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)