The treatment and care of emotionally disturbed children and adolescents are of great concern to various State agencies including the Maryland Department of Health, Department of Human Services, Maryland State Department of Education and Department of Juvenile Justice. The Maryland Department of Health, Department of Human Services, Maryland State Department of Education, and Department of Juvenile Services, by statute, are responsible to ascertain that applicants for licenses conform to the regulations promulgated under the legal authority vested in the respective departments. In this chapter, the following terms have the meanings indicated. Terms Defined. “Accreditation organization” means a private entity that conducts inspections and surveys of health care facilities based on nationally recognized and developed standards. “Accredited residential treatment center” means a residential treatment center that is accredited by: The Joint Commission on Accreditation of Healthcare Organizations; The Commission on Accreditation of Rehabilitation Facilities; or The Council on Accreditation. “Adverse event” means an unexpected occurrence that: Is related to a resident’s medical or behavioral treatment; and Is not related to the natural course of the resident’s illness or underlying disease condition. “Center” means a residential treatment center. “Change in condition” means a significant change in a resident’s physical, mental, or psychological status including: Life-threatening conditions; Clinical complications, including significant somatic symptoms that require the assessment or treatment by qualified medical personnel; The need to discontinue a medication or treatment because of: An adverse consequence; or The need to begin a new form of treatment; Evaluation at or admission to a hospital; Injuries that require the assessment of or treatment by qualified medical personnel; The use of restraint or seclusion; and Suicide attempts. “Department” means the Maryland Department of Health. “Fire authorities” means the official fire safety agency including the State Fire Marshal and local fire departments or fire marshals as appropriate. “Governing body” means the organizational structure that is responsible for all center operations, including: Establishing policy; Maintaining quality care; and Providing management and planning for the center. “Joint Commission” means the voluntary national healthcare accreditation service recognized for: Medicare certification purposes by Public Law 89-97; and Maryland State licensure purposes by Health-General Article, §19-2302, Annotated Code of Maryland. “Licensee” means the individual, partnership, association, or corporation to which a license is issued. “Nonaccredited residential treatment center” means a residential treatment center that is not accredited by: The Joint Commission on Accreditation of Healthcare Organizations; The Commission on Accreditation of Rehabilitation Facilities; or The Council on Accreditation. “Person” means an individual, receiver, trustee, guardian, personal representative, fiduciary, or representative of any kind and any partnership, firm, association, corporation, or other entity. “Resident” means any child or adolescent domiciled in a center for the purpose of receiving the services offered by a residential treatment center. “Residential treatment center” means a psychiatric institution that provides campus-based intensive and extensive evaluation and treatment of children and adolescents with severe and chronic emotional disturbances who require a self-contained therapeutic, educational, and recreational program in a residential setting. “Secretary" means the Secretary of Health. License Required. A person may not establish, conduct, maintain, or operate in the State a center without first obtaining a license from the Secretary. Separate License Required. Centers maintained on separate premises shall obtain separate licenses, even though operated under the same management. License Not Required Under This Chapter. The following facilities are not deemed to be within the purview of these licensing requirements and are not required to obtain a license under these provisions: Any institution for well children, including day nurseries, child care centers, foster boarding homes, and institutions for intellectually disabled children; and Institutions operated by the Federal Government. Posting of License. The license shall be posted conspicuously on the premises. Other Licensing Requirements. Before issuing a license the Secretary shall receive written notification that the center meets the following requirements: Clinical services and treatment program shall be approved by the Department; Child care services and program shall be approved by the Department of Human Services in accordance with its published regulations; The educational program shall be approved by the State Department of Education. Licensed Capacity. A center may not admit residents in excess of the number authorized and shown on the current license. Application. Applicants shall conform to the following: An applicant desiring to open or to continue the operation of an existing center shall file with the Secretary, on a written or electronic form provided by the Secretary: The name of the applicant desiring the license; and The location of the center, the name of the person in charge, and any additional documents and information that the Secretary may require. Application on behalf of a corporation or association or a governmental unit or agency shall be made by two of its officers, and the names of their board members shall be submitted. All licenses shall expire 3 years from the date of issuance unless revoked. The applicant for an original license shall submit the following, and insure that current copies are on file with the Department: Written permission from local zoning authority for an original license in municipalities which have established zoning; Written approval from the appropriate fire authorities; A current food service permit; and Copy of signed agreement between the center and the principal somatic physician and psychiatrist. Renewal. Application for the renewal of the license shall be made each year at least 30 days before expiration of issued license, submitted on written or electronic forms provided by the Secretary. License renewal shall be based on accreditation by the Joint Commission, the Commission on Accreditation of Rehabilitation Facilities, or the Council on Accreditation. The center shall be required to submit evidence of current accreditation that shall include: A copy of the current accreditation letter issued to the center; A copy of the standards determined not to be in compliance, or with recommendations for improvement issued to the center; and The evidence of the action taken to correct noncompliance which was submitted to the accreditation organization. Restrictions. Centers licensed under these regulations may not use in their title words “Hospital”, “Sanitarium”, “Nursing”, “Convalescent”, or “Rest”. A license shall be valid only in the hands of the licensee to whom it is issued and may not be subject to sale, assignment, or other transfer, voluntary or involuntary, nor may a license be valid for any premises other than those for which originally issued. Duration of License. Licenses are valid for 1 year from the date of issuance unless revoked. Licenses for Less Than 12 Months for the Operation of Hospitals and Related Institutions. The Secretary may issue a provisional license to a nonaccredited residential treatment center if: The nonaccredited residential treatment center is pending accreditation by The Joint Commission, the Commission on Accreditation of Rehabilitation Facilities, or the Council on Accreditation; and The provision license is valid for a period not to exceed 12 months. The Secretary shall deny a license to a person who has been convicted of a felony that relates to Medicaid or to a nursing home. The Secretary shall revoke the license of any licensee convicted of a felony that relates to Medicaid or to a nursing home. The Secretary may deny or revoke a license if the center does not meet the requirements of: Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland; and Any regulation adopted under Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland, including this chapter. A center subject to denial or revocation of license under this chapter, may request a hearing as set forth in accordance with Regulation .20 of this chapter. Open to Inspection. A center licensed under this chapter and any premises proposed to be operated by an applicant for a license shall be open at all reasonable times to inspection by: The Secretary or designee; The Department of Human Services; The Maryland State Department of Education; The Department of Juvenile Services; or Any other agency authorized by the Secretary. Submission of Plans. Plans shall be submitted to the Secretary before construction or alterations begin affecting its functional structure or normal bed capacity. These plans shall have the prior approval of local zoning authorities and the appropriate fire authorities. The Secretary shall review promptly the plans and shall notify the applicant or licensee within 30 days that the building, alteration, additions, or changes, are approved or disapproved with the recommendations that the Secretary may make. If an application is disapproved, the applicant or licensee shall be informed of the reasons at the time of notification. Application to Service Facilities. A system of water supply, plumbing, sewerage, electrical power, garbage or refuse disposal may not be installed or extended until complete plans and specifications have been submitted and approved in accordance with §A, of this regulation. Construction. A new building designated as a residential treatment center and any existing building proposed for conversion for this use shall meet the following: The construction of the building shall prevent the entrance and harborage of rats and other rodents; The center shall comply with all other applicable governing laws or ordinances; and The center shall be constructed to comply with the requirements of the Americans with Disabilities Act. Heating. A center shall be equipped with a central heating system capable of maintaining a minimum temperature of 68°F throughout the residential section of the building when the temperature falls to 0°F or below. Alternate modern types of heating systems may be accepted if approved by the fire authorities. Space heaters and portable heaters are not acceptable. Lighting. Lighting shall be adequate for the activities conducted in the various areas. Bedrooms and dormitories shall be lighted by outside windows and shall also have artificial light adequate for reading and other uses. All entrances, hallways, stairways, inclines, ramps, cellars, attics, storerooms, kitchens, laundries, and service units shall have sufficient artificial lighting to prevent accidents and promote efficiency of service. Bathrooms. A center shall provide the following minimum bathroom facilities: One hand sink and one toilet for each six residents of the same sex on each floor; One bathtub or shower for each 12 beds on each floor; The number of beds for which the center is licensed shall be used in determining the number of bathroom fixtures required even if some of the beds are not occupied; There shall be one complete bathroom on each floor used by the residents, regardless of the number of beds; All bath and toilet rooms shall be easily accessible, conveniently located and well lighted with a night light burning all night and have mechanical exhaust ventilation; A lavatory or toilet facility may not: Open directly into a kitchen, pantry or food preparation room; or Be located so that a resident is required to pass through another resident's room to enter it; and Bathrooms shall be constructed using anti-ligature fixtures and designed for the safety of the residents. Plumbing. All plumbing within the building shall be installed in conformance with existing building and sanitary regulations. All sewage disposal shall be in accordance with existing regulations. Water Supply. Centers shall be served by water from a safe public water supply, if available, as determined by the Department. If a safe public water supply is not available, a private water supply approved by the Department may be used. Adequacy. The supply shall be adequate in quantity and delivered under sufficient pressure to satisfactorily serve fixtures in the center. Temperature. The hot water heating equipment shall be of sufficient capacity to supply an adequate amount of water not in excess of 125°F for bathing and showering. The center shall install mixing valves or other anti-scalding devices. Hot water for kitchen and laundry use shall be at least 160°F. Seclusion and Restraint. Seclusion and restraint rooms shall be constructed and maintained free of hazards to ensure the safety of the residents. The rooms shall allow for the unobstructed view of the resident. The rooms shall be equipped with adequate lighting for the staff to view the resident. Locking mechanisms on doors shall allow for prompt access in the event of an emergency. The rooms shall be adequate in size for staff to safely restrain residents or provide emergency care and treatment. A center shall be free from fire hazards and shall comply with all applicable local fire and building codes and the safety requirements of the National Fire Protection Association, NFPA 101 “Life Safety Code”, which is incorporated by reference at COMAR 29.06.01.06. Cleanliness and Maintenance. The following shall be observed: The building and all its parts and facilities shall be kept in good repair, neat, and attractive. The safety and comfort of the residents shall be the first consideration. All walls, floors, ceilings, windows, and fixtures shall be kept clean. Interior walls and floors shall be easily cleanable. Adequate storage space shall be provided for excess supplies, personal possessions of residents and staff, linens, and similar items. This storage space may not constitute a fire or accident hazard, and may not be in the way of residents or staff. All supplies shall be stored 10 inches off the floor and away from the wall to allow for cleaning and pest control. The grounds shall be kept clean, neat, reasonably attractive, and free of hazards. The center shall be maintained free from insects and rodents. Bathtubs and hand sinks may not be used for laundering or storing soiled linens. Bathtubs and shower stalls may not be used for storage. The center shall provide adequate furnishings and equipment to meet the needs of the residents, including but not limited to: Beds and mattresses in good repair; A storage area for each resident within their room; A desk and chair for each resident room; and Adequate furnishings in dayrooms and lounge areas to allow for recreational and relaxation purposes. Dietary Requirements. The following minimum requirements shall be observed: A minimum of three meals in each 24 hour period shall be served. In addition, nutritious between meal and bedtime snacks should be offered to all residents no less than 1-1/2 to 2 hours before the next meal. There may not be an interval longer than 12 hours from the evening meal or substantial bedtime snack to breakfast. The diet shall consist of simply prepared, appropriately served, palatable foods including a minimum of the following daily: Meat, fish, poultry, eggs: Two servings per day; Vegetables and fruits: Four servings per day, including one serving of citrus fruit or tomato daily and one serving of a dark green or deep yellow vegetable or fruit five times weekly; Breads and Cereals: Four servings daily. Size of servings and consistency or texture of food will be regulated by the age and condition of the residents. A record of the current week's menu plan shall be posted and kept on file for the following 2 weeks. A time schedule for service of meals to residents and personnel should be established and it is recommenced that meals be served approximately 4 hours apart for breakfast, lunch and dinner. Special diets or any variation of these requirements ordered by the resident's physician shall be provided for residents as ordered. Meals shall be served in a dining or community room equipped with furniture and utensils appropriate to the age and development of the residents. A resident with a temporary illness shall be served privately. Sanitation and Personal Hygiene. All applicable requirements of COMAR 10.15.03 shall be observed. Responsibility. The licensee is responsible for conformance with licensing regulations. Responsible Person. The licensee or administrator appointed by the licensee and all persons in supervisory or other responsible positions shall be 21 years old or older. The licensee shall ensure 24-hour coverage by an administrator or designee. Qualifications of Administrator. The administrator of the center shall be a psychiatrist, psychologist, social worker, registered nurse, or any other person trained in the behavioral sciences or in administration. The administrator shall be capable by experience and training of directing and supervising persons working in the center. Financial Responsibility. The licensee shall provide to the Secretary assurance of financial responsibility to meet the minimum needs for services offered, safety, maintenance, food, and comfort of the residents of the center. Compliance with Regulations. The licensee shall charge the administrator to be familiar with this chapter. The licensee or administrator shall also familiarize employees with those standards related to their work. The center’s governing body shall be responsible for the center’s compliance with all applicable federal and State regulations. Availability of Information. The licensee or administrator shall make available to the Secretary such information as may be requested to ensure that the institution is meeting requirements of this chapter. Supervision of Treatment Program. Treatment at any center shall be under the direction of a qualified psychiatrist who is responsible for the adequacy, quality, and appropriateness of the treatment program for each resident. There shall be sufficient professional personnel to ensure the implementation of the treatment program for each resident. Medical Supervision. A resident shall be under the medical care of a physician licensed in the State. Each resident shall have a complete physical examination done within 30 days before admission, and updated within 72 hours after admission, and at appropriate, regularly scheduled intervals thereafter. Principal Physician. The center shall arrange for a physician to serve as principal physician and a qualified relief to cover periods when their services are not available. The medical director or assigned on call physician shall respond at times of emergency and be available as needed to advise the administrator and nursing staff on medical questions. Restrictions on Medication. Medication may not be given without the written order of a physician, nurse practitioner, or physician assistant except in an emergency when medication or treatment may be given on the verbal or telephone order of the prescriber. These orders shall be entered on the doctor's order sheet and shall be confirmed by the prescriber at the next visit. Medication Handling. The center shall comply with all applicable Federal, State, and local laws and ordinances, standards, and codes regulating the purchasing, handling, storage, administration, and recording of medications, including controlled substances. The administrator shall employ sufficient and qualified personnel to ensure adequate treatment and care of the residents and the maintenance, cleaning, and housekeeping. The staff shall be sufficient in number so that the individual needs of residents are met. Provision shall be made for relief personnel during vacations or other relief periods. The relief personnel shall have qualifications equivalent to those of the person being relieved. Clinical staff shall, at a minimum, have current training in: CPR; The Heimlich maneuver; and First aid. The center shall ensure that one or more competent trained individuals are present 24 hours a day with the required skills to address medical and behavioral emergencies. The center shall maintain personnel records on each employee, including: The initial application; Current professional license and certification; Criminal background checks; and Performance appraisals and annual competency evaluations. Each staff member shall have a pre-employment examination for tuberculosis and additional testing when known TB exposure occurs. There shall be personnel policies which define staff jobs, qualifications, hours, vacation, sick leave, and retirement. Usable Living Space Needed. Each center shall provide at least 35 square feet of usable floor space per resident, in addition to bedroom space, in order to meet minimal requirements for dining, living, and recreational facilities. A minimum of 80 square feet is required for single occupancy bedrooms, and 60 square feet per bed for multiple occupancy bedrooms. Usable space excludes service areas, entrance ways, door swing areas, closets, dormers, and other breaks in floor areas. Closet Space. Adequate closet space, conveniently located, shall be provided to allow each resident to keep necessary items of clothing and other personal belongings. Areas Devoted to Educational Programs. Provision of space for classrooms and other educational activities shall be made in accordance with the needs of the center as approved by the Department of Education. The use of restraints and seclusion shall be in compliance with 42 CFR §§483.352—483.376 Condition of Participation for the Use of Seclusion and Restraint in Psychiatric Residential Treatment Facilities Providing Inpatient Psychiatric Services For Individuals Under Age 21. Notwithstanding any other provision of this chapter, residential treatment centers shall be open to inspections by the Department to investigate and resolve any complaint concerning: Resident care; Safety; Medical and nursing supervision; Physical environment; Sanitation; or Dietary matters. Complaints. To expeditiously resolve a complaint that alleges the existence of any non-life-threatening deficiency, the Department may refer the complaint directly to the residential treatment center. If appropriate, issues relating to the practice of medicine or the licensure or conduct of a health professional may be referred to the residential treatment center and to the appropriate health occupation licensing board for resolution. If the Department determines that the center has not satisfactorily addressed the referred complaint or if the complaint alleges the existence of a potentially serious or life-threatening deficiency, the Department shall conduct an independent investigation. When conducting its independent investigation of an accredited residential treatment center, the Department shall use the standards of the accreditation organization that accredits the residential treatment center and this chapter. The center shall furnish to the Secretary reports covering the following: Deaths, serious injuries, or unusual incidents, including suicide attempts, by no later than the close of business of the next business day following the event; and Any occurrences which threaten the welfare, safety, or health of any resident of the center such as fire, infectious disease outbreaks, or poisoning. The center shall comply with the reporting requirements of the Department of Juvenile Services, the Department of Human Services, the Maryland State Department of Education, or other placement agencies. The center shall comply with the reporting requirements of 42 CFR §483.374(b) and (c). Serious Occurrence Notification. Staff shall report any serious occurrence described in 42 CFR §483.374(b) involving a resident to both the State Medicaid agency and the State-designated Protection and Advocacy System by not later than close of business the next business day after a serious occurrence. The report shall include: The name of the resident involved in the serious occurrence; and A description of the occurrence. In the case of a minor, the center shall notify the resident’s parent or parents or legal guardian or legal guardians: As soon as possible; or No later than 24 hours after the serious occurrence. Staff shall document in the resident’s record that the serious occurrence was reported to both the State Medicaid agency and the State-designated Protection and Advocacy System, including the name of the individual to whom the incident was reported. A copy of the report shall be maintained in the resident’s record, as well as in the incident and accident report logs kept by the center. Civil Money Penalties. The Secretary may impose a civil money penalty on a person if: The person maintains or operates an unlicensed center; or A serious or life-threatening patient care deficiency exists and the center fails to correct the deficiency through immediate corrective action. In determining whether a civil money penalty is to be imposed, the Secretary shall consider the following factors: Number, nature, and seriousness of the patient care deficiencies; The extent to which the patient care deficiency or deficiencies are part of an ongoing pattern during the preceding 24 months; The degree of risk to the health, life, or safety of the residents of the center that is caused by the patient care deficiency or deficiencies; The efforts made by, and the ability of the center to correct, the patient care deficiency or deficiencies through implementation of immediate corrective action; and The center’s prior history of compliance. If the Department determines that a person has been operating an unlicensed center, the Department may impose a civil money penalty not to exceed $10,000. If the Department determines that a serious or life-threatening deficiency or an ongoing pattern of deficiencies exists, the Department shall notify the center of the deficiency or deficiencies and may: Impose a per-day civil money penalty not to exceed $10,000 until sustained compliance has been achieved; Permit the center the opportunity to correct the deficiencies by a specific date; or Impose a per-instance civil money penalty not to exceed $10,000 for each instance of violation. If the Department permits a center the opportunity to correct the deficiencies by a specific date, and the center fails to comply with this requirement, the Department may impose a per-day civil money penalty for each day of violation until correction of the deficiency or deficiencies has been verified and sustained compliance has been maintained. If the Department proposes to impose a civil money penalty, the Secretary shall issue an order which shall state the: Deficiency or deficiencies on which the order is based; Amount of civil money penalties to be imposed; and Manner in which the amount of civil money penalties imposed was calculated. A center subject to a civil money penalty under this regulation may request a hearing as set forth in accordance with Regulation .20 of this chapter. A request for a hearing shall be filed with the Office of Administrative Hearings, with a copy to the Office of Health Care Quality of the Department, not later than 30 days after receipt of notice of the Secretary's action. This request shall include a copy of the Secretary's action. A hearing requested under this chapter shall be conducted in accordance with: State Government Article, Title 10, Subtitle 2, Annotated Code of Maryland; COMAR 28.02.01; and COMAR 10.01.03. The burden of proof is as provided in COMAR 10.01.03.16. Unless otherwise stated in this chapter, the Office of Administrative Hearings shall issue a proposed decision within the time frames set forth in COMAR 28.02.01. The aggrieved person may file exceptions as provided in COMAR 10.01.03.18. A final decision by the Secretary shall be issued in accordance with COMAR 10.01.03.20. Within 24 hours of an event or change in condition and in accordance with State and federal confidentiality laws, a center shall attempt to notify a resident and a resident’s representative, family member, legal guardian, or custodian of: A change in the resident’s condition; An adverse event that affected the resident; and If appropriate, the corrective action taken. The notification may be waived by the individual identified under Regulation .19A of this chapter if the individual sends a written response instructing the center that the individual: Waives the required notifications; or Requests that the notification be provided only under the circumstances identified in the written response. All written responses waiving some or all notifications shall be maintained in the resident’s medical record. The center shall document in the medical records that the required notification were completed. The documentation shall include: The nature of the event or change in condition; The names of the individuals who received notification; The dates and times of the notifications; and The name of the staff who made the notifications. If a center has made reasonable attempts to notify the required individuals and has been unable to make contact, the failure to reach the individuals shall be documented in the medical records. If the Department determines that the center has failed to provide the required notification, the Department shall require the center as part of its plan of correction to provide notification as soon as possible. The center shall post the list of resident rights in areas of the center where the residents can read the posting. A resident of a residential treatment center has the right to: Be treated with respect; Have their cultural spiritual, personal beliefs, values, and preferences respected; Personal privacy; Practice their religious beliefs; Receive information about care and treatment in a manner that he or she understands; Be free from neglect, exploitation, and verbal, sexual, physical, and mental abuse; Access protection and advocacy services; Receive care in a safe setting; File a complaint and have it investigated without fear of retribution; Have visitors in accordance with the center’s visitation policy; Send and receive mail; Consult with their attorney, advocate, or social worker in private; and Make and receive telephone calls in accordance with the center’s policy. The resident’s parents or guardians or, if the resident is age 18 or older, the resident shall have the right to: Be involved in the treatment planning process; Consent to treatment and medication; Be informed of changes in the treatment plan and medication regimen; Withhold consent for treatment; and Have complaints investigated in a timely manner. A resident’s rights shall only be restricted if the provision of that right poses a threat to the therapeutic needs of the resident or places the resident’s or other residents’ safety and security at risk. Restrictions on a resident’s rights shall be documented in the treatment plan and reviewed and approved by the treatment team. Restrictions on a resident’s rights shall be removed as soon as possible when the restriction is not therapeutically indicated. Health-General Article, §§19-301, 19-305, 19-308, 19-309, 19-320, 19-323, and 19-360, Annotated Code of Maryland Effective date: April 17, 1967 Amended effective March 27, 1973 Amended effective March 22, 1974 Regulation .02C amended effective January 20, 2014 (41:1 Md. R. 13) Regulation .03 amended effective March 13, 2017 (44:5 Md. R. 292) Regulation .03A amended effective August 29, 2016 (43:17 Md. R. 953) Regulation .11B amended effective February 15, 2016 (43:3 Md. R. 272) Chapter revised effective May 22, 2017 (44:10 Md. R. 472) Regulation .02B amended effective June 8, 2026 (53:11 Md. R. 484) Regulation .04A, D amended effective June 8, 2026 (53:11 Md. R. 484) Regulation .17B amended effective June 8, 2026 (53:11 Md. R. 484) Annotation: COMAR 10.07.04 cited in Attorney General Opinion No. 82-034 (November 18, 1982)