9 CSR — Department of Mental Health

Division 10 Director, Department of Mental Health

Chapter 1 Organization and Description

9 CSR 10-1.030 Guidelines for Membership on Regional Developmental Disabilities MENTAL HEALTH Mental Health Description {#sec-9-csr-10-1.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-1.030}

9 CSR 10-1.010 General Organization {#sec-9-csr-10-1.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-1.010}

PURPOSE: This rule describes the organization of the department and where the public may obtain information about the department as required by section 536.023, RSMo.

(1) The Department of Mental Health (DMH) was established by the Omnibus Reorganization Act of 1974. Under Chapter 630, RSMo the department shall administer, maintain, and develop facilities and services for persons affected by mental disorders, developmental disabilities, and alcohol or drug abuse. The department further seeks to reduce the incidence and prevalence of disabling conditions; to systematically plan on a regional and statewide basis for the provision of services; to certify or license, or both, certain residential facilities, day programs, and specialized services; to conduct research and program evaluation to improve services; and to develop staff and analyze mental health manpower needs.

(2) As set out in section 630.015, RSMo, the State Mental Health Commission appoints the department director with the advice and consent of the senate. The director serves at the pleasure of the commission. As set out in

section 630.025, RSMo, the commission sets the salary of the department director. The other statutory duties of the commission are mainly advisory as set out in section 630.015, RSMo. Membership and meeting requirements of the commission are set out in

section 630.010, RSMo.

(3) The department director heads the department as its chief executive officer as set out in section 630.025, RSMo to perform the duties and exercise the powers as may be imposed or conferred upon him/her by law.

(4) The department service delivery system is divided into the following two (2) divisions as described in other rules of this title: the Division of Behavioral Health and the Division of Developmental Disabilities.

(A) The Division of Behavioral Health provides comprehensive mental health and substance use disorder prevention, treatment, and recovery services. The division oversees stateoperated facilities for people with serious mental illnesses and children with severe emotional disturbances. Community-based treatment is provided through contracted, certified agencies that serve children, youth, and adults. Recovery services support individuals in recovery from serious mental illness or substance use disorders. Prevention services are provided through a network of contracted, certified agencies that offer education and early intervention activities for children, youth, and families. Prevention Resource Centers are the primary source of technical assistance for local communities.

(B) The Division of Developmental Disabilities serves a population that has such developmental disabilities as cerebral palsy, head injury, autism, epilepsy, and certain learning disabilities. Such conditions must have been manifested before age twenty-two (22) with the expectation that they will continue. To be eligible for services from the division, persons with these disabilities must have substantial functional limitations in two (2) or more of the following areas of major life activities: self-care, receptive and expressive language development and use, learning, selfdirection, capacity for independent living or economic self-sufficiency, and mobility. This division’s primary mission is to assist persons with developmental disabilities through programs and services to enable those persons to live independently and productively.

(5) The department provides administrative and technical support for the entire department and its divisions through the following units:

(A) The Division of Administration provides a range of administrative and financial services to help the department achieve effective results. The office’s services can be divided into the following areas:

Budget and Finance;
Accounting;
Purchasing and General Services; and 4. Medicaid Reimbursements;

(B) The Office of Human Resources is responsible for supplying administrative support for employment, labor relations, recruitment, compensation management, and affirmative action. The Office of Human Resources’ phone number is (573) 751-4991;

(C) The Office of Public and Legislative Affairs disseminates information to the public concerning mental health programs and services. The office works with state and local officials, stakeholders, the public, and other state departments to advocate for the department’s objectives by advancing legislative initiatives designed to develop sound public policies relating to mental health services.

The Office of Public and Legislative Affairs’ phone number is (573) 751-1647;

(D) The Office of Constituent Services advocates for individuals (and their families) who receive services for developmental disabilities, mental illnesses, and substance use disorders, and responds to issues regarding consumer rights. The phone number of the Office of Constituent Services is (573) 751- 8088, or toll-free at 1-800-364-9687; and (E) The Office of Deaf Services provides training, consultation, and technical assistance to DMH facilities and contracted providers delivering mental health services to eligible individuals who are deaf or hard of hearing. The office also oversees policy development, best practices, and program development informed by advisory input from DMH stakeholders. The phone number of the Office of Deaf Services is (573) 526- 1857.

(6) In accordance with various authorizing statutes, the department promulgates rules by filing them with the secretary of state. The department also adopts department-wide operating regulations concerning its internal management. Each facility adopts policies that are directly relevant only to its own operations.

Rules are available at the department central office for public inspection and review, as well as online at the secretary of state’s website at https://www.sos.mo.gov/adrules/csr/current/9 csr/9csr.

(7) A records custodian, appointed by the department director, is responsible for the maintenance of the department’s records. Procedures for the release of information on any meeting, record, or vote is available from the records custodian directly, located at the Department of Mental Health, 1706 East Elm Street, PO Box 687, Jefferson City, MO 65102. The records custodian shall also provide information on charges for record copying, timelines for producing records, and assistance for persons with disabilities, for example, large print or Braille materials.

Filed July 1, 1997, effective Dec. 30, 1997.

Amended: Filed April 17, 2002, effective Oct. 30, 2002. Amended: Filed March 9, 2018, effective Oct. 30, 2018. *Original authority: 536.023, RSMo 1975, amended 1976, 1997, 2004 and 630.050, RSMo 1980, amended 1993, 1995, 2008.

Op. Atty. Gen. No. 70, Wilson (8-27-79).

JOHNR. ASHCROFT(9/30/18)

Except under the interstate compact on mental health, the Department of Mental Health does not have the authority to place patients out of the state.

Op. Atty. Gen. No. 228, Robb (6-28-73). The Division of Mental Health has the authority and the duty to charge for the care and treatment of a juvenile committed to the Division of Mental Health by the juvenile court or transferred to the Division of Mental Health from the State Board of Training Schools pursuant to section 211.201, RSMo if such person is determined to be a private patient pursuant to the provisions of section 202.863, RSMo.

Op. Atty. Gen. No. 60, Robb (1-17-73).The Division of Mental Health is required to adopt rules for all institutions accepting the mentally retarded including facilities operated by the division itself. Homes and institutions which are licensed under the provisions of chapter 198, RSMo as nursing homes by the Division of Health and which come within the provisions of section 202.905, RSMo, must also be licensed by the Division of Mental Health and must conform to the rules promulgated by the respective divisions.

Op. Atty. Gen. No. 66, Nanson (6-18-58).

The Division of Mental Diseases may charge pay patients in state hospitals the maximum amount fixed by the division for each institution or any amount below that maximum based upon the ability, or means of the patient, to pay. A husband is liable for the support of his wife unless she has abandoned him/her without good cause or has abandoned him/her with cause, and has contracted an adulterous relationship consequently; that a husband is liable for the support of his minor children; that in the absence of the husband or his inability to support minor children the same obligation devolves upon the wife. Persons who adopt a child and persons who stand in the position of in loco parentishave the same duty to support as do natural parents.

History

AUTHORITY: sections 536.023 and 630.050, RSMo 2016. Original rule filed April 8, 1976, effective July 12, 1976. Rescinded and readopted: Filed April 14, 1981, effective Aug. 17, 1981. Amended: Filed May 25, 1995, effective Nov. 30, 1995. Amended:

9 CSR 10-1.030 Guidelines for Membership on Regional Developmental Disabilities Advisory Councils {#sec-9-csr-10-1.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-1.030}

(Moved to 9 CSR 45-6.010)

4CODE OF STATE REGULATIONS

(9/30/18) JOHNR. ASHCROFT

Chapter 2 Standards for All Residential Facilities Subject to Licensing

9 CSR 10-2.010 Rules Applicable to all Residential Facilities for the Mentally Retarded Subject to Licensing {#sec-9-csr-10-2.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-2.010}

9 CSR 10-2.015 Licensure Procedures RSMo Supp. 1982. Emergency rule filed Aug. 27, 1981, effective Sept. 7, 1981, expired Jan. 1, 1982. Original rule filed Sept. 14, 1981, effective Jan. 1, 1982. Rescinded: {#sec-9-csr-10-2.015 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-2.015}

9 CSR 10-2.020 Definitions {#sec-9-csr-10-2.020 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-2.020}

9 CSR 10-2.030 Application of Standards {#sec-9-csr-10-2.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-2.030}

9 CSR 10-2.040 Issuance of License {#sec-9-csr-10-2.040 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-2.040}

(Rescinded January 1, 1982)

Filed Sept. 14, 1981, effective Jan. 1, 1982.

History

AUTHORITY: sections 630.050 and 630.655, RSMo 1980. Original rule filed Jan. 16, 1975, effective Jan. 26, 1975. Emergency rescission filed Aug. 27, 1981, effective Sept. 7, 1981, expired Jan. 1, 1982. Rescinded:

9 CSR 10-2.043 Removal of Department of Mental Health Clients from Unlicensed Facilities RSMo Supp. 1982. Original rule filed April 13, 1978, effective Aug. 11, 1978. Rescinded: {#sec-9-csr-10-2.043 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-2.043}

9 CSR 10-2.044 Removal of Department of Mental Health Clients from Uncertified Facilities RSMo Supp. 1982. Original rule filed July 10, 1978, effective Oct. 13, 1978. Rescinded: {#sec-9-csr-10-2.044 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-2.044}

9 CSR 10-2.050 Hearing Procedure {#sec-9-csr-10-2.050 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-2.050}

(Rescinded January 1, 1982)

Filed Sept. 14, 1981, effective Jan. 1, 1982.

History

AUTHORITY: sections 630.050 and 630.655, RSMo 1980. Original rule filed Jan. 16, 1975, effective Jan. 26, 1975. Emergency rescission filed Aug. 27, 1981, effective Sept. 7, 1981, expired Jan. 1, 1982. Rescinded:

9 CSR 10-2.060 Facility Admission Policies {#sec-9-csr-10-2.060 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-2.060}

9 CSR 10-2.070 Facility Education, Training and Recreation {#sec-9-csr-10-2.070 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-2.070}

9 CSR 10-2.080 Records {#sec-9-csr-10-2.080 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-2.080}

9 CSR 10-2.090 Resident Living {#sec-9-csr-10-2.090 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-2.090}

9 CSR 10-2.100 Construction of Physical Plant Facilities {#sec-9-csr-10-2.100 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-2.100}

9 CSR 10-2.110 Revocation or Suspension of License Emergency rule filed June 14, 1979, effective June 25, 1979 expired Oct. 22, 1979. {#sec-9-csr-10-2.110 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-2.110}

MATTBLUNT(10/31/01)

Chapter 3 Standards for Group Care Homes Subject to Licensing

9 CSR 10-3.010 Food Service Facilities {#sec-9-csr-10-3.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-3.010}

9 CSR 10-3.020 Fire Protection and Safety {#sec-9-csr-10-3.020 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-3.020}

9 CSR 10-3.030 Medical and Health Care {#sec-9-csr-10-3.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-3.030}

9 CSR 10-3.040 Personnel Policies MATTBLUNT(10/31/01) {#sec-9-csr-10-3.040 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-3.040}

Chapter 4 Standards for Residential Centers Subject to Licensing

9 CSR 10-4.010 Food Service Facilities {#sec-9-csr-10-4.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-4.010}

9 CSR 10-4.020 Fire Protection and Safety {#sec-9-csr-10-4.020 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-4.020}

9 CSR 10-4.030 Medical and Health Care {#sec-9-csr-10-4.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-4.030}

9 CSR 10-4.040 Personnel Policies MATTBLUNT(10/31/01) {#sec-9-csr-10-4.040 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-4.040}

Chapter 5 General Program Procedures

9 CSR 10-5.010 General Rules Applicable for Foster Care Homes for the Mentally {#sec-9-csr-10-5.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.010}

9 CSR 10-5.220 Privacy Rule of the Health Insurance Portability and Accountability {#sec-9-csr-10-5.220 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.220}

9 CSR 10-5.010 General Rules Applicable for Foster Care Homes for the Mentally Retarded Subject to Certification {#sec-9-csr-10-5.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.010}

9 CSR 10-5.020 Definitions {#sec-9-csr-10-5.020 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.020}

9 CSR 10-5.030 Application and Discussion of Standards Original rule filed Dec. 17, 1975, effective Dec. 27, 1975, Rescinded: {#sec-9-csr-10-5.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.030}

9 CSR 10-5.040 Hearing Procedure {#sec-9-csr-10-5.040 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.040}

9 CSR 10-5.050 Admission Policies for Foster Care Homes {#sec-9-csr-10-5.050 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.050}

9 CSR 10-5.060 Education, Training and Recreation {#sec-9-csr-10-5.060 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.060}

History

AUTHORITY sections 630.050 and 630.705, RSMo Supp. 1982.

9 CSR 10-5.070 Records {#sec-9-csr-10-5.070 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.070}

9 CSR 10-5.080 Resident Living {#sec-9-csr-10-5.080 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.080}

9 CSR 10-5.090 Construction of Physical Plant Facilities {#sec-9-csr-10-5.090 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.090}

9 CSR 10-5.100 Food Handling and Sanitation {#sec-9-csr-10-5.100 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.100}

9 CSR 10-5.110 Fire Protection and Safety {#sec-9-csr-10-5.110 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.110}

9 CSR 10-5.120 Medical and Health Care {#sec-9-csr-10-5.120 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.120}

9 CSR 10-5.130 Qualifications of Foster Care Parents {#sec-9-csr-10-5.130 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.130}

9 CSR 10-5.150 Individualized Habilitation Plan Procedures {#sec-9-csr-10-5.150 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.150}

(Moved to 9 CSR 45-3.010)

9 CSR 10-5.170 Residential Rate Setting {#sec-9-csr-10-5.170 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.170}

(Moved to 9 CSR 45-4.010)

9 CSR 10-5.180 Advance Directives {#sec-9-csr-10-5.180 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.180}

PURPOSE: This rule defines terms and establishes policies and procedures to be followed by all facilities operated by the Department of Mental Health and by other department-related facilities for assuring the rights of residents and patients to participate in and direct health care decisions affecting them.

(1) Terms defined in sections 630.005, 631.005, 632.005 and 633.005, RSMo are incorporated by reference for use in this

rule. Also, as used in this rule, unless the context clearly indicates otherwise, the following terms shall mean:

(A) Adult—an individual eighteen (18) years of age or older;

(B) Advance directive—a written instrument, such as a living will or durable power of attorney for health care, relating to the provision of health care for an individual when that individual is in a terminal condition or is incapacitated;

(C) Attending physician—the physician selected by or assigned to an individual and who has primary responsibility for the treatment and care of the individual. If more than one (1) physician shares that responsibility, any of those physicians may act as the attending physician;

(D) Attorney-in-fact—an individual or corporation appointed to act as an agent of a principal (resident or patient) in a written power of attorney for health care allowed under law;

(E) Competent—not having been adjudicated incapacitated;

(F) Death-prolonging procedure—any medical procedure or intervention that, when applied to an individual, would serve only to artificially prolong the dying process and where, in the judgment of the attending physician pursuant to usual and customary medical standards, death will occur within a short time whether the procedure or intervention is used. Deathprolonging procedures shall not include administration of medication or performance of a medical procedure considered necessary to provide comfort or care or to alleviate pain, or the performance of any procedure to provide nutrition or hydration;

(G) Decision-making capacity—ability to make choices that reflect an understanding of the nature and effect of treatment options as well as the consequences of choices;

(H) Department facilities—facilities operated by the department;

(I) Durable power of attorney for health care—a written instrument executed by a competent adult, notarized and expressly giving an agent or attorney-in-fact the authority to consent to or to prohibit any type of health care, medical care, treatment or procedures to the extent authorized in sections 404.800–404.865, RSMo;

(J) Health care—any treatment, service or procedure to diagnose or treat the physical or mental condition of a resident or patient;

(K) Health care facility—an individual or agency licensed, certified or otherwise authorized or permitted by law to administer health care in the ordinary course of business or professional practice;

(L) Incapacitated—unable by reason of any physical or mental condition to receive and evaluate information or to communicate decisions to an extent that an individual lacks capacity to meet essential requirements for food, clothing, shelter, safety or other care such that serious physical injury, illness or disease is likely to occur;

(M) Living will—a written instrument executed by a competent adult under sections 459.010–459.055, RSMo and declaring direction for the withholding or withdrawal of death-prolonging procedures and becoming operative if the adult is in a terminal condition;

(N) Patient—an individual under observation, care, treatment or rehabilitation by any hospital or other mental health facility pursuant to the provisions of Chapter 632, RSMo;

(O) Resident—a person receiving residential services from a facility, other than a mental health facility, operated by the department;

(P) Terminal condition—an incurable or irreversible condition that, in the opinion of the attending physician, is such that death will occur within a short time, regardless of the application of medical procedures; and (Q) Voluntary resident or patient—a person who has willingly chosen or consented to receive services from the department and who is receiving services in a department facility, or a person for whom a guardian has been appointed under

Chapter 475, RSMo and the guardian has been authorized to admit the resident or patient for services from the department.

(2) The department shall honor the right of all competent adult voluntary residents and patients to make decisions regarding their health care, including the right to accept or refuse medical or surgical treatment, except that if a Division of Comprehensive Psychiatric Services facility’s clinical staff determines that an emergency exists because a resident or patient is likely to do physical harm or present life-threatening behavior to him/herself or other residents or patients, the staff may administer psychotropic medication without the resident’s or patient’s consent. All competent adult residents and patients shall have the right to execute advance directives without regard to their voluntary or involuntary status. No department facility shall condition the provision of care or treatment, or otherwise discriminate against a resident or patient based on whether the individual has executed an advance directive.

(3) Using materials prepared by the department, all department facilities shall provide staff and community education about advance directives and the department’s policy on carrying out those directives by department facilities.

(4) Except as provided in sections (5) and (6), at the time an adult resident or patient is admitted to a department facility, the facility’s staff shall— (A) Provide written information about resident’s or patient’s rights to accept or refuse death-prolonging procedures and to execute advance directives;

(B) Provide written information about the department’s policy on advance directives;

(C) Ask the resident or patient if s/he has executed an advance directive; and (D) At his/her request, refer a competent adult resident or patient without an advance directive for assistance in completing one.

(5) If, at time of admission, department facility staff determine that a competent adult resident or patient lacks decisionmaking capacity, for example, due to intoxication or an acute episode of mental illness, the staff shall— (A) If the resident or patient is accompanied by a friend, relative or guardian, discuss health care decisions and advance directives with that person as set out in section (4) of this rule;

(B) Document the lack of decision-making capacity in the resident’s or patient’s medical record and the discussion of health care decisions and advance directives with the friend, relative or guardian rather than the resident or patient; or (C) If the resident or patient is unaccompanied, delay a discussion of health care decisions and advance directives; and (D) Document the lack of decision-making capacity in the resident’s or patient’s medical record and that a discussion of health care decisions and advance directives was delayed.

(6) For a resident or patient with whom department facility staff did not discuss health care decisions and advance directives at the time of admission as set out in section (4) because the resident or patient lacked decision-making capacity, when the staff determine that the resident or patient has regained decision-making capacity, the staff shall hold the discussion and document it in the resident’s or patient’s medical record, regardless of whether the resident or patient was accompanied at time of admission.

(7) Staff of department facilities shall document in each adult resident’s or patient’s medical record whether the resident or patient has executed an advance directive. If a resident or patient has executed an advance directive, staff shall presume the resident or patient was competent when the advance directive was executed and that the advance directive was properly executed unless a court determines otherwise. Upon permission of the resident or patient, guardian or attorneyin-fact, and if a copy of the advance directive is provided by the resident or patient, guardian or attorney-in-fact, staff shall place a copy of the advance directive in the resident’s or patient’s medical record.

(8) Because the department has a statutory mission to habilitate, treat or rehabilitate its residents and patients in department facilities, it shall not withhold or withdraw— (A) Food, hydration, antibiotics or antiseizure medication for the purpose of ending life;

(B) Psychotropic drugs essential to treatment of mental illness that are otherwise authorized by law or department

rule; or (C) Any medication, medical procedure or intervention that, in the opinion of facility staff, is necessary to prevent the suicide of a resident or patient.

(9) When it is determined that a resident or patient is incapacitated or in a terminal condition and that the resident or patient has an advance directive, department facility staff shall carry out the advance directive in the facility where the resident or patient resides unless— (A) The resident’s or patient’s advance directive specifies procedures prohibited under the department policy set out in

section (8);

(B) The resident’s or patient’s attorney-in-fact under a durable power of attorney for health care requests procedures prohibited under the department policy set out in section (8);

(C) The resident or patient is pregnant and has a living will that calls for withdrawing or withholding treatment; or (D) The head of the facility determines that the facility is not equipped to provide acute and specialized medical care needed by the resident or patient.

(10) If based upon section (9) of this rule, the head of a department facility determines that the facility shall not carry out a resident’s or patient’s advance directive in the facility, the department facility staff, in conjunction with the resident or patient or the resident’s or patient’s guardian or attorney-in-fact, shall take all reasonable steps to transfer the resident or patient to a health care facility that is equipped and willing to carry out the resident’s or patient’s advance directive. At a minimum, these steps shall include, if necessary, assistance from department facility case managers in locating a health care facility that is equipped and willing to carry out the advance directive and case managers’ assistance with transferring the resident or patient to the health care facility.

(11) If a resident or patient with an advance directive is transferred from a department facility to another health care facility at the request of the department, the department will pay for transportation to and care in the health care facility if all other resources available to the resident or patient have been exhausted.

(12) A resident or patient may revoke an advance directive at any time and in any manner by which s/he is able to communicate, regardless of mental or physical condition. If an incapacitated resident or patient or a resident or patient in a terminal condition revokes an advance directive, department facility staff shall notify the resident’s or patient’s attorneyin-fact or legal guardian of the revocation and the manner by which the advance directive was revoked.

(13) If any resident or patient notifies department facility staff in any manner by which s/he is able to communicate that s/he wishes to revoke an advance directive, department facility staff shall immediately document the revocation in the resident’s or patient’s medical record and the manner by which the advance directive was revoked and shall notify orally any other staff known to be involved in the resident’s or patient’s health care.

(14) An advance directive also shall be revoked upon execution of a subsequent advance directive by the resident or patient.

(15) No department employee may recommend or otherwise suggest to a resident or patient that the resident or patient alter or revoke his/her advance directive.

(16) Department facility staff shall act upon a revocation of a resident’s or patient’s advance directive when the resident or patient is incapacitated or in a terminal condition and is not able to make treatment decisions if— (A) The revocation is documented in the resident’s or patient’s medical record; or (B) The staff member in charge of the resident’s or patient’s treatment at that time has actual knowledge of the revocation.

(17) Department facility staff shall periodically review the status of resident’s and patient’s advance directives as necessary or when requested by the resident or patient or the guardian or attorney-in-fact.

(18) Except to the extent the right is limited by the durable power of attorney for health care or any federal law, an attorney-in-fact under a durable power of attorney for health care has the same right as the resident or patient to receive information about health care proposed for the resident or patient, to receive and review the resident’s or patient’s medical records and to consent to disclosure of the medical records, except that the right of access to medical records is not a waiver of any evidentiary privilege.

(19) No employee of a department facility shall serve as an attorney-in-fact under a durable power of attorney for health care for any resident or patient receiving care or treatment at the facility at which the employee works unless that employee is related by marriage or consanguinity within the second degree or unless the employee and resident or patient are members of the same community of persons who are bound by vows to a religious life and who conduct or assist in the conducting of religious services and actually and regularly engage in religious, benevolent, charitable or educational ministry, or the performance of health care services.

History

AUTHORITY: section 630.050, RSMo 1986. Original rule filed June 30, 1992, effective April 8, 1993. Original authority: 630.050, RSMo 1980.

9 CSR 10-5.190 Background Screening Requirements {#sec-9-csr-10-5.190 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.190}

PURPOSE: This rule establishes background screening requirements for staff and certain volunteers, students, and members of a provider’s household in any public or private facilities, community residential facilities, day programs, or specialized service operated, licensed, certified, accredited, in possession of deemed status, or funded by the Department of Mental Health.

(1) Definitions. The following definitions apply to terms used in this rule:

(A) DMH—the Missouri Department of Mental Health;

(B) Members of the provider’s household—persons age eighteen (18) or older whose permanent residence is the provider’s household, or persons who visit the home on a frequent basis, or persons who spend the night in the home on a frequent basis such that direct, unsupervised contact with individuals served is likely to occur. For purposes of this rule, “frequent” means six (6) or more times over a rolling twelve- (12-) month period;

(C) Natural supports—supports provided by a person of the individual’s choice that assist him or her in achieving his or her goals and facilitate his or her integration into the community.

Natural supports are provided by persons who are not paid staff of an agency but may be initiated, planned, and facilitated in partnership with an agency;

(D) Staff (staff member, employee, personnel)—a paid employee or contractor providing services or supports on behalf of the agency on a full- or part-time basis who has contact with individuals served by the agency;

(E) Student (student worker, student intern, practicum student)—a person who is not on the agency or provider payroll, but as part of his or her education or training has direct contact with individuals served;

(F) Visitor—a family member, friend, clergy, or other person invited by the individual served; and (G) Volunteer—an unpaid person formally recognized by the agency to provide direct services or supports to individuals it serves.

(2) For the purposes of this rule, public or private facilities, community residential facilities, day programs, and specialized services (agencies) are divided into two (2) categories, as follows:

(A) Category I. Agencies that are certified or licensed exclusively by the Department of Mental Health (DMH) or, although not certified or licensed, are funded by DMH.

Specifically this category includes:

All agencies certified by DMH;
Agencies that have contractual arrangements with DMH but are exempt from DMH’s licensing and certification process due to accreditation or other reason; and 3. Agencies that are licensed by DMH and do not have a license from another state agency; and (B) Category II. Agencies that have a license or certificate from another state agency. Specifically, this category includes agencies licensed by the Children’s Division or the Department of Health and Senior Services; also included are intermediate care facilities/for individuals with intellectual or developmental disabilities (ICF/IDD). Agencies included in Category II are subject to rules regarding criminal record review as promulgated by the state agency that licenses or certifies them and are not subject to sections (4) through (7) of this rule, however, all other sections of this rule apply.

(3) This rule applies to— (A) Paid and unpaid staff and volunteers of the agency, including student workers; and (B) For residential services, members of the provider’s household, except children under the age of eighteen (18), who have contact with individuals served.

(4) Each agency defined under Category I above shall make the following inquiries for all new staff, volunteers, students, and members of the provider’s household, where applicable:

(A) An inquiry with the Department of Health and Senior Services to determine whether the person having contact with individuals served is listed on the employee disqualification list of the Department of Social Services or the Department of Health and Senior Services;

(B) An inquiry with DMH to determine whether the person is on the DMH disqualification registry; and (C) A criminal background check with the Missouri State Highway Patrol. The request for the background check does not require fingerprints and shall be in accordance with requirements of the Missouri State Highway Patrol under

Chapter 43, RSMo. The agency may use a private investigatory agency to conduct this review.

(5) The criminal background check and inquiries required under section (4) of this rule shall be initiated within two (2) working days of hire for staff who will have contact with individuals served. The criminal background check and inquiries required under section (4) of this rule shall be initiated prior to a volunteer, student, or members of the provider’s household having contact with individuals served, where applicable. A criminal background check is not required for visitors, persons providing natural supports, students, or other persons who are job shadowing and do not have unsupervised contact with individuals served, or volunteers who do not have unsupervised contact with individuals served.

(6) Each agency included under Category I above shall require all new applicants for employment, volunteer positions, students, and members of the provider’s household, where applicable, who will have contact with individuals served to— (A) Sign a consent form authorizing a criminal record review with the highway patrol, either directly through the patrol or through a private investigatory agency;

(B) Disclose his/her criminal history, including any conviction or a plea of guilty to a misdemeanor or felony charge and any suspended imposition of sentence, any suspended execution of sentence, or any period of probation or parole; and (C) Disclose if s/he is listed on the employee disqualification list of the Department of Social Services or the Department of Health and Senior Services, or the DMH disqualification registry.

(7) Each agency shall develop policies and procedures regarding the implementation of this rule and the disposition of information provided by the criminal record review. At a minimum the policies and procedures shall include:

(A) Procedures for obtaining the criminal record review;

(B) Procedures for confidentiality of records; and (C) Guidelines for evaluating information received through the criminal record review which establish a clear boundary between convictions that by statute exclude an individual from service, and convictions that would not automatically exclude an individual.

(8) Offenses under section 630.170, RSMo, that disqualify a person from service are as follows:

(A) A person is disqualified from holding any position in the agency if that person— 1. Has been found guilty of or pleaded guilty to or nolo contendere, including having received a suspended imposition of sentence or suspended execution of sentence to any of the following offenses:

A. Abuse or neglect of an individual served as defined in

section 630.155, RSMo;

B. Furnishing unfit food to an individual served as defined in section 630.160, RSMo; or C. Vulnerable person abuse, as described in sections 565.210 to 565.214, RSMo, as those sections existed prior to January 1, 2017.

Is listed on the DMH disqualification registry; or 3. Is listed on the employee disqualification list of the Department of Health and Senior Services or Department of Social Services;

(B) A person who has been found guilty of or pleaded guilty to or nolo contendere, including having received a suspended imposition of sentence or suspended execution of sentence, to any of the offenses specified in section 630.170.2, RSMo, is disqualified from holding any position having contact with individuals served in the agency. For reference purposes, DMH maintains an updated list of disqualifying crimes under section 630.170, RSMo, at http://dmh.mo.gov/about/employeedisqualification/.

A person who has been found guilty of or pleaded guilty or nolo contendere, including having received a suspended imposition of sentence or suspended execution of sentence, to a violation of section 577.010, RSMo or section 577.012, RSMo and who is alleged and found by the court to be an aggravated or chronic offender under section 577.023, RSMo, is disqualified from holding any position having contact with individuals served in the agency if the person is hired by the agency after January 1, 2014.

(9) Any person disqualified from employment under this

rule may request an exception from the DMH Exceptions Committee in accordance with 9 CSR 10-5.210 Exceptions Committee Procedures.

(A) The right to request an exception under this subsection does not apply to persons who are disqualified due to being listed on the employee disqualification registry of the Department of Social Services or Department of Health and Senior Services, nor does it apply under section 630.170.4, RSMo, to persons who are disqualified due to any offenses pursuant to the provisions of Chapter 566 or sections 565.020, 565.021, 568.020, 568.060, 569.025, as that section existed prior to January 1, 2017, or 574.080, RSMo. For reference purposes, DMH maintains an updated list of disqualifying crimes not eligible for exception under section 630.170.4, RSMo, at http:// dmh.mo.gov/about/employeedisqualification/.

(10) For the purposes of this rule, a verdict of not guilty by reason of insanity (NGRI) is not per se disqualifying. A suspended imposition of sentence (SIS) or suspended execution of sentence (SES) is disqualifying.

(11) Any person who has committed a disqualifying crime as identified in section (8) of this rule, unless the person has received an exception from DMH, is not eligible for hire by an agency. However, the agency retains the discretionary

(B) Have received an exception from the Exceptions Committee; or (C) Have received a verdict of Not Guilty by Reason of Insanity.

rule filed Aug. 15, 1997, effective March 30, 1998. Amended: Filed Oct. 29, 1998, effective May 30, 1999. Amended: Filed Nov. 3, 2003, effective April 30, 2004. Amended: Filed March 29, 2004, effective Sept. 30, 2004. Amended: Filed Jan. 22, 2019, effective Aug. 30, 2019. *Original authority: 192.2495, RSMo 1996, amended 1997, 1998, 2003, 2014, 2016, 2018; 630.170, RSMo 1980, amended 1982, 1996, 1998, 2001, 2003; 630.655, RSMo 1980; and 630.710, RSMo 1980, amended 1996, 1998.

History

authority to deny employment to persons who— (A) Have committed crimes not identified as disqualifying;
AUTHORITY: sections 630.170, 630.655, and 630.710, RSMo 2016, and section 192.2495, RSMo Supp. 2018. Emergency rule filed Aug. 15, 1997, effective Aug. 28, 1997, expired Feb. 26, 1998. Original

9 CSR 10-5.200 Report of Complaints of Abuse, Neglect and Misuse of Funds/Property {#sec-9-csr-10-5.200 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.200}

PURPOSE: This rule prescribes procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/ property in an agency that is licensed, certified, accredited, in possession of deemed status, and/or funded by the Department of Mental Health (department) as required by sections 630.135, 630.167, 630.168, 630.655, and 630.710, RSMo. The rule also sets forth due process procedures for persons who have been accused of abuse, neglect, and misuse of funds/property.

(1) The following words and terms, as used in this rule, mean:

(A) Agency: An organization that is licensed, certified, accredited, in possession of deemed status, and/or funded by the Department of Mental Health;

(B) Consumer: An individual (client, resident, patient) receiving department-funded services directly from an agency;

(D) Employee: A person employed by or contracted by an agency or a person serving as a volunteer or student for the agency;

(E) Misuse of funds/property: The misappropriation or conversion for any purpose of a consumer’s funds or property by an employee or employees with or without the consent of the consumer or the purchase of property or services from a consumer in which the purchase price substantially varies from the market value;

(F) Neglect: Failure of an employee to provide reasonable or necessary services to maintain the physical and mental health of any consumer when that failure presents either imminent danger to the health, safety, or welfare of a consumer or a substantial probability that death or serious physical injury would result. This would include, but is not limited to, failure to provide adequate supervision during an event in which one consumer causes serious injury to another consumer;

(G) Physical abuse:

An employee purposefully beating, striking, wounding, or injuring any consumer;
In any manner whatsoever, an employee mistreating or maltreating a consumer in a brutal or inhumane manner; or 3. An employee handling a consumer with any more force than is reasonable for a consumer’s proper control, treatment, or management;

(H) Sexual abuse: Any touching, directly or through clothing, of a consumer by an employee for sexual purpose or in a sexual manner. This includes, but is not limited to:

Kissing;
Touching of the genitals, buttocks, or breasts;
Causing a consumer to touch the employee for sexual purposes;
Promoting or observing for sexual purpose any activity or performance involving consumers including any play, motion picture, photography, dance, or other visual or written representation;
Failing to intervene or attempting to stop inappropriate sexual activity or performance between consumers; and/or 6. Encouraging inappropriate sexual activity or performance between consumers; and (I) Verbal abuse: An employee making a threat of physical violence to a consumer, when such threats are made directly to a consumer or about a consumer in the presence of a consumer.

(2) This rule applies to any director, supervisor, or employee of any agency. Facilities, programs, and services that are operated by the department are regulated by the department’s operating regulations and are not included in this rule.

(A) Any such person shall immediately file a written complaint if that person has reasonable cause to believe that a consumer has been subjected to any of the following while under the care of an agency:

Physical abuse;
Sexual abuse;
Misuse of funds/property;
Neglect; or 5. Verbal abuse.

(B) A complaint under subsection (2)(A) above shall be made to the head of the agency and to the department’s regional office, supported community living placement office, or district administrator office. If the allegation results in an investigation, the head of the agency shall make reasonable arrangements with respect to the alleged perpetrator to assure the safety of all of the agency’s consumers. Such arrangements may include, but are not limited to, leave with or without pay or transfer to a position where there is no client contact.

(C) The head of the agency shall forward the complaint to— 1. The Children’s Division if the alleged victim is under the age of eighteen (18); or 2. The Division of Senior Services and Regulation if the alleged victim is a resident or client of a facility licensed by the Division of Senior Services and Regulation or receiving services from an entity under contract with the Division of Senior Services and Regulation.

(D) Failure to report shall be cause for disciplinary action, criminal prosecution, or both.

(3) The head of the agency shall immediately report to the local law enforcement official if there is a reasonable suspicion that any of the following abuse or neglect has occurred— (A) Sexual abuse; or (B) Abuse or neglect that results in physical injury; or (C) Abuse, neglect, or misuse of funds/property if the head of the agency has cause to believe that criminal misconduct is involved.

(4) If a complaint has been made under this rule, the head of the agency shall fully cooperate with law enforcement authorities and with department employees or employees from other agencies authorized to investigate the complaint.

Failure to cooperate may result in contract termination or dismissal of the employee.

(5) A department investigator shall gather facts and conduct an investigation regarding the alleged abuse or neglect. The investigation shall be conducted in accordance with the procedures and time frames established under the department’s operating regulations. Upon completion of the investigation, the investigator shall present written findings of facts to the head of the supervising facility.

(6) Within twenty (20) calendar days of receiving the final report from the investigator, if there is a preliminary determination of abuse, neglect, or misuse of funds/property, the head of the supervising facility or department designee shall send to the alleged perpetrator a letter summarizing the allegations and findings that are the basis for the alleged abuse/neglect/misuse of funds or property; the agency will be copied. The letter shall comply with the constraints regarding confidentiality contained in section 630.167, RSMo, and shall be sent by regular and certified mail.

(A) The alleged perpetrator may meet with the head of the supervising facility or department designee, submit comments, or present evidence; the agency may be present and present comments or evidence in support of the alleged perpetrator.

If the alleged perpetrator wishes to have this meeting, s/he must notify the head of the supervising facility or department designee within twenty (20) calendar days from the date of the letter.

(B) This meeting shall take place within twenty (20) calendar days from the date of the letter, unless the parties mutually agree upon an extension.

(C) Within twenty (20) calendar days of the meeting, or if no request for a meeting is received within twenty (20) calendar days from the date of the letter, the head of the supervising facility or department designee shall make a final determination as to whether abuse/neglect/misuse of funds or property took place. The perpetrator shall be notified of this decision by regular and certified mail; the agency will be copied. If the charges do not meet the criteria in section (10), the decision of the head of the supervising facility or department designee shall be the final decision of the department.

(D) If the charges meet the criteria in section (10), the letter shall advise the perpetrator that they have twenty (20) calendar days from the date of the letter to contact the department’s hearings administrator if they wish to appeal a finding of abuse, neglect, or misuse of funds/property.

(E) If there is no appeal, the decision of the head of the supervising facility or department designee shall be the final decision of the department.

(F) The department’s effort to notify the alleged perpetrator at his/her last known address by regular and certified mail shall serve as proper notice. The alleged perpetrator’s refusal to receive certified mail does not limit the department’s ability to make a final determination. Evidence of the alleged perpetrator’s refusal to receive certified mail shall be sufficient notice of the department’s determination.

(7) If an appeal is requested, the hearings administrator shall schedule the hearing to take place within ninety (90) calendar days of the request, but may delay the hearing for good cause shown. Hearings shall be conducted in accordance with the procedures set forth in 9 CSR 10-5.230.

(8) The decision of the hearings administrator shall be the final decision of the department. The hearings administrator shall notify the perpetrator, by certified mail, and the head of the supervising facility or department designee of the decision within twenty (20) calendar days of the appeal hearing; the agency will be copied.

(9) For those charges in section (10), an alleged perpetrator does not forfeit his/her right to an appeal with the department’s hearings administrator when s/he declines to meet with the head of the supervising facility under subsections (6)(A) and (6)

(B) of this rule.

(10) If the department substantiates that a person has perpetrated physical abuse, sexual abuse, verbal abuse, neglect, or misuse of funds/property, the perpetrator shall not be employed by the department, nor be licensed, employed, or provide services by contract or agreement at an agency. The perpetrator’s name shall be placed on the department Disqualification Registry pursuant to section 630.170, RSMo. Persons who have been disqualified from employment may request an exception by using the procedures described in 9 CSR 10-5.210 Exception Committee Procedures.

(11) In accordance with 9 CSR 10-5.190, no person convicted of specified crimes may serve in facilities or programs licensed, certified, or funded by the department.

(12) No director, supervisor, or employee of an agency shall evict, harass, dismiss, or retaliate against a consumer or employee because he or she or any member of his or her family has made a report of any violation or suspected violation of consumer abuse, neglect, or misuse of funds/property. Penalties for retaliation may be imposed up to and including cancellation of agency contracts and/or dismissal of such person.

(13) If an event deadline falls on a Saturday, Sunday, or legal holiday, the last day of the period so computed shall extend to the next calendar day that is not a Saturday, Sunday, or legal holiday.

History

AUTHORITY: sections 630.135, 630.168, 630.655, and 630.705, RSMo 2000 and sections 630.050, 630.165, 630.167, and 630.170, RSMo Supp. 2008. Original rule filed Oct. 29, 1998, effective May 30, 1999. Emergency amendment filed March 29, 2002, effective May 2, 2002, terminated Oct. 30, 2002. Amended: Filed March 29, 2002, effective Oct. 30, 2002. Amended: Filed May 5, 2003, effective Dec. 30, 2003. Emergency amendment filed Aug. 11, 2005, effective Sept. 16, 2005, expired Feb. 28, 2006. Amended: Filed Aug. 11, 2005, effective March 1, 2006. Amended: Filed Dec. 1, 2008, effective May 30, 2009. Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008; 630.135, RSMo 1980; 630.165, RSMo 1980, amended 1996, 2003, 2007, 2008; 630.167, RSMo 1980, amended 1985, 1990, 1993, 1996, 1998, 2003, 2007, 2008; 630.168, RSMo 1980, amended 1987, 1996; 630.170, RSMo 1980, amended 1982, 1996, 1998, 2001, 2003, 2008; 630.655, RSMo 1980; and 630.705, RSMo 1980, amended 1982, 1984, 1985, 1990, 2000.

9 CSR 10-5.206 Report of Events {#sec-9-csr-10-5.206 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.206}

PURPOSE: This rule prescribes procedures for documenting, reporting, analyzing, and addressing certain events that affect individuals who reside in a community residential program or are receiving day program or specialized services from an agency that is licensed, certified, accredited, in possession of deemed status, is funded by, and/or has a contractual relationship with the Department of Mental Health for the provision of services as required by sections 630.005, 630.020, 630.163, 630.165, 630.167, and 630.655, RSMo.

(1) Definitions. The following words and terms, as used in this

rule, mean:

(B) Affiliate, an organization that is contracted with the department to provide specific community psychiatric rehabilitation (CPR) services in a designated geographic region;

(C) Agency, a community residential program/center, day program, group home, outpatient program, and/or specialized services licensed, certified, deemed certified, or deemed licensed by the department, and/or funded by, and/or has a contractual relationship with the department for the provision of services. This does not include entities licensed by the Department of Health and Senior Services under Chapter 198, RSMo, unless the entity is also licensed by the department to serve individuals that have a primary diagnosis of mental illness and/or developmental disability and their services and supports are funded by the department;

(D) Customer Information Management, Outcomes, and Reporting, Event Management and Tracking (CIMOR-EMT), system used by the department to collect and analyze relevant data on events that have actual or potential adverse outcomes for individuals served. Data is entered into the system by agency staff or department staff in accordance with established policies and procedures;

(E) Deemed status, acknowledges that an agency is monitored and held accountable by a recognized national accrediting body and the department accepts the agency’s verification of good standing with the accrediting body as sufficient to meet the department’s standards of care;

(F) Department, the Department of Mental Health, executive agency of Missouri state government comprised of the Division of Behavioral Health (DBH) and Division of Developmental Disabilities (DD) and its regional and district offices;

(G) Division of Behavioral Health (DBH), operating division of the department responsible for ensuring prevention, evaluation, treatment, recovery supports, and rehabilitation services are available for individuals and family members experiencing a substance use disorder and/or mental illness;

(H) Division of Developmental Disabilities (DD), operating division of the department responsible for supporting the needs of individuals, family members, and caregivers who experience a developmental disability;

(I) EMT Community Event Report, form used by community providers for reporting events to the department in accordance with DBH and DD protocol;

(J) Guardian, individual who is court appointed to be legally responsible for the care and custody of the individual being served;

(K) Individual, a person/consumer/client receiving department-funded services directly from an agency or selfdirected services;

(L) Reportable events/categories, events affecting individuals residing in or receiving services from an agency, as defined in subsection (1)(C) of this rule, that meet reporting requirements applicable to DBH or DD;

(M) On-call system, procedure in which identified staff in DD are available to receive notification of reportable events requiring immediate notification during non-business hours, a weekend, or holiday;

(N) Plan of Action (POA), documents the action to be taken by agency staff to reduce the likelihood an event will recur or to remediate an area found out of compliance. Such action may include, but is not limited to, staff training, improvements to the physical plant, and/or revision of operating procedures;

(2) Reporting Requirements. This rule applies to any employee of an agency as defined in subsection (1)(C) of this rule.

(A) Agency designee(s) shall ensure events are reported in accordance with protocol established by DD or DBH, as applicable to the individual being served.

Event reports involving individuals served by DD shall be submitted via the CIMOR-EMT system in accordance with established protocols.
Event reports involving individuals served by DBH shall be submitted to designated DBH staff via the EMT Community Event Report form MO 650-9475, included herein, in accordance with established protocols.

A. Administrative agents/affiliates shall be notified of events involving individuals receiving DBH-funded services.

The administrative agent/affiliate shall submit event reports to the appropriate DBH regional office staff via the EMT Community Event Report form MO 650-9475, included herein, in accordance with established protocols.

(B) Any allegation or suspicion of abuse, neglect, or misuse of funds/property, as defined in 9 CSR 10-5.200, which is reported to or suspected by agency staff must be immediately reported to the applicable division in accordance with procedures described in 9 CSR 10-5.200.

(C) Events requiring immediate notification which occur after 5:00 p.m. on a weekday, weekend, or holiday shall be reported as follows:

To DBH staff no later than the next business day in a written report utilizing the EMT Community Event Report form MO 650-9475.
To DD staff verbally in accordance with the on-call protocol, followed by entry into CIMOR-EMT on the next business day.

(D) The parent(s) of a minor or the legal guardian of an individual who is involved in a report of abuse, neglect, and/ or misuse of funds/property shall receive verbal notification from agency staff regarding the details of the event, except the names of any employees or other individuals shall not be revealed. This notification shall occur as soon as possible, but no later than twenty-four (24) hours following the agency’s notification of the alleged event.

Email or text communication may be substituted for the verbal notification if the parent/guardian has indicated that is the preferred means of communication.
The date and time of parent/guardian notification shall be documented on the event report.
Agency staff shall communicate to the parent/guardian that the applicable division (DBH or DD) has been notified of the event.
If the parent/guardian is suspected to be involved in the event, notification to the parent/guardian shall be waived.
If agency staff are unable to contact the parent/ guardian regarding such an event, efforts to comply must be documented and included in the agency’s event report to the applicable division.

(3) Policies and Procedures. Agencies shall maintain and implement written policies and procedures to ensure the event notification, reporting requirements, and division-specific protocol outlined in this rule are followed.

(A) The policies and procedures shall clearly indicate the action to be taken by the agency if staff fail to report an event in accordance with the event notification, reporting requirements, and division-specific protocol outlined in this

rule.

(B) The agency shall ensure all employees, contracted staff, students/interns, and volunteers receive training on the event notification and reporting requirements applicable to their agency, including the agency’s internal policies and procedures.

This training shall be included as part of the agency’s orientation process and take place within the first thirty (30) days of employment and annually thereafter.
Employees, contracted staff, students/interns, and volunteers who will have direct contact with individuals served must be trained on the event notification, reporting requirements, and division-specific protocol prior to interacting alone with individuals.
This training shall include review of the definitions included in 9 CSR 10-5.200 for abuse, neglect, and misuse of funds/property.

(4) Plan of Action (POA) and Follow-up. The DBH or DD may request a POA from an agency based on the facts surrounding the event. This POA is subject to approval by the DBH or DD designee, must be carried out as specified, and shall be implemented by the agency in accordance with the approval criteria issued by the applicable division.

(A) Corrective measures and action steps to resolve the issue must be documented and maintained by the agency and be available for review by DBH or DD staff or other authorized representatives upon request.

(5) Failure to follow these regulations may result in administrative sanctions up to and including contract cancellation or revocation of licensure, certification, or deemed status.

History

AUTHORITY: sections 630.020, 630.165, and 630.655, RSMo 2016, and sections 630.005 and 630.167, RSMo Supp. 2021. Original rule filed March 1, 2005, effective Oct. 30, 2005. Amended: Filed Aug. 26, 2005, effective Feb. 28, 2006. Amended: Filed March 9, 2022, effective Sept. 30, 2022. Original authority: 630.005, RSMo 1980, amended 1981, 1982, 1990, 1993, 1995, 1996, 2007, 2011, 2014, 2018; 630.020, RSMo 1980; 630.165, RSMo 1980, amended 1996, 2003, 2007, 2008, 2011, 2014; 630.167, RSMo 1980, amended 1985, 1990, 1993, 1996, 1998, 2003, 2007, 2008, 2011, 2014, 2018; and 630.655, RSMo 1980.

9 CSR 10-5.210 Exceptions Committee Procedures {#sec-9-csr-10-5.210 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.210}

PURPOSE: This rule establishes procedures for requesting an exception from the administrative rules of the Department of Mental Health.

(1) Definitions. The following terms are defined as follows:

(A) Disqualifying incident, a crime which under 9 CSR 10- 5.190 results in a person being disqualified from employment, or one (1) or more administrative findings of abuse, neglect, or misuse of funds/property which, under 9 CSR 10-5.200 leads to a person being listed on the Department of Mental Health disqualification registry; and (B) Exception, a decision by the department not to enforce an administrative rule under the individual circumstances described in the request for an exception and the conditions described in the approval. The following requests for exceptions will not be considered:

A contention that the rule is not valid;
A contention that the provider is in fact in compliance with the rule; and 3. A request for an interpretation of a rule.

(2) Rules Subject to an Exception. Only the following rules may be the subject of an exception:

(A) Licensure rules for community residential programs and day programs promulgated under 9 CSR 40;

(B) Certification rules for substance use disorder prevention and treatment programs and mental health programs promulgated under 9 CSR 10-7 and 9 CSR 30;

(C) Certification rules under 9 CSR 45 for programs serving persons with intellectual or developmental disabilities (IDD) under the Medicaid Home- and Community-Based Services Waiver programs;

(D) Any other administrative rule promulgated by the Department of Mental Health that specifically allows for an exception; and (E) Rules related to disqualification from employment under

9 CSR 10-5.190 and 9 CSR 10-5.200. In the context of employment disqualification the following apply: {#sec-9-csr-10-5.190 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.190}

A person may not request an exception until twelve (12) months have passed since the sentence of the court or since the department gave official notice of the person’s name being added to the Department of Mental Health disqualification registry.

A. This subsection does not apply to individuals who are currently seeking certification from or have been certified by the Missouri Credentialing Board as a peer specialist and are supported for an exception by a substance use disorder treatment program, mental health program, or recovery support program that is operated, licensed, certified, accredited, in possession of deemed status, or funded by the Division of Behavioral Health. If an exception is granted to the individual under this provision, it shall be limited to the individual’s employment at the supporting program. Should the individual end employment with the substance use disorder treatment program, mental health program, or recovery support program during the twelve (12) months since the sentence of the court, the individual must seek a new exception that is subject to the same limitations as set forth herein. Once twelve (12) months have passed since the sentence of the court, the limitations set forth herein are no longer required; and 2. The exceptions option under this administrative rule does not replace or substitute for the appeal procedures afforded under Department Operating Regulation (DOR) 2.205 and 9 CSR 10-5.200 or any other administrative process. A person is not required to exhaust the appeal procedures as a prerequisite to requesting an exception; however, an exception will not be considered while an appeal is pending.

(3) Eligibility for an Exception. The following may apply for an exception:

(A) A chief executive officer, or designee, on behalf of a community residential program, day program, or specialized service, or an employee thereof;

(B) An individual on his or her behalf, with respect to disqualification from employment under 9 CSR 10-5.190 and 9 CSR 10-5.200;

(C) A facility operated by the department on behalf of a community residential program, day program, or specialized service licensed, operated, certified, accredited, in possession of deemed status, or funded by the department; and (D) Any other person or entity affected by an administrative

rule under subsection (2)(E) of this rule.

(4) Exceptions Process. Requests for an exception must include the information specified in this rule in order to be considered by the exceptions committee.

(A) A person may request an exception by sending to the exceptions committee a written request which— 1. Cites the rule number in question;

Indicates why and for how long compliance with the

rule should be waived; and 3. Is accompanied by supporting documentation, if appropriate.

(B) In addition, the following additional items must be part of a request under 9 CSR 10-5.190, related to disqualification from employment:

A letter from the disqualified person containing the following information:

A. A description of the disqualifying incident;

B. When the disqualifying incident occurred;

C. If the disqualifying incident was a crime, the sentence of the court;

D. Mitigating circumstances, if any;

E. Activities and accomplishments since the disqualifying incident;

F. The names and dates of any relevant training or rehabilitative services;

G. The type of service and/or program the applicant wishes to provide for individuals with an IDD or a behavioral health disorder;

H. Identification of the type of employment or position the applicant wishes to maintain or obtain and the name of the IDD, substance use disorder, or mental health program in which he or she wishes to work or continue working; and I. Changes in personal life since the disqualifying incident (e.g., marriage, family, and education);

References, i.e., written recommendations from at least three (3) persons who verify the applicant’s assertions; and 3. Work history, with particular emphasis on work in the IDD and/or behavioral health field.

(C) Request for exceptions should be sent to Exceptions Committee Coordinator, Office of General Counsel, Department of Mental Health, PO Box 687, Jefferson City, MO 65102.

(5) Response. Within forty-five (45) calendar days of receiving a request for an exception, the exceptions committee shall respond in writing. The committee may approve a request, approve the request with conditions, deny the request, or defer a decision pending receipt of additional information.

(6) Decisions. Decisions of the exceptions committee are not subject to appeal. Persons aggrieved by a decision may modify and repeat a request after six (6) months.

(7) Documentation. A recipient of an exception shall maintain documentation of all approved exceptions and make the documentation available for review upon request by authorized staff of the department.

(8) Expiration Date for an Exception.

(A) An exception becomes null and void without any further action by the department under any of the following circumstances:

An expiration date is announced in the letter of approval;
The subject for whom the exception was granted changes employment; or 3. There are changes in other circumstances specified in the exception approval letter that invalidates the justification for granting the exception.

(B) If an exception expires under this section, it may be renewed by submission of a new request.

(9) Rescinding Decisions. The exceptions committee may rescind any exception if, in its judgment, any of the following occur:

(A) The provider failed to meet a condition of the exception or to maintain documentation required under section (7) of this rule;

(B) It is discovered the request contained misleading, incomplete, or false information;

(C) The exception results in poor quality of care, or risk/harm to an individual being served; or (D) The applicant received new criminal charges since the exception was granted.

(10) Notice of Rescission. If the committee rescinds an exception, the committee shall provide all concerned parties with a notice of rescission with an effective date. There shall be no appeal of a rescission of an exception.

Filed Nov. 3, 2003, effective April 30, 2004. Amended: Filed April 13, 2004, effective Oct. 30, 2004. Amended: Filed June 30, 2021, effective Dec. 30, 2021. Amended: Filed July 14, 2022, effective Jan. 30, 2023. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008; 630.170, RSMo 1980, amended 1982, 1996, 1998, 2001, 2003, 2008, 2012, 2013; and 630.656, RSMo 1995.

History

AUTHORITY: sections 630.050, 630.170, and 630.656, RSMo 2016. Original rule filed Feb. 23, 2001, effective Sept. 30, 2001. Amended:

9 CSR 10-5.220 Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA) {#sec-9-csr-10-5.220 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.220}

PURPOSE: This rule specifies the policies and procedures required for covered entities under the HIPAA privacy rule.

(1) This rule applies to all programs that are licensed, certified, accredited, in possession of deemed status, funded by, and/or have a contractual relationship with the Department of Mental Health.

(2) Definitions. The following terms, as used in this rule, shall mean:

(A) HIPAA—The Health Insurance Portability Accountability Act (45 CFR parts 160 and 164) as it relates to the Privacy Rule;

(B) Protected Health Information (PHI)—As defined by HIPAA (45 CFR section 160.103), PHI is individually identifiable health information that is— 1. Transmitted by electronic media;

Maintained in electronic media; or 3. Transmitted or maintained in any other form or medium;

(C) Individually identifiable health information—As defined by HIPAA (45 CFR section 160.103), information that is a subset of health information, including demographic information collected from an individual, and— 1. Is created or received by a healthcare provider, health plan, employer, or healthcare clearinghouse; and 2. Relates to the past, present, or future physical or mental health or condition of an individual; the provision of healthcare to an individual; or the past, present, or future payment for the provision of healthcare to an individual; and— A. That identifies the individual; or B. With respect to which there is reasonable basis to believe the information can be used to identify the individual;

(D) Business associate—As defined by HIPAA (45 CFR section 160.103), with respect to a covered entity, a person who— 1. On behalf of the covered entity or of an organized healthcare arrangement in which the covered entity participates, but other than in the capacity of a member of the workforce of such covered entity or arrangement;

Creates, receives, maintains, or transmits protected health information for a function or activity regulated by this

rule and 45 CFR section 160.103, including claims processing or administration, data analysis, processing or administration, utilization review, quality assurance, patient safety activities listed at 42 CFR 3.20, billing, benefit management, practice management, and repricing; or 3. Provides, other than in the capacity of a member of the workforce of such covered entity, legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services to or for such covered entity, or to or for an organized healthcare arrangement in which the covered entity participates, where the provision of the service involves the disclosure of protected health information from such covered entity or arrangement, or from another business associate of such covered entity or arrangement, to the person.

(3) Covered Entity. All providers that determine they qualify as a covered entity must comply with the provisions of the privacy

rule of the Health Insurance Portability and Accountability Act (HIPAA).

(A) A covered entity is defined as a healthcare provider that transmits any health information in electronic form in connection with a transaction covered by section 160.103 of 45 CFR part 160, a health plan, or a healthcare clearinghouse.

(B) If a provider is a covered entity, HIPAA requires the appropriate policies and procedures be in place to comply with the HIPAA Privacy Rule. HIPAA requires such policies and procedures to include but not be limited to the following:

Notice of Privacy Practices;
Amendment of Protected Health Information (PHI);
Client Access to PHI;
Accounting of Disclosures;
Workforce Training;
Verification;
Authorization for Disclosures of PHI;
HIPAA Complaint Process;
Marketing (if applicable);
Research (if applicable);
Audit and Monitoring of HIPAA compliance; and 12. Business Associates Agreements with companies qualifying as business associates as defined in this rule and in 45 CFR part 160.

(C) Where existing confidentiality protections provided by 42 CFR part 2, related to the release of records pertaining to substance use disorders, are greater than HIPAA, then any such provision of 42 CFR part 2 shall be the guiding law.

Emergency rule filed April 1, 2003, effective April 14, 2003, expired Oct. 14, 2003. Original rule filed April 1, 2003, effective Oct. 30, 2003. Amended: Filed March 9, 2022, effective Sept. 30, 2022. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008.

History

AUTHORITY: section 630.050, RSMo 2016, and 45 CFR parts 160 and 164, the Health Insurance Portability and Accountability Act.

9 CSR 10-5.230 Hearings Procedures {#sec-9-csr-10-5.230 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.230}

PURPOSE: This rule sets out procedures for requesting and conducting hearings before the Department of Mental Health Hearings Administrator as provided for in 9 CSR 10-5.200.

rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

(1) Requests for hearings shall be submitted in the following manner:

(A) All requests for hearings shall be made in writing by the appellant or their attorney to the hearings administrator within twenty (20) calendar days from the date of the final determination letter as set out in 9 CSR 10-5.200(6)(D). The request may be hand-delivered or sent by mail, email, or facsimile.

A request for hearing filed by hand delivery or mail is considered received on the date received by the office of the hearings administrator. Mailed requests shall be sent to the Office of Hearings Administrator, Department of Mental Health, 1706 East Elm St., PO Box 687, Jefferson City, MO 65102.
A request for hearing filed by email or facsimile is considered received at the time the office of the hearings administrator receives the request, provided that the original of the document is sent to the office of the hearings administrator and received within ten (10) calendar days of the email or fax.

If a request arrives by email or fax after 5 p.m., Central Time, and before 12 a.m., Central Time, or on a Saturday, Sunday, or legal holiday, it is considered filed on the next working day. Requests filed by facsimile shall be sent to the office of hearings administrator’s designated line specified in the information provided to the appellant by the department.

Requests filed by email shall be sent to the office of hearings administrator’s designated email address included with the information provided to the appellant by the department.

A. The time controlling when a facsimile arrives at the office of the hearings administrator is the office of the hearings administrator’s facsimile machine journal. The time controlling when an email arrives at the office of the hearings administrator is the timestamp in the original message.

B. The person filing by email or facsimile bears the risk of loss in transmission, non-receipt, or illegibility. If the request for hearing is not received or is materially illegible, the request is not considered filed and is totally null and void for all purposes; and (B) The request for a hearing shall set out the appellant’s name, current address, telephone number, and email address and that of their attorney, if applicable; the decision being appealed, the date of the decision, and the name of the person making the decision and a brief statement of the appellant’s reason for appealing the decision.

(2) Appellants may represent themselves and handle their own cases, but shall have the right to retain representation by a Missouri-licensed attorney. A party to an appeal cannot be represented by anyone other than a duly licensed attorney, with the exception of representation by an advocate, parent, or legal guardian as provided in 9 CSR 45-2.020 or internal Department Operating Regulation 4.470 (effective/published June 22, 2022), Department Operating Regulation 4.533 (effective/published June 22, 2022), or Department Operating

Regulation 4.563 (effective/published June 23, 2021), hereby incorporated by reference and made a part of this rule, published by and available from the Department of Mental Health, 1706 E. Elm St., Jefferson City, MO 65101, (573) 751-4122.

This rule does not incorporate any subsequent amendments or changes to these regulations. If either party is represented by an attorney, the attorney shall promptly notify the office of hearings administrator and enter their appearance.

(3) When a hearing has been requested, the hearings administrator shall schedule the hearing within the time period required by regulations after receiving the request for hearing, but may delay the hearing for good cause shown.

(4) The hearings administrator may schedule a pre-hearing conference with the parties. The hearings administrator may meet (in person, via telephone, or video conference) with the parties and their representatives at a pre-hearing conference to determine the facts at issue. At the pre-hearing conference, the parties may stipulate to mutually agreed matters or the appeal may be resolved by agreement of the parties. All parties are required to provide the hearings administrator with a current address, telephone number, and email address. If the appellant fails to provide the hearings administrator with a current address, phone number, or email address and cannot be reached to schedule a pre-hearing conference or fails to participate in a prehearing conference after receiving written notice of the date and time of the conference, it shall be deemed that the appellant no longer wishes to proceed with the appeal and is withdrawing the appeal.

(5) The hearings administrator shall send written notice of hearing and prehearing dates to the parties and representatives no less than ten (10) calendar days before the scheduled date for such hearing, unless there is good cause to shorten the period to provide notice.

(6) The hearings administrator may grant continuances for good cause. A continuance must be requested no later than seventy-two (72) hours, excluding Saturdays, Sundays, and legal holidays, prior to the scheduled date and time of the hearing or prehearing. Absent exigent circumstances, requests for continuances received less than seventy-two (72) hours prior to the hearing or prehearing shall not be considered.

(7) Requests for subpoena shall be governed by the following requirements:

(A) A request for a subpoena for attendance at depositions or hearings shall be made in writing and specify the name of the persons, the address(es) where the person can be served with the subpoena, the deposition or hearing location, and the time the person is expected to appear at the deposition or hearing location;

(B) A request for a subpoena duces tecum shall be made in writing and specify the name of the person, the address(es) where the person can be served with the subpoena, the documents the person is to provide, a statement of what is intended to be proved by the documents, where they should bring the documents, and a date when the documents are to be provided;

(C) All subpoena requests shall be sent by mail, fax, or email to the hearings administrator and opposing party at least five (5) working days before the hearing or deposition, unless there is good cause to shorten the period to request the subpoena;

(D) Any motions to quash a subpoena must be sent to the hearings administrator within three (3) working days of receiving the subpoena request;

(E) If no objection is sustained to a subpoena request, the hearings administrator shall prepare the subpoena and send the subpoena to the party who requested it. It is the responsibility of the person who requested the subpoena to have it served. Service of the subpoena is to be effected in accordance with section 536.077, RSMo; and (F) If a subpoena for a witness was not requested in accordance with this rule, good cause will not be found to continue the hearing for that witness’s failure to appear.

(8) The appellant or his/her attorney may request copies of any documents referred to in the decision letter from the attorney representing the department. If the documents involve protected health information, the attorney shall request a protective order from the hearings administrator. The protective order shall provide that no documents containing protected health information shall be released to anyone except the appellant or his/her attorney, and the appellant or his/her attorney shall return any documents provided to him or her before the end of the hearing.

(9) All parties who are represented by an attorney shall submit a proposed order with every motion or request that is filed or presented to the hearings administrator.

(10) The hearing shall be conducted according to the following procedures:

(A) The hearing shall be conducted by video conferencing unless the appellant files a written request for an in-person hearing. All in-person hearings will be conducted at the facility where the decision was made, unless the hearings administrator finds good cause to hold the hearing in another place;

(B) If the appellant or their attorney does not appear at the hearing and does not call the facility or the hearings administrator to provide notification of an exigent circumstance requiring a continuance within thirty (30) minutes of the time set out in the notice, it shall be deemed that the appellant no longer wishes to proceed with the appeal and is withdrawing the appeal;

(C) At the beginning of the hearing, the hearings administrator shall state the reason for the hearing and outline the hearing procedure;

(D) Both parties shall be given the opportunity to present opening statements. The department shall present its witnesses and exhibits first, then the appellant shall present their witnesses and exhibits. The department shall have the burden of proof by a preponderance of the evidence. Both parties shall be given the opportunity to present closing statements;

(E) All witnesses shall be sworn or affirmed. All witnesses are subject to cross-examination;

(F) The hearings administrator, at the request of either party or on their own motion, may order the witnesses to be separated so as to preclude any witness, other than the parties, from hearing the testimony of other witnesses. When requested by the appellant, only one (1) person in addition to counsel may remain in the room to represent the department;

(G) The formal rules of evidence shall not apply at these hearings. Parties may introduce any relevant evidence at the discretion of the hearings administrator;

(H) In all cases of allegations of abuse, neglect, or misuse of funds/property, the attorney representing the department shall offer the investigative report into evidence at the administrative hearing. In accordance with section 630.167.3(1), RSMo, the investigative report shall be admitted into evidence;

(I) The hearings administrator may exclude evidence that is purely cumulative;

(J) The hearings administrator may take administrative notice of department rules, department operating regulations, and facility policies without the necessity of an offer into evidence; and (K) The hearing shall be recorded. After the hearings administrator issues their decision, a copy of the recording shall be made available to either party upon request. The department will not transcribe the recording from aural to written form. The cost of a transcription shall be borne by the requesting party.

(11) All requests shall be in writing and directed to the attention of the hearings administrator and copied to the other party. This includes such matters as requests for continuances, documents, recordings, remote witness testimony, subpoenas, protective orders, and copies of decision. Requests may be mailed to the office of the hearings administrator at 1706 East Elm St., PO Box 687, Jefferson City, MO 65102 or faxed or emailed as specified in the information provided to the appellant by the department.

(12) The hearings administrator’s decision is final and is subject to judicial review in accordance with sections 536.100 to 536.140, RSMo.

A motion for attorney’s fees, if any, shall be filed with the office of the hearings administrator within thirty (30) calendar days of the date of the decision. The filing of a petition for judicial review does not stay the thirty- (30-) day filing requirement.

History

AUTHORITY: section 630.050, RSMo 2016, and section 630.167, RSMo Supp. 2022. Original rule filed Dec. 1, 2008, effective May 30, 2009. Amended: Filed Jan. 11, 2023, effective July 30, 2023. Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008, and 630.167, RSMo 1980, amended 1985, 1990, 1993, 1996, 1998, 2003, 2007, 2008, 2011, 2014, 2018.

9 CSR 10-5.240 Behavioral Health Healthcare Home {#sec-9-csr-10-5.240 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.240}

(Moved to 9 CSR 10-7.035)

9 CSR 10-5.250 Screening and Assessment for Behavioral Changes {#sec-9-csr-10-5.250 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-5.250}

PURPOSE: This rule establishes guidelines for the screening and assessment of individuals receiving services from state owned or operated facilities to determine whether changes in behavior or mental status are caused by or associated with a medical condition.

(1) Definitions— (A) Department—Department of Mental Health (DMH);

(B) Interdisciplinary team (IDT)—staff who know the individual well and possess the knowledge, skills, and expertise necessary to accurately identify a comprehensive array of the individual’s needs and design a program responsive to those needs; and (C) State owned or operated facilities—includes state Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) as defined in 42 CFR section 440.150, RSMo, psychiatric residential treatment facilities, and state operated home and community-based waiver services.

(2) The provisions of this rule do not apply to long-term care facilities licensed under Chapter 198, RSMo, hospitals licensed under Chapter 197, RSMo, or hospitals as defined in section 197.020, RSMo.

(3) Members of the IDT who are supporting individuals in state owned or operated facilities shall document and collect data.

(4) Based on a review of the data, the department shall first assess whether there is a relationship between a physiological event and/or illness and behavior. If a medical condition is suspected as the possible cause of the behavior change, medical assessment and treatment shall be accessed. After treating the medical condition or ruling out a medical or physiological event, the department shall then take other actions regarding psychiatric consultation and treatment.

History

AUTHORITY: section 630.050, RSMo Supp. 2013, and section 630.108, RSMo Supp. 2014. Original rule filed Dec. 10, 2015, effective June 30, 2016. Amended: Filed May 13, 2016, effective Nov. 30, 2016. Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.108, RSMo 2014.

Chapter 6 Human Rights Compliance by Contractors to the Department of Mental Health

9 CSR 10-6.010 State Affirmative Action {#sec-9-csr-10-6.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-6.010}

(Rescinded February 25, 1996)

9 CSR 10-6.020 Human Rights Contract Compliance System {#sec-9-csr-10-6.020 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-6.020}

(Rescinded February 25, 1996)

Rebecca McDowell Cook (1/26/96) to the Department of Mental Health9 CSR 10-6

Chapter 7 Core Rules for Psychiatric and Substance Use Disorder Treatment Programs

9 CSR 10-7.010 Essential Principles and Outcomes {#sec-9-csr-10-7.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-7.010}

PURPOSE: This rule describes the essential principles and outcomes applicable to Opioid Treatment Programs, Comprehensive Gambling Disorder Treatment Programs, Institutional Treatment Centers, Recovery Support Programs, Substance Awareness Traffic Offender Programs (SATOP), Substance Use Disorder Treatment Programs, Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric Rehabilitation Programs (CPR), and Outpatient Mental Health Treatment Programs. The performance indicators listed in this

rule are examples of how an essential principle can be measured and do not constitute a list of specific requirements. The indicators include data that may be compiled by a program as well as areas a surveyor may observe or monitor, including satisfaction and feedback from individuals served, and other data the department may compile and distribute. A program may also use additional or other means to demonstrate achievement of these principles and outcomes.

(1) Applying the Essential Principles. The organization’s service delivery practices shall incorporate the essential principles listed in this rule in a manner that:

(A) Is adapted to the needs of different populations served;

(B) Is understood and practiced by staff providing services and supports;

(D) Supports individuals in improving their capacities in all areas of functioning; and (E) Assists individuals in achieving their goals for recovery/ resiliency and successfully managing their symptoms.

(2) Outcome Domains. Services shall be delivered in a manner that promotes positive outcomes in the emotional, behavioral, social, and family functioning of individuals served. Positive outcomes for individuals served are expected in the following domains:

(A) Emotional and physical safety for themselves and others in his or her environment;

(B) Improved functioning and management of daily activities including management of the symptoms associated with a behavioral health disorder;

(D) Satisfaction with services;

(E) Increased/sustained employment or return to/remain in school;

(F) Decreased involvement with the justice system;

(G) Increased stability in housing;

(H) Increased family, natural support, and social connections;

(I) Increased parenting capacities;

(J) Increased retention in services for substance use disorders, decreased inpatient hospitalization for mental health treatment, and reduction in out-of-home placement services;

(K) Improved physical health and wellness; and (L) Increased sense of empowerment in management of their lives in all domains.

(3) Measuring Program Effectiveness. An organization shall measure outcomes for the individuals it serves and collect data related to the domains listed in paragraph (2) of this rule.

The data assists the organization in monitoring the quality of its services and determining their impact on the emotional, physical, social, and behavioral health of individuals served.

In order to promote consistency and the wider applicability of outcome data, the department may require, at its option, the use of designated outcome measures and instruments for services funded by the department.

(4) Essential Principle—Therapeutic Alliance.

(A) The organization shall promote easy and timely access to services, engagement in services, and development of an ongoing therapeutic alliance by— 1. Treating people with respect and dignity;

Enhancing motivation and self-direction through identification of meaningful goals that establish positive expectations;
Working with family members and other natural supports, parents/guardians, courts, and other support systems to promote the individual’s participation in services;
Addressing barriers to accessing treatment and other support services;
Providing education to individuals, family members/ natural supports, and parents/guardians to promote understanding of services and supports in relationship to individual functioning or symptoms and to promote understanding of individual responsibilities in the process;
Empowering individuals to assume an active role in developing and achieving productive goals and identification of services;
Delivering services in a manner that is responsive to each individual’s developmental needs, cultural background, gender identity, gender expression, language and communication skills, sexual orientation, and other factors as indicated; and 8. Recognizing the unique needs and priorities of individuals served as well as the challenges he or she may face in their journey of recovery/resiliency.

(B) Performance indicators may include, but are not limited 1. Convenient hours of operation consistent with the needs and schedules of individuals served;

Geographic accessibility, including transportation arrangements, as needed;
Rate of attendance at scheduled services;
Individuals consistently reporting that staff listen to and understand them;
Treatment retention rate;
Rate of successfully completing treatment goals and/or the treatment episode; and 7. Satisfaction with services as conveyed by individuals served and their family members and other natural supports.

(5) Essential Principle—Person- and Family-Centered Care.

Services shall be provided in a manner that addresses each individual’s needs, goals, preferences, cultural traditions, family situation, and values.

(A) Individuals served and family members/natural supports of their choice shall be provided with information about the treatment options available in order to make informed decisions about the type and duration of services and providers.

(B) Development and implementation of a treatment plan that assists each individual in achieving his or her personal goals of recovery and resilience is a collaborative process involving the individual, family members/natural supports of his/her choice, and treatment team.

(C) For children and youth, person-centered planning is incorporated into a family-driven, developmentally appropriate, and youth-guided approach that recognizes the importance of family in the lives of children and the impact of services and supports on the entire family.

(D) When the family or natural support system may jeopardize safety (such as domestic violence, child abuse and neglect, separation and divorce, and/or financial and legal difficulties), services shall be available to educate family members/natural supports about the impact of these issues and strategies to reduce risk factors.

(E) Assistance in finding options for transportation, childcare, and safe and appropriate housing shall be utilized as necessary in order for individuals to participate in services and meet recovery/resiliency goals.

(F) For adults with children, services to enhance their parenting capacities shall be provided or arranged.

(G) Performance indicators may include, but are not limited to:

Variability in the type and amount of services an individual receives consistent with his/her needs, goals, and progress;
Hospital readmission rates;
Rate of family/natural support engagement in direct services (such as family therapy) and continuing care;
Number of individuals receiving withdrawal management/detoxification services who continue treatment;
Satisfaction with shared decision-making as conveyed by individuals served and their family members and other natural supports.

(6) Essential Principle—Least Restrictive Environment.

(A) Individuals shall be served in the most appropriate setting available based on their personal goals for recovery/ resiliency and readiness to change, while assuring emotional and physical safety and protection from harm.

(B) Performance indicators may include, but are not limited 1. Utilization rate of inpatient hospitalization, residential support, and out- of-home placement;

Length of stay for inpatient hospitalization, residential support, and out-of-home services;
Consistent use of admission eligibility criteria;
Distribution of individuals served among settings;
Ongoing assessment of individuals to ensure the appropriate and least restrictive environment; and 6. Satisfaction with services as conveyed by individuals served and their family members or other natural supports.

(7) Essential Principle—Promoting Recovery and Resilience.

Services and supports shall be delivered in a manner consistent with the concept of recovery as defined by the Substance Abuse and Mental Health Services Administration (SAMHSA) as a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. Services are provided that build, enhance, and activate skills for recovery and resilience for individuals, families, and other natural supports.

(A) Staff shall offer support and encouragement and model recovery/resilience from a behavioral health disorder, serious emotional disturbance, and/or substance use disorder in ways that are specific to the needs of each individual served.

Services are provided in a safe, welcoming, culturally sensitive, trauma-sensitive, and age-appropriate environment where all individuals are engaged as equal partners.

(B) Individuals are educated about their illness, coping skills, and strategies to prevent a recurrence of symptoms and are encouraged to accomplish tasks and goals in an independent manner without undue staff assistance.

Health—overcoming or managing one’s disease(s) or symptoms such as:

A. Abstaining or reducing harmful use of alcohol, illicit drugs, and non-prescribed medications;

B. Participating in appropriate health care services to lower the incidence of diabetes, cardiovascular disease, coronary artery disease, HIV, and hepatitis C; and C. Making informed, healthy choices that support physical and emotional well-being.

Home—having a stable and safe place to live;
Purpose—conducting meaningful daily activities such as a job, school volunteerism, family caretaking, or creative endeavors, and the independence, income, and resources to participate in society; and 4. Community—having relationships and social networks that provide support, friendship, love, and hope.

(D) Performance indicators may include, but are not limited 1. Measures of symptom frequency and severity;

Improved functioning related to— A. Health, wellness and nutrition;

B. Personal care (hygiene, grooming, dress);

C. Communication;

D. Money management;

E. Safety;

F. Occupational/educational status;

G. Legal situation;

H. Social and family/natural support relationships;

I. Housing stability, maintenance;

J. Problem solving, decision making, and coping skills;

K. Managing time, leisure skills, and productivity;

Tapering the intensity and frequency of services, consistent with individual progress; and 4. Satisfaction with services as conveyed by individuals served and their family members and other natural supports.

(8) Essential Principle—Peer Support and Social Networks.

Individuals served and their parents/legal guardians, family members, and other natural supports shall have access to peer support services, social networks, and resources in the community.

(A) Peer support encompasses a range of activities and interactions between people who share similar experiences of being diagnosed with a mental health condition, substance use disorder, or both. Through shared understanding, respect, and mutual empowerment, peer support specialists help people become and stay engaged in the recovery process and reduce the likelihood of a return to substance use. Peer support services can effectively extend the reach of treatment beyond the clinical setting into the everyday environment of individuals seeking a successful, sustained recovery process.

(B) Peer support services shall be provided in a manner that reflect the core competencies, principles, and values identified in the publication, Core Competencies for Peer Workers in Behavioral Health Services, December 2017, developed by and available from SAMHSA, 5600 Fishers Lane, Rockville, MD 20857, (877) 726-4727. The referenced document does not include any later revisions or updates.

(D) Performance indicators may include, but are not limited 1. Rate of participation in community-based recovery support groups;

Involvement with a wide range of individuals in social activities and networks (such as church, clubs, and sporting activities);
Number of certified peer specialists employed by the organization and documented delivery of peer support services; and 4. Satisfaction with peer support services and accessibility to social networks as conveyed by individuals served and their family members/natural supports.

(9) Essential Principle—Medication Services. Individuals shall have access to medications to treat mental illness and substance use disorders, including tobacco use.

(A) The organization shall implement written policies and procedures related to its medication practices.

(B) Individuals shall be educated about available medications, their intended benefits, and potential side effects in order to make informed choices regarding their use. Use of medication is not a requirement for receiving behavioral health services.

Individuals shall not be denied their medication(s) because they are not participating in treatment.

(C) Staff of the organization, including contracted prescribers and providers, must be familiar with the full range of FDAapproved medications available for mental illness, substance use disorders, including tobacco use, and shall not be limited to a single model, approach, category, or formulation of medications.

(D) Individuals shall be educated about the importance of taking medication as prescribed and provided with aids such as pill boxes and blister packs, once-a-day long-acting medications, depot injections, and generic or lower-cost alternatives, when appropriate.

(E) Medication compliance shall be monitored by staff, as indicated by clinical need, to assist individuals in anticipating early warning signs of a recurrence of symptoms and develop strategies to maintain health and wellness.

(F) Routine communication and coordination with other service providers regarding the individual’s medical conditions, test results, and prescribed medications occurs as clinically indicated.

(G) Performance indicators may include, but are not limited 1. Number of individuals receiving an FDA-approved medication for a diagnosed mental illness and/or substance use disorder, including tobacco use;

Variability in the use of FDA-approved medications for mental illness and substance use disorders, including tobacco use;
Reduction in rates of recurrence of symptoms among individuals served; and 4. Improvement in treatment retention and completion rates.

(10) Essential Principle—Services for Co-Occurring Disorders.

Coordinated, evidence-based services shall be provided or arranged for individuals with a diagnosed co-occurring disorder.

(A) Each individual seeking services shall be screened and assessed for co-occurring disorders and have access to a full range of services provided by qualified, trained staff.

(B) Each individual shall receive services necessary to fully address his/her treatment needs. The program providing screening and assessment shall— 1. Directly provide all necessary services in accordance with the program’s capabilities and certification/deemed status;

Make a referral to a program which can provide all necessary services and maintain appropriate involvement until the individual is admitted to the program which he/she has been referred; or 3. Provide services within its capability and promptly arrange additional services from another program.

(C) Services are continuously coordinated between programs, where applicable. Programs shall ensure services are not redundant or conflicting and maintain communication regarding the individual’s treatment plan and progress.

(D) Performance indicators may include, but are not limited 1. Reduction in hospitalization rates;

Reduction in incarceration rates;
Reduction in readmissions to withdrawal management/ detoxification services;
Increased stable housing/independent living arrangements;
Increased rates of competitive employment; and 6. Increased access to medical care.

(11) Essential Principle—Trauma-Informed Care. Clinical and nonclinical staff shall be competent in recognizing and responding appropriately to the presence of the effects of past and current traumatic experiences in the lives of individuals (A) A trauma-informed organization— 1. Realizes the widespread impact of trauma and understands potential paths for recovery;

Recognizes the signs and symptoms of trauma in individuals, families/natural supports, staff, and others involved in the continuum of care;
Responds by fully integrating knowledge about trauma into its policies, procedures, practices, and environments; and 4. Seeks to actively prevent re-traumatization.

(B) Each individual shall receive services necessary to fully address his/her treatment needs. Appropriately trained staff shall screen for each individual’s history of trauma and current personal safety in accordance with a model approved by the department. The agency providing the screening shall— 1. Directly provide necessary services to address the impact of trauma in accordance with the program’s capabilities and certification;

Make a referral to a provider that can offer the necessary trauma services and continue to provide other needed services and maintain appropriate involvement until the individual is admitted to the agency which he/she is being referred; or 3. Provide services within its capability and promptly arrange additional services from another provider.

(C) Services shall be continuously coordinated between providers, as applicable, to ensure services are not redundant or conflicting and to maintain communication regarding the individual’s treatment plan and progress.

(D) Individual trauma counseling shall be provided by a licensed mental health professional with specialized training in trauma services and/or equivalent work experience.

(E) Performance indicators may include, but are not limited 1. Decrease in trauma and mental health symptoms and substance use;

Improvement in daily functioning;
Improvement in relationships and self-esteem;
Decrease in utilization of crisis-based services; and 5. Improvement in housing stability.

(12) Essential Principle—Easy and Timely Access to Services.

Services are easy to find, affordable, and readily available to individuals in the community.

(A) Services are available at convenient times and locations for individuals and their family members/natural supports, with prompt screening and engagement regardless of ability to pay.

(B) Interim services are made available to eligible individuals, when possible, by the organization or through referral to other community resources when immediate admission cannot be provided.

(C) Outreach and educational activities shall be conducted on a regular basis to educate the public about behavioral health issues, prevention strategies, diagnoses, and the availability of services in the community.

(D) Telehealth/telemedicine and other forms of technology are utilized in accordance with federal confidentiality regulations to increase access, engagement, and retention.

(E) Partnerships and affiliations among physical and behavioral health providers, law enforcement, courts, schools/ universities, hospitals, family services, and other community resources shall be developed and actively implemented to educate staff, improve communication, and provide for easier access to the range of services and supports needed by the population served.

(F) Individuals shall be informed of available resources for housing, transportation, and childcare to assist them in accessing and engaging in necessary services and supports.

(G) Performance indicators may include, but are not limited 1. Same-day access to services;

Reduced wait time to set a first or subsequent appointment(s);
Increased retention in services; and 4. Satisfaction with accessibility to services as conveyed by individuals served and their family members/natural supports, referral sources, and other community partners.

(13) Essential Principle–Qualified and Competent Workforce. A core workforce (employed or contracted) shall be maintained that is appropriately qualified and determined competent to adequately address the needs of the population served and deliver the behavioral health services the organization is certified/deemed certified to provide.

(A) Staff shall have opportunities to participate in continuing education, training, technical assistance, or other workforce development activities related to evidence-based and best practices, federal, state and/or department initiatives, stateof-the-art technology, and other advances in the behavioral health field to enhance service delivery practices and improve individual outcomes.

(B) Direct service staff shall demonstrate competency in the areas identified by the Centers for Medicare and Medicaid Services, National Direct Service Workforce Resource Center, Final Competency Set, December 2014, 7500 Security Blvd., Baltimore, MD 21244, available at https://www.medicaid.gov/ medicaid/ltss/workforce/index.html. The referenced document does not include any later updates or revisions. Competent staff shall— 1. Communicate in a respectful and clear manner, verbal and written, to build trust and productive relationships with individuals/families, co-workers and others;

Use person-centered practices, assist individuals to make choices and plan goals, and provide services to help individuals to achieve their goals;
Closely monitor an individual’s physical and emotional health, gather information about the individual, and communicate observations to guide services;
Identify risks and behaviors that can lead to a crisis, and use effective strategies to prevent or intervene in the crisis in collaboration with others;
Be attentive to signs of abuse, neglect, or exploitation and follow procedures to protect an individual from such harm.

Help individuals avoid unsafe situations and use appropriate procedures to assure safety during emergency situations;

Work in a professional and ethical manner, maintaining confidentiality and respecting individual and family rights;
Provide advocacy and empower and assist individuals to advocate for what they need;
Help individuals to achieve and maintain good physical and emotional health essential to their well-being;
Help individuals to manage the personal, financial, and household tasks that are necessary on a day-to-day basis to pursue an independent, community-based lifestyle;
Help individuals to be a part of the community through valued roles and relationships, and assist individuals with major transitions that occur in community life;
Respect cultural differences and provide services and supports that fit with an individual’s preferences; and 12. Obtain and maintain necessary professional credential(s) and seek opportunities to improve their skills and work practices through further education, training, and selfdevelopment.

(C) Staff shall provide services within the scope of their respective state credential(s) and in accordance with all applicable federal, state, or local laws and other regulations.

(D) Performance indicators may include, but are not limited 1. A qualified and diverse workforce acclimated to the community culture;

Delivery of culturally appropriate services and supports;
Documented delivery of a broad range of individual and group services including specialized services for co-occurring disorders and trauma;
Satisfaction with services and supports as conveyed by individuals, family members/natural supports, referral sources, and other community stakeholders.

(14) Essential Principle—Employment. All individuals served who have a desire to work shall have access to appropriate resources to assist them in overcoming or addressing symptoms that interfere with seeking, obtaining, and maintaining a job.

(A) Evidence-based and best practices shall be implemented to promote recovery/resiliency and assist individuals in obtaining and maintaining integrated, competitive, and meaningful employment of their choice.

(B) Staff shall work collaboratively with individuals and their family members/natural supports, parents/guardians, or other caregivers to include educational, vocational, and/ or employment goals on the individual treatment plan and provide appropriate support to assist the individual in achieving those goals.

(C) Performance indicators may include, but are not limited 1. Individuals served obtain and maintain a job of their choice;

Documented delivery of services that assist individuals with job-seeking skills and symptom-management on the job;
Effective working relationships with employment, vocational, and educational resources in the community; and 4. Satisfaction with employment, vocational, and education-related services and supports as conveyed by individuals, family members/natural supports.

(15) Essential Principle—Care Planning and Care Coordination.

Services shall be coordinated to promote accurate diagnosis and treatment, improve the individual experience of care, enhance health and wellness outcomes, and increase efficiency across healthcare delivery systems.

(A) Service delivery staff shall engage in care-planning and coordination activities identified by SAMHSA’s Health Resources and Services Administration, Center for Integrated Health Solutions, 1400 K Street NW, Suite 400, Washington, D.C. 20005, (202) 684-7457, including, but not limited to:

Developing integrated treatment plans with the individual and family members/natural supports, parents/ guardians, caregivers of his/her choice, and members of the service delivery team;
Monitoring each individual’s participation in and response to treatment on a regular basis in order to match and adjust the type and intensity of services to the individual’s needs and ensure the timely and unduplicated provision of care;
Utilizing the treatment plan to link multiple services, healthcare providers, and community resources to meet the individual’s needs;
Ensuring the flow and timely exchange of information among the individual, family members/natural supports, parents/guardians, caregivers and linked providers;
Working collaboratively to resolve differing perspectives, priorities, and schedules among providers;
Providing or arranging access to services that focus on benefits and financial counseling, transportation, home care, social services, peer support, and medication for substance use disorders;
Implementing disease management strategies for selected health conditions (such as asthma, diabetes, COPD, cardiovascular disease and hypertension, obesity, tobacco use), combining the use of engagement tools, health risk assessments, cognitive and behavioral interventions, medications, webbased tools, protocols and guidelines, formularies, monitoring devices, shared decision-making aids, illness and whole health self-management strategies, peer support and empowerment approaches; and 8. Effectively connecting individuals who cannot be adequately served by the treatment team or within the setting to other appropriate services.

(B) Care planning and care coordination involves active partnerships with community resources to ensure access and seamless transition to other services and supports for individuals and families/natural supports served. Community resources include, but are not limited to, local primary care providers, hospital systems, health homes, schools, and vocational rehabilitation and employment entities.

(C) When an individual misses an appointment or drops out of services, steps shall be taken to reengage him or her in services by making reminder calls, addressing basic needs that may be preventing them from participating, and offering peer support.

(D) Performance indicators may include, but are not limited 1. Reduction in emergency room visits;

Reduction in hospitalizations;
Reduction in costs and duplication of services;
Documented delivery of services related to recovery planning, health and wellness;
Satisfaction with services as conveyed by individuals, family members/natural supports.

9 CSR 10-7.020 Rights, Responsibilities, and Grievances {#sec-9-csr-10-7.020 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-7.020}

PURPOSE: This rule describes individual rights, the orientation process, and grievance procedures applicable to Comprehensive Gambling Disorder Treatment Programs, Institutional Treatment Centers, Opioid Treatment Programs, Recovery Support Programs, (REACT), Substance Use Disorder Treatment Programs, Community Psychiatric Rehabilitation Programs (CPR), and Outpatient Mental Health Treatment Programs.

(1) General Policy and Practice. The organization demonstrates through its policies, procedures, and practices an ongoing commitment to the rights, dignity, and respect of the individuals it serves. In addition to the requirements of this

rule, the organization must also comply with 9 CSR 10-5.200, Procedures for Reporting Complaints of Abuse, Neglect, and Misuse of Funds/Property.

(2) Information and Orientation. Each individual served shall receive an orientation about what to expect while receiving services and his or her role in treatment. The orientation is provided in a timely manner based on the individual’s presenting condition and type of services he or she will receive.

The orientation must be understandable to the person served and available in written form. Written acknowledgement of receipt of the orientation must be documented.

(A) An individual who is admitted to a program on a voluntary basis is expected to give written, informed consent to care and treatment.

(B) As applicable to the individual, the orientation shall include, but is not limited to, an explanation of— 1. Program rules and participation requirements, rights, responsibilities, and behavioral expectations;

Available services and supports, including crisis assistance;
Complaint and appeal procedures;
Ways in which input can be given;
The organization’s confidentiality policies;
Continuing recovery planning;
Discharge criteria and procedures;
Access to after-hour services;
Reporting requirements for individuals mandated to participate in services;
Financial obligations, fees, and financial arrangements for services provided by the organization;
Health and safety policies including, but not limited to, the use of emergency safety interventions, use of tobacco products, illegal or legal substances brought into the program, prescription medication brought into the program, and weapons brought into the program;
Layout of the premises including emergency exits and/ or shelters;
Education regarding advance directives when indicated;
The assessment process and the individual’s role in developing his/her treatment plan and personal goals for recovery/resiliency, the course of services, expectations for legally required appointments, sanctions, or court notifications;
Composition of the treatment team.

(C) Each individual shall be informed of the process to make an inquiry, file a complaint, or report a violation of his/her rights to the department. Written information regarding these processes is readily accessible to individuals at all times and reasonable assistance from staff is available, if necessary.

(D) When appropriate, family members and other natural supports, parents/guardians, or other caregivers are provided with information to promote their participation in relevant services or decisions about the care and treatment of the individual being served.

(3) Rights Which Cannot Be Limited. Each individual has basic rights to humane care and treatment that cannot be limited under any circumstances.

(A) The following rights apply to all settings:

To receive prompt evaluation, care and treatment;
To receive services in the least restrictive environment;
To receive services in a clean and safe setting;
To receive services without discrimination based on race, ethnicity, gender, gender identity, gender expression, sexual orientation, creed, marital status, national origin, disability, or age;
To confidentiality of information and records in accordance with federal and state law and regulation;
To be treated with dignity and be addressed in a respectful, age appropriate manner;
To be free from verbal, sexual, and physical abuse, neglect, corporal punishment, and other mistreatment such as humiliation, threats, or exploitation;
To be the subject of an experiment or research only with one’s informed, written consent, or the consent of an individual legally authorized to act, and to decide to withdraw at any time;
To medical care and treatment in accordance with accepted standards of medical practice, if the certified organization offers medical care and treatment; and 10. To consult with a private, licensed practitioner at one’s own expense.

(B) The following additional rights apply to individuals receiving residential support, and where otherwise applicable, shall not be limited under any circumstances:

To a nourishing, well-balanced, varied diet;
To attend or not attend religious services;
To communicate by sealed mail or otherwise with the department and, if applicable, legal counsel and court of jurisdiction;
To receive visits from one’s attorney, physician, or clergy in private at reasonable times; and 5. To be paid for work unrelated to treatment, except an individual may be expected to perform limited tasks and chores within the program that are designed to promote personal involvement and responsibility, skill-building, or peer support. Any tasks and chores beyond routine care and cleaning of activity or bedroom areas within the program must be directly related to recovery and treatment plan goals developed with the individual.

A. An individual receiving services may perform labor that contributes to the operations and maintenance of a facility/ program, which would otherwise require the organization to employ staff, as long as the individual is compensated at a rate derived from the value of the work performed and in accordance with applicable federal and state minimum wage laws.

(4) Rights Subject to Limitation. Each individual shall have further rights and privileges which can be limited only if the program director or designee determines it is necessary to ensure personal safety or the safety of others.

(A) Any limitation due to safety considerations shall occur only if it is— 1. Applied on an individual basis;

Authorized by the organization’s director or designee;
Documented in the individual’s record;
Justified by sufficient documentation;
Reviewed on a regular basis; and 6. Rescinded at the earliest clinically appropriate time.

(B) In all care and treatment settings, each individual has the right to see and review his/her record, except specific information the program director determines would be detrimental to the individual or records provided by other individuals or agencies may be excluded from such review. Any restrictions must be documented and include specific rationale for the decision. The organization may require a staff member to be present whenever an individual accesses the record.

(C) The following additional rights and privileges apply to individuals receiving residential support and where otherwise applicable:

To wear one’s own clothes and keep and use one’s own personal possessions;
To keep and be allowed to spend a reasonable amount of one’s own funds;
To have reasonable access to a telephone to make and to receive confidential calls;
To have reasonable access to current newspapers, magazines, and radio and television programming;
To be free from seclusion and restraint;
To have opportunities for physical exercise and outdoor recreation;
To receive visitors of one’s choosing at reasonable hours;
To communicate by sealed mail with individuals outside the facility.

(5) Other Legal Rights. All individuals have the same legal rights and responsibilities as any other citizen, unless otherwise limited by law.

(A) In accordance with section 208.009, RSMo, individuals presenting for services who are not legal residents of the United States cannot receive any Missouri state benefit unless his/her lawful presence in the United States is verified by the federal government.

(B) Organizations shall not knowingly provide nonemergency services to individuals who are eighteen (18) years of age or older and whose presence in the United States is unlawful.

(C) Individuals seeking nonemergency state or local public benefits shall provide affirmative proof they are a citizen or permanent resident of Missouri and the United States or are lawfully present in the United States. Affirmative proof is considered to be at least one of the following:

Documentary evidence recognized by the Missouri Department of Revenue when processing an application for a driver’s license;
A Missouri driver’s license;
MO HealthNet identification card; or 4. Any document issued by the federal government that confirms an alien’s lawful presence in the United States.

(6) Access to Services. The organization shall have written policies and procedures regarding the provision of services for individuals who fall under the protection of the Americans with Disabilities Act of 1990.

(A) An individual shall not be denied admission or services solely on the grounds of prior treatment, withdrawal from treatment against advice, or continuation or return of symptoms after prior treatment.

(7) Grievances. The organization shall establish policies, procedures, and practices to ensure all individuals receive a prompt, responsive, impartial review of any grievance or alleged violation of rights.

(A) Reasonable assistance from staff shall be provided to an individual wishing to file a grievance.

(B) The review shall be consistent with principles of due process.

(C) The organization shall cooperate with the department in any review or investigation conducted by the department or its authorized representative.

(8) Records of Events and Reporting Requirements. All organizations must maintain records of events and comply with reporting requirements as specified in 9 CSR 10-5.200 and 9 CSR 10-5.206.

rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed Dec. 12, 2001, effective June 30, 2002. Amended: Filed July 29, 2002, effective March 30, 2003. Amended: Filed Nov. 5, 2018, effective June 30, 2019.

9 CSR 10-7.030 Service Delivery Process and Documentation {#sec-9-csr-10-7.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-7.030}

PURPOSE: This rule describes requirements for the delivery and documentation of services in Opioid Treatment Programs, Substance Use Disorder Treatment Programs, Comprehensive Gambling Disorder Treatment Programs, Community Psychiatric Rehabilitation Programs (CPR), and Outpatient Mental Health (1) Screening. The organization shall implement written policies and procedures to ensure individuals seeking assistance via telephone, in person, or by referral have prompt access to screening to determine the need for further clinical assessment. The screening process is welcoming, conducted in a safe, culturally and linguistically appropriate manner, and conveys a hopeful message to individuals and their families/ natural supports.

(A) At the individual’s first contact with the organization (whether by telephone or in person), emergency, urgent, or routine service needs shall be identified and addressed as follows:

Emergency service needs are indicated when a person presents a likelihood of immediate harm to self or others Qualified staff must address emergency needs immediately;
An urgent need is one that, if not addressed immediately, could result in the individual becoming a danger to self or others or could cause a health risk. Appropriately qualified staff shall address urgent service needs within one (1) business day of the time the request was made; and 3. Routine service needs are indicated when a person requests services or follow-up but otherwise presents no significant impairment in the ability to care for self and no apparent harm to self or others. Routine service needs shall be addressed within ten (10) days.

(B) Documentation of the screening shall include but is not 1. A brief interview with the individual or referral source to obtain basic information and presenting situation and symptoms;

Collection of basic demographic information;
Identification of requested service needs;
Determination of the organization’s ability to provide the requested services; and 5. Referral and coordination with alternate resources when the screening agency cannot meet the individual’s service needs.

(C) The organization’s performance improvement processes shall ensure trained staff uniformly administer its designated screening instrument(s). Each screening shall be signed and documented by staff.

(2) Admission Assessment. The organization shall implement written policies and procedures to ensure all individuals participate in an admission assessment to determine service needs. Programs should only admit individuals who will benefit from available services. Comprehensive Substance Treatment and Rehabilitation (CSTAR) programs must comply with assessment requirements specified in 9 CSR 30-3.151 and fulfill department contract requirements. Community Psychiatric Rehabilitation (CPR) programs must comply with assessment requirements specified in 9 CSR 30- 4.035 and fulfill contract requirements.

(A) Documentation of the admission assessment shall include but is not limited to— 1. Personal and identifying information;

Presenting problem and referral source;
Status as a current or former member of the U.S. Armed Forces;
Brief history of previous substance use and/or psychiatric treatment, including the type of admission(s);
Family history of substance use disorders and/or mental illness;
Trauma history (experienced and/or witnessed abuse, neglect, violence, sexual assault) and whether the individual receiving services has concerns for their safety, such as intimate partner violence;
Current medications and any known allergies or allergic reactions;
Current substance use, including utilization of a standardized and validated alcohol and substance-use screening instrument;
Current mental health symptoms, including utilization of standardized and validated depression and suicide screening instruments;
Physical health concerns, including a health screening, previously identified medical diagnoses, and identification of unmet needs with specific recommendations for further evaluation, treatment, and referral;
Diagnosis and clinical summary by a licensed mental health professional, including substance use and mental health;
Family, social, legal, and vocational/educational status and functioning;
Statement of needs, goals, preferences, and treatment expectations;
Current housing situation; and 15. Dated signature, title, and credential(s) of staff completing the assessment. Signature stamps/typed signatures shall not be used.

(B) The admission assessment shall be completed within seventy-two (72) hours for individuals in a residential level of care or within the first three (3) outpatient visits.

(3) Consent to Treatment. Each individual served or a parent/ guardian must provide informed, written consent to treatment.

(A) A copy of the consent form, which must contain the date of consent and signature of the individual served or a parent/ guardian, shall be retained in the individual record.

(B) Consent to treat shall be updated annually, including the date of consent and signature of the individual served or a parent/guardian, and be maintained in the individual record.

(4) Crisis Prevention Plan. If a potential risk for suicide, violence, or other at-risk behavior (such as increased isolation, increased substance use, heightened depression or anxiety) is identified during the assessment process and any time during the individual’s time in services, a crisis prevention plan shall be developed with the individual as soon as possible.

(A) At a minimum, the crisis prevention plan shall include factors that may precipitate a crisis, a hierarchical list of selfcare and self-help strategies identified by the individual to regain a sense of control to return to their level of functioning before the crisis or emergency, and a hierarchical list of staff interventions that may be used when a critical situation occurs.

(B) Staff shall conduct a monthly case review of all critical interventions that occurred during the previous month and incorporate the results into the organization’s performance improvement processes.

(5) Individual Treatment Plan. Each individual and/or their parent or guardian shall participate in developing a treatment plan using information from the assessment process and shall receive a copy of the plan. CSTAR programs shall comply with treatment plan requirements specified in 9 CSR 30-3.151 and fulfill department contract requirements. CPR programs shall comply with treatment plan requirements specified in 9 CSR 30-4.035 and fulfill contract requirements.

(A) The treatment plan shall include but is not limited to— 1. Identifying information;

Objectives that— A. Are reflective of the individual’s culture and ethnicity;

B. Are linked to the individual’s assessed needs and goals;

C. Are achievable, measurable, time specific, strengthsand skills-based;

D. Identify supports and resources needed to meet objectives; and E. Are understandable, developmentally appropriate, and responsive to the disability/disorder or concerns of the individual;

Duration and frequency of interventions, staff responsible for intervention, and action steps of the individual and parents/guardians, family, or other natural supports;
Other community resources and/or peer, family, and recovery supports necessary; and 5. Dated signature, title, and credential(s) of staff completing the plan. Signature stamps/typed signatures shall not be used. The individual shall also sign the plan unless a current signed consent to treatment is included in the individual record.

(B) A licensed mental health professional shall approve (sign/ date) treatment plans. Signature stamps/typed signatures shall not be used.

(6) Treatment Plan Updates. Progress toward treatment goals and objectives shall be reviewed and updated on a periodic

basis with active involvement of the individual served, parent/ guardian, and family members/natural supports as applicable and appropriate.

(A) At a minimum, treatment plans shall be reviewed every six (6) months to assess continued need for services, responses to treatment, and progress achieved during the past six (6) months. The occurrence of a crisis or significant clinical event may require further review and modification of the treatment plan. Updates must be documented in the individual record.

(B) The dated signature(s), title(s), and credential(s) of staff completing the review must be included on the treatment plan update. The individual served shall also sign the plan unless there is a current signed consent to treatment included in the individual record.

(7) Ongoing Service Delivery. The individual treatment plan guides ongoing service delivery. Services may begin before the admission assessment and treatment plan are fully developed.

(A) Staff with appropriate training, licenses, and credentials shall provide identified services and supports.

(B) Services shall be provided in accordance with applicable eligibility criteria. Decisions regarding the treatment setting, intensity, and duration of services are based on the needs of the individual, including but not limited to— 1. Need for personal safety and protection from harm;

Severity of the behavioral health disorder;
Emotional and behavioral functioning and need for structure;
Social, family, and community functioning;
Readiness to change;
Availability of peer and social supports for recovery/ resiliency;
Ability to avoid high-risk behaviors; and 8. Ability to cooperate with and benefit from the services offered.

(C) Services shall be developmentally appropriate and responsive to the individual’s social/cultural situation and any linguistic/communication needs.

(D) Coordination of care is demonstrated when multiple agencies or programs are providing services and supports.

(E) To the fullest extent possible, individuals are responsible for action steps to achieve their goals. Services and supports provided by staff should be readily available to help individuals achieve their goals and objectives.

(8) Missed Appointments. Organizations shall implement written policies and procedures to contact individuals who miss a scheduled program activity or appointment consistent with their service needs.

(A) Such efforts shall be initiated within forty-eight (48) hours unless circumstances indicate an immediate contact should be made due to the individual’s symptoms and functioning or the nature of the scheduled service.

(B) Efforts to contact the individual shall be documented.

(9) Service Transition, Transfer, and Discharge Planning. The organization shall implement written policies and procedures for developing transfer, transition, and discharge plans for (A) Transfer, transition, and discharge planning begins at admission, or as soon as clinically appropriate, to assist the individual in moving from one level of care to another within the organization or obtain needed services from another service provider.

Individuals are actively involved in developing their transfer, transition, and/or discharge plan. Family members/ natural supports, program staff, referral source(s), and staff or peers involved in follow-up services and supports in the community are included when applicable and permitted.
The plan shall be signed by the staff person who completes it. The individual served and/or parents/legal guardians, family members, or other natural supports shall receive a copy of the plan, as appropriate.
The transition and discharge plans identify services and supports, designated provider(s), and other planned activities designed to support the gains achieved by the individual during participation in services. Plans shall include but are not A. Date of next appointment(s) for follow-up services or other supports, as applicable;

B. Action steps to access support system(s) or other resources to assist in community integration and obtain help if symptoms recur and additional services/supports are needed;

C. Safe use of medication(s) as prescribed;

D. Referral information such as contact name, telephone number, locations, hours, and days of services, when applicable;

E. Action steps for maintaining a healthy lifestyle such as exercising, volunteering, participating in support groups, and managing personal finances.

(B) A written discharge summary shall be completed to ensure the individual record includes documented treatment episode(s) and the outcome of each episode, including but not 1. Date of admission and discharge;

Identified needs at admission;
Referral source, as applicable;
Services provided and the extent to which established goals and objectives were achieved;
Reason(s) for or type of discharge;
Diagnosis or diagnostic impression at last contact;
Recommendations for continued services and supports;
Information on medication(s) prescribed or administered, as applicable; and 9. Dated signature, title, and credential(s) of staff completing the discharge summary/discharge plan (not a signature stamp or typed signature).

(C) Follow-up with individuals who have an unplanned discharge shall be conducted in accordance with the organization’s written policies and procedures which include but are not limited to— 1. Clarifying the reason for the unplanned discharge;

Determining if further services are needed; and 3. Referring the individual to other necessary services, if applicable.

(D) The organization shall implement written policies and procedures to ensure a seamless transition for individuals who transfer to more or less intensive services, to another component of care, or are being discharged from the program.

(10) Crisis Assistance and Intervention. Ready access to crisis assistance and intervention shall be available to all individuals served, when needed.

(A) The organization shall directly provide or arrange for crisis assistance to be available twenty-four (24) hours per day, seven (7) days per week. Services shall be provided by qualified staff in accordance with applicable program rules and include in-person intervention when clinically indicated.

(B) If the organization utilizes the services of the designated Access Crisis Intervention (ACI), 988 Call Center, or Mobile Crisis Response provider for the region, a formal written agreement, memorandum of understanding, or contractual relationship shall be established and documented to support the coordination of services and sharing of information to meet individual needs.

(C) If crisis services are provided within the organization, there shall be more than one (1) staff person designated to ensure coverage during leaves of absence.

(11) Service Delivery Practices. The organization shall incorporate evidence-based and emerging best practices into its service array that are designed to— (A) Support the recovery, resiliency, health, and wellness of the individuals and families/natural supports served;

(B) Enhance the quality of life for individuals and families/ natural supports served;

(D) Restore and/or improve functioning; and (E) Support the integration of individuals into the community.

(12) Utilization Review. Services funded by the department are subject to utilization review by department staff to ensure they are necessary, appropriate, likely to benefit the individual, and provided in accordance with admission criteria and service definitions. The department has authority in all matters subject to utilization review including eligibility, service definition, authorization, and limitations.

(13) Designated or Required Instruments. In order to promote consistency in clinical practice, eligibility determination, service documentation, and outcome measurement, the department may require the use of designated instruments in the screening, assessment, and treatment process. The required use of particular instruments is applicable to services funded by the department.

(14) Organized Record System and Documentation Requirements. The organization must maintain an organized clinical record system that ensures easily retrievable, complete, and usable records stored in a secure and confidential manner.

(A) The organization shall implement written policies and procedures to ensure— 1. All local, state, and federal laws and regulations related to the confidentiality of records and release of information are followed;

Electronic health record systems conform to federal and state regulations;
Individual records are retained for at least six (6) years or until all litigation, adverse audit findings, or both, are resolved;
Ready access to paper or electronic records requested by authorized staff and/or other authorized parties, including department staff;
Any errors are marked through with a single line, initialed, and dated by the staff person making the correction;
All services provided are adequately documented in the individual record to ensure the type(s) of services rendered and the amount of reimbursement received by the organization can be readily discerned and verified with reasonable certainty.

A. Adequate individual records are of the type and in a form such that symptoms, conditions, diagnoses, treatments, prognosis, and the identity of the individual to which these things relate can be readily discerned and verified with reasonable certainty. All documentation must be available at the site where the service was rendered. The record must be legible and made contemporaneously with the delivery of the service (at the time the service was performed or within five (5) business days of the time it was provided), address the individual’s specifics including, at a minimum, individualized statements that support the assessment or treatment encounter.

(B) Unless specified otherwise by another payer source(s), all treatment sessions must have accompanying documentation that includes the following:

First name, last name, and middle initial or date of birth of the individual and any other identifying information required by a payer source, such as a Document Control Number (DCN);
Accurate, complete, and legible description of each service provided;
Name, title, credential(s), and dated signature of the provider/staff delivering the service (not a signature stamp or typed signature);
Name of referring entity, when applicable;
Date of service (month/day/year);
Actual begin and end time taken to deliver a service;
Setting in which the service was provided;
Plan of treatment, evaluation(s), test(s), findings, results, and prescription(s), as necessary;
Need for the service(s) in relationship to the individual treatment plan;
Individual’s progress toward the goals stated in the individual treatment plan; and 11. For applicable programs, adequate invoices, trip tickets/ reports, activity log sheets.

(C) The content of the individual record must include but is not limited to— 1. Signed consent to treatment, updated annually;

Documented acknowledgment of orientation to the program;
Screening, admission assessment, treatment plan, and related reviews/updates;
Service delivery and progress notes;
Transfer, transition, and discharge plan(s), as applicable.
Documentation of any referral(s) to other services or community resources and outcome of those referrals;
Signed authorization(s) to release confidential information, as applicable;
Missed appointments and efforts to reengage the individual, as applicable;
Urine drug screening(s) or other lab reports, as applicable;
Crisis or other significant clinical events;
Follow-up for an unplanned discharge, as applicable;
Proof of purchase for medications, housing, transportation, or other services/supports utilized by the individual during the episode of care.

(15) The organization is subject to recoupment of all or part of reimbursement from the department if individual records do not document— (A) The service was actually provided;

(B) The service was delivered by a qualified staff person within established program time frames;

(D) The amount, duration, and length of service; and (E) The services/supports were delivered under the direction of a current treatment plan, including but not limited to medication(s), transportation, and housing.

(16) Other Regulations. Core Rules for Psychiatric and Substance Use Disorder Treatment Programs apply to all organizations that are certified/deemed certified by the department to provide behavioral health and/or substance use disorder treatment services.

(A) Organizations that have a contract with the department shall comply with contractual requirements as well as program-specific regulations, which take precedence over Core Rules if there is a conflict.

Dec. 12, 2001, effective June 30, 2002. Amended: Filed Nov. 5, 2018, effective June 30, 2019. ** Amended: Filed March 5, 2024, effective Oct. 30, 2024. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008, and 630.055, **Pursuant to Executive Order 21-09, 9 CSR 10-7.030, subsection (2)(B) and paragraph (4)(A)5. was suspended from April 23, 2020 through December 31, 2021.

9 CSR 10-7.035 Behavioral Health Healthcare Home {#sec-9-csr-10-7.035 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-7.035}

PURPOSE: This rule establishes the requirements for designation as a Behavioral Health Healthcare Home by the department. A Healthcare Home is an alternative approach to the delivery of healthcare services that have a reasonable likelihood of resulting in a better experience and improved outcomes for individuals served as compared to traditional healthcare.

(1) Behavioral Health Healthcare Home Qualifications.

(A) Initial Provider Qualifications. In order to be recognized as a Behavioral Health Healthcare Home, a provider must, at a minimum, meet the following criteria:

Have a substantial percentage of individuals served enrolled in Medicaid. Percentage requirements will be determined by the department;
Have strong, engaged leadership committed to and capable of leading the organization through the transformation process to Healthcare Home service delivery practices and sustaining those practices as demonstrated through the application process and agreement to participate in learning activities, including in-person sessions and regularly scheduled phone calls as required by the department;
Meet the department’s minimum access requirements.

Prior to implementation of Behavioral Health Healthcare Home service coverage, provide assurance to the department of enhanced access to the care team by individuals served, including the development of alternatives to face-to-face visits, such as telephone or email, twenty-four (24) hours per day, seven (7) days per week;

Actively use the department’s identified health information technology tool to conduct care coordination, input metabolic syndrome screening results, track and measure care of individuals, automate care reminders, produce exception reports for care planning, and monitor medication adherence;
Conduct wellness interventions as indicated based on the individual’s level of risk;
Complete status reports to document the individual’s housing, legal, employment, education, and custody status;
Agree to convene regular, ongoing, and documented internal Healthcare Home team meetings to plan and implement goals and objectives of ongoing practice transformation;
Agree to participate in department-approved evaluation activities;
Agree to develop required reports describing Healthcare Home activities, efforts, and progress in implementing Healthcare Home services;
Maintain compliance with all of the terms and conditions as a Behavioral Health Healthcare Home provider or face termination as a provider of Healthcare Home services;
Present a proposed Behavioral Health Healthcare Home service delivery model the department determines will have a reasonable likelihood of being cost effective. Cost effectiveness will be determined based on the size of the proposed Behavioral Health Healthcare Home, Medicaid caseload, percentage of caseload with eligible chronic conditions, and other factors to be determined by the department.

(B) Ongoing Provider Qualifications. Each provider must also— 1. Coordinate care and build relationships with regional hospital(s) or system(s) to develop a structure for transitional care planning, including communication of inpatient admissions of Healthcare Home participants, and maintain a mutual awareness and collaboration to identify individuals seeking emergency department services who might benefit from connection with a Healthcare Home, and encourage hospital staff to notify the area Behavioral Health Healthcare Home staff of such opportunities;

Develop quality improvement plans to address gaps and opportunities for improvement identified during and after the application process;
Demonstrate continuing development of fundamental Healthcare Home functionality through an assessment process to be determined by the department;
Demonstrate significant improvement on clinical indicators specified by and reported to the department;
Meet accreditation standards approved by the department; and 6. Provide Behavioral Health Healthcare Home services that demonstrate overall cost effectiveness.

(2) Scope of Services. This section describes the activities behavioral health providers will be required to engage in, and the responsibilities they will fulfill, if recognized as a Behavioral Health Healthcare Home.

(A) Healthcare Home Services. The Healthcare Home Team shall assure the following health services are received, as necessary, by all individuals served in the Behavioral Health Healthcare Home:

Comprehensive Care Management. Comprehensive care management includes the following services:

A. Identification of high-risk individuals and use of information obtained during the enrollment process to determine level of participation in care management services;

B. Assessment of preliminary service needs;

C. Development of treatment plans including individual goals, preferences, and optimal clinical outcomes;

D. Assignment of care team roles and responsibilities;

E. Development of treatment guidelines that establish clinical pathways for care teams to follow across risk levels or health conditions;

F. Monitor individual and population health status and service use to determine adherence to, or variance from, treatment guidelines; and G. Development and dissemination of reports that indicate progress toward meeting outcomes for individual satisfaction, health status, service delivery, and costs;

Care Coordination. Care coordination consists of the implementation of the individualized treatment plan through appropriate linkages, referrals, coordination, and follow-up to needed services and supports, including referral and linkage to long-term services and supports. Specific care coordination activities include but are not limited to:

A. Appointment scheduling;

B. Conducting referrals and follow-up monitoring;

C. Participating in hospital discharge processes; and D. Communicating with other providers and the individual and their family members/natural supports;

Health Promotion Services. Services shall minimally consist of health education specific to an individual’s chronic conditions, development of self-management plans with the individual, education regarding the importance of immunizations and screenings, child physical and emotional development, providing support for improving social networks, and healthy lifestyle interventions, including but not limited A. Substance use prevention;

B. Smoking prevention and cessation;

C. Nutritional counseling;

D. Obesity reduction and prevention;

E. Increasing physical activity; and F. Health promotion services also assist individuals in the implementation of their treatment plan and place a strong emphasis on person-centered empowerment to understand and self-manage chronic health conditions;

Comprehensive Transitional Care. Members of the care team must provide care coordination services designed to streamline plans of care, reduce hospital admissions, ease the transition to long-term services and supports, and interrupt patterns of frequent hospital emergency department use.

Members of the care team collaborate with physicians, nurses, social workers, discharge planners, pharmacists, and others to continue implementation of the treatment plan with a specific focus on increasing individuals’ and family members’ ability to manage care and live safely in the community and shift the use of reactive care and treatment to proactive health promotion and self-management;

Individual and Family Support Services. Services include but are not limited to advocating for individuals and families and assisting with, obtaining, and adhering to medications and other prescribed treatments. Care team members are responsible for identifying resources for individuals to support them in attaining their highest level of health and functioning in their families and in the community, including transportation to medically necessary services. A primary focus will be to help individuals increase their health literacy, self-manage care, and participate in the ongoing revision of their care/treatment plan. For individuals with developmental disabilities (DD), the care team will refer to, and coordinate with, the approved DD case management entity for services more directly related to habilitation or a particular healthcare condition; and 6. Referral to Community and Social Support Including Long-term Services and Supports. This involves providing assistance for individuals to obtain and maintain eligibility for healthcare, disability benefits, housing, personal need, and legal services, as examples. For individuals with DD, the care team will refer to, and coordinate with, the approved DD case management entity for this service.

(B) Healthcare Home Staffing. Behavioral Health Healthcare Home providers will augment their current treatment teams by adding Healthcare Home Director(s), Specialized Healthcare Consultant(s), and Nurse Care Manager(s) to provide consultation as part of the care team and assist in delivering Healthcare Home services. Care Coordinator(s) will also be funded to assist with Healthcare Home supporting functions.

(C) Learning Activities. Behavioral health providers will be supported in transforming service delivery by participating in statewide learning activities. Providers will participate in a variety of learning supports, up to and including learning collaboratives specifically designed to demonstrate how to operate as a Behavioral Health Healthcare Home and provide care using a whole person approach that integrates behavioral health, primary care, and other needed services and supports.

Learning activities will be supplemented with periodic calls to reinforce the learning sessions, practice coaching, and monthly practice reporting (data and narrative) and feedback.

Learning activities will support Behavioral Health Healthcare Home providers in addressing the following:

A. Providing quality-driven, cost-effective, culturally appropriate, and person- and family-centered healthcare home services;

B. Coordinating and providing access to high-quality healthcare services informed by evidence-based clinical practice guidelines;

C. Coordinating and providing access to preventive and health promotion services, including prevention of mental illness and substance use disorders;

D. Coordinating and providing access to mental health and substance use disorder treatment services;

E. Coordinating and providing access to comprehensive care management, care coordination, and transitional care across settings. Transitional care includes appropriate followup from inpatient to other settings, such as participation in discharge planning and facilitating transfer from a pediatric to an adult system of healthcare;

F. Coordinating and providing access to chronic disease management, including self-management support to individuals and their families;

G. Coordinating and providing access to individual and family supports, including referral to community, social support, and recovery services;

H. Coordinating and providing access to long-term care supports and services;

I. Developing a person-centered care plan for each individual that coordinates and integrates all of his or her clinical and non-clinical healthcare related needs and services;

J. Demonstrating a capacity to use health information technology to link services, facilitate communication among team members and between the care team and individual and family caregivers, and provide feedback to practices, as feasible and appropriate; and K. Establishing a continuous quality improvement program and collecting and reporting on data that permits an evaluation of increased coordination of care and chronic disease management on individual level clinical outcomes, experience of care outcomes, and quality of care outcomes at the population level.

(D) Patient Registry. Behavioral Health Healthcare Homes shall utilize the patient registry approved by the department.

A patient registry is a system for tracking information the department deems critical to the management of the health of the population being served through a Healthcare Home, including dates of delivered and needed services, laboratory values needed to track chronic conditions, and other measures of health status. The registry shall be used for— 1. Tracking;

Risk stratification;
Analysis of population health status and individual needs; and 4. Reporting as specified by the department.

(E) Data Reporting. Behavioral Health Healthcare Homes shall submit the following reports to the department as specified:

Monthly updates identifying the Behavioral Health Healthcare Home’s staffing patterns, enrollment status, hospital follow-ups, and notifications provided to primary healthcare providers; and 2. Other reports as specified by the department.

(F) Demonstrated Evidence of Healthcare Home Transformation. Providers are required to demonstrate evidence of transformation to the Behavioral Health Healthcare Home model on an ongoing basis using measures and standards established by the department and communicated to the providers. Transformation to the Behavioral Health Healthcare Home service delivery model is exhibited when a provider— 1. Demonstrates development of fundamental Healthcare Home functionality at six (6) months and twelve (12) months based on an assessment process determined by the department.

Providers must demonstrate continued improvement and functionality for as long as they maintain their Behavioral Health Healthcare Home designation; and 2. Demonstrates improvement on clinical indicators specified by and reported to the department.

(G) Participation in Evaluation. Providers shall participate in ongoing evaluation. Participation may entail responding to surveys and requests for interviews with Behavioral Health Healthcare Home staff and individuals served. Providers shall provide all requested information to the evaluator in a timely fashion.

(H) Notification of Staffing Changes. Providers are required to notify the department within five (5) working days of staff changes in any of the Healthcare Home staff positions referenced in subsection (2)(B) of this rule.

(I) Providers shall work cooperatively with the department to support approved training, technology, and administrative services required for ongoing implementation and support of the Behavioral Health Healthcare Homes.

(3) Patient Eligibility and Enrollment. This section describes eligibility and enrollment requirements for Behavioral Health Healthcare Homes.

(A) Individuals receiving Medicaid benefits must meet one (1) of the following criteria to be eligible for services from a designated Behavioral Health Healthcare Home:

Be diagnosed with a serious and persistent mental health condition (adults with Serious Mental Illness (SMI) and children with Severe Emotional Disturbance (SED)); or 2. Be diagnosed with a mental health condition and substance use disorder; or 3. Be diagnosed with a mental health condition and/or substance use disorder, and one (1) other chronic condition including diabetes, chronic obstructive pulmonary disease (COPD), asthma, cardiovascular disease, overweight (body mass index (BMI) > 25), tobacco use, developmental disability, or complex trauma.

(B) Providers may determine enrollment in the Behavioral Health Healthcare Home for individuals being served within their organization who meet eligibility requirements in accordance with the following:

Enrollment is based on the choice of individuals served;
Individuals may choose not to enroll in the Behavioral Health Healthcare Home or may choose another provider’s Behavioral Health Healthcare Home if one exists in their area.

(C) Behavioral Health Healthcare Homes must follow Healthcare Home enrollment procedures, including submittal of the required Healthcare Home enrollment form(s).

(4) Healthcare Home Payment Components. This section describes the payment process for Behavioral Health Healthcare Homes.

(A) General.

All payments to a Behavioral Health Healthcare Home are contingent on the site meeting the Behavioral Health Healthcare Home requirements set forth in this rule. Failure to meet these requirements is grounds for revocation of a site’s designation as a Behavioral Health Healthcare Home and for termination of payments specified within this rule.
Reimbursement for Healthcare Home services will be in addition to a provider’s existing reimbursement for services and procedures and will not change existing reimbursement for services and procedures that are not part of the Behavioral Health Healthcare Home.
The department reserves the right to make changes to the payment methodology.

(B) Types of Payments.

Clinical Care Management Per Member Per Month (PMPM). PMPM reimburses for the cost of staff primarily responsible for delivery of Behavioral Health Healthcare Home services not covered by other reimbursement and whose duties are not otherwise reimbursable by Medicaid.

Filed June 13, 2023, effective Jan. 30, 2024. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008.

History

AUTHORITY: section 630.050, RSMo 2016. This rule originally filed as 9 CSR 10-5.240. Emergency rule filed Dec. 20, 2011, effective Jan. 1, 2012, expired June 28, 2012. Original rule filed Oct. 17, 2011, effective June 29, 2012. Moved to 9 CSR 10-7.035 and amended: Filed Sept. 14, 2018, effective March 30, 2019. Amended:

9 CSR 10-7.040 Performance Improvement {#sec-9-csr-10-7.040 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-7.040}

PURPOSE: This rule describes requirements for performance improvement activities in Opioid Treatment Programs, Substance Disorder Treatment Programs, Institutional Treatment Programs, Recovery Support Programs, Substance Awareness Traffic (1) Performance Improvement. The organization shall develop, implement, and maintain an effective, ongoing, agency-wide and data-driven performance measurement and performance improvement program/process. These activities allow the organization to objectively review how well it is accomplishing its mission, and develop and initiate performance improvement changes.

(A) The performance measurement and performance improvement program encompasses the organization’s full array of clinical services and focuses on indicators related to improved behavioral health or other healthcare outcomes for (B) Direct service staff and medical staff shall be actively involved in performance measurement and improvement activities including, but not limited to, clinical care issues and practices related to the use of medications.

(C) Components of the organization’s performance measurement and performance improvement program includes, but is not limited to:

A description of its purpose, priorities, policies, and goals;
A description of the measurement analysis and how it will help define future performance improvement activities;
A description of evaluation and quality assurance activities that will be utilized to determine the effectiveness of the performance improvement plan;
A description of the organizational systems needed to implement the plan including the functions, descriptions of accountability, and roles and responsibilities of staff or performance improvement committee; and 5. A plan for communicating planned activities and processes to staff and the governing body on a regular basis.

(2) Performance Improvement Plan. The organization shall develop and implement an annual performance improvement plan. The plan is updated on an ongoing basis to reflect changes, corrections, and other modifications and reviewed annually with the organization’s governing body.

(A) Direct service staff, individuals served, and family members/natural supports are involved in the planning, design, implementation and review of the organization’s performance improvement activities.

(B) The performance improvement plan shall include, but is not limited to:

A process for obtaining satisfaction and other feedback related to service delivery from individuals served, family members/natural supports, and other stakeholders;
A process to measure outcomes for individuals served;
A review of clinical records to ensure all required documentation is thorough, timely and complete;
A process to evaluate whether services are effective, appropriate, and relate to treatment goals;
Activities to improve access and retention in services;
Review of clinical staff training and competencies;
Review of critical/sentinal events, grievances, and complaints; and 8. A process for monitoring compliance of subcontractors.

(3) Performance Measurement and Analysis. Performance measurement is a process by which an organization monitors important aspects of its programs, systems, and care processes.

Qualitative and quantitative data is collected, systematically aggregated, and analyzed on an ongoing basis to assist organizational leadership in evaluating whether the adequate structure and correct processes are in place to achieve the organization’s desired results.

(A) Properly trained staff shall use valid, reliable processes to collect and analyze data. The data may be used to— 1. Distinguish between expected behavioral health outcomes and actual outcomes in areas such as employment/ return to school, stable housing, decreased involvement in the justice system, improved physical health and wellness, and increased engagement in services;

Establish baseline measures before improvements are made;
Make decisions based on solid evidence;
Allow performance comparisons across sites;
Monitor process changes to ensure improvements are sustained over time;
Recognize improved performance;
Determine the effectiveness of evidence-based and/or best practices provided;
Monitor and continually improve management, clinical services, and support services; and 9. Address undesirable patterns in performance and sentinel events.

(B) Results of the performance analysis are available to individuals served, family members/natural supports, other stakeholders, and the department.

(4) The department may require, at its option, the use of designated measures or instruments in the performance measurement and improvement process in order to promote consistency in data collection, analysis, and applicability. The required use of particular measures or instruments applies to programs or services funded by the department.

(5) Documentation. The organization shall maintain documentation of its performance measurement and performance improvement program and be able to demonstrate its operation to staff of the department, accrediting body, or other interested parties.

(A) Documentation shall include, but is not limited to, the following types of information:

Management reports;
Strategic plans;
Budgets;
Accessibility plans;
Technology plans and analysis;
Risk analysis reports and information;
Environmental health and safety reports;
Financial reports;
Quality assurance reports including review of clinical records to ensure documentation requirements are being met;
Data collected;
Demographic information of individuals served; and 12. Satisfaction data of individuals, family members/ natural supports, and other stakeholders.

9 CSR 10-7.050 Research {#sec-9-csr-10-7.050 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-7.050}

PURPOSE: This rule establishes standards and procedures for conducting research in Opioid Treatment Programs, Substance (1) General Policy. The organization shall have a written policy regarding research activities involving individuals served. The organization may prohibit research activities.

(2) Policies and Practices in Conducting Research. If research is conducted, the organization shall assure that— (A) Compliance is maintained with all federal, state, and local laws and regulations concerning the conduct of research including, but not limited to, sections 630.192, 630.199, 630.194, and 630.115 RSMo, 9 CSR 60-1.010, and 9 CSR 60-1.015.

(B) Participating individuals are not the subject of experimental research without their prior written and informed consent or that of their guardian.

(C) Participating individuals understand they may decide not to participate or may withdraw from any research at any time for any reason.

(3) Notice to the Department. If any participating individual is receiving services funded by the department, the organization shall assure the research has the prior approval of the department and immediately inform the department of any adverse outcome experienced by an individual served due to participation in a research project.

9 CSR 10-7.060 Emergency Safety Interventions {#sec-9-csr-10-7.060 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-7.060}

PURPOSE: This rule establishes requirements for the use of restraint, seclusion, and time out in Substance Use Disorder Treatment Programs, Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), Opioid Treatment Programs, Gambling Disorder Treatment Programs, Substance Awareness Traffic Offender Programs (SATOP), Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric Rehabilitation Programs (CPR), and Outpatient Mental Health Treatment Programs.

(1) General Principles and Practices. The organization shall implement written policies and procedures to prevent and respond to disruptive behaviors, behavioral crises, and psychiatric crises that may occur with individuals served, staff, visitors, and others. All efforts shall be made to minimize re-traumatization of persons served or others involved in a disruptive situation, including consideration as to whether the program is suitable to meet the individual’s needs.

(A) Policies and procedures shall indicate whether time-out, seclusion, and restraint are used in the organization, by whom, and under what circumstances, including protocols for their use with children/youth, adults, and individuals with special needs.

(B) Organizations may prohibit by policy and practice the use of time-out, seclusion, and restraint and must have policies and procedures for addressing disruptive behaviors, behavioral crises, and psychiatric crises.

Available to all program staff and service providers;
Available to individuals served and parents/guardians, family members, and other natural supports, as appropriate;
Developed with input from individuals served and, whenever possible, parents/guardians, family members, and other natural supports; and 5. Consistent with department regulations regarding individual rights.

(D) As applicable to the population served, all staff and volunteers having direct contact with individuals served shall receive documented initial and ongoing competency-based training on evidence-based and best practice interventions to prevent disruptive behaviors and behavioral crises and to address them in the least restrictive manner if they occur.

(E) All organizations shall prohibit by policy and practice— 1. Aversive conditioning of any kind—the application of startling, unpleasant, or painful stimulus or stimuli that have a potentially harmful effect on an individual in an effort to decrease maladaptive behavior;

Withholding of food, water, or bathroom privileges;
Painful stimuli;
Corporal punishment (such as use of pepper spray, mace, Taser, stun gun);
Techniques that obstruct the individual’s airways or impairs breathing;
Techniques that restrict the individual’s ability to communicate;
Use of time-out or other disciplinary action for staff convenience; and 8. Chemical restraints—use of a medication to sedate or limit an individual’s ability to participate in treatment rather than treat the symptoms of a behavioral health disorder as prescribed and specified in the individual treatment plan. Medication used as prescribed and as indicated in the individual’s treatment plan to treat symptoms of a behavioral disorder, including aggressive behavior, is not considered chemical restraint.

(2) Seclusion and Restraint. Recognizing there are times when other interventions such as de-escalation or a change in the physical environment are not successful and there is imminent danger of serious harm to the individual or others, seclusion or restraint may be necessary to ensure safety. Any emergency safety interventions used by the organization must promote the rights, dignity, and safety of individuals being served.

Organizations utilizing seclusion and restraint must obtain a separate written authorization from the department, in addition to complying with all other requirements of this

rule. The department may issue such authorization on a timelimited basis subject to renewal.

(A) Staff of the organization shall assure seclusion and restraint are only used when an individual’s behavior presents an immediate risk of danger to themselves or others and no other safe or effective treatment intervention is possible.

These measures shall only be implemented when alternative, less restrictive interventions have failed or cannot be safely implemented. Crisis prevention techniques shall be used to de-escalate such occurrences, when possible. Seclusion and restraint are never used as treatment interventions. They are emergency/security measures to maintain safety when all other less restrictive interventions are inadequate.

(B) The use of seclusion or restraint shall be in accordance with the order of the organization’s attending physician or clinical director. Staff shall notify the attending physician or clinical director at the earliest possible time when a situation has a significant likelihood of leading to seclusion or restraint.

If seclusion or restraint is initiated prior to obtaining an order, staff must obtain an order immediately.

(D) Orders for seclusion or restraint shall be individualized to each event, define specific time limits, and be ended at the earliest possible time. Orders shall not exceed four (4) hours for adults, two (2) hours for children/youth age nine (9) to seventeen (17), and one (1) hour for children under age nine (9).

If there is a need for continuing seclusion or restraint beyond the time limits specified herein, the attending physician or clinical director must write a new order for seclusion or restraint.

(E) Seclusion and restraint shall only be implemented by staff who are trained and competent in the proper techniques for administering/applying the form of seclusion or restraint ordered and for providing ongoing monitoring and assessment of individuals for their safety and well-being. At a minimum, initial and periodic training shall include:

Techniques to identify individual behaviors, events, and environmental factors that may trigger circumstances requiring the use of seclusion or restraint;
The use of nonphysical intervention skills;
Use of the least restrictive intervention based on an individualized assessment of the individual’s medical and/or behavioral status or condition;
The safe application and use of all types of seclusion or restraint used by the organization, including how to recognize and respond to signs of physical and psychological distress;
Clinical identification of specific behavioral changes that indicate restraint or seclusion is no longer necessary;
Monitoring the physical and psychological well-being of the individual who is secluded or restrained, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified in the organization’s policies and procedures associated with face-toface evaluations; and 7. The use of First Aid techniques and certification in CPR, including required periodic recertification.

(F) When an individual is being secluded or restrained, trained staff shall continually observe and assess him or her to assure appropriate care and treatment including, but not limited to:

Attention to vital signs;
Need for meals and liquids;
Need for bathing and use of the restroom; and 4. Need for seclusion or restraint to continue.

(G) Staff observing the individual shall immediately notify the attending physician or clinical director if his or her behavior has improved such that seclusion or restraint can be ended.

Use of seclusion or restraint shall be discontinued when the attending physician or clinical director determines the need for the intervention is no longer present or the individual’s needs can be addressed using less restrictive methods.

(H) All orders for seclusion or restraint must be documented in the individual record as soon as possible and shall include, but is not limited to:

Reason for the intervention;
Staff who ordered the intervention;
Type of intervention used;
Starting and ending time;
Regular observations of the individual, including any resulting injuries or other issues as a result of the intervention;
Notification of parent/guardian, as applicable;
Notification of healthcare provider, as applicable; and 8. Modifications to the treatment plan as a result of the intervention.

(I) The organization’s clinical director and/or performance improvement coordinator shall review every episode of seclusion or restraint within seventy-two (72) hours of the occurrence to ensure policies and procedures were followed and identify any areas needing improvement. A written report on the organization’s overall use of emergency safety interventions, including progress made in reducing their use, shall be prepared at least annually and reviewed by organizational leadership.

(3) Behavior Modification Plans. Behavior modification plans are designed to assist individuals in being successful while engaged in services and minimize inappropriate behaviors.

Behavioral expectations, procedures, and consequences shall be clearly defined and explained to the individual served.

(A) The need for a behavior modification plan shall be evaluated upon— 1. Any incident of seclusion or restraint;

The use of time-out two (2) or more times per day; or 3. The use of time-out three (3) or more times per week.

(B) The behavior modification plan shall be developed with the individual served and his or her parents/guardian and family members/natural supports, as appropriate.

(C) The plan shall identify what the individual is attempting to communicate or achieve through his or her behavior before identifying interventions to change it.

(D) The plan shall be reevaluated within the first seven (7) days after it is developed, and every seven (7) days thereafter, to determine whether inappropriate behavior is being reduced and more functional alternatives achieved by the individual.

April 15, 2002, effective Nov. 30, 2002. Amended: Filed Aug. 12, 2019, effective Feb. 29, 2020.

9 CSR 10-7.070 Medications {#sec-9-csr-10-7.070 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-7.070}

PURPOSE: This rule describes training and procedures for the proper storage, use and administration of medications in Alcohol and Drug Abuse Treatment Programs, Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), Compulsive Gambling Treatment Programs, Substance Abuse Traffic Rehabilitation Programs (CPRP), and Psychiatric Outpatient Programs.

(1) General Guidelines, Policies and Practices. The following requirements apply to all programs, where applicable.

(A) The organization shall assure that staff authorized by the organization and by law to conduct medical, nursing and pharmaceutical services do so using sound clinical practices and following all applicable state and federal laws and regulations.

(B) The organization shall have written policies and procedures on how medications are prescribed, obtained, stored, administered and disposed.

(C) The organization shall implement policies that prevent the use of medications as punishment, for the convenience of staff, as a substitute for services or other treatment, or in quantities that interfere with the individual’s participation in treatment and rehabilitation services.

(D) The organization shall allow individuals to take prescribed medication as directed.

Individuals cannot be denied service due to taking prescribed medication as directed. If the organization believes that a prescribed medication is subject to abuse or could be an obstacle to other treatment goals, then the organization’s treatment staff shall attempt to engage the prescribing physician in a collaborative discussion and treatment planning process. If the prescribing physician is nonresponsive, a second opinion by another physician may be used.
Individuals shall not be denied service solely due to not taking prescribed medication as directed. However, a person may be denied service if he or she is unable to adequately participate in and benefit from the service offered due to not taking medication as directed.

(2) Medication Profile. Where applicable, the individual’s record shall include a medication profile that includes name, age, weight, current diagnosis, current medication and dosage, prescribing physician, allergies to medication, non-prescription medication and supplements, medication compliance; and other pertinent information related to the individual’s medication regimen.

(3) Prescription of Medication. If a program prescribes medications, there shall be documentation of each medication service episode including description of the individual’s presenting condition and symptoms, pertinent medical and psychiatric findings, other observations, response to medication, and action taken.

(4) Medication Administration and Related Requirements.

The following requirements apply to programs that prescribe or administer medication and to those programs where individuals self-administer medication under staff observation.

(A) Staff Training and Competence. The organization shall ensure the training and competence of staff in the administration of medication and observation for adverse drug reactions and medication errors, consistent with each staff individual’s job duties.

Staff whose duties include the administration of medication shall complete Level I medication aide training in accordance with 19 CSR 30-84.030. This requirement shall not apply to those staff who— A. Have prior education and training which meets or exceeds the Level I medication aide training hours and skill objectives; or B. Work in settings where clients self-administer their own medication under staff observation.
Staff whose duties are limited to observing clients self-administer their own medication or to documenting that medication is taken as prescribed shall have available to them a physician, pharmacist, registered nurse or reference material for consultation regarding medications and their actions, possible side effects, and potential adverse reactions.
Staff whose duties are limited to observing clients self-administer their own medication or to documenting that medication is taken as prescribed shall receive education on general actions, possible side effects, and potential adverse reactions to medications.

(B) Education. If medication is part of the treatment plan, the organization shall document that the individual and family member, if appropriate, understands the purpose and side effects of the medication.

(C) Compliance. The program shall take steps to ensure that each individual takes medication as prescribed and the program shall document any refusal of medications. A licensed physician shall be informed of any ongoing refusal of medication.

(D) Medication Errors. The program shall establish and implement policies defining the types of medication errors that must be reported to a licensed physician.

(E) Adverse Drug Reactions. A licensed physician shall be immediately notified of any adverse reaction. The type of reaction, physician recommendation and subsequent action taken by the program shall be documented in the individual’s record.

(F) Records and Documentation. The organization shall maintain records to track and account for all prescribed medications in residential programs and, where applicable, in nonresidential programs.

Each individual receiving medication shall have a medication intake sheet which includes the individual’s name, known allergies, type and amount of medication, dose and frequency of administration, date and time of intake, and name of staff who administered or observed the medication intake. If medication is self-administered, the individual shall sign or initial the medication intake sheet.
The amount of medication originally present and the amount remaining can be validated by the medication intake sheet.
Documentation of medication intake shall include overthe-counter products.
Medication shall be administered in single doses to the extent possible.
The organization shall establish a mechanism for the positive identification of individuals at the time medication is dispensed, administered or self-administered under staff observation.

(G) Emergency Situations. The organization’s policies shall address the administration of medication in emergency situations.

Medical/nursing staff shall accept telephone medication orders only from physicians who are included in the organization’s list of authorized physicians and who are known to the staff receiving the orders. A physician’s signature shall authenticate verbal orders within five (5) working days of the receipt of the initial telephone order.
The organization may prohibit telephone medication orders, if warranted by staffing patterns and staff credentials.

(H) Periodic Review. The organization shall document that individuals’ medications are evaluated by qualified staff at least every six (6) months to determine their continued effectiveness.

(I) Individuals Bringing Their Own Medication. Any medication brought to the program by an individual served is allowed to be administered or self-administered only when the medication is appropriately labeled.

(J) Labeling. All medication shall be properly labeled.

Labeling for each medication shall include drug name, strength, dispense date, amount dispensed, directions for administration, expiration date, name of individual being served, and name of the prescribing physician.

(K) Storage. The organization shall implement written policies and procedures on how medications are to be stored.

The organization shall establish a locked storage area for all medications that provides suitable conditions regarding sanitation, ventilation, lighting and moisture.
The organization shall store ingestible medications separately from noningestible medications and other substances.
The organization shall maintain a list of personnel who have been authorized access to the locked medication area and who are qualified to administer medications.

(L) Inventory. Where applicable, the organization shall implement written policies and procedures for:

Receipt and disposition of stock pharmaceuticals must be accurately documented;
A log shall be maintained for each stock pharmaceutical that documents receipts and disposition;
At least quarterly, each stock pharmaceutical shall be reconciled as to the amount received and the amount dispensed; and 4. A stock supply of a controlled substance must be registered with the Drug Enforcement Administration and the Missouri Department of Health, Bureau of Narcotics and Dangerous Drugs.

(M) Disposal. The organization shall implement written procedures and policies for the disposal of medication.

Medication must be removed on or before the expiration date and destroyed.
Any medication left by an individual at discharge shall be destroyed within thirty (30) days.
The disposal of all medications shall be witnessed and documented by two (2) staff members.

History

AUTHORITY: sections 630.050 and 630.055, RSMo 2000. Original April 15, 2002, effective Nov. 30, 2002. Original authority: 630.050, RSMo 1980, amended 1993, 1995 and 630.055, RSMo 1980.

9 CSR 10-7.080 Dietary Service {#sec-9-csr-10-7.080 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-7.080}

PURPOSE: This rule establishes dietary and food service requirements in Opioid Treatment Programs, Substance Use Disorder Treatment Programs, Comprehensive Substance (1) Dietary Requirements. The organization shall comply with state, county, and city health regulations applicable to its food and dietary components. This includes food storage, preparation, and service, including catered food through a contractual arrangement and food brought to a program by (A) All programs shall ensure— 1. Proper diet and food preparation are addressed as part of the individualized treatment planning process, if identified as a need during the assessment or is a treatment goal of the individual;

All appliances for food storage and preparation are clean and in safe and good operating condition;
Hand washing facilities including hot and cold water, soap, and hand drying means are readily accessible to individuals and staff;
Fresh water is available to individuals at all times;
Consideration is given to the food habits, personal, cultural, and religious preferences and medical needs of individuals served, including provisions for special diets for medical reasons;
Meals and snacks are served in a clean dining area with appropriate eating utensils for each individual as applicable;
Meals and snacks are nutritious, balanced, and varied based on The Dietary Guidelines for Americans 2015-2020, 8th Edition, published by and available from the Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, 1101 Wootton Parkway, Suite LL100, Rockville, MD 20852 and downloadable at https://health.gov/ dietaryguidelines/2015/guidelines/. The referenced guide does not include any later amendments or additions.
Meals and snacks are provided at scheduled times comparable to mealtimes in the community;
Food is stored to maintain safety and sanitation standards based on the Missouri Food Code, 2013 edition, published by and available from the Missouri Department of Health and Senior Services, Bureau of Environmental Health Services, PO Box 570, Jefferson City, MO 65102-0570. The referenced guide does not include any later amendments or additions;
Food preparation areas and utensils are cleaned and sanitized after use and are kept in good repair; and 11. Inspections are current, documented, and available on site and in compliance with state, local, and/or city regulations.

9 CSR 10-7.090 Governing Authority and Program Administration {#sec-9-csr-10-7.090 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-7.090}

PURPOSE: This rule describes requirements for and responsibilities of the governing body in Opioid Treatment Programs, Substance (1) Governing Body. The organization shall have a designated governing body with legal authority and responsibility over its policies and operations. The governing authority ensures the organization complies with all federal, state, local, and municipal laws and regulations, as applicable. The chief executive officer is responsible to the governing body for the overall day-to-day operations of the organization, including the control, utilization, and conservation of its physical and financial assets and the recruitment and direction of the staff.

(A) The governing body has written documents of its source of authority that are available to the public upon request. The source of authority document includes, but is not limited to— 1. The eligibility criteria for governing body membership;

The number and types of membership;
The method of selecting members;
The number of members necessary for a quorum;
Attendance requirements for governing body membership;
The duration of appointment or election for governing body members and officers; and 7. The powers and duties of the governing body and its officers and committees, or the authority and responsibilities of any person legally designated to function as the governing body.

(B) The requirements of section (1) are not applicable to state-operated programs except such programs must have an administrative structure with identified lines of authority to ensure responsibility and accountability for the successful operation of its behavioral health services.

(2) Composition of the Governing Body and Meetings. Members of the governing body shall have a demonstrated interest in the area(s) and/or region(s) served by the organization. A current roster of the governing body members shall be maintained and available to the public upon request.

(A) Members of the governing body shall represent the demographics of the population served including, but not limited to, geographic area, race, ethnicity, gender identity, disability, age, and sexual orientation. Individuals living with mental illness and/or a substance use disorder and family members/natural supports, and parents/legal guardians of children, adolescents, and adults receiving services shall have meaningful input to the governing body.

(B) The governing body shall meet at least quarterly and maintain an accurate record of meetings including dates, attendance, discussion items, and actions taken.

(3) Functions of the Governing Body. Duties of the governing body shall include, but are not limited to— (A) Providing fiscal planning and oversight;

(B) Ensuring implementation of an organizational performance improvement and measurement process;

(D) Ensuring responsiveness to the communities and individuals served;

(E) Delegating operational management to a chief executive officer and, as necessary, to program managers to effectively operate its services; and (F) Designating contractual authority.

(4) Policy and Procedure Manual. The organization shall maintain a policy and procedure manual which accurately describes and guides the operation of its services and promotes compliance with applicable regulations. Additional policies and procedures for specialized programs/services may be specified in department contracts. The policy and procedure manual shall be readily available to staff and the public upon request and shall include, but is not limited to:

(A) Mission, goals, and objectives of the organization;

(B) Organization of the agency;

(D) Service delivery process, documentation, and individual records in accordance with 9 CSR 10-7.030;

(E) Service array including, but not limited to:

Description of all services available, including crisis assistance;
Outreach and education strategy for all services;
Location of service sites, hours, and days of operation for each site;
Accessibility, including provisions for individual choice of services and location;
Referral process including follow-up, continuity of care, and timely transfer of records.

(F) Performance measurement and improvement in accordance with 9 CSR 10-7.040;

(G) Research in accordance with 9 CSR 10-7.050;

(H) Emergency safety interventions in accordance with 9 CSR 10-7.060;

(I) Medications in accordance with 9 CSR 10-7.070;

(J) Dietary services in accordance with 9 CSR 10-7.080;

(K) Governing authority and program administration in accordance with 9 CSR 10-7.090;

(L) Fiscal management in accordance with 9 CSR 10-7.100;

(M) Personnel in accordance with 9 CSR 10-7.110;

(N) Physical environment and safety in accordance with 9 CSR 10-7.120;

(O) Background screenings in accordance with 9 CSR 10- 5.190;

(P) Report of complaints of abuse, neglect, and misuse of funds/property in accordance with 9 CSR 10-5.200 and 9 CSR 10-5.206;

(Q) Routine monitoring of individual records for compliance with applicable standards;

(R) Commonly occurring issues with individuals served such as missed appointment, accidents on the premises, suicide attempts, threats, loitering, and non-compliance with program policies and procedures; and (S) Relevant information related to services available for children and youth addressing any and all aspects of paragraph (4)(A)–(R) of this rule.

(5) Corporate Compliance. Each organization shall have a corporate compliance plan to assure federal and state regulatory, contractual obligations, and requirements are fulfilled and services are provided with integrity and the highest standards of excellence.

(A) A staff member of the organization shall serve as the corporate compliance officer and be responsible for coordinating, implementing, and monitoring the corporate compliance plan.

(B) The corporate compliance plan shall include education and training of staff and specific oversight activities to monitor and detect potential fraud and abuse.

(6) Agency Contracts. The organization shall establish a formal, accountable relationship with any contractor that provides a direct service and is not an employee of the organization.

(A) The organization retains full responsibility for all services provided by a contractor. All services must meet the requirements of all laws, rules, regulations, and contracts applicable to the organization.

(B) The department reserves the right to approve any contractor utilized by an organization when the services to be provided are certified or deemed by the department. The department, at its sole discretion, may require such approval prior to the utilization of any contractor.

(C) The organization retains full responsibility for all legal and financial responsibilities related to execution of the contract.

(7) Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Regulatory Compliance. The organization shall comply with applicable requirements as set forth in 9 CSR 10- 5.220.

History

AUTHORITY: sections 630.050 and 630.055, RSMo 2016. 45 CFR parts 160 and 164, the Health Insurance Portability and Accountability Act of 1996. Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Emergency amendment filed April 1, 2003, effective April 14, 2003, expired Oct. 14, 2003. Amended: Filed April 1, 2003, effective Oct. 30, 2003. Amended: Filed March 15, 2010, effective Sept. 30, 2010. Amended: Filed Nov. 5, 2018, effective June 30, 2019.

9 CSR 10-7.100 Fiscal Management {#sec-9-csr-10-7.100 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-7.100}

PURPOSE: This rule describes fiscal policies and procedures for Opioid Treatment Programs, Substance Use Disorder Treatment Programs, Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), Gambling Disorder Treatment Programs, Recovery Support Programs, Substance Awareness Traffic (1) Generally Accepted Accounting Principles. The organization has fiscal management policies, procedures and practices consistent with generally accepted accounting principles and, as applicable, state and federal law, regulation, or funding requirements.

(2) Monitoring and Reporting Financial Activity. The organization assigns responsibility for fiscal management to a designated staff member who has the skills, authority, and support to fulfill these responsibilities.

(A) An annual budget shall be reviewed and approved by the board of directors prior to the beginning of the organization’s fiscal year. Fiscal reports shall be reviewed by the board of directors and administrative staff on at least a quarterly basis.

(B) Financial activity measures shall be utilized on a regular

basis to monitor and ensure the organization’s ability to pay current liabilities and maintain adequate cash flow.

(D) The organization has an annual audit by an independent, certified public accountant if required by funding sources or otherwise required by federal or state law or regulation. The audit is reviewed and approved by the governing body and made available to staff who have responsibility for budget and management. Adverse audit findings are addressed and resolved in a timely manner.

(E) As applicable, the organization conducts an internal quarterly review of a representative sampling of invoices reimbursed by the department to determine accuracy and identify any necessary corrective action.

(3) Fee Schedule. The organization has a current written fee schedule approved by the governing body that is readily available to staff and individuals/families being served.

(4) Retention and Availability of Fiscal Records. Fiscal records shall be retained for at least six (6) years or until any litigation and/or adverse audit findings are resolved. Department staff and its authorized representative(s) shall be allowed to inspect and examine the organization’s premises and/or records related to services funded by the department without limitation.

Records must be easily retrievable, complete, and auditable.

If access is denied or limited, the department reserves the right to terminate payments for services from the day access is denied or limited.

(5) Insurance Coverage. Adequate insurance coverage shall be maintained by the organization to protect its physical and financial resources. Insurance coverage for all people, buildings and equipment shall be maintained and shall include fidelity bond, automobile liability, where applicable, and broad form comprehensive general liability for property damage and bodily injury including wrongful death and incidental malpractice.

(6) Accountability for the Funds of Persons Served. If the organization is responsible for funds belonging to persons served, there shall be procedures that identify those funds and provide accountability for any expenditure of those funds. Such funds shall be expended or invested only with the informed consent and approval of the individuals or, if applicable, their legally appointed representatives. The individuals shall have access to the records of their funds. When benefits or personal allowance monies are received on behalf of individuals or when the organization acts as representative payee, such funds are segregated for each individual for accounting purposes and are used only for the purposes for which those funds were received.

9 CSR 10-7.110 Personnel {#sec-9-csr-10-7.110 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-7.110}

PURPOSE: This rule describes personnel policies and procedures for Opioid Treatment Programs, Substance Use Disorder Treatment Programs, Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), Gambling Disorder Treatment Programs, Institutional Treatment Centers, Substance Awareness Traffic (1) Policies and Procedures. The organization shall maintain personnel policies, procedures, and practices in accordance with local, state and federal laws and regulations.

(A) The policies and procedures shall include written job descriptions for each position, provisions for annual written performance reviews with all employees, and a current table of organization reflecting each position and, where applicable, the relationship to the larger organization of which the program or service is a part.

(B) Policies and procedures shall be consistently and fairly applied in the recruitment, selection, development, and termination of staff.

(2) Qualified and Trained Staff. Qualified staff shall be available in sufficient numbers to ensure effective service delivery.

The organization shall establish, maintain, and implement a written plan for professional growth and development of staff.

(A) The organization shall ensure staff possess the training, experience, and credentials to effectively perform their assigned services and duties.

All individuals holding a position within the organization shall complete orientation and training within the first thirty (30) days of employment in order to be knowledgeable in core competency areas. Staff who are promoted or transferred to a new job assignment shall receive training and orientation to their new responsibilities within thirty (30) days of actual transfer.

(B) Within the scope of their position in the organization, staff shall have a working familiarity with core competencies prior to performing their job as follows:

Know the organization’s population served, scope of program, mission, vision, and policies and procedures;
Understand and perform respective job assignments;
Abide by applicable regulations for rights, ethics, confidentiality, corporate compliance, and abuse and neglect;
Know agency protocols for responding to emergencies at the program or while providing services in the community, including protocols for infection control and agency procedures to maximize safety for individuals served, staff members, and the public.

(D) Qualifications and credentials of staff shall be verified prior to employment, including primary source verification.

(E) Clinical supervision of direct service staff shall be provided on an ongoing basis to ensure adequate supervisory oversight and guidance, particularly for staff who lack credentials for independent practice in Missouri.

(F) Training and continuing education opportunities are available to all direct service staff in accordance with their job duties and any licensing or credentialing requirements.

All staff who provide services or are responsible for the supervision of persons served shall participate in at least thirtysix (36) clock hours of relevant training during a two (2)-year period. A minimum of twelve (12) clock hours of training must be completed annually.
Training shall assist staff in meeting the needs of persons served, including persons with co-occurring and trauma-related disorders.
The organization shall maintain a record of participation in training and staff development activities.

(G) When services and supervision are provided twentyfour (24) hours per day, the organization maintains staff on duty, awake, and fully dressed at all times. A schedule or log is maintained which accurately documents staff coverage.

(3) Ethical Standards of Behavior. Staff shall adhere to ethical standards of behavior in their relationships with individuals being served.

(A) Staff shall maintain an objective, professional relationship with individuals being served at all times.

(B) Staff shall not enter dual or conflicting relationships with individuals being served which might affect professional judgment or increase the risk of exploitation.

(C) The organization shall establish policies and procedures regarding staff relationships with individuals currently being served and individuals previously served.

(D) The organization shall establish policies and procedures regarding staff use of social media, including how violations of the procedures will be managed.

(E) The organization shall establish standards of conduct for volunteers and students, as applicable.

(4) Volunteers. If the organization uses volunteers to assist with service delivery, it shall establish and consistently implement policies and procedures to guide the roles and activities of volunteers in an organized and productive manner. The agency shall ensure volunteers are qualified to provide the services rendered, have a background screening in accordance with 9 CSR 10-5.190, and receive orientation, training, and adequate supervision.

(A) Orientation shall occur within thirty (30) days of the individual’s volunteer work with the organization including, but not limited to:

Client rights, confidentiality policies and procedures, and abuse, neglect, and misuse of funds as defined in 9 CSR 10-5.200;
Emergency policies and procedures of the program;
Philosophy, values, mission, and goals; and 4. Other topics relevant to their assignment(s).

(5) Practicum/Intern Students. If the organization uses practicum/intern students in a department-funded program, he/she must be enrolled and participating in an accredited college/university in a field of study including, but not limited to, social work, psychology, sociology, or nursing.

(A) The student and agency must have a written plan documenting the following:

Name of the student, educational institution, and degree program;
Brief description of the status of the student with respect to degree completion including semester/hours remaining, projected completion date, and time period of the practicum or internship;
A job description of the specific role of the student with respect to the program and population served;
A specific plan for supervision of the student including name and title of the direct supervisor. The plan must detail the frequency and duration of the supervision activities including the scope of case/record reviews, the location of the supervisor with respect to the service delivery locations, and emergency backup supervision arrangements; and 5. A list of the specific services the agency has approved the student to deliver. Students cannot deliver services reimbursed by Medicaid unless they meet the provider eligibility requirements through prior experience and education.

(B) The student must have a letter from their academic advisor attesting to their qualifications and eligibility for the proposed practicum.

(C) The student must be under the close supervision of the direct clinical supervising professional of the agency. The person providing the supervision must be qualified to provide the services they are supervising.

A student who provides counseling services must be in a master’s program or above and be approved for the practicum by the college/university.
To provide case management, community support, and other support services, a student must be in the final year of a bachelor’s program or an associate program approved by the 3. A student may be assigned a limited caseload based on background and prior experience.

(D) The agency shall ensure students have a background screening in accordance with 9 CSR 10-5.190 and receive orientation and training consistent with the organization’s policies for new employees.

(E) Service delivery by the student must be documented according to department standards and policy.

All documentation of billable services must be reviewed and countersigned by an individual who meets department criteria for a qualified mental health professional or supervisor of counselors, a community support specialist, or case manager, as appropriate.
Services shall be billed using appropriate existing service codes and reimbursed at the established contract rate for the anticipated degree, unless a distinct student rate has been established for the service.

rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed Aug. 28, 2002, effective April 30, 2003. Amended: Filed Nov. 5, 2018, effective June 30, 2019.

9 CSR 10-7.120 Physical Environment and Safety {#sec-9-csr-10-7.120 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-7.120}

PURPOSE: This rule describes requirements for the physical environment and safety in Opioid Treatment Programs, Substance (1) General Requirements. The organization shall provide services in an environment that ensures the health, safety, and security of individuals served, staff, and others.

(A) All buildings used for programmatic activities shall meet applicable state and local fire safety, building, occupancy, and health requirements.

(B) The organization shall maintain documentation on site of all inspections and correction of any cited deficiencies to assure compliance with applicable state and local fire safety, building, and health requirements.

(C) A currently certified/deemed organization that relocates any program into a new physical environment or constructs an addition to an existing building(s) must ensure the new location and/or building(s) comply with this rule in order to maintain certification/deemed status by the department.

(2) Physical Access. Individuals must be able to readily access the organization’s services. The organization shall demonstrate an ability to remove architectural and other barriers that may confront individuals otherwise eligible for services.

(3) Adequate Space and Furnishings. Individuals are served in an environment with adequate space, equipment, and furnishings for all program activities and for maintaining privacy and confidentiality.

(A) In keeping with the specific purpose of the service, the organization shall make available— 1. A reception/waiting area that safely accommodates individuals served and visitors to the program;

Private areas for confidential individual and group services;
An area(s) for indoor social and recreational activities;
Restrooms in adequate number to meet the needs of (B) The use of televisions, cell phones, computers, laptops, or other electronic devices shall not interfere with the therapeutic program.

(4) Environment. Individuals are served in an environment that is clean and comfortable and in safe and proper operating condition. The organization shall— (A) Provide adequate and comfortable lighting;

(B) Maintain heating, ventilation, and cooling systems to ensure a temperature-controlled environment that meets the reasonable comfort needs of individuals served;

(D) Provide effective pest control measures;

(E) Store trash and garbage in covered containers that are removed on a regular basis;

(F) Maintain the facility to be free of undesirable odors;

(G) Provide stocked, readily accessible first-aid supplies; and (H) Take measures to prevent, detect, and control infections among individuals and personnel, and have protocols for proper treatment and training of staff, individuals served, and others.

(5) Off-Site Functions. If the organization offers services at locations in the community other than at its physical facility location(s), usual and reasonable precautions shall be taken to ensure the safety of individuals participating in services at off-site locations.

(6) Emergency Preparedness and Safety. In keeping with the specific purpose of the service(s) provided, the organization shall have a written emergency preparedness plan to maintain continuity of its operations in preparation for, during, and after an emergency or disaster. Consultation with the local Federal Emergency Management Agency or other recognized resource for emergency planning and preparedness in developing the plan is recommended.

(A) The emergency preparedness plan shall include, but is not limited to, potential medical emergencies, natural disasters, fires, bomb threats, utility failures, and violent or other threatening situations. The plan shall be posted and accessible at all times, at all program locations.

(B) The plan shall include, but is not limited to— 1. When evacuation is necessary;

Complete evacuation from each physical facility with a designated gathering point;
When sheltering in place is appropriate and any additional steps necessary to ensure safety (such as sealing a room);
The safety and accounting for all persons involved, including responsible staff;
Temporary shelter when applicable;
Identification of essential services;
Continuation of essential services when applicable; and 8. Notification of the appropriate emergency authorities.

(C) Evacuation routes with diagrams giving clear directions on how to exit the building safely and in a timely manner shall be posted in locations easily accessible to individuals served, staff, and visitors.

(D) Staff shall demonstrate knowledge and ability to implement the emergency preparedness plan and, where applicable, the evacuation plan.

(E) Unannounced tests/drills of all emergency procedures shall be conducted at least annually on each shift and at each program location. Results of all tests/drills shall be reviewed and documented with corrective action taken, as needed, including training and education of staff.

(7) Hazard Prevention, Detection, and Safety Equipment. The organization shall maintain fire and other safety equipment in proper operating condition and implement practices to protect all individuals from fire, smoke, harmful fumes, and other safety hazards. An annual inspection in accordance with the Life Safety Code of the National Fire Protection Association (NFPA) shall be conducted.

(A) Organizations shall maintain a fire detection and notification system that detects smoke, fumes and/or heat and sounds an alarm that can be heard throughout the premises, above the noise of normal activities, radios, and televisions.

(B) Portable ABC-rated fire extinguishers shall be located on each floor used by individuals being served as specified by the local authority. Additional fire extinguishers shall be located in or near the kitchen, laundry room, furnace room, and other areas as recommended by the local authority.

(D) Each floor used by individuals served shall have at least two (2) means of exit that are independent of and remote from one another.

Outside fire escape stairs may constitute one (1) means of exit in existing buildings. Fire escape ladders shall not constitute one (1) of the required means of exit.
The means of exit shall be free of any item that would obstruct the exit route.
Outside stairways shall be kept clear and be substantially constructed to support people during evacuation. Newly constructed fire exits shall meet requirements of the NFPA Life Safety Code.
Outside stairways shall be reasonably protected against blockage by a fire. This may be accomplished by physical separation, distance, arrangement of the stairs, protection of openings, exposing the stairs, or other means acceptable to the local authority.
Outside stairways in buildings with three (3) or more stories shall be constructed of noncombustible material, such as iron or steel.

(E) Unless otherwise determined by the local authority, based on a facility’s overall size and use, the requirement of two (2) or more means of exit on each floor may be waived for sites that meet each of the following conditions:

Do not offer overnight sleeping accommodations;
Do not cook meals on a regular basis; and 3. Do not provide services on-site to twenty (20) or more individuals at a given time as a usual and customary pattern of service delivery.

(F) Combustible supplies and equipment such as oil base paint, paint thinner, and gasoline, shall be separated from other parts of the building in accordance with stipulations of the local authority.

(G) Smoke detectors shall be installed in accordance with the recommendations of the NFPA codes and be functional at all times.

If the program serves individuals who are deaf, the smoke detectors must have an alarm system designed for hearing-impaired persons as specified by the NFPA codes.

(H) Organizations using equipment or appliances that pose a potential carbon monoxide risk shall install a carbon monoxide detector(s) as specified by the NFPA codes. Carbon monoxide detectors must be functional at all times.

(I) All staff of the organization must be trained and demonstrate the ability to operate the organization’s fire alarm system, fire extinguishers, and other safety devices.

(J) The NFPA codes shall prevail in the interpretation of these fire safety standards.

(K) The organization shall maintain a smoke-free environment.

(8) Safe Transportation. The organization shall ensure transportation for individuals served is provided in a safe and accessible manner as applicable.

(A) All vehicles used by the organization to transport persons served shall have— 1. Regular inspection and maintenance as legally required;

Adequate first-aid supplies and fire suppression equipment secured in any van, bus, or other vehicle used to transport more than four (4) individuals. Staff operating such a vehicle shall have training in emergency procedures and the handling of accidents and road emergencies and have access to a cell phone or other communication device in the vehicle.

(B) All staff who transport persons served shall be properly licensed with driving records acceptable to the agency.

(D) Organizations that provide transportation for children shall comply with state and federal car seat laws and regulations.

(E) If transportation services are contracted, the organization shall conduct an annual review to ensure the contractor meets the requirements in subsections (A) through (D) of this section.

9 CSR 10-7.130 Procedures to Obtain Certification {#sec-9-csr-10-7.130 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-7.130}

PURPOSE: This rule describes procedures to obtain certification as a Substance Use Disorder Treatment Program, Comprehensive Substance Treatment and Rehabilitation Program (CSTAR), Institutional Treatment Center, Gambling Disorder Treatment Program, Prevention Program, Recovery Support Program, Substance Awareness Traffic Offender Program (SATOP), Required Education Assessment and Community Treatment Program (REACT), Community Psychiatric Rehabilitation (CPR) Program, or Outpatient Mental Health Treatment Program.

(1) Certification Standards. Under sections 376.779.3 and 4, 630.010, and 630.655, RSMo, the department is mandated to develop certification standards and to certify an organization’s level of services as necessary and applicable for it to operate, receive funds from the department, and participate in department programs eligible for Medicaid reimbursement.

Certification does not constitute an assurance or guarantee the department will fund designated services or programs.

(A) A key goal of certification is to enhance the quality of care and services with a focus on the needs and outcomes of persons served.

(B) The primary function of the certification process is assessment of an organization’s compliance with the department’s standards of care. A further function is to identify and encourage developmental steps toward improved program operations, satisfaction with services, and successful outcomes for individuals served.

(2) Under section 630.050, RSMo, the department shall certify each community psychiatric rehabilitation (CPR) provider’s rehabilitation program services as a condition of participation in the CPR program.

(3) Organizations must meet criteria as specified below to be eligible for certification as a CPR provider.

(A) The organization must meet a minimum of one (1) of the following:

Meets the eligibility requirements for receipt of federal mental health block grant funds for the provision of clinical treatment services;
Has a current and valid contract for the provision of clinical treatment services with the department pursuant to 9 CSR 25-2; or 3. Has been certified as a CPR provider at least once prior to November 7, 1993, and has maintained certification continuously since November 7, 1993.

(B) Organizations that meet at least one (1) of the requirements specified in paragraphs (3)(A)1.-3. of this rule must meet all of the following requirements:

Has maintained compliance with department outpatient mental health certification requirements as specified in 9 CSR 30-4.190 for one (1) certification cycle;
Complies with 9 CSR 10-5, 9 CSR 10-7, and 9 CSR 30-4, as applicable;
Has the capacity to provide in-person, face-to-face services from a physical location in the state of Missouri;
Is accredited to provide behavioral health services by the Commission on Accreditation of Rehabilitation Facilities (CARF)

International, The Joint Commission, Council on Accreditation, or other entity recognized by the department;

Has the capacity to collect, analyze, and report outcome and other data related to the population served to the department in accordance with established protocol; and 6. Incorporate evidence-based, best, and promising practices into its service array. At a minimum, the organization shall employ or have a formal contract with the following:

A. Licensed and credentialed professionals with expertise and specialized training in the treatment of traumarelated disorders;

B. Licensed and credentialed professionals with expertise and specialized training in the treatment of co-occurring disorders (substance use and mental illness);

C. Licensed psychiatrists;

D. Certified Peer Specialists and Certified Family Support Providers who are credentialed by the Missouri Credentialing Board;

E. Clinical staff who have completed departmentapproved training on suicide prevention; and F. Clinical staff who have completed departmentapproved training on smoking cessation.

(4) The department shall certify, as a result of a certification survey or deeming, each CPR program as designated and eligible to serve children and youth under the age of eighteen (18).

(5) To be eligible to serve children and youth under the age of eighteen (18), a certified or deemed-certified CPR program shall:

(A) Have a current and valid contract for services with the department pursuant to 9 CSR 25-2;

(B) Meet the eligibility requirements for receipt of federal mental health block grant funds;

Crisis intervention mobile response;
Screening and assessment;
Medication services; and 4. Intensive case management consistent with state plan approved services; and (D) Have experience and expertise in delivering a department-approved home-based crisis intervention program of psychiatric services for children and youth.

(6) A certified or deemed-certified CPR program in each designated service area may serve transition-age youth, age sixteen (16) and older, meeting the diagnostic eligibility requirements in 9 CSR 30-4.042 without the certification specified in sections (4) and (5) of this rule. The clinical record must include documentation it is clinically and developmentally appropriate to serve the individual in an adult program.

(7) Application Process and Fees. An organization may request certification by completing the application form as required by the department for this purpose, and submitting the application and any specified documentation to: Department of Mental Health, PO Box 687, Jefferson City, MO 65102.

(A) The application must include a current written description of the program(s) and service(s) for which the organization is seeking certification from the department.

(B) A new applicant shall not use a name which implies a relationship with another organization, government agency, or judicial system when a formal organizational relationship does not exist.

(D) An organization that submits an incomplete application will receive written notice from the department. A complete application must be resubmitted to the department in order to be considered for certification. If the resubmitted application is determined to be incomplete, the organization will receive written notification from the department. The department may deny the applicant from reapplying for a period of up to one (1) year from the date of notification.

(E) A certification fee is required for the Substance Awareness Traffic Offender Program (SATOP). The fee structure is based on the number of individuals served by the agency as follows:

The fee is one hundred twenty-five dollars ($125) if less than two hundred fifty (250) individuals were served by the agency during the prior survey year;
The fee is two hundred fifty dollars ($250) if the agency served at least two hundred fifty (250) individuals but no more than four hundred ninety-nine (499) individuals during the prior survey year; and 3. A fee of five hundred dollars ($500) is required if at least five hundred (500) individuals were served by the agency during the prior survey year.

(F) The SATOP fee schedule may be adjusted annually by the (G) Each organization is responsible for monitoring the expiration date of their certification and applying for renewal of certification. The application form and required documentation must be submitted to the department at least sixty (60) calendar days prior to expiration of the existing certificate.

Applications for renewal of certification received after the expiration date or organizations that do not reapply, are subject to termination of certification status and may be required to resubmit an application for certification to the 2. Organizations that choose not to renew certification must provide written notification to the department sixty (60) calendar days prior to the expiration date on the certificate.

(H) Organizations may withdraw an application at any time during the certification process, unless otherwise required by law.

(I) The organization agrees, by act of submitting an application, to allow and assist department representatives in fully and freely conducting any survey procedures and to provide department representatives reasonable and immediate access to premises, individuals, staff, and requested information.

(J) The organization must provide information and documentation to the department that is accurate and complete. Falsification or fabrication of any information used to determine compliance with requirements may be grounds to deny issuance of or to revoke certification.

(8) Certification Process. The department grants certification based on its review of an organization’s compliance with standards of care for behavioral health services.

(A) For nationally accredited organizations that do not provide opioid treatment— 1. The department may grant a certificate to organizations that have obtained accreditation for services provided from CARF International, The Joint Commission, Council on Accreditation, or other entity recognized by the department.

Certification from the department will be equivalent to the period of time granted by the accrediting body;

Organizations seeking deemed certification status from the department must complete the application for accredited organizations and submit it to the department. The application must include documentation of current accreditation status, the accrediting body’s survey report of findings, and the behavioral health services for which the organization is accredited;
The department will review the accrediting body’s program accreditation to determine if it is equivalent to the department’s program certification. The department, at its option, may visit the organization’s program site(s) solely for the purpose of clarifying information contained in the organization’s application and its description of programs and services, and/or determining those programs and services eligible for certification by the department;
Notice of any change in an organization’s accreditation status must be provided in writing to the department within seven (7) calendar days of notification from the accrediting body; and 5. The department may rescind certification if an organization loses its accreditation.

(B) For non-accredited organizations, the department will conduct a survey to determine compliance with applicable sections of department certification standards.

The department provides advance written notice of routine, planned surveys including date(s), procedures, and an agreed upon schedule of activities. Survey procedures may include, but are not limited to:

A. Interviews with staff, individuals served, and other interested parties;

B. Tour and inspection of program sites;

C. Review of administrative records to verify compliance with requirements;

D. Review of personnel records;

E. Review of service documentation;

F. Observation of program activities; and G. Review of data regarding practice patterns and outcome measures, as available.

The surveyor(s) will hold an entrance and exit conference with staff of the organization to discuss survey arrangements and survey findings, respectively.
A surveyor will immediately cite any serious area of non-compliance which could result in actual jeopardy to the safety, health, or welfare of persons served. The surveyor will not leave the program until an acceptable plan of correction is presented by staff which assures the surveyor there is no further risk of jeopardy to persons served.
Within thirty (30) calendar days after the exit conference, the department will send a written survey report to the organization’s director and governing body president, including any areas of noncompliance as applicable. The report shall be available for review by staff and the public, upon request.

A. Within thirty (30) calendar days of receipt of a notice of noncompliance, a plan of correction must be submitted to the department.

B. The plan of correction must address each area of noncompliance, action steps to correct each area of noncompliance, staff responsible for each action step, target date for completion, and where and how corrections will be verified.

C. Within fifteen (15) calendar days of receipt of a plan of correction, the department will notify the organization of its decision to approve, disapprove, or require revisions to the proposed plan of correction.

D. At the department’s discretion, a follow-up survey may be conducted to review the areas of noncompliance and ensure the organization fully complies with applicable standards of care. The organization will receive advance, written notice of the survey date(s) and procedures.

E. If all areas of noncompliance are corrected and no other deficiencies are found on the follow-up survey, certification may be granted.

F. If all areas of noncompliance are not corrected on the follow-up survey, or new areas of noncompliance are cited, the application for certification will be denied and the organization will be required to reapply for certification by submitting a new application to the department. The department may deny certification to an organization for a period of up to one (1) year from the date of notification of noncompliance.

G. In the event the organization has not submitted an acceptable plan of correction to the department within ninety (90) calendar days of the date of the initial notice of noncompliance, it shall be subject to expiration or denial of certification.

(C) Organizations determined to be in compliance with certification standards may be awarded certification by the 1. The department has the authority to determine an organization’s time period for certification based on its performance, survey findings, and existing certification status, as applicable.

Certification will be valid until the expiration date shown on the certificate issued by the department unless the certificate is modified, revoked, suspended, or the department grants the organization a temporary certification status.

(9) Certification Status. The department grants certification on a deemed, temporary, provisional, conditional, or compliance status. In determining certification status, the department considers patterns and trends of performance identified during the survey.

(A) Deemed status. Deemed status acknowledges a behavioral health services provider is monitored and held accountable by a recognized national accrediting body and the department accepts the organization’s “good standing” as sufficient to meet its standards of care.

(B) Temporary status. Temporary certification may be granted to a certified organization if the survey process has not been completed prior to the expiration of an existing certificate and the applicant is not at fault for failure or delay in completing the survey process.

The time period for temporary certification is determined by the department based upon progression of the survey process, including situations in which an organization is required to submit a plan of correction to address areas of noncompliance with standards. Consideration will be given to an organization’s request for an extension of their existing certificate.

(C) Provisional status. The department may grant provisional certification to an organization applying for initial certification when the results of the survey determine the organization has not yet demonstrated full compliance with standards related to ongoing program activities, but is compliant with standards of care related to the following:

Governing authority;
Policies and procedures;
Physical plant and safety; and 4. Personnel and staffing patterns sufficient to provide services.

A. Provisional certification status will not exceed a six- (6-) month time period. Within six (6) months of granting provisional certification, the department will conduct a comprehensive site survey and make a further determination of the organization’s certification status.

(D) Conditional status. Conditional certification may be granted to an organization when survey findings indicate areas of noncompliance with standards that may affect quality of care for individuals served, but there is reasonable expectation the organization can achieve compliance within a stipulated time period.

Conditional certification may be granted for a six (6) month time period.
The department may monitor progress, require the organization to submit progress reports, or both.
The organization will be expected to correct all areas of noncompliance prior to the expiration of the conditional certification status.
The department may conduct a follow-up survey prior to expiration of the conditional certification status to review the areas of noncompliance and ensure the organization fully complies with applicable standards of care.

A. If all areas of noncompliance are corrected and no other deficiencies are found, certification may be granted for a one- (1-) to three- (3-) year period.

B. If all areas of noncompliance are not corrected on the follow-up survey, or new areas of noncompliance are cited, conditional certification status will expire and the organization will be required to reapply for certification by submitting a new application to the department. The department, at its discretion, may deny the applicant for a period of up to one (1) year from the date of notice of noncompliance.

(E) Compliance status. The department may award compliance status to an organization for a period of one (1) to three (3) years when survey findings indicate the organization meets applicable standards of care.

(F) The department, at its discretion, may issue an extension of an organization’s certification status.

(10) Investigations. The department, at its discretion, may investigate any written complaint regarding the operation of a certified program or service.

(11) Scheduled and Unscheduled Surveys. The department may conduct a scheduled or unscheduled survey of an organization at any time to monitor ongoing compliance with applicable standards of care. If any survey finds conditions that are not in compliance with applicable certification standards, the department may require corrective action steps and may change the organization’s certification status consistent with procedures set out in this rule.

(12) Organizational Changes. A certificate is the property of the department and applies solely to the organization named in the application. The certificate is valid only as long as the organization meets standards of care and is not transferable to another entity without prior, written approval from the (A) The organization shall keep the certificate issued by the department in a readily available and visible location.

(B) The department must be notified a minimum of thirty (30) calendar days in advance if a certified organization— 1. Is sold or changes ownership;

Is discontinued and ceases business operations;
Leases some or all operations at its certified address(es) to another entity;
Moves to a different location;
Appoints a new director; or 6. Changes programs or services offered.

(D) A new application for certification is required for a change in ownership and the addition of a program/service which the organization is not certified by the department to provide.

In the event of a change in ownership, the organization must be certified under the new ownership prior to beginning operations under the new title.
Certification under previous ownership becomes null and void if the new owner(s) fail to submit an application for certification from the department.
A certified organization that establishes a new program or type of service must request and obtain certification from the department for the new program or service and comply with applicable standards.

(E) At the discretion of the department, the thirty- (30-) calendar day prior notification required in subsection (12)

(B) of this rule may be waived in the event of an emergent or catastrophic situation. In the event of such a situation, the certified organization must provide written notice to the department as soon as possible, but no later than seven (7) calendar days after becoming aware of the need for the change in the organization.

(13) Subcontracts. Certified or deemed organizations may subcontract for services covered under their certificate in accordance with 9 CSR 10-7.090(6).

(14) Denial or Revocation of Certification. The department may deny issuance of and may revoke certification based on a determination that— (A) The nature of the deficiencies results in substantial probability of or actual jeopardy to individuals being served;

(B) Serious or repeated incidents of abuse, neglect, and/or misuse of funds/property, or violation of individual rights have occurred;

(C) Fraudulent fiscal practices have transpired or significant and repeated errors in billings to the department have occurred;

(D) Information used to determine compliance with requirements was falsified or fabricated;

(E) The nature and extent of deficiencies results in the failure to conform to the basic principles and requirements of the program or service being offered;

(F) Compliance with standards has not been attained by an organization upon expiration of provisional or conditional certification.

(15) Program Monitor. The department, at its discretion, may place a monitor at a program if there is substantial probability of or actual jeopardy to the safety, health, and/or welfare of individuals being served.

(A) The cost of the monitor shall be charged to the organization at a rate which recoups all reasonable expenses incurred by the department.

(B) The department will remove the monitor when a determination is made that the safety, health, and/or welfare of individuals served is no longer at risk.

(C) The department may take other action to ensure and protect the safety, health, and/or welfare of individuals being (16) Appeal Process. An organization which has had certification denied or revoked may appeal to the director of the department within thirty (30) calendar days following receipt of the notice of denial or revocation. The director of the department conducts a hearing under procedures set out in Chapter 536, RSMo, and issues findings of fact, conclusions of law, and a decision which will be final.

(17) Administrative Sanctions. The department may impose administrative sanctions.

(A) The department may suspend the certification process pending completion of an investigation when an applicant for certification or staff of the organization are under investigation for fraud, misuse of funds/property, abuse and/or neglect of persons served, or improper clinical practices.

(B) The department may administratively sanction a certified organization that has been found to have committed fraud, misuse of funds/property, abuse and/or neglect of persons served, or improper clinical practices, or had reason to know its staff were engaged in such practices.

(C) Administrative sanctions include but are not limited to suspension of certification, clinical review requirements, suspension of new admissions, denial or revocation of certification, or other actions as determined by the department.

(D) The department may refuse to accept an application for certification from an organization for a period of up to twentyfour (24) months if certification is denied or revoked, or the organization has been found to have committed fraud, misuse of funds/property, abuse and/or neglect of persons served, improper clinical practices, or whose staff and/or clinicians were engaged in improper practices.

(E) An organization may appeal these sanctions pursuant to

section (16) of this rule.

(18) Request for Exception. An organization may request the department’s exceptions committee to waive a requirement for certification if the director of the organization provides evidence that a waiver is in the best interest of individuals (A) A request for a waiver must be submitted in accordance with 9 CSR 10-5.210, Exceptions Committee Procedures.

Sept. 25, 2002, effective April 30, 2003. Amended: Filed March 3, 2003, effective Sept. 30, 2003. Amended: Filed Nov. 5, 2018, effective June 30, 2019. Amended: Filed April 11, 2023, effective Oct. 30, 2023. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008, and 630.055,

9 CSR 10-7.140 Definitions {#sec-9-csr-10-7.140 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-7.140}

PURPOSE: This rule defines terms used in the certification of psychiatric and substance abuse programs.

(1) The definitions included in this rule shall apply to:

(A) 9 CSR 10-7 Core Rules for Psychiatric and Substance Abuse Programs;

(B) 9 CSR 30-3 Certification Standards for Alcohol and Drug Abuse; and (C) 9 CSR 30-4 Certification Standards for Mental Health Programs.

(2) Unless the context clearly indicates otherwise, the following terms shall mean:

(A) Abstinence, the non-use of alcohol and other drugs;

(B) Admission, entry into the treatment and rehabilitation process after an organization has determined an individual meets eligibility criteria for receiving its services;

(D) Agency, this term may be used interchangeably with organization. See the definition of organization;

(E) Alcohol or drug-related traffic offense, an offense of driving while intoxicated, driving with excessive blood alcohol content, or driving under the influence of alcohol or drugs in violation of state law;

(F) Alcohol or drug treatment and rehabilitation program, a program certified by the Department of Mental Health as providing treatment and rehabilitation of substance abuse in accordance with service and program requirements under 9 CSR 30-3.100 through 9 CSR 30-3.199;

(G) Applicant, an organization seeking certification from the department under 9 CSR 30;

(H) Assessment, systematically collecting information regarding the individual’s current situation, symptoms, status and background, and developing a treatment plan that identifies appropriate service delivery;

(I) Associate substance abuse counselor, a trainee that must meet requirements for registration, supervision, and professional development as set forth by either— 1. The Missouri Substance Abuse Counselors Certification Board, Inc.; or 2. The appropriate board of professional registration within the Department of Economic Development for licensure as a psychologist, professional counselor, or social worker;

(J) Certification, determination and recognition by the Department of Mental Health that an organization complies with applicable rules and standards of care under 9 CSR;

(K) Client, this term may be used interchangeably with individual. See the definition of individual;

(L) Clinical utilization review, a process of service authorization and/or review established by the department and conducted by credentialed staff in order to promote the delivery of services that are necessary, appropriate, likely to benefit the individual, and provided in accordance with admission criteria and service definitions;

(M) Compulsive gambling, the chronic and progressive preoccupation with gambling and the urge to gamble. This term may be used interchangeably with pathological gambling;

(N) Co-occurring disorders, presence of both substance and psychiatric disorders which impede the individual’s functioning or ability to manage daily activities, consistent with diagnostic criteria established in the current edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association;

(O) Corporal punishment, purposeful infliction of physical pain upon an individual for punitive or disciplinary reasons;

(P) Crisis, an event or time period for an individual characterized by substantial increase in symptoms, legal or medical problems, and/or loss of housing or employment or personal supports;

(Q) Day, a calendar day unless specifically stated otherwise;

(R) Deficiency, a condition, event or omission that does not comply with a certification rule;

(S) Department, the Department of Mental Health;

(T) Director, the Department of Mental Health director or designee;

(U) Discharge, the time when an individual’s active involvement with the program concludes in accordance with treatment plan goals, any applicable utilization criteria, and/ or program rules;

(V) Discharge planning, an activity to assist an individual’s further participation in services and supports in order to promote continued recovery upon completion of a program or level of care;

(W) Facility, physical plant or site used to provide services;

(X) Family/family members, persons who comprise a household or are otherwise related by marriage or ancestry and are being affected by the psychiatric or substance abuse problems of another member of the household or family;

(Y) Improper clinical practices, performance or behavior which constitutes a repeated pattern of negligence or which constitutes a continuing pattern of violations of laws, rules, or regulations;

(Z) Individual, a person/consumer/client receiving services from a program certified under 9 CSR 30;

(AA) Least restrictive environment and set of services, a reasonably available setting or program where care, treatment, and rehabilitation is particularly suited to the type and intensity of services necessary to implement a person’s treatment plan and to assist the person in maximizing functioning and participating as freely as feasible in normal living activities, giving due consideration to the safety of the individual, other persons in the program, and the general public;

(BB) Licensed independent practitioner, a person who is licensed by the state of Missouri to independently perform specified practices in the health care field;

(CC) Medication, a drug prescribed by a physician or other legally authorized professional for the purpose of treating a medical condition;

(DD) Medication (self-administration under staff observation), actions wherein an individual takes prescribed medication, including selection of the appropriate dose from a properly labeled container. The individual has primary responsibility for taking medication as prescribed, with the staff role to ensure client access to their personal medication in a timely manner and to observe clients as they select and ingest medication;

(EE) Mental health, a broad term referring to disorders related to substance abuse, mental illness and/or developmental disability;

(FF) Mental illness, impairment or disorder that impedes an individual’s functioning or ability to manage daily activities and otherwise meets eligibility criteria established by the Division of Comprehensive Psychiatric Services;

(GG) Neglect (Class I), in accordance with 9 CSR 10-5.200;

(HH) Neglect (Class II), in accordance with 9 CSR 10-5.200;

(II) Nonresidential, service delivery by an organization that does not include overnight sleeping accommodations as a component of providing twenty-four (24) hour per day supervision and structure;

(JJ) Organization, an agency that is incorporated and in good standing under the requirements of the Office of the Secretary of State of Missouri and that provides care, treatment or rehabilitation services to persons with mental illness or substance abuse;

(KK) Outcome, a specific measurable result of services provided to an individual or identified target population;

(LL) Peer support, mutual assistance in promoting recovery offered by other persons experiencing similar psychiatric or substance abuse challenges;

(MM) Performance indicator, data used to measure the extent to which a treatment principle, expected outcome, or desired process has been achieved;

(NN) Physical abuse, in accordance with 9 CSR 10-5.200;

(OO) Primary diagnosis, a diagnosis of a mental illness, disability, or substance abuse disorder that is not due to a co-existing illness. A person with a primary diagnosis would still meet full criteria for that diagnosis in the absence of any co-existing disorder. A person may have several primary diagnoses, and a primary diagnosis is not necessarily the diagnosis causing the most severe impairment.

(PP) Program, an array of services designed to achieve specific goals for an identified target population in accordance with designated procedures and practices;

(QQ) Qualified mental health professional—any of the following:

A physician licensed under Missouri law to practice medicine or osteopathy and with training in mental health services or one (1) year of experience, under supervision, in treating problems related to mental illness or specialized training;
A psychiatrist, a physician licensed under Missouri law who has successfully completed a training program in psychiatry approved by the American Medical Association, the American Osteopathic Association or other training program identified as equivalent by the department;
A psychologist licensed under Missouri law to practice psychology with specialized training in mental health services;
A professional counselor licensed under Missouri law to practice counseling and with specialized training in mental health services;
A clinical social worker licensed under Missouri law with a master’s degree in social work from an accredited program and with specialized training in mental health services;
A psychiatric nurse, a registered professional nurse licensed under Chapter 335, RSMo with at least two (2) years of experience in a psychiatric setting or a master’s degree in psychiatric nursing;
An individual possessing a master’s or doctorate degree in counseling and guidance, rehabilitation counseling and guidance, rehabilitation counseling, vocational counseling, psychology, pastoral counseling or family therapy or related field who has successfully completed a practicum or has one (1) year of experience under the supervision of a mental health professional;
An occupational therapist certified by the American Occupational Therapy Certification Board, registered in Missouri, has a bachelor’s degree and has completed a practicum in a psychiatric setting or has one (1) year of experience in a psychiatric setting, or has a master’s degree and has completed either a practicum in a psychiatric setting or has one (1) year of experience in a psychiatric setting;
An advanced practice nurse—as set forth in section 335.011, RSMo, a nurse who has had education beyond the basic nursing education and is certified by a nationally recognized professional organization as having a nursing specialty, or who meets criteria for advanced practice nurses established by the Board of Nursing; and 10. A psychiatric pharmacist as defined in 9 CSR 30-4.030;

(RR) Qualified substance abuse professional, a person who demonstrates substantial knowledge and skill regarding substance abuse by being one (1) of the following:

A physician or qualified mental health professional licensed or provisionally licensed in Missouri; or 2. A person who is certified or registered as a substance abuse professional by the Missouri Credentialing Board;

(SS) Quality improvement, an approach to the continuous study and improvement of the service delivery process and outcomes in order to effectively meet the needs of persons served;

(TT) Recovery, continuing steps toward a positive state of health that includes stabilized symptoms of mental illness, substance abuse or both, meaningful and productive relationships and roles within the community, and a sense of personal well-being, independence, choice and responsibility to the fullest extent possible;

(UU) Rehabilitation, a process of restoring a person’s ability to attain or maintain normal or optimum health or constructive activity by providing services and supports;

(VV) Relapse, recurrence of substance abuse in an individual who has previously achieved and maintained abstinence for a significant period of time beyond detoxification;

(WW) Relapse prevention, assisting individuals to identify and anticipate high risk situations for substance use, develop action steps to avoid or manage high risk situations, and maintain recovery;

(XX) Research, in accordance with 9 CSR 60-1.010 this term is defined as experimentation or intervention with or on individuals, including behavioral or psychological research, biomedical research, and pharmacological research. Excluded are those instances where the manipulation or application is intended solely and explicitly for individual treatment of a condition, falls within the prerogative of accepted practice and is subject to appropriate quality assurance review.

Also excluded are activities limited to program evaluation conducted by staff members as a regular part of their jobs, the collection or analysis of management information system data, archival research or the use of departmental statistics;

(YY) Residential, service delivery by an organization that includes overnight sleeping accommodations as a component of providing twenty-four (24) hour per day supervision and structure;

(ZZ) Restraint, restricting an individual’s ability to move by physical, chemical or mechanical methods in order to maintain safety when all other less restrictive interventions are inadequate;

(AAA) Restraint (chemical), medication not prescribed to treat an individual’s medical condition and administered with the primary intent of restraining an individual who presents a likelihood of physical injury to self or others;

(BBB) Restraint (mechanical), the use of any mechanical device that restricts the movement of an individual’s limbs or body and that cannot be easily removed by the person being restrained;

(CCC) Restraint (physical), physically holding an individual and restricting freedom of movement to restrain temporarily for a period longer than ten (10) minutes an individual who presents a likelihood of physical injury to self or others;

(DDD) Screening, the process in which a trained staff member gathers and evaluates relevant information through an initial telephone or face-to-face interview with a person seeking services in order to determine that services offered by the program are appropriate for the person;

(EEE) Seclusion, placing an individual alone in a separate room with either a locked door or other method that prevents the individual from leaving the room;

(FFF) Sentinel event, a serious event that triggers further investigation each time it occurs. It is typically an undesirable and rare event;

(GGG) Service, the provision of prevention, care, treatment, or rehabilitation to persons affected by mental illness or substance abuse;

(HHH) Sexual abuse, in accordance with 9 CSR 10-5.200;

(III) Staff member/personnel, an employee of a certified organization or a person providing services on a contractual

basis on behalf of the organization;

(JJJ) Substance, alcohol or other drugs, or both;

(KKK) Substance abuse, unless the context clearly indicates otherwise, a broad term referring to alcohol or other drug abuse or dependency in accordance with criteria established in the current edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association;

(LLL) Supports, array of activities, resources, relationships and services designed to assist an individual’s integration into the community, participation in treatment, improved functioning, or recovery;

(MMM) Treatment, application of planned procedures intended to accomplish a change in the cognitive or emotional conditions or the behavior of a person served consistent with generally recognized principles or practices in the mental health field;

(NNN) Treatment plan, a document which sets forth individualized care, treatment, and rehabilitation goals and the specific methods to achieve these goals for persons affected by mental illness or substance abuse, and which details the individual’s treatment program as required by law, rules, and funding sources;

(OOO) Treatment principle, basic precept or approach to promote the effectiveness of care, treatment and rehabilitation services and the dignity and involvement of persons served;

(PPP) Verbal abuse, in accordance with 9 CSR 10-5.200.

(3) Singular terms include the plural and vice versa, unless the context clearly indicates otherwise.

Amended: Filed March 3, 2016, effective Oct. 30, 2016.

History

AUTHORITY: section 630.050, RSMo Supp. 2013, and section 630.055, RSMo 2000. Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed April 15, 2002, effective Nov. 30, 2002. Amended: Filed Aug. 31, 2006, effective April 30, 2007.

Chapter 31 Reimbursement for Services

9 CSR 10-31.010 Determination of the Charges for Mental Health Services Based Upon Ability to Pay {#sec-9-csr-10-31.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-31.010}

(Rescinded January 1, 1982)

Original rule filed Dec. 23, 1975, effective Jan. 2, 1976. Rescinded: Filed Aug. 13, 1981, effective Jan. 1, 1982.

Op. Atty. Gen. No. 228, Robb (6-28-73).

The Division of Mental Health has the

Op. Atty. Gen. No. 66, Nanson (6-18-58).

The Division of Mental Diseases may charge pay patients in state hospitals the maximum amount fixed by the division for each institution or any amount below that maximum based upon the ability, or means of the patient, to pay. A husband is liable for the support of his wife unless she has abandoned him without good cause or has abandoned him with cause and has contracted an adulterous relationship consequently; that a husband is liable for the support of his minor children; that in the absence of the husband or his inability to support minor children the same obligation devolves upon his wife. Persons who adopt a child and persons who stand in the position of in loco parentis have the same duty to support as do natural parents.

History

AUTHORITY: section 202.330, RSMo Supp.
authority and the duty to charge for the care and treatment of a juvenile committed to the Division of Mental Health by the juvenile court or transferred to the Division of Mental Health from the State Board of Training Schools pursuant to section 211.201, RSMo, if this person is determined to be a private patient pursuant to the provisions of section 202.863, RSMo.

9 CSR 10-31.011 Standard Means Test {#sec-9-csr-10-31.011 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-31.011}

PURPOSE: This rule prescribes a standard means test as required by section 630.210, RSMo, to determine amounts to be charged for services provided or procured by the Department of Mental Health.

(1) Definitions. The terms defined in section 630.005, RSMo, are incorporated by reference as though set out in this rule. The following other terms used in this rule, unless the text clearly requires otherwise, shall mean:

(A) Adjusted gross monthly income—the income remaining after allowable deductions permitted by this rule;

(B) Community psychiatric rehabilitation center (CPR provider or CPR program)—an organization which provides or arranges for, at the minimum, the following core services: intake and annual evaluations, crisis intervention and resolution, medication services, consultation services, medication administration, community support, and psychosocial rehabilitation in a nonresidential setting for individuals with serious mental illness in conjunction with standards set forth in 9 CSR 30-4.031–9 CSR 30-4.047;

(C) Community services—any services purchased or provided by the department that are not included in the definition of “longterm care”;

(D) Community support services—for the Division of Developmental Disabilities (DD), this means all Purchase of Service (POS) services, case management services for clients residing in Community Placement Program (CPP) facilities and in their natural homes, Choices for Families services, and all voucher services; for the Division of Comprehensive Psychiatric Services (CPS), this means Family Preservation services, Intensive Case Management services for children and adults, Supported Housing Voucher Program or Housing and Urban Development (HUD)

Housing Voucher Program services, and Intergrated Employment Support services; for the Division of Alcohol and Drug Abuse (ADA), this applies to drug-free counseling services provided to clients participating in a methadone maintenance program who have become drug-free;

(E) Early intervention services—developmental services provided by qualified personnel to meet infant’s or toddler’s developmental needs in one (1) or more of the following areas: physical development, cognitive development, language and speech development, psychosocial development, or self-help skills.

Early intervention services must be provided in conformity with an individualized family service plan. Early intervention services may include, but are not limited to:

Family training, counseling, and home visits;
Special instructions;
Speech pathology and audiology;
Occupational therapy;
Physical therapy;
Transportation;
Psychological services;
Social work;
Case management services;
Nursing services;
Nutrition services;
Medical services for diagnostic or evaluation purposes;
Early identification, screening, and assessment services; and 14. Health services which enable infants or toddlers to benefit from other early intervention services;

(F) Financially responsible person—the individual who is obligated by law or this rule to pay charges for services;

(G) Gross monthly income (earned and unearned)—the total monthly income from all sources before payroll deductions, other withholdings, and expenses incurred in earning the income. Examples would include salaries and wages, dividends, annuities, interest, rents, pensions, disability and survivor benefits, Workers’ Compensation, unemployment compensation, maintenance and child support payments, bonuses, tips and gratuities, income from business or profession, and any other taxable and nontaxable income;

(H) Household size—the number of persons dependent upon the income of the financially responsible person including the person (recipient) receiving services, except for a blended family situation. Dependency for family members, other than the recipient, must meet the dependency test in the federal Internal Revenue Code;

(I) Long-term care—continuous residential care (excluding supportive housing) which meets any of the following conditions:

Admission to a habilitation center;
Admission to a community placement facility;
A statement signed by a physician or a qualified mental health professional that the care is for an indeterminate period; or 4. The care has been provided for at least twenty-four (24) months without any documentation in the recipient’s individualized treatment, habilitation, or rehabilitation plan indicating discharge is imminent (within ninety (90) days);

(J) Monthly rate—the amount determined by application of the sliding fee scale to be charged for services provided in a month;

(K) Provider—a public or private agency offering services to individuals approved for Department of Mental Health (DMH)-funded services;

(L) Recipient-client, patient, or resident— the person receiving services;

(M) Representative payee—guardian, ROBINCARNAHAN(4/30/10) trustee, conservator, or other fiduciary appointed to receive a beneficiary’s benefits (for example, Social Security, Railroad Retirement);

(N) Sliding fee scale—a table for determining the monthly rate to be charged to a financially responsible person for services; and (O) Unearned income—income that is not derived from employment. Examples would include maintenance and child support monies, interests, pensions, unemployment benefits, Workers’ Compensation, and benefits from the Social Security Administration, Railroad Retirement Board, Civil Service Commission, Veterans Administration, and other similar types of income.

(2) Charges Not to Exceed Costs. The charges determined by the application of this

rule shall not exceed costs. For providers operated by the department, the costs are determined annually as required by section 630.210, RSMo. For other providers, the costs are authorized by contract with the department. If more than one (1) source of reimbursement is being charged, then collectively the charges shall not exceed costs.

(3) Community Support Incentives/POS. The following financial incentives shall be provided to clients and families receiving less costly community support services:

(A) Clients or their financially responsible parties shall be assessed at a rate of one-fourth (1/4) their monthly ability to pay, for community support services which are received by the client, except for the case management services specified in subsection (3)(B). Insurance companies and other third-party payers shall be billed at actual cost for all community support services, including the case management services specified in subsection (3)(B); and (B) For case management services reimbursed by the Division of Developmental Disabilities and intensive case management services reimbursed by the Division of Comprehensive Psychiatric Services, only clients or their financially responsible parties with annual adjusted gross incomes exceeding one hundred thousand dollars ($100,000) in 1991 dollars, adjusted annually for inflation using the Consumer Price Index (CPI), shall be assessed a charge, and the charge shall be the lesser of actual cost or one-fourth (1/4) their monthly ability to pay.

(4) Health Insurance. The provider shall apply to the costs incurred for providing services to the recipient the benefits received or available on behalf of or to the recipient from private and public health insurance, health services corporation and health maintenance organization plans, policies and contracts including individual, company, fraternal, group, Medicare, Medicaid, and similar plans to the extent and limits of the coverage for the recipient. If a federal program requires the department to accept federal reimbursement as full payment as a condition of participation in the program for certain services, the provider shall not charge the financially responsible person for the services except the federally permitted deductibles or coinsurances.

(5) Financial Responsibility. As set out in

section 630.205, RSMo, the following are jointly and severally liable to pay under this

rule for services rendered to a recipient:

(A) The recipient;

(B) The recipient’s estate only to the extent of the assets in the estate, if the recipient has a conservator or is deceased;

(C) The recipient’s spouse unless otherwise provided for in a separation agreement or dissolution order approved by a court of competent jurisdiction;

(D) The recipient’s natural parents’ ability to pay is based separately on their own income with each claiming the children from that marriage as dependents. All child support, even if it is for other children that were a result of that marriage that are not our clients, will be considered in total income;

(E) Any fiduciary, such as a trustee, only to the extent of the assets the fiduciary is holding on behalf of or for the recipient, which assets may be used according to law; except for any assets held in the Missouri Family Trust Fund on behalf of or for the recipient;

(F) Any representative payee to the extent of the benefits and assets under the law governing and permitting payment of benefits and assets for the recipient;

(G) The recipient’s parents if the recipient is a minor (under age eighteen (18)), except the following:

The parents of a minor recipient who has been emancipated;
The parents of a minor recipient if the parents have relinquished parental responsibility through legal adoption or have had parental rights terminated by an action of a juvenile court;
The parents of a recipient age three to eighteen (3–18), a recipient age three to twenty-one (3–21), or the spouse or estate of a recipient age three to twenty-one (3–21) are not liable for the cost of education, special education, or related services. The parents of a recipient age birth to three (0–3) are not liable for the cost of prevention and early intervention services provided through P.L. 102-119 Part H First Steps. The term special education, as used in this rule, is defined in 34 CFR Section 300a.14. The term related services, as used in this rule, is defined in 34 CFR 300a.13;
The adoptive parents of a minor recipient who had been, before the adoption, court committed to the legal custody of the department, the Department of Social Services, or a charitable organization; and 5. Stepparents’ income;

(H) If two (2) or more members of a household receive services in the same month, the provider shall charge no more than the amounts determined by application of the sliding fee scale for one (1) recipient.

Before this shall apply, the financially responsible person shall notify the provider when services are provided to more than one (1) member of the household in the same month;

(I) If the recipient is eligible for Medicaid (under any state entitlement program), Supplemental Security Income (SSI), General Relief (GR), or Food Stamps, the Standard Means Test (SMT) is not required to be implemented, with the exceptions that are found in other parts of this rule. Documentation of the eligibility must be placed in the financial file in lieu of an SMT;

(J) If the recipient is eligible for Title IV- A, the SMT will not need to be implemented. Documentation of eligibility must be placed in the financial file in lieu of an SMT;

(K) If it appears from the application of the SMT that the recipient could be assessed under more than one (1) client identifier, the formula which requires the least amount of client pay will be used; and (L) The department shall consider noncustodial parents court orders regarding support payments and medical coverage obligations.

(6) Charges for Nonresidents. If a recipient of any age is not domiciled in this state, as defined in 9 CSR 10-31.016, then those responsible to pay, the parents, school district, special district or state department or agency of the recipient’s domicile, under this

rule are liable to pay the full cost of the services.

(7) Sliding Fee Scale. The scale determines (4/30/10) ROBINCARNAHAN the monthly rate to be charged to a financially responsible person for services. The scale was developed using three hundred percent (300%) of the federal poverty guidelines for the year 2009 and income withholding tables for federal and state taxes. The scale shall be updated annually when changes have occurred in the federal poverty guidelines or the tax withholding tables. The adjusted gross monthly income on the sliding fee scale is determined by deducting the following expenses from gross income:

(A) Business expenses and expenses incurred on income-producing property when the income is included in gross income under this rule and the expenses were deducted on the federal income tax return;

(B) Business expenses which have no history and are now being claimed will be based on federal tax guidelines; if a review finds business expenses were invalid, then the rate will be adjusted to their ability to pay, retroactively;

(C) Medical expenses deducted by the taxpayer (financially responsible person) on the most recent filed tax year that exceed the federal percentage rate allowable of the federal adjusted gross income in (1996) or medical expenses that exceed the federal percentage and cannot be claimed on the federal tax return due to inability to itemize deductions, proof of payment must be presented;

(D) Medical expenses, anticipated or unanticipated, that will be scheduled as a monthly payment. Documentation must be presented that the payments have been or are being made. If a review finds that payments were not or are not being made, then the rate will be adjusted to their actual ability to pay, retroactively; and (E) Child support paid by a parent, whether the parent can claim the child as a dependent or not, shall be a deduction to income. Documentation must be provided that payments are being made.

(8) Charges for Long-Term Care. The charges shall be determined under this section, and only under this section, when the recipient requires long-term care.

(A) If the recipient is with his/her spouse or dependents, the provider shall charge the recipient, his/her estate, fiduciary, or representative payee as follows: If the recipient is with his/her spouse or dependents, all unearned income should be treated as earned income and assessed according to the sliding fee scale, except in those cases where the spouses are estranged.

(B) If the recipient in a residential care or inpatient facility purchased or operated by DMH is without spouse or dependents, then the provider shall consider all of a recipient’s real and personal property when the provider has obtained and filed an annual statement from a licensed physician or a qualified mental health professional indicating that the recipient requires full-time residential services or, if the recipient has been in full-time residential services, twenty-four (24) or more continuous months previously. The provider shall charge all costs until the recipient’s estate is reduced to the allowable amount for Medicaid eligibility, except cash and securities shall not exceed ninety-five percent (95%) of the Medicaid limit on cash and securities. The provider (DMH-operated or purchased facility) shall apply all unearned income to the cost of services, except that the provider shall make an allowance of thirty dollars ($30) or more per month for personal spending as specified in the recipient’s individualized treatment, habilitation, or rehabilitation plan. If the representative payee is the conservator, then the court-ordered costs shall be a reduction in the amount assessed upon the recipient’s benefits.

(C) Subsections (8)(A) and (B) of this rule may be waived whenever the release of the recipient is imminent (within ninety (90) days), the unmet needs of the recipient have been documented and the recipient’s existing funds are inadequate to pay the costs of the needs documented in the recipient’s individualized habilitation, rehabilitation, or treatment plan.

(9)

Charges for Community Services. Only financially responsible persons whose income is equal to, or greater than, three hundred percent (300%) of the federal poverty guidelines shall be assessed a monthly rate using the sliding fee scale, except that no financially responsible person shall be assessed a monthly rate for services received through a Community Psychiatric Rehabilitation Center or Compulsive Gambling services as defined in 9 CSR 30-3.134(1).

(10) Working Clients. If the recipient is a working client and is without a spouse, dependents, or both, the provider shall apply to costs of services forty percent (40%) of all net earned income exceeding one hundred dollars ($100) per month, except in cases where DMH is not paying room and board costs. In these cases, the sliding fee scale shall be applied.

(11) Documentation Requirements. For community services, the financially responsible persons shall certify their income to the provider. If the provider has reasons to believe that the income certified by the financially responsible persons is inaccurate, then the provider shall request the documentation required below for individuals receiving longterm care. For long-term care, the financially responsible persons shall furnish the provider written statements of their income (for example, most recent year’s filed complete federal tax return) or other supporting documentation requested by the provider for income verification. If the provider applies the longterm care provisions under this rule, then the provider shall obtain a statement of the recipient’s personal and real assets and other supporting documentation. Documentation must be provided for any deductions to gross income.

(12) Failure to Comply. The provider shall have the recipient or financially responsible person apply for benefits and entitlements described in this rule if it appears the recipient is eligible. The provider may charge the financially responsible person all costs of providing or procuring the services when the recipient or financially responsible person— (A) Deliberately fails to divulge financial resources upon request of the provider;

(B) Fails to apply or permit the provider to apply for benefits; or (C) Fails to assign benefits.

(13) Failure to Pay. The provider may take action to collect any unpaid amounts charged based on the sliding fee scale or the full cost based on the failure to comply. These actions may include, but are not limited to, Missouri State Income Tax Intercept and any further action allowable under state and federal law.

(14) Voluntary Payments. The provider may accept voluntary payments from individuals not legally obligated to pay and payments made in addition to the amounts determined by application of this rule. Providers operated by the department shall receive gifts, donations, devises, or bequests as set out in

section 630.330, RSMo. For services to clients, vendors or department-operated providers may set a minimal charge for services to clients which may exceed the monthly charge applicable under this rule. The charge shall not exceed five dollars ($5) per visit and shall be an offset against any charges determined as otherwise applicable under this

rule, per program, per provider. If one (1) client is assessed a minimal charge, all clients ROBINCARNAHAN(4/30/10) in that program must be assessed the same minimal charge. The provider can determine that an urgent need for immediate services overrides any inability or refusal to pay.

(15) Test Application Procedures. The director delegates his/her authority to complete the SMT to any provider operated by the department. Other providers (for example, nonstate community mental health centers or substance abuse programs) which serve recipients directly without having them go through department case management shall apply the test if the providers agree to do so under the terms of contracts with the department.

(A) The provider shall apply the SMT contained in this rule at admission, annually after admission if the recipient is still receiving services, upon request from the recipient or responsible party, or by the initiative of the provider or the department director due to any significant change in financial status.

(B) The provider shall apply the test in this

rule on all recipients as of February 26, 1993.

(C) Upon request for review, the provider shall change the monthly rate, if warranted, effective to the first day of the month of the date of request.

(D) As other substantial changes occur in income or asset status, the provider shall reapply the test and the changes shall be effective as of the first day of the month following the date of the reapplication of the test. If inaccurate or fraudulent information was provided for determining charges, or if the recipient is entitled to retroactive benefits, the provider shall retroactively change the amount charged.

(16) Appeal Procedures. The application of the SMT may be appealed by the financially responsible person to the chief administrative officer of the provider and then the department director as follows:

(A) The chief administrative officer of the provider shall review upon appeal the application of the test as to the verification of financial resources, the determination of charges, and issue a decision to the financially responsible person;

(B) The decision of the chief administrative officer of the provider may be appealed to the department director within fifteen (15) days of the receipt of the decision. The director will review appeals only if the recipient or responsible party alleges the incorrect application of the test. Upon completion of the review, the director shall issue a decision which may alter application of the test;

(C) As set out in section 630.210, RSMo, the decision of the director may be reviewed in the circuit court of Cole County or the circuit court in the county where the financially responsible person legally obligated to pay resides according to the procedure set out in

Chapter 536, RSMo; and (D) Pending the decision upon appeal by the provider’s chief administrative officer, the decision of the department director, if appealed, or decision of a court of competent jurisdiction, if judicially reviewed, whichever is later, the department shall hold the provider harmless and shall pay disputed amounts to the provider, if necessary, to continue services to the recipient. If the financially responsible person is deemed obligated to pay any of the disputed amounts after the appeal is completed, then the financially responsible person shall pay the amounts to the provider as an offset to the department’s future support or to the department if no future department support is to be provided.

(17) Probation and Parole Clients. For services provided under terms and conditions of probation and parole, the provider may determine charges related to income and consistent with the treatment and rehabilitation goals of the terms and conditions of proba tion and parole as approved in writing by the department and the supervising court.

(18) Waiver Authority. The director may waive the application of the SMT to specific services, programs, or populations, or for specific purposes, or in specific situations, when the director determines that it is in the best interests of the state, the department, and the individuals served by the department to do so. Examples of situations in which waivers may be deemed appropriate include natural or man-made disasters, temporary services or programs which are not suited to the current SMT process, specific situations in which collections do not justify the administrative burden of applying the SMT, and situations in which the cost of providing services is fully covered by another funding source.

Filed Oct. 11, 1984, effective Jan. 14, 1985.

Amended: Filed Aug. 15, 1985, effective Nov. 11, 1985. Emergency amendment filed June 17, 1986, effective June 27, 1986, expired Oct. 15, 1986. Amended: Filed July 14, 1986, effective Nov. 28, 1986. Emergency amendment filed Dec. 20, 1990, effective Dec. 30, 1990, expired April 28, 1991.

Amended: Filed Dec. 21, 1990, effective April 29, 1991. Emergency amendment filed May 21, 1991, effective July 1, 1991, expired Oct. 28, 1991. Amended: Filed Feb. 15, 1991, effective Aug. 30, 1991. Emergency

rule filed Oct. 13, 1992, effective Oct. 23, 1992, expired Feb. 19, 1993. Emergency amendment filed Oct. 23, 1992, effective Nov. 2, 1992, expired Feb. 19, 1993.

Rescinded and readopted: Filed May 15, 1992, effective Feb. 26, 1993. Emergency

rule filed Feb. 10, 1993, effective Feb. 20, 1993, expired June 19, 1993. Amended: Filed Nov. 4, 1992, effective May 6, 1993. Amended: Filed July 17, 1995, effective Jan. 30, 1996. Amended: Filed Dec. 1, 2009, effective May 30, 2010. 1995, 2008 and 630.210, RSMo 1980, amended 1981, 1982, 1993, 2004.

History

AUTHORITY: sections 630.050 and 630.210, RSMo Supp. 2009. Original rule filed May 12, 1981, effective Jan. 1, 1982. Emergency amendment filed March 19, 1982, effective April 1, 1982, expired July 11, 1982. Amended: Filed April 14, 1982, effective July 11, 1982. Emergency amendment filed Dec. 20, 1982, effective Jan. 1, 1983, expired April 1, 1983. Emergency amendment filed June 20, 1983, effective July 1, 1983, expired Nov. 1, 1983. Amended: Filed June 20, 1983, effective Nov. 1, 1983. Emergency amendment filed Sept. 13, 1983, effective Oct. 1, 1983, expired Jan. 1, 1984. Amended: Filed Sept. 13, 1983, effective Jan. 1, 1984. Amended:

9 CSR 10-31.012 State Income Tax Refund Intercept Hearing Procedure {#sec-9-csr-10-31.012 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-31.012}

PURPOSE: This rule prescribes a hearing procedure for taxpayers who protest, in writing, the application of their state income tax refunds to debts owed to the Department of Mental Health.

(1) If a taxpayer does not request a hearing, in writing, within thirty (30) days of the receipt of the Notice of Mental Health Debt Offset from the Department of Revenue, then— A) The taxpayer is forever barred from asserting a defense to the application of the tax refund to a debt owed to the Department of Mental Health; and (B) The state income tax refund shall be applied as an offset to the debt owed to the Department of Mental Health.

(4/30/10) ROBINCARNAHAN

(2) A request for a hearing shall be denied when the request for the hearing— (A) Is not within thirty (30) days of the receipt of the Notice of Mental Health Debt Offset from the Department of Revenue;

(B) Is not in writing;

(C) Raises issues only which have been previously litigated; and (D) Does not raise any factual issues on the amount of the debt or the responsibility for the debt.

(3) A taxpayer’s intercepted state income tax refund shall be relinquished to the taxpayer when the taxpayer asserts and proves any of the following defenses:

(A) The debt is for a child under age eighteen (18) and the taxpayer is not the natural or adoptive parent;

(B) The debt is for a debtor spouse and the taxpayer was not married to the debtor spouse at the time the debt was incurred;

(D) The debt is barred from collection by a United States bankruptcy court;

(E) The taxpayer was erroneously identified as the debtor because of a mistake in the Social Security number; and (F) Any other valid defense in fact or law appropriate for consideration.

(4) In the case of a joint or combined return, the taxpayer named in the return against whom no debt is claimed must file with the Department of Mental Health for an apportionment of the refund within thirty (30) days of the date of receipt of the Notice of Intent to Offset. The Department of Mental Health shall mail to the taxpayer a determination of apportionment within ninety (90) days after the filing of the taxpayer’s application for apportionment of the refund. The department’s decision on apportionment shall be final upon the expiration of thirty (30) days from the date on which the determination of apportionment is mailed, unless within the thirty (30)-day period from the mailing date of the determination, the taxpayer applies to the Department of Mental Health for a hearing with the Department of Mental Health on the issue of apportionment. The hearing shall be conducted by the director or his/her designee.

(5) An evidentiary hearing shall be scheduled when the amount of the debt or the responsibility for the debt can not be resolved, except by a hearing. If an evidentiary hearing is required, the Department of Mental Health shall set the time and place for the hearing.

Failure of the taxpayer to appear at the time and place scheduled for the hearing shall be deemed an acknowledgement of the debt by the taxpayer and shall result in debt offset.

The hearing, if held, shall be conducted in accordance with the provisions of Chapter 536, RSMo.

History

AUTHORITY: sections 143.787 and 630.050, RSMo 1986. Original rule filed April 26, 1991, effective Sept. 30, 1991. Original authority: 143.787, RSMo 1982 and 630.050, RSMo 1980.

9 CSR 10-31.014 Waiver of Standard Means Test for Children in Need of Mental Health Services {#sec-9-csr-10-31.014 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-31.014}

PURPOSE: This rule implements a revision to section 630.210, RSMo requiring the department to promulgate a rule waiving the Standard Means Test for a child in need of mental health services.

(1) Definitions.

(A) The terms defined in 9 CSR 10-31.011 Standard Means Test are incorporated by reference as though set out in this rule.

(B) A “child in need of mental health services,” as used in this rule, is any child who qualifies to receive services from the Department of Mental Health under Chapters 630, 631, 632 or 633, RSMo.

(2) Request for Waiver. At the time of initial application of the Standard Means Test (SMT) for a child in need of mental health services, and at the time of any subsequent reapplication, the provider shall inform the financially responsible person that the SMT may be waived.

(A) The provider shall make available to the financially responsible person information on how to submit a request for SMT waiver.

(B) The financially responsible person shall submit the request in writing to the department director, with a copy to the provider.

(C) For the initial waiver request made on behalf of a child, the provider shall not charge the monthly rate as determined by application of the SMT for services provided during any month in which the request is under review or appeal. This provision applies only to the first waiver request made on behalf of the child.

(D) A waiver may be approved, or approved with conditions, for up to one (1)

year. It is the responsibility of the financially responsible person to notify the provider of any significant change in financial status. A waiver may be reevaluated at the initiative of the department director due to any significant change in financial status.

(3) Review of Request for Waiver. Upon receipt of a request for SMT waiver the department director shall designate an individual or individuals to review the request.

The designee or designees shall approve, approve with conditions, or deny the request within seven (7) working days of receipt of the written request. The designee or designees shall provide notice of the decision to the requestor by certified mail with copy to the provider.

(4) Consideration of Request. In making the decision to approve, approve with conditions, or deny the request, the designee or designees will consider information presented by the requestor. The requestor may, but is not required to, include information regarding one or more of the items listed below, or any other information in support of their request:

(A) The recommendation of the local care team, or other designated local or regional children’s mental health authority that waiving the SMT will contribute to the therapeutic needs of the child by allowing the child to remain in the custody of the parent or custodian;

(B) History of the child being in state custody due exclusively to the need for mental health services;

(C) Statement from the financially responsible person that their primary motivation for requesting the waiver is to avoid loss of custody because they are unable to pay the monthly amount as determined by application of the Standard Means Test;

(D) Past efforts of the financially responsible person to obtain needed medical care, and expenses incurred by the financially responsible person for the treatment of the mental health condition or for the physical health of the child necessitated by the onset of the mental health condition;

(E) The parent or custodian’s history of insurance benefits expended for physical and mental health treatment of the child and their current attempts to obtain commercial or government-sponsored insurance coverage; and (F) The parent or custodian’s overall wherewithal to pay for the child’s mental health treatment needs at the time of requesting the waiver, including gross income, med ical expenses, assets, liabilities, and financial responsibility for other dependents in the home.

(5) Denial of Request. A request for waiver shall be denied when the request for waiver— (A) Is not submitted in writing;

(B) Does not raise factual issues sufficient to show that inappropriate transfer of custody to the Children’s Division is likely to occur absent the waiver; or (C) Does not present persuasive, factual evidence that the financially responsible person cannot afford to pay the monthly amount required by the application of the Standard Means Test.

(6) Appeal of Denial. Within seven (7) working days of receipt of notice of approval with conditions or denial of a request, the financially responsible person may appeal the approval with conditions or denial in writing to the department director, with copy to the provider.

(7) Review of Appeal. Within seven (7) working days of receipt of the written appeal, and upon completion of review, the department director shall issue a decision which may alter the approval with conditions or denial.

The department director shall provide notice of the decision by certified mail to the financially responsible person with copy to the provider. The decision of the department director shall be the final decision of the department.

rule filed Sept. 2, 2004, effective Sept. 15, 2004, expired March 13, 2005. Original rule filed Sept. 2, 2004, effective March 30, 2005. *Original authority: 630,050, RSMo 1980, amended 1993, 1995 and 630.210, RSMo 1980, amended 1981, 1982, 1993, 2004.

History

AUTHORITY: sections 630.050, RSMo 2000 and 630.210, RSMo Supp. 2004. Emergency

9 CSR 10-31.016 Determining State of Domicile {#sec-9-csr-10-31.016 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-31.016}

PURPOSE: This rule prescribes department procedures for determining the domiciliary state of any patient resident or client receiving services from a facility, program, or service operated or funded by the department as required by section 630.210, RSMo.

(1) A person domiciled in Missouri is one who resided in Missouri not for a mere special or temporary purpose, but with intent to remain in Missouri permanently or for an indefinite time which may be demonstrated, but not necessarily determined by—ownership of a residence in Missouri, filing of a Missouri state income tax return, voter registration in Missouri, registration of a motor vehicle in Missouri, employment in Missouri, or the receipt of public assistance from Missouri.

(2) A person and a person’s dependents are domiciled in Missouri when the person is a member of the armed services and stationed in Missouri. Domicile shall continue to be conferred upon dependents of a member, if they remain in Missouri, after the member of the armed services is transferred from Missouri.

(3) The domicile of a minor under the age of eighteen (18) and not emancipated shall be that of the parent(s) having physical custody of the minor.

(4) The domicile of a minor under the age of eighteen (18) whose parents are deceased or parental rights have been terminated shall be the state in which a guardian has been appointed for the minor, or the current domicile of the minor’s guardian.

(5) A person at or over the age of eighteen (18) is considered incapable of forming his/her own intent to be domiciled in Missouri when— (A) The person’s Intelligence Quotient (IQ) is forty-nine (49) or less, or has a mental age of seven (7) or less based on a comprehensive test of intelligence;

(B) The person is declared legally incapacitated as defined in section 475.010, RSMo; or (C) Medical documentation or other documentation acceptable to the department supports a finding that the person is incapable of forming intent to be domiciled in Missouri.

(6) The domicile of a person at or over the age of eighteen (18) who is incapable of forming intent to be domiciled under section (5) of this rule shall be the current domicile of the person’s guardian, unless the person has previously established domicile in and continuously resided in the state of Missouri, in which case, domicile shall remain the state of Missouri.

(7) Domiciliary status shall not be conferred on persons placed in institutions in Missouri by another state.

(8) Missouri is not the state of domicile when the person— (A) Removes him/herself and his/her personal effects from Missouri with an intent to establish domicile elsewhere;

(B) Accepts employment, other than on a temporary basis, in another state and does not retain a residence in Missouri;

(D) Becomes a registered voter in another state;

(E) Renounces Missouri as his/her state of domicile;

(F) Licenses his/her motor vehicle in another state; or (G) Performs any other act which indicates intent to abandon Missouri as state of domicile.

Filed Dec. 4, 1990, effective April 29, 1991.

Amended: Filed Nov. 4, 2016, effective June 30, 2017. 1995, 2008 and 630.210, RSMo 1980, amended 1981, 1982, 1993, 2004, 2011.

History

AUTHORITY: sections 630.050 and 630.210, RSMo 2016. Original rule filed Nov. 22, 1983, effective April 15, 1984. Amended:

9 CSR 10-31.020 Determination of the Charges for Outpatient Services Provided or Procured {#sec-9-csr-10-31.020 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-31.020}

(Rescinded January 1, 1982)

Original rule filed June 16, 1977, effective Oct. 13, 1977. Rescinded: Filed Aug. 13, 1981, effective Jan. 1, 1982.

History

AUTHORITY: section 202.330, RSMo Supp.

9 CSR 10-31.030 Intermediate Care Facility for Individuals with Intellectual Disabilities Federal Reimbursement Allowance {#sec-9-csr-10-31.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-31.030}

PURPOSE: This rule establishes the formula to determine the Federal Reimbursement Allowance for each Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) operated primarily for the care and treatment of individuals with intellectual and developmental disabilities. This rule applies to both private ICF/IIDs and ICF/IID facilities operated by the Department of Mental Health and requires these facilities to pay for the privilege of engaging in the business of providing ICF/IID services to individuals in Missouri.

(1) The following words and terms, as used in this rule, mean:

(A) Base cost report. MO HealthNet cost report for the second prior fiscal year relative (5/31/17) JOHNR. ASHCROFT to the State Fiscal Year (SFY) for which the assessment is being calculated (For example, the SFY 2009 Federal Reimbursement Allowance (FRA) assessment will be determined using the Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) cost report from FY 2007.);

(B) Department. Department of Mental Health;

(D) Division. Division of Developmental Disabilities, Department of Mental Health;

(E) Engaging in the business of providing residential habilitation care. Accepting payment for ICF/IID services rendered;

(F) Fiscal period. Twelve- (12-) month reporting period determined by the State Fiscal Year;

(G) Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID).

A private or department facility that admits individuals with intellectual and developmental disabilities for residential habilitation and other services pursuant to Chapters 630 and 633, RSMo, and that has been certified to meet the conditions of participation under 42 CFR 483, Subpart I;

(H) Intermediate Care Facility for Individuals with Intellectual Disabilities Federal Reimbursement Allowance ICF/IID FRA.

The assessment paid by each ICF/IID;

(I) Net revenues. Gross revenues less bad debts, less charity care, and less contractual allowances; and (J) Trend factor. Centers for Medicare and Medicaid Services (CMS) Prospective Payment System Skilled Nursing Facility Input Price Index (SNF IPI) four (4) quarter moving average (Source: GLOBAL INSIGHT, INC, 4th Qtr, 2007) (4 Quarter Moving Average Percent Changes in the CMS Prospective Payment System Skilled Nursing Facility Input Price Index (SNF IPI) using Forecast Assumptions, by Expense Category: 1990- 2017).

(2) Each ICF/IID operated primarily for the care and treatment of individuals with intellectual and developmental disabilities engaging in the business of providing residential habilitation and other services in Missouri shall pay an ICF/IID FRA. The ICF/IID FRA shall be calculated by the department as follows:

(A) Beginning on July 1, 2008, and each year thereafter, the ICF/IID FRA annual assessment shall be five and forty-nine hundredths percent (5.49%) of the ICF/IID’s net revenues determined from the base cost report relative to the State Fiscal Year for which the assessment is being calculated. The cost report shall be trended forward from the second prior year to the current fiscal year by applying the SNF IPI trend factor for each year under the ICF/IID FRA calculation;

(B) Beginning on October 1, 2011, and each year thereafter, the ICF/IID FRA annual assessment shall be five and ninety-five hundredths percent (5.95%) of the ICF/IID’s net revenues determined from the base cost report relative to the State Fiscal Year for which the assessment is being calculated. The cost report shall be trended forward from the second prior year to the current fiscal year by applying the SNF IPI trend factor for each year under the ICF/IID FRA calculation;

(C) The annual assessment shall be divided into twelve (12) equal amounts and collected over the number of months the assessment is effective. The assessment is made payable to the director of the Department of Revenue to be deposited in the state treasury in the ICF/IID FRA Fund;

(D) If the assessment amount determined using the second prior year cost report trended forward for the same year is greater than the actual assessment maximum amount on the current year ICF/IID provider tax revenues in the aggregate, then the department will offset the tax collections for the next year by each provider’s pro-rata share of the difference between the amount of the tax as determined in subsection (2)(A) of 9 CSR 10-31.030 and the actual SFY amount determined from the current year ICF/IID cost report;

(E) If an ICF/IID does not have a base cost report, net revenues shall be estimated as follows:

Net revenues shall be determined by computation of the ICF/IID’s projected annual patient days multiplied by its interim established per diem rate; and (F) The ICF/IID FRA assessment for ICF/IIDs that merge operation under one (1)

MO HealthNet provider number shall be determined as follows:

The previously determined ICF/IID FRA assessment for each ICF/IID shall be combined under the active MO HealthNet provider number for the remainder of the State Fiscal Year after the division receives official notification of the merger; and 2. The ICF/IID FRA assessment for subsequent fiscal years shall be based on the combined data for both facilities.

(3) The department shall prepare a notification schedule of the information from each ICF/IID’s second prior year cost report and provide each ICF/IID with this schedule.

(A) The schedule shall include:

Provider name;
Provider number;
Fiscal period;
Total number of licensed beds;
Total bed days;
Net revenues; and 7. Total amount of the assessment for the State Fiscal Year for which the assessment is being calculated and monthly assessment amount due each month.

(B) Each ICF/IID required to pay the ICF/IID FRA shall review this information, and if it is not correct, the ICF/IID must notify the department of such within fifteen (15) days of receipt of the notification schedule. If the ICF/IID fails to submit the corrected data within the fifteen- (15-) day time period, the ICF/IID shall be barred from submitting corrected data later to have its ICF/IID FRA assessment adjusted.

(4) Payment of ICF/IID FRA Assessment.

(A) Each ICF/IID may request that its ICF/IID FRA be offset against any MO HealthNet payment due. A statement authorizing the offset must be on file with the MO HealthNet Division before any offset may be made relative to the ICF/IID FRA. Any balance due after the offset shall be remitted by the ICF/IID to the department. The remittance shall be made payable to the director of the Department of Revenue. If the remittance is not received before the next MO HealthNet payment cycle, the MO HealthNet Division shall offset the balance due from that check.

(B) If no offset has been authorized by the ICF/IID, the MO HealthNet Division will begin collecting the ICF/IID FRA on the first day of each month. The ICF/IID FRA shall be remitted by the ICF/IID facility to the MO HealthNet Division. The remittance shall be made payable to the director of the Department of Revenue and deposited in the state treasury to the credit of the ICF/IID FRA Fund.

(C) If the ICF/IID is delinquent in the payment of its ICF/IID FRA assessment, the director of the Department of Social Services shall withhold and remit to the Department of Revenue an amount equal to the assessment from any payment made by the MO Health- Net Division to the ICF/IID provider.

Amended: Filed Nov. 4, 2016, effective June 30, 2017.

Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 633.401, RSMo 2008, amended 2009, 2011, 2014, 2015, 2016.

History

AUTHORITY: sections 630.050 and 633.401, RSMo 2016. Emergency rule filed July 1, 2008, effective July 11, 2008, expired Dec. 28, 2008. Original rule filed July 1, 2008, effective Feb. 28, 2009. Emergency amend ment filed Sept. 1, 2011, effective Oct. 1, 2011, expired March 28, 2012. Amended: Filed Sept. 1, 2011, effective March 30, 2012.

9 CSR 10-31.040 Community Mental Health Center Clinic UPL {#sec-9-csr-10-31.040 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-31.040}

PURPOSE: This rule establishes the formula to determine supplemental payments under Medicaid subject to the clinic upper payment limit to Community Mental Health Center Clinics (CMHC).

(1) Definitions. The terms used in this rule shall mean— (A) Medicare rate is the rate established in the 2010 Resource Based Relative Value Scale (RVRVS) table plus the Health Professional Shortage Area (HPSA) add-on payment; and (B) Current Medicaid rate is the rate on file with the MO HealthNet Division at the beginning of the state fiscal year.

(2) Supplemental Payment to Community Mental Health Centers. The Department of Mental Health (DMH) contracts with privately owned and operated Community Mental Health Centers (CMHCs), which act as administrative entities of DMH. The CMHCs are designated as entry and exit points for DMH services and are required to provide a comprehensive array of services to any DMH patients in their designated service areas who seek care.

(3) To recognize the CMHCs’ higher costs of doing business and their role as safety net providers, each Missouri CMHC will be paid an annual supplement, calculated at the beginning of each state fiscal year, and payable in quarterly installments. The supplemental payment will increase reimbursement for CMHC-provided clinics to 1.36 times the Medicare rate for such services, an amount that the state reasonably estimates to be comparable to that paid by private commercial payers. The payment will be subject to the clinic upper payment limit established at 42 CFR 447.321.

(4) Amount of Annual Supplemental Payment. Each CMHC’s annual payment will be determined using the following methodology.

(A) For each service procedure where there is a corresponding Medicare fee for a CMHC-provided clinic procedure, DMH will subtract the current Medicaid rate from the market proxy of 1.36 times the Medicare rate, then multiply the result by the number of units of service.

(B) For each service procedure where there is no corresponding Medicare fee for a CMHC-provided clinic procedure, DMH will calculate the difference between what the CMHC received under the current Medicaid rate and what the CMHC would have received if paid the cost-based fee used to approximate the commercial rate for such procedures, then multiply the result by the number of units of service.

(C) The amounts calculated in subsections (4)(A) and (4)(B) will be added together to determine each CMHC’s total supplemental payment.

(D) In all years subsequent to state fiscal year 2012, the results of these calculations will be multiplied by a trend factor equal to the Consumer Price Index in the expenditure category Medical Care Services/Professional Services.

(5/31/17) JOHNR. ASHCROFT

History

AUTHORITY: section 630.050, RSMo Supp. 2011, and sections 630.655 and 632.050, RSMo 2000. Original rule filed Feb. 1, 2012, effective Aug. 30, 2012. 1995, 2008; 630.655, RSMo 1980; and 632.050, RSMo 1980.

Division 20 Division of Alcohol and Drug Abuse

Chapter 2 Certification Standards for Alcohol and Drug Abuse Programs

9 CSR 20-2.010 Definitions Sept. 11, 1983. {#sec-9-csr-20-2.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 20-2.010}

9 CSR 20-2.020 Procedure to Obtain Certification Sept. 11, 1983. {#sec-9-csr-20-2.020 omnilex-key=us-mo-regs-official--title-9--9 CSR 20-2.020}

9 CSR 20-2.030 Required Organization Structure {#sec-9-csr-20-2.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 20-2.030}

9 CSR 20-2.040 General Policy {#sec-9-csr-20-2.040 omnilex-key=us-mo-regs-official--title-9--9 CSR 20-2.040}

9 CSR 20-2.050 Client Record {#sec-9-csr-20-2.050 omnilex-key=us-mo-regs-official--title-9--9 CSR 20-2.050}

9 CSR 20-2.060 Required Treatment Procedures Sept. 11, 1983. {#sec-9-csr-20-2.060 omnilex-key=us-mo-regs-official--title-9--9 CSR 20-2.060}

9 CSR 20-2.070 Fiscal Management MATTBLUNT(10/31/01) {#sec-9-csr-20-2.070 omnilex-key=us-mo-regs-official--title-9--9 CSR 20-2.070}

Division 25 Fiscal Management

Chapter 2 Purchase of Service Contracting

9 CSR 25-2.005 Definitions {#sec-9-csr-25-2.005 omnilex-key=us-mo-regs-official--title-9--9 CSR 25-2.005}

PURPOSE: This rule defers to state statute for the definition of terms used in this chapter.

(1) Definitions for terms for this chapter can be found in section 630.005, RSMo.

Oct. 16, 1986, effective July 13, 1987. Emer- Amended: Filed Aug. 1, 1990, effective Dec. 31, 1990. Emergency amendment filed July 7, 1992, effective July 17, 1992, expired Nov. 13, 1992. Amended: Filed July 7, 1992, effective Feb. 26, 1993. Amended: Filed June

9 CSR 25-2.105 Purchasing Services for Individuals Served by the Department {#sec-9-csr-25-2.105 omnilex-key=us-mo-regs-official--title-9--9 CSR 25-2.105}

PURPOSE: This rule prescribes the procurement process for purchasing services for individuals being served by the department. As set out in sections 34.100 and 630.405, RSMo, the commissioner of administration shall have the power to delegate his/her

(1) As set out in sections 34.100 and 630.405, RSMo, the commissioner of administration has delegated his/her authority to the department to purchase services from providers directly rather than through the Division of Purchasing of the Office of Administration.

The commissioner delegates the authority by letter to the department director on an annual or triennial basis.

(2) The director may designate administrative entities for the purchase of services for individuals served by the Division of Behavioral Health and the Division of Developmental Disabilities as defined in

section 630.407, RSMo.

(3) As set out in section 630.407, RSMo, the department may contract directly with administrative entities without competitive bids.

Filed July 1, 2003, effective Dec. 30, 2003.

Amended: Filed Feb. 23, 2018, effective Sept. 30, 2018.

History

authority to the department to purchase services for individuals it serves. The delegation of authority requires the department to comply with the basic intent of public procurement procedures to purchase the services.

9 CSR 25-2.205 Request for Proposal Development {#sec-9-csr-25-2.205 omnilex-key=us-mo-regs-official--title-9--9 CSR 25-2.205}

(Rescinded December 30, 2003)

Amended: Filed July 7, 1992, effective Feb. 26, 1993. Rescinded: Filed June 30, 2003, effective Dec. 30, 2003.

History

AUTHORITY: sections 34.100, 630.050 and 630.405, RSMo 1986. Original rule filed Oct. 16, 1986, effective July 13, 1987. Emergency amendment filed July 7, 1992, effective July 17, 1992, expired Nov. 13, 1992.

9 CSR 25-2.305 Invitation for Bid Solicitation Procedures {#sec-9-csr-25-2.305 omnilex-key=us-mo-regs-official--title-9--9 CSR 25-2.305}

PURPOSE: This rule prescribes department procedures for soliciting bidders in response to an invitation for bid for services which require a competitive bid.

(1) The department complies with Office of Administration, Division of Purchasing rules, regulations, and requirements related to the Invitation for Bid (IFB) process as set out in

Chapter 34, RSMo, 1 CSR 40, the state procurement manual, and Division of Purchasing policies and procedures.

Oct. 16, 1986, effective July 13, 1987. Emergency amendment filed July 7, 1992, effective July 17, 1992, expired Nov. 13, 1992.

Amended: Filed July 7, 1992, effective Feb. 26, 1993. Amended: Filed Oct. 31, 2000, effective May 30, 2001. Amended: Filed June

9 CSR 25-2.405 Invitation for Bid Evaluation and Award {#sec-9-csr-25-2.405 omnilex-key=us-mo-regs-official--title-9--9 CSR 25-2.405}

PURPOSE: This rule prescribes the evaluation and award procedures for an invitation for bid.

(1) The department complies with Office of Administration, Division of Purchasing rules and regulations and requirements related to the Invitation for Bid (IFB) evaluation and award process as set out in Chapter 34, RSMo, 1 CSR 40, the state procurement manual, and Division of Purchasing policies and procedures.

Oct. 16, 1986, effective July 13, 1987. Emer- Amended: Filed Aug. 14, 1990, effective March 14, 1991. Emergency amendment filed July 7, 1992, effective July 17, 1992, expired Nov. 13, 1992. Amended: Filed July 7, 1992, effective Feb. 26, 1993. Amended: Filed June

9 CSR 25-2.505 Protest and Appeal Procedures {#sec-9-csr-25-2.505 omnilex-key=us-mo-regs-official--title-9--9 CSR 25-2.505}

PURPOSE: This rule prescribes procedures for bidders to protest a department decision regarding the award of contract(s), as a result of a competitive Invitation for Bid process.

(1) A bid award protest must be submitted in writing to the division director, or their designee, for which the services are to be purchased (directors of the Division of Developmental Disabilities or Division of Behavioral Health). Award protests must be received by the department within ten (10) business days after the date of award. If the tenth day falls on 4CODE OF STATE REGULATIONS (8/31/18) JOHNR. ASHCROFT a Saturday, Sunday, or state holiday, the period shall extend to the next state business day. A protest submitted after the ten- (10-) business day period will not be considered.

(A) The written protest must include the following information:

Name, address, and phone number of the protester;
Signature of the protester or the protester’s representative;
Solicitation number;
Detailed statement describing the grounds for the protest; and 5. Supporting exhibits, evidence, or documents to substantiate claim.

(B) A protest which does not contain the information specified in this rule may be denied solely on that basis.

(C) All protests filed in a timely manner will be reviewed by the division director or designee. The division director or designee will only issue a determination on the issues asserted in the protest.

(D) A protest that is untimely or fails to establish standing to protest will be summarily denied. In other cases, the determination will contain findings of fact, an analysis of the protest, and a conclusion that the protest will either be sustained or denied. If the protest is sustained, remedies include canceling the award. If the protest is denied, no further action will be taken by the department.

Oct. 16, 1986, effective July 13, 1987. Emer- Amended: Filed Aug. 14, 1990, effective March 14, 1991. Amended: Filed Dec. 12, 2001, effective June 30, 2002. Amended:

Chapter 3 Miscellaneous Rules

9 CSR 25-3.030 Access for Inspection of Public Records and Fees for {#sec-9-csr-25-3.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 25-3.030}

9 CSR 25-3.050 Payment to School Districts for Special Education Services for Children Admitted to Programs or Facilities of the Department of Mental Health MENTAL HEALTH {#sec-9-csr-25-3.050 omnilex-key=us-mo-regs-official--title-9--9 CSR 25-3.050}

9 CSR 25-3.030 Access for Inspection of Public Records and Fees for Copying of Public Records {#sec-9-csr-25-3.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 25-3.030}

PURPOSE: This rule prescribes requirements for individuals and organizations to gain access to public records of the department and fees for copying of those public records.

(1) Access for inspection of public records shall be granted and copying of those records shall be provided by the department based upon a review of each request. Access for inspection of public records shall be allowed during the normal business hours of the administrative offices of the department facility where the records are stored. Copies of public records shall be provided by the department and shall be subject to the collection of established search and copy fees and applicable sales tax and shipping charges.

(2) Requests for access to or copying of public records may be made in person, by telephone or by any other convenient means.

However, should any question arise whether a requested record is a closed record or is confidential as provided by law, this request shall be made in writing and forwarded to the Custodian of Records, Department of Mental Health, P.O. Box 687, Jefferson City, MO 65102. The custodian shall notify the individual or organization within three (3) business days from the date the request was received by the custodian whether access is granted or denied.

(3) As provided under section 610.026, RSMo, access to public records for a short duration of time during normal business hours will normally be provided without charge. The department may negotiate a space or rental fee with the requester to provide access to public records when the access will be for an extensive period of time or will otherwise be disruptive to the normal operations of the department. Copies of public records will be provided by the department for the following copy and search fees:

(A) Paper copies no larger than nine by fourteen inches (9" × 14")—$.10 per page;

(B) Duplicating time—an hourly fee not to exceed the average hourly rate of pay for the department’s clerical staff; and (C) Research time—the actual cost of research time.

(4) Fees for duplicating other types of records and other formats including electronic data shall be based on the actual cost of search and duplication or as otherwise provided by section 610.026, RSMo.

(5) In accordance with the Americans with Disabilities Act, no additional fees shall be assessed for transcribing public records into Braille, audiotape or other suitable form.

(6) As authorized by law, the department may furnish copies without charge or at reduced charges when it is determined to be in the public interest and is not primarily in the commercial interest of the requester. For official state administrative and business purposes, copies of records may be provided without charge to— (A) State and federal agencies, appropriation committees and interagency committees;

(B) Courts, attorneys and guardians-adlitem in criminal and civil commitment, guardianship or juvenile proceedings;

(D) Agencies of other states in exchange for comparable reports; and (E) Department employees, advisory councils, commissions, task forces and committees when required by their work.

Amended: Filed July 17, 1995, effective Feb. 25, 1996. Amended: Filed Feb. 1, 2005, effective July 30, 2005. *Original authority: 610.010, RSMo 1973 amended 1977, 1978, 1982, 1987, 1993; 610.011, RSMo 1987; 610.015, RSMo 1973, amended 1973, 1987, 1993; 610.020, RSMo 1973, amended 1982, 1987, 1993; 610.021, RSMo 1987, amended 1993; 610.022, RSMo 1987, amended 1993; 610.023, RSMo 1987; 610.024, RSMo 1987; 610.026, RSMo 1987; 610.027, RSMo 1982, amended 1987, 1990; 610.028, RSMo 1982, amended 1987; 610.029, RSMo 1993; and 610.030, RSMo 1973, amended 1982.

History

AUTHORITY: sections 610.010–610.030 and 630.050, RSMo 2000. Original rule filed June 17, 1986, effective Dec. 1, 1986.

9 CSR 25-3.040 Compensation to Public Administrators {#sec-9-csr-25-3.040 omnilex-key=us-mo-regs-official--title-9--9 CSR 25-3.040}

PURPOSE: This rule sets guidelines for compensation to public administrators and applies to all department facilities and department-operated programs designated as representative payee for consumer entitlements when the public administrator is guardian and/or conservator.

(1) A facility/program shall debit an individual’s Consumer Banking account to compensate a public administrator for the amount allowed by the court in accordance with the following:

(A) The department facility/program is representative payee for Social Security Administration (SSA), Supplemental Security Income (SSI), veterans’ benefits; railroad retirement benefits; civil service annuities; federal, state, or city retirement programs or any other retirement or benefit program;

(B) The payment for the compensation is not prohibited by the benefit program which will be used to pay the requested compensation; and (C) If the expenditure would place the consumer in present or future jeopardy or adversely affect the services to the consumer, the facility/program with administrative control of the consumer’s account shall consult legal counsel as to whether a modification of the court order shall be sought.

History

AUTHORITY: section 630.050, RSMo 2016. Original rule filed Feb. 1, 1988, effective June 27, 1988. Amended: Filed Feb. 27, 2018, effective Sept. 30, 2018. Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008.

9 CSR 25-3.050 Payment to School Districts for Special Education Services for Children Admitted to Programs or Facilities of the Department of Mental Health {#sec-9-csr-25-3.050 omnilex-key=us-mo-regs-official--title-9--9 CSR 25-3.050}

(Rescinded May 30, 1999)

History

AUTHORITY: sections 162.970 and 630.050, RSMo 1986. Original rule filed Nov. 6, 1991, effective April 9, 1992. Rescinded: Filed Nov. 30, 1998, effective May 30, 1999.

9 CSR 25-3.060 Payments to Counties with State Mental Health Facilities {#sec-9-csr-25-3.060 omnilex-key=us-mo-regs-official--title-9--9 CSR 25-3.060}

PURPOSE: This rule prescribes requirements for counties to receive payment from the department for personnel costs relating to mental health facilities.

(1) The City of St. Louis and Buchanan, Callaway, Jackson and St. Francois counties may employ an assistant prosecuting attorney, county counselor or circuit attorney and other investigative and clerical personnel to provide services related to mental health and mental health facilities. The department shall pay these governmental units for these personnel costs from funds appropriated for this purpose.

JOHNR. ASHCROFT(8/31/18)

(2) Each eligible governmental unit may employ an assistant prosecuting attorney, county counselor or circuit attorney who shall be compensated fifteen thousand dollars ($15,000) annually. In addition, investigative and clerical personnel may be employed and the total compensation for these personnel shall not exceed fifteen thousand dollars ($15,000) annually.

(3) Each eligible governmental unit shall submit a request for payment using the form prescribed by the department (MO 650-7975) or an invoice or other document which provides the information disclosed on this form. This request for payment shall be submitted after July 1 of each fiscal year.

(4) The request for payment shall disclose each personnel position, the name of the person employed and the actual salary costs for the preceding fiscal year and the positions and projected salary costs for the current fiscal year.

(5) Upon receipt of the request for payment, the department shall issue a warrant to pay the amount of the projected salary costs for the current fiscal year adjusted for the amount, if any, that the payment for the preceding fiscal year differed from the actual expenditures for that year. These warrant payments shall only be made from funds appropriated for this purpose.

4CODE OF STATE REGULATIONS

(8/31/18) JOHNR. ASHCROFT

ROBINCARNAHAN(6/30/05)

History

AUTHORITY: sections 56.700 and 630.050, RSMo 1994. Original rule filed July 17, 1995, effective Feb. 25, 1996. Original authority: 56.700, RSMo 1979, amended 1989 and 630.050, RSMo 1980, amended 1993.

Chapter 4 Vendor Procedures

9 CSR 25-4.040 Recovery of Overpayments to Providers {#sec-9-csr-25-4.040 omnilex-key=us-mo-regs-official--title-9--9 CSR 25-4.040}

PURPOSE: This rule prescribes requirements for the collection of overpayments made by the department to providers and for the assessment of interest charges on overpayments.

(1) Providers that deliver care, treatment, habilitation or rehabilitation services to clients under contract with the department may receive an overpayment which must be repaid to the department. An overpayment is any payment by the department which is:

(A) Greater than the contracted rate for a service less any portion paid by or on behalf of a client;

(B) For services not provided;

(C) For services not authorized in the contract; or (D) For services provided contrary to the provisions of the contract.

(2) On determination an overpayment has been made, the department shall notify the provider by certified mail of the amount of the overpayment, the basis of the overpayment and request reimbursement. The date on the certified mail return receipt shall be the official date of notice of overpayment.

(3) If the provider concurs with the overpayment, the provider should promptly contact the department and make arrangements for repayment to avoid interest charges. Any overpayment not repaid within forty-five (45) days from the date of notice shall accrue interest charges on the unpaid balance from the date of notice of overpayment.

(4) If the provider does not concur with the overpayment, the provider may request a review of the overpayment by the department.

This request must be made within thirty (30) days of receipt of the notice of overpayment.

The department shall review the overpayment within fifteen (15) days of the request for review. If requested by the provider, the review will be conducted in person and the department will notify the provider of the date, time and place for the review. The criteria for the review shall be to:

(A) Verify the overpayment was properly determined in accordance with the terms of the provider contract;

(B) Verify the overpayment amount has been properly calculated;

(C) Examine and accept additional documentation or other material from the provider; and (D) Upon completion of the review, the department shall notify the provider of the results of the review in writing.

(5) After any review, if requested, and the overpayment amount has been finally determined, the department shall initiate appropriate collection actions.

(A) If any portion of the overpayment consists of Medicaid claims payments, these claims shall be subject to recovery provisions of the Medicaid program and shall be referred to the Department of Social Services, Division of Medical Services.

(B) If any portion of the overpayment is due and payable to the Department of Mental Health, such amounts shall be collected in accordance with the following provisions.

(6) Whether or not the provider requests a review, the department and the provider have forty-five (45) days from the date of notice of overpayment to negotiate a repayment plan.

A repayment plan may allow for payments over a specific time period and shall not exceed twelve (12) months. The repayment plan must be in writing and be signed by the department and the provider. If a repayment plan is not adopted, the overpayment is immediately due and payable.

(7) The department shall specify the method of repayment which may include direct payment by the provider, deduction from future amounts due to the provider, or both. The department shall maintain a record of each overpayment in an account showing the amount due, payments received and interest charged.

(8) An overpayment account shall be considered to be delinquent if:

(A) The account is not subject to a repayment plan and it is not repaid within fortyfive (45) days from the date of notice of overpayment; or (B) The account is subject to a repayment plan and an installment payment is not received within thirty (30) days of the installment due date.

(9) The department may take appropriate actions to recover delinquent amounts due to the department, which may include:

(A) Sending notices to the provider requesting immediate payment;

(B) Deducting the overpayment from amounts due to the provider by the department; and (C) Filing a claim for debt offset with the Director of Revenue to recover the overpayment from any refunds due to the provider by the Department of Revenue.

(10) An overpayment account shall be considered to be in default if:

(A) The account is not subject to a repayment plan and is not fully repaid within six (6) months from the date of notice of the overpayments; or (B) The account is subject to a repayment plan and is delinquent for more than three (3) months in installment payments.

(11) The department may take appropriate actions to seek recovery of overpayment accounts which are in default. These actions may include:

(A) Deducting the overpayment from amounts due to the provider by the department;

(B) Filing a claim for debt offset with the Director of Revenue to recover the overpayment from any refunds due to the provider by the Department of Revenue; and (C) Certifying the overpayment to general counsel or the Office of the Attorney General to seek a judgment for settlement of the amount due.

(12) Interest shall be charged on any overpayment balance not repaid within forty-five (45) days of the date of notice of overpayment. Interest shall accrue from the date of notice of overpayment and be calculated on a daily basis. The interest rate to be charged on overpayments may vary and will be set for each calendar year. The rate of interest shall be the annual rate determined by the Department of Revenue, as provided in section 32.085, RSMo, plus three (3) percentage points. Payments received by the department shall first be applied to accrued interest and then to reduce the balance of the overpayment.

Filed Feb. 15, 2000, effective Aug. 30, 2000. *Original authority: 630.050, RSMo 1980, amended 1993, 1995.

Rebecca McDowell Cook (7/31/00)

History

AUTHORITY: section 630.050, RSMo Supp. 1999. Emergency rule filed Aug. 3, 1984, effective Aug. 13, 1984, expired Dec. 10, 1984. Original rule filed Sept. 10, 1984, effective Dec. 13, 1984. Amended: Filed July 17, 1995, effective Feb. 25, 1996. Amended:

Chapter 5 Administration of Personal Spending Funds

9 CSR 25-5.010 Guidelines for Planning Client Personal Spending Allowances MENTAL HEALTH Personal Spending Funds {#sec-9-csr-25-5.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 25-5.010}

9 CSR 25-5.010 Guidelines for Planning Client Personal Spending Allowances {#sec-9-csr-25-5.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 25-5.010}

(Rescinded October 30, 2018)

Original rule filed Oct. 19, 1984, effective Feb. 11, 1985. Rescinded: Filed March 9, 2018, effective Oct. 30, 2018.

JOHNR. ASHCROFT(9/30/18)

History

AUTHORITY: section 630.050, RSMo 1986.

Chapter 9 Audit Procedures

9 CSR 25-9.070 Audit Conferences {#sec-9-csr-25-9.070 omnilex-key=us-mo-regs-official--title-9--9 CSR 25-9.070}

(Rescinded March 30, 1996)

Rebecca McDowell Cook (Z/29/96)

Division 30 Certification Standards

Chapter 2 Standards for County-Funded Mental Health Services

9 CSR 30-2.010 Designation of Programs to Receive County Community Mental Health Funds {#sec-9-csr-30-2.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-2.010}

PURPOSE: This rule prescribes the procedures to be used to designate programs eligible to receive county community mental health funds as set out in sections 205.975— 205.990, RSMo.

(1) The department shall designate community mental health centers in each mental health service area which may receive funds collected under sections 205.975—205.990, RSMo.

The records, operations and services provided by an entity receiving county funding under sections 205.975—205.990, RSMo shall be subject to annual review or inspection by the department.

(2) As set out in section 205.985(4), RSMo, the county board of trustees shall submit information by January 1 of each year to the department about the disbursement of money from the community mental health fund.

(3) Any program designated by the department to provide services with funds from counties under sections 205.975-205.990, RSMo may provide these services within the mental health service area, directly or indirectly, through contract or affiliate agreements with a qualified community mental health center, mental health clinic, or other public facility or not-for-profit corporation for such comprehensive mental health services for the residents of such county, as specified by the county board of trustees.

(4) The county board of trustees shall deem as eligible to receive county community mental health funds, as set out in sections 205.975—205.990, RSMo, those public or nonprofit community mental health centers that submit proof that the following standards have been met:

(A) That the agency shall have a governing body which has full legal authority and responsibility for the overall functioning of the program, with written documentation of the source of authority through charter, constitution, bylaws or license;

(B) That the agency shall have policies and procedures that implement sections 630.110 and 630.115, RSMo to enhance and protect the human, civil, constitutional and statutory rights of each client;

(D) That the agency shall have services accessible to handicapped individuals or have a written plan for how these handicapped individuals can access necessary services (this offsets any concerns about the federal Americans with Disabilities Act (ADA) legislation);

(E) That the agency shall have fiscal management policies and procedures in accordance with generally accepted accounting principles;

(F) That the agency shall have a written fee schedule that shall be available to all staff and to the clients;

(G) That the agency shall have written policies and procedures to insure that an adequate number of qualified staff are available to support the functions of the agency, and the policies include an equal opportunity plan for hiring staff for the agency;

(H) That the agency shall demonstrate the personnel meet any local, state or federal requirements for their profession;

(I) That the agency’s policies and procedures shall include policies concerning client neglect and abuse and procedures for investigation of alleged violations;

(J) That each agency shall pay clients for work in the program unrelated to their treatment. Wages paid to clients who work shall be in compliance with applicable local, state or federal requirements;

(K) That the agency shall have a written policy concerning research activities which involve clients of the program, and shall abide by all local, state and federal laws and regulations concerning the conduct of research;

(L) That the agency maintain an organized record system on each client which contains a collection of client information and services provided, and that those records shall be stored in a manner so as to properly safeguard confidentiality yet be readily available to staff;

(M) That the agency shall require an initial clinical assessment based upon the presenting problem; shall further require a treatment plan based on the presenting problems and the initial assessment and shall enter a discharge summary in the record at the time of service termination;

(N) That the agency shall have written policies and procedures that will assist with client referral between the agency’s components or between the agency and other service providers and shall assure continuity of care between referring agencies;

(O) That the agency shall have written policies and procedures on how medications are prescribed, obtained, stored, how medication is to be dispensed or administered, or both, including medication clients bring to the program, and for recording client intake of medication which shall include client name, medication, dose of medication, date and frequency of intake and name of staff who observed the medication intake;

(P) That the agency shall have written policies and procedures defining client eligibility requirements, intake procedures and client assessment; or (Q) The center or affiliated public or notfor-profit corporation has been certified by the Division of Alcohol or Drug Abuse under the applicable program certification standards set out in 9 CSR 30-3.010, 9 CSR 30-3.020, 9 CSR 30-3.030, 9 CSR 30-3.040, 9 CSR 30-3.050, 9 CSR 30-3.060, 9 CSR 30-3.070, 9 CSR-30-3.080, 9 CSR 30-3.200, 9 CSR 30-3.210, 9 CSR 30-3.220, 9 CSR 30-3.230, 9 CSR 30-3.240, 9 CSR 30-3.250, 9 CSR 30-3.400, 9 CSR 30-3.410, 9 CSR 30-3.420, 9 CSR 30-3.500, 9 CSR 30-3.510, 9 CSR 30-3.600, 9 CSR 30-3.610, 9 CSR 30-3.810, 9 CSR 30-3.820, 9 CSR 30-3.830, 9 CSR 30-3.840, 9 CSR 30--3.850, 9 CSR 30- 3.851, 9 CSR 30-3.852, 9 CSR 30-3.853, 9 CSR 30-3.860, 9 CSR 30-3.870, 9 CSR 30- 3.880, 9 CSR 30-3.890, 9 CSR 30-3.900, 9 CSR 30-3.910, 9 CSR 30-3.920, 9 CSR 30- 3.930, 9 CSR 30-3.940, 9 CSR 30-3.950, 9 CSR 30-3.960 and 9 CSR 30-3.970.

(5) No community mental health center designated by the department or other public or not-for-profit corporation providing comprehensive mental health services through contract or affiliation agreement with a designated community mental health center shall provide any comprehensive mental health service unless the center or affiliated public or not-for-profit corporation has been certified by the department to provide these services under the applicable program certification standards set out in 9 CSR 30-3.010—9 CSR 30-3.630, 9 CSR 30-3.810—9 CSR 30- 3.970, or 9 CSR 30-4.030—9 CSR 30-4.047.

(6) Nothing in section (5) of this rule shall be taken to require that any designated community mental health center or affiliated public or not-for-profit corporation shall be prohibited from providing any comprehensive mental health service for which no certification standards exist.

JASONKANDER(6/30/14)

Original rule filed Dec. 10, 1981, effective April 11, 1982. Emergency rescission and

rule filed Feb. 14, 1992, effective Feb. 24, 1992, expired June 15, 1992. Rescinded and readopted: Filed Feb. 14, 1992, effective June 25, 1992. Amended: Filed July 17, 1995, effective March 30, 1996. Amended:

Filed Dec. 30, 2013, effective July 30, 2014. *Original authority 1969, amended 1978.

History

AUTHORITY: section 205.987, RSMo 2000. Emergency rule filed Nov. 12, 1981, effective Dec. 11, 1981, expired April 10, 1982.

9 CSR 30-2.020 Designation and Inspection Procedures {#sec-9-csr-30-2.020 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-2.020}

9 CSR 30-2.030 General Planning and Policy Requirements {#sec-9-csr-30-2.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-2.030}

9 CSR 30-2.040 Standards for Mandatory and Optional Services 4CODE OF STATE REGULATIONS (6/30/14) JASONKANDER {#sec-9-csr-30-2.040 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-2.040}

Chapter 3 Substance Use Disorder Treatment Programs

9 CSR 30-3.032 Certification of Substance Use Disorder Prevention and Treatment {#sec-9-csr-30-3.032 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.032}

9 CSR 30-3.060 Environment {#sec-9-csr-30-3.060 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.060}

(Rescinded October 30, 2001) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

9 CSR 30-3.100 General Requirements for Substance Use Disorder Treatment {#sec-9-csr-30-3.100 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.100}

9 CSR 30-3.110 Service Definitions, Staff Qualifications, and Documentation {#sec-9-csr-30-3.110 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.110}

9 CSR 30-3.151 Eligibility Determination, Assessment, and Treatment Planning in Comprehensive Substance Treatment and Rehabilitation {#sec-9-csr-30-3.151 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.151}

9 CSR 30-3.152 Comprehensive Substance Treatment and Rehabilitation (CSTAR) {#sec-9-csr-30-3.152 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.152}

Utilizing the American Society of Addiction Medicine (ASAM)

9 CSR 30-3.155 Staff Requirements for Comprehensive Substance Treatment and {#sec-9-csr-30-3.155 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.155}

9 CSR 30-3.157 Community Support in Comprehensive Substance Treatment and {#sec-9-csr-30-3.157 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.157}

9 CSR 30-3.190 Comprehensive Substance Treatment and Rehabilitation (CSTAR) {#sec-9-csr-30-3.190 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.190}

9 CSR 30-3.192 Comprehensive Substance Treatment and Rehabilitation (CSTAR) {#sec-9-csr-30-3.192 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.192}

9 CSR 30-3.230 Required Educational Assessment and Community Treatment {#sec-9-csr-30-3.230 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.230}

9 CSR 30-3.740 Environment {#sec-9-csr-30-3.740 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.740}

(Rescinded October 30, 2001) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66

9 CSR 30-3.800 Required Educational Assessment and Community Treatment {#sec-9-csr-30-3.800 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.800}

9 CSR 30-3.830 Comprehensive Substance Treatment and Rehabilitation Program {#sec-9-csr-30-3.830 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.830}

9 CSR 30-3.851 Specialized Program for Women and Children {#sec-9-csr-30-3.851 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.851}

9 CSR 30-3.890 Personnel, Staff Qualifications, Responsibilities and Training {#sec-9-csr-30-3.890 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.890}

9 CSR 30-3.920 Governing Authority and Program Administration {#sec-9-csr-30-3.920 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.920}

9 CSR 30-3.010 Definitions {#sec-9-csr-30-3.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.010}

Filed July 15, 1987, effective July 1, 1988. Amended: Filed Jan. 19, 1988, effective July 1, 1988. Emergency amendment filed Oct. 4, 1988, effective Oct. 14, 1988, expired Jan. 14, 1989. Amended: Filed Oct. 4, 1988, effective Jan. 14, 1989. Amended: Filed June 27, 1995, effective Dec. 30, 1995. Amended: Filed Oct. 13, 1995, effective April 30, 1996. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001.

History

AUTHORITY: sections 313.842, 630.050 and 630.655, RSMo 1994.

9 CSR 30-3.020 Procedures to Obtain Certification {#sec-9-csr-30-3.020 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.020}

Filed May 6, 1985, effective Sept. 1, 1985. Amended: Filed Jan. 19, 1988, effective July 1, 1988. Amended: Filed Aug. 14, 1995, effective Feb. 25, 1996. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001.

History

AUTHORITY: sections 630.050, 630.655 and 631.010, RSMo 1994.

9 CSR 30-3.022 Transition to Enhanced Standards of Care {#sec-9-csr-30-3.022 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.022}

(Rescinded July 30, 2018)

Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Rescinded:

Filed Jan. 12, 2018, effective July 30, 2018.

History

AUTHORITY: sections 630.050, 630.655 and 631.010, RSMo 2000.

9 CSR 30-3.030 Governing Authority Feb. 28, 2001, effective Oct. 30, 2001. {#sec-9-csr-30-3.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.030}

9 CSR 30-3.032 Certification of Substance Use Disorder Prevention and Treatment Programs {#sec-9-csr-30-3.032 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.032}

PURPOSE: This rule identifies the types of substance use disorder prevention and treatment programs and services eligible for certification from the department and the applicable requirements.

(1) Types of Programs and Services. Certification from the department is available for the following types of programs and services:

(A) Comprehensive Substance Treatment and Rehabilitation (CSTAR), including specialized programs for adolescents, women and children, adult general population, and opioid use disorders;

(B) Gambling disorder treatment;

(D) Opioid treatment;

(E) Outpatient treatment;

(F) Prevention;

(G) Recovery support;

(H) Required Educational Assessment and Community Treatment (REACT);

(I) Residential treatment;

(J) Substance Awareness Traffic Offender Program (SATOP);

(K) Withdrawal management.

(2) Applicable Program Regulations. The organization must comply with the regulations applicable to each program and/ or service for which certification is being sought.

(3) Other Regulations. In addition to the regulations for specific programs and services as specified in 9 CSR 30-3, the organization must comply with other applicable regulations as follows:

(A) 9 CSR 10-7.010 to 9 CSR 10-7.140, Core Rules for Psychiatric and Substance Use Disorder Treatment Programs;

(B) 9 CSR 10-5.190 Background Screening Requirements;

(D) 9 CSR 10-5.206 Report of Events; and (E) 9 CSR 10-5.220 Privacy Rule of Health Insurance Portability and Accountability Act of 1996 (HIPAA).

(4) Approval of Programs and Sites. The department must authorize and approve each proposed program/service and site prior to the delivery of services.

(A) Organizations requesting certification must comply with 9 CSR 10-7.130, Procedures to Obtain Certification, by submitting a fully completed application to the department.

(B) Notice of any change in program location, service array, or administration must be submitted to the department for approval prior to the change to ensure the program meets all applicable requirements, which may include an on-site review of the physical environment and safety practices.

(C) All opioid treatment programs shall meet the program and/or site approval requirements of this rule, as well as the requirements specified under 9 CSR 30-3.132.

History

AUTHORITY: sections 302.540, 630.050, 630.655, and 631.102, RSMo 2016. 45 CFR parts 160 and 164, the Health Insurance Portability and Accountability Act of 1996. Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed March 8, 2002, effective Sept. 30, 2002. Emergency amendment filed April 1, 2003, effective April 14, 2003, expired Oct. 14, 2003. Amended: Filed April 1, 2003, effective Oct. 30, 2003. Amended: Filed May 28, 2021, effective Dec. 30, 2021. Original authority: 302.540, RSMo 1983, amended 1984, 1993, 1996, 2001, 2002, 2003, 2014; 630.050, RSMo 1980, amended 1993, 1995, 2008; 630.655, RSMo 1980; and 631.102, RSMo 1997.

9 CSR 30-3.040 Client Rights {#sec-9-csr-30-3.040 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.040}

History

AUTHORITY: sections 630.050, 630.110–630.125, 630.200 and 630.655, RSMo 1986. Original rule filed May 13, 1983, effective Sept. 13, 1983. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001.

9 CSR 30-3.050 Planning and Evaluation Feb. 28, 2001, effective Oct. 30, 2001. {#sec-9-csr-30-3.050 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.050}

9 CSR 30-3.060 Environment {#sec-9-csr-30-3.060 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.060}

rule filed May 13, 1983, effective Sept. 13, 1983. Amended: Filed Dec. 13, 1983, effective April 12, 1984. Rescinded and readopted:

Filed June 2, 1988, effective Nov. 1, 1988. Rescinded: Feb. 28, 2001,

9 CSR 30-3.070 Fiscal Management {#sec-9-csr-30-3.070 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.070}

Original rule filed May 13, 1983, effective Sept. 13, 1983. Rescinded:

Filed Feb. 28, 2001, effective Oct. 30, 2001.

History

AUTHORITY: sections 630.050, 630.455 and 630.655, RSMo 1986.

9 CSR 30-3.080 Personnel {#sec-9-csr-30-3.080 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.080}

Filed July 15, 1987, effective July 1, 1988. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001.

History

AUTHORITY: sections 630.050, 630.200 and 630.655, RSMo 1986.

9 CSR 30-3.100 General Requirements for Substance Use Disorder Treatment Programs {#sec-9-csr-30-3.100 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.100}

PURPOSE: This rule describes general requirements applicable to all certified/deemed certified substance use disorder treatment programs as well as specific requirements that pertain to organizations that are funded by and/or have a contractual relationship with the department for the provision of services.

(1) Screening and Assessment. All individuals shall be screened and assessed as specified in 9 CSR 10-7.030 Service Delivery Process and Documentation, and in accordance with programspecific requirements included in these regulations.

(2) Diagnosis. Eligibility for services shall include a diagnosis of a substance use disorder by a licensed diagnostician in accordance with the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5), 2013, incorporated by reference and made a part of this rule as published by the American Psychiatric Association, 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209-3901. This rule does not incorporate any (A) The following mental health professionals are approved to render diagnoses in accordance with the DSM-5:

Physicians/Psychiatrists;
Psychologists (licensed or provisionally licensed);
Advanced Practice Registered Nurses;
Professional Counselors (licensed or provisionally licensed);
Marital and Family Therapists (licensed or provisionally licensed);
Licensed Clinical Social Workers;
Licensed Master Social Workers who are under registered supervision with the Missouri Division of Professional Registration for licensure as a Clinical Social Worker. LMSWs not under registered supervision for their LCSW credential cannot render a diagnosis.

(B) Signatures can be obtained by a face-to-face meeting with a licensed diagnostician or a face-to-face meeting with a master’s level Qualified Addiction Professional (QAP) or a Qualified Mental Health Professional (QMHP) followed by sign off by a licensed diagnostician. Signature stamps shall not be used.

(C) The diagnosis is not considered complete until the diagnostician’s signature is obtained. The licensed diagnostician is accountable for the stated diagnoses.

(D) A licensed supervisor must sign off on assessments and diagnoses completed by provisionally licensed providers.

(3) Treatment Plan. All individuals shall participate in the development of an individual treatment plan and regular plan reviews and updates as specified in 9 CSR 10-7.030 Service Delivery Process and Documentation, and in accordance with program-specific requirements included in these regulations.

(4) Services to Family Members. Family therapy and family conference shall be available to family members of persons participating in substance use disorder treatment.

(A) Family members shall be routinely informed of available services and the program shall demonstrate the ability to effectively engage family members in the recovery process.

(B) A separate record for a family member is not required if group rehabilitative support is the only service provided by a program that is funded by/contracted with the department.

Documentation of group rehabilitative support sessions and the participating family member(s) shall be maintained.

(5) Peer Support and Social Networks. Services shall be designed and organized to engage individuals and their family members/natural supports in peer support services, social networks, and resources in the community.

(6) Services to Women. An organization that lacks certification to provide women and children’s CSTAR services must meet the following requirements in order to provide services to women:

(A) Offer gender-specific groups which address therapeutic issues relevant to women;

(B) Have staff with experience and training in the delivery of services for women with substance use disorders, including cooccurring disorders and trauma-related services and supports;

(C) Women who are pregnant shall be referred to a women and children’s CSTAR program unless it is documented in the clinical record the program can meet the individual’s treatment needs, or the program cannot immediately make arrangements for admission to a women and children’s CSTAR 1. If temporary admission to the program is necessary, arrangements for transfer to a women and children’s CSTAR program shall be completed as soon as possible, with efforts documented in the clinical record; and (D) If the program is unable to refer a woman who is pregnant to a women and children’s CSTAR program or immediately assess and admit her to provide interim services, staff shall contact designated department staff to make arrangements for immediate admission to treatment with another provider.

(7) Services to Adolescents. An organization that lacks certification to provide adolescent CSTAR services must meet the following requirements in order to provide services to adolescents:

(A) Offer groups specifically for adolescents; and (B) Have staff with experience and training in the provision of services for adolescents with substance use disorders.

(8) Program Schedule. A current schedule of groups and other structured program activities shall be maintained.

(A) Each person shall actively participate in program activities, with individualized scheduling and services based on his/her treatment goals and needs and physical and behavioral health status.

(9) Priority Populations. Individuals who will be receiving department-funded/contracted services shall be appropriately screened at the point of first contact to determine if a crisis situation exists and whether they meet eligibility criteria as a priority population.

(A) The following populations shall receive priority assessment and admission to appropriate services:

Women who are pregnant and inject drugs;
Women who are pregnant;
Individuals who have injected drugs in the past thirty (30) days;
Civil involuntary commitments—ninety-six (96) hour commitments must be admitted to withdrawal management services, and thirty (30) day commitments must be admitted to withdrawal management services or residential treatment;
Individuals determined to be high risk who are referred by the Department of Corrections’ institutions and Division of Probation and Parole via the designated referral form and protocol;
Applicants for and recipients of Temporary Assistance for Needy Families (TANF) referred by the Department of Social Services, Family Support Division, via electronic referral and protocol;
Children/youth and families served through the Children’s System of Care; and 8. Other populations specified by the department.

A. Women who are pregnant and individuals who are involuntarily committed must receive immediate admission.

B. High-risk referrals from correctional institutions and probation and parole shall be assessed and admitted to appropriate services within five (5) business days of initial contact or scheduled release date.

C. Other priority populations shall be assessed and admitted to appropriate services within seventy-two (72) hours of initial contact.

(10) Referrals and Interim Services. If an individual who will be receiving department-funded/contracted services has been determined to have injected drugs within the past thirty (30) days, and he/she cannot be assessed and admitted to the program within forty-eight (48) hours of receiving such a request, staff shall— (A) Refer the individual to an alternative substance use disorder treatment program that has sufficient capacity to admit him/her within forty-eight (48) hours; or (B) Provide interim substance use services within forty-eight (48) hours of the initial request and admit him/her to treatment within one hundred twenty (120) days of the initial request.

(C) Interim services shall be provided until the individual is enrolled in an episode of care. Interim services are intended to maintain engagement and help the individual recognize the harmful consequences of substance use, reduce the adverse health effects of substance use, and reduce the likelihood of detrimental or unlawful behavior.

An assessment is not required for individuals receiving interim services.
Interim services may be delivered on an individual or group basis.
Documentation must be included in the individual record for those who miss a scheduled session or refuse interim services, including efforts to reengage.
Interim services must include, but are not limited to:

A. Counseling and education about HIV, tuberculosis (TB), and hepatitis;

B. Counseling and education about the risks of sharing needles;

C. Counseling and education about the risks of transmission of infectious diseases to sexual partners and infants and measures to ensure such transmission does not occur;

D. Referral for HIV, TB, or hepatitis treatment services, if necessary;

E. Group rehabilitative support focusing on reducing the adverse health effects of substance use or other aspects of treatment and recovery; and F. Referral to recovery support programs or self-help (mutual support) groups that offer social, emotional, and informational support for individuals seeking treatment and educational materials that will increase understanding about addiction and recovery, including other local resources available.

Interim services may include services such as motivational interviewing to establish a therapeutic partnership and support engagement in treatment when the program has the capacity to admit the individual into an appropriate episode of care.

(11) Waiting Lists. The department may require organizations that receive federal block grant funds to maintain a waiting list for specific populations to meet block grant reporting requirements. When a waiting list is required, the organization shall— (A) Document the individual’s date of placement on the list, including identified needs;

(B) Implement a process for maintaining contact with individuals who meet criteria as a priority population and are awaiting admission to treatment;

(D) Identify procedures for referring individuals who are in crisis or are a priority population to necessary care or interim (E) Document all contacts with individuals on the waiting list; and (F) Respond to long-term waiting lists through strategic or community-based planning, involvement of support services, and referral to available services/supports.

(12) Discharge. Each individual’s length of engagement in services shall be based on his/her needs and progress in achieving treatment goals.

(A) Criteria to consider in determining successful completion and discharge from treatment includes, but is not limited to, the individual’s ability to— 1. Recognize and understand his/her substance use disorder and its resulting impact on family members/natural supports, impairments on health and social functioning, and other societal consequences;

Demonstrate absence of an immediate or a recurring crisis that poses a substantial risk for a return to use of substances;
Stabilize emotional problems, when applicable, such as not experiencing serious psychiatric symptoms and taking medication as prescribed;
Demonstrate independent living skills;
Implement a plan to prevent return to use of substances;
Develop family and/or social networks which support recovery/resiliency and a continuing recovery plan.

(B) Discharges prior to an individual accomplishing his/her treatment goals shall be documented in the individual record, including the rationale for discharge.

Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. ** Rescinded and readopted: Filed May 28, 2021, effective Dec. 30, 2021. **Pursuant to Executive Order 21-07, 9 CSR 30-3.100, paragraph (6)(A)2. was suspended from April 23, 2020 through August 31, 2021.

9 CSR 30-3.110 Service Definitions, Staff Qualifications, and Documentation Requirements for Substance Use Disorder {#sec-9-csr-30-3.110 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.110}

PURPOSE: This rule defines and describes services, staff qualifications, and documentation requirements for certified/ deemed certified substance use disorder treatment programs.

(1) Service Definitions and Staff Qualifications. Services shall be provided as defined in this rule, in accordance with the organization’s certification and contractual status with the (A) Case management—links the individual and family members with needed services and supports. Key service functions include, but are not limited to:

Arranging for or referring individuals/family members to appropriate services/supports and resources;
Communicating with referral sources and coordinating services with other entities including, but not limited to, physical and behavioral healthcare providers, the criminal justice system, and social service agencies; and 3. Assisting individuals in resolving a crisis situation.
Services shall be provided by— A. A qualified addiction professional (QAP);

B. An associate addiction counselor (AAC); or C. A staff person with a bachelor’s degree in social work, psychology, nursing, or a closely related field from an accredited college or university. Equivalent experience may be substituted on the basis of one (1) year for each year of required educational training.

(B) Collateral dependent counseling (individual and group)— face-to-face, goal-oriented therapeutic interaction with an individual, or a group of individuals, to address dysfunctional behaviors and life patterns associated with being a family member of an individual who has a substance use disorder and is currently participating in treatment. Group sessions shall not exceed twelve (12) family members, which may involve multiple individuals engaged in treatment.

This service shall only be provided to family members of the individual in treatment when the services are for the direct benefit of the individual in accordance with his/her needs and goals identified in the treatment plan, and for assisting in the individual’s recovery.
The individual being served in treatment shall not participate in collateral dependent counseling sessions.
Key service functions include, but are not limited to:

A. Exploration of substance use disorders and its impact on the family member’s functioning;

B. Development of coping skills and personal responsibility for changing one’s own dysfunctional patterns in relationships;

C. Examination of attitudes, feelings, and long-term consequences of living with a person with a substance use disorder;

D. Identification and consideration of alternatives and structured problem-solving;

E. Productive and functional decision-making; and F. Development of motivation and action by group members through peer support, structured confrontation, and constructive feedback.

Counseling for family members age five (5) and younger shall only be provided when the child is shown to have the requisite social and verbal skills to participate in and benefit from the service.
This service shall be provided by a Marital and Family Therapist or QAP practicing within his/her current competence.
Group services for children under age twelve (12) shall be provided by a graduate of an accredited college or university with a bachelor’s degree in counseling, psychology, social work, or closely related field.

(C) Communicable disease counseling—assists individuals in understanding how to reduce the behaviors that interfere with their ability to lead healthy, safe lives and help them achieve optimal functioning and desired personal potential.

Topics may include, but are not limited to, disclosing human immunodeficiency virus (HIV), sexually transmitted infections (STI), tuberculosis (TB) status, and/or substance use to family members/natural supports, addressing stigma in accessing services, maximizing healthcare service interactions, reducing substance use and avoiding overdose, and addressing anxiety, anger, and depressive episodes.

The program shall have a working relationship with the local health department, a physician, or other qualified healthcare practitioner to provide individuals with necessary testing for HIV, TB, STIs, and hepatitis.
Prior to an individual being tested for HIV, counseling shall be provided by a staff person who is knowledgeable about communicable diseases including HIV, STIs, and TB through training and/or previous employment experience.
The program shall make referrals and cooperate with appropriate entities to ensure coordinated treatment is provided for individuals with positive test results.
Post-test counseling may be provided for individuals who test positive for HIV or TB. Program staff providing post-test counseling must be knowledgeable about additional services and care coordination available through the Department of Health and Senior Services.
Program staff shall arrange and coordinate post-test follow-up for individuals who test positive for a STI or hepatitis.
This service shall be provided by a licensed mental health professional, QAP, or AAC who is knowledgeable about communicable diseases including HIV, STIs, and TB through training and/or previous employment experience. Knowledge shall include, but is not limited to, awareness of risks, disease management/treatment and resources for care, confidentiality requirements, and therapeutically assisting individuals in understanding and appropriately responding to test results.

(D) Community support—as specified in 9 CSR 30-3.157;

(E) Crisis prevention and intervention—face-to-face emergency or telephone intervention available twenty-four (24) hours per day, on an unscheduled basis, to assist individuals in resolving a crisis and providing support and assistance to promote a return to routine, adaptive functioning.

Minimum service functions shall include, but are not A. Interacting with the identified individual and his or her family members/natural supports, legal guardian, or a combination of these;

B. Specifying factors that led to the individual’s crisis state, when known;

C. Identifying maladaptive reactions exhibited by the individual;

D. Evaluating potential for rapid regression;

E. Attempting to resolve the crisis; and F. Referring the individual for treatment in an alternative setting when indicated.

Documentation must include— A. A description of the precipitating event(s)/situation when known;

B. A description of the individual’s mental status;

C. The intervention(s) initiated to resolve the individual’s crisis state;

D. The individual’s response to the intervention(s);

E. The individual’s disposition; and F. Planned follow-up by staff.

Services must be provided by a qualified mental health professional (QMHP) or QAP. Non-licensed or non-credentialed staff providing this service must have immediate, twenty-four (24) hour telephone access to consultation with a licensed physician/psychiatrist, licensed physician assistant, licensed assistant physician, or advanced practice registered nurse (APRN).

(F) Day treatment—combines group rehabilitative support with medically necessary services that are structured and therapeutic and focus on providing opportunities for individuals to apply and practice healthy skills, decisionmaking, and appropriate expression of thoughts and feelings.

Day treatment shall be provided in a group setting.
Services shall be designed to assist individuals with compensating for or eliminating functional deficits and interpersonal and/or environmental barriers associated with a substance use disorder. Services are intended to restore individuals to being active and productive members of their family, community, and/or culture to the fullest extent possible.
Key service functions include, but are not limited to:

A. Promoting an understanding of the relevance of the nature, course, and treatment of substance use disorders to assist individuals in understanding their individual recovery needs and how they can restore functionality;

B. Assisting in the development and implementation of lifestyle changes needed to cope with the side effects of addiction, use of prescribed psychotropic medications, and/ or promote recovery from the disabilities, negative symptoms, and/or functional delays associated with a substance use disorder; and C. Assisting with the restoration of skills and use of resources to address symptoms that interfere with activities of daily living and community integration.

Services shall be provided by a team consisting of Group Rehabilitation Support Specialists and Day Treatment Technicians.

(G) Drug testing—conducted to determine and detect an individual’s use of alcohol or other drugs and/or monitor compliance with a prescribed medication regimen as a necessary support and adjunct to treatment.

Drug testing may be of greater importance for individuals— A. With known or suspected diversion of medication for substance use disorders;

B. Who present in person to the program with symptoms and signs of intoxication or withdrawal;

C. With a self-reported or otherwise identified overdose;

D. With significantly unstable opioid and/or other substance use disorders.

Test results shall be discussed with persons served in order to intervene with substance use behavior, including updates to the treatment plan based on test results.
Test results and actions taken shall be documented in the individual record, including the category or type of test (on-site or laboratory), the number of panels, types of drugs tested for, and the test results.
Drug testing may be performed on-site or sent to a laboratory. A laboratory which analyzes specimens must meet all applicable state and federal laws and regulations.
Written policies and procedures regarding the collection and handling of specimens shall be implemented.

Urine or other specimens shall be collected in a manner that communicates respect for persons served, while taking reasonable steps to prevent falsification of samples.

The program shall implement written policies and procedures outlining the interpretation of results and actions to be taken when the presence of alcohol or other drugs has been determined.

(H) Family conference—intervention that enlists the assistance of the individual’s support system through meeting with family members, referral sources, and other natural supports about the individual’s treatment plan, continuing recovery plan, and discharge plan. The service must include the individual served and be for his/her direct benefit in accordance with needs and goals identified in the treatment plan and to assist in his/her recovery.

Key service functions include, but are not limited to:

A. Communicating about issues in the individual’s home that are barriers to achieving his/her treatment goals;

B. Identifying relapse triggers and establishing a continuing recovery plan;

C. Assessing the need for family therapy or other referrals to support the family system; and D. Participating in continuing recovery and discharge planning conferences.

Services shall be provided by a QAP or AAC.
Documentation must indicate the relationship of the family members and/or other participants to the individual in (I) Family therapy—face-to-face counseling or family-based therapeutic interventions (such as role playing or educational discussions) for the individual served and/or one (1) or more of his/her family members/natural supports. Services must be for the direct benefit of the individual served in accordance with his/her treatment needs and goals and to assist in their recovery.
Services shall address and resolve patterns of dysfunctional communication and interactions that have become persistent over time, particularly as they relate to alcohol and/or other drug use.
Services may be offered to members of a single family or members of multiple families dealing with similar issues.
Services may be provided in an office setting or the individual’s home, depending on those involved.
Key service functions include, but are not limited to:

A. Utilizing generally accepted principles of family therapy to influence family interaction patterns;

B. Examining family interaction styles, confronting patterns of dysfunctional behavior, and strengthening communication patterns that promote healthy family function;

C. Facilitating family participation in family self-help recovery groups;

D. Developing and applying skills and strategies for improving family functioning; and E. Promoting healthy family interactions independent of formal helping systems.

Documentation must indicate the relationship of the family members/natural supports to the individual engaged in treatment.
In any calendar month, for fifty percent (50%) of family therapy sessions, the individual engaged in treatment must be present, in addition to one (1) or more of his/her family members/natural supports. Family members younger than age twelve (12) can be counted as one (1) of the required family members when the child is shown to have the requisite social and verbal skills to participate in and benefit from the service.
Services shall be provided by a professional who— A. Is licensed or provisionally licensed in Missouri as a marital and family therapist; or B. Has a degree in marriage and family therapy, psychology, social work, or counseling and— (I) Has at least one (1) year of supervised experience in family therapy and has specialized training in family therapy;

(II) Receives close supervision from a professional who meets the requirements of subparagraph (1)(I)7.A. and B. of this

rule; or C. A QAP who receives close supervision from an individual who meets the requirements of subparagraphs (1)

(I)7.A. and B. of this rule.

(J) Group counseling—face-to-face, goal-oriented therapeutic interaction between a counselor and two (2) or more individuals based on needs and goals specified in their treatment plans.

Services shall be designed to promote individual functioning and recovery through personal disclosure and interpersonal interaction among group members.

This service can include trauma-related symptoms and co-occurring behavioral health and substance use disorders.
Evidence-based practices, such as motivational interviewing and cognitive behavioral therapy, shall be utilized by appropriately trained staff.
Some scheduled group sessions may not be applicable to or appropriate for all individuals, therefore, participation shall be on a designated or selective basis. Examples of designated or selective groups include, but are not limited to, parenting skills, budgeting, anger management, domestic violence, cooccurring disorders, life skills, and trauma.
Key service functions include, but are not limited to:

A. Facilitating individual disclosure of addiction-related issues which permits generalization of the issues to the larger group;

B. Promoting recognition of addictive thinking and behaviors and teaching strategies that support non-use of alcohol and/or other drugs that interfere with the individual’s functioning;

C. Preparing individuals to cope with physical, cognitive, and emotional symptoms of craving alcohol and/or other drugs;

D. Encouraging and modeling productive and positive interpersonal communication; and E. Developing motivation and action by group members through peer influence, structured confrontation, and constructive feedback.

Services shall be provided by a QAP, QMHP, AAC, or an intern/practicum student as specified in 9 CSR 10-7.110(5).
The usual and customary group size is twelve (12) individuals. The size of group counseling sessions shall not exceed an average of twelve (12) individuals during a calendar month, per facilitator, per group.
A group log or documentation in the individual record (paper or electronic format) shall be maintained for each session documenting the type of service, summary of the service, date, actual beginning and ending time of the group, each individual’s in and out time, and the signature and title of the staff member providing the service. Signature stamps shall not be used.

(K) Group rehabilitative support—facilitated group discussions based on individual needs and treatment plan goals to promote an understanding of the relevance of the nature, course, and treatment of substance use disorders to assist individuals in understanding their recovery needs and how they can restore functionality.

Key service functions include, but are not limited to:

A. Classroom style didactic lecture to present information about a topic and its relationship to substance use;

B. Presentation of audio-visual materials that are educational in nature with required follow-up discussion.

Instructional aids shall be incorporated into education sessions to enhance understanding and promote discussion and interaction among individuals. Aids may include, but are not limited to, DVDs or other electronic media, worksheets, and informational handouts and shall not comprise more than twenty percent (20%) of group rehabilitative support sessions;

C. Promotion of discussion and questions about the topic presented to the individuals in attendance; and D. Generalization of the information and demonstration of its relevance to recovery and enhanced functioning.

The program shall develop a schedule and curriculum for delivery of group rehabilitative support that addresses topics and issues relevant to the individuals served. Individuals shall attend group sessions that are relevant to their needs and goals based on the assessment and interventions recommended in their individual treatment plan.
Services shall be provided by a group rehabilitation support specialist who is present throughout the session and— A. Is suited by education, background, or experience to present the information being discussed;

B. Demonstrates competency and skill in facilitating group discussions; and C. Has knowledge of the topic(s) being taught.

Group size shall not exceed an average of thirty (30) individuals during a calendar month, per facilitator, per group session.
A group log or documentation in the individual record (paper or electronic format) shall be maintained for each session documenting the type of service, summary of the service, date, actual beginning and ending time of the group, each individual’s in and out time, and the signature and title of the staff member providing the service. Signature stamps shall not be used.

(L) Individual counseling—face-to-face, structured, and goaloriented therapeutic counseling designed to resolve issues related to the use of alcohol and/or other drugs that interfere with the individual’s functioning.

Evidence-based interventions including, but not limited to, motivational interviewing, cognitive behavioral therapy, and trauma-informed care shall be utilized, when appropriate.
Key service functions shall include, but are not limited to:

A. Exploration of an identified problem and its impact on the individual’s functioning;

B. Examination of attitudes, feelings, and behaviors that promote recovery and improved functioning;

C. Identification and consideration of alternatives and structured problem-solving;

D. Discussion of skills to aid in making positive decisions;

E. Application of information presented in the program to the individual’s life situation to promote recovery and improved functioning.

Services shall be provided by a QAP, QMHP, AAC, or an intern/practicum student as specified in 9 CSR 10-7.110(5).

(M) Individual counseling, co-occurring disorders— individual, face-to-face, structured and goal-oriented therapeutic interaction between an individual and a counselor designed to identify and resolve issues related to substance use and co-occurring mental illness functioning.

This service must be provided by— A. A licensed or provisionally licensed qualified mental health professional (QMHP);

B. An individual holding the Co-Occurring Disorders Professional or Co-Occurring Disorders Professional/Diplomate credential from the Missouri Credentialing Board;

C. A non-licensed QMHP who meets the co-occurring counselor competency requirements established by the department; or D. A QAP who meets the co-occurring counselor competency requirements established by the department.

(N) Individual counseling, trauma—individual, face-to-face counseling provided to the individual in accordance with his/ her treatment plan to resolve issues related to psychological trauma in the context of a substance use disorder. Personal safety and empowerment of the individual must be addressed.

This service must be provided by a— A. Licensed or provisionally licensed mental health professional; or B. Professional licensed by the Missouri Division of Professional Registration who is practicing within their current competence.
Qualified staff must have specialized training on trauma and trauma-informed care and/or equivalent work experience and shall utilize an evidence-based treatment model for the delivery of this service.

(O) Medication services—goal-oriented interaction to assess the appropriateness of medications in an individual’s treatment, periodic evaluation/reevaluation of the efficacy of prescribed medications, and ongoing management of a medication regimen within the context of the individual’s 1. Key service functions include, but are not limited to:

A. Assessment of the individual’s presenting condition;

B. Mental status exam;

C. Review of symptoms and screening for medication side effects;

D. Review of functioning;

E. Assessment of the individual’s ability to self-administer medications;

F. Education regarding the effects of medication and its relationship to the individual’s substance use disorder and/or mental illness; and G. Prescription of medication(s), when indicated.

Services shall be provided by a licensed physician, or licensed psychiatrist, or licensed physician assistant, licensed assistant physician, or APRN who is in a collaborating practice agreement with a licensed physician.

(P) Medication services support—medical and other consultative services for the purpose of monitoring and managing an individual’s health needs while taking medications.

Services must be provided by a registered nurse (RN) or licensed practical nurse (LPN).

(Q) Peer and family support—coordinated services within the context of a comprehensive, individualized treatment plan that includes specific individualized goals. Services are person-centered and promote the individual’s ownership of his/her treatment plan.

Services may be provided to the individual’s family/ natural supports when the services are for the direct benefit of the individual served in accordance with his/her needs and goals identified in the treatment plan and to assist in the individual’s recovery.
Key service functions include, but are not limited to:

A. Planning in a person-centered manner to promote the development of self-advocacy skills;

B. Empowering the individual to take a proactive role in developing, updating, and implementing his/her personcentered treatment plan;

C. Providing crisis support;

D. Assisting the individual and his/her family and other natural supports in the use of positive self-management techniques, problem-solving skills, coping mechanisms, symptom management, and communication strategies identified in the treatment plan, so the individual remains in the least restrictive setting, achieves recovery and resiliency goals, self-advocates for quality physical and behavioral health services, and has access to strength-based behavioral health and physical health services in the community;

E. Assisting individuals and their family members/ natural supports in identifying strengths and personal/family resources to aid recovery, promote resilience, and recognize their capacity for recovery/resilience;

F. Serving as an advocate, mentor, or facilitator for resolution of issues and skills necessary to enhance and improve the health of a child/youth with a substance use and/ or co-occurring disorder; and G. Providing information and support to the parent(s)/ caregiver(s) of a child who has a serious emotional disorder so they have a better understanding of the child’s needs, the importance of his/her voice in the development and implementation of the individual treatment plan, the roles of the various service/support providers and the importance of the team approach, and assisting in the exploration of options to be considered as part of treatment.

Services shall be provided by a certified peer specialist or family support provider.

(R) Withdrawal management/detoxification, as defined in 9 CSR 30-3.120.

(2) Ratio of Qualified Addiction Professionals. A majority of the program’s staff who provide individual and group counseling shall be Qualified Addiction Professionals (QAP).

(3) Supervision of Associate Counselors. If an AAC provides individual or group counseling, he/she shall meet the requirements of the Missouri Credentialing Board or the appropriate board of professional registration within the Department of Commerce and Insurance. All counselor functions performed by an AAC shall be performed pursuant to the supervisor’s authority, oversight, guidance, and full professional responsibility.

(A) The supervisor shall review and countersign documentation in individual records made by the AAC.

(B) Documentation which must be countersigned includes the initial treatment plan, treatment plan updates, and discharge summaries.

(C) A training plan must be in place for each AAC and be available for review by department staff or other authorized representatives.

(4) Credentials for Supervisor of Counselors. Unless otherwise required by these rules, supervision of counselors must be provided by a QAP who has— (A) A degree from an accredited college in an approved field of study; or (B) Four (4) or more years of employment experience in the treatment and rehabilitation of persons with substance use disorders.

Filed Sept. 25, 2002, effective May 30, 2003. Rescinded and readopted: Filed May 28, 2021, effective Dec. 30, 2021.

9 CSR 30-3.120 Detoxification {#sec-9-csr-30-3.120 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.120}

PURPOSE: This rule describes the goals, eligibility and discharge criteria, levels of care, and performance indicators for detoxification programs.

(1) Goals. Detoxification is the process of withdrawing a person from alcohol, other drugs or both in a safe, humane, and effective manner. The goals of detoxification services are to help persons become— (A) Alcohol and drug-free in a safe manner without suffering severe physical consequences of withdrawal. Medical services shall be provided or arranged, when clinically indicated; and (B) Involved in continuing treatment. Each person shall be oriented to treatment resources and recovery concepts and shall be assisted in making arrangements for continuing (2) Screening. Upon initial contact, a person shall be screened by a trained staff member and assigned to a level of care based on the signs and symptoms of intoxication, impairment or withdrawal, as well as factors related to health and safety.

(A) A screening protocol approved by a physician shall be used to evaluate the person’s physical and mental condition and to guide the level of care decision. The department may require, at its option, the use of a standardized screening protocol for those services funded by the department or provided through a service network authorized by the department.

(B) The assigned level of care shall have the ability to effectively address the person’s physical and mental condition.

(3) Eligibility Criteria. In order to be eligible for detoxification services, a person must present symptoms of intoxication, impairment or withdrawal and also must require supervision and monitoring of their physical and mental status to ensure safety. A person qualifies for detoxification services on a residential basis if one or more of the following additional criteria are met:

(A) Demonstrates a current inability to minimally care for oneself;

(B) Lacks a supportive, safe place to go and demonstrates a likelihood of continued use of alcohol or other drugs if free to do so;

(C) Requires ongoing observation and monitoring of vital signs due to a prior history of physical complications associated with withdrawal or the severity of current symptoms of intoxication, impairment or withdrawal; or (D) Presents a likelihood of harm to self or others as a result of intoxication, impairment or withdrawal.

(4) Certified Levels of Care. A person shall be assigned to one (1) of the following levels of detoxification service in accordance with the screening protocol and admission criteria. An agency may offer and be certified for one (1) or more of the following levels of detoxification service:

(A) Social Setting Detoxification. This level of care is offered by trained staff in a residential setting with services and admission available twenty-four (24) hours per day, seven (7) days per week.

Medical personnel are not available on-site to prescribe, dispense or administer medications or to diagnosis and treat health problems.
A person, who is admitted to social setting detoxification with medication for an established physical or mental health condition, may continue to self-administer his or her medication;

(B) Modified Medical Detoxification. This level of care is offered by medical staff in a non-hospital setting with services and admission available twenty-four (24) hours per day, seven (7) days per week.

Routine medical services are provided, and medications are used, when clinically indicated, to alleviate symptoms of intoxication, impairment or withdrawal.
A registered or licensed nurse is on duty at all times.

Licensed nursing staff receive clinical supervision by a registered nurse.

There is on call at all times a physician or an advanced practice nurse licensed and authorized to title and practice as an advanced practice nurse pursuant to section 335.016, RSMo and who is engaged in a written collaborative practice arrangement as defined by law.

(C) Medical Detoxification. This level of care is offered by medical staff in a licensed hospital with services and admission available twenty-four (24) hours per day, seven (7) days per week. Emergency and non-emergency medical services are provided, and medications are used, when clinically indicated, to alleviate symptoms of impairment or withdrawal.

(5) Safety and Supervision. All detoxification services shall be provided in a humane manner and shall ensure the safety and well-being of persons served.

(A) There shall be monitoring and assessment of the person’s physical and emotional status during the detoxification process.

Vital signs shall be taken on a regular basis, with the frequency determined by client need based on a standardized assessment instrument.
Blood alcohol concentration may be monitored upon admission and thereafter as indicated. Further testing of urine or blood may be conducted by qualified personnel.

(B) Staff coverage in residential settings shall ensure the continuous supervision and safety of clients.

Two (2) staff members shall be on-site at all times, and additional staff may be required, as warranted by the size of the program and the responsibilities and duties of staff members.
Staff providing direct supervision and monitoring of clients shall demonstrate competency in recognizing symptoms of intoxication, impairment and withdrawal; monitoring vital signs; and understanding basic principles and resources for substance abuse treatment.
Clients shall be supervised at all times by a staff member with current certification in first aid and cardiopulmonary resuscitation.

(6) Continuing Treatment. Detoxification services shall actively encourage each person to address substance abuse issues and to make arrangements for continuing treatment. There shall be documentation of services delivered and arrangements for continuing treatment. A comprehensive assessment and master treatment plan are not required during detoxification.

(A) Information and education shall be given to each person regarding substance abuse issues.

(B) Individual and group sessions shall be provided, and each person shall be expected to participate in these sessions, to the extent warranted by their physical and mental status.

Staff shall assist in making referrals and other arrangements, as needed.
Any client refusal of treatment services or referrals shall be documented.

(D) A qualified substance abuse professional shall be available and involved in providing individual and group sessions and making arrangements for continuing treatment.

(7) Discharge Criteria. A person shall be successfully discharged or transferred from the detoxification service when they are physically and mentally able to function without the supervision, monitoring and support of this service.

(8) The program handles applications for civil detention of intoxicated persons in accordance with sections 631.115, 631.120 and 631.125, RSMo 2000 unless a waiver is granted in writing by the department.

Filed Oct. 15, 2001, effective April 30, 2002. Amended: Filed April 15, 2002, effective Nov. 30, 2002.

9 CSR 30-3.130 Outpatient Treatment {#sec-9-csr-30-3.130 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.130}

PURPOSE: This rule describes the levels of outpatient care that may be certified and the goals, eligibility criteria, and available services. Discharge criteria and performance indicators for outpatient programs are also identified.

(1) Available Services. An array of services shall be available on an outpatient basis to persons with substance abuse problems and their family members. The program shall provide all services and comply with the functions required under 9 CSR 30-3.110.

(2) Certified Levels of Care. Outpatient services shall be organized and certified according to levels of care. Each of the levels of care shall vary in the intensity and duration of services offered.

(A) The levels of care may include— 1. Community-based primary treatment. This level of care is the most structured, intensive, and short-term service delivery option with services offered on a frequent, almost daily basis;

Intensive outpatient rehabilitation. This level of care provides intermediate structure, intensity and duration of treatment and rehabilitation, with services offered on multiple occasions per week;
Supported recovery. This level of care provides treatment and rehabilitation on a regularly scheduled basis, with services offered on approximately a weekly basis unless other scheduling is clinically indicated.

(B) All outpatient services and levels of care offered by an organization shall be certified in accordance with this rule.

An organization shall be certified as providing one of the following methods of outpatient service delivery:

Supported recovery;
Intensive outpatient rehabilitation and supported recovery; or 3. Community-based primary treatment, intensive outpatient rehabilitation and supported recovery.

(C) Outpatient services shall be provided in a coordinated manner responsive to each person’s needs, progress and outcomes.

The organization shall ensure that individuals can access an appropriate level of care.

A. If all three (3) outpatient levels of care are not offered, the organization shall demonstrate that it effectively helps persons to access other levels of care that may be available in the local geographic area, as needed.

B. The organization must demonstrate that it effectively helps persons to access detoxification and residential treatment services, as needed.

An organization with multiple service sites shall not be required to offer its certified levels of care at every site, if it can demonstrate that an individual has reasonable access to its levels of care through coordinated service delivery.
A light meal shall be served at a site to those individuals who receive services for a period of more than four (4) consecutive hours. Additional meals shall be provided, if warranted by the program’s hours of operation.

(3) Individualized Treatment Options. The levels of care shall be used in a manner that provides individualized treatment options and offers service intensity in accordance with the needs, progress and outcomes of each person served.

(A) A person may enter treatment at any level of care in accordance with eligibility criteria.

(B) A person can move from one level of care to another over time in accordance with symptoms, progress, outcomes and other clinical factors.

The duration of each level of care shall be time-limited and tailored to the individual’s needs.
A person may be transferred to a more intensive level of care if there is a continuing inability to make progress toward treatment and rehabilitation goals.

(4) Community-Based Primary Treatment. This level of care is the most structured, intensive, and short-term service delivery option. Structured services shall be offered at least five (5) days per week and should approximate the service intensity of residential treatment.

(A) Eligibility for primary treatment shall be based on— 1. Evidence that the person cannot achieve abstinence without close monitoring and structured support; and 2. Need for frequent, almost daily services and supervision.

(B) Expected outcomes for primary treatment are to— 1. Interrupt a significant pattern of substance abuse;

Achieve a period of abstinence;
Enhance motivation for recovery; and 4. Stabilize emotional and behavioral functioning.

Each person shall participate in at least twenty-five (25) hours of service per week, unless contraindicated by the individual’s medical, emotional, legal, and/or family circumstances, and unless residential support is provided.
Where residential support is provided, each person shall be offered additional structured therapeutic activities in accordance with residential treatment standards.
Each person shall participate in at least one (1) hour per week of individual counseling. Additional individual counseling shall be provided, in accordance with the individual’s needs.
For community-based primary treatment that is funded by the department or provided through a service network authorized by the department, day treatment may be specified as the applicable service for this level of care.

(5) Intensive Outpatient Rehabilitation. This level of care offers an intermediate intensity and duration of treatment. Services should be offered on multiple occasions during each week.

(A) Eligibility for intensive outpatient rehabilitation shall be 1. Ability to limit substance use and remain abstinent without close monitoring and structured support;

Absence of crisis that cannot be resolved by community support services;
Evidence of willingness to participate in the program, keep appointments, participate in self-help, etc.; and 4. Willingness, as clinically appropriate, to involve significant others in the treatment process, such as family, employer, probation officer, etc.

(B) Expected outcomes for intensive outpatient rehabilitation are to— 1. Establish and/or maintain sobriety;

Improve emotional and behavioral functioning; and 3. Develop recovery supports in the family and community.

(C) The program shall offer at least ten (10) hours of service 1. Each person shall be expected to participate in at least ten (10) hours of service per week, unless contraindicated by the individual’s medical, emotional, legal, and/or family circumstances.

Each person shall participate in at least one (1) hour per week of individual counseling.

(6) Supported Recovery. This level of care offers treatment on a regularly scheduled basis, while allowing for a temporary increase in services to address a crisis, relapse, or imminent risk of relapse. Services should be offered on approximately a weekly basis, unless other scheduling is clinically indicated.

(A) Eligibility for supported recovery shall be based on— 1. Lack of need for structured or intensive treatment;

Presence of adequate resources to support oneself in the community;
Absence of crisis that cannot be resolved by community support services;
Willingness to participate in the program, keep appointments, participate in self-help, etc.;
Evidence of a desire to maintain a drug-free lifestyle;
Involvement in the community, such as family, church, employer, etc.; and 7. Presence of recovery supports in the family and/or community.

(B) Expected outcomes for supported recovery are to— 1. Maintain sobriety and minimize the risk of relapse;

Improve family and social relationships;
Promote vocational/educational functioning; and 4. Further develop recovery supports in the community.

(C) The program shall offer at least three (3) hours of service per week. Each person shall be expected to participate in any combination of services determined to be clinically necessary.

(7) Continued Services. The treatment episode or level of care shall be reviewed for the appropriateness of continued services if the person presents repeated relapse incidents, a pattern of noncompliance or poor attendance, threats or aggression toward staff or other clients, or failure to comply with basic program rules.

(8) Discharge Criteria. Each person’s length of stay in outpatient services shall be individualized, based on the person’s needs and progress in achieving treatment goals.

(A) An individual should be considered for successful completion and discharge from outpatient services upon— 1. Recognizing and understanding his/her substance abuse problem and its impacts;

Achieving a continuous period of sobriety;
Absence of immediate or recurring crisis that poses a substantial risk of relapse;
Stabilizing emotional problems, when applicable (for example, not experiencing serious psychiatric symptoms, taking psychotropic medication as prescribed, etc.);
Demonstrating independent living skills;
Implementing a relapse prevention plan; and 7. Developing family and/or social networks which support recovery and a continuing recovery plan.

(B) A person may be discharged from outpatient services before accomplishing these goals if— 1. Commitment to continuing services is not demonstrated by the client; or 2. No further progress is imminent or likely to occur.

Filed Oct. 15, 2001, effective April 30, 2002. Amended: Filed July 29, 2002, effective March 30, 2003.

9 CSR 30-3.132 Opioid Treatment Programs {#sec-9-csr-30-3.132 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.132}

PURPOSE: This rule describes the specific functions, policies, and practices required for certified opioid treatment programs.

(1) Certification Requirements. To be certified as an opioid treatment program (OTP) by the department, the program must comply with the following prior to delivering services:

(A) The program shall comply with applicable federal, state, and local laws and regulations, including those under the jurisdiction of the U.S. Drug Enforcement Administration (DEA);

Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (HHS/SAMHSA); and the Department of Health and Senior Services, Bureau of Narcotics and Dangerous Drugs (DHSS/BNDD);

(B) The program shall comply with 9 CSR 10-5 General Program Procedures, 9 CSR 10-7 Core Rules for Psychiatric and Substance Use Disorder Treatment Programs, and 9 CSR 30-3 Substance Use Disorder Prevention and Treatment Programs, as applicable; and (C) The program shall have appropriate accreditation from CARF International (CARF), The Joint Commission (TJC), Council on Accreditation (COA), or other accrediting body approved by the department for the services described in the regulation.

National accreditation or recognition as an OTP or accreditation or recognition as an OTP in a state other than Missouri is not equivalent to certification as an OTP by the department.

(2) Medication Administration, Dispensing, and Use. OTPs shall only utilize medications for opioid use disorder (MOUD) that are approved by the Food and Drug Administration under

section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) for use in the treatment of opioid use disorder (OUD).

(A) Opioid agonist, partial agonist, and antagonist treatment medications shall be administered and dispensed by a practitioner licensed in Missouri and registered under the appropriate state and federal laws to administer or dispense opioid drugs.

(B) Written policies and procedures shall be maintained to ensure the following dosage form and initial dosing requirements are met:

Methadone is prescribed by a qualified prescriber, administered and dispensed only in oral form, and formulated in a manner to reduce its potential for parenteral abuse; and 2. For each new individual enrolled in an OTP, the initial dose of methadone shall be individually determined and shall include consideration of the type(s) of opioid(s) involved in the individuals opioid use disorder, other medications or substances being taken, medical history, and severity of opioid withdrawal.

(C) The total dose for the first day shall not exceed fifty (50) milligrams unless the OTP practitioner, licensed under Missouri law and registered under the appropriate Missouri and federal laws to administer or dispense MOUD, finds sufficient medical rationale, including but not limited to if the individual is transferring from another OTP on a higher dose that has been verified, and documents in the individual’s record that a higher dose was clinically indicated.

Each opioid agonist medication is administered and dispensed in accordance with its approved product labeling.

Dosing and administration decisions shall be made by a qualified prescriber familiar with the most up-to-date product labeling. These procedures must ensure any significant deviations from the approved labeling, including deviations with regard to dose, frequency, or the conditions of use described in the approved labeling, are specifically documented in the individual record.

(D) If a prescription drug monitoring program (PDMP) is available, the program physician and other staff, as permitted, shall register and utilize the PDMP in accordance with federal, state, and local regulations. Policies and procedures shall be maintained regarding use of the PDMP information for diversion control planning.

(E) Individuals admitted to an OTP may be provided with naloxone or, if insured, a prescription for naloxone.

(3) Program Administration. The OTP shall have a program sponsor and a medical director.

(A) The program sponsor shall be responsible for the general establishment, certification, accreditation, and operation of the program, ensuring it is in continuous compliance with all federal, state, and local laws and regulations related to the use of opioid agonist and partial agonist treatment medications in the treatment of opioid use disorder.

(B) The medical director shall be a physician licensed in Missouri and is responsible for overseeing all medical services and behavioral health services provided by the OTP, performing them directly or by delegating specific responsibilities to an authorized program physician and healthcare professionals functioning under their direct supervision. The medical director shall ensure all medical, psychiatric, nursing, pharmacy, toxicology, and other services offered by the OTP are conducted in compliance with federal, state, and local regulations at all times. Other responsibilities of the medical director include, but are not limited to— 1. Ensuring individuals meet admission criteria and receive the required physical examination(s) and laboratory testing;

Prescribing methadone and other FDA-approved medications with the individual’s input, ensuring the prescribed dosage of medication is appropriate to their needs;
Reviewing each individual’s initial treatment plan and reviewing and updating the plan based on their needs; and 4. Coordinating care and consulting with each individual’s treatment team on a regular basis.

(4) Service Delivery Requirements. A range of treatment and rehabilitation services shall be provided to address the therapeutic needs of individuals served. The combination and frequency of services shall be tailored to each individual based on an individualized assessment and treatment plan that was created after shared decision-making between the individual served and the clinical team. All medications approved by the FDA for treatment of OUD shall be available to meet individual needs.

(A) At a minimum, the following services as defined in 9 CSR 30-3.110 or as specified in another regulation, must be available to all individuals based on needs and treatment goals:

Comprehensive assessment;
Communicable disease counseling;
Community support;
Transfer, transition, and discharge planning;
Crisis prevention and intervention;
Drug testing;
Employment/education services;
Family conference;
Family therapy;
Group counseling, including trauma and co-occurring disorders;
Group rehabilitative support;
Individual counseling, including trauma and cooccurring disorders;
Medication services;
Medication services support; and 15. Medical evaluations, as specified in this rule.

(B) The services must be available at the OTP’s primary location or through a documented agreement with another qualified service provider. Services shall be offered at least six (6) days per week. Medical and psychosocial services shall be available during the early morning and/or evening to ensure individuals have access to services.

(C) All medical services shall be offered and occur simultaneously with clinical therapy, education, development of positive social supports, and ongoing treatment and rehabilitation for substance use disorders and related life issues.

(D) OTPs shall directly provide, or make available through referral to adequate and reasonably accessible community resources, other support services including, but not limited to, rehabilitation, education, and employment for individuals who request such services or have been determined by program staff to be in need of these services.

(E) Information and education shall be provided in areas such as community resources and behavioral health disorders.

(F) Services may be provided via telehealth to enhance accessibility for individuals served.

(5) Admission Criteria. Individuals shall meet diagnostic criteria for active moderate to severe OUD, OUD remission, or high risk for recurrence or overdose.

(A) The program physician shall ensure each individual voluntarily chooses treatment with MOUD, all relevant facts concerning the use of the MOUD are clearly and adequately explained, and each individual provides informed consent to (B) Documentation in the individual record must indicate clinical signs and symptoms of opioid use disorder.

(C) Decisions regarding the most appropriate medication shall be individualized, based on personal needs and goals, throughout the individual’s engagement in treatment.

(6) Admission for Priority Populations. OTPs that have a contract with the department shall ensure priority admission for— (A) Women who are pregnant and use intravenous drugs;

(B) Women who are pregnant or postpartum, up to one (1) year after delivery;

(D) Women who have children and are at risk of losing custody or are attempting to regain custody;

(E) Individuals who test positive for the human immunodeficiency virus (HIV);

(F) Individuals determined to be high risk and are referred for treatment by Department of Corrections’ institutions and the Division of Probation and Parole via the designated referral form and protocol, as well as individuals referred from federal correctional institutions;

(G) Individuals who are applying for or receiving Temporary Assistance for Needy Families (TANF) and are referred for treatment by the Department of Social Services, Family Support Division, via the designated electronic referral process and protocol.

Women who are pregnant shall receive immediate 2. High-risk referrals from correctional institutions and probation and parole shall be assessed and admitted within five (5) working days of initial contact or scheduled release date, including weekends and holidays.
If the OTP is unable to assess and admit an individual who uses intravenous drugs within forty-eight (48) hours of receiving such a request, interim services shall be available in accordance with department contract requirements;

(H) Interim treatment, as defined in section (17) of this rule, shall be available for individuals who are eligible for treatment but cannot be immediately admitted to the OTP where services are being sought or through documented agreement with another OTP; and (I) Individuals seeking treatment who are participants in the MO HealthNet program and do not meet priority population criteria shall be given an appointment in a timely manner and shall not be placed on a wait list.

(7) Admission Protocol. Prior to admission, staff shall verify and document the individual seeking services is not currently enrolled in another opioid treatment program utilizing a central registry, if available, or other client enrollment/admission database, such as the department’s Customer Information, Management, Outcomes, and Reporting (CIMOR) system, for verification purposes.

(A) An individual currently enrolled in an OTP shall not be permitted to obtain treatment in any other OTP except in exceptional circumstances.

If the medical director or program physician of the OTP where the individual is currently enrolled determines exceptional circumstances exist, the individual may be granted permission to seek treatment at another OTP. Justification for the exceptional circumstances must be included in the individual record at both program locations.

(B) Upon admission, an initial medical examination shall be completed by an appropriately licensed practitioner for each individual. The initial examination shall ensure the individual meets admission criteria and there are no contraindications to treatment with MOUD. A full history and examination to determine the individual’s broader health status, including lab testing, may be required as determined by an appropriately licensed practitioner.

If the licensed practitioner is not an OTP practitioner, the screening examination must be completed no more than seven (7) days prior to OTP admission. When the examination is performed outside of the OTP, the written results and narrative of the examination, as well as available lab testing results, must be transmitted to the OTP and verified by an OTP practitioner, consistent with applicable privacy laws.
A full in-person physical examination, including the results of serology and other tests that are considered to be clinically appropriate, must be completed within fourteen (14) calendar days following an individual’s admission to the OTP.

The full exam can be completed by a non-OTP practitioner if the exam is verified by a licensed OTP practitioner as being true and accurate and transmitted in accordance with applicable privacy laws.

(C) Serology and other testing, as deemed medically appropriate by the licensed OTP, shall not be drawn more than thirty (30) days prior to admission to the OTP and may form

part of the full history and examination.

(D) The screening and full examination may be completed via telehealth if a practitioner or primary care provider determines an adequate evaluation can be accomplished for individuals being admitted to the OTP for use of buprenorphine or methadone.

When using telehealth, the following shall apply:

A. When evaluating patients for treatment with Schedule II medications (such as methadone), audio-visual telehealth platforms must be used, except when not available to the patient. When not available, it is acceptable to use audio-only devices, but only when the patient is in the presence of a licensed practitioner who is registered to prescribe (including dispense) controlled medications. The OTP practitioner shall review the examination results and order treatment medications as indicated.

(E) In evaluating patients for treatment with Schedule III medications (such as buprenorphine) or medications not classified as a controlled medication (such as naltrexone), audio-visual or audio only platforms may be used. The OTP practitioner shall review the examination results and order treatment medications as indicated.

An individual’s refusal to undergo lab testing for cooccurring physical health conditions shall not preclude them from access to treatment, provided such refusal does not have potential to negatively impact treatment with medications.
Women should have a pregnancy test as deemed clinically appropriate.
Serology testing and other testing as deemed medically appropriate by the licensed OTP practitioner based on the screening or full history and examination, drawn not more than thirty (30) days prior to admission to the OTP, may form

part of the full history and examination.

(8) Assessments.

(A) The screening and full examination may be completed via telehealth for those patients being admitted for treatment at the OTP with either buprenorphine or methadone, if a practitioner or primary care provider determines that an adequate evaluation of the patient can be accomplished via telehealth.

(B) When using telehealth, the following caveats apply:

In evaluating patients for treatment with Schedule II medications (such as methadone), audio-visual telehealth platforms must be used, except when not available to the patient. When not available, it is acceptable to use audio-only devices, but only when the patient is in the presence of a licensed practitioner who is registered to prescribe (including dispense) controlled medications. The OTP practitioner shall review the examination results and order treatment medications as indicated;
In evaluating patients for treatment with Schedule III medications (such as buprenorphine) or medications not classified as a controlled medication (such as naltrexone), audio-visual or audio only platforms may be used. The OTP practitioner shall review the examination results and order treatment medications as indicated;
Screening shall determine the risk of undiagnosed conditions such as hepatitis C, HIV, sexually transmitted infections, cardiopulmonary disease, and sleep apnea to determine if further diagnostic testing such as laboratory analysis, a cardiogram, or others are needed;
Positive screening results or disease risks should have a care coordination plan that is seen through to completion, regardless of whether this is accomplished via services provided directly by the OTP or through referral to another provider; and 5. A complete medical history, physical examination, and laboratory testing shall not be required for an individual who has had such medical evaluation within the prior thirty (30) days, or a physical examination completed no later than five (5) days after admission. The program shall have documentation of the medical evaluation and any significant findings in the individual record. Physical evaluations shall be completed no less than once per year.

(9) Pregnant and Postpartum Women. Written policies and procedures shall be maintained and implemented to address the needs of women who are pregnant and postpartum.

Prenatal care and other gender-specific services for women who are pregnant must be provided by the OTP or by referral to an appropriate healthcare provider.

(A) For pregnant women who are receiving methadone or buprenorphine, the program shall have written policies and procedures in place to ensure— 1. The initial dose of medication for a newly admitted woman who is pregnant, and the subsequent induction and dosing strategy, reflect the same effective dosing protocols used for all other individuals;

The methadone dose is carefully monitored, especially during the third trimester when pregnancy induces changes such as the rate at which methadone is metabolized or eliminated from the system, potentially necessitating either an increased or a split dose; and 3. Women who become pregnant during treatment are maintained at pre-pregnancy dosage, if effective, and are managed with the same dosing principles used with women who are not pregnant.

(B) Withdrawal management after pregnancy shall occur as clinically indicated and documented, or is requested by the (C) When a planned discharge occurs, OTP staff shall document the contact information of the physician or other authorized healthcare professional to whom the individual has been referred, including the reason for discharge.

(D) Mothers shall be educated about neonatal abstinence syndrome, its symptoms, potential effects on the infant, and need for treatment if it occurs.

(10) Safety and Health. The program shall implement written policies, procedures, and practices which ensure access to services and address the safety and health of individuals served. The provider shall— (A) Ensure continued opioid treatment for individuals in the event of an emergency, pandemic, or natural disaster by cooperating with other OTPs, including those in surrounding states, to develop and maintain medication dosing arrangements;

(B) Utilize a central registry, if available, or other individual enrollment/admission system such as the department’s CIMOR system, to coordinate services;

(D) Provide information and education to individuals on prevention and transmission of HIV-related conditions;

(E) Provide or arrange HIV testing and pre- and post-test counseling for individuals;

(F) Provide or arrange testing for TB, hepatitis C, and sexually transmitted infections upon admission and at least annually thereafter;

(G) Provide medical evaluations to individuals upon admission and at least annually thereafter, including cardiac risk assessment;

(H) Utilize infection control procedures in accordance with federal, state, and local regulations; and (I) Arrange medical care for women during pregnancy, if necessary, and document the arrangements made and action taken by the individual.

(11) Staff Training. Each person engaged in the treatment of OUD must have sufficient education, training, and experience, or any combination thereof, to enable that person to perform the assigned functions. All direct service staff and medical staff shall complete four (4) clock hours of training relevant to service delivery in an opioid treatment setting during a two- (2-) year period. This training applies to the required thirtysix (36) clock hours of training during a two- (2-) year period specified in 9 CSR 10-7.110(2)(F)1. and fifty (50) clock hours of training annually specified in 9 CSR 30-3.155(4)(H)1.-4.

(12) Testing and Screening for Drug Use. The program shall use drug screenings as a clinical tool for purposes such as diagnosis and treatment planning.

(A) Each individual shall have an initial toxicology test as part of the admission process. At a minimum, admission samples shall be analyzed for opiates, methadone, marijuana, cocaine, barbiturates, benzodiazepines, buprenorphine, amphetamines, fentanyl, and alcohol.

(B) If there is a history of misuse of prescription opioid analgesics, an expanded toxicology panel that includes these opioids shall be administered. Additional testing shall be based on individual needs and local drug use patterns and trends.

(C) Random drug testing of each individual in treatment shall be conducted at least eight (8) times during a twelve- (12-) month period, allowing for extenuating circumstances on behalf of the individual receiving services.

(13) Unsupervised Approved Use (Take-Home) of Medication.

The medical director shall ensure policies and procedures for approval of take-home methadone do not create barriers to individuals in treatment. The dispensing restrictions set forth in this section of this rule do not apply to buprenorphine and buprenorphine products.

(A) Any individual in comprehensive treatment may receive individualized take-home doses as ordered for days that the clinic is closed for business, including one (1) weekend day (e.g., Sunday) and state and federal holidays, no matter the length of time in treatment.

(B) Decisions on dispensing MOUD to individuals for unsupervised use, beyond that set forth in this rule, shall be determined by the medical director or appropriately licensed medical practitioner. In determining which individuals may be approved for unsupervised use, the medical director shall consider, among other pertinent factors that indicate that the therapeutic benefits of unsupervised doses outweigh the risks, the following criteria:

Absence of recent misuse of drugs (opioid or nonnarcotic), including alcohol, other physical or behavioral health conditions that increase the risk of individual harm as it relates to the potential for overdose, or the ability to function safely;
Regularity of attendance for supervised medication administration;
Absence of serious behavioral problems that endanger the patient, the public, or others;
Absence of known recent involvement in the legal involved system, such as drug dealing;
Assurance that take-home medication can be safely transported and stored; and 6. Any other criteria that the medical director or medical practitioner considers relevant to the individual’s safety and the public’s health.

(C) Determinations for unsupervised use of methadone and the basis for such determinations shall be documented in the (D) Take-home doses dispensed to individuals shall be subject to the following:

During the first fourteen (14) days of treatment, the takehome supply is limited to seven (7) days;
From fifteen (15) days of treatment, the take-home supply is limited to fourteen (14) days. In the second ninety (90) days of treatment, the take-home supply is limited to two (2) doses per week; and 3. From thirty-one (31) days of treatment, the take-home supply provided to an individual is not to exceed twenty-eight (28) days.

(E) It remains within the OTP practitioner’s discretion to determine the number of take-home doses, but this determination must be based on the criteria listed in subsection (13)(B) of this rule.

(F) OTPs must implement written procedures to identify theft or diversion of take-home medications, including labeling containers with the OTP’s name, address, and telephone number. Programs must also ensure take-home supplies are packaged in a manner designed to reduce the risk of accidental ingestion, including use of child-proof containers.

(G) Program staff shall educate individuals about safe transportation and storage of methadone, as well as emergency procedures in case of accidental ingestion.

(H) Individuals approved for take-home doses of methadone must have a lock box for safe transportation and home storage.

(I) OTPs shall implement written policies and procedures that address the responsibilities of individuals who are approved for take-home doses of methadone, including methods to assure appropriate use and storage of the medication.

(J) Staff shall regularly monitor each individual’s use of takehome medication to ensure security of the medication and prevent diversion. When determined necessary, the medical director and staff may review an individual’s unsupervised use and may deny or rescind take-home privileges. Such action shall be documented in the individual record, including the rationale for denial or rescission of unsupervised use.

(K) The time in treatment requirements outlined in paragraphs (13)(D)1. to 3. of this rule are minimum reference points after which an individual may be considered for takehome medication privileges. The time references do not mean an individual in treatment for a particular time has a specific right for approval of take-home medication.

(L) Any deviation from the regulations for unsupervised use of methadone as specified in this rule requires prior approval from the state opioid treatment authority (SOTA), or designee, and/or SAMHSA.

The Exception Requests and Record of Justification form SMA-168 must be submitted to the SOTA/designee and/or SAMHSA as specified in section (25) of this rule. Justification for an exception may include, but is not limited to, transportation hardships, employment, vacation, medical or family emergencies, or other unexpected circumstances.

(14) Guest Medication. Individuals who travel, but do not meet the criteria for take-home medication as specified in section (13) of this rule, should be considered for guest medication in accordance with the 2020 Guidelines for Guest Medications, hereby incorporated by reference and made a part of this rule, as published by the American Association for the Treatment of Opioid Dependence, 225 Varick St., Suite 402, New York, NY 10014, (212) 566-5555. This rule does not incorporate any (A) Guest medication provides a mechanism for individuals to travel from a home program for business, pleasure, or family emergencies. It also provides an option for individuals who need to travel for a period of time that exceeds the amount of eligible take-home doses to do so within regulatory requirements.

(B) Individuals shall be on a stable dose of methadone and not be scheduled for a dose increase or decrease during guest medication.

(15) Continuity of Care. The program shall implement written policies and procedures to address continuity of care for individuals who are unable to participate in regularly scheduled visits for observed ingestion of medication due to illness, pregnancy, participation in residential treatment, incarceration, lack of transportation, or other situations.

(A) A chain-of-custody process shall be implemented to document the transportation, delivery, administration, and observation of medication when an individual is unable to report to the program as required.

(16) Diversion Control. OTPs shall maintain and implement a written diversion control plan as part of its performance improvement process. The plan shall contain specific measures to reduce the possibility of diversion of controlled substances from legitimate treatment use. Medical and administrative staff of the program shall be assigned to implement the diversion control measures and functions described in the diversion control plan.

(17) Interim Treatment. The program sponsor of an OTP may place an individual who is eligible for admission to comprehensive treatment into interim treatment, if the individual cannot be placed in an OTP within a reasonable geographic area within fourteen (14) days of the individual’s seeking admission to (A) An initial and at least two (2) other drug screens shall be obtained from an individual during the maximum of one hundred eighty (180) days permitted for interim treatment.

(B) By day one hundred twenty (120), a plan for continuing treatment beyond one hundred eighty (180) days must be created and documented in the individual’s clinical record.

(C) The OTP shall maintain and implement written policies and procedures for transferring individuals from interim to comprehensive treatment.

The transfer criteria shall include, at a minimum, a preference for admitting women who are pregnant into interim treatment and criteria for transferring individuals from interim to comprehensive treatment.

(D) Interim treatment shall be provided in a manner consistent with all applicable federal and state laws, including sections 1923, 1927(a), and 1976 of the Public Health Service Act (21 U.S.C. 300x-23, 300x-27(a), and 300y-11).

(E) Individuals enrolled in interim treatment shall not be discharged without the approval of an OTP practitioner, who shall consider ongoing and individual treatment needs, which are to be documented in the clinical record, while awaiting transfer to a comprehensive treatment program.

(F) The program shall notify the SOTA when an individual begins interim treatment, when the individual leaves interim treatment, and before the date of transfer to comprehensive treatment, documenting all notifications in the individual record.

(G) SAMHSA may revoke the interim authorization for a program that fails to comply with the provisions of this section of this rule.

(H) SAMHSA will consider revoking the interim treatment authorization of a program if the state in which the program operates is not in compliance with the provisions of 42 CFR

section 8.11(g).

(I) All requirements for comprehensive treatment apply to interim treatment with the following exceptions:

The opioid agonist treatment medication is required to be administered daily under observation;
An initial treatment plan and periodic treatment plan reviews are not required;
A primary counselor is not required to be assigned to the individual but crisis services, including shelter support, should be available;
Interim treatment shall not be provided for longer than one hundred eighty (180) days in any twelve- (12-) month period; and 5. The rehabilitative, educational, and other counseling services specified in section (4) of this rule are not required to be provided to the individual.

(18) Medically Supervised Withdrawal. The program shall maintain and implement written policies and procedures that are designed to ensure that those patients who choose to taper from MOUD are provided the opportunity to do so with informed consent and at a mutually agreed-upon rate that minimizes taper-related risks. Medically supervised withdrawal may be voluntary or involuntary, as specified in sections (19) and (21) of this rule.

(A) The individual’s treatment plan shall include a strategy to transition to another form of medication, if needed. Review of the risks and benefits of withdrawal shall be provided, and informed consent shall be obtained from individuals who voluntarily choose this treatment option. Such consent must be documented in the clinical record by the treating practitioner.

(B) Individuals shall be educated about the risks of a recurrence of symptoms and potential for fatal overdose following withdrawal, and be offered relapse prevention services that includes counseling, naloxone, and opioid antagonist therapy.

(C) OTPs shall offer a variety of supportive options as part of the transition from opioid agonist therapy, such as increased counseling sessions prior to discharge, and individuals shall be encouraged to attend a twelve- (12-) step or other mutualhelp program sensitive to the needs of individuals receiving treatment with medication.

(19) Voluntary Medically Supervised Withdrawal. Voluntary medically supervised withdrawal may be initiated by the individuals served or the program physician in collaboration with the individual as part of individualized treatment planning.

(A) As deemed clinically appropriate, women shall have a pregnancy test and the results reviewed prior to initiation of medically supervised withdrawal.

(B) For women who are pregnant, the physician shall not initiate withdrawal before fourteen (14) weeks or after thirtytwo (32) weeks of pregnancy.

(C) If an individual experiences intolerable withdrawal symptoms or actual or potential return to use, the physician shall consider stopping the withdrawal process and restoring the individual to a previously effective dose. In collaboration with the individual served, the physician shall determine if an additional period of maintenance is necessary before further medically supervised withdrawal is attempted.

(D) Regardless of whether medically supervised withdrawal is conducted with or against medical advice (AMA), careful review of the risks and benefits of withdrawal from treatment must be provided to the individual and informed written consent obtained from those who choose to initiate medically supervised withdrawal.

(20) Withdrawal Against Medical Advice (AMA). Individuals who request voluntary medically supervised withdrawal from medication treatment AMA of the physician or program staff may receive it. Individuals have the right to leave treatment when they choose to do so.

(A) The same services that are available to individuals engaged in voluntary medically supervised withdrawal shall be offered to individuals choosing medically supervised withdrawal AMA.

(B) The program must fully document the issue(s) that caused the individual to seek discharge, steps taken to avoid discharge, and the circumstances of readmission, as applicable.

(C) In the case of a woman who is pregnant, the program must keep the physician or agency providing prenatal care informed, consistent with the privacy standards of 42 CFR

section 2.

(21) Involuntary Withdrawal from Treatment (Administrative Withdrawal). Individuals shall be retained in treatment for as long as they can benefit from it and express a desire to continue treatment. Administrative withdrawal is typically involuntary and shall be used only when all other therapeutic options have been exhausted by program staff. OTPs may refer or transfer individuals to a suitable alternative treatment program, as clinically indicated.

(A) Missing scheduled appointments and/or continued drug use shall not be the sole reason for initiating involuntary withdrawal for an individual being served.

(B) If involuntary withdrawal is initiated for an individual, the program shall follow the criteria included in the December 2024, Federal Guidelines for Opioid Treatment Programs, incorporated by reference and made a part of this rule as published by SAMHSA, Center for Substance Abuse Treatment, 1 Choke Cherry Rd., Rockville, MD 20857, (877) 726-4727, publication number PEP24-02-011. This rule does not incorporate any subsequent amendments or additions to this publication.

(22) Medication Storage and Security. The program shall ensure the security of its medication supply and shall account for all medications kept on site at all times.

(A) The program shall meet the requirements of the DEA and BNDD.

(B) The program shall maintain an acceptable security system, and the system shall be checked on a quarterly basis to ensure continued safe operation.

(C) The program shall physically separate the narcotic storage and dispensing area from other parts of the facility used by individuals.

(D) The program shall implement written policies and procedures to ensure positive identification of all individuals before any medication is administered. Verification shall include a minimum of two (2) forms of identification.

(E) The program shall implement written policies and procedures for recording each individual’s medication intake and maintaining a daily medication inventory.

(23) Medication Units. Certified OTPs may establish medication units that are authorized to dispense MOUD. Services provided at the medication unit must comply with 42 CFR section 8.2.

(A) Prior to establishing a medication unit, the OTP must notify and receive prior approval from the SOTA/designee and SAMHSA by submitting form SMA-162. The required documents include, but are not limited to— 1. A description of how the medication unit will receive its medication supply;

An affirmative statement that the medication unit is limited to administering and dispensing the narcotic treatment drug and collecting samples for drug testing or analysis;
An affirmative statement that the program sponsor agrees to retain responsibility for individual treatment and care;
A diagram and description of the facility to be used as a medication unit;
Total number of individuals to be served by the primary OTP and medication unit;
Total number of individuals that will be served only at the medication unit;
A justification for the need to establish a medication unit; and 8. The name and address of any other active medication unit(s) attached to the primary OTP.

(B) A DEA inspection and approval must be obtained prior to opening a medication unit. A medication unit must have a separate and unique DEA registration.

(D) Medication units are not required to be free-standing entities and may be located at a hospital or community pharmacy, for example.

(E) The certified OTP shall be responsible for all operations of an approved medication unit.

(24) Mobile Units. A mobile unit, for the purpose of dispensing opioid agonist treatment medications to individuals for observed ingestion, may be established if approval is granted by the DEA allowing such units to be considered a coincidental activity of the registered OTP. OTPs shall follow all federal, state, and local regulations regarding the operation of a mobile unit.

(25) Exception Requests and Records of Justification. Any deviation from these regulations requires prior approval from the SOTA/designee and/or SAMHSA. Requests must be submitted on the Exception Request and Record of Justification form (SMA-168) electronically.

(A) OTPs shall follow department requirements for submitting form SMA-168 to the SOTA/designee and/or SAMHSA. Failure to submit the completed form and obtain prior approval from the SOTA/designee and/or SAMHSA constitutes a regulatory violation which may jeopardize the OTP’s accreditation and certification status.

(B) SAMHSA and the SOTA/designee must be notified of any change to the OTP sponsor or medical director within three (3) weeks of the change by submitting SAMHSA form SMA-162 in accordance with established procedures.

rule originally filed as 9 CSR 30-3.610. Original rule filed May 13, 1983, effective Sept. 13, 1983. Rescinded and readopted: Filed May 3, 1994, effective Nov. 30, 1994. Amended: Filed July 29, 1997, effective Jan. 30, 1998. Moved to 9 CSR 30-3.132 and amended:

Filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed Oct. 15, 2001, effective April 30, 2002. Amended: Filed March 8, 2002, effective Sept. 30, 2002. Amended: Filed July 1, 2003, effective Dec. 30, 2003. Emergency amendment filed Nov. 8, 2004, effective Nov. 18, 2004, expired May 16, 2004. Amended: Filed Nov. 8, 2004, effective April 30, 2005. Amended: Filed Feb. 1, 2005, effective July 30, 2005. Rescinded and readopted: Filed May 28, 2021, effective Dec. 30, 2021. Amended: Filed Aug. 19, 2025, effective March 30, 2026. *Original authority: 630.655, RSMo 1980, and 631.102, RSMo 1997.

History

AUTHORITY: sections 630.655 and 631.102, RSMo 2016. This

9 CSR 30-3.134 Gambling Disorder Treatment {#sec-9-csr-30-3.134 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.134}

PURPOSE: This rule describes the specific service delivery requirements for gambling disorder treatment. publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

(1) Service Functions. The key functions of gambling disorder treatment and rehabilitation services shall include— (A) Utilizing evidence-based treatment principles to promote positive changes in gambling behavior and lifestyle;

(B) Exploring the gambling behavior and its impact on self, marriages, partnerships, and families;

(D) Teaching effective methods to deal with urges to gamble to include use of medication assisted treatment as indicated;

(E) Enhancing motivation and creative problem-solving for the individual and his/her family and other natural supports;

(F) Addressing financial problems incurred as a result of the gambling behavior with appropriate referrals, as needed; and (G) Determining suicide risk and the presence of co-occurring behavioral health factors to determine the need for ancillary treatment services.

(2) Treatment Goals and Performance Outcomes. Indicators of a positive treatment outcome include the reduction or cessation of gambling behavior, as well as improvements and/or involvement in family and other natural support relationships, leisure and social activities, educational/ vocational functioning, legal status, psychological functioning, and financial situation.

(3) Eligibility Criteria. Eligibility for gambling disorder treatment shall be based on criteria for persistent and recurrent problematic gambling behavior as defined in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, 800 Maine Avenue S.W., Suite 900, Washington, DC 20024, www.psychiatry.org and does not include any later amendments or additions. There must be documentation in the individual record of the specific behaviors and circumstances demonstrating how the person meets treatment criteria. The department may require the use of designated instruments for the admission and eligibility determination processes for individuals receiving services funded by the department. The referenced guide does not include any later amendments or additions.

(4) Available Services. Gambling disorder treatment services shall be offered on an individual, family, and group basis in an outpatient setting. Available services include individual counseling, group rehabilitative support and counseling, family therapy, and collateral relationship counseling.

(A) Each individual shall be oriented to and encouraged to participate in mutual support groups, if available.

(B) Family members and other natural supports of persons with a gambling disorder shall be encouraged to participate in treatment. Such participation does not include counseling sessions for family members and other natural supports on an ongoing basis to resolve other personal problems or other behavioral health disorders.

(C) The treatment provider shall arrange other services and make referrals to address other problems the individual or the family may have such as financial problems, substance use, or other behavioral health disorders.

(5) Clinical Review and Data Reporting. Services are subject to clinical review by the department in accordance with 9 CSR 10- 7.030. Providers shall comply with data reporting requirements established by the department for individuals whose services are funded by the department.

(6) Certified Gambling Disorder Counselor. A certified gambling disorder counselor demonstrates substantial knowledge and skill in the treatment of individuals with persistent and recurrent problematic gambling behavior by having completed a designated training program sponsored or approved by the Missouri Credentialing Board, and being either— (A) A counselor, clinical social worker, psychologist, or physician licensed in Missouri by the Division of Professional Registration; or (B) Possess a qualifying certified level credential as designated by the Missouri Credentialing Board.

(7) Credentialing of Gambling Disorder Counselors. The Missouri Credentialing Board designates the credential of a gambling disorder counselor to individuals who meet the qualifications specified in this rule. This credential is a requirement for providing gambling disorder counseling services eligible for funding by the department.

(A) A person may request an application for the Gambling Disorder Counselor credential from the Missouri Credentialing Board, 428 E. Capitol Avenue, 2nd Floor, Jefferson City, MO 65101, (573) 616-2300, www.missouricb.com.

(B) The credential is issued for a period of time coinciding with the period of licensure or certification otherwise required of the applicant, up to a maximum period of two (2) years.

(C) The credential may be renewed upon further application and verification that the counselor continues to meet all qualifications. For renewal, the applicant must have received during the past two (2) years at least fourteen (14) hours of training sponsored or approved by the Missouri Credentialing Board that is directly related to the treatment of gambling disorders.

(D) Credentialed counselors shall adhere to the code of ethics for their profession in providing services for individuals with gambling disorders.

Any complaint or grievance received by the department regarding a counselor providing services to individuals for a gambling disorder shall be forwarded to the applicable licensure or certification body.
Any sanction arising from a code of ethics violation shall be deemed as applying equally to the gambling disorder credential.

Filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed April 20, 2018, effective Nov. 30, 2018. Amended: Filed June 29, 2023, effective Jan. 30, 2024. *Original authority: 313.842, RSMo 1991, amended 1996, 2000; 630.050, RSMo 1980, amended 1993, 1995, 2008; and 630.655, RSMo 1980.

History

AUTHORITY: sections 313.842, 630.050, and 630.655, RSMo 2016. This rule originally filed as 9 CSR 30-3.611. Original rule filed Oct. 13, 1995, effective April 30, 1996. Amended: Filed Jan. 10, 1997, effective Aug. 30, 1997. Moved to 9 CSR 30-3.134 and amended:

9 CSR 30-3.140 Residential Treatment {#sec-9-csr-30-3.140 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.140}

PURPOSE: This rule describes the goals, eligibility and discharge criteria, available services, and performance indicators for residential treatment.

(1) Treatment Goals. Residential treatment shall offer an intensive set of services in a structured alcohol- and drug-free setting. Services shall be organized and directed toward the primary goals of— (A) Stabilizing a crisis situation, where applicable;

(B) Interrupting a pattern of extensive or severe substance abuse;

(D) Promoting the individual’s recognition of a substance abuse problem and its effects on his/her life;

(E) Developing recovery skills, including an action plan for continuing sobriety and recovery; and (F) Promoting the individual’s support systems and community reintegration.

(2) Eligibility Criteria. In order to fully participate in and benefit from the intensive set of services offered in residential treatment, a person must meet the following admission and eligibility criteria:

(A) Does not demonstrate symptoms of intoxication, impairment or withdrawal that would hinder or prohibit full participation in treatment services. A screening instrument, that includes vital signs, must be used with all prospective clients to identify symptoms of intoxication, impairment, or withdrawal and, when indicated, detoxification services must be provided or arranged;

(B) Needs an alternative, supervised living environment to ensure safety and protection from harm;

(C) Meets the general treatment eligibility requirement of a current diagnosis of substance abuse or dependence and, in addition, demonstrates one or more of the following— 1. Recent patterns of extensive or severe substance abuse;

Inability to establish a period of sobriety without continuous supervision and structure;
Presence of significant resistance or denial of an identified substance abuse problem; or 4. Limited recovery skills and/or support system; and (D) A client may qualify for transfer from outpatient to residential treatment if the person— 1. Has been unable to establish a period of sobriety despite active participation in the most intensive set of services available on an outpatient basis; or 2. Presents imminent risk of serious consequences associated with substance abuse.

(3) Safety and Supervision. The residential setting shall ensure the safety and well-being of persons served.

(A) Staff coverage shall ensure the continuous supervision and safety of clients.

There shall be an adequate number of paid staff on duty (awake and dressed) at all times. At least two (2) staff shall be on duty, unless otherwise stipulated in these rules or authorized in writing by the department through the exceptions process.

Additional staff shall be required, if warranted by the size of the program and the responsibilities and duties of the staff members.

Clients shall be supervised at all times by a staff member with current certification in first aid and cardiopulmonary resuscitation.

(B) The program shall immediately and effectively address any untoward or critical incident including, but not limited to, any incident of alcohol or drug use by a client on its premises.

(4) Intensive Services with Individualized Scheduling. Services shall be responsive to the needs of persons served.

(A) There shall be a current schedule of program activities that offers a minimum of fifty (50) hours of structured, therapeutic activity per week.

Therapeutic activities shall be provided seven (7) days 2. Group education and group counseling must constitute at least twenty (20) of the required hours of therapeutic activity (B) At least one (1) hour of individual counseling per week shall be provided to each client. Additional individual counseling shall be provided, in accordance with the individual’s needs.

(5) Discharge Criteria. Each client’s length of stay in residential treatment shall be individualized, based on the person’s needs and progress in achieving treatment goals.

(A) To qualify for successful completion and discharge from residential treatment, the person should— 1. Demonstrate a recognition and understanding of his/her substance abuse problem and its impacts;

Achieve an initial period of sobriety and accept the need for continued care;
Develop a plan for continuing sobriety and recovery;
Take initial steps to mobilize supports in the community for continuing recovery.

(B) A person may be discharged before accomplishing these goals if maximum benefit has been achieved and— 1. No further progress is imminent or likely to occur;

Clinically appropriate therapeutic efforts have been made by staff; and 3. Commitment to continuing care and recovery is not demonstrated by the client.

(6) The program handles applications for continued civil detention in accordance with sections 631.140, 631.145 and 631.150, RSMo 2000.

Filed Oct. 15, 2001, effective April 30, 2002. Amended: Filed April 15, 2002, effective Nov. 30, 2002.

9 CSR 30-3.150 Comprehensive Substance Treatment and Rehabilitation (CSTAR) {#sec-9-csr-30-3.150 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.150}

PURPOSE: This rule establishes requirements for service delivery as a Comprehensive Substance Treatment and Rehabilitation (CSTAR) program. publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

(1) Program Requirements. In order to be certified by the department to provide CSTAR services, the organization must— (A) Comply with 9 CSR 10-7, 9 CSR 10-5, and 9 CSR 30-3, as (B) Be accredited to provide substance use disorder treatment services by Commission on Accreditation of Rehabilitation Facilities (CARF) International, The Joint Commission, Council on Accreditation, or other entity recognized by the department;

(C) Have the capacity to collect, analyze, and report outcome and other data related to the population served to the department in accordance with established protocol;

(D)

Incorporate evidence-based, best, and promising practices into its service array.

At a minimum, the organization shall employ or have a formal contract with the following:

A. Licensed and credentialed professionals with expertise and specialized training in the treatment of traumarelated disorders;

B. Licensed and credentialed professionals with expertise and specialized training in the treatment of cooccurring disorders (substance use and mental illness);

C. Licensed prescribers to provide FDA-approved medications which can be provided in an outpatient setting for the treatment of opioid use and other substance use disorders (methadone must be provided by a certified opioid treatment program). Long-term medications shall be offered and prescribed, as medically appropriate;

D. Certified Peer Specialists who have completed department-approved training and credentialing;

E. Clinical staff who have completed departmentapproved training on smoking cessation;

F. Clinical staff who have completed departmentapproved training on suicide prevention; and (E) Have clinical staff who are trained and qualified to utilize The ASAM Criteria: Treatment Criteria for Addictive, Substance- Related, and Co-Occurring Conditions, 2013, hereby incorporated by reference and made a part of this rule, published by and available from The American Society of Addiction Medicine, 11400 Rockville Pike, Suite 200, Rockville, MD 20852, (301) 656-3920. This rule does not incorporate any subsequent (2) Other Applicable Program Requirements. A CSTAR program shall meet the following additional requirements when the department determines they are applicable:

(A) Services offered on a residential basis shall comply with requirements for residential treatment; and (B) Requirements as a specialized program for adolescents or as a specialized program for women and children shall be met, where applicable.

(3) Medicaid Eligibility. An organization must be certified as a CSTAR program to qualify for Medicaid reimbursement for delivery of substance use disorder treatment services to eligible persons.

(A) A CSTAR program shall comply with applicable state and federal Medicaid requirements.

(B) If there is a change in the Medicaid eligibility or financial status of a person served, the individual shall not be prematurely discharged from the CSTAR program or otherwise denied CSTAR services. The program shall— 1. Continue to provide all necessary and appropriate services until the individual meets treatment plan goals and criteria for discharge; or 2. Transition the individual to another provider and document in the individual’s record there is continuity of clinically appropriate treatment services.

(4) Temporary Waiver. Upon the effective date of this rule, the department will grant a one- (1-) year waiver from the requirements specified in subsections (1)(B) and (1)(E) of this

rule to programs that have a current and valid CSTAR contract with the department and continue to meet certification and contract requirements.

(A) Waivers shall be temporary and time limited.

The initial waiver period of one (1) year may be renewed or extended by the department annually thereafter.
The total period of waiver shall not exceed three (3) years unless otherwise determined by the department.

Filed March 25, 2021, effective Sept. 30, 2021. Amended: Filed Aug. 7, 2023, effective Feb. 29, 2024.

9 CSR 30-3.151 Eligibility Determination, Assessment, and Treatment Planning in Comprehensive Substance Treatment and Rehabilitation (CSTAR) Programs {#sec-9-csr-30-3.151 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.151}

PURPOSE: This rule specifies the eligibility determination, assessment, treatment planning, and documentation requirements for Comprehensive Substance Treatment and Rehabilitation (CSTAR) programs.

(1) Consent to Treatment. Each individual served or a parent/guardian must provide informed, written consent to (A) A copy of the consent form, which must include the date of consent and signature of the individual served or a parent/ guardian, shall be retained in the individual record.

(B) Consent to treat shall be updated annually, including the date of consent and signature of the individual served or a parent/guardian, and be maintained in the individual record.

(2) Eligibility Determination. Eligibility determination may be completed to expedite the admission process for individuals seeking services. Eligibility determination requires a diagnosis and placement in a level of care.

(A) A diagnosis shall be rendered in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR), 2022, hereby incorporated by reference and made a part of this rule, published by and available from the American Psychiatric Association, 800 Maine Avenue SW, Suite 900, Washington, DC 20024, (202) 559-3900. This rule does not incorporate any subsequent amendments or additions to this publication.

(B) The following licensed or provisionally licensed mental health professionals (LMHP) are approved to render diagnoses.

Professionals possessing the credentials listed below are expected to provide services within their scope of practice in the area(s) in which they are adequately trained and should not practice beyond their individual level of competence:

Physician (including psychiatrist);
Physician assistant;
Assistant physician;
Resident physician (including psychiatrist);
Advanced practice registered nurse (APRN);
Psychologist;
Professional counselor;
Marital and family therapist; and 9. Licensed clinical social worker.

(C) Individuals shall be placed in a level of care utilizing The ASAM Criteria: Treatment Criteria for Addictive, Substance- Related, and Co-Occurring Conditions, 2013, hereby incorporated available from the American Society of Addiction Medicine, Inc., 11400 Rockville Pike, Suite 200, Rockville, MD 20852, (301) 656-3920. This rule does not incorporate any subsequent (D) Eligibility determination shall be completed by qualified staff as follows:

An LMHP conducts a diagnostic assessment, including dated signature; or 2. A qualified addiction professional (QAP) or qualified mental health professional (QMHP) assists in obtaining information from the individual to complete the eligibility determination with finalization by an LMHP for completion of the diagnosis and clinical summary, including dated signature.

(E) Documentation of eligibility determination, with inclusion of The ASAM Criteria (abbreviated) as referenced in subsection (2)(C) of this rule, must include the following:

Presenting problem and referral source;
Brief history of previous substance use disorder/ psychiatric treatment, including type of admission;
Current medications;
Current substance use supporting the diagnosis;
Current mental health symptoms;
Current medical conditions;
Diagnoses, including substance use, mental disorders, medical conditions, and notation for psychosocial and contextual factors;
Functional assessment using a department-approved instrument, if required;
Identification of urgent needs including suicide risk, personal safety, and risk to others;
Initial treatment recommendations;
Initial treatment goals to meet immediate needs within the first forty-five (45) days of service; and 12. Dated signature(s), title(s), and credential(s) of staff determining eligibility.

(3) Comprehensive Assessment. A comprehensive assessment shall be completed for each individual as follows:

(A) On the date of admission or within seven (7) days of the date of CSTAR eligibility determination, if completed, for individuals admitted to a residential level of care; or (B) On the date of admission or within thirty (30) days of the date of CSTAR eligibility determination, if completed, for individuals admitted to an outpatient level of care;

(C) If a diagnosis was rendered through eligibility determination, other trained staff may assist in collecting assessment information from the individual with finalization by a QAP or QMHP, including development of treatment recommendations;

(D) If a diagnosis is rendered during the assessment process, finalization by an LMHP is required for completion of the diagnosis and clinical summary;

(E) The ASAM Criteria as referenced in subsection (2)(C) of this rule shall be utilized in completing the comprehensive assessment. Documentation of the comprehensive assessment shall include but is not limited to the following:

Basic information (demographics, age, language spoken);
Presenting concerns from the perspective of the individual, including reason for referral/referral source, what occurred to cause them to seek services;
Risk assessment for determining emergency, urgent, or routine need for services (suicide, safety, risk to others);
Trauma history (experienced and/or witnessed abuse, neglect, violence, sexual assault);
Substance use treatment history and current use including alcohol, tobacco, and/or other drugs. For children/ youth, prenatal exposure to alcohol, tobacco, or other substances;
Mental status;
Mental health treatment history;
Medication information including current medications, medication allergies/adverse reactions, efficacy of current or previously used medications;
Physical health summary (health screen, current primary care, vision and dental, date of last examinations, current medical concerns, body mass index, tobacco use status, and exercise level. Immunizations for children/youth and medical concerns expressed by family members that may impact the child/youth;
Assessed needs based on functioning (challenges, problems in daily living, barriers, and obstacles);
Risk-taking behaviors, including child/youth risk behavior(s);
Living situation including living accommodations (where and with whom), financial situation, guardianship, need for assistive technology, and parental/guardian custodial status for children/youth;
Family, including cultural identity, current and past family life experiences. For family functioning/dynamics, relationships, current issues/concerns impacting children/ youth;
Developmental information, including an evaluation of current areas of functioning such as motor development, sensory, speech, hearing and language, emotional, behavioral, intellectual functioning, and self-care abilities;
Spiritual beliefs/religious orientation;
Sexuality, including current sexual activity, safe sex practices, and sexual orientation;
Need for and availability of social, community, and natural supports/resources such as friends, pets, meaningful activities, leisure/recreation interests, self-help groups, resources from other agencies, interactions with peers including child/youth and family;
Legal involvement history;
Legal status such as guardianship, representative payee, conservatorship, and probation/parole;
Education, including intellectual functioning, literacy level, learning impairments, attendance, and achievement;
Employment, including current work status, work

history, interest in working, and work skills;

Status as a current or former member of the U.S. Armed Forces;
Clinical formulation, an interpretive summary including identification of co-occurring or co-morbid disorders and psychological/social adjustment to disabilities and/or disorders;
Diagnosis(es);
Individual’s expression of service preferences;
Assessed needs/treatment recommendations such as life goals, strengths, preferences, abilities, and barriers; and 27. Dated signature(s), title(s), and credential(s) of staff completing the comprehensive assessment; and (F) The date of the LMHP’s signature on the eligibility determination or assessment, if eligibility determination is not completed, is the effective date of program eligibility, and is the date on which billing for CSTAR services may begin.

(4) Assessment Updates. Assessment updates shall be completed as clinically indicated by the treatment team and as specified in The ASAM Criteria, as referenced in subsection (2)(C) of this rule, to facilitate transition between levels and placement in the appropriate level of care.

(A) At a minimum, reassessment in outpatient levels of care shall take place every twelve (12) months.

(B) Documentation for assessment updates shall include— 1. A narrative summary of the individual’s risk ratings in each of the six (6) ASAM dimensions;

The recommended level of care; and 3. Any recommended changes to the treatment plan based on the reassessment.

(5) Initial Treatment Plan. A treatment plan shall be developed for each individual admitted to CSTAR within forty-five (45) days of the date of admission with completion of a comprehensive assessment or eligibility determination with requirements met.

(A) The treatment plan shall be developed collaboratively with the individual and/or parent/guardian and members of the treatment team with input from family members/natural supports, as appropriate.

(B) Documentation for completion of the initial treatment plan must include, at a minimum— 1. Identifying information;

Goals as expressed by the individual served and family members/natural supports, as appropriate, that are measurable, achievable, time-specific with start date, strength/ skill based, and include supports/resources needed to meet goals and potential barriers to achieving goals;
Specific treatment objectives, including a start date, that are understandable to the individual served, sufficiently specific to assess progress, responsive to the disability or concern, and reflective of age, development, culture, and ethnicity;
Specific interventions and services including action steps, modalities, and services to be utilized, duration and frequency of interventions, who is responsible for the intervention, and action steps of the individual served and family members/natural supports, as appropriate;
Identification of other agency/community resources and supports including others providing services, plans for coordinating with other agencies, services needed beyond the scope of the CSTAR program to be addressed through referral/ services with another organization;
Transfer, treatment, and discharge planning beginning at the point of admission and includes but is not limited to criteria for service conclusion, how the individual served and/ or parent/guardian and treatment team will know treatment goals have been accomplished; and 7. Dated signature of the QAP or QMHP completing the plan with finalization by an LMHP. The LMHP’s dated signature certifies that treatment is needed and services are appropriate as described in the treatment plan and does not recertify the diagnosis. The individual must also sign the plan unless there is a current signed consent to treatment included in the (6) Treatment Plan Updates. Treatment plans shall be updated each time an individual is reassessed as specified in section (4) of this rule. A functional assessment may be utilized as the treatment plan update.

(A) At a minimum, treatment plans shall be reviewed and updated every ninety (90) days to determine the individual’s continued need for services and progress achieved during the past ninety (90) days. The occurrence of a crisis or significant clinical event may require a further review and modification of the treatment plan.

(B) The plan shall be updated collaboratively with the individual and/or parent/guardian and reflect the individual’s current strengths, needs, abilities, and preferences in the goals and objectives that have been established or continued based on the review. Updates must be documented in the individual record with one (1) of the following:

A progress note which specifies updates made to the treatment plan; or 2. A treatment plan review conducted quarterly; or 3. An updated functional assessment score with a brief narrative.

(C) The dated signature(s), title(s), and credential(s) of staff completing the review must be included on the treatment plan update. The individual served shall also sign the plan unless there is a current signed consent to treatment included in the (7) Crisis Prevention Plan. If a potential risk for suicide, violence, risk of relapse, overdose, or other at-risk behavior is identified during the assessment process, or any time during the individual’s engagement in services, a crisis prevention plan shall be developed as specified in 9 CSR 10-7.030(3).

(A) Documentation for completion of the crisis prevention plan shall include, at a minimum— 1. Factors that may precipitate a crisis;

A hierarchical list of skills/strengths identified by the individual to regain a sense of control to return to their level of functioning before the crisis or emergency; and 3. A hierarchical list of staff interventions that may be used when a critical situation occurs.

(8) Service Transition, Transfer, and Discharge Planning.

Transfer, transition, and discharge planning begins at admission. Decisions concerning continued service, transfer, or discharge involve review of the treatment plan and assessment of the individual’s progress, with clearly defined and agreed-upon goals and outcomes, rather than the result of a preset program structure.

(9) Data. The CSTAR program shall provide data to the department, upon request, regarding characteristics of individuals served, services, costs, or other information in a format specified by the department.

(10) Availability of Records. All documentation must be made available to department staff and other authorized representatives for review/audit purposes. Documentation must be legible and made contemporaneously with the delivery of the service (at the time the service was provided or within five (5) business days of the time it was provided), and address individual specifics including, at a minimum, individualized statements that support the assessment or treatment encounter.

Original rule filed Aug. 7, 2023, effective Feb. 29, 2024.

9 CSR 30-3.152 Comprehensive Substance Treatment and Rehabilitation (CSTAR) Utilizing the American Society of Addiction Medicine (ASAM) Criteria {#sec-9-csr-30-3.152 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.152}

PURPOSE: This rule specifies the requirements for Comprehensive Substance Treatment and Rehabilitation (CSTAR) programs providing services in accordance with The ASAM Criteria:

Treatment Criteria for Addictive, Substance-Related, and Co- Occurring Conditions.

(1) This regulation applies to CSTAR programs that have not been granted a temporary waiver as specified in 9 CSR 30- 3.150(4).

(2) Policies and Procedures. In addition to the policies and procedures specified in 9 CSR 10-7.090(4), the organization shall have policies and procedures addressing the following:

(A) Drug screenings in accordance with The ASAM Criteria:

Treatment Criteria for Addictive, Substance-Related, and Co- Occurring Conditions, 2013, 3rd Edition, hereby incorporated available from the American Society of Addiction Medicine, Inc., 11400 Rockville Pike, Suite 200, Rockville, MD 20852, (301) 656-3920. This rule does not incorporate any subsequent amendments or additions to this publication;

(B) Treatment of co-occurring disorders in accordance with The ASAM Criteria (abbreviated) as referenced above; and (C) Staff training requirements in accordance with 9 CSR 30-3.155.

(3) Performance Improvement. In addition to the performance improvement requirements specified in 9 CSR 10-7.040, the organization shall have a performance improvement plan that addresses the clinical case review process via internal peer review in accordance with The ASAM Criteria as referenced in subsection (2)(A) of this rule.

(4) Levels of Care. Certification from the department is available for the following ASAM levels of care:

(A) Outpatient— 1. Level 0.5, early intervention;

Level 1, outpatient services; and 3. Level 1 OTP, opioid treatment services; and (B) Intensive outpatient (team-based services)— 1. Level 1-WM, ambulatory withdrawal management without extended on-site monitoring;
Level 2-WM, ambulatory withdrawal management without extended on-site monitoring;
Level 2-WM-EM, ambulatory withdrawal management with extended on-site monitoring;
Level 2.1, intensive outpatient services; and 5. Level 2.5, partial hospitalization services; and (C) Residential (team-based services)— 1. Level 3.1, clinically managed low intensity residential 2. Level 3.2-WM, clinically managed residential withdrawal management;
Level 3.3, clinically managed population-specific highintensity residential services;
Level 3.5, clinically managed high-intensity residential 5. Level 3.5, clinically managed high-intensity residential services (women and children); 6.

Level 3.5, clinically managed medium-intensity residential services (adolescents); 7.

Level 3.7, medically monitored intensive inpatient services; and 8. Level 3.7-WM, medically monitored inpatient withdrawal management.

(5) Telemedicine. Telemedicine is considered a face-to-face service. Services in all levels of care may be provided via telemedicine, including individual services within residential levels of care such as medication services, individual counseling, and medication services support.

(6) Billing Requirements. No more than one (1) per diem treatment rate may be billed per day for team-based services (intensive outpatient and residential levels of care), with the exception of Level 1-WM and Level 2-WM.

(A) The minimum number of hours of services outlined in this rule for specific levels of care must be provided on a daily

basis in order for the service provider to bill for a team-based service as supported by The ASAM Criteria and individual treatment plans. If a program does not provide the minimum number of hours specified, it is at risk of recoupment of funds by the department or other authorized representative(s).

Level 1-WM and Level 2-WM may be offered in conjunction with other outpatient levels of care (ASAM Levels 1, 2.1, and 2.5) with the expectation that if additional services are needed, the individual receives them in the appropriate level of care. Providers shall comply with the ASAM Billing Overlap Guidance, 2022, hereby incorporated by reference and made a part of this rule, developed by and available from the Department of Mental Health, 1706 E. Elm St., PO Box 687, Jefferson City MO 65101, (573) 751-4942, https://dmh.mo.gov/ media/file/asam-billing-overlap-guidance. This rule does not incorporate any subsequent amendments or additions to this publication.

(7) Minimum Staffing Requirements. Providers shall comply with the The ASAM Minimum Staffing Standards for Department of Mental Health, 2022, hereby incorporated by reference and made a part of this rule, developed by and available from the Department of Mental Health, 1706 E. Elm St., PO Box 687, Jefferson City MO 65101, (573) 751-4942, https://dmh.mo.gov/ media/pdf/dbh-asam-minimum-staffing-requirements. This

rule does not incorporate any subsequent amendments or additions to this publication.

(8) Multidimensional Assessment. The ASAM multidimensional assessment shall be utilized as specified in 9 CSR 30-3.151 to assist in determining each individual’s placement in a level of care that meets individual service needs.

(A) The six (6) dimensions include— 1. Dimension 1, acute intoxication and/or withdrawal potential—exploring an individual’s past and current experiences of substance use and withdrawal;

Dimension 2, biomedical conditions/complications— exploring an individual’s health history and current physical condition;
Dimension 3, emotional, behavioral, or cognitive conditions and complications—exploring an individual’s thoughts, emotions, and mental health issues;
Dimension 4, readiness to change—exploring an individual’s readiness and interest in changing;
Dimension 5, relapse, continued use, or continued problem potential—exploring an individual’s unique relationship with relapse or continued use or problems; and 6. Dimension 6, recovery/living environment—exploring an individual’s recovery or living situation, and the surrounding people, places, and things.

(B) All components of The ASAM Criteria, as referenced in subsection (2)(A) of this rule, must be considered when determining level of care placement for individuals served.

The levels of care available in the CSTAR program are defined in this rule.

(C) The admission guidelines included in this rule do not constitute a comprehensive list of placement criteria for the levels of care. All dimensional admission criteria specified in The ASAM Criteria must be considered when determining level of care placement for individuals served.

(9) Level 0.5 Early Intervention. Services shall be designed to address problems or risk factors related to substance use and to help individuals recognize the harmful consequences of highrisk substance use.

(A) Level 0.5 services include— 1. Individual counseling;

Group counseling;
Group rehabilitative support;
Family therapy;
Community support; and 6. Screening, brief intervention, and referral to treatment (SBIRT).

(B) Individuals meeting diagnostic criteria for a substance use disorder shall be referred to ongoing treatment, as appropriate.

Referral may also include medical, psychological, or psychiatric services, including assessment and community social services.

(C) Length of service shall vary based on factors such as the individual’s ability to comprehend the information provided and use that information to make behavior changes and avoid problems related to substance use, or the appearance of new problems that require treatment at another level of care.

(D) Admission guidelines for Level 0.5— 1. Acute intoxication and/or withdrawal potential— withdrawal can be safely managed in an outpatient setting;

Biomedical conditions and complications—none or very stable, any biomedical conditions and problems, if any, are sufficiently stable to permit participation in outpatient treatment;
Emotional, behavioral, or cognitive conditions and complications—none or very stable or receiving concurrent mental health monitoring. Adolescents are not at risk of harm and experiencing minimal current difficulties with activities of daily living, but there is significant risk of deterioration;
Readiness to change—the individual is open to recovery or willing to explore their substance use disorder and/or mental health condition and is at least contemplating change. The individual may require monitoring and motivating strategies to engage in treatment and to progress through the stages of change;
Relapse, continued use, or continued problem potential—the individual is able to achieve or maintain nonuse of alcohol and/or other drugs and pursue related recovery or motivational goals with minimal support; and 6. Recovery environment—family and environment can support recovery with limited assistance, or the individual has the skills to cope. Adolescents’ risk of initiation of or progression in substance use and/or high-risk behaviors is increased by substance use or values about use. High-risk behaviors of family, peers, or others in the adolescent’s social support system.

(10) Level 1 Outpatient Services. Level 1 outpatient services consist of professionally directed assessment, diagnosis, treatment, and recovery services provided in an organized outpatient treatment setting.

(A) Services shall include, but are not limited to— 1. Individual counseling;

Group counseling;
Family therapy;
Peer and family support;
Group rehabilitative support;
Medication services;
Medication services support;
Crisis intervention; and 9. Community support.

(B) For individuals with mental health conditions, issues of psychotropic medications, mental health treatment, and their relationship to substance use shall be addressed, as needed.

(C) Services shall vary in level of intensity based on individual needs and shall be fewer than nine (9) contact hours per week for adults age eighteen (18) and older, and fewer than six (6) contact hours per week for adolescents age nine (9) through eighteen (18).

(D) The duration of treatment shall vary based on the severity of the individual’s illness and their response to (E) Admission guidelines for Level 1— 1. Acute intoxication and/or withdrawal potential— withdrawal can be safely managed in an outpatient setting;

Biomedical conditions and complications—any biomedical conditions and problems, if any, are sufficiently stable to permit participation in outpatient treatment;
Emotional, behavioral, or cognitive conditions and complications—none or very stable or receiving concurrent mental health monitoring. Adolescents are not at risk of harm and experiencing minimal current difficulties with activities of daily living, but there is significant risk of deterioration;
Readiness to change—the individual is open to recovery or willing to explore their substance use disorder and/or mental health condition and is at least contemplating change. The individual may require monitoring and motivating strategies to engage in treatment and to progress through the stages of change;
Relapse, continued use, or continued problem potential—the individual is able to achieve or maintain nonuse of alcohol and/or other drugs and pursue related recovery or motivational goals with minimal support; and 6. Recovery environment—family and environment can support recovery with limited assistance, or the individual has the skills to cope.

(11) Level 1 Opioid Treatment Program (OTP). Level 1 OTPs provide community-based outpatient treatment for individuals with a diagnosed opioid use disorder. Medications shall be provided in conjunction with highly structured psychosocial programming that addresses major lifestyle, attitudinal, and behavioral issues that could undermine an individual’s recovery-oriented goals.

(A) OTPs shall comply with the federal opioid treatment regulations set forth under 42 CFR 8.12 and 9 CSR 30-3.132.

(B) OTPs shall administer medications approved by the Food and Drug Administration (FDA) to treat opioid use disorder and alleviate the adverse medical, psychological, and physical side effects of opioid dependence.

(C) Interventions shall include, but are not limited to— 1. Nursing assessment at the time of admission which is reviewed by a physician to determine the need for opioid treatment services, eligibility, and appropriate level of care placement for admission and referral;

A fully documented physical examination by a program physician or an assistant physician (AP), physician assistant (PA), advanced practice registered nurse (APRN), or resident physician working under the supervision of the program physician. The full medical examination, including the results of serology and other tests, must be completed within fourteen (14) days following admission;
A pregnancy test for women, as deemed clinically appropriate; and 4. Referral and assistance, as needed, for the individual mental health services.

(D) Admission guidelines for Level 1 OTP— 1. Acute intoxication and/or withdrawal potential—meets diagnostic criteria for an opioid use disorder;

Biomedical conditions and complications—meets biomedical criteria for opioid use disorder and may have a concurrent biomedical illness that can be treated on an outpatient basis;
Emotional, behavioral, or cognitive conditions and complications—none or stable or receiving concurrent mental health monitoring and/or treatment;
Readiness to change—requires a structured therapeutic and pharmacotherapy program to promote treatment progress and recovery;
Relapse, continued use, or continued problem potential—high risk of return to use of opioids or continued use without opioid pharmacotherapy, close outpatient monitoring, and structured support; and 6. Recovery environment—sufficiently supportive that outpatient treatment is feasible, or the individual does not have an adequate primary or social support system, but has demonstrated motivation and willingness to obtain such a support system.

(12) Level 1-WM Ambulatory Withdrawal Management Without Extended On-Site Monitoring. Organized outpatient services shall be delivered by trained clinicians who provide medically supervised evaluation, withdrawal management, and referral services according to a predetermined schedule.

Services shall be provided in regularly scheduled sessions under a defined set of policies and procedures or medical protocols.

(A) This level of care may be offered in conjunction with ASAM outpatient levels 1, 2.1, and 2.5 with the expectation that if additional services are needed, the individual receives them in the appropriate level of care.

(B) Services shall include, but are not limited to— 1. Assessment;

Medication or non-medication methods of withdrawal 3. Non-pharmacological clinical support;
Involvement of family members/natural supports in the withdrawal management process;
Physician and/or nurse monitoring, assessment, and withdrawal; and 6. Referral for counseling and involvement in community recovery support groups and arrangements for counseling, medical, psychiatric, and continuing care.

(D) Interventions shall include, but are not limited to— 1. A medical history and physical examination by a A. A physical examination not performed by a physician shall be dated and countersigned by a physician during the treatment episode or within seventy-two (72) hours, whichever occurs sooner, signifying their review of and concurrence with the findings;

Daily assessment of progress during withdrawal management and any treatment changes, or less frequent if the severity of withdrawal is sufficiently mild or stable;
Transfer, treatment, and discharge planning, beginning at the point of admission; and 4. Referral and assistance for the individual to gain access (E) Individuals shall meet the diagnostic criteria for a substance withdrawal disorder and the ASAM dimensional criteria for admission to this level of care.
For individuals whose presenting alcohol or other (F) Individuals shall remain in this level of care until— 1. Their withdrawal signs and symptoms are sufficiently resolved such that they can participate in self-directed recovery or ongoing treatment without the need for further medical or nursing withdrawal management monitoring; or 2. Their signs and symptoms of withdrawal have failed to respond to treatment and have intensified such that transfer to a more intensive level of withdrawal management service is indicated; or 3. They are unable to complete withdrawal management at Level 1-WM despite an adequate trial; for example, they are experiencing intense craving and evidence insufficient coping skills to prevent continued use concurrent with the withdrawal management medication, indicating a need for more intensive services.

(13) Level 2-WM Ambulatory Withdrawal Management Without Extended On-Site Monitoring. Organized outpatient services shall be provided by trained clinicians to treat the individual’s level of clinical severity to achieve safe and comfortable withdrawal from mood-altering chemicals and to effectively facilitate their entry into ongoing treatment and recovery.

(A) This level of care can be offered in conjunction with ASAM outpatient levels 1, 2.1, and 2.5 with the expectation that if additional services are needed, the individual receives them in the appropriate level of care.

(B) Services shall include, but are not limited to— 1. Assessment;

Medication or non-medication methods of withdrawal 3. Non-pharmacological clinical support;
Involvement of family members/natural supports in the withdrawal management process;
Physician and/or nurse monitoring, assessment, and withdrawal; and 6. Referral for counseling and involvement in community recovery support groups and arrangements for counseling, medical, psychiatric, and continuing care.

(D) Interventions shall include, but are not limited to— 1. A medical history and physical examination by a A. A physical examination not performed by a hours, whichever occurs sooner, signifying their review of and concurrence with the findings;

Daily assessment of progress during withdrawal management and any treatment changes;
Transfer, treatment, and discharge planning, beginning at the point of admission; and 4. Referral and assistance for the individual to gain access (E) Individuals shall meet the diagnostic criteria for substance withdrawal disorder and the ASAM dimensional criteria for 1. For individuals whose presenting alcohol or other (F) Individuals shall remain in this level of care until— 1. Their withdrawal signs and symptoms are sufficiently resolved such that they can be safely managed in a less intensive level of care; or 2. Their signs and symptoms of withdrawal have failed to respond to treatment and have intensified (based on a standardized scoring system) such that transfer to a more intensive level of withdrawal management service is indicated;
They are unable to complete withdrawal management at Level 2-WM despite an adequate trial; for example, they are experiencing intense craving and have insufficient coping skills to prevent continued alcohol or other drug use, indicating a need for more intensive services.

(14) Level 2-WM-EM Ambulatory Withdrawal Management with Extended On-Site Monitoring. Organized outpatient services shall be provided by trained clinicians who provide medically supervised evaluation, withdrawal management, and referral services. Services shall be designed to treat the individual’s level of clinical severity to achieve safe and comfortable withdrawal from mood-altering chemicals and to effectively facilitate the individual’s entry into ongoing treatment and recovery.

(B) Services shall include, but are not limited to— 1. Assessment;

Medication or non-medication methods of withdrawal 3. Non-pharmacological clinical support;
Involvement of family members/natural supports in the withdrawal management process; and 5. Physician and/or nurse monitoring, assessment, and withdrawal.

(D) Services shall include up to twenty-three (23) hours of continuous observation, monitoring, and support in a supervised environment for the individual to achieve initial recovery from the effects of alcohol and/or other drugs and to be appropriately transitioned to the most appropriate level of care to continue the recovery process.

(E) Individuals must be discharged within twenty-three (23) hours of admission.

(F) Programs shall operate twenty-four (24) hours per day, seven (7) days per week. Staff shall be dressed and awake. Twenty-four- (24-) hour access to emergency medical consultation services shall be available.

(G) Interventions shall include, but are not limited to— 1. A medical history and physical examination by a A. A physical examination not performed by a hours, whichever occurs sooner, signifying their review of and concurrence with the findings;

Daily assessment of progress during withdrawal management and any treatment changes;
Transfer, continuing recovery, and discharge planning beginning at the point of admission;
Conduct or arrange for appropriate laboratory and toxicology tests which can be point-of-care testing, as medically necessary; and 5. Referral and assistance for the individual to gain access (H) Individuals shall meet the diagnostic criteria for substance withdrawal disorder and the ASAM dimensional criteria for admission.
For individuals whose presenting alcohol or other (I) Individuals shall remain in this level of care until— 1. Their withdrawal signs and symptoms are sufficiently resolved such that the individual can be safely managed in a less intensive level of care; or 2. Their signs and symptoms of withdrawal have failed to respond to treatment and have intensified (based on a standardized scoring system) such that transfer to a more intensive level of withdrawal management service is indicated;
They are unable to complete withdrawal management at Level 2-WM despite an adequate trial; for example, they are experiencing intense craving and have insufficient coping skills to prevent continued alcohol or other drug use, indicating a need for more intensive services.

(15) Level 2.1 Intensive Outpatient Treatment. This level of care shall include professionally directed assessment, diagnosis, treatment, and recovery services provided in an organized, non-residential treatment setting.

(A) Services shall include, but are not limited to— 1. Psychiatric, medical, and laboratory services, as needed;

Comprehensive bio-psychosocial assessments and individualized treatment, allowing for a valid assessment of dependency;
Frequent monitoring/management of the individual’s medical and emotional concerns in order to avoid hospitalization;
Individual counseling, group counseling, family therapy, peer and family support, crisis intervention, and community support; and 5. Monitoring of substance use, medication services, medication services support, medical and psychiatric examinations, crisis intervention, and orientation and referral to community-based support groups.

(B) Timely access to additional support systems and services including medical, psychological, and toxicology shall be available through consultation or referral.

(C) Services shall vary in level of intensity and shall include nine (9) or more contact hours per week for adults, age eighteen (18) years and older, not to exceed nineteen (19) hours per week. Services for adolescents age nine (9) through seventeen (17) shall include six (6) or more contact hours per week, not to exceed nineteen (19) hours per week. The week starts on the individual’s date of admission.

The duration of treatment shall vary based on the severity of the individual’s illness and their response to 2. Individuals shall receive a minimum of one hour and thirty minutes (1.5) hours of services per day.

(D) Interventions shall include, but are not limited to— 1. Monitoring, including biomarkers and/or toxicology testing, as medically necessary;

Random drug screening, as medically necessary, to treatment plan; and 3. Documented referral to more or less intensive services.

(E) Individuals shall meet diagnostic criteria for a substance use disorder and the ASAM dimensional criteria for admission. If the individual’s presenting substance use

history is inadequate to substantiate such a diagnosis, the probability of such a diagnosis may be determined from information appropriately submitted or obtained from collateral parties such as family members, legal guardian, or natural supports. Additional admission guidelines include— 1. Acute intoxication and/or withdrawal potential— withdrawal needs can be safely managed in an intensive outpatient setting. The adolescent who is appropriately placed in this level of care is likely to attend, engage, and participate in treatment as evidenced by being able to tolerate mild subacute withdrawal symptoms, has made a commitment to sustain treatment and follow treatment recommendations, and has external supports to promote engagement in treatment;

Biomedical conditions and complications—none or sufficiently stable to permit participation in outpatient treatment;
Emotional, behavioral, or cognitive conditions and complications—none to moderate. If present, the individual must receive appropriate co-occurring disorder services depending on their level of function, stability, and degree of impairment in this dimension;
Readiness to change—requires structured therapy and a programmatic milieu to promote treatment progress and recovery because motivational interventions at another level of care were unsuccessful. Adolescents admitted to this level of care may be only passively involved in treatment or demonstrate variable adherence with attendance at outpatient treatment sessions or self-help groups;
Relapse, continued use, or continued problem potential—experiencing an intensification of symptoms of the substance-related disorder and level of functioning is deteriorating despite modification of the treatment plan.

Alternatively, there is a high likelihood of relapse, continued use, or continued problems without close monitoring and support several times a week as indicated by the individual’s lack of awareness of relapse triggers, difficulty in coping or in postponing immediate gratification, or ambivalence toward treatment; and 6. Recovery environment—insufficiently supportive environment and the individual lacks the resources or skills necessary to maintain an adequate level of functioning without services in intensive outpatient treatment. Alternatively, the individual lacks social contacts, has unsupportive social contacts that jeopardize recovery, or has few friends or peers who do not use alcohol or other drugs.

(16) Level 2.5 Partial Hospitalization Services. A planned format of services shall be delivered on an individual and group basis to meet individual needs.

(A) Services shall include, but are not limited to— 1. Psychiatric, medical, and laboratory services, as needed;

Comprehensive bio-psychosocial assessments and individualized treatment, allowing for a valid assessment of dependency;
Frequent monitoring/management of the individual’s medical and emotional concerns in order to avoid hospitalization;
Individual counseling, group counseling, family therapy, peer and family support, crisis intervention, and community support; and 5. Monitoring of substance use, medication services, medication services support, medical and psychiatric examinations, crisis intervention, and orientation to community-based support groups.

(B) A minimum of twenty (20) hours of clinically intensive programming shall be provided per week, based on individual treatment plans. The week starts on the individual’s date of 1. Individuals shall receive a minimum of two hours and twenty-four minutes (2.4 hours) of services per day.

(C) Interventions shall include, but are not limited to— 1. A physical examination based on the individual’s medical condition. Such determinations are made according to established program protocols which include reliance on the individual’s personal healthcare provider, when possible.

Examinations are based on the staff’s capabilities and the severity of the individual’s symptoms, and are approved by a physician; and 2. Random drug screening, as medically necessary, to (D) Individuals must meet diagnostic criteria for a substance admission. If the individual’s presenting substance use history is inadequate to substantiate such a diagnosis, the probability appropriately submitted or obtained from collateral parties such as family members, legal guardian, or natural supports.

Acute intoxication and/or withdrawal potential— withdrawal needs can be safely managed in a partial hospital setting;
Biomedical conditions and complications—none or not sufficient to interfere with treatment but are severe enough to distract from recovery efforts and require medical monitoring and/or medical management;
Emotional, behavioral, or cognitive conditions and complications—none to moderate. If present, the individual must receive appropriate co-occurring disorder services depending on the their level of function, stability, and degree of impairment in this dimension;
Readiness to change—the individual requires structured therapy and a programmatic milieu to promote treatment progress and recovery because motivational interventions at another level were unsuccessful;
Relapse, continued use, or continued problem potential—the individual is experiencing an intensification of symptoms related to their substance use disorder and their level of functioning is deteriorating despite modification of the treatment plan and active participation in a Level 1 or Level 2.1 program; and 6. Recovery environment—insufficiently supportive environment and the individual lacks the resources or skills necessary to maintain an adequate level of functioning without services in a partial hospitalization program. Alternatively, family members and/or other natural supports who live with the individual are not supportive of their recovery goals or are passively opposed to their treatment.

(17) Level 3.1 Clinically Managed Low-Intensity Residential Services. Programs shall provide a structured recovery environment which allows sufficient stability to prevent or minimize relapse or continued use and continued problem potential for individuals served.

(A) Treatment services are focused on improving the individual’s readiness to change and/or functioning and coping skills. Services shall include, but are not limited to— 1. Individual counseling;

Group counseling;
Group rehabilitative support;
Family therapy;
Medication services;
Medication services support; and 7. Community support.

(B) Individuals shall participate in at least five (5) hours of services per week. The week starts on the individual’s date of admission. Mutual/self-help meetings shall not be included in the five (5) hours of treatment per week.

The target length of stay is one (1) to three (3) months, based on individual needs.

(C) Programs shall be staffed twenty-four (24) hours per day, (D) Interventions shall include, but are not limited to— 1. Tuberculosis screening and testing, provided directly or 2. Random drug screening, as medically necessary, to 3. Documented physical examination one (1) month 4. Referral and assistance, as needed, for the individual to gain access to other needed substance use disorder or mental health services;

Orientation and facilitated connections to recovery co-occurring disorders, as appropriate and for the continuation of appropriate treatment; and 6. Specific and documented plans for community reintegration and transition to less intensive levels of residential and treatment support, including the aftercare to which the individual is being discharged.

(E) Individuals must meet diagnostic criteria for a substance admission. If the individual’s presenting substance use history is inadequate to substantiate such a diagnosis, the probability appropriately submitted or obtained from collateral parties such as family members, legal guardian, or natural supports.

Acute intoxication and/or withdrawal potential— none, or minimal/stable withdrawal risk and can be safely managed in this level of care. The adolescent’s status in this dimension is characterized by problems with intoxication or withdrawal (if any) that are being managed through concurrent placement at another level of care for withdrawal management (typically Level 1, 2.1, or 2.5);
Biomedical conditions and complications—biomedical problems, if any, are stable and do not require medical or nurse monitoring and the individual is capable of self-administering any prescribed medications. The adolescent’s status in this dimension is characterized by a biomedical condition that distracts from recovery efforts and requires limited residential supervision to ensure adequate treatment and provide support to overcome the distraction, or continued substance use would place them at risk of serious damage to their physical health;
Emotional, behavioral, or cognitive conditions and complications—minimal problems in this area. The individual’s mental status is assessed as sufficiently stable to allow them to participate in therapeutic interventions provided at this level of care and to benefit from treatment. The adolescent’s status in this dimension is characterized by at least one (1) of the following:

A. Risk of dangerous consequences because of the lack of a stable environment;

B. Emotional, behavioral, or cognitive problems result in moderate impairment in social functioning;

C. Moderate impairment in their ability to manage the activities of daily living;

D. History and present situation suggests an emotional, behavioral, or cognitive condition would become unstable without twenty-four (24) hours supervision; or E. Emotional, behavioral, or cognitive condition suggests the need for low-intensity and/or longer term reinforcement and practice of recovery skills in a controlled environment;

Readiness to change—open to recovery, but in need of a structured, therapeutic environment to promote treatment progress and recovery due to impaired ability to make behavior changes without the support of a structured environment;
Relapse, continued use, or continued problem potential— understands the risk of relapse, but lacks relapse prevention skills or requires a structured environment to continue to apply recovery and coping skills. The adolescent is at high risk of substance use or deteriorated mental functioning with dangerous emotional, behavioral, or cognitive consequences in the absence of twenty-four- (24-) hour structured support;
Recovery environment—able to cope for limited periods of time outside of the twenty-four- (24-) hour structure, but the environment jeopardizes recovery. The adolescent’s home environment is too chaotic or ineffective to support or sustain treatment goals such that recovery is assessed as unachievable without residential support.

(18) Level 3.2 Clinically Managed Residential Withdrawal Management. Services shall be provided in an organized, residential, non-medical setting and be delivered by appropriately trained staff who provide safe, twenty-four- (24-) hour supervision, observation, and support for individuals who are intoxicated or experiencing withdrawal.

(A) Programs may be staffed to supervise self-administered medications for management of withdrawal symptoms. All programs shall have established clinical protocols to identify individuals in need of medical services beyond the program’s capacity and to arrange for transfer to an appropriate healthcare facility.

(B) Services shall include, but are not limited to— 1. Individual counseling;

Group counseling;
Group rehabilitation support;
Peer and family support;
Community support; and 6. Medical and medication services support.

(D) Programs shall be staffed twenty-four (24) hours per (E) Interventions shall include, but are not limited to— 1. Random drug screening, as medically necessary, to reinforce treatment gains, as appropriate to the individual’s 2. A medical history and physical examination by a A. A physical examination that is not performed by a hours, whichever occurs sooner, signifying their review of and concurrence with the findings;

A comprehensive nursing assessment at admission which includes a substance use history and assessment recommendations that are reviewed with a physician; and 4. Documented referral and assistance for the individual mental health services.

(F) Individuals admitted to this level of care are experiencing signs and symptoms of withdrawal, or there is evidence (based on history of substance intake, age, gender, previous withdrawal history, present symptoms, physical condition and/or emotional, behavioral, or cognitive conditions) that withdrawal is imminent. The individual is assessed as not being at risk of severe withdrawal and moderate withdrawal is safely manageable at this level of service.

In addition, the individual may be assessed as not requiring medication to assist in managing withdrawal symptoms, but requires this level of service to complete withdrawal management and enter into continued treatment or self-help recovery because of inadequate home supervision or support structure, as evidenced by meeting one (1) of the following criteria:

A. The individual’s recovery environment is not supportive of withdrawal management and entry into treatment, and they do not have sufficient coping skills to safely manage issues in the recovery environment; or B. The individual has a recent history of withdrawal management at less intensive levels of service that is marked by inability to complete withdrawal management or to enter into continuing substance use disorder treatment, and continues to have insufficient skills to complete withdrawal management; or C. The individual recently demonstrated an inability to complete withdrawal management at a less intensive level of service, as evidenced by continued use of non-prescribed drugs or other substances.

(19) Level 3.3 Clinically Managed, Population-Specific High Intensity Residential Services (Adult Criteria). Programs shall provide a structured recovery environment in combination with high-intensity clinical services to meet the individual’s functional limitations and to support recovery from substancerelated disorders.

(A) Length of stay is based on the individual’s severity of illness, level of function, and progress in treatment.

(B) Individuals shall receive a minimum of twenty (20) hours of services per week. The week starts on the individual’s date of admission.

At least ten (10) of the twenty (20) hours of services shall include a combination of individual counseling, group counseling, group rehabilitative support, family therapy, peer and family support, community support, medication services, and medication services support.

(C) Programs shall be staffed twenty-four (24) hours per day, (D) Interventions shall include, but are not limited to— 1. Tuberculosis screening and testing provided directly or 2. Random drug screening, as medically necessary, to reinforce treatment gains, as appropriate to the individual’s 3. Comprehensive nursing assessment completed within 4. A documented physical examination one (1) month 5. Referral and assistance, as needed, for the individual mental health services; and 6. Orientation and facilitated connections to recovery of appropriate treatment.

(E) Individuals admitted to this level of care must meet diagnostic criteria for a moderate or severe substance admission. If the individual’s presenting history is inadequate diagnosis may be determined from information submitted by collateral parties such as family members/natural supports and legal guardians. Additional guidelines include— 1. Acute intoxication and/or withdrawal potential—none, or minimal risk of withdrawal, or withdrawal needs can be safely managed at this level;

Biomedical conditions and complications—none or stable. Any biomedical problems do not require medical or nurse monitoring and the individual is capable of selfadministering any prescribed medications;
Emotional, behavioral, or cognitive conditions and complications—the individual’s mental status (including emotional stability and cognitive functioning) is assessed as sufficiently stable to permit them to participate in the therapeutic interventions provided at this level of care and to benefit from treatment;
Readiness to change—because of the intensity and chronicity of the substance use disorder or the individual’s cognitive limitations, they have little awareness of the need for continuing care or the existence of their substance use or mental health problem and need for treatment and, therefore, has limited readiness to change;
Relapse, continued use, or continued problem potential—the individual has limited awareness of relapse triggers and is in imminent danger of relapse or continued substance use. The individual requires relapse prevention activities that are delivered at a slower pace, more concretely, and more repetitively within a twenty-four (24) hour structured environment; and 6. Recovery environment—the environment interferes with recovery and is characterized by moderately high risk of initiation or repetition of physical, sexual, or emotional abuse, or substance use is so prevalent the individual is unable to cope outside of a twenty-four- (24-) hour supervised setting.

(20) Level 3.5 Clinically Managed High-Intensity Residential Services (Adult Criteria). Programs shall be designed to serve individuals who, because of specific functional limitations, need a safe and stable environment in order to develop and/or demonstrate sufficient recovery skills so they do not immediately relapse or continue to use in an imminently dangerous manner upon transfer to a less intensive level of care. Individual needs are of such severity that treatment cannot be safely provided in a less intensive level of care.

(A) Length of stay is based on the individual’s severity of illness, level of function, and progress in treatment.

(B) Individuals shall receive at least a twenty- (20-) hour 1. At least ten (10) of the twenty (20) hours shall include a combination of individual counseling, group counseling and rehabilitative support, family therapy, peer and family support, community support, crisis intervention, medication services, and/or medication services support.

(C) Programs shall be staffed twenty-four (24) hours per day, (D) Interventions shall include, but are not limited to— 1. Tuberculosis screening and testing provided directly 2. Random drug screening, as medically necessary, to 3. Comprehensive nursing assessment completed within 4. A documented physical examination one (1) month 5. Modification to the treatment plan based on review 6. Referral and assistance as needed for the individual 7. Orientation and facilitated connections to recovery of appropriate treatment; and 8. Documented plans for community reintegration and individual is being discharged.

(E) Individuals admitted to this level of care must meet diagnostic criteria for a substance use disorder of moderate to high severity, as well as the ASAM dimensional criteria for admission. If the individual’s presenting history is inadequate diagnosis may be determined from information submitted by collateral parties such as family members/natural supports, and legal guardians. Other admission guidelines include— 1. Acute intoxication and/or withdrawal potential—none, or withdrawal symptoms can be safely managed at this level;

Biomedical conditions and complications—none or stable and the individual can self-administer any prescribed medication or, if their condition is severe enough to distract from treatment and recovery, the individual can receive medical monitoring within the program or through another 3. Emotional, behavioral, or cognitive conditions and complications—the individual’s mental status (including emotional stability and cognitive functioning) is assessed as sufficiently stable to permit them to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. Despite the individual’s best efforts, they are unable to control their use of alcohol and/or other drugs, and their level of dysfunction is so severe they would not be successful in a less structured level of care;
Readiness to change—the individual has marked difficulty with or opposition to treatment, with dangerous consequences, and has limited insight and awareness of the need for continuing care or the existence of their substance use or mental health problem and need for treatment, thereby has limited readiness to change;
Relapse, continued use, or continued problem potential—the individual is unable to recognize relapse triggers and has no recognition of the skills needed to prevent continued use, with limited ability to initiate or sustain ongoing recovery in a less structured environment; and 6. Recovery environment—the individual lives in an environment with moderately high risk of neglect, initiation, or repetition of physical, sexual, or emotional abuse, or is in a culture highly invested in substance use. The individual lacks skills to cope with challenges to recovery outside of a highly structured twenty-four- (24-) hour setting.

(21) Level 3.5, Clinically Managed Medium Intensity Residential Services (Adolescent Criteria). This is a residential program offering a twenty-four- (24-) hour supportive treatment environment. Adolescents placed in this level of care typically have impaired functioning across a broad range of psychosocial domains. These impairments may be expressed as disruptive behaviors, delinquency and juvenile justice involvement, educational difficulties, family conflicts and chaotic home situations, developmental immaturity, and psychological problems.

(A) Length of stay shall be based on the individual’s severity (B) Individuals shall receive at least a twenty- (20-) hour 1. At least ten (10) of the twenty (20) hours shall include a combination of individual counseling, group counseling and rehabilitative support, family therapy, peer and family support, community support, medication services, and/or medication services support.

(C) Programs shall be staffed twenty-four (24) hours per day, (D) Interventions shall include, but are not limited to— 1. Tuberculosis screening and testing provided directly 2. Random drug screening, as medically necessary, to 3. Comprehensive nursing assessment completed within 4. A documented physical examination one (1) month 5. Modification to the treatment plan based on review 6. Referral and assistance, as needed, for the individual to gain access to other needed medical, substance use disorder, and/or mental health services;

Orientation and facilitated connections to recovery of appropriate treatment;
Documented plans for community reintegration and individual is being discharged; and 9. Educational services provided in accordance with state regulations, including opportunities to address deficits in the education level of adolescents who have fallen behind because of their involvement with alcohol and/or other drugs.

(E) Adolescents admitted to this level of care must meet diagnostic criteria for a substance use disorder of moderate to high severity, as well as the ASAM dimensional criteria for admission. If the adolescent’s presenting history is inadequate diagnosis may be determined from information submitted by family members/natural supports and legal guardians.

Acute intoxication and/or withdrawal potential—at risk of or experiencing acute or subacute intoxication or withdrawal, with mild to moderate symptoms. Needs secure placement and increased treatment intensity to support engagement in treatment, ability to tolerate withdrawal, and prevention of immediate continued use. Alternatively, the adolescent has a history of unsuccessful treatment at the same or a less intensive level of care;
Biomedical conditions and complications—biomedical conditions distract from recovery efforts and require residential supervision (that is unavailable in a less intensive level of care) to ensure adequate treatment, or the adolescent requires medium-intensity residential treatment to provide support to overcome the distraction. Continued substance use would place the adolescent at risk of serious damage to their physical health because of a biomedical condition (such as pregnancy or HIV) or an imminently dangerous pattern of high-risk use;
Emotional, behavioral, or cognitive conditions and complications—the adolescent is at moderate but stable risk of imminent harm to self or others and needs medium intensity, twenty-four- (24-) hour monitoring and/or treatment for protection and safety, however, does not require access to medical or nursing services. Their recovery efforts are negatively impacted by their emotional, behavioral, or cognitive problems in significant and distracting ways;
Readiness to change—because of the intensity and chronicity of their substance use disorder and/or mental health problems, the adolescent has limited insight into and little awareness of the need for continuing care or the existence of their substance use disorder or mental health issues and has limited readiness to change. The individual has marked difficulty in understanding the relationship between their substance use disorder, mental health, or life problems and their impaired coping skills and level of functioning, often blaming others for their problems;
Relapse, continued use, or continued problem potential—the adolescent does not recognize relapse triggers and lacks insight into the benefits of continuing care, and is therefore, not committed to treatment. Their continued use of substances poses an imminent danger of harm to self or others in the absence of twenty-four- (24-) hour monitoring and structured support; and 6. Recovery environment—living and social environments have a high risk of neglect or initiation or repetition of physical, sexual, or severe emotional abuse, such that the adolescent is assessed as being unable to achieve or maintain recovery without residential treatment.

(22) Level 3.5 Clinically Managed High-Intensity Residential Services (Women and Children). Programs shall provide a twenty-four- (24-) hour supportive treatment environment specializing in services for women who are pregnant, postpartum, and/or have children. Programs shall arrange for gender-specific substance use disorder treatment and other therapeutic interventions for women and comply with child supervision and other requirements specified in 9 CSR 30-3.190.

(A) Length of stay shall be based on the individual’s severity (B) Individuals shall receive at least a twenty- (20-) hour 1. At least ten (10) of the twenty (20) hours shall include a combination of individual counseling, group counseling and rehabilitative support, family therapy, peer and family support, crisis intervention, community support, medication services, and/or medication services support.

(C) Programs shall be staffed twenty-four (24) hours per day, (D) Interventions shall include, but are not limited to— 1. Tuberculosis screening and testing provided directly or 2. Random drug screening, as medically necessary, to 3. Comprehensive nursing assessment completed within 4. A documented physical examination one (1) month 5. Children accompanying their mother to services shall receive a screening by a qualified mental health professional (QMHP) or qualified addiction professional (QAP) to determine the appropriateness and need for services.

A. If services are determined to be a need for the child(ren), a licensed diagnostician shall complete an assessment with diagnosis;

Modification to the treatment plan based on review 7. Referral and assistance as needed for the individual to gain access to other needed substance use disorder and/or 8. Orientation to and facilitated connections to recovery of appropriate treatment;
Documented plans for community reintegration and individual is being discharged.

(E) Individuals who are admitted to this level of care must meet diagnostic criteria for a substance use disorder of moderate to high severity, as well as the ASAM dimensional criteria for admission. If the individual’s presenting history is inadequate to substantiate such a diagnosis, the probability submitted by collateral parties such as family members, legal guardians, and significant others.

(F) Priority shall be given to women who are pregnant, postpartum, or have children in their physical care and custody. Additional admission guidelines include— 1. Acute intoxication and/or withdrawal potential—none, or withdrawal symptoms can be safely managed at this level;

Biomedical conditions and complications—none or stable and the individual can self-administer any prescribed medication, or if the condition is severe enough to distract from treatment and recovery, the individual can receive medical monitoring within the program or through another 3. Emotional, behavioral, or cognitive conditions and complications—mental status (including emotional stability and cognitive functioning) is assessed as sufficiently stable to permit them to participate in the therapeutic interventions provided at this level of care and to benefit from treatment;
Readiness to change—significant difficulty with treatment, with negative consequences, and may have significant limitations in the areas of readiness to change.

Recovery may be perceived as providing a lesser return for the effort;

Relapse, continued use, or continued problem potential—needs skills to prevent continued use and may have relapse, continued use, or continued problem potential; and 6. Recovery environment—the individual lives in an environment with moderately high risk of neglect, initiation or repetition of physical, sexual, or emotional abuse, or is in a culture highly invested in substance use. The individual lacks skills to cope with challenges to recovery outside of a highly structured twenty-four- (24-) hour setting. These social influences may represent a sense of hopelessness or an acceptance of deviance as normative.

(23) Level 3.7 Medically Monitored Intensive Inpatient Services (Adult Criteria). Programs shall provide a planned and structured regimen of twenty-four- (24-) hour professionally directed evaluation, observation, medical monitoring, and substance use disorder treatment in a residential setting.

Individuals in this level of care may have co-occurring substance use and mental health disorders that need to be stabilized. The target population includes individuals with a high risk of withdrawal symptoms and moderate co-occurring psychiatric and/or medical problems that are of sufficient severity to require twenty-four- (24-) hour treatment.

(A) Length of stay shall be based on the individual’s severity (B) Individuals shall receive thirty (30) hours of structured treatment per week. The week starts on the individual’s date of admission.

At least ten (10) of the thirty (30) hours shall include a combination of individual counseling, group counseling, group rehabilitative support, family therapy, peer and family support, crisis intervention, community support, medication services, and/or medication services support.

(C) Programs shall be staffed twenty-four (24) hours per day, (D) Interventions shall include, but are not limited to— 1. Tuberculosis screening and testing provided directly 2. Random drug screening, as medically necessary, to 3. Nursing assessment at time of admission by an RN (or APRN, physician, resident physician, assistant physician, physician assistant in the absence of an RN);

A physician or AP, PA, APRN, or resident physician assesses the individual within twenty-four (24) hours of admission or, within twenty-four (24) hours of admission, a physician reviews and updates the record of a physical examination that was conducted no more than seven (7) days prior to admission. A physician must be available to assess the individual thereafter, as medically necessary;
Additional medical specialty consultation, psychological, laboratory, and toxicology services are available onsite, through consultation, or referral;
Referral and assistance, as needed, for the individual mental health services; and 7. Orientation and facilitated connections to recovery resources and community supports, including referrals to self-help programs for identified psychiatric, substance use and co-occurring disorders as appropriate and for the continuation of appropriate treatment.

(E) Individuals admitted to this level of care must meet diagnostic criteria for a moderate or severe substance use disorder, as well as the ASAM dimensional criteria for admission. If the individual’s presenting history is conflicting or inadequate to substantiate such a diagnosis, the probability provided by family members/natural supports and legal guardians. Additional admission criteria includes— 1. Acute intoxication and/or withdrawal potential—high risk of withdrawal symptoms that can be managed in a Level 3.7 program;

Biomedical conditions and complications—moderate to severe conditions which require twenty-four- (24-) hour nursing and medical monitoring or active treatment but not the full resources of an acute care hospital;
Emotional, behavioral, or cognitive conditions and complications—moderate to severe conditions and complications (such as diagnosable co-morbid mental disorders or symptoms). These symptoms may not be severe enough to meet diagnostic criteria but interfere or distract from recovery efforts (for example, anxiety/hypomanic or depression and/or cognitive symptoms) and may include compulsive behaviors, suicidal or homicidal ideation with a recent history of attempts but no specific plan, or hallucinations and delusions without acute risk to self or others. Psychiatric symptoms are interfering with abstinence, recovery, and stability to such a degree that the individual needs a structured twenty-four- (24-) hour, medically monitored (but not medically managed) environment to address recovery efforts;
Readiness to change—the individual is unable to acknowledge the relationship between the substance use disorder and mental health and/or medical issues, or is in need of intensive motivating strategies, activities, and processes available only in a twenty-four- (24-) hour structured medically monitored setting (but not medically managed);
Relapse, continued use, or continued problem potential—the individual is experiencing an escalation of relapse behaviors and/or acute psychiatric crisis and/or reemergence of acute symptoms and is in need of twenty-four- (24-) hour monitoring and structured support; and 6. Recovery environment—the environment or current living arrangement is characterized by a high risk of initiation or repetition of physical, sexual, or emotional abuse or substance use so prevalent that the individual is assessed as unable to achieve or maintain recovery at a less intensive level of care.

(24) Level 3.7 Medically Monitored Intensive Inpatient Services (Adolescent Criteria). Programs shall provide a planned and structured regimen of twenty-four- (24-) hour professionally directed evaluation, observation, medical monitoring, and substance use disorder treatment. For adolescents, this level of treatment is often necessary to orient the individual to the structure of daily life. Services must be provided in accordance with 9 CSR 30-3.192.

(A) Length of stay shall be based on the individual’s severity (B) Individuals shall receive at least thirty (30) hours of structured treatment per week. The week starts on the individual’s date of admission.

At least ten (10) of the thirty (30) hours shall include a combination of individual counseling, group counseling, group rehabilitative support, family therapy, peer and family support, community support, medication services, and/or medication services support.

(C) Elements of the assessment and treatment plan review in this level of care for adolescents shall include— 1. An initial withdrawal assessment within twenty-four (24) hours of admission, or earlier if clinically warranted;

Daily nursing withdrawal monitoring assessments and continuous availability of nursing evaluation; and 3. Daily availability of medical evaluation, with continuous on-call coverage.

(D) Programs shall be staffed twenty-four (24) hours per (E) Interventions shall include, but are not limited to— 1. Tuberculosis screening and testing provided directly 2. Random drug screening, as medically necessary, to 3. Nursing assessment at the time of admission by an RN (or APRN, physician, resident physician, assistant physician, physician assistant in the absence of an RN);

A physician or AP, PA, APRN, or resident physician assesses the individual within twenty-four (24) hours of admission or, within twenty-four (24) hours of admission, a physician reviews and updates the record of a physical examination that was conducted no more than seven (7) days prior to admission. A physician must be available to assess the individual thereafter, as medically necessary;
Additional medical specialty consultation, psychological, laboratory, and toxicology services are available on-site, through consultation or referral;
Referral and assistance, as needed, for the individual 7. Orientation and facilitated connections to recovery help programs for identified psychiatric, substance use, and cooccurring disorders, as appropriate, and for the continuation of appropriate treatment; and 8. Educational services provided in accordance with state regulations, including opportunities to address deficits in the educational level of adolescents who have fallen behind because of their involvement with alcohol and/or other drugs.

(F) Adolescents admitted to this level of care must meet diagnostic criteria for a moderate or severe substance use disorder, as well as ASAM dimensional criteria for admission. If the adolescent’s presenting history is conflicting or inadequate diagnosis may be determined from information provided by collateral parties such as parent/guardian, family members, or other natural supports. Additional admission guidelines include— 1. Acute intoxication and/or withdrawal potential— experiencing or at risk of acute or subacute intoxication or withdrawal with moderate to severe signs and symptoms.

The individual needs twenty-four- (24-) hour treatment services including the availability of active medical and nurse monitoring to manage withdrawal, support engagement in treatment, and prevent immediate continued use;

Biomedical conditions and complications—significant risk of serious damage to physical health or concomitant biomedical conditions, or a biomedical condition requires twenty-four- (24-) hour nursing and medical monitoring or active treatment, but not the full resources of an acute care hospital;
Emotional, behavioral, or cognitive conditions and complications—moderate and possibly unpredictable risk of imminent harm to self or others and needs twenty-four- (24-) hour monitoring and/or treatment in a high-intensity programmatic environment for safety;
Readiness to change—despite experiencing serious consequences or effects of the substance use disorder and/ or behavioral health problem, does not accept or relate the disorder to the severity of the presenting problem. The individual is in need of intensive monitoring strategies, activities, and processes available in a twenty-four- (24-) hour setting;
Relapse, continued use, or continued problem potential—experiencing an acute psychiatric or substance use crisis, marked by intensification of symptoms of the substance use or mental disorder such as poor impulse control or drugseeking behavior; and 6. Recovery environment—has been living in an environment in which supports that might otherwise have enabled treatment at a less intensive level of care are unavailable, or the family is unable to sustain treatment attendance at a less intensive level of care.

(25) Level 3.7 Medically Monitored Inpatient Withdrawal Management (Adult Criteria). Services shall be provided by medical and nursing professionals who provide medically supervised evaluation under a defined set of physicianapproved policies and physician-monitored procedures or clinical protocols.

(A) Twenty-four- (24-) hour observation, monitoring, and treatment shall be provided by an interdisciplinary team of trained staff.

(B) Individuals remain in this level of care until withdrawal signs and symptoms are sufficiently resolved such that they can be safely managed at a less intensive level of care, or their signs and symptoms of withdrawal have failed to respond to treatment and have intensified (as confirmed by higher scores on a standardized scoring system).

(C) Services shall include assessment, individual and group counseling, group rehabilitative support, peer/family support, community support, medication services, crisis intervention, and medication services support.

(D) Admissions shall be accepted twenty-four (24) hours per Services shall be available seven (7) days per week. The week starts on the individual’s date of admission.

(E) Interventions shall include, but are not limited to— 1. Random drug screening, as medically necessary, to 2. A nursing assessment by an RN at admission (or APRN, resident physician, assistant physician, physician assistant in the absence of an RN) that is reviewed with a physician;

A physician or AP, PA, APRN, or resident physician assessment within twenty-four (24) hours of admission or, within twenty-four (24) hours of admission, a physician reviews and updates the record of a physical examination that was conducted no more than seven (7) days prior to admission. A physician must be available to assess the individual thereafter, as medically necessary;
Daily assessment of the individual’s progress through withdrawal management and any treatment changes;
For individuals new to the program, it is recommended that an assessment be completed within twenty-four (24) hours of admission which substantiates appropriate level of care placement; and 6. Referral and assistance for the individual to gain access Original rule filed Aug. 7, 2023, effective Feb. 29, 2024.

9 CSR 30-3.155 Staff Requirements for Comprehensive Substance Treatment and Rehabilitation (CSTAR) Programs {#sec-9-csr-30-3.155 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.155}

PURPOSE: This rule describes requirements for caseload size, clinical privileging, training, and core competencies for staff working in CSTAR programs.

(1) Other Regulations. Each organization that is certified/ deemed certified by the department as a CSTAR program shall comply with requirements set forth in Department of Mental Health Core Rules for Psychiatric and Substance Use Disorder Treatment Programs, 9 CSR 10-7.110 Personnel.

(2) Qualified Staff. The program director shall ensure an adequate number of qualified professionals are available to provide CSTAR services.

(A) Caseload size may vary according to the acuity, symptom complexity, and needs of individuals served. An individual being served or his or her parent/guardian has the right to request an independent review by the CSTAR director if they believe individual needs are not being met. If the CSTAR director deems it necessary, caseload size or other changes may be implemented.

(B) The supervisory-to-staff ratio shall be based on the needs of individuals being served, focusing on successful outcomes and satisfaction with services and supports as expressed by persons served.

(C) The organization shall have policies and procedures for monitoring and adjusting caseload size and ensure there is documented, ongoing supervision of clinical and direct service staff.

(3) Clinical Privileging. The program shall have and implement a process for granting clinical privileges to practitioners to deliver CSTAR services.

(A) Each treatment discipline shall define clinical privileges based upon identified and accepted criteria approved by the governing body.

(B) The process shall include periodic review of each practitioner’s credentials, performance, education, and the like, and the renewal or revision of clinical privileges at least every two (2) years.

(C) Initial granting and renewal of clinical privileges shall be 1. Well-defined written criteria for qualifications, clinical performance, and ethical practice related to the goals and objectives of the program;

Verified licensure, certification, or registration, if 3. Verified training and experience;
Recommendations from the agency’s program, department service, or all of these, in which the practitioner will be or has been providing service;
Evidence of current competence;
Evidence of health status related to the practitioner’s ability to discharge his/her responsibility, if indicated; and 7. A statement signed by the practitioner that he/she has read and agrees to be bound by the policies and procedures established by the provider and governing body.

(D) Renewal or revision of clinical privileges shall also be 1. Relevant findings from the CSTAR program’s quality assurance activities; and 2. The practitioner’s adherence to the policies and procedures established by the CSTAR program and its governing body.

(E) As part of the privileging process, the CSTAR program shall establish procedures to— 1. Afford a practitioner an opportunity to be heard, upon request, when denial, curtailment, or revocation of clinical privileges is planned;

Grant temporary privileges on a time-limited basis; and 3. Ensure that non-privileged staff receive close and documented supervision from privileged practitioners until training and experience are adequate to meet privilege requirements.

(4) Training and Staff Competencies. Direct care staff and staff providing supervision to direct care staff shall complete training in the service competency areas listed below.

(A) Competent staff shall— 1. Operate from person-centered, person-driven, recoveryoriented, and stage-wise service delivery approaches that promote health and wellness;

Develop cultural competence that results in the ability to understand, communicate with, and effectively interact with people across cultures;
Deliver services according to key service functions that are evidence-based and best practices;
Practice in a manner that demonstrates respect and understanding of the unique needs of persons served;
Use effective strategies for engagement, re-engagement, relationship-building, and communication; and 6. Be knowledgeable of mandated reporting requirements for abuse and neglect of children and reporting requirements related to abuse, neglect, or financial exploitation of senior citizens and individuals who are disabled.

(B) Staff providing supervision to community support specialists must have additional training or experience in order to be knowledgeable in the supervision competency areas listed below. Competent supervisors— 1. Practice in a manner that demonstrates use of management strategies that focus on individual outcomes, care coordination, collaboration, and communication with other service providers both within and external to the organization;

Ensure new and existing staff are competent by providing training/supervision, guidance and feedback, field mentoring, and oversight of services to individuals served by the team;
Ensure processes exist for tracking and review of data such as missed appointments, hospitalization and follow-up care, crisis responsiveness and follow-up, timeliness and quality of documentation, and need for outreach and engagement;
Monitor and review services, interventions, and contacts with individuals served to ensure services are implemented according to individualized treatment plans or crisis prevention plans, evaluate the effectiveness and appropriateness of services in achieving recovery/resiliency outcomes in areas such as housing, employment, education, leisure activities, and family, peer, and social relationships.

(C) New staff shall job shadow their supervisor and/or experienced staff in a position equivalent to their qualifications and skill level.

(D) Staff shall receive ongoing and regular clinical supervision.

(E) A written plan shall be developed indicating how competencies will be measured and ensured for all staff providing direct services and staff providing supervision including, but not limited to, some combination of the following:

Testing;
Observation/field supervision;
Clinical supervision/case discussion;
Quality review of case documentation;
Use of relevant findings from quality assurance activities;
Satisfaction with services as conveyed by individuals served and family members/natural supports;
Stakeholder/interagency satisfaction with services; and 8. Treatment outcomes for individuals and family members/natural supports.

(F) Demonstrated competency must be documented within the first six (6) months of employment with the CSTAR program.

(G) Staff shall participate in at least thirty-six (36) clock hours of relevant training during any two (2) year period.

A minimum of twelve (12) clock hours of training must be completed annually.

(H) CSTAR programs providing services in accordance with The ASAM Criteria shall ensure the following training requirements are met:

All direct care staff are trained on utilization of The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, 2013, 3rd edition, hereby incorporated available from the American Society of Addiction Medicine (ASAM), Inc., 11400 Rockville Pike, Suite 200, Rockville, MD 20852, (301) 656-3920. This rule does not incorporate any Training must be provided by an entity with permission from ASAM to deliver the training;
All direct care staff participate in fifty (50) hours of annual training including, but not limited to— A. Treatment of co-occurring disorders;

B. Suicide prevention (best-practice or evidence-based), as specified in the organization’s Zero Suicide Plan;

C. Trauma-informed care, must align with the agency’s trauma-informed assessment and implementation plan;

Annual training applies to the requirement specified in subsection (4)(G) of this rule; and 4. Ongoing training based on staff roles and responsibilities including, but not limited to— A. Peer support, provided by the Missouri Credentialing Board;

B. Family support, provided by the Missouri Credentialing Board;

C. Smoking cessation, approved by the department; and D. The ASAM Criteria advanced training (must be provided by an entity with permission from ASAM to deliver the training).

(I) Documentation of all orientation, training, job shadowing, and supervision activities must be maintained and available for review by department staff or other authorized representatives.

(J) Documentation of training must include the topic, date(s) and length, skills targeted/objective of skill, certification/ continuing education units (as applicable), location, and name, title, and credentials of instructor(s).

Original rule filed May 28, 2021, effective Dec. 30, 2021. Amended:

Filed Aug. 7, 2023, effective Feb. 29, 2024.

9 CSR 30-3.157 Community Support in Comprehensive Substance Treatment and Rehabilitation (CSTAR) Programs {#sec-9-csr-30-3.157 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.157}

PURPOSE: This rule establishes the requirements for community support services provided in CSTAR programs.

(1) Service Delivery. The CSTAR program shall establish an identifiable unit which coordinates and provides community support services for children, youth, families, and/or adults.

The unit shall be organized to perform functions within the scope of community support services, including critical interventions.

(2) Policies and Procedures. The CSTAR program shall implement policies and procedures to provide adequate, appropriate, and effective community support services to individuals. Policies and procedures shall include:

(A) A mechanism to assure the provision of all needed substance use disorder treatment services, as indicated in the individual’s current treatment plan;

(B) A mechanism to assure the provision of all needed services in addition to those provided by the CSTAR program, as indicated in the individual’s current treatment plan;

Procedures to assure each individual is afforded an opportunity to express preferences in the selection of a community support specialist; and 2. A mechanism to assure all individuals admitted who need community support are assigned to an active caseload of a community support specialist;

(D) A process to assure an effective transfer and follow-up of an individual between or among community support specialists or community support teams. Staff shall document the rationale for the transfer, the individual’s acceptance, and follow-up by the community support specialist in the clinical record;

(E) A process for determining overall increase or decrease in the level of functioning for individuals served through ongoing performance improvement activities;

(F) A method to assure staff providing community support services in the CSTAR program have the opportunity to participate and contribute to the agency’s performance improvement process;

(G) Development of suitable revisions to treatment goal(s) as indicated by growth or deterioration of individual functioning and/or condition; and (H) Program and aggregate evaluation activities to determine effectiveness of services delivered.

(3) Staff Requirements. The CSTAR program shall ensure an adequate number of appropriately qualified staff are available to provide community support services and functions.

(A) Qualified staff includes:

A qualified addiction professional (QAP) as defined in 9 CSR 10-7.140;
A qualified mental health professional (QMHP) as defined in 9 CSR 10-7.140;
An individual with a bachelor’s degree in a human services field which includes social work, psychology, nursing, education, criminal justice, recreational therapy, human development and family studies, counseling, child development, gerontology, sociology, human services, behavioral science, and rehabilitation counseling;
An individual with any four (4) year combination of higher education and qualifying experience;
An individual with any four (4) year degree and two (2) years of qualifying experience;
An individual with an Associate of Applied Science in Behavioral Health Support degree from an approved institution; or 7. An individual with four (4) years of qualifying experience.

(B) Qualifying experience must include delivery of services to individuals with mental illness, substance use disorders, or developmental disabilities. Experience must include some combination of the following:

Providing one-on-one or group services with a rehabilitation/habilitation and recovery/resiliency focus;
Teaching and modeling for individuals how to cope and manage psychiatric, developmental, or substance use disorder issues while encouraging the use of natural resources;
Supporting individuals in their efforts to find and maintain employment and/or to function appropriately in family, school, and community settings; and 4. Assisting individuals to achieve the goals and objectives in their individual treatment plan.

(C) It is the responsibility of the CSTAR program to document how staff meet the qualifications based on the criteria in subsections (3)(A) and (3)(B) of this rule.

(D) Community support specialists must also complete orientation and training required by the department.

(E) Community support specialists must be supervised by— 1. A qualified addiction professional (QAP);

A qualified mental health professional (QMHP);
Staff possessing a Master’s degree in a behavioral health or related field who has completed a practicum or has one (1) year of experience in a behavioral health field; or 4. Staff who meet the qualifications of a community support specialist with at least three (3) years of populationspecific experience providing community support services in accordance with the key service functions specified in paragraphs (5)(B)1. to 8. of this rule.

(F) Community support supervisors who are not a QAP or QMHP must be supervised by a QAP or QMHP.

(4) Monitoring. To the extent the individual is able to participate, periodic observation and monitoring shall take place in his/ her home or other community location as stipulated in the individual treatment plan.

(A) Observation and monitoring shall be documented including, but not limited to:

Assessment of the individual’s mental health status and/ or substance use;
Safety and home care; and 3. Functional abilities and skill transference related to activities of daily living including educating, demonstrating, observing, and practicing skills in his/her environment.

(5) Service Delivery. Community support is a comprehensive service designed to reduce the individual’s disability resulting from a mental illness, emotional disorder, and/or substance use disorder and restore functional skills of daily living, principally by developing natural supports and solutionoriented interventions intended to achieve recovery/resiliency as identified in the goals and/or objectives in the individual (A) This service may be provided to the individual’s family/ natural supports when such services are for the direct benefit of the individual served, in accordance with the needs and goals identified in the treatment plan, to assist in the individual’s recovery/resiliency. Most contact occurs in community locations where the individual lives, works, attends school, and/or socializes.

(B) Key service functions of community support shall include, but are not limited to:

Developing recovery goals and identifying needs, strengths, skills, resources, and supports and teaching individuals how to use them to support recovery, identifying barriers to recovery, and assisting individuals in the development and implementation of plans to overcome them;
Helping individuals restore skills and resources negatively impacted by their substance use disorder and/or co-occurring mental illness or emotional disorder including, but not limited to:

A. Seeking or successfully maintaining employment or volunteering including, but not limited to, communication, personal hygiene and dress, time management, capacity to follow directions, planning transportation, managing symptoms/cravings, learning appropriate work habits, and identifying behaviors that interfere with work performance;

B. Maintaining success in school including, but not limited to, communication with teachers, personal hygiene and dress, age appropriate time management, capacity to follow directions and carry out school assignments, appropriate study habits, and identifying and addressing behaviors that interfere with school performance; and C. Obtaining and maintaining housing in the least restrictive setting including, but not limited to, issues related to nutrition, meal preparation, and personal responsibility;

Supporting and assisting individuals in a crisis to access needed treatment services to resolve the crisis;
Continuing recovery planning and discharge planning with individuals who are hospitalized for a medical or behavioral health condition;
Assisting individuals, other natural supports, and referral sources in identifying risk factors related to relapse in mental illness and/or substance use disorders, developing strategies to prevent relapse, and advising and otherwise assisting individuals in implementing those strategies;
Promoting the development of positive support systems by providing information to family members/natural supports, as appropriate, regarding mental illness, emotional disorders, and/or substance use disorders and ways they can be of support to their family member’s recovery. Such activities must be directed toward the primary well-being and benefit of the individual served;
Developing and advising individuals on implementing lifestyle changes needed to cope with the side effects of psychotropic medications and/or to promote recovery/ resiliency from the disabilities, negative symptoms, and/or functional deficits associated with a mental illness, emotional disorder, and/or substance use disorder; and 8. Advising individuals on maintaining a healthy lifestyle including, but not limited to, recognizing the physical and psychological signs of stress, creating a self-defined daily routine that includes adequate sleep and rest, walking or exercise and appropriate levels of activity and productivity, involvement in creative or structured activities that counteract negative stress responses, learning to assume personal responsibility and care for minor illnesses, and knowing when professional medical attention is needed.

(6) Documentation. Documentation must be maintained in the individual record for each community support session, service, or activity in accordance with 9 CSR 10-7.030(13). The following must also be documented:

(A) Phone contacts; and/or (B) Pertinent/significant information reported by family members/natural supports regarding a change in the individual’s condition and/or an unusual or unexpected occurrence in his/her life.

Original rule filed May 28, 2021, effective Dec. 30, 2021.

9 CSR 30-3.160 Institutional Treatment Centers {#sec-9-csr-30-3.160 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.160}

(Rescinded June 30, 2024)

Filed March 20, 2019, effective Oct. 30, 2019. Rescinded: Filed Nov. 30, 2023, effective June 30, 2024.

History

AUTHORITY: sections 313.842, 630.050, and 630.655, RSMo 2016.

9 CSR 30-3.190 Comprehensive Substance Treatment and Rehabilitation (CSTAR) Program for Women and Children {#sec-9-csr-30-3.190 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.190}

PURPOSE: This rule establishes requirements for CSTAR programs serving women and children.

(1) Treatment Philosophy and Guiding Principles. Women and children’s CSTAR programs shall demonstrate through policy and practice that women’s substance use disorders differ from men’s, both in their etiology and the services and supports needed for recovery.

(A) Women and children’s CSTAR programs shall ensure— 1. Emotional and physical safety of the women and children served takes precedence over other considerations in the delivery of services;

Women-only therapeutic environments are available;
Trauma-sensitive services and supports to increase women’s access to care, engagement, and retention in treatment are provided or arranged, such as community support, transportation, and child care;
Women-specific service needs and topic areas are addressed in treatment and through support services; and 5. Multiple modalities are offered to meet the needs of women such as group and individual counseling, community support, peer support, and opportunities for women to be in treatment with their children.

(B) Staff shall possess the knowledge and expertise to engage women with histories of trauma, recognize the presence of trauma symptoms, understand the role of trauma in the lives of women seeking services, and conduct themselves in ways that are not retraumatizing to those being served. The following trauma-informed principles shall be integrated into the program’s service delivery practices:

Safety—ensuring physical and emotional safety for individuals and staff;
Trustworthiness—maximizing trustworthiness through task clarity, consistency, and maintaining appropriate interpersonal boundaries;
Choice—maximizing the experience of developmentally appropriate choice and control;
Collaboration—maximizing collaboration and sharing of power between individuals and staff; and 5. Empowerment—building on individuals’ capacities, encouraging them to have a voice and mastery of life, and prioritizing power and growth.

(C) All women shall receive or have trauma-informed, evidence-based services available and shall not be required to disclose their trauma history in order to receive those services.

Women’s treatment shall incorporate universal, traumainformed principles into every service, regardless of whether trauma is disclosed.

(D) The Substance Abuse and Mental Health Services Administration (SAMHSA), Treatment Improvement Protocol 51, Substance Abuse Treatment: Addressing the Specific Needs of Women, 2015, hereby incorporated by reference and made a

part of this rule, shall serve as a guide for the program’s service delivery practices. This document is published by and available from SAMHSA, 1 Choke Cherry Road, Rockville, Maryland 20857, (877) 726-4727, www.samhsa.gov. This rule does not incorporate any subsequent amendments or additions to this publication.

(2) Eligibility Criteria and Program Structure. The program shall provide treatment services and other supports solely to women and their children. Services shall be based on individual and family needs, in accordance with admission and eligibility criteria for CSTAR.

(A) Priority admission shall be for women who are— 1. Pregnant and inject drugs;

Pregnant;
Postpartum (up to one (1) year after delivery);
Have children in their care and custody, including those at risk of losing custody or attempting to regain custody of their children;
Applicants or recipients of Temporary Assistance for Needy Families referred by the Department of Social Services, Family Support Division; and 6. Other populations specified by the department.

(B) Women who meet priority criteria shall be immediately admitted to the CSTAR program and receive appropriate 1. If the program is unable to provide immediate admission, staff shall facilitate referral to another women and children’s CSTAR program that can provide immediate admission.

If immediate admission with an alternative women and children’s CSTAR program is not available for a woman who is pregnant, program staff shall contact designated department staff to obtain assistance in facilitating arrangements for immediate admission with another program.
Women shall not be denied admission based solely on medication prescribed and monitored by a licensed physician, physician assistant, assistant physician, or advanced practice registered nurse (APRN) for an opioid disorder or other physical or behavioral health disorder.

(C) Adolescents who meet priority criteria shall be admitted if, in the staff’s clinical judgment, the adolescent can appropriately participate in and benefit from the services and milieu offered. Programs shall have policies and procedures for serving adults and adolescents in the same environment.

(D) Culturally competent services shall be provided in the context of a family-centered and family-focused treatment model. Members of the treatment team shall be responsible for adapting to the needs of the mother and her family. An array of services shall be available to— 1. Assist families in functioning as a unit by establishing and maintaining a schedule, structure, regular habits, and healthy routines;

Allow for an integrated family plan that builds coherence and prioritizes the needs of individual family members;
Accommodate children who accompany their mother, in accordance with the mother’s wishes;
Address substance use, mental, physical and emotional health, developmental, social, economic, and environmental needs of women and their families;
Allow women to define their families and focus on healthy relationships between parents, children, and others identified by the mother;
Address evolving and changing family engagement, recognizing everyone may not participate at the same time, stay the same length of time, or have the same motivations;
Assist women and their families in accessing other services and supports in the community.

(E) Family oriented living arrangements, indoor recreational space for children and families, and safe, protected outdoor recreational and leisure space shall be available.

(F) Women and their children shall have access to ageappropriate physical healthcare, including obstetric and pediatric care.

(3) Gender-Responsive Services. The program shall address therapeutic issues relevant to women and their specific needs, as identified in individual treatment plans.

(A) Staff shall understand and recognize the distinctive characteristics and biopsychosocial issues associated with women in general, and specifically women who have substance use disorders, to provide effective treatment.

(B) Services shall be culturally sensitive and recognize the unique characteristics of women’s initiation of substance use, effects of use, histories of trauma, co-occurring mental, developmental, and physical health disorders, and other treatment issues specific to women.

(C) Services shall be designed to assist women in maintaining their recovery and resiliency, such as— 1. Parenting and child development;

Life skills;
Family programs;
Facilitation of supervised parent-child bonding;
Educational remediation and support;
Employment readiness services;
Linkages with legal and child welfare systems, including reunification with children if applicable;
Housing support efforts and referrals;
Co-occurring disorder services, including access to psychological and pharmacological treatments for mental health disorders;
Education and linkage to eating disorder and nutrition 11. Medication services, including access to approved medication to treat substance use disorders for women who are pregnant; and 12. Recovery support and community support services that address long-term recovery needs such as domestic violence services, career counseling, legal services, and transportation (4) Child Care. The program shall ensure child care is not a barrier to engagement in services or retention in treatment by ensuring coordination or facilitation of child care when the mother is participating in services.

(A) Programs offering on-site child care shall obtain licensure as a child care center as specified in 5 CSR 25-500.

(B) On-site child care shall— 1. Be designed to meet the developmental needs of the various age groups served and address cultural and other identified needs;

Provide each child with a variety of easily accessible, developmentally appropriate learning and play materials;
Provide for a balance between free play and organized activities, between individual play and sharing experiences among children, and promote individual contact between staff and each child;
Provide reasonable regularity of age-appropriate activities with allowance for a variety of special events and time for children to be outdoors daily, weather permitting;
Be culturally responsive, nonjudgmental, trauma sensitive, and respectful;
Take responsible precautions to ensure a safe, welcoming, and sanitary environment appropriate for children;
Ensure no weapons are brought on to the premises;
Provide privacy (such as use of bathroom, sleeping arrangements) for opposite sex children transitioning into school and for any children demonstrating a need for privacy;
Accommodate the needs of children with disabilities in accordance with the Americans with Disabilities Act as amended (ADAAA) or refer to another provider if the child’s needs are identified to be beyond the scope of the program.

The ADAAA, effective January 1, 2009, is hereby incorporated by reference and made a part of this rule and is available from the U.S. Department of Justice, 950 Pennsylvania Avenue NW, Civil Rights Division, Disability Rights Section-NYA, Washington, DC 20530, (800) 514-0301 voice, (800) 514-0383 TTY. This rule does not incorporate any subsequent amendments or additions to this publication.

(C) Child care may be arranged through a contractual agreement with a local, licensed child care center. Contracts shall comply with 9 CSR 10-7.090(6).

(D) Child care will not be funded by the department for children who are over fourteen (14) years of age, unless specific authorization has been granted by department staff.

(5) Supervision of Children. The program shall ensure children in child care are supervised in accordance with Department of Elementary and Secondary Education staff/child ratios as specified in 5 CSR 25-500.

(A) The parent/guardian shall be responsible for providing supervision when the child is not attending child care or participating in other scheduled program activities.

(B) Program staff shall assist the parent in providing ageappropriate activities, training, and guidance.

(6) Education for Children. The program shall assist the parent/ guardian as necessary to ensure educational opportunities for school-age children in accordance with the requirements of the Department of Elementary and Secondary Education.

(7) Assessing Children’s Needs and Documenting Services.

Program staff shall inform women of the services available for children and educate them about involving their children in treatment while respecting the mother’s wishes.

(A) When the mother chooses to involve her children in treatment, a trained staff member shall complete an initial screening utilizing an age-appropriate, validated instrument to determine specific service needs beyond child care and community support. The screening shall include an interview with at least one (1) parent and the child, whenever appropriate.

(B) If the need for a clinical assessment is indicated by the screening, a qualified staff member shall complete an assessment utilizing an age-appropriate, validated instrument.

The assessment must be completed prior to delivery of services beyond child care and community support.

(C) An individual plan shall be developed based on the needs of the mother and child, with the results of the assessment serving as a guide. The child’s consent for treatment must be signed by the legal guardian.

(D) Services provided for children, including child care and community support, shall be documented in a separate clinical record for the child. The record shall include the child’s developmental, physical, emotional, social, educational, and family background and current status.

(8) Services for Children. The program shall ensure traumainformed services are available to address therapeutic issues relevant to children, based on the needs of individuals being served at those locations.

(A) Developmentally appropriate activities and services shall be offered to meet the social, emotional, and behavioral needs of children to— 1. Build self-esteem and self-awareness;

Learn to identify and express feelings;
Build positive family relationships;
Learn healthy social engagement, peer relationships, social pressure skills, and teamwork;
Develop decision-making skills;
Learn self-management (impulse control, stress management, and goal-setting);
Understand substance use disorders and its effects on the family;
Learn and practice nonviolent ways to resolve conflict;
Learn safety practices such as personal space, boundaries, and personal safety;
Address developmental needs; and 11. Provide education on preventing alcohol, tobacco, and other drug use.

(B) Services for children shall address the issues and needs identified by the mother and her children, as documented in the individual plan, utilizing structured and unstructured therapeutic activity.

(C) Specialized services shall be provided including, but not limited to, children with high risk of sexual abuse, sexual acting-out behaviors, suicide risk, and the service needs of infants, toddlers, and preschoolers.

(D) Services for children from birth to three (3) years of age shall include, at a minimum, developmentally appropriate parent-child interactive bonding activities and developmentally appropriate structured activities that promote and nurture the growth and well-being of the infant.

(9) Qualified and Competent Staff. The program shall maintain a core workforce (employed or contracted) that is appropriately qualified and determined to be competent to adequately address the needs of women and children and deliver the behavioral health services the program is certified to provide.

(A) The program shall document that staff providing services for women and/or children have training in the following areas:

Trauma knowledge, trauma-informed treatment, identification of signs and symptoms of domestic violence, spousal or partner abuse, and child abuse and neglect, with special emphasis on failure to thrive and sexual abuse of children;
Child development and age-appropriate behaviors;
Parenting attachment styles and skills appropriate to infants, toddlers, preschool, and school-age children; and 4. The impact of substance use and substance use disorders on parenting and family units.

(B) The program shall document that staff working with children have ongoing training and demonstrate jobappropriate functional comprehension in the following areas:

The impact of prenatal drug and alcohol exposure on child development;
The effect of substance use disorders on parenting children and families;
Trauma knowledge, trauma’s impact on child brain development, and long-term impact of adverse childhood experiences;
Parenting attachment styles and skills appropriate to infants, toddlers, preschool, and school-age children;
Appropriate play activities according to developmental stage;
Common children’s behavioral and developmental problems;
Recognition of sexual acting-out behavior; and 8. The substance use disorder recovery process, especially as it relates to family units.

(10) Health Promotion. The program shall maintain a safe, healthy environment that is responsive to the physical, behavioral, and emotional health needs of women and children.

(A) A full-time licensed nurse shall be accessible to women and children to provide trauma-informed medical and other consultative services necessary to monitor and manage health issues.

Services performed by a licensed practical nurse (LPN) must fall within their scope of practice and shall be supervised by a licensed physician (including psychiatrist), licensed physician assistant, licensed assistant physician, APRN, or registered nurse (RN).

(B) Key service functions of the nurse(s) shall include, but are not limited to— 1. Obtaining initial medical histories and vital signs of individuals admitted to the program;

Monitoring general health needs and meeting with individuals about medical concerns;
Providing disease prevention, risk reduction, and reproductive health education;
Reviewing medication requirements and educating individuals about the benefits of taking medications as prescribed and monitoring medication compliance; and 5. Monitoring lab levels, including consultation with the individual served, her physician, and the treatment team.

(C) The program shall employ staff in sufficient numbers and with appropriate training to respond to emergency situations and provide cardiopulmonary resuscitation (CPR) when necessary.

At least one (1) staff member who has current training in First Aid and CPR for infants, children, and adults shall be on duty seven (7) days per week, twenty-four (24) hours per day.
Staff must maintain current First Aid and CPR certification for healthcare providers through training that includes hands-on practice and in-person skills assessment.

Online-only training is not acceptable.

(D) The program shall demonstrate effective working relationship(s) with a licensed physician, hospital, and/or clinic to provide access to emergency services and/or ongoing medical care for women, including pregnant and postpartum women, and their children.

(E) The program shall ensure an evaluation of medical need for each woman and child and shall ensure that each woman and child is medically stable to safely and adequately participate in services. For women, the evaluation of medical need shall include:

Current physical status, including vital signs; and 2. Symptoms of intoxication, impairment, or withdrawal.

(F) The program shall ensure that recommendations related to an individual’s behavioral or physical health from a licensed physician (including psychiatrist), licensed physician assistant, licensed assistant physician, or APRN are encouraged and coordinated regularly by their primary health care provider.

(G) Health-related services may include but are not limited to— 1. Nutritional counseling;

Education about reproductive health;
Wellness programs;
Education on sleep and dental hygiene;
Education about trauma and long-term physical health risks and conditions;
Education about sexually transmitted infections and infectious diseases, such as viral hepatitis and HIV/AIDS; and 7. Preventive healthcare education.

(H) If a specialized program for women and children provides withdrawal management/detoxification services, the program shall comply with applicable standards under 9 CSR 30-3.120. A specialized program for women and children shall not be required to accept applications for ninety-six- (96-) hour civil detention of intoxicated persons due to the presence of children within the program.

Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Rescinded and readopted: Filed Aug. 17, 2022, effective March 30, 2023.

9 CSR 30-3.192 Comprehensive Substance Treatment and Rehabilitation (CSTAR) Program for Adolescents {#sec-9-csr-30-3.192 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.192}

PURPOSE: This rule establishes requirements for certified/deemed certified CSTAR programs for adolescents.

(1) Other Regulations. Adolescent CSTAR programs shall comply with 9 CSR 10-7 Core Rules for Psychiatric and Substance Use Disorder Treatment Programs, 9 CSR 10-5 General Program Procedures, and 9 CSR 30-3 Substance Use Disorder Prevention and Treatment Programs, as applicable.

(2) Age Criteria. The program shall provide treatment, rehabilitation, and other services solely to individuals age nine through seventeen (9-17) and their family members/natural supports, as appropriate. Services in a residential setting shall be available for individuals age twelve through seventeen (12- 17).

(A) Exceptions to the age requirements may be authorized through the department’s clinical review process.

(3) Registered Sex Offenders and Youth Identified on the Juvenile County Registry. Prior to admission, program staff shall verify whether the individual is registered as a juvenile sex offender in the county in which they reside pursuant to

section 211.425, RSMo, or is identified as an offender on the Missouri State Highway Patrol (MSHP) sex offender registry pursuant to sections 589.400-589.425, RSMo.

(A) If the individual is an identified juvenile sex offender on the juvenile county sex offender registry, admission to the CSTAR program can be considered.

(B) If the individual is an identified offender on the MSHP sex offender registry, admission to the CSTAR program shall not be made.

(C) All results of verification with the county juvenile sex offender registry or MSHP sex offender registry, as well as decisions related to program admission, shall be documented and a record of communication to the individual’s parent/ guardian and referral source(s), as applicable, shall be maintained by the program.

If the parent/guardian disagrees with a decision of ineligibility for admission, they shall be informed of the grievance process of the CSTAR program.

(D) If the individual is not admitted to the program within sixty (60) days after program staff have conducted verification of the county juvenile sex offender registry, staff are responsible for rechecking the registry prior to admission. Rechecking the registry is always an option and should be completed any time there is a concern, even when the sixty (60) days have not yet passed.

(E) The MSHP registry is updated in real time and should be checked any time the sixty (60) days has passed.

(4) Eligibility Criteria and Level of Care. The program shall comply with 9 CSR 30-3.151 Eligibility Determination, Assessment, and Treatment Planning in CSTAR Programs, to ensure individuals are placed in the appropriate level of care and receive individualized services.

(5) Treatment Principles and Therapeutic Issues Relevant to Adolescents. The program shall address therapeutic issues relevant to adolescents and shall address their specific needs.

The following principles and methods shall be reflected in services delivered to adolescents:

(A) Adolescents are effectively treated in therapeutic environments that are programmatically and physically separate from treatment services for adults;

(B) Services shall maintain individuals in the family and community setting, as clinically appropriate;

(C) Services shall involve parents/guardian and other family members/natural supports in the treatment and recovery process, when clinically appropriate. If the caregivers are not available, program staff shall assist in developing alternate social and family/natural support systems for the adolescent;

(D) Services to family members/natural supports shall be directed to understanding and supporting the adolescent’s recovery and resiliency, identifying and intervening with any behavioral health needs of their caregiver(s), improving parenting skills and communication skills within the family or with other caregivers/natural supports, and facilitating improved family function;

(E) A cooperative team approach shall be utilized in order to provide a consistent therapeutic environment;

(F) Effectively treating substance use disorders in adolescents requires identifying and treating other co-occurring conditions they may have;

(G) Services shall be coordinated with the juvenile justice system, children’s services, and other community agencies to ensure the needs of individuals are met;

(H) Staff shall possess the knowledge and expertise to engage adolescents with histories of trauma, recognize the presence of trauma symptoms, understand the role of trauma in the lives of adolescents, and conduct themselves in ways that are not retraumatizing to those being served;

(I) Issues such as violence, child abuse, and risk of suicide shall be identified and addressed;

(J) Communicable disease counseling and testing for sexually transmitted infections, such as HIV and hepatitis B and C, are important aspects of adolescent treatment (refer to 9 CSR 30-3.110(C) for service delivery requirements). Testing may be waived if parent/guardian consent is not obtained and is documented, as applicable to the individual served; and (K) Service delivery shall address recovery/resiliency skill development including, but not limited to— 1. Substance use prevention and education;

Assertiveness training;
Conflict resolution skills;
Emotional regulation;
Social network development;
Leisure time management;
Problem-solving skills;
Adolescent development;
Sexual health; and 10. Trauma.

(6) Treatment Setting. Adolescents may receive substance use disorder treatment services in a variety of settings including but not limited to the following:

(A) Home of the parent/guardian;

(B) Foster home;

(D) Juvenile detention (services are not reimbursable by Medicaid);

(E) Other supervised living arrangements;

(F) Independent living; and (G) School.

(7) Family Involvement. Each adolescent’s living arrangement and family situation shall be reviewed by program staff in order to identify needs and to develop treatment goals and recovery supports for the adolescent and their family members and/or other natural supports.

(A) This review shall be conducted by a licensed mental health professional (LMHP) or a qualified addiction professional (QAP) or qualified mental health professional (QMHP) who is under the supervision of an LMHP.

(B) Refusal by the caregiver for an in-home visit shall not constitute automatic denial of treatment services for the (C) The program shall actively involve family members/natural supports in the treatment process including educational and counseling sessions and transfer and discharge planning, unless contraindicated for legal or clinical reasons which are documented in the individual record. Efforts to involve family members/natural supports, and any reasons for lack of participation, shall be included in documentation.

(D) Staff shall orient the parent or legal guardian regarding— 1. Treatment philosophy and design;

Discipline and any emergency safety interventions used by the program;
Availability of staff to conduct home-based treatment and community support services;
Emergency medical procedures; and 5. Expectations about ongoing participation by family members/natural supports.

(8) Educational and Vocational Opportunities. The program shall have established partnerships with local school district(s) to ensure individuals’ academic and vocational needs are met in accordance with their Individual Education Program (IEP) and/or 504 Plan.

(A) For youth enrolled in American Society of Addiction Medicine (ASAM) Level 1, Level 2.1, or Level 2.5, certain CSTAR services may be provided within the school setting. An agreement for the provision of such services must be arranged by the CSTAR provider and their local school district(s). The ASAM Criteria: Treatment Criteria for Addictive, Substance- Related, and Co-Occurring Conditions, 3rd Edition, 2013, is hereby incorporated by reference and made a part of this rule as published by and available from The American Society of Addiction Medicine, 11400 Rockville Pike, Suite 200, Rockville, MD 20852, (301) 656-3920. This rule does not incorporate any (B) CSTAR services delivered in the school setting are limited to three (3) hours, twelve (12) units per week total.

Comprehensive assessment;
Community support;
Individual counseling;
Group counseling;
Group rehabilitative support;
HIV pre-testing and post-testing counseling;
Medication services support;
Family therapy/conference; and 9. Peer support.

(9) Privilege System. Any system used by the program that encourages/rewards appropriate behaviors or restricts privileges in response to an individual exhibiting impermissible behaviors must be trauma sensitive, defined in writing, stated in behavioral terms to the extent possible, and applied consistently to all individuals.

(10) Safety and Health. The program shall maintain a safe, healthy environment which is responsive to the behavioral and physical health needs of adolescents.

(A) Adolescents shall be prohibited from using tobacco or products containing nicotine on the premises, grounds, and any off-site program functions with the exception of prescribed nicotine replacement therapies with parent/guardian consent.

(B) Physical examinations shall be completed as specified in 9 CSR 30-3.152.

(C) The program shall demonstrate effective collaborative working relationship(s) with local healthcare providers, hospital(s), urgent care clinic(s), and other community resources to provide physical health care for adolescents, as needed.

(11) Staff Training and Supervision. The program shall comply with The ASAM Minimum Staffing Standards for Department of Mental Health, September 2022, hereby incorporated by reference and made a part of this rule, developed by and available from the Department of Mental Health, 1706 E.

Elm St., PO Box 687, Jefferson City MO 65101, (573) 751-4942, https://dmh.mo.gov/media/pdf/dbh-asam-minimum-staffingrequirements. This rule does not incorporate any subsequent (12) Structured Activities. In addition to treatment services, individuals receiving services in a residential level of care shall participate in structured activities during daytime and evening hours such as academic education, completing assignments, self-help groups, family visits, and positive leisure activities.

(13) Staffing Patterns in Residential Levels of Care. Programs shall comply with The ASAM Minimum Staffing Standards for Department of Mental Health, September 2022, hereby incorporated by reference and made a part of this rule, developed by and available from the Department of Mental Health, 1706 E. Elm St., PO Box 687, Jefferson City MO 65101, (573) 751-4942, https://dmh.mo.gov/media/pdf/dbh-asam-minimumstaffing-requirements. This rule does not incorporate any (A) If the program serves a mixed-gender population in residential levels of care, the staffing pattern shall include at least one (1) female and at least one (1) male staff member any time individuals are present.

(B) If a residential level of care is provided only for individuals of the female gender, a female staff member must be present twenty-four (24) hours per day, seven (7) days per week.

(C) If a residential level of care is provided only for individuals of the male gender, a male staff member must be present twenty-four (24) hours per day, seven (7) days per week.

Refer to 9 CSR 10-7.010(4)(A)7. and 9 CSR 10-7.020(3)(A)4., related to service delivery practices that are responsive to individual needs.

Filed April 15, 2002, effective Nov. 30, 2002. Amended: Filed July 29, 2002, effective March 30, 2003. Amended: Filed Sept. 14, 2023, effective March 30, 2024.

9 CSR 30-3.195 Outpatient Substance Use Disorder Treatment Programs {#sec-9-csr-30-3.195 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.195}

PURPOSE: This rule specifies service delivery requirements for certified/deemed certified outpatient substance use disorder treatment programs that do not have a contractual relationship with the department for the provision of services.

(1) General Requirements. Each agency that is certified/deemed certified by the department as an outpatient substance use disorder treatment program shall comply with requirements set forth in Department of Mental Health Core Rules for Psychiatric and Substance Use Disorder Treatment Programs, 9 CSR 10-7.010 through 9 CSR 10-7.140, as applicable.

(A) The agency shall have written policies and procedures defining eligibility for services, screening, admission, and clinical assessment to assist in the support of each individual.

(B) The program shall maintain reasonable hours to assure accessibility.

(2) Services. An intake screening and admission assessment shall be conducted in accordance with 9 CSR 10-7.030 (1) and (2).

(A) At a minimum, the following services as defined in 9 CSR 30-3.110, or in other regulations as indicated, shall be provided on an outpatient basis in accordance with individual needs:

Case management;
Continuing recovery planning, as defined in 9 CSR 10- 7.030(8);
Crisis prevention and intervention;
Family conference;
Family therapy;
Group rehabilitative support;
Individual and group counseling, including trauma and co-occurring disorders;
Medication services;
Treatment planning as defined in 9 CSR 10-7.030(4) and (5); and 10. Information and education, such as community resources available, substance use disorders, and behavioral health disorders.

(B) If the program does not directly provide all of the services specified in paragraphs (2)(A)1. to 10. of this rule, the services must be available to all individuals through coordinated and documented service delivery practices with other qualified providers within the same geographic area.

(3) Treatment Planning. Services shall be provided under the direction of an individual treatment plan as specified in 9 CSR 10-7.030(4). Each individual served or parent/guardian must provide informed, written consent to treatment prior to delivery of services, and a copy of the consent form must be retained in the individual’s record. Consent to treat documentation shall be updated annually, as applicable.

(A) An initial treatment plan goal shall be developed at intake to address immediate needs during the admission process to the outpatient treatment program.

(B) The treatment plan shall be completed within the first three (3) outpatient visits.

Each individual shall participate in the development of his/her treatment plan.

(C) Treatment plans shall be reviewed and updated every ninety (90) days to reflect the individual’s progress and changes in treatment goals and services.

(D) Treatment plans must be revised and rewritten at least annually.

(E) Treatment plans shall be developed and approved by a licensed mental health professional or qualified addiction professional (QAP).

(4) Staff Requirements. Individual and group counseling must be delivered by a licensed mental health professional, QAP, or associate counselor.

(5) Records. Each agency shall maintain an organized clinical record system (electronic or paper) in accordance with 9 CSR 10-7.030(13) which ensures easily retrievable, complete, and usable records stored in a secure and confidential manner.

(A) Each agency shall implement written procedures to assure quality of individual records, including a routine review to ensure documentation requirements are being met.

Original rule filed May 28, 2021, effective Dec. 30, 2021.

9 CSR 30-3.200 Research {#sec-9-csr-30-3.200 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.200}

History

AUTHORITY: sections 630.050, 630.192–630.198 and 630.655, RSMo 1986. Original rule filed May 13, 1983, effective Sept. 13, 1983.

9 CSR 30-3.201 Substance Awareness Traffic Offender Programs {#sec-9-csr-30-3.201 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.201}

PURPOSE: This rule identifies the Department of Mental Health as being responsible for the certification of Substance Awareness Traffic Offender Programs (SATOP) as mandated by state statute.

The rule includes program purpose and mission, functions, certification requirements, and types of SATOPs certified by the (1) Purpose and Mission. The Substance Awareness Traffic Offender Programs (SATOP) is a statewide system of comprehensive, accessible, community-based education and treatment programs for individuals referred as the result of an alcohol- or drug-related traffic offense. The department develops the standards by which SATOPs operate in Missouri and certifies programs to provide services in accordance with those standards.

(A) The mission of SATOP is to— 1. Inform and educate individuals about the dangers and consequences of alcohol- and drug-impaired driving;

Educate youth about the risks and consequences of alcohol and drug use and help them develop skills to make healthy choices;
Motivate individuals for personal change and growth;
Contribute to the public health and safety of Missouri by preventing and reducing the prevalence of alcohol- and drugimpaired driving.

(B) Completion of a SATOP is a prerequisite for driver’s license reinstatement for individuals who— 1. Have pleaded guilty or have been found guilty of an alcohol- or drug-impaired driving offense;

Have been referred as a result of an administrative suspension or revocation of their driver’s license, court order, condition of probation, or plea bargain; or 3. Have been charged with minor in possession and zero tolerance offenses.

(2) Program Functions. SATOPs shall provide or arrange for screening, clinical assessment when indicated, education, and treatment services for individuals referred to the program.

(A) All SATOPs shall comply with the 2023 edition of the SATOP Provider Manual, hereby incorporated by reference and made a part of this rule as published by and available from the Department of Mental Health, 1706 E. Elm Street, PO Box 687, Jefferson City, MO 65102. This rule does not incorporate any (3) Performance Indicators. The following are intended as examples of indicators that can be used by the department and the SATOP to demonstrate achievement of the program’s

purpose, mission, and functions. Indicators can include, but are not limited to— (A) Characteristics of persons participating in SATOP such as demographics, blood alcohol content (BAC) at the time of arrest, prior drinking and driving arrests, prior participation in a SATOP, and prior treatment for a substance use disorder;

(B) Consistent use of screening criteria including the rate at which persons are assigned to the various types of education and treatment programs;

(D) Reductions in alcohol- and drug-impaired driving among those who complete a SATOP; and (E) Program satisfaction and feedback from individuals served.

(4) Types of Programs. The department certifies the following types of SATOPs:

(A) Offender Management Unit (OMU) – entry point for individuals referred to a SATOP where they are screened by a SATOP Qualified Professional (SQP) and referred to the appropriate education or treatment program;

(B) Adolescent Diversion Education Program (ADEP) – basic education for individuals under the age of twenty one (21) who have been charged with or convicted of alcohol- and drug-related driving offenses under Missouri’s Abuse and Lose, Minor in Possession, or Zero Tolerance laws;

(C) Offender Education Program (OEP) – basic education for first-time adult offenders to assist them in understanding the consequences of alcohol- and drug-impaired driving and identifying strategies to assist in changing their behavior;

(D) Weekend Intervention Program (WIP) – specialized intervention services and education for high-risk, firsttime offenders and individuals with multiple driving while intoxicated or driving under the influence (DWI/DUI) offenses who are showing signs and symptoms of a substance use disorder with mild to moderate severity;

(E) Clinical Intervention Program (CIP) – intensive outpatient treatment for individuals who have multiple DWI/DUI offenses or high-risk, first-time offenders who are showing signs and symptoms of a substance use disorder with moderate severity;

(F) Serious and Repeat Offender Program (SROP) – intensive treatment for individuals who have multiple DWI/DUI offenses and are identified through the screening process as having high-risk, high-need risk factors, and a diagnosed substance use disorder.

(5) Requirements for Program Certification. SATOPs must be located in an office, clinic, or other professional setting that allows for private, one-on-one interviews and ensures confidentiality for individuals served. The department must approve program location(s) prior to the delivery of services.

(A) All SATOPs shall comply with 9 CSR 30-3.032.

(B) CIPs and SROPs shall comply with 9 CSR 30-3.130 and fulfill department contract requirements.

(C) The following rules are waived for OMUs, OEPs, ADEPs, and WIPs unless the department determines a specific requirement is applicable due to the unique circumstances and service delivery methods of a program:

9 CSR 10-7.030;
9 CSR 10-7.060;
9 CSR 10-7.080;
9 CSR 30-3.100; and 5. 9 CSR 30-3.110.

(6) Other Requirements. In addition to the requirements listed under 9 CSR 30-3.032, the department uses the following criteria in certifying Substance Awareness Traffic Offender Programs:

(A) The department reserves the right to limit the issuance of SATOP certification in areas of the state where it cannot be determined a need exists for the service and/or it cannot be determined the proposed service will serve the best interest of individuals in that area.

Determination of need is at the department’s sole discretion as the designated state authority responsible for SATOP certification.
The determination of need is based on applicable data, such as the number of DWI/DUI arrests and the number of currently certified SATOPs within the proposed service area;

(B) The department must approve any new program site prior to the delivery of SATOP services at the site; and (C) The department reserves the right to deny certification to any SATOP that does not provide a minimum of services for at least fifty (50) persons per year.

(7) Treatment Programs Recognized for SATOP. When the screening results indicate the need for treatment for a substance use disorder, arrangements shall be made for the person to participate in treatment services.

(A) The department recognizes the following types of treatment programs for individuals with an alcohol- and/or drug-related traffic offense whose SATOP screening indicates the need for treatment:

Substance use disorder treatment programs certified by the department;
CIPS; and 3. SROPs.

(8) Compliance. Failure to adhere to the stipulations, conditions, RSMo Supp. 2023.* This rule was originally filed as 9 CSR 30- 3.700. Emergency rule filed April 22, 1983, effective May 2, 1983, expired Aug. 11, 1983. Original rule filed May 13, 1983, effective Sept. 11, 1983. Amended: Filed May 6, 1985, effective Sept. 1, 1985.

Rescinded and readopted: Filed Nov. 2, 1987, effective May 15, 1988.

Amended: Filed Sept. 5, 1990, effective Feb. 14, 1991. Emergency amendment filed May 3, 1994, effective July 1, 1994, expired Oct. 28, 1994. Emergency amendment filed Oct. 17, 1994, effective Oct. 28, 1994, expired Feb. 24, 1995. Amended: Filed May 3, 1994, effective Nov. 30, 1994. Amended: Filed April 29, 1998, effective Oct. 30, 1998. Moved to 9 CSR 30-3.201 and amended: Filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed June 15, 2004, effective Jan. 30, 2005. Amended: Filed Feb. 16, 2018, effective Aug. 30, 2018. Amended: Filed Nov. 4, 2020, effective May 30, 2021.

Amended: Filed June 29, 2023, effective Jan. 30, 2024. 1993, 1996, 2001, 2002, 2003, 2014; 302.580, RSMo 1982, amended 1993, 1996, 2003, 2014; 577.001, RSMo 1982, amended 1986, 1996, 2005, 2014, 2015, 2016, 2017, 2018,

9 CSR 30-3.202 SATOP Administration and Service Documentation {#sec-9-csr-30-3.202 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.202}

PURPOSE: This rule establishes administrative procedures and practices in the operation of Substance Awareness Traffic Offender Programs.

(1) Access. The program shall be accessible to the public by maintaining reasonable business hours and ready telephone access.

(2) Admission. Substance Awareness Traffic Offender Programs (SATOPs) shall accept individuals referred by a court order, condition of probation or parole, or plea bargain who have had their driver’s license administratively revoked or suspended for reasons of an alcohol- or drug-related traffic offense.

Individuals will be screened by a qualified staff person to determine program placement. Women who are pregnant must be referred to a department-certified women’s treatment program for a clinical assessment to determine service needs.

(3) Conflict of Interest. An agency which operates probation services, court supervision programs, or counseling programs not certified by the department must keep these functions separate and distinct from SATOP.

(A) The agency must clearly communicate to individuals that completion or the failure to complete these programs will not affect the outcome of their participation in SATOP.

(4) Notice to Individuals Served. Written notice shall be provided to individuals regarding the cost of the program, dates, times, location, and requirements for successful program completion.

(5) Attendance Records. Attendance records shall be maintained for each session.

(6) Receipts. Receipts shall be issued for all fees collected from individuals enrolled in a SATOP.

(7) Program Participation. All SATOPs shall have written policies and procedures which are followed by staff to manage situations in which an individual arrives at a program under the influence of alcohol and/or illegal drugs, is not taking prescription medication(s) as directed, or is detracting from a program due to uncooperative behavior.

(A) A written report of the situation shall be prepared by the staff person(s) involved. The report shall be reviewed by the program administrator who is responsible for determining the individual’s continued participation in the program.

(B) A person who has justifiably been denied access or is removed from a program is not considered to have satisfactorily completed the program.

(C) Readmission to a program for an individual who has justifiably been denied access or removed shall be in accordance with the program’s policies and procedures. Proactive measures should be taken to assist individuals in reengaging in services and successfully completing a program.

(D) Individuals who continue to actively use alcohol and/or illegal drugs, or do not take prescribed medication as directed while enrolled in a program, may be referred to more intensive services such as withdrawal management and substance use disorder treatment with residential support. In these instances, the individual may fulfill SATOP requirements by completing a comparable program.

(8) Screening and Referral Process. Offender Management Unit (OMUs) must have written policies and procedures for conducting individualized screenings and issuing program recommendations based on screening results.

(A) The screening recommendation is provided in writing to each individual at the completion of the screening.

(B) Each individual is informed of their right to a second opinion from an alternative OMU and right to judicial review if he/she objects to the recommendation of the originating OMU. The notice must be in written format and signed by the 1. The following criteria applies to second opinions:

A. The right to a second opinion is forfeited if the individual has enrolled in the originating OMU’s recommended program;

B. The alternative OMU must conduct a thorough review of the individual’s original screening recommendation and obtain a copy of the SATOP Offender Assignment form from the originating OMU (release of information is not required);

C. The alternative OMU must obtain a current driving record from the Department of Revenue or other reliable source;

D. The individual must pay the screening fee for the second opinion but is not required to pay the supplemental fee; and E. The OMU issuing the second opinion is the official OMU of record. The OMU is responsible for issuing the screening recommendation to the individual, monitoring the individual’s compliance with the recommendation, and notifying the originating OMU to close the individual’s record in their (C) An individual who objects to an OMU’s screening recommendation may file a petition for review and determination in the circuit court of the county in which the recommendation was made pursuant to sections 302.304 and 302.540, RSMo. The motion must be filed using the printed form provided by the Office of State Courts Administrator, 2112 Industrial Drive, PO Box 104480, Jefferson City, MO 65110.

(9) Resources and Referrals. All SATOPs shall maintain a resource directory of area self-help groups and substance use disorder treatment programs that is readily accessible to individuals being served.

(A) Each individual who receives a recommendation for substance use disorder treatment shall be given a directory of certified treatment programs for the area in which he/she chooses to obtain services. A statement shall be signed by the individual acknowledging receipt of the directory as well as notice that he/she is not required to obtain recommended services from the same agency that conducted the screening.

(10) Program Evaluation. All persons participating in a SATOP shall be asked to complete a course evaluation. The evaluation process must assure anonymity.

(A) Participants may be encouraged, but not required, to sign the evaluation form.

(B) Evaluations shall be retained by the program for one (1) calendar year.

(11) Data Collection. The program shall cooperate with all SATOP quality assurance and data collection requirements regarding the program operation, individual demographics, or other data collection that may be required by the department.

(12) Organized Record System and Individual Records. All SATOPs must maintain an organized record system which ensures easily retrievable, complete, and usable records.

Records must be stored in a secure and confidential manner in accordance with state and federal requirements.

(A) Records required by the department shall be maintained in paper form or electronic medium at the location services are provided or at the provider’s address of record with the (B) Copies of records must be provided upon request by the department or its authorized representative(s), regardless of the medium in which they are maintained.

(C) Individual records must be retained for at least six (6) years or until all litigation, adverse audit findings, or both, are resolved regardless of the medium in which they are maintained.

(D) Individual records for OMUs shall include, but are not 1. Demographic information;

Proper signed release of information forms, as applicable;
Signed acknowledgement by the individual indicating receipt of— A. Individual rights, responsibilities, and grievance procedures;

B. Screening recommendation;

C. Notice of option for a second opinion and judicial review;

D. List of referral sources; and E. Notice that services may be obtained from another 4. Driving record check by the Department of Revenue (if another source is used, provider is responsible for ensuring its reliability);

Documentation of an individualized screening including date administered, name and signature of the SATOP Qualified Professional, summary of results including substance use

history, and education or treatment recommendation;

SATOP Offender Assignment form; and 7. SATOP Completion Certificate (if program was completed).

(E) Individual records for persons enrolled in an education program shall include, but are not limited to:

Dates of attendance;
Demographic information;
Scored pretest(s) and posttest(s) measuring knowledge gain and attitude change;
Proper signed release of information forms, as applicable;
Signed acknowledgement by the individual indicating receipt of individual rights, responsibilities, and grievance procedures, list of referral sources, and notice that services may be obtained from another provider;
Results of blood alcohol content (BAC) tests, as applicable;
SATOP Offender Assignment form; and 8. SATOP Completion Certificate (if program was completed).

(F) Individual records for persons enrolled in the Clinical Intervention Program and Serious and Repeat Offender Program shall include, but are not limited to:

Consent to treatment;
Proper signed release of information forms, as applicable;
Individual treatment plan;
Treatment plan reviews and updates;
Continuing recovery plan based upon the principles of recovery and resilience as identified in 9 CSR 10-7.010(7) including at a minimum:

A. Date of next appointment for follow-up services or other supports;

B. Action steps to access personal support system(s) or other resources to assist in continuing his/her recovery, wellbeing, and community integration or if symptoms recur and additional services/supports are needed;

C. Instructions for safe use of medication(s) as prescribed;

D. Referral information such as contact name, telephone number, locations, hours, and days of services, when applicable;

Discharge plan that includes, but is not limited to:

A. Admission date;

B. Reason for admission;

C. Referral source;

D. Reason for or type of discharge;

E. Date of discharge;

F. Description of services provided and the extent to which established goals and objectives were achieved;

G. Recommendations for continued services and supports;

H. Medical status and information on medication(s) prescribed or administered, when applicable; and I. Signature of staff completing the plan.

(13) Additional Record Requirements for the Adolescent Diversion Education Program (ADEP). For individuals participating in the ADEP who are under the age of eighteen (18) and are not emancipated, there shall be documentation showing— (A) Efforts to involve the parent or guardian in the program;

(B) Results of the efforts, that is, whether the parent or guardian participated and the extent of participation; and (C) Where applicable, the parent or guardian’s view of substance use patterns and possible effects on family, social, legal, emotional, physical, financial, educational, and vocational functioning.

(14) Compliance. Failure to adhere to the stipulations, conditions, and the requirements set forth in this rule shall be considered

Filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed June 15, 2004, effective Jan. 30, 2005. Amended: Filed Feb. 16, 2018, effective Aug. 30, 2018. Amended: Filed Nov. 4, 2020, effective May 30, 2021. *Original authority: 302.304, RSMo 1961, amended 1972, 1973, 1979, 1983, 1984, 1989, 1991, 1996, 1999, 2001, 2002, 2003, 2008, 2012, 2013, 2014, 2015; 302.420, RSMo 1987, amended 1991, 1993, 1996, 2003, 2014; 302.425, RSMo 1987, amended 1991, 1996, 2014; 302.540, RSMo 1983, amended 1984, 1993, 1996, 2001, 2002, 2003, 2014; 302.580, RSMo 1982, amended 1993, 1996, 2003, 2014; 577.001, RSMo 1982, amended 1986, 1996, 2005, 2014, 2015, 2016, 2017, 2018, 2020; 630.050, RSMo 1980, amended 1993, 1995, 2008; 630.053, RSMo 1993, amended 1995, 1996, 2011; 630.655, RSMo 1980; and 631.010, RSMo 1980.

History

AUTHORITY: sections 302.304, 302.420, 302.425, 302.540, 302.580, 630.050, 630.053, 630.655, and 631.010, RSMo 2016, and section 577.001, RSMo Supp. 2020. This rule was originally filed as 9 CSR 30-3.730. Original rule filed Nov. 2, 1987, effective May 15, 1988. effective Oct. 30, 1998. Moved to 9 CSR 30-2.202 and amended:

9 CSR 30-3.204 SATOP Personnel {#sec-9-csr-30-3.204 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.204}

PURPOSE: This rule describes the personnel policies and staff qualifications for Substance Awareness Traffic Offender Programs and establishes specific policies and procedures for the revocation or suspension of credentialed personnel.

(1) Qualifications of Staff. Staff must have specialized training in providing services for individuals who have been arrested for an alcohol- and/or drug-related traffic offense.

(A) Staff must be credentialed by the Missouri Credentialing Board, 428 E. Capitol Avenue, 2nd Floor, Jefferson City, MO 65101, and must meet the designated requirements prior to the delivery of services. Substance Awareness Traffic Offender Programs (SATOP) credentials include:

SATOP Qualified Professional (SQP); and 2. SATOP Qualified Instructor (SQI).

(B) SATOP screenings shall be conducted by a SQP.

(D) Education services shall be provided by a SQP or SQI.

(E) Staff who administer screenings and provide education and treatment services shall— 1. Not have a suspension or revocation of their driver’s license within the preceding two (2) years of administering screenings or providing education and treatment services.

Verification of staff driving records shall be completed annually and maintained in personnel records;

Not have received a citation or been charged with any state or municipal alcohol- or drug-related offense within the preceding two (2) years of administering screenings and providing education and treatment services, except when found not guilty in a court of competent jurisdiction;
Not have allowed the use of alcohol, illegal drugs, or misuse of prescription medications to interfere with the conduct of their SATOP job duties;
Successfully complete SATOP training offered or approved by the department; and 5. Meet background screening requirements specified in 9 CSR 10-5.190.

(2) Reporting Requirements. Administrators and staff of a certified SATOP have the duty to report to the department the suspected failure of any individual to meet applicable program standards and requirements.

(A) Complaints or allegations which must be reported to the department include:

Failure of a SATOP to meet personnel requirements under this rule;
Violations of individual rights under 9 CSR 10-7.020;
Fraudulent or false reporting to the department, Department of Revenue, courts, or other entity;
Performance of duties for which an individual is not appropriately credentialed;
Conviction, plea of guilty, or suspended imposition of sentence for any felony or alcohol- or drug-related offense;
Failure to cooperate in any investigation by the department or authorized by the department;
Abuse, neglect, or misuse of funds/property in accordance with 9 CSR 10-5.200; and 8. Offenses considered disqualifying crimes under section 630.170, RSMo.

(3) Guest Speakers. A program which utilizes guest speakers shall have written policies and procedures for their recruitment, selection, training, supervision, dismissal, and compensation.

(A) The program shall maintain a roster of all approved guest speakers and a description of the duties or tasks of each.

(B) Guest speakers are not considered instructors for the

purpose of these rules.

(4) Compliance. Failure to adhere to stipulations, conditions, RSMo Supp. 2020.* This rule was originally filed as 9 CSR 30-3.750.

Original rule filed Nov. 2, 1987, effective May 15, 1988. Amended:

Filed Oct. 2, 1990, effective Feb. 14, 1991. Emergency amendment filed May 3, 1994, effective July 1, 1994, expired Oct. 28, 1994.

Amended: Filed May 3, 1994, effective Nov. 30, 1994. Emergency amendment filed Oct. 17, 1994, effective Oct. 28, 1994, expired Feb. 24, 1995. Amended: Filed Oct. 17, 1994, effective April 30, 1995.

Amended: Filed April 29, 1998, effective Oct. 30, 1998. Moved to

9 CSR 30-3.204 and amended: Filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed June 15, 2004, effective Jan. 30, 2005. {#sec-9-csr-30-3.204 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.204}

Amended: Filed Feb. 16, 2018, effective Aug. 30, 2018. Amended:

Filed Nov. 4, 2020, effective May 30, 2021. 1993, 1996, 2001, 2002, 2003, 2014; 302.580, RSMo 1982, amended 1993, 1996, 2003, 2014; 577.001, RSMo 1982, amended 1986, 1996, 2005, 2014, 2015, 2016, 2017, 2018,

9 CSR 30-3.206 SATOP Structure {#sec-9-csr-30-3.206 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.206}

PURPOSE: This rule establishes basic requirements and structure for Substance Awareness Traffic Offender Programs, including the screening and referral process and fee structure.

(1) Assessment Process and Program Assignment. Offender Management Units (OMU) are the designated entry point for individuals referred to a Substance Awareness Traffic Offender Programs (SATOP).

(A) All OMUs must be certified by the department to provide the Offender Education Program. Substance use disorder treatment programs that are contracted by a DWI court to serve serious and repeat offenders are excluded from this requirement.

(B) All individuals are screened at the OMU by a SATOP Qualified Professional (SQP). The SQP assigns the individual to an education or treatment program based on screening results, department referral criteria, and his/her professional judgment.

(D) Individuals are not required to fulfill their SATOP requirement with the OMU that conducted his/her screening.

Individuals may request to attend a program based on circumstances such as distance, work schedule, or other factors. The originating OMU shall provide each individual with the contact information for certified SATOPs in his/her chosen location in order to select a service provider.

(E) The OMU provides a referring court or probation and parole office with a copy of the SATOP Offender Assignment form, upon request, and with proper release of information from the individual.

(2) Assessment Process. A SQP shall conduct a screening for each individual who presents to the OMU to determine his/her service needs. Screening recommendations are impartial and based solely on the needs of the individual and the welfare of society.

(A) The screening process includes, but is not limited to:

Collection of basic demographic information;
Completion of the 2013 edition of the Driver Risk Inventory-2 (DRI-2) published by and available from Behavior Data Systems, PO Box 44256, Phoenix, AZ 85064-4256. The document incorporated by reference does not include any later amendments or additions;
A face-to-face interview with the SQP, including information related to any previous substance use treatment;
A written summary of findings and program assignment;
Driving record report from the Department of Revenue or other reliable source;
Blood alcohol content (BAC) at time of arrest and/or toxicology results, if available; and 7. Completion of the SATOP Assignment Form and, when required, a narrative report to the court with release of information from the individual.

(B) Coordination with the courts, probation and parole, Department of Revenue, or other entities shall be provided, as necessary, to verify service recommendations are understood by all parties.

(C) Individuals who have a serious emotional disorder or serious mental illness which may interfere with his/her participation in SATOP shall be referred to a qualified mental health professional for an evaluation. Participation in SATOP may be delayed until the individual’s mental health needs are evaluated and necessary services are obtained.

The OMU shall maintain an affiliation agreement or memorandum of understanding with a certified community mental health center or a licensed mental health professional in order to promptly coordinate mental health services.

(D) Individuals shall receive written notification from the OMU that the screening is valid for six (6) months from the date of completion and payment for a second screening will be required if the six- (6-) month time period lapses prior to engagement in the assigned level of service, unless— 1. A motion for judicial review has been filed, or;

A second opinion from an alternate OMU is obtained prior to the end of the six- (6-) month period.

(E) Individual records may be closed after the six- (6-) month period expires unless a motion for judicial review or second opinion applies.

(3) Program Referral Guidelines. The SQP shall base program assignment on his/her professional judgment, screening results, and referral guidelines established by the department, as follows:

(A) 1st Offense—Offender Education Program (OEP) or Adolescent Diversion Education Program (ADEP) unless a more intense program is indicated by factors such as blood alcohol content at time of arrest, other alcohol- or drug-related arrests, results of the DRI-2, prior treatment for a substance use disorder, or occupational, relationship, medical, or other issues;

(B) 2nd offense—Weekend Intervention Program (WIP) unless a more intense program is indicated by factors such as blood alcohol content at the time of arrest, other alcohol- or drug-related arrests, results of the DRI-2, prior treatment for a substance use disorder, or occupational, relationship, medical, or other issues;

(C) 3rd offense—Clinical Intervention Program (CIP) unless a more intense program is indicated by factors such as blood alcohol content at the time of arrest, other alcohol- or drugrelated arrests, results of the DRI-2, prior treatment for a substance use disorder, or occupational, relationship, medical, or other issues;

(D) Prior and Persistent Offender—Serious and Repeat Offender Program (SROP). Individuals who have a BAC of 0.15 or greater at time of arrest, two (2) or more arrests for driving under the influence of alcohol or drugs with administrative action by the Department of Revenue, and meet diagnostic criteria for a substance use disorder, thereby meeting the statutory definition as a prior or persistent offender, shall be referred to intensive treatment.

As used in these SATOP rules, the terms prior and persistent offender mean— A. Prior offender, a person who has pleaded guilty to or has been found guilty of one (1) intoxication-related traffic offense, where such prior offense occurred within five (5) years of the occurrence of the intoxication-related traffic offense for which the person is charged;

B. Persistent offender, a person who has pleaded guilty to or has been found guilty of two (2) or more intoxicationrelated traffic offenses; a person who has pleaded guilty to or has been found guilty of involuntary manslaughter pursuant to section 565.024.1(2) or (3), RSMo; assault in the second degree pursuant to section 565.060.1(4), RSMo; assault of a law enforcement officer in the second degree pursuant to section 565.082.1(4), RSMo;

(E) Exceptions to these referral guidelines require prior approval from the department.

(4) OEP and ADEP Requirements. The OEP and ADEP are designated for individuals with a first-time alcohol- or drugimpaired driving offense. Educational sessions and discussions focus on helping individuals assess his/her personal responsibility related to alcohol- and drug-impaired driving.

(A) OEPs and ADEPs must maintain a contract with the department and conduct the respective program in accordance with the 2017 edition of the OEP Missouri Curriculum Guide or the 2014 edition of the ADEP Missouri Curriculum Guide produced by The Change Companies, 5221 Sigstrom Dr., Carson City, NV 89706. Prior approval from the department is required to alter the content and methods in the curriculum guides incorporated herein by reference. The referenced guides do not include any later amendments or additions.

(B) At least ten (10) hours of education and discussion must be provided to individuals over a period of at least two (2) calendar days. Sessions shall not exceed six (6) hours per day (excluding breaks) and should begin and end at times that are accessible for participants. No more than twenty percent (20%) of the educational component may consist of electronic media/ audiovisual aids.

(C) Program size must ensure the opportunity for participation from individuals in attendance. Group sessions are limited to thirty (30) individuals. Parents, guardians, or other natural supports who attend a session or part of a session are not included in the limit of thirty (30) individuals.

(D) Prior to successful program completion, each individual must develop a personal plan of action to assist them in preventing alcohol- and drug-impaired driving behavior in the future.

(5) WIP Requirements. The WIP is designated for individuals with a second alcohol- or drug-impaired driving offense and those identified through the SATOP screening as being a high risk, first-time driving while intoxicated or driving under the influence (DWI/DUI) offender.

(A) WIPs must maintain a contract with the department and conduct the program in accordance with the 2017 edition of the WIP Missouri Curriculum Guide produced by The Change Companies, 5221 Sigstrom Dr., Carson City, NV 89706. Prior approval from the department is required to alter the content and methods in the curriculum guide incorporated herein by reference. The referenced guide does not include any later amendments or additions.

(B) The WIP is an intensive education program conducted during a forty-eight (48) hour weekend in a supervised and structured location approved by the department. Sessions shall begin and end at times that are accessible for participants.

(C) The program requires a minimum of twenty (20) hours of combined individual counseling and group education and discussion that assists individuals in assessing their personal responsibility related to alcohol- and drug-impaired driving and taking proactive steps to prevent future occurrences of impaired driving.

Individual counseling shall be provided by a SQP.
Small group discussions shall be facilitated by at least one (1) SQP or Qualified Addiction Professional (QAP) per twelve (12) participants. In the event two (2) staff co-facilitate a small group, one (1) of the staff may be a SATOP Qualified Instructor or an Associate Alcohol Drug Counselor if the group size does not exceed twenty-four (24) individuals.
Group education sessions shall not exceed thirty (30) individuals per staff member, including lectures and audiovisual presentations. Group education shall be conducted by a SQP or SQI.

(D) Meals and snacks shall be provided for individuals participating in the WIP at times comparable to normal meal times in the community. Preparation and management of meals and snacks must meet applicable state, county, and/or city health regulations.

(E) Instructional aids shall be incorporated into education sessions to enhance understanding and promote discussion and interaction among participants. Aids may include but are not limited to DVD’s or other electronic media, worksheets, and informational handouts and shall not comprise more than twenty percent (20%) of group education sessions.

(F) Guest speakers may be utilized in education sessions but shall not comprise more than twenty percent (20%) of the educational component of the program.

(6) CIP Requirements. The CIP addresses the needs of high-risk first and second-time DWI/DUI offenders, third-time offenders, and individuals identified during the SATOP screening process as meeting diagnostic criteria for a substance use disorder or being at risk for a substance use disorder. Services focus on substance use disorders and the resolution of problems related to substance use and the individual’s drinking and driving behavior.

(A) CIPs must maintain a contract with the department and comply with 9 CSR 30-3.130.

(B) A SQP or QAP shall utilize a department-approved instrument to administer a comprehensive assessment for each individual admitted to the program.

Assessment results shall be utilized to develop an individual treatment plan. Treatment plan reviews and updates shall be conducted as specified in 9 CSR 10-7.030.
Family members and/or other natural supports shall be involved in the development of the individual treatment plan, as appropriate and allowable. The reason(s) for nonparticipation of family members/natural supports shall be documented in the individual record.

(C) Each individual admitted to a CIP must complete fifty (50) hours of therapeutic, structured activities through a combination of individual and group counseling and group rehabilitative support in accordance with contract requirements. Services and activities must be accessible to individuals who are employed, in school, have family/childcare responsibilities, or other obligations.

(D) The CIP is intended to be completed over a six (6) to eight (8) week time period and should not be completed in less than (3) weeks nor extend beyond six (6) months. The actual time period for completion of the program is based on individual needs.

(E) Individual and group counseling sessions must be facilitated by a Qualified Addiction Professional or SQP. Group counseling sessions are limited to twelve (12) individuals per staff member. In order to accommodate individuals in accessing services, group size may be greater than twelve (12) individuals with approval from the department.

(F) Group rehabilitative support sessions shall be facilitated by a SQP or SQI. Group rehabilitative support sessions are limited to thirty (30) individuals per staff member.

(G) A blood alcohol content (BAC) or urine test shall be conducted for each individual a minimum of one (1) time per week. Random BAC tests and/or urine tests may also be conducted. All test results shall be documented in the (7) SROP Requirements. The SROP addresses the needs of highrisk, high-need adults who have a DWI/DUI offense and meet criteria for a moderate to severe substance use disorder with the potential for recidivism. Services focus on substance use disorders and the resolution of problems related to substance use and the individual’s drinking and driving behavior.

(A) SROPs must maintain a contract with the department and comply with 9 CSR 30-3.130.

(B) A SQP or Qualified Addiction Professional shall utilize a department-approved instrument to administer a comprehensive clinical assessment for each individual admitted to the program.

Assessment results shall be utilized to develop an individual treatment plan. Treatment plan reviews and updates shall be conducted as specified in 9 CSR 10-7.030.
Family members and/or other natural supports shall be involved in the development of the individual treatment plan, as appropriate and allowable. The reason(s) for nonparticipation of family members/natural supports shall be documented in the individual record.

(C) Each individual admitted to a SROP must complete a minimum of seventy-five (75) hours of therapeutic, structured activities through a combination of individual and group counseling and group rehabilitative support in accordance with contract requirements. Services shall be structured to address the specific and unique needs of serious and repeat DWI/DUI offenders.

(D) Services shall include at least thirty-five (35) hours of individual and group counseling provided by a Qualified Addiction Professional or SQP. Group counseling sessions are limited to twelve (12) individuals per staff member. In order to accommodate individuals in accessing services, group size may be greater than twelve (12) individuals with approval from the department.

(E) Services shall be based on individual needs and should be completed in no less than ninety (90) days.

(8) Treatment Services for Youth. Individuals under the age of eighteen (18) whose screening results indicate the need for intensive treatment shall be referred to and successfully complete a substance use disorder treatment program for adolescents. The program must be certified by the department or nationally accredited to provide services for adolescents.

(9) Comparable Program for Missouri Residents. Missouri residents who have pled guilty or have been found guilty of an alcohol- or drug-related traffic offense may complete a comparable program in lieu of a SATOP to be eligible for license reinstatement.

(A) A comparable program is one that is state-certified and/or nationally accredited as a substance use disorder treatment program by The Joint Commission, Commission on Accreditation of Rehabilitation Facilities, Council on Accreditation, or other accrediting body recognized by the (B) Individuals must receive a drug and alcohol screening, comprehensive assessment, and successfully complete the recommended treatment services from the comparable 1. Missouri residents must complete a minimum of one hundred twenty (120) hours of treatment in no less than twentyone (21) days. Treatment hours must include a minimum of forty (40) hours of individual and group counseling. The remaining hours must include a combination of driver-related education, individual counseling, group counseling, group rehabilitative support, and family therapy.

(C) The provider of services shall verify the individual’s successful program completion on the SATOP Comparable Program Completion form.

The individual shall present the SATOP Comparable Program Completion form to an OMU where a SATOP Completion Certificate will be issued to him/her. A SATOP screening is not required; however, the supplemental fee shall be collected from the individual. The OMU may charge an additional processing fee.
The OMU shall conduct a review of the individual’s current driving record to ensure there are no alcohol- or drugrelated traffic offenses during or after the treatment episode.

(10) Comparable Program for Out-of-State Residents. Individuals who have had an alcohol- or drug-related traffic offense in Missouri but live in or have moved to another state must complete a SATOP or a comparable program to be eligible for license reinstatement.

(A) To complete a comparable program, the individual must have a drug and alcohol screening and complete the recommendation of the screening. The provider of the screening and provider of services must be certified/licensed by the state of residence and/or be accredited by The Joint Commission, Commission on Accreditation of Rehabilitation Facilities, Council on Accreditation, or other accrediting body recognized by the department.

A minimum of ten (10) hours of drug and alcohol education is required unless the screening results indicate the need for more intensive services.
The department shall make the final determination regarding the acceptability of the out-of-state program.

(B) A completed SATOP Comparable Program Completion form must be submitted to the department by one (1) of the following methods:

Email to satop@dmh.mo.gov;
Mail to Department of Mental Health, Controller’s Office, SATOP, PO Box 596, Jefferson City, MO 65102-0596; or 3. Submit electronically to the department by accessing the form at https://dmh.mo.gov/media/pdf/satop-comparableprogram-completion-form.

(C) Payment of the SATOP supplemental fee for a SATOP comparable program must be submitted to the department by one (1) of the following methods:

Electronic payment following the instructions at https:// magic.collectorsolutions.com/magic-ui/en-US/Login/momental-health; or 2. Mail the supplemental fee of two hundred forty-nine dollars ($249) in the form of a signed money order made payable to the Mental Health Earnings Fund, Department of Mental Health, Controller’s Office, SATOP, PO Box 596, Jefferson City, MO 65102-0596.

A. The supplement fee should not be paid until after the SATOP Comparable Program Completion form has been submitted in accordance with the instructions in subsection (10)(B) of this rule.

B. Payment must include the individual’s name, date of birth, last four (4) digits of their Social Security number, and driver’s license number, if known.

(D) Questions regarding the SATOP Comparable Program Completion form or payment of the supplemental fee should be directed to the SATOP help desk at (573) 522-4020. Information is also available on the SATOP website at https://dmh.mo.gov/ behavioral-health/satop.

(E) Following review of the comparable program, department staff will provide notification of the individual’s program completion to the Missouri Department of Revenue.

(11) Department of Corrections Treatment Programs. Substance use disorder treatment programs completed by individuals who are incarcerated in a Missouri Department of Corrections facility may be recognized as a SATOP comparable program.

Individuals must contact the Department of Corrections to obtain information on approved programs.

(12) SATOP Costs and Fees. The costs for the screening, education, and treatment programs are established by the department and reviewed periodically. Costs shall not be greater than relative costs indicate. Programs shall not establish costs or fees that are not specified in this rule unless prior authorization from the department is granted. All fees are to be paid by the individual being served.

(A) The screening fee includes monitoring the individual’s progress in the assigned education or treatment program and case coordination with the department, courts, probation and parole, Department of Revenue, and other entities as necessary.

(B) The cost for treatment in a department-certified and contracted substance use disorder treatment program is based on actual services provided.

(C) All individuals referred to a SATOP, including those participating in a comparable program as outlined in this rule, are required to pay a supplemental fee as specified in 9 CSR 30-3.208. The supplemental fee is in addition to the cost of the screening, education, and treatment services.

(D) Costs for individuals participating in a WIP, CIP, SROP, or a department-certified and contracted substance use disorder treatment program may be partially offset in accordance with 9 CSR 10-31.011.

(13) Successful Program Completion. Successful completion of a SATOP requires that the individual— (A) Is free from alcohol or illegal drug use when participating in services and, as applicable, uses prescription medication as prescribed during program participation;

(B) Attends all sessions on time;

(D) Completes all assignments and cooperatively participates in all class activities;

(E) Pays all fees prior to program completion; and (F) Completes and signs all required forms.

(14) Completion Certificate. A SATOP Completion Certificate is issued to each individual within seven (7) calendar days of his/her successful completion of an education or treatment (A) The OMU that completed the screening and issued the program recommendation is responsible for issuing the SATOP Completion Certificate to the individual. The Department of Revenue receives automatic notification of each individual’s successful program completion via the department’s automated processing system.

(B) If an individual fulfills their SATOP requirement with a provider other than the OMU that completed the screening and issued the program recommendation, the provider of services notifies the originating OMU of the individual’s successful program completion. Notification must be provided to the originating OMU in a timely manner to ensure the SATOP Completion Certificate is issued to the individual within seven (7) calendar days of successful program completion.

(C) If an individual completes a comparable program, an OMU must create the SATOP Completion Certificate and indicate that a comparable program was completed. Automated notification of the individual’s successful program completion is provided to the department through the department’s automated processing system.

(15) Compliance. Failure to adhere to the stipulations, conditions, RSMo Supp. 2023.* This rule was originally filed as 9 CSR 30- 3.760. Original rule filed Nov. 2, 1987, effective May 15, 1988.

Emergency amendment filed April 20, 1988, effective May 15, 1988, expired Aug. 31, 1988. Amended: Filed April 20, 1988, effective Aug. 31, 1988. Amended: Filed July 6, 1992, effective Feb. 26, 1993. effective Oct. 30, 1998. Moved to 9 CSR 30-3.206 and amended:

Filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed March 8, 2002, effective Sept. 30, 2002. Amended: Filed July 29, 2003, effective March 30, 2004. Amended: Filed June 15, 2004, effective Jan. 30, 2005. Amended: Filed Feb. 16, 2018, effective Aug. 30, 2018.

Amended: Filed Nov. 4, 2020, effective May 30, 2021. Amended:

Filed June 29, 2023, effective Jan. 30, 2024. 1993, 1996, 2001, 2002, 2003, 2014; 302.580, RSMo 1982, amended 1993, 1996, 2008, 2014; 577.001, RSMo 1982, amended 1986, 1996, 2005, 2014, 2015, 2016, 2017, 2018,

9 CSR 30-3.208 SATOP Supplemental Fee {#sec-9-csr-30-3.208 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.208}

PURPOSE: This rule establishes a supplemental fee which shall be collected by all certified Substance Awareness Traffic Offender Programs as required by state statute and outlines the procedures for submitting supplemental fees to the department.

(1) Supplemental Fee. All Substance Awareness Traffic Offender Programs shall collect a supplemental fee from each individual admitted to the program in accordance with section 302.540, RSMo.

(A) The supplemental fee is determined by the department and is in addition to any other costs associated with the (B) The supplement fee is collected one (1) time per offense, regardless of the level of service the individual receives.

(2) Remittance of Supplemental Fees. On or before the fifteenth day of each month, program administrators shall remit the total of all supplemental fees collected during the prior calendar month, less two percent (2%) which, by law, may be retained by the program to offset collection and remittance costs.

(A) Remittance shall be mailed to: Mental Health Earnings Fund, Controller’s Office, Department of Mental Health, 1706 East Elm Street, PO Box 596, Jefferson City, MO 65102.

(B) Transfer of supplemental fees from the program to the Mental Health Earnings Fund shall be in the form of a single check made payable to the Mental Health Earnings Fund. The payment shall include the SATOP Supplemental Fee Remittance Summary and Agency Tally Sheet.

(C) Failure to remit supplemental fees to the department on a timely basis will be considered cause for revocation of program certification.

If supplemental fees, including interest and penalties, are not remitted to the department within six (6) months of the due date, the Attorney General of the state of Missouri shall initiate appropriate action for collection of the fees.

(3) Documentation of Supplemental Fee Transactions. Each program shall maintain, at its principal administrative center, a single record of all supplemental fee transactions which is separate from all other program records. This separate record will facilitate audits conducted by the department or the State Auditor’s Office. A separate program record of supplemental fee transactions shall include copies of monthly remittance forms, copies of checks forwarded to the Mental Health Earnings Fund, and receipts issued by the department.

(4) Acceptance of Supplemental Fees. The department will only accept supplemental fee remittances from certified SATOPs. If an agency’s certification is revoked, the department will accept the supplemental fees owed prior to the date of revocation. The agency shall issue a refund to any individuals from whom a supplemental fee was collected after the date of revocation.

(5) Notice of Supplemental Fee. Programs shall post, in places readily accessible to persons served, one (1) or more copies of a Student Notice Poster which shall be provided by the department at no cost to the program. Posters shall explain the statutory requirement for the supplemental fees, disposition of supplemental fees, and the means by which programs collect and remit supplemental fees.

(6) Compliance. Failure to adhere to the stipulations, conditions, cause for revocation of program certification.

RSMo Supp. 2020.* This rule was originally filed as 9 CSR 30-3.790.

Original rule filed Sept. 1, 1993, effective Jan. 31, 1994. Amended:

Filed April 29, 1998, effective Oct. 30, 1998. Moved to 9 CSR 30- 3.208 and amended: Filed Feb. 28, 2001, effective Oct. 30, 2001.

Amended: Filed July 29, 2003, effective March 30, 2004. Amended:

Filed June 15, 2004, effective Jan. 30, 2005. Amended: Filed Feb. 16, 2018, effective Aug. 30, 2018. Amended: Filed Nov. 4, 2020, effective May 30, 2021. 1993, 1996, 2001, 2002, 2003, 2014; 302.580, RSMo 1982, amended 1993, 1996, 2003, 2014; 577.001, RSMo 1982, amended 1986, 1996, 2005, 2014, 2015, 2016, 2017, 2018,

9 CSR 30-3.210 Clients’ Records {#sec-9-csr-30-3.210 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.210}

Filed Jan. 19, 1988, effective July 1, 1988. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001.

History

AUTHORITY: sections 630.050, 630.140 and 630.655, RSMo 1986.

9 CSR 30-3.220 Referral Procedures Feb. 28, 2001, effective Oct. 30, 2001. {#sec-9-csr-30-3.220 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.220}

9 CSR 30-3.230 Required Educational Assessment and Community Treatment Program (REACT) {#sec-9-csr-30-3.230 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.230}

PURPOSE: This rule identifies the Department of Mental Health (department) as being responsible for the certification of REACT programs as mandated by state statute.

(1) Mission. As specified in section 559.633, RSMo, REACT is a statewide system of comprehensive, accessible, communitybased education and treatment programs designed for individuals who have been found guilty of, or pled guilty to a Chapter 195 felony drug offense. The mission of REACT is— (A) To promote a drug- and crime-free lifestyle for individuals served;

(B) To provide education and/or treatment on the multifaceted consequences of substance use for individuals served;

(C) To engage individuals appropriate for treatment towards personal change and recovery; and (D) To contribute to public health and safety in Missouri.

(2) Program Functions. REACT programs shall provide or arrange for screening, education, and treatment services for individuals referred to the program.

(3) Performance Indicators. The following are intended as examples of indicators that can be used by the department and the organization providing REACT to demonstrate achievement of the program’s mission and functions. Indicators can include, but are not limited to the following:

(A) Characteristics of persons participating in REACT such as type of offense, prior alcohol and drug offenses, and prior treatment history;

(B) Consistent use of screening criteria including the rate at which persons are assigned to education and treatment programs;

(D) Reductions in alcohol and drug offenses among those who complete REACT; and (E) Satisfaction with services and feedback as reported by individuals served.

(4) Types of Programs. The department recognizes and certifies the following types of REACT programs:

(A) REACT Screening Unit (RSU)—provide substance use screenings as part of the assessment process, including an individualized interview and recommendation and referral for further services for individuals under the purview of section 559.630, RSMo; and (B) REACT Education Program (REP)—provide basic education over the course of ten (10) hours to assist individuals in understanding the choices they made that led to their arrest and the resulting consequences. All persons completing this course shall develop a personal change plan to assist them in preventing future offenses.

(5) Requirements for Program Certification. REACT programs shall comply with 9 CSR 30-3.032.

(A) Requirements under 9 CSR 10-7.120 shall be applicable based on the type of services provided by the program and whether services are offered to individuals and groups at the program site. In addition— 1. The program must be located in an office, clinic, or other professional setting.

Screenings must be located in a setting which provides space for private, one-on-one interviews and ensures confidentiality. With the department’s written approval, screenings may be conducted at other locations on a limited

basis, if confidentiality is assured and the individual agrees to a screening at the alternate site.

(B) The following regulations shall be waived for REACT programs unless the department determines a specific requirement is applicable due to the unique circumstances and service delivery methods of a program:

9 CSR 10-7.010;
9 CSR 10-7.030;
9 CSR 10-7.060;
9 CSR 10-7.070;
9 CSR 10-7.080;
9 CSR 30-3.100; and 7. 9 CSR 30-3.110.

(6) Other Requirements. Agencies certified as a REACT program shall follow the regulations in 9 CSR 30-3.201 through 9 CSR 30- 3.208, unless otherwise specified in this rule.

(7) Staff Requirements. REACT programs shall not utilize any person under the supervision of any federal, state, county, and/or city correctional department to provide services to offenders.

(8) Screening Requirements. All persons referred to REACT shall receive an individualized screening prior to participating in services to determine the severity of his or her substance use disorder and the type of education and/or treatment needed.

The program shall utilize a screening instrument approved by the Department of Corrections (DOC).

(A) Policies and procedures shall define the program’s screening process, including referral criteria when the screening determines additional services are needed. The screening process shall include, but is not limited to:

Collection of demographic information;
Use of the standardized screening instrument as required by DOC;
A face-to-face interview with a qualified addiction professional (QAP);
A summary report of screening results;
Completion of the REACT Offender Assignment form and a narrative report provided to the individual’s probation/ parole officer; and 6. Case coordination as needed with the courts, probation and parole, and/or DOC to verify education and treatment recommendations have been completed.

(B) A written screening recommendation shall be provided to the person served.

(C) With proper authorization from the individual served, collaborative data may be obtained such as treatment history and relevant information from family members and other natural supports.

(D) Individuals may participate in a REP with an agency that did not conduct his/her screening due to reasonable circumstances such as distance, work schedule, or other timerelated factors.

(9) Quality Recommendations. The program must develop screening recommendations that are— (A) Impartial and solely based on the needs of the offender and the welfare of society; and (B) Never used as a means of case finding for any particular treatment program or as a marketing tool for any REACT (10) Referral Guidelines. The program must base its recommendation and referral plan for each person on the following guidelines:

(A) REP unless treatment for a substance use disorder is indicated by factors such as other alcohol/drug-related arrests, screening instrument recommendations, prior alcohol/drug treatment, or other occupational, relationship, or medical problems; and (B) Individuals who have a serious emotional disorder or serious mental illness which may interfere with his/her participation in REACT shall be referred to a qualified mental health professional for an evaluation. Participation in REACT may be delayed until the individual’s mental health needs are evaluated and necessary services are obtained.

RSUs shall maintain an affiliation agreement or memorandum of understanding with a certified community mental health center or a licensed mental health professional in order to promptly coordinate mental health services.

(11) Screening Cost. The cost of the screening is determined by DOC and shall be paid by the individual served. The screening fee shall not be excessively greater than relative costs indicate and include the costs for any case coordination functions necessary to— (A) Monitor the individual’s progress in the education or treatment program(s); and/or (B) Coordinate with the courts or probation and parole.

(12) Notice of Program Assignment and Completion. The RSU that conducts the screening shall provide each individual with a REACT Offender Assignment form after completion of the screening and a REACT Report of Offender Compliance form indicating successful completion or unsuccessful completion of the education portion of the program.

(A) The RSU shall provide a copy of the REACT Offender Assignment form to the referring probation and parole office within one (1) week of completion of the screening. The RSU shall provide a copy of the REACT Report of Offender Compliance form to the referring probation and parole office within one (1) week of each individual’s successful program completion.

(B) The RSU shall send a copy of the REACT Offender Assignment form and the REACT Report of Offender Compliance form to DOC, Division of Offender Rehabilitation Services, 2715 Plaza Drive, Jefferson City, MO 65109.

(C) The RSU shall provide a REACT Completion Certificate to each individual served who successfully completes the (13) Cost of the REP. The individual served shall pay for the cost of the REP. The cost is determined and approved by DOC and shall cover the operating expenses of the REP.

(14) Curriculum Guide. The REP shall be conducted in accordance with the curriculum established by DOC. A program must specifically request and obtain approval from DOC before deviating in any manner from the established curriculum.

(15) Treatment Programs Recognized for REACT. When the screening indicates the individual’s need for substance use disorder treatment, arrangements shall be made for the person to participate in such services.

(A) The recognized providers of treatment services for individuals in the REACT program include department-certified, deemed certified, and nationally accredited substance use disorder treatment programs.

(16) Criteria for Successful Completion of Treatment. In order to be recognized by REACT as successfully completing treatment, the individual must have written verification from a department-certified, deemed certified, or nationally accredited substance use disorder treatment program that he or she has— (A) Participated as scheduled in treatment services for a period of at least ninety (90) days;

(B) Successfully achieved his/her personal recovery goals;

(C) Met any other program requirements for successful completion of treatment. Individuals with a moderate to severe substance use disorder who have a history of multiple offenses must participate in a minimum of seventy-five (75) hours of treatment services during the treatment episode.

(D) Individuals who complete a department-certified, deemed certified, or nationally accredited substance use disorder treatment program after being charged or adjudicated for their offense, but prior to screening with a RSU, must receive approval from DOC to waive the REACT requirements as a result of his/her participation in such treatment.

(17) Cost of Treatment. The individual served is responsible for all costs related to completion of substance use disorder treatment referenced in or required by this rule.

(A) Costs related to treatment shall be based on the department’s Standard Means Test sliding fee scale.

(B) Programs may develop long-term payment plans to reasonably assist individuals in paying any outstanding balances.

(18) Review and Approval of Costs. All REACT screening and education fees approved by DOC shall be periodically reviewed and adjusted, if necessary, based on the best interests of individuals served, society, and the programs.

(19) Supplemental Fee. All REACT programs shall collect a sixty dollar ($60) supplemental fee from all individuals entering the program in addition to any other costs that may be charged by the program. The supplemental fee shall be collected no more than one (1) time from any individual who has entered REACT, whether for screening or for an educational program.

(20) Remittance of Supplemental Fees. On or before the fifteenth (15th) day of each month, REACT program directors shall remit the total of all supplemental fees collected during the prior calendar month, less two percent (2%) which, by law, may be retained by the program to offset collection and remittance costs.

(A) Remittance shall be mailed to: Correctional Substance Abuse Earnings Fund, Department of Corrections, 2729 Plaza Drive, Jefferson City, MO 65102.

(B) Transfer of supplemental fees from the program to the Correctional Substance Abuse Earnings Fund shall be in the form of a single check made payable to the Correctional Substance Abuse Earnings Fund.

(C) Program remittance checks shall be accompanied by a Supplemental Fee Remittance Form (to be provided by DOC at no cost to the program), which shall list name and Social Security Number of persons paying each supplemental fee being remitted.

(21) Documentation of Supplemental Fee Transactions. Each REACT program shall maintain, at its principal administrative center, a single record of all supplemental fee transactions which is separate from all other program records. This separate record will facilitate audits that may be conducted periodically by the department, DOC, or the state auditor’s office. A separate program record of supplemental fee transactions shall include copies of monthly remittance forms and copies of checks forwarded to the Correctional Substance Abuse Earnings Fund.

(22) Acceptance of Supplemental Fees. DOC shall accept supplemental fee remittances only from certified REACT programs. Supplemental fee remittances, if received by DOC from any agency not certified, will be returned to that agency.

If an agency’s certification has been revoked, DOC will only accept supplemental fee remittances that were collected prior to the date the agency’s certification was revoked. Remittances collected by the agency from individuals after the date of the revocation shall not be accepted by DOC. In such case, the supplemental fee must be returned to the individual by the agency.

(23) Compliance. Failure to adhere to the stipulations, conditions, and requirements set forth in this rule shall be considered cause for revocation of program certification.

Moved to 9 CSR 30-3.230 and amended: Filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed Jan. 22, 2019, effective Aug. 30, 2019. *Original authority: 559.630, RSMo 1998; 559.633, RSMo, 1998, amended 2014; 559.635, RSMo 1998; 630.050, 1980, amended 1993, 1995, 2008; 630.655, RSMo 1980;

History

AUTHORITY: sections 559.630, 559.633, 559.635, 630.050, 630.655, and 631.010, RSMo 2016. This rule originally filed as 9 CSR 30- 3.800. Original rule filed Oct. 16, 1998, effective March 30, 1999.

9 CSR 30-3.240 Medication Feb. 28, 2001, effective Oct. 30, 2001. {#sec-9-csr-30-3.240 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.240}

9 CSR 30-3.250 Dietary Services {#sec-9-csr-30-3.250 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.250}

rule filed May 13, 1983, effective Sept. 13, 1983. Amended: Filed June 2, 1988, effective Nov. 1, 1988. Rescinded: Filed Feb. 28, 2001,

9 CSR 30-3.300 Prevention Programs {#sec-9-csr-30-3.300 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.300}

PURPOSE: This rule identifies the expected outcomes, strategies, and operational requirements for prevention programs.

(1) Program Description. A prevention program offers a planned, organized set of activities designed to reduce the risk of and incidence of illegal or age-inappropriate use of alcohol, tobacco, and other drugs.

(A) Prevention activities and services are provided to an identified target population within a designated geographic area.

(B) The target population may include individuals, groups, organizations, communities, and the general public. The target population may include individuals or groups considered to be at-risk or high-risk in their potential for substance use; however, prevention activities are not specifically or primarily directed to persons who need treatment for a substance use disorder.

(C) A prevention program provides services that are comprehensive, research based, and culturally sensitive and relevant.

(D) A prevention program serves all age groups and populations where the need is evident, including special populations.

(2) Use of Risk Reduction Strategies. A prevention program implements strategies which reduce the risk of and the incidence of illegal or age-inappropriate use of alcohol, tobacco, and other drugs. The program shall implement the following risk reduction strategies in accordance with the type of prevention services and programming it offers:

(A) Increase awareness of the nature and extent of such substance use and their effects on individuals, families, and communities;

(B) Inform others about available prevention and treatment (C) Develop social and life skills which reduce the potential for such substance use;

(D) Identify and address risk and protective factors associated with substance use;

(E) Provide and assist with constructive and healthy activities to offset the attraction of such substance use or to meet needs which otherwise may be fulfilled by these substances;

(F) Identify persons who may have become involved in the initial, inappropriate, or illegal use of alcohol, tobacco, and/ or other drugs and then arrange support and other referrals, as needed;

(G) Assess community needs and assist in the development of community planning and action;

(H) Establish or change community attitudes, norms, and policies known to influence the incidence of such substance use;

(I) Actively intervene with individuals and populations who have multiple risk factors for such substance use; and (J) Organize, coordinate, train, and assist other community groups and organizations in their efforts to reduce such substance use.

(3) Types of Certified Programs. An agency may be certified to provide one (1) or more of the following types of prevention programs:

(A) Primary Prevention Program;

(B) Targeted Prevention Program; or (C) Statewide Prevention Resource Center.

(4) Requirements for Certification. A prevention program shall comply with rules and standards listed under 9 CSR 30-3.032.

(A) Requirements under 9 CSR 10-7.120 are applicable based on the type of services provided by the prevention program and whether services are offered to individuals and groups at the program site.

(B) The following rules and standards are waived for prevention programs, unless the department determines that a specific requirement is applicable due to the unique circumstances and service delivery methods of a program:

9 CSR 10-7.010;
9 CSR 10-7.020;
9 CSR 10-7.030;
9 CSR 10-7.060;
9 CSR 10-7.070;
9 CSR 10-7.080;
9 CSR 30-3.100; and 8. 9 CSR 30-3.110.

(5) Qualifications of Staff. Services shall be provided by a qualified prevention specialist who demonstrates substantial skill by being— (A) A graduate of an accredited college or university with a bachelor’s degree in community development, education, public administration, public health, psychology, sociology, social work, or closely related field and have one (1) year or more of full-time equivalent professional experience in education, public health, mental health, human services, or a closely related area. Additional years of experience may be substituted on a year-for-year basis for the education requirement; or (B) A prevention professional that is credentialed by the Missouri Credentialing Board to provide prevention services.

(6) Documentation of Resources and Services. All prevention programs shall maintain— (A) A current listing of resources within the geographic area in order to readily identify available substance use disorder treatment and prevention resources, as well as other resources applicable to the target population;

(B) Informational and technical materials that are current, relevant, and appropriate to the program’s goals, content, and target population.

Materials and their use shall accommodate persons with special needs, or the materials can be readily adapted to meet those needs.
Materials shall be periodically reviewed by staff and advisory board to ensure relevance to the target population and consistency with current prevention research. The advisory board shall include members of the target population and a broad range of representatives from other community groups and organizations; and (C) A record of all service activities. The record shall— 1. Identify the presenter and participants;
Describe the service activity;
State how the activity meets the specific needs of the individual, group, or community organization served;
Include consents for participation or releases of information, as applicable; and 5. Include or summarize participant evaluations, as applicable.

(7) Primary Prevention Program. A Primary Prevention Program shall offer comprehensive services and activities to a specified target population(s) in its effort to reduce the risk of and incidence of illegal or age-inappropriate use or misuse of alcohol, tobacco, and other drugs.

(A) A primary prevention program shall offer all of the following types of prevention services: information, education, alternatives, problem identification and referral, communitybased process, and environmental services.

Unless otherwise indicated, the target population for information, education, alternatives, and problem identification and referral services shall include, but is not limited to, one (1) or more of the following: persons who are at risk for a substance use disorder; families or friends, or both, of persons at risk for a substance use disorder; school officials or employers of persons at risk for a substance use disorder; caretakers and families of elderly or populations with other special needs.
Unless otherwise indicated, the target population for community-based process and environmental services shall include, but is not limited to, persons at risk for a substance use disorder; community groups mobilizing to combat inappropriate substance use including civic and volunteer organizations; church; schools; business; healthcare facilities and retirement communities; state and municipal governments; and other related community organizations.

(B) Information services shall increase awareness of the nature, extent, and effects of such substance use.

Information services are characterized by one- (1-) way communication from the presenter to the target population.
In addition to the target populations listed in subsection (7)(A), the target population information services may include the general public.
Examples of information service activities include: distributing written materials such as brochures, pamphlets, newsletters, resources directories, and other relevant materials; distributing audiovisual materials such as films, tapes, public service announcements, and other relevant materials; functioning as information resource center or clearinghouse; arranging speakers and presentations; and operating as a designated access point for computerized information networks.

(C) Education services shall develop social and life skills, such as conflict resolution, decision-making, leadership, peer resistance, and refusal skills.

Education services are characterized by interaction between the facilitator and the participants to promote certain skills and behaviors.
Examples of education service activities include classroom or small group sessions for person of any age, peer leader and helper programs, and parenting and family management classes.

(D) Alternatives shall provide healthy and constructive activities to offset the attraction of such substance use or to meet needs which otherwise may be fulfilled by these substances.

Alternative services engage the target population in recreational and other activities that exclude such substance use.
Examples of alternative service activities include developing and supporting community service activities, teen institutes and other leadership training and activities for youth, adults, parents, school faculty, or others.

(E) Problem identification and referral services shall assist in arranging support, education, and other referrals, as needed, for persons who have become involved in the initial, inappropriate, or illegal use of alcohol, tobacco, and drugs.

This service does not include a professional or comprehensive assessment and determination of the need for substance use disorder treatment.
Examples of specific problem identification and referral activities include training and consultation to student assistance programs, employee assistance programs, medication support programs for the elderly, and other programs and organizations that may intervene with persons in the target population.

(F) Community-based process shall involve the assessment of community needs and the promotion of community planning and action in order to enhance other prevention and treatment services and to reduce the incidence of such substance use.

The target population shall include community coalitions. A community coalition must have broad-based community representation and participation, such as civic organizations, neighborhood groups, churches, schools, law enforcement, healthcare and substance treatment facilities, businesses, and governmental organizations.
Examples of community-based process activities include assessing community needs and risk factors and recruiting, training, and consulting with community coalitions.

(G) Environmental services shall positively effect community policies, attitudes, and norms known to influence the incidence of such substance use.

Environmental services may address legal/regulatory initiatives, service/action initiatives, or both.
Examples of environmental services include maintaining current information regarding environmental strategies; training and consulting with community coalitions in the development and implementation of such strategies; serving as a resource to school, businesses, and other community organizations in the development of policies; and providing information regarding alcohol and tobacco availability, advertising and pricing strategies.

(8) Targeted Prevention Program. A Targeted Prevention Program shall actively intervene with individuals and populations that have multiple risk factors for the illegal or age-inappropriate use or misuse of alcohol, tobacco, and other drugs. The program shall reduce risk factors and reduce the likelihood of such substance use and include effective prevention strategies that are based on research findings.

(A) The target population shall include:

Persons at risk of developing a substance use disorder, such as out-of-school youth, youth dropouts, or persons prone to violence; and 2. Individuals and groups that influence those persons at risk for a substance use disorder, such as parents; teachers, families and caretakers of elderly, or populations with other special needs; and school based and community groups, including civic and volunteer organizations, churches, and other related community organizations.

(B) The program may be located in school or other community settings.

(C) The program shall provide and promote social and emotional support, skill development, counseling, and other preventive services for persons and populations with multiple risk factors.

(D) Examples of specific services and activities include early identification and intervention; efforts to prevent dropping out of school; after-school recreational and educational activities; development of social and life skills such as conflict resolution, decision making, leadership, peer resistance, and refusal skills; group counseling or individual counseling, or both; parent training and consultation with school staff or other community organizations.

(9) Statewide Prevention Resource Center. A statewide prevention resource center shall organize, coordinate, train, assist, and recognize community, regional, and state resources in their efforts to reduce the illegal or age-inappropriate use or misuse of alcohol, tobacco, and other drugs.

(A) The target population shall include community coalitions and other community organizations including primary prevention programs; and other community and state resources.

(B) Examples of specific activities include:

Conducting statewide and regional workshops and conferences;
Where applicable, distributing a state-wide newsletter that contains current information about prevention activities and issues;
Providing information and technical assistance regarding effective prevention strategies that are based on research findings;
Recognizing accomplishments by community coalitions and sponsoring recognition events;
Coordinating prevention activities and resources development with other state level organizations and state agencies; and 6. Expanding and strengthening the network of community and state organizations involved in prevention activities.

(10) All prevention programs shall participate in program evaluation activities as required by the department.

Filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed Oct. 15, 2001, effective April 30, 2002. Amended: Filed March 9, 2018, effective Oct. 30, 2018. *Original authority: 630.655, RSMo 1980.

History

AUTHORITY: section 630.655, RSMo 2016. This rule was originally filed as 9 CSR 30-3.630. Original rule filed May 13, 1983, effective Sept. 13, 1983. Rescinded and readopted: Filed June 27, 1995, effective Dec. 30, 1995. Moved to 9 CSR 30-3.300 and amended:

9 CSR 30-3.310 Recovery Support Programs {#sec-9-csr-30-3.310 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.310}

PURPOSE: This rule describes the certification and service delivery requirements for recovery support programs.

(1) Program Description. Recovery support programs offer individuals recovery support services such as care coordination, spiritual and group counseling, life skills training, recovery housing, and transportation assistance, before, during, after, or independent of substance use disorder treatment provided by an organization certified by the department. These services are offered in a multitude of settings including, but not limited to, community support groups, faith-based organizations, and self-help and peer recovery groups. Recovery support programs are person-centered, allowing individuals the opportunity to direct his/her recovery process.

(2) Types of Programs. Certification is available for the following types of recovery support programs and services:

(A) Care coordination. Care coordination consists of assisting individuals with accessing the network of services and other community resources available to facilitate retention in substance use disorder treatment and/or sustained recovery.

This may include, but is not limited to, consultation with the individual’s treatment provider, procurement of medication for a mental and/or substance use disorder through charitable programs, assistance in finding and securing permanent housing, development of a social support system, and when funded by the department, bus passes to eligible individuals.

A care coordination service provider shall meet the following requirements:

Services shall be provided by recovery support program staff;
Services shall include, but are not limited to:

A. Arranging, referring, and when necessary, advocating for quality services to which the individual is entitled;

B. Monitoring provider service delivery and ensuring communication among service providers;

C. Locating and coordinating services specific to crisis resolution; and D. Training in resource acquisition;

(B) Peer recovery drop-in center. Peer recovery drop-in center service emphasizes building peer relationships to help support personal choice(s), respect, and recovery. A peer recovery drop-in center shall meet the following requirements:

Each center shall be managed by a Missouri Recovery Support Specialist or Missouri Recovery Specialist – Peer as designated by the Missouri Credentialing Board;
Each center shall be staffed with a minimum of eighty percent (80%) staff and volunteers who are in recovery from a substance use disorder or co-occurring mental and substance use disorder;
The drop-in center shall create a home-like environment, including a living room type space with chairs, couches, and lighting for informal conversation, and a separate space for group meetings;
The drop-in center shall provide coffee, tea, or other free or low-cost beverages and may offer free or low-cost healthy food items;
The drop-in center shall offer recreational activities that induce social interaction, such as playing cards and other games, as well as the opportunity to participate in formal peer counseling and structured life-skill building groups;
The drop-in center shall provide a physically and emotionally safe environment that is accessible on foot or through public transportation; otherwise, the program shall provide or arrange for alternative transportation;
The drop-in center hours of operation shall be geared to the needs of individuals and include evening and weekend hours, at a minimum five (5) days per week for four (4) hours per day;
Drop-in center services shall be voluntary, free of charge, and free of expectations of length of participation;
A calendar of groups meetings, educational opportunities, and recreational activities shall be posted and updated at least monthly; and 10. Drop-in center services shall provide information on and coordination with social service support agencies in the community, as well as traditional behavioral health and physical health care service providers;

(C) Recovery coaching. Recovery coaching offers the individual support to develop proactive recovery-oriented problem solving skills for the future. A recovery coaching program shall meet the following requirements:

Recovery coaching shall be offered before, after, or concurrently with any department-funded certified substance use disorder treatment program;
Recovery coaching shall be a one-to-one service delivered face-to-face or, with department approval, through telehealth;
Recovery coaching shall not be considered a substitute for services delivered by a certified substance use disorder treatment program;
Recovery coaching shall be provided by a Missouri Recovery Support Specialist or a Missouri Recovery Support Specialist - Peer as designated by the Missouri Credentialing Board; and 5. Recovery coaching services and activities shall include, but are not limited to:

A. Helping individuals connect with peers and their communities to develop a network for information and support;

B. Sharing experiences of recovery, including the use of recovery tools, and modeling successful recovery behaviors;

C. Helping individuals make independent choices and taking a proactive role in their recovery;

D. Assisting individuals with identifying strengths and personal resources to aid in setting and achieving recovery goals; and E. Conducting periodic recovery management check-ups and assessing victories, strengths, challenges, and setbacks;

Wellness coaching is recovery coaching that focuses on the relevant physical health factors previously identified by the individual as problematic, including:

A. Low levels of physical activity/sedentary lifestyle;

B. Use of tobacco and other addictive substances;

C. Lack of nutrition and dietary education;

D. Diet and glucose monitoring for diabetes prevention and management;

E. Oral hygiene/dental health practices; and/or F. Use of medications which contribute to metabolic syndrome, obesity, and other health conditions;

Employment coaching is recovery coaching that assists individuals in finding and maintaining competitive and gainful employment and may include, but is not limited to:

A. Assisting in identifying tasks and activities geared toward career exploration and planning;

B. Assisting with job searching and preparation; and/or C. Assisting in the development of self-management skills, interpersonal skills for the workplace, social and communication skills, and job maintenance;

(D) Spiritual counseling. Spiritual counseling helps individuals explore problems and conflicts from a spiritual perspective. Spiritual counseling shall meet the following requirements:

Services shall be provided by qualified clergy. A qualified clergy is defined as an ordained clergy by a recognized religious organization with at least one (1) of the following credentials:

A. Missouri Recovery Support Specialist (MRSS);

B. Missouri Recovery Support Specialist-Peer (MRSS-P);

C. Certified Alcohol Drug Counselor (CADC);

D. Certified Reciprocal Alcohol Drug Counselor (CRADC);

E. Certified Reciprocal Advanced Alcohol Drug Counselor (CRAADC);

F. Recognized Substance Abuse Professional (RSAP);

G. Certified Criminal Justice Professional (CCJP);

H. Physician;

I. Licensed Professional Counselor (LPC);

J. Licensed Marriage and Family Therapist (LMFT);

K. Licensed Clinical Social Worker (LCSW); or L. Licensed Psychologist;

Religious organization shall mean that defined in 352.400.1(5), RSMo.
The individual’s spiritual beliefs, morals, ideas, values, and conflicts shall be explored in a safe and non-judgmental manner; and 4. Spiritual counseling services shall include one (1) or more of the following:

A. Establishing or re-establishing a relationship with a higher power;

B. Developing personal connectedness with a spiritual, religious, or faith-based entity;

C. Acquiring skills needed to cope with life-changing incidents;

D. Adopting positive values or principles;

E. Identifying a sense of purpose and mission for one’s life;

F. Achieving serenity and peace of mind;

G. Finding life purpose;

H. Overcoming emotional, social, mental, or physical obstacles; and/or I. Putting pain and grief into perspective;

(E) Support, educational, or life-skills groups. Support, educational, or life-skills groups provide support for individuals in recovery by offering encouragement and connections with others who share similar experiences. Support, educational, or life-skills groups shall meet the following requirements:

Group services shall address recovery, employment, spiritual, and/or wellness issues relevant to the needs of the individuals served;
Groups may be formed around shared identity such as common cultural or religious affiliation, shared experiences, and/or goals such as community re-entry following incarceration, HIV status, or challenges in parenting;
Group sessions may consist of the presentation of general information and application of the information to participants through group discussion designed to promote recovery and enhance social functioning;
Support group services shall include, but are not limited to:

A. Classroom-style didactic lecture to present information about a topic and its relationship to substance use disorders and recovery;

B. Presentation of educational audiovisual materials with required follow-up discussion;

C. Promotion of discussion and questions about the topic presented to the individuals in attendance;

D. Generalization of the information and demonstration of its relevance to recovery and enhanced functioning;

E. Facilitating disclosure of issues that permits generalization of the issue to the larger group;

F. Promoting positive help-seeking and supportive behaviors; and G. Encouraging and modeling productive and positive interpersonal communication;

A support, educational, or life-skills group session shall include a qualified facilitator and at least two (2) but no more than thirty (30) individuals per group in order to promote participation;

(F) Transportation. Transportation services assist individuals enrolled in a certified recovery support program or substance use disorder treatment program in achieving and sustaining recovery goals when they do not have the means to provide personal transportation. Transportation services shall meet the following requirements:

Transportation shall be limited to specific destinations and/or appointments as defined by the department. Allowable transportation services shall include:

A. To and from a certified substance use disorder treatment program;

B. To and from a certified recovery support program;

C. To and from a doctor’s appointment, dental appointment, or appointment with other healthcare providers;

D. To and from probation and parole, court, or other criminal justice agencies; and E. To and from employment-seeking activities and/or active employment;

Staff or volunteers who provide transportation services shall meet the background screening requirements in 9 CSR 10-5.190 and hold a class E chauffeur’s license, or if transporting more than fifteen (15) passengers, a CDL license;
The vehicle used for transportation shall be currently licensed, properly insured, and provide safe and reliable transportation for individuals served;
Staff or volunteers who provide transportation shall have access to a communication device in the vehicle at all times;

(G) Recovery housing. Recovery housing is a direct service that provides supervised, short-term housing to individuals with substance use disorders or co-occurring mental and substance use disorders. Recovery housing services shall meet the following requirements:

To be eligible for recovery housing, the individual shall be participating in a department certified and funded substance use disorder treatment program or recovery support program;
Recovery housing levels of support and supervision shall include one (1) of the following:

A. Peer-run: At least weekly house meetings facilitated by staff; or B. Monitored: At least a daily monitoring visit by staff; or C. Supervised: twenty-four- (24-) hour supervision of individuals by staff, with a minimum of three (3) different staff members providing supervision per twenty-four- (24-) hour period;

Each recovery housing provider that offers the selfpay option to individuals served shall have written rental agreement policies and procedures that include, but are not A. An explanation of the housing arrangements shall be posted in all housing units;

B. The grounds for termination of the rental agreement;

C. The terms of the agreement shall be established and explained to each individual at admission to housing services;

D. If an individual enters into a rental agreement for housing with the recovery support organization, a signed copy of that rental agreement shall be kept in the individual record;

Recovery housing properties shall— A. Provide proof of an initial successful Housing Quality Standards (HQS) inspection conducted by an HQS inspector;

B. Provide proof of a successful annual fire inspection;

C. Provide proof of meeting all local government occupancy/safety requirements such as an occupancy permit, zoning approval, and/or other correspondence showing approval from the local municipal or county governing body;

Recovery housing properties inspected and approved as meeting standards of a state/local/regional/national provider organization such as the National Association of Recovery Residences shall be exempt from requirements in paragraph (2)(G)4. of this rule.

(3) Specialized Services. Recovery support programs that specialize in serving minority or other populations with unique recovery needs may tailor individual and group services to address specific needs. These specialized populations, services, and philosophies may be combined in multiple ways to include, but not be limited to:

(A) Employment;

(B) Faith and spiritual beliefs;

(D) Offender re-entry;

(E) Peer supports; and (F) Wellness.

(4) Program Certification. Certification is required for a recovery support organization to obtain and maintain a contract with the department, to participate in department programs eligible for Medicaid reimbursement, and to serve individuals whose referral sources require the provider to be certified by the department. Organizations accredited under standards of care for recovery support services by the National Association of Recovery Residences (NARR), the Council on Accreditation of Peer Recovery Support Services (CAPRSS), the local affiliates of NARR or CAPRSS, or other entity recognized by the department may be eligible for certification through deeming. Certification or deemed status does not constitute an assurance or guarantee that the department or other entity will fund or utilize designated services or programs.

(A) An organization seeking certification or deemed status as a recovery support program shall comply with certification requirements set forth in 9 CSR 10-7.130, as well as all department rules and standards contained herein.

(B) The following core rules for psychiatric and substance use disorder treatment programs shall be met by recovery support programs:

9 CSR 10-7.010 Treatment Principles and Outcomes;
9 CSR 10-7.020 Rights, Responsibilities, and Grievances;
9 CSR 10-7.040 Quality Improvement;
9 CSR 10-7.050 Research;
9 CSR 10-7.060 Behavior Management;
9 CSR 10-7.070 Medications;
9 CSR 10-7.080 Dietary Service;
9 CSR 10-7.090 Governing Authority and Program Administration;
9 CSR 10-7.100 Fiscal Management;
9 CSR 10-7.110 Personnel;
9 CSR 10-7.120 Physical Plant and Safety;
9 CSR 10-7.130 Procedures to Obtain Certification;
9 CSR 10-7.140 Definitions.

9 CSR 10-5.190 Background Screening for Employees and Volunteers;
9 CSR 10-5.200 Report of Complaints of Abuse, Neglect, and Misuse of Funds/Property;
9 CSR 10-5.206 Report of Events;
9 CSR 10-5.210 Exceptions Committee Procedures;
9 CSR 10-5.220 Privacy Rule of Health Insurance Portability and Accountability Act of 1996 (HIPAA); and 6. 9 CSR 10-5.230 Hearings Procedures.

(D) The following department rules and standards shall be waived for recovery support programs unless the department determines that a specific requirement is applicable due to the unique circumstances and service delivery methods of a particular recovery support program:

9 CSR 10-7.030 Service Delivery Process and Documentation;
9 CSR 30-3.100 Service Delivery Process and Documentation; and 3. 9 CSR 30-3.110 Service Definitions and Staff Qualifications.

(5) Staff. Qualified staff shall be available in sufficient numbers to ensure effective service delivery.

(A) All staff and volunteers of recovery support programs shall meet background screening requirements in 9 CSR 10-5.190. The Missouri Department of Health and Senior Services Family Care Registry or other department-approved background screening service shall be used.

(B) All staff and volunteers who have contact with individuals receiving services shall, at a minimum, meet departmentapproved qualifications and complete six (6) hours of annual training on ethics and professional boundaries. The six (6) hours of annual ethics and boundaries training shall apply to the required thirty-six (36) hours of training, every two (2) years, for personnel as referenced in 9 CSR 10-7.110(2)(E)1.

(C) Training activities shall be documented in each employee’s personnel file and shall include the training topic, name of instructor, date(s) of training, certification/continuing education units, and location.

(D) Former recipients of services who transition to staff and volunteer roles shall have been in continuous personal recovery from a substance use disorder or co-occurring mental and substance use disorder for a period equal to or greater than twelve (12) months. Continuous personal recovery shall mean the individual— 1. Has not used any illegal drugs;

Has not used any physician-prescribed medication in a non-prescribed way;
Has not used any over-the-counter medication except for its intended use;
Has abstained from all use of alcohol; and 5. Is successfully managing their mental illness.

(E) All staff and volunteers of a certified recovery support program shall adhere to the Missouri Recovery Support Specialist (MRSS) Code of Ethics, or if functioning in a peer role, Missouri Recovery Support Specialist - Peer (MRSS-P) Code of Ethics, January, 2016, incorporated by reference, without any later amendments or additions, as published by the Missouri Credentialing Board, 428 E. Capitol Avenue, Jefferson City, MO 65101.

(F) The recovery support program shall establish and consistently implement policies and procedures to guide the roles and activities of volunteers and staff in an organized and productive manner.

(G) Minimum qualifications for supervision of staff and volunteers include holding any of the following credentials: qualified substance abuse professional (QSAP) as defined in 9 CSR 10-7.140(2)(RR); Licensed Professional Counselor (LPC);

Licensed Marriage and Family Therapist (LMFT); Licensed Clinical Social Worker (LCSW); Licensed Psychologist; qualified clergy as defined in paragraph (2)(D)1. of this rule; or a director of a certified recovery support program. Acceptable supervision shall include a minimum of one (1) hour every month of face-to-face individual or group supervision.

(6) Admission Criteria. The criteria for admission to a recovery support program shall include at least one (1) of the following:

(A) The individual has a current substance use disorder or co-occurring mental and substance use disorder as identified in the screening and assessment process outlined in section (8) of this rule;

(B) The individual is in recovery from a substance use disorder or co-occurring mental and substance use disorder and in need of services as identified in the screening and assessment process outlined in section (8) of this rule; or (C) The individual is re-entering the community from a correctional facility and has a prior history of a substance use disorder or co-occurring mental and substance use disorder.

(7) Treatment Goals. Successful outcomes for individuals participating in recovery support services include, but are not (A) Obtaining and maintaining sobriety;

(B) Minimizing the risk of relapse;

(D) Improving employment/educational func tioning;

(E) Promoting productive use of time;

(F) Developing social support;

(G) Developing spiritual support;

(H) Developing safe and stable housing;

(I) Complying with all legal, court, probation, or parole requirements;

(J) Minimizing harmful social or behavioral risk; and/or (K) Improving physical health and wellness.

(8) Screening, Assessment, and Recovery Plan. Each individual participating in recovery support services, as defined in this

rule, shall be subject to a screening, an assessment, and the development of an individualized recovery plan.

(A) Screening. Each individual requesting a recovery support service(s) shall have prompt access to a screening to determine eligibility, substance use and/or co-occurring mental and substance use disorder history, and recovery needs. The screening shall— 1. Be conducted by a recovery support program and/or substance use disorder treatment program certified by the department;

Be conducted by trained staff;
Be responsive to the individual’s requests and needs;
Include written notice to the individual regarding service eligibility and an initial course of action. If indicated, the individual shall be linked to other appropriate services and resources in the community. Referrals to other community resources shall include active care coordination to ensure the individual accesses appropriate supports.

(B) Assessment. Each individual requesting a recovery support service(s) shall participate in a recovery-oriented assessment that identifies his/her needs and goals, guides the development of an individualized recovery plan, and ensures engagement in appropriate recovery services. The participation of family and other natural supports and collateral parties (e.g., referral source, employer, other community agencies) in the assessment and development of the recovery plan shall be encouraged, as appropriate, and based upon the wishes of the 1. The assessment shall be conducted by an organization certified by the department as a substance use disorder treatment program or a recovery support program.

The assessment shall be completed by a person who meets established criteria for a qualified substance abuse professional (QSAP) as defined in 9 CSR 10-7.140(2)(RR).
The assessment shall be completed within thirty (30) days of initial contact with the recovery support program. This time period does not include weekends and holidays observed by the state of Missouri.

A. If an individual is determined to have active or a severe substance use disorder, mental illness, or co-occurring mental and substance use disorder, presents symptoms of intoxication, impairment or withdrawal, cannot achieve abstinence without close monitoring, or requires structured support and daily supervision, he or she shall be referred to a certified substance use disorder treatment program or certified community mental health center for services.

B. The recovery support program may provide interim services for individuals with severe substance use, mental illness, or a co-occurring mental and substance use disorder while he/she is waiting for higher intensity services.

Documentation of the screening and assessment shall include, but is not limited to, the following:

A. Demographic and identifying information;

B. Needs, goals, and expectations from the person requesting services;

C. Presenting situation/problem and referral source;

D. History of previous and current psychiatric and/or substance use disorder treatment;

E. Wellness screening;

F. Current medications and medication allergies;

G. Alcohol and drug use history, including duration, patterns, and consequences of use;

H. Current psychiatric symptoms;

I. Family, social, legal, vocational and educational status, and functioning;

J. Current use of resources and services from other community agencies; and K. Personal strengths, including family and other natural supports, social, peer, and recovery history.

The recovery support program shall actively coordinate other services and make appropriate referrals to ensure the safety and well-being of individuals with severe substance use, mental illness, physical health conditions, or other basic needs.

(C) Individualized Recovery Plan. The individualized recovery plan shall reflect the person’s unique needs and goals with a focus on integration and inclusion in his/her community, building healthy relationships with family and other natural supports systems, and accessing other community supports.

Services may begin before the assessment is completed and the recovery plan is fully developed.

Each individual participating in a recovery support program shall actively participate in the creation of a recovery plan within thirty (30) days of admission to the recovery support program. A qualified substance abuse professional and other member(s) of the individual’s recovery team shall also participate in development of the recovery plan.
The recovery plan shall guide ongoing service delivery and shall be signed by the individual.
The recovery plan shall be based on the individual’s initial screening and assessment as well as an assisted selfassessment of his or her goals and the strengths and capacities that he or she will use or rely upon to achieve these goals.
Service needs beyond the scope of the recovery support program that are being addressed by referral to or coordination with another community organization shall be included in the recovery plan.
Progress toward achievement of recovery goals shall be reviewed on a periodic basis to ensure the plan reflects current issues and maintains relevance for the individual. Each individual shall directly participate in regular reviews and updates of their recovery plan and shall sign the review.

(9) Organized Record System. Each recovery support program shall have an organized record system for each individual that receives recovery support services.

(A) Records shall be maintained in a manner that ensures confidentiality and security. The organization shall abide by all local, state, and federal laws and regulations concerning the confidentiality of records.

(B) If records are maintained on a computer system, there shall be a backup process in place to safeguard records in the event of operator or equipment failure and to ensure security from inadvertent or unauthorized access.

(C) The recovery support program shall retain individual records for at least six (6) years from the date of service or until all litigation, adverse audit findings, or both, are resolved.

(D) The recovery support program shall assure ready access to all records, including computerized records, by authorized staff and other authorized parties including department staff.

(10) Documentation. Services funded by the department shall be entered in the department-approved electronic record system. Services documented shall be legible, clear, complete, accurate, and recorded in a timely fashion not to exceed twenty-four (24) hours from service delivery with indelible ink, print, or approved electronic record system.

(A) Entries shall be dated and authenticated by the staff member providing the service, including name and title. Any errors on paper documentation shall be marked through with a single line, initialed, and dated.

(B) There shall be documentation of services provided and results accomplished.

Description of the specific service provided;
The date and actual time (beginning and ending times) the service was rendered;
Name and title of the person who rendered the service;
The setting in which the service was rendered;
The relationship of the services to the recovery plan; and 6. Description of the individual’s response to the service provided.

(D) Where applicable, the record shall also include documentation of referrals to other services or community resources and the outcome of those referrals, signed authorization to release confidential information, missed appointments and efforts to re-engage the individual, urine drug screening or other toxicology reports, and crisis or other significant events that may impact the recovery process.

History

AUTHORITY: section 630.050, RSMo Supp. 2013, and section 630.055, RSMo 2000. Original rule filed on April 4, 2016, effective Oct. 30, 2016. Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.055, RSMo 1980.

9 CSR 30-3.410 Modified Medical Detoxification Feb. 28, 2001, effective Oct. 30, 2001. {#sec-9-csr-30-3.410 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.410}

9 CSR 30-3.420 Medical Detoxification Services Feb. 28, 2001, effective Oct. 30, 2001. {#sec-9-csr-30-3.420 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.420}

9 CSR 30-3.500 Residential Programs Feb. 28, 2001, effective Oct. 30, 2001. {#sec-9-csr-30-3.500 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.500}

9 CSR 30-3.510 Adolescent Program {#sec-9-csr-30-3.510 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.510}

rule filed May 6, 1985, effective Sept. 1, 1985. Amended: Filed Dec. 16, 1988, effective March 15, 1989. Amended: Filed June 27, 1995, effective Dec. 30, 1995. Rescinded: Filed Feb. 28, 2001, effective Oct.

History

AUTHORITY: sections 630.050 and 630.655, RSMo 1994. Original

9 CSR 30-3.600 Outpatient Programs Feb. 28, 2001, effective Oct. 30, 2001. {#sec-9-csr-30-3.600 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.600}

9 CSR 30-3.610 Methadone Treatment {#sec-9-csr-30-3.610 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.610}

(Moved to 9 CSR 30-3.132)

9 CSR 30-3.611 Compulsive Gambling Treatment {#sec-9-csr-30-3.611 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.611}

(Moved to 9 CSR 30-3.134)

9 CSR 30-3.620 Information and Referral Program Feb. 28, 2001, effective Oct. 30, 2001. {#sec-9-csr-30-3.620 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.620}

9 CSR 30-3.621 Central Intake Program {#sec-9-csr-30-3.621 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.621}

History

AUTHORITY: sections 630.050, RSMo Supp. 1993 and 630.655, RSMo 1986. Original rule filed Sept. 15, 1994, effective Feb. 26, 1995. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001.

9 CSR 30-3.630 Prevention Programs {#sec-9-csr-30-3.630 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.630}

(Moved to 9 CSR 30-3.300)

9 CSR 30-3.700 Substance Abuse Traffic Offender Programs {#sec-9-csr-30-3.700 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.700}

(Moved to 9 CSR 30-3.201)

9 CSR 30-3.710 Definitions {#sec-9-csr-30-3.710 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.710}

History

AUTHORITY: sections 302.510, 302.540, 577.001, 577.049, 577.520, 577.525, 630.050 and 630.053, RSMo Supp. 1997 and 630.655 and 631.010, RSMo 1994. Original rule filed Nov. 2, 1987, effective May 15, 1988. Emergency amendment filed Oct. 4, 1988, effective Oct. 14, 1988, expired Jan. 14, 1989. Amended: Filed Oct. 4, 1988, effective Jan. 14, 1989. Emergency amendment filed April 4, 1989, effective April 14, 1989, expired July 14, 1989. Amended: Filed April 4, 1989, effective July 14, 1989. Emergency amendment filed April 4, 1989, effective April 14, 1989, expired July 14, 1989. Emergency amendment filed May 3, 1994, effective July 1, 1994, expired Oct. 28, 1994. Emergency amendment filed Oct. 17, 1994, effective Oct. 28, 1994, expired Feb. 24, 1995. Amended: Filed May 3, 1994, effective Nov. 30, 1994. Amended: Filed April 29, 1998, effective Oct. 30, 1998. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001.

9 CSR 30-3.720 Procedures to Obtain Certification effective Oct. 30, 1998. Rescinded: Filed Feb. 28, 2001, effective Oct. {#sec-9-csr-30-3.720 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.720}

9 CSR 30-3.730 Administration {#sec-9-csr-30-3.730 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.730}

(Moved to 9 CSR 30-3.202)

9 CSR 30-3.740 Environment effective Oct. 30, 1998. Rescinded: Filed Feb. 28, 2001, effective Oct. {#sec-9-csr-30-3.740 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.740}

9 CSR 30-3.750 Personnel {#sec-9-csr-30-3.750 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.750}

(Moved to 9 CSR 30-3.204)

9 CSR 30-3.760 Program Structure {#sec-9-csr-30-3.760 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.760}

(Moved to 9 CSR 30-3.206)

9 CSR 30-3.770 Client Records expired Oct. 28, 1994. Amended: Filed May 3, 1994, effective Nov. 30, 1994. Emergency amendment filed Oct. 17, 1994, effective Oct. 28, 1994, expired Feb. 24, 1995. Amended: Filed Oct. 17, 1994, effective April 30, 1995. Amended: Filed April 29, 1998, effective Oct. 30, 1998. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001. {#sec-9-csr-30-3.770 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.770}

9 CSR 30-3.780 Curriculum and Training Amended: Filed April 29, 1998, effective Oct. 30, 1998. Rescinded: {#sec-9-csr-30-3.780 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.780}

Filed Feb. 28, 2001, effective Oct. 30, 2001.

9 CSR 30-3.790 Supplemental Fee {#sec-9-csr-30-3.790 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.790}

(Moved to 9 CSR 30-3.208)

9 CSR 30-3.800 Required Educational Assessment and Community Treatment Program {#sec-9-csr-30-3.800 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.800}

(Moved to 9 CSR 30-3.230)

9 CSR 30-3.810 Definitions Dec. 30, 1995. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001. {#sec-9-csr-30-3.810 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.810}

9 CSR 30-3.820 Procedures to Obtain Certification Dec. 30, 1995. Emergency amendment filed Dec. 20, 1995, effective Dec. 30, 1995, expired June 26, 1996. Amended: Filed Dec. 20, 1995, effective June 30, 1996. Rescinded: Filed Feb. 28, 2001, effective Oct. {#sec-9-csr-30-3.820 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.820}

9 CSR 30-3.830 Comprehensive Substance Treatment and Rehabilitation Program Description Dec. 30, 1995. Amended: Filed July 30, 1998, effective Feb. 28, 1999. {#sec-9-csr-30-3.830 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.830}

9 CSR 30-3.840 Treatment and Rehabilitation Process Dec. 30, 1995. Amended: Filed July 30, 1998, effective Feb. 28, 1999. {#sec-9-csr-30-3.840 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.840}

9 CSR 30-3.850 Service Provision 15, 1990, effective Nov. 30, 1990. Rescinded and readopted: Filed May 3, 1994, effective Nov. 30, 1994. Amended: Filed June 27, 1995, effective Dec. 30, 1995. Emergency amendment filed Dec. 20, 1995, effective Dec. 30, 1995, expired June 26, 1996. Amended: Filed Dec. 20, 1995, effective June 30, 1996. Amended: Filed July 30, 1998, {#sec-9-csr-30-3.850 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.850}

9 CSR 30-3.851 Specialized Program for Women and Children 3, 1994, effective Nov. 30, 1994. Amended: Filed July 30, 1998, {#sec-9-csr-30-3.851 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.851}

9 CSR 30-3.852 Specialized Program for Adolescents 3, 1994, effective Nov. 30, 1994. Amended: Filed June 27, 1995, effective Dec. 30, 1995. Amended: Filed July 30, 1998, effective Feb. 28, 1999. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001. {#sec-9-csr-30-3.852 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.852}

9 CSR 30-3.853 Adolescent Residential Support 3, 1994, effective Nov. 30, 1994. Amended: Filed July 30, 1998, {#sec-9-csr-30-3.853 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.853}

9 CSR 30-3.860 Quality Assurance effective Nov. 30, 1994. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001. {#sec-9-csr-30-3.860 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.860}

9 CSR 30-3.870 Behavior Management {#sec-9-csr-30-3.870 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.870}

9 CSR 30-3.880 Client Records Dec. 30, 1995. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001. {#sec-9-csr-30-3.880 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.880}

9 CSR 30-3.890 Personnel, Staff Qualifications, Responsibilities and Training Dec. 30, 1995. Amended: Filed July 30, 1998, effective Feb. 28, 1999. {#sec-9-csr-30-3.890 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.890}

9 CSR 30-3.900 Client Rights effective Nov. 30, 1994. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001. {#sec-9-csr-30-3.900 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.900}

9 CSR 30-3.910 Research {#sec-9-csr-30-3.910 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.910}

9 CSR 30-3.920 Governing Authority and Program Administration effective Nov. 30, 1994. Amended: Filed July 30, 1998, effective Feb. 28, 1999. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001. {#sec-9-csr-30-3.920 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.920}

9 CSR 30-3.930 Fiscal Management {#sec-9-csr-30-3.930 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.930}

9 CSR 30-3.940 Environment, Safety and Sanitation {#sec-9-csr-30-3.940 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.940}

9 CSR 30-3.950 Accessibility {#sec-9-csr-30-3.950 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.950}

9 CSR 30-3.960 Dietary Services 15, 1990, effective Nov. 30, 1990. Amended: Filed July 30, 1998, {#sec-9-csr-30-3.960 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.960}

9 CSR 30-3.970 Medication Management {#sec-9-csr-30-3.970 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3.970}

Chapter 4 Mental Health Programs

9 CSR 30-4.005 Eligibility Criteria and Admission Criteria for Community Psychiatric {#sec-9-csr-30-4.005 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.005}

9 CSR 30-4.031 Procedures to Obtain Certification for Centers {#sec-9-csr-30-4.031 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.031}

9 CSR 30-4.032 Administrative Structure for Community Psychiatric Rehabilitation {#sec-9-csr-30-4.032 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.032}

9 CSR 30-4.033 Fiscal Management of Community Psychiatric Rehabilitation Programs {#sec-9-csr-30-4.033 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.033}

9 CSR 30-4.034 General Staffing Requirements for Community Psychiatric {#sec-9-csr-30-4.034 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.034}

9 CSR 30-4.035 Eligibility Determination, Assessment, and Treatment Planning in Community Psychiatric Rehabilitation Programs . . . . . . . . . . . . . . . . . . . . . . . .8 {#sec-9-csr-30-4.035 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.035}

9 CSR 30-4.036 Research by a Community Psychiatric Rehabilitation Program {#sec-9-csr-30-4.036 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.036}

9 CSR 30-4.037 Client Environment in a Community Psychiatric Rehabilitation {#sec-9-csr-30-4.037 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.037}

9 CSR 30-4.038 Client Rights for Community Psychiatric Rehabilitation Programs {#sec-9-csr-30-4.038 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.038}

9 CSR 30-4.041 Medication Procedures at Community Psychiatric Rehabilitation {#sec-9-csr-30-4.041 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.041}

9 CSR 30-4.042 Eligibility Criteria and Admission Criteria for Community Psychiatric {#sec-9-csr-30-4.042 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.042}

9 CSR 30-4.043 Service Provision, Staff Qualifications, and Documentation {#sec-9-csr-30-4.043 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.043}

9 CSR 30-4.0431 Integrated Treatment for Co-Occurring Disorders (ITCD) in Community {#sec-9-csr-30-4.0431 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.0431}

9 CSR 30-4.0432 Assertive Community Treatment (ACT) in Community Psychiatric {#sec-9-csr-30-4.0432 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.0432}

9 CSR 30-4.046 Psychosocial Rehabilitation (PSR) in Community Psychiatric {#sec-9-csr-30-4.046 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.046}

9 CSR 30-4.047 Community Support in Community Psychiatric Rehabilitation {#sec-9-csr-30-4.047 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.047}

9 CSR 30-4.120 Environment {#sec-9-csr-30-4.120 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.120}

(Rescinded October 30, 2001) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

9 CSR 30-4.005 Eligibility Criteria and Admission Criteria for Community Psychiatric Rehabilitation Programs {#sec-9-csr-30-4.005 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.005}

PURPOSE: This rule establishes criteria and procedures for admission of eligible individuals to a community psychiatric rehabilitation (CPR) program. publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

(1) The department designates the minimum geographic boundaries for CPR service areas throughout the state.

Exceptions to the designated service areas may be granted by (A) The CPR program shall operate within its designated service area and provide services to eligible individuals to the extent adequate program capacity allows.

(B) Policies and procedures shall ensure eligible individuals have access to CPR services throughout the twelve (12) months of the year and to other services/resources beyond the scope of the program.

(D) Community support and crisis intervention services shall be available to eligible individuals in their home and other locations apart from the CPR offices/facilities.

(E) Policies and procedures shall ensure eligible individuals are not required to visit a pre-selected site to receive needed services, other than medication, physician consultation, and psychosocial rehabilitation (PSR). Individuals shall have a choice in the location where they receive CPR services, to the extent program capacity and the treatment plan allows.

(2) The CPR program shall have written policies and procedures defining its service delivery process, including screening, eligibility determination, admission, assessment, treatment and recovery planning, and discharge for individuals served.

(A) Policies and procedures shall ensure admission to services within ten (10) business days of the date of eligibility determination for individuals with serious mental illness or serious emotional disturbance.

(B) Individuals shall not be denied admission to a CPR program based on eligibility for Medicaid benefits or other sources of reimbursement for services.

(3) Policies and procedures shall ensure all CPR services are provided under the direction of a physician/physician extender and are medically necessary and reasonable for the treatment of the individual’s mental illness or disorder.

(A) Emergency and crisis intervention services shall be provided prior to completion of the initial comprehensive assessment for individuals determined to need immediate assistance.

(B) A physician/physician extender must be available for emergency and crisis intervention services twenty-four (24) hours per day, seven (7) days per week.

(4) The CPR program shall implement written policies and procedures to ensure eligible individuals are admitted to treatment within ten (10) days of the date of eligibility determination.

(A) CPR services shall be prioritized for individuals who— 1. Have been discharged from inpatient psychiatric hospitalization programs within the last ninety (90) days;

Are residents of supervised or semi-independent apartments, psychiatric group homes, or community residential programs;
Have been committed by court order under provisions of section 632.385, RSMo;
Have been conditionally released under section 552.040, RSMo;
Are homeless or considered homeless in accordance with the following criteria:

A. Persons who are sleeping in places not meant for human habitation such as cars, parks, sidewalks, and abandoned buildings;

B. Persons who are sleeping in emergency shelters or doubled up (unable to maintain their housing situation and forced to stay with a series of friends and/or extended family members, paying no rent, and uncertain as to how long they will be able to stay);

C. Persons who are from transitional or supportive housing for homeless persons who originally came from streets or emergency shelters;

D. Persons who are being evicted within the week from a private dwelling unit, no subsequent residence has been identified, and they lack the resources and support networks needed to obtain access to housing;

E. Persons who are being discharged within the week from facilities in which they have been a resident for more than ninety (90) consecutive days, no subsequent residence has been identified, and they lack the resources and support networks needed to obtain access to housing; and F. Persons who are fleeing or attempting to flee domestic violence, have no other residence, and lack the resources or support networks to obtain other permanent housing;

Are having a current episode of acute crisis or being referred from the crisis system;
Have used a hospital emergency room related to a psychiatric illness two (2) or more times during the prior year;
Have attempted suicide;
Are high utilizers of Medicaid services with co-occurring behavioral health and other chronic health conditions; and 10. Children and adolescents at risk of disruption from a preferred living environment due to symptoms of a serious emotional disturbance.

(5) The CPR program may refuse admission when an individual poses an imminent threat of harm to self or others, or the program is operating at full capacity (a level previously determined by organizational leadership). The program shall implement policies and procedures to monitor capacity.

(6) Eligibility criteria for admission to a CPR program shall include:

(A) Disability—there is clear evidence of serious and/or substantial impairment in the individual’s ability to function at an age or developmentally appropriate level due to serious psychiatric disorder in each of the following two (2) areas of behavioral functioning as indicated by the eligibility determination and comprehensive assessment:

Social role functioning/family life—the ability to sustain functionally the role of a worker, student, homemaker, family member, or a combination of these; and 2. Daily living skills/self-care skills—the ability to engage in personal care (such as grooming, personal hygiene) and community living (handling individual finances, using community resources, performing household chores), learning ability/self-direction, and activities appropriate to the individual’s age, developmental level, and social role functioning.

(B) Diagnosis—a licensed diagnostician certifies a primary diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) published by and available from the American Psychiatric Association, 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209-3901 or the International Classification of Diseases Tenth Revision (ICD-10) published by and available from the World Health Organization, 525 23rd Street N.W., Washington, DC 20037. The diagnosis may coexist with other psychiatric diagnoses. Specific diagnoses for eligibility can be found in the MO HealthNet CPR Provider Manual published by and available from the Missouri Department of Social Services, 615 Howerton Court, PO Box 6500, Jefferson City, MO 65102-6500. The referenced documents do not include any later revisions or updates.

(C) Duration—rehabilitation services shall be provided for individuals whose mental illness is of sufficient duration as evidenced by one (1) or more of the following:

Received psychiatric treatment more intensive than outpatient more than once in a lifetime (crisis services, alternative home care, partial hospital, inpatient);
Experienced an occurrence of continuous residential care, other than hospitalization, for a period long enough to disrupt the normal living situation;
Exhibited the psychiatric disability for one (1) year or more; or 4. Treatment of the psychiatric disorder has been or will be required for longer than six (6) months.

(D) For adults and children age six (6) and above a functional assessment may be used to establish eligibility for CPR services, including results from a standardized assessment prescribed by (E) Individuals currently enrolled in a CPR program for youth are automatically eligible for admission to an adult CPR program when the transfer is determined to be clinically appropriate and documented in the record.

(7) Children and youth under the age of eighteen (18) may be provisionally admitted to a CPR program based on the (A) Disability—there is clear evidence of serious and/or substantial impairment in the child’s ability to function at an age or developmentally appropriate level due to serious psychiatric disorder in each of the following two (2) areas of behavioral functioning as indicated by the eligibility determination and comprehensive assessment:

Social role functioning/family life—the child is at risk of out-of-home or out-of-school placement; and 2. Daily living skills/self-care skills—the child is unable to engage in personal care, such as grooming and personal hygiene, and in community living such as performing school work or household chores, learning, self-direction or activities appropriate to the individual’s age, developmental level, and social role functioning.

(B) Diagnosis—if a child is exhibiting behaviors or symptoms consistent with a non-established CPR eligible diagnosis, he/ she may be provisionally admitted for further evaluation.

There may be insufficient clinical information because of rapidly changing developmental needs to determine if a CPR diagnosis is appropriate without an opportunity to observe and evaluate the child’s behavior, mood, and functional status. In such cases documentation must clearly support the individual’s level of functioning based on disability as defined in subsection (7)(A) of this rule.

section for a period of ninety (90) days prior to provisional admission.

(D) Provisional admission shall not exceed ninety (90) days.

Immediately upon completion of the ninety (90) days, or sooner if the individual has been determined to have an eligible diagnosis as indicated in subsection (A) of this section, the diagnosis must be documented and he/she may continue to receive services in the program.

(E) If a child who was provisionally admitted is determined to be ineligible for CPR services, staff shall directly assist the individual and/or family in arranging follow-up services needed. Arrangements for follow-up services must be documented in the discharge summary.

(F) All admission documentation is required for those provisionally admitted with the exception of the comprehensive assessment which may be deferred for ninety (90) days.

(8) The CPR program shall ensure individuals receive the most appropriate care and treatment available. Transferring an individual to another service, from a community program to a hospital, hospital to a community program, or to another CPR program consistent with individual needs, may be considered to obtain necessary care and treatment.

(A) Written procedures shall ensure exchange of information within five (5) days when an individual is referred or transferred to another service component within the organization or to an outside provider for services. Policies and procedures must ensure— 1. Applicable records, portions of records, and other information are readily transferable and handled in compliance with state and federal confidentiality regulations; and 2. Timely follow-up is made with the alternate CPR program or service provider.

(B) Policies and procedures stipulate the conditions under which referrals are made, such as the need for special services not provided by the current CPR program or the need for ancillary services which will contribute to the well-being of the individual.

(C) Policies and procedures shall assure continuity of care among referring providers including prior inpatient hospitalization, residential support, and outpatient psychiatric and/or substance use disorder treatment.

(D) A current resource directory of area community service agencies must be readily available to individuals and family members/natural supports for referral purposes and upon request by the public.

(9) The CPR program shall coordinate with providers of inpatient psychiatric care to assure continuity of services for eligible individuals returning to the community. This includes active participation of community support staff in discharge planning for the individual.

(A) Policies and procedures shall ensure individuals engaged in CPR have a documented consultation with a community support specialist within five (5) days of discharge from inpatient psychiatric care, including active follow-up within five (5) days for individuals who fail to keep their appointment.

(10) The CPR program shall implement written policies and procedures to ensure individuals who miss a scheduled appointment for services or whose absence is unanticipated are contacted by a community support specialist or other staff person providing their services/supports. The procedures shall establish time frames for contacting individuals, consistent with clinical needs and the seriousness of their disability, not to exceed forty-eight (48) hours.

(11) The CPR program shall provide equal opportunity to individuals with disabilities in accordance with the Americans with Disabilities Act.

(12) The program shall have policies and procedures to ensure individuals determined ineligible for CPR services are referred to other programs and services in the community for which they may be eligible.

(13) The CPR program shall only admit individuals who will benefit from services available. Individuals who have not received services for a six- (6-) month period should be discharged from the program.

(14) The CPR program shall participate in coordination and liaison activities with the adult and juvenile justice systems (A) Promote effective relationships with local law enforcement systems (including courts) through training, education, and consultation;

(B) Educate law enforcement and court officials, juvenile officers, and probation/parole personnel about services offered by the CPR program; and (C) Provide CPR services, as capacity allows, to persons with serious mental illness who are on probation/parole or in forensic aftercare by working with probation/parole and juvenile officers and department forensic case monitors within the limits of confidentiality.

(15) The CPR program shall participate in coordination and liaison activities with federal, state, and local public assistance agencies, housing agencies, and employment/vocational support agencies to— (A) Promote effective relationships through training, education, and consultation;

(B) Educate staff about services offered by the CPR provider;

(C) Assist individuals in seeking public benefits to expedite the application process and maintain/regain their eligibility for assistance within the limits of confidentiality.

This rule originally filed as 9 CSR 30-4.042. Original rule filed Jan. 19, 1989, effective April 15, 1989. Emergency amendment filed Aug. 27, 1993, effective Sept. 8, 1993, expired Nov. 7, 1993. Emergency amendment filed Oct. 28, 1993, effective Nov. 7, 1993, expired March 6, 1994. Amended: Filed Aug. 27, 1993, effective April 9, 1994. Emergency amendment filed Feb. 15, 1994, effective March 6, 1994, expired April 10, 1994. Emergency amendment filed April 21, 1994, effective May 2, 1994, expired Aug. 29, 1994. Amended:

Filed April 21, 1994, effective Oct. 30, 1994. Amended: Filed Dec. 13, 1994, effective July 30, 1995. Emergency amendment filed Aug. 11, 1999, effective Aug. 22, 1999, expired Feb. 17, 2000. Amended:

Filed Aug. 11, 1999, effective Feb. 29, 2000. Emergency amendment filed June 30, 2000, effective July 11, 2000, expired Feb. 22, 2001.

Amended: Filed June 30, 2000, effective Jan. 30, 2001. Emergency amendment filed Dec. 28, 2001, effective Jan. 13, 2002, expired July 11, 2002. Amended: Filed Dec. 28, 2001, effective July 12, 2002.

Amended: Filed July 31, 2002, effective March 30, 2003. Amended:

Filed March 15, 2010, effective Sept. 30, 2010. Amended: Filed Dec. 1, 2011, effective June 30, 2012. Moved to 9 CSR 30-4.005 and amended: Filed April 29, 2019, effective Nov. 30, 2019. Amended:

Filed March 9, 2022, effective Sept. 30, 2022.

9 CSR 30-4.010 Definitions {#sec-9-csr-30-4.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.010}

rule filed June 14, 1985, effective Dec. 1, 1985. Emergency amendment filed July 2, 1992, effective July 12, 1992, expired Nov. 8, 1992. Emergency amendment filed July 6, 1993, effective July 16, 1993, expired Nov. 12, 1993. Amended: Filed July 6, 1993, effective March 10, 1994. Amended: Filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed July 31, 2002, effective March 30, 2003.

Rescinded: Filed April 29, 2019, effective Nov. 30, 2019.

9 CSR 30-4.020 Procedures to Obtain Certification 28, 2001, effective Oct. 30, 2001. Rescinded: Filed April 29, 2019, effective Nov. 30, 2019. {#sec-9-csr-30-4.020 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.020}

9 CSR 30-4.025 Implementation of Certification Authority for Certain Programs Emergency rule filed Nov. 6, 1985, effective Nov. 16, 1985, expired March 7, 1986. {#sec-9-csr-30-4.025 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.025}

9 CSR 30-4.030 Certification Standards Definitions {#sec-9-csr-30-4.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.030}

section 630.050, RSMo Supp. 2011. Original rule filed Jan. 19, 1989, effective April 15, 1989. Emergency amendment filed Aug. 27, 1993, effective Sept. 8, 1993, expired Nov. 7, 1993. Emergency amendment filed Oct. 28, 1993, effective Nov. 7, 1993, expired March 6, 1994.

Emergency amendment filed Feb. 15, 1994, effective March 6, 1994, expired April 10, 1994. Amended: Filed Aug. 27, 1993, effective April 9, 1994. Amended: Filed Dec. 13, 1994, effective July 30, 1995.

Emergency amendment filed Aug. 11, 1999, effective Aug. 22, 1999, expired Feb. 17, 2000. Amended: Filed Aug. 11, 1999, effective Feb. 29, 2000. Amended: Filed Feb. 28, 2001, effective Oct. 30, 2001.

Emergency amendment filed Dec. 28, 2001, effective Jan. 13, 2002, expired July 11, 2002. Amended: Filed Dec. 28, 2001, effective July 12, 2002. Amended: Filed July 31, 2002, effective March 30, 2003.

Amended: Filed Dec. 1, 2011, effective June 30, 2012. Rescinded:

Filed April 29, 2019, effective Nov. 30, 2019.

History

AUTHORITY: sections 630.055 and 632.050, RSMo 2000, and

9 CSR 30-4.031 Procedures to Obtain Certification for Centers {#sec-9-csr-30-4.031 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.031}

Emergency amendment filed Dec. 9, 1993, effective Dec. 24, 1993, expired April 22, 1994. Amended: Filed Aug. 16, 1993, effective April 9, 1994. Amended: Filed Aug. 27, 1993, effective April 9, 1994.

Amended: Filed Dec. 13, 1994, effective July 30, 1995. Amended:

Filed Feb. 28, 2001, effective Oct. 30, 2001. Emergency amendment filed Dec. 28, 2001, effective Jan. 13, 2002, expired July 11, 2002.

Amended: Filed Dec. 28, 2001, effective July 12, 2002. Rescinded:

Filed April 29, 2019, effective Nov. 30, 2019.

History

AUTHORITY: sections 630.050, 630.655 and 632.050, RSMo 2000. amendment filed Aug. 16, 1993, effective Aug. 26, 1993, expired Dec. 23, 1993. Emergency amendment filed Aug. 27, 1993, effective Sept. 8, 1993, expired Nov. 7, 1993. Emergency amendment filed Oct. 28, 1993, effective Nov. 7, 1993, expired March 6, 1994.

9 CSR 30-4.032 Administrative Structure for Community {#sec-9-csr-30-4.032 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.032}

PURPOSE: This rule sets out responsibilities and authority of the director of a community psychiatric rehabilitation (CPR) program.

(1) Each organization that is certified or deemed certified as a CPR program by the department shall comply with requirements set forth in Department of Mental Health Core Rules for Psychiatric and Substance Use Disorder Treatment Programs, 9 CSR 10- 7.090 Governing Authority and Program Administration.

(2) A CPR program director shall be appointed whose qualifications, authority, and duties are defined in writing. The director shall have responsibility and authority for all operating elements of the CPR program, including all administrative and service delivery staff. If the CPR program director is not a qualified mental health professional (QMHP) as defined in 9 CSR 10-7.140, a clinical supervisor who is a QMHP shall be designated by the agency to monitor and supervise all clinical aspects of the program. If the agency is certified to provide services to children and youth, the CPR program director shall have at least two (2) years of supervisory experience with children and youth. If the CPR program director does not meet these requirements, the agency shall identify a clinical supervisor for children and youth services who is a QMHP who has responsibility for monitoring and supervising all clinical aspects of the program and meets the above requirements.

(3) The CPR program shall maintain a policy and procedure manual for all aspects of its operations including, but not limited to:

(A) Personnel and staff development in accordance with 9 CSR 30-4.034;

(B) Admission criteria, referral process, and transfer of records in accordance with 9 CSR 30-4.005;

(C) Provision of core and optional CPR services as specified in 9 CSR 30-4.043; and (D) Specialized programs and/or services as specified in department contracts. 30, 2001. Emergency amendment filed Dec. 28, 2001, effective Jan. 13, 2002, expired July 11, 2002. Amended: Filed Dec. 28, 2001, effective July 12, 2002. Amended: Filed April 29, 2019, effective Nov. 30, 2019.

9 CSR 30-4.033 Fiscal Management of Community Psychiatric {#sec-9-csr-30-4.033 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.033}

9 CSR 30-4.034 General Staffing Requirements for {#sec-9-csr-30-4.034 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.034}

PURPOSE: This rule specifies requirements for caseload size, clinical privileging, and core competencies for staff working in CPR programs.

(1) Each organization that is certified or deemed certified as a CPR program by the department shall comply with Programs, 9 CSR 10-7.110 Personnel.

(2) Qualified Staff. The program director shall ensure an adequate number of qualified professionals are available to provide community psychiatric rehabilitation (CPR) services.

(A) Caseload size may vary according to the acuity, symptom complexity, and needs of individuals served. An individual being served or his or her parent/guardian has the right to request an independent review by the CPR director if they believe individual needs are not being met. If the CPR director deems it necessary, caseload size or other changes may be implemented.

(B) The supervisory-to-staff ratio shall be based on the needs of individuals being served, focusing on successful outcomes and satisfaction with services and supports as expressed by persons served.

(C) The organization shall have policies and procedures for monitoring and adjusting caseload size and ensure there is documented, ongoing supervision of clinical and direct service staff.

(3) The program shall have and implement a process for granting clinical privileges to practitioners to deliver CPR (A) Each treatment discipline shall define clinical privileges based upon identified and accepted criteria approved by the governing body.

(C) Initial granting and renewal of clinical privileges shall be based on— 1. Well-defined written criteria for qualifications, clinical performance, and ethical practice related to the goals and objectives of the program;

Verified licensure, certification, or registration, if applicable;
Verified training and experience;
Recommendations from the agency’s program, department service, or all of these, in which the practitioner will be or has been providing service;
Evidence of current competence;
Evidence of health status related to the practitioner’s ability to discharge his/her responsibility, if indicated; and 7. A statement signed by the practitioner that he/she has read and agrees to be bound by the policies and procedures established by the provider and governing body.

(D) Renewal or revision of clinical privileges shall also be based on— 1. Relevant findings from the CPR program’s quality assurance activities; and 2. The practitioner’s adherence to the policies and procedures established by the CPR program and its governing body.

(E) As part of the privileging process, the CPR program shall establish procedures to— 1. Afford a practitioner an opportunity to be heard, upon request, when denial, curtailment, or revocation of clinical privileges is planned;

Grant temporary privileges on a time-limited basis; and 3. Ensure that non-privileged staff receive close and documented supervision from privileged practitioners until training and experience are adequate to meet privilege requirements.

(4) Direct care staff and staff providing supervision to direct care staff shall complete training in the service competency areas listed below.

(A) Competent staff shall— 1. Operate from person-centered, person-driven, recoveryoriented, and stage-wise service delivery approaches that promote health and wellness;

Develop cultural competence that results in the ability to understand, communicate with, and effectively interact with people across cultures;
Deliver services according to key service functions that are evidence-based and best practices;
Practice in a manner that demonstrates respect and understanding of the unique needs of persons served;
Use effective strategies for engagement, re-engagement, relationship-building, and communication; and 6. Be knowledgeable of mandated reporting requirements for abuse and neglect of children and reporting requirements related to abuse, neglect, or financial exploitation of senior citizens and individuals who are disabled.

Ensure new and existing staff are competent by providing training/supervision, guidance and feedback, field mentoring, and oversight of services to individuals served by the team;
Ensure processes exist for tracking and review of data such as missed appointments, hospitalization and follow-up care, crisis responsiveness and follow-up, timeliness and quality of documentation, and need for outreach and engagement;
Monitor and review services, interventions, and contacts with individuals served to ensure services are implemented according to individualized treatment plans or crisis prevention plans, evaluate the effectiveness and appropriateness of services in achieving recovery/resiliency outcomes in areas such as housing, employment, education, leisure activities and family, peer and social relationships.

(C) New staff shall job shadow their supervisor and/or experienced staff in a position equivalent to their qualifications and skill level.

(D) Staff shall receive ongoing and regular clinical supervision.

Observation/field supervision;
Clinical supervision/case discussion;
Quality review of case documentation;
Use of relevant findings from quality assurance activities;
Satisfaction with services as conveyed by individuals served and family members/natural supports;
Stakeholder/interagency satisfaction with services; and 8. Treatment outcomes for individuals and family members/natural supports.

(F) Demonstrated competency must be documented within the first six (6) months of employment with the CPR program.

(G) Staff shall participate in at least thirty-six (36) clock hours of relevant training during any two (2) year period. A minimum of twelve (12) clock hours of training must be completed annually.

(H) Documentation of all orientation, training, job shadowing, and supervision activities must be maintained and available for review by department staff or other authorized representatives.

(I) Documentation of training must include the topic, date(s) and length, skills targeted/objective of skill, certification/ continuing education units (as applicable), location, and name, title, and credentials of instructor(s). amendment filed Aug. 27, 1993, effective Sept. 8, 1993, expired Nov. 7, 1993. Emergency amendment filed Oct. 28, 1993, effective Nov. 7, 1993, expired March 6, 1994. Emergency amendment filed Feb. 15, 1994, effective March 6, 1994, expired April 10, 1994. Amended:

Filed Aug. 27, 1993, effective April 9, 1994. Emergency amendment filed June 15, 1994, effective June 25, 1994, expired Oct. 21, 1994.

Amended: Filed June 15, 1994, effective Oct. 30, 1994. Amended:

Filed Dec. 13, 1994, effective July 30, 1995. Emergency amendment filed Aug. 11, 1999, effective Aug. 22, 1999, expired Feb. 17, 2000.

Amended: Filed Aug. 11, 1999, effective Feb. 29, 2000. Amended:

Filed Feb. 28, 2001, effective Oct. 30, 2001. Emergency amendment filed Dec. 28, 2001, effective Jan. 13, 2002, expired July 11, 2002.

Amended: Filed Dec. 28, 2001, effective July 12, 2002. Amended:

Filed July 31, 2002, effective March 30, 2003. Amended: Filed May 12, 2010, effective Nov. 30, 2010. Amended: Filed Dec. 1, 2011, effective June 30, 2012. Amended: Filed April 29, 2019, effective Nov. 30, 2019.

9 CSR 30-4.035 Eligibility Determination, Assessment, and Treatment Planning in Community Psychiatric {#sec-9-csr-30-4.035 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.035}

PURPOSE: This rule specifies the eligibility determination, comprehensive assessment, functional assessment, treatment planning, and documentation requirements for community psychiatric rehabilitation (CPR) programs.

(1) Each organization that is certified or deemed certified as a CPR program by the department shall comply with Programs, 9 CSR 10-7.030 Service Delivery Process and Documentation.

(2) Eligibility Determination. Eligibility determination may be completed to expedite the admission process and requires confirmation of an eligible diagnosis as evidenced by a signature from a licensed diagnostician or a physician/ physician extender. Physician extender includes a licensed assistant physician, physician assistant, psychiatric resident, psychiatric pharmacist, and APRN. The licensed diagnostician or physician/physician extender is accountable for the stated diagnosis.

(A) The following mental health professionals are approved to render diagnoses:

Physician (includes psychiatrist, psychiatry resident, assistant physician, and physician assistant);
Psychologist (licensed or provisionally licensed);
Advanced Practice Registered Nurse (APRN);
Professional Counselor (licensed or provisionally licensed);
Marital and Family Therapist (licensed or provisionally licensed);
Licensed Clinical Social Worker (LCSW); and 7. Licensed Master Social Worker (LMSW) under registered supervision with the Missouri Division of Professional Registration for licensure as a Clinical Social Worker. LMSWs not under registered supervision for their LCSW credential cannot render a diagnosis.

(B) The professions listed in paragraphs (2)(A)1. to 7. are categorically approved as licensed diagnosticians as long as the diagnostic activities performed fall within the scopes of practice for each. Individuals possessing these credentials should practice in the areas in which they are adequately trained and should not practice beyond their individual levels of competence.

(C) The signature/date from a licensed diagnostician or physician/physician extender is required prior to delivery of CPR services. The signature can be obtained as follows:

Consultation with the organization’s licensed diagnostician (licensed psychologist, licensed professional counselor, LCSW) or a physician/physician extender; or 2. Consultation with an unlicensed qualified mental health professional (QMHP) with sign-off by the organization’s licensed diagnostician or a physician/physician extender; or 3. Written confirmation of an eligible diagnosis received from a physician for a psychiatric hospitalization within ninety (90) days of discharge.

(D) CPR services are billable to the department beginning on the date eligibility determination is completed.

(E) Documentation of eligibility determination must include, 1. Presenting problem and referral source;

Brief history of previous psychiatric/addiction treatment including type of admission;
Current medications;
Current mental health symptoms supporting the diagnosis;
Current substance use;
Current medical conditions;
Diagnoses, including mental disorders, medical conditions, and notation for psychosocial and contextual factors;
Identification of urgent needs including suicide risk, personal safety, and risk to others;
Initial treatment recommendations;
Initial treatment goals to meet immediate needs within the first forty-five (45) days of service; and 11. Signature, date, and title of staff completing the eligibility determination, except when the diagnosis is established as specified in paragraph (2)(C)3. of this rule.

(3) Consent to Treatment. Each individual served or a parent/ guardian must provide informed, written consent to treatment.

(A) A copy of the consent form, which must include the date of consent and signature of the individual served or a parent/ guardian, shall be retained in the individual record.

(B) Consent to treat shall be updated annually, including the date of consent and signature of the individual served or a parent/guardian, and be maintained in the individual record.

(4) Initial Comprehensive Assessment. A comprehensive assessment must be completed within thirty (30) days of eligibility determination or date of admission if eligibility determination was not completed.

(A) Documentation of the initial comprehensive assessment must include, at a minimum:

Basic information (demographics, age, language spoken);
Presenting concerns from the perspective of the individual, including reason for referral/referral source, what occurred to cause him/her to seek services;
Risk assessment (suicide, safety, risk to others);
Trauma history (experienced and/or witnessed abuse, neglect, violence, sexual assault);
Mental health treatment history;
Mental status;
Substance use treatment history and current use including alcohol, tobacco, and/or other drugs; for children/ youth, prenatal exposure to alcohol, tobacco, or other substances;
Medication information, including current medications, medication allergies/adverse reactions, efficacy of current or previously used medications;
Physical health summary (health screen, current primary care, vision and dental, date of last examinations, current medical concerns, body mass index, tobacco use status, and exercise level; immunizations for children/youth, and medical concerns expressed by family members that may impact the child/youth);
Functional assessment using an instrument approved by the department for individuals whose diagnosis requires a functional score to support admission, and if required by the department as part of the initial comprehensive assessment for all individuals (challenges, problems in daily living, barriers);
Risk-taking behaviors including child/youth risk behavior(s);
Living situation, including where living and with whom, financial situation, guardianship, need for assistive technology, and parental/guardian custodial status for children/youth;
Family, including cultural identity, current and past family life experiences, family functioning/dynamics, relationships, current issues/concerns impacting children/ youth;
Developmental information, including an evaluation of current areas of functioning such as motor development, sensory, speech problems, hearing and language problems, emotional, behavioral, intellectual functioning, self-care abilities;
Spiritual beliefs/religious orientation;
Sexuality, including current sexual activity, safe sex practices, and sexual orientation;
Need for and availability of social, community, and natural supports/resources such as friends, pets, meaningful activities, leisure/recreational interests, self-help groups, resources from other agencies, interactions with peers including child/youth and family;
Legal involvement history;
Legal status such as guardianship, representative payee, conservatorship, probation/parole;
Education, including intellectual functioning, literacy level, learning impairments, attendance, achievement;
Employment, including current work status, work

history, interest in working, and work skills;

Status as a current or former member of the U.S. Armed Forces;
Clinical formulation, an interpretive summary including identification of co-occurring or co-morbid disorders, psychological/social adjustment to disabilities and/or disorders;
Diagnosis;
Individual’s expression of service preferences;
Assessed needs/treatment recommendations such as life goals, strengths, preferences, abilities, barriers; and 27. Signature and date of the staff person completing the assessment.

(5) Annual Assessment. An annual assessment must be completed for individuals engaged in CPR services.

(A) Documentation of the annual assessment must include, 1. Identification of sections of the clinical assessment being updated, such as check boxes;

Updated narrative for each section of the previous assessment that has changed;
Clinical formulation (interpretive summary);
Diagnosis change/update;
Individual’s expression of service preferences;
Assessed needs/treatment recommendations; and 7. Signature and date of the staff person completing the assessment, community support supervisor (unless they are completing the assessment), and a licensed diagnostician or physician/physician extender.

(6) Initial Treatment Plan. An individual treatment plan must be developed within forty-five (45) days of completion of eligibility determination or date of admission to CPR if eligibility determination was not completed.

(A) The treatment plan shall be developed collaboratively with the individual or parent/guardian and a QMHP, the individual’s community support supervisor, if different from the QMHP, and a physician/physician extender.

(B) Documentation for completion of the initial treatment plan must include, at a minimum:

Identifying information;
Goals as expressed by the person served and family members/natural supports, as appropriate, that are measurable, achievable, time-specific with start date, strength/skill based and include supports/resources needed to meet goals and potential barriers to achieving goals;
Specific treatment objectives, including a start date, that are understandable to the individual served, sufficiently specific to assess progress, responsive to the disability or concern, and reflective of age, development, culture, and ethnicity;
Specific interventions including action steps, modalities, and services to be used, duration and frequency of interventions, who is responsible for the intervention, and action steps of the individual served and family members/ natural supports;
Identification of other agency/community resources and supports including others providing services, plans for coordinating with other agencies, services needed beyond the scope of the CPR program to be addressed through referral/ services with another organization;
Anticipated discharge and continuing recovery planning which includes but is not limited to criteria for service conclusion, how will the individual served and/or parent/guardian and clinician know treatment goals have been accomplished; and 7. Signature and date of the QMHP/community support supervisor.

A. Physician/physician extender signature and date must be obtained within ninety (90) days of completion of the eligibility determination after a consultation or case review.

The physician/physician extender signature certifies treatment is needed and services are appropriate, as described in the treatment plan, and does not recertify the diagnosis.

B. A licensed psychologist may approve (sign and date) the treatment plan when the person served is not currently receiving prescribed medications to treat a mental health condition and the clinical recommendations do not include a need for prescribed medications to treat a mental health condition.

(7) Treatment Plan Review. If a functional assessment is not completed, the treatment plan must be reviewed with each individual every ninety (90) days to assess the continued need for services and progress achieved during the past ninety (90) days.

(A) The treatment plan shall reflect the individual’s current strengths, needs, abilities, and preferences in the goals and objectives that have been established or continued based on the review.

(B) The treatment plan shall be updated to reflect the current needs and goals of the individual and must be documented in the individual’s record and may be recorded in— 1. A progress note which specifies updates made to the treatment plan; or 2. A treatment plan review conducted quarterly.

(C) Treatment plan reviews shall be completed, signed, and dated by a QMHP, community support supervisor, or community support specialist.

(8) Annual Treatment Plan. Treatment plans must be updated annually for individuals engaged in CPR services to reflect current goals, needs, and progress in treatment.

(A) The plan is updated collaboratively with the individual or parent/guardian, community support supervisor, community support specialist, and physician/physician extender.

A licensed psychologist may take the place of the physician/physician extender when the person served is not currently receiving prescribed medications to treat a mental health condition and the clinical recommendations do not include a need for prescribed medications to treat a mental health condition.

(B) Documentation for completion of the annual treatment plan must include at a minimum:

Updates related to the annual assessment and periodic updates to the functional assessment or treatment plan;
Signature and date of community support supervisor;
Signature and date of community support specialist;
Signature and date of physician/physician extender or licensed psychologist.

(9) Functional Assessment. A department-approved functional assessment must be completed for individuals whose diagnosis requires a functional score to support admission, and if required by the department as part of the initial comprehensive assessment. The functional assessment shall be updated in accordance with the timeframes established by the department to assess current level of functioning, progress toward treatment objectives, and appropriateness of continued services. The treatment plan shall be revised to incorporate the results of the initial functional assessment and subsequent updates.

(A) Documentation of the initial functional assessment and regular updates shall include, at a minimum:

Barriers, issues, or problems conveyed by the individual, parent/guardian, family members/natural supports, and/or staff indicating the need for focused services;
A brief explanation of any changes or progress in the daily living functional abilities in the prior ninety (90) days;
A description of the changes for the treatment plan based on information obtained from the functional assessment.

(B) Documentation of the findings from the functional assessment includes any of the following:

A narrative section with the treatment plan that includes the functional update content requirements;
A narrative section on the functional assessment with the content requirements; or 3. A progress note in the individual record documenting the content requirements.

(C) Completed functional assessments must be available to department staff and other authorized representatives for review/audit purposes upon request.

(D) For individuals receiving services in a community residential program, the functional assessment must be completed a minimum of every ninety (90) days and documented in the individual record.

(10) Crisis Prevention Plan. If a potential risk for suicide, violence, or other at-risk behavior is identified during the assessment process, and any time during the individual’s time in services, a crisis prevention plan shall be developed with the individual.

(A) Documentation for completion of the crisis prevention plan shall include, at a minimum, factors that may precipitate a crisis, a hierarchical list of self-care and self-help strategies identified by the individual to regain a sense of control to return to their level of functioning before the crisis or emergency, and a hierarchical list of staff interventions that may be used when a critical situation occurs.

(11) Discharge. When individuals are discharged from CPR services, a discharge summary must be prepared and entered in the individual record in accordance with 9 CSR 10-7.030.

(12) Data. The CPR program shall provide data to the department, upon request, regarding characteristics of individuals served, services, costs, or other information in a format specified by (13) Availability of Records. All documentation must be made available to department staff and other authorized representatives for review/audit purposes at the site where the service(s) was rendered. Documentation must be legible and made contemporaneously with the delivery of the service (at the time the service was provided or within five (5) business days of the time it was provided), and address individual specifics including, at a minimum, individualized statements that support the assessment or treatment encounter. effective July 30, 1995. Emergency amendment filed Aug. 11, 1999, effective Aug. 22, 1999, expired Feb. 17, 2000. Amended: Filed Aug. 11, 1999, effective Feb. 29, 2000. Amended: Filed Feb. 28, 2001, effective Oct. 30, 2001. Emergency amendment filed Dec. 28, 2001, effective Jan. 13, 2002, expired July 11, 2002. Amended: Filed Dec. 28, 2001, effective July 12, 2002. Amended: Filed March 15, 2010, effective Sept. 30, 2010. Amended: Filed Dec. 1, 2011, effective June 30, 2012. Amended: Filed April 29, 2019, effective Nov. 30, 2019. ** Amended: Filed March 9, 2022, effective Sept. 30, 2022. **Pursuant to Executive Order 21-09, 9 CSR 30-4.035, sections (3) and (5) was suspended from April 23, 2020 through December 31, 2021.

9 CSR 30-4.036 Research by a Community Psychiatric Rehabilitation Program {#sec-9-csr-30-4.036 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.036}

9 CSR 30-4.037 Client Environment in a Community Psychiatric Rehabilitation Program {#sec-9-csr-30-4.037 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.037}

9 CSR 30-4.038 Client Rights for Community Psychiatric {#sec-9-csr-30-4.038 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.038}

9 CSR 30-4.039 Service Provision {#sec-9-csr-30-4.039 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.039}

Emergency amendment filed Feb. 15, 1994, effective March 6, 1994, expired April 10, 1994. Amended: Filed Aug. 27, 1993, effective April 9, 1994. Amended: Filed Dec. 13, 1994, effective July 30, 1995.

Emergency amendment filed Aug. 11, 1999, effective Aug. 22, 1999, expired Feb. 17, 2000. Amended: Filed Aug. 11, 1999, effective Feb. 29, 2000. Amended: Filed Feb. 28, 2001, effective Oct. 30, 2001.

Emergency amendment filed Dec. 28, 2001, effective Jan. 13, 2002, expired July 11, 2002. Amended: Filed Dec. 28, 2001, effective July 12, 2002. Amended: Filed Dec. 1, 2011, effective June 30, 2012.

Rescinded: Filed April 29, 2019, effective Nov. 30, 2019.

History

AUTHORITY: sections 630.655 and 632.050, RSMo 2000, and

9 CSR 30-4.040 Quality Assurance {#sec-9-csr-30-4.040 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.040}

9 CSR 30-4.041 Medication Procedures at Community {#sec-9-csr-30-4.041 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.041}

PURPOSE: This rule sets out procedures to safely record, store and administer medications at a community psychiatric rehabilitation program facility site or in off-site situations.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated or expensive. Therefore, the material which is so incorporated is on file with the agency who filed this rule, and with the Office of the Secretary of State. Any interested person may view this material at either agency’s headquarters or the same will be made available at the Office of the Secretary of State at a cost not to exceed actual cost of copy reproduction. The entire text of the

rule is printed here. This note refers only to the incorporated by reference material.

(1) Each agency that is certified shall comply with requirements set forth in Department of Mental Health Core Rules for Psychiatric and Substance Abuse Programs, 9 CSR 10-7.070 Medications.

(2) The community psychiatric rehabilitation (CPR) provider shall make available to all staff, consultation with a registered nurse or physician to check medication procedures.

(3) A physician shall review and evaluate medications at least every six (6) months, except as specified in the client’s individualized treatment plan. Face-to-face contact with the client and review of relevant documentation in the client record, such as progress notes and treatment plan reviews, shall constitute the review and evaluation.

(4) The CPR provider shall develop all medication policies and procedures in conjunction with a psychiatrist.

(5) The following forms are included herein:

(A) Form number MO 650-6250; and (B) Form number MO 650-1485.

(6) The following publication is incorporated by reference:

(A) United States Pharmacopeia Standards.

History

AUTHORITY: section 630.655, RSMo 2000. Original rule filed Jan. 30, 2001. Amended: Filed July 31, 2002, effective March 30, 2003.

9 CSR 30-4.042 Eligibility Criteria and Admission Criteria for Community Psychiatric Rehabilitation Programs {#sec-9-csr-30-4.042 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.042}

(Moved to 9 CSR 30-4.005)

9 CSR 30-4.043 Service Provision, Staff Qualifications, and Documentation Requirements for Community Psychiatric {#sec-9-csr-30-4.043 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.043}

PURPOSE: This rule specifies the core and optional psychiatric treatment services, staffing requirements, and documentation requirements for community psychiatric rehabilitation (CPR) programs.

(1) CPR programs shall comply with requirements set forth in department Core Rules for Psychiatric and Substance Use Disorder Treatment Programs, 9 CSR 10-7.030 Service Delivery Process and Documentation.

(A) Service delivery and documentation requirements specific to the CPR program are included in this rule.

(2) Core Services. At a minimum, CPR programs shall directly provide the following core services, or ensure the services are available through a subcontract as specified in 9 CSR 10- 7.090(6):

(A) Eligibility determination (to expedite the admission process, if necessary), in accordance with 9 CSR 30-4.005;

(B) Initial comprehensive assessment, in accordance with 9 CSR 30-4.035;

(D) Treatment planning, in accordance with 9 CSR 30-4.035;

(E) Community support, in accordance with 9 CSR 30-4.047;

(F) Crisis Prevention and Intervention—face-to-face emergency or telephone intervention available twenty-four (24) hours a day, on an unscheduled basis, to assist individuals in resolving a crisis and providing support and assistance to promote a return to routine, adaptive functioning. Services must be provided by a qualified mental health professional (QMHP), licensed mental health professional (LMHP), qualified addiction professional (QAP), or community support specialist with population-specific experience providing community support services in accordance with the key service functions specified in 9 CSR 30-4.047(5)(B). Nonmedical staff providing crisis prevention and intervention must have immediate, twenty-four (24) hour telephone access to consultation with a physician/physician extender. Minimum service functions shall include, but are not limited to— 1. Interacting with the identified individual and their family members/natural supports, legal guardian, or a combination of these;

Specifying factors that led to the individual’s crisis state, when known;
Identifying maladaptive reactions exhibited by the individual;
Evaluating potential for rapid regression;
Attempting to resolve the crisis; and 6. Referring the individual for treatment in an alternative setting when indicated;
Documentation must include— A. A description of the precipitating event(s)/situation when known;

B. A description of the individual’s mental status;

C. The intervention(s) initiated to resolve the individual’s crisis state;

D. The individual’s response to the intervention(s);

E. The individual’s disposition; and F. Planned follow-up by staff;

(G) Integrated Treatment for Co-Occurring Disorders (ITCD), in accordance with 9 CSR 30-4.0431;

(H) Medication Administration—assures the appropriate administration and continuing effectiveness of medication(s) being prescribed for the individual served. Services must be provided by a physician, assistant physician, physician assistant, registered professional nurse (RN), licensed practical nurse (LPN), advanced practice registered nurse (APRN), psychiatric resident, or psychiatric pharmacist. Key service functions shall include— 1. Administering therapeutic injections of medication (subcutaneous or intramuscular);

Monitoring lab tests/levels including consultation with the physician(s), individual served, and community support specialist;
Coordinating medication needs with the individual served and his or her family members/natural supports, as appropriate, and pharmacy staff, including the use of indigent drug programs (does not include routine placing of prescription orders and refills with pharmacies);
Setting up medication boxes;
Delivering medication to the individual’s home;
Educating the individual about medications;
Recording the individual’s initial histories and vital signs;
Ensuring medication is taken as prescribed;
Monitoring side effects of medication including the use of standardized evaluations; and 10. Monitoring prescriber’s orders for treatment modifications and educating the individual served;

(I) Medication Services—goal-oriented interaction with the individual served regarding the need for medication and management of a medication regimen. A physician/physician extender shall provide this service, subject to the guidelines and limitations promulgated for each specialty in statutes and administrative rules.

Individuals requiring or requesting medication shall be seen by a qualified staff person within fifteen (15) days, or sooner if clinically indicated. All efforts shall be made to ensure established psychotropic medications are continued without interruption. Medication services must occur at least every six (6) months for individuals taking psychiatric medications. Key service functions shall include, but are not limited to— A. Review of the individual’s presenting condition;

B. Mental status exam;

C. Review of symptoms and medication side effects;

D. Review of the individual’s functioning;

E. Review of the individual’s ability to self-administer medication;

F. Education on the effects of medication and its relationship to the individual’s mental illness and choice of medication; and G. Prescription of medications when indicated.

Documentation for medication services must include, A. A description of the individual’s presenting condition;

B. Pertinent medical and psychiatric findings;

C. Observations and conclusions;

D. Any side effects of medication as reported by the individual;

E. Actions and recommendations regarding the individual’s ongoing medication regimen; and F. Pertinent information reported by family members/ natural supports regarding a change in the individual’s condition or an unusual or unexpected occurrence in his or her life, or both;

(J) Metabolic Syndrome Screening—identifies risk factors for obesity, hypertension, hyperlipidemia, and diabetes. The screening is required annually for adults and children/youth who are receiving antipsychotic medication.

Services must be provided by an RN or LPN. Key service functions shall include, but are not limited to:

A. Taking and recording vital signs;

B. Conducting lab tests to assess lipid levels and blood glucose levels and/or HgbA1c, or arranging and coordinating lab tests to assess lipid levels and blood glucose levels and/or HgbA1c;

C. Obtaining results of recently completed lab tests from other health care providers to assess lipid levels and blood glucose levels and/or HgbA1c; and D. Recording the results of the metabolic screening on a form/tool approved by the department.

Metabolic syndrome screening is limited to no more than one (1) screening every ninety (90) days, per individual. If the lab tests are conducted by a nurse, an analyzer approved by the department must be used.
Documentation must reflect completion of the Metabolic Syndrome Screening and Monitoring Tool and a summary progress note;

(K) Physician Consultation/Professional Consultation— medical services provided by a physician, assistant physician, physician assistant, APRN, psychiatric resident, or a psychiatric pharmacist. The service is intended to provide direction to treatment and consists of a review of an individual’s current medical situation either through consultation with one (1) staff person, or a team discussion(s) related to a specific individual.

This service cannot be substituted for supervision or face-toface intervention with the individual. Key service functions shall include, but are not limited to:

An assessment of the individual’s presenting condition as reported by staff;
Review of the treatment plan through consultation;
Participant-specific consultation with staff especially in situations which pose a high risk of psychiatric decompensation, hospitalization, or safety issues; and 4. Participant-specific recommendations regarding high risk issues and, when needed, to promote early intervention;

(L) Psychosocial Rehabilitation for Adults, in accordance with 9 CSR 30-4.046.

(3) Optional Services. In addition to the core services defined in section (2) of this rule, the following optional services may be provided directly by the CPR program, or through a subcontract as specified in 9 CSR 10-7.090(6):

(A) Adult Inpatient Diversion, in accordance with 9 CSR 30- 4.045;

(B) Assertive Community Treatment (ACT), in accordance with 9 CSR 30-4.032;

(D) Co-Occurring Individual Counseling, a structured, goaloriented therapeutic process in which an individual interacts with a qualified provider in accordance with their treatment plan to resolve problems related to their documented mental illness and substance use disorder that interferes with functioning.

Services involve the use of evidence-based practices such as motivational interviewing, cognitive behavior therapy, and relapse prevention.
Counseling provided to the individual’s family is for the direct benefit of the individual served in accordance with their needs and treatment goals, and for the purpose of assisting in the individual’s recovery.
Services must be provided by a QMHP or QAP;

(E) Co-Occurring Group Counseling—goal-oriented therapeutic interaction between a counselor and two (2) or more individuals as specified in individual treatment plans to promote self-understanding, self-esteem, and resolution of personal problems related to the individual’s documented mental disorders and substance use disorders through personal disclosure and interpersonal interaction among group members. This service utilizes evidence-based practices.

Services must be provided by a QMHP or QAP;
Group size shall not exceed ten (10) individuals;

(F) Co-Occurring Group Rehabilitative Support—informational and experiential services to assist individuals, family members, and others identified by the individual as a primary natural support, in the management of substance use and mental health disorders.

Services are delivered through systematic, structured, didactic methods to increase knowledge of mental illnesses and substance use disorders. This includes integrating affective and cognitive aspects in order to enable the individuals served, as well as family members/natural supports, to cope with the illness and understand the importance of their individual plan of care.
The primary goal is to restore lost functioning and promote reintegration and recovery through knowledge of one’s disease, symptoms, and precursors to crisis, crisis planning, community resources, recovery management, and medication action, interaction, and side effects.
The service includes use of evidence-based practices such as promotion of participation in peer self-help, brain chemistry and functioning, the latest research on illness causes and treatments, medication education and management, symptom management, behavior management, stress management, improving daily living skills, and independent living skills.
Group size is limited to twenty (20) individuals.
Services must be provided by staff who have documented education and experience related to the topic presented and either be or be supervised by a QMHP or a QAP;

(G) Day Treatment for Children/Youth—an intensive array of services provided to children/youth in a highly structured and supervised environment designed to reduce symptoms of a psychiatric disorder and maximize the individual’s functioning so they can attend school and interact in their community and family setting. Services are individualized based on individual needs and include a multidisciplinary approach to care under the direction of a physician. The provision of educational services must comply with the Individuals with Disabilities Education Act and section 167.126, RSMo.

Hours of operation are based on program capacity, staffing availability, space requirements, and as specified by 2. Eligibility criteria includes— A. For children six (6) years of age and older, the individual must be at risk of inpatient or residential placement as a result of a serious emotional disturbance (SED);

B. For children five (5) years of age or younger, the individual must exhibit one (1) or more of the following:

(I) Has been expelled from multiple day care/early learning programs due to emotional or behavioral dysregulation in relation to SED or diagnosis based on the 2021 edition of the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-5 TM , Version 2.0), published by and available from ZERO TO THREE, 2445 M Street NW, Suite 600, Washington, DC 20037, telephone (202) 638-1144 or (800) 899-4301. The document incorporated by reference does not include any later amendments or additions;

(II) Is at risk for placement in an acute psychiatric hospital or residential treatment center as a result of a SED; or (III) Has a score in the seriously impaired functioning level on the standardized functional tools approved by the department for this age range.

Key service functions shall include, but are not limited to:

A. Providing integrated treatment combining education, counseling, and family interventions;

B. Promoting active involvement of the parent/guardian in the program;

C. Consulting and coordinating with the individual’s/ family’s private service providers, as applicable, to establish and maintain continuity of care;

D. Coordinating and sharing information with the individual’s school, including discharge planning, consistent with the Family Educational Rights and Privacy Act and Health Insurance Portability and Accountability Act (HIPAA);

E. Requesting screening and assessment reports from the individual’s school to determine any special education needs;

F. Planning the individualized educational needs with the individual’s school; and G. Providing other core services as prescribed by the department.

For programs serving children three (3) to five (5) years of age, services must be provided by a team of at least one (1) QMHP and one (1) appropriately certified, licensed, or credentialed ancillary staff. For programs serving school-age children, services must be provided by a team consisting of at least one (1) QMHP and two (2) appropriately certified, licensed, or credentialed ancillary staff. Ancillary staff include— A. Occupational therapists;

B. Physical therapists;

C. Assistant behavior analysts;

D. Individuals with a bachelor’s degree in child development, psychology, social work, or education;

E. Individuals with an associate’s degree, or two (2) years of college, and two (2) years of experience in a mental health or child-related field; and F. Individuals meeting the qualifications of a community support specialist with at least three (3) years of populationspecific experience providing community support services in accordance with the key service functions for community support services as specified in 9 CSR 30-4.047.

Documentation must include relevant information reported by family members/natural supports regarding a change in the individual’s condition or an unusual or unexpected occurrence in their life;

(H) Evidence-Based Practices for Children and Youth, in accordance with 9 CSR 30-4.045;

(I) Family Assistance—services focus on development of home and community living skills and communication and socialization skills for children and youth, including coordination of community-based services. Staff must have a high school diploma or equivalent and two (2) years of experience working with children who have a SED or have experienced abuse and neglect. Staff must also complete training approved by/provided by the department and be supervised by a QMHP. Key service functions shall include, but are not limited to:

Modeling appropriate behaviors and coping skills for the child;
Exposing the child to activities that encourage positive choices, promote self-esteem, support academic achievement, and develop problem-solving skills for home and school;
Teaching appropriate social skills through hands-on experiences; and 4. Mentoring appropriate social interactions with the child or resolving conflict with peers;

(J) Family Support—provides a support system for parents/ caregivers of an individual twenty-five (25) years of age and younger who has a SED. Activities are directed and authorized by the individualized treatment plan. Services must be provided by a family member of an individual twenty-five (25) years of age and younger who has or had a behavioral or emotional disorder. The family member must have a high school diploma or equivalent certificate, complete training required by the department, and be supervised by a QMHP. Key service functions shall include, but are not limited to:

Providing information and support to the parents/ caregivers so they have a better understanding of the individual’s needs and options to be considered as part of treatment;
Assisting the parents/caregivers in understanding the planning process and importance of their voice in the development and implementation of the individualized treatment plan;
Providing support to empower the parents/caregivers to be a voice for the individual and family in the planning meeting;
Working with the family to highlight the importance of individualized planning and the strengths-based approach;
Assisting the family in understanding the roles of various providers and the importance of the team approach;
Discussing the benefits of natural supports within the family and community;
Introducing methods for problem-solving and developing strategies to address issues needing attention;
Providing support and information to parents and caregivers to shift from being the decision maker to the support person as the individual becomes more independent;
Connecting families to community resources;
Empowering parents, caregivers, and individuals served to become involved in activities related to planning, developing, implementing, and evaluating programs and 11. Connecting parents, caregivers, and individuals served to others with similar lived experiences to increase their support system;

(K) Individual Professional PSR and Group Professional PSR— mental health interventions provided on an individual or group

basis. A skills-based approach is utilized to address identified behavioral problems and functional deficits related to a mental disorder that interfere with an individual’s personal, family, or community adjustment. Maximum group size is one (1) professional to eight (8) individuals. This service cannot be provided to individuals under the age of five (5). Services must be provided by the following staff who complete training required by the department:

A professional counselor licensed or provisionally mental health services;
A licensed clinical social worker or master social worker mental health services;
A licensed, provisionally licensed, or temporarily licensed psychologist under Missouri law with specialized training in mental health services; or 4. A marital and family therapist licensed or provisionally mental health services.

(L) Intensive CPR, in accordance with 9 CSR 30-4.045;

(M) Metabolic Syndrome Screening—optional service for individuals not receiving antipsychotic medications and, if provided, must be in accordance with subsection (2)(J) of this

rule;

(N) Peer Support—assists individuals in their recovery from a behavioral health disorder in a person-centered, recoveryfocused manner. Individuals direct their own recovery and advocacy processes to develop skills for coping with and managing their symptoms, and identify and utilize natural support systems to maintain and enhance community living skills. Services are directed toward achievement of specific goals defined by the person served and specified in the individual treatment plan.

Peer support services shall be provided in a manner that reflect the core competencies, principles, and values identified in the publication, Core Competencies for Peer Workers in Behavioral Health Services, 2018, developed by and available from the Substance Abuse and Mental Health Services Administration (SAMHSA), 5600 Fishers Lane, Rockville, MD 20857, (877) 726- 4727, hereby incorporated by reference and made a part of this rule. This rule does not incorporate any subsequent amendments or additions to this publication.
Services are provided by Certified Peer Specialists who have at least a high school diploma or equivalent certificate, complete applicable training and testing required by the department, and are supervised by a QMHP. Certified Peer Specialists are part of the individual’s treatment team and participate in staff meetings/discussions related to services, but they cannot be assigned an independent caseload. The Certified Peer Specialist Code of Ethics must be followed. Job duties include, but are not limited to:

A. Starting and sustaining mutual support groups;

B. Promoting dialogues on recovery and resilience;

C. Teaching and modeling skills to manage symptoms;

D. Teaching and modeling skills to assist in solving problems;

E. Supporting efforts to find and maintain paid employment;

F. Using the stages in recovery concept to promote selfdetermination; and G. Assisting peers in setting goals and following through on wellness and health activities.

Certified Peer Specialists use the power of peers to support, encourage, and model recovery and resilience from behavioral health disorders in ways that are specific to the needs of each individual. Services may be provided on an individual or group basis and are designed to assist individuals in achieving the goals and objectives on their individual treatment plan or recovery plan. Activities emphasize the opportunity for individuals to support each other as they move forward in their recovery. Interventions may include, but are not limited to:

A. Sharing lived experiences of recovery, sharing and supporting the use of recovery tools, and modeling successful recovery behaviors;

B. Helping individuals recognize their capacity for resilience;

C. Helping individuals connect with other peers and their community at large;

D. Helping individuals who have behavioral health disorders develop a network for information and support;

E. Assisting individuals in making independent choices and taking a proactive role in their treatment;

F. Assisting individuals in identifying strengths and personal resources to aid in their recovery; and G. Helping individuals set and achieve recovery goals;

(O) Psychosocial Rehabilitation Illness Management and Recovery (PSR-IMR), in accordance with 9 CSR 30-4.046;

(P) Psychosocial Rehabilitation for Youth, in accordance with 9 CSR 30-4.046; and (Q) Professional Parent Home-Based Services and Treatment Family Home-Based Services (ICPR for Children/Youth in Residential Settings), in accordance with 9 CSR 30-4.045. amendment filed Aug. 27, 1993, effective Sept. 8, 1993, expired Nov. 7, 1993. Emergency amendment filed Oct. 28, 1993, effective Nov. 7, 1993, expired March 6, 1994. Emergency amendment filed Feb. 15, 1994, effective March 6, 1994, expired April 10, 1994. Amended:

Filed Aug. 27, 1993, effective April 9, 1994. Amended: Filed Dec. 13, 1994, effective July 30, 1995. Emergency amendment filed Aug. 11, 1999, effective Aug. 22, 1999, expired Feb. 17, 2000. Amended:

Filed Aug. 11, 1999, effective Feb. 29, 2000. Amended: Filed Feb. 28, 2001, effective Oct. 30, 2001. Emergency amendment filed Dec. 28, 2001, effective Jan. 13, 2002, expired July 11, 2002. Amended: Filed Dec. 28, 2001, effective July 12, 2002. Amended: Filed Dec. 1, 2011, effective June 30, 2012. Amended: Filed April 29, 2019, effective Nov. 30, 2019. Amended: Filed March 9, 2022, effective Sept. 30, 2022. *Original authority: 630.050, RSMo 1980, amended 1993, 995, 2008; 630.655, RSMo

9 CSR 30-4.0431 Integrated Treatment for Co-Occurring Disorders (ITCD) in Community Psychiatric Rehabilitation Programs {#sec-9-csr-30-4.0431 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.0431}

PURPOSE: This rule sets forth standards and regulations for the provision of ITCD in community psychiatric rehabilitation programs (CPR) for adults.

(1) ITCD is integrating substance use disorder treatment with community psychiatric rehabilitation for individuals with cooccurring psychiatric and substance use disorders. ITCD is a practice based on evidence and research for individuals with serious mental illness and substance use disorders.

(2) Organizations certified or deemed certified by the department as CPR programs may offer further specialized treatment for co-occurring psychiatric and substance use disorders and shall use the Integrated Treatment for Co-Occurring Disorders:

The Evidence resource KIT published in 2010 by the U. S.

Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, Publication No. SMA-08-4366, Rockville, MD 20009. This publication may be downloaded at https://store. samhsa.gov/product/Integrated-Treatment-for-Co-Occurring- Disorders-Evidence-Based-Practices-EBP-KIT/SMA08-4367. The resource KIT incorporated by reference with this rulemaking does not include any later amendments or additions.

(3) The agency shall have policies approved by the governing body as defined in 9 CSR 10-7.090 that are consistent with the provision of effective evidence-based interventions to guide the co-occurring services and be consistent with the ITCD model of treatment.

(4) Admission Criteria. Persons meeting criteria for ITCD must meet admission criteria as defined in 9 CSR 30-4.005 and must have a co-occurring substance use disorder.

(A) Individuals shall receive screening for both mental health and substance use disorders.

(B) If individuals present with both mental health and substance use identified service needs, the individuals shall receive an integrated assessment identifying service needs as well as stage of readiness for change.

(5) Personnel and Staff Development. ITCD shall be delivered by a multidisciplinary team responsible for coordinating a comprehensive array of services available to the individual through CPR with the amount and frequency of service commensurate with the individual’s assessed need.

(A) The multidisciplinary team shall include but is not limited to the following:

A physician/physician extender (physician extender includes licensed assistant physician, physician assistant, psychiatric resident, psychiatric pharmacist, and advanced practice registered nurse (APRN);
A registered professional nurse (RN);
A qualified mental health professional (QMHP);
Additional staff sufficient to provide community support and retain the responsibility for acquisition of appropriate housing and employment services;
A qualified co-occurring disorders specialist is defined as a person who demonstrates substantial knowledge and skill regarding substance use disorders by being one (1) of the A. A physician or QMHP in Missouri or an individual who meets the applicable training and credentialing required by the Missouri Credentialing Board for any of the following accreditations (Qualified Addiction Professional):

(I) Certified Alcohol and Drug Counselor (CADC);

(II) Certified Reciprocal Alcohol and Drug Counselor (CRADC);

(III) Certified Reciprocal Advanced Alcohol and Drug Counselor (CRAADC);

(IV) Certified Criminal Justice Addictions Professional (CCJP);

(V) Registered Alcohol Drug Counselor-Provisional (RADC-P);

(VI) Registered Alcohol Drug Counselor (RADC);

(VII) Co-Occurring Disorders Professional (CCDP); or (VIII) Co-Occurring Disorders Professional-Diplomat (CCDP-D); and B. The QMHP or QAP shall also have one (1) year of training or supervised experience in substance use disorder treatment. If they have less than one (1) year of experience in providing co-occurring disorder treatment, they shall be actively acquiring twenty-four (24) hours of training in cooccurring disorders content and receive supervision from experienced co-occurring disorders staff as approved by the department.

(B) The multidisciplinary treatment team shall meet regularly to discuss each individual’s progress and goals and provide insights and advice to one another.

(C) Multidisciplinary team members shall receive ongoing training in ITCD and have a training plan that addresses specific ITCD criteria, including co-occurring disorders, motivational interviewing, stage-wise treatment, cognitive behavioral interventions, and substance use disorders treatment.

(D) The number of integrated treatment teams is determined by the needs and number of individuals being supported.

(E) Only qualified staff shall provide integrated treatment for co-occurring disorder services. Qualified staff for each service are— 1. Individual counseling, group counseling, and assessment, a QMHP, or a QAP who meets the co-occurring counselor competency requirements established by the department; and 2. Group psychosocial rehabilitation services, eligible providers shall have documented education and experience related to the topic presented and either be, or be supervised by, a QMHP or QAP who meets co-occurring counselor competency requirements established by the department.

(6) Treatment.

(A) ITCD shall be delivered according to the ITCD model and criteria specified by the department. Services are time unlimited with the intensity modified according to level of need and degree of recovery; include outreach efforts and interventions to promote physical health, especially related to substance use; and target specific services to individuals who do not respond to treatment.

(B) In addition to eligible CPR services, integrated treatment for co-occurring disorder services include the following:

Co-occurring individual counseling. A structured goal-oriented therapeutic process in which an individual interacts with a counselor in accordance with the individual’s treatment plan in order to resolve problems related to the individual’s documented mental and substance use disorders that interfere with func tioning. Individual co-occurring counseling involves the use of practices such as motivational interviewing, cognitive behavioral therapy, harm reduction, and relapse prevention. Individual co-occurring counseling may include interaction with one (1) or more members of the individual’s family or other natural supports for the purpose of assessment or supporting the individual’s recovery;
Co-occurring group counseling. Goal-oriented therapeutic interaction among a counselor and two (2) or more individuals as specified in individual treatment plans designed to promote individual self-understanding, self-esteem, and resolution of personal problems related to the individual’s documented mental disorders and substance use disorders through personal disclosure and interpersonal interaction among group members. Group size shall not exceed ten (10) individuals;
Co-occurring group psychosocial rehabilitation services.

Informational and experiential services designed to assist individuals, family members, and others identified by the individual as a primary natural support, in the management of the substance use and mental health disorders. Services are delivered through systematic, structured, didactic methods to increase knowledge of mental illnesses and substance use disorders. This includes integrating affective and cognitive aspects in order to enable the individuals receiving services, family members, and other natural supports to cope with the illness and understand the importance of their individual plan of care. The primary goal is to restore lost functioning and promote reintegration and recovery through knowledge of one’s disease, symptoms, understanding of the precursors to crisis, crisis planning, community resources, recovery management, and medication action, interaction, and side effects. Group size shall not exceed twenty (20) individuals;

Co-occurring assessment supplement. Individuals who present with both substance use and mental health identified service needs must receive additional assessments to document the co-occurring disorders and assess the interaction of the cooccurring disorders over time;
The agency shall arrange for referrals for withdrawal management/detoxification or hospitalization services when appropriate;
The agency shall provide housing and vocational services consistent with the ITCD model; and 7. Other services as appropriate.

(C) Staff shall help individuals in the engagement and persuasion stages recognize the consequences of their substance use, resolve ambivalence related to their addiction, and introduce them to self-help principles. Individuals in the active treatment or relapse prevention stage shall receive cooccurring individual and/or group counseling and be assisted in connecting with self-help programs in the community.

(D) Families and other natural supports shall receive education and, as appropriate, be involved in counseling.

(7) Records.

(A) An integrated treatment plan shall be developed by the multi-disciplinary team, including input from the integrated treatment specialist, and shall include participation of the individual receiving services.

(B) The treatment plan shall address mental health and substance use disorder treatment strategies that involve building both skills and supports for recovery.

(8) Performance Improvement. The agency’s performance improvement plan shall include monitoring its compliance with the ITCD program model and identifying and measuring satisfaction and outcomes of individuals served. Fidelity improvement shall be included as part of the agency’s overall performance improvement efforts.

(9) The team shall participate in fidelity reviews and fidelity improvement activities conducted by the department.

Original rule filed Sept. 2, 2008, effective April 30, 2009. Amended:

Filed April 29, 2019, effective Nov. 30, 2019. Amended: Filed March 9, 2022, effective Sept. 30, 2022.

9 CSR 30-4.0432 Assertive Community Treatment (ACT) in {#sec-9-csr-30-4.0432 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.0432}

PURPOSE: This rule sets forth standards and regulations for the provision of ACT services in community psychiatric rehabilitation programs for adults.

(1) Assertive Community Treatment (ACT) is a transdisciplinary team model used to deliver comprehensive and flexible treatment, support, and services to adults or transition-age youth who have the most severe symptoms of a serious mental illness or severe emotional disturbance and who have the greatest difficulty with basic daily activities.

(A) These regulations apply to all ACT teams including specialized teams for women and children, transition-age youth, transition-age youth with behavioral health and developmental disabilities, transition-age youth with co-occurring disorders, and forensic assertive community treatment.

(2) Organizations certified or deemed certified as Community Psychiatric Rehabilitation (CPR) providers by the department may offer ACT services and shall use the Assertive Community Treatment: How to Use the Evidence-Based Practice KIT published in 2008 by the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services, Publication No. SMA-08-4344, Rockville, MD 20008.

This publication may be downloaded at https://store.samhsa. gov/product/Assertive-Community-Treatment-ACT-Evidence- Based-Practices-EBP-KIT/sma08-4345. Agencies shall also use A Manual for ACT Start-Up by Deborah J. Allness, M.S.S.W., and William H. Knoedler, M.D., published in 2003 by National Alliance for the Mentally Ill (NAMI), 3803 N. Fairfax Drive, Suite 100, Arlington, VA 22203, (703) 524-7600. The documents incorporated by reference with this rule do not include any later amendments or additions.

(3) Agencies providing ACT services shall comply with Programs, 9 CSR 10-7.010 through 9 CSR 10-7.140.

(4) The agencies providing ACT services shall have policies approved by the governing body as defined in 9 CSR 10-7.090 that are consistent with the provision of effective evidencebased interventions to guide the ACT services and be consistent with the ACT model of treatment.

(5) Personnel and Staff Development. ACT shall be delivered by a transdisciplinary team (team) responsible for coordinating a comprehensive array of services. The team shall include, but is not limited to, the following disciplines:

(A) The team shall have adequate prescribing capacity by meeting one (1) of the following:

A physician/physician extender who shall be available a minimum of sixteen (16) hours per week to no more than fifty (50) individuals to assure adequate direct psychiatric treatment;
A combination of a physician/physician extender equaling sixteen (16) hours per week shall be available to no more than fifty (50) individuals (physician extender includes licensed assistant physician, physician assistant, psychiatric resident, psychiatric pharmacist, and advanced practice registered nurse (APRN)); or 3. In a service area designated as a Mental Health Professional Shortage Area, the psychiatrist, physician assistant, psychiatric pharmacist, assistant physician, or psychiatric resident shall be available ten (10) hours per week to no more than fifty (50) individuals; or an advanced practice registered nurse shall be available sixteen (16) hours per week to no more than fifty (50) individuals; two (2) prescribers working on the same team must include each prescriber working a minimum of eight (8) hours per week;

(B) The ACT team prescriber shall attend at least two (2) team meetings per week either face-to-face or by teleconference;

(C) A registered nurse with six (6) months of psychiatric nursing experience who shall work with no more than fifty (50) individuals on a full-time basis;

(D) A team leader who is a qualified mental health professional (QMHP) as defined in 9 CSR 10-7.140 that is full time on the team with one (1) year of supervisory experience and a minimum of two (2) years experience working with adults and/ or transition-age youth with a serious mental illness or severe emotional disturbance in community settings;

(E) A qualified co-occurring disorders specialist by being one (1) of the following:

A physician or QMHP in Missouri or an individual who meets the applicable training and credentialing required by the Missouri Credentialing Board for any of the following accreditations (QAP):

A. Certified Alcohol and Drug Counselor (CADC);

B. Certified Reciprocal Alcohol and Drug Counselor (CRADC);

C. Certified Reciprocal Advanced Alcohol and Drug Counselor (CRAADC);

D. Certified Criminal Justice Addictions Professional (CCJP);

E. Registered Alcohol Drug Counselor-Provisional (RADC-P);

F. Registered Alcohol Drug Counselor (RADC);

G. Co-Occurring Disorders Professional (CCDP); and H. Co-Occurring Disorders Professional-Diplomat (CCDP-D);

The QMHP or QAP shall also have one (1) year of training or supervised experience in substance use disorder treatment.

If they have less than one (1) year of experience in providing cooccurring disorder treatment, they shall be actively acquiring twenty-four (24) hours of training in co-occurring disorders content and receive supervision from experienced co-occurring disorders staff as approved by the department;

(F) The team shall have adequate employment and education specialization capacity by meeting one (1) of the following:

An employment and education specialist who qualifies as a community support specialist as defined in 9 CSR 10-7.140 with one (1) year of experience and training in supported employment shall be available to no more than fifty (50) individuals; or 2. If the employment and education specialist is not assigned to a team full-time or is assigned to a team with less than fifty (50) individuals, the employment and education specialist shall attend at least two (2) team meetings per week;

(G) The team shall include a peer specialist who is selfidentified as currently or formerly receiving mental health services; is assigned full-time to a team and participates in the clinical responsibilities and functions of the team in providing direct services; and serves as a model, a support, and a resource for the team members and individuals being served. Peer specialists, at a minimum, shall meet the qualifications of a Certified Peer Specialist as defined in 9 CSR 10-7.140;

(H) The team shall include a program assistant. The program assistant shall have education and experience in human services or office management. The program assistant shall organize, coordinate, and monitor all non-clinical operations of the team including, but not limited to, the following:

Managing medical records;
Operating and coordinating the management information system; and 3. Triaging telephone calls and coordinating communication between the team and individuals receiving ACT services;

(I) Other team members may be assigned to work exclusively with the team and must qualify as a community support specialist or a qualified mental health professional as defined in 9 CSR 10-7.140; and (J) In addition to training required in 9 CSR 30-4.034, team members shall receive ongoing training relevant to ACT (6) Team Operations.

(A) The team shall function as the primary provider of services for the purpose of recovery from serious mental illness or severe emotional disturbance and/or substance use disorders and shall have responsibility to help adults or transition-age youth meet their needs in all aspects of living in the community.

(B) The team shall meet face-to-face at least five (5) times per week to review the status of each individual via the daily communication log, staff report, services, and contacts scheduled per treatment plans and triage.

(D) The ACT specialists shall cross-train their teammates to help each member develop knowledge and skills for each specialty area.

(7) Eligibility Criteria. Adults or transition-age youth who receive ACT services typically have needs that have not been effectively addressed by traditional, less intensive behavioral health services. Individuals shall have at least one (1) of the diagnoses as specified by the department, meet one (1) or more of the conditions specified in this rule, and meet all other CPR admission criteria as defined in 9 CSR 30-4.005.

(A) The diagnosis may coexist with other psychiatric diagnoses.

(B) For adults or transition-age youth exhibiting extraordinary clinical needs, the team may apply to the department to approve admission to ACT services.

Recent discharge from an extended stay of three (3) months or more in a state hospital for an adult or an extended stay in a residential facility for transition-age youth (ages 16- 25);
High utilization of two (2) admissions or more per year in an acute psychiatric hospital and/or six (6) or more per year for psychiatric emergency services;
Have a co-occurring substance use disorder greater than six (6) months duration;
Exhibit socially disruptive behavior with high risk of involvement in the justice system including arrest and incarceration;
Reside in substandard housing, is homeless, or at imminent risk of becoming homeless;
Experience the symptoms of an initial episode of psychosis within the past two (2) years (hallucinations, delusions or false beliefs, confused thinking, or other cognitive difficulties) leading to a significant decrease in overall functioning; or 7. Other indications demonstrating that the adult or transition-age youth has difficulty thriving in the community.

(8) Admission Process.

(A) The team shall develop a process for identifying adults or transition-age youth who are appropriate for ACT services.

(B) When the team receives a referral for ACT services, the team leader shall confirm the individual meets the ACT eligibility criteria.

(C) The team leader shall arrange an admission meeting that includes current providers of services, the team leader, and the individual. The meeting may also include, but is not limited to, 1. Family members, significant others, natural supports or guardians, if the individual grants permission;

Team members who will be working with the newly enrolled individual; and/or 3. The team psychiatrist.

(D) At the admission meeting, team members shall introduce themselves and explain the ACT program.

(E) When the individual decides he or she accepts ACT services, the team shall immediately open a record and schedule initial service contacts with the individual for the next few days.

(F) An initial assessment shall be completed on the day of admission. The initial assessment shall be based on information obtained from the individual, referring treatment provider, and family/natural supports or other supporters who participate in the admission process and shall include, but not be limited to, 1. The individual’s mental and functional status;

The effectiveness of past treatment; and 3. The current treatment, rehabilitation, and support service needs.

(G) The initial treatment plan shall be completed on the day of admission, include initial needs and interventions, be used to support recovery, and be used by the team as a guide until the comprehensive assessment and treatment plans are completed.

(H) The team shall ensure the individual receiving services participates in the development of the treatment plan.

(I) The team’s physician/physician extender shall approve the treatment plan. A licensed psychologist, as a team member, may approve the treatment plan only when the individual is currently receiving no prescribed medications to treat a mental health condition and the clinical recommendations do not include a need for prescribed medications for a mental health condition.

(9) Comprehensive Assessment and Treatment Planning.

(A) To be in compliance with this standard, the team shall follow a systematic process including admission, comprehensive and ongoing assessment, and continuous treatment planning utilizing the assessment and treatment planning protocol and components included in the publication A Manual for ACT Start-Up and in the fidelity protocol specified by the department.

(B) The team shall conduct the comprehensive ACT assessment as they are working with the individual in the community delivering services outlined in the initial treatment plan.

history, including trauma history, past treatment, and to become acquainted with the individual and their family members. This assessment enables the team to individualize and tailor ACT services to ensure courteous, helpful, and respectful treatment. The comprehensive assessment includes, but is not limited to:

Psychiatric history, mental status, and diagnosis;
Physical health;
Use of drugs and/or alcohol;
Education and employment;
Social development and functioning;
Activities of daily living;
Family structure and relationships; and 8. Functional assessment approved by the department for individuals whose diagnosis requires a functional score to support admission and if required by the department as part of the comprehensive assessment.

(D) Team members, with supervision from the team leader, shall complete their respective sections of the comprehensive assessment within thirty (30) days of admission.

(E) The assessment is ongoing throughout the course of ACT treatment and consists of information and understanding obtained through day-to-day interactions with the individual, the team, and others, such as landlords, employers, family, friends, and others in the community.

(F) The comprehensive assessment is a daily and ongoing process that is continuously updated and documented as information changes or is received.

(G) Treatment plans shall be developed utilizing information obtained from the comprehensive assessment.

(H) Treatment plans shall contain objective goals based on the individual’s preferences and shall be person-specific.

(I) Treatment plans shall contain specific interventions and services that will be provided, by whom, for what duration, and location of the service.

(J) The comprehensive treatment plan shall be developed within forty-five (45) days of admission.

(K) The treatment plan shall be revised or re-written every six (6) months.

(10) Service Provision.

(A) ACT services shall be delivered seven (7) days per week, including evenings and holidays based upon individual needs.

(B) At least two (2) hours of direct ACT services shall be available on each day of the weekend and on holidays.

(D) The team shall be available to individuals on an ACT team who are in crisis twenty-four (24) hours a day, seven (7) days a week. The team is the first-line crisis evaluator and responder. If another crisis responder screens calls, there is minimal triage. When the team is contacted, the team shall determine the need for team intervention and whether that be by telephone or face-to-face, with back-up by the team leader and ACT team prescriber.

(E) Individualized, practical crisis prevention plans shall be available to staff who are on call.

(F) Individuals shall be offered services on a time unlimited

basis, with less than ten percent (10%) dropping out annually, excluding those who graduate from services.

(G) The team shall provide goal driven services for all individuals enrolled in ACT including, but not limited to:

Psychopharmacologic treatment;
Nursing;
Integrated treatment for co-occurring disorders;
Supported employment and education;
Peer support;
Crisis intervention;
Psychiatric rehabilitation and skills training to improve functioning;
Wellness management and recovery;
Empirically supported psychotherapy; and 10. Supportive housing.

(H) The team shall have a process to manage emergency funds for individuals served.

(I) The ratio for clinical staff to individuals served, excluding the psychiatrist, shall be no more than one to ten (1:10).

(J) The ratio for clinical staff to individuals served shall be no more than one to thirteen (1:13) if the team continues to demonstrate outcomes in areas such as employment, housing, and hospitalizations comparable to teams with lower caseloads.

(K) The clinical team shall be of sufficient, absolute size to consistently provide necessary staffing diversity and coverage, based on team caseload size.

(L) At a minimum, individuals shall be contacted face-to-face by the team an average of two (2) hours per week.

(M) For individuals who refuse services, the team shall attempt to engage individuals with at least two (2) face-to-face contacts per month for a minimum of six (6) months.

(N) Individuals who are experiencing severe, emergent, or acute symptoms shall be contacted multiple times daily by the team.

(O) At a minimum, seventy-five percent (75%) of team contacts shall occur out of the office.

(P) Individuals shall have direct contact with more than two (2) team members per month.

(Q) Individuals with co-occurring disorders shall be provided integrated mental health and substance use disorder treatment.

(R) The team shall monitor and, when needed, provide supervision, education, and support in the administration of psychiatric medications for all individuals.

(S) The team shall monitor symptom response and medication side-effects.

(T) The team shall educate individuals and families about symptom management and early identification of symptoms.

(U) The team shall have an average of one (1) or more contacts per month with family and support systems in the community, including landlords and employers, after obtaining the individual’s permission.

(V) The team shall actively and assertively engage and reach out to family members, natural supports, and significant others to include, but not be limited to, the following:

Establishing ongoing communication and collaboration between the team, family members/natural supports, and others;
Educating the family/natural supports about mental illness or severe emotional disturbance and/or substance use disorder and the family’s role in treatment;
Educating the family/natural supports about symptoms management and early identification of symptoms indicating onset of illness; and 4. Providing interventions to promote positive interpersonal relationships.

(W) At a minimum, the team supports, facilitates, or ensures the individual’s access to the following services:

Medical and dental services;
Social services;
Transportation; and 4. Legal advocacy.

(X) Inpatient admissions shall be jointly planned with the team and the team, at a minimum, shall make weekly contact with individuals while hospitalized.

(Y) The team shall coordinate discharge planning in cooperation with hospital staff.

(11) Transition to Less Intensive Services.

(A) The team shall conduct regular assessment of the need for ACT services.

(B) The team shall use explicit criteria or markers for the need to transfer to a less intensive service option.

(D) The team shall monitor the individual’s status following transition based on individual need.

(E) There shall be an option to return to the team, as needed.

(F) A transition plan shall be developed incorporating graduated step down in intensity and including overlapping team meetings as needed to facilitate the transition of the individual.

(G) The individual shall be engaged in the next step of treatment and rehabilitation.

(H) Documentation of transition to less intensive services shall include a systematic plan to maintain continuity of treatment at appropriate levels of intensity to support the individual’s continued recovery and have easy access to return to the ACT team if needed.

(I) A discharge summary shall include, but is not limited to, 1. Dates of admission and transition to less intensive services;

Reason for admission and referral source;
Diagnosis or diagnostic impression;
Description of services provided and outcomes achieved, including any prescribed medication, dosage, and response;
Reason for or type of transition or discharge from the team; and 6. Medical status and needs that may require ongoing monitoring and support.

(J) An aftercare plan shall be completed prior to transition to less intensive services or discharge from the team. The plan shall identify services, designated provider(s), or other planned activities designed to promote further recovery.

(12) Records.

(A) The ACT provider shall implement policies and procedures to assure routine monitoring of individual records for compliance with applicable standards.

(B) All staff contacts with individuals shall be documented and easily accessible to team members.

(C) Each individual’s record shall document services, activities, or sessions that involve the individual including— 1. The specific services rendered;

The date and actual time the service was rendered;
The name of the team member who rendered the service;
The setting in which the services were rendered;
The amount of time it took to deliver the services;
The relationship of the services to the treatment regimen described in the treatment plan; and 7. Updates describing the individual’s response to prescribed care and treatment.

(D) In addition to documentation required under subsection (12)(C), for medication services, the ACT provider shall provide additional documentation for each service episode, unit, or as clinically indicated, for each service provided to the individual as follows:

Description of the individual’s presenting condition;
Pertinent medical and psychiatric findings;
Observations and conclusions;
Individual’s response to medication, including identifying and tracking over time one (1) or more target symptoms for each medication prescribed;
Actions and recommendations regarding the individual’s ongoing medication regimen; and 6. Pertinent/significant information reported by family members, natural supports, or significant others regarding a change in the individual’s condition, an unusual or unexpected occurrence in the individual’s life, or both.

(E) The ACT team shall update the treatment plan or department-approved functional assessment every ninety (90) days to assess individual functioning, progress toward treatment objectives, and appropriateness of continued services. The treatment plan shall be revised and updated based on the findings from the functional assessment. Documentation in the individual record shall include but is not limited to:

Barriers, issues, or problems identified by the individual, family, guardian, and/or team that identify the need for focused services;
A brief explanation of any change or progress in the daily living functional abilities in the prior ninety (90) days;
A description of the changes for the plan of treatment based on information obtained from the functional assessment.

(F) The ACT program also shall include other information in the individual record, if not otherwise addressed in the intake/ annual evaluation or treatment plan, including— 1. The individual’s medical history, including— A. Medical screening or relevant results of physical examinations; and B. Diagnosis, physical disorders, and therapeutic orders;

Evidence of informed consent;
Results of prior treatment; and 4. Condition at discharge from prior treatment.

(G) Any authorized person making any entry in an individual’s record shall sign and date the entry, including corrections to information previously entered in the individual’s record.

(H) The ACT program shall implement written procedures to ensure exchange of information within five (5) working days when an individual is referred or transfers to another service component within the organization or to an outside entity for (I) The ACT provider shall provide information, as requested, regarding individual characteristics, services, and costs to the department in a format established by the department.

(13) Performance Improvement. The agency’s performance improvement plan shall include monitoring compliance with the ACT standards.

(A) Records shall show evidence that the team monitors hospitalization, housing, employment/education, substance use, and contact with the justice system for all individuals using a tracking form approved by the department and submitted to the department on a quarterly basis.

(B) The agency shall include fidelity improvement as part of its overall performance improvement efforts.

(D) Team members or a designee(s) shall meet with the department and stakeholder groups and collaborate as needed.

Original rule filed Aug. 14, 2009, effective March 30, 2010.

Amended: Filed April 29, 2019, effective Nov. 30, 2019. Amended:

Filed March 9, 2022, effective Nov. 30, 2022.

9 CSR 30-4.044 Behavior Management {#sec-9-csr-30-4.044 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.044}

9 CSR 30-4.045 Intensive Community Psychiatric Rehabilitation (ICPR) {#sec-9-csr-30-4.045 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.045}

PURPOSE: This rule sets forth standards and regulations for the provision of ICPR services.

(1) Intensive Community Psychiatric Rehabilitation (ICPR). ICPR is separate and distinct from other community psychiatric rehabilitation (CPR) services. The individual treatment plan shall specify interventions and supports to be provided by ICPR staff that are separate from other CPR services (such as community support) to prevent duplication of services.

(A) Services are designed to help individuals who are experiencing a severe psychiatric condition, alleviating or eliminating the need to admit them into a psychiatric inpatient setting or a restrictive living setting. ICPR is a comprehensive, time-limited, community-based service for individuals who are exhibiting symptoms that interfere with individual/family life in a highly disabling manner.

(B) ICPR in all settings (children/youth and adult) must be approved by the department prior to implementation. Written proposals shall be submitted to the department and must include the following:

The proposed service, setting, and timeline for implementation;
Method for determining eligibility for the service;
Staffing patterns/staff qualifications, including identification of the qualified mental health professional (QMHP) who supervises the ICPR setting;
Evidence that the site(s) is safe;
Process for obtaining multidisciplinary input into treatment plans;
Type of documentation to be used;
Strategy for preventing the duplication of services and supports delivered by residential and community-based CPR staff;
Plan for financial separation of room and board from 9. Plan for providing personal spending funds to individuals served.

(C) ICPR is intended for— 1. Persons who would be hospitalized without the provision of intensive community-based intervention;

Persons who have extended or repeated hospitalizations;
Persons who have psychiatric crisis episodes;
Persons who are at risk of being removed from their home or school to a more restrictive environment; and 5. Persons who require assistance in transitioning from a highly restrictive setting to a community-based alternative, including specifically persons being discharged from inpatient psychiatric settings who need intensive CPR services and may require assertive outreach and engagement.

(D) Treatment teams deliver services that will maintain the individual within the family and significant support systems and assist them in meeting basic living needs and age appropriate developmental needs.

(2) Admission Criteria. To be eligible for ICPR, the individual must meet admission criteria as defined in 9 CSR 30-4.005 and at least one (1) of the following criteria:

(A) Is being discharged from a department facility or bed funded by the department;

(B) Has had extended or repeated psychiatric inpatient hospitalizations or crisis episodes within the past six (6) months;

(C) Has received services in multiple out-of-home residential settings due to their mental disorder; or (D) Is at risk of being removed from their home, school, or other community living situation.

(3) Staff Requirements. Staff requirements for ICPR in residential settings are as follows:

(A) Intensive Residential Treatment Settings (IRTS) and Psychiatric Individualized Supported Living (PISL), in accordance with 9 CSR 40-1 and 9 CSR 40-4.001;

(B) Clustered apartments (CA). Staff shall be available on a full- or part-time basis in accordance with the agency’s written proposal approved by the department;

Clustered apartment services are provided on-site at the individual’s place of residence. Staff providing services shall be located on site, within a five (5) mile radius of the CA, or within a ten (10) minute drive of the CA.

(C) Treatment Family Home-Based Services and Professional Parent Home-Based Services, as specified in section (7) of this

rule and 9 CSR 40-6.001.

(4) Treatment for Children/Youth and Adults. All treatment teams shall be supervised by a qualified mental health professional (QMHP). The team coordinates a comprehensive array of services available to the individual through the CPR program as specified in 9 CSR 30-4.043. Other services shall be provided as clinically appropriate to meet individual needs, however, shall not duplicate services being provided on site.

Each team shall include:

(A) Staff required to provide specific services identified on the individualized treatment plan;

(B) The individual receiving services and family members or other natural supports, if developmentally appropriate;

Multiple face-to-face contacts with the individual on a weekly basis, and may require contact on a daily basis, as required for each service type;
Services that are available twenty-four (24) hours per day, seven (7) days per week for programs that require daily 3. Crisis response services that may be coordinated with an existing crisis system;

(D) The amount and frequency of services is based upon the individual’s assessed acuity and need;

(E) A crisis prevention plan shall be developed for each individual, including clinical issues that may impact transition to less intensive services;

(F) At a minimum, quarterly treatment plan reviews shall occur to ensure individuals are receiving the appropriate level of services to meet needs and goals; and (G) Individuals no longer need ICPR when— 1. There is a reduction of severe symptoms; and 2. They are able to function without intensive services; or 3. They choose to no longer receive intensive services.

(5) Documentation Requirements. ICPR services must be documented in accordance with 9 CSR 10-7.030(13), and as specified in this rule.

(A) For individuals currently enrolled in the CPR program, the following documentation is required upon admission to ICPR:

Verification they meet admission criteria;
Acuity level; and 3. Treatment plan update indicating the higher level of service the individual will be receiving.

(B) For individuals newly admitted directly from the community into ICPR, an intake evaluation must be completed to substantiate acuity and criteria for admission.

Each individual shall have a psychiatric evaluation at admission. For individuals discharged from inpatient hospitalization into ICPR, a psychiatric evaluation completed at the facility/hospital may be initially accepted.
The comprehensive assessment must be completed within thirty (30) days of admission except for individuals admitted provisionally.
Treatment plans shall be developed upon admission and be updated at least quarterly, or more frequently if clinically indicated.

(C) Treatment plans shall be reviewed as required for each service type and documented in the individual record with a summary progress note, including updates to the treatment plan as appropriate.

(D) Upon change from ICPR services, a transition summary must be completed by a QMHP and included in an updated (6) ICPR for Children and Youth. Services are medically necessary to maintain a child with a Serious Emotional Disturbance (SED) in their natural home, or maintain a child with a serious mental illness or SED in a community setting who has a

history of failure in multiple community settings, and/or the presence of ongoing risk of harm to self or others, which would otherwise require long-term psychiatric hospitalization.

Clinical interventions are provided by a multidisciplinary treatment team on a daily basis, and the interventions must be available twenty-four (24) hours per day, seven (7) days per week for stabilization purposes. The child’s family and other natural supports may receive services when they are for the direct benefit of the child in accordance with their individual (A) When a child/youth is receiving this service, it is vital that the parent/guardian be actively involved in the program if the individual is to receive the full benefit of the program. Services shall be provided to the child/youth’s family and other natural supports when such services are for the direct benefit of the individual, in accordance with their needs and treatment goals identified in the treatment plan, and for assisting in their recovery.

(B) Services shall include, but are not limited to:

Medication administration/management of medication;
Ongoing behavioral health assessment and diagnosis;
Monitoring to assure individual safety;
Individual and group counseling; and 5. Community support.

Physician, psychiatrist, child psychiatrist, psychiatric resident, assistant physician, physician assistant, or Advanced Practice Registered Nurse (APRN);
QMHP;
RN;
LPN;
Community Support Specialist; and 6. Individuals with a high school diploma, or equivalent certificate, under the direction and supervision of a QMHP.

(D) Services are limited to ninety (90) days. Exceptions may be granted by the department and must be documented in the individual record.

(7) ICPR for Children/Youth in Residential Settings (Treatment Family Home-Based Services and Professional Parent Home- Based Services). Intensive therapeutic interventions are provided to improve the child’s functioning and prevent them from being removed from their natural home and placed into a more restrictive residential treatment setting due to a SED.

(A) Services are for children whose therapeutic needs cannot be met in their natural home or an alternative therapeutic environment is required for transition back to their home or least restrictive setting.

(B) Providers must complete extensive, specialized training required by the department and meet department licensure requirements as specified in 9 CSR 40-6.

(C) The provider shall participate in pre-placement and ongoing meetings with the child’s CPR treatment team and assist in development of the treatment plan. The provider is responsible for implementing the treatment plan and maintaining contact with the child’s natural parent/guardian and completing documentation as required by the department.

(D) Services and supports are individualized and strengthbased to meet the needs of the child and family across life domains to promote success, safety, and permanence in the home, school, and community. Therapeutic interventions target the child’s serious mental health issues and promote positive development and healthy family functioning.

(E) Children must meet CPR admission criteria and their behavior must be sufficiently under control to live safely in a community setting with appropriate support.

(F) Staff of the CPR program who supervise the child’s services must be available twenty-four (24) hours a day, seven (7) days per week to assist the provider if a crisis situation occurs.

(G) Placement, duration, and intensity of services is based on the specific needs of each child as specified in the MO HealthNet CPR Provider Manual, hereby incorporated by reference and made a part of this rule and available from the Department of Social Services, 615 Howerton Court, PO Box 6500, Jefferson City, MO 65102-6500, and as specified in the department contract, September 2019. This rule does not incorporate any subsequent amendments or additions to this publication.

(H) A maximum of three (3) children may receive services in a Treatment Family Home (TFH), subject to licensed capacity.

One (1) child may be served in a Professional Parent Home (PPH).

(8) Evidence-Based Practices (EBP) for Youth. Services involve proven treatment supports for children and youth to address specific behavioral health needs. The selected EBP is based on individual needs and desired outcomes as identified in the (A) The EBP must be approved by the department.

(B) Activities associated with the service must include, but are not limited to:

Extensive monitoring and data collection;
Specific skills-training in a prescribed or natural environment; and 3. Prescriptive responses to a psychiatric crisis and/or frequent contact with the individual and/or family, in addition to the arranged therapy sessions.

(9) ICPR for Adults in Non-Residential Settings. Services are delivered by teams using one (1) of the following methods:

(A) Linking and transitioning individuals from acute or longterm services to less intensive treatment. The time frame for services is approximately ninety (90) days or less, but varies according to individual needs;

(B) Modified Assertive Community Treatment (ACT), as approved by the department. The time frame varies based on individual needs; or (C) Intensive wrap-around stabilization services for individuals with substantial mental health needs who may otherwise require inpatient hospitalization. The expected period of engagement is approximately ninety (90) days or less, but varies according to individual needs.

(D) Teams may be designated exclusively for individuals in ICPR or be mixed teams serving individuals in ICPR and rehabilitation services.

(E) A department-approved functional assessment must be completed monthly and documented in the individual record.

(F) Community support services shall not be provided while an individual is receiving ICPR non-residential services.

(10) ICPR for Transition Age Youth in Non-Residential Settings.

Services are delivered by transdisciplinary specialty teams using intensive wrap-around stabilization for individuals with substantial mental health and/or co-occurring needs, with the primary diagnosis being a mental disorder.

(A) Services are for individuals who may otherwise require inpatient hospitalization. The period of engagement varies based upon individual needs as specified in the treatment plan.

(B) An initial comprehensive assessment must be completed within thirty (30) days of admission.

(C) An individual treatment plan shall be developed within forty-five (45) days of admission and shall be updated as required by the department.

(11) ICPR for Adults in Residential Settings (IRTS, PISL, Clustered Apartments). Medically necessary services/supports are provided to adults who have a serious mental illness and are transitioning from an inpatient psychiatric hospital to the community, or who are at risk of returning to inpatient care due to their clinical status or need for increased support. Services and supports are provided on site where the individual lives under the supervision of a QMHP. Residential settings are structured to meet individual needs to ensure safety and prevent the individual’s return to a more restrictive setting for (A) Staff providing services/supports must be at least eighteen (18) years of age and have a minimum of a high school diploma or equivalent certificate. Two (2) years of direct heath care experience, or a bachelor’s degree in behavioral sciences, is preferred.

(B) Staff must be systematically trained to provide intensive interventions and supports to reduce the symptoms of mental illness, and provide de-escalation and intervention techniques to individuals in a psychiatric crisis who are exhibiting behaviors potentially dangerous to themselves or others. A training plan must be in place for each staff person identifying specific topics and frequency of refresher training on each topic, including documentation of course completion.

(C) Support and rehabilitation services related to activities of daily living and crisis prevention and intervention must be provided.

(D) Documentation must reflect delivery of direct (face-toface) services and supports such as, daily summary progress notes, group notes, individualized progress notes documenting interventions including crisis assistance, conflict management, behavior redirection, and prompting or reminders.

(12) Children’s Inpatient Diversion. A full array of intensive clinical services are provided to children/youth in a highly structured therapeutic setting. Services are designed to restore the child to a prior level of functioning, decrease risk of harm, and prevent transition to a more restrictive setting.

(A) Emergency medical services must be available on site or in close proximity.

(B) A psychiatrist must supervise services which are delivered by a multi-disciplinary treatment team.

(D) Licensed occupational and recreational therapists must be available based on individual needs.

(E) The provision of services is limited to certified or deemedcertified CPR programs for children and youth. The service must be accredited by a national accrediting body approved by the department.

(F) There shall be one (1) staff person for every two (2) individuals served during waking hours. The ratio for staff to individuals served may decrease to one (1) staff to six (6) individuals during sleeping hours.

(13) Adult Inpatient Diversion. A full array of intensive clinical services are provided to adults in a highly supervised twentyfour (24) hour, structured therapeutic setting. Services are designed to restore the individual to a prior level of functioning, decrease risk of harm, and prepare for transition to a less restrictive setting.

(A) Emergency medical services must be available on site or in close proximity.

(B) Intensive therapeutic services must be provided in a coordinated effort under the direction of a psychiatrist.

Other staff on the treatment team includes licensed nurses, licensed psychologists, social workers, counselors, psychosocial rehabilitation specialists, and other trained supportive staff.

Nursing;
Community support;
Psychosocial rehabilitation; and 4. Treatment for co-occurring disorders and other evidencebased services.

(D) The provision of services is limited to CPR programs for adults. The service must be accredited by a national accrediting body approved by the department.

(E) The staffing ratio for daytime and evening hours shall be one staff to six individuals served (1:6), and one staff to eight individuals served (1:8) during nighttime hours.

Emergency rule filed Dec. 28, 2001, effective Jan. 13, 2002, expired July 11, 2002. Original rule filed Dec. 28, 2001, effective July 12, 2002. Emergency amendment filed June 14, 2010, effective July 1, 2010, expired Feb. 24, 2011. Amended: Filed June 14, 2010, effective Feb. 24, 2011. Amended: Filed April 29, 2019, effective Nov. 30, 2019.

Amended: Filed March 9, 2022, effective Sept. 30, 2022.

9 CSR 30-4.046 Psychosocial Rehabilitation (PSR) in {#sec-9-csr-30-4.046 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.046}

PURPOSE: This rule provides standards for PSR programs operated as part of a community psychiatric rehabilitation (CPR) program.

(1) The Psychosocial Rehabilitation (PSR) program must be accredited by CARF International, The Joint Commission, Council on Accreditation, or other accrediting body recognized by the department. If the PSR program is not accredited, department licensure rules as specified in 9 CSR 40-1 and 9 CSR 40-9 shall apply, as applicable, until accreditation is obtained.

(2) The community psychiatric rehabilitation (CPR) program shall provide or arrange transportation to and from the PSR site, and to/from various locations in the community, to provide individuals with opportunities for off-site training and rehabilitation in realistic settings.

(3) Policies and procedures shall be implemented for intake screening, referral, and assignment of individuals eligible for (4/30/24) John R. Ashcroft (A) Intake policies and procedures shall define referral procedures to be followed for persons determined ineligible for PSR services.

(B) The maximum wait time from an individual’s initial faceto-face contact with the PSR program to intake screening shall be ten (10) working days, or sooner, if clinically indicated.

(C) The intake screening shall determine the individual’s need for PSR, functional strengths and weaknesses, and transportation needs.

(D) PSR services shall be incorporated into the individual’s treatment plan within forty-five (45) days of admission to the program.

(4) Policies and procedures shall ensure program staff document measurable progress for individuals engaged in key services.

(A) Key services shall include, but are not limited to— 1. Training/rehabilitation in community living skills;

Development of personal support systems through a group modality; and 3. Prevocational training/rehabilitation provided directly by the program or through subcontract, including at a minimum— A. Interview and job application skills;

B. Therapeutic work opportunities; and C. Temporary employment opportunities.

(B) Documentation of key services must include— 1. A weekly note summarizing specific services rendered, the individual’s involvement in and response to the services, and relationship of the services to the treatment plan;

Pertinent information reported by family members or other natural supports regarding a change in the individual’s condition and/or an unusual or unexpected occurrence in his or her life; and 3. Daily attendance records, including each individual’s actual attendance time and the activity or session attended (this information does not need to be integrated into the individual record). Attendance records must be available to department staff and other authorized representatives for audit and monitoring purposes, upon request.

(5) PSR services shall be structured and may occur during the day, evening, weekend, or a combination of these, to effectively address the rehabilitation needs of individuals served. Services and activities are not limited to the program location/site.

(A) The program shall directly provide or ensure the following services available for individuals served:

Opportunities for training and rehabilitation in daily living skills, including activities associated with meal preparation and laundry, at a minimum;
Off-site training/rehabilitation in community living skills; and 3. Opportunities for family members/natural supports and advocates to participate in the planning, development, and evaluation of the PSR program.

(6) PSR for Adults. Services are for adults who need ageappropriate, developmentally focused rehabilitation. A combination of goal-oriented and rehabilitative services shall be provided in a group setting to assist individuals in developing personal support systems, social skills, community living skills, and pre-vocational skills that promote community inclusion, integration, and independence.

(A) Key service functions shall include, but are not limited 1. Screening to evaluate the appropriateness of the individual’s participation in PSR;

Addressing individualized program goals and objectives;
Enhancing independent living skills;
Addressing basic self-care skills; and 5. Enhancing use of personal support systems.

(B) The director of the program must be a Qualified Mental Health Professional (QMHP) with two (2) years of relevant work experience.

(D) Each day program shall have, as a minimum, a daily direct care staff ratio of one (1) staff person for each sixteen (16) individuals served (1:16) unless program needs or the needs of individuals being served require otherwise.

(E) At least one (1) staff person must be on duty at all times when individuals enrolled in PSR are present at the program.

(7) PSR for Children and Youth. A combination of goal-oriented and rehabilitative services shall be provided in a group setting to improve or maintain the child’s ability to function as independently as possible within their family and/or in the community. Services are provided according to the individual treatment plan, with an emphasis on community integration, independence, and resiliency. Hours of operation are determined by the program based on capacity, staffing availability, geography, and space requirements, but shall be no more than six (6) hours daily, per child.

(A) The director must be a qualified mental health professional (QMHP) with two (2) years of experience working with children and youth. One (1) full-time mental health professional must be available during the provision of services.

(B) Staffing ratios shall be based on the ages and needs of the children being served. For individuals aged eleven (11) and younger, the staffing ratio shall be one (1) staff to eight (8) participants (1:8). For individuals aged twelve (12) to seventeen (17), the staffing ratio shall be one (1) staff to ten (10) participants (1:10).

Registered nurse;
Occupational therapist;
Recreational therapist;
Rehabilitation therapist;
Community support specialist;
Certified family support provider; and 7. Certified peer specialist.

(D) Key service functions shall include but are not limited 1. Assisting the child in gaining or regaining skills for community/family living such as personal hygiene, completing age-appropriate household chores, and family, peer, and school activities;

Developing interpersonal skills which provide a sense of participation and personal satisfaction (opportunities should be age and culturally appropriate daytime and evening activities which offer the chance for companionship, socialization, and skill building); and 3. Assisting the child and family in developing normative behaviors and expectations of relationships and providing the opportunity to practice affiliated skills which can be valuable to an individual reestablishing family and personal support relationships.

(E) Group sessions may be provided for parents/guardians to develop and enhance parenting skills. In these situations, the PSR services and expected goals and outcomes must be documented in the child/youth’s treatment plan and clearly relate to the treatment and rehabilitation goals of the child or youth.

(8) Psychosocial Rehabilitation Illness Management and Recovery (PSR-IMR). Services promote physical and mental wellness, well-being, self-direction, personal empowerment, respect, and responsibility. Services shall be provided in individual and group settings using curriculum approved by the department. Services must be delivered by staff who have completed required training.

(A) The maximum group size shall not exceed eight (8) individuals; however, if there are other curriculum-based approaches that suggest different group size guidelines, larger groups may be approved by the department.

(B) Services shall be person-centered and strength-based including, but not limited to— 1. Psychoeducation;

Relapse prevention; and 3. Coping skills training.

(D) If a program is accredited by Clubhouse International and submits its accreditation report to the department, it may be deemed as a PSR-IMR program by the department.

(E) Required documentation includes a weekly note summarizing the services rendered and the individual’s response to the services, and pertinent information reported by family members or other natural supports regarding a change in the individual’s condition, or an unusual/unexpected occurrence in their life, or both.

If an individual is participating in PSR-IMR and PSR, a single, weekly summary progress note must clearly address the PSR-IMR and PSR sessions and activities during the week, or two (2) separate summary progress notes must address each type of PSR service provided during the week.
Daily attendance records or logs clearly identifying and distinguishing PSR-IMR as the specific type of session/activity, with actual attendance times and description of service, must also be maintained. The attendance records/logs must be available for audit and monitoring purposes, but do not need to be integrated into each clinical record. effective July 30, 1995. Amended: Filed Dec. 1, 2011, effective June 30, 2012. Amended: Filed April 29, 2019, effective Nov. 30, 2019.

Amended: Filed March 9, 2022, effective Sept. 30, 2022. Amended:

Filed Oct. 18, 2023, effective May 30, 2024.

9 CSR 30-4.047 Community Support in Community {#sec-9-csr-30-4.047 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.047}

PURPOSE: This rule sets out requirements for community support services provided by a community psychiatric rehabilitation program.

(1) Service Delivery. The community psychiatric rehabilitation (CPR) program shall establish an identifiable unit which coordinates and provides community support services for children, youth, families, and/or adults. The unit shall be organized to perform functions within the scope of community support services, including critical interventions.

(2) Policies and Procedures. The CPR program shall implement policies and procedures to provide adequate, appropriate, and effective community support services to individuals. Policies and procedures shall include:

(A) A mechanism to assure the provision of all needed CPR services, as indicated in the individual’s current treatment plan;

(B) A mechanism to assure the provision of all needed services in addition to those provided by the CPR program, as indicated in the individual’s current treatment plan;

Procedures to assure each individual is afforded an opportunity to express preferences in the selection of a community support specialist; and 2. A mechanism to assure all individuals admitted who need community support are assigned to an active caseload of a community support specialist;

(E) A process for determining overall increase or decrease in the level of functioning for individuals served through ongoing performance improvement activities;

(F) A method to assure staff providing community support services in the CPR program have the opportunity to participate and contribute to the agency’s performance improvement process;

(3) Staff Requirements. The CPR program shall ensure an adequate number of appropriately qualified staff are available to provide community support services and functions.

(A) Qualified staff includes:

A qualified addiction professional (QAP) as defined in 9 CSR 10-7.140;
A qualified mental health professional (QMHP) as defined in 9 CSR 10-7.140;
An individual with a bachelor’s degree in a human services field which includes social work, psychology, nursing, education, criminal justice, recreational therapy, human development and family studies, counseling, child development, gerontology, sociology, human services, behavioral science, and rehabilitation counseling;
An individual with any four- (4-) year combination of higher education and qualifying experience;
An individual with any four- (4-) year degree and two (2) years of qualifying experience;
An individual with an Associate of Applied Science in Behavioral Health Support degree from an approved institution; or 7. An individual with four (4) years of qualifying experience.

(4/30/24) John R. Ashcroft 1. Providing one-on-one or group services with a rehabilitation/habilitation and recovery/resiliency focus;

Teaching and modeling for individuals how to cope and manage psychiatric, developmental, or substance use disorder issues while encouraging the use of natural resources;
Supporting individuals in their efforts to find and maintain employment and/or to function appropriately in family, school, and community settings; and 4. Assisting individuals to achieve the goals and objectives in their individual treatment plan.

(C) It is the responsibility of the CPR program to document how staff meet the qualifications based on the criteria in subsections (3)(A) and (3)(B) of this rule.

(D) Community support specialists must also complete orientation and training required by the department.

(E) Community support specialists must be supervised by— 1. A qualified addiction professional (QAP);

A qualified mental health professional (QMHP);
Staff possessing a Master’s degree in a behavioral health or related field who has completed a practicum or has one (1) year of experience in a behavioral health field; or 4. Staff who meet the qualifications of a community support specialist with at least three (3) years of populationspecific experience providing community support services in accordance with the key service functions specified in paragraphs (5)(B)1. to 8. of this rule.

(F) Community support supervisors who are not a QAP or QMHP must be supervised by a QAP or QMHP.

(A) Observation and monitoring shall be documented including, but not limited to:

Assessment of the individual’s mental health status and/ or substance use;
Safety and home care; and 3. Functional abilities and skill transference related to activities of daily living including educating, demonstrating, observing, and practicing skills in his/her natural environment.

(5) Service Delivery. Community support is a comprehensive service designed to reduce the individual’s disability resulting from a mental illness, emotional disorder, and/or substance use disorder and restore functional skills of daily living, principally by developing natural supports and solutionoriented interventions intended to achieve recovery/resiliency as identified in the goals and/or objectives in the individual (A) This service may be provided to the individual’s family/ natural supports when such services are for the direct benefit of the individual served, in accordance with needs and goals identified in the treatment plan, to assist in the individual’s recovery/resiliency. Most contact occurs in community locations where the individual lives, works, attends school, and/or socializes.

(B) Key service functions of community support shall include, but are not limited to:

Developing recovery goals and identifying needs, strengths, skills, resources, and supports and teaching individuals how to use them to support recovery, identifying barriers to recovery, and assisting individuals in the development and implementation of plans to overcome them;
Helping individuals restore skills and resources negatively impacted by their substance use disorder and/or co-occurring mental illness or emotional disorder including, but not limited to:

Supporting and assisting individuals in a crisis to access needed treatment services to resolve the crisis;
Continuing recovery planning and discharge planning with individuals who are hospitalized for a medical or behavioral health condition;
Assisting individuals, other natural supports, and referral sources in identifying risk factors related to relapse in mental illness and/or substance use disorders, developing strategies to prevent relapse, and advising and otherwise assisting individuals in implementing those strategies;
Promoting the development of positive support systems by providing information to family members/natural supports, as appropriate, regarding mental illness, emotional disorders, and/or substance use disorders and ways they can be of support to their family member’s recovery. Such activities must be directed toward the primary well-being and benefit of the individual served;
Developing and advising individuals on implementing lifestyle changes needed to cope with the side effects of psychotropic medications and/or to promote recovery/ resiliency from the disabilities, negative symptoms, and/or functional deficits associated with a mental illness, emotional disorder, and/or substance use disorder; and 8. Advising individuals on maintaining a healthy lifestyle including, but not limited to, recognizing the physical and psychological signs of stress, creating a self-defined daily routine that includes adequate sleep and rest, walking or exercise and appropriate levels of activity and productivity, involvement in creative or structured activities that counteract negative stress responses, learning to assume personal responsibility and care for minor illnesses and knowing when professional medical attention is needed.

9 CSR 30-4.100 Governing Authority {#sec-9-csr-30-4.100 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.100}

9 CSR 30-4.110 Client Rights {#sec-9-csr-30-4.110 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.110}

9 CSR 30-4.120 Environment {#sec-9-csr-30-4.120 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.120}

9 CSR 30-4.130 Fiscal Management {#sec-9-csr-30-4.130 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.130}

9 CSR 30-4.140 Personnel {#sec-9-csr-30-4.140 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.140}

9 CSR 30-4.150 Research {#sec-9-csr-30-4.150 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.150}

rule filed June 14, 1985, effective Dec. 1, 1985. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001.

History

AUTHORITY: sections 630.050 and 630.655, RSMo 1986. Original

9 CSR 30-4.160 Client Records 28, 2001, effective Oct. 30, 2001. Rescinded: Filed April 29, 2019, effective Nov. 30, 2019. {#sec-9-csr-30-4.160 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.160}

9 CSR 30-4.170 Referral Procedures {#sec-9-csr-30-4.170 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.170}

rule filed June 14, 1985, effective Dec. 1, 1985. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001.

History

AUTHORITY: sections 630.050 and 630.655, RSMo 1986. Original

9 CSR 30-4.180 Medication {#sec-9-csr-30-4.180 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.180}

9 CSR 30-4.190 Outpatient Mental Health Treatment Programs {#sec-9-csr-30-4.190 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.190}

PURPOSE: This rule prescribes policies and procedures for outpatient mental health treatment programs.

(1) Each agency that is certified by the department as an outpatient mental health treatment program shall comply with all requirements set forth in Department of Mental Health Core Rules for Psychiatric and Substance Use Disorder Treatment Programs, 9 CSR 10-7.010 through 9 CSR 10-7.140.

(A) The agency shall have written policies and procedures defining eligibility for services, screening, admission, and clinical assessment to assist in the support of each individual.

(B) The program shall maintain reasonable hours to assure accessibility.

(2) The program shall ensure an intake screening and admission assessment is conducted in accordance with 9 CSR 10-7.030 (1) and (2).

(A) The following services shall be provided on an outpatient

basis, in accordance with individual needs:

Crisis prevention and intervention;
Treatment planning;
Individual and group counseling;
Continuing recovery planning; and 5. Information and education.

(3) Consent to Treatment. Each individual served or a parent/ guardian must provide informed, written consent to treatment.

(A) A copy of the consent form, which must include the date of consent and signature of the individual served or a parent/ guardian, shall be retained in the individual record.

(B) Consent to treat shall be updated annually, including the date of consent and signature of the individual served or a parent/guardian, and be maintained in the individual record.

(4) Services shall be provided under the direction of an individual treatment plan as specified in 9 CSR 10-7.030(4).

(A) An initial treatment goal shall be developed at intake to address immediate needs during the admission process to the outpatient treatment program.

(B) The admission assessment and treatment plan shall be completed within the first three (3) outpatient visits.

Each individual shall participate in the development of their treatment plan.
For children and youth, the parent or guardian must participate in the development of the treatment plan and the child/youth shall participate, as appropriate.

(C) Treatment plans shall be reviewed and updated every ninety (90) days to reflect the individual’s progress and changes in treatment goals and services.

(D) Treatment plans must be revised and rewritten at least annually to align with the annual assessment to reflect current needs and goals.

(E) Treatment plans shall be approved by a licensed mental health professional as defined in 9 CSR 30-4.035(2)(A).

(5) Individual and group counseling must be delivered by a licensed mental health professional.

(6) Each agency shall maintain an organized clinical record system in accordance with 9 CSR 10-7.030(13) which ensures easily retrievable, complete, and usable records stored in a secure and confidential manner.

(A) Each agency shall implement written procedures to assure quality of individual records, including a routine review to ensure documentation requirements are being met.

History

AUTHORITY: sections 630.050 and 630.655, RSMo 2016. Original 28, 2001, effective Oct. 30, 2001. Amended: Filed April 29, 2019, effective Nov. 30, 2019. Amended: Filed March 9, 2022, effective Sept. 30, 2022. Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008, and 630.655, RSMo 1980.

9 CSR 30-4.195 Access Crisis Intervention (ACI) Programs {#sec-9-csr-30-4.195 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-4.195}

PURPOSE: This rule sets forth standards and regulations for ACI Programs.

(1) The ACI program is provided or arranged by administrative agents.

(2) The terms defined in section 630.005, RSMo are used in this

rule.

(3) Unless the context clearly requires otherwise, the following terms as used in this rule shall mean— (A) Access Crisis Intervention (ACI)—crisis intervention/ referral services provided twenty-four (24) hours per day, seven (7) days per week by telephone hotline or face-to-face mobile response at the location of the crisis or at another location in the community;

(B) Administrative agent—an agency and its approved designee(s) authorized by the Division of Behavioral Health (DBH) as an entry and exit point into the state mental health service delivery system for a geographic service area defined by the department;

(C) Advocate—individual who assists those receiving department-funded services with treatment planning, care issues, and the complaint/grievance and resolution process;

(D) Community outreach/education plan—a plan outlining how individuals receiving services and their family members/ natural supports, advocates, state agencies, law enforcement and others in the community will become familiar with the local Access Crisis Intervention System;

(E) Community Psychiatric Rehabilitation Program—a specialized program that provides or arranges for, at a minimum, the following core services: eligibility determination, initial comprehensive assessment, annual assessment, treatment planning, crisis intervention and resolution, medication services, physician/professional consultation services, medication administration, community support, metabolic syndrome screening (for individuals receiving antipsychotic medication), and psychosocial rehabilitation in a nonresidential setting for individuals with serious mental illness or serious emotional disturbances;

(F) Community support—as defined in 9 CSR 30-4.047;

(G) Crisis Intervention Team (CIT)—law enforcement officers with specialized training for response to behavioral health crisis;

(H) Individual served—anyone receiving department-funded services directly from an organization/agency;

(I) Internal agency protocol—a specific method indicating how the agency plans to respond to guidelines set forth by the department;

(J) Mobile crisis response—specialized staff available twentyfour (24) hours per day, seven (7) days per week to assess and intervene face-to-face with individuals where the crisis is occurring or another secure location in the community;

(K) Qualified Mental Health Professional (QMHP)—as defined in 9 CSR 10-7.140;

(L) Risk assessment—the process of assessing dangerousness to self or others;

(M) Residential crisis services—a service used for persons who are at high risk for hospitalization or who are being diverted from hospitalization and can include specific crisis stabilization units, group homes, residential, apartments, motels/hotels, and foster home type settings;

(N) Specialized program—programs operated by an agency that provide specific services to designated eligible individuals enrolled in that program;

(O) Telephone hotline services—a published, centralized, twenty-four (24) hours per day, seven (7) days per week staffed toll-free telephone number to provide direct means of crisis assessment and triage for individuals in crisis, their families/ natural supports, and agencies needing assistance; and (P) Withdrawal management/detoxification—support provided to persons served during withdrawal from alcohol and/or other drugs.

(4) Records and Documentation Requirements.

(A) A treatment plan is not required for individuals receiving only telephone hotline or mobile outreach through the ACI program. Evidence of coordination between the ACI staff and the treating staff for individuals currently receiving department-funded services, or those who are in the process of being admitted to a CPR program, must be docu mented in the individual record.

(B) At a minimum, programs funded for ACI must keep the following records for telephone hotline services when possible to obtain from caller:

Date and time of telephone call;
Identity of caller, including but not limited to, parent, individual receiving services, law enforcement, judge, hospital, emergency room, mental health professional;
Name, address, telephone number, and date of birth;
Presenting problem; and 5. Disposition and follow-up.

(D) When a call is received on behalf of another individual who is in crisis, the caller and the individual in crisis must both be identified as recipients of the crisis intervention services provided by the ACI program. For data collection purposes, the identified service recipient is the individual in crisis.

(E) At a minimum, agencies providing ACI services must keep the following records for mobile outreach services when the individual agrees to provide identifying information:

Date and time of referral;
Date, time and place of face-to-face contact;
Person accompanying mobile worker;
Person in attendance at face-to-face contact;
Name, address, telephone number, date of birth;
Presenting problem; and 7. Disposition and follow-up.

(F) The agency must document when the individual does not provide identifying information.

(G) Agencies providing ACI services must submit data reports and documentation to the department in accordance with the department’s standardized form and protocol.

(H) Agencies providing ACI services must meet the documentation and confidentiality requirements as defined in 9 CSR 10-7.030.

(5) Treatment.

(A) Each administrative agent must provide or arrange for the delivery of ACI services.

(B) ACI programs must operate or arrange for a twenty-four- (24-) hour per day, seven (7) day per week telephone hotline.

Each program shall have a written description of the telephone hotline system including the following:

Name of the agency or contractor that operates the hotline;
Numbers and qualifications of hotline staff;
Written documentation that clinical supervision is provided including, but not limited to: meeting minutes, supervision logs, or peer review processes;
Written description of how the telephone hotline is staffed;
Written documentation of case reviews and quality assurance activities relating to hotline services;
Written documentation of how telephone hotline services are provided to individuals who are deaf, have limited English proficiency, or are from cultural minority groups;
Written description of ongoing hotline outreach activities; and 8. Written description of a process for identifying and utilizing community resources in the delivery of telephone hotline service.

(C) Each administrative agent must have a designated agency staff person or persons on call to the ACI system twenty-four (24) hours per day, seven (7) days per week.

(D) If the individual served, advocate, family member/ natural support requests to speak with a staff member from a specialized program including, but not limited to, the CPR program’s community support specialist and the ACI clinical staff have determined this action is clinically necessary, the ACI hotline staff shall contact the appropriate designated agency staff person.

(E) The ACI hotline staff shall remain in contact with the caller until a successful hand-off contact between caller and designated agency staff person has occurred.

(F) Once contact between the caller and agency staff has occurred, the designated agency staff person shall respond to the caller and/or secure the appropriate requested specialized program personnel involved.

(G) The designated agency staff person shall remain in contact with the caller until a successful hand-off or contact between specialized program personnel and caller has occurred.

(H) Each administrative agent must have a written internal agency protocol in place for how the designated agency staff person will be able to contact staff from specialized programs that require twenty-four (24) hour, seven (7) day per week crisis intervention as a component of their service menu.

(I) If ACI staff does not follow the procedure listed in subsection (H) of this rule, there must be a written protocol for contacting the ACI supervisor and the specialized program supervisor within twenty-four (24) hours to review the immediate action taken and then reviewed for a performance improvement process within forty-eight (48) hours.

(J) ACI programs must have a written description for resource and referral to the following services:

Acute hospitalization;
Medical services;
Withdrawal management/detoxification services;
Priority outpatient scheduling within twenty-four (24) hours or the next working day;
Children and youth services; and 6. Psychiatric availability.

(K) ACI programs must operate a twenty-four- (24-) hour per day, seven (7) day per week mobile response system.

Each program shall have a written description of the mobile response system including the following:

Name of the agency or contractor that operates the mobile response system;
Written description of how mobile crisis response teams are staffed twenty-four (24) hours per day, seven (7) days per week;
Numbers and qualifications of staff;
Written documentation that clinical supervision is provided including, but not limited to: meeting minutes, supervision logs, or peer review processes;
Written documentation of case reviews and quality assurance activities relating to mobile response services; and 6. Written documentation of how mobile response services respond to individuals who are deaf, have limited English proficiency, or are from cultural minority groups.

(L) ACI programs shall provide mobile response to known and unknown individuals twenty-four (24) hours per day, seven (7) days per week at the location of the crisis or another secure community location.

(M) Mobile response shall not be provided exclusively in emergency rooms, jails, or mental health facilities.

(N) When a call is referred to mobile response, a phone-only response is appropriate if the clinical needs of the person who is in crisis can be addressed over the phone and/or the crisis has been deescalated.

(O) Each agency providing ACI services must have safety mechanisms in place for mobile response. These may include, but are not limited to:

Mobile phones;
Risk assessments for phone and continually during contact;
Availability of multiple staff to respond for face-to-face contact;
Backup availability; and 5. Written protocols for mobile response to be delivered in safe locations when necessary.

(P) In crisis situations in which law enforcement need to be contacted by the ACI staff, the ACI staff must make the initial contact and remain involved until the crisis is resolved, by phone or with the mobile response team.

ACI staff shall first contact law enforcement officers trained in crisis intervention, if they are available in the city/ county where the crisis situation is taking place and ACI staff have established arrangements to make direct contact with them.

(Q) If the caller is not satisfied, the grievance procedure must be followed as defined in 9 CSR 10-7.020(7).

(6) Performance Improvement.

(A) Each administrative agent must develop a community outreach/education plan that includes details of how the following groups will become familiar with the ACI system:

Families/natural supports;
Individuals receiving services;
Advocates of individuals receiving services;
State agencies including, but not limited to, the Department of Social Services, Family Support Division, Children’s Division, and Division of Youth Services; the Department of Health and Senior Services, Division of Senior and Disability Services; and the Department of Corrections, Division of Probation and Parole;
Emergency responders (law enforcement agencies, 911, paramedics);
Primary and secondary schools;
Court system including, but not limited to, juvenile, family, mental health, and drug courts;
Residential care programs, homeless shelters, public housing;
Public health agencies;
Community health centers;
Primary care medical offices; and 12. General public.

(B) The community outreach/education plan must include the various action steps that will be taken in educating the community as to how to access the ACI system through written material and other means of communication.

basis.

(D) Agencies providing ACI services must be able to demonstrate their community awareness and education activities, at least annually, in a report or other format specified by the department which may include, but is not limited to, number of hotline calls, walk-ins, media outreach, and outreach/educational efforts with schools, law enforcement, or other entities in the community.

(E) The telephone number for ACI must be published in local telephone books distributed in each service area and be prominently displayed on agency websites and social media pages.

(F) If the level of crisis services provided by an agency is significantly below the state average or other established benchmarks, this circumstance must be addressed in the performance improvement plan.

(G) Agencies providing ACI services must promptly respond to requests from local institutions of higher education to assist in developing appropriate crisis response systems on college campuses.

(7) Personnel and Staff Development.

(A) Staff providing telephone hotline services must have a bachelor’s degree with three (3) years of behavioral health and crisis intervention experience or a master’s degree with one (1) year of behavioral health and crisis intervention experience.

Staff providing telephone hotline services must be supervised by a QMHP.
Staff providing telephone hotline services must have immediate access to a QMHP.

(B) For mobile response, the mobile crisis team shall have at least one (1) QMHP to provide face-to-face crisis intervention for each mobile response.

(D) The agency shall have written documentation that clinical supervision is provided on a scheduled basis including, but not limited to: meeting minutes, supervision logs, or peer review processes.

(E) For administrative agents that subcontract for hotline services this standard applies. Administrative agents shall have designated staff on call to the ACI system twenty-four (24) hours per day, seven (7) days per week for specialized programs. This designated staff person or persons shall have received crisis intervention training and have experience in responding to crisis situations with individuals and families.

(F) Each agency shall have an ACI Training Plan. The training plan shall include individuals served, families/natural supports, and advocates in the development and implementation of the plan.

(G) Staff providing ACI services shall complete the designated ACI training required by the department at least annually that includes, but is not limited to, the following core competencies as defined by the department:

Crisis intervention strategies and techniques;
ACI and legal issues;
Safety;
ACI responsiveness to individuals and families served;
Available resources and services in the community.

(H) ACI staff shall have a working familiarity with the core competencies prior to providing crisis intervention services.

(I) New ACI staff shall be trained and document the demonstration of the core competencies within the first six (6) months of employment.

(J) The administrative agent shall describe how the core competencies will be incorporated into the ACI staff training program on an ongoing basis.

(K) Each agency shall provide a written plan of how it will measure the competencies of the ACI staff. The plan must include at least two (2) measurable outcomes including, but not limited to:

Review of case documentation;
Review of assessment forms for appropriate interventions;
Question, answer, observation, and feedback by supervisory staff and peers.

(L) New ACI staff must receive clinical supervision and jobshadow the supervisor or experienced crisis workers for a minimum of forty (40) hours prior to providing crisis services.

rule filed Aug. 28, 2002, effective April 30, 2003. Amended: Filed Dec. 29, 2003, effective July 30, 2004. Amended: Filed April 29, 2019, effective Nov. 30, 2019. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.055, RSMo 1980.

History

AUTHORITY: sections 630.050 and 630.655, RSMo 2016. Original

Chapter 5 Standards for Programs for Persons with Mental Retardation of Development Disabilities

9 CSR 30-5.010 Individualized Supported Living Services—Definitions {#sec-9-csr-30-5.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-5.010}

(Moved to 9 CSR 45-3.020)

9 CSR 30-5.020 Individualized Supported Living Services—Quality Outcome Standards {#sec-9-csr-30-5.020 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-5.020}

(Moved to 9 CSR 45-5.020)

9 CSR 30-5.030 Individualized Supported Living Services—Provider Certification {#sec-9-csr-30-5.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-5.030}

(Moved to 9 CSR 45-5.030)

9 CSR 30-5.040 Individualized Supported Living Services—Individual Rights {#sec-9-csr-30-5.040 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-5.040}

(Moved to 9 CSR 45-3.030)

9 CSR 30-5.050 Certification of Medicaid Agencies Serving Persons with Developmental Disabilities {#sec-9-csr-30-5.050 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-5.050}

(Moved to 9 CSR 45-5.010)

9 CSR 30-5.060 Development of Intermediate Care Facilities for Persons with Mental Retardation {#sec-9-csr-30-5.060 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-5.060}

(Moved to 9 CSR 45-4.020)

MATTBLUNT(10/31/01)

Development Disabilities9 CSR 30-5

Chapter 6 Certified Community Behavioral Health Organization

9 CSR 30-6.010 Certified Community Behavioral Health Clinic {#sec-9-csr-30-6.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-6.010}

PURPOSE: This rule establishes the requirements for Certified Community Behavioral Health Clinic (CCBHC) to provide a comprehensive range of mental health and substance use disorder services to people with serious mental illness, serious emotional disturbances, long-term chronic addiction, mild or moderate mental illness and substance use disorders, and complex health conditions. CCBHC provides services regardless of an individual’s ability to pay, including those who are underserved, have low incomes, are insured, uninsured, Medicaid-eligible, and active duty U.S. Armed Forces or veterans.

PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

(1) Definitions. The following definitions apply to terms used in this rule:

(A) Certified Community Behavioral Health Clinic (CCBHC)— an entity certified by the department to provide CCBHC services within their designated service area(s). The entity must be a nonprofit organization and an administrative agent or affiliate provider in Missouri;

(B) Community Needs Assessment—an assessment of the behavioral health needs of all individuals living in the service area(s) served by the CCBHC, including unserved and underserved communities. The CCBHC’s staffing plans, accessibility plans, and scope of services shall be based on results of the community needs assessment;

(C) Department—the Department of Mental Health; and (D) Designated Collaborating Organization (DCO)—an entity that is not under the direct supervision of a Certified Community Behavioral Health Clinic (CCBHC) but is engaged in a contractual arrangement with a CCBHC to provide CCBHC services under the same requirements as the CCBHC.

(2) Regulations. All CCBHCs shall comply with 9 CSR 10-5 General Program Procedures, 9 CSR 10-7 Core Rules for Psychiatric and Substance Use Disorder Treatment Programs, 9 CSR 30-3 Substance Use Disorder Treatment Programs, and 9 CSR 30-4 Mental Health Programs, as applicable.

(3) Designated Service Areas and Community Needs Assessment.

Organizations must be certified by the department to provide CCBHC services in one (1) or more service areas as established by the department under 9 CSR 30-4.005. The required CCBHC services, as specified in this rule, must be provided in each designated service area.

(A) Each CCBHC shall develop and maintain services and supports designed to meet the needs of the populations of focus. Populations of focus shall include— 1. Adults with serious mental illness as defined in 9 CSR 30-4.005(6);

Children and youth with serious emotional disturbances as defined in 9 CSR 30-4.005(7);
Children, adolescents, and adults with moderate to severe substance use disorders;
Children with behavioral health disorders who are in state custody;
Individuals involved with law enforcement, the courts, and hospital emergency rooms who have been identified as in need of community behavioral health services; and 6. Current or former members of the U.S. Armed Forces.

(B) Each CCBHC shall regularly assess the unique sociodemographic factors of their service area(s) by conducting a community needs assessment and implementing strategies to improve access, quality of care, and reduce health disparities experienced by relevant cultural and linguistic minorities. The needs assessment shall be documented and include, but is not limited to— 1. Description of service area(s) and sites where CCBHC services are offered;

Prevalence of mental health and substance use disorders and related needs in the service area(s);
Economic factors and social determinants of health affecting access to care in the service area(s);
Cultures and languages of populations in the service area(s);
Identification of underserved populations;
Description of how the CCBHC’s staffing plan will address findings of the needs assessment;
Input from people with lived experience of behavioral health disorders and key community partners on community needs, CCBHC services, access to care, and barriers to care;
Identification of potential partnerships with entities in the service area, including but not limited to— A. Schools;

B. Child welfare agencies;

C. Youth and adult justice agencies and facilities (including drug, mental health, veterans, and other specialty courts);

D. Regional treatment centers for youth;

E. State licensed and nationally accredited child placement agencies for therapeutic foster care services;

F. Social and human service organizations;

G. Federally Qualified Health Centers (FQHC) and, as applicable, Rural Health Clinics (RHCs); and H. 988 Suicide & Crisis Lifeline call center.

(C) Informed by the community needs assessment, the CCBHC shall conduct outreach, engagement, and retention activities to support inclusion and access to services for unserved and underserved individuals and populations.

(D) A staffing plan shall be developed based on results of the needs assessment, including staff identified in section (7) of this rule.

(E) The community needs assessment and staffing plan shall be updated as needed, no less frequently than every three (3) years.

(4) Availability and Accessibility of Services. Services shall not be denied or limited based on an individual’s ability to pay, place of residence, homelessness, or lack of permanent address.

(A) CCBHCs shall provide, at a minimum, crisis response, evaluation, and stabilization, as needed, for individuals who present for services but do not reside within the CCBHC’s designated service area(s). Policies and procedures shall specify the CCBHC’s process for managing the ongoing treatment needs of such individuals, such as linkage to a CCBHC in the service area where the individual currently lives.

(B) Informed by the community needs assessment, CCBHCs shall provide outpatient services at times and locations that ensure accessibility and meet the needs of individuals in the service area, including some evening hours and, when appropriate and practicable, weekend hours.

(C) CCBHCs shall ensure— 1. No individual in the populations of focus is denied services including, but not limited to, crisis management because of an inability to pay for such services; and 2. Any fees or payments required by the CCBHC for such services shall be reduced as provided by the sliding fee schedule described in section (14) of this rule in order to enable the CCBHC to fulfill the assurance described in paragraph (4)

(D) CCBHCs shall ensure individuals determined to need specialized behavioral health services beyond the scope of its program are referred to a qualified provider(s) for necessary services.

(E) CCBHCs shall utilize telehealth/telemedicine, video conferencing, remote monitoring, asynchronous interventions, and other technologies, to the extent possible, in alignment with the preferences of the individual receiving services to support access to all required services.

(5) Certification and National Accreditation. CCBHCs shall maintain national accreditation and/or department certification as specified below.

(A) Certification/deemed certification from the department in accordance with 9 CSR 30-3 and 9 CSR 30-4 to provide— 1. American Society of Addiction Medicine (ASAM) Level 1 Outpatient and Level 2.1 Intensive Outpatient Services for adolescents and adults, and Level 1-WM Ambulatory Withdrawal Management without Extended On-Site Monitoring for adults. The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, 3rd edition (2013), incorporated by reference and made a part of this rule, is developed by and available from the American Society of Addiction Medicine, Inc., 11400 Rockville Pile, Suite 200, Rockville, MD 20852, (301) 656-3920. This rule does not incorporate any subsequent amendments or additions to this publication; and 2. Community Psychiatric Rehabilitation (CPR) for children, youth, and adults.

(B) Appropriate accreditation from CARF International (CARF), The Joint Commission (TJC), Council on Accreditation (COA), or other accrediting body approved by the department for the following services. National accreditation as a CCBHC or recognition as a CCBHC in states other than Missouri does not constitute an award of certification status as a CCBHC by the department:

Certified Community Behavioral Health Clinics;
Healthcare home for children, youth, and adults;
Outpatient mental health and substance use disorder treatment services for children, youth, and adults;
Crisis and information call center for the provision of a twenty-four- (24-) hour crisis line for children, youth, and adults with mental health and/or substance use disorders;
Crisis intervention services for the provision of a twentyfour- (24-) hour mobile crisis team for children, youth, and adults with mental health and substance use disorders.

A. If the CCBHC contracts with a DCO to provide crisis and information call center and/or crisis intervention services, the DCO must be accredited as specified above.

(C) Provisional certification from the department to provide outpatient mental health treatment and substance use disorder treatment for children, youth, and adults is acceptable until accreditation is obtained as specified.

(D) Temporary waiver. Upon effective date of this rule, the department will grant a one- (1-) year waiver from the requirements specified in paragraph (5)(B)1.

(E) Waivers shall be temporary and time limited.

The initial waiver period of one (1) year may be renewed or extended by the department annually thereafter.
The total waiver period shall not exceed three (3) years unless otherwise determined by the department.

(6) Required Services. CCBHCs shall provide a comprehensive array of services to create and enhance access, stabilize people in crisis, and provide the necessary treatment for individuals with the most serious, complex mental illnesses and substance use disorders.

(A) The following core CCBHC services must be directly provided by the CCBHC or by contract with an approved DCO in each designated service area:

Crisis mental health services, including— A. Twenty-four- (24-) hour crisis receiving and stabilization services that include, at a minimum, walk-in mental health and substance use disorder services for voluntary individuals;

B. Twenty-four- (24-) hour mobile crisis response teams; and C. Twenty-four- (24-) hour emergency crisis intervention services.

(B) The following services must be directly provided by the CCBHC:

Screening, assessment, and diagnosis, including risk assessment;
Individualized treatment, including risk assessment and crisis prevention planning (supports for children and adolescents must comprehensively address family/caregiver, school, medical, mental health, substance use, psychosocial, and environmental issues);
Outpatient mental health services;
Substance use disorder treatment services including— A. Individual and group counseling;

B. Group rehabilitative support;

C. Community support;

D. Peer support;

E. Family therapy;

F. Medication services to support medication assisted treatment; and G. American Society of Addiction Medicine (ASAM) Level 1 Outpatient and Level 2.1 Intensive Outpatient, Level 1-WM Ambulatory Withdrawal Management without Extended On- Site Monitoring as referenced in paragraph (5)(A)1. of this rule.

Services shall include treatment of tobacco use disorders;

Outpatient clinic primary care screening and monitoring of key health indicators and health risks;
Community support;
Psychiatric rehabilitation services;
Peer support, counseling, and family support services, including peer and family support services for individuals receiving CPR and/or Comprehensive Substance Treatment and Rehabilitation (CSTAR) services, consistent with the array of services and supports specified in the job descriptions of Certified Family Support Providers and Certified Peer Specialists;
Outpatient mental health services for active members of the U.S. Armed Forces and veterans;
Outreach services to reduce unnecessary utilization of emergency rooms by the populations of focus, including community support specialists to respond to and engage individuals who present at collaborating emergency rooms.

Individuals shall be assisted in accessing necessary resources to meet basic needs, on an emergency basis, as well as accessing CCBHC services on an emergency, urgent, and/or routine basis, as needed; and 11. Outpatient primary care screening and monitoring of key health indicators and health risk— A. The medical director shall develop organizational protocols that conform to A and B grade screening recommendations of the United States Preventive Services Task Force, including but not limited to human immunodeficiency virus (HIV) and viral hepatitis;

B. The medical director shall develop organizational protocols to ensure screening for individuals receiving services who are at risk for common physical health conditions experienced by CCBHC populations across the lifespan.

Protocols shall include— (I) Identifying people receiving services with chronic diseases;

(II) Ensuring that people receiving services are asked about physical health symptoms; and (III) Establishing systems for collection and analysis of laboratory samples.

(C) In addition to the core services, CCBHCs shall directly provide, contract with a DCO, or have a documented relationship with an organization that is certified/deemed certified by the department to provide the following services:

General adult, adolescent, and women and children’s CSTAR services;
Recovery support services, if services are available in the CCBHC’s designated service area(s); and 3. Outreach, engagement, and retention activities to support inclusion and access to services by underserved individuals and populations, as informed by the community needs assessment.

(7) Required Staff and Training. Informed by the community needs assessment, CCBHCs shall maintain adequate staffing to meet the needs of individuals receiving services, as reflected in treatment plans, and as required to meet the requirements of this regulation. Staff may be full- or part-time employees of the CCBHC or contracted by the CCBHC to provide services.

(A) Required staff shall include— 1. Medical Director who is a licensed psychiatrist.

A. If after reasonable efforts a CCBHC is unable to employ or contract with a psychiatrist as medical director, a medically trained behavioral health care professional with prescriptive

Licensed mental health professionals with expertise and specialized training in the treatment of trauma-related disorders;
Community Behavioral Health Liaison (a cooperative agreement with a CCBHC that employs a Community Behavioral Health Liaison is acceptable);
Clinical staff to complete comprehensive assessments, annual assessments, and treatment plans;
Licensed mental health professionals who have completed training on evidence-based, best, and promising practices as required by the department;
Qualified practitioner(s) to treat opioid use disorders with Food and Drug Administration (FDA) approved medications.

Methadone must be provided by a certified opioid treatment program;

Community Support Specialists who have completed department-approved wellness training;
Individuals who have completed department-approved smoking cessation training;
Certified Family Support Providers who are credentialed by the Missouri Credentialing Board; and 10. Certified Peer Specialists who are credentialed by the Missouri Credentialing Board.

(B) CCBHCs shall have a training plan for all staff (directly employed and contracted) who have direct contact with individuals served and/or their family members/natural supports.

As part of employee orientation, and at reasonable intervals thereafter, training shall be provided on— A. Evidence-based practices;

B. Cultural competency;

C. Person-centered, family-centered, and recoveryoriented planning and services;

D. Trauma-informed care;

E. CCBHC policies and procedures for continuity of operations/disasters;

F. CCBHC policies and procedures for integration and coordination with primary care providers;

G. Services for individuals with co-occurring mental health and substance use disorders.

As part of employee orientation and annually thereafter, training shall be provided on— A. Risk assessment;

B. Suicide and overdose prevention and response; and C. Role of family support providers and certified peer specialists in service delivery.

Training may be provided online.
Training shall be aligned with the National Standards for Culturally and Linguistically Appropriate Services (CLAS), 2013, incorporated by reference and made a part of this rule, developed by and available from the U.S. Department of Health and Human Services, Office of Minority Health, Tower Oaks Bldg., 1101 Wootton Parkway, Suite 100, Rockville, MD 20852, (800) 444-6472. This rule does not incorporate any subsequent amendments or additions to this publication.
CCBHCs shall have written policies and procedures describing its method(s) of assessing staff competency and maintaining written documentation of in-service training.

Documentation shall include training provided to each employee having direct contact with individuals served for the duration of their employment with the CCBHC.

(8) Screening, Assessment, Treatment Planning, and Crisis Planning. Unless a specific tool is required by the department, CCBHC staff shall use standardized and validated screening and assessment tools, including functional assessments and screening tools that are age appropriate, accommodate all literacy levels and disabilities (such as hearing disability and/ or cognitive limitations), and brief motivational interviewing techniques, when appropriate.

(A) At first contact, whether in person, by telephone, or using other remote communication, individuals seeking CCBHC services shall receive a preliminary screening to determine acuity of need. Emergency, urgent, or routine service needs shall be identified and addressed as follows:

Individuals who present with emergency needs shall receive services immediately, including arrangements for any necessary outpatient follow-up services;
Individuals who present with an urgent need shall receive clinical services and an eligibility determination within one (1) business day of the time the request was made; and 3. Individuals who present with routine needs shall receive clinical services and an eligibility determination within ten (10) days of first contact.

(B) Following the preliminary screening, qualified staff shall conduct a comprehensive assessment or eligibility determination. Completion of the eligibility determination is not required; however, it may be completed before the comprehensive assessment to expedite the admission process as specified in 9 CSR 30-3.151(2)(D)-(E) and 9 CSR 30-4.035(2).

A risk assessment shall be included as part of the eligibility determination or comprehensive assessment, whichever occurs first, and shall include— 1. Depression screening for all adolescents age thirteen (13) to eighteen (18) years of age;

Depression screening for all adults age nineteen (19) and older;
Suicide risk assessment for all adolescents and adults diagnosed with major depression;
Brief health screen, as specified by the department;
Alcohol use disorder screening; and 6. Substance use disorder screening, including opioid use disorder.

(C) The comprehensive assessment must be completed within the first three (3) outpatient visits or within treatment program timelines as specified in 9 CSR 30-3.151(3) and 9 CSR 30-4.035(4).

(D) Results of the comprehensive assessment shall be utilized to develop an initial treatment plan within sixty (60) days of the individual’s first contact with the CCBHC, unless a shorter time frame is required by a specific treatment program. The treatment plan shall be developed collaboratively with the individual served and/or parents/guardian, family members, and other natural supports, as appropriate.

(E) At a minimum, treatment plans shall be reviewed and updated every six (6) months, or more frequently if clinically indicated or as outlined according to service fidelity/criteria.

Changes shall be made in accordance with personal preference by the individual receiving services, when appropriate. To align documentation between multiple programs, treatment plan reviews shall be coordinated with the individual’s entire treatment team to cover goals addressed in all programs. A functional assessment may be utilized as the treatment plan review/update.

The occurrence of a crisis or significant clinical event may require a further review and modification of the treatment plan.
The updated treatment plan shall reflect the individual’s current strengths, needs, abilities, and preferences in the goals and objectives that have been established or continued based on the review. Updates must be documented in the individual record by one (1) of the following:

A. A progress note which specifies updates made to the treatment plan; or B. A treatment plan review; or C. An updated functional assessment score with a brief narrative.

(F) The initial treatment plan and treatment plan updates must include the dated signature(s), title(s), and credential(s) of staff completing the plan. The individual served shall also sign the plan unless there is a current signed consent to treatment included in the individual record.

(G) Individuals who are receiving services from a CCBHC and are seeking routine outpatient clinical services must be provided with an appointment within ten (10) business days of the request for an appointment.

If an individual receiving services from a CCBHC presents with an emergency/crisis need, appropriate action shall be taken immediately based on the needs of the individual, including immediate crisis response if necessary.
If an individual receiving services presents with an urgent, non-emergency need, clinical services are generally provided within one (1) business day of the time the request is made, or at a later time if that is the preference of the individual.

(H) If a potential risk for suicide, violence, or other at-risk behavior (such as increased isolation, increased substance use, heightened depression or anxiety) is identified during the assessment process and any time during the individual’s time in services, a crisis prevention plan shall be developed with the individual as soon as possible.

At a minimum, the crisis prevention plan shall include factors that may precipitate a crisis, a hierarchical list of selfcare and self-help strategies identified by the individual to regain a sense of control to return to their level of functioning before the crisis or emergency, and a hierarchical list of staff interventions that may be used when a critical situation occurs.

(I) Individuals receiving services from a CCBHC shall be educated about crisis planning, psychiatric advanced directives, and access to crisis services, including the 988 Suicide & Crisis Lifeline (by call, chat, or text), other area hotlines and warm lines, as appropriate, and if risk indicates, overdose prevention, including access to naloxone for opioid overdose.

The individual’s health record shall include documentation of any advance directives related to treatment and crisis planning. If the individual receiving services does not wish to share their preferences, that decision shall be documented.

(J) Appropriate care coordination requires the CCBHC to make and document reasonable attempts to determine any medications prescribed by other providers. To the extent that state law allows, the state Prescription Drug Monitoring Program (PDMP) must be consulted during the comprehensive assessment. Upon appropriate consent to release of information, the CCBHC is also required to provide such information to other providers not affiliated with the CCBHC to the extent necessary for safe and quality care. Current state regulations found in

History

authority and appropriate education, licensure, and experience in psychopharmacology, and who can prescribe and manage medications independently pursuant to state law, may serve as the medical director. In addition, if a CCBHC is unable to hire a psychiatrist and hires another prescriber, psychiatric consultation shall be obtained regarding behavioral health clinical service delivery, quality of the medical component of care, and integration and coordination of behavioral health and primary care;

9 CSR 30-3 significantly restrict the provider type eligible to access the PDMP. {#sec-9-csr-30-3 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-3}

(9) Consent to Treatment. Each individual served or a parent/ guardian must provide informed, written consent to treatment.

(A) A copy of the consent form, which must include the date of consent and signature of the individual served or a parent/ guardian, shall be retained in the individual record.

(B) Consent to treat shall be updated annually, including the date of consent and signature of the individual served or a parent/guardian, and be maintained in the individual record.

(10) Services for Members of the U.S. Armed Forces and Veterans.

CCBHCs must determine whether all individuals seeking service are current or former members of the U.S. Armed Forces.

(A) CCBHCs shall refer Active Duty and activated Reserve Component service members to their Military Treatment Facility or TRICARE PRIME Remote Primary Care Manager for referral to services.

(B) Selective Reserve service members not on active duty, who are enrolled in TRICARE Reserve Select, shall be referred to a TRICARE Reserve Select provider.

(C) If an individual is a veteran not currently enrolled in the Veterans Health Administration (VHA), CCBHC staff must offer to assist them in enrolling in the VHA.

(11) Withdrawal Management. CCBHCs must have partnerships that ensure care coordination to the appropriate level of withdrawal management services, if such services exist within the CCBHC service area as follows:

(A) Each CCBHC shall directly provide ASAM Level 1-Withdrawal Management (WM) services as referenced in paragraph (5)(A)1. of this rule;

(B) Each CCBHC shall have an agreement with a partnering entity, if the CCBHC does not directly provide the following services or if such an entity exists within the CCBHC’s service area to provide— 1. ASAM Level 2-WM with and without Extended On-Site Monitoring;

ASAM Level 3.2 Clinically Managed Residential Withdrawal Management; and 3. ASAM Level 3.7 Medically Monitored Inpatient Withdrawal Management.

(12) Care Coordination. CCBHCs shall actively pursue and promote collaborative working relationships with the broad array of community organizations and providers that deliver services and supports for individuals receiving services from the CCBHC.

(A) CCBHC policies and procedures shall describe its care coordination roles and responsibilities with other community providers (with other community providers within the CCBHC service area), including but not limited to— 1. Primary care providers;

Emergency rooms;
Hospitals;
Inpatient psychiatric facilities;
Opioid treatment programs;
Residential substance use disorder treatment programs; and 7. Residential programs serving children and youth.

(B) These partnerships should be supported by formal, signed agreements detailing the role(s) of each party, but if not possible, the CCBHC shall document attempts to develop formal agreements and describe its unsigned joint protocols for care coordination.

(C) Consistent with requirements of privacy, confidentiality, and individual preference and need, CCBHC staff shall assist individuals and family members/natural supports of children and youth who are referred to external providers or resources in obtaining an appointment and track participation in services to ensure coordination and receipt of support. Policies and procedures shall ensure reasonable attempts are made and documented to— 1. Track admissions and discharges of individuals not eligible for Medicaid benefits to and from a variety of settings, and to provide transitions to safe community settings; and 2. Follow up with individuals served within twenty-four (24) hours following hospital discharge.

(D) Nothing about a CCBHC’s agreements for care coordination shall limit an individual’s freedom of choice of provider(s) with the CCBHC or its DCOs.

(E) CCBHCs shall utilize Missouri Behavioral Health Connect (MOConnect), the designated platform to identify, unify, and track behavioral health treatment resources.

(F) For all individuals in the populations of focus, CCBHC staff shall inquire whether they have a PCP, assist individuals who do not have a PCP to acquire one, and establish policies and procedures that promote and describe the coordination of care with each individual’s PCP.

(G) For all individuals in the populations of focus, CCBHC staff shall document in the individual record the name of each individual’s PCP, indicate they are assisting them in acquiring a PCP, or the individual refuses to provide the name of their PCP or accept assistance in acquiring a PCP.

(13) Evidence-Based Practices. CCBHCs shall incorporate evidence-based and emerging best practices into its service array.

(A) CCBHCs shall have adopted, or be participating in, a department-approved initiative to promote supported employment, trauma-informed care, and suicide prevention.

(B) CCBHCs shall have adopted with fidelity a model for providing integrated treatment for co-occurring disorders approved by the department.

(C) CCBHCs shall demonstrate a continued commitment to adopting or continuing evidence-based and emerging best practices to fidelity, such as— 1. Assertive Community Treatment (ACT);

Measurement-Based Care;
Supported housing;
Parent-Child Interaction Therapy;
Dialectical Behavior Therapy;
Multi-systemic Therapy;
First Episode Psychosis; and 8. Eye Movement Desensitization and Reprocessing (EMDR).

(14) Fee Schedule. CCBHCs shall publish a sliding fee discount schedule that includes all services the CCBHC offers. The fee schedule shall conform to applicable state or federal statutory and administrative requirements for existing clinics. Absent applicable state or federal requirements, the schedule is based on locally prevailing rates or charges and include reasonable costs of operation.

(A) Written policies and procedures shall be maintained by the CCBHC describing eligibility for services and implementation of the sliding fee discount schedule which must ensure— 1. Equitable use of the sliding fee schedule for all individuals seeking services;

The provision of services regardless of ability to pay; and 3. Waiver or reduction of fees for those unable to pay.

(B) The CCBHC shall screen each individual seeking services to determine eligibility for a sliding fee discount.

(C) If a CCBHC service is provided through a DCO, the DCO shall provide such services in accordance with the CCBHC fee schedule and corresponding policies and procedures.

The CCBHC shall provide the DCO with a copy of its policies and procedures related to the sliding fee discount program.
Prior to the provision of a CCBHC service, the CCBHC shall inform the DCO if an individual has been determined eligible for a fee discount. The DCO is not required to conduct its own discount eligibility screening.

(D) CCBHCs (and their DCOs, as applicable) shall provide individuals and their family members/natural supports with information regarding the sliding fee discount program.

The fee discount schedule shall be communicated in languages and formats appropriate for individuals seeking services who have limited English proficiency, literacy barriers, or disabilities.
The fee discount schedule shall be posted on the CCBHC/ DCO website, posted in the CCBHC waiting/reception area, and accessible to people receiving services and family members/ natural supports.

(15) Quality and Reporting. CCBHCs shall maintain a health information technology (HIT) system that includes but is not limited to electronic health records of all individuals served.

Electronic health record systems must comply with state and federal regulations.

(A) The CCBHC uses technology that has been certified to current criteria on the Certified Health IT Product List (CHPL) for the following required core set of certified HIT capabilities:

Capability to capture structured information in individual records, including demographic information such as race, ethnicity, preferred language, sexual and gender identity, and disability status;
At a minimum, support care coordination by sending and receiving summary of care records;
Provide people receiving services with timely electronic access to view, download, or transmit their health information or to access their health information via an application programming interface (API) using a personal health app of their choice;
Provide evidence-based clinical decision support; and 5. Electronically transmit prescriptions to the pharmacy.

(B) The following information shall be collected and be available for reporting to the department or other entities, upon request:

The number and percentage of new and established individuals served who were determined to need emergency, urgent, and routine care;
The number and percentage of new and established individuals with urgent needs who began receiving needed clinical services within one (1) business day;
The number and percentage of new and established individuals with routine needs who began receiving needed clinical services within ten (10) business days; and 4. The mean number of days from first contact to completion of the comprehensive assessment/eligibility determination and initial treatment plan for individuals served.

(C) The CCBHC shall develop, implement, and maintain an effective, CCBHC-wide continuous quality improvement (CQI) plan for the services provided.

The medical director shall be involved in the aspects of the CQI plan that apply to the quality of the medical components of care, including coordination and integration with primary care.
A critical review process shall be developed to review CQI outcomes and implement changes to staffing, services, and availability that will improve the quality and timeliness of services.
The plan shall focus on indicators related to— A. Improved behavioral and physical health outcomes for individuals served and actions to demonstrate improvement in CCBHC performance, when warranted; and B. Improved patterns of care delivery such as reductions in emergency department use, rehospitalizations, and repeated crisis episodes for individuals served.
The CQI plan shall include provisions to ensure known significant events are reviewed including, at a minimum— A. Deaths by suicide or suicide attempts of people receiving services;

B. Fatal and non-fatal overdoses;

C. All-cause mortality for individuals receiving CCBHC services;

D. Thirty (30) day hospital readmissions for psychiatric or substance use reasons; and E. Events the state or applicable accreditation bodies may deem appropriate for examination and remediation as

part of a CQI plan.

The CQI plan shall include a specific focus on populations experiencing health disparities (including racial and ethnic groups and sexual and gender minorities) and address how the CCBHC will use disaggregated data from the quality measures and, as available, other data to track and improve outcomes for populations facing health disparities.

(D) The CCBHC shall have a continuity of operations/disaster plan that ensures staff, individuals receiving services, and healthcare and community partners are notified when a disaster/emergency occurs or services are disrupted.

The CCBHC shall, to the extent feasible, identify alternative locations and methods to sustain service delivery and access to behavioral health medications during emergencies and disasters.
The plan shall address HIT systems, security/ransomware protection, backup, and access to these IT systems, including health records, in case of disaster.

(16) DCO Contracts. If the CCBHC enters into a contractual agreement(s) with a DCO, the contract shall include the following provisions:

(A) DCO staff having contact with individuals served, and/or their families, are subject to the same training requirements as staff of the CCBHC;

(B) The CCBHC coordinates care and services provided by the DCO in accordance with the individual’s current treatment plan;

(D) The individual’s freedom to choose service providers is maintained;

(E) All individuals have access to the CCBHC’s grievance procedures; and (F) Services provided by the DCO shall meet the same quality standards as those provided by the CCBHC.

(17) Governing Body Representation. CCBHCs shall ensure a substantial number of people with lived experience of mental health and substance use disorders, and their family members/ natural supports, have meaningful participation in developing initiatives, identifying community needs, goals, and objectives, providing input on service development, continuous quality improvement processes, human resource planning, budget development, and decision making.

(A) Meaningful and substantial participation shall be demonstrated by one (1) of the following options:

At least fifty-one percent (51%) of the CCBHC governing body consists of individuals with lived experience of mental health and/or substance use disorders and their family members/natural supports. The CCBHC must describe how it meets this requirement, or provide a transition plan with timeline for meeting it; or 2. Other means shall be established to demonstrate meaningful participation in board governance involving people with lived experience of behavioral health disorders (such as creating an advisory committee that reports to the board). The CCBHC shall provide staff support to the individuals involved in any alternate approach that is equivalent to the support given to the governing board.

(B) If the CCBHC utilizes the criteria specified in paragraph (17)(A)2. of this rule, the governing board shall establish protocols for incorporating input from individuals with lived experience and their family members/natural supports.

Board meeting summaries shall be shared with those participating in the alternate arrangement and recommendations from the alternate arrangement shall be entered into the formal board record.
A member or members of the arrangement as established in paragraph (17)(A)2. of this rule must be invited to board meetings, and representatives of the alternate arrangement must have the opportunity to regularly address and share recommendations directly with the board and have their comments and recommendations recorded in the board minutes.
The CCBHC shall provide staff support for posting an annual summary of the recommendations from the alternate arrangement as established in paragraph (17)(A)2. of this rule on the CCBHC website.

(C) If paragraph (17)(A)2. of this rule is chosen, the CCBHC must obtain approval from the department. The CCBHC shall make available the results of its efforts in terms of outcomes and resulting changes.

(D) If the CCBHC is a subsidiary or part of a larger corporate organization and cannot meet the requirements identified in paragraphs (17)(A)1. and 2. of this rule, the CCBHC shall specify why it cannot meet these requirements. The CCBHC shall have or develop an advisory structure and describe other methods for individuals with lived experience and family members/ natural supports to provide meaningful participation with the governing body.

(E) CCBHCs must be able to document input from individuals served and their parents/guardian, family members, natural supports, and communities served, including the impact on its policies, processes, and services.

(F) To the extent practicable, each CCBHC’s governing body and/or advisory board shall be representative of the populations served in terms of demographic factors such as geographic area, race, ethnicity, sex, gender identity, disability, age, and sexual orientation in terms of health and behavioral health needs.

(G) Each CCBHC’s governing body members or advisory board members shall be selected for their expertise in health services, community affairs, local government, finance and accounting, legal affairs, trade unions, faith communities, commercial and industrial concerns, and/or social service agencies within the communities served.

(H) No more than fifty percent (50%) of the governing body members may derive more than ten percent (10%) of their annual income from the health care industry.

Amended: Filed Oct. 9, 2025, effective April 30, 2026. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008, and 630.055, RSMo 1980.

History

AUTHORITY: sections 630.050 and 630.655, RSMo 2016. Emergency rule filed March 20, 2019, effective July 1, 2019, expired Oct. 30, 2019. Original rule filed March 20, 2019, effective Oct. 30, 2019. Amended: Filed June 13, 2023, effective Jan. 30, 2024.

Chapter 7 Crisis Services

9 CSR 30-7.010 Behavioral Health Crisis Centers {#sec-9-csr-30-7.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-7.010}

PURPOSE: This rule sets forth regulations for behavioral health crisis centers.

(1) Definitions. Unless the context clearly requires otherwise, the following terms as used in this rule mean— (A) Behavioral Health Crisis Center (BHCC), unit which operates twenty-four (24) hours per day, seven (7) days per week and provides crisis services for individuals in severe distress with up to twenty-three (23) consecutive hours of supervised care to assist with deescalating the severity of their crisis;

(B) Crisis intervention, designed to interrupt and/or ameliorate a behavioral health crisis experience. The goal of crisis intervention is symptom reduction, observation, stabilization, and restoration to a previous level of functioning for the individual being served. Primary components include, but are not limited to— 1. Preliminary assessment of risk, mental status, substance use status, and medical stability;

Stabilization of immediate crisis;
Determination of the need for further evaluation and/or behavioral health services; and 4. Linkage to needed additional treatment services;

(C) Crisis stabilization, a direct service that assists with deescalating the severity of an individual’s level of distress and/ or need for urgent care associated with a behavioral health disorder; and (D) Urgent Care Behavioral Health Crisis Center (U-BHCC), unit which operates less than twenty-four (24) hours per day, seven (7) days per week, and provides crisis services for individuals in severe distress with supervised care to assist with deescalating the severity of their crisis.

(2) Program Description. BHCCs and U-BHCCs are provided or arranged by an administrative agent or an affiliate. Services shall be provided in accordance with the 2020 edition of the National Guidelines for Behavioral Health Crisis Care, hereby incorporated by reference and made a part of this rule, and can be obtained from the Substance Abuse and Mental Health Services Administration (SAMHSA), 5600 Fishers Lane, Rockville, MD 20857, (877) 726-4727. This rule does not incorporate any subsequent amendments or additions to this publication.

(A) Services shall be designed to serve as a community-based alternative to emergency department services, unnecessary hospitalization, and/or jail confinement by offering assessment, treatment, and short term stabilization for individuals with a mental health and/or substance use disorder.

(B) As specified in best practice one (1) of the National Guidelines for Behavioral Health Crisis Care, as referenced in

section (2) of this rule, centers shall function as a twenty-four (24) hour or less crisis receiving and stabilization facility.

(3) Certification/National Accreditation. At a minimum, organizations shall comply with 9 CSR 10-7.130 Procedures to Obtain Certification, to apply for certification/deemed status as a BHCC or U-BHCC and— (A) Be certified by the department as a Certified Community Behavioral Health Organization (CCBHO);

(B) Obtain appropriate accreditation for crisis services within three (3) years of obtaining certification/deemed status (if not accredited for such at the time of initial application to the department) from the Commission on Accreditation of Rehabilitation Facilities (CARF) International, The Joint Commission (TJC), or Council on Accreditation (COA); and (C) The CCBHO may arrange for BHCC or U-BHCC services to be provided through a designated collaborating organization (DCO).

(4) Program Requirements. BHCCs and U-BHCCs shall provide prompt assessment, stabilization (with or without medication), and determination of an appropriate level of care for the individual’s continued behavioral health treatment in order to prevent unnecessary hospitalization, emergency department services, and/or jail confinement.

(A) In accordance with minimum expectation three (3) of referenced in section (2) of this rule, services shall be designed to address— 1. Behavioral/mental health crisis situations, including substance use; and 2. Varying clinical conditions to include individuals with co-occurring behavioral health and intellectual/developmental disabilities.

(5) Target Populations. The target population includes individuals with a confirmed or suspected mental health and/ or substance use disorder diagnosis who are experiencing a behavioral crisis or are presenting for urgent behavioral health needs who are— (A) Children and youth, individuals age five (5) to seventeen (17) years; and/or (B) Individuals age eighteen (18) years and older.

(6) Physical Environment and Safety. All BHCCs and U-BHCCs shall be in compliance with 9 CSR 10-7.120 Physical Environment and Safety, and applicable state and local building codes, fire codes, and ordinances to ensure the health, safety, and security of all individuals.

(A) The physical environment shall— 1. Promote a sense of safety, calm, and deescalation for individuals and staff;

Have adequate space to ensure the comfort of individuals served;
Have adequate space to ensure privacy and confidentiality for individuals served;
Have furnishing and fixtures that are constructed of durable materials not capable of breakage into pieces that could be used as a weapon, ligature risk, or for self-harm; and 5. Have interior finishes, lighting, and furnishings that suggest a non-institutional setting that conforms to applicable fire and safety codes.

(B) In accordance with best practice two (2) of the National Guidelines for Behavioral Health Crisis Care, as referenced in

section (2) of this rule, policies and procedures shall ensure there are designated areas for individuals being transported to the center by law enforcement/first responders and those seeking services on a walk-in basis.

Hours of operation shall be clearly communicated to law enforcement and other referral sources.

(5/31/23) John R. Ashcroft (C) If the BHCC/U-BHCC has an open floor model, space for screening, evaluation, and treatment services must be separate for children/youth and adults, if both are served.

(7) Care Criteria. Each BHCC and U-BHCC shall implement written screening and intake criteria for individuals who present for an evaluation.

(A) A “no wrong door” access model shall be utilized. In accordance with minimum expectations one (1), six (6), and seven (7) of the National Guidelines for Behavioral Health Crisis Care, as referenced in section (2) of this rule, all individuals who present for an evaluation and/or stabilization shall be screened as specified in subsection (7)(C) of this rule, including walk-ins and those who are referred/transported by law enforcement.

(B) If screening results in an individual not being offered services, documentation of the rationale for the denial of services and facilitated referral of the individual to other appropriate services must be maintained.

(C) Service criteria shall include but is not limited to— 1. Presence of a suspected and/or known mental illness diagnosis and/or substance-related disorder and the individual is expressing a need for behavioral health services; and 2. Presence of a severe situational crisis; and/or 3. Presence of risk of harm to self, others, and/or property (risk may range from mild to imminent).

(D) In accordance with minimum expectation two (2) of referenced in section (2) of this rule, medical clearance is not required prior to provision of services, however, each individual served must be assessed for medical stability and receive necessary medical support while in the program.

In accordance with minimum expectation four (4) of referenced in section (2) of this rule, physical health issues that can be appropriately managed by crisis center staff shall be addressed by qualified staff in accordance with policies and procedures.
If a physical health issue occurs requiring medical care that cannot be addressed while an individual is receiving services in the BHCC/U-BHCC, the treating center shall arrange for the individual to be appropriately transported to a medical facility to address the physical health issue.

(E) As appropriate, medications (including medication assisted treatment for a substance use disorder) shall be prescribed while connecting the individual with ongoing services.

(8) Staff Qualifications. In accordance with minimum expectation five (5) of the National Guidelines for Behavioral Health Crisis Care, as referenced in section (2) of this rule, the BHCC/U-BHCC shall be adequately staffed to meet the treatment needs of individuals served and to ensure their safety and the safety of staff.

(A) Each center shall have the staffing capacity to assess individuals’ physical health needs and deliver care for most minor physical health challenges, with established written protocols to transfer an individual to more medically staffed services, if needed.

(B) The center shall be staffed by a multidisciplinary team who is able to respond to the needs of individuals experiencing all levels of crisis. Staff shall include but is not limited to— 1. Medical director—a licensed psychiatrist (available via telemedicine or audio-only). The medical director for the BHCC/U-BHCC can be the same individual who serves in this capacity for the CCBHO.

A. Direct services shall be provided by a licensed physician (includes psychiatrist) or licensed psychiatric mental health nurse practitioner (PMHNP), advanced practice registered nurse (APRN), physician assistant, resident physician (includes psychiatrist), and/or assistant physician in a written collaborative practice arrangement with a physician and with experience treating the target population. Services may be provided via telemedicine.

B. BHCCs and U-BHCCs shall have access to a practitioner to prescribe medications approved by the Food and Drug Administration to treat opioid use disorders (methadone must be provided by a certified opioid treatment program);

Clinical program director—must be a qualified mental health professional (QMHP) to oversee program operations and clinical practice, with experience treating the target population;
Nurse—registered nurse (RN) or licensed practical nurse (LPN); and 4. Certified peer specialist.

(9) Staff Coverage. Staff coverage shall ensure the continuous supervision and safety of individuals served. Staff coverage shall be determined by the agency.

(A) Coverage at a minimum, shall include— 1. Two (2) behavioral health staff must be on-site during receiving hours;

One (1) QMHP must be available during receiving hours (may be via telemedicine);
One (1) RN or one (1) LPN must be available during receiving hours (may be via telemedicine); and 4. A physician (includes psychiatrist), PMHNP, APRN, assistant physician, resident physician (includes psychiatrist), and/or physician assistant must be available during receiving hours and must immediately respond to calls from staff, delay not to exceed one (1) hour.

(B) Qualified staff must be available to administer, screen, inventory, and store prescribed medications within their scope of duties, practice, training, and as authorized by statute.

(C) Qualified staff, within their scope of duties, practice, and/ or training, shall be available to conduct an initial health assessment and utilize evidence-based tools to determine the individual’s medical stability, intoxication, substance use, and/ or level withdrawal/impairment.

(10) Policies and Procedures. The BHCC/U-BHCC shall maintain and implement written policies and procedures including, but not limited to— (A) Intake screening, service, and clinical assessment protocols;

(B) Community outreach and education strategies for crisis stabilization services, including access to and location of service site(s), hours, and days of operation for each site through written material and other means of communication, and how these components will be accomplished on an ongoing basis;

(C) Detoxification/withdrawal management services as defined in 9 CSR 30-3.120. If the BHCC/U-BHCC does not provide this service, facilitated referrals to a local hospital or another qualified service provider shall be made for withdrawal management or other medical services, if determined necessary during an individual’s evaluation process;

(D) Safety and emergency protocols as specified in 9 CSR 10-7.120 Physical Environment and Safety, as well as specific protocols for the population served;

(E) Prescription medication protocols, including storage of medications in accordance with 9 CSR 10-7.070;

(F) Screening for and accessing services for emergency medical conditions, including transport by emergency medical service;

(G) Monitoring the physical and psychological well-being of individuals including but not limited to respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified in the organization’s policies and procedures associated with evaluations;

(H) Linking individuals to housing services upon discharge, as needed;

(I) Linking individuals to transportation services upon discharge, as needed;

(J) Linking individuals to social services or community resources, as needed;

(K) Assessment and referral process for individuals with a suspected substance use disorder and/or mental health disorder;

(L) Care coordination and continuity of care for individuals served including but not limited to referral process, follow-up, and transfer of records within five (5) days, in accordance with best practice five (5) of the National Guidelines for Behavioral Health Crisis Care, as referenced in section (2) of this rule;

(M) Infection prevention and control; and (N) Use of physical and chemical restraints as specified in 9 CSR 10-7.060 Emergency Safety Interventions.

(11) Community Partnerships. BHCCs and U-BHCCs shall have a referral relationship, collaborative agreement, and/ or memorandum of understanding (MOU) with the following community providers:

(A)

Crisis response with law enforcement, dispatch, emergency medical services, and first responders;

(B) Local hospitals, primary care clinics, and Federally Qualified Health Centers (FQHC);

(C)

Qualified providers of detoxification/withdrawal management services;

(D) Schools;

(E) Housing supports;

(F) Local Continuum(s) of Care; and (G) Recovery support and recovery housing providers.

(12) Coordination and Continuity of Care. Service coordination and continuity of care efforts shall include but are not limited to— (A) Identifying and linking individuals with available community resources necessary to stabilize the crisis and ensure transition to routine care;

(B) Referring individuals to behavioral health services if not currently receiving such services;

(C) Connecting and/or referring individuals to appropriate local resources including emergency room enhancement (ERE) staff, community behavioral health liaisons (CBHLs), and/or certified peer specialists, who shall conduct and document timely follow-up to determine the individual’s current status and need for any additional assistance or services;

(D) Contacting and coordinating care with current service providers, when feasible and in accordance with state and federal confidentiality regulations;

(E) Connecting individuals to housing, food, or other resources;

(F) Connecting individuals with recovery support and/or recovery housing providers;

(G) Connecting individuals with community-based behavioral health providers in other geographic regions; and (H) Incorporating some form of intensive support beds into a partner program (within the organization or with another local agency), if available, for individuals who need additional support beyond that of the BHCC/U-BHCC in accordance with best practice three (3) of the National Guidelines for Behavioral Health Crisis Care, as referenced in section (2) of this rule.

(13) Documentation Requirements. Based on the individual’s ability to cooperate and communicate with staff due to their crisis situation, the following intake documentation shall be obtained:

(A) Presenting problem and referral source, if applicable;

(B) Rationale for denial of services and referral of the individual to other appropriate services, if necessary;

(D) Status as a current or former member of the U.S. Armed Forces;

(E) Current mental health and substance use symptoms;

(F) Current medications and any medications administered;

(G) Screening for suicide risk and completion of a comprehensive, standardized suicide risk assessment and planning, when clinically indicated, in accordance with minimum expectation eight (8) of the National Guidelines for Behavioral Health Crisis Care, as referenced in section (2) of this

rule;

(H) Screening for risk of violence and completion of a comprehensive, standardized violence risk assessment and planning, when clinically indicated, in accordance with minimum expectation nine (9) of the National Guidelines for Behavioral Health Crisis Care, as referenced in section (2) of this

rule;

(I) Current trauma-related symptoms and/or concerns for personal safety;

(J) Crisis intervention and prevention plan, when clinically indicated (a copy shall be provided to the individual served); and (K) Discharge information including outcome of the crisis, services provided, treatment/recovery plan, care coordination efforts, follow-up, and referrals.

(14) Measuring Program Effectiveness. In accordance with best practice four (4) of the National Guidelines for Behavioral Health Crisis Care, as referenced in section (2) of this rule, BHCCs and U-BHCCs shall collect, enter, and submit data utilizing all reporting tools as directed by the department.

(15) Staff Training and Education. Staff are expected to comply with the training requirements specified in 9 CSR 10-7.110(2)

(F), Personnel. All staff of the BHCC/U-BHCC shall complete minimum training requirements as follows:

(A) Screening, assessment, and planning for risk of suicide;

(B) Screening, assessment, and planning for risk of violence;

(D) Basic First Aid;

(E) Cardiopulmonary Resuscitation (CPR); and (F) Administration of naloxone, as appropriate with staff qualifications.

(16) Trauma-Informed Care. Services shall be provided in accordance with 9 CSR 10-7.010(11), Essential Principle, Trauma- Informed Care.

(8/31/23) John R. Ashcroft

History

AUTHORITY: section 630.050, RSMo 2016. Original rule filed Nov. 2, 2022, effective June 30, 2023. Original authority: 630.050, RSMo 1980, amended 1993, 1995, and 2008.

9 CSR 30-7.020 Sobering Centers {#sec-9-csr-30-7.020 omnilex-key=us-mo-regs-official--title-9--9 CSR 30-7.020}

PURPOSE: This rule sets forth requirements for operation of a sobering center.

(1) Definitions. Unless the context clearly requires otherwise, the following terms as used in this rule shall mean— (A) Sobering center, short-term care facility designed to allow an individual who is intoxicated and nonviolent to safely recover from the immediately debilitating effects of alcohol and drugs. Sobering centers typically operate twenty-four (24) hours per day, seven (7) days per week and provide supervised care for individuals experiencing acute intoxication for up to twenty-three (23) consecutive hours; and (B) Acute intoxication, a transient condition that follows the ingestion or consumption of alcohol or a psychoactive substance and results in disturbances in the level of consciousness, cognition, perception, judgment, affect or behavior, or other psychophysiological functions and responses.

(2) Program Description. Sobering centers are operated by a Certified Community Behavioral Health Organization (CCBHO).

(A) Services shall be designed to serve as a community-based alternative to emergency department services, unnecessary hospitalization, and/or jail confinement, offering short-term stabilization for individuals experiencing acute intoxication.

(3) Certification. At a minimum, the organization shall comply with 9 CSR 10-7.130 Procedures to Obtain Certification, to apply for certification/deemed status as a sobering center by the department.

(4) Program Requirements. Sobering centers shall provide prompt assessment, stabilization (with or without medication), and determination of appropriate monitoring needed for the individual to return to a state of clinical sobriety.

(A) Services shall be designed to address acute intoxication with the goal of symptom reduction as evidenced by— 1. Eating, drinking, and/or swallowing without difficulty;

Walking without ataxia or unsteady gait;
Baseline mental status representing unimpaired cognition; and 4. Cognitive status supporting reasonable decisions.

(B) Referrals to community resources and/or treatment and recovery services shall be made, as appropriate.

(5)

Target Population. The target population includes individuals age eighteen (18) years and older who are experiencing acute intoxication and have a high or imminent risk of law enforcement contact and/or emergency department intervention.

(6) Physical Environment and Safety. All sobering centers shall be in compliance with 9 CSR 10-7.120 Physical Environment and Safety, and applicable state and local building codes, fire codes, and ordinances to ensure the health, safety, and security of all individuals.

(A) The physical environment shall— 1. Promote a sense of safety and calm for individuals and staff;

Have adequate space to ensure the comfort of individuals served;
Have adequate space to ensure privacy and confidentiality for individuals served;
Have furnishing and fixtures that are constructed of durable materials not capable of breakage into pieces that could be used as a weapon, ligature risk, or for self-harm; and 5. Have interior finishes, lighting, and furnishings that suggest a non-institutional setting that conforms to applicable fire and safety codes.

(7) Care Criteria. Each sobering center shall implement written screening and intake criteria for individuals who present for services.

(A) All individuals who present for services from a referral source shall be screened as specified in subsection (7)(C) of this rule, including those who are referred/transported by law enforcement.

Hours of operation shall be clearly communicated to law enforcement and other referral sources.

(B) If in-person screening results in an individual not being offered services, documentation of the rationale for the denial of services and facilitated referral of the individual to other appropriate services must be maintained.

(C) Service criteria shall include, but is not limited to— 1. Presence of acute intoxication; and 2. Presence of high or imminent risk of law enforcement contact and/or emergency department intervention.

(D) Medical clearance is not required prior to provision of services; however, each individual served must be able to ambulate with minimal assistance, including the use of assistive devices required for existing medical conditions.

Individuals referred from a hospital must meet medical stability eligibility criteria.
If a physical health issue requiring medical care occurs that cannot be addressed while an individual is receiving services in the sobering center, the treating center shall arrange for the individual to be appropriately transported to a medical facility to address the physical health issue.

(E)

As appropriate, medications (including medicationassisted treatment for a substance use disorder) shall be prescribed while coordinating ongoing services with the individual.

(8) Staff Qualifications. The sobering center shall be adequately staffed to meet the needs of individuals served to ensure their safety and the safety of staff.

(A) Each center shall have the staffing capacity to monitor vital signs with established written protocols to transfer an individual to a medical facility, if needed.

(B) The center shall be staffed by a multidisciplinary team that is able to respond to the needs of individuals experiencing acute intoxication. Staff shall include, but is not limited to— 1. Medical director, a licensed physician. The medical director for the sobering center can be the same individual who serves as the medical director for the Certified Community Behavioral Health Organization (CCBHO).

A. Direct services shall be provided by a licensed physician (includes psychiatrist), resident physician (includes psychiatrist), physician assistant, assistant physician, licensed psychiatric mental health nurse practitioner (PMHNP), and/or advanced practice registered nurse (APRN) who is in a written collaborative practice arrangement with a physician and with experience treating the target population. Services may be provided via telemedicine;

Qualified practitioner(s) to treat opioid use disorders with narcotic medications approved by the Food and Drug Administration (methadone must be provided by a certified opioid treatment program);
Clinical program director, a qualified mental health professional (QMHP) to oversee program operations and clinical practice, with experience treating the target population;
Nurse, paramedic, or emergency medical technician (EMT); and 5. Certified peer specialist(s).

(9) Staff Coverage. Staff coverage shall ensure the continuous supervision and safety of individuals served. Staff coverage shall be determined by the sobering center.

(A) At a minimum, coverage shall include— 1. Two (2) behavioral health staff who are on-site during receiving hours;

One (1) QMHP who is available during receiving hours (may be via telemedicine);
One (1) nurse, paramedic, or EMT who is available during receiving hours (may be via telemedicine); and 4. A physician or resident physician (including psychiatrist), assistant physician, physician assistant, PMHNP, and/or APRN, who is available during receiving hours and must immediately respond to calls from staff, delay not to exceed one (1) hour.

(B) Qualified staff must be available to administer, screen, inventory, and store prescribed medications within their scope of duties, practice, and/or training.

(C) Qualified staff, within their scope of duties, practice, and/or training, shall be available to conduct an initial health assessment and utilize evidence-based tools to determine the individual’s medical stability, intoxication, substance use, and/ or level of withdrawal/impairment.

(10) Policies and Procedures. The sobering center shall maintain and implement written policies and procedures including but not limited to— (A) Intake screening, service, and clinical assessment protocols;

(B) Community outreach and education strategies for acute intoxication stabilization services including access to and location of service site(s), hours, and days of operation for each site through written material and other means of communication, and how these components will be accomplished on an ongoing basis;

(C) Withdrawal management (detoxification) services as defined in 9 CSR 30-3.120. If the sobering center does not provide this service, facilitated referrals to a local hospital or another qualified service provider shall be made for withdrawal management or other medical services, if determined necessary during an individual’s evaluation process;

(D) Safety and emergency protocols as specified in 9 CSR 10-7.120 Physical Environment and Safety, as well as specific protocols for the population served;

(E) Prescription medication protocols, including storage of medications in accordance with 9 CSR 10-7.070;

(F) Screening for and accessing services for emergency medical conditions, including transport by first responders/ emergency medical service;

(H) Linking individuals to housing services upon discharge, as needed;

(I) Linking individuals to transportation services upon discharge, as needed;

(J) Linking individuals to social services or community resources, as needed;

(K) Assessment and referral process for individuals with a suspected substance use disorder and/or mental health disorder;

(L) Care coordination and continuity of care for individuals served including but not limited to referral process, follow-up, and transfer of records within five (5) days, as applicable;

(M) Infection prevention and control; and (N) Exclusion criteria and protocol when the sobering center is not able to provide services to an individual.

(11) Referral Sources. At a minimum, the following are required referral sources for consideration for admission:

(A) Law enforcement;

(B) Emergency medical services;

(D) Engaging Patients in Care Coordination (EPICC) Coaches;

(E) Community-based organizations participating in department supported outreach services;

(F) Local hospitals, primary care clinics, urgent care clinics, and Federally Qualified Health Centers (FQHC);

(G) Community Behavioral Health Liaisons; and (H) Mobile Crisis Response.

(12) Community Partnerships. At a minimum, sobering centers shall have a referral relationship, collaborative agreement, and/ or memorandum of understanding (MOU) with the following community providers/agencies:

(A) Qualified providers of withdrawal management services;

(B) Housing supports;

(D) Local Continuum(s) of Care; and (E) Recovery support and recovery housing providers.

(13) Coordination and Continuity of Care. Service coordination and continuity of care efforts shall include, but are not limited to:

(A) Identifying and linking individuals with available community resources necessary to ensure transition to routine care;

(B) Referring individuals to behavioral health services, if they are not already receiving those services;

(C) Connecting and/or referring individuals to appropriate local resources including emergency room enhancement (ERE) staff, community behavioral health liaisons (CBHL), and/ or certified peer specialists who shall conduct and document timely follow-up to determine the individual’s current status and need for additional assistance or services;

(D) Contacting and coordinating care with current service providers when feasible and in accordance with state and federal confidentiality regulations;

(E) Connecting individuals to housing, food, or other resources;

(F) Connecting individuals with recovery support and/or recovery housing providers;

(G) Connecting individuals with community-based behavioral health providers in other geographic regions; and (H) Incorporating intensive support beds into a partner program (within the organization or with another local agency), if available, for individuals who need additional support beyond that of the sobering center.

(14) Documentation Requirements. Based on the individual’s ability to cooperate and communicate with staff due to their presenting condition, the following intake documentation shall be obtained:

(A) Presenting problem and referral source, if applicable;

(8/31/23) John R. Ashcroft (B) Rationale for denial of services and referral of the individual to other appropriate services, if necessary;

(D) Status as a current or former member of the U.S. Armed Forces;

(E) Current mental health and substance use symptoms;

(F) Current medications and any medications administered;

(G) Screening for suicide risk and completion of a comprehensive, standardized suicide risk assessment and planning, when clinically indicated;

(H) Screening for risk of violence and completion of a comprehensive, standardized violence risk assessment and planning, when clinically indicated;

(I) Current concerns for personal safety; and (J) Discharge information including services provided, care coordination efforts, follow-up, and referrals.

(15) Measuring Program Effectiveness. Sobering centers shall collect, enter, and submit data utilizing all reporting tools as directed by the department.

(16) Staff Training and Education. Staff shall comply with the training requirements specified in 9 CSR 10-7.110 Personnel, subsection (2)(F). All staff of the sobering center shall complete minimum training requirements as follows:

(A) Screening, assessment, and planning for risk of suicide;

(B) Screening, assessment, and planning for risk of violence;

(D) Basic First Aid;

(E) Cardiopulmonary Resuscitation (CPR);

(F) Administration of naloxone; and (G) Trauma-informed care.

History

AUTHORITY: section 630.050, RSMo 2016. Original rule filed March 21, 2023, effective Sept. 30, 2023. Original authority: 630.050, RSMo 1980, amended 1993, 1995, and 2008.

Division 40 Licensing Rules

Chapter 1 Definitions, Licensing Procedures, and General Requirements for Community Residential Programs and Day Programs

9 CSR 40-1.100 Implementation of Licensure Authority for Certain Day Programs {#sec-9-csr-40-1.100 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-1.100}

9 CSR 40-1.105 Implementation of Licensing Authority for Certain Day Programs MENTAL HEALTH Procedures, and General Requirements for Community Residential Programs and Day Programs {#sec-9-csr-40-1.105 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-1.105}

9 CSR 40-1.010 Definitions {#sec-9-csr-40-1.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-1.010}

(Rescinded January 15, 1984)

RSMo Supp. 1982. Original rule filed Feb. 9, 1983, effective July 11, 1983. Emergency rescission filed Sept. 20, 1983, effective Oct. 1, 1983, expired Jan. 15, 1984. Rescinded:

Filed Sept. 20, 1983, effective Jan. 15, 1984.

9 CSR 40-1.015 Definitions {#sec-9-csr-40-1.015 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-1.015}

PURPOSE: This rule defines terms used in licensing procedures and rules developed under sections 630.705–630.760, RSMo, for all community residential programs and day programs subject to licensure by the department, including Residential Care Facilities and Assisted Living Facilities dually licensed by the Department of Health and Senior Services. entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this

rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no ial. The entire text of the rule is printed here.

(1) Unless the context clearly indicates otherwise, the terms defined in sections 630.005, 632.005 and 633.005, RSMo and as used in 9 CSR 40 are incorporated by reference as if set out in this rule.

(2) The following additional words and terms, as used in 9 CSR 40, mean:

(A) Administrative agent, an organization and its approved designee(s) authorized by the department as an entry and exit point into the state mental health service delivery system for a geographic service area defined by the department. Administrative agents provide statewide access crisis intervention services, including a twenty-four (24) hour crisis mobile response by qualified mental health professionals;

(B) Access Crisis Intervention (ACI), as defined in 9 CSR 30-4.195 Access Crisis Intervention (ACI) Programs;

(C) Affiliate, an organization that is contracted with the department to provide specific community psychiatric rehabilitation (CPR) services for adults in a specific designated geographic region;

(D) Applicant, an individual, partnership, association, corporation, or governmental entity which has applied to the department for a license or program license;

(E) Assisted living facility (ALF), any residence, intermediate care facility, or skilled nursing facility licensed under Chapter 198, RSMo, that provides twenty-four (24) hour care and services and protective oversight to three (3) or more adults who need assistance with activities of daily living and instrumental activities of daily living; storage, distribution, or administration of medications; and/or supervision of health care under the direction of a licensed physician;

(F) Behavioral health, the promotion of mental health, resilience, and well-being, the treatment of mental health and substance use disorders, and the support of individuals who experience and/or are in recovery from these conditions, along with their families/natural supports and communities;

(G) Behavioral crisis/mental health crisis, any situation in which a person’s behavior puts him/her at risk of hurting him/herself or others and/or prevents him/her from being able to care for him/herself or function effectively in the community;

(H) Behavioral health services, mental health services, substance use disorder treatment services, or a combination of both, for youth, children, and adults. Services may be provided in a residential program, on an outpatient basis, or in a home or community (I) Care plan, document developed by staff of a community residential program or day program in collaboration with the individual served and family members/natural supports, as appropriate, which includes measurable goals and objectives important to the individual to assist him or her in achieving personally defined outcomes, ensures delivery of services and supports in a manner that reflect personal preferences and choices, and contributes to the assurance of health and wellness of the individual served;

(J) Community Psychiatric Rehabilitation (CPR), an array of community-based outpatient mental health services for children, youth, and adults who have been diagnosed with a severe, disabling mental illness or serious emotional disturbance.

Administrative agents or their affiliates are responsible for providing these services to eligible individuals in designated service area(s);

(K) Community residential program, any premises where services, structure, oversight, and supports are provided on a residential

basis for adults with mental illness who otherwise would not be able to function outside of psychiatric inpatient care due to the severity and chronicity of their mental illness. This includes, but is not limited to, Intensive Residential Treatment Settings (IRTS), Psychiatric Individualized Supported Living (PISL), Residential Care Facilities (RCF), Intermediate Care Facilities (ICF), and Assisted Living Facilities (ALF);

(L) Competency-based training, the provision of knowledge and skills sufficient to enable the trained staff person to meet specified standards of performance consistent with generally accepted professional standards or specified in law, regulation, or policy, as validated by the person’s demonstration that he/she can use such knowledge or skills effectively;

(M) Compliance, a program may be found in compliance with these licensing rules when deficiencies do not involve— 1. Abuse or neglect—any instance of abuse/neglect in which corrective action has not been taken;

Life endangering conditions—any single life-endangering event or combination of minor deficiencies which collectively are life endangering or which become perilous contingent upon an event such as the outbreak of fire;
Legal requirements-deficiencies related to statutory requirements for programs licensed by the department, such as individual rights and licensing procedures;
Repeated deficiencies—issues which may or may not be serious in and of themselves, but which become significant when left uncorrected according to agreed upon schedules over a period of time;
Numerous deficiencies—deficiencies which may or may not be serious themselves, but become significant collectively because they indicate an ineffective maintenance plan, deficient environmental standards, inadequate orientation or training of staff, poor nursing care practice, inadequate diet, lack of treatment or rehabilitation, ineffective policies and procedures, inadequate staffing, improper recordkeeping, or other issues which may affect the well being of individuals served; or 6. Minimum environmental requirements—quantitative requirements under environment and fire safety/emergency preparedness relating to minimum dimensions for hallways, doors, ceiling heights, window space, floor space, number of bathrooms, and individuals per bedroom;

(N) Consent agreement, an agreement with the department that is entered into by the director of a community residential program or day program to obtain a probationary license. Such a consent agreement will include a provision that the director of the program will voluntarily surrender the license if compliance with licensing requirements is not reached in accordance with the terms and deadlines established under the agreement. The agreement specifies the stages, actions, and time span to achieve compliance;

(O) Continuing care, the provision of a treatment plan and program structure that will ensure an individual receives the type of care he/she needs at the time, particularly at the point of discharge or transfer from the current program. Programs are flexible and tailored to the changing needs of individuals (P) Crisis, an event or time period for an individual characterized by a substantial increase in symptoms, legal or medical problems, and/or loss of housing, employment, or personal supports;

(Q) Crisis prevention plan, developed with individuals who have a mental illness when a potential risk for suicide, violence, or other at-risk behavior is identified during the assessment process or any time during the individual’s engagement in services. At a minimum, the crisis prevention plan includes factors that may precipitate a crisis, a hierarchical list of skills/strengths identified by the individual to regain a sense of control to return to his/her level of functioning before the crisis or emergency, and a hierarchical list of staff interventions that may be used when a critical situation occurs;

(R) Deemed license, acknowledges that an organization/program is monitored and held accountable by a recognized national accrediting body and the department accepts the organization’s verification of good standing with the accrediting body as sufficient to meet the department’s standards of care;

(S) Deficiency, a condition, event, or omission that does not comply with a department licensing rule;

(T) Discharge, the point at which an individual’s active involvement with a treatment or rehabilitation program concludes in accordance with the goals in his or her individual support plan (ISP), individual treatment plan (ITP), or care plan, applicable utilization criteria, and/or program rules;

(U) Electronic health record (EHR), digital version of individual records;

(V) Family living arrangement (FLA) for adults, a program in the owned or leased permanent residence of the licensee, serving no more than three (3) adults who have a developmental disability who are integrated into the licensee’s family unit. The licensee of the home provides care and support as directed in the individual support plan (ISP);

(W) Family living arrangement (FLA) for children/youth, a program in the owned or leased permanent residence of the licensee in which mental health interventions are provided for children and youth placed in the home, allowing the child to remain in his/her community until returning to his/her natural home or alternative community placement to avoid being removed from a community setting;

(X) Individual, a person/consumer/client receiving services from a program licensed under 9 CSR 40;

(Y) Individualized education plan (IEP), a plan developed by trained school staff for children who have a disability and a need for specialized instruction;

(Z) Individual support plan (ISP), a document resulting from a person-centered planning process with an individual with intellectual or developmental disabilities, with assistance as needed by a representative, in collaboration with an interdisciplinary team.

The plan is intended to identify the strengths, capacities, preferences, needs, and desired outcomes of the person served. The process may include other people freely chosen by the individual who are able to contribute to the process. The person-centered planning process enables and assists the individual in accessing a personalized mix of paid and nonpaid services and supports that will assist him/her in achieving personally defined outcomes and the training, supports, therapies, treatments, and/or other services that become

part of the ISP;

(AA) Individual Treatment Plan (ITP), written document developed in collaboration with the individual seeking assistance for a behavioral health condition (or his or her parent/legal guardian) that identifies the individual’s strengths, goals, preferences, abilities, physical and behavioral health needs, and desired outcomes for a healthy lifestyle in the community. Treatment staff, treatment team members, and family members/natural supports (if acceptable to the individual being served) participate in the development of the plan and assist the individual in identifying and accessing a mix of services and supports to meet his/her needs and achieve desired goals for recovery and resiliency;

(BB) Intensive Residential Treatment Setting (IRTS), living environment where medically necessary services/supports are provided for five (5) to sixteen (16) adults with serious mental illness who are transitioning from an inpatient psychiatric hospital to the community, or are at risk of returning to inpatient care due to their clinical status or need for increased support.

This environment is most appropriate for individuals who can tolerate regular interaction with their peers, but have significant difficulties with activities of daily living and may require round-the-clock observation and oversight and/or periodic redirection from staff to avoid behaviors potentially harmful to themself or others;

(CC) Isolation, removing an individual from a social setting to prevent spread of contagious disease;

(DD) License, written notification that a community residential program or day program complies with department licensing requirements to serve individuals with mental illness, intellectual disabilities, and developmental disabilities;

(EE) Licensee, an individual, partnership, association, corporation, or governmental entity which has received a license or program license from the department to operate a community residential program or day program to provide services and supports for individuals with mental illness, intellectual disabilities, and developmental disabilities;

(FF) Mechanical supports, supportive devices used in normative situations to achieve proper body position and balance; these are not restraints;

(GG) Medication administration, qualified staff preparing and/or giving a legally prescribed individual dose of medication to an individual served, including observation and monitoring the individual’s response to the medication;

(HH) Medication control, the process of physically controlling, transporting, storing, and disposing of medications, including medications self-administered by individuals (II) Medication use, the practice of handling, prescribing, and dispensing medication (including administering and observing selfadministration) to persons served in response to specific symptoms, behaviors, and conditions for which the use of medication is indicated and deemed effective. This includes prescribed and sample medications and may, when required as part of the treatment regimen, include over-the-counter or alternative medication provided to persons served;

(JJ) Misuse of funds/property, as defined in 9 CSR 10-5.200, Report of Complaints of Abuse, Neglect, and Misuse of Funds/Property;

(KK) Natural supports, provided by a person of the individual’s choice to assist him or her in achieving personal goals and facilitating integration into their community. Natural supports are provided by persons who are not paid staff of an agency but may be initiated, planned, and facilitated in partnership with an agency;

(LL) Neglect, as defined in 9 CSR 10- 5.200, Report of Complaints of Abuse, (MM) Outcome, a specific measurable result of services/supports provided to an individual or identified target population;

(NN) Person-centered, services and supports developed in collaboration with the individual served that are respectful of informed consent and the preferences of the individual, resulting in a therapeutic alliance which contributes significantly to treatment/rehabilitation outcomes;

(OO) Physical abuse, as defined in 9 CSR (PP) Probationary license, written authorization to continue service delivery for a specified period of time to enable a licensee to achieve compliance with the department’s licensing requirements as set forth in a consent agreement between the department and the licensee;

(QQ) Program license, written notification that a community residential program with a current license, temporary operating permit, or probationary license from the Department of Health and Senior Services (DHSS) under sections 198.006—198.096, RSMo, also meets the department’s licensing requirements relative to admission criteria, care, treatment, and habilitation or rehabilitation needs of individuals served;

(RR) Psychiatric crisis, an individual is exhibiting a substantial increase in symptoms related to a severe emotional disturbance or mental illness based upon his or her baseline functioning. The reason(s) why the crisis occurred and how it is expressed varies by individual and may include harm to self or others, disorientation, being out of touch with reality, compromised ability to function, or other expression of emotional distress not characteristic to the individual. Immediate clinical assessment and intervention is necessary to ensure the safety of the individual and others;

(SS) Psychiatric Individualized Supported Living (PISL), living environment where medically necessary services/supports are provided for one (1) to four (4) adults with serious mental illness who are transitioning from an inpatient psychiatric hospital to the community, or are at risk of returning to inpatient care due to their clinical status or need for increased support. This environment is most appropriate for individuals who— 1. Have intermittent difficulty tolerating other individuals in their immediate living area;

Require access to an individual bedroom to avoid psychiatric relapse, aggression, or other behaviors associated with a risk of re-hospitalization; and/or 3. Have substantial difficulties with activities of daily living and require roundthe-clock observation and oversight; and/or 4. Require daily redirection from staff to avoid behaviors potentially harmful to themselves or others;

(TT) Qualified mental health professional (QMHP), any of the following:

A physician licensed under Missouri law to practice medicine or osteopathy and with training in mental health services or one (1) year of experience, under supervision, in treating problems related to mental illness or specialized training;
A psychiatrist licensed under Missouri law as a physician and who has successfully completed a training program in psychiatry approved by the American Medical Association, the American Osteopathic Association, or other training program identified as equivalent by DMH;
A psychologist licensed under Missouri law to practice psychology with specialized training in mental health services;
A professional counselor licensed under Missouri law to practice counseling with specialized training in mental health ser- 5. A clinical social worker licensed under Missouri law with a master’s degree in social work from an accredited program and with specialized training in mental health ser- 6. A psychiatric nurse licensed under

Chapter 335, RSMo, as a registered professional nurse with at least two (2) years of experience in a psychiatric or substance use disorder treatment setting or a master's degree in psychiatric nursing;

An individual possessing a master's or doctorate degree in counseling and guidance, rehabilitation counseling and guidance, vocational counseling, psychology, pastoral counseling, family therapy, or related field who has successfully completed a practicum or has one (1) year of experience under the supervision of a QMHP;
An occupational therapist certified by the National Board for Certification in Occupational Therapy, registered in Missouri, who has a bachelor's degree and has completed a practicum in a psychiatric setting or has one (1) year of experience in a psychiatric setting, or has a master's degree and has completed either a practicum in a psychiatric setting or has one (1) year of experience in a psychiatric setting;
An advanced practice registered nurse (APRN) under section 335.016, RSMo, who has had education beyond the basic nursing education and is certified by a nationally recognized professional organization as having a nursing specialty, or who meets criteria for APRNs established by the board of nursing; or 10. A psychiatric pharmacist, registered pharmacist in good standing with the Missouri Board of Pharmacy who is a board-certified psychiatric pharmacist through the Board of Pharmaceutical Specialties, or a registered pharmacist currently in a psychopharmacology residency where the service has been supervised by a board-certified psychiatric pharmacist;

(UU) Reciprocal license, issued by the department to a residential program that has a current valid license as a Residential Treatment Agency for Children and Youth from the Department of Social Services under 13 CSR 35-71, if the applicant has applied for a license from the department and paid the application fee;

(VV) Research, as defined in 9 CSR 60- 1.010;

(WW) Residential care facility (RCF), as defined in section 198.006, RSMo;

(XX) Residential program, program in the community serving ten (10) or more individuals with intellectual or developmental disabilities by providing social support, health supervision, and habilitation training in skills of daily living;

(YY) Restraint, as defined in 9 CSR 10- 7.140;

(ZZ) Safety crisis plan, as defined in 9 CSR 45-3.090 Behavior Supports;

(AAA) Scheduled (controlled) medication, categories or schedules assigned to medication by the Drug Enforcement Administration based on a drug’s acceptable medical use and the drug’s abuse or dependency potential;

(BBB) Seclusion, involuntary confinement of an individual alone in a room or an area from which he/she is physically prevented from leaving or having contact with others;

(CCC) Self-administration of medication (adults), the application of a medication, (whether by injection, inhalation, oral ingestion, or any other means) by the individual served to his or her body, and may include the program storing the medication and staff handing the medication container to the individual at the time designated to take the medication;

(DDD) Sexual abuse, as defined in 9 CSR (EEE) Staff (staff member, employee, personnel), paid employee or contractor providing services and/or supports on behalf of a licensed or deemed licensed program, on a full- or part-time basis, and has contact with individuals served by the program;

(FFF) Stock supply/stock pharmaceutical, prescription and non-prescription medication stored on-site for the provision of medication services by a program. Stock supplies are checked by qualified staff on a routine basis for expiration dates and reviewed annually by a pharmacy consultant and approved by the medical director or pharmacy technician;

(GGG) Substance use disorder, diagnostic term in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) referring to recurrent use of alcohol or other drugs that causes clinically and functionally significant impairment such as health problems, disability, and failure to meet major responsibilities at work, school, or home. Depending on the level of severity, this disorder is classified as mild, moderate, or severe. The document incorporated by reference does not include any later revisions or updates and is available from the American Psychiatric Association, 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209-3901;

(HHH) Supports, array of activities, resources, relationships, and services designed to assist an individual’s integration into the community, participation in services/supports, improve functioning, and/or recovery and resiliency;

(III) Targeted case management, Medicaid program that assists individuals served by the Division of Developmental Disabilities (DD) to gain access to needed medical, social, educational, and other services;

(JJJ) Temporary operating permit, written authorization from the department permitting a licensee seeking license renewal or a new owner applying for an initial license to continue service delivery pending completion of the licensing survey process and the applicant is not at fault for any delay in the process;

(KKK) Time-out, temporarily separating a person from an environment where he or she has exhibited unacceptable behavior;

(LLL) Trauma, experiences that cause intense physical and psychological stress reactions. May refer to a single event, multiple events, or a set of circumstances experienced by an individual as physically and emotionally harmful or threatening and has lasting adverse effects on the individual’s physical, social, emotional, or spiritual wellbeing;

(MMM) Treatment, a professionally recognized approach that applies accepted theories, principles, and techniques designed to achieve rehabilitative outcomes for individuals served;

(NNN) Verbal abuse, as defined in 9 CSR Neglect, and Misuse of Funds/Property; and (OOO) Volunteer, an unpaid person formally recognized by a program to provide direct services or supports to individuals it serves.

(3) Unless the context clearly indicates otherwise, certain terms shall be used in 9 CSR 40 as follows:

(A) Parent, the parent of a minor child unless his/her parental rights have been terminated, or the parent of an adult who consents to having the parent have access to or participate in the record or activity subject of a particular rule. The term shall be disregarded if the individual’s parents are deceased or have had their parental rights terminated; and (B) Guardian, the person appointed by a Missouri court of competent jurisdiction to have the care, custody, and control of the individual. The term shall be disregarded if the individual has not had a guardian appointed.

RSMo 2016.* Original rule filed Oct. 13, 1983, effective Jan. 15, 1984. Amended:

Filed March 14, 1984, effective Aug. 15, 1984. Amended: Filed July 15, 1985, effective Feb. 1, 1986. Amended: Filed Jan. 2, 1990, effective June 11, 1990. Amended:

Filed Jan. 31, 1991, effective July 8, 1991.

Amended: Filed July 17, 1995, effective March 30, 1996. Amended: Filed May 14,

9 CSR 40-1.050 Licensure Procedures {#sec-9-csr-40-1.050 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-1.050}

(Rescinded January 15, 1984)

RSMo Supp. 1982. Original rule filed Feb. 9, 1983, effective July 11, 1983. Emergency rescission filed Sept. 20, 1983, effective Oct. 1, 1983, expired Jan. 15, 1984. Rescinded:

Filed Sept. 20, 1983, effective Jan. 15, 1984.

9 CSR 40-1.055 Licensing Procedures {#sec-9-csr-40-1.055 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-1.055}

PURPOSE: This rule describes the application and licensing process for community residential programs and day programs subject to licensure from the department, including Residential Care Facilities (RCF) and Assisted Living Facilities (ALF) dually licensed by the Department of Health and Senior Services ial. The entire text of the rule is printed here.

(1) As set out in section 630.705, RSMo, each community residential program (hereafter referred to as residential program) or day program serving individuals with mental illness, intellectual disabilities, or developmental disabilities (IDD) shall have a license or program license from the department unless specifically exempted under section 630.705.3., RSMo.

(2) The department issues the following types of licenses:

(A) A license to operate a day program when the program serves individuals with a diagnosed mental illness or IDD;

(B) A license to operate a residential program, including a group home or family living arrangement, when individuals with a mental illness or IDD diagnosis are being served in the program;

(C) A program license to a residential program that is licensed under Chapter 198, RSMo, as a Residential Care Facility (RCF) or Assisted Living Facility (ALF) that serves any individual with an IDD or a majority of individuals with a mental illness diagnosis;

(D) A reciprocal license to a residential program licensed by the Department of Social Services (DSS) as a Residential Treatment Agency for Children and Youth.

(3) Residential programs and day programs located at the same physical address, but separately licensed by the department, may share staff as long as each program independently meets applicable staffing requirements for the population being served.

(4) A day program that is part of a Community Psychiatric Rehabilitation (CPR) program and is certified or deemed certified by the department under 9 CSR 10-7.130 and 9 CSR 30-4, will not be separately licensed by the department’s Office of Licensure and Certification.

(5)

An agency or individual may request to be licensed by completing the application form included herein and submitting the application and other documentation as specified. The application form can be downloaded from the department’s website https://dmh.mo.gov/media/pdf/applicationlicensure. Completed applications must be mailed to: Department of Mental Health, Office of Licensure and Certification, PO Box 687, Jefferson City, MO 65102, fax (573) 751-7815, or emailed to: DMH- OLC@dmh.mo.gov.

(6) An application for an initial license must be submitted not less than thirty (30) days prior to the opening date for a new residential program or day program. The application must be approved by department staff prior to a Division of Fire Safety inspection or department license inspection being scheduled. A diagram of the interior of the building(s), in approximate scale, and a narrative indicating how each area of the building will be used is required for first-time applicants.

(A) Prior to new construction, remodeling an existing structure(s), or any structural alterations to an existing building, a copy of the plans must be submitted to the Office of Licensure and Certification for review and approval, including an explanation for utilizing each area of the building. The architect or contractor shall certify in writing the plans are in compliance with these licensing regulations.

Construction shall not begin until the plans have been reviewed and approved by the Division of Fire Safety. All plans for new construction, remodeling, and additions must comply with the 2010 Americans with Disabilities Act Standards for Accessible Design, hereby incorporated by reference and is published by and available from the U.S. Department of Justice, Civil Rights Division, 950 Pennsylvania Avenue NW, Washington, DC 20530, available at: ence material listed in this paragraph of this 2. During the construction or remodeling process, an inspection of the framing, wiring, and rough-in wiring for the fire alarm system must be conducted by the Division of Fire Safety before the walls are enclosed.

Failure to have these inspections constitutes cause for disapproval by the Division of Fire Safety.

An existing residential program or day program shall not increase the capacity of any room or total capacity of any building without meeting new construction requirements as specified in this rule.

(7) The department issues a license to operate a residential program or day program serving any individual with an IDD or a majority of individuals with a mental illness if the applicant— (A) Has applied for a license from the department and paid the application fee;

(B) Has not had a license or program license denied or revoked by the department;

(C) Is in compliance with applicable state laws and regulations, including the regulations established by the department pursuant to section 630.710, RSMo.

(8) The department will issue a program license to a residential program that has a current, valid license from the Department of Health and Senior Services (DHSS) under

Chapter 198, RSMo, as an ALF or RCF when the program serves any individual with an IDD or a majority of individuals with a mental illness, if the applicant— (A) Has applied for a license from the department and paid the application fee;

(B) Has not had a license or program license denied or revoked by DHSS or the department; and (C) Is in compliance with applicable state laws and department licensing regulations as specified in 9 CSR 40-1.060 Program Administration and 9 CSR 40-1.075 Person- Centered Services.

(9) The department will issue a reciprocal license to a residential program that has a current valid license as a Residential Treatment Agency for Children and Youth from the DSS under 13 CSR 40-71, if the applicant has applied for a license from the department and paid the application fee.

(A) The department delegates its survey

(10) The department recognizes and deems as licensed any residential program that is— (A) An Intermediate Care Facility (ICF) for Individuals with Intellectual Disabilities (ICF/IID) certified under Title XIX of the Social Security Act, 42 U.S.C. section 1396, and the regulations contained in 42 CFR part 442, as long as the facility remains certified;

(B) An ICF or Skilled Nursing Facility (SNF) licensed under Chapter 198, RSMo, and certified under Title XIX of the Social Security Act, 42 U.S.C. section 1396, and the regulations contained in 42 CFR part 442, as long as the facility remains certified.

(C) The department does not issue a license to a residential program that meets the criteria for deemed status as specified in this

section of this rule.

(11) The department recognizes and deems as licensed a residential program or day program that maintains accreditation from CARF International, The Council on Quality and Leadership, The Joint Commission, or other accrediting body recognized by the department.

(A) Accredited agencies must— 1. Submit a copy of the accrediting body’s survey report to the department within thirty (30) days of receipt, including verification of the accreditation time period and programs/services that are accredited;

Notify the department of any investigation by the accrediting body related to a complaint;
Notify the department of any changes in accreditation status during the time period of accreditation and resurvey; and 4. Ensure they are compliant with all department licensing regulations pertaining to service delivery and fire safety.

(B) Deemed status may be revoked by the department if an agency fails to comply with the requirements outlined in paragraph (11)(A)1.-4. of this rule.

(C) The department does not issue a license to an agency that meets the criteria for deemed status as specified in this section of (12) Agencies that are deemed as licensed by the department are not exempt from monitoring of service delivery practices, individual safety, or environmental conditions through other functions conducted by the department.

(13) License fees are as follows and must be included with the individual/agency’s application for licensure from the department:

(A) Ten dollars ($10) for residential programs and day programs that admit more than three (3) but less than ten (10) individuals;

(B) Fifty dollars ($50) for residential programs and day programs that admit ten (10) or more individuals;

(C) The fee is based on the total available capacity of the residential program or day program, not the number of individuals currently being served. The license fee is nonrefundable; and (D) The license fee does not apply to residential programs or day programs applying for a licensed capacity of three (3) or fewer individuals or to residential programs or day programs owned and operated by a government entity.

(14) The department considers an application for licensure to be active for no more than one (1) year. If the department does not issue a license or program license within one (1) year from the date of application, the applicant must submit a new application with the applicable fee, if necessary, to be considered for licensure.

(15) A license is issued for a period of one (1) year unless it is revoked by the department prior to the expiration date. The department provides each licensee with a renewal notice at least one hundred twenty (120) business days prior to expiration of the existing valid license.

(16) The licensee shall submit the application for a license for a succeeding year to the department at least ninety (90) business days before the expiration date of its current license.

(17) If the licensee does not apply for a renewal license within at least ninety (90) business days before the expiration date of the license, the department will notify the director of the program that it is not authorized under Missouri law to serve individuals with mental illness or IDD without a license.

(18) If an application for a license is not submitted to the department at least thirty (30) business days prior to the expiration of an existing valid license, department staff will notify the program director that the program will not be licensed after the expiration date of the license. A copy of the letter will be provided to applicable areas of the department and to any state or local government agencies with the potential to be affected by the program’s non-licensed status.

(19) If the department has reasonable grounds to believe a residential program or day program required to be licensed under sections 630.705–630.760, RSMo, is operating without a license, the department will attempt to investigate to determine whether a license is required. If department staff are not permitted access to inspect the program, or if the program director refuses to permit access for an inspection, the department will apply to the circuit court of the county in which the program is located for an order authorizing entry for such inspection.

(20) If the department has not completed its license inspection before the expiration date of a current license and the applicant is not at fault for the delay, a temporary operating permit, not to exceed ninety (90) business days, will be issued by the department in order to complete the survey.

(A) An applicant seeking license renewal is at fault for reasons including, but not limited 1. The licensee did not apply for a new license or program license at least thirty (30) days prior to the expiration date of the existing license;

The department found the licensee to be out of compliance with its licensing requirements and the director of the program failed to achieve compliance prior to expiration of the license; and/or 3. The licensee refused to allow a license inspection by the department or otherwise to cooperate with the licensing survey team.

(21) The department considers a change in agency ownership to have occurred under any of the following circumstances:

(A) An individual licensee incorporates or forms a partnership;

(B) A change in the majority interest of the partners, with respect to a licensee which is a general partnership;

(C) A change in the majority interest of the general partners or in the majority interest of limited partners, with respect to a licensee which is a limited partnership; or (D) A change in the person(s) who owns, holds, or has the power to vote the majority of any class of stock issued by the corporation, with respect to a licensee which is a corporation.

(22) The department may grant a temporary operating permit for a specified period of time, not to exceed ninety (90) business days, under the following circumstances:

(A) To authorize continuity of services and allow department staff to evaluate an application for a license or program license as a result of any change in ownership of a residential program or day program; or (B) To determine compliance with applicable state laws and regulations, including the standards established by the department pursuant to section 630.710, RSMo, if the applicant— 1. Has applied for a license and paid the appropriate application fee;

Has not had a license or program license denied or revoked by the department; or 3. Is licensed by DHSS as defined in

Chapter 198, RSMo, as an ALF or RCF, if applicable.

(23) Each application for licensure must include the name and contact information of the director of the agency and the staff person in charge of administration of the residential program or day program.

(24) The director of the residential program or day program shall cooperate with and assist authorized department staff or its representatives in making announced and unannounced licensing surveys by allowing access to the program’s premises, records, staff, and individuals served.

(25) After receiving a complete application for an initial license or renewal license, department staff will conduct an on-site inspection of the residential program or day program to assess compliance with these licensing regulations. This may include, but is not limited to, interviews with agency and/or program staff and individuals served, a review of agency records, and observation of program activities and environmental conditions.

(A) At the conclusion of the on-site license inspection, department staff will hold an exit conference with the program director and other relevant staff to discuss results of the inspection.

(B) If the department determines the program is in compliance with the provisions of sections 630.705 through 630.760, RSMo, and these licensing regulations, a license or program license will be issued.

(26) If the department determines an applicant or existing licensee is not in compliance with these licensing regulations at the time of the inspection, the applicant will be notified as follows:

(A) The program director will be informed of the area(s) of noncompliance during the exit conference with department staff;

(B) Within twenty (20) business days after completion of the on-site license inspection, a written report will be sent to the program director explaining the area(s) of noncompliance;

(C) The licensing report will require the program director to submit a plan of correction to the department within twenty (20) business days of receipt;

(D) The plan of correction shall address each deficiency cited in the report and include action steps and time frames for achieving compliance, including:

How program staff will identify individuals served, other staff, and/or maintenance areas potentially affected by the deficient practice(s);
How program staff will monitor corrective action taken, including measures or systemic changes to ensure the deficient practice(s) do not reoccur;
The date when full compliance with licensing regulations will be achieved; and 4. The staff person(s) responsible for implementing the plan of correction in the (E) Within ten (10) business days following receipt of the program’s plan of correction, the department will issue written approval or disapproval of the plan to the program director;

(F) Department staff will reinspect the program within sixty (60) business days after the original inspection to determine if deficiencies are being corrected as required in the approved plan of correction or any subsequent authorized modification. The reinspection may be conducted through a desk audit at the department’s discretion.

If the department determines the program is in compliance with licensing regulations, a license will be issued to the program.
If the department determines the program has not achieved compliance with licensing regulations or the program director is not correcting the noted areas of noncompliance in accordance with the approved plan of correction, the department will issue written notice of noncompliance to the program director by certified mail/return receipt requested;

(G) The notice of noncompliance will inform the program director that the department may seek the imposition of any of the sanctions and remedies provided for in

section 630.755, RSMo, or any other action authorized by law; and (H) The program director may choose to enter into a consent agreement with the department to obtain a probationary license.

The consent agreement will include a provision that the program director shall voluntarily surrender the license if compliance is not reached in accordance with the terms and deadlines established under the consent agreement. The agreement will specify the stages, actions, and time span to achieve compliance with licensing regulations.

(27) New applicants not licensed by the department and not currently serving individuals with mental illness or IDD that fail to correct a deficieny(cies) and submit a plan of correction or otherwise cooperate with the licensing process, will not be formally denied a license. The application will be allowed to expire and considered withdrawn.

(28) The department license is issued for the residential program or day program location and the individual, partnership, association, corporation, or governmental entity named on the application. The license is not valid for programs operated by the same agency that are located on different premises.

(29) The license issued by the department to the day program or residential program must be posted in a conspicuous place on the premises.

(30) The department maintains a directory of all licensed residential programs and day programs and posts the directory on its public website.

(31) The department or its authorized representatives may conduct announced or unannounced inspections during a licensure year to determine compliance with its licensing regulations in identified areas of focus. If the residential program or day program is found to be out of compliance with department licensing requirements, the license or program license will be revoked if the program does not achieve compliance as specified by the department.

(32) The department may deny a new application or a renewal application for licensure or revoke an existing license if a residential program or day program fails to comply with sections 630.705—630.760, RSMo, and corresponding licensing regulations and fails to submit and/or implement an approved plan of correction as described in section (26) of this (A) Prior to the formal notice of license denial or revocation, the department will send a written notice of its intent to deny/revoke and the reasons for such action to the program director by certified mail/return receipt requested. The program director shall have ten (10) business days from the date of receipt to request a review by the department’s hearing administrator. The review shall occur within fifteen (15) business days of the department’s receipt of the request for a hearing from the program director.

(B) The review by the department’s hearing administrator is not applicable when a license was denied or revoked due to substantiated abuse, neglect, or misuse of funds/property pursuant to 9 CSR 10-5.200, 9 CSR 10-5.206, and 19 CSR 30-88.010.

(C) The written notice of license revocation or denial shall be effective not less than thirty (30) business days from the date of mailing by certified mail/return receipt requested or of personal service of the notice upon the licensee. The effective date of license revocation or denial will be included in the department’s notice to the program director.

(D) The notice of revocation or denial shall inform the applicant or licensee of the right to seek a determination of the revocation or denial by the Administrative Hearing Commission as set out in sections 621.045, 621.189, and 621.193, RSMo, and the right to stay the department’s action pending the determination under rules promulgated by the Administrative Hearing Commission unless, upon application of the department, the commission finds that continued operation before final determination by the commission would present an imminent danger to the health, safety, or welfare of any individual, or likelihood that death or serious injury would result.

(E) The department will notify DHSS and DSS within ten (10) business days of revoking or denying a program license.

(33) As set out in section 630.750, RSMo, if the department finds a licensed residential program or day program is not in compliance with any licensing regulation(s) which presents either an imminent danger to the health, safety, or welfare of any individual or a substantial probability that death or serious physical harm would result, and the area(s) of noncompliance is not immediately corrected, the department director shall issue a notice of noncompliance to the program director and initiate the procedures set out in section (32) of this rule to deny or revoke the program’s license.

(34) The director of a residential program or day program may withdraw an application for a license or program license any time during the inspection process by submitting written notification to the department attesting it does not meet the criteria for licensing.

(35) At any time after a department licensing inspection is conducted, the director of a residential program or day program may choose to enter into a consent agreement with the department to obtain a probationary license.

The consent agreement shall include a provision that the program director shall voluntarily surrender the license if compliance is not reached in accordance with the terms and deadlines established under the agreement.

The agreement shall specify the actions and time schedule to achieve compliance with these licensing regulations.

(36) A residential program or day program may ask for a waiver of a licensing requirement(s) by submitting a request to the department’s Exceptions Committee as specified in 9 CSR 10-5.210.

Amended: Filed March 14, 1984, effective Aug. 15, 1984. Amended: Filed July 15, 1985, effective Feb. 1, 1986. Amended: Filed March 18, 1987, effective Aug. 15, 1987.

Amended: Filed Jan. 2, 1990, effective June 11, 1990. Emergency amendment filed Sept. 15, 1992, effective Oct. 1, 1992, expired Jan. 28, 1993. Amended: Filed Sept. 15, 1992, effective April 8, 1993. Amended: Filed April 1, 1993, effective Dec. 9, 1993. Amended:

Filed July 17, 1995, effective March 30, 1996. Amended: Filed May 14, 2020, effective Dec. 30, 2020. 1995, 2008; 630.135, RSMo 1980; and 630.705, RSMo 1980, amended 1982, 1984, 1985, 1990, 2000, 2011, 2014.

History

authority to the DSS, Children’s Division, for compliance with licensing rules as a Residential Treatment Agency for Children and Youth under 13 CSR 40-71.
AUTHORITY: sections 630.050, 630.135, and 630.705, RSMo 2016. Original rule filed Oct. 13, 1983, effective Jan. 15, 1984.

9 CSR 40-1.060 Program Administration {#sec-9-csr-40-1.060 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-1.060}

PURPOSE: This rule specifies the administrative requirements for all community resiwith 9 CSR 40-1.055, including Residential Care Facilities (RCF) and Assisted Living Facilities (ALF) dually licensed by the Department of Health and Senior Services (1) Director. Each community residential program and day program shall have a chief administrative officer/program director who shall— (A) Be empowered to make decisions regarding the operation of the program;

(B) Delegate a staff person who is empowered to act for him/her when absent from the program; and (C) Report any change in the ownership, management, or administration to the department within five (5) days.

(2) Licensing. The director shall ensure the program maintains a license in good standing with the Department of Health and Senior Services (DHSS) as specified in 9 CSR 40- 1.055, subsection (2)(C), if applicable.

(3) Policies and Procedures. A policy and procedure manual shall be maintained on-site which promotes compliance with these licensing regulations and other federal, state, and/or local regulations applicable to the pro- (A) The director shall ensure the policies and procedures are followed by staff and are readily available for review by all employees, department staff, and other authorized representatives. The policy and procedure manual shall include, but is not limited to:

A description of program goals, mission, purpose, services, and costs;
The number, characteristics, and needs of individuals served, including how the program is specifically designed to support those needs;
Admission, discharge, and transfer of individuals served which ensures— A. The program does not admit, nor keep in residence, any person whose needs exceed its provisions for care, support, and program functions;

B. Each individual admitted is able to function safely within the physical environment of the program;

C. Individuals admitted to an adult residential program or day program are at least eighteen (18) years of age; and D. The program does not admit more individuals than its licensed capacity;

Rights, responsibilities, and grievance procedures in accordance with 9 CSR 40- 1.065;
Provisions for an organized record system in accordance with 9 CSR 40-1.070;
Delivery of person-centered services in accordance with 9 CSR 40-1.075;
Dietary services in accordance with 9 CSR 40-1.080;
Use and storage of firearms and ammunition in accordance with 9 CSR 40- 1.085 subsection (12)(A);
Environmental safety and maintenance in accordance with 9 CSR 40-1.085;
Fire safety and emergency preparedness in accordance with 9 CSR 40-1.090;
Background screening process in accordance with 9 CSR 10-5.190;
Reporting of complaints of abuse, neglect, and misuse of funds/property in accordance with 9 CSR 10-5.200 and 9 CSR 10-5.206;
Research in accordance with 9 CSR 60-1.010;
The care and maintenance of pets, including documentation of all applicable vaccinations and health statements in accordance with local and state regulations; and 15. Employee policies and procedures including, but not limited to:

A. Orientation process;

B. Health and safety practices, use of tobacco products, illegal and legal substances brought into the program, prescription medication brought into the program, and weapons brought into the program; and C. Confidentiality of individual records and information.

(B) Policies and procedures shall clearly state that an individual receiving services cannot supervise or discipline another individual who is receiving services.

(C) Business activities shall not be allowed on the premises of the program other than those authorized by the department as consistent with the health, welfare, and safety of individuals served and as compatible with the integrity of the program.

(4) Staffing and Training. Staff shall be available in sufficient numbers to provide necessary and beneficial services/supports and possess the training, experience, and credentials to effectively perform their assigned duties.

(A) All employees shall complete orientation and training within the first thirty (30) days of employment in order to be knowledgeable of their job duties including, but not limited to:

An overview of the population served, program goals, mission, policies, and 2. Respective job assignment(s) and related duties;
Regulations regarding individual rights, confidentiality, duty to warn, and reporting alleged abuse, neglect, and misuse of funds/property of individuals served in accordance with 9 CSR 10-5.200, 9 CSR 10- 5.206, and 19 CSR 30-88.010; and 4. Emergency and evacuation policies and procedures, including protocol to be followed when accompanying individuals in the community.

(B) Staff who are promoted or transferred to a new job assignment(s) shall receive training and orientation on their new responsibilities within thirty (30) days of actual transfer to the new assignment.

(C) A new employee shall not be assigned sole responsibility for implementation of an individual support plan (ISP), individual treatment plan (ITP), or care plan until his or her training and orientation have been completed.

(D) Each employee providing direct services and/or supports shall participate in annual in-service training including, but not limited to:

Emergency and evacuation policies and procedures;
Individual rights;
Infection control procedures;
Reporting of abuse, neglect, and misuse of funds/property in accordance with 9 CSR 10-5.200, 9 CSR 10-5.206, and 19 CSR 30-88.010; and 5. Specialized training to meet the needs of individuals served.

(E) Records of attendance and documentation of successful completion of all training and orientation must be documented in a centralized location and/or each employee’s personnel record, including the trainee’s name, topic, date(s), length of time or training, and instructor(s) name, title, credentials, and signature.

(5) Volunteers. If the program uses volunteers to provide services and/or supports, written policies and procedures shall be implemented to guide the roles and activities of volunteers in an organized and productive manner. Volunteers shall be qualified to deliver the services and/or supports provided, have a background screening in accordance with 9 CSR 10-5.190, and receive orientation, training, and adequate supervision.

(A) Orientation shall occur within thirty (30) days of the individual’s volunteer work with the program including, but not limited 1. An overview of the population served, program goals, mission, policies, and 2. Regulations regarding individual rights, confidentiality, duty to warn, and reporting alleged abuse, neglect, and misuse of funds/property of individuals served in accordance with 9 CSR 10-5.200, 9 CSR 10- 5.206, and 19 CSR 30-88.010;

Emergency and evacuation policies and procedures, including protocol to be followed when accompanying individuals in the community; and 4. Other topics relevant to their assignment(s).

(6) Emergency Planning. The policies and procedures for emergency situations shall include instructions for staff and individuals served including, but not limited to:

(A) Medical emergencies, including response to an incapacitated person, protocol for initiating a 911 emergency call, and use of cardiopulmonary resuscitation (CPR) and First Aid.

Drills shall be conducted at least quarterly for staff involved in the 911 protocol and administration of CPR and first aid.
Trained staff shall be available in sufficient numbers to respond to emergency situations and provide first aid and CPR, when necessary. At least one (1) trained staff person shall be on duty in the program twentyfour (24) hours per day, seven (7) days per week. Depending on the configuration of the building and number of individuals being served, more than one (1) trained staff person per shift may be required.

A. Staff must maintain current First Aid and CPR certification for healthcare providers through training that includes hands-on practice and in-person skills. Training provided solely online is not acceptable;

(B) Natural disasters, such as a fire or tornado;

(D) Utility failure;

(E) Violent or threatening situations;

(F) Elopements;

(G) Behavioral crisis;

(H) Psychiatric crisis;

(I) Death of an individual served;

(J) Arrest or detention of an individual (K) Use of cellular phones during an emergency; and (L) Infectious or contagious disease.

Policies and procedures for the prevention, containment, and reporting of infectious and contagious diseases shall be established in accordance with DHSS communicable disease regulations as specified in 19 CSR 20-20, available at: https://s1.sos.mo.gov/cmsimages/adrules/csr /current/19csr/19c20-20.pdf.
Any employee or volunteer diagnosed or suspected of having a contagious or infectious disease shall not work with individuals served or in dietary service until a written statement is obtained from a healthcare provider indicating the disease is no longer contagious or is found to be noninfectious.

(7) Emergency Safety Interventions. Written policies and procedures shall be implemented to prevent and respond to disruptive behavior, a behavioral crisis, or a psychiatric crisis that may occur with individuals served, staff, visitors, and others. All efforts shall be made to minimize re-traumatization of persons served or others involved in a disruptive situation, including consideration as to whether the program is suitable to meet the individual’s needs.

(A) Policies and procedures shall indicate whether time-out, seclusion, and restraint are used in the program. If such interventions are used, policies and procedures shall include, but are not limited to:

Staff authorized to order, apply, and monitor their use;
Protocol for their use with individuals 3. Time limits for such orders;
Duration of such orders;
Incorporation of such orders in the ISP, ITP, or care plan of the individual served; and 6. Documentation of such orders in the individual record.

(B) Programs may prohibit by policy and practice the use of time-out, seclusion, and restraint and must implement policies and procedures to address disruptive behaviors and behavioral and psychiatric crises.

Available to all program staff and service providers;
Available to individuals served and parents/guardians, family members, and other natural supports, as appropriate;
Developed with input from individuals served and, whenever possible, parents/guardians, family members, and other natural supports; and 5. Consistent with department regulations regarding individual rights.

(D) All staff and volunteers having direct contact with individuals served shall receive documented initial and ongoing competencybased training on evidence-based and best practice interventions for preventing disruptive behaviors, behavioral crises, and psychiatric crises and addressing them in the least restrictive manner if they occur.

(E) All programs shall prohibit by policy and practice— 1. Aversive conditioning of any kind— the application of startling, unpleasant, or painful stimulus or stimuli that have a potentially harmful effect on an individual in an effort to decrease maladap tive behavior;

Withholding of food, water, or bathroom privileges;
Painful stimuli;
Corporal punishment (such as use of pepper spray, mace, Taser, stun gun);
Techniques that obstruct an individual’s airway or impairs breathing;
Techniques that restrict an individual’s ability to communicate;
Use of time-out or other disciplinary action for staff convenience; and 8. Chemical restraints—use of a medication to sedate or limit an individual’s ability to participate in services/supports rather than treat the symptoms of his or her behavioral health disorder or IDD as prescribed and specified in the ISP, ITP, or care plan. Medication used as prescribed and as indicated in the individual’s plan to treat symptoms of a behavioral health disorder or IDD, including aggressive behavior, is not considered a chemical restraint.

(F) Preventive strategies including, but not limited to, de-escalation, changes to the physical environment (time-away), redirection, and active listening shall be employed to moderate potentially aggressive behavior.

(G) Seclusion and restraint shall only be used when an individual’s behavior presents an immediate risk of danger to themselves or others and no other safe or effective treatment intervention is possible. These measures shall only be implemented when alternative, less restrictive interventions have failed or cannot be safely implemented. Seclusion and restraint are never used as treatment interventions. They are emergency/security measures to maintain safety when all other less restrictive interventions are inadequate.

(H) The use of seclusion or restraint shall be in accordance with the order of the program’s attending physician or clinical director. Staff shall notify the attending physician or clinical director at the earliest possible time when a situation has a significant likelihood of leading to seclusion or restraint.

If seclusion or restraint is initiated prior to obtaining an order, staff must obtain an order immediately.

(I) Standing or pro re nata (PRN) orders for seclusion or restraint are not allowed.

(J) Orders for seclusion or restraint shall be individualized to each event, define specific time limits, and be ended at the earliest possible time. Orders shall not exceed four (4) hours for adults, two (2) hours for children/youth age nine (9) to seventeen (17), and one (1) hour for children under age nine (9). If there is a need for continuing seclusion or restraint beyond the time limits specified herein, the attending physician or clinical director must write a new order for seclusion or restraint.

(K) Seclusion and restraint shall only be implemented by staff who are trained and competent in the proper techniques for administering/applying the form of seclusion or restraint ordered, and for providing ongoing monitoring and assessment of individuals for their safety and well-being. At a minimum, documented initial and ongoing training shall include:

Techniques to identify individual behaviors, events, and environmental factors that may trigger circumstances requiring the use of seclusion or restraint;
The use of nonphysical intervention skills;
Choosing the least restrictive intervention based on an individualized assessment of the individual’s medical and/or behavioral status or condition;
The safe application and use of all types of seclusion or restraint used by the program, including how to recognize and respond to signs of physical and psychological distress;
Clinical identification of specific behavioral changes that indicate restraint or seclusion is no longer necessary;
Monitoring the physical and psychological well-being of the individual who is secluded or restrained, including, but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified in the program’s policies and procedures associated with face-toface evaluations; and 7. The use of first aid techniques and certification in CPR, including required periodic recertification.

A. Staff administering seclusion or restraint shall receive annual training and demonstrate competence on the particular intervention(s) ordered and used in the pro- (L) Mechanical supports are not considered restraints.

(M) While an individual is being secluded or restrained, trained staff shall continually observe and assess him or her to assure appropriate care and treatment including, but not limited to:

Attention to vital signs;
Need for meals and liquids;
Bathing and use of the restroom; and 4. Need for seclusion or restraint to continue.

(N) Documentation of an order for seclusion, restraint, or time-out shall be placed in the individual record as soon as possible after the occurrence and include, but not be limited 1. Reason for the intervention;

Staff who ordered the intervention;
Type of intervention used;
Starting and ending time;
Regular observations of the individual including any resulting injuries or other issues as a result of the intervention;
Notification of parent/guardian, as applicable;
Notification of healthcare provider, as applicable; and 8. Modifications to the ISP, ITP, or care plan as a result of the intervention.

(O) The program’s clinical director and/or performance improvement coordinator shall review every episode of seclusion, restraint, or time-out to ensure policies and procedures were followed and to identify any areas needing improvement. A written report on the program’s overall use of these interventions, including progress made in reduction of their use, shall be prepared at least annually and reviewed by administrative leadership of the organization/program.

(8) Behavior Support Plans. Behavior support plans shall be developed as specified in

9 CSR 10-7.060 and 9 CSR 45-3.090. {#sec-9-csr-10-7.060 omnilex-key=us-mo-regs-official--title-9--9 CSR 10-7.060}

9 CSR 40-1.065 Individual Rights and Responsibilities {#sec-9-csr-40-1.065 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-1.065}

PURPOSE: This rule specifies the rights and responsibilities of individuals receiving services in a community residential program or day program subject to licensure by the department in accordance with 9 CSR 40- 1.055, including Residential Care Facilities (RCF) and Assisted Living Facilities (ALF) dually licensed by the Department of Health and Senior Services (DHSS).

(1) Each individual receiving services is entitled to the following without limitations:

(A) To humane care and treatment;

(B) To medical care and treatment in accordance with the highest standards accepted in medical practice to the extent available at the community residential program or day (C) To safe and sanitary housing;

(D) To not participate in nontherapeutic labor;

(E) To attend or not to attend religious ser- (F) To receive prompt evaluation, care, treatment, and rehabilitation about which he/she is informed insofar as he/she is capable of understanding;

(G) To be treated with dignity as a human being;

(H) To not be the subject of experimental research without his/her prior written and informed consent or that of his/her parent or guardian, and to decide not to participate or withdraw from any research at any time, for any reason;

(I) To have access to consultation with a private physician at his/her own expense;

(J) To be evaluated, treated, or habilitated in the least restrictive environment;

(K) To not be subjected to any hazardous treatment or surgical procedure unless the individual or his/her parent or guardian consents, or unless such treatment or surgical procedure is ordered by a court of competent jurisdiction;

(L) In the case of hazardous treatment or irreversible surgical procedures to have, upon request, an impartial review prior to implementation except in case of emergency procedures required for the preservation of his/her life;

(M) To a nourishing, well-balanced, and varied diet;

(N) To be free from verbal, physical and sexual abuse, misuse of funds/property, and neglect; and (O) To an impartial review of alleged violations of rights.

(2) Each individual served is entitled to the following unless the program director determines it is inconsistent with the individual’s therapeutic care, treatment, habilitation, or rehabilitation and the safety of other individuals in the program and public safety:

(A) To wear his/her own clothes and keep and use personal possessions;

(B) To keep and be allowed to spend a reasonable amount of his/her own money;

(D) To receive visitors (family, friends, clergy, or other invited person) of his/her choice at reasonable times;

(E) To have reasonable access to a telephone to make and receive confidential calls;

(F) To have access to his/her mental health and physical health records;

(G) To have opportunities for physical exercise and outdoor recreation; and (H) To have reasonable, prompt access to current newspapers, magazines, radio, and television programming.

Any limitation(s) imposed by the program director or designee, including the reason(s) for such limitation(s), must be documented in the individual record.

(3) In addition to the rights specified in sections (1) and (2) of this rule, residential programs and day programs serving individuals with Intellectual or Developmental Disability (IDD) shall comply with 9 CSR 45-3.030.

(4) Policies and procedures shall not be developed that limit the individual rights identified in this rule.

(A) Each individual shall be involved in any process that limits his/her rights, and any limitations must be documented in the Individual Support Plan (ISP), Individual Treatment Plan (ITP), or care plan. Documentation shall include the timeframe for each limitation and the process by which the individual’s rights will be restored to him/her.

(5) As set out in section 630.760, RSMo, in addition to rights provided for individuals served in residential facilities or day programs licensed by the department, individuals in facilities and programs licensed by the department shall have the same rights as individuals as defined in section 198.088, RSMo.

(6) Individuals shall have an absolute right to receive visits from their attorney, physician, clergy, or case manager in private at reasonable times.

(7) Notwithstanding any limitations authorized under section (2) of this rule on the right of communication, all individuals shall be entitled to communicate by sealed mail with the department, their legal counsel, and with the court, if any, which has jurisdiction over the individual.

(8) As set out in section 630.120, RSMo, no individual, either voluntary or involuntary, shall be presumed to be incompetent, to forfeit any legal right, responsibility, or obligation or to suffer any legal disability as a citizen, unless otherwise prescribed by law, as a consequence of receiving evaluation, care, treatment, habilitation, or rehabilitation for a mental illness, intellectual or developmental disability, or substance use disorder.

(9) Each individual shall be informed of the process to make an inquiry, file a complaint, or report a violation of his/her rights to the department. Information shall be readily accessible to individuals at all times with staff assistance provided, if necessary.

(10) The individual rights included in this

rule shall be readily available in accessible format to all individuals served without undue assistance or effort from program staff.

(11) Services shall be provided in a manner and an environment that maintains or enhances each individual’s dignity and respect in full recognition of his/her individuality. Staff shall conduct activities in a manner that assists individuals in maintaining and enhancing their self-esteem and self-worth.

(A) Case discussions, consultations, examinations, and treatment are confidential and shall be conducted privately with each individual being served.

(B) Privacy shall be respected during toileting, bathing, and other activities of personal hygiene except as needed for safety or assistance.

(C) Each individual’s private space and property shall be respected including, but not limited to, obtaining his/her permission before changing a radio or television station, knocking on doors and requesting permission to enter, closing doors as requested, and not moving or inspecting personal possessions without permission unless there is reasonable suspicion of a health or safety concern.

(D) Individuals shall be allowed to decorate their personal space to create a homelike environment in accordance with safety regulations of the program.

(E) When possible, individuals shall have a choice in their roommate and, based on financial means and availability, be allowed to choose a shared or private room.

(F) As appropriate and allowed by the individual served, family members and other natural supports and/or parents/guardian shall be provided with information to promote their participation in relevant services/supports and decisions related to the individual.

(12) Information and Orientation. Each individual admitted to a residential program or day program shall receive an orientation about what to expect while receiving services and supports, their role in services/supports, and program policies and procedures. The orientation must be provided within one (1) week of admission, and annually after that, and be documented in the individual record.

(A) The orientation shall be provided in verbal and written form and be explained in a manner that is understandable to the individual. The orientation shall include, but is not limited to— 1. Program rules, daily routines, participation requirements, rights, responsibilities, and behavioral expectations;

Available services, supports, and activities;
Complaint and appeal procedures;
Confidentiality policies;
Transition and discharge criteria and 6. Financial obligations, fees, and financial arrangements for services/supports provided by the program;
Health and safety policies regarding use of tobacco products, illegal or legal substances brought into the program, prescription medication brought into the program, and weapons and ammunition brought into the program;
Layout of the premises, including emergency exits and/or shelters, and review of fire and disaster drill procedures;
Visitor policies and procedures;
Advance directives, when indicated;
The individual’s role in developing his or her ISP, ITP, or care plan.

(13) Social Committee. Residential programs and day programs having a licensed capacity of ten (10) or more individuals shall establish a committee, if one (1) does not currently exist, to review existing and planned social and structured activities for the program.

(A) The committee shall regularly review program policies and practices to ensure the legal rights of individuals served are consistently maintained.

(B) Membership on the committee shall include, at a minimum, individuals with mental illness and IDD, and program staff familiar with and able to make decisions related to program activities/functions. Family members or other natural supports, service providers, and other community members may participate on the committee. Minutes of committee meetings shall be readily available for review by individuals served, other interested parties, and department staff or its authorized representatives.

(14) Guardian. No facility or day program administrator shall be guardian of the individuals in the facility or day program as stipulated in section 475.055, RSMo.

9 CSR 40-1.070 Organized Record System {#sec-9-csr-40-1.070 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-1.070}

PURPOSE: This rule specifies the requirements for maintenance of records in all community residential programs and day programs subject to licensure by the department in accordance with 9 CSR 40-1.055, including Residential Care Facilities (RCF) and Assisted Living Facilities (ALF) dually (1) Maintenance of Records. An organized record system shall be maintained at the residential program or day program which ensures easily retrievable, complete, and usable records stored in a secure and confidential manner.

(A) The program shall implement written policies and procedures to ensure— 1. All local, state, and federal laws and regulations related to the confidentiality of records and release of information are followed;

Electronic health record systems conform to federal and state regulations;
Individual records are retained for at least six (6) years or until all litigation, adverse audit findings, or both, are resolved;
Ready access to paper or electronic records requested by department staff and other authorized representatives; and 5. Services are documented in a manner to ensure the type of service rendered and the amount of reimbursement received by the program can be readily discerned and verified with reasonable certainty.

(2) Registry. The program shall maintain a permanent, chronological registry documenting the date and name of each person admitted, date of discharge, and destination at time of discharge.

(3) Content of Records. Individual records must include current information related to each individual’s support and services.

Records must be readily available for review by department staff or other authorized representatives.

(A) Individual records must include, but are not limited to:

First name, last name, and middle initial;
Date of birth;
Photograph, not more than one (1) year old;
Height and weight;
Language spoken;
Date of admission;
Diagnosis;
Signed consent by the individual or parent/guardian or other legal representative, as applicable;
Acknowledgment of orientation to the 10. Name, address, and telephone number of parent/guardian, next of kin, or other responsible party;
Sources of financial support/insurance and burial plans, as applicable;
Name and contact information of healthcare provider(s);
Reports of any change in condition, injury, accident, or deviation from routine delivery of services (to be entered at the time of occurrence);
Documentation of any referral(s) to other services or community resources and outcome of those referrals;
Reports of comprehensive evaluations and annual physical examinations including vision, hearing, dental, and/or laboratory screenings recommended by the individual’s primary healthcare provider, and current immunization record;
Signed authorization(s) to release confidential information, as applicable;
Crisis or other significant events;
Physician’s orders for adaptive equipment, as applicable;
Individualized education plan (IEP) and school record, if attending;
Plans for educational/vocational goals and activities, as applicable;
Quarterly height, if the individual is in a developmental period, and monthly weight; and 22. The Individual Support Plan (ISP), Individual Treatment Plan (ITP), or care plan, including documentation related to behavioral objectives and related progress.

(4) Entries in Records. Authorized staff making any entry in an individual’s record must include his or her signature, title, and date, including corrections to information previously entered in the record.

(5) Consultation Services. Any required consultation services that are reimbursed by the department must be documented in the individual record, including the consultant’s findings and recommendations. Recommendations regarding the program as a whole must be documented in the program’s administrative records.

(6) Proof of Licensure. The department’s most recent licensing report, including any noted license violations or deficient practices and related corrective action taken by the program, shall be displayed in accessible public areas on the program premises.

(7) Inventory of Personal Items. At the time of admission and at regular intervals, program staff shall inventory each individual’s personal possessions, if applicable.

Separate records with backup documentation, receipts, and notations shall be maintained for— (A) Personal finances, updated monthly, at a minimum;

(B) Inventory of personal possessions, updated annually; and (C) Medication, upon admission and as required in 9 CSR 40-1.075.

(8) Drills. A record of scheduled and unscheduled emergency drills shall be maintained at the program. The record shall include any problems encountered on the part of staff or individuals served to respond properly during the drill and corrective action taken.

(9) Personnel Records. Personnel records shall be maintained for all program employees. Records must be readily accessible to department staff and other authorized representatives.

(A) Employee records shall include, but are not limited to:

Application for employment;
Education and license/certification, as required for the position;
Verification of completion of training courses, orientation, and other professional development;
Background screening; and 5. Screenings for communicable diseases.

(10) Organizational Chart. An organizational chart for the overall program and job descriptions for each position shall be maintained by the program.

(11) Work Schedule. A record of days and hours worked by each employee shall be maintained at the program location.

(12) Program Departures. A log shall be maintained to document when an individual being served leaves the program premises.

The log shall include the individual’s name and signature (or the name and signature of the family member/legal representative with whom they are departing the premises), departure time, destination, anticipated return time, and actual return time to the pro- (13) Availability of Records. Program records, reports, or other data shall be made available to department staff or its authorized representatives, upon request, in a manner that protects the rights of staff and individuals served.

9 CSR 40-1.075 Person-Centered Services {#sec-9-csr-40-1.075 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-1.075}

PURPOSE: This rule specifies the service delivery requirements for all community resiwith 9 CSR 40-1.055, including Residential Care Facilities (RCF) and Assisted Living Facilities (ALF) dually licensed by the Department of Health and Senior Services entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this

rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no ial. The entire text of the rule is printed here.

(1) Person-Centered Planning. Each individual being served in a residential program or day program who has a diagnosed mental illness and/or Intellectual or Developmental Disabilities (IDD) must have a plan to guide service delivery and coordinate resources and supports in accordance with his or her needs, expressed preferences, and decisions concerning his/her life in the community.

(A) Types of plans— 1. Individual Support Plan (ISP)—developed as defined in 9 CSR 45-3.010; a copy is provided to the residential program or day program by staff of the Developmental Disabilities (DD) targeted case management team;

Individual Treatment Plan (ITP)— developed by the individual served and/or his or her parents/guardian, with assistance from staff of the administrative agent or affiliate involved in his or her care and treatment; a copy is provided to the residential program or day program by staff of the administrative agent or affiliate; and 3. Care Plan—for individuals who do not have an ISP or ITP, developed by the individual served and/or his or her parents/guardian with assistance from staff of the residential program or day program, family members, and other natural supports of his/her choice.

A. Care plans shall be developed within thirty (30) days of an individual’s admission to a residential program or day program. If the individual already has a care plan, the plan shall be updated within thirty (30) days of admission to create action steps to support implementation of the plan and add any new services or supports needed.

B. The care plan shall include measurable goals and objectives important to the individual such as, self-sufficiency, community membership and involvement, education and employment, leisure time and activities, health and wellness, and personal relationships. The plan assists the individual in achieving personally defined outcomes, ensures delivery of services and supports in a manner that reflect personal preferences and choices, and contributes to the assurance of health and wellness.

(B) Residential services and supports consistent with the individual’s needs and goals must be addressed in his/her plan. If the ISP, ITP, or care plan does not include services/supports specific to the residential program or day program, staff shall incorporate appropriate services/supports into the plan with input from the individual served and/or family members and other natural supports, as appropriate.

Staff of the residential program or day program enter monthly documentation into each individual’s ISP, ITP, or care plan including, at a minimum, progress toward personal goals, modifications to necessary services and supports, and significant changes in the person’s life, as applicable;
Quarterly and annual reviews and updates to the ISP or ITP are completed by staff of the DD case management team or administrative agent or affiliate respectively.

A copy is maintained on file at the residential program or day program; and 3. Care plans are updated at least annually by staff of the residential program or day program in collaboration with the individual served and/or his or her parents/guardian, family members, and other natural supports of his/her choice.

(D) Individuals shall be supported in their efforts to obtain and maintain competitive employment of their choice, participate in job-training programs, educational opportunities, self-help skills, leisure time activities, and other programs of their choice.

(E) Opportunities for a variety of activities inside and outside the program shall be available, consistent with the interests of individuals served.

(2) Health Screen and Risk Assessment.

Within thirty (30) days of transition into a residential program or day program, each individual served shall have verification in his/her record of having a health screening and risk assessment within the past year from their primary healthcare provider. The primary healthcare provider may be a physician, assistant physician, advanced practice registered nurse (APRN), or physician assistant.

(A) The health screening and any additional screenings or tests shall be directed by the individual’s primary healthcare provider.

(B) Individuals shall receive vision, hearing, and dental examinations as recommended by their primary healthcare provider.

(C) Individuals shall receive psychiatric evaluations and continuing care and treatment by a physician or physician’s designee of their choice, as needed.

(D)

Immunizations shall be current as recommended by DHSS 2020 immunization schedules incorporated by reference and available at: https://health.mo.gov/living/wellness/immunizations/schedules.php., MO Department of Health and Senior Services, 912 Wildwood, PO Box 570, Jefferson City, Missouri 65102, Phone: 573-751-6400. This amendments or additions to the schedules grams from complying with schedules set reference material listed in this subsection of (E) Individuals shall receive an annual health screening unless specified otherwise by their primary healthcare provider.

(F) A risk assessment shall be completed for each individual at the time of admission to the residential program or day program to identify factors that may influence his or her behavior. The assessment shall include, but is not limited to:

Suicide risk;
Risk of self-harm;
Risk of harm to others;
Physical, sexual, and/or emotional abuse experienced or witnessed;
History and presence of trauma symptoms; and 6. Aggressive or disruptive behavior.

(G) A safety crisis plan or crisis prevention plan shall be developed with individuals identified as having risk factors for harm to self or others. The plans must be readily accessible to all staff involved in the individual’s support.

Individuals with pro re nata (PRN) orders for antipsychotic medication(s) must have parameters for use in their safety crisis plan or crisis prevention plan, including nonpharmacological interventions.
PRN use of antipsychotic medication for individuals with a safety crisis plan or crisis prevention plan shall be reviewed quarterly by the individual’s primary healthcare provider.

(H) If an individual needs support with personal hygiene, grooming, telephone use, or other aspect of daily living, appropriate assistance shall be provided by staff and must be specified in his or her ISP, ITP, or care plan.

(I) Prompt healthcare, including dental treatment, shall be arranged for individuals receiving services in a residential program, as needed.

(3) General Healthcare and Medications.

Medications for individuals served shall be properly stored and administered by staff.

(A) An order from a licensed physician (including psychiatrist) or an assistant physician, physician assistant, or APRN who is in a collaborating practice arrangement with a licensed physician is required for all medication and treatment being administered to individuals in the program except nonprescription topical medications. Orders must include diagnosis and indications for use.

(B) Each individual’s record shall include current orders from all healthcare providers and all orders shall be followed by staff.

(C) Medication and treatment orders shall be reviewed as directed by the individual’s primary healthcare provider, and all reviews must be documented at least annually in the individual record. Orders do not need to be rewritten if there are no changes; the healthcare provider’s signature and date are sufficient.

(D) PRN orders for antipsychotic medication(s) must be documented in the individual’s record with parameters for use, including non-pharmacological interventions.

(E) Standing PRN orders for the entire residential program or day program are not permitted.

(F) PRN orders for nonprescription medication and treatment may be utilized if the individual’s primary healthcare provider’s order specifies the dosage and/or treatment for specific indications.

(G) In an emergency, a healthcare provider may give or change an order by telephone. In such cases, the order must be signed by the healthcare provider within forty-eight (48) hours of the order being issued by telephone.

(H) For individuals under the care of multiple healthcare providers, all medical orders shall be maintained together in the individual record.

(I) Individuals shall be provided with a comprehensive list of their medications to take to healthcare and dental appointments.

(J) Any special dietary needs must be included in the individual’s orders from their primary healthcare provider.

(4) Administration of Medication. A safe and effective process for medication control and use shall be implemented and maintained by staff.

(A) All medication administered to individuals served must be in accordance with their primary healthcare provider’s orders using acceptable nursing practices.

(B) Staff who administer medication must be at least eighteen (18) years of age.

(D) All staff who administer and/or observe self-administration of medication by individuals served, with the exception of licensed physicians, nurses, pharmacists, assistant physicians, and physician assistants, must comply with one (1) of the following prior to the provision of services:

Complete training and remain in good standing as a Level I Medication Aide or Certified Medication Technician with DHSS as specified at: https://health.mo.gov/safety/cnaregistry/lima .php; or 2. Complete Medication Aide training in accordance with curriculum established by the Division of Developmental Disabilities as specified in 9 CSR 45-3.070, available at: https://www.sos.mo.gov/cmsimages/adrules/csr/current/9csr/9c45-3.pdf.

A. Medication Aides must update and document their training every two (2) years.

(E) At least one (1) staff person trained in medication administration must be on duty in the residential program or day program twenty-four (24) hours per day, seven (7) days per week.

(F) Self-administration of medication is allowed and must be supervised by staff trained in medication administration.

If an individual self-administers medication, it must be included in his or her primary healthcare provider’s orders and his/her ITP, ISP, or care plan, including the level of supervision and documentation required.

Self-administration of medication should be encouraged, and individuals should be assisted in learning how to safely manage their medications.

(G) Errors in administration of medication must be reported immediately to the individual’s primary healthcare provider, parent/guardian, if applicable, and to the department as specified in 9 CSR 10-5.206.

(5) Storage and Disposal of Medication. All medications, including over-the-counter medications, must be packaged and labeled in accordance with applicable professional pharmacy standards and state and federal drug laws.

(A) All prescription medications shall be supplied as individual prescriptions except when an emergency medication supply is allowed.

(B) Labeling of medications must include accessory and cautionary instructions, expiration date, when applicable, and the name of the medication as specified in the primary healthcare provider’s order. Over-the-counter medications must be labeled with at least the individual’s name. Medications shall not be repackaged or altered by staff except as allowed when an individual temporarily leaves the program premises.

The program shall have policies and procedures for family members and other natural supports and/or legal representative to provide adequate advance notice so prescription medication can be provided in a separate container by the pharmacy when an individual will be leaving the program for an extended period.

Schedule II-V medications must be stored separately from other medications under double lock;
Internal and external medications must be stored separately; and 3. Medications requiring refrigeration must be stored in a locked container separated from food.

(D) Controlled medications must be documented on a medication administration record and controlled substance count sheet in accordance with state and federal regulations.

(E) Stock supplies of nonprescription medication may be kept in the program when specific medications are approved in writing by a consulting physician, registered nurse, or pharmacist.

(F) Unused, discontinued, outdated, or deteriorated prescription and over-thecounter medications must be properly disposed of in accordance with DHSS regulation 19 CSR 30-86.042(60), available at: https://www.sos.mo.gov/cmsimages/adru les/csr/previous/19csr/19csr1012/19c30- 86.pdf.

Medications shall be destroyed within the program by a pharmacist and a licensed nurse or by two (2) licensed nurses. When two (2) licensed nurses are not available, medications must be destroyed by two (2) staff who have authority to administer medications, one (1) of whom is a licensed nurse or a pharmacist.
A record of all destroyed medications must be maintained at the program and include the individual’s name, date, medication name and strength, quantity, prescription number, and signatures of staff destroying the medication.
A record of medications released or returned to a pharmacy must be maintained by the program and include the individual’s name, date, medication name and strength, quantity, prescription number, and signature(s) of the staff who received and released the medications.

(6) Equipment. Medical equipment and firstaid supplies needed to treat simple emergencies must be maintained in operable condition and be available at the program at all times.

If the program has medical and nursing equipment, it must be maintained in operable condition and stored so it is reasonably accessible and used only for the purpose intended.

(7) Isolation. If a healthcare provider recommends an individual with a contagious or infectious disease be placed in isolation, staff of the program shall ensure the recommendation is implemented immediately.

(8) Personal Supports. Staff of the program shall ensure individuals have access to clean clothing and personal care items, as needed.

(A) Each individual shall have an adequate supply of properly-fitting, age-appropriate clothing that is neat, clean, seasonable, and suitable to the occasion. Identification on clothing should be discreet.

(B) Each individual shall have his/her own toothbrush, toothpaste, washcloth, towel, comb or hairbrush, or both.

(C) Shaving equipment shall be provided, as needed, in accordance with the ISP, ITP, or care plan of the individual served.

(D) Personal hygiene items shall be stored to maintain sanitary conditions and prevent the transmission of communicable disease.

(E) Individuals shall be trained and supported in developmental and self-help skills to include dressing, grooming, toileting, bathing/showering, and hygiene, as needed.

(F) Individuals shall be trained and supported in eating skills and the use of adaptive equipment in accordance with their individual needs.

9 CSR 40-1.080 Dietary Services {#sec-9-csr-40-1.080 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-1.080}

PURPOSE: This rule specifies the dietary service requirements for all community resiwith 9 CSR 40-1.055. This rule does not apply to Residential Care Facilities (RCF) and Assisted Living Facilities (ALF) dually rial. The entire text of the rule is printed (1) Meal Preparation and Food Storage. The program must comply with state, county, and city health regulations applicable to its food and dietary components, including catered food through a contractual arrangement and food brought to the program by individuals served. Inspections must be current and in compliance with state, local, and/or city regulations and available on site.

(A) All food must be purchased, prepared, and stored in accordance with safety and sanitation regulations of the DHSS Missouri Food Code, 19 CSR 20-1.025, available at: https://health.mo.gov/safety/foodsafety/pdf/ missourifoodcode.pdf.

(B) All programs shall ensure— 1. Proper diet and food preparation are addressed as part of the individualized planning process, if identified as a need or goal of the individual.

A. Individuals who prepare their own meals or help with meal preparation shall be assisted by staff, as needed.

B. Individuals shall be assisted and educated about purchasing and safely storing food and drinks in a manner that prevents spoilage and contamination.

C. Individuals shall be supported in developing meal plans and grocery lists and educated and assisted by staff, as needed, in order to meet any special dietary requirements;

A sufficient number of appliances and equipment are available for food preparation including, but not limited to, a stove and refrigerator, dishes, cookware, and utensils to meet the needs of individuals served. All equipment must be in safe and good operating condition and food preparation areas, appliances, and equipment are cleaned and sanitized after each use;
Meals and snacks are served in a clean dining area with tables, chairs, eating utensils, and dishes designed and provided to meet individual needs;
Handwashing accommodations including hot and cold water, soap, and hand-drying are readily accessible to individuals and staff;
The temperature of hot water at all faucets accessible to individuals served must be controlled by a thermostatic mixing valve or other means, so the water temperature does not exceed one hundred twenty degrees Fahrenheit (120 ° F);
Dishwasher(s) shall be supplied with an adequate amount of wash and rinse water at one hundred forty degrees Fahrenheit (140 ° F) at a minimum. A three- (3-) vat sink in lieu of a dishwasher may be used based on the size of the program;
If a three- (3-) vat sink is used, it must be of sufficient depth and size to accommodate utensils most frequently used in the preparation and serving of food;
If hot water is temporarily unavailable, chemicals used for sanitizing equipment, dishes, and utensils shall be used in accordance with the Environmental Protection Agency (EPA) registered label use instructions, 1200 Pennsylvania Avenue, N.W., Washington, DC 20460 available at: https://www.epa.gov/pesticideregistration/selected-epa-registered-disinfectants and in accordance with the Missouri Food Code, 19 CSR 20-1.025, available at: https://health.mo.gov/safety/foodsafety/pdf/ missourifoodcode.pdf. It is recommended that single-use, disposable dishes/utensils and prepared foods be used if hot water is not available. Larger cooking equipment may be washed with the EPA-registered label sanitizer product and be air dried; and 9. Programs serving ten (10) or more individuals must provide a place for handwashing adjacent to work areas that includes hot and cold water, soap, paper towels, or electrical hand-drying devices.

(2) Balanced Diet. A balanced variety of healthy foods and drinks, with opportunities for choice, shall be available to individuals each day.

(A) Meals and snacks shall be based on the Dietary Guidelines for Americans 2015-2020, 8th Edition, incorporated by reference and published in the Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, 1101 Wootton Parkway, Suite LL100, Rockville, MD 20852, available at https://health.gov/dietaryguidelines/2015/guidelines/. This rule does not additions to the guidelines listed above. This plying with guidelines set forth in newer versions of the incorporated by reference material listed in this subsection of this rule.

(B) Meals and drinks shall be prepared and served at scheduled times, comparable to mealtimes in the community, or as necessary to meet individual needs and schedules.

Ready access to nutritious snacks shall be available, including in the evening.

(C) Meals and drinks shall be prepared and served at proper temperatures to conserve nutritive value and enhance flavor and appearance.

(D) Documented consultation with a licensed dietitian or registered nurse must take place at least annually for individuals with special diets.

(E) Milk provided to individuals served must be Grade A pasteurized milk or Grade A certified, pasteurized milk.

(F) Cool, safe drinking water approved by the state or local public health authority must be available to individuals at all times. Single-serving cups or glasses shall be available for individuals unable to drink from a water fountain.

(G) Consideration shall be given to the food habits, personal, cultural, and religious preferences, and medical needs of individuals served, including provisions for special diets for medical reasons.

(H) When individuals require blended food, program staff shall prepare, measure, and serve it individually, not mixed together.

(I) The consistency and texture of food shall meet each individual’s needs. Individuals shall not be fed in a prone position.

(J) Individuals requiring liquid or soft diets shall be provided with nourishing, supplementary food between meals to meet their nutritional needs.

(K) Meals may be served family style to provide a home-like atmosphere.

(L) Individuals served shall have the opportunity to participate in planning menus and options for food substitutions. Menus should be developed at least one (1) week in advance.

(M) Menus covering at least a three- (3-) month time period shall be available for review by department staff or other authorized representatives.

9 CSR 40-1.085 Environment {#sec-9-csr-40-1.085 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-1.085}

PURPOSE: This rule specifies the environmental requirements for all community resiwith 9 CSR 40-1.055. This rule does not apply to Residential Care Facilities (RCF) and Assisted Living Facilities (ALF) dually rial. The entire text of the rule is printed (1) Physical Environment. All residential programs and day programs shall be in compliance with applicable state and local building codes, fire codes, and ordinances to ensure the health, safety, and security of all individuals.

(A) The physical environment shall— 1. Be clean, structurally sound, and attractive inside and out;

Have solid, skid-proof floors that are free from tripping hazards and, unless carpeted, have a smooth finish;
Have ceilings at least seven feet, six inches (7'6") in height in all rooms used by individuals served. Allowances may be made by Division of Fire Safety staff for the installation of ductwork and plumbing. No more than forty percent (40%) of the ceiling in each room shall be below minimal height, with no portion of the ceiling lower than six feet, eight inches (6' 8");
Be equipped with a functional heating and air conditioning system with room temperatures maintained to meet the reasonable comfort needs of individuals served;
Be free of noxious odors;
Have control measures to prevent rodent and insect infestation;
Have windows, doors, and vents for ventilation and temperature control that operate as designed and are maintained to repel rodents and insects;
Comply with Department of Housing and Urban Development (HUD) 2017 Lead- Based Paint Regulations, 24 CFR Part 35, hereby incorporated by reference and available from HUD, 451 7th Street S.W., Washington, DC 20410, (202) 708-1112, TTY (202) 708-1455, available at: https://www.ecfr.gov/cgi-bin/textidx?c=ecfr&SID=e1741143a75841f15fcfd9 30d325ac2b&rgn=div5&view=text&node= 24:1.1.1.1.24&idno=24. This rule does not additions to the regulations listed above. This plying with regulations set forth in newer versions of the incorporated by reference material listed in this paragraph of this rule; and 9. Have adequate fencing around swimming pools, sewage lagoons, liquefied petroleum gas (LPG) tanks, and other potentially hazardous areas.

(B) Any relocation, construction of additional space, or remodeling of a currently licensed program must be in compliance with

9 CSR 40-1.055 subsection (6)(A). {#sec-9-csr-40-1.055 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-1.055}

(2) Modular Unit. A residential program or day program shall not be located in a modular unit as defined in section 700.010(8), RSMo.

(3) Manufactured Home. A residential program or day program may be located in a manufactured home as defined in section 700.010(6), RSMo. If a manufactured home is being used, documentation must be maintained on site indicating the home meets the HUD Manufactured Home Construction and Safety Standards, 24 CFR Part 3280, hereby incorporated by reference and is available from the U.S. Government Publishing Office, 732 N. Capital Street NW, Washington, DC 20401, (866) 512-1800 and at: https://www.ecfr.gov/cgi-bin/textidx?SID=a2c5655a37054c584f7dd6a0ed240 fb8&node=pt24.5.3280&rgn=div5. This reference material listed in this section of this (4) Accessibility. Residential programs and day programs serving individuals with physical disabilities must be barrier free and have grab bars, ramps, railings, or other means of accessibility that are maintained to function properly and comply with the 2010 Americans with Disabilities Act Standards for Accessible Design, hereby incorporated by reference and developed by the U.S. Department of Justice, 950 Pennsylvania Avenue NW, Washington, DC 20530-0001, (202) 514-2000 and available at: ments or additions to the standards listed from complying with standards set forth in ence material listed in this section of this (5) Bedrooms. Individuals receiving services in a residential program shall be provided with a bedroom to meet their specific needs.

(A) All bedrooms shall— 1. Provide at least sixty (60) square feet of floor space per individual in multiple sleeping rooms, and at least eighty (80) square feet of floor space per individual in single sleeping rooms;

Have no more than four (4) individuals in a shared room, except behavioral health community residential programs shall have no more than one (1) individual per room as specified in 9 CSR 40-4.001;
Have at least one (1) outside window for evacuation purposes that complies with state and local fire safety codes. Windows shall operate as designed, without the use of tools to open or close, provide full visual access to the outdoors, have a clear opening of not less than twenty inches (20") in width and twenty-four inches (24") in height, and be no more than forty-four inches (44") above the finished floor. Any latching window device must be operable from not more than fifty-four inches (54") above the finished floor;
Have a floor level which is no more than three feet (3') below the outside grade on the window side of the room;
Have a clean and comfortable pillow, mattress, and bed. Cots, convertible beds, and bunk beds shall not be used. Hospital beds may be used in accordance with an order from the individual’s primary healthcare provider. Each individual’s mattress shall be at least as long as his/her height with the exception of individuals in the developmental period, in which case the mattress shall be at least four inches (4") longer than his/her height;
Have furnishings in good operating condition for each individual including, at a minimum, a chair (with the exception of individuals using a wheelchair or those who prefer not to have a chair), closet space, a place for storage of personal items, and space for hanging pictures or wall decor;
Have clean sheets, pillowcases, mattress cover, bedspread, and blanket(s) to meet individual needs; and 8. Have an interior door for safety and privacy, unless staff supervision and monitoring are required as documented in the Individual Support Plan (ISP), Individual Treatment Plan (ITP), or care plan of the individual served. Locking devices for bedroom doors must comply with regulations of the 2018 National Fire Protection Association (NFPA) Life Safety Code 101, hereby incor- 02169-9101, (617) 770-3000 or 1-800-344- 3555, available at: www.nfpa.org. This rule ence material listed in this paragraph of this (6) Living Space. Programs shall have a living room and/or recreational area(s), kitchen, and dining area(s) with sufficient equipment, supplies, and furnishings to meet the needs of individuals served. Equipment and furnishings shall include, at a minimum, tables, chairs, sofas, and bookshelves to meet individual needs.

(A) Furnishings and equipment shall be clean and in good operating condition.

(B) All windows shall operate as designed, without the use of tools, and provide visibility to the outdoors.

(D) Areas designated as living/recreational space shall not be used as sleeping space.

(7) Bathrooms. Each residential program or day program shall have at least one (1) bathroom with at least one (1) toilet, one (1) sink with mirror, and one (1) tub or shower in good operating condition, including hot and cold running water, for each six (6) individuals being served.

(A) Bathrooms must have a window or other adequate ventilation and be designed to meet the needs of individuals served.

(B) For multi-stall bathrooms, separate bathrooms shall be available for each sex unless reasonable justification is provided to the department that this is not necessary.

(8) Water Supply. If the water supply is not that of the city or county in which the program is located, the water supply must meet the drinking water regulations promulgated by the Department of Natural Resources, 10 CSR 60.

(9) Electrical. The program’s electrical system must comply with all state and local regulations and the NFPA 2017 National Electrical Code, hereby incorporated by reference and available from NFPA, 1 Batterymarch Park, Quincy, MA 02169-9101, (800)-344-3555, available at: https://www.nfpa.org/NEC/electrical-codesand-standards. A written statement from a licensed electrician must be submitted to the department when the program applies for an initial license and whenever modifications are made, verifying the electrical system is in compliance with these regulations. This rule ence material listed in this section of this (A) Each program shall have sufficient lighting and electrical outlets to meet the needs of individuals served. Extension cords shall not be used.

(B) If surge protectors/power strips are used, they must be Underwriters’ Laboratory (UL) approved or comply with other recognized electrical appliance approval standards.

Surge protectors/power strips shall not be placed under rugs, in doorways, or other areas where they may present a tripping hazard or be subject to physical damage.

(10) Plumbing. The plumbing system in the program shall comply with all state and local regulations and the 2018 National Standard Plumbing Code, hereby incorporated by reference and developed by and available from the International Association of Plumbing and Mechanical Officials, 180 S. Washington St., Suite 100, Falls Church, VA 22046, (800) 533-7694, available at: https://www.phccweb.org/tools-resources/nspc/. A written statement from a licensed plumber must be submitted to the department at the time of the program’s initial application for licensure and whenever modifications are made, verifying the plumbing system is in compliance with these regulations. This rule does not incorporate any subsequent amendments or additions to the regulations listed above. This rule does not prohibit programs from complying with regulations set forth in newer versions of the incorporated by reference material listed in this section of this rule.

(A) Clean water must be distributed to all plumbing fixtures and wastewater must leave the building to an approved area without presence of sewer gas or backups.

(B) Plumbing fixtures and pipes must be free of leaks and threats to individual health and safety.

(C) Hot water must be thermostatically controlled so the water temperature does not exceed one hundred twenty degrees Fahrenheit (120°F).

(D) Water-heating equipment must be installed in accordance with the 2018 National Standard Plumbing Code and in a manner that does not present safety hazards to individuals served. Unless enclosed, water heaters shall not be located in bedrooms or living areas where safety hazards may exist. Fuel-burning equipment must be properly vented and have proper clearance from combustible materials.

(E) The program must utilize a public sewage system, if available. If a public sewage system is not available, a private sewage disposal system that complies with all local and state regulations and the requirements of the 2018 National Standard Plumbing Code, hereby incorporated by reference shall be used, developed by and available from the International Association of Plumbing and Mechanical Officials, 180 S. Washington St., Suite 100, Falls Church, VA 22046, (800) 533-7694, available at: https://www.phccweb.org/toolsresources/nspc/. This rule does not incorporate any subsequent amendments or additions to the regulations listed above. This rule does not prohibit programs from complying with regulations set forth in newer versions of the incorporated by reference material listed in this subsection of this rule.

(11) Telephones. An adequate number of telephones, appropriate to the needs of individuals being served in the program, must be reasonably accessible and located to allow individuals to make and receive private calls. Free local telephone access shall be available for individuals to contact their healthcare providers or other service providers such as behavioral health, developmental disabilities, housing, employment, and educational resources.

(A) Cellular phones may be used when all of the following conditions are met:

The phone must always have a signal;
The phone must always be charged;
The phone is set up to allow individuals to make and receive normal calls;
The phone must remain in the program at all times; and 5. The emergency plan for the program must address the use of cellular phones.

(B) Telephone numbers for the local fire department, police and/or sheriff’s department, Access Crisis Intervention, Missouri Adult Abuse and Neglect Hotline, National Suicide Prevention Lifeline, and department’s Office of Constituent Services shall be readily accessible where telephones are located.

(C) The telephone number for each individual’s support team member(s) or administrative agent/affiliate staff shall be readily accessible to individuals served and staff in the program.

(12) Safety Risks. Hazardous flammable or combustible materials, toxic cleaning supplies, sharp objects, and other items determined as potentially harmful shall be stored based upon the assessed safety needs of individuals being served in the program, as specified in their ISP, ITP, or care plan. These items must be inaccessible to individuals served if they are unable to handle them safely.

(A) Unless prohibited, firearms and/or ammunition on the premises or in vehicles shall be kept in a locked space or container that cannot be accessed by anyone other than the owner of the firearm and/or ammunition.

(13) Maintenance. The program director shall ensure there is a system in place for ongoing maintenance of the program premises.

(14) Transportation. Vehicles used by program staff to transport individuals served shall be properly registered, insured, and maintained. Vehicles shall have working seat belts and be accessible if used to transport individuals with physical disabilities. The agency shall comply with state and federal seat belt and car seat laws and regulations when transporting individuals served. Verification of a current driver’s license for all staff providing transportation must be maintained in personnel files.

(A) Program staff are responsible for the care, safety, and supervision of individuals served when they are transported from the operating site to other locations in the community.

(B) Staffing ratios shall be maintained at any time the program transports individuals away from its operating site.

9 CSR 40-1.090 Fire Safety and Emergency Preparedness {#sec-9-csr-40-1.090 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-1.090}

PURPOSE: The rule prescribes fire safety and emergency preparedness requirements for all residential programs and day programs subject to licensure by the department in accordance with 9 CSR 40-1.055. This rule does not apply to Residential Care Facilities (RCF) and Assisted Living Facilities (ALF) dually licensed by the Department of Health and Senior Services (DHSS).

rial. The entire text of the rule is printed (1) General Requirements. The program director shall ensure all local building codes, fire codes, and ordinances are followed and all hazard detection systems, alarm systems, and other safety equipment are maintained in proper operating condition. Practices shall be implemented to protect all individuals from fire, smoke, noxious fumes, and other safety hazards.

(A) Each residential program and day program shall be inspected at least annually by a Division of Fire Safety inspector. Initial and annual inspection reports must be maintained on site and be available for review by department staff and other authorized representatives.

(B) The 2018 regulations of the NFPA Life Safety Code 101 will prevail in the interpretation of these rules. The regulations are incor- 02169, (617) 770-3000 or 1-800-344-3555, available at: www.nfpa.org. This rule does not incorporate any subsequent amendments or additions to the regulations listed above.

This rule does not prohibit programs from complying with the regulations set forth in newer editions of the incorporated by reference material listed in this subsection of this (C) The program address must be posted on the outside of the building where it is plainly visible from the street with numbers/letters at least four inches (4") in height and contrasting color with the building.

(D) Evacuation routes, with diagrams giving clear directions on how to safely exit the building in a timely manner, must be posted in locations throughout the building that are easily accessible to individuals served, staff, and visitors.

(E) Staff shall demonstrate the knowledge and ability to implement the program’s emergency preparedness and evacuation plans and be trained and demonstrate the ability to operate the fire alarm system, fire extinguishers, and other safety devices. Training must be documented in personnel records, including date(s) and signature of trainer(s).

(F) A fire drill shall be conducted at least one (1) time per quarter, with a minimum of one (1) annual drill during sleeping hours.

All staff and individuals on each shift must participate in at least one (1) annual fire drill.

All drills must comply with the specifications of the posted evacuation plan.

(G) In addition to fire drills, staff and individuals served shall participate in other emergency drills at least quarterly and as specified in the emergency policies and procedures.

Individuals who are unable to react to emergency situations in a safe and expedient manner must have the supports necessary to implement their individual emergency plan.
Each drill must be documented and reviewed by staff responsible for execution of the emergency practices. Documentation shall include, but is not limited to, number of staff and individuals present during the drill, success of the drill or problems encountered, length of the drill, and corrective action taken, including training and education of staff and individuals served, as necessary.

(H) Hangings or draperies shall not be placed over exit doors or located where they conceal or obscure any exit.

(I) Stairways, sidewalks, ramps, and porches shall be kept clear of ice, snow, and any other obstacles that may be a potential fall or tripping hazard.

(J) Fresh-cut Christmas trees shall not be used unless they are treated with a flame resistant material and documentation of such is maintained on-site.

(K) Candles and other devices that have an open flame shall not be used indoors. Shortterm, supervised use of candles for special occasions or dinners is permitted.

(L) A program served by a volunteer or membership fire department shall maintain documentation of a current contract or proof of membership on-site.

(M) Staff shall notify the nearest fire department when the residential program or day program becomes operational and maintain the required signed documentation by the local authority (fire department notification form) on-site.

(N) Clothes dryers shall be properly maintained and vented to the outside, or as recommended by the manufacturer.

(O) Smoking shall not be allowed inside the program. At the discretion of the program director, designated outdoor smoking areas may be provided away from doors and windows. Supervision must be maintained based upon individual needs as documented in the Individual Support Plan (ISP), Individual Treatment Plan (ITP), or care plan.

(2) Hazard Detection, Alarms, and Extinguishment. All smoke detectors, carbon monoxide detectors, alarm systems, sprinkler systems, and adaptive alarm systems must be installed and maintained in accordance with the 2018 NFPA Life Safety Code 101, incor- 02169, (617) 770-3000 or 1-800-344-3555, available at: www.nfpa.org. Staff of the Division of Fire Safety may make additional requirements to provide adequate life safety protection if it is determined the safety of individuals is endangered. This rule does not additions to the regulations listed above.

This rule does not prohibit programs from complying with the regulations set forth in newer editions of the incorporated by reference material listed in this section.

(A) Fire detection and other emergency notification systems shall be maintained to sound an alarm that can be heard throughout the premises, above the noise of normal activities, radios, and televisions. Notification must be provided automatically without delay. Pre-signal systems are prohibited.

Staff of the Division of Fire Safety may make additional requirements to provide adequate life safety protection if it is determined the safety of individuals is endangered.

Adaptive emergency alarm systems must be installed if individuals who are deaf are being served in the program.

(B) At least one (1) portable, five pound (5 lb.) ABC-rated fire extinguisher, with directions for use on the equipment, must be located on each floor of the building including in or near every kitchen, storage room, furnace area, and other mechanical equipment rooms.

Additional fire extinguishers may be required by the local authority based on the floor plan and number of levels being used by individuals served so travel distance is no greater than seventy-five feet (75') between fire extinguishers.

All staff of the program must be knowledgeable on the location and use of the fire extinguisher(s).
Education provided to staff on the use of fire extinguishers must be documented and available on site, including date(s) and signature of trainer(s).
Fire extinguishers must be inspected and approved annually by a fire safety authority. Documentation of the inspection and approval, including date and signature of inspector, must be maintained on-site.

(C) Programs serving four (4) or fewer individuals must have at least one (1) certified Underwriters’ Laboratories, Inc. (UL) or Factory Mutual (FM) smoke detector on each floor in close proximity to bedrooms, hallways, living spaces, kitchen, storage rooms, offices, and any other areas deemed necessary by Division of Fire Safety staff.

If battery-powered smoke detectors are used, they must be tested monthly and batteries changed as needed. Documentation including the dates, testing, and changing of batteries must be maintained on site.
Smoke detectors that are ten (10) years old or older must be replaced with new smoke detectors of the same style. Date(s) of installation must be maintained on site.

(D) Programs serving five (5) or more individuals must have a full coverage electrical fire alarm system with battery backup, a master control panel, smoke detectors, heat sensors, and pull station. Horns and strobe lights connected to the fire alarm must be installed throughout the building(s). All equipment must be UL- or FM-certified and installed on a dedicated circuit in the breaker box.

The system must be tested, inspected, and approved semi-annually by an authorized inspector. A copy of the test report and approval of the system must be maintained on site.
Heat detectors shall be installed in all mechanical rooms, kitchens, and throughout the attic.
Smoke detectors that are connected to a fire alarm system must be replaced after ten (10) years of service or recalibrated by the manufacturer of the smoke detector. If the smoke detectors are recalibrated, temporary smoke detectors must be installed so the fire alarm system continues to function properly.

(E) In addition to having an electrical alarm system, programs serving five (5) or more individuals must have an automatic fire sprinkler system when any of the following conditions apply:

Individuals served use any floor above the second (2nd) floor of the building;
Individuals who require mechanical or staff assistance to evacuate the building use any floor above or below the first (1st) floor; or 3. Individuals use a floor below the level of exit discharge, such as a basement, which exceeds twelve hundred (1,200) square feet in total area.

A. The water supply for the sprinkler system may be a domestic water source, if the domestic water system is designed to adequately support the design flow of the largest number of sprinklers in any one area.

The automatic sprinkler system shall be installed and maintained in accordance with the 2019 NFPA Standards for Installation of Sprinkler Systems, NFPA, 1 Batterymarch Park, Quincy, MA 02169, (617) 770-3000 or 1-800-344-3555 incorporated by reference and available at: https://www.nfpa.org/codesand-standards/all-codes-and-standards/list-ofcodes-and-standards/detail?code=13. This 5. The sprinkler system shall be tested, inspected, and approved semi-annually by an authorized inspector. A copy of the test report and approval of the system shall be kept on file at the program for review by Division of Fire Safety staff, department staff, or other authorized representatives.

(F) Programs using a commercial stove, deep fryer, or two (2) home-type ranges placed side by side must be equipped with a range hood and extinguishing system with an automatic cutoff of the fuel supply and exhaust system in case of fire.

The hood and extinguishment system must be inspected by a qualified technician to ensure they are in good operating condition in accordance with the 2017 NFPA Standards for Ventilation Control and Fire Protection of Commercial Cooking Operations, incorporated by reference and available at NFPA, 1 Bat- 770-3000 or 1-800-344-3555, available at: https://www.nfpa.org/codes-andstandards/all-codes-and-standards/list-ofcodes-and-standards/detail?code=96. This 2. The range hood and extinguishment system shall be connected to the control panel of the fire alarm system. The activation of the range hood fire extinguishment system must cause the fire alarm system to activate throughout the building.
Home-type ranges separated by an eighteen inch (18") cabinet are not required to have an extinguishing system installed above them. Programs using a home-type range with no more than four (4) burners and/or grill are not required to have a fire extinguishing system above the range.

(G) Programs that have an attached garage and/or use gas utilities, equipment, or appliances that pose a potential carbon monoxide risk, shall install carbon monoxide detectors on each level of the building according to the 2018 NFPA Life Safety Code 101 and the recommendation of the local authority. The regulations are incorporated by reference and available from NFPA, 1 Batterymarch Park, Quincy, MA 02169, (617) 770-3000 or 1-800- 344-3555, and available at: www.nfpa.org.

This rule does not incorporate any subsequent amendments or additions to the regulations listed above. This rule does not prohibit programs from complying with the regulations set forth in newer editions of the incorporated by reference material listed in this subsection of this rule.

If an elevated carbon monoxide level is detected in a program during a fire inspection, all gas-fired appliances must be checked by a heating and air conditioning company to identify the source of the carbon monoxide.

Until program staff have documentation on file verifying all gas-fired appliances were checked by a heating and air conditioning company, are in safe working order, and the building(s) is determined safe by the local

If a level of carbon monoxide is determined that endangers the lives of individuals, the local authority shall take measures necessary to ensure their safety which may include evacuating or closing the program. Program staff shall obtain and maintain documentation on site verifying all gas-fired appliances were checked by a heating and air conditioning company and are in safe working order. The program must be reinspected by the local

(3) Means of Egress and Exits. Means of egress and exit from all buildings shall be maintained in accordance with the 2018 NFPA Life Safety Code 101. The regulations are incorporated by reference and available from NFPA, 1 Batterymarch Park, Quincy, MA 02169, (617) 770-3000 or 1-800-344- 3555, available at: www.nfpa.org. This rule from complying with the regulations set forth erence material listed in this section.

(A) All programs must meet the following requirements:

Each floor used by individuals served shall have at least two (2) remotely located means of exit. At least one (1) of these exits must lead directly outside at ground level, to an outside stairway, or to an enclosed stairway constructed of materials with at least a one- (1-) hour fire resistance rating on each level and an exit leading directly outside;
Each exit door shall be at least thirty inches (30") wide in existing licensed buildings and at least thirty-six inches (36") wide in buildings constructed after the effective date of these licensing rules;
All means of egress shall be free of items that would obstruct the path of travel;
Doors that serve as a means of exit shall not be locked or blocked against egress travel when the building is occupied. Door locks requiring a key, tool, special code, or knowledge to unlock from the inside shall not be used;
Overhead garage doors shall not be considered as exit doorways;
Mirrors shall not be placed on exit doors or adjacent to any exit in such a manner to confuse the direction of the exit;
All hallways must have a clear width of at least thirty-six inches (36") wide and be kept free of all articles that might impede an individual’s evacuation from the building, including wheelchairs, walkers, or other support equipment;
Dead-end hallways cannot exceed twenty feet (20');
No primary means of escape or planned exit shall lead through a bathroom, storage room, furnace room, garage, or any other room deemed hazardous by the local
All ramps must be accessible, safe, and installed in accordance with the 2010 Americans with Disabilities Act Standards for Accessible Design, established by the U.S. Department of Justice, Civil Rights Division, 950 Pennsylvania Avenue NW, Washington DC 20530, (800)514-0301, incorporated by reference and available at: ments or additions to the standards listed from complying with the standards set forth erence material listed in this paragraph of this

rule; and 11. Programs that have stairs, including stairs used as a fire escape, shall meet the requirements of the 2010 Americans with Disabilities Act Standards for Accessible Design, established by the U.S. Department of Justice, Civil Rights Division, 950 Pennsylvania Avenue NW, Washington DC 20530, (800) 514-0301, incorporated by reference and available at: tandards/2010ADAstandards.htm, the 2018 NFPA Life Safety Code 101, incorporated by reference and available from NFPA, 1 Bat- 770-3000 or 1-800-344-3555, available at: www.nfpa.org., and the local authority. This grams from complying with the standards set forth in newer editions of the incorporated by (B) Programs serving five (5) or more individuals shall meet the following requirements for means of egress and exit:

All outside exit doors must swing in the direction of egress travel;
All exit doors must be clearly marked and illuminated; and 3. Emergency lighting with battery backup shall be installed to light all paths of egress travel. The location and number of emergency lights shall be determined by the local authority. Emergency lights shall be tested monthly with documentation maintained on site indicating which lights were tested, the date tested, and the name and signature of the staff performing the test.

(C) Each wing or hallway in programs serving ten (10) or more individuals must be separated into fire compartment areas by fire doors and walls having not less than a one- (1-) hour rating. All fire doors shall be equipped with a door closer and may be held open at all times with an electrical magnetic switch that is interconnected to the fire alarm system.

(4) Appliances and Mechanical Equipment.

All heating, cooling, ventilation system(s), other mechanical equipment, and appliances shall be installed and maintained in accordance with manufacturer’s recommendations.

(A) Use of unvented fuel-fired room heaters, portable electric space heaters, and floor furnaces is not permitted.

(B) If wall heaters are used, they must be installed and approved by the local authority and include adequate guards.

Fireplaces used for decorative purposes shall be installed, operated, and maintained in a safe manner. The use of a woodor gas-burning fireplace is permitted only if the fireplace is built of firebrick or metal, enclosed by masonry, has a metal or tempered glass screen, and is inspected and approved by a local authority with documentation maintained on-site.
Fireplaces not in compliance with these requirements may be in the home if they are for decorative purposes only, or if they are equipped with decorative-type electric logs or other electric heaters which bear the UL label and are constructed of electrical components complying with and installed in compliance with the NFPA 2017 National Electrical Code, NFPA, 1 Batterymarch Park, Quincy, MA 02169-7471, (800) 344- 3555, incorporated by reference and available at: https://www.nfpa.org/NEC/electricalcodes-and-standards. This rule does not additions to the standards listed above. This plying with the standards set forth in newer editions of the incorporated by reference material listed in this paragraph of this rule.

(D) If the building has elevator(s), the elevator(s) shall be inspected annually by a state-licensed inspector and have a stateissued operating permit from the Division of Fire Safety available for review.

(5) Protection. Smoke stop partition(s) in all programs must comply with the requirements of the Division of Fire Safety and the 2018 NFPA Life Safety Code 101, NFPA, 1 Bat- 770-3000 or 1-800-344-3555, incorporated by reference and available at: www.nfpa.org.

section.

(6) Interior Finish. Interior finish in all programs must comply with requirements of the Division of Fire Safety and the 2018 NFPA Life Safety Code 101, NFPA, 1 Batterymarch Park, Quincy, MA 02169, (617) 770-3000 or 1-800-344-3555, incorporated by reference and available at: www.nfpa.org. This rule from complying with the regulations set forth erence material listed in this section.

History

authority, the fire inspection will not be approved.
authority and determined safe before individuals can return or the program can reopen.
authority;

9 CSR 40-1.100 Implementation of Licensure Authority for Certain Day Programs and Community Residential Facilities Emergency rule filed Sept. 20, 1983, effective Oct. 1, 1983, expired Jan. 15, 1984. {#sec-9-csr-40-1.100 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-1.100}

9 CSR 40-1.105 Implementation of Licensing Authority for Certain Day Programs and Community Residential Facilities {#sec-9-csr-40-1.105 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-1.105}

(Rescinded December 30, 2020)

RSMo 1994. Original rule filed Oct. 13, 1983, effective Jan. 15, 1984. Emergency amendment filed June 10, 1985, effective June 24, 1985, expired Oct. 7, 1985. Amended: Filed June 10, 1985, effective Oct. 8, 1985. Amended: Filed July 15, 1985, effective Feb. 1, 1986. Amended: Filed Jan. 2, 1990, effective June 11, 1990. Emergency amendment filed Feb. 2, 1990, effective Feb. 15, 1990, expired May 1, 1990. Amended:

Filed Feb. 2, 1990, effective Sept. 28, 1990.

Amended: Filed April 1, 1993, effective Dec. 9, 1993. Amended: Filed July 17, 1995, effective March 30, 1996. Amended: Filed Aug. 11, 1995, effective March 30, 1996.

Rescinded: Filed May 14, 2020, effective Dec. 30, 2020.

9 CSR 40-1.118 Licensing Advisory Board {#sec-9-csr-40-1.118 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-1.118}

(Rescinded November 30, 2018)

RSMo 1994. Original rule filed Aug. 4, 1987, effective Jan. 15, 1988. Amended: Filed April 14, 1988, effective Sept. 11, 1988. Emergency amendment filed March 30, 1990, effective April 15, 1990, expired Aug. 1, 1990.

Amended: Filed March 30, 1990, effective June 30, 1990. Amended: Filed July 17, 1995, effective March 30, 1996. Rescinded:

Filed March 20, 2018, effective Nov. 30, 2018.

Chapter 2 Rules for All Day Programs and Community Residential Facilities

9 CSR 40-2.010 Resident Rights {#sec-9-csr-40-2.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-2.010}

History

AUTHORITY: sections 630.135 and 630.705, RSMo 1982. Original rule filed Feb. 9, 1983, effective July 11, 1983. Rescinded: Filed Oct. 13, 1983, effective Jan. 15, 1984.

9 CSR 40-2.015 Resident and Client Rights {#sec-9-csr-40-2.015 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-2.015}

(Rescinded December 30, 2020)

Amended: Filed July 17, 1995, effective March 30, 1996. Rescinded: Filed May 14, 2020, effective Dec. 30, 2020.

History

AUTHORITY: sections 630.050, 630.135, 630.168 and 630.705, RSMo 1994. Original 1984. Amended: Filed March 14, 1984, effective Aug. 15, 1984. Amended: Filed April 1, 1993, effective Dec. 9, 1993.

9 CSR 40-2.030 Report of Complaints of Abuse and Neglect {#sec-9-csr-40-2.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-2.030}

Rescinded: Filed Oct. 13, 1983, effective Jan. 15, 1984.

History

AUTHORITY: section 630.050, 630.135 and 630.705, RSMo Supp. 1982. Original rule filed Feb. 9, 1983, effective July 11, 1983.

9 CSR 40-2.035 Report of Complaints of Abuse and Neglect {#sec-9-csr-40-2.035 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-2.035}

(Rescinded May 30, 1999)

Filed Jan. 31, 1991, effective July 8, 1991.

Amended: Filed July 17, 1995, effective March 30, 1996. Rescinded: Filed Oct. 29, 1998, effective May 30, 1999.

History

AUTHORITY: sections 630.050, 630.135, 630.168 and 630.705, RSMo 1994. Original 1984. Amended: Filed July 15, 1985, effective Feb. 1, 1986. Amended: Filed Jan. 2, 1990, effective June 11, 1990. Amended:

9 CSR 40-2.050 Research Protection {#sec-9-csr-40-2.050 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-2.050}

Rescinded: Filed Oct. 13, 1983, effective Jan. 15, 1984.

History

AUTHORITY: sections 630.050, 630.135 and 630.705, RSMo Supp. 1982. Original rule filed Feb. 9, 1983, effective July 11, 1983.

9 CSR 40-2.055 Research Protection {#sec-9-csr-40-2.055 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-2.055}

(Rescinded March 30, 1996)

History

AUTHORITY: sections 630.050, RSMo 1986 and 630.705, RSMo Supp. 1990. Original 1984. Rescinded: Filed July 17, 1995, effective March 30, 1996.

9 CSR 40-2.070 Administrative Policies and Procedures {#sec-9-csr-40-2.070 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-2.070}

9 CSR 40-2.075 Administrative Policies and Procedures {#sec-9-csr-40-2.075 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-2.075}

(Rescinded December 30, 2020)

RSMo 1994. Original rule filed Oct. 13, 1983, effective Jan. 15, 1984. Amended:

Filed Aug. 4, 1987, effective Jan. 15, 1988.

Amended: Filed Jan. 2, 1990, effective June 11, 1990. Amended: Filed April 1, 1993, effective Dec. 9, 1993. Amended: Filed July 17, 1995, effective March 30, 1996. Rescinded: Filed May 14, 2020, effective Dec. 30, 2020.

9 CSR 40-2.090 Recordkeeping {#sec-9-csr-40-2.090 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-2.090}

9 CSR 40-2.110 Admission Criteria {#sec-9-csr-40-2.110 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-2.110}

9 CSR 40-2.120 Admission Criteria for the Mentally Disordered Emergency rule filed Sept. 20, 1983, effective Oct. 1, 1983, expired Jan. 15, 1984. {#sec-9-csr-40-2.120 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-2.120}

9 CSR 40-2.130 Care and Habilitation {#sec-9-csr-40-2.130 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-2.130}

9 CSR 40-2.135 Programming for the Mentally Disordered Emergency rule filed Sept. 20, 1983, effective Oct. 1, 1983, expired Jan. 15, 1984. {#sec-9-csr-40-2.135 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-2.135}

9 CSR 40-2.140 Maintenance, Housekeeping and Laundry {#sec-9-csr-40-2.140 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-2.140}

9 CSR 40-2.150 Fire Safety {#sec-9-csr-40-2.150 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-2.150}

Chapter 3 Rules for Residential Facilities Licensed by the Division of Aging Serving People Who Are Mentally Ill, Mentally Disordered, Mentally Retarded or Developmentally Disabled

9 CSR 40-3.135 Care, Treatment, Habilitation and Rehabilitation People Who Are Mentally Ill, Mentally Disordered, Mentally Retarded or Developmentally Disordered9 CSR 40-3 MENTAL HEALTH Facilities Licensed by the Division of Aging Serving People Who Are Mentally Ill, Mentally Disordered, Mentally Retarded or Developmentally Disabled {#sec-9-csr-40-3.135 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-3.135}

9 CSR 40-3.010 Physical Plant {#sec-9-csr-40-3.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-3.010}

9 CSR 40-3.030 General Medical and Health Care {#sec-9-csr-40-3.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-3.030}

9 CSR 40-3.050 Food Services {#sec-9-csr-40-3.050 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-3.050}

9 CSR 40-3.070 Adequate Staff {#sec-9-csr-40-3.070 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-3.070}

9 CSR 40-3.115 Admission Criteria {#sec-9-csr-40-3.115 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-3.115}

(Rescinded December 30, 2020)

Filed July 15, 1985, effective Feb. 1, 1986.

History

AUTHORITY: sections 630.050 and 630.705, RSMo (1994). Original rule filed Oct. 13, 1983, effective Jan. 15, 1984. Amended:

9 CSR 40-3.135 Care, Treatment, Habilitation and Rehabilitation {#sec-9-csr-40-3.135 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-3.135}

(Rescinded December 30, 2020)

Filed March 14, 1984, effective Aug. 15, 1984. Amended: Filed July 15, 1985, effective Feb. 1, 1986. Amended: Filed Jan. 2, 1990, effective June 11, 1990. Amended:

Filed April 1, 1993, effective Dec. 9, 1993.

Amended: Filed July 17, 1995, effective March 30, 1996. Rescinded: Filed May 14, 2020, effective Dec. 30, 2020.

History

AUTHORITY: sections 630.050 and 630.705, RSMo (1994). Original rule filed Oct. 13, 1983, effective Jan. 15, 1984. Amended:

Chapter 4 Behavioral Health Community Residential Programs

9 CSR 40-4.001 Program and Staffing Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 {#sec-9-csr-40-4.001 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-4.001}

9 CSR 40-4.034 General Medical and Health Care for the Mentally Disordered. . . . . . . . . . . . . 4 {#sec-9-csr-40-4.034 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-4.034}

9 CSR 40-4.116 Admission Criteria for Psychiatric Group Homes II {#sec-9-csr-40-4.116 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-4.116}

9 CSR 40-4.135 Care, Treatment, Habilitation and Rehabilitation {#sec-9-csr-40-4.135 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-4.135}

9 CSR 40-4.145 Maintenance, Housekeeping and Laundry Residential Programs {#sec-9-csr-40-4.145 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-4.145}

9 CSR 40-4.001 Program and Staffing Requirements {#sec-9-csr-40-4.001 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-4.001}

PURPOSE: This rule describes the populations served and requirements for services, supports, and staffing in behavioral health community residential programs subject to licensure by the department.

(1) Regulations. Licensed behavioral health community residential programs (hereafter referred to as residential programs) shall comply with 9 CSR 40-1 unless specified otherwise in this rule.

(2) Fire Safety. Psychiatric Individualized Supported Living (PISL) programs shall comply with 9 CSR 40-1.090 Fire Safety and Emergency Preparedness, with modifications as specified— (A) Subsection (1)(A), Division of Fire Safety inspection is waived;

(B) Subsection (1)(D), evacuation routes do not need to be posted in the home. Documented training and education on safe exit from the home shall be provided for individuals served.

Documentation must include dates of training/education and signature of staff providing the training/education; and (C) Subsection (1)(M), notification and documentation from the local fire authority is waived.

(3) Program Structure. Community residential programs provide a high level of services, structure, oversight, and support for adults with serious mental illness who are transitioning from an inpatient psychiatric hospital to the community, or are at risk of returning to inpatient care due to their clinical status or need for increased support. An extensive array of medically necessary services are provided to assist the individual in managing their psychiatric symptoms, co-occurring disorders, functional deficits, and problematic behaviors.

(A) Supports and rehabilitation services related to an individual’s needs for activities of daily living and crisis prevention and intervention must be provided. Rehabilitation services may be available on-site and in the community to promote recovery and a reduction in symptoms in order for each individual to progress toward more independent living.

Service supports for community activities shall be made available which are separate and distinct from intensive residential treatment settings (IRTS) and psychiatric individualized supported living (PISL) services provided onsite. When individuals participate in community services and activities away from the residential site, staffing requirements shall be maintained on-site in accordance with paragraphs (5)

(A)1.-2. of this rule.

(B) All individuals receiving services/supports must have an individual treatment plan (ITP) developed by staff of the administrative agent or affiliate involved in their care and shall receive services in accordance with 9 CSR 40-1.075 Person- Centered Services.

A copy of each individual’s current ITP and crisis prevention plan shall be maintained in a manner so they are readily accessible to staff working in the program.

Documentation must indicate program staff are knowledgeable about each individual’s treatment plan and crisis prevention plan.

(C) Each residential program shall be structured to ensure safety and prevent the individual’s need for a more restrictive setting. The type of program is based on individual needs for supervision and oversight, tolerance for interactions with other individuals, and the ability to participate in and benefit from other community-based interventions.

(D) Psychiatric Individualized Supported Living (PISL) is comprised of services and supports provided in a private home for one (1) to four (4) adults and is most appropriate for individuals who— 1. Have intermittent difficulty tolerating other individuals in their immediate living environment; and 2. Require access to an individual bedroom to promote psychiatric wellness and reduce the potential for aggression or other behaviors associated with a risk of re-hospitalization;

Have substantial difficulties with activities of daily living and require around-the-clock observation and oversight;
Require daily redirection from staff to avoid behaviors potentially harmful to themselves or others.

A. Each individual served in a PISL shall have a private, single bedroom unless staff of the administrative agent or affiliate provide adequate justification to the department for shared rooms. Single bedrooms must meet requirements for square footage as specified in 9 CSR 40-1.085(5)(A)1.

(E) Intensive residential treatment setting (IRTS) provides service and supports for five (5) to sixteen (16) adults and is most appropriate for individuals who— 1. Can tolerate regular interaction with their peers, but have significant difficulties with activities of daily living;

May require around-the-clock observation and oversight;
Require periodic redirection from staff to avoid behaviors potentially harmful to themselves or others.

A. Each individual served in an IRTS shall have a private, single bedroom unless staff of the administrative agent or affiliate provide adequate justification to the department for shared rooms. Single bedrooms must meet requirements for square footage as specified in 9 CSR 40-1.085(5)(A)1.

(4) Staffing. Each residential program shall have a director who is responsible for making decisions regarding program operations. The director shall delegate a staff person to act on his/ her behalf when unavailable. Oversight of the program must be provided by a qualified mental health professional (QMHP) as defined in 9 CSR 40-1.015(2)(TT).

(A) Staff providing services and supports must be at least eighteen (18) years of age and have a minimum of a high school diploma or equivalent certificate.

(B) Staff must be systematically trained to provide intensive interventions and supports to reduce the symptoms of mental illness and co-occurring disorders. Training shall include interventions to redirect individuals in a psychiatric crisis who are exhibiting behaviors potentially dangerous to themselves or others.

(C) Each staff person must have a training plan that identifies specific topics and frequency of refresher training on each topic, including documentation of course completion.

(5) Supervision of Individuals Served. Staff supervision of individuals being served in the program shall be provided in accordance with their assessed needs as documented in the ITP. A system must be in place to ensure each individual is monitored in accordance with his or her ITP. Services and monitoring shall be documented.

(2/29/24) John R. Ashcroft (A) Twenty-four (24) hour protective oversight shall be provided as follows:

PISL programs shall have at least one (1) staff person on duty at the residential setting who is dressed and awake twenty-four (24) hours per day, seven (7) days per week; and 2. IRTS shall have at least one (1) staff person on duty at the residential setting during the day and evening shifts for every eight (8) individuals receiving services, and one (1) staff person on duty at the residential setting who is dressed and awake during the night shift for every sixteen (16) individuals served.

(B) Procedures shall be in place for staff to rapidly respond to unauthorized absences of individuals being served in the program.

(C) Procedures shall be in place to maintain adequate staffing when responding to emergent situations to assure the health and safety of individuals being served.

(D) Staff shall be trained on de-escalation and intervention techniques for individuals who may engage in behavior that may be harmful to themselves or others.

(E) Staffing requirements shall be maintained at all times at the residential site.

(6) Program Supervision. A qualified mental health professional (QMHP) as defined in 9 CSR 40-1.015, shall be on site in PISL and IRTS programs a minimum of eight (8) hours per week to provide supervision, program planning, consultation, treatment planning, and support.

(A) A QMHP shall be available twenty-four (24) hours per day, seven (7) days per week, to intervene in crisis situations that may occur in the program.

(7) Nursing Services. A licensed registered nurse (RN) shall be on-site in PISL and IRTS programs a minimum of four (4) hours per week to provide oversight and coordination of nursing and medical protocols and individual needs.

(A) On-site nursing oversight and coordination may be performed by a licensed practical nurse (LPN) for a minimum of eight (8) hours per week in lieu of the on-site RN under the following circumstances:

An RN is available to the LPN and other program staff for consultation and is able to respond on-site, if needed, in the event an individual experiences a change of condition.

The staffing plan shall reflect availability of the RN, including location and proximity to the program; and 2. The LPN consults with an RN on a monthly basis, at a minimum, regarding observations and findings regarding physicians’ orders, medication administration trends and patterns, health conditions, and care processes for individuals served.

Observations and findings reviewed must be documented in each individual’s records and include the dated signature and credentials of the RN providing the consultation or dated signature of the LPN indicating the name of the consulting RN.

rule filed May 14, 2020, effective Dec. 30, 2020. Amended: Filed Sept. 14, 2023, effective March 30, 2024. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008, and 630.705, RSMo 1980, amended 1982, 1984, 1985, 1990, 2000, 2011, 2014.

History

AUTHORITY: sections 630.050 and 630.705, RSMo 2016. Original

9 CSR 40-4.010 Physical Plant {#sec-9-csr-40-4.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-4.010}

9 CSR 40-4.030 General Medical and Health Care {#sec-9-csr-40-4.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-4.030}

9 CSR 40-4.034 General Medical and Health Care for the Mentally Disordered Emergency rule filed Sept. 20, 1983, effective Oct. 1, 1983, expired Jan. 15, 1984. {#sec-9-csr-40-4.034 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-4.034}

9 CSR 40-4.050 Food Services {#sec-9-csr-40-4.050 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-4.050}

9 CSR 40-4.070 Adequate Staff {#sec-9-csr-40-4.070 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-4.070}

9 CSR 40-4.074 Adequate Staff for the Mentally Disordered Emergency rule filed Sept. 20, 1983, effective Oct. 1, 1983, expired Jan. 15, 1984. {#sec-9-csr-40-4.074 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-4.074}

9 CSR 40-4.095 Recordkeeping March 14, 1984, effective Aug. 15, 1984. Amended: Filed Jan. 2, 1990, effective June 11, 1990. Amended: Filed July 17, 1995, effective March 30, 1996. Rescinded: Filed May 14, 2020, effective Dec. 30, 2020. {#sec-9-csr-40-4.095 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-4.095}

9 CSR 40-4.115 Admission Criteria 1985, effective Feb. 1, 1986. Amended: Filed Sept. 4, 1985, effective Feb. 1, 1986. Amended: Filed Jan. 2, 1990, effective June 11, 1990. {#sec-9-csr-40-4.115 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-4.115}

Amended: Filed April 1, 1993, effective Dec. 9, 1993. Amended: Filed July 17, 1995, effective March 30, 1996. Rescinded: Filed May 14, 2020, effective Dec. 30, 2020.

9 CSR 40-4.116 Admission Criteria for Psychiatric Group Homes II {#sec-9-csr-40-4.116 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-4.116}

rule filed July 17, 1995, effective March 30, 1996. Rescinded: Filed May 14, 2020, effective Dec. 30, 2020.

9 CSR 40-4.135 Care, Treatment, Habilitation and Rehabilitation 1985, effective Feb. 1, 1986. Amended: Filed Jan. 2, 1990, effective June 11, 1990. Amended: Filed April 1, 1993, effective Dec. 9, 1993. {#sec-9-csr-40-4.135 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-4.135}

Amended: Filed July 17, 1995, effective March 30, 1996. Rescinded:

Filed May 14, 2020, effective Dec. 30, 2020.

9 CSR 40-4.145 Maintenance, Housekeeping and Laundry March 14, 1984, effective Aug. 15, 1984. Amended: Filed July 17, 1995, effective March 30, 1996. Rescinded: Filed May 14, 2020, effective Dec. 30, 2020. {#sec-9-csr-40-4.145 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-4.145}

9 CSR 40-4.155 Fire Safety 1985, effective Feb. 1, 1986. Amended: Filed Jan. 2, 1990, effective June 11, 1990. Amended: Filed July 17, 1995, effective March 30, 1996. Rescinded: Filed May 14, 2020, effective Dec. 30, 2020. {#sec-9-csr-40-4.155 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-4.155}

Chapter 5 Rules for Group Homes and Residential Centers

9 CSR 40-5.010 Physical Plant {#sec-9-csr-40-5.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-5.010}

9 CSR 40-5.015 Physical Plant RSMo (1994). Original rule filed Oct. 13, 1983, effective Jan. 15, 1984. Amended: {#sec-9-csr-40-5.015 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-5.015}

Filed March 14, 1984, effective Aug. 15, 1984. Amended: Filed July 15, 1985, effective Feb. 1, 1986. Amended: Filed Jan. 2, 1990, effective June 11, 1990. Amended:

Filed April 1, 1993, effective Dec. 9, 1993.

Amended: Filed July 17, 1995, effective March 30, 1996. Rescinded: Filed June 30, 2021, effective Jan. 30, 2022.

9 CSR 40-5.030 General Medical and Health Care {#sec-9-csr-40-5.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-5.030}

9 CSR 40-5.035 General Medical and Health Care RSMo (1994). Emergency rule filed Sept. 20, 1983, effective Oct. 1, 1983, expired Jan. 15, 1984. Original rule filed Oct. 13, 1983, effective Jan. 15, 1984. Amended: Filed March 14, 1984, effective Aug. 15, 1984. {#sec-9-csr-40-5.035 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-5.035}

Amended: Filed July 15, 1985, effective Feb. 1, 1986. Amended: Filed Jan. 2, 1990, effective June 11, 1990. Amended: Filed April 1, 1993, effective Dec. 9, 1993. Amended: Filed July 17, 1995, effective March 30, 1996.

Rescinded: Filed June 30, 2021, effective Jan. 30, 2022.

9 CSR 40-5.050 Food Services {#sec-9-csr-40-5.050 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-5.050}

9 CSR 40-5.055 Food Services RSMo (1994). Original rule filed Oct. 12, 1983, effective Jan. 15, 1984. Amended: {#sec-9-csr-40-5.055 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-5.055}

Filed March 14, 1984, effective Aug. 11, 1984. Amended: Filed July 15, 1985, effective Feb. 1, 1986. Amended: Filed Jan. 2, 1990, effective June 11, 1990. Amended:

Filed April 1, 1993, effective Dec. 9, 1993.

Amended: Filed July 17, 1995, effective March 30, 1996. Rescinded: Filed June 30, 2021, effective Jan. 30, 2022.

9 CSR 40-5.070 Adequate Staff {#sec-9-csr-40-5.070 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-5.070}

9 CSR 40-5.075 Adequate Staff {#sec-9-csr-40-5.075 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-5.075}

PURPOSE: This rule prescribes the staffing requirements for group homes and residential centers subject to licensure from the department.

(1) Licensed group homes and residential centers shall comply with 9 CSR 40-1, unless specified otherwise in this rule.

(2) Staffing requirements shall be as follows, unless program needs or the needs of individuals served justify otherwise:

(A) Programs providing a group living arrangement and minimum level of habilitation and supervision for individuals with mild to moderate levels of adaptive functioning, are ambulatory or mobile non-ambulatory, have basic self-help skills but may need minimal assistance or prompting with daily skills, and have no severe medical or maladaptive behaviors— 1. Day and evening shifts—one (1) staff to eight (8) individuals served (1:8); and 2. Night shift—one (1) staff to sixteen (16) individuals served (1:16);

(B) Programs providing a group living and habilitation environment for individuals with moderate to severe levels of adaptive functioning, are ambulatory or mobile non-ambulatory, need training in basic self-help skills, socialization, and daily living skills, and have no severe medical needs or severe maladaptive behaviors— 1. Day and evening shifts—one (1) staff to four (4) individuals served (1:4); and 2. Night shift—one (1) staff to eight (8) individuals served (1:8);

(C) Programs providing a habilitation environment for individuals with various levels of adaptive functioning, are non-ambulatory and unable to provide for their own needs, or ambulatory/non-ambulatory with intensive medical/physical needs or severe maladaptive behaviors— 1. Day and evening shifts—one (1) staff to three (3) individuals served (1:3); and 2. Night shift—one (1) staff to six (6) individuals served (1:6);

(D) For purposes of this section of this

rule, shifts are defined as follows:

Day shift—approximately 7:00 a.m. to 3:00 p.m.;
Evening shift—approximately 3:00 p.m. to 11:00 p.m.; and 3. Night shift—approximately 11:00 p.m. to 7:00 a.m.;

(E) The ratios are minimum staff requirements. An increase in the number of individuals being served above the maximum specified in this section of this rule shall require additional staff;

(F) Staff required under this section of this

rule shall be dressed and awake at night, as required by the needs of individuals served and the size of the physical facility;

(G) When individuals served are absent from the program, staffing levels may be proportionately reduced. If all individuals are absent from the program, staff shall be available by telephone twenty-four (24) hours per day, seven (7) days per week to respond to emergencies that may occur with individuals served;

(H) Program needs or the needs of individuals served may justify alternate staffing ratios based on the following considerations:

The physical layout of the facility;
If individuals served are awake and active at night;
If there are individuals who are blind and/or deaf;
Qualifications of the staff;
Goals and objectives of individuals served;
Obvious indications that staff are unable to meet the needs of individuals being served or are unable to meet minimum environmental requirements; and 7. The availability of backup staff; and (I) An individual may be at the program without the presence of staff for a specific period of time, if it is documented in the individual support plan (ISP) that the individual has the necessary knowledge and skills to function safely.

(3) All staff responsible for direct care of individuals served shall be eighteen (18) years of age or older.

(4) In addition to direct care staff, there shall be sufficient personnel to provide basic services including, but not limited to, dietary and maintenance of the environment/facility.

Volunteers shall not be considered in the computation of adequate staff.

(5) A program which accepts individuals in need of considerable nursing care shall employ a licensed registered nurse (RN).

Considerable nursing care may include, but is not limited to, injections, inhalation therapy, intravenous fluids, suctioning, ostomy irrigation, lesion dressing, aseptic dressing, catheter irrigation, care for pressure sores, and physiotherapy.

(A) The RN shall be designated the nurse in charge and shall— 1. Be responsible for twenty-four- (24-) hour nursing care of individuals, including the storage and administration of medications and maintenance of medical records and nursing records;

Share responsibilities with the program director and attending physician for drug control procedures, environmental health, safety, and dietary procedures;
Be on call when licensed practical nurses (LPNs) are on duty; and 4. Ensure an LPN is on duty when the licensed RN is not present at the program.

Unless the needs of individuals require nursing oversight, an LPN is not required if staff on the night shift are trained in emergency medical procedures and medication administration.

(B) The required RN may be hired on a consultant basis if— 1. The needs of the individuals do not require his/her presence at the program; and 2. He or she assumes the responsibilities outlined under paragraphs (5)(A)1. and 2. of this rule.

(6) Staff shall participate in training as required by the department. Records of attendance and documentation of successful completion of training shall be maintained as specified in 9 CSR 40-1.060(4)(E).

RSMo 2016.* Emergency rule filed Sept. 20, 1983, effective Oct. 1, 1983, expired Jan. 15, 1984. Original rule filed Oct. 13, 1983, effective Jan. 15, 1984. Amended: Filed March 14, 1984, effective Aug. 15, 1984.

Amended: Filed June 30, 2021, effective Jan. 30, 2022. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008, and 630.705, RSMo 1980, amended 1982, 1984, 1985, 1990, 2000, 2011, 2014.

(12/31/21) JOHN R. ASHCROFT

Chapter 6 Rules for Family Living Arrangements

9 CSR 40-6.014 Physical Plant Requirements for the Mentally Retarded or {#sec-9-csr-40-6.014 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.014}

9 CSR 40-6.030 General Medical and Health Care for the Mentally Disordered. . . . . . . . . . . . . 4 {#sec-9-csr-40-6.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.030}

9 CSR 40-6.034 General Medical and Health Care for the Mentally Retarded or {#sec-9-csr-40-6.034 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.034}

9 CSR 40-6.114 Admission Criteria for the Mentally Retarded or Developmentally {#sec-9-csr-40-6.114 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.114}

9 CSR 40-6.145 Maintenance, Housekeeping and Laundry for the Mentally Retarded {#sec-9-csr-40-6.145 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.145}

9 CSR 40-6.001 Provider Requirements and Program Structure {#sec-9-csr-40-6.001 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.001}

PURPOSE: This rule specifies the licensing and program requirements for family living arrangements (FLA).

(1) Regulations. In addition to the requirements of this rule, providers of family living arrangements (FLA) shall comply with 9 CSR 40-1 unless specified otherwise in this rule.

(2) Licensure Requirements. Applicants for licensure to provide services and supports in a FLA must have documentation of ownership of their home or, if renting, documentation of a current lease agreement and approval from the landlord to provide family living arrangements.

(A) Each applicant must— 1. Be twenty-five (25) years of age or older;

Have at least a high school diploma or equivalent certificate;
Successfully complete all background screenings required by the department, including out-of-state background screenings and/or reference checks, if he or she has resided in Missouri for less than five (5) years;
Submit to a home study, an interview and selection process, and licensure by the department; and 5. Have safe, reliable transportation and appropriate insurance as required by Missouri laws.

(B) Providers must complete specialized training required by the department. Training must be documented as specified in 9 CSR 40-1.060(4)(E).

(3) Fire Safety. FLA providers shall comply with 9 CSR 40-1.090 Fire Safety and Emergency Preparedness, with modifications as specified:

(A) Subsection (1)(A), Division of Fire Safety inspection is waived;

(B) Subsection (1)(D), evacuation routes do not need to be posted in the home. Documented training and education on safe exit from the home shall be provided for individuals served.

Training and education must be documented, including dates and signature of provider; and (C) Subsection (1)(M), notification and documentation from the local fire authority is waived.

(4) Program Structure. FLA providers will be trained, supervised, and supported by staff of the referring/administering agency.

FLA providers may serve one (1) to three (3) individuals in the home.

(A) FLA providers have a primary role in the therapeutic interventions and supports provided to the individual(s) served and will be responsible for implementing the individual treatment plan (ITP) or individual support plan (ISP).

(B) Placement, duration, and intensity of services and supports will be based on admission criteria established by the department.

(C) Individuals served shall have the opportunity to participate in daily family and community life, including services and activities such as religious affiliation (if desired), physical activities, shopping, and volunteering in accordance with their ITP or ISP.

(D) Supervision of individuals served shall be provided as specified in their ITP or ISP.

(E) Services and supports provided must be documented as required by the department.

(F) Providers shall maintain contact with staff of the administering/referring agency and the individual’s parents/ guardian and other family members/natural supports as specified in the ITP or ISP and as required by the department.

(G) Provider(s) shall participate in pre-placement meetings and ongoing meetings with the individual’s support team or treatment team, including development of the ITP or ISP and updating the plan as required by the department and/or referring/administering agency.

(H) A copy of each individual’s current ITP or ISP and crisis prevention plan or safety crisis plan, as applicable, shall be maintained in a manner so they are readily accessible.

(I) Staff from the referring/administering agency will regularly monitor each individual’s progress and provide adjunctive services in accordance with his or her ITP or ISP.

(5) Dietary Requirements. 9 CSR 40-1.080 Dietary Services is waived. FLAs shall ensure the following dietary requirements are met:

(A) Proper diet and food preparation shall be addressed as

part of the individualized planning process;

(B) Individuals who prepare their own meals or help with meal preparation shall be assisted, as needed;

(C) Individuals shall be supported in developing meal plans and grocery lists and educated and assisted, as needed, in order to meet any special dietary requirements;

(D) Individuals shall be assisted and educated about purchasing, preparing, and safely storing food and drinks in a manner that prevents spoilage and contamination;

(E) Documented consultation with a licensed dietitian or registered nurse must take place at least annually for individuals with special diets;

(F) Documented staff training regarding specialized diets, as applicable;

(G) A balanced variety of healthy foods and drinks, with opportunities for choice, shall be available to individuals each day, and ready access to nutritious snacks shall be available at all times;

(H) Consideration shall be given to the food habits, personal, cultural, religious preferences, and medical needs of individuals served, including provisions for special diets for medical reasons;

(I) When individuals require blended food, the food shall be prepared, measured, and served individually and not mixed together;

(J) The consistency and texture of food shall meet each individual’s needs. Individuals shall not be fed in a prone position;

(K) Individuals requiring liquid or soft diets shall be provided with nourishing, supplementary food between meals to meet their nutritional needs;

(L) Meals may be served family style to provide a home-like atmosphere;

(M) A sufficient number of appliances and equipment shall be available for food preparation including but not limited to a stove and refrigerator, dishes, cookware, and utensils to meet the needs of individuals served. All equipment must be in safe and good operating condition and food preparation areas, appliances, and equipment shall be cleaned and sanitized after each use; and (N) The temperature of hot water at all faucets accessible to individuals served must be controlled by a thermostatic mixing valve or other means so the water temperature does not (2/29/24) John R. Ashcroft exceed one hundred twenty degrees Fahrenheit (120°F), unless individuals served can self-regulate water temperature.

History

AUTHORITY: sections 630.050 and 630.705, RSMo 2016. Original

9 CSR 40-6.010 Physical Plant Requirements for the Mentally Disordered Jan. 15, 1984. {#sec-9-csr-40-6.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.010}

9 CSR 40-6.014 Physical Plant Requirements for the Mentally Retarded or Developmentally Disabled Jan. 15, 1984. {#sec-9-csr-40-6.014 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.014}

9 CSR 40-6.015 Physical Plant {#sec-9-csr-40-6.015 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.015}

Amended: Filed July 17, 1995, effective March 30, 1996. Rescinded:

Filed May 14, 2020, effective Dec. 30, 2020.

History

AUTHORITY: sections 630.050 and 630.705, RSMo (1994). Original March 14, 1984, effective Aug. 15, 1984. Amended: Filed July 15, 1985, effective Feb. 1, 1986. Amended: Filed Jan. 2, 1990, effective June 11, 1990. Amended: Filed April 1, 1993, effective Dec. 9, 1993.

9 CSR 40-6.030 General Medical and Health Care for the Mentally Disordered Jan. 15, 1984. {#sec-9-csr-40-6.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.030}

9 CSR 40-6.034 General Medical and Health Care for the Mentally Retarded or Developmentally Disabled Jan. 15, 1984. {#sec-9-csr-40-6.034 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.034}

9 CSR 40-6.035 General Medical and Health Care {#sec-9-csr-40-6.035 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.035}

Amended: Filed July 17, 1995, effective March 30, 1996. Rescinded:

Filed May 14, 2020, effective Dec. 30, 2020.

History

AUTHORITY: sections 630.050 and 630.215, RSMo (1994). Original March 14, 1984, effective Aug. 15, 1984. Amended: Filed July 15, 1985, effective Feb. 1, 1986. Amended: Filed Jan. 2, 1990, effective June 11, 1990. Amended: Filed April 1, 1993, effective Dec. 9, 1993.

9 CSR 40-6.050 Food Services for the Mentally Disordered Jan. 15, 1984. {#sec-9-csr-40-6.050 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.050}

9 CSR 40-6.054 Food Services for the Mentally Retarded or Jan. 15, 1984. {#sec-9-csr-40-6.054 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.054}

9 CSR 40-6.055 Food Services {#sec-9-csr-40-6.055 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.055}

History

AUTHORITY: sections 630.050 and 630.705, RSMo (1994). Original Jan. 2, 1990, effective June 11, 1990. Amended: Filed July 17, 1995, effective March 30, 1996. Rescinded: Filed May 14, 2020, effective Dec. 30, 2020.

9 CSR 40-6.070 Adequate Staff for the Mentally Disordered Jan. 15, 1984. {#sec-9-csr-40-6.070 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.070}

9 CSR 40-6.074 Adequate Staff for the Mentally Retarded or Jan. 15, 1984. {#sec-9-csr-40-6.074 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.074}

9 CSR 40-6.075 Adequate Staff {#sec-9-csr-40-6.075 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.075}

Rescinded: Filed May 14, 2020, effective Dec. 30, 2020.

History

AUTHORITY: sections 630.050 and 630.215, RSMo (1994). Original July 15, 1985, effective Feb. 1, 1986. Amended: Filed Jan. 2, 1990, effective June 11, 1990. Amended: Filed April 1, 1993, effective Dec. 9, 1993. Amended: Filed July 17, 1995, effective March 30, 1996.

9 CSR 40-6.090 Recordkeeping for the Mentally Disordered Jan. 15, 1984. {#sec-9-csr-40-6.090 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.090}

9 CSR 40-6.095 Recordkeeping for the Mentally Retarded or Jan. 15, 1984. {#sec-9-csr-40-6.095 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.095}

9 CSR 40-6.110 Admission Criteria for the Mentally Disordered Jan. 15, 1984. {#sec-9-csr-40-6.110 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.110}

9 CSR 40-6.114 Admission Criteria for the Mentally Retarded or Developmentally Disabled Jan. 15, 1984. {#sec-9-csr-40-6.114 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.114}

9 CSR 40-6.130 Programming for the Mentally Disordered Jan. 15, 1984. {#sec-9-csr-40-6.130 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.130}

9 CSR 40-6.134 Programming for the Mentally Retarded or Jan. 15, 1984. {#sec-9-csr-40-6.134 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.134}

9 CSR 40-6.140 Maintenance, Housekeeping and Laundry for the Mentally Disordered Jan. 15, 1984. {#sec-9-csr-40-6.140 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.140}

9 CSR 40-6.145 Maintenance, Housekeeping and Laundry for the Mentally Retarded or Developmentally Disabled Jan. 15, 1984. {#sec-9-csr-40-6.145 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-6.145}

Chapter 7 Rules for Semi-Independent Living Arrangements

9 CSR 40-7.015 Physical Plant Filed March 14, 1984, effective Aug. 15, 1984. Amended: Filed July 15, 1985, effective Feb. 1, 1986. Amended: Filed Jan. 2, 1990, effective June 11, 1990. Amended: {#sec-9-csr-40-7.015 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-7.015}

Filed July 17, 1995, effective March 30, 1996. Rescinded: Filed May 14, 2020, effective Dec. 30, 2020.

9 CSR 40-7.035 General Medical and Health Care Filed March 14, 1984, effective Aug. 15, 1984. Amended: Filed July 15, 1985, effective Feb. 1, 1986. Amended: Filed Jan. 2, 1990, effective June 11, 1990. Amended: {#sec-9-csr-40-7.035 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-7.035}

Filed July 17, 1995, effective March 30, 1996. Rescinded: Filed May 14, 2020, effective Dec. 30, 2020.

9 CSR 40-7.055 Food Services Filed Jan. 2, 1990, effective June 11, 1990. {#sec-9-csr-40-7.055 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-7.055}

Amended: Filed July 17, 1995, effective March 30, 1996. Rescinded: Filed May 14, 2020, effective Dec. 30, 2020.

9 CSR 40-7.070 Adequate Staff Emergency rule filed Sept. 20, 1983, effective Oct. 1, 1983, expired Jan. 15, 1984. {#sec-9-csr-40-7.070 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-7.070}

9 CSR 40-7.075 Adequate Staff Filed July 15, 1985, effective Feb. 1, 1986. {#sec-9-csr-40-7.075 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-7.075}

Chapter 8 Rules for Psychiatric Group Homes

9 CSR 40-8.075 Adequate Staff {#sec-9-csr-40-8.075 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-8.075}

(Rescinded December 30, 2020)

Filed July 15, 1985, effective Feb. 1, 1986.

Amended: Filed Jan. 2, 1990, effective June 11, 1990. Amended: Filed Dec. 29, 1995, effective March 30, 1996. Amended: Filed July 17, 1995, effective March 30, 1996.

Rescinded: Filed May 14, 2020, effective Dec. 30, 2020.

History

AUTHORITY: sections 630.050 and 630.705, RSMo (1994). Original rule filed Oct. 13, 1983, effective Jan. 15, 1984. Amended:

Chapter 9 Day Programs Serving Individuals with Mental Illness and Intellectual or Developmental Disabilities

9 CSR 40-9.135 Care, Treatment, Habilitation and Rehabilitation Intellectual or Developmental Disabilities9 CSR 40-9 MENTAL HEALTH Individuals with Mental Illness and Intellectual or Developmental Disabilities {#sec-9-csr-40-9.135 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-9.135}

9 CSR 40-9.015 Physical Plant Requirements 11, 1990. Amended: Filed July 17, 1995, effective March 30, 1996. Rescinded: Filed May 14, 2020, effective Dec. 30, 2020. {#sec-9-csr-40-9.015 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-9.015}

9 CSR 40-9.035 General Medical and Health Care Amended: Filed Aug. 4, 1987, effective Nov. 15, 1987. Amended: Filed Jan. 2, 1990, effective June 11, 1990. Amended: Filed July {#sec-9-csr-40-9.035 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-9.035}

9 CSR 40-9.055 Food Services {#sec-9-csr-40-9.055 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-9.055}

9 CSR 40-9.075 Program and Staffing Requirements {#sec-9-csr-40-9.075 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-9.075}

PURPOSE: This rule specifies the program and staffing requirements for day programs serving individuals with mental illness, intellectual disabilities, and developmental disabilities (IDD) that are subject to licensure by the department.

(1) Licensed day programs shall comply with

9 CSR 40-1 unless specified otherwise in this {#sec-9-csr-40-1 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-1}

rule.

(2) Day programs shall provide structured activities, services, and supports to assist individuals in developing personal support systems, social skills, community living skills, basic self-care skills, and pre-vocational skills that promote community inclusion, integration, and independence.

(A) Activities and services/supports shall be based on the individual support plan (ISP), individual treatment plan (ITP), or care plan of each individual being served as specified in 9 CSR 40-1.075(1).

(B) Activities and services/supports may take place during the day, evening, weekend, or a combination of these, to effectively address the needs of individuals served.

Activities and services/supports are not limited to the program site to provide individuals with opportunities for off-site training and rehabilitation in realistic community settings.

(C) Transportation to/from the program site to various locations in the community shall be provided for individuals served to promote participation and involvement in outside activities and services/supports. Permission forms for off-site activities, signed by the individual served or their parent/guardian, as applicable, shall be maintained on-site.

Program staff are responsible for the care, safety, and supervision of individuals served when they are transported from the operating site to other locations in the community, and staff ratios shall be maintained at the operating site.

(3) All direct care staff must be eighteen (18) years of age or older and have a high school diploma or equivalent certificate.

(A) Staffing requirements for day programs serving adults with mental illness— 1. The director must be a Qualified Mental Health Professional (QMHP) with two (2) years of relevant work experience;

At a minimum, a daily direct care staff ratio of one (1) staff person for each sixteen (16) individuals served (1:16) shall be maintained, unless program needs or the needs of individuals being served require otherwise; and 3. At least one (1) staff person must be on duty at all times when individuals served are present at the program.

(B) Staffing requirements for day programs serving children and youth with serious emotional disturbances— 1. The director must be a QMHP with two (2) years of experience working with children and youth;

One (1) full-time mental health professional must be available during the provision of services;
Direct care staffing ratios shall be based on the ages and needs of the children/youth being served.

A. At a minimum, a daily staffing ratio of one (1) staff to four (4) individuals (1:4) shall be maintained for children/youth between the ages of three (3) and eleven (11).

A daily staffing ratio of one (1) staff to six (6) individuals (1:6) shall be maintained for children/youth between the ages of twelve (12) and seventeen (17);

Based on the needs of children/youth being served, other staff shall include:

A. Registered nurse;

B. Occupational therapist;

C. Recreational therapist;

D. Rehabilitation therapist;

E. Community support specialist;

F. Family assistance worker; and 5. At least one (1) staff person must be on duty at all times when individuals served are present at the program.

(C) Staffing requirements for day programs serving individuals with IDD shall be as follows, unless program needs or the needs of individuals being served require otherwise:

For children and youth between the ages of three (3) and eleven (11), the daily staffing ratio shall be one (1) staff to four (4) individuals (1:4);
For children/youth between the ages of twelve (12) and seventeen (17), the daily staffing ratio shall be one (1) staff to six (6) individuals (1:6); and 3. For adults, the daily staffing ratio shall be a minimum of one (1) staff for each sixteen (16) individuals (1:16) served.

RSMo 2016.* Original rule filed Oct. 13, 17, 1995, effective March 30, 1996. Amend- *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.705, RSMo 1980, amended 1982, 1984, 1985, 1990, 2000, 2011, 2014.

9 CSR 40-9.095 Recordkeeping 11, 1990. Amended: Filed July 17, 1995, effective March 30, 1996. Rescinded: Filed May 14, 2020, effective Dec. 30, 2020. {#sec-9-csr-40-9.095 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-9.095}

9 CSR 40-9.115 Admission Criteria {#sec-9-csr-40-9.115 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-9.115}

9 CSR 40-9.135 Care, Treatment, Habilitation and Rehabilitation {#sec-9-csr-40-9.135 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-9.135}

9 CSR 40-9.145 Maintenance, Housekeeping and Laundry Amended: Filed July 17, 1995, effective March 30, 1996. Rescinded: Filed May 14, 2020, effective Dec. 30, 2020. {#sec-9-csr-40-9.145 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-9.145}

9 CSR 40-9.155 Fire Safety (11/30/20) JOHN R. ASHCROFT {#sec-9-csr-40-9.155 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-9.155}

Chapter 10 Rules for Day Programs Serving People Who Are Mentally Ill or Mentally Disordered

9 CSR 40-10.015 Physical Plant Requirements 1986. Original rule filed June 17, 1986, 1996. Rescinded: Filed May 14, 2020, effec- {#sec-9-csr-40-10.015 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-10.015}

9 CSR 40-10.035 General Medical and Health Care 1986. Original rule filed June 17, 1986, 1996. Rescinded: Filed May 14, 2020, effec- {#sec-9-csr-40-10.035 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-10.035}

9 CSR 40-10.055 Food Services 1986. Original rule filed June 17, 1986, {#sec-9-csr-40-10.055 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-10.055}

9 CSR 40-10.075 Adequate Staff 1986. Original rule filed June 17, 1986, {#sec-9-csr-40-10.075 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-10.075}

9 CSR 40-10.095 Recordkeeping 1986. Original rule filed June 17, 1986, 1996. Rescinded: Filed May 14, 2020, effec- {#sec-9-csr-40-10.095 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-10.095}

9 CSR 40-10.115 Admission Criteria 1986. Original rule filed June 17, 1986, {#sec-9-csr-40-10.115 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-10.115}

9 CSR 40-10.135 Care, Treatment and Rehabilitation 1986. Original rule filed June 17, 1986, effective Nov. 13, 1986. Amended: Filed Aug. 18, 1987, effective Nov. 15, 1987. Amended: {#sec-9-csr-40-10.135 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-10.135}

Filed Jan. 2, 1990, effective June 11, 1990.

Amended: Filed April 1, 1993, effective Dec. 9, 1993. Amended: Filed July 17, 1995, effective March 30, 1996. Rescinded: Filed May 14, 2020, effective Dec. 30, 2020.

9 CSR 40-10.145 Maintenance, Housekeeping and Laundry 1986. Original rule filed June 17, 1986, effective Nov. 13, 1986. Amended: Filed July 17, 1995, effective March 30, 1996. Rescinded: Filed May 14, 2020, effective Dec. 30, 2020. {#sec-9-csr-40-10.145 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-10.145}

9 CSR 40-10.155 Fire Safety 1986. Original rule filed June 17, 1986, 1996. Rescinded: Filed May 14, 2020, effec- {#sec-9-csr-40-10.155 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-10.155}

Chapter 11 Rules for Psychiatric Group Home IIs

9 CSR 40-11.015 Physical Plant 1987. Amended: Filed Jan. 2, 1990, effective {#sec-9-csr-40-11.015 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-11.015}

9 CSR 40-11.035 General Medical and Health Care 1987. Amended: Filed Jan. 2, 1990, effective {#sec-9-csr-40-11.035 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-11.035}

9 CSR 40-11.055 Food Services 1987. Amended: Filed Jan. 2, 1990, effective {#sec-9-csr-40-11.055 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-11.055}

9 CSR 40-11.075 Adequate Staff 1987. Amended: Filed Jan. 2, 1990, effective {#sec-9-csr-40-11.075 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-11.075}

9 CSR 40-11.095 Recordkeeping 1987. Amended: Filed Jan. 2, 1990, effective {#sec-9-csr-40-11.095 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-11.095}

9 CSR 40-11.115 Admission Criteria 1987. Amended: Filed April 1, 1993, effective Dec. 9, 1993. Rescinded: Filed May 11, {#sec-9-csr-40-11.115 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-11.115}

9 CSR 40-11.135 Care, Treatment, Habilitation and Rehabilitation 1987. Amended: Filed Jan. 2, 1990, effective {#sec-9-csr-40-11.135 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-11.135}

9 CSR 40-11.145 Maintenance, Housekeeping and Laundry 1987. Rescinded: Filed May 11, 1995, effective March 1, 1996. {#sec-9-csr-40-11.145 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-11.145}

9 CSR 40-11.155 Fire Safety 1987. Amended: Filed Jan. 2, 1990, effective MATTBLUNT(10/31/01) {#sec-9-csr-40-11.155 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-11.155}

Chapter 12 Rules for Psychiatric Group Home IIIs

9 CSR 40-12.015 Physical Plant {#sec-9-csr-40-12.015 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-12.015}

9 CSR 40-12.035 General Medical and Health Care {#sec-9-csr-40-12.035 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-12.035}

9 CSR 40-12.055 Food Services {#sec-9-csr-40-12.055 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-12.055}

9 CSR 40-12.075 Adequate Staff {#sec-9-csr-40-12.075 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-12.075}

9 CSR 40-12.095 Recordkeeping {#sec-9-csr-40-12.095 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-12.095}

9 CSR 40-12.115 Admission Criteria Rescinded: Filed May 11, 1995, effective March 1, 1996. {#sec-9-csr-40-12.115 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-12.115}

9 CSR 40-12.135 Care, Treatment, Habilitation and Rehabilitation {#sec-9-csr-40-12.135 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-12.135}

9 CSR 40-12.145 Maintenance, Housekeeping and Laundry filed Nov. 10, 1988, effective Feb. 11, 1989. {#sec-9-csr-40-12.145 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-12.145}

Rescinded: Filed May 11, 1995, effective March 1, 1996.

9 CSR 40-12.155 Fire Safety MATTBLUNT(10/31/01) {#sec-9-csr-40-12.155 omnilex-key=us-mo-regs-official--title-9--9 CSR 40-12.155}

Division 45 Division of Developmental Disabilities

Chapter 2 Eligibility for Services

9 CSR 45-2.020 Appeals Procedures for Service Eligibility Through the Division of {#sec-9-csr-45-2.020 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-2.020}

9 CSR 45-2.010 Eligibility for Services From the Division of Developmental Disabilities {#sec-9-csr-45-2.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-2.010}

PURPOSE: This rule describes the process and terminology used to determine eligibility for Division of Developmental Disabilities PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. Therefore, the material which is so incorporated is on file with the agency who filed this rule, and with the Office of the Secretary of State. Any interested person may view this material at either agency’s headquarters or the same will be made available at the Office of the Secretary of State at a cost not to exceed actual cost of copy reproduction. The entire text of the

rule is printed here. This note refers only to the incorporated by reference material.

(1) Eligibility—Through this rule, the department intends to assist applicants for division services as they proceed through the eligibility determination process and to direct division staff so that they may assist applicants and individuals in expeditiously obtaining accurate, comprehensive evaluations and needed services. Specifically, the division intends to— (A) Implement the concept of functional assessment for determining eligibility and to discontinue the practice of linking eligibility to a specific diagnosis;

(B) Provide equal access to eligibility determinations and habilitation services for all persons with developmental disabilities;

(C) Give specific consideration to eligibility for young children at risk of becoming developmentally delayed or developmentally disabled, so adhering to the prevention mission of the department and saving future state costs by maximizing each child’s potential through early intervention and ameliorative services;

(D) Reduce administrative and bureaucratic barriers to obtaining comprehensive evaluations and services so that eligible persons expeditiously may access the array of services offered by the division;

(E) Accept responsibility for offering services to eligible persons and for assisting those persons—as well as those persons found ineligible—in accessing appropriate services from other state and local agencies, including other divisions within the department;

(F) Emphasize that other state, county, and local agencies also have a role to play in delivering coordinated, appropriate services to persons with developmental disabilities;

(G) Expedite and facilitate eligibility determination by— 1. Accepting as automatically eligible for screening those persons referred by other agencies which have found those persons eligible for their services;

Accepting, and not duplicating, assessment information provided by other private and public bodies, including schools, if regional offices determine that information to be reliable and appropriate;
Using the screening process only to facilitate an applicant’s eligibility, not to screen the applicant out of eligibility except an applicant whose disability clearly was not manifested before age twenty-two (22);
Combining whenever possible the screening and assessment processes so that they are not necessarily two (2) separate steps in the comprehensive evaluation process, for example, finding applicants eligible at screening, or waiving screening in favor of determining eligibility through assessment; and 5. Making the application and comprehensive evaluation processes easy for applicants, for example, screening or assessing applicants in their homes as feasible or aiding them with transportation to regional offices as feasible;

(H) Ensure that eligibility decisions are based upon the following considerations, among others:

The best interest of the individual or applicant; and 2. The individual’s or applicant’s level of adaptive behavior and functioning, including the effect upon the individual’s ability to function at either the same or an improved level of interpersonal and functional skills if services are denied or withdrawn; and (I) Develop a training curriculum on the eligibility determination process and provide comprehensive initial and ongoing training for regional office personnel.

(2) Definitions—As used in this rule, unless the context clearly indicates otherwise, the following terms also mean:

(A) Applicant—A person who has applied for services from the division and/or that person’s representative;

(B) Assessment—The process of identifying an individual’s health status and intellectual, emotional, physical, developmental, and social functioning levels for use in determining eligibility or developing the service plan;

(C) Assessment team—Professionals employed by the Division of Developmental Disabilities with specialized training and experience in the field of developmental disabilities who determine the applicant’s eligibility for services;

(D) Client—Any person who is placed by the department in a facility or program licensed and funded by the department or who is a recipient of services from a Regional Office (RO).

Clients will be referred to as individuals throughout this rule;

(E) Cognitive or physical impairment–An impairment that results from anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques;

(F) Comprehensive evaluation—A study, including a sequence of observations and/or examinations of an individual, and/or a review of records such as medical and other relevant records, leading to conclusions and recommendations regarding eligibility.

For children from birth through age four (0–4), a comprehensive evaluation may include, but not necessarily be limited to, an assessment team’s— A. Assessment of the child using First Steps eligibility criteria, or review of evidence of one (1) of the at-risk factors set out in paragraphs (3)(A)1.–3. of this rule, coupled with a review of scores on the Vineland Adaptive Behavior Scales (Vineland);

B. Review of available educational and medical information;

C. Review of additional individualized assessment and interview results to provide evidence of cognitive or physical impairments likely to continue indefinitely, evidence of substantial functional limitations caused by cognitive or physical impairments, and evidence of a need for sequential and coordinated special services which may be of lifelong or extended duration; and D. Formulation of conclusions and recommendations.

For individuals ages five (5) and older, a comprehensive evaluation may include but not necessarily be limited to an interdisciplinary assessment team’s— A. Review of the results of the Missouri Adaptive Abilities Scale (MAAS);

B. Review of available vocational and medical information, and educational information;

E. Designated representative—A parent, relative, or other person designated by an adult who does not have a guardian. The designated representative may participate in the development of the individual support plan at the request of, and as directed by, the individual;

(G) Developmental delay— 1. A delay, as measured and verified by appropriate diagnostic measures and procedures, which results in a child having obtained no more than approximately fifty percent (50%) of the developmental milestones and skills that would be expected of a child of equal age and considered to be developing within normal limits. The delay must be identified in one (1) or more of the following five (5) developmental areas: cognitive, speech or language, self-help, physical (including vision and hearing), or psychosocial; or 2. Demonstrated atypical development in any one (1) of the five (5) developmental areas, based on professional judgment of an assessment team and documented by— A. Systematic and documented observation of functional abilities in daily routine;

B. Developmental history; and C. Other appropriate assessment procedures which may include but are not necessarily limited to parent report, criteria-referenced assessment, and developmental checklist;

(H) Developmental disability—A disability which— 1. Is attributable to— A. Intellectual developmental disorder, cerebral palsy, epilepsy, head injury, autism, or a learning disability related to a brain dysfunction; or B. Any other cognitive or physical impairment or combination of cognitive or physical impairments;

Is manifested before the person attains age twenty-two (22);
Is likely to continue indefinitely;
Results in substantial functional limitations in two (2) or more of the following six (6) areas of major life activities: self-care, receptive and expressive language development and use, learning, self-direction, capacity for independent living or economic self-sufficiency, and mobility; and 5. Reflects the person’s need for a combination and sequence of special, interdisciplinary or generic care, habilitation, or other services which may be of lifelong or extended duration and are individually planned and coordinated;

(I) Eligible—Qualified through a comprehensive evaluation by the Division of Developmental Disabilities to receive services from the division, but not necessarily entitled to a specific service;

(J) First Steps—A program of the Department of Elementary and Secondary Education (DESE) offering coordinated services to Missouri families of children, birth to age three (3), who have delayed development or diagnosed conditions that are associated with developmental disabilities. First Steps is governed by 5 CSR 25-100.120 in accordance with Part C of the federal Individuals with Disabilities Education Act (IDEA);

(K) Individual support plan (ISP)—A document directed by the individual, with assistance as needed from a representative, in collaboration with a planning team. The ISP identifies strengths, capacities, preferences, needs, and desired outcomes of the individual. The ISP shall encompass a personalized mix of paid and non-paid services and supports that will assist him/ her to achieve personally defined outcomes. Training, supports, therapies, treatments, and/or other services to be provided for the individual become part of the ISP;

(L) Individual support plan team (ISP team)—The individual, the individual’s designated representative(s), the support coordinator, and representatives of services required or desired by the individual;

(M) Initial plan—A document that notifies the individual of eligibility for services and facilitates referral to case management;

(N) Intellectual developmental disorder—Significantly subaverage general intellectual functioning, at or below two (2) standard deviations below the mean, including a margin for measurement error when appropriate, as measured by an individually administered, comprehensive, and psychometrically sound test of intelligence. Intellectual developmental disorder originates before age eighteen (18) and is associated with significant impairment in adaptive behavior as assessed by both clinical evaluation and culturally appropriate, psychometrically sound measures;

(O) Intake—The process conducted prior to determination of eligibility by which data is gathered from an applicant;

(P) Legal representative—Parent of a minor child or legal guardian;

(Q) Logging—Recording in a uniform, consistent manner those dates and activities related to application, comprehensive evaluation, and other eligibility determination procedures as well as dates and activities related to applicant and individual appeals;

(R) Major life activities— 1. Self-care—Daily activities which enable a person to meet basic needs for food, hygiene, and appearance; demonstrated ongoing ability to appropriately perform basic activities of daily living with little or no assistance or supervision;

Receptive and expressive language—Communication involving verbal and nonverbal behavior enabling a person to understand and express ideas and information to the general public with or without assistive devices; demonstrated ability to understand ordinary spoken and written communications and to speak and write well enough to communicate thoughts accurately and appropriately on an ongoing basis;
Learning—General cognitive competence and ability to acquire new behaviors, perceptions, and information and to apply experiences in new situations; demonstrated ongoing ability to acquire information, process experiences, and appropriately perform ordinary, cognitive, age-appropriate tasks on an ongoing basis;
Mobility—Motor development and ability to use fine and gross motor skills; demonstrated ongoing ability to move about while performing purposeful activities with or without assistive devices and with little or no assistance or supervision;
Self-direction—Management and control over one’s social and personal life; ability to make decisions and perform activities affecting and protecting personal interests; demonstrated ongoing ability to take charge of life activities as age-appropriate through an appropriate level of selfresponsibility and assertiveness; and 6. Capacity for independent living or economic selfsufficiency—Age-appropriate ability to live without extraordinary assistance from other persons or devices, especially to maintain normal societal roles; ability to maintain adequate employment and financial support; ability to earn a living wage, net (determined by the assessment team for each individual), after payment of extraordinary expenses caused by the disability; demonstrated ability to function on an ongoing

basis as an adult independent of extraordinary emotional, physical, medical, or financial support systems;

(S) Markedly disturbed social relatedness—A condition found in children from birth through age four (0–4) and characterized by— 1. Persistent failure to initiate or respond in an ageappropriate manner to most social interactions; for example, absence of visual tracking and reciprocal play, lack of vocal imitation or playfulness, apathy, little or no spontaneity, or lack of or little curiosity and social interest; or 2. Indiscriminate sociability; for example, excessive familiarity with relative strangers by making requests and displaying affection;

(T) Missouri Adaptive Abilities Scale (MAAS)—A standardized, normative, and criterion-based instrument used to determine the existence and severity of substantial functional limitations of major life activities;

(U) Screening—Initial evaluation services, possibly including review by an assessment team of information collected during the intake and application processes to substantiate that the applicant is developmentally disabled or is suspected to be developmentally disabled and requires further assessment for eligibility determination;

(V) Substantial—At least two (2) or more standard deviations below the mean, taking into consideration the standard error of measure, on a standardized, norm-referenced measure;

(W) Substantial functional limitation—An inability, due to a cognitive or physical impairment, to independently perform a major life activity within expectations of age and culture; and (X) Temporary action plan—A written plan authorizing additional time for the purpose of completing the comprehensive evaluation.

(3) Eligibility for services from the division is predicated on the applicant’s either having an intellectual developmental disorder or developmental disability or being at risk of becoming developmentally delayed or developmentally disabled. The following criteria is used in carrying out comprehensive evaluations for determining eligibility for services from the division:

(A) Children From Birth Through Age Four (0–4). Individuals participating in the First Steps Program under DESE are eligible for services under the Division of Developmental Disabilities.

The Division shall determine eligibility for those children not enrolled in First Steps based on one (1) of the following at-risk circumstances, when coupled with a score of at least one and one-half (1.5) standard deviations below the mean, taking into consideration the standard error of measure, in any one (1) area of a norm-referenced, standardized, and age-appropriate measure of adaptive function:

Receipt by the division of documentation, based upon an individualized assessment from a qualified developmental disabilities professional, that there is markedly disturbed social relatedness in most contexts which puts the child at risk of becoming developmentally delayed or developmentally disabled; or 2. Determination by a regional office that a child’s primary caregiver has a developmental disability and that the developmental disability could put the child at risk of becoming developmentally delayed or developmentally disabled;

(B) Children Ages Five Through Seventeen (5–17).

Children scoring as follows on the MAAS shall be considered to have substantial functional limitations in two (2) or more areas of major life activity:

A. One and one-half (1.5) standard deviations below the mean in at least two (2) developmental areas; or B. Two (2) or more standard deviations below the mean in only one (1) developmental area.

(C) Adults Ages Eighteen (18) and Older. Adults whose comprehensive evaluations, including results of the MAAS, indicate deficits in two (2) or more of the areas of major life activity shall be considered to have substantial functional limitations in those areas.

(4) Eligibility Process.

(A) Regional offices shall complete comprehensive evaluations within thirty (30) business days after receipt of valid applications and sufficient supporting medical, psychological, and/or educational reports. A Division of Developmental Disabilities staff member shall be designated to help ensure the eligibility determination process proceeds in a timely manner. The name of that individual shall be given to all applicants. This staff member shall have access to all necessary information relevant to the application for services.

(B) Individuals may apply for services only on application forms provided by the division.

By the end of the next business day after any referral, inquiry, or request for services, a regional office shall provide application forms and information about services offered by the division unless it is clearly evident that the inquiry, request, or referral has been made to the division inappropriately or is for a person who is clearly ineligible for services. In cases of evident ineligibility or inappropriate inquiries, requests, or referrals, regional offices shall refer individuals for whom services have been requested to appropriate agencies within five (5) business days after the inquiry, request, or referral.
For an individual’s request for services to be considered, the regional office must receive a valid application for services.

An application shall be valid only if signed or marked by the applicant. A mark must be witnessed.

Regional office staff shall contact the individual within ten (10) business days of receipt of an invalid application to obtain a valid application so that the eligibility process can continue.
If the regional office has not received an application within thirty (30) calendar days of the date it was provided to the individual, regional office staff shall contact the individual directly by telephone, electronic or regular mail, or in person to determine if the individual desires to continue the application for services and, if so, if assistance is needed in completing an application.

(C) A comprehensive evaluation includes— 1. A norm-referenced, standardized, and age-appropriate measure of adaptive function shall be used during assessment of children up to age five (5) to determine if substantial functional limitations exist; or 2. The MAAS shall be used during comprehensive evaluation of individuals age five (5) and older to determine if substantial functional limitations exist.

(D) When “in-person” meetings, including assessments, are required, the regional office staff shall conduct such meetings in applicants’ homes as feasible unless applicants request other sites. If meetings are at the Regional Office, the regional office staff shall work with applicants to secure transportation to the offices.

(E) If an applicant who claims eligibility due to intellectual developmental disorder has not been found to have substantial functional limitations in two (2) or more areas of major life activity under this rule, the assessment team shall consider any additional assessments or other relevant information provided by the applicant to determine if the applicant has an intellectual developmental disorder. One (1) or more standardized testing tools currently defined by the American Association on Intellectual and Developmental Disabilities shall be used in conducting adaptive behavioral assessment.

(F) If within thirty (30) business days of receipt of a valid application the assessment team finds the applicant ineligible for services, the regional office shall— 1. Provide, to the applicant, within one (1) business day of the decision, written notice of right to appeal the decision, a statement of the legal and factual reasons for the denial, a notice of the appeals process contained in 9 CSR 45-2.020, and a brochure which explains the appeals process;

Orally provide to the applicant, within one (1) business day of the decision, if possible, the reasons for ineligibility and an explanation of the applicant’s right to appeal, along with information about how and to whom to request an appeal; and 3. Make referrals within five (5) business days of the decision to other agencies and monitor services received by the applicant for at least thirty (30) calendar days from the date of the ineligibility determination.

(G) If the assessment team cannot make an eligibility determination within thirty (30) business days of receipt of a valid application because the regional office has not received collateral data or other information critical to the determination, the assessment team shall develop a temporary action plan within that thirty- (30-) business-day period, and the office may take up to thirty (30) additional business days to determine eligibility.

For an applicant then determined eligible during the additional thirty- (30-) business-day period, the assessment team also shall develop the initial plan within the thirty (30) business days of the determination of eligibility.
For individuals needing immediate services, the service coordinator also shall develop an initial ISP within five (5) business days after the eligibility determination unless an ISP has already been developed.
For an applicant determined ineligible during the additional thirty- (30-) business-day period, the regional office shall provide written and oral notices as set out in paragraphs (4)(F)1. and 2. of this rule and shall make referrals to other agencies and monitor services received by the applicant as set out in paragraph (4)(F)3. of this rule.

(H) If the assessment team has received collateral data and all other information necessary for the determination and does not make a determination within thirty (30) business days, they have an additional five (5) business days to make a determination.

For an applicant then determined eligible, the office shall proceed as set out in paragraphs (4)(I)1.–3. of this rule.
For an applicant then determined ineligible, the office shall proceed as set out in paragraphs (4)(F)1.–3. of this rule.

(I) For an applicant determined eligible within thirty (30) business days of receipt of valid application— 1. The regional office shall provide written notice of eligibility and client status within three (3) business days of the determination;

The planning team shall develop an ISP within thirty (30) business days after the date of the eligibility determination; and 3. For individuals needing immediate services, the service coordinator also shall develop an initial ISP within five (5) business days after the eligibility determination.

(J) The Regional Office (RO) shall reassess individuals through comprehensive evaluation as needed. RO shall discharge individuals who are no longer eligible for services and individuals for whom division services are no longer appropriate.

Not later than sixty (60) calendar days before a reassessment, the regional office shall provide to the individual a written notice of the upcoming reassessment and of the possibility that division services may be discontinued.
If, as a result of the comprehensive evaluation, an individual is found ineligible or no longer in need of services, the regional office shall provide written and oral notice as set out in paragraphs (4)(F)1. and 2. of this rule and shall prepare a discharge plan which shall provide at least sixty (60) calendar days from the date of that plan for the individual to transition from division services into services from other agencies. The regional office and the individual’s support coordinator shall monitor and assist with that transition.

(K) Regional office staff shall log the disposition of all applications, including eligibility determinations, appeals, and referrals to other agencies. Comprehensive evaluation activities noted throughout this rule shall be logged immediately or on the same business day.

(L) If an applicant or legal representative disagrees with an ineligibility determination, the determination may be appealed under procedures contained in 9 CSR 45-2.020

Amended: Filed June 25, 1996, effective Feb. 28, 1997. Amended:

Filed Feb. 1, 2012, effective Sept. 30, 2012. Amended: Filed Sept. 26, 2022, effective April 30, 2023. ** *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008. **Pursuant to Executive Order 21-09, 9 CSR 45-2.010, subsection (4)(I) was suspended from April 23, 2020 through December 31, 2021.

History

AUTHORITY: section 630.050, RSMo 2016. This rule was previously filed as 9 CSR 50-1.045. Original rule filed Oct. 2, 1991, effective May 14, 1992. Amended: Filed May 25, 1995, effective Dec. 30, 1995. Amended: Filed Oct. 25, 1995, effective April 30, 1996.

9 CSR 45-2.015 Prioritizing Access to Funded Services {#sec-9-csr-45-2.015 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-2.015}

PURPOSE: This rule establishes how individuals otherwise eligible for services will be selected for funded services and programs administered by the Department of Mental Health, Division of Developmental Disabilities, when services cannot be provided to all eligible individuals with developmental disabilities in the state of Missouri through the funding that is appropriated.

(1) Definitions.

(A) Community services—Supports funded and purchased through the Department of Mental Health Purchase of Service (POS) system with general revenue appropriations to assist and/or developmental disabilities to live in the community.

Eligibility for MO HealthNet is not required. Community services includes services for people with autism spectrum disorders funded with general revenue appropriations and administered through the Autism Projects defined at 9 CSR 45- 3.060.

(B) Community Support waiver—A set of services, not including residential services, for MO HealthNet eligible (C) Comprehensive waiver—A set of services, including residential services, for MO HealthNet-eligible individuals who have an intellectual developmental disorder and/or a developmental disability who have been determined to otherwise require the level of care provided in an ICF/DD.

(D) Division—Division of Developmental Disabilities.

(E) Intermediate care facility for intellectual developmental disorder and/or a developmental disability—Any facility certified under 42 CFR 440.150. These facilities are referred to as intermediate care facilities for developmental disabilities (ICF/ DD) throughout this rule.

(F) Missouri Children with Developme ntal Disabilities waiver (MOCDD)—A set of services, not including residential services, for children under the age of eighteen (18) living with their parents, who will qualify for MO HealthNet by qualifying for the waiver, who have an intellectual developmental disorder (G) Partnership for Hope waiver—A set of services, not including residential services, for MO HealthNet-eligible The Partnership for Hope is a county-based waiver operational in any Missouri county with a levy authorized under section 205.968, RSMo, whose board of directors has authorized funds to support the Partnership for Hope waiver or in any Missouri county approved by the Centers for Medicare and Medicaid Services for inclusion in this waiver.

(H) Prioritization of Need (PON) scoring—A process that assigns a score to the level of need for an individual, as set forth in 9 CSR 45-2.017. PON scoring is used to determine access to services when funding is limited and shall be applied to all individuals prior to participation in any of the following programs:

Comprehensive waiver;
Community Support waiver;
Missouri Children with Developmental Disabilities waiver (MOCDD ); or 4. Community services funded with general revenue appropriations and purchased through the Department of Mental Health Purchase of Service (POS) system.

(I) Waiting list—A list of all people who have qualified for but are not currently receiving services from the division. The waiting list shall be subdivided into the following categories:

Children under the age of eighteen who are not eligible for MO HealthNet, who have needs that require the level of care in an ICF/DD, and who would otherwise be eligible for the MOCDD waiver;
Individuals who are eligible for MO HealthNet who have needs that require the level of care in an ICF/DD and are otherwise eligible for the comprehensive waiver; and 3. Individuals who are eligible for MO HealthNet who have needs requiring the level of care in an ICF/DD, who do not have an immediate need for residential services but have service needs beyond the scope of the Partnership for Hope waiver; and 4. Individuals who are eligible for MO HealthNet, who have needs requiring the level of care in an ICF/DD, whose needs can be met safely with services in the Partnership for Hope waiver.

(2) Prioritizing Access to State General Revenue-Funded Autism Project-Funded Services (defined at 9 CSR 45-3.060). People who are on this waiting list shall be prioritized for access to general revenue funded services based on PON score. When two (2) or more individuals have the same PON score, the individual(s) who has been on the waiting list the longest time shall be given priority.

(3) The following sections describe how the waiting list for home and community-based waivers will be established and managed when funding is limited and establishes the methods used to determine which waiver is most appropriate to meet the needs of individuals when funding becomes available.

(A) Individuals who reside in a participating Partnership for Hope waiver county who would otherwise require care in a ICF/DD may be considered for enrollment in the waiver if the individual is experiencing crisis or meets other priority criteria as outlined below in this rule. When participation in the Partnership for Hope waiver is limited by available funds, individuals experiencing a crisis will be served first. If more than one (1) individual is experiencing a crisis, the individual who has been waiting the longest will be served first. If no one is experiencing a crisis, then individuals meeting other priority criteria will be served. If more than one (1) individual meets priority criteria, the individual who has been waiting the longest will be served first.

To be considered for access based on a crisis, an individual must be experiencing one (1) of the following:

A. Health and safety conditions pose a serious risk of immediate harm or death to the individual or others;

B. Loss of primary caregiver support or change in caregiver’s status to the extent the caregiver cannot meet needs of the individual; or C. Abuse, neglect, or exploitation of the individual.

To be considered for access to the Partnership for Hope waiver when no one in that county who is on the waiting list is experiencing a crisis, individuals meeting the following criteria will be served on the basis of length of time on the waiting list:

A. The individual’s circumstances or conditions necessitate substantial accommodation that cannot be reasonably provided by the individual’s primary caregiver;

B. The individual has exhausted both their educational and Vocational Rehabilitation (VR) benefits or they are not eligible for VR benefits and they have a need for preemployment or employment services;

C. Individual has been receiving supports (other than case management) from local funding for three (3) months or more and the services are still needed and the service can be covered by the waiver; and D. Individual living in a non-Medicaid funded residential care facility chooses to transition to the community and has been determined to be capable of residing in a less restrictive environment with access to Partnership for Hope waiver (B) Individuals who are determined to meet emergency criteria as described in 9 CSR 45-2.017(1)(E) and who require out-of-home residential services or for whom out-of-home residential care is imminent, and whose needs cannot be met with services and supports other than residential services or whose needs for services is anticipated to be in excess of the cost limitations of other waivers shall receive priority consideration to participate in the Comprehensive waiver.

Individuals on the waiting list shall be enrolled in the Comprehensive waiver according to the PON score, as set forth in 9 CSR 45-2.017 as funding becomes available.
When two (2) or more individuals have the same PON score, the individual(s) who has been on the waiting list the longest time shall be given priority access to the Comprehensive waiver.
When individuals on the waiting list are offered and refuse waiver services a new PON assessment shall be completed.

(C) Individuals on the waiting list whose needs can be met without residential services, whose needs can be met safely in the community, and whose annual service costs is anticipated to be less than the cost limits of those waivers, shall be prioritized for access in waivers other than the Comprehensive waiver.

(D) Children under the age of eighteen (18) who would otherwise require care in an ICF/DD, but who are not otherwise eligible for MO HealthNet because of parental income and/ or assets, may be considered for participation in the MOCDD waiver, and shall be served from the waiting list as turnover occurs based on prioritized need. When two (2) or more individuals have the same PON score, the individual(s) who has been on the waiting list the longest time shall be given priority.

When individuals on the waiting list are offered and refuse the service or services for which they were placed on the waiting list, they are removed from the waiting list. Should services be desired in the future, a new ISP and PON may be submitted.

(4) Program Turnover.

(A) Funds becoming available due to participants leaving (turnover) any programs listed under subsection (1)(I) shall first be used for individuals served in that program who have increased needs. When these needs are met, funds that become available from turnover may be used to enroll new individuals in the program.

(5) No individual shall receive services under more than one (1) home and community-based waiver at the same time, including home and community-based waivers operated by any other Missouri state agency. Any individual who is eligible for services under more than one (1) waiver and has priority access to services based on their score as set forth in 9 CSR 45- 2.017, when funding is available under both programs, shall be offered a choice of the waiver that best meets their needs, including home and community-based waivers operated by any other Missouri state agency.

(6) An individual may receive services under a waiver and may also receive community services funded with general revenue appropriations and purchased through the Department of Mental Health Purchase of Service (POS) system with approval from the division director when there is a need that cannot be met with waiver services.

Amended: Filed Sept. 26, 2022, effective April 30, 2023. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 633.110, RSMo 1980, amended 2011.

History

AUTHORITY: sections 630.050 and 633.110.2., RSMo 2016. Emergency rule filed Oct. 1, 2004, effective Oct. 15, 2004, expired April 15, 2005. Original rule filed March 31, 2006, effective Nov. 30, 2006. Amended: Filed Feb. 1, 2012, effective Sept. 30, 2012.

9 CSR 45-2.017 Utilization Review Process {#sec-9-csr-45-2.017 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-2.017}

PURPOSE: This rule formally establishes a statewide utilization review process to: ensure individuals eligible for division services with similar needs are treated consistently and fairly throughout the state; ensure each individual’s annual plan accurately reflects the individual’s needs; ensure levels of service are defined and documented within the outcomes of each individual’s plan; prioritize need for services; and ensure accountability of public funds.

(1) Definitions.

(A) Authorization—Approval notice to a provider that a specific amount of service at a specific rate may be provided to an individual.

(B) Budget—The total cost of services and supports funded through the division recommended or approved to meet an individual’s needs identified in an Individualized Support Plan. Services and supports paid for outside of the department billing system are excluded from the budget.

(D) Division—Division of Developmental Disabilities.

(E) Emergency criteria consist of one (1) or more of the following:

The individual is in immediate need of life-sustaining services (food and shelter, or protection from harm) and there is no alternative to division funding or provision of those services;
The individual needs immediate services in order to protect self or another person from imminent physical harm;
The individual is residing in an intermediate care facility for persons who have developmental disabilities (ICF/ DD) or a skilled nursing facility (SNF) and has been assessed as able to live in a less restrictive arrangement in the community, the individual wants to live in the community, and appropriate services and supports can be arranged through the waiver;
The individual had been receiving significant services through division waiver-funded programs and services, is evaluated to still need the significant level of services, but is no longer eligible for the program or services due to age; or 5. The individual is in the care and custody of the Department of Social Services, Children’s Division, which has a formal agreement in place with the division to fund the costs of waiver services for the specific individual or for individuals who are in a Voluntary Placement Agreement (VPA).

(F) Missouri Adaptive Ability Scale (MAAS)—A normreferenced, standardized assessment of functional ability.

The MAAS shall be used to determine number and severity of functional limitations for eligibility, prioritization of need score, and rate setting.

(G) Person-centered planning process—A process directed by the individual, with assistance as needed from a guardian, public administrator, the responsible party, or other person as freely chosen by the individual. The process may include other individuals freely chosen by the participant who are able to serve as important contributors to the process. The personcentered planning process enables and assists the individual to access a personalized mix of paid and non-paid services and supports that will assist him/her to achieve personally defined outcomes and the training, supports, therapies, treatments, and/or other services become part of the ISP.

(H) Prioritization of need (PON) score— A component of the MAAS that quantifies the level of impairment of an individual and is used to determine priority of access to services. The PON score is expressed on a one (1) to five (5) scale with five (5) being the highest possible score.

(I) Responsible party—The parent(s) of a minor child, spouse, court appointed guardian, public administrator, or any other person who has legal authority to make decisions for a person served by the division.

(J) Senate Bill 40 County Developmental Disability Boards (SB40 Board)—County boards established pursuant to section 205.970, RSMo, to provide services with voter approved tax levies to residents of that county who are handicapped persons as defined in sections 178.900 and 205.968, RSMo.

(K) Individualized Support Plan (ISP)—A document directed by the individual, with assistance as needed from a representative, in collaboration with a planning team. The ISP identifies strengths, capacities, preferences, needs, and desired outcomes of the individual. The ISP shall encompass personalized mix of paid and non-paid services and supports that will assist him/her to achieve personally defined outcomes.

Training, supports, therapies, treatments, and/or other services to be provided for the individual become part of the ISP.

(L) Service/Support—Informal and formal means of meeting needs identified in the ISP.

(M) Utilization Review (UR)—A formal process at the regional office to review PON, proposed ISPs, and budgets and make recommendations for approval, modification, or denial of the requested services. The regional director or assistant regional director has the authority to review and approve recommended services and may designate individuals to review and approve recommended services. The authority to deny or modify requested services lies solely with the regional director or assistant regional director.

(2) Following the establishment of eligibility for division services in accordance with 9 CSR 45-2.010, the personcentered planning process begins. An ISP is developed through discussion with the individual and/or guardian and with input from others as directed by the individual and/or guardian. The ISP, budget, and PON (if applicable), are then submitted to UR, and a copy of the ISP, budget, and PON (if applicable), is provided to the individual and/or guardian.

(A) A PON score is necessary when there is a request to begin participation in any waiver.

(B) A new assessment of PON shall be completed when an individual on a waiting list experiences a change in personal circumstances, environment, or family situation impacting level of need.

When individuals will be receiving funded services for the first time;
When the individual’s ISP and budget is amended by adding new services or increasing the dollar amount of a specific service;
When individuals who are participating in the Partnership for Hope waiver move from a participating county into one that does not participate in the Partnership for Hope waiver; or 4. Any other situation at the discretion of the regional director.

(D) UR is not necessary when there is no change to the ISP or budget, but the ISP may be reviewed at the discretion of the regional director.

(E) In emergency situations as described in paragraphs (1)

(E)1.-5. of this rule, the regional director has the authority to approve an increase in a ISP to protect the health and safety of an individual and to subsequently report the decision to the support coordinator who will develop an ISP amendment.

(3) Following implementation of the initial ISP and annually thereafter, two (2) months prior to the proposed ISP and budget implementation, the service coordinator shall meet with the individual, the individual’s family, and as appropriate the individual’s responsible party to prepare an ISP and budget with justification for the individual’s support needs.

(A) The ISP and budget shall be agreed to and the ISP shall be signed by the individual and/or responsible party.

(4) One (1) month prior to the proposed ISP and budget implementation, the service coordinator shall submit the signed ISP to the regional director or the regional director’s designee for approval. Plans submitted that include services with a start date less than thirty (30) days from the implementation date shall not expedite approval timelines.

(A) If the ISP and budget submission to UR shall otherwise be delayed due to the inability of the service coordinator to obtain the signature of the individual or responsible party, then the ISP and budget shall be forwarded to UR without the signature and a copy of the ISP and budget shall be mailed to the individual or responsible party.

(5) UR shall recommend for approval a service/support for inclusion on a prioritized waiting list if the service/support meets each of the following criteria:

(A) Need for the service/support is documented in the ISP as necessary for the individual’s health, safety, and/or independence and alternative funding or programs are not available to meet the need;

(B) Need for the service/support is specifically related to the person’s disability (i.e., not something that would be needed regardless of the person’s disability); and (C) Individuals evaluated with needs meeting emergency criteria receive highest priority in receiving funding for (6) The division shall maintain a waitlist for entry into the Division of Developmental Disabilities waiver- funded services.

The regional office enters individuals on a prioritized waiting list when services requested in an approved ISP require entry into a waiver. Individuals evaluated with needs meeting emergency criteria receive highest priority in receiving funding for services.

(7) UR shall review the ISP, budget and PON (when required) within six (6) business days of receipt. A PON score based on the emergency criteria will be reviewed by the regional director or their designee for verification.

(A) If sufficient information is submitted, the regional director or the designee may approve the ISP and budget.

The regional director or designee has five (5) business days to render a decision.

(B) If more information is needed or changes are necessary in the budget or service authorization associated with a ISP, that information shall be requested from the service coordinator, who has ten (10) business days to respond. Upon receipt of the requested information or following the conclusion of these ten (10) business days, the regional director or designee will then have five (5) business days to render a decision.

(8) Following the decision by the regional director or designee, a decision letter and the completed ISP and budget shall be provided within ten (10) business days of the decision to the individual and/or responsible party, service coordinator, and provider(s). If the regional director disapproves or modifies an ISP and budget, the regional director shall include in the decision letter the reason(s) for the disapproval or modification and must provide information on rights to appeal.

(9) The individual or responsible party may appeal the decision, in writing or verbally, to the regional director or assistant regional director within thirty (30) calendar days from the date of the decision letter.

(A) If necessary, appropriate staff shall assist the individual or responsible party in making the appeal.

(B) The regional director or designee may meet with the individual or responsible party and any staff to consider any information relevant to the final decision and to hear any comments or objections related to the decision.

(C) Within ten (10) business days after receiving the appeal, the regional director or designee shall notify the individual or responsible party in writing of the decision.

(10) When the decision, as set forth in section (8) above, results in any individual being denied service(s) based on a determination the individual is not eligible for the service(s) or adversely affects a waiver service for an individual, the individual and/or responsible party may appeal in accordance with the procedures set forth in 9 CSR 45-2.020(3)(C).

(A) An individual and/or responsible party participating in a Division MO HealthNet/Medicaid waiver program has appeal rights through both the Department of Mental Health and the Department of Social Services. Those individuals may appeal to Department of Social Services before, during, or after exhausting the Department of Mental Health appeal process.

Once the appeal process through Department of Social Services begins, appeal rights through the Department of Mental Health cease. Individuals appealing to the Department of Social Services must do so in writing within ninety (90) calendar days of written notice of the adverse action to request an appeal hearing. Requests for appeal to the Department of Social Services should be sent to MO HealthNet Division, Constituent Services Unit, PO Box 6500, Jefferson City, MO 65102-6500, or call Constituent Services Unit at 1 (800) 392-2161.

(11) If an individual and/or responsible party timely files an appeal of a decision, services currently being provided under an existing ISP will not be suspended, reduced, or terminated pending a hearing decision unless the individual or legal representative requests in writing that services be suspended, reduced, or terminated.

(A) The individual and/or responsible party may be responsible for repayment of any federal or state funds expended for services while the appeal is pending if the hearing decision upholds the director’s decision.

(12) The service coordinator shall provide guidance to the individual, family, and the responsible party about any alternative resources potentially available to support needs that are not approved through the UR process.

(13) New services/supports that result in an increase in the total budget shall not begin before the ISP and budget are approved through the UR process and approved by the regional director or designee, except in an emergency situation approved by the regional director or designee. Services approved due to an emergency situation may not exceed sixty (60) calendar days.

An extension of up to an additional sixty (60) calendar days may be requested in writing and may be approved in writing at the discretion of the regional office director.

(14) Budgets are determined by the total cost of all services and supports paid through the billing system of the department.

Services and supports paid for outside of the department billing system are excluded.

(A) When multiple family members are receiving division services, this shall be noted. All of the budgets shall be considered together in the utilization review process in order to have a comprehensive picture of all services/supports going into a single home so the necessary level of services can be determined. This does not require each family member’s ISP be on the same plan year, but does require all of the current supports in the home be considered.

(B) Applicable Medicaid State Plan services shall be accessed first when the individual is MO HealthNet-eligible and the services will meet the individual’s needs.

(15) A review, modification in units, or denial of a service should not delay the implementation of other services in the plan.

(16) Other ISP and budget reviews shall continue to be completed by the service coordinator and/or service coordination supervisor, as directed by the regional director.

rule filed March 31, 2006, effective Nov. 30, 2006. Amended: Filed Feb. 1, 2012, effective Sept. 30, 2012. Amended: Filed Sept. 27, 2022, effective April 30, 2023.** *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 633.110, RSMo 1980, amended 2011. **Pursuant to Executive Order 21-09, 9 CSR 45-2.017, paragraph (3)(B)2. was suspended from April 23, 2020 through December 31, 2021.

History

AUTHORITY: sections 630.050 and 633.110.2., RSMo 2016. Original

9 CSR 45-2.020 Appeals Procedures for Service Eligibility Through the Division of Developmental Disabilities {#sec-9-csr-45-2.020 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-2.020}

PURPOSE: This rule prescribes procedures for appealing decisions on service eligibility.

(1) As used in this rule, the following terms mean:

(A) Appeals referee—shall be an impartial, neutral, trained decision maker not employed with the Division of Developmental Disabilities;

(B) Applicant—a person suspected to have an intellectual developmental disorder or developmental disability and for whom application has been made for regional office services or the person’s representative;

(C) Client—a person who receives services of the Division of Developmental Disabilities or their representative. Clients will be referred to as individuals hereafter in this rule;

(D) Representative—shall include but not necessarily be limited to the applicant’s/individual’s legal guardian, parent of a minor applicant, or individual and protector (as defined by 9 CSR 45-3.040); and (E) Supervisor—a supervisor of service coordinators in a regional office or a unit director in a developmental disability facility.

(2) Any person who is suspected to have an intellectual developmental disorder or developmental disability shall be eligible for initial diagnostic and counseling services through the regional office.

(A) These rules are to be liberally construed in order to assure that all claims are decided on the merits of the individual’s claims and in the individual’s best interests. The rules regarding the time and manner in which a person may appeal shall be liberally interpreted to decide claims on the merits.

(B) Decisions as to an applicant’s eligibility for services, or an individual’s eligibility for continued services, shall be based on an assessment of the applicant’s/individual’s eligibility as determined by Missouri statutes. In making their determinations, staff (for example, members of the assessment team, service coordinators, regional director or their designee, appeals referees, and the director of the Missouri Department of Mental Health (DMH)) shall consider but need not be limited to each of the following factors and the appeals referee shall include in his/her written decision findings of fact and conclusions of law on each criterion considered:

The best interest of the individual/applicant;
The person’s level of adaptive behavior and functioning, including the effect upon the individual’s ability to function at either the same or an improved level of interpersonal and functional skills if support from the DMH and contracting private providers is withdrawn or denied; and 3. Whether the individual is eligible for services under the laws of Missouri.

(3) If the applicant, based upon the initial diagnostic evaluation or comprehensive evaluation, or if a individual, based upon a reevaluation, has been determined ineligible for regional office services, the applicant or individual may appeal the decision on eligibility.

(A) Appropriate, effective notice of the eligibility determination shall be given to the applicant/individual. This notice shall be given in writing, and verbally, when possible, on a standard DMH form within ten (10) business days of the ineligibility decision. The written notice shall include a specific statement of the factual and legal reasons for ineligibility, a statement that the applicant/individual has the right to appeal that decision and the name, address, and telephone number of the regional office staff person to contact for further information about the decision, the appeals process, or both. In addition to the notice, the applicant/individual shall receive a brochure which explains the appeals process and the appeals procedures open to the applicant/individual.

If there is any question about the applicant’s/individual’s ability to understand either the form or the brochure after s/he receives his/her notice in person or by telephone, the Missouri Division of Developmental Disabilities staff person shall verbally explain the basis for the denial of eligibility and the appeals process to the applicant/individual and shall assist the applicant/individual in initiating an appeal and contacting Missouri Protection and Advocacy Services. Notice shall be hand-delivered or shall be sent by registered or certified United States mail, return receipt requested, and given verbally, where appropriate, at least thirty (30) calendar days prior to the effective date of the proposed action.

(B) The applicant or individual may appeal the decision, in writing or verbally, to the regional office staff within thirty calendar (30) days from the date of receiving the written notice.

If necessary, appropriate staff shall assist the applicant/ individual in making the appeal.
The applicant or individual may present any information relevant to the appeal. The regional director or their designee shall meet with the applicant/individual and any staff to attempt to resolve differences and receive information on the matter.
Within ten (10) business days after receiving the appeal, the regional director or their designee shall notify the applicant verbally, when possible, and in writing of his/her findings and decision and of the right to appeal, including notice of where and how to direct appeal.

(C) If the applicant/individual disagrees with the decision of the regional director or their designee, the applicant/individual, verbally or in writing, may notify the regional office staff within thirty (30) calendar days of the date of receipt of the decision that the applicant/individual wishes to present the case to an appeals referee. If the applicant/individual verbally requests an appeal to the appeals referee, regional office staff shall send the person a notice via registered or certified mail, return receipt requested, verifying that the applicant/individual has verbally requested an appeal. The regional office staff also shall forward the verification notice to the appeals referee.

The referee shall be an employee of the department. The referee shall hear all appeals.
The appeals referee shall notify the applicant or individual in writing of the date, time, and location of the hearing before the referee. Effective notice of the hearing shall be given at least thirty (30) calendar days prior to the date of the hearing and shall contain a statement of the issues to be determined at the hearing. If any party has good cause for postponement or rescheduling, the request shall be granted.

Absent good cause, the hearing shall be held no later than sixty (60) calendar days from the date of the claimant’s request for a hearing. The hearing shall be held at a location convenient for the individual/applicant, usually the regional office identified in the appeal.

The applicant/individual shall have the right to representation either by an attorney or another advocate. Upon written notice that an individual is represented by an attorney/ advocate, the attorney/advocate shall be provided with copies of notices, and the like. Upon request of the individual/ applicant or his/her attorney/advocate, copies of all documents relevant to the appeal shall be made available without charge within five (5) business days of the date of the request. An individual or his/her attorney/advocate shall have the right to inspect and copy all relevant Missouri DMH documents, including but not necessarily limited to department rules and applicant/individual records if release is authorized in writing by the applicant/individual, including third-party individual records in the custody of the department that were utilized in making the decision on eligibility.
The appeals referee shall rest his/her decision solely on the evidence presented at the hearing. The referee shall not review any documents concerning the applicant’s/individual’s eligibility that are not properly submitted on the record during the hearing. The appeals referee, in addition, shall not discuss the applicant’s/individual’s appeal with any party other than in the context of the hearing, questioning witnesses on the record, or both. The referee shall assure that the claimant receives a full and fair hearing. After the conclusion of the hearing, the referee shall issue a written decision, including findings of fact and conclusions of law, within thirty (30) calendar days of the close of the hearing. The decision shall be mailed to the regional office and to the claimant and his/her attorney/ advocate, if any, by registered or certified mail, return receipt requested. Upon request of the claimant, regional office staff may be consulted by the claimant for an explanation of the decision and its implications. The decision also shall contain a brief description of further appeal rights provided by this rule.

Within thirty (30) calendar days of the decision, the referee shall have the authority to vacate or amend his/her decision at the request of the claimant or his/her attorney/advocate or the head of the regional office with notice to the others for good cause shown.

The head of the regional office shall have the burden of proof and burden of going forward to either establish that the applicant does not meet the state’s statutory criteria for services eligibility or that the individual has so improved that s/he no longer would benefit from the level of services which had been previously provided.
During the hearing, the applicant/individual or the head of the regional office shall have the right to speak on behalf of self, to present witnesses, to be represented by an attorney or other advocate, to submit any additional information, and to cross examine witnesses who have appeared on behalf of the regional office.

A. If the applicant or individual is represented by legal counsel, the claimant or his/her counsel shall notify the head of the regional office within ten (10) calendar days from the date that counsel is retained for the hearing.

B. If the applicant or individual is represented by legal counsel at the hearing, the head of the regional office shall request representation from the attorney general’s office. The request for representation should be made to the attorney general’s office as soon as practicable. Notice to the applicant/ individual and attorney that the attorney general’s office will appear in the case should be made at least five (5) calendar days before the hearing.

Unless otherwise provided in this rule, the hearing shall be conducted by the provisions of Chapter 536, RSMo.
The referee shall electronically record the hearing. The recording of the hearing shall be kept for one (1) year after the date of the hearing. The recording shall be available to the individual/applicant or his/her attorney/advocate or the regional office director for purposes of review for further appeal.

(D) Either party may appeal the decision of the appeals referee to circuit court as provided by Chapter 536, RSMo. For purposes of appeal, the recording of the hearing before the appeals referee shall be transcribed at the expense of the party appealing but shall be without cost to the applicant/individual who is indigent as determined by the department or the circuit court.

(E) Pending an administrative appeal or appeal before circuit court if the appeals referee’s decision is appealed, the department shall not reduce or terminate the applicant’s or individual’s services or benefits. No applicant’s or individual’s benefits or services shall be reduced or terminated until appeal procedures are exhausted.

(4) If an individual disagrees with the decision made by regional office staff regarding eligibility for a specified service through the division, except referral for community placement from a department developmental disability facility, the individual may appeal the decision.

(A) The appeal may be presented orally or in writing to the appropriate supervisor within thirty (30) calendar days from receipt of the oral or written notice, whichever is earlier.

If necessary, the appropriate staff shall assist the individual in making the appeal.
The individual may present, and the supervisor shall accept and consider, any information relevant to the appeal.

The supervisor may meet with the individual and any staff to discuss and resolve differences.

Within ten (10) business days after receiving the information presented by the individual, the supervisor shall notify the individual in writing and verbally of the supervisor’s finding and decision and the right of the individual to appeal to the regional office director or their designee.

(B) If the individual disagrees with the decision of the supervisor, the individual shall be entitled to utilize the same appeal procedures to the regional office director or their designee, the appeals referee, and the circuit court as provided in section (3) of this rule.

Amended: Filed May 25, 1995, effective Dec. 30, 1995. Amended:

Filed Feb. 1, 2012, effective Sept. 30, 2012. Amended: Filed Sept. 27, 2022, effective April 30, 2023. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008.

History

AUTHORITY: section 630.050, RSMo 2016. This rule was previously filed as 9 CSR 50-3.705. Original rule filed April 17, 1987, effective Oct. 1, 1987. Amended: Filed Jan. 15, 1993, effective Aug. 8, 1993.

Chapter 3 Services and Supports

9 CSR 45-3.010 Individual Support Plans {#sec-9-csr-45-3.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-3.010}

PURPOSE: This rule prescribes procedures for development and implementation of individual support plans for all individuals receiving services from the Division of Developmental Disabilities.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive.

This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction.

This note applies only to the reference material. The entire text of the rule is printed here.

(1) Definitions.

(A) Assessment—the process of gathering information about an individual for use by the individual support plan team as a basis for the individual support plan. Assessment, as used in this rule, does not include determination of eligibility by the Department of Mental Health (DMH) as set forth in 9 CSR 45- 2.010.

(B) Division—the Division of Developmental Disabilities.

(C) Home and Community-based Waivers— also referred to as home and communitybased services (HCBS) in this rule; a set of long-term community-based supports and services authorized by the Centers for Medicare and Medicaid Services which are provided as an alternative to care in institutions such as nursing facilities and intermediate care facilities for individuals with intellectual disabilities.

(D) Individual Support plan (ISP)—a document developed by the individual, with assistance as needed from a representative, in collaboration with the individual support plan team. The ISP identifies strengths, capacities, preferences, needs, and desired outcomes of the individual. The ISP encompasses a personalized mix of paid and non-paid services and supports that will assist him/her to achieve personally defined outcomes.

Training, supports, therapies, treatments and/or other services to be provided for the individual become part of the ISP. ISP is also referred to as a person-centered service plan.

(E) Individual support plan team—the individual, the individual’s guardian or designated representative(s), and the support coordinator. Providers of waiver-funded services may also participate in the support plan team if such participation is requested by the individual, guardian, or designated representative.

(F) MO HealthNet—Missouri’s name for the state’s Medicaid program, authorized under Title XIX of the Social Security Act.

(G) MO HealthNet participant—an individual enrolled with MO HealthNet.

(H) Natural supports—any unpaid support including, but not limited to, immediate and extended family members, friends, co-workers, neighbors, and community services available to any individual regardless of disability.

(I) Reassessment—data obtained from training programs, results of screenings, and formal or informal assessments completed since the previous ISP team meeting.

(J) Waiver participant—individual receiving HCBS services.

(2) Every individual referred to a qualified provider of targeted case management who is a participant of MO HealthNet or who receives any services funded by the division, including services under a home and community-based waiver or services funded only by general revenue, shall have an individual support plan (ISP).

(3) Person-centered planning shall be done in accordance with 42 CFR 441.301(c)(1). The individual shall lead the person-centered planning process where possible. The individual's representative should have a participatory role, as needed and as defined by the individual or guardian, if applicable. In addition to being led by the individual receiving services and supports, the person-centered planning process shall— (A) Include people chosen by the individual;

(B) Provide necessary information and support to ensure that the individual directs the process to the maximum extent possible, and is enabled to make informed choices and decisions;

(D) Reflect cultural considerations of the individual and be conducted by providing information in plain language and in a manner that is accessible to individuals with disabilities and persons who are limited English proficient; and (E) Include strategies for solving conflict or disagreement within the process, including clear conflict of interest guidelines for all planning participants.

(4) In accordance with 42 CFR 441.301(c)(2), the ISP shall reflect the services and supports that are important for the individual to meet the needs identified through an assessment of functional need, as well as what is important to the individual with regard to preferences for the delivery of such services and supports. Commensurate with the level of need of the individual and the scope of services and supports available through the division, the ISP shall— (A) Reflect the individual’s strengths and preferences;

(B) Reflect clinical and support needs as identified through an assessment of functional need;

(D) Reflect the services and supports (paid and unpaid) to assist the individual to achieve identified goals, and the providers of those services and supports, including natural supports;

(E) Reflect risk factors and measures in place to minimize them, including individualized back-up plans and strategies when needed;

(F) Be understandable to the individual receiving services and supports, and the individuals important in supporting him or her.

At a minimum, for the ISP to be understandable, it is written in plain language and in a manner that is accessible to individuals with disabilities and persons who are limited English proficient;

(G) Identify the individual and/or entity responsible for monitoring the ISP;

(H) Be distributed to the individual and any other individuals or providers who sign the plan, as specified in section (5) of this

rule;

(I) Include those services, the purpose or control of which the individual elects to selfdirect or designate an authorized representative to direct on his or her behalf;

(J) Prevent the provision of unnecessary or inappropriate services and supports; and (K) Document that any restrictions of individual rights is supported by a specific assessed need and justified in the ISP in accordance with 42 CSR 441.301(c)(2).

(5) The ISP shall be finalized and agreed to, with the informed consent of the individual in writing, and signed by all individuals and providers responsible for its implementation in accordance with 42 CFR 441.301(c)(2)(ix), with the exception of providers of assistive technology, dental, durable medical equipment, environmental accessibility adaptations, specialized medical equipment and supplies, and transportation.

(A) Signatures may be added to the plan electronically using a format accepted by MO HealthNet.

(B) If it is not possible to obtain a written signature from the individual or guardian, the Division Regional Office Director or his or her designee may approve an exception if the following steps are completed:

At least two (2) attempts to obtain the signature are documented. One (1) attempt may be either by phone or E-mail, and the other attempt documented through certified mail with delivery validated by a signed return receipt;
A justification is attached to the ISP describing these and any other efforts made to obtain the signature; and 3. The regional director may require additional efforts by the support coordinator to obtain the signature from the individual or guardian.

(C) If the exception to the signature is approved by the regional director or designee, a copy of the approved exception request is sent to everyone to whom a copy of the ISP is distributed.

(6) ISP Review: The ISP shall be reviewed and revised upon reassessment of functional need in accordance with 9 CSR 45-2.010 at least every twelve (12) months, when the individual's circumstances or needs change significantly, or at the request of the individual. The reassessment of functional need shall be completed within ninety (90) days before the ISP review.

(7) ISP updates require prior written approval from the ISP team before implementation of the change and signatures in accordance with

section (5) of this rule. ISP updates requiring prior written approval include:

(A) Addition of a new service;

(B) Increase or decrease in amount and/or frequency of a service already in place;

(D) Limitation of rights as set forth in 9 CSR 45-3.030; and (E) Change in ISP outcomes.

(8) Changes in legal information including, but not limited to, arrests, incarceration, court orders, and legal actions other than changes in guardianship shall be documented in the ISP but shall not require prior written approval or signatures if the change does not result in a change in services.

(9) Denial, reduction, or termination of a service is subject to appeal as set forth in 9 CSR 45-2.020.

(10) Changes in training plans or methods to ensure progress toward achievement of outcomes already documented in the ISP may be made by the provider of the related service as needed without approval of the ISP team.

(11) The division may authorize emergency residential services, respite care, or crisis intervention for up to thirty (30) days without prior approval of the ISP team.

(12) The division shall provide guidance and technical assistance to providers of support coordination in the person-centered planning process and the development and oversight of the ISP.

(13) Individuals with developmental disabilities, as defined in 9 CSR 45-2.010, but who are not MO HealthNet participants and who do not receive services from the division funded by general revenue shall be provided with individualized information based on, but not limited to, their age, diagnosis, and geographic residence.

Filed Jan. 22, 2019, effective Aug. 30, 2019. *Original authority: 630.655, RSMo 1980.

History

AUTHORITY: section 630.655, RSMo 2016. The rule was previously filed as 9 CSR 10- 5.150. Original rule filed Nov. 30, 1990, effective April 29, 1991. Amended: Filed May 25, 1995, effective Dec. 30, 1995. Amended:

9 CSR 45-3.020 Individualized Supported Living Services—Definitions {#sec-9-csr-45-3.020 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-3.020}

(Rescinded June 30, 2016)

This rule was previously filed as 9 CSR 30- 5.010. Emergency rule filed Aug. 4, 1992, effective Sept. 1, 1992, expired Dec. 29, 1992. Original rule filed Aug. 4, 1992, effective Feb. 26, 1993. Amended: Filed May 25, 1995, effective Dec. 30, 1995. Rescinded:

Filed Dec. 8, 2015, effective June 30, 2016.

History

AUTHORITY: section 630.050, RSMo 1994.

9 CSR 45-3.030 Individual Rights {#sec-9-csr-45-3.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-3.030}

PURPOSE: This rule defines the rights of persons eligible for services from the Division of Developmental Disabilities (Division of DD).

(1) All individuals served by the Division of DD shall be entitled to the following rights and privileges without limitation, unless otherwise provided by law:

(A) To be treated with respect and dignity as a human being;

(B) To have the same legal rights and responsibilities as any other citizen;

(C) To receive services regardless of race, creed, marital status, national origin, disability, religion, sexual orientation, gender, or age;

(D) To be free from physical, emotional, sexual, and verbal abuse, and financial exploitation;

(E) To receive services and supports to achieve the maximum level of independence;

(F) To have access to all rules, policies, and procedures governing the operations of the Division of DD in an accessible format, and to have those rules, policies, and procedures explained in a manner that is easily understood;

(G) Within one’s financial means, to have a choice where to live and whether or not to share a home with other people;

(H) To direct one’s own person-centered planning process and to choose others to be included in that process;

(I) To participate fully in the community;

(J) To communicate in any form and to have privacy of communications;

(K) To accept or decline supports and services;

(L) To have freedom of choice among Division of DD approved providers;

(M) To seek employment and work in competitive integrated settings;

(N) To participate or decline participation in any study or experiment;

(O) To choose where to go to church or place of worship, or to refuse to go to a church or place of worship;

(P) To have rights, services, supports, and clinical records regarding services explained in a manner that is easily understood and in an accessible format;

(Q) To have all of an individual’s records maintained in a confidential manner;

(R) To report any violation of one’s rights free from retaliation and without fear of retaliation; and (S) To be informed on how to make an inquiry, file a complaint or report a violation of one’s rights, and to be assisted in these processes, if requested.

(2) Adults who do not have a legal guardian have the right to designate a representative to act on one’s behalf for purposes of receiving services from the Division of DD.

(3) An individual’s rights as outlined in section one (1) may not be restricted, including, but not limited to, by a provider of targeted case management or home and community based services, without due process. Due process under this provision includes the right to be notified and heard on the limitation or restriction, the right to be assisted through external advocacy if an individual disagrees with the limitation or restriction, and the right to be informed of available (7/31/19) JOHN R. ASHCROFT options to restore the individual’s rights.

Filed July 25, 2016, effective Feb. 28, 2017. 1995, 2008.

History

AUTHORITY: section 630.050, RSMo 2016. This rule was previously filed as 9 CSR 30- 5.040. Emergency rule filed Aug. 4, 1992, effective Sept. 1, 1992, expired Dec. 29, 1992. Original rule filed Aug. 4, 1992, effective Feb. 26, 1993. Amended: Filed May 25, 1995, effective Dec. 30, 1995. Amended:

9 CSR 45-3.040 Rights of Designated Representatives, Parents, and Guardians {#sec-9-csr-45-3.040 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-3.040}

PURPOSE: This rule prescribes policies for designation of representatives and recognition of certain rights of designated representatives, parents, and guardians of individuals receiving services from the Division of Developmental Disabilities (Division of DD).

(1) Definitions.

(A) Designated representative—a parent, relative, or other person designated by an adult who does not have a guardian. The designated representative may participate in the person-centered planning process and development of the individual support plan, at the request of, and as directed by, the individual.

(B) Circle of support—team supporting the individual and participating in the personcentered planning process.

(C) Person-centered planning process—a process directed by the individual, with the inclusion of a circle of support created by or with the individual, which may include a guardian, public administrator, the individual, and/or persons freely chosen by the individual who are able to serve as important contributors to the process. The person-centered planning process enables and assists the individual to access a personalized mix of paid and non-paid services and supports that will assist him/her to achieve personally defined outcomes. These trainings, supports, therapies, treatments, and/or other services will become part of the individualized support plan.

(D) Individual Support Plan (ISP)—A document that results from the person centered comes.

(2) The Division of DD shall recognize that the ISP process is directed by the individual and their circle of support. Parents and legal guardians, who are willing and able to exercise their rights, may participate in personcentered planning, development, and implementation of the ISP, and/or referral as set out in this rule.

(3) As set out in section 633.110, RSMo, parents of minor children and youth and legal guardians have the right to approve or refuse supports or placement of their children or wards.

(4) Adults who have not been declared legally incapacitated may give their written consent for parents, relatives, or other persons to serve as their designated representative to advocate for and advise, guide, and encourage the individual and members of the individual support plan team in developing and implementing individual support plans.

Written consent for designated representatives shall include written authorization to disclose protected health information.

(A) In accordance with the federal Health Insurance Portability and Accountability Act of 1996, as amended, and departmental policy, the consent shall authorize the designated representatives’ access to those individual records specified by the individual and for periods of time specified by the individual.

(B) Designated representatives shall not have the right to approve or refuse referral, support, or placement of individuals and should act as the individual’s advocate against or in support of recommended changes.

(C) Individuals may revoke their consent in writing at any time and the Division of DD and all parties responsible for the implementation of the ISP shall recognize the revocations immediately.

(D) Written consents and revocations shall be maintained in the individual’s ISP and copies shall be given to designated representatives.

Filed July 25, 2016, effective Feb. 28, 2017. 1995, 2008.

History

AUTHORITY: section 630.050, RSMo 2016. This rule was previously filed as 9 CSR 50- 1.055. Original rule filed March 4, 1992, effective Aug. 6, 1992. Amended: Filed May 25, 1995, effective Dec. 30, 1995. Amended:

9 CSR 45-3.050 Admission and Treatment of Clients with Aggressive Behaviors {#sec-9-csr-45-3.050 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-3.050}

(Rescinded September 30, 2002)

This rule was previously filed as 9 CSR 50- 1.060. Original rule filed Sept. 1, 1993, effective Jan. 31, 1994. Amended: Filed May 25, 1995, effective Dec. 30, 1995.

Rescinded: Filed March 11, 2002, effective Sept. 30, 2002.

History

AUTHORITY: section 630.050, RSMo 1994.

9 CSR 45-3.060 Services for Individuals with Autism Spectrum Disorder {#sec-9-csr-45-3.060 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-3.060}

PURPOSE: This rule establishes programs and services for persons with autism and their families.

(1) Terms defined in sections 630.005, 633.005, and 633.220, RSMo are incorporated by reference for use in this rule. Also, the following terms mean:

(A) Autism spectrum disorder (ASD)—a group of neurodevelopmental disorders characterized by persistent deficits in social communication and social interaction across multiple contexts as well as by restricted, repetitive patterns of behaviors, interests, or activities. Symptoms of ASD must be present in the early developmental period and cause significant impairment in social, occupational, or other important areas of functioning;

(B) Family support—services and helping relationships for the purpose of maintaining and enhancing family caregiving. Family support may be any combination of services that enable individuals with autism to reside within their family homes and remain integrated within their communities. Family support services are— 1. Based on individual and family needs;

Easily accessible for the family;
Family-centered and culturally sensitive;
Flexible and varied to meet the changing needs of the family members;
Identified by the family; and 6. Provided in a timely manner contingent upon availability of resources; and (C) Service provider—a person or an entity which provides and receives reimbursement for autism programs and services as specified in section (3) of this rule.

(2) The Division of Developmental Disabilities (Division of DD) shall establish programs and services for persons with autism. The Division of DD shall establish such programs and services in conjunction with persons with ASD and their families. The programs and services shall be designed to enhance the abilities of persons with ASD and their families’ abilities to meet needs they identify. The programs and services shall— (A) Develop skills for persons with autism through supports, services, and teaching;

(B) Teach families to provide behavioral supports to members with autism; and (C) Provide needed family support.

(3) The Division of DD Director, with input from the Missouri Parent Advisory Committee on Autism, shall divide the state into at least five (5) regions and establish autism programs and services which are responsive to the needs of persons with autism and families consistent with contemporary and emerging best practices. The boundaries of such regions, to the extent practicable, shall be contiguous with relevant boundaries of political subdivisions and health service areas. Such regions shall be referred to as regional autism projects in this rule.

(4) Regional Autism Projects may provide or purchase, but shall not be limited to, the following services:

(A) Assessment;

(B) Advocacy training;

(D) Communication and language therapy;

(E) Consultation on individualized education and habilitation plans;

(F) Crisis intervention;

(G) Information and referral assistance;

(H) Life skills;

(I) Music therapy;

(J) Occupational therapy, sensory integration therapy, and consultation;

(K) Parent or caregiver training;

(L) Public education and information dissemination;

(M) Respite care;

(N) Staff training;

(O) Social skills training; and (P) Other contemporary and emerging evidence-based practices.

(5) Regional Autism Projects shall each have regional parent advisory councils composed of from seven to nine (7–9) persons that have family members with autism, including family members that are young children, school-age children, and adults. The members shall be Missouri residents and their family members with autism shall have met the Division of DD’s eligibility requirements specified under 630.005, RSMo.

(A) One-third (1/3) of the members serving on July 1, 1995, shall continue to serve until July 1, 1996. One-third (1/3) shall serve until July 1, 1997, and the remaining onethird (1/3) shall serve until July 1, 1998.

Length of those terms shall be determined by drawing lots.

(B) Upon expiration of members’ terms, new members shall be nominated by the councils for three- (3-) year terms or until their successors have been elected. New members of each of the five (5) regional parent advisory councils shall be appointed by the Division of DD Director or designee from nominations submitted by the regional parent advisory councils. No member shall serve more than two (2) consecutive three- (3-) year terms. No council member shall be a service provider, a member of a service provider’s board of directors, or an employee of a service provider or the Division of DD. Regional parent advisory councils shall be encouraged to maintain membership from each region within their project boundaries. The councils shall make every effort to elect members to represent the cultural diversity of the project areas and to represent persons with autism of all ages and capabilities.

(C) Each council shall elect a chairperson, vice-chairperson, and secretary. Annual elections shall occur in July. The councils shall meet bimonthly or more often at the call of the chairpersons. A simple majority of the membership shall constitute a quorum.

(D) Each council shall establish bylaws specific to the council’s project area and consistent with parameters established by the Missouri Parent Advisory Council on Autism set out in section (6).

(E) The councils’ responsibilities shall include, but not be limited to, the following:

Advocacy;
Contract monitoring;
Review of annual Department of Mental Health audits of projects;
Recommendation of services to be provided based on input from families;
Recommendation of policy, budget, and service priorities;
Monthly review of service delivery;
Planning;
Public education and awareness;
Recommendation of service providers to the Division of DD for administration of the projects; and 10. Recommendation of contract cancellation.

(F) In the event a parent advisory council disagrees with a decision of the Division of DD Regional Director’s designee related to operation of the autism project, the issue may be referred to the Missouri Parent Advisory Committee on Autism for its recommendation to the Division of DD Director.

(6) The Division of DD shall establish the Missouri Parent Advisory Committee on Autism. It shall be composed of two (2) representatives and one (1) alternate from each of the five (5) regional parent advisory councils set out in this rule. It shall also include one (1) person with autism and one (1) alternate, a person with autism, who are not members of a regional parent advisory council. The committee shall be appointed by the Division of DD Director.

(A) The Division of DD Director shall make every effort to appoint members nominated by the regional parent advisory councils.

The membership should represent the cultural diversity of the state and represent persons with autism of all ages and capabilities;

(B) One-third (1/3) of the members serving on January 1, 1995, serve until January 1, 1996. One-third (1/3) shall serve until January 1, 1997, and the remaining one-third shall serve until January 1, 1998. Length of those terms shall be determined by drawing lots.

(C) Upon expiration of the terms, members shall be appointed by the Division of DD Director for three- (3-) year terms or until their successors have been appointed. No member shall serve more than two (2) consecutive three- (3-) year terms.

(D) At its annual meeting in July, the Missouri Parent Advisory Committee on Autism shall elect a chairperson, a vice-chairperson, and a secretary. The committee shall meet quarterly or more often at the call of the chairperson. A simple majority of the membership shall constitute a quorum.

(E) The committee’s responsibilities shall include, but not be limited to, the following:

Communication with the projects set out in section (3) to provide up-to-date information to them and the families they serve;
Determining project outcomes for autism services;
Determining roles and responsibilities of the regional parent advisory councils set out in section (5);
Development of positive relationships with the Department of Elementary and Secondary Education and local school districts;
Establishing policy for the Missouri Parent Advisory Committee on Autism;
Fostering unity with and among the projects set out in section (3) to ensure joint support for legislative, budget, and other issues;
Planning and sponsorship of statewide activities;
Provision of program recommendations to the Division of DD;
Recommendation of service providers to the Division of DD Director in the event a regional parent advisory council and Division of DD Director’s designee cannot reach consensus;
Recommendation of issue resolutions to the Division of DD Director; and 11. Submission of an annual report to the Missouri Commission on Autism Spectrum Disorders, the governor, the director of the Department of Mental Health, and the director of the Division of DD.

Filed July 31, 1998, effective Jan. 30, 1999.

Amended: Filed July 25, 2016, effective Feb. 28, 2017. 1995, 2008 and 633.220, RSMo 2009.

(7/31/19) JOHN R. ASHCROFT

History

AUTHORITY: sections 630.050 and 633.220, RSMo 2016. Original rule filed Feb. 6, 1995, effective Sept. 30, 1995. Amended:

9 CSR 45-3.070 Certification of Medication Aides Serving Persons with Developmental Disabilities {#sec-9-csr-45-3.070 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-3.070}

PURPOSE: Individuals who administer medications or supervise self-administration of medications in any residential setting or day program funded, licensed or certified by the Department of Mental Health to provide services to persons who are mentally retarded or developmentally disabled, are required to be either a physician, a licensed nurse, a certified medication technician, a certified medication employee, a level I medication aide or Department of Mental Health medication aide. The provisions of the rule do not apply to family-living arrangements unless they are receiving reimbursement through the Medicaid Home and Community-Based Waiver for persons with developmental disabilities. This rule sets forth the requirements for approval of a Medication Aide Training Program designating the required course curriculum content, outlining the qualifications required of students and instructors, designating approved training facilities and outlining the testing and certification requirements.

Therefore, the material which is so incorporated is on file with the agency who filed this

rule, and with the Office of the Secretary of State. Any interested person may view this material at either agency’s headquarters or the same will be made available at the Office of the Secretary of State at a cost not to exceed actual cost of copy reproduction. The entire text of the rule is printed here. This note refers only to the incorporated by reference material.

(1) The purpose of the Medication Aide Training Program shall be to prepare individuals for employment as medication aides in any residential setting or day program funded, licensed or certified by the Department of with mental retardation or developmental disabilities. The training program does not prepare individuals for the parenteral administration of medications such as insulin or the administration of medications or other fluids via enteral feeding tubes.

(2) All aspects of the Medication Aide Training Program included in this rule shall be met in order for a program to be considered approved.

(3) The objectives of the Medication Aide Training Program shall be to ensure that the medication aide will be able to— (A) Define the role of a medication aide;

(B) Prepare, administer and chart medications by nonparenteral routes;

(D) Identify responsibilities associated with control and storage of medications; and (E) Utilize appropriate drug reference materials.

(4) The course shall be a minimum of sixteen (16) hours of integrated formal instruction and practice sessions supervised by an approved instructor.

(5) The curriculum content shall include procedures and instructions in the following areas: basic human needs and relationships; drug classifications and their implications; assessing drug reactions; techniques of drug administration; documentation; medication storage and control; drug reference resources; and infection control.

(6) The approved course curriculum shall be the manual entitled Level I Medication Aide (IE 64-1), developed by the Department of Elementary and Secondary Education, Department of Mental Health and the Division of Aging and produced by the Instructional Materials Laboratory, University of Missouri-Columbia. This manual is incorporated by reference in this rule.

Students and instructors each shall have a copy of this manual.

(7) A student shall not administer medications without the instructor present until s/he successfully completes the course and obtains a certificate.

(8) Student Qualifications.

(A) Any individual employable in a residential setting or day program funded, licensed or certified by the Department of who are mentally retarded or developmentally disabled, and who meet the requirements of 9 CSR 10-5.190, shall be eligible to enroll as a student in this course or to challenge the final examination.

(B) An individual may qualify as a medication aide by successfully challenging the final examination if that individual has successfully completed a medication administration course and is currently employed to perform medication administration tasks in a residential setting or day program operated, funded, licensed or certified by the Department of Mental Health to provide services to persons who are mentally retarded or developmentally disabled.

(9) Those persons wanting to challenge the final examination shall submit a request in writing to the Missouri Division of Mental Retardation and Developmental Disabilities enclosing applicable documentation. If approved to challenge the examination, the Division of Mental Retardation and Developmental Disabilities will send the applicant a letter to present to an approved instructor so arrangements can be made for testing.

(10) Instructor Qualifications.

(A) An instructor shall be currently licensed to practice as either a registered nurse or practical nurse in Missouri or shall hold a current temporary permit from the Missouri State Board of Nursing. The licensee shall not be subject to current disciplinary action such as censure probation, suspension or revocation. If the individual is a licensed practical nurse, the following additional requirements shall be met:

Shall not be waived: the instructor has a valid Missouri license or a temporary permit from the Missouri State Board of Nursing; and 2. Shall be a graduate of an accredited program, which has pharmacology in the curriculum.

(B) In order to be qualified as an instructor, the individual shall— 1. Have attended a “Train the Trainer” workshop to implement the Level I Medication Aide Training Program conducted by a Missouri registered nurse presenter approved by the Missouri Division of Aging.

Meet at least one (1) of the following criteria:

A. Have had one (1) year’s experience working in a long-term care (LTC) facility licensed by the Division of Aging or in a residential facility or day program operated, funded, licensed or certified by the Department of Mental Health within the past five (5) years; or B. Be currently employed in a LTC facility licensed by the Department of Mental Health and shall have been employed by that facility for at least six (6) months; or C. Shall be an instructor in a Health Occupations Education Program.

(11) Sponsoring Agencies.

(A) The Medication Aide Training Program may be sponsored by providers of residential or day programs operated, funded, licensed or certified by the Department of Mental Health, Division of Mental Retardation and Developmental Disabilities.

(B) The sponsoring agency is responsible for obtaining an approved instructor, determining the number of manuals needed for a given program, ordering the manuals for the (6/30/20) JOHN R. ASHCROFT students and presenting a class schedule for approval by the local regional center. The sponsoring agency shall maintain the following documentation: the name of the approved instructor; the instructor’s Social Security number, current address and telephone number; the number of students enrolled; the name, address, telephone number, Social Security number and age of each student; the name and address of the facility that employs the student, if applicable; the date and location of each class to be held; and the date and location of the final examination. If there is a change in the date and location of the training, the sponsoring agency shall notify the local regional center.

(C) Classrooms used for training shall contain sufficient space, equipment and teaching aids to meet the course objectives as determined by the Division of Mental Retardation and Developmental Disabilities.

(D) If the instructor is not directly employed by the agency, there shall be a signed written agreement between the sponsoring agency and the instructor which shall specify the role, responsibilities and liabilities of each party.

(12) Testing.

(A) The final examination shall consist of a written and a practicum examination administered by the instructor.

The written examination shall include questions based on the course objectives developed by the Division of Mental Retardation and Developmental Disabilities.
The practicum examination shall be conducted in a residential setting or day program operated, funded, licensed or certified by the Department of Mental Health, Division of Mental Retardation and Developmental Disabilities or an LTC facility which shall include the preparation and administration by nonparenteral routes and recording of medications administered to consumers under the direct supervision of the instructor and the person responsible for medication administration in the facility. When it is not feasible and/or possible to conduct the practicum examination in an approved residential or day program, the instructor may request a waiver from the local regional center to conduct the practicum examination in an approved simulated classroom situation.

(B) A score of eighty percent (80%) is required for passing the final written examination and one hundred percent (100%) accuracy in the performance of the steps of procedure in the practicum examination.

(C) The final examination, if not successfully passed, may be retaken within ninety (90) days one (1) time without repeating the course, however, those challenging the final examination must complete the course if the examination is not passed in the challenge process.

(D) The instructor shall complete final records and shall submit these and all test booklets to the sponsoring agency.

(13) Records and Certification.

(A) Records.

The sponsoring agency shall maintain records of all individuals who have been enrolled in the Medication Aide Training Program and shall submit to the local regional center all test booklets, a copy of the score sheets and a complete class roster.
A copy of the final record shall be provided to any individual enrolled in the course.
A final record may be released only with written permission from the student in accordance with the provisions of the Privacy Act—PL 900-247.

(B) Certification.

The regional center shall issue a Department of Mental Health, Division of Mental Retardation and Developmental Disabilities, Medication Aide Certificate to employable individuals successfully completing the course upon receiving the required final records and test booklets from the sponsoring agency.
The regional center shall enter the names of all individuals receiving a Medication Aide Certificate in the Division of Mental Retardation and Developmental Disabilities Medication Aide Registry.
Medication aides who do not currently meet certification requirements must successfully pass the Level I Medication Aide course or challenge the final examination, if eligible, and obtain a Division of Mental Retardation and Developmental Disabilities Medication Aide Certificate within eighteen (18) months from the effective date of this

regulation. Individuals who fail to comply shall not be allowed to administer medications.

Individuals who hold a Medication Aide Certificate issued by a regional center or a Division of Aging Level I Medication Aide Certificate, and have completed biannual training as required in section (14), will meet the requirements of this rule.

(14) Bi-Annual Training Program.

(A) Level I medication aides shall participate in a minimum of four (4) hours of medication administration training every two (2) years in order to administer medications in a residential setting or day program funded, certified or licensed by the Department of who are mentally retarded or developmentally disabled. The training shall be taken in two (2) two (2)-hour blocks or a four (4)-hour block and must be completed by the anniversary date of the medication aide’s initial level I medication aide certificate. The training shall be— 1. Offered by a qualified instructor as outlined in section (10) of this rule; and 2. Documented on the Level I Medication Aide Bi-Annual Training form MO 650-8730 and kept in the employee’s personnel file. This form is incorporated by reference in this rule.

(B) The training shall address at the least the following:

Medication ordering and storage;
Medication administration;

A. Use of generic drugs;

B. How to pour, chart, administer and document;

C. Information and techniques specific to the following: inhalers, eye drops, topical medications and suppositories;

D. Infection control;

E. Side effects and adverse reactions;

F. New medications and/or new procedures;

G. Medication errors;

Individual rights, and refusal of medications and treatments;
Issues specific to the facility/program as indicated by the needs of the consumers, and the medications and treatments currently being administered; and 5. Corrective actions based on problems identified by the staff, the trainees or issues identified by regulatory and accrediting bodies, professional consultants or by any other authoritative source.

(C) The Department of Mental Health regional centers will routinely monitor the quality of medication administration. When quality assurance monitoring documents that a medication aide is not administering medications within training guidelines, the regional center may require the aide to take additional training in order to continue passing medications in the residential setting or day program.

(15) Revocation of Certification.

(A) If the Department of Mental Health upon completion of an investigation, finds that a medication aide has stolen or diverted drugs from a consumer or facility or has had his/her name added to the Department of Mental Health Employee Disqualification Registry or Division of Aging Employee Disqualification Registry, the Department of Mental Health shall render the medication aide’s certificate invalid.

History

AUTHORITY: sections 630.050 and 633.190, RSMo 2000. Original rule filed Jan. 10, 2001, effective Aug. 30, 2001. 1995; 633.190, RSMo 1993, amended 1995. Pursuant to Executive Order 21-09, 9 CSR 45-3.070, section (4), subparagraph (10)(A)2.B., and subsections (14)(A) and (14)(B) was suspended from April 23, 2020 through December 31, 2021.

9 CSR 45-3.080 Self-Directed Supports {#sec-9-csr-45-3.080 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-3.080}

PURPOSE: This rule establishes the scope of and requirements for the use of Self-Directed Supports, a service delivery option available under Home and Community Based waivers as created by section 1915(c) of the Social Security Act.

(1) Definitions.

(A) Agency-based supports—supports provided by a public or private agency, including independent contractors, under contract with the Department of Mental Health and enrolled with the MO HealthNet Division to serve participants of any home and community-based waivers operated by the department.

(B) Back-up plan—an emergency plan developed to address situations when the employee providing essential supports is unavailable. The individual support plan for all individuals receiving self- and familydirected supports must provide information about the back-up plan.

(C) Budget authority—the right and responsibility of the employer to exercise control and management of a yearly budget allocation.

(D) Designated representative (DR)—a parent, relative, or other person designated by an adult individual or a guardian, who shall act in the best interest of the individual and serves at the discretion of the individual.

(E) Employer—individual receiving services through self-directed supports and/or person with the power to act on such individual’s behalf, such as: a designated representative; guardian; or parent, if the individual is a minor. The employer maintains the Federal Employer Identification Number and employs persons to provide services to the individual.

(F) Employment authority—the right and responsibility of the employer to recruit, hire, train, manage, supervise, fire, and establish the wages for employees within the limits described in section (16) of this rule.

(G) Family member—a parent, stepparent, sibling, child, grandchild, or grandparent related by blood, adoption, or marriage, or a spouse.

(H) Fiscal management service (FMS)—a service to assist the employer with payrollrelated functions. The FMS ensures the selfdirected supports program meets federal, state, and local employment tax, labor and workers’ compensation insurance rules, and other requirements that apply when the individual or his/her designee functions as the employer of workers. The FMS makes financial transactions on behalf of the individual.

(I) Home and community-based waivers (HCB waivers)—a set of long term community-based supports and services authorized by the Centers for Medicare and Medicaid Services which are provided as an alternative to care in institutions such as nursing facilities and intermediate care facilities for individuals with intellectual disabilities. The specific services provided under a home and community-based waiver is referred to as home and community-based services.

(J) Improvement plan—a corrective action plan to address issues of non-compliance with program requirements. The goal of the improvement plan is to focus on needed supports to ensure the employer succeeds when using self-directed supports.

(K) Individual—person receiving supports through a home and community-based waiver.

(L) Individual Support Plan (ISP)—a document that results from the person-centered comes.

(M) Individual Support Plan team (ISP team)—the individual, the individual’s designated representative(s), and the support coordinator. Providers of waiver-funded services may also participate in the support plan team if such participation is requested by the individual or guardian.

(N) Natural supports—unpaid support provided through relationships that occur in everyday life. Natural supports typically involve family members, friends, co-workers, neighbors, acquaintances, and community resources.

(O) Self-directed supports (SDS)—a service delivery option available under the home and community-based waivers for persons with intellectual and developmental disabilities and who wish to exercise more choice, control, and authority over their supports.

(2) Eligibility Criteria. Every individual who is receiving services through an HCB waiver shall have the opportunity to utilize SDS as his/her own employer as long as— (A) The individual; designated representative; guardian; or a parent, if the individual is a minor, is willing and able to act as the employer, assuming both budget and employment responsibilities while receiving HCB waiver services from the Division of Developmental Disabilities (DD); and (B) The Division of DD does not find good cause to deny the use of this service model under the criteria stated in section (11) of this rule.

(3) Designated Representative. An individual who is eighteen (18) years or older, a guardian, or a parent (if the individual is a minor), may identify a designated representative for purposes of utilizing SDS. Designated representatives must demonstrate a history of knowledge of the individual’s preferences, values, needs, and other relevant information.

The individual, his or her planning team, and regional office are responsible to ensure that this representative is able to perform all the employer-related responsibilities and complies with requirements associated with representing the individual in directing services and supports.

(A) The following individuals may be designated as a representative:

Spouse, unless a formal legal action for divorce is pending;
An adult child of the individual;
A parent;
An adult brother or sister;
Another adult relative of the individual;
A legal guardian; and 7. Any other adult chosen by the individual with approval of the ISP team consistent with the requirements of this section.

(4) Employer Rights and Responsibilities.

(A) The employer must manage the employees’ day-to-day activities ensuring supports are provided as written in the ISP.

(B) The employer may choose to hire eligible persons in accordance with the HCB waiver services requirements and with the following exceptions:

A spouse;
A parent or stepparent of an individual under age eighteen (18);
A legal guardian;
A designated representative; or 5. A person who is disqualified from employment under section 630.170, RSMo.

(C) The employer shall complete all forms required by the state’s FMS contractor, including Internal Revenue Service (IRS) and Missouri state tax forms.

(D) The employer shall obtain a Federal Employer Identification Number (FEIN) in the name of the individual (or parent/guardian if the individual is under the age of eighteen (18)), with the assistance of the FMS.

(E) The employer shall follow all federal (2/28/22) JOHN R. ASHCROFT and state employment laws and regulations including, but not limited to:

Recruiting, interviewing, checking references, hiring, training, scheduling work, managing and terminating employee(s). This includes directing the day-to-day care of the individual and addressing conflicts between employees;
Submitting all new employee paperwork to the FMS prior to the initiation of service. All required documents must be completed, submitted, and approved as a complete packet in order for them to be processed in a timely manner. Incomplete documents may delay an employee’s start date;
Providing equal employment opportunities to all employees and interested employees without discrimination as to race, creed, color, national origin, gender, age, disability, marital status, sexual orientation, or any other legally protected status in all employment decisions, including recruitment, hiring, changing schedules and number of hours worked, layoffs, and terminations, and all other terms and conditions of employment.

The employer accepts full and specific responsibility for following Equal Opportunity laws and requirements regarding employees. Each employee is to be treated fairly and consistently. For example, if the employer decides to check references on one (1) employee, it must be done for all employees;

An employee may not provide services while the individual is hospitalized or receiving any other direct care service reimbursed through the MO HealthNet Division (MHD);
Reviewing and approving time worked, which authorizes billing;
Submitting documentation of time worked in a timely manner in accordance with the FMS payroll schedule. The employer and employee signatures on/approval of the time sheet validates that the information submitted is accurate and true. If the employer signs/approves and the hours have not been worked, the employer will be held financially liable for payment for the time reported but not worked;
The employer is responsible for monitoring the monthly spending summary report provided by the FMS and for keeping all expenditures within the individual budget allocation as specified in the ISP. The employer agrees to reimburse the FMS for any payment of wages and expenses in excess of the amount in the individual budget allocation. Payment to the employee is limited to services actually delivered by the employee;
If the employer authorizes use of all funds/hours before the end of the period, the employer is responsible for other service arrangements; for example, use of non-paid natural supports. The employer is responsible for the payment of any wages and expenses in excess of the individual budget allocation.

Employees must be paid for all hours worked;

Informing the FMS within one working day of any changes in the individual’s status, including name, address, telephone number, hospitalization, and termination of program eligibility; and 10. Informing the FMS of the employee pay rate (wages), including timely notification of changes to the pay rate. Changes in pay rates must occur at the beginning of a pay period.

(F) The following must be reported immediately:

Any possible fraud, including MHD fraud to the FMS;
Abuse, neglect, misuse of property or funds, health risk, or other reportable event to the appropriate authorities. Reports of abuse, neglect, or exploitation of adults shall be made to the Department of Health and Senior Services, to the Division of DD, or to the individual’s support coordinator; and 3. Employee changes, including name, address, contact number, and/or employment status.

(G) Appointment of a temporary representative if the employer is not capable or available to manage employees and contact made to the support coordinator to evaluate if a new representative must be appointed.

(H) Establishing a work schedule for employees. Time worked by employees in excess of forty (40) hours per week cannot be billed to MHD. Hours worked over forty (40) hours per week are the responsibility of the employer and must be paid through the FMS to ensure employee taxes are withheld.

(I) The employer shall not supplement wages to the employee outside of the fiscal management agreement.

(J) In accordance with the approved HCB waivers, payment for personal assistance services is not allowed for employee sleep time.

If an employer schedules an employee to work a period of twenty-four (24) consecutive hours or more, the employer and employee may agree to exclude from hours worked up to eight (8) hours of sleep time when both of the following conditions are met:

The employer furnishes sleeping facilities; and 2. The employee can usually sleep uninterrupted.

(5) Combination of Supports. An individual receiving service through an HCB waiver may receive a combination of supports through SDS and agency-based supports so long as services from one (1) program do not duplicate services from the other.

(6) Exemption from Personal Assistance Services Training. The employer may exempt training for personal assistant services under the following circumstances documented in the ISP:

(A) Duties of the personal assistant will not require skills to be attained from the training requirement; or (B) The personal assistant has adequate knowledge or experience as determined by the employer.

(7) Family Members Providing Services. The only service family members may provide is personal assistance services and only if he/she is not disqualified under section (4).

When a family member provides personal assistance support, the ISP must reflect— (A) The individual is not opposed to a family member providing the service;

(B) The services to be provided are solely to support the individual and not household tasks expected to be shared with people living in the family unit;

(C) The ISP team determines the paid family member will best meet the needs of the individual; and (D) The family member cannot be paid for over forty (40) hours per week. Support in excess of forty (40) hours per week provided by a family member is considered a natural (unpaid) support.

(8) Parameter of Services. Services that may be self-directed are specified in each HCB waiver for people with developmental disabilities operated by the Division of DD and approved by the Centers for Medicare and Medicaid Services. Services included in the individual’s ISP that may not be self-directed will be delivered through agency-based supports by a provider chosen by the individual.

(9) Consumer-Directed Personal Assistance Program through the Department of Health and Senior Services. Individuals who receive services under the consumer-directed personal assistance program authorized in 19 CSR 15

Chapter 8 and administered by the Department of Health and Senior Services (DHSS) may not simultaneously use SDS under any HCB waiver operated by the Division of DD.

Individuals eligible to self-direct supports under both the DHSS consumer-directed personal assistance program and under an HCB waiver operated by the Division of DD must choose which program to direct supports under and choose a quali fied provider of (2/28/22) JOHN R. ASHCROFT agency-based supports for the other.

(10) Voluntary Termination. If an individual voluntarily requests to terminate SDS in order to receive services through an agency, the support coordinator will work with the individual, guardian, or designated representative to select a provider agency and transition services to agency-based supports by changing prior authorizations based on the individual’s needs. When the self-directed services are voluntarily terminated, the same level of service is offered to the individual through agency-based supports.

(11) Denial and Mandatory Termination of SDS. The option of self-direction may be denied or terminated under any of the following conditions:

(A) The ISP team determines the health and safety of the individual is at risk;

(B) The employer is unable or unwilling to ensure employee records are accurately kept;

(D) The employer is unable or unwilling to use adequate supports or unable or unwilling to stay within the budget allocation; or (E) The employer has been the subject of a Medicaid audit resulting in sanctions for false or fraudulent claims under 13 CSR 70- 3.030 Conditions of Provider Participation, Reimbursement, and Procedures of General Applicability, Sanctions for False or Fraudulent Claims for MHD.

(12) Improvement Plans.

(A) When an employer is found to be out of compliance with program requirements, an improvement plan shall be established. The improvement plan shall be jointly developed by the employer, individual, support broker, support coordinator, and other regional office staff, as needed.

(B) The plan shall include the specific issues of concern and shall include specific strategies and time frames for improvement.

(C) Failure to successfully meet the terms of the improvement plan within the established time frames shall result in termination of the option to use SDS.

(13) Termination of SDS for Non-Compliance.

Except under circumstances described in section (11) of this rule, before terminating SDS, the support coordinator or appropriate staff of the regional office will first counsel the employer to assist in understanding the issues, inform the employer what corrective action is needed, and offer assistance in making changes. Counseling shall include the establishment of an improvement plan. If the employer refuses to cooperate, including failure to successfully carry out the terms of the improvement plan, the option of SDS shall be terminated.

(A) A letter shall be sent notifying the employer that the option of SDS will be terminated and a choice of agency-based providers offered.

(B) A choice of agency-based provider(s) must be made within fifteen (15) days.

(C) The employer may request a meeting with the regional director to discuss the unsuccessful completion of the improvement plan. The request for a meeting must be made within five (5) business days of the written notification that the option of SDS will be terminated.

(D) The regional director must schedule the meeting within ten (10) business days of the request.

(E) The regional director shall make a final decision within three (3) business days of the meeting. The decision of the regional director shall be final.

(14) Immediate Termination for Non- Compliance. When there is evidence of fraud or repeated patterns or trends of non-compliance with program requirements, counseling has been provided to the employer, an improvement plan has been established but has not been successfully completed within the agreed upon time frames, the regional director shall immediately terminate SDS and shall authorize agency-based services from a provider agency chosen by the individual.

(A) The regional office shall request repayment from the employer for any recoupments by the Department of Social Services Missouri Medicaid Audit and Compliance office from the DMH Division of DD.

(15) Service Level Requirements after SDS Termination. When the option for SDS is terminated, the same level of services must be made available to the individual through a qualified waiver provider. The individual shall have a choice of provider.

(16) Individual Budget Allocation, Employee Wages, and Reimbursement.

(A) The SDS individual budget allocation shall be based on the total number of hours needed for the span dates of the ISP multiplied by the statewide base rate for comparable agency-based supports.

(B) The SDS individual budget allocation shall be equal to but shall not exceed the level of support the individual would receive from a provider agency.

(C) Supports included in the SDS individual budget allocation to be paid through the HCB waiver shall not supplant or duplicate natural supports available to the individual.

(D) The Department of Social Services, MHD shall establish maximum allowable rates as recommended by DMH for all HCB supports.

(E) Once the individual receives their SDS individual budget allocation, the employer is responsible to set the wages of his/her employees. Wages shall not be less than minimum wage and not in excess of the MHD maximum allowable rate. The wage includes the net pay to the employee plus all related taxes, worker’s compensation, and unemployment insurance.

(17) Fiscal management services (FMS).

(A) DMH shall select a FMS contractor through a competitive bid process.

(B) The FMS shall perform the following functions:

Managing and directing the distribution of funds contained in the individual budget allocation;
Facilitating the employment of staff by the employer by performing employer responsibilities such as processing payroll, withholding and filing federal state, and local taxes, and making tax payments to appropriate tax authorities;
Performing fiscal accounting and making expenditure reports to the employer and state authorities;
Collecting provider qualifications and training information;
Conducting background screens of potential employee candidates;
Collecting documentation of services provided; and 7. Collecting and processing employees’ time sheets.

History

AUTHORITY: sections 630.050 and 630.655, RSMo 2016. Original rule filed Dec. 19, 2016, effective July 30, 2017. Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.655, RSMo 1980. Pursuant to Executive Order 21-09, 9 CSR 45-3.080, subsections (4)(H) and (7)(D) was suspended from April 23, 2020 through December 31, 2021.

9 CSR 45-3.090 Behavior Supports {#sec-9-csr-45-3.090 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-3.090}

PURPOSE: This rule sets forth requirements for providers under contract with the Department of Mental Health to support individuals with intellectual and developmental disabilities and assure the rights of individuals to receive best practice behavior strategies that lead to greater independence and enhanced quality of life. This rule describes the division’s oversight of behavior supports, establishes and describes the role and function of behavior supports review committees.

(1) Definitions— (A) Applied behavior analysis—The design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationships between environment and behavior, as established in section 337.300(1), RSMo;

(B) Behavior analysis services—Use of applied behavior analysis principles and technology to assist support systems of individuals with challenging behaviors to prevent those behaviors as well as teach, promote, encourage, and reinforce alternative skills and behaviors;

(C) Behavior support plan (BSP)—A part of the individual support plan that is comprised of behavior analytic procedures developed to systematically address behaviors to be reduced or eliminated and behavior skills to be learned;

(D) Blocking—A staff person using a part of their body to prevent an individual from inflicting or incurring harm when an individual is attempting to hit, kick, or otherwise harm himself or herself, the staff, or another person. Use of pads, cushions, or pillows to soften or prevent impact to the individual or others is also considered blocking. Blocking does not involve grasping or holding any part of the individual’s body;

(E) Challenging behaviors—Culturally undesirable behavior(s) likely to both limit access to the community and interfere with independence and autonomy;

(F) Chemical restraint—Medications (prescribed or over-the-counter) administered with the primary intent of restraining an individual who presents a likelihood of serious physical injury to himself or others, not prescribed to treat a person’s medical condition (as defined in section 630.005, RSMo);

(G) Due process—The right to be notified and heard on the limitation or restriction, the right to be assisted through external advocacy if an individual disagrees with the limitation or restriction, and the right to be informed of available options to restore the individual’s rights;

(H) Emergency interventions—Reactive strategies that are not part of the individual’s plan used to maintain safety of the individual or others in the threat of imminent harm.

These are strategies used for one (1) or two (2) incidents until a planned intervention is developed in the safety crisis plan and/or BSP. These emergency interventions may involve physical restraint strategies. These interventions must be least restrictive and comply with statutes, rules, regulations, and policies of the division;

(I) Emergency intervention system—also called physical crisis management programs—A formal curriculum and training program to teach prevention, de-escalation, and physical restraint, also called manual holds, to maintain safety in emergency situations;

(J) Exclusion time out—The temporary exclusion of an individual from access to reinforcement, as part of a formal BSP, in which, contingent upon the individual’s undesirable behavior(s), the individual is excluded from the potentially reinforcing situation but remains in the same area with others present;

(K) Functional Behavior Assessment (FBA)—Information-gathering process used to understand the purpose of challenging behavior. The functional assessment must be designed and monitored by a licensed behavior analyst, or licensed psychologist, counselor, or social worker trained in behavior analysis;

(L) Informed consent—Consent for treatment based on certain basic elements that include: an understandable explanation and

purpose of the procedure to be followed, a description of physical, emotional, or mental discomfort or risk to be expected, an offer to answer any inquiries concerning the procedure, and an explanation that at any time consent can be rescinded. Informed consent must be obtained from the individual, or the guardian for individuals who have a guardian. Every effort should be made to obtain informed agreement from individuals with guardians;

(M) Individual Support Plan (ISP)—A document that results from the person centered comes;

(N) ISP team—The individual, the individual’s designated representative(s), and the support coordinator. Providers of waiverfunded services may also participate in the ISP team if the individual or guardian requests such participation;

(O) Least restrictive procedure—A procedure that maximizes an individual’s freedom of movement, access to personal property, and/or ability to refuse while maintaining safety. The degree of restrictiveness is based on a comparison of the various possible procedures that would maintain safety for the individual in a given situation;

(P) Licensed behavioral support professional—individual licensed in the state of Missouri under section 337.315 (6) and (7), RSMo.

(Q) Manual hold—also called physical restraint and manual restraint—Any physical hold involving a restriction of an individual’s voluntary movement. Physically assisting someone who is unsteady, or blocking to prevent injury, is not considered a manual hold;

(R) Mechanical restraints—Any device, instrument, or physical object used to confine or otherwise limit an individual’s freedom of movement that cannot be easily removed.

Examples may include locking a wheelchair, taking crutches, taking power mechanism from wheelchairs, special seat belts that cannot be removed by the individual, or other ways of restricting an individual’s mobility.

Mechanical restraints are prohibited from use in home and community based settings. The following are not considered mechanical restraints:

Medical protective equipment prescribed as part of medical treatment for a medical issue;
Physical equipment or orthopedic appliances, surgical dressings or bandages, or supportive body bands or other restraints necessary for medical treatment, routine physical examinations, or medical tests;
Devices used to support functional body position or proper balance, or to prevent a person from falling out of bed, or falling out of a wheelchair;
Typical equipment used for safety during transportation, such as seatbelts or wheelchair tie-downs; or 5. Mechanical supports or supportive devices used in normative situations to achieve proper body position and balance;

(S) Person centered planning process—A process directed by the individual, with the inclusion of a circle of support created by or with the individual, a guardian, the responsible party or other person as freely chosen by the individual, who are able to serve as important contributors to the process. The person-centered planning process enables and assists the individual to access a personalized mix of paid and non-paid services and supports that will assist him/her to achieve personally defined outcomes. These trainings, supports, therapies, treatments and/or other services become part of the ISP;

(T) Preventative strategies—Clearly defined protocols which describe knowledge and skill sets that providers and/or the individual must implement in order to prevent occurrences of undesirable behaviors or the use of restrictive supports while also creating increased opportunities for success.

Preventative strategies are documented in the support section of the ISP;

(U) PRN—A medical term meaning “when necessary”;

(V) PRN Psychotropic medication for behavioral support—Medication (pharmacologic agent) that affects a person’s mental status and is prescribed to be given according to circumstance rather than at a scheduled time.

If utilized, the BSP/ISP must include skill or responses to be developed to reduce the need for the PRN and must specifically describe strategies to address the situation prompting the PRN use. Use of PRN psychotropic medication is considered both a reactive strategy and a restrictive intervention;

(W) Provider—Any entity or person under contract with the Department of Mental Health (DMH) to serve individuals with developmental disabilities funded by general revenue or through home and communitybased waivers administered by DMH;

(X) Psychotropic/behavior control medications—Any medication that affects the person’s mental status or behaviors regardless of their diagnoses;

(Y) Qualified personnel—Staff persons who have received training, demonstrated competency, and maintained required certification and understanding of the following:

The Physical Crisis Management System utilized at the agency in which they are employed;
The implementation of the individual’s safety crisis plan;
The implementation of the BSP and ISP;
All requirements as a service provider outlined in the most current service definitions for providers;

(Z) Reactive strategies—Actions, responses, and planned and unplanned interventions in response to challenging behavior.

Emergency interventions are types of reactive strategies. Reactive strategies have the aim of bringing about immediate change in an individual’s behavior or control over a situation so that risk associated with the behavior is minimized. Reactive strategies may take a number of forms and can include environmental, psychosocial, and restrictive interventions. Such procedures may be utilized as a first time response to an emergency situation. This also includes responses that are more delayed such as restricting access to the community or increased levels of supervision;

(AA) Reactive strategy threshold—The use of five (5) or more reactive strategies within a one (1) month period. This threshold applies to the use of reactive strategies that also meet the definition of restrictive interventions;

(BB) Regional Behavior Supports Committee (RBSC)—A committee consisting of a chairperson who is a Licensed Behavior Analyst, employed by the division and appointed by the division director or designee, along with qualified members, whose functions include meeting the expectations set forth in this rule;

(CC) Regional Office (RO)—Local offices of the Division of Developmental Disabilities (referred to as “the division” throughout this document) serving a defined geographic region of the state;

(DD) Restrictive interventions—The use of interventions that restrict movement, access to other individuals, locations or activities, restrict rights or employ aversive methods to modify behavior. These may also be called restrictive supports, procedures, or strategies;

(EE) Safety assessment—An assessment by the planning team and a medical professional of an individual’s physical, and/or emotional status. This includes history and current conditions that might affect safe usage of any reactive strategies, and identifies those reactive strategies that should not be used with the individual due to medical or psychological issues of safety. The safety assessment should be completed annually or on the occasion of any significant change;

(FF) Safety crisis plan—An individualized plan outlining the reactive strategies designed to most safely address dangerous behaviors at the time of their occurrence or to prevent their imminent occurrence, included as part of a BSP or ISP;

(GG) Seat belt guard—A safety device to prevent the release of the seat belt while the car is in motion. Seat belt guards are not mechanical restraints;

(HH) Seclusion time-out—The involuntary confinement of an individual alone in a room or an area from which the individual is physically prevented from having contact with others or leaving. This is sometimes referred to as a safe room or calm room. Locked rooms (using a key lock or latch system not requiring staff directly holding the mechanism) are prohibited.

(II) Significantly challenging behaviors— Actions of the individual which can be expected to result in issues described in paragraphs 1.—6. below. Services to address these behaviors may necessitate involvement of a licensed behavior analyst or other licensed professional with appropriate training and experience— 1. Have resulted in external or internal injury requiring medical attention or are expected to increase in frequency, duration, or intensity such that medical attention may be necessary without intervention by a licensed behavior support professional;

Have occurred or are expected to occur with sufficient frequency, duration, or intensity that a life-threatening situation might result because of self-injury, aggression, or property destruction. Examples include excessive eating or drinking, vomiting, ruminating, eating non-nutritive substances, refusing to eat, swallowing excessive amounts of air, or running into traffic;
Have resulted or are expected to result in major property damage or destruction, value of property more than two hundred dollars ($200);
Have resulted in or are expected to result in arrest and confinement by law enforcement personnel;
Have resulted in the need for additional staffing and/or behavioral/medical personal assistant services; or 6. Have resulted in the repeated use of emergency interventions and restrictive supports; and (JJ) Waiver assurances—As a condition of waiver approval by the Centers for Medicare and Medicaid Services, states collect and report performance data to measure compliance with assurances specified in the Code of Federal Regulations at 42 CFR 441.302.

(2) Rights of individuals and assurances.

(A) No individual shall experience restrictive supports without due process. Restrictive supports include, but are not limited to, any limitation of access to:

Communication with others;
Leisure activities;
The individual’s own money or personal property;
Goods or services per typical routines;
Access to parts of the home or the community; and 6. Privacy or independence via any direct observation and procedures such as continuous one-to-one staffing during times or places which would otherwise be considered private.

(B) In addition to those rights described in and assured by federal and state law and 9 CSR 45-3.030, all individuals served by the division have the right to be treated with dignity and respect, to receive services in the least restrictive environment, and to be assured freedom from coercion and aversive stimuli.

(C) All individuals served by the division have strategies that may prevent problem situations and challenging behaviors included in their ISPs. Preventive strategies shall meet the following conditions:

If there is a BSP, preventive strategies must be included;
Preventive strategies may be developed by non-licensed team members if the behavior of concern meets the following conditions:

A. The behavior has not caused significant injury or danger to self, others, or property; and B. The behavior has not restricted the individual’s access to the community, and if the support strategies involved typically may be considered public domain by promoting a more positive environment, enriching the individual’s daily routine, and teaching more functional skills, but are not solely the practice of applied behavior analysis.

(D) Individuals who are receiving paid supports who have experienced or are considered by the person centered planning team as likely to experience emergency interventions shall— 1. Have qualified personnel supporting them who have been competency trained in an emergency intervention system, who maintain current certification in the system;

Have a safety assessment and a current safety crisis plan with all support providers.

(3) Service delivery.

(A) Individuals have the right to receive appropriate supports and services in accordance with their ISP and in accordance with 9 CSR 45-2.017.

(B) Individuals are integrated in and have access to the greater community in accordance with 42 CFR 441.301. The division ensures that services provided are of good quality and comparable to those provided to persons in the community without disabilities.

(C) Providers comply with the terms and conditions of the home and community-based waivers approved by the Centers for Medicare and Medicaid Services and operated by the division and the MO HealthNet DD Waiver Provider Manual.

(4) Contracted providers shall monitor and implement positive proactive strategies to reduce the likelihood that an individual will require reactive strategies or restrictive interventions. Providers shall develop processes to review the problem situations when the reactive strategy threshold is reached.

(A) Individuals reaching the reactive strategy threshold trigger the planning team’s extensive review and analysis of the problem situations. The planning team should— 1. Convene within five (5) business days to complete the review and any restrictions of the supports, environment, training for staff, medications, or other issues that might affect the individual;

Identify triggers, preventative strategies, and barriers to using the least restrictive strategies;
Consider the need for a functional behavior assessment, and development of a formal BSP or revision of an existing BSP;
Develop new or revised proactive strategies and strategies to prevent situations that are likely to result in use of reactive strategies.

(B) Any individual meeting the reactive strategy threshold for three (3) consecutive quarters should be referred to the Regional Behavior Support Review Committee for consultation. If an individual meets the reactive strategy threshold of five (5) or more in a one (1) month period, the planning team should request the support coordinator submit a request for behavioral services.

(5) Restrictive Interventions other than approved physical crisis management procedures shall not be used as an emergency or crisis intervention.

(A) Use of restrictive procedures that meet the definition of reportable events must be reported in accordance with 9 CSR 10-5.206.

(B) Restrictive interventions are utilized only as alternatives to more restrictive placements and only as a means to maintain safety and allow the teaching of alternative skills that the individual can utilize to more successfully live in the community.

Identification of a specific and individualized assessed need;
Documentation that the positive interventions and supports used prior to any modifications to the ISP;
Documentation that less intrusive interventions were tried but were not successful;
Regular collection and review of data to measure the ongoing effectiveness of the intervention;
Established time limits for periodic reviews to determine if the intervention is still necessary or can be terminated;
Informed consent of the individual or their legal guardian; and 7. Assurances that interventions and supports will cause no harm to the individual as described in 42 CFR 441.301(c)(2)(xiii).

(D) Prohibited procedures—The following interventions are prohibited by the division and are considered at high risk for causing harm:

Any technique that interferes with breathing or any strategy in which a pillow, blanket, or other item is used to cover the individual’s face;
Prone restraints (on stomach); restraints positioning the individual on their back supine; or restraints against a wall or object;
Restraints which involve staff lying/sitting on top of an individual;
Restraints that use the hyperextension of joints;
Any technique or modification of a technique which has not been approved by the division, and/or for which the person implementing the technique has not received division-approved training;
Mechanical restraints;
Any strategy that may exacerbate a known medical or physical condition, or endanger the individual’s life, or is otherwise contraindicated for the individual by medical or professional evaluation;
Use of any reactive strategy or restrictive intervention on a “PRN” or “as needed” basis;
Standing orders for use of restraint procedures not part of a comprehensive safety crisis plan that delineates prevention, deescalation, and least restrictive procedures to attempt prior to use of restraint;
Any procedure used as punishment, for staff convenience, or as a substitute for engagement, active treatment, or behavior support services;
Use of law enforcement or emergency departments cannot be incorporated into ISPs or BSPs as “PRN” procedures or as contingencies to eliminate or reduce problem behaviors;
Reactive strategy techniques administered by other individuals who are being supported by the agency;
Corporal punishment or use of aversive conditioning—Applying painful stimuli as a penalty for certain behavior, or as a behavior modification technique;
Overcorrection strategies— Requiring the performance of repetitive behavior as a consequence of undesirable behavior designed to produce a reduction of the frequency of the behavior;
Placing persons in totally enclosed cribs or barred enclosures other than cribs;
Any treatment, procedure, technique, or process prohibited by federal or state statute.

(E) Procedures that may be conditionally approved in writing by the division— 1. Any modification to a physical crisis management technique or any non-nationally recognized physical crisis management system;

Seclusion time-out placement of a person alone in a secured room or area which the person cannot leave at will shall only be utilized as part of an approved BSP. The use of seclusion time-out requires ongoing services from a licensed behavioral service provider and prior review and approval by the RBSC; and 3. Use of physical crisis management procedures when part of a comprehensive safety crisis plan that delineates prevention, de-escalation, and least restrictive procedures to attempt prior to use of restraint.

(6) BSPs are developed by a licensed behavioral service provider in collaboration with the individual’s support system. The techniques included in the plan are based on a functional assessment of the target behaviors.

The techniques meet the requirements for the practice of applied behavior analysis under sections 337.300 through 337.345, RSMo.

The BSP includes the following information:

(A) Alternative behaviors for reduction and replacement of target behaviors, defined in observable and measurable terms. They are specifically related to the individual and relevant environmental variables based on FBA;

(B) Goals and objectives for acquisition of appropriate alternative behaviors;

(C) Interventions aligned with positive functional relationships described in FBA including strategies to address establishing operations, contextual factors, antecedent stimuli, contributing and controlling consequences, and physiological and medical variables;

(D) Data collected must include antecedents/triggers, description of events, duration, consequence/result, and effects of interventions;

(E) If physical restraint or seclusion timeout are used, health status is monitored and data documented for one (1) hour after the event in fifteen (15) minute intervals. Health status data includes monitoring of vital signs including pulse, visual observations of energy/lethargy level, engagement with others, and other observed reactions;

(F) Description of specific data collection methods for target behaviors to assess the effectiveness of the strategies and data collection methods to assess the fidelity of implementation strategies;

(G) Data displayed in graphic format in the monthly progress reports, with indications for the environmental conditions and changes relevant to target behaviors;

(H) Proactive strategies to prevent challenging behaviors, improve quality of life, promote desirable behaviors, and teach skills, that are specifically described for consistent implementation by family and/or staff;

(I) Specific strategies with detailed instructions for reinforcement of desirable target behaviors;

(J) Specific strategies to generalize and maintain the desired effects of the BSP, including strategies for fading contrived contingencies to natural contingencies to support system changes and maintain these strategies after BSP is faded;

(K) A safety crisis plan if it is necessary to have strategies to intervene with at risk behaviors to maintain safety;

(L) If a plan includes physical restraint or seclusion time-out, specific criteria and procedures are identified;

(M) Target behavior(s) related to the symptoms for which psychotropic medications were prescribed and when they should be administered and the process for communicating data with the prescribing physician;

(N) Description of less restrictive methods attempted in the past, their effectiveness, and rationale that proposed BSP strategies are the least restrictive and most likely to be effective as demonstrated by research or history of individual;

(O) The method of performance based training to competency for caregivers and staff providing oversight;

(P) The qualified behavioral service provider reviews data at least monthly; and (Q) Description of how the plan will be communicated to all supports and services including the frequency with which the ISP team will receive updates.

(7) A safety crisis plan is developed by the support team after the first use of any reactive strategy or when the personal history of the individual indicates there is a likelihood that reactive strategies may be needed in the future, or where the individual’s support team plans to use reactive strategies.

(A) If reactive strategies are considered likely and necessary, the team should be proactive and consider the need for more specialized support strategies in the ISP and services such as Person Centered Strategies Consultant or Behavior Analysis Services (see Medicaid Waiver service definitions).

(B) Procedures identified are least restrictive and within safety parameters of the safety assessment. These are used as a last resort after implementation of proactive, positive approaches.

(C) If a safety crisis plan includes physical restraint, exclusion time-out, or seclusion time-out, specific criteria and procedures are identified.

(D) The plan includes the informed consent of the person, their parent, or guardian.

(E) The safety crisis plan is a part of the ISP.

(F) Safety crisis plans are part of any BSP.

(8) If a safety crisis plan includes the use of physical restraint, the name of the approved or nationally recognized crisis management program must be included in the individual’s safety crisis plan (as per section 630.175.1, RSMo). Restraints are only used in situations of imminent harm to prevent an individual from injuring self or others. Less restrictive crisis management procedures, including deescalation techniques and environmental management, should be attempted prior to use of any type of restraint. Use of physical restraints are documented in a safety crisis plan.

(A) Physical Restraints. Techniques used to physically restrain individuals are limited to those from nationally recognized physical crisis management programs or internally developed programs approved by the division.

Requests for use of physical crisis management systems other than those that are nationally recognized must be made, in writing, to the Chief Behavior Analyst of the division. If internally developed systems are approved and utilized, a quarterly analysis of the use of the restraint procedures and strategies to eliminate the need is completed and submitted to the Chief Behavior Analyst.
The physical restraint techniques are used only in the manner designed, are formally trained to competency, and staff maintain certification as specified by the physical crisis management system.
Physical restraint techniques are only employed for situations of imminent harm to self or others and not to protect property.
Any improper or unauthorized use of a physical restraints or excessive application of force may be considered abuse and may prompt an investigation.
Blocking is not considered a physical restraint procedure if used as defined in this

rule.

(B) Chemical restraints include prescription and over the counter medications and require the approval of the division director or his/her designee prior to implementation of these restraints. Any use of a chemical restraint must be included in an approved safety crisis plan meeting the following criteria:

Identification of chemical restraints to be used;
Written physician orders for any chemical restraints are time limited and for no longer than three (3) hours;
Written physician orders are placed in the individual's record and contain at least the following information:

A. Brief description of the imminent harm situation including ongoing activities, staff actions, and the individual’s actions that relate to the imminent harm;

B. Type of chemical restraint used;

C. The time when the order was written;

D. The time when the chemical restraint was first adminis tered;

Ongoing visual observation and safety checks during the time that the chemical restraint is affecting the individual;
Standing or PRN orders for chemical restraints shall not be used. Specification in a safety crisis plan or reactive strategies deemed safe for an individual and/or recommended as the most likely to be effective will not be considered as PRN orders;
The authorized medical professional designated by the physician writing the order observes the individual and evaluates the situation within thirty (30) minutes from the time chemical restraints were initiated; and 7. In an emergency in which an on-site authorized physician is not available, only a registered nurse or a qualified licensed practical nurse may administer chemical restraints to an individual and only after receiving an oral order from an authorized physician.

A. The documentation of such oral orders include the following:

(I) Name of physician who gave the order;

(II) Name of nurse who received the order;

(III) Name of nurse who actually administered the chemical restraint—identify behaviors requiring the chemical restraint in specific terms that allow measurement;

(IV) Anticipated effects of the medication and time frame related to the effects.

B. The person administering the chemical restraints documents the information required and the physician's oral order in the individual’s record or equivalent record.

C. The oral order is signed by a physician as soon as possible after the initial administration of the chemical restraint.

(9) Utilization of a seclusion time-out (or safe-room) procedure requires prior approval from the Chief Behavior Analyst. Request for such approval must include a functional assessment of the target behavior, a BSP, the rationale for the use of the procedure, and data supporting the need for the procedure and that less restrictive interventions were ineffective. The Chief Behavior Analyst must also approve of the designated time-out area or room.

(A) Seclusion time-out will become a prohibited procedure as of July 1, 2021.

(B) Behavioral services remain active during the time period in which the BSP (seclusion time-out intervention) is in place.

section (6) of this rule as well as the following:

Specification that only qualified personnel may use seclusion time-out for an individual under conditions set out in an approved BSP;
If the BSP includes time-out, it is reviewed and approved by the following:

A. RBSC;

B. The individual or the family, or legal guardian as appropriate; and C. The Chief Behavior Analyst or designee;

Target behaviors, operationally defined, and consistent with the function identified in the functional assessment for the target behavior;
Description of strategies to ensure high rates of positive reinforcement and engaging activities are available for the individual making “time in” an enriched situation;
Criteria for release from seclusion time-out and discontinuation of a seclusion time-out episode— A. Release from seclusion time-out criteria is limited to no more than five (5) minutes of calm behavior;

B. Total duration for the seclusion time-out episode is no more than one (1) hour except in extraordinary instances (during initial stage of program) that are personally approved at the time of occurrence by the behavior analyst and reviewed within one (1) business day by the region’s assigned area behavior analyst;

C. Continuous observation of the person in time-out;

D. Seclusion time-out will be discontinued if there are any signs of injury or medical emergency and the person will be assessed by appropriate medical personnel;

E. The date, time, and duration of each seclusion time-out intervention is documented on a data sheet and on an event management form.

(D) Time-out areas or rooms shall meet the following safety and comfort requirements:

Areas and rooms to be utilized for seclusion time-out and the procedures for the use of seclusion time-out are reviewed and approved by the Chief Behavior Analyst or designee;
Continuous observation of the individual in the area is maintained at all times;
Adequate lighting and ventilation is used at all times;
The area or room is void of objects and fixtures such as light switches, electrical outlets, door handles, wire, glass, and any other objects that could pose a potential danger to the individual in time-out;
If there is a door to the room or area, it will open in the direction of egress such that the individual in the room is not able to bar the door to prevent entry;
The door is void of any locks or latches that could allow the door to be locked without continuous engagement by a staff person; and 7. The room or area will be at least six (6) feet by six (6) feet in size or large enough for any individual who will utilize the room to lie on the floor without head or feet hitting walls or door.

(10) The division provides oversight for services provided to individuals with significantly challenging behaviors through RBSCs. The division establishes at least two (2) RBSCs.

Additional RBSCs may be established depending upon need and staff capacity.

(A) Members of the RBSC are appointed by the division director or designee.

(B) The RBSC consists of three (3) to five (5) members including:

A chairperson who is a licensed behavior analysis employed by the division;
A member or members of the provider community licensed to practice applied behavior analysis or who provided behavior therapy under contract with DMH prior to January, 2012 or who are working towards Board Certified Behavior Analyst (BCBA) or Board Certified Assistant Behavior Analyst (BCaBA) certification under the supervision of a licensed behavior analysis; and 3. A medical consultant or other professionals as indicated by the information under review or requested by the chairperson.

(D) The purpose of RBSCs is to promote the implementation of best practice strategies that lead to greater independence and enhanced quality of life for individuals experiencing challenging behaviors. RBSCs ensure the following:

That waiver assurances are met;
That best practice behavioral services are followed;
That ethical guidelines are followed;
That behavioral strategies are least restrictive; and 5. That implementation of strategies documented in the ISPs and BSPs support progress toward greater independence and enhanced quality of life.

(E) The division establishes RBSC review criteria to prioritize the individuals with significantly challenging behaviors and those individuals whose supports include restrictive interventions.

Individuals experiencing significantly challenging behaviors reaching threshold criteria for reactive strategies, or who have been prescribed psychotropic/behavior control medications, or who have PRN psychotropic medication for behavioral support.
A BSP may be reviewed based on a request by the members of the ISP, including, but not limited to, the parent/guardian, support coordinator, or Regional Director (or designee) to provide technical assistance.
The Regional Director and the RBSC prioritize reviews to ensure appropriate representation based upon issues that represent regional challenges to meet identified objectives.
The RBSC shall respond to requests for review within thirty (30) calendar days of receipt of the request.
The support coordinator and provider of BSPs and ISPs reviewed by the RBSC will receive written summary of the RBSC's recommendations within five (5) working days of the RBSC's review of the BSPs or ISPs.

(11) If use of prohibited or unauthorized procedures is discovered, the following occurs:

(A) Regional Director is notified of the use of prohibited procedures, the agency involved, persons for whom the procedures were utilized, and reasons for use;

(B) Regional Director directs regional staff and Area Behavior Analyst to conduct a focused review of the agency;

(C) If the focused review confirms that prohibited or unauthorized procedures were used, the Regional Director will be informed and notify the provider and support coordinator;

(D) Area Behavior Analyst works with planning teams to determine appropriateness of strategies and need for additional services to assist the provider to address the situations positively, proactively, and preventatively;

(E) Area Behavior Analyst refers supports of individuals, for whom the prohibited practices have been used, to the RBSC; and (F) Follow up reviews of the provider will occur to ensure that appropriate procedures and supports are utilized and prohibited practices have been discontinued for a duration determined by the Chief Behavior Analyst.

History

AUTHORITY: sections 630.050 and 630.175, RSMo Supp 2019. Original rule filed Sept. 20, 2019, effective March 30, 2020. Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.175, RSMo 1980, amended 1996, 2008, 2014, 2016, 2019.

Chapter 4 Financial Procedures

9 CSR 45-4.010 Residential Rate Setting {#sec-9-csr-45-4.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-4.010}

(Rescinded November 30, 2018)

This rule was previously filed as 9 CSR 10- 5.170. Original rule filed Dec. 11, 1989, effective June 15, 1990. Amended: Filed May 25, 1995, effective Dec. 30, 1995. Rescinded:

Filed March 20, 2018, effective Nov. 30, 2018.

History

AUTHORITY: section 630.655, RSMo 1994.

9 CSR 45-4.020 Development of Intermediate Care Facilities for Individuals with Intellectual Disabilities {#sec-9-csr-45-4.020 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-4.020}

PURPOSE: This rule prescribes procedures on development of intermediate care facilities for persons with mental retardation.

(1) As used in this rule, a provider that owns, operates, or has interest in only one (1) intermediate care facility for individuals with intellectual disabilities (ICF/IID) is— (A) A sole proprietor that owns no interest in another ICF/IID;

(B) A partnership or a majority of the partnership that owns no interest in another ICF/IID; or (C) A corporation that has neither any officers nor a majority of board members in common with another corporation which has any interest in an ICF/IID.

(2) Any entity intending to operate a Medicaid-reimbursed ICF/IID in excess of those beds in existence on May 29, 1991, shall give written notice of that intent to the Department of Mental Health’s Division of Developmental Disabilities (Division of DD) between July 1 and October 1 of the fiscal year preceding the fiscal year in which the provider intends to operate the ICF/IID.

(3) No provider may be reimbursed under Medicaid to operate an ICF/IID without a provider agreement issued by the Department of Social Services’ MO HealthNet Division (MHD). The MHD shall not issue a provider agreement without receiving either a certificate of authorization or an acknowledgment of exemption from the Division of DD.

(4) After May 29, 1991, the Division of DD shall issue an acknowledgment of exemption to permit the MHD to issue a provider agreement to a certified ICF/IID if— (A) The ICF/IID will have six (6) or fewer beds;

(B) The provider does not own, operate, or have any interest in any other ICF/IID; and (C) The provider has notified the Division of DD between July 1 and October 1 of its intent to operate the ICF/IID during the next fiscal year.

(5) Any provider that has received an exemption under section (4) and then either obtains, operates, or acquires an interest in any other Medicaid-enrolled ICF/IID, or seeks to enroll an additional ICF/IID in the Medicaid program, shall forfeit the exemption granted under section (4). As soon as the ICF/IID for which exemption was originally granted can be accommodated in the Medicaid Home and Community-Based Waiver Program, the Division of DD shall notify the MHD to that effect, and MHD shall terminate the ICF/IID provider agreement within thirty (30) days after receipt of the notification from the Division of DD.

(6) After May 29, 1991, the Division of DD may issue a certificate of authorization to permit the MHD to issue a provider agreement for a provider to operate an ICF/IID of seven (7) or more beds if— (A) The proposed ICF/IID is to be a freestanding facility and not attached to any other existing ICF/IID;

(B) The provider has notified the Division of DD between July 1 and October 1 of its intent to operate the ICF/IID during the next fiscal year; and (C) The ICF/IID cannot be accommodated within the federal Home and Community- Based Waiver Program for persons with developmental disabilities as determined by the Division of DD.

4CODE OF STATE REGULATIONS

(10/31/18) JOHNR. ASHCROFT

6CODE OF STATE REGULATIONS

(10/31/18) JOHNR. ASHCROFT

Filed May 13, 2016, effective Nov. 30, 2016. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 660.075, RSMo 1991, amended 2014.

History

AUTHORITY: section 630.050, RSMo Supp. 2013, and section 660.075, RSMo Supp. 2014. This rule originally filed as 9 CSR 30- 5.060. Original rule filed Sept. 1, 1993, effective April 9, 1994. Amended: Filed May 25, 1995, effective Dec. 30, 1995. Amended:

9 CSR 45-4.030 Family Support Stipends {#sec-9-csr-45-4.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-4.030}

(Rescinded October 30, 2016)

This rule was originally filed as 9 CSR 70- 1.010. Original rule filed April 4, 1994, effective Oct. 30, 1994. Amended: Filed May 25, 1995, effective Dec. 30, 1995. Rescinded:

Filed March 3, 2016, effective Oct. 30, 2016.

History

AUTHORITY: section 633.190, RSMo 1994.

9 CSR 45-4.040 Family Support Loans {#sec-9-csr-45-4.040 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-4.040}

(Rescinded October 30, 2016)

This rule was originally filed as 9 CSR 70- 1.015. Original rule filed April 4, 1994, effective Oct. 30, 1994. Amended: Filed May 25, 1995, effective Dec. 30, 1995. Rescinded:

Filed March 3, 2016, effective Oct. 30, 2016.

History

AUTHORITY: section 633.190, RSMo 1994.

Chapter 5 Standards for Community-Based Services

9 CSR 45-5.010 Certification of Home and Community-Based Providers Serving Persons with Intellectual and Developmental Disabilities. . . . . . . . . . . . . . . . . . . . . . . . 3 {#sec-9-csr-45-5.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-5.010}

9 CSR 45-5.020 Individualized Supported Living Services—Quality Outcome Standards {#sec-9-csr-45-5.020 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-5.020}

9 CSR 45-5.030 Individualized Supported Living Services—Provider Certification {#sec-9-csr-45-5.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-5.030}

9 CSR 45-5.040 Missouri Alliance for Individuals with Developmental Disabilities {#sec-9-csr-45-5.040 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-5.040}

9 CSR 45-5.110 Fire Safety for Facility-based Day Habilitation and Employment {#sec-9-csr-45-5.110 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-5.110}

9 CSR 45-5.010 Certification of Home and Community- Based Providers Serving Persons with Intellectual and Developmental Disabilities {#sec-9-csr-45-5.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-5.010}

PURPOSE: This rule defines terms, establishes principles, and sets out the process by which agencies providing individualized supported living (ISL), group home, shared living, day habilitation, individualized skills development, community networking, outof-home respite, intensive therapeutic residential habilitation, and employment services to individuals with intellectual and developmental disabilities through the Medicaid Home and Community-Based Waiver (HCBS) attain certification.

(1) The Division of Developmental Disabilities (division) establishes procedures under which a provider of Medicaid home and community-based waiver services to individuals with intellectual or developmental disabilities attains certification. In establishing those procedures, the division makes the following assumptions:

(A) An individual with an intellectual or developmental disability and the individual’s family can best determine the services the individual wants and needs;

(B) The division and the provider collaborate to provide quality services and supports that effectively and efficiently meet needs of individuals with intellectual or developmental disabilities within the contexts of the individual’s expressed needs;

(C) Through ongoing monitoring, individuals with intellectual or developmental disabilities and their families are best positioned to determine the quality of the individual’s services and supports and the effectiveness of the services and supports in meeting their needs;

(D) The certification process is flexible and person-centered and serves three (3) critical purposes— 1. To determine how well providers fulfill their responsibilities to individuals with intellectual or developmental disabilities;

To determine systems changes and practices needed so that the provider will be more responsive to the individual’s needs; and 3. To enhance inclusion and self-determination of individuals with intellectual or developmental disabilities as valued members of their communities;

(E) Providers shall subscribe to and meet all principles in this

rule. The division shall enforce those principles; and (F) A residential or day program that attains certification from the division to deliver Medicaid Home and Community- Based Waiver services is not subject to the requirements of 9 CSR 40-1 Licensing Rules.

(2) Terms defined in sections 630.005 and 633.005, RSMo, are incorporated by reference for use in this rule. As used in this rule, unless the context clearly indicates otherwise, the following terms also mean— (A) Department—unless otherwise specified, the Department of Mental Health (DMH);

(B) Individual—a person who has been found eligible for services with the Division of Developmental Disabilities; and (C) Provider—any entity or person under contract or applying for a contract with the Department of Mental Health (DMH) to serve individuals with intellectual or developmental disabilities funded by general revenue or through home and community-based waivers administered by DMH.

(3) Providers certified under this rule shall comply with 42 CFR 441.301, January 2014, hereby incorporated by reference and made a part of this rule as published by and available in the Code of Federal Regulations, Office of Federal Register, National Archives and Records Administration, 7 G Street NW, Suite A-734, Washington, DC 20401, (201) 741-6000. 42 CFR 441. 301 ensures individuals served have full access to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community to the same degree of access as individuals not receiving Medicaid HCBS. This rule does not incorporate any subsequent amendments or additions to this publication.

(4) This section prescribes eight (8) sets of principles for providers serving participants of any HCBS waiver operated by DMH.

(A) Individuals are integrated in and have access to the greater community.

Individual’s decisions are respected.
Individuals are supported in being active participants in the community.
Individuals have knowledge of or access to information regarding age-appropriate activities reflective of their interests, needs, and preferences.
Individuals are supported in participating in nondisability-specific activities/functions that are not limited to individuals with disabilities.
Individuals are supported in participating in cultural and ethnic activities that reflect their interests and preferences.
Individuals are supported in learning to use and have ready access to public transportation, if available in their community.
Individuals are supported in attending religious services and worshiping as they choose.
Individuals are supported in regularly receiving and visiting family, friends, or other community members.
Individuals are supported by persons who are knowledgeable and respectful of their wants, needs, and preferences.
Individuals are able to come and go in the community in accordance with their wants, needs, and preferences.
Individuals are supported in their efforts to further their education and skill development, in the area and manner of their choice.

(B) Individuals are provided with opportunities to seek employment and work in competitive integrated settings, engage in community life, and control personal resources.

Individuals are supported in participating in competitive integrated employment opportunities of their choice within the community.
Individuals are assisted in obtaining employment in a setting that is non-disability-specific and fully integrated into the community.
Individuals are supported in obtaining employment in a setting that is located among other private businesses and facilitates integration with the greater community.
Individuals are supported in obtaining employment in a setting which encourages interaction with the public.
Individuals who work in provider owned and controlled employment settings have knowledge of or access to information regarding competitive work outside of the setting.
Individuals are supported in obtaining employment in settings physically accessible and which do not limit individuals’ mobility or freedom of movement in the workplace, including access to bathrooms and break rooms.
Individuals are supported in self-advocacy activities in the workplace.
Individuals are supported in making decisions and exercising autonomy to the greatest extent possible. Individual’s decisions are respected.
Individuals are supported in obtaining employment with wages and benefits, including but not limited to medical benefits, annual leave, sick leave, and retirement programs, to the same extent as individuals not receiving Medicaid-funded HCBS.
Individuals seeking employment services are given informed choice of available providers and setting options from which to choose.
Employment services are provided in a manner and setting that reflects the individual’s wants, assessed needs, and preferences, taking into account the individual’s skills, capabilities, and aptitudes.
Individuals are supported in developing and maintaining relationships with coworkers.
Individuals are supported by staff who are knowledgeable about the individual’s capabilities, interests, preferences, and needs related to employment.
Individuals are supported in making a budget, which takes into account the individual’s financial goals.
Individuals are supported in making informed choices related to working, earning, spending, and saving.
Individuals are supported in controlling their personal finances/resources.
Individuals are supported in becoming financially independent.

(C) Individuals receive services in the community to the same degree of access as individuals not receiving Medicaidfunded HCBS.

Individuals who receive specialized supports receive them in a place or manner typical for all other community members.
Individuals are supported in living, working, and participating in activities located in settings that are integrated into the community and consistent with their interests.
Individuals are provided community options in order to make informed choices of how and where they receive their services and their choices are honored.
Individuals are supported in finding living arrangements that are non-disability-specific and fully integrated into the community, which they can afford with their own income.
Individuals are supported in learning transportation skills and are transported safely.
Individuals’ environments are secure, stable, and physically accessible to the individual.

(D) The residence is selected by the individual from among setting options including non-disability-specific settings.

Individuals are supported and given informed choice in selecting settings to receive Medicaid waiver services that are reflective of the individual’s wants, needs, and preferences.
Individuals are given the opportunity and choice to reside in community settings with individuals not receiving Medicaid Home and Community-Based Services.
The setting is physically accessible without obstructions that limit individual mobility in the setting.
Individuals own, rent, or occupy, under a legally enforceable agreement, their own specific unit/dwelling. A copy of the lease, residency agreement, or other written agreement is maintained.
Individuals’ residences are located among other residences that facilitate integration with the greater community.
Individuals’ residences are indistinguishable from other residences; for example, the use of yard signs or other advertisement should not be used which distinguish the setting as disability specific.
Individuals are supported in opening their homes to interact with community members of their choice.
Individuals have freedom to move about inside and outside of their residence and are not restricted to or from any areas or rooms within their residence.
Individuals have full access to the typical facilities in a home such as a kitchen, dining area, laundry, bathroom, and living room.
Individuals have choice with whom they live and how to furnish and decorate their home.

(E) Individuals are assured the right of privacy, respect, and freedom from coercion and restraint.

Individuals’ right to personal privacy, dignity, and respect is ensured and supported.
Provider policy, procedure, and practices shall protect and promote the rights of each individual.
Each individual’s privacy is respected in their sleeping or living unit, as determined by the individual.
In provider owned and/or controlled residential settings, the following applies:

A. Units have entrance doors lockable by the individual, with only appropriate staff having keys to doors; and B. Individuals sharing units have a choice of housemates in that setting.

Individuals are informed both orally and in writing, in a manner that the individual understands, of their rights in accordance with sections 630.110 and 630.115, RSMo, and 9 CSR 45-3.030, and responsibilities and advocacy resources, documented in writing and signed by the individual or guardian, as applicable. Notification is made prior to or upon receiving services and annually thereafter. Receipt is acknowledged in writing.
Individuals are supported by staff who are knowledgeable and trained annually, with documentation of the training, on individual rights in accordance with sections 630.110 and 630.115, RSMo, and 9 CSR 45-3.030.
Annually, individuals shall be given information written or communicated in a format understood by the individual on how to file a grievance with the provider or complaint with 8. Individuals are supported by not having limitations imposed on their rights without due process, as required by 9 CSR 45-3.030.
Individuals are supported in an environment where they are free to communicate privately with whom they choose.
Individuals have access to telephones appropriate to their needs and accessible at all times. Individuals are able to make and receive calls privately.
Individuals who are unable to open or read their own mail are supported by staff to whom they have given consent.
Individuals are supported by staff who are trained annually in identifying, preventing, detecting, and reporting abuse and neglect.
Abuse and neglect are prohibited by provider policy and procedures. Providers follow their policies and procedures and ensure action is taken to protect individuals who report abuse or neglect.
Individuals are supported in planning and participating in discussions regarding their lives.
Individuals are supported by staff who are knowledgeable of the provider policies on confidentiality and the Privacy Rule of Health Insurance Portability and Accountability Act of 1996 (HIPAA) Health Information Protection. Staff shall maintain all information about individuals in confidence and shall not share information about individuals without consent.
Individuals have access to their records and are supported in maintaining their records where they choose.

Staff shall assist them as needed in reviewing records and answering questions.

Individuals are supported in environments that support their dignity. Signs shall not be posted in easily visible areas describing information about the individual that is private or confidential.
Individuals are supported in their activities of daily living in a manner that is dignified and respectful.
Individuals are supported in making decisions and not persuaded through the use of intimidation, force, or threats.
Individuals are not treated differently or retaliated against for exercising his/her rights.
Individuals are free from mechanical, physical, and chemical restraints.

(F) Individual initiative, autonomy, and independence are optimized in making life choices.

Individuals’ needs and preferences are honored.

Individuals’ right to choice and self-determination are respected.

Individuals are supported in a manner that meets the individual’s expressed wants, needs, and preferences.
Individuals determine the quality and the effectiveness of the services and supports in meeting their needs.
Individuals are supported in their efforts to be active members of the community.
Individuals are encouraged to interact with members of the community both inside and outside their home.
Individuals are supported in dressing and grooming consistent with personal preferences.
Individuals are supported in carrying out activities of daily living, including dressing, eating, and grooming, in a manner that enhances their self-esteem and self-worth.
Individuals receive supports in a manner that promotes positive involvement in the community.
Individuals have the option to participate in political activities of their choice in the community.
Individuals have the freedom and support to control their own schedules and activities and have access to food at any time.
Individuals are supported, and assistance provided as needed, to furnish and decorate their sleeping and living units as they choose.
Individuals are encouraged and supported in developing and sustaining friendships and family relationships.
Individuals are supported in developing intimate relationships of their choice.
Individuals are supported in their efforts to have social contact with the same people and have repeated opportunities for social contact with the same people or groups of people.
Individuals are supported in their efforts to be involved in activities at times which take into consideration their wants, needs, and preferences.
Individuals are supported by staff who emphasize to others their abilities and interests.
Individuals are able to have visitors of their choosing at any time.
Individuals have the option to join and be supported in assuming roles in community organizations.
Individuals have the option to join and be supported in assuming roles in religious organizations.
Individuals have the option to and are supported in volunteering and helping in the community.
Individuals are informed and assisted in determining how they would like to make decisions about their health care, and whether or not they would like anyone else to be involved in those decisions.
Individuals with limited ability to communicate are supported by persons knowledgeable of how they communicate physical needs, how they communicate emotional and psychological needs.
Individuals are supported in an environment where individuals engage in positive, acceptable interactions.
Individuals are self-aware and use personal competencies.
Individuals are offered training and ongoing support in developing their self-advocacy skills.

(G) Individuals are supported in making choices regarding services and supports and who provides them.

Individuals choose the services and supports they want and need.
Individuals are provided options in a manner that allows informed choice in selecting who their provider of services will be and their choices are honored.
Individuals are provided options in manner that allows informed choice in selecting settings to receive Medicaid waiver services that are reflective of the individual’s wants, needs, and preferences, and their choices are honored.
Individuals have choice in selecting their own health care providers to meet their needs.
Individuals participate in making decisions about their health care and their decisions are recognized and supported.
Individuals’ personal preferences are supported.

(H) Individuals are assured their basic needs will be met.

Individuals are supported by staff who are knowledgeable of, have access to, and who provide services in accordance with their current Individualized Support Plan (ISP).
Individuals have the right to receive physical, emotional, and mental health care from the practitioner of their choice.
Individuals obtain routine medical and preventative medical care at intervals typical for the individual’s gender, age, and condition.
Individuals obtain dental, hearing, and vision exams, and follow-up treatment as recommended by their practitioner.
Individuals requiring specialized medical services have access to specialists.
Individuals are supported in accessing their physician or medical care consistent with their wants, needs, and preferences.
Individuals are supported in eating a diet which honors individual choice and meets nutritional needs.
Individuals who have a specialized diet, prescribed to meet identified healthcare needs of the individual, are informed of the reason for the diet and consent to the diet.

Orders for specialized diets are reviewed at least annually by a registered dietician, the individual’s physician, physician assistant, or advanced practical nurse (APN). Direct care staff shall be trained by either a dietician or registered nurse in the preparation and implementation of the diet prior to providing independent direct care services. Individual choice shall be honored. Providers may elect to have management staff trained as a trainer for non-nurse delegated diets.

Individuals are educated about and supported in choosing to participate in wellness activities and fitness programs, both in their home and in their community.
Individuals’ health is protected through measures typically taken to prevent communicable diseases for persons with similar health status. Individuals shall be supported by persons who are knowledgeable of infection control practices through annual training.
Individuals are educated about the purpose, benefits, risks, and side effects of all prescribed medications and treatments, to assist them in making informed choices about their health care. Individuals are respected in their decision to refuse medication and treatment.
Individuals are supported in taking medications, receiving treatments, and utilizing adaptive equipment as prescribed.
Individuals are encouraged and supported in learning to safely manage and self-administer their medications as reflected in their ISP.
Individuals’ medications are reviewed annually by their physician to determine their continued effectiveness.

The provider shall develop an effective system of medication administration, including monthly review of the medication system by a registered nurse.

Staff who assist in the system of medication administration shall be certified as a DD Medication Aide or be a licensed nurse or pharmacist. Individuals and staff shall be knowledgeable of the individuals’ medical conditions and possible side effects of medication.
Individuals receive the necessary services, supports, and degree of supervision consistent with the personal abilities of the individual and in accordance with their ISP.
Individuals’ homes and other environments are clean, safe, and well maintained.
Individuals are supported in obtaining living arrangements that are safe and take into account their physical abilities.
Individuals’ homes and environments are modified and/or adapted to meet identified needs as described in ISPs and are based upon assessments to ensure safety and mobility.
Individuals’ homes and other environments comply with federal, state, and local building and environmental codes.
Individuals’ safety is assured through preventive maintenance of vehicles, equipment, and buildings.
Individuals have the opportunity to assist in maintaining their home.
The temperature of individuals’ homes is determined by the individuals who live there. Homes shall have heating and air conditioning equipment capable of maintaining temperatures within a comfortable range for the individual.
In situations in which individuals do not have the ability to regulate water temperatures or have a physical or health condition that makes self-regulation unsafe, water temperatures are not to exceed 120 degrees Fahrenheit at the point of use.
Individuals are supported in responding to emergencies in a safe manner.
Individuals are supported by staff knowledgeable about emergency procedures, as included in the provider’s written procedures and any additional expectations as indicated in the individual’s ISP.
Individuals participate in emergency drills (tornado, earthquake, intruder) occurring during daytime, evening, and sleep hours at least four (4) times annually. Individuals participate in fire drills at least four (4) times annually, including one (1) during sleep hours. Documentation of drills shall be maintained.
Individuals shall have access to adequate evacuation exits which are appropriate to their abilities and an unobstructed path of egress to safety.
Individuals shall have access to at least one (1) fire extinguisher on each floor of the home. At least one (1) fire extinguisher shall be accessible in or near the kitchen area. All fire extinguishers shall have an expiration date or maintenance tag/documentation and indicator of charge. The fire extinguisher shall have directions for use on the equipment and shall be within the expiration date.
Individuals’ homes shall have operable smoke detectors on each level of the home, including basements. Detectors shall be located in or near each bedroom and in proximity to the area where an individual or staff sleep. Smoke detectors shall be placed in the home according to manufacturer’s recommendations.
Individuals have adaptive emergency alarm systems based upon need.
Individuals’ homes which utilize gas appliances and/or have an attached garage shall have operable carbon monoxide detectors on each level of the home, including basements.
Individuals have the option to take first aid and cardiopulmonary resuscitation training and have access to basic first aid supplies.
Staff shall maintain current first aid and cardiopulmonary resuscitation (CPR) certification for healthcare providers through training using curricula that is comparable to National Safety Council, American Red Cross, or American Heart Association. Training shall include hands-on practice and in-person skills assessment. Online-only certification is not acceptable. Individuals are provided first aid and cardiopulmonary resuscitation by knowledgeable staff, in accordance with their written advance directive.
Each provider shall have written policies and procedures approved by the department regarding medical emergencies.

Such policies and procedures shall include— A. Protocol for initiating 911 emergency call;

B. Protocol for use of CPR and first aid;

C. Instructions for staff and individuals on how to respond to an incapacitated person; and D. A system for ensuring emergency response drills on the emergency protocol are conducted at least every six (6) months for all staff.

Individuals experiencing events that meet reportable event criteria shall have those events reported to the department, per 9 CSR 10-5.206.
Individuals and staff who support them have access to current contact information for family, guardians, or other interested parties identified by the individual.
Storage of materials necessary for household maintenance should be stored according to safety standards for the item itself as well as according to supports specified in the ISP. If there are restrictions, the individual shall be given due process.
Staff use and individuals are supported to use safe and sanitary practices in food storage, preparation, and cleanup.
Individuals who need assistance to eat are provided needed supports and adaptations, as identified in the ISP.
Individuals use mechanical supports only as prescribed.

Individuals are supported by staff who are knowledgeable of use of the supports as addressed in the ISP.

Individuals are supported in the use and maintenance of adaptive, corrective, mobility, orthotic, and prosthetic equipment, as addressed in the ISP. Individuals and staff are trained in purpose, use, and maintenance of the equipment.

(5) Every two (2) years, all agencies shall seek certification under this section except that agencies accredited by nationally recognized accrediting bodies approved by the division shall not be required to seek certification. The division director shall issue two- (2-) year certificates to agencies successfully completing the process and requirements.

History

AUTHORITY: section 630.655, RSMo 2016. This rule originally filed as 9 CSR 30-5.050. Original rule filed July 25, 1994, effective March 30, 1995. Emergency amendment filed July 20, 1995, effective July 30, 1995, expired Nov. 26, 1995. Amended: Filed July 20, 1995, effective Nov. 30, 1995. Amended: Filed May 25, 1995, effective Dec. 30, 1995. Rescinded and readopted: Filed Aug. 2, 2023, effective Feb. 29, 2024.

9 CSR 45-5.020 Individualized Supported Living Services— Quality Outcome Standards {#sec-9-csr-45-5.020 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-5.020}

(Rescinded March 30, 2005)

History

AUTHORITY: section 630.050, RSMo 1994. This rule was originally filed as 9 CSR 30-5.020. Emergency rule filed Aug. 4, 1992, effective Sept. 1, 1992, expired Dec. 29, 1992. Original rule filed Aug. 4, 1992, effective Feb. 26, 1993. Amended: Filed May 25, 1995, effective Dec. 30, 1995. Rescinded: Filed Sept. 1, 2004, effective March 30, 2005.

9 CSR 45-5.030 Individualized Supported Living Services— Provider Certification {#sec-9-csr-45-5.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-5.030}

(Rescinded March 30, 2005)

History

AUTHORITY: section 630.050, RSMo 1994. This rule was originally filed as 9 CSR 30-5.030. Emergency rule filed Aug. 4, 1992, effective Sept. 1, 1992, expired Dec. 29, 1992. Original rule filed Aug. 4, 1992, effective Feb. 26, 1993. Amended: Filed May 25, 1995, effective Dec. 30, 1995. Rescinded: Filed Sept. 1, 2004, effective March 30, 2005.

9 CSR 45-5.040 Missouri Alliance for Individuals with Developmental Disabilities {#sec-9-csr-45-5.040 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-5.040}

(Rescinded June 30, 2016)

History

AUTHORITY: section 633.010, RSMo 1994. Original rule filed Feb. 15, 2000, effective Aug. 30, 2000. Rescinded: Filed Dec. 8, 2015, effective June 30, 2016.

9 CSR 45-5.060 Procedures to Obtain Certification {#sec-9-csr-45-5.060 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-5.060}

PURPOSE: This rule describes procedures to obtain certification as a provider of individualized supported living (ISL), group home, shared living, employment services, day habilitation, individualized skills development, community networking, out of home respite, and intensive therapeutic residential habilitation services through the home and community-based waivers for individuals with intellectual and developmental disabilities.

(1) Under section 630.655, RSMo, the department is mandated to develop certification standards and to certify providers to operate, receive funds from the department, and be eligible for Medicaid reimbursement. However, certification in itself does not constitute an assurance or guarantee the department will fund designated services or programs.

(A) A key goal of certification is to enhance the quality of care and life for individuals with a focus on their needs, preferences, and desired outcomes.

(B) The primary function of the certification process is assessment of a provider’s compliance with current standards of care and state and federal requirements. A further function is to identify and ensure corrective action is taken for deficiencies identified during the survey process to ensure health and welfare of persons served by the provider.

(2) An entity or individual who has received approval to contract with the department and who has successfully enrolled with MO HealthNet as a provider may request to become a provider of certified services by completing an application form as required by the department for this

purpose and submitting the application form and other documentation as specified. The completed application is sent to Department of Mental Health, Office of Licensure and Certification, PO Box 687, Jefferson City, MO 65102, fax (573) 751-9207, or emailed to DMH-OLC@dmh.mo.gov.

(A) The applicant must submit a current written description of the programs and services for which it is seeking certification by the department.

(B) Certification fees are not required.

(C) The department reviews a completed application within thirty (30) calendar days of receipt to determine whether the applicant would be appropriate for certification. The department notifies the provider of its determination. A certificate is issued if— 1. The department has determined the application is complete and all necessary documents have been filed with the application; and 2. The department has determined the provider, programs, and services are compliant with state and federal laws and the corresponding rules.

(D) A site survey of the applicant will be conducted to determine compliance with standards.

(E) Certified providers need to apply for recertification at least sixty (60) calendar days prior to expiration of its existing certificate. Recertification includes a new application and required documentation.

(F) Ninety (90) calendar days after its receipt, the department considers any application for certification withdrawn if it is submitted without all the required information and documents.

(G) An applicant can withdraw its application at any time during the certification process, unless otherwise required by law.

(3) The department conducts site surveys at a provider for the purpose of determining compliance with certification standards, program requirements, and other state and federal regulations.

(4) The department recognizes and deems as certified a provider that maintains accreditation under standards for services provided by the department from the Commission on Accreditation of Rehabilitation Facilities (CARF), The Council on Quality and Leadership (The Council), or Joint Commission on Accreditation of Healthcare Organizations (Joint Commission). The deemed provider must— (A) Submit to the department a copy of the most recent accreditation survey report and verification of the accreditation time period and dates within thirty (30) calendar days of receipt from the accreditation agency;

(B) Notify the department when the accreditation agency makes a complaint investigation visit within seven (7) calendar days;

(C) Notify the department of any changes in accreditation status during the time period of accreditation and resurvey within seven (7) calendar days; and (D) Ensure compliance with all certification rules and regulations pertaining to the service provided, including fire safety regulations;

(E) The Division of Developmental Disabilities may conduct a scheduled or unscheduled site survey of an accredited provider at any time to monitor ongoing compliance with the standards and requirements. If any survey finds conditions that are not in compliance with applicable standards, the division may request corrective action steps.

(5) Deemed providers are not excluded from monitoring of service delivery by other quality integrated functions within (6) The department provides advance notice and coordinates with the provider to schedule routine, planned surveys.

(A) The department notifies the applicant and the division’s regional offices (ROs) regarding survey procedures and a copy of any survey instrument that may be used.

Survey procedures include but are not limited to observation and inspection of service sites, interviews with provider staff, individuals being served, and other interested parties, review of provider administrative records necessary to verify compliance with requirements, review of personnel records and service documentation, and observation of program activities.

The review of personnel records includes eligibility for employment, documentation of training, and driver’s license related to the billing of service.

(B) The applicant agrees, by act of submitting an application, to allow and assist department representatives in fully and freely conducting these survey procedures and to provide department representatives reasonable and immediate access to premises, individuals, and requested information.

(C) A provider shall cooperate with the certification process. The provider shall provide information and documentation that is accurate and complete. Actions of the provider, including but not limited to falsification or fabrication of any information used to determine compliance with requirements, may be grounds to deny issuance of or to revoke certification.

(7) Surveyor(s) will hold entrance and exit conferences with the provider to discuss survey arrangements and survey findings, respectively. If a surveyor identifies a deficiency that could result in actual jeopardy to the safety, health, or welfare of persons served, the surveyor will not leave the program until an acceptable plan of correction is presented which assures the surveyor that there is no further risk of jeopardy to persons served. The RO will be notified of the conditions that existed and the accepted plan of correction.

(8) Within thirty (30) calendar days after the exit conference, the department will provide a written survey report to the provider’s chief executive officer and/or the provider contact on the provider application and the division.

(A) The report details all deficiencies identified during the (B) Upon specific request, the provider shall make the report available to the staff, individuals served, and to the public.

(9) If deficiencies are identified, the department will include in the survey report a request for the provider to submit a plan of correction.

(A) The plan must address each deficiency and specify the method of correction and the final date of correction, including identification of other individuals having the potential to be affected by the same deficient practice, how the provider will monitor its corrective action including the job title of the individual responsible for monitoring compliance on an ongoing basis, and what systemic changes have been put into place to ensure the deficient practice doesn’t occur again. The provider is encouraged to work with the RO to develop a plan of correction. No final date of correction will exceed one hundred eighty (180) calendar days from the exit date of the survey.

(B) Within fifteen (15) calendar days after receiving the plan of correction, the department notifies the provider and the division of its decision to approve, deny, or require revisions of the proposed plan.

(C) The surveyor assures the plan of correction has been implemented and deficiencies corrected. The department determines if it is necessary for the surveyor to make a return visit to the provider based on the criteria of the plan of correction and will notify the division and ROs of revisit.

(D) In the event the provider has not submitted a plan of correction acceptable to the department within sixty (60) calendar days of the original date that written notice of deficiencies was presented by certified mail to the provider, it is subject to expiration of certification.

(10) The department sends copies of survey reports, notification about the status of plans of correction, and any other communication relevant to survey to the mailing address and electronic mail address on file in the provider’s application and/or the provider’s chief executive officer.

(11) The department may grant certification on a temporary, provisional, conditional, or regular status.

(A) Temporary status is granted to a provider if the survey process has not been completed prior to the expiration of an existing certificate and the applicant is not at fault for failure or delay in completing the survey process.

(B) Provisional status for a period not exceeding one (1) year is granted to a new provider, a provider which has undergone a change of ownership, or a currently certified provider adding a waivered service based on a review which finds the program in compliance with requirements related to policy and procedure, personnel qualifications and training, and physical plant and fire safety compliance, when applicable, sufficient to begin providing services. Provisional status is effective the date compliance is determined by the Office of Licensure and Certification (OLC) and after the contract with the provider has been executed by the RO.

The department shall conduct a comprehensive site survey of the provisionally certified provider and makes further determination of the provider’s certification status no sooner than ninety (90) calendar days after the provider begins providing services to individuals nor later than the expiration date of the provisional certificate.
If the provider has begun providing services prior to the expiration of the provisional certificate but for less than ninety (90) calendar days, the OLC director may extend the provisional status for up to one hundred twenty (120) calendar days to allow time for a comprehensive survey to occur.
If the provider does not begin serving individuals prior to the expiration date of the provisional certificate, the provisional certificate expires and the provider is required to reapply.
If an existing provider of employment services (prevocational services, career planning, job development, and supported employment) wants to add an additional employment service to their certification, the OLC director may waive the provisional certification process and grant regular certification status to the provider for the new service if— A. The provider submits an application for certification B. All required environmental and fire safety surveys have been completed;

C. The provider’s certification survey was completed D. The provider is currently in compliance;

E. The RO agrees with waiving the provisional process F. The provider has not been on conditional status 5. If an existing provider of day habilitation services wants to add community networking or individual skill development, the OLC director may waive the provisional certification and grant regular certification status to the provider for the new service if— A. The provider submits an application for certification B. The provider’s certification survey was completed C. The provider is currently in compliance;

D. The RO agrees with waiving the provisional process E. The provider has not been on conditional status 6. If an existing provider of community networking or individual skill development wants to add community networking or individual skill development to their certification, the OLC director may waive the provisional certification and grant regular certification status to the provider for the new service if— A. The provider submits an application for certification B. The provider’s certification survey was completed C. The provider is currently in substantial compliance;

D. The RO agrees with waiving the provisional process E. The provider has not been on conditional status (C) Following the period of provisional status, a regular certificate to provide Medicaid waiver services is awarded to a provider following a comprehensive site survey by the department that determines the provider is in compliance and meets all standards relating to quality of care and the safety, health, rights, and welfare of persons served. If deficiencies are cited during a survey, any and all deficiencies must be corrected prior to the department issuing a certificate. The effective date of the certificate is the date the agency was determined to be in compliance as a result of the comprehensive survey and is effective up to two (2) years.

(D) Conditional status is granted to a provider following a site survey by the department that determines there are pervasive and/or significant deficiencies with standards that may affect quality of care to individuals and there is a reasonable expectation the provider can achieve compliance within a stipulated time period. The department considers patterns and trends of performance identified during the site 1. The period of conditional status shall not exceed one hundred eighty (180) calendar days. The department may directly monitor progress, may require the provider to submit progress reports, or both.

The department will conduct an additional site survey within the one hundred eighty (180) calendar day review period and make an additional determination of the provider’s compliance with all standards.
During the period of conditional status, the department may, at its discretion, take actions per sections (17) and (19) of this rule.
At the expiration of conditional status, if the provider is in compliance, the department will issue a certificate with an effective date of the end of the conditional status and expiring two (2) years from the expiration date of the previous certification cycle.

(12) The department may investigate any complaint regarding the operation of a certified or deemed certified program or service. If conditions are found that are not in compliance with applicable certification standards, the department may, at its sole discretion, notify the accrediting organization of any concerns.

(13)

The department may conduct a scheduled or unscheduled site survey of a provider at any time to monitor ongoing compliance with the certification standards. If any survey finds conditions that are not in compliance with applicable certification standards, the department may require corrective action steps and may change the provider’s certification status consistent with procedures set out in this rule.

(14) The department certifies only the provider(s) named in the application. The provider(s) may not transfer certification without the written approval of the department.

(A) A certificate is the property of the department and is valid only as long as the provider meets standards of care and other requirements.

(B) Within seven (7) calendar days of the effective date that a certified provider has a change in accreditation status or discontinues operation, the provider shall provide written notice to the OLC and RO of any such change.

(C) Within seven (7) calendar days of the effective date that a certified provider is sold or undergoes a change of ownership, the provider shall submit a written notice to the OLC and the RO of any such change. A change in ownership is considered to have occurred under the following circumstances:

A new corporation, partnership, limited partnership, limited liability company, or other entity assumes ownership of the operation;
An individual incorporates or forms a partnership;
With respect to a certificate holder which is a general partnership, a change occurs in the majority interest of the partners;
With respect to a certificate holder which is a limited partnership, a change occurs in the majority interest of the general or limited partners;
With respect to a certificate holder which is a corporation, a change occurs in the persons who own, hold, or have the power to vote the majority of any class of stock issued by the corporation; and 6. A certificate holder’s change of Federal Employer Identification Number (FEIN).

(D) Providers may not change the premises of a group home, day habilitation program, or onsite employment service site without prior notification to the OLC and RO and approval by DMH and the Missouri Department of Public Safety.

(E) A provider must be certified to provide a waivered service prior to providing the service. Any provider that establishes a new program or type of program shall operate that program in accordance with applicable standards. A provisional review, site survey, or comprehensive site survey is conducted as determined by the department.

(15)

The department may revoke or deny issuance of certification based on a determination that— (A) The nature of the deficiencies results in substantial probability of or actual jeopardy to individuals being served;

(B) Serious or repeated incidents of abuse or neglect of individuals being served or violations of rights have occurred;

(C) Fraudulent fiscal practices have transpired or significant and repeated errors in billings to the department have occurred;

(D) Failure to participate in the certification process in good faith, including falsification or fabrication of any information used to determine compliance with requirements;

(E) The nature and extent of deficiencies results in the failure to conform to the certification standards of the program or service being offered;

(F) Compliance with standards has not been attained by a provider upon expiration of conditional certification;

(G) Failure to allow the surveyors entry into service site areas or to access individuals receiving services;

(H) Contract for service delivery has ended with the department;

(I) Any provider, or member, partner, administrator, executive director, or program director is found to have disqualifying offense under section 630.170, RSMo, unless an exception has been granted through the DMH Exceptions Committee under sections 630.656 and 630.170, RSMo; or (J) Any provider, or member, partner, administrator, executive director, or program director of a certified agency is found to have ever acted or omitted their duty in a manner which materially and adversely affected the health, safety, welfare, or property of an individual receiving services.

(16) If a certified provider discontinues operation as evidenced by the fact that no individual has received a certified service from the provider for the previous twelve (12) months or any time the department is unable to freely gain entry to conduct an inspection, the provider is considered no longer certified. The department notifies the provider in writing that the certificate is void.

(17) The department director, at its discretion, may— (A) Place a monitor at a program if there is substantial probability of or actual jeopardy to the safety, health, rights, or welfare of individuals being served.

The cost of the monitor is charged to the provider at a rate which will recoup all reasonable expenses incurred by 2. The department shall remove the monitor when a determination is made that the safety, health, rights, and welfare of individuals being served are no longer at risk;

(B) Take other action to ensure and protect the safety, health, or welfare of individuals being served; and (C) Initiate additional service delivery review through other quality integrated functions established within the department.

(18) A provider which has had certification denied or revoked may appeal in writing to the director of the department within thirty (30) calendar days following notice of the denial or revocation being presented by certified mail to the provider. The director of the department shall conduct a hearing under procedures set out in Chapter 536, RSMo, and issue findings of fact, conclusions of law, and a decision which shall be final.

(19) The department has authority to impose administrative sanctions.

(A) The department may suspend the certification process pending completion of an investigation when a provider that has applied for certification or the staff of that provider is under investigation for fraud, financial abuse, abuse or neglect of persons served, revocation of persons’ rights without due process, or improper clinical practices. This includes but is not limited to investigations by any state authority for Medicaid audit and compliance, any state authority for child or adult abuse, neglect or financial exploitation, the Health and Human Services Office of Inspector General, or other local, state, or federal law enforcement.

(B) The department may administratively sanction a certified provider that has been found to have committed fraud, financial abuse, abuse of persons served, or improper clinical practices, or that had reason to know its staff were engaged in such practices.

(C) Administrative sanctions include but are not limited to suspension of certification, clinical utilization review requirements, clinical audit, suspension of new admissions or referrals, implementation of a corrective action plan, denial or revocation of certification, or other actions as determined by the department.

(D) The department has the authority to refuse to accept an application for certification from a provider that has had certification denied or revoked or that has been found to have committed fraud, financial abuse, or improper clinical practices, or whose staff and clinicians were engaged in improper practices.

(E) A provider which has certification denied or revoked as an administrative sanction may appeal these sanctions pursuant to section (18).

(20) A provider may request the department’s exceptions committee waive a requirement for certification if the head of the provider organization provides evidence that a waiver is in the best interests of the individuals it serves.

(A) A request for a waiver is in writing and includes justification for the request.

(B) The request is submitted to Exceptions Committee, Department of Mental Health, PO Box 687, Jefferson City, MO 65102.

(C) The exceptions committee holds meetings in accordance with Chapter 610, RSMo, and responds with a written decision within forty-five (45) calendar days of receiving a request.

(D) The exceptions committee may issue a waiver on a time-limited or other basis.

(E) If a waiver request is denied, the provider has forty-five (45) calendar days from date of denial to fully comply with the standard unless a different time period is specified by the committee.

Filed June 28, 2023, effective Jan. 30, 2024. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008, and 630.655, RSMo 1980.

History

AUTHORITY: sections 630.050 and 630.655, RSMo 2016. 45 CFR parts 160 and 164, the Health Insurance Portability and Accountability Act of 1996. Emergency rule filed Feb. 13, 2002, effective March 1, 2002, expired Aug. 27, 2002. Original rule filed Feb. 13, 2002, effective Aug. 30, 2002. Emergency amendment filed April 1, 2003, effective April 14, 2003, expired Oct. 14, 2003. Amended: Filed April 1, 2003, effective Oct. 30, 2003. Rescinded and readopted:

9 CSR 45-5.105 Definitions for Fire Safety Rules {#sec-9-csr-45-5.105 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-5.105}

PURPOSE: This rule establishes definitions for the fire safety rules promulgated under this chapter.

(1) The following terms shall mean:

(A) Alterations, changes made to the structure or floor plan of the facility by removing or adding walls and doors or adding space;

(B) Commercial range is any range or stovetop classified as commercial by the manufacturer or larger in size than a common residential range, equipped with four (4) or more burners/elements and may be equipped with a cooking grill or griddle surface;

(C) Dead-end is a corridor or hallway with no exit at the end that causes occupants to retrace their path to reach an exit;

(D) Department of Public Safety, Division of Fire Safety is the state agency to which the department delegates its authority for fire safety inspections of on-site day habilitation programs and waiver group homes subject to rules promulgated under 9 CSR 45 Chapter 5;

(E) Exit is the portion of a means of egress that is separated from all other areas of the building or structure by construction or equipment required to provide a protected way of travel to the exit discharge. Exits include exterior exit doors, exit passageways, horizontal exits, separated exit stairs, and separated exit ramps;

(F) Exit access is the portion of a means of egress that leads to an exit;

(G) Exit discharge is the portion of a means of egress between the termination of an exit and a public way;

(H) Fire barrier is a structural element, either vertical or horizontal, such as a wall or floor assembly that is designed and constructed with a specified fire resistance rating to limit the spread of fire and restrict the movement of smoke. Such barriers may have protected openings;

(I) Fire door is a combination of the fire door, frame, hardware and other accessories which together provide a specific degree of fire protection to the opening;

(J) Fire resistance rating is the length of time in minutes or hours that materials or structural elements can withstand fire exposure;

(K) Flame resistant material is the property of material or their structural elements that prevents or retards the passage of excessive heat, hot gases, or flames under the conditions in which they are used;

(L) Flame retardant is a chemical applied to material or other substance that is designed to retard ignition or the spread of fire;

(M) Home type range is a typical home type cooking stove;

(N) Interior finish includes the interior wall and ceiling finish, and interior floor finish;

(O) Level exit discharge is a horizontal plane that is located from the point at which an exit terminates and the exit discharge begins. The horizontal plane shall not vary more than two inches (2”) in rise or fall;

(P) Level is the portion of a building included between the upper surface of a floor and the ceiling above it, or any upper surface of a floor and the ceiling above it that is separated by more than five (5) steps on a stairway;

(Q) Means of egress is a continuous and unobstructed way of travel from any point in a building or structure to a public way.

A means of egress consists of three (3) distinct parts: the exit access, the exit, and the exit discharge;

(R) Means of escape is a way out of a residential unit that does not conform to the strict definition of means of egress but does meet the intent of the definition by providing an alternative way out of a building;

(S) Mixed occupancy is when a facility is located in the same building or structure as another occupancy. This may include a business or place of assembly;

(T) Non-combustible material is a material that, in the form in which it is used and under the conditions anticipated, will not ignite, burn, support combustion, or release flammable vapors when subjected to fire or heat. Examples of such materials include steel, concrete, and masonry.

(U) Public way is a street, alley, or other similar parcel of land essentially open to the outside air that is deeded, dedicated, or otherwise permanently appropriated to the public for public use and having a clear width and height of not less than ten feet (10');

(V) Remote exit or means of egress is when two (2) exits or two (2) exit access doors are required. Each exit or exit access door shall be placed at a distance apart equal to at least one-half (1/2) the length of the maximum overall diagonal dimension of the building or area to be used;

(W) Self-closing means to be equipped with an approved device that will ensure closing after having been opened;

(X) Smoke barrier is a structural element, either vertical or horizontal, such as a wall, floor, or ceiling assembly that is designed and constructed to restrict the movement of smoke.

A smoke barrier may or may not have a fire resistance rating;

(Y) Supervised automatic sprinkler system is a system with the initiating devices monitored by the fire alarm control panel. This may include switches used to monitor the position of valves, a low air pressure switch, a water flow switch, and a tamper switch; and (Z) Waiver Group Home- a residential facility owned and operated by a provider that provides Medicaid waiver services.

A certified group home is similar in appearance to a singlefamily dwelling and provides care, supervision, and skills training in activities of daily living, home management, and community integration. Group homes do not provide shared living or individualized supported living services.

(2) In the context of rules promulgated under 9 CSR 45, the term department shall mean the Department of Mental Health (DMH).

(3) Terms not defined in this rule shall be understood as defined in the fire safety code of the National Fire Protection Association (NFPA).

9 CSR 45-5.110 Fire Safety for Facility-based Day Habilitation and Employment Service Settings {#sec-9-csr-45-5.110 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-5.110}

PURPOSE: This rule establishes fire safety requirements for facilitybased day habilitation and employment service settings funded through the Medicaid home and community-based waivers. The department delegates its authority for fire safety inspections under this rule to the Department of Public Safety, Division of Fire Safety.

(1) General Requirements.

(A) People participating in facility-based day habilitation and employment service settings are restricted to using the floor of the building that is at ground level exit discharge. Exception:

People participating in facility-based day habilitation and employment services may use the floor below and above the level of exit discharge if the entire building is protected throughout with an approved automatic sprinkler system.

(B) No facility-based day habilitation and employment service shall be located in the same building as a high hazard occupancy.

(C) The staff of the facility shall conduct at least one (1) fire drill at least once a month. In addition, a natural disaster drill will be conducted at least twice per year. The staff shall maintain a written record at the facility of the date, type of drill, time required to evacuate the building, whether the evacuation was completed, notation of any problems evacuating, and the number of occupants present during the drill.

(D) Unscheduled drills shall be held at the Division of Fire (E) During severe weather, fire drills may be postponed.

(F) Each fire drill shall evacuate all persons from the building and be conducted as follows:

Drills simulate an actual fire condition;
Occupants and staff members do not obtain clothing or personal effects after the alarm has sounded;
The occupants and staff members proceed to a of the building to defend in place; and 4. Occupants and staff members remain in place until a (G) No window in a facility shall have bars or any other item placed over it in a stationary manner that would impede a rescue or evacuation attempt.

(H) All flammable/combustible liquids, matches, toxic cleaning supplies, poisonous materials, medicines, or other hazardous items shall be stored so as to be inaccessible to the occupants.

(I) The building numbers shall be plainly visible from the street in case of emergency: at least four (4) inches in height and contrasting color with the building.

(J) Good housekeeping practices ensuring fire safety will be (K) Stairways, walks, ramps, and porches shall be kept free of (L) Fresh-cut Christmas trees shall not be used, unless they (M) The facility may use a cellular phone when all of the 1. The phone must always have a signal;

The phone must always be charged;
The phone must be able to make and receive normal 4. The phone must remain at the facility at all times; and 5. The emergency plan for the facility must address the use (N) The facility shall notify the nearest fire department that (O) Facilities served by a volunteer or membership fire (P) The facility shall, as soon as possible, no later than the following business day, report any fire in the facility to the Division of Fire Safety and the Department of Mental Health.

(Q) The Division of Fire Safety may make additional (R) Prior to new construction, remodeling existing structures, (S) During the construction or remodeling process, the to request these inspections in a timely manner may result in an unapproved fire inspection from the Division of Fire Safety.

(T) The ceiling height in all facilities shall be a minimum of Division of Fire Safety inspector for some areas that are below seven feet six inches (7'6") for the installation of ductwork and plumbing, with no part of the ceiling less than six feet eight inches (6' 8").

(U) Facilities shall comply with all local building codes, fire (V) The latest edition of the National Fire Protection (W) Each facility-based day habilitation and employment service setting shall be inspected at least once annually by a Division of Fire Safety inspector. The Department of Mental Health will initiate the fire safety inspection. If a facility is found out of compliance with the fire safety rules, the department will apply procedures for achieving compliance as promulgated under 9 CSR 45-5.060.

(2) Means of Egress Requirements.

(A) Each floor occupied in the facility shall have not less than two (2) remotely located means of egress. Each exit door in existing approved facilities shall not be less than thirtytwo inches (32") wide. All exit doors in new construction and facilities approved for service delivery after the effective date of this rule shall be a minimum of thirty-six inches (36") wide.

(B) No door in the path of travel to the means of egress shall be less than thirty-two inches (32") wide in an approved existing facility.

(C) At no time shall the occupants of the facility exit through a bathroom, storage room, furnace room, kitchen, garage, or any other room deemed hazardous by the Division of Fire Safety inspector.

(D) All exit doors shall swing in the direction of egress travel and have door closures attached. In smaller facilities that care for ten (10) or fewer individuals, the exit doors may swing inward providing all of the individuals are ambulatory. Door closures are not required in smaller facilities.

(E) Emergency lighting that has a battery backup shall be of emergency lights shall be determined by the Division of Fire Safety. These lights shall be tested monthly and documentation kept indicating what lights are tested and the date and name of the person performing the test.

(F) Lighted exit signs with a battery backup shall be installed direct the occupants to the exits. Lighted exit signs shall be tested monthly and documentation kept indicating what lights are tested and the date and name of the person performing the test.

(G) No locks that require a key or special knowledge to unlock (H) Overhead garage doors are not recognized as exit (I) Mirrors shall not be placed on exit doors or adjacent to any exit in such a manner to confuse the direction of the exit. All exit doors shall be readily recognizable.

(J) All hallways shall have a clear width of at least thirty-six (K) Dead-end corridors/hallways shall not exceed twenty feet (20').

(L) All facilities that have a set of stairs or use stairs as an exterior fire escape shall be constructed as follows:

All stairs shall be at least thirty-six inches (36") wide. Fire escapes shall be constructed of noncombustible materials;
A maximum rise of eight inches (8");
A minimum tread of nine inches (9");
A maximum height between landings of twelve feet 5. A minimum landing size of forty-four inches (44");
Handrails placed on both sides of sturdy construction 7. An outside diameter of the handrails of at least one and 8. Handrails with a clearance of at least one and one-half which it is attached; and 9. Spiral staircase or winder is not permitted.

(M) Every ramp used in the component of the means of egress shall be a minimum of forty-four inches (44") wide, and have landings at the top and bottom being the same width as the ramp. Ramp height shall comply with the following:

Ramps less than three inches (3”) in height have a slope 2. Ramps with a height of three to six inches (3"–6") have a slope of one inch (1") per ten inches (10") of run; and 3. Ramps with a height greater than six inches (6") have a (N) All ramps shall have a slip-resistant surface and be (O) All ramps over ten inches (10") in height shall have (3) Windows for Emergency Rescue and Ventilation.

(A) Every room or space greater than three hundred (300) square feet used by individuals shall have at least one (1) outside window for emergency rescue and ventilation. The window shall comply with the following:

Is operable from the inside without the use of tools;
Provides a clear opening of at least twenty inches (20") wide, twenty-four inches (24") in height, and has a total clear opening space no less than 5.7 square feet in size;
The bottom of the window opening is no more than forty-four inches (44") above the floor;
Any latching device is operated easily;
Provides a clear opening that is a rectangular solid, with a minimum width and height that provides the required 5.7 square feet opening and a minimum depth of twenty inches (20") to allow passage through the opening;
The windows shall be accessible by the fire department and open into an area having access to a public way.

(B) Subsection (3)(A) does not apply in the following situations:

In buildings protected throughout by an approved, supervised automatic sprinkler system;
When the room or space has a door leading directly to the outside of the building; or 3. If it is an interior room greater than three hundred (300) square feet in size and has two (2) remotely located means of egress and the egress doors are a minimum of thirty-six inches (36") wide and swings in the direction of egress.

(4) Travel Distance to Exits.

(A) The travel distance between any room door intended as an exit access or an exit shall not exceed one hundred feet (B) The travel distance between any point in a room and an (C) The travel distance in (A) and (B) above shall be permitted to be increased by fifty feet (50') in buildings protected throughout by a supervised automatic sprinkler system that is approved by the Division of Fire Safety inspector, based on the National Fire Protection Association Standards for Sprinkler Systems.

(5) Protection.

(A) Any vertical openings and stairwells shall be enclosed and protected with a one- (1-) hour fire barrier and self-closing device attached to the door.

(B) All furnace rooms, rooms containing water heaters, boiler rooms, laundry rooms, and storage rooms shall be separated from the remainder of the building by construction having not less than a one- (1-) hour fire resistance rating. All doors to these rooms shall have a self-closing device attached and a one- (1-) hour fire resistive rating. The one- (1-) hour rating required for these rooms or areas are not required if the facility installs a one and three quarters inch (1 ¾") thick solid core wood door or a twenty (20) minute fire rated door with a self-closure device installed and an automatic sprinkler head supplied by the domestic water supply or has an approved automatic sprinkler system. A fire alarm initiating device shall be installed in these rooms or areas. Before approval of the sprinkler installation the pipe (minimum ½ inch diameter) and fittings are tested and approved to the 1881 or 1887 standard for use in sprinkler applications. If the sprinkler option is chosen, the above appliances must be enclosed in a smoke resistant enclosure.

The door to these rooms shall be a minimum of one and three quarters inch (1 ¾") solid bonded wood core door with a selfclosing device or a twenty minute fire rated door. No open penetrations including combustion air or return air vents are close on activation of the fire alarm or smoke detectors are allowed.

(C) Facility-based day habilitation and employment service settings shall be separated from other occupancies in the same building in accordance with the following:

Use Group Fire Wall Separation in Hours Place of assembly 2 Business 1 Mercantile 2 Institutional restrained 1 Hotels or dormitories 2 (6) Interior Finish.

(A) Interior wall and ceiling finishes throughout shall be a (B) All wall studs, ceiling joists, and floor joists shall be (C) Hangings or draperies shall not be placed over exit doors Safety inspector to review. An exception can be made for window valances and shall be noted by the inspector on the fire inspection survey.

(7) Detection, Alarms, Extinguishment.

(A) All facility-based day habilitation and employment service settings programs serving forty-nine (49) people or less shall have smoke detectors installed on each level, in all occupied spaces, storage rooms, and throughout all corridors and in all other locations as deemed necessary by the Division of Fire Safety inspector. All smoke detectors shall be powered by the building’s electrical system and have a nine- (9-) volt battery backup and be interconnected. Smoke detectors shall be installed and arranged so that the activation of any smoke detector causes the operation of an alarm in all detectors that is clearly audible throughout the building, including in bathrooms, corridors, and activity rooms, and above the noise of radios, televisions, and noises of normal activity.

(B) All facility-based day habilitation and employment service settings programs serving fifty (50) people or more shall have a full coverage electrical fire alarm system. Pull stations shall be mounted at each exit door, and horns/strobes shall be installed throughout the facility. Smoke detectors shall be installed in all rooms, throughout all corridors, in all living spaces, storage rooms, and offices. Additional smoke detectors may be required by the Division of Fire Safety inspector as deemed necessary. Heat detectors shall be installed in all mechanical rooms, kitchens, laundry rooms, closets, and throughout the attic. The battery backup control panel shall be Underwriters Laboratories, Inc. (UL) or Factory Mutual (F.M.) listed and installed on a dedicated circuit in the breaker box. The fire alarm system shall be installed and maintained in accordance with the NFPA 72 Fire Alarm Code and in good working order.

(C) The fire alarm system shall be monitored by a monitoring company or transmitted directly to the fire department when fifty (50) or more individuals are present.

(D) All facilities shall have the fire alarm system tested, inspected, and approved annually by a fire alarm company in accordance with the NFPA 72 Fire Alarm Code. A copy of the test report and approved inspection report of the system shall be kept on file at the facility for review by the Division of Fire Safety inspector and the department.

(E) Occupant notification shall be provided automatically (F) Any facility that has hearing-impaired occupants shall make adequate provisions so that the activation of any fire alarm system shall notify the occupants of the building.

The Division of Fire Safety inspector may require additional adequate modification.

(G) All smoke detectors that are ten (10) years old or older shall be replaced with new smoke detectors of the same style. The new smoke detectors shall have the installation date written on the side of the detector for the Division of Fire Safety inspector to reference. All smoke detectors that are connected to a fire alarm system shall be replaced after ten (10) years of service, or recalibrated by the smoke detector’s manufacturer. If the (H) Facilities using any equipment or appliances using wood or fossil fuel that pose a potential carbon monoxide Fire Safety may require additional carbon monoxide detectors if the Division of Fire Safety inspector determines that the safety of the occupants is endangered.

Carbon monoxide detectors shall be in good operating facility shall install a detector that is powered by the building’s 2. If an elevated carbon monoxide level is detected during documentation on file at the facility verifying that all gas-fired company and are in safe working order, and the facility is determined safe by the Division of Fire Safety inspector, the fire 3. If a level of carbon monoxide is determined that endangers the lives of the occupants in care, the Division of Fire Safety inspector shall take measures necessary to protect the occupants. This may include evacuation of the building or closing the facility. The facility shall obtain and have on file at the facility, documentation verifying all gas-fired appliances were checked by a heating and air conditioning company and are in safe working order. The facility shall be reinspected by the Division of Fire Safety inspector and determined safe before the occupants can return to the building or the facility can reopen.

(I) At least one (1) portable (five pound (5 lb)) 2A–10B:C (J) Fire extinguishers shall be installed and maintained (8) Heating, Ventilating, Air Conditioning, and Mechanical (A) Unvented fuel-fired room heaters, portable electric space (B) No facility shall be allowed to heat the facility with a wood burning stove, fireplace, or wood burning furnace located inside of the structure.

(C) All gas and electric heating equipment shall be equipped (D) Facilities with a water heater two hundred thousand (E) All furnace rooms shall be properly vented. Furnace (F) All joints in the gas supply pipe shall be located outside of (G) Gas shutoff valve shall be located next to all gas appliances, furnaces, hot water heaters.

(H) All furnaces shall be equipped with an electrical fused (I) If a furnace or water heater is located inside a garage, the this room shall also have a fire rating of thirty (30) minutes and have a door closure attached. Open penetrations, including combustion air or return air vents, shall not be allowed to penetrate these enclosures or doors. Louvers that close on activation of the fire alarm or smoke detectors are allowed.

(J) All furnace rooms and rooms containing the water heater combustion air is drawn from inside the structure and one (1) square inch per four thousand (4,000) Btus input if the air is drawn from outside of the structure. There shall be two (2)

(K) One (1) combustion air vent opening shall be permitted manufacturer’s instructions and have the proper clearance around the unit or a minimum of one inch (1") from the sides and back, and six inches (6") from the front of the unit.

(L) Air conditioning, heating, ventilating ductwork, and Fire Safety.

(M) All elevators shall be inspected bi-annually by a state (N) If any combustibles are stored in a furnace room, they (9) Electrical Services.

(A) Electrical wiring shall be installed and maintained in good working order. If the Division of Fire Safety inspector considers the wiring to be unsafe for the occupants or it is installed improperly, an inspection by a licensed electrician may be required prior to fire safety approval. The inspection by the licensed electrician shall be based on National Fire (B) No electrical extension cords will be allowed, unless approved in writing by the Division of Fire Safety inspector.

(10) Equivalency Concepts. Nothing in this rule is intended to

9 CSR 45-5.130 Fire Safety for Group Homes Serving 4–9 People homes serving four to nine (4–9) people funded through the Medicaid home and community-based waiver. {#sec-9-csr-45-5.130 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-5.130}

This rule does not apply to individual supported living in private residences.

The department delegates its authority for fire safety inspections under this rule to the Department of Public Safety, Division of Fire Safety.

(1) General Requirements.

(A) The staff shall conduct at least one (1) fire drill per month and one (1) natural disaster drill per quarter, with a minimum of one (1) fire and one (1) natural disaster drill per year conducted while the individuals are sleeping. A drill must be conducted within one (1) week of the arrival of a new individual. The staff shall maintain a written record at the facility of the date, type of drill, time required to evacuate the building, whether the evacuation was completed, notation of any problems evacuating, and number of occupants present during the drill.

(B) Unscheduled drills shall be held at the Division of Fire (C) During severe weather, fire drills may be postponed.

(D) Each fire drill shall evacuate all persons from the and each fire drill shall be conducted as follows:

Drills simulate an actual fire condition;
Occupants (referred to hereafter as “individuals”) and 3. The individuals and staff members proceed to a remote to avoid fire danger, or in case of natural disaster drill to a predetermined point inside of the building; and 4. Individuals and staff members remain in place until a 5. Exception. If there is potential harm to residents during drills because a resident is medically fragile, the provider may arrange the drill to not involve the medically fragile. However, all individuals who are medically fragile must participate in a drill at least once per year. This must be documented in the home.

(E) No window in a facility shall have bars or any other item (F) All flammable/combustible liquids, matches, toxic (G) Clothes dryers shall be vented to the outside or as recommended by the manufacturer and maintained properly.

(H) The house numbers shall be plainly visible from the street in case of emergency, at least four inches (4") in height and a (I) Good housekeeping practices ensuring fire safety will be (J) Stairways, walks, ramps, and porches shall be kept free of (K) Fresh-cut Christmas trees shall not be used unless they (L) Candles and other devices that have an open flame shall (M) The facility may use a cellular phone when all of the 1. The phone must always have a signal;

The phone must always be charged;
The phone must be able to make and receive normal 4. The phone must remain at the facility at all times; and 5. The emergency plan for the facility must address the use (N) The facility shall notify the nearest fire department that (O) Facilities served by a volunteer or membership fire (P) The facility shall, as soon as possible but no later than the following business day, report any fire in the facility to the Division of Fire Safety and the Department of Mental Health.

(Q) The Division of Fire Safety may make additional (R) Prior to new construction, remodeling existing structures, and Certification Unit, the second copy to the Division of (S) During the construction or remodeling process, the to have these inspections constitutes cause for disapproval by the Division of Fire Safety.

(T) Facilities that were certified and areas approved for care prior to the effective date of this rule shall have ceilings at least seven feet (7') in height. Facilities initially certified and areas initially approved for care on or after the effective date of this rule shall meet all the requirements of this rule and shall have ceilings at least seven feet, six inches (7'6”) in height. If structural alterations are made in facilities certified prior to the effective date of this rule, those facilities shall meet all the requirements of this rule and shall have ceilings at least seven feet, six inches (7'6") in height in the altered space.

Allowance will be made by the Division of Fire Safety inspector for the installation of ductwork and plumbing. No more than forty percent (40%) of the ceiling in each room shall be below minimal height, with no portion of the ceiling lower than six feet, eight inches (6' 8").

(U) Facilities shall comply with all local building codes, fire (V) The latest edition of the National Fire Protection (W) Each group home shall be inspected at least once annually by a Division of Fire Safety inspector. The Department of Mental Health will initiate the fire safety inspection. If a facility is found out of compliance with the fire safety rules, the department will apply procedures for achieving compliance as promulgated under 9 CSR 45-5.060.

(2) Means of Egress Requirements.

(A) Each floor occupied in the home shall have not less than egress shall not be a window. Each exit door shall not be less than thirty inches (30") wide, except that newly constructed doorways shall be at least thirty-six inches (36") wide.

(B) Individual sleeping rooms in all new group homes (C) Wheelchairs, walkers, and other support equipment shall (D) No door in the path of travel to the means of egress shall be less than thirty inches (30") wide. Except that newly constructed doorways shall be at least thirty-six inches (36").

(E) No primary means of escape or planned exit shall lead through a bathroom, storage room, furnace room, garage, or any other room deemed hazardous by the fire inspector.

Exception: Kitchens shall not be considered hazardous unless they have commercial stoves without extinguishing equipment or other features that lend themselves to rapid fire development.

(F) All required outside exit doors shall swing in the direction of egress travel if there are more than six (6) individuals living in the home and one (1) or more person(s) is non-ambulatory.

In other words, if there are six (6) individuals or less and all are ambulatory, the required exit doors do NOT have to swing in the direction of egress travel.

(G) Emergency lighting that has a battery backup shall be installed to light the path of egress. The Division of Fire Safety inspector shall determine the location and number of emergency lights. Emergency lights shall be tested monthly and documentation indicating which lights were tested, the date tested, and the name of the person performing the test kept for review by the Division of Fire Safety.

(H) No locks that require a key or special knowledge to unlock the lock from the inside shall be allowed. Delayed egress locks complying with section 7.2.1.6.1 of the 2012 edition NFPA 101 are permitted, provided that no more than one (1) such device is located in any egress path.

(I) Overhead garage doors are not recognized as exit (J) Mirrors shall not be placed on exit doors or adjacent to any exit in such a manner to confuse the direction of the exit. All exit doors shall be readily recognizable.

(K) All hallways shall have a clear width of at least thirty-six (L) Dead-end corridors/hallways shall not exceed twenty feet (20').

(M) Facilities initially certified and areas initially approved on or after the effective date of this rule, shall meet the following requirements. All facilities that have a set of stairs or use stairs as a fire escape shall be constructed as follows:

All stairs shall be at least thirty-six inches (36") wide.

New fire escapes shall be constructed of noncombustible materials. Existing fire escapes shall be of sturdy construction and, at the discretion of the Division of Fire Safety, may be required to be load tested;

A maximum rise of eight inches (8");
A minimum tread of nine inches (9");
A maximum height between landings of twelve feet 5. A minimum landing size of forty-four inches by fortyfour inches (44" × 44");
Handrails placed on both sides of sturdy construction 7. An outside diameter of the handrails of at least one and 8. Handrails with a clearance of at least one and one-half 9. Spiral staircases or winders are not permitted.

(N) Every ramp used in the component of the means of egress ramp. Ramp height shall comply with the following:

Ramps less than three inches (3") in height have a slope 2. Ramps with a height of three to six inches (3"–6") have a 3. Ramps with a height greater than six inches (6") have a (O) All ramps shall have a slip-resistant surface and be (P) All ramps over ten inches (10") in height shall have (3) Travel Distance to Exits.

(A) The travel distance between any room door intended as an exit access and an exit shall not exceed one hundred feet (B) The travel distance between any point in a room and an (C) The travel distance between any point in a sleeping room and an exit access door in that room shall not exceed fifty feet (50'). Exception: The travel distance in (A) and (B) of this subsection shall be permitted to be increased by fifty feet (50') in buildings protected throughout by a supervised automatic sprinkler system that is approved by the Division of Fire Safety inspector, based on the National Fire Protection Association, Standards for Sprinkler Systems.

(4) Protection.

(A) Vertical openings shall be protected so that no primary a fire-resisting capability of not less than one- (1-) hour and resists the passage of smoke. All doors or openings shall have (B) Exception. Specific residential facilities that were certified prior to the effective date of this rule with or without twenty- (20-) minute fire barriers in interior stairways as required by subsection (4)(A) shall be considered in compliance with current of residents is increased.

(C) All furnace rooms, rooms containing water heaters, building by a construction having not less than a one- (1-) hour fire resistance rating. Doors to these rooms must be closed at all times. Doors to these rooms shall also have a one- (1-) hour fire resistance rating. The door(s) shall also have door closure(s) attached.

(D) Exception: Specific residential facilities that were certified prior to the effective date of this rule shall be considered in compliance with subsection (4)(C) of this rule if the facility installs a sprinkler head off the domestic water supply or has an approved automatic sprinkler system and a fire alarm initiating device shall be installed in the high hazard area.

(E) Exception. The one- (1-) hour fire resistance rating required for rooms or areas listed in subsection (4)(C) of this rule is not required if the facility installs a sprinkler head off the domestic water supply or has an approved automatic sprinkler system and a fire alarm initiating device shall be installed in the high hazard area, and a one and three-fourths inches (1 3/4") thick solid core door or a twenty- (20-) minute fire rated door is installed with a self-closing device attached to prevent the passage of smoke. Before approval of the sprinkler installation the pipe and fittings are tested and approved to the 1881 or 1887 standard for use in sprinkler applications. If the sprinkler option is chosen, the above appliances must be enclosed in smoke resistant enclosures. The door to these rooms shall be a minimum of one and three-fourths inches (1 3/4") solid bonded wood core door with a self-closing device or a twenty minute fire rated door. No open penetrations including combustion air or return air vents shall be allowed to penetrate these (F) Every unoccupied attic space shall be subdivided by draft stops having a one- (1-) hour fire rating, into areas not to exceed three thousand (3,000) square feet. Exception: Subdivisions described in this subsection are not required if the space is protected throughout by an approved, automatic sprinkler system.

(5) Interior Finish.

(A) Interior wall and ceiling finishes throughout shall be a (B) All wall studs, ceiling joists, and floor joists shall be (C) Hangings or draperies shall not be placed over exit doors Safety inspector to review. Exception shall be made for small window valances. These exceptions shall be noted on the fire inspection survey.

(6) Detection, Alarms, Extinguishment.

(A) Smoke detectors shall be installed in all sleeping rooms, throughout all corridors, in all living spaces, storage rooms, offices, and any other areas that are deemed necessary by the Division of Fire Safety inspector. Smoke detectors shall be in good operating condition and functional at all times. Smoke detectors may be battery powered. However, if smoke detectors are not operational during two (2) separate inspections, the facility will be required to install smoke detectors that are powered by the home’s electrical system and have a battery backup. These detectors shall be interconnected so that the activation of one (1) detector will cause an alarm in all detectors. Smoke detectors that are not operational must be documented on inspection surveys. All new construction or facilities licensed and approved after the date of these rules shall have smoke detectors powered by the building’s electrical system, have a battery backup, and be interconnected so activation of a single smoke alarm causes alarm in all smoke detectors.

(B) All smoke detectors that are ten (10) years old or older inspector to reference.

The Division of Fire Safety inspector may require additional adequate notification.

(E) Occupant notification shall be provided automatically (F) All homes with fire alarm systems shall continue to have the fire alarm system tested, inspected, and approved annually by a fire alarm company and a copy of the test report and approval of the system kept on file at the residence for review (G) Residences using any equipment or appliances using wood or fossil fuel that pose a potential carbon monoxide 1. Carbon monoxide detectors shall be in good operating condition. If a battery operated detector is not operational, the 2. If an elevated carbon monoxide level is detected during a fire inspection, the residence shall have all gasfired appliances checked by a heating and air conditioning company to identify the source of the carbon monoxide. Until the residence has documentation on file at the home verifying that all gas-fired appliances were checked by a heating and air conditioning company and are in safe working order, and the facility is determined safe by the Division of Fire Safety, the fire 3. If a level of carbon monoxide is determined that Safety inspector shall take measures necessary to protect the occupants. This may include evacuation of the home or closing the residence. The residence shall obtain and have on file at the home, documentation verifying that all gas-fired appliances were checked by a heating and air conditioning company and are in safe working order. The residence shall be reinspected by the Division of Fire Safety inspector and determined safe before the occupants can return to the home or the residence can reopen.

(H) At least one (1) portable (five pound (5 lb)) 2A-10B:C fire extinguisher shall be required in all homes. One (1) fire extinguisher shall be located in the kitchen. Additional fire extinguishers shall be placed throughout the home and the travel distance shall be no greater than seventy-five feet (75') be required by the Division of Fire Safety depending on the floor plan arrangement of space and the number of levels used.

(I) Fire extinguishers shall be installed and maintained and inspected and approved annually by a fire extinguisher company. Documentation of the inspection and approval shall be on file at the facility and available for review by the Division of Fire Safety inspector.

(J) Homes shall meet the following requirements of subsections (6)(J) and (6)(K) of this rule. Homes using a commercial stove, deep fryer, or two (2) home type ranges placed side by side, shall be equipped with a range hood and extinguishing system with an automatic cutoff of the fuel supply and exhaust system in case of fire. The hood and hood extinguishment system shall be inspected by a qualified technician to insure they are in good working condition and installed/maintained correctly.

The technician shall base this inspection on National Fire Protection Association, Chapter 96, Standard for Fire Protection of Commercial Cooking Operations. Exceptions: 1) Home type ranges separated by an eighteen inch (18") cabinet shall not be required to have an extinguishing system installed above them. 2) Facilities that cook on a home type range with no more than four (4) burners and/or grill, does not need to install a fire extinguishing system above the range.

(K) The range hood fire extinguishment system shall be (7) Heating, Ventilating, Air Conditioning, and Mechanical (A) Unvented fuel-fired room heaters, portable electric space (B) No facility shall be allowed to heat the home with a wood inside of the structure as a primary source of heat. Fireplaces need to be approved for use by the Division of Fire Safety inspector. If the fireplace is approved for use all chimneys shall be inspected annually and cleaned if necessary by a qualified technician or company, with documentation kept for review (C) All gas and electric heating equipment shall be equipped (D) Facilities with a water heater two hundred thousand British thermal units (200,000 Btus) per hour input or larger, or that are heating with a boiler, shall have a valid permit from (E) All furnace rooms shall be properly vented. Furnace (F) All joints in the gas supply pipe shall be located outside of (G) A gas shutoff valve shall be located next to all gas appliances, furnaces, and water heaters.

(H) All furnaces shall be equipped with an electrical fused (I) If a furnace or water heater is located inside a garage, the this room shall also have a minimum thirty- (30-) minute fire rating and have a door closure attached. Open penetrations, including combustion air or return air vents, shall not be close on activation of the fire alarm or smoke detectors are allowed.

(K) One (1) combustion air vent opening shall be permitted (L) Air conditioning, heating, ventilating ductwork, and Fire Safety inspector.

(M) Any furnace or air handling equipment that has airflow (N) All elevators shall be inspected bi-annually by a state (O) If any combustibles are stored in a furnace room, they (8) Electrical Services.

(A) Electrical wiring shall be installed and maintained in the wiring to be unsafe for the occupants or it is installed required prior to fire safety approval. The inspection by the licensed electrician shall be based on National Fire Protection Association, Chapter 70, National Electrical Code.

(B) No electrical extension cords will be allowed, unless approved in writing by the Division of Fire Safety inspector.

Extension cords shall not be permanently affixed to the structure or replace permanent wiring. Exception: The use of Underwriters Laboratories, Inc. (UL) approved fused power surge strips is acceptable.

(9) Equivalency Concepts. Nothing in this rule is intended to

9 CSR 45-5.140 Fire Safety for Group Homes Serving 10–16 People homes serving ten to sixteen (10–16) people funded through the Medicaid home and community-based waiver. The department delegates its authority for fire safety inspections under this rule to the Department of Public Safety, Division of Fire Safety. {#sec-9-csr-45-5.140 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-5.140}

(1) General Requirements.

(A) The staff shall conduct at least one (1) fire drill per month and one (1) natural disaster drill per quarter, with a minimum of two (2) drills, one (1) fire and one (1) natural disaster, conducted annually while the individuals are sleeping. A drill must be conducted within one (1) week of the arrival of a new individual. The staff shall maintain a written record at the facility of the date, type of drill, time required to evacuate the building whether the evacuation was completed, notation of any problems evacuating, and number of occupants present during the drill.

(B) Unscheduled drills shall be held at the Division of Fire (C) During severe weather, fire drills may be postponed.

(D) Each fire drill shall evacuate all persons from the and conducted as follows:

Drills simulate an actual fire condition;
Occupants (referred to hereafter as “individuals”) and 3. The occupants and staff members proceed to a of the building;
Individuals and staff members remain in place until a recall is issued or until they are dismissed; and 5. Exception. If there is potential harm to individuals during drills because a resident is medically fragile, the provider may arrange the drill to not involve the medically fragile. However, all individuals who are medically fragile must participate in a drill at least once per year. This must be documented in the home.

(H) The house numbers shall be plainly visible from the street in case of emergency, at least four inches (4") in height and (I) Good housekeeping practices ensuring fire safety will be (J) Stairways, walks, ramps, and porches shall be kept free of (K) Fresh-cut Christmas trees shall not be used unless they (L) Candles and other devices that have an open flame shall (M) The facility may use a cellular phone when all of the 1. The phone must always have a signal;

The phone must always be charged;
The phone must be able to make and receive normal 4. The phone must remain at the facility at all times; and 5. The emergency plan for the facility must address the use (N) The facility shall notify the nearest fire department that (O) Facilities served by a volunteer or membership fire (P) The facility shall, as soon as possible but no later than the following business day, report any fire in the facility to the Division of Fire Safety office and the Department of Mental Health.

(T) The ceiling height in all facilities shall be a minimum of Division of Fire Safety for some areas that are below seven feet six inches (7'6") for the installation of ductwork and plumbing.

No more than forty percent (40%) of the ceiling in each room shall be below minimal height, with no portion of the ceiling lower than six feet eight inches (6' 8").

(U) Facilities shall comply with all local building codes, fire (V) The latest edition of the National Fire Protection (W) Each group home shall be inspected at least once annually by a Division of Fire Safety inspector. The department will initiate the fire safety inspection. If a facility is found out of compliance with the fire safety rules, the department will apply procedures for achieving compliance as promulgated under 9 CSR 45-5.060.

(2) Means of Egress Requirements.

(A) Each floor occupied in the home shall have not less than egress shall not be a window. Existing licensed and approved facilities shall have exit doors with a minimum width of thirty inches (30") wide. All new construction and facilities licensed and approved after the effective date of these rules shall have exit doors with a minimum width of thirty-six inches (36").

(E) No primary means of escape shall lead through a bathroom, storage room, furnace room, kitchen, garage, or any other room deemed hazardous by the Division of Fire Safety.

(F) All exit doors shall swing in the direction of egress travel and shall have door closures attached.

(G) Emergency lighting that has a battery backup shall be of emergency lights shall be determined by the Division of Fire Safety inspector. Emergency lights shall be tested once per month and documentation indicating which lights were tested, the date tested, and the name of the person performing the test kept for review by the Division of Fire Safety.

(H) Lighted exit signs with a battery backup shall be installed direct the occupants to the exits. Lighted exit signs shall be tested once per month and documentation shall be kept for review by the Division of Fire Safety.

(I) No locks that require a key or special knowledge to unlock (J) Overhead garage doors are not recognized as exit (K) Mirrors shall not be placed on exit doors or adjacent to any exit in such a manner to confuse the direction of the exit.

All exit doors shall be readily recognizable.

(L) All hallways shall have a clear width of at least thirty-six (M) Dead-end corridors/hallways shall not exceed twenty feet (20').

(N) Each wing or corridor of the facility shall be separated into fire compartment areas by fire doors and walls, having not less than a one- (1-) hour rating. All fire doors shall be equipped with a door closure and may be held open at all times with an electrical magnetic switch that is interconnected to the fire alarm system.

(O) Facilities initially certified and areas initially approved on or after the effective date of this rule, shall meet the following requirements. All facilities that have a set of stairs or use stairs as a fire escape shall be constructed as follows:

All stairs shall be at least thirty-six inches (36") wide.

Fire escapes shall be constructed of noncombustible materials.

Existing fire escapes shall be of sturdy construction and, at the discretion of the Division of Fire Safety, may be required to be load tested;

A maximum rise of eight inches (8");
A minimum tread of nine inches (9");
A maximum height between landings of twelve feet 5. A minimum landing size of forty-four inches (44");
Handrails placed on both sides of sturdy construction 7. An outside diameter of the handrails of at least one and 8. Handrails with a clearance of at least one and one-half 9. Spiral staircase or winder is not permitted.

(P) Every ramp used in the component of the means of egress ramp. Ramp height shall comply with the following:

Ramps less than three inches (3") in height have a slope 2. Ramps with a height of three to six inches (3"–6") have a 3. Ramps with a height greater than six inches (6") have a (Q) All ramps shall have a slip-resistant surface and be (R) All ramps over ten inches (10") in height shall have (3) Travel Distance to Exits.

section shall be permitted to be increased by fifty feet (50') in buildings protected throughout by a supervised automatic sprinkler system that is approved by the Division of Fire Safety, based on the National Fire Protection Association, Standards for Sprinkler Systems.

(4) Protection.

(A) Vertical openings shall be protected so that no primary a fire-resisting capability of not less than one (1) hour and resists the passage of smoke. Any doors or openings shall have (B) Exception. Specific residential facilities that were certified prior to the effective date of this rule with twenty- (20-) minute fire barriers shall be considered in compliance with current of residents are increased.

(C) Interior stairways shall be closed with one- (1-) hour fire barriers, with all openings equipped with smoke actuated automatic-closing or self-closing doors having a fire resistance comparable to that required for the enclosure.

(D) All furnace rooms, rooms containing water heaters, building by construction having not less than a one- (1-) hour fire-resistance rating. All doors to these rooms shall have a selfclosing device attached and shall have a minimum one- (1-) hour fire rating.

(E) Exception. The one- (1-) hour fire resistance rating required for rooms or areas listed in subsection (4)(C) of this rule is not required if the facility installs a sprinkler head off the domestic water supply or has an approved automatic sprinkler system and a fire alarm initiating device shall be installed in the high hazard area. For group homes certified after the effective date of this rule, a one and three-fourths inches (1 3/4") thick solid core door or a twenty- (20-) minute fire rated door shall be installed with a self-closing device attached to prevent the passage of smoke. Before approval of the sprinkler installation the pipe and fittings are tested and approved to the 1881 or 1887 standard for use in sprinkler applications. If the sprinkler option is chosen, the above appliances must be enclosed in smoke resistant enclosures. The door to these rooms shall be a minimum of one and three-fourths inches (1 3/4") solid bonded wood core door with a self- closing device or a twenty minute fire rated door. No open penetrations including combustion air or return air vents shall be allowed to penetrate these (F) Every unoccupied attic space shall be subdivided by draft stops having a one- (1-) hour fire rating, into areas not to exceed three thousand (3,000) square feet. Exception: Subdivisions described in this subsection are not required if the space is protected throughout by an approved, automatic sprinkler system.

(G) All doors to sleeping rooms shall have a fire resistance rating of twenty (20) minutes.

(5) Interior Finish.

(A) Interior wall and ceiling finishes throughout shall be a (B) All wall studs, ceiling joists, and floor joists shall be (C) Hangings or draperies shall not be placed over exit doors Safety to review. Exception shall be made for small window valances. These exceptions shall be noted on the fire inspection (6) Detection, Alarms, Extinguishment.

(A) All facilities shall have a full coverage electrical fire alarm system. Pull stations shall be mounted at each exit door and horn strobes shall be installed throughout the facility. Smoke detectors shall be installed in all sleeping rooms, throughout all corridors, in all living spaces, storage rooms, and offices.

Additional smoke detectors may be required by the Division of Fire Safety inspector as deemed necessary. Heat detectors shall be installed in all mechanical rooms, kitchens and throughout the attic. The battery backup control panel shall be Underwriters Laboratory (UL) or Factory Mutual (F.M.) listed and installed on a dedicated circuit breaker box. The fire alarm system shall be installed and maintained in good working order and shall be UL or F.M. listed. The fire alarm system shall be installed and maintained per the National Fire Alarm Code (NFPA 72) and the National Electrical Code.

(B) All smoke detectors that are ten (10) years old or older to reference.

(C) All smoke detectors that are connected to a fire alarm (D) Any residence that has hearing-impaired occupants shall make adequate provisions so that the activation of any fire alarm system shall notify the occupants of the home. The Division of Fire Safety may require additional requirements for the hearing-impaired occupants to insure adequate notification.

(E) Occupant notification shall be provided automatically (F) All facilities shall have the fire alarm system tested, inspected, and approved annually by a fire alarm company and a copy of the test report and approval of the system kept on file at the facility for review by the Division of Fire Safety.

This may include evacuation of the building or closing the facility. The facility shall obtain and have on file at the facility, documentation verifying that all gas-fired appliances were checked by a heating and air conditioning company and are in safe working order. The facility shall be re-inspected by the Division of Fire Safety and determined safe before the occupants can return to the building or the facility can reopen.

(H) At least one (1) portable (five pound (5 lb)) 2A-10B:C (I) Fire extinguishers shall be installed and maintained (J) Facilities using a commercial stove, deep fryer, or two (2) home type ranges placed side by side, or a home type range that produces a grease laden vapor shall be equipped with a range hood and extinguishing system with an automatic cutoff of the fuel supply and exhaust system in case of fire. A qualified technician shall inspect these systems to insure they are in good working condition and installed/maintained correctly.

The qualified technician shall base this inspection on the National Fire Protection Association, Chapter 96, Standard for Fire Protection of Commercial Cooking Operations. Exception:

Home type ranges separated by an eighteen inch (18") cabinet shall not be required to have an extinguishing system installed above them. 2) Facilities that cook on a home type range, and have a menu that does not include frying, or emitting a grease laden vapor, and have an approval letter from the Department of Mental Health, do not need to install a fire extinguishing system above the range.

(C) All gas and electric heating equipment shall be equipped (D) Facilities with a water heater two hundred thousand (E) All furnace rooms shall be properly vented. Furnace (F) All joints in the gas supply pipe shall be located outside of (G) A gas shutoff valve shall be located next to all gas appliances, furnaces, and water heaters.

Combustion or return openings shall not allow the passage of smoke to the facility.

(K) One (1) combustion air vent opening shall be permitted (L) Air conditioning, heating, ventilating ductwork, and Fire Safety.

(M) Any furnace or air handling equipment that has air flow (N) All elevators shall be inspected bi-annually by a state (O) If any combustibles are stored in a furnace room, they (8) Electrical Services.

(A) Electrical wiring shall be installed and maintained in the wiring to be unsafe for the occupants or if it is installed required prior to fire safety approval. The inspection by the licensed electrician shall be based on the National Fire (B) No electrical extension cords will be allowed, unless approved in writing by the Division of Fire Safety. Extension cords shall not be permanently affixed to the structure or replace permanent wiring. Exception: The use of Underwriters Laboratories, Inc. (UL) approved fused power surge strips is acceptable.

(9) Equivalency Concepts. Nothing in this rule is intended to

9 CSR 45-5.150 Fire Safety for Group Homes Serving 17 or More People homes serving seventeen (17) or more people funded through the Medicaid home and community-based waiver. The department delegates its authority for fire safety inspections under this rule to the Department of Public Safety, Division of Fire Safety. {#sec-9-csr-45-5.150 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-5.150}

(1) General Requirements.

(A) The staff shall conduct at least one (1) fire drill per month and one (1) natural disaster drill per quarter, with a minimum of two (2) drills, one (1) fire and one (1) natural disaster, conducted annually while the individuals are sleeping. A drill must be conducted within one (1) week of the arrival of a new individual. The staff shall maintain a written record at the facility of the date, type of drill, time required to evacuate the building, whether the evacuation was completed, notation of any problems evacuating, and number of occupants present during the drill.

(B) Unscheduled drills shall be held at the Division of Fire (C) During severe weather, fire drills may be postponed.

(D) Each fire drill shall evacuate all persons from the and be conducted as follows:

Drills simulate an actual fire condition;
Occupants (referred to hereafter as “individuals”) and 3. The individuals and staff members proceed to a of the building; and 4. Individuals and staff members remain in place until a 5. Exception. If there is potential harm to individuals during drills because a resident is medically fragile, the provider may arrange the drill to not involve the medically fragile. However, all individuals who are medically fragile must participate in a drill at least once per year. This must be documented in the home.

(E) No window in a facility shall have bars or any other item (F) All flammable/combustible liquids, matches, toxic (G) Clothes dryers shall be vented to the outside and maintained per the manufacturer’s instructions.

The phone must always be charged;
The phone must be able to make and receive normal 4. The phone must remain at the facility at all times; and 5. The emergency plan for the facility must address the use (N) The facility shall notify the nearest fire department that (O) Facilities served by a volunteer or membership fire (P) The facility shall, as soon as possible, no later than the following business day, report any fire in the facility to the Division of Fire Safety office and the Department of Mental Health.

(Q) The Division of Fire Safety may make additional (R) Prior to new construction, remodeling existing structures, (S) During the construction or remodeling process, the provider shall request a framing and wiring inspection and an inspection for the rough-in wiring for the fire alarm system by the Division of Fire Safety before the walls are enclosed.

Failure to have these inspections conducted will result in an unapproved fire inspection from the Division of Fire Safety.

(T) The ceiling height in all facilities shall be a minimum of Division of Fire Safety for some areas that are below seven feet six inches (7'6") for the installation of ductwork and plumbing.

No more than forty percent (40%) of the ceiling in each room shall be below minimal height, with no portion of the ceiling less than six feet eight inches (6' 8").

(U) Facilities shall comply with all local building codes, fire (V) The latest edition of the National Fire Protection (W) Each residential facility shall be inspected at least once annually by a Division of Fire Safety inspector. The department will initiate the fire safety inspection. If a facility is found out of compliance with the fire safety rules, the department will apply procedures for achieving compliance as promulgated under 9 CSR 45-5.060.

(2) Means of Egress Requirements.

(A) Each floor occupied in the home shall have not less than egress shall not be a window. Each exit door shall not be less than thirty-six inches (36") wide.

(E) No primary means of escape shall lead through a bathroom, storage room, furnace room, kitchen, garage, or any other room deemed hazardous by the Division of Fire Safety inspector.

(F) All exit doors shall swing in the direction of egress travel and shall have door closures attached.

(G) Emergency lighting that has a battery backup shall be of emergency lights shall be determined by the Division of Fire Safety inspector. Emergency lights shall be tested monthly and documentation indicating which lights were tested, the date tested, and the name of the person performing the test kept for review by the Division of Fire Safety.

(H) Lighted exit signs with a battery backup shall be installed direct the occupants to the exits.

All exit doors shall be readily recognizable.

(L) All hallways shall have a clear width of at least thirty-six (M) Dead-end corridors/hallways shall not exceed twenty feet (20').

(O) Facilities initially certified and areas initially approved on or after the effective date of this rule, shall meet the following requirements. All facilities that have a set of stairs, or use stairs as a fire escape shall be constructed as follows:

All stairs shall be at least thirty-six inches (36") wide.

Fire escapes shall be constructed of noncombustible materials.

Existing fire escapes shall be of sturdy construction and, at the discretion of the Division of Fire Safety, may be required to be load tested;

A maximum rise of eight inches (8");
A minimum tread of nine inches (9");
A maximum height between landings of twelve feet 5. A minimum landing size of forty-four inches (44");
Handrails placed on both sides of sturdy construction 7. An outside diameter of the handrails of at least one and 8. Handrails with a clearance of at least one and one-half 9. Spiral staircase or winder is not permitted.

(P) Every ramp used in the component of the means of egress ramp. Ramp height shall comply with the following:

Ramps less than three inches (3") in height have a slope 2. Ramps with a height of three to six inches (3"–6") have a 3. Ramps with a height greater than six inches (6") have a (Q) All ramps shall have a slip-resistant surface and be (R) All ramps over ten inches (10") in height shall have (3) Travel Distance to Exits.

(A) The travel distance between any room door intended as an exit access or an exit shall not exceed one hundred feet (B) The travel distance between any point in a room and an (C) At the discretion of the Division of Fire Safety inspector and in consideration of the presence of an automated sprinkler system, the distances in subsections (A) and (B) of this section may be extended by fifty feet (50').

(4) Protection.

(A) Vertical openings shall be protected so that no primary a fire-resisting capability of not less than one- (1-) hour and resists the passage of smoke. Any doors or openings shall have (B) Exception. Specific residential facilities that were certified prior to the effective date of this rule with twenty- (20-) minute fire barriers shall be considered in compliance with current of residents is increased.

(C) Interior stairways shall be closed with one- (1-) hour fire barriers, with all openings equipped with smoke-actuated automatic-closing or self-closing doors having a fire resistance comparable to that required for the enclosure.

(D) All furnace rooms, rooms containing water heaters, building by construction having not less than a one- (1-) hour fire resistance rating. All doors to these rooms shall have a selfclosing device attached and shall have a minimum one- (1-) hour fire rating.

(E) All doors to sleeping rooms shall have a fire resistance rating of twenty (20) minutes.

(F) All buildings shall be protected throughout by an approved, automatic sprinkler system installed and maintained in accordance with the National Fire Protection Association, Standards for Installation of Sprinkler Systems. Quick response or residential sprinkler heads shall be installed throughout the structure.

(G) The sprinkler system shall initiate the fire alarm system upon activation of water flow.

(H) Tamper switches shall be installed on the sprinkler system valves and shall transmit a supervisory signal to the fire alarm control panel.

(I) All facilities shall have the sprinkler system tested, inspected, and approved annually by a fire sprinkler company.

A copy of the test report and approval of the system shall be kept on file at the facility for review by the Division of Fire Safety inspector.

(5) Interior Finish.

(A) Interior wall and ceiling finishes throughout shall be a (B) All wall studs, ceiling joists, and floor joists shall be (C) Hangings or draperies shall not be placed over exit doors Safety inspector to review. Exception shall be made for small window valances. These exceptions shall be noted on the fire inspection survey.

(6) Detection, Alarms, Extinguishment.

(A) All facilities shall have a full coverage electrical fire alarm system. Pull stations shall be mounted at each exit door. Horns and strobe lights connected to the fire alarm shall be installed throughout the facility. Smoke detectors shall be installed in all sleeping rooms, throughout all corridors, in all living spaces, storage rooms, and offices. Additional smoke detectors may be required by the Division of Fire Safety as deemed necessary. Heat detectors shall be installed in all mechanical rooms, kitchens, and throughout the attic. The battery backup control panel shall be Underwriters Laboratories, Inc. (UL) or Factory Mutual (F.M.) listed and installed on a dedicated circuit in the breaker box. The fire alarm system shall be installed and maintained in good working order and should be Underwriters Laboratories, Inc. (UL) or Factory Mutual (F.M.) listed. The fire system shall be installed and maintained per the National Fire Alarm Code (NFPA 72) and the National Electrical Code.

(B) All smoke detectors that are ten (10) years old or older to reference.

(C) All smoke detectors that are connected to a fire alarm (D) Any facility that has hearing-impaired occupants shall make adequate provisions so that the activation of any fire alarm system shall notify the occupants of the home. The Division of Fire Safety inspector may require additional adequate notification.

(G) Facilities using any equipment or appliances using wood or fossil fuel, and that pose a potential carbon monoxide 1. Carbon monoxide detectors shall be in good operating 2. If an elevated carbon monoxide level is detected during documentation on file at the home verifying that all gas-fired company and are in safe working order, and the facility is determined safe by the Division of Fire Safety inspector, the fire 3. If a level of carbon monoxide is determined that Safety inspector shall take measures necessary to protect the occupants. This may include evacuation of the building or closing the facility. The facility shall obtain and have on file at the facility, documentation verifying that all gas-fired company and are in safe working order. The facility shall be reinspected by the fire inspector and determined safe before the occupants can return to the building or the facility can reopen.

(H) At least one (1) portable (five pound (5 lb)) 2A-10B:C (I) Fire extinguishers shall be installed and maintained (J) Facilities using a commercial stove, deep fryer, or two (2) home type ranges placed side by side, or a home type range that produces a grease laden vapor shall be equipped with a range hood and extinguishing system with an automatic cutoff of the fuel supply and exhaust system in case of fire. The Division of Fire Safety inspector shall inspect these systems to insure they are in good working condition and installed/ maintained correctly. The Division of Fire Safety inspector shall base this inspection on the National Fire Protection Association,

Chapter 96, Standard for Fire Protection of Commercial Cooking Operations.

(C) All gas and electric heating equipment shall be equipped size from the opening of the temperature and pressure valve.

(D) Facilities with a water heater two hundred thousand (E) All furnace rooms shall be properly vented. Furnace (F) All joints in the gas supply pipe shall be located outside of (G) A gas shutoff valve shall be located next to all gas appliances, furnaces, and hot water heaters.

(H) All furnaces shall be equipped with an electrical fused (I) If a furnace or water heater is located inside a garage, the room as described in subsection (4)(C) of this rule having a fire rating of thirty (30) minutes. The door to this room shall also have a minimum thirty (30) minute fire rating and have a door closure attached. Open penetrations, including combustion air or return air vents, shall not be allowed to penetrate these (J) All furnace rooms and rooms containing the gas water heater shall have adequate combustion air for the units. The vent size opening for the combustion air shall be measured at one (1) square inch per one thousand (1,000) Btus input if the combustion air is drawn from inside the structure and one (1) square inch per four thousand (4,000) Btus input if the air is drawn from outside of the structure. There shall be two (2) combustion air vent openings in each furnace room, one (1) located at the lower level and the other at the upper level.

(K) One (1) combustion air vent opening shall be permitted (L) Air conditioning, heating, ventilating ductwork, and Fire Safety inspector.

(9) Equivalency Concepts. Nothing in this rule is intended to

Chapter 6 Advisory Councils

9 CSR 45-6.010 Guidelines for Membership on Regional Developmental Disabilities Advisory Councils {#sec-9-csr-45-6.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-6.010}

(Rescinded July 30, 2018)

Filed May 25, 1995, effective Dec. 30, 1995.

Rescinded: Filed Jan. 12, 2018, effective July 30, 2018.

JOHNR. ASHCROFT(6/30/18)

History

AUTHORITY: section 633.040, RSMo (1994). This rule was originally filed as 9 CSR 10-1.030. Original rule filed July 1, 1988, effective Nov. 25, 1988. Amended:

Chapter 7 Developmental Disabilities Health Home

9 CSR 45-7.010 Developmental Disabilities Health Home {#sec-9-csr-45-7.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 45-7.010}

PURPOSE: This rule establishes the requirements for designation as a Developmental Disabilities (DD) Health Home by the Missouri Department of Mental Health (DMH), Division of Developmental Disabilities (Division of DD), for the Missouri Department of Social Services (DSS), MO HealthNet Division (MHD), to support individuals with intellectual and developmental disabilities who have chronic conditions and are served by the Division of DD.

(1) Definitions.

(A) Behavioral Health—The promotion of mental health, resilience, and well-being, the treatment of mental health and substance use disorders, and the support of individuals who experience and/or are in recovery from these conditions, along with their family or other natural supports and communities.

(B) Centers for Medicare & Medicaid Services (CMS)—CMS is a federal agency within the United States Department of Health and Human Services that administers Medicaid programs.

(C) Chronic or At-Risk Conditions—For the purpose of DD Health Home eligibility, chronic or at-risk conditions are as follows:

Intellectual and/or developmental disability;
Diabetes;
Asthma;
Cardiovascular disease (CVD) or hypertension;
Chronic obstructive pulmonary disease (COPD);
Overweight (body mass index (BMI)>25);
Dementia;
Dependent on a ventilator;
One (1) of the Fatal Five Plus conditions or one (1) or more chronic conditions that could lead to one (1) of the following Fatal Five Plus conditions:

A. Pulmonary aspiration;

B. Bowel obstruction;

C. Gastroesophageal reflux disease (GERD);

D. Seizures;

E. Sepsis;

F. Dehydration;

Tobacco use;
Diagnosis of Autism Spectrum Disorder; and 12. Healthcare level of 3 or greater as identified by the Health Risk Screening Tool.

(D) EMR—Electronic medical records, also referred to as electronic health records (EHR).

(E) Health Home—A Health Home provides coordination of health care to individuals with chronic physical and/or behavioral health conditions, using a partnership or team approach between the Health Home team and individuals in order to achieve improved health care, to avoid preventable hospitalizations and emergency department use.

(F) DD Health Home Enrollees—Individuals eligible for Division of DD services with one (1) or more chronic/at-risk conditions as defined in enrollment/eligibility criteria section.

(G) DD Health Home Provider—DD Contracted Targeted Case Management (TCM) and/or DD Home and Community-Based Services (HCBS) certified or accredited waiver providers who meet criteria for DD health home provider eligibility.

(H) DD Health Home Team—DD Health Home core team shall consist of the following staff: Health Home Director, Nurse Care Manager, Physician Consultant (Advanced Practice Registered Nurse (APRN) as substitute and defined in the DD Health Home Provider Operations Manual), Specialized Healthcare Consultant, and DD Health Home Facilitator. Based on the unique needs of the individual, additional staff may be identified.

(I) Health Risk Screening Tool—The Health Risk Screening Tool (HRST) is a tool used to provide early detection of health risks and destabilization.

(J) Health Risk Support Plan (HRSP)—The HRSP are standardized electronic templates in the department’s identified system which is a component of the individual’s Individual Support Plan (ISP) and serves to identify implementation strategies to mitigate risk and improve health outcomes.

(K) Intellectual and/or Developmental Disability (IDD)— Adults and youth who meet the Missouri state statute definition of Developmental Disability, section 630.005(9), RSMo.

“Developmental disability,” a disability that is attributable to intellectual disability, cerebral palsy, epilepsy, head injury or autism, or a learning disability related to a brain dysfunction; or any other mental or physical impairment or combination of mental or physical impairments; and is manifested before the individual attains age twenty-two (22); and is likely to continue indefinitely; and results in substantial functional limitations in two (2) or more of the following areas of major life activities: self-care; receptive and expressive language development and use; learning; self-direction; capacity for independent living or economic self-sufficiency; mobility; and reflects the individual’s need for a combination and sequence of special, interdisciplinary, or generic care, habilitation or other services which may be of lifelong or extended duration and are individually planned and coordinated.

(L) Missouri Department of Social Services (DSS), MO HealthNet Division (MHD)—Single State Medicaid authority.

(M) Social Determinants of Health (SDOH)—The nonmedical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies, racism, climate change, and political systems.

(2) Developmental Disabilities Health Home Qualifications.

(A) Initial Provider Qualifications. In addition to being a DD service provider of TCM or DD HCBS waiver services, each DD Health Home provider must meet state qualifications, which may be amended from time to time as necessary and appropriate, but minimally require that each Health Home— 1. Must be enrolled in Missouri’s Medicaid program and agree to comply with all Medicaid program requirements;

DD Health Home providers can either directly provide, or subcontract for the provision of DD Health Home services.

The DD Health Home remains responsible for all DD Health Home program requirements, including services performed by the contractor;

Have strong, engaged leadership personally committed to and capable of leading the DD Health Home through the transformation process and sustaining transformed DD Health Home processes as demonstrated through— A. The provider designation review;

B. Agreement to participate in learning activities, including in-person sessions and regularly scheduled phone calls; and C. Provider leadership, in collaboration with the state, have presented the state-developed introductory presentation to Missouri’s DD Health Home initiative to provider staff and board of directors;

Meet the state’s minimum access requirements as follows: Prior to implementation of DD Health Home service coverage, provide assurance of enhanced individual access to the health team, including the development of alternatives to face-to-face visits, such as telephone or email, twenty-four (24) hours per day seven (7) days per week;
Actively use MHD and DMH information technology (IT) systems to conduct care coordination and prescription monitoring for Medicaid individuals;
Utilize the department’s identified system to input annual metabolic screening results, track and measure care of individuals, automate care reminders, and maintain other items as required by the department;
Routinely use an electronic health management tool to determine individualized health risks (i.e., Health Risk Screening Tool (HRST));
Routinely use an electronic health management tool to determine problematic prescribing patterns;
Conduct wellness interventions as indicated based on the individual’s level of risk;
Agree to convene regular, ongoing, and documented internal DD Health Home team meetings to plan and implement DD Health Home healthcare goals and objectives of ongoing practice transformation;
Agree to participate in CMS and state-required evaluation activities;
Agree to develop required reports describing DD Health Home activities, efforts, and progress in implementing DD Health Home services;
Maintain compliance with the terms and conditions as a DD Health Home provider or risk termination as a provider of DD Health Home services;
Present a proposed DD Health Home service delivery model the department determines will have a reasonable likelihood of being cost-effective. Cost effectiveness will be determined based on the size of the proposed DD Health Home, Medicaid caseload, percentage of caseload with eligible chronic conditions of individuals, and other factors to be determined by DMH.

(B) Ongoing Provider Qualifications. Each provider must also— 1. Continue to have a strong, engaged leadership personally committed to and capable of leading the DD Health Home through the transformation process and sustaining transformed DD Health Home processes as evidenced by successful participation in the leadership training and learning collaborative developed for DD Health Home;

Coordinate care and build relationships with regional hospital(s) or hospital system(s) to develop a structure for transitional care planning, including communication of inpatient admissions of DD Health Home individuals, and maintain a mutual awareness and collaboration to identify individuals seeking emergency department services who might benefit from connection with a DD Health Home, and encourage hospital staff to notify the area DD Health Home staff of such opportunities;
Develop quality improvement plans to address gaps and opportunities for improvement identified during and after the application process;
Demonstrate development of fundamental DD Health Home functionality through an assessment process to be applied by Division of DD;
Demonstrate significant improvement on clinical indicators specified by and reported to Division of DD;
Submit data reports as required by DSS and/or Division of DD;
Provide DD Health Home services that demonstrate overall cost effectiveness;
Participate in technical assistance conference calls and webinars as requested by DSS and/or Division of DD;
Meet standards as determined by DMH.

(3) Scope of Services. This section describes the activities Division of DD providers will be required to engage in, and the responsibilities they will fulfill, if recognized as a DD Health Home.

(A) Division of DD Health Home Services. The DD Health Home Team shall assure the following health services are received, as necessary, by all individuals served in the DD Health Home:

Comprehensive care management. Comprehensive care management services include— A. Determining level of participation in care management services based upon individualized information provided through the HRST and HRSP, and other individual information;

B. Assessment of preliminary service needs, which includes reviewing and identifying gaps in the overall personcentered plan which may include the HRSP and Behavior Support Plan (BSP);

C. DD Health Home development of individual DD Health Home healthcare goals, preferences, and optimal clinical outcomes;

D. Assigning health team roles and responsibilities;

E. Developing guidelines for health teams to follow across risk levels or health conditions;

F. Monitoring of individual and population health status and service use to determine adherence to or variance from DD Health Home healthcare goals and identified service needs identified in the overall person-centered plan; and G. Developing and disseminating reports that indicate the individual’s progress toward meeting outcomes for individual satisfaction, health status, service delivery, and costs;

Care coordination. Care coordination is the implementation of the overall individual person-centered plan with active individual and family involvement through appropriate linkages, referrals, coordination, and follow-up to needed services and supports. Care coordination is designed to be delivered in a flexible manner best suited to the individual’s preferences and to support DD Health Home healthcare goals that have been identified by developing linkages and skills in order to allow the individual to reach their full potential and increase their independence in obtaining and accessing services. Specific activities include but are not limited to— A. Participating in hospital discharge processes to support the individual’s transition to the community;

B. Communicating and consulting with the individual, providers, and collateral contacts; and C. Facilitating regularly scheduled interdisciplinary team meetings to review person-centered plans and assess progress toward identified DD Health Home healthcare goals;

Health promotion. Health promotion shall minimally consist of educating and engaging the individual in making decisions that promote independent living skills and lifestyle choices that achieve the following goals:

A. Good health;

B. Proactively managing chronic conditions;

C. Identifying risk factors early; and D. Screening for emerging health problems;

Health promotion services include but are not limited to— A. Promoting the individual’s education of their chronic conditions;

B. Developing self-management plans with the individual;

C. Conducting medication reviews and regimen compliance;

D. Providing support to the individual for improving social networks and health-promoting lifestyle interventions, including but not limited to preventative health practices for the IDD population, nutritional counseling, obesity reduction and prevention, and increasing physical activity; and E. Assisting the individual to participate in DD Health Home healthcare goal planning with an emphasis on personcentered empowerment and the development of health literacy skills to help the individual understand and selfmanage chronic health conditions;

Comprehensive transitional care from inpatient to other settings. Comprehensive transitional care services include but are not limited to— A. Facilitating the individual’s transition between care levels, such as a hospital, nursing facility and residential supports, or when opting for a new DD Health Home provider;

B. Collaborating and establishing relationships with the individual’s physicians, nurses, social workers, discharge planners, pharmacists, and others to continue implementation of the overall person-centered plan. Specific focus is on increasing the individual’s ability to manage care and live safely in the community, and shift the use of reactive care and treatment to proactive health promotion and self-management;

C. Communicating with and educating the individual and providers located at the setting from which the individual is transitioning, and at the setting to which the individual is transitioning;

D. Ensuring the individual’s prompt access to follow-up care after discharge (e.g., care record from discharge entity, medication reconciliation, reviewing person-centered plan to assure access to needed community services, appointment scheduling); and E. Providing care coordination services designed to streamline person-centered plans, reduce hospital admissions, ease the transition to long-term services and supports, and interrupt patterns of frequent hospital emergency department use;

Individual and family support. Individual and family support is intended to assist the individual to facilitate and maintain quality of life and explore community options to promote overall quality of life through health stabilization and improved health outcomes. Activities include but are not limited to— A. Educating and guiding in self-advocacy support with the individual;

B. Increasing the individual’s health literacy skills and ability to self-manage their care;

C. Identifying resources for the individual to address the gaps identified in the overall person-centered plan to improve his or her overall health and ability to function within his or her family and in the community;

D. Educating the individual on the importance of obtaining and adhering to medications and other prescribed treatments; and E. Assisting the individual with developmental disabilities for whom primary services needs are more directly related to treatment (e.g., treatment for a behavioral health condition and/or particular healthcare condition(s)), referring and coordinating with the approved care management entity for the MO Community Mental Health Center (CMHC) Health Care Home or MO Primary Care Health Home for services more directly related to those aforementioned conditions; and 7. Referral to community and social support services.

Referral to community and social support services involves identifying gaps in the overall person-centered plan that are connecting the individual to community based resources and referrals that support Social Determinants of Health (SDOH). It also includes identifying resources to reduce barriers that will promote the individual’s overall quality of life through health stabilization and improved overall health outcomes.

(B) DD Health Home Administration. Each DD Health Home provider shall employ a DD Health Home Director. The DD Health Home core team shall consist of the following staff:

Nurse Care Manager, Physician Consultant (APRN as a substitute and defined in the DD Health Home Provider Operations Manual), Specialized Healthcare Consultant, and DD Health Home Facilitator. Based on the unique needs of the individual, additional staff may be identified.

(C) Learning Activities. The MO DD Health Homes will be supported as the state continually assesses the DD Health Homes to determine training needs. DD Health Homes will participate in a variety of centralized learning supports including but not limited to learning collaboratives, webinars, training and technical assistance including peer-led training and community resources.

(D) Department’s Identified System. DD Health Homes shall utilize the department’s identified system approved by the Division of DD. The department’s identified system is a system for tracking information the Division of DD deems critical to the management of the health of the population being served through the DD Health Home, including dates of delivered and needed services, laboratory values needed to track chronic conditions, and other measures of health status. The department’s identified system shall be used for— 1. Tracking;

Risk stratification;
Analysis of population health status and individual needs; and 4. Reporting as specified by the Division of DD.

(E) Data Reporting. DD Health Homes shall be required to submit the following reports to the Division of DD as specified:

Monthly updates identifying the DD Health Home’s staffing patterns, enrollment status, hospital follow-ups, and notifications provided to primary healthcare providers; and 2. Other reports as specified by the Division of DD.

(4) Patient Eligibility and Enrollment. This section describes eligibility and enrollment requirements for DD Health Home.

(A) Eligibility. Individuals eligible for Division of DD services shall meet the following criteria to be eligible for services from a designated DD Health Home:

Have a chronic condition of intellectual and/or developmental disability; and 2. Have or be at risk of developing one (1) of the following conditions:

A. Diabetes;

B. Asthma;

C. Cardiovascular disease (CVD) or hypertension;

D. Chronic obstructive pulmonary disease (COPD);

E. Overweight (body mass index (BMI)>25);

F. Dementia;

G. Dependent on a ventilator;

H. One (1) of the Fatal Five Plus conditions or one (1) or more chronic conditions that could lead to one (1) of the following Fatal Five Plus conditions:

(I) Pulmonary aspiration;

(II) Bowel obstruction;

(III) Gastroesophageal reflux disease (GERD);

(IV) Seizures;

(V) Sepsis;

(VI) Dehydration;

I. Tobacco use;

J. Diagnosis of Autism Spectrum Disorder; or K. Healthcare level of 3 or greater as identified by the Health Risk Screening Tool.

(B) Enrollment Requirements. Individuals eligible for DD Health Home services will be assigned to eligible providers.

Upon enrollment, individuals assigned to a DD Health Home will be informed by the Department of Mental Health. The notice will describe assignment of the individual to a DD Health Home, provide a brief description of DD Health Home services, and describe the process for the individual to change DD Health Home provider, and opt-out of receiving services from the assigned DD Health Home provider.

(5) DD Health Home Provider Designation Process.

(A) The Division of DD shall establish procedures under which a Medicaid-enrolled provider attains designation as a DD Health Home provider.

The designation process shall be person-centered and serve the following critical purposes— A. To determine how well DD Health Home providers fulfill their responsibilities to individuals enrolled in a DD Health Home; and B. To determine systems changes and practices needed so that DD Health Home providers will be more responsive to the individual’s needs.
DD Health Home providers shall demonstrate innovation and initiative in pursuing, as well as commitment toward, continuous quality improvement in realizing best practices and outcomes associated with— A. Health Home core functional components— (I) Provide quality-driven, cost-effective, culturally appropriate, and person- and family-centered Health Home services;

(II) Coordinate access to high quality health care services informed by evidence-based clinical practice guidelines;

(III) Coordinate access to preventive and health promotion services, including prevention of mental illness and substance use disorders;

(IV) Coordinate and provide access to behavioral health services, including mental health and substance use;

(V) Coordinate access to comprehensive care management, care coordination, and transitional care across settings. Transitional care includes appropriate follow-up from inpatient to other settings, such as participation in discharge planning and facilitating transfer from a pediatric to an adult system of health care;

(VI) Coordinate access to chronic disease management, including self-management support to individuals and their families;

(VII) Coordinate access to individual and family supports, including referral to community, social support, and recovery services;

(VIII) Coordinate access to long-term care supports and services;

(IX) Develop a person-centered care plan for each individual that coordinates and integrates all of his or her clinical and non-clinical healthcare-related needs and services;

(X) Demonstrate a capacity to use health information technology to link services, facilitate communication among team members and between the health team and individual and family caregivers, and provide feedback to practices, as feasible and appropriate; and (XI) Establish a continuous quality improvement program, and collect and report on data that permits an evaluation of increased coordination of care and chronic disease management on individual-level clinical outcomes, experience of care outcomes, and quality of care outcomes at the population level; and B. Service delivery system principles— (I) Demonstrate clinical competency for serving the complex needs of health home enrollees using evidence-based protocols;

(II) Demonstrate the ability for effectively coordinating the full range of medical, behavioral health, long-term services and supports, and social services for medically complex individuals with chronic conditions;

(III) Provide Health Home services that operate under a “whole-person” approach to care using a comprehensive needs assessment and an integrated person-centered care planning process to coordinate care;

(IV) Have conflict of interest safeguards in place to assure enrollee rights and protections are not violated, and that services are coordinated in accordance with enrollee needs expressed in the person-centered care plan;

(V) Provide access to timely health care twenty-four (24) hours a day, seven (7) days a week to address any immediate care needs of their Health Home enrollees;

(VI) Have in place operational protocol, as well as communication procedures to assure care coordination across all elements of the healthcare system (hospitals, specialty providers, social service providers, other community based settings, etc.);

(VII) Have protocols for ensuring safe care transitions, including established agreements and relationships with hospitals and other community-based settings;

(VIII) Establish a continuous quality improvement program that includes a process for collection and reporting of Health Home data for quality monitoring and program performance; permits evaluation of increased coordination and chronic disease management on individual-level clinical outcomes, experience of care outcomes, and quality of care outcomes at the population level;

(IX) Use data for population health management, tracking tests, referrals and follow-up, and medication management;

(X) Use health information technology to link services and facilitate communication among interdisciplinary team members and other providers to coordinate care and improve service delivery across the care continuum.

Upon initial application and on a biennial basis thereafter, all DD Health Home providers shall seek DD Health Home designation under this section except those providers appropriately accredited by nationally recognized accrediting bodies for DD Health Homes approved by Division of DD shall not be required to seek designation. The division director shall issue a DD Health Home designation to providers successfully completing the process and requirements of this section.

(B) The Division of DD recognizes and deems as designated a provider that has attained full accreditation under standards for DD Health Home from a nationally recognized accrediting body. The deemed provider must— 1. Submit to the Division of DD a copy of the most recent accreditation survey report and verification of the accreditation time period and dates within thirty (30) calendar days of receipt from the accrediting body;

Notify the Division of DD when accreditation surveys are scheduled or when the accrediting body makes complaint investigation visits;
Notify the Division of DD of any changes in accreditation status during the time period of accreditation and resurvey;
Identify the Division of DD as a primary stakeholder for contact by the accrediting body during survey and resurvey data-gathering processes; and 5. The Division of DD may conduct a scheduled or unscheduled survey of an accredited DD Health Home provider at any time to monitor ongoing compliance with the standards and requirements. If any survey finds conditions that are not in compliance with applicable standards, the Division of DD may require corrective action steps and may change the provider’s designation status consistent with procedures set out in this

rule.

(C) Participation in Designation. Participation may entail responding to surveys and requests for interviews with DD Health Home staff and individuals served. Providers shall provide all requested information as directed by the Division of DD. A provider must engage in the designation process in good faith. The provider must provide information and documentation that is accurate and complete. Failure to participate in good faith, including falsification or fabrication of any information used to determine compliance with requirements, may be grounds to deny issuance of or to revoke designation.

The Division of DD shall conduct a comprehensive survey at an organization for the purpose of determining compliance with DD Health Home standards, standards of care, program/ service rules, and other requirements, except as stipulated in paragraph (5)(A)3.

A. The Division of DD shall provide advance notice and scheduling of routine, planned surveys.

B. The Division of DD shall notify the applicant regarding survey date(s), procedures, and a copy of any survey instrument that may be used. Survey procedures will include but are not limited to interviews with provider staff, individuals being served, and other interested parties; review of provider administrative records necessary to verify compliance with requirements; and review of personnel records and service documentation.

C. The applicant agrees, by act of submitting a DD Health Home application, to allow and assist Division of DD representatives in fully and freely conducting these survey procedures, initially and ongoing, and to provide Division of DD representatives reasonable and immediate access to premises, individuals, and requested information.

D. The surveyor(s) shall hold entrance and exit conferences with the organization to discuss survey arrangements and survey findings, respectively. If there are any deficiencies found during the survey, the provider will be required to submit a plan of correction before designation can be approved.

E. If a plan of correction is not required, the Division of DD shall issue DD Health Home designation to the provider’s director within thirty (30) calendar days after the exit conference, indicating the DD Health Home provider can provide Health Home services.

F. Division of DD will identify and set timelines for issues/enhancements to be addressed with the DD Health Home provider. At the discretion of the Division of DD, a followup review will be completed once issues have been addressed.

If issues/enhancements have been satisfactorily addressed, Division of DD will issue DD Health Home designation to the provider.

(I) The report shall note all deficiencies identified during the survey.

(II) The Division of DD shall send a notice of deficiency and the report.

(III) The DD Health Home provider shall make the report available to their staff and to the public upon request.

(IV) Within thirty (30) calendar days of the date that a notice of deficiency and the report is presented to the DD Health Home provider, the provider shall submit to the Division of DD a plan of correction. The plan must address each deficiency, specifying the method of correction and the date the correction shall be completed. The provider will work with the Division of DD to develop a plan of correction. No correction date will exceed ninety (90) calendar days.

(V) Within fifteen (15) calendar days after receiving the plan of correction, the Division of DD shall notify the DD Health Home provider of its decision to approve or require revisions of the proposed plan.

(VI) The Division of DD will assure that the plan of correction has been implemented and deficiencies corrected.

Division of DD shall determine if it is necessary to make a return visit to the DD Health Home provider based on the criteria of the plan of correction.

(VII) In the event that the provider has not submitted a plan of correction acceptable to Division of DD within fortyfive (45) calendar days of the original date that written notice of deficiencies was presented by certified mail to the DD Health Home provider, it shall be subject to expiration or denial of designation.

G. The Division of DD may grant designation on a temporary, initial, conditional, deemed, or compliance status.

The Division of DD will notify the Division of DD Director of any change in the status of a provider.

(I) Temporary status may be granted to a DD Health Home provider if the designation process has not been completed prior to the expiration of an existing designation and the applicant is not at fault for failure or delay in completing the designation process.

(II) Initial status for a period of not exceeding one (1) year may be granted to a new provider based on a designation review which finds the program in compliance with requirements related to policy and procedure, facility, trainings and personnel to begin providing services. The initial designation will be awarded for one (1) year and a follow-up visit will occur prior to the initial designation expiration date to ensure the DD Health Home provider is demonstrating continued improvement and functionality.

(a) In the Division of DD’s initial determination and granting of initial designation, the provider shall not be expected to fully comply with those standards which reflect ongoing program activities.

(b) The Division of DD shall conduct a comprehensive survey of the initially designated provider and shall make further determination of the provider’s designation status no later than the expiration date of the initial designation.

(III) Conditional status may be granted to a provider following a survey by the Division of DD that determines that there are pervasive and/or significant deficiencies with standards that may affect quality of care to individuals and there is reasonable expectation that the provider can achieve compliance within a stipulated time period. The Division of DD may consider patterns and trends of performance identified during the survey.

(a) The period of conditional status shall not exceed one hundred eighty (180) calendar days. The Division of DD may directly monitor progress, may require the provider to submit progress reports, or both.

(IV) The Division of DD shall conduct a further survey within the one hundred eighty- (180-) day period and make a further determination of the provider’s compliance with standards.

(V) Designation status may be awarded to a provider for a period of two (2) years following a survey by the Division of DD that determines the provider meets all standards relating to quality of care and the safety, health, rights, and welfare of individuals served.

H. If deficiencies are cited during a survey, any and all such deficiencies must be corrected in accordance with the plan of correction prior to the Division of DD awarding designation status.

I. The Division of DD may investigate any complaint regarding the operation of a designated or deemed provider. If conditions are found that are not in compliance with applicable requirements, the Division of DD may, at its sole discretion for deemed providers, notify the accrediting body of any concerns.

J. The Division of DD may conduct a scheduled or unscheduled survey of a provider at any time to monitor ongoing compliance with the standards and requirements. If any survey finds conditions that are not in compliance with applicable standards, the Division of DD may require corrective action steps and may change the provider’s designation status consistent with procedures set out in this rule.

K. The Division of DD may deny issuance of and may revoke designation based on a determination that includes but is not limited to— (I) The nature of the deficiencies results in substantial probability of or actual jeopardy to individuals being served;

(II) Serious or repeated incidents of abuse or neglect of individuals being served or violations of rights have occurred;

(III) Fraudulent fiscal practices have transpired or significant and repeated errors in billings to the Division of DD have occurred;

(IV) Failure to participate in the designation process in good faith, including falsification or fabrication of any information used to determine compliance with requirements;

(V) The nature and extent of deficiencies results in the failure to conform to the standards of the program being offered; or (VI) Compliance with standards has not been attained by an organization upon expiration of conditional designation.

L. An organization which has had designation denied or revoked may meet with the Division of DD Director or designee to appeal the decision to revoke designation.

(I) The provider must notify the department’s division director or designee in writing within ten (10) business days of the date on the termination letter. The appeal shall include the following— (a) The name of the provider;

(b) The name and contact information of the person requesting the appeal;

(II) The meeting shall take place within seven (7) business days from the date of the request.

(III) Within seven (7) business days of the meeting, the division director or designee shall make a final determination as to whether the decision remains in effect. The provider shall be notified of this decision by regular and certified mail.

(IV) The decision of the division director or designee shall be the final decision of the department.

M. A designation is valid only as long as the provider meets standards of care and other requirements.

N. The provider shall maintain the designation issued by the Division of DD in a readily available location.

O. Within seven (7) business days of the time a designated provider organization is discontinued, moved to a new location, or has a change in accreditation status, the provider shall provide written notice to the Division of DD of any such change.

P. The Division of DD shall designate only the provider(s) named in the application.

Q. The provider(s) may not transfer designation without the written approval of the department.

R. Within seven (7) calendar days of the effective date that a designated provider is sold or undergoes a change of ownership, the provider shall submit a written notice to the division of any such change. A change in ownership is considered to have occurred under the following circumstances:

(I) A new corporation, partnership, limited partnership, limited liability company, or other entity assumes ownership of the operation;

(II) An individual incorporates or forms a partnership;

(III) With respect to a designated provider that is a general partnership, a change occurs in the majority interest of the partners;

(IV) With respect to a designated provider that is a limited partnership, a change occurs in the majority interest of the general or limited partners;

(V) With respect to a designated provider that is a corporation, a change occurs in the persons who own, hold, or have the power to vote the majority of any class of stock issued by the corporation.

(VI) A designated provider’s change of Federal Employer Identification Number (FEIN).

S. The organization must comply with other applicable requirements as set forth in 9 CSR 10-5.220 Privacy Rule of Health Insurance Portability and Accountability Act of 1996 (HIPAA).

(6) Demonstrated Evidence of DD Health Home Transformation.

(A) Providers are required to demonstrate evidence of transformation to the DD Health Home model on an ongoing

basis using measures and standards established by the Division of DD and communicated to the providers. Transformation to the DD Health Home service delivery model is exhibited when a provider— 1. Demonstrates development of fundamental DD Health Home functionality initially upon enrollment, one (1) year prior to the expiration of the initial designation, and biennially thereafter, based on an assessment process determined by the Division of DD. Additional reviews may be indicated on a case-by-case basis. Providers must demonstrate continued improvement and functionality for as long as they maintain their DD Health Home designation; and 2. Demonstrates progress toward established goals and objectives related to the clinical indicators as determined by Division of DD.

(B) Notification of Staffing Changes. Providers are required to notify the Division of DD within seven (7) business days of staff changes in the DD Health Home Director, Physician Consultant (APRN as substitute), Nurse Care Manager(s), and DD Health Home Facilitator.

(C) Providers shall work cooperatively with the Division of DD to support approved training, technology, and administrative services required for ongoing implementation and support of the DD Health Homes.

(7) Health Home Payment Components. This section describes the payment process for Developmental Disabilities Health Homes.

(A) General.

All payments to a DD Health Home are contingent on the program meeting the DD Health Home requirements set forth in their Health Home applications, as determined by the state of Missouri. Failure to meet such requirements is grounds for revocation of Health Home status and for termination of payments.
Reimbursement for DD Health Home services will be in addition to a provider’s existing reimbursement for services and procedures and will not change existing reimbursement for services and procedures that are not part of the DD Health Home.
The Division of DD reserves the right to make changes to the payment methodology.

(B) Types of Payments.

Clinical Care Management per Member per Month (PMPM) payment. Missouri will pay DD Health Homes the cost of staff primarily responsible for delivery of services not covered by other reimbursement (Health Home Director, Physician Consultant (APRN as substitute), Nurse Care Manager, Specialized Healthcare Consultant and DD Health Home Facilitator), whose duties are not otherwise reimbursable by MO HealthNet. In addition, the DD Health Home PMPM will include Health Home specific training, technical assistance, administration, and data analytics. Staff costs are based on the Bureau of Labor Statistics data. All DD Health Home providers will receive the same PMPM rate. The PMPM method will be reviewed periodically to determine the rate is economically efficient and consistent with quality of care.

The individual is identified as meeting the DD Health Home eligibility criteria on the state-run DD Health Home department’s identified system.
The individual is enrolled with a designated billing DD Health Home provider, and is enrolled in only one (1) Health Home at a time, regardless of type.
The minimum DD Health Home service required to merit payment of the PMPM is that the individual has received care management monitoring for treatment gaps that was documented or another DD Health Home service was provided that was documented.
The DD Health Home will report that the minimal service required for the PMPM rate payment occurred on a monthly DD Health Home attestation report.

(D) Except as otherwise noted in the plan, state-developed PMPM rates are the same for both governmental and private providers of DD Health Home services.

(8) Policies and Procedures. The organization shall maintain a policy and procedure manual that accurately describes and guides the operation of its services and promotes compliance with applicable regulations. The policy and procedure manual shall be readily available to staff and the public upon request and shall include but is not limited to— (A) The DD Health Home provider will develop policies and procedures in accordance with 9 CSR 10-5 to include— 1. 9 CSR 10-5.190 Background Screening Requirements;

9 CSR 10-5.200 Report of Complaints of Abuse, Neglect and Misuse of Funds/Property;
9 CSR 10-5.206 Report of Events; and 4. 9 CSR 10-5.220 Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA) and 42 CFR; and (B) The DD Health Home provider will develop policies and procedures to address the following:
Opt-out process for individuals that otherwise qualify for DD Health Home services;
Transfer and discharge processes for DD Health Home individuals;
Primary care physician referrals;
Primary care physician or other specialty care coordination;
Twenty-four (24) hour coverage in accordance with paragraph (2)(A)3. of this rule;
Prescription monitoring;
Health Risk Screening Tool and routine monitoring;
Quality assurance/quality improvement process as related to DD Health Home;
Guidelines to follow across risk levels or health conditions;
Follow-up care after discharge related to transitional care;
Training requirements for DD Health Home staff;
DD Health Home data reporting;
Composition of DD Health Home team;
Notification of DD Health Home staffing changes;
Utilization of the department’s identified system;
Complaints and grievances; and 17. Attestation and documentation.

(9) Incorporation by Reference. This rule incorporates by reference the following:

(A) The DD Health Home Provider Operations Manual is incorporated by reference and made a part of this rule as published May 15, 2024, by the Department of Mental Health, Division of Developmental Disabilities, at its website at https:// dmh.mo.gov/dev-disabilities/health-home. This rule does not incorporate any subsequent amendments or additions to this publication.

(10) Electronic Medical Records. DD Health Home providers are required to utilize and maintain electronic medical records of all individuals served. Electronic medical records systems must comply with state and federal regulations.

rule filed Feb. 26, 2024, effective Sept. 30, 2024. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008.

History

AUTHORITY: section 630.050, RSMo 2016. Emergency rule filed May 29, 2024, effective July 1, 2024, expired Aug. 30, 2024. Original

Division 50 Admission Criteria

Chapter 1 Definitions and Procedures

9 CSR 50-1.015 Definitions {#sec-9-csr-50-1.015 omnilex-key=us-mo-regs-official--title-9--9 CSR 50-1.015}

9 CSR 50-1.025 Application Procedures {#sec-9-csr-50-1.025 omnilex-key=us-mo-regs-official--title-9--9 CSR 50-1.025}

9 CSR 50-1.035 Assessment Procedures {#sec-9-csr-50-1.035 omnilex-key=us-mo-regs-official--title-9--9 CSR 50-1.035}

9 CSR 50-1.045 Eligibility for Services From the Division of Mental Retardation and Developmental Disabilities {#sec-9-csr-50-1.045 omnilex-key=us-mo-regs-official--title-9--9 CSR 50-1.045}

(Moved to 9 CSR 45-2.010)

9 CSR 50-1.055 Rights of Protectors, Parents and Guardians {#sec-9-csr-50-1.055 omnilex-key=us-mo-regs-official--title-9--9 CSR 50-1.055}

(Moved to 9 CSR 45-3.040)

9 CSR 50-1.060 Admission and Treatment of Clients with Aggressive Behaviors {#sec-9-csr-50-1.060 omnilex-key=us-mo-regs-official--title-9--9 CSR 50-1.060}

(Moved to 9 CSR 45-3.050)

MATTBLUNT(10/31/01)

Chapter 2 Mental Health Services

9 CSR 50-2.010 Admissions to Children’s Supported Community Living {#sec-9-csr-50-2.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 50-2.010}

PURPOSE: This rule prescribes admissions criteria, the application process, and placement procedures for Children’s Supported Community Living (SCL) funded by the Division of Behavioral Health. This rule applies to administrative agents.

(1) Definitions. Terms defined in sections 630.005 and 632.005, RSMo, shall be used in the interpretation and enforcement of this

rule. Unless the Division of Behavioral Health’s (DBH) supported community living (SCL) contract clearly requires otherwise, the following other terms used in this rule shall mean:

(B) Applicant, a minor for whom placement services in SCL has been requested;

(C) Chief of Children’s Community Operations (CCCO), DBH staff who oversee services and supports for children and youth in assigned regions of the state;

(D) Community psychiatric rehabilitation (CPR), an array of community-based, outpatient mental health services for children, youth, and adults who have been diagnosed with a severe, disabling mental illness or serious emotional disturbance.

Administrative agents or affiliates are responsible for providing these services to eligible individuals in their designated service area(s);

(E) Domicile administrative agent, the service area in which a child’s legal guardian resides or, if the child is under the jurisdiction of a juvenile court, the service area of the juvenile court that has assumed jurisdiction of the child;

(F) Regional community operations, the DBH office responsible for processing SCL placement funds for the administrative agent(s) in that region; and (G) SCL placement, placement of a child/youth who has a diagnosed serious emotional disturbance (SED) into an out-ofhome setting when determined clinically necessary by staff of the referring administrative agent. These settings include Professional Parent Homes (PPH), Treatment Family Homes (TFH), and residential treatment facilities where services are provided to address the psychosocial and medical needs of youth with the goal of moving them into a less restrictive level of care.

(2) Application for SCL. The application for placement in SCL shall be made by the child’s parents/legal guardian by completing the application form included herein. The application shall be submitted to the administrative agent overseeing the child’s care.

(3) Eligibility Criteria. Children’s SCL is a time-limited placement resource for children/youth under the age of eighteen (18) who have been determined by administrative agent staff to be eligible for clinical treatment services in a PPH, TFH, or residential treatment facility due to a demonstrated inability to function in any less restrictive setting.

(A) Exceptions for SCL services for individuals up to age twenty-one (21) may be granted by the CCCO in the domicile county/region where the youth resides.

(B) Children/youth requiring SCL shall have been diagnosed with a SED as specified in 9 CSR 30-4.005(7) unless an exception is granted by the CCCO. These children may be unable to consistently function in a public school, may present a chronic runaway risk, and may present a history of emotional dys-

regulation which may include physical aggression toward self and/or others.

(4) Ineligible Applicants. Children/youth shall be considered ineligible for SCL if— (A) There is no primary psychiatric diagnosis as specified in 9 CSR 30-4.005(6);

(B) The child has a medical condition that requires considerable supervision and ongoing treatment which inhibits effective clinical treatment for his/her psychiatric disorder;

(D) The application is submitted solely for the purpose of securing residential placement for a school-aged child as defined in Chapter 162, RSMo, to receive an appropriate education; or (E) The child’s symptoms meet acute definition.

(5) Screening. Applicants for admission to SCL shall be screened by staff of the administrative agent to determine eligibility for services and placement need, if any. Screenings shall be conducted in settings that ensure privacy and confidentiality for individuals served.

(6) Registered Sex Offenders and Youth Identified on the Juvenile County Registry.

(A) Youth who are identified on the Missouri State Highway Patrol Sex Offender Registry shall not be placed in a youth residential treatment facility. Placement in a TFH or PPH may be considered if other children residing in the home, in any capacity, are over the age of eighteen (18) and do not have a diagnosed intellectual or developmental disability. Requirements for the proximity of the TFH or PPH to a school, childcare facility, public park, or public swimming pool as defined in the department’s out-ofhome placement protocol shall be followed.

(B) For a youth who is identified as a juvenile sex offender on the juvenile county registry, placement in a TFH or PPH may be considered if all of the other individuals residing in the home, in any capacity, are over the age of eighteen (18) and do not have a diagnosed intellectual or developmental disability. There shall be no one under the age of eighteen (18) in the home, including the provider’s natural, adopted, or other children living in the home. Placement can be made in a residential facility as long as the requirements in the department’s out-of-home placement protocol are followed and clinical judgment is exercised.

(C) If a registered sex offender or identified juvenile sex offender is being considered for SCL, the administrative agent shall comply with the department’s established out-ofhome placement protocol and notification procedures.

(7) Notification to the Applicant. The administrative agent shall communicate acceptance or denial of the application to the child’s parent/guardian. Notification shall be documented and a record of the communication shall be maintained by the administrative agent.

(A) If the parent/guardian disagrees with a decision of ineligibility for admission, they shall be informed of the grievance process of the administrative agent managing the referral.

(8) Appropriate Placement. Before placing a child in SCL, the administrative agent shall consider each of the following:

(A) The best interest of the child;

(B) The least restrictive environment for care and treatment consistent with needs and conditions of the child;

(C) The capacity of the proposed residential setting to provide necessary care and treatment for the child which is of comparable quality to existing care and treatment based upon investigation of the alternative facility and its program of care and treatment;

(D) The relationship of the child to family, guardian, or friends/natural supports and the ability to maintain those relationships and encourage visits beneficial to the child.

(9) Consent for Placement.

(A) If the applicant is a minor or has a legal guardian, the administrative agent shall obtain consent of the parent or guardian before placement.

(B) If the application is for a child who is an involuntary commitment under Chapter 211 or Chapter 632, RSMo, the administrative agent shall notify the court of competent jurisdiction of the proposed placement and allow ten (10) working days for the court to object.

(C) Notwithstanding the provisions of sections 211.151, 211.161, and 211.181, RSMo, and any other provision of law contrary to this section, the juvenile court may not order that children be detained by, committed to, or otherwise placed in the Department of Mental Health for periods longer than thirty (30) days except as provided in sections 211.201 to 211.207, RSMo.

(10) Release of Information. The administrative agent shall obtain appropriate releases of referral information signed by the parent or guardian. The referral information shall include appropriate psychiatric, medical, and social information.

(11) Admission Procedures. If the administrative agent approves the applicant for admission into children’s SCL, staff shall follow DBH procedures for admission.

(A) A staff person of the administrative agent shall be assigned to coordinate services with the child and his or her parents/guardian, family members/natural supports, and other agencies, as appropriate.

(B) Administrative agent staff shall assist the child’s parent/guardian in applying for Medicaid and submitting verification of the application to the designated DBH regional community operations office.

(C) Selection of the SCL provider shall be coordinated with the child’s parent/guardian, including an interview and pre-placement visit with the proposed provider, as appropriate.

(D) The administrative agent shall maintain documentation in the child’s record regarding his/her placement in SCL including, but not limited to:

Signed acknowledgement of notice of privacy and practices;
SCL application form;
Results of the comprehensive clinical assessment;
Evaluation including diagnosis, IQ test results (if available), current level of functioning, recommended services/supports, and psychosocial history within the past six (6) months performed by a qualified mental health professional;
Educational evaluation and school records, including cumulative record, diagnostic summary, individualized education plan (IEP) or 504 plan, or documentation from the home school district that the child does not have an IEP or 504 plan;
Immunization record;
Physical examination by a licensed healthcare provider within the past six (6) months, including any laboratory tests or imaging ordered;
Document of legal guardianship or copy of birth certificate, divorce decree, or court order verifying custody, as applicable;
Completed and scored standard means test;
Notice of cost;
Consent agreement for SCL services (must be signed by the parent/legal guardian and staff of the administrative agent managing the placement);
Notification of change report, including any co-payment from any other source(s) and/or ancillary funds associated with the placement such as personal spending allowances, transportation assistance, or special needs (must be submitted to the designated DBH regional community operations office within five (5) calendar days after the placement is made); and 13. Juvenile sex offender background check and Missouri State Highway Patrol sex offender background check.

(E) Copies of the documentation specified in paragraphs (11)(D)1.–13. of this rule shall be sent to the SCL provider prior to or at the time of the child’s admission to the program.

This information shall be available for review by department staff and other authorized representatives upon request.

(F) Within five (5) calendar days of the child’s placement in SCL, the administrative agent shall provide the DBH regional community operations office with completed copies of the SCL application, consent and agreement to SCL, notice of change, standard means test, notice of cost, and face sheet, including the child’s demographic information and diagnosis.

(12) Out-of-Region Placements. All referrals and placements with a children’s SCL provider outside the administrative agent’s designated service area shall be managed by the domicile administrative agent, including funding for such placements.

(A) Staff of the domicile administrative agent shall provide continued monitoring of the child to ensure appropriate services are provided, including participating in monthly treatment team meetings, reviewing assessment/evaluation information and progress reports, and participating in discharge planning to ensure continuity of services when the child is placed back into his/her domicile region.

(B) The administrative agent shall notify the DBH domicile region CCCO of any outof-region placements to ensure the SCL provider is addressing the child’s needs and meeting department contract requirements.

(C) The domicile administrative agent shall send the documentation specified in paragraphs (11)(D)1.–13. of this rule to the outof-region SCL provider prior to or at the time of the child’s admission to the program.

(13) Inpatient Psychiatric Placements.

Referrals to a DBH inpatient psychiatric facility shall be made directly by the domicile administrative agent.

(A) The administrative agent shall inform the DBH domicile region CCCO when such referrals are made.

(B) Upon placement into the DBH facility, the domicile CCCO shall notify the CCCO in the region where the inpatient psychiatric facility is located.

(C) Staff of the domicile administrative agent shall monitor the child’s clinical care by participating in monthly treatment team meetings, reviewing assessment/evaluation information and progress reports, and participating in discharge planning to ensure continuity of services when the child is placed back into his/her domicile region.

(14) Service Delivery. Responsibilities of the administrative agent overseeing the child’s care and treatment while in SCL shall include, but are not limited to:

(A) Ensuring the child’s parent/guardian is advised of all appropriate services and placement resources in order to give informed parental consent, including the opportunity to interview staff and tour residential treatment programs;

(B) Facilitating and participating in development of the child’s treatment plan for residential services to ensure the plan includes measurable goals, participating in treatment plan reviews and discharge planning, and maintaining a copy of the treatment plan in the administrative agent’s clinical record;

(C) Documenting the child’s progress on a monthly basis, at a minimum, to ensure he/she is safe, healthy, and progressing in clinical treatment, including the addition of measureable actions and steps to address any concerns noted in regard to his/her achievement of treatment goals;

(D) Assuring appropriate services are provided to the child;

(E) Communicating with the parent/guardian, court, and/or other agency staff involved in the child’s services and supports, as applicable;

(F) Coordinating and assisting in securing necessary clothing, personal items, and transportation, if needed, in accordance with personal spending guidelines;

(G) Coordinating and assisting in obtaining needed services, such as medical care and outpatient psychiatric services;

(H) Arranging for hospitalization for appropriate psychiatric services, if needed;

(I) Arranging for transfer to another residential treatment provider, if needed;

(J) Reporting any issues or concerns to the DBH regional CCCO;

(K) Ensuring personal spending is consistent with the child’s needs as identified in the treatment plan;

(L) Ensuring there is progress toward achievement of individual and family-based goals identified in the treatment plan, which may include pursuing other treatment options if progress is not occurring; and (M) Ensuring discharge planning begins at the time of admission and the discharge plan has clear objectives consistent with the overall goals identified in the individual treatment plan, and that necessary coordination and linkages with appropriate family members/natural supports and community resources are included and documented in the plan.

(15) Funding. Funding for SCL will be approved by the CCCO or designee for an applicant based on the— (A) Applicant’s acceptance by a proposed SCL provider; and (B) Availability of funds.

Filed March 30, 1992, effective Jan. 15, 1993. Amended: Filed July 17, 1995, effective March 30, 1996. Amended: Filed Feb. 9, 2021, effective Aug. 30, 2021. 1995, 2008 and 630.705, RSMo 1980, amended 1982, 1984, 1985, 1990, 2000, 2011, 2014.

History

AUTHORITY: sections 630.050 and 630.705, RSMo 2016. Original rule filed Feb. 29, 1988, effective July 25, 1988. Amended:

9 CSR 50-2.020 Guidelines for Conditional Release {#sec-9-csr-50-2.020 omnilex-key=us-mo-regs-official--title-9--9 CSR 50-2.020}

PURPOSE: This rule sets guidelines for implementation of section 632.385, RSMo and applies to all department facilities and private mental health facilities certified by the Division of Comprehensive Psychiatric Services to provide outpatient treatment.

(1) The head of a mental health facility or designee may conditionally release a client who is involuntarily detained pursuant to

Chapter 632, RSMo for twenty-one (21) days, ninety (90) days or one (1) year, for a period not to exceed one (1) year, under written conditions provided by the facility. The facility shall have a continuing responsibility to assist the client in following the written conditions and, as provided in section (6) of this rule, may revoke the client’s conditional release and return the client to the facility for further inpatient treatment.

(2) The head of the facility or designee shall develop written conditions for the client’s release. These conditions may include, but are not limited to, the following:

(A) Where the client will reside;

(B) What medications the client must take to treat the mental illness;

(C) When and where the client will receive required psychotherapy, day treatment, supported community living services or other required care and treatment necessary to continue the client on conditional release;

(D) Which behaviors the client is expected to exhibit or avoid; and (E) Any other conditions necessary for the client to comply with to reasonably assure success.

(3) The client, the head of the facility or designee and the persons providing services to the client while on conditional release shall agree to the conditions of the release agreement.

(4) The head of the releasing facility or designee may modify the client’s conditions for release when s/he believes that these changes are in the best interest of the client.

Suggested modifications to the conditional release agreement may be made to the head of the releasing facility or designee by the client or the persons providing services. Any modifications shall be given to the client in writing and as required in sections (3) and (5) of this rule.

(5) The signed conditional release shall be filed by the head of the facility or designee with the probate division of the circuit court that committed the client. Copies of the conditional release shall be given to— (A) The client;

(B) The facility that conditionally released the client;

(D) The client’s last attorney of record;

(E) The prosecuting attorney, county counselor or circuit attorney, as appropriate.

(6) If the client violates one (1) or more conditions of the release, the head of the facility or designee that conditionally released the client shall be notified. After review the head of the facility or designee may revoke the client’s conditional release and return the client to the hospital if there is reason to believe that— (A) The client has violated one (1) or more of the conditions of release;

(B) The client requires resumption of fulltime hospitalization; or (C) The safety of the client or public may be in jeopardy if the client is not hospitalized.

(7) If a decision to revoke the client’s conditional release is made by the head of the facility or designee, s/he shall notify and give written notice as to the conditions that were violated, how they were violated and reasons for returning the client to inpatient hospitalization within ninety-six (96) hours of the client’s return to the mental health facility to the following:

(A) The client;

(B) The person(s) providing services which are called for by the conditions of release;

(D) The client’s last attorney of record;

(E) The prosecuting attorney, county counselor or circuit attorney, as appropriate.

(8) If, after given notice, the client refuses to return to the facility, the head of the facility or designee may take the written notice to the probate division of the circuit court where the conditional release was filed and request that the probate division of the circuit court issue a warrant for the client’s apprehension and return to the facility. The court may consider the request on an ex parte basis. Any court costs related to revocation shall be paid as provided in section 632.415, RSMo.

(9) When the client is returned to the facility, the head of the facility or designee shall give written notification to the client that if the client disagrees with the revocation that the client may ask the court to hold a hearing on the matter. Upon readmission to the facility, the client shall be given notice of his/her commitment rights as if s/he were detained for the initial ninety-six (96)-hour period and be given the name and phone number of his/her attorney who represented him/her in the last commitment hearing. The attorney who represented the client on the last commitment hearing shall continue to be the attorney of record unless the client has obtained other legal counsel. If the attorney of record is unable to represent the client, a new attorney shall be designated by the facility from the list of attorneys.

(10) The period of inpatient hospitalization shall not exceed the period of time left on the previous commitment without further hearings for the next appropriate period of commitment. The head of the facility placing the client on conditional release shall keep adequate records to assure that the client is not involuntarily treated as an inpatient for a longer period than necessary while on conditional release.

History

AUTHORITY: section 630.050, RSMo 2000. Original rule filed Aug. 4, 1988, effective Jan. 13, 1989. Amended: Filed Jan. 31, 2006, effective Aug. 30, 2006. 1995.

9 CSR 50-2.510 Admissions to Adult Community Residential Settings {#sec-9-csr-50-2.510 omnilex-key=us-mo-regs-official--title-9--9 CSR 50-2.510}

PURPOSE: This rule prescribes eligibility and admission criteria, the application process, and notification procedures for adult community residential settings funded by the Division of Behavioral Health (DBH). This

rule applies to administrative agents, affiliates, and community residential settings.

(1) Definitions. Terms defined in sections 630.005 and 632.005, RSMo, shall be used in the interpretation and enforcement of this

rule. Unless the Division of Behavioral Health (DBH) residential services contract clearly requires otherwise, the following other terms, as used in this rule, shall mean:

(B) Affiliate, an organization that is contracted with the department to provide specific community psychiatric rehabilitation (CPR) services for adults in a designated geographic area;

(D) Charged consumer, an individual who has been permanently determined to lack capacity to understand the proceedings against him/her or to assist in his/her own defense under section 552.020, RSMo, for offenses the individual would otherwise have been required to register as an offender on or after January 1, 1995, under sections 589.400 to 589.425, RSMo;

(E) Charged consenting consumer, a charged consumer whose guardian has given consent to the DBH regional community operations office to disclose such legal charges against his/her ward to other individuals (guardian, if appointed) who may or will be residing with the charged consumer;

(F) Community Psychiatric Rehabilitation (CPR), an array of community-based, outpatient mental health services for children, youth, and adults who have been diagnosed with a severe, disabling mental illness or serious emotional disturbance.

Administrative agents or their affiliates are responsible for providing these services to eligible individuals in their designated service area(s);

(G) DBH-funded community residential setting (used interchangeably in this rule with residential setting), living arrangements in the community designated for adults who meet the admission criteria specified in this

rule. These settings include, but are not limited to, Psychiatric Individualized Supported Living (PISL), Intensive Residential Treatment Settings (IRTS), clustered apartments, residential care facilities, assisted living facilities, and intermediate care facilities;

(H) Forensic client, a person who is a client of the Division of Behavioral Health pursuant to sections 552.030 and 552.040, RSMo;

(I) General notification, written notification to an individual (guardian, if appointed) receiving DBH funding in a residential setting or other community dwelling, such as an apartment setting, of the potential to reside with a registered offender or charged consumer;

(J) Regional community operations, the DBH office responsible for overseeing DBHfunded community residential settings in assigned regions of the state;

(K) Registered offender, a person who is registered or will be registered by law enforcement upon discharge from a DBHoperated inpatient psychiatric facility or correctional facility pursuant to sections 589.400 to 589.425, RSMo; and (L) Specific notification, written notification to an individual (guardian, if appointed) receiving DBH funding in a residential setting or other community dwelling, such as an apartment setting, when a registered offender or charged consenting consumer has been referred for admission to the same setting, as well as when a registered offender or charged consenting consumer currently resides in the same setting, regardless of whether the offender or charged consenting consumer requires DBH funding. Specific notification is managed by the DBH regional community operations office. Specific notification of a registered offender includes the name of the offender, physical description, registerable offense(s), associated date(s) of offense(s), and the name of the residential setting where the offender is referred to or resides. The specific notification of a charged consenting consumer includes the name of the charged consumer, offense(s) and associated date(s) of offense(s), and the name of facility the charged consenting consumer is referred to or resides.

(2) Forensic Clients. All forensic clients shall have priority for admission to a DBH-funded residential setting appropriate to their service and support needs.

(3) Individuals in DBH Inpatient Psychiatric Facilities. All adults being served in a DBH inpatient psychiatric facility who are referred to an administrative agent/affiliate shall receive priority consideration for admission to a DBH-funded residential setting appropriate to their service and support needs.

(4) Other Eligibility Criteria. An applicant who does not meet the criteria of section (2) or (3) of this rule shall meet all of the following criteria to be eligible for admission to a residential setting:

(A) Be at least eighteen (18) years of age;

(B) Qualify for admission to a CPR program as specified in 9 CSR 30-4.005(6); and (C) Have a mental disorder that constitutes substantial impairment in social role functioning and daily living skills based upon the clinical judgment of the administrative agent/affiliate, which must include documentation that the individual cannot function successfully outside a mental health facility without appropriate services and supports in a community residential setting. Substantial impairment may include, but is not limited to, the following behavioral characteristics:

Substantial need for mental health treatment and social services;
History of inability or unwillingness to participate in treatment, including taking medications as prescribed;
Inadequate living skills to provide for basic necessities of food, clothing, shelter, safety, personal care, and health care without assistance;
Inadequate social skills, which may be exhibited in aggressive or withdrawn behavior;
Frequent personal crises requiring emergency treatment or support and assistance;
Inability to effectively access community services and supports;
Lack of a personal support system (for example, family or other natural supports) to assist in accessing services/supports;
Lack of sustained employment.

(5) Ineligible Applicants. The administrative agent/affiliate’s staff shall consider an applicant ineligible for admission to a residential setting if— (A) The primary diagnosis is a substance use disorder, intellectual disability, or developmental disability;

(B) Medical needs supersede the psychiatric disorder and require considerable supervision and ongoing treatment for a medical condition;

(D) The primary diagnosis is dementia; or (E) Appropriate services have been established that are otherwise available through alternative resources.

(6) Screening. Applicants for admission to a residential setting shall be screened by the administrative agent/affiliate to determine eligibility. Screenings shall be conducted in settings that ensure privacy and confidentiality for individuals served.

(7) Eligibility Determination. The administrative agent/affiliate shall determine if an applicant is eligible for admission to a residential setting. Priority shall be given to individuals identified in sections (2) and (3) of this rule.

(A) The administrative agent/affiliate shall communicate acceptance or denial of the application to the referral source.

Notification shall be documented and a record of the communication shall be maintained by the administrative agent/affiliate.

(B) If an individual (guardian, if appointed) disagrees with a decision of ineligibility for admission, he/she shall be informed of the grievance process of the administrative agent/affiliate managing the referral.

(8) Appropriate Residential Setting. Prior to admitting an individual to a residential setting, the administrative agent/affiliate shall ensure the setting meets the individual’s needs.

(A) Each of the following shall be considered to ensure the proposed residential setting is appropriate:

The best interest of the individual;
The least restrictive environment for care and treatment, consistent with needs of the individual;
The capacity of the proposed residential setting to provide necessary care and treatment for the individual;
The relationships of the individual to family, guardian, friends, and other natural supports and the ability to maintain those relationships and encourage visits beneficial to the individual; and 5. The preferences of the individual (guardian, if appointed) in the residential setting chosen.

(B) If a residential care facility, assisted living facility, or intermediate care facility is determined to be the appropriate residential setting for the individual, the facility must be licensed by the department and the Department of Health and Senior Services as specified in 9 CSR 40-1.055.

(9) Release of Information. The administrative agent/affiliate staff shall obtain appropriate releases of referral information signed by the individual (guardian, if appointed). The administrative agent/affiliate staff shall submit the referral information to the proposed residential setting including appropriate psychiatric, medical, and social information.

(10) Admissions. The administrative agent/affiliate shall follow DBH procedures to manage admissions to residential settings.

(11) Notification Procedures. Department requirements shall be followed for notifying individuals (guardians, if appointed) referred to a residential setting who may reside with or may themselves be a registered offender under sections 589.400 to 589.425, RSMo, or charged consumer under section 552.020, RSMo, for offenses they would otherwise have been required to register as an offender under sections 589.400 to 589.425, RSMo.

(A) The following procedures shall be followed when an individual requiring DBH funding for housing or Intensive CPR (ICPR) services is referred to or residing in a residential setting or other community living arrangement, such as a single or multiple occupancy dwelling:

Prior to admission, a query with the Missouri State Highway Patrol shall be completed by the administrative agent/affiliate or DBH regional community operations office to verify the referred individual’s status as a registered offender. If the administrative agent/affiliate manages the query, staff must comply with department policies and procedures related to the offender query process;
Prior to admission, general notification must be provided to each individual (guardian, if appointed) referred to inform him/her of the potential to reside with a registered offender(s) or charged consumer(s).

A. General notification to the individual (guardian, if appointed) referred shall be issued by the administrative agent/affiliate or DBH regional community operations office.

If the administrative agent/affiliate manages the general notification, staff must comply with department policies and procedures related to the general notification process.

The general notice must be received by the individual (guardian, if appointed) prior to admission to the residential setting;

Specific notification involving a registered offender will be issued by the DBH regional community operations office.

A. The administrative agent/affiliate shall notify the DBH regional community operations office that specific notification is required when they refer a registered offender requiring DBH funding to a residential setting, or the individual being referred will be residing in the same residential setting as a registered offender.

B. Specific notification will be issued by the DBH regional community operations office prior to the admission of each individual (guardian, if appointed) referred who requires DBH funding and will be residing in the same setting as a registered offender, regardless of whether the registered offender receives DBH funding.

C. Specific notification is also issued by the DBH regional community operations office prior to admission of each individual (guardian, if appointed) requiring DBH funding in a residential setting or dwelling when a registered offender is referred for admission to the same setting, regardless of whether the referred offender requires DBH funding.

D. Individuals who require DBH funding shall not be admitted to the residential setting or dwelling until the DBH regional community operations office completes the specific notification process and notifies the administrative agent/affiliate that the individual can be admitted; and 4. Specific notification of a charged consenting consumer shall be issued by the DBH regional community operations office to each individual (guardian, if appointed) referred who requires DBH funding and will be residing in the same setting as a charged consenting consumer, regardless of whether the charged consenting consumer receives DBH funding.

A. The administrative agent/affiliate shall notify the DBH regional community operations office that specific notification is required if the administrative agent/affiliate is aware the referred individual is a charged consumer, or if the referred individual will be residing in the same setting as a charged consenting consumer.

B. The DBH regional community operations office will determine if the charged consumer (guardian, if appointed) consents to release information of his/her charged status to DBH-funded individuals residing in the residential setting or dwelling, including the individual’s name and nature and date(s) of the crime(s) for which the charged consumer would have been required to register if he/she had been convicted.

(I) Regardless of whether consent to disclose these charges is obtained, the charged consumer may be admitted to the residential setting or dwelling.

(II) If consent is obtained, the DBH regional community operations office will send specific notification to DBH-funded individuals referred to or residing in the residential setting or dwelling.

C. Individuals who require DBH funding shall not be admitted to the residential setting or dwelling until the DBH regional community operations office completes the specific notification process and notifies the administrative agent/affiliate that the individual may be admitted.

(B) Offender notification procedures shall be followed by DBH-contracted residential settings prior to admitting a registered offender or charged consumer who does not receive services from an administrative agent/affiliate or funding from DBH.

When a residential setting intends to admit a registered offender, and the individual is not involved with an administrative agent/affiliate and does not require DBH funding, staff of the residential setting shall notify the DBH regional community operations office. The notification must be prior to the individual’s admission if DBH-funded individuals currently reside at the residential setting. The DBH regional community operations office will verify the registered offender’s criminal offense(s) and date(s) for which registration is required with the Missouri State Highway Patrol.
When the residential setting intends to admit a charged consumer, and the individual is not involved with an administrative agent/affiliate and does not require DBH funding, staff of the residential setting shall notify DBH. The DBH regional community operations office will obtain records to verify the charged consumer’s name and nature of the crime(s) for which the charged consumer would have been required to register if he/she had been convicted. Following verification of individual’s charged crime(s) and date(s), the DBH regional community operations office will request consent of the charged consumer (guardian, if appointed) to disclose his/her name and nature of the crime(s) to individuals requiring DBH funding who are referred to or residing at the residential setting. If consent is obtained, the individual is considered a charged consenting consumer.
If there are individuals funded by DBH who are referred to or residing at the residential setting, specific notification procedures as specified in this rule must be completed by the DBH regional community operations office prior to the admission of a registered offender or charged consenting consumer.
Registered offenders or charged consumers shall not be admitted to the residential setting until the DBH regional community operations office completes the specific notification process and notifies staff of the residential setting that the individual may be admitted.

A. If there are no individuals referred to or residing at the residential setting who require DBH funding, notifications are not required and the registered offender, charged consumer, or charged consenting consumer may be admitted to the residential setting.

B. Staff of the residential setting shall notify the DBH regional community operations office of the registered offender or charged consumer’s admission and discharge date. The department will provide this information to the administrative agent/affiliate in the service area where the residential setting is located.

(C) The administrative agent/affiliate shall maintain a record of all DBH-funded and/or contracted residential settings in their service area(s) where registered offenders and charged consenting consumers are residing in order to inform DBH regional community operations staff when specific notification is required.

(D) The administrative agent/affiliate shall maintain a record of individuals receiving DBH funding in residential settings and dwellings.

(12) Prescribed Medication. At the time of admission to a residential setting, the administrative agent/affiliate shall ensure the individual has access to his/her prescribed medication.

(13) Bedrooms. Individuals receiving DBH funding to live in a community residential setting shall not share a bedroom with more than one (1) person unless the administrative agent/affiliate provides adequate justification for other arrangements to the DBH regional community operations office and prior approval is granted for such arrangements.

(A) Single occupancy bedrooms are required for clustered apartments, Intensive Residential Treatment Settings (IRTS), and Psychiatric Individualized Supported Living (PISL).

(B) Further restrictions regarding sharing of bedrooms may be required based on individual needs, preferences, and least restrictive environment considerations.

(14) Discharge. DBH funding for an individual’s personal needs and room and board shall be discontinued if there are other sufficient financial resources to cover these costs.

Filed Jan. 31, 2006, effective Aug. 30, 2006.

Amended: Filed Feb. 9, 2021, effective Aug. 30, 2021. 1995, 2008.

History

AUTHORITY: section 630.050, RSMo 2016. Original rule filed July 3, 1986, effective Dec. 15, 1986. Amended: Filed July 17, 1995, effective March 30, 1996. Amended:

Chapter 3 Eligibility Appeals Procedures

9 CSR 50-3.705 Appeals Procedures for Service Eligibility Through the Division of Mental Retardation and Developmental Disabilities {#sec-9-csr-50-3.705 omnilex-key=us-mo-regs-official--title-9--9 CSR 50-3.705}

(Moved to 9 CSR 45-2.020)

MATTBLUNT(10/31/01)

Chapter 4 Services for Persons with Developmental Disabilities

9 CSR 50-4.010 Client Absences from Community Residential Facilities {#sec-9-csr-50-4.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 50-4.010}

(Rescinded December 30, 1995)

Original rule filed April 7, 1993, effective Oct. 10, 1993. Rescinded: Filed June 13, 1995, effective Dec. 30, 1995.

MATTBLUNT(10/31/01)

History

AUTHORITY: section 630.050, RSMo 1986.

Division 60 Research

Chapter 1 Rules for Conducting Research and Program Evaluation

9 CSR 60-1.010 Application for Client Research {#sec-9-csr-60-1.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 60-1.010}

PURPOSE: This rule prescribes procedures by which applications for research involving any client or patient or any individual identified by virtue of being a former client or patient of the department are submitted and reviewed for approval.

(1) The terms defined in section 630.005, RSMo are incorporated into this regulation.

As used in this administrative rule the following terms mean:

(A) Archival research is the review or analysis of historical data generated by the department and kept as part of the permanent management information record;

(B) Behavioral or psychological research is the experimentation with patients, clients, or residents to determine the effects of manipulation or application of environmental variables including, but not limited to, experimental use of behavior modification;

(C) Biomedical research is experimentation by intruding into a patient’s, client’s, or resident’s body to monitor the biological reaction to controlled stimuli or biological study involving experimental medical or surgical procedures, withdrawal or removal of body tissues or fluids, or input of energy or manipulation of bodily processes;

(D) Professional review committee (PRC) is the ten- (10-) person committee established under section 630.193, RSMo and appointed by the department director or designee to review and recommend approval or disapproval of proposed research projects;

(E) Pharmacological research is experimentation with patients, clients, or residents to determine responses to drugs or other substances;

(F) Program evaluation is an activity designed to assess or evaluate policies, procedures, or programs currently in operation to determine their effectiveness or usefulness or to identify needed changes, including survey research and specifically limited to instances where no manipulation of variables or conditions is involved; and (G) Research is experimentation or intervention with or on departmental patients, clients, or residents, including behavioral or psychological research, biomedical research, pharmacological research, and program evaluation. Excluded are those instances where the manipulation or application is intended solely and explicitly for individual treatment of a condition, falls within the prerogative of accepted practice, and is subject to appropriate quality assurance review. Also excluded are activities limited to program evaluation conducted by staff members as a regular part of their jobs, the collection or analysis of management information system data, archival research, or the use of departmental statistics.

(2) Any person may request to do research on departmental clients by requesting the application for research with clients from the department director or designee. It is incumbent on the individual wishing to conduct research to seek and gain approval for research before initiating the project.

(3) The person requesting to do research shall send an application to the department director or designee as indicated on the application. Based on the completed application, the department director or designee may exempt from PRC review those projects which do not meet the criteria of research as defined in

section (1). In the case of projects approved by the facility director which are exempted from review, the facility director accepts the responsibility of insuring client confidentiality, informed consent, and the right to refuse to participate.

(4) For approved projects, it is incumbent on the principal investigator to ensure that execution of the project does not violate statutes.

(5) Statements provided in this regulation shall not be construed to limit client rights established by statutes, including the right to informed consent and the right to refuse to participate.

Amended: Filed July 17, 1995, effective March 30, 1996. Amended: Filed July 26, 2016, effective Feb. 28, 2017. *Original authority: 630.192, RSMo 1980, amended 1996, 2011 and 630.193 to 630.198, RSMo 1980. See Missouri Revised Statutes, 2016.

History

AUTHORITY: sections 630.192, 630.193 to 630.198, RSMo 2016. Original rule filed March 18, 1987, effective Aug. 15, 1987.

9 CSR 60-1.015 Review of Research in Progress {#sec-9-csr-60-1.015 omnilex-key=us-mo-regs-official--title-9--9 CSR 60-1.015}

PURPOSE: This rule prescribes the procedures by which the Professional Review Committee may review and investigate research.

(1) The terms defined in section 630.005, RSMo are incorporated into this rule. As used in this administrative rule, the following terms mean:

(A) Professional review committee (PRC) is the ten- (10-) person committee established under section 630.193, RSMo and appointed by the department director or designee to review and recommend approval or disapproval of proposed research projects;

(B) Approved research is any behavioral or psychological research, biomedical research, pharmacological research, or program evaluation approved by the PRC;

(C) Facility director is the chief administrator or director of a state facility, vendor facility, or vendor agency which serves clients of the Department of Mental Health; and (D) PRC coordinator is appointed by the department director or designee.

(2) Research which has been approved by the PRC shall be reviewed at one hundred eighty- (180-) day intervals or more often as determined by the PRC from the date of approval until the project is completed. The principal investigator shall submit information as specified by the PRC regarding the status of the research project.

(A) The principal investigator shall provide a report of the results to the department upon completion of the project.

(B) Based on the information obtained in a review, the PRC shall investigate the project if any harm, increased risk of harm or unapproved deviation from the research protocol occurs.

(3) Any written complaint regarding research which produced harm, increased risk of harm or which failed to conform to approved research protocol shall be investigated by the PRC.

(A) A complaint may be filed with a member of the PRC or its coordinator, or with a facility director where research is being conducted. Those receiving complaints shall provide a copy of the complaint to the coordinator.

(B) The coordinator shall notify the principal investigator and all facility directors where the project is being conducted of any complaints received.

(D) The facility director shall investigate the complaint and provide recommendations to the coordinator of the PRC within ten (10) days of the filing of the complaint. The facility director may chose to suspend or halt the project after receiving notification of a com plaint. The JOHNR. ASHCROFT(1/29/17) facility director shall notify the principal investigator and the coordinator of any decision to suspend or halt a research project.

(4) The PRC may investigate any research project which it has approved. The PRC shall investigate any approved research project when it has reason to believe that harm or increased risk of harm to the subjects or deviation from approved protocol has occurred.

(A) The PRC may halt the research project while it is under investigation.

(B) The principal investigator shall provide information requested by the PRC that is necessary for the investigation.

(D) Staff of vendor agencies serving clients of the department shall provide information requested by the PRC necessary for the investigation.

(E) The PRC shall rule on projects which have been investigated.

The PRC may take into account information received from the facility director where the project is conducted, from the principal investigator, and from other sources having information pertaining to the project.
The PRC may rule to halt the project or suspend the project until deficiencies are corrected.
The principal investigator and the facility director shall be notified of the decision of the PRC.

(5) At the request of a facility director, the PRC may investigate research activities which have not been reviewed including archival studies and program evaluation projects.

Filed May 20, 1996, effective Dec. 30, 1996.

Amended: Filed July 26, 2016, effective Feb. 28, 2017. *Original authority: 630.194, RSMo 1980.

History

AUTHORITY: section 630.194, RSMo 2016. Original rule filed Nov. 30, 1987, effective May 12, 1988. Rescinded: Filed Sept. 1, 1995, effective March 30, 1996. Readopted:

9 CSR 60-1.020 Archival and Program Evaluation Activities {#sec-9-csr-60-1.020 omnilex-key=us-mo-regs-official--title-9--9 CSR 60-1.020}

(Rescinded March 30, 1996)

Filed July 17, 1995, effective March 30, 1996.

History

AUTHORITY: sections 630.192 to 630.198, RSMo 1986. Original rule filed March 18, 1987, effective Aug. 15, 1987. Rescinded:

9 CSR 60-1.030 Research Review Committee {#sec-9-csr-60-1.030 omnilex-key=us-mo-regs-official--title-9--9 CSR 60-1.030}

(Rescinded March 30, 1996)

Filed July 17, 1995, effective March 30, 1996.

4CODE OF STATE REGULATIONS

(1/29/17) JOHNR. ASHCROFT

History

AUTHORITY: sections 630.196 and 630.198, RSMo 1986. Original rule filed March 18, 1987, effective Aug. 15, 1987. Rescinded:

Division 70 Financial Assistance

Chapter 1 Family Support

9 CSR 70-1.010 Family Support Stipends {#sec-9-csr-70-1.010 omnilex-key=us-mo-regs-official--title-9--9 CSR 70-1.010}

(Moved to 9 CSR 45-4.030)

9 CSR 70-1.015 Family Support Loans {#sec-9-csr-70-1.015 omnilex-key=us-mo-regs-official--title-9--9 CSR 70-1.015}

(Moved to 9 CSR 45-4.040)

MATTBLUNT(10/31/01)

Division 80 Division of Comprehensive Psychiatric Services

Chapter 1 Standards and Procedures for Program Recognition, Client Admissions and Performance

9 CSR 80-1.005 Civil Outpatient Detention and Treatment Programs {#sec-9-csr-80-1.005 omnilex-key=us-mo-regs-official--title-9--9 CSR 80-1.005}

PURPOSE: This rule defines terms and establishes standards and procedures for program recognition, client admissions and discharges, and performance of civil outpatient detention and treatment programs.

(1) The terms defined in sections 630.005 and 632.005, RSMo are incorporated by reference for use in 9 CSR 80-1.005(1) through (35).

(2) As used in 9 CSR 80-1.005(1) through (35), unless the context clearly indicates otherwise, the following terms shall mean:

(A) Care provider, the person or persons who can demonstrate that they are primarily responsible for the health care of the person with a mental illness. The term does not apply to any person providing care through the hospitals, nursing homes, group homes or any other such facility;

(B) Discharge, formal dismissal of a client from the recognized mental health program;

(C) Likelihood of serious harm, any one (1) or more of the following but does not require actual physical injury to have occurred:

A substantial risk that serious physical harm will be inflicted by a person upon his/her own person, as evidenced by recent threats, including verbal threats, or attempts to commit suicide or inflict physical harm on him/herself. Evidence of substantial risk may also include information about patterns of behavior that historically have resulted in serious harm previously being inflicted by a person upon him/herself;
A substantial risk that serious physical harm to a person will result or is occurring because of an impairment in his/her capacity to make decisions with respect to his/her hospitalization and need for treatment as evidenced by his/her current mental disorder or mental illness which results in an inability to provide for his/her own basic necessities of food, clothing, shelter, safety or medical care or his/her inability to provide for his/her own mental health care which may result in a substantial risk of serious physical harm. Evidence of that substantial risk may also include information about patterns of behavior that historically have resulted in serious harm to the person previously taking place because of a mental disorder or mental illness which resulted in his/her inability to provide for his/her basic necessities of food, clothing, shelter, safety or medical or mental health care; or 3. A substantial risk that serious physical harm will be inflicted by a person upon another as evidenced by recent overt acts, behavior or threats, including verbal threats, which have caused such harm or which would place a reasonable person in reasonable fear of sustaining such harm. Evidence of that substantial risk may also include information about patterns of behavior that historically have resulted in physical harm previously being inflicted by a person upon another person;

(D) Mental illness, a state of impaired mental processes, which impairment results in a distortion of a personís capacity to recognize reality due to hallucinations, delusions, faulty perceptions or alterations of mood, and interferes with an individualís ability to reason, understand or exercise conscious control over his/her actions. The term mental illness does not include the following conditions unless they are accompanied by a mental illness as otherwise defined in Chapter 630, RSMo:

Mental retardation, developmental disability or narcolepsy;
Simple intoxication caused by substances such as alcohol or drugs;
Dependence upon or addiction to any substances such as alcohol or drugs; or 4. Any other disorders such as senility, which are not of an actively psychotic nature;

(E) Ninety-six (96) hours, shall be construed and computed to exclude Saturdays, Sundays and legal holidays which are observed either by the court or by the mental health facility where the respondent is detained;

(F) Outpatient commitment, legal status of a person who has been involuntarily detained for outpatient mental health treatment by the court pursuant to Chapter 632, RSMo;

(G) Recognized, a mental health program is considered to be recognized when it has received written notification from the Department of Mental Health that it has met the criteria established in 9 CSR 80-1.005(3) and (4) and is authorized to accept persons for admission who have been involuntarily RSMo; and (H) Release, termination of a detention order as a result of reaching the specified end date or resulting from change in client mental status, behavior, or admission status.

(3) To be eligible to be recognized by the department as a treatment program for persons who are detained for outpatient mental health treatment by the court pursuant to

Chapter 632, RSMo, a mental health program mustó (A) Be a comprehensive community-based mental health program that is designated to provide targeted case management (TCM) and holds current and valid certification without limitations by the Department of Mental Health as a Community Psychiatric Rehabilitation (CPR) program and as an outpatient program;

(B) Operate or arrange for availability of a twenty-four (24)-hour crisis response system for psychiatric clients; and (C) Have a current purchase of service contract with the Division of Comprehensive Psychiatric Services.

(4) CPR or outpatient program providers with provisional or probationary certification status shall not be recognized by the department and are not eligible to admit persons who are (5) Only recognized programs can admit persons who have a mental illness and are (6) Eligible programs shall make a written application for recognition to the Division of Comprehensive Psychiatric Services.

(A) The written application shall specify the name of the agency, the name of the executive director of the agency, the name of the CPR program it operates and the program director name(s), the geographic area served, the judicial districts included in the service area, the average number of clients enrolled in outpatient and CPR at any given time, the client capacity for each of its programs, copies of required certificates for CPR and outpatient programs, the name of the contact person for department or court communications, an affidavit attesting to compliance with 9 CSR 80-1.005(1) through (35) and any other information deemed necessary by the department.

(B) For programs requesting renewal of their recognition status, the written request shall be submitted to the department at least sixty (60) days prior to expiration of recognition.

(C) The department reserves the right to request additional information prior to recognizing the program or at any time while the program is recognized by the department.

(D) The department reserves the right to conduct unannounced, on-site review activities of applicants or recognized programs.

(7) Upon receipt of the written request for recognition, the department shall review the request and issue its written decision regarding the request within thirty (30) working days.

(A) The department may recognize a program for a time period not to exceed one (1)

year. The written notice to the applicant/program shall specify the expiration date of the recognition.

(B) The department may deny recognition to a program ifó 1. The program does not meet the criteria established in sections (3) and (4) above;

The application includes information that is false;
The program is found to have committed fraud or illegal activities or had reason to know its staff were engaged in fraud or illegal activities;
The program employs any individual to provide services for which the individual is not licensed as required by law;
The program employs any individual who is statutorily excluded from service as a result of convictions under sections 630.170 and 660.317, RSMo, specificallyó A. A person who has been convicted of, found guilty to, pled guilty to or nolo contendereto any of the following crimes shall be disqualified from holding any position in the agency:

(I) Physical abuse or Class I Neglect of a patient, resident or client;

(II) Furnishing unfit food to patients, residents or clients; and (III) Failure of a specified professional to report suspected abuse or neglect of a patient;

B. A person who has been convicted of, found guilty to, pled guilty to or nolo contendereto any of the following felonies shall be disqualified from holding any direct-care position in the agency:

(I) First or second degree murder; second degree murder;

(II) Voluntary manslaughter (includes assistance in self-murder);

(III) Involuntary manslaughter;

(IV) First or second degree assault;

(V) Assault while on school property;

(VI) Unlawful endangerment of another;

(VII) First or second degree assault of a law enforcement officer;

(VIII) Tampering with a judicial officer;

(IX) Kidnapping;

(X) Felonious restraint;

(XI) False imprisonment;

(XII) Interference with custody;

(XIII) Parental kidnapping;

(XIV) Child abduction;

(XV) Elder abuse in the first degree or the second degree;

(XVI) Harassment;

(XVII) Stalking;

(XVIII) Forcible rape;

(XIX) First or second degree statutory rape;

(XX) Sexual assault;

(XXI) Forcible sodomy;

(XXII) First or second degree statutory sodomy;

(XXIII) First or second degree child molestation;

(XXIV) Deviate sexual assault;

(XXV) First degree sexual misconduct;

(XXVI) Sexual abuse;

(XXVII) Endangering the welfare of a child;

(XXVIII) Abuse of a child;

(XXIX) Robbery in the first degree or second degree;

(XXX) Arson in the first or second degree;

(XXXI) First or second degree pharmacy robbery;

(XXXII) Incest;

(XXXIII) Causing catastrophe;

(XXXIV) First degree burglary; or (XXXV) Any equivalent felony offense; or 6. The program interferes with or refuses access by authorized agents of the Department of Mental Health to the programís sites of operation, to client or other records required in this rule, or to staff.

(8) The department may suspend or revoke recognition of a program at any time tható (A) The program does not meet the criteria established in sections (3) and (4) above;

(B) The program is not in substantial compliance with the requirements codified in 9 CSR 80-1.005(1) through (35);

(D) The program is found to have committed fraud or illegal activities or had reason to know its staff were engaged in fraud or illegal activities;

(E) The program employs any individual to provide services for which the individual is not licensed as required by law or is disqualified from employment as specified in paragraph (7)(B)5. above; or (F) The program interferes with or refuses access by authorized agents of the Department of Mental Health to the programís sites of operation, to client or other records required in this rule, or to staff.

(9) When recognition has been denied, suspended, or revoked, a program may appeal to the director of the department within thirty (30) days of receiving notice of the denial or revocation. The director of the department shall conduct a hearing under procedures set out in Chapter 536, RSMo and shall issue findings of fact, conclusions of law and a decision that shall be the final decision of the department.

(10) A recognized program shall be responsible for notifying the department of material changes in status that occur during their recognition period such as, but not limited to, change in location, change in ownership, change in corporate status, legal proceedings initiated against the agency, change in regulatory status, accreditation or certification status, or other substantive changes in the programís status or ability to perform its duties related to outpatient detention and treatment.

(11) The department shall maintain a listing of programs recognized to admit and serve persons who have been detained for outpatient mental health treatment.

(12) At a minimum the program shall have the capability to conduct clinical screenings on a twenty-four (24)-hour-per-day basis, seven (7) days per week to allow for next day admissions for persons detained by the court for outpatient mental health treatment.

(A) The method to contact the program to arrange for admissions shall be specified in written form to the access/crisis intervention system (ACI) hotline and all mental health coordinators in the programís service area.

(B) An individual who has been detained by the court for outpatient treatment shall not be placed on a waiting list for admission or services.

(13) For each person admitted for outpatient mental health treatment by the court pursuant to Chapter 632, RSMo, the program must have made a determination that the program 4CODE OF STATE REGULATIONS (3/31/98) Rebecca McDowell Cook can and will provide necessary and appropriate care, treatment and services to the individual in the least restrictive environment that will reasonably assure the individualís safety and the safety of the public.

(A) The program shall promptly provide this information for inclusion in the petition to the court.

(B) If a clinical screening is required to make a determination of appropriateness for admission, the screening shall be conducted within twenty-four (24) hours of the request.

(C) Screening and evaluation activities shall be adequate to address a broad range of clinical, social, and environmental factors that have relevance to the decision to accept or deny admission including, but not limited to:

Determination that the person has a mental illness;
Interventions and adaptations necessary to reasonably assure client and public safety including the frequency and nature of monitoring efforts designed for the individual;
Amount and nature of available support of family, friends and other social supports;
History of response to treatment and willingness to comply with medication and other necessary treatments;
Personís motivation and available resources for living in the community;
Assessment of the personís need for guardianship and the programís obligation to petition for guardianship, if needed; and 7. Adequacy of the recommended services to provide needed support to the person to live safely in the community.

(D) When a program has made a determination to accept a person for admission, the program shall also specify, in writing, specific conditions of participation individualized to address the personís situation. These conditions of commitment shall be included in the petition to the court and the program shall review the conditions with the person to be admitted as well as care providers and other caregivers, as appropriate and consistent with statutes and regulations governing client confidentiality.

(14) A person shall not be considered eligible for admission to a recognized agency for involuntary outpatient detention and mental health treatment if the personó (A) Has been committed to the Department of Mental Health for treatment pursuant to

Chapter 552, RSMo and such commitment remains in force;

(B) Is under the age of eighteen (18) and has a parent or legal guardian responsible for making treatment decisions; or (C) Has been determined to be incapacitated and a guardian has been appointed by the probate court pursuant to Chapter 475, (15) When a person is determined to be eligible for admission to the program for outpatient mental health treatment, the program shall specify in writing the range of care, treatment and services that shall be provided to the person, the source of funding for the specified interventions, the individualized conditions of commitment for the person, and the name of the inpatient mental health facility that has agreed to accept the person for admission and treatment at the direction of the program. This information shall be promptly furnished to the court in written form.

(16) Within seven (7) days of admission or sooner if clinically indicated, a treatment plan shall be completed that encompasses the requirements set forth in section (15) above.

(A) Services shall be designed to educate and assist the individual to comply with treatment that results in return to voluntary status as soon as possible.

(B) To the extent possible and consistent with client confidentiality, the treatment planning process should include family members, care providers, caregivers and other members of the clientís support system.

(C) In addition to meeting the requirements of the appropriate CPR certification standards, the treatment plan for each person ment shall also address conditions of commitment and the following issues, at a minimum:

Monitoring and limitations of client residence, movement and travel;
Communication protocols and coordination with other health care providers during the period of involuntary commitment to reasonably assure client and public safety;
Consequences of noncompliance related to criteria for referral to inpatient treatment;
Medication compliance and monitoring; and 5. Conditions of release from involuntary outpatient commitment.

(D) The treatment plan shall be reviewed on a periodic basis but no less frequently than monthly, and more often if clinically indicated.

(E) The program shall notify the court when a client detained for outpatient treatment fails to comply with conditions of commitment and the program is no longer able to reasonably assure client and/or public safety.

(F) A copy of the clientís ITP shall be sent to the inpatient facility that has agreed to accept the client when directed by the program.

(17) The program shall maintain a client listing of persons currently being served by the program who have been involuntarily ment. To assure continuity of care, the list shall be updated on a daily basis and shall be provided, with a current treatment plan and additional clinical information as indicated, to the hotline staff of the appropriate ACI system and to the mental health coordinator for the area in which the client lives.

(18) When a client has been detained for outpatient mental health treatment and the program has good cause to believe that immediate detention to an inpatient setting is required because the client presents a likelihood of serious harm as defined in subsection (2)(C) due to mental illness, the programó (A) Shall confirm and document in the client record, based on an evaluation by a qualified mental health professional, that the client requires immediate detention to an inpatient setting;

(B) Shall involve the responsible physician, if appropriate, in the decision to arrange inpatient admission;

(C) Shall initiate the admission process with appropriate staff of the inpatient facility specified in the petition or court order that agreed to accept the client;

(D) Shall direct that the client be detained for up to ninety-six (96) hours at an appropriate inpatient facility that has agreed to accept the client;

(E) May authorize the sheriff to detain and transport the client to the inpatient facility;

(F) Shall promptly provide a letter or other written documentation to the inpatient facility directing the inpatient facility to admit the client and detailing the clinical reasons for the inpatient admission, including specific violations of conditions of commitment, as appropriate, and other relevant clinical information;

(G) Shall provide written notice to the client of the clinical reasons for the inpatient admission, including violation of conditions of commitment;

(H) Shall immediately provide written notification to the committing court including copies of correspondence and notice described in (18)(G) and (H) above; and (I) Shall provide copies of documents referenced in (18)(G) and (H) above to counsel for the client and counsel for the petitioner.

(19) The program director shall release any person who is involuntarily detained for outpatient treatment when, in his/her opinion and based on a determination by a qualified mental health professional, the person is no longer mentally ill or, although mentally ill, does not present a likelihood of serious harm as defined in subsection 2(C), even though the detention period has not expired.

(A) The release decision shall be based on information gathered in observation of the client including but not limited to response to treatment, and mental status as well as information gathered from family and others who interact with the client.

(B) The program shall document in the client record their clinical rationale for the release decision.

(C) When the program releases a person prior to expiration of the detention order, the program shall send written notification to the court and the mental health coordinator.

(20) Whenever a client who has been detained for outpatient treatment requests to be voluntarily admitted to the program and the program agrees and accepts the person for voluntary admission, the involuntary detention shall end and the program shall send written notice to the court and the mental health coordinator.

(A) Upon request by a client for voluntary admission, the program shall evaluate the request to include considerations such as, but not limited to, clientís mental status and competency to make decisions, the genuineness of the request, whether the client still meets commitment criteria of likelihood of serious harm, and the clientís understanding of the proposed course of outpatient treatment. The program shall utilize information gained through observation of the client and information gathered from family, care providers and others.

(B) If, as a result of the review of the request, it is determined that the client is capable of making decisions, has made the request in good faith, and consents to voluntarily participate in outpatient treatment to reasonably assure client and public safety, the program shall grant the request in a timely manner.

(C) Changing a clientís status from involuntary to voluntary shall not be used solely to avoid civil detention proceedings or for staff convenience.

(D) The program shall document their activities and clinical judgments related to acceptance or denial of changes in client admission status in response to client requests.

(21) Any person who has been committed to the program on an outpatient basis shall be entitled to a reexamination of the court order on his/her own motion, or that of his/her parent, spouse, relative, friend or attorney to the court. Upon receipt of the motion, the court shall conduct proceedings in accordance with 632.340, RSMo.

(22) At any time that a client who is detained for outpatient treatment fails to comply with the conditions of the court order or conditions of commitment, the program shall request a hearing pursuant to 632.340, (23) At the end of any detention period ordered by the court, the client shall be discharged unlessó (A) A petition for further detention is filed and heard for successive outpatient detention periods; or (B) The client consents to continuing treatment.

(24) As required by section 632.392, RSMo, for all clients released or discharged from outpatient commitment for any reasonó (A) The program shall provide to the client and the care provider a written packet of educational information developed and supplied by the department describing symptoms of common mental illnesses, early warning signs of decompensation, and availability of other education, community and statewide services;

(B) The program may disclose confidential treatment information to the primary care provider or care providers, when such information is medically necessary for the provision of appropriate health care treatment by the care provider or is reasonably related to the safety of the client or care provider;

(C) Prior to the disclosure of the information specified in subsection (24)(B) above, the mental health program shalló 1. Provide written notice to the client;

Request in writing the consent of the client;
Work with the client and care provider to encourage and secure appropriate client authorization;
Function as a mediator, negotiating the boundaries of confidentiality to meet the needs of the client and care provider; and 5. Work with the client to stress the importance of keeping the care provider informed and involved with his/her treatment process;

(D) If the client refuses to consent and the treating physician deems the information is medically necessary for the appropriate provision of health care or treatment by the care provider or is related to the safety of the client or care provider, the information may still be released to the appropriate care provider;

(E) The reason for the intended disclosure, the specific information to be released and the persons to whom the disclosure is to be made, even if consent has not been obtained, will be provided to the client and care provider; and (F) All these procedures shall be documented by the treating physician in the client record, including a specific notation as to whether client consent was given.

(25) Whenever possible, the program shall plan for orderly discharge and referral of discharged clients to appropriate services and support systems.

(26) The program shall maintain information to document its participation as a recognized program to accept outpatient commitments in a format approved by the department.

(A) The program shall document referrals from the court, admissions, denials, client grievances and their resolution, and discharges.

(B) The program shall submit information in aggregate form to the department on a periodic basis or upon request.

(D) The department reserves the right to review and verify such information on-site.

(27) The program shall be responsible for maintaining clinical records for persons receiving services consistent with these standards 9 CSR 80-1.005(1) through (35) and other applicable standards.

(28) The program shall maintain clinical records for persons who have been committed to their program on an outpatient basis for at least five (5) years following the last clinical contact with the person.

(29) For those persons who have been detained for involuntary outpatient treatment and are enrolled in CPR services, the program shall submit CPR outcome information required by the department on a periodic

basis and shall appropriately identify individuals on outpatient commitment status. The program will maintain the ability to track persons on outpatient commitment separately from other CPR clients.

6CODE OF STATE REGULATIONS

(3/31/98) Rebecca McDowell Cook (30) The department shall have the authority to access program records and client records for purposes of monitoring the performance of any recognized program.

(31) The program shall cooperate fully with any investigations of client abuse, neglect, exploitation or violation of client rights.

(32) The program shall cooperate fully with on-site program reviews by authorized agents of the department related to complaints received about the agency, its staff or operations.

(33) When these standards are more stringent than those in other certification or licensure regulations, these standards shall supersede for persons who are involuntarily committed on an outpatient basis.

(34) Agency quality assurance and quality improvement mechanisms and plans at the program should incorporate specific indicators for monitoring the performance and outcomes for outpatient commitment clients.

(35) The agency shall assure that its staff are appropriately trained for provision of outpatient commitment to its clients ordered for such treatment by the court.

(A) The agency shall send appropriate staff to training required by the department.

(B) The agency shall implement orientation and training to assure that staff have adequate information to effectively perform their staff functions in the provision of outpatient commitment to detained persons including, but not limited to, training regarding methods to work with families and promote their involvement in treatment.

(C) The department may require the agency, at its own expense, to provide additional training to its staff if the agencyís performance is not in substantial compliance with the requirements codified in 9 CSR 80- 1.005(1) through (35).

History

AUTHORITY: sections 630.655, RSMo (1994) and 632.005(13) and 632.330, RSMo (Cum. Supp. 1997). Original rule filed Oct. 10, 1997, effective April 30, 1998. Original authority: 650.655, RSMo (1980); 632.005, RSMo (1980), amended 1985, 1988, 1996; and 632.330, RSMo (1980), amended 1996.