104 CMR 27.00

104 CMR 27.00: Licensing and operational standards for mental health facilities

This regulation establishes licensing and operational standards for mental health facilities licensed, contracted for, or operated by the Massachusetts Department of Mental Health. It covers psychiatric hospitals, psychiatric units within general or public health hospitals, community mental health centers with inpatient units, and Intensive Residential Treatment Programs (IRTPs) for adolescents. Facility operators must meet requirements for licensure classes, staffing, accreditation, deemed status, surveys, deficiency correction, and—where applicable—substance use disorder treatment services provided within these facilities.

104 CMR: DEPARTMENT OF MENTAL HEALTH
104 CMR 27.00: LICENSING AND OPERATIONAL STANDARDS FOR MENTAL HEALTH
FACILITIES
Section
SUBPART A: SCOPE AND DEFINITIONS
27.01: Scope
27.02: Definitions
SUBPART B: LICENSING
27.03: Licensing; Generally
27.04: Licensing; Intensive Residential Treatment Programs (IRTP)
SUBPART C: OPERATIONAL STANDARDS FOR MENTAL HEALTH FACILITIES
27.05: General Admission Procedures
27.06: Voluntary and Conditional Voluntary Admission
27.07: Three-day Involuntary Commitment
27.08: Transfer and Transport of Patients
27.09: Discharge
27.10: Treatment
27.11: Periodic Review
27.12: Prevention of Restraint and Seclusion and Requirements When Used
27.13: Human Rights
27.14: Human Rights Officer; Human Rights Committee
27.15: Absence without Authorization
27.16: Records and Records Privacy
27.17: Interpreter Services
SUBPART D: OPERATIONAL STANDARDS FOR SUBSTANCE USE DISORDER TREATMENT
FACILITIES
27.18: Substance Use Disorder Treatment Facility
SUBPART A: SCOPE AND DEFINITIONS
27.01: Scope
Unless the contrary is specified in a particular section, the provisions of 104 CMR 27.00
apply to all facilities that are licensed, contracted for, or operated by the Department of Mental
Health (Department).
27.02: Definitions
For purposes of 104 CMR 27.00, the following terms shall have the following meanings:
Clinician. A physician or qualified advanced practice registered nurse, authorized, as applicable,
by the Department pursuant to 104 CMR 33.00: Designation and Appointment of Qualified
Mental Health Professionals, or by the facility, to perform the functions described in 104 CMR
27.00.
Deficiency Notice. Written notice and order of correction relating to a finding by the Department
that a Facility is not in compliance with the requirements of M.G.L. c. 19, § 19 or 104 CMR
27.00. A deficiency notice may include an order of correction contained within a decision of the
director of licensing issued pursuant to 104 CMR 32.00: Investigation and Reporting
Responsibilities.
Facility. A Department-operated hospital, community mental health center with inpatient unit,
or psychiatric unit within a public health hospital; a Department-licensed psychiatric hospital;
a Department-licensed psychiatric unit within a general hospital; or an intensive residential
treatment program for adolescents that is either designated as a facility under the control of the
Department or licensed by the Department.
(Mass. Register #1446 6/25/21)
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.02: continued
Facility Direc tor. Th e superintendent, chief e xecutive of ficer, prog ram dire ctor, or othe r
administrator designated by the facility to have administrative oversight of a facility, or his or
her designee.
Facility Medical Director. The senior physician with responsibility for clinical oversight of a
facility or his or her physician designee.
Informed Consent. The knowing consent, voluntarily given by the patient, or his or her legally
authorized representative, who can understand and weigh the risks and benefits of the particular
treatment, including medication, being proposed.
Original License. A license, including a provisional license, issued to a facility not previously
licensed, or a license issued to an existing facility in which there has been a change in ownership
or location or a change in class of license or specialized service.
Patient. A person who has been admitted to a facility pursuant to M.G.L. c. 123, and 104 CMR
27.00.
Psychiatric Ad vanced Pr actice Re gistered N urse (P sychiatric APR N). A re gistered n urse
licensed under M.G.L. c. 112, § 80B and authorized by the Board of Registration in Nursing to
practice as a Psychiatric Advanced Practice Registered Nurse, including authorization to practice
as a Psychiatric Mental Health Nurse Clinical Specialist.
Qualified Advanced Practice Registered Nurse (Qualified APRN). A registered nurse licensed
under M.G.L. c. 112, § 80B and authorized by the Board of Registration in Nursing to practice
as an Advanced Practice Registered Nurse.
Specialty Population. An identified group of individuals with clinical needs in addition to their
mental health needs that may require the provision of specialized services, staff competencies,
or treatment structure in order to receive suitable treatment within a facility. These groups may
include, but ar e not nec essarily limited to, in dividuals with co-occ urring mental hea lth and
intellectual or developmental disabilities, complex m edical needs, or substanc e use disorder,
older a dults or c hildren. Ha ving a histo ry of , o r c oexisting ide ntification w ith, a sp ecialty
population does not necessarily require the provision of specialized services for every admission
to a facility.
SUBPART B: LICENSING
27.03: Licensing; Generally
(1) Pursuant to M.G.L. c. 19, the Department is responsible for developing and maintaining a
comprehensive area-based system of mental health services for citizens of the Commonwealth.
Critical to fulfilling this responsibility is striving to assure that individuals in need of menta l
health services are able to access those services in a timely manner and from a geographically
reasonable location. Facilities licensed in accordance with 104 CMR 27.00 fill an essential role
in the Commonwealth’s mental health service system and as such must be operated so as to meet
the mental health needs of the Commonwealth as a whole as such needs may be determined from
time to time by the Department.
(2) In determining the needs of the Commonwealth, the Department shall consider the health
needs of persons with a mental illness in the commonwealth, including underserved populations
and persons with co-occurring mental illness and substance use disorder, and in particular shall
evaluate whether individuals have access to the appropriate services that meet their specific
behavioral he alth c are ne eds in a tim ely ma nner a nd, w here po ssible, a g eographically
appropriate location. The Department will evaluate factors across the delivery system including,
but not limited to, the number of beds in facilities that are licensed pursuant to 104 CMR 27.00
and in operation, by region and by license type, i.e., general psychiatric services, or services for
specialty populations.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.03: continued
(3) The Depar tment will review the ne eds of the Commonwea lth no less freque ntly than
biannually to determine sufficiency of licensed capacity for general and specialty populations and
in conducting such re view may consider f actors including, but not be limit ed to, emer gency
department utilization and wait time, inpatient utilization and wait time, and judicial referrals.
In conducting this review, the D epartment will consult wit h stakeholders including, but not
limited to , c ommercial a nd pu blic pa yers, e mergency de partments, in patient f acilities,
intermediate car e provide rs, and pa tients, and shall consult with and utiliz e data from the
Department of Public Health, the Center for Health Information and Analysis, and the Health
Policy Commission.
(4) All priva te, county or municipal mental he alth facilities are subject to licensing b y the
Department pursuant to M.G.L. c. 19, § 19. A hospital, clinic or nursing home licensed by the
Department of Public Health under M.G.L. c. 111 which admits persons with mental illness only
on voluntary status, need not be lice nsed by the Depa rtment of Menta l Health. All other
hospitals licensed by the Department of Public Health which admit persons with mental illness
on any admission status other than, or in addition to, voluntary status pursuant to 104 CMR
27.00, Subpart C shall also be licensed by the Department of Mental Health.
104 CMR: DEPARTMENT OF MENTAL HEALTH
NON-TEXT PAGE
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.03: continued
(5) General and Specialty Populations.
(a) The De partment may establish clinical compe tencies a nd additional opera tional
standards f or c are a nd tr eatment o f p atients a dmitted to fa cilities li censed p ursuant t o
104 CMR 27.00, including for specialty populations. Clinical competencies and operational
standards established by the Department shall incorporate national and local standards of
practice where such standards of practice exist, and to the extent deemed appropriate by the
Department.
(b) No facility shall hold itself out as providing specialized care for population(s) for which
the Department has established clinical competencies and operational standards, nor shall any
facility preferentially admit patients within such population(s), unless it has applied for and
received a license certifying that the facility meets the applicable clinical competencies and
operational standards for care and treatment of the specialty population(s).
(c) Nothing in 104 CMR 27.03(5) shall per mit a fac ility to have exclusion criteria that
would result in the refusal to admit a patient who meets the general admission criteria for the
facility, based solely upon the determination that the patient may also meet the criteria for
a specialty population.
(6) No original license shall be issued to e stablish or maintain a facility subject to licensure
under 104 CMR 27.00, unless there is need for such a facility as determined by the Department,
and the applicant has the demonstrated ability, by virtue of current operation or by history to
meet such needs.
(7) All licensed facilities shall provide services to commonwealth residents with public health
insurance on a non-discr iminatory basis and shall re port the fa cility's payer mix t o the
Department on a quarterly basis in form and format as determined by the Department; provided,
however, the De partment may acc ept payer mix re ports from ex isting public data source s
including, but not limited to, those from the Center for Health Information and Analysis, to meet
these reporting requirements.
(8) Types of Licenses. Licensed mental health facilities shall be issued a single license which
may incorporate one or more of the following classes:
(a) Class II. License to provide diagnosis and treatment of adults on voluntary status under
M.G.L. c. 123, § 10.
(b) Class III. License to provide diagnosis and treatment of adults on conditional voluntary
status under M.G.L . c. 123, §§ 10 and 11, and on involuntary committed status under
M.G.L. c. 123, §§ 7, 8 and 12.
(c) Class IV. (Reserved).
(d) Class V. License to provide evaluation, diagnosis and treatment of patients committed
under M.G.L. c. 123, §§ 15, 16, 17 and 18.
(e) Class VI. License to provide diagnosis and treatment of minors on voluntary or
conditional vo luntary sta tus un der M .G.L. c . 1 23, § § 1 0 a nd 11, and on inv oluntarily
committed status under M.G.L. c. 123, §§ 7, 8 and 12.
(f) Limited Class VI. License to provide diagnosis and treatment of minors 16 through 17
years of age on adult units on voluntary or conditional voluntary status under M.G.L. c. 123,
§§ 10 and 11, and on involuntarily committed status under M.G.L. c. 123, §§ 7, 8 and 12.
(g) Class VII. License to provide diagnosis and treatment of adolescents in an Intensive
Residential Treatment Program (IRTP) on voluntary or conditional voluntary status under
M.G.L. c. 123, §§ 10 and 11, and on involuntarily committed status under M.G.L. c. 123,
§§ 7 and 8. An IRTP may not be granted a Class VIII license to administer electroconvulsive
treatment.
(h) Class VIII. License to administer electroconvulsive treatment in a facility otherwise
licensed by the Department.
(9) Duration of License, Change in Ownership or Location.
(a) Licenses issued under 104 CMR 27.03 shall be valid for a term of two years and may
be renewed for like terms, subject to limitation, suspension or revocation for cause.
(b) Licenses issued under 104 CMR 27.03 are not transferrable without the approval of the
Department. Licensees wishing to transfer a license to another individual or entity or to
relocate to another location must submit an application for such c hange in license to the
Department and shall subm it the fee established by the Depa rtment. Approva l of such
application shall be subject to determination by the Department that the facility continues to
satisfy applicable provisions of 104 CMR 27.00.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.03: continued
(10) Requirements for License or Renewal.
(a) Every facility applying for a license or for a subsequent renewal of such license shall use
the forms pre scribed by the Depa rtment and shall subm it the fee established by the
Department. A schedule of licensing fees may be obtained from the Department.
(b) No a pplication for licensure or for renewal of a license shall be approved unless the
facility demonstrates, and the Department determines, that the facility it seeks to license is:
1. responsible and suitable to meet the needs of the Commonwealth; and
2. able to meet the clinical competencies and operational standards for providing care
and treatment to the population(s) it will serve.
(c) Every facility seeking a license shall submit the following:
1. a stateme nt of ownership, a plan showing the extent of the property, location and
plans of existing buildings, and any plans and specifications of buildings to be erected
or renovated. Notice shall be given to the Department by the facility of any changes in
these matters.
2. document ation which demonstrates compliance with applicable provisions of the
Facility Guidelines: Institute Guidelines for Design and Construction of Hea lth Care
Facilities, or other nationally recognized standards, for facilities of the type licensed.
3. Written plans describing:
a. its plan for delivery and supervision of clinical services. All clinical services, as
well as the supervision of such services, shall be performed by personnel qualified
by license or experience in the field in which they are performing.
b. its pl an for assuring adequate and appropriate staffing to meet the needs of the
patient population at all times.
c. its plan for phy sical ada ptations, such as by providing single occupa ncy
bedrooms, when necessary to address behavioral acuity in its patient population, as
needed.
d. its progr am of orienta tion, continuing educ ation and demonstra tion of
competencies for all personnel who provide care and treatment to patients.
e. A ttestation that the facility provides, or for an original license, will provide,
services to Comm onwealth residents with public health insuranc e on a
non-discriminatory basis.
4. A comprehensive strategic plan to prevent, reduce and, wherever possible, eliminate
restraint and seclusion as required and defined in 104 CMR 27.12(1).
(d) In its application for a license, or for renewal of a license, the facility shall include a
detailed description of its physical facilities as well as its plan for providing age appropriate
programming and services. This plan a nd description shall be subject to approva l by the
Department. The plan shall include, but not be limited to, psychiatric, medical, nursing,
social w ork a nd p sychological s ervices, o ccupational t herapy, p hysical t herapy, i f a ny,
recreational ac tivities and e quipment and per son-centered trea tment. I n addition, for
facilities license d as Class VI , L imited VI and VII, the plan sha ll include educa tional
programs, and youth guided and family driven treatment.
(e) A currently licensed facility seeking to renovate or expand such that there is a change
in its capacity, or a significant change is its physical plant, or to significantly alter its service
delivery program shall submit for appr oval such doc umentation as the De partment may
reasonably require demonstrating the facility’s continued compliance with the provisions of
104 CMR 27.00.
(f) T he Department may at any time require a facility which has been granted a license
pursuant to 104 CMR 27.00 to demonstrate its compliance with applicable law, accreditation
or ce rtification standa rds, Depa rtment reg ulations, or implementation of any
recommendations for corr ections or de ficiencies, by submitt ing suc h documentation or
reports or permitting suc h inspection as may be re quested by th e Department. The
Department may require a validation survey of a licensed facility to verify such compliance.
(11) Staffing.
(a) All facilities subject to licensure shall meet the following staffing requirements:
1. Th e fa cility sh all h ave sufficient s taff wh o h ave tr aining a nd de monstrate
competencies in functions consistent with their job responsibilities and, if required, have
certification, and who demonstrate competencies, in such specialty services as the facility
may provide.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.03: continued
2. The facility shall maintain staffing to meet the operational capacity of the facility at
levels deemed adequate by the Department.
3. If the facility is operating below its licensed capacity, it shall specify in its application
the reasons for operating below its licensed capac ity and its plan to meet the staf fing
requirements for its full licensed capacity.
4. The nursing and other clinical personnel shall be adequately prepared by education,
training and experience to provide care and treatment for persons with mental illness.
(b) Facilities licensed as Class II, III, V, VI, Limited VI, VIII, or any combination thereof,
shall meet the following requirements:
1. The facility director shall hold an adva nced degree from an a ccredited college or
university in a discipline appropriate to the care and treatment of persons with mental
illness. I f the dire ctor is not a fully licensed phy sician, there shall be a director of
psychiatric or medical services for such facility who is a physician fully licensed to
practice medicine under Massachusetts law, and who is certified or eligible to be certified
by the American Board of Psychiatry and Neurology in psychiatry; provided that in the
discretion of the Department, and subject to such conditions as the Department may
impose, experience and expertise may be conside red in lieu of B oard certification or
eligibility.
2. The fa cility shall have a physician, under full or limited licensure a s defined by
Massachusetts law, or a Qualified APRN, on the premises at all times.
a. If the physician or Qualified APRN is not designated pursuant to 104 CMR 33.02,
the facility may apply for a waiver of such designation in accordance with 104 CMR
27.03(24).
b. After business hours and du ring weekends and holidays, the requir ements of
104 CMR 27.03(11)(b)2. may be satisfied through utilization of telemedicine or other
technology pursuant to protocols approved by the Department that assure visual
communication with an off -premises physician or Qua lified APRN who is eit her
designated pursuant to 104 CMR 33. 02: Designation of Physicians Pursuant to
M.G.L. c. 123, § 12( b) or ha s r eceived a wa iver in a ccordance wi th 1 04 CMR
27.03(24), and adequate on-premises medical and clinical staff. Any such protocol
shall require that the f acility have a n on-call designated or wa ived physician or
Qualified APRN who can be physically present at the facility within one hour. 
3. There shall be an identified nurse leader of the facility, (e.g., Director of Nursing,
Chief Nursing Officer, Vice President of Nursing or Nurse Manager), who shall hold an
advanced degree in psychiatric nursing, or an advanced degree in nursing and at least five
years of experience in psychiatric nursing leadership, and shall be licensed to practice
professional nursing. I f the nurse leader doe s not meet the deg ree or experienc e
requirements, the facility shall provide for a person with such a degree, experience and
license to provide supervision to t he nurse leader and to coordinate and over see the
training for its nursing personnel.
4. A registered nurse licensed to practice professional nursing under Massachusetts law
shall be on duty on each unit of the facility at all times.
(c) A fa cility licensed a s Class VI , L imited VI or VI I shall have on its staff or , as
consultants, a pediatrician and a pediatric neurologist, both of whom shall be fully licensed
to practice medicine under Massachusetts law.
(12) Additional Requirements for Class VIII Facilities. In addition to complying wit h all
applicable standards in 104 CMR 27.00, a facility licensed as Class VIII shall comply with the
following requirements:
(a) The facility shall have policies and procedures for the administration of electroconvulsive
treatment (ECT) in compliance with the standards set forth by the Joint Commission, or other
nationally recognized accreditation agency approved by the Depa rtment, and the c urrent
practice guidelines established by the American Psychiatric Association.
(b) All facilities administering ECT to inpatients or outpatients shall maintain such data as
the Department may determine, which shall be available to the Department for inspection
upon request and at the time of the facility’s licensing survey.
(13) Additional Requirements for Facilities or Programs That Provide Certain Substance Use
Disorder Treatment Services.
(a) Definitions applicable to 104 CMR 27.03(13):
Adverse Drug Event. An undesirable effect reasonably associated with use of a drug that
may occur as part of the pharmacological action of the drug or may be unpredictable in its
occurrence. Adverse Drug Event does not include all adverse events observed during use of
a drug; only those adverse events for which there is some basis to believe there is a causal
relationship between the drug and the occurrence of the adverse drug event.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.03: continued
BSAS. T he B ureau o f S ubstance Ad diction Se rvices w ithin t he Depart ment o f P ublic
Health.
(b) In addition to complying with all applicable standards in this title, a facility that provides
substance use disorder treatment services, as provided in 104 CMR 27.03(13), shall comply
with the following requirements, if applicable.
1. A f acility that is within a general hospital licensed by the Department of Public
Health under M.G.L. c. 111, § 51 that offers a separate, identifiable inpatient substance
use disorder treatment unit or program, or that holds itself out as providing substance use
disorder tre atment or ser vices as a primary or spec ialty service , shall meet the
requirements of 105 CMR 164.012(D)(2).
2. A facility that is not within a general hospital licensed by the Department of Public
Health under M.G.L. c. 111, § 51 that offers a separate, identifiable inpatient substance
use disorder treatment unit or program, or that holds itself out as providing substance use
disorder treatment or services as a primary or specialty service shall apply for and obtain
a BSAS license from a Department of Mental Health licensed facility as provided in
105 CMR 164.012(D)(3).
3. A facility that provides substance use disorder treatment or services incidental to the
evaluation, diagnostic and treatment services for which it is licensed under 104 CMR
27.00, and that does not offer a separate, identifiable inpatient substance use disorder
treatment unit or prog ram, or holds itself out as pr oviding su bstance use disorder
treatment or services as a primary or specialty service, shall:
a. A dopt a nd fo llow B SAS a pproved p rotocols fo r t he pr ovision of me dically
monitored detoxification or opioid treatment.
b. Include in its application for a license or renewal of a license a description of the
inpatient substance use disorder treatment or services it provides, including a copy
of the protocols it has adopted pursuant to 104 CMR 27.03(13)(b)3.a., a statement
of the a pproximate per centage of its pat ients who rec eive suc h service s, and a
statement attesting that it does not hold itself out as providing substance use disorder
treatment or services as a primary or specialty service.
c. Include in its application for a license a description of its group and individual
substance use disorder programming for patients who are dually diagnosed with a
mental illness and a substance use disorder, including its plan for assisting patients
in obtaining care coordination upon discharge from inpatient acute level care.
(c) In addition to the reporting requirements provided in 104 CMR 32.00: Investigation and
Reporting Responsibiliti es, a fa cility that provides substance use disorder trea tment or
services as provided in 104 CMR 27.03(13) shall report any adverse drug events that occur
in connection with such treatment or services to the DMH Director of Licensing no later than
the next business day following the occurrence of such adverse event.
(14) Accreditation.
(a) A facility seeking a license as Class II, III, V, VI, Limited VI, VIII, or any combination
thereof, or a renewal of such license, shall be accredited by the Joint Commission or other
nationally recognized accreditation agency approved by the Department utilizing the
applicable standards as promulgated by said Joint Commission or agency. Facilities that
have not yet attained accreditation must be in substantial compliance with those standards,
and must submit a plan for obtaining accreditation within a reasonable period of time.
(b) A facility seeking a license as Class VII, or a renewal of such license, shall be accredited
as a residential treatment program by the Joint Commission or other nationally recognized
accreditation agency approved by the Depa rtment. Fa cilities that have not y et attained
accreditation must be in substantial compliance with the standards for residential treatment
programs set forth by said Joint Commission or agency, and must submit a plan for obtaining
accreditation within a reasonable period of time.
(15) Deemed Status. In addition to the Departmental action on license applications as set forth
in 104 CMR 27.03(15)(a) through (i), and any additional requirements for Class VII facilities set
forth in 10 4 CM R 27 .04, the Department m ay a pprove lic ensure of a ccredited f acilities in
accordance with the following requirements for deemed status:
(a) In its application for licensure or for renewal of a license, an accredited facility which
desires to obtain or retain dee med status shall provide a c opy of the fa cility’s cur rent
accreditation letter a nd th e accrediting agency’s explanation of its survey findings. The
facility shall also:
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.03: continued
1. Provide the De partment with notice of any survey or inspection conducted by the
accrediting agency, including notice of the time and place of summation conferences
scheduled at the completion of any such survey or inspection; provided however, that in
the event of an unannounced survey or inspection, such notice shall be provided as soon
as possible after the initiation of such survey or inspection;
2. Permit Department observers at the summation conferences scheduled at the
completion of any survey or inspection conducted by the accrediting agency;
3. Provide copies of any accreditation letters, the accrediting agency’s explanation of
its survey findings received while its license is in eff ect; and a ny other a ccreditation
information requested.
(b) A facility requesting deemed status shall submit for Department review and approval
written plans, pol icies a nd proce dures that de monstrate complianc e with Depa rtment
regulations governing restraint and seclusion, human rights, investigation of complaints,
interpreter services, and delivery and supervision of clinical services.
(c) The Department may at any time require a facility which has been granted deemed status
to demonstrate its compliance with applicable la w, accreditation standards , Department
regulations, or implementation of any recommendations for corrections or deficiencies, by
submitting such documentation or reports or permitting such inspection as may be requested
by the Department. The Department may require a validation survey of an accredited facility
to verify such compliance.
(d) A f acility which has be en g ranted deeme d status shall imm ediately notify the
Department of any change in its accreditation status.
(e) The Department may revoke the deemed status of an accredited facility if:
1. The facility loses its accreditation;
2. The facility fails to cooperate with the Department’s validation survey or requests for
documentation or reports;
3. The facility fails to cooperate with a Department investigation in accordance with
104 CMR 32.00: Investigation and Reporting Responsibilities;
4. The fa cility is out of compliance w ith applicable a ccreditation standards a nd a
significant deficiency is determined to exist;
5. The fa cility is out of conformity with its pl ans for compliance with Depart ment
regulations on restraint and seclusion, human rights, including reasonable access to fresh
air, investigation of complaints and interpreter services; or
6. The facility is out of compliance with other applicable Department regulations.
(f) A facility whose deemed status has been revoked may be subject to a licensing review
or full survey pursuant to 104 CMR 27.00.
(g) A facility may request an informal administrative review of a decision to deny or revoke
deemed status. The facility must request an informal administrative review in writing within
15 days of the date it receives notice of the denial or revocation of its deemed status by the
Department. The r equest shall state the reasons why the fa cility considers t he denial or
revocation of deemed status incorrect. The w ritten request shall be acc ompanied by any
supporting evidence or arguments.
(h) The Department shall notify the fa cility, in writing, of the r esults of the infor mal
administrative review within 20 days of receipt of the request for review. Failure of the
Department to respond within that time shall be consider ed confirmation of the denia l or
revocation of deemed status.
(i) Following denial or revocation under 104 CMR 27.03(15)(e), the Department may, upon
application of the facility, reinstate deemed status to an accredited facility if the Department
finds the facility meets the requirements of 104 CMR 27.03(15).
(16) If a facility is not yet accredited or if an accredited facility chooses not to apply for deemed
status, it shall be subject to a full survey for licensure by the Department.
(17) Renewal of License.
(a) Facilities seeking renewal of a license shall meet all requirements for licensure specified
in 104 CMR 27.00 and 104 CMR 32.00: Investigation and Reporting Responsibilities.
(b) Facilities seeking renewal of a license must submit to the Department completed forms
and fees required by the Department at least 60 days prior to the expiration of the cur rent
license or approval.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.03: continued
(c) If the complete renewal application is timely filed with the Department, the facility’s
then current license or approval shall not expire until the Department makes a determination
on the renewal application.
(18) Provisional Licenses.
(a) The Depar tment may issue a provisional license or appr oval in response to a new
application for a facility not currently in operation for which compliance cannot be fully
determined without an evaluation of the facility operation.
(b) When the Depar tment finds that a fa cility that is apply ing for re-licensure has not
complied with all applicable regulations, but is in substantial compliance and has submitted
an acceptable plan of correction for bringing the facility into full compliance, the Department
may issue a provisional license, provided that:
1. The facility demonstrates to the Department’s satisfaction a good faith intent to meet
all the requirements;
2. The Department finds that the service offered protects the health and safety of the
facility’s patients; and
3. The De partment finds that the facility evidences the potential for full compliance
within a reasonable period of time, not to exceed six months.
(c) A provisional license or approval is valid for a period not to exceed six months, but may
be extended for additional periods not to exceed six months at the Department’s discretion,
subject to such terms or restrictions as the Department may determine. The Department may
issue a provisional license or approval only when a facility submits a written plan for full
compliance with the requirements of 104 CMR 27.00. This written plan shall include
specific target dates for achieving full compliance.
(19) Departmental Action on License Application.
(a) Upon receipt and review of all required documentation, and after any site visit or survey
deemed necessary by the Department, the Department may take one of the following actions:
1. Approve the facility for licensure, if:
a. no deficiencies are outstanding;
b. the applica tion meets criteria of re sponsibility and suitability for mee ting the
needs of the Commonwealth as determined by the Department; and
c. the a pplication assure s that no patient who meet s the clinical cr iteria for
involuntary commitment pursuant to M.G.L . c. 123, § 12(b) , or who ha s been
committed pursuant to M.G.L . c. 12 3, § 12(e) will be reje cted f or admission;
provided however, that a facility may deny admission to such a patient only if it
complies with the provisions of 104 CMR 27.05(3).
2. Approve the facility for licensure, subject to demonstrated progress by the facility in
implementing a plan of c orrection approve d by the Depart ment addre ssing a ny
deficiencies or failure to meet requirements under of 104 CMR 27.03(19)(a)1.
3. Approve the facility for a provisional license subject to such conditions as noted in
27.03(18), or as the Department deems necessary.
4. Disapprove the facility for licensure until such time as identified de ficiencies are
corrected.
(b) For applications for license renewal, the Department’s determination that the facility is
meeting the needs the Commonwealth shall include:
1. a re view o f admi ssion data su bmitted b y the fa cility pu rsuant t o 1 04 CMR
27.05(3)(e); and
2. an assessment of whether the facility is in compliance with clinical competencies and
operational standards as established by the Department and adherence to all licensure
requirements set forth in 104 CMR 27.00.
(20) Departmental Surveys and Inspection; Deficiency Notices, Plans of Corrections.
(a) T he Department shall conduct a survey at least every two years of each facility to
determine the facility’s compliance with applicable provisions of M.G.L. c. 19, § 19 and the
Department’s regulations. The survey of a f acility granted deemed status shall be for the
purpose of determining the f acility’s compliance with Depar tment regulations governing
restraint and seclusion, human rights, investigation of complaints, and interpreter services,
and its plan for delivery and supervision of clinical services.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.03: continued
(b) Notwithstanding the provisions of 104 CMR 27.03(20)(a), the Department may, at any
time, conduct announced or unannounced inspections of any facility licensed hereunder to
determine compliance with acc reditation standards or the applica ble provisions of the
Department’s regulations. Such inspect ions need not per tain to any actual or suspecte d
deficiency in compliance with acc reditation standar ds or applica ble provisions of the
Department’s reg ulations. Refusal to permit inspections shall be suff icient ca use for
revocation of a facility’s license.
(c) The scope of the Department’s inspections shall include any aspect of the operation of
the facility and may include, but is not limited to, confidential interviews with patients and
staff, and examination and review of all records, including those of current and discharged
patients.
(d) The Depa rtment shall provide a c opy of the surve y or inspection re port and a ny
deficiency notice to the facility director.
The notice shall include a statement of the deficiencies found, and the provision(s) of law
and regulation relied upon, and shall specify a reasonable time, not more than 60 days
after re ceipt of the notice, by which time the fa cility shall remedy or cor rect eac h
deficiency cited in the notice; provided, however, that in the case of a deficiency which,
in the opinion of the Department, is not capable of correction within 60 days, t he
Department's statement of deficiencies shall require the facility's corrective action plan
to propose correction of such deficiency within a reasonable time period. A deficiency
notice issued pursuant to 104 CMR 27.03(20)(d) shall also include notice of actions the
Department may take in the event facility fails to remedy or correct a cited deficiency by
the date specified in the written deficiency notice or fails to remedy or correct a cited
deficiency by the date specified in a plan for correction, as accepted or modified by the
Department, pursuant to 104 CMR 27.03(20)(e). 
 (e) Plan of Correc tion. The fac ility shall submit to the Department a written plan for
correction of each violation cited in a deficiency notice within a time period specified by the
Department in the deficiency notice.
1. The plan of correction shall set forth, with respect to each deficiency, the specific
corrective step(s) to b e taken, a timetable for each step, and the date by which full
compliance will be achieved. The timetable and the compliance dates shall be consistent
with achievement of compliance in the most expeditious manner possible. The plan of
correction shall be signed by the facility director or his or her designee.
2. Unless the De partment states in the de ficiency notice that more urgent corrective
action is necessary, based on the seriousness of the deficiency, the facility shall be given
no more than 60 days from receipt of the deficiency notice to remove the deficiency. The
Department may specify a different date by which the corrections shall be completed, in
the event that the facility requests additional time and the Department determines that it
is necessary.
3. The Department shall review the plan of correction and will provide written notice
of either the acceptance or rejection of the plan. In such written notice, the Department
may modify, or order the modification of, a nonconforming written plan for correction.
A nonconforming plan must be amended and resubmitted within ten business days of the
date of notice of rejection; provided however, that 
4. Not more than seven days after the re ceipt of notice of such a modification of a
written plan for correction, the facility may file a written request with the Department for
administrative reconsideration of the modified plan for correction or any portion thereof.
5. Nothing in 104 CMR 27.03(20) shall be construed to prohibit the Department from
enforcing a rule, regulation, deficiency notice or plan for correction, administratively or
in court, without first affording the facility with formal opportunity to make correction
or to seek administrative reconsideration where, in the opinion of the Department, the
violation of such rule, regulation, deficiency notice or plan for correction jeopardizes the
health or safety of patients or the public or seriously limits the capacity of a facility to
provide adequate care, or where the violation of such rule, regulation, deficiency notice
or plan for correction is the second or subsequent such violation occurring during a
period of 12 months. 
(21) Failure to Comply with Requirements for Licensure. 
(a) Failure to comply with the requirements for licensure as set forth in 104 CMR 27.00
may constitute sufficient cause for the Department to deny, suspend, revoke, or restrict the
applicability of, or refuse to renew, one or more classes of licenses.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.03: continued
(b) I f a facility fails to reme dy or correct a cited de ficiency by the date specified in the
written deficiency notice or fails to remedy or correct a cited deficiency by the date specified
in a plan for correction, as accepted or modified by the Department, the Department may: 
1. suspend, limit, restrict or revoke the license of the facility; 
2. impose a fine upon the facility; 
3. pursue any other sanction as the Department may impose administratively upon the
facility; or 
4. impose any comb ination of the pe nalties set forth in 104 CMR 27.03(21)(b) 1.
through 3. 
(c) A fine imposed pursuant to 104 CMR 27.03(21) shall not exceed $1,000 per deficiency
for each day the deficiency continues to exist beyond the date prescribed for correction.
(d) A f acility has the right to appeal any Department action to suspend, limit, restrict or
revoke the license of the facility or to impose a fine upon the facility, pursuant to 104 CMR
27.03(21) under 801 CMR 1.01: Formal Rules by filing with the Director of Licensing a
Notice of Claim for an Adjudicatory Proceeding within 14 days of receipt of notice of such
action.
(22) Grounds for Denial, Refusal to Renew, Restriction, Suspension or Revocation of License.
Each of the following, in and of itself, shall constitute full and adequate grounds to deny, revoke,
suspend, restrict, or refuse renewal of a license:
(a) Failure to meet the applicable requirements for licensure as specified in 104 CMR 27.00;
(b) F ailure to m eet the requirements of applicable federal or state law or regulations,
including failure to comply with the laws of the Commonwealth related to taxes and child
support, workers compensation, or failure to maintain professional and commercial insurance
coverage.
(c) V iolation of any applicable requirement of 104 CMR 2 7.00 and 104 CMR 32.00: 
Investigation and Reporting Responsibilities.
(d) Failure to give proper care and treatment to patients.
(e) Failure to submit an acceptable plan of correction pursuant to 104 CMR 27.03(20).
(f) Failure to remedy or correct a cited violation.
(g) Denial of entry to agents of the Department or attempt to impede the work of a duly
authorized representative of the Department.
(h) Knowingly making an omission of material information or providing false or misleading
statements orally or in writing to the Department.
(i) Operating without a required license or approval or after the expiration of a license or
approval if the facility has not timely submitted an application for renewal.
(j) Determination by the Department that there is a discrepancy between the representations
by a facility as to the treatment services to be afforded patients and the treatment services
actually rendered or to be rendered.
(k) Conviction of a person with significant financial or management interest in the facility
of Medicare or Medicaid fraud or other c riminal offense related to the oper ation of the
facility.
(l) Conviction of a facility or a person with significant financial or management interest in
the facility of a violent crime against a person, which indicates that operation of the facility
may endanger the public health or safety.
(m) Other Grounds. Nothing in 104 CMR 27.03(22) shall limit the Department’s adoption
of policies and g rounds for de nial, ref usal to rene w, or re vocation through formal and
informal rule making.
(23) Required Notifications to the Department. In addition to, and notwithstanding, any other
provision of 104 CMR 27.00 or 104 CMR 32.00: Investigation and Reporting Responsibilities,
facilities shall comply with the following notification requirements:
(a) C hange of Name, Ownership, or Location. At least 90 days prior to a change in
location, name, ownership or control of the facility, the facility shall notify the Department
in writing of the proposed change as provided in 104 CMR 27.03(9). Upon receipt of such
notice, the Department shall determine whether additional action is required.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.03: continued
(b) Change in Accreditation or Certification; Notices of Termination, Immediate Jeopardy,
and Corrective Action Orders. A fac ility shall immediately notify the Department of any
change, o r n otice of c hange, in its a ccreditation or Center f or Me dicare a nd Me dicaid
Services (CMS) certification status including, but not lim ited to, Notices of Te rmination,
Notices of Immediate Jeopardy, or issuance of corrective action orders by the accrediting
entity or CMS. A facility’s response to any such notice, order or other change, or notice of
change, in ac creditation or cer tification status shall be deliver ed to the De partment
simultaneously with delivery to the accreditation entity or CMS.
(c) Legal Proceedings. The facility shall report in writing to the Department any civil action
or criminal charge that is brought against the facility or any person employed by the facility
that relates to the delivery of the service or may affect the continued operation of the facility.
The report shall be given to the Department as soon as the facility is aware of the action and
no later than 24 hours of the facility becoming aware of any legal action or within 24 hours
of service of notice upon the facility or its agent, whichever occurs first.
(d) Closure. When a facility plans to cease operation, the facility shall:
1. Notify the Department in writing at least 90 days prior to cessation of operations and
closure. Such notification shall specify the date of closure and shall include the facility’s
plan for closure. This notification requirement shall include closures due to foreclosure
or bankruptcy proceedings.
2. In the case of involuntary closure not due to an action of the Department, notify the
Department as soon as the facility is aware of the pending closure and prior to cessation
of operations and closure.
(e) Interruption or Suspension of Service. If a facility determines that the health, safety or
well-being of patients is in im minent danger as a result of c onditions existing within the
service, program or facility, the facility shall verbally notify the Department immediately, and
in writing w ithin one business day , upon becoming aware of the danger to pa tients. The
Department shall consult with the facility regarding the need to interrupt or suspend services.
(f) C hange of Program or Service Provision. A facility shall notify the Department in
writing at least 30 da ys before any substantial change in program or service provision as
provided i n 1 04 C MR 2 7.03(9). The D epartment s hall d etermine w hether s uch ch ange
requires re-licensure.
(g) Change of Senior Leadership. A facility shall notify the Department at least two weeks
before a planned change of senior leadership of the facility. In the event of an unplanned
departure of a senior leader, the facility shall notify the Department in writing within two
business days of the unplanned departure.
(h) Death, Serious Incident, Accident or Fire, Safety and Health Conditions. The facility
shall verbally notify the Department immediately, and in writing within one business day,
of the following:
1. upon learning of the death of any patient currently admitted to, or within 30 days of
discharge from, the facility, regardless of where the death occurs; 
2. any serious incident including, but not limited to, a complaint reportable pursuant to
104 CMR 32.04(2)(a), which occurs under facility auspices, or concerning any patient
currently admitted to, or within 30 days of dischar ge from, the fac ility, regardless of
location;
3. any fire or other event resulting in damage to the facility; 
4. any alleged abuse or neglect, or sexual or serious physical assault, which occurs
between or among patients at the facility, or which occurs between or among patients and
staff regardless of location, including any incident which is reported to another agency
or law enforcement including, but not limited to:
a. any reports of child abuse or neglect made under M.G.L. c. 119, § 51A;
b. any reports of elder abuse or neglect made under M.G.L. c. 19A, § 15; and
c. any reports of abuse of a disabled person made under M.G.L. c. 19C;
5. any condition at the facility which poses a threat to the health or safety of patients or
staff; for example, conditions which limit access, unsanitary conditions, fire hazards, loss
of essential services such as he at, hot water and electricity, regardless of whether the
conditions cause a n interruption of ser vice. The fac ility shall co nsult with the
Department to determine whether the condition requires an interruption or suspension
of service;
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.03: continued
6. confirme d cases among staff or patients of communica ble disease s which ar e
reportable under 105 CMR 300.000: Reportable Diseases; and
7. any complaint communicated to the facility by the Occupational Safety and Health
Administration (OSHA) or the Commonwealth Division of Labor Standards (DLS), as
well as any findings, citations, agreements or other notifications from OSHA or DLS in
connection with such complaints.
(24) Waiver.
(a) The requirements of 104 CMR 27.00 shall be strictly enforced, and shall not be subject
to waiver , except as specifically authorized by the Depa rtment in acc ordance with the
provisions of 104 CMR 27.03(24).
(b) No waiver may be granted by the Department without written documentation supporting
the request for a waiver and a determination by the Department that:
1. The health, safety, or welfare of neither patients nor staff may be adversely affected
by granting the waiver; and
2. In justification of the waiver, a substitute provision or alternative standard has been
stated and is found by the Department to result in comparable services to the patients, and
to which the f acility will be held accountable to the same degree and manner as any
provision of 104 CMR 27.00.
(c) Waivers may be granted for the duration of a facility’s license, or for such other period
of time as the Department may determine, and may be renewable.
(d) The granting of a waiver for any single facility or period of time shall not require or
signify the granting of a waiver for any other facility or period of time.
27.04: Licensing: Intensive Residential Treatment Programs (IRTP)
(1) Adolescent Intensive Residential Treatment Program. An adolescent Intensive Residential
Treatment Program (IRTP) is a residential mental health program which provides comprehensive
treatment and education in a secure setting to adolescents with serious emotional disturbance or
mental illness and which has the capacity to admit such adolescents pursuant to the provisions
of M.G.L. c. 123, §§ 7, 8, 10 and 11. IRTPs may not receive a Class VIII license to administer
electroconvulsive treatment.
(2) Eligibility. Only individuals who meet the following criteria may be eligible for admission
to an IRTP:
(a) The individual shall be 13 through 18 years of age. An individual already admitted to
an IRTP who turns 19 y ears old may , upon approva l of the Com missioner or designee,
remain there to complete his or her course of treatment;
(b) The individual has been determined to require continuing care and treatment in a secure
residential setting;
(c) Failure to place the individual in a secure treatment setting would create a likelihood
of serious harm by reason of mental illness; and
(d) There is no appropriate, less restrictive setting available.
(3) Admission. I ndividuals who meet the I RTP eligibility criteria may be admitted to and
retained in an IRTP only in accordance with the provisions of M.G.L. c. 123, §§ 7 and 8 or 10
and 11, and the applicable provisions of 104 CMR 27.00. For I RTPs operated by or under
contract with the Depa rtment, individuals may only be admitted upon appr oval of the
Department. Refe rrals for admission to an I RTP operated by or under cont ract with the
Department shall be made through an admissions process, as designated by the Department, and
shall contain such clinical information and documentation as the Department may require.
(4) Location. If an IRTP is located on the grounds of a state hospital or in the same building
as an inpatient mental health unit, it shall have program, kitchen and eating facilities separate
from those of the state hospital or inpatient unit.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.04: continued
(5) Staffing. Each IRTP shall be staffed at a level sufficient to meet the clinical needs of the
patients, as well as the administrative and ancillary services necessary to the operation of the
IRTP, consistent with the require ments of J oint Com mission or other acc reditation agency
approved by the Department. Among the clinical staff shall be persons in appropriate disciplines
qualified t o provide servic es which sha ll include, but are not limi ted to: psy chiatric and
psychological intervention; individual, group and family therapy; nursing care; milieu support;
medication administration; discharge planning; education; rehabilitation services; recreation; and
peer and family support.
(a) E ach IRTP sha ll have sufficient full-time senior management to provide adequate
oversight o f p rogram, c linical a nd ps ychiatric op erations. Se nior m anagers wi th
responsibility for c linical matters shall b e mental hea lth professionals, license d as
independent practitioners in their field of training and expertise. At lea st one member of
senior management shall be a licensed mental health professional who is, by training or
experience, a specialist in the treatment of adolescents.
(b) Ea ch IRTP shall have a psy chiatrist, who is board c ertified or eligible in child and
adolescent psychiatry, available for consultation and shall have a psychiatrist on-site or on-
call, 24 hours per day, for psychiatric emergencies.
(c) Eac h I RTP shall have sufficie nt qualified re gistered nurses on e ach shift f or the
administration of reg ularly prescribed medications, as well as f or administrati on of pro
renata (PRN) and emergency medication and conducting examinations pursuant to 104 CMR
27.12.
(d) E ach IRTP shall have a sufficient number of independently licensed mental health
professionals such that the primary individual and family therapist for each adolescent shall
be so licensed.
(e) P rovision shall be made to ensure that sufficient back-up personnel are available to
respond within a reasonable time in emergency situations.
(6) General Physical Requirements.
(a) Each IRTP shall provide outdoor recreational and indoor space that is safe, comfortable,
well-lit, well-ventilated, adequate in size and of sufficient quality to be utilized in a manner
consistent with the overall philosophy and treatment goals of the IRTP.
(b) Ea ch IRTP shall provide sufficient sec urity features to ena ble the staff to preve nt
physical harm to patients and to staff, including the capacity to lock the IRTP.
SUBPART C: OPERATIONAL STANDARDS FOR MENTAL HEALTH FACILITIES
27.05: General Admission Procedures
(1) For the purpose of involuntary commitment, mental illness is defined as a substantial
disorder of thought, mood, perception, orientation, or memory which grossly impairs judgment,
behavior, capacity to recognize reality or ability to meet the ordinary demands of life, but shall
not include intellectual or developmental disabilities, autism spectrum disorder, traumatic brain
injury or psychiatric or behavioral disorders or symptoms due to another medical condition as
provided in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5 editionth
published by the American Psychiatric Association, or except as provided in 104 CMR 27.18,
alcohol and substance use disorders; provided however, that the pre sence of such c onditions
co-occurring with a mental illness shall not disqualify a person who otherwise meets the criteria
for admission to a mental health facility.
(2) For the purposes of voluntary or conditional voluntary admission to mental health facilities
in the Commonwealth, any degree of seve rity of a m ental disorder, including c o-occurring
substance use disorders, may qualify a person for admission to a mental hea lth facility at the
discretion of the facility director or designee when it is determined that the person is in need of
care and treatment, and that the admitting facility is suitable for such care and treatment.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.05: continued
(3) No facility licensed as Class III through VII shall have exclusion criteria for admission that
would result in the rejection of any patient who has been determined by a designated physician
or des ignated Psychiatric APRN of the fa cility to meet the clinica l criteria for involuntary
commitment p ursuant t o M .G.L. c . 1 23, § 12(b), or wh o h as b een c ommitted p ursuant t o
M.G.L. c. 123, § 12(e); provided however, that a facility that has been certified to treat specialty
populations, such as for treating geriatric patients or patients with co-occurring intellectual or
developmental disabilities, may preferentially admit such patients. Fa cilities may not deny
admission to a patient for whom it has the clinical competency and staffing to appropriately treat,
except as provided in 104 CMR 27.05(3) (b) through (d).
(a) A facility licensed as Class III through VII shall have the capacity to care for patients
otherwise meeting admission criteria who have co-occurring medical needs in accordance
with clinical competencies and operational standards determined by the Department.
(b) A facility may deny admission to a patient if such admission would result in a census
exceeding the facility’s operational capacity; provided however, that the facility is able to
demonstrate that, despite its best efforts, it is unable to accommodate the additional capacity.
(c) A facility may deny admission to a patient if such admission would result in a census
exceeding the facility’s licensed capacity.
(d) A facility may deny admission to a patient whose needs have been determined by the
facility medical director to exceed the facility's capability at the time admission is sought.
The determination shall include the factors justifying denial of admission and why mitigating
efforts, su ch a s u tilization o f a dditional st aff, w ould h ave be en in adequate. T his
determination must be recorded in writing and shall be subject to review by the Department;
provided however, that such written determination need not contain patie nt-identifiable
information.
(e) Facilities shall keep data on patients referred for admission in a form and format and
containing data elements as determined by the Department; provided however, that facilities
shall not be requir ed to maintain patient-ide ntifiable data on individuals not accepted for
admission. Such data shall be available for inspection by the Department upon request.
(4) A dmission Ex amination. Upon admission, eac h patient shall rec eive a mental status
examination and, within 24 hours of admission, a complete psychiatric and physical examination.
In the ca se of a dmissions to an I RTP, such phy sical examination shall occur w ithin seven
calendar days of admission. As part of the admission examination, staff shall seek to determine
from the pa tient, the pa tient’s r ecord, the pa tient’s le gally a uthorized r epresentative or , if
appropriate, from other sources, whether the patient has a history of trauma including, but not
limited to, physical or sexual abuse or witnessing violence. At the completion of each admission
examination, the admitti ng clinician shall make an admission diag nosis, and shall enter the
findings of such admission examination in the patient’s medical record.
(5) Admission Examination for Patients Younger than 22 Years Old.
(a) In addition to the requirements of 104 CMR 27.05(4), the admission examination for
patients younger than 22 years old shall include a determination as to whether the patient has
special educational needs.
(b) I f the pa tient has specia l educational needs, the facility director shall seek w ritten
authorization to provide n ecessary clinical informa tion to the patient’s L ocal Education
Authority (LEA) in orde r that an e ducational program can be jointly developed for suc h
patient by the LEA and the facility.
(6) Notice to Family or Others.
(a) Admission of Patients 16 Years of Age or Older. In accordance with M.G.L. c. 123, § 4,
the fa cility dir ector o r designee sh all, wi thin 4 8 h ours a fter a dmission of a ny pa tient,
including a patient 16 or 17 years of age who has applied for admission himself or herself,
notify the patient’s legally authorized representative or, if there is no such legally authorized
representative and the patient does not knowingly object, his or her nearest relative. Notice
may be given by telephone, letter or other appropriate means.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.05: continued
(b) Emergency or Court Ordered Admissions of Minors. Except in the case of a mature or
emancipated minor as defined in 104 CMR 25.03: Emancipated and Mature Minors, the
legally authorized representative of a minor shall be notified immediately upon receipt of the
minor who is admitted pursuant to court order or an application for admission pursuant to
M.G.L. c. 123, § 12.
(7) D enial of Admission. Ap plicants for voluntary or conditional voluntary admission to
mental health facilities shall not be denied admission without an explanation of the basis for such
refusal, and a lternatives s hall be offered or recommended by the admitting c linician where
feasible.
(8) Prohibition of Admission of I ndividuals Younger than 19 Years Old to Adult I npatient
Units; Exceptions. Except as provided in 104 CMR 27.05(8), no individual y ounger than 19
years old shall be admitted to an adult unit of a Department operated facility.
(a) The Department may place an individual 17 or 18 years of age on such an adult inpatient
unit where a judg e of a court o f competent jurisdiction has issued an orde r for the
commitment of the individual to a mental hea lth facility pursuant to the provisions of
M.G.L. c. 123, §§ 15, 16, 17 or 18, or whe re the individual has been c ommitted to the
Department of Youth Services, and the Commissioner or designee has determined that one
or both of the following factors exist:
1. placement of the individual on an adolescent inpatient unit would create a likelihood
of serious harm to the individual or others; or
2. the individual is in need of stricter secur ity than is available on an adole scent
inpatient unit.
(b) The factors to be considered in the above determinations include, but are not limited to,
the following:
1. the nature, circumstances and seriousness of the offense with which the individual
has been charged;
2. the individual’s court and delinquency record;
3. the individual’s maturity;
4. the individual’s history of mental illness;
5. the individual’s social history;
6. the risk of harm presented by the individual’s placement on an adolescent inpatient
unit;
7. the individual’s history of victimizing others; and
8. the mental health treatment most suitable for the individual.
(c) Specialty services or units designated by the Department may admit individuals younger
than 19 y ears old, provided th at they ensure appropr iate sepa rate phy sical spac e and
programmatic services, as approved by the Commissioner.
(9) Unless otherwise specified, computation of time for any action required to be taken under
104 CMR 27.00 shall be in accordance with 104 CMR 25.04: Computation of Time.
27.06: Voluntary and Conditional Voluntary Admission
(1) Eligibility for Voluntary or Conditional Voluntary Admission.
(a) A person may be admitted on a voluntary status pursuant to M.G.L. c. 123, § 10 or a
conditional voluntary status pursuant to M.G.L . c. 123, §§ 10 and 11 to a facility upon
written application, provided that in the opinion of the fa cility director, or designee, such
patient qualifies for admission in accordance with 104 CMR 27.05(2), and has the capacity
to apply for such admission and is desirous of receiving treatment.
(b) A pe rson’s a pplication for voluntar y or conditional voluntary status shall only be
accepted upon a determination by the admitting or treating clinician that the p atient has
reached 16 years of age, has capacity to apply for such status, and is in need of c are and
treatment, or if applica tion is m ade on be half of the patient by a leg ally authorized
representative that the legally authorized representative has authority to do so.
1. An application made on behalf of a minor by the minor’s parent or guardian may be
accepted upon a determination by the admitting or treating clinician that the person
making such application is in fact the minor’s legally authorized representative.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.06: continued
2. An applica tion made on behalf of a person by his or her health care agent may be
accepted upon a determination by the admitting or treating clinician that the health care
agent is acting pursuant to a va lid and invoked hea lth care proxy that has not been
revoked by the patient.
(c) For purposes of 104 CMR 27.06, capacity to apply means:
1. that a patient admitted on a voluntary status understands that he or she is in a facility
for treatment and that he or she may leave the facility at any time.
2. that a patient admitted on a conditional voluntary status understands that he or she
is in a facility for treatment, understands the three-day notice provisions, and understands
the facility director’s right to file a petition for commitment and thereby retain him or her
at the facility.
(2) Prior to admission, such person shall be afforded the opportunity for consultation with an
attorney, or with a person who is working under the supervision of an attorney, concerning the
legal effect of the admission.
(3) Upon admission, the patient and his or her legally authorized representative shall receive
information concerning the legal and human rights which he or she retains after admission to the
facility.
(4) A patient on voluntary status shall be discharged upon his or her request, or upon the request
of the patient’s legally authorized representative who applied for the admission of such patient,
in as provided in 104 CMR 27.09.
(5) A patient on conditional voluntary status, or a legally authorized representative who applied
for the admission of such patient, may be required to give three days prior written notice to the
facility director of his or her intention to leave such facility or to withdraw such patient from the
facility. Upon submission of a three-day notice, the facility director shall proceed as provided
in 104 CMR 27.09(4).
(a) A patient admitted on application of a health care agent pursuant to a health care proxy
that has not been affirmed in accordance with M.G.L. c. 201D may revoke such proxy orally
or in writing, which revocation shall constitute submission of a three-day notice; provided
however, that the patient may retract such three-day notice pursuant to 104 CMR 27.06(5)(b).
The submission of a three-day notice by such a patient shall be deemed a revocation of the
health care proxy for purposes of 104 CMR 27.06(5).
(b) A thr ee-day notice may only be re tracted by written not ice to the facility director;
provided however, that such retraction shall only be accepted upon a determination by the
facility director or designee that the patient has the capacity to apply for conditional voluntary
status pursuant to 104 CMR 27.06(1)(c).
(c) A three-day notice and any retraction thereof shall become part of the patient’s record.
(d) The form and c ontent of a thre e-day notice, or r etraction thereof, shall be dee med
sufficient so long as it conveys the patient’s intention, without requirement that it be on any
particular form of the facility.
(6) Prior to admitting a person on conditional voluntary status, the admitting personnel shall
inform such person of the three-day notice requirements established in M.G.L. c. 123, § 11, and
of the fa cility director’s right to file a petition for commitment upon notice that the patient
wishes to leave, pursuant to M.G.L. c. 123, § 11.
(7) A patient who is 16 or 17 years of age, or who during the course of hospitalization reaches
16 years of age, and who has been admitted to a facility on a voluntary or conditional voluntary
status by application of a legally authorized representative shall have the same rights as those
patients 16 y ears of age or older who have applied and be en admitted on their ow n behalf,
including the right to leave the facility upon submission of a three-day notice of intent to do so,
and th e right to remain at the facility, upon written application, despite notice by a legally
authorized representative of intention to withdraw such patient.
(8) Application for conditional voluntary admission shall be made only upon such form as the
Department may prescribe.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.07: Three-day Involuntary Commitment
(1) No person shall be admitted to a facility upon application for involuntary hospitalization
pursuant to M.G.L. c. 123, § 12, unless the person, or his or her legally authorized representative,
has been given the opportunity by the facility to apply for admission under M.G.L. c. 123, §§ 10
and 11. For a patient 16 or 17 years of age, this opportunity must be given to both the patient
and his or her legally authorized representative. The right to convert to voluntary or conditional
voluntary status may be exercised by a patient or his or her legally authorized representative at
any time within the three-day period. A mental health professional responsible for the patient
admitted pursuant to M.G.L. c. 123, § 12 shall ag ain inform the patient or legally authorized
representative, within three days of admission, of the right to change status, and shall record so,
informing the patient or the legally authorized representative in the patient’s record.
(2) Examination Prior to Admission. Persons for whom application has been made for three-
day in voluntary hospitaliz ation pursuant to M.G.L . c. 123, § 12, and w ho have not be en
examined by a designated clinician prior to reception at the admitting facility, shall receive such
examination immediately after reception at such facility. If the clinician determines that failure
to hospitalize such person would create a likelihood of serious harm by reason of mental illness,
he or she may admit such person to the facility for care and treatment.
(a) For the purposes of 104 CMR 27.07(2), “immediately” shall mean within two hours of
the patient’s reception at the facility.
(b) If the designated clinician at the facility is engaged in an emergency situation elsewhere,
he or she shall conduct such an examination as soon as such emergency no longer requires
his or her attention.
(c) The requirement for examination may be satisfied through utilization of telemedicine
or other technology pursuant to protocols approved by the Department that assure verbal and
visual observation and communication between the patient and an off-premises designated
clinician and adequate on-premises clinical staff; provided however, that a patient admitted
involuntarily pursuant to M.G.L. c. 123, § 12(b), or who is determined to have capacity to
be admitted under conditional voluntary status pursuant to M.G.L. c. 123, §§ 10 and 11, and
has been so admitted after an examination conducted via telemedicine, shall be examined by
a designated clinician as soon as possible and no later than the next calendar day following
the admission.
(3) Upon admission of a person to a facility pursuant to M.G.L. c. 123, § 12(b), the facility shall
inform the person and his or her legally authorized representative that it shall, upon request,
notify the Committee for Public Counsel Services of the person’s name and location, upon which
notice the Committee will appoint an attorney to meet with the person.
(4) Emergency Hearing. The facility shall inform a patient admitted pursuant to M.G.L. c. 123,
§ 12(b) and his or her legally authorized representative of the right to request an emergency court
hearing if his or her legally authorized representative has reason to believe that the admission is
the result of an abuse or misuse of the provisions of M.G.L. c. 123, § 12(b). The facility shall,
upon request, provide the patient and his or her legally authorized representative with the form
that may be used to request such a hearing and shall take steps to transmit any such completed
forms to the court in accordance with the requirements of the court with jurisdiction over the
facility.
27.08: Transfer and Transport of Patients
(1) 104 CMR 27.08 g overns the transfer of patients pursuant to M.G.L. c. 123, § 3 and the
transport of patients pursuant to M.G.L. c. 123, § 21.
(2) For the purposes of 104 CMR 27.08(3) through (8), “emergency” shall mean those medical,
surgical and psychiatric crises which, in the opinion of the facility director, threaten the safety,
health or life of the pa tient or others, a nd which could no t be appr opriately trea ted in the
transferring facility.
(3) Permitted Transfers; Exceptions. Any patient admitted to a facility may be transferred from
that facility to any other facility, provided that except in an emergency:
(a) Patients on voluntary status under 104 CMR 27.06 shall not be subject to transf er
without their written consent; and 
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.08: continued
(b) Patients on conditional voluntary status under 104 CMR 27.06 may refuse transfer.
Such refusal may be considered equivalent to submission of the patient’s three-day written
notice of his or her intention to leave or withdraw from the facility. Upon such refusal, the
facility director may file a petition for commitment under the provisions of M.G.L. c. 123,
§§ 7 and 8 if the patient meets the criteria for commitment, or may withdraw the notice of
transfer provided to the patient pursuant to 104 CMR 27.08(9).
(4) Absent an emergency, a patient 16 years of age or older on conditional voluntary status at
a facility may not be transferred from that facility over his or her objection, or in the case of a
minor, or a patient admitted by health care agent pursuant to a properly invoked and affirmed
health care proxy, over the objection of such minor or patient’s legally authorized representative,
unless a court of competent jurisdiction enters a commitment order pursuant to M.G.L. c. 123,
§§ 7 and 8.
(5) Abse nt an emer gency, a patien t younger than 16 years old who has bee n admitted to a
facility pursuant to his or her legally authorized representative’s authority, may not be transferred
from that facility over the objection of the legally authorized representative, unless a court of
competent jurisdiction enters a commitment order pursuant to M.G.L. c. 123, §§ 7 and 8.
(6) In no event shall an application for admission pursuant to M.G.L. c. 123, § 12(a) be issued
in order to transfer a patient in lieu of compliance with the requirements of M.G.L. c. 123, § 3,
and 104 CMR 27.08.
(7) Patients transferred pursuant to M.G.L. c. 123, § 3, and 104 CMR 27.08 shall be admitted
to the receiving facility under the same legal status pursuant to which the patient was
hospitalized a t th e tr ansferring fa cility. T ransfer o f a pa tient c ommitted p ursuant t o
M.G.L. c. 123 shall not extend the period of such commitment.
(8) A patient who is admitted or committed to a facility licensed pursuant to 104 CMR 27.00,
who is transferred to a medical facility for treatment of a medical condition during the period of
his or her a dmission or commitment, may be readmitted to the transfe rring facility under the
same legal status pursuant to which the patient was admitted or committed to the transferring
facility; provided however, that for a patient who is committed pursuant to a court order, such
court order has not expired at the time of readmission.
(9) Transfer Procedures.
(a) The approval of the director of the receiving facility shall be obtained by the transferring
facility.
(b) The director of the transferring facility shall give six days written notice to the patient
to be transferred and, if applicable, to his or her legally authorized representative; provided
however, that if such transfer must be made immediately because of an emergency, notice
shall be given within 24 hours after the transfer pursuant to M.G.L. c. 123, § 3. The notice,
which shall include the patient or leg ally autho rized repre sentative’s r ight to objec t as
provided in 104 CMR 27.0 8(4) and (5), shall be pr ovided in a for m prescribed by the
Department.
(c) The director shall inform the patient that notice of transfer shall also be given to his or
her nearest relative; unless the patient knowingly objects.
(d) A patient or a legally authorized representative with authority to admit the patient to a
psychiatric facility may waive the six days notice requirement.
(e) A copy of the notice of transfer, along with a copy of the patient’s underlying admission
status documentation, shall accompany the patient to the receiving facility.
(10) Transport of Patients Admitted to a Facility; Limitations of Use of Restraint.
(a) The tra nsport of a pa tient in a fac ility may be author ized by the fa cility director, or
designee, on a form approved by the Department, for the following purposes:
1. Transfer to another facility pursuant to M.G.L. c. 123, § 3;
2. Movement among separate campuses of a single facility;
3. Evaluation and/or treatment at a medical facility or office and return to the facility;
4. Attendance at court proceedings and return to the facility;
5. Transf er to or f rom another state pursuant to the I nterstate Compact on Mental
Health, M.G.L. c. 123, App. §§ 1-1 through 1-4; and
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.08: continued
6. Other destinations with the approval of the facility director or designee.
(b) Restraint of a patient in a facility by or under the supervision of the facility’s staff may
not be used in the course of transport, unless such restraint is necessary for the safety of the
patient being transported or of others who are likely to come into contact with the patient
being transported. Such restraint must be by the least restrictive method to assure the safety
of the patient or others in accordance with 104 CMR 27.08(10). Su ch restraint must be
authorized by a clinician authorized to order restraint pursuant to 104 CMR 27.12(8)(a)1.,
or in an emergency when an authorized clinician is not available, by a staff person authorized
to initiate restraint pursuant to 104 CMR 27.12(8)(a)2.
1. If the patient is being transported by the facility, or under the supervision of the
facility’s staff, then the clinician's authorization shall describe the circumstances under
which restraint may be used in the course of transport and method of restraint that may
be employed.
a. No locked mechanical restraint devices requiring the use of a key for their release
may be used in the course of transport.
b. Only restraint procedures or devices that have been approved by the facility for
such purposes may be used for restraint during transport, and monitoring staff must
have received appropriate training on such approved procedures and devices.
c. No patient shall be placed in restraints in the course of transport, unless a staff
member i s assigned to provide one-to-one monitoring as provided in 104 CMR
27.12(8)(h)1. through 6.
d. During the transport, the monitoring staff person must carry a copy of the form
which authorizes the restraint during transport.
e. The driver of the vehicle in which the patient is bein g transported may not be
assigned to provide such monitoring.
f. No staff member who has not been trained in accordance with 104 CMR 27.12(3)
may be authorized to apply restraints to a patient in th e course of transport, or to
monitor a patient who is in restraints in the course of transport.
g. Except as provided in 104 CMR 27.08(10)(c) and (d), restraint ordered pursuant
to 104 CMR 27.08(10) may only last while the patient is unde r the supervision of
facility staff, a nd s hall t erminate i f t he p atient i s a dmitted t o a m edical f acility,
including the emer gency department of suc h medical f acility for e valuation or
treatment.
(c) I f the patient is being transported by ambulance, then restraint may be used only in
accordance with M.G.L. c. 111C, § 18.
(d) Nothing in 104 CMR 27.08(10) sha ll be deeme d to reg ulate the use of re straint by
licensed la w enf orcement personne l in the transport of pa tients in the custody of such
personnel.
(e) The use of seatbelts or a “child safety door lock” shall not be considered restraint for
purposes of 104 CMR 27.08(10).
(f) Wh ere the need for restraint during transport for purposes described in 104 CMR
27.08(10)(a) is anticipated, consideration should be given to delaying such transport until
such patient no longer requires restraint, if such delay is reasonable.
(g) Unless the patient is fully discharged prior to transport, a patient transported pursuant
to 104 CMR 27.08(10) shall remain on the a dmission status under which the patient was
admitted to the facility, until such time as the patient is fully discharged from the facility;
provided however, that an order of transport pursuant to 104 CMR 27.08(10) shall not extend
any relevant time period including, but not limited to, expiration of a commitment order, for
such admission.
27.09: Discharge
(1) Discharge Procedures.
(a) A facility shall arrange for necessary post-discharge support and clinical services. Such
measures shall be documented in the medical record.
(b) A f acility shall make e very effort to avoid discharge to a shelter or the stree t. The
facility sh all t ake ste ps to i dentify a nd of fer a lternative op tions to a patient and sh all
document such measures, including the competent refusal of alternative options by a patient,
in the medical record. In the case of such discharge, the facility shall nonetheless arrange for
or, in the case of a competent refusal, identify post-discharge support and clinical services.
The facility shall keep a record of all discharges to a shelter or the street, in a form approved
by the Department, and submit such information to the Department on a quarterly basis.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.09: continued
(c) When a patient in a facility operated by or under contract to the Department is a client
of the Department pursuant to 104 CMR 29.00: Application for DMH Services, Referral,
Service Planning and Appeals, the service planning process outlined in 104 CMR 29.00 shall
be undertaken prior to discharge.
(d) A facility shall keep a record of all patients discharged therefrom, and shall provide such
information to the Department upon request.
(2) Voluntary Admission Status. A patient voluntarily admitted to a facility under 104 CMR
27.06 shall be discharged upon his or her request, or upon the request of the patient’s legally
authorized representative who applied for the admission of such patient, without a requirement
of a three-day notice.
(3) Discharge Initiated by Facility Director. The facility director may discharge any patient
admitted as a voluntar y or conditional voluntary patient at any time he or she de ems such
discharge in the best intere st of such patient; provided how ever, that if a leg ally authorized
representative made the application for admission, 14 days notice shall be given to such legally
authorized representative prior to such discha rge, in accordance with M.G.L. c. 123, § 10(a ).
With the consent of such legally authorized representative, the facility director may discharge
the patient at any time.
(4) Conditional Voluntary Admission Status. A patient admitted to a facility on conditional
voluntary status under 104 CMR 27.06 shall be discharged by the facility upon his or her request;
provided however, he or she shall give three days written notice of his or her intent to leave the
facility to the facility director, and may be retained at the facility for such three-day notice period,
during which time the facility director may require an examination of such patient to determine
his or her suitability for discha rge. Such patients ma y be retained at the f acility beyond the
expiration of the three-day notice period if, prior to the expiration of the said three-day notice
period, the f acility direc tor files with a c ourt of compe tent jurisdiction, a petition for the
commitment of such patient at the s facility.
(5) Discharge at Request of Legally Authorized Representative. A patient admitted by his or
her legally authorized representative may be discharged at the request of such legally authorized
representative consistent with procedures for discharge of a patient admitted upon his or her own
authority.
(6) Patients 16 or 17 Ye ars of Age. A patient who is 16 or 17 years of age, or who turns 16
years old during the course of hospitalization, and who has been admitted to a facility as a
voluntary or conditional voluntary patient by application of a legally authorized representative,
shall have the same rights pertaining to release, withdrawal and discharge as those patients 16
years of age or older who have applied for and been admitted on a voluntary or conditional
voluntary status to the facility on their own behalf.
(7) Involuntary Commitment Status.
(a) Three-day Commitment. A patient admitted to a facility under M.G.L. c. 123, § 12, may
be discharged by the facility director at any time during such period of hospitalization if the
facility dir ector determines that such patient is not in need of care and treatment in the
facility. The three-day hospitalization period authorized under M.G.L. c. 123, § 12 shall not
be extended and, at the end of such period, a patient so hospitalized shall be discharged by
the facility unless, prior to expiration, such patient has applied for, and has been admitted on
voluntary or conditional voluntary status to the fac ility, or the facility director has filed a
petition for an order of commitment.
(b) Prolonged Commitment. A patient committed to a facility by order of a c ourt of
competent jurisdiction shall be discharged by the facility upon the expiration of the order,
unless the commitment order is renewed under the procedures established in M.G.L. c. 123,
§§ 7 and 8.
(c) Ex cept a s provided in 104 CMR 27. 09(8), at any time during the per iod of
hospitalization, the facility director may discharge such patient if he or she determines that
such patient is no longer in need of care and treatment.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.09: continued
(8) Forensic Commitment Status.
(a) A patient committed to facility under M.G.L. c. 123, § 15 shall not be discharged, except
to the committing court, or upon other court order.
(b) A pa tient committed to a facility under M.G.L. c. 123, § 16 shall not be discha rged,
unless appropriate notice ha s been g iven by the fa cility director to the court a nd district
attorney which has or had jurisdiction of the relevant criminal case. If within 30 days of the
receipt o f s uch c ommunication th e d istrict a ttorney h as n ot f iled a p etition f or f urther
commitment of such patient, the patient may be discharged. The patient shall be held at the
facility for such 30-day period, unless the district a ttorney provides written notice that he
does not intend to petition for further commitment.
(c) I n the eve nt the fac ility direc tor intend s to remove or modify any court orde red
restrictions on such a patient’s movements, he or she shall communicate the intention to
remove or modify such restriction in writing to the court which ordered the commitment and
the district attorney who has or had jurisdiction of the relevant criminal case. If within 14
days neither the court nor district attorney makes written objection thereto, such restrictions
may be removed or modified.
(d) The requirements of 104 CMR 27.09(8)(b) and (c) shall not apply to patients originally
committed after a finding of incompetence to stand trial whose criminal charges have been
dismissed.
(e) A patient on commitment status under M.G.L. c. 123, § 16 who was found incompetent
to stand trial and whose charges are dismissed may be discharged at any time if the facility
director determines th at s uch p atient i s n o lo nger in n eed o f c are a nd tr eatment. The
dismissal of criminal charges shall not, however, terminate the underlying commitment
order. Any subsequent commit ment proce edings for such a patient shall be unde r
M.G.L. c. 123, §§ 7 and 8.
(f) A patient hospitalize d at a f acility pursuant to M.G.L . c. 123, § 18 shall not be
discharged, except to the custody of the plac e of de tention from w hich the patient wa s
hospitalized, unless such patient’s sentence, or other authority under which the patient is
being held in custody, has expired.
27.10: Treatment
(1) Informed Consent, Consent to Treatment.
(a) Upon admission to a fac ility a patient sha ll, upon giving informed c onsent, receive
treatment and rehabilitation when ordered in accordance with accepted therapeutic practice.
(b) Prior to an a djudication of incapacity or invocation and affirmation of a he alth care
proxy, a patient retains the right to accept or refuse treatment.
(c) Informed consent must be documented in the patient’s medical record.
(d) Extraordinary treatment, as defined by statute or case law including, but not limited to,
treatment with antipsychotic medication, may not be administered or performed without the
patient’s specific informed consent. I n the ca se of a patient who lac ks capacity to give
informed consent, such treatment may not be administered or performed without prior review
and approval by a court of competent jurisdiction or in the case of a minor or a patient with a
properly invoked healthcare proxy, the consent of his or her legally authorized representative.
(e) For a patient who is believed to lack capacity to give informed consent to treatment with
antipsychotic medication, and who is not being treated pursuant to consent by the parent of a
minor or by a hea lth care agent pursuant to a pr operly invoked and a ffirmed health care
proxy, the rig ht to refu se such medic ation may be over ridden prior to an adjudica tion of
incapacity and court approval of a treatment plan only in rare circumstances to prevent an
immediate, s ubstantial a nd i rreversible d eterioration o f t he p atient’s m ental i llness. If
treatment is to be continued over the patient’s objection, and the patient continues to lack
capacity, then an adjudication of incapacity and court approval of a treatment plan must be
sought.
(2) Electroconvulsive Treatment for Patients Younger than 16 Years Old.
(a) Electroconvulsive treatment shall not be administered to any patient younger than 16
years old, unless the Commissioner or designee concurs. 
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.10: continued
(b) The approval of the administration of electroconvulsive treatments to patients younger
than 16 y ears old shall be based on suc h written recommendations and inde pendent
consultations as the Commissioner or designee deems appropriate under the circumstances
of the individual case.
(c) The Commissioner or desig nee’s approval, and the ba sis therefore, shall bec ome a
permanent part of the patient’s record.
(3) Routine and Preventive Treatment. A patient shall be informed upon admission and at each
periodic r eview of the routine and preventive treatment that is ordinarily performed at, or
arranged by , the fa cility. Routine and preve ntive trea tment includes standar d medical
examinations, clini cal tests, standa rd immuniz ations, and tre atment for minor illnesses a nd
injuries. A patient who has capacity to give informed consent regarding routine and preventive
treatment may accept or refuse such treatment, except that a refusal may be overridden by the
facility director, without special court authorization, when the treatment consists of:
(a) a complete physical examination, and associated routine laboratory tests, required by law
to be conducted upon admission and at least annually thereafter.
(b) immunizations or trea tment required by law or ne cessary to prevent the sprea d of
infection or disease.
(4) Written Treatment Plan.
(a) The patient has the right to participate in the development and implementation of his or
her treatment plan.
(b) As part of the treatment of a patient in a facility, there shall be a written assessment of
the strengths and needs of the patient and a written, multi-disciplinary treatment plan, which
shall be developed with the maximum possible participation of the patient or the patient’s
legally authorized representative.
(c) The tre atment plan, upon ac ceptance by the pa tient or his or her legally authorized
representative, shall be implemented by the facility staff in good faith within the limits of
available resources.
(d) There shall be a periodic written assessment of treatment progress. Modifications of the
treatment plan and the rationale for such modifications shall be documented in the patient’s
record.
(5) Additional Requirements for Patients Eligible for Public School Education.
(a) T reatment plans for patients who are “children with special needs”, as defined in
M.G.L. c. 71B shall, where appropriate, take into account the pla n for pr oviding special
education services developed in accordance with 603 CMR: Department of Elementary and
Secondary Education.
(b) Treatment plans for patients who are eligible for public school education but who are
not “children with special needs” as defined in M.G.L. c. 71B, § 1, shall, if appropriate, and
in addition to all other requirements for treatment plans, reflect such patient’s educational
needs.
27.11: Periodic Review
(1) Schedule of Periodic Reviews. Every facility shall conduct a periodic review of each patient
upon admission, and for patients whose hospitalizations are expected to b e at least 90 days,
during the first three months, during the second three months, and annually thereafter until
discharge, except that for facilities licensed as Class VI, Limited Class VI and VII and for units
of Department facilities that admit patients y ounger than 19 years old, such periodic reviews
shall be conducted as clinically indicated but no less frequently than quarterly.
(2) Notice to Patient and Family. Prior to the periodic review, the facility director or designee
shall give reasonable advance written notice to each patient and his or her legally authorized
representative. I f there is no legally authorized repr esentative, the direc tor shall inform the
patient that, unless the patient know ingly objects, notice of the periodic review shall also be
given to his or her nearest relative giving the date of such review. 
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.11: continued
(3) Thorough Clinical Examination. Each per iodic review shall include a thorough clinical
examination, which shall consist of: a mental status examination; a review of the patient’s
clinical history, including a revie w of the tre atment plan, of r esponse to tre atment, and of
medications administere d; and an e valuation of g eneral beha vior and socia l interac tion by
clinical personnel from the various disciplines providing treatment. At least once in every 12-
month period, a thorough clinical examination shall also include a physical examination.
(4) Evaluation of Capacity. For each periodic review, the legal capacity of a patient shall be
evaluated to determine whether he or she has capacity to remain on, or to apply for, voluntary
or conditional voluntary status, to render informed consent to customary and usual medical care
or extraordinary treatment, including administration of antipsychotic medications, or to manage
his or her own funds in accordance with the requirements of 104 CMR 30.01(4): Evaluation of
Ability to Manage Funds.
(a) If a patient on voluntary or conditional voluntary status is believed no longer to have
capacity to remain on that status, and the p atient remains in need of continued
hospitalization, the n th e fa cility dir ector sh all t ake re asonable ste ps to o btain a lternate
authority fo r con tinued hosp italization b y se eking a n o rder o f commitment p ursuant t o
M.G.L. c. 123, §§ 7 and 8, or obtain consent of a legally authorized representative.
(b) If the question of a patient’s capacity is raised by a periodic review or if the facility
director has reason to believe that a patient who has been under the care of the facility, who
is not under g uardianship or conser vatorship, is unable to ca re for his or her person or
property, the facility director shall promptly take reasonable steps to initiate the process to
obtain a legally authorized representative.
(5) C onsideration of Alternatives to Facility. F or each periodic review the alternatives to
hospitalization should be evaluated, with consideration being given to specific and available
resources in the community which the patient could utilize.
(6) Results of the Periodic Review.
(a) Upon completion of every periodic review subsequent to admission, the person in charge
of conducting the review shall prepare a full and complete record of all information presented
at such review, including medical evidence or information, the reasons for a determination
that a patient requires continued care and treatment at the facility, and the consideration given
to alternatives to continued hospitalization. This written record of each periodic review shall
become part of the patient’s medical record.
(b) If upon completion of the periodic review, it is determined that the patient is in need of
further care and treatment, the facility director or designee shall notify the patient and his or
her legally authorized repr esentative of that determination, and of the rig ht to leave the
facility if he or she was not committed under a court order. If there is no legally authorized
representative, the director shall inform the patient that, unless the patient knowingly objects,
notice of the determination shall also be given to his or her nearest relative. If said patient
is not committed under a court order and does not choose further treatment as an inpatient,
within 14 days of said notification the patient shall be discharged or shall be made the subject
of a petition for a court ordered commitment. Following any review under the provisions of
104 CMR 27.11, or at any other time, any patient who is no long er in need of care as an
inpatient shall, subject to the provisions of 104 CMR 27.09, be discharged.
27.12: Prevention of Restraint and Seclusion and Requirements When Used
(1) Restra int and seclusion may only be used in facilities operated by the Depa rtment, or
licensed as Class III through VII; provided however, that no such seclusion or restraint of a minor
may occur except in a facility that has been inspected and specially certified by the Department.
(2) Prevention/Minimal Use of Restraint and Seclusion. A facility subject to 104 CMR 27.12
that uses re straint or sec lusion shall develop and implement a stra tegic plan to re duce and,
wherever possible, eliminate the use of r estraint and se clusion. The strategic plan should be
updated at least annually to reflect progress in implementation and to ensure efforts to reduce or
eliminate restraint are ongoing. The facility's strategic plan shall include, at a minimum, the
following:
(a) a posted statement of the facility’s commitment to the prevention and minimal use of
restraint and seclusion;
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.12: continued
(b) policies and procedures that support the prevention and minimal use of re straint and
seclusion;
(c) staff training that focuses on crisis prevention, de-escalation and alternatives to restraint
and seclusion;
(d) prog ramming and milieu that are consistent with the prevention and minimal use of
restraint and seclusion;
(e) the development and integration of peer and family support within the program. This
should include peer involvement in interventions to reduce the use of restraint and seclusion;
(f) the development and use of sensory interventions and therapies designed to calm and
comfort patients that utilize sight, touch, sound, taste, smell, pre ssure, weight or physical
activity;
(g) designation of a comfort or sensory space on the unit for patients to utilize to practice
sensory modulation, coping skills, and/ or self-soothing techniques. This space should be
a dedicated room including, but not limited to, a temporary location where staff may bring
appropriate supplies and equipment for patient use;
(h) the development and use of an individual crisis prevention plan for each patient;
(i) assessment of the impact of trauma experience and the potential for re-traumatization for
both patients and staff;
(j) the regular use of debriefing activities for both patients and staff;
(k) the process for addressing patient concerns and complaints about the use of restraint or
seclusion; and
(l) the use of data to monitor and improve qua lity and prevent and minimize the use of
restraint and seclusion, such as identifying times or shifts with a high incidence of restraint
or seclusion.
(3) Staff Training.
(a) A facility shall ensure that all unit staff and other staff who may be involved in restraint
and seclusion receive training, and demonstrate competencies, in the prevention and minimal
use of restraint and seclusion prior to participating in any episode of restraint or seclusion.
Such training shall be completed no later than one month after hire, and shall be included in
annual training thereafter. Training shall include, at a minimum, the following:
1. the harmful emotional and physical effects of restraint and seclusion on patients and
staff;
2. the impact of trauma, including sexual and physical abuse and witnessing of violence,
on both patients and staff;
3. the impact of restraint or seclusion on patients with a history of trauma, including the
potential for re-traumatization;
4. calming and soothing, crisis prevention and de-escalation approaches and strategies;
and
5. the use of individualized crisis prevention plans.
(b) In addition to the training in 104 CMR 27.12(3)(a), staff who may be directly involved
in authorizing, ordering, administering or applying, monitoring, or assessing for release from
restraint or seclusion shall receive additional training, and annual retraining thereafter. No
staff shall be permitted to participa te in any restraint or seclusion prior to re ceiving such
additional training. Such training shall include, at a minimum, the following:
1. applicable legal and clinical requirements for restraint and seclusion;
2. the safe and appropriate initiation of physical contact and application and monitoring
of restraint and seclusion; and
3. approaches to facilitate the earliest possible release from restraint or seclusion.
(c) Following initial training and each annual retraining, a facility shall require each staff
member to demonstrate competencies in all areas of training. Staff shall not participate in
an episode of restraint or seclusion prior to completing required training and demonstrating
necessary competenc ies. A fa cility shall maintain documentation of staf f training and
competencies.
(4) Individualized Crisis Prevention Planning. A facility shall develop an Individualized Crisis
Prevention Plan with each patient.
(a) Definition. An Individualized Crisis Prevention Plan is an age and developmentally
appropriate, patient-specific plan or safety tool that identifies triggers that may signal or lead
to agitation or distress in the patient and strategies to help the patient and staff intervene with
de-escalation techniques to reduce such agitation and distress and avoid the use of restraint
and seclusion. 
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.12: continued
(b) Development of the Individualized Crisis Prevention Plan. As soon as possible after
admission, facility staff shall collaborate with each patient and his or her legally authorized
representative, if any, and, where appropriate, with other sources, such as family members,
caregivers, to complete a nd implement an I ndividualized Crisis Prevention Plan. I f the
patient refuses or is unable to participate in the initial development of the plan, staff shall
develop a plan using available information and shall make continuing efforts to include the
patient’s participation in review and revision of the plan. Relevant clinical data, including
medical risk factors, physical, learning, or cognitive disability, and the patient’s history of
trauma shall inform the development of the plan. The plan shall include, at a minimum, the
following elements:
1. identification of triggers that signal or lead to agitation or distress in the patient and,
if not addressed, may result in the use of restraint or seclusion;
2. identification of the particular approaches and strategies that are most helpful to the
patient in reduc ing a gitation or distress, such as e nvironmental supports, phy sical
activity, and sensory interventions; and
3. in order to minimiz e trauma or re-traumatization if restraint or sec lusion is us ed,
identification of the patient’s preferences, such as type of intervention and positioning,
gender of staff who administer and monitor the r estraint or seclusion, and supportive
interventions that may have a calming effect on the patient.
(c) Update and Revision of Plan. The plan shall be updated, as necessary, to reflect changes
in such triggers and strategies as well as following a ny restraint or seclusion episode a nd
shall be reviewed at each treatment plan review.
(d) Access to Plan. A facility shall ensure that all staff on all shifts are aware of and have
ready access to the individualiz ed crisis prevention plans for the patients in their care. A
copy of the Individualized Crisis Prevention Plan and any revisions thereto, shall be recorded
in the patient record and a copy shall be given to the patient and his or her legally authorized
representative, if applicable.
(5) Debriefing Activities. Recognizing that an episode of restraint or seclusion is a traumatic
event affecting patients, staff, and the milieu, debriefing after such an event is critical. Therefore,
a facility shall develop procedures to ensure that debriefing activities occur after each episode
of re straint or sec lusion in order to deter mine what led to the i ncident, what mi ght have
prevented or curtailed it, how to prevent future incidents, and to address the emotional needs of
patients and staff who were impacted. Debriefing activities shall be documented and used in
treatment planning, r evision of the individualized crisis prevention plan, a nd ong oing
facility-wide restraint and seclusion prevention efforts.
(a) Staff Debriefing. As soon as possible following each episode of restraint or seclusion,
supervisory staff and staff involved in the episode shall convene a debriefing. The debriefing
shall, at a minimum, include the following:
1. identification of what led to the episode;
2. determination of whether the individual crisis prevention plan was used;
3. assessment of alternative interventions that may have avoided the use of restraint or
seclusion;
4. deter mination of whether the patient’s phy sical and p sychological nee ds were
appropriately addressed and that the patient’s right to privacy was maintained;
5. consideration of counseling or medical evaluation and treatment for the involved
patient and/or staff for any emotional or physical trauma that may have resulted from the
incident;
6. consideration of whether other patients and staff who may have witnessed or
otherwise been affected by the incident should be involv ed in debriefing activities or
offered counseling;
7. determ ination o f w hether t he le gally a uthorized r epresentative, if a ny, f amily
members, or others should be notified of and/or involved in debriefing activities; and
8. consideration of whether additional supervision or training should be provided to
staff involved in the incident.
(b) Patient Debriefing.
1. As soon as possible, but no later than 48 hours after a patient’s release from restraint
or seclusion, taking into consideration the emotional needs of the patient, the patient shall
be asked to debrief and provide comment either in writing or verbally on the episode.
The debriefing should, at a minimum, include:
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.12: continued
a. a review of the circumstances leading to the episode;
b. consideration of staff or patient actions that could have helped to prevent or that
may have c ontributed to the episode, including the ade quacy of the pa tient’s
Individualized Crisis Prevention Plan; and
c. a disc ussion of the ty pe of r estraint or se clusion used, and a ny physical or
psychological effects the patient may be experiencing from the restraint or seclusion.
2. Wheneve r possible and a ppropriate, the staff participating in debr iefing with the
patient shall not have been involved in the episode of restraint or seclusion.
3. The pa tient’s comments, if any, shall be included on the de briefing and comment
form.
a. The patient may complete the debriefing and comment form during the debriefing
or afterwards, or may chose not to do so.
b. Th e sta ff pe rson sh all p rovide the pati ent w ith a ny ne cessary a ssistance in
completing the patient debriefing and comment form.
c. If the patient does not complete the form, but provides verbal or other response
to the episode, the staff person shall document such response on the form.
d. Staff efforts to encourage the patient to provide comments shall be documented
on the debriefing and comment form.
e. Efforts to engage a patient who has refused to participate in debriefing activities
after t he 48 -hour p eriod sh all b e do cumented a nd sh all continue a s c linically
appropriate.
4. The patient debriefing and comment form or other documentation shall be attached
to the restraint and seclusion form and included in the patient record. Copies of the form
shall be forwarded to the treatment team and the human rights officer as soon as possible
once completed; provided however, that the treatment team shall review the episode no
later than at its next scheduled meeting.
5. Th e pa tient s hall be n otified o f t he c omplaint pr ocedure ou tlined in 10 4 CM R
32.00: Investigation and Reporting Responsibilities. The human rights officer shall offer
to meet with a patient who r equests such a meeting , or whose c omments about or
description of an episode of restraint or seclusion suggests a possible rights violation or
other harmful consequence.
(c) Senior Administrative Review. Senior administrative and clinical staff shall conduct
a review of each episode of restraint or seclusion by the next business day. Such review shall
include consideration of whether:
1. A patient or staff member experienced significant emotional or physical injury as a
result of the episode;
2. The e pisode of re straint or sec lusion exceeded six hours or ep isodes of restraint
and/or seclusion for a patient exceeded 12 hours in the aggregate in any 48-hour period;
3. An exception to t he restrictions on mechanic al restraint of minors has occ urred
pursuant to 104 CMR 27.12(8)(g)5.;
4. The episode appears to be part of a pattern warranting review;
5. The episode is marked by unusual circumstances;
6. The episode resulted in a complaint or reportable incident, including patient or staff
injury, pursuant to 104 CMR 32.00: Investigation and Reporting Responsibilities; or
7. There were multiple patients restrained or secluded at one time.
(6) Senior a dministrative and clinical staff shall conduct regular reviews of all incidents of
restraint and seclusion. The pur pose of suc h review is to determine the need f or expert
consultation, training, performance improvement activities, change in policy, or other appropriate
measures to further reduce and prevent the occurrence of restraint and seclusion.
(7) Senior a dministrative reviews shall not become part of the patient’s record, but shall be
documented a nd shal l inform the implementation of the f acility’s strategic plan deve loped
pursuant to 104 CMR 27.12(2).
(8) Requirements for the Use of Restraint and Seclusion.
(a) Definitions. For purposes of 104 CMR 27.12, the following definitions shall apply: 
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.12: continued
1. Authorized Clinician. An authorized clinician is any physician or Psychiatric APRN
who has been authorized by the facility director to order medication restraint, mechanical
restraint, physical restraint or seclusion, to examine patients in such restraint or seclusion,
and to assess for readiness for release and order release from restraint or seclusion.
2. Authorized Staff Person. An authorized staff person is any member of the licensed
clinical staff at a facility who has been authorized by the facility director to initiate or
renew m echanical restraint, p hysical r estraint or se clusion pu rsuant t o 1 04 CMR
27.12(8)(e)2. or (f)1., and to assess f or readiness for release and order release from
restraint or seclusion.
3. Restraint. Restraint, for purposes of 104 CMR 27.00, means behavioral restraint,
including medication restraint, mec hanical r estraint and physical restraint. Restraint
means bodily physical restriction, mechanical devices, or medication that unreasonably
limits fr eedom of mov ement. Re straint do es n ot i nclude the us e of re straint in
association with ac ute medical or surg ical care, adaptive support in re sponse to the
patient’s assessed physical needs, or standard practices, including limitation of mobility
related to medical, dental, diagnostic, or surgical procedures and related post-procedure
care.
a. Medic ation Restraint. Medication restraint occ urs when a patient is g iven a
medication or combination of medications to control the patient’s behavior or restrict
the patient’s freedom of movement and which is not the standard treatment or dosage
prescribed for the patient’s condition.
Medication restraint shall not include:
i. involuntary administrations of medication when administered in an emergency
to prevent immediate, substantial and irreversible deterioration of serious mental
illness, provided that the requirements of 104 CMR 27.10(1)(c) are complied
with; or
ii. for other treatment purposes when administered pursuant to a court approved
substituted judgment treatment plan.
b. Mecha nical Restraint. Mechanical restraint occurs when a physical device or
devices are used to restrain a patient by restricting the movement of a patient or the
movement or normal function of a portion of his or her body.
c. Physical Restraint. Physical restraint occurs when a manual method is used to
restrain a patient by restricting a patient’s freedom of movement or normal access to
his or her body. T he application of force to p hysically hold a patient in order to
administer a medic ation ag ainst the patient’s wishe s, including c ourt order ed
medication, is considered a physical restraint.
Physical restraint shall not include:
i. non-forcible guiding or escorting of a patient to another area of the facility
where the patient can easily remove or escape the grasp; or
ii. taking reasonable steps to prevent a patient at imminent risk of entering a
dangerous situation from doing so with a limited response to avert injury, such
as blocking a blow, breaking up a fight, or preventing a fall, a jump, or a run into
danger.
4. Seclusion.
a. Se clusion occurs w hen a pa tient i s in voluntarily c onfined in a ro om a nd is
physically prevented from lea ving, or reasonably believes tha t he or she w ill be
prevented from leaving, by means that include, but are not limited to, the following:
i. manually, mechanically, or electrically locked doors, or “one-way doors”, that
when closed and unlocked, cannot be opened from the inside;
ii. physical intervention of staff; and
iii. coercive measures, such as the threat of restraint, sanctions, or the loss of
privileges that the patient would otherwise have, used for the purpose of keeping
the patient from leaving the room.
b. Seclusion shall not include voluntary, collaborative separation from a group or
activity for the purpose of calming a patient.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.12: continued
(b) Emergency Basis for Medication Restraint, Mechanical Restraint, Physical Restraint or
Seclusion. Medication restraint, mechanical restraint, physical restraint or seclusion may be
used only in an emergency, such as the occurrence of, or serious threat of, extreme violence,
personal injury, or attempted suicide. Such emergencies shall only include situations where
there is a substantial risk of, or the occurrence of, serious self-destructive behavior, or a
substantial risk of, or the oc currence of, serious physical assault. As used in the previous
sentence, a substantial risk includes only the serious, imminent threat of bodily harm, where
there is the present ability to effect such harm, where there is the present ability to effect such
harm; provided however, that physical restraint may be used in accordance with 104 CMR
27.12, if it is determined to be necessary to safely administer court authorized treatment.
1. Restriction on Medication Restra int, Mechanical Restraint, Phy sical Restraint or
Seclusion; U se of I ndividualized Cr isis Pr evention Pl an. Me dication r estraint,
mechanical restraint, physical restraint or seclusion may be used only after the failure of
less restrictive alternatives, including strategies identified in the Individualized Crisis
Prevention Plan, or after a determination that such alternatives would be inappropriate
or ineff ective unde r the c ircumstances, and may be used only for the pur pose of
preventing the continuation or renewal of such emergency condition. The preferences
in the patient’s I ndividualized Cri sis Prevention Plan, such as ty pe of r estraint or
seclusion and gender of staff, shall be c onsidered in ordering or initiating re straint or
seclusion.
2. Dura tion of Medication Restra int, Mechanic al Restraint, Phy sical Restraint, or
Seclusion. Medication restraint, mechanical restraint, physical restraint or seclusion may
only be used for the period of time necessary to accomplish its purpose; but in no event
beyond the periods established in 104 CMR 27.12(8)(e) through (g).
3. PRN Orders Prohibited. No “ PRN” or “as required” authorization of medication
restraint, mechanical restraint, physical restraint or seclusion may be written.
4. Seclusion Used with Mechanical Restraint Prohibited. No patient shall be placed in
seclusion while in mechanical restraints.
5. Other Requir ements. When an e mergency condition exi sts justifying the use of
medication restraint, mechanical restraint, physical restraint or seclusion, such use must
conform to all applicable requirements of 104 CMR 27.12.
(c) Physical and Mechanical Restraint or Seclusion – Physical Conditions.
1. Position in Physical or Mechanical Restraint. A patient shall be placed in a position
that allows airway access and does not compromise respiration. A face-down position
shall not be used, unless:
a. ther e is a spec ified patient preferenc e and no psy chological or me dical
contra-indication to its use; or
b. there is an overriding psychological or medical justification for its use, which
shall be documented.
2. Personal Needs and Comfort. Provision shall be made for appropriate attention to
the per sonal nee ds of t he patient, including acc ess to food and dr ink and toileting
facilities, by staff assistance or otherwise, and for the patient’s physical and mental
comfort.
3. Personal Dignity. Patients in restraints or seclusion shall be fully clothed, limited
only by patient safe ty considerations related to the ty pe of inter vention used, and the
restraint devices used shall afford patients maximum personal dignity.
4. Physical Environment. The physical environment shall be as conducive as possible
to fac ilitating ea rly rele ase, with attention to calming the patient with sensory
interventions where possible and appropriate.
5. Se clusion – O bservation. Any room used to confine a patient in seclusion must
provide for complete visual observation of the patient so confined.
6. Mechanical Restraint – Locks Prohibited. No locked mechanical restraint devices
requiring the use of a key for their release may be used.
(d) Medication Restraint – Order. A patient may be given medication restraint only on the
order of an authorized clinician who has determined, either while present at the time of (i.e.,
at any time during the course of) the emergency justifying the use of th e restraint or after
telephone consultation with a physician, registered nurse or certified physician assistant who
is present at the time and site of the emergency and who has personally examined the patient,
and using all relevant information available regarding the patient, that s uch medication
restraint is the least restrictive, most appropriate alternative available.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.12: continued
1. Such order, along with the reasons for its issuance, shall be recorded in writing at the
time of its issuance.
2. Such order shall be signed at the time of its issuance by such authorized clinician if
present at the time of the emergency.
3. Such order, if authorized by telephone, shall be transcribed and signed at the time of
its issuance by the physician, registered nurse or physician assistant who is present at the
time of the emergency.
4. An authorized clinician shall conduct an in-person examination of the patient as soon
as possible, but no later than w ithin one hour of the initiation of the re straint if the
restraint was authorized by telephone. Such examination must include documentation
of both a physical and behavioral assessment conducted of the patient.
5. The requirement for examination pursuant to104 CMR 27.12(8)(d)4. may be satisfied
through utilization of telemedicine or other technology pursuant to protocols approved
by the Department that assure verbal and visual observation and communication between
the patient and an off-premises authorized clinician and adequate on-premises clinical
staff only in cases where a physician, registered nurse or certified physician assistant has
assessed the patient and determined that:
a. the medication restraint has taken effect and the patient is not in need of further
restraint;
b. the patient has not experienced side effects of the medication restraint; and 
c. there are no apparent medical or physical conditions, including injury, related to
the medication restraint that require an in-person examination. 
(e) Initiation of Mechanical Restraint, Physical Restraint or Seclusion.
1. The orde r that a pa tient be place d in mechanic al restraint, physical restraint, or
seclusion shall be made by an authorized clinician who is present when an emergency as
defined in 104 CMR 27.12(8)(b) occurs, except as provided in 104 CMR 27.12(8)(e)2.
a. Such order along with the reasons for its issuance and criteria for release shall be
recorded in writing and signed at the time of its issuance by such clinician.
b. Such order shall authorize use of mec hanical restraint, physical restraint or
seclusion fo r n o mo re tha n tw o h ours, s ubject to the additional r estrictions in
104 CMR 27.12(8)(g).
c. Su ch order shall terminate w henever a release decision is m ade pursuant to
104 CMR 27.12(8)(h)8., a nd shall be subject to the monit oring, examination and
release provisions of 104 CMR 27.12(8)(h).
2. I f an authorized clinician is not pres ent when an emergency justifying the use of
mechanical restraint, physical restraint or seclusion occurs, a patient may be placed in
mechanical restraint, physical restraint or seclusion at the initiation of an authorized staff
person, subject to the following conditions and limitations;
a. Su ch in itiation shall b e su bject to the a dditional r estrictions in 1 04 CMR
27.12(8)(g).
b. Such initiation along with the reasons for its issuance shall be recorded in writing
and signed at the time of the incident by such authorized staff person.
c. Such initiation shall authorize use of mechanical restraint, physical restraint or
seclusion for no more than one hour, shall terminate whenever a release decision is
made pursuant to 104 CMR 27.12(8)(h)8., and shall be subject to the monitoring,
examination and release provisions of 104 CMR 27.12(8)(h).
d. An authorized clinician shall conduct an in-person examination of the patient as
soon as possible, but no later than one hour of such initiation of mechanical restraint,
physical restraint, or seclusion. Such examination must i nclude documentation of
both a physical and behavioral assessment conducted of the patient.
e. The requirement for examination pursuant to 104 CMR 27.12(8)(e)2.d. may be
satisfied through utilization of telemedicine or other technology pursuant to protocols
approved by the Depa rtment that assure verba l and visual observa tion and
communication between the pa tient and an off-premises authorized clinician and
adequate on-premises clinical staff only in cases where restraint or seclusion episode
has ended, the patient has been permanently released from restraint or seclusion in
accordance with 104 CMR 27.12(8) (h)8., and there are no apparent medical or
physical conditions, including injury, related to the mechanical restraint or seclusion
restraint that require an in-person examination.
3. At the time of initiation of restra int, an author ized staff pe rson, or a uthorized
clinician shall observe and make written note of the patient’s physical status, including
respiratory functioning, skin color and condition, and the presence of undue pressure to
any part of the body.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.12: continued
(f) Mechanical Restraint, Physical Restraint or Seclusion – Renewals to Continue Use.
1. Continuation for a Second H our of Me chanical Restraint, Phy sical Restraint or
Seclusion Initiated by an Authorized Staff Person – Exceptional Circumstances. In
exceptional circumstances, where an authorized clinician has not examined the patient
within th e fi rst ho ur of ini tiation o f restraint or se clusion a s r equired by 104 CM R
27.12(8)(e)2.d, an authorized staff person may issue a single renewal for a second one
hour period, subject to the following conditions and limitations:
a. Such renewal shall be subject to the additional restrictions i n 1 04 CMR
27.12(8)(g).
b. Such renewal may only be issued if such authorized staff person determines that
such restraint or seclusion is necessary to prevent the continuation or renewal of an
emergency condition or conditions as defined in 104 CMR 27.12(8)(b).
c. Such re newal shall authorize use of mec hanical restraint, physical restraint or
seclusion for no more than one hour, shall terminate whenever a release decision is
made pursuant to 104 CMR 27.12(8)(h)8., and shall be subject to the monitoring,
examination and release provisions of 104 CMR 27.12(8)(h). 
d. An authorized clinician shall conduct an in-person examination of the patient as
soon as possible, but no later than w ithin one hour of such renewal of mechanical
restraint, physical restraint or seclusion, and may order the restraint to continue for
no more than two hour s from the initiation of th e restraint or seclusion by the
authorized staff person, subject to the additional restrictions in 104 CMR 27.12(8)(g).
2. Continuation of Mechanical Restraint or Seclusion for Additional Two-hour Periods.
Subsequent orders for renewals of mechanical restraint or seclusion may be made for up
to two-hour periods only if an authorized clinician has examined the patient and ordered
such renewal prior to the expiration of the prece ding order, subject to the following
conditions and limitations.
a. Such a renewal order shall be subject to the additional restrictions in 104 CMR
27.12(8)(g).
b. Such a renewal order may only be issued if such clinician determines that such
restraint or seclusion is nece ssary to preve nt the continuati on or re newal of an
emergency condition or conditions as defined in 104 CMR 27.12(8)(b).
c. Each such order shall be recorded in writing and signed by such clinician, but
only after examination of the patient in restraint or seclusion by such clinician.
d. Each such order shall authorize continued use of mechanical restraint or seclusion
for no more than two hours from the time of expiration of the preceding order, shall
terminate whenever a release decision is made pursuant to 104 CMR 27.12(8)(h)8.,
and shall be subjec t to the mo nitoring, e xamination and re lease provisions of
104 CMR 27.12(8)(h). Continuation of a re straint or sec lusion requires
documentation that the patient’s sy mptoms necessitate the c ontinuation of the
restraint or seclusion.
(g) Additional Restrictions and Limitations on the Use of Restraint or Seclusion.
1. No episode of physical restraint shall exceed two hours.
2. No order for the restraint or seclusion of a minor younger than nine years old may
exceed one hour.
3. No minor younger than nine years old shall be in seclusion or restraint for more than
one hour in any 24-hour period.
4. No minor nine through 17 years of age shall be in seclusion for more than two hours
in any 24-hour period.
5. No minor younger than 13 years old may be placed in mechanical restraint, except
under the following conditions:
a. The facility medical director is notified prior to the use of such restraint or
immediately after t he ini tiation o f t he re straint, if a n e mergency a s d efined in
104 CMR 27.12(8)(b) occurs. The facility medical director shall inquire about the
circumstances warranting the use of such restraint, the efforts made to de-escalate the
situation, the alternatives to such r estraint consid ered and tried, any preferences
indicated in the Individual Crisis Prevention Plan, and whe ther other measures or
resources mi ght b e he lpful i n a voiding the use of me chanical r estraint or in
facilitating early release.
b. The facility director shall also be immediately informed of the use of such
restraint and shall report it in writing to the Department by the next business day.
c. All other applicable provisions of 104 CMR 27.12 shall be complied with.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.12: continued
6. Mechanical Restraint or Seclusion Exceeding Six Hours or Multiple Episodes. If an
episode of mechanical restraint or seclusion has exceeded five hours and it is expected
that a new order will be issued to extend the episode beyond six hours or if there are two
or more episodes of any restraint or seclusion for a patient in any 12-hour period, the
facility director and fa cility medical dire ctor shall be notified. The f acility medical
director shall inquire about the circumstances of the episode(s) of restraint or seclusion,
the efforts made to facilitate release, and the impediments to such release, and help to
identify additional measures or resources that might be beneficial in facilitating release
or preventing additional episodes.
7. Mechanical Restraint or Seclusion Exceeding 12 Hours or Total Episodes Exceeding
12 Hours in a 48- hour Period. If an episode of mec hanical restraint or seclusion has
exceeded 11 hours and it is expected that a new order will be issued to extend the episode
beyond 12 hours, or if episodes of restraint and/or seclusion for a patient have exceeded
12 hours in the aggregate in any 48-hour period, the following shall occur:
a. The patient shall receive a medical assessment.
b. The facility director and facility medical director shall be notified. The facility
medical director shall inquire about the outcome of the measures identified pursuant
to 104 CMR 27.12(8)( g)6., in the ca se of a continuous episode, and about t he
circumstances that resulted in the continued or multiple use of restraint or seclusion.
The facility medical director shall take steps, including consultation with appropriate
parties, to identify and implement strategies to facilitate release as soon as possible
and/or e liminate the use of multiple episodes, such as psy chopharmacological
reevaluation or other consultation, assistance w ith communication, including
interpreter services, and consideration of involving family members or other trusted
individuals.
c. The episode(s) shall be reported to the Department by the next business day.
8. Release Prior to Ex piration of Order. I f a patient is released from a restraint or
seclusion prior to the expiration of the original order and an emergency as defined in
104 CMR 27.12(8)(b) oc curs prior to such order’s expiration, a new or der must be
obtained prior to reinitiating the use of restraint or seclusion. Such return to restraint or
seclusion shall be documented in the record and the procedures for ordering or initiating
restraint or seclusion pursuant to 104 CMR 27.12(8)(e) shall be followed.
(h) Monitoring and Assessment of Patients in Mechanical Restraint, Physical Restraint or
Seclusion; Release.
1. One- on-one Staff Monitoring. Whenever a pa tient is in phy sical or mec hanical
restraint or seclusion, a staff person shall be specifically assigned to monitor such patient
one-on-one.
2. The staff person conducting such monitoring may be immediately outside a space in
which a pa tient is being secluded without mechanica l restra int provided that the
following conditions are met:
a. The staff person must be in full view of the patient (e.g., the patient may approach
the seclusion door and see the staff person through a window in the door if he or she
wishes to do so); and
b. The staff person must be able at all times to observe the patient.
3. The staff person shall monitor a patient in mechanical or physical restraint by being
situated so that the staff person is able to hear and be heard by the patient and visually
observe the patient at all times. It is not necessary for a staff person monitoring a patient
in mechanical or phy sical restraint to be in full view of the pa tient; although if suc h
visibility has been expressed as a preference by the patient, consideration shall be given
to honoring such preference.
4. Sta ff who monitor a patient in physical or mechanical restraint or seclusion shall
continually assist and support the patient, including monitoring phy sical and
psychological status and comfort, body alignment, and circulation, taking vital signs
when in dicated, a nd mon itoring fo r r eadiness f or re lease pu rsuant t o 1 04 CMR
27.12(8)(h)6. Such monitoring activities shall be documented every 15 minutes.
5. Sta ff wh o mo nitors a pa tient i n r estraint o r s eclusion sh all a ttempt a ppropriate
interventions designed to calm the patient throughout the episode of restraint or seclusion
and shall ensure that the patient has access to a means of marking the passage of time,
either visually or verbally.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.12: continued
6. Monitoring for Readiness for Release.
a. St aff c onducting monitoring sh all c ontinually c onsider w hether a pa tient i n
mechanical restraint, physical restraint or sec lusion appears ready to be re leased.
Whenever the staff person believes that the patient may be ready to be released from
such restraint or seclusion either because the criteria for release have been met or an
emergency condition or conditions as defined in 104 CMR 27.12(8)(b) no longer
exists, he or she shall immediately notify an authorized clinician or authorized staff
person, who shall promptly assess the patient for readiness to be released.
b. If a patient falls asleep while in mechanical restraint, staff conducting monitoring
shall notify an authorized clinician or authorized staff person, who shall release the
patient from the restraint or seclusion, unless such efforts are reasonably expected to
re-agitate the patient.
c. I f, at a ny time during mechanical restraint, physical restraint, or sec lusion, a
patient is briefly released from such restraint or seclusion to attend to personal needs
pursuant to 104 CMR 27.12(8)(c)2., or for other purpose, staff conducting monitoring
shall notify an authorized staff person as soon as possible, who shall promptly assess
the patient for readiness to be released.
7. Assessment. An authorized staff person or authorized clinician shall assess a patient
in mechanical or physical restraint or seclusion for physical and psychological comfort,
including vital signs, and readiness to be released at least every 30 minutes and at any
other time that it appears that the patient is ready to be released. Such assessments shall
be documented in the record.
8. Permanent Release. A patient shall be released from mechanical restraint, physical
restraint or seclusion as soon as a n authorized clinician or a uthorized sta ff person
determines a fter e xamination o f th e p atient o r c onsultation w ith s taff th at suc h
mechanical restraint, physical restraint, or seclusion is no longer needed to prevent the
continuation or renewal of an emergency condition or conditions as defined in 104 CMR
27.12(8)(b) and, in no event, no later than the expiration of an initial or renewed order
for such mechanical restraint or seclusion, unless such order is renewed in accordance
with the requirements or 104 CMR 27.12(8)(f). The circumstances considered in making
such a de termination shall be docume nted and sig ned by the authorized clinician or
authorized staff person making the determination.
(i) Documentation Requirements.
1. The Restra int and Seclusion Form. Ea ch facility shall ensure that a restraint and
seclusion form is complete d on each occasion when a patient is pl aced in restraint or
seclusion. The restraint and seclusion form shall conform to the following requirements:
a. The restraint and seclusion form, including the patient debriefing and comment
form, must be in a form approved by the Department. 
b. The completed restraint and seclusion form shall be placed in the patient’s record.
One copy shall be used for the patient’s comments pursuant to 104 CMR 27.12(4)(b),
and one copy shall be used for the review by the Commissioner or designee pursuant
to 104 CMR 27.12(8)(i)3.
c. Any attachments, including the patient debriefing and comment form required by
104 CMR 27.12 shall be included with each copy of the restraint and seclusion form.
2. Examinations. Examinations of patients conducted pursuant to 104 CMR 27.12 shall
be documented in the patient’s record.
3. Submission to the Commissioner; Review. At the end of each month, a facility shall
submit to the Department copies of all restraint and seclusion forms with attachments,
if any, required by 104 CMR 27.12 and an aggregate report for each facility unit, on a
form approved by the Department, containing statistical data on the episodes of restraint
and seclusion for the month. The Commissioner or designee shall review such aggregate
reports a nd re view a sample of re straint a nd se clusion fo rms, a nd sh all m aintain
statistical records of all uses of restraint or seclusion, organized by facility and unit.
4. Human Rights Committee/Human Rights Officer Review. At the end of each month,
copies of all restraint and seclusion forms and attachments and aggregate reports, if any,
sent to the Department pursuant to 104 CMR 27.12(8)(i)3. shall be se nt to the human
rights committee of the facility, if operated by or under contract to the Department, and
otherwise to the human rights officer, which shall review the use of all restraints by the
facility or program. The committee or human rights officer shall have the authority to:
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.12: continued
a. re view all pertinent data concerning the behavior that necessitated restraint or
seclusion;
b. obtain information about the patient’s needs from appropriate staff, relatives and
other persons with direct contact or special knowledge of the patient;
c. mo nitor the use of the individual crisis prevention plan and consider all less
restrictive alternatives to restraint and seclusion in meeting the patient’s needs;
d. review and refer to the person in charge for action in accordance with 104 CMR
32.00: Investigation and Reporting Responsibilities all complaints that the rights of
a patient are being abridged by the use of restraint or seclusion; and
e. generally monitor the use of restraint and seclusion in the facility.
27.13: Human Rights
(1) No right protected by the Constitutions or laws of the United States and the Commonwealth
of Massachusetts shall be abridged solely on the basis of a patient’s admission or commitment
to a fa cility, except insofar a s the exercise of such r ights ha ve bee n limit ed by a cour t of
competent jurisdiction. Furthermore, no patient shall be deprived of the right to manage his or
her affairs, to contract, to hold professional, occupational or vehicle operator’s licenses, to make
a will, to marry, to hold or convey property or to vote in local, state, or federal elections solely
by reason of his or her admission or commitment to a facility.
(2) In cases where there has been an adjudication that a patient lacks capacity, or when a legally
authorized representative has bee n appointed or de signated on beha lf of such patient, suc h
patient’s human rights may be limited only to the extent of the legally authorized representative’s
authority. If at any time during a patient’s treatment, the clinical team believes the patient to
lack capacity to make treatment or other personal or financial decisions, the director or designee
shall notify the patient that a recommendation may be made that there be an adjudication or other
determination of the capacity of such patient.
(3) Right to Treatment. Each patient admitted to a facility shall, subject to his or her giving
informed consent, receive treatment suited to his or her needs which shall be administere d
skillfully, safely, and humanely with full respect for dignity and personal integrity.
(4) Right to Education. Patients younger than 22 years old, under the care and treatment of the
Department, ha ve the ri ght t o r eceive e ducation and training a ppropriate to t heir ne eds in
accordance with M.G.L. c. 71B, and 603 CMR 28.00: Special Education.
(5) No facility shall employ corporal punishment, infliction of pain or physical discomfort, or,
except as required for medical procedures or treatment, deprivation of food or sleep for any
purpose.
(6) In addition to the foregoing, a patient of a facility:
(a) shall have reasonable access to a telephone to make and receive confidential telephone
calls and to assistance, when desired and necessary to implement this right, provided that
such calls do not constitute a criminal act or represent an unreasonable infringement of other
patients’ right to make and receive phone calls;
(b) shall have the right to send and receive sealed, unopened, uncensored mail, provided
however, tha t th e fa cility dir ector or de signee ma y dir ect, for good c ause a nd wi th
documentation of specific facts in the pa tient’s record, that a particular patient’s mail be
opened and inspected in front of the patient, without it being read by staff, for the sole
purpose of preventing the transmission of contraband. Writing materials and postage stamps
in reasonable quantities shall be made available for use by patients. Reasonable assistance
shall be provided to patients in writing, addressing and posting letters and other documents
upon request;
(c) s hall have the right to receive visitors of such patient’s own choosing daily and in
private, at reasonable times. Hours during which visitors may be received may be limited
only to protect the privacy of other patients and to avoid serious disruptions in the normal
functioning of the facility and shall be sufficiently flexible as to accommodate individual
needs and desires of such patients and their visitors;
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.13: continued
(d) shall have the right to a humane psychological and physical environment. Each such
patient shall be provide d living quar ters and a ccommodations which a fford privacy and
security in resting, sleeping, dressing, bathing and personal hygiene, reading and writing, and
in toileting. 104 CMR 27.13 sh all not be interpre ted as re quiring individual sleeping
quarters;
(e) shall have the rig ht to rece ive, or re fuse, visits and telephone calls fr om his or her
attorney or legal advocate, physician, psychologist, clergy or social worker at any reasonable
time, regardless of whether the patient initiated or requested the visit or telephone call;
(f) s hall have reasonable daily access to the outdoors, as weather conditions reasonably
permit, in a manner consistent with the patient’s clinical condition and safety as determined
by the treating clinician and with the ability of the facility to safely provide access.
1. For purposes of 104 CMR 27.13(6)(f) reasonable daily access shall mean supervised
or unsupervised daily access to the outdoors, individually or in groups.
a. Nothing in 104 CMR 27.13(6)(f) shall be construed to:
i. prohibit a facility from establishing reasonable schedules or designated times
for t he pr ovision of a ccess t o th e ou tdoors, a s lo ng a s e ach p atient has a
reasonable opportunity to access the outdoors on a daily basis, consistent with the
provisions of 104 CMR 27.13(6)(f), dur ing one or more of the sche duled or
designated times;
ii. require a facility to conduct clinical programming outdoors; or
iii. require a facility to provide access to the outdoors “on demand”.
b. No pa tient s hall b e c ompelled to pa rticipate in c linical programming a s a
condition of accessing the outdoors.
2. For purposes of 104 CMR 27.13(6)(f), outdoors shall mean a space or area outside
of a building, which may include a porch, courtyard, roof deck or open space surrounded
by a building, and may be fenced, locked or otherwise secured.
3. A patient’s initial psychiatric examination conducted within 24 hours of admission
shall include a written assessment of the patient’s ability to access the outdoors consistent
with his or her clinical condition and safety. Factors that may be considered in such
assessments may include, but are not necessarily limited to:
a. acuity of symptoms;
b. medical conditions;
c. forensic legal status, including pending charges and bail status;
d. risk of elopement;
e. need for secure or nonsecure space;
f. level of supervision required to ensure safety;
g. ability of the facility to meet the patient’s requirements for safety; and
h. adequacy of historical or observational data upon which to make a determination.
4. A p atient’s status regarding access to the outdoors shall be re viewed at treatment
team meetings and reassessed by the treating clinician whenever it appears that there has
been a change in circumstances that may affect the patient’s ability to safely access the
outdoors.
a. A de cision ma de in a ccordance wi th 104 CM R 27 .13(6)(f)3. o r 1 04 CMR
27.13(6)(f)4. to restrict a patient’s access to the outdoors shall be reviewed daily to
determine whether there is a change relative to the factors that resulted in the
restriction. If such a determination is made, a new assessment shall be conducted.
b. A patient whose access to the outdoors has been restricted in accordance with
104 CMR 27.13(6)(f)3., may request a new assessment at any time. Such assessment
shall be conducted within a reasonable period of time; provided however, there shall
be no requirement to provide more than one assessment in a 24-hour period.
c. I n the event a change in c ircumstances that may affect the patient's ability to
safely a ccess t he ou tdoors o ccurs outside of no rmal bu siness h ours, a n o n-duty
clinician acting on behalf of the treating clinician may, in accordance with 104 CMR
27.13(6)(f)3. and 4., restrict or authorize such access as indicated by the change in
circumstances. Any such restriction of access shall be reviewed in accordance with
104 CMR 27.13(6)(f)4. 
5. The facility shall have a written plan to implement its obligation to provide patients
access to the outdoors.
a. The plan shall include the following:
i. proce dures, including staffing and o ther safety requirements, to allow for
access to nonsecure outdoor space for pa tients who have be en asse ssed as
clinically appropriate and safe to exercise this option; and
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.13: continued
ii. procedures, including staffing and other safety requirements, to allow for
access to secure outdoor space, if available, for patients who have been assessed
as clinically appropriate and safe to exercise this option.
b. Reasonable efforts to safely provide access to outdoor space may include, but
shall not be limited to:
i. rea sonable capital expenditures to develop, construct or otherwise acquire
outdoor space;
ii. reasonable modifications of staffing patterns to permit staff escorts; or
iii. reasonable modifications to building access policies to permit patient access
to common areas of the facility or proximate to the facility not nor mally
dedicated as patient areas.
c. If the facility determines that it cannot safely provide secure outdoor access due
to staffing or physical plant limitations, it shall:
i. identify and document such limitations in the plan; and
ii. identify what actions the facility will take to address these limitations and the
time frame for the actions.
If the facility determines that the limitations cannot be reasonably remedied, the
facility shall identify the re asons for such determination. Such rea sons shall be
documented with sufficient detail to enable the De partment to determine whether
they constitute reasonable justification.
d. Upon request of the Department, but no less frequently than in its application for
licensure or license rene wal, the f acility shall demonstrate to the D epartment’s
satisfaction that its plan is curr ent and that it has identified, c onsidered and
implemented all reasonable actions to safely provide access to outdoor space. 
6. The facility shall have procedures intended to ensure patient and staff safety at such
times that patients are exercising their right of access to the outdoors. Such procedures
may include, but are not necessarily limited to:
a. ava ilability of ele ctronic communication for sta ff supervising patients or for
patients accessing the outdoors without staff supervision;
b. application of appropriate patient to staff ratios, including staffing requirements
for patients not accessing the outdoors, taking into account the number of patients
accessing the outdoors and any provisions for supervision determined by the treating
clinician;
c. use of security cameras to monitor outdoor areas; and
d. provisions for alter ing designated times for access to accommodate inclement
weather.
(g) shall, upon admission and upon re quest at any time thereafter, be provided with the
name, address, and telephone numbe r of the Me ntal Health Legal Advisors Committ ee,
Committee for Public Counsel S ervices, and authorized Protection and Advoc acy
organizations, and shall be provided with reasonable assistance in contacting and receiving
visits or telephone ca lls from attorneys or paralegals from such or ganizations; provided
further, that the fa cility shall designate reasonable times for unsolicited visits and for the
dissemination of educational materials to patients by such attorneys or paralegals;
(h) shall have the right to file complaints and to have complaints responded to in accordance
with 104 CMR 32.00: Investigation and Reporting Responsibilities.
(7) Any rights set forth in 104 CMR 27.13(6)(a), (c) or (f) may be temporarily suspended, but
only by the facility director or designee upon concluding that based on the experience of the
patient’s exercise of such right, such further exercise of it in the immediate future would present
a substantial risk of serious harm to said patient or others and that less restrictive alternatives
have either been tried or failed or would be futile to attempt. Such suspension shall be reviewed
at le ast daily a nd sh all l ast n o lo nger t han th e tim e ne cessary to p revent t he ha rm, a nd its
imposition shall be documented with specific facts in the patient’s record. Notice of suspensions
of rights under 104 CMR 27.13(7) shall be provided to the facility’s human rights officer.
(8) A n assessment or decision concerning the exercise of the rights set forth in 104 CMR
27.13(6)(a) through (f), and the reasons, therefore, shall be documented with specific facts in the
patient’s record and subject to timely appeal. An appeal brought pursuant to 104 CMR 27.13(8)
shall be initiated by the filing of a complaint in accordance with 104 CMR 32.00: Investigation
and Reporting Responsibilities, and shall be subject to the provisions thereof.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.13: continued
(9) Patients have the right to be free from unreasonable searches of their person or property.
(10) Ea ch fa cility shall develop a written policy , consist ent with applicable law and the
requirements of 104 CMR 27.13, reg arding patient possessions and the implementation of
searches and seizures within the facility.
(a) Patients shall be informed of the policy upon admission to the facility. The policy shall,
at a minimum, detail circumstances in which a search may be authorized and require that, in
all except emergency circumstances, patients:
1. be informed of a search prior to the search;
2. be provided an opportunity to consent to the search; and
3. be present during the search of their property.
(b) If a search of a pa tient's property needs to be performed in an e mergency, when the
patient is not present during the search, the patient shall be informed as soon as possible
about the search. In addition, the nature of the emergency, the extent and results of the
search, and the reason(s) that patient was not present during the search shall be documented
in the patient's record.
(c) Nothing in 104 CMR 27.13(10) shall prohibit a facility from having a policy of routine
searches of patients on admission or upon returning from authorized or unauthorized time
off unit; of periodic unit searches for contraband; or implementation of search protocols for
visitors.
(11) Right of Habeas Corpus. Any patient involuntarily committed to any facility who believes
or has reason to believe he or she should no longer be retained may make written application to
the superior court for a judicial determination of the necessity of continued commitment pursuant
to M.G.L. c. 123, § 9(b).
(12) Rig hts at Court Hear ing. Whene ver a court he aring is held u nder the provisions of
M.G.L. c. 123 for the commitment or further retention of a patient in a facility, such patient shall
have the right to a timely hearing and representation by counsel as provided by law.
(13) Rights of Aliens. Aliens shall have the same rights under the provisions of M.G.L. c. 123
as citizens of the United States.
(14) No patient shall be photographed, interviewed or exposed to public view for purposes of
commercial exploitation without the express written consent of the patient or, if applicable, the
patient's legal guardian; provided however, that a patient may be photographed by the facility for
purposes of internal security, such as for medication administration or patient identification.
(15) Human Rights Information to Each Patient on Admission. A member o f the admitting
staff shall give each patient, and, if applicable, his or her legally authorized representative, at the
time of admission a copy of the rights set forth in 104 CMR 27.13, or other materials explaining
his or her rights prepared in accordance with Departmental guidelines.
(16) Copies of Rights Posted and Available in Facilities. Each facility shall post a copy of the
rights set forth in 104 CMR 27.13 in the admitting room of the facility, in each unit, and in other
appropriate and conspicuous places in the facility, and shall make copies available upon request.
27.14: Human Rights Officer; Human Rights Committee
(1) Human Rights Officer. Each facility shall have a person or person employed by or affiliated
with the facility appointed to serve as the human rights officer and to undertake the following
responsibilities:
(a) To participate in training programs for human rights officers offered by the Department;
(b) To inform, train and assist patients in the exercise of their rights;
(c) T o assist patients in obtaining legal information, advice and representation through
appropriate means, including referral to attorneys or legal advocates when appropriate; and
(d) I n the case of Department facilities, to s erve as staff to t he facility’s human rights
committee.
The human rights officer must have no day-to-day duties that are in conflict with his or her
responsibilities as a human rig hts officer, including carrying out fact-finding activities under
104 CMR 32.00: Investigation and Reporting Responsibilities.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.14: continued
(2) Human Rights Committ ee. F or ea ch fa cility opera ted by , or under contra ct to the
Department, the Commissioner or designee shall establish, impanel and empower a human rights
committee in a ccordance wi th t he pr ovisions o f 1 04 CMR 27.14. Suc h a hu man r ights
committee may be established jointly with other programs in an Area; provided however, that
the number, geographical separateness or programmatic diversity of the programs is not so great
as to limit the effectiveness of the committee in meeting the requirements of 104 CMR 27.14.
(3) The majority of members of each human r ights committee shall be curr ent or for mer
consumers of mental health services, family members of consumers, or advocates; provided
however, that a member who has any direct or indirect financial or administrative interest in the
facility or the Department shall notify the facility director or Commissioner, as applicable, in
writing.
(4) The general responsibility of each such human rights committee shall be to monitor the
activities of the f acility with reg ard to the huma n rights of the patien ts in the fac ility. The
specific duties of the committee shall include:
(a) Reviewing and making inquiry into complaints and allegations of patient mistreatment,
harm or violation of patient’s rights and referral of such complaints for investigation in
accordance wi th t he re quirements of 10 4 CM R 32 .00: Investigation a nd R eporting
Responsibilities;
(b) Reviewing and monitoring the use of restraint, seclusion and other physical limitations
on movement;
(c) Reviewing and monitoring the methods utilized by the facility to inform patients and
staff of the patient’s rights, to train patients served by the program in the exercise of their
rights, and to provide patients with opportunities to exercise their rights to the fullest extent
of their capabilities and interests;
(d) Ma king recommendations to t he facility to improve the deg ree to which the human
rights of patients served by the facility are understood and enforced; and
(e) Visiting the facility with prior notice or without prior notice provided good cause exists.
(5) Ea ch such huma n rights commit tee shall meet as often a s necessary upon call of the
chairpersons, or upon request of any two members, but no less often than quarterly. Minutes of
all committee meetings shall be kept and sha ll be available for inspection by the Department
upon request. The committee shall develop operating rules and procedures, as necessary.
27.15: Absence without Authorization
(1) C lassification as AWA. An y patient admitted or committed to a Department facility
pursuant to M.G.L. c. 123, §§ 7, 8, 10, 11, 12, 15, 16, 17 or 18, who leaves the facility grounds
or an off-grounds program or activity without permission and fails to return within a reasonable
time, or any patient who, having left the facility with permission, fails to return at the designated
time or within a reasonable time thereafter, shall be classified by the facility director as "absent
without authorization" (AWA).
(2) Classification as AWA: Action to Be Taken.
(a) I mmediate Cla ssification. A p atient w ho is a dmitted or committed p ursuant t o
M.G.L. c. 123, §§ 7, 8, 10, 11 or 12 and who is at a high risk of harm to self or others or a
patient who is com mitted pursuant to M.G.L. c. 123, §§ 15, 16, 17 or 18 w ho leaves the
facility g rounds or a n off- grounds prog ram or a ctivity without p ermission shall be
immediately classified as AWA.
(b) Classifica tion by Midnight Census. A patient who does not meet the cr iteria of
104 CMR 27.15(2)(a) shall be cla ssified as AWA if he or she has not retur ned within a
reasonable time based on clinical judgment or by the midnight census, whichever is earlier.
(c) The facility shall take prompt and vigorous measures to secure the patient’s return.
(d) When a patient is classified as AWA, the facility director or designee shall immediately
notify the following parties:
1. Local and State Police. The police shall be provided with the patient’s description,
other information that would assist the police in locating the patient, and information of
the patient’s tendencies to be assaultive, homicidal, suicidal or to use weapons;
2. the district attorney of the county in which the facility is located;
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.15: continued
3. the patient’s next of kin;
4. the patient’s legally authorized representative;
5. any person known to be placed at risk because the patient has left the facility; and
6. designated individuals within the Department.
(3) Return from AWA: Action to Be Taken.
(a) A patient who had been admitted pursuant to M.G.L. c. 123, §§ 10 and 11 or committed
pursuant to M.G.L. c. 123, §§ 7 and 8, and who has not been discharged from the facility as
provided in 104 CMR 27.15(4), may return or be returned to the facility under the original
legal status within six months of being classified as AWA; provided however, if a patient
was hospitalized pursuant to an order of commitment under M.G.L. c. 123, §§ 7 and 8 that
has expired. Such patient may not be retained involuntarily unless he or she is assessed and
admitted in accordance with the requirements of M.G.L. c. 123, § 12, and 104 CMR 27.07.
(b) A patient who was committed to a Department facility pursuant to M.G.L. c. 123, §§ 15,
16, 17 or 18 may return or be returned to the facility under the original legal status; provided
however, that a patient who was committed after a finding of incompetence to stand trial
whose cha rges have been dismissed, and w hose commitment has expired, may not be
retained involuntarily unless he or she is assessed a nd admitted in acc ordance with the
requirements of M.G.L. c. 123, § 12, and 104 CMR 27.07.
(c) All parties who were notified at the time of a patient’s classification as AWA, shall be
notified of the patient’s return to the facility by the facility director or designee.
(4) Discharge of Patients on AWA: Action to Be Taken.
(a) Six months after being classified as AWA, a patient on AWA who is not committed
pursuant to M.G.L. c. 123, §§ 15, 16, 17 or 18 may be discharged from the facility upon
authorization by the facility director after review by senior clinical staff; provided however,
that a patient who was committed after a finding of incompetence to s tand trial whose
charges h ave be en d ismissed ma y be so dis charged; p rovided f urther, t hat the fa cility
director, in consultation with senior clinical staff, may discharge a patient on AWA status
at an earlier date.
(b) Except for a patient who was committed after a finding of incompetence to stand trial
whose charges have been dismissed, there shall be no discharge of a person on AWA status
who has been committed to a Department facility pursuant to M.G.L. c. 123, §§ 15, 16, 17
or 18.
(c) All parties who were notified at the time of a patient’s classification as AWA, shall be
notified of the facility’s decision to discharge the patient pursuant to 104 CMR 27.15(4)(a).
27.16: Records and Records Privacy
(1) Each facility shall maintain a patient record containing all significant clinical information
for each patient admitted to the facility. “Patient record” shall refer to the medical and
psychiatric record of a patient admitted to a facility providing care and treatment, and shall not
include any financial, statistical or bookkeeping records of the facility.
(2) Contents of Patient Record. A patient record shall include:
(a) identification data, including patient’s admission status;
(b) admission information, including admission diagnosis;
(c) health care proxies and advance directives;
(d) history and results of physical examination and psychiatric examination or mental status;
(e) consent forms;
(f) social service and nurses’ notes, and psychological reports;
(g) reports of clinical laboratory examinations and X-rays, if any;
(h) reports of diagnostic and therapeutic procedures;
(i) diagnoses recorded in accordance with the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5), 5 edition published by the American Psychiatric Association;th
(j) progress notes;
(k) reports of periodic reviews;
(l) conclusions, including primary and secondary final diagnoses and clinical resume;
(m) all restraint and seclusion orders, including comment forms;
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.16: continued
(n) le gal documents, including commitment orders and records of transfer, inc luding
notices of transfer, advanced directives, guardianship;
(o) records of all placements;
(p) reports of treatment for accidents, injuries or severe illnesses while the patient is in the
care of the facility;
(q) any required risk identifications and assessments;
(r) requests for and authorizations to disclose information from such individual patient
record;
(s) discharge information; and
(t) any other information deemed necessary and significant to the care and treatment of the
patient.
The patient record shall not include eva luations of compe tence to stand trial or cr iminal
responsibility conducted pursuant to M.G.L. c. 123, §§ 15 or 16, unless such evaluations have
been released to the record by the court that ordered such evaluation.
(3) Maintenance of Records for 20 Years. Each facility shall maintain each patient record for
at least 20 years after closing of the record due to discharge or death or the last date of service.
Prior to destruction of a record, the facility must notify the Department of Public Health in
accordance with the process specified in 105 CMR 130.370: Retention of Records. Each facility
shall develop and comply with written procedures concerning maintenance and destruction of
records.
(4) Format and Storage of Records. Patient records may be handwritten, printed, typed or in
electronic digital format, or any combination thereof, or converted to electronic digital format
or an alternative archival method. Handwritten, printed or typed medical records that have been
converted to electronic digital format or an alternative archival format may be destroyed before
the expiration of the 20-y ear retention period. The manne r of de struction must ensure the
confidentiality of patient information. Medical records in electronic digital format shall have the
same force and effect as the original records from which they were made. Any form of electronic
storage system shall have adequate backup and security provisions to safeguard against data loss,
as well as against unauthorized access.
(5) Notice of Privacy Practices. Each facility shall provide each patient with a notice of privacy
practices which meets the requirements set forth in 45 CFR 164.520. Additionally, such notice
shall describe the facility procedures regarding retention of records.
(6) Reporting Patient Data to the Department. Each facility shall maintain and make available
to the Department such statistical and diagnostic data as may be required by the Department.
(7) Confidentiality of Records. Each facility shall employ reasonable physical, technical and
administrative safe guards to ensur e the c onfidentiality, integrity and ava ilability of patient
records, and shall comply with all applicable federal and state laws and regulations. Except as
provided in 104 CMR 27.16, all records relating to any patients admitted to or treated by a
facility shall be private and not open to public inspection.
(8) Inspection by Patient, Legally Authorized Representative or Patient’s Attorney.
(a) A patient and the patient’s legally authorized representative shall be permitted to inspect
the patient’s records, unless a licensed health care professional of the facility determines that:
1. inspection by the patient is reasonably likely to endanger the life or physical safety
of the patient or another person;
2. the record makes reference to another person (other than a health care provider) and
inspection is reasonably likely to cause substantial harm to such other person; or
3. inspection by the legally authorized representative is reasonably likely to cause
substantial harm to the patient or another person.
(b) If access to a record is denied based on the criteria in 104 CMR 27.16(8)(a), the patient
or legally authorized representative shall be informed of, and have, the right to appeal. The
determination on appeal must be made by a licensed healthcare professional, other than the
person who made the initial decision to deny access, and such determination shall be final.
(c) The pa tient’s attorney shall be per mitted to ins pect the r ecord upon request. The
Commissioner or designee may require that the request be in writing and may further require
appropriate verification of the attorney client relationship.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.16: continued
(d) Clinical staff may offe r to rea d or interpr et the re cord, w hen nec essary, for the
understanding of the patient or his or her legally authorized representative. However, in no
circumstance may a patient be denied access to a record solely because he or she declines the
offer of clinical staff to read or interpret the record.
(e) The facility director may require the legally authorized representative’s consent before
permitting a patient younger than 18 years old to inspect his or her own r ecords, provided
that a patient who is 1 6 or 17 years of age and admitted himself or herself pursuant to
M.G.L. c. 123, §§ 10 and 11, may inspect records of the admittance without such consent.
The records of drug or medical or dental treatment of a patient younger than 18 years old who
has b een d etermined to be a n e mancipated o r m ature min or a s p rovided in 10 4 CM R
25.03: Emancipated a nd Ma ture Mi nors shall be conf idential betwee n the minor and
physician or dentist and shall not be released, except in accordance with M.G.L. c. 112, §
12F.
(9) Inspection by or Disclosure to Other Persons.
(a) The records of a patient shall be open to inspection or disclosure upon proper judicial
order, whether or not such order is made in connection with pending judicial proceedings.
1. For the purposes of 104 CMR 27.16(9), “proper judicial order” shall mean an order
signed by a justice or special justice of a court of competent jurisdiction as defined by the
General Laws, or a clerk or assistant clerk of such a court acting upon instruction of such
a justice. A subpoena shall not be deemed a “proper judicial order”.
2. Whenever practicable, a patient and the patient’s legally authorized representative,
if any, shall be informed of a court order for the production of the patient’s record.
(b) The records of a patient, or parts thereof, shall be open to inspection or disclosure by
other third parties, upon receipt of written a uthorization from the patient or the patient’s
legally authorized representative, provided that such written authorization shall meet the
requirements set forth in 45 CFR 164.508.
(c) The Commissioner or designee may permit inspection or disclosure of the records of a
patient where he or she has made a determination that such inspection or disclosure:
1. would be in the best interest of the patient; and
2. is permitted by the privac y regulations promulgated under the Health Insurance
Portability and Accountability Act (HIPAA) at 45 CFR Parts 160 and 164.
(d) Without limiting the discretionary authority of the Commissioner or designee to identify
other situations where inspection or disclosure is in the patient’s best interest, the following
inspections or disclosures are deemed to be in the patient’s best interest:
1. for purposes of treatment, payment, and health care operations as permitted by the
privacy regulations promulgated under HIPAA at 45 CFR Parts 160 and 164;
2. to obtain authority for a legally authorized repr esentative to act on the patient’s
behalf, or to obtain a judicial de termination of substituted judgm ent, when a clinica l
determination has been made that the patient lacks capacity to render informed consent
to treatment;
3. to persons conducting an investigation involving the patient pursuant to 104 CMR
32.00: Investigation and Reporting Responsibilities;
4. to persons engaged in research if such access is approved by the Department pursuant
to 104 CMR 31.00: Human Subject Research Authorization and Monitoring;
5. to make reports of communicable and other infectious disease to the Department of
Public He alth a nd/or loc al bo ard of h ealth c onsistent w ith 10 5 CM R
300.000: Reportable Disease s, Surveillance, and Isolation and Quarantine
Requirements; and
6. in the case of death, to coroners, medical examiners or funeral home directors.
(e) Records may be disclosed as required by law. In addition to the laws and regulations
of the Department, such laws include, but are not limited to:
1. M.G.L. c. 6, §§ 178C through 178Q (Sex Offender Registry Law);
2. M.G.L. c. 19A, § 15 (Executive Office of Elder Affairs - abuse of elderly persons, 60
years of age or older);
3. M.G.L. c. 19C, § 10 (Disabled Persons Protection Commission - abuse of disabled
persons 18 through 59 years of age);
4. M.G.L . c. 119, § 51A a nd 51B (Department of Children and F amilies - abuse or
neglect of children younger than 18 years old);
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.16: continued
5. 42 U.S.C. 10806 (Protection and Advocacy for Mentally Ill Individuals); and
6. M.G.L. c. 221, § 34E (Mental Health Legal Advisors Committee).
(f) Pursuant to M.G.L. c. 6A, § 16, the Department must offset the costs of the services
which it provides directly or through contract by maximizing all Title XIX and other federal,
state and private health insurance reimbursement which might be available for such services.
Accordingly, without limiting 104 CMR 27.16(9)(d)1., records may be disclosed by the
Department and/or its agents for the purposes of:
1. benefits/insurance coverage/availability inquiries;
2. obtaining third-party reimbursement;
3. appeals of reimbursement denials; and
4. charging fee payers as set forth in 104 CMR 30.04: Charges for Services.
(g) Any inspection or disclosure pursuant to 104 C MR 27.16(9)(c) through (f) shall be
limited to th e minimum information nece ssary to achieve the per mitted inspection or
disclosure.
(10) Notwithstanding the provisions of 104 CMR 27.16(8) and (9), inspection or disclosure of
records or information shall not be permitted in the following circumstances:
(a) if the re cord or information was o btained from someone other than a he alth care
provider under a promise of confidentiality, and the requested disclosure would likely reveal
the source;
(b) on a temporary basis only, by or to the patient during the course of research involving
treatment, where the patient agreed to such temporary suspension of access when consenting
to participation in the research study;
(c) if the s ubject of the re cord is in the custody of a c orrectional institut ion and the
correctional in stitution ha s r equested th at a ccess n ot b e pr ovided f or heal th a nd sa fety
reasons; or
 (d) if the records are created in anticipation of litigation.
27.17: Interpreter Services
(1) F or the purpose s of 104 CMR 27.17, the following wor ds shall have the f ollowing
meanings:
(a) Competent Interpreter Services. Interpreter services performed by a person who is fluent
in English and in the language of a non-English speaker, who is trained and proficient in the
skill and ethics of interpreting and who is knowledgeable about the specialized terms and
concepts that need to be interpreted for purposes of receiving care and treatment.
(b) F acility. A De partment-operated h ospital, c ommunity me ntal he alth c enter w ith
inpatient unit, or psy chiatric unit within a public health hospital; a De partment-licensed
psychiatric hospital; or a Department-licensed psychiatric unit within a general hospital.
(c) Non-English Speaker. A person who cannot speak or understand, or has difficulty
speaking or under standing, English because the spea ker primarily or only uses a spoke n
language other than English.
(2) Each facility shall in connection with the delivery of inpatient services, if an appropriate
bilingual practitioner is not ava ilable, provide competent interpr eter services to every non-
English speaker who is a patient.
(3) Based on the volume and diversity of non-English-speaking patients served by the facility,
the facility shall use reasonable judgment as to whether to employ, or to contract for, the on-call
use of one or more inter preters for pa rticular languages when needed, or to use compe tent
telephonic or te leviewing int erpreter s ervices; p rovided that such f acility sh all o nly us e
competent telephonic or televiewing interpreter services in situations where either:
(a) there is no reasonable way to anticipate the need for employed or contracted interpreters
for a particular language; or
(b) there occurs, in a particular instance, an inability to provide competent services by an
employed or contracted interpreter.
(4) Interpreter services shall be available 24 hours per day and seven days per week.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.17: continued
(5) The facility shall not require, suggest, or encourage the use of family members or friends
of patients as interpreters and shall not, except in exceptional circumstances, use minor children
as interpreters.
(6) The facility shall post signs and provide written notification of the right to and availability
of interpreter services to patients in their primary language.
(7) The facility shall develop written policies and procedures that are consistent with 104 CMR
27.17 and that assist staff and patients in accessing interpreter services.
SUBPART D: OPERATIONAL STANDARDS FOR SUBSTANCE USE DISORDER TREATMENT
FACILITIES
27.18: Substance Use Disorder Treatment Facility
(1) Scope. The provisions of 104 CMR 27.18 apply to all Facilities, or units within a facility,
that are operated by the Department of Mental Health to provide substance use disorder treatment
for adults who are subject to an order of involuntary commitment under M.G.L. c. 123, § 35.
Except as expressly provided in 104 CMR 27.18, no other provisions of 104 CMR 27.00 shall
apply to Facilities subject to 104 CMR 27.18.
(2) Commitment Status under M.G.L. c. 123, § 35. A substance use disorder, as defined in
105 CMR 164.006: Definitions shall qualify as a category of mental illness for the purpose of
involuntary commitment under M.G.L. c. 123, § 35. A substance use disorder shall not qualify
as a c ategory of mental illness for the purpose of involuntary commitment under any other
section of M.G.L. c. 123.
(3) Substance Use Disorder Treatment Facility (facility). Substance use disorder treatment
facility provides a range of services, including medically monitored detoxification, medically
assisted treatment and clinical stabilization services for adults 18 years of age or older who are
subject to an order of involuntary commitment under M.G.L. c. 123, § 35.
(4) Approval to Operate. The facility shall not operate without approval of the Department of
Public Health. The Department of Public Health shall have the right to inspect the facility prior
to granting su ch a pproval, a nd a t a ny oth er t ime, to de termine c ompliance wi th a pplicable
requirements of 105 CMR 164.000: Licensure of Substance Abuse Treatment Programs.
(5) Applicable Standards for Substance Use Disorder Treatment. In addition to the operational
standards of 104 CMR 2 7.00, the facility shall also meet the requirements for substance use
disorder treatment as set forth in 105 CMR 164.012(D)(3). The facility may request a waiver
of on e or mor e of the se re quirements in a ccordance wi th t he pr ovisions o f 1 05 CMR
164.023: Waivers.
(6) A dmission Criteria. A facility or unit within a facility may be designated for a specific
population, such as male or female, and may restrict admission to members of that population.
In addition, only patients who meet the following criteria may be admitted to and retained in the
facility:
(a) The individual must be 18 years of age.
(b) The individual must be subjec t to an order of involuntary commitment u nder the
provisions of M.G.L. c. 123, § 35.
Individuals who meet the admission criteria may be admitted to and retained in the facility
only in accordance with the provisions of M.G.L c. 123, § 35.
(7) Facility Medical Director. The facility shall designate a psychiatrist as the facility medical
director who shall be responsible for administering all medical or behavioral health services
performed a t the faci lity. The facility medical dire ctor shall be f ully licensed to pra ctice
medicine under Massachusetts law, and shall have completed a minimum of six months clinical
experience with alcohol or other substance use disorders.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.18: continued
(8) Staffing Pattern. The facility shall establish a staffing pattern that includes staff in sufficient
numbers, qualifications and shift coverage to ensure the provision of services, safety of patients
and staff and operation of the program in accordance with the requirements of 104 CMR 27.18.
(9) General Physical Requirements. The facility shall provide space that is safe, comfortable,
well-lit, well-ventilated, a dequate in siz e and of sufficient quality to be ut ilized in a manner
consistent with the overall philosophy and treatment goals of the program. The facility shall also
provide sufficient security features to enable the staff to prevent physical harm to patients and
to staff and to prevent elopement from the facility, including the capacity to lock the facility to
prevent unauthorized access to the community.
(10) Policies and Procedures. The facility shall have written policies and procedures consistent
with the require ments of this tit le and a ccepted standards of ca re for substance use disorder
treatment services and applicable law.
(11) Treatment. Each patient shall be informed upon admission of the right to receive treatment
upon g iving infor med conse nt. The patient s hall, upon giving informed c onsent, rec eive
substance use disorder treatment and services, as needed. If a patient is deemed incapable of
giving informed consent, medication treatment may not be administered or performed without
authorization b y a c ourt of c ompetent j urisdiction or the c onsent o f t he pa tient’s le gally
authorized representative. Prior to an adjudication of incapacity and appointment of a guardian,
or activation of a health care proxy, a patient retains the right to accept or refuse medications as
prescribed.
(12) Periodic Review. In addition to the clinical reviews required pursuant to 104 CMR
27.18(21)(a), the facility shall conduct a periodic review of each patient upon admission and
once during the first three months of admission in accordance with M.G.L. c. 123, § 4. Each
patient shall be provide d advance written notice of the scheduled review and sha ll have the
opportunity to participate to the ful lest extent possible. Notice to fa mily members sha ll be
provided upon the e xpress written consent of the pa tient or the patient’s le gally authorized
representative.
(13) Patient Rights. The legal and civil rights of patients are set forth in 104 CMR 27.13. In
addition, a patient receiving substance use disorder treatment shall have the right to have drug
screens conducted in a manner that preserves the patient’s dignity. The facility shall safeguard
and ensure these rights and shall appoint a human rights officer and establish a human rights
committee in accordance with the requirements of 104 CMR 27.14.
(14) Restraint and Seclusion. The facility shall comply with all standards and requirements for
the use of restraint and seclusion as provided in 104 CMR 27.12.
(15) Patient Records. Records of the identity, diagnosis, prognosis or treatment of any patient
shall be privileged and confidential and shall only be disclosed in conformity with applicable
state and federal laws and regulations regarding the confidentiality of patient records including,
but not limited to, 42 CFR Part 2 (Confidentiality of Alcohol and Drug Abuse Patient Records),
and 45 CFR Parts 160 and 164 ( HIPAA Privacy and Secur ity Rules) and , to the extent not
preempted by federal law, M.G.L. c. 123, § 36 and 104 CMR 27.16.
(a) Each patient record shall be maintained and stored in accordance with the requirements
of 42 CFR Part 2, and 104 CMR 27.16(3) and (4).
(b) Each patient receiving substance use disorder treatment shall be provided a notice of
privacy practices which meets the requirements of 42 CFR Part 2 and 45 CFR Parts 160 and
164.
(c) Inspection of the record by the patient or others shall be governed by 42 CFR Part 2,
and all applicable federal and state laws and regulations.
(16) Comp laints and Investigations. Any patient in a fa cility shall have the right to make a
complaint regarding any incident or condition which he or she believes to be dangerous, illegal
or inh umane a s thos e te rms a re de fined in 10 4 CM R 32 .00: Investigation and Reporting
Responsibilities. Co mplaints sh all b e re ported, re viewed, inv estigated a nd re solved in
accordance with the requirements of 104 CMR 32.00.
104 CMR: DEPARTMENT OF MENTAL HEALTH
27.18: continued
(17) Interpreter Services. The f acility shall provide competent interpreter services for non-
English speaking patients in accordance with the requirements of 104 CMR 27.17. The facility
may contract interpreter services pursuant to a Qualified Service Organization Agreement subject
to the requirements of 42 CFR Part 2.
(18) Tr ansfer. A pa tient who is subject to an orde r of involunt ary commitment under
M.G.L. c. 123, § 35 may be transferred to another facility in accordance with the requirements
of M.G.L. c. 123, § 3. The receiving facility must be approved by the Department of Public
Health to provide substance use disorder treatment to patients involuntarily committed under
M.G.L. c. 123, § 35.
(19) Tr ansport. A pa tient who is subject to an order of involuntary commitment under
M.G.L. c. 123, § 35 may be transported for evaluation or treatment to a medical facility, court,
or to o ther d estination approved b y the fa cility dir ector, f acility me dical di rector, o r t heir
designee(s). The provisions of 104 CMR 27.08(10) shall permit and govern the use of restraint
during transport.
(20) Abse nce without Authorization. A fa cility shall have a written plan f or an emergency
response when a patient leaves the facility grounds or an off-grounds activity without permission.
The facility’s plan shall spec ify action to be take n by facility staff, a nd notice to interested
parties, including law enforcement, as permitted by law.
(21) Disc harge. A pa tient who is subject to an orde r of involuntary commitment under
M.G.L. c. 123, § 35 may be released prior to the expiration of the commitment period under the
order upon proper judicial order or upon written determination by the facility director that release
of that individual will not result in a likelihood of serious harm to the patient or others as a result
of the patient’s substance use disorder.
(a) A clinical review of the necessity of the commitment shall be conducted on days 30, 45,
60 and 75, as long as the c ommitment continues. The results of clinic al reviews must be
documented in the patient’s medical record.
(b) Upon discharge, the individual shall be encouraged to consent to, and shall be provided
with, a re commended post-discharge treatment plan with identified re sources for further
treatment. Upon receipt of authorization consistent with 104 CMR 27.18(11), the facility
shall refer the individual to an appropriate program or service provider for further treatment.
REGULATORY AUTHORITY
104 CMR 27.00: M.G.L. c. 19, §§ 1, 7, 8, 18 and 19; M.G.L. c. 123, § 2.