Description of Services. A detoxification program shall provide services to an intoxicated patient by: Monitoring the decreasing amount of psychoactive substances in the body; Managing the withdrawal symptoms; and Motivating the individual to participate in an appropriate treatment program for alcohol or other drug dependence. A detoxification program shall: Avoid potentially harmful consequences of withdrawal from alcohol and drug dependence as medically possible; Provide a space to house and observe patients suffering from withdrawal symptoms; Ease physical discomfort during the withdrawal process; and Facilitate transition to a treatment continuum of care which may include: Ongoing alcohol or drug treatment in a residential or outpatient treatment program; Referral to mental health treatment; and Referral to self-help recovery programming. Level I-D Ambulatory Detoxification Without Extended On-Site Monitoring. Description of Services. Ambulatory detoxification without extended on-site monitoring services offers evaluation, detoxification, and referral under medical supervision to patients who require services in an office setting or healthcare, correctional, or addictions treatment facility. This program may be certified as a separate program or be combined with a Level I outpatient program. Patients who are appropriate for this level of treatment meet the current edition of the American Society of Addiction Medicine Patient Placement Criteria, or its equivalent as approved by the Alcohol and Drug Abuse Administration. Staffing. A program shall employ: Appropriately credentialed staff as described in COMAR 10.47.01.06; A licensed physician; and A registered nurse. To perform the program's services, a program shall also employ sufficient licensed health care professionals, which may include: Physician assistants; Nurse practitioners; Registered nurses; or Licensed practical nurses. Services. Detoxification services shall include: A physical examination by a medical doctor, physician assistant, or nurse practitioner within a reasonable time frame; An assessment as described in COMAR 10.47.01.04; An individualized treatment plan as described in COMAR 10.47.01.04; Administration and monitoring of medication, including administration and monitoring of psychotropic medication by qualified nursing staff, as necessary; Monitoring of vital signs; Discharge or transfer planning as described in COMAR 10.47.01.04; and A mental health focused assessment for patients taking or prescribed psychotropic medication: Approved by the registered nurse and the program physician; and Overseen by the registered nurse. Documentation. The clinical staff providing services shall: Write a patient progress note after each counseling session; and Place the note in the patient's record. Referral Services. The program shall offer the following services or maintain a listing of agency referral agreements for the following services: Medical, psychological, and psychiatric consultation; Laboratory services; Transportation services; and Substance abuse/dependence and mental health treatment programs. Emergency Services. A program shall have a written agreement with a nearby hospital to provide necessary emergency medical support services. The agreement shall include: An emergency protocol describing the manner in which patients are referred to the hospital and provided appropriate care; Cooperative arrangements that specifically assign responsibility to provide transportation; The manner in which hospital on-call coverage is provided; A mechanism to provide psychiatric evaluation, if necessary; A prescreening protocol for patients referred to the ambulatory detoxification program from the hospital; and A written protocol for the transfer of a patient to continued treatment. Level II-D Ambulatory Detoxification with Extended On-Site Monitoring. Description of Services. An ambulatory detoxification with extended on-site monitoring services shall: Offer evaluation, detoxification, and referral under medical supervision to patients who require services in an office setting, healthcare, correctional, or addictions treatment facility; and Be certified as a separate program or be combined with intensive outpatient or partial hospitalization treatment. Patients who are appropriate for this level of treatment meet the current edition of the American Society of Addiction Medicine Patient Placement Criteria for either Level II.1 or Level II.5, or its equivalent as approved by the Administration. Staffing. A program shall employ: Appropriately credentialed staff as described in COMAR 10.47.01.06; A licensed physician, physician assistant, or a licensed nurse practitioner; and Additional medical staff which shall be a: Licensed physician's assistant; Registered nurse; or Licensed practical nurse. Services. Detoxification services shall include: A physical examination by a medical doctor, physician assistant, or nurse practitioner within 24 hours of admission; An assessment as described in COMAR 10.47.01.04; An individualized treatment plan as described in COMAR 10.47.01.04; Administering and monitoring of medication, as necessary; Monitoring of vital signs; and Discharge or transfer planning as described in COMAR 10.47.01.04. Documentation. The clinical staff person providing the service shall: Write a patient progress note after each counseling session; and Place the note in the patient's record. Referral Services. The program shall offer or maintain a listing of agency referral agreements for the following services: Medical, psychological, and psychiatric consultation; Laboratory services; Transportation services; and Substance abuse/dependence and mental health treatment programs. Emergency Services. A program shall have a written agreement with a nearby hospital to provide necessary emergency medical support services. This agreement shall include: An emergency protocol describing the manner in which patients are referred to the hospital and provided appropriate care; Cooperative arrangements that specifically assign responsibility to provide transportation; The manner in which hospital on-call coverage is provided; A mechanism to provide psychiatric evaluation, if necessary; A prescreening protocol for patients referred to the ambulatory detoxification program from the hospital; and A written protocol for the transfer of a patient to continued treatment. Level III.2-D Clinically Managed Residential Detoxification. Description of Services. Clinically managed residential detoxification services are provided for patients whose intoxication or withdrawal signs and symptoms are sufficiently severe to require 24-hour structure and support and may be offered at Level III.3 or Level III.5 programs. Patients who are appropriate for this level of treatment: Meet the current edition of the American Society of Addiction Medicine Patient Placement Criteria, or its equivalent as approved by the Administration; and Are intoxicated, show moderate withdrawal signs and symptoms, or evidence that withdrawal is imminent. Staffing. A program: Shall employ appropriately credentialed staff as described in COMAR 10.47.01.06; May not have a patient to alcohol and drug counselor ratio that exceeds eight patients to one full-time alcohol and drug counselor if counseling services are available; Shall have a physician, physician assistant, or nurse practitioner available 24 hours a day; Shall provide licensed nursing services between 7 a.m. and 11 p.m. daily as follows: A registered nurse shall provide at least 8 hours of coverage a day 5 days a week; and The remainder of coverage may be provided by either a licensed practical nurse or a registered nurse; and Shall have at least two employees trained in crisis management and cardiopulmonary resuscitation on duty between the hours of 11 p.m. and 7 a.m., 7 days a week. Program Services. A program shall provide the following services: Nursing assessment upon admission; Physical examination by a medical doctor, physician assistant, or nurse practitioner within 24 hours of admission if clinically indicated; Assessment as described in COMAR 10.47.01.04; Individualized treatment plan appropriate to a short term detoxification treatment regimen; Discharge or transfer planning as described in COMAR 10.47.01.04; Monitoring of vital signs as clinically indicated; Administering of medication, as necessary; and Adjunct services, which may include: Basic alcohol or other drug education; Family services; and Motivational counseling. Documentation. Designated clinical staff shall: Write a patient progress note at the end of each day services are provided; and Place the progress note in the patient's record. Referral Services. The program shall offer the following services or maintain a listing of agency referral agreements for the following services: Medical, psychological, and psychiatric consultation; Laboratory services; Transportation services; and Substance abuse or dependence and mental health treatment programs. Emergency Services. A program shall have a written agreement with a nearby hospital to provide necessary emergency medical support services. The agreement shall include: An emergency protocol describing the manner in which patients are referred to the hospital and provided appropriate care; Cooperative arrangements that specifically assign responsibility to provide transportation; The manner in which hospital on-call coverage is provided; A mechanism to provide psychiatric evaluation, if necessary; A prescreening protocol for patients referred to the inpatient detoxification program from the hospital; and A written protocol for the transfer of a patient to continued treatment. Patients Treated with Opioid Maintenance Medication. A detoxification facility is not limited in the number of admissions for detoxification of patients who are treated with opioid maintenance medication. A detoxification facility is not limited in the total number of doses of opioid maintenance medication that it will accept from patients who: Attend the detoxification program; and Require opioid maintenance medication for opioid detoxification or detoxification for substances other than opioids. Level III.7-D Medically Monitored Inpatient Detoxification. Description of Services. Medically monitored inpatient detoxification services offer 24-hour medically supervised evaluation and withdrawal management by medical professionals at an inpatient facility and may be offered with therapeutic community or medically monitored intensive inpatient treatment. This is an Intermediate Care Facility/C. Patients who are appropriate for this level of treatment: Meet the current edition of the American Society of Addiction Medicine Patient Placement Criteria, or its equivalent as approved by the Administration, for this level of treatment; and Are intoxicated, show physical signs of withdrawal, or both. Staffing. A program: Shall employ appropriately credentialed staff as described in COMAR 10.47.01.06; May not have a patient to alcohol and drug counselor ratio that exceeds eight patients to one full-time alcohol and drug counselor if counseling services are available; Shall have on-site physician, physician assistant, or nurse practitioner coverage available to provide initial assessment and documented referral for care, and to monitor progress in treatment; Shall have a physician, physician assistant, or nurse practitioner on call 24 hours a day; and Shall have nursing services during all hours of service, including at least 8 hours of service provided by a licensed registered nurse. Program Services. A program shall provide the following services: Nursing assessment upon admission; Physical examination by a medical doctor, physician assistant, or nurse practitioner within 24 hours of admission; An assessment as described in COMAR 10.47.01.04; Individualized treatment plan appropriate to a short term detoxification treatment regimen; Discharge or transfer planning as described in COMAR 10.47.01.04; Monitoring of vital signs; Administering of medication, as necessary; and Adjunct services, which may include: Basic alcohol and drug education; Family services; and Motivational counseling. Documentation. Designated clinical staff shall write a patient progress note at the end of each day services are provided and place the progress note in the patient's record. Referral Services. The program shall offer or have available through referral the following: Medical, psychological, and psychiatric consultation; Laboratory services; Transportation services; and Substance abuse or dependence and mental health treatment programs. A program shall have a written agreement with a nearby hospital to provide necessary emergency medical support services. This agreement shall include: An emergency protocol describing the manner in which patients are referred to the hospital and provided appropriate care; Cooperative arrangements that specifically assign responsibility to provide transportation; The manner in which hospital on-call coverage is provided; A mechanism to provide psychiatric evaluation, if necessary; A prescreening protocol for patients referred to the inpatient detoxification program from the hospital; and A written protocol for the transfer of a patient to continued treatment. Patients Treated with Opioid Maintenance Medication. A detoxification facility is not limited in the number of admissions for detoxification of patients who are treated with opioid maintenance medication. A detoxification facility is not limited in the total number of doses of opioid maintenance medication that it will accept from patients who: Attend the detoxification program; and Require opioid maintenance medication for opioid detoxification or detoxification for substances other than opioids