office of certification mental illness and substance abuse services division p.o. box 301410
DESCRIPTION
Office of Certification Mental Illness and Substance Abuse Services Division P.O. Box 301410 Montgomery AL 36130-1410 www.mh.alabama.gov Beth Malone, MHSAS Director of Certification 334-242-3969 [email protected]. To access this PowerPoint with live links visit the link below:. - PowerPoint PPT PresentationTRANSCRIPT
OFFICE OF CERTIFICATION
Mental Illness and Substance Abuse Services DivisionP.O. Box 301410
Montgomery AL 36130-1410 www.mh.alabama.gov
Beth Malone, MHSAS Director of Certification334-242-3969
http://www.mh.alabama.gov/Downloads/SACR/NewProviderOrientation_July2014.ppsx
Or visit www.mh.alabama.gov
Click on yellow SUBSTANCE icon thenclick Certification
TO ACCESS THIS POWERPOINT WITH LIVE LINKS VISIT THE LINK BELOW:
MHSA OFFICE OF CERTIFICATION STAFF
SITE REVIEW TEAM Cathy Anderson - [email protected] Johnson - [email protected] Marshall - [email protected] McCoy - [email protected] Mitchell - [email protected] Stiles - [email protected]
Makala Lane, Administrative [email protected]
YOU WILL RECEIVE A CERTIFICATE FOR ATTENDING THIS ORIENTATION
HOWEVER, ATTENDING THIS ORIENTATION DOES NOT MEAN YOU
ARE CERTIFIED TO PROVIDE SERVICES.
Certificate of Attendance
WHAT CERTIFICATION DOES NOT MEAN
State certification does not constitute a
contractual agreement between Mental Health
Substance Abuse Division (MHSA) and the
service provider for services.
WHY IS CERTIFICFACTION REQUIRED?
Alabama Department of Mental Health is the state agency responsible for serving Alabama citizens with mental illnesses, developmental disabilities, and substance use disorders. The department was formally established by Alabama Act 881 in 1965. ADMH’s authority is defined in Code of Alabama 1975, Section 22-50-1 thru 22-50-90.
Compliance is required by LAW!
580-3-23-.02 (3) It is under this statutory authority that the Department of Mental Health requires compliance with these standards through these certification regulations by entities that hold themselves out as providers of services to persons with mental illness, developmental disabled, and/or substance abuse in the State of Alabama.
EXEMPTIONS TO 580‑3‑23
General or psychiatric hospitals licensed as such by the
Alabama Board of Health
Public or private educational institutions.
Qualified member of professions in their own private
practice (such as licensed physicians, psychologists, psychiatrists, social workers, etc.)
THINGS TO CONSIDER BEFORE YOU MOVE FORWARD ON BECOMING A CERTIFIED
DMH PROVIDER:The state is divided into regions. Each
region has a mental health center responsible for conducting a needs assessment. The purpose of the needs assessments is to identify gaps in services.
First, visit the link below to see the mental health center’s needs assessment, then contact the mental health center and discuss what gaps services they have in their needs assessment. http://www.mh.alabama.gov/ADPR/310BoardStrategicPlans.aspx
You will have to work with them no matter what services you provide, mental illness or substance abuse.
Link to Certified Mental Health Centers and Providershttp://www.mh.alabama.gov/Downloads/MI/MI_Programs_Directory.pdf
Link to Certified Substance Abuse Providershttp://www.mh.alabama.gov/SA/FindServices.aspx
Be sure to look at the links above to see what kind of services are being
offered in your county.
IMPORTANT LINKS:
MENTAL ILLNESS
DEPARTMENT OF MENTAL HEALTH MENTAL ILLNESS COMMUNITY PROGRAMS ADMINISTRATIVE CODE CHAPTER
580-2-9PROGRAM OPERATION
TABLE OF CONTENTS
580-2-9.01 Type Of Certificate580-2-9.02 Governing Authority580-2-9.03 Mental Illness Program Staff580-2-9.04 Consumer Protection580-2-9.05 Reserved580-2-9.06 Consumer Recordshttp://www.mh.alabama.gov/downloads/SACR/SACR131105_MHSAReportingProceduresAndForms_5-2012.pdf
580-2-9.07 Performance Improvement580-2-9.08 General Clinical Practice
“WHAT SERVICES DO I WANT TO PROVIDE TO PEOPLE SUFFERING
FROM MENTAL ILLNESS?” WHAT ARE THE OPTIONS?
All must be in policy and procedure manual
580-2-9.09 General Outpatient580-2-9.10 Child and Adolescent In-Home Intervention580-2-9.11 Adult In-Home Intervention580-2-9.12 Emergency Services580-2-9.13 Partial Hospitalization Program580-2-9.14 Adult Intensive Day Treatment580-2-9.15 Adult Rehabilitative Day Program580-2-9.16 Child and Adolescent Day Treatment580-2-9.17 Case Management580-2-9.18 Residential Services
“WHAT SERVICES DO I WANT TO PROVIDE TO PEOPLE SUFFERING
FROM MENTAL ILLNESS?” What are the options? (continued)
Choose what service you want to apply for and READ THE CODE.
580-2-9.19 Designated Mental Health Facility580-2-9.20 Consultation and Education580-2-9.21 Assertive Community Treatment580-2-9.22 Program for Assertive Community Treatment580-2-9.23 Child and Adolescent Seclusion and Restraint580-2-9.24 Adult Seclusion and Restraint580-2-9.25 Therapeutic Individualized Rehabilitation Services580-2-9.26 Indigent Drug Program
WHAT SERVICES DO I WANT TO PROVIDE TO PEOPLE SUFFERING
FROM MENTAL ILLNESS?” WHAT ARE THE OPTIONS? (continued) Choose what
service you want to apply for and READ THE CODE.
IF YOU APPLY TO BE A MENTAL HEALTH CENTER YOU MUST OFFER ALL OF THE FOLLOWING: 1. The provider must provide the following
services as defined in the paragraph below directly through its employees:
(i) Emergency Services,(ii) Outpatient Services,(iii) Consultation and Education
Services, and(iv) Partial Hospitalization/Intensive
Day Treatment/Rehabilitative Day Program, and
(v) Must provide residential services either directly through its employees or through agreement with other certified providers.
IF YOU ARE APPLYING TO BE A MENTAL HEALTH PROVIDERS YOU CAN
APPLY FOR THE FOLLOWING:
1. Emergency Services Administrative Code 580-2-9.12
2. Outpatient Services Administrative Code 580-2-9.09
3. Consultation and Education Services Administrative Code 580-2-9.204. Partial Hospital/Day Treatment Services Administrative Code 580-2-9.135. Residential Services Administrative Code 580-2-9.18
Foster Care programs must be through a contract with the mental health center.
WHAT SERVICES DO I WANT TO PROVIDE TO PEOPLE SUFFERING
FROM MENTAL ILLNESS?” WHAT ARE THE OPTIONS?
There are three basic options for providing Mental Health services to individuals suffering from mental illness in Alabama:
Housing support (e.g. foster home) for a small number of MI clients who are receiving treatment through a local Mental Health agency
Individual programs that target specific populations
and MI treatment needs in a particular area (e.g. residential services also referred to as group home)
Comprehensive MI treatment and support services for
a large and diverse population of clients (e.g. Mental Health Center)
HOUSING SUPPORT/FOSTER CARE
A single site residence that provides group living for adults, three meals a day, 24/7 supervision/staff. Staff are required to have a high school education or a GED.
Operated under Contractual agreement with the local Community Mental Health Center
HOUSING SUPPORT/FOSTER CARE
The foster care facility shall be monitored at least monthly by the designated CMHC to ensure compliance with the contractual agreement and these standards.
DMH only certifies foster homes that are under contract with a certified community mental health center (CMHC).
Applications for Mental Illness Foster Care must be signed by the respective CMHC that proposes to subcontract with the provider prior to being submitted.
STAFF QUALIFICATIONS REQUIREMENTS
580-2-9-.03 Mental Illness Program Staff
The executive director of a provider shall be a full-time employee and shall have at least a master’s degree in an administrative or mental health related field and at least five years of post master’s progressive managerial experience…..
There shall be a full-time Clinical Director (in addition to the Executive Director) who has full-time responsibility for the quality of clinical care and the appropriateness of clinical programs. The Clinical Director shall have as a minimum either a master’s degree in psychology, social work,…….
STAFF QUALIFICATIONS CONSISTENT FOR EACH TYPE OF RESIDENTIAL
PROGRAM CERTIFIED
The program coordinator shall have a bachelor’s degree in a mental health service related field, shall have two years experience in a direct service area, and be trained in recovery/psychiatric rehabilitation principles……..
The coordinator shall have three years experience in a mental illness residential setting, demonstrate the ability to communicate clearly orally and in writing, demonstrate the ability to maintain clinical records in accordance with standards……..
SUBSTANCE ABUSE
TABLE OF CONTENTS580-9-44-.01 Definitions580-9-44-.02 Personnel580-9-44-.03 Client Rights580-9-44-.04 Abuse and Neglect580-9-44-.05 Grievances, Complaints and Appeals580-9-44-.06 Confidentiality and Privacyhttp://www.mh.alabama.gov/downloads/SATR/SATR71012_42CFRRegulations.pdf
Required Releases: http://www.mh.alabama.gov/SACR/42CRFAndHIPAARelease.aspx
ALABAMA DEPARTMENT OF MENTAL HEALTH SUBSTANCE ABUSE SERVICES ADMINISTRATIVE CODE CHAPTER 580-
9-44PROGRAM OPERATIONS
WHAT SERVICES DO I WANT TO PROVIDE TO PEOPLE SUFFERING
FROM SUBSTANCE ABUSE?” WHAT ARE THE OPTIONS?
All must be in policy and procedure manual
580-9-44-.07 Seclusion and Restraint580-9-44-.08 Child and Adolescent Seclusion and Restraint580-9-44-.09 Incident Reporting – procedures and formshttp://www.mh.alabama.gov/downloads/SACR/SACR131105_MHSA_ReportingProceduresAndForms_5-2012.pdf
“WHAT SERVICES DO I WANT TO PROVIDE TO PEOPLE SUFFERING
FROM SUBSTANCE ABUSE?” WHAT ARE THE OPTIONS? (continued)
All must be in policy and procedure manual
All must be in policy and procedure manual
580-9-44-.10 Infection Control580-9-44-.11 Performance Improvement580-9-44-.12 Operational Policies and Procedures Manual580-9-44-.13 Program Description
580-9-44-.14 Level 0.5: Early Intervention580-9-44-.15 Level I: Outpatient Treatment580-9-44-.16 Level I-D: Ambulatory Detoxification580-9-44-.17 Level II.1: Intensive Outpatient Treatment580-9-44-.18 Level II.5: Partial Hospitalization Treatment Program580-9-44-.19 Level II-D: Ambulatory Detoxification With Extended On-Site Monitoring
“WHAT SERVICES DO I WANT TO PROVIDE TO PEOPLE SUFFERING
FROM SUBSTANCE ABUSE?” WHAT ARE THE OPTIONS? (continued) Choose what
service you want to apply for and READ THE CODE.
580-9-44-.20 Level III.01: Transitional Residential Program580-9-44-.21 Level III.1: Clinically Managed Low Intensity Residential Treatment Program580-9-44-.22 Level III.2-D: Clinically Managed Residential Detoxification580-9-44-.23 Level III.3: Clinically Managed Medium Intensity Residential Treatment Program For Adults Without Extended On-Site Monitoring
“WHAT SERVICES DO I WANT TO PROVIDE TO PEOPLE SUFFERING FROM
SUBSTANCE ABUSE?” WHAT ARE THE OPTIONS? (CONTINUED)
Choose what service you want to apply for and READ THE CODE.
580-9-44-.24 Level III.5: Clinically Managed Medium Intensity Residential Treatment Program For Adolescents580-9-44-.25 Level III.5: Clinically Managed High Intensity Residential Treatment Program For Adults580-9-44-.26 Level III.7: Medically Monitored Intensive Residential Treatment Program For Adults580-9-44-.27 Level III.7: Medically Monitored High Intensity Residential Treatment Program For Adolescents580-9-44-.28 Level III.7-D: Medically Monitored Residential Detoxification580-9-44-.29 Level I-O: Opioid Maintenance Therapy
“WHAT SERVICES DO I WANT TO PROVIDE TO PEOPLE SUFFERING
FROM SUBSTANCE ABUSE?” WHAT ARE THE OPTIONS? (continued)
Choose what
service you want to
apply for and READ THE CODE.
YOUR AGENCY IS REQUIRED BY THE ADMINISTRATIVE CODE TO
HAVE: o Full-Time Executive Director Cannot be both or any other position in your organization o Full-Time/Contract Clinical Director Cannot be both or any other position in your organization o Program Coordinator
o Substance abuse staff will need to be certified as a substance abuse professional: http://www.aadaa.us/certification-membership/
or http://www.naadac.org/about
POLICY AND PROCEDURE MANUAL
Criminal Background Check information
Articles of Incorporation
Board by-laws including a list of Board Members
Board minutes
Program Description for each service you are applying for
Copy of most recent fiscal audit (if applicable)
Resumes of Executive Director and Board President
THE FOLLOWING MUST BE INCLUDED WITH YOUR APPLICATION
A policy and procedures manual is a crucial tool for running a business.
It serves as a consistent source for organizational policy, which are the overall regulations that govern the business, and the procedures that define how those policies will be implemented.
A policy and procedure manual exists to answer the what and how of operations. It spells out for all employees what is expected of them and how to accomplish it. It contains instructions on how to perform a task. It ensures routine jobs get performed safely and in compliance with the Administrative Code.
POLICY AND PROCEDURE MANUAL Very important and required with
all applications
Your procedures manual can be a three ring binder, a folder on a network share drive. What’s important is that everyone understands what constitutes your policy and procedure manual and where a policy or procedure can be found when someone needs it.
Your policy and procedure manual will be unique to your program, and should contain the required minimum policies listed in the Administrative Code. Therefore, you must be familiar with the entire Administrative Code and other laws that pertain to operating a behavior health program such as HIPPA, 42 C.F.R. Part 2, Evidence Based Practices for the population you intend to serve.
POLICY AND PROCEDURE MANUAL
(continued)
Procedures are really about communication. Your employees need to understand what is expected of them. Your employees need a procedures manual to reference for training. Your supervisors need a policy manual to reference for managing business processes. By documenting your procedures, you are communicating what is important for growth, quality, and customer satisfaction.
POLICY AND PROCEDURE MANUAL (continued)
WRITING A POLICY AND PROCEDURE
(continued)
Your POLICY is the Administrative Code. Use the Administrative Code numbers.
Your PROCEDURE is the what and how of operations. It spells out for all employees what is expected of them and how to accomplish it. It contains instructions on how to perform a task. It ensures routine jobs get performed safely and in compliance with the Administrative Code.
EXAMPLE:Administrative Code: 580-9-44-.10(2)(g) Infection Control.
The entity shall develop, maintain, and document compliance with a written
plan for exposure control relative to infectious diseases that shall, at a
minimum, include the following requirements: (g) TB Testing for all employees prior to initiation of duties after
hiring and annually thereafter.
Procedure:
Prior to employment and annually thereafter all persons hired by organization shall be required to have a TB 2-step skin test. Each employee will be required to have proof of current TB 2-step
skin test results. The test results shall be kept in the employee’s personnel file and
available for review by appropriate authorities and Department of Mental Health (DMH).
Date of Policy: January 23, 2014
Administrative Code 580-9-44.13(20)(d) (1-2) Client Records.When client records are corrected or amendments are completed using the mark through method, amendments or marked through changes must be executed as follows:
1. The information to be amended is struck out with a single line that allows the stricken information to be read.
2. The amended entry is initialed and dated.
Procedure: All corrections or amendments in a client record will use a mark through method and must be executed as follows: 1. The information to be amended is struck out with a single line that allows the stricken information to be read. 2. The amended entry is initialed and dated.
White out or correction fluid will not be used in a client record.
Example: Date of Policy: January 23, 2014
NURSE DELEGATION PROGRAM AND REQUIRED
FORMS
For residential services, there shall be a registered nurse or licensed
practical nurse as a full-time or part-time employee or a consultant
to the provider who is responsible for supervision of delegation of
medication assistance to the unlicensed personnel.
Access to an on-call nurse must be available 24 hours a day, 7 days
a week. Provider will implement policies and procedures approved
by their Board of Directors requiring full compliance with the
Alabama Board of Nursing regulation 610X7.06 Alabama
Department of Mental Health Residential Community Programs.
http://www.mh.alabama.gov/ADSDND/
Must be trained on the 6 dimensions of American Society of Addiction Medicine (ASAM):
http://www.mh.alabama.gov/Video/ASAMtraining.aspx
Must use the DMH Integrated Placement Assessment Tool for assessing the client needs:
http://www.mh.alabama.gov/SATR/AssessmentPlacement.aspx
ADMINISTRATIVE CODE REQUIREMENTS FORSUBSTANCE ABUSE
IMPORTANT LINKS
Incident Reporting Procedureshttp://www.mh.alabama.gov/downloads/SACR/SACR131105_MHSA_ReportingProceduresAndForms_5-2012.pdf
Administrative Code for Substance Abuse http://www.mh.alabama.gov/Downloads/SACR/SA_Administrative_Code.pdf
Administrative Code for Mental Illness http://www.mh.alabama.gov/Downloads/SACR/SA_Administrative_Code.pdf
FAQ on mental Illness:http://www.mh.alabama.gov/MI/FAQ.aspx?sm=b_e
Administrative Code for Life Safety http://www.mh.alabama.gov/Downloads/COPP/COPP90107_580-3-22LifeSafetyMinimunStandards4PhysicalFacilities.pdf
Site Visit Report Scoreshttp://www.mh.alabama.gov/COCA/SiteVisitReports/default.aspx
IMPORTANT LINKS
APPLICATION/SUPPORTING DOCUMENTS
All applications to the Alabama Department of Mental Health (ADMH) for certification of community programs shall be submitted in original to:
Debbie PopwellDMH Office of Certification Administration 100
North Union StreetP.O. Box 301410
Montgomery, Alabama 36130-1410
READ! READ!
READ!
IMPORTANT!!!