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Alabama License Reinstatement

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A. Ant, CADC-II

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Author: A. Ant, CADC-II, Licensing & Accreditation Expert

Disclaimer: This content is provided for general informational purposes only and should not be construed as legal, regulatory, or licensing advice. Requirements change frequently. Consult qualified professionals for guidance specific to your situation.

Alabama writes a two-strike rule into its certification regulations. Under rule 580-3-23-.16, a program “consistently fails to meet standards” when it lands on provisional certification twice in a twelve-month period, and consistent failure is a ground for decertification by the Alabama Department of Mental Health (ADMH). A provisional certificate lasts no more than 60 days, so two of them inside a year is a short road. The rule offers no step called reinstatement. A decertified program gives back its certificate and, unless the Commissioner waives it, goes through initial certification again from the start.

That matters more in Alabama than in states where certification is voluntary. Code of Ala. §22-50-17(a) bars anyone from operating a facility that treats mental illness or substance abuse “without being certified by the department or licensed by the State Board of Health.” Losing ADMH certification takes away the program’s legal footing along with the credential. We did not find the penalty provision for operating without certification, so we won’t guess at one, but we would not keep serving clients after a final decertification order.

The Enforcement Path, Step by Step

The deadlines in this section come from chapter 580-3-23 (the official PDF and the Cornell copies of individual rules), §22-50-19 on the Legislature’s site, and ADMH’s Incident Management Plan. Where we say what a step means for a program, that is our reading.

StageADMH certification (ch. 580-3-23)ADPH hospital license (ch. 420-5-7)
After a surveyReport within 30 days of the site visit, by certified mail (.12). Plan of Action due within 30 days of receiving it (.13)ADPH survey, which a Joint Commission accredited hospital is spared under §22-21-24
Correction deadlinesLife Safety deficits within 30 days, other standards within 60 days of the visit (.13)Not covered by the sources for this guide
Middle stepProvisional certification up to 60 days, then a next certification period capped at one year (.07, .12)License may be downgraded
Loss of credentialRescission or revocation for material neglect of or noncompliance with standards, immediate suspension or revocation for a serious threat to consumers (.16)Revocation on grounds listed in 420-5-7-.02
ChallengeAppeal of a decertification recommendation to the Commissioner within 15 working days of receiving it, hearing under the Alabama Administrative Procedure Act (.15), then circuit court within 15 days of the final order (§22-50-19)Hearing under the Administrative Procedure Act and chapter 420-1-3
FinesNone we found in 580-3-23 or 580-2-20Not reviewed for this guide

From Site Visit to Provisional Status

Most trouble begins with the site visit report, which ADMH sends by certified mail “Within thirty (30) days of the site visit” under 580-3-23-.12. The clock for the Plan of Action starts when the report arrives, and the plan is due “within thirty (30) days after the date of receipt of the Site Visit Report” (580-3-23-.13). The correction deadlines run from the visit itself, though: 30 days for Life Safety deficits and 60 days for everything else. By the time the report shows up, some of that time is already gone.

A program that isn’t in substantial compliance can be placed on provisional certification “not to exceed sixty (60) days” (580-3-23-.07(2)). Coming off provisional status doesn’t restore a full term. Under 580-3-23-.07, the next certification period after a provisional certificate is limited to one year, and a decertification under any ADMH division limits all of the provider’s certifications to one year. Incident reporting carries its own one-year penalty. Since October 1, 2017, ADMH has required certified providers to file incident reports electronically in Therap and to have the technology to run it, and the Incident Management Plan, Part B says of that requirement, “Failure to abide by this standard will result in a critical finding and an automatic one-year certification.” A program that would otherwise score its way into a two-year certificate can lose a year simply by not having Therap up and running.

Decertification and the Appeal Windows

Rule 580-3-23-.16 gives the Commissioner two kinds of authority. Certification can be rescinded or revoked for “material neglect of, disregard of, or noncompliance with these standards,” and it can be suspended or revoked immediately when there is a “serious threat to the safety and welfare of any consumer served.” Decertification may be limited to the services of one division, so a provider certified for both substance use and mental health services could lose one and keep the other. When decertification is recommended, the program can appeal or ask for a delay of up to 60 days, which the Commissioner may or may not grant.

The appeal window is measured in working days. Under 580-3-23-.15, a decertification recommendation “may be appealed to the Commissioner within fifteen (15) working days” of the provider receiving it, and the Commissioner cannot order final decertification until the provider has had an administrative hearing conducted under the Alabama Administrative Procedure Act. After the final order, §22-50-19 allows review in circuit court, “provided a sworn complaint is filed within 15 days of the date of such order or decision, charging that such order or decision was arbitrary, illegal or capricious,” along with security for costs. Fifteen days is short for a court filing, so counsel should be lined up before the hearing ends.

Getting Certified Again

Alabama sets no waiting period that we found. What it does set is a restart. Rule 580-3-23-.07 has the certificate returned to ADMH on decertification, and initial certification must be completed again unless the Commissioner waives it. A site that closes, or a service that goes dark for more than 30 days, triggers the same return of the certificate. In practice, a decertified provider goes back through the prospective provider process: the Relias orientation training, a new application through ACAP, the $1,500 non-refundable fee after ADMH’s fee letter, a Life Safety inspection, temporary operating authority and an initial site visit. For a program that brings itself back up to standard, 580-3-23-.16 provides for recertification “for a period of one year from the date of the expiration of the entity’s previous certification.”

In our reading, the application will be read against the history. The rules call for criminal background checks on the primary operator for new applicants (580-3-23-.08(6)), and a reviewer at the Office of Certification Administration will have the decertification file. Accreditation won’t carry a program around this. ADMH “may accept” outside accreditation in lieu of an additional review under 580-3-23-.08(2), but that is discretionary and names no accreditor, and we would not expect it to be granted to a provider coming back from decertification. Questions about a reapplication go to contactoca.dmh@mh.alabama.gov.

Renewals That Slip

Recertification site visits happen “within a sixty (60) day period prior to the expiration” of the certificate (580-3-23-.17), and later visits may be unannounced (580-3-23-.10). A certificate that expires without that visit has no grace provision we could find. The safer assumption is that a lapsed program starts over as a new applicant, so contact OCA well before the 60-day window opens if a visit hasn’t been scheduled.

Psychiatric Hospitals Licensed by ADPH

A psychiatric hospital is licensed by the Alabama Department of Public Health, Bureau of Health Provider Standards, not certified by ADMH. Rule 420-5-7-.02 lets the Board revoke a hospital license (“The Board may revoke a license to operate a hospital if it finds any of the following”) or downgrade it, with hearings under the Administrative Procedure Act and chapter 420-1-3. Hospital licenses run for the calendar year and “shall expire on December 31.” ADPH’s fee table charges a late renewal penalty of $300 or 100 percent of the renewal fee, whichever is greater. A Joint Commission accredited hospital is “licensable without further inspection or survey” under §22-21-24, but must still apply, and under 420-5-7-.02(6) the hospital must tell ADPH in writing, promptly, if its accreditor or deemed status changes. In our reading, a hospital that loses accreditation goes back to ordinary state surveys. The Bureau’s acute care line is (334) 206-5366. More on these settings is in Alabama Mental Health Inpatient Licensing.

A Plan of Action ADMH Can Close

From our experience with surveys, the plans that close quickly take each cited standard in order, quote the rule number, say what changed, name the staff member who owns it, give a completion date inside the 30 or 60 day window, and attach evidence such as a revised policy page, a signed training roster or a fresh chart audit. Life Safety items deserve their own list, because their 30-day clock is the shorter one. Where an incident sits behind a citation, attach the Therap General Event Report and its follow-up record, since the Part B plan expects critical incidents reported within 24 hours and followed up within 15 days. For how a program is built in the first place, see Alabama Drug and Alcohol Inpatient Treatment Licensing, Alabama Drug and Alcohol Outpatient Treatment Licensing and the overview at Alabama Behavioral Health Licensing.

Frequently Asked Questions

How many provisional certifications can an Alabama program receive before decertification?

Rule 580-3-23-.16 treats provisional certification twice within a twelve-month period as consistently failing to meet standards, which is a ground for decertification by the Alabama Department of Mental Health. Each provisional certificate lasts no more than 60 days.

How long does a program have to appeal an ADMH decertification finding?

Fifteen working days from receiving the decertification recommendation to appeal to the Commissioner under rule 580-3-23-.15, and no final decertification can issue before a hearing under the Alabama Administrative Procedure Act. Once a final order issues, Code of Ala. §22-50-19 gives 15 days to file a sworn complaint in circuit court.

Is there a waiting period before a decertified Alabama program can reapply?

We found none in chapter 580-3-23. The certificate goes back to ADMH and initial certification has to be completed again unless the Commissioner waives it, which means a new application through ACAP, the fee, a Life Safety inspection and an initial site visit.

Holding an ADMH site visit report and counting working days? Get in touch.

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