Ala. Admin. Code r. 580-9-44-.26

Level III.7: Medically Monitored Intensive Residential Treatment Program for Adults

This regulation establishes operating standards for Level III.7 Medically Monitored Intensive Residential Treatment Programs for Adults in Alabama, corresponding to ASAM Level 3.7. Operators must develop written program descriptions, admission criteria based on ASAM PPC-2R dimensional criteria and DSM diagnostic criteria, and provide 24-hour structured residential treatment with on-duty awake staff, nursing coverage, and physician availability within 24 hours of admission. The rule also sets specific requirements for co-occurring disorders enhanced programs and programs serving women with dependent children, including staffing qualifications, service intensity (minimum 20 structured hours per week), documentation, and training standards.

Ala. Admin. Code r. 580-9-44-.26 - Level III.7: Medically Monitored Intensive 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.7 Medically Monitored Intensive Treatment Program for
 Adults 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.7 Medically Monitored Intensive 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.7 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.7 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.7 Program which shall include, at a minimum, individuals:
 
(I)
 Whose assessed severity of illness
 warrants this level of care, including but not limited to, adults whose
 subacute biomedical and emotional, behavioral, or cognitive problems are so
 severe that they require medically monitored treatment, but do not need the
 full resources of an acute care general hospital.

(II)
 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.7 Adult Program meets: 
 
(I)
 The diagnostic criteria for a substance
 dependence 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 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.7 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.7 Program for Women and
 Dependent Children:
(I)
 Meets 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)

 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.7 Medically
 Monitored Intensive Residential Program shall demonstrate the capacity to
 provide a basic regimen of treatment services appropriate to the client'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)
 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.7 Co-occurring Disorders Medically Monitored Intensive
 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)
 Intensive case
 management.

(vi)
 Women
 and Dependent Children Program Specific Criteria: Each Level III.7 Women and
 Dependent Children Medically Monitored Intensive 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.

(IV)

 Academic and vocational services.

(V)
 Financial resource development and
 planning.

(VI)
 Family planning
 services.

4.

 Therapeutic Component Implementation. The entity shall document the
 implementation of a planned regimen of professionally directed program
 activities for clients and their families. Evaluation, treatment and care shall
 be 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.7
 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 and recovery support services and
 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.
 Skill
 development to support productive daily activity and successful reintegration
 into the family and community.

XI.

 Supervised therapeutic recreational activities.

(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.

5.

 Documentation: Each Level III.7 Medically Monitored Intensive 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.7 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)
 The availability of a physician
 or physician extender to assess each client in person within twenty-four (24)
 hours of admission and thereafter as medically necessary.

(ii)
 Emergency consultation with a physician
 available twenty-four (24) hours a day, seven (7) days a week.

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

(iv)
 The availability of a
 MAS Registered Nurse to conduct a nursing assessment at the time of admission,
 monitor the client's progress during treatment and manage medication
 administration.

(v)
 Telephone or in
 person consultation with a MAS Nurse twenty-four (24) hours a day, seven (7)
 days a week.

(vi)
 Indicated
 laboratory and toxicology testing.

(vii)
 Indicated medical procedures.

(viii)
 Medical treatment.

(ix)
 Psychiatric services shall be available
 within eight (8) hours by telephone or twenty-four (24) hours in
 person.

(x)
 Community based
 services assessed as needed but not provided by the entity.

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

7.
 Program Personnel. Each Level III.7
 Intensive 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)
 Nursing
 Personnel. MAS Registered Nurses or Licensed Practical Nurses shall be
 available for primary nursing care and observation twenty-four (24) hours a
 day.

(ii)
 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.

(iii)
 Clinical Personnel. The entity shall
 maintain an adequate number of clinical personnel to sustain the Level III.7
 Adult Program as delineated in its operational procedures.

(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.7 Program
 shall be assigned to a specific primary counselor.

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

(vii)
 Co-occurring Disorders
 Program Specific Criteria.
(I)
 Each Level
 III.7 Co-occurring Enhanced Medically Monitored 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
 supervised experience in a direct service area treating individuals who have
 co-occurring disorders.

(II)
 Each
 Level III.7 Co-occurring Enhanced Intensive 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.

(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 responsibility 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)
 Direct Care Personnel. All other direct
 care personnel in a Level III.7 Co-occurring Enhanced Intensive 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)
 Clinical Personnel. The
 entity shall maintain an adequate number of clinical personnel to sustain the
 Level III.7 Co-occurring Enhanced 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.7 Residential Program shall be assigned to a primary
 counselor.

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

(ix)
 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.7 Intensive 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.7 Women and
 Dependent Children Program shall be assigned to a primary counselor.

(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.7
 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.7 Intensive 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 twenty (20) 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.7 Intensive 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.7 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 assessment and intake services at its Level III.7 Medically Monitored
 Intensive 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-.26

 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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