COMAR Title10, Subtitle 47 Alcohol

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COMAR Title10, Subtitle 47Alcohol Drug
AbuseAdministrationEffective May 5, 2008
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PresenterDonald L. Hall, MHS, LCADCDivision
Director Quality Assurance Maryland Alcohol
Drug Abuse Administration(410) 402
8590dhall_at_dhmh.state.md.us
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Goal

• The goal of this workshop is to highlight some of
  the changes in COMAR Title 10 Subtitle 47 and
  provide an understanding of what will be expected
  of substance abuse providers to meet the
  requirements of certification, recertification
  and compliance reviews.

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The process of revising the regulations has taken
four years. It started with meeting and focus
groups of ADAA stake holders. It continued with
postings of the COMAR drafts on the ADAA website
and rewrites based on the comments from the field.
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Once the final draft had been completed it was
posted on the Maryland Register for 30 days for
comments. All comments from the public and the
field were responded to by ADAA. At that point
the draft was submitted to the Joint Committee on
Administrative, Executive, and Legislative Review
(AELR) for promulgation.
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The AELR Committee expressed some concerns
which lead to additional meetings and a revision
to the COMAR draft. Now the field has a
revised Code of Maryland Regulations
Title 10, Subtitle 47 Alcohol
and Drug Abuse
Administration
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Revisions have been made in most of the chapters
of COMAR 10.47. One chapter has been removed,
Chapter 6, Alcohol and Drug Treatment to Work
Pilot Program. New Chapter 3, Specific Program
Requirements for Correctional Levels of Care.
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Chapter 01 Requirements
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.02 Definitions. (19) Correctional Facility.
(a) Correctional facility means an institution
overseen by the State or one of the 24
subdivisions where individuals are incarcerated.
(b) Correctional facility includes a jail,
detention center, prison, or correctional halfway
house.
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(22) Critical Incident. (a) Critical incident
means a life, safety, or health threat involving
the staff or patients participating in a program.
(b) Critical incident includes, but is not
limited to, death or physical or sexual assault.
(23) Critical incident report means the
documentation of a critical incident.
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(48) Prevention program means the Early
Intervention Level 0.5 level of treatment as
described in COMAR 10.47.02.03. This reference
is based on statutory language and will be
changed when COMAR is revised in the near future.
This is NOT a reference to the traditional
community Prevention Program. This is clearly a
reference to EARLY INTERVENTION Level 0.5.
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(57) Treatment plan goal means an intended
resolution of a patient's clinical condition or
problem that is completed within a specific
amount of time and will contribute to the
completion of treatment in a program.
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(58) Treatment plan objective means a
behaviorally measurable symptom or social, legal,
or family change that results in a stepwise
achievement of a treatment goal.
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.03 Governance. 10.47.01.03. C. Implement
personnel policies and procedures that
include (2) Personnel policies that include
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(h) As part of the employment or volunteer
application process, requiring the applicant to
complete and sign a sworn statement or written
affirmation disclosing the existence of a
criminal conviction, probation before judgment
disposition, not criminally responsible
disposition, or pending charges without a final
disposition Documentation must be provided for
volunteers as well as employees
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(j)  Providing information to the employee so the
employee may determine whether he or she needs
testing or vaccination or both for hepatitis.
Programs must implement employee education
regarding hepatitis, as part of their
orientation as well as update their policy and
procedure manual.
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10.47.01.03 D. Manage the program
by (1) Implementing a policy and procedure
manual that contains (a) An all hazards
emergency protocol plan, approved by the
Administration and updated at the time of
recertification, that includes
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(i) The name of the contact person for access to
medical and clinical records (iii) Notification
procedures for the State Methadone Authority,
program staff, and patients (iv) A policy
regarding patient access to emergency mental
health services necessitated by a hazardous
event and (v) A policy assuring that
correctional levels of care comply with the
institution's all hazards emergency plan
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Prepare a plan for managing all emergencies
necessitated by a hazardous event. ADAA can
provide a check list as a guide. Update policies
and procedures for each situation. Reporting
information Alcohol and Drug Abuse
Administration, Compliance Section, Fax for
reporting is 410-402-8606.
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.04 Clinical Requirements B. Assessment. (1) A
program shall prepare a comprehensive assessment
for each patient, unless the patient is being
readmitted to the same program or admitted to a
different program within 30 days of the patient's
last discharge, or has received an assessment by
a licensed or certified clinician or program
within 30 days, in which case the program may
update the prior assessment.
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Programs update comprehensive assessment
information in the policy and procedure manuals
and review requirements when patients are
admitted from prior treatment.
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C. Treatment Plans. (i) Long-range and
short-range treatment plan goals and objectives
(ii) Strategy for implementation of treatment
plan goals and objectives (iii) Target dates
for completion of treatment plan goals and
objectives Drop-down treatment plan in SMART
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D. Infectious Disease Education. Within the first
30 days of treatment, a program shall ensure and
document in the patient record that human
immunodeficiency virus, hepatitis, sexually
transmitted diseases, and tuberculosis education
was completed, including Programs must include
required information in education and risk
assessment for patients.
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G. Discharge. (3) The discharge summary shall be
completed within 30 days of the patient's
discharge from the program. (4) In the event of
a patient's transfer from the program to another
program, the discharging program shall complete a
written transfer summary.
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(5) The transfer summary shall include (a) The
reason for admission (b) The reason for
discharge (c) The individual's address
(d) The diagnosis and prognosis at the time of
discharge and (e) Current medications, if
applicable. (6) The transfer summary shall be
completed at the time of the patient's discharge
from the program.
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I. Medication Control and Staff
Requirements. (1) A program shall develop and
implement a written policy and procedure
governing the use of controlled dangerous
substances and other drugs used by the program.
The policies shall include (e) Procedures for
all Level III programs to hold securely all
take-home opioid therapy medication for patients
who are on opioid maintenance therapy.
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(4) Medication Errors. (a) For a medication
error regarding administration, dispensing,
documentation, inventory, or storage, an
appropriate clinical staff person shall complete
a report at the time of the incident. Programs
must update policy and procedure manuals address
the management of medication errors.
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(b) The report shall be filed and brought to the
immediate attention of the (i) Administrator
and (ii) Medical director, if a medical director
is employed by the program. (5) Programs shall
report the diversion of any controlled substance
to the Administration as soon as the diversion is
discovered. Reporting information Alcohol and
Drug Abuse Administration, Compliance Section,
Fax for reporting is 410-402-8606.
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.05 Environmental Requirements. A. Life Safety
Requirements. A Program shall (3) Maintain
documentation of legally required periodic
evacuation drills, if applicable
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• .06 Staff Requirements
• 10.47.01.06
• Administrator.
• Required the position
• Establishes the qualifications and duties
• D. Clinical Staff.
• Must be credentialed and or privileged to
• include students, interns, and volunteers.
• All staff must sign statement that they
• reviewed and understand PP.

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.07 Patient Rights and Grievance
Procedures In this chapter the language was made
clearer to clarify the expectations.
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.08 Records Established that records must be
maintained, transferred, and destroyed as per
identified state and federal laws. C.
Electronic Records. Establishes how an
electronic record shall be maintained and what
the hard copy file shall contain.
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.
.09 Referral Agreements and Program
Cooperation There were no changes in this section

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Chapter 02 Specific Program Requirements
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.03 Early Intervention Level 0.5 A. Prevention
Program Description. The prevention program shall
treat patients who are, for a known reason, at
risk for developing alcohol or other drug abuse
or dependence but for whom there is not yet
sufficient information to document alcohol or
other drug abuse or dependence. Level 0.5 is
Early Intervention (This is NOT a reference to
Community prevention programs)
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D. Program services include (1) Assessments as
described in COMAR 10.47.01.04 within 2 weeks of
admission (2) An individualized treatment plan
as described in COMAR 10.47.01.04, completed and
signed by the alcohol and drug counselor and
patient within 7 working days of the
comprehensive assessment and updated every 90
days
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.04 Outpatient Services Level I. A. Program
Description. The program shall provide outpatient
evaluation and treatment to patients who require
services for less than 9 hours weekly for adults
and 6 hours weekly for adolescents.
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D. Program Services. A program shall provide the
following services (1) An assessment as
described in COMAR 10.47.01.04 within 2 weeks of
admission (2) An individualized treatment plan
as described in COMAR 10.47.01.04 completed and
signed by the alcohol and drug counselor and
patient within 7 working days of the
comprehensive assessment and updated every 90
days
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(5) Family services that shall include an
assessment for family treatment needs and, as
clinically appropriate Family assessment and
treatment, if needed is now required.
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• .05 Intensive Outpatient Services Level II.1 and
  Partial Hospitalization Services Level II.5.
• (1) From 9 to 20 hours weekly for adult
• intensive outpatient services
• (2) From 6 to 20 hours weekly for adolescent
  intensive outpatient services, based on the
  adolescents' developmental and clinical needs
  and
• (3) From 20 to 35 hours weekly for adult and
  adolescent partial hospitalization services.

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D. Program Services. A program shall provide the
following services (1) An assessment as
described in COMAR 10.47.01.04 within 1 week of
admission (2) An individualized treatment plan
as described in COMAR 10.47.01.04 completed and
signed by the alcohol and drug counselor and
patient within 5 working days of the
comprehensive assessment and updated every 30
days
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• F. Referral Services. The program shall offer
  the following services or maintain a listing of
  agency referral agreements for the following
  services
• Medical services with medical consultations
  available
• Specifies the time frames for services
• (4) Mental health services with psychiatric
  consultations available
• Specifies the time frames for services

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.06 Residential Service Clinically Managed Low
Intensity Treatment Level III.1. D. Program
Services. A clinically managed low intensity
treatment program shall provide the following
services (1) An assessment as described in
COMAR 10.47.01.04 within 2 weeks of admission
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(2) An individualized treatment plan as described
in COMAR 10.47.01.04 completed and signed by the
alcohol and drug counselor and patient within 7
working days of the comprehensive assessment and
updated every 60 days
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F. Referral Services. The program shall offer the
following services or maintain a listing of
agency referral agreements for the following
services (1)  Physical examinations as
determined by medical condition, within a
reasonable time (2)  Services through the
Division of Rehabilitation Services
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(4) Mental health services, which shall include
(a) Medication monitoring for patients who are
admitted on or are prescribed psychotropic
medications and (b) Services appropriate to
the severity and urgency of the patient's mental
condition
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.07 Residential Services Clinically Managed
Medium Intensity Treatment Level
III.3. D. Program Services. A program shall
provide the following services (1) An
assessment as described in COMAR 10.47.01.04
within 1 week of admission
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(2) An individualized treatment plan as described
in COMAR 10.47.01.04 completed and signed by the
alcohol and drug counselor and patient within 3
working days of the comprehensive assessment and
updated every 30 days
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F. Referral Services. The program shall offer the
following services or maintain a listing of
agency referral agreements for the following
services (1) Physical examinations as
determined by medical condition, within a
reasonable time (3) Services through the
Division of Rehabilitation Services
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(5) Mental health services, which shall include,
as appropriate to the severity and urgency of the
patient's mental condition (a) Medication
monitoring for patients who are admitted on or
are prescribed psychotropic medications and
Monitoring would include observing signs and
symptoms. This includes how a patient is
clinically responding to medication, dose
adjustments, etc and managing, if co-occurring
disorder capable, or referring out.
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(b) At least one of the following services
(i) Services available by telephone within
8 hours of a request or (ii) Services
available onsite or closely coordinated
off-site within 24 hours of a request
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.08 Residential ServicesClinically Managed High
Intensity Treatment Level III.5. D. Program
Services. A program shall provide the following
services (3) An assessment as described in
COMAR 10.47.01.04 within 2 days of admission
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(4) An individualized treatment plan as described
in COMAR 10.47.01.04 completed and signed by the
alcohol and drug counselor and patient within 2
working days of the comprehensive assessment with
a treatment plan update every 30 days
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F. Referral Services. The program shall offer the
following services or maintain a listing of
agency referral agreements for the following
services (4) Mental health services, which
shall include, as appropriate to the severity and
urgency of the patient's mental condition
(a) Medication monitoring for patients who are
admitted on or are prescribed psychotropic
medications and
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(b) At least one of the following services
(i) Services available by telephone within 8
hours of a request or (ii) Services available
on-site or closely coordinated off-site within 24
hours of a request
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.09 Residential ServicesMedically Monitored
Intensive Inpatient Treatment Level III.7.
D. Program Services. A program shall provide
(1) An assessment as described in COMAR
10.47.01.04 within 2 days of admission
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(2) An individualized treatment plan as described
in COMAR 10.47.01.04C completed and signed by the
alcohol and drug counselor and patient within 7
working days of the comprehensive assessment with
a treatment plan update completed every 7 days
(3) A minimum of 36 hours of therapeutic
activities a week including, but not limited to
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E. Medically Monitored Services. This section
explains nursing services, medication
monitoring Physician, physician assistant or
nurse practitioner services Establishes time
frames for services
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.10 Detoxification Services. C. Level I-D
Ambulatory Detoxification Without Extended
On-Site Monitoring. D. Level II-D Ambulatory
Detoxification with Extended On-Site
Monitoring. E. Level III.2-D Clinically Managed
Residential Detoxification. F. Level III.7-D
Medically Monitored Inpatient Detoxification.
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C. Level I-D Ambulatory Detoxification Without
Extended On-Site Monitoring. Staffing
requirements for Level D will be waived based
on written request and programs receiving a
waiver will follow the staffing requirements for
Level II-D. This staffing issue will be
addressed in the next revision of COMAR.
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E. Level III.2-D Clinically Managed Residential
Detoxification. F. Level III.7-D Medically
Monitored Inpatient Detoxification. There are
provisions in COMAR for Levels III.2-D and
III.7-D, when treating patients with opioid
maintenance medication
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(8) Patients Treated with Opioid Maintenance
Medication. (a) A detoxification facility is
not limited in the number of admissions for
detoxification of patients who are treated with
opioid maintenance medication. (b) A
detoxification facility is not limited in the
total number of doses of opioid maintenance
medication that it will accept from patients who
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(i) Attend the detoxification program and
(ii) Require opioid maintenance medication for
opioid detoxification or detoxification for
substances other than opioids.
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.11 Opioid Maintenance Therapy. A. Program
Description. Opioid maintenance therapy
(1) Uses pharmacological interventions,
including full and partial opiate agonist
treatment medications, to provide treatment,
support, and recovery to opioid-addicted
patients
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Buprenorphine is not restricted to use within OMT
programs. Buprenorphine may be use in any level
of care without certification as an Opioid
Maintenance Therapy Program.
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C. Staffing. (1) The patient to alcohol and drug
counselor ratio may not exceed 50 patients to one
full-time counselor. (2) Medical Director.
Grandfathering for Medical Directors has been
added.
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D. An opioid maintenance therapy program
shall (5) Develop procedures, approved by the
Administration, that mandate clinical
intervention if a patient's drug test result
indicates substance use. See TIP 43, Chapters
8 and 9
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G. Opioid maintenance programs shall arrange for
transportation of medication to and from the
following levels of care (1) Residential
treatment at Levels III.3, III.5, and III.7, as
described in Regulations .07.09 of this chapter
(2) Detoxification services at Level III.2-D
and III.7-D, as described in Regulation .10 of
this chapter or (3) Residential treatment at
Level III.1, ..
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J. Criteria for Take-Home Privileges. Before the
patient may take home any dose the patient shall
(1) Meet the criteria set within 42 CFR 8 and
(2) Provide the program with a working lock
box for the take-home medication. No other
requirements have been added.
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Chapter 03Specific Program
Requirements for Correctional Levels of Care
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The Correctional levels of care are .03
Correctional Level I. .04 Correctional Level
II.1. .05 Correctional Level II.5. .06
Correctional Level III.1. .07 Correctional Level
III.5. The levels are based on the ASAM levels
of care and services provide at those levels.

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.01 Scope. Establishes requirements and
exemption that have been for correctional
programs taking into consideration institutional
policy and procedures. C. Staffing. These
programs were not assigned staffing a ratio.
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F. Referral Services. The program shall have
available through referral the following at the
time of the patient's release from the
institution Detention Centers will be waived
from this requirement for patients who remain
incarcerated for at least 31 days after discharge
from treatment. This includes correctional
treatment levels I, II.1, II.5, III.1,and III.5.
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Chapter 04Certification Requirements
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.03 Certification Required. A.  All programs and
prevention programs shall be certified by the
Department before program services and prevention
program services may be provided in the State.
This reference to prevention covers Level 0.5
Early Intervention.
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.04 Type and Duration of Certification. D. Surren
der of Certification. A program shall surrender
its certificate to the Administration on .05
Application Process and Evaluation. (4) An
application fee of 700 with initial application
and at recertification, if the program provides
opioid maintenance therapy as described in COMAR
10.47.02.11.
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The fee was required by the Budget Reconciliation
Act 2004. This requirement for certification
helps align the Alcohol and Drug Abuse
Administration with other administrations that
are certified by the Office of Health Care
Quality.
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.07 Investigation or Inspection by the
Administration or Office of Health Care Quality.
Program must be open to ADAA and OHCQ for
announced or unannounced inspections and
investigations. .08 Denial, Probation,
Intermediate Sanctions, Suspension, or
Revocation. Establishes Program Sanctions
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Chapter 05 Education Programs
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.04 Program Requirements. The program
shall A.  Comply with COMAR 10.47.01 and
10.47.02.03 Programs must comply with Chapter 1
Requirements and Chapter 2 Specific Program
Requirements, .03 Early Intervention Level 0.5.
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This was done to establish consistency and basic
quality of care standards for DWI education. The
Administration's required curriculum has been
updated .05 Denial, Probation, Intermediate
Sanctions, Suspension, or Revocation. Establishes
Sanctions Education Program
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Chapter 06Substance Abuse
Treatment Outcomes Partnerships-
(S.T.O.P.) Fund

• There were no changes made in
• Chapter 06.

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Thank You For Supporting Good
Clinical Practice!

• Please send any additional questions to Paulette
  Clem, Chief of Legislation and Regulation
• pclem_at_dhmh.state.md.us
• Phone [phone]
• COMAR 10.47
• www.dsd.state.md.us