are tailored to the needs of the specific client population. (vi) Referral for other services as according to the client’s assessed needs. 7. Program Personnel. Each level I Outpatient Program shall employ an adequate number of qualified individuals to provide personalized care for its clientele and to meet the program’s goals and objectives. (i) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level I Outpatient program as delineated in its operational plan. (ii) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (iii) Every client in a Level I program shall be assigned to a specific Primary Counselor for care management. (iv) Each primary counselor shall maintain a case load not to exceed forty (40) clients with active cases at any one time. (v) Adolescent Program Specific Criteria Adolescent Program Specific Criteria: (I) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level I Adolescent Outpatient program as delineated in its operational plan. (II) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (III) Every client in a Level I adolescent program shall be assigned to a specific Primary Counselor for care management. (IV) Each primary counselor shall maintain a case load not to exceed thirty (30) clients with active cases at any one time. (vi) Co-occurring Disorders Program Specific Criteria: (I) The Level I Co-occurring Enhanced Outpatient Program shall have access to psychiatric services (led by a qualified psychiatrist or nurse practitioner) that are fully capable of evaluating, diagnosing, and prescribing medications to clients with co-occurring disorders. On-call psychiatric services shall be available twenty-four (24) hours a day, seven (7) days a week. (II) Treatment staff that provide therapy and ongoing clinical assessment services to individuals diagnosed with co-occurring disorders. (III) Every client in a Level I Enhanced Co-occurring Outpatient Program shall be assigned to a specific Primary Counselor for care management. (IV) Each primary counselor shall maintain a case load not to exceed thirty (30) clients with active cases at any one time. (vii) Women and Dependent Children Program Specific Criteria: (I) Direct Care Personnel. All direct care personnel shall be a qualified paraprofessional to provide the specific services delineated in the entity’s operational plan for this level of care. (II) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level I Women and Dependent Children Outpatient Program as delineated in its operational plan. (III) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (IV) Every client in a Level I Women and Dependent Children Program shall be assigned to a specific primary counselor for care management. (V) Each primary counselor shall maintain a case load not to exceed thirty (30) clients with active cases at any one time. 8. Training. The entity shall provide written documentation that all Level I Program personnel satisfy the competency and training requirements as specified in Rule 580-9-44-.02(3). 9. Service Intensity. The entity shall document that the amount and frequency of Level I Outpatient services are established on the basis of the unique needs of each client served, not to exceed eight (8) contact hours weekly. 10. Length of Service. The entity shall provide written documentation that the duration of treatment in each Level I Outpatient Program shall vary as determined by: (i) The severity of the client’s illness. (ii) The client’s ability to comprehend the information provided and use that information to implement treatment strategies and attain treatment goals; or (iii) The appearance of new problems that require another level of care; or (iv) The availability of services at an assessed level of need when Level I services have been utilized as interim services. 11. Service Availability: The entity shall provide written documentation describing the process utilized to establish the hours of service availability for its Level I Outpatient Programs. At a minimum, this process shall: (i) Include consideration of the needs of the target population, including work, school and parenting responsibilities. (ii) Include consideration of transportation accessibility. (iii) Not be based solely on standard eight (8) to five (5), Monday through Friday office hours. Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Amended: Published January 31, 2023; effective March 17, 2023. 580-9-44-.16 Level I-D: Ambulatory Detoxification Without Extended On-Site Monitoring (1) Rule Compliance. Each Level I-D Detoxification Program shall comply with the following rules and the rules specified in this chapter. (a) Program Description: The entity shall develop, maintain and implement a written program description that defines the Level I-D Ambulatory Detoxification without Extended On-site Monitoring Program it provides to include the following specifications: 1. Location: The entity shall specifically identify and describe the setting in which Level I-D Ambulatory Detoxification without Extended On-Site Monitoring Services shall be provided. Services may be provided in any appropriate setting that protects the client’s right to privacy, confidentiality, safety and including but not limited to, a general healthcare facility, a physician’s office or an addiction or mental health treatment facility as pre-authorized by DMH. 2. Admission Criteria: The entity shall develop, maintain and document implementation of written criteria for admission to its Level I-D Ambulatory Detoxification without Extended On-Site Monitoring Program and the following specifications: (i) The entity’s admission criteria shall specify the target population for the Level I-D Program, which shall include, at a minimum, individuals: (I) Experiencing mild withdrawal or at risk of experiencing withdrawal from alcohol and/or other drugs at a level of assessed severity appropriate for outpatient care. (II) Who have adequate systems in place to support outpatient detoxification process. (ii) The entity shall provide written documentation in individual case records that each client admitted to receive Level I-D Ambulatory Detoxification without Extended On-Site Monitoring Services meets: (I) The diagnostic criteria for a Substance Induced Disorder as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders. (II) The dimensional criteria for admission to this level of care as defined in the ASAM PPC-2R. 3. Core Services: Each Level I-D Detoxification Program shall demonstrate the capacity to provide a basic level of skilled treatment services appropriate to the needs of its clientele. (i) At a minimum, the Level I-D Ambulatory Detoxification Program shall document the capacity to provide the following core services: (I) Placement assessment. (II) Individual counseling. (III) Psychoeducation. (IV) Family counseling. (V) Peer support. (VI) Medication administration. (VII) Medication monitoring. (VIII) Alcohol and/or drug screening/testing. (IX) Case management: I. Case planning. II. Linkage. III. Advocacy. IV. Monitoring. 4. Therapeutic Component Implementation. The entity shall document implementation of medical and other clinical services organized to enhance the client’s understanding of addiction, support completion of the detoxification process and initiate transfer to an appropriate level of care for continued treatment. (i) Service strategies for each Level I-D Detoxification Program shall include, at a minimum: (I) Implementation of individualized counseling plan strategies. (II) Completion of a comprehensive medical history and physical examination of the client at admission. (III) Protocols and/or standing orders, established by the entity’s medical director for management of detoxification from each major drug category of abused drugs that are consistent with guidelines published by nationally recognized organizations, including but not limited to, Substance Abuse and Mental Health Services Administration (SAMHSA), American Society of Addiction Medicine (ASAM), the American Psychiatric Association, and the American Academy of Addiction Psychology. I. Level I-D Ambulatory Detoxification Programs that utilize Benzodiazepines in the detoxification protocol: A. Shall have written protocols and procedures to show that all doses or amounts of benzodiazepines are carefully monitored and are slowly reduced as appropriate. B. Shall have written longer-term detoxification protocols and procedures that adhere to general principles of management including clear indications of benzodiazepine dependence, clear intermediate treatment goals and strategies, regular review and methods to prevent diversion from the plan. (IV) Individual ongoing assessment services, including, but not limited to: I. Physical examination by a physician, physician assistant or nurse practitioner. II. Human services need assessment by a case manager. (V) Medication administration and monitoring services including specific procedures for pregnant women. (VI) Motivational enhancement therapy. (VII) Direct affiliation with other levels of care. 5. Documentation: In addition to meeting the requirements an individualized progress note shall be recorded for each respective service provided in Level I-D: (i) Daily assessment of progress, including response to medication, which also notes any treatment regimen changes. (ii) Regular and frequent monitoring of vital signs. (iii) The use of detoxification rating scale tables and flow sheets. (iv) Physician review of all services. 6. Support Systems. The Level I-D Ambulatory Detoxification Program shall develop, maintain and document implementation of written policies and procedures utilized to provide client access to support services on site or through consultation or referral, which shall minimally include: (i) Specialized clinical consultation for biomedical, emotional, behavioral and cognitive problems. (ii) Appropriate laboratory and toxicology testing. (iii) Psychological and psychiatric services. (iv) Twenty-four (24) hour access to emergency services. (v) Transportation. 7. Program Personnel. Each Level I-D Detoxification Program shall employ an adequate number of qualified individuals to provide personalized care for its clientele and to meet the program’s goals and objectives. (i) Medical Director: The Level I-D Detoxification Program shall have a medical director who is a physician licensed to practice in the State of Alabama, with a minimum of one (1) year experience treating persons with substance use disorders. The medical director shall be responsible for admission, diagnosis, medication management and client care. (ii) Nursing Services Director: The Level I-D Program shall have a nursing services director who shall be a Registered Nurse licensed according to Alabama law with training and work experience in behavioral health. (iii) Nursing Personnel: The entity shall have an adequate number of Alabama licensed nurses to assure that the administration of medications during Level I-D Services complies with applicable state and federal regulations. (iv) Case Manager Coordinator: The entity shall have a case manager coordinator who shall be available to the Level I-D Program on at least a 50% Full-time Equivalent (FTE) basis and shall, at a minimum: (I) Have a Bachelor’s Degree in a behavioral science, at least two (2) years case management experience relative to substance use disorders, and completed DMH/Mental Illness and Substance Abuse Services Division approved case management training. (II) Supervise and delegate responsibilities to case managers working in the Level I-D Program. (III) Ensure the availability of person-centered case management services to facilitate Level I-D clients’ transition into ongoing treatment and recovery. (IV) Each client shall be assigned to a case manager for care management. (V) All direct care personnel shall have the qualifications, as a qualified paraprofessional, to provide the specific services delineated in the entity’s program description for this level of care. 8. Training. The entity shall provide written documentation that all Level I-D Program personnel satisfy the competency and training requirements as specified in Rule 580-9-44-.02(3). 9. Service Intensity. The entity shall document in the clinical record that Level I-D Services are provided in regularly scheduled sessions and that the frequency and amount of these services are established on the basis of the unique needs of each client served. 10. Length of Service. The entity shall provide written documentation in the clinical record that the duration of treatment in a Level I-D Program shall vary as determined by the client’s assessed needs and that the client continues in treatment until: (i) Withdrawal signs and symptoms are sufficiently resolved; or (ii) Withdrawal signs and symptoms have failed to respond to treatment and have intensified warranting a transfer to a more intense level of care; or (iii) The client is otherwise unable to complete detoxification at this level of care. 11. Service Availability: The entity shall provide written documentation describing the process utilized to establish the hours of service availability for its Level I-D Ambulatory Detoxification Programs. At a minimum, this process shall: (i) Include consideration of the needs of the target population, including work, school and parenting responsibilities. (ii) Include consideration of transportation accessibility. (iii) Not be based solely on standard eight (8) to five (5), Monday through Friday office hours. Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Amended: Published January 31, 2023; effective March 17, 2023. 580-9-44-.17 Level II.1: Intensive Outpatient Treatment (1) Rule Compliance. Each Level II.1 Intensive Outpatient Program shall comply with the following rules and the rules specified in this chapter. (a) Program Description. The entity shall develop, maintain and implement a written program description that defines the Level II.1 Intensive Outpatient Program it provides to include the following specifications: 1. Location. The entity shall specifically identify and describe the setting in which Level II.1 Intensive Outpatient Services shall be provided. Services may be provided in any appropriate setting that protects the client’s right to privacy, confidentiality, safety and meets the DMH facility certification standards. 2. Admission Criteria. The entity shall develop, maintain and implement written criteria for admission to its Level II.1 Outpatient Program and the following specifications: (i) The entity’s admission criteria shall specify the target population for the Level II.1 Program which shall include, at a minimum, individuals whose assessed severity of illness initially warrants this level of care including but not limited to: (I) Individuals who have fairly stable to stable mental and/or physical health problems; and (II) Who have supportive living arrangements. (ii) The entity shall provide written documentation in individual case records that each client admitted to receive Level II.1 Intensive Outpatient Services meets: (I) The diagnostic criteria for a substance dependence disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders; and (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (iii) Adolescent Program Specific Criteria: The entity shall provide written documentation in individual case records that each adolescent admitted to receive Level II.1 Intensive Outpatient Services meets: (I) The diagnostic criteria for a substance use disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders. (II) The adolescent dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (iv) Co-occurring Disorders Program Specific Criteria: The entity shall provide written documentation in individual case records that each client admitted to receive Level II.1 Intensive Outpatient Services in a Co-occurring Enhanced Treatment Program meets: (I) The diagnostic criteria for a substance dependence and mental illness disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders; and (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (v) Women and Dependent Children Program Specific Criteria: The entity shall provide written documentation in individual case records that each client admitted to receive Level II.1 Intensive Outpatient Services in a Women and Children Program: (I) Meets the diagnostic criteria for a substance dependence disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders. (II) Meets the dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (III) Is pregnant; or (IV) Has care and custody of dependent children; or (V) Has lost custody of dependent children and has the potential for family reunification. 3. Core Services. Each Level II.1 Intensive Outpatient Program shall demonstrate the capacity to provide a basic level of skilled treatment services appropriate to the needs of its clientele. (i) At a minimum, the Level II.1 Intensive Outpatient Program shall directly or by referral provide the following core services: (I) Placement assessment. (II) Individual counseling. (III) Group counseling. (IV) Family counseling. (V) Psychoeducation. (VI) Mental health consultation. (VII) Recovery support services. (VIII) Peer counseling services. (IX) Medication management. (X) Alcohol and/or drug screening/testing. (XI) Smoking cessation. (XII) Sign language interpreter services. (XIII) HIV early intervention services. (XIV) Case management: I. Case planning. II. Linkage. III. Advocacy. IV. Monitoring. (ii) Adolescent Program Specific Criteria: Each Level II.1 Adolescent Intensive Outpatient Program shall document the capacity to provide each of the core services to include the following services: (I) Activity therapy. (II) Academic and vocational services. (III) Vocational services. (iii) Co-occurring Disorders Program Specific Criteria: Each level II.1 Co-occurring Disorders Intensive Outpatient Program shall document the capacity to provide each of the core services to include the following services: (I) Basic living skills. (II) Crisis intervention services. (III) Intensive case management. (IV) Academic and vocational services. (iv) Women and Dependent Children Program Specific Criteria: Each Level II.1 Women and Dependent Children Intensive Outpatient Program shall document the capacity to provide each of the core services and/or arrange for the following services: (I) Transportation. (II) Child sitting services. (III) Developmental delay and/or prevention services. (IV) Activity therapy. (V) Parenting skills development. 4. Therapeutic Component Implementation. The entity shall document implementation of regularly scheduled treatment sessions that are provided in an amount, frequency and intensity appropriate to the client’s assessed needs and expressed desires for care. (i) Service strategies for each Level II.1 Intensive Outpatient Program shall include, at a minimum: (I) Implementation of individualized counseling plan strategies. (II) Ongoing individualized assessment. (III) Motivational enhancement and engagement strategies. (IV) Relapse prevention strategies. (V) Interpersonal choice/decision-making skill development. (VI) Health education. (VII) Random drug screening. (VIII) Medication administration and monitoring. (IX) Gender responsive treatment. (ii) Adolescent Program Specific Criteria: Each Level II.1 Adolescent Intensive Outpatient Program shall document the capacity to provide the service strategies and the following therapeutic components: (I) Adolescent specific evidence based therapeutic interventions. (II) Client education on key adolescent development issues including, but not limited to, adolescent brain development and the impact of substance use, emotional and social influence on behavior, value system development, puberty/physical development, sexuality and self-esteem. (III) Recreation and leisure time skills training. (IV) Family, community and school reintegration services. (V) Academic or vocational services. (iii) Co-occurring Disorders Program Specific Criteria: Each Level II.1 Co-occurring Disorders Outpatient Program shall document the capacity to provide the service strategies and the following therapeutic components: (I) Groups and classes that address the signs and symptoms of mental health and substance use disorders. (II) Groups, classes and training to assist clients in becoming aware of cues or triggers that enhance the likelihood of alcohol and drug use or psychiatric decompensation and to aid in development of alternative coping responses to those cues. (III) Dual recovery groups that provide a forum for discussion of the interactions of and interrelations between substance use and mental health disorders. (IV) Intensive Case Management. (iv) Women and Dependent Children Program Specific Criteria: Each Level II.1 Women and Dependent Children Intensive Outpatient Program shall document the capacity to provide the service strategies and the following therapeutic components: (I) Specific services which address issues of relationships, parenting, abuse and trauma. (II) Primary medical care, including prenatal care. (III) Primary pediatric care for children. (IV) Therapeutic interventions for children which address their developmental needs and issues of sexual abuse and neglect. (V) Outreach to inform pregnant women of the services and priorities. (VI) Interim services while awaiting admission to this level of care. (VII) Recreation and leisure time skills training. (VIII) Academic and vocational services. (IX) Financial resource development and planning. (X) Family planning services. 5. Documentation: For each day in attendance, an individualized progress note shall be recorded to reflect services provided in Level II.1. 6. Support Systems. Each Level II.1 Intensive Outpatient Program shall develop, maintain and document implementation of written policies and procedures which govern the process used to provide client access to support services on site or through consultation or referral, which shall include: (i) Medical, psychiatric, psychological, laboratory and toxicology services. (ii) Medical and psychiatric consultation shall be available within twenty-four (24) hours by telephone or, if in person, within seventy-two (72) hours. (iii) Direct affiliation with or coordination through referral to more and less intensive levels of care and supportive housing services. (iv) Emergency services shall be available by telephone twenty-four (24) hours a day, seven (7) days a week. (v) Mutual self-help groups that are tailored to the needs of the specific client population. (vi) Referral for other services as according to the client’s assessed needs. 7. Program Personnel. Each level II.1 Intensive Outpatient Program shall employ an adequate number of qualified individuals to provide personalized care for its clientele and to meet the program’s goals and objectives. (i) Direct Care Personnel. All direct care personnel shall be qualified as a qualified paraprofessional to provide the specific services delineated in the entity’s operational procedures for this level of care. (ii) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level II.1 Intensive Outpatient Program as delineated in its operational procedures. (iii) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (iv) Every client in a Level II.1 Program shall be assigned to a specific primary counselor for care management. (v) Each primary counselor shall maintain a caseload not to exceed thirty (30) clients with active cases at any one time. (vi) Adolescent Program Specific Criteria. (I) Direct Care Personnel. All direct care personnel shall be qualified, as a qualified paraprofessional to provide the specific services delineated in the entity’s operational plan for this level of care. (II) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level II.1 Adolescent Intensive Outpatient Program as delineated in its operational plan. (III) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (IV) Every client in a Level II.1 Adolescent Intensive Outpatient Program shall be assigned to a specific primary counselor for care management. (V) Each primary counselor shall maintain a case load not to exceed thirty (30) clients with active cases at any one time. (vii) Co-occurring Disorders Program Specific Criteria. (I) The Level II.5 Co-occurring Enhanced Partial Hospitalization Program shall have access to psychiatric services (led by a qualified psychiatrist or nurse practitioner) that are fully capable of evaluating, diagnosing and prescribing medications to clients with co-occurring disorders. On-call psychiatric services shall be available twenty-four (24) hours a day, seven (7) days a week. (III) Treatment organization/agency shall have access to an Alabama licensed physician, full time, part time, or on contract, who shall be available to the program for client care and shall assume liability for the medical aspects of the program. (VI) Treatment staff that provide therapy and ongoing clinical assessment services to individuals diagnosed with co-occurring disorders shall have, at a minimum: I. A master’s degree in a behavioral health related field with a minimum of two (2) years’ work experience with individuals who have co-occurring disorders, mental health or substance use disorders. II. Specialized training to work with individuals who have co-occurring disorders. (V) All other direct care personnel in a Level II.1 Co-occurring Enhanced Intensive Outpatient Program shall be qualified as a qualified paraprofessional to provide the specific services delineated in the entity’s operational plan for this level of care. (VI) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level II.1 Co-occurring Enhanced Outpatient Program as delineated in its operational plan. (VII) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (VIII) Every client in a Level II.1 Co-occurring Intensive Outpatient Program shall be assigned to a specific primary counselor for care management. (IX) Each primary counselor shall maintain a case load not to exceed twenty (20) clients with active cases at any one time. (viii) Women and Dependent Children Program Specific Criteria: (I) Direct Care Personnel. All direct care personnel shall be qualified as a qualified paraprofessional to provide the specific services delineated in the entity’s operational plan for this level of care. (II) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level II.1 Women and Dependent Children Intensive Outpatient Program as delineated in its operational plan. (III) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (IV) Every client in a Level II.1 Women and Dependent Children Program shall be assigned to a specific primary counselor for case management. (V) Each primary counselor shall maintain a case load not to exceed twenty (20) clients with active cases at any one time. 8. Training. The entity shall provide written documentation that all Level II.1 Program personnel satisfy the competency and training requirements as specified in Rule 580-9-44-.02(3). 9. Service Intensity. (i) The entity shall document that the amount and frequency of Level II.1 Intensive Outpatient Services are established on the basis of the unique needs of each client served and shall be available a minimum of nine (9) hours but no greater than nineteen (19) hours each week. (ii) Adolescent Program Specific Criteria. The entity shall document that the amount and frequency of Level II.1 Intensive Outpatient Services for adolescents are established on the basis of the unique needs of each client served and shall be available a minimum of six (6) hours but no greater than nineteen (19) hours each week. 10. Length of Service: The entity shall provide written documentation that the duration of treatment in each Level II.1 Intensive Outpatient Program shall vary as determined by: (i) The severity of the client’s illness. (ii) The client’s ability to comprehend the information provided and use that information to implement treatment strategies and attain treatment goals. (iii) The appearance of new problems that require another level of care; or (iv) The availability of services at an assessed level of need, when Level II.1 service have been utilized as interim services. 11. Service Availability: The entity shall provide written documentation describing the process utilized to establish the hours of service availability for its Level II.1 Intensive Outpatient Programs. At a minimum, this process shall: (i) Include consideration of the needs of the target population, including work, school and parenting responsibilities. (ii) Include consideration of transportation accessibility. (iii) Not be based solely on standard eight (8) to five (5), Monday through Friday office hours. Authority: Code of Ala. 1975, §22-50-11. History: History: New Rule: Filed January 26, 2012; effective March 1, 2012. Amended: Published January 31, 2023; effective March 17, 2023. 580-9-44-.18 Level II.5: Partial Hospitalization Treatment Program (1) Rule Compliance. Each Level II.5 Partial Hospitalization Program shall comply with the following rules and the rules specified in this chapter: (List applicable rules found throughout the standards) (a) Program Description. The entity shall develop, maintain and implement a written program description that defines the Level II.5 Partial Hospitalization Program it provides, as according to Rule 580-9-44-.13 and the following specifications: 1. Location. The entity shall specifically identify and describe the setting in which Level II.5 Partial Hospitalization Services shall be provided. Services may be provided in any appropriate setting that protects the client’s right to privacy, confidentiality, safety and meets DMH facility certification criteria. 2. Admission Criteria. The entity shall develop, maintain and implement written criteria for admission to its Level II.5 Partial Hospitalization Program, in compliance with the requirements of Rule 580-9-44-.13(9), and the following specifications: (i) The entity’s admission criteria shall specify the target population for the Level II.5 Program, which shall include at a minimum, individuals whose assessed severity of illness initially warrants this level of care including but not limited to: (I) Individuals who have fairly unstable mental and/or physical health problems. (II) Who have unstable or dysfunctional, but adequate living arrangements. (ii) The entity shall provide written documentation in individual case records that each client admitted to receive Level II.5 Partial Hospitalization Services meets: (I) The diagnostic criteria for a substance dependence disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders. (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (iii) Adolescent Program Specific Criteria: The entity shall provide written documentation in individual case records that each adolescent admitted to receive Level II.5 Partial Hospitalization Services meets: (I) The diagnostic criteria for a substance use disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders. (II) The adolescent dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (iv) Co-occurring Disorders Program Specific Criteria: The entity shall provide written documentation in individual case records that each individual admitted to receive Level II.5 Partial Hospitalization Services in a Co-occurring Enhanced Treatment Program meets: (I) The diagnostic criteria for a substance dependence and mental illness disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders. (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (v) Women and Dependent Children Program Specific Criteria: The entity shall provide written documentation in individual case records that each client admitted to receive Level II.5 Partial Hospitalization Services in a Women and Dependent Children Program meets: (I) The diagnostic criteria for a substance dependence disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders. (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (III) Is pregnant; or (IV) Has care and custody of dependent children; or (V) Has lost custody of dependent children and has the potential for family reunification. 3. Core Services. Each Level II.5 Partial Hospitalization Program shall demonstrate the capacity to provide a basic level of skilled treatment services appropriate to the needs of its clientele. (i) At a minimum, the Level II.5 Partial Hospitalization Program shall provide the following core services: (I) Placement assessment. (II) Individual counseling. (III) Group counseling. (IV) Family counseling. (V) Psychoeducation. (VI) Mental health consultation. (VII) Recovery support services. (VIII) Peer counseling services. (IX) Medication management. (X) Alcohol and/or drug screening/testing. (XI) Smoking cessation. (XII) Sign language interpreter services. (XIII) HIV early intervention services. (XIV) Case management: I. Case planning. II. Linkage. III. Advocacy. IV. Monitoring. (ii) Adolescent Program Specific Criteria: Each Level II.5 Partial Hospitalization Program shall document the capacity to provide each of the core services to include the following services: (I) Activity therapy. (II) Academic or vocational services. (iii) Co-occurring Disorders Program Specific Criteria: Each Level II.5 Partial Hospitalization Program shall document the capacity to provide each of the core services to include the following services: (I) Basic living skills. (II) Crisis intervention services. (III) Activity therapy. (IV) Intensive case management. (iv) Women and Dependent Children Program Specific Criteria: Each Level II.5 Women and Dependent Children Partial Hospitalization Program shall document the capacity to provide each of the core services and/or arrange for the following services: (I) Transportation. (II) Child sitting services. (III) Developmental delay and prevention services. (IV) Activity therapy. (V) Parenting skills development. 4. Therapeutic Component Implementation. The entity shall document implementation of regularly scheduled treatment sessions that are provided in an amount, frequency and intensity appropriate to the client’s assessed needs and expressed desires for care. (i) Service strategies for each Level II.5 Partial Hospitalization Program shall include, at a minimum: (I) Implementation of individualized counseling plan strategies. (II) Ongoing individualized assessment services. (III) Motivational enhancement and engagement strategies. (IV) Relapse prevention strategies. (V) Interpersonal choice/decision-making skill development. (VI) Health education. (VII) Random drug screening. (VIII) Medication administration and monitoring. (VII) Family education. (X) Gender responsive treatment. (ii) Adolescent Program Specific Criteria: Each Level II.5 Adolescent Partial Hospitalization Program shall document the capacity to provide the service strategies to include the following therapeutic components: (I) Adolescent specific evidence based therapeutic interventions. (II) Client education on key adolescent development issues including, but not limited to, adolescent brain development and the impact of substance use, emotional and social influence on behavior, value system development, puberty/physical development, sexuality and self-esteem. (III) Recreation and leisure time skills training. (IV) Family, community and school reintegration services. (V) Academic or vocational services (iii) Co-occurring Disorders Program Specific Criteria: Each Level II.5 Co-occurring Enhanced Partial Hospitalization Program shall document the capacity to provide the service strategies to include the following therapeutic components: (I) Groups and classes that address the signs and symptoms of mental health and substance use disorders. (II) Groups, classes and training to assist clients in becoming aware of cues or triggers that enhance the likelihood of alcohol and drug use or psychiatric decompensation and to aid in development of alternative coping responses to those cues. (III) Dual recovery groups that provide a forum for discussion of the interactions of and interrelations between substance use and mental health disorders. (IV) Intensive case management. (iv) Women and Dependent Children Program Specific Criteria: Each Level II.5 Women and Dependent Children Partial Hospitalization Program shall document the capacity to provide the service strategies and/or arrange for the following therapeutic components: (I) Specific services which address issues of relationships, parenting abuse and trauma. (II) Primary medical care, including prenatal care. (III) Primary pediatric care for children. (IV) Therapeutic interventions for children which address their developmental needs and issues of sexual abuse and neglect. (V) Outreach to inform pregnant women of the services and priorities. (VI) Interim services while awaiting admission to this level of care. (VII) Recreation and leisure time skills training. (VIII) Academic and vocational services. (IX) Financial resources and planning. (X) Family planning services. 5. Documentation: For each day in attendance an individual progress note shall be recorded to reflect services provided in Level II.5 Partial Hospitalization. 6. Support Systems. Each Level II.5 Partial Hospitalization Program shall develop, maintain and document implementation of written policies and procedures that govern the process used to provide client access to support services on site, or through consultation or referral, which shall minimally include: (i) Medical, psychiatric, psychological, laboratory and toxicology services. (ii) Medical and psychiatric consultation shall be available within twenty-four (24) hours by telephone or, if in person, within forty-eight (48) hours. (iii) Direct affiliation with, or coordination through referral to more and less intensive levels of care and supportive housing services. (iv) Emergency services shall be available by telephone twenty-four (24) hours a day, seven (7) days a week. (v) Mutual self-help groups that are tailored to the needs of the specific client population. (vi) Referral for other services as according to the client’s assessed needs. 7. Program Personnel. Each Level II.5 Partial Hospitalization Program shall employ an adequate number of qualified individuals to provide personalized care for its clientele and to meet the program’s goals and objectives. (i) Direct Care Personnel. All direct care personnel shall be qualified as a qualified paraprofessional to provide the specific services delineated in the entity’s operational procedures for this level of care. (ii) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level II.5 Partial Hospitalization Program as delineated in its operational procedures. (iii) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (iv) Every client in a Level II.5 Partial Hospitalization Program shall be assigned to a specific Primary Counselor for care management. (v) Each primary counselor shall maintain a case load not to exceed thirty (30) clients with active cases at any one time. (vi) Adolescent Program Specific Criteria. (I) Direct Care Personnel. All direct care personnel shall be qualified as a qualified paraprofessional to provide the specific services delineated in the entity’s operational plan for this level of care. (II) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level II.5 Partial Hospitalization Program as delineated in its operational plan. (III) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (IV) Every client in a Level II.5 Adolescent Partial Hospitalization Program shall be assigned to a specific primary counselor for care management. (V) Each primary counselor shall maintain a case load not to exceed thirty (30) clients with active cases at any one time. (vii) Co-occurring Disorders Program Specific Criteria. (I) The Level II.5 Co-occurring Enhanced Partial Hospitalization Program shall have access to psychiatric services (led by a qualified psychiatrist or nurse practitioner) that are fully capable of evaluating, diagnosing and prescribing medications to clients with co-occurring disorders. On-call psychiatric services shall be available twenty-four (24) hours a day, seven (7) days a week. (II) The treatment organization/agency shall have access to an Alabama licensed physician, full time, part time, or on contract, who shall be available to the program for client care and shall assume liability for the medical aspects of the program. (III) Treatment staff that provide therapy and ongoing clinical assessment services to individuals diagnosed with co-occurring disorders, shall have, at a minimum: I. A master’s degree in a behavioral health related field with a minimum of two (2) years’ work experience with individuals who have co-occurring disorders, mental health or substance use disorders. II. Specialized training to work with individuals who have co-occurring disorders. (V) All other direct care personnel in a Level II.5 Co-occurring Enhanced Partial Hospitalization Program shall be qualified, as a qualified paraprofessional to provide the specific services delineated in the entity’s operational procedures for this level of care. (VI) The entity shall maintain an adequate number of clinical personnel to sustain the Level II.5 Co-occurring Enhanced Partial Hospitalization Program as delineated in its operational procedures. (VII) The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (VIII) Every client in a Level II.5 Co-occurring Enhanced Partial Hospitalization Program shall be assigned to a specific primary counselor for care management. (IX) Each primary counselor shall maintain a case load not to exceed twenty (20) clients with active cases at any one time. (viii) Women and Dependent Children Program Specific Criteria: (I) Direct Care Personnel. All direct care personnel shall be qualified, as a qualified paraprofessional to provide the specific services delineated in the entity’s operational plan for this level of care. (II) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level II.5 Women and Dependent Children Partial Hospitalization Program as delineated in its operational plan. (III) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (IV) Every client in a Level II.5 Women and Dependent Children program shall be assigned to a specific primary counselor for care management. (V) Each primary counselor shall maintain a case load not to exceed twenty (20) clients with active cases at any one time. 8. Training. The entity shall provide written documentation that all Level II.5 program personnel satisfy the competency and training requirements as specified in Rule 580-9-44-.02(3). 9. Service Intensity: The entity shall document that the amount and frequency of Level II.5 Partial Hospitalization Services are established on the basis of the unique needs of each client served and shall be available a minimum of twenty (20) hours each week. 10. Length of Service: The entity shall provide written documentation that the duration of treatment in each Level II.5 Partial Hospitalization Program shall vary as determined by: (i) The severity of the client’s illness. (ii) The client’s ability to comprehend the information provided and use that information to implement treatment strategies and attain treatment goals. (iii) The appearance of new problems that require another level of care; or (iv) The availability of services at an assessed level of need when Level II.5 services have been utilized as interim services. 11. Service Availability: The entity shall provide written documentation describing the process utilized to establish the hours of service availability for its Level II.5 Partial Hospitalization Program. At a minimum, this process shall: (i) Include consideration of the needs of the target population, including work, school and parenting responsibilities. (ii) Include consideration of transportation accessibility. (iii) Not be based solely on standard eight (8) to five (5), Monday through Friday office hours. Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Amended: Published January 31, 2023; effective March 17, 2023. 580-9-44-.19 Level II-D: Ambulatory Detoxification With Extended On-Site Monitoring (1) Rule Compliance. Each Level II-D Ambulatory Detoxification Program shall comply with the following rules and the rules specified in this chapter. (a) Program Description. The entity shall develop, maintain and implement a written program description that defines the Level II-D Ambulatory Detoxification Program it provides, as according to Rule 580-9-44-.13 and the following specifications: 1. Location. The entity shall specifically identify and describe the setting in which Level II-D Ambulatory Detoxification with Extended On-Site Monitoring services shall be provided. Services may be provided in any appropriate setting that protects the client’s right to privacy, confidentiality, safety and meets the DMH facility certification standards. 2. Admission Criteria: The entity shall develop, maintain and document implementation of written criteria for admission to its Level II-D Ambulatory Detoxification With Extended On-Site Monitoring Program, in compliance with the requirements of Rule 580-9-44-.13(9) and the following specifications: (i) The entity’s admission criteria shall specify the target population for the Level II-D program, which shall include, at a minimum, individuals who: (I) Have been assessed as being at moderate risk of severe withdrawal syndrome outside of the program setting. (II) Are free of severe, unstabilized physical and psychiatric complications. (III) Who do not have adequate family or other service systems in place to support an outpatient detoxification process. (ii) The entity shall provide written documentation in individual case records that each client admitted to receive Level II-D Ambulatory Detoxification with Extended On-Site Monitoring Services meets: (I) The diagnostic criteria for Substance Induced Disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders. (II) The dimensional criteria for admission to this level of care as defined in the ASAM PPC-2R. 3. Core Services: Each Level II-D Ambulatory Detoxification Program shall demonstrate the capacity to provide a basic level of skilled treatment services appropriate to the needs of its clientele. (i) At a minimum, the Level II-D Ambulatory Detoxification Program shall document the capacity to provide the following core services: (I) Placement assessment. (II) Individual counseling. (III) Group counseling. (IV) Psychoeducation. (V) Family counseling. (VI) Medical and somatic services. (VII) Medication administration. (VIII) Medication monitoring. (IX) Alcohol and/or drug screening/testing. (X) Case management: I. Case planning. II. Linkage. III. Advocacy. IV. Monitoring. 4. Therapeutic Component Implementation: The entity shall document implementation of medical and other clinical services organized to enhance the client’s understanding of addiction, support completion of the detoxification process and initiate transfer to an appropriate level of care for continued treatment. The entity’s Level II-D program shall, at a minimum, consist of the following components: (i) Completion of a comprehensive medical history and physical examination of the client at admission. (ii) Protocols and/or standing orders, established by the entity’s medical director, for management of detoxification from each major drug category of abused drugs that are consistent with guidelines published by nationally recognized organizations (e.g., SAMHSA, ASAM, American Academy of Addiction Psychology). (I) Level II-D Ambulatory Detoxification Programs that utilize benzodiazepines in the detoxification protocol: I. Shall have written protocols and procedures to show that all doses or amounts of benzodiazepines are carefully monitored and are slowly reduced as appropriate. II. Shall have written longer-term detoxification protocols and procedures that adhere to general principles of management including clear indications of benzodiazepine dependence, clear intermediate treatment goals and strategies, regular review and methods to prevent diversion from the plan. (iii) On-site physician and/or nurse monitoring, assessment and management of signs and symptoms of intoxication and withdrawal. (iv) Medication administration and monitoring services including specific procedures for pregnant women. (v) Ongoing Intake Interview Examination. (vi) Direct affiliation with other levels of care. 5. Documentation: Level II-D Ambulatory Detoxification Programs shall provide the following: (i) Documentation of each clinical/therapeutic intervention provided. (ii) Daily assessment of progress including response to medication, which also notes any treatment changes. (iii) Monitoring of vital signs each day the client is on site. (iv) The use of detoxification rating scale tables and flow sheets. (v) Physician review of all services. 6. Support Systems. The Level II-D Ambulatory Detoxification Program shall develop, maintain and document implementation of written policies and procedures utilized to provide client access to support services on site, or through consultation or referral, which shall minimally include: (i) Specialized clinical consultation for biomedical, emotional, behavioral and cognitive problems. (ii) Appropriate laboratory and toxicology testing. (iii) Psychological and psychiatric services. (iv) Transportation. (v) Twenty-four (24) hour access to emergency medical services. 7. Program Personnel: Each Level II-D Ambulatory Detoxification Program shall employ an adequate number of qualified individuals to provide personalized care for its clientele and to meet the program’s goals and objectives. (i) Medical Director: The Level II-D Detoxification Program shall have a medical director who is a physician licensed to practice in the state of Alabama, with a minimum of one (1) year experience treating persons with substance induced disorders. The medical director shall be responsible for admission, diagnosis, medication management and client care. (ii) Nursing Services Director: The Level II-D Program shall have a nursing services director who shall be a Registered Nurse licensed according to Alabama law, with training and work experience in behavioral health. (iii) Nursing Personnel: The entity shall have an adequate number of Alabama licensed nurses to assure that the administration of medications during Level I-D services complies with applicable state and federal regulations. (I) There shall be a Registered Nurse or Licensed Practical Nurse on site during all hours of the Level II-D Program’s operation. (v) Clinical staff providing services shall have access to a full-time clinical director. (vi) All direct care personnel shall have the qualifications as a qualified paraprofessional, to provide the specific services delineated in the entity’s program description for this level of care. (vii) The entity shall maintain an adequate number of physicians, nurses, counselors and case managers to sustain the Level II-D Ambulatory Detoxification Outpatient Program as delineated in its program operational procedures. (viii) The entity shall maintain an adequate number of administrative support personnel to sustain the program’s administrative functions. 8. Training. The entity shall provide written documentation that all Level II-D Program personnel satisfy the competency and training requirements as specified in Rule 580-9-44-.02(3). 9. Service Intensity. The entity shall document in the clinical record that Level II-D Services are provided in regularly scheduled sessions and that: (i) The entity has the demonstrated capacity to provide a structured program of clinical services for a minimum of nine (9) hours per week. (ii) The frequency and amount of Level II-D Services are established on the basis of the unique needs of each client served. 10. Length of Service. The entity shall provide written documentation in the clinical record that the duration of treatment in a Level II-D Program varies as determined by the client’s assessed needs and that the client continues in treatment until: (i) Withdrawal signs and symptoms are sufficiently resolved; or (ii) Withdrawal signs and symptoms have failed to respond to treatment and have intensified warranting a transfer to a more intense level of care; or (iii) The client is, otherwise, unable to complete detoxification at this level of care. 11. Service Availability: The entity shall provide written documentation describing the process utilized to establish the hours of service availability for its Level II-D Program. At a minimum, this process shall: (i) Include consideration of the needs of the target population including work, school and parenting responsibilities. (ii) Include consideration of transportation. (iii) Not be based solely on standard eight(8) to five(5), Monday through Friday office hours. Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Amended: Published January 31, 2023; effective March 17, 2023. 580-9-44-.20 Level III.01: Transitional Residential Program (1) Rule Compliance. Each Level III.01 Transitional Residential Program shall comply with the following rules and the rules specified in this chapter. Mental Health Chapter 580-9-44 Revised 3/17/23 9-44-81 (a) Program Description. The entity shall develop, maintain, and implement a written program description that defines the Level III.01 Transitional Residential Program it provides, as according to Rule 580-9-44-.13 and the following specifications: 1. Location. The entity shall specifically identify and describe the setting in which the Level III.01 Transitional Residential Program shall be provided. Services shall be provided in any facility that meets all applicable federal, state and local certification, licensure, building, life-safety, fire, health and zoning regulations including the DMH facility certification standards. 2. Admission Criteria: The entity shall develop, maintain and document implementation of written criteria for admission to its Level III.01 Transitional Residential Program, in compliance with the requirements of Rule 580-9-44-.13(9) and the following specifications: (i) The entity’s admission criteria shall specify the target population for its Level III.01 Services, which shall include, at a minimum: (I) Individuals whose assessed severity of illness warrants this level of care. (II) Individuals who have a need for support in a twenty-four (24) hour drug-free environment in order to reintegrate into the community after treatment in a more intense level of care. (ii) The entity shall provide written documentation in individual case records that each client admitted to a Level III.01 Program meets the following diagnostic and modified ASAM PPC2R dimensional criteria for this level of care: (I) The client shall meet the criteria for a substance use disorder, as according to the specific diagnostic criteria given in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. (II) Acute Intoxication and/or Withdrawal: I. The client shall not report experiencing or display any signs or symptoms of alcohol or other drug withdrawal. (III) Biomedical Conditions and Complications: I. The client’s biomedical problems, if any, shall be stable, and shall not require medical or nurse monitoring by the transitional program. II. The client shall be capable of self-administering any prescribed or required over the counter medication. (IV) Emotional, Behavioral, or Cognitive Conditions and Complications: I. The client shall not report or display symptoms of a co-occurring psychiatric, emotional, behavioral, or behavioral condition; or II. The client’s co-occurring psychiatric, emotional, behavioral, or cognitive disorder shall be: A. Stable. B. Self-manageable. C. Addressed concurrently through appropriate psychiatric services. III. The client shall be assessed as not posing a risk of harm to self or others. (V) Readiness to Change: I. The client shall acknowledge the existence of a substance use disorder, or a co-occurring substance use and psychiatric, emotional, behavioral, or cognitive disorder and expresses and demonstrates a desire to make needed changes to support recovery. (VI) Relapse, Continued Use, or Continued Problem Potential: I. The client’s history indicates a high risk of relapse in a less structured level of care; or II. The client needs regimented support to maintain engagement in a recovery focused process on community reintegration. (VII) Recovery Environment: I. The client has insufficient resources and skills to maintain a recovery-oriented lifestyle outside of a twenty-four (24) hour supportive environment. 3. Core Services: Each Level III.01 Transitional Residential Program shall demonstrate the capacity to provide a basic level of treatment services appropriate to the needs of its clientele. (i) At a minimum, the entity shall demonstrate and document its capacity to provide a twenty-four (24) hour structured residential treatment environment with the following core services: (I) Placement assessment. (II) Psychoeducation. (III) Peer support. (IV) Daily living skills. (V) Alcohol and/or drug screening/testing. (VI) Transportation. (VII) Case Management: I. Case planning. II. Linkage. III. Advocacy. IV. Monitoring. 4. Therapeutic Component Implementation. The entity shall document implementation of regularly scheduled treatment sessions that are provided in an amount, frequency and intensity appropriate to the client’s assessed needs and expressed desires for care. (i) Service strategies for each Level III.01 Transitional Residential Program shall include, at a minimum: (I) Maintenance of an alcohol and illicit drug free environment. (II) Implementation of individualized service plan strategies. (III) On duty, awake staff shall provide supervision of client’s health, welfare and safety twenty-four (24) hours a day. (IV) All clients enrolled in Level III.01 Programs shall have access to clinical services twenty-four (24) hours a day, seven (7) days a week. (V) The entity shall document the provision of planned recovery support services and activities that shall, at a minimum, include: I. Motivational strategies. II. Relapse prevention counseling. III. Interpersonal choices/decision making skills development. IV. Development of a social network supportive of recovery. V. Daily living and recovery skills development. VI. Random drug screening. VII. Health education. 5. Documentation. Individualized progress notes shall be recorded each day for each respective service provided in Level III.01 Services. 6. Support Systems. Each level III.01 Transitional Residential Program shall develop, maintain and document implementation of written policies and procedures that govern the process used to provide client access to support services at the Level III.01 Program site, or through consultation or referral, which shall minimally include: (i) Telephone or in person consultation with emergency services twenty-four (24) hours a day, seven (7) days a week. (ii) Telephone or in person consultation with a Registered Nurse twenty-four (24) hours a day, seven (7) days a week. (iii) Direct affiliation with or coordination through referral to more and less intensive levels of care. (iv) Direct affiliation with or coordination through referral to supportive services, including vocational rehabilitation, literacy training and adult education. (v) Mutual self-help groups which are tailored to the needs of the specific client population. 7. Program Personnel. Each Level III.01 Transitional Residential Program shall employ an adequate number of qualified individuals to provide personalized care for its clientele and to meet the program’s goals and objectives. (i) Direct Care Personnel: All direct care personnel shall have the qualifications as a qualified paraprofessional to provide the specific services delineated in the entity’s program description for this level of care. (iii) Administrative Support Personnel: The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (iii) Every client in a Level III.01 Transitional Residential Program shall be assigned to a specific primary counselor for care management. 8. Training. The entity shall provide written documentation that all Level III.01 Program personnel satisfy the competency and training requirements as specified in Rule 580-9-44-.02(3). 9. Service Intensity. The entity shall document that the amount and frequency of Level III.01 Services are established on the basis of the unique needs of each client served. 10. Length of Service. The entity shall provide written documentation that the duration of treatment in its Level III.01 Program is variable as determined by: (i) The severity of the client’s illness. (ii) The client’s ability to comprehend the information provided and use that information to meet treatment goals and strategies; or (iii) The appearance of new problems that require another level of care; or (iv) The availability of services at an assessed level of need, when a Level III.01 Transitional Residential Program has been utilized as an interim level of care. 11. Service Availability: The entity shall provide written documentation describing the process utilized to establish hours of availability for screening, assessment and intake services, admission and counseling services at its Level III.01 Transitional Residential Program. At a minimum, this process shall: (i) Include consideration of the needs of the target population, including work, school and parenting responsibilities. (ii) Include consideration of transportation accessibility. (iii) Not be based solely on standard eight (8) to five (5), Monday through Friday office hours. Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Amended: Published January 31, 2023; effective March 17, 2023. 580-9-44-.21 Level III.1: Clinically Managed Low Intensity Residential Treatment Program (1) Rule Compliance. In addition to compliance with the rules as specified in this chapter, each Level III.1 Clinically Managed Low Intensity Residential Treatment Program shall comply with the rules as specified in the following chapters. (a) Program Description. The entity shall develop, maintain and implement a written program description that defines the Level III.1 Clinically Managed Low Intensity Residential Treatment Program it provides, as according to Rule 580-9-44-.13 and the following specifications: 1. Location. The entity shall specifically identify and describe the setting in which the Level III.1 Program shall be provided. Services shall be provided in any facility that meets all applicable federal, state and local certification, licensure, building, life-safety, fire, health and zoning regulations including the DMH facility certification standards. 2. Admission Criteria: The entity shall develop, maintain and document implementation of written criteria for admission to its Level III.1 Program, in compliance with the requirements of Rule 580-9-44-.13(9) and the following specifications: (i) The entity’s admission criteria shall specify the target population for its Level III.1 Services, which shall include, at a minimum, individuals: (I) Whose assessed severity of illness warrants this level of care including, but not limited to: I. Individuals who have a need for structure and support in a twenty-four (24) hour drug-free environment in order to: A. Engage in treatment. B. Sustain participation in regular productive, daily activities or current treatment for physical or mental disorders. C. Develop, integrate and practice recovery and coping skills. D. Continue treatment for a substance use disorder as a step-down from a more intense level of care. (ii) The entity shall provide written documentation in individual case records that each client admitted to a Level III.1 Program meets: (I) The diagnostic criteria for a substance use disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders. (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (iii) Adolescent Program Specific Criteria: The entity shall provide written documentation in individual case records that each adolescent admitted to a Level III.1 Program meets: (I) The diagnostic criteria for a substance use disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders. (II) The adolescent dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (iv) Co-occurring Disorders Program Specific Criteria: The entity shall provide written documentation in individual case records that each individual admitted to a Level III.1 Co-occurring Enhanced Treatment Program meets: (I) The diagnostic criteria for a substance dependence and mental illness disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders. (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (v) Women and Dependent Children Program Specific Criteria: The entity shall provide written documentation in individual case records that each client admitted to a Level III.1 Program for Women and Dependent Children: (I) Meets the diagnostic criteria for a substance dependence disorder as defined in the most recent edition Diagnostic and Statistical Manual for Mental Disorders; and (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (III) Is pregnant; or (IV) Has care and custody of dependent children; or (V) Has lost custody of dependent children and has the potential for family reunification. 3. Core Services: Each Level III.1 Low Intensity Residential Program shall demonstrate the capacity to provide a basic level of treatment services appropriate to the needs of its clientele. (i) At a minimum, the entity shall demonstrate and document its capacity to provide a twenty-four (24) hour structured residential treatment environment with the following core services: (I) Placement assessment. (II) Individual counseling. (III) Group counseling. (IV) Family counseling. (V) Psychoeducation. (VI) Peer support. (VII) Daily living skills. (VIII) Medication management. (IX) Alcohol and/or drug screening/testing. (X) Transportation. (XI) Case management: I. Case planning. II. Linkage. III. Advocacy. IV. Monitoring. (ii) Medical Services. Medical services, including a physical examination, shall be provided as specified by the entity’s medical protocols established as required by Rule 580-9-44-.13(24). (iii) Adolescent Program Specific Criteria: Each Level III.1 Adolescent Low Intensity Residential Treatment Program shall document the capacity to provide each of the core services and the following services: (I) Activity therapy. (II) Academic or vocational services. (iv) Co-occurring Disorders Program Specific Criteria: Each Level III.1 Co-occurring Disorders Low Intensity Residential Treatment Program shall document the capacity to provide each of the core services and the following services: (I) Basic living skills. (II) Crisis intervention services. (III) Activity therapy. (IV) Intensive case management. (v) Women and Dependent Children Program Specific Criteria: Each Level III.1 Women and Dependent Children Low Intensity Residential Treatment Program shall document the capacity to provide each of the core services and the following services: (I) Transportation. (II) Child sitting services. (III) Developmental delay and prevention services. (IV) Activity therapy. (V) Parenting skills development. 4. Therapeutic Component Implementation. The entity shall document implementation of regularly scheduled treatment sessions that are provided in an amount, frequency and intensity appropriate to the client’s assessed needs and expressed desires for care. (i) Service strategies for each Level III.1 Residential Program shall include, at a minimum: (I) Maintenance of an alcohol and illicit drug-free residential environment. (II) Implementation of individualized counseling plan strategies. (III) On duty, awake staff shall provide supervision of client’s health, welfare and safety twenty-four (24) hours a day. (IV) All clients enrolled in Level III.1 Programs shall have access to clinical services twenty-four (24) hours a day, seven (7) days a week. (V) The entity shall document the provision of planned counseling and recovery support services and activities that shall, at a minimum, include: I. Motivational and engagement strategies. II. Relapse prevention. III. Interpersonal choice/decision making skill development. IV. Development of a social network supportive of recovery. V. Daily living and recovery skills development. VI. Random drug screening. VII. Health education. VIII. Medication management and administration. (ii) Adolescent Program Specific Criteria: Each Level III.1 Adolescent Low Intensity Residential Treatment Program shall document the capacity to provide the service strategies and the following therapeutic components: (I) Client education on key adolescent development issues, including but not limited to, adolescent brain development and the impact of substance use, emotional and social influence on behavior, value system development, puberty/physical development, sexuality and self-esteem. (II) Recreation and leisure time skills training. (III) Gender specific treatment. (IV) Family, community and school reintegration services. (V) Academic or vocational services. (iii) Co-occurring Disorders Program Specific Criteria: Each Level III.1 Co-occurring Disorders Low Intensity Residential Program shall document the capacity to provide the service strategies and the following therapeutic components: (I) Groups and classes that address the signs and symptoms of mental health and substance use disorders. (II) Groups, classes and training to assist clients in becoming aware of cues or triggers that enhance the likelihood of alcohol and drug use or psychiatric decompensation and to aid in development of alternative coping responses to those cues. (III) Dual recovery groups that provide a forum for discussion of the interactions of and interrelations between substance use and mental health disorders. (IV) Intensive case management. (iv) Women and Dependent Children Program Specific Criteria: Each Level III.1 Low Intensity Residential Treatment Women and Dependent Children Program shall document the capacity to provide the service strategies and the following therapeutic components: (I) Gender specific services which address issues of relationships, parenting, abuse and trauma. (II) Primary medical care including prenatal care. (III) Primary pediatric care for children. (IV) Therapeutic interventions for children which address their developmental needs and issues of sexual abuse and neglect. (V) Outreach to inform pregnant women of the services and priorities. (VI) Interim services while awaiting admission to this level of care. (VII) Recreation and leisure time skills training. (VIII) Academic or vocational services. (IX) Financial resource development and planning. (X) Family planning services. 5. Documentation: Each Level III.1 Intensive Outpatient Program shall provide the following documentation in each client record: (i) Individualized progress notes shall be recorded each day for each respective service provided in Level III.1 Services. 6. Support Systems. Each Level III.1 Program shall develop, maintain and document implementation of written policies and procedures which govern the process used to provide client access to support services on site, or through consultation or referral, which shall minimally include: (i) Telephone or in person consultation with a physician available twenty-four (24) hours a day, seven (7) days a week. (ii) Telephone or in person consultation with emergency services twenty-four (24) hours a day, seven (7) days a week. (iii) Direct affiliation with, or coordination through referral to more and less intensive levels of care. (iv) Direct affiliation with, or coordination through referral to supportive services, including vocational rehabilitation, literacy training and adult education. (v) Mutual self-help groups which are tailored to the needs of the specific client population. 7. Program Personnel. Each level III.1 Low Intensity Residential Program shall employ an adequate number of qualified individuals to provide personalized care for its clientele and to meet the program’s goals and objectives. (i) Direct Care Personnel. All direct care personnel shall have the qualifications as specified to provide the specific services delineated in the entity’s program description for this level of care. (ii) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level III.1 Program as delineated in its operational procedures. (iii) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (iv) Every client in a Level III.1 program shall be assigned to a specific primary counselor for care management. (v) Each primary counselor shall maintain a case load not to exceed fifteen (15) clients with active cases at any one time. (vi) Adolescent Program Specific Criteria. (I) Direct Care Personnel. All direct care personnel shall be qualified as a qualified paraprofessional to provide the specific services delineated in the entity’s operational plan for this level of care. (II) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level III.1 Low Intensity Residential Program as delineated in its operational plan. (III) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (IV) Every client in a Level III.1 Adolescent Low Intensity Residential Treatment Program shall be assigned to a specific primary counselor for care management. (V) Each primary counselor shall maintain a case load not to exceed fifteen (15) clients with active cases at any one time. (vii) Co-occurring Disorders Program Specific Criteria. (I) Each Level III.1 Co-occurring Enhanced Low Intensity Residential Program shall have access to psychiatric services (led by a qualified psychiatrist or nurse practitioner) that are fully capable of evaluating, diagnosing and prescribing medications to clients with co-occurring disorders. On-call psychiatric services shall be available twenty-four (24) hours a day, seven (7) days a week. (II) The treatment organization/agency shall have access to an Alabama licensed physician, full time, part time, or on contract, who shall be available to the program for client care and shall assume liability for the medical aspects of the program. (III) Treatment staff that provide therapy and ongoing clinical assessment services to individuals diagnosed with co-occurring disorders shall have, at a minimum: I. A master’s degree in a behavioral health related field with a minimum of two (2) years’ work experience with individuals who have co-occurring disorders, mental health, or substance use disorders. II. Specialized training to work with individuals who have co-occurring disorders. (V) All other direct care personnel in a Level III.1 Co-occurring Enhanced Low Intensity Residential Program shall be qualified as a qualified paraprofessional to provide the specific services delineated in the entity’s operational plan for this level of care. (VI) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level III.1 Co-occurring Enhanced Residential Program as delineated in its operational plan. (VII) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (VIII) Every client in a Level III.1 Residential Program shall be assigned to a specific primary counselor for care management. (IX) Each primary counselor shall maintain a case load not to exceed sixteen (16) clients with active cases at any one time. (viii) Women and Dependent Children Program Specific Criteria: (I) Direct Care Personnel. All direct care personnel shall be qualified as a qualified paraprofessional to provide the specific services delineated in the entity’s operational plan for this level of care. (II) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level III.1 Low Intensity Women and Dependent Children Residential Program as delineated in its operational plan. (III) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (IV) Every client in a Level III.1 Women and Dependent Children Program shall be assigned to a specific primary counselor for care management. (V) Each primary counselor shall maintain a case load not to exceed ten (10) clients with active cases at any one time. 8. Training. The entity shall provide written documentation that all Level III.1 Program personnel satisfy the competency and training requirements as specified in Rule 580-9-44-.02(3). 9. Service Intensity: The entity shall document that the amount and frequency of Level III.1 Low Intensity Residential Treatment Services are established on the basis of the unique needs of each client served. To assist in addressing these needs the entity shall ensure the availability of no less than five (5) hours of structured services each week. 10. Length of Service: The entity shall provide written documentation that the duration of treatment in each Level III.1 Low Intensity Residential Program shall vary as determined by: (i) The severity of the client’s illness. (ii) The client’s ability to comprehend the information provided and use that information to implement treatment strategies and attain treatment goals. (iii) The appearance of new problems that require another level of care; or (iv) The availability of services at an assessed level of need when a Level III.1 Residential Program has been utilized to provide interim services. 11. Service Availability: The entity shall provide written documentation describing the process utilized to establish hours of availability for screening, assessment and intake service, and counseling services at its Level III.1 Low Intensity Residential Program. At a minimum, this process shall: (i) Include consideration of the needs of the target population, including work, school and parenting responsibilities. (ii) Include consideration of transportation accessibility. (iii) Not be based solely on standard eight (8) to five (5), Monday through Friday office hours. Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Amended: Published January 31, 2023; effective March 17, 2023. 580-9-44-.22 Level III.2-D: Clinically Managed Residential Detoxification (1) Rule Compliance. In addition to compliance with the rules as specified in this chapter, each Level III.2-D Clinically Managed Residential Detoxification Program shall comply with the rules as specified in the following chapters. (a) Program Description. The entity shall develop, maintain and implement a written program description that defines its Level III.2-D Program, as according to Rule 580-9-44-.13 and the following specifications: 1. Location. The entity shall specifically identify and describe the setting in which the Level III.2-D Program is provided. Services may be provided in any facility that meets all applicable federal, state and local certification, licensure, building, life-safety, fire, health and zoning regulations including the DMH facility certification standards. 2. Admission Criteria: The entity shall develop, maintain and document implementation of written criteria for admission to its Level III.2-D Program, in compliance with the requirements of Rule 580-9-44-.13(9) and the following specifications: (i) The entity’s admission criteria shall specify the target population for the Level III.2-D Program, which shall include, at a minimum, individuals who: (I) Are experiencing signs and symptoms of withdrawal, or there is evidence based on history of substance intake, age, gender, previous withdrawal history, present symptoms, physical condition and/or emotional behavioral or cognitive condition that withdrawal syndrome is imminent. (II) Assessed as not being at risk of severe withdrawal syndrome and moderate withdrawal is safely manageable at this level. (III) Have a history of insufficient skills and supports to complete detoxification at a less intense level of care. (ii) The entity shall provide written documentation in individual case records that each client admitted to receive Level III.2-D services meets: (I) The diagnostic criteria for Substance Induced Disorder as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. (II) The dimensional criteria for admission to this level of care as defined in the ASAM PPC-2R. 3. Core Services: At a minimum, the Level III.2-D Program shall document the capacity to provide the following core services: (i) Placement assessment. (ii) Individual counseling. (iii) Group counseling. (iv) Psychoeducation. (v) Family counseling. (vi) Peer support. (vii) Medical and somatic services. (viii) Medication administration. (ix) Medication monitoring. (x) Alcohol and/or drug screening/testing. (xi) Case management: (I) Case planning. (II) Linkage. (III) Advocacy. (IV) Monitoring. 4. Therapeutic Component Implementation: The entity shall document implementation of medical and other clinical services organized to enhance the client’s understanding of addiction, support completion of the detoxification process and initiate transfer to an appropriate level of care for continued treatment. The entity’s Level III.2-D Program shall, at a minimum, consist of the following components: (i) Completion of a comprehensive medical history and physical examination of the client at admission. (ii) Protocols and/or standing orders, established by the entity’s medical director, for management of detoxification from each major drug category of abused drugs that are consistent with guidelines published by nationally recognized organizations (e.g., SAMHSA, ASAM, American Academy of Addiction Psychology). (I) Level III.2-D Programs that utilize benzodiazepines in the detoxification protocol: I. Shall have written protocols and procedures to show that all doses or amounts of benzodiazepines are carefully monitored and are slowly reduced as appropriate. II. Shall have written longer-term detoxification protocols and procedures that adhere to general principles of management, including clear indications of benzodiazepine dependence, clear intermediate treatment goals and strategies, regular review and methods to prevent diversion from the plan. (iii) On duty awake staff shall provide supervision for each client’s health, welfare and safety twenty-four (24) hours a day, seven (7) days a week. (iv) On-site physician care and phone availability twenty-four (24) hours a day, seven (7) days a week. (v) Credentialed personnel who are trained and competent to implement physician approved protocols for client observation and supervision, determination of appropriate level of care and facilitation of the client’s transitioning to continuing care. (vi) Services designed explicitly to safely detoxify clients without the need for ready on-site access to medical and nursing personnel. (vii) Medical evaluation and consultation available twenty-four (24) hours a day in accordance with practice guidelines. (viii) Clinicians who assess and treat clients are able to obtain and interpret information regarding the needs of the client to include the signs and symptoms of alcohol and other drug intoxification and withdrawal, as well as, the appropriate treatment and monitoring of these conditions. (ix) Medication administration and monitoring services, including specific procedures for pregnant women. (x) Continuous assessment. (xi) Planned counseling and other therapeutic interventions. (xii) Motivational enhancement therapy. (xiii) Direct affiliation with other levels of care. 5. Documentation: Level III.2-D Programs shall provide the following clinical record documentation: (i) Documentation of each clinical/therapeutic intervention provided. (ii) Daily assessment of progress, through detoxification, including response to medication, which also notes any treatment changes. (iii) Monitoring of vital signs, at a minimum, every eight (8) hours until discharge. (iv) The use of detoxification rating scale tables and flow sheets. 6. Support Systems: The Level III.2-D Program shall develop, maintain and document implementation of written policies and procedures utilized to provide client access to support services on site, or through consultation or referral, which shall minimally include availability to: (i) Specialized clinical consultation for biomedical, emotional, behavioral and cognitive problems. (ii) Appropriate laboratory and toxicology testing. (iii) Psychological and psychiatric services. (iv) Transportation. (v) Twenty-four (24) hour emergency medical services. 7. Staff Requirements. (i) Medical Director. The Level III.2-D Program shall have a medical director who is a physician licensed to practice in the State of Alabama, with a minimum of one (1) year experience treating persons with substance induced disorders. The medical director shall be responsible for admission, diagnosis, medication management and client care. (ii) Nursing Services Director. The Level III.2-D Program shall have a nursing services director who shall be a Registered Nurse licensed according to Alabama law, with training and work experience in behavioral health. (iii) There shall be a Registered Nurse (RN) or Licensed Practical Nurse (LPN) on site during all hours of the Level III.2-D Program’s operation. (iv) Direct Care Personnel. All direct care personnel shall have the qualifications as a qualified paraprofessional to provide the specific services delineated in the entity’s program description for this level of care. (v) The entity shall maintain an adequate number of personnel, including physicians, nurses, counselors and case managers to sustain the Level III.2-D Program as delineated in its operational plan. (vi) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. 8. Training: The entity shall provide written documentation that: (i) All Level III.2-D Program personnel satisfy the requirements of the core training curriculum, as specified in Rule 580-9-44-.02(3). (ii) All clinical and medical services staff in a Level III.2-D Program shall receive training during the initial twelve (12) months employment and develop basic competencies in the following areas: (I) Biopsychosocial dimensions of alcohol and other drug dependence, including: I. The signs and symptoms of alcohol and other drug intoxication and withdrawal. II. Evidence-based treatment and monitoring strategies for alcohol and other drug intoxication and withdrawal. III. Continuing care motivational and engagement strategies. (II) Pharmacotherapy. (III) ASAM Patient Placement Criteria. (IV) Assessment of and service planning to address biopsychosocial needs. 9. Service Intensity: The entity shall document in the clinical record that the intensity of Level III.2-D Services is established on the basis of the unique needs of each client served. 10. Length of Service: The entity shall provide written documentation in the clinical record that the duration of treatment in a Level III.2-D Program varies as determined by the client’s assessed needs, and that the client continues in treatment until: (i) Withdrawal signs and symptoms are sufficiently resolved; or (ii) Withdrawal signs and symptoms have failed to respond to treatment and have intensified warranting a transfer to a more intense level of care; or (iii) The client is, otherwise, unable to complete detoxification at this level of care. Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Amended: Published January 31, 2023; effective March 17, 2023. 580-9-44-.23 Level III.3: Clinically Managed Medium Intensity Residential Treatment Program For Adults (1) Rule Compliance. In addition to compliance with the rules as specified in this chapter, each Level III.3 Clinically Managed Medium Intensity Residential Treatment Program shall comply with the rules as specified in the following chapters. (a) Program Description. The entity shall develop, maintain and implement a written program description that defines the Level III.3 Clinically Managed Medium Intensity Residential Treatment Program it provides, as according to Rule 580-9-44-.13 and the following specifications: 1. Location. The entity shall specifically identify and describe the setting in which the Level III.3 Program shall be provided. Services shall be provided in any facility that meets all applicable federal, state and local certification, licensure, building, life-safety, fire, health and zoning regulations including the DMH facility certification standards. 2. Admission Criteria: The entity shall develop, maintain and document implementation of written criteria for admission to its Level III.3 Program, in compliance with the requirements of Rule 580-9-44-.13(9) and the following specifications: (i) The entity’s admission criteria shall specify the target population for its Level III.3 Services which shall include, at a minimum, individuals: (I) Who are at least nineteen (19) years old. (II) Whose assessed severity of illness warrants this level of care including, but not limited to: I. Individuals who have a substance dependence disorder and concomitant cognitive impairments, developmental delays, emotional, and/or behavioral problems; and/or II. Significant functional deficits in regard to management of activities of daily living. (ii) The entity shall provide written documentation in individual case records that each client admitted to a Level III.3 Program meets: (I) The diagnostic criteria for a substance dependence disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders. (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (iii) Co-occurring Disorders Program Specific Criteria. The entity shall provide written documentation in individual case records that each individual admitted to a Level III.3 Co-occurring Enhanced Treatment Program meets: (I) The diagnostic criteria for a substance dependence and mental illness disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders. (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (iv) Women and Dependent Children Program Specific Criteria: The entity shall provide written documentation in individual case records that each client admitted to a Level III.3 Program for Women and Dependent Children: (I) Meets the diagnostic criteria for a substance dependence disorder as defined in the most recent edition Diagnostic and Statistical Manual for Mental Disorders. (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (III) Is pregnant; or (IV) Has care and custody of dependent children; or (V) Has lost custody of dependent children and has the potential for family reunification. 3. Core Services: Each Level III.3 Medium Intensity Residential Program shall demonstrate the capacity to provide a basic level of treatment services appropriate to the needs of its clientele. (i) At a minimum, the entity shall demonstrate and document its capacity to provide a twenty-four (24) hour structured residential treatment environment with the following core services: (I) Placement assessment. (II) Individual counseling. (III) Group counseling. (IV) Family counseling. (V) Psychoeducation. (VI) Peer support. (VII) Medical and somatic services. (VIII) Daily living skills. (IX) Medication management. (X) Alcohol and/or drug screening/testing. (XI) Transportation. (XII) Case management: I. Case planning. II. Linkage. III. Advocacy. IV. Monitoring. (ii) Medical Services. Medical Services shall be provided as specified by the entity’s medical protocols established as required by Rule 580-9-44-.13(24). (I) Clients who have not had a physical examination within the last twelve (12) months shall be scheduled a physical examination within two weeks of admission. (II) Pregnant clients who are not receiving routine prenatal care shall be seen by physician within two (2) weeks of admission. (iii) Family Support. The entity shall initiate and document in the client record continuous efforts to involve the client’s family and other natural supports in the treatment process. (iv) Co-occurring Disorders Program Specific Criteria: Each Level III.3 Co-occurring Disorders Low Intensity Residential Treatment Program shall document the capacity to provide each of the core services and the following services: (I) Mental health consultation. (II) Crisis intervention services. (III) Activity therapy. (IV) Intensive case management. (v) Women and Dependent Children Program Specific Criteria: Each Level III.3 Women and Dependent Children Medium Intensity Residential Treatment Program shall document the capacity to provide each of the core services and the following services: (I) Child sitting services. (II) Developmental delay and prevention services. (III) Activity therapy. (IV) Parenting skills development. (V) Academic and vocational services. (VI) Financial resource development and planning. (VII) Family planning services. 4. Therapeutic Component Implementation. The entity shall document implementation of regularly scheduled treatment sessions that are provided in an amount, frequency and intensity appropriate to the client’s assessed needs and expressed desires for care. (i) Service strategies for each Level III.3 Residential Program shall include, at a minimum: (I) On duty, awake staff shall provide supervision of client’s health, welfare and safety twenty-four (24) hours a day. (II) Client shall have access to clinical services personnel twenty-four (24) hours a day, seven (7) days a week. (III) Daily clinical services to improve the client’s ability to structure and reorganize the tasks of daily living and recovery. (IV) The provision of daily scheduled treatment and recovery support services and activities that shall, at a minimum, include those that address: I. Implementation of individualized service plan strategies. II. Relapse prevention. III. Interpersonal choice/decision making skill development. IV. Development of a social network supportive of recovery. V. Daily living and recovery skills development. VI. Random drug screening. VII. Health education. VIII. Medication administration and monitoring. 5. Documentation: Each Level III.3 Medium Intensity Residential Program shall provide the following documentation in each client record: (i) Individualized progress notes shall be recorded each day for each respective service provided in Level III.3 Services. 6. Support Systems. Each Level III.3 Program shall develop, maintain and document implementation of written policies and procedures which govern the process used to provide client access to support services on site, or through consultation or referral, which shall minimally include: (i) Telephone or in person consultation with a physician available twenty-four (24) hours a day, seven (7) days a week. (ii) Telephone or in person consultation with emergency services twenty-four (24) hours a day, seven (7) days a week. (iii) Telephone or in person consultation with a registered nurse twenty-four (24) hours a day, seven (7) days a week. (iv) Direct affiliation with or coordination through referral to more and less intensive levels of care. (v) Direct affiliation with or coordination through referral to supportive services including vocational rehabilitation, literacy training and sheltered workshops. (vi) Mutual self-help groups which are tailored to the needs of the specific client population. (vii) Appropriate laboratory and toxicology testing. (viii) Psychological and psychiatric services. (ix) Direct affiliation with or coordination through referral to more and less intensive levels of care. 7. Program Personnel. Each level III.3 Medium Intensity Residential Program shall employ an adequate number of qualified individuals to provide personalized care for its clientele and to meet the program’s goals and objectives. (i) Direct Care Personnel. All direct care personnel shall have the qualifications to provide the specific services delineated in the entity’s program description for this level of care. (ii) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level III.3 Program as delineated in its operational procedures. (iii) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (iv) Every client in a Level III.3 Program shall be assigned to a specific primary counselor for care management. (v) Each primary counselor shall maintain a case load not to exceed twenty (20) clients with active cases at any one time. (vi) Co-occurring Disorders Program Specific Criteria. (I) Each Level III.3 Co-occurring Enhanced Medium Intensity Residential Program shall have access to psychiatric services led by a qualified psychiatrist or nurse practitioner that are fully capable of evaluating, diagnosing and prescribing medications to clients with co-occurring disorders. On-call psychiatric services shall be available twenty-four (24) hours a day, seven (7) days a week. (II) The treatment organization/agency shall have access to an Alabama licensed physician, full time, part time or on contract who shall be available to the program for client care and shall assume liability for the medical aspects of the program. (III) Treatment staff that provide therapy and ongoing clinical assessment services to individuals diagnosed with co-occurring disorders shall have, at a minimum; I. A master’s degree in a behavioral health related field with a minimum of two (2) years’ work experience with individuals who have co-occurring disorders, mental health or substance use disorders. II. Specialized training to work with individuals who have co-occurring disorders. (V) All other direct care personnel in a Level III.3 Co-occurring Enhanced Medium Intensity Residential Program shall be qualified, as a qualified paraprofessional to provide the specific services delineated in the entity’s operational plan for this level of care. (VI) Every client in a Level III.3 Residential Program shall be assigned to a specific primary counselor for care management. (VII) Each primary counselor shall maintain a case load not to exceed ten (10) clients with active cases at any one time. (vii) Women and Dependent Children Program Specific Criteria. (I) Direct Care Personnel. All direct care personnel shall be qualified as a qualified paraprofessional to provide the specific services delineated in the entity’s operational plan for this level of care. (II) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level III.3 Medium Intensity Women and Dependent Children Residential Program as delineated in its operational plan. (III) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (IV) Every client in a Level III.3 Women and Dependent Children Program shall be assigned to a specific primary counselor for care management. (V) Each primary counselor shall maintain a case load not to exceed ten (10) clients with active cases at any one time. 8. Training. The entity shall provide written documentation that all Level III.3 Program personnel satisfy the competency and training requirements as specified in Rule 580-9-44-.02(3). 9. Service Intensity: (i) The entity shall document that the amount and frequency of Level III.3 Medium Intensity Residential Treatment Services are established on the basis of the unique needs of each client served. To assist in addressing these needs, the entity shall ensure the availability of no less than fifteen (15) hours of structured services each week. 10. Length of Service: The entity shall provide written documentation that the duration of treatment in each Level III.3 Medium Intensity Residential Program shall vary as determined by: (i) The severity of the client’s illness. (ii) The client’s ability to comprehend the information provided and use that information to implement treatment strategies and attain treatment goals. (iii) The appearance of new problems that require another level of care; or (iv) The availability of services at an assessed level of need when a Level III.3 Residential Program has been utilized to provide interim services. 11. Service Availability: The entity shall provide written documentation describing the process utilized to establish hours of availability for screening, assessment and intake service and counseling services at its Level III.3 Medium Intensity Residential Program. At a minimum this process shall: (i) Include consideration of the needs of the target population including work, school and parenting responsibilities. (ii) Include consideration of transportation accessibility. (iii) Not be based solely on standard eight (8) to five (5), Monday through Friday office hours. Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Amended: Published January 31, 2023; effective March 17, 2023. 580-9-44-.24 Level III.5: Clinically Managed Medium Intensity Residential Treatment Program For Adolescents (1) Rule Compliance. In addition to compliance with the rules as specified in this chapter, each Level III.5 Clinically Managed Medium Intensity Residential Treatment Program for Adolescents shall comply with the rules as specified in the following chapters. (a) Program Description. The entity shall develop, maintain and implement a written program description that defines its Level III.5 Adolescent Clinically Managed Medium Intensity Residential Treatment Program, as according to Rule 580-9-44-.13 and the following specifications: 1. Location. The entity shall specifically identify and describe the setting in which the Level III.5 Adolescent Program shall be provided. Services may be provided in any facility that meets all applicable federal, state and local certification, licensure, building, life-safety, fire, health and zoning regulations, including the DMH facility certification standards. 2. Admission Criteria: The entity shall develop, maintain and document implementation of written criteria for admission to its Level III.5 Adolescent Program in compliance with the requirements of Rule 580-9-44-.13(9) and the following specifications: (i) The entity’s admission criteria shall specify the target population for its Level III.5 Adolescent Services which shall include, at a minimum, individuals: (I) Who are less than nineteen (19) years old. (II) Whose assessed severity of illness warrants this level of care including but not limited to individuals who have impaired functioning across a broad range of psychosocial domains that may be expressed as: I. Disruptive behaviors. II. Delinquency and juvenile justice involvement. III. Educational difficulties. IV. Family conflicts and chaotic home situations. V. Developmental immaturity and/or VI. Psychological problems. (III) Who do not require significant medical, psychiatric, or nurse monitoring or interventions. (IV) For whom treatment for identified problems has been rendered ineffective at less intensive levels of care. (ii) The entity shall provide written documentation in individual case records that each client admitted to a Level III.5 Adolescent Program meets: (I) The diagnostic criteria for a substance related disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders; and (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (iii) Co-occurring Disorders Program Specific Criteria. The entity shall provide written documentation in individual case records that each individual admitted to a Level III.5 Adolescent Co-occurring Enhanced Treatment Program meets: (I) The diagnostic criteria for a substance related and mental illness disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders. (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (iv) Women and Dependent Children Program Specific Criteria: The entity shall provide written documentation in individual case records that each client admitted to a Level III.5 Adolescent Program for Women and Dependent Children: (I) Meets the diagnostic criteria for a substance related disorder as defined in the most recent edition Diagnostic and Statistical Manual for Mental Disorders. (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (III) Is pregnant; or (IV) Has care and custody of dependent children; or (V) Has lost custody of dependent children and has the potential for family reunification. 3. Core Services: Each Level III.5 Adolescent Medium Intensity Residential Program shall demonstrate the capacity to provide a basic regimen of treatment services appropriate to the adolescent’s developmental and cognitive levels and other assessed needs. (i) At a minimum, the entity shall demonstrate and document its capacity to provide a twenty-four (24) hour structured residential treatment environment with accessibility to the following core services: (I) Placement assessment. (II) Individual counseling. (III) Group counseling. (IV) Family counseling. (V) Psychoeducation. (VI) Peer support. (VII) Medical and somatic services. (VIII) Daily living skills. (IX) Medication management. (X) Medication administration. (XI) Alcohol and/or drug screening/testing. (XII) Transportation. (XIII) Activity therapy. (XIX) Case management: I. Case planning. II. Linkage. III. Advocacy. IV. Monitoring. (ii) Medical Services. The entity shall implement procedures for the provision of medical services as according to protocols established in compliance with Rule 580-9-44-.13(24). (I) Clients who have not had a physical examination within the last twelve (12) months shall be scheduled a physical examination within two (2) weeks of admission. (II) Pregnant clients who are not receiving routine prenatal care shall be seen by physician within two (2) weeks of admission. (iii) Mental Health Services. The entity shall develop, maintain and document implementation of written policies and procedures to ensure that each client’s mental health needs are identified through the assessment process and access to appropriate care for these needs is provided concurrently with treatment for assessed substance related disorders. (iv) Family Support. The entity shall initiate and document in the client record continuous efforts to involve the client’s family and other natural supports in the treatment process. (v) Co-occurring Disorders Program Specific Criteria: Each Level III.5 Adolescent Co-occurring Disorders Medium Intensity Residential Treatment Program shall document the capacity to provide each of the core services and the following services: (I) Mental health consultation. (II) Crisis intervention services. (vi) Women and Dependent Children Program Specific Criteria: Each Level III.5 Adolescent Women and Dependent Children Medium Intensity Residential Treatment Program shall document the capacity to provide each of the core services and the following services: (I) Child sitting services. (II) Developmental delay and prevention services. (III) Parenting skills development. 4. Therapeutic Component Implementation. The entity shall document the implementation of a planned regimen of twenty-four (24) hour professionally directed program activities for adolescents and their families. Evaluation, treatment and care shall be provided in an amount, frequency and intensity appropriate to the client’s assessed needs and expressed desires for care. (i) Service strategies for each Level III.5 Adolescent Residential Program shall include, at a minimum: (I) On duty, awake staff shall provide supervision of client’s health, welfare and safety twenty-four (24) hours a day. (II) Clients shall have access to clinical services personnel twenty-four (24) hours a day, seven (7) days a week. (III) Daily clinical services to improve the client’s ability to structure and reorganize the tasks of daily living and recovery. (IV) The provision of daily scheduled treatment, recovery support services and other activities that shall, at a minimum, include those that address: I. Implementation of individualized service plan strategies. II. Development and application of recovery skills including relapse prevention. III. Interpersonal choice/decision making skill development. IV. Enhancement of the understanding of addiction. V. Development of a social network supportive of recovery. VI. Random drug screening. VII. Health education. VIII. Medication administration and monitoring. IX. Promotion of successful involvement in regular productive daily activity such as school or work. X. Enhancement of personal responsibility, developmental maturity and prosocial values. XI. Educational services in accordance with state and local regulations. XII. Opportunities to remedy educational deficits created by involvement with alcohol and other drugs. (ii) The entity shall actively promote and provide referrals and/or access to community support services. (iii) All services shall be organized and provided according to evidence-based and best practice standards and guidelines. (iv) Co-occurring Disorders Program Specific Criteria: Each Level III.5 Adolescent Co-occurring Enhanced Program shall document the capacity to provide the service strategies and the following therapeutic components: (I) Groups and classes that address the signs and symptoms of mental health and substance use disorders. (II) Groups, classes and training to assist clients in becoming aware of cues or triggers that enhance the likelihood of alcohol and drug use or psychiatric decompensation and to aid in development of alternative coping responses to those cues. (III) Dual recovery groups that provide a forum for discussion of the interactions of and interrelations between substance use and mental health disorders. (IV) Intensive case management. (v) Women and Dependent Children Program Specific Criteria: Each Level III.5. Adolescent Women and Dependent Children Program shall document the capacity to provide the service strategies and the following therapeutic components: (I) Gender specific services which address issues of relationships, parenting, abuse and trauma. (II) Primary medical care including prenatal care. (III) Primary pediatric care for children. (IV) Therapeutic interventions for children which address their developmental needs and issues of sexual abuse and neglect. (V) Outreach to inform pregnant women of the services and priorities. (VI) Interim services while awaiting admission to this level of care. (VII) Recreation and leisure time skills training. (VIII) Academic and vocational services. (IX) Family planning services. 5. Documentation: Each Level III.5 Adolescent Medium Intensity Residential Program shall provide the following documentation in each client record: (i) Individualized progress notes shall be recorded each day for each respective service provided. 6. Support Systems. Each Level III.5 Adolescent Program shall develop, maintain and document implementation of written policies and procedures which govern the process used to provide client access to support services on site, or through consultation or referral, which shall minimally include: (i) Emergency consultation with a physician available twenty-four (24) hours a day, seven (7) days a week. (ii) Telephone or in person consultation with emergency services twenty-four (24) hours a day, seven (7) days a week. (iii) Telephone or in person consultation with a MAS nurse twenty-four (24) hours a day, seven (7) days a week. (iv) Indicated laboratory and toxicology testing. (v) Indicated medical procedures. (vi) Medical treatment. (vii) Psychological and psychiatric treatment. (viii) Direct affiliation with or coordination through referral to more and less intensive levels of care, including detoxification services. 7. Program Personnel. Each Level III.5 Adolescent Medium Intensity Residential Program shall employ an adequate number of qualified individuals to provide personalized care for its clientele and to meet the program’s goals and objectives. (i) Direct Care Personnel. All direct care personnel shall have the qualifications, as a qualified paraprofessional to provide the specific services delineated in the entity’s program description for this level of care. (ii) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level III.5 Program as delineated in its operational procedures. (iii) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (iv) Each primary counselor shall maintain a case load not to exceed ten (10) clients with active cases at any one time. (v) Co-occurring Disorders Program Specific Criteria. (I) Each Level III.5 Adolescent Co-occurring Enhanced Medium Intensity Residential Program shall have access to psychiatric services led by a qualified psychiatrist or nurse practitioner that are fully capable of evaluating, diagnosing and prescribing medications to clients with co-occurring disorders. On-call psychiatric services shall be available twenty-four (24) hours a day, seven (7) days a week. (II) The treatment organization/agency shall have access to an Alabama licensed physician, full time, part time or on contract who shall be available to the program for client care and shall assume responsibility for the medical aspects of the program. (III) All other direct care personnel in a Level III.5 Adolescent Co-occurring Enhanced Medium Intensity Residential Program shall be qualified, as a qualified paraprofessional to provide the specific services delineated in the entity’s operational plan for this level of care. (IV) Every client in a Level III.5 Adolescent Residential Program shall be assigned to a specific primary counselor for care management. (V) Each primary counselor shall maintain a case load not to exceed sixteen (16) clients with active cases at any one time. (vi) Women and Dependent Children Program Specific Criteria. (I) Direct Care Personnel. All direct care personnel shall be qualified, as a qualified paraprofessional to provide the specific services delineated in the entity’s operational plan for this level of care. (II) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level III.5 Adolescent Medium Intensity Women and Dependent Children Residential Program as delineated in its operational plan. (III) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (IV) Every client in a Level III.5 Adolescent Women and Dependent Children program shall be assigned to a specific Primary Counselor for care management. (V) Each primary counselor shall maintain a case load not to exceed ten (10) clients with active cases at any one time. 8. Training. The entity shall provide written documentation that all Level III.5 Adolescent Program personnel satisfy the competency and training requirements as specified in Rule 580-9-44-.02(3). 9. Service Intensity: (i) The entity shall document that the amount and frequency of Level III.5 Adolescent Medium Intensity Residential Treatment Services are established on the basis of the unique needs of each client served. To assist in addressing these needs, the entity shall ensure the availability of no less than fifteen (15) hours of structured services each week. (ii) The entity shall provide written documentation describing the procedures utilized to ensure the provision of services appropriate to the client’s developmental stage and level of comprehension, including any necessary adaptations. 10. Length of Service: The entity shall provide written documentation that the duration of treatment in each Level III.5 Adolescent Medium Intensity Residential Program shall vary as determined by: (i) The severity of the client’s illness. (ii) The client’s ability to comprehend the information provided and use that information to implement treatment strategies and attain treatment goals. (iii) The appearance of new problems that require another level of care; or (iv) The availability of services at an assessed level of need, when a Level III.5 Adolescent Residential Program has been utilized to provide interim services. 11. Service Availability: The entity shall provide written documentation describing the process utilized to establish hours of availability for screening assessment and intake services at its Level III.5 Medium Intensity Adolescent Residential Program. At a minimum, this process shall: (i) Include consideration of the needs of the target population, including work, school and parenting responsibilities. (ii) Include consideration of transportation accessibility. (iii) Not be based solely on standard eight (8) to five (5), Monday through Friday office hours. Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Amended: Published January 31, 2023; Effective March 17, 2023. 580-9-44-.25 Level III.5: Clinically Managed High Intensity Residential Treatment Program For Adults (1) Rule Compliance. In addition to compliance with the rules as specified in this chapter, each Level III.5 Clinically Managed High Intensity Residential Treatment Program shall comply with the rules as specified in the following chapters. (a) Program Description. The entity shall develop, maintain and implement a written program description that defines the Level III.5 Clinically Managed High Intensity Residential Treatment Program it provides, as according to Rule 580-9-44-.13 and the following specifications: 1. Location. The entity shall specifically identify and describe the setting in which the Level III.5 Program shall be provided. Services shall be provided in any facility that meets all applicable federal, state and local certification, licensure, building, life-safety, fire, health and zoning regulations, including the DMH facility certification standards. 2. Admission Criteria: The entity shall develop, maintain and document implementation of written criteria for admission to its Level III.5 Program, in compliance with the requirements of Rule 580-9-44-.13(9) and the following specifications: (i) The entity’s admission criteria shall specify the target population for its Level III.5 Services, which shall include, at a minimum, individuals who have been assessed to have multiple, significant social and psychological functional deficits that cannot be adequately addressed on an outpatient basis. (ii) The entity shall provide written documentation in individual case records that each client admitted to a Level III.5 Program meets: (I) The diagnostic criteria for a substance dependence disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders. (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (iii) Co-occurring Disorders Program Specific Criteria. The entity shall provide written documentation in individual case records that each individual admitted to a Level III.5 Co-occurring Enhanced Treatment Program meets: (I) The diagnostic criteria for a substance dependence and mental illness disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders. (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (iv) Women and Dependent Children Program Specific Criteria: The entity shall provide written documentation in individual case records that each client admitted to a Level III.5 Program for Women and Dependent Children: (I) Meets the diagnostic criteria for a substance dependence disorder as defined in the most recent edition Diagnostic and Statistical Manual for Mental Disorders. (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (III) Is pregnant; or (IV) Has care and custody of dependent children; or (V) Has lost custody of dependent children and has the potential for family reunification. 3. Core Services: Each Level III.5 High Intensity Residential Program shall demonstrate the capacity to provide a basic level of treatment services appropriate to the needs of its clientele. (i) At a minimum, the entity shall demonstrate and document its capacity to provide a twenty-four (24) hour structured residential treatment environment with the following core services: (I) Placement assessment. (II) Individual counseling. (III) Group counseling. (IV) Family counseling. (V) Psychoeducation. (VI) Peer support. (VII) Medical and somatic services. (VIII) Daily living skills. (IX) Medication management. (X) Alcohol and/or drug screening/testing. (XI) Transportation. (XII) Case Management: I. Case planning. II. Linkage. III. Advocacy. IV. Monitoring. (ii) Medical Services. Medical Services shall be provided as specified by the entity’s medical protocols established as required by Rule 580-9-44-.13(24). (I) Clients who have not had a physical examination within the last twelve (12) months shall be provided a physical examination within two (2) weeks of admission. (II) Pregnant clients who are not receiving routine prenatal care, shall be seen by physician within two (2) weeks of admission. (iii) Mental Health Services. The entity shall develop, maintain and document implementation of written policies and procedures to ensure that each client’s mental health needs are identified through the assessment service process and access to appropriate care for these needs is provided concurrently with treatment for assessed substance related disorders. (iv) Family Support. The entity shall initiate and document in the client record continuous efforts to involve the client’s family and other natural supports in the treatment process. (v) Co-occurring Disorders Program Specific Criteria: Each Level III.5 Co-occurring Disorders Low Intensity Residential Treatment Program shall document the capacity to provide each of the core services and the following services: (I) Mental health consultation. (II) Crisis intervention services. (III) Activity therapy. (IV) Intensive case management. (vi) Women and Dependent Children Program Specific Criteria: Each Level III.5 Women and Dependent Children Medium Intensity Residential Treatment Program shall document the capacity to provide each of the core services and the following services: (I) Child sitting services. (II) Developmental delay and prevention services. (III) Activity therapy. (IV) Parenting skills development. (V) Academic and vocational services. (VI) Financial resource development and planning. (VII) Family planning services. 4. Therapeutic Component Implementation. The entity shall document implementation of regularly scheduled treatment sessions that are provided in an amount, frequency and intensity appropriate to each client’s assessed needs and expressed desires for care. (i) Service strategies for each Level III.5 Residential Program shall include, at a minimum: (I) On duty awake staff shall provide supervision of client’s health, welfare and safety twenty-four (24) hours a day. (II) Client shall have access to clinical services personnel twenty-four (24) hours a day, seven (7) days a week. (III) Daily clinical services to improve the client’s ability to structure and reorganize the tasks of daily living and recovery. (IV) The provision of daily scheduled treatment and recovery support services and activities that shall, at a minimum, include those that address: I. Implementation of individualized service plan strategies. II. Relapse prevention. III. Interpersonal choice/decision making skill development. IV. Development of a social network supportive of recovery. V. Daily living and recovery skills development. VI. Random drug screening. VII. Health education. VIII. Medication administration and monitoring. (ii) The entity shall actively promote and provide referrals and/or access to community support services. (iii) All services shall be organized and provided according to evidence-based and best practice standards and guidelines. (iv) Co-occurring Disorders Program Specific Criteria: Each Level III.5 Co-occurring Enhanced Program shall document the capacity to provide the service strategies and the following therapeutic components: (I) Groups and classes that address the signs and symptoms of mental health and substance use disorders. (II) Groups, classes and training to assist clients in becoming aware of cues or triggers that enhance the likelihood of alcohol and drug use or psychiatric decompensation and to aid in development of alternative coping responses to those cues. (III) Dual recovery groups that provide a forum for discussion of the interactions of and interrelations between substance use and mental health disorders. 5. Documentation: Each Level III.5 High Intensity Residential Program shall provide the following documentation in each client record: (i) Individualized progress notes shall be recorded each day for each respective service provided in Level III.5 Services. 6. Support Systems. Each Level III.5 Program shall develop, maintain and document implementation of written policies and procedures which govern the process used to provide client access to support services on site or through consultation or referral, which shall minimally include: (i) Telephone or in person consultation with a physician available twenty-four (24) hours a day, seven (7) days a week. (ii) Telephone or in person consultation with emergency services twenty-four (24) hours a day, seven (7) days a week. (iii) Telephone or in person consultation with a registered nurse twenty-four (24) hours a day, seven (7) days a week. (iv) Direct affiliation with, or coordination through referral to more and less intensive levels of care. (v) Direct affiliation with, or coordination through referral to supportive services, including vocational rehabilitation, literacy training and adult education. (vi) Mutual self-help groups which are tailored to the needs of the specific client population. (vii) Appropriate laboratory and toxicology testing. (viii) Psychological and psychiatric services. (ix) Direct affiliation with or coordination through referral to more and less intensive levels of care. (x) Co-occurring Disorders Program Specific Criteria: In addition to compliance with the criteria, each Level III.5 Co-occurring Enhanced High Intensity Residential Program shall provide client access to intensive case management services. (xi) Women and Dependent Children’s Program Specific Criteria: In addition to compliance with the criteria, the each Level III.5 High Intensity Residential Treatment Program for Women and Dependent Children shall provide client access to the following support services: (I) Academic and vocational services. (II) Financial resource development and planning. (III) Family planning services. 7. Program Personnel. Each level III.5 High Intensity Residential Program shall employ an adequate number of qualified individuals to provide personalized care for its clientele and to meet the program’s goals and objectives. (i) Direct Care Personnel. All direct care personnel shall be qualified as a qualified paraprofessional to provide the specific services delineated in the entity’s operational procedures for this level of care. (ii) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level III.5 High Intensity Residential Program as delineated in its operational procedures. (iii) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (iv) Every client in a Level III.5 Program shall be assigned to a specific primary counselor for care management. (v) Each primary counselor shall maintain a case load not to exceed sixteen (16) clients with active cases at any one time. (vi) Co-occurring Disorders Program Specific Criteria. (I) The Level III.5 Co-occurring Enhanced High Intensity Residential Program shall be coordinated by a full-time member of the staff who has the minimum of a master’s degree in a mental health related field and at least two (2) years post master’s supervised experience in a direct service area treating clients with co-occurring disorders. (II) The Level III.5 Co-occurring Enhanced Program shall have access to psychiatric services led by a qualified psychiatrist or nurse practitioner that are fully capable of evaluating, diagnosing and prescribing medications to clients with co-occurring disorders. On-call psychiatric services shall be available twenty-four (24) hours a day, seven (7) days a week. (III) The treatment organization/agency shall have access to an Alabama licensed physician, full time, part time, or on contract who shall be available to the program for client care and shall assume liability for the medical aspects of the program. (IV) Treatment staff that provide therapy and ongoing clinical assessment services to individuals diagnosed with co-occurring disorders, shall have at a minimum, I. A master’s degree in a behavioral health related field with a minimum of two (2) years’ work experience with individuals who have co-occurring disorders, mental health or substance use disorders. II. Specialized training to work with individuals who have co-occurring disorders. (V) All other direct care personnel in a Level III.5 Co-occurring Enhanced Program shall be qualified to provide the specific services delineated in the entity’s operational plan for this level of care. (VI) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level III.5 Enhanced High Intensity Residential Program as delineated in its operational plan. (VII) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (VIII) Every client in a Level III.5 Co-occurring Program shall be assigned to a specific primary counselor for care management. (IX) Each primary counselor shall maintain a case load not to exceed sixteen (16) clients with active cases at any one time. (vii) Women and Dependent Children Program Specific Criteria: (I) Each Level III.5 Women and Dependent Children High Intensity Residential Program shall be coordinated by a full-time member of the staff who has a minimum of a master’s degree in a behavioral health related field and at least two (2) years post master’s supervised experience in a direct service area treating women who have substance use, mental health or co-occurring mental health and substance use disorders. (II) Direct Care Personnel. All direct care personnel shall be qualified as a qualified paraprofessional to provide the specific services delineated in the entity’s operational plan for this level of care. (III) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level III.5 Women and Dependent Children Program as delineated in its operational plan. (IV) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (V) Every client in a Level III.5 Women and Dependent Children Program shall be assigned to a specific primary counselor for care management. (VI) Each primary counselor shall maintain a case load not to exceed ten (10) clients with active cases at any one time. 8. Training. The entity shall provide written documentation that all Level III.5 Program personnel satisfy the competency and training requirements as specified in Rule 580-9-44-.02(3). 9. Service Intensity: The entity shall develop, maintain and document implementation of policies and procedures in regard to service intensity for its Level III.5 Residential Program, which shall at a minimum specify: (i) The amount and frequency of Level III.5 Services are established on the basis of the unique needs of each client served. (ii) The program has the capacity to provide a minimum of twenty-five (25) contact hours of clinical services weekly for each client. 10. Length of Service: The entity shall provide written documentation that the duration of treatment in its Level III.5 Program is variable as determined by: (i) The severity of the client’s illness. (ii) The client’s ability to comprehend the information provided and use that information to meet treatment goals and strategies; or (iii) The appearance of new problems that require another level of care; or (iv) The availability of services at an assessed level of need, when a Level III.5 High Intensity Residential Program has been utilized as an interim level of care. 11. Service Availability: The entity shall provide written documentation describing the process utilized to establish hours of availability for screening, assessment and intake service, admission and counseling services at its Level III.5 High Intensity Residential Program. At a minimum, this process shall: (i) Include consideration of the needs of the target population, including work, school and parenting responsibilities. (ii) Include consideration of transportation accessibility. (iii) Not be based solely on standard eight (8) to five (5), Monday through Friday office hours. Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Amended: Published January 31, 2023; effective March 17, 2023. 580-9-44-.26 Level III.7: Medically Monitored Intensive Residential Treatment Program for Adults (1) Rule Compliance. In addition to compliance with the rules as specified in this chapter, each Level III.7 Medically Monitored Intensive Treatment Program for Adults shall comply with the rules as specified in the following chapters. (a) Program Description. The entity shall develop, maintain and implement a written program description that defines its Level III.7 Medically Monitored Intensive Residential Treatment Program, as according to Rule 580-9-44-.13 and the following specifications: 1. Location. The entity shall specifically identify and describe the setting in which the Level III.7 Program shall be provided. Services may be provided in any facility that meets all applicable federal, state and local certification, licensure, building, life-safety, fire, health and zoning regulations including the DMH facility certification standards. 2. Admission Criteria: The entity shall develop, maintain and document implementation of written criteria for admission to its Level III.7 Program, in compliance with the requirements of Rule 580-9-44-.13(9) and the following specifications: (i) The entity’s admission criteria shall specify the target population for its Level III.7 Program which shall include, at a minimum, individuals: (I) Whose assessed severity of illness warrants this level of care, including but not limited to, adults whose subacute biomedical and emotional, behavioral, or cognitive problems are so severe that they require medically monitored treatment, but do not need the full resources of an acute care general hospital. (II) For whom treatment for identified problems has been rendered ineffective at less intensive levels of care. (ii) The entity shall provide written documentation in individual case records that each client admitted to a Level III.7 Adult Program meets: (I) The diagnostic criteria for a substance dependence disorder as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (iii) Co-occurring Disorders Program Specific Criteria. The entity shall provide written documentation in individual case records that each individual admitted to a Level III.7 Co-occurring Enhanced Treatment Program meets: (I) The diagnostic criteria for a substance dependence and mental illness disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders. (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (iv) Women and Dependent Children Program Specific Criteria: The entity shall provide written documentation in individual case records that each client admitted to a Level III.7 Program for Women and Dependent Children: (I) Meets the diagnostic criteria for a substance dependence disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders. (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (III) Is pregnant; or (IV) Has care and custody of dependent children; or (V) Has lost custody of dependent children and has the potential for family reunification. 3. Core Services: Each Level III.7 Medically Monitored Intensive Residential Program shall demonstrate the capacity to provide a basic regimen of treatment services appropriate to the client’s developmental and cognitive levels and other assessed needs. (i) At a minimum, the entity shall demonstrate and document its capacity to provide a twenty-four (24) hour structured residential treatment environment with accessibility to the following core services: (I) Placement assessment. (II) Individual counseling. (III) Group counseling. (IV) Family counseling. (V) Psychoeducation. (VI) Peer support. (VII) Medical and somatic services. (VIII) Daily living skills. (IX) Medication management. (X) Medication administration. (XI) Alcohol and/or drug screening/testing. (XII) Transportation. (XIII) Activity therapy. (XIX) Case management: I. Case planning. II. Linkage. III. Advocacy. IV. Monitoring. (ii) Medical Services. The entity shall implement procedures for the provision of medical services, as according to protocols established in compliance with Rule 580-9-44-.13(24). (I) Pregnant clients who are not receiving routine prenatal care shall be seen by physician within two (2) weeks of admission. (iii) Mental Health Services. The entity shall develop, maintain and document implementation of written policies and procedures to ensure that each client’s mental health needs are identified through the assessment service process and access to appropriate care for these needs is provided concurrently with treatment for assessed substance related disorders. (iv) Family Support. The entity shall initiate and document in the client record continuous efforts to involve the client’s family and other natural supports in the treatment process. (v) Co-occurring Disorders Program Specific Criteria: Each Level III.7 Co-occurring Disorders Medically Monitored Intensive Residential Treatment Program shall document the capacity to provide each of the core services and the following services: (I) Mental health consultation. (II) Crisis intervention services. (III) Intensive case management. (vi) Women and Dependent Children Program Specific Criteria: Each Level III.7 Women and Dependent Children Medically Monitored Intensive Residential Treatment Program shall document the capacity to provide each of the core services and the following services: (I) Child sitting services. (II) Developmental delay and prevention services. (III) Parenting skills development. (IV) Academic and vocational services. (V) Financial resource development and planning. (VI) Family planning services. 4. Therapeutic Component Implementation. The entity shall document the implementation of a planned regimen of professionally directed program activities for clients and their families. Evaluation, treatment and care shall be provided in an amount, frequency and intensity appropriate to each client’s assessed needs and expressed desires for care. (i) Service strategies for each Level III.7 Residential Program shall include, at a minimum: (I) On duty awake staff shall provide supervision of client’s health, welfare and safety twenty-four (24) hours a day. (II) Clients shall have access to clinical services personnel twenty-four (24) hours a day, seven (7) days a week. (III) Daily clinical services to improve the client’s ability to structure and reorganize the tasks of daily living and recovery. (IV) The provision of daily scheduled treatment and recovery support services and activities that shall, at a minimum, include those that address: I. Implementation of individualized service plan strategies. II. Development and application of recovery skills including relapse prevention. III. Interpersonal choice/decision making skill development. IV. Enhancement of the understanding of addiction. V. Development of a social network supportive of recovery. VI. Random drug screening. VII. Health education. VIII. Medication administration and monitoring. IX. Promotion of successful involvement in regular productive daily activity, such as school or work. X. Skill development to support productive daily activity and successful reintegration into the family and community. XI. Supervised therapeutic recreational activities. (ii) The entity shall actively promote and provide referrals and/or access to community support services. (iii) All services shall be organized and provided according to evidence-based and best practice standards and guidelines. 5. Documentation: Each Level III.7 Medically Monitored Intensive Residential Program shall provide the following documentation in each client record: (i) Individualized progress notes shall be recorded each day for each respective service provided. 6. Support Systems. Each Level III.7 Program shall develop, maintain and document implementation of written policies and procedures, which govern the process used to provide client access to support services on site or through consultation or referral, which shall minimally include: (i) The availability of a physician or physician extender to assess each client in person within twenty-four (24) hours of admission and thereafter as medically necessary. (ii) Emergency consultation with a physician available twenty-four (24) hours a day, seven (7) days a week. (iii) Telephone or in person consultation with emergency services twenty-four (24) hours a day, seven (7) days a week. (iv) The availability of a MAS Registered Nurse to conduct a nursing assessment at the time of admission, monitor the client’s progress during treatment and manage medication administration. (v) Telephone or in person consultation with a MAS Nurse twenty-four (24) hours a day, seven (7) days a week. (vi) Indicated laboratory and toxicology testing. (vii) Indicated medical procedures. (viii) Medical treatment. (ix) Psychiatric services shall be available within eight (8) hours by telephone or twenty-four (24) hours in person. (x) Community based services assessed as needed but not provided by the entity. (xi) Direct affiliation with or coordination through referral to more and less intensive levels of care including detoxification services. 7. Program Personnel. Each Level III.7 Intensive Residential Program shall employ an adequate number of qualified individuals to provide personalized care for its clientele and to meet the program’s goals and objectives. (i) Nursing Personnel. MAS Registered Nurses or Licensed Practical Nurses shall be available for primary nursing care and observation twenty-four (24) hours a day. (ii) Direct Care Personnel. All direct care personnel shall have the qualifications as a qualified paraprofessional to provide the specific services delineated in the entity’s program description for this level of care. (iii) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level III.7 Adult Program as delineated in its operational procedures. (iv) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (v) Every client in a Level III.7 Program shall be assigned to a specific primary counselor. (vi) Each primary counselor shall maintain a case load not to exceed ten (10) clients with active cases at any one time. (vii) Co-occurring Disorders Program Specific Criteria. (I) Each Level III.7 Co-occurring Enhanced Medically Monitored Intensity Residential Program shall be coordinated by a full-time member of the staff who has the minimum of a master’s degree in a mental health related field and at least two (2) years supervised experience in a direct service area treating individuals who have co-occurring disorders. (II) Each Level III.7 Co-occurring Enhanced Intensive Residential Program shall have access to psychiatric services led by a qualified psychiatrist or nurse practitioner that are fully capable of evaluating, diagnosing and prescribing medications to clients with co-occurring disorders. On-call psychiatric services shall be available twenty-four (24) hours a day, seven (7) days a week. (III) The treatment organization/agency shall have access to an Alabama licensed physician, full time, part time, or on contract who shall be available to the program for client care and shall assume responsibility for the medical aspects of the program. (IV) Treatment staff that provide therapy and ongoing clinical assessment services to individuals diagnosed with co-occurring disorders shall have, at a minimum, I. A master’s degree in a behavioral health related field with a minimum of two (2) years’ work experience with individuals who have co-occurring disorders, mental health, or substance use disorders. II. Specialized training to work with individuals who have co-occurring disorders. (V) Direct Care Personnel. All other direct care personnel in a Level III.7 Co-occurring Enhanced Intensive Residential Program shall be qualified as a qualified paraprofessional to provide the specific services delineated in the entity’s operational plan for this level of care. (VI) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level III.7 Co-occurring Enhanced Residential Program as delineated in its operational plan. (VII) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (VIII) Every client in a Level III.7 Residential Program shall be assigned to a primary counselor. (IX) Each primary counselor shall maintain a case load not to exceed ten (10) clients with active cases at any one time. (ix) Women and Dependent Children Program Specific Criteria. (I) Direct Care Personnel. All direct care personnel shall be qualified as a qualified paraprofessional to provide the specific services delineated in the entity’s operational plan for this level of care. (II) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level III.7 Intensive Women and Dependent Children Residential Program as delineated in its operational plan. (III) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (IV) Every client in a Level III.7 Women and Dependent Children Program shall be assigned to a primary counselor. (V) Each primary counselor shall maintain a case load not to exceed ten (10) clients with active cases at any one time. 8. Training. The entity shall provide written documentation that all Level III.7 Program personnel satisfy the competency and training requirements as specified in Rule 580-9-44-.02(3). 9. Service Intensity: (i) The entity shall document that the amount and frequency of Level III.7 Intensive Residential Treatment Services are established on the basis of the unique needs of each client served. To assist in addressing these needs the entity shall ensure the availability of no less than twenty (20) hours of structured services each week. 10. Length of Service: The entity shall provide written documentation that the duration of treatment in each Level III.7 Intensive Residential Program shall vary as determined by: (i) The severity of the client’s illness. (ii) The client’s ability to comprehend the information provided and use that information to implement treatment strategies and attain treatment goals. (iii) The appearance of new problems that require another level of care; or (iv) The availability of services at an assessed level of need, when a Level III.7 Residential Program has been utilized to provide interim services. 11. Service Availability: The entity shall provide written documentation describing the process utilized to establish hours of assessment and intake services at its Level III.7 Medically Monitored Intensive Residential Program. At a minimum, this process shall: (i) Include consideration of the needs of the target population, including work, school and parenting responsibilities. (ii) Include consideration of transportation accessibility. (iii) Not be based solely on standard eight (8) to five (5), Monday through Friday office hours. Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Amended: Published January 31, 2023; effective March 17, 2023. 580-9-44-.27 Level III.7: Medically Monitored High Intensity Residential Treatment Program For Adolescents (1) Rule Compliance. In addition to compliance with the rules as specified in this chapter, each Level III.7 Medically Monitored High Intensity Residential Treatment Program for Adolescents shall comply with the rules as specified in the following chapters. (a) Program Description. The entity shall develop, maintain and implement a written program description that defines its Level III.7 Adolescent Medically Monitored High Intensity Residential Treatment Program, as according to Rule 580-9-44-.13 and the following specifications: 1. Location. The entity shall specifically identify and describe the setting in which the Level III.7 Adolescent Program shall be provided. Services may be provided in any facility that meets all applicable federal, state and local certification, licensure, building, life-safety, fire, health and zoning regulations including the DMH facility certification standards. 2. Admission Criteria: The entity shall develop, maintain, and document implementation of written criteria for admission to its Level III.7 Adolescent Program, in compliance with the requirements of Rule 580-9-44-.13(9) and the following specifications: (i) The entity’s admission criteria shall specify the target population for its Level III.7 Adolescent Services, which shall include, at a minimum, individuals: (I) Who are less than nineteen (19) years old and: (II) Whose assessed severity of illness warrants this level of care, including but not limited to adolescents whose sub-acute biomedical and emotional, behavioral, or cognitive problems are so severe that they require medically monitored treatment but do not need the full resources of an acute care general hospital. (III) For whom treatment for identified problems has been rendered ineffective at less intensive levels of care. (ii) The entity shall provide written documentation in individual case records that each client admitted to a Level III.7 Adolescent Program meets: (I) The diagnostic criteria for a substance related disorder as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (iii) Co-occurring Disorders Program Specific Criteria. The entity shall provide written documentation in individual case records that each individual admitted to a Level III.7 Adolescent Co-occurring Enhanced Treatment Program meets: (I) The diagnostic criteria for a substance related and mental illness disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders. (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (iv) Women and Dependent Children Program Specific Criteria: The entity shall provide written documentation in individual case records that each client admitted to a Level III.7 Adolescent Program for Women and Dependent Children: (I) Meets the diagnostic criteria for a substance related disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders. (II) The dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R. (III) Is pregnant; or (IV) Has care and custody of dependent children; or (V) Has lost custody of dependent children and has the potential for family reunification. 3. Core Services: Each Level III.7 Adolescent High Intensity Residential Program shall demonstrate the capacity to provide a basic regimen of treatment services appropriate to the adolescent’s developmental and cognitive levels and other assessed needs. (i) At a minimum, the entity shall demonstrate and document its capacity to provide a twenty-four (24) hour structured residential treatment environment with the following core services: (I) Placement assessment. (II) Individual counseling. (III) Group counseling. (IV) Family counseling. (V) Psychoeducation. (VI) Peer support. (VII) Medical and somatic services. (VIII) Daily living skills. (IX) Medication management. (X) Medication administration. (XI) Alcohol and/or drug screening/testing. (XII) Transportation. (XIII) Activity therapy. (XIX) Case management: I. Case planning. II. Linkage. III. Advocacy. IV. Monitoring. (ii) Medical Services. The entity shall implement procedures for the provision of medical services as according to protocols established in compliance with Rule 580-9-44-.13(24). (I) Pregnant clients who are not receiving routine prenatal care shall be seen by physician within two (2) weeks of admission. (iii) Mental Health Services. The entity shall develop, maintain and document implementation of written policies and procedures to ensure that each client’s mental health needs are identified through the assessment service process and access to appropriate care for these needs is provided concurrently with treatment for assessed substance related disorders. (iv) Family Support. The entity shall initiate and document in the client record continuous efforts to involve the client’s family and other natural supports in the treatment process. (v) Co-occurring Disorders Program Specific Criteria: Each Level III.7 Adolescent Co-occurring Disorders High Intensity Residential Treatment Program shall document the capacity to provide each of the core services and the following services: (I) Mental health consultation. (II) Crisis intervention services. (III) Intensive case management. (vi) Women and Dependent Children Program Specific Criteria: Each Level III.7 Adolescent Women and Dependent Children High Intensity Residential Treatment Program shall document the capacity to provide each of the core services and the following services: (I) Child sitting services. (II) Developmental delay and prevention services. (III) Parenting skills development. (IV) Academic and vocational services. (V) Financial resource development and planning. (VI) Family planning services. 4. Therapeutic Component Implementation. The entity shall document the implementation of a planned regimen of professionally directed program activities for adolescents and their families. Evaluation, treatment and care shall be provided in an amount, frequency and intensity appropriate to the client’s assessed needs and expressed desires for care. (i) Service strategies for each Level III.7 Adolescent Residential Program shall include, at a minimum: (I) On duty awake staff shall provide supervision of client’s health, welfare and safety twenty-four (24) hours a day. (II) Clients shall have access to clinical services personnel twenty-four (24) hours a day seven (7) days a week. (III) Daily clinical services to improve the client’s ability to structure and reorganize the tasks of daily living and recovery. (IV) The provision of daily scheduled treatment and recovery support services and activities that shall, at a minimum, include those that address: I. Implementation of individualized service plan strategies. II. Development and application of recovery skills including relapse prevention. III. Interpersonal choice/decision making skill development. IV. Enhancement of the understanding of addiction. V. Development of a social network supportive of recovery. VI. Random drug screening. VII. Health education. VIII. Medication administration and monitoring. IX. Promotion of successful involvement in regular productive daily activity, such as school or work. X. Enhancement of personal responsibility, developmental maturity and prosocial values. XI. Educational services in accordance with state and local regulations. XII. Opportunities to remedy educational deficits created by involvement with alcohol and other drugs. XIII. Supervised therapeutic recreational activities. (ii) The entity shall actively promote and provide referrals and/or access to community support services. (iii) All services shall be organized and provided according to evidence-based and best practice standards and guidelines. 5. Documentation: Each Level III.7 Adolescent High Intensity Residential Program shall provide the following documentation in each client record: (i) Individualized progress notes shall be recorded each day for each respective service provided. 6. Support Systems. Each Level III.7 Adolescent Program shall develop, maintain and document implementation of written policies and procedures which govern the process used to provide client access to support services on site or through consultation or referral, which shall minimally include: (i) The availability of a physician or physician extender to assess each adolescent in person within twenty-four (24) hours of admission and thereafter as medically necessary. (ii) Emergency consultation with a physician available twenty-four (24) hours a day seven (7) days a week. (iii) Telephone or in person consultation with emergency services twenty-four (24) hours a day seven (7) days a week. (iv) The availability of a MAS Registered Nurse to conduct a nursing assessment at the time of admission, monitor the client’s progress during treatment and manage medication administration. (v) Telephone or in person consultation with a MAS Nurse twenty-four (24) hours a day, seven (7) days a week. (vi) Indicated laboratory and toxicology testing. (vii) Indicated medical procedures. (viii) Medical treatment. (ix) Psychological and psychiatric treatment. (x) Community based services assessed as needed but not provided by the entity. (xix) Direct affiliation with or coordination through referral to more and less intensive levels of care including detoxification services. 7. Program Personnel. Each Level III.7 Adolescent High Intensity Residential Program shall employ an adequate number of qualified individuals to provide personalized care for its clientele and to meet the program’s goals and objectives. (i) Nursing Personnel. MAS Registered Nurses or Licensed Practical Nurses shall be available for primary nursing care and observation twenty-four (24) hours a day. (ii) Direct Care Personnel. All direct care personnel shall have the qualifications as a qualified paraprofessional to provide the specific services delineated in the entity’s program description for this level of care. (iii) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level III.7 Program as delineated in its operational procedures. (iv) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (v) Every client in a Level III.7 Adolescent Program shall be assigned to a specific primary counselor for care management whose principal responsibilities shall include, but not limited to: (I) Development and implementation of the individualized service plan. (II) Ensuring service delivery and coordination of service delivery as delineated in the plan. (III) Evaluation of the client’s overall progress in treatment and preparation of staffing reports. (IV) Discharge and continuing care planning and implementation. (vii) Each primary counselor shall maintain a case load not to exceed ten (10) clients with active cases at any one time. (viii) Co-occurring Disorders Program Specific Criteria. (I) Each Level III.7 Adolescent Co-occurring Enhanced High Intensity Residential Program shall be coordinated by a full-time member of the staff who has the minimum of a master’s degree in a mental health related field and at least two (2) years supervised experience in a direct service area treating adolescent clients with co-occurring disorders. (II) Each Level III.7 Adolescent Co-occurring Enhanced High Intensity Residential Program shall have access to psychiatric services led by a qualified psychiatrist or nurse practitioner that are fully capable of evaluating, diagnosing and prescribing medications to clients with co-occurring disorders. On-call psychiatric services shall be available twenty-four (24) hours a day, seven (7) days a week. (III) The treatment organization/agency shall have access to an Alabama licensed physician, full time, part time, or on contract, who shall be available to the program for client care and shall assume responsibility for the medical aspects of the program. (IV) Treatment staff that provide therapy and ongoing clinical assessment services to individuals diagnosed with co-occurring disorders, shall have at a minimum, I. A master’s degree in a behavioral health related field with a minimum of two (2) years’ work experience with individuals who have co-occurring disorders, mental health or substance use disorders. II. Specialized training to work with individuals who have co-occurring disorders. (V) All other direct care personnel in a Level III.7 Adolescent Co-occurring Enhanced High Intensity Residential Program shall be qualified to provide the specific services delineated in the entity’s operational plan for this level of care. (VI) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level III.7 Adolescent Co-occurring Enhanced Residential Program as delineated in its operational plan. (VII) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (VIII) Every client in a Level III.7 Adolescent Residential Program shall be assigned to a specific primary counselor for care management as a qualified paraprofessional. (viii) Women and Dependent Children Program Specific Criteria. (I) Direct Care Personnel. All direct care personnel shall be qualified as qualified paraprofessional to provide the specific services delineated in the entity’s operational plan for this level of care. (II) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level III.7 Adolescent High Intensity Women and Dependent Children Residential Program as delineated in its operational plan. (III) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program’s administrative functions. (IV) Every client in a Level III.7 Adolescent Women and Dependent Children Program shall be assigned to a specific primary counselor for care management. (V) Each primary counselor shall maintain a case load not to exceed ten (10) clients with active cases at any one time. 8. Training. The entity shall provide written documentation that all Level III.7 Adolescent Program personnel satisfy the competency and training requirements as specified in Rule 580-9-44-.02(3). 9. Service Intensity: (i) The entity shall document that the amount and frequency of Level III.7 Adolescent High Intensity Residential Treatment Services are established on the basis of the unique needs of each client served. To assist in addressing these needs, the entity shall ensure the availability of no less than twenty (20) hours of structured services each week. (ii) The entity shall provide written documentation describing the procedures utilized to ensure the provision of services appropriate to the client’s developmental stage and level of comprehension including any necessary adaptations. 10. Length of Service: The entity shall provide written documentation that the duration of treatment in each Level III.7 Adolescent High Intensity Residential Program shall vary as determined by: (i) The severity of the client’s illness. (ii) The client’s ability to comprehend the information provided and use that information to implement treatment strategies and attain treatment goals. (iii) The appearance of new problems that require another level of care; or (iv) The availability of services at an assessed level of need, when a Level III.7 Adolescent Residential Program has been utilized to provide interim services. 11. Service Availability: The entity shall provide written documentation describing the process utilized to establish hours of availability for Behavioral Health Screening and Diagnostic Interview Examination Services at its Level III.7 High Intensity Residential Program. At a minimum, this process shall: (i) Include consideration of the needs of the target population, including work, school and parenting responsibilities. (ii) Include consideration of transportation accessibility. (iii) Not be based solely on standard eight (8) to five (5), Monday through Friday office hours. Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Amended: Published January 31, 2023; effective March 17, 2023. 580-9-44-.28 Level 3.7-D: Medically Monitored Residential Detoxification Program And Level 3.7-D NTP: Medically Monitored Residential Detoxification Narcotic Treatment Program (1) Scope. This Chapter establishes rules for the operation of Medically Monitored Residential Detoxification Programs (Level 3.7-D) and Medically Monitored Residential Detoxification Programs designated as Narcotic Treatment Programs (Level 3.7-D NTP). (2) Definitions. The following definitions apply to this Chapter: (a) Accreditation elements: The standards that are developed and adopted by an accreditation body and approved by the Substance Abuse and Mental Health Services Administration (SAMHSA). (b) Detoxification: The dispensing of medication, approved for such purposes, in decreasing doses to an individual to alleviate adverse physical or psychological effects incident to withdrawal from the continuous or sustained use of alcohol and/or other relevant addictive drugs. Detoxification functions, also, as a method of bringing the individual to a drug-free state within such period. (c) Federal opioid treatment standards: 42 CFR 8.12. (d) Level 3.7-D Medically Monitored Residential Detoxification Program: An organized regimen of services provided by nursing and medical professionals, which provides for 24-hour medically supervised alcohol or other drug withdrawal management with medication approved for such use. (e) Level 3.7-D NTP Medically Monitored Residential Detoxification Program: An organized regimen of services provided by nursing and medical professionals, which provides for 24-hour medically supervised opioid withdrawal management utilizing buprenorphine or a buprenorphine combination product approved for treatment of opioid use disorders by the Food and Drug Administration (FDA). A Level 3.7-D NTP may not dispense Methadone unless the entity is certified by the Alabama Department of Mental Health to operate an Opioid Treatment Program in compliance with Chapter 580-9-44-.29 of these rules and holds a valid Certificate of Need for the operation of a Methadone Treatment Program issued by the Alabama State Health Planning and Development Agency. (f) Long-term detoxification: Detoxification treatment services provided for a period more than 30 days, but not in excess of 180 days. (g) Medical director: A physician, licensed to practice medicine in Alabama, who assumes responsibility for administering all medical services performed by the program, either by performing them directly or by delegating specific responsibility to authorized program physicians and healthcare professionals functioning under the medical director’s direct supervision. (h) Program sponsor: The individual, named in the entity’s application for certification by SAMHSA as according to 42 CFR 8.11, who is responsible for the operation of the Level 3.7–D NTP. The sponsor assumes responsibility for all of the entity’s employees, including any practitioners, agents, or other persons providing medical, rehabilitative, or counseling services. (i) Short-term detoxification: Detoxification treatment for a period not in excess of 30 days. (3) Rule Compliance. (a) In addition to compliance with the rules as specified in this chapter, each Level 3.7-D and 3.7-D NTP shall comply with the rules as specified in the following chapters: 580-9-44-.02 Personnel, 580-9-44-.03 Client Rights, 580-9-44-.04 Abuse and Neglect, 580-9-44-.05 Grievances, Complaints and Appeals, 580-9-44-.06 Confidentiality and Privacy, 580-9-44-.07 Seclusion and Restraint, 580-9-44-.08 Child and Adolescent Seclusion and Restraint, 580-9-44-.09 Incident Reporting, 580-9-44-.10 Infection Control, 580-9-44-.11 Performance Improvement, 580-9-44-.12 Operational Policies and Procedures Manual, and 580-9-44-.13 Program Description. (b) Each Level 3.7-D NTP shall comply with all regulations enforced by the DEA under 21 CFR Chapter II, and Chapter 580-9-44 Mental Health Revised 3/17/23 9-44-156 must be registered by the DEA before administering or dispensing opioid agonist treatment medications. (c) Each Level 3.7-D NTP must operate in accordance with Federal opioid treatment standards and approved accreditation elements. (4) Program Description. The entity shall develop, maintain and implement a written program description that defines its Level 3.7-D program or Level 3.7-D NTP, as according to Rule 580-9-44-.13 and the following specifications: (a) Location. The entity shall specifically identify and describe the setting in which the Level 3.7-D Program or Level 3.7-D NTP is provided. Services may be provided in any facility that meets all applicable federal, state and local certification, licensure, building, life-safety, fire, health and zoning regulations including the DMH facility certification standards. (b) Admission Criteria: 1. Level 3.7-D. The entity’s admission criteria shall specify the target population for the Level 3.7-D Program, which shall include, at a minimum, individuals who are experiencing signs and symptoms of withdrawal, or for whom there is evidence that a withdrawal syndrome is imminent, and who have a history of insufficient skills and supports to complete detoxification at a less intense level of care. (i) The entity shall provide written documentation in individual case records that each patient admitted to receive Level 3.7-D services meets the diagnostic criteria for a Substance Related Disorder as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. (ii) The entity shall provide written documentation in individual case records that each patient admitted to receive Level 3.7-D services meets the dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM Criteria. 2. Level 3.7-D NTP. The entity’s admission criteria shall specify the target population for the Level 3.7-D NTP Program, which shall include, at a minimum, individuals who are experiencing signs and symptoms of opioid withdrawal, or for whom there is evidence that a withdrawal syndrome is imminent; and who have a history of insufficient skills and supports to complete detoxification at a less intense level of care. (i) The entity shall provide written documentation in individual case records that each patient admitted to receive Level 3.7-D NTP services meets the diagnostic criteria for an Opioid Related Disorder as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. (ii) The entity shall provide written documentation in individual case records that each patient admitted to receive Level 3.7-D NTP services meets the dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM Criteria. (iii) The entity shall not admit a patient for more than two detoxification treatment episodes in one year. Patients with two or more unsuccessful detoxification episodes within a 12-month period must be assessed by the program’s Medical Director or other authorized medical professional for other forms of treatment. (c) Core Services: At a minimum, each Level 3.7-D Program and 3.7D NTP shall document the capacity to provide the following core services: 1. Placement assessment. 2. Individual counseling. 3. Group counseling. 4. Psychoeducation. 5. Family counseling. 6. Peer support. 7. Medical and somatic services. 8. Medication administration. 9. Medication monitoring. 10. Alcohol and/or drug screening/testing. 11. Case management, including: (i) Case planning. (ii) Linkage. (iii) Advocacy. 12. Patient Progress Monitoring. (d) Therapeutic Component Implementation: The entity shall document implementation of medical and other clinical services organized to enhance the patient’s understanding of addiction, support completion of the detoxification process and initiate transfer to an appropriate level of care for continued treatment. At a minimum, this shall include the following therapeutic components: 1. For each Level 3.7-D program: (i) Completion of a comprehensive medical history and physical examination of the patient at admission. (ii) Protocols established by the entity’s medical director, for management of detoxification from each major drug category of abused drugs that are consistent with guidelines published by nationally recognized organizations (e.g., SAMHSA, ASAM, American Academy of Addiction Psychology) and with product labeling of medications utilized. (iii) Level 3.7-D Programs that utilize benzodiazepines in the detoxification protocol shall have: (I) Written protocols and procedures to show that all doses or amounts of benzodiazepines are carefully monitored and are slowly reduced as appropriate. (II) Written longer-term detoxification protocols and procedures that adhere to general principles of management, including clear indications of benzodiazepine dependence, clear intermediate treatment goals and strategies, regular review and methods to prevent diversion from the plan. 2. For each Level 3.7-D NTP: (i) The Level 3.7-D NTP shall maintain current procedures that are designed to ensure that patients are admitted to short- or long-term detoxification treatment by a program physician, who determines that such treatment is appropriate for the specific patient by applying established diagnostic criteria. (ii) Each patient must undergo a complete, fully documented physical evaluation by a program physician or a primary care physician, or an authorized healthcare professional under the supervision of a program physician, before admission to the Level 3.7-D NTP. The full medical examination, including the results of serology and other tests, must be completed within 14 days following admission. (iii) The program must maintain current policies and procedures that reflect the special needs of patients who are pregnant. Prenatal care and other gender specific services for pregnant patients must be provided either by the Level 3.7-D NTP or by referral to appropriate healthcare providers. (iv) The entity shall maintain current procedures adequate to ensure that each buprenorphine and/or buprenorphine combination product used by the program is administered and dispensed in accordance with its approved product labeling. Dosing and administering decisions shall be made by a program physician familiar with the most up-to-date product labeling. (v) Medication orders and changes in dosage shall be written on an acceptable order sheet and signed by a program physician or through utilization of a comparable electronic signatory process. (vi) Policies and procedures for medication administration, dispensing, and use shall ensure that buprenorphine and buprenorphine combination products are administered or dispensed only by a physician, pharmacist, registered nurse, or licensed practical nurse. (vii) At least one (1) initial drug test should be conducted for patients in short-term detoxification treatment for analysis of illicit drug use or prescription drug misuse. (viii) Buprenorphine and/or buprenorphine combination products shall only be dispensed or administered to patients who are admitted to the Level 3.7-D NTP. The entity shall not prescribe or dispense buprenorphine and/or buprenorphine combination products for unsupervised and/or take-home use or for use in another level of treatment. 3. Each Level 3.7-D Program and Level 3.7-D NTP shall provide: (i) On duty awake staff shall provide supervision each patient’s health, welfare and safety twenty-four (24) hours a day, seven (7) days a week. (ii) On-site physician care and phone availability twenty-four (24) hours a day, seven (7) days a week. (iii) Nurse monitoring, assessment and management of signs and symptoms of intoxication and withdrawal twenty-four (24) hours a day, seven (7) days a week. (iv) A pregnancy test for females of childbearing age prior to administration of medication. (v) Medication administration and monitoring services, including specific procedures for pregnant women. (vi) Continuous assessment. (vii) Planned counseling and other therapeutic interventions. (viii) Motivational enhancement therapy. (ix) Peer support services. (x) Relapse prevention counseling. (xi) Overdose prevention education. (xii) Direct affiliation with other levels of care. (e) Documentation: 1. Each Level 3.7-D Programs and Level 3.7-D NTP shall provide the following clinical record documentation: (i) Documentation of each clinical/therapeutic intervention provided. (ii) Daily assessment of progress, including response to medication, which also notes any treatment changes. (iii) Monitoring of vital signs, at a minimum, every eight (8) hours until discharge. (iv) The use of detoxification rating scale tables and flow sheets. 2. Each Level 3.7-D NTP. (i) The entity shall establish and maintain a recordkeeping system that is adequate to document and monitor patient care that complies with all Federal and State reporting requirements relevant to opioid drugs approved for use in treatment of opioid addiction. All records are required to be kept confidential in accordance with all applicable Federal and State requirements. (ii) The Level 3.7 NTP shall include, as an essential part of the recordkeeping system, documentation in each patient's record that the entity made a good faith effort to review whether or not the patient is enrolled in an Opioid Treatment Program (OTP) or taking other opioids that would contraindicate buprenorphine treatment. (f) Support Systems: Each Level 3.7-D Program and 3.7-D NTP shall develop, maintain, and document implementation of written policies and procedures utilized to provide patient access to support services on site, or through consultation or referral, which shall minimally include: 1. Specialized clinical consultation for biomedical, emotional, behavioral and cognitive problems. 2. Appropriate laboratory and toxicology testing. 3. Psychological and psychiatric services. 4. Transportation. 5. Twenty-four (24) hour access to emergency medical services. (g) Staff Requirements. 1. Each Level 3.7-D and 3.7-D NTP shall, at a minimum, maintain the following positions as part of its staff: (i) Medical Director. The medical director shall be a physician licensed to practice in the State of Alabama, who has a minimum of one (1) year experience treating substance related disorders. The medical director shall be responsible for admission, diagnosis, medication management, patient care, and for ensuring that the program is in compliance with all Federal, State, and local laws and regulations. (ii) Each Program shall be coordinated by a full-time employee who is an Alabama licensed Registered Nurse, Nurse Practitioner, Physician, or Physician’s Assistant, with two (2) years direct care experience treating substance related disorders. (iii) Nursing Services Director. Program shall have a nursing services director who shall be a Registered Nurse licensed according to Alabama law, with training and work experience in behavioral health. (iv) There shall be a Registered Nurse (RN) or Licensed Practical Nurse (LPN) on site during all hours of the Program’s operation. (v) Direct Care Personnel. All direct care personnel must have sufficient education, training, and experience, or a combination thereof, to enable that person to perform the assigned job responsibilities. All physicians, nurses, and other licensed professional care providers, including certified addiction counselors, must comply with the credentialing requirements of their respective professions. (vi) The entity shall maintain an adequate number of personnel, including physicians, nurses, counselors and case managers to sustain the Program as delineated in its operational plan. (vii) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the Program’s administrative functions. (h) Training: Each Level 3.7-D and 3.7-D NTP shall provide written documentation that: 1. All program personnel satisfy the requirements of the core training curriculum, as specified in Rule 580-9-44-.02(3). 2. All clinical and medical services staff receive training during the initial twelve (12) months employment and develop basic competencies in the following areas: (i) Biopsychosocial dimensions of substance related disorders. (ii) The signs and symptoms of alcohol and other drug intoxication and withdrawal. (iii) Evidence-based treatment and monitoring strategies for alcohol and other drug intoxication and withdrawal. (iv) Continuing care motivational and engagement strategies. (v) Pharmacotherapy. (vi) ASAM Criteria. (vii) Assessment of and service planning to address biopsychosocial needs. (i) Service Intensity: The entity shall document in the clinical record that the intensity of Level 3-D Services and Level 3.7-D NTP is established on the basis of the unique needs of each served. (j) Length of Service: The entity shall provide written documentation in the clinical record that the duration of treatment in each Level 3.-D Program and 3.7-D NTP varies as determined by the patient’s assessed needs, and that the patient continues in treatment until: 1. Withdrawal signs and symptoms are sufficiently resolved; or 2. Withdrawal signs and symptoms have failed to respond to treatment and have intensified warranting a transfer to a more intense level of care; or 3. The patient is, otherwise, unable to complete detoxification at this level of care. K. Diversion Control Plan. Each Level 3.7-D NTP shall maintain a current Diversion Control Plan (DCP) as part of its quality assurance program that, at a minimum: 1. Contains specific measures to reduce the possibility of diversion of controlled substances from legitimate use, and 2. Assigns specific responsibility to the medical and administrative staff of the Level 3.7–D NTP for carrying out the diversion control measures and functions described in the DCP. (l) Emergency Administration of Medication. Each Level 3.7-D program and Level 3.7-D NTP shall maintain policies and procedures for administration of patient medication in the event of an emergency leading to the temporary closure of the program. Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. 580-9-44-.29 Level I-O: Opioid Maintenance Therapy (1) Rule Compliance. Each Level I-O Opioid Treatment Program (OTP) shall comply with all applicable rules and the rules specified in this chapter: (a) Program Description. The entity shall develop, maintain, and implement a written program description that defines its Level I-O Opioid Treatment Program (OTP): 1. Location. The entity shall specifically identify and describe the setting in which the Level I-O Opioid Treatment Program (OTP)is provided. Services may be provided in any facility that meets all applicable federal, state, and local certification, licensure, building, life-safety, fire, health and zoning regulations, including the DMH facility certification standards. 2. Admission Criteria. The entity shall develop, maintain and document implementation of written criteria for admission to its Level I-O Opioid Treatment Program (OTP), the following specifications: Comprehensive Physical Assessment in addition to the required ADMH Placement Assessment. An OTP shall maintain current procedures to ensure that recipients admitted to treatment by qualified personnel who have determined, using acceptable medical criteria, the recipient meets the following and shall be documented in the recipient’s record: (i) The recipient meets diagnostic criteria for a moderate to severe Opioid Use Disorder (OUD) or (ii) The recipient has an active moderate to severe OUD, or (iii) Opioid Use Disorder, or (iv) Is at high risk for recurrence or overdose. (v) Recipient voluntarily chooses treatment with Medication for Opioid Disorder (MOUD) and that all relevant facts concerning the use of MOUD are clearly and adequately explained to the recipient and each recipient provides informed consent to treatment. (vi) Adolescent Specific Criteria. An individual eighteen (18) years of age or older, may consent to OTP treatment and the consent of no other person shall be deemed necessary, no person under the age of eighteen (18) may be admitted to OTP treatment unless a parent, legal guardian, or responsible adult designated by the relevant State authority consents in writing to such treatment. 3. Core Services. Each Level I-O OTP shall demonstrate the capacity to provide a basic regimen of treatment services appropriate to the recipient’s developmental and cognitive levels and other assessed needs. (i) At a minimum, the entity shall demonstrate and document its capacity to provide the following core services: (I) Placement assessment. (II) Medication management. (III) Medication administration. (IV) Alcohol and/or drug screening/testing. (V) Individual counseling. (VI) Group counseling. (VII) Family counseling. (VIII) Psychoeducation. (IX) Case management: I. Case planning. II. Linkage. III. Advocacy. IV. Monitoring. (ii) Medical Services. The entity shall have medical protocols established for OTP by a licensed physician who is full-time, part-time or under contract with the entity as the medical director. The medical protocol shall be in compliance with the program standards, ethics and licensure requirements of the medical profession. (iii) Mental Health Services. The entity shall develop, maintain and document implementation of policies and procedures to ensure that recipients with mental health needs are identified through assessment services and have access to appropriate care concurrently with OTP. (iv) Family Support. The entity shall initiate and document in the recipient record: (I) Continuous efforts to involve the recipient’s family and other natural supports in the treatment process, with recipient’s consent. (II) Family and other natural supports’ participation in the recipient’s treatment process, with recipient’s consent. 4. Therapeutic Component Implementation. (i) Each Level I-O OTP shall provide written documentation of compliance with all applicable local, state, and federal regulations, including Federal Regulation 42 CFR Part 8, DEA, Certificate of Need, etc. in addition to all applicable sections of the rules set forth, herein. (ii) Each Level I-O OTP shall establish a written schedule of operating hours and services that shall: (I) Provide for dosing and counseling services not less than five (5) days per week, unless there are closures state and/or federal holidays, and/or emergency closings. (II) Establish hours of operation that are flexible to accommodate the majority of recipients. (III) Provide access to clinical services personnel twenty-four (24) hours a day, seven (7) days a week. (iii) Counseling Services : The entity shall document the provision of scheduled counseling and recovery support services and activities that shall, at a minimum, include: (I) Interventions that address: I. Emotional and psychological needs. II. Health education. III. Medication administration and monitoring. 5. Required services. (i) General . OTPs shall provide adequate: (I) Medical, counseling, vocational, educational, and other screening, assessment, and treatment services to meet the recipient’s needs, with the combination and frequency of services tailored to each individual recipient based on individual assessment and the recipient’s care plan that was created after shared decision making between the recipient and the clinical team. (II) These services shall be available at the primary facility, except where the program sponsor has entered into a documented agreement with a private or public organization, practitioner, or institution to provide these services to recipients enrolled in the OTP. (III) The program sponsor, in any event, shall be able to document that these services are fully and reasonably available to recipients. (ii) Initial medical examination. (I) OTPs shall require each recipient to undergo an initial medical examination by the program’s medical director, or a physician or physician extender properly authorized by the medical director and per State law. The initial medical examination shall be comprised of two (2) parts: I. A screening examination to ensure the recipient meets criteria for admission and that there are no contraindications to treatment with MOUD; and II. A full history and examination, to determine the recipient’s broader health status, with lab testing as determined to be required by an appropriately licensed practitioner. A recipient’s refusal to undergo lab testing for co-occurring physical health conditions should not preclude them from access to treatment, provided such refusal does not have potential to negatively impact treatment with medications. (II) No contraindications present, a recipient may commence treatment with MOUD after the screening examination has been completed. I. Both the screening examination and full examination shall be completed by appropriately licensed practitioner. II. If the licensed practitioner is not an OTP practitioner, the screening examination shall be completed no more than seven (7) days prior to OTP admission. III. Where the examination is performed outside the OTP, the written results and narrative of the examination as well as available lab testing results, shall be transmitted consistent with applicable privacy laws, to the OTP, and verified by an OTP practitioner. (III) A full in-person physical examination, including the results of serology and other tests that are considered to be clinically appropriate shall be completed within fourteen (14) calendar days following a recipient’s admission to the OTP. The full exam is verified by a licensed OTP practitioner as being true and accurate and transmitted in accordance with applicable privacy laws. (IV) Serology testing and other testing as deemed medically appropriate by the licensed OTP practitioner based on the screening or full history and examination, collected not more than thirty (30) days prior to admission to the OTP, may form part of the full history and examination. (V) The screening and full examination may be completed via telehealth for those recipients being admitted for treatment at the OTP with either buprenorphine or methadone, if a practitioner or primary care provider determines that an adequate evaluation of the recipient can be accomplished via telehealth and according to state and federal law. (iii) Special services for pregnant recipients. OTPs shall maintain current policies and procedures that reflect the special needs and priority for treatment admission of recipients with MOUD who are pregnant. (I) Pregnancy should be confirmed if possible. Refusal of pregnancy test shall not result in the denial of access to treatment to include MOUD. (II) Evidenced-based treatment protocols for the pregnant recipient, such as split dosing regimens, shall be instituted after assessment by the OTP practitioner and documentation that confirms the clinical appropriateness of such an evidenced-based treatment protocol. (III) Prenatal care and other sex-specific services, including reproductive health services, for pregnant and postpartum recipients shall be provided and documented either by the OTP or by referral to the appropriate healthcare practitioners. (IV) Specific services, including reproductive health services for pregnant and postpartum recipients shall be provided and documented either by the OTP or by referral to appropriate healthcare practitioner. (iv) Initial and periodic physical and behavioral health assessment services. (I) Each recipient admitted to an OTP shall be given a physical and behavioral health assessment, which includes but is not limited to: I. Screening from imminent risk of harm to self or others, within fourteen (14) calendar days of admission, and periodically by Qualified Substance Use Professional I (QSUP I) and/or Qualified Substance Use Professional II (QSUP II). II. These assessments must address the need and/or response to treatment, adjust treatment interventions, including MOUD, as necessary, and provide person-centered treatment plan. III. Preparation of a treatment plan that includes the recipient’s goals and mutually agreed upon actions for the recipient to meet those goals in addition to requirements of 580-2-20-.08, including: A. Harm reduction interventions. B. The recipient’s needs and goals in the areas of education, vocational training, and employment. C. The medical and psychiatric, psychological, economic, legal, housing, and other recovery supported services that a recipient needs and wishes to pursue. D. The treatment plan also shall identify the recommended frequency with which services are to be provided. E. The treatment plan shall be reviewed and updated to reflect responses to treatment and recovery support services, and adjustments made that reflect changes in the context of the recipient’s life, their current needs for and interests in medical, psychiatric, social, and psychological services, and current needs for and interests in education, vocational training, and employment services. (II) The periodic physical examination shall not occur less than one time each calendar year and be conducted by an OTP practitioner. The periodic physical examination shall include review of: I. MOUD dosing, II. Treatment response, III. Other substance use needs, IV. Responses and recipient identified goals, and V. Other relevant physical and psychiatric treatment needs and goals. VI. The periodic physical examination shall be documented in the recipient record. (v) Counseling and psychoeducational services. (I) OTPs shall provide adequate substance use disorder counseling and psychoeducation to each recipient as clinically necessary and mutually agreed upon, including harm reduction education and recovery-oriented counseling. (II) This counseling shall be provided by program counselor, qualified by education, training, or experience to assess the psychological and sociological background of recipients, engage with recipients, to contribute to the appropriate treatment plan for the recipient and to monitor and update recipient progress. (III) Recipient refusal of counseling shall not preclude them from receiving MOUD. (IV) OTPs shall provide counseling on preventing exposure to, and the transmission of, human immunodeficiency virus (HIV), viral hepatitis, and sexually transmitted infections (STIs) and either directly provide services and treatments or actively link to treatment each recipient admitted or readmitted to treatment who has received positive test results for these conditions form initial and/or periodic medical examinations. (V) OTPs shall provide directly, or through referral to adequate and reasonably accessible community resources, vocational training, education, and employment services for recipients who request such services or for whom these needs have been identified and mutually agreed upon as beneficial by the recipient and the program staff. 6. Recipient Orientation: (i) All recipients shall be oriented to the MOUD process prior to administration of any medication. (ii) The entity shall provide written documentation that each recipient, upon admission and throughout the treatment process, receives oral and written information that explains in a manner understood by the recipient: (I) Signs and symptoms of overdose and when to seek emergency assistance. (II) A description of the MOUD to be administered by the program, including potential: I. Benefits. II. Risks. III. Side effects. IV. Drug interactions. (III) Common myths about MOUD used in the treatment and withdrawal process. (IV) The nature of substance use disorders (SUD). (V) The goals and benefits of MOUD and the process of recovery. (VI) Noncompliance and discharge procedures, including administrative withdrawal from medication. (VII) Toxicology testing procedures. (VIII) Medication dispensing procedures. 7. Drug Testing: The entity shall develop, describe in writing and document implementation of an organized process to monitor drug use by program participants, which shall, at a minimum 580-2-20-.09 (17) and include the following specifications: (i) When conducting random drug testing, OTP/s shall use drug tests that have received the Food and Drug Administration’s (FDA) marketing authorization for commonly used and misused substances that may impact recipient safety, recovery, or otherwise complicate substance use disorder treatment, at a frequency that is in accordance with generally accepted clinical practice and as indicated by a recipient’s response to and stability in treatment but no fewer than eight (8) random drug tests per year, allowing for extenuating circumstances at the individual recipient level. (i i ) The results of a drug test shall be utilized as a guide to review and modify treatment approaches and not as the sole criterion to discharge a recipient from treatment. (iii) Toxicology tests shall be completed within fourteen (14) days of admission, at a minimum, screen for: (I) Opiates. (II) Methadone. (III) Benzodiazepines. (IV) Cocaine. (V) Amphetamines/methamphetamine. (VI) Tetrahydrocannabinol. (VII) Alcohol. (VIII) Fentanyl. (IX) Any other drug known to be frequently abused in the locality of the OTP. (iv) The entity shall document the utilization of drug testing cutoff concentrations as follows: (I) Opiate: 300 ng/ml (II) Methadone: 300 ng/ml (III) Benzodiazepine: 200 ng/ml (IV) Cocaine: 300 ng/ml (V) Amphetamine/methamphetamine: 1000 ng/ml (VI) Tetrahydrocannabinol: 200 ng/ml (VII) Alcohol: .03 gm/dl (VIII) Fentanyl: 2 ng/ml. (IX) Buprenorphine: 5ng/ml. (v) The OTP shall provide documentation that all drug tests are conducted by a laboratory certified by an independent, federally approved accreditation entity. (vi) The results of all drug tests shall be filed in the recipient record. 8. Take Home Medication: The entity shall develop, maintain, and document implementation of written policies and procedures that govern the processes utilized to provide recipients with unsupervised use of program dispensed Opioid treatment medication. At a minimum, these policies and procedures shall include the following specifications: (i) The entity’s medical director, in consultation with the recipient’s treatment team, shall make all decisions relative to dispensing Medication for Opioid Use Disorder (MOUD) to recipients for unsupervised use or “take-home” medication doses, in consideration of the following minimum criteria: (I) Any recipient in comprehensive treatment may receive their individualized take-home doses as ordered for days that the clinic is closed for business, State and Federal holidays, no matter their length of time in treatment. (II) OTP decisions on dispensing MOUD to recipients for unsupervised use beyond that set forth shall be determined by an appropriately licensed OTP medical practitioner or medical director. In determining which recipients may receive unsupervised medication doses, the medical director or program medical practitioner shall consider among other pertinent factors that indicate that the therapeutic benefits of unsupervised doses outweigh the risks, the following criteria: I. Absence of active substance use disorders, other physical or behavioral health conditions that increase the risk of recipient harm as it relates to the potential for overdose, or the ability to function safely. II. Regularity of attendance for supervised medication administration. III. Absence of serous behavioral problems that endanger the recipient, the public or others. IV. Absence of known recent diversion activity. V. Whether take-home medication can be safely transported and stored. VI. Any other criteria that the medical director or medical practitioner considers relevant to the recipient’s safety and the public’s health. (III). Such determinations and the basis for such determinations consistent of take-home medications shall be documented in the recipient record. If it is determined that a recipient is safely able to manage unsupervised doses of MOUD set forth in 580-9-44-.29 (1)(a) 9. (i)(II) I. through IV. , the dispensing restrictions criteria as follows shall apply: I. During the first fourteen (14) days of treatment, the take-home supply is limited to seven (7) days. It remains with the OTP practitioner’s discretion to determine the number of take-home doses up to seven (7) days. The rationale underlying the decision to provide unsupervised doses of methadone or buprenorphine shall be documented in the recipient’s record. II. From fifteen (15) days of treatment the take-home supply is limited to fourteen (14) days. It remains with the OTP practitioner’s discretion to determine the number of take-home doses up to fourteen (14) days. The rationale underlying the decision to provide unsupervised doses of methadone or buprenorphine shall be documented in the recipient’s record. III. From thirty-one (31) days of treatment, the take-home supply provided to a recipient is not to exceed twenty-eight (28) days. It remains with the OTP practitioner’s discretion to determine the number of take-home doses up to twenty-eight (28) days. The rationale underlying the decision to provide unsupervised doses of methadone or buprenorphine shall be documented in the recipient’s record. 9. Diversion Control: OTPs shall maintain current procedures adequate to identify the theft or diversion of take-home medications, including labeling containers with the OTP’s name, address, and telephone number. Programs also shall ensure that each individual take-home dose is packaged in the manner that is designed to reduce the risk of accidental ingestion, including child-proof containers (see Poison Prevention Packaging Act, Pub. L. 91-601 (15 U.S.C. 1471 et seq.). The diversion control plan shall, at a minimum, include the following elements: (i) A process for routine surveillance and monitoring of the internal and external treatment environment to identify diversion problems. (ii) A process for continuous examination of dosing and take-home dispensing practices to identify weaknesses in the dispensing of medication that could lead to diversion problems. (iv) A process to address identified diversion problems through corrective and preventive efforts. (vi) Programs shall provide education to each recipient on: Safely transporting medication from the OTP to their place of residence; and the safe storage of take-home doses at the individual’s place of residence, including child and household safety precautions. The provision of this education shall be documented in the recipient’s record. 10. Dosing: The entity shall develop, maintain and document implementation of written policies and procedures to govern the process of medication dispensing, administration and use that shall, at a minimum, include the following specifications: (i) OTPs shall ensure that MOUD are administered or dispensed only by a practitioner licensed under the appropriate State law and registered under the appropriate State and Federal laws to administer or dispense MOUD, or by an agent of such a practitioner, supervised by and under the order of the licensed practitioner and if consistent with Federal and State law. (ii) Only Physicians licensed in Alabama can prescribe and modify prescriptions for Methadone. (iii) Certified Registered Nurse Practitioner shall maintain current Qualified Alabama Controlled Substances Registration Certification (QACSC) can only prescribe Buprenorphine. (iv) OTPs shall only use those MOUD that are approved by the Food and Drug Administration under section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) for use in the treatment of OUD. In addition, OTPs who are fully compliant with the protocol of an investigational use of a drug and other conditions set forth in the application may administer a drug that has been authorized by the Food and Drug Administration under an investigational use in the treatment of OUD. Currently the following MOUD will be considered to be approved by the Food and Drug Administration for use in the treatment of OUD: (I) Methadone. (II) Buprenorphine and buprenorphine combination products that have been approved for use in the treatment of OUD. (III) Naltrexone. (v) OTPs shall maintain current procedures that are adequate to ensure that the following dosage form and initial dosing requirements are met: (I) Methadone shall be administered or dispensed only in oral form and shall be formulated in such a way as to reduce its potential for parenteral misuse. (II) For each new recipient enrolled in an OTP, the initial dose of methadone shall be individually determined and shall include consideration of the type(s) of opioid(s) involved in the recipient’s opioid use disorder, other medications or substances being taken, medical history, and severity of opioid withdrawal. (III) The total dose for the first day should not exceed 50 milligrams unless the OTP physician, licensed under the appropriate State law and registered under the appropriate State and Federal laws to administer or dispense MOUD, finds sufficient medical rationale, including but not limited to if the recipient is transferring from another OTP on a higher dose that has been verified, and documents in the recipient record that a higher dose was clinically indicated. (v) OTPs shall maintain current procedures adequate to ensure that each MOUD used by the program is administered and dispensed in accordance with its FDA approved product labeling. The program shall ensure that any significant deviations from the approved labeling, including deviations with regard to dose, frequency, or the conditions of use described in the approved labeling, are specifically documented in the recipient’s record. 11. Split Dosing means dispensing of a single dose of MOUD as separate portions to be taken within 24-hour period. (i) Split dosing is indicated among but not limited to those who recipients who: (I) Possess a genetic variant which increases methadone metabolism; (II) Concurrently take other medications or drink alcohol that also induce hepatic enzymes leading to more rapid metabolism of methadone; (III) Who are pregnant; or (IV) For whom methadone or buprenorphine are being used to treat a concurrent pain indication in addition to diagnosis of OUD. This leads to more stable, steady-state medication levels. (ii) The organization shall have a written split dosage policy that shall include evidenced-based treatment protocols such as split dosing regimens, shall be instituted after assessment by the OTP practitioner and documentation that confirms the clinical appropriateness of such an evidenced-based treatment protocol. 12. Guest Dosing: The entity shall develop, maintain and document implementation of dosing policies and procedures for the provision of MOUD to a guest recipient in a program in which the recipient is not enrolled. 13. Recordkeeping and recipient confidentiality. (i) OTPs shall establish and maintain a recordkeeping system that is adequate to document and monitor recipient care in addition to the requirements of 580-2-20-.08. 1. This system is required to comply with all Federal and State reporting requirements, relevant to MOUD approved for use in treatment of OUD. 2. All records are required to be kept confidential in accordance with all applicable Federal and State requirements. (ii) OTPs shall include, as an essential part of the recordkeeping system, documentation in each recipient’s record that the OTP made a good faith effort to determine whether the recipient is enrolled in any other OTP. The agency shall check the central registry to monitor for multiple enrollments of a recipient in more than one (1) OTP at the same time. (I) A recipient enrolled in an OTP shall not be permitted to obtain treatment in any other OTP except in circumstances involving an inability to access care at the recipient’s OTP of record. (II) Such circumstances include, but are not limited to, travel for work, family events, temporary relocation, or an OTP’s temporary closure. (III) If the medical director or program practitioner of the OTP in which the recipient is enrolled determines that such circumstances exist, the recipient may seek treatment at another OTP, provided the justification for the particular circumstances are noted in the recipient’s record both at the OTP in which the recipient is enrolled and at the OTP that will provide the MOUD. (iii) The entity shall obtain the recipient’s written consent, in accordance with 42 CFR Part 2, to photograph the applicant at the time of admission. The photograph shall be maintained in the recipient record. (iv) The entity shall require that all recipients show proof of identification. A copy of current identification will be maintained in the recipient record. 14. Withdrawal management. An OTP shall maintain current procedures that are designed to ensure that those recipients who choose to taper from MOUD are provided the opportunity to do so with informed consent and at a mutually agreed-upon rate that minimizes taper-related risk. Such consent shall be documented in the recipient’s record by treating practitioner. 15. Recipient Transfers: The Level I-O Program shall develop, maintain and document implementation of written policies and procedures to effect orderly transfer of recipients between substance use programs, which shall, at a minimum, address the following specifications: (i) A recipient’s request for transfer to another MOUD provider shall be honored without restriction, even if the recipient has an outstanding financial balance. (ii) Records to the receiving MOUD provider shall be provided promptly and shall include, at a minimum: (I) Dose level, to be confirmed by nursing staff at transferring clinic and documented in the clinical record. (II) Reason for transfer. (III) Other information as requested by the receiving program and specified in an appropriate recipient authorization for release of information. 16. Documentation: The OTP shall comply with all standards set forth in Rule 580-2-20-.08 of these rules, and, in addition, shall comply with the requirements of this section: Clinical records of clients receiving MOUD shall include the following documentation: (I) Each dose of medication administered, with a copy of the physician’s order for medication. (II) Coordination of care with physicians prescribing psychoactive and/or control medication to recipients receiving MOUD services. 17. Administrative and organizational structure. An OTP’s organizational structure and facility shall be adequate to ensure quality recipient care and to meet the requirements of all pertinent Federal, State, and local laws and regulations. At a minimum, each OTP shall formally designate: (i) Program Sponsor is responsible for the operation of the OTP and who resumes responsibility for all its employees, including any practitioners, agents, or other persons providing medical, behavioral health, or social services at the program or any of its medication units. 1. The program sponsor shall ensure a physician who is licensed to practice in the State of Alabama occupies the position of medical director within the OTP. 2. The program sponsor responsible for the OTP operation shall agree on behalf of the OTP to adhere to all requirements set forth in these standards. 3. If the Program Sponsor meets the requirements for Executive Director set forth in Rule 580-2-20-.03 (1), they may serve as both the Program Sponsor and the Executive Director. (ii) Medical Director. The medical director, who shall be a physician who is licensed to practice in the State of Alabama, shall assume responsibility for all medical and behavioral health services performed by the OTP. In addition, the medical director shall be responsible for ensuring that the OTP is in compliance with all Federal, State, and local laws and regulations. (iii) Pharmacist: The agency shall follow Alabama Board of Pharmacy requirements. (iv) Nursing Personnel: The entity shall have Alabama licensed nurses to assure that all MOUDs utilized during OTP are administered in compliance with Alabama Board of Nursing regulations. (I) There shall be a Registered Nurse (RN) or Licensed Practical Nurse (LPN) on site during administration and dispensing of MOUDs. (v) All recipients will be assigned to the caseload of a primary counselor who meets the qualifications of a QSUP I or QSUP II. The caseload of each primary counselor shall not exceed fifty (50) recipients. 18. Interim treatment means that on a temporary basis, a recipient may receive some services from OTP, while awaiting access to more comprehensive treatment services. The duration of interim services is limited to 180 days. Comprehensive treatment is treatment that includes the continued use of MOUD provided in conjunction with an individualized range of appropriate harm reduction, medical, behavioral health, and recovery support services. (i) The program sponsor of an OTP may admit an individual, who is eligible for admissions to comprehensive treatment, into interim treatment if comprehensive services are not readily available within a reasonable geographic area and within fourteen (14) days of individual’s seeking treatment. (I) At least two (2) drug tests shall be obtained from recipients during the maximum 180 days permitted for interim treatment. (II) A program shall establish and follow reasonable criteria for establishing priorities for moving recipients from interim to comprehensive treatment. (III) These transition criteria shall be in writing and shall include, at a minimum, prioritization of pregnant recipients in admitting recipients to interim treatment and from interim to comprehensive treatment. (IV) Interim treatment shall be provided in a manner consistent with applicable Federal and State laws, including sections 123, 1227(a), and 1976 of the Public Health Service Act 921 U.S.C 300x-23, 300x-27(a), and 300y-11). (ii) The program shall receive approval from the SOTA prior to the initiation of interim services and notify SOTA when a recipient: (I) Begins interim treatment, (II) Leaves interim treatment, and (III) Before the date of transfer to comprehensive services and shall document such notifications. (iii) Interim authorization may be revoked if the program fails to comply with these provisions or fails to be in compliant with Federal and State laws and regulations. (iv) All requirements for comprehensive treatment apply to interim treatment with the following exceptions: (I) A primary counselor is not required to be assigned to the recipient, but crisis services, including shelter, support, should be available. (II) Interim treatment cannot be provided for longer than 180 days in any 12-month period. (III) By day 120, a plan for continuing treatment beyond 180 days shall be created and documented in the recipient’s record. (IV) Formal counseling, vocational training, employment, economic, legal, educational, and other recovery support services are not required to be offered to the recipient. However, information pertaining to locally available, community-based resources for ancillary services should be made available to the individual recipients in interim treatment. Authority: Code of Ala. 1975, §22-50-11. History: New Rule: Filed January 26, 2012; effective March 1, 2012. Amended: Published January 31, 2023; Effective March 17, 2023. Amended: Published December 31, 2025; effective February 14, 2026.