This chapter applies to clinical programs that provide a combination of developmental and mental health services in a preschool setting, made accessible and available to children and the families of children who are at risk for or who are emotionally disturbed, who have behavior or adjustment problems, or both. The Department shall grant approval to an agency to be eligible to receive State funds for providing therapeutic nursery services if the agency meets the requirements of this chapter and COMAR 10.21.16, 10.21.17, and 07.04.02. In this chapter, terms have the meanings stated in COMAR 10.21.17 and this regulation. Terms Defined. “Individualized family service plan (IFSP)” means the plan defined in COMAR 10.09.40. “Learning center” means a designated area of a classroom that serves children in a therapeutic nursery and that is equipped specifically for the development of a particular skill, including, but not limited to, fine motor, gross motor, and socialization. “Primary caretaker” means the child's custodial parent or parents, or the adult with whom the child currently resides. “Program A” means a therapeutic nursery that provides services to children who are younger than 3 years old and whose primary caretakers are present on the site of the therapeutic nursery to participate in the treatment process with the child. “Program B” means a therapeutic nursery that provides services to children who are 3 years old or older, and younger than 5 years old. A provider of therapeutic nursery services shall ensure that services: Are appropriate to the cultural and psychosocial developmental needs of the child; Are provided: For a minimum of 3 hours per day, 3 days per week at each site; and In either a free-standing program or as an integral component of a preschool program in which services are offered in a therapeutic milieu; Are provided by staff who: As determined by the program, are appropriately credentialed and privileged; and Organize and manage the milieu to: Foster clinically appropriate social, intellectual, emotional, and physical growth; Handle aggression in a nonpunitive manner that promotes growth and learning; Reinforce the child's ability to function with peers in a social environment; Model and provide opportunities for children to behave in age-appropriate ways, such as: Being playful; Assuming responsibility for carrying out routine activities; Exhibiting independence and initiative in planning their own learning; Getting along with others; and Being courteous; Facilitate the child's awareness of appropriate behavior in a predictable, constructive, and timely manner; and Help children to make choices and to negotiate disagreements among themselves, rather than resolving conflicts for them; Are provided in an environment that: Is consistent with existent standards of program design; Is organized so that the child can function in an environment with a minimum of adult direction; Has space that facilitates the activities of each learning center allocated to each center; Has sufficient space and separation between learning centers so that children can engage in activities of their choice without distracting or being distracted by others; Provides materials that are available for children's use and are otherwise appropriately stored; and Displays exhibits of children's work that reflect children's current experiences, developmental level, diversity, and individuality; Are designed to develop or improve the ability of the primary caretaker to care for the child; and Maintain linkage with schools and preschool programs to effect transition at the appropriate time and with the necessary support services. Referral. A therapeutic nursery may accept a referral to the therapeutic nursery from: Education, social service, or health care agency staff; Family members; or Other interested individuals and agencies. Eligibility. A child is eligible for therapeutic nursery services if the child: Has or is at risk for a mild to severe mental disorder, as defined in the current Diagnostic and Statistical Manual of Mental Disorders, or mild to severe behavioral problems, or both; Is at risk for emotional or behavioral problems because the child: Is experiencing substantial developmental delay or atypical development which, if left untreated, is likely to impair severely the child's ability to function independently, as measured by diagnostic instruments and procedures that meet usual and customary practice standards, in one or more of the following areas: Cognitive development; Physical development; Language and speech development; Psychosocial development; or Self-help skills; Has experienced psychological trauma, as identified by an evaluation by a mental health professional; Has a diagnosed physical or mental condition which has a high probability of resulting in developmental delay; or Has been excluded, for developmental or behavioral problems, from more than one preschool or day care program; Is at risk for emotional or behavioral problems and is a child who is being assessed or has been assessed in a suspected child abuse or neglect investigation pursuant to Family Law Article, §5-701 et seq., Annotated Code of Maryland; or Is at risk for emotional or behavioral problems because of significant family history, as identified by an evaluation by a mental health professional. Admission. A therapeutic nursery program may admit a child: If the child is: For Program A, younger than 3 years old, and the primary caretaker is available to participate in the treatment process; or For Program B, 3 years old or older, but younger than 5 years old; Upon the written or tape-recorded consent of the child's parent or guardian; and For whom a physician orders therapeutic nursery services as medically necessary. A therapeutic nursery program may not admit a child: Whose primary or sole diagnosis or condition is: Mental retardation; Visual impairment; Hearing impairment; Physical disorder; or Technology dependence; or Who has cognitive deficits that severely limit the ability to benefit from the treatment modalities provided by the therapeutic nursery. Assessment. If a comprehensive developmental assessment has not been completed within the 90 days before admission, before the child's 6th visit, the therapeutic nursery staff shall assure the completion of an assessment, including, when appropriate, standardized measurement, that includes, at a minimum, an assessment of the following: Social and emotional development; Cognitive skills and deficits; Language development; Motor skills, fine and gross; Self-help and adaptive skills; Family history and evaluation; Home environment; Developmental history; Mental status; and Medical history and needs, if any. Diagnosis. Before the child's 6th visit, an individual qualified to diagnose under the provisions of Health Occupations Article, Annotated Code of Maryland, shall: Conduct a face-to-face evaluation of the child; Formulate and document a diagnosis; and Document the rationale for the diagnosis. Individual Treatment Plan (ITP). Treatment Team. At a minimum, the following individuals shall participate on a child's treatment team: At least one of the following: The therapeutic nursery physician; or A staff psychologist or psychologist consultant; At least one other mental health professional; All therapeutic nursery staff who are involved in providing services to the child and family; and If the therapeutic nursery is affiliated with an educational preschool program, the educational staff, as determined appropriate by the therapeutic nursery clinical director. Plan. Before the child's 6th visit, the therapeutic nursery treatment team, working cooperatively with the child's primary caretaker and classroom teacher, shall prepare an ITP that includes: The diagnostic formulation, as required by §B of this regulation; A description of the child's behavior that includes: Problem list; and Asset list; Goals and objectives stated in behavioral, measurable terms; Treatment strategies; Classroom interventions; Home interventions; For children in Program A, that portion of an IFSP, if any, that pertains to therapeutic nursery services; and As relevant, the information about the following from the child's parent, guardian, or primary caretaker, in consultation with appropriate health care or other service providers: Instructions for care in an emergency; History of allergies, including to medication; History of seizures; Medication prescribed; Nutritional requirements, limitations, and feeding procedures; and Essential medical or nonmedical treatments or procedures, including any advanced directives. Signatures on the ITP. The following shall sign the ITP: The treatment coordinator of the therapeutic nursery; The therapeutic nursery physician, staff psychologist, or psychologist consultant; If the child is receiving medication, the therapeutic nursery physician; If the individual who signs under the provisions of §C(3)(b) of this regulation is also the treatment coordinator, at least one other mental health professional; and Following review of the ITP, the parent, guardian, or primary caretaker. 45-Day Review. At a minimum of every 45 days: The treatment coordinator shall: Review the progress on the ITP; Document in the child's record a description of progress toward goals and changes in goals and interventions based on the review of progress under §C(4)(a)(i) of this regulation; and Update the ITP accordingly; and A minimum of two treating mental health professionals shall sign the 45-day review. 3-Month Review. Every 3 months, at a treatment team meeting, the: Treatment team shall review the ITP according to the process outlined in §C(4) of this regulation; Treatment coordinator shall update and sign the 3-month review; and Therapeutic nursery physician, staff psychologist, or psychologist consultant shall sign the ITP review. Continuing Evaluation. In order to ensure that services to a child are timely and appropriate, therapeutic nursery staff shall document in the child's record: As outlined in the policy and procedures manual, contact notes regarding all clinically relevant face-to-face, telephone, and written contacts with or about the child, including the dates, locations, and types of contacts; and Progress summary notes, entered at least monthly, by staff members involved in the child's treatment and classroom activities, regarding progress toward treatment goals. Therapies. The therapeutic nursery program shall provide the following therapies: If required by the ITP, individual therapy: With the therapeutic nursery mental health professional staff; With the community psychotherapist who is currently treating the child; or By referral; For children in Program A, conjoint therapy involving an individual child or groups of children with their primary caretakers; Milieu therapy that uses the environment as a tool to assist the child, in keeping with routine developmental expectations, to manage behavior and function appropriately and cooperatively with peers and adults. Daily Activities. The therapeutic nursery program shall implement, on a consistent, regular basis, a plan for daily activities that: Incorporate a variety of experiences with language, music, art, science, dramatic play, block play, and equipment and materials that promote large and small muscle development; Allow for self-selected and planned as well as individual and small group activities; and Include safe, regular, and developmentally appropriate outdoor play, with supervision consistent with the staff-to-child ratio required under Regulation .08D of this chapter. Services for Families. The therapeutic nursery program shall provide services to families, including but not limited to: As indicated by the ITP, counseling or therapy: With the therapeutic nursery mental health professional staff; With the community psychotherapist who is currently treating the child; or By referral; Orientation for parents, guardians, or primary caretakers to the specialized treatment interventions that are designed to facilitate the child's continued development; Mental health support groups; and Therapeutic home visits. Interagency Consultation and Referral. Services to Center. If the therapeutic nursery is included within another early childhood program, the therapeutic nursery staff shall provide those services to the early childhood program that the therapeutic nursery staff determine to be appropriate, including, but not limited to: Staff development and training; Mental health consultation regarding specific clinical interventions to be used in relating to therapeutic nursery children; Classroom consultation, including observation and feedback; and When necessary, psychoeducational strategic consultation. Referral Services. For those services indicated in a child's ITP and not provided by the therapeutic nursery staff, the program shall have a policy and procedure for referral for: Therapy, pursuant to §§A(1)(c) and C(1)(c) of this regulation; and Evaluative or support services, including but not limited to: Speech and language; Vision and hearing; Special instruction, special education, or other early intervention; Somatic care; Occupational therapy assessment and treatment; and Psychological testing. Not later than the date of admission, the therapeutic nursery program shall provide a written policy statement on discharge and transition procedures to parents, legal guardians, and primary caretakers. To the extent practicable, parents, legal guardians, or primary caretakers as well as referring agencies or professionals, and the continuing care providers shall participate in discharge and transition planning. Within 15 days of discharge, the therapeutic nursery staff shall complete a discharge summary in accordance with the provisions of COMAR 10.21.17.07D(3). With the consent of a parent or legal guardian as necessary, the therapeutic nursery program shall forward a copy of the discharge summary to the continuing care provider. Criteria for discharge include but are not limited to: Symptomatic alleviation; Achievement of treatment goals; Readiness for participation in off-site educational programs; or Inability of the enrollee or the primary caretaker, or both, to comply with program requirements. Based on the complexity of the services provided and the number of enrollees in the therapeutic nursery, a therapeutic nursery program shall provide sufficient staff to maintain the staff-to-child ratio provided in §E of this regulation and to carry out the therapeutic goals of the therapeutic nursery. Therapeutic Nursery Staff. A provider of therapeutic nursery services shall ensure that the therapeutic nursery staff includes, at a minimum: A program director who: Is a mental health professional or has a master's degree in a health services administration field; Is on a site of the therapeutic nursery at least 50 percent of the operating hours of the therapeutic nursery program; If a therapeutic nursery program operates in more than one site, has contact with each site each week; and Is responsible for operational oversight for, at a minimum: Fulfilling the administrative requirements under COMAR 10.21.17; Recruiting, hiring, and providing administrative supervision of staff; Developing and implementing the budget; Keeping the governing body informed of, at a minimum, the program's approval status and performance; and Recruiting and enrolling program participants; A clinical director who: Is a mental health professional; Is on a site of the therapeutic nursery at least 50 percent of the operating hours of the therapeutic nursery program; If a therapeutic nursery program operates in more than one site, has contact with each site each week; If the clinical director is also the program director, is on a site at the therapeutic nursery program on a full-time basis during the operating hours of the therapeutic nursery program; and Is responsible for oversight for, at a minimum, the following: Development of the ITP; Providing clinical supervision of staff, including the educational staff of a therapeutic nursery program that is not affiliated with an educational preschool program; Development of therapeutic strategies that may be used in the classroom; Development of treatment programs; Quality improvement; and Inservice training; A therapeutic nursery physician who: Has completed a residency in child psychiatry in an accredited program; As specified in the employment or consultant contract, is available on a therapeutic nursery site for the amount of time necessary to carry out the duties outlined in §B(3)(c) of this regulation, and, at a minimum: If 25 or fewer children are enrolled in the therapeutic nursery program, for a minimum of 2 hours per week; and For 1 additional hour per week for every additional one to ten children who are enrolled in the therapeutic nursery program; and Is responsible for, at a minimum, the following: Establishing and maintaining appropriate standards for treatment, including therapeutic modalities and prescribing practices; Unless carried out by other staff qualified under the provisions of Health Occupations Article, Annotated Code of Maryland, as required under the provisions of Regulation .05B and C of this chapter, diagnostic formulation and participation in the development and signing of the ITP and the ITP 3-month reviews; Clinical supervision of those cases requiring face-to-face medical review; Review of medication utilization and corrective feedback when utilization is found to be inappropriate; and Medical aspects of quality improvement; and A staff psychologist or psychologist consultant who: As specified in the employment or consultant contract, is available on the site or sites of the therapeutic nursery program for the amount of time necessary to carry out the duties outlined in §B(4)(b) of this regulation; and Is responsible for, at a minimum, the following: Unless carried out by other staff qualified under the provisions of Health Occupations Article, Annotated Code of Maryland, as required under the provisions of Regulation .05B and C of this chapter, diagnostic formulation and participation in the development and signing of the ITP and the ITP 3-month reviews; As needed, performing psychological assessment and testing; and Making appropriate referral for those cases requiring face-to-face medical review. Treatment Coordinator. The program director shall assign to each child who is admitted to a therapeutic nursery a treatment coordinator who is a mental health professional. Educational Staff. If the therapeutic nursery is not affiliated with an educational preschool program, the therapeutic nursery educational staff shall: Be sufficient to carry out the educational programs provided by the therapeutic nursery and the classroom strategies described in the ITPs; and Meet the qualifications required under COMAR 13A.09.09.05C. Staff-to-Child Ratio. The therapeutic nursery program shall ensure that the following required treatment or education staff-to-child ratio is maintained at all times: For Program A, a staff-to-child ratio of at least one staff member for every five enrollees; and For Program B: If the therapeutic nursery is not affiliated with an educational preschool program, a staff-to-child ratio of at least one staff member for every four enrollees; and If the therapeutic nursery is affiliated with an educational preschool program, a staff-to-child ratio of at least one therapeutic nursery treatment staff member for every 10 preschool children, provided that not more than four children are therapeutic nursery enrollees. In addition to the policy and procedure requirements outlined in COMAR 10.21.17.08, a therapeutic nursery program shall adopt policies and procedures for: Licensure by the Department of Human Services under COMAR 07.04.02; Physical setting, furnishings, materials, and equipment, as required by Regulations .10 and .11 of this chapter; Health and safety, as required by Regulation .12 of this chapter; and Transportation, as required by Regulation .13 of this chapter. Capacity. The Department shall determine the capacity of a therapeutic nursery based on: Space requirements under §C(1) of this regulation; Staff requirements, including the staff-to-child ratio, required under Regulation .08D of this chapter; and Maintenance of the therapeutic milieu described in Regulation .03B(2) of this chapter. The program director of the therapeutic nursery program shall limit the number of enrollees to the capacity applied for and approved by the Department. Requirements for the Building. The therapeutic nursery program shall operate the program in a building that conforms to the applicable federal, State, and local laws and regulations, including but not limited to: Zoning; Sanitation; Fire and safety codes; and The requirements of the Americans with Disabilities Act. Indoor Space. The therapeutic nursery program shall: For each child enrolled in the therapeutic nursery, provide a minimum of 35 square feet of floor space, not including spaces, such as vestibules and corridors, food preparation areas, bathrooms, adult work areas, and storage spaces, that are not available for the daily program activities of the children; and Provide suitable space for individual, family, group, and play therapies. Outdoor Space. The therapeutic nursery program shall ensure compliance with applicable State and local laws and regulations for outdoor space, including but not limited to water safety requirements. Materials and Equipment. In addition to any other requirements of law or regulation, the therapeutic nursery program shall: Provide a sufficient quantity and variety of materials and equipment for indoor and outdoor activities, according to the numbers and ages of the children enrolled, including materials and equipment for: Vigorous play; Creative or dramatic play; Socialization; Manipulation, including construction, exploration of art, music, language arts, and science; and Individual pursuits; Store materials and equipment so that they are accessible to a child at the appropriate time; and Ensure that the materials and equipment used by children in the therapeutic nursery are: Safe; Clean; Nontoxic; Free from hazards, including lead paint; In good repair; and Age appropriate. Furnishings. In addition to any other requirements of law or regulation, the therapeutic nursery program shall provide: Furnishings that are proportional to a child's size; and At least the following: Multipurpose tables and chairs; and A suitable crib, bed, cot, or mat and clean bedding for each child who requires a rest period during the hours of operation of the therapeutic nursery. Storage. In addition to any other requirements of law or regulation, the therapeutic nursery program shall: Provide storage for: Materials and equipment that are for a child's use; Portable equipment intended for outdoor use; Beds and bedding when they are not in use; Each child's clothing and possessions in a space designated for each child; and Materials, equipment, furnishings, and supplies being held in reserve; and Ensure that all potentially hazardous items, including knives, tools, poisonous and toxic materials, prescription and nonprescription medicines, cleaning materials, and matches, are stored: In a safe manner; When applicable, in original containers; and Out of the reach of children. The therapeutic nursery program director shall: Ensure that a criminal background investigation as required under Family Law Article, §§5-560 — 5-568, Annotated Code of Maryland, has been completed and is on file in each staff member's personnel record; If a child is involved in an accident or is injured while in attendance at a therapeutic nursery program: Notify the primary caretaker on the day that the accident or injury occurs; If the injury is serious, notify the parent or guardian immediately; Ensure that appropriate treatment is provided; and Document the incident according to the requirements of the risk management policy of the therapeutic nursery; At all times that children are participating in the therapeutic nursery program, ensure that staff are present who hold current certificates indicating approved training in: Infant and child cardiopulmonary resuscitation (CPR); First aid; and If wading or swimming are therapeutic nursery activities, Red Cross water safety; Prepare an emergency evacuation plan that: Is approved by the local fire authority; Is posted in each room of the therapeutic nursery; The staff and children practice at least monthly, and the staff maintain a written record of the dates and times of the practices; and Includes: Safe routes by which the staff and children may exit each area in the event of fire or other emergency requiring evacuation of the building; The address of a location that can be used by the staff and children in the event of fire or other emergency until the parents, guardians, or primary caretakers of the children are notified; and The provisions that, during an evacuation or a practice, a designated staff member take out of the building the record of attendance for that date and verify the presence of each child in attendance; Provide telephones that are accessible to the staff in each activity area in the therapeutic nursery, and post the following information next to each telephone: 911 telephone number to summon fire, police, and rescue services; The name, address, and telephone number of the therapeutic nursery; Telephone number of the child protective services unit of the local department of social services; and Telephone number of a poison control center; Release a child: Only to the child's parent, guardian, or primary caretaker; or If so directed by the child's parent, guardian, or primary caretaker, to another individual whose identity is verified; As required by COMAR 10.06.01: Report communicable diseases; and Restrict attendance by staff and children with communicable diseases; Not permit anyone to use alcohol or controlled dangerous substances on the premises or to smoke cigarettes, cigars, or pipes in rooms or areas approved for use by a child; Implement measures to prevent the spread of disease including requiring that staff wash hands and ensure that a child's hands are washed thoroughly with soap and water after toileting, before handling food, after outdoor activities, and at other times necessary to prevent the spread of disease; Provide for general cleanliness by ensuring that: All surfaces, furnishings, materials, and equipment are clean; Except for emergencies and clean-up activities that are part of the daily program, cleaning is not conducted while rooms are occupied by children; Refuse containers in the building are: Noncombustible; and If they contain soiled diapers, lined with a disposable liner, covered with a lid, and inaccessible to children; and Refuse containers outside the building meet the standards required by local code; and Provide written notification to each staff member and documentation that each staff member has read and understood the notification regarding: The location of the telephone and the emergency telephone numbers specified in §E of this regulation; The location of each child's emergency form; Emergency evacuation procedures; Identity of the staff members who have appropriate first aid, CPR, and Red Cross water safety training; Signs and symptoms of abuse and neglect; The requirements and procedures for reporting suspected child: Abuse directly to the local department of social services or law enforcement agency; and Neglect directly to the local department of social services; Risk management; and The contents of this chapter. If the therapeutic nursery provides transportation, the therapeutic nursery program shall ensure that: Vehicles used for the transport of therapeutic nursery enrollees are in compliance with the requirements outlined in Transportation Article, Title 22, Annotated Code of Maryland; Each driver: Possesses a valid Class D license; and Presents the driver's record, certified by the Motor Vehicle Administration, showing not more than two points, at the time of employment and annually after that; and In addition to the driver, at least one staff member is present in the vehicle to supervise the children at all times. Health-General Article, §§10-901 and 10-902, Annotated Code of Maryland Effective date: January 2, 1995 (21:26 Md. R. 2187)