New Mental Health Standards

580-9-40 ORGANIZATIONAL GOVERNANCE AND MANAGEMENT

580-9-40.01 GOVERNING AUTHORITY

(1) OPERATIONAL AUTHORITY. The service provider shall be a legally constituted entity and shall maintain current written evidence of its source of authority to operate and to provide the services for which certification is requested. This evidence shall consist of:

(a) Articles of Incorporation;

(b) A corporate charter;

(c) A partnership agreement;

(d) Executive Order of the Governor;

(e) Act of the Legislature;

(f) A statement of sole proprietorship; or

(g) Other documentation that establishes the provider as a legal Alabama entity.

(2) GOVERNING AUTHORITY DESIGNATION. There shall be written documentation of the entity’s designation of a Governing Authority that shall have ultimate managerial control and legal responsibility for all program operations, which includes at a minimum, the following specifications:

(a) The Governing authority shall be distinct in composition and function from its operating and administrative staff.

(b) When an entity is organized as a for-profit or not-for-profit corporation, partnership, or association, the governing authority shall be a formal board of directors.

(c) When an entity’s organizational structure designates an individual as the governing authority, there shall be written documentation of the existence and operation of an organized advisory board which, at a minimum, shall:

1. Provide advice to the governing authority.

2. Establish and document implementation of written bylaws.

3. Reflect the diversity of the community and the clientele served by the agency.

4. Meet on a regular basis.

5. Maintain written records of meetings.

(3) DUTIES OF THE GOVERNING AUTHORITY. The entity shall provide written documentation of all responsibilities of the governing authority and shall maintain written evidence of implementation of these duties, which at a minimum shall include:

(a) Ensure compliance with all applicable federal, state, and local laws and regulatory requirements;

(b) Establish the entity’s mission, goals, and objectives;

(c) Establish and monitor controls to ensure the appropriateness, adequacy, and quality of services provided by the entity.

(d) Secure adequate resources to operate on a fiscally sound basis and to accomplish the goals and objectives of the organization, including

1. Ensure that the agency is adequately funded to provide the certified services;

2. Provide physical facilities, staff, equipment, supplies, and other needs adequate and sufficient to provide the certified services;

3. Review and approve the entity’s annual budget;

4. Insure that the agency maintains adequate insurance coverage to protect its resources.

(e) Maintain a qualified executive director to manage the day-to-day affairs of the agency, including

1. Establish the qualifications of the executive director in accordance with the mission of the agency.

2. Specify the duties and authority of the executive director.

3. Recruit, hire, and perform annual evaluations of the executive director’s job performance.

(f) Establish processes to engage and obtain ongoing input from all stakeholders, including personnel, current and former program participants, and community representatives for the purpose of identifying needs, enhancing services, and improving outcomes.

(g) Maintain accessibility to personnel, program participants, and the community served.

(h) Review and approve all contracts.

(i) Routinely evaluate the efficiency and effectiveness of the organization and make recommendations for modifications as deemed necessary or beneficial based on the evaluation.

(j) Ensure governing authority participation in the entity’s DMH certification review process.

(k) Provide immediate notification to DMH of changes of the agency’s executive director.

(l) Meet as the board of directors or with the governing body’s advisory committee, in accordance with the entity’s organizational structure, no less than on a quarterly basis.

(m) Ensure the development, maintenance, and implementation of a Polices and Procedures Manual as specified in ??????

(n) Review and approve written administrative, personnel, and clinical policies and procedures as specified by these rules.

(4) BYLAWS. The governing authority shall develop and adopt written bylaws and/or policies that shall minimally:

(a) Delineate the powers and duties of:

1. The board of directors;

2. Governing authority committees and task groups;

3. Advisory groups to the governing authority; and

4. The entity’s executive director.

(b) Describe membership requirements, terms of appointment, and attendance requirements;

(c) Define the process of election or appointment of officers, and terms of office;

(d) Establish meeting frequency;

(e) Establish the quorum necessary to transact business.

(f) Define conflict of interest and establish procedures to address such.

(5) MEMBERSHIP. The membership of the board of directors, advisory board to the governing body, and related committees shall be inclusive of persons who:

(a) Represent the geographic regions served by the organization;

(b) Reflect the diversity of the geographic region served by the organization;

(c) Are persons who are consumers of the types of services provided by the entity; and

(d) Are family members of consumers of the types of services provided by the entity.

(6) CONSUMER ADVISORY COMMITTEE. The governing authority shall establish the organizational structure for, support, and maintain an active consumer advisory committee that shall function to inform and assist the entity’s efforts to appropriately address the needs of individuals and communities served. This committee shall minimally:

(a) Participate in an orientation and training process established by the governing authority;

(b) Make recommendations to the governing authority as a result of systematic monitoring and review of the entity’s operational policies and procedures;

(c) Advocate for resources to address the needs of individuals and communities adversely impacted by substance use and addiction;

(d) Participate in the entity’s performance improvement processes;

(e) Incorporate a process to obtain feedback from active clients and their families relative to, at a minimum, timeliness, appropriateness, and effectiveness of services provided by the agency.

(f) Maintain formal meeting minutes and other records of its activities, and provide access to this information as directed by the governing authority.

(g) Consist of no less than ten members, all being former recipients of services for prevention, treatment, or care of substance related disorders, and:

1. Are representative of the entity’s target population; and

2. Who are not employed in an occupation relating to alcoholism or drug addiction.

(7) MINUTES. Minutes of all board of directors, advisory board, committee, and task group meeting shall be kept and shall:

(a) Minimally include:

1. Date of the meeting.

2. Meeting Location.

3. Names of persons in attendance.

4. Discussion summaries.

5. Decisions reached.

6. Actions taken.

7. Signature of the recorder and an authorized officer of the governing body.

(b) Be accessible for review by DMH upon request.

(c) Be made available upon request to personnel, program participants, families served, and the general public, subject to limitations imposed to protect confidentiality, privacy, and proprietary information.

(8) EXECUTIVE DIRECTOR. The governing body shall designate an individual to serve as the entity’s executive director.

(a) The executive director’s qualifications, authority, and responsibilities shall be:

1. Defined in writing;

2. Incorporated into the entity’s policy and procedures manual;

3. Incorporated into the bylaws of the governing authority, as appropriate to the entity’s organizational structure;

4. Incorporated into the executive director’s personnel record; and

5. Reviewed, updated as necessary, and reauthorized by the governing body, annually.

(b) The executive director shall demonstrate responsibility and authority for the following functions, at a minimum:

1. Management of the day-to-day operations of the entity’s facilities and programs as according to policies and procedures established by the governing body.

2. Compliance with laws, rules, regulations, standards, and policies relative to all aspects of the entity’s operations.

3. Planning, organizing, and directing activities as may be delegated by the Board of Directors.

4. Designating, in writing, an individual to act in the absence of the executive director.

(c) The executive director shall have access to all programs and premises under governance of the entity.

(9) PROGRAM PLANNING AND EVALUATION. The governing body shall develop and document implementation of a written strategic plan.

(a) The entity’s strategic plan shall, at a minimum:

1. Define the entity’s mission, goals, and objectives.

2. Incorporate a process for ongoing analysis of the substance abuse service needs of the population within the geographic area served, and for identification of accessible community resources to address those needs.

3. Demonstrate an understanding of the service needs of the population within the geographic area served.

4. Incorporate findings from the entity’s performance improvement system, as appropriate.

5. Incorporate results relative to previously established goals and strategies.

6. Include an evaluation process to assess progress toward goal attainment.

7. Be formally approved by the governing body.

8. Be reviewed and updated as necessary, but no less than annually.

(b) The entity shall prepare an annual year-end management report representative of strategic planning activities.

(c) The entity shall describe and document implementation of the process utilized for dissemination of the strategic plan and management report to key stakeholders, including but not limited to:

1. The governing authority.

2. The entity’s staff.

3. DMH.

4. The public.

10. PERFORMANCE IMPROVEMENT: The provider shall provide written documentation of the entity’s operation and maintenance of a Performance Improvement System.

(a) The Performance Improvement System shall be designed to:

1. Monitor and assess organizational processes and outcomes;

2. Correct and follow-up on identified organizational problems;

3. Improve the quality of services provided;

4. Improve client and family satisfaction with services provided.

(b) The Performance Improvement System shall provide meaningful opportunities for input, relative to the operation and improvement of services, from key stakeholders including clients, family members, consumer groups, advocates, and advocacy organizations.

(c) The Performance Improvement System shall be described in a written plan which, at a minimum shall:

1. Identify and encompass all program service areas and functions, including volunteer and subcontracted client services;

2. Outline the provider’s mission related to Performance Improvement.

3. Include the entity’s goals and objectives for Performance Improvement.

4. Define the organizational structure of Performance Improvement activities, which shall include establishment of a functional Performance Improvement Committee. This committee shall:

(i) Consist of representatives of various professional disciplines within the organization.

(ii) Determine the processes and outcomes to be monitored, in addition to those required by theses rules.

(iii) Determine the frequency in which information will be reviewed.

(iv) Select indicators.

(v) Evaluate gathered information.

(vi) Decide actions to be taken to correct identified problems.

(vii) Recommend corrective actions.

(viii) Evaluate implementation and effectiveness of corrective actions taken.

(ix) Meet at least quarterly.

(x) Generate written, dated minutes of each meeting prior to the next meeting that shall include, at a minimum:

(l) Member attendance.

(II) Indicators reviewed at the meeting.

(III) Conclusions reached.

(IV) Recommendations for corrective action, if any; and

(V) Indicators to be reviewed at the next meeting.

(xi) Document all performance improvement activities and maintain them on-site for review for a minimum of two (2) years.

(xii) Establish specific staff responsibility for coordination of the Performance Improvement System;

(xiii) Specify the manner in which Performance Improvement findings and recommendations are communicated to all levels of the organization and key stakeholders, including, but not limited to:

(I) The governing authority.

(II) Staff.

(III) Clients, families, and advocates.

(IV) DMH.

xiv. Provide for review and approval by the Governing Body on an annual basis and when revisions are made.

(d) PERFORMANCE IMPROVEMENT ACTIVITIES. The entity shall develop, maintain, and document implementation of written policies and procedures to:

1. Establish quality indicators that are:

(i) Relevant to the level of care and services provided;

(ii) Based upon professionally recognized standards of care;

(iii) Inclusive of indicators required by DMH.

2. Systematically record , monitor, and evaluate in comparison with state-wide data provided by DMH, the entity’s program utilization data , including, but not limited to:

(i) Time from initial client contact with the program to initial appointment.

(ii) Appointment no show rates.

(iii) Assessment only (i.e. clients who have an assessment and do not follow through with treatment recommendation and those who are not deemed appropriate for any LOC).

(iv) The number of active cases.

(v) Retention rates.

(vi) Length of stay.

(vii) The number of re-admitted cases;

(viii) The number of program discharges;

(ix) The number of terminated due to chooses no further treatment;

(x) The number of drop outs due to unable to contact.

(xi) The number of referrals to another agency.

(xii) The number of transfers to another level of care within the continuum of care

(xiii) The number and types of services rendered to clients;

(xiv) Average number of individuals waiting for admission; and

(xv) Average number of days individuals remain on the waiting list for admission.

3. Monitor service access and retention processes;

4. Conduct periodic and timely review of any deficiencies, requirements, and performance improvement recommendations received from DMH certification site visits, advocacy visits, and/or from any other pertinent regulatory, accrediting, or licensing bodies. This process shall include a specific mechanism for the development, implementation, and evaluation of the effectiveness of action plans designed to correct deficiencies and prevent reoccurrence of deficiencies cited;

5. Conduct an administrative and clinical review of a representative sample of active and closed client records. This review shall function to:

(i) Assess the appropriateness of the admission relative to published admission criteria.

(ii) Assess the presence, accuracy and completeness of clinical documentation in relation to these rules and the organization’s policies and procedures;

(iii) Monitor the timeliness, adequacy, and appropriateness of service planning for each client, which shall address, at a minimum:

(I) Timeliness of individualized service plan development.

(II) Implementation of service plan reviews and updates as required by program policy and DMH.

(III) Appropriateness of the individualized service plan in relation to assessed client needs.

(IV) Involvement of the client and family in the service planning process.

(V) Evidence of cultural competency in service planning and delivery.

(VI) Documentation of service delivery in relation to the Individualized Service Plan.

(iv) Adequacy of case development and management.

6. Assess the satisfaction of clients and families, including,

(i) The client’s perception of the outcome of services received.

(ii) The client’s perception of the quality of the therapeutic alliance.

(iii) Other perceptions of clients and families regarding factors which impact care and treatment, including but not limited to:

(1) Access to care.

(II) Program information.

(III) Staff helpfulness.

7. Monitor Treatment outcomes, with proximal formal client feedback in real time (i.e. session rating scales, stage of change, etc.) and post-treatment outcomes (i.e. NOMs) including but not limited to those specified in ********follow-up*.;

8. Monitor appropriate utilization of clinical/treatment services and other resources for the clients served i.e. clinical peer reviews, clinical reviews, etc.

9. Determine if treatment or care procedures are deficient or flawed;

10. Monitor critical incidents involving clients to include at a minimum:

(i) Timeliness of identification and reporting of critical incidents;

(ii) Identification of trends and actions taken to reduce risk, and to improve the safety of the service environment for clients, families, employees, and visitors.

11. Monitor staff development activities.
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(e) The entity shall document development and implementation of a process to develop:

1. Quarterly reports of performance improvement activities, findings, and recommendations; and

2. An annual aggregate review of performance improvement findings, assessment of trends and patterns, actions taken relative to findings, and recommendations for needed improvements.


(11) OPERATIONAL POLICIES AND PROCEDURES MANUAL: The entity shall develop a written, indexed, Policies and Procedures Manual which shall, minimally, contain each of the required written policies, procedures, practices, plans, and processes as specified by these rules.

(a) All policies and procedures contained within the Policies and Procedures manual shall be:

1. Approved by the organization’s governing body.

2. Developed with the input by the programs’ staff, clients, their families, and client advocates.

3. Consistent with DMH-SASD standards relative to client rights

(b) The Policies and Procedures Manual shall be:

1. Updated as needed, with changes approved by the governing authority before they are instituted, as documented in writing.

2. Reviewed, at least, on an annual basis by the Governing Authority with this review process documented in writing.

3. Easily accessible to all program personnel, with a copy available at each service location.

4. Accessible for review by DMH upon request.

(c) There shall be written policies and procedures to describe how the Policies and Procedures Manual is made accessible to the public.

(d) All entries in the policies and procedures manual shall be dated and signed by the entity’s executive director and an authorized officer of the governing body.

(e) Revisions to any page or section of the Policies and Procedures Manual must show the date of governing body approval and the effective date of each respective revision.

580-9-40.02 FISCAL MANAGEMENT.

(1) The entity shall establish and document compliance with written fiscal management policies and procedures.

(a) The Governing Body shall consistently monitor compliance with formal fiscal management policies and procedures and to ensure the source and adequacy of financial assets necessary to operate the program:

1. The entity shall document and demonstrate the availability of adequate funding to provide the certified or certification eligible services described in its operational plan.

2. The entity shall document and demonstrate the availability of physical facilities, staff, equipment, supplies, and other essential resources that are adequate and appropriate for provision of the certified services or certification eligible services described in its operational plan.

3. The entity provide documentation of adequate insurance coverage for the protection of the physical and financial resources of the program, coverage of the building, automobiles, and equipment, and coverage of the governing body, clients, staff, and the general public relative to its interaction with the entity.

(i) The governing body shall determine and secure insurance coverage limits based upon assessment of the risks associated with the services provided.

(b) The entity shall document utilization of an accounting system and generally accepted procedures to support fiscal monitoring and management that, at a minimum:

1. Ensures financial transactions are handled in a uniform manner.

2. Enables financial transactions to be reconciled and summarized at least monthly.

3. Establishes processes for accounts receivable, accounts payable, purchasing and inventory.

4. Establishes policies and procedures for the handling of cash.

5. Establishes policies and procedures to account for employees’ time and to allocate this time to appropriate cost centers.

4. Establishes non-conflicting staff responsibilities for management of the entities finances implementation of accounting procedures.

(c) The entity shall establish and implement written accounting procedures to determine cost per unit of service.

1. Costs per unit of service shall be reviewed annually.

2. Results of the annual review shall be incorporated into the development of the operating budget in the form of increased charges or expenses.

(d) The entity shall establish and implement written accounting procedures to recover third party payments.

1. A process to determine eligibility of all clients for third party coverage shall be established.

2. All third party payers obliged to pay all or part of a fee for service shall be billed by the entity.

3. A process to monitor and follow-up third party billings shall be established.

(e) The entity shall establish a written schedule of fees for each service provided.

1. The fee schedule shall be reviewed and adjusted annually to reflect current costs for each unit of service.

2. Clients and third party payers shall be charged and billed in a manner consistent with the fee schedule.

3. The entity shall not charge exorbitant or unreasonable fees that are unsubstantiated by reasonable costs for delivery of the specific service.

(f) The entity shall operate on the basis of an annual budget that is established and approved by the governing body.

1. The governing body, executive director, and senior management staff shall participate in development of the operating budget.

2. The operating budget shall specify revenues by source and expenditures by both line item and component.

3. Written procedures shall be established and implemented relative to the steps and authority required for budget revisions.

4. The operating budget shall be formally reviewed and approved by the governing body prior to the beginning of each entity’s fiscal year.

(g) The entity shall have an annual audit which shall conform to the requirements of General Audit and Accounting Principle (GAAP) and shall be:

1. Performed in accordance with applicable state and Federal regulations.

2. Shall accurately reflect the entity’s financial position at the time of the audit and shall assess its accounting policies, procedures, and operations in light of generally accepted accounting practices.

3. Shall be reviewed by and accepted by the governing authority.

4. Subject to review by DMH.

(h) The entity shall develop and document implementation of written policies and procedures that prohibit members of the governing body or personnel employed by the entity from payment or receipt of any commission, remuneration, gift, consideration, or benefit of any kind related to the referral of an individual to any of the entity’s programs for services.

(2) The entity shall establish and document implementation of a written plan outlining strategies for sustainability, that shall be reviewed and updated annually.

(3) The entity shall adhere to all reporting requirements of the DMH in regard to fiscal management.

580-9-40.03 PERSONNEL

(1) PERSONNEL POLICIES AND PROCEDURES: The entity shall develop, maintain, and document implementation of written personnel policies and procedures that are in compliance with all federal, state, and local laws and regulations relative to personnel and employment. The entity shall, at a minimum:

(a) Establish a written and dated non-discrimination policy in the organization’s hiring practices that shall address nondiscrimination on the basis of:

1. Race.

2. Religion.

3. Gender.

4. Ethnicity.

5. Age.

6. Disabilities.

7. Sexual orientation.

(b) Maintain a U. S. Department of Labor certification for all employees paid less than the current minimum wage, as required by the Social Security Act and the Fair Labor Standards Act.

(c) Adhere to immigration/citizenship standards as outlined by the U. S. Department of Labor.

1. Specifically ensure that all labor performed for the entity by current and former clients is consistent with applicable local, state, and federal law.

2. Address, at a minimum:

(i) Recruitment, selection, and utilization of employees, volunteers, interns, and students.

(ii). Wage and salary administration.

(iii) Employee benefits.

(iv) Promotions.

(v) Working hours.

(vi) Leave time.

(vii) Lines of authority.

(viii) Rules of conduct.

(ix) Alcohol and drug use and use disorders by employees.

(x) Disciplinary action and termination.

(xi) Standards of ethical conduct.

(xii) Accidents and safety issues.

(xiii) Infection control.

(xiv) Employee grievance procedures.

(xv) Performance appraisal.

(xvi) Drug-free workplace.

(xvii) Employee drug testing.

(xviii) Requirements for physical exams and testing for and reporting infectious diseases.

(xix) Employee assistance for alcohol and drug use disorders and other employee problems.

(xx) Nepotism.

(xxi) Conflict of Interest.

(xxii) Employee retention.

(d) Specifically identify the entity’s rules regarding hiring of current and former clients.

(d) Be reviewed annually, modified as needed, and approved in writing by the governing authority.

(2) QUALIFIED TREATMENT PERSONNEL: The entity shall employ a sufficient number of qualified and trained personnel to ensure the health, safety, and well-being of its clientele, and to support efficient utilization of its resources.

(a) The entity shall develop, maintain, and document implementation of written policies and procedures to ensure that all personnel meet and remain current on credentials required for certification, licensure, and for job performance and service delivery as specified by these rules.

(b) CLINICAL DIRECTOR: The entity shall employ a Clinical Director, who shall be responsible, in conjunction with the Executive Director, for the quality and appropriateness of clinical services within the entity’s treatment program(s). The Clinical Director:

1. Shall possess, at a minimum, a master's degree from an accredited university or college in psychology, social work, community, rehabilitation, or pastoral counseling, family therapy, or other behavioral health area that requires equivalent clinical course work, and have a minimum of three years post master's relevant clinical experience; OR

3. Shall be a physician who has completed an approved three year residency in psychiatry.

(c) PROGRAM COORDINATOR: The entity shall employ a Program Director or Coordinator for each, respective, level of care offered within an organization who shall meet the qualifications set forth in these rules for the specified level of care. The individual shall assume responsibility for:

1. Management of the day-to-day operations of the respective level of care; and

2. Ensuring the availability of adequate resources to meet the program’s objectives.

3. Ensuring that the level of care is provided in accordance with the rules established, herein, and in accordance with the goals and objectives established for this service by the governing authority.

(d) QUALIFIED SUBSTANCE ABUSE PROFESSIONALS (QSAP): The entity shall utilize qualified substance abuse professionals, exclusively, to provide clinical assessment, individual service planning, treatment, and care for individuals with substance related disorders, in accordance with personnel requirements of each Respective service. A QSAP shall consist of:

1. An individual who
(i) Has a Master’s degree or above from an accredited college or university in psychology, social work, community, rehabilitation, or pastoral counseling, family therapy, or other behavioral health area that requires equivalent clinical course work; and
(ii) Has successfully completed a relevant clinical practicum; or
(iii) Has one (1) year of relevant clinical experience under the supervision of a qualified substance abuse professional; or
(iv) Holds a substance abuse counselor certification credential from the:
(I) National Association of Alcoholism and Drug Abuse Counselors; or the
(II) The International Certification and Reciprocity Consortium/Alcohol and Other Drug Abuse, Inc; or
(III) Participates in concurrent clinical supervision as according to the criteria specified in rule ******* by a QSAP who meets the criteria in rule ***** up until attainment of two years substance abuse treatment experience; OR
2. An individual licensed in the State of Alabama as a:
(i) Professional Counselor;
(ii) Clinical Social Worker;

(iii) Psychiatric Clinical Nurse Specialist;
(iv) Psychiatric Nurse Practitioner;
(v) Marriage and Family Therapist;
(vi) Clinical Psychologist;
(vii) Physician’s Assistant; or
(viii) Physician; and
(ix) Documents competency by training and/or experience in the following areas of addiction counseling: clinical evaluation; treatment planning; referral; service coordination; counseling; client, family, and community education; documentation; professional and ethical responsibilities; or
(I) Holds a substance abuse counselor certification credential from the:
I. National Association of Alcoholism and Drug Abuse Counselors; or
II. The International Certification and Reciprocity Consortium/Alcohol and Other Drug Abuse, Inc.; or
III. The American Society of Addiction Medicine; OR
3. An individual who:
(i) Has a Bachelor’s Degree from an accredited college or university in psychology, social work, community, rehabilitation, or pastoral counseling, family therapy, or other behavioral health area that requires equivalent clinical course work; and
(ii) Has two (2) years of relevant clinical experience under the supervision of a qualified substance abuse professional; or
(iii) Holds a substance abuse counselor certification credential from the:
(l) National Association of Alcoholism and Drug Abuse Counselors; or the
(II) The International Certification and Reciprocity Consortium/Alcohol and Other Drug Abuse, Inc.; or
(III) Participates in concurrent clinical supervision as according to the criteria specified in rule ******* by a QSAP who meets the criteria in rule ***** up until attainment of two years substance abuse treatment experience; OR
4. An individual licensed in the State of Alabama as a:
(i) Bachelor Level Social Worker; or as a Registered Nurse; and
(ii) Has two (2) years of relevant clinical experience under the supervision of a qualified substance abuse professional; or
(iii) Holds a substance abuse counselor certification credential from the:
(l) National Association of Alcoholism and Drug Abuse Counselors; or the
(II) The International Certification and Reciprocity Consortium/Alcohol and Other Drug Abuse, Inc.; or
(III) Participates in ongoing supervision as according to the criteria specified in rule ******* by a QSAP who meets the criteria in rule ***** up until attainment of two years substance abuse treatment experience; OR
5. An individual who:
(i) Has a minimum of four years full-time paid employment experience providing direct treatment and care services for individuals who have substance-related disorders, under the supervision of a qualified substance abuse professional; and

(ii) Documented competency by training and/or experience in all of the following areas of addiction counseling: clinical evaluation; treatment planning; referral; service coordination; counseling; client, family, and community education; documentation; professional and ethical responsibilities; and
(iii) Holds a substance abuse counselor certification credential from the:
(l) National Association of Alcoholism and Drug Abuse Counselors; or the
(ll) The International Certification and Reciprocity Consortium/Alcohol and Other Drug Abuse, Inc.; and
(iv) All Clinical Directors and QSAPs who do not hold a license to practice, as specified in*****), shall within two years of hire or within two years of the effective date of these rules, attain a substance abuse counselor certification credential from the:
(I) National Association of Alcoholism and Drug Abuse Counselors; or the
(II) The International Certification and Reciprocity Consortium/Alcohol and Other Drug Abuse, Inc.
(e) QUALIFIED PARAPROFESSIONALS: The entity shall utilize qualified paraprofessionals to assist in the delivery of substance abuse treatment services and to provide recovery support services. A qualified paraprofessional shall have the following minimum qualifications:
1. A high school diploma or equivalent; and

(i) One year or more of experience providing direct treatment or recovery support services to persons with a substance related disorder; and

(ii) Demonstration of competency in the provision of addictions treatment; and

(iii) Completion of a minimum of nine (9) college semester hours or one hundred forty-four (144) contact hours of continuing education in areas of addiction counselor competency; or

2. Completion of a DMH approved recovery or peer support specialist training program; and

(i) Concurrent participation in clinical supervision as according to the criteria specified in rule ******* by a QSAP who meets the criteria in rule *****.

(3) QUALIFIED PREVENTION PERSONNEL.

(4) ORGANIZATIONAL CHART: The entity shall maintain a current organizational chart that shall:

(a) Clearly describe the functional lines of authority, oversight, management, and consultative relationships between each position, body, or board that is operational within the organization, including part-time, volunteer, and contract positions.

(b) Be updated and disseminated to the governing body and all agency personnel annually.

(5) JOB DESCRIPTIONS: Each position contained within the organizational chart shall have a written job description that:

(a) States the position’s title.

(b) States the position’s requirements for education, training, experience, skills, and/or credentials.

(c) Identifies the reporting supervisor.

(d) Identifies each position supervised.

(e) Delineates the actual duties and responsibilities of the position.

(f) Identifies the effective date.

(g) Is reviewed, signed, and dated by the employee and the employee’s immediate supervisor:

1. During the period of initial job orientation.

2. Within thirty days of a revision to the position’s qualifications and/or duties.

3. At the time of change to a different position.

4. No less than on an annual basis.

(h) Is maintained in the personnel record of each employee.


(6) PERSONNEL RECORDS: Personnel records shall be maintained for each employee, and all contractors, students, and volunteers who have direct contact with program participants that contain, at a minimum:

(a) A complete job application.

(b) A resume.

(c) Documentation of the entity’s verification of all professional credentials, including transcripts of education, license, registration, and/or certification for all applicable personnel.

(d) Documentation of the employee’s criminal background check.

(e) Reference information.

(f) Starting date of employment, and ending date as applicable.

(g) Documentation of the content and completion of an initial orientation and training process.

(h) Documentation of continuing education.

(i) Documentation of incident reports, disciplinary actions, and commendations.

(j) Annual performance evaluations.

(k) A copy of the employee’s valid drivers’ license if the employee’s job function entails or could entail the transportation of clients.

(l) A copy of the job description and documentation that a copy was provided to the employee.

(m) Documentation of review and agreement to adhere to privacy and confidentiality regulations that protect client information.

(n) Other information as required by law.

(7) PRIVACY AND CONFIDENTIALITY. The entity shall develop, maintain, and document implementation of written policies and procedures to protect the confidentiality and privacy of:

(a) Personnel records.

(b) Employee health related information received, including, but not limited to:

(1) Requests for medical or family leave.

(2) Results of infectious disease testing.

(3) Results of alcohol and/or drug screens.

(4) Physician authorized return to work permits.

(5) Results of physical examinations.

(8) STAFF DEVELOPMENT. The entity shall develop, maintain, and document implementation of written policies and procedures that establish a staff development and training program for all employees, students, and volunteers. This program shall include, at a minimum, the following requirements:

(a) PERSONNEL ORIENTATION: An orientation process shall be conducted for each new employee, student, or volunteer that includes, but is not limited to,

(1) Oral review of written information on:

(i) The agency’s mission, philosophy, organizational structure, and description of services.

(ii) Program participants’ rights to privacy and confidentiality.

(iii) Program participants’ applicable rights to service provision.

(iv) The agency’s personnel policies and procedures and code of ethics.

(v) Infection control, safety and emergency procedures.

(vi) Crisis intervention procedures.

(vii) Incident reporting procedures.

(viii) Job specific duties and responsibilities.

(ix) Supervision.

(x) Electronic media access requirements.

(xi) DMH Certification Standards.

(2) The provision that each employee will be given an employee handbook that addresses, at a minimum, each item presented during the orientation process.

(3) A policy stipulating that that an employee will not be permitted to assume job responsibilities until completion of the orientation process.

(b) ANNUAL TRAINING: On an annual basis, the entity shall provide training for each employee that addresses the following topics:

(1) Crisis intervention.

(2) Management of disruptive behavior.

(3) Suicide prevention/intervention.

(4) Confidentiality and privacy of client information.

(5) Cultural competency relative to the program’s target population.

(6) Infectious disease prevention and management, to include at a minimum: TB, HIV/AIDS, Sexually Transmitted Diseases and Hepatitis.

(7) Program policies and procedures.

(8) DMH Certification Standards.

(c) FIRST AID/CARDIOPULMONARY RESUSCITATION (CPR) TRAINING: All staff shall obtain, within one month of hire, and continuously maintain current certification in First Aid and CPR.

(d) PROFESSIONAL DEVELOPMENT: The entity shall establish and support professional development activities for all paid personnel and permanent volunteers that shall include, at a minimum:

(1) An annual agency-wide training needs assessment, which shall incorporate, at a minimum:

(i) A survey of the entity’s personnel to determine professional development needs.

(ii) Findings from performance appraisals and clinical supervision activities.

(iii) Findings from the entity’s performance improvement activities.

(iv) Findings from DMH certification and other program monitoring site visits.

(2) The provision of in-service and offsite training opportunities to meet needs identified in the training assessment, including known credentialing requirements.

(3) Written agency and individual employee staff development plans that are, based, at a minimum, upon performance appraisals and training needs assessments as required in *******, implemented, reviewed, and updated, at least, annually.

(4) A process to inform the agency’s personnel of:

(i) New developments in the treatment and prevention of substance use disorders;

(ii) Changes in regulatory requirements; and

(iii) Changes in the operational policies and procedures of the entity.

(e) COMPETENCY AND TRAINING: TREATMENT PERSONNEL. All individuals providing treatment and recovery support services shall have appropriate training to support knowledge and skill development in the transdisciplinary foundations of addictions practice.

1. Training provided shall be consistent with the clinician’s job qualifications, work experience, and job responsibilities.

2. Training shall support development of appropriate competencies, in accordance with latest edition of TAP 21 published by the Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, incorporated, herein, by reference, within two (2) years of hire in the following transdisciplinary foundations:

(i) Understanding Addiction.

(ii) Treatment Knowledge.

(iii) Application to Practice.

(iv) Professional Readiness.

3. QUALIFIED SUBSTANCE ABUSE PROFESSIONALS: All qualified substance abuse professionals shall have appropriate training to support development of knowledge, skill, and attitude competencies underlying the eight practice dimensions of addiction counseling.

(i) Training shall be consistent with the clinician’s job qualifications, work experience, and professional responsibilities.

(ii) Training shall support development of appropriate competencies, in accordance with latest edition of TAP 21 published by the Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, incorporated, herein, by reference, within two (2) years of hire in the following practice dimensions:

(I) Clinical Evaluation, including:

I. Screening.

II. Assessment.

(II) Treatment Planning.

(III) Referral.

(IV) Service Coordination, including:

I. Implementing the Treatment Plan.

II. Consulting.

III. Continuing Assessment and Treatment Planning.

(V) Counseling, including

I. Individual Counseling.

II. Group counseling.

III. Counseling Families, Couples, and Significant Others.

(VI) Client, Family, and Community Education.

(VII) Documentation.

(VIII) Professional and Ethical Responsibilities.

4. ADOLESCENT PROGRAM SPECIFIC CRITERIA.

(i) All clinical staff in adolescent programs shall have adequate knowledge, skills, attitudes, and attributes to provide effective service delivery for the program’s specified target population.

(ii) The entity shall provide continuous training to ensure development of the following competencies for clinicians working in adolescent programs:

(I) Knowledge of developmental, cultural, gender, psychological, family, and legal issues unique to adolescents who have substance related disorders.

(II) Knowledge of the needs of special populations, including, homeless, juvenile justice involved, homosexual, bisexual, transgendered youth, and youth with co-existing disorders

(III) Knowledge and skills to implement treatment approaches specific to adolescents and their families that address:

I. Adolescent growth and development.

II. Trauma, including sexual and physical abuse.

III. Mental health problems.

IV. Sexual orientation issues.

VI. Psychopharmacology.

VII. Referral and community resources.

VIII. Cognitive impairments.

IX. Gender specific concerns.

(IV) Knowledge and skills to:

I. Perform age-appropriate assessments of individuals.

II. Formulate an individualized service plan and develop a community support plan for individuals.
III. Tailor interventions which support the process of recovery for individuals.

IV. Tailor interventions appropriate to the individual’s assessed stage of readiness to change.

V. Make available required support for individuals who choose to participate in 12-Step Recovery programs.

(V) Attitudes and attributes to establish a supportive, therapeutic alliance with adolescents and their families.

5. CO-OCCURRING DISORDERS PROGRAM SPECIFIC CRITERIA. All clinical staff working in co-occurring enhanced programs shall have adequate knowledge, skills, and attitudes to provide effective service delivery for the program’s specified target population.

(i) Training shall be provided to support development of the following competencies within twelve (12) months of hire:

(I) Screen for mental health and substance use problems using DMH approved screening instruments.

(II) Develop a preliminary impression of the presenting problem.

(III) Use basic engagement skills, including:

I. Stabilization, outreach, assistance with practical needs, and building the therapeutic alliance.

II. Basic motivational interviewing.

III. Use techniques designed for de-escalation of client behavior when needed.

(ii) Knowledge of crisis management procedures, including:

(I) Know the behavior/physiological signs for intoxication and withdrawal from various stances, and the signs of risk to self or others.

(II) Follow the crisis management procedures if someone is intoxicated or in withdrawal from substances, and/or reporting suicidal ideation and/or homicidal ideation.

(III) Knowledge of referral processes and uses them assertively when needed.

(IV) Coordinate care assertively when multiple providers are concurrently involved in care.

(V) Display patience, persistence and optimism.

(iii) The entity shall provide continuous training to ensure development of the following competencies for clinicians working in co-occurring enhanced programs:

(I) Conduct integrated assessments.

(II) Knowledge of the drug classes and mental health diagnostic categories used in the DSM IV.

(III) Determine severity of disorders.

(IV) Knowledge of the current street names of the various drugs.

(V) Assess stage of change for both disorders.

(VI) Complete a functional assessment.

(VII) Document mental health and substance use disorder diagnoses.

(VIII) Perform integrated and collaborative service planning with a focus on shared decision making.

(IX) Conduct engagement, education, and treatment for both mental health and substance use disorders.

(X) Use advanced motivational interviewing strategies.

(XI) Know the basic social learning theory concepts that underlie a Cognitive Behavioral Therapy (CBT) Approach. Complete a functional analysis (behavior chain) and teach coping skills (e.g. rationale and guidelines, modeling, role plays, providing constructive feedback, and assisting consumers/ individuals in recovery to practice exercises in their community).

(XII) Be able to modify counseling strategies for clients in recovery with a severe mental illness.

(XIII) Use stage-wise treatment methods, employing treatment strategies compatible with each stage of change for each disorder.

(XIV) Understand the 12-Steps used in AA/NA self-help groups, and assertively link people with COD to ones that are welcoming or specific to COD (i.e. Dual Recovery Anonymous).

5. WOMEN AND DEPENDENT CHILDREN PROGRAM SPECIFIC CRITERIA.

(i) All clinical staff working in women and dependent children’s programs shall have adequate knowledge, skills, attitudes and attributes to provide effective service delivery for the program’s specified target population.

(ii) The entity shall provide continuous training to ensure development of the following competencies for clinicians working in women and dependent children’s programs:

(I) Knowledge of sex and gender differences in the experience of substance use.

(II) Knowledge of the relationship between substance use, violence, and mental health problems common to women and girls.

(III) Knowledge of barriers to care for women with substance use disorders, and skills to tailor strategies to minimize the impact of these barriers.

(IV) Skills to implement gender specific clinical interventions that address:

I. Substance use by pregnant women and mothers.

II. Fetal alcohol spectrum disorders.

III. The impact of substance use and parenting.

IV. The relationship between women, trauma, and substance use.

V. The role of relationships in women’s lives.

VI. Race, ethnicity, culture, spirituality, sexual orientation and functioning.

VII. Child care issues relative to addiction, treatment, and recovery.

VIII. Economic and self-sufficiency.

IX. Competency building and empowerment.

V. Skills to provide gender specific assessments.

VI. Knowledge and skills to develop gender specific service plans that address the needs of the woman and her family.

iii. Knowledge and skills to:

(I) Tailor interventions appropriate to the individual’s assessed stage of readiness to change.

(II) Tailor interventions which support the process of recovery for individuals.

(III) Provide family and social support.

(IV) Work across systems of care, facilitate and participate in teamwork and partnerships.

(V) Make available required support for individuals who choose to participate in 12-Step Recovery programs.

iv. Knowledge of:

(I) Medical, psychiatric, and behavioral syndromes and symptoms with which children and adolescents in families with substance abuse present.

(II) Medical and behavioral treatment of children in families affected by substance abuse.
(III) Potential benefit to both the child and the family of timely and early intervention services for children, and strategies for implementation of these services.

(IV) Community resources available for children and adolescents in families with substance abuse, and the ability to access these services.

(V) The impact of parental tobacco use on children.

v. Attitudes and attributes to establish a supportive, therapeutic alliance with women and their families.

6. QUALIFIED PARAPROFESSIONALS.

7. PREVENTION PERSONNEL.

(i) All individuals providing prevention services shall have adequate knowledge, skills, attitudes and attributes to provide effective service delivery for the program’s specified target population.

(ii) The entity shall provide continuous training to ensure development of the following competencies for individuals providing prevention services:

(I)


(9) DOCUMENTATION: The entity shall maintain written records of completion of orientation, training, and professional development activities that document, at a minimum:

(a) Dates of the orientation, professional development, and training activity.

(b) Curriculum summary.

(c) Identification of the specific counseling competency addressed, as appropriate.

(d) Competency assessment or rating.

(e) Names and credentials of trainer.

(f) Length of session.

(g) Credits earned as applicable.

10. CLINICAL SUPERVISION. The entity shall document effective oversight of clinical services, as according to the following requirements:

(a) The entity shall identify a clinical supervisor for each level of care.

(b) Clinical supervision may be provided in-house or through a contractual arrangement established between the entity and a qualified clinical supervisor.

(c) Clinical supervision shall be provided by an individual who meets the requirements specified in *****.

(d) The entity shall develop, maintain, and document implementation of written policies and procedures that govern the process of clinical supervision, which shall, at a minimum, include the following requirements:

1. All staff providing direct services, who are not licensed independent practitioners, shall receive clinical supervision on a continuous basis.

(i) A minimum of one hour of clinical supervision shall be provided each week for each Qualified Substance Abuse Professional who provides at least twenty (20) hours of direct services weekly.

(ii) A minimum of one hour of clinical supervision shall be provided every two weeks for each Qualified Substance Abuse Professional who provides less than 20 hours of direct services weekly.

(iii) Master Degree level Qualified Substance Abuse Professionals participating in concurrent supervision as specified in **********, shall receive a minimum of two (2) hours of clinical supervision monthly, in addition to that specified in ***** until such time that one year of substance abuse treatment experience is attained.

(iv) Bachelor Degree level Qualified Substance Abuse Professionals participating in concurrent supervision as specified in ********** and ********, shall receive a minimum of two (2) hours of clinical supervision monthly, in addition to that specified in ***** until such time that two years of substance abuse treatment experience is attained.

(v) Qualified Paraprofessionals working at least twenty hours per week shall receive a minimum of two hours clinical supervision weekly.

(vi) Qualified Paraprofessionals working less than twenty hours per week shall receive a minimum of one hour of clinical supervision every two weeks.

2. Supervision shall include, but shall not be limited to:

(i) Direct observation of service delivery.

(ii) Case study review and discussion.

(iii) Audit of clinical records.

(iv) Assessment and discussion of core competencies.

(v) Assessment and discussion of therapeutic alliances.

(vi) Assessment of treatment effectiveness and review of client outcomes.

(vii) Employee skill development.

(viii) Employee education relative to clinical policies and procedures, treatment modalities, and specific job functions.

3. Clinical supervision may be conducted on an individual and group basis.

(i) All employees shall have a minimum of one hour individual supervision monthly.

(ii) Group supervision shall include no more than twelve (12) supervisees.

(iii) Clinical supervision shall be documented.

(I) Documentation shall include, at a minimum:

I. Names of the supervisor and supervisee(s);

II. Specification of individual or group supervision;

III. Date of supervision;

IV. A description of supervisory activities;

V. Identification of opportunities for staff development and improvements in the quality of care.

(II) Supervisory audit of clinical records shall be documented within the records reviewed, in addition to documentation as specified in **********.

(11) VOLUNTEERS: Entities utilizing volunteers shall develop, maintain, and document implementation of written policies and procedures governing their selection and utilization within the organization.

(a) At a minimum, the entity’s policies and procedures relative to volunteers shall include the following elements:

1. Procedures and criteria used to select volunteers, including sobriety requirements for individuals in recovery from substance use disorders.

2. Specific responsibilities and tasks of volunteers.:

3. Specific accountability and reporting requirements of volunteers.

4. Responsibility for reviewing the performance of volunteers and for providing appropriate feedback in regard to such.

5. Procedures for discontinuing or moving a volunteer from an assigned task or from the agency.

(b) Volunteers shall provide direct services to clients only if they meet all requirements applicable to paid staff for delivery of the same service, and are under the direct supervision of a qualified substance abuse professional.

(c) An appropriately qualified staff member shall be designated to coordinate and supervise volunteer services.

(d) An individual personnel record shall be maintained for each volunteer as specified in rule ******.

(e) All volunteers shall participate in an orientation process as specified in rule ***********.

(12) STUDENTS/INTERNS: Entities providing on-the-job educational/training opportunities for students through practicums, internships, or other supervised learning experiences shall develop, maintain, and document implementation of written policies and procedures governing this process.

(a) At a minimum, policies and procedures relative to students and interns shall include the following requirements:

1. Procedures and criteria used to select students/interns.

2. Identification of minimum qualifications for each position available for learning experiences.

3. Delineation of specific roles and responsibilities of students and interns, including scope of practice restrictions.

4. Procedures for discontinuing a student/intern learning experience.

5. Identification of specific personnel who shall, at a minimum:

(i) Coordinate and supervise the entity’s student/intern placement process.

(ii) Serve as the entity’s liaison between the agency and the school making student/intern placements.

(iii) Provide direct supervision of the student/intern.

(iv) Assume responsibility for reviewing the performance of volunteers and for providing appropriate feedback in regard to such.

(b) An individual personnel record shall be maintained for each student/intern as specified in rule ******.

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