Ala. Admin. Code r. 580-2-20-.03

Current through Register Vol. 42, No. 7, April 30, 2024

Section 580-2-20-.03 - Personnel

(1) There shall be a full-time executive director who has overall responsibility for the operation of the agency. The executive director shall:

(a) Have at least a master's degree in Public Health, Business Administration, Public Administration, Psychology, Counseling, Social Work or related field and at least five (5) years managerial experience in a mental health or substance abuse treatment setting; or

(b) Have a Bachelor's Degree in Public Health, Business Administration, Public Administration, Psychology, Counseling, Social Work or related field and at least ten (10) years managerial experience in mental health or substance abuse treatment setting.

(c) Notify MHSAS within thirty (30) days of changes in Executive Director.

(d) Be verified for compliance with ADMH Administrative Code by ADMH MHSAS certification process.

(2) 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 as delineated in the job description. The Clinical Director shall:

(a) Have a minimum of either a master's degree in psychology, social work, counseling, or psychiatric nursing and have a minimum of 3 years post master's relevant clinical experience or be a physician who has completed an approved residency in psychiatry.

(b) For agencies who provide substance abuse treatment services, have a license or a substance abuse counselor certification credential from the Alabama Association of Addiction Counselors, National Association of Alcoholism and Drug Abuse Counselors, Alabama Alcohol and Drug Abuse Association, or International Certification and Reciprocity Consortium/Alcohol and Other Drug Abuse, Inc.

(c) Notify MHSAS within thirty (30) days of changes in Clinical Director.

(d) Be verified for compliance with ADMH Administrative Code by ADMH MHSAS certification process.

(3) There shall be a Business Manager/Chief Financial Officer or equivalent:

(a) The financial accounting operations of a service provider organization with a total annual budget exceeding $750,000 shall be supervised by a full-time employee or contracted service who has the following qualifications:

1. At least a bachelor's degree in accounting or business, finance, management, public administration, with at least three (3) college accounting courses.

2. At least two (2) years accounting experience.

(b) The financial accounting operations of a service provider organization with a total annual budget less than $750,000 shall be supervised by an employee or contracted service who/which has the following qualifications:

1. Demonstrated familiarization with Generally Accepted Accounting Principles and;

2. At least two (2) years accounting/bookkeeping experience.

(4) An individual who met the requirements of the Administrative Code 580-9-44-.02 Personnel effective March 2012 or Administrative Code 580-2-9-.03 MI Program Staff July 2010 and was employed prior to the approval of these rules shall be in good standing.

(5) In certain situations, the Commissioner of ADMH may waive the requirements of this chapter as necessary to serve the DMH services recipients and/or the interests of the public.

(6)Mental Illness Program Staff Only. The agency shall have policies and procedures that detail the following personnel requirements:

(a) There shall be a psychiatrist, as a full-time or part-time employee or a consultant to the provider who is responsible for medical aspects of consumer psychiatric care as delineated in the job description or employment contract. Access to on-call psychiatric services shall be available 24 hours a day, 7 days a week and must be documented.

(b) There is an organizational chart that depicts functional areas of responsibility and lines of supervision for all programs operated by the agency.

(c) Each direct treatment service functional area of responsibility on the organizational chart shall be coordinated by a member of the staff who has a master's degree in a mental health related field and at least one (1) year post master's supervised experience in a direct service area. Program coordinators of Adult Rehabilitative Day Programs shall have at a minimum of a bachelor's degree, or RN. Both shall have a minimum of one (1) year supervised post degree mental health related experience.

(d) 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 shall 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 610-X-7.06 Alabama Department of Mental Health Residential Community Programs.

(e) All treatment staff who provide therapy and clinical assessments for mental illness consumers shall have a master's degree in a mental health related field and have successfully completed a mental health clinical practicum or have six (6) months post-master's level experience in a mental health clinical field.

(f) Treatment staff who do not have a mental health clinical practicum master's degree shall:

1. Complete an in-house practicum, receive face-to-face (virtual or in person) supervision from a therapist who has a master's degree in a mental health related field and at least two (2) years post master's degree mental health experience in a direct service functional area for six (6) months.

2. Supervision shall include at least two (2) face-to-face supervisory sessions per month for a minimum of one (1) hour per session.

3. Upon completion of the required clinical practicum, an additional six (6) months of supervision is required and shall include at least two (2) face-to-face supervisory sessions per month minimum one (1) hour per session.

(g) The credentials of staff shall be appropriate for the levels and types of services they are providing. The following are approved minimum qualifications:

1. Mental Health Rehabilitative Services Professional who meets one (1) of the following:

(i) A psychologist licensed under Alabama law.

(ii) A professional counselor licensed under Alabama law.

(iii) An independent clinical social worker licensed under Alabama law.

(iv) A marriage and family therapist licensed under Alabama law.

(v) A registered nurse licensed under Alabama law who has completed a master's degree in psychiatric nursing.

(vi) A Masters Level Clinician is an individual possessing a master's degree or above from a university or college with an accredited program for the respective degree in psychology, social work, counseling, or other mental health human service field areas who meets at least one (1) of the following qualifications:

(I) Has successfully completed a clinical practicum as a part of the requirement for the degree OR

(II) Has six (6) months of post master's level clinical experience supervised by a master's level or above clinician with two years of postgraduate clinical experience.

2. A physician licensed under Alabama law to practice medicine or osteopathy.

3. A physician assistant licensed under Alabama law and practicing within the guidelines as outlined by the Alabama Board of Medical Examiners.

4. A Certified Registered Nurse Practitioner (CRNP) licensed under Alabama law practicing within the scope as defined by the Joint Committee of the Alabama Board of Nursing and the Alabama Board of Medical Examiners for Advanced Practice Nurses.

5. A pharmacist licensed under Alabama state law may provide medication monitoring.

6. A Registered Nurse licensed under Alabama state law.

7. A Practical Nurse licensed under Alabama state law.

8. Qualified Mental Health Provider - Bachelor's - A person with a bachelor's degree in a mental health human services field.

9. Qualified Mental Health Provider- Non-Degreed - A person with a high school diploma or GED supervised by a Rehabilitative Services Professional.

10. A Nursing Assistant certified pursuant to Alabama State Law.

11. Medication Assistant Certified (MAC) Worker - A person working under a Medication Assistance Supervising (MAS) nurse that meets the Alabama Board of Nursing requirements.

12. A Certified Mental Health Youth Peer Specialist -Youth who has personal verified lived experience with children and adolescents.

(h) Staff who provide services primarily to recipients who are deaf/hard of hearing shall have either two (2) years supervised experience with the specific subgroup, or two (2) specialized graduate courses related specifically to the subgroup or twelve (12) continuing education credits of training in the specialty area to work with this subgroup or shall receive supervision by a staff member with the required training/ experience.

(i) Staff who provide treatment and clinical services primarily to children and adolescents shall have one (1) year experience working with children and adolescents and shall receive ten (10) hours of specialized training to be completed within one (1) year form the date they began providing such services.

(j) Teachers who provide educational service to children shall meet the requirements outlined by the Alabama State Department of Education.

(k) All staff positions who are required to complete an ADMH certification training program will be outlined under their targeted service area.

(l) All staff who transport consumers shall have a valid driver's license.

(m) Documentation of all required supervision shall include the following information for each supervisory session:

1. Name and signature of supervisor.

2. Name and signature of employee.

3. Date of supervision.

4. Amount of time in supervisory session.

5. Brief description of topics covered in session.

(n) The agency shall conduct criminal background checks on all employees/volunteers/agents prior to employment/ engagement.

(o) Students who are completing a graduate degree in psychology, counseling, social work, or psychiatric nursing may be used for direct services under the following conditions:

1. The student is in a clinical practicum or internship that is part of an officially sanctioned academic curriculum.

2. The student receives a minimum of one (1) hour per week direct clinical supervision (face-to-face) from a mental health professional having at least two (2) years post master's experience in a direct mental health service functional area.

3. The student's clinical notes shall be cosigned by the agency's supervisor who directly supervises the student.

(p) All employees/staff having direct service contact with recipients shall be trained in the following prior to working alone with recipients:

1. Management of aggressive/assaultive behavior and

2. Crisis intervention techniques.

3. The training must have been within the past two (2) years.

(q) All unlicensed staff who have direct service contact with recipients shall receive initial training on the following topics:

1. Diagnostic categories.

2. Classes of psychotropic medications.

3. Recovery orientation.

4. Interaction with consumers and families.

(r) Each program provides training for all staff on abuse and neglect and all state laws pertaining to abuse and neglect including reporting required by the Department of Human Resources. Training is required for all new employees within thirty (30) days for non-direct care staff. For direct care staff, training is required prior to working alone with recipients and on an annual basis thereafter.

Ala. Admin. Code r. 580-2-20-.03

Adopted by Alabama Administrative Monthly Volume XXXVII, Issue No. 01, October 31, 2018, eff. 11/30/2018.

Amended by Alabama Administrative Monthly Volume XLI, Issue No. 07, April 28, 2023, eff. 6/12/2023.

Author: Division of Mental Health and Substance Abuse Services, DMH

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