ALABAMA DEPARTMENT OF MENTAL HEALTH

AND MENTAL RETARDATION

ADMINISTRATIVE CODE

CHAPTER 580-3-23 CERTIFICATION OF COMMUNITY PROGRAMS

TABLE OF CONTENTS

580-3-23-.01 Introduction

580-3-23-.02 Statutory Authority

580-3-23-.03 Reserved

580-3-23-.04 Compliance

580-3-23-.05 Applicability

580-3-23-.06 Definitions Of Types Of Certifications/Certificates

580-3-23-.07 Period Of Certification

580-3-23-.08 Application Process

580-3-23-.09 New Services

580-3-23-.10 Site Visits

580-3-23-.11 Unannounced Visits

580-3-23-.12 Site Visit Reports

580-3-23-.13 Entity’s Plan Of Action

580-3-23-.14 DMH/MR Response To Plan Of Action

580-3-23-.15 Appeal Procedures Within DMH/MR

580-3-23-.16 Decertification/Final Decision

580-3-23-.17 Renewal Of Certification

580-3-23-.01 Introduction. These regulations establish reasonable certification rules for community programs which provide mental health services, mental retardation services, and substance abuse services.

Author: DMH/MR Office of Certification

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

History: New Rule: Filed October 1, 2001; effective November 5, 2001.

580-3-23-.02 Statutory Authority.

(1) The Alabama Department of Mental Health and Mental Retardation (DMH/MR) was created by Alabama Acts 1965, Act 881, as codified in the Code of Ala. 1975, Sections 22-50-1 through 22-50-90. Pursuant to these provisions, the DMH/MR has the authority to establish standards for all operations and activities of the State related to the provision of services to persons with mental illness, mental retardation, and/or substance abuse.

(2) Code of Ala. 1975, defines mental health services as diagnosis of, prevention of, and research into the causes of all forms of mental or emotional illness, including, but not limited to, alcoholism, drug addiction, epilepsy or mental retardation.

(3) It is under this statutory authority that the Department of Mental Health and Mental Retardation requires compliance with these standards through these certification regulations by entities that hold themselves out as providers of services to persons with mental illness, mental retardation, and/or substance abuse in the State of Alabama.

Author: DMH/MR Office of Certification

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

History: New Rule: Filed October 1, 2001; effective November 5, 2001.

580-3-23-.03 Reserved

580-3-23-.04 Compliance.

(1) No person, partnership, corporation or association of persons shall operate a facility or institution for the care or treatment of any kind of mental or emotional illness or services to the mentally retarded or substance abuse services without first being certified for the physical facility by the Department of Mental Health and Mental Retardation or being licensed by the State Board of Health.

(2) All programs after the effective date of the minimum standards contained herein shall comply with said standards. The Commissioner of the Department of Mental Health and Mental Retardation, and those persons designated by him/her, will monitor compliance with these minimum physical facility and programmatic standards.

Author: DMH/MR Office of Certification

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

History: New Rule: Filed October 1, 2001; effective November 5, 2001.

580-3-23-.05 Applicability.

(1) The following entities which provide services to persons with mental illness, mental retardation, or substance abuse may be considered exempt from the certification requirements by the DMH/MR:

(a) General or psychiatric hospitals licensed as such by the Alabama Board of Health, unless the hospital requests to be a designated Mental Health Facility as certified by DMH/MR.

(b) Federal or state agencies.

(c) Public or private educational institutions.

(d) Qualified member of professions in their own private practice (such as licensed physicians, psychologists, psychiatrists, social workers, or Christian Science practitioners) as contemplated by the Code of Ala. 1975, Section 22-50-17.

(e) Voluntary self-help groups.

(f) Groups, organizations or persons that provide only incidental or shelter-type services, but do not hold themselves out as providing treatment or services to persons who have mental illness, mental retardation, or substance abuse services needs.

(g) Religious groups that operate non-treatment services solely for members of their church/organization, and do not hold themselves out as providing treatment services to persons who have mental illness, mental retardation, or substance abuse services needs.

(h) Private homes or services that do not hold themselves out as providing services to persons with mental illness, mental retardation, or substance abuse.

(i) Family member services, i.e. services provided by family members of the family related by blood or by marriage for which no remuneration is received.

(j) A "private residence" that meets both of the following criteria:

1. The home/apartment was chosen by the individual who owns it or resides there (it was not chosen by DMH/MR staff, or a certified or contracted entity); and

2. There are no monies flowing through DMH/MR that go towards the rent/lease/purchase of the residence.

(k) An entity that is funded and monitored under the Individuals with Disabilities Education Act (IDEA), Part C, Early Intervention Program.

(l) A provider certified as an ICF/MR by the State Department of Public Health.

(2) DMH/MR in its sole discretion may choose to accept wholly or partially a certificate/license/accreditation issued by any other state or national regulatory or other body for services and providers that would otherwise be reviewed through the DMH/MR certification process.

Author: DMH/MR Office of Certification

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

History: New Rule: Filed October 1, 2001; effective November 5, 2001. Amended: Filed August 13, 2002; effective September 17, 2002.

580-3-23-.06 Definitions Of Types Of Certifications/ Certificates.

(1) Agency-specific.

(a) Community Mental Health Center (CMHC) - The entity providing mental health services in a coordinated manner that assures access to inpatient and residential care and to community supports for adults with serious mental illness and children and adolescents with severe emotional disturbances. CMHC’s will be certified by DMH/MR as defined in the Alabama Administrative Code §580-2-13.01. The entity must provide the following services directly through its employees:

1. Emergency services.

2. Outpatient services.

3. Consultation and education services.

4. Partial hospitalization/intensive day treatment/rehabilitative day services in order to be certified as a CMHC. The entity must also provide residential services either directly or through agreement with another certified provider.

(b) Mental Health, Mental Retardation, or Substance Abuse Services Provider- An entity can be certified as a Mental Health Services Provider if it elects to provide one or more of the services required for Community Mental Health Center certification. The Mental Health, Mental Retardation, or Substance Abuse Services Provider may seek certification for any (but not all) of the following services:

1. Emergency services.

2. Outpatient services.

3. Consultation and education.

4. Substance abuse prevention activities

5. Partial hospitalization/intensive day treatment/ rehabilitative day services/habilitation, or;

6. Residential services.

(c) 310 Boards Certification. - Code of Ala. 1967, Act Number 310, as codified in Code of Ala. 1975, Sections 22-51-1 through 14, provides for the formation of public corporations to contract with the DMH/MR in constructing facilities and operating programs for mental health services. Such entities are commonly referred to, and are referred to herein, as "310 Boards." 310 Boards will be certified by the DMH/MR as defined in the Alabama Administrative Code, Section 580-1-2-.02 and Section 580-1-2-.06.

(2) Location-specific.

(a) Community Residential Facility – A community-based living facility providing services to individuals with mental retardation, mental illness, or substance abuse in accordance with their assessed/identified needs.

1. Mental Illness Residential – A residential setting providing congregate living and dining to consumers. Residential services offered vary by type of program but all residential services must provide assistance with applying for benefits, social and communication skills, medication management, basic living skills, vocational skills, community orientation, recreational activities, transportation, education, and family support. Specific types of residential programs are defined in the Alabama Administrative Code, Section 580-2-13.

2. Mental Retardation Residential - A community-based living facility providing services to individuals with mental retardation in accordance with their assessed/identified needs, and the client’s/guardian’s choice of services and supports, and may address health, social, community living, personal, behavioral, basic living, work, and leisure skills, and other services/supports as needed and/or as desired by the individual to gain as much independence and self-direction as possible.

3. Substance Abuse Residential.

(i) Residential Detoxification - An acute care residential service that provides medical intervention intended to rid the client of the presence of alcohol or drugs in his/her system, to promote recovery from the toxic effects of the drugs or alcohol, and to restore psychological, physiological, and behavioral function. The service is intended for clients who are suffering from severe or prolonged alcohol or drug intoxication, have symptoms of withdrawal, and who require the control afforded by a treatment service providing twenty-four (24) hour monitoring by medical staff.

(ii) Crisis Residential Adult - A highly structured, short-term, intensive chemical dependency treatment services and intensive therapeutic activities, conducted in a twenty-four (24) hour supervised living arrangement operated by the facility staffed with awake employees around the clock, which is designed to initiate and promote the client’s chemical free lifestyle.

(iii) Crisis Residential Adolescent - A highly structured, short-term, intensive chemical dependency treatment service, and intensive therapeutic activities, conducted in a twenty- four (24) hour supervised living arrangement operated by the facility using awake staff, around the clock, which is designed to initiate and promote the client’s chemical free lifestyle. An adolescent is a minor child, age twelve (12) through eighteen (18) years, whose disabilities of minority have not been removed by judicial decree or by marriage. Programs specifically for adolescents must be designed to meet the special needs of adolescents, including academics.

(iv) Residential Rehabilitation - A residential service that provides chemical dependency supportive services and therapeutic activities conducted in a residential setting designed to provide the environment conducive to recovery and to promote reintegration into the mainstream of society.

(v) Residential Treatment for Pregnant and Postpartum Women - A residential service for pregnant women and their children that provides around the clock awake staff, continuously available onsite emergency medical assistance, a structured, and supervised peer group living arrangement emphasizing abstinence from alcohol/drugs, support group meetings, social, and vocational rehabilitation. It is a twenty-four (24) hour a day, seven (7) day per week, full time living arrangement, which offers childcare, linkages with education opportunities, job placement, and referral.

4. The following Community Residential Facilities occupied by four (4) or more consumers shall be classified as "new or existing Residential Board and Care Occupancies" (NFPA).

(i) Therapeutic group home.

(ii) Group foster home.

(iii) Partial hospitalization facility.

(iv) Residential substance abuse rehabilitation facility.

(v) Crisis residential substance abuse facility.

5. The following Community Residential Facilities occupied by three (3) or less consumers shall be classified new or existing one and two (2) family dwellings (NFPA).

(i) Foster Care Home (MI).

(ii) Semi-Independent Living Facility (MR).

(1) The following Community Residential Facilities occupied by three (3) or less, shall be classified new or existing apartments.

(i) Semi-independent Living Apartment (MI-MR).

(ii) Independent Living Apartment (MI-MR).

(b) Day services.

1. Mental Illness Day Treatment.

(i) Partial Hospitalization Program - An intensive, structured, active, clinical treatment program with the goal of acute symptom remission, hospital avoidance, and/or reduction of inpatient length of stay.

(ii) Adult Intensive Day Treatment – An identifiable and distinct program that provides highly structured services designed to bridge acute treatment and increased level of functioning and enhance community integration.

(iii) Rehabilitative Day Program – An identifiable and distinct program that provides long-term recovery, achievement of personal life goals, recovery of self-worth, illness management, and help to consumers to allow them to become productive participants in family and community life.

(iv) Child and Adolescent Day Treatment – A combination of goal oriented treatment services provided according to a multiple hour schedule over a week’s time for clients under the age of 18. Key service functions will include initial screening, development of an individualized plan; individual group, and family psychiatric interventions; education for client’s parents/guardians regarding emotional/cognitive development and needs, personal care skills, and services to enhance, family, social, community, and leisure skills.

2. Mental Retardation Day Habilitation Services - Services that focus on providing assistance with acquisition, retention, or improvement in self-help, socialization, work, and adaptive skills, occurring in a non-residential setting, separate from the home or facility in which the individual normally resides. Day habilitation services are based on identified needs and desires of the client, and may also serve to reinforce skills or lessons taught at school, in therapy, at home, or other setting.

(c) Outpatient/Case Management/Other Hourly Services.

1. Mental Illness.

(i) General Outpatient – A program that includes a variety of treatment modalities and techniques and admission criteria inclusive of all ages, persons with serious mental illness/severe emotional disturbance, and persons discharged from inpatient psychiatric treatment. Services are planned and designed to assess and meet individual needs.

(ii) Emergency Services – The program must provide a twenty-four(24)-hour per seven (7) day week capability to respond to an emergency need for mental health services for enrolled consumers. Such capability shall include a telephone response by a clinician or a trained volunteer, face-to-face response by a clinician, and adequate provision for handling special and difficult cases.

(iii) Case Management – A client, focused strategy for engaging seriously mentally ill (SMI) adults and severely emotionally disturbed (SED) children/adolescents in necessary community support systems and services in order to improve their chances for recovery and successful community living. Key services include client specific assessment of need, development of a client coordinated written plan, assisting client through crisis situation, and/or arranging for the provision of assistance, services and ongoing reevaluation of needs and progress towards goals.

2. Mental Retardation - Case Management services which will assist individuals in gaining access to needed services and supports, to include funding for services, as well as needed medical, social, educational and other services and supports, to include crisis and advocacy services; ongoing monitoring of the provision of services included in the individual’s plan of care; assessment/re-assessment of level of care and review of plans of care. Other hourly services are those non-medical care, supervision, and socialization that would prevent the need for institutionalization.

3. Substance Abuse.

(i) Opioid Treatment-Opioid treatment is the dispensing of an opioid agonist treatment medication, along with a comprehensive range of medical and rehabilitative services to an individual to alleviate the adverse medical, psychological or physical effects incident to opiate addiction. Admission to maintenance treatment will be made by qualified personnel using accepted medical criteria such as the Diagnostic and Statistical Manual for Mental Disorders (DMS-IV), to determine that the person is currently addicted to an opioid drug, and that the person became addicted at least one year before admission to treatment. This service may also include short-term detoxification (less than thirty (30) days) or long-term detoxification (more than thirty (30) days, less than one hundred eighty (180) days).

(ii) Intensive Adult/Adolescent - Chemical dependency treatment services and intensive therapeutic activities provided to adult/adolescents which are designed to initiate and promote a client’s chemical free lifestyle in a non-residential setting. At a minimum this service has to be offered 2.5 hours a day, three days a week.

(iii) Intensive Specialized Women’s Programs - Chemical dependency treatment services and intensive therapeutic activities provided to pregnant women and women with dependent children which are designed to initiate and promote a client’s chemical free lifestyle. The programs must provide a standard psychosocial assessment, gender-specific substance abuse education, gender specific substance abuse therapy; group, family, and individual counseling; supportive counseling/education and detoxification if needed.

(iv) Prevention Program - Strategies developed to limit substance experimentation/use from beginning, or the identification and education in the earliest stages of alcohol, tobacco, or other drug use/abuse to preclude the onset of detrimental effect.

(v) Case Management - A service designed to assist individuals in accessing a broader array of services: physical and mental health, educational, vocational, financial, and legal, etc. Case Management includes needs assessment, case planning, crisis intervention, transportation, linkage to other resources, and advocacy.

(vi) Detoxification - A safe and effective medical management process provided in a non-residential setting for the purpose of withdrawing an individual from an addictive substance; the process is designed to result in normal physiological functioning.

(vii) Individual Counseling - A one-on-one interaction between an individual client and a counselor or therapist designed to assist in identifying and addressing those issues and problems specific to that person which prevent the initiation and maintenance of a lifestyle free of chemicals of abuse.

(viii) In-Home Intervention (pregnant women and women with dependent children)-Time limited, home based services provided by a treatment team (two-person team, one master’s level substance abuse professional and one person with a bachelor’s level degree) to alleviate an immediate crisis situation, stabilize the family unit, and prevent out-of-home placement of the client.

(ix) Ancillary Services (specialized women’s programs only)-These services include parenting, case management, childcare, and transportation (if needed).

(x) Family Counseling-A structured interaction of the client and/or his/her family member(s) with a counselor or therapist designed to assist the family in identifying and addressing those issues and problems that prevent the initiation and maintenance of a lifestyle free of chemicals.

(xi) Diagnostic Testing - Administration of standardized objective and/or projective tests of an intellectual, personality, or related nature in a face-to-face interaction between the client and staff member and interpretation of the test results.

(xii) HIV counseling (individual, group, family, case management) - A structured interaction between substance abuse treatment clients and a qualified SA counselor or HIV specially trained therapist designed to assist clients in preparing for HIV testing, dealing with test results, and/or modifying risky behavior designed to reduce the transmission of HIV.

4. Outpatient/Case Management-The following outpatient services facilities shall be classified as "New or existing Business occupancies" (NFPA).

(i) Mental Health Services Provider.

(ii) Community Mental Health Center.

(iii) Community Mental Health Center Satellite Facilities.

5. The following Day Services Facilities shall be classified as "New or existing Educational occupancies" (NFPA).

(i) Intensive Day Treatment (MI).

(ii) Rehabilitation Day Treatment (MI).

(iii) Child and Adolescent Day Treatment (MI).

(iv) Day Habilitation Services (MR).

(v) Day Training Facilities (MR).

(vi) Work Activity Center (MR).

(vii) Outpatient Services (SA).

(viii) Intensive Outpatient Services (SA).

(ix) Specialized Women’s (SA).

(x) Methadone Clinic/Opiate Replacement (SA).

Author: DMH/MR Office of Certification

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

History: New Rule: Filed October 1, 2001; effective November 5, 2001. Amended: Filed August 13, 2002; effective September 17, 2002.

580-3-23-.07 Period Of Certification.

(1) The provider is notified by the Commissioner of the status of certification.

(2) Certificates may be issued for a period of up to two (2) years. If a program does not sufficiently meet all DMH/MR certification standards, it may be granted a provisional certification not to exceed sixty (60) days.

(3) If the agency holds a provisional certification following a survey, there will be an automatic one (1) year restriction on the period for certification.

(4) If an agency is decertified under any division standards, the period of certification by the DMH/MR is automatically limited to one (1) year for all DMH/MR Divisions’ certifications.

(5) When DMH/MR issues a certificate, the certificate will be retroactive to the expiration date of the last certification and will be for the shortest period specified by any one division’s review.

(6) A separate certificate is issued for each site, program, or service operated or provided by an entity.

(7) The certificate will reflect compliance with administrative standards, programmatic standards, and with Life Safety Code requirements as applicable.

(8) The certificate must be maintained at the site of the service. If there is no physical plant for a specific service, the certificate will be maintained in the agency’s main office.

(9) When a program is decertified, or the operation of a site or services ceases to exist or services are not provided for more than thirty (30) days, any current certificate must be returned to the DMH/MR Facilities Certification Office and, unless waived by the Commissioner of DMH/MR, the procedure for initial certification of the program or service (580-3-23-.08 and 580-3-23-.09) must once again be completed before the program can resume the services.

Author: DMH/MR Office of Certification

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

History: New Rule: Filed October 1, 2001; effective November 5, 2001. Amended: Filed August 13, 2002; effective September 17, 2002.

580-3-23-.08 Application Process.

(1) A completed application for certification is sent by the provider/applicant to DMH/MR Facilities Certification Office sixty (60) days prior to projected date of service implementation. Any additional documentation must be submitted as required and specified by DMH/MR. For Methadone Clinic applications, an entity must also submit a Certificate of Need as approved by the Alabama State Health Planning and Development Agency.

(2) DMH/MR may accept a certification/license/ accreditation issued by other generally accepted recognized state or national organizations in lieu of an additional review through the DMH/MR certification process. However, DMH/MR reserves the right to apply DMH/MR certification standards to areas it determines are not adequately addressed in other state or national standards. Further, the DMH/MR reserves the right to conduct reviews, including onsite visits if appropriate, of programs that are certified/licensed/accredited by other entities where there is evidence of significant deficiencies.

(2) The DMH/MR Facilities Certification Office submits the application to the respective DMH/MR Division(s) for approval according to the type(s) of services proposed by the provider.

(3) Applications for MI Adult Foster Care are forwarded by the Facilities Certification Office to the respective Community Mental Health Center that contracts with the provider. The CMHC approves the application and forwards it to the DMH/MR Facilities Certification Office. The DMH/MR Facilities Certification Office submits the application to the MI Division.

(4) The applicable DMH/MR Division(s) review/approve the application and returns a copy of the approval to the DMH/MR Facilities Certification Office. An initial Life-Safety and Programmatic review is conducted, if applicable, by designated DMH/MR representatives. Applications remain valid for up to six (6) months after receipt by DMH/MR if the service has not been initiated by the provider or approved by DMH/MR.

(5) For new applicants/providers, the DMH/MR will conduct criminal background checks on the primary operator and/or subcontractor of the program as defined in the Alabama Administrative Code, Section 580-3-23-.06(1)(a) and Section 580-3-23-.06(1)(b).

(6) When the facility passes the initial certification review, the program is issued a letter of Temporary Operating Authority by the DMH/MR Commissioner for a period up to six (6) months. The Facilities Certification Office prepares a letter of Temporary Operating Authority for the Commissioner to sign and forwards the signed letter to the respective Provider/Applicant.

Author: DMH/MR Office of Certification

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

History: New Rule: Filed October 1, 2001; effective November 5, 2001.

580-3-23-.09 New Services.

(1) When a certified entity develops new programs or services covered by DMH/MR standards, DMH/MR must be informed of the plan in writing and adequate documentation as specified by DMH/MR must be submitted to permit a determination that the plans are compliant with Life Safety/and/or programmatic standards established for that service/program.

(2) Once necessary documents and information are received, a Life Safety and/or programmatic review is conducted as needed.

Author: DMH/MR Office of Certification

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

History: New Rule: Filed October 1, 2001; effective November 5, 2001.

580-3-23-.10 Site Visits.

(1) A review of administrative requirements as set out in the Alabama Administrative Code, Sections 580-2-13, 580-1-2, and 580-5-30, shall be separate from program site visits.

(2) A site visit is conducted within six months of initial certification, but in any event, prior to the expiration of the Letter of Temporary Operating Authority. The Provider may be required to submit additional documents prior to the on-site certification survey.

(3) The initial program site visit and/or administrative review will be scheduled with the agency. All subsequent program site visits will occur in accordance with the period of certification renewal date and may be unannounced. All subsequent administrative reviews will be conducted in accordance the period of certification renewal date and with DMH/MR policies.

(4) At the end of each day of the site visit, a debriefing will be held with the agency’s executive director or his designee and the surveyor to review any problems that may have been found that day.

(5) At the conclusion of the program site visit, preliminary findings are given orally to the Agency Director and any selected staff, board members, and representatives of consumers and families available for the exit interview.

(6) An exit interview will be conducted upon the completion of the respective Division’s/Office’s survey. An entity should have the opportunity to clarify or present evidence of compliance on issues being cited by the survey team. At the exit meeting, the entity should provide documentation/ information related to specific citations or the entity will be afforded the opportunity to provide documentation to demonstrate compliance to the respective division with one (1) working day of the exit meeting.

Author: DMH/MR Office of Certification

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

History: New Rule: Filed October 1, 2001; effective November 5, 2001. Amended: Filed August 13, 2002; effective September 17, 2002.

580-3-23-.11 Unannounced Visits.

(1) DMH/MR or its agents has the authority to periodically monitor entities’ continuing compliance with standards, or contract requirements, as applicable, to conduct reviews and investigations at any time or to investigate a complaint or when other information is received regarding consumer rights, services, and/or program operations.

(2) If there are findings of non-compliance, the procedures specified in 580-3-23-.13 through 580-3-23-.15 will be followed.

Author: DMH/MR Office of Certification

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

History: New Rule: Filed October 1, 2001; effective November 5, 2001.

580-3-23-.12 Site Visit Reports.

(1) Within thirty (30) days of the site visit, the Certification Site Visit Report will be sent to the Agency’s Director via certified mail. As applicable, a copy of the report will be sent to the agency’s Board of Directors and, as applicable, a copy will be sent to the Executive Director of an agency holding the contract with DMH/MR (if the agency certified is a sub-contracting agency).

(2) The Certification Site Visit Report lists each standard not met and specific findings, which constitute the basis for noncompliance, and may also include recommendations for standards that need quality improvement. The report will specify timeframes for mandatory compliance with specific standards.

(3) If the agency fails any division’s survey, a letter included in the site visit report to the agency’s Executive Director, via certified mail, specifies that the agency is provisionally certified for a period of up to sixty (60) days, and all applicable parties will be notified.

Author: DMH/MR Office of Certification

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

History: New Rule: Filed October 1, 2001; effective November 5, 2001. Amended: Filed August 13, 2002; effective September 17, 2002.

580-3-23-.13 Entity’s Plan of Action. If the provider receives a provisional or one-year certificate, the provider is required to submit to the respective/applicable Division/Office a Plan of Action for issues cited, within thirty (30) days after the date of receipt of the Site Visit Report. The plan must project compliance within thirty (30) days for each deficit cited for Life-Safety issues identified by the survey team, and must project compliance with specified divisional standards within sixty (60) days after the completion of the site visit. A shorter timeframe may be required if findings indicate a risk to the health/safety of persons served and/or for non-compliance with specified standards.

Author: DMH/MR Office of Certification

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

History: New Rule: Filed October 1, 2001; effective November 5, 2001. Amended: Filed August 13, 2002; effective September 17, 2002.

580-3-23-.14 DMH/MR Response To Plan Of Action.

(1) Actions taken by the respective DMH/MR Division/Office when the agency’s Plan of Action is received may include one or more of the following:

(a) Approve and recommend certification.

(b) Request additional documentation or a supplemental plan of action.

(c) Provide technical assistance in deficient area(s) if requested in writing to Service Division.

(d) Conduct follow-up site visit prior to the end of the sixty (60) day period (following the site visit which discovered the deficiencies in question), or other period specified for compliance by DMH/MR.

(2) If the agency does not comply with specified standards, a follow-up site survey must be conducted, or a recommendation for decertification of the agency must be recommended by the surveyor.

Author: DMH/MR Office of Certification

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

History: New Rule: Filed October 1, 2001; effective November 5, 2001.

580-3-23-.15 Appeal Procedures Within DMH/MR.

(1) A recommendation by any DMH/MR Division for decertification may be appealed to the Commissioner within fifteen (15) working days of the entity receiving the report/ recommendation. The appeal by the entity must specify the precise reason(s) for the appeal and provide documentation to support modification of the site visit findings/recommendation for decertification.

(2) Any final decision to order decertification of a program or to deny initial certification will be made by the DMH/MR Commissioner after the affected provider is afforded the opportunity for an administrative hearing on the matter. Such hearings will be conducted in accordance with the Alabama Administrative Procedures Act.

Author: DMH/MR Office of Certification

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

History: New Rule: Filed October 1, 2001; effective November 5, 2001. Amended: Filed August 13, 2002; effective September 17, 2002.

580-3-23-.16 Decertification.

(1) If the entity does not comply with required certification criteria within a specified timeframe, a recommendation for decertification is made to the DMH/MR Commissioner by the respective DMH/MR Division/Office. A copy of this recommendation is sent, via certified mail, to the Executive Director of the agency, and to its Board of Directors, and, as applicable, to the executive director of an agency holding the contract with DMH/MR.

(2) If the Commissioner notifies an entity of the intent to decertify their program it may appeal the decision for decertification, or it may request a delay for up to ninety (90) days in the Commissioner’s final decision due to extenuating circumstances which must be specified, in order to fully comply with applicable standards. It remains solely within the discretion of the DMH/MR Commissioner to approve such a delay, based upon the type(s) and/or numbers of deficits or standards not met. If approved, the Commissioner will notify the provider of the period of time within which the entity must comply with standards.

(3) If the entity does not appeal the decision for decertification, or does not request a delay to comply with standards, the entity will be decertified on the date specified by the DMH/MR Commissioner.

(4) After notice to an entity and an opportunity for the entity to respond, the DMH/MR Commissioner may rescind or revoke any certification for any material neglect of, disregard of, or noncompliance with these standards and/or violation of federal, state or local law. The DMH/MR Commissioner, may immediately, without notice suspend or revoke any Department Certificate under these standards if the Commissioner finds that a provider’s deficiencies with a standard (or standards) poses a serious threat to the safety and welfare of any consumer served as determined by the Commissioner.

(5) If the entity has complied with standards within the timeframe specified in the Certification Site Visit Report, or as specified by the Commissioner after having granted a delay to come into compliance, a recommendation is made by the respective Division(s) to the DMH/MR Commissioner to certify/re-certify the entity for a period of one year from the date of the expiration of the entity’s previous certification.

(6) Failure to comply with one Division’s/Office’s standards will result in a recommendation for decertification of the entity for the provision of those services only. An entity may continue and be certified to provide services of another division(s) as long as the entity complies with those certification standards.

Author: DMH/MR Office of Certification

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

History: New Rule: Filed October 1, 2001; effective November 5, 2001. Amended: Filed August 13, 2002; effective September 17, 2002.

580-3-23-.17 Renewal Of Certification.

(1) Site visits for the purpose of certification are scheduled and conducted within a sixty (60) day period prior to the expiration of the entity’s current certification.

(2) Updated information regarding services may be requested from an entity by any DMH/MR Division at any time.

Author: DMH/MR Office of Certification

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

History: New Rule: Filed October 1, 2001; effective November 5, 2001. Amended: Filed August 13, 2002; effective September 17, 2002.