Ala. Admin. Code r. 580-9-44-.19

Level II-D: Ambulatory Detoxification With Extended On-site Monitoring

This regulation establishes certification standards for Level II-D Ambulatory Detoxification with Extended On-Site Monitoring programs in Alabama, governed by the Department of Mental Health. Operators must develop written program descriptions, admission criteria aligned with ASAM PPC-2R dimensional criteria, and demonstrate capacity to provide core clinical services including medical monitoring, counseling, medication administration, and case management. Programs must maintain qualified personnel (including a licensed physician medical director and on-site nursing coverage during all operating hours), document daily clinical progress, and structure services at a minimum of nine hours per week with availability tailored to client needs.

Ala. Admin. Code r. 580-9-44-.19 - Level II-D: Ambulatory Detoxification With Extended On-site Monitoring 

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(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.

Notes

Ala. Admin. Code
 r. 
580-9-44-.19

 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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