Ala. Admin. Code r. 580-2-20-.08

Recipient Records

This regulation establishes comprehensive recipient records requirements for Alabama Department of Mental Health provider organizations delivering mental health and substance use services. Operators must maintain a single case file per recipient with specified demographic, clinical, and case management content; implement formal systems to control, secure, and track record access; retain records for a minimum of seven years after discharge (or seven years past age of majority for adolescents); and follow detailed requirements for treatment/service planning, clinical documentation, authorization for disclosure, and continuing care planning. Separate provisions apply to mental illness-only and substance use-only programs throughout.

Ala. Admin. Code r. 580-2-20-.08 - Recipient Records 

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(1)
 A
 single case file must be established for each recipient which includes any
 clinical and case management documentation. The case file may be maintained in
 physical or electronic format. All requirements in this section apply
 regardless of format.

(2)
 If the
 recipient is involved in more than one program, ready access to recipient
 information necessary for the safety of the recipient, obtaining emergency
 medical attention and coordination of services across programs shall be
 assured.

(3)
 The provider
 organization shall establish a formal system to control and manage access to
 recipient records that shall include, at a minimum: 
 
(a)
 Procedures for control and management of
 access to paper and electronic records.

(b)
 Establish a system to secure recipient
 records from unauthorized access.

(c)
 Designated staff position(s) responsible
 for the storage and protection of recipient records.

(d)
 A process in which the location of a
 record can be tracked and documented at all times.

(e)
 Identification of program personnel with
 access to recipient records.

(f)
 A
 process for providing recipients access to their records.

(g)
 A process for storing closed recipient
 records and for disposing of outdated records.

(h)
 Recipient records shall be retained after
 termination, discharge, or transfer of the recipient for a minimum of seven (7)
 years.

(i)
 Adolescent recipient
 records shall be retained after termination, discharge, or transfer of the
 recipient for a minimum of seven (7) years after age of majority for
 children/adolescents.

(4)

 All entries and forms completed by the service provider in the recipient record
 shall be: 
(a)
 Dated and signed.

(b)
 Made in ink and be legible or recorded in
 an electronic format.

(c)

 Appropriately authenticated in the electronic system for organizations that
 maintain electronic records.

(5)
 Corrections are made in a manner that
 clearly identifies what is being corrected, by whom, and the date of
 correction. White-out in paper record is not permitted. Corrections in
 electronic records shall have an audit trail.

(6)
 The following information shall be
 documented in the recipient record:
(a)
 Case
 number.

(b)
 Recipient
 name.

(c)
 Date of birth.

(d)
 Sex assigned.

(e)
 Race/ethnic background.

(f)
 Hearing status.

(g)
 Language of preference.

(h)
 Home address.

(i)
 Current telephone number.

(j)
 Next of kin or person to be contacted in
 case of emergency.

(k)
 Marital
 status.

(l)
 Social Security
 number.

(m)
 Referral
 source.

(n)
 Reason for
 referral.

(o)
 Presenting
 problem(s).

(p)
 Admission type
 (new, readmission).

(q)
 Date of
 admission to the program/service.

(r)
 Substance Use Only - date of treatment
 initiation (first day of service within level of care).

(s)
 Family history.

(t)
 Educational history.

(u)
 Mental Illness Only:
 Educational/Employment/ vocational goals and/or aspirations, as
 appropriate.

(v)
 Relevant medical
 background.

(w)

 Employment/vocational history.

(x)

 Psychological/psychiatric treatment history.

(y)
 Military status.

(z)
 Legal history.

(aa)
 Alcohol/drug use history.

(bb)
 Targeted Case Management only, this is
 not required.

(cc)
 History of
 trauma.

(dd)
 Thoughts and behavior
 related to suicide.

(ee)
 Thoughts
 and behavior related to aggression.

(ff)
 Initial diagnostic
 formulation.

(gg)
 Identification of
 initial services, referrals and/or recommendations for subsequent treatment
 and/or assessment.

(hh)
 Referral to
 other medical, professional, or community services as indicated.

(ii)
 Special supports for recipients who have
 mobility challenges, hearing or vision loss, and/or limited English
 Proficiency.

(jj)
 Screening
 tool(s), as appropriate.

(kk)

 Intake/Assessment tool(s).

(ll)
 A
 written authorization for disclosure covering each instance in which
 information concerning the identity of diagnosis, prognosis, treatment, or case
 management of the recipient is disclosed. -Each authorization for disclosure
 shall contain all the following information: 
 
1.
 The name of the agency that is to make the
 disclosure.

2.
 The name or title of
 the person to whom, or organization to which, disclosure is to be
 made.

3.
 The full name of the
 recipient.

4.
 The specific purpose
 or need for the disclosure.

5.
 The
 extent and/or nature of information to be disclosed.

6.
 A statement that the authorization is
 subject to revocation by the recipient or recipient's lawful representative at
 any time except to the extent that action has been taken in reliance thereon
 and in accordance with 42 CFR Part 
2
 and HIPPA.

7.
 A specification of the date (no more than
 2 years as long as the original purpose/need still exists), event, or condition
 upon which the authorization will expire without express revocation.

8.
 The date on which the authorization is
 signed.

9.
 The signature of the
 recipient (or lawful representative, if applicable). 
 
(i)
 There should be 2 witnesses to the
 recipient's signature if the recipient signs with a mark (e.g. signs with an
 "X").

(ii)
 If authorization is
 given by telecommunication, it shall be documented in recipient record. When
 authorization is given by telecommunication, the recipient's actual signature
 is obtained at the earliest opportunity. Signature can be obtained
 electronically or in person.

(iii)

 If the recipient is under the age of consent or adjudicated incompetent, the
 parent/lawful representative must sign the written
 authorization.

10.

 Documentation that authorization was obtained through interpretation or
 translation when the recipient is deaf or limited English
 proficient.

(mm)
 A
 consent for follow up form which authorizes contact for up to one year after
 case closure.

(7)
 There
 shall be in the record of each recipient who is deaf or has limited English
 proficiency an approved ADMH Office of Deaf Services notification of free
 language assistance form which includes the following: 
 
(a)
 Signatures of the recipient and witnessed
 by a staff person fluent in the recipient's preferred language or an
 interpreter completed at intake/assessment and annually thereafter. Signatures
 shall be obtained by the following procedures: 
 
1.
 For deaf recipients, this form shall be
 witnessed by a staff person from the Office of Deaf Services or approved by the
 Office of Deaf Services.

2.
 For
 hearing persons with limited English proficiency the following shall apply: 
 
(i)
 When agency staff fluent in the language
 of preference of the recipient is utilized, the agency staff shall sign this
 form.

(ii)
 When a face-to-face
 interpreter is utilized, the interpreter shall sign this form.

(iii)
 When telephonic interpreter services
 are utilized, the name of telephonic service, interpreter's identification
 number and name of interpreter and credentials, if given, shall be documented
 on this form.

(8)
 For each event/service interpreter(s) are
 utilized, the interpreter's name and credentials shall be documented in the
 recipient's record.
(a)
 If telephonic
 interpreter services are utilized, the name of telephonic service and
 interpreter's identification number are documented in recipient
 record.

(9)
 Individual
 Service/Treatment Planning Process. Each entity shall develop, maintain, and
 document implementation of written policies and procedures defining the
 recipient's service/treatment planning process that shall include, at a
 minimum, the following components:
(a)
 Mental
 Illness Only: An initial individualized service/treatment plan shall be
 completed by the fifth face to face outpatient service, within ten working days
 after admission into all day programs or residential programs, or within other
 time limits that may be specified under programs specific
 requirements.

(b)
 Substance Use
 Only: An initial individualized service/treatment plan shall be completed by
 the tenth calendar day after admission into an outpatient program or completed
 by the fifth calendar day after admission to a residential program.

(c)
 The service/treatment plan shall include
 the following:
1.
 Identification of clinical
 issues that will be the focus of treatment.

2.
 Specific services necessary to meet
 recipient's needs.

3.
 Referrals as
 appropriate for needed services not provided directly by the agency.

4.
 Identification of expected outcomes toward
 which the recipient and treatment provider will be working to impact upon the
 specific clinical issues.

5.
 Upon
 completion of a communication assessment, identify any language supports
 necessary to implement service/treatment plan for recipients who are deaf, hard
 of hearing and/or Limited English Proficiency.

6.
 Identification of needed safety
 interventions based on history of harm to self or others.

7.
 All treatment goals and objectives shall
 be measurable.

8.
 Mental Illness
 Only:
(i)
 Represents a person-centered
 recovery-oriented treatment planning process through which recipients are
 assisted to articulate their vision and hope for how their lives will be
 changed for the better within three to five years (long term recovery vision)
 and to identify short-term outcomes that will assist in achieving the recovery
 goal (treatment goals).

(ii)
 Uses
 strength-based approach to treatment planning by identifying recipient and
 environmental positive attributes that can be used to support achievement of
 goals and objectives.

(iii)

 Identifies psychiatric, psychological, environmental, and skills deficits that
 are barriers to achieving desired outcomes.

(iv)
 Identifies treatment supports that are
 needed to address barriers to achieving desired therapeutic
 goal.

(d)
 The
 plan shall be developed in partnership with the recipient and/or lawful
 representative, as appropriate, based upon the recipient's goals.

(e)
 The recipient will sign/mark the
 service/treatment plan to document the recipient's participation in developing
 and/or revising the plan. If the recipient is under the age of consent or
 adjudicated incompetent, the parent/lawful representative must sign the
 service/treatment plan.

(f)
 The
 agency shall specify the processes used to ensure that the recipient: 
 
1.
 Will be an active participant in the
 treatment/service planning process.

2.
 Is provided the opportunity to involve
 family members or significant others of his/her choice in formulation, review,
 and update of the service/treatment plan.

(g)
 The treatment/service plan must be
 approved in writing or electronically by any of the following: 
 
1.
 Physician, physician assistant, a
 Certified Nurse Practitioner, or a registered nurse with a master's degree in
 psychiatric nursing. Shall be licensed under Alabama law and practicing within
 the guidelines of their licensure boards,

2.
 Licensed psychologist licensed
 professional counselor, licensed master's social worker, licensed independent
 clinical social worker, licensed marriage and family therapist. Shall be
 licensed under Alabama law and practicing within the guidelines of their
 licensure boards,

3.
 Substance Use
 Only: QSAP I.

(h)
 Mental
 Illness Only: After completion of the initial treatment plan, staff shall
 review and update the recipient's treatment plan: 
 
1.
 Once every three months for all
 residential and day programs or earlier if needed.

2.
 Outpatient treatment plans every twelve
 months or within other time limits that may be specified under program specific
 requirements to determine the recipient's progress toward treatment objectives,
 the appropriateness of the services furnished, and the need for continued
 treatment.

3.
 Providers must
 document this review in the recipient's record by noting on the treatment plan
 or a treatment plan review form that the treatment plan has been reviewed and
 updated or continued without change.

(i)
 Substance Use Only: After completion of
 the initial treatment plan, staff shall review and update the recipient's
 treatment plan as specified in level of care.

(j)
 Treatment/service plan shall be
 maintained as a working document throughout the recipient's treatment and/or
 care process with modifications to the treatment/service plan based on the
 recipient's progress, the lack of progress, recipient preferences, or other
 documented clinical issues.

(k)

 Document in recipient's record that recipient was offered a copy of
 treatment/service plan. If copy is refused, document reason for
 refusal.

(10)
 Substance
 Use Only: Continuing Care Plan. Each recipient shall develop a continuing care
 plan as a part of their service planning process that begins at the initiation
 of services/treatment. The continuing care plan shall support the recipient's
 recovery efforts after discharge from treatment and be based on recipient's
 individual needs and available resources.
(a)

 A copy of the continuing care plan shall be filed in the recipient's case
 record.

(b)
 Continuing care plan
 shall be signed by recipient and qualified substance abuse professional who
 assisted recipient in the development of plan.

(11)
 Clinical Documentation. Documentation in
 the recipient's record for each session, service, or activity shall include: 
 
(a)
 The identification of the specific
 services rendered.

(b)
 The date and
 the amount of time that the services were rendered to include the time started
 and time ended.

(c)
 The signature
 and credentials of the staff person who rendered the service(s) or as specified
 within service/program requirements.
1.

 Printed name of staff person who rendered the service(s) shall be below or next
 to signature.

2.
 Shall be
 appropriately authenticated in the electronic system for electronic
 records.

(d)
 The
 identification of the setting in which the service(s) were rendered.

(e)
 A written assessment of the recipient's
 progress, or lack thereof, related to each of the identified clinical issues
 discussed.

(f)
 All entries must be
 legible and complete.

(g)

 Documentation of recipient's signatures shall be entered on a sign-in sheet,
 service receipt, or any other record, to include electronic, that can be used
 to indicate the recipient's signature and the date of service for services
 received. Recipient's signature is only required one time per day that services
 are provided.
1.
 The following services do not
 require recipient signatures:
(i)
 Any ADMH
 approved non-face to face services that are provided remotely or
 indirectly.

(ii)
 Crisis
 Intervention and mental health care coordination.

(iii)
 Mental Illness only: Assertive
 Community Treatment (ACT}, Program for Assertive Community Treatment (PACT),
 Child and Adolescent In-Home, High Intensity Care Coordination (HICC), Low
 Intensity Care Coordination (LICC), pre-hospitalization screening,
 psychoeducation.

(h)
 Documentation shall not be
 repetitive.

(i)
 Documentation of
 services provided shall not be preprinted or predated. After each service
 provided in a group setting, progress notes shall: 
 
1.
 Identify the number of participants, the
 topic, and a general description of the session. This information may be copied
 for each participant.

2.
 Each
 recipient shall have individualized documentation relative to the recipient's
 specific interaction in the group and how it relates to their treatment/service
 plan.

(j)
 Documentation
 of services received by recipient and recipient's progress shall match the
 goals on the recipient's treatment/service plan and the plan shall match the
 needs of the recipient. The interventions shall be appropriate to meet the
 goals. There shall be clear continuity in the recipient record.

(k)
 Documentation must provide enough detail
 and explanation to justify the service.

(l)
 Substance Use Only: Documentation must be
 completed and placed in recipient record within two (2) business days of
 service being provided.

(m)
 Mental
 Illness Only: Documentation must be completed and placed in recipient record
 after completion of services as outlined below: 
 
1.
 For each outpatient contact within two (2)
 business days.

2.
 For residential
 programs, a written assessment of the recipient's progress, or lack thereof,
 related to each of the identified clinical issues discussed shall be documented
 for every two (2) weeks and placed in record within two (2) business
 days.

3.
 For partial
 hospitalization, each service delivered shall be documented every day and
 placed in record within two business days.

4.
 For Intensive Day Treatment and Child and
 Adolescent Day Treatment on a weekly basis a progress note written or co-signed
 by the program coordinator/case responsible staff member with equivalent
 credentials and placed in record within two (2) business days.

5.
 For Rehabilitative Day Programs every two
 (2) weeks a progress note written or co-signed by the program coordinator/case
 responsible staff member with equivalent credentials and placed in record
 within two (2) business days.

(12)
 All medication information shall be
 documented within the recipient record. If recipient reports no medication(s),
 documentation shall indicate no medications. The medication information shall
 contain all the following information:
(a)
 A
 list of all medication(s) reported by the recipient at
 intake/assessment.

(b)
 All
 medications, to include but not limited to psychotropic, and non-psychotropic,
 prescribed by the provider and by other practitioners.

(c)
 Non-prescription medications.

(d)
 For all medications prescribed by the
 agency, documentation shall include:
1.
 The
 name of medication.

2.
 Strength and
 dosage of the medication.

3.
 The
 date prescribed.

4.
 Number of
 refills permitted.

5.
 The
 prescriber's name.

(e)

 The provider shall have a system for tracking due dates for injections
 administered by the provider and scheduling recipients accordingly.

(f)
 Mental Illness Only: Medications shall be
 updated at least annually.

(g)

 Substance Use Disorder Only: Medications shall be reviewed at each Case
 Review.

(13)
 Transfer.
 Documentation of transfer to a separate program/level of care within same
 agency shall be clearly documented as a transfer that shall include the
 following:
(a)
 Information related to the
 transfer within the agency to different level of care/program.

(b)
 Document that transfer was discussed with
 recipient or recipient's lawful representative.

(c)
 If not discussed with recipient,
 documentation shall include reason why transfer was not discussed with
 recipient or recipient's lawful representative.

(14)
 Discharge. Documentation of the
 discharge shall:
(a)
 Be entered into each
 recipient's record and shall include a description of the reasons for
 discharge, regardless of discharge type.

(b)
 The summary shall include: 
 
1.
 A summary of goals for continuing care
 after discharge.

2.
 An evaluation
 of the recipient's progress toward goals established in the service/treatment
 plan and participation in the program.

3.
 The discharge summary shall be signed by
 the recipient, when possible, the primary counselor, and for Substance Use
 Disorder only, the clinical director or designee.

4.
 A copy of the discharge summary shall be
 provided to the recipient upon discharge, when possible.

5.
 Mental Illness Only: In the event of loss
 of contact or death, an administrative discharge shall be completed. A summary
 is not required and only the reason for discharge shall be
 documented.

(c)
 Mental
 Illness Only: Be entered into each recipient's record within fifteen (15) days
 after discharge or up to one hundred eighty (180) days after receipt of last
 service specifying the status of the case.

(d)
 Substance Use Disorder Only: Be entered
 into each recipient's record within five (5) days after discharge or thirty
 (30) days after receipt of last service.

(e)
 Substance Use Disorder Only: Notify the
 recipient's referral source of recipient's discharge with written informed
 consent of the recipient. Agency shall follow all federal regulations and laws
 regarding confidentiality and privacy i.e., 42 CFR Part 
2
 and HIPPA and shall
 document notification in recipient's record.

Notes

Ala. Admin. Code
 r. 
580-2-20-.08

Adopted by
 
Alabama
 Administrative Monthly Volume XLI, Issue No. 04, January 31,
 2023
, eff. 
3/17/2023
.

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

Statutory Authority:

Code of Ala.
 1975
, §
 
22-50-11

.

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