Ala. Admin. Code r. 580-9-44-.22

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

Section 580-9-44-.22 - Level III.2-D: Clinically Managed Residential Detoxification

(1) Rule Compliance. In addition to compliance with the rules as specified in this chapter, each Level III.2-D Clinically Managed Residential Detoxification 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 its Level III.2-D 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.2-D Program is 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.2-D 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 III.2-D Program, which shall include, at a minimum, individuals who:

(I) Are experiencing signs and symptoms of withdrawal, or there is evidence based on history of substance intake, age, gender, previous withdrawal history, present symptoms, physical condition and/or emotional behavioral or cognitive condition that withdrawal syndrome is imminent.

(II) Assessed as not being at risk of severe withdrawal syndrome and moderate withdrawal is safely manageable at this level.

(III) Have a history of insufficient skills and supports to complete detoxification at a less intense level of care.

(ii) The entity shall provide written documentation in individual case records that each client admitted to receive Level III.2-D services meets:

(I) The diagnostic criteria for Substance Induced 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 ASAM PPC-2R.

3. Core Services: At a minimum, the Level III.2-D 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) Peer support.

(vii) Medical and somatic services.

(viii) Medication administration.

(ix) Medication monitoring.

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

(xi) 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 III.2-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 III.2-D 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 duty awake staff shall provide supervision for each client's health, welfare and safety twenty-four (24) hours a day, seven (7) days a week.

(iv) On-site physician care and phone availability twenty-four (24) hours a day, seven (7) days a week.

(v) Credentialed personnel who are trained and competent to implement physician approved protocols for client observation and supervision, determination of appropriate level of care and facilitation of the client's transitioning to continuing care.

(vi) Services designed explicitly to safely detoxify clients without the need for ready on-site access to medical and nursing personnel.

(vii) Medical evaluation and consultation available twenty-four (24) hours a day in accordance with practice guidelines.

(viii) Clinicians who assess and treat clients are able to obtain and interpret information regarding the needs of the client to include the signs and symptoms of alcohol and other drug intoxification and withdrawal, as well as, the appropriate treatment and monitoring of these conditions.

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

(x) Continuous assessment.

(xi) Planned counseling and other therapeutic interventions.

(xii) Motivational enhancement therapy.

(xiii) Direct affiliation with other levels of care.

5. Documentation: Level III.2-D Programs shall provide the following clinical record documentation:

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

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

(iii) Monitoring of vital signs, at a minimum, every eight (8) hours until discharge.

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

6. Support Systems: The Level III.2-D 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 availability to:

(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 emergency medical services.

7. Staff Requirements.

(i) Medical Director. The Level III.2-D 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 III.2-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) There shall be a Registered Nurse (RN) or Licensed Practical Nurse (LPN) on site during all hours of the Level III.2-D Program's operation.

(iv) 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.

(v) The entity shall maintain an adequate number of personnel, including physicians, nurses, counselors and case managers to sustain the Level III.2-D Program as delineated in its operational plan.

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

8. Training: The entity shall provide written documentation that:

(i) All Level III.2-D Program personnel satisfy the requirements of the core training curriculum, as specified in Rule 580-9-44-.02(3).

(ii) All clinical and medical services staff in a Level III.2-D Program shall receive training during the initial twelve (12) months employment and develop basic competencies in the following areas:

(I) Biopsychosocial dimensions of alcohol and other drug dependence, including:

I. The signs and symptoms of alcohol and other drug intoxication and withdrawal.

II. Evidence-based treatment and monitoring strategies for alcohol and other drug intoxication and withdrawal.

III. Continuing care motivational and engagement strategies.

(II) Pharmacotherapy.

(III) ASAM Patient Placement Criteria.

(IV) Assessment of and service planning to address biopsychosocial needs.

9. Service Intensity: The entity shall document in the clinical record that the intensity of Level III.2-D Services is 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 III.2-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.

Ala. Admin. Code r. 580-9-44-.22

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.