Ala. Admin. Code r. 580-9-44-.24

Level III.5: Clinically Managed Medium Intensity Residential Treatment Program For Adolescents

This regulation establishes operating standards for Level III.5 Clinically Managed Medium Intensity Residential Treatment Programs for Adolescents in Alabama, corresponding to ASAM Level III.5 substance use residential care. Covered entities must meet admission criteria (including ASAM PPC-2R dimensional criteria and DSM diagnostic criteria for substance-related disorders), provide a 24-hour structured residential environment with a defined set of core clinical services, maintain appropriate staffing ratios, and document individualized treatment plans and daily progress notes. Special program tracks for co-occurring disorders and women with dependent children carry additional service and staffing requirements.

Ala. Admin. Code r. 580-9-44-.24 - Level III.5: Clinically Managed Medium Intensity Residential Treatment Program For Adolescents 

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(1)
 Rule
 Compliance. In addition to compliance with the rules as specified in this
 chapter, each Level III. 5 Clinically Managed Medium Intensity Residential
 Treatment Program for Adolescents 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.5 Adolescent Clinically Managed Medium
 Intensity Residential Treatment 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.5
 Adolescent Program shall be 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.5 Adolescent 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.5 Adolescent Services which shall include, at a minimum, individuals: 
 
(I)
 Who are less than nineteen (19) years
 old.

(II)
 Whose assessed severity
 of illness warrants this level of care including but not limited to individuals
 who have impaired functioning across a broad range of psychosocial domains that
 may be expressed as:
I.
 Disruptive
 behaviors.

II.
 Delinquency and
 juvenile justice involvement.

III.

 Educational difficulties.

IV.

 Family conflicts and chaotic home situations.

V.
 Developmental immaturity and/or

VI.
 Psychological
 problems.

(III)
 Who do
 not require significant medical, psychiatric, or nurse monitoring or
 interventions.

(IV)
 For whom
 treatment for identified problems has been rendered ineffective at less
 intensive levels of care.

(ii)
 The entity shall provide written
 documentation in individual case records that each client admitted to a Level
 III.5 Adolescent Program meets:
(I)
 The
 diagnostic criteria for a substance related disorder as defined in the most
 recent edition of the Diagnostic and Statistical Manual for Mental Disorders;
 and

(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.5 Adolescent Co-occurring Enhanced Treatment Program meets: 
 
(I)
 The diagnostic criteria for a substance
 related 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.5 Adolescent Program for Women and Dependent Children: 
 
(I)
 Meets the diagnostic criteria for a
 substance related 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.5 Adolescent
 Medium Intensity Residential Program shall demonstrate the capacity to provide
 a basic regimen of treatment services appropriate to the adolescent's
 developmental and cognitive levels and other assessed needs. 
 
(i)
 At a minimum, the entity shall
 demonstrate and document its capacity to provide a twenty-four (24) hour
 structured residential treatment environment with accessibility to 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)
 Medication
 administration.

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

(XII)

 Transportation.

(XIII)
 Activity
 therapy.

(XIX)
 Case management: 
 
I.
 Case planning.

II.
 Linkage.

III.
 Advocacy.

IV.
 Monitoring.

(ii)
 Medical Services. The entity shall
 implement procedures for the provision of medical services as according to
 protocols established in compliance with 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 (2) 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)
 Mental
 Health Services. The entity shall develop, maintain and document implementation
 of written policies and procedures to ensure that each client's mental health
 needs are identified through the assessment process and access to appropriate
 care for these needs is provided concurrently with treatment for assessed
 substance related disorders.

(iv)

 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.

(v)

 Co-occurring Disorders Program Specific Criteria: Each Level III.5 Adolescent
 Co-occurring Disorders Medium 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.

(vi)
 Women and Dependent Children Program
 Specific Criteria: Each Level III. 5 Adolescent 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)
 Parenting skills
 development.

4.

 Therapeutic Component Implementation. The entity shall document the
 implementation of a planned regimen of twenty-four (24) hour professionally
 directed program activities for adolescents and their families. Evaluation,
 treatment and care shall be 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.5
 Adolescent 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)
 Clients 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, recovery support services and other
 activities that shall, at a minimum, include those that address: 
 
I.
 Implementation of individualized service
 plan strategies.

II.
 Development
 and application of recovery skills including relapse prevention.

III.
 Interpersonal choice/decision making
 skill development.

IV.
 Enhancement
 of the understanding of addiction.

V.
 Development of a social network supportive
 of recovery.

VI.
 Random drug
 screening.

VII.
 Health
 education.

VIII.
 Medication
 administration and monitoring.

IX.

 Promotion of successful involvement in regular productive daily activity such
 as school or work.

X.
 Enhancement
 of personal responsibility, developmental maturity and prosocial
 values.

XI.
 Educational services in
 accordance with state and local regulations.

XII.
 Opportunities to remedy educational
 deficits created by involvement with alcohol and other
 drugs.

(ii)
 The
 entity shall actively promote and provide referrals and/or access to community
 support services.

(iii)
 All
 services shall be organized and provided according to evidence-based and best
 practice standards and guidelines.

(iv)
 Co-occurring Disorders Program Specific
 Criteria: Each Level III. 5 Adolescent Co-occurring Enhanced Program shall
 document the capacity to provide the service strategies and the following
 therapeutic components: 
(I)
 Groups and
 classes that address the signs and symptoms of mental health and substance use
 disorders.

(II)
 Groups, classes and
 training to assist clients in becoming aware of cues or triggers that enhance
 the likelihood of alcohol and drug use or psychiatric decompensation and to aid
 in development of alternative coping responses to those cues.

(III)
 Dual recovery groups that provide a
 forum for discussion of the interactions of and interrelations between
 substance use and mental health disorders.

(IV)
 Intensive case
 management.

(v)
 Women and
 Dependent Children Program Specific Criteria: Each Level III. 5. Adolescent
 Women and Dependent Children Program shall document the capacity to provide the
 service strategies and the following therapeutic components: 
 
(I)
 Gender specific services which address
 issues of relationships, parenting, abuse and trauma.

(II)
 Primary medical care including prenatal
 care.

(III)
 Primary pediatric care
 for children.

(IV)
 Therapeutic
 interventions for children which address their developmental needs and issues
 of sexual abuse and neglect.

(V)

 Outreach to inform pregnant women of the services and priorities.

(VI)
 Interim services while awaiting
 admission to this level of care.

(VII)
 Recreation and leisure time skills
 training.

(VIII)
 Academic and
 vocational services.

(IX)
 Family
 planning services.

5.
 Documentation: Each Level III.5 Adolescent
 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.

6.
 Support
 Systems. Each Level III.5 Adolescent 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)
 Emergency 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 MAS nurse twenty-four (24) hours a day, seven (7) days a
 week.

(iv)
 Indicated laboratory and
 toxicology testing.

(v)
 Indicated
 medical procedures.

(vi)
 Medical
 treatment.

(vii)
 Psychological and
 psychiatric treatment.

(viii)

 Direct affiliation with or coordination through referral to more and less
 intensive levels of care, including detoxification
 services.

7.
 Program
 Personnel. Each Level III. 5 Adolescent 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, as a qualified
 paraprofessional 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. 5
 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)
 Each primary counselor shall maintain a
 case load not to exceed ten (10) clients with active cases at any one
 time.

(v)
 Co-occurring Disorders
 Program Specific Criteria.
(I)
 Each Level
 III.5 Adolescent 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 responsibility for the medical aspects of the
 program.

(III)
 All other direct
 care personnel in a Level III.5 Adolescent 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.

(IV)
 Every client in a Level III.5 Adolescent
 Residential Program shall be assigned to a specific primary counselor for care
 management.

(V)
 Each primary
 counselor shall maintain a case load not to exceed sixteen (16) clients with
 active cases at any one time.

(vi)
 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. 5 Adolescent 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. 5
 Adolescent 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.5
 Adolescent 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.5 Adolescent 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.

(ii)
 The entity shall provide
 written documentation describing the procedures utilized to ensure the
 provision of services appropriate to the client's developmental stage and level
 of comprehension, including any necessary adaptations.

10.
 Length of Service: The entity shall
 provide written documentation that the duration of treatment in each Level III.
 5 Adolescent 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.5 Adolescent 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 services at its Level
 III.5 Medium Intensity Adolescent 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-.24

 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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