Ala. Admin. Code r. 580-9-44-.27

Level III.7: Medically Monitored High Intensity Residential Treatment Program For Adolescents

This regulation establishes operating standards for Level III.7 Medically Monitored High Intensity Residential Treatment Programs for Adolescents in Alabama, corresponding to ASAM Level 3.5 residential substance use treatment. Covered facilities must provide 24-hour medically monitored residential care, including core clinical services (individual, group, and family counseling, medication management, medical services, and case management), with specific additional requirements for co-occurring disorders programs and women-with-dependent-children programs. Operators must meet staffing, training, documentation, admission criteria, and service intensity requirements (minimum 20 structured hours per week) as set forth in this chapter and referenced rules.

Ala. Admin. Code r. 580-9-44-.27 - Level III.7: Medically Monitored High 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.7 Medically Monitored High 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.7 Adolescent Medically Monitored High
 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.7
 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.7 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.7 Adolescent Services, which shall include, at a minimum, individuals:
 
(I)
 Who are less than nineteen (19) years old
 and:

(II)
 Whose assessed severity
 of illness warrants this level of care, including but not limited to
 adolescents whose sub-acute 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.

(III)
 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 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 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 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.7 Adolescent Program for
 Women and Dependent Children:
(I)
 Meets the
 diagnostic criteria for a substance related 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 Adolescent
 High 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 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 Adolescent Co-occurring Disorders High 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)
 Intensive case
 management.

(vi)
 Women
 and Dependent Children Program Specific Criteria: Each Level III.7 Adolescent
 Women and Dependent Children High 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.

(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 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.7
 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 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.
 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.

XIII.
 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 Adolescent 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.

6.
 Support Systems. Each Level III.7
 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)
 The availability
 of a physician or physician extender to assess each adolescent 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)
 Psychological and psychiatric
 treatment.

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

(xix)
 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
 Adolescent 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)

 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
 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 Adolescent
 Program shall be assigned to a specific primary counselor for care management
 whose principal responsibilities shall include, but not limited to: 
 
(I)
 Development and implementation of the
 individualized service plan.

(II)

 Ensuring service delivery and coordination of service delivery as delineated in
 the plan.

(III)
 Evaluation of the
 client's overall progress in treatment and preparation of staffing
 reports.

(IV)
 Discharge and
 continuing care planning and implementation.

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

(viii)
 Co-occurring Disorders
 Program Specific Criteria.
(I)
 Each Level
 III.7 Adolescent 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
 supervised experience in a direct service area treating adolescent clients with
 co-occurring disorders.

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

(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)
 All other direct care personnel in a
 Level III.7 Adolescent Co-occurring Enhanced High Intensity Residential 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.7
 Adolescent 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 Adolescent Residential Program shall be assigned to a specific
 primary counselor for care management as a qualified
 paraprofessional.

(viii)

 Women and Dependent Children Program Specific Criteria. 
 
(I)
 Direct Care Personnel. All direct care
 personnel shall be qualified as 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 Adolescent High 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.7 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.7 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.7 Adolescent High 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 twenty (20) 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.7 Adolescent High 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.7 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 Behavioral Health Screening and Diagnostic Interview
 Examination Services at its Level III.7 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-.27

 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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