Ala. Admin. Code r. 580-9-44-.22

Level III.2-D: Clinically Managed Residential Detoxification

This regulation establishes operating standards for Level III.2-D Clinically Managed Residential Detoxification programs licensed by the Alabama Department of Mental Health. Operators must develop written program descriptions, admission criteria, core service capabilities, and clinical documentation protocols aligned with ASAM PPC-2R criteria. Staffing requirements include a licensed physician medical director, a registered nurse nursing services director, and 24/7 on-site nursing coverage. Programs must implement detoxification protocols, continuous client monitoring, and structured pathways to continuing care upon completion of withdrawal management.

Ala. Admin. Code r. 580-9-44-.22 - Level III.2-D: Clinically Managed Residential Detoxification 

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(1)
 Rule
 Compliance. In addition to compliance with the rules as specified in this
 chapter, each Level III.2-D Clinically Managed Residential Detoxification
 Program shall comply with the rules as specified in the following chapters. 
 
(a)
 Program Description. The entity shall
 develop, maintain and implement a written program description that defines its
 Level III.2-D Program, 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 the Level III.2-D
 Program is provided. Services may be provided in any facility that meets all
 applicable federal, state and local certification, licensure, building,
 life-safety, fire, health and zoning regulations including the DMH facility
 certification standards.

2.

 Admission Criteria: The entity shall develop, maintain and document
 implementation of written criteria for admission to its Level III.2-D 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
 III.2-D Program, which shall include, at a minimum, individuals who: 
 
(I)
 Are experiencing signs and symptoms of
 withdrawal, or there is evidence based on history of substance intake, age,
 gender, previous withdrawal history, present symptoms, physical condition
 and/or emotional behavioral or cognitive condition that withdrawal syndrome is
 imminent.

(II)
 Assessed as not
 being at risk of severe withdrawal syndrome and moderate withdrawal is safely
 manageable at this level.

(III)

 Have a history of insufficient skills and supports to complete detoxification
 at a less intense level of care.

(ii)
 The entity shall provide written
 documentation in individual case records that each client admitted to receive
 Level III.2-D services meets:
(I)
 The
 diagnostic criteria for Substance Induced Disorder as defined in the most
 recent edition of the Diagnostic and Statistical Manual of Mental Disorders of
 the American Psychiatric Association.

(II)
 The dimensional criteria for admission
 to this level of care as defined in the ASAM
 PPC-2R.

3.
 Core
 Services: At a minimum, the Level III.2-D 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)
 Peer
 support.

(vii)
 Medical and somatic
 services.

(viii)
 Medication
 administration.

(ix)
 Medication
 monitoring.

(x)
 Alcohol and/or drug
 screening/testing.

(xi)
 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 III.2-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 III.2-D 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 duty awake staff shall provide
 supervision for each client's health, welfare and safety twenty-four (24) hours
 a day, seven (7) days a week.

(iv)

 On-site physician care and phone availability twenty-four (24) hours a day,
 seven (7) days a week.

(v)

 Credentialed personnel who are trained and competent to implement physician
 approved protocols for client observation and supervision, determination of
 appropriate level of care and facilitation of the client's transitioning to
 continuing care.

(vi)
 Services
 designed explicitly to safely detoxify clients without the need for ready
 on-site access to medical and nursing personnel.

(vii)
 Medical evaluation and consultation
 available twenty-four (24) hours a day in accordance with practice
 guidelines.

(viii)
 Clinicians who
 assess and treat clients are able to obtain and interpret information regarding
 the needs of the client to include the signs and symptoms of alcohol and other
 drug intoxification and withdrawal, as well as, the appropriate treatment and
 monitoring of these conditions.

(ix)
 Medication administration and monitoring
 services, including specific procedures for pregnant women.

(x)
 Continuous assessment.

(xi)
 Planned counseling and other therapeutic
 interventions.

(xii)
 Motivational
 enhancement therapy.

(xiii)
 Direct
 affiliation with other levels of care.

5.
 Documentation: Level III.2-D Programs
 shall provide the following clinical record documentation: 
 
(i)
 Documentation of each
 clinical/therapeutic intervention provided.

(ii)
 Daily assessment of progress, through
 detoxification, including response to medication, which also notes any
 treatment changes.

(iii)
 Monitoring
 of vital signs, at a minimum, every eight (8) hours until discharge.

(iv)
 The use of detoxification rating scale
 tables and flow sheets.

6.
 Support Systems: The Level III.2-D 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 availability
 to:
(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 emergency medical services.

7.
 Staff Requirements. 
 
(i)
 Medical Director. The Level III.2-D
 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 III.2-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)
 There shall be a Registered Nurse (RN)
 or Licensed Practical Nurse (LPN) on site during all hours of the Level III.2-D
 Program's operation.

(iv)
 Direct
 Care Personnel. 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.

(v)
 The entity shall maintain an adequate
 number of personnel, including physicians, nurses, counselors and case managers
 to sustain the Level III.2-D Program as delineated in its operational
 plan.

(vi)
 Administrative Support
 Personnel. The entity shall maintain an adequate number of support personnel to
 sustain the program's administrative functions.

8.
 Training: The entity shall provide written
 documentation that:
(i)
 All Level III.2-D
 Program personnel satisfy the requirements of the core training curriculum, as
 specified in Rule
 
580-9-44-.02
(3)
.

(ii)
 All clinical and medical services staff
 in a Level III.2-D Program shall receive training during the initial twelve
 (12) months employment and develop basic competencies in the following areas: 
 
(I)
 Biopsychosocial dimensions of alcohol and
 other drug dependence, including:
I.
 The signs
 and symptoms of alcohol and other drug intoxication and withdrawal.

II.
 Evidence-based treatment and monitoring
 strategies for alcohol and other drug intoxication and withdrawal.

III.
 Continuing care motivational and
 engagement strategies.

(II)
 Pharmacotherapy.

(III)
 ASAM Patient Placement
 Criteria.

(IV)
 Assessment of and
 service planning to address biopsychosocial
 needs.

9.

 Service Intensity: The entity shall document in the clinical record that the
 intensity of Level III.2-D Services is 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 III.2-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.

Notes

Ala. Admin. Code
 r. 
580-9-44-.22

 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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