Ala. Admin. Code r. 580-2-20-.12 - MI Day Programs

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The agency shall have a program description for MI Day Treatment service/program. The program description shall include all requirements per 580-2-20-.09(2) (a-e) General Clinical Practice and the program(s) criteria as follows:

(1) Adult Rehabilitation Day Program (RDP). The program description is consistent with the provisions of this section and defines Rehabilitative Day Program (RDP) as an identifiable and distinct program that provides long-term recovery services with the goals of improving functioning, facilitating recovery, achieving personal life goals, regaining self-worth, optimizing illness management, and helping recipients to become productive participants in family and community life. The program description shall include all of the following components:

(a) A description of the target population of serious mental illness (SMI).

(b) Age range.

(d) Location of the geographic service area for the program.

(e) Specifies that the program is staffed by qualified individuals whose primary job function is specific to Rehabilitative Day Program.

(f) Admission criteria shall address inclusionary criteria as follows:

1. Presence of a psychiatric diagnosis.

2. Mild to moderate persistent, chronic, and/or refractory symptoms and impairments in one (1) or more areas of living (e.g. difficulty attaining & sustaining life goals and/or community integration).

3. Does not meet admission or continued stay criteria for more intensive levels of care such as PHP or AIDT but requires the daily structure and services of a recovery oriented rehabilitative milieu to improve or maintain level of functioning, achieve personal life goals, and sustain a positive quality of life.

4. RDP services are reasonably expected to improve the individual's functional level, increase quality of life, and facilitate attainment of personal life goals.

5. Be approved by a qualified staff member.

(g) Discharge/transfer criteria shall include the following:

1. Rehabilitative goals have been met and the individual no longer needs this type of service.

2. Less intensive levels of care can reasonably be expected to improve or maintain the individual's level of symptom remission, condition, functional level, quality of life, attainment of life goals, and recovery; or the degree of impairment, severity of symptoms, and/or level of functioning necessitates admission to a more intensive level of care.

3. The individual primarily needs support, activities, socialization, or custodial care that could be provided in other less intensive settings (e.g. peer support group, drop in center, or senior citizen's center).

4. The individual chooses not to participate.

(h) Exclusionary criteria must include the following:

1. The person's level of functioning requires a more intensive level of care.

2. The individual is not experiencing mild or moderate persistent, chronic symptoms, impairments in one (1) or more areas of daily life, difficulty attaining and sustaining life goals and/or problems with community integration.

(i) The RDP constitutes active structured, rehabilitative interventions that specifically address the individual's life goals, builds on personal strengths and assets, improves functioning, increases skills, promotes a positive quality of life, and develops support networks. The RDP should include an initial screening and an individualized treatment plan. Based on the specific focus of the program and the needs and preferences of recipients, the adult RDP shall provide the following:

1. Initial screening to evaluate the appropriateness of the recipient's participation in the program.

2. Development of an individualized program plan.

3. As well as at least one (1) more service from the following based on the needs and preferences of recipient's participation in the program:

(i) Psychoeducational services

(ii) Basis Living Skills

(iii) Coping skills training closely related to presenting problems (e.g., stress management, symptom management, assertiveness training, and problem solving)

(iv) Utilization of community resources.

(j) The program coordinator must have at a minimum a bachelor's degree in a mental health related field and at least one (1) year of direct service experience in a mental health setting or be a registered nurse with at least one (1) year of mental health experience.

(k) The overall staff present to recipient ratio cannot exceed one to twenty (1:20). If a program has a capacity of twenty (20) or less, an additional staff person should be present during the hours of operation to permit individualized treatment.

(l) Records document that recipients admitted to the RDP meet the admission criteria.

(m) Records document that the recipients admitted to the RDP do not meet the exclusionary criteria.

(n) Rehabilitative Day Programs shall be scheduled at least four (4) hours per day one (1) day per week.

(o) Recipients who are deaf or who have limited English proficiency shall have effective communication access provided by staff proficient in the recipients' preferred language, or by a qualified interpreter. Proficient in American Sign Language is defined as having at least an Intermediate Plus level in the Sign Language Proficiency Interview.

(p) Documentation that communication access has been provided for recipients who are deaf or who have limited English proficiency.

(q) The use of family members to interpret is discouraged due to the possibility of conflicts of interest. If family members are used to interpret, this shall be noted on the waiver. Family members under the age of eighteen (18) cannot be used as interpreters.

(r) Programming will be modified to provide effective participation for all recipients who are deaf.

(s) Recipients are scheduled to attend RDP at least once a week based on individual goals, preferences, needs and circumstances.

(t) The record documents that the treatment plan for rehabilitative day services is evaluated at least every three (3) months to assure that continued participation in RDP is clinically indicated.

(2) Adult Intensive Day Treatment (AIDT). The program description is consistent with the provisions of this section and defines Intensive Day Treatment (AIDT) as an identifiable and distinct program that provides highly structured services designed to bridge acute treatment and less intensive services such as rehabilitative and outpatient with the goals of community living skills acquisition/enhancement, increased level of functioning, and enhanced community integration. The program description shall include all of the following components:

(a) A description of the target population of SMI.

(b) Age range.

(d) Location of the geographic service area for the program.

(e) Specifies that the program is staffed by qualified individuals whose primary job function is specific to Adult Intensive Day Program.

(f) Admission shall include address inclusionary criteria as follows:

1. Presence of a psychiatric diagnosis.

2. Moderately disabling persistent, chronic, and/or refractory symptoms with no significant clinical progress made or expected in a less intensive level of care.

3. Symptoms that do not meet admission criteria for more intensive levels of care but do require the daily structure and supervision of a treatment oriented therapeutic milieu.

4. AIDT can be reasonably expected to improve the recipient's symptoms, condition, or functional level sufficient to permit transition to a less intensive level of care.

5. Be approved by a qualified staff.

(g) Discharge/transfer criteria shall include the following:

1. Treatment plan goals and objectives have been substantially attained and continued treatment can be provided in less intensive levels of care.

2. Recipient's degree of impairment, severity of symptoms, and level of functioning have improved enough to resume normal activities or to receive less intensive services (e.g., rehabilitative day program, case management, standard outpatient services).

3. Recipient's degree of impairment, severity of symptoms, and/or level of functioning necessitates admission to a more intensive level of care.

4. Recipient is unwilling or unable to participate in/ benefit from the program due to severity of symptoms, functional impairment, behavioral problems, personal choice, or cognitive limitations despite repeated documented efforts to engage the recipient.

(h) Exclusionary criteria shall address the following:

1. The recipient's degree of impairment, severity of symptoms, and level of functioning require a more intensive level of care.

2. The recipient is experiencing mild persistent, chronic symptoms without acute exacerbation and less intensive levels of care can reasonably be expected to improve the recipient's symptoms, condition, and functional level.

(i) The program description defines the expected length of stay (LOS) as intermediate term, not to exceed six (6) months unless clinically justified.

(j) The program description shall state the procedure for extending a recipient past the expected LOS and must require at least one (1) of the following continued stay criteria:

1. Goals and objectives specified on the treatment plan have not been substantially attained or new problems have emerged, and further treatment can be reasonably expected to result in progress toward goals and objectives and/or continued stability.

2. Continued treatment cannot be provided in less intensive levels of care (e.g., rehabilitative day program, case management, standard outpatient services) due to a reasonable risk of relapse and/or hospitalization based on documented clinical judgment or failed attempts to transition the recipient to a less intensive level of care.

3. Be approved by a qualified staff member.

(k) The following services shall be available within the program as indicated by individual recipient needs:

1. Initial screening to evaluate the appropriateness of the recipient's participation in the program.

2. Development of an individualized treatment plan.

3. Individual, group, and family therapy.

4. Coping skills training (e.g. stress management, symptom management, problem solving).

5. Utilization of community resources.

6. Family education closely related to the presenting problems such as diagnosis, symptoms, medication, coping skills, etc.

7. Basic living skills

8. Recipient education closely related to presenting problems such as diagnosis, symptoms, medication, etc. rather than academic training.

(l) The program coordinator must have a master's degree in a mental health related field and one (1) year of post-master's direct mental illness experience.

(m) The overall staff present to recipient ratio cannot exceed one to sixteen (1:16). If a program has a capacity of sixteen (16) or less, an additional staff person shall be present during the hours of operation to permit individualized treatment.

(n) The program is operated a minimum of four (4) hours per day and at least four (4) days per week.

(o) Recipient records document that the recipient received a minimum of one (1) hour of individual or group therapy weekly.

(p) There is documentation in the recipient record that group therapy size does not exceed sixteen (16) in each group.

(q) The AIDT program's length of stay (LOS) is an intermediate term, not to exceed six (6) months unless clinically justified.

(r) Extensions of LOS clearly document reasons consistent with the continued stay criteria, specify a period not to exceed three (3) months, specify clinical objectives to be achieved during the extension, and are approved by a staff member.

(s) Each recipient in an Intensive Day Treatment program shall have a counselor/therapist.

(t) Program statistics document that recipients are scheduled to attend three to five (3 to 5) days per week and at least four (4) hours per day. If a recipient is scheduled less frequently, it is clearly documented that the recipient is in a brief transition period, not to exceed three (3) months.

(u) Recipients who are deaf or limited English proficient shall have effective communication access provided by staff proficient in the recipient's preferred language, or by a qualified interpreter. Proficient in American Sign Language is defined as having at least an Intermediate Plus level on the Sign Language Proficiency Interview.

(v) Documentation that communication access has been provided for recipients who are deaf or who have limited English proficiency.

(w) The use of family members to interpret is discouraged due to the possibility of conflicts of interest. If family members are used to interpret, this shall be noted on the waiver. Family members under the age of eighteen (18) cannot be used as interpreters.

(x) Programming will be modified to provide effective participation for all recipients who are deaf.

(3) Partial Hospitalization Program (PHP). The program description is consistent with the provisions of this section and defines the Partial Hospitalization Program (PHP) as an identifiable and distinct organizational unit that provides intensive, structured, active, clinical treatment with the goal of acute symptom remission, hospital avoidance, and/or reduction of inpatient length of stay. The program description shall include all of the following components:

(a) A description of the target population of SMI.

(b) Age range.

(d) Location of the geographic service area for the program.

(e) Specifies that the program is staffed by qualified individuals whose primary job function is specific to Partial Hospitalization Program.

(f) Admission criteria shall include the following inclusionary criteria:

1. Presence of a psychiatric diagnosis.

2. Acute psychiatric symptoms resulting in marked or severe impairment in multiple areas of daily life sufficient to make hospitalization very likely without admission to PHP.

3. Admission is an alternative to continued hospitalization.

4. Severe persistent symptoms without acute exacerbation where significant clinical progress has not been made in a less intensive treatment setting and where PHP services are reasonably expected to improve the recipient's symptoms, condition, or functional level.

(g) Discharge/transfer criteria shall include the following:

1. Treatment plan goals and objectives have been substantially attained and continued treatment can be provided in less intensive levels of care.

2. Recipient's degree of impairment, severity of symptoms, and level of functioning have improved enough to resume normal activities (school, work, home) or to receive less intensive services (e.g. intensive day treatment, rehabilitative day program, standard outpatient services, case management, etc.).

3. Recipient's degree of impairment, severity of symptoms, and/or level of functioning necessitates admission to a more intensive level of care.

5. Recipient primarily needs support, activities, socialization, custodial, respite, or recreational care that could be provided in other less intensive settings (e.g. drop-in center, senior center, peer support group.)

(h) Exclusionary criteria shall address the following:

1. The recipient requires a more intensive level of care.

2. The recipient is experiencing mild to moderate symptoms without an acute exacerbation.

3. Less intensive levels of treatment can reasonably be expected to improve the recipient's symptoms, condition, and functional level.

(i) The program description clearly identifies the PHP as a time-limited program with the expected length of stay (LOS) not to exceed three (3) months, unless clinically justified, but not more than six (6) months per admission.

(j) The program description shall state the procedure for extending a recipient past the expected LOS. The psychiatrist, certified nurse practitioner, or physician assistant certifies the need to extend the length of stay for a specified period of time not to exceed three (3) one (1) month extensions to achieve clearly articulated clinical objectives. An extension in LOS shall have at least one (1) of the following criteria for continued stay:

2. Continued treatment cannot be provided in less intensive levels of care due to a reasonable risk of relapse and/ or hospitalization based on documented clinical judgment or failed attempts to transition the recipient to a less intensive level of care.

(k) The following services shall be available and provided as indicated by the initial screening:

1. Medication evaluation and medication management.

2. Individual, group, and family therapy.

3. Coping skills training closely related to presenting problems e.g. stress management, symptom management, assertiveness training, and problem solving as opposed to basic living skills such as money management, cooking, etc.

4. Activity therapy closely related to the presenting problems that necessitated admission (e.g. aerobics, maintaining a recovery diary, creative expression (art, poetry, drama) pertaining to the recovery process).

5. Medication administration.

6. Medication monitoring.

7. Family education closely related to the presenting problems such as diagnosis, symptoms, medication, coping skills, etc.

8. Recipient education closely related to presenting problems such as diagnosis, symptoms, medication, etc. rather than academic training.

9. Documentation of daily services attended must be in each recipient's record.

(l) Partial Hospitalization Programs shall have a multi-disciplinary treatment team under the direction of a psychiatrist, certified registered nurse practitioner, or physician's assistant. The team may include social workers, counselors, psychologists, nurses, certified peer specialists, bachelor level staff, occupational therapists, recreational therapists, activity therapists, substance use disorder counselors, and other staff trained to work with psychiatric patients. At a minimum, the treatment team shall include a psychiatrist or certified nurse practitioner or physician's assistant, master's level clinician, a licensed practical nurse, and at least one (1) other trained professional and/or para-professional. The clinician, nurse, and other staff member will each be present during the hours of program operation.

(m) A qualified interpreter will be present at all team meetings when a recipient who is deaf or who has limited English proficiency is present.

(n) There shall be a sufficient number of staff for the daily census of the program with a minimum staff to recipient ratio of one to ten (1:10).

(o) The program coordinator must have a master's degree in a mental health related field and at least two (2) years of post-master's direct mental illness service experience or be a registered nurse with a minimum of two (2) years of psychiatric experience.

(p) A psychiatrist, certified nurse practitioner, or physician's assistant shall be responsible for providing and documenting the following services:

1. Order for admission.

2. Initial psychiatric evaluation.

3. Initial approval and monthly review of the treatment plan.

4. Medication evaluation and management services.

5. Evaluation of readiness for discharge and discharge order.

6. At least monthly face-to-face assessment of the recipient and as medically/psychiatrically indicated.

7. Face-to-face evaluation and certification of need for continued stay on at least a monthly basis.

(q) Each patient in a Partial Hospitalization Program shall have a qualified counselor/therapist.

(r) The PHP Program shall be scheduled at least four (4) hours per day, five (5) days per week for day programs and a minimum of sixteen (16) hours over at least four (4) days per week for evening programs.

(s) Recipient records document that the recipient received at a minimum one (1) hour of individual or group therapy weekly unless clinically contraindicated and documented.

(t) Group size (all types of groups with the exception of activity therapy) shall not exceed sixteen (16).

(u) Recipients in a PHP shall be scheduled at least four (4) hours per day, three to five (3-5) days per week based on individual clinical needs, preferences, and circumstances. When clinically indicated, less frequent attendance may be utilized during a brief period of transition to less intensive levels of care.

(v) The PHP is a time-limited program with the length of stay (LOS) not to exceed three (3) months, unless clinically justified, but not more than six (6) months per admission.

(w) Extensions of Length of Stay clearly document reasons consistent with the continued stay criteria, specify a period of time not to exceed one (1) month, specify clinical objectives to be achieved during the extension, are certified by a psychiatrist, a certified nurse practitioner, or licensed physician's assistant, and do not exceed three (3) extensions.

(x) Recipients who are deaf or limited English proficient shall have effective communication access to these services provided by staff proficient in the recipient's preferred language, o or by a qualified interpreter. Proficient in American Sign Language is defined as having at least an Intermediate Plus level on the Sign Language Proficiency Interview.

(y) Documentation that communication access has been provided for recipients who are deaf or who have limited English proficiency.

(z) The use of family members to interpret is discouraged due to the possibility of conflicts of interest. If family members are used to interpret, this shall be noted on the waiver. Family members under the age of eighteen (18) cannot be used as interpreters.

(aa) Programming will be modified to provide effective participation for all recipients who are deaf.

(4) Child and Adolescent Day Treatment. The program description is consistent with the provisions of this section. The program description shall include all of the following components:

(a) A description of the target population of SED.

(b) Age range.

(d) Location of the geographic service area for the program.

(e) Specifies that the program is staffed by qualified individuals whose primary job function is specific to Child and Adolescent Day Treatment.

(f) Admission criteria shall be comprehensive enough to justify a recipient's treatment in Child and Adolescent Day Treatment and shall include the following:

1. Presence of a psychiatric diagnosis.

2. Presence of a combination of at least five (5) of the following inclusionary criteria, whose severity would prevent treatment in a less intensive environment or for a temporary, clinically justified period of more intensive services to prevent regression:

(i) Poor self-control.

(ii) Cruelty to animals.

(iii) Inappropriate aggressive behavior.

(iv) Angry/hostile temper tantrums.

(v) Hyperactivity.

(vi) Withdrawn.

(vii) Running away.

(viii) Destructiveness.

(ix) Poor school performance.

(x) Truancy.

(xi) Defiance of authority.

(xii) Manipulative behavior.

(xiii) Sexual maladjustment.

(xiv) Assaultive behavior.

(xv) Child abuse victim.

(xvi) Depression.

(xvii) Anxiety.

(xviii) Homicidal/suicidal ideation.

(xix) Drug experimentation.

(xx) Sexual abuse.

(xxi) Irrational fears.

(xxii) Attention seeking behavior.

(xxiii) Encopretic/enuretic.

(xxiv) Low frustration tolerance.

(xxv) Inadequate social skills.

(xxvi) Dysfunctional family relationships.

(g) Admission is approved by Licensed Independent Practitioners.

(h) Recipient shall have documented moderately disabling persistent, chronic, and/or refractory symptoms with no significant clinical progress made or expected in a less intensive level of care.

(i) The program can be reasonably expected to improve the recipient's symptoms, condition, or functional level sufficient to permit transition to a less intensive level of care.

(j) The program description shall state the expected length of stay (LOS) which should not exceed one (1) academic year.

(k) The program description shall state the procedure for extending a recipient past the expected LOS and shall include the following continued stay criteria:

1. Goals and objectives specified on the treatment plan have not been substantially attained or new problems have emerged.

2. Further treatment can be reasonably expected to result in progress toward goals and objectives and/or continued stability.

3. Documented clinical judgment indicates that continued treatment cannot be provided in less intensive levels of care due to reasonable risk of relapse and/or hospitalization.

4. Documented clinical judgment indicates that an attempt to transition the recipient to a less intensive level of care is reasonably expected to result in the re-emergence of symptoms sufficient to meet admission criteria.

5. A qualified staff member approves extending the length of stay of a specified period of time not to exceed four (4) months per extension to achieve clearly articulated clinical objective.

(l) Discharge/transfer criteria shall include the following:

1. Treatment plan goals and objectives have been substantially attained and continued treatment can be provided in less intensive levels of care.

2. Recipient's degree of impairment, severity of symptoms, and level of functioning have improved enough or resume normal activities or to receive less intensive services.

3. Recipient's degree of impairment, severity of symptoms, and/or level of functioning necessitate admission to a more intensive level of care.

4. Recipient is unwilling or unable to participate in/benefit from the program due to severity of symptoms, functional impairment, behavioral problems, personal choice, or cognitive limitation despite repeated documented efforts to engage the recipient.

(m) Exclusionary criteria shall address the following:

1. The recipient's degree of impairment, severity of symptoms, and level of functioning require a more intensive level of care.

(n) The Child and Adolescent Day Treatment shall constitute active, intensive treatment that specifically addresses the presenting problems that necessitate admission. The daily schedule of services attended must be in each recipient's record, and recipient/staff interviews confirm that the required services are provided. Recipient records document an initial screening, an individualized treatment plan to include documentation of the recipient's participation in the program and the development of the treatment plan, and verify an active, intensive treatment program. Key service functions include, at a minimum, the following services:

1. Initial screening to evaluate the appropriateness of the recipient's participation in the program.

2. Development of an individualized program plan.

3. Individual, group, and family therapy.

4. Psychoeducational services.

5. Basic Living Skills.

6. Coping skills training closely related to presenting problems (e.g., stress management, assertiveness training, and problem solving).

7. Education services for children who are attending Day Treatment instead of a local school.

(o) The program coordinator must have a master's degree in a mental health related field and one (1) year of direct mental illness service experience, six (6) months of which must be in services for children and adolescents

(p) The overall staff present to recipient ratio cannot exceed one to ten (1:10). In a program that has only ten (10) recipients, there must be at least one (1) other staff member present during hours of operation.

(q) Programs with an educational component must be in operation five (5) days per week with a minimum of two (2) hours treatment/non-educational service per day. Programs that do not have an educational component must be in operation a minimum of three (3) days per week and have a minimum of three (3) hours of service each day with the exception of pre-school and after-school programs which must operate a minimum of two (2) hours per day.

(r) Recipient's records document that the recipient received at a minimum one (1) hour of group therapy per week and one (1) hour of individual or family therapy at least once a month. The minimum services may be met in more than one (1) session of less than one (1) hour each. The time requirements for pre-school day treatment are one (1) half hour of group therapy per week and one (1) half hour individual or family therapy at least once a month.

(s) There is documentation that group therapy size does not exceed ten (10) in each session.

(t) Recipient records document that group and individual therapy address clinical issues identified in the recipient's treatment plans.

(u) Extensions of length of stay clearly document:

1. Clinical reasons for extension.

2. Specify a period of time not to exceed four (4) months.

3. Specify clinical objectives to be achieved during the extension and are approved by a qualified staff member.

4. Recipient records indicate that extensions of length of stay are consistent with procedures for extending length of stay as stated in the program description.

(v) Child and Adolescent Day Treatment programs that children attend instead of a Local Educational Agency (LEA) must be registered with the Alabama State Department of Education. The program must agree to meet the minimum assurance statements and guidelines set forth by the Alabama State Department of Education.

(w) All Child and Adolescent Day Treatment Programs that serve school-age children with an educational component must provide an educational curriculum or document coordination with the Local Education Agency.

(x) Recipients who are deaf or limited English proficiency shall have effective communication access to these services provided by staff proficient in the recipient's preferred language or a qualified interpreter. Proficient in American Sign Language is defined as having at least an Intermediate Plus level on the Sign Language Proficiency Interview.

(y) Documentation that communication access has been provided for recipients who are deaf or who have limited English proficiency.

(aa) Programming will be modified to provide effective participation for all recipients who are deaf.

Notes

Ala. Admin. Code r. 580-2-20-.12

Adopted by Alabama Administrative Monthly Volume XLI, Issue No. 07, April 28, 2023, eff. 6/12/2023.

Author: Division of Mental Health and Substance Use Services, ADMH

Statutory Authority: Code of Alabama 1975, § 22-50-11

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