Ala. Admin. Code r. 580-9-44-.25

Level III.5: Clinically Managed High Intensity Residential Treatment Program For Adults

This regulation establishes operating standards for Alabama's Level III.5 Clinically Managed High Intensity Residential Treatment Program for Adults, corresponding to ASAM Level 3.5 substance use residential treatment. Operators must comply with detailed requirements covering program description, admission criteria (including co-occurring disorders and women with dependent children sub-programs), core and therapeutic services, staffing qualifications, training, documentation, support systems, and service intensity (minimum 25 clinical contact hours per week). The rule applies specifically to adult clients with substance dependence disorders, with specialized tracks for those with co-occurring mental health disorders and for women with dependent children.

Ala. Admin. Code r. 580-9-44-.25 - Level III.5: Clinically Managed High 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.5 Clinically Managed High 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.5 Clinically Managed High 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.5 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.5 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 Services, which shall include, at a minimum, individuals who have been
 assessed to have multiple, significant social and psychological functional
 deficits that cannot be adequately addressed on an outpatient basis.

(ii)
 The entity shall provide written
 documentation in individual case records that each client admitted to a Level
 III.5 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.5 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.5 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.5 High
 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 provided 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 service 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 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.

(vi)

 Women and Dependent Children Program Specific Criteria: Each Level III.5 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 each client's assessed needs and
 expressed desires for care. 
(i)
 Service
 strategies for each Level III.5 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.

(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 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.

5.

 Documentation: Each Level III.5 High 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.5
 Services.

6.
 Support
 Systems. Each Level III.5 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 adult
 education.

(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.

(x)
 Co-occurring Disorders
 Program Specific Criteria: In addition to compliance with the criteria, each
 Level III.5 Co-occurring Enhanced High Intensity Residential Program shall
 provide client access to intensive case management services.

(xi)
 Women and Dependent Children's Program
 Specific Criteria: In addition to compliance with the criteria, the each Level
 III.5 High Intensity Residential Treatment Program for Women and Dependent
 Children shall provide client access to the following support services: 
 
(I)
 Academic and vocational
 services.

(II)
 Financial resource
 development and planning.

(III)

 Family planning services.

7.
 Program Personnel. Each level III.5 High
 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 be qualified as a qualified
 paraprofessional to provide the specific services delineated in the entity's
 operational procedures for this level of care.

(ii)
 Clinical Personnel. The entity shall
 maintain an adequate number of clinical personnel to sustain the Level III.5
 High Intensity Residential 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.5 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)

 Co-occurring Disorders Program Specific Criteria. 
 
(I)
 The Level III.5 Co-occurring Enhanced
 High Intensity Residential Program shall be coordinated by a full-time member
 of the staff who has the minimum of a master's degree in a mental health
 related field and at least two (2) years post master's supervised experience in
 a direct service area treating clients with co-occurring disorders.

(II)
 The Level III.5 Co-occurring Enhanced
 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.

(III)
 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.

(IV)
 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.5 Co-occurring Enhanced Program shall be qualified to provide the
 specific services delineated in the entity's operational plan for this level of
 care.

(VI)
 Clinical Personnel. The
 entity shall maintain an adequate number of clinical personnel to sustain the
 Level III.5 Enhanced High Intensity Residential Program as delineated in its
 operational plan.

(VII)

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

(VIII)
 Every client in a
 Level III.5 Co-occurring Program shall be assigned to a specific primary
 counselor for care management.

(IX)

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

(vii)
 Women and Dependent Children Program
 Specific Criteria:
(I)
 Each Level III.5 Women
 and Dependent Children High Intensity Residential Program shall be coordinated
 by a full-time member of the staff who has a minimum of a master's degree in a
 behavioral health related field and at least two (2) years post master's
 supervised experience in a direct service area treating women who have
 substance use, mental health or co-occurring mental health and substance use
 disorders.

(II)
 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.

(III)
 Clinical Personnel. The entity shall
 maintain an adequate number of clinical personnel to sustain the Level III.5
 Women and Dependent Children Program as delineated in its operational
 plan.

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

(V)
 Every client in a Level III.5 Women and
 Dependent Children Program shall be assigned to a specific primary counselor
 for care management.

(VI)
 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 Program personnel satisfy the competency and
 training requirements as specified in Rule
 
580-9-44-.02
(3)
.

9.
 Service Intensity: The entity shall
 develop, maintain and document implementation of policies and procedures in
 regard to service intensity for its Level III.5 Residential Program, which
 shall at a minimum specify:
(i)
 The amount and
 frequency of Level III.5 Services are established on the basis of the unique
 needs of each client served.

(ii)

 The program has the capacity to provide a minimum of twenty-five (25) contact
 hours of clinical services weekly for each client.

10.
 Length of Service: The entity shall
 provide written documentation that the duration of treatment in its Level III.5
 Program is variable 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 meet treatment goals and
 strategies; or

(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 High Intensity Residential Program
 has been utilized as an interim level of care.

11.
 Service Availability: The entity shall
 provide written documentation describing the process utilized to establish
 hours of availability for screening, assessment and intake service, admission
 and counseling services at its Level III.5 High 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-.25

 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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