“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)