COMAR 10.21.21

Chapter 21 Community Mental Health Programs — Psychiatric Rehabilitation Programs for Adults

This chapter establishes service requirements and staffing standards for Psychiatric Rehabilitation Programs (PRPs) in Maryland, including Residential Rehabilitation Programs (RRPs), that provide psychiatric rehabilitation services to adults with serious mental illness. Operators must meet approval criteria, conduct rehabilitation assessments and develop Individual Rehabilitation Plans within 30 days of enrollment, maintain specified staff qualifications and staff-to-client ratios, and ensure 24/7 on-call and crisis intervention access. The chapter also governs supported housing services, medication monitoring, wellness self-management, and documentation requirements for all PRP and RRP services.

Code of Maryland Regulations

Chapter 21 Community Mental Health Programs — Psychiatric Rehabilitation Programs for Adults

Administrative History

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

——————

Chapter revised effective September 7, 1998 (25:18 Md. R. 1434)

——————

Chapter revised effective January 14, 2008 (35:1 Md. R. 22)

Regulation .06D
 amended effective January 21, 2013 (40:1 Md. R. 20)

Authority

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

.01 Scope.

This chapter outlines the service requirements and staffing standards for a psychiatric rehabilitation program (PRP) that provides psychiatric rehabilitation services to an adult at the program site or at an off-site location, including a residential rehabilitation program, appropriate to the individual's needs.

.02 Definitions.

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

.03 Approval.

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

A.
 For approval outlined in 
COMAR 10.21.16
;

B.
 For administration outlined in 
COMAR 10.21.17
; and

C.
 Of this chapter.

.04 Program Model.

A.
 A provider of PRP services for adults shall:

(1)
 Have a facility or office 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.

B.
 The program director shall organize program services and supports to:

(1)
 Facilitate an individual's recovery, including the individual's ability to make decisions about the individual's life and create opportunities for choice regarding:

(a)
 Home;

(b)
 School or work; and

(c)
 Community; and

(2)
 Promote the use of community resources and self-help organizations to support the individual to participate fully in the community.

C.
 The program director shall ensure that:

(1)
 Services are:

(a)
 Appropriate to the age of the populations being served;

(b)
 Offered at times and places, according to the needs of the individuals served; and

(c)
 Coordinated with other mental health services that the individual is receiving;

(2)
 If the PRP provides services to individuals in a specific age group or with a particular clinical profile, the initiation of service criteria are consistent with the populations to be served; and

(3)
 If the PRP provides services in a facility, the services are provided on a regular basis and include a variety of group and individual rehabilitation activities that incorporate individual rehabilitation goals, needs, and choices.

Cross References

10.21.22.07A

.05 Eligibility, Screening, and Initiation of Service.

A.
 Eligibility. An individual is eligible for PRP services if:

(1)
 The individual is in need of program services to enable the individual to improve or restore independent living and social skills necessary to support the individual's:

(a)
 Recovery;

(b)
 Ability to make informed decisions and choices; and

(c)
 Participation in community life;

(2)
 The individual meets medical necessity criteria for PRP services;

(3)
 The individual agrees to apply for medical assistance, as appropriate; and

(4)
 The services are preauthorized, as needed, by the Administration's administrative services organization (ASO), according to the provisions of 
COMAR 10.21.17.04A
.

B.
 Screening. Within 10 working days of receipt by the program of a complete referral for PRP services:

(1)
 Staff assigned by the program director shall conduct a screening assessment to determine whether rehabilitation services are medically needed by the individual;

(2)
 If, following the screening assessment under 
§B(1) of this regulation
, the program director determines that the program's services are not appropriate for an individual who has been referred, the program director shall, in writing:

(a)
 Inform the individual of the determination and the reason;

(b)
 Provide the individual with recommendations for alternative services, if appropriate; and

(c)
 With proper consent, notify the referral source, the family, or others designated by the individual of the determination and of any recommendations for other services;

(3)
 Unless the program director has notified the individual of the determination under 
§B(2) of this regulation
, the program director shall notify the individual whether the program:

(a)
 Accepts the individual, in which case, the program director shall identify a date that the program can initiate services to the individual;

(b)
 Will accept the individual, following an updated review of the individual's eligibility status, when program capacity permits, in which case the program director shall inform the individual of the:

(i)
 Individual's placement on a waiting list, if any; and

(ii)
 Estimated date services may be initiated; or

(c)
 Will accept the individual following the individual's discharge or release from an inpatient facility, RTC, or detention center;

(4)
 If the individual is placed on a waiting list under 
§B(3)(b) of this regulation
, the program staff shall discuss with the individual:

(a)
 The option of remaining on the program's waiting list until the date established under 
§B(3)(b) of this regulation
; and

(b)
 Alternative services that are available.

C.
 Entitlements and Fees. PRP staff assigned by the program director shall:

(1)
 Determine if the individual has, or may be eligible, for federal or State entitlements;

(2)
 Assist the individual, if necessary, to apply for all entitlements for which the individual may be eligible if the individual does not have entitlements;

(3)
 Document in the individual's medical record:

(a)
 That the individual has all entitlements; or

(b)
 The outcome of the entitlement application;

(4)
 Discuss with the individual the charges for services, and, when applicable, the process for determining ability to pay; and

(5)
 Provide written documentation to the individual regarding the charges for services and the process for determining ability to pay.

.06 Evaluation and Planning Services.

A.
 Review of Somatic Status.

(1)
 According to the provisions outlined in this section and upon an individual's enrollment into the program, a staff member assigned by the program director shall document in the individual's medical record:

(a)
 Pertinent past and current 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 medications; and

(iii)
 Needed somatic care follow-up, if any; and

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

(2)
 When indicated, the individual's rehabilitation coordinator shall communicate with the individual's primary care provider and document the communication in the individual's medical record.

(3)
 When indicated, the individual's rehabilitation coordinator shall discuss with the individual the need for medical and dental care, facilitate access to care, and document the communication in the individual's medical record.

B.
 Rehabilitation Assessment.

(1)
 Within 30 calendar days of initiation of PRP services, RRP services, or both, staff assigned by the program director to conduct assessments shall complete a face-to-face rehabilitation assessment with the individual and, with proper consent, family or others designated by the individual.

(2)
 The assigned staff shall document in the rehabilitation assessment, at a minimum:

(a)
 The individual's strengths, skills, wants, and needs in the following areas:

(i)
 Independent living;

(ii)
 Housing;

(iii)
 Employment;

(iv)
 Self-administration and management of medications;

(v)
 Mobility and transportation;

(vi)
 Social relationships and leisure activities;

(vii)
 Education and vocational training;

(viii)
 Adaptive equipment or resources; and

(ix)
 Other factors that may pose a challenge to the individual's successful recovery and rehabilitation;

(b)
 Current resources and support system;

(c)
 As relevant, a review of the individual's legal status and forensic history, if any;

(d)
 The individual's history of substance abuse, if any;

(e)
 Behaviors, if any, that are potentially dangerous to the individual or others; and

(f)
 For individuals receiving RRP services, the individual's:

(i)
 Need for RRP services;

(ii)
 Ability to perform basic self-care and to maintain personal safety; and

(iii)
 Need for changing intensity of intervention based on the episodic nature of mental illness.

C.
 Individual Rehabilitation Plan (IRP).

(1)
 Initial IRP. Within 30 calendar days of initiation of PRP or RRP services and based on the rehabilitation assessment described in 
§B of this regulation
, the individual and the individual's rehabilitation coordinator shall prepare an initial IRP:

(a)
 In collaboration with:

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

(ii)
 When appropriate and with proper consent, other mental health service providers, as available; and

(b)
 That includes, at a minimum:

(i)
 The individual's recovery and rehabilitation expectations and responsibilities;

(ii)
 A description of needed and desired program services and interventions, and staff responsible for implementation;

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

(iv)
 Rehabilitation goals in measurable terms, and target dates for each goal;

(v)
 When appropriate, identification of, recommendations for, and collaboration with, other services to support the individual's recovery and rehabilitation, including but not limited to mental health treatment, residential services, self-help organizations, and somatic care; and

(vi)
 For individuals receiving RRP services, the frequency of residential services and intensity of staff support.

(2)
 Individual Treatment and Rehabilitation Plan (ITRP). With the individual and in collaboration with the mental health treatment coordinator, the rehabilitation coordinator may combine the required elements of an ITP and IRP in one document, the ITRP.

(3)
 Rehabilitation Plan Review. At a minimum of every 6 months, the rehabilitation coordinator, with the individual, shall:

(a)
 Review and record in the individual's medical record:

(i)
 The individual's progress toward the accomplishment of previously identified rehabilitation goals;

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

(iii)
 Changes in interventions, as appropriate; and

(b)
 Communicate promptly the results of the review to:

(i)
 Relevant program staff; and

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

(4)
 Signature of the IRP or ITRP and Reviews.

(a)
 The following shall sign that they agree with the IRP or ITRP and reviews:

(i)
 The individual; and

(ii)
 The individual's rehabilitation coordinator.

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

(c)
 If the individual is unwilling to sign agreement with the IRP or ITRP and reviews, the individual's rehabilitation coordinator shall:

(i)
 Verify the individual's verbal agreement with the IRP or ITRP and reviews; and

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

(d)
 In addition, for an ITRP, at least two licensed mental health professionals, who collaborate about the individual's treatment, shall sign the ITRP and ITRP reviews, including:

(i)
 The individual's treatment coordinator; and

(ii)
 If the individual is receiving medication prescribed through an outpatient mental health center (OMHC), the OMHC psychiatrist.

(5)
 Upon completion of an IRP, ITRP, or review, an individual's rehabilitation coordinator shall assure that the individual is offered a copy of the plan or review and document the individual's receipt or decline of the offer in the individual's medical record.

D.
 Continuing Evaluation.

(1)
 Contact Notes. Staff shall document in the individual's medical record:

(a)
 Each contact with or about the individual, including, at a minimum:

(i)
 The date and location of service;

(ii)
 The start time and either the duration or end time, unless the information is in a readily accessible billing document;

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

(iv)
 The delivery of services specified by the IRP or ITRP;

(v)
 A brief description of the service provided; and

(vi)
 A legible signature, which may include an electronic signature, and printed or typed name of the program staff member providing care, with the appropriate title; and

(b)
 For individuals receiving RRP services, any change in intensity of staff support delivered at the RRP.

(2)
 Monthly Summary Notes. At a minimum, each month the rehabilitation coordinator shall record in the individual's medical record, either a contact note or a progress summary note that includes:

(a)
 An assessment of the individual's progress toward goal achievement that incorporates the perspective of both the individual served and staff involved;

(b)
 Changes in the individual's status; and

(c)
 A summary of the rehabilitation services and interventions provided.

(3)
 If not documented in §D(1) or (2) of this regulation, the rehabilitation coordinator shall document any significant changes or events, including hospitalizations, that affect the individual's rehabilitation.

(4)
 The rehabilitation coordinator shall document that the individual's wants and needs and progress are promptly communicated to:

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

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

Cross References

10.09.33.01B(4)(b)

.07 Rehabilitation and Support Services Provided.

A.
 Rehabilitation and support services may only be provided:

(1)
 To an individual consistent with the individual's IRP or ITRP; and

(2)
 By staff who have been determined competent by the program to provide the services.

B.
 Rehabilitation and Recovery Activities. The program director shall ensure that the program provides rehabilitation activities directed toward the individual's recovery and the improvement or restoration of skills, including:

(1)
 Self-care skills, including personal hygiene, grooming, nutrition, dietary planning, food preparation, and self-administration of medication;

(2)
 Social skills, including community integration activities, developing natural supports, and developing linkages with and supporting the individual's participation in community activities;

(3)
 Independent living skills, including:

(a)
 Skills necessary for housing stability;

(b)
 Community awareness;

(c)
 Mobility and transportation skills;

(d)
 Money management;

(e)
 Accessing available entitlements and resources;

(f)
 Supporting the individual to obtain and retain employment; and

(g)
 Wellness self-management; and

(4)
 Activities that support the individual's cultural interests.

C.
 Medication Services.

(1)
 Administration.

(a)
 An individual licensed to administer medication under 
Health Occupations Article, Annotated Code of Maryland
, may do so.

(b)
 A licensed practical nurse or a registered nurse may delegate the administration of medication only according to the provisions of 
COMAR 10.27.11
.

(2)
 Monitoring. A PRP staff member shall provide the following services for psychiatric and somatic medications:

(a)
 Support the individual's self-administration of prescribed medication;

(b)
 Read the medication label to ensure that each container of medication is clearly labeled with the individual's name, the contents, directions for use, and expiration date;

(c)
 To the extent possible, monitor compliance with instructions appearing on the medication label;

(d)
 Ensure that each individual has secure, appropriate, and accessible space in which to store medications;

(e)
 Observe and document any apparent reactions to medication and, either verbally or in writing and in a timely fashion, communicate to the prescribing authority any problems that possibly may be related to the medication; and

(f)
 Reinforce, with the individual, education on the role and effects of medication in symptom management.

D.
 Health Promotion and Training. PRP staff shall encourage health promotion activities, such as proper nutrition and exercise.

E.
 Promotion of Individual Wellness Self Management and Recovery.

(1)
 Staff shall:

(a)
 Provide education and information regarding mental illness and recovery; and

(b)
 Support the individual to identify effective strategies to assist the individual to manage the individual's wellness.

(2)
 The strategies shall include, at a minimum, the individual's identification of:

(a)
 Potential challenging symptoms;

(b)
 Warning signs of relapse;

(c)
 Helpful interventions; and

(d)
 Other people the individual identifies to support the individual's recovery.

(3)
 The individual's wellness self-management strategies shall be documented and may be incorporated in the individual's IRP, Residential Rehabilitation Program Managed Intervention Plan, as outlined in 
Regulation .08 of this chapter
, mental health advance directive, or any combination of these items.

(4)
 The strategies shall be reviewed at the time of the IRP review and may be revised or revoked at any time at the request of the individual.

F.
 On-Call and Emergency Response. The program director shall assure that:

(1)
 On-call and crisis intervention services are available 24 hours per day, 7 days per week, by telephone, to an individual who has been admitted to the PRP; and

(2)
 All relevant staff shall assist the individual to access, as appropriate, the OMHC, mobile crisis, residential crisis services, hospitals, and other service providers that are designated to provide crisis and emergency care and treatment.

G.
 Linkage with an Individual in a Psychiatric Inpatient Facility or Detention Center.

(1)
 If an individual who is enrolled in a program is admitted to a psychiatric inpatient facility or detention center, the rehabilitation coordinator shall make reasonable efforts to maintain ongoing communication with the individual and the individual's inpatient treatment team.

(2)
 To the degree permitted by the setting, PRP staff serving the individual shall participate in aftercare or release planning from that setting.

Cross References

10.21.22.10B

10.21.22.10D(1)

.08 Residential Rehabilitation Program (RRP) Managed Intervention Plan (MIP).

A.
 The program director shall:

(1)
 Ensure that the program has a written policy regarding the development of and process for the implementation of a managed intervention plan (MIP) for an individual receiving RRP services; and

(2)
 Upon initiation of service, document that the individual has received the written policy regarding the MIP.

B.
 For an individual at risk of an unplanned discharge, the rehabilitation coordinator, in collaboration with the individual, shall prepare an MIP that includes:

(1)
 Identification of the issues or symptoms that prompt the implementation of the MIP;

(2)
 Steps and planned interventions, including, but not limited to:

(a)
 A description of additional individualized services and supports that may be needed;

(b)
 Verbal notification;

(c)
 Written notification;

(d)
 Temporary interruption of RRP services, which shall include:

(i)
 The identification of temporary residential alternatives, if any; and

(ii)
 Notification to the CSA;

(e)
 Identification of the individuals involved in implementing the MIP; and

(f)
 The signature of the:

(i)
 Individual;

(ii)
 Individual's rehabilitation coordinator;

(iii)
 Individual's family or others, if designated by the individual.

C.
 The elements of the MIP may be included in a revised IRP.

Cross References

10.21.21.07E(3)

10.21.22.11A(2)

.09 Supported Housing Services for Adults.

A.
 Housing Development. The program director shall ensure that the program:

(1)
 Collaborates with the CSA to access affordable housing in the community;

(2)
 Maintains information about available regular housing that is:

(a)
 Integrated throughout the community;

(b)
 Not conditional upon an individual's participation in mental health treatment or support services; and

(c)
 Within the price range that is affordable to individuals enrolled in the program; and

(3)
 In conjunction with the CSA:

(a)
 Attempts to develop financial resources to assist an individual temporarily in such circumstances as an individual's hospitalization or loss of job, benefits, or housemate; and

(b)
 Establishes priorities by which housing financial resources are allocated to individuals.

B.
 Housing Needs Assessment. The program director shall ensure that program staff, in collaboration with the individual, conduct an assessment of:

(1)
 The individual's housing needs; and

(2)
 If the individual does not have housing that the individual considers adequate, the rehabilitative skills that the individual needs to obtain the housing of choice.

C.
 Accessing and Sustaining Housing. The program director shall ensure that the program provides, as needed by and acceptable to the individual, services that are directed at:

(1)
 Assisting an individual in making choices about where and with whom to live by developing or restoring the basic social and living skills needed to:

(a)
 Link, when interested, with other individuals with similar interests and housing requirements;

(b)
 Evaluate financial resources, available natural supports, and needed and desired community services; and

(c)
 Secure available private and public housing financial assistance;

(2)
 Developing or restoring appropriate basic living skills and supports to keep housing, such as:

(a)
 Responsibilities for upkeep of the property and personal belongings;

(b)
 Development of community resources and natural supports;

(c)
 Housemate conflict resolution; and

(d)
 Landlord-tenant negotiations regarding such issues as rent, needed repairs, and complaints; and

(3)
 Providing support, as determined by the individual's need.

.10 Staff Qualifications and Responsibilities.

A.
 Program Director. The program director:

(1)
 Shall have sufficient qualifications, knowledge, and experience to execute the duties of the position;

(2)
 Shall be knowledgeable of the regulations applicable to the program;

(3)
 Shall be responsible for administrative oversight of the PRP including, at a minimum:

(a)
 Fulfilling the administrative requirements under 
COMAR 10.21.17
;

(b)
 Fulfilling the programmatic requirements of this chapter;

(c)
 Keeping the advisory committee, or governing body, whichever is applicable, informed of, at a minimum, the program's approval status and performance;

(d)
 Quality management; and

(e)
 Ensuring the development of a staffing plan that identifies the type and number of staff needed to provide a program of rehabilitation and recovery services for individuals with serious mental illness; and

(4)
 May be responsible for the duties of the psychiatric rehabilitation specialist under 
§B of this regulation
 as specified in Regulation .11B — D of this chapter.

B.
 Psychiatric Rehabilitation Specialist. The program director shall employ at least one psychiatric rehabilitation specialist who:

(1)
 Is either a:

(a)
 Licensed mental health professional;

(b)
 Rehabilitation counselor who is currently certified by the Commission on Rehabilitation Counselor Certification; or

(c)
 Bachelor's prepared certified psychiatric rehabilitation practitioner currently certified by the U.S. Psychiatric Rehabilitation Association;

(2)
 Develops and assures that rehabilitation services meet the needs of the individuals served by the program;

(3)
 Oversees the daily program of rehabilitation services; and

(4)
 Educates direct care staff on how to provide rehabilitation services that correlate to the goals identified in the individual's IRP or ITRP.

C.
 Psychiatric Rehabilitation Direct Care Staff. The program shall employ psychiatric rehabilitation direct care staff who:

(1)
 Have 40 hours of PRP training before independently providing PRP services;

(2)
 Have, at a minimum, a high school diploma or equivalency diploma; and

(3)
 Are responsible for implementing the rehabilitation activities outlined in the individual's IRP.

Cross References

10.21.21.11B(2)(a)

10.21.21.11C(2)(a)

10.21.21.11D(2)(c)

.11 Required Program Staff.

A.
 A provider shall ensure that the staff of the PRP includes the following, who are employed by the PRP for the amounts of time outlined in §§B — D of this regulation:

(1)
 A program director;

(2)
 A psychiatric rehabilitation specialist; and

(3)
 Psychiatric rehabilitation direct care staff.

B.
 If a PRP has fewer than 30 enrollees, the PRP shall employ either:

(1)
 A program director and a psychiatric rehabilitation specialist, each of whom is employed by the program for a minimum of 20 hours per week; or

(2)
 A program director who is responsible for the duties of the program director and the duties of a psychiatric rehabilitation specialist, if the program director:

(a)
 Has the qualifications described under 
Regulation .10B(1) of this chapter
;

(b)
 Is employed by the program for 40 hours per week; and

(c)
 Devotes at least 20 hours per week to the development and implementation of rehabilitation services that reflect the needs of the individuals served by the program.

C.
 If a PRP has 30 — 100 enrollees, the PRP shall employ either:

(1)
 A program director and a psychiatric rehabilitation specialist, each of whom is employed by the program for a minimum of 20 hours per week, and one of whom is employed for an additional 20 hours; or

(2)
 A program director who is responsible for the duties of the program director and the duties of the psychiatric rehabilitation specialist, if the program director:

(a)
 Has the qualifications described under 
Regulation .10B(1) of this chapter
;

(b)
 Is employed by the program for 40 hours per week; and

(c)
 Designates staff to devote 20 hours per week to carrying out specific assigned administrative duties.

D.
 If a PRP has more than 100 enrollees, the PRP program shall employ:

(1)
 A program director who is employed for 40 hours per week; and

(2)
 A psychiatric rehabilitation specialist or specialists and staff assigned to administrative duties as follows:

(a)
 A psychiatric rehabilitation specialist who is on site 40 hours per week;

(b)
 Two psychiatric rehabilitation specialists, each of whom is on site for 20 hours per week; or

(c)
 If the program director has the qualifications described under 
Regulation .10B(1) of this chapter
:

(i)
 A psychiatric rehabilitation specialist who is employed 20 hours per week; and

(ii)
 Staff designated to devote 20 hours per week carrying out specific assigned administrative duties.

.12 Ratio.

A.
 The program shall maintain an average ratio of at least one rehabilitation staff member serving each ten individuals who are receiving on-site PRP services, or receiving off-site PRP services in a group.

B.
 To achieve this ratio, the program:

(1)
 May not include:

(a)
 The program director; or

(b)
 Consultants and volunteers; and

(2)
 May include students only if, in calculating the ratio, five rehabilitation staff are on duty for each student.

.13 Volunteers and Students.

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

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