Ala. Admin. Code r. 580-9-44-.16

Level I-D: Ambulatory Detoxification Without Extended On-Site Monitoring

This Alabama regulation establishes licensing and operating standards for Level I-D Ambulatory Detoxification Without Extended On-Site Monitoring programs, which provide outpatient withdrawal management services for individuals experiencing mild substance withdrawal. Operators must develop written program descriptions, admission criteria aligned with ASAM PPC-2R dimensional criteria, and protocols for medication management (including benzodiazepine use) approved by a licensed medical director. Requirements cover core services, staffing qualifications (medical director, nursing director, case managers), documentation, training, service intensity, and hours of availability.

Ala. Admin. Code r. 580-9-44-.16 - Level I-D: Ambulatory Detoxification Without Extended On-Site Monitoring 

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(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.

Notes

Ala. Admin. Code
 r. 
580-9-44-.16

 New Rule: Filed January
 26, 2012; effective March 1, 2012.

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

Author:
 Substance Abuse Services Division

Statutory Authority:

Code of Ala.
 1975
, §
 
22-50-11
.

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