This chapter establishes the approval requirements and operating standards for Residential Rehabilitation Programs (RRPs) in Maryland, which are community-based residential settings operated by psychiatric rehabilitation programs (PRPs) to support adults with mental illness in developing daily living skills and integrating into community life. Operators must meet site, staffing, and service requirements—including inspection and certification of each residence by a residential specialist, individualized rehabilitation planning, and tiered staffing support levels (general or intensive)—in order to obtain and maintain Department approval. The chapter also governs discharge, suspension, and quality management obligations for RRP program directors.
View official sourceCode of Maryland Regulations Chapter 22 Community Mental Health Programs — Residential Rehabilitation Programs Administrative History Effective date: Regulations .01 — .12 adopted as an emergency provision effective January 16, 1995 (21:26 Md. R. 2183); adopted permanently effective April 24, 1995 (22:8 Md. R. 596) —————— Chapter revised effective November 30, 1998 (25:24 Md. R. 1774) Regulation .07B amended effective October 17, 2011 (38:21 Md. R. 1278) Authority Health-General Article, §§10-901 and 10-902, Annotated Code of Maryland .01 Scope. A. The purpose of this chapter is to outline the site, staffing, and service requirements that a psychiatric rehabilitation program (PRP) shall fulfill in order to be eligible to be approved to provide residential rehabilitation program (RRP) services. B. The Department may approve a program as an RRP if the applicant: (1) Is approved by the Department under COMAR 10.21.21 ; (2) Leases or owns at least one residence to be operated under the requirements of this chapter; and (3) For a residence of four or more individuals, holds a license under COMAR 10.21.04 . .02 Definitions. In this chapter, terms have the meanings stated in COMAR 10.21.17 . .03 Application and Initial Approval Process. A. Consultation. Before submitting an application, a PRP that is applying for approval to operate an RRP may request assistance regarding the proper compilation of application materials and completion of the application from the Administration or the appropriate: (1) Core service agency (CSA) director; or (2) Residential specialist. B. Program Application. A PRP that is applying for approval to operate an RRP shall include with the application for program approval under COMAR 10.21.16.03B : (1) A description of the type of service that the program intends to provide, including: (a) An estimate of the total number of individuals to be served by the RRP; and (b) The capacity of the RRP to provide general or intensive staffing, as defined in Regulation .09D of this chapter ; and (2) A copy of the residential specialist's certificate of approval of the residence, as granted under the provisions of §C(4)(a)(i) of this regulation . C. Initial Approval of a Residence. (1) Application for Approval of a Residence. A PRP that is applying for approval of a residence as a component of an RRP or an applicant for licensure of a group home under COMAR 10.21.04 shall submit to the residential specialist an application that: (a) Is on the form approved by the Department with the requirement that all questions be answered and all required documents be attached; (b) Includes documentation: (i) That the residence is or will be owned or leased by the applicant; (ii) Of fire, liability, and hazard insurance coverage on the building in which the residence is located; and (iii) Of compliance with relevant federal, State, or local ordinances, laws, regulations, and orders, including zoning and safety, that are applicable to housing for individuals without disabilities. (2) Review of Application. Within 5 working days of receipt of an application for approval of an RRP residence, the residential specialist shall review the application for completeness, and if the application is: (a) Complete, arrange with the applicant to inspect the residence; or (b) Incomplete, promptly return it to the applicant with written instructions regarding proper completion of the application. (3) Initial Inspection of Residence. Within 10 working days of receipt of a completed application, in collaboration with a representative of the applicant, the residential specialist, using the residential checklist, shall inspect the residence for compliance with Regulation .05 of this chapter . (4) Initial Certification of a Residence by a Residential Specialist. (a) Based on the inspection conducted under §C(3) of this regulation , within 5 working days of the inspection, the residential specialist shall issue to the applicant, with copies to the Administration and CSA, one of the following: (i) A certificate of general approval of the residence; (ii) Notice of provisional approval, based on noncompliance with specific site requirements under Regulation .05 of this chapter ; or (iii) Notice that the residence is not approved, based on noncompliance with specific site requirements under Regulation .05 of this chapter . (b) If the residential specialist issues a notice under §C(4)(a)(ii) or (iii) of this regulation, the residential specialist shall, at the applicant's request: (i) Evaluate the applicant's efforts to attain compliance; and (ii) If necessary, reinspect the residence. (c) Following an evaluation under §C(4)(b) of this regulation , the residential specialist shall issue one of the following: (i) A certificate of general approval of the residence; (ii) Notice of continued provisional approval; or (iii) Notice of denial of approval, advising the applicant of hearing rights, as provided in COMAR 10.21.16.11 or COMAR 10.21.04.06G, as applicable. Cross References 10.21.22.04A(1)(a)(i) 10.21.22.04A(2) 10.21.22.09D .04 Process for Annual Approval of a Residence. A. Annual Review of a Residence. Within not more than 1 year from the date of the last certificate of approval of a residence, the residential specialist, using the residential checklist, shall: (1) Conduct an on-site evaluation to: (a) Inspect the residence for continued compliance with: (i) The documentation required under Regulation .03C(1)(b) of this chapter ; and (ii) Site requirements outlined in Regulation .05 of this chapter , using the residential checklist; (b) Document residents' assessment of the residence and of services described in Regulations .05, .08, and .09 of this chapter through face-to-face interviews, in an RRP residence of: (i) One to three residents, with at least one individual; or (ii) Four or more residents, with at least 30 percent of the individuals living in the residence; and (c) Verify, when appropriate: (i) Residents' collection of entitlements; and (ii) The program's fee collections; (2) Based on the inspection conducted under §A(1)(a) of this regulation , issue the certification or notice described in Regulation .03C(4)(a) of this chapter to the RRP program director, with copies to the: (a) PRP program director; and (b) Director of the CSA; and (3) Notify the RRP program director, in writing, of significant information collected under §A(1)(b) or (c) of this regulation. B. Notice of Noncompliance with Site Requirements. If the residential specialist finds that the residence is not in compliance with a site requirement or requirements outlined in Regulation .05 of this chapter , the residential specialist shall: (1) If the deficiency does not pose an imminent risk to the health, safety, or welfare of an individual served: (a) Give the RRP program director written notice of provisional approval, identifying the deficiency and the time frame, of not more than 30 days, to correct the deficiency; and (b) If necessary, reinspect the residence to determine compliance; (2) If the deficiency poses a risk to the health, safety, or welfare of an individual served; (a) Give the RRP program director written notice that the Department intends not to approve the residence, citing the reason for the disapproval, with copies to the: (i) PRP program director; and (ii) Director of the CSA; and (b) Request corrective action within 24 hours; (3) If the deficiency cited under: (a) §B(1) of this regulation is within 30 days: (i) Corrected, issue a certificate of general approval; or (ii) Not corrected, reevaluate the approval status of the residence and provide that information to the Department's designated approval unit for consideration when evaluating the approval status of the RRP; and (b) Section B(2) of this regulation is not corrected within 24 hours, give the RRP program director, with copies to the PRP program director and Director of the CSA, written notice of: (i) The emergency suspension of the approval of the residence, under State Government Article, §10-226, Annotated Code of Maryland ; (ii) Hearing rights, as provided in COMAR 10.21.16.11 ; and (iii) The obligation to relocate residents according to the provisions of §C of this chapter. C. Relocation of Residents. If approval of a residence is suspended under the provisions of §B(3)(b) of this regulation , the RRP director shall relocate residents according to the plan adopted under Regulation .05D of this chapter . D. Extension of Approval Status of a Residence. If the residential specialist does not complete a site inspection before an on-site review by the Department's designated approval unit, the Secretary shall maintain the RRP's existing approval status, pending receipt of the residential specialist's determination of approval status of a residence or residences. Cross References 10.21.22.12B .05 Site Requirements. A. General Requirements. The RRP director shall ensure that: (1) All areas of a residence, including storage areas, are safe, clean, and free of hazards and clutter; (2) A residence has: (a) No housing code or zoning violations; (b) Working smoke alarms or smoke detectors that meet local fire codes for residential dwellings; (c) Hot and cold running water and adequate light, heat, and ventilation; and (d) Sufficient, appropriate, and functional furnishings, equipment, supplies, and utensils comparable to those found in the residences of nondisabled individuals; (3) A resident: (a) Has the resources to purchase or has access to food: (i) For at least three meals per day for 7 days each week; and (ii) That meets the individual's dietary, nutritional, and religious needs; (b) Has the resources to acquire an adequate supply of soap, towels, and toilet tissue; (c) Who self-administers medication, has access to a secure storage area for the individual's medications; (d) Has access to a secure storage area for funds and valuables; (e) Has access to transportation; (f) Has access to a telephone in the residence; and (g) To the extent possible, may use personal possessions and preferences in furnishing and decorating the resident's space; and (4) The following emergency procedures are in place: (a) Posted near the telephone are telephone numbers for the: (i) Fire department, police, ambulance, and poison control center; and (ii) Program's on-call staff; and (b) An emergency evacuation procedure that is explained to and practiced by residents within 10 days of residence and, at a minimum, every 3 months after that. B. Bedrooms. The RRP director shall ensure that a bedroom has: (1) A minimum of 70 square feet for a single bedroom and a minimum of 120 square feet for a double bedroom; (2) A door, except for an efficiency apartment; (3) Closet space for each individual in or convenient to each bedroom; (4) Window covering for privacy; (5) A bed with a clean mattress and pillow; (6) At least two sets of linens per individual; and (7) Not more than two residents. C. Toilet and Bathing Areas. The RRP director shall ensure that: (1) The residence has a minimum of one full bathroom for every four residents; (2) A full bathroom includes at least one toilet, one basin, and one tub or shower connected to hot and cold water; (3) Bathrooms are easily accessible and conveniently located, not more than one floor level from living, dining, and sleeping rooms; and (4) Bathrooms provide for individual privacy. D. Relocation Plan. Each program shall have a written relocation plan that: (1) Specifies where residents may live temporarily if the residential specialist determines that conditions in the approved residence pose an imminent risk to the health, safety, or welfare of a resident; (2) Is approved by the CSA; (3) Is updated annually; and (4) Is submitted to the residential specialist. Cross References 10.21.22.03C(3) 10.21.22.03C(4)(a)(ii) 10.21.22.03C(4)(a)(iii) 10.21.22.04A(1)(a)(ii) 10.21.22.04B 10.21.22.04C .06 Residential Rehabilitation Program Model. A. The RRP director shall organize, maintain, and develop: (1) Policies directed to ensure the provision of flexible services which respond to the current needs of an individual in an RRP; and (2) Services that: (a) Promote the individual's ability to engage and participate in appropriate community activities; and (b) In a supportive environment, enable the individual to develop the daily living skills needed for independent functioning. B. The RRP director shall ensure that the residential rehabilitation program: (1) Is located in the community, unless given an exemption by the CSA; (2) Offers a home-like environment; and (3) Provides goal-directed PRP services that facilitate rehabilitation and integration into community life. Cross References 10.21.22.09A 10.21.22.11B(1) .07 Eligibility, Screening, and Enrollment. A. An RRP shall conduct eligibility review, screening, and enrollment according to the provisions of COMAR 10.21.21.04 . B. If the RRP residence is a group home that is licensed under COMAR 10.21.04 , the RRP shall admit residents according to the additional limitations outlined under COMAR 10.21.04.03B and C. .08 Evaluation and Planning Services. A. Assessment. Within 30 days of initiation of RRP services, staff, in collaboration with the individual, shall complete an RRP assessment that includes: (1) The rehabilitation service requirements noted in the PRP assessment; and (2) An assessment of the individual's: (a) Need for RRP services; (b) Behaviors, if any, that are potentially dangerous to self or others; (c) Ability to perform basic self-care and to maintain personal safety; (d) History, if any, of requiring intermittent intensive levels of support in order to remain in the community; and (e) Need for changing intensity of intervention based on the episodic nature of illness. B. Individualized Rehabilitation Plan (IRP). (1) Initial IRP. Within 30 days of initiation of RRP services and based on the assessment in §A of this regulation , staff shall specify in the IRP: (a) RRP goals; and (b) The range of: (i) Frequency of residential services; and (ii) Intensity of staff support, as described in Regulation .09D of this chapter . (2) If the individual's service needs change, the RRP staff shall: (a) Provide and document in the individual's record the services required by the change; (b) Notify relevant staff of the change initiated; and (c) Incorporate this information in the next IRP review. (3) IRP Review. As frequently as necessary, as determined by an individual's rehabilitation coordinator, and at a minimum of every 6 months, the rehabilitation coordinator 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 individual's progress; and (iii) Changes in interventions, including staff responsibility; (b) Communicate promptly the results of the IRP review to: (i) Relevant program staff; and (ii) With proper consent, family or significant others designated by the individual, and community mental health programs providing services to the individual. (4) Signature of the IRP and Reviews. Staff shall obtain the individual's written or tape-recorded agreement or disagreement with the plan and, in addition, the following shall sign the plan and reviews: (a) The rehabilitation coordinator; and (b) Staff responsible for implementing the plan. C. Continuing Evaluation. The RRP director shall ensure that RRP staff document in the individual's PRP record contact notes and, at least monthly, progress summary notes of services, including any change in intensity of staff support, delivered at the RRP. D. Documentation. RRP staff shall document the assessment, IRP, contact notes, and progress summary notes for residential services in either: (1) The PRP record; or (2) In documents separate from the PRP record, if the PRP record references the separate documents. Cross References 10.21.22.09B(1) .09 Residential Rehabilitation and Support Services Provided. In addition to the provision of PRP services, the RRP program director shall ensure that: A. RRP services support the program model outlined in Regulation .06 of this chapter ; B. Staff provide an appropriate range of services: (1) Based on the assessment under Regulation .08A of this chapter ; and (2) In a flexible manner, as needed by the individual; C. Appropriate staff maintain linkage, as described in COMAR 10.21.21.06F, with a resident who is in a psychiatric inpatient facility or detention center; and D. Staff support, based on the program description as referenced in Regulation .03B(1) of this chapter , is provided at the level indicated by the individual's need, as follows: (1) General support, which provides that, at a minimum, staff: (a) Are available, on call, 24 hours per day, 7 days per week; and (b) Have at least one face-to-face contact per individual per week; or (2) Intensive support, which provides that staff are available, on site, for: (a) Daily support for a specific number of individuals; and (b) A minimum of 40 hours per week for up to 24 hours per day, 7 days per week. Cross References 10.21.22.03B(1)(b) 10.21.22.08B(1)(b)(ii) 10.21.22.11B(3) 10.21.22.12A .10 Discharge, Suspension, and Discontinuation of Residential Services. A. Discharge Policy. The program director shall: (1) Collaborate with the Administration's administrative services organization (ASO) to: (a) Arrange for discharge from the program when services are no longer authorized by the Administration's ASO; and (b) Discontinue residential services to an individual whose clinical needs exceed the RRP's ability to secure the safety and welfare of the individual or others; (2) Maintain clearly written policies and procedures for: (a) The process for discharge from the program; and (b) Temporary suspension from a residence; and (3) Discontinue residential services to an individual whose clinical needs exceed the RRP's ability to secure the safety and welfare of the individual or others, including the: (a) Criteria for discontinuation; and (b) Progressive steps and interventions that the program will enact before discontinuation. B. Collaborative Discharge. When the Administration's ASO, in consultation with the rehabilitation coordinator, determines that services are no longer medically necessary, the rehabilitation coordinator shall follow the provisions for collaborative discharge outlined in COMAR 10.21.21.07B . C. Suspension. (1) If an individual's clinical needs exceed the RRP's ability to secure the safety and welfare of the individual or others, the RRP program director may ask the individual to leave the residence on a temporary basis, as an alternative to the individual's termination from the residence. (2) To implement a suspension identified in §C(1) of this regulation , the RRP program director: (a) In writing, shall inform: (i) The individual of the suspension and the reason for the determination; and (ii) When involved and with proper consent, the CSA and the Administration's ASO of the suspension; (b) Shall give information on placement alternatives; and (c) May provide temporary housing options. D. Program's Recommendation to Discontinue Residential Services. If the program director recommends discontinuing residential services to an individual whose clinical needs exceed the RRP's ability to secure the safety and welfare of the individual or others, the program director shall: (1) Provide written notice of the discontinuation, according to the provisions of COMAR 10.21.21.07D ; (2) When possible, give the individual information about appropriate alternative services; (3) When authorized, arrange for outreach, by PRP staff, to encourage the individual to access appropriate services; and (4) Complete a discharge summary in accordance with COMAR 10.21.17.07D(3). .11 RRP Staff. A. RRP Program Director. The PRP program director shall either: (1) Carry out the RRP program director's duties that are delineated in this chapter; or (2) Appoint an RRP program director with the qualifications outlined in COMAR 10.21.21.08C . B. RRP Staff. The RRP program director shall ensure the deployment of sufficient staff to carry out the RRP: (1) Model described in Regulation .06 of this chapter ; (2) Activities outlined in the individual's IRPs; and (3) Staff support outlined in Regulation .09D of this chapter . .12 Quality Management (QM). A. In addition to the QM requirements in COMAR 10.21.17.10 , annually the RRP program director shall complete and document reviews of the RRP's staff support, as described in Regulation .09D of this chapter , to evaluate the relationship between staff deployment and the: (1) Number of: (a) Admissions to inpatient psychiatric facilities; (b) Visits to emergency departments; and (c) Suspensions and terminations; and (2) Results of the program's risk management (RM) analysis conducted under the provisions of COMAR 10.21.17.10C(3). B. The RRP program director shall evaluate the results of the interviews conducted by the residential specialist under the provisions of Regulation .04A(1) of this chapter and, when appropriate, modify the RRP services being delivered. C. The RRP program director shall notify the CSA director of the results of the analysis conducted under §A(1) of this regulation .