Ala. Admin. Code r. 580-9-44-.23

Level III.3: Clinically Managed Medium Intensity Residential Treatment Program For Adults

This regulation establishes operating standards for Level III.3 Clinically Managed Medium Intensity Residential Treatment Programs for Adults in Alabama, corresponding to ASAM Level 3.3. Operators must meet admission criteria (clients must be at least 19 years old with a substance dependence disorder), provide a 24-hour structured residential environment with specified core services (counseling, case management, medical services, daily living skills, etc.), maintain appropriate staffing ratios and qualifications, and document at least 15 hours of structured services per week. Specialized program tracks are addressed for co-occurring disorders and for women with dependent children.

Ala. Admin. Code r. 580-9-44-.23 - Level III.3: Clinically Managed Medium Intensity Residential Treatment Program For Adults 

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(1)
 Rule
 Compliance. In addition to compliance with the rules as specified in this
 chapter, each Level III.3 Clinically Managed Medium Intensity Residential
 Treatment 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 the Level III.3 Clinically Managed Medium Intensity Residential
 Treatment 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 the Level III.3 Program
 shall be provided. Services shall 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.3 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 its Level
 III.3 Services which shall include, at a minimum, individuals:
 
(I)
 Who are at least nineteen (19) years
 old.

(II)
 Whose assessed severity
 of illness warrants this level of care including, but not limited to:
 
I.
 Individuals who have a substance
 dependence disorder and concomitant cognitive impairments, developmental
 delays, emotional, and/or behavioral problems; and/or

II.
 Significant functional deficits in regard
 to management of activities of daily living.

(ii)
 The entity shall provide written
 documentation in individual case records that each client admitted to a Level
 III.3 Program meets:
(I)
 The diagnostic
 criteria for a substance dependence disorder as defined in the most recent
 edition of the Diagnostic and Statistical Manual for Mental
 Disorders.

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

(iii)
 Co-occurring Disorders Program Specific
 Criteria. The entity shall provide written documentation in individual case
 records that each individual admitted to a Level III.3 Co-occurring Enhanced
 Treatment Program meets:
(I)
 The diagnostic
 criteria for a substance dependence and mental illness disorder as defined in
 the most recent edition of the Diagnostic and Statistical Manual for Mental
 Disorders.

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

(iv)
 Women and Dependent Children Program
 Specific Criteria: The entity shall provide written documentation in individual
 case records that each client admitted to a Level III.3 Program for Women and
 Dependent Children:
(I)
 Meets the diagnostic
 criteria for a substance dependence disorder as defined in the most recent
 edition Diagnostic and Statistical Manual for Mental Disorders.

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

(III)
 Is pregnant;
 or

(IV)
 Has care and custody of
 dependent children; or

(V)
 Has lost
 custody of dependent children and has the potential for family
 reunification.

3.
 Core Services: Each Level III.3 Medium
 Intensity Residential Program shall demonstrate the capacity to provide a basic
 level of treatment services appropriate to the needs of its clientele. 
 
(i)
 At a minimum, the entity shall
 demonstrate and document its capacity to provide a twenty-four (24) hour
 structured residential treatment environment with the following core services: 
 
(I)
 Placement assessment.

(II)
 Individual counseling.

(III)
 Group counseling.

(IV)
 Family counseling.

(V)
 Psychoeducation.

(VI)
 Peer support.

(VII)
 Medical and somatic services.

(VIII)
 Daily living skills.

(IX)
 Medication management.

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

(XI)

 Transportation.

(XII)
 Case
 management:
I.
 Case planning.

II.
 Linkage.

III.
 Advocacy.

IV.
 Monitoring.

(ii)
 Medical Services. Medical Services shall
 be provided as specified by the entity's medical protocols established as
 required by Rule
 
580-9-44-.13
(24)
.
 
(I)
 Clients who have not had a physical
 examination within the last twelve (12) months shall be scheduled a physical
 examination within two weeks of admission.

(II)
 Pregnant clients who are not receiving
 routine prenatal care shall be seen by physician within two (2) weeks of
 admission.

(iii)
 Family
 Support. The entity shall initiate and document in the client record continuous
 efforts to involve the client's family and other natural supports in the
 treatment process.

(iv)

 Co-occurring Disorders Program Specific Criteria: Each Level III.3 Co-occurring
 Disorders Low Intensity Residential Treatment Program shall document the
 capacity to provide each of the core services and the following services: 
 
(I)
 Mental health consultation.

(II)
 Crisis intervention services.

(III)
 Activity therapy.

(IV)
 Intensive case
 management.

(v)
 Women and
 Dependent Children Program Specific Criteria: Each Level III.3 Women and
 Dependent Children Medium Intensity Residential Treatment Program shall
 document the capacity to provide each of the core services and the following
 services: 
(I)
 Child sitting
 services.

(II)
 Developmental delay
 and prevention services.

(III)

 Activity therapy.

(IV)
 Parenting
 skills development.

(V)
 Academic
 and vocational services.

(VI)

 Financial resource development and planning.

(VII)
 Family planning
 services.

4.

 Therapeutic Component Implementation. The entity shall document implementation
 of regularly scheduled treatment sessions that are provided in an amount,
 frequency and intensity appropriate to the client's assessed needs and
 expressed desires for care. 
(i)
 Service
 strategies for each Level III.3 Residential Program shall include, at a
 minimum: 
(I)
 On duty, awake staff shall
 provide supervision of client's health, welfare and safety twenty-four (24)
 hours a day.

(II)
 Client shall have
 access to clinical services personnel twenty-four (24) hours a day, seven (7)
 days a week.

(III)
 Daily clinical
 services to improve the client's ability to structure and reorganize the tasks
 of daily living and recovery.

(IV)

 The provision of daily scheduled treatment and recovery support services and
 activities that shall, at a minimum, include those that address: 
 
I.
 Implementation of individualized service
 plan strategies.

II.
 Relapse
 prevention.

III.
 Interpersonal
 choice/decision making skill development.

IV.
 Development of a social network
 supportive of recovery.

V.
 Daily
 living and recovery skills development.

VI.
 Random drug screening.

VII.
 Health education.

VIII.
 Medication administration and
 monitoring.

5.
 Documentation: Each Level III.3 Medium
 Intensity Residential Program shall provide the following documentation in each
 client record:
(i)
 Individualized progress
 notes shall be recorded each day for each respective service provided in Level
 III.3 Services.

6.

 Support Systems. Each Level III.3 Program shall develop, maintain and document
 implementation of written policies and procedures which govern the process used
 to provide client access to support services on site, or through consultation
 or referral, which shall minimally include: 
 
(i)
 Telephone or in person consultation with
 a physician available twenty-four (24) hours a day, seven (7) days a
 week.

(ii)
 Telephone or in person
 consultation with emergency services twenty-four (24) hours a day, seven (7)
 days a week.

(iii)
 Telephone or in
 person consultation with a registered nurse twenty-four (24) hours a day, seven
 (7) days a week.

(iv)
 Direct
 affiliation with or coordination through referral to more and less intensive
 levels of care.

(v)
 Direct
 affiliation with or coordination through referral to supportive services
 including vocational rehabilitation, literacy training and sheltered
 workshops.

(vi)
 Mutual self-help
 groups which are tailored to the needs of the specific client
 population.

(vii)
 Appropriate
 laboratory and toxicology testing.

(viii)
 Psychological and psychiatric
 services.

(ix)
 Direct affiliation
 with or coordination through referral to more and less intensive levels of
 care.

7.
 Program
 Personnel. Each level III.3 Medium Intensity Residential 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)
 Direct Care Personnel. All direct care
 personnel shall have the qualifications to provide the specific services
 delineated in the entity's program description for this level of
 care.

(ii)
 Clinical Personnel. The
 entity shall maintain an adequate number of clinical personnel to sustain the
 Level III.3 Program as delineated in its operational procedures.

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

(iv)
 Every client in a Level III.3 Program
 shall be assigned to a specific primary counselor for care
 management.

(v)
 Each primary
 counselor shall maintain a case load not to exceed twenty (20) clients with
 active cases at any one time.

(vi)

 Co-occurring Disorders Program Specific Criteria. 
 
(I)
 Each Level III.3 Co-occurring Enhanced
 Medium Intensity Residential Program shall have access to psychiatric services
 led by a qualified psychiatrist or nurse practitioner that are fully capable of
 evaluating, diagnosing and prescribing medications to clients with co-occurring
 disorders. On-call psychiatric services shall be available twenty-four (24)
 hours a day, seven (7) days a week.

(II)
 The treatment organization/agency shall
 have access to an Alabama licensed physician, full time, part time or on
 contract who shall be available to the program for client care and shall assume
 liability for the medical aspects of the program.

(III)
 Treatment staff that provide therapy
 and ongoing clinical assessment services to individuals diagnosed with
 co-occurring disorders shall have, at a minimum; 
 
I.
 A master's degree in a behavioral health
 related field with a minimum of two (2) years' work experience with individuals
 who have co-occurring disorders, mental health or substance use
 disorders.

II.
 Specialized training
 to work with individuals who have co-occurring disorders.

(V)
 All other direct care personnel in a
 Level III.3 Co-occurring Enhanced Medium Intensity Residential Program shall be
 qualified, as a qualified paraprofessional to provide the specific services
 delineated in the entity's operational plan for this level of care.

(VI)
 Every client in a Level III.3
 Residential Program shall be assigned to a specific primary counselor for care
 management.

(VII)
 Each primary
 counselor shall maintain a case load not to exceed ten (10) clients with active
 cases at any one time.

(vii)
 Women and Dependent Children Program
 Specific Criteria.
(I)
 Direct Care Personnel.
 All direct care personnel shall be qualified as a qualified paraprofessional to
 provide the specific services delineated in the entity's operational plan for
 this level of care.

(II)
 Clinical
 Personnel. The entity shall maintain an adequate number of clinical personnel
 to sustain the Level III.3 Medium Intensity Women and Dependent Children
 Residential Program as delineated in its operational plan.

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

(IV)
 Every client in a Level III.3 Women and
 Dependent Children Program shall be assigned to a specific primary counselor
 for care management.

(V)
 Each
 primary counselor shall maintain a case load not to exceed ten (10) clients
 with active cases at any one time.

8.
 Training. The entity shall provide written
 documentation that all Level III.3 Program personnel satisfy the competency and
 training requirements as specified in Rule
 
580-9-44-.02
(3)
.

9.
 Service Intensity: 
 
(i)
 The entity shall document that the amount
 and frequency of Level III.3 Medium Intensity Residential Treatment Services
 are established on the basis of the unique needs of each client served. To
 assist in addressing these needs, the entity shall ensure the availability of
 no less than fifteen (15) hours of structured services each
 week.

10.
 Length of
 Service: The entity shall provide written documentation that the duration of
 treatment in each Level III.3 Medium Intensity Residential Program shall vary
 as determined by: 
(i)
 The severity of the
 client's illness.

(ii)
 The client's
 ability to comprehend the information provided and use that information to
 implement treatment strategies and attain treatment goals.

(iii)
 The appearance of new problems that
 require another level of care; or

(iv)
 The availability of services at an
 assessed level of need when a Level III.3 Residential Program has been utilized
 to provide interim services.

11.
 Service Availability: The entity shall
 provide written documentation describing the process utilized to establish
 hours of availability for screening, assessment and intake service and
 counseling services at its Level III.3 Medium Intensity Residential 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 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-.23

 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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