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)