This chapter establishes core operating standards for Missouri Department of Mental Health-certified psychiatric and substance use disorder treatment programs, including Opioid Treatment Programs, CSTAR, Institutional Treatment Centers, Community Psychiatric Rehabilitation Programs, Outpatient Mental Health Treatment Programs, and several other named program types. Operators must implement essential principles covering therapeutic alliance, person- and family-centered care, least restrictive environment, recovery promotion, peer support, and medication services. Programs are required to measure outcomes across emotional, behavioral, social, and family functioning domains and collect data to demonstrate program effectiveness. Certification procedures, personnel, physical environment, fiscal management, and grievance processes are also governed by this chapter.
View official sourceCODE OF STATE REGULATIONS 1 John R. Ashcroft (9/30/24) Secretary of State rules of Department of Mental Health Division 10—Director, Department of Mental Health Chapter 7—Core Rules for Psychiatric and Substance Use Disorder Treatment Programs Title Page 9 CSR 10-7.010 Essential Principles and Outcomes ..................................... 3 9 CSR 10-7.020 Rights, Responsibilities, and Grievances ................................ 7 9 CSR 10-7.030 Service Delivery Process and Documentation ............................ 9 9 CSR 10-7.035 Behavioral Health Healthcare Home ................................... 12 9 CSR 10-7.040 Performance Improvement ............................................ 15 9 CSR 10-7.050 Research ............................................................ 16 9 CSR 10-7.060 Emergency Safety Interventions ....................................... 16 9 CSR 10-7.070 Medications ........................................................ 18 9 CSR 10-7.080 Dietary Service ...................................................... 19 9 CSR 10-7.090 Governing Authority and Program Administration ...................... 20 9 CSR 10-7.100 Fiscal Management .................................................. 21 9 CSR 10-7.110 Personnel .......................................................... 22 9 CSR 10-7.120 Physical Environment and Safety ..................................... 23 9 CSR 10-7.130 Procedures to Obtain Certification .................................... 25 9 CSR 10-7.140 Definitions ......................................................... 29 CODE OF STATE REGULATIONS 3 John R. Ashcroft (9/30/23) Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH MENTAL HEALTH TITLE 9—DEPARTMENT OF MENTAL HEALTH Division 10—Director, Department of Mental Health Chapter 7—Core Rules for Psychiatric and Substance Use Disorder Treatment Programs 9 CSR 10-7.010 Essential Principles and Outcomes PURPOSE: This rule describes the essential principles and outcomes applicable to Opioid Treatment Programs, Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), 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; (C) Is consistent with clinical studies and practice guidelines for achieving positive outcomes; (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; (C) Abstinence from drug and/or alcohol use or decrease in harmful use of substances; (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; 2. Enhancing motivation and self-direction through identification of meaningful goals that establish positive expectations; 3. Working with family members and other natural supports, parents/guardians, courts, and other support systems to promote the individual’s participation in services; 4. Addressing barriers to accessing treatment and other support services; 5. 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; 6. Empowering individuals to assume an active role in developing and achieving productive goals and identification of services; 7. 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 to— 1. Convenient hours of operation consistent with the needs and schedules of individuals served; 2. Geographic accessibility, including transportation arrangements, as needed; 3. Rate of attendance at scheduled services; 4. Individuals consistently reporting that staff listen to and understand them; 5. Treatment retention rate; 6. 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 4 CODE OF STATE REGULATIONS (9/30/23) John R. Ashcroft Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF MENTAL HEALTH 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH 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: 1. Variability in the type and amount of services an individual receives consistent with his/her needs, goals, and progress; 2. Hospital readmission rates; 3. Rate of family/natural support engagement in direct services (such as family therapy) and continuing care; 4. Number of individuals receiving withdrawal management/detoxification services who continue treatment; and 5. 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 to— 1. Utilization rate of inpatient hospitalization, residential support, and out- of-home placement; 2. Length of stay for inpatient hospitalization, residential support, and out-of-home services; 3. Consistent use of admission eligibility criteria; 4. Distribution of individuals served among settings; 5. 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. (C) The four dimensions of recovery shall be incorporated into the organization’s service delivery practices: 1. 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. 2. Home—having a stable and safe place to live; 3. 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 to— 1. Measures of symptom frequency and severity; 2. 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; and K. Managing time, leisure skills, and productivity; 3. 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 CODE OF STATE REGULATIONS 5 John R. Ashcroft (9/30/23) Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH MENTAL HEALTH available from SAMHSA, 5600 Fishers Lane, Rockville, MD 20857, (877) 726-4727. The referenced document does not include any later revisions or updates. (C) Certified peer specialists shall be utilized within the organization’s service array. (D) Performance indicators may include, but are not limited to— 1. Rate of participation in community-based recovery support groups; 2. Involvement with a wide range of individuals in social activities and networks (such as church, clubs, and sporting activities); 3. 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 FDA- approved 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 to— 1. Number of individuals receiving an FDA-approved medication for a diagnosed mental illness and/or substance use disorder, including tobacco use; 2. Variability in the use of FDA-approved medications for mental illness and substance use disorders, including tobacco use; 3. 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; 2. 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 to— 1. Reduction in hospitalization rates; 2. Reduction in incarceration rates; 3. Reduction in readmissions to withdrawal management/ detoxification services; 4. Increased stable housing/independent living arrangements; 5. 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 served. (A) A trauma-informed organization— 1. Realizes the widespread impact of trauma and understands potential paths for recovery; 2. Recognizes the signs and symptoms of trauma in individuals, families/natural supports, staff, and others involved in the continuum of care; 3. 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; 2. 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. 6 CODE OF STATE REGULATIONS (9/30/23) John R. Ashcroft Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF MENTAL HEALTH 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH (E) Performance indicators may include, but are not limited to— 1. Decrease in trauma and mental health symptoms and substance use; 2. Improvement in daily functioning; 3. Improvement in relationships and self-esteem; 4. 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 to— 1. Same-day access to services; 2. Reduced wait time to set a first or subsequent appointment(s); 3. 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, state- of-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; 2. Use person-centered practices, assist individuals to make choices and plan goals, and provide services to help individuals to achieve their goals; 3. Closely monitor an individual’s physical and emotional health, gather information about the individual, and communicate observations to guide services; 4. 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; 5. 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; 6. Work in a professional and ethical manner, maintaining confidentiality and respecting individual and family rights; 7. Provide advocacy and empower and assist individuals to advocate for what they need; 8. Help individuals to achieve and maintain good physical and emotional health essential to their well-being; 9. 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; 10. 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; 11. 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 self- development. (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 to— 1. A qualified and diverse workforce acclimated to the community culture; 2. Delivery of culturally appropriate services and supports; 3. Documented delivery of a broad range of individual and group services including specialized services for co-occurring disorders and trauma; 4. 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 CODE OF STATE REGULATIONS 7 John R. Ashcroft (9/30/23) Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH MENTAL HEALTH achieving those goals. (C) Performance indicators may include, but are not limited to— 1. Individuals served obtain and maintain a job of their choice; 2. Documented delivery of services that assist individuals with job-seeking skills and symptom-management on the job; 3. 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: 1. 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; 2. 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; 3. Utilizing the treatment plan to link multiple services, healthcare providers, and community resources to meet the individual’s needs; 4. Ensuring the flow and timely exchange of information among the individual, family members/natural supports, parents/guardians, caregivers and linked providers; 5. Working collaboratively to resolve differing perspectives, priorities, and schedules among providers; 6. 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; 7. 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, web- based 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 to— 1. Reduction in emergency room visits; 2. Reduction in hospitalizations; 3. Reduction in costs and duplication of services; 4. Documented delivery of services related to recovery planning, health and wellness; 5. Satisfaction with services as conveyed by individuals, family members/natural supports. AUTHORITY: sections 630.050 and 630.055, RSMo 2016.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed Nov. 5, 2018, effective June 30, 2019. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.055, RSMo 1980. 9 CSR 10-7.020 Rights, Responsibilities, and Grievances PURPOSE: This rule describes individual rights, the orientation process, and grievance procedures applicable to Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), Gambling Disorder Treatment Programs, Institutional Treatment Centers, Opioid Treatment Programs, Recovery Support Programs, Substance Awareness Traffic Offender Programs (SATOP), Required Education Assessment and Community Treatment 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; 2. Available services and supports, including crisis assistance; 3. Complaint and appeal procedures; 4. Ways in which input can be given; 5. The organization’s confidentiality policies; 6. Continuing recovery planning; 7. Discharge criteria and procedures; 8. Access to after-hour services; 9. Reporting requirements for individuals mandated to 8 CODE OF STATE REGULATIONS (9/30/23) John R. Ashcroft Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF MENTAL HEALTH 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH participate in services; 10. Financial obligations, fees, and financial arrangements for services provided by the organization; 11. 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; 12. Layout of the premises including emergency exits and/ or shelters; 13. Education regarding advance directives when indicated; 14. 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; and 15. 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: 1. To receive prompt evaluation, care and treatment; 2. To receive services in the least restrictive environment; 3. To receive services in a clean and safe setting; 4. To receive services without discrimination based on race, ethnicity, gender, gender identity, gender expression, sexual orientation, creed, marital status, national origin, disability, or age; 5. To confidentiality of information and records in accordance with federal and state law and regulation; 6. To be treated with dignity and be addressed in a respectful, age appropriate manner; 7. To be free from verbal, sexual, and physical abuse, neglect, corporal punishment, and other mistreatment such as humiliation, threats, or exploitation; 8. 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; 9. 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: 1. To a nourishing, well-balanced, varied diet; 2. To attend or not attend religious services; 3. To communicate by sealed mail or otherwise with the department and, if applicable, legal counsel and court of jurisdiction; 4. 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; 2. Authorized by the organization’s director or designee; 3. Documented in the individual’s record; 4. Justified by sufficient documentation; 5. 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: 1. To wear one’s own clothes and keep and use one’s own personal possessions; 2. To keep and be allowed to spend a reasonable amount of one’s own funds; 3. To have reasonable access to a telephone to make and to receive confidential calls; 4. To have reasonable access to current newspapers, magazines, and radio and television programming; 5. To be free from seclusion and restraint; 6. To have opportunities for physical exercise and outdoor recreation; 7. To receive visitors of one’s choosing at reasonable hours; and 8. 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 CODE OF STATE REGULATIONS 9 John R. Ashcroft (9/30/24) Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH MENTAL HEALTH 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: 1. Documentary evidence recognized by the Missouri Department of Revenue when processing an application for a driver’s license; 2. A Missouri driver’s license; 3. 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. AUTHORITY: sections 630.050 and 630.055, RSMo 2016.* Original 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. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.055, RSMo 1980. 9 CSR 10-7.030 Service Delivery Process and Documentation PURPOSE: This rule describes requirements for the delivery and documentation of services in Opioid Treatment Programs, Substance Use Disorder Treatment Programs, Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), Gambling Disorder Treatment Programs, Community Psychiatric Rehabilitation Programs (CPR), and Outpatient Mental Health Treatment Programs. (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: 1. 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; 2. 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 limited to— 1. A brief interview with the individual or referral source to obtain basic information and presenting situation and symptoms; 2. Collection of basic demographic information; 3. Identification of requested service needs; 4. 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; 2. Presenting problem and referral source; 3. Status as a current or former member of the U.S. Armed Forces; 4. Brief history of previous substance use and/or psychiatric treatment, including the type of admission(s); 5. Family history of substance use disorders and/or mental illness; 6. 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; 7. Current medications and any known allergies or allergic reactions; 8. Current substance use, including utilization of a standardized and validated alcohol and substance-use 10 CODE OF STATE REGULATIONS (9/30/24) John R. Ashcroft Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF MENTAL HEALTH 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH screening instrument; 9. Current mental health symptoms, including utilization of standardized and validated depression and suicide screening instruments; 10. 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; 11. Diagnosis and clinical summary by a licensed mental health professional, including substance use and mental health; 12. Family, social, legal, and vocational/educational status and functioning; 13. Statement of needs, goals, preferences, and treatment expectations; 14. 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 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. (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; 2. 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, strengths- and 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; 3. Duration and frequency of interventions, staff responsible for intervention, and action steps of the individual and parents/guardians, family, or other natural supports; 4. 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; 2. Severity of the behavioral health disorder; 3. Emotional and behavioral functioning and need for structure; 4. Social, family, and community functioning; 5. Readiness to change; 6. Availability of peer and social supports for recovery/ resiliency; 7. 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. CODE OF STATE REGULATIONS 11 John R. Ashcroft (9/30/24) Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH MENTAL HEALTH (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 individuals served. (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. 1. 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. 2. 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. 3. 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 limited to— 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; and 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 limited to— 1. Date of admission and discharge; 2. Identified needs at admission; 3. Referral source, as applicable; 4. Services provided and the extent to which established goals and objectives were achieved; 5. Reason(s) for or type of discharge; 6. Diagnosis or diagnostic impression at last contact; 7. Recommendations for continued services and supports; 8. 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; 2. 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; (C) Reduce symptoms or needs and build resilience; (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; 12 CODE OF STATE REGULATIONS (9/30/24) John R. Ashcroft Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF MENTAL HEALTH 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH 2. Electronic health record systems conform to federal and state regulations; 3. Individual records are retained for at least six (6) years or until all litigation, adverse audit findings, or both, are resolved; 4. Ready access to paper or electronic records requested by authorized staff and/or other authorized parties, including department staff; 5. Any errors are marked through with a single line, initialed, and dated by the staff person making the correction; and 6. 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: 1. 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); 2. Accurate, complete, and legible description of each service provided; 3. Name, title, credential(s), and dated signature of the provider/staff delivering the service (not a signature stamp or typed signature); 4. Name of referring entity, when applicable; 5. Date of service (month/day/year); 6. Actual begin and end time taken to deliver a service; 7. Setting in which the service was provided; 8. Plan of treatment, evaluation(s), test(s), findings, results, and prescription(s), as necessary; 9. Need for the service(s) in relationship to the individual treatment plan; 10. 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; 2. Documented acknowledgment of orientation to the program; 3. Screening, admission assessment, treatment plan, and related reviews/updates; 4. Service delivery and progress notes; 5. Transfer, transition, and discharge plan(s), as applicable. 6. Documentation of any referral(s) to other services or community resources and outcome of those referrals; 7. Signed authorization(s) to release confidential information, as applicable; 8. Missed appointments and efforts to reengage the individual, as applicable; 9. Urine drug screening(s) or other lab reports, as applicable; 10. Crisis or other significant clinical events; 11. Follow -up for an unplanned discharge, as applicable; and 12. 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; (C) The service meets the service definition; (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 pro - gram-specific regulations, which take precedence over Core Rules if there is a conflict. AUTHORITY: sections 630.050 and 630.055, RSMo 2016.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed 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, RSMo 1980. **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 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: 1. Have a substantial percentage of individuals served enrolled in Medicaid. Percentage requirements will be determined by the department; 2. 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 CODE OF STATE REGULATIONS 13 John R. Ashcroft (9/30/24) Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH MENTAL HEALTH phone calls as required by the department; 3. 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; 4. 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; 5. Conduct wellness interventions as indicated based on the individual’s level of risk; 6. Complete status reports to document the individual’s housing, legal, employment, education, and custody status; 7. Agree to convene regular, ongoing, and documented internal Healthcare Home team meetings to plan and implement goals and objectives of ongoing practice transformation; 8. Agree to participate in department-approved evaluation activities; 9. Agree to develop required reports describing Healthcare Home activities, efforts, and progress in implementing Healthcare Home services; 10. 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; and 11. 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; 2. Develop quality improvement plans to address gaps and opportunities for improvement identified during and after the application process; 3. Demonstrate continuing development of fundamental Healthcare Home functionality through an assessment process to be determined by the department; 4. Demonstrate significant improvement on clinical indicators specified by and reported to the department; 5. 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: 1. 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; 2. 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; 3. 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 to— 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; 4. 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; 5. 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 14 CODE OF STATE REGULATIONS (9/30/24) John R. Ashcroft Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF MENTAL HEALTH 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH 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. 1. 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 follow- up 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; 2. Risk stratification; 3. 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: 1. 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. CODE OF STATE REGULATIONS 15 John R. Ashcroft (9/30/24) Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH MENTAL HEALTH (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: 1. 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: 1. Enrollment is based on the choice of individuals served; and 2. 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. 1. 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. 2. 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. 3. The department reserves the right to make changes to the payment methodology. (B) Types of Payments. 1. 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. 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: Filed June 13, 2023, effective Jan. 30, 2024. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008. 9 CSR 10-7.040 Performance Improvement PURPOSE: This rule describes requirements for performance improvement activities in Opioid Treatment Programs, Substance Use Disorder Treatment Programs, Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), Gambling Disorder Treatment Programs, Institutional Treatment Programs, Recovery Support Programs, Substance Awareness Traffic Offender Programs (SATOP), Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric Rehabilitation Programs (CPRP), and Outpatient Mental Health Treatment Programs. (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 individuals served. (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: 1. A description of its purpose, priorities, policies, and goals; 2. A description of the measurement analysis and how it will help define future performance improvement activities; 3. A description of evaluation and quality assurance activities that will be utilized to determine the effectiveness of the performance improvement plan; 4. 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: 1. A process for obtaining satisfaction and other feedback related to service delivery from individuals served, family members/natural supports, and other stakeholders; 2. A process to measure outcomes for individuals served; 3. A review of clinical records to ensure all required documentation is thorough, timely and complete; 4. A process to evaluate whether services are effective, appropriate, and relate to treatment goals; 5. Activities to improve access and retention in services; 6. Review of clinical staff training and competencies; 7. Review of critical/sentinal events, grievances, and complaints; and 8. A process for monitoring compliance of subcontractors. 16 CODE OF STATE REGULATIONS (9/30/24) John R. Ashcroft Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF MENTAL HEALTH 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH (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; 2. Establish baseline measures before improvements are made; 3. Make decisions based on solid evidence; 4. Allow performance comparisons across sites; 5. Monitor process changes to ensure improvements are sustained over time; 6. Recognize improved performance; 7. Determine the effectiveness of evidence-based and/or best practices provided; 8. 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: 1. Management reports; 2. Strategic plans; 3. Budgets; 4. Accessibility plans; 5. Technology plans and analysis; 6. Risk analysis reports and information; 7. Environmental health and safety reports; 8. Financial reports; 9. Quality assurance reports including review of clinical records to ensure documentation requirements are being met; 10. Data collected; 11. Demographic information of individuals served; and 12. Satisfaction data of individuals, family members/ natural supports, and other stakeholders. AUTHORITY: sections 630.050 and 630.055, RSMo 2016.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed Nov. 5, 2018, effective June 30, 2019. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.055, RSMo 1980. 9 CSR 10-7.050 Research PURPOSE: This rule establishes standards and procedures for conducting research in 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 Offender Programs (SATOP), Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric Rehabilitation Programs (CPRP), and Outpatient Mental Health Treatment Programs. (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. AUTHORITY: sections 630.050 and 630.055, RSMo 2016.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed Nov. 5, 2018, effective June 30, 2019. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.055, RSMo 1980. 9 CSR 10-7.060 Emergency Safety Interventions 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 CODE OF STATE REGULATIONS 17 John R. Ashcroft (9/30/24) Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH MENTAL HEALTH 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. (C) All policies and procedures must be— 1. Approved by the organization’s board of directors; 2. Available to all program staff and service providers; 3. Available to individuals served and parents/guardians, family members, and other natural supports, as appropriate; 4. 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; 2. Withholding of food, water, or bathroom privileges; 3. Painful stimuli; 4. Corporal punishment (such as use of pepper spray, mace, Taser, stun gun); 5. Techniques that obstruct the individual’s airways or impairs breathing; 6. Techniques that restrict the individual’s ability to communicate; 7. 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 time- limited 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. (C) Standing or Pro re nata (PRN) orders for seclusion or restraint are not allowed. (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: 1. Techniques to identify individual behaviors, events, and environmental factors that may trigger circumstances requiring the use of seclusion or restraint; 2. The use of nonphysical intervention skills; 3. Use of the least restrictive intervention based on an individualized assessment of the individual’s medical and/or behavioral status or condition; 4. 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; 5. Clinical identification of specific behavioral changes that indicate restraint or seclusion is no longer necessary; 6. 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-to- face 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: 1. Attention to vital signs; 2. Need for meals and liquids; 3. 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 18 CODE OF STATE REGULATIONS (9/30/24) John R. Ashcroft Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF MENTAL HEALTH 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH 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: 1. Reason for the intervention; 2. Staff who ordered the intervention; 3. Type of intervention used; 4. Starting and ending time; 5. Regular observations of the individual, including any resulting injuries or other issues as a result of the intervention; 6. Notification of parent/guardian, as applicable; 7. 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; 2. 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. AUTHORITY: sections 630.050 and 630.055, RSMo 2016.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed April 15, 2002, effective Nov. 30, 2002. Amended: Filed Aug. 12, 2019, effective Feb. 29, 2020. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.055, RSMo 1980. 9 CSR 10-7.070 Medications 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 Offender Programs (SATOP), Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric 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. 1. 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. 2. 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. 1. 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. 2. Staff whose duties are limited to observing clients CODE OF STATE REGULATIONS 19 John R. Ashcroft (9/30/24) Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH MENTAL HEALTH 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. 3. 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. 1. 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. 2. The amount of medication originally present and the amount remaining can be validated by the medication intake sheet. 3. Documentation of medication intake shall include over- the-counter products. 4. Medication shall be administered in single doses to the extent possible. 5. 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. 1. 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. 2. 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. 1. The organization shall establish a locked storage area for all medications that provides suitable conditions regarding sanitation, ventilation, lighting and moisture. 2. The organization shall store ingestible medications separately from noningestible medications and other substances. 3. 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: 1. Receipt and disposition of stock pharmaceuticals must be accurately documented; 2. A log shall be maintained for each stock pharmaceutical that documents receipts and disposition; 3. 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. 1. Medication must be removed on or before the expiration date and destroyed. 2. Any medication left by an individual at discharge shall be destroyed within thirty (30) days. 3. The disposal of all medications shall be witnessed and documented by two (2) staff members. AUTHORITY: sections 630.050 and 630.055, RSMo 2000.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed 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 PURPOSE: This rule establishes dietary and food service requirements in 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 Offender Programs (SATOP), Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric Rehabilitation Programs (CPRP), and Outpatient Mental Health Treatment Programs. (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 individuals served. 20 CODE OF STATE REGULATIONS (9/30/24) John R. Ashcroft Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF MENTAL HEALTH 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH (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; 2. All appliances for food storage and preparation are clean and in safe and good operating condition; 3. Hand washing facilities including hot and cold water, soap, and hand drying means are readily accessible to individuals and staff; 4. Fresh water is available to individuals at all times; 5. 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; 6. Meals and snacks are served in a clean dining area with appropriate eating utensils for each individual as applicable; 7. 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. 8. Meals and snacks are provided at scheduled times comparable to mealtimes in the community; 9. 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; 10. 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. AUTHORITY: sections 630.050 and 630.055, RSMo 2016.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed Nov. 5, 2018, effective June 30, 2019. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.055, RSMo 1980. 9 CSR 10-7.090 Governing Authority and Program Administration PURPOSE: This rule describes requirements for and responsibilities of the governing body in 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 Offender Programs (SATOP), Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric Rehabilitation Programs (CPRP), and Outpatient Mental Health Treatment Programs. (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; 2. The number and types of membership; 3. The method of selecting members; 4. The number of members necessary for a quorum; 5. Attendance requirements for governing body membership; 6. 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; (C) Approving policies to guide administrative operations and service delivery; (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; (C) Rights, responsibilities, and grievance procedures in CODE OF STATE REGULATIONS 21 John R. Ashcroft (9/30/24) Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH MENTAL HEALTH accordance with 9 CSR 10-7.020; (D) Service delivery process, documentation, and individual records in accordance with 9 CSR 10-7.030; (E) Service array including, but not limited to: 1. Description of all services available, including crisis assistance; 2. Outreach and education strategy for all services; 3. Location of service sites, hours, and days of operation for each site; 4. Accessibility, including provisions for individual choice of services and location; 5. 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. 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. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.055, RSMo 1980. 9 CSR 10-7.100 Fiscal Management 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 Offender Programs (SATOP), Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric Rehabilitation Programs (CPRP), and Outpatient Mental Health Treatment Programs. (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. (C) There are adequate internal controls for safeguarding or avoiding misuse of assets. (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. 22 CODE OF STATE REGULATIONS (9/30/24) John R. Ashcroft Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF MENTAL HEALTH 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH (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. AUTHORITY: sections 630.050 and 630.055, RSMo 2016.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed Nov. 5, 2018, effective June 30, 2019. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.055, RSMo 1980. 9 CSR 10-7.110 Personnel 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 Offender Programs (SATOP), Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric Rehabilitation Programs (CPRP), and Outpatient Mental Health Treatment Programs. (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. 1. 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: 1. Know the organization’s population served, scope of program, mission, vision, and policies and procedures; 2. Understand and perform respective job assignments; 3. Abide by applicable regulations for rights, ethics, confidentiality, corporate compliance, and abuse and neglect; 4. 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. (C) A background screening shall be conducted for all staff in accordance with 9 CSR 10-5.190. (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. 1. All staff who provide services or are responsible for the supervision of persons served shall participate in at least thirty- six (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. 2. Training shall assist staff in meeting the needs of persons served, including persons with co-occurring and trauma-related disorders. 3. The organization shall maintain a record of participation in training and staff development activities. (G) When services and supervision are provided twenty- four (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 CODE OF STATE REGULATIONS 23 John R. Ashcroft (9/30/24) Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH MENTAL HEALTH 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: 1. Client rights, confidentiality policies and procedures, and abuse, neglect, and misuse of funds as defined in 9 CSR 10-5.200; 2. Emergency policies and procedures of the program; 3. 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: 1. Name of the student, educational institution, and degree program; 2. 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; 3. A job description of the specific role of the student with respect to the program and population served; 4. 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. 1. 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. 2. 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 department. 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. 1. 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. 2. 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. AUTHORITY: sections 630.050 and 630.055, RSMo 2016.* Original 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. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.055, RSMo 1980. 9 CSR 10-7.120 Physical Environment and Safety PURPOSE: This rule describes requirements for the physical environment and safety in 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 Offender Programs (SATOP), Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric Rehabilitation Programs (CPRP), and Outpatient Mental Health Treatment Programs. (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. 24 CODE OF STATE REGULATIONS (9/30/24) John R. Ashcroft Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF MENTAL HEALTH 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH (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; 2. Private areas for confidential individual and group services; 3. An area(s) for indoor social and recreational activities; and 4. Restrooms in adequate number to meet the needs of individuals served. (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; (C) Provide screens on outside doors and windows if they are to be kept open; (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; 2. Complete evacuation from each physical facility with a designated gathering point; 3. When sheltering in place is appropriate and any additional steps necessary to ensure safety (such as sealing a room); 4. The safety and accounting for all persons involved, including responsible staff; 5. Temporary shelter when applicable; 6. Identification of essential services; 7. 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. (C) Fire extinguishers shall be clearly visible and maintained with a charge. (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. 1. 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. 2. The means of exit shall be free of any item that would obstruct the exit route. 3. 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. 4. 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. 5. 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: 1. Do not offer overnight sleeping accommodations; 2. 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 CODE OF STATE REGULATIONS 25 John R. Ashcroft (9/30/24) Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH MENTAL HEALTH the recommendations of the NFPA codes and be functional at all times. 1. 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; and 2. 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. (C) All vehicles used to transport individuals served shall be properly registered and insured. (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. AUTHORITY: sections 630.050 and 630.055, RSMo 2016.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed Nov. 5, 2018, effective June 30, 2019. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.055, RSMo 1980. 9 CSR 10-7.130 Procedures to Obtain Certification 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: 1. Meets the eligibility requirements for receipt of federal mental health block grant funds for the provision of clinical treatment services; 2. 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: 1. Has maintained compliance with department outpatient mental health certification requirements as specified in 9 CSR 30-4.190 for one (1) certification cycle; 2. Complies with 9 CSR 10-5, 9 CSR 10-7, and 9 CSR 30-4, as applicable; 3. Has the capacity to provide in-person, face-to-face services from a physical location in the state of Missouri; 4. 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; 5. 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 trauma- related 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 department- approved training on suicide prevention; and F. Clinical staff who have completed department- approved training on smoking cessation. (4) The department shall certify, as a result of a certification 26 CODE OF STATE REGULATIONS (9/30/24) John R. Ashcroft Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF MENTAL HEALTH 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH 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; (C) Provide a comprehensive array of psychiatric services to children and youth including, but not limited to: 1. Crisis intervention mobile response; 2. Screening and assessment; 3. 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. (C) Department staff review each application to determine whether the applicant meets the criteria for certification. (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: 1. 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; 2. 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 department. (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. 1. 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 department. 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; 2. 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; 3. 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; 4. 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 CODE OF STATE REGULATIONS 27 John R. Ashcroft (9/30/24) Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH MENTAL HEALTH conduct a survey to determine compliance with applicable sections of department certification standards. 1. 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. 2. The surveyor(s) will hold an entrance and exit conference with staff of the organization to discuss survey arrangements and survey findings, respectively. 3. 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. 4. 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 department. 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. 2. 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. 1. 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: 1. Governing authority; 2. Policies and procedures; 3. 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. 1. Conditional certification may be granted for a six (6) month time period. 2. The department may monitor progress, require the organization to submit progress reports, or both. 3. The organization will be expected to correct all areas of noncompliance prior to the expiration of the conditional certification status. 4. 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. 28 CODE OF STATE REGULATIONS (9/30/24) John R. Ashcroft Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF MENTAL HEALTH 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH 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 department. (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; 2. Is discontinued and ceases business operations; 3. Leases some or all operations at its certified address(es) to another entity; 4. Moves to a different location; 5. Appoints a new director; or 6. Changes programs or services offered. (C) Failure to notify the department as required may result in administrative sanctions or revocation of certification. (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. 1. 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. 2. Certification under previous ownership becomes null and void if the new owner(s) fail to submit an application for certification from the department. 3. 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 served. (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 CODE OF STATE REGULATIONS 29 John R. Ashcroft (9/30/24) Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH MENTAL HEALTH 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 twenty- four (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 served. (A) A request for a waiver must be submitted in accordance with 9 CSR 10-5.210, Exceptions Committee Procedures. AUTHORITY: sections 630.050 and 630.055, RSMo 2016.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed 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, RSMo 1980. 9 CSR 10-7.140 Definitions 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; (C) Adolescent, a person between the ages of twelve through seventeen (12–17) years inclusive; (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, 30 CODE OF STATE REGULATIONS (9/30/24) John R. Ashcroft Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF MENTAL HEALTH 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH 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: 1. 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; 2. 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; 3. A psychologist licensed under Missouri law to practice psychology with specialized training in mental health services; 4. A professional counselor licensed under Missouri law to practice counseling and with specialized training in mental health services; 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 services; 6. 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; 7. 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; 8. 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; 9. 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: 1. 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 CODE OF STATE REGULATIONS 31 John R. Ashcroft (9/30/24) Secretary of State DIVISION 10—DIRECTOR, DEPARTMENT OF 9 CSR 10-7—DEPARTMENT OF MENTAL HEALTH MENTAL HEALTH 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; and (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. 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. Amended: Filed March 3, 2016, effective Oct. 30, 2016. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.055, RSMo 1980.