Ala. Admin. Code r. 580-2-20-.03

Personnel

This personnel regulation establishes minimum qualifications and requirements for staff at Alabama Department of Mental Health-certified mental health and substance abuse service provider agencies. It covers executive directors, clinical directors, financial officers, psychiatrists, therapists, and direct care staff, specifying education, licensure, supervision, training, and background check requirements. Specific provisions address staff serving mental illness programs, including outpatient, day, and residential services, as well as staff working with children, adolescents, and deaf/hard-of-hearing populations.

Ala. Admin. Code r. 580-2-20-.03 - Personnel 

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(1)
 There shall be
 a full-time executive director who has overall responsibility for the operation
 of the agency. The executive director shall:
 
(a)
 Have at least a master's degree in Public
 Health, Business Administration, Public Administration, Psychology, Counseling,
 Social Work or related field and at least five (5) years managerial experience
 in a mental health or substance abuse treatment setting; or

(b)
 Have a Bachelor's Degree in Public
 Health, Business Administration, Public Administration, Psychology, Counseling,
 Social Work or related field and at least ten (10) years managerial experience
 in mental health or substance abuse treatment setting.

(c)
 Notify MHSAS within thirty (30) days of
 changes in Executive Director.

(d)

 Be verified for compliance with ADMH Administrative Code by ADMH MHSAS
 certification process.

(2)
 There shall be a full-time Clinical
 Director (in addition to the Executive Director) who has full-time
 responsibility for the quality of clinical care and the appropriateness of
 clinical programs as delineated in the job description. The Clinical Director
 shall: 
(a)
 Have a minimum of either a
 master's degree in psychology, social work, counseling, or psychiatric nursing
 and have a minimum of 3 years post master's relevant clinical experience or be
 a physician who has completed an approved residency in psychiatry.

(b)
 For agencies who provide substance abuse
 treatment services, have a license or 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.

(c)
 Notify MHSAS within thirty (30) days of
 changes in Clinical Director.

(d)

 Be verified for compliance with ADMH Administrative Code by ADMH MHSAS
 certification process.

(3)
 There shall be a Business Manager/Chief
 Financial Officer or equivalent: 
(a)
 The
 financial accounting operations of a service provider organization with a total
 annual budget exceeding $750,000 shall be supervised by a full-time employee or
 contracted service who has the following qualifications: 
 
1.
 At least a bachelor's degree in accounting
 or business, finance, management, public administration, with at least three
 (3) college accounting courses.

2.

 At least two (2) years accounting experience.

(b)
 The financial accounting operations of a
 service provider organization with a total annual budget less than $750,000
 shall be supervised by an employee or contracted service who/which has the
 following qualifications:
1.
 Demonstrated
 familiarization with Generally Accepted Accounting Principles and;

2.
 At least two (2) years
 accounting/bookkeeping experience.

(4)
 An individual who met the requirements of
 the Administrative Code
 
580-9-44-.02
 Personnel effective
 March 2012 or Administrative Code
 
580-2-9-.03
 MI Program Staff July
 2010 and was employed prior to the approval of these rules shall be in good
 standing.

(5)
 In certain
 situations, the Commissioner of ADMH may waive the requirements of this chapter
 as necessary to serve the DMH services recipients and/or the interests of the
 public.

(6)

Mental Illness Program Staff Only.
 The
 agency shall have policies and procedures that detail the following personnel
 requirements: 
(a)
 There shall be a
 psychiatrist, as a full-time or part-time employee or a consultant to the
 provider who is responsible for medical aspects of consumer psychiatric care as
 delineated in the job description or employment contract. Access to on-call
 psychiatric services shall be available 24 hours a day, 7 days a week and must
 be documented.

(b)
 There is an
 organizational chart that depicts functional areas of responsibility and lines
 of supervision for all programs operated by the agency.

(c)
 Each direct treatment service functional
 area of responsibility on the organizational chart shall be coordinated by a
 member of the staff who has a master's degree in a mental health related field
 and at least one (1) year post master's supervised experience in a direct
 service area. Program coordinators of Adult Rehabilitative Day Programs shall
 have at a minimum of a bachelor's degree, or RN. Both shall have a minimum of
 one (1) year supervised post degree mental health related experience.

(d)
 For residential services, there shall be
 a registered nurse or licensed practical nurse as a full-time or part-time
 employee or a consultant to the provider who is responsible for supervision of
 delegation of medication assistance to the unlicensed personnel. Access to an
 on-call nurse shall be available 24 hours a day, 7 days a week. Provider will
 implement policies and procedures approved by their Board of Directors
 requiring full compliance with the Alabama Board of Nursing regulation
 610-X-7.06 Alabama Department of Mental Health Residential Community
 Programs.

(e)
 All treatment staff
 who provide therapy and clinical assessments for mental illness consumers shall
 have a master's degree in a mental health related field and have successfully
 completed a mental health clinical practicum or have six (6) months
 post-master's level experience in a mental health clinical field.

(f)
 Treatment staff who do not have a mental
 health clinical practicum master's degree shall: 
 
1.
 Complete an in-house practicum, receive
 face-to-face (virtual or in person) supervision from a therapist who has a
 master's degree in a mental health related field and at least two (2) years
 post master's degree mental health experience in a direct service functional
 area for six (6) months.

2.

 Supervision shall include at least two (2) face-to-face supervisory sessions
 per month for a minimum of one (1) hour per session.

3.
 Upon completion of the required clinical
 practicum, an additional six (6) months of supervision is required and shall
 include at least two (2) face-to-face supervisory sessions per month minimum
 one (1) hour per session.

(g)
 The credentials of staff shall be
 appropriate for the levels and types of services they are providing. The
 following are approved minimum qualifications: 
 
1.
 Mental Health Rehabilitative Services
 Professional who meets one (1) of the following: 
 
(i)
 A psychologist licensed under Alabama
 law.

(ii)
 A professional counselor
 licensed under Alabama law.

(iii)

 An independent clinical social worker licensed under Alabama law.

(iv)
 A marriage and family therapist licensed
 under Alabama law.

(v)
 A registered
 nurse licensed under Alabama law who has completed a master's degree in
 psychiatric nursing.

(vi)
 A Masters
 Level Clinician is an individual possessing a master's degree or above from a
 university or college with an accredited program for the respective degree in
 psychology, social work, counseling, or other mental health human service field
 areas who meets at least one (1) of the following qualifications: 
 
(I)
 Has successfully completed a clinical
 practicum as a part of the requirement for the degree OR

(II)
 Has six (6) months of post master's
 level clinical experience supervised by a master's level or above clinician
 with two years of postgraduate clinical experience.

2.
 A physician licensed under
 Alabama law to practice medicine or osteopathy.

3.
 A physician assistant licensed under
 Alabama law and practicing within the guidelines as outlined by the Alabama
 Board of Medical Examiners.

4.
 A
 Certified Registered Nurse Practitioner (CRNP) licensed under Alabama law
 practicing within the scope as defined by the Joint Committee of the Alabama
 Board of Nursing and the Alabama Board of Medical Examiners for Advanced
 Practice Nurses.

5.
 A pharmacist
 licensed under Alabama state law may provide medication monitoring.

6.
 A Registered Nurse licensed under Alabama
 state law.

7.
 A Practical Nurse
 licensed under Alabama state law.

8.
 Qualified Mental Health Provider -
 Bachelor's - A person with a bachelor's degree in a mental health human
 services field.

9.
 Qualified Mental
 Health Provider- Non-Degreed - A person with a high school diploma or GED
 supervised by a Rehabilitative Services Professional.

10.
 A Nursing Assistant certified pursuant to
 Alabama State Law.

11.
 Medication
 Assistant Certified (MAC) Worker - A person working under a Medication
 Assistance Supervising (MAS) nurse that meets the Alabama Board of Nursing
 requirements.

12.
 A Certified
 Mental Health Youth Peer Specialist -Youth who has personal verified lived
 experience with children and adolescents.

(h)
 Staff who provide services primarily to
 recipients who are deaf/hard of hearing shall have either two (2) years
 supervised experience with the specific subgroup, or two (2) specialized
 graduate courses related specifically to the subgroup or twelve (12) continuing
 education credits of training in the specialty area to work with this subgroup
 or shall receive supervision by a staff member with the required training/
 experience.

(i)
 Staff who provide
 treatment and clinical services primarily to children and adolescents shall
 have one (1) year experience working with children and adolescents and shall
 receive ten (10) hours of specialized training to be completed within one (1)
 year form the date they began providing such services.

(j)
 Teachers who provide educational service
 to children shall meet the requirements outlined by the Alabama State
 Department of Education.

(k)
 All
 staff positions who are required to complete an ADMH certification training
 program will be outlined under their targeted service area.

(l)
 All staff who transport consumers shall
 have a valid driver's license.

(m)

 Documentation of all required supervision shall include the following
 information for each supervisory session: 
1.

 Name and signature of supervisor.

2.
 Name and signature of employee.

3.
 Date of supervision.

4.
 Amount of time in supervisory
 session.

5.
 Brief description of
 topics covered in session.

(n)
 The agency shall conduct criminal
 background checks on all employees/volunteers/agents prior to employment/
 engagement.

(o)
 Students who are
 completing a graduate degree in psychology, counseling, social work, or
 psychiatric nursing may be used for direct services under the following
 conditions:
1.
 The student is in a clinical
 practicum or internship that is part of an officially sanctioned academic
 curriculum.

2.
 The student receives
 a minimum of one (1) hour per week direct clinical supervision (face-to-face)
 from a mental health professional having at least two (2) years post master's
 experience in a direct mental health service functional area.

3.
 The student's clinical notes shall be
 cosigned by the agency's supervisor who directly supervises the
 student.

(p)
 All
 employees/staff having direct service contact with recipients shall be trained
 in the following prior to working alone with recipients: 
 
1.
 Management of aggressive/assaultive
 behavior and

2.
 Crisis intervention
 techniques.

3.
 The training must
 have been within the past two (2) years.

(q)
 All unlicensed staff who have direct
 service contact with recipients shall receive initial training on the following
 topics: 
1.
 Diagnostic categories.

2.
 Classes of psychotropic
 medications.

3.
 Recovery
 orientation.

4.
 Interaction with
 consumers and families.

(r)
 Each program provides training for all
 staff on abuse and neglect and all state laws pertaining to abuse and neglect
 including reporting required by the Department of Human Resources. Training is
 required for all new employees within thirty (30) days for non-direct care
 staff. For direct care staff, training is required prior to working alone with
 recipients and on an annual basis thereafter.

Notes

Ala. Admin. Code
 r. 
580-2-20-.03

Adopted by
 
Alabama
 Administrative Monthly Volume XXXVII, Issue No. 01, October 31,
 2018
, eff. 
11/30/2018
.

Amended by
 
Alabama
 Administrative Monthly Volume XLI, Issue No. 07, April 28, 2023
,
 eff. 
6/12/2023
.

Author:
 Division of Mental Health and Substance
 Abuse Services, DMH

Statutory Authority:

Code of Ala.
 1975
, §
 
22-50-11
.

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