Chapter 02. Specific Program Requirements

Assessments as described in COMAR 10.47.01.04 within 2 weeks of admission;

An individualized treatment plan as described in COMAR 10.47.01.04, completed and signed by the alcohol and drug counselor and patient within 7 working days of the comprehensive assessment and updated every 90 days;

Group or individual counseling, or both, as clinically indicated;

Family counseling, as clinically indicated;

Alcohol and drug education; and

Referral for further assessment or to another level of treatment, as clinically indicated.

Mental health services;

Social services; and

Substance abuse treatment programs.

Meet the current edition of the American Society of Addiction Medicine Patient Placement Criteria for Level I, or its equivalent as approved by the Administration; and

Have a physical and emotional status that allows them to function in their usual environment.

Services shall be provided by appropriately credentialed staff as described in COMAR 10.47.01.06.

The adult patient to alcohol and drug counselor ratio may not exceed 30 adult patients weekly to one full-time alcohol and drug counselor.

The child and adolescent patient to alcohol and drug counselor ratio may not exceed 25 adolescent patients weekly to one full-time alcohol and drug counselor.

An assessment as described in COMAR 10.47.01.04 within 2 weeks of admission;

An individualized treatment plan as described in COMAR 10.47.01.04 completed and signed by the alcohol and drug counselor and patient within 7 working days of the comprehensive assessment and updated every 90 days;

Case management services;

Group or individual counseling sessions;

Family services that shall include an assessment for family treatment needs and, as clinically appropriate:

Medical examinations;

Services through the Division of Rehabilitation Services;

Vocational assistance;

Mental health services;

Substance abuse treatment programs;

Legal assistance; and

Social services.

From 9 to 20 hours weekly for adult intensive outpatient services;

From 6 to 20 hours weekly for adolescent intensive outpatient services, based on the adolescents' developmental and clinical needs; and

From 20 to 35 hours weekly for adult and adolescent partial hospitalization services.

Services shall be provided by appropriately credentialed staff as described in COMAR 10.47.01.06.

The patient to alcohol and drug counselor ratio may not exceed 15 patients to one full-time alcohol and drug counselor.

An assessment as described in COMAR 10.47.01.04 within 1 week of admission;

An individualized treatment plan as described in COMAR 10.47.01.04 completed and signed by the alcohol and drug counselor and patient within 5 working days of the comprehensive assessment and updated every 30 days;

Case management services;

At least one group counseling session a week;

At least one individual session every 2 weeks;

Family services, which may include an assessment for family needs and, as clinically appropriate:

Write a patient progress note at the end of each week that services are provided; and

Place the progress note in the patient's record.

Medical services with medical consultations available:

Services through the Division of Rehabilitation Services;

Vocational assistance;

Mental health services with psychiatric consultations available:

Substance abuse treatment programs;

Legal assistance; and

Social services.

Meet the current edition of the American Society of Addiction Medicine Patient Placement Criteria for Level III.1, or its equivalent as approved by the Administration; and

Be capable of self-care but not ready to return to family or independent living.

Services shall be provided by appropriately credentialed staff as described in COMAR 10.47.01.06.

A clinically managed low intensity treatment program shall employ:

The patient to alcohol and drug counselor ratio may not exceed 15 patients to one full-time alcohol and drug counselor.

Staff may not dispense medications.

An assessment as described in COMAR 10.47.01.04 within 2 weeks of admission;

An individualized treatment plan as described in COMAR 10.47.01.04 completed and signed by the alcohol and drug counselor and patient within 7 working days of the comprehensive assessment and updated every 60 days;

Periodic group counseling that focuses on relapse prevention;

Case management services;

Individual counseling, at least monthly; and

Leisure and recreational activities.

Physical examinations as determined by medical condition, within a reasonable time;

Services through the Division of Rehabilitation Services;

Vocational assistance;

Mental health services, which shall include:

Legal assistance;

Substance abuse treatment programs;

Social services;

Family services; and

Education.

Meet the current edition of the American Society of Addiction Medicine Patient Placement Criteria for Level III.3, or its equivalent as approved by the Administration;

Are chronic alcohol or other drug dependent individuals;

Do not need skilled nursing care;

May have a history of multiple admissions to alcohol or drug abuse or dependence programs as defined in COMAR 10.47.01;

May have physical and mental disabilities as a result of prolonged alcohol or other drug use; and

Have been identified as individuals for whom a controlled environment and supportive therapy are necessary for an indefinite period of time.

Services shall be provided by appropriately credentialed staff as described in COMAR 10.47.01.06.

The patient to alcohol and drug counselor ratio may not exceed 15 patients to one full-time alcohol and drug counselor.

At least one staff member certified in cardiopulmonary resuscitation and trained in crisis intervention shall be on duty between 11 p.m. and 7 a.m.

An assessment as described in COMAR 10.47.01.04 within 1 week of admission;

An individualized treatment plan as described in COMAR 10.47.01.04 completed and signed by the alcohol and drug counselor and patient within 3 working days of the comprehensive assessment and updated every 30 days;

Alcohol and drug education;

Individual counseling;

Leisure and recreation counseling; and

Assistance with vocational issues.

Physical examinations as determined by medical condition, within a reasonable time;

Medical care;

Services through the Division of Rehabilitation Services;

Vocational assistance;

Mental health services, which shall include, as appropriate to the severity and urgency of the patient's mental condition:

Substance abuse treatment programs;

Legal assistance;

Family services; and

Social services.

Provide a highly structured environment in combination with moderate to high intensity treatment and ancillary services to support and promote recovery; and

Be characterized by its reliance on the treatment community as a therapeutic agent.

Services shall be provided by appropriately credentialed staff as described in COMAR 10.47.01.06.

A program shall have sufficient physician, physician assistant, or nurse practitioner services to:

The patient to alcohol and drug counselor ratio may not exceed 15 patients for one full-time alcohol and drug counselor.

At least one staff member certified in cardiopulmonary resuscitation and trained in crisis intervention shall be on duty between 11 p.m. and 7 a.m.

A preliminary medical assessment within 36 hours of the patient's admission;

A physical examination by a medical doctor, physician assistant, or nurse practitioner within the first week of the patient's admission;

An assessment as described in COMAR 10.47.01.04 within 2 days of admission;

An individualized treatment plan as described in COMAR 10.47.01.04 completed and signed by the alcohol and drug counselor and patient within 2 working days of the comprehensive assessment with a treatment plan update every 30 days;

Monitoring of medication, as necessary; and

A minimum of 36 hours of therapeutic activities a week, including but not limited to:

Medical care;

Services through the Division of Rehabilitation Services;

Vocational assistance;

Mental health services, which shall include, as appropriate to the severity and urgency of the patient's mental condition:

Substance abuse treatment programs;

Legal assistance; and

Social services.

Offer a planned regimen of 24-hour professionally directed evaluation, care, and treatment in an inpatient setting;

Act as an Intermediate Care Facility Type C/D; and

Meet the certification requirements for detoxification services as described in COMAR 10.47.02.10E.

Meet the current edition of the American Society of Addiction Medicine Patient Placement Criteria for Level III.7, or its equivalent as approved by the Administration; and

Require 24-hour monitoring and care for subacute biomedical and emotional or behavioral conditions severe enough to warrant inpatient treatment.

Appropriately credentialed staff as described in COMAR 10.47.01.06;

Staffing which allows for detoxification and can provide services necessary for treatment of coexisting medical, emotional, or behavioral problems that could interfere with recovery;

A patient to alcohol and drug counselor ratio not exceeding eight patients for one full-time alcohol and drug counselor;

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;

A physician on call 24 hours a day;

Nursing services, between 7 a.m. and 11 p.m., 7 days a week, including:

At least two employees on duty between the hours of 11 p.m. and 7 a.m., 7 days a week, trained in crisis management and cardiopulmonary resuscitation.

An assessment as described in COMAR 10.47.01.04 within 2 days of admission;

An individualized treatment plan as described in COMAR 10.47.01.04C completed and signed by the alcohol and drug counselor and patient within 7 working days of the comprehensive assessment with a treatment plan update completed every 7 days;

A minimum of 36 hours of therapeutic activities a week including, but not limited to:

Nursing Services. Services shall include:

Physician, Physician Assistant, or Nurse Practitioner Services.

Services through the Division of Rehabilitation Services;

Vocational assistance;

Mental health services;

Substance abuse treatment programs;

Legal assistance; and

Social services.

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.

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:

Description of Services.

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.

Services. Detoxification services shall include:

Documentation. The clinical staff providing services shall:

Referral Services. The program shall offer the following services or maintain a listing of agency referral agreements for the following services:

Emergency Services.

Description of Services. An ambulatory detoxification with extended on-site monitoring services shall:

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:

Services. Detoxification services shall include:

Documentation. The clinical staff person providing the service shall:

Referral Services. The program shall offer or maintain a listing of agency referral agreements for the following services:

Emergency Services. A program shall have a written agreement with a nearby hospital to provide necessary emergency medical support services. This agreement shall include:

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:

Staffing. A program:

Program Services. A program shall provide the following services:

Documentation. Designated clinical staff shall:

Referral Services. The program shall offer the following services or maintain a listing of agency referral agreements for the following services:

Emergency Services.

Patients Treated with Opioid Maintenance Medication.

Description of Services.

Patients who are appropriate for this level of treatment:

Staffing. A program:

Program Services. A program shall provide the following services:

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:

A program shall have a written agreement with a nearby hospital to provide necessary emergency medical support services. This agreement shall include:

Patients Treated with Opioid Maintenance Medication.

Uses pharmacological interventions, including full and partial opiate agonist treatment medications, to provide treatment, support, and recovery to opioid-addicted patients;

Is a separate service that is certified and offered by a program as described in COMAR 10.47.02.03 — .11;

Complies with the requirements under this regulation; and

Can be provided in correctional facility based programs.

The patient to alcohol and drug counselor ratio may not exceed 50 patients to one full-time counselor.

Medical Director. The program shall have a medical director who is a physician and who:

A program unable to hire a medical director who meets the criteria set forth in §C(2) of this chapter may hire an interim medical director under the following conditions:

Have hours that meet the needs of the patients;

Establish an answering system when the program is closed which provides direct contact or call back by a staff member capable of addressing emergency patient issues; and

Complete an individualized treatment plan which is described in COMAR 10.47.01.04 as follows:

Conduct random drug testing on each patient at least monthly, in accordance with State law;

Conduct random drug testing at a minimum for the following substances:

Ensure that positive screens are validated using federally approved, State-certified laboratories;

If appropriate, use temperature sensitive cups in place of direct observation; and

Develop procedures, approved by the Administration, that mandate clinical intervention if a patient's drug test result indicates substance use.

Maintain patients with a dose adequate to alleviate all withdrawal symptoms;

Employ dose increases and behavior therapy before mandatory detoxification for patients continuing to use drugs;

Establish patient dosing on an individual need;

Provide flexible dosage tapering at patient request; and

Develop a detoxification schedule at least 21 days long with daily dosage reductions less than 5 percent of the original total dose, regardless of the patient's ability to pay.

Residential treatment at Levels III.3, III.5, and III.7, as described in Regulations .07 — .09 of this chapter;

Detoxification services at Level III.2-D and III.7-D, as described in Regulation .10 of this chapter; or

Residential treatment at Level III.1, when the patient cannot obtain or transport his or her own take-home opioid maintenance medication because of developmental or physical disabilities or because the patient does not have access to transportation.

Patient's behavior on program premises is abusive, violent, or illegal;

Patient fails to pay fees and has been informed in writing and counseled as to responsibility and possible sanctions including detoxification;

Patient misses 3 consecutive medication days, and the program physician after a reevaluation has determined that administrative detoxification is warranted; or

Clinical staff documents therapeutic reasons for detoxification, which may include continued use of illicit drugs or an unwillingness to follow appropriate clinical interventions.

Meet the criteria set within 42 CFR Part 8; and

Provide the program with a working lock box for the take-home medication.

Provide referral services as required by the level of treatment under which the program is certified; and

Maintain a listing of agency referral agreements for the services.