# COMAR Title 10 — Maryland Department of Health

## Subtitle 21 — Behavioral Health Regulations

### Chapter 13 — Use of Quiet Room and Use of Seclusion

#### Regulation .12 Variance with Standards.

*COMAR 10.21.13.12*

A. 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.

B. There may not be any variance with standards established in:

  (1) This regulation;

  (2) Regulation .03 of this chapter;

  (3) Regulation .04 of this chapter;

  (4) Regulation .05B—E, G, and I of this chapter;

  (5) Regulation .07A of this chapter;

  (6) Regulation .09 of this chapter;

  (7) Regulation .10A, D, E(1), and F of this chapter; and

  (8) Regulation .11 of this chapter.

C. Staff shall document, on the facility's variance report, a variance with standards permitted under this chapter.

D. The CEO shall rule on and document each variance permitted in §A of this regulation to determine whether the variance was:

  (1) An extreme crisis;

  (2) A deviation from the facility's procedure; or

  (3) A problem in the facility's policy which is correctable by administrative action.

E. The CEO shall assure that the facility's quality assurance process incorporates a monthly review of any variance permitted in §A of this regulation.