Ala. Admin. Code r. 580-2-20-.09

General Clinical Practice

This regulation establishes general clinical practice standards for Alabama Department of Mental Health (ADMH) certified behavioral health providers, covering both mental health and substance use disorder programs. Operators must maintain program descriptions for each level of care, implement written policies on screening, intake/assessment, admission and exclusionary criteria, referral, waiting list management, drug testing, and language access. Specific requirements apply separately to mental illness and substance use disorder providers, including ASAM-based placement assessments for SUD programs and priority admission criteria for vulnerable populations such as pregnant individuals and those who inject drugs.

Ala. Admin. Code r. 580-2-20-.09 - General Clinical Practice 

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(1)
 Any reference to "written" notification
 in these rules indicated that the recipient is entitled to receive information
 in their preferred language and in a manner understood by the
 recipient.

(2)
 A program
 description shall be maintained for each level of care or program provided by
 the agency. The program description shall include: 
 
(a)
 The nature and scope of the program or
 the level of care.

(b)
 Service area
 for the program or level of care.

(c)
 Staffing pattern to include the number
 and credentials of staff assigned to the program or level of care as required
 by specific program standards.

(d)

 Admission criteria.

(e)

 Discharge/transfer criteria and procedures.

(3)
 Each recipient admitted for treatment
 must be assigned to an appropriately qualified staff member or clinical
 treatment team who has the primary responsibility for
 coordination/implementation of the treatment/service plan.

(4)
 In accordance with all local, state and
 federal law(s), the provider must have written policies that protect the
 recipient against discrimination in the provision of services regardless of the
 recipient's age, race, creed, national origin, language of preference, sex,
 social status, disability status or length of residence in the service area
 except that specialized services/programs may be developed for specific target
 populations.

(5)
 The program shall
 make good faith efforts to follow up within a reasonable time for missed
 appointments for all high-risk recipients with clinical indicators such as but
 not limited to the following:
(a)
 Recipients
 who were discharged from psychiatric inpatient services (local or state) in the
 past year.

(b)
 Recipients who were
 decompensating on the last visit.

(c)
 Recipients who are considered to have
 intent to harm self or others.

(d)

 Substance Use Disorders Only: Pregnant women and individuals who inject
 drugs.

(6)
 Provider shall
 have and implement written policies and procedures to ensure recipients
 physical access to structures and individualized access to services that
 address the needs of recipients, family members or significant
 others.

(7)
 The provider shall have
 and implement written policies and procedures that prohibit creation after the
 fact, alteration, or falsification of original administrative or clinical
 documentation.

(8)
 The provider
 shall have and implement written policies and procedures to assure that
 recipients who are deaf or who have limited English proficiency are provided
 culturally and linguistically appropriate access to services to include but not
 limited to the following:
(a)
 Free language
 assistance shall be offered to recipients with limited English proficiency or
 who are deaf. All interpreters must be qualified as defined by state and
 federal law to work in the assigned setting with preference given to Qualified
 Mental Health Interpreters as defined by Administrative Code
 580-3-24.

(b)
 While face-to-face
 interpreter services are preferable, procedures shall specify how services will
 be secured when face-to-face interpreters are not available. Procedures shall
 include the following:
1.
 For recipients
 needing spoken language assistance, telephonic or video remote interpreting
 services may be used.

2.
 Video
 remote interpreters may be used for deaf recipients using sign
 language.

3.
 Video relay services
 shall not be used for deaf recipients using sign language when providing
 treatment.

4.
 Video relay services
 may be used for making appointments.

(c)
 If qualified interpreters are offered and
 refused, refusal shall be documented on an approved ADMH Office of Deaf
 Services notification of free language assistance form in the recipient's
 file.

(d)
 If family members are
 used to interpret, this shall be documented on an approved ADMH Office of Deaf
 Services notification of free language assistance form.

(e)
 Individuals under the age of 18 shall not
 be utilized as interpreters.

(f)

 For recipients who are deaf, hard of hearing, or physically disabled,
 appropriate environmental and/or communication accommodations shall be provided
 on an individually assessed basis.
1.

 Treatment shall be modified to effectively serve recipients who are hard of
 hearing.

(g)
 Treatment
 for recipients who are deaf or who have limited English proficiency shall be
 offered by staff fluent in the language of the recipient's choice or by using
 qualified interpreters. This shall be documented on an approved ADMH Office of
 Deaf Services notification of free language assistance form. 
 
1.
 Staff providing direct services to deaf
 recipients shall be fluent, defined as advanced or better on the Sign Language
 Proficiency Interview or an equivalent rating on an assessment approved by ADMH
 Office of Deaf Services, prior to providing services.

(h)
 Treatment will be modified to effectively
 serve recipients who are deaf as determined by a communication assessment
 conducted by the Office of Deaf Services or staff approved by the Office of
 Deaf Services. This communication assessment shall be filed in the recipient's
 record.

(9)
 Screening.
 The provider shall have and implement written policies and procedures for a
 screening process to briefly screen individuals prior to initiation of a
 behavioral health assessment or diagnostic interview examination. At a minimum,
 this process shall:
(a)
 Describe the screening
 process.

(b)
 Specify the
 instrument(s) or process utilized to conduct the screening process. Substance
 Use Disorder providers shall use the ADMH approved screening instrument(s).
 Mental Health providers shall use an ADMH approved screening instrument(s) when
 applicable.

(c)
 Describe the
 procedures followed when the screening process: 
 
1.
 Identifies risk factors for mental health,
 substance use or co-occurring disorder(s).

2.
 Does not identify risk factors for a
 mental health, substance use or co-occurring disorder(s).

3.
 Identifies the need for crisis
 intervention.

4.
 Identifies special
 supports for recipients who have mobility challenges, hearing or vision loss,
 and/or Limited English proficiency.

(d)
 Specify the procedures for documenting
 the screening process and that the results of the screening were explained to
 the recipient and recipient's lawful representative as
 appropriate.

(10)

 Intake/Assessment. All providers seeking to have a recipient admitted to an
 ADMH certified level of care/service shall have and implement written policies
 and procedures to: 
(a)
 Intake/assessment
 shall be a clinical interview with recipient, and may include family members,
 lawful representative, significant other, as appropriate.

(b)
 Substance Use Disorder Only: 
 
1.
 Conduct or receive from an ADMH certified
 provider an ADMH approved placement assessment or receive an assessment from
 noncertified agency containing an evaluation of each recipient's level of
 functioning in the six (6) ASAM dimensions.

2.
 Scheduling a placement assessment and how
 this information is publicized.

3.

 Identify any additional tools the provider chooses to utilize in the assessment
 process.

4.
 Addressing request by
 other organizations to conduct a placement assessment.

5.
 Develop a level of care recommendation
 based upon the Placement Assessment, which shall describe the role of the
 recipient and significant others/lawful representative in this
 process.

6.
 Describe the procedure
 when the placed level of care is different from the assessed level of
 care.

(c)
 Mental Illness
 Only:
1.
 Conduct an assessment/intake,
 utilizing an ADMH approved assessment tool, if applicable, in developing
 service/treatment planning processes:
(i)

 Shall be completed prior to development of initial treatment plan and at
 discharge, if applicable.

(ii)

 Updates shall be conducted within other time limits specified under programs
 specific requirements.

(iii)
 Shall
 be placed in the recipient record, if applicable.

(iv)
 Case Management services do not require
 a clinical intake. However, case management does require an ADMH approved
 assessment tool to be completed.

2.
 Assignment of a diagnosis (most current
 DSM or ICD). The diagnosis must be signed by a licensed physician, a licensed
 psychologist, a licensed professional counselor, a licensed marriage and family
 therapist, a certified registered nurse practitioner, or licensed physician's
 assistant licensed under Alabama law and operating within licensee's scope of
 practice.

3.
 Development of an
 initial treatment/service recommendations for subsequent treatment and/or
 evaluation.

(d)
 Initiate
 service delivery including referral(s), as appropriate, based upon the
 recipient's level of care or service recommendation, which shall identify the
 procedures followed when the placement assessment or intake identifies the need
 for:
1.
 An available level of care or
 service(s).

2.
 A level of care or
 service that is otherwise unavailable at assessing provider.

3.
 Crisis intervention.

(e)
 The entity shall submit placement
 assessment/intake data to the ADMH Management Information System according to
 the most recent edition of Data Reporting Guidelines established and published
 by ADMH.

(11)
 Referral
 Policies/Community Linkage. The provider shall have and implement written
 policies and procedures for referring recipients to outside services based on
 individual needs and receiving recipient referrals from other service
 providers.

(12)
 Admission Criteria.
 Each provider shall have and implement compliance with the following written
 criteria that shall, at a minimum:
(a)
 Specify
 the unique characteristics of the program's target population.

(b)
 Define the admission criteria for each
 level of care or program provided.

(c)
 Describe the process implemented when an
 individual is found to be ineligible for admission. This process shall include
 the following procedures, at a minimum:
1.

 Upon request, a written rationale that objectively states or describes the
 reasons for service denial shall be provided to recipients who have been
 determined ineligible for admission within five (5) working days.

2.
 Provide referrals appropriate to the
 prospective recipient's needs.

3.
 A
 description of the appeal policies and procedures for persons denied admission,
 which shall include the process in which recipients are informed of this
 right.

(d)
 Substance Use
 Disorder Only: Describe the process utilized for prioritizing admission
 requests and specify that priority access to admission for treatment will be
 given to the following groups in order of priority: 
 
1.
 Individuals who are pregnant and have a
 substance use disorder(s) and whose route of administration is
 intravenous.

2.
 Individuals who are
 pregnant and have a substance use disorder(s).

3.
 Individuals who have a substance use
 disorder(s) and whose route of administration is intravenous.

4.
 Women with dependent children and have a
 substance use disorder(s).

5.

 Individuals who are HIV positive and have a substance use
 disorder(s).

6.
 All others with
 substance use disorders.

(13)
 Readmission Criteria. Each provider
 shall have and implement policies and procedures regarding criteria and process
 for readmission.

(14)
 Exclusionary
 Criteria. Each provider shall have and implement policies and procedures
 regarding criteria used to deny admission or readmission of recipients into the
 program. 
 
Any program's exclusionary criteria shall comply with federal,
 state and local law. The provider's policies, procedures and practices shall
 not support admission denials based exclusively on:

(a)
 Pregnancy status.

(b)
 Educational achievement and
 literacy.

(c)
 Income level and
 ability to pay. This shall not apply to certified substance use disorder
 treatment providers who do not have a contract with ADMH.

(d)
 Need for or current use of medication
 assisted therapy.

(e)
 Existence of
 a co-occurring mental illness and substance use disorder.

(f)
 HIV status.

(g)
 Previous admissions to the
 program.

(h)
 Prior withdrawal from
 treatment against clinical advice.

(i)
 Referral source.

(j)
 Involvement with the criminal justice
 system.

(k)
 Relapse.

(l)
 Disability.

(m)
 Language of
 preference.

(15)

 Substance Use Disorder Only: Case Review. Each provider shall have and
 implement written policies and procedures that define a case review that shall,
 at a minimum, incorporate the following elements: 
 
(a)
 Completed by recipient's primary
 counselor.

(b)
 Conducted at
 intervals as defined in level of care.

(c)
 Continuing Service/Transfer/ Discharge
 Criteria which consist of the following:
1.

 Making progress.

2.
 Not yet making
 progress, but able to in the current level of care/program.

3.
 New problems have been identified but
 these can be handled in the current level of care/program.

4.
 Achieved goals set but requires chronic
 disease management at a less intensive level of care/program.

5.
 Unable to resolve problems despite
 amendments to the treatment/service plan.

6.
 Intensification or introduction of new
 problems that require a different level of care/program.

7.
 Recipient preferences.

8.
 Goals have been met to the extent that the
 services are no longer needed.

(d)
 Narrative supporting the above
 choice.

(e)
 Document the case
 review was discussed with the recipient and others designated by the recipient
 as active participants in the decision-making process.

(16)
 Waiting List Maintenance. The provider
 shall establish a formal process to address requests for services when space is
 unavailable in the program/service. This process shall include, at a minimum: 
 
(a)
 Written procedures for management of the
 waiting list that shall include, at a minimum, provisions for: 
 
1.
 Referral for emergency services.

2.
 Maintaining contact with a recipient or
 referral source while awaiting space availability.

3.
 Adding and removing a recipient from the
 waiting list.

4.
 Substance Use
 Disorder Only: Recipient access to interim services while awaiting program
 admission shall be made available no later than forty-eight (48) hours after
 the initial request for admission. At a minimum, interim services provided by
 the agency shall include:
(i)
 Counseling and
 education about HIV and TB.

(ii)

 Risk of needle sharing.

(iii)
 Risks
 of transmission of HIV to sexual partners and Infants.

(iv)
 Steps that can be taken to ensure that
 HIV and TB transmission does not occur.

(v)
 Referral for HIV or TB treatment, if
 necessary.

(vi)
 Pregnant
 individuals with substance use disorders receive counseling on the effects of
 alcohol and drug use on the fetus.

(vii)
 Pregnant individuals with substance use
 disorders are referred for pre-natal care, if not already receiving prenatal
 care.

5.
 Substance Use
 Only: Specify that priority access to admission for treatment will be given to
 the priority population outlined in
 
580-2-20-.09
(12)
.

(b)
 The provider shall identify and designate
 staff position(s) who has responsibility for management of the waiting
 list(s).

(c)
 The provider shall
 comply with requests from ADMH for data reports relative to waiting list
 maintenance and management i.e., compliance with ADMH Data Management
 System(s).

(17)
 Drug
 Testing. The agency shall have and implement written policies and procedures
 addressing circumstances under which drug screening of recipients may be
 utilized and how recipients will be notified of drug testing procedures. If it
 is utilized at any point, the program shall: 
 
(a)
 Identify circumstances under which drug
 testing of recipients will occur.

(b)
 Indicate specimens used for testing
 including breath, blood, urine, hair and saliva.

(c)
 Establish chain of custody procedures
 that protect against the falsification and/or contamination of any
 specimen.

(d)
 Demonstrate that the
 individual's privacy is protected each time a specimen is collected.

(e)
 Define method of observation.

(f)
 Location of where the specimen will be
 collected.

(g)
 Individualized drug
 screen procedures, which include:
1.
 Frequency
 of testing based on needs of the recipient or as identified in level of
 care/program.

2.
 Procedures used to
 ensure that drug test screening results are not used as the sole basis for
 treatment decisions or termination of treatment.

3.
 Procedures to ensure that drug testing is
 used as a treatment tool and is addressed with the recipient.

4.
 Procedures to review for false-negative
 and false- positive results.

(h)
 The provider shall establish a reasonable
 timeframe to discuss with the recipient and document all drug testing results,
 confirmation results and related follow-up therapeutic interventions in the
 recipient record.

(18)

 The provider shall have and implement written policies and procedures governing
 tobacco use at the provider's physical facility(ies) by the program's staff and
 recipients that includes compliance with federal, state, and local ordinances.
 Tobacco use includes, but is not limited to, cigarettes, smokeless tobacco, and
 e-cigarettes and other vaping products.
(a)

 Substance Use Only: Provide services that address tobacco use either directly
 or by referral for all recipients enrolled in each level of care who have
 requested these services.

(19)
 Transportation. When a provider provides
 transportation, the provider shall have and implement written policies and
 procedures that govern recipient transportation and include, at a minimum, the
 following specifications:
(a)
 Document that
 vehicles operated by the provider to transport recipients shall have: 
 
1.
 Properly operating seat belts or child
 restraint seats.

2.
 Provide for
 seasonal comfort with properly functioning heat and air conditioning.

3.
 Vehicles are in good repair and have
 regular maintenance inspections.

(b)
 The number of recipients permitted in any
 vehicle shall not exceed the number of seats, seat belts and age-appropriate
 child restraint seats.

(c)
 Vehicles
 operated by the provider shall carry proof of: 
 
1.
 Accident and liability
 insurance.

2.
 The vehicle's current
 registration.

(d)

 Vehicles operated by the provider shall have an operational fire extinguisher
 and a first aid kit that are not expired.

(e)
 The driver of any vehicle used in
 recipient transportation shall carry, at all times, the name and telephone
 number of the program's staff to notify in case of a medical or other
 emergency.

(f)
 The driver of any
 vehicle used in recipient transportation shall be: 
 
1.
 At least eighteen (18) years old and in
 possession of a valid driver's license.

2.
 Prohibited from the use of
 tobacco/vaping/e- cigarette and smokeless tobacco products, cellular phones or
 other mobile devices, or from eating while transporting recipients.

3.
 Prohibited from leaving a recipient
 unattended in the vehicle at any time.

4.
 Prohibited from making stops between
 authorized destinations, altering destinations, and taking recipients to
 unauthorized locations.

(g)
 The provider shall provide an adequate
 number of staff for supervision of recipients during transportation to ensure
 the safety of all passengers.

(h)

 Substance Use Only: All vehicles operated by the agency to transport recipients
 shall not be identifiable as a vehicle belonging to a substance use disorder
 treatment program.

Notes

Ala. Admin. Code
 r. 
580-2-20-.09

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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