This chapter governs the procedure for the involuntary admission of individuals to inpatient mental hygiene facilities, including State facilities, private psychiatric facilities, acute general hospitals with inpatient psychiatric units, and Veterans' Administration hospitals pursuant to Health-General Article, §§10-603, 10-613 — 10-617, 10-620, 10-631 — 10-633, and 10-803— 10-806, Annotated Code of Maryland. This chapter is not intended to impose any exhaustion requirement upon an individual as a prerequisite to the individual's pursuing concurrently or in any order any available legal remedy to obtain release from an inpatient facility. In this chapter, the following terms have the meanings indicated. Terms Defined. “Administration” means the Behavioral Health Administration. “Administrative law judge (ALJ)” means an individual in the Office of Administrative Hearings who is authorized under State Government Article, §9-1604, Annotated Code of Maryland, to conduct hearings under this chapter. “Application for involuntary admission (Application for IVA)” means the application required under Health-General Article, §§10-614 and 10-615, Annotated Code of Maryland, to initiate the IVA of an individual to an inpatient facility. “Change of status hearing” means the IVA hearing that is convened when appropriate staff at an inpatient facility complete the application and certificates for IVA on behalf of an individual who is voluntarily admitted or court-ordered to the inpatient facility. “Department” means the Maryland Department of Health. “Discharge” means authorization by a physician for a voluntarily or involuntarily admitted individual to leave an inpatient facility. “Discharge summary” means a written evaluation by a physician that includes, at a minimum, the individual's diagnoses, summary of the treatment provided and progress during the current stay at the discharging inpatient facility, current mental status, prescribed medications, and treatment recommendations. “Geriatric Evaluation Services (GES)” means the staff of the county health departments that evaluate the appropriateness of admissions to State facilities or Veterans' Administration hospitals of individuals 65 years old or older. “Indigent” means that an individual has neither sufficient property to support the individual nor anyone able to support the individual to whom the individual is entitled to look for support. “Individual treatment plan (ITP)” means a treatment plan prepared for an individual in an inpatient facility according to the requirements outlined in Health-General Article, §10-706, Annotated Code of Maryland, and COMAR 10.21.03. Inpatient Facility. “Inpatient facility” means an inpatient institution that provides evaluation, care, or treatment for individuals who have mental disorders. “Inpatient facility” includes a Veterans' Administration (VA) hospital. “Involuntary admission (IVA)” means that an individual has been admitted to an inpatient facility by an ALJ following an IVA hearing pursuant to Health-General Article, §10-632, Annotated Code of Maryland. “Involuntary admission hearing (IVA hearing)” means an administrative proceeding at which an administrative law judge determines whether an individual who has been confined in an inpatient facility on the basis of application and certificates for IVA is retained as an inpatient or released from the inpatient facility without being admitted. “Medical clearance” means that an individual has been evaluated by a physician, a physician's assistant, or a nurse practitioner, and the evaluator has confirmed with the receiving inpatient facility that the receiving facility has the capacity to provide the necessary and appropriate medical management of the individual. “Medical record” means a record as defined in Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland. Mental Disorder. “Mental disorder” means a behavioral or emotional illness that results from a psychiatric or neurological disorder. “Mental disorder” includes a mental illness that substantially impairs the mental or emotional functioning of an individual so as to make care or treatment necessary or advisable for the welfare of the individual or for the safety of the person or property of another. “Mental disorder” does not include mental retardation or a primary diagnosis of alcohol or drug abuse. “Nolle pros” means “nolle prosequi” as set forth in Maryland Rule 4-247. “Observation status” means the status of an individual between the time the individual is initially confined in an inpatient facility on the basis of application and certificates for IVA and the time the individual is either admitted, voluntarily or involuntarily, to the inpatient facility or is released by a physician or by an ALJ from the inpatient facility without being admitted. “Office of Administrative Hearings (OAH)” means the office created under State Government Article, §9-1602, Annotated Code of Maryland. “Office of the Public Defender (OPD)” means the office created under Article 27A, Annotated Code of Maryland. “Party” means the inpatient facility or the individual for whom an IVA hearing has been convened. “Petition for emergency evaluation” means a petition filed under the provisions of Health-General Article, §§10-620 — 10-629, Annotated Code of Maryland, to initiate the evaluation of an individual in an emergency facility that is designated by the Department, under the provisions of Health-General Article, §10-621, Annotated Code of Maryland, to perform emergency psychiatric evaluations. “Physician” means an individual who is licensed under Health Occupations Article, Title 14, Annotated Code of Maryland, to practice medicine in this State or, if the individual is working in a Veterans' Administration Hospital, authorized by the U.S. Department of Veterans' Affairs to practice medicine. “Physician’s, psychologist’s, or psychiatric nurse practitioner’s certificate” means the certificate completed according to the provisions of Health-General Article, §§10-616 — 10-617, Annotated Code of Maryland. “Presenter” means the individual, including an assistant attorney general, designated by the chief executive officer of an inpatient facility, who acts on behalf of the inpatient facility at an IVA hearing. “Psychiatric nurse practitioner” means an individual licensed under Health-Occupations Article, Title 8, Annotated Code of Maryland, to practice nursing in this State as a certified registered nurse practitioner-psychiatric mental health (CRNP-PMH). “Psychiatrist” means a physician who is identified as a specialist in psychiatry by the Board of Physician Quality Assurance or, if the physician is working in a Veterans' Administration Hospital, by the U.S. Department of Veterans' Affairs. “Psychologist” means an individual who is: Licensed under Health Occupations Article, Title 18, Annotated Code of Maryland, to practice psychology or, if the individual is working in a Veterans' Administration Hospital, authorized by the U.S. Department of Veterans' Affairs to practice psychology; and Listed in the National Register of Health Service Providers in Psychology. “Release” means the authorization for an individual who is confined in an inpatient facility on the basis of application and certificates for IVA to leave the inpatient facility: Given by a physician during the observation status period; or Ordered by an ALJ at an IVA hearing. “Secretary” means the Secretary of Health. “Semiannual hearing” means the hearing that is held not sooner than 5 months or later than 6 months following an involuntarily admitted individual's last IVA hearing. “State inpatient facility” means an inpatient institution that is owned or operated by the State and that provides evaluation, care, or treatment for individuals who have mental disorders. “Stet” means the postponement of a trial pursuant to Maryland Rule 4-248. “Voluntary admission” means that an individual has been admitted to an inpatient facility on the basis of: A signed and endorsed formal application for voluntary admission pursuant to Health-General Article, §10-609 or 10-610, Annotated Code of Maryland; An informal request for admission pursuant to Health-General Article, §10-609, Annotated Code of Maryland; or If the voluntary admission is to a VA hospital, the procedure established by the VA hospital. “Working day” means any day except Saturday, Sunday, or a holiday on which State offices are closed. An applicant for IVA shall: Have a legitimate interest in the welfare of the individual for whom IVA is sought; Submit an application on the form required by: The Veterans' Administration, if the application is submitted to a Veterans' Administration hospital; or The Administration, if the application is submitted to an inpatient facility other than a Veterans' Administration hospital; Fill out the appropriate form completely; and Sign and date the application form. The Administration shall provide an application form that includes the following: The statutory authority for the application; The form number (MDH34) and revision date; Spaces for the: Name of the inpatient facility to which the application for IVA is submitted; Name of the individual for whom IVA is sought; Name, home or agency address, telephone number, and relationship to the individual or official capacity of the applicant; and Signature of the applicant and the date that the application is made. The following shall be submitted when initiating the IVA of an individual: An application for IVA completed under the provisions of Regulation .03 of this chapter; and A certificate completed by: Two physicians; One physician and one psychologist; or One physician and one psychiatric nurse practitioner. The Secretary shall provide the certificate that includes the following: The statutory authority for the certificate; The form number (MDH2) and revision date; A list of the appropriate documentation that shall be attached to one of the certificates; A statement that the certificate may not be used for the IVA of an individual if the examination on which the certificate is based was done: More than 1 week before the certificate is signed; or More than 30 days before the inpatient facility or the Veteran’s Administration hospital receives the application for admission; A list of the State inpatient facilities and the catchment areas from which each facility accepts referrals; Spaces for the following information: The name, address, and telephone number of the certifying physician, psychologist, or psychiatric nurse practitioner; The name, address, identifying data, and the next of kin of the individual for whom the certificate is made; The date that the physician, psychologist, or psychiatric nurse practitioner examined the individual; A diagnosis of a mental disorder of the individual; An opinion that: The individual needs inpatient care or treatment; and Admission to an inpatient facility is needed for the protection of the individual or another; and The individual's: Current medications; and Emergency medications; A statement of whether the individual who completes the certificate is a physician, psychologist, or psychiatric nurse practitioner; The statement that the physician, psychologist, or psychiatric nurse practitioner: Has no financial interest, through ownership or compensation, in a proprietary inpatient facility, and admission to that proprietary inpatient facility is sought for the individual whose status is being certified; and Is not related, by blood or marriage, to the individual or to the applicant; and Space for the signature of the physician, psychologist, or psychiatric nurse practitioner and for the date and time the certificate is signed. To complete a certificate for IVA, a physician, psychologist, or psychiatric nurse practitioner shall: Personally examine an individual for whom an application for IVA has been completed under the provisions of Regulation .03 of this chapter; Completely fill out the form described under §B of this regulation; Sign, date, and time the certificate not later than 1 week following the examination required under §C(1) of this regulation; and Attach to one of the certificates for IVA copies of any available current medical reports or records that support the individual's need for involuntary care or treatment in an inpatient facility, with reports including at a minimum: The diagnosis of mental disorder, current symptoms, and psychiatric history; A summary of the medical history, including documentation of medical clearance; An explanation of why the individual meets the following requirements for IVA: The individual has a mental disorder; The individual needs inpatient care or treatment; The individual presents a danger to the life or safety of the individual or of others; The individual is unable or unwilling to be admitted voluntarily; There is no available, less restrictive form of intervention that is consistent with the welfare and safety of the individual; and Unless the individual is an emergency evaluee, if the individual is 65 years old or older and is being referred for admission to a State inpatient facility or a VA hospital, a GES team has determined that there is no available, less restrictive form of care or treatment that is adequate for the needs of the individual; If the individual is an emergency evaluee, a copy of the petition for emergency evaluation; and If the individual is discharged from an inpatient facility after appropriate staff at the inpatient facility have completed application and certificates for IVA to initiate the direct confinement of the individual in another inpatient facility: The information outlined in §C(4)(a) — (d) of this regulation; The discharge summary; A copy of the individual's most recent ITP completed in accordance with Health-General Article, §10-706, Annotated Code of Maryland, and COMAR 10.21.03; and Copies of all voluntary and involuntary admissions documents relating to the current admission at the inpatient facility from which the individual is discharged. An inpatient facility may not use for the admission of an individual a certificate that: Is based on an examination that was done: More than 1 week before the certificate is signed; or More than 30 days before the inpatient facility receives the application for admission; or Was previously used in connection with the taking into confinement on observation status an individual who subsequently was admitted to or released or discharged from an inpatient facility. If an individual is confined on observation status in an inpatient facility on the basis of an application and certificates for IVA, staff at the inpatient facility shall inform the individual of the individual's status and rights: By giving the individual the Notice of Status and Rights form described under §C of this regulation and provided by the Administration; By explaining the information on the form to the individual in English or in the language and terms that are appropriate to the individual's condition and ability to understand; and At the following times: Within 12 hours of the individual's initial confinement in an inpatient facility on the basis of application and certificates for IVA under the provisions of Regulations .03 and .04 of this chapter; When certificates for IVA are executed for the purpose of changing the individual's status in accordance with Regulation .08B of this chapter; and When certificates are executed for the purpose of recertifying the individual for a semiannual hearing in accordance with Health-General Article, §10-806(d), Annotated Code of Maryland, and Regulation .08C of this chapter. Staff shall file a copy of the Notice of Status and Rights form in the individual's medical record and give copies to: When possible, the individual's parent, guardian, or next of kin; and If the individual does not understand the notice, the individual's: Parent, guardian, or next of kin; The applicant for IVA; and Any other person who has significant interest in the status of the individual. The Administration shall provide a Notice of Status and Rights form that includes the following: The statutory authority for the notice; The form number (MDH33) and revision date; A statement of the rights provided under Health-General Article, §10-631, and Title 10, Subtitle 7, Annotated Code of Maryland; The right and access to legal counsel provided under Health-General Article, §10-631(a)(2) — (4), Annotated Code of Maryland; The hearing rights enumerated under Health-General Article, §10-632, Annotated Code of Maryland, and Regulation .09C of this chapter; The right to request a judicial hearing on the cause and legality of the individual's admission and continued detention according to Health-General Article, §§10-804 and 10-805, Annotated Code of Maryland; and Spaces for: The name of the individual; The name of the inpatient facility; The basis for the individual's status and the provisions of law pertaining to the status; The signature of the individual and date that the individual received the notice; An explanation, if the individual does not sign the notice; An indication of whether the notice is given to a parent, guardian, or next of kin; An indication of whether the individual understands the notice; and Signature of inpatient facility staff who gives the notice to the individual and date that the notice is given. Staff at an inpatient facility shall inform an individual of the individual's right to an IVA hearing in accordance with the requirements for providing Notice of Status and Rights delineated in Regulation .05 of this chapter. Staff shall give the Notice of Hearing: Orally; and On the form provided by the OAH which shall include: The date, time, and place that the hearing will be held; The legal authority for and purpose of the hearing; A short statement explaining why the individual's involuntary admission is being sought; The standards delineated in Health-General Article, §10-632, Annotated Code of Maryland, that govern whether the individual shall be involuntarily admitted; Notice of the individual's right to consult with an attorney of the individual's choice and, if the individual is unable to afford an attorney, the availability of representation at the hearing through the Office of the Public Defender, Mental Health Division; and A list of the individual's rights at a hearing as set forth in Regulation .09C of this chapter. Staff shall file a copy of the Notice of Hearing form in the individual's medical record and give a copy to the individual's parent, guardian, or next of kin. Upon a properly executed application executed in accordance with Regulation .03 of this chapter and certificates for IVA and all required attachments in accordance with Regulation .04 of this chapter, an inpatient facility that accepts individuals who are referred for IVA may take an individual into confinement on observation status. GES Evaluation. If an individual is an emergency evaluee, and the individual is 65 years old or older, on the first working day after the individual is taken into confinement on observation status, staff at a State inpatient facility or Veterans' Administration hospital shall: Notify the GES team in the county where the individual resides; and Document whether the GES grants clearance for the involuntary admission of the individual. Examination. A psychiatrist shall examine an individual if the individual remains confined on observation status in an inpatient facility within 24 hours of the initial confinement. If a physician who examines an individual confined on observation status determines that the individual does not meet the requirements for IVA outlined in Health-General Article, §10-617, Annotated Code of Maryland, and Regulation .04C(4)(c) of this chapter, the physician shall: If the individual meets the requirements for voluntary admission, offer the individual an application for voluntary admission; or Immediately release the individual, following: Notification to the parent or guardian that the individual is being released, if the individual is a minor or is a disabled adult who is under guardianship of the parent or guardian under the provisions of Estates and Trusts Article, §13-708, Annotated Code of Maryland; and Preparation of a written aftercare plan in accordance with Health-General Article, §10-809, Annotated Code of Maryland. Medical Records. An inpatient facility shall maintain the medical records for individuals who are confined on observation status separate from the inpatient medical records of the facility. The inpatient facility may not disclose an individual's observation status medical record in any way that would indicate that the individual had been present in the inpatient facility, except: For the sole purposes of: Providing notice of admission status and rights and notice of hearing to the individual's parent, guardian, or next of kin, in accordance with Regulations .05 and .06 of this chapter; Calling witnesses to testify at the individual's IVA hearing; and Fulfilling the provisions of Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland; or Upon the authorization of the individual. Staff at the inpatient facility where an individual is confined may use prior observation status medical records, as necessary, to provide for the proper care or treatment of the individual. Rights. An individual who is confined on observation status in an inpatient facility shall be entitled to the rights granted in accordance with Health-General Article, Title 10, Subtitle 7, and Title 4, Subtitle 3, Annotated Code of Maryland. An individual taken into an inpatient facility in accordance with §A of this regulation shall remain confined on observation status until the individual is: Voluntarily admitted to the inpatient facility in accordance with the provisions of Health-General Article, §10-609 or 10-610, Annotated Code of Maryland, and if the individual is: A minor, a parent or guardian who is not a representative of a State agency signs an application for voluntary admission of a minor, in accordance with Health-General Article, §10-610, Annotated Code of Maryland; A minor who is confined in a State inpatient facility, a parent or guardian has not previously executed an application for voluntary admission of a minor during the minor individual's current confinement in the State inpatient facility; and Not a disabled adult who is under guardianship of the person under the provisions of Estates and Trusts Article, §13-708, Annotated Code of Maryland; Released by a physician of the inpatient facility before the scheduled IVA hearing pursuant to §C(2)(b) of this regulation; Admitted to the inpatient facility by an ALJ following an IVA hearing in accordance with Health-General Article, §10-632, Annotated Code of Maryland, and Regulation .09G of this chapter; or Released from the inpatient facility by an ALJ following an IVA hearing in accordance with Health-General Article, §10-632, Annotated Code of Maryland, and Regulation .09G of this chapter. Discharge of an Individual on Observation Status and Referral for Direct IVA at Another Inpatient Facility. An inpatient facility may refer for IVA to another inpatient facility an individual who is confined on observation status only if the receiving inpatient facility agrees to have the hearing held within 10 days of the individual's initial confinement in the discharging inpatient facility on the basis of application and certificates for IVA. Payment or Reimbursement for Care or Treatment. Payment or reimbursement for care or treatment of an individual who is confined on observation status in, or who is involuntarily admitted to, an inpatient facility shall be in accordance with the provisions of Health-General Article, Title 16, Subtitle 2, Annotated Code of Maryland. Initial Hearing. When an individual is confined on observation status in an inpatient facility on the basis of application and certificates for IVA, inpatient facility staff shall: Schedule a hearing to take place within 10 days of the individual's initial confinement in the inpatient facility; Notify the OAH and the OPD that the hearing has been scheduled; and Give the Notice of Status and Rights in accordance with Regulation .05 of this chapter, and Notice of Hearing in accordance with Regulation .06 of this chapter. The ALJ may postpone the hearing for good cause or by agreement of the parties, and the postponement shall be: For not more than 7 days; On the record; and One time only. Change of Status Hearing. An inpatient facility that accepts individuals who are referred for IVA may initiate the procedure outlined in this section to change the admission status of an individual when, in the clinical judgment of the individual's treating physician, the individual meets the requirements for IVA outlined in Health-General Article, §10-617, Annotated Code of Maryland, and Regulation .04C(4)(c) of this chapter, and the individual is: Admitted voluntarily pursuant to Health-General Article, §10-609, Annotated Code of Maryland, and the individual requests discharge or otherwise demonstrates that the individual is unwilling or unable to continue to agree to voluntary treatment; A minor who is admitted on the basis of an application for voluntary admission of a minor signed by the parent or guardian, pursuant to Health-General Article, §10-610, Annotated Code of Maryland, and the: Parent or guardian requests release of the minor; or Minor has been admitted to a State inpatient facility, and the minor is in need of care or treatment for longer than 20 days; or Admitted on the basis of a court order pursuant to Health-General Article, §12-104 or 12-110, Annotated Code of Maryland, and the Office of the State's Attorney or the court has agreed to dismiss, nolle prosequi, or stet the charges. Two physicians or one physician and one psychologist shall evaluate the individual and, if the individual meets the requirements for IVA outlined in Health-General Article, §10-617, Annotated Code of Maryland, and Regulation .04C(4)(c) of this chapter, shall submit an application for IVA of the individual in accordance with the provisions of Regulation .03 of this chapter and complete certificates for IVA in accordance with the provisions of Regulation .04 of this chapter: Within 3 days of the request for discharge, if the individual was admitted on the basis of a formal, written application for voluntary admission; Before 4 p.m. on the day of the request for discharge, if the individual was admitted voluntarily on the basis of an informal request; Before the expiration of the 20-day maximum stay, if the individual is a minor who was admitted to a State inpatient facility on the basis of an application for voluntary admission signed by the parent or guardian; and By the close of business of the next working day following official notification that the charges have been dismissed, nolle prossed, or stetted. Following completion of the application and certificates for IVA under §B(2) of this regulation, staff at the inpatient facility shall: Schedule a hearing to take place within 10 days of the completion of application and certificates for IVA in accordance with §B(2) of this regulation; Notify the OAH and the OPD that the hearing has been scheduled; Give the Notice of Status and Rights in accordance with Regulation .05 of this chapter, and Notice of Hearing pursuant to Regulation .06 of this chapter; and If the individual is 65 years old or older and is in a State inpatient facility or Veterans' Administration hospital, and during the individual's current stay in the State facility or Veterans' Administration hospital the individual has not been approved for IVA by the GES: Notify the GES in the county of the individual's last residence that application and certificates for IVA have been completed; and Document that the GES team has determined that there is no available, less restrictive form of care or treatment that is adequate for the needs of the individual. If an inpatient facility does not accept individuals who are referred for IVA, and an individual is admitted voluntarily, pursuant to Health-General Article, §10-609, Annotated Code of Maryland, if the individual requests to be discharged from the inpatient facility or otherwise demonstrates that the individual is unwilling or unable to continue to agree to voluntary treatment, before discharging the individual, staff at the inpatient facility: May initiate the procedure outlined in §B(2) of this regulation and arrange to refer the individual to an inpatient facility that accepts individuals who are referred for IVA; and Shall assure that a hearing shall be held at the receiving inpatient facility within 10 days of completion of application and certificates for IVA in accordance with §B(2) of this regulation. Semiannual Hearing. Facility staff shall schedule a hearing for the purpose of determining whether an individual continues to meet the requirements for IVA outlined in Health-General Article, §10-617, Annotated Code of Maryland, and Regulation .04C(4)(c)(i) — (v) of this chapter: Not sooner than 5 months or later than 6 months from the date that the individual is involuntarily admitted to an inpatient facility following an IVA hearing in accordance with §A or B of this regulation; and Semiannually after that. At least 7 days before the date a semiannual hearing is scheduled to take place: Two physicians or one physician and one psychologist or one physician and one psychiatric nurse practitioner shall complete certificates for IVA in accordance with the provisions of Regulation .04 of this chapter; Staff at the inpatient facility shall give the Notice of Status and Rights in accordance with Regulation .05 of this chapter, and Notice of Hearing pursuant to Regulation .06 of this chapter; Staff at the inpatient facility shall notify the OAH and the OPD that a hearing has been scheduled; and If the individual is 65 years old or older and is in a State inpatient facility or Veterans' Administration hospital, and during the individual's current stay in the State inpatient facility or Veterans' Administration hospital the individual has not been approved for IVA by the GES, State inpatient facility or Veterans' Administration hospital staff shall: Notify the GES in the county of the individual's last residence that certificates for IVA have been completed; and Document that the GES team has determined that there is no available, less restrictive form of care or treatment that is adequate for the needs of the individual. A parent or guardian of a minor individual may not execute an application for voluntary admission of the minor at the time that a semiannual hearing is scheduled for the minor. Powers and Duties of ALJ. An ALJ from the OAH shall conduct a hearing at the inpatient facility according to the rules of procedure outlined in COMAR 28.02.01. Location. Unless the ALJ, for good cause, relocates a hearing, the hearing shall take place in the inpatient facility where the individual is confined, and the inpatient facility shall provide a room that: During the hearing, is used for no other purpose; Has sufficient space and adequate and appropriate furnishings to accommodate the ALJ, the parties, and any others participating in the hearing; and Includes a speaker telephone that is adequate for the purpose of taking testimony by telephone. Rights of Parties. At a hearing, the parties have the right to: Be represented by counsel; Present witnesses; Cross-examine witnesses presented by the other party; Present documentary or other relevant evidence; Submit rebuttal evidence; and Present summation and argument. In addition, an individual has the right to: Wear the individual's own clothes; and Be present or waive the right to be present, if the waiver is: Knowingly and intelligently made; Witnessed by the individual's counsel; and Witnessed by the ALJ. Record of Hearing. The ALJ shall make and maintain a record of the hearing, and the record shall: Be an audio recording of the oral proceedings before the ALJ; Include a full description of the documentary evidence submitted at the hearing, but may not include the physical evidence itself; Be maintained for a period of 3 years following the hearing; and Upon request, be made available to a party to the hearing or to a party's counsel or authorized representative to listen to the record. Upon request by a party to the hearing, the OAH shall transcribe the record, and the record shall be: Paid for by the requesting party in accordance with the charges established in State Government Article, §10-621, Annotated Code of Maryland, and COMAR 10.01.08.14; or Provided without cost to an individual who: Has filed an appeal in proper person; and Is indigent. Testimony. The ALJ shall require the inpatient facility to provide for the testimony of one of the following, who has personally examined the individual within 48 hours before the hearing: A psychiatrist; A physician in an accredited residency program in psychiatry if the physician in the residency program in psychiatry is under the supervision of the psychiatrist who is responsible for the treatment of the individual who is the subject of the hearing; or A psychologist. Unless the inpatient facility demonstrates exceptional and compelling circumstances, the ALJ shall require the examining psychiatrist, physician in the residency program in psychiatry identified under §E(1)(b) of this regulation, or psychologist, to testify in person at the hearing. If the ALJ determines that a certifying physician or, psychologist, has not submitted adequate information with the certificate and that additional testimony from the certifying physician or, psychologist, may materially assist the ALJ to make an informed decision, the ALJ may; Require the certifying physician or, psychologist, to attend and testify at the hearing; or Receive the testimony of the certifying physician or, psychologist, by telephone. Burden of Proof. The burden of proof is on the inpatient facility to demonstrate by clear and convincing evidence that: The individual has a mental disorder; The individual needs inpatient care or treatment; The individual presents a danger to the life or safety of the individual or of others; The individual is unable or unwilling to be admitted voluntarily; There is no available, less restrictive form of intervention that is consistent with the welfare and safety of the individual; and If the individual is 65 years old or older and is being referred for admission to a State inpatient facility or VA hospital, a GES team has determined that there is no available, less restrictive form of care or treatment that is adequate for the needs of the individual. Findings and Conclusions. After the evidence and testimony are presented, and following summation and argument by the parties, the ALJ shall: Consider all evidence and testimony of record; Rule on issues raised by the individual that relate to the process by which the: Individual was taken into and confined during observation status; Individual's admission status was changed according to the provisions of Regulation .08B of this chapter; or Individual is presented for a semiannual hearing under the provisions of Regulation .08C of this chapter; Order the release of the individual from the inpatient facility if: An error in the process occurred; The error in the process is substantial; and No other available remedy is consistent with due process and the protection of the individual's rights; Order the release of the individual from the inpatient facility unless the inpatient facility meets the burden of proof outlined in §F of this regulation; State on the record the: Findings, including whether the individual waived the right to attend the hearing; Conclusions of law on any relevant issue presented; Right of the individual to appeal the decision of the ALJ pursuant to State Government Article, §§10-215 and 10-216, Annotated Code of Maryland, and the procedure for requesting an appeal; and Right of the individual to seek judicial release from the inpatient facility pursuant to the provisions of Health-General Article, §§10-804 and 10-805, Annotated Code of Maryland; and Give to the individual a written decision which shall: Be on the form provided by the OAH; Include the conclusions and the rights enumerated under §G(5) of this regulation; State whether the inpatient facility has proven that the individual meets each of the requirements for IVA outlined in Health-General Article, §10-617, Annotated Code of Maryland, and §F of this regulation; and By copy, be: Given to the presenter; Filed in the individual's medical record; and If the individual is a minor, given to the individual's parent or guardian if the parent or guardian is present at the hearing. If an individual is released from an inpatient facility by an ALJ under the provisions of Regulation .09G(3) of this chapter, and the individual’s treating physician, psychologist, or psychiatric nurse practitioner determines, based on the individual’s behavior and clinical condition after the hearing, that the individual meets the requirements for IVA outlined in Health-General Article, §10-617, Annotated Code of Maryland, and Regulation .04C(4)(c)(i) — (v) of this chapter: After the individual has been given the opportunity to leave the inpatient facility, the treating physician, psychologist, or psychiatric nurse practitioner may file a petition for emergency evaluation as the means of initiating an emergency psychiatric evaluation; and The inpatient facility may not accept the application and certificates for IVA that initiated the individual's initial confinement under Regulation .07A of this chapter for the purpose of taking the individual into confinement on observation status following the release. Unless an individual is discharged from one State inpatient facility and referred for IVA in another State inpatient facility: When an inpatient facility discharges an individual who has been involuntarily admitted pursuant to Health-General Article, §10-632, Annotated Code of Maryland, and Regulation .09G of this chapter, and refers the individual for IVA in another inpatient facility, appropriate staff at the discharging inpatient facility shall: Complete an application and certificates for IVA, including the required documentation outlined in Regulation .04C(4) of this chapter; and On or before the date of the referral for IVA, provide all the records necessary for the continuing care or treatment of the individual pursuant to Health-General Article, §§4-306(a)(5), 4-307(h)(1)(i), 10-807(d), and 19-308.2, Annotated Code of Maryland. Upon arrival of an individual who is referred for IVA and receipt of the documentation listed in §A of this regulation, the receiving inpatient facility shall: Take the individual into observation status in accordance with Regulation .07 of this chapter; and Schedule an IVA hearing in accordance with the provisions of Regulation .08A of this chapter. Health-General Article, §§7.5-204 — 7.5-205, 10-603, 10-615 — 10-616, 10-619 and 10-806(d)(3), Annotated Code of Maryland Effective date: December 5, 1970 Amended effective October 1, 1973 Chapter revised effective October 12, 1981 (8:20 Md. R. 1635) Annotation: COMAR 10.21.01.04B and .07E cited in Attorney General Opinion No. 86-031 (May 12, 1986) Regulations .01 — .10 repealed and new Regulations .01 — .11 adopted effective September 28, 1992 (19:19 Md. R. 1708) Regulation .02 amended effective September 13, 1993 (20:18 Md. R. 1430) Regulation .02B amended effective March 28, 2016 (43:6 Md. R. 409); January 2, 2017 (43:26 Md. R. 1445) Regulation .04 amended effective March 28, 2016 (43:6 Md. R. 409) Regulation .04B amended effective January 2, 2017 (43:26 Md. R. 1445) Regulation .08C amended effective March 28, 2016 (43:6 Md. R. 409) Regulation .09 amended effective September 13, 1993 (20:18 Md. R. 1430) Regulation .10 amended effective March 28, 2016 (43:6 Md. R. 409) “Adolescents” means persons 13 to 18 years old. “Board” means the executive authority and policy-making group which operates a psychiatric day treatment center for mentally ill persons. “Children” means persons younger than 13 years old. “Consumer” means a person who has received or is receiving services in any program, public or private, providing mental health services or is the relative of a person receiving or having received these services. “Full treatment day” for the purposes of these regulations means 6-1/2 hours. The minimum unit of service or half treatment day is 4 consecutive hours. “Health authority” means the Maryland Department of Health or a designated local health officer. “Psychiatric day treatment center” means the premises on which psychiatric day treatment is provided. “Psychiatric day treatment services” means intensive, nonresidential psychiatric treatment for any part of a 24-hour day for a minimum of 4 consecutive hours per day. Patients admitted to these services are those for whom at the time of admission, it is reasonable to anticipate that maximum day treatment benefits would be achieved within 30 full treatment days. If at any point in the course of treatment it is believed that patients would benefit from additional intensive treatment, beyond the 30-day period, continued day treatment may be provided, but the record shall document justification for the continued intensive treatment. Day treatment services provide flexible scheduling to meet the needs of the individual patient so that the 30 treatment days may nor may not be consecutive. The services given may be part of a psychiatric hospital program, or a psychiatric unit of a general hospital, or a free-standing community-based mental health program which has an arrangement for appropriate support services with a licensed general hospital or a licensed psychiatric hospital. Psychiatric day treatment services provide active psychiatric treatment. Psychiatric day treatment services do not provide residential care, nor are they identical with socializing and activity programs, recreational community programs, or day care facilities which do not provide active psychiatric treatment. Program Approval. Psychiatric day treatment services which are under the auspices of a psychiatric unit located in a licensed psychiatric hospital or under the auspices of a psychiatric unit of a licensed acute general hospital shall be reviewed and approved by the Mental Hygiene Administration on the basis of these regulations. Free-standing psychiatric day treatment services and those under the auspices of a community mental health program shall also be reviewed and approved by the Mental Hygiene Administration on the basis of these regulations. Standards for Psychiatric Day Treatment Services. The daily treatment program shall provide intensive treatment following a treatment plan developed by a multi-disciplinary staff team on the basis of an evaluation of the patient's needs. A variety of psychiatric modes shall be available, including psychopharmacological treatment, occupational therapy, activity therapy, and other necessary medical, psychological, and social services. There shall be an acceptable plan and procedure which fix responsibility for the care and treatment of the patient if an emergency occurs during the patient's stay within the day treatment service. The treatment center shall have an agreement with at least one licensed general or psychiatric hospital to provide inpatient services as needed. The day treatment program shall assure continuity of care by developing appropriate mechanisms for referral to outpatient services if the patient does not have a private therapist and to necessary support and residential services, developing written agreements whenever feasible. When patients continue in treatment with a therapist who is not a member of the day treatment program team, the program shall have an agreement with the therapist which clearly delineates relative treatment responsibilities of the day treatment team and the other therapist. A registered nurse shall be on the premises throughout the treatment day. Within 4 working days of admission, every patient shall have an individual treatment plan, developed collaboratively by a multi-disciplinary team, which clearly defines expectations and means of accomplishing the goals of the plan. The treatment plan shall be signed by the psychiatrist responsible for its development. The names of the other members of the mental health treatment team involved in the development of the plan shall be listed adjacent to the signature of the psychiatrist. The treatment plan shall describe the patient's problems and probable diagnosis, state the short- and long-term goals of treatment, and delineate the modalities, including medications, to be used to accomplish these goals. The treatment plan shall record any physical condition which can affect the treatment plan. There shall be a utilization review committee which shall include at least one qualified person who has no financial or other direct interest, past or present, in the treatment of the patient or the operation of the program. In addition to its other duties, the committee shall review the treatment plans for patients whose expected length of stay exceeds 30 full treatment days. Programs for children, adolescents, and adults shall be separate, although some activities may be shared with mutual benefit. Each day treatment program shall describe in writing its mechanisms for quality assurance, including systematic case review and program evaluation, and shall define the composition and responsibilities of the utilization review committee. Capacity of Psychiatric Day Treatment Center. The number of persons treated at any one time in each psychiatric day treatment center shall be limited according to the premises, staff, and equipment as set forth in Regulation .10 of this chapter. Criteria for admission shall be established for types of patients the program is designed to benefit, the goals and objectives of treatment, and the means by which these goals and objectives will be accomplished. Admission criteria may not discriminate against anyone on the basis of age, sex, race, creed, color, national origin, or handicapping conditions. For clinical purposes, program services may be offered for defined target groups. Admission criteria shall take into account the physical and medical status of the patient. Measures shall be taken to assure that patients are free from communicable diseases, such as tuberculosis. Programs shall require that the referring source submit written records whenever possible. Criteria for admission shall be available to the utilization review committee. Criteria for discharge shall be established and shall be available for use by the utilization review committee. Discharge criteria may include, but not be limited to, symptomatic improvement; readiness for participation in voluntary, educational, or vocational programs; achievement of treatment goals; inability to comply with program requirements; or the need for 24-hour hospitalization. Clinical records shall contain sufficient information to identify the patient clearly, to support the diagnosis, to justify the treatment plan, and to document the results accurately. A clinical record shall be established for every person admitted to a day treatment program and shall include: Identifying information, including names, current addresses, and telephone numbers of the patients, relatives, or guardians; Presenting problem, the results of mental and physical examinations, diagnosis, treatment plan, a record of the implementation of the treatment plan, and the discharge disposition and referrals; Evidence of appropriate release-of-information procedures and informed consent, if applicable. A system of identification and filing of clinical records shall be maintained to facilitate the prompt location of the patient's clinical record. Provision shall be made for storing records to assure their security and to maintain their confidentiality. The record shall be retained for at least 3 years after the discharge of a patient unless the patient is a minor. In that case, it shall be retained for at least 3 years past the date on which the minor would reach the age of majority. Record retention by State or State-funded programs shall conform to the requirements of the records management division. Professional and paraprofessional staff shall be adequate to carry out the treatment program. Minimum requirements for the staff are as follows: The staff of a psychiatric day treatment program shall be a multi-disciplinary team, including a psychiatrist, a registered nurse, and representatives of other appropriate disciplines, at least on a part-time basis. The psychiatrist on the team shall be responsible for overall patient care. The mental health team, including a psychiatrist, shall evaluate and make a diagnosis for each patient and shall develop a treatment plan. After the treatment plan is made, a psychiatrist shall be involved in the treatment plan as needed and shall be available on call. He shall meet with the staff at least weekly to review treatment plans for each individual patient. Each day treatment program shall have a director with clearly defined authority and responsibility for administration and service. Each program shall establish a system of supervision and of continuing education and training for all staff, including any students. If volunteers are employed in patient care, programs shall provide a system of screening and training volunteers. Volunteers shall receive continuing supervision in their activities. The supervisor shall assure that volunteers are not asked to perform duties beyond their skill and understanding. Medications shall be stored separately in locked facilities and dispensed by qualified staff, in conformity with Health Occupations Article, §12-301, Annotated Code of Maryland. Any corporation delivering day treatment services shall have a valid charter of incorporation. Every day treatment program shall have a mechanism to assure community and consumer participation in the establishment of policies and procedures related to the operation of the program and for continuing review and evaluation of the implementation of these policies. Participation may be provided by inclusion of consumer and community representatives in the membership of the board of directors, if one exists, or by an advisory board whose members include consumer and community representatives. Existing boards of directors or advisory boards of sponsoring agencies may perform this function if consumer and community interests are appropriately represented. Standards for Administration of Day Treatment Programs. There shall be an organizational chart clearly showing intra-organizational relationships and lines of authority. Every program shall have a policies-and-procedures manual which, among other elements, describes its mission, its geographic service area, its target population, its organizational structure, its clinical policies, its operating procedures, types of services provided, with responsibility for supervision clearly defined. There shall be a personnel policy manual which shall include written job descriptions for all staff positions, policies and procedures for personnel evaluation, and grievance procedures. Every program shall have an itemized budget showing all sources of income and the services being funded. All programs shall maintain a generally accepted accounting system. Patient Rights. Written policies describing patient rights shall be made available to persons admitted to the service. All patient information, verbal and written, shall be held confidential and restricted to staff members engaged in the treatment of the patient, to individuals authorized to participate in quality assurance and utilization review of records, and to designated representatives of authorized funding, licensing, and certifying agencies which must evaluate programs in order to carry out their responsibilities. With proper authorization from the patient, relevant information may be disclosed to staff members of agencies providing necessary social and other support services to the patient. Program staff shall provide the patient in writing with a description of the program, including admissions and discharge policies, and an explanation of charges and methods of determining fees. Program staff shall establish mechanisms to assure the patient of the opportunity to be consulted and informed on procedures related to his care. The leader of the patient's treatment team shall give him, on request, current information in regard to his treatment and condition. Program staff shall inform patients receiving chemotherapy of the effects of the medication, including benefits and possible side effects. Program staff shall establish mechanisms for patients to register grievances and for appeal and review. The Mental Hygiene Administration shall be responsible for approving the programmatic aspects of the day treatment services. Approval shall be issued on the basis of a formal scheduled site visit by a designated evaluation team of the Administration on the basis of these regulations. Initial Approval. The site-visit team shall make a recommendation for approval or disapproval in writing to the Director of the Mental Hygiene Administration. A copy of the recommendation shall be sent simultaneously to the program. The program shall have the right to question the recommendation of the evaluation team by sending a reply in writing to the Director of the Mental Hygiene Administration within 20 days of the receipt of the recommendation. This reply shall give reasons why the recommendation is not justified. Upon request, a conference shall be held with all parties present before the final determination. The Director of the Mental Hygiene Administration shall have the final decision for granting or withholding approval to programs after consideration of the position presented by the evaluated program and after consultation with members of the site-visit team. Provisional Approval. Provisional approval may be granted to programs in which the deficiencies cited have no adverse effect on the life-safety or health status of patients and the facility has concrete plans to correct these deficiencies by a prescribed date. The Mental Hygiene Administration may establish conditions in giving provisional approval and set a date by which those conditions shall have been met. Revocation of Approval. Approval may be revoked after notice and hearing before the Director of the Mental Hygiene Administration or his designee upon finding of failure to comply with standards or to comply with conditions of approval when a provisional approval has been given. Notice of an intent to revoke approval and the grounds for the revocation shall be given in writing to the Director of the program. The program shall have the right to file a reply in writing to the notice of intent to revoke within 20 days of the receipt of the notice. The reply shall set forth why the revocation is not justified. The program shall have the right to representation by counsel, and the hearing shall follow procedures set forth in COMAR 10.01.03 Procedures for Hearings Before the Secretary of Health. A program whose approval has been revoked may appeal the decision to the Secretary of Health under Article 41, §251, according to the procedures set forth in COMAR 10.01.03 Procedures for Hearings Before the Secretary of Health. Location. The premises on which a psychiatric day treatment center is to be located shall be served by a good road. Accessible public transportation is desirable. Communication. There shall be at least one telephone readily available — not a pay station or locked telephone — in the building and additional telephones or extensions as may be required to summon help promptly in case of fire or other emergencies. Buildings. Any building used for a psychiatric day treatment center shall be kept in good repair, neat, clean, attractive, and safe. Housekeeping shall meet the highest possible standards of hygiene and cleanliness. All floors, walls, ceilings, windows, and fixtures shall be kept clean. Interior walls and floors shall be of a character to permit frequent and easy cleaning. The building shall be accessible to the handicapped. The facility shall be kept free of unnecessary accumulations of unused furniture, equipment, linen, clothing, and similar items. All paint shall be free from lead. The director shall provide for the safety and protection of all occupants and assure the elimination of all hazards. Adequate provision and training shall be made for fire-control equipment, fire escapes, and evacuation of persons in case of fire or other emergency. Fire drills shall be held on a regular basis. Any proposed alterations, additions, or changes shall be submitted to the health authority so that they may be approved or disapproved with such recommendations as deemed necessary. Sanitation. Sewage Disposal. The method of sewage disposal shall conform to COMAR 10.17.03 and be approved by the health authority. Water Supply. A safe drinking-water supply, as determined by COMAR 10.17.02 and approved by the health authority, shall be provided. Plumbing. All plumbing and plumbing fixtures shall be so constructed, installed, and maintained as to prevent cross-connections or other sanitation hazards, as required by the applicable State and local plumbing codes. Garbage and Refuse Disposal. Garbage and refuse shall be kept in watertight metal containers with tight-fitting covers and shall be removed from the premises at frequent intervals. Heating. The building, whenever possible, shall be equipped with a heating plant with design capability of maintaining a temperature of 75°F in mean winter temperatures in patient areas. Space heaters and portable heaters are prohibited. Chimney, flues, and pipes connected with the heating facility shall be checked and cleaned annually. The fuel supply shall be handled according to the regulations of the State Fire Prevention Commission. If coal is used, ashes may not be stored in flammable containers pending disposal. Insects and Rodents. The premises shall be maintained free of insects and rodents through an active pest-control program and elimination of garbage. Gas and Electric Appliances. All gas appliances shall be installed and used in accordance with the applicable codes. Screens. All outside doors, windows, and other outside openings shall be screened with wire screen or its equal with not less than 16 meshes per linear inch. All screen doors shall be equipped with self-closing devices and, when closed, fit tightly enough to prevent entrance of flies, mosquitoes, other insects, and rodents. Window screens shall fit closely enough to keep out insects and be easily removed. Lighting. Each area used for therapy purposes shall be provided with sufficient artificial lighting so that the combined natural and artificial lighting shall be capable of providing a minimum illumination of 100-foot candles at work surfaces at all times when the psychiatric day treatment center. is in operation and at least 20-foot candles on all stairways and corridors. Glare shall be kept at a minimum by: Providing shades or curtains at all windows exposed to direct sunlight unless seating is arranged so that no person while at work will be required to face a glaring surface; Using lighting fixtures designed so that bare lamps or tubes are shielded at normal viewing angles; Using light-colored flat paint or other light finishes on ceilings and upper side walls (semi-gloss finishes may be used on lower side walls and other wood trim where frequent cleaning is necessary); Employing non-glossy, light-colored finishes on work tables to minimize glare by reflection. Space and Ventilation Requirements. Adequate space to meet the requirements of program activities shall be available. Space for individual and group therapy, for occupational and activities therapy, and a kitchen area for patient use in acquiring and practicing activities of daily living shall be available. Rooms with a total window area of less than 10 percent and an openable window area of less than 5 percent of the floor area may be used only if there is provision for air exchange and ventilation according to the standards of the ASHRAE Code. Healthful humidity and comfortable temperatures shall be maintained in patient areas during the summer months. Sanitary Facilities. The drinking-water supply may not be located in the bathroom. One drinking-water facility shall be available for every 4o persons or fewer on each floor. There shall be one toilet and one lavatory provided for every 10 persons of the same sex or fewer. The lavatory shall be in close proximity to each toilet. The floor in each toilet room shall have a waterproof, non-absorbent finish, and the walls shall be smoothly finished with a hard surface. Grab bars shall be provided in toilets and bathing areas. Towels shall be of the single-service type and shall be provided on single-service towel dispensers in all toilet rooms. Mechanical hand-drying devices may be used instead of towel dispensers. There shall be hot and cold running water, soap, and toilet paper provided in the toilet rooms at all times. The temperatures of the hot water may not exceed 125°F in patient areas. Food Facilities. If food is prepared on the premises, the applicable sections of COMAR 10.15.03 relating to approved source of food, food temperatures and storage, storage of dangerous chemicals, handwashing, and dishwashing (sanitizing) shall serve as the standards. Safety. Stairways shall be kept free of obstructions. Fire-exit doors shall be maintained in working order. The facility shall be free of mechanical and electrical hazards. Non-slip surfaces and coverings shall be provided in risk areas, such as tubs, showers, and stairways. Poisonous and flammable products are prohibited unless stored in accordance with State Fire Prevention code requirements. Provisions for Handicapped. Provisions for the handicapped shall be made according to the American National Standards Institute (ANSI) A 117.1 to meet the anticipated needs of the population served. Janitors' Closets and Slop Sinks. The facility shall provide janitors' closets with slop sinks as follows: At least one per building shall be provided in non-hospital-based programs; At least one for every 100 persons, one per resident building, or one per resident floor, whichever is most stringent, shall be provided in hospital-based programs. Mops and supplies may not be stored on the floor in the closet. The closet shall be vented to the outside. Storage. Storage areas shall be provided and located according to efficiency of scheduling, operation, and patient needs. Minimal Equipment. Minimal equipment for a psychiatric day treatment center shall be adequate to meet the demands of the program according to the number of clients in attendance. Health-General Article, §2-104, Annotated Code of Maryland Effective date: November 25, 1961 Amended effective August 4, 1965 and April 15, 1974 Chapter revised effective May 29, 1981 (8:11 Md. R. 974) These regulations shall apply to every individual admitted either voluntarily or involuntarily to any inpatient mental health facility licensed by, or under the jurisdiction of, the Maryland Department of Health. These regulations may not apply to institutions for the care of developmentally disabled patients, or to those patients committed by the courts for evaluation only. These regulations are supplemental to any other laws and regulations that may be applicable. In the event of conflict between these regulations or laws and any other regulations or laws, the more stringent shall apply. “Active treatment” means the regular participation by a patient in professionally developed and supervised activities, experiences, or therapies based on an individual treatment plan. “Department” means the Maryland Department of Health. “Mental health professional treatment team” means: One or more duly licensed physicians or psychiatrists, one of whom shall assume responsibility for the development and implementation of an individual treatment plan. If the physician member of the mental health professional treatment team has less than 2 years of post-degree experience in a mental health setting, at least one other member of the team shall have attained the master's degree and have 2 years of post-degree experience in a mental health setting. One or more of the following mental health professionals: A psychologist, licensed in the State, or an individual with a master's degree in psychology or a related field from an accredited college or university in a program acceptable to the Board of Examiners of Psychologists, under the supervision of a licensed psychologist, and with at least 2 years of postdegree experience in a mental health setting; A professional registered nurse licensed in the State with at least one of the following credentials: Two years of psychiatric nursing experience; A bachelor of science degree and 1 year of psychiatric experience; or A master's degree and 1 year of psychiatric nursing experience; A social worker, licensed in the State, with a master's degree in social work from an accredited school of social work and 2 years experience, 1 of which shall have been in a mental health setting; or An occupational therapist, licensed in the State, with a bachelor of science degree in occupational therapy from an accredited school of occupational therapy and 2 years experience, 1 of which shall have been in a mental health setting. Other members of the hospital staff who work directly with the patient, including other professionals and paraprofessionals and professionals in service and in training. “Patient” means any person voluntarily or involuntarily admitted to one of the mental health facilities under the jurisdiction of, or licensed by, the Maryland Department of Health pursuant to the provisions of Health-General Article, Title 10, Annotated Code of Maryland. The individual treatment plan is a comprehensive and thoughtfully written plan based on an initial diagnostic impression and an overall evaluation of the patient's specific needs and problems. It includes an inventory of the patient's strengths as well as weaknesses, and sets forth short-term measurable goals and behaviorally stated objectives aimed at maximal restoration of the patient's adaptive capacity and return to the community as soon as possible. Based on the above goals objectives, a plan of active treatment shall be prescribed which aims at the arrest, reversal, and amelioration of the patient's illness symptoms. There shall be included a long-range discharge goal as well as an estimate of the probable length of inpatient stay needed before transfer to a less restrictive or intensive treatment milieu. The individual treatment plan shall be initially recorded and appropriately updated in the patient's permanent medical record. The initial individual treatment plan shall be developed by members of the mental health professional treatment team who are directly involved in the patient's care including at least one member each from Regulation .02C(1) and (2), of this chapter. The initial individual treatment plan shall be signed by the physician responsible for its development. The names of the other members of the mental health professional treatment team involved in the development of the plan shall be noted adjacent to the signature of the physician. A comprehensive, thoughtfully written, and properly signed individual treatment plan shall be recorded in the permanent medical record, or on a separate form which will become part of the permanent medical record, no later than 15 days after admission. The individual treatment plan shall include or refer to essential written or verbal information which has been gathered, as well as relevant information derived from other parts of the medical record, that will help identify the specific needs and problems of the individual patient. The individual treatment plan shall also include an initial psychiatric diagnosis recorded in the official nomenclature of the American Psychiatric Association, discharge planning data relating to community and financial resources available to the patient, and the legal status of the patient. Information may not be gathered without the consent of the patient or of the patient's parent or legally appointed representative if the patient is a minor or is incompetent. The individual treatment plan shall include a notation of any therapeutic task, labor, recreation, or other scheduled activity to be performed by the patient, including the rationale for these in relation to the treatment plan and the projected goals. The individual treatment plan shall include, when applicable, a description of the patient's individualized educational plan. Special education plans, in conformance with the regulations of the Department of Education, are mandatory for patients through 20 years old. The individual treatment plan shall include, when feasible, patient participation in accordance with Health-General Article, §10-706, Annotated Code of Maryland. Care shall be taken to preserve the confidentiality of the patient-mental health professional treatment team member relationship. Information from a patient's record, including the individual treatment plan, may not be disclosed to any person, organization, or agency except in the case of a court order or with the written consent of the patient or of the patient's parent, if the patient is a minor, or legally appointed representative, if the patient is incompetent. The individual treatment plan shall be periodically reassessed by members of the mental health professional treatment team who are working directly with the patient, including at least one member each from Regulation .02C(1) and (2), of this chapter, including the physician responsible for the implementation of the plan. This reassessment shall be made no less than once every 15 days for the first 2 months for all newly admitted or readmitted patients, and after that, at least once every 60 days. The mental health professional treatment team members who make the reassessment shall place a written entry in the permanent medical record or on a separate form which will become part of the permanent medical record. This entry shall be signed by the physician responsible for the implementation of the plan. The names of the other members of the mental health professional treatment team involved in the reassessment of the plan shall be noted adjacent to the signature of the physician. The initial individual treatment plan and all subsequent reassessments shall be easily identifiable as a separate, comprehensively written, and properly signed entry into the permanent medical record or on a separate form which will become part of the permanent medical record. If any section or provision of these regulations is declared unconstitutional or void by any court of competent jurisdiction, or its applicability to any person or circumstances is held invalid, the constitutionality or validity of the remainder of these regulations and their applicability to other persons and circumstances may not be affected, and, to this end, the sections and provisions of these regulations are declared to be severable. Health-General Article, §10-705, Annotated Code of Maryland Effective date: June 25, 1975 (2:14 Md. R. 1016) Annotation: COMAR 10.21.03 cited in Attorney General Opinion No. 82-034 (November 18, 1982) Chapter revised effective January 9, 1989 (15:27 Md. R. 3129) This chapter establishes the licensing procedure for group homes for adults with mental disorders. In this chapter, terms have the meanings stated in COMAR 10.21.17. Definition of Group Home. “Group home” means a community-based residential program that provides services: For individuals who have been or are under treatment for a mental disorder; When possible, in the individual's community of origin; and In a home-like environment. “Group home” means a private group home as defined in Health-General Article, §§10-514(b), (d) — (e) and 10-518(b), Annotated Code of Maryland, as either a: Small private group home, which: Admits at least four but not more than eight individuals; and Is deemed conclusively a single-family residence and is permitted in all residential zones; or Large private group home, which: Admits at least nine but not more than 16 individuals; and Is deemed conclusively a multifamily residence and is permitted in zones of similar density. “Group home” does not include a: Foster home that is the domicile of the foster parent; or Facility that is: Owned by or leased to the State or any public agency; Regulated by the Department of Juvenile Services or Developmental Disabilities Administration; or Organized wholly or partly to make a profit. A group home may admit an individual if the individual: Has a mental disorder; Because of the mental disorder, requires residential services for assistance and support in community living; Has the ability to understand and states, in writing, willingness to comply with the rules and regulations of the group home; and Is able to take appropriate action, under emergency conditions, for self-preservation. A group home may not admit an individual if the individual: Has a primary diagnosis of alcoholism, drug addition, or severe brain damage; or Shows current violent or antisocial behavior. If an individual is a Medicaid recipient or an individual for whom, because of the severity of the illness and financial need, the cost of care is subsidized through the public mental health system, the individual may be admitted to a group home only if the services are preauthorized by the Administration's administrative services organization (ASO), according to the provisions of COMAR 10.09.70.07. A person shall obtain a license from the Department before operating a group home. The Secretary shall grant a license to an applicant to operate a group home, as described in Regulation .02 of this chapter, if the applicant fulfills the requirements for: Licensure under this chapter; Administrative requirements under COMAR 10.21.17; Psychiatric rehabilitation programs under COMAR 10.21.21; and Residential rehabilitation programs under COMAR 10.21.22. Consultation. Before submitting an application, an applicant for licensure to operate a group home may request assistance from the Department's designated licensure unit or the appropriate core service agency (CSA) regarding the proper compilation of application materials and completion of the application. Application for Licensure. An applicant for licensure for a group home shall: Submit, to the Department's designated licensure unit, a signed, notarized application on the form approved by the Department with the requirement that all questions be answered and all required documents be attached; Include in the application: The applicant's: Name; Agency affiliation, if any; and Address; Documentation: Of the applicant's not-for-profit status; That the applicant has sufficient financial resources or that sufficient resources are available to the applicant for the establishment and operation of the residence; The following information about the property: The street address of the property or, if it has no street address, a description that adequately identifies the location; and If the applicant does not own the property, the name and address of the owner; The satisfactory reports, not more than 1 year old, of the group home that are required by the local jurisdiction, including, at a minimum: A fire safety inspection report; and In addition, for a large group home, a health inspection report; Written material that describes how the applicant intends the program to comply with the: Requirements outlined in this chapter; Administrative requirements outlined in COMAR 10.21.17; and Programmatic and staffing requirements outlined in COMAR 10.21.21 and 10.21.22; When applicable, a letter of intent that explains how the proposed services meet a need identified in the Administration-approved CSA plan; and When applicable, documentation that the program will collaborate with the CSA, as required under COMAR 10.21.17.04; Documentation that the group home: Is compatible with the nature and character of the area involved; Is near transportation facilities; and Meets or, on completion, will meet general zoning requirements regarding size, density, land use, and architectural guidelines that apply to the location; Submit with the application a copy of the residential specialist's certificate of approval of the residence, as granted under the provisions of COMAR 10.21.22; and Forward a copy of the: Application cover letter to the Administration; and Application to the: CSA, if the jurisdiction in which the program is to be located is served by a CSA; or Health officer, if the jurisdiction in which the program is to be located is not served by a CSA. Initial License. Within 90 days of receipt of an application completed according to Regulation .05B of this chapter, the Department's designated licensure unit: Shall: Evaluate the application; Meet with the applicant; and Conduct an on-site review to inspect the physical plant and evaluate the proposed group home; and May ask the group home program director to submit a program improvement plan regarding deficiencies cited by the licensure unit. Based on the evaluation conducted under §A(1)(a) and the results of the plan under §A(1)(b) of this regulation, the Secretary shall either: Issue a license for a period of 2 years, if the group home: Has no deficiencies that constitute a threat to the health, safety, or welfare of the individuals served; and Complies with the requirements outlined in this chapter and COMAR 10.21.17, 10.21.21, and 10.21.22; or Propose to deny a license. If the Secretary takes the action in §A(2)(b) of this regulation, the Secretary shall advise the applicant of hearing rights, as described in Regulation .12 of this chapter. Renewal License. If a group home licensee proposes to continue to operate, the licensee shall file an application for renewal: At least 60 days before the expiration of the current license; With the Department's designated licensure unit, with copies to the CSA and the Administration; and On the form approved by the Department with the requirement that all questions be answered and all required documents be attached. Upon receipt of an application for renewal, the Department's designated licensure unit: Shall conduct an on-site evaluation of the group home; and May ask the group home program director to submit a program improvement plan regarding deficiencies cited by the licensure unit. Based on the evaluation under §B(2)(a) and the results of the plan under §B(2)(b) of this regulation, the Secretary shall either: Issue a license for a period of 2 years, if the group home: Has operated satisfactorily under the current license; and Complies with the requirements outlined in this chapter and COMAR 10.21.17, 10.21.21, and 10.21.22; or Propose to deny a license. If the Secretary takes the action in §B(3)(b) of this regulation, the Secretary shall advise the applicant of hearing rights, as described in Regulation .12 of this chapter. Waivers and Variances. Waivers. The Secretary may not waive the requirements of any regulation adopted under this chapter. Variances. The Secretary may grant a variance to a regulation if the Secretary: Receives a written request from a program; and Finds that the intent of the regulation to which a variance is sought is met by the alternative proposed by the program. The Secretary may not grant a variance that would endanger the health or safety of the individuals served. The Secretary may grant a variance that: Remains in effect for as long as the program continues to comply with the conditions under which the variance is granted; or Is time limited. The Secretary shall issue a written decision, including the reason or reasons for granting or not granting the variance, and shall: Send the decision to the program for inclusion in the program's official file; and Enter the decision in the records of the Department. Request for Deemed Status. If a group home is licensed by the Department and is accredited by the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) or the Rehabilitation Accreditation Commission (CARF), the governing body of the group home may request that the Secretary grant the group home deemed status by submitting a written request: At least 90 days before the expiration of the group home's license; To the: Administration; CSA, if the jurisdiction in which the program is to be located is served by a CSA; and Health officer, if the jurisdiction in which the program is to be located is not served by a CSA; and That includes the: Application required under Regulation .05B of this chapter; and Accreditation body's full report including the group home's status and any conditions placed on the group home. Evaluation of Request for Deemed Status. Within 30 calendar days of receipt of the request under §A of this regulation: The Administration, in consultation with the CSA: Shall evaluate the: Application; Report of the accreditation body; and Most recent report by the Department's designated licensure unit; May meet with the applicant; and May arrange for an on-site evaluation; and The Director shall recommend to the Secretary a decision regarding deemed status, based on: Comparison of the standards used by the accreditation body with the requirements outlined in COMAR 10.21.17, 10.21.21, 10.21.22, and this chapter; and The results of an on-site evaluation, if any. Decision Regarding Deemed Status. Based on the evaluation of the request for deemed status conducted under §B of this regulation, within 45 calendar days of completion of the evaluation, the Secretary shall: Decide, whether to: Grant deemed status; Grant deemed status with conditions, which may include evaluation by the Department's designated licensure unit; or Propose to deny deemed status; and Send notice of the proposed decision to the: Department's designated licensure unit; Governing body; Group home director; Administration; and As applicable, either the CSA director or health officer. Proposal to Deny Deemed Status. If the Secretary proposes to deny approval of deemed status, the Secretary shall give written notice of the proposed denial to those listed in §C(2) of this regulation. In the notice under §D(1) of this regulation, the Secretary shall include: The date that the Secretary proposes to deny approval of deemed status; Location, including street address, to which the proposed denial applies; The facts that warrant the proposed denial; and Notification that, before the denial, the program has a right to a hearing. Upon receipt of the notice under §D(2) of this regulation, the chairman of the governing body may: Withdraw the request for deemed status; and Request an on-site review for approval by the Department's designated licensure unit. If the governing body does not take the action under §D(3) of this regulation and if, after notice and opportunity to be heard, the Secretary denies approval of deemed status, the Director shall notify the governing body that, unless the program elects not to seek approval, the Department's designated approval unit shall conduct an on-site review for the purpose of granting or denying a license. The Department may make announced and unannounced visits to a group home. If the Department receives information that the safety or welfare of an individual served is in jeopardy, the Department shall promptly: Conduct and document an investigation; and Based on the investigation under §B(1) of this regulation, take appropriate action, including: Outlining the requirements for the group home to correct the problems identified; or Initiating any of the following: Emergency suspension, under the provisions of Regulation .09B of this chapter; Disciplinary action, including suspension, revocation, probation, or banning new admissions under the provisions of Regulation .09C of this chapter; or Receivership, under the provisions of Regulation .11 of this chapter. Denial of License. If the Secretary proposes to deny a license to an applicant under the provisions of this chapter, the Secretary shall give written notice of the proposed denial to the: Chairman of the governing body; Program director; Administration; and As applicable, either the CSA director or the health officer. In the notice under §A(1) of this regulation, the Secretary shall include: The date on which the Secretary proposes to deny the license; Location, including street address, to which the proposed denial applies; The facts that warrant the proposed denial of the license; Citation of the regulation or regulations upon which the proposed denial is based; and Notification that, before the deprivation of a license, the group home may request a hearing under the provisions of Regulation .12 of this chapter. If, after notice and opportunity to be heard, the Secretary denies a license to a group home, the governing body shall assure that, within 10 working days, the program director: Notifies the residents in the group home of the denial; When appropriate, notifies the CSA or the Administration of the denial and cooperates with the CSA or the Administration in accessing appropriate alternate housing for individuals in the group home; and Ceases operations of the group home. Emergency Suspension of License. Pursuant to State Government Article, §10-226, Annotated Code of Maryland, upon findings of conditions that pose an imminent risk to the health, safety, or welfare of an individual served by a group home, the Secretary may order the immediate suspension of the license of the group home and the cessation of operations. If the Secretary takes the action under §B(1) of this regulation, the Secretary shall promptly give written notice of the proposed emergency suspension to the: Chairman of the governing body; Program director; Administration; and As applicable, either the CSA director or the health officer. In the notice under §B(2) of this regulation, the Secretary shall include: The effective date of the emergency suspension; Location, including street address, to which the emergency suspension applies; The findings under §B(1) of this regulation and the reasons that support the findings; Notification that: Following the emergency suspension, the group home may request a hearing under the provisions of Regulation .12 of this chapter; and The emergency suspension may lead to revocation of the license if the violation or violations are not corrected within the time period specified by the Department. If the Secretary suspends the license, the governing body shall assure that the program director immediately takes the action described under §A(3) of this regulation. Disciplinary Action. The Secretary may propose to take any of the following disciplinary actions against the license to operate a group home: Revocation; Suspension; Probation, with conditions; or Banning new admissions. The Secretary may propose to take one of the actions outlined in §C(1) of this regulation if the group home: Is out of compliance with the requirements of this chapter; or Obtains or attempts to obtain licensure by fraud, misrepresentation, or the submission of false information to the Secretary. Within 45 calendar days in advance of the proposed action taken under this regulation, the Secretary shall send written notice of the proposed action to the: Chairman of the governing body; Program director; Administration; and As applicable, either the CSA director or the health officer. In the notice under §C(3) of this regulation, the Secretary shall include: The date on which the Secretary proposes to take action against the license; Location, including street address, to which the proposed action applies; The facts that warrant the proposed action; Citation of the regulation or regulations upon which the proposed action is based; and Notification that, before the action, the group home has the right to request a hearing under the provisions of Regulation .12 of this chapter. If, after notice and opportunity to be heard, the Secretary takes disciplinary action, the governing body shall assure that, within 10 working days, the program director takes the action described under §A(3) of this regulation. If a group home requests that licensure be discontinued: The Secretary shall discontinue licensure; and The governing body shall assure that, within 10 working days, the program director takes the action described under Regulation .09A(3) of this chapter. The Secretary may take action to initiate receivership under the provisions of Health-General Article, §§19-333 — 19-339, Annotated Code of Maryland. Within 10 working days of receipt of notification that the Secretary proposes to deny approval or initiate disciplinary action, the chairman of the governing body may file a written request for a hearing with the Office of Administrative Hearings, with copies to the: Administration; CSA director; and Director of the Department's designated licensure unit. If the chairman of the governing body does not file a request for hearing that is post-marked within 10 working days of receipt of the notification, the group home waives the right to request a hearing, and the Secretary may effect the proposed action. If a timely request for hearing has been received, the Office of Administrative Hearings shall: Notify the director and the chairman of the governing body of the date, time, and location of the hearing; and Hold a hearing and render a proposed decision to the Secretary in accordance with COMAR 28.02.01. After giving parties the opportunity to file exceptions under the provisions of State Government Article, §10-216, Annotated Code of Maryland, the Secretary shall issue a final decision according to State Government Article, §10-221, Annotated Code of Maryland, and send notice of the decision to the: Director; and Chairman of the governing body. Further Appeal. A group home may appeal any final decision by the Secretary by following the provisions of Health-General Article, §10-524, and State Government Article, Title 10, Subtitle 2, Annotated Code of Maryland. Health-General Article, §§10-514 — 10-524 and 10-604, Annotated Code of Maryland Effective date: July 25, 1980 (7:15 Md. R. 1424) Recodified from COMAR 10.21.05 to 10.21.04 Chapter revised effective October 14, 1991 (18:20 Md. R. 2199) Chapter, Group Homes for the Mentally Disabled, repealed and new Chapter, Community Mental Health Programs — Group Homes for Adults with Mental Illness, adopted effective October 5, 1998 (25:20 Md. R. 1529) This chapter applies to aftercare plans, which are: Provided to an individual who has been accepted under the provisions of Health-General Article, Title 10, Subtitle 6, Health-General Article, Title 12, Subtitle 1, or Courts and Judicial Proceedings Article, Title 3, Subtitle 8, Annotated Code of Maryland, in one of the following: Mental Hygiene Administration facility under Health-General Article, §10-406, Annotated Code of Maryland; Private psychiatric inpatient facility; Residential treatment center for children and adolescents; or Psychiatric unit in an acute care general hospital; and Designed to: Enhance the opportunity for the individual to live in the community; and Assist in the prevention of homelessness. In this chapter, the following terms have the meanings indicated. Terms Defined. “Accepted” means: Taken into confinement on the basis of an application and certificate for involuntary admission, according to the provisions of Health-General Article, §§10-614 — 10-616, Annotated Code of Maryland; or Admitted, as defined in §B(4) of this regulation. “Administration” means the Mental Hygiene Administration. “Administrative services organization (ASO)” means the organization under contract with the Administration to provide administrative services for the public mental health system. “Admitted” means: Admitted voluntarily, according to the provisions of Health-General Article, §10-609 or 10-610, Annotated Code of Maryland; Admitted involuntarily, by an administrative law judge, according to the provisions of Health-General Article, §10-632, Annotated Code of Maryland; or Committed by a court according to the provisions of: Health-General Article, Title 12, Subtitle 1, Annotated Code of Maryland; or Courts and Judicial Proceedings Article, Title 3, Subtitle 8, Annotated Code of Maryland. “Aftercare plan” means the plan developed by inpatient facility staff according to the requirements of Health-General Article, §10-809, Annotated Code of Maryland. “Chief executive officer (CEO)” means the individual responsible for the overall management of a facility. “Discharge” means authorization by a physician for a voluntarily or involuntarily admitted individual to leave an inpatient facility. “Proper consent” means consent given by the individual, or, if the individual is a child or adolescent, by the individual's parent or guardian, to release relevant information. “Release” means the authorization for an individual who is confined in an inpatient facility on the basis of an application and certificate for involuntary admission to leave the inpatient facility: Given by a physician during the observation status period; or Ordered by an administrative law judge at an involuntary admissions hearing. Staff designated by the CEO to assist individuals in aftercare planning shall, as soon as possible after acceptance, in collaboration with the individual: Initiate the aftercare planning process; With proper consent, involve in the aftercare planning process: Community-based service providers; Family members; Others who have a personal interest in the individual; and Third-party payors, including Medical Assistance, the Administration's ASO, or private insurance carriers, if involved, for authorization of outpatient services; Assist in applying for benefits to which the individual may be entitled and document the outcome of the benefits application process in the individual's record. Before discharge or release, designated staff shall: Provide notification of the discharge or release: With proper consent, to: The individual's next-of-kin; As appropriate, the core service agency (CSA); Community-based treatment and support services providers rendering services before the individual's inpatient admission; and Third-party payors, including Medical Assistance, the Administration's ASO, or private insurance carriers, if involved, for authorization of outpatient services; and If the individual is a minor, to the parent or guardian; and Assist the individual to participate in the aftercare plan by: Explaining to the individual the benefits of: The aftercare plan; Community-based treatment and support services; and The involvement of family or others who have a personal interest in the individual; Encouraging the individual to consent to the aftercare plan; and Arranging appointments for the individual with appropriate community programs. In collaboration with community programs and government agencies that have agreed to provide aftercare services to the individual after discharge or release, designated staff shall prepare a written aftercare plan that includes: The individual's: Name; Date of birth; and Address and telephone number upon discharge or release; For a minor or an individual under guardianship, the name, address, and telephone number of the custodial adult or guardian; If the individual will reside in program-arranged housing, the name, address, telephone number, and contact person of the placement agency; The date and type of admission and discharge or release; The scheduled court date, if any; The diagnoses, including existing psychiatric, somatic, and dental diagnoses, and level of functional assessment; The type of treatment initiated; The name, address, and telephone number of the primary care provider; Medication information, including the: Medication prescribed; Dosage schedules; Amount of each medication given to the individual upon discharge or release; and Information necessary to help the individual to obtain the prescribed medication in the community; The most recent laboratory results, including therapeutic drug levels; If applicable, a description of: Allergies, including medication allergies; Nutritional requirements; and Active somatic problems requiring continued attention; Information on the individual's medical insurance coverage, including the: Company; Policy number; Name of the policy holder; and Preauthorization information, if given, for services to be initiated upon discharge or release; Entitlements, if any, and status; The plan for continuing treatment, including but not limited to: Outpatient mental health treatment services; Somatic care; Psychiatric rehabilitation and support services; When appropriate, substance abuse services; and Case management; A list of additional referrals indicated, such as: Public social services; Legal aid; Educational services; Housing services; Vocational services; Peer support services; and Available crisis services; and Any identifying information required by the Administration's ASO. Designated staff shall provide the individual with the opportunity to consent or withhold consent for release of all or any portion of the plan to any provider. Within 48 hours or by the first appointment, whichever is sooner, designated staff shall provide the aftercare plan, in accordance with the provisions of §A of this regulation, to the: Community treatment and support programs designated in the aftercare plan; Family members or others with a personal interest in the individual, if any, who are identified in the aftercare plan to provide housing; and Third-party payors, if involved, for authorization of outpatient services. Designated staff shall document in the individual's medical record who received information from the aftercare plan. If the individual does not consent to an aftercare plan, designated staff shall: Place in the individual's record a statement to this effect signed, when possible, by the individual, the individual's guardian, or, for a minor, the parent or guardian; and Provide to the individual, in writing, information on outpatient mental health clinics, crisis and emergency services, and other available community mental health services and resources within the jurisdiction in which the individual resides, and document in the individual's record what information was provided. Health-General Article, §§10-709 and 10-809, Annotated Code of Maryland Effective date: December 14, 1998 (25:25 Md. R. 1831) This chapter establishes procedures and standards for residential admission to the Regional Institutes for Children and Adolescents (RICAs). The RICAs are mental health facilities licensed and operated by the Maryland Department of Health for the residential treatment of severely emotionally disturbed children and adolescents. The following terms have the meanings indicated. Terms Defined. “Administration” means the Maryland Department of Health. “Applicant” means a child or adolescent who is the subject of an application for admission to a RICA. “Director” means the Director of the Maryland Department of Health. “Mental disorder” means a behavioral or emotional illness that results from a psychiatric or neurological disorder and is referenced in Health-General Article, §10-620(e)(1), Annotated Code of Maryland. “Resident” means a child or adolescent who is admitted to a RICA for residential treatment. “Residential treatment” means a program of active psychiatric treatment that is provided on a residential basis, under the direction of a psychiatrist, and in conformity with an individualized treatment plan. “RICA” means a Regional Institute for Children and Adolescents. On referral by a public or private agency or mental health professional, application for admission to a RICA may be made by: The parent or guardian of a child or adolescent under 18 years old; An adolescent, if the adolescent is 16 years old or older; or A State or county agency that has custody of a child or adolescent, with the signed consent of the parent or guardian or in accordance with a court order. The admission application shall be on a form prescribed by the Administration and shall include: The name, date of birth, sex, legal domicile, and present residence of the applicant; A statement based on clinical evaluation by a mental health professional that the applicant has a long term and severe mental disorder and is in need of residential treatment; and A recent history of the applicant's psychiatric or psychological treatment, educational or special educational services, and involvement with community agencies. Available medical records and psychiatric or psychological evaluations describing the applicant's mental disorder and need for residential treatment shall be attached to the admission application. The referring agency or mental health professional shall be responsible for assuring that appropriate written consent is obtained so as to permit that all required completed application materials may be sent to the RICA. Each RICA shall maintain an admission team which consists of a physician, mental health and educational professionals and other persons, as appropriate. The RICA admission team shall determine whether the applicant meets the admission standards set forth in Regulation .05 of this chapter, within 10 working days of receipt of the completed application. The applicant and referring agency or mental health professional shall be notified by the RICA admission team as to whether the applicant meets the admission criteria. If the admission team determines that the admission criteria are met, a pre-admission interview shall be scheduled by the RICA at the earliest convenient date for all parties involved. A child or adolescent may be admitted to a RICA if the: Individual has a long-term and severe mental disorder; Individual has treatment needs that cannot be met through available community-based programs; Residential treatment provided by the RICA can reasonably be expected to improve the individual's condition or prevent further regression so that the individual can return to the community. The child or adolescent shall be between 12 and 17 years old at the time of admission. The RICA admission team may waive the age limit in appropriate cases. A RICA may not admit a child or adolescent who has: A primary diagnosis of alcoholism, drug addiction, or severe brain damage; or Cognitive deficits which severely limit the individual's ability to use the treatment modalities provided. A child or adolescent who otherwise meets the admission standards may not be denied residential treatment solely because the individual resides outside the regular catchment area served by the RICA, as established by the Director. The Director shall take into consideration the ratio of residential treatment beds to population base and proximity to the program when establishing the catchment areas, and shall review and revise the catchment areas, as appropriate, every 5 years beginning in 1990. Priority for admission shall be given to applicants living in the catchment area served by the RICA. If a child or adolescent meets the admission standards but the RICA is occupied to its licensed capacity, priority on the waiting list for admission shall be given to those individuals who have the most severe mental disorders as exhibited by level of dysfunctions. Residents shall be accorded the rights enumerated in the Health-General Article, §§10-701 through 10-709, Annotated Code of Maryland, and shall be informed of these rights upon admission. An individualized treatment plan shall be developed and implemented for each resident in accordance with Health-General Article, §10-706, Annotated Code of Maryland, and COMAR 10.21.03. An educational program shall be provided for each resident based on educational needs and shall include, when appropriate, an individualized educational program in accordance with COMAR 13A.05.01. An aftercare plan shall be developed for each resident before release from a RICA in cooperation with the referring agency or professional, parent, or guardian or other appropriate agencies in accordance with the Health-General Article, §§10-709 and 10-809, Annotated Code of Maryland. A RICA may establish a separate unit for short term evaluation of children and adolescents referred by a Juvenile Court. Admission from the court evaluation unit to the regular residential treatment program shall be in accordance with the procedures and standards set forth in Regulations .04 and .05 of this chapter. Health-General Article, §§2-104, 10-204, 10-401, 10-406, 10-407, 10-602, 10-609, and 10-610, Annotated Code of Maryland Effective date: July 1, 1985 (12:9 Md. R. 811) This chapter establishes the procedures and standards for operating, programming, and staffing a therapeutic group home (TGH) for children. In this chapter, terms have the meanings stated in COMAR 14.31.05, 14.31.06, and in this chapter. Terms Defined. “Administration” means the Mental Hygiene Administration. “Case coordinator” means the mental health professional or residential care specialist supervised by a mental health professional who coordinates the services, as outlined in a child's TGH individual treatment plan (ITP), to the child. “Clinical coordinator” means the mental health professional who is responsible for oversight of the clinical services provided to children in a TGH. “Contact note” means an entry that: Is made in an individual's medical record by a program staff member; and Describes face-to-face, written, or telephone contact with or regarding the individual. “Core service agency (CSA)” means the county or multi-county authority, designated under Health-General Article, Title 10, Subtitle 12, Annotated Code of Maryland, and approved by the Department, that is responsible for planning, managing, and monitoring publicly funded mental health services. “Department” means the Maryland Department of Health. “Governor’s Office for Children (GOC)” means the office created under Executive Order 01.01.2005.34. “Group home” means a private group home, as defined in Health-General Article, §10-514, Annotated Code of Maryland, that provides mental health services in a residential facility. “Managed care organization (MCO)” means a health care organization, as defined in Health-General Article, §15-101(f), Annotated Code of Maryland. “Medical record” means a record as defined in Health-General Article, §4-301, Annotated Code of Maryland. “Mental health professional” means: A psychiatrist; or An individual who is authorized by the Health Occupations Article, Annotated Code of Maryland, to provide the service for which the individual is privileged. “Primary caretaker” means the: Child's custodial parent or parents; Adult with whom the child currently resides; or Legal guardian. “Privileging” means the process by which a program determines that staff members are qualified to perform assigned duties. “Progress summary note” means an entry by an individual's treatment coordinator in the individual's medical record and that describes the individual's progress toward the goals delineated in the individual's ITP. “Secretary” means the Secretary of Health, or the Secretary's designee. “Small private group home” means a residence as defined in Health-General Article, §§10-514(d) and (e) and 10-518(b), Annotated Code of Maryland. Therapeutic Group Home (TGH). “Therapeutic group home (TGH)” means a small private group home. “Therapeutic group home (TGH)” does not include a foster home that is the domicile of the foster parent. “Therapeutic group home (TGH)” does not include a facility that is: Owned by or leased to the State or any public agency; Regulated by the Department of Juvenile Services, Department of Human Services, or Developmental Disabilities Administration; or Organized wholly or partly to make a profit. “Therapeutic milieu” means an environment that is clinically structured to provide mental health treatment in a place other than the individual's residence. Proposal. An individual or organization that proposes to provide therapeutic living services for children in a TGH shall: Direct an initial inquiry for obtaining a license to the GOC, in accordance with COMAR 14.31.05.05; and Submit to GOC, in accordance with COMAR 14.31.05.05, a proposal describing the: Physical plant in which the children will reside; and Program service plan, as described in Regulation .05C of this chapter. GOC shall designate a lead agency. Lead Agency. If GOC designates the Department as lead agency, on receipt of the proposal submitted under §A of this regulation, the Secretary shall notify the Director of the Administration, who shall: Forward a copy of the proposal to: The CSA director, if appropriate; and The designated licensure unit of the Department; and Within 2 weeks, send the applicant the Department application form and instructions. Before operating a TGH, a person shall obtain a license from the Department under the provisions of this chapter and COMAR 14.31.05 for each TGH site in which children reside. The Secretary shall grant a license to an applicant to operate a TGH if the applicant fulfills the requirements for: Licensure under COMAR 14.31.05; and Service and staffing under this chapter. Consultation. If the Administration is the designated lead agency, an applicant for licensure for a TGH, before submitting an application, may request assistance from the designated licensure unit of the Department, the appropriate CSA director, or the Administration regarding the proper compilation of application materials and completion of the application. Application. An applicant for licensure of a TGH shall: Submit, to the Department's designated licensure unit, a signed, notarized application on the form approved by the Department with the requirement that all questions be answered and all required documents be attached; Include in the application: The applicant's: Name; Agency affiliation, if any; and Address; Documentation: Of the applicant's not-for-profit status; and That the applicant has sufficient financial resources or that sufficient resources are available to the applicant for the establishment and operation of the residence; The following information about the property: The street address of the location of the TGH or, if it has no street address, a description that adequately identifies the location of the property; and If the applicant does not own the property, the name and address of the owner; The satisfactory fire, safety, and health inspection reports, not more than 1 year old, of the TGH that are required by the local jurisdiction; Written material that describes how the applicant intends to comply with the requirements outlined in: COMAR 14.31.05; and This chapter; An explanation of the need for the TGH, including, if the jurisdiction in which the TGH is to be located is served by a CSA, a letter of intent that explains how the TGH meets a need identified in the Administration-approved CSA plan; When applicable, documentation that the TGH will collaborate with the CSA, as required under Regulation .07 of this chapter; Documentation that the TGH: Is near transportation facilities, or has a plan for the provision of transportation services based on the individual's need; and Meets, or on completion will meet, general zoning requirements regarding size, density, land use, and architectural guidelines that apply to the site; and The applicant's program service plan, as outlined in §C of this regulation; and Forward a copy of the: Application cover letter to the Administration; and Application to the: CSA, if the jurisdiction in which the TGH is to be located is served by a CSA; or Administration, if the jurisdiction in which the TGH is to be located is not served by a CSA. Program Service Plan (PSP). On the form approved by the Administration, as part of the application, a TGH shall submit a PSP that includes: If appropriate, a copy of the articles of incorporation, organizational chart, bylaws, and list of the members, including officers, of the governing body; Documentation that at least 1/3 of the members of either the governing body or an advisory committee includes representation of consumers, former consumers, or family members; The proposed budget for the TGH; A description of: The number of children, as well as their age groups and other relevant characteristics, that the TGH expects to serve; The geographic area to be served; The goals, objectives, and expected outcomes of the program; The plan for the provision of the following services: Medical; Dental; Required education; Social and recreational; Nutritional; and Mental health treatment; The method for linkage with service providers and community resources, including, when applicable, written agreements with inpatient facilities and other providers of health, mental health, and social services; and The methods by which quality, including risk management and utilization review, are assured; and A list of staff positions, their job descriptions and educational and clinical training requirements, and staffing patterns, including an organizational chart detailing lines of authority and responsibility. Governing Body. A provider that is licensed by the Department under this chapter to operate a TGH shall be governed by a body that shall: Carry out the responsibilities under COMAR 14.31.06.04; and Either: Include the membership described under §B(1) of this regulation; or Appoint an advisory committee for the TGH that includes the membership described under §B(1) of this regulation. The chairman of the governing body shall maintain documentation of: The legal form of organization of the operator of the TGH; The minutes of all regularly scheduled meetings; and Any registration required by the State Department of Assessments and Taxation to operate as a business in Maryland. Advisory Committee. When appointing an advisory committee under §A(1)(b)(ii) of this regulation, the governing body shall assure that the committee is composed of members: That reflect the cultural and ethnic profile of the community or communities being served; and At least 1/3 of whom are individuals who are: Currently or were previously served by a TGH or other community-based mental health program; Family members of individuals who are currently or were previously served by a TGH or other community-based mental health program; or Members of a mental health advocacy organization. An advisory committee appointed under §B(1) of this regulation shall, at a minimum: Establish and maintain a regular meeting schedule; and Advise the governing body regarding the duties described under COMAR 14.31.06.04. If the jurisdiction in which a TGH is located is served by a CSA, the governing body shall document that the program shall: Submit the following information to the CSA: Documentation that the program budget is adequate to support the program's ability to provide authorized services; The program service plan; Data that incorporate outcome measures; and A yearly summary that, at a minimum, includes: Relevant financial statements or documentation of an audit that certifies that the TGH is fiscally sound; Program planning and evaluation, as identified in COMAR 14.31.06.19; and Service utilization data; Collaborate with the CSA in: The process developed by the CSA for screening and exploring alternatives for an individual served by the TGH for whom inpatient facility admission is being initiated; The CSA's protocol for resolution of conflict between the TGH and: The child or family of a child served; and Another program or agency; and The CSA's procedures for prevention of the appearance or occurrence of conflict of interest in the operation and oversight of the program's provision of mental health services; Contract, as necessary, with the CSA; and Make available to the CSA any medical records that are needed by the CSA for the purpose of: Assessing the quality of care; or Investigating a complaint or grievance. If the jurisdiction in which a TGH is located is not served by a CSA, the chairman of the governing body shall document that the program shall submit information to and collaborate with the Administration, as required under this regulation. A TGH provides therapeutic living services: For at least four but not more than eight children; By providing access to a combination of developmental, diagnostic, and therapeutic mental health services; When possible, in the child's community of origin; and In a home-like environment. The chief executive officer of a TGH shall assure that a TGH: Provides to each child in the TGH mental health care and treatment: That can reasonably be expected to benefit the child; and By an adequate staff or, under agreement, by a provider of mental health services; Has sufficient staff to provide adequate supervision to the children in the TGH, including 24-hour supervision for each resident not participating in a program outside the TGH; and Coordinates treatment in the TGH with the appropriate public or nonpublic educational program. The chief executive officer of the TGH shall assure that services are: Appropriate to the cultural and psychosocial developmental needs of the child; Provided by staff who: As determined by the program, are appropriately credentialed and privileged; and Organize and manage the therapeutic milieu to: Foster clinically appropriate social, cognitive, emotional, and physical growth; Handle aggression in a nonpunitive manner that promotes growth and learning; Reinforce the child's ability to function with peers in a social environment; Model and provide opportunities for children to behave in age-appropriate ways, such as assuming responsibility for carrying out routine activities, exhibiting independence and initiative in planning their own activities, getting along with others, and demonstrating age-appropriate social skills; Facilitate the child's awareness of appropriate behavior in a predictable, constructive, and timely manner; and Help children to make choices and to negotiate disagreements among themselves, rather than resolving conflicts for them; Provided in an environment that is: Consistent with existing standards of program design; and Organized consistent with the learning styles and developmental needs of the child; and Designed to foster positive relationships between the child and the child's parents or guardians and, if other than a parent, the child's primary caretaker, and the anticipated post-placement caretaker. Eligibility. A child is eligible for admission to a TGH if: The child: Has a mental disorder; Is or should be receiving treatment for the mental disorder; Because of the mental disorder, requires residential services not available in the home; Needs 24-hour supervision in a structured private group home; Has the ability to understand and states, in writing, a willingness to comply with the rules and regulations of the TGH; and Has the ability to act appropriately under emergency conditions; and There is no less restrictive form of treatment that is consistent with the welfare and safety of the child. A TGH may not admit or retain as a resident a child if the child: Has a primary diagnosis of alcoholism, drug addiction, or severe brain damage; Shows current violent or antisocial behavior; or Has cognitive deficits that severely limit the child's ability to benefit from the treatment modalities provided. Application for Admission. An applicant to a TGH shall use an application form which outlines the following requirements: Identifying data, including but not limited to: Name, date of birth, sex, legal domicile, and current residence of the child; Names, addresses, and telephone numbers of persons or agencies having legal care or custody of the child; and Documentation of the child's custody status, including, if relevant, documentation of agreements regarding responsibility for financial support and health care; Authorization to release information signed by the child's parent or guardian; Based on a comprehensive mental health assessment by an individual authorized, under Health Occupations Article, Annotated Code of Maryland, to formulate a psychiatric diagnosis, a statement including: The psychiatric diagnosis and the rationale for the diagnosis; An explanation of why the child would benefit from the treatment and related services provided in and by a TGH; The treatment goals for the child, if TGH placement occurs; Any history of violence or trauma, and the potential for current violent behavior; and Documentation that the child meets the eligibility criteria outlined in §A of this regulation; A recent history of the child's: Mental health treatment, including relevant psychiatric and psychological evaluations; Family status; Education, including documentation of a handicapping condition, if any; and Involvement, if any, with community agencies; Relevant medical records; and Unless the child has a guardian that is a State agency, a written and signed statement that, at the time of application for admission, the child's parent or guardian: Agrees to the placement; Agrees to the rules and regulations of the TGH; and Enters into an agreement regarding the responsibility for payment for the child's medical and mental health care. If, under §B(3) of this regulation, the child has a history of violent behavior, TGH staff shall be permitted to plan and collaborate with the clinical referral source to develop a treatment plan which addresses the current potential for violent behavior. Admissions Procedures. An applicant for admission of a child to a TGH shall: Submit an application for admission, as described in §B of this regulation, to the TGH chief executive officer; and Forward copies of the application to the Administration and the CSA, if the jurisdiction in which the child's parent or guardian resides is served by a CSA. On receipt of an application for admission to the TGH, the TGH chief executive officer, in collaboration with appropriate TGH mental health professional staff, may conduct a pre-admission interview with: The applicant for admission to a TGH; If other than the applicant, the: Child; Child's parent or guardian; or Referring agency; and As appropriate, past or current providers of the following services: Educational; Social; and Mental health treatment. Within 2 weeks of receipt of an application for admission, the TGH chief executive officer shall: In consultation with clinical and residential staff at the TGH and based on the eligibility criteria outlined under §A of this regulation, determine whether the TGH is the appropriate setting for the child; Notify the applicant of the determination; If the determination is that the TGH is not appropriate for the child, notify the applicant of: The reason for the determination; and A recommendation regarding the appropriate level of care; and Notify the appropriate CSA director and the Administration of the determination. If the TGH chief executive officer approves the application for admission, the chief executive officer shall give to the applicant written notice of: If a bed is available, the date of admission to the TGH; or If a bed is not available within the following 21 days: The child's position on the TGH's waiting list; The process for reviewing the child's waiting list status; and Information about appropriate placement alternatives. The chief executive officer of a TGH shall assure that children in the TGH receive: Physical and dental examinations, care, and treatment for children who are: Eligible for Medical Assistance, services through the managed care organization, as required by COMAR 10.09.67; or Not eligible for Medical Assistance, through written agreements with appropriate providers, as indicated under COMAR 01.04.04.19; From an appropriate public or nonpublic program, education, as indicated under COMAR 01.04.04.18B; and From a mental health professional: Regular individual mental health treatment, according to the ITP developed by the mental health professional; and As required by the child's ITP, needed evaluation and consultation. Therapeutic Milieu. The clinical coordinator, as defined in Regulation .14C of this chapter, shall assure maintenance of the therapeutic milieu in order to foster achievement of a child's treatment goals. Diagnosis. Within 1 week of a child's admission to the TGH, the clinical coordinator shall ensure that a staff member authorized under the Health Occupations Article, Annotated Code of Maryland, and credentialed and privileged by the program to formulate a psychiatric diagnosis, shall: Formulate and document in the child's medical record a diagnosis based on a face-to-face assessment of the child, that includes: A description of the presenting problem; Relevant history; Mental status examination; and The rationale for the diagnosis; or Affirm the psychiatric diagnosis documented as part of the application for admission under Regulation .09B(3) of this chapter that has been entered in the child's medical record. Assessment. Using the evaluation materials submitted as part of the application for admission, before or within 1 week of the child's admission to the TGH, the TGH clinical coordinator shall assure the completion of an assessment that includes, as indicated, an assessment of the child's: Developmental history; Educational history; Family history and evaluation of current family status, including legal custody status; Home environment; Social, emotional, and cognitive development; Motor, language, and self-care skills development; History, if any, of: Substance abuse; Physical or sexual abuse; and Home or community violence; Local department of social services or Department of Juvenile Services involvement, if any; Mental status; and Medical history and needs, including, if any, history of allergies, neurologic disorders, and communicable diseases. Initial Brief Treatment Plan. Not later than 1 week following admission, the TGH clinical coordinator shall prepare an initial brief treatment plan: Based on the: Application materials submitted as required under Regulation .09B of this chapter; and Assessment under §C of this regulation; In collaboration with: The child; The primary caretaker; Appropriate TGH staff; and As appropriate and with proper consent, interested and available community treatment providers; and That includes, at a minimum: The treatment goals expressed by the referring agency, if any; The process of orientation to the TGH; and Initial expectations regarding the child's adjustment to residential placement. TGH Individual Treatment Plan (ITP). Treatment Team. At a minimum, the following individuals shall participate on a child's treatment team: The TGH psychiatrist; The clinical coordinator; The child's case coordinator; and Other TGH staff who are involved in providing services to the child and family. The clinical coordinator shall invite, as appropriate and with proper consent, family members and community-based providers of services to the child, including but not limited to school and mental health treatment staff, to participate as members of the child's treatment team. Initial ITP. Within 30 days after a child is admitted to a TGH and based on the initial brief treatment plan and current observations and reports, the TGH clinical coordinator shall prepare an ITP to be addressed by TGH staff: In collaboration with: The child; The treatment team; If present and as appropriate, the primary caretaker, family and others involved in the child's care; and Other providers of care or treatment; That identifies the: Providers of mental health treatment; Providers of medical and dental care; Educational program; and TGH case coordinator; That is coordinated with the child's: Individualized educational plan (IEP), when applicable; ITP prepared by the providers of mental health treatment; and Medical care provider; That documents the following information: Based on the physical examination required under Regulation .10A of this chapter, somatic care recommendations, including any medication prescribed, and precautions; Nutritional requirements and limitations, if any; and Essential medical or non-medical treatments or procedures, if any; That includes, at a minimum: The psychiatric diagnosis, as documented under §B of this regulation, in consultation with the providers of mental health treatment; A description of the child's current behavior, symptoms, and level of functioning that includes the child's presenting strengths, needs, and treatment expectations and responsibilities; A description of the family's or significant others' strengths and needs, as they relate to the child; When appropriate, identification of particular behaviors that result or may be expected to result from the child's psychiatric symptoms; Based on consultation with the providers of education and mental health treatment, short-term and long-term mental health treatment goals that are outcome-oriented and that are stated in behavioral, measurable terms; As needed, other goals related to family, socialization and recreation, and activities of daily living; and Identification of any medication prescribed for the treatment of a mental disorder and required monitoring of same; and That specifies treatment strategies to be provided by TGH staff, including: Recommended modality and frequency of interventions; Target dates for goal achievement; The designation of TGH staff responsible for implementing the elements of the plan; and When appropriate, identification of, referral to, and collaboration with other services to support the child's treatment. ITP Review. As frequently as necessary, as determined by the TGH clinical coordinator, and, at a minimum of every 90 days, at a treatment team meeting with, unless clinically contraindicated, the child, the clinical coordinator shall: Review and record in the child's medical record: The child's progress toward the accomplishment of previously identified mental health treatment and other goals; Goal changes based on a review of progress; Changes in treatment strategies; and Changes in diagnosis; and Communicate the results of the treatment plan review to: The child, if the child did not attend the ITP review team meeting; The primary caretaker, if present; Relevant program staff; and The providers of mental health treatment services. Signature of the ITP and ITP Reviews. The child and the child's parent or guardian shall sign or tape-record agreement or disagreement with the ITP and reviews. A child's primary caretaker, if other than the parent or guardian, shall sign or tape-record acknowledgment of the ITP and reviews. In addition, the following TGH staff shall sign the ITP and reviews: Psychiatrist; Clinical coordinator; and Case coordinator. If the child’s parent, guardian, or primary caretaker does not sign the ITP or ITP reviews, staff shall document efforts to obtain the signature and reason why the signature could not be obtained. Continuing Evaluation. Contact Notes. Staff involved in the contact shall document in the child's TGH medical record all significant clinically relevant face-to-face, telephone, and written contacts with or about the child, including the dates, locations, and types of contacts. Progress Summary Notes. At least every 2 weeks, a child's case coordinator shall: Record in the child's TGH medical record a progress summary note regarding: The delivery of services specified by the ITP; Progress toward goal achievement; Changes in the individual's status; and If applicable, suggested changes in treatment goals and services delivered; and Assure that the child's needs and progress are communicated to those listed under §E of this regulation. Case Coordination. The TGH clinical director shall assure that a child's case coordinator: Integrates appropriate therapeutic and educational services into the child's ITP by coordinating with the child's previous placement provider, school, clinic or other mental health providers, and, if any, employer; Makes home visits and meets with the primary caretaker to ameliorate problems in the home and facilitate reunification; and Participates in treatment team meetings for the purposes of collaborating in service delivery and advocating for the child. Group Therapy. Appropriately credentialed and privileged TGH staff or consultants shall, at least weekly at the TGH, provide group therapy that, unless otherwise indicated in the child's ITP, includes every child in the TGH. Pychoeducational Groups. As required by the child's ITP, the child's care coordinator shall assure that the child has the opportunity to participate in appropriate groups for children who have special needs, including but not limited to groups for children who have been affected by: Substance abuse; Sexual assault; Physical abuse; or Home or community violence. Medication Services. The TGH clinical coordinator shall assure that medications prescribed for a child are stored securely and made available to the child as appropriate. Administration. If a child's ITP requires that TGH staff administer medication, the following requirements apply: Only an individual licensed under the Health Occupations Article, Annotated Code of Maryland, to administer medication may do so; and Only a licensed practical nurse or a registered nurse may delegate the administration of medication according to the provisions of COMAR 10.27.11. Monitoring. When required by the child's ITP, a TGH staff member privileged to do so shall provide the following services: Supporting the child's self-administration of prescribed medication; To the extent possible, monitoring compliance with instructions appearing on the label; Reading the label to assure that each container of medication is clearly labeled with the child's name, the contents, directions for use, and expiration date; Observing and documenting any apparent reactions to medication and, either verbally or in writing and in a timely fashion, communicating to the prescribing authority and TGH psychiatrist any problems that possibly may be related to the medication; and Reinforcing education on the role and effects of medication in symptom management. Health Promotion and Training. When indicated in the child's ITP, TGH staff privileged to do so shall provide basic health teaching in the following areas: Nutrition; Exercise; Dental care; Substance abuse prevention; and Prevention of injury and illness at home and in the community. The clinical coordinator shall assure the provision of training in communicable disease prevention, including prevention of sexually transmitted diseases and blood-borne pathogens, including HIV/AIDS. Discharge Procedures. A TGH licensee shall: Carry out discharge planning in accordance with COMAR 14.31.06.17; and If appropriate, forward a copy of each discharge plan to the appropriate CSA and the Administration. General. The chief executive officer shall assure that: Basic life needs are met, according to the requirements of COMAR 01.04.04.17; and Communication and visiting policies and daily routines are implemented according to the requirements of: Health-General Article, §§10-702 — 10-703, Annotated Code of Maryland; COMAR 10.21.09; and COMAR 14.31.06.09B. Supervision. The chief executive order shall assure that TGH staff, as defined in Regulation .14 of this chapter, provides supervision for each resident not participating in a program outside the TGH, as follows: During hours that children are awake and in the TGH, at least one staff member shall be present for every three children in the TGH; During children's sleeping hours, at least one awake staff member shall be present in the TGH; and At all times, at least one staff member shall be available, at the request of on-duty staff, to arrive at the TGH within 1 hour of the request. Activity. As required under COMAR 14.31.06.05H, the clinical coordinator shall assign staff to plan and implement daily activities that utilize the therapeutic milieu to foster clinically appropriate social, cognitive, emotional, and physical growth, including but not limited to: Group and self-directed leisure activities, both on-site and off-site, including activities related to sports and the arts; Working with the child to develop an activities schedule, including: Weekend and vacation plans; and Activities that support the child's cultural interests; and Developing linkages with and supporting a child's participation in community activities. Homework. Child care staff shall supervise and assist a child with homework: Based on the child's needs; and By coordinating with the school. Independent Living Skills. As required under COMAR 14.31.06.12C, in order to assist a child to develop the skills required to live independently as an adult, and as appropriate to a child's age and ability, the chief executive officer shall assign TGH staff to provide activities related to: Homekeeping, including: Meal preparation, including: Menu planning; Shopping; Cooking; and Cleaning up; Laundry; and Basic housekeeping; Personal hygiene; Money-management, including basic banking knowledge; Self-preservation; and Accessing community resources, including locating and using public transportation. Work Experience. A TGH that arranges a work experience for a child shall follow the procedure in COMAR 14.31.06.12D. Required Staff. The governing body of a TGH shall assure that TGH staff is sufficient in numbers and qualifications to: Carry out the TGH program service plan described in Regulation .05C of this chapter and program model described in Regulation .08 of this chapter; Provide the services, including supervision and staff-to-child ratio, required under Regulations .12 and .13 of this chapter; and Carry out the requirements of the ITPs of the TGH residents. Chief Executive Officer. The governing body shall employ a TGH chief executive officer who: Meets the qualifications and experience required under COMAR 14.31.06.06A; Is on duty at the TGH for the amount of time necessary to carry out the duties outlined in this chapter and, at a minimum, 20 hours per week; Is responsible for credentialing and privileging staff; Is responsible for administrative oversight for, at a minimum: Fulfilling the administrative requirements under COMAR 14.31.05; Assuring compliance with this chapter; Maintaining sufficient staff, including recruiting, hiring, training, scheduling, and terminating; Assuring the availability, 24 hours per day, 7 days per week, of a TGH psychiatrist; In collaboration, when appropriate, with the clinical coordinator, assuring that all staff are appropriately supervised; In collaboration with the clinical coordinator and program staff, identifying staff training needs and the provision of inservice training, as required under COMAR 14.31.06.05F, and, in addition, assuring a minimum level of staff competence in at least the following: Understanding mental disorders and treatment modalities, including medication; Use of seclusion, restraint, and quiet room, as governed by COMAR 10.21.12 and 10.21.13; Verbal de-escalation and aggression management techniques and procedures; Appropriate response to communicable diseases and use of universal precautions; Emergency preparedness and evacuation plan; and Implementation of children's rights; Quality management; Developing and implementing the budget; Maintaining the physical plant; and Keeping the governing body informed of, at a minimum, the program's licensure status and performance; May carry out the duties of the clinical coordinator, as described under §C of this regulation, if the chief executive officer is: A mental health professional; On duty at the TGH at least 40 hours per week, 20 hours of which must be during times when the children or adolescents are normally on-site; and If carrying out the duties of the clinical coordinator, shall hire an additional mental health professional for an additional 20 hours per week to assist with the duties described under §C of this regulation. Clinical Coordinator. If the chief executive officer is not the clinical coordinator, the chief executive officer shall hire a clinical coordinator who is: A mental health professional; On duty at the TGH at least 20 hours per week during times when the children or adolescents are normally on-site; and Responsible for, at a minimum: Development of treatment procedures, including admission and discharge procedures; Development of the ITP and ITP reviews, including appropriate coordination with a child's: IEP; ITP developed by the providers of mental health treatment; and Medical care providers; Interpreting the children's assessments and evaluations to staff; Establishing and maintaining linkage with schools and community treatment providers; Establishing protocols for medical and psychiatric emergencies and crisis response plans; Providing clinical supervision of staff; and If assigned by the TGH chief executive officer, maintenance of the therapeutic milieu described in Regulation .08C(2)(b) of this chapter. TGH Psychiatrist. The chief executive officer shall assure the availability of a psychiatrist who: Has completed a residency in child psychiatry in an accredited program; As specified in the employment or consultant contract, is available: For the amount of time necessary to carry out the duties outlined in §D(3) of this regulation; and To respond to emergencies 24 hours per day, 7 days per week; and Is responsible for: Participation in the screening, assessment, admission, and discharge processes; Formulating and documenting a diagnosis, according to Regulation .11B of this chapter; Participation in the development and signing of a child's ITP and ITP reviews; Clinical supervision of those cases requiring face-to-face medical review; Consulting with staff regarding the maintenance of the therapeutic milieu; Review of medication utilization and corrective feedback when utilization is found to be inappropriate; and Medical aspects of quality management. Case Coordinator. The TGH chief executive officer shall employ a sufficient number of case coordinators, each of whom is: Either a: Mental health professional; or Residential care specialist who: Has a minimum of a high school diploma or equivalent; and Is supervised by a mental health professional; Available to be with the child, on site in the TGH, at least 4 days per week; and Responsible for the duties delineated under Regulation .12A of this chapter. Residential Care Specialist. The TGH chief executive officer shall employ a sufficient number of residential care specialists who: As determined by the chief executive officer, have sufficient qualifications and experience to carry out the duties of the position; Have training applicable to the service, including, at a minimum, training outlined in §B(3)(g) of this regulation; As permitted under the Health Occupations Article, Annotated Code of Maryland, and as privileged by the program, are available to carry out the residential services delineated under Regulation .13 of this chapter. Program Coordinator. The TGH chief executive officer may employ a program coordinator, who shall be a mental health professional, to manage the therapeutic milieu as outlined in §C(3) of this regulation. A TGH shall report the required data in the form and at the times specified by the Administration. TGH staff shall explain to a child enrolled in a program and to the child's parent, guardian, and, if other than the parent, the primary caretaker, of the child's rights as set forth in Health-General Article, Title 10, Subtitle 7, and Title 4, Subtitle 3, Annotated Code of Maryland. A TGH shall develop and implement a process for the prompt and objective resolution of grievances that may be presented by a child or by a child's parent, guardian, or primary caretaker. The TGH shall prominently display, in accessible centralized locations, the written description of the grievance procedure. Health-General Article, §§10-501 — 10-524, 10-701 — 10-714, 10-901, 10-920 — 10-926, 16-101 — 16-303; Article 49D, §4; Annotated Code of Maryland Effective date: January 13, 1986 (13:1 Md. R. 16) Regulation .01 amended effective February 15, 1993 (20:3 Md. R. 259) Regulation .02B amended effective February 15, 1993 (20:3 Md. R. 259) Regulation .03 amended effective February 15, 1993 (20:3 Md. R. 259) Regulation .05 amended effective February 15, 1993 (20:3 Md. R. 259) Regulation .09A amended effective February 15, 1993 (20:3 Md. R. 259) Regulation .14 amended effective February 15, 1993 (20:3 Md. R. 259) Regulations .01 — .14 repealed and new Regulations .01 — .17 adopted effective November 27, 2000 (27:23 Md. R. 2147) Regulation .02 amended effective April 29, 2013 (40:8 Md. R. 723) Regulation .03 amended effective April 29, 2013 (40:8 Md. R. 723) Regulation .04 amended effective April 29, 2013 (40:8 Md. R. 723) Regulation .05B amended effective April 29, 2013 (40:8 Md. R. 723) Regulation .06 amended effective April 29, 2013 (40:8 Md. R. 723) Regulation .07A amended effective April 29, 2013 (40:8 Md. R. 723) Regulation .09 amended effective April 29, 2013 (40:8 Md. R. 723) Regulation .11E amended effective April 29, 2013 (40:8 Md. R. 723) Regulation .12F amended effective April 29, 2013 (40:8 Md. R. 723) Regulation .13 amended effective April 29, 2013 (40:8 Md. R. 723) Regulation .14B, C amended effective April 29, 2013 (40:8 Md. R. 723) Regulation .14G adopted effective April 29, 2013 (40:8 Md. R. 723) The following regulations govern the provision of services for hearing impaired mentally ill patients within the Administration's facilities and the designated inpatient hearing impaired unit. The following terms have the meanings indicated. Terms Defined. “Administration” means the Maryland Department of Health Administration. “Audiologist” means an individual who is authorized to practice audiology under Health Occupations Article, Title 2, Annotated Code of Maryland. “Certified interpreter for hearing impaired persons” means an interpreter who possesses at the minimum a Comprehensive Skills Certificate issued by the Registry of Interpreters for the Deaf. “Documented history of deafness or hearing impairment” means a documented diagnosis of hearing impairment made by an audiologist or by a Board-eligible or Board-certified otolaryngologist. “Facility” means an inpatient or residential treatment program operated directly by the Administration. “Gross testing” means either an interactive process which screens a person's ability to follow ordinary conversation or pure tone audiometric screening. “Hearing aid” means any instrument or device designed for or represented as aiding, improving, or correcting hearing and any parts, attachments, or accessories of this instrument or device. “Hearing impaired individual” means a person with an impairment so severe that with or without amplification, the processing of linguistic information through hearing is impaired. “Individual treatment plan” means the plan of care identified for each patient as outlined in COMAR 10.21.03. “Mental illness” means an illness resulting from a psychiatric disorder and does not include a primary diagnosis of alcohol or drug abuse or developmental disability. “Otolaryngologist” means a physician identified by the State Board of Physician Quality Assurance as a specialist in otolaryngology as set forth in Health Occupations Article, §14-704, Annotated Code of Maryland. “Physician” means an individual who is authorized to practice medicine under Health Occupations Article, Title 14, Annotated Code of Maryland. “Pure tone audiometric screening” means the pure tone air conduction screening procedure used to rapidly and effectively identify a patient with a hearing impairment that interferes with or has the potential for interfering with communication. “Qualified allied health professional” means the staff assigned by the facility and trained by an audiologist in procedures outlined in this chapter. “Rinne and Weber testing” means the tuning fork test used to differentiate between conductive and sensory-neural hearing losses. “Speech-language pathologist” means an individual who is authorized to practice speech-language pathology under Health Occupations Article, Title 19, Annotated Code of Maryland. “Speech reading” means the use of visual cues in determining what the speaker is saying and may also be referred to as lip reading. “Unit” means the inpatient unit of the institution designated by the Administration created specifically to treat those patients having both a mental illness and a hearing impairment. Patients admitted to facilities shall be screened for hearing impairment. Gross Testing of Hearing Sensitivity. At each facility, an examination shall be performed for gross testing of hearing sensitivity on all newly admitted patients within 24 hours of admission. This examination shall be performed: By a physician or a qualified allied health professional; and According to the following protocol: Testing shall occur consistently at a fixed distance from the speaker at all times; In order to prevent speech reading which could be interpreted as a false positive, the speaker's face may not be in view by the patient while testing is in process; and Non-English speaking patients shall be tested in the language the patient is known to speak or is believed to comprehend. Testing performed in conformance with §B(1) of this regulation shall be repeated within 15 days after admission on all patients not already tested with a pure tone screening audiometer. Each test performed in compliance with this regulation shall be documented in the patient's chart. Once a hearing impairment is suspected: Rinne and Weber testing shall be performed; and Referral shall be made for audiometric screening. Audiometric Screening. Patients with Suspected Hearing Impairment. Pure tone audiometric screening shall occur within 3 working days from the period specified in §B(1), of this regulation, for any patient who: Is suspected of having a hearing impairment on the basis of any of the above tests; Was unresponsive because of a possible hearing impairment; or Responded in a manner that may be construed as a mental disorder, but may be confused with a possible hearing impairment. Patients suspected of having a hearing impairment on the basis of the latest pure tone audiometric screening shall be referred promptly but in not more than 5 working days to an audiologist or an otolaryngologist. Referral shall be documented in the patient's chart. Upon recommendation by either the otolaryngologist or audiologist, further evaluation by a speech-language pathologist shall be conducted. If the audiometric screening in this section is used as the initial screening test, that audiometric screening shall be sufficient testing on admission unless otherwise ordered. Patients Not Identified as Hearing Impaired. As soon as possible, but within 90 days after admission, each patient who has not already been screened with an audiometer shall be so evaluated. Each patient's annual physical examination shall include audiometric screening. The screening results shall be documented in the patient's chart. Procedures for Audiometric Screening. The audiometric screening shall be performed in accordance with the standards outlined in Regulations .04 and .05 of this chapter. The audiometric screening shall be administered by either: A physician trained to screen hearing according to the protocol established in this chapter; An audiologist; or Appropriately and periodically trained allied health care staff, under the supervision and monitoring of an audiologist. An audiologist shall determine the facility's training protocol and frequency of training for allied health care staff. At a minimum, training shall occur at least once a year. Patients Exempted from Audiometric Screening. If the patient has a history of hearing impairment as defined in Regulation .02B(8) of this chapter and documented by an audiologist or physician, the screening procedure identified in §B and C of this regulation is not required within the first year after admission. Treatment recommendations related to the patient's hearing impairment made by either an audiologist, otolaryngologist, or speech pathologist, shall be incorporated in the patient's Individual Treatment Plan. Provision and Maintenance of Hearing Aids. The patient and appropriate staff on each shift shall receive, in accordance with a plan developed by an audiologist, instructions on the care, use, and inspection of the hearing aid by staff referenced in §C(4)(b)(i) and (ii) of this regulation or the hearing aid vendor. Designated staff, as identified in the Individual Treatment Plan, shall be responsible for ensuring daily monitoring of hearing aids, and implementing timely repair and immediate replacement of batteries. Identification of the need for replacement as well as the replacement of the patient's hearing aid shall be documented in the patient's record. Denial of hearing aid replacement by the treatment team or the patient's refusal to accept a hearing aid shall be documented and be reevaluated at a minimum of every 3 months. The facility shall provide a hearing aid to the patient when an otolaryngologist or audiologist determines that a patient would benefit from amplification and related accessories. Payments for aids shall follow the Administration's policy on payment for medical devices. Staff, as defined in Regulation .03C(4)(b), of this chapter, shall conduct manually administered, individual pure tone air conduction screening procedures for identification audiometry on each patient with a developmental age of 3 years or older. The following apply: Patients with a developmental age of less than 3 years shall be referred to an audiologist for an evaluation. Group screening may not be conducted on any patient. Pure tone testing shall use test frequencies at 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz. Screening levels shall be 20dB hearing level at all frequencies tested. Audiometers Used for Screening Purposes. For either a limited range or a narrow range audiometer, audiometers shall meet the requirements found in “Specifications for Audiometers” (ANSI S3.6-1969, American National Standards Institute), which is incorporated by reference. Audiometers shall be calibrated by an appropriately and professionally trained person at least annually. Sound pressure at the ear phones shall be checked at least every 3 months. Daily listening checks shall be performed to determine that the audiometer is grossly in calibration and that no defects exist in major components. An audiologist shall instruct support personnel in the proper handling and operation of audiometric equipment in order to minimize the need for repairs and to improve test accuracy. In accordance with Regulation .05 and the requirements found in “Criteria for Permissible Ambient Noise During Audiometric Testing” (ANSI S3.1-1977 American National Standards Institute), which is incorporated by reference, ambient noise levels may not exceed 41.5 dB Sound Pressure Level (SPL) at 500 Hz, 49.5 dB SPL at 1000 Hz, 54.5 dB SPL at 2000 Hz, and 62 dB SPL at 4000 Hz when measured using a sound level meter with octave-band filters centered on the screening frequencies. Nonresponse to the recommended screening levels at any frequency in either ear shall constitute failure. Failures shall be rescreened within the same screening session, if possible. Failures on rescreening shall be referred for an audiologic evaluation by an audiologist. The test tones listed in this regulation shall meet the allowable octave-band ambient noise levels which are noted in the following table taken from page 5 of the May 1985 ASHA journal: Test frequency 500 1000 2000 4000 Octave-band cutoff 300 600 1200 2400 Frequencies 600 1200 2400 4800 Octave-band level: Ear covered with earphone mounted in MX-41/AR cushion 21.5 29.5 34.5 42 Plus ASHA screening level 20 20 20 20 Resultant maximum ambient noise level allowable for ASHA screening 41.5 49.5 54.5 62 Transfer Criteria. To be transferred to the unit, each patient shall: Meet the statutory criteria for admission as set forth in Health-General Article, §10-609 — 10-619, Annotated Code of Maryland, and other applicable regulations related to the involuntary and voluntary admissions to facilities. Have documentation of deafness or a hearing impairment. Currently be using visual, manual, or tactile modes of communication which include but are not limited to American sign language, finger spelling, or speech reading, or be capable of being trained in the use of those methods. Be 14 years old or older. Patients 14 to 18 years old shall reside in: A separate inpatient residence designated for minors and attend the day program of the hearing-impaired unit if the: Treatment teams of the unit and of the minor's inpatient residence approve; Approval is documented in the progress notes and the Individual Treatment Plan; and Individual Treatment Plan is not in conflict with the Individual Educational Plan; The unit if the: Unit treatment team approves; and Individual plan for treatment indicates the need for placement on the unit. Be capable, with auxiliary aids, if necessary, of participating in professionally developed and supervised therapies, experiences, and activities provided by the unit. Have documentation in that patient's record that the patient does not object to participation on the unit, based on information necessary to make an informed judgment. Referral Procedures to the Unit After a Patient is Admitted to a Facility. Referral procedures for facilities shall be established by the Administration. Unit staff, in consultation with the treating physician, shall: Follow the Administration's referral procedures; and Within 7 days of a determination of hearing impairment by history or pure tone audiometric screening, determine the appropriateness of transfer of that patient to the unit. Unit Personnel and Training. The unit shall be directed by and include a complement of professional staff who have training or experience, or both, in working with hearing impaired mentally ill persons. Unit staff shall develop and maintain skills relevant to the provision of services for hearing impaired persons which include, but are not limited to, training in the psychosocial needs of hearing impaired persons and instruction in American sign language. A credentialing process to review the continuing education program for unit staff shall be determined by the Administration. Certified interpreters for hearing impaired patients, or other staff who possess equivalent qualifications as determined by a certified interpreter designated by the facility for that purpose, shall be on duty on the unit 24 hours a day. Facility staff may not be scheduled to provide interpreter services and any other services at the same time. Each hearing impaired patient in a facility, regardless of other handicapping conditions, shall be referred for evaluation for transfer to the unit pursuant to this regulation and Regulations .06 and .08A of this chapter. The following apply: The referring facility's treating physician shall refer any: Previously diagnosed hearing impaired patient to the unit within 72 hours of admission; or Patient newly identified as hearing impaired pursuant to this chapter, within 72 hours of identification. The unit staff, in consultation with the patient's treating physician at the referring facility, shall assess the appropriateness of the transfer, including but not limited to the criteria listed in Regulation .06A of this chapter. The assessment and decision regarding transfer of the patient shall be documented and sent to the referring facility by the unit's assessment team within 7 working days of referral. The decision regarding transfer and its rationale shall: Become a part of the permanent record; and Include the names and titles of the assessment team members. If, after referral and assessment, the patient's transfer to the unit is denied, the decision and its rationale shall be documented in the patient's chart by the unit's director or unit director's designee. If the decision is made to transfer the patient to the unit, the transfer shall occur not later than 2 working days after the determination to do so, unless a bed is not available on the unit. The unit shall establish and maintain a waiting list for patients who have been accepted into the unit and are awaiting transfer. The date of entry onto the waiting list shall determine placement on the waiting list, except that priority shall be given to transfer patients from areas of known shortage of resources for mentally ill hearing impaired persons. Decisions related to priority transfers shall be made by the unit director or the unit director's designee. Unless the age of a minor hearing impaired patient precludes transfer to the unit, the referring facility's treating physician shall refer the patient for evaluation to the unit at least every 60 days in order to: Reevaluate the appropriateness for the transfer to the unit; and Obtain consultation for any appropriate treatment options. The facility shall provide auxiliary aids in accordance with the provisions of §504 of the Rehabilitation Act of 1973, 29 U.S.C. §794 and its implementing regulations, 45 CFR §84.52(d), which are incorporated by reference, for the hearing impaired patient to participate in the facility's professionally developed and supervised activities, therapies, and experiences. Auxiliary aids may include but are not limited to interpreter services, notetakers, special hearing assistive devices, and telecommunication devices for the deaf (TTD). Complaints about the individual application of this chapter may be addressed through any patient grievance mechanism. Health-General Article, §10-204, Annotated Code of Maryland Effective date: January 8, 1990 (16:26 Md. R. 2792) These regulations govern the rights of patients in all facilities as defined in Health-General Article, §§10-101(e) and 10-703, Annotated Code of Maryland. Pursuant to Health-General Article, §10-703, Annotated Code of Maryland, and for the safety and well-being of patients, their visitors and staff members, all of these facilities shall provide public notice to patients, family members, and friends of the hours allowed for visiting on facility grounds and the conditions under which visiting is permitted. The following terms have the meanings indicated. Terms Defined. “Administration” means the Mental Hygiene Administration. “Attorney” means a person licensed to practice law or the attorney's agent. “Clergy” means an official of a recognized church, religious society, or congregation of any sect, order, or denomination. “Disorderly manner” means conduct as defined by Criminal Law Article, §10-202, Annotated Code of Maryland. “Drugs” means any medically unauthorized substance as defined by Criminal Law Article, §5-101(f), Annotated Code of Maryland. “Facility” means any public or private hospital, clinic, or other institution that provides or purports to provide treatment or other services for a mental disorder, except an acute care general hospital that does not have a separately identified inpatient psychiatric service. “Patient” means any individual receiving care and treatment in a facility. “Physician” means an individual who is authorized to practice medicine under Health Occupations Article, Title 14, Annotated Code of Maryland. “Professional staff” means any clinical staff who is either licensed or certified in a health care field or clinical staff in charge of a residential area. “Visitor” means a person who is coming to see a patient and is not acting as an agent of the facility or the Maryland Department of Health. All facilities shall provide a conspicuously posted notice to patients, family members, and friends of the hours allowed for visiting on facility grounds and the conditions under which visiting is permitted. Visitation procedures and visiting hours shall be reasonable and each facility shall allow for visiting hours for at least 1 hour per day for each day of the week. Each facility administrator shall be responsible for ensuring that these regulations are available for review and shall post notice of the facility's visiting hours in a prominent location. Visiting hours do not apply to the patient's clergy or attorney who may visit the patient at any reasonable hour. Visiting hours do not apply during those times a person visits the patient at the request of the treatment team. Patients who wish to visit with children under the age of 12 may request a suitable location from the staff for the visit. Specific areas shall be designated as visitor areas and may be subject to supervision by facility staff. Patients shall have the right to converse in private subject to the restrictions of Health-General Article, §10-703(c), Annotated Code of Maryland. Visitors may not be allowed on the patient units without staff permission or supervision, or both. Visiting may not be allowed in seclusion rooms. Staff may not provide child care services for visitors. Visitors who leave children unattended and without adequate supervision shall be asked to correct the situation or shall be expected to terminate the visit immediately. Specific visitor behaviors that are prohibited include, but are not limited to: Verbal or physical abuse or both of staff or patients; Drinking of alcoholic beverages; Use of drugs; Distribution of alcoholic beverages or drugs; Intoxication when on the premises; Disregard for patient or staff safety; Assaultive behavior; or Acting in a disorderly manner. The staff may ask visitors to remove from the facility any items or to submit the items to search. Specific notice to this effect shall be posted conspicuously at all times. Professional staff shall request any visitor who jeopardizes the care or treatment of patients or the safety of patients, staff, or other visitors to leave the facility immediately and explain at the time of the request the reason or reasons for making the request. Whenever a visitor refuses to leave, the visitor shall be informed that the facility police or law enforcement agencies shall be called immediately to escort the visitor off facility premises. If the visitor continues to resist, formal arrest procedures may be initiated. Specific notice to this effect shall be posted conspicuously at all times. Incidents. Any visitor behavior that leads to removal of the visitor from the premises shall be documented. Any incident that requires police intervention shall be reported and documented in accordance with facility procedures. Whenever a visitor is removed from the facility as a result of their disorderly manner, the treatment team shall review the incident and determine what restrictions, if any, shall be placed on the individual's future visiting privileges. If restrictions are placed on an individual's future visiting privileges, the restrictions shall be subject to the requirements identified in Regulation .08B of this chapter. Patient Restriction. Visitation shall be restricted only for a medically justified reason, and may not be used as a means of punishment. The physician's order restricting patient visitation rights shall: Be written as an order in the patient's permanent record; Be subject to ongoing review; Automatically expire after 30 calendar days; and Be rewritten, if necessary, subject to the provisions of this subsection. The rationale for the restriction shall be noted in the patient's permanent record and signed by the physician. Restrictions shall be documented in the patient's individualized treatment plan as defined in COMAR 10.21.03. A member of the treatment team shall inform the patient in a timely fashion of the restriction, its rationale, and the length of time the restriction is in effect. With the consent of the patient, visitors shall be informed by the facility's Clinical Director, or the Clinical Director's designee, that a patient's visits are restricted and the length of time that the restriction is in effect. Upon request and with the consent of the patient, a visitor shall receive written notification of the restriction or restrictions. Whenever a patient refuses visitors, the refusal shall be noted in the patient's records and may be reviewed by the treatment team. The patient's refusal shall be honored. With the consent of the patient, visitors shall be informed in a timely manner of the patient's refusal. When a patient refuses to receive a visitor and refuses to permit the facility to inform the visitor of the patient's refusal, the facility's communications with the visitor shall be consistent with these wishes. Complaints about the individual application of this chapter may be addressed through any patient grievance mechanism. Health-General Article, §§10-101(e) and 10-703, Annotated Code of Maryland Effective date: January 8, 1990 (16:26 Md. R. 2793) This chapter sets forth the requirements for a provider of psychiatric residential treatment facilities (PRTF) Medicaid demonstration waiver services as set forth in COMAR 10.09.79. These services are: Caregiver peer-to-peer support; Crisis and stabilization services; Expressive and experiential behavioral services; Family and youth training; Respite services (in-home and out-of-home); and Youth peer-to-peer support. In this chapter, terms have the meanings stated in COMAR 10.09.79. The Department shall grant approval to providers to be eligible to receive State and federal funds for PRTF waiver services if the provider meets the requirements set forth in this chapter. Application. To provide PRTF waiver services, a provider applicant shall: Submit an application to the Department; Submit the application on the form approved by the Department, with all questions answered and all required documents attached; and Attest that the provider applicant is in compliance with the general provider requirements and specific PRTF waiver service requirements set forth in this chapter and in COMAR 10.09.36. Application Modification. A provider that proposes to change its PRTF waiver services sites by adding, closing, or moving locations shall submit an application modification, on the form required by the Department, to the Department. If the Department approves the application modification, the existing provider approval shall extend to the additional site, as applicable. Approval. The Department may grant approval to an applicant provider, for a period not to exceed 12 months, if the Department determines that the provider: On the effective date of this chapter, has an existing contract with an existing care management entity under contract with a local management board in a service area; Has no deficiencies that constitute a threat to the health, safety, or welfare of the individuals served; and Attests that it complies with the requirements set forth in this chapter, and with the specific service requirements set forth in COMAR 10.09.79. If the provider is granted approval under §D(1) of this regulation, to continue to be approved, the provider shall, within 12 months, submit documentation of compliance with the requirements set forth in this chapter, and with the specific service requirements set forth in COMAR 10.09.79. The Department shall grant approval to a provider if the Department determines that the provider applicant meets the requirements set forth in this chapter and the specific service requirements set forth in COMAR 10.09.79. Recertification. The provider is subject to recertification by the Department every 3 years. Sale or Transfer of Approval. The Department's approval of a PRTF waiver service provider is valid only for the provider to which the Department grants approval. A provider may not sell, assign, or transfer approval to another provider. Denial of Approval. If the Department proposes to deny approval to an applicant under the provisions of this chapter, the Department shall give written notice of the proposed denial to the: Provider applicant; Care management entity; and Administrative service organization (ASO). In the notice under §A(1) of this regulation, the Department shall include: The date on which the Department proposes to deny approval; The facts that warrant the proposed denial of approval; Citation of the regulation or regulations upon which the proposed denial is based; Notification that before the denial of approval, the provider may request a hearing under the provisions of COMAR 10.21.16; and When feasible, notification of a case resolution conference. Disciplinary Action. The Department may propose to take any of the following disciplinary actions against a provider: Revocation of approval; Suspension of approval; Probation with conditions; or Banning new admissions. The Department may propose to take one of the actions outlined in §B(1) of this regulation if the provider: Is out of compliance with the requirements of: This chapter; or COMAR 10.09.79; Fails to maintain financial viability; or Obtains or attempts to obtain approval by fraud, misrepresentation, or the submission of false information to the Department. Except under §C of this regulation, the Department shall send written notice of the proposed action not less than 45 calendar days in advance of the proposed action taken under this regulation to the: Provider; Care management entity; and ASO. In the notice under §B(3) of this regulation, the Department shall include: The date on which the Department proposes to take action and, when feasible, the date of a case resolution conference; The facts that warrant the proposed action; Citation of the regulation or regulations upon which the proposed action is based; and Notification that, before the action, the provider has the right to request a hearing under the provisions of COMAR 10.21.16. If, after notice and opportunity to be heard, the Department takes disciplinary action, the provider shall, within 10 working days: Notify individuals or the guardians of individuals receiving services of the action; and If the program ceases operations: Notify individuals or the guardians of individuals receiving services of the suspension; and Cooperate with the care management entity, child and family team, and the Mental Hygiene Administration in accessing appropriate alternate services for individuals served by the provider. Emergency Suspension of Approval. Under State Government Article, §10-226, Annotated Code of Maryland, upon findings of conditions that pose an imminent risk to the health, safety, or welfare of an individual served by a provider, the Department may order the immediate suspension of the approval of the provider and the cessation of operation. If the Department takes the action under §C(1) of this regulation, the Department shall promptly give written notice of the proposed emergency suspension to the: Provider; Care management entity; and ASO. In the notice under §C(2) of this regulation, the Department shall include: The proposed effective date of the emergency suspension; When feasible, the date of a pre-deprivation hearing and a case resolution conference before the Department's final action; The findings under §C(1) of this regulation and the reasons that support the findings; Notification that: Following the emergency suspension, the provider may request a hearing under the provisions of COMAR 10.21.16; and The emergency suspension may lead to revocation of the approval if the violation or violations are not corrected within the time period specified by the Department. If the Department suspends approval, the provider shall immediately: Notify individuals or the guardians of individuals receiving services of the suspension; Cooperate with the care management entity, child and family team, and the Mental Hygiene Administration in accessing appropriate alternate services for individuals in the program; and Cease operations of the program. A provider of PRTF waiver services shall: Provide the documentation required by the Department for initial approval and provider recertification, or as requested by the Department; Be approved by the Department as meeting the requirements of this chapter and COMAR 10.09.79, and being able to provide the services set forth in COMAR 10.09.79; Have a provider agreement in effect, to include adherence to quality assurance, auditing, and monitoring policies and procedures; Receive training and certification as required and approved by MHA and determined to be appropriate for the level and scope of services provided; Meet all the conditions for participation in COMAR 10.09.36 except as otherwise specified in this chapter; Maintain general liability insurance, and provide proof of this insurance at the time of initial application to be a provider of PRTF waiver services, at recertification, and upon request by the Department; Make available to the Department and federal funding agents all records, including but not limited to personnel files for each individual employed, and financial, treatment, and service records for inspection and copying; and Comply with the following prohibitions against utilization of staff: Unless waived by the Department in accordance with §D of this regulation, prohibit from working with the participant or the participant's family any staff, volunteers, students, or any individual who is: Convicted of, received probation before judgment, or entered a plea of nolo contendere to a felony or a crime of moral turpitude or theft; or Has an indicated finding of child abuse or neglect; Before permitting staff, volunteers, students, or any individual from working with the participant, or the participant's family: Ensure that, at its own expense, all staff, volunteers, students, and any individual have background checks as set forth in §§B and C of this regulation; Review the results of the background checks; and Maintain the background checks in the individual's personnel file; and Maintain written documentation in the individual's personnel file that the director and all direct service provider staff including, but not limited to, volunteers, interns, and students, meet the criteria set forth in this regulation. Required Criminal Background Checks. For each individual providing services to participants and their families in the PRTF waiver, the provider shall: Before employment, submit an application for a child care criminal history record check to the Criminal Justice Information System Central Repository, Department of Public Safety and Correctional Services (DPSCS), in accordance with Family Law Article, §5-561, Annotated Code of Maryland; and Request that DPSCS send the report to: The director of the agency if the request is from a provider agency concerning staff, volunteers, students, or interns who will work with the participant or family; or To the Department's designee, if the provider is a self-employed, independent practitioner, or the director of the agency. Required Check for Abuse or Neglect. For each individual providing services to participants and their families in the PRTF waiver, the provider shall: Before employing any individual, submit a notarized Consent for Release of Information/Background Clearance Request form to the Department of Human Services (DHS) or a local department of social services (DSS) in the jurisdiction in which the individual lives, pursuant to COMAR 07.02.07.19; and Request that DHS or the local DSS send the report to: The director of the agency if the request is from a provider agency concerning staff, volunteers, or students who will work with the participant or family; or To the Department's designee, if the provider is a self-employed, independent practitioner, or the director of the agency. Waiver of Employment Prohibitions. The Department may waive the prohibition against working with the participant or the participant's family if the provider submits a request to the Department together with the following documentation that: For criminal background checks: The conviction, the probation before judgment, or plea of nolo contendere to the felony or the crime involving moral turpitude or theft was entered more than 10 years before the date of the employment application; The criminal history does not indicate behavior that is potentially harmful to participants; and Includes a statement from the individual as to the reasons the prohibition should be waived; and For abuse and neglect findings: The indicated finding occurred more than 7 years before the date of the clearance request; The summary of the indicated finding does not indicate behavior that is potentially harmful to the participant or the participant's family; and Includes a statement from the individual as to the reasons the prohibition should be waived. To be eligible to provide PRTF waiver services as a provider of in-home or out-of-home respite services under COMAR 10.09.79.06B, a provider shall: Meet the requirements of COMAR 10.21.27; Ensure that respite care specialists are: 21 years old or older and have a high school diploma; or Between 18 and 20 years old and in possession of at least an associate or bachelor's degree from an accredited school in a human services field; Ensure that: In-home respite services are provided in the participant's home; and Out-of-home respite services are: Provided in a community based alternative living arrangement outside the participant's home; and Where applicable, delivered in accordance with COMAR 14.31.05 — 14.31.07. A family support organization may provide PRTF waiver services of caregiver peer-to-peer support, youth peer-to-peer support, or family and youth training. To be eligible to provide PRTF waiver services as a family support organization, the organization shall: Be a private, nonprofit entity designated under §501(c)(3) of the Internal Revenue Service Code, and submit copies of the certificate of incorporation and Internal Revenue Service designation; Have a board of directors comprised of more than 50 percent caregivers with a primary daily responsibility for raising a child or youth up to 26 years old with emotional, behavioral, or mental health challenges; Submit a list of board members with identification of those who are caregivers meeting the criteria in §A(2) of this regulation; Establish hiring practices that give preference to: Current or previous caregivers of a child or youth with emotional, behavioral, or mental health challenges; Youth who are 18 through 26 years old, who have or had emotional or behavioral health challenges, or both; or Both §A(4)(a) and (b) of this regulation; Submit a copy of the organization's personnel policy that sets forth the preferred employment criteria stated in §A(4) of this regulation; Employ a staff that is comprised of at least 75 percent individuals who are: Current or previous caregivers of a child or youth with emotional, behavioral, or mental health challenges; or Youth who are 18 through 26 years old with emotional, behavioral, or mental health challenges; Submit a list of staff and positions held with identification of those who fit the experienced caregiver and youth criteria stated in §A(6) of this regulation; and Submit a certificate of eligibility that includes: Attestation of compliance with §A(1) — (6) of this regulation; and The organization's mission statement that establishes the purpose of the organization as providing support and education to youth with emotional, behavioral, or mental health challenges and their caregivers. Caregiver Peer-to-Peer Support Provider. To provide the services set forth COMAR 10.09.79.06B, the provider shall: Be employed by a family support organization; Be 21 years old or older; Receive supervision from an individual who is 21 years old or older, and has at least 3 years of experience providing peer-to-peer support; Have current or prior experience as a caregiver of a child with SED or a young adult with SMI; and Receive training and certification as approved by MHA. Youth Peer-to-Peer Support Provider. To provide services set forth in COMAR 10.09.79.06B, a provider shall: Be 18 years old or older but not older than 26 years old; Be employed by a family support organization; Have experience with State or local services and systems as a consumer who has had emotional, behavioral, or mental health challenges; Be supervised by an individual who is 21 years old or older, and has at least 3 years of experience providing peer-to-peer support or working with youth, or both; and Receive training and certification as approved by MHA. Family and Youth Training Providers. To provide services set forth COMAR 10.09.79.06B, a provider shall be: An approved waiver provider agency, including but not limited to, a family support organization; or An approved individual waiver service provider. Qualifications to Provide Family and Youth Training Services. All family and youth training providers shall: Receive training and certification as approved by MHA; and Have been a co-trainer with an experienced lead trainer. Youth training providers shall: Be 18 years old or older but not older than 26 years old; and Have experience with State or local services and systems as a consumer who has or had emotional, behavioral or mental health challenges. Family training providers shall: Be 21 years old or older; and Have current or prior experience as a caregiver of a child with SED or a young adult with SMI. Expressive and experiential behavioral services are: Art behavioral services; Dance/movement behavioral services; Equine-assisted behavioral services; Horticultural behavioral services; Music behavioral services; and Psychodrama/drama behavioral services. Qualification to Provide Expressive and Experiential Behavioral Services. To provide a particular service set forth under COMAR 10.09.79.06B, an individual shall have: A bachelor's or master's degree from an accredited college or university; and Current registration in the applicable association as outlined in §B(2) of this regulation. Association Registration. Art Behavioral Services. To provide art behavioral services, an individual shall be currently registered as a registered art therapist by: The Art Therapy Credentials Board in the American Art Therapy Association; or A comparable association with equivalent requirements. For Dance Behavioral Services. To provide dance behavioral services, an individual shall be currently registered as a dance therapist registered, or an academy of dance therapists registered in: The American Dance Therapy Association; or A comparable association with equivalent requirements. For Equine-Assisted Behavioral Services. To provide equine-assisted behavioral services, an individual shall be currently certified by: The Equine Assisted Growth and Learning Association (EAGALA) to provide services under the EAGALA model; The North American Handicapped Riding Association (NAHRA); or A comparable association with certification requirements at least equivalent to EAGALA or NAHRA. For Horticultural Behavioral Services. To provide horticultural behavioral services, an individual shall be currently registered as a horticultural therapist registered in: The American Horticultural Therapy Association; or A comparable association with equivalent requirements. For Music Behavioral Services. To provide music behavioral services, an individual shall be currently registered as a music therapist-board certified by the Board for Music Therapists, Inc: In the American Association for Music Therapy, Inc.; or A comparable association with equivalent requirements. For Psychodrama/Drama Behavioral Services. To provide psychodrama/drama behavioral services, an individual shall be currently registered as a registered drama therapist or a board certified trainer in: The National Association for Drama Therapy; or A comparable association with equivalent requirements. To provide the services set forth COMAR 10.09.79.06B, a provider shall: Be an agency; Have a current formal written agreement with a local core service agency to serve as a crisis response system; Have capacity to provide or arrange for services 24 hours a day, 7 days per week, including: Face-to-face clinical care; Psychiatric consultation; and Person-to-person phone coverage; Employ clinical supervisors who: Are licensed in good standing under Health Occupations Article, Annotated Code of Maryland, as a psychiatrist, social worker, registered nurse, or mental health professional; Are permitted to provide supervision under their respective practice act; and Have experience providing crisis response services; and Employ behavior care aides who: Are 21 years old or older; Have a bachelor's degree in a human services field; and Receive initial and ongoing training on crisis and stabilization services. Health-General Article, §§10-901 and 15-130.1, Annotated Code of Maryland Effective date: April 20, 2009 (36:8 Md. R. 595) This chapter outlines the requirements that a provider of residential therapeutic services to emotionally or behaviorally disordered children shall meet to be eligible to accept children placed by the Mental Hygiene Administration. In this chapter, the following terms have the meaning indicated. Terms Defined. “Direct supervision” means that a provider staff member maintains continuous visual contact with the child. “Family of origin” means the child's parent, guardian, or primary caretaker. “Least restrictive setting” means the treatment program or facility in which needed services are delivered in the environment that least limits the child being served. “Oversight” means that a provider staff member approves and is aware of the child's activities. “Primary caretaker” means the adult individual who carries responsibility for the welfare of a child where the child resides. “Secure setting” means a treatment program or facility that is locked to prevent a child from leaving without staff permission. A provider of residential therapeutic services may not be eligible to accept children placed by the Maryland Department of Health unless the provider: Is licensed by the Department of: Human Services, under the provisions of COMAR 07.02.23 or 07.02.13; Juvenile Services, under the provisions of COMAR 16.06.01; or Maryland Department of Health , under the provisions of COMAR 10.21.07; Has rates that are established by the Negotiated Rates Process of the Rates Management Unit, Social Services Administration of the Department of Human Services as authorized under the provisions of COMAR 21.14.01.04B(2); Provides the following core services: Care and 24-hour supervision in a residential setting; Direct provision of food and clothing; Social work or case management services; Recreational activities; Access and linkage to appropriate community resources, including but not limited to: Medical care; Dental care; Mental health treatment; Education; and Social services; and Crisis intervention planning; Provides the additional services that, based on a documented clinical assessment, are required by the child who is being referred, including but not limited to: A location as close as possible to the child's family of origin; The least restrictive setting appropriate to the child's needs; and As appropriate to the child's needs, a level of supervision that provides: Opportunity for off-site activities, with oversight by provider staff; or For a placement that is authorized by the State Coordinating Council for Residential Placement of Handicapped Children or a local coordinating council, as authorized under Article 49D, §§13 — 19, Annotated Code of Maryland: Structured, on-site activities, with direct supervision by provider staff, and 24-hour awake staff; or The level of supervision described in §D(3)(b)(i) of this regulation in a secure setting; and Is in compliance with all applicable laws and regulations, including but not limited to laws and regulations governing patient rights, as set forth in Health-General Article, §§10-701 — 10-707, Annotated Code of Maryland. Health-General Article, §10-902, Annotated Code of Maryland Effective date: Regulations .01 — .03 adopted as an emergency provision effective October 13, 1992 (19:22 Md. R. 1980); adopted permanently effective March 29, 1993 (20:1 Md. R. 27) These regulations govern the use of quiet rooms and restraint in all facilities as defined in Health-General Article, §§10-101(g) and 10-701, Annotated Code of Maryland. These regulations are supplemental to any other applicable law and regulation. In the event of conflict between these regulations and any other regulations or laws, the more stringent apply. In this chapter, the following terms have the meanings indicated. Terms Defined. Category I Restraint. “Category I restraint” means a device identified by the facility which limits a patient's mobility to the extent that the patient would not be able to independently reposition himself or herself or would otherwise be rendered helpless in an emergency. “Category I restraint” includes, but is not limited to, four-point restraints. “Category II restraint” means any device which is not considered by the facility as a category I restraint and includes, but is not limited to, mittens and vests. “Chief executive officer (CEO)” means the individual responsible for the overall management of a facility. “Child” means an individual younger than 12 years old. “Clinical director” means the psychiatrist in charge of the clinical care of all psychiatric patients in the facility. “Emergency situation” means a situation in which a patient's behavior poses a serious and imminent danger to the physical safety of self or others. “Facility” means any public or private hospital, clinic, or other institution that provides or purports to provide treatment or other services for a mental disorder, except an acute general hospital that does not have a separately identified inpatient psychiatric service. “Full view” means the unobstructed view by the assigned staff of a restrained patient. “Patient” means an individual receiving services for a mental disorder in a facility and includes any student receiving care and treatment in that facility. “Physician” means an individual who is authorized to practice medicine under Health Occupations Article, Title 14, Annotated Code of Maryland. “Protective device” means any adaptive or assistive device or devices which restrict the movement of the whole or a portion of a patient's body for the purpose of preventing unintentional harm to self or others or which are used for promoting or maintaining normative body functions. Prone Restraint. “Prone restraint” means restricting the free movement of all or a portion of a patient’s body through the use of physical force or mechanical devices while the patient is in a prone position. “Prone restraint” does not mean a technique for transitioning a patient to a restraint position that involves momentarily placing the individual face down. “Quiet room” means an unlocked room that patients are not physically prevented from leaving, which is designated for patients' voluntary use to allow them time out of the company of other patients. “Registered nurse” means an individual who is licensed to practice registered nursing under Health Occupations Article, Title 8, Annotated Code of Maryland. Restraint. “Restraint” means: Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move their arms, legs, body, or head freely; or A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. “Restraint” does not include a helmet when used as a sole form of restraint or a protective device. “Seclusion” means the involuntary confinement of a patient under the direction of a physician or registered nurse alone in a room which a patient is physically prevented from leaving. “Trauma-informed care” means mental health treatment that includes: An appreciation for the high prevalence of trauma experienced by individuals receiving mental health services; An understanding of the neurological, biological, psychological, and social effects of trauma and violence, including sexual abuse and exploitation, on an individual; and An understanding of the environment, practices, and treatments that may need to be modified to address trauma issues. “Treatment team” means the patient's treatment team as defined in COMAR 10.21.03.02C. Staff authorized under the provisions of Regulation .05B of this chapter may use a restraint: Only during an emergency in which the behavior of the patient places the patient or others in serious threat of violence or injury; If ordered by a physician in writing; or If at the direction of a registered nurse, if a physician's order is obtained within 2 hours of the action. Staff may not use a restraint: As a mode or course of treatment; As punishment, coercion, discipline, or retaliation; For the convenience of staff; To prevent damage or destruction to property; or To prevent serious disruption of the therapeutic environment. Staff shall use a restraint: In a humane, safe, and effective manner; Without intent to harm or create undue discomfort to the patient; and and For the shortest possible length of time, regardless of the length of time in the physician's order. Staff authorized under the provisions of Regulation .05B of this chapter may order the use of a restraint only if the physician, following a clinical evaluation of the patient, determines that: The patient's behavior poses an emergency situation; and Less restrictive or alternative approaches have been determined to be ineffective to ensure the safety of the patient, staff, or others. The approaches referred to in §D(2) of this regulation may include, but are not limited to: Clinical interventions; Quiet room; Medication or medications; Deescalation techniques; Trauma-informed care interventions; Calling the hospital's response team for assistance; and Consulting the patient's care plan for personalized strategies. When the definition of a restraint or a protective device is in dispute, in each case under discussion, the clinical director or the clinical director's physician designee shall clarify and document in the patient's medical record the device's correct purpose. The patient's treatment team shall document in the treatment plan the team's rationale for use of a protective device. A facility shall: Have a written policy specifying the method used to ensure that a patient whose primary language or method of communication is nonverbal is able to effectively communicate distress during a physical restraint or hold; and Ensure that all staff at the facility who are authorized to participate in a physical restraint or hold of a patient are trained in the method specified in the written policy in accordance with §A(1) of this regulation. A physician who is responsible either for the care of the patient or for assessment of the appropriateness of a restraint or, when the appropriate physician is not readily available to assess the patient, a registered nurse shall conduct a clinical evaluation of the patient to determine whether an emergency situation is present. Before using restraint, the physician or registered nurse shall assess whether less restrictive or alternative approaches have been determined to be ineffective to ensure the safety of the patient, staff, or others. When a physician, as identified in §B of this regulation, is immediately available, the physician shall be responsible for determining a patient's need for a restraint and make the decision whether to restrain. Authorization in the Absence of a Physician. When a physician, as identified in §B of this regulation, is not immediately available, a registered nurse shall determine a patient's need for restraint and may initiate and direct the use of restraint. Within 2 hours of the implementation of the restraint, a physician shall give a written or verbal order for any restraint initiated by a registered nurse and, at that time, shall make the clinical determination to continue or to discontinue the restraint. When possible, staff shall advise a patient, in a nonthreatening manner, that continuation of a specific behavior may result in the use of restraint. When a physician or registered nurse determines that the use of a restraint is appropriate, staff involved shall make a reasonable effort to verbally persuade the patient to be cooperative with the restraint. Staff shall apply a restraint only in accordance with the facility's policy and procedure manual. For the patient's safety and the safety of others: Staff shall place the patient in the restraint in as dignified a manner as the situation permits, using the least amount of physical force necessary; As necessary, additional staff shall participate in the placement of a patient in restraint; The patient shall be free from subject prone restraint; and The patient shall be free from a restraint that: Applies pressure to the patient’s back; Obstructs the airway of the patient or impairs the patient’s ability to breathe; Obstructs a staff member’s view of the patient’s face; or Restricts the patent’s ability to communicate distress. Unless a physician or registered nurse determines that it is unsafe to do so, staff shall permit the patient to wear all or a portion of the patient's own clothes or another form of attire. Staff shall search the patient for potentially harmful objects. If staff determine a need for objects to be removed pursuant to §F of this regulation, staff shall ask the patient, in a nonthreatening manner, to surrender the objects. Unless contraindicated for safety reasons, staff shall permit the patient to wear eyeglasses, hearing aids, dentures, or prosthetic devices. When placing a patient in a restraint, staff shall inspect each restraining device and ensure that each restraining device is safely and securely applied. As necessary, staff shall ensure that each restraint is padded to provide appropriate protection for the patient. In addition to the requirements outlined in this chapter, when: Restraining a child, staff may not use four-point restraints; and Applying or repositioning a restraint, staff shall avoid the application of force on long bone joints. Regardless of the physical setting in which the patient is placed, at a minimum, one staff member shall be assigned continuously while the patient is in a category I restraint. While the patient is restrained, in order to provide appropriate clinical care, at a minimum, staff clinically trained to do so shall: Keep the patient in full view at all times; Protect the patient from harm by others; Closely observe the patient at least every 15 minutes, and document each observation by the observer; Unless contraindicated by circumstances as assessed and documented by a physician or registered nurse, at least hourly, make and document personal contact with the patient for the purpose of: Determining if the patient has any special needs which need attention; Checking circulation of the extremities restrained; Adjusting the restraint; and Realigning the body or massaging the extremities restrained, or both; Unless contraindicated by circumstances as assessed and documented by a physician or registered nurse, offer or provide the following: Full range of motion, every 2 hours; Toilet facilities, at least every 2 hours; Bathing and oral hygiene, at least once during a 24-hour period; Meals, at the regularly scheduled hours and under the supervision of nursing personnel; and Fluids, at least every 2 hours; and As clinically indicated, record temperature, pulse, blood pressure, and respirations. At least once every 2 hours, a physician or registered nurse shall assess the appropriateness of continuing the restraint and document the factors supporting the assessment in the patient's medical record. When the patient's behavior no longer places the patient or others in serious threat of violence or injury, the patient shall be released from restraint. Staff may not initiate “standing” or “as needed” orders for restraint. Each order for restraint, used for the management of an emergency in which the behavior of the patient places the patient or others in serious threat of violence or injury, may only be renewed in accordance with the following limits not to exceed 24 hours total: Four hours for adults 18 years of age or older; Two hours for children and adolescents 9 to 17 years of age; or One hour for children under 9 years of age. After 24 hours, before writing a new order for the use of restraint for the management of an emergency in which the behavior of the patient places the patient or others in serious threat of violence or injury, a physician must: See, assess, and conduct a face-to-face evaluation of the patient to determine whether continuous restraint is appropriate; Document in the patient's medical record the observed behavior that confirms that the patient, if released from restraint, would continue to present a danger to self or others; Follow all requirements outlined in this chapter, including but not limited to §B of this regulation; and Obtain the authorization of the clinical director or the clinical director's physician designee, neither of whom may be the treating physician. Upon a request from a patient's treating physician, prior to authorizing continued restraint in accordance with §C(4) of this regulation, the clinical director or the clinical director's designee shall perform a face-to-face evaluation of the patient who is restrained. Following the initial 24 hours of restraint authorized under §C of this regulation, additional periods of restraint, not to exceed 24 hours each, may be authorized only if the restraint is provided in accordance with §§B—D of this regulation. Treatment Team Involvement. Minimally, at regularly scheduled meetings, the patient's treatment team shall examine the use of restraint for that patient. Within 5 working days from the initiation of continuous restraint, regardless of whether the patient remains in restraint, the treatment team shall: When applicable, review the appropriateness of the continued use of restraint; Establish and implement a plan to eliminate the need for further restraint; and Identify a team member who shall explain to the patient the potential risks and benefits of continuous restraint. Restraint Orders. A physician shall: To initiate the use of restraint: Enter an order in the patient's medical record; or Authorize an order to be written by a registered nurse on the physician's order sheet in the patient's medical record: Indicating that physician's verbal order for restraint; or Directing the release of the patient and the rationale for that release; Countersign all verbal orders within 24 hours of the order's being written; and Include in the order for restraint: The date and time that the order was written; The specific type of restraint to be used; The maximum duration of restraint from the time that the restraint was initiated; The specific rationale for restraint; Special precautions, if any, to safeguard the patient; The physician's signature; and In the case of a verbal order, the names of both the ordering physician and the registered nurse who received the verbal order. As soon as possible after implementation, but not later than the close of the shift, staff shall: Document the implementation of restraint in the patient's medical record; and Include in the documentation the following information: A description of the specific behavior leading to restraint; Whether and which less restrictive techniques were used, and, if not, why not; Whether a formal call for facility staff response was required, the names of staff assisting in the restraint, and the circumstances while restraining the patient; The readily observable physical condition of the patient; The date and time of the restraint and signature of the recorder; Whether the patient was permitted to wear the patient's own clothes or other attire and, if not, the reason or reasons for this; and A description of any physical injury to either the patient or others resulting from placement of the patient in restraint. While a patient is restrained, staff shall document the clinical interventions employed, including those listed in Regulation .08 of this chapter. Release from Restraint. When a physician clinically determines that a patient is to be released from restraint, the physician shall: Order the release and write, sign, and date a note indicating the rationale for the release; and If verbally ordering the release, write, sign, and date the note not later than 24 hours after a verbal order to release. When a registered nurse clinically determines that the release of the patient before the maximum period specified on a physician's order is appropriate, the registered nurse shall: Direct termination of the restraint; and Document, sign, and date the rationale for the termination of restraint in the patient's medical record. Patient Request. A patient may request the use of a quiet room and, unless clinically contraindicated, may be granted use of a quiet room. Unless staff terminates use of the quiet room for clinical reasons, the patient may terminate self-initiated use of the quiet room at any time. Staff Request. When staff, permitted by the facility to initiate and terminate use of a quiet room, determine that the use of the quiet room is clinically indicated, staff may request that a patient voluntarily enter into the quiet room. Staff may not coerce a patient into entering the quiet room. When the patient enters the quiet room, staff shall discuss with the patient: The recommended length of stay in the quiet room; The behaviors expected of the patient before and upon return to the milieu; and The primary interventions to be initiated if the use of the quiet room is terminated by the patient before the time recommended by staff or is determined to be ineffective. Staff shall determine the need for removal of any harmful objects in the room or from the patient. If staff determine a need for objects to be removed pursuant to §C of this regulation, staff shall ask the patient, in a nonthreatening manner, to surrender the objects. While a quiet room is in use, the staff shall assure that the quiet room door is not locked or in a position that prevents a patient from exiting the room voluntarily. Observation and Documentation. Staff shall: Be assigned to monitor the patient and the safety of the environment while a patient is in the quiet room; When the quiet room is used as a clinical intervention, observe the patient at least once every 30 minutes and document the observation in the patient's medical record; and At least every 2 hours, evaluate the effectiveness of the outcome and document the clinical rationale for continued use of the quiet room. A physician shall review the use of the quiet room after 6 hours and, if use of the quiet room is continued, at least every 24 hours after that. Use of a quiet room may be terminated at any time: Upon the decision of the patient; or As clinically determined by staff. The clinical director or the clinical director's designee shall review daily all uses of restraint and investigate unusual or possibly unwarranted patterns of use. The physician involved in the restraint may not function in the capacity outlined in §A of this regulation. A facility shall identify a committee to review periodically, but not less than quarterly, the use of restraint to assure that the standards maintained by the facility are, at a minimum, consistent with this chapter. Staff who implement orders for restraint: Shall have documented annual training in the proper use of physical restraint and hold including training for special populations which include, but are not limited to, children and the elderly; Shall have documented annual training in trauma-informed care and demonstrate competency in providing trauma-informed care services; and May not implement orders for restraint until trained by the facility to do so unless, in an emergency situation, the safety of the patient or others is threatened. The facility's chief executive officer or the chief executive officer's designee is responsible for assuring that the restraint devices used in that facility are maintained in accordance with acceptable standards for hygiene and safety. If seclusion is used in conjunction with restraint, staff shall also comply with COMAR 10.21.13. Complaints about the individual application of this chapter may be addressed through any patient grievance mechanism. Excluding the prohibition described in §B of this regulation, staff may not vary from the standards identified in this chapter unless the variation is for an extreme crisis. There may not be any variance with standards established in this regulation and in Regulations .03 and .04, .06B—G and I—J, .07, .09A, .11, .12A and D—F, .13, and .14 of this chapter. Staff shall document, on the facility's variance report, a variance with standards permitted under this chapter. The CEO shall rule on and document each variance permitted in §A of this regulation to determine whether the variance was: An extreme crisis; A deviation from the facility's procedure; or A problem in the facility's policy which is correctable by administrative action. The CEO shall assure that the facility's quality assurance process incorporates a monthly review of any variance permitted in §A of this regulation. Health-General Article, §§10-101(g) and 10-701, Annotated Code of Maryland Effective date: October 25, 1993 (20:21 Md. R. 1654) Regulation .01 amended effective February 14, 2026 (52:23 Md. R. 1139) Regulation .02B amended effective February 14, 2026 (52:23 Md. R. 1139) Regulation .03 amended effective February 14, 2026 (52:23 Md. R. 1139) Regulation .05 amended effective February 14, 2026 (52:23 Md. R. 1139) Regulation .06D amended effective February 14, 2026 (52:23 Md. R. 1139) Regulation .08D amended effective February 14, 2026 (52:23 Md. R. 1139) Regulation .09 amended effective February 14, 2026 (52:23 Md. R. 1139) Regulation 10D amended effective February 14, 2026 (52:23 Md. R. 1139) Regulation .12D, F amended effective February 14, 2026 (52:23 Md. R. 1139) These regulations govern the use of quiet rooms and seclusion in all facilities as defined in Health-General Article, §§10-101(g) and 10-701, Annotated Code of Maryland. These regulations are supplemental to any other applicable law and regulation. In the event of conflict between these regulations and any other regulations or laws, the more stringent apply. In this chapter, the following terms have the meanings indicated. Terms Defined. “Chief executive officer (CEO)” means the individual responsible for the overall management of a facility. “Clinical director” means the psychiatrist in charge of the clinical care of all psychiatric patients in that facility. “Emergency situation” means any situation in which a patient's behavior poses a serious and imminent danger to the physical safety of self or others. “Facility” means any public or private hospital, clinic, or other institution that provides or purports to provide treatment or other services for a mental disorder, except an acute general hospital that does not have a separately identified inpatient psychiatric service. “Patient” means an individual receiving services for a mental disorder in a facility and includes any student receiving care and treatment in that facility. “Physician” means an individual who is authorized to practice medicine under Health Occupations Article, Title 14, Annotated Code of Maryland. Prone Restraint. “Prone restraint” means restricting the free movement of all or a portion of a patient’s body through the use of physical force or mechanical devices while the patient is in a prone position. “Prone restraint” does not mean a technique for transitioning a patient to a restraint position that involves momentarily placing the individual face down. “Quiet room” means an unlocked room that patients are not physically prevented from leaving, which is designated for patients' voluntary use to allow them time out of the company of other patients. “Registered nurse” means an individual who is licensed to practice registered nursing under Health Occupations Article, Title 8, Annotated Code of Maryland. “Seclusion” means the involuntary confinement of a patient under the direction of a physician or registered nurse alone in a room which a patient is physically prevented from leaving. “Trauma-informed care” means mental health treatment that includes: An appreciation for the high prevalence of trauma experienced by individuals receiving mental health services; An understanding of the neurological, biological, psychological, and social effects of trauma and violence, including sexual abuse and exploitation, on an individual; and “Treatment team” means the patient's mental health professional treatment team as defined in COMAR 10.21.03.02C. Staff authorized under the provisions of Regulation .04C of this chapter may use seclusion: Only during an emergency in which the behavior of the patient places the patient or others in serious threat of violence or injury; and If ordered by a physician in writing; or If at the direction of a registered nurse if a physician's order is obtained within 2 hours of the action. Staff may not use seclusion: As a mode or course of treatment; As punishment, coercion, discipline, or retaliation; For the convenience of staff; To prevent damage or destruction to property; or To prevent serious disruption of the therapeutic environment. Staff shall conduct seclusion: In a humane, safe, and effective manner; Without intent to harm or create undue discomfort to the patient; and For the shortest possible length of time, regardless of the length of time in the physician's order. Staff authorized under the provisions of Regulation .04C of this chapter may order the use of seclusion only if that staff person, following a clinical evaluation of the patient, determines that: The patient's behavior poses an emergency situation; and Less restrictive or alternative approaches have been determined to be ineffective to ensure the safety of the patient, staff, or others. The approaches referred to in §D(2) of this regulation may include, but are not limited to: Clinical interventions; Quiet room; Medication or medications; Deescalation techniques; Trauma-informed care interventions; Calling the hospital's response team for assistance; and Consulting the patient's care plan for personalized strategies. A facility shall have a written policy specifying the method used to ensure that a patient whose primary language or method of communication is nonverbal is able to effectively communicate distress during a seclusion. A facility shall ensure that all staff at the facility who are authorized to participate in a seclusion of patients are trained in the method specified in the written policy in accordance with §A(1) of this regulation. A physician who is responsible either for the care of the patient or for assessment of the appropriateness of seclusion or, when the appropriate physician is not readily available to assess the patient, a registered nurse shall conduct a clinical evaluation of the patient to determine whether an emergency situation is present. Before instituting seclusion, the physician or registered nurse shall assess whether less restrictive or alternative approaches have been determined to be ineffective to ensure the safety of the patient, staff, or others. When a physician, as identified in §C of this regulation, is immediately available, the physician shall be responsible for determining a patient's need for seclusion and make the decision whether to seclude. Authorization in the Absence of a Physician. When a physician, as identified in §C of this regulation, is not immediately available, a registered nurse shall determine a patient's need for seclusion and may initiate and direct the use of seclusion. Within 2 hours of the implementation of the seclusion, a physician shall give a written or verbal order for any seclusion initiated by a registered nurse and, at that time, shall make the clinical determination to continue or discontinue the seclusion. When possible, staff shall advise a patient, in a nonthreatening manner, that continuation of a specific behavior may result in the use of seclusion. When a physician or registered nurse determines that the use of seclusion is appropriate, staff involved shall make a reasonable effort to verbally persuade the patient to enter the seclusion room. For patient's safety and the safety of others: Staff shall place the patient in the seclusion room in as dignified a manner as the situation permits, using the least amount of physical force necessary; As necessary, additional staff shall participate in the placement of a patient in seclusion; The patient shall be free from prone restraint; and The patient shall be free from restraint that: Applies pressure to the individual’s back; Obstructs the airway of the individual or impairs the individual’s ability to breathe; Obstructs a staff member’s view of the individual’s face; or Restricts the individual’s ability to communicate distress. Unless a physician or registered nurse determines that it is unsafe to do so, staff shall permit the patient to wear all or a portion of the patient's own clothes or another form of attire. Staff shall search the patient for potentially harmful objects. If staff determines a need for objects to be removed pursuant to §E of this regulation, staff shall ask the patient, in a nonthreatening manner, to surrender the objects. Unless contraindicated for safety reasons, staff shall permit the patient to wear eyeglasses, hearing aids, dentures, or prosthetic devices. Staff shall inspect the seclusion room for potentially dangerous conditions and, as appropriate, shall fully secure the room. If a patient is confined to a room in a manner that meets the definition of seclusion in accordance with Regulation .02B of this chapter, the patient is considered to be subject to seclusion, regardless of whether the room used is typically used as a seclusion room. While the patient is secluded, in order to provide appropriate clinical care, at a minimum, clinically trained staff shall: Observe the patient at least every 15 minutes, and document each observation by the observer; Unless contraindicated by circumstances as assessed and documented by a physician or registered nurse, at least hourly, make and document personal contact with the patient for the purpose of determining if the patient has any special needs which need attention; Unless contraindicated by circumstances as assessed and documented by a physician or registered nurse, offer or provide the following: Toilet facilities, at least every 2 hours; Bathing and oral hygiene, at least once during a 24-hour period; Meals, at the regularly scheduled hours and under the supervision of nursing personnel; and Fluids, at least every 2 hours; and As clinically indicated, record temperature, pulse, blood pressure, and respirations. At least once every 2 hours, a physician or registered nurse shall assess the appropriateness of continuing the seclusion and document the factors supporting the assessment in the patient's medical record. When the patient's behavior no longer places the patient or others in serious threat of violence or injury, the patient shall be released from seclusion. Staff may not initiate “standing” or “as needed” orders for seclusion. Each order for seclusion, used for the management of an emergency in which the behavior of the patient places the patient or others in serious threat of violence or injury, may only be renewed in accordance with the following limits not to exceed 24 hours total: Four hours for adults 18 years of age or older; Two hours for children and adolescents 9 to 17 years of age; or One hour for children under 9 years of age. After 24 hours, before writing a new order for the use of seclusion for the management of an emergency in which the behavior of the patient places the patient or others in serious threat of violence or injury, a physician must: See, assess, and conduct a face-to-face evaluation of the patient to determine whether continuous seclusion is appropriate; and Document in the patient's medical record the observed behavior that confirms that the patient, if released from seclusion, would continue to present a danger to self or others; Follow all requirements outlined in this chapter, including but not limited to §B of this regulation; and Obtain the authorization of the clinical director or the clinical director's physician designee, neither of whom may be the treating physician. Upon a request from a patient's treating physician, prior to authorizing continued seclusion, in accordance with §C(4) of this regulation, the clinical director or the clinical director's designee shall perform a face-to-face evaluation of the patient who is secluded. Following the initial 24 hours of seclusion authorized under §C of this regulation, additional periods of restraint, not to exceed 24 hours each, may be authorized only if the seclusion is provided in accordance with §§B—D of this regulation. Treatment Team Involvement. Minimally, at regularly scheduled meetings, the patient's treatment team shall review the use of seclusion for that patient. Within 5 working days from the initiation of continuous seclusion, regardless of whether the patient remains in seclusion, the treatment team shall: When applicable, review the appropriateness of the continued use of seclusion; Establish and implement a plan to eliminate the need for further seclusion; and Identify a team member who shall explain to the patient the potential risks and benefits of continuous seclusion. Seclusion Orders. A physician shall: To initiate the use of seclusion: Enter an order in the patient's medical record; or Authorize an order to be written by a registered nurse on the physician's order sheet in the patient's medical record: Indicating that physician's verbal order for seclusion; or Directing the release of the patient and the rationale for that release; Countersign all verbal orders within 24 hours of the order's being written; and Include in the order for seclusion: The date and time that the order was written; The maximum duration of seclusion from the time that the seclusion was initiated; The specific rationale for seclusion; Special precautions, if any, to safeguard the patient; The physician's signature; and In the case of a verbal order, the names of both the ordering physician and the registered nurse who received the verbal order. As soon as possible after implementation, but not later than the close of the shift, staff shall: Document the implementation of seclusion in the patient's medical record; and Include in the documentation the following information: A description of the specific behavior leading to seclusion; Whether and which less restrictive techniques were used, and, if not, why not; Whether a formal call for facility staff response was required, the names of staff assisting in the seclusion, and the circumstances while secluding the patient; The readily observable physical condition of the patient; The date and time of the seclusion and signature of the recorder; Whether the patient was permitted to wear the patient's own clothes or other attire and, if not, the reason or reasons for this; and A description of any physical injury to either the patient or others resulting from placement of the patient in seclusion. While a patient is in seclusion, staff shall document in the patient's medical record the clinical interventions employed, including those listed in Regulation .06 of this chapter. Release from Seclusion. When a physician clinically determines that a patient is to be released from seclusion, the physician shall: Direct termination of the seclusion with or without a physician's order; and If verbally ordering the release, write, sign, and date the note not later than 24 hours after a verbal order to release. When a registered nurse clinically determines that the release of the patient before the maximum period specified on a physician's order is appropriate, the registered nurse shall: Order termination of the seclusion with or without a physician's order, unless the physician's order specifically requires physician concurrence with the termination; and Document, sign, and date the rationale for the termination of seclusion in the patient's record. Patient Request. A patient may request the use of a quiet room and, unless clinically contraindicated, may be granted use of a quiet room. Unless staff terminates use of the quiet room for clinical reasons, the patient may terminate self-initiated use of the quiet room at any time. Staff Request. When staff, permitted by the facility to initiate and terminate use of a quiet room, determine that the use of the quiet room is clinically indicated, staff may request that a patient voluntarily enter into the quiet room. Staff may not coerce a patient into entering the quiet room. When the patient enters the quiet room, staff shall discuss with the patient: The recommended length of stay in the quiet room; The behaviors expected of the patient before and upon return to the milieu; and The primary interventions to be initiated if the use of the quiet room is terminated by the patient before the time recommended by staff or is determined to be ineffective. Staff shall determine the need for removal of any harmful objects in the room or from the patient. If staff determine a need for objects to be removed pursuant to §C of this regulation, staff shall ask the patient, in a nonthreatening manner, to surrender the objects. While a quiet room is in use, the staff shall assure that the quiet room door is not locked or in a position that prevents a patient from exiting the room voluntarily. Observation and Documentation. Staff shall: Be assigned to monitor the patient and the safety of the environment while a patient is in the quiet room; When the quiet room is used as a clinical intervention, observe the patient at least once every 30 minutes and document the observation in the patient's medical record; and At least every 2 hours, evaluate the effectiveness of the outcome and document the clinical rationale for continued use of the quiet room. A physician shall review the use of the quiet room after 6 hours and, if use of the quiet room is continued, at least every 24 hours after that. Use of a quiet room may be terminated at any time: Upon the decision of the patient; or As clinically determined by staff. The clinical director or the clinical director's designee shall review daily all uses of seclusion and investigate unusual or possibly unwarranted patterns of use. The physician involved in the seclusion may not function in the capacity outlined in §A of this regulation. A facility shall identify a committee to review periodically, but not less than quarterly, the use of seclusion to assure that the standards maintained by the facility are, at a minimum, consistent with this chapter. Staff who implement orders for seclusion: Shall have documented annual training in the proper use of seclusion including training for special populations which include, but are not limited to, children and the elderly; Shall have documented annual training in trauma-informed care and demonstrate competency in providing trauma-informed care services; May not implement orders for seclusion until trained by the facility to do so unless, in an emergency situation, the safety of the patient or others is threatened. Standards for a Seclusion Room. The CEO or the CEO's designee is responsible for assuring that the seclusion room or rooms in the facility are maintained in accordance with acceptable standards for hygiene and safety. Staff shall ensure that each seclusion room: Unless clinically contraindicated and the record reflects that assessment, has a mattress provided; At the beginning of each shift, is inspected and maintained for proper temperature, ventilation, safety, lighting, sanitation, and freedom from dangerous conditions; and Is fitted with a means of observation that affords staff a view of the entire room and permits clinical staff periodically to observe the patient. If restraint is used in conjunction with seclusion, staff shall also comply with COMAR 10.21.12. Complaints about the individual application of this chapter may be addressed through any patient grievance mechanism. Excluding the prohibition described in §B of this regulation, staff may not vary from the standards identified in this chapter unless the variation is for an extreme crisis. There may not be any variance with standards established in: This regulation; Regulation .03 of this chapter; Regulation .04 of this chapter; Regulation .05B—E, G, and I of this chapter; Regulation .07A of this chapter; Regulation .09 of this chapter; Regulation .10A, D, E(1), and F of this chapter; and Regulation .11 of this chapter. Staff shall document, on the facility's variance report, a variance with standards permitted under this chapter. The CEO shall rule on and document each variance permitted in §A of this regulation to determine whether the variance was: An extreme crisis; A deviation from the facility's procedure; or A problem in the facility's policy which is correctable by administrative action. The CEO shall assure that the facility's quality assurance process incorporates a monthly review of any variance permitted in §A of this regulation. Health-General Article, §§10-101(g) and 10-701, Annotated Code of Maryland Effective date: October 25, 1993 (20:21 Md. R. 1654) Regulation .01 amended effective November 24, 2025 (52:23 Md. R. 1139) Regulation .02B amended effective November 24, 2025 (52:23 Md. R. 1139) Regulation .03 amended effective November 24, 2025 (52:23 Md. R. 1139) Regulation .04 amended effective November 24, 2025 (52:23 Md. R. 1139) Regulation .05C amended effective November 24, 2025 (52:23 Md. R. 1139) Regulation .05I adopted effective November 24, 2025 (52:23 Md. R. 1139) Regulation .06C amended effective November 24, 2025 (52:23 Md. R. 1139) Regulation .07 amended effective November 24, 2025 (52:23 Md. R. 1139) Regulation .08D amended effective November 24, 2025 (52:23 Md. R. 1139) Regulation .01D, F amended effective November 24, 2025 (52:23 Md. R. 1139) Regulation .12B amended effective November 24, 2025 (52:23 Md. R. 1139) These regulations govern the administrative process to be used to ensure that the rights of residents residing in the Behavioral Health Administration facilities are protected. Although the residents and the legal assistance providers ultimately shall decide whether to invoke the Resident Grievance System, it is the intent that the Resident Grievance System provide a fair, efficient, and complete mechanism for receiving, investigating, and resolving resident complaints, including rights issues, in a timely manner. In this chapter, the following terms have the meanings indicated. Terms Defined. “Central Review Committee” means the Maryland Department of Health (MDH) staff or their respective designees in the following positions: The Director of the Behavioral Health Administration; The clinical director of the Behavioral Health Administration; and The Director of the Resident Grievance System. “Chief executive officer (CEO)” means the individual appointed by the Director of the Behavioral Health Administration to act on the Director’s behalf in the overall management of a Behavioral Health Administration facility. “Coe consent decree” means the legally binding consent decree in Coe v. Hughes ordered by the United States District Court for Maryland which sets forth the legal rights of Mental Hygiene Administration facility residents with respect to the provision of legal and other related services by the legal assistance provider and the rights advisor. “Department (MDH)” means the Maryland Department of Health. “Director of Resident Grievance System” means the individual designated by the Deputy Secretary of Public Health Services to supervise the rights advisors and to perform the duties required to implement the Resident Grievance System. “Facility” means an inpatient or residential institution that is owned or directly operated by the Behavioral Health Administration. “Grievance” means a written or oral statement, as authorized in Regulation .05B of this chapter, alleging that a: Resident's rights have been unfairly limited or violated or are likely to be violated in the immediate future; Resident has been abused, neglected, or mistreated; or Facility has acted in an illegal or improper manner with respect to a resident or a group of residents. “Grievant” means a resident on whose behalf a grievance is filed, whether initiated by the resident, an employee of a facility, a family member of the resident, or an interested person. “Legal assistance provider (LAP)” means the lawyers and legally trained individuals who work under the lawyers' supervision who are responsible for providing legal services in accordance with the Coe consent decree. “Resident” means an individual who resides in a Behavioral Health Administration inpatient or residential facility or who was released or discharged from the facility within the past 90 days. “Resident Grievance System (RGS)” means the accessible administrative mechanism designed to protect a resident's rights through the investigation, processing, and resolution of grievances and implementation of the resolution. “Residents' rights committee” means a committee composed of at least nine members who are representative of: Facility staff; Residents, former residents, and residents' family members; and Advocacy groups. “Rights advisor” means an individual assigned as a resident advocate to implement the RGS. “Rights issue” means an alleged violation of a resident's rights guaranteed by federal and State constitutions, statutes, regulations, common law, or policies of the Maryland Department of Health and the facility. “Unit director” means an individual who has administrative authority within an organizational component of a facility. “Working day” means every day excluding Saturdays, Sundays, and holidays on which State offices are closed. When invoked, and when the process provides a fair, efficient, and complete remedy for allegations of rights violations, a grievant, when involved, the grievant's LAP, and the facility shall follow the four-stage administrative procedure outlined in this chapter. Through a timely process of systematic and orderly stages as outlined in this chapter, all those involved in the RGS process shall give grievances a fair consideration. To ensure that the rights of residents in the Behavioral Health Administration facilities are fully protected and that allegations of rights violations are investigated and resolved, the Director of the RGS shall provide an accessible internal system. The rights advisor shall investigate grievances: Promptly, impartially, and with the least disruption to the grievant's treatment plan; and Without abridging the right of a grievant to have the grievance process transpire within the required time frames or be completed within 65 working days. Except in accordance with the provisions outlined in Regulations .06—.10 of this chapter, and except to the extent necessary to conduct an investigation, report on the results of the investigation, and resolve the grievance, the individuals involved in the investigation of a grievance shall keep confidential the information gathered or disclosed during the course of the investigation. If a LAP is involved, the rights advisor shall provide to the LAP reports on the status of the grievances processed, the administrative decisions of the RGS at each stage, and the remaining RGS stages scheduled or to be scheduled. The Department may not subject an individual to discipline, harassment, or retribution for filing a grievance, pursuing a remedy for a grievance or, in cases when a grievance is substantiated, obtaining corrective action through the RGS. A resident who has concerns, including grievances, may request resolution from: The treatment team; or If the resident chooses not to involve the treatment team, the RGS. Except as provided in §J of this regulation, a grievant may terminate a grievance through the RGS at any time, either orally or in writing. If the termination is oral, the rights advisor shall document the oral termination of a grievance in the record of the grievance that is maintained by the rights advisor. If a grievant seeks to terminate a grievance that alleges abuse or serious harm or the potential for abuse or serious harm, the rights advisor shall notify the CEO and the Director of the RGS, either of whom may determine whether the investigation may continue. Within the time periods specified in Regulations .06—.09 of this chapter, the rights advisor shall file, investigate, and review a grievance, render a decision, and notify the grievant. In cases in which grievances alleging abuse have been substantiated, the facility shall take corrective action immediately. If time periods for stages lapse and extensions are denied, the rights advisor shall proceed with the next stage of the grievance. Those involved in the RGS process shall ensure that they complete the process within 65 working days. The rights advisor shall: Investigate all complaints in a professionally appropriate manner; Attempt to resolve grievances fairly and thoroughly; Prepare written reports for each grievance investigated; Maintain the RGS reports; Attempt to identify residents who may benefit from services offered by the LAP and: Refer the residents identified to the LAP; and Advise the LAP of the referrals; Investigate abuse allegations, even though the State police and the facility also may be conducting an investigation of the same allegations; Monitor any corrective action used to resolve grievances, and: Notify the CEO if corrective action has not been taken; and If corrective action has not been taken by the CEO within a reasonable period of time, notify the RGS Director; When a rights advisor discusses a grievance with a grievant, inform the grievant that, if the grievant requests, the rights advisor is available to attend and advocate for the grievant before the Behavioral Health Administration committees, boards, and tribunals; Inform the grievant of the right to appeal a decision during any stage of the grievance process, and if a grievant wishes to appeal: Upon request, file an appeal on behalf of the grievant; Advise the grievant that the resident may be represented by a LAP following the completion of stage 2 of the grievance procedure; and With the grievant's consent, attend and advocate in the best possible manner for the grievant on appeal, except in cases when, as a result of the rights advisor's professional judgment, the grievant's case is determined to be frivolous; and In cases when, as a result of the rights advisor's professional judgment, the grievant's case is determined to be frivolous, forward the grievance to the Director of the RGS. The Director of the RGS shall: If the rights advisor for a facility is not available for 2 or more consecutive working days, designate an alternate rights advisor; Arrange for the provision of appropriate training to: The rights advisors; and Facility staff, regarding relevant legal documents, including Department policies and procedures, related to residents' rights; If a rights advisor informs the Director of the RGS that the CEO has not taken corrective action within a reasonable period of time, notify the Director of the Behavioral Health Administration, who shall ensure that grievance resolution, at any level, is implemented promptly; If a rights advisor informs the Director of the RGS that the rights advisor has determined that a grievant's grievance is frivolous, review the determination, and, following that review, if the Director of the RGS: Agrees with the rights advisor and a LAP is involved, forward the grievance to the LAP, who may request continuation of the RGS process; or Does not agree with the rights advisor, notify: The rights advisor to proceed with the grievance; and The LAP of the action taken; and Make appropriate arrangements to ensure that a rights advisor shall: Be independent to discharge responsibilities; As necessary to conduct an investigation, have the access to facility staff, the LAP, and others relevant to the investigation; and Have access to a resident's medical records: Excluding conditions outlined in Regulation .05C(2)(c) of this chapter, subject to the provisions in Health-General Article, §10-701(d), Annotated Code of Maryland, or any other applicable provisions of law; and Immediately, in cases of allegations of abuse or neglect of the resident. A facility shall provide for a direct and effective means of communication between the residents and the rights advisor, including but not limited to communication by telephone and in person. The following may present a grievance to a rights advisor: A resident; An employee of a facility; A resident's family member; A LAP; or An interested person. If the grievance is initiated orally, the rights advisor shall: Assist in completing a grievance form and, if possible, obtain the grievant's signature; and If a grievance is initiated on the resident's behalf: Contact the resident to determine if the resident wants the matter to be investigated; Counsel the resident about the resident's rights regarding the grievance procedure; and If the resident elects to proceed with the grievance, obtain the resident's written consent to investigate or, if the resident does not sign, document the rationale for not obtaining the resident's signature. Pursuant to §E of this regulation, a resident about whom a grievance is initiated may elect not to file a grievance or may withdraw a grievance before disclosure of identity of the resident is made, if the resident notifies the rights advisor of the withdrawal or election not to file. If a resident elects not to file a grievance or if the grievant has requested that a grievance be withdrawn or is unable or unwilling to respond, the rights advisor shall proceed with the investigation if the: Rights advisor believes that the: Situation has resulted or may result in serious harm to the grievant or other residents; Complaint appears to have substantial merit and requires further investigation; Grievance highlights issues which may affect a substantial number of other residents; or Director of the RGS grants approval to proceed. The rights advisor shall keep the identity of the grievant confidential except when: Confidentiality interferes with investigation or resolution of the grievance; or Good cause requires disclosure of the grievant's identity. If the rights advisor determines that disclosure of the identity of the grievant is necessary according to the provisions of §F of this regulation, the rights advisor shall: Inform the grievant of the disclosure; and Assure that disclosure be limited to that which is necessary to investigate, assess, and resolve the grievance. A facility employee shall report immediately to the CEO and the rights advisor all physical or sexual abuse as defined in Health-General Article, §10-705(a), Annotated Code of Maryland. A facility employee shall file a grievance on behalf of a resident when, in that employee's reasonable judgment, there exist instances of rights violations, mental, physical, or sexual abuse, neglect or mistreatment, or instances when the facility has acted in an illegal or improper manner with respect to a resident or a group of residents. If requested by a resident, a facility employee shall: Notify the rights advisor immediately of the request; or If the rights advisor is not immediately available: Leave a written or a tape-recorded message concerning the request; and Contact the Director of the RGS for issues which require an immediate response. Except for good cause, the rights advisor shall process grievances in the order received, if first priority is given to cases alleging: Abuse; Neglect; or Mistreatment. If a grievance alleges abuse: The rights advisor shall investigate; The CEO of the facility shall refer the grievance to the Maryland State Police or the appropriate law enforcement agency for investigation; and For residents up to 18 years old, the CEO shall refer the grievance to the local department of social services. In addition to the requirements outlined in §L of this regulation, the CEO may: Conduct an investigation of the alleged abuse case; and Refer the alleged abuse case to the treatment team. If grievances refer to the same incident: The rights advisor may treat the grievances as one issue; and For cases involving more than one grievant, the rights advisor shall send separate notices and copies of decisions and appeals of decisions to each grievant. If the rights advisor is the subject of the grievance, the rights advisor shall inform the grievant of the name, mailing address, and telephone number of the Director of the RGS who shall: Appoint a substitute rights advisor for the purpose of that grievance; and Notify the CEO of the substitute appointment. The LAP may conduct interviews with residents. When the LAP refers a case that results in a grievance or is asked by the grievant for representation, the LAP: Shall inform the grievant that the LAP may not represent the grievant in the RGS process until stage 2 of the grievance procedure has been completed; May represent a grievant pursuant to the requirements and limitations outlined in this chapter; and Shall receive reports from the rights advisor while the investigation is in progress and at the conclusion of each stage. For a grievance that is initiated after the effective date of this chapter, and upon request by the grievant, the rights advisor shall provide the grievant or, if involved, the LAP, with the documents that may be considered in making a decision on the grievance. Rights Advisor's Investigation and Mediation. The rights advisor shall respond to the grievance by meeting with: The grievant; The individual filing the grievance, if other than the resident; The grievant's LAP, if involved; and If applicable, any witness to the incident. Except for good cause, the rights advisor shall notify the grievant before reviewing the grievant's medical record. The rights advisor shall: Determine an appropriate course of action for processing the grievance, which may include, but is not limited to: Interviews in person or by telephone; Requests for documents and correspondence; Notification to the grievant regarding the facility's clinical review panel option if the grievance relates to a grievant's refusal to take medication prescribed for treatment of a mental disorder; and Classification of alleged rights violations in accordance with guidelines developed by the Director of the RGS; Keep the grievant informed of all steps taken to resolve the grievance; and Render a decision on a grievance within 10 working days of receipt of the grievance. The rights advisor shall make every effort to negotiate, mediate, and resolve the grievance fairly at this stage. If action is taken and the grievant is satisfied, the case is closed. If, as a result of the rights advisor's professional judgment, a grievance is determined to be frivolous, the rights advisor shall inform the grievant of that finding and of the grievant's right to appeal and the appeal procedure. If a grievance with merit is not resolved to the grievant's satisfaction, and the grievant wishes to appeal, the rights advisor shall forward a copy of the grievance, including a description of the issues and recommendations, to the unit director as outlined in Regulation .07 of this chapter. If, in the rights advisor's professional judgment, the nature of the grievance is not frivolous, but the grievance either cannot be substantiated or appears to have no merit, the rights advisor shall: Inform the grievant of the decision and the right to appeal; With the consent of the grievant, assist the grievant in filing an appeal; and Document the findings and forward a copy of the report describing the findings to: The Director of the RGS; The unit director; The grievant; If involved, the grievant's LAP; and The CEO. If a grievance with merit is resolved to the grievant's satisfaction, the rights advisor shall forward a copy of the decision to: The unit director; The grievant; The CEO; and If involved, the grievant's LAP. If the rights advisor's initial investigation concludes there is substantial risk of serious harm, or there is the potential for serious harm to a grievant if the alleged violation is not remedied promptly: The rights advisor shall inform immediately the: Unit director or the unit director's designee; CEO or the CEO's designee; Director of the RGS; and Director of the Behavioral Health Administration or the Behavioral Health Administration Director’s designee; and The unit director, the CEO, or their respective designees shall: Perform an investigation; and If the grievance is substantiated, develop and implement a solution within 24 hours of receiving the rights advisor's report. The unit director shall: Review the rights advisor's report; Discuss the matter with any individual involved; and Within 5 working days of receipt of the report, decide whether to: Accept the rights advisor's report, completely or in part with respect to the facts as found; or Modify or reject the recommendations made by the rights advisor. The unit director shall write and forward a decision to the rights advisor, who shall forward copies to the grievant, the CEO and, if involved, the grievant's LAP. If the unit director concludes that a grievance has been substantiated and requires remedial action, the unit director immediately shall: Notify the CEO and, if indicated, the clinical director; and Provide a remedy, which may include, but is not limited to: Directing a change in practice; or Seeking approval for changes in policy. If the grievant is: Satisfied with the action taken by the unit director, the grievance ends at this stage; or Dissatisfied with the action taken by the unit director and wishes to pursue the grievance, the rights advisor shall: If the grievant requests the review, request a review by the residents' rights committee, notifying the CEO of the request for the review; and Subsequently request a review by the CEO. If the grievant requests a review by the residents' rights committee before the CEO's review, the residents' rights committee shall: Meet within 15 working days of receipt of the grievance; Review the information obtained by the rights advisor; Review information presented by the grievant; Review the decision of the unit director; If involved, review information presented by the LAP; Review all relevant data pertaining to the grievance; and Forward written recommendations to the CEO. A review by the residents' rights committee: May include further investigation into the circumstances of the grievance; May not be limited to consideration of the record of the grievance from prior proceedings; and At the request of the grievant, may be waived. The rights advisor: Shall notify all interested persons, including involved staff, the grievant, and, if involved, the grievant's LAP of the time and location of the residents' rights committee meetings; Shall present information obtained at prior proceedings; Shall inform the grievant and, if involved, the grievant's LAP of all recommendations made by the residents' rights committee; and May not be present during the residents' rights committee deliberations. All interested persons including involved staff, the grievant, and, if involved, the grievant's LAP: Shall be invited to attend the residents' rights committee meeting to present information relating to the grievance; and May not be present during residents' rights committee deliberations. Upon receipt of the residents' rights committee's recommendations, the CEO or the CEO's designee shall: Determine what action, if any, is to be taken; and Notify the residents' rights committee in writing of any action taken. Completion of time periods specified within stage 3 are dependent upon the following: If the LAP is involved, the CEO or the CEO's designee: Shall respond within 15 working days to the residents' rights committee's recommendations; and May request an oral presentation from the LAP, if the LAP submits a written summary of the presentation before the meeting; If the LAP is not involved, the CEO or the CEO's designee shall respond within 5 working days to the residents' rights committee's recommendations. The CEO or the CEO's designee shall write and forward a decision to the rights advisor. The rights advisor shall forward copies of the decision of the CEO or the CEO's designee to: The grievant; If involved, the grievant's LAP; The Director of the RGS; If involved, the residents' rights committee; and The unit director. If the CEO or the CEO's designee substantiates the grievance, the CEO or the CEO's designee shall identify in the decision: The corrective action to provide a complete remedy to the grievant for the violation; and Time frames, consistent with this chapter, for implementing the corrective action. If the grievant is: Satisfied with the action taken by the CEO or the CEO's designee, the grievance ends at this stage; or Dissatisfied with the decision of the CEO or the CEO's designee, the rights advisor shall inform the grievant of the appeal process to the Central Review Committee. If requested by the grievant, the rights advisor shall file an appeal to the Central Review Committee within 5 working days after receipt of the decision by the CEO or the CEO's designee. The Central Review Committee: Shall meet within 10 working days of receipt of an appeal; Shall review all prior information concerning the grievance; May perform an investigation of the grievance which shall be accomplished within 10 additional working days; and At the request of the grievant, may sequester those who are presenting information to the Committee. For a grievance that is initiated after the effective date of this chapter, if a LAP is representing a grievant, the Central Review Committee, at the request of the grievant, shall: Allow the LAP to be present for argument or while evidence is presented by any other person; and Hear a presentation from the LAP before making a decision, if the LAP submits a written summary of the presentation before the meeting. The Central Review Committee shall write and forward a decision to: The CEO of the facility; The grievant; If involved, the grievant's LAP; The rights advisor; and If involved, the residents' rights committee. If the grievant is: Satisfied with the decision of the Central Review Committee, the case is closed; or Dissatisfied with the decision of the Central Review Committee, the rights advisor shall promptly inform the grievant of additional relevant legal services which the grievant may contact. Notification of Status. Within 20 working days, the Central Review Committee, through the Director of the RGS, shall request from the facility CEO a written report of the status of the implementation of the recommendations made during the grievance process. Until the decision is fully implemented, the CEO shall make periodic reports to the Central Review Committee through the RGS Director every 30 days. The Director of the RGS shall ensure that RGS reports: May not be released to other persons except as provided within this chapter; and Identify the alleged violations, the decision, and the remedy. With the identity of those involved in the grievance deleted, the Director of the RGS shall ensure that the decisions on all 4th-stage grievances be: Included in the annual report of the RGS Director; Made available for public review at the Department's Resident Grievance System Office; Sent to other rights advisors; Sent to the Deputy Secretary for Public Health Services, the LAP, and members of the Coe Board of Review; and Sent to the Behavioral Health Administration facility CEOs. With the identity of those involved in the grievance deleted, all decisions with Statewide impact, as determined by the Director of the RGS, shall be: Circulated to those enumerated in §B of this regulation; and Sent to all Behavioral Health Administration personnel involved in or affected by the decision. RGS reports and other documents concerning a grievance may not be placed in the resident's medical record unless otherwise required by law. A facility may not place the reports of the RGS in an employee's personnel file. The rights advisor may not be a witness in an agency proceeding against an employee, unless the rights advisor is a first-hand witness to events being reviewed. If allegations are made against an employee: The rights advisor shall immediately give the employee and the employee's Department head a copy of the information relevant to the allegation; and Within 5 working days of receipt of the information, the employee shall respond, in writing, to the rights advisor assigned to that facility. Notice of Grievance Decision. The rights advisor shall give written notice of a grievance decision involving an employee to the director of the division of personnel and the employee's Department head at the facility. The personnel director shall forward a copy of the notice in §D(1) of this regulation to the employee, the employee's supervisor, and the employee's Department head. Nothing shall prevent a facility from taking appropriate action against an employee for events which come to the attention of the facility through the RGS. The RGS may not affect employee rights as mandated by State Personnel and Pensions Article, Annotated Code of Maryland. This chapter does not modify the resident's: Legal rights; Access to seek private legal counsel from attorneys not receiving funding for legal assistance from the Maryland Department of Health; or Access to a court. The Resident Grievance System is not governed by the contested case provisions of the Administrative Procedure Act, State Government Article, Title 10, Annotated Code of Maryland. Health-General Article, §7.5-201, 7.5-205(D), 10-701, Annotated Code of Maryland Effective date: March 28, 1994 (21:6 Md. R. 467) Regulation .01 amended effective October 23, 2017 (44:21 Md. R. 983) Regulation .02B amended effective January 26, 1998 (25:2 Md. R. 76); October 23, 2017 (44:21 Md. R. 983) Regulation .03C amended effective October 23, 2017 (44:21 Md. R. 983) Regulation .04 amended effective October 23, 2017 (44:21 Md. R. 983) Regulation .06H amended effective October 23, 2017 (44:21 Md. R. 983) Regulation .10B, C amended effective October 23, 2017 (44:21 Md. R. 983) These regulations govern payment for specific emergency services, as defined in Health-General Article, §10-628, Annotated Code of Maryland, rendered as a direct consequence of a petition for emergency evaluation. In this chapter, the following terms have the meanings indicated. Terms Defined. “Consultant” means a physician, licensed by the State, who is not a salaried staff member of the emergency facility and who is authorized by the emergency facility to perform an examination of an emergency evaluee. “Department” means the Maryland Department of Health. “Designated emergency facility” means a health care organization currently identified by the Department to perform the functions identified in Health-General Article, §10-624, Annotated Code of Maryland, or this chapter, or both. “Emergency evaluee” means an individual who has been referred to a designated emergency facility on the basis of a petition for emergency evaluation. “Emergency service” means the service rendered as a direct result of the execution of a valid petition. “Emergency vehicle” means: A vehicle operated by a law enforcement officer; or An ambulance regulated according to COMAR 14.22.01 — 14.22.12. “Examination” means a face-to-face diagnostic interview and examination by a consultant physician that includes a medical history, an assessment of mental status, a neurological examination, an assessment of dangerousness, and a written report outlining the consultant physician's findings and conclusions. “Inpatient facility” means an inpatient institution that provides evaluation, care, or treatment for individuals who have mental disorders. “Petition” means a petition for emergency evaluation that is made by an individual who has reason to believe that the emergency evaluee has a mental disorder and that there is danger of the emergency evaluee's doing bodily harm to the petitioner or another individual. “Provider” means an individual, an association, a partnership, an incorporated or unincorporated group, or a hospital that renders health care service to an emergency evaluee. The Department shall pay for emergency service only if: As determined according to Health-General Article, §16-202, Annotated Code of Maryland, the emergency evaluee cannot pay the charge for the service; and The emergency evaluee does not have health insurance, including Medicare or Medical Assistance, that covers the allowable payment for the service. The Department shall limit services payable under this chapter to the following emergency services: The basic emergency room fee in a designated emergency facility; The initial examination performed in the emergency room of a designated psychiatric emergency facility by a consultant physician; and Transportation for the emergency evaluee in an emergency vehicle: From the site where the emergency evaluee is located to the designated emergency facility; and If staff at the emergency facility complete an application and two certificates for involuntary admission according to the provisions of Health-General Article, §§10-615 — 10-616, Annotated Code of Maryland, from the designated emergency facility to the inpatient facility where the emergency evaluee is referred for admission. The provider shall submit the following documents: A request for payment on a form designated by the Department; A bill that specifies the: Name of the emergency evaluee; Date of service; and Description of service; A copy of the current petition for emergency evaluation; If the bill is for an examination by a consultant physician, a copy of the consultant physician's evaluation that is signed by the examining consultant physician; If the bill is for transportation of an emergency evaluee from a designated emergency facility to an inpatient facility, copies of both completed certificates for involuntary admission and the application for involuntary admission; and Any other documentation required by the Department to determine that the conditions of this chapter have been met. The provider shall submit the request for payment within 12 months of the date of service. The Department may refuse a request for payment if the request is not accompanied by properly completed forms and documents required under §A of this regulation. The Department shall pay: Hospitals, at rates approved by the Health Services Cost Review Commission; Physicians, the lesser of the: Amount billed; or The Statewide average of prevailing charges for an examination by a physician consultant based on Medicare's 75th percentile as determined according to 42 CFR Sec. 405.504; and Transportation providers, if transportation is by: Ambulance, the lesser of the: Amount billed; or The Statewide average of prevailing charges for an ambulance based on Medicare's 75th percentile; or A law enforcement officer in an emergency vehicle: The cost per mile based on the county's established rates for emergency vehicles; and The cost of the law enforcement officer's hourly wage for the number of hours, not to exceed 4 hours, required to transport the emergency evaluee. Before billing the Department, the provider shall: Take all reasonable steps to collect the charge from the emergency evaluee and, if applicable, from insurers, including Medicare and Medical Assistance; or Make and document a determination of the evaluee's inability to pay, according to the provisions of Regulation .03 of this chapter. A provider: Shall accept as payment in full the maximum payment amount allowable under Medicare for services rendered to eligible participants; and May not bill the Department for any amount in excess of that allowable under §B(1) of this regulation. If a provider receives payment from both the Department and another source, within 30 calendar days of receipt of payment by the other source, the provider shall refund to the Department the amount in excess of the maximum payment allowable under the provisions of §B of this regulation that was paid by the Department. The provider shall immediately reimburse the Department for any overpayment. Access to Care. Providers of emergency services shall give an emergency evaluee equal access to treatment and services that are available or medically indicated, regardless of diagnosis, handicap status, race, age, sex, national origin, religious or political opinions or affiliations, or sources of payment for care. Providers of emergency services shall recognize and respect an emergency evaluee's dignity in the provision of care and treatment. Confidentiality. The emergency evaluee's medical record is governed by the provisions of confidentiality as set forth in Health-General Article, Title 4, Subtitle 3, and §19-308.2, Annotated Code of Maryland. The right of confidentiality does not preclude routine audit or payment processes. Health-General Article, §10-628, Annotated Code of Maryland Effective date: May 9, 1994 (21:9 Md. R. 751) This chapter outlines the process for application for, denial of, and disciplinary action on, the approval for a program to be eligible to receive State or federal funds for providing community mental health services. This chapter does not apply to programs approved under COMAR 10.21.07 Therapeutic Group Homes or Federally Qualified Health Centers. In this chapter, terms have the meanings indicated in COMAR 10.21.17. To be eligible for approval under this chapter, a program shall: Meet the requirements of: This chapter; COMAR 10.21.17; The chapter under this subtitle that outlines the requirements for the specific program; and Medical Assistance regulations, including, but not limited to COMAR 10.09.36, 10.09.59. and 10.09.70; and Demonstrate compliance with: Relevant federal, State, or local ordinances, laws, regulations, and orders governing the program; and The satisfactory fire, safety, and health inspection reports of the site that are required by the local jurisdiction, if a program provides services at a site whose primary function is the delivery of mental health services. Consultation. Before submitting an application, an applicant for approval of a program may request assistance from the Department's designated approval unit or the appropriate core service agency (CSA) director regarding the proper compilation of application materials and completion of the application. Lead CSA Determination. For programs providing services in multiple jurisdictions, the Administration, in collaboration with the appropriate CSAs, shall determine the lead CSA. Application. An applicant for approval of a program shall: Submit an application to the Department’s designated approval unit; Submit the application on the written or electronic form approved by the Department, with all questions answered and all required documents attached; Include in the application, at a minimum, the following information: Documentation of the applicant's program service plan, as outlined in Regulation .05 of this chapter; A written business plan that clearly demonstrates the program's ability to provide services in accordance with applicable Maryland regulations and Medicaid and Medicare funding requirements; Information to demonstrate the program's financial viability, including, but not limited to: Salary structure; Client mix; Anticipated administrative expenses; Necessary cash reserves to maintain the program during the start-up phase and a financial crisis; Identification of the individual responsible for providing the required financial information; and Other information deemed necessary by the Department; A summary of the program's demonstrated experience in the field of mental health; Prior licensing reports issued within the previous 10 years from any in-State or out-of-State entities associated with the program, including deficiency reports and compliance records from which the Department may make reasoned decisions about the qualifications of the program; Disclosure of: Any license or approval revocation within the previous 10 years by the Department or other licensing agency; Whether the program, or corporation or entity associated with the program, has surrendered or defaulted on its license or approval for reasons related to disciplinary action, within the previous 10 years; and Any corporate officer who has served as a corporate officer for a corporation or entity that has had a license revoked, or has surrendered or defaulted on its license or approval for reasons related to disciplinary action within the previous 10 years; A written quality assurance plan that addresses how the organization will ensure the health and safety of the individuals served by the program and the quality of services provided to individuals by the program; and For 26 U.S.C. §501(c)(3) organizations, a statement of how the organization intends to satisfy its charitable mission; and Forward a copy of the: Completed application to the: CSA of the jurisdiction where the program services are to be delivered; or For programs providing services in multiple jurisdictions, lead CSA identified under §B of this regulation; and Application cover letter to the Administration and all CSAs of the jurisdictions where the program plans to deliver services. Action by the CSA or Lead CSA. The CSA, or lead CSA identified under §B of this regulation, shall submit to the Department's designated approval unit: Verification that: The program agrees to collaborate with all CSAs where the program proposes to provide services, according to the provisions of COMAR 10.21.17.06; and The financial information submitted under §C of this regulation appears to demonstrate potential financial viability of the program; and Comments, if any, on the content of the application. Application Modification. A program that proposes to change its program sites by adding, closing, or moving locations shall submit an application modification, on the form required by the Department, to the Department's designated approval unit. If the Department's designated approval unit approves the application modification, the existing program approval shall extend to the additional site, as applicable. On the forms approved by the Administration as part of the application required under Regulation .04C of this chapter or COMAR 10.21.04.05B, a program shall submit a PSP that includes a description of: The range of services that the program will provide; The populations to be served, including age groups and other relevant characteristics, and the number of individuals that the program expects to serve; Program sites and hours of operation, and the method to ensure that services are accessible to the individuals served; The goals, objectives, and expected outcomes of the program; The composition of the program's governing body, board of directors, or advisory committee, whichever applies, as outlined in COMAR 10.21.17.05A; The jurisdictions where services will be provided and the number of services to be provided in each jurisdiction; and The jurisdiction where most of the program's services will be rendered. The Department's designated approval unit shall evaluate the application to determine whether the applicant adequately documents that the: Proposed program has met all approval requirements; Applicant has reviewed and is knowledgeable regarding all applicable regulations; and Program will be financially viable. Before making a determination under §A of this regulation, the Department's designated approval unit may: Request clarification of application materials; and Consult with the CSA director, or lead CSA director, and the Administration. Before determining that a program is eligible for approval under this or any other chapter of the Administration's regulations, the Department shall conduct an on-site investigation of the program and meet with the applicant. If the Department's designated approval unit determines that the program meets all approval requirements, the Secretary shall: Issue temporary approval according to the provisions of §B of this regulation; and Forward copies of the approval to the: Appropriate CSA; Administration; ASO; Medical Assistance Program; and The program's chief executive officer (CEO) and president of the advisory committee or governing body, whichever applies. Duration of Temporary Approval. The temporary approval is valid for a period of not more than 6 months unless: Before the end of 6 months, the program requests an extension due to a delay in beginning operations; and Upon the recommendation of the Department's designated approval unit, the Secretary grants an extension of not more than 6 months. If a program is granted an extension of temporary approval under §B(1)(b) of this regulation, and the program fails to begin operation during the effective date of the extension, the program's approval automatically ceases. Denial of Temporary Approval. The Department may deny temporary approval to an applicant if the Department's designated approval unit determines that the application does not meet all approval requirements. The Department may deny a license or approval to: Any corporation or entity that has had a license or approval revoked by the Department or other licensing agency, or has surrendered or defaulted on its license or approval for reasons related to disciplinary action, within the previous 10 years; and Any corporation or entity that has a corporate officer who has served as a corporate officer for a corporation or entity that has had a license revoked, or has surrendered or defaulted on its license or approval for reasons related to disciplinary action, within the previous 10 years. The Secretary may, according to the provisions of Regulation .12A of this chapter, issue an initial notice of proposed denial of temporary approval. If the Secretary takes the action in §C(1) or (2) of this regulation, the Secretary shall advise the applicant of hearing rights, as described in Regulations .12A and .16 of this chapter. Before the expiration of a temporary approval period: The Department's designated approval unit shall conduct an on-site review to determine approval status outlined in Regulation .08 of this chapter; and Following completion of the on-site review required under §D(1) of this regulation, the Secretary shall grant or propose to revoke approval according to the provisions of Regulation .08 or .12 of this chapter. Approval Without Conditions. The Secretary shall grant approval without conditions to a program if, based on an on-site review, the Department's designated approval unit determines that the program complies with the requirements for approval. Unless the program has been granted deemed status under Regulation .10 of this chapter, within not more than 3 years of the date of the program's last full on-site review, the Department's designated approval unit shall conduct a full, on-site review of the program. Based on the review conducted under §A(2) of this regulation, the Secretary shall redetermine the program's approval status according to the provisions of this chapter. Approval with Conditions. The Secretary may grant approval with conditions to a program if, based on an on-site review, the Department's designated approval unit determines that the program: Is deficient in one or more of the requirements under this chapter, COMAR 10.21.17, or the chapter under the subtitle for the specific program; Has no deficiencies that constitute a threat to health, safety, or welfare of the individuals served; Has documented that the program will collaborate with the CSA, as required under COMAR 10.21.17.06; and Has submitted an acceptable program improvement plan within the time frame established under §B(3) of this regulation. If the Secretary grants a program an approval with conditions under §B(1) of this regulation, the Secretary shall notify the program that the Department's designated approval unit may conduct a focused review under the provisions of §B(4) of this regulation. Program Improvement Plan (PIP). Within 10 working days of receipt of the list of deficiencies cited during the on-site review, the program director shall: Submit a proposed PIP that addresses the identified deficiencies to the CSA or lead CSA; and Collaborate with the CSA or lead CSA to finalize the PIP. Within 30 calendar days of receipt of the list of deficiencies cited during the on-site review, the program director shall submit: The PIP to the Department's designated approval unit; and Documentation of the collaboration with the CSA or lead CSA. Unless an extension has been granted by the Department's designated approval unit, if a program fails to submit a completed PIP within the time frames established in §B(3)(a) and (b) of this regulation, the Secretary may pursue disciplinary action under Regulation .12C of this chapter. Focused Review. For programs that have been granted approval with conditions, the Department's designated approval unit may conduct a focused review to: Reevaluate the deficiencies cited during the on-site review conducted under §B(1) of this regulation; and Review the program's progress on the PIP. Based on the focused review conducted under §B(4)(a) of this regulation, the Secretary shall redetermine the program's approval status according to the provisions of this chapter. Regular Program Review. Within 3 years of the date of the program's last full on-site review, the Department's designated approval unit shall conduct a full, on-site review of the program. Based on the review conducted under §B(5)(a) of this regulation, the Secretary shall redetermine the program's approval status according to the provisions of this chapter. Certificate of Approval. If the Department's designated approval unit determines that a program is eligible for approval, the Secretary shall issue a certificate of approval to the program director that specifies the: Chapter under which the program has been approved; Type of approval; and Beginning and expiration dates of the approval period. The Secretary shall notify the Administration, the CSA of the jurisdiction where the program provides services, the Medical Assistance Program, and the ASO of the program's approval. The program director shall ensure that the certificate of approval is available during the regular hours of operation. Sale or Transfer of Certificate of Approval. The Secretary's certificate of approval of a program, issued according to the provisions of §C(1) of this regulation, is valid only for the program to which the Secretary's certificate of approval is issued. A program may not sell, assign, or transfer a certificate of approval to another program. Extension of Approval Status. The Secretary shall maintain the program's existing approval status if, before the expiration of approval period, the: Department's designated approval unit does not complete an on-site review; or Department does not reach a decision regarding approval. Waivers. The Secretary may not waive the requirements of any regulation adopted under: This chapter; COMAR 10.21.17; or The chapter under this subtitle that outlines the requirements for a specific program. Variances. A program that is approved under Regulation .08 of this chapter may apply for a variance. When a program is approved under Regulation .08 of this chapter, the Secretary may grant a variance for a regulation if the Secretary: Receives a written request from a program on the form required by the Administration; and Finds that the intent of the regulation to which a variance is sought is met by the alternative proposed by the program. The Secretary may not grant a variance that would endanger the health or safety of the individuals served. The Secretary may grant a variance that: Remains in effect for as long as the program continues to comply with the conditions under which the variance is granted; or Is time limited. The Secretary shall: Issue a written decision, including the reason or reasons for granting or not granting the variance; Send the decision to the: Program director; CSA; and Department's designated approval unit; and Enter the decision in the records of the Department. Initial Request for Deemed Status. If a program is approved under Regulation .08 of this chapter and is accredited under relevant behavioral health care standards of the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) or the Rehabilitation Accreditation Commission (CARF), the program director may request that the Secretary grant the program deemed status by submitting a written request to the Administration and the CSA at least 90 days before the expiration of the program's current approval status that includes the: Application for deemed status; Accreditation body's full report, including the program's status and any conditions placed on the program; Most recent report by the Department's designated approval unit; and Program improvement plans, if any, required by the accreditation body or the Department's designated approval unit. Request for Renewal of Deemed Status. The program may request that the Secretary renew the program's deemed status by submitting a written request to the Administration at least 60 calendar days before the expiration of the program's current deemed status that includes the: Application for deemed status renewal; Most recent accreditation body's full report, including the program's status and any conditions placed on the program; Program improvement plan, if any, required by the accreditation body; and Documentation of verification from the CSA or lead CSA, of program compliance with the conditions, if any, outlined under §D(1)(b) of this regulation. Evaluation of Request for Initial Deemed Status or Renewal of Deemed Status. Within 60 calendar days of receipt of the request under §A or B of this regulation: The Administration, in consultation with the CSA or lead CSA, and the Department's designated approval unit: Shall evaluate the request for deemed status; May meet with the program director; and May arrange for an on-site evaluation; and The Director shall recommend to the Secretary a decision regarding deemed status, based on: Comparison of the standards used by the accreditation body with the chapter under this subtitle that outlines the requirements for the specific program; and The results of an on-site evaluation, if any. Decision Regarding Deemed Status. Based on the evaluation of the request for deemed status conducted under §C of this regulation, the Secretary shall: Decide whether to: Approve deemed status; Approve deemed status with conditions, which may include evaluation by the Department's designated approval unit; or Propose to deny approval of deemed status; and Send notice of the decision to the: Department's designated approval unit; Program director; Administration; and CSA or lead CSA. Denial of Deemed Status. If the Secretary proposes to deny approval of deemed status, the Secretary shall give written notice of the proposed denial to the: Department's designated approval unit; Program director; Administration; and CSA or lead CSA. In the notice under §E(1) of this regulation, the Secretary shall include: The date that the Secretary proposes to deny approval of deemed status; and The facts that warrant the proposed denial of deemed status. Upon receipt of the notice under §E(2) of this regulation, the program director may: Withdraw the request for deemed status; and Request an on-site review for approval by the Department's designated approval unit. If the program director does not take the action under §E(3) of this regulation and if, after notice and opportunity to be heard, the Secretary denies approval of deemed status, the Director shall notify the program director that, unless the program elects not to seek approval, the Department's designated approval unit shall conduct an on-site review for the purpose of granting or denying approval under Regulation .08 or .12 of this chapter. The Department, its designees, the Administration, the Administration's ASO, CSA, and federal funding agents may: Make announced and unannounced visits to a program; and Inspect and copy all records, including, but not limited to financial, treatment, and service records. Denial of Approval. If the Secretary proposes to deny approval to an applicant under the provisions of this chapter, the Secretary shall give written notice of the proposed denial to the: Applicant; Program's CEO and president of the advisory committee or governing body, whichever applies; Administration; CSA or lead CSA; ASO; and Medical Assistance Program. In the notice under §A(1) of this regulation, the Secretary shall include: The date on which the Secretary proposes to deny approval; The facts that warrant the proposed denial of approval; Citation of the regulation or regulations upon which the proposed denial is based; and Notification: That before the denial of approval, the program may request a hearing under the provisions of Regulation .16 of this chapter; and When feasible, of a case resolution conference. Emergency Suspension of Approval. Under State Government Article, §10-226, Annotated Code of Maryland, upon findings of conditions that pose an imminent risk to the health, safety, or welfare of an individual served by a program, the Secretary may order the immediate suspension of the approval of the program and the cessation of operation. If the Secretary takes the action under §B(1) of this regulation, the Secretary shall promptly give written notice of the proposed emergency suspension to the: Program director; President of the program's advisory committee, board of directors, or governing body, whichever is applicable; Administration; CSA or lead CSA; Department's designated approval unit; ASO; and Medical Assistance Program. In the notice under §B(2) of this regulation, the Secretary shall include: The proposed effective date of the emergency suspension; When feasible, the date of a pre-deprivation hearing and a case resolution conference prior to the Department's final action; The findings under §B(1) of this regulation and the reasons that support the finding; Notification that: Following the emergency suspension, the program may request a hearing under the provisions of Regulation .16 of this chapter; and The emergency suspension may lead to revocation of the approval if the violation or violations are not corrected within the time period specified by the Department. If the Secretary suspends approval, the program director shall immediately: Notify individuals or the guardians of individuals receiving services of the suspension; Cooperate with the CSA or lead CSA and the Administration in accessing appropriate alternate services for individuals in the program; and Cease operations of the program. Disciplinary Action. The Secretary may propose to take any of the following disciplinary actions against a program: Revocation of approval; Suspension of approval; Probation with conditions; or Banning new admissions. The Secretary may propose to take one of the actions outlined in §C(1) of this regulation if the program: Is out of compliance with the requirements of: This chapter; COMAR 10.21.17; or The chapter under this subtitle that outlines the requirements for the specific program; Fails to maintain financial viability; or Obtains or attempts to obtain approval by fraud, misrepresentation, or the submission of false information to the Secretary. Except under §B of this regulation, no less than 45 calendar days in advance of the proposed action taken under this regulation, the Secretary shall send written notice of the proposed action to the: Program director; President of the program's advisory committee, board of directors, or governing body, whichever is applicable; Administration; and CSA or lead CSA. In the notice under §C(3) of this regulation, the Secretary shall include: The date on which the Secretary proposes to take action, and when feasible, the date of a case resolution conference; The facts that warrant the proposed action; Citation of the regulation or regulations upon which the proposed action is based; and Notification that, before the action, the program has the right to request a hearing under the provisions of Regulation .16 of this chapter. If, after notice and opportunity to be heard, the Secretary takes disciplinary action, the program director shall, within 10 working days: Notify individuals or the guardians of individuals receiving services of the action; and If the program ceases operations: Notify the CSA or lead CSA and the Administration of the cessation; and Cooperate with the CSA or lead CSA and the Administration in accessing appropriate alternate services for individuals in the program. If a program intends to discontinue operation, the program director shall, no less than 60 calendar days before the program intends to discontinue operation, submit to the Department's approval unit, the Administration, and the lead CSA its written plan for: Cessation of operations, including relevant dates; Transitioning individuals within its program to other mental health services; Storing and protecting all records; Notifying employees, consultants, and consumers of its cessation of operations; If a nonprofit organization, the return of funds to the State, as required; Reimbursement of employees for lost benefits, such as sick leave, vacation, and pension plan transitions; and An audited financial statement, current as of the date of the request to discontinue operations. Within 30 days of receipt of the program's request to discontinue operations, the Department's approval unit shall: Notify the program in writing whether its plan is acceptable; and If the plan is unacceptable, meet with the program and the lead CSA to formulate a plan that protects the health, safety, and welfare of the individuals served by the program and program staff. The program may not discontinue operations until the Department's approval unit authorizes this discontinuation. The program shall be responsible for delivering services to the individuals in its program until such time as the Department's approval unit approves the discontinuation. The program shall surrender its approval to provide services concurrent with the date on which it ceases operation. At all times, the program shall cooperate with the Administration, the Department's approval unit, and the lead CSA. Failure to comply with any section of this regulation may result in monetary penalties against the program's surety bond. If a program that is discontinuing operation does not comply with §§A — F of this regulation, the Secretary may deny approval to any future application that the program, or principals of the program, may submit. If a program wishes to discontinue approval, the program director shall, not less than 60 calendar days before the date the program wishes to discontinue approval: Submit to the Department's designated approval unit a letter requesting discontinuation of approval; and Notify, in writing, the: Individuals or the guardians of individuals receiving services that the program has requested discontinuation of approval, and the effective date of the discontinuation; and CSA or lead CSA, the Administration, Medical Assistance Program, and the ASO of the discontinuation of approval and the effective date of discontinuation. Within 60 calendar days from the receipt of the request for discontinuation of approval, the Secretary shall: Notify, in writing, the program director of the discontinuation of the program's approval and the effective date; and Forward a copy of the discontinuation to the Administration, Medical Assistance Program, CSA, and the ASO. When a program's decision to discontinue approval results in the discontinuation of services to any individual receiving services, the program director shall cooperate with the CSA or lead CSA and the Administration in accessing appropriate alternate services for individuals in the program. The Secretary may take action to initiate receivership under the provision of Health-General Article, §§19-333 — 19-339, Annotated Code of Maryland. If the Secretary proposes to deny approval or initiate disciplinary action, the Secretary shall give the program director written notice of the proposed action, according to the provisions outlined in Regulation .12A — C of this chapter. Within 10 working days of receipt of the notification of the action under §A of this regulation, the program director may file a written request for a hearing with the Office of Administrative Hearings, with copies to the: Administration; CSA or lead CSA; and Director of the Department's designated approval unit. If the program director does not file a request for hearing that is postmarked within 10 working days of receipt of the notification, the program waives the right to request a hearing, and the Secretary may effect the proposed action. If a timely request for hearing has been received, the Office of Administrative Hearings shall: Notify the Director and the program director of the date, time, and location of the hearing; and Hold a hearing and render a proposed decision to the Secretary in accordance with COMAR 28.02.01. After giving parties the opportunity to file exceptions and make oral arguments under the provisions of State Government Article, §10-216, Annotated Code of Maryland, the Secretary shall issue a final decision according to State Government Article, §10-221, Annotated Code of Maryland, and send notice of the decision to the: Administration; ASO; Appropriate CSA; Medical Assistance Program; and Program director. Further Appeal. A program may appeal any final decision by the Secretary by following the provisions of Health-General Article, §2-207, and State Government Article, Title 10, Subtitle 2, Annotated Code of Maryland. Health-General Article, §§7.5-205, 10-901, and 10-902, Annotated Code of Maryland Effective date: January 2, 1995 (21:26 Md. R. 2187) Chapter revised effective October 5, 1998 (25:20 Md. R. 1529) Regulations .01 — .12 repealed and new Regulations .01 — .16 adopted effective January 14, 2008 (35:1 Md. R. 19) Regulation .04C amended effective March 13, 2017 (44:5 Md. R. 292) This chapter delineates the administrative requirements for a community mental health program. In COMAR 10.21.16 and subsequent community mental health program chapters, the following terms have the meanings indicated. Terms Defined. “Ability to pay” means the individual's ability to pay for mental health services, as determined according to the provisions of COMAR 10.04.02. “Administration” means the Mental Hygiene Administration. “Administrative services organization (ASO)” means the entity with which the Administration may contract to provide the services described in COMAR 10.09.70 for the public mental health system. “Advance directive for mental health services” means a plan made by an individual pursuant to Health-General Article, §5-602.1, Annotated Code of Maryland. “Aftercare plan” means the plan developed by inpatient facility staff according to the requirements of Health-General Article, §10-809, Annotated Code of Maryland and COMAR 10.21.05. “Case coordination” means the process by which mental health and related support services to an individual are coordinated and monitored. “Case resolution conference (CRC)” means an informal proceeding before an evidentiary hearing to determine if there are grounds for settlement of a contested case. “Community support specialist” means the case manager as defined in COMAR 10.09.45. “Contact note” means an entry that is made in an individual's medical record by a program staff member and that describes face-to-face, written, or telephone contact with or regarding the individual. “Core service agency (CSA)” means the county or multicounty authority, designated under Health-General Article, Title 10, Subtitle 12, Annotated Code of Maryland, to carry out the duties set forth therein. “Credentialing” means the collection, verification, and assessment of information regarding four critical parameters: Current licensure; Relevant training; Current competence; and The ability to perform clinical responsibilities. “Crisis intervention” means the therapeutic response that provides immediate care or referral for an individual with urgent mental health need. “Day treatment program” means a program approved under COMAR 10.21.02 and is also referred to as partial hospitalization or psychiatric day treatment. “Deemed status” means the Secretary's granting of approval under this subtitle to a program, based on the program's accreditation under the relevant behavioral healthcare standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or Rehabilitation Accreditation Commission (CARF). “Department” means the Maryland Department of Health. “Designated emergency facility” means a health care facility identified under Health-General Article, §10-620, Annotated Code of Maryland, to perform the duties under Health-General Article, §10-624, Annotated Code of Maryland. “Director” means the Director of the Mental Hygiene Administration. “Discharge plan” means a brief description of the recommendations for continued treatment. “Discharge summary” means a detailed review of services provided to an individual, including, at a minimum, the items outlined in Regulation .11C of this chapter. “Enhanced support” means short-term, in-home services, in addition to other services to an individual, by a program that is approved by the Administration to provide this service, to support the individual to remain in the community. “Enrolled” means the program's formal acceptance and admission of an individual into the program. “Facility” has the meaning indicated in Health-General Article, §10-102(e), Annotated Code of Maryland, and may also be referred to as a site. “Governing body” means the organizational structure that is responsible for all program operations, including: Establishing policy; Maintaining quality care; and Providing management and planning for the program. “Grievance” means an oral or written complaint filed by or on behalf of an individual regarding the denial of services based on eligibility or medical necessity criteria. “Group home” means a private group home as defined in Health-General Article, §10-514, Annotated Code of Maryland, and licensed under COMAR 10.21.04. “Guardian” means a guardian as defined in Estates and Trusts Article, §13-101, Annotated Code of Maryland. “HIPAA” means part of the federal act outlined in 42 U.S.C. §1320D et seq., as amended, and the implementing regulations at 45 CFR Parts 160 and 164, as amended. “Health officer” means the individual nominated by a county and appointed by the Secretary under the provision of Health-General Article, Title 3, Subtitle 3, Annotated Code of Maryland. “Health promotion and training” means activities to increase an individual's awareness of physical and mental health status and of the resources required to help promote good physical and mental health. “Independent living skills training” means activities to promote, maintain, or restore an individual's ability to perform essential activities of daily life. “Individual” means: An adult; A person authorized to consent to health care for an adult; A minor; A minor who is 16 years old or older, if the medical care concerns treatment to which the minor has the right to consent, and if the minor has consented to treatment; A parent; A guardian; The attorney of the minor; The custodian of the minor; or A representative of the minor designated by a court who can legally consent to treatment consistent with the authority granted. “Individual rehabilitation plan (IRP)” means the plan prepared according to the requirements outlined in the chapter or chapters under this subtitle that delineate the requirements for the specific rehabilitation program. Individual Treatment and Rehabilitation Plan (ITRP). “ITRP” means the plan prepared according to the requirements outlined in the chapter or chapters under this subtitle that delineate the requirements for the specific program. “ITRP” may substitute for a separate ITP and IRP. “Individual Treatment Plan (ITP)” means the plan prepared according to the requirements outlined in the chapters under this subtitle that delineate the requirements for the specific program. “Inpatient facility” means an inpatient institution that provides evaluation, treatment, and 24-hour residential care for individuals who have mental disorders. “Lead CSA” means, for programs that provide services in multiple jurisdictions, the CSA identified by the Administration in collaboration with the appropriate CSAs to represent all involved jurisdictions. “Managed intervention plan (MIP)”: Means the plan that is developed, when appropriate, that details the strategies to be implemented in times of crisis to provide for a revised plan of services and supports to maintain the individual in a residential rehabilitation program residence, to prevent the unplanned discontinuation of services, or to prevent an inpatient admission; and May be incorporated into the individual rehabilitation plan (IRP) or individual treatment and rehabilitation plan (ITRP). “Maryland Medical Records Act” means the act outlined in Health-General Article, §4-301, Annotated Code of Maryland. “Medical Assistance Program” means the Medical Assistance Program as defined in COMAR 10.09.36.01. “Medicare” means the insurance program administered by the federal government under Title XVIII of the Social Security Act, 42 U.S.C. §1395 et seq., as amended. Medication Monitoring. “Medication monitoring” means: Providing face-to-face assistance to an individual to achieve compliance with treatment with all prescribed psychiatric or somatic medications; and As needed, reviewing the individual's existing medication regimen with the appropriate physician. “Medication monitoring” does not mean: Prescribing medication; Measuring or pouring medicine; Preparation of a syringe for injection; or Administration of medication. “Mental health professional” means an individual who is licensed, certified, or otherwise legally authorized to provide the mental health service: Under Health Occupations Article, Annotated Code of Maryland; or In the state where the service is rendered. “Mental health program (program)” means a community-based program that is approved by the Department under this subtitle to be eligible to receive State or federal funds, or both. “Mental health vocational program (MHVP)” means a program approved under COMAR 10.21.28. “Minor” means an individual who is younger than 18 years old. “Mobile treatment services (MTS) program” means a program approved under COMAR 10.21.19. “Nurse” means an individual who is licensed and legally authorized to practice as a nurse: Under Health Occupations Article, Annotated Code of Maryland; or In the state where the service is rendered. “Occupational therapist” means an individual who is licensed and legally authorized to practice as an occupational therapist: Under Health Occupations Article, Annotated Code of Maryland; or In the state where the service is rendered. “On-call” means the availability of designated program staff 24 hours per day, 7 days per week. “Outpatient mental health center (OMHC)” means a program approved under COMAR 10.21.20. “Physician” means an individual who is licensed and legally authorized to practice medicine: Under Health Occupations Article, Annotated Code of Maryland; or In the state where the service is rendered. “Primary care provider (PCP)” means a practitioner who is the primary coordinator of care for the individual, whose responsibility it is to provide accessible, continuous, comprehensive, and coordinated health care services and includes PCPs covering the full range of benefits required by the Maryland Medicaid Managed Care Program, as specified in COMAR 10.09.67. “Primary caretaker” means the minor's custodial parent or parents or the adult with whom the minor currently resides. “Privileging” means the process by which a program determines that staff members are qualified to perform assigned duties. “Professional counselor” means an individual who is certified or licensed and legally authorized to practice as a professional counselor: Under Health Occupations Article, Annotated Code of Maryland; or In the state where the service is rendered. “Program director” means the individual who is responsible for the daily operations of a program, as outlined in the chapter under this subtitle that delineates the requirements for a specific program. “Program improvement plan (PIP)” means a written statement from a program that documents the program's methods and time frames for correcting deficiencies cited by the Department's designated approval unit. “Progress summary note” means an entry by an individual's program coordinator in the individual's medical record that summarizes the individual's progress toward goals delineated in the individual's ITP, IRP, or ITRP. “Provisional diagnosis” means the diagnosis given as a result of an initial assessment of the symptoms at the first encounter with an individual that lasts only until the correct nature of the illness has been clarified by further clinical examination. “Psychiatric rehabilitation program (PRP)” means a program approved under COMAR 10.21.21 for adults, and COMAR 10.21.29 for minors, or both. “Psychiatrist” means a physician who: Is certified in psychiatry by the American Board of Psychiatry and Neurology; or Has completed the minimum educational and training requirements to be qualified to take the Board of Psychiatry and Neurology examination for certification in psychiatry. “Psychologist” means an individual who is licensed and legally authorized to practice as a psychologist: Under Health Occupations Article, Annotated Code of Maryland; or In the state where the service is rendered. “Psychologist Associate” means an individual approved by the Board of Examiners of Psychologists for exemption to perform psychological services pursuant to Health Occupations Article, §18-301(b)(3), Annotated Code of Maryland, and COMAR 10.36.07. Public Mental Health System (PMHS). “Public mental health system” means the system for the delivery of mental health treatment and supports to individuals who meet medical necessity criteria and financial eligibility as established by the Maryland Department of Health Administration. “Public mental health system” includes the specialty mental health system described in COMAR 10.09.70. “Quality management (QM)” means the process by which a program maintains and improves the quality of services. “Referral” means a contact made with a program by an individual, or on behalf of an individual, for mental health services. “Rehabilitation coordinator” means the program staff person who is responsible for coordinating and providing rehabilitation services to an individual. “Residence” means a housing unit leased or owned by an approved residential rehabilitation program (RRP). “Residential checklist” means the form issued by the Department for the purpose of recording information gathered during the inspection of rehabilitation residences. “Residential crisis services (RCS)” means services provided by a program approved under COMAR 10.21.26. “Residential rehabilitation program (RRP)” means a program that is approved under COMAR 10.21.22. “Residential specialist” means the individual designated by the Department or the CSA to inspect, monitor, and determine the approval status of a residence. “Respite care services” means services provided by a program approved under COMAR 10.21.27. “Secretary” means the Secretary of Health or the Secretary's designee. “Serious emotional disturbance” means a condition that is: Manifest in an individual younger than 18 years old; Diagnosed according to a current diagnostic classification system that is recognized by the Secretary, excluding the following, unless they co-exist with a diagnosable psychiatric disorder: Developmental disorders; Substance abuse; and Disorder classified under the “V” code; and Characterized by a functional impairment that substantially interferes with or limits the minor's functioning in the family, school, or community. “Serious mental illness” means a mental disorder that is: Manifest in an individual 18 years old or older; Diagnosed, according to a current diagnostic classification system that is recognized by the Secretary as: Schizophrenic disorder; Major affective disorder; Other psychotic disorder; or Borderline or schizotypal personality disorder, with the exclusion of an abnormality that is manifested only by repeated criminal or otherwise antisocial conduct; and Characterized by impaired functioning on a continuing or intermittent basis, for at least 2 years, and includes at least three of the following: Inability to maintain independent employment; Social behavior that results in interventions by the mental health system; Inability, due to cognitive disorganization, to procure financial assistance to support living in the community; Severe inability to establish or maintain a personal support system; or Need for assistance with basic living skills. “Social skills training” means activities to diminish tendencies toward isolation and withdrawal by assisting individuals to acquire, maintain, or develop communication and other interpersonal skills. “Social worker” means an individual who is licensed and legally authorized to practice as a social worker: Under Health Occupations Article, Annotated Code of Maryland; or In the state where the service is rendered. “Supported housing” means activities to enable an individual to maintain housing of the individual's choice. “Therapeutic group home (TGH)” means a program that is licensed under COMAR 10.21.04, 10.21.07, and COMAR 14.31.05, 14.31.06, and 14.31.07. “Therapeutic milieu” means an environment that is clinically structured to provide mental health treatment in a place other than the individual's residence. “Therapeutic nursery program (TNP)” means a program approved under COMAR 10.21.18. “Treatment coordinator” means the licensed mental health professional who is responsible for coordinating and providing mental health services to an individual. “Working day” means any day except Saturday, Sunday, or a holiday on which State offices are closed. Authorization for Services. The program shall comply with the provisions of this regulation when the program provides services to: A Medicaid recipient; or An individual for whom, because of the severity of the mental illness and, based on the Administration's determination of the individual's ability to pay, the cost of care is subsidized, wholly or in part, through the public mental health system. Before rendering services to an individual, a provider shall notify the Administration's administrative services organization (ASO), or for those services approved by the CSA, the CSA of the jurisdiction where the individual resides, as appropriate, and receive preauthorization for services, according to the provisions of COMAR 10.09.70.07. When the Administration's ASO contacts a program directly to refer an individual, and the individual does not make an initial appointment or does not keep the initial appointment, program staff shall: Attempt to reschedule an initial appointment for the individual; and If that fails, notify the Administration's ASO that the individual has not received services. Preauthorization is not required before a provider renders services in an emergency. If a program discontinues admissions, the program director shall notify the CSA and the Administration's ASO, if appropriate. Payment for Services. Fee Schedule. The Administration shall reimburse an eligible provider for rendering authorized services: In accordance with the State budget; According to the provisions of and at the rates established under COMAR 10.21.25; or Pursuant to grants or contracts funded by the State or the CSAs. If an individual is not a Medicaid recipient and, because of the severity of the individual's mental illness and financial need, the cost of the individual's care is subsidized wholly or in part with public funds, the provider shall: Receive payment if the individual meets eligibility criteria established by the Administration; Collect information from an individual to assess the individual's ability to pay, including information regarding any applicable insurance benefits; Assess the individual's ability to pay and determine the required co-payment; and Make collections of the co-payment according to the requirements in Health-General Article, §§16-201 — 16-204, Annotated Code of Maryland. Medicare Recipients. If a provider renders services to individuals who are Medicare recipients, the provider shall comply with all federal Medicare requirements. If a provider does not comply with all Medicare requirements, the provider may not seek reimbursement by the PMHS. Consent for Services. Before initiating services to an individual, a program shall: Obtain consent from the individual to: Render services to the individual; and Involve, as appropriate, the appropriate CSA, the individual's family members, and others designated by the individual in the individual's service process; Review with the individual: That the program may disclose, without consent, certain protected health information, and obtain an acknowledgment from the individual of having received notice that such disclosure may occur; That the program may disclose, without consent, protected health information to other medical assistance programs and providers; and The requirements of the Health Insurance Portability and Accountability Act and the Maryland Medical Records Act, as to scope and limits of the confidentiality provisions; and If the individual is a minor who cannot consent to services, obtain the appropriate consents and make the required disclosures. If the individual agrees to consent to services but is unable or unwilling to give written consent, a program shall: Document the reasons why the individual cannot give written consent; Verify the individual's verbal consent to services; and Periodically attempt to obtain written consent and document such efforts. Orientation. On or before the date that an individual receives services, the program director shall ensure that an individual who has been admitted to the program receives information, verbally and in writing, including, but not limited to: A description of the services available; Individual rights and responsibilities; Program hours and on-call procedures; The program's procedures for discharge; The program's procedures for confidentiality; Crisis intervention services; and The complaint and grievance processes. The individual's program coordinator shall document in the individual's medical record the individual's receipt of the information contained in §B(1) of this regulation. Advance Directive for Mental Health Services. For individuals who are 16 years old or older, the program director shall: Ensure that an individual who has been admitted to the program receives information, verbally and in writing, regarding making an advance directive for mental health services; Document whether an individual has a current advance directive for mental health services; If an individual has a mental health advance directive, include a copy of the document in the individual's medical record; and If an individual requests assistance with making an advance directive for mental health services, assign staff to assist the individual. Membership. A provider that is approved by the Department under this subtitle to operate a program shall have an advisory committee that is composed of members: That reflect the cultural and ethnic profile of the community or communities being served; and At least one-third of whom are individuals who identify themselves as being in one of the following categories: Currently served or were previously served by a mental health program; Family members of individuals who are currently served or were previously served by a mental health program; or Members of a mental health advocacy organization. Responsibilities of the Advisory Committee. The advisory committee shall: Establish and maintain a regular meeting schedule; Maintain documentation of the meetings, including: Date; Members present; and Summary of the topics discussed; Review a program's: Mission; Long-range goals; Policies and procedures; and Services, hours, and location for consistency with community needs; Advise the program director regarding the items outlined under §B(2) of this regulation; and If applicable, annually review whether the program is satisfying its charitable mission. If a program has a governing body or board of directors, whichever applies, composed of the membership described under §A of this regulation, and the governing body or board of directors carries out the duties described under §B of this regulation, an additional advisory committee is not required. Limitation. In order for a program to be eligible to receive funds under this or any other chapter of the Administration's regulations, the following individuals may not serve on the governing body, board of directors, or advisory committee, whichever applies: An immediate family member of an employee of a program; A person who is compensated for providing goods and services to the program; and A person who has served as a member of a governing body, board of directors, or advisory committee of a program that has had a license or approval revoked by the Department within the previous 10 years. The program director shall: Submit annually to the CSA, or, when providing services in multiple jurisdictions, the lead CSA, and the Community Services Reimbursement Rate Commission, an annual summary that, at a minimum, includes: Relevant financial statements or documentation and results of a financial audit; Wage and benefit information for each job classification, including, but not limited to: Administrative staff; Supervisory staff; Clinical staff; and Direct care staff; Other information deemed necessary by the Department and the Community Services Reimbursement Rate Commission; Collaborate with the CSA in the planning and development of services to be delivered in the CSA's jurisdiction; and Ensure that the program participates with the CSA's: Protocol for resolution of conflict between the program and an individual served, or another program or agency, or both; and Procedures for prevention of the appearance or occurrence of conflict of interest in the operation of the program's provision of mental health services. A community mental health program shall develop a program model that promotes recovery and resiliency as required according to the chapter under this subtitle for the specific program. The program director shall ensure that information and services are provided: In a culturally sensitive manner; and At a suitable reading comprehension level. General Requirements. The program shall, either manually or electronically: Establish a record for an individual who receives services from the program; and Ensure that entries in the record are dated, signed, and include the signer's degree or license, or if the signer has no degree or license, the signer's staff position. The program director shall ensure that individuals' program records are: Maintained in a manner that is consistent with the medical records confidentiality and disclosure requirements of: Maryland Confidentiality of Medical Records Act, Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland; and Relevant federal statutes and regulations, including the Health Insurance Portability Act, 42 U.S.C. §1320D et seq., and implementing regulations at 45 CFR Parts 160 and 164; Located so that the records are convenient and available to designated staff; Managed by a designated staff member who is responsible for appropriate records control, including storage, security, and indexing of records; and Subject to the requirements of confidentiality laws and regulations, are made available to the Department, the Administration's ASO, the CSA, and the Office of Inspector General, as necessary to carry out required activities. Contents of Record. When an individual is enrolled in a program, the program shall maintain a record of, at a minimum: Identifying information, including but not limited to: Name, sex, race, marital status, and date of birth of the individual; Address and telephone number; and As permitted by law, Social Security number; Name, address, and telephone number of the individual to be contacted in case of emergency; Dates of enrollment and initial service; Source of referral; If the individual has been referred upon discharge from an inpatient facility: A copy of the aftercare plan and discharge summary; or Documentation that the program has requested a copy of the aftercare plan and discharge summary; If an individual has been court-ordered to receive evaluation or treatment, a copy of the court order; Documentation of verification of the individual's financial information, or, if the individual is a minor, the minor's parent's financial information necessary to implement the Department's requirements on the setting of charges and collection of fees; Presenting problem and history of the presenting problem, including, if known, precipitating factors and, if any, history of substance abuse; Either, if indicated and relevant: Copies of reports and recommendations of prior treatment, tests, and evaluations, including, when received, a report or summary of current physical examination; or Documentation that the program has requested a copy of any reports and recommendations of prior treatment, tests, and evaluations; For a minor who is enrolled in a program, copies of legal documents related to the minor's status, including but not limited to: Court orders; and Custody agreements; For a minor who is enrolled in a program, an emergency contact form, which is up-to-date and which includes: The name, address, and daytime telephone number of the primary caretaker; The name, address, and telephone number of the primary care provider; and If available, the names, addresses, and daytime telephone numbers of at least two individuals to be contacted in case of emergency when the primary caretaker cannot be reached; The consent forms, signed by the individual or the individual's parent or guardian, as appropriate, for: Participation in the program and activities provided by the program; and Releasing information to or requesting information from other agencies, including the CSA, and health care providers; Documentation of the clinical information as required in the chapter under this subtitle for specific program requirements; If applicable, names and either addresses or telephone numbers of the individual's psychiatrist, therapist, case manager, primary care provider, managed care organization, and insurance carrier; and The individual's discharge plan and summary. The program shall have and maintain written policies that, at a minimum include: The program's mission and goals; A description of the organizational structure of the program; Identification of the duties of the program director and, if applicable, the medical director or clinical director; and The policies and procedures for: Ensuring individual rights, including confidentiality, and providing a complaint process; Providing the services in the chapter under this subtitle that outlines the requirements for the specific program; Screening, admission, transition, and discharge; If the program provides case coordination, assisting program enrollees with access to all entitlements, pertinent resources, insurance benefits, and reimbursements for which the individual is eligible; If applicable to the program, storing, handling, prescribing, administering, and disposing of medications; If applicable to the program, monitoring of psychiatric and somatic medication; If applicable, accounting for the use and expenditure of an individual's funds; Staffing, including, if required under the chapter in this subtitle that outlines the provisions for the specific program, 24 hours, on-call and emergency coverage; If the program provides services in a facility, a disaster and emergency evacuation plan; According to federal and State requirements, safety precautions, infection control, and communicable disease control; Incident reporting; Crisis response plan; and Information about any State and federal laws pertaining to civil or criminal penalties for false claims and statements and whistle blower protections, including the necessity for preventing and detecting fraud, waste, and abuse. At least every 3 years, appropriate program staff shall review and, as necessary, revise the policies and procedures. The program shall maintain written personnel policies, including, at a minimum: Contents of an employee's personnel file, including, at a minimum: Name; Current job classification; Current job description; Resume containing educational background, relevant work experience, and specialized skills; Copies of required certificates and licenses and primary source verification; Documentation of a criminal background investigation as follows: If the employee works with or has access to minors, a background investigation following the procedures set forth in Family Law Article, §§5-560 — 5-568, Annotated Code of Maryland; and If the employee works in a group home, a background investigation following the procedures set forth in Health-General Article, Title 19, Subtitle 19, Annotated Code of Maryland; Information received from the employee's references; Documentation of orientation, continuing education and training activities, and privileges granted; and If the staff person's duties require transportation of staff or individuals served: Proof of a valid driver's license issued in the state of the employee's residence; and Updated annually, a driver's license report from the appropriate state; Staff orientation, supervision, training, and education; Method of access to an employee's personnel file; Substance abuse policy; Ethical guidelines for employees; and Confidentiality guidelines regarding disclosure requirements of: Maryland Confidentiality of Medical Records Act, Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland; and Relevant federal statutes and regulations, including the Health Insurance Portability and Accountability Act, 42 U.S.C. §§1320D et seq., and implementing regulations at 45 CFR Parts 160 and 164. When an individual has attained the goals identified in the individual's service plan, the individual's program coordinator shall begin the process for discharge planning. Discharge Policy. The program shall have and maintain written policies and procedures, which may be contained in one document, that include: The process for all types of discharge from the program, including: Collaborative discharge; The individual's discontinuation of services; The program's recommendation to discontinue services; and The ASO's determination to discontinue authorization for services; and The individual's right to appeal. Discharge Plan. The individual's program coordinator and the individual, if appropriate, shall develop a discharge plan that: Is based on an assessment of the individual's current status, service needs, and mutually agreed upon goal attainment; Includes: A brief description of the recommendations for continued treatment, if any; Referrals for continuing services; and Information about how the individual can re-access services when needed; and With proper consent, is developed in collaboration with family or others designated by the individual, and other treatment, rehabilitation, and service providers. The individual's program coordinator shall provide the individual with a copy of the discharge plan as soon as possible, but in no event, not later than the date of discharge. Discharge Summary. Within 10 working days after an individual is discharged from a program, a staff person responsible for coordinating services to the individual shall complete and sign a discharge summary that includes, at a minimum, the: Reason for admission; Reason for discharge; Services provided, including the frequency and duration of services; Progress that was made; Diagnosis at the time of discharge, if appropriate; Current medications, if any; Continuing service recommendations and summary of the transition process; and Extent of the individual's involvement in the discharge plan. Program's Recommendation to Discontinue Services. If, in consultation with the program director, the program coordinator recommends discontinuing services for an individual for whom, because of the individual's actions, the program's services are not effective, or the individual's clinical needs exceed the program's ability to secure the safety and welfare of the individual or others, the program director shall provide written notice of the intention to discontinue services and recommend referral for alternative services. Except in the case of imminent danger, the program director shall provide the notice at least 30 calendar days before discontinuing services. The program director shall assure that the notice is sent to the individual and, with proper consent, to: Family or others designated by the individual; and If appropriate, the CSA and the Administration's ASO, for referral for alternative services. The notice shall include: The effective date of the action; The reason for the action; and A discharge plan. If an individual presents as a danger to self or to others, the program director shall make necessary arrangements to try to protect the individual, others, or both, and link the individual with the appropriate level of care. ASO's Determination to Discontinue Authorization for Services. If the Administration's ASO determines that services are no longer medically necessary, the program coordinator shall follow the provision for discharge outlined in §C of this regulation. Supervision. The program director shall: Establish a system to ensure ongoing supervision of staff; and Determine the need for staff supervision on the basis of: Credentials, competencies, experience, education, and training; Performance standards and outcome measures identified by the quality management process; Size of caseload; and Severity of illness of individuals enrolled in the program. Orientation. The program director shall assure that staff: Within the first week of employment, receive an orientation regarding the: Mission of the program; Fundamental rights of the individuals the program serves, including grievance, complaint, and confidentiality procedures of the program; Psychiatric and medical emergency procedures of the program, including crisis management and suicide prevention; and If the program provides services in a facility, emergency evacuation procedures; and Within 2 months, receive orientation including, but not limited to, the following: Program policies and procedures; Personnel policies and procedures; and Overview of the public mental health services delivery system. Continuing Education. The program director shall assure that staff who provide direct services to individuals participate in at least 8 hours of annual educational activities related to the provision of the program's services. CPR and First Aid. The program director shall ensure that at least one staff member with certification in cardiopulmonary resuscitation (CPR) and standard first aid is on-site during the hours the program is open. Students. A program may use students to provide services to individuals only if the students: Are pursuing degrees at accredited colleges or universities toward state licensure as mental health professionals; Deliver services as part of formal fieldwork placements through accredited colleges and universities; Comply with their respective professional licensing laws, including supervision requirements, as outlined in Health Occupations Article, Annotated Code of Maryland; and Are appropriately screened, oriented to the program's policies and procedures, and supervised. Volunteers. A program may use volunteers to assist with program activities only if the: Volunteers are at least 16 years old, and with proper consent, if applicable; Volunteers are appropriately screened, oriented to the program's policies and procedures, and supervised; and Program has a written policy regarding the scope of the volunteers' duties. A volunteer may not substitute for required program staff. A program shall establish and maintain a QM process in accordance with the requirements of this regulation. QM Plan. The program director shall develop and, at least every 3 years, review a written QM plan that: Provides for an internal, ongoing quality performance evaluation process that describes the: Program goals; and Mechanisms, including staff responsible and resources available, for implementing the QM process; Is oriented to the individuals served and emphasizes recovery, collaboration, continuity of care, accessibility, accountability, and efficiency; Includes a system to evaluate: Quality of care and services rendered to individuals; Staff performance in the provision of the services; Staff competencies; and Appropriateness of the program's: Services, including accessibility and hours of operation; Staff; and If the program provides services in a facility, physical plant, and environment; Includes a process for the adequate collection of data in order to identify problems; and In order for staff to implement actions to correct deviations from the program's established standards, identifies a plan that: Is based on: The data collected under §B(4) of this regulation; Input from staff and individuals served; A review of the program's outcomes; and Current trends in efficient and effective treatment and services; Is consistent with the program model and the specialized needs of those served; and Provides for ongoing internal review of the program, including monitoring for effectiveness of changes incorporated. Risk Management (RM). The program director shall develop and, at least every 3 years, review a written RM plan, which may be a component of the QM plan, that: Includes policies and procedures for critical incidents, including: Suicides; and Unfavorable service-related outcomes, including discharges that are not mutually agreed upon; Includes a mechanism by which the program director reports: An allegation of mental, physical, or sexual abuse or neglect of an individual, as provided under Health-General Article, §10-705, and Family Law Article, Title 5, Subtitle 7, and Title 14, Annotated Code of Maryland; and The death of an individual, as outlined in Regulation .13 of this chapter; and Tracks and evaluates incidents reported under §C(1) and (2) of this regulation and complaints filed under Regulation .16 of this chapter to determine trends. Program Service Outcomes. The program director shall: Comply with the outcome reporting requirements as determined by the Administration; Report data when required and as specified by the Administration; Conduct and analyze the results of an annual satisfaction survey of the program's consumers; Develop a process to inform the individuals served of the program's service outcomes; and Make programmatic changes as appropriate. Upon notification of the death of any individual in a State funded or operated program or facility, the administrative head of the program or facility shall: Report the death according to the provisions of Health-General Article, §10-714(a), Annotated Code of Maryland; and Use the form required by the Administration. The program director shall ensure that staff and consultants perform only those duties for which the staff and consultants have the appropriate credentials and competencies according to the provisions of this regulation. Staff Credentials. The program director shall ensure that the program has in effect a process for reviewing credentials that requires the program to collect, verify, review, and document the following information: Education; If required, primary source verification of licenses or certification under Health Occupations Article, Annotated Code of Maryland, to practice a health occupation; and Documentation of professional liability insurance that is carried either individually or through the program. Staff Competencies. The program director, in consultation, if appropriate, with the medical director, clinical director, or program psychiatrist, shall develop and implement: A process by which the program reviews and evaluates: Education, credentials, and additional training; Relevant work experience, including experience with populations served by the program, including but not limited to: Adults with serious and persistent mental illness; Children and adolescents with serious emotional disturbance; and Elderly individuals with mental illness; and Competencies required to perform the services rendered; A system to grant, deny, suspend, or revoke privileges to perform specific services; and Methods for periodic review of credentials and competencies. Staff Criminal Conduct. If a staff member is charged with a crime that involves abuse of an individual, or individuals served by the program, the governing body, board of directors, or advisory committee, whichever applies, shall have a process to determine, without the participation of the staff member in interest, whether the staff member can continue to provide services. If the governing body, board of directors, or advisory committee, whichever applies, determines that the staff member may continue to provide services, the governing body, board of directors, or advisory committee, whichever applies, shall determine the capacity in which the staff member may continue to provide services until the charges are resolved. A program shall: Explain to an individual enrolled in a program the individual's rights as set forth in Health-General Article, Title 10, Subtitle 7, and Title 4, Subtitle 3, Annotated Code of Maryland; Provide, in writing, information regarding an individual's rights as outlined in §A of this regulation to an individual enrolled in a program; and Prominently display, in accessible centralized locations, the individual's rights as outlined in §A of this regulation. A program may not use restraints or seclusion. A program shall develop and implement an internal process for the prompt and objective resolution of complaints related to services provided that may be presented by an individual. The program shall prominently display, in accessible centralized locations, the written description of the complaint process. A program shall: Prepare the document describing the program's complaint process; Include as part of the written complaint process a form for the individual's use when filing a complaint, and a process by which, if requested by the individual, a program staff member or individual chosen by the individual receiving services, can assist in its completion; and Provide a copy of the program's complaint process for each individual: During the individual's orientation; and At any time upon an individual's request. A program shall include in the complaint process required by §A of this regulation the procedures for registering and responding to the complaints in a timely fashion, which: Require a complaint to be reviewed by the program and, if applicable, the CSA, within 30 calendar days of the program's receipt of the complaint; Allow participation by others designated by the individual; Allow information to be presented to support the individual's position; Ensure the participation of the program staff members who have the authority to implement corrective action; Require documentation of the substance of the complaints and the actions taken; Include a review which: Provides an opportunity, if the individual chooses, to have the individual's complaint reviewed by the CSA director or the CSA director's designee; Requires the program, before making a final determination, to collaborate with the CSA to address the individual's complaint; and Include written notification of the program's determination to: The individual who filed the complaint; and If the program's final determination conflicts with the CSA's opinion, the Administration. If the program's final determination conflicts with the CSA's opinion, the Administration may review the complaint as indicated. Unless the individual presents a serious risk to self or others, the program shall postpone taking action until the recommendations of the CSA and the Administration have been made, if applicable. If an individual has a grievance regarding the denial of services based on eligibility or medical necessity criteria, the individual may file the grievance according to the procedures outlined in COMAR 10.09.70.08. Health-General Article, §§10-901 and 10-902, Annotated Code of Maryland Effective date: January 2, 1995 (21:26 Md. R. 2187) Chapter revised effective October 5, 1998 (25:20 Md. R. 1530) Regulations .01 — .14 repealed and new Regulations .01 — .17 adopted effective January 14, 2008 (35:1 Md. R. 19) Regulation .17 amended effective October 6, 2008 (35:20 Md. R. 1775) This chapter applies to clinical programs that provide a combination of developmental and mental health services in a preschool setting, made accessible and available to children and the families of children who are at risk for or who are emotionally disturbed, who have behavior or adjustment problems, or both. The Department shall grant approval to an agency to be eligible to receive State funds for providing therapeutic nursery services if the agency meets the requirements of this chapter and COMAR 10.21.16, 10.21.17, and 07.04.02. In this chapter, terms have the meanings stated in COMAR 10.21.17 and this regulation. Terms Defined. “Individualized family service plan (IFSP)” means the plan defined in COMAR 10.09.40. “Learning center” means a designated area of a classroom that serves children in a therapeutic nursery and that is equipped specifically for the development of a particular skill, including, but not limited to, fine motor, gross motor, and socialization. “Primary caretaker” means the child's custodial parent or parents, or the adult with whom the child currently resides. “Program A” means a therapeutic nursery that provides services to children who are younger than 3 years old and whose primary caretakers are present on the site of the therapeutic nursery to participate in the treatment process with the child. “Program B” means a therapeutic nursery that provides services to children who are 3 years old or older, and younger than 5 years old. A provider of therapeutic nursery services shall ensure that services: Are appropriate to the cultural and psychosocial developmental needs of the child; Are provided: For a minimum of 3 hours per day, 3 days per week at each site; and In either a free-standing program or as an integral component of a preschool program in which services are offered in a therapeutic milieu; Are provided by staff who: As determined by the program, are appropriately credentialed and privileged; and Organize and manage the milieu to: Foster clinically appropriate social, intellectual, emotional, and physical growth; Handle aggression in a nonpunitive manner that promotes growth and learning; Reinforce the child's ability to function with peers in a social environment; Model and provide opportunities for children to behave in age-appropriate ways, such as: Being playful; Assuming responsibility for carrying out routine activities; Exhibiting independence and initiative in planning their own learning; Getting along with others; and Being courteous; Facilitate the child's awareness of appropriate behavior in a predictable, constructive, and timely manner; and Help children to make choices and to negotiate disagreements among themselves, rather than resolving conflicts for them; Are provided in an environment that: Is consistent with existent standards of program design; Is organized so that the child can function in an environment with a minimum of adult direction; Has space that facilitates the activities of each learning center allocated to each center; Has sufficient space and separation between learning centers so that children can engage in activities of their choice without distracting or being distracted by others; Provides materials that are available for children's use and are otherwise appropriately stored; and Displays exhibits of children's work that reflect children's current experiences, developmental level, diversity, and individuality; Are designed to develop or improve the ability of the primary caretaker to care for the child; and Maintain linkage with schools and preschool programs to effect transition at the appropriate time and with the necessary support services. Referral. A therapeutic nursery may accept a referral to the therapeutic nursery from: Education, social service, or health care agency staff; Family members; or Other interested individuals and agencies. Eligibility. A child is eligible for therapeutic nursery services if the child: Has or is at risk for a mild to severe mental disorder, as defined in the current Diagnostic and Statistical Manual of Mental Disorders, or mild to severe behavioral problems, or both; Is at risk for emotional or behavioral problems because the child: Is experiencing substantial developmental delay or atypical development which, if left untreated, is likely to impair severely the child's ability to function independently, as measured by diagnostic instruments and procedures that meet usual and customary practice standards, in one or more of the following areas: Cognitive development; Physical development; Language and speech development; Psychosocial development; or Self-help skills; Has experienced psychological trauma, as identified by an evaluation by a mental health professional; Has a diagnosed physical or mental condition which has a high probability of resulting in developmental delay; or Has been excluded, for developmental or behavioral problems, from more than one preschool or day care program; Is at risk for emotional or behavioral problems and is a child who is being assessed or has been assessed in a suspected child abuse or neglect investigation pursuant to Family Law Article, §5-701 et seq., Annotated Code of Maryland; or Is at risk for emotional or behavioral problems because of significant family history, as identified by an evaluation by a mental health professional. Admission. A therapeutic nursery program may admit a child: If the child is: For Program A, younger than 3 years old, and the primary caretaker is available to participate in the treatment process; or For Program B, 3 years old or older, but younger than 5 years old; Upon the written or tape-recorded consent of the child's parent or guardian; and For whom a physician orders therapeutic nursery services as medically necessary. A therapeutic nursery program may not admit a child: Whose primary or sole diagnosis or condition is: Mental retardation; Visual impairment; Hearing impairment; Physical disorder; or Technology dependence; or Who has cognitive deficits that severely limit the ability to benefit from the treatment modalities provided by the therapeutic nursery. Assessment. If a comprehensive developmental assessment has not been completed within the 90 days before admission, before the child's 6th visit, the therapeutic nursery staff shall assure the completion of an assessment, including, when appropriate, standardized measurement, that includes, at a minimum, an assessment of the following: Social and emotional development; Cognitive skills and deficits; Language development; Motor skills, fine and gross; Self-help and adaptive skills; Family history and evaluation; Home environment; Developmental history; Mental status; and Medical history and needs, if any. Diagnosis. Before the child's 6th visit, an individual qualified to diagnose under the provisions of Health Occupations Article, Annotated Code of Maryland, shall: Conduct a face-to-face evaluation of the child; Formulate and document a diagnosis; and Document the rationale for the diagnosis. Individual Treatment Plan (ITP). Treatment Team. At a minimum, the following individuals shall participate on a child's treatment team: At least one of the following: The therapeutic nursery physician; or A staff psychologist or psychologist consultant; At least one other mental health professional; All therapeutic nursery staff who are involved in providing services to the child and family; and If the therapeutic nursery is affiliated with an educational preschool program, the educational staff, as determined appropriate by the therapeutic nursery clinical director. Plan. Before the child's 6th visit, the therapeutic nursery treatment team, working cooperatively with the child's primary caretaker and classroom teacher, shall prepare an ITP that includes: The diagnostic formulation, as required by §B of this regulation; A description of the child's behavior that includes: Problem list; and Asset list; Goals and objectives stated in behavioral, measurable terms; Treatment strategies; Classroom interventions; Home interventions; For children in Program A, that portion of an IFSP, if any, that pertains to therapeutic nursery services; and As relevant, the information about the following from the child's parent, guardian, or primary caretaker, in consultation with appropriate health care or other service providers: Instructions for care in an emergency; History of allergies, including to medication; History of seizures; Medication prescribed; Nutritional requirements, limitations, and feeding procedures; and Essential medical or nonmedical treatments or procedures, including any advanced directives. Signatures on the ITP. The following shall sign the ITP: The treatment coordinator of the therapeutic nursery; The therapeutic nursery physician, staff psychologist, or psychologist consultant; If the child is receiving medication, the therapeutic nursery physician; If the individual who signs under the provisions of §C(3)(b) of this regulation is also the treatment coordinator, at least one other mental health professional; and Following review of the ITP, the parent, guardian, or primary caretaker. 45-Day Review. At a minimum of every 45 days: The treatment coordinator shall: Review the progress on the ITP; Document in the child's record a description of progress toward goals and changes in goals and interventions based on the review of progress under §C(4)(a)(i) of this regulation; and Update the ITP accordingly; and A minimum of two treating mental health professionals shall sign the 45-day review. 3-Month Review. Every 3 months, at a treatment team meeting, the: Treatment team shall review the ITP according to the process outlined in §C(4) of this regulation; Treatment coordinator shall update and sign the 3-month review; and Therapeutic nursery physician, staff psychologist, or psychologist consultant shall sign the ITP review. Continuing Evaluation. In order to ensure that services to a child are timely and appropriate, therapeutic nursery staff shall document in the child's record: As outlined in the policy and procedures manual, contact notes regarding all clinically relevant face-to-face, telephone, and written contacts with or about the child, including the dates, locations, and types of contacts; and Progress summary notes, entered at least monthly, by staff members involved in the child's treatment and classroom activities, regarding progress toward treatment goals. Therapies. The therapeutic nursery program shall provide the following therapies: If required by the ITP, individual therapy: With the therapeutic nursery mental health professional staff; With the community psychotherapist who is currently treating the child; or By referral; For children in Program A, conjoint therapy involving an individual child or groups of children with their primary caretakers; Milieu therapy that uses the environment as a tool to assist the child, in keeping with routine developmental expectations, to manage behavior and function appropriately and cooperatively with peers and adults. Daily Activities. The therapeutic nursery program shall implement, on a consistent, regular basis, a plan for daily activities that: Incorporate a variety of experiences with language, music, art, science, dramatic play, block play, and equipment and materials that promote large and small muscle development; Allow for self-selected and planned as well as individual and small group activities; and Include safe, regular, and developmentally appropriate outdoor play, with supervision consistent with the staff-to-child ratio required under Regulation .08D of this chapter. Services for Families. The therapeutic nursery program shall provide services to families, including but not limited to: As indicated by the ITP, counseling or therapy: With the therapeutic nursery mental health professional staff; With the community psychotherapist who is currently treating the child; or By referral; Orientation for parents, guardians, or primary caretakers to the specialized treatment interventions that are designed to facilitate the child's continued development; Mental health support groups; and Therapeutic home visits. Interagency Consultation and Referral. Services to Center. If the therapeutic nursery is included within another early childhood program, the therapeutic nursery staff shall provide those services to the early childhood program that the therapeutic nursery staff determine to be appropriate, including, but not limited to: Staff development and training; Mental health consultation regarding specific clinical interventions to be used in relating to therapeutic nursery children; Classroom consultation, including observation and feedback; and When necessary, psychoeducational strategic consultation. Referral Services. For those services indicated in a child's ITP and not provided by the therapeutic nursery staff, the program shall have a policy and procedure for referral for: Therapy, pursuant to §§A(1)(c) and C(1)(c) of this regulation; and Evaluative or support services, including but not limited to: Speech and language; Vision and hearing; Special instruction, special education, or other early intervention; Somatic care; Occupational therapy assessment and treatment; and Psychological testing. Not later than the date of admission, the therapeutic nursery program shall provide a written policy statement on discharge and transition procedures to parents, legal guardians, and primary caretakers. To the extent practicable, parents, legal guardians, or primary caretakers as well as referring agencies or professionals, and the continuing care providers shall participate in discharge and transition planning. Within 15 days of discharge, the therapeutic nursery staff shall complete a discharge summary in accordance with the provisions of COMAR 10.21.17.07D(3). With the consent of a parent or legal guardian as necessary, the therapeutic nursery program shall forward a copy of the discharge summary to the continuing care provider. Criteria for discharge include but are not limited to: Symptomatic alleviation; Achievement of treatment goals; Readiness for participation in off-site educational programs; or Inability of the enrollee or the primary caretaker, or both, to comply with program requirements. Based on the complexity of the services provided and the number of enrollees in the therapeutic nursery, a therapeutic nursery program shall provide sufficient staff to maintain the staff-to-child ratio provided in §E of this regulation and to carry out the therapeutic goals of the therapeutic nursery. Therapeutic Nursery Staff. A provider of therapeutic nursery services shall ensure that the therapeutic nursery staff includes, at a minimum: A program director who: Is a mental health professional or has a master's degree in a health services administration field; Is on a site of the therapeutic nursery at least 50 percent of the operating hours of the therapeutic nursery program; If a therapeutic nursery program operates in more than one site, has contact with each site each week; and Is responsible for operational oversight for, at a minimum: Fulfilling the administrative requirements under COMAR 10.21.17; Recruiting, hiring, and providing administrative supervision of staff; Developing and implementing the budget; Keeping the governing body informed of, at a minimum, the program's approval status and performance; and Recruiting and enrolling program participants; A clinical director who: Is a mental health professional; Is on a site of the therapeutic nursery at least 50 percent of the operating hours of the therapeutic nursery program; If a therapeutic nursery program operates in more than one site, has contact with each site each week; If the clinical director is also the program director, is on a site at the therapeutic nursery program on a full-time basis during the operating hours of the therapeutic nursery program; and Is responsible for oversight for, at a minimum, the following: Development of the ITP; Providing clinical supervision of staff, including the educational staff of a therapeutic nursery program that is not affiliated with an educational preschool program; Development of therapeutic strategies that may be used in the classroom; Development of treatment programs; Quality improvement; and Inservice training; A therapeutic nursery physician who: Has completed a residency in child psychiatry in an accredited program; As specified in the employment or consultant contract, is available on a therapeutic nursery site for the amount of time necessary to carry out the duties outlined in §B(3)(c) of this regulation, and, at a minimum: If 25 or fewer children are enrolled in the therapeutic nursery program, for a minimum of 2 hours per week; and For 1 additional hour per week for every additional one to ten children who are enrolled in the therapeutic nursery program; and Is responsible for, at a minimum, the following: Establishing and maintaining appropriate standards for treatment, including therapeutic modalities and prescribing practices; Unless carried out by other staff qualified under the provisions of Health Occupations Article, Annotated Code of Maryland, as required under the provisions of Regulation .05B and C of this chapter, diagnostic formulation and participation in the development and signing of the ITP and the ITP 3-month reviews; Clinical supervision of those cases requiring face-to-face medical review; Review of medication utilization and corrective feedback when utilization is found to be inappropriate; and Medical aspects of quality improvement; and A staff psychologist or psychologist consultant who: As specified in the employment or consultant contract, is available on the site or sites of the therapeutic nursery program for the amount of time necessary to carry out the duties outlined in §B(4)(b) of this regulation; and Is responsible for, at a minimum, the following: Unless carried out by other staff qualified under the provisions of Health Occupations Article, Annotated Code of Maryland, as required under the provisions of Regulation .05B and C of this chapter, diagnostic formulation and participation in the development and signing of the ITP and the ITP 3-month reviews; As needed, performing psychological assessment and testing; and Making appropriate referral for those cases requiring face-to-face medical review. Treatment Coordinator. The program director shall assign to each child who is admitted to a therapeutic nursery a treatment coordinator who is a mental health professional. Educational Staff. If the therapeutic nursery is not affiliated with an educational preschool program, the therapeutic nursery educational staff shall: Be sufficient to carry out the educational programs provided by the therapeutic nursery and the classroom strategies described in the ITPs; and Meet the qualifications required under COMAR 13A.09.09.05C. Staff-to-Child Ratio. The therapeutic nursery program shall ensure that the following required treatment or education staff-to-child ratio is maintained at all times: For Program A, a staff-to-child ratio of at least one staff member for every five enrollees; and For Program B: If the therapeutic nursery is not affiliated with an educational preschool program, a staff-to-child ratio of at least one staff member for every four enrollees; and If the therapeutic nursery is affiliated with an educational preschool program, a staff-to-child ratio of at least one therapeutic nursery treatment staff member for every 10 preschool children, provided that not more than four children are therapeutic nursery enrollees. In addition to the policy and procedure requirements outlined in COMAR 10.21.17.08, a therapeutic nursery program shall adopt policies and procedures for: Licensure by the Department of Human Services under COMAR 07.04.02; Physical setting, furnishings, materials, and equipment, as required by Regulations .10 and .11 of this chapter; Health and safety, as required by Regulation .12 of this chapter; and Transportation, as required by Regulation .13 of this chapter. Capacity. The Department shall determine the capacity of a therapeutic nursery based on: Space requirements under §C(1) of this regulation; Staff requirements, including the staff-to-child ratio, required under Regulation .08D of this chapter; and Maintenance of the therapeutic milieu described in Regulation .03B(2) of this chapter. The program director of the therapeutic nursery program shall limit the number of enrollees to the capacity applied for and approved by the Department. Requirements for the Building. The therapeutic nursery program shall operate the program in a building that conforms to the applicable federal, State, and local laws and regulations, including but not limited to: Zoning; Sanitation; Fire and safety codes; and The requirements of the Americans with Disabilities Act. Indoor Space. The therapeutic nursery program shall: For each child enrolled in the therapeutic nursery, provide a minimum of 35 square feet of floor space, not including spaces, such as vestibules and corridors, food preparation areas, bathrooms, adult work areas, and storage spaces, that are not available for the daily program activities of the children; and Provide suitable space for individual, family, group, and play therapies. Outdoor Space. The therapeutic nursery program shall ensure compliance with applicable State and local laws and regulations for outdoor space, including but not limited to water safety requirements. Materials and Equipment. In addition to any other requirements of law or regulation, the therapeutic nursery program shall: Provide a sufficient quantity and variety of materials and equipment for indoor and outdoor activities, according to the numbers and ages of the children enrolled, including materials and equipment for: Vigorous play; Creative or dramatic play; Socialization; Manipulation, including construction, exploration of art, music, language arts, and science; and Individual pursuits; Store materials and equipment so that they are accessible to a child at the appropriate time; and Ensure that the materials and equipment used by children in the therapeutic nursery are: Safe; Clean; Nontoxic; Free from hazards, including lead paint; In good repair; and Age appropriate. Furnishings. In addition to any other requirements of law or regulation, the therapeutic nursery program shall provide: Furnishings that are proportional to a child's size; and At least the following: Multipurpose tables and chairs; and A suitable crib, bed, cot, or mat and clean bedding for each child who requires a rest period during the hours of operation of the therapeutic nursery. Storage. In addition to any other requirements of law or regulation, the therapeutic nursery program shall: Provide storage for: Materials and equipment that are for a child's use; Portable equipment intended for outdoor use; Beds and bedding when they are not in use; Each child's clothing and possessions in a space designated for each child; and Materials, equipment, furnishings, and supplies being held in reserve; and Ensure that all potentially hazardous items, including knives, tools, poisonous and toxic materials, prescription and nonprescription medicines, cleaning materials, and matches, are stored: In a safe manner; When applicable, in original containers; and Out of the reach of children. The therapeutic nursery program director shall: Ensure that a criminal background investigation as required under Family Law Article, §§5-560 — 5-568, Annotated Code of Maryland, has been completed and is on file in each staff member's personnel record; If a child is involved in an accident or is injured while in attendance at a therapeutic nursery program: Notify the primary caretaker on the day that the accident or injury occurs; If the injury is serious, notify the parent or guardian immediately; Ensure that appropriate treatment is provided; and Document the incident according to the requirements of the risk management policy of the therapeutic nursery; At all times that children are participating in the therapeutic nursery program, ensure that staff are present who hold current certificates indicating approved training in: Infant and child cardiopulmonary resuscitation (CPR); First aid; and If wading or swimming are therapeutic nursery activities, Red Cross water safety; Prepare an emergency evacuation plan that: Is approved by the local fire authority; Is posted in each room of the therapeutic nursery; The staff and children practice at least monthly, and the staff maintain a written record of the dates and times of the practices; and Includes: Safe routes by which the staff and children may exit each area in the event of fire or other emergency requiring evacuation of the building; The address of a location that can be used by the staff and children in the event of fire or other emergency until the parents, guardians, or primary caretakers of the children are notified; and The provisions that, during an evacuation or a practice, a designated staff member take out of the building the record of attendance for that date and verify the presence of each child in attendance; Provide telephones that are accessible to the staff in each activity area in the therapeutic nursery, and post the following information next to each telephone: 911 telephone number to summon fire, police, and rescue services; The name, address, and telephone number of the therapeutic nursery; Telephone number of the child protective services unit of the local department of social services; and Telephone number of a poison control center; Release a child: Only to the child's parent, guardian, or primary caretaker; or If so directed by the child's parent, guardian, or primary caretaker, to another individual whose identity is verified; As required by COMAR 10.06.01: Report communicable diseases; and Restrict attendance by staff and children with communicable diseases; Not permit anyone to use alcohol or controlled dangerous substances on the premises or to smoke cigarettes, cigars, or pipes in rooms or areas approved for use by a child; Implement measures to prevent the spread of disease including requiring that staff wash hands and ensure that a child's hands are washed thoroughly with soap and water after toileting, before handling food, after outdoor activities, and at other times necessary to prevent the spread of disease; Provide for general cleanliness by ensuring that: All surfaces, furnishings, materials, and equipment are clean; Except for emergencies and clean-up activities that are part of the daily program, cleaning is not conducted while rooms are occupied by children; Refuse containers in the building are: Noncombustible; and If they contain soiled diapers, lined with a disposable liner, covered with a lid, and inaccessible to children; and Refuse containers outside the building meet the standards required by local code; and Provide written notification to each staff member and documentation that each staff member has read and understood the notification regarding: The location of the telephone and the emergency telephone numbers specified in §E of this regulation; The location of each child's emergency form; Emergency evacuation procedures; Identity of the staff members who have appropriate first aid, CPR, and Red Cross water safety training; Signs and symptoms of abuse and neglect; The requirements and procedures for reporting suspected child: Abuse directly to the local department of social services or law enforcement agency; and Neglect directly to the local department of social services; Risk management; and The contents of this chapter. If the therapeutic nursery provides transportation, the therapeutic nursery program shall ensure that: Vehicles used for the transport of therapeutic nursery enrollees are in compliance with the requirements outlined in Transportation Article, Title 22, Annotated Code of Maryland; Each driver: Possesses a valid Class D license; and Presents the driver's record, certified by the Motor Vehicle Administration, showing not more than two points, at the time of employment and annually after that; and In addition to the driver, at least one staff member is present in the vehicle to supervise the children at all times. Health-General Article, §§10-901 and 10-902, Annotated Code of Maryland Effective date: January 2, 1995 (21:26 Md. R. 2187) This chapter applies to programs organized to provide intensive, assertive mental health treatment and support services delivered by a multidisciplinary treatment team to an adult or a minor whose mental health treatment needs have not been met through routine, traditional outpatient mental health programs. Services are provided flexibly and in the various community settings determined by the needs of the individual. The purpose of mobile treatment services (MTS) is to enable the individual to: Remain in the community, thus reducing the individual's admissions to emergency rooms, inpatient facilities, or detention centers; and Achieve transition to less intensive outpatient services. In this chapter, terms have the meanings stated in COMAR 10.21.17. The Department shall grant approval to a program to be eligible to receive State or federal funds for providing MTS if the program meets the requirements: For approval outlined in COMAR 10.21.16; For administration outlined in COMAR 10.21.17; and Of this chapter. The program director shall assure that services: Are therapeutic and are age and culturally appropriate; Are provided by MTS staff who: As determined by the program, are appropriately credentialed and privileged; and Are available: As indicated in the screening assessment or the individual's ITP, to deliver services at a time and in a setting agreeable to the individual served; and On an on-call basis, 24 hours per day, 7 days per week; Engage an individual who is unable or unwilling to use traditional mental health services by: Using an assertive approach in making services available and acceptable to the individual by: Identifying and addressing stressors that the individual identifies as priorities; Developing creative individualized approaches in an effort to engage the individual in services; and Recognizing that establishing a therapeutic relationship may take place over an extended period of time; and Being sufficiently flexible to allow for the delivery of service in the setting and at the time that is appropriate for the individual's needs; Establish between the individual and the MTS staff a therapeutic relationship that includes mutual development of short-term and long-term goals for the individual; Respect the individual's privacy at the individual's residence by: Except in an emergency, notifying the individual, in advance, of the time that MTS staff will visit the individual's home; Having private conversations; Obtaining the individual's permission to bring anyone else to the individual's home; and If requested, terminating a home visit; and Assist the individual to interact with agencies and others to: Have access to services and entitlements necessary to support adequate living conditions; Maintain continuity of care by coordinating access to various treatment and rehabilitation services; Promote community participation by engaging in age-appropriate social and recreational activities; and Access housing, if necessary. Eligibility. An individual is eligible for MTS if: Based on a screening assessment conducted according to the provisions of §B of this regulation, the individual would benefit from services that are: Directed at providing mental health treatment; and Available, by being delivered at a site that is accessible to an individual who: Is homeless; Has been unable or unwilling to use, on a continuing basis, community-based mental health services that are prescribed for the individual; or Is in an institution or inpatient facility and would be able to reside in a community setting if the individual received MTS and other appropriate support services; and The services are preauthorized by the Administration's administrative services organization (ASO), according to the provisions of COMAR 10.21.17.02-1A. Screening Assessment. Within 10 working days of receipt of a referral for MTS, the MTS mental health professional who is assigned to conduct screenings shall: Conduct a face-to-face screening assessment with the individual referred to assess the individual's: Needs, strengths, and available resources; and Willingness to participate in MTS; Meet with the individual in the individual's home or at a site that is most appropriate to the individual's needs and preferences; As appropriate and with proper consent, meet with the family members and significant others designated by the individual; and Unless the individual is referred to the Administration's ASO for alternative services under §B(2) of this regulation: Determine priority for enrollment based on acuity of the individual's need; and Arrange an appointment for a psychiatric evaluation, as described under Regulation .05A of this chapter. If, following the screening assessment under §B(1) of this regulation, the program director determines that the program's services are not appropriate for an individual who has been referred, the program director shall, in writing, promptly: Inform the individual and, if the individual is a child, the parent or guardian, of the determination and the reason; With proper consent, notify the family or significant others designated by the individual of the determination and of any recommendations for other services; and Notify the CSA and the Administration's ASO for appropriate alternative referral. Admission. An MTS program shall admit an individual if the services are authorized, as needed, by the Administration's ASO, according to the provisions of COMAR 10.21.17.02-1A. Initial MTS Psychiatric Evaluation. Within 30 days of receipt of referral for MTS, the MTS psychiatrist, in collaboration with the individual's assigned treatment coordinator, shall conduct a face-to-face evaluation of the individual to: Collect and evaluate relevant history; Evaluate current mental status, including: The need for medication; and A review of current medications and source of prescriptions; Assess the individual's general physical health, and either: Perform a physical examination; Document a physical examination of the individual during the prior year; Refer the individual for a physical examination; or Waive the requirement that the individual have a physical examination and document the rationale for the waiver; Formulate and document the psychiatric diagnosis and the rationale for the diagnosis or affirm a psychiatric diagnosis that has been entered in the individual's MTS medical record; In collaboration with the individual: Identify the individual's needs, strengths, and goals; and Assess the individual's level of functioning and availability of family and other social supports; Document the rationale for the determination that MTS are medically necessary; and Develop an initial brief plan of care. Diagnosis. As required under §A(4) of this regulation, the MTS psychiatrist shall conduct the evaluation and formulate and document the psychiatric diagnosis or affirm a psychiatric diagnosis that has been entered in the individual's MTS medical record. An individual qualified to diagnose under the provisions of Health Occupations Article, Annotated Code of Maryland, may provide continuing psychiatric diagnosis. Individual Treatment Plan (ITP). Treatment Team. At least the following shall participate as members of an individual's MTS treatment team: The MTS psychiatrist or a third-year or fourth-year psychiatric resident who is supervised by the MTS psychiatrist; A licensed social worker; A registered nurse; The individual's treatment coordinator, as defined under Regulation .09 of this chapter; and When available, any other staff involved in providing services to the individual. Initial ITP. Before the 45th day after an individual is admitted to MTS, based on the screening assessment under Regulation .04B of this chapter and psychiatric evaluation under Regulation .05A of this chapter, the treatment team, under the direction of the treatment coordinator, in collaboration with the individual and, with proper consent, family members or significant others designated by the individual, shall prepare an ITP that includes: The psychiatric diagnosis; Description of the individual's current behavior and level of functioning that includes the individual's needs and strengths; When relevant to the individual, a description of the family's or significant others' needs and strengths; Short-term and long-term goals, including the plan for transitioning to traditional outpatient mental health services, that are outcome-oriented and that are stated in behavioral, measurable terms; Treatment strategies, including: Recommended type and frequency of interventions; The method of providing the services required under Regulation .06 of this chapter; and Target dates for goal achievement; and The designation of MTS staff responsible for implementing the elements of the plan. 3-Month ITP Review. At a minimum of every 3 months at a treatment team meeting, the individual's treatment coordinator, in collaboration with the individual, shall review the ITP and record in the individual's medical record: A description of progress toward the goals; Changes in goals and interventions based on the review of progress documented by the individual's treatment coordinator; and A statement validating the need for continued MTS. Signature of the ITP and ITP Reviews. The individual shall sign or tape record agreement or disagreement with the plan. The MTS psychiatrist and the individual's treatment coordinator shall sign the ITP and the ITP 3-month reviews. Continuing Evaluation. In order to ensure that services to an individual are timely and appropriate, the staff shall document in the individual's medical record: Contact notes, regarding all face-to-face and other clinically relevant contacts with or about the individual; and Progress summary notes, entered at least monthly by the individual's treatment coordinator, that include: A description of progress toward the goals; and Changes in goals and interventions based on the review of progress. Medication Services. Evaluation and Prescription. When prescribing medication for an individual, the MTS psychiatrist shall: Conduct a face-to-face evaluation of the individual; Through a medical history, evidence of a recent physical examination, records review, laboratory testing, or other appropriate measures, assure that there are no contraindications to the prescription of specific medications; Document in the individual's medical record the rationale for prescribing the medication; Explain to the individual or the individual's legal guardian both the benefits and the side effects of prescribed psychiatric medications before and, when appropriate, during treatment and document the explanation in the individual's medical record; and Order and monitor tests at medically recommended intervals and document the results in the individual's medical record. Administration. An individual licensed under Health Occupations Article, Annotated Code of Maryland, to administer medication may do so. A licensed practical nurse or a registered nurse may delegate the administration of medication only according to the provisions of COMAR 10.27.11. Monitoring. When required by the individual's ITP, a member of the treatment team credentialed and privileged to do so shall provide the following services: Supporting the individual's self-administration of prescribed medication; To the extent possible, monitoring compliance with instructions appearing on the label; Reading the label to ensure that each container of medication is clearly labeled with the individual's name, the contents, directions for use, and expiration date; Ensuring that each individual has secure, appropriate, and accessible space in which to store medications; Observing and documenting any apparent reactions to medication and, either verbally or in writing and in a timely fashion, communicating to the prescribing authority any problems that possibly may be related to the medication; and Reinforcing education on the role and effects of medication in symptom management. Education Regarding Medication. As required by an individual's ITP, a nurse, a physician, or other privileged and credentialed staff shall educate the individual and, with the individual's consent, the individual's family or significant others, by: Verifying the individual's understanding of the directions for administration of medication; and Providing information regarding: The role, effects, and importance of medication in symptom management; Expected benefits and expected side effects of prescribed medication; and Nutritional and dietary expectations and risks related to the individual's medication regimen. Independent Living Skills Assessment and Training. The MTS staff shall: In collaboration with the individual, assess the individual's level of functioning in the areas of: Community living skills, including but not limited to: Mobility training; and Money management; Activities of daily living, including: Meal planning and preparation; Personal hygiene; and Grooming; and Interpersonal and socialization skills, including: Communication; and Leisure and social activities; and Based on the assessment conducted under §B(1) of this regulation, provide rehabilitation activities to assist with and facilitate the individual's acquisition and improvement of independent living skills. Health Promotion and Training. To supplement and support the somatic health care provided by an individual's primary health care provider, the MTS psychiatrist or registered nurse shall carry out health promotion activities, including but not limited to: Monitoring of a chronic medical condition that is managed by a primary health care provider, including: Teaching on illness prevention and wellness maintenance; and Reinforcement of instructions given by the primary health care provider; Evaluating an acute problem to determine the most appropriate health care provider and referring the individual to the provider; and Assisting an individual to understand and carry out health-care-related behaviors, including activities related to diagnostic testing preparation and prescribed treatment for acute and short-term illness. When indicated in the individual's ITP, MTS staff shall provide basic health teaching in the following areas: Nutrition; Exercise; Dental care; Substance abuse prevention; and Prevention of injury and illness at home and in the community. MTS staff credentialed and privileged to do so shall provide training in communicable disease prevention, including prevention of sexually transmitted diseases and bloodborne pathogens, including HIV/AIDS. Interactive Therapies. MTS staff shall provide, as required in the individual's ITP, therapies, including individual, group, and family therapy focused on: Assessment and definition of problems; Planning and goal setting; Development of effective problem-solving techniques; Evaluation of progress; and Other issues raised by the individual. Crisis Intervention Service. The MTS treatment team shall provide to an individual who is receiving MTS a crisis intervention service that is: Designed to be implemented in the event of a crisis in the home or other setting in which the individual is involved; Explained in terms understandable to the individual; and Available, on an on-call basis, 24 hours per day, 7 days per week. Support, Linkage, and Advocacy. The MTS treatment team shall assure appropriate coordination with community and family resources that are considered essential to meeting the individual's identified needs, including but not limited to intervention and advocacy with: MTS staff and other community mental health and rehabilitation service providers; Mental health clinic and psychiatric rehabilitation programs; Social service agencies; Courts and detention centers; Providers of needed medical and dental services; Immediate and extended family members; For school age children, the educational system; and Recreational activities. Housing Development. The program director shall ensure that the program: Collaborates with the CSA in developing the CSA's plan for affordable, accessible housing in the community; Maintains information about available regular housing that is: Integrated throughout the community; Not limited as to length of stay, or conditional upon an individual's participation in mental health treatment or support services; and Within the price range that is affordable to individuals enrolled in the program; and In conjunction with the CSA: Attempts to develop financial resources to assist an individual temporarily in such circumstances as an individual's hospitalization or loss of job, benefits, or housemate; and Establishes priorities by which housing financial resources are allocated to individuals. Housing Needs Assessment. The program director shall ensure that program staff, in collaboration with the individual, conduct an assessment of: The individual's housing needs; and If the individual does not have housing that the individual considers adequate, the rehabilitative skills that the individual needs to obtain the housing of choice. Accessing and Sustaining Housing. The program director shall ensure that the program provides, as needed by and acceptable to the individual, services that are directed at: Assisting an individual in making choices about where and with whom to live by developing or restoring the basic social and living skills needed to: Link, when interested, with other individuals with similar interests and housing requirements; Evaluate financial resources, available natural supports, and needed and desired community services; Locate available properties and, when interested, negotiate acquisition; and Secure available financial entitlements and U.S. Department of Housing and Urban Development Section 8 and other types of housing financial assistance; Developing or restoring appropriate basic living skills and supports to keep housing, such as: Responsibilities for upkeep of the property and personal belongings; Maintaining an adequate supply of food and household goods; Development of community resources and natural supports; Housemate conflict resolution; and Landlord-tenant negotiations regarding such issues as rent, needed repairs, and complaints; and Additional support, as determined by the individual's need. Discharge Procedures. An MTS program may discharge an individual from MTS only when: The individual: Is unwilling to continue to accept MTS; Is admitted to an inpatient facility for longer than 3 months; or Moves from the area served by MTS; or The Administration's ASO determines that transition and discharge from MTS is medically appropriate. When an MTS program discharges an individual under §A(1)(a)(i) or (ii) of this regulation, the MTS program shall, as authorized: Permit the individual to re-enroll in MTS; and Make assertive efforts to re-enroll the individual. When an MTS program discharges an individual under §A(1)(a)(iii) of this regulation, the MTS program shall, when possible and as authorized, refer the individual for appropriate mental health and support services in the individual's community. When transition and discharge from MTS is authorized under §A(1)(b) of this regulation, the MTS treatment coordinator, in collaboration with an individual, shall: Document the individual's: Achievement of treatment goals; Anticipated needs for treatment and rehabilitation services; and Readiness for participation in outpatient mental health clinic (OMHC) or other appropriate outpatient mental health services, as demonstrated by keeping appointments, using transportation independently, obtaining and taking prescribed medications, and actively participating in treatment; and In consultation with the Administration's ASO, prepare a transition plan, according to the provisions of §B of this regulation. Transition Services. When the Administration's ASO authorizes a transition plan, the individual's treatment coordinator, in consultation with the Administration's ASO, shall: Arrange transition services in collaboration with: The individual; The treatment team; As appropriate and with proper consent, family members and significant others designated by the individual; and Designated transition service providers; Provide authorized MTS transition services, refer the individual for other appropriate services, and arrange to initiate authorized services before a planned discharge; With proper consent and as authorized by the Administration's ASO, facilitate the individual's transition to other appropriate services by: Inviting the designated provider or providers of mental health services to whom the individual has been referred to participate in the transition planning; Forwarding to the provider or providers a copy of the transition and discharge plan; and For a period of time based on the individual's needs, periodically meeting with the individual and the provider or providers, as necessary to facilitate transition; If the individual does not successfully complete transition, arrange, if authorized by the Administration's ASO, for the continuation of MTS; and Complete a discharge summary in accordance with COMAR 10.21.17.07D(3). A provider of MTS shall ensure that the MTS staff includes, at a minimum: A program director who: Is a mental health professional; Is available to provide MTS administration and supervision: If fewer than 40 individuals are receiving services, for an amount of time calculated on the basis of 1/2 hour per week for each individual who is receiving services; or If 40 or more individuals are receiving services, 20 hours per week; Is responsible for operational oversight for, at a minimum: Fulfilling the administrative requirements under COMAR 10.21.17 and the day-to-day clinical responsibilities for MTS; Recruiting, hiring, training, and supervising staff; Developing and implementing the budget; Keeping the governing body informed of, at a minimum, the program's approval status and performance; Ensuring that MTS are available to the individual, if needed, 24 hours per day, 7 days per week, and establishing on-call responsibilities; Ensuring continuity of care during the time that an individual is receiving MTS by evaluating caseloads and coordinating staff schedules; and Ensuring that transition services are provided; and May carry out any of the clinical and training duties of a mental health professional or other MTS staff; A psychiatrist who: Is involved, for an amount of time calculated on the basis of at least 1/4 hour per week for each individual who is receiving services, in: Consultation with MTS staff; and Evaluating and providing MTS; Ensures that MTS are provided in accordance with accepted standards of medical practice; Following a screening evaluation of an individual completed under Regulation .04B of this chapter, has an initial face-to-face contact with the individual, as required under Regulation .05A of this chapter, to: Formulate and document the psychiatric diagnosis or affirm a psychiatric diagnosis that has been entered in the individual's MTS medical record; Assess medical needs; Confirm the medical necessity of MTS; When appropriate, order MTS for the individual; and Authorize the initial ITP; Is responsible for, at a minimum, the following: Evaluating the individual, face-to-face, at least every 3 months; As required under the provisions of Regulation .05C of this chapter, participating in the development, required periodic review, and signing of an individual's ITP; Prescribing medication and providing other medication services outlined in Regulation .06A of this chapter; Providing the appropriate treatment indicated in the individual's ITP; and Supervising psychiatric residents, if any, who provide MTS, including, if duties are delegated, providing, at least monthly, a review of the status of the individuals whom the resident is treating; May delegate the following duties to a third-year or fourth-year resident of an accredited program in psychiatry: Except for the initial 3-month evaluation, the periodic evaluations required under §B(4)(a) of this regulation; Participation in the development, required periodic review, and signing of an individual's ITP, required under §B(4)(b) of this regulation; If the resident is a licensed physician, prescribing medication and providing other medication services, as provided under §B(4)(c) of this regulation; and As provided in §B(4)(d) of this regulation, providing the appropriate treatment indicated in the individual's ITP; and May not delegate: The initial psychiatric evaluation; Formulation and documentation of the psychiatric diagnosis or affirmation of a psychiatric diagnosis that has been entered in the individual's MTS medical record; or Ordering of MTS for an individual; A registered nurse who: Is licensed under the provisions of Health Occupations Article, Title 8, Annotated Code of Maryland; Participates in MTS for an amount of time calculated on the basis of at least 1 hour per week for each individual who is receiving services; and As permitted under Health Occupations Article, Annotated Code of Maryland, performs assigned duties that the nurse is credentialed and privileged to perform, including but not limited to: Medication administration and other medication services outlined in Regulation .06A of this chapter; and Health promotion and training, as outlined in Regulation .06C of this chapter; At least one social worker who: Is licensed under the provisions of Health Occupations Article, Title 19, Annotated Code of Maryland; and As permitted under Health Occupations Article, Annotated Code of Maryland, performs assigned duties the social worker is credentialed and privileged to perform, including but not limited to: Interactive therapies, as outlined in Regulation .06D of this chapter; Support, linkage, and advocacy, as outlined in Regulation .06F of this chapter; and Discharge and transition services as outlined in Regulation .07 of this chapter; and At least one mental health professional who: May include the staff identified in §§C and D of this regulation; and As permitted under Health Occupations Article, Annotated Code of Maryland, performs assigned duties that the mental health professional is credentialed and privileged to perform, including but not limited to: Conducting the screening evaluation required under Regulation .04B of this chapter and participating in the initial psychiatric evaluation required under Regulation .05A of this chapter; According to the provisions of Regulation .05C of this chapter, reviewing and signing an individual's ITP; The duties outlined in Regulations .06 and .07 of this chapter that the mental health professional is licensed or credentialed and privileged to perform; When credentialed and privileged by the program to do so, functioning as the treatment coordinator for individuals who are receiving MTS; Supervising direct service providers; and Assuring that, before the provision of MTS and, as needed, on an in-service basis, appropriate training is provided to direct service providers. The program director shall assign to each individual who is receiving MTS a mental health professional who is the individual's treatment coordinator, and who shall: Assess the individual's needs by: Collaborating in the initial psychiatric evaluation conducted according to the provisions of Regulation .05A of this chapter; and Collecting and evaluating relevant history; Establish and maintain a therapeutic relationship; Direct the development of the ITP and required periodic updates, as outlined in Regulation .05C of this chapter; Ensure appropriate linkage with treatment services by providing: Outreach, which includes: Meeting with the individual in the individual's home or at a site that is most appropriate to the individual's needs and preferences; and Crisis intervention; Advocacy, which includes assisting the individual to acquire treatment and rehabilitation services acceptable to the individual and entitlements, housing, and other basic necessities; and Coordination of service plans with other agencies and providers; Monitor the progress of the individual by: Conducting periodic assessments of the individual's living situation; Conducting face-to-face assessments of the individual's mental status, including the individual's: Appearance; Behavior; Affect; Thought processes; Judgment; and Insight; and Maintaining progress summary notes, as required under the provisions of Regulation .05D(2) of this chapter; As required by the individual's ITP, provide interactive therapies delineated under Regulation .06D of this chapter; and When appropriate, recommend discharge and prepare, with the individual, a discharge plan, according to the provisions of Regulation .07 of this chapter. As needed, based on the number of individuals served, the program director may include on the MTS staff direct service providers who: May include the staff identified in Regulation .08C and D of this chapter; and As permitted under Health Occupations Article, Annotated Code of Maryland, perform assigned duties that the direct service provider is credentialed and privileged to perform. A provider of MTS shall base the capacity of the MTS program on the basis of one full-time treatment staff person for each 12 individuals served. Health-General Article, §§10-901 and 10-902, Annotated Code of Maryland Effective date: January 2, 1995 (21:26 Md. R. 2188) Regulation .01C repealed effective August 24, 1998 (25:17 Md. R. 1360) Regulation .02-1 adopted effective August 24, 1998 (25:17 Md. R. 1360) Regulation .03F amended effective August 24, 1998 (25:17 Md. R. 1360) Regulation .04 amended effective August 24, 1998 (25:17 Md. R. 1360) Regulation .05 amended effective August 24, 1998 (25:17 Md. R. 1360) Regulation .06-1 adopted effective August 24, 1998 (25:17 Md. R. 1360) Regulation .07 repealed and new Regulation .07 adopted effective August 24, 1998 (25:17 Md. R. 1360) Regulation .08A amended effective August 24, 1998 (25:17 Md. R. 1360) This chapter applies to programs that provide mental health treatment services to individuals on an outpatient basis. In this chapter, terms have the meanings stated in COMAR 10.21.17. The following applicants shall be eligible for approval as an outpatient mental health center (OMHC), if the applicant demonstrates experience providing mental health services for a minimum of 1 year: A group practice; or A program currently approved under another Mental Hygiene Administration community mental health program chapter. The Department shall grant approval to a program to be eligible to receive State or federal funds for providing services if the program meets the requirements: Outlined under §A of this regulation; For approval outlined in COMAR 10.21.16; For administration outlined in COMAR 10.21.17; For Medical Assistance providers outlined in COMAR 10.09.36, 10.09.59, and 10.09.70; and Of this chapter. An outpatient mental health center (OMHC) shall provide services that are: Age and culturally appropriate; Coordinated with other components of the service delivery system; and Focused on recovery and resiliency. An OMHC shall ensure that clinical services are only rendered by mental health professionals who are authorized under Health Occupations Article, Annotated Code of Maryland, and appropriately credentialed by the program to perform the service. An OMHC shall ensure that the services required under this chapter are accessible and available: At least 40 hours per week; During some weekend and evening hours; and For emergency coverage, 24 hours per day, 7 days per week as specified in Regulation .08F of this chapter. An OMHC shall: Have a facility that: Meets all relevant federal, State, or local ordinances, laws, regulations, and orders governing the program; Is not located in a private residence; Is accessible to the public; and Contains a secure area where records, logs, and business information may be kept; and Prominently display the hours of operation of the facility or office. Intensive Outpatient Services. An OMHC may provide short-term, intensive outpatient services. If an OMHC provides intensive outpatient services, the services shall: Be delivered by a multidisciplinary team for a minimum of 3 hours of therapeutic services per day; and Include: At least two group therapies; and Physician services as needed. For individuals receiving intensive outpatient services, the individual's ITP shall be reviewed weekly by the individual and the individual's treatment coordinator. Eligibility. An individual is eligible for services through the public mental health system (PMHS) if the services are preauthorized, if required, by the Administration's administrative services organization (ASO), according to the provisions of COMAR 10.21.17.03A. In addition to those individuals described in §A(1) of this regulation, an OMHC may provide services to other individuals who wish to contract privately for services. If an OMHC provides services to an individual described in §A(2) of this regulation, an OMHC may not seek reimbursement by the PMHS for providing services to that individual. Screening Assessment. An OMHC licensed mental health professional, in collaboration with the individual referred, shall conduct a screening assessment to assess the individual's goals for recovery, strengths, available resources, and treatment needs: Within 5 working days of receipt of a referral from an inpatient facility for OMHC services; or By the date established under §B(2) of this regulation for all other referrals. For referrals that are not from an inpatient facility, the program director shall: In collaboration with the medical director, establish a procedure to review clinical acuity as described by the referral source; Based on the review of clinical acuity described in §B(2)(a) of this regulation, establish the date for a screening assessment; and Inform the individual of: The date established for the screening assessment; or If, due to program capacity, there will be a delay in the screening assessment, a tentative time frame for services. If, following the screening assessment under §B(1) of this regulation, the OMHC program director, or licensed mental health professional designated by the program director, determines that the OMHC's services are not appropriate for an individual referred, the OMHC shall advise the individual and, if appropriate, notify the ASO and CSA. Enrollment. Unless an individual has been determined to be clinically inappropriate for services under the provisions of §B(3) of this regulation, an OMHC shall: Initiate evaluation and treatment services for an individual who has been referred from an inpatient facility, within 5 working days of the screening assessment conducted under §B(1) of this regulation; or For all other referrals screened under §B(2) of this regulation, the program director shall: In collaboration with the medical director, establish a procedure to review clinical acuity as described by the referral source; Assign priority for OMHC services based on clinical acuity; Inform the individual of: The estimated date evaluation and treatment services may be initiated; and If, due to program capacity, there will be a delay in the initiation of treatment services, alternative services that are available. Orientation. The program director shall ensure that an individual who has been enrolled in the OMHC, or if the individual is a minor, the minor's parent or guardian, receives an orientation as outlined in COMAR 10.21.17.04B. Assessment and Diagnosis. The medical director shall ensure that an appropriate licensed mental health professional shall, by the individual's second visit and based on the initial face-to-face diagnostic evaluation of the individual: Formulate and document in the individual's medical record information that includes: A description of the presenting problem; Relevant history, including family history and somatic problems; Mental status examination; and A diagnosis and the rationale for the diagnosis; or Document: The reason for not formulating a diagnosis; and A plan, including time frame, for formulating a diagnosis. Co-Occurring Substance Abuse Screening Assessment. The face-to-face diagnostic assessment conducted under §A of this regulation shall include a screening assessment, using a scientifically validated, and if available, age appropriate tool, to determine whether the individual has a co-occurring substance abuse disorder. Additional Assessment for a Minor. In addition to the requirements outlined in §A of this regulation, before a minor's fifth visit, the minor's assigned treatment coordinator shall: Conduct a face-to-face evaluation with the minor to assess the minor's level of functioning and availability of family and other social supports; and If a comprehensive assessment, that includes the elements listed in §C(2) of this regulation, has not been completed within the 6 months before enrollment, assure the completion of an assessment, that includes, at a minimum, the minor's: Developmental history; Educational history and current placement; Home environment; Family history and evaluation of the current family status, including legal custody status; Social, emotional, and cognitive development; Motor, language, and self-care skills development; History, if any, of substance abuse; History, if any, of physical or sexual abuse; History, if any, of out-of-home placements; and Involvement, if any, with the local department of social services or Department of Juvenile Services. Review of Somatic Status. According to the provisions described in §D of this regulation and upon an individual's enrollment into the program, an appropriate licensed mental health professional shall document in the individual's medical record: Pertinent past and current somatic medical history including: The individual's somatic health problems, if any, including but not limited to allergies, neurologic disorders, and communicable diseases; Relevant medical treatment, including medication; and A recommendation, if any, for somatic care follow-up; If the individual does not have a primary care provider, the plan, if indicated, including the time frame, for the individual's referral to a primary care provider for evaluation and treatment; and An exchange of medical information with the primary care provider. With proper consent and if clinically indicated, the individual's treatment coordinator shall maintain and document ongoing collaboration and coordination with the individual's primary care provider. Individual Treatment Plan (ITP). Initial ITP. Not later than the fifth visit after an individual is enrolled in an OMHC and based on the assessment conducted under Regulation .05B of this chapter, the treatment coordinator and the individual, and if the individual is a minor, the minor's parent, guardian, or primary caretaker if appropriate, shall develop an ITP in collaboration with: With proper consent, family or others designated by the individual, and others involved in the individual's care; and Other OMHC staff, as appropriate. The ITP shall include, at a minimum: The individual's diagnosis; The individual's presenting needs, strengths, recovery, and treatment expectations and responsibilities; A description of needed and desired treatment and interventions to be provided, specifying the modality, frequency, and responsible staff; A description of how the needed and desired treatment will help the individual to manage the individual's psychiatric disorder and to support recovery; Short-term and long-term treatment goals in measurable terms and target dates for each goal; and If appropriate, identification of, referral for, and collaboration with other services or child service agencies and providers to support the individual's treatment and recovery, including but not limited to mental health residential services, psychiatric rehabilitation services, self-help organizations, vocational programs, substance abuse services, the local department of social services, the local department of juvenile services, schools, and somatic care. The content of the ITP shall be communicated to: Relevant program staff; and With proper consent, family or others designated by the individual and, if applicable, community mental health programs providing services to the individual. ITP Review. As frequently as necessary, as determined by the individual and the individual's treatment coordinator, and at a minimum of every 6 months, the individual and the treatment coordinator shall: Review the ITP with the individuals identified under §A(1) of this regulation; Based on the review, record in the individual's medical record: An assessment of the individual's progress toward the accomplishment of previously identified treatment goals that incorporates the perspective of the individual served; Goal changes based on a review of progress; Changes in treatment strategies; and Changes in diagnosis, if any; and Communicate the results of the treatment plan review to: Relevant program staff; With proper consent, substance abuse treatment providers and primary care provider, as appropriate; With proper consent, family or others designated by the individual and community mental health programs providing services to the individual. Signature of the ITP and Reviews. Except as provided in §A(3)(b) of this regulation, the individual shall sign agreement with the plan and reviews. If the individual is unwilling to sign agreement with the plan and reviews, the individual's treatment coordinator shall: Verify the individual's verbal agreement with the plan and reviews; and Document the rationale for the individual's refusal to sign. If the individual is a minor, the minor's parent or guardian, or if other than the minor's parent or guardian, the minor's primary caretaker shall sign agreement with the plan and reviews. With proper consent, family or others designated by the individual, including the individual's caregivers, may sign the plan and reviews. At least two licensed mental health professionals who collaborate about the individual's treatment, shall sign the plan and reviews. If the individual is receiving medication prescribed through the OMHC, an OMHC psychiatrist, or Certified Registered Nurse Practitioner in psychiatry, whomever prescribes the medication, shall sign the plan and reviews. Upon completion of an ITP or ITP review, an individual's treatment coordinator shall assure that the individual is offered a copy of the plan or review and document the individual's acceptance or decline of the offer in the individual's medical record. Individual Treatment and Rehabilitation Plan (ITRP). Staff may combine the required elements of an ITP and IRP in one document, the ITRP. Continuing Evaluation and Treatment. Contact Note. Staff shall document each contact with the individual, including, at a minimum: The date; The start time and either the duration or the end time; The individual's chief medical complaint or reason for the visit; The individual's mental status; The delivery of services specified by the ITP; A brief description of the service provided; The plan for changes in treatment, if any; The individual's progress toward treatment goals; and A legible signature, which may include an electronic signature, and printed or typed name of the licensed mental health professional providing care, with the appropriate title. The treatment coordinator shall document any significant changes or events, including hospitalizations, that affect the individual's treatment. The treatment coordinator shall ensure that the individual's needs and progress are communicated to: Staff involved in the implementation of the ITP; and With proper consent: Community mental health programs providing services to the individual; and Family or others designated by the individual. An OMHC shall have the capacity to provide the treatment services outlined in §§B — F of this regulation as required by the individual's ITP. Mental Health Treatment. The program director shall ensure that licensed mental health professionals provide mental health treatment including: Individual therapy; Family therapy; and Group therapy. Psychological Evaluation and Testing. The program director shall ensure that, if medically necessary and required by an individual's ITP, the OMHC provides psychological evaluation and testing by a staff psychologist or psychologist consultant, or by referral. Co-Occurring Substance Abuse Treatment. The program director shall ensure that the program provides substance abuse treatment as a component of its mental health program for individuals with secondary co-occurring disorders or has a written plan to coordinate mental health services with a certified substance abuse program if necessary. If the assessment conducted under Regulation .06B of this chapter indicates that the individual has a secondary co-occurring substance abuse disorder, the individual's treatment plan and progress notes shall: If the program is providing substance abuse treatment, reflect the course of treatment relative to the disorder; or If the program is not providing substance abuse treatment, with proper consent and if indicated, include documentation of coordination of care and collaboration with the provider of substance abuse services. Medication Services. The medical director shall ensure that appropriate staff are trained and updated on the use, effect, interactions, and potential side effects of medication used by individuals served by the program. Appropriate licensed mental health professionals shall, as clinically indicated, provide the following services: Prescription; Administration; Monitoring; and Education regarding medication. Prescription. Staff identified under §E(2) of this regulation shall: When initially prescribing medication for an individual: Conduct a face-to-face evaluation of the individual; Assess whether there are contraindications to prescription of specific medications; Involve the individual in the choice of medication; Document in the individual's medical record the rationale for prescribing the medication; Explain the benefits and possible side effects of taking or not taking prescribed psychiatric medications and document the explanation; With proper consent and if appropriate, promptly notify anyone responsible for administering or monitoring medication, of the medication regimen; and With proper consent and if clinically indicated, notify the individual's primary care physician of medication prescription, if any; and If managing medication on an ongoing basis: At a minimum of every 90 days, evaluate the individual face-to-face; Alter medications and adjust dosage as clinically indicated; Document the rationale for the current prescription; Order and monitor tests at medically recommended intervals and document results in the individual's medical record; Educate the individual and others designated by the individual about prescribed medications, including the name of medication, dosage, frequency, proper storage, expected results, and potential side effects; With proper consent and if appropriate, promptly notify anyone responsible for administering or monitoring medication, of any changes in the medication regimen; and Notify the individual's primary care physician every 6 months of medication changes, if any. On-Call and Crisis Intervention Services. The program director shall ensure that on-call and crisis intervention services are provided by a program's licensed mental health professional to an individual who has been enrolled in the OMHC: Face-to-face during the 40 hours that the OMHC is open; or By telephone, on an on-call basis, 24 hours per day, 7 days per week, during the hours the OMHC is not open: Through the OMHC; or By written agreement with another OMHC or mental health crisis service provider. If clinically appropriate, a crisis response plan or an advance directive for mental health services shall be developed and documented in the medical record, that: An individual and, if the individual is a minor, the primary caretaker may implement in the event of or to prevent a crisis at home, school, work, or other setting in which the individual is involved; and Is stated in terms that the individual and, if involved, the primary caretaker understand. In combination with one or more of the treatment services outlined in Regulation .08 of this chapter, an OMHC shall have the capacity to provide, as required by an individual's ITP, the support services outlined in §§B — E of this regulation. Referral Services. The program director shall ensure that the OMHC provides recommendations and referral, if appropriate, for: Psychiatric rehabilitation and support services; Somatic care; Speech and language services; Vision and hearing services; Special instruction, special education, or other educational interventions; Occupational therapy; Self-help organizations; and Substance abuse services. Education Regarding Medication. A nurse, a physician, or other appropriate licensed mental health professional shall educate the individual, and with proper consent, the individual's family or others designated by the individual, by: Verifying the individual's understanding of the directions for administration of medication; and Providing information regarding: The role, effects, and importance of medication in symptom management; Expected benefits and potential side effects of prescribed medication; and Nutritional and dietary expectations and risks related to the individual's medication regimen. Case Coordination Services. If indicated, the treatment coordinator shall support the individual to: Apply for all applicable entitlement programs; and Access other needed services and resources, as appropriate. Linkage with an Individual in a Psychiatric Facility, RTC, RCS Program, or Detention Center. The program director shall maintain written policies and procedures, which may be contained in one document, for the purpose of continuity of care when individuals receive mental health services in more restrictive settings. Required Staff. The OMHC shall have staff that is sufficient in numbers and qualifications to provide clinically appropriate services to the individuals served and includes, at a minimum: A program director who is: A licensed mental health professional, or has a master's degree in one of the following fields: Mental health; Health services; or Business administration; Employed by the OMHC at least 20 hours per week; and Responsible for administrative oversight of the OMHC, including, at a minimum: Fulfilling the administrative requirements under COMAR 10.21.17; Fulfilling the requirements of this chapter; Ensuring the continuity of service if clinical staff at the OMHC site are unavailable to fulfill their responsibilities to the individuals served; Ensuring a system of clinical supervision of the multidisciplinary treatment staff; and Having knowledge of all regulatory requirements related to the operation of the program; A medical director who: Is a psychiatrist; Is employed by and is on site at the OMHC at least 20 hours per week; If employed full time by the program, may also serve as program director; and Has overall responsibility for clinical services, including, at a minimum: Establishing and maintaining appropriate standards for diagnosis and treatment, including therapeutic modalities and prescribing practices; Medical aspects of quality management; Adequate physician coverage; and Ensuring adequate clinical supervision of treatment staff; A multidisciplinary licensed mental health professional staff that: Provides evaluation and treatment services; Is in addition to the OMHC psychiatrist; and Includes representatives of two different mental health professions both of which are represented on-site 50 percent of the OMHC's regularly scheduled hours. Students. The program may use students according to the provisions of COMAR 10.21.17.12E. Volunteers. The program may use volunteers according to the provisions of COMAR 10.21.17.12F. An OMHC program that operates multiple sites shall assure that each additional site adheres to the application modification as outlined in COMAR 10.21.16.04E. The program director and the medical director shall, on a routine basis, and as clinically required, provide on-site consultation at each site to ensure adequate clinical and administrative oversight. The program shall designate for each additional OMHC site: A clinical coordinator who: Is a licensed mental health professional with demonstrated competency in clinical supervision; Is located at each additional OMHC site for 50 percent of the site's regularly scheduled hours; Has regular, direct access to the medical director and all clinical and administrative resources of the OMHC; and Provides clinical oversight of the individuals served; A psychiatrist who: Need not be the medical director of the OMHC; and Is on-site according to the needs of the individuals served; and A multidisciplinary licensed mental health professional staff that: Provides evaluation and treatment services; Is in addition to the OMHC psychiatrist; and Includes representatives of two different mental health professions both of which are represented on-site 50 percent of the OMHC's regularly scheduled hours. Staff at each additional OMHC site shall have direct access to the program director, the medical director, and all other clinical and administrative resources of the OMHC as needed. Health-General Article, §§10-901 and 10-902, Annotated Code of Maryland Effective date: February 13, 1995 (22:3 Md. R. 153) Chapter revised effective November 16, 1998 (25:23 Md. R. 1696) Regulations .01 — .08 repealed and new Regulations .01 — .11 adopted effective January 14, 2008 (35:1 Md. R. 19) Regulation .07B amended effective April 29, 2013 (40:8 Md. R. 724) This chapter outlines the service requirements and staffing standards for a psychiatric rehabilitation program (PRP) that provides psychiatric rehabilitation services to an adult at the program site or at an off-site location, including a residential rehabilitation program, appropriate to the individual's needs. In this chapter, terms have the meanings stated in COMAR 10.21.17. The Department shall grant approval to a program to be eligible to receive State or federal funds for providing PRP services if the program meets the requirements: For approval outlined in COMAR 10.21.16; For administration outlined in COMAR 10.21.17; and Of this chapter. A provider of PRP services for adults shall: Have a facility or office that: Meets all relevant federal, State, or local ordinances, laws, regulations and orders governing the program; Is not located in a private residence; Is accessible to the public; and Contains a secure area where records, logs, and business information may be kept; and Prominently display the hours of operation of the facility or office. The program director shall organize program services and supports to: Facilitate an individual's recovery, including the individual's ability to make decisions about the individual's life and create opportunities for choice regarding: Home; School or work; and Community; and Promote the use of community resources and self-help organizations to support the individual to participate fully in the community. The program director shall ensure that: Services are: Appropriate to the age of the populations being served; Offered at times and places, according to the needs of the individuals served; and Coordinated with other mental health services that the individual is receiving; If the PRP provides services to individuals in a specific age group or with a particular clinical profile, the initiation of service criteria are consistent with the populations to be served; and If the PRP provides services in a facility, the services are provided on a regular basis and include a variety of group and individual rehabilitation activities that incorporate individual rehabilitation goals, needs, and choices. Eligibility. An individual is eligible for PRP services if: The individual is in need of program services to enable the individual to improve or restore independent living and social skills necessary to support the individual's: Recovery; Ability to make informed decisions and choices; and Participation in community life; The individual meets medical necessity criteria for PRP services; The individual agrees to apply for medical assistance, as appropriate; and The services are preauthorized, as needed, by the Administration's administrative services organization (ASO), according to the provisions of COMAR 10.21.17.04A. Screening. Within 10 working days of receipt by the program of a complete referral for PRP services: Staff assigned by the program director shall conduct a screening assessment to determine whether rehabilitation services are medically needed by the individual; If, following the screening assessment under §B(1) of this regulation, the program director determines that the program's services are not appropriate for an individual who has been referred, the program director shall, in writing: Inform the individual of the determination and the reason; Provide the individual with recommendations for alternative services, if appropriate; and With proper consent, notify the referral source, the family, or others designated by the individual of the determination and of any recommendations for other services; Unless the program director has notified the individual of the determination under §B(2) of this regulation, the program director shall notify the individual whether the program: Accepts the individual, in which case, the program director shall identify a date that the program can initiate services to the individual; Will accept the individual, following an updated review of the individual's eligibility status, when program capacity permits, in which case the program director shall inform the individual of the: Individual's placement on a waiting list, if any; and Estimated date services may be initiated; or Will accept the individual following the individual's discharge or release from an inpatient facility, RTC, or detention center; If the individual is placed on a waiting list under §B(3)(b) of this regulation, the program staff shall discuss with the individual: The option of remaining on the program's waiting list until the date established under §B(3)(b) of this regulation; and Alternative services that are available. Entitlements and Fees. PRP staff assigned by the program director shall: Determine if the individual has, or may be eligible, for federal or State entitlements; Assist the individual, if necessary, to apply for all entitlements for which the individual may be eligible if the individual does not have entitlements; Document in the individual's medical record: That the individual has all entitlements; or The outcome of the entitlement application; Discuss with the individual the charges for services, and, when applicable, the process for determining ability to pay; and Provide written documentation to the individual regarding the charges for services and the process for determining ability to pay. Review of Somatic Status. According to the provisions outlined in this section and upon an individual's enrollment into the program, a staff member assigned by the program director shall document in the individual's medical record: Pertinent past and current medical history including: The individual's somatic health problems, if any, including but not limited to allergies, neurologic disorders, and communicable diseases; Relevant medical treatment, including medications; and Needed somatic care follow-up, if any; and When the individual does not have a primary care provider and if indicated, the plan, including the time frame, for the individual's referral to a primary care provider for evaluation and treatment. When indicated, the individual's rehabilitation coordinator shall communicate with the individual's primary care provider and document the communication in the individual's medical record. When indicated, the individual's rehabilitation coordinator shall discuss with the individual the need for medical and dental care, facilitate access to care, and document the communication in the individual's medical record. Rehabilitation Assessment. Within 30 calendar days of initiation of PRP services, RRP services, or both, staff assigned by the program director to conduct assessments shall complete a face-to-face rehabilitation assessment with the individual and, with proper consent, family or others designated by the individual. The assigned staff shall document in the rehabilitation assessment, at a minimum: The individual's strengths, skills, wants, and needs in the following areas: Independent living; Housing; Employment; Self-administration and management of medications; Mobility and transportation; Social relationships and leisure activities; Education and vocational training; Adaptive equipment or resources; and Other factors that may pose a challenge to the individual's successful recovery and rehabilitation; Current resources and support system; As relevant, a review of the individual's legal status and forensic history, if any; The individual's history of substance abuse, if any; Behaviors, if any, that are potentially dangerous to the individual or others; and For individuals receiving RRP services, the individual's: Need for RRP services; Ability to perform basic self-care and to maintain personal safety; and Need for changing intensity of intervention based on the episodic nature of mental illness. Individual Rehabilitation Plan (IRP). Initial IRP. Within 30 calendar days of initiation of PRP or RRP services and based on the rehabilitation assessment described in §B of this regulation, the individual and the individual's rehabilitation coordinator shall prepare an initial IRP: In collaboration with: And with proper consent, family or others designated by the individual, and others involved in the individual's care; and When appropriate and with proper consent, other mental health service providers, as available; and That includes, at a minimum: The individual's recovery and rehabilitation expectations and responsibilities; A description of needed and desired program services and interventions, and staff responsible for implementation; A description of how the needed and desired skills and supports will help the individual to manage the individual's psychiatric disorder and to support recovery; Rehabilitation goals in measurable terms, and target dates for each goal; When appropriate, identification of, recommendations for, and collaboration with, other services to support the individual's recovery and rehabilitation, including but not limited to mental health treatment, residential services, self-help organizations, and somatic care; and For individuals receiving RRP services, the frequency of residential services and intensity of staff support. Individual Treatment and Rehabilitation Plan (ITRP). With the individual and in collaboration with the mental health treatment coordinator, the rehabilitation coordinator may combine the required elements of an ITP and IRP in one document, the ITRP. Rehabilitation Plan Review. At a minimum of every 6 months, the rehabilitation coordinator, with the individual, shall: Review and record in the individual's medical record: The individual's progress toward the accomplishment of previously identified rehabilitation goals; Goal changes, based on a review of the progress; and Changes in interventions, as appropriate; and Communicate promptly the results of the review to: Relevant program staff; and With proper consent, family or others designated by the individual, and community mental health programs providing services to the individual. Signature of the IRP or ITRP and Reviews. The following shall sign that they agree with the IRP or ITRP and reviews: The individual; and The individual's rehabilitation coordinator. With proper consent, family or others designated by the individual, including the individual's caregivers, may sign the IRP or ITRP and reviews. If the individual is unwilling to sign agreement with the IRP or ITRP and reviews, the individual's rehabilitation coordinator shall: Verify the individual's verbal agreement with the IRP or ITRP and reviews; and Document the rationale for the individual's refusal to sign. In addition, for an ITRP, at least two licensed mental health professionals, who collaborate about the individual's treatment, shall sign the ITRP and ITRP reviews, including: The individual's treatment coordinator; and If the individual is receiving medication prescribed through an outpatient mental health center (OMHC), the OMHC psychiatrist. Upon completion of an IRP, ITRP, or review, an individual's rehabilitation coordinator shall assure that the individual is offered a copy of the plan or review and document the individual's receipt or decline of the offer in the individual's medical record. Continuing Evaluation. Contact Notes. Staff shall document in the individual's medical record: Each contact with or about the individual, including, at a minimum: The date and location of service; The start time and either the duration or end time, unless the information is in a readily accessible billing document; The individual's chief medical complaint or reason for the visit; The delivery of services specified by the IRP or ITRP; A brief description of the service provided; and A legible signature, which may include an electronic signature, and printed or typed name of the program staff member providing care, with the appropriate title; and For individuals receiving RRP services, any change in intensity of staff support delivered at the RRP. Monthly Summary Notes. At a minimum, each month the rehabilitation coordinator shall record in the individual's medical record, either a contact note or a progress summary note that includes: An assessment of the individual's progress toward goal achievement that incorporates the perspective of both the individual served and staff involved; Changes in the individual's status; and A summary of the rehabilitation services and interventions provided. If not documented in §D(1) or (2) of this regulation, the rehabilitation coordinator shall document any significant changes or events, including hospitalizations, that affect the individual's rehabilitation. The rehabilitation coordinator shall document that the individual's wants and needs and progress are promptly communicated to: Staff involved in the implementation of the IRP; and With proper consent, family or others designated by the individual, and community mental health programs providing services to the individual. Rehabilitation and support services may only be provided: To an individual consistent with the individual's IRP or ITRP; and By staff who have been determined competent by the program to provide the services. Rehabilitation and Recovery Activities. The program director shall ensure that the program provides rehabilitation activities directed toward the individual's recovery and the improvement or restoration of skills, including: Self-care skills, including personal hygiene, grooming, nutrition, dietary planning, food preparation, and self-administration of medication; Social skills, including community integration activities, developing natural supports, and developing linkages with and supporting the individual's participation in community activities; Independent living skills, including: Skills necessary for housing stability; Community awareness; Mobility and transportation skills; Money management; Accessing available entitlements and resources; Supporting the individual to obtain and retain employment; and Wellness self-management; and Activities that support the individual's cultural interests. Medication Services. Administration. An individual licensed to administer medication under Health Occupations Article, Annotated Code of Maryland, may do so. A licensed practical nurse or a registered nurse may delegate the administration of medication only according to the provisions of COMAR 10.27.11. Monitoring. A PRP staff member shall provide the following services for psychiatric and somatic medications: Support the individual's self-administration of prescribed medication; Read the medication label to ensure that each container of medication is clearly labeled with the individual's name, the contents, directions for use, and expiration date; To the extent possible, monitor compliance with instructions appearing on the medication label; Ensure that each individual has secure, appropriate, and accessible space in which to store medications; Observe and document any apparent reactions to medication and, either verbally or in writing and in a timely fashion, communicate to the prescribing authority any problems that possibly may be related to the medication; and Reinforce, with the individual, education on the role and effects of medication in symptom management. Health Promotion and Training. PRP staff shall encourage health promotion activities, such as proper nutrition and exercise. Promotion of Individual Wellness Self Management and Recovery. Staff shall: Provide education and information regarding mental illness and recovery; and Support the individual to identify effective strategies to assist the individual to manage the individual's wellness. The strategies shall include, at a minimum, the individual's identification of: Potential challenging symptoms; Warning signs of relapse; Helpful interventions; and Other people the individual identifies to support the individual's recovery. The individual's wellness self-management strategies shall be documented and may be incorporated in the individual's IRP, Residential Rehabilitation Program Managed Intervention Plan, as outlined in Regulation .08 of this chapter, mental health advance directive, or any combination of these items. The strategies shall be reviewed at the time of the IRP review and may be revised or revoked at any time at the request of the individual. On-Call and Emergency Response. The program director shall assure that: On-call and crisis intervention services are available 24 hours per day, 7 days per week, by telephone, to an individual who has been admitted to the PRP; and All relevant staff shall assist the individual to access, as appropriate, the OMHC, mobile crisis, residential crisis services, hospitals, and other service providers that are designated to provide crisis and emergency care and treatment. Linkage with an Individual in a Psychiatric Inpatient Facility or Detention Center. If an individual who is enrolled in a program is admitted to a psychiatric inpatient facility or detention center, the rehabilitation coordinator shall make reasonable efforts to maintain ongoing communication with the individual and the individual's inpatient treatment team. To the degree permitted by the setting, PRP staff serving the individual shall participate in aftercare or release planning from that setting. The program director shall: Ensure that the program has a written policy regarding the development of and process for the implementation of a managed intervention plan (MIP) for an individual receiving RRP services; and Upon initiation of service, document that the individual has received the written policy regarding the MIP. For an individual at risk of an unplanned discharge, the rehabilitation coordinator, in collaboration with the individual, shall prepare an MIP that includes: Identification of the issues or symptoms that prompt the implementation of the MIP; Steps and planned interventions, including, but not limited to: A description of additional individualized services and supports that may be needed; Verbal notification; Written notification; Temporary interruption of RRP services, which shall include: The identification of temporary residential alternatives, if any; and Notification to the CSA; Identification of the individuals involved in implementing the MIP; and The signature of the: Individual; Individual's rehabilitation coordinator; Individual's family or others, if designated by the individual. The elements of the MIP may be included in a revised IRP. Housing Development. The program director shall ensure that the program: Collaborates with the CSA to access affordable housing in the community; Maintains information about available regular housing that is: Integrated throughout the community; Not conditional upon an individual's participation in mental health treatment or support services; and Within the price range that is affordable to individuals enrolled in the program; and In conjunction with the CSA: Attempts to develop financial resources to assist an individual temporarily in such circumstances as an individual's hospitalization or loss of job, benefits, or housemate; and Establishes priorities by which housing financial resources are allocated to individuals. Housing Needs Assessment. The program director shall ensure that program staff, in collaboration with the individual, conduct an assessment of: The individual's housing needs; and If the individual does not have housing that the individual considers adequate, the rehabilitative skills that the individual needs to obtain the housing of choice. Accessing and Sustaining Housing. The program director shall ensure that the program provides, as needed by and acceptable to the individual, services that are directed at: Assisting an individual in making choices about where and with whom to live by developing or restoring the basic social and living skills needed to: Link, when interested, with other individuals with similar interests and housing requirements; Evaluate financial resources, available natural supports, and needed and desired community services; and Secure available private and public housing financial assistance; Developing or restoring appropriate basic living skills and supports to keep housing, such as: Responsibilities for upkeep of the property and personal belongings; Development of community resources and natural supports; Housemate conflict resolution; and Landlord-tenant negotiations regarding such issues as rent, needed repairs, and complaints; and Providing support, as determined by the individual's need. Program Director. The program director: Shall have sufficient qualifications, knowledge, and experience to execute the duties of the position; Shall be knowledgeable of the regulations applicable to the program; Shall be responsible for administrative oversight of the PRP including, at a minimum: Fulfilling the administrative requirements under COMAR 10.21.17; Fulfilling the programmatic requirements of this chapter; Keeping the advisory committee, or governing body, whichever is applicable, informed of, at a minimum, the program's approval status and performance; Quality management; and Ensuring the development of a staffing plan that identifies the type and number of staff needed to provide a program of rehabilitation and recovery services for individuals with serious mental illness; and May be responsible for the duties of the psychiatric rehabilitation specialist under §B of this regulation as specified in Regulation .11B — D of this chapter. Psychiatric Rehabilitation Specialist. The program director shall employ at least one psychiatric rehabilitation specialist who: Is either a: Licensed mental health professional; Rehabilitation counselor who is currently certified by the Commission on Rehabilitation Counselor Certification; or Bachelor's prepared certified psychiatric rehabilitation practitioner currently certified by the U.S. Psychiatric Rehabilitation Association; Develops and assures that rehabilitation services meet the needs of the individuals served by the program; Oversees the daily program of rehabilitation services; and Educates direct care staff on how to provide rehabilitation services that correlate to the goals identified in the individual's IRP or ITRP. Psychiatric Rehabilitation Direct Care Staff. The program shall employ psychiatric rehabilitation direct care staff who: Have 40 hours of PRP training before independently providing PRP services; Have, at a minimum, a high school diploma or equivalency diploma; and Are responsible for implementing the rehabilitation activities outlined in the individual's IRP. A provider shall ensure that the staff of the PRP includes the following, who are employed by the PRP for the amounts of time outlined in §§B — D of this regulation: A program director; A psychiatric rehabilitation specialist; and Psychiatric rehabilitation direct care staff. If a PRP has fewer than 30 enrollees, the PRP shall employ either: A program director and a psychiatric rehabilitation specialist, each of whom is employed by the program for a minimum of 20 hours per week; or A program director who is responsible for the duties of the program director and the duties of a psychiatric rehabilitation specialist, if the program director: Has the qualifications described under Regulation .10B(1) of this chapter; Is employed by the program for 40 hours per week; and Devotes at least 20 hours per week to the development and implementation of rehabilitation services that reflect the needs of the individuals served by the program. If a PRP has 30 — 100 enrollees, the PRP shall employ either: A program director and a psychiatric rehabilitation specialist, each of whom is employed by the program for a minimum of 20 hours per week, and one of whom is employed for an additional 20 hours; or A program director who is responsible for the duties of the program director and the duties of the psychiatric rehabilitation specialist, if the program director: Has the qualifications described under Regulation .10B(1) of this chapter; Is employed by the program for 40 hours per week; and Designates staff to devote 20 hours per week to carrying out specific assigned administrative duties. If a PRP has more than 100 enrollees, the PRP program shall employ: A program director who is employed for 40 hours per week; and A psychiatric rehabilitation specialist or specialists and staff assigned to administrative duties as follows: A psychiatric rehabilitation specialist who is on site 40 hours per week; Two psychiatric rehabilitation specialists, each of whom is on site for 20 hours per week; or If the program director has the qualifications described under Regulation .10B(1) of this chapter: A psychiatric rehabilitation specialist who is employed 20 hours per week; and Staff designated to devote 20 hours per week carrying out specific assigned administrative duties. The program shall maintain an average ratio of at least one rehabilitation staff member serving each ten individuals who are receiving on-site PRP services, or receiving off-site PRP services in a group. To achieve this ratio, the program: May not include: The program director; or Consultants and volunteers; and May include students only if, in calculating the ratio, five rehabilitation staff are on duty for each student. Students. The program may use students according to the provisions of COMAR 10.21.17.12E. Volunteers. The program may use volunteers according to the provisions of COMAR 10.21.17.12F. Health-General Article, §§10-901 and 10-902, Annotated Code of Maryland Effective date: February 13, 1995 (22:3 Md. R. 153) Chapter revised effective September 7, 1998 (25:18 Md. R. 1434) Chapter revised effective January 14, 2008 (35:1 Md. R. 22) Regulation .06D amended effective January 21, 2013 (40:1 Md. R. 20) The purpose of this chapter is to outline the site, staffing, and service requirements that a psychiatric rehabilitation program (PRP) shall fulfill in order to be eligible to be approved to provide residential rehabilitation program (RRP) services. The Department may approve a program as an RRP if the applicant: Is approved by the Department under COMAR 10.21.21; Leases or owns at least one residence to be operated under the requirements of this chapter; and For a residence of four or more individuals, holds a license under COMAR 10.21.04. In this chapter, terms have the meanings stated in COMAR 10.21.17. Consultation. Before submitting an application, a PRP that is applying for approval to operate an RRP may request assistance regarding the proper compilation of application materials and completion of the application from the Administration or the appropriate: Core service agency (CSA) director; or Residential specialist. Program Application. A PRP that is applying for approval to operate an RRP shall include with the application for program approval under COMAR 10.21.16.03B: A description of the type of service that the program intends to provide, including: An estimate of the total number of individuals to be served by the RRP; and The capacity of the RRP to provide general or intensive staffing, as defined in Regulation .09D of this chapter; and A copy of the residential specialist's certificate of approval of the residence, as granted under the provisions of §C(4)(a)(i) of this regulation. Initial Approval of a Residence. Application for Approval of a Residence. A PRP that is applying for approval of a residence as a component of an RRP or an applicant for licensure of a group home under COMAR 10.21.04 shall submit to the residential specialist an application that: Is on the form approved by the Department with the requirement that all questions be answered and all required documents be attached; Includes documentation: That the residence is or will be owned or leased by the applicant; Of fire, liability, and hazard insurance coverage on the building in which the residence is located; and Of compliance with relevant federal, State, or local ordinances, laws, regulations, and orders, including zoning and safety, that are applicable to housing for individuals without disabilities. Review of Application. Within 5 working days of receipt of an application for approval of an RRP residence, the residential specialist shall review the application for completeness, and if the application is: Complete, arrange with the applicant to inspect the residence; or Incomplete, promptly return it to the applicant with written instructions regarding proper completion of the application. Initial Inspection of Residence. Within 10 working days of receipt of a completed application, in collaboration with a representative of the applicant, the residential specialist, using the residential checklist, shall inspect the residence for compliance with Regulation .05 of this chapter. Initial Certification of a Residence by a Residential Specialist. Based on the inspection conducted under §C(3) of this regulation, within 5 working days of the inspection, the residential specialist shall issue to the applicant, with copies to the Administration and CSA, one of the following: A certificate of general approval of the residence; Notice of provisional approval, based on noncompliance with specific site requirements under Regulation .05 of this chapter; or Notice that the residence is not approved, based on noncompliance with specific site requirements under Regulation .05 of this chapter. If the residential specialist issues a notice under §C(4)(a)(ii) or (iii) of this regulation, the residential specialist shall, at the applicant's request: Evaluate the applicant's efforts to attain compliance; and If necessary, reinspect the residence. Following an evaluation under §C(4)(b) of this regulation, the residential specialist shall issue one of the following: A certificate of general approval of the residence; Notice of continued provisional approval; or Notice of denial of approval, advising the applicant of hearing rights, as provided in COMAR 10.21.16.11 or COMAR 10.21.04.06G, as applicable. Annual Review of a Residence. Within not more than 1 year from the date of the last certificate of approval of a residence, the residential specialist, using the residential checklist, shall: Conduct an on-site evaluation to: Inspect the residence for continued compliance with: The documentation required under Regulation .03C(1)(b) of this chapter; and Site requirements outlined in Regulation .05 of this chapter, using the residential checklist; Document residents' assessment of the residence and of services described in Regulations .05, .08, and .09 of this chapter through face-to-face interviews, in an RRP residence of: One to three residents, with at least one individual; or Four or more residents, with at least 30 percent of the individuals living in the residence; and Verify, when appropriate: Residents' collection of entitlements; and The program's fee collections; Based on the inspection conducted under §A(1)(a) of this regulation, issue the certification or notice described in Regulation .03C(4)(a) of this chapter to the RRP program director, with copies to the: PRP program director; and Director of the CSA; and Notify the RRP program director, in writing, of significant information collected under §A(1)(b) or (c) of this regulation. Notice of Noncompliance with Site Requirements. If the residential specialist finds that the residence is not in compliance with a site requirement or requirements outlined in Regulation .05 of this chapter, the residential specialist shall: If the deficiency does not pose an imminent risk to the health, safety, or welfare of an individual served: Give the RRP program director written notice of provisional approval, identifying the deficiency and the time frame, of not more than 30 days, to correct the deficiency; and If necessary, reinspect the residence to determine compliance; If the deficiency poses a risk to the health, safety, or welfare of an individual served; Give the RRP program director written notice that the Department intends not to approve the residence, citing the reason for the disapproval, with copies to the: PRP program director; and Director of the CSA; and Request corrective action within 24 hours; If the deficiency cited under: §B(1) of this regulation is within 30 days: Corrected, issue a certificate of general approval; or Not corrected, reevaluate the approval status of the residence and provide that information to the Department's designated approval unit for consideration when evaluating the approval status of the RRP; and Section B(2) of this regulation is not corrected within 24 hours, give the RRP program director, with copies to the PRP program director and Director of the CSA, written notice of: The emergency suspension of the approval of the residence, under State Government Article, §10-226, Annotated Code of Maryland; Hearing rights, as provided in COMAR 10.21.16.11; and The obligation to relocate residents according to the provisions of §C of this chapter. Relocation of Residents. If approval of a residence is suspended under the provisions of §B(3)(b) of this regulation, the RRP director shall relocate residents according to the plan adopted under Regulation .05D of this chapter. Extension of Approval Status of a Residence. If the residential specialist does not complete a site inspection before an on-site review by the Department's designated approval unit, the Secretary shall maintain the RRP's existing approval status, pending receipt of the residential specialist's determination of approval status of a residence or residences. General Requirements. The RRP director shall ensure that: All areas of a residence, including storage areas, are safe, clean, and free of hazards and clutter; A residence has: No housing code or zoning violations; Working smoke alarms or smoke detectors that meet local fire codes for residential dwellings; Hot and cold running water and adequate light, heat, and ventilation; and Sufficient, appropriate, and functional furnishings, equipment, supplies, and utensils comparable to those found in the residences of nondisabled individuals; A resident: Has the resources to purchase or has access to food: For at least three meals per day for 7 days each week; and That meets the individual's dietary, nutritional, and religious needs; Has the resources to acquire an adequate supply of soap, towels, and toilet tissue; Who self-administers medication, has access to a secure storage area for the individual's medications; Has access to a secure storage area for funds and valuables; Has access to transportation; Has access to a telephone in the residence; and To the extent possible, may use personal possessions and preferences in furnishing and decorating the resident's space; and The following emergency procedures are in place: Posted near the telephone are telephone numbers for the: Fire department, police, ambulance, and poison control center; and Program's on-call staff; and An emergency evacuation procedure that is explained to and practiced by residents within 10 days of residence and, at a minimum, every 3 months after that. Bedrooms. The RRP director shall ensure that a bedroom has: A minimum of 70 square feet for a single bedroom and a minimum of 120 square feet for a double bedroom; A door, except for an efficiency apartment; Closet space for each individual in or convenient to each bedroom; Window covering for privacy; A bed with a clean mattress and pillow; At least two sets of linens per individual; and Not more than two residents. Toilet and Bathing Areas. The RRP director shall ensure that: The residence has a minimum of one full bathroom for every four residents; A full bathroom includes at least one toilet, one basin, and one tub or shower connected to hot and cold water; Bathrooms are easily accessible and conveniently located, not more than one floor level from living, dining, and sleeping rooms; and Bathrooms provide for individual privacy. Relocation Plan. Each program shall have a written relocation plan that: Specifies where residents may live temporarily if the residential specialist determines that conditions in the approved residence pose an imminent risk to the health, safety, or welfare of a resident; Is approved by the CSA; Is updated annually; and Is submitted to the residential specialist. The RRP director shall organize, maintain, and develop: Policies directed to ensure the provision of flexible services which respond to the current needs of an individual in an RRP; and Services that: Promote the individual's ability to engage and participate in appropriate community activities; and In a supportive environment, enable the individual to develop the daily living skills needed for independent functioning. The RRP director shall ensure that the residential rehabilitation program: Is located in the community, unless given an exemption by the CSA; Offers a home-like environment; and Provides goal-directed PRP services that facilitate rehabilitation and integration into community life. An RRP shall conduct eligibility review, screening, and enrollment according to the provisions of COMAR 10.21.21.04. If the RRP residence is a group home that is licensed under COMAR 10.21.04, the RRP shall admit residents according to the additional limitations outlined under COMAR 10.21.04.03B and C. Assessment. Within 30 days of initiation of RRP services, staff, in collaboration with the individual, shall complete an RRP assessment that includes: The rehabilitation service requirements noted in the PRP assessment; and An assessment of the individual's: Need for RRP services; Behaviors, if any, that are potentially dangerous to self or others; Ability to perform basic self-care and to maintain personal safety; History, if any, of requiring intermittent intensive levels of support in order to remain in the community; and Need for changing intensity of intervention based on the episodic nature of illness. Individualized Rehabilitation Plan (IRP). Initial IRP. Within 30 days of initiation of RRP services and based on the assessment in §A of this regulation, staff shall specify in the IRP: RRP goals; and The range of: Frequency of residential services; and Intensity of staff support, as described in Regulation .09D of this chapter. If the individual's service needs change, the RRP staff shall: Provide and document in the individual's record the services required by the change; Notify relevant staff of the change initiated; and Incorporate this information in the next IRP review. IRP Review. As frequently as necessary, as determined by an individual's rehabilitation coordinator, and at a minimum of every 6 months, the rehabilitation coordinator shall: Review and record in the individual's medical record: The individual's progress toward the accomplishment of previously identified rehabilitation goals; Goal changes, based on a review of the individual's progress; and Changes in interventions, including staff responsibility; Communicate promptly the results of the IRP review to: Relevant program staff; and With proper consent, family or significant others designated by the individual, and community mental health programs providing services to the individual. Signature of the IRP and Reviews. Staff shall obtain the individual's written or tape-recorded agreement or disagreement with the plan and, in addition, the following shall sign the plan and reviews: The rehabilitation coordinator; and Staff responsible for implementing the plan. Continuing Evaluation. The RRP director shall ensure that RRP staff document in the individual's PRP record contact notes and, at least monthly, progress summary notes of services, including any change in intensity of staff support, delivered at the RRP. Documentation. RRP staff shall document the assessment, IRP, contact notes, and progress summary notes for residential services in either: The PRP record; or In documents separate from the PRP record, if the PRP record references the separate documents. In addition to the provision of PRP services, the RRP program director shall ensure that: RRP services support the program model outlined in Regulation .06 of this chapter; Staff provide an appropriate range of services: Based on the assessment under Regulation .08A of this chapter; and In a flexible manner, as needed by the individual; Appropriate staff maintain linkage, as described in COMAR 10.21.21.06F, with a resident who is in a psychiatric inpatient facility or detention center; and Staff support, based on the program description as referenced in Regulation .03B(1) of this chapter, is provided at the level indicated by the individual's need, as follows: General support, which provides that, at a minimum, staff: Are available, on call, 24 hours per day, 7 days per week; and Have at least one face-to-face contact per individual per week; or Intensive support, which provides that staff are available, on site, for: Daily support for a specific number of individuals; and A minimum of 40 hours per week for up to 24 hours per day, 7 days per week. Discharge Policy. The program director shall: Collaborate with the Administration's administrative services organization (ASO) to: Arrange for discharge from the program when services are no longer authorized by the Administration's ASO; and Discontinue residential services to an individual whose clinical needs exceed the RRP's ability to secure the safety and welfare of the individual or others; Maintain clearly written policies and procedures for: The process for discharge from the program; and Temporary suspension from a residence; and Discontinue residential services to an individual whose clinical needs exceed the RRP's ability to secure the safety and welfare of the individual or others, including the: Criteria for discontinuation; and Progressive steps and interventions that the program will enact before discontinuation. Collaborative Discharge. When the Administration's ASO, in consultation with the rehabilitation coordinator, determines that services are no longer medically necessary, the rehabilitation coordinator shall follow the provisions for collaborative discharge outlined in COMAR 10.21.21.07B. Suspension. If an individual's clinical needs exceed the RRP's ability to secure the safety and welfare of the individual or others, the RRP program director may ask the individual to leave the residence on a temporary basis, as an alternative to the individual's termination from the residence. To implement a suspension identified in §C(1) of this regulation, the RRP program director: In writing, shall inform: The individual of the suspension and the reason for the determination; and When involved and with proper consent, the CSA and the Administration's ASO of the suspension; Shall give information on placement alternatives; and May provide temporary housing options. Program's Recommendation to Discontinue Residential Services. If the program director recommends discontinuing residential services to an individual whose clinical needs exceed the RRP's ability to secure the safety and welfare of the individual or others, the program director shall: Provide written notice of the discontinuation, according to the provisions of COMAR 10.21.21.07D; When possible, give the individual information about appropriate alternative services; When authorized, arrange for outreach, by PRP staff, to encourage the individual to access appropriate services; and Complete a discharge summary in accordance with COMAR 10.21.17.07D(3). RRP Program Director. The PRP program director shall either: Carry out the RRP program director's duties that are delineated in this chapter; or Appoint an RRP program director with the qualifications outlined in COMAR 10.21.21.08C. RRP Staff. The RRP program director shall ensure the deployment of sufficient staff to carry out the RRP: Model described in Regulation .06 of this chapter; Activities outlined in the individual's IRPs; and Staff support outlined in Regulation .09D of this chapter. In addition to the QM requirements in COMAR 10.21.17.10, annually the RRP program director shall complete and document reviews of the RRP's staff support, as described in Regulation .09D of this chapter, to evaluate the relationship between staff deployment and the: Number of: Admissions to inpatient psychiatric facilities; Visits to emergency departments; and Suspensions and terminations; and Results of the program's risk management (RM) analysis conducted under the provisions of COMAR 10.21.17.10C(3). The RRP program director shall evaluate the results of the interviews conducted by the residential specialist under the provisions of Regulation .04A(1) of this chapter and, when appropriate, modify the RRP services being delivered. The RRP program director shall notify the CSA director of the results of the analysis conducted under §A(1) of this regulation. Health-General Article, §§10-901 and 10-902, Annotated Code of Maryland Effective date: Regulations .01 — .12 adopted as an emergency provision effective January 16, 1995 (21:26 Md. R. 2183); adopted permanently effective April 24, 1995 (22:8 Md. R. 596) Chapter revised effective November 30, 1998 (25:24 Md. R. 1774) Regulation .07B amended effective October 17, 2011 (38:21 Md. R. 1278) This chapter establishes the process for deposits to and disbursements from a community-based fund that is established when a ward is closed at a State inpatient facility. In this chapter, the following terms have the meanings indicated. Terms Defined. “Administration” means the Mental Hygiene Administration. “Admission” means that an individual is: Taken into observation status on the basis of certification for involuntary admission under Health-General Article, §§10-614 — 10-617, Annotated Code of Maryland, and COMAR 10.21.01.07; or Voluntarily admitted under the provisions of Health-General Article, §10-609 or 10-610, Annotated Code of Maryland. “Average annual itemized expenses” means the amount budgeted for institutional services and administrative overhead costs that are appropriated for the facility in the fiscal year in which downsizing occurs. “Core service agency (CSA)” means the county or multicounty authority, designated under Health-General Article, Title 10, Subtitle 12, Annotated Code of Maryland, and approved by the Department, that is responsible for planning, managing, and monitoring publicly funded mental health services. “Department” means the Maryland Department of Health. “Director” means the Director of the Maryland Department of Health. “Downsizing” means the process by which the Administration analyzes the projected capacity of a State inpatient facility and implements procedures to close a ward or wards. “Fund” means the Mental Hygiene Community-Based Services Fund established according to the requirements of Health-General Article, §10-208, Annotated Code of Maryland. “Secretary” means the Secretary of Health. “State inpatient facility” means a facility listed in Health-General Article, §10-406(a), Annotated Code of Maryland. The Administration shall identify annually the number and size of wards, if any, marked for closure at each State inpatient facility. The Administration may use State general funds that are appropriated in advance to assist in downsizing. In planning for the provision of appropriate treatment and support services in the community, if the jurisdictions to which individuals discharged from the closing wards are: Served by a core service agency (CSA) or agencies, the Administration shall collaborate with the appropriate CSA; or Not served by a CSA, the Administration, in collaboration with the local health officer, shall carry out the necessary planning. When the Administration determines to close a ward or wards of a facility, the Administration shall assure that savings resulting from the downsizing are used as provided under Regulation .05 of this chapter. In depositing to the Fund, the Administration shall follow the following process: Calculate the net daily cost of maintaining an individual in the facility by: Subtracting from the facility's total general fund appropriation: Average annual itemized expenses for costs that are required to continue to provide care, treatment, and support services; Cost for new admissions to the facility under Health-General Article, Title 10, Subtitle 6, Annotated Code of Maryland; and Cost for court-ordered evaluations and commitments to the facility under Health-General Article, Title 12, Annotated Code of Maryland; and Dividing the net result under §B(1)(a) of this regulation by the average patient population of the facility, to arrive at the net facility cost per individual per day; According to the planning process under Regulation .03C of this chapter, determine the community cost per individual per day of providing appropriate treatment and mental health support services; Subtract from the facility cost per individual per day yielded under §B(1) of this regulation the community cost per individual per day yielded under §B(2) of this regulation to yield the savings per individual per day; Multiply the savings per individual per day under §B(3) of this regulation by the capacity of the ward or wards closed to arrive at the total savings per day; and For the fiscal year that the ward is closed, deposit to the Fund the prorated amount, based on the total savings per day under §B(4) of this regulation, multiplied by the number of days that the ward is vacated. The Administration shall ensure that the first priority for disbursements from the Fund is for the care and treatment of individuals discharged from the closed ward or wards. The Administration may not use the Fund to supplant State general fund resources for existing community services. Disbursements from the Fund, in excess of the amount required to annualize the cost of care and treatment of individuals discharged from the closed ward or wards, are subject to the State appropriations process. The Director shall ensure that the Fund is used to provide needed services in the community, including but not limited to: Case management; Crisis services; Outpatient mental health clinic; Psychiatric day treatment; Group home placement; Mobile treatment services; Psychiatric rehabilitation; Residential rehabilitation; Supported employment; Supported living; Therapeutic group homes; and Consumer-operated programs. Portions of the Fund that are unspent at the end of a fiscal year, and earned interest, shall remain in the Fund to be used for the purposes specified in this regulation. On or before January 1 of each year, the Secretary shall prepare a report on the Fund to be submitted to the General Assembly and the Department of Fiscal Services. The Secretary shall include in the report: The number and capacity of State inpatient facility wards closed during the prior fiscal year; An accounting of: The amount deposited to the Fund according to the methodology outlined under Regulation .04 of this chapter, and All other amounts reallocated from facilities to community programs; An accounting of disbursements from the Fund in accordance with Regulation .05 of this chapter; and The number and capacity of State inpatient facility wards planned for closure during the current fiscal year. Health-General Article, §10-208, Annotated Code of Maryland Effective date: October 23, 1995 (22:21 Md. R. 1616) Regulation .02B amended effective February 9, 1998 (25:3 Md. R. 145) Regulation .03C amended effective February 9, 1998 (25:3 Md. R. 145) COMAR 01.04.03 is incorporated by reference. Article 49D, §4, Annotated Code of Maryland Effective date: May 5, 1997 (24:9 Md. R. 657) This chapter establishes the fees that the Department reimburses for mental health services that are rendered by a provider to an individual who receives Medicaid-reimbursable or State-supported services. The Department shall reimburse the lower of the amount billed or the fee established under this chapter, after the application of an individual's copayment, based on the ability-to-pay determination according to Regulation .03 of this chapter. The Department may reimburse for non-Medicaid-reimbursable mental health services to the extent that State resources permit. According to the provisions of this chapter, the Department shall reimburse a mental health services provider: That is: A community-based mental health program that is approved by the Department; or An appropriately credentialed individual practitioner who contracts with the Department's Medical Assistance Program; For specific services that are delivered to: Medicaid recipients; or Individuals for whom, because of the severity of their mental illness and their financial need, the cost of mental health services is subsidized, in whole or in part, by State general funds for services not reimbursed under a grant or a contract. This chapter does not establish fees for services that are provided by: A federally qualified health center; An inpatient facility regulated by the Health Services Cost Review Commission, to an inpatient or resident of the facility; or A home health agency licensed under COMAR 10.09.04. The mental health service provider shall bill services using: The procedural terminology codes contained in the most current Physician's Current Procedural Terminology (CPT) manual published by the American Medical Association and incorporated by reference in COMAR 10.09.09.07D; and If there is no current CPT code for the service, a customized code published by the Administration. The mental health service provider, by submitting a claim for reimbursement for service, certifies that the service is medically necessary, has been delivered and meets the description and intent of the CPT code which is contained on its claim for reimbursement. Medicare Recipients. If a provider renders services to individuals who are Medicare recipients, the provider shall comply with all federal Medicare requirements. If a provider does not comply with all Medicare requirements, the provider may not seek reimbursement by the PMHS. In this chapter, terms have the meanings stated in COMAR 10.21.17, COMAR 10.63.01.02, and this regulation. Terms Defined. “Ability-to-pay schedule” means the schedule adopted, according to the provisions of Health-General Article, Title 16, Subtitle 2, Annotated Code of Maryland, by the Secretary to evaluate and establish the extent of a consumer's ability to pay for services rendered. “Administration” means the Behavioral Health Administration. “Assertive Community Treatment Program (ACT)” means an evidence-based practice program approved by the Administration under its regulations. “Core service agency (CSA)” has the meaning stated in COMAR 10.63.01.02. “Day habilitation” has the meaning stated in COMAR 10.09.46. “Emergency department” means an organized hospital-based facility that provides unscheduled episodic services, 24 hours per day, 7 days per week, to individuals who present for immediate medical attention. Emergency Service. “Emergency service” means a service that is provided to an individual who presents a danger to the life or safety of the individual or another. “Emergency service” does not include a residential or mobile crisis service. “Enhanced support” means short-term, in-home services, in addition to other services to an individual, provided by a program to support the individual to remain in the community: For mobile treatment services: Under COMAR 10.21.19 if approved; and Under COMAR 10.63.03.04 if licensed; For adult psychiatric rehabilitation services: Under COMAR 10.21.21 if approved; and Under COMAR 10.63.03.09 if licensed; or For outpatient mental health services; Under COMAR 10.21.20 if approved; and Under COMAR 10.63.03.05 if licensed. “Evidence-based practice (EBP)” is an Administration-approved practice that applies to certain clinical or rehabilitative interventions provided by public mental health service providers. “Family psychoeducation” is an evidence-based practice approved by the Administration under its regulations. “Fee” means the dollar amount, established by the Secretary, that a provider may charge an individual who receives services under this chapter for a unit of service, before the application of an ability-to-pay determination. “Individual practitioner” means: A marriage and family therapist who is licensed and legally authorized to practice clinical marriage and family therapy in the state in which the service is rendered; A nurse psychotherapist who is: Licensed and legally authorized to practice as a nurse psychotherapist in the state in which the service is rendered; and Certified by the Maryland Board of Nursing or an equivalent board of nursing in another state as a nurse psychotherapist, and demonstrates, by training and experience, the competency to provide the mental health services; A certified registered nurse practitioner psychiatric mental health (CRNP-PMH) who is: Licensed and legally authorized to practice as a certified registered nurse practitioner — psychiatric in the state in which the service is rendered to perform independently the services set forth in COMAR 10.27.07; and Certified by the Maryland Board of Nursing or an equivalent board of nursing in another state as a certified registered nurse practitioner with a specialty in psychiatry pursuant to COMAR 10.27.07 and demonstrates, by training and experience, the competency to provide the mental health services; An occupational therapist who: Is licensed and legally authorized to practice as an occupational therapist in the state in which the service is rendered, and Demonstrates, by training and experience, the competency to provide mental health services; A physician who: Is licensed and legally authorized to practice as a physician in the state in which the service is rendered, and Demonstrates, by training and experience, the competency to provide mental health services; A professional counselor who is licensed and legally authorized to practice as a clinical professional counselor in the state in which the service is rendered; A psychologist who: Is licensed and legally authorized to practice as a psychologist in the state in which the service is rendered, and Demonstrates, by training and experience, the competency to provide mental health services; or A social worker who is licensed and legally authorized to practice as a clinical social worker in the state in which the service is rendered. “Intensive outpatient services” means services that are delivered to an individual by a multidisciplinary team for a minimum of 3 hours of therapeutic activities, including at least two group therapies. “Level I” means a level of service provided to an individual who is enrolled in the Traumatic Brain Injury Waiver Program, based on the requirements for intensity of services and staffing outlined in: For individuals receiving residential habilitation services, COMAR 10.09.46.07D(2); For individuals receiving day habilitation services, COMAR 10.09.46.08F(2); and For individuals receiving supported employment services, COMAR 10.09.46.09C(2). “Level II” means a level of service provided to an individual who is enrolled in the Traumatic Brain Injury Waiver Program, based on the requirements for intensity of services and staffing outlined in: For individuals receiving residential habilitation services, COMAR 10.09.46.07D(3); For individuals receiving day habilitation services, COMAR 10.09.46.08F(3); and For individuals receiving supported employment services, COMAR 10.09.46.09C(3). “Level III” means a level of service provided to an individual who is enrolled in the Traumatic Brain Injury Waiver Program, based on the requirements for intensity of services and staffing outlined in: For individuals receiving residential habilitation services, COMAR 10.09.46.07D(4); For individuals receiving day habilitation services, COMAR 10.09.46.08F(4); and For individuals receiving supported employment services, COMAR 10.09.46.09C(4). “Local behavioral health authority (LBHA)” has the meaning stated in COMAR 10.63.01.02. Mental Health Program. “Mental health program” means a program that provides a plan of mental health treatment or mental health rehabilitation, consisting of various therapeutic modalities, that is: Approved by the Department under this subtitle or COMAR 10.09 to be eligible to receive State or federal funds; and Provided in the community. “Mental health program” includes: Non-hospital-based partial hospitalization (psychiatric day treatment) services under COMAR 10.21.02 if approved, and COMAR 10.63.03.08 if licensed; Therapeutic nursery programs under COMAR 10.21.18; Mobile treatment services under COMAR 10.21.19 if approved, and COMAR 10.63.03.04 if licensed; Outpatient mental health clinic (OMHC) services under COMAR 10.21.20 if approved, and COMAR 10.63.03.05 if licensed; Psychiatric rehabilitation programs for adults under COMAR 10.21.21 if approved, and COMAR 10.63.03.09 if licensed, including supported living services; Residential rehabilitation programs under COMAR 10.21.22 if approved, and COMAR 10.63.04.05 if licensed; Home health services under COMAR 10.09.04; Supported employment programs under COMAR 10.21.28 if approved, and COMAR 10.63.03.16 if licensed; Respite care programs under COMAR 10.21.27 if approved, and COMAR 10.63.03.15 if licensed; Residential crisis services programs under COMAR 10.21.26 if approved, and COMAR 10.63.04.04 if licensed; and Therapeutic and psychiatric rehabilitation services for minors under COMAR 10.21.29 if approved, and COMAR 10.63.03.10 if licensed. Mobile Treatment. “Mobile treatment” means a program approved under COMAR 10.21.19, or licensed under COMAR 10.63.03.04. “Mobile treatment” does not include transporting an individual to a program site to receive services. Off-Site. “Off-site” means a location, other than a site defined in §B(11) of this regulation, to which mental health program staff travels to provide services to an individual. “Off-site” includes, with respect to psychiatric rehabilitation program services, those services delivered to an individual: In the individual's home, including a residential rehabilitation program residence; At a job site; or At another community location appropriate to the individual's needs. “Off-site” does not include: A juvenile detention center; or Any facility or group home that is licensed to provide rehabilitative or therapeutic services, or living skills. “On-site” means a mental health program facility or other site to which a program has access and at which the program regularly delivers services to individuals who come to the site for the services. Other Mental Health Professional. “Other mental health professional” means an individual who is licensed, certified, or otherwise legally authorized to independently provide the mental health service. “Other mental health professional” includes a: Licensed certified social worker — clinical; Nurse psychotherapist; Licensed clinical professional counselor; Licensed clinical marriage and family therapist; or Certified registered nurse practitioner — psychiatric mental health (CRNP-PMH). “Outpatient mental health clinic (OMHC)” means a program approved under COMAR 10.21.20 or licensed under COMAR 10.63.03.05. “Partial hospitalization program” means a program approved under COMAR 10.21.02 or licensed under COMAR 10.63.03.08. “Program” means a mental health program as defined in §B(8) of this regulation. “Provider” means: A community-based mental health program as defined in §B(8) of this chapter; or An individual practitioner as defined in §B(7) of this chapter. “Psychiatric rehabilitation program for adults (PRP)” means a program approved under COMAR 10.21.21 or licensed under COMAR 10.63.03.09. “Residential crisis services (RCS)” means a program approved under COMAR 10.21.26 or licensed under COMAR 10.63.04.04. “Residential habilitation” has the meaning stated in COMAR 10.09.46. “Residential rehabilitation program (RRP)” means a program approved under COMAR 10.21.22 or licensed under COMAR 10.63.04.05. “Respite care” means services that are approved under COMAR 10.21.27 or licensed under COMAR 10.63.03.15 “Secretary” means the Secretary of Health “Serious emotional disturbance” means a condition that is: Manifest in an individual younger than 18 years old; Diagnosed according to a current diagnostic and statistical manual of the American Psychiatric Association that is recognized by the Secretary, excluding the following, unless it coexists with a diagnosable psychiatric disorder: Developmental disorder; Substance abuse; and Disorder classified under the “V” code; and Characterized by a functional impairment that substantially interferes with or limits the child's role or functioning in the family, school, or community activities, including the following: Inability to achieve or maintain one or more developmentally appropriate social, behavioral communicative, or adaptive skills; or Episodic, recurrent, and continuous functional impairments. “Serious and persistent mental disorder” means a disorder that is: Manifest in an individual 18 years old or older; Diagnosed, according to a current diagnostic and statistical manual of the American Psychiatric Association that is recognized by the Secretary, as: Schizophrenic disorder; Major affective disorder; Other psychotic disorder; or Borderline or schizotypal personality disorders, with the exclusion of an abnormality that is manifested only by repeated criminal or otherwise antisocial conduct; and Characterized by impaired role functioning, on a continuing or intermittent basis, for at least 2 years, including at least three of the following: Inability to maintain independent employment; Social behavior that results in intervention by the mental health system; Inability, due to cognitive disorganization, to procure financial assistance to support living in the community; Severe inability to establish or maintain a personal social support system; Need for assistance with basic living skills. “Therapeutic and psychiatric rehabilitation services for minors” means a program approved under COMAR 10.21.29 or licensed under COMAR 10.63.03.10. Claims Submission. In order to be reimbursed by the Department, an approved provider shall submit a claim when the provider has: Obtained authorization to provide the services for which the claim is being submitted; Delivered the service; Documented provision of service as required; and Complied with any regulatory preconditions for the delivery of the service. Claims Retraction. The Department may retract any payments made to any PMHS provider for paid claims if an audit indicates that: The services were not provided; The services were not medically necessary; There is no documentation that the services were provided; The precondition for the delivery of the service was not met; or The provider failed to comply with §H of this regulation. If the Department retracts funds from a provider under §B of this regulation, within 30 days following the retraction the Department shall provide notice and an opportunity for a hearing. Limitations. The Department shall reimburse, for services delivered on the same service date for the same individual, an outpatient mental health center (OMHC) for a maximum of two therapy sessions subject to the following conditions: Only one may be an individual therapy session; Only one may be a group therapy session; and Only one may be a family therapy session, either with or without the individual. The Department may not reimburse an OMHC for the following services delivered to the same individual on the same service date: Individual therapy with medication management session, and medication management session; Diagnostic interview or assessment, and a treatment planning session; and A diagnostic interview or assessment, and a therapy session. For all other providers, the Department shall reimburse for only one service per service date. Limitations Exception. The Department may provide an exception to the limitation rule on outpatient services if the ASO finds that the service: Is medically necessary; Is not duplicative; and Has been preauthorized. The Department shall reimburse Psychiatric Rehabilitation Program services provided to a child residing in a therapeutic group home, as defined in COMAR 10.21.07 when the TGH certifies that its negotiated rate does not include payment for the PRP services. The Department may not reimburse outpatient mental health services provided to an individual when the individual is in a hospital or residential treatment center. The Department may not reimburse PRP providers until the PRP has met the minimum service encounters as defined in Regulation .09 of this chapter. For individual practitioners, when services are preauthorized, the following documentation is required before submitting for payment for services rendered: For each individual served, the medical record, which shall include the following documentation: A signed consent to treatment; A comprehensive assessment that includes the: Individual or family’s presenting problem; Individual or family’s history; Individual’s diagnosis; and Rationale for the diagnosis; and An individualized treatment plan that includes the: Problems, needs, strengths, and goals that are measurable; Interventions that are medically necessary; and Signatures of the individual, or if the individual is a minor, the guardian, and the treating mental health professional; and Progress notes for each face-to-face contact including: Date of service; Start time and end time; Location; Summary of interventions provided; and The treating mental health professional’s signature and date of service. Services rendered by an individual practitioner may only be reimbursed for the licensed mental health professionals authorized by the practice board to diagnose and treat psychiatric disorders as identified in this chapter of regulations. Providers who billed for services rendered from July 1, 2013 until the effective date of these regulations may resubmit their claims and be reimbursed for these services as set forth in Regulations .05 — .12 of this chapter. Except if an individual is a Medicaid recipient: A provider shall provide to the Administration's designee the information needed to assess an individual's ability to pay; The Administration's designee shall assess the individual's ability to pay and determine the required copayment; and The provider shall make collections of the copayment according to the requirements in Health-General Article, §§16-201 — 16-204, Annotated Code of Maryland. The Department shall furnish to a provider, on request, an ability-to-pay schedule, including periodic updates. Diagnostic Interview. The Department shall reimburse a provider for a face-to-face diagnostic interview, as follows: For a child or adolescent, when rendered by a provider with demonstrated competency to provide mental health services to children or adolescents: OMHC ... $190.23; Physician ... $151.68; Psychologist ... $121.08; Other mental health professionals ... $106.01; For an adult: OMHC ... $170.32; Physician ... $151.68; Psychologist ... $121.08; Other mental health professional ... $106.01. Individual Therapy. The Department shall reimburse a provider for an individual therapy session, as follows: For a child or adolescent, when rendered by a provider with demonstrated competency to provide mental health services to children or adolescents: For 30 minutes: OMHC ... $59.19; Physician ... $50.05; Psychologist ... $40.09; Other mental health professional ... $34.98; For 20 — 30 minutes, with biofeedback training: OMHC ... $50.05; Physician ... $50.05; Psychologist ... $40.09; Other mental health professional ... $34.98; For 45 minutes: OMHC ... $105.20; Physician ... $90.94; Psychologist ... $72.65; Other mental health professional ... $63.77; For 45 — 50 minutes, with biofeedback training: OMHC ... $90.94; Physician ... $90.94; Psychologist ... $72.65; Other mental health professional ... $63.77; For 60 minutes in an OMHC ... $105.20; For an adult: For 30 minutes: OMHC ... $50.05; Physician ... $50.05; Psychologist ... $40.09; Other mental health professional ... $34.98; For 20 — 30 minutes, with biofeedback training: OMHC ... $50.05; Physician ... $50.05; Psychologist ... $40.09; Other mental health professional ... $34.98; For 45 minutes: OMHC ... $90.94; Physician ... $90.94; Psychologist ... $72.65; Other mental health professional ... $63.77; For 45 — 50 minutes, with biofeedback training: OMHC ... $90.94; Physician ... $90.94; Psychologist ... $72.65; Other mental health professional ... $63.77; For 60 minutes in an OMHC ... $90.94. Family Therapy. The Department shall reimburse a provider for a family therapy session, as follows: When the identified patient is a child or adolescent and the service is rendered by a provider with demonstrated competency to provide mental health services to children or adolescents: Without the identified patient: OMHC ... $104.13; Physician ... $85.02; Psychologist ... $69.96; Other mental health professional ... $53.81; With the identified patient, for 20 — 30 minutes: OMHC ... $58.65; Physician ... $58.65; Psychologist ... $46.82; Other mental health professional ... $41.17; With the identified patient, for 45 — 60 minutes: OMHC ... $107.62; Physician ... $94.71; Psychologist ... $76.41; Other mental health professional ... $65.64; When the identified patient is an adult: Without the identified patient for 45 — 60: OMHC ... $90.14; Physician ... $85.02; Psychologist ... $69.96; Other mental health professional ... $53.81; With the identified patient, for 45 — 60 minutes: OMHC ... $94.71; Physician ... $94.71; Psychologist ... $76.41; Other mental health professional ... $65.64. Group Therapy. The Department shall reimburse a provider for each individual, up to a maximum of 10, in a group therapy session as follows: When the identified patient is a child or adolescent and the service is rendered by a provider with demonstrated competency to provide mental health services to children or adolescents: For 45 — 60 minutes: OMHC ... $40.90; Physician ... $24.75; Psychologist ... $24.75; Other mental health professional ... $24.75; For more than 75 minutes in an OMHC ... $50.58; When the identified patient is an adult: For 45 — 60 minutes: OMHC ... $38.74; Physician ... $24.75; Psychologist ... $24.75; Other mental health professional ... $24.75; For more than 75 minutes in an OMHC ... $50.58. Psychological Testing. The Department shall reimburse a psychologist for conducting psychological testing, up to a maximum of 8 hours per year per individual as follows: OMHC psychologist ... $99.02 per hour; Other psychologist ... $99.02 per hour; OMHC psychologist associate ... $27.55 per hour; Other psychologist associate ... $27.55 per hour. Occupational Therapy. The Department shall reimburse an occupational therapist for providing services, as follows: To an individual, payable in 15-minute increments, for face-to-face: Therapeutic activities ... $11.83 per 15 minutes; Self-care, home management training ... $11.83 per 15 minutes; Community and work reintegration ... $11.83 per 15 minutes; Development of cognitive skills ... $11.83 per 15 minutes; Occupational therapy evaluation and re-evaluation ... $15.07 per 15 minutes; For each individual, up to a maximum of 10, in a group therapy session of a minimum of 60 minutes ... $18.30. Physician Services. The Department shall reimburse for services rendered to a child, adolescent, or adult, by an appropriately privileged physician or certified registered nurse practitioner — psychiatric only, as follows: The patient's primary care physician in an inpatient or partial hospital setting: Initial care: For a minimum of 30 minutes ... $108.43; For a minimum of 50 minutes ... $147.19; For a minimum of 70 minutes ... $216.47; Subsequent care: For a minimum of 15 minutes ... $41.71; For a minimum of 25 minutes ... $76.73; For a minimum of 35 minutes ... $110.63; Discharge day management: For 30 minutes or less ... $77.68; For more than 30 minutes ... $114.63; For discharge data submission ... $21.53; For individual therapy, in an inpatient setting: For 30 minutes ... $43.78; For 45 minutes ... $82.30; The patient's primary certified registered nurse practitioner — psychiatric, in an inpatient or partial hospital setting: Initial care: For a minimum of 30 minutes ... $108.43; For a minimum of 50 minutes ... $147.19; For a minimum of 70 minutes ... $216.47; Subsequent care: For a minimum of 15 minutes ... $41.71; For a minimum of 25 minutes ... $76.73; For a minimum of 35 minutes ... $110.63; Discharge day management: For 30 minutes or less ... $77.68; For more than 30 minutes ... $114.63; For individual therapy, in an inpatient setting: For 30 minutes ... $30.65; For 45 minutes ... $57.61; For electroconvulsive therapy, in an inpatient setting: Including monitoring ... $98.39; Anesthesia ... $98.27; A consultant physician, or a consultant certified registered nurse practitioner — psychiatric, in an inpatient or partial hospital setting, initial consult, for a minimum of: 20 minutes ... $51.66; 40 minutes ... $79.60; 55 minutes ... $121.30; 80 minutes ... $174.86; 110 minutes ... $217.80; A consultant physician or a consultant certified registered nurse practitioner — psychiatric, in an outpatient setting: For a minimum of 15 minutes ... $51.49; For a minimum of 30 minutes ... $96.74; For a minimum of 40 minutes ... $131.91; For a minimum of 60 minutes ... $194.98; For a minimum of 80 minutes ... $237.73; Treatment Planning. The Department shall reimburse an OMHC for providing an OMHC-enrolled individual with one face-to-face treatment planning meeting every 6 months, at the rate of $82.87 per planning meeting. Multifamily Group Therapy. The Department shall reimburse an OMHC for providing multifamily group therapy, with the identified patient, for families of: Children and adolescents, for 45 — 60 minutes, with the child present ... $41.98 per family; Children and adolescents, for 20 — 30 minutes, with the child present ... $38.55 per family; Adults, for 45 — 60 minutes, with the adult present ... $39.83 per family; Adults, for 20 — 30 minutes, with the adult present ... $35.75 per family; Family Psychoeducation. The Department shall reimburse a provider, when the provider has been approved by the Administration to provide evidence-based services, for a family psychoeducation session with or without the identified adult, at a rate of $53.81 per family. Prolonged Services. The Department shall reimburse an OMHC for providing, on-site, prolonged services, face-to-face with the identified patient, as follows: For 30 — 74 minutes ... $106.79; For an additional period of 30 minutes ... $104.10. Venipuncture and Injection. The Department shall reimburse an OMHC for providing: Routine venipuncture ... $14.94; Therapeutic injection ... $14.94. Intensive Outpatient Services. The Department shall reimburse an OMHC for providing intensive outpatient services, when the services are delivered by a multidisciplinary team for a minimum of 3 hours of therapeutic activities, including needed physician services and at least two group therapies, as follows: For children or adolescents ... $154.17 per day; For adults ... $129.69 per day. Discharge Data Submission. The Department shall reimburse an OMHC $21.53 for discharge data submission. Therapeutic Nursery Programs. The Department shall reimburse a program approved under COMAR 10.21.18 to provide therapeutic nursery services to eligible children, younger than 5 years old, at a rate of $42.20 per day, for a minimum of 3 days per week, 3 hours per day. Mobile Treatment Services. The Department shall reimburse a program for mobile treatment services delivered to an individual: For a minimum of four face-to-face services, and according to a treatment plan that outlines the expected type and frequency of services; At the rate of: $839.45 per month; or If the individual is a Medicare recipient, $643.58 per month, if the program has: Delivered services according to the provision of §A(1) of this regulation; and Billed applicable Medicare reimbursed services; For enhanced support, when the need for short-term one-to-one support is documented and approved by the Administration or its designee: At the rate of $12.91 per hour; Up to a maximum of $129.10 per day; Not to exceed 30 days per calendar year. For evidence-based programs, assertive community treatment (ACT), at the rate of: For Medicaid recipients and other individuals meeting eligibility criteria for uninsured, $1,183.34 per month; or If the individual has Medicare only, $1,049.31 per month. Partial Hospitalization. For programs approved under COMAR 10.21.02 or licensed under COMAR 10.63.03.08, the Department shall reimburse: A non-hospital-based partial hospitalization (psychiatric day treatment) program, for services provided to an eligible Medicaid recipient: For a full day, a minimum of 6.5 hours of therapeutic activities per day ... $203.68 per day; For a half day, or intensive, outpatient services, when the services are delivered by a multidisciplinary team, for a minimum of 4 hours of therapeutic activities, including at least two group therapies ... $110.85 per day; HSCRC programs that meet the minimum requirements of COMAR 10.21.02, at the rate established by the HSCRC; OMHC, for intensive outpatient services provided to a Medicaid recipient in a psychiatric day treatment program: For adults ... $129.69; For children and adolescents ... $154.17; and For physician services, at the rates established under Regulation .06D of this chapter. The Department may not reimburse a partial hospitalization program (psychiatric day treatment) or an OMHC intensive outpatient mental health program on the same day that an intensive outpatient program or service is provided for substance abuse treatment. Residential Crisis Services. The Department shall reimburse a provider for residential crisis services delivered to an individual, as follows: As an alternative to inpatient admission or to shorten the length of inpatient stay: For clinical services ... $252.34 per day; For room and board ... $12.59 per day; Treatment foster care ... $162.25 per day; and For physician services, at the rates established for services rendered to an individual in an inpatient setting under Regulation .05D of this chapter. Psychiatric Rehabilitation Program (PRP) Services. The Department shall reimburse a PRP for providing face-to-face rehabilitation services to an individual with a serious emotional disturbance (SED) or serious and persistent mental disorder (SPMD), by a monthly rate that is based on a minimum and maximum range of services, when the PRP submits monthly supporting encounter data after services are provided to the individual, within which the provider shall meet the needs of the individual, as follows: Assessment ... $61.62; PRP services to an employed individual in a supported employment program, delivered at the job site, at a rate of $107.62 per month, for: A minimum of two services per month; A maximum of 30 services per month; A minimum of 15 minutes per service; and A maximum of one service per day. Additional PRP Services. In addition to the services outlined in §A of this regulation, the Department shall reimburse a PRP for providing face-to-face rehabilitation services to an individual with SED or SPMD by a monthly rate that is based on a minimum and maximum range of services, within which the provider shall meet the needs of the individual, as follows: PRP Community Psychiatric Support Services delivered to an individual with an SED or an SPMD, whose functioning is severely impaired, and who is living with a parent, guardian, or relative who is legally responsible for the individual's care, as follows: When on-site and off-site services are delivered to an individual by one PRP, $426.99 per month for: A minimum of three and a maximum of 30 services per month, on-site or off-site; On-site services, at a minimum of 60 minutes per service; Off-site services, at a minimum of 15 minutes per service; and A maximum of one on-site or one off-site service per day; or When on-site and off-site services are delivered to an individual by two PRPs, a PRP may receive reimbursement for either on-site or off-site services, but not both, as follows: On-site services, at a rate of $183.22 per month, for a minimum of two services and a maximum of 30 services per month, at a minimum of 60 minutes per service; Off-site services, at a rate of $243.76 per month, for a minimum of two services and a maximum of 30 services per month, at a minimum of 15 minutes per service; and Limited to reimbursement for one on-site and one off-site service per day; PRP supported living for services delivered to an individual with an SED or an SPMD, whose functioning is severely impaired, and who is living independently or with individuals who are not legally responsible for their care, as follows: When services are delivered to an individual by one PRP, $760.88 per month as follows: A minimum of six and a maximum of 30 services per month, on-site or off-site; On-site services, at a minimum of 60 minutes per service; Off-site services, at a minimum of 15 minutes per service; and Limited to one on-site and off-site service per day; or When on-site and off-site services are delivered to an individual by two PRPs, a PRP may receive reimbursement for either on-site or off-site services, but not both, as follows: On-site services, at a rate of $259.37 per month, for a minimum of three services and a maximum of 30 services per month, at a minimum of 60 minutes per service; Off-site services, at a rate of $501.51 per month, for a minimum of five services and a maximum of 30 services per month and a minimum of 15 minutes per service; and Limited to reimbursement for one on-site or off-site service per day; PRP services delivered to individuals in residential rehabilitation programs (RRPs) as follows: General support: On-site, at a rate of $447.70 per month, for a minimum of four services, up to 30 services per month, at a minimum of 60 minutes per service; Off-site, at a rate of $1,202.13 per month, for a minimum of 13 services, up to 30 services per month, at a minimum of 15 minutes per service; or Any combination of on-site or off-site PRP services, at a rate of $1,649.83 per month, for a minimum of 17 services, up to 30 services per month, at a minimum of 30 minutes per service; or Intensive support: On-site, at a rate of $447.70 per month, for a minimum of four services, up to 30 services per month, at a minimum of 60 minutes per service; Off-site, at a rate of $3,123.17 per month, for a minimum of 19 services, up to 30 services per month, at a minimum of 15 minutes per service; or Any combination of on-site or off-site PRP services, at a rate of $3,570.87 per month, for a minimum of 23 services, up to 30 services per month, at a minimum of 30 minutes per service; or PRP services delivered to individuals when transitioning from inpatient level of care to the community, any combination of on-site or off-site PRP services, at a rate of $447.70 per month, for a minimum of 4 services, up to 30 services per month, at a minimum of 60 minutes per service. RRP Services. The Department shall reimburse an RRP for providing services to an individual with a serious and persistent mental disorder and whose functioning is severely impaired, as follows: Room and board ... $12.59 per day; A provider may collect additional fees from an individual not covered by the rate established in §B(1) of this regulation to cover a portion of costs of food, shelter, and other household expenses associated with an individual's basic needs in an RRP residence, not to exceed the provider's cost of care. Mental Health Vocational Programs (MHVP). The Department shall reimburse a program that is approved for mental health vocational services for providing supported employment services to an individual with a mental disorder: If the service is authorized by the Administration or its designee; If the program documents an individual's application to the Division of Rehabilitation Services (DORS) and has documentation of the decision on the application; and At the following rates, per individual approved for supported employment services: Completion of vocational assessment, individual supported employment plan, referral to DORS, and education regarding entitlements and work incentives, not more than three times per year ... $430.49; Job placement of the individual, not more than three times per year ... $1,075.14; Intensive job coaching, if not otherwise reimbursed, at a maximum of $7.40 per 15 minutes, up to a lifetime maximum of $2,750 per individual; and Extended MHVP support ... $349.77 per month. Mental Health Vocational Programs — Evidence-Based Programs. The Department shall reimburse an MHVP evidence-based program: If the service is authorized by the Administration or its designee; If the program documents an individual's application to the Division of Rehabilitation Services (DORS) and has documentation of the decision on the application; and At the following rates, per individual approved for supported employment services: Completion of vocational assessment, individual supported employment plan, referral to DORS, and education regarding entitlements and work incentives not more than three times per year ... $430.49; Job placement of the individual not more than three times per year ... $1,075.14; Intensive job coaching, if not otherwise reimbursed, at a maximum of $7.40 per 15 minutes, up to a lifetime maximum of $2,750.00 per individual; Clinical service coordination at a rate of $107.62 per month, that is documented and includes, with the individual's consent, at a minimum: Monthly collaboration with the individual's treatment or psychiatric rehabilitation team; and Face-to-face contact every 6 months with the individual's treating clinician or psychiatrist; and Extended PRP support to an individual in a supported employment program at a rate of $430.49 per month for: A minimum of three services per month; A maximum of 30 services per month; A minimum of 15 minutes per service; and A maximum of one service per day. Respite Care. The Department shall reimburse a program that is approved for respite care for providing services to a child or adolescent with a serious emotional disturbance, whose functioning is severely impaired, or an adult with a serious and persistent mental disorder, whose functioning is severely impaired, as follows: For children: General support in a facility ... $174.34 per day; or In-home respite, when the need for short-term, one-to-one support is documented or for in-home respite and approved by the CSA up to a maximum of 10 hours per day at a rate of ... $3.49 per 15 minutes; For adults, general support in a residential rehabilitation program ... $75.61 per day. Enhanced Support. When the need for short-term, one-to-one support is documented and approved by the CSA, the Department shall reimburse an OMHC, PRP, RRP, or MTS for providing services to a child or adolescent with an SED or an adult with an SPMD, and whose functioning is seriously impaired, at the rate of $12.91 per hour up to a maximum of $129.10 per day, not to exceed 30 days per year. Therapeutic Behavioral Services. The Department shall reimburse a therapeutic behavioral services provider, as defined in COMAR 10.09.34, as follows: One-to-one behavioral aide services to a child or adolescent ... $5.39 per 15 minutes; Initial assessment and development of a behavioral plan ... $105.51; Reassessment and development of a new behavioral plan ... $99.18. Adult Mental Health Case Management. The Department shall reimburse a designated program that is approved by the Core Service Agency for mental health case management according to COMAR 10.09.45 for providing case management services to an adult with a serious and persistent mental health disorder as follows: Assessment ... $108.61; Case Management Service units, for a minimum of 60 minutes of face-to-face and non-face-to-face case management service at a rate of $108.61 per day for: General level up to 2 units per month; or Intensive level up to 5 units per month; and When an individual is referred to case management by the Administration or its designee, and is transitioning from an institute for mental disease or hospital, one transitional visit at a rate of $159.55. Mental Health Case Management: Care Coordination for Children and Youth. The Department shall reimburse a designated program that is approved by the Core Service Agency to provide mental health case management services to a child or adolescent with a serious emotional disorder, according to COMAR 10.09.90, as follows: Case Management Service units, for a minimum of 15 minutes of face-to-face and non-face-to-face case management service at a rate of $20.19 per 15 minutes for: Level I — General Coordination up to 12 units of service per month, with a minimum of two units of face-to-face contact; Level II — Moderate Care Coordination up to 30 units of service per month, with a minimum of four units of face-to-face contact; and Level III — Intensive Care Coordination up to 60 units of service per month, with a minimum of six units of face-to-face contact; and For comprehensive assessment and reassessment case management service units, for Level I and Level II only, four additional face-to-face units of service above the monthly maximum may be billed during the first month of service to the participant and every 6 months thereafter. Residential Habilitation Services. The Department shall reimburse a program approved under COMAR 10.09.46 to provide residential habilitation services to an individual who is enrolled in the TBI Waiver Program: At the following rates: Level I ... $192.76 per day; Level II ... $255.24 per day; Level III ... $353.11 per day; According to the need for the level of support documented in an individual's waiver plan of care and approved by the Administration; and According to the institutional level of care determined by the Department's utilization control agent. Day Habilitation Services. The Department shall reimburse a program approved under COMAR 10.09.46 to provide day habilitation services to an individual who is enrolled in the TBI Waiver Program: At the following rates: Level I ... $49.76 per day; Level II ... $86.81 per day; Level III ... $122.14 per day; According to the need for the level of support documented in an individual's waiver plan of care and approved by the Administration; and According to the institutional level of care determined by the Department's utilization control agent. Supported Employment Services. The Department shall reimburse a program approved under COMAR 10.09.46 to provide supported employment services to an individual who is enrolled in the TBI Waiver Program: At the following rates: Level I ... $29.53 per day; Level II ... $49.76 per day; Level III ... $122.14 per day; According to the need for the level of support documented in an individual's waiver plan of care and approved by the Administration; and According to the institutional level of care determined by the Department's utilization control agent. Individual Support Services. The Department shall reimburse a program approved under COMAR 10.09.46 to provide individual support services, as defined in COMAR 10.22.07, to an individual who is enrolled in the TBI Waiver Program at a rate of $24.14 per hour, not to exceed 8 hours per day. The Department shall reimburse an emergency department for providing emergency mental health services to an individual who is enrolled in the public mental health system, for services rendered by an appropriately privileged physician or certified registered nurse practitioner — psychiatric as follows: For a problem focused history, a problem focused examination, and straightforward medical decision making ... $22.27; For an expanded problem focused history, an expanded problem focused examination, and medical decision making of low complexity ... $43.80; For an expanded problem focused history, an expanded problem focused examination, and medical decision making of moderate complexity ... $65.29; For a detailed history, a detailed examination, and medical decision making of moderate complexity ... $124.63; For a comprehensive history, a comprehensive examination, and medical decision making of high complexity ... $182.80. New Patients. The Department shall reimburse for evaluation and management services for new patients, including medication management: For a problem focused history, or a problem focused examination, and straightforward medical decision making of minor complexity: OMHC ... $48.70; Physician ... $48.70; Certified registered nurse practitioner — psychiatric ... $48.70; For an expanded problem focused history, or an expanded problem focused examination, and straightforward medical decision making: OMHC ... $82.48; Physician ... $82.48; Certified registered nurse practitioner — psychiatric ... $82.48; For a detailed history, or a detailed examination, and medical decision of low complexity: OMHC ... $119.25; Physician ... $119.25; Certified registered nurse practitioner — psychiatric ... $119.25; For a comprehensive history, or a comprehensive medical examination, with medical decision making of moderate complexity: OMHC ... $181.64; Physician ... $181.64; Certified registered nurse practitioner — psychiatric ... $181.64; For a comprehensive history, or a comprehensive medical examination, with medical decision making of high complexity: OMHC ... $224.53; Physician ... $224.53; Certified registered nurse practitioner — psychiatric ... $224.53. Established Patients. The Department shall reimburse for evaluation and management services for established patients, including medication management: For a history, or examination, where presenting problems are minimal, and straightforward medical decision making of minor complexity: OMHC ... $22.72; Physician ... $22.72; Certified registered nurse practitioner — psychiatric ... $22.72; For a problem focused history, or a problem focused examination, and straightforward medical decision making: OMHC ... $48.70; Physician ... $48.70; Certified registered nurse practitioner — psychiatric ... $48.70; For an expanded history, or an expanded examination, and medical decision of low complexity: OMHC ... $80.11; Physician ... $80.11; Certified registered nurse practitioner — psychiatric ... $80.11; For a detailed history, or a detailed medical examination, with medical decision making of moderate complexity: OMHC ... $117.60; Physician ... $117.60; Certified registered nurse practitioner — psychiatric ... $117.60; For a comprehensive history, or a comprehensive medical examination, with medical decision making of high complexity: OMHC ... $157.64; Physician ... $157.64; Certified registered nurse practitioner — psychiatric ... $157.64. The Department shall reimburse an OMHC for crisis therapy, as follows: For a child or adolescent, when rendered by a provider with demonstrated competency to provide mental health services to children or adolescents: For the first 60 minutes ... $118.37; For an additional period of 30 minutes ... $61.77; For an adult: For the first 60 minutes ... $100.10; For an additional period of 30 minutes ... $54.16. Health-General Article, §§10-901, 15-103, and 15-105; Title 16, Subtitles 1 and 2; Annotated Code of Maryland Effective date: Regulations .01 — .08 adopted as an emergency provision effective July 1, 1997 (24:18 Md. R. 1293); adopted permanently effective October 20, 1997 (24:21 Md. R. 1449) Chapter revised as an emergency provision effective July 1, 1998 (25:14 Md. R. 1123) Chapter revised effective October 1, 1998 (25:18 Md. R. 1435 and 25:19 Md. R. 1506) Chapter revised as an emergency provision effective March 1, 2000 (27:4 Md. R. 451); revised permanently effective June 26, 2000 (27:12 Md. R. 1139) Regulation .01D amended as an emergency provision effective July 1, 2002 (29:24 Md. R. 1915); amended permanently effective December 23, 2002 (29:25 Md. R. 1982) Regulation .02B amended as an emergency provision effective July 1, 2002 (29:24 Md. R. 1915); amended permanently effective December 23, 2002 (29:25 Md. R. 1982) Regulation .02B amended as an emergency provision effective July 1, 2003 (30:17 Md. R. 1202); amended permanently effective October 27, 2003 (30:21 Md. R. 1529) Regulation .04A, B amended as an emergency provision effective July 1, 2002 (29:24 Md. R. 1915); amended permanently effective December 23, 2002 (29:25 Md. R. 1982) Regulation .05A, D amended as an emergency provision effective July 1, 2002 (29:24 Md. R. 1915); amended permanently effective December 23, 2002 (29:25 Md. R. 1982) Regulation .06A amended as an emergency provision effective July 1, 2002 (29:24 Md. R. 1915); amended permanently effective December 23, 2002 (29:25 Md. R. 1982) Regulation .09A, B amended as an emergency provision effective July 1, 2002 (29:24 Md. R. 1915); amended permanently effective December 23, 2002 (29:25 Md. R. 1982) Regulation .10A, D amended as an emergency provision effective July 1, 2002 (29:24 Md. R. 1915); amended permanently effective December 23, 2002 (29:25 Md. R. 1982) Regulation .11A amended as an emergency provision effective July 1, 2002 (29:24 Md. R. 1915); amended permanently effective December 23, 2002 (29:25 Md. R. 1982) Regulation .14 adopted as an emergency provision effective July 1, 2003 (30:17 Md. R. 1202); adopted permanently effective October 27, 2003 (30:21 Md. R. 1529) Chapter revised as an emergency provision effective February 1, 2004 (31:5 Md. R. 446); revised permanently effective June 7, 2004 (31:11 Md. R. 857) Regulation .08B amended effective December 19, 2005 (32:25 Md. R. 1942) Regulation .08H adopted effective December 19, 2005 (32:25 Md. R. 1942) Chapter revised as an emergency provision effective July 1, 2006 (33:15 Md. R. 1274); emergency status extended at 34:4 Md. R. 397; revised permanently effective February 26, 2007 (34:4 Md. R. 400) Regulations .02, .03, and .05 — .10 amended as an emergency provision effective July 1, 2008 (35:21 Md. R. 1822) Regulations .02, .03, and .05 — .10 amended as an emergency provision effective December 22, 2008 (36:2 Md. R. 97); amended permanently effective March 23, 2009 (36:6 Md. R. 491) Regulation .03 amended effective January 2, 2017 (43:26 Md. R. 1445) Regulation .03B amended effective January 7, 2013 (39:26 Md. R. 1664); February 3, 2014 (41:2 Md. R. 91) Regulation .03-1 adopted as an emergency provision effective December 22, 2008 (36:2 Md. R. 97); adopted permanently effective March 23, 2009 (36:6 Md. R. 491) Regulation .03-1 amended effective June 27, 2011 (38:13 Md. R. 755) Regulation .03-2 adopted as an emergency provision effective December 22, 2008 (36:2 Md. R. 97); emergency status expired June 19, 2009 Regulation .03-2 amended effective January 7, 2013 (39:26 Md. R. 1664); February 3, 2014 (41:2 Md. R. 91) Regulations .05 — .11 amended as an emergency provision effective July 1, 2007 (34:17 Md. R. 1506); amended permanently effective October 8, 2007 (34:20 Md. R. 1739) Regulation .05 — .11 amended effective January 7, 2013 (39:26 Md. R. 1664); February 3, 2014 (41:2 Md. R. 91) Regulation .08 amended effective June 27, 2011 (38:13 Md. R. 755) Regulation .08C amended effective January 2, 2017 (43:26 Md. R. 1445) Regulation .09I adopted as an emergency provision effective October 20, 2009 (36:24 Md. R. 1855); adopted permanently effective February 8, 2010 (37:3 Md. R. 176) Regulation .09I amended effective June 27, 2011 (38:13 Md. R. 755); December 11, 2014 (41:24 Md. R. 1427) Regulation .09J adopted effective December 11, 2014 (41:24 Md. R. 1427) Regulation .11 amended effective February 3, 2014 (41:2 Md. R. 91) Regulation .12 adopted effective February 3, 2014 (41:2 Md. R. 91) Regulation .13 adopted effective February 3, 2014 (41:2 Md. R. 91) This chapter outlines the staffing and service requirements for a provider of residential crisis services. In this chapter, terms have the meanings stated in COMAR 10.21.17 and this regulation. Term Defined. “Residential crisis services (RCS)” means intensive mental health and support services that are: Provided to a child or an adult with mental illness who is experiencing or is at risk of a psychiatric crisis that would impair the individual's ability to function in the community; and Designed to prevent a psychiatric inpatient admission, provide an alternative to psychiatric inpatient admission, shorten the length of inpatient stay, or reduce the pressure on general hospital emergency departments. The Department shall grant approval to a program to be eligible to receive State or federal funds for providing RCS if the program: Meets the requirements: For approval outlined in COMAR 10.21.16; For administration outlined in COMAR 10.21.17; and Of this chapter, including approval, based on the requirements for intensity of services and staffing outlined in this chapter, for one or more of the following: Inpatient admission prevention; Inpatient admission alternative; or Treatment foster care in a foster home licensed under COMAR 07.02.21; For a program that provides RCS to a child, documents State licensure for the location in which the child will be housed while receiving crisis services; and For a program that provides services to an adult: Documents State licensure for the location in which the individual will be housed while receiving crisis services; Meets the residential site requirements outlined under COMAR 10.21.22, as documented by the residential specialist; or Is located in subacute beds in an inpatient psychiatric facility. A provider of RCS shall assure that services are: Therapeutic; Provided by staff who, as determined by the program, are appropriately credentialed and privileged; Available: 24 hours per day, 7 days per week; On a short-term basis, as needed to resolve an immediate crisis; and At a location in the community, unless given a written exemption from the core service agency (CSA). A provider of RCS shall assure that services are adequate to support one or more of the following levels of service: Inpatient admission prevention, which provides: Services to an individual who, based on the individual's history, as evaluated by a physician or a mental health professional, has a mental disorder and, without RCS, is at risk for inpatient admission or cannot be discharged from an inpatient facility; and Staff adequate to support the services under §B(1)(a) of this regulation, as outlined under Regulations .08 and .09 of this chapter; Inpatient admission alternative, which provides: Services to an individual who, based on an evaluation by a physician or a mental health professional, has a mental disorder, presents a danger to self or others, and would, without RCS, be admitted to or could not be discharged from an inpatient facility; and Staff adequate to support the services under §B(2)(a) of this regulation, as outlined under Regulations .08 and .10 of this chapter, including access to a psychiatrist 24 hours per day, 7 days per week; or Treatment foster care, which provides: Services to an individual who, based on an evaluation by a physician or mental health professional, has a mental disorder, and is in need of a high level of treatment intervention in a family setting; and Staff adequate to support services under §B(3)(a) of this regulation, as outlined under Regulations .08 and .11 of this chapter. A provider of RCS shall assure that services are designed to: Avert or shorten the length of inpatient admissions; Defuse a current crisis, evaluate the nature of the crisis, stabilize the individual to the pre-crisis level of functioning, and intervene to reduce the likelihood of crisis recurrence; Assist the individual and members of the individual's natural support system to recognize and take preventive action to resolve situations that lead to crisis; Provide counseling, training, and support for crisis prevention, identification, and intervention for individuals and, if appropriate, their families; Link individuals with services and supports in the community including, but not limited to, financial, educational, social, medical, and mental health resources that will enable the individual to: Return to the individual's previous living situation; or Secure an alternative living situation; and Offer a home-like environment that provides goal-directed services to facilitate safe discharge from residential crisis services. A provider of RCS shall assure that services are coordinated with, when appropriate: An individual's custodial agents; Designated psychiatric emergency facilities; Psychiatric inpatient facilities; Psychiatric rehabilitation programs; Outpatient mental health clinics; Somatic care providers; Schools; Other agencies involved with the individual, including, but not limited to: Local departments of social services; Department of Juvenile Services; The local education authority; The local coordinating council (LCC); The local management board; and Criminal justice agencies; and Other public and private providers of mental health services to an individual. Eligibility and Referral. An individual is eligible for RCS if: The individual: Is a participant, as described in COMAR 10.21.25.01D(2), in the public mental health system; Has a diagnosis that is listed in COMAR 10.09.70.02; Due to acute symptomatology related to the individual's psychiatric condition, has impaired ability to function within the individual's community living situation and is in need of RCS to avoid inpatient psychiatric admission or to shorten the length of inpatient stay; For clinical reasons, requires a temporary separation from the individual's current living situation; Has stated a willingness to comply with program rules, or, for a child, a parent or guardian has stated a willingness to comply with program rules; Expects, with staff support, to be able to comply with treatment recommendations; and Is able, with staff support, to care for physical needs and basic personal hygiene; and The services are preauthorized, as needed, by the Administration's administrative services organization (ASO) according to the provisions of COMAR 10.21.17.02-1A. An individual is not eligible for RCS if the individual: Has a sole diagnosis of substance abuse, mental retardation, or dementia; Is in need of immediate involuntary inpatient psychiatric admission; As determined by an individual authorized under Health Occupations Article, Annotated Code of Maryland, to make medical determinations, is medically unstable; or Does not meet the eligibility criteria under §A(1)(a) of this regulation. An RCS program may not exclude an individual solely because the individual: Does not participate in other treatment or rehabilitation programs; or Is homeless. Screening Assessment. If an individual who is authorized for services has not, before the individual's entry into the RCS program, been evaluated face-to-face by a physician who documents the elements included in this section, an appropriately privileged mental health professional, in collaboration with the individual, shall conduct a screening assessment to: Assess the individual's needs and willingness to participate in RCS; Document: The diagnosis, if any, provided by the referral source; and If applicable, medications that are prescribed for the individual; In consultation with the individual and, if any, the referral source, outline a preliminary plan for the RCS services to be provided if the individual enters RCS services, including, at a minimum, the level and type of staff support required for the individual's first 48 hours in the program, and, when appropriate, enhanced support such as: 24-hour, on-site; 24-hour, on-site, awake; or One-to-one; and Inform the individual of the rules of the program and the process and procedure for discharge, including situations as outlined under Regulation .12E of this chapter. If, following the assessment under §B(1) of this regulation, the RCS program director determines that the program's services are not appropriate for an individual who has been referred, the program director shall promptly: Inform the individual and, if the individual is a child, the parent or guardian, of the determination and the reason; With proper consent, notify the family or significant others designated by the individual of the determination and of any recommendations for other services; and Notify the CSA and the Administration's ASO for appropriate alternative referral. Admission. Unless an individual has been re-referred to the Administration's ASO under the provisions of §B(2)(c) of this regulation, an RCS program shall initiate services to an individual if: The individual accepts the rules of the RCS program; and When the individual referred for RCS is a child, the parent or guardian signs an agreement with the provider to accept the child for placement upon discharge from RCS. Initial Evaluation. Before the development of the individual treatment plan (ITP), an individual entitled under Health Occupations Article, Annotated Code of Maryland, to render a psychiatric diagnosis shall conduct a face-to-face evaluation with the individual, and, if the individual is a child, with the child's primary caretaker, to: Describe the presenting problem and history of present illness; Collect and evaluate relevant medical and mental health history, including, if any: Previous inpatient and outpatient treatment; and A review of current medications and source of prescriptions; Evaluate current mental status; Either: Formulate and document a psychiatric diagnosis and the rationale for the diagnosis; or Affirm the psychiatric diagnosis, not more than 1 year old, formulated by the referral source and documented in the individual's medical record; and Identify needed treatment. Assessment. Before the development of the ITP, the individual's assigned treatment coordinator shall conduct a face-to-face evaluation with the individual, and, if the individual is a child, with the child's primary caretaker, to: Identify the individual's strengths, needs, and desires; Assess the individual's level of functioning and availability of family and other social supports; Complete an assessment that includes, at a minimum, a review of: The individual's: Legal status; Housing status; Current employment and economic status; History of substance abuse; History of physical or sexual abuse; History of violence or assaultive behaviors; Natural support system; Activities of daily living; and Interpersonal skills; and For a child, in addition to the requirements of §B(3)(a) of this regulation, the child's: Developmental status; Educational history and current placement; Involvement with other agencies; Home environment; and Family history and evaluation of the current family status, including legal custody status; and Initiate the process to determine who will provide the individual's mental health care and treatment upon discharge from crisis services. Diagnosis. The program director shall assure that, before the development of the ITP, RCS staff documents the psychiatric diagnosis rendered according to §A(4) of this regulation. Somatic Care. The program director shall assure that RCS staff coordinates an individual's care with, when known and with proper consent, the individual's somatic care provider. Within 48 hours before or not more than 72 hours after an individual's admission into the program, an individual authorized under Health Occupations Article, Annotated Code of Maryland, shall: Assess the individual's general physical health; Determine whether the individual requires a physical examination or somatic care follow-up; and Make appropriate referrals for services. Individual Treatment Plan (ITP). Treatment Team. At a minimum the following shall participate as members of an individual's RCS program treatment team: The designated treatment coordinator; Relevant RCS staff providing services to the individual; and When available, relevant staff from other agencies currently providing services to the individual. Individual Treatment Plan. Within 24 hours of placement in an RCS program, based on the screening evaluation under Regulation .05C of this chapter, the initial evaluation under Regulation .06A of this chapter, the assessment under Regulation .06B of this chapter, and the psychiatric diagnosis under Regulation .06C of this chapter, the treatment team shall prepare an ITP: In collaboration with: The individual; For a child, the parent or guardian and, if other than the parent or guardian, the primary caretaker; and When appropriate and with proper consent, the individual's family and others involved in the individual's care; That includes, at a minimum: The psychiatric diagnosis as provided in Regulation .06C of this chapter; A description of the individual's current behavior, symptoms, and level of functioning that includes the individual's presenting strengths, needs, and treatment expectations and responsibilities; When relevant to the individual, a description of the family's or significant others' needs and strengths; Mental health treatment goals, including the plan for transition and discharge, to be accomplished during an individual's residence in an RCS program, which are outcome oriented and stated in behavioral, measurable terms; and The anticipated length of stay in the RCS program; and That specifies treatment strategies, including: Recommended modality and frequency of interventions, including, if appropriate, case management services; Target dates for goal achievement; The designation of RCS staff responsible for implementing the elements of the plan; Scheduled daytime activities, if any, such as a partial hospitalization program (PHP), psychiatric rehabilitation program (PRP) on-site or off-site services, and school services; and When appropriate, identification of, recommendations for referral to, and collaboration with, other services to support the individual's treatment. Signature of the ITP. The individual or, for a child, the parent or guardian shall sign or tape record agreement or disagreement with the ITP and reviews. A child's primary caretaker, if other than the parent or guardian, shall sign or tape record acknowledgment of the ITP and reviews. In addition, the following shall sign the ITP and reviews: The individual's treatment coordinator; When there is an RCS psychiatrist, the RCS psychiatrist; and When there is a mental health professional, the mental health professional. Discharge Before the ITP. When an individual is discharged within 24 hours of admission to RCS, if the treatment team has not developed an ITP, the treatment coordinator shall document, in the individual's medical record, a brief description of the goals established and interventions employed. Continued Evaluation. Contact Notes. In order to assure that services to an individual are timely and appropriate, staff shall document in the individual's medical record contact notes regarding all clinically relevant face-to-face, telephone, and written contacts with or about the individual, including the dates, locations, and types of contacts. Progress Summary Notes. The individual's treatment coordinator shall document or assure that staff document in the individual's medical record a daily progress summary note that includes: A description of progress toward goals; Changes in goals and interventions based on the review of progress; and The rationale for the changes. The program director shall ensure that the RCS staff is sufficient in numbers and qualifications to carry out the program's service goals and includes, at a minimum, the staff identified in this regulation and Regulations .09 — .11 of this chapter. Program Director. The governing body shall employ a program director who: As determined by the governing body, has sufficient qualifications, knowledge, and experience to execute the duties of the position; Is available to provide RCS administration and supervision: For the amount of time necessary to carry out the duties and, at a minimum, 10 hours per week; and If a RCS program operates in more than one site, by: Designating, as necessary, staff to manage services at each site and report to the program director and Having contact with each site each week; Is responsible for operational oversight for, at a minimum: Fulfilling the administrative requirements under COMAR 10.21.17 and the day-to-day operations of the RCS program; Maintaining sufficient staff, including recruiting, hiring, scheduling, and terminating; Consulting on the development and implementation of the budget; Keeping the governing body informed of, at a minimum, the program's approval status and performance; and In collaboration with appropriate RCS staff, assuring staff compliance with: Credentialing and privileging; Appropriate training and supervision; and When required, the on-call availability of a psychiatrist; and If appropriately credentialed and privileged, may provide RCS services. Treatment Coordinator. The program director shall assign to each individual who is receiving RCS a treatment coordinator who, as privileged by the program, shall provide or coordinate the services outlined in this chapter for the specific type and level of RCS. Direct Service Providers. The program director shall employ a sufficient number of direct service providers who: As determined by the program, have sufficient qualifications and experience to carry out the duties of the position; Before providing services, have training applicable to the service, including, at a minimum, training in: Crisis intervention; Suicide prevention; Behavior modification; and Family interactions; and As permitted under the Health Occupations Article, Annotated Code of Maryland, and as privileged by the program, provide the level and intensity of supervision and support required under this chapter for the specific type and level of RCS indicated in an individual's ITP. Staff Support. The program director shall assure that the program: Has at least one staff person on duty at all times that a resident is present in the RCS facility; Has the capacity for and, when required by an individual's ITP, provides 24-hour awake staff support; Has the capacity for 1:4 coverage and, when required by an individual's ITP, provides 1:4 coverage; and If the program serves children, provides at least one staff member for every three children. Psychiatric Evaluation and Intervention. The program director shall assure that a psychiatrist provides evaluation and prescribed needed treatment interventions, either: By consultation with the psychiatrist who is currently treating the individual; or Through a written agreement with a provider of mental health treatment, who will provide face-to-face evaluation by a psychiatrist before the development of the ITP. Treatment and Support Services. The program director shall assign to each individual who is receiving RCS a treatment coordinator who shall assure that the individual receives: The care or treatment recommended under Regulation .07A of this chapter; Monitoring of the individual's condition; Supportive counseling focused on: Assessment and definition of problems; Planning and goal setting; Development of effective problem-solving techniques; and Evaluation of progress; Assistance in accessing community resources, including case management, that are essential to meeting the individual's identified needs; and Transition services and discharge planning. Medication Services. Monitoring. A member of the treatment team privileged to do so shall provide the following medication monitoring services: Supporting the individual's self-administration of medications, including both prescribed and over-the-counter medications; To the extent possible, monitoring compliance with instructions appearing on the label or a more recent physician's order; Reading the label to assure that each container of medication is clearly labeled with the individual's name, the contents, directions for use, and expiration date; Assuring that each individual has secure, appropriate, and accessible space in which to store medications; Observing and documenting medications taken and any apparent reactions to the medication, and, either verbally or in writing and in a timely fashion, communicating to the prescribing authority problems that possibly may be related to the medication; and Reinforcing education on the role and effects of medication in symptom management. Administration. If an individual's ITP requires that RCS staff administer medication, only an individual authorized to do so under Health Occupations Article, Annotated Code of Maryland, may administer medication. Staff Support. The program director shall ensure: That sufficient staff are on duty at all times to relate to the expected clinical needs of the individuals in the residence; and At a minimum: The provision of at least one on-site, awake staff for every four individuals receiving RCS or, if a child is in the residence, one staff for every three individuals; The availability, based upon clinical acuity and the request of on-duty staff, of at least one other staff member to arrive at the RCS program within 1 hour of a request; and That the program has the capacity for 1:1 coverage, and provides 1:1 coverage when clinically indicated. Psychiatric Evaluation and Intervention. The program director shall assure that a psychiatrist: Is available on call, 24 hours per day, 7 days per week; Within 24 hours of an individual's admission: Conducts a face-to-face evaluation; Either: Formulates and documents a psychiatric diagnosis and the rationale for the diagnosis; or Affirms the psychiatric diagnosis formulated under Regulation .06A(4) of this chapter; and Through participation in the ITP, prescribes treatment interventions; and If the individual presents a danger to self, indicates appropriate staff coverage and precautions. Treatment and Support Services. The program director shall ensure that a mental health professional: Provides regular supervision of all treatment staff; and Each day, either: Monitors, face-to-face, an individual's condition and documents significant changes; or Consults with staff regarding the clinical needs of an individual. The program director shall assign a treatment coordinator who shall assure that the individual receives: Care or treatment recommended under Regulation .07A of this chapter; and The services under Regulation .09C(1)(c) — (e) of this chapter. Medication Services. Monitoring. When required by the individual's ITP, a member of the treatment team credentialed and privileged to do so shall provide medication monitoring, as outlined in Regulation .09C(2)(a) of this chapter. Administration. The program director shall assure that an individual authorized under Health Occupations Article, Annotated Code of Maryland, is available to administer medication in a case where medication administration is required by an individual's ITP. Staff Support. The RCS program director shall assure that: RCS mental health professional staff provides, to the foster care provider, specialized training in mental health crisis recognition, management, and intervention, before placing any individuals in the foster home; and The RCS program has the capacity to provide staff to deliver, in the foster home, on an emergency basis: 24-hour, awake supervision; and One-to-one support. Psychiatric Evaluation and Intervention. The program director shall ensure appropriate evaluation and documentation of needed treatment interventions: By consultation with the psychiatrist who is currently treating the individual; Through a written agreement with a provider of mental health treatment, who will provide face-to-face evaluation by a psychiatrist before the development of the ITP; or Through a written agreement with an outpatient mental health clinic, approved under COMAR 10.21.20, that will provide consultation with a psychiatrist and face-to-face evaluation by a mental health professional privileged by the program and appointed by the medical director to provide the service. Treatment and Support Services. The program director shall assure that: An individual receives the care or treatment outlined in the ITP under Regulation .07A of this chapter; and As required by an individual's ITP, a mental health professional is available to provide mental health services on site at the foster home. Medication Services. A foster care provider shall: Administer an individual's medications, as permitted under COMAR 10.27.11; or Monitor an individual's self-administration of medications. The program director shall assure that, if an individual's ITP requires that RCS staff provide medication services, monitoring or administration of medication is carried out as outlined under Regulation .09C(2) of this chapter. Discharge Policy. The program director shall: Collaborate with the Administration's ASO to: Arrange for discharge from the program when services are no longer authorized by the Administration's ASO; and Make recommendations for referral for alternative services for an individual for whom the program's services are not appropriate; and Maintain clearly written policies and procedures for: Transition services; Collaborative discharge from the program; and Making recommendations for discharge and referral for alternative services for an individual for whom the program's services are not appropriate. Transition. The treatment coordinator shall: Collaborate with the Administration's ASO to provide interim services and assure appropriate referrals for authorization for case management and other service providers before discharge; and With proper consent and while the individual is still in the RCS program, contact the providers who have been authorized to provide the services designated in the discharge summary. Collaborative Discharge. When the Administration's ASO, in consultation with the treatment coordinator, determines that services are no longer medically necessary, the rehabilitation coordinator shall: Prepare a discharge plan based on an assessment of the individual's current service needs and mutually agreed upon goals, in collaboration with: The individual, and, for a child, the primary caretaker; and With proper consent: Family or significant others designated by the individual; and When feasible, other treatment and service providers; When needed, make appropriate recommendations to the Administration's ASO for treatment, rehabilitation, and community supports; and Complete a discharge summary in accordance with COMAR 10.21.17.07D(3). Individual's Discontinuation of Services. When an individual discontinues services before a planned, collaborative discharge as described in §C of this regulation, the treatment coordinator shall: When possible, give the individual information about appropriate alternate services; If authorized by the Administration's ASO, provide appropriate outreach to encourage the individual to access appropriate services; With proper consent, provide notice of the discontinuation to: The emergency contact named by the individual at the time of admission; When feasible, other service providers, including the individual's somatic care provider, when known; and When needed, the CSA and the Administration's ASO, for referral for appropriate alternative services; and Complete a discharge summary in accordance with COMAR 10.21.17.07D(3). Program's Recommendation to Discontinue Services. If, in consultation with the program director, the treatment coordinator recommends discharging an individual who does not comply with the program's rules or for whom the program's services are not appropriate, the program director shall: Provide written notice of the intention to discharge from services and recommend referral for alternative services: To the individual and, for a child, the parent or guardian and, if other than the parent or guardian, the primary caretaker; With proper consent to: The emergency contact named by the individual at the time of admission; When feasible, other service providers; and When needed, the CSA and the Administration's ASO, for referral for appropriate alternative services; That includes: The effective date of the action; The reason for the action; and When possible, a discharge plan; and Complete a discharge summary in accordance with COMAR 10.21.17.07D(3). Health-General Article, §§10-901 and 10-902, Annotated Code of Maryland Effective date: December 28, 1998 (25:26 Md. R. 1926) Regulation .02B amended as an emergency provision effective June 1, 2007 (34:13 Md. R. 1149); amended permanently effective August 13, 2007 (34:16 Md. R. 1432) Regulation .03C amended as an emergency provision effective June 1, 2007 (34:13 Md. R. 1149); amended permanently effective August 13, 2007 (34:16 Md. R. 1432) This chapter outlines the staffing and service requirements for a provider of respite care services. In this chapter, terms have the meanings stated in COMAR 10.21.17 and in this regulation. Term Defined. “Respite care” means services that are: Provided for an adult with serious and persistent mental illness or a child with serious emotional disturbance; Provided on a short-term basis in a community-based setting; and Designed to support an individual to remain in the individual's home by: Providing the individual with enhanced support or a temporary alternative living situation; or Assisting the individual's home caregiver by temporarily freeing the caregiver from the responsibility of caring for the individual. The Department shall grant approval to a program to be eligible to receive State or federal funds for providing respite care services if the program: Is approved as: A mobile treatment services (MTS) provider under COMAR 10.21.19; An outpatient mental health clinic (OMHC) under COMAR 10.21.20; or A psychiatric rehabilitation program (PRP) under COMAR 10.21.21; and Meets the requirements of this chapter, including approval to provide either or both of the following specific respite care services: In-home respite, in an individual's place of residence; Out-of-home respite, in a home or facility that is appropriately licensed, registered, or approved, based on: The age of individuals receiving services; and Whether the respite is partial day or overnight. The program director shall assure that respite care services are: Designed to fit the needs of the individuals served and their caregivers; and Delivered by individuals who are privileged by the program to provide a particular service. As approved under this chapter, a program may provide respite care services as needed for an individual: With advance planning; or As needed in an immediate situation, to resolve or ameliorate a problem in the living situation. Referral. An individual or the individual's caregiver may request respite care services, or an agency providing mental health treatment or support services to an individual may refer the individual for respite care services. Eligibility. An individual is eligible to receive respite care if: The individual is a participant, as described in COMAR 10.21.25.01D(2), in the public mental health system; The individual has a diagnosis that is listed in COMAR 10.09.70.02; The individual is: An adult who has serious and persistent mental illness and who lives independently or in a family-like setting, or in a residential rehabilitation program (RRP) under the provisions of COMAR 10.21.22; or A child who has a serious emotional disturbance and who lives with a parent, guardian, or other primary caretaker in a family-like home, or in a foster home under the provisions of COMAR 07.02.11 or 07.02.21; and The services are preauthorized, as needed, by the Administration's administrative services organization (ASO) according to the provisions of COMAR 10.21.17.02-1A. An individual is not eligible to receive respite care if the individual is a resident of a therapeutic group home (TGH) licensed under COMAR 10.21.07 or a facility licensed under Health-General Article, Title 19, Annotated Code of Maryland. Screening. Upon receipt of a referral for respite care, the program director shall ensure that respite care staff: Conduct a screening assessment with the: Individual for whom respite care services are requested; The caregiver or significant other, if any; and Referral source, if any; Evaluate whether the respite care is needed: At a specific future time; Immediately; or Intermittently; Outline, in consultation with the individual and the caregiver, a preliminary plan, including the schedule for respite care, for the services to be provided in accordance with this chapter; Based on consultation with the individual and, if any, the referral source, document: The expected duration of the respite care; The frequency, level, and type of staff contacts needed, such as staff availability: At a minimum, on call, 24 hours per day, 7 days per week; or On site for up to 24 hours per day, 7 days per week; and If applicable, medications that are prescribed for the individual; and Inform the individual and the caregiver of the rules for the respite care episode. Acceptance. Upon acceptance of an individual for respite care, staff assigned by the program director, in consultation with the individual and the caregiver, shall: Perform an assessment of: The individual's and the caregiver's strengths and needs; and Interventions needed by the individual during respite; In order to ensure continuity of care, document information regarding, at a minimum, the individual's participation in: Outpatient mental health treatment; Psychiatric rehabilitation; School; Work; or Other scheduled activities; Taking into consideration the needs under §§C(4) and D(2) of this regulation, formulate an initial plan for respite services, including the: Schedule for providing respite care; Location; Level of staff support; Schedule of the individual's activities during respite; and Needed interventions to facilitate the individual's remaining in or returning to the living situation. The program director shall ensure that: Services are planned according to the duration, frequency, and location of the respite care; An individual receives services according to a plan that includes: Based on the initial plan under Regulation .05D(3) of this chapter, a schedule of the individual's activities during respite; When needed, medication monitoring; and The frequency and intensity of staff support; Services are coordinated with an individual's individual treatment plan or individual rehabilitation plan; Respite staff document a plan to be implemented in the event of a crisis; and Staff provide referrals or coordinate referrals with other current treatment providers, as needed, for additional services for the individual. Planned Conclusion. At the agreed upon time of conclusion of a respite care episode, the program director shall assure that staff document a summary of the episode in the individual's record. Individual's Discontinuation of Services. If an individual elects to discontinue services before the planned conclusion of a respite episode, as described in §A of this regulation, the program director shall: Promptly notify the individual's caregiver or designated emergency contact; If the individual is a child, discharge the child only to an adult who is legally responsible for the child; Notify the CSA and the Administration's ASO of the action; and Assure that staff document a summary of the episode in the individual's record. Program's Recommendation to Discontinue Services. If the program director recommends discharging an individual who does not comply with the program's rules or for whom the program's services are not appropriate, the program director shall follow the provisions outlined in §B of this regulation. Respite Care Program Director. The MTS, OMHC, or PRP program director shall either: Carry out the respite care program director's duties that are delineated in this chapter; or Appoint a respite care program director with sufficient qualifications, knowledge, and experience to execute the duties of the position. Respite Care Specialists. The respite care program director shall employ a sufficient number of staff who: As determined by the program director, have sufficient qualifications and experience to carry out the duties of the position; Before providing services, have training applicable to the service, including, at a minimum, training in: Mental illness and emotional disorders; Psychiatric medications; Crisis intervention; Family interactions; and For staff who provide services to children: Growth and development; and Behavioral intervention; and As permitted under the Health Occupations Article, Annotated Code of Maryland, and as privileged by the program, are available to carry out the: Program model described in Regulation .04 of this chapter; and Activities outlined in an individual's respite care plan under Regulation .06 of this chapter. Health-General Article, §§10-901 and 10-902, Annotated Code of Maryland Effective date: November 16, 1998 (25:23 Md. R. 1697) This chapter outlines the staffing and service requirements that a mental health vocational program (MHVP) shall fulfill to be approved by the Department to be eligible to receive State or federal funds to provide services. In this chapter, terms have the meanings stated in COMAR 10.21.17 and in this regulation. Terms Defined. Agency-Sponsored Employment. “Agency-sponsored employment” means an employment program designed to assist an individual to obtain employment at locations owned, leased, rented, or managed by the provider, at other locations by an agency-held contract, at a consumer-operated business or program, or work enclave that provides: Compensation to individuals according to the standards established by the Department of Labor; Opportunity for individuals to have contact with nondisabled individuals and the public to the same extent that nondisabled individuals in comparable positions interact with the public; and Additional supports, as needed, to the individual in the work setting. “Agency-sponsored employment” does not include sheltered workshops. “Competitive work” means employment in the competitive labor market that pays minimum wage or higher and compensation is consistent with the wage standards provided in the Fair Labor Standards Act. “Consumer-operated business” means a program owned or managed by an individual who has a disclosed mental illness that provides compensated employment for an individual who has a disclosed mental illness. “Employment specialist” means a program staff member who helps individuals in the public mental health system (PMHS) to: Obtain competitive employment; Learn work tasks; Resolve job-related or on-the-job problems; and Maintain competitive employment. “Extended support services” means ongoing support services and other appropriate services needed to support and maintain an individual after the individual has made the transition from time-limited, intensive job-coaching services. “Industry” means the employer hiring an individual in the public mental health system. “Integrated work” means work that provides an individual an opportunity to interact with nondisabled individuals. “Intensive job coaching” means frequent and intensive support provided to an individual at a job site and off a job site during the initial stages of an individual's employment in order for an individual to learn and to manage a job. “Job stability” means a situation in which an individual is performing job duties satisfactorily and is reasonably expected to continue that level of performance. “Natural support” means the assistance received from an individual's family members, significant others, friends, neighbors, and coworkers. “Sheltered workshop” means employment in a workshop or work-activity center or a physically separated department of an agency or organization having an identifiable program of rehabilitation, separate tasks, supervision, records, and compensation for individuals with disabilities. “Supported employment program” means a program designed to assist an individual to obtain competitive employment in an integrated work environment that provides: Compensation to individuals of at least minimum wage; An individualized approach that establishes an hours-per-week employment goal to maximize an individual's vocational potential; Additional supports, as needed, delivered where appropriate; and Transitional employment placements, as appropriate. “Transitional employment” means a series of planned temporary, sequential job placements, with continuous support services, provided to an individual in the public mental health system until job permanency is achieved. “Work enclave” means a group of individuals with mental illness for whom an agency: Has negotiated access to jobs in community businesses; Guarantees completion of the individuals' work; and Provides compensation for the hours worked. The Department may approve a program as an MHVP if the program meets the requirements: For approval outlined in COMAR 10.21.16; For administration outlined in COMAR 10.21.17; and Of this chapter. Before rendering services to an individual, a provider shall notify the core service agency (CSA) of the jurisdiction in which the individual resides and receive preauthorization for services. The program director shall ensure that services: Are designed to: Support an individual in the public mental health system to be able to: Choose, obtain, and maintain employment; Make vocational decisions and career changes; and Enhance an individual's natural supports; Are provided in a flexible manner to support an individual's vocational plan throughout an individual's employment, including periods of unemployment; Include: Ongoing assessment and planning with an individual and, when appropriate, an individual's family or natural supports; As needed, vocational training; Marketing to industries in the community; and Referral for services an individual needs, which are not provided by the program; Promote placement in a work environment that: Is free of recognized hazards likely to cause serious bodily injury or death and comply with any specific safety and health standards set for the industry; If not free of all recognized hazards likely to cause serious bodily injury or death, provides information to employees regarding the exposure to hazardous materials and substances; and Compensates individuals at least at minimum wage; and Are adequate to support an individual's placement in a supported employment program or an agency-sponsored employment program. Eligibility. An individual is eligible for MHVP services if: The individual: Is a participant in the public mental health system; Has a diagnosis listed in COMAR 10.09.70.02; Is an individual for whom competitive employment has not occurred, has been interrupted, or has been intermittent; Wants to work; and Is in need of ongoing MHVP services to enable the individual to choose, obtain, or maintain employment; and The services are preauthorized by the CSA of the jurisdiction in which the individual resides. Screening. Upon receipt of a referral and when appropriate, the program shall request authorization from the appropriate CSA to provide services. Within 10 working days of receipt by the program of CSA authorization for MHVP assessment under §A(2) of this regulation, staff assigned by the program director, in collaboration with the individual, shall conduct a screening assessment to: Assess the individual's: Interest in employment and desire to work; Willingness to participate in MHVP services; and MHVP services needs; and Determine the program's ability to address the individual's employment needs identified in §B(2)(a)(iii) of this regulation. After the screening under §B(2) of this regulation, if the program director determines that a program's services are not appropriate for an individual, the program director shall, in writing, promptly: Inform the individual of the determination and the reason; Provide the individual with recommendations for alternative services; With proper consent, notify the family or significant others designated by the individual, of the determination and of any recommendations for other services; and Notify the CSA of the determination. Within 10 working days of the screening conducted under §B(2) of this regulation, unless the program director has notified the individual and the CSA of the determination under §B(3) of this regulation, the program director shall notify the individual that the program either: Accepts the individual and identifies a date that the program proposes to initiate services to the individual; or Will accept the individual, following an updated review of the individual's eligibility status, when program capacity permits. If the individual is accepted under §B(4)(b) of this regulation, the program director shall inform the individual of the: Individual's placement on a waiting list, if any; and Estimated date services may be initiated. If the individual is placed on a waiting list under §B(5)(a) of this regulation, the program director shall discuss with the individual: The option of remaining on the program's waiting list until the date established under §B(5)(b) of this regulation; and Alternative services that are available. Enrollment. Within 10 working days of the date established under §B(4)(a) of this regulation or following an updated review under §B(4)(b) of this regulation, MHVP staff assigned by the program director shall: Provide an orientation to the program, including: A description of the MHVP services available; and The individual's rights and responsibilities; and In writing, inform the individual of the policy and procedures for discharge, including conditions, as outlined in Regulation .11D of this chapter, that may result in the program's discharging an individual, and making recommendations for alternative services. Vocational Assessment. Within 10 working days of initiation of MHVP services, MHVP staff assigned by the program director to conduct assessments, in collaboration with the individual and, with proper consent, family or significant others designated by the individual, shall complete a face-to-face MHVP assessment that includes, at a minimum: Documentation of the individual's employment interests, preferences, and skills; An evaluation that identifies the individual's competencies, work needs, and readiness for employment; Identification of obstacles and barriers to work such as transportation and impact on entitlements; Relevant information from the screening conducted under Regulation .06B of this chapter; and If appropriate, relevant information from previous vocational screenings or assessments. Individual Vocational Plan (IVP). Initial IVP. Within 30 days of initiation of MHVP services and based on the vocational assessment completed according to §A of this regulation, the individual's employment specialist shall prepare an initial IVP: In collaboration with: The individual; With proper consent, family or significant others designated by the individual and others involved in the individual's care; and If appropriate and with proper consent, other mental health service providers, as available; That, if applicable and with proper consent, is coordinated with the: Maryland State Department of Education, Division of Rehabilitation Services' (DORS) individual plan for employment; and Individual's individual treatment plan, individual rehabilitation plan, and case management personal plan; That is designed to assist the individual to identify, obtain, and maintain vocational goals; That identifies the individual's: Strengths; Vocational service needs; Vocational goals, including target dates; Vocational interventions, including but not limited to a systematic plan of instruction in work skills and behaviors to be learned and, if applicable, benefits management and staff responsible for implementation; and Plan for obtaining a job that matches the individual's interests, preferences, abilities, and needed accommodations and adaptations. IVP Review. As frequently as necessary, as determined by an individual's employment specialist, and at least every 6 months, the employment specialist, in consultation with the individual, shall: Review and record in the individual's employment record: The individual's progress toward the accomplishment of previously identified vocational goals; Goal changes, based on a review of the individual's progress; and Changes in interventions, including staff responsibility; Communicate promptly the results of the review to: Relevant program staff; and With the individual's consent, community mental health programs providing services to the individual and family or significant others; Assess the individual's satisfaction with the job and the MHVP services; and When the individual is employed through agency-sponsored employment, assess the individual's preferences and readiness for competitive work. Signature of the IVP and IVP Reviews. The employment specialist shall obtain the individual's written or witnessed verbal agreement or disagreement with the plan, and, in addition, the following shall sign the plan and reviews: The employment specialist; and Other MHVP staff responsible for implementing the plan. Continuing Evaluation. At least once a month the employment specialist shall record in the individual's MHVP employment record a progress summary note regarding: The delivery of services, including those outlined in Regulation .07B(1)(d) of this chapter, specified by the IVP; Progress toward goal achievement; Changes in the individual's status; If applicable, coordination with DORS; and If applicable, suggested changes in employment goals and vocational services delivered. Entitlement and Resource Education Services. The program director shall ensure that MHVP staff educate an individual about: The financial impact of employment on disability benefits, entitlements, and other benefits; Access to such Social Security programs as Plan to Achieve Self- Sufficiency and Impairment-Related Work Expense and the individual's rights and responsibilities under such programs; Access to additional benefits and other resources; and Benefits and risks of disclosure to the employer of the individual's disability. Job Development and Placement Services. The program director shall ensure that MHVP staff: Develop close cooperation with industries, unions, and other community resources related to employment opportunities; Regularly survey the local business community and develop an ongoing marketing strategy to increase employment opportunities for individuals served; When appropriate, facilitate an appropriate match between an individual and a job by reviewing the: Benefits and wages; Necessary work skills; Required functional abilities; If applicable, accommodations and adaptations required for the individual; Opportunities to participate in work-related social activities to develop natural support; and Employee orientation; When appropriate, ensure that the individual receives, at a minimum, information regarding the: Job duties; Salary scale and benefits; Work schedule; Responsibilities of the employer; Responsibilities of the individual; Fringe benefits; Wage payment practices; Nondiscrimination provisions; and Process for the filing and resolution of grievances; and When an individual's employment status changes, assists the individual to maintain the goal of employment by facilitating additional job placements. Employment Support Services. The program director shall ensure that, as required by an individual's IVP, the individual's employment specialist: Provides or arranges for the provision of: Job coaching, which includes training in job tasks and responsibilities; Assistance, upon request, and with the individual's consent, to the industry on effective strategies to help the individual remain on the job; and Activities directed toward the development of skills, including, but not limited to: Personal hygiene and grooming specific to the employment environment; Effective communication with supervisor and coworkers; and Transportation to and from work; and Extended support services, which may include §C(1)(a) — (c) of this regulation, in order to assist the individual to maintain employment; Encourages the individual to: Use natural supports; and Develop an employment-related support system through relationships with coworkers, supervisors, and others in the work environment; Provides the services outlined in this regulation, when appropriate, and with the individual's consent, at the job site or at another location appropriate to the individual's needs; and Has at least two face-to-face contacts a month with the individual. In addition to the requirements under Regulations .01B(1) and .05E(1) of this chapter, an MHVP supporting individuals in a SEP program shall provide: With proper consent, at least one contact per month with the industry to receive information regarding the individual's performance on the job; and The services outlined in this chapter. In addition to the requirements under Regulations .01B(2) and .05E(2) of this chapter, an MHVP supporting individuals in an agency-sponsored program shall: Provide additional supports to the individual at the work site, which shall include: Staff, on site, during the hours the individual is employed, to provide: Supervision; Skills assessment; On-the-job training; and Mentoring; and Documentation of an assessment of the individual's potential for community employment at least semiannually; In accordance with personnel policy and procedure, provide the individual with the following, if provided to nondisabled employees: Employee benefits; For each pay period, a written statement that indicates gross pay, hours worked, deductions, and net pay; Consistent with federal wage and hour laws at least annually, a review of the individual's wages and work performance; and Wages based on individual performance rather than on group wage payments; If paying subminimum wages, be in compliance with DOL regulations, documented by the appropriate DOL certificate; and Provide the services outlined in this chapter. Discharge Policy. The program director shall: Maintain clearly written policies and procedures for: The process for discharge; If the program's services are not appropriate for the individual, making recommendations for discontinuing services and referring the individual for alternative services, including the criteria for discontinuing services according to this paragraph; and Providing the individual with information about how to reaccess services when needed; and Notify the authorizing CSA of the determination under §A(1)(b) of this regulation. Collaborative Discharge. When the employment specialist, in collaboration with the individual, determines that MHVP services are no longer appropriate, the employment specialist shall: Prepare a discharge plan: In collaboration with: The individual; and With proper consent, family or significant others designated by the individual and, if feasible, other treatment and service providers; and That is based on an assessment of the individual's current vocational status, service needs, and mutually agreed-upon goals; As necessary, make appropriate recommendations for treatment, rehabilitation, and community supports; Complete a discharge summary in accordance with COMAR 10.21.17.07D(3); and Notify the CSA of the discharge. Individual's Discontinuation of Services. When an individual discontinues services before a planned, collaborative discharge as described in §B of this regulation, the employment specialist shall: If possible, give the individual information about appropriate alternative services; If authorized, provide outreach to encourage the individual to access appropriate services; With proper consent and if needed, provide notice of the discontinuation to the CSA or the Department's administrative services organization for referral for appropriate alternative services; and Complete a discharge summary in accordance with COMAR 10.21.17.07D(3). Program's Recommendation to Discontinue Services. If, in consultation with the program director, the employment specialist recommends discontinuing services for an individual for whom, because of the individual's actions, the program's services are not appropriate, the program director shall provide written notice of the intention to discontinue services and recommend referral for alternative services. Except in the case of imminent danger, the program director shall provide the notice at least 30 days before discontinuing services. The program director shall ensure that the notice is sent to the individual and, with proper consent, to the CSA or the Department's administrative services organization for referral for appropriate alternative services. The program director shall include in the notice: The effective date of the action; The reason for the action; and If possible, a discharge plan. The program director shall ensure that staff complete a discharge summary in accordance with COMAR 10.21.17.07D(3). A provider of MHVP shall ensure that MHVP staff includes, at a minimum: A program director who: Has sufficient qualifications, knowledge, and experience to execute the duties of the position; Is available for an amount of time calculated on the basis of a half-hour per individual receiving services, up to a maximum of 40 hours per week; Is available to provide MHVP administration and supervision; and May provide MHVP services; Employment specialists who have sufficient qualifications, knowledge, and experience to work with the individuals served by the program; and Program staff sufficient to carry out the: Program model described in Regulation .04 of this chapter; Services delineated under Regulation .10 of this chapter; and Activities outlined in the individual's IVP. The program director shall assure that the MHVP: Has a clear description of the role and function of the staff providing MHVP services; Staff is sufficient in numbers and qualifications to carry out the program's service goals and includes, at a minimum, the staff identified in this regulation; and Has a contingency plan for staff availability to provide necessary MHVP services to an individual in the absence of regularly assigned staff. Ratio. A provider of MHVP services shall maintain a maximum ratio of one MHVP employment specialist serving each 15 individuals receiving MHVP services. Volunteers, Students, and Trainees. The program may use volunteers, students, and trainees according to the provisions of COMAR 10.21.17.09E. Health-General Article, §§10-901 and 10-902, Annotated Code of Maryland Effective date: July 9, 2001 (28:13 Md. R. 1215) This chapter outlines the service requirements and staffing standards for a psychiatric rehabilitation program (PRP) for minors that provides psychiatric rehabilitative services to a minor. In this chapter, terms have the meanings stated in COMAR 10.21.17. The Department shall grant approval to a program to be eligible to receive State or federal funds for providing PRP services for minors if the program meets the requirements: For approval outlined in COMAR 10.21.16; For administration outlined in COMAR 10.21.17; For Medical Assistance providers outlined in COMAR 10.09.36, 10.09.59, and 10.09.70; and Of this chapter. A provider of PRP services for minors shall: Have a facility that: Meets all relevant federal, State, or local ordinances, laws, regulations, and orders governing the program; Is not located in a private residence; Is accessible to the public; and Contains a secure area where records, logs, and business information may be kept; Prominently display the hours of operation of the facility; Provide services at the PRP facility and at other locations according to the needs of the individuals served; Assure that individuals receiving services have the choice to receive services on-site or at another suitable location; and Assure that program staff are available by telephone, on call, 24 hours per day, 7 days per week. The program director shall organize program services and supports to: Facilitate the development of a minor's independent living and social skills, including the minor's ability to make decisions about the minor's life and create opportunities for choice, to the degree that is age and developmentally appropriate, regarding: Home; School or work; and Community; and Promote the use of community resources to integrate the minor into the community. The program director shall ensure that: Services are: Appropriate to the age of the populations being served; Offered at times suitable to the minors served; Coordinated with other mental health services that the minor is receiving; Goal directed; Outcome focused; Available as long as the minor meets medical necessity criteria for PRP services; Based on a functional assessment of the minor across life domains; Part of a total plan of care, which is directed at maintaining the minor in their home and preventing out-of-home placement; Integrated with the minor's ITP; and Designed to reduce functional behavioral impairments and restore and strengthen age-appropriate skills; If the PRP provides services to minors in a specific age group or with a particular clinical profile, the initiation of service criteria is consistent with the populations to be served; When the PRP provides services in a facility, the services shall be provided on a regular basis and include a variety of group and individual rehabilitation activities that incorporate individual rehabilitation goals; and If the PRP provides services to both minors and adults, the program activities for minors are separate from program activities for adults, unless the adult receiving PRP services is a parent or caregiver of the minor. A parent or guardian of a minor shall receive all notifications and information regarding PRP services for a minor, unless the minor is 16 years old or older and has consented to PRP services rather than a parent. If a minor who is 16 years old or older and has consented to PRP services rather than a parent or guardian, consent from the minor shall be obtained before providing a parent or guardian any notifications or information regarding PRP services for a minor. Eligibility. A minor is eligible for PRP services if, as a result of a serious emotional disturbance, the: Minor: Has been referred for PRP services by a licensed mental health professional who is providing inpatient, residential treatment center, or outpatient mental health services to the minor; Is currently in, and remains in active mental health treatment; and Has the appropriate consent to participate in PRP services; and Administration's administrative services organization: Determines that the services are medically necessary; and Authorizes the services according to the provisions of COMAR 10.21.17.03A. PRP services for minors shall be prioritized for minors who have a serious emotional disturbance and who meet the following eligibility criteria: Have severe functional impairments in at least one or more life domains; Based on the clinical evaluation and ongoing treatment plan, are, with PRP services, expected to have reduced symptoms of their mental illness or their functional behavioral impairment as a result of their mental illness; Have an impairment as a result of their mental illness that results in: A clear, current threat to the minor's ability to be maintained in the minor's customary setting; An emerging or pending risk to the safety of the minor or others; or Other evidences of significant psychological or social impairment such as inappropriate social behavior causing serious problems with peer or family relationships; Due to dysfunction, is at risk for requiring a higher level of care, or is returning from a higher level of care; There is clinical evidence that: The current intensity of outpatient treatment will not be sufficient to reduce the minor's symptoms and functional behavioral impairment resulting from the mental illness and restore the minor to an appropriate functional level, or prevent clinical deterioration, or avert the need to initiate a more intensive level of care due to the current risk to the individual or others; or For minors transitioning from an inpatient, day hospital, or residential treatment setting to a community setting, PRP services will be necessary to prevent clinical deterioration and support successful transition back to the community, or avert the need to initiate or continue a more intensive level of care; The minor's disorder can be expected to improve through medically necessary rehabilitation or there is clinical evidence that this intensity of psychiatric rehabilitation is needed to maintain the minor's level of functioning; and The minor is judged to be in enough behavioral control to be safe in the psychiatric rehabilitation program and benefit from the psychiatric rehabilitation provided. In addition to those minors outlined in §A(1) and (2) of this regulation, a PRP for minors may provide services to other minors who either contract privately for services or for whom another agency contracts for services. If a PRP for minors provides services to a minor outlined in §A(3) of this regulation, the PRP may not seek reimbursement by the PMHS for providing services to that minor. Screening. Within 5 working days of receipt by the program of a complete referral for PRP services, staff assigned by the program director, in collaboration with the minor and the minor's parent or guardian, if appropriate, shall schedule an appointment to conduct a face-to-face screening assessment to: Assess the minor's: Rehabilitation services needs; Willingness to participate in PRP services; and Determine the program's ability to address the needs identified in §B(1)(a) of this regulation. If, following the screening assessment under §B(1) of this regulation, the program director determines that the program's services are not appropriate for a minor who has been referred, the program director shall, in writing, promptly: Inform the minor and the parent or guardian, if appropriate, of the determination and the reason; and Provide the minor, and the parent or guardian, if appropriate, with recommendations for alternative services. Within 5 working days of the screening assessment conducted under §B(1) of this regulation, unless the program director has notified the minor of the determination under §B(2) of this regulation, the program director shall notify the minor and the parent or guardian, if appropriate, whether the program: Accepts the minor and identifies a date that the program can initiate services to the minor; Will accept the minor, following an updated review of the minor's eligibility status, when program capacity permits, and inform the minor of the: Minor's placement on a waiting list, if any; and Estimated date services may be initiated; or Will accept the minor following the minor's discharge or release from an inpatient facility, RTC, or detention center. If the minor is placed on a waiting list under §B(3)(b) of this regulation, the program director shall discuss with the minor and, if appropriate, the minor's parent or guardian: The option of remaining on the program's waiting list until the date established under §B(3)(b) of this regulation; and Alternative services that are available. Initiation of Services. Before the initiation of services, PRP staff assigned by the program director shall: Document: That a parent or guardian has applied for entitlements for which the minor may be eligible; If the application has been made, the outcome of the minor's application; and If the application has not been made, that staff have assisted the minor's parent or guardian to apply for entitlements; and Discuss with the minor and, if appropriate, the minor's parent or guardian, and provide written documentation to the minor and, if appropriate, the minor's parent or guardian, of the charges for services and, if applicable, the process for determining ability to pay. Review of Somatic Status. According to provisions outlined in this section and upon a minor's enrollment into the program, a staff member assigned by the program director shall document in the minor's medical record: Pertinent past and current medical history including: The minor's somatic health problems, if any, including but not limited to allergies, neurologic disorders, and communicable diseases; Relevant medical treatment, including medications; and Needed somatic care follow-up, if any; and If the minor does not have a primary care provider, and, if indicated, the plan, including the time frame, for the minor's referral to a primary care provider for evaluation and treatment. If indicated, the minor's rehabilitation coordinator shall document and communicate with the minor's primary care provider. If indicated, the minor's rehabilitation coordinator shall discuss with the minor, and the parent or guardian, if appropriate, the need for medical care and facilitate access to said care. Rehabilitation Assessment. Within 14 calendar days of initiation of PRP services, PRP staff assigned by the program director to conduct assessments, in collaboration with the minor and, with proper consent, the parent or guardian, shall complete a face-to-face rehabilitation assessment. The assigned staff shall document in the rehabilitation assessment, at a minimum: The minor's age and developmentally appropriate strengths, skills, and needs in the following areas: Self-care skills; Social, peer, family, and teacher interaction skills; Participation in psychiatric treatment; Semi-independent living skills; Family support and resources; Academic achievement; Community and informal support systems; and Adaptive equipment or resources; As relevant, a review of the minor's legal status and forensic history, if any; and The minor's history of physical abuse, sexual abuse, or substance abuse, if any. Individual Rehabilitation Plan. Initial IRP. Within 30 calendar days of initiation of PRP services and based on the rehabilitation assessment described in §B of this regulation, the minor's rehabilitation coordinator shall prepare an initial IRP: In collaboration with: The minor; The parent or guardian, if appropriate; and If appropriate and with proper consent, other mental health service providers, as available; That includes, at a minimum: The minor's presenting needs, strengths, and rehabilitation expectations and responsibilities; A description of needed and desired program services and interventions and staff responsible for implementation; A description of how the needed and desired skills and supports will help the minor to be successfully maintained in the home or community, and manage the minor's psychiatric disorder; Rehabilitation goals in measurable terms, and target dates for each goal; and If appropriate, identification of, recommendations for, and collaboration with, other services to support the minor's rehabilitation, including but not limited to mental health treatment, residential services, and somatic care; and That is reflective of the minor's overall plan of care. Individual Treatment and Rehabilitation Plan (ITRP). In collaboration with the mental health treatment coordinator, the rehabilitation coordinator may combine the required elements of an ITP and IRP in one document, the ITRP. Rehabilitation Plan Review. As frequently as necessary, as determined by a minor's rehabilitation coordinator, and, at a minimum of every 3 months, the rehabilitation coordinator, in consultation with the minor, shall: Review and record in the minor's medical record: The minor's progress toward the accomplishment of previously identified rehabilitation goals; Goal changes, based on a review of the minor's progress; Changes in interventions, as appropriate; and Progress toward the reduction of functional behavioral impairments and restoration of specific age-appropriate skills; Communicate promptly the results of the review to: Relevant program staff; The minor's parent or guardian, if appropriate; With proper consent, community mental health programs providing services to the minor; and With proper consent, the referring licensed mental health provider; and If the minor's service needs change, provide and document in the minor's record: The suggested changes in rehabilitation goals and services; and Staffing and support services required by the change. Signature of the IRP Plan and Reviews. The following shall sign agreement with the IRP and ITRP reviews: The minor; The minor's rehabilitation coordinator; and The minor's parent or guardian, if appropriate. If the minor is unwilling to sign an agreement with the IRP and ITRP reviews, the minor's rehabilitation coordinator shall: Verify the minor's verbal agreement with the IRP and ITRP reviews; Document the rationale for the minor's refusal to sign; and Obtain the agreement and signature of agreement of the minor's parent or guardian. In addition, for an ITRP, at least two mental health professionals, who collaborate about the minor's treatment, shall sign the IRP and ITRP reviews, including: The minor's rehabilitation coordinator, and if the rehabilitation coordinator is not a mental health professional, the mental health professional who supervises the rehabilitation coordinator; and The minor's treating mental health professional; If the minor is receiving medication prescribed through an outpatient mental health clinic (OMHC), the minor's rehabilitation coordinator shall provide the OMHC psychiatrist with a copy of the minor's IRP and ITRP reviews. Continuing Evaluation. Contact Notes. Staff shall document: Each contact with or about the individual, including, at a minimum: The date; The start and end time of services, if not documented in a readily accessible billing document; The minor's chief medical complaint or reason for the visit; The delivery of services specified by the IRP or ITRP; A brief description of the service provided; and A legible signature, which may include an electronic signature, and printed or typed name of the program staff member providing care, with the appropriate title. Progress Summary Notes. At a minimum, each month, the rehabilitation coordinator shall record in the minor's medical record a progress summary note that includes: The staff member's assessment of the minor's progress toward goal achievement in measurable terms; The minor's assessment of progress toward goal achievement; and Justification for the need for ongoing PRP services. If at least one contact note described in §D(1) of this regulation includes the information outlined in §D(2) of this regulation, the monthly progress summary note is not required. The rehabilitation coordinator shall document that the minor's needs and progress are promptly communicated to: Staff involved in the implementation of the IRP or ITRP; and The minor's parent or guardian, if appropriate; and With proper consent, other community mental health programs providing services to the minor. PRP services may only be provided to a minor if identified in the minor's IRP and referred for PRP services by: A licensed mental health professional who is providing inpatient, residential treatment center, or outpatient mental health services to the minor; and Staff who have been privileged by the program to provide the services. Rehabilitation Activities. The program director shall ensure that the program provides rehabilitation activities directed toward the development or restoration of skills including: Age-appropriate self care skills, including: Personal hygiene; Grooming; Nutrition; Dietary planning; Food preparation; and Self-administration of medication; Social skills, including community integration activities, developing natural supports, and developing linkages with and supporting the minor's participation in community activities; Independent living skills, including: Maintenance of the minor's living environment; Community awareness; Mobility skills; Money management; and Accessing available entitlements; Activities that support the minor's cultural interests; Conflict resolution; Anger management; Interactive skills with peers and authority figures; Maintaining personal living space; Maintaining age-appropriate boundaries; Maintaining personal safety in a social environment; and Time management, including constructive use of structured and unstructured time. Medication Services. Administration. An individual licensed to administer medication under Health Occupations Article, Annotated Code of Maryland, may do so. A licensed practical nurse or a registered nurse may delegate the administration of medication only according to the provisions of COMAR 10.27.11. Monitoring. A PRP staff member shall provide the following services: Support the individual's self-administration, as appropriate, of prescribed medication; Read the medication label to ensure that each container of medication is clearly labeled with the individual's name, the contents, directions for use, and expiration date; To the extent possible, monitor compliance with instructions appearing on the medication label; Ensure that each individual has secure, appropriate, and accessible space in which to store medications; Observe and document any apparent reactions to medication and, either verbally or in writing and in a timely fashion, communicate to the prescribing authority any problems that possibly may be related to the medication; and Reinforce, with the individual, education on the role and effects of medication in symptom management. Promotion of Illness Self Management. As is age appropriate, staff shall provide education and information regarding mental illness. The program director shall ensure that the minor's rehabilitation coordinator collaborates with the minor to identify effective strategies to assist the minor to manage the minor's illness. The strategies identified under §D(2) shall include, at a minimum, the minor's identification of: Potential problematic symptoms; Warning signs of relapse; Helpful interventions; and Other individuals the minor identifies to resolve the situation in order for the minor to remain in service or to seek treatment. The minor's illness self management strategies shall be documented and may be incorporated in the minor's IRP, ITP, mental health advance directive, or any combination of them. The strategies shall be reviewed at the time of the IRP review and may be revised or revoked at any time at the request of the minor. On-Call and Emergency Response. The program director shall assure that: On-call and emergency response services are available by a licensed mental health professional to an individual who has been admitted to the PRP: Face-to-face during the hours that the PRP is open; and By telephone, on an on-call basis, 24 hours per day, 7 days per week, during the hours the PRP is not open: Through the PRP; or Through an agreement with another mental health crisis service provider; PRP staff provide to a minor: Intensive support and assistance, as authorized, including but not limited to: Providing one-to-one staff support for the minor, if necessary; Escorting the minor while accessing needed assistance or services; and Obtaining input from the mental health professional who is providing outpatient mental health services to the minor; Information regarding needed services; and If necessary, referral for appropriate health care. If emergency care is necessary, all relevant staff shall: Have access to the names, addresses, and telephone numbers of providers, including the hospital, that are designated to provide emergency care and treatment to the minors served; and Be appropriately trained to link minors to emergency care, as needed. Linkage with a Minor in a Psychiatric Inpatient Facility, Residential Treatment Center (RTC), or Detention Center. If a minor who is enrolled in a program is admitted to a psychiatric inpatient facility, RTC, or detention center, the rehabilitation coordinator shall make reasonable efforts to maintain ongoing communication with the minor and the minor's inpatient treatment team. To the degree permitted by the setting, PRP staff serving the minor shall participate in aftercare or release planning from that setting. The program director shall maintain clearly written policies and procedures, which may be contained in one document, for the process for discharge from the program as outlined in COMAR 10.21.17.11. Following an analysis of the complexity and number of minors served, the program director, with input from program staff, shall ensure the development of a staffing plan that identifies the type and number of staff needed to implement the program's rehabilitation service goals. A provider shall ensure that the staff includes the following, who are employed by the PRP for the amounts of time outlined in §§C — E of this regulation: A program director, who: Is qualified according to §F(1) of this regulation and who is responsible for the duties under §F(2) of this regulation; and May be responsible for the duties of the rehabilitation specialist under §G(1)(b) of this regulation, if the program director: Is qualified according to §G(1)(a) of this regulation; and Devotes the time required, under §C, D, or E of this regulation, to the development and implementation of rehabilitation services that reflect the need of the minors served by the program; As required under §C, D, or E of this regulation, a rehabilitation specialist or specialists, qualified according to §G(1)(a) of this regulation, to carry out the duties under §G(1)(b) of this regulation; and As required under §D or E of this regulation, staff designated to carry out administrative duties assigned by the program director. If a PRP has fewer than 30 enrollees, the PRP shall employ either: A program director and a rehabilitation specialist, each of whom is employed by the program for a minimum of 20 hours per week; or A program director who is responsible for the duties of the program director and the duties of a rehabilitation specialist, if the program director: Has the qualifications described under §G(1)(a) of this regulation; Is employed by the program for 40 hours per week; and Devotes at least 20 hours per week to the development and implementation of rehabilitation services that reflect the needs of the minors served by the program. If a PRP has 30 — 100 enrollees, the PRP shall employ either: A program director, who is employed by the program for a minimum of 20 hours per week, and a rehabilitation specialist, who is employed by the program for a minimum of 40 hours per week; or A program director who is responsible for the duties of the program director and the duties of a rehabilitation specialist, if the program director: Has the qualifications described under §G(1)(a) of this regulation; Is employed by the program for 40 hours per week; and Designates staff who devote 20 hours per week to carrying out specific assigned administrative duties. If a PRP has more than 100 enrollees, the PRP program shall employ: A program director who is employed by the program for 40 hours per week; and A rehabilitation specialist or specialists and staff assigned to administrative duties, as follows: A rehabilitation specialist who is employed by the program for 40 hours per week; Two rehabilitation specialists, each of whom is employed by the program for 20 hours per week; or If the program director has the qualifications described under §G(1)(a) of this regulation: A rehabilitation specialist who is employed by the program for 20 hours per week; and Designated staff who devote 20 hours per week to carrying out specific assigned administrative duties. Program Director. The program director: Shall have: Sufficient qualifications, knowledge, and experience to execute the duties of the position; and A minimum of 3 years experience working with emotionally disturbed youth; and Is responsible for administrative oversight of the PRP, including, at a minimum: Fulfilling the administrative requirements under COMAR 10.21.17; Fulfilling the programmatic requirements of this chapter; Keeping the advisory committee, or governing body, whichever is applicable, informed of, at a minimum, the program's approval status and performance; and Quality management. Psychiatric Rehabilitation Staff. The program director shall employ psychiatric rehabilitation staff, including: At least one rehabilitation specialist who: Is a licensed mental health professional with a minimum of 2 years direct care experience working with emotionally disturbed youth; Shall advise the program director regarding development and implementation of rehabilitation services that reflect the need of the minors served by the program; Has overall responsibility for rehabilitation services, including: Developing and assuring that rehabilitation services meet the needs of the individuals served by the program; and Providing oversight for the daily program of rehabilitation services; and Shall educate direct care staff on how to document the correlation between rehabilitation activities and the goals identified in the IRP or ITRP; Direct service staff who: Are supervised by a licensed mental health professional or a rehabilitation specialist; Have 60 hours of on-the-job direct PRP supervision before providing services to minors served by the program without direct supervision; At a minimum, have: A bachelor's degree in a health-related field; An associate's degree in a health-related field; 30 hours, or their equivalent, of college credit toward a bachelor's degree in a health-related field; or 1 year of work experience in a supervised mental health setting; and Are responsible for implementing the rehabilitation activities outlined in the minor's IRP. Ratio. The program shall maintain an average ratio of at least one rehabilitation staff member serving each six minors who are either attending the PRP facility or receiving off-site services. To achieve this ratio, the program: May not include: The program director; or Volunteers; and May include students only if, in calculating the ratio, three rehabilitation staff are on duty for each student. Students. The program may use students according to the provisions of COMAR 10.21.17.11E. Volunteers. The program may use volunteers according to the provisions of COMAR 10.21.17.11F. Health-General Article, §§10-901 and 10-902, Annotated Code of Maryland Effective date: April 10, 2006 (33:7 Md. R. 669) Regulation .05A amended effective February 12, 2007 (34:3 Md. R. 299) Regulation .07A amended effective February 12, 2007 (34:3 Md. R. 299) This chapter applies to public mental health system (PMHS) outpatient mental health centers (OMHC) or individual psychiatrists to provide psychiatric consultation, evaluation, and ongoing treatment, via interactive video telemental health (TMH) technologies to eligible individuals: Located in designated rural geographic areas of Maryland; or For whom personal psychiatric services are not available. The purpose of providing psychiatric care via TMH technology is to: Improve access to outpatient psychiatric care, thus reducing the individual's admission to emergency rooms, inpatient facilities, or detention centers; Improve access to outpatient and inpatient psychiatric subspeciality consultation, thus improving diagnostic clarification, treatment recommendations, and planning for the individual; and Improve capacity and choice for outpatient ongoing psychiatric treatment, thus reducing the need to travel outside the community when local resources are limited. In this chapter, terms have the meanings stated in COMAR 10.21.17 and this regulation. Terms Defined. “Critical access hospital” means a hospital that is certified to receive cost-based reimbursement from Medicare. “Designated rural geographic areas” means the rural geographical areas in Maryland identified by the Department that typically have mental health needs that have limited local mental health resource capacity or specialty psychiatric care. “Distant site” means the site at which the psychiatrist is located at the time the mental health service is provided via a telecommunications system. “Emergency department services” means initial hospital services provided to individuals with a broad spectrum of illnesses and injuries, some of which may be life-threatening and requiring immediate attention. “Federally qualified health center” has the meaning stated in Health-General Article, §24-1301, Annotated Code of Maryland. “Individual practitioner” means a psychiatrist who is licensed to practice psychiatry in Maryland, and either: Is certified in psychiatry by the American Board of Psychiatry and Neurology; or Has completed the minimum educational and training requirements to be qualified to take the Board of Psychiatry and Neurology examination for certification in Neurology. “Not available” means that the PMHS administrative services organization certifies that the individual cannot access psychiatric services. “Originating site” means a site that has been approved by the Department to provide TMH services, at which an eligible individual is located at the time the service is delivered via a telecommunications system. “Originating site fee” means the amount the Department reimburses an approved TMH originating site. “Professional fee” means the amount the Department reimburses an approved TMH distant facility or licensed individual mental health professional: For a clinical care opinion, treatment, or both; To purchase, install, and maintain video conferencing equipment; To pay for line or per minute usage charges, or both; and For any additional programmatic, administrative, clinical, or contingency support at the distant site. Public Mental Health System (PMHS). “Public mental health system” means the system for the delivery of mental health treatment and supports to individuals who meet medical necessity criteria and financial eligibility as established by the Administration. “Public mental health system” includes the specialty mental health system described in COMAR 10.09.70. “Rural health clinic” means a facility that meets the definition of a rural health clinic as contained in 42 CFR §491.2(f), as amended. “Security” means the protection of information and information systems from unauthorized access, use, disclosure, disruption, modification, or destruction. “Telemental Health (TMH)” means the delivery of mental health care at a distance through the use of technology-assisted communication. “Telepresenter” means the individual at the originating site who introduces the patient to the distant site provider for examination, and to whom the distant site provider may delegate tasks and activities, and who is: A licensed independent practitioner; or Licensed or certified to perform health care services by licensing, training, or experience for the performance of the task or activity as long as the task or activity does not require the exercise of independent medical judgment for its performance. “Telepresenter fee” means the amount the Department reimburses a licensed, independent provider to present an individual to the TMH provider, due to medical necessity, to successfully complete the examination. “Virtual private network connection” means a method of connecting to a private network via a public network. The Department shall grant approval to a TMH provider to be eligible to receive State or federal funds for providing interactive TMH services if the TMH provider meets the requirements of this chapter and: For outpatient mental health centers, COMAR 10.21.20; or If the TMH provider is an individual psychiatrist, COMAR 10.09.36. TMH provides the opportunity for community-based medical and mental health providers to access general or subspecialty psychiatric care providers from other areas of the State. TMH providers may be private practice, part of a hospital, academic, health, or mental health care system. PMHS approved community-based providers or individual practitioners may engage in agreements with TMH providers for services. Fee-for-service reimbursement shall be at an enhanced rate, as stipulated by the Department, provided all applicable provisions of this chapter are met and funds are available. Individual Eligibility. An individual is eligible to receive TMH services if the individual: Is Medicaid eligible; Meets the eligibility and medical necessity criteria for participation in the Public Mental Health System; Resides in one of the designated rural geographic areas or whose situation makes person-to-person psychiatric services unavailable; and Voluntarily consents to TMH services, which shall be documented in the individual's medical record. Individual Provider Eligibility. A provider of TMH services shall be a psychiatrist who: Has an active: License to practice psychiatry in Maryland; and Medicaid provider number; Complies with professional practice standards; and Completes a registration to provide TMH health services. Originating Site Facility Eligibility. The following Maryland sites may be approved as an originating site for THM health service delivery: County government offices appropriate for private clinical evaluation services; Critical Access Hospital; Federally Qualified Health Center; Hospital; Outpatient mental health center; Physician's office; Rural Health Clinic; Elementary, middle, high, or technical school with a supported nursing, counseling or medical office; or College or university student health or counseling office. Distant Site Location Eligibility. An approved distant TMH location shall be within the State. A provider of TMH health services shall have video technology components as follows: A minimum bandwidth of 384 KBPS (H.263), 256 KBPS (H.264), or technical equivalent; A monitor with a: Minimum net display of 16" diagonally; and Non-anamorphic video picture display; A minimum video resolution of 1 Common Intermediate Format (CIF), or 1 Source Input Format (SIF); Internet protocol sessions that are encrypted unless they are conducted entirely on a protected network, or using a virtual private network connection; and A camera at the originating site, that has pan, tilt, and zoom capabilities that can be remotely controlled from the distant site. All originating and distant TMH sites shall comply with the rules and regulations concerning the privacy and security of protected health information under: Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland; and The Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. §§1320D et seq., as amended, and the implementing regulations at 45 CFR Parts 160 and 164, as amended. Originating Site. The originating site shall: Be responsible for maintaining a complete medical record as if the individual were seen face-to-face at the originating site; Meet the facility and community standard for medical record completion and retention, including applicable record reviews; and Be responsible for any proper release of information contained in an individual's medical record. Distant Site. The distant site shall maintain copies of all documentation completed by the distant site TMH provider unless the distant site TMH provider enters the information directly into the originating site's electronic medical record system. The distant site, as part of its quality improvement system, shall have a process to review TMH care. As part of quality monitoring, when the originating site's electronic medical records are reviewed at the distant site, the: Review may include the TMH provider's documentation online, if authorized; or Distant site may request sections of the individual's electronic medical record from the originating site for the distant site peer review. TMH records shall be retained according to the provisions of Health-General Article, §4-403, Annotated Code of Maryland. TMH services shall be authorized by the Administration's administrative service organization. The Department shall reimburse an approved TMH provider for rendering the following psychiatric services to an eligible child, adolescent, or adult via a telecommunications system: Diagnostic interview; Individual therapy, with or without medication evaluation and management; Family therapy, with or without the identified patient; Group therapy for each individual, up to a maximum of 8 individuals; Outpatient evaluation and management for a new or established patient; Outpatient office consultation for a new or established patient; Initial inpatient consultation for a new or established patient; and Emergency department services. There are three categories of fees that the Department shall reimburse an approved TMH provider, as applicable: Originating site fee; Professional fee; and Telepresenter fee. Originating Site Fee. The originating site facility fee is set forth by the Center for Medicare and Medicaid Services, published annually and included in the Medicare Physician Fee Schedule Final Rule, issued by November 1, prior to the start of the calendar year for which it is effective. Originating sites only may file for reimbursement and shall use the appropriate code modifier. Fees paid to the originating site may be used to: Purchase, install, and maintain video conferencing equipment; Pay for line or per minute usage charges, or both; and Any additional programmatic, administrative, clinical or contingency support at the originating site. Professional Fee. Professional Fee for individual providers or OMHC providing TMH is set forth in COMAR 10.21.25. Telepresenter Fee. Telepresenter Fees for assisting in TMH are set forth in 10.21.25 and subject to the following requirements prior to billing: A telepresenter fee is applicable only when, due to medical necessity, a licensed independent practitioner is required to present the individual to the distant provider to successfully complete the examination; Fees for telepresenters that are not licensed independent practitioners, and fees for telepresenters that are licensed independent practitioners, but their presence is not medically necessary, are included as part of the originating site facility fee; and The distant provider shall clearly document in the individual's medical record the rationale requiring the involvement of the licensed independent practitioner, as medically necessary, at any particular session. Health-General Article, §10-901, Annotated Code of Maryland Effective date: September 6, 2010 (37:18 Md. R. 1214) Effective January 27, 2023, there is a Maryland Mental Health and Substance Use Disorder Registry and Referral System to provide a statewide system through which health care providers can identify and access available inpatient and outpatient mental health and substance use services for patients in a seamless manner. This chapter applies to: Hospitals under Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland; Freestanding medical facilities under Health-General Article, Title 19, Subtitle 3(a), Annotated Code of Maryland; and Any other provider type designated by the Department by issuance of a transmittal sent to all designated providers. In this chapter, the following terms have the meanings indicated. Terms Defined. “Department” means the Maryland Department of Health. “Facility” means a hospital, freestanding medical facility, or provider designated by the Department. “Hospital” means a general or special hospital licensed under Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland, and COMAR 10.07.01. “Maryland Mental Health and Substance Use Disorder Registry and Referral System” or “Bed Registry and Referral System” means the system operated by the Department through which health care providers can identify and access available inpatient and outpatient mental health and substance use services for patients. A facility shall: Refer an individual who may require additional care coordination for inpatient, outpatient, or community-based behavioral health services, after undergoing an initial psychiatric evaluation, no later than 48 hours after arrival at the facility at a phone number or website address designated by the Department through written directives to implement the Bed Registry and Referral System; and Provide all necessary patient information, including, but not limited to, diagnosis and level of care recommendations to the respective care coordination centers. A facility shall report current bed availability and census information, and any additional relevant information requested by the Department, to populate the inpatient psychiatric bed board as necessary to keep the information updated, but not less than three times per day, during the following periods: 9 a.m. to 12 p.m.; 1 p.m. to 3 p.m.; and 4 p.m. to 7 p.m. A hospital that violates this chapter is subject to the fines, penalties, and actions specified in Health-General Article, Title 19, Annotated Code of Maryland. A provider who violates this chapter is subject to the fines, penalties, and actions specified in Health-General Article, Title 7.5, Annotated Code of Maryland, and COMAR 10.63. Health-General Article, §7.5-802, Annotated Code of Maryland Effective date: Regulations .01—.05 adopted as an emergency provision effective January 27, 2023 (50:4 Md. R. 119); expired effective July 26, 2023 Regulations .01—.06 adopted effective June 24, 2024 (51:12 Md. R. 619)