This chapter outlines the service requirements and staffing standards for a psychiatric rehabilitation program (PRP) for minors that provides psychiatric rehabilitative services to a minor. In this chapter, terms have the meanings stated in COMAR 10.21.17. The Department shall grant approval to a program to be eligible to receive State or federal funds for providing PRP services for minors if the program meets the requirements: For approval outlined in COMAR 10.21.16; For administration outlined in COMAR 10.21.17; For Medical Assistance providers outlined in COMAR 10.09.36, 10.09.59, and 10.09.70; and Of this chapter. A provider of PRP services for minors shall: Have a facility that: Meets all relevant federal, State, or local ordinances, laws, regulations, and orders governing the program; Is not located in a private residence; Is accessible to the public; and Contains a secure area where records, logs, and business information may be kept; Prominently display the hours of operation of the facility; Provide services at the PRP facility and at other locations according to the needs of the individuals served; Assure that individuals receiving services have the choice to receive services on-site or at another suitable location; and Assure that program staff are available by telephone, on call, 24 hours per day, 7 days per week. The program director shall organize program services and supports to: Facilitate the development of a minor's independent living and social skills, including the minor's ability to make decisions about the minor's life and create opportunities for choice, to the degree that is age and developmentally appropriate, regarding: Home; School or work; and Community; and Promote the use of community resources to integrate the minor into the community. The program director shall ensure that: Services are: Appropriate to the age of the populations being served; Offered at times suitable to the minors served; Coordinated with other mental health services that the minor is receiving; Goal directed; Outcome focused; Available as long as the minor meets medical necessity criteria for PRP services; Based on a functional assessment of the minor across life domains; Part of a total plan of care, which is directed at maintaining the minor in their home and preventing out-of-home placement; Integrated with the minor's ITP; and Designed to reduce functional behavioral impairments and restore and strengthen age-appropriate skills; If the PRP provides services to minors in a specific age group or with a particular clinical profile, the initiation of service criteria is consistent with the populations to be served; When the PRP provides services in a facility, the services shall be provided on a regular basis and include a variety of group and individual rehabilitation activities that incorporate individual rehabilitation goals; and If the PRP provides services to both minors and adults, the program activities for minors are separate from program activities for adults, unless the adult receiving PRP services is a parent or caregiver of the minor. A parent or guardian of a minor shall receive all notifications and information regarding PRP services for a minor, unless the minor is 16 years old or older and has consented to PRP services rather than a parent. If a minor who is 16 years old or older and has consented to PRP services rather than a parent or guardian, consent from the minor shall be obtained before providing a parent or guardian any notifications or information regarding PRP services for a minor. Eligibility. A minor is eligible for PRP services if, as a result of a serious emotional disturbance, the: Minor: Has been referred for PRP services by a licensed mental health professional who is providing inpatient, residential treatment center, or outpatient mental health services to the minor; Is currently in, and remains in active mental health treatment; and Has the appropriate consent to participate in PRP services; and Administration's administrative services organization: Determines that the services are medically necessary; and Authorizes the services according to the provisions of COMAR 10.21.17.03A. PRP services for minors shall be prioritized for minors who have a serious emotional disturbance and who meet the following eligibility criteria: Have severe functional impairments in at least one or more life domains; Based on the clinical evaluation and ongoing treatment plan, are, with PRP services, expected to have reduced symptoms of their mental illness or their functional behavioral impairment as a result of their mental illness; Have an impairment as a result of their mental illness that results in: A clear, current threat to the minor's ability to be maintained in the minor's customary setting; An emerging or pending risk to the safety of the minor or others; or Other evidences of significant psychological or social impairment such as inappropriate social behavior causing serious problems with peer or family relationships; Due to dysfunction, is at risk for requiring a higher level of care, or is returning from a higher level of care; There is clinical evidence that: The current intensity of outpatient treatment will not be sufficient to reduce the minor's symptoms and functional behavioral impairment resulting from the mental illness and restore the minor to an appropriate functional level, or prevent clinical deterioration, or avert the need to initiate a more intensive level of care due to the current risk to the individual or others; or For minors transitioning from an inpatient, day hospital, or residential treatment setting to a community setting, PRP services will be necessary to prevent clinical deterioration and support successful transition back to the community, or avert the need to initiate or continue a more intensive level of care; The minor's disorder can be expected to improve through medically necessary rehabilitation or there is clinical evidence that this intensity of psychiatric rehabilitation is needed to maintain the minor's level of functioning; and The minor is judged to be in enough behavioral control to be safe in the psychiatric rehabilitation program and benefit from the psychiatric rehabilitation provided. In addition to those minors outlined in §A(1) and (2) of this regulation, a PRP for minors may provide services to other minors who either contract privately for services or for whom another agency contracts for services. If a PRP for minors provides services to a minor outlined in §A(3) of this regulation, the PRP may not seek reimbursement by the PMHS for providing services to that minor. Screening. Within 5 working days of receipt by the program of a complete referral for PRP services, staff assigned by the program director, in collaboration with the minor and the minor's parent or guardian, if appropriate, shall schedule an appointment to conduct a face-to-face screening assessment to: Assess the minor's: Rehabilitation services needs; Willingness to participate in PRP services; and Determine the program's ability to address the needs identified in §B(1)(a) of this regulation. If, following the screening assessment under §B(1) of this regulation, the program director determines that the program's services are not appropriate for a minor who has been referred, the program director shall, in writing, promptly: Inform the minor and the parent or guardian, if appropriate, of the determination and the reason; and Provide the minor, and the parent or guardian, if appropriate, with recommendations for alternative services. Within 5 working days of the screening assessment conducted under §B(1) of this regulation, unless the program director has notified the minor of the determination under §B(2) of this regulation, the program director shall notify the minor and the parent or guardian, if appropriate, whether the program: Accepts the minor and identifies a date that the program can initiate services to the minor; Will accept the minor, following an updated review of the minor's eligibility status, when program capacity permits, and inform the minor of the: Minor's placement on a waiting list, if any; and Estimated date services may be initiated; or Will accept the minor following the minor's discharge or release from an inpatient facility, RTC, or detention center. If the minor is placed on a waiting list under §B(3)(b) of this regulation, the program director shall discuss with the minor and, if appropriate, the minor's parent or guardian: The option of remaining on the program's waiting list until the date established under §B(3)(b) of this regulation; and Alternative services that are available. Initiation of Services. Before the initiation of services, PRP staff assigned by the program director shall: Document: That a parent or guardian has applied for entitlements for which the minor may be eligible; If the application has been made, the outcome of the minor's application; and If the application has not been made, that staff have assisted the minor's parent or guardian to apply for entitlements; and Discuss with the minor and, if appropriate, the minor's parent or guardian, and provide written documentation to the minor and, if appropriate, the minor's parent or guardian, of the charges for services and, if applicable, the process for determining ability to pay. Review of Somatic Status. According to provisions outlined in this section and upon a minor's enrollment into the program, a staff member assigned by the program director shall document in the minor's medical record: Pertinent past and current medical history including: The minor's somatic health problems, if any, including but not limited to allergies, neurologic disorders, and communicable diseases; Relevant medical treatment, including medications; and Needed somatic care follow-up, if any; and If the minor does not have a primary care provider, and, if indicated, the plan, including the time frame, for the minor's referral to a primary care provider for evaluation and treatment. If indicated, the minor's rehabilitation coordinator shall document and communicate with the minor's primary care provider. If indicated, the minor's rehabilitation coordinator shall discuss with the minor, and the parent or guardian, if appropriate, the need for medical care and facilitate access to said care. Rehabilitation Assessment. Within 14 calendar days of initiation of PRP services, PRP staff assigned by the program director to conduct assessments, in collaboration with the minor and, with proper consent, the parent or guardian, shall complete a face-to-face rehabilitation assessment. The assigned staff shall document in the rehabilitation assessment, at a minimum: The minor's age and developmentally appropriate strengths, skills, and needs in the following areas: Self-care skills; Social, peer, family, and teacher interaction skills; Participation in psychiatric treatment; Semi-independent living skills; Family support and resources; Academic achievement; Community and informal support systems; and Adaptive equipment or resources; As relevant, a review of the minor's legal status and forensic history, if any; and The minor's history of physical abuse, sexual abuse, or substance abuse, if any. Individual Rehabilitation Plan. Initial IRP. Within 30 calendar days of initiation of PRP services and based on the rehabilitation assessment described in §B of this regulation, the minor's rehabilitation coordinator shall prepare an initial IRP: In collaboration with: The minor; The parent or guardian, if appropriate; and If appropriate and with proper consent, other mental health service providers, as available; That includes, at a minimum: The minor's presenting needs, strengths, and rehabilitation expectations and responsibilities; A description of needed and desired program services and interventions and staff responsible for implementation; A description of how the needed and desired skills and supports will help the minor to be successfully maintained in the home or community, and manage the minor's psychiatric disorder; Rehabilitation goals in measurable terms, and target dates for each goal; and If appropriate, identification of, recommendations for, and collaboration with, other services to support the minor's rehabilitation, including but not limited to mental health treatment, residential services, and somatic care; and That is reflective of the minor's overall plan of care. Individual Treatment and Rehabilitation Plan (ITRP). In collaboration with the mental health treatment coordinator, the rehabilitation coordinator may combine the required elements of an ITP and IRP in one document, the ITRP. Rehabilitation Plan Review. As frequently as necessary, as determined by a minor's rehabilitation coordinator, and, at a minimum of every 3 months, the rehabilitation coordinator, in consultation with the minor, shall: Review and record in the minor's medical record: The minor's progress toward the accomplishment of previously identified rehabilitation goals; Goal changes, based on a review of the minor's progress; Changes in interventions, as appropriate; and Progress toward the reduction of functional behavioral impairments and restoration of specific age-appropriate skills; Communicate promptly the results of the review to: Relevant program staff; The minor's parent or guardian, if appropriate; With proper consent, community mental health programs providing services to the minor; and With proper consent, the referring licensed mental health provider; and If the minor's service needs change, provide and document in the minor's record: The suggested changes in rehabilitation goals and services; and Staffing and support services required by the change. Signature of the IRP Plan and Reviews. The following shall sign agreement with the IRP and ITRP reviews: The minor; The minor's rehabilitation coordinator; and The minor's parent or guardian, if appropriate. If the minor is unwilling to sign an agreement with the IRP and ITRP reviews, the minor's rehabilitation coordinator shall: Verify the minor's verbal agreement with the IRP and ITRP reviews; Document the rationale for the minor's refusal to sign; and Obtain the agreement and signature of agreement of the minor's parent or guardian. In addition, for an ITRP, at least two mental health professionals, who collaborate about the minor's treatment, shall sign the IRP and ITRP reviews, including: The minor's rehabilitation coordinator, and if the rehabilitation coordinator is not a mental health professional, the mental health professional who supervises the rehabilitation coordinator; and The minor's treating mental health professional; If the minor is receiving medication prescribed through an outpatient mental health clinic (OMHC), the minor's rehabilitation coordinator shall provide the OMHC psychiatrist with a copy of the minor's IRP and ITRP reviews. Continuing Evaluation. Contact Notes. Staff shall document: Each contact with or about the individual, including, at a minimum: The date; The start and end time of services, if not documented in a readily accessible billing document; The minor's chief medical complaint or reason for the visit; The delivery of services specified by the IRP or ITRP; A brief description of the service provided; and A legible signature, which may include an electronic signature, and printed or typed name of the program staff member providing care, with the appropriate title. Progress Summary Notes. At a minimum, each month, the rehabilitation coordinator shall record in the minor's medical record a progress summary note that includes: The staff member's assessment of the minor's progress toward goal achievement in measurable terms; The minor's assessment of progress toward goal achievement; and Justification for the need for ongoing PRP services. If at least one contact note described in §D(1) of this regulation includes the information outlined in §D(2) of this regulation, the monthly progress summary note is not required. The rehabilitation coordinator shall document that the minor's needs and progress are promptly communicated to: Staff involved in the implementation of the IRP or ITRP; and The minor's parent or guardian, if appropriate; and With proper consent, other community mental health programs providing services to the minor. PRP services may only be provided to a minor if identified in the minor's IRP and referred for PRP services by: A licensed mental health professional who is providing inpatient, residential treatment center, or outpatient mental health services to the minor; and Staff who have been privileged by the program to provide the services. Rehabilitation Activities. The program director shall ensure that the program provides rehabilitation activities directed toward the development or restoration of skills including: Age-appropriate self care skills, including: Personal hygiene; Grooming; Nutrition; Dietary planning; Food preparation; and Self-administration of medication; Social skills, including community integration activities, developing natural supports, and developing linkages with and supporting the minor's participation in community activities; Independent living skills, including: Maintenance of the minor's living environment; Community awareness; Mobility skills; Money management; and Accessing available entitlements; Activities that support the minor's cultural interests; Conflict resolution; Anger management; Interactive skills with peers and authority figures; Maintaining personal living space; Maintaining age-appropriate boundaries; Maintaining personal safety in a social environment; and Time management, including constructive use of structured and unstructured time. Medication Services. Administration. An individual licensed to administer medication under Health Occupations Article, Annotated Code of Maryland, may do so. A licensed practical nurse or a registered nurse may delegate the administration of medication only according to the provisions of COMAR 10.27.11. Monitoring. A PRP staff member shall provide the following services: Support the individual's self-administration, as appropriate, of prescribed medication; Read the medication label to ensure that each container of medication is clearly labeled with the individual's name, the contents, directions for use, and expiration date; To the extent possible, monitor compliance with instructions appearing on the medication label; Ensure that each individual has secure, appropriate, and accessible space in which to store medications; Observe and document any apparent reactions to medication and, either verbally or in writing and in a timely fashion, communicate to the prescribing authority any problems that possibly may be related to the medication; and Reinforce, with the individual, education on the role and effects of medication in symptom management. Promotion of Illness Self Management. As is age appropriate, staff shall provide education and information regarding mental illness. The program director shall ensure that the minor's rehabilitation coordinator collaborates with the minor to identify effective strategies to assist the minor to manage the minor's illness. The strategies identified under §D(2) shall include, at a minimum, the minor's identification of: Potential problematic symptoms; Warning signs of relapse; Helpful interventions; and Other individuals the minor identifies to resolve the situation in order for the minor to remain in service or to seek treatment. The minor's illness self management strategies shall be documented and may be incorporated in the minor's IRP, ITP, mental health advance directive, or any combination of them. The strategies shall be reviewed at the time of the IRP review and may be revised or revoked at any time at the request of the minor. On-Call and Emergency Response. The program director shall assure that: On-call and emergency response services are available by a licensed mental health professional to an individual who has been admitted to the PRP: Face-to-face during the hours that the PRP is open; and By telephone, on an on-call basis, 24 hours per day, 7 days per week, during the hours the PRP is not open: Through the PRP; or Through an agreement with another mental health crisis service provider; PRP staff provide to a minor: Intensive support and assistance, as authorized, including but not limited to: Providing one-to-one staff support for the minor, if necessary; Escorting the minor while accessing needed assistance or services; and Obtaining input from the mental health professional who is providing outpatient mental health services to the minor; Information regarding needed services; and If necessary, referral for appropriate health care. If emergency care is necessary, all relevant staff shall: Have access to the names, addresses, and telephone numbers of providers, including the hospital, that are designated to provide emergency care and treatment to the minors served; and Be appropriately trained to link minors to emergency care, as needed. Linkage with a Minor in a Psychiatric Inpatient Facility, Residential Treatment Center (RTC), or Detention Center. If a minor who is enrolled in a program is admitted to a psychiatric inpatient facility, RTC, or detention center, the rehabilitation coordinator shall make reasonable efforts to maintain ongoing communication with the minor and the minor's inpatient treatment team. To the degree permitted by the setting, PRP staff serving the minor shall participate in aftercare or release planning from that setting. The program director shall maintain clearly written policies and procedures, which may be contained in one document, for the process for discharge from the program as outlined in COMAR 10.21.17.11. Following an analysis of the complexity and number of minors served, the program director, with input from program staff, shall ensure the development of a staffing plan that identifies the type and number of staff needed to implement the program's rehabilitation service goals. A provider shall ensure that the staff includes the following, who are employed by the PRP for the amounts of time outlined in §§C — E of this regulation: A program director, who: Is qualified according to §F(1) of this regulation and who is responsible for the duties under §F(2) of this regulation; and May be responsible for the duties of the rehabilitation specialist under §G(1)(b) of this regulation, if the program director: Is qualified according to §G(1)(a) of this regulation; and Devotes the time required, under §C, D, or E of this regulation, to the development and implementation of rehabilitation services that reflect the need of the minors served by the program; As required under §C, D, or E of this regulation, a rehabilitation specialist or specialists, qualified according to §G(1)(a) of this regulation, to carry out the duties under §G(1)(b) of this regulation; and As required under §D or E of this regulation, staff designated to carry out administrative duties assigned by the program director. If a PRP has fewer than 30 enrollees, the PRP shall employ either: A program director and a rehabilitation specialist, each of whom is employed by the program for a minimum of 20 hours per week; or A program director who is responsible for the duties of the program director and the duties of a rehabilitation specialist, if the program director: Has the qualifications described under §G(1)(a) of this regulation; Is employed by the program for 40 hours per week; and Devotes at least 20 hours per week to the development and implementation of rehabilitation services that reflect the needs of the minors served by the program. If a PRP has 30 — 100 enrollees, the PRP shall employ either: A program director, who is employed by the program for a minimum of 20 hours per week, and a rehabilitation specialist, who is employed by the program for a minimum of 40 hours per week; or A program director who is responsible for the duties of the program director and the duties of a rehabilitation specialist, if the program director: Has the qualifications described under §G(1)(a) of this regulation; Is employed by the program for 40 hours per week; and Designates staff who devote 20 hours per week to carrying out specific assigned administrative duties. If a PRP has more than 100 enrollees, the PRP program shall employ: A program director who is employed by the program for 40 hours per week; and A rehabilitation specialist or specialists and staff assigned to administrative duties, as follows: A rehabilitation specialist who is employed by the program for 40 hours per week; Two rehabilitation specialists, each of whom is employed by the program for 20 hours per week; or If the program director has the qualifications described under §G(1)(a) of this regulation: A rehabilitation specialist who is employed by the program for 20 hours per week; and Designated staff who devote 20 hours per week to carrying out specific assigned administrative duties. Program Director. The program director: Shall have: Sufficient qualifications, knowledge, and experience to execute the duties of the position; and A minimum of 3 years experience working with emotionally disturbed youth; and Is responsible for administrative oversight of the PRP, including, at a minimum: Fulfilling the administrative requirements under COMAR 10.21.17; Fulfilling the programmatic requirements of this chapter; Keeping the advisory committee, or governing body, whichever is applicable, informed of, at a minimum, the program's approval status and performance; and Quality management. Psychiatric Rehabilitation Staff. The program director shall employ psychiatric rehabilitation staff, including: At least one rehabilitation specialist who: Is a licensed mental health professional with a minimum of 2 years direct care experience working with emotionally disturbed youth; Shall advise the program director regarding development and implementation of rehabilitation services that reflect the need of the minors served by the program; Has overall responsibility for rehabilitation services, including: Developing and assuring that rehabilitation services meet the needs of the individuals served by the program; and Providing oversight for the daily program of rehabilitation services; and Shall educate direct care staff on how to document the correlation between rehabilitation activities and the goals identified in the IRP or ITRP; Direct service staff who: Are supervised by a licensed mental health professional or a rehabilitation specialist; Have 60 hours of on-the-job direct PRP supervision before providing services to minors served by the program without direct supervision; At a minimum, have: A bachelor's degree in a health-related field; An associate's degree in a health-related field; 30 hours, or their equivalent, of college credit toward a bachelor's degree in a health-related field; or 1 year of work experience in a supervised mental health setting; and Are responsible for implementing the rehabilitation activities outlined in the minor's IRP. Ratio. The program shall maintain an average ratio of at least one rehabilitation staff member serving each six minors who are either attending the PRP facility or receiving off-site services. To achieve this ratio, the program: May not include: The program director; or Volunteers; and May include students only if, in calculating the ratio, three rehabilitation staff are on duty for each student. Students. The program may use students according to the provisions of COMAR 10.21.17.11E. Volunteers. The program may use volunteers according to the provisions of COMAR 10.21.17.11F. Health-General Article, §§10-901 and 10-902, Annotated Code of Maryland Effective date: April 10, 2006 (33:7 Md. R. 669) Regulation .05A amended effective February 12, 2007 (34:3 Md. R. 299) Regulation .07A amended effective February 12, 2007 (34:3 Md. R. 299)