Ala. Admin. Code r. 580-9-44-.21 - Level III.1: Clinically Managed Low Intensity Residential Treatment Program

(1) Rule Compliance. In addition to compliance with the rules as specified in this chapter, each Level III.1 Clinically Managed Low Intensity Residential Treatment Program shall comply with the rules as specified in the following chapters.

(a) Program Description. The entity shall develop, maintain and implement a written program description that defines the Level III.1 Clinically Managed Low Intensity Residential Treatment Program it provides, as according to Rule 580-9-44-.13 and the following specifications:

1. Location. The entity shall specifically identify and describe the setting in which the Level III.1 Program shall be provided. Services shall be provided in any facility that meets all applicable federal, state and local certification, licensure, building, life-safety, fire, health and zoning regulations including the DMH facility certification standards.

2. Admission Criteria: The entity shall develop, maintain and document implementation of written criteria for admission to its Level III.1 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.1 Services, which shall include, at a minimum, individuals:

(I) Whose assessed severity of illness warrants this level of care including, but not limited to:

I. Individuals who have a need for structure and support in a twenty-four (24) hour drug-free environment in order to:

A. Engage in treatment.

B. Sustain participation in regular productive, daily activities or current treatment for physical or mental disorders.

C. Develop, integrate and practice recovery and coping skills.

D. Continue treatment for a substance use disorder as a step-down from a more intense level of care.

(ii) The entity shall provide written documentation in individual case records that each client admitted to a Level III.1 Program meets:

(I) The diagnostic criteria for a substance use 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) Adolescent Program Specific Criteria: The entity shall provide written documentation in individual case records that each adolescent admitted to a Level III.1 Program meets:

(I) The diagnostic criteria for a substance use disorder as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders.

(II) The adolescent dimensional criteria for admission to this level of care as defined in the most recent edition of the ASAM PPC-2R.

(iv) Co-occurring Disorders Program Specific Criteria: The entity shall provide written documentation in individual case records that each individual admitted to a Level III.1 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.

(v) 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.1 Program for Women and Dependent Children:

(I) Meets the diagnostic criteria for a substance dependence disorder as defined in the most recent edition Diagnostic and Statistical Manual for Mental Disorders; and

(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.1 Low Intensity Residential Program shall demonstrate the capacity to provide a basic level of treatment services appropriate to the needs of its clientele.

(i) At a minimum, the entity shall demonstrate and document its capacity to provide a twenty-four (24) hour structured residential treatment environment with the following core services:

(I) Placement assessment.

(II) Individual counseling.

(III) Group counseling.

(IV) Family counseling.

(V) Psychoeducation.

(VI) Peer support.

(VII) Daily living skills.

(VIII) Medication management.

(IX) Alcohol and/or drug screening/testing.

(X) Transportation.

(XI) Case management:

I. Case planning.

II. Linkage.

III. Advocacy.

IV. Monitoring.

(ii) Medical Services. Medical services, including a physical examination, shall be provided as specified by the entity's medical protocols established as required by Rule 580-9-44-.13(24).

(iii) Adolescent Program Specific Criteria: Each Level III.1 Adolescent Low Intensity Residential Treatment Program shall document the capacity to provide each of the core services and the following services:

(I) Activity therapy.

(II) Academic or vocational services.

(iv) Co-occurring Disorders Program Specific Criteria: Each Level III.1 Co-occurring Disorders Low Intensity Residential Treatment Program shall document the capacity to provide each of the core services and the following services:

(I) Basic living skills.

(II) Crisis intervention services.

(III) Activity therapy.

(IV) Intensive case management.

(v) Women and Dependent Children Program Specific Criteria: Each Level III.1 Women and Dependent Children Low Intensity Residential Treatment Program shall document the capacity to provide each of the core services and the following services:

(I) Transportation.

(II) Child sitting services.

(III) Developmental delay and prevention services.

(IV) Activity therapy.

(V) Parenting skills development.

4. Therapeutic Component Implementation. The entity shall document implementation of regularly scheduled treatment sessions that are provided in an amount, frequency and intensity appropriate to the client's assessed needs and expressed desires for care.

(i) Service strategies for each Level III.1 Residential Program shall include, at a minimum:

(I) Maintenance of an alcohol and illicit drug-free residential environment.

(II) Implementation of individualized counseling plan strategies.

(III) On duty, awake staff shall provide supervision of client's health, welfare and safety twenty-four (24) hours a day.

(IV) All clients enrolled in Level III.1 Programs shall have access to clinical services twenty-four (24) hours a day, seven (7) days a week.

(V) The entity shall document the provision of planned counseling and recovery support services and activities that shall, at a minimum, include:

I. Motivational and engagement strategies.

II. Relapse prevention.

III. Interpersonal choice/decision making skill development.

IV. Development of a social network supportive of recovery.

V. Daily living and recovery skills development.

VI. Random drug screening.

VII. Health education.

VIII. Medication management and administration.

(ii) Adolescent Program Specific Criteria: Each Level III. 1 Adolescent Low Intensity Residential Treatment Program shall document the capacity to provide the service strategies and the following therapeutic components:

(I) Client education on key adolescent development issues, including but not limited to, adolescent brain development and the impact of substance use, emotional and social influence on behavior, value system development, puberty/physical development, sexuality and self-esteem.

(II) Recreation and leisure time skills training.

(III) Gender specific treatment.

(IV) Family, community and school reintegration services.

(V) Academic or vocational services.

(iii) Co-occurring Disorders Program Specific Criteria: Each Level III.1 Co-occurring Disorders Low Intensity Residential Program shall document the capacity to provide the service strategies and the following therapeutic components:

(I) Groups and classes that address the signs and symptoms of mental health and substance use disorders.

(II) Groups, classes and training to assist clients in becoming aware of cues or triggers that enhance the likelihood of alcohol and drug use or psychiatric decompensation and to aid in development of alternative coping responses to those cues.

(III) Dual recovery groups that provide a forum for discussion of the interactions of and interrelations between substance use and mental health disorders.

(IV) Intensive case management.

(iv) Women and Dependent Children Program Specific Criteria: Each Level III.1 Low Intensity Residential Treatment Women and Dependent Children Program shall document the capacity to provide the service strategies and the following therapeutic components:

(I) Gender specific services which address issues of relationships, parenting, abuse and trauma.

(II) Primary medical care including prenatal care.

(III) Primary pediatric care for children.

(IV) Therapeutic interventions for children which address their developmental needs and issues of sexual abuse and neglect.

(V) Outreach to inform pregnant women of the services and priorities.

(VI) Interim services while awaiting admission to this level of care.

(VII) Recreation and leisure time skills training.

(VIII) Academic or vocational services.

(IX) Financial resource development and planning.

(X) Family planning services.

5. Documentation: Each Level III.1 Intensive Outpatient Program shall provide the following documentation in each client record:

(i) Individualized progress notes shall be recorded each day for each respective service provided in Level III.1 Services.

6. Support Systems. Each Level III.1 Program shall develop, maintain and document implementation of written policies and procedures which govern the process used to provide client access to support services on site, or through consultation or referral, which shall minimally include:

(i) Telephone or in person consultation with a physician available twenty-four (24) hours a day, seven (7) days a week.

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

(iii) Direct affiliation with, or coordination through referral to more and less intensive levels of care.

(iv) Direct affiliation with, or coordination through referral to supportive services, including vocational rehabilitation, literacy training and adult education.

(v) Mutual self-help groups which are tailored to the needs of the specific client population.

7. Program Personnel. Each level III.1 Low 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) Program Coordinator. Each Level III.1 Low Intensity Residential Treatment Program shall have a full-time program coordinator or manager who shall have a minimum of three (3) years' work experience in a direct service area treating clients with substance use or co-occurring mental health and substance use disorders, plus other qualifications and credentials as designated in writing by the governing authority.

(ii) Direct Care Personnel. All direct care personnel shall have the qualifications as specified 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.1 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.1 program shall be assigned to a specific primary counselor for care management.

(vi) Each primary counselor shall maintain a case load not to exceed fifteen (15) clients with active cases at any one time.

(vii) Adolescent 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.1 Low Intensity 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.1 Adolescent Low Intensity Residential Treatment Program shall be assigned to a specific primary counselor for care management.

(V) Each primary counselor shall maintain a case load not to exceed fifteen (15) clients with active cases at any one time.

(viii) Co-occurring Disorders Program Specific Criteria.

(I) Each Level III.1 Co-occurring Enhanced Low 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.

(II) The treatment organization/agency shall have access to an Alabama licensed physician, full time, part time, or on contract, who shall be available to the program for client care and shall assume liability for the medical aspects of the program.

(III) 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.1 Co-occurring Enhanced Low Intensity 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.1 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.1 Residential Program shall be assigned to a specific primary counselor for care management.

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

(viii) 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.1 Low 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.1 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.1 Program personnel satisfy the competency and training requirements as specified in Rule 580-9-44-.02(3).

9. Service Intensity: The entity shall document that the amount and frequency of Level III.1 Low 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 five (5) 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.1 Low 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.1 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 screening, assessment and intake service, and counseling services at its Level III.1 Low 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-.21

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.