This chapter governs the identification, assessment, and treatment of hearing-impaired mentally ill patients within Maryland Department of Health Administration-operated inpatient and residential facilities, including a designated specialized unit at Springfield Hospital. Facility operators must screen all newly admitted patients for hearing impairment within 24 hours, follow defined audiometric protocols, incorporate hearing-related treatment recommendations into individual treatment plans, and maintain hearing aids. The chapter also establishes transfer criteria, referral procedures, and staffing/interpreter requirements for the specialized hearing-impaired inpatient unit.
View official sourceCode of Maryland Regulations Chapter 08 Services for Mentally Ill Hearing Impaired Patients in Facilities Administrative History Effective date: January 8, 1990 (16:26 Md. R. 2792) Authority Health-General Article, §10-204, Annotated Code of Maryland .01 Scope. The following regulations govern the provision of services for hearing impaired mentally ill patients within the Administration's facilities and the designated inpatient hearing impaired unit. .02 Definitions. A. The following terms have the meanings indicated. B. Terms Defined. (1) “Administration” means the Maryland Department of Health Administration. (2) “Audiologist” means an individual who is authorized to practice audiology under Health Occupations Article, Title 2, Annotated Code of Maryland . (3) “Certified interpreter for hearing impaired persons” means an interpreter who possesses at the minimum a Comprehensive Skills Certificate issued by the Registry of Interpreters for the Deaf. (4) “Documented history of deafness or hearing impairment” means a documented diagnosis of hearing impairment made by an audiologist or by a Board-eligible or Board-certified otolaryngologist. (5) “Facility” means an inpatient or residential treatment program operated directly by the Administration. (6) “Gross testing” means either an interactive process which screens a person's ability to follow ordinary conversation or pure tone audiometric screening. (7) “Hearing aid” means any instrument or device designed for or represented as aiding, improving, or correcting hearing and any parts, attachments, or accessories of this instrument or device. (8) “Hearing impaired individual” means a person with an impairment so severe that with or without amplification, the processing of linguistic information through hearing is impaired. (9) “Individual treatment plan” means the plan of care identified for each patient as outlined in COMAR 10.21.03 . (10) “Mental illness” means an illness resulting from a psychiatric disorder and does not include a primary diagnosis of alcohol or drug abuse or developmental disability. (11) “Otolaryngologist” means a physician identified by the State Board of Physician Quality Assurance as a specialist in otolaryngology as set forth in Health Occupations Article, §14-704, Annotated Code of Maryland . (12) “Physician” means an individual who is authorized to practice medicine under Health Occupations Article, Title 14, Annotated Code of Maryland . (13) “Pure tone audiometric screening” means the pure tone air conduction screening procedure used to rapidly and effectively identify a patient with a hearing impairment that interferes with or has the potential for interfering with communication. (14) “Qualified allied health professional” means the staff assigned by the facility and trained by an audiologist in procedures outlined in this chapter. (15) “Rinne and Weber testing” means the tuning fork test used to differentiate between conductive and sensory-neural hearing losses. (16) “Speech-language pathologist” means an individual who is authorized to practice speech-language pathology under Health Occupations Article, Title 19, Annotated Code of Maryland . (17) “Speech reading” means the use of visual cues in determining what the speaker is saying and may also be referred to as lip reading. (18) “Unit” means the inpatient unit of the institution designated by the Administration created specifically to treat those patients having both a mental illness and a hearing impairment. Cross References 10.21.08.03D .03 Identification of Hearing Impaired Patients. A. Patients admitted to facilities shall be screened for hearing impairment. B. Gross Testing of Hearing Sensitivity. (1) At each facility, an examination shall be performed for gross testing of hearing sensitivity on all newly admitted patients within 24 hours of admission. This examination shall be performed: (a) By a physician or a qualified allied health professional; and (b) According to the following protocol: (i) Testing shall occur consistently at a fixed distance from the speaker at all times; (ii) In order to prevent speech reading which could be interpreted as a false positive, the speaker's face may not be in view by the patient while testing is in process; and (iii) Non-English speaking patients shall be tested in the language the patient is known to speak or is believed to comprehend. (2) Testing performed in conformance with §B(1) of this regulation shall be repeated within 15 days after admission on all patients not already tested with a pure tone screening audiometer. (3) Each test performed in compliance with this regulation shall be documented in the patient's chart. (4) Once a hearing impairment is suspected: (a) Rinne and Weber testing shall be performed; and (b) Referral shall be made for audiometric screening. C. Audiometric Screening. (1) Patients with Suspected Hearing Impairment. (a) Pure tone audiometric screening shall occur within 3 working days from the period specified in §B(1), of this regulation, for any patient who: (i) Is suspected of having a hearing impairment on the basis of any of the above tests; (ii) Was unresponsive because of a possible hearing impairment; or (iii) Responded in a manner that may be construed as a mental disorder, but may be confused with a possible hearing impairment. (b) Patients suspected of having a hearing impairment on the basis of the latest pure tone audiometric screening shall be referred promptly but in not more than 5 working days to an audiologist or an otolaryngologist. Referral shall be documented in the patient's chart. (c) Upon recommendation by either the otolaryngologist or audiologist, further evaluation by a speech-language pathologist shall be conducted. (d) If the audiometric screening in this section is used as the initial screening test, that audiometric screening shall be sufficient testing on admission unless otherwise ordered. (2) Patients Not Identified as Hearing Impaired. As soon as possible, but within 90 days after admission, each patient who has not already been screened with an audiometer shall be so evaluated. (3) Each patient's annual physical examination shall include audiometric screening. The screening results shall be documented in the patient's chart. (4) Procedures for Audiometric Screening. (a) The audiometric screening shall be performed in accordance with the standards outlined in Regulations .04 and .05 of this chapter. (b) The audiometric screening shall be administered by either: (i) A physician trained to screen hearing according to the protocol established in this chapter; (ii) An audiologist; or (iii) Appropriately and periodically trained allied health care staff, under the supervision and monitoring of an audiologist. (c) An audiologist shall determine the facility's training protocol and frequency of training for allied health care staff. At a minimum, training shall occur at least once a year. D. Patients Exempted from Audiometric Screening. If the patient has a history of hearing impairment as defined in Regulation .02B(8) of this chapter and documented by an audiologist or physician, the screening procedure identified in §B and C of this regulation is not required within the first year after admission. E. Treatment recommendations related to the patient's hearing impairment made by either an audiologist, otolaryngologist, or speech pathologist, shall be incorporated in the patient's Individual Treatment Plan. F. Provision and Maintenance of Hearing Aids. (1) The patient and appropriate staff on each shift shall receive, in accordance with a plan developed by an audiologist, instructions on the care, use, and inspection of the hearing aid by staff referenced in §C(4)(b)(i) and (ii) of this regulation or the hearing aid vendor. (2) Designated staff, as identified in the Individual Treatment Plan, shall be responsible for ensuring daily monitoring of hearing aids, and implementing timely repair and immediate replacement of batteries. (3) Identification of the need for replacement as well as the replacement of the patient's hearing aid shall be documented in the patient's record. (4) Denial of hearing aid replacement by the treatment team or the patient's refusal to accept a hearing aid shall be documented and be reevaluated at a minimum of every 3 months. (5) The facility shall provide a hearing aid to the patient when an otolaryngologist or audiologist determines that a patient would benefit from amplification and related accessories. Payments for aids shall follow the Administration's policy on payment for medical devices. .04 Standards for Identification Audiometry. A. Staff, as defined in Regulation .03C(4)(b), of this chapter, shall conduct manually administered, individual pure tone air conduction screening procedures for identification audiometry on each patient with a developmental age of 3 years or older. The following apply: (1) Patients with a developmental age of less than 3 years shall be referred to an audiologist for an evaluation. (2) Group screening may not be conducted on any patient. B. Pure tone testing shall use test frequencies at 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz. Screening levels shall be 20dB hearing level at all frequencies tested. C. Audiometers Used for Screening Purposes. (1) For either a limited range or a narrow range audiometer, audiometers shall meet the requirements found in “Specifications for Audiometers” (ANSI S3.6-1969, American National Standards Institute), which is incorporated by reference. (2) Audiometers shall be calibrated by an appropriately and professionally trained person at least annually. (3) Sound pressure at the ear phones shall be checked at least every 3 months. (4) Daily listening checks shall be performed to determine that the audiometer is grossly in calibration and that no defects exist in major components. (5) An audiologist shall instruct support personnel in the proper handling and operation of audiometric equipment in order to minimize the need for repairs and to improve test accuracy. D. In accordance with Regulation .05 and the requirements found in “Criteria for Permissible Ambient Noise During Audiometric Testing” (ANSI S3.1-1977 American National Standards Institute), which is incorporated by reference, ambient noise levels may not exceed 41.5 dB Sound Pressure Level (SPL) at 500 Hz, 49.5 dB SPL at 1000 Hz, 54.5 dB SPL at 2000 Hz, and 62 dB SPL at 4000 Hz when measured using a sound level meter with octave-band filters centered on the screening frequencies. E. Nonresponse to the recommended screening levels at any frequency in either ear shall constitute failure. F. Failures shall be rescreened within the same screening session, if possible. G. Failures on rescreening shall be referred for an audiologic evaluation by an audiologist. .05 Requirements for the Acoustical Environment. The test tones listed in this regulation shall meet the allowable octave-band ambient noise levels which are noted in the following table taken from page 5 of the May 1985 ASHA journal: Test frequency 500 1000 2000 4000 Octave-band cutoff 300 600 1200 2400 Frequencies 600 1200 2400 4800 Octave-band level: Ear covered with earphone mounted in MX-41/AR cushion 21.5 29.5 34.5 42 Plus ASHA screening level 20 20 20 20 Resultant maximum ambient noise level allowable for ASHA screening 41.5 49.5 54.5 62 .06 Springfield Hospital Unit for Hearing Impaired Patients. A. Transfer Criteria. To be transferred to the unit, each patient shall: (1) Meet the statutory criteria for admission as set forth in Health-General Article, §10-609 — 10-619, Annotated Code of Maryland, and other applicable regulations related to the involuntary and voluntary admissions to facilities. (2) Have documentation of deafness or a hearing impairment. (3) Currently be using visual, manual, or tactile modes of communication which include but are not limited to American sign language, finger spelling, or speech reading, or be capable of being trained in the use of those methods. (4) Be 14 years old or older. Patients 14 to 18 years old shall reside in: (a) A separate inpatient residence designated for minors and attend the day program of the hearing-impaired unit if the: (i) Treatment teams of the unit and of the minor's inpatient residence approve; (ii) Approval is documented in the progress notes and the Individual Treatment Plan; and (iii) Individual Treatment Plan is not in conflict with the Individual Educational Plan; (b) The unit if the: (i) Unit treatment team approves; and (ii) Individual plan for treatment indicates the need for placement on the unit. (5) Be capable, with auxiliary aids, if necessary, of participating in professionally developed and supervised therapies, experiences, and activities provided by the unit. (6) Have documentation in that patient's record that the patient does not object to participation on the unit, based on information necessary to make an informed judgment. B. Referral Procedures to the Unit After a Patient is Admitted to a Facility. (1) Referral procedures for facilities shall be established by the Administration. (2) Unit staff, in consultation with the treating physician, shall: (a) Follow the Administration's referral procedures; and (b) Within 7 days of a determination of hearing impairment by history or pure tone audiometric screening, determine the appropriateness of transfer of that patient to the unit. C. Unit Personnel and Training. (1) The unit shall be directed by and include a complement of professional staff who have training or experience, or both, in working with hearing impaired mentally ill persons. (2) Unit staff shall develop and maintain skills relevant to the provision of services for hearing impaired persons which include, but are not limited to, training in the psychosocial needs of hearing impaired persons and instruction in American sign language. A credentialing process to review the continuing education program for unit staff shall be determined by the Administration. (3) Certified interpreters for hearing impaired patients, or other staff who possess equivalent qualifications as determined by a certified interpreter designated by the facility for that purpose, shall be on duty on the unit 24 hours a day. (4) Facility staff may not be scheduled to provide interpreter services and any other services at the same time. Cross References 10.21.08.07A(2) .07 Determination of Placement. A. Each hearing impaired patient in a facility, regardless of other handicapping conditions, shall be referred for evaluation for transfer to the unit pursuant to this regulation and Regulations .06 and .08A of this chapter. The following apply: (1) The referring facility's treating physician shall refer any: (a) Previously diagnosed hearing impaired patient to the unit within 72 hours of admission; or (b) Patient newly identified as hearing impaired pursuant to this chapter, within 72 hours of identification. (2) The unit staff, in consultation with the patient's treating physician at the referring facility, shall assess the appropriateness of the transfer, including but not limited to the criteria listed in Regulation .06A of this chapter . (3) The assessment and decision regarding transfer of the patient shall be documented and sent to the referring facility by the unit's assessment team within 7 working days of referral. (4) The decision regarding transfer and its rationale shall: (a) Become a part of the permanent record; and (b) Include the names and titles of the assessment team members. (5) If, after referral and assessment, the patient's transfer to the unit is denied, the decision and its rationale shall be documented in the patient's chart by the unit's director or unit director's designee. B. If the decision is made to transfer the patient to the unit, the transfer shall occur not later than 2 working days after the determination to do so, unless a bed is not available on the unit. C. The unit shall establish and maintain a waiting list for patients who have been accepted into the unit and are awaiting transfer. D. The date of entry onto the waiting list shall determine placement on the waiting list, except that priority shall be given to transfer patients from areas of known shortage of resources for mentally ill hearing impaired persons. E. Decisions related to priority transfers shall be made by the unit director or the unit director's designee. .08 Services for Hearing Impaired Patients Not in the Unit. A. Unless the age of a minor hearing impaired patient precludes transfer to the unit, the referring facility's treating physician shall refer the patient for evaluation to the unit at least every 60 days in order to: (1) Reevaluate the appropriateness for the transfer to the unit; and (2) Obtain consultation for any appropriate treatment options. B. The facility shall provide auxiliary aids in accordance with the provisions of §504 of the Rehabilitation Act of 1973, 29 U.S.C. §794 and its implementing regulations, 45 CFR §84.52(d), which are incorporated by reference, for the hearing impaired patient to participate in the facility's professionally developed and supervised activities, therapies, and experiences. Auxiliary aids may include but are not limited to interpreter services, notetakers, special hearing assistive devices, and telecommunication devices for the deaf (TTD). .09 Procedure Pertaining to Complaints. Complaints about the individual application of this chapter may be addressed through any patient grievance mechanism.