COMAR 10.21.20

Chapter 20 Community Mental Health Programs — Outpatient Mental Health Centers

This chapter establishes approval requirements and operating standards for Outpatient Mental Health Centers (OMHCs) in Maryland's public mental health system. Operators must meet staffing requirements (including a licensed program director and psychiatrist medical director), provide core treatment services (individual, family, and group therapy, medication management, and crisis/on-call coverage 24/7), conduct structured screening assessments and develop individualized treatment plans, and coordinate care with other community mental health and substance abuse providers. OMHCs may also offer intensive outpatient services and must maintain policies for continuity of care when individuals transition to more restrictive settings.

Code of Maryland Regulations

Chapter 20 Community Mental Health Programs — Outpatient Mental Health Centers

Administrative History

Effective date: February 13, 1995 (22:3 Md. R. 153)

——————

Chapter revised effective November 16, 1998 (25:23 Md. R. 1696)

——————

Regulations 
.01
 — 
.08
 repealed and new Regulations 
.01
 — 
.11
 adopted effective January 14, 2008 (35:1 Md. R. 19)

Regulation .07B
 amended effective April 29, 2013 (40:8 Md. R. 724)

Authority

Health-General Article, §§10-901 and 10-902, Annotated Code of Maryland

.01 Scope.

This chapter applies to programs that provide mental health treatment services to individuals on an outpatient basis.

.02 Definitions.

In this chapter, terms have the meanings stated in 
COMAR 10.21.17
.

.03 Approval.

A.
 The following applicants shall be eligible for approval as an outpatient mental health center (OMHC), if the applicant demonstrates experience providing mental health services for a minimum of 1 year:

(1)
 A group practice; or

(2)
 A program currently approved under another Mental Hygiene Administration community mental health program chapter.

B.
 The Department shall grant approval to a program to be eligible to receive State or federal funds for providing services if the program meets the requirements:

(1)
 Outlined under 
§A of this regulation
;

(2)
 For approval outlined in 
COMAR 10.21.16
;

(3)
 For administration outlined in 
COMAR 10.21.17
;

(4)
 For Medical Assistance providers outlined in 
COMAR 10.09.36
, 
10.09.59
, and 
10.09.70
; and

(5)
 Of this chapter.

.04 Program Model.

A.
 An outpatient mental health center (OMHC) shall provide services that are:

(1)
 Age and culturally appropriate;

(2)
 Coordinated with other components of the service delivery system; and

(3)
 Focused on recovery and resiliency.

B.
 An OMHC shall ensure that clinical services are only rendered by mental health professionals who are authorized under 
Health Occupations Article, Annotated Code of Maryland
, and appropriately credentialed by the program to perform the service.

C.
 An OMHC shall ensure that the services required under this chapter are accessible and available:

(1)
 At least 40 hours per week;

(2)
 During some weekend and evening hours; and

(3)
 For emergency coverage, 24 hours per day, 7 days per week as specified in 
Regulation .08F of this chapter
.

D.
 An OMHC shall:

(1)
 Have a facility that:

(a)
 Meets all relevant federal, State, or local ordinances, laws, regulations, and orders governing the program;

(b)
 Is not located in a private residence;

(c)
 Is accessible to the public; and

(d)
 Contains a secure area where records, logs, and business information may be kept; and

(2)
 Prominently display the hours of operation of the facility or office.

E.
 Intensive Outpatient Services.

(1)
 An OMHC may provide short-term, intensive outpatient services.

(2)
 If an OMHC provides intensive outpatient services, the services shall:

(a)
 Be delivered by a multidisciplinary team for a minimum of 3 hours of therapeutic services per day; and

(b)
 Include:

(i)
 At least two group therapies; and

(ii)
 Physician services as needed.

(3)
 For individuals receiving intensive outpatient services, the individual's ITP shall be reviewed weekly by the individual and the individual's treatment coordinator.

.05 Eligibility, Screening, Enrollment, and Orientation.

A.
 Eligibility.

(1)
 An individual is eligible for services through the public mental health system (PMHS) if the services are preauthorized, if required, by the Administration's administrative services organization (ASO), according to the provisions of 
COMAR 10.21.17.03A
.

(2)
 In addition to those individuals described in 
§A(1) of this regulation
, an OMHC may provide services to other individuals who wish to contract privately for services.

(3)
 If an OMHC provides services to an individual described in 
§A(2) of this regulation
, an OMHC may not seek reimbursement by the PMHS for providing services to that individual.

B.
 Screening Assessment.

(1)
 An OMHC licensed mental health professional, in collaboration with the individual referred, shall conduct a screening assessment to assess the individual's goals for recovery, strengths, available resources, and treatment needs:

(a)
 Within 5 working days of receipt of a referral from an inpatient facility for OMHC services; or

(b)
 By the date established under 
§B(2) of this regulation
 for all other referrals.

(2)
 For referrals that are not from an inpatient facility, the program director shall:

(a)
 In collaboration with the medical director, establish a procedure to review clinical acuity as described by the referral source;

(b)
 Based on the review of clinical acuity described in 
§B(2)(a) of this regulation
, establish the date for a screening assessment; and

(c)
 Inform the individual of:

(i)
 The date established for the screening assessment; or

(ii)
 If, due to program capacity, there will be a delay in the screening assessment, a tentative time frame for services.

(3)
 If, following the screening assessment under 
§B(1) of this regulation
, the OMHC program director, or licensed mental health professional designated by the program director, determines that the OMHC's services are not appropriate for an individual referred, the OMHC shall advise the individual and, if appropriate, notify the ASO and CSA.

C.
 Enrollment. Unless an individual has been determined to be clinically inappropriate for services under the provisions of 
§B(3) of this regulation
, an OMHC shall:

(1)
 Initiate evaluation and treatment services for an individual who has been referred from an inpatient facility, within 5 working days of the screening assessment conducted under 
§B(1) of this regulation
; or

(2)
 For all other referrals screened under 
§B(2) of this regulation
, the program director shall:

(a)
 In collaboration with the medical director, establish a procedure to review clinical acuity as described by the referral source;

(b)
 Assign priority for OMHC services based on clinical acuity;

(c)
 Inform the individual of:

(i)
 The estimated date evaluation and treatment services may be initiated; and

(ii)
 If, due to program capacity, there will be a delay in the initiation of treatment services, alternative services that are available.

D.
 Orientation. The program director shall ensure that an individual who has been enrolled in the OMHC, or if the individual is a minor, the minor's parent or guardian, receives an orientation as outlined in 
COMAR 10.21.17.04B
.

Cross References

10.21.20.07A(1)(a)

.06 Evaluative Services Provided.

A.
 Assessment and Diagnosis. The medical director shall ensure that an appropriate licensed mental health professional shall, by the individual's second visit and based on the initial face-to-face diagnostic evaluation of the individual:

(1)
 Formulate and document in the individual's medical record information that includes:

(a)
 A description of the presenting problem;

(b)
 Relevant history, including family history and somatic problems;

(c)
 Mental status examination; and

(d)
 A diagnosis and the rationale for the diagnosis; or

(2)
 Document:

(a)
 The reason for not formulating a diagnosis; and

(b)
 A plan, including time frame, for formulating a diagnosis.

B.
 Co-Occurring Substance Abuse Screening Assessment. The face-to-face diagnostic assessment conducted under 
§A of this regulation
 shall include a screening assessment, using a scientifically validated, and if available, age appropriate tool, to determine whether the individual has a co-occurring substance abuse disorder.

C.
 Additional Assessment for a Minor. In addition to the requirements outlined in 
§A of this regulation
, before a minor's fifth visit, the minor's assigned treatment coordinator shall:

(1)
 Conduct a face-to-face evaluation with the minor to assess the minor's level of functioning and availability of family and other social supports; and

(2)
 If a comprehensive assessment, that includes the elements listed in 
§C(2) of this regulation
, has not been completed within the 6 months before enrollment, assure the completion of an assessment, that includes, at a minimum, the minor's:

(a)
 Developmental history;

(b)
 Educational history and current placement;

(c)
 Home environment;

(d)
 Family history and evaluation of the current family status, including legal custody status;

(e)
 Social, emotional, and cognitive development;

(f)
 Motor, language, and self-care skills development;

(g)
 History, if any, of substance abuse;

(h)
 History, if any, of physical or sexual abuse;

(i)
 History, if any, of out-of-home placements; and

(j)
 Involvement, if any, with the local department of social services or Department of Juvenile Services.

D.
 Review of Somatic Status.

(1)
 According to the provisions described in 
§D of this regulation
 and upon an individual's enrollment into the program, an appropriate licensed mental health professional shall document in the individual's medical record:

(a)
 Pertinent past and current somatic medical history including:

(i)
 The individual's somatic health problems, if any, including but not limited to allergies, neurologic disorders, and communicable diseases;

(ii)
 Relevant medical treatment, including medication; and

(iii)
 A recommendation, if any, for somatic care follow-up;

(b)
 If the individual does not have a primary care provider, the plan, if indicated, including the time frame, for the individual's referral to a primary care provider for evaluation and treatment; and

(c)
 An exchange of medical information with the primary care provider.

(2)
 With proper consent and if clinically indicated, the individual's treatment coordinator shall maintain and document ongoing collaboration and coordination with the individual's primary care provider.

Cross References

10.21.20.08D(2)

.07 Treatment Planning and Documentation.

A.
 Individual Treatment Plan (ITP).

(1)
 Initial ITP.

(a)
 Not later than the fifth visit after an individual is enrolled in an OMHC and based on the assessment conducted under 
Regulation .05B of this chapter
, the treatment coordinator and the individual, and if the individual is a minor, the minor's parent, guardian, or primary caretaker if appropriate, shall develop an ITP in collaboration with:

(i)
 With proper consent, family or others designated by the individual, and others involved in the individual's care; and

(ii)
 Other OMHC staff, as appropriate.

(b)
 The ITP shall include, at a minimum:

(i)
 The individual's diagnosis;

(ii)
 The individual's presenting needs, strengths, recovery, and treatment expectations and responsibilities;

(iii)
 A description of needed and desired treatment and interventions to be provided, specifying the modality, frequency, and responsible staff;

(iv)
 A description of how the needed and desired treatment will help the individual to manage the individual's psychiatric disorder and to support recovery;

(v)
 Short-term and long-term treatment goals in measurable terms and target dates for each goal; and

(vi)
 If appropriate, identification of, referral for, and collaboration with other services or child service agencies and providers to support the individual's treatment and recovery, including but not limited to mental health residential services, psychiatric rehabilitation services, self-help organizations, vocational programs, substance abuse services, the local department of social services, the local department of juvenile services, schools, and somatic care.

(c)
 The content of the ITP shall be communicated to:

(i)
 Relevant program staff; and

(ii)
 With proper consent, family or others designated by the individual and, if applicable, community mental health programs providing services to the individual.

(2)
 ITP Review. As frequently as necessary, as determined by the individual and the individual's treatment coordinator, and at a minimum of every 6 months, the individual and the treatment coordinator shall:

(a)
 Review the ITP with the individuals identified under 
§A(1) of this regulation
;

(b)
 Based on the review, record in the individual's medical record:

(i)
 An assessment of the individual's progress toward the accomplishment of previously identified treatment goals that incorporates the perspective of the individual served;

(ii)
 Goal changes based on a review of progress;

(iii)
 Changes in treatment strategies; and

(iv)
 Changes in diagnosis, if any; and

(c)
 Communicate the results of the treatment plan review to:

(i)
 Relevant program staff;

(ii)
 With proper consent, substance abuse treatment providers and primary care provider, as appropriate;

(iii)
 With proper consent, family or others designated by the individual and community mental health programs providing services to the individual.

(3)
 Signature of the ITP and Reviews.

(a)
 Except as provided in 
§A(3)(b) of this regulation
, the individual shall sign agreement with the plan and reviews.

(b)
 If the individual is unwilling to sign agreement with the plan and reviews, the individual's treatment coordinator shall:

(i)
 Verify the individual's verbal agreement with the plan and reviews; and

(ii)
 Document the rationale for the individual's refusal to sign.

(c)
 If the individual is a minor, the minor's parent or guardian, or if other than the minor's parent or guardian, the minor's primary caretaker shall sign agreement with the plan and reviews.

(d)
 With proper consent, family or others designated by the individual, including the individual's caregivers, may sign the plan and reviews.

(e)
 At least two licensed mental health professionals who collaborate about the individual's treatment, shall sign the plan and reviews.

(f)
 If the individual is receiving medication prescribed through the OMHC, an OMHC psychiatrist, or Certified Registered Nurse Practitioner in psychiatry, whomever prescribes the medication, shall sign the plan and reviews.

(4)
 Upon completion of an ITP or ITP review, an individual's treatment coordinator shall assure that the individual is offered a copy of the plan or review and document the individual's acceptance or decline of the offer in the individual's medical record.

(5)
 Individual Treatment and Rehabilitation Plan (ITRP). Staff may combine the required elements of an ITP and IRP in one document, the ITRP.

B.
 Continuing Evaluation and Treatment.

(1)
 Contact Note. Staff shall document each contact with the individual, including, at a minimum:

(a)
 The date;

(b)
 The start time and either the duration or the end time;

(c)
 The individual's chief medical complaint or reason for the visit;

(d)
 The individual's mental status;

(e)
 The delivery of services specified by the ITP;

(f)
 A brief description of the service provided;

(g)
 The plan for changes in treatment, if any;

(h)
 The individual's progress toward treatment goals; and

(i)
 A legible signature, which may include an electronic signature, and printed or typed name of the licensed mental health professional providing care, with the appropriate title.

(2)
 The treatment coordinator shall document any significant changes or events, including hospitalizations, that affect the individual's treatment.

(3)
 The treatment coordinator shall ensure that the individual's needs and progress are communicated to:

(a)
 Staff involved in the implementation of the ITP; and

(b)
 With proper consent:

(i)
 Community mental health programs providing services to the individual; and

(ii)
 Family or others designated by the individual.

.08 Treatment Services.

A.
 An OMHC shall have the capacity to provide the treatment services outlined in §§B — F of this regulation as required by the individual's ITP.

B.
 Mental Health Treatment. The program director shall ensure that licensed mental health professionals provide mental health treatment including:

(1)
 Individual therapy;

(2)
 Family therapy; and

(3)
 Group therapy.

C.
 Psychological Evaluation and Testing. The program director shall ensure that, if medically necessary and required by an individual's ITP, the OMHC provides psychological evaluation and testing by a staff psychologist or psychologist consultant, or by referral.

D.
 Co-Occurring Substance Abuse Treatment.

(1)
 The program director shall ensure that the program provides substance abuse treatment as a component of its mental health program for individuals with secondary co-occurring disorders or has a written plan to coordinate mental health services with a certified substance abuse program if necessary.

(2)
 If the assessment conducted under 
Regulation .06B of this chapter
 indicates that the individual has a secondary co-occurring substance abuse disorder, the individual's treatment plan and progress notes shall:

(a)
 If the program is providing substance abuse treatment, reflect the course of treatment relative to the disorder; or

(b)
 If the program is not providing substance abuse treatment, with proper consent and if indicated, include documentation of coordination of care and collaboration with the provider of substance abuse services.

E.
 Medication Services.

(1)
 The medical director shall ensure that appropriate staff are trained and updated on the use, effect, interactions, and potential side effects of medication used by individuals served by the program.

(2)
 Appropriate licensed mental health professionals shall, as clinically indicated, provide the following services:

(a)
 Prescription;

(b)
 Administration;

(c)
 Monitoring; and

(d)
 Education regarding medication.

(3)
 Prescription. Staff identified under 
§E(2) of this regulation
 shall:

(a)
 When initially prescribing medication for an individual:

(i)
 Conduct a face-to-face evaluation of the individual;

(ii)
 Assess whether there are contraindications to prescription of specific medications;

(iii)
 Involve the individual in the choice of medication;

(iv)
 Document in the individual's medical record the rationale for prescribing the medication;

(v)
 Explain the benefits and possible side effects of taking or not taking prescribed psychiatric medications and document the explanation;

(vi)
 With proper consent and if appropriate, promptly notify anyone responsible for administering or monitoring medication, of the medication regimen; and

(vii)
 With proper consent and if clinically indicated, notify the individual's primary care physician of medication prescription, if any; and

(b)
 If managing medication on an ongoing basis:

(i)
 At a minimum of every 90 days, evaluate the individual face-to-face;

(ii)
 Alter medications and adjust dosage as clinically indicated;

(iii)
 Document the rationale for the current prescription;

(iv)
 Order and monitor tests at medically recommended intervals and document results in the individual's medical record;

(v)
 Educate the individual and others designated by the individual about prescribed medications, including the name of medication, dosage, frequency, proper storage, expected results, and potential side effects;

(vi)
 With proper consent and if appropriate, promptly notify anyone responsible for administering or monitoring medication, of any changes in the medication regimen; and

(vii)
 Notify the individual's primary care physician every 6 months of medication changes, if any.

F.
 On-Call and Crisis Intervention Services.

(1)
 The program director shall ensure that on-call and crisis intervention services are provided by a program's licensed mental health professional to an individual who has been enrolled in the OMHC:

(a)
 Face-to-face during the 40 hours that the OMHC is open; or

(b)
 By telephone, on an on-call basis, 24 hours per day, 7 days per week, during the hours the OMHC is not open:

(i)
 Through the OMHC; or

(ii)
 By written agreement with another OMHC or mental health crisis service provider.

(2)
 If clinically appropriate, a crisis response plan or an advance directive for mental health services shall be developed and documented in the medical record, that:

(a)
 An individual and, if the individual is a minor, the primary caretaker may implement in the event of or to prevent a crisis at home, school, work, or other setting in which the individual is involved; and

(b)
 Is stated in terms that the individual and, if involved, the primary caretaker understand.

Cross References

10.21.20.04C(3)

10.21.20.09A

.09 Support Services.

A.
 In combination with one or more of the treatment services outlined in 
Regulation .08 of this chapter
, an OMHC shall have the capacity to provide, as required by an individual's ITP, the support services outlined in §§B — E of this regulation.

B.
 Referral Services. The program director shall ensure that the OMHC provides recommendations and referral, if appropriate, for:

(1)
 Psychiatric rehabilitation and support services;

(2)
 Somatic care;

(3)
 Speech and language services;

(4)
 Vision and hearing services;

(5)
 Special instruction, special education, or other educational interventions;

(6)
 Occupational therapy;

(7)
 Self-help organizations; and

(8)
 Substance abuse services.

C.
 Education Regarding Medication. A nurse, a physician, or other appropriate licensed mental health professional shall educate the individual, and with proper consent, the individual's family or others designated by the individual, by:

(1)
 Verifying the individual's understanding of the directions for administration of medication; and

(2)
 Providing information regarding:

(a)
 The role, effects, and importance of medication in symptom management;

(b)
 Expected benefits and potential side effects of prescribed medication; and

(c)
 Nutritional and dietary expectations and risks related to the individual's medication regimen.

D.
 Case Coordination Services. If indicated, the treatment coordinator shall support the individual to:

(1)
 Apply for all applicable entitlement programs; and

(2)
 Access other needed services and resources, as appropriate.

E.
 Linkage with an Individual in a Psychiatric Facility, RTC, RCS Program, or Detention Center. The program director shall maintain written policies and procedures, which may be contained in one document, for the purpose of continuity of care when individuals receive mental health services in more restrictive settings.

.10 Program Staff.

A.
 Required Staff. The OMHC shall have staff that is sufficient in numbers and qualifications to provide clinically appropriate services to the individuals served and includes, at a minimum:

(1)
 A program director who is:

(a)
 A licensed mental health professional, or has a master's degree in one of the following fields:

(i)
 Mental health;

(ii)
 Health services; or

(iii)
 Business administration;

(b)
 Employed by the OMHC at least 20 hours per week; and

(c)
 Responsible for administrative oversight of the OMHC, including, at a minimum:

(i)
 Fulfilling the administrative requirements under 
COMAR 10.21.17
;

(ii)
 Fulfilling the requirements of this chapter;

(iii)
 Ensuring the continuity of service if clinical staff at the OMHC site are unavailable to fulfill their responsibilities to the individuals served;

(iv)
 Ensuring a system of clinical supervision of the multidisciplinary treatment staff; and

(v)
 Having knowledge of all regulatory requirements related to the operation of the program;

(2)
 A medical director who:

(a)
 Is a psychiatrist;

(b)
 Is employed by and is on site at the OMHC at least 20 hours per week;

(c)
 If employed full time by the program, may also serve as program director; and

(d)
 Has overall responsibility for clinical services, including, at a minimum:

(i)
 Establishing and maintaining appropriate standards for diagnosis and treatment, including therapeutic modalities and prescribing practices;

(ii)
 Medical aspects of quality management;

(iii)
 Adequate physician coverage; and

(iv)
 Ensuring adequate clinical supervision of treatment staff;

(3)
 A multidisciplinary licensed mental health professional staff that:

(a)
 Provides evaluation and treatment services;

(b)
 Is in addition to the OMHC psychiatrist; and

(c)
 Includes representatives of two different mental health professions both of which are represented on-site 50 percent of the OMHC's regularly scheduled hours.

B.
 Students. The program may use students according to the provisions of COMAR 10.21.17.12E.

C.
 Volunteers. The program may use volunteers according to the provisions of COMAR 10.21.17.12F.

.11 Multi-Facility Programs.

A.
 An OMHC program that operates multiple sites shall assure that each additional site adheres to the application modification as outlined in 
COMAR 10.21.16.04E
.

B.
 The program director and the medical director shall, on a routine basis, and as clinically required, provide on-site consultation at each site to ensure adequate clinical and administrative oversight.

C.
 The program shall designate for each additional OMHC site:

(1)
 A clinical coordinator who:

(a)
 Is a licensed mental health professional with demonstrated competency in clinical supervision;

(b)
 Is located at each additional OMHC site for 50 percent of the site's regularly scheduled hours;

(c)
 Has regular, direct access to the medical director and all clinical and administrative resources of the OMHC; and

(d)
 Provides clinical oversight of the individuals served;

(2)
 A psychiatrist who:

(a)
 Need not be the medical director of the OMHC; and

(b)
 Is on-site according to the needs of the individuals served; and

(3)
 A multidisciplinary licensed mental health professional staff that:

(a)
 Provides evaluation and treatment services;

(b)
 Is in addition to the OMHC psychiatrist; and

(c)
 Includes representatives of two different mental health professions both of which are represented on-site 50 percent of the OMHC's regularly scheduled hours.

D.
 Staff at each additional OMHC site shall have direct access to the program director, the medical director, and all other clinical and administrative resources of the OMHC as needed.