This chapter sets forth additional requirements that a program shall meet to be certified to offer a particular level of treatment. The program shall meet the requirements of COMAR 10.47.01 and 10.47.03.
In this chapter, terms have the meanings stated in COMAR 10.47.01.02.
Prevention Program Description. The prevention program shall treat patients who are, for a known reason, at risk for developing alcohol or other drug abuse or dependence but for whom there is not yet sufficient information to document alcohol or other drug abuse or dependence.
Patients who are appropriate for this level of treatment shall meet the current edition of the American Society of Addiction Medicine Patient Placement Criteria for Level 0.5, or its equivalent as approved by the Administration.
Staffing. Services shall be provided by appropriately credentialed staff as described in COMAR 10.47.01.06.
Program services include:
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.
Documentation. The clinical staff providing the service shall write a patient progress note after each counseling session and shall place the note in the patient's record.
Referral Services. The prevention program shall offer the following services or maintain a listing of agency referral agreements for the following services:
Mental health services;
Social services; and
Substance abuse treatment programs.
Program Description. The program shall provide outpatient evaluation and treatment to patients who require services for less than 9 hours weekly for adults and 6 hours weekly for adolescents.
Patients who are appropriate for this level of treatment shall:
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.
Staffing.
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.
Program Services. A program shall provide the following services:
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:
Alcohol and drug education; and
Family counseling.
Documentation. The clinical staff providing the service shall write a patient progress note after each counseling session and shall 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 examinations;
Services through the Division of Rehabilitation Services;
Vocational assistance;
Mental health services;
Substance abuse treatment programs;
Legal assistance; and
Social services.
Program Description. A program shall provide structured outpatient evaluation and treatment to patients who require programming:
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.
Patients who are appropriate for this level of treatment shall 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.
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.
Program Services. A program shall provide the following services:
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:
Alcohol and drug education; and
Family counseling.
Documentation. A designated clinical staff person shall:
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.
Referral Services. The program shall offer the following services or maintain a listing of agency referral agreements for the following services:
Medical services with medical consultations available:
Within 24 hours of a request for service by telephone for intensive outpatient services;
Within 72 hours of a request for service in person for intensive outpatient services;
Within 8 hours of a request for service by telephone for partial hospitalization services; and
Within 48 hours of a request for service in person for partial hospitalization services;
Services through the Division of Rehabilitation Services;
Vocational assistance;
Mental health services with psychiatric consultations available:
Within 24 hours of a request for service by telephone for intensive outpatient services;
Within 72 hours of a request for service in person for intensive outpatient services;
Within 8 hours of a request for service by telephone for partial hospitalization services; and
Within 48 hours of a request for service in person for partial hospitalization services;
Substance abuse treatment programs;
Legal assistance; and
Social services.
Program Description. Clinically managed low intensity treatment programs shall offer treatment services at least 5 hours a week directed toward preventing relapse, applying recovery skills, promoting personal responsibility, and reintegration.
Patients who are appropriate for this level of treatment shall:
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.
Staffing.
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:
One individual as clinical supervisor who may also be the program's administrator;
Another individual as house manager;
At least one staff member to be on duty at all times; and
At least one staff member who is certified in cardiopulmonary resuscitation, and who has been trained in crisis intervention to be on duty between 11 p.m. and 7 a.m.
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.
Program Services. A clinically managed low intensity treatment program shall provide the following services:
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.
Documentation. The clinical staff providing the service shall write a patient progress note after each counseling session and shall 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:
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:
Medication monitoring for patients who are admitted on or are prescribed psychotropic medications; and
Services appropriate to the severity and urgency of the patient's mental condition;
Legal assistance;
Substance abuse treatment programs;
Social services;
Family services; and
Education.
Program Description. A clinically managed medium intensity treatment program provides a structured environment in combination with medium intensity treatment and ancillary services to support and promote recovery.
Patients who are appropriate for this level of treatment:
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.
Staffing.
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.
Program Services. A program shall provide the following services:
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.
Documentation. A designated clinical staff shall write a patient progress note at the end of each week 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:
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:
Medication monitoring for patients who are admitted on or are prescribed psychotropic medications; and
At least one of the following services:
Services available by telephone within 8 hours of a request; or
Services available onsite or closely coordinated off-site within 24 hours of a request;
Substance abuse treatment programs;
Legal assistance;
Family services; and
Social services.
Program Description. A clinically managed high intensity residential program shall:
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.
Patients who are appropriate for this level of treatment meet the current edition of the American Society of Addiction Medicine Patient Placement Criteria for Level III.5, or its equivalent as approved by the Administration.
Staffing.
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:
Provide initial diagnostic work-up;
Provide identification of medical and surgical problems for referral; and
Handle medical emergencies when necessary.
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.
Program Services. A program shall provide the following services:
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:
At least weekly individual counseling;
Group counseling;
Alcohol and drug education;
Career counseling;
Nutrition education; and
Family services.
Documentation. A designated clinical staff shall write a patient progress note at the end of each week 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 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:
Medication monitoring for patients who are admitted on or are prescribed psychotropic medications; and
At least one of the following services:
Services available by telephone within 8 hours of a request; or
Services available on-site or closely coordinated off-site within 24 hours of a request;
Substance abuse treatment programs;
Legal assistance; and
Social services.
Program Description. A medically monitored intensive inpatient treatment program shall:
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.
Patients who are appropriate for this level of treatment:
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.
Staffing. A program shall have:
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:
8 hours a day, 5 days a week coverage by a registered nurse; and
The remainder of coverage by a licensed practical nurse; and
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.
Program Services. A program shall provide:
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:
A minimum of one weekly individual counseling session;
Group counseling;
Alcohol and drug education;
Nutrition education;
Weekly family sessions; and
Case management.
Medically Monitored Services.
Nursing Services. Services shall include:
An assessment at the time of the patient's admission, including a mental health focused assessment:
Approved by the registered nurse and program physician;
Completed by qualified staff; and
Overseen by a registered nurse for patients admitted with any prescribed medication; and
Medication monitoring conducted by:
The registered nurse or overseen by the registered nurse in conjunction with the program's physician; and
Qualified nursing staff for patients who are admitted on or are prescribed any medications.
Physician, Physician Assistant, or Nurse Practitioner Services.
A physician, physician assistant, or nurse practitioner shall:
Assess a patient within 24 hours of admission; and
Continue to assess the patient as is medically necessary after the first 24 hours of admission.
A physician, physician assistant, or nurse practitioner shall conduct a physical examination of a patient within 96 hours of admission to the program.
A physician or physician assistant shall assess a patient undergoing detoxification within 24 hours of admission or earlier if it is medically necessary to conduct the assessment in less than 24 hours.
A physician or physician assistant shall provide on-site monitoring and further evaluation of patients undergoing detoxification on a daily basis, if medically necessary.
A physician or physician assistant shall be available by telephone at all times to consult about patients undergoing detoxification.
Documentation. A 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:
Services through the Division of Rehabilitation Services;
Vocational assistance;
Mental health services;
Substance abuse treatment programs;
Legal assistance; and
Social services.
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
Program Description. Opioid maintenance therapy:
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 program shall comply with federal regulation 42 CFR 8.
Staffing.
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:
Has 3 years documented experience providing services to persons who are addicted to alcohol or other drugs, including at least 1 year of experience in the treatment of opioid addiction with opioid maintenance therapy;
Meets at least one of the following criteria:
Has been continuously employed as the medical director for opioid maintenance therapy programs from or before August 1, 2002;
Is certified in addiction medicine by the American Society of Addiction Medicine;
Is certified in added qualifications in addiction psychiatry by the American Board of Psychiatry and Neurology, Inc.; or
Is certified in added qualifications in addiction medicine by the appropriate specialty boards of the American Osteopathic Association; and
Takes an active part in interdisciplinary team meetings, not less than every 2 weeks.
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:
The program shall submit a training plan for the interim medical director to the Administration for approval;
The plan shall address a means for achieving minimal competencies and proficiencies until the interim medical director meets qualifications set forth in §C(1) of this chapter; and
The interim medical director shall meet the qualifications within 48 months of being hired.
An opioid maintenance therapy program shall:
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:
Completed and signed by the alcohol and drug counselor and patient within 7 working days of the comprehensive assessment;
Updated every 90 days for the first year of treatment; and
After completion of 1 year of continuous treatment and if the patient meets the requirements for unsupervised or take home use set forth in CFR 42 §8.12(i), the individualized treatment plan may be updated every 180 days and signed by the alcohol and drug counselor and patient.
Random Drug Testing. The program shall:
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:
Benzodiazepines;
Marijuana;
Cocaine;
Opiates;
Alcohol; and
Methadone;
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.
Dosage. The program shall:
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.
Opioid maintenance programs shall arrange for transportation of medication to and from the following levels of care:
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.
Opioid maintenance programs may transfer care of a patient to a closer opioid maintenance program when the patient is also being treated at a residential program or for detoxification services in a different county or jurisdiction.
Programs may administratively detoxify or transfer a patient only if the:
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.
Criteria for Take-Home Privileges. Before the patient may take home any dose the patient shall:
Meet the criteria set within 42 CFR Part 8; and
Provide the program with a working lock box for the take-home medication.
Referral Services. Programs shall:
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.
Health-General Article, §§8-401 — 8-405 and 19-308, Annotated Code of Maryland
Effective date: November 4, 1985 (12:22 Md. R. 2107)
Regulations .01—.11, DWI Program Protocols, repealed and new Regulations .01—.11, Specific Program Requirements, adopted effective June 10, 2002 (29:11 Md. R. 882)
Regulation .03 amended as an emergency provision effective April 1, 2008 (35:9 Md. R. 894); amended permanently effective May 5, 2008 (35:9 Md. R. 898)
Regulation .04 amended as an emergency provision effective April 1, 2008 (35:9 Md. R. 894); amended permanently effective May 5, 2008 (35:9 Md. R. 898)
Regulation .05 amended as an emergency provision effective April 1, 2008 (35:9 Md. R. 894); amended permanently effective May 5, 2008 (35:9 Md. R. 898)
Regulation .06 amended as an emergency provision effective April 1, 2008 (35:9 Md. R. 894); amended permanently effective May 5, 2008 (35:9 Md. R. 898)
Regulation .07 amended as an emergency provision effective April 1, 2008 (35:9 Md. R. 894); amended permanently effective May 5, 2008 (35:9 Md. R. 898)
Regulation .08 amended as an emergency provision effective April 1, 2008 (35:9 Md. R. 894); amended permanently effective May 5, 2008 (35:9 Md. R. 898)
Regulation .09 amended as an emergency provision effective April 1, 2008 (35:9 Md. R. 894); amended permanently effective May 5, 2008 (35:9 Md. R. 898)
Regulation .10 amended as an emergency provision effective April 1, 2008 (35:9 Md. R. 894); amended permanently effective May 5, 2008 (35:9 Md. R. 898)
Regulation .11 amended as an emergency provision effective April 1, 2008 (35:9 Md. R. 894); amended permanently effective May 5, 2008 (35:9 Md. R. 898)
Regulation .11D amended effective December 12, 2013 (40:24 Md. R. 2017)