Ala. Admin. Code r. 580-9-44-.26 - Level III.7: Medically Monitored Intensive Residential Treatment Program for Adults

(1) Rule Compliance. In addition to compliance with the rules as specified in this chapter, each Level III.7 Medically Monitored Intensive Treatment Program for Adults shall comply with the rules as specified in the following chapters.

(a) Program Description. The entity shall develop, maintain and implement a written program description that defines its Level III.7 Medically Monitored Intensive Residential Treatment Program, as according to Rule 580-9-44-.13 and the following specifications:

1. Location. The entity shall specifically identify and describe the setting in which the Level III.7 Program shall be provided. Services may be provided in any facility that meets all applicable federal, state and local certification, licensure, building, life-safety, fire, health and zoning regulations including the DMH facility certification standards.

2. Admission Criteria: The entity shall develop, maintain and document implementation of written criteria for admission to its Level III.7 Program, in compliance with the requirements of Rule 580-9-44-.13(9) and the following specifications:

(i) The entity's admission criteria shall specify the target population for its Level III.7 Program which shall include, at a minimum, individuals:

(I) Whose assessed severity of illness warrants this level of care, including but not limited to, adults whose subacute biomedical and emotional, behavioral, or cognitive problems are so severe that they require medically monitored treatment, but do not need the full resources of an acute care general hospital.

(II) For whom treatment for identified problems has been rendered ineffective at less intensive levels of care.

(ii) The entity shall provide written documentation in individual case records that each client admitted to a Level III.7 Adult Program meets:

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

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

(iii) Co-occurring Disorders Program Specific Criteria. The entity shall provide written documentation in individual case records that each individual admitted to a Level III.7 Co-occurring Enhanced Treatment Program meets:

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

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

(iv) Women and Dependent Children Program Specific Criteria: The entity shall provide written documentation in individual case records that each client admitted to a Level III.7 Program for Women and Dependent Children:

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

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

(III) Is pregnant; or

(IV) Has care and custody of dependent children; or

(V) Has lost custody of dependent children and has the potential for family reunification.

3. Core Services: Each Level III.7 Medically Monitored Intensive Residential Program shall demonstrate the capacity to provide a basic regimen of treatment services appropriate to the client's developmental and cognitive levels and other assessed needs.

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

(I) Placement assessment.

(II) Individual counseling.

(III) Group counseling.

(IV) Family counseling.

(V) Psychoeducation.

(VI) Peer support.

(VII) Medical and somatic services.

(VIII) Daily living skills.

(IX) Medication management.

(X) Medication administration.

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

(XII) Transportation.

(XIII) Activity therapy.

(XIX) Case management:

I. Case planning.

II. Linkage.

III. Advocacy.

IV. Monitoring.

(ii) Medical Services. The entity shall implement procedures for the provision of medical services, as according to protocols established in compliance with Rule 580-9-44-.13(24).

(I) Pregnant clients who are not receiving routine prenatal care shall be seen by physician within two (2) weeks of admission.

(iii) Mental Health Services. The entity shall develop, maintain and document implementation of written policies and procedures to ensure that each client's mental health needs are identified through the assessment service process and access to appropriate care for these needs is provided concurrently with treatment for assessed substance related disorders.

(iv) Family Support. The entity shall initiate and document in the client record continuous efforts to involve the client's family and other natural supports in the treatment process.

(v) Co-occurring Disorders Program Specific Criteria: Each Level III.7 Co-occurring Disorders Medically Monitored Intensive Residential Treatment Program shall document the capacity to provide each of the core services and the following services:

(I) Mental health consultation.

(II) Crisis intervention services.

(III) Intensive case management.

(vi) Women and Dependent Children Program Specific Criteria: Each Level III.7 Women and Dependent Children Medically Monitored Intensive Residential Treatment Program shall document the capacity to provide each of the core services and the following services:

(I) Child sitting services.

(II) Developmental delay and prevention services.

(III) Parenting skills development.

(IV) Academic and vocational services.

(V) Financial resource development and planning.

(VI) Family planning services.

4. Therapeutic Component Implementation. The entity shall document the implementation of a planned regimen of professionally directed program activities for clients and their families. Evaluation, treatment and care shall be provided in an amount, frequency and intensity appropriate to each client's assessed needs and expressed desires for care.

(i) Service strategies for each Level III.7 Residential Program shall include, at a minimum:

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

(II) Clients shall have access to clinical services personnel twenty-four (24) hours a day, seven (7) days a week.

(III) Daily clinical services to improve the client's ability to structure and reorganize the tasks of daily living and recovery.

(IV) The provision of daily scheduled treatment and recovery support services and activities that shall, at a minimum, include those that address:

I. Implementation of individualized service plan strategies.

II. Development and application of recovery skills including relapse prevention.

III. Interpersonal choice/decision making skill development.

IV. Enhancement of the understanding of addiction.

V. Development of a social network supportive of recovery.

VI. Random drug screening.

VII. Health education.

VIII. Medication administration and monitoring.

IX. Promotion of successful involvement in regular productive daily activity, such as school or work.

X. Skill development to support productive daily activity and successful reintegration into the family and community.

XI. Supervised therapeutic recreational activities.

(ii) The entity shall actively promote and provide referrals and/or access to community support services.

(iii) All services shall be organized and provided according to evidence-based and best practice standards and guidelines.

5. Documentation: Each Level III.7 Medically Monitored Intensive Residential Program shall provide the following documentation in each client record:

(i) Individualized progress notes shall be recorded each day for each respective service provided.

6. Support Systems. Each Level III.7 Program shall develop, maintain and document implementation of written policies and procedures, which govern the process used to provide client access to support services on site or through consultation or referral, which shall minimally include:

(i) The availability of a physician or physician extender to assess each client in person within twenty-four (24) hours of admission and thereafter as medically necessary.

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

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

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

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

(vi) Indicated laboratory and toxicology testing.

(vii) Indicated medical procedures.

(viii) Medical treatment.

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

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

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

7. Program Personnel. Each Level III.7 Intensive Residential Program shall employ an adequate number of qualified individuals to provide personalized care for its clientele and to meet the program's goals and objectives.

(i) Nursing Personnel. MAS Registered Nurses or Licensed Practical Nurses shall be available for primary nursing care and observation twenty-four (24) hours a day.

(ii) Direct Care Personnel. All direct care personnel shall have the qualifications as a qualified paraprofessional to provide the specific services delineated in the entity's program description for this level of care.

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

(iv) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program's administrative functions.

(v) Every client in a Level III.7 Program shall be assigned to a specific primary counselor.

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

(vii) Co-occurring Disorders Program Specific Criteria.

(I) Each Level III.7 Co-occurring Enhanced Medically Monitored Intensity Residential Program shall be coordinated by a full-time member of the staff who has the minimum of a master's degree in a mental health related field and at least two (2) years supervised experience in a direct service area treating individuals who have co-occurring disorders.

(II) Each Level III.7 Co-occurring Enhanced Intensive Residential Program shall have access to psychiatric services led by a qualified psychiatrist or nurse practitioner that are fully capable of evaluating, diagnosing and prescribing medications to clients with co-occurring disorders. On-call psychiatric services shall be available twenty-four (24) hours a day, seven (7) days a week.

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

(IV) Treatment staff that provide therapy and ongoing clinical assessment services to individuals diagnosed with co-occurring disorders shall have, at a minimum,

I. A master's degree in a behavioral health related field with a minimum of two (2) years' work experience with individuals who have co-occurring disorders, mental health, or substance use disorders.

II. Specialized training to work with individuals who have co-occurring disorders.

(V) Direct Care Personnel. All other direct care personnel in a Level III.7 Co-occurring Enhanced Intensive Residential Program shall be qualified as a qualified paraprofessional to provide the specific services delineated in the entity's operational plan for this level of care.

(VI) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level III.7 Co-occurring Enhanced Residential Program as delineated in its operational plan.

(VII) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program's administrative functions.

(VIII) Every client in a Level III.7 Residential Program shall be assigned to a primary counselor.

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

(ix) Women and Dependent Children Program Specific Criteria.

(I) Direct Care Personnel. All direct care personnel shall be qualified as a qualified paraprofessional to provide the specific services delineated in the entity's operational plan for this level of care.

(II) Clinical Personnel. The entity shall maintain an adequate number of clinical personnel to sustain the Level III.7 Intensive Women and Dependent Children Residential Program as delineated in its operational plan.

(III) Administrative Support Personnel. The entity shall maintain an adequate number of support personnel to sustain the program's administrative functions.

(IV) Every client in a Level III.7 Women and Dependent Children Program shall be assigned to a primary counselor.

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

8. Training. The entity shall provide written documentation that all Level III.7 Program personnel satisfy the competency and training requirements as specified in Rule 580-9-44-.02(3).

9. Service Intensity:

(i) The entity shall document that the amount and frequency of Level III.7 Intensive Residential Treatment Services are established on the basis of the unique needs of each client served. To assist in addressing these needs the entity shall ensure the availability of no less than twenty (20) hours of structured services each week.

10. Length of Service: The entity shall provide written documentation that the duration of treatment in each Level III.7 Intensive Residential Program shall vary as determined by:

(i) The severity of the client's illness.

(ii) The client's ability to comprehend the information provided and use that information to implement treatment strategies and attain treatment goals.

(iii) The appearance of new problems that require another level of care; or

(iv) The availability of services at an assessed level of need, when a Level III.7 Residential Program has been utilized to provide interim services.

11. Service Availability: The entity shall provide written documentation describing the process utilized to establish hours of assessment and intake services at its Level III.7 Medically Monitored Intensive Residential Program. At a minimum, this process shall:

(i) Include consideration of the needs of the target population, including work, school and parenting responsibilities.

(ii) Include consideration of transportation accessibility.

(iii) Not be based solely on standard eight (8) to five (5), Monday through Friday office hours.

Notes

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

New Rule: Filed January 26, 2012; effective March 1, 2012. Amended by Alabama Administrative Monthly Volume XLI, Issue No. 04, January 31, 2023, eff. 3/17/2023.

Author: Substance Abuse Services Division

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