This chapter outlines the staffing and service requirements for a provider of residential crisis services. In this chapter, terms have the meanings stated in COMAR 10.21.17 and this regulation. Term Defined. “Residential crisis services (RCS)” means intensive mental health and support services that are: Provided to a child or an adult with mental illness who is experiencing or is at risk of a psychiatric crisis that would impair the individual's ability to function in the community; and Designed to prevent a psychiatric inpatient admission, provide an alternative to psychiatric inpatient admission, shorten the length of inpatient stay, or reduce the pressure on general hospital emergency departments. The Department shall grant approval to a program to be eligible to receive State or federal funds for providing RCS if the program: Meets the requirements: For approval outlined in COMAR 10.21.16; For administration outlined in COMAR 10.21.17; and Of this chapter, including approval, based on the requirements for intensity of services and staffing outlined in this chapter, for one or more of the following: Inpatient admission prevention; Inpatient admission alternative; or Treatment foster care in a foster home licensed under COMAR 07.02.21; For a program that provides RCS to a child, documents State licensure for the location in which the child will be housed while receiving crisis services; and For a program that provides services to an adult: Documents State licensure for the location in which the individual will be housed while receiving crisis services; Meets the residential site requirements outlined under COMAR 10.21.22, as documented by the residential specialist; or Is located in subacute beds in an inpatient psychiatric facility. A provider of RCS shall assure that services are: Therapeutic; Provided by staff who, as determined by the program, are appropriately credentialed and privileged; Available: 24 hours per day, 7 days per week; On a short-term basis, as needed to resolve an immediate crisis; and At a location in the community, unless given a written exemption from the core service agency (CSA). A provider of RCS shall assure that services are adequate to support one or more of the following levels of service: Inpatient admission prevention, which provides: Services to an individual who, based on the individual's history, as evaluated by a physician or a mental health professional, has a mental disorder and, without RCS, is at risk for inpatient admission or cannot be discharged from an inpatient facility; and Staff adequate to support the services under §B(1)(a) of this regulation, as outlined under Regulations .08 and .09 of this chapter; Inpatient admission alternative, which provides: Services to an individual who, based on an evaluation by a physician or a mental health professional, has a mental disorder, presents a danger to self or others, and would, without RCS, be admitted to or could not be discharged from an inpatient facility; and Staff adequate to support the services under §B(2)(a) of this regulation, as outlined under Regulations .08 and .10 of this chapter, including access to a psychiatrist 24 hours per day, 7 days per week; or Treatment foster care, which provides: Services to an individual who, based on an evaluation by a physician or mental health professional, has a mental disorder, and is in need of a high level of treatment intervention in a family setting; and Staff adequate to support services under §B(3)(a) of this regulation, as outlined under Regulations .08 and .11 of this chapter. A provider of RCS shall assure that services are designed to: Avert or shorten the length of inpatient admissions; Defuse a current crisis, evaluate the nature of the crisis, stabilize the individual to the pre-crisis level of functioning, and intervene to reduce the likelihood of crisis recurrence; Assist the individual and members of the individual's natural support system to recognize and take preventive action to resolve situations that lead to crisis; Provide counseling, training, and support for crisis prevention, identification, and intervention for individuals and, if appropriate, their families; Link individuals with services and supports in the community including, but not limited to, financial, educational, social, medical, and mental health resources that will enable the individual to: Return to the individual's previous living situation; or Secure an alternative living situation; and Offer a home-like environment that provides goal-directed services to facilitate safe discharge from residential crisis services. A provider of RCS shall assure that services are coordinated with, when appropriate: An individual's custodial agents; Designated psychiatric emergency facilities; Psychiatric inpatient facilities; Psychiatric rehabilitation programs; Outpatient mental health clinics; Somatic care providers; Schools; Other agencies involved with the individual, including, but not limited to: Local departments of social services; Department of Juvenile Services; The local education authority; The local coordinating council (LCC); The local management board; and Criminal justice agencies; and Other public and private providers of mental health services to an individual. Eligibility and Referral. An individual is eligible for RCS if: The individual: Is a participant, as described in COMAR 10.21.25.01D(2), in the public mental health system; Has a diagnosis that is listed in COMAR 10.09.70.02; Due to acute symptomatology related to the individual's psychiatric condition, has impaired ability to function within the individual's community living situation and is in need of RCS to avoid inpatient psychiatric admission or to shorten the length of inpatient stay; For clinical reasons, requires a temporary separation from the individual's current living situation; Has stated a willingness to comply with program rules, or, for a child, a parent or guardian has stated a willingness to comply with program rules; Expects, with staff support, to be able to comply with treatment recommendations; and Is able, with staff support, to care for physical needs and basic personal hygiene; and The services are preauthorized, as needed, by the Administration's administrative services organization (ASO) according to the provisions of COMAR 10.21.17.02-1A. An individual is not eligible for RCS if the individual: Has a sole diagnosis of substance abuse, mental retardation, or dementia; Is in need of immediate involuntary inpatient psychiatric admission; As determined by an individual authorized under Health Occupations Article, Annotated Code of Maryland, to make medical determinations, is medically unstable; or Does not meet the eligibility criteria under §A(1)(a) of this regulation. An RCS program may not exclude an individual solely because the individual: Does not participate in other treatment or rehabilitation programs; or Is homeless. Screening Assessment. If an individual who is authorized for services has not, before the individual's entry into the RCS program, been evaluated face-to-face by a physician who documents the elements included in this section, an appropriately privileged mental health professional, in collaboration with the individual, shall conduct a screening assessment to: Assess the individual's needs and willingness to participate in RCS; Document: The diagnosis, if any, provided by the referral source; and If applicable, medications that are prescribed for the individual; In consultation with the individual and, if any, the referral source, outline a preliminary plan for the RCS services to be provided if the individual enters RCS services, including, at a minimum, the level and type of staff support required for the individual's first 48 hours in the program, and, when appropriate, enhanced support such as: 24-hour, on-site; 24-hour, on-site, awake; or One-to-one; and Inform the individual of the rules of the program and the process and procedure for discharge, including situations as outlined under Regulation .12E of this chapter. If, following the assessment under §B(1) of this regulation, the RCS program director determines that the program's services are not appropriate for an individual who has been referred, the program director shall promptly: Inform the individual and, if the individual is a child, the parent or guardian, of the determination and the reason; With proper consent, notify the family or significant others designated by the individual of the determination and of any recommendations for other services; and Notify the CSA and the Administration's ASO for appropriate alternative referral. Admission. Unless an individual has been re-referred to the Administration's ASO under the provisions of §B(2)(c) of this regulation, an RCS program shall initiate services to an individual if: The individual accepts the rules of the RCS program; and When the individual referred for RCS is a child, the parent or guardian signs an agreement with the provider to accept the child for placement upon discharge from RCS. Initial Evaluation. Before the development of the individual treatment plan (ITP), an individual entitled under Health Occupations Article, Annotated Code of Maryland, to render a psychiatric diagnosis shall conduct a face-to-face evaluation with the individual, and, if the individual is a child, with the child's primary caretaker, to: Describe the presenting problem and history of present illness; Collect and evaluate relevant medical and mental health history, including, if any: Previous inpatient and outpatient treatment; and A review of current medications and source of prescriptions; Evaluate current mental status; Either: Formulate and document a psychiatric diagnosis and the rationale for the diagnosis; or Affirm the psychiatric diagnosis, not more than 1 year old, formulated by the referral source and documented in the individual's medical record; and Identify needed treatment. Assessment. Before the development of the ITP, the individual's assigned treatment coordinator shall conduct a face-to-face evaluation with the individual, and, if the individual is a child, with the child's primary caretaker, to: Identify the individual's strengths, needs, and desires; Assess the individual's level of functioning and availability of family and other social supports; Complete an assessment that includes, at a minimum, a review of: The individual's: Legal status; Housing status; Current employment and economic status; History of substance abuse; History of physical or sexual abuse; History of violence or assaultive behaviors; Natural support system; Activities of daily living; and Interpersonal skills; and For a child, in addition to the requirements of §B(3)(a) of this regulation, the child's: Developmental status; Educational history and current placement; Involvement with other agencies; Home environment; and Family history and evaluation of the current family status, including legal custody status; and Initiate the process to determine who will provide the individual's mental health care and treatment upon discharge from crisis services. Diagnosis. The program director shall assure that, before the development of the ITP, RCS staff documents the psychiatric diagnosis rendered according to §A(4) of this regulation. Somatic Care. The program director shall assure that RCS staff coordinates an individual's care with, when known and with proper consent, the individual's somatic care provider. Within 48 hours before or not more than 72 hours after an individual's admission into the program, an individual authorized under Health Occupations Article, Annotated Code of Maryland, shall: Assess the individual's general physical health; Determine whether the individual requires a physical examination or somatic care follow-up; and Make appropriate referrals for services. Individual Treatment Plan (ITP). Treatment Team. At a minimum the following shall participate as members of an individual's RCS program treatment team: The designated treatment coordinator; Relevant RCS staff providing services to the individual; and When available, relevant staff from other agencies currently providing services to the individual. Individual Treatment Plan. Within 24 hours of placement in an RCS program, based on the screening evaluation under Regulation .05C of this chapter, the initial evaluation under Regulation .06A of this chapter, the assessment under Regulation .06B of this chapter, and the psychiatric diagnosis under Regulation .06C of this chapter, the treatment team shall prepare an ITP: In collaboration with: The individual; For a child, the parent or guardian and, if other than the parent or guardian, the primary caretaker; and When appropriate and with proper consent, the individual's family and others involved in the individual's care; That includes, at a minimum: The psychiatric diagnosis as provided in Regulation .06C of this chapter; A description of the individual's current behavior, symptoms, and level of functioning that includes the individual's presenting strengths, needs, and treatment expectations and responsibilities; When relevant to the individual, a description of the family's or significant others' needs and strengths; Mental health treatment goals, including the plan for transition and discharge, to be accomplished during an individual's residence in an RCS program, which are outcome oriented and stated in behavioral, measurable terms; and The anticipated length of stay in the RCS program; and That specifies treatment strategies, including: Recommended modality and frequency of interventions, including, if appropriate, case management services; Target dates for goal achievement; The designation of RCS staff responsible for implementing the elements of the plan; Scheduled daytime activities, if any, such as a partial hospitalization program (PHP), psychiatric rehabilitation program (PRP) on-site or off-site services, and school services; and When appropriate, identification of, recommendations for referral to, and collaboration with, other services to support the individual's treatment. Signature of the ITP. The individual or, for a child, the parent or guardian shall sign or tape record agreement or disagreement with the ITP and reviews. A child's primary caretaker, if other than the parent or guardian, shall sign or tape record acknowledgment of the ITP and reviews. In addition, the following shall sign the ITP and reviews: The individual's treatment coordinator; When there is an RCS psychiatrist, the RCS psychiatrist; and When there is a mental health professional, the mental health professional. Discharge Before the ITP. When an individual is discharged within 24 hours of admission to RCS, if the treatment team has not developed an ITP, the treatment coordinator shall document, in the individual's medical record, a brief description of the goals established and interventions employed. Continued Evaluation. Contact Notes. In order to assure that services to an individual are timely and appropriate, staff shall document in the individual's medical record contact notes regarding all clinically relevant face-to-face, telephone, and written contacts with or about the individual, including the dates, locations, and types of contacts. Progress Summary Notes. The individual's treatment coordinator shall document or assure that staff document in the individual's medical record a daily progress summary note that includes: A description of progress toward goals; Changes in goals and interventions based on the review of progress; and The rationale for the changes. The program director shall ensure that the RCS staff is sufficient in numbers and qualifications to carry out the program's service goals and includes, at a minimum, the staff identified in this regulation and Regulations .09 — .11 of this chapter. Program Director. The governing body shall employ a program director who: As determined by the governing body, has sufficient qualifications, knowledge, and experience to execute the duties of the position; Is available to provide RCS administration and supervision: For the amount of time necessary to carry out the duties and, at a minimum, 10 hours per week; and If a RCS program operates in more than one site, by: Designating, as necessary, staff to manage services at each site and report to the program director and Having contact with each site each week; Is responsible for operational oversight for, at a minimum: Fulfilling the administrative requirements under COMAR 10.21.17 and the day-to-day operations of the RCS program; Maintaining sufficient staff, including recruiting, hiring, scheduling, and terminating; Consulting on the development and implementation of the budget; Keeping the governing body informed of, at a minimum, the program's approval status and performance; and In collaboration with appropriate RCS staff, assuring staff compliance with: Credentialing and privileging; Appropriate training and supervision; and When required, the on-call availability of a psychiatrist; and If appropriately credentialed and privileged, may provide RCS services. Treatment Coordinator. The program director shall assign to each individual who is receiving RCS a treatment coordinator who, as privileged by the program, shall provide or coordinate the services outlined in this chapter for the specific type and level of RCS. Direct Service Providers. The program director shall employ a sufficient number of direct service providers who: As determined by the program, have sufficient qualifications and experience to carry out the duties of the position; Before providing services, have training applicable to the service, including, at a minimum, training in: Crisis intervention; Suicide prevention; Behavior modification; and Family interactions; and As permitted under the Health Occupations Article, Annotated Code of Maryland, and as privileged by the program, provide the level and intensity of supervision and support required under this chapter for the specific type and level of RCS indicated in an individual's ITP. Staff Support. The program director shall assure that the program: Has at least one staff person on duty at all times that a resident is present in the RCS facility; Has the capacity for and, when required by an individual's ITP, provides 24-hour awake staff support; Has the capacity for 1:4 coverage and, when required by an individual's ITP, provides 1:4 coverage; and If the program serves children, provides at least one staff member for every three children. Psychiatric Evaluation and Intervention. The program director shall assure that a psychiatrist provides evaluation and prescribed needed treatment interventions, either: By consultation with the psychiatrist who is currently treating the individual; or Through a written agreement with a provider of mental health treatment, who will provide face-to-face evaluation by a psychiatrist before the development of the ITP. Treatment and Support Services. The program director shall assign to each individual who is receiving RCS a treatment coordinator who shall assure that the individual receives: The care or treatment recommended under Regulation .07A of this chapter; Monitoring of the individual's condition; Supportive counseling focused on: Assessment and definition of problems; Planning and goal setting; Development of effective problem-solving techniques; and Evaluation of progress; Assistance in accessing community resources, including case management, that are essential to meeting the individual's identified needs; and Transition services and discharge planning. Medication Services. Monitoring. A member of the treatment team privileged to do so shall provide the following medication monitoring services: Supporting the individual's self-administration of medications, including both prescribed and over-the-counter medications; To the extent possible, monitoring compliance with instructions appearing on the label or a more recent physician's order; Reading the label to assure that each container of medication is clearly labeled with the individual's name, the contents, directions for use, and expiration date; Assuring that each individual has secure, appropriate, and accessible space in which to store medications; Observing and documenting medications taken and any apparent reactions to the medication, and, either verbally or in writing and in a timely fashion, communicating to the prescribing authority problems that possibly may be related to the medication; and Reinforcing education on the role and effects of medication in symptom management. Administration. If an individual's ITP requires that RCS staff administer medication, only an individual authorized to do so under Health Occupations Article, Annotated Code of Maryland, may administer medication. Staff Support. The program director shall ensure: That sufficient staff are on duty at all times to relate to the expected clinical needs of the individuals in the residence; and At a minimum: The provision of at least one on-site, awake staff for every four individuals receiving RCS or, if a child is in the residence, one staff for every three individuals; The availability, based upon clinical acuity and the request of on-duty staff, of at least one other staff member to arrive at the RCS program within 1 hour of a request; and That the program has the capacity for 1:1 coverage, and provides 1:1 coverage when clinically indicated. Psychiatric Evaluation and Intervention. The program director shall assure that a psychiatrist: Is available on call, 24 hours per day, 7 days per week; Within 24 hours of an individual's admission: Conducts a face-to-face evaluation; Either: Formulates and documents a psychiatric diagnosis and the rationale for the diagnosis; or Affirms the psychiatric diagnosis formulated under Regulation .06A(4) of this chapter; and Through participation in the ITP, prescribes treatment interventions; and If the individual presents a danger to self, indicates appropriate staff coverage and precautions. Treatment and Support Services. The program director shall ensure that a mental health professional: Provides regular supervision of all treatment staff; and Each day, either: Monitors, face-to-face, an individual's condition and documents significant changes; or Consults with staff regarding the clinical needs of an individual. The program director shall assign a treatment coordinator who shall assure that the individual receives: Care or treatment recommended under Regulation .07A of this chapter; and The services under Regulation .09C(1)(c) — (e) of this chapter. Medication Services. Monitoring. When required by the individual's ITP, a member of the treatment team credentialed and privileged to do so shall provide medication monitoring, as outlined in Regulation .09C(2)(a) of this chapter. Administration. The program director shall assure that an individual authorized under Health Occupations Article, Annotated Code of Maryland, is available to administer medication in a case where medication administration is required by an individual's ITP. Staff Support. The RCS program director shall assure that: RCS mental health professional staff provides, to the foster care provider, specialized training in mental health crisis recognition, management, and intervention, before placing any individuals in the foster home; and The RCS program has the capacity to provide staff to deliver, in the foster home, on an emergency basis: 24-hour, awake supervision; and One-to-one support. Psychiatric Evaluation and Intervention. The program director shall ensure appropriate evaluation and documentation of needed treatment interventions: By consultation with the psychiatrist who is currently treating the individual; Through a written agreement with a provider of mental health treatment, who will provide face-to-face evaluation by a psychiatrist before the development of the ITP; or Through a written agreement with an outpatient mental health clinic, approved under COMAR 10.21.20, that will provide consultation with a psychiatrist and face-to-face evaluation by a mental health professional privileged by the program and appointed by the medical director to provide the service. Treatment and Support Services. The program director shall assure that: An individual receives the care or treatment outlined in the ITP under Regulation .07A of this chapter; and As required by an individual's ITP, a mental health professional is available to provide mental health services on site at the foster home. Medication Services. A foster care provider shall: Administer an individual's medications, as permitted under COMAR 10.27.11; or Monitor an individual's self-administration of medications. The program director shall assure that, if an individual's ITP requires that RCS staff provide medication services, monitoring or administration of medication is carried out as outlined under Regulation .09C(2) of this chapter. Discharge Policy. The program director shall: Collaborate with the Administration's ASO to: Arrange for discharge from the program when services are no longer authorized by the Administration's ASO; and Make recommendations for referral for alternative services for an individual for whom the program's services are not appropriate; and Maintain clearly written policies and procedures for: Transition services; Collaborative discharge from the program; and Making recommendations for discharge and referral for alternative services for an individual for whom the program's services are not appropriate. Transition. The treatment coordinator shall: Collaborate with the Administration's ASO to provide interim services and assure appropriate referrals for authorization for case management and other service providers before discharge; and With proper consent and while the individual is still in the RCS program, contact the providers who have been authorized to provide the services designated in the discharge summary. Collaborative Discharge. When the Administration's ASO, in consultation with the treatment coordinator, determines that services are no longer medically necessary, the rehabilitation coordinator shall: Prepare a discharge plan based on an assessment of the individual's current service needs and mutually agreed upon goals, in collaboration with: The individual, and, for a child, the primary caretaker; and With proper consent: Family or significant others designated by the individual; and When feasible, other treatment and service providers; When needed, make appropriate recommendations to the Administration's ASO for treatment, rehabilitation, and community supports; and Complete a discharge summary in accordance with COMAR 10.21.17.07D(3). Individual's Discontinuation of Services. When an individual discontinues services before a planned, collaborative discharge as described in §C of this regulation, the treatment coordinator shall: When possible, give the individual information about appropriate alternate services; If authorized by the Administration's ASO, provide appropriate outreach to encourage the individual to access appropriate services; With proper consent, provide notice of the discontinuation to: The emergency contact named by the individual at the time of admission; When feasible, other service providers, including the individual's somatic care provider, when known; and When needed, the CSA and the Administration's ASO, for referral for appropriate alternative services; and Complete a discharge summary in accordance with COMAR 10.21.17.07D(3). Program's Recommendation to Discontinue Services. If, in consultation with the program director, the treatment coordinator recommends discharging an individual who does not comply with the program's rules or for whom the program's services are not appropriate, the program director shall: Provide written notice of the intention to discharge from services and recommend referral for alternative services: To the individual and, for a child, the parent or guardian and, if other than the parent or guardian, the primary caretaker; With proper consent to: The emergency contact named by the individual at the time of admission; When feasible, other service providers; and When needed, the CSA and the Administration's ASO, for referral for appropriate alternative services; That includes: The effective date of the action; The reason for the action; and When possible, a discharge plan; and Complete a discharge summary in accordance with COMAR 10.21.17.07D(3). Health-General Article, §§10-901 and 10-902, Annotated Code of Maryland Effective date: December 28, 1998 (25:26 Md. R. 1926) Regulation .02B amended as an emergency provision effective June 1, 2007 (34:13 Md. R. 1149); amended permanently effective August 13, 2007 (34:16 Md. R. 1432) Regulation .03C amended as an emergency provision effective June 1, 2007 (34:13 Md. R. 1149); amended permanently effective August 13, 2007 (34:16 Md. R. 1432)