This chapter sets forth the descriptions of and the criteria for the community behavioral health programs that are permitted to operate in Maryland, so long as they have valid and current accreditation-based licenses under this subtitle. To be licensed under this subtitle, an integrated behavioral health program shall: Meet the requirements for an: Outpatient mental health center, as outlined in Regulation .05 of this chapter; and Outpatient treatment level 1 program, as outlined in Regulation .06 of this chapter; and Have the capacity to provide, as appropriate: Mental health evaluation and treatment services to individuals with mental health diagnoses; Substance-related disorder evaluation and treatment services to individuals with a substance-related disorder; and Integrated mental health and substance-related disorder evaluation and treatment services to individuals with both a substance use disorder and a mental health diagnosis. An integrated behavioral health program may provide the following services if the program’s license specifically authorizes the services: A withdrawal management service as described in Regulation .18 of this chapter; and An opioid treatment service as described in Regulation .19 of this chapter. To be licensed under this subtitle, an intensive outpatient treatment level 2.1 program shall provide structured outpatient substance-related disorder treatment based on a comprehensive assessment, for: Individuals who meet the ASAM Criteria for level 2.1; and Adults, from 9 to 20 hours weekly, and individuals younger than 18 years old for 6 to 20 hours weekly. An intensive outpatient treatment level 2.1 program may provide the following services if the program’s license specifically authorizes the services: A withdrawal management service as described in Regulation .18 of this chapter; and An opioid treatment service as described in Regulation .19 of this chapter. In order to be licensed under this subtitle, a mobile treatment services program shall: Provide intensive, assertive outpatient mental health treatment and support services by a multidisciplinary team to an individual who is homeless or is otherwise unable or unwilling to access traditional outpatient treatment services as follows: Flexibly in a community setting considered appropriate to the individual; and On an on-call basis, 24 hours per day, 7 days a week; Be designed to enable the individual to remain in the community, thus reducing admissions to emergency rooms, inpatient facilities, or detention facilities; and Provide discharge services, including developing a transition plan and arranging to initiate authorized services before the planned discharge, in collaboration with the individual, the treatment team, family members, and significant others who are designated by the individual, the CSA, LBHA, ASO and the designated transition service providers. In order to be licensed under this subtitle, an outpatient mental health center shall: Provide regularly-scheduled outpatient mental health treatment services in a community-based setting; Provide, at a minimum, individual, group, and family therapy and medication management; Employ a medical director, who: Is a psychiatrist; Has over-all responsibility for clinical services; and Is on-site at least 20 hours per week; and Employ multidisciplinary clinical treatment staff who is authorized to provide the services under Health Occupations Article, Annotated Code of Maryland. In order to be licensed under this subtitle, an outpatient treatment level 1 program shall provide outpatient substance-related disorder treatment based on a comprehensive assessment: For individuals who: Meet the ASAM Criteria for level 1; Have a physical and emotional status that allows the individual to function in the individual’s usual environment; and For adults, require services for fewer than 9 hours weekly, or, for individuals younger than 18 years old, require services for fewer than 6 hours weekly. An outpatient treatment level 1 program may provide the following services if the program’s license specifically authorizes the services: A withdrawal management service as described in Regulation .18 of this chapter; and An opioid treatment service as described in Regulation .19 of this chapter. A partial hospitalization treatment level 2.5 program shall provide structured outpatient substance-related disorder treatment based on a comprehensive assessment for: Individuals who meet the ASAM Criteria for level 2.5; and From 20 to 35 hours weekly. A partial-hospitalization treatment-level 2.5 program may provide the following services if the program’s license specifically authorizes the services: A withdrawal management service as described in Regulation .18 of this chapter; and An opioid treatment service as described in Regulation .19 of this chapter. In order to be licensed under this subtitle, a psychiatric day treatment program (PDTP) shall: Provide short-term, intensive, day or evening mental health treatment and support services for individuals who do not require 24-hour care; Focus on the amelioration of an individual’s acute psychiatric symptoms; and Be medically supervised and staffed by a multidisciplinary treatment team that includes, at a minimum: A psychiatrist; and A registered nurse. In order to be licensed under this subtitle, a psychiatric rehabilitation program for adults (PRP-A) shall: Provide community-based comprehensive rehabilitation and recovery services and supports, including, but not limited to: Community living skills; Activities of daily living; and Family and peer support; Promote successful community integration and use of community resources; Be under the direction of a rehabilitation specialist who is: A licensed mental health professional; Certified by the Commission on Rehabilitation Counselor Certification; or Certified by the Psychiatric Rehabilitation Association; and Employ the rehabilitation specialist in §C of this regulation: At least 20 hours per week when the program serves less than 30 individuals; or 40 hours per week when the program serves 30 individuals or more. In order to be licensed under this subtitle, a psychiatric rehabilitation program for minors (PRP-M) shall provide community-based comprehensive rehabilitation services and supports designed to: Promote resiliency; and Facilitate the development or restoration of appropriate skills in an individual younger than 18 years old including but not limited to: Self-care skills; Social, peer, family, and teacher interactions; and Semi-independent living skills; and Promote successful integration into the community and the use of community resources. The program shall be under the direction of a rehabilitation specialist who has a minimum of 2 years direct care experience working with youth with a serious emotional disorder and who is: A licensed mental health professional; or Certified by the Psychiatric Rehabilitation Association and has obtained the Psychiatric Rehabilitation Association Children’s Psychiatric Rehabilitation Certificate. The PRP-M shall employ the rehabilitation specialist in §B of this regulation for: At least 20 hours per week when the program serves less than 30 individuals; or At least 40 hours per week when the program serves 30 individuals or more. In order to be licensed under this subtitle, a residential-low intensity level 3.1 program shall provide clinically-managed, low intensity, substance-related disorder treatment in large and small halfway houses, as defined in Health-General Article, §8-101, Annotated Code of Maryland, to individuals who: Meet the ASAM Criteria for level 3.1; and Are capable of self-care but are not ready to return to family or independent living. Services shall be: Provided for a minimum of 5 hours per week, and Directed toward: Preventing relapse; Applying recovery skills; and Reintegrating into the community. A residential-low intensity level 3.1 program may provide the following services if the program’s license specifically authorizes the services: A withdrawal management service as described in Regulation .18 of this chapter; and An opioid treatment service as described in Regulation .19 of this chapter. In order to be licensed under this subtitle, a residential-medium intensity level 3.3 program shall provide clinically-managed, medium intensity, substance-related disorder treatment based on a comprehensive assessment: In a structured environment in combination with medium-intensity treatment and ancillary services to support and promote recovery; From 20 to 35 hours weekly; and To individuals who: Meet the ASAM Criteria for level 3.3; Are chronic alcohol- or other drug-dependent; Do not need skilled nursing care; May have a history of multiple admissions to substance related disorder programs described in this chapter; May have physical or mental disabilities resulting from a prolonged substance-related disorder; and Have been identified as requiring a controlled environment and supportive therapy for an indefinite period of time. A residential-medium intensity level 3.3 program may provide the following services if the program’s license specifically authorizes the services: A withdrawal management service as described in Regulation .18 of this chapter; and An opioid treatment service as described in Regulation .19 of this chapter. In order to be licensed under this subtitle, a residential-high intensity level 3.5 program shall provide clinically-managed, high-intensity, substance-related disorder treatment services based on a comprehensive assessment: In a highly-structured environment, in combination with moderate- to high-intensity treatment and ancillary services to support and promote recovery; For a minimum of 36 hours of therapeutic activities a week; That are characterized by reliance on the treatment community as a therapeutic agent; and To individuals who meet the ASAM Criteria for level 3.5. A residential-high intensity level 3.5 program may provide the following services if the program’s license specifically authorizes the services: A withdrawal management service as described in Regulation .18 of this chapter; and An opioid treatment service as described in Regulation .19 of this chapter. In order to be licensed under this subtitle, a residential-intensive level 3.7 program shall provide medically-monitored, intensive substance-related disorder treatment based on a comprehensive assessment: To individuals who meet the ASAM Criteria for level 3.7; For a minimum of 36 hours of therapeutic activities a week; On a planned regimen of 24-hour evaluation, care, and treatment in a residential setting; In an Intermediate Care Facility Type C/D; and While meeting the requirements for withdrawal management services as outlined in Regulation .18 of this chapter. If the program's license specifically authorizes the service, a residential-intensive level 3.7 program may provide an opioid treatment service as described in Regulation .19 of this chapter. A residential-intensive level 3.7 program shall employ a physician, nurse practitioner, or physician assistant who: Assesses each patient in person within 24 hours of admission or earlier, if medically necessary; Assesses each patient thereafter, as medically necessary; and Is available to provide on-site monitoring of care and further evaluation on a daily basis. In order to be licensed under this subtitle, a respite care services (RPCS) program: Shall provide short-term, in home or overnight temporary services to support an individual to remain in the individual’s home: Through enhanced support or a temporary alternate living arrangement; or By temporarily freeing the caregiver from the responsibility of caring for the individual; and For individuals younger than 21 years old, may offer overnight respite in an appropriately licensed program or therapeutic foster care home. In order to be licensed under this subtitle, a supported employment program (SEP) shall: Provide services designed to assist an individual to choose, obtain, and maintain competitive employment; and Assist an individual to obtain competitive employment in an integrated work environment that provides: Compensation of at least minimum wage; An individualized approach that establishes an hours-per-week employment goal to maximize an individual’s vocational potential; and Additional supports, as needed, delivered where appropriate. A substance-related disorder treatment program located in a State or local correctional facility requires a license under this chapter in order to operate. A withdrawal management service is one that: May be provided at one or more of the following ASAM levels: Level 1-WM, ambulatory withdrawal management without extended on-site monitoring; Level 2-WM, ambulatory withdrawal management with extended on-site monitoring; Level 3.2-WM, clinically-managed residential withdrawal management; or Level 3.7-WM, medically-monitored residential withdrawal management; Monitors the decreasing amount of psychoactive substances in the body; Manages the withdrawal symptoms; Motivates the individual to participate in appropriate treatment programs for alcohol or other drug dependence; Provides additional referrals as necessary; and At Level I-WM, Level 2-WM, and Level 3.7-WM, employs a physician, nurse practitioner, or physician assistant who: Obtains a comprehensive medical history and physical examination of the patient at admission; and Medically monitors each patient. An opioid treatment service is one that: Complies with the requirements of 42 CFR §8; Is under the direction of a medical director who is a physician and: Has at least 3 years of documented experience providing services to persons with substance-related disorders and opioid use disorders, including at least 1 year of experience in the treatment of opioid use disorder with opioid maintenance therapy and is board-certified in addiction medicine or addiction psychiatry; or Is certified in added qualifications in addiction psychiatry by the American Board of Psychiatry and Neurology, Inc.; Uses pharmacological interventions, including dispensing of full and partial opiate agonist treatment medications as part of treatment, support, and recovery services to an individual with an opioid addiction; Provides clinical services to each patient at a frequency based on the patient’s clinical stability level, not to exceed an overall program average of 50:1 patient-to-counselor ratio; Arranges for any opioid maintenance medication dispensed to a patient to be transported to the following service sites: Residential programs at Levels 3.3, 3.5, and 3.7, as described in Regulations .12—.14 of this chapter; Withdrawal management services at ASAM levels 3.2-WM and 3.7-WM as described in Regulation .18 of this chapter; or Residential programs at levels 3.1, when the patient, because of a developmental or physical disability, or lack of access to transportation, cannot obtain or transport the patient’s take-home opioid maintenance medication; In accordance with 21 CFR §1300, et seq., arranges transportation of opioid maintenance medication from the program sites identified in §E of this regulation or confirms the disposal of such medication when a patient leaves residential levels of care; Conducts random drug testing on each patient at least monthly, according to the provisions of COMAR 10.10.03.02; Conducts random drug testing, at a minimum, for the following substances: Benzodiazepines; Marijuana; Cocaine; Opiates; Alcohol; Methadone or buprenorphine, whichever is appropriate; and Oxycodone; Develops a taper 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; Nonvoluntarily tapers or transfers 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 taper; Patient misses 3 consecutive medication days, and the program physician, after reevaluation, has determined that nonvoluntary taper is warranted; or Clinical staff documents therapeutic reasons for taper, which may include continued use of illicit drugs or an unwillingness to follow appropriate clinical interventions; Requires that a patient show evidence of the availability of locked storage before a patient may take home any dose of medication; and Provides clinical services addressing any substance-use disorders to each patient. 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 performed for the benefit of persons served. In order to be licensed under this subtitle, a mobile crisis team within a mobile crisis team program shall: Meet the requirements of COMAR 10.63.01, 10.63.02, and 10.63.06 and this regulation; Provide, 24 hours per day, 7 days per week, 365 days per year, professional intervention for children or adults whose behaviors are consistent with experiencing: A mental health crisis; A substance use disorder crisis; or Both §B(2)(a) and (b) of this regulation; Meet the requirements defined in Health-General Article, Title 10, Subtitle 14, Annotated Code of Maryland; Be pre-approved by the Department or its designee to participate in the public behavioral health system to receive funding through the Department; and Respond to urgent symptoms or behaviors that are disrupting an individual’s behavioral health functioning. Mobile crisis team response may also include engaging law-enforcement where the addition of a law enforcement presence provides additional safety measures, when indicated, for all individuals involved in the mobile crisis intervention. Mobile Crisis Team Program Services. A mobile crisis team program shall provide the following services: In-person, community-based professional and peer intervention services which shall: Be age and culturally appropriate, and explained in terms understandable to the individual; Be designed to: De-escalate an individual’s behavioral health crisis; Evaluate the nature of the crisis; Stabilize the individual to the pre-crisis level of functioning; and Maintain continuity of care by coordinating access to various treatment and support services; Be deployed to the location of an individual in crisis; Address immediate dynamics that may be contributing to the crisis; Include a response initiated by a mobile crisis team within an average of 60 to 120 minutes of determining an individual is in need of crisis intervention; Use evidence-based tools to screen, assess, stabilize, and refer persons, as clinically indicated; Be provided by a mobile crisis team that is nearest to the location of the individual in crisis; and Be provided under the documented supervision of a licensed mental health professional approved by the appropriate board to supervise. Crisis Intervention Services. A mobile crisis team program shall provide medically necessary crisis intervention services, inclusive of the following: Triage and screening to determine the level of risk faced by the individual in crisis and assess the most appropriate response; An immediate assessment conducted by a licensed mental health professional to determine the services necessary to stabilize the crisis for the individual; A plan for de-escalation and resolution of the crisis, including in-person interventions for immediate de-escalation of presenting behavioral symptoms; Brief therapeutic and skill-building interventions and therapeutic counseling techniques specific to the crisis that aims to lower risks and resolve the crisis so that a higher level of care is not needed; Case management and care coordination services, which may include referrals to other services as well as follow-up contacts; Engaging peer and natural and family support when appropriate; A safety crisis plan, which shall aim to keep an individual in crisis and their environment safe and may include the distribution of opioid overdose reversal drugs, lethal means counseling, and other evidence-based interventions; Stabilization services to ensure the individual’s safety and connection to needed resources to reduce the behavioral symptoms leading to crisis; and Follow-up screening and assessment for ongoing risk when indicated by the needs of persons served, in-person, via phone, or via telehealth following the initial crisis intervention. Follow-up services, provided in-person, via phone, or via telehealth, which shall include, but are not limited to: Referral and linkage with other service providers; and Ongoing coordination to meet identified resource needs. Mobile Crisis Team Program Staffing. A mobile crisis team program shall include at least one licensed mental health professional available at all times, either via telehealth or face-to-face, who is: Licensed at the independent practice level; Eligible to oversee the staff of the team; and Eligible to complete an emergency petition. A mobile crisis team: Shall include two staff members responding in-person; Shall include a licensed mental health professional face-to-face or via telehealth; and May not include law enforcement, if present, as part of the two-person response team. Mobile Crisis Team Program Staff Training Requirements. All mobile crisis team program staff shall complete required trainings approved by the Department. A mobile crisis team 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 staff member of a mobile crisis team; and Ensures that all staff receive competency verification following all initial and ongoing training. All mobile crisis teams shall be trained in the mobile response and stabilization services (MRSS) model. Mobile Crisis Team Program Reporting Requirements. A mobile crisis team program shall provide data on outcomes and social determinants of care to the State in the format and frequency required by the Department. A mobile crisis team program shall obtain pre-approval from the Department and LBHA or CSA to operate mobile crisis services in the PBHS to ensure services meet local community needs for behavioral health crisis services. 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. Health-General Article, §§7.5-204, 8-402, 8-404, and 10-901, and 10-1402, Annotated Code of Maryland Effective date: July 1, 2016 (43:10 Md. R. 585) Regulation .14 amended effective February 27, 2017 (44:4 Md. R. 255) Regulation .18 amended effective February 27, 2017 (44:4 Md. R. 255) Regulation .19J amended effective February 27, 2017 (44:4 Md. R. 255) Regulation .20 adopted effective May 27, 2024 (51:10 Md. R. 526) Regulation .21 adopted effective May 27, 2024 (51:10 Md. R. 526)