Ala. Admin. Code r. 580-9-44-.19

Current through Register Vol. 43, No. 1, October 31, 2024

Section 580-9-44-.19 - Level II-D: Ambulatory Detoxification With Extended On-site Monitoring

(1) Rule Compliance. Each Level II-D Ambulatory Detoxification Program shall comply with the following rules and the rules specified in this chapter.

(a) Program Description. The entity shall develop, maintain and implement a written program description that defines the Level II-D Ambulatory Detoxification 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 Level II-D Ambulatory Detoxification with Extended On-Site Monitoring services shall be provided. Services may be provided in any appropriate setting that protects the client's right to privacy, confidentiality, safety and meets the DMH facility certification standards.

2. Admission Criteria: The entity shall develop, maintain and document implementation of written criteria for admission to its Level II-D Ambulatory Detoxification With Extended On-Site Monitoring 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 the Level II-D program, which shall include, at a minimum, individuals who:

(I) Have been assessed as being at moderate risk of severe withdrawal syndrome outside of the program setting.

(II) Are free of severe, unstabilized physical and psychiatric complications.

(III) Who do not have adequate family or other service systems in place to support an outpatient detoxification process.

(ii) The entity shall provide written documentation in individual case records that each client admitted to receive Level II-D Ambulatory Detoxification with Extended On-Site Monitoring Services meets:

(I) The diagnostic criteria for Substance Induced Disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders.

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

3. Core Services: Each Level II-D Ambulatory Detoxification Program shall demonstrate the capacity to provide a basic level of skilled treatment services appropriate to the needs of its clientele.

(i) At a minimum, the Level II-D Ambulatory Detoxification Program shall document the capacity to provide the following core services:

(I) Placement assessment.

(II) Individual counseling.

(III) Group counseling.

(IV) Psychoeducation.

(V) Family counseling.

(VI) Medical and somatic services.

(VII) Medication administration.

(VIII) Medication monitoring.

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

(X) Case management:

I. Case planning.

II. Linkage.

III. Advocacy.

IV. Monitoring.

4. Therapeutic Component Implementation: The entity shall document implementation of medical and other clinical services organized to enhance the client's understanding of addiction, support completion of the detoxification process and initiate transfer to an appropriate level of care for continued treatment. The entity's Level II-D program shall, at a minimum, consist of the following components:

(i) Completion of a comprehensive medical history and physical examination of the client at admission.

(ii) Protocols and/or standing orders, established by the entity's medical director, for management of detoxification from each major drug category of abused drugs that are consistent with guidelines published by nationally recognized organizations (e.g., SAMHSA, ASAM, American Academy of Addiction Psychology).

(I) Level II-D Ambulatory Detoxification Programs that utilize benzodiazepines in the detoxification protocol:

I. Shall have written protocols and procedures to show that all doses or amounts of benzodiazepines are carefully monitored and are slowly reduced as appropriate.

II. Shall have written longer-term detoxification protocols and procedures that adhere to general principles of management including clear indications of benzodiazepine dependence, clear intermediate treatment goals and strategies, regular review and methods to prevent diversion from the plan.

(iii) On-site physician and/or nurse monitoring, assessment and management of signs and symptoms of intoxication and withdrawal.

(iv) Medication administration and monitoring services including specific procedures for pregnant women.

(v) Ongoing Intake Interview Examination.

(vi) Direct affiliation with other levels of care.

5. Documentation: Level II-D Ambulatory Detoxification Programs shall provide the following:

(i) Documentation of each clinical/therapeutic intervention provided.

(ii) Daily assessment of progress including response to medication, which also notes any treatment changes.

(iii) Monitoring of vital signs each day the client is on site.

(iv) The use of detoxification rating scale tables and flow sheets.

(v) Physician review of all services.

6. Support Systems. The Level II-D Ambulatory Detoxification Program shall develop, maintain and document implementation of written policies and procedures utilized to provide client access to support services on site, or through consultation or referral, which shall minimally include:

(i) Specialized clinical consultation for biomedical, emotional, behavioral and cognitive problems.

(ii) Appropriate laboratory and toxicology testing.

(iii) Psychological and psychiatric services.

(iv) Transportation.

(v) Twenty-four (24) hour access to emergency medical services.

7. Program Personnel: Each Level II-D Ambulatory Detoxification 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) Medical Director: The Level II-D Detoxification Program shall have a medical director who is a physician licensed to practice in the state of Alabama, with a minimum of one (1) year experience treating persons with substance induced disorders. The medical director shall be responsible for admission, diagnosis, medication management and client care.

(ii) Nursing Services Director: The Level II-D Program shall have a nursing services director who shall be a Registered Nurse licensed according to Alabama law, with training and work experience in behavioral health.

(iii) Nursing Personnel: The entity shall have an adequate number of Alabama licensed nurses to assure that the administration of medications during Level I-D services complies with applicable state and federal regulations.

(I) There shall be a Registered Nurse or Licensed Practical Nurse on site during all hours of the Level II-D Program's operation.

(v) Clinical staff providing services shall have access to a full-time clinical director.

(vi) 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.

(vii) The entity shall maintain an adequate number of physicians, nurses, counselors and case managers to sustain the Level II-D Ambulatory Detoxification Outpatient Program as delineated in its program operational procedures.

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

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

9. Service Intensity. The entity shall document in the clinical record that Level II-D Services are provided in regularly scheduled sessions and that:

(i) The entity has the demonstrated capacity to provide a structured program of clinical services for a minimum of nine (9) hours per week.

(ii) The frequency and amount of Level II-D Services are established on the basis of the unique needs of each client served.

10. Length of Service. The entity shall provide written documentation in the clinical record that the duration of treatment in a Level II-D Program varies as determined by the client's assessed needs and that the client continues in treatment until:

(i) Withdrawal signs and symptoms are sufficiently resolved; or

(ii) Withdrawal signs and symptoms have failed to respond to treatment and have intensified warranting a transfer to a more intense level of care; or

(iii) The client is, otherwise, unable to complete detoxification at this level of care.

11. Service Availability: The entity shall provide written documentation describing the process utilized to establish the hours of service availability for its Level II-D 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.

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

Ala. Admin. Code r. 580-9-44-.19

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.