Ala. Admin. Code r. 580-2-20-.13 - MI Residential Services

The agency shall have a program description for MI Residential services/programs. Residential setting applies to settings that provide congregate living and dining to recipients. 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) Staffing pattern of the home consistent with staffing requirements for each type of residential program certified.

(2) Type of the program to include:

(a) The number of beds.

(b) Services to be provided.

(c) Serious mental illness (SMI) or serious emotionally disturbed (SED) population served.

(d) Age range.

(e) Expected length of stay.

(f) Expected outcomes.

(3) Staff qualifications consistent with requirements for each type of residential program certified.

(4) Service area for the program.

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

(a) Require the recipient's willingness to participate in daily structured activities.

(b) Require a principal psychiatric diagnosis.

(c) Require a setting that has staff on the premises twenty-four (24) hours/day when recipients are present and a combination of the following criteria, whose severity would preclude treatment in a less restrictive environment:

1. Impaired contact with reality manifested by hallucinations, delusions, or ideas of reference.

2. Withdrawal, regression, or confusion not warranting inpatient hospitalization.

3. Moderate to severe disabling depression.

4. Moderate to severe disabling anxiety.

5. Disabling somatic symptoms.

6. Poor medication compliance.

7. Inpatient care is not warranted.

8. Poor socialization skills.

9. Inappropriate attention-seeking behaviors.

10. Poor interpersonal skills.

11. Inadequate problem-solving skills.

(6) Discharge/transfer criteria and procedures.

(7) Exclusionary criteria must include the following:

(a) Primary diagnosis of the following:

1. "Z" Code.

2. Substance Use Disorder.

3. Autism Spectrum Disorder.

4. Developmental/Intellectual Disability.

5. Organic Mental Disorder.

6. Traumatic Brain Injury.

7. Primary physical disorder (serious illness requiring hospital care, nursing care, home health care, or impaired mobility that prohibits participation in program services).

(8) The program description should indicate that the following services, at a minimum, should be either provided in-house or arranged for by the residential staff, depending upon the needs of the individual recipient:

(a) Assistance in applying for benefits.

(b) Assistance in improving social and communication skills.

(c) Assistance with medication management.

(d) Assistance in the development of basic living skills (money management, laundering, meal preparation, shopping, transportation, house cleaning, personal hygiene, nutrition, and health and safety).

(e) Vocational services.

(f) Community orientation.

(g) Recreation and activities.

(h) Assistance in locating long term community placement in least restrictive setting.

(i) Transportation to and from necessary community services and supports.

(j) Education about psychiatric illness.

(k) Family support and education.

(l) The program description for a child/adolescent residential program must include a description of how the child/ adolescent shall continue to receive appropriate education while in the program.

(9) The program description addresses a procedure for referral to the appropriate resource (DHR, Probate Court, etc.) for those recipients who may need a legal guardian/lawful representative while residing in the program.

(10) Residential facilities shall demonstrate on-site staff coverage twenty-four (24) hours a day, seven (7) days per week as indicated by staff duty rosters.

(11) The personnel records of all residential staff have current certification for First Aid and CPR from an authorized certifying agency. Staff are trained prior to working alone with recipients.

(12) There is documentation that all residential staff who transport recipients have a current valid driver's license. The license shall be appropriate for the type of vehicle operated by the driver.

(13) The majority of residential staff of a residential program serving primarily recipients who are deaf shall hold at least Intermediate Plus level proficiency in American Sign Language as measured by the Sign Language Proficiency Interview (SLPI) with at least one proficient person per shift. Staff providing clinical services shall have an Advanced Plus fluency or use a qualified interpreter. Non-signing staff will engage in on-the-job training to learn American Sign Language.

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

(15) Residential programs shall provide or arrange access to a wide range of services. The following services, at a minimum, shall be either provided in-house or arranged for by the residential staff, depending upon the needs of the individual recipient:

(a) Assistance in applying for benefits.

(b) Assistance in improving social and communication skills.

(c) Assistance with medication management.

(d) Assistance in the development of basic living skills (money management, laundering, meal preparation, shopping, transportation, house cleaning, personal hygiene, nutrition, and health and safety).

(e) Vocational services.

(f) Community orientation.

(g) Recreation and activities.

(h) Assistance in locating long term community placement in least restrictive setting.

(i) Transportation to and from necessary community services and supports.

(j) Education about psychiatric illness.

(k) Family support and education.

(l) Monthly/weekly schedule of activities and recipient/ staff member interview confirm that the appropriate services are being accessed or provided to recipients of residential services.

(m) The recipients' records indicate that the required services are being provided.

(n) The recipients' records indicate that the provision of communication access for people who are deaf is consistent with programming offered by the home.

(16) There are policies and procedures designed to assure that meals are nutritious, offer a variety of foods, and reflect recipient preferences to the extent possible. Agency policies and procedures shall include, at a minimum, the following:

(a) Provide each recipient a variety of three (3) nutritious meals plus snacks per day seven (7) days per week as evidenced by weekly menus. (Exception: Recipients served a meal at another location).

(b) Assure that recipients who are involved in activities outside of the home during mealtimes get a meal.

(c) Provision of special diets based on recipient needs.

(17) There is a policy stating that staff shall not serve as the legal guardian for recipients of the residential facility.

(18) All filled prescriptions controlled by staff of residential facilities shall be stored in a locked cabinet or other substantially constructed storage area that precludes unauthorized entry. There shall be a written policy that medication cabinets be locked when not in use.

(19) There shall be a written policies and procedures regarding disposition of all medications in residential programs in accordance with ADMH Nurse Delegation Guidelines, Alabama Board of Pharmacy and Drug Enforcement Agency (DEA).

(20) There must be written procedures for handling the disruptive behavior of recipients. Staff shall be trained in these procedures. Such procedures shall include:

(a) Access to agency backup staff and appropriate community personnel.

(b) If incarceration is necessary, the following procedures are required, or documentation of why, in an individual case, they could not be implemented:

1. Face-to-face contact by a mental health professional either prior to or within two (2) hours of incarceration.

2. A staff member informs the jail/detention center of the recipient's medication and offer to bring medication to the jail/detention center.

3. Regular visits by a staff member during incarceration unless it is considered to be non-therapeutic or is not permitted by the jail/detention center and is so documented in the recipient's record.

4. If the recipient is on temporary visit status, the state hospital will be notified within twenty-four (24) hours.

5. The emergency contact will be notified within twenty-four (24) hours.

(21) There is a policy that recipients will not be discharged solely on the basis of one positive urine analysis showing the presence of alcohol, illegal drugs, or medication not prescribed.

(22) At the time of admission, the provider will secure a written agreement with the recipient, family member, lawful representative, placing agency, or significant other indicating who will be responsible for medical and dental expenses.

(23) All residential programs must demonstrate their recipient's accessibility to a local licensed hospital for the purpose of providing emergency hospital care.

(24) Residential programs will assist recipients in obtaining necessary medical care.

(25) First aid supplies in the type and quantity approved by a registered nurse or a pharmacist shall be kept in a readily accessible location for all shifts and will be restocked upon use.

(26) There shall be adequate room for private visits with relatives and friends, for small group activities, and for social events and recreational activities.

(27) In residential programs occupied by recipients who are deaf, an adaptive telecommunication device must be present in order to allow the recipient to make and receive telephone calls.

(28) Radios, televisions, books, current magazines and newspapers, games, etc. shall be available for recipients. In homes occupied by deaf recipients, televisions will have closed-caption turned on.

(29) In the case of death, the provider shall:

(a) Follow the most recent ADMH Incident Management Plan for all deaths.

(b) Follow all local, state and federal guidelines/laws regarding reporting deaths

(30) If the provider uses residential beds for respite services (also known as crisis respite), the following criteria shall be met:

(a) There are written admission, expected length of stay, and continued stay criteria.

(b) There is a written screening/referral protocol.

(c) Services provided and documented must be appropriate to meet the identified needs of each person admitted for crisis respite services.

(d) The beds must be in a certified residential program.

(31) The capacity of each type of residential program shall not exceed ten (10) except in cases where a waiver is recommended by the Associate Commissioner for Mental Health and Substance Abuse Services (MHSAS) and approved by the ADMH Commissioner based upon the presence of a compensating advantage to the residents in increased privacy and personal space. Programs in excess of a capacity of ten (10) and/or that have more than two (2) residents per bedroom that have been previously certified are eligible to continue to be certified at the existing capacity and bedroom occupancy at the existing location so long as compliance with all applicable administrative codes are maintained. If a previously certified program with a capacity greater than ten (10) and/or with more than two (2) residents per bedroom changes location, the new location cannot exceed a capacity of ten (10) and cannot have more than two (2) residents per bedroom unless a waiver of this administrative code, applied for in writing, is granted by the ADMH Commissioner.

(32) There shall be written program rules developed in accordance with the following principles:

(a) Be developed with documented active participation of recipients and staff.

(b) Promote individual responsibility and prohibit rules for staff convenience and rules based on one person's behavior.

(c) Be based on the Rights Protection and Advocacy guidelines for recipient rights and responsibilities.

(d) Address the following areas, at a minimum.

1. Visitation hours.

2. Sign in/out requirements.

3. Curfew.

4. Sexual contact on provider/facility property which respect recipient's dignity, privacy, and need for social interaction with others.

5. Supervised access to the kitchen for health and safety reasons.

6. Possession and consumption of legal and illegal substances.

7. Possession of weapons.

(e) Provide for resolution of disputes on an individual basis. When necessary, adjustments should be made to the treatment plan.

(f) Make clear the consequences when rules are not followed.

(g) Limit chores to those necessary to maintain personal and treatment areas and prohibit using recipients for other duties unless the recipient chooses to perform those duties and is compensated fairly.

(h) Application of the rules and consequences will be fair, consistent, and recognize extenuating circumstances.

(33) An Adult Small Capacity (3-bed) Residential Home shall meet the following criteria:

(a) The program coordinator shall have one of the following:

1. A bachelor's degree in a mental health service-related field with one (1) year experience in a direct mental health service-related field.

2. A bachelor's degree not in a mental health service-related field with two (2) years of experience in a direct mental health service-related field.

3. No degree or high school diploma/GED with three (3) years of experience working directly in a mental health residential setting(s).

(b) All staff shall receive initial training related to the special needs of the population served.

(c) The program has the following staffing pattern:

1. Day Shift - one (1) Program Coordinator (5 days per week) and one (1) Mental Health Worker (2 days per week).

2. Evening Shift - one (1) Mental Health Worker (7 days per week).

3. Night Shift - one (1) Mental Health Worker (7 days per week, awake).

(d) The program shall provide specialized services that are based on the admission criteria contained in the program description.

(34) An Adult Residential Care Home with Specialized Basic Services shall meet the following criteria:

(a) The program coordinator shall have one of the following:

1. A bachelor's degree in a mental health service-related field with one (1) year experience in a direct service-related field.

2. A bachelor's degree not in a mental health service-related field with two (2) years of experience in a direct mental health service-related field.

3. No degree or high school diploma/GED with three (3) years of experience working directly in a mental health residential setting(s).

(b) All staff shall receive initial training related to the special needs of the population served.

(c) The program shall provide specialized services that are based on the admission criteria contained in the program description.

(d) The program has the following staffing pattern for a four (4) to ten (10) bed home:

1. Day shift - one (1) Program Coordinator (5 days per week), and 1 Mental Health Worker (2 days per week).

2. Evening shift - one (1) Mental Health Worker (7 days per week).

3. Night shift - one (1) Mental Health Worker (7 days per week, awake).

(e) The program has the following staffing pattern for an eleven (11) to sixteen (16) bed home:

1. Day Shift - one (1) Program Coordinator (5 days/ week), 1 Mental Health Worker (7 days/week).

2. Evening Shift - one (1) Mental Health Worker (7 days/week).

3. Night Shift - one (1) Mental Health Worker (7 days/ week, awake).

(35) An Adult Residential Care Home with Specialized Behavioral Services shall meet the following criteria:

(a) The program coordinator shall have one of the following:

1. A bachelor's degree in a mental health service-related field with one (1) year experience in a direct mental health service-related field.

2. A bachelor's degree not in a mental health service-related field with two (2) years of experience in a direct mental health service-related field.

3. No degree or high school diploma/GED with three (3) years of experience working directly in a mental health residential setting(s).

(b) All staff shall receive initial training related to the special needs of the population served.

(c) The program shall provide specialized services that are based on the admission criteria contained in the program description.

(d) The program has the following staffing pattern for a four (4) to ten (10) bed home:

1. Day shift - 1 Program Coordinator (5 days per week), one (1) Mental Health Worker five (5) days per week, and two (2) Mental Health Worker (2 days per week).

2. Evening shift - two (2) Mental Health Workers (7 days per week).

3. Night shift - one (1) Mental Health Workers (7 days per week, awake).

(e) The program has the following staffing pattern for an eleven (11) to sixteen (16) bed home:

1. Day Shift - 1 Program Coordinator (5day/week), one (1) Mental Health Worker 5 days/week, and two (2) Mental Health Workers (2 days/week).

2. Evening Shift - two (2) Mental Health Workers (7days/week).

3. Night Shift - two (2) Mental Health Workers (7 days/ week, a minimum of one (1) awake).

(36) An Adult Residential Care Home with Specialized Medical Services shall meet the following criteria:

(a) The program coordinator shall be a registered nurse.

(b) All staff shall receive initial training related to the special needs of the population served.

(c) The program shall provide specialized services that are based on the admission criteria contained in the program description.

(d) The program has the following staffing pattern for a four (4) to ten (10) bed home:

1. Day shift - one (1) registered nurse (7 days per week), and one (1) Mental Health Worker (7 days per week).

2. Evening shift - one (1) licensed practical nurse and one (1) Mental Health Worker (7 days per week).

3. Night shift - one (1) licensed practical nurse and one (1) Mental Health Worker (both 7 days per week, both awake).

(e) The program has the following staffing pattern for an eleven (11) to sixteen (16) bed home:

1. Day Shift - one (1) Registered Nurse (7 days/week), two (2) Mental Health Worker (7days/week).

2. Evening Shift - one (1) Licensed Practical Nurse and two (2) Mental Health Workers (7 days/week).

3. Night Shift - one (1) Licensed Practical Nurse and one (1) Mental Health Worker (7 days/week, both awake).

(37) A Crisis Residential Unit (CRU) program shall meet the following criteria:

(a) The program coordinator shall have a master's degree in a mental health service-related field and one (1) year post master's experience in a direct mental health service-related or be a registered nurse with one (1) year in a mental health service-related field.

(b) The program shall provide specialized services that are based on the admission criteria contained in the program description.

(c) All staff shall receive initial training related to the special needs of the population served.

(d) A psychiatrist, a certified registered nurse practioner (CRNP) or physician assistant (PA) shall make rounds at a minimum of two (2) non-consecutive days per week and shall be on call seven (7) days per week.

(e) The expected length of stay is based on an ADMH approved program description, not to exceed six (6) to twelve (12) months. Extensions of LOS clearly document reasons consistent with the continued stay criteria, specify a period of time not to exceed three (3) months, specify clinical objectives to be achieved during the extension, and are approved by a qualified staff member.

(f) Intensive Case Management shall be available within the organization to facilitate discharge planning and diversion from hospitalization in a state hospital.

(g) The program has the following staffing pattern for a maximum of ten (10) beds or less:

1. Day shift - .10 psychiatrist/CRNP/PA, 1 MA (5 days per week), 1 RN or LPN (7 days per week), one (1) Mental Health Worker (7 days per week), where the MA position or the RN may be the program coordinator.

2. Evening shift -one (1) RN or LPN (7 days per week) and 1 Mental Health Worker (7 days per week).

3. Night shift - one (1) RN or LPN and 1 Mental Health Worker (both 7 days per week).

(h) The program has the following staffing pattern for eleven (11) to sixteen (16) beds:

1. Day Shift - .15 psychiatrist/CRNP/PA (includes on-call time), one (1) MA (5 days/week), one (1) RN or LPN (7 days/week), one (1) BA, CPS-Adult, or Mental Health Worker (7 days/week), and one (1) Mental Health Worker (7 days/week) where either the MA position or the RN may be the program coordinator.

2. Evening Shift - one (1) RN or LPN and two (2) Mental Health Workers (7 days/week).

3. Night Shift - one (1) RN or LPN and two (2) Mental Health Workers (7 days/week, all awake).

(38) The Transitional Age Residential Care Program (age 17-25) shall meet the following criteria:

(a) The Program Coordinator shall have either a bachelor's degree in a mental health service-related field or be a Registered Nurse. The Program Coordinator shall have at least one (1) year post-degree direct service experience with adolescents/youth.

(b) Recipients shall continue to receive educational services while in the residential program, if deemed appropriate based upon an assessment of educational needs and age. School-age recipients shall receive the required educational elements as outlined by the Alabama State Department of Education, unless modified by an Individual Education Program (IEP). If the educational program is provided by the residential program, it must be registered with the Alabama State Department of Education. If the program is receiving special education funds, the program must agree to meet the minimum assurance statements set forth by the Alabama State Department of Education.

(c) The recipient's IEP shall be followed and updated as needed while in residential care, including providing access to special needs services. The recipient and/or lawful representative shall be informed of any meeting regarding an update or alteration in the recipient's IEP.

(d) All staff shall receive initial training (before working alone with recipients) and 20 hours of annual training related to the target population with 2 of those hours involving the perspective of families and recipients with regard to residential treatment.

(e) The program shall provide specialized services that are based on the essential service components and the admission criteria contained in the program description. Custody must be verified through the admission process, if applicable.

(f) The frequency and intensity of treatment interventions must be specified in the individual treatment plans. Individual service elements must meet the applicable criteria in the Outpatient Service standards.

(g) The treatment plans are consistent with the admission criteria.

(h) The recipients shall receive at least one (1) hour of individual therapy and one (1) hour of group therapy each week. There is documentation that there are no more than 10 recipients in each group therapy session.

(i) The clinical backgrounds of the recipients should be considered when room assignments are made.

(j) Within ninety (90) to one hundred-eighty (180) days prior to discharge the residential facility will begin coordinating recommended transitional services.

(k) Within fourteen (14) days prior to discharge, with the permission of the recipient and/or lawful representative/ legal guardian, the program shall set up appointments for the recipient for all recommended follow-up services.

(l) Upon discharge, the recipient and/or lawful representative/legal guardian will be given a list of all medications given during the residential stay and an explanation for why they were prescribed and the reason for discontinuation, if applicable.

(m) The program has the following staffing pattern for sixteen (16) beds:

1. Day Shift - one (1) Program Coordinator (5 days per week), 1 BA Care Coordinator/Case Manager (7 days per week), and 1 Mental Health Worker (7 days per week).

2. Evening Shift - two (2) Mental Health Workers (7 days per week).

3. Night Shift - two (2) Mental Health Workers (7 days per week with at least one (1) awake)

(n) Admissions will be drawn primarily from persons referred from state psychiatric hospitals.

(39) A Child/Adolescent Residential program must meet the following criteria:

(a) The program coordinator shall have a master's degree in a mental health service-related field and shall have at least two (2) years post master's experience in a direct service functional area. One of the two years post master's experience must be with children/adolescents.

(b) Children/adolescents shall continue to receive an appropriate education while in the residential program. Children and adolescents shall receive the required educational elements as outlined by the Alabama State Department of Education, modified by an Individual Education Program (IEP). If the educational program is provided by the residential program, it must be registered with the Alabama State Department of Education. If the program is receiving special education funds, the program must agree to meet the minimum assurance statements set forth by the Alabama State Department of Education.

(c) Staffing pattern shall be outlined in the program description and approved by ADMH. The staffing pattern shall reflect the number of children/adolescents being served, staff to recipient ratio, and the acuity of the treatment needs of those being served.

(d) All staff shall receive initial (before working alone with recipients) and twenty (20) hours of annual training related to the target population with two (2) of those twenty (20) hours involving the perspective of families and recipients with regard to residential treatment.

(e) The frequency and intensity of treatment interventions shall be specified in the individual treatment plans. Individual service elements shall meet the applicable criteria in the Outpatient Service standards.

(f) The treatment plans are consistent with the admission criteria.

(g) The child/adolescent shall be assessed for special education services. Once assessed, if the child/adolescent is determined to qualify for Special Education services, an Individualized Education Plan (IEP) is developed, and a copy is placed in the clinical record.

(h) If a child/adolescent has an IEP, it shall be followed while in residential care including any updates. The lawful representative/legal guardian shall be informed of any meeting regarding an update or alteration in the child/ adolescent's IEP.

(i) Children/adolescents shall receive at least one (1) hour of individual therapy and one (1) hour of group therapy each week. There is documentation that there are no more than ten (10) recipients in each group therapy session.

(j) The clinical backgrounds of the children and adolescents shall be considered when room assignments are made.

(k) Within ninety (90) to one hundred-eighty (180) prior to discharge, the residential facility will begin coordinating recommended transitional services.

(l) Within fourteen (14) days prior to discharge, with the permission of the lawful representative/legal guardian, the facility will set up appointments for the child/adolescent for all recommended follow-up services.

(m) Upon discharge, the lawful representative/legal guardian will be given a list of all medications given during the residential stay and an explanation for why they were prescribed and the reason for discontinuation, if applicable.

(40) A Medication/Observation/Meals (MOM) program is exempt from the following general residential standards in this section (5) (a), (15) (l) and (m), (16) (a) (b) (c), (18), (28), (31), and (32) (a-H), and must meet the following criteria:

(a) The program coordinator shall have one of the following:

1. A bachelor's degree in a mental health service-related field with one (1) 2 year of experience in a direct mental health service-related field.

2. A bachelor's degree not in a mental health service-related field with two (2) years of experience in a direct mental health service-related field.

3. No degree or high school diploma/GED with three (3) years of experience working directly in a mental health residential setting(s).

(b) All staff shall receive initial related to the special needs of the population served.

(c) The program shall provide specialized services that are based on the admission criteria contained in the program description. The program description shall specifically address provisions for the following core services: meals, observation, and medication.

(d) Residents shall be provided choice to what degree, if any, they wish to participate in on-site activities.

(e) Outpatient Services such as psychiatry, nursing, and therapy services shall be delivered on-site or staff shall arrange services offsite, to include transportation as clinically appropriate.

(f) Living units shall be exclusively for the target population and shall be communally located with 24/7 on-site awake staff.

(g) The number of living units located at one site shall not exceed 30 unless approved by the Department of Mental Health.

(h) The program has the following staffing pattern for a twenty (20) bed location:

1. Day shift - 1 Program Coordinator (5 days per week), .10 full-time equivalent psychiatrist, .10 full-time equivalent MA therapist, and .10 full-time equivalent registered nurse, and 1 Mental Health Worker or Certified Peer Specialist- Adult (7 days per week).

2. Evening shift - 1 Mental Health Worker or Certified Peer Specialist - Adult (7 days per week).

3. Night Shift - 1 Mental Health Worker or Certified Peer Specialist - Adult (7 days per week, awake).

(i) The program has the following staffing pattern for a twenty-one (21) to thirty (30) bed per location:

1. Day shift - one (1) Program Coordinator (5 days per week),.10 full-time equivalent psychiatrist, .10 full-time equivalent MA therapist, and .10 full-time equivalent registered nurse, one (1) Mental Health Workers or Certified Peer Specialist- Adult (7 days per week) and one (1) Mental Health Worker or Certified Peer Specialist - Adult (2 days per week).

2. Evening shift - two (2) Mental Health Workers or Certified Peer Specialist - Adult (7 days per week).

3. Night Shift - 2 Mental Health Workers or Certified Peer Specialist - Adult (7 days per week, awake).

Notes

Ala. Admin. Code r. 580-2-20-.13

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