Definition. In this regulation, the following term has the meaning indicated. Term Defined. “Program” means the site and service combination which: Is recognized through licensure to offer an organized system of activities to provide an alternative to emergency departments for behavioral health crisis care, emergency petition assessment, and avoidable inpatient or carceral engagement; and Serves as a critical access point for individuals experiencing a mental health, substance use disorder, substance use related, or combined crisis. In order to be licensed under this subtitle, a BHCSC program shall: Meet the requirements of this regulation; Meet the requirements of Health-General Article, Title 10, Annotated Code of Maryland; Meet the requirements of COMAR 10.63.01—10.63.06; and Be pre-approved by the Department or its designee to receive PBHS funding before participating in the PBHS. BHCSC Program Services. The BHCSC program shall: Provide crisis response services as outlined in Health-General Article, Title 10, Subtitle 14, Annotated Code of Maryland; Process involuntary admissions according to Health-General Article, §§10-613—10-621, Annotated Code of Maryland; Provide BHCSC services 24 hours a day, 7 days a week, 365 days a year; Initiate triage upon patient arrival and deliver this service in a manner that aligns with best practice and makes reasonable efforts to minimize time on-site at the BHCSC for law enforcement or other first responders; Use evidence-based tools to screen, assess, stabilize, and refer persons, as clinically indicated; Provide medical screening at triage for the presence of any condition of sufficient severity to require transfer to an appropriate facility for immediate medical or surgical care; Provide active acute mental health and substance use disorder crisis intervention and stabilization services in a BHCSC setting that is not in the Health Services Cost Review Commission regulated space of a hospital, for children, adolescents, and adults whose behaviors are consistent with experiencing: A mental health crisis; A substance use disorder crisis; or Both §C(7)(a) and (b) of this regulation; Provide assessment, counseling, de-escalation, and safety planning; Initiate, maintain, and prescribe psychotropic and somatic medications as appropriate, including: PRN intramuscular medication; Long-acting injectable antipsychotic medication; Medications used for withdrawal management; and Medications for Opioid Use Disorder; Provide withdrawal management services for all substances; and Maintain compliance with the model program structure and facility standards designed by the Department, as required by Health-General Article, §10-621, Annotated Code of Maryland. BHCSC Staffing Requirements. A BHCSC program shall designate a program director who is a licensed mental health professional operating at the independent level of practice who shall be responsible for the overall management and operation of the BHCSC and whose qualifications and duties are defined in the individual’s job description. The job description shall ensure that other job responsibilities will not impede the operation and administration of the BHCSC. A BHCSC program shall have a nursing manager who is a registered nurse. A BHCSC program shall continuously employ an adequate number of staff and ensure an appropriate staff composition are on-site to: Carry out the BHCSC program’s services, goals, and objectives; and Ensure the continuous provision of sufficient supervision and monitoring of individuals receiving crisis stabilization services. A BHCSC program shall employ a qualified prescriber or prescribers who are authorized to prescribe medications by the Maryland Board of Physicians or the Maryland Board of Nursing to provide general medical services and prescription of medications and treatment, and who shall: Be available 24 hours per day; Make daily rounds, including in-person reassessment, to any individual who has been emergency petitioned and remains in the BHCSC for more than 24 hours; and Be approved by the Department if the qualified prescriber is not a psychiatrist or a psychiatric nurse practitioner. A physician shall be on call at all times for the provision of those BHCSC services that may only be provided by a physician. There shall be a minimum of one registered nurse on site at all times. There shall be additional staff, including mental health professionals, on-site at all times to provide active crisis intervention to ensure BHCSC services are provided by personnel within their scope of practice and with expertise appropriate to the service recipient's needs. BHCSC Staffing Plan. A BHCSC program shall develop and maintain a written staffing plan designed to ensure sufficient coverage, discipline mix, service quality, and safety and which shall: Outline the qualifications and duties of each staff position; and Be approved by the Department at the time of licensure. A BHCSC program shall notify the Department of any changes in staffing composition, or an addition or reduction in staffing numbers that varies from the approved staffing plan by greater than 10 percent. BHCSC Program Quality Assurance and Reporting. A BHCSC program shall begin assessment and active treatment immediately upon a patient’s admission. A BHCSC program shall ensure that, within 60 minutes or less of the individual’s arrival, a registered nurse initiates an in-person nursing assessment and physical exam in collaboration with the approved physician or psychiatric nurse practitioner, and develops and implements an initial treatment plan for services in the BHCSC. A BHCSC mental health professional shall provide a crisis assessment at the earliest opportunity. For individuals in the BHCSC under an emergency petition with stays beyond 24 hours, BHCSC mental health professional staff shall perform, at a minimum, daily in-person reassessment. Crisis assessments shall be staffed with the approved physician or psychiatric nurse practitioner. An approved physician or psychiatric nurse practitioner shall review and sign off on every discharge plan for individuals receiving services in the BHCSC. An initial evaluation by an approved physician or psychiatric nurse practitioner shall be completed at the earliest reasonable opportunity, which shall be no later than 4 hours after admission, either in-person or via telehealth, and include the following: A medical evaluation; Assessment of suicide, homicide, violence, and other risk factors; and Review and authorization of the BHCSC initial crisis intervention care plans. A BHCSC program shall maintain relationships with existing community behavioral health service providers who may receive referrals from the BHCSC, which shall include written referral agreements with the following: Outpatient community behavioral health providers; Hospital psychiatric units; Residential crisis programs; Respite programs; Residential substance use treatment programs; and Providers of medications for opioid use disorders. A BHCSC program shall make documented attempts to contact and follow up with all individuals discharged to a community setting and, for individuals who received outpatient services and who initially presented or were later evaluated as a danger to self or others, follow up within 72 hours after discharge from the BHCSC. A BHCSC program shall have protocols, which may include referral agreements with other programs, that provide for admission and treatment of individuals with: Limited English proficiency; Hearing and speaking disabilities; and Physical, developmental, and intellectual disabilities. A BHCSC program shall develop and maintain written triage policies and procedures approved by the Department, including ability to accept and provide services to individuals under an emergency petition and individuals referred by 9-8-8 and other local crisis hotlines. A BHCSC program shall notify the Department and LBHA, in a form and manner determined by the Department, of the following: Initiation of diversion status for the BHCSC program; and Diversion of any individual on an emergency petition. A BHCSC program shall maintain a referral log that includes documentation and rationale for individuals not accepted for admission or transfer to the BHCSC, and make this available to the Department upon request. A BHCSC program shall develop, implement, and maintain written policies and procedures in place to ensure the safety of all individuals, regardless of age. A BHCSC program shall provide data to support quality assurance and improvement initiatives to the State in the format and frequency requested by the Department. BHCSC Program Staff Training Requirements. BHCSC program staff shall complete required trainings approved by the Department. A BHCSC program shall have a training and competency plan in place that: Is reviewed annually; Is consistent with: Accreditation requirements; and Requirements published by the Department; Defines the core competencies needed to provide reliable and high-quality care for each clinical discipline within their scope of practice as a part of the BHCSC program; and Ensures that all staff receive needed training and competency verification. Clinical Record Documentation. A BHCSC program shall maintain, either manually or electronically, adequate documentation of each contact with a participant as part of the medical record, which, at a minimum, includes: The date or dates of service within the BHCSC, including triage and discharge times; The individual’s presenting problems or reason for the BHCSC admission; A brief description of services provided, including progress notes; An official e-Signature, or a legible signature, along with the printed or typed name, and appropriate title of each individual providing services; Documentation of risk assessments; Documentation of medication evaluation and management throughout the stabilization period; Crisis assessment or assessments by the mental health professional staff; and A crisis discharge plan for each individual, which shall indicate the referrals and other activities intended to maintain stabilization. Seclusion and Restraint. A BHCSC program shall have the capacity for both seclusion and restraint. For purposes of this regulation: Seclusion has the meaning set forth in 42 CFR §482.13(e)(1)(ii); and Restraint has the meaning set forth in 42 CFR §482.13(e)(1)(i). A BHCSC program shall be compliant with State and federal seclusion and restraint regulations and laws, including 42 CFR §482.13 and Health-General Article, §10-701, Annotated Code of Maryland, and any successor laws and regulations. Application of seclusion or restraint within a BHCSC program requires: Use as a last resort, only after less restrictive interventions have been considered or tried, unless the emergency nature of the situation precludes the latter, and An order from an approved physician or other clinician permitted by law, with exceptions noted for an emergency as outlined in §I(4) of this regulation. Seclusion and restraint may be initiated by a registered nurse, if a physician or other clinician permitted by law is not present and an emergency situation warrants immediate seclusion or restraint, in which case: BHCSC staff shall obtain an order as soon as possible, but no later than within 1 hour; and A clinical assessment by a psychiatrist or psychiatric nurse practitioner shall occur within 1 hour of initiation or renewal by a registered nurse. An order for seclusion or restraint may not exceed 4 hours for adults, 2 hours for youth 9 years old or older, and 1 hour for children younger than 9 years old. Such an order does not require continuation of the seclusion or restraint for the entire time specified by the order. The seclusion or restraint shall be discontinued as soon as clinically indicated. An individual in seclusion or restraint shall be maintained on 1:1 observation the entire time the individual is secluded or restrained to protect them from harm. Restraint and seclusion shall never occur simultaneously for an individual. Environmental/Life Safety Requirements. A BHCSC program shall: Provide a comfortable, furnished admission pre-triage waiting area for individuals who voluntarily present; Provide a locked and secure dedicated drop-off admission space, designed to accommodate those individuals who have been emergency petitioned; Provide a comfortable, furnished waiting area for individuals accompanying participants in the BHCSC program; Allow for continual visual observation and monitoring of individuals being served; Ensure a safe environment of care for a participant younger than 18 years old by having a separation from adults, with appropriate staff maintaining an adequate level of supervision; Ensure that the 23-hour crisis BHCSC shall have at least one locked door seclusion room, which: Shall be a minimum of 80 square feet; Allows for continual visual observation and monitoring that allows for immediate emergency response; and Uses a locking mechanism consistent with National Fire Protection Association (NFPA) standards for the facility; and Ensure that there is at least one quiet room that is separate from the seclusion room and remains unlocked whenever in use. The Department may require the BHCSC program to add additional seclusion or quiet rooms, based on the intended capacity of the BHCSC Program. The BHCSC program facility shall be free from fire hazards and have: Adequate smoke detectors; Working and updated fire extinguishers; Fire sprinklers as required by law; A written fire evacuation plan; and A current fire inspection certification. The BHCSC program shall conduct and document an annual environmental safety review and take actions to replace items that create an unnecessary risk of self-harm with safer items designed for behavioral health settings, including, but not limited to: Anchor points; Door handles; Curtains; Hooks; and Shower rods and curtains. The BHCSC program shall comply with applicable federal, State, and local sanitation, building, fire codes, and zoning requirements. The BHCSC program shall maintain documentation of legally and accreditation required periodic evacuation drills. The BHCSC program shall have: Bathrooms; Telephones; An automated external defibrillator; and Confidential office space for treatment. BHCSC Dietary Services. BHCSC program dietary services shall be as follows: At least three meals plus an evening snack provided daily with no more than 14 hours between any two meals; Dietary services shall comply with applicable local, State, and federal laws; A BHCSC program shall have a written plan describing the organization and delivery of dietary services; and A dietitian licensed under Health Occupations Article, §5-101, Annotated Code of Maryland, shall develop and implement the dietary service plan. Infection Control — Universal Precautions. A BHCSC program shall observe universal precautions as required under COMAR 10.52.11 as applicable to health care facilities. Site Inspection. At a minimum, an annual site inspection of each BHCSC shall be conducted by the assigned LBHA. Required Management Staff. The required staff in a BHCSC program, as defined in subsection §D of this regulation and COMAR 10.63.01, and subject to the requirements for reporting of vacancies under COMAR 10.63.01.05, includes: Program director; Medical director; Nurse manager; and Mental health professionals in the event that the vacancy leads to an inability to meet the staffing requirements of the regulation.