This Missouri regulation establishes standards and procedures for 'recognition' (a form of program authorization) of civil outpatient detention and treatment programs under the Division of Comprehensive Psychiatric Services. Programs must be certified community-based mental health providers offering targeted case management, Community Psychiatric Rehabilitation, and outpatient services, and must maintain a 24-hour crisis response capability. The rule governs the application, approval, denial, suspension, and revocation of recognition status, as well as admission, screening, and discharge requirements for persons involuntarily detained for outpatient mental health treatment by a court.
View official sourceCODE OF STATE REGULATIONS 1Rebecca McDowell Cook (3/31/98) Secretary of State Rules of Department of Mental Health Division 80Division of Comprehensive Psychiatric Services Chapter 1Standards and Procedures for Program Recognition, Client Admissions and Performance Title Page 9 CSR 80-1.005 Civil Outpatient Detention and Treatment Programs .....................................3 Title 9DEP ARTMENT OF MENTAL HEALTH Division 80Division of Comprehensive Psychiatric Services Chapter 1Standards and Procedures for Program Recognition, Client Admissions and Performance 9 CSR 80-1.005 Civil Outpatient Detention and Treatment Programs PURPOSE: This rule defines terms and establishes standards and procedures for pro- gram recognition, client admissions and dis- charges, and performance of civil outpatient detention and treatment programs. (1) The terms defined in sections 630.005 and 632.005, RSMo are incorporated by ref- erence for use in 9 CSR 80-1.005(1) through (35). (2) As used in 9 CSR 80-1.005(1) through (35), unless the context clearly indicates oth- erwise, the following terms shall mean: (A) Care provider, the person or persons who can demonstrate that they are primarily responsible for the health care of the person with a mental illness. The term does not apply to any person providing care through the hospitals, nursing homes, group homes or any other such facility; (B) Discharge, formal dismissal of a client from the recognized mental health program; (C) Likelihood of serious harm, any one (1) or more of the following but does not require actual physical injury to have occurred: 1. A substantial risk that serious physi- cal harm will be inflicted by a person upon his/her own person, as evidenced by recent threats, including verbal threats, or attempts to commit suicide or inflict physical harm on him/herself. Evidence of substantial risk may also include information about patterns of behavior that historically have resulted in serious harm previously being inflicted by a person upon him/herself; 2. A substantial risk that serious physi- cal harm to a person will result or is occur- ring because of an impairment in his/her capacity to make decisions with respect to his/her hospitalization and need for treatment as evidenced by his/her current mental disor- der or mental illness which results in an inability to provide for his/her own basic necessities of food, clothing, shelter, safety or medical care or his/her inability to provide for his/her own mental health care which may result in a substantial risk of serious physical harm. Evidence of that substantial risk may also include information about patterns of behavior that historically have resulted in serious harm to the person previously taking place because of a mental disorder or mental illness which resulted in his/her inability to provide for his/her basic necessities of food, clothing, shelter, safety or medical or mental health care; or 3. A substantial risk that serious physi- cal harm will be inflicted by a person upon another as evidenced by recent overt acts, behavior or threats, including verbal threats, which have caused such harm or which would place a reasonable person in reasonable fear of sustaining such harm. Evidence of that substantial risk may also include information about patterns of behavior that historically have resulted in physical harm previously being inflicted by a person upon another per- son; (D) Mental illness, a state of impaired mental processes, which impairment results in a distortion of a persons capacity to rec- ognize reality due to hallucinations, delu- sions, faulty perceptions or alterations of mood, and interferes with an individuals ability to reason, understand or exercise con- scious control over his/her actions. The term mental illness does not include the following conditions unless they are accompanied by a mental illness as otherwise defined in Chap- ter 630, RSMo: 1. Mental retardation, developmental disability or narcolepsy; 2. Simple intoxication caused by sub- stances such as alcohol or drugs; 3. Dependence upon or addiction to any substances such as alcohol or drugs; or 4. Any other disorders such as senility, which are not of an actively psychotic nature; (E) Ninety-six (96) hours, shall be con- strued and computed to exclude Saturdays, Sundays and legal holidays which are observed either by the court or by the mental health facility where the respondent is detained; (F) Outpatient commitment, legal status of a person who has been involuntarily detained for outpatient mental health treatment by the court pursuant to Chapter 632, RSMo; (G) Recognized, a mental health program is considered to be recognized when it has received written notification from the Depart- ment of Mental Health that it has met the cri- teria established in 9 CSR 80-1.005(3) and (4) and is authorized to accept persons for admission who have been involuntarily detained for outpatient mental health treat- ment by the court pursuant to Chapter 632, RSMo; and (H) Release, termination of a detention order as a result of reaching the specified end date or resulting from change in client men- tal status, behavior, or admission status. (3) To be eligible to be recognized by the department as a treatment program for per- sons who are detained for outpatient mental health treatment by the court pursuant to Chapter 632, RSMo, a mental health pro- gram must (A) Be a comprehensive community-based mental health program that is designated to provide targeted case management (TCM) and holds current and valid certification with- out limitations by the Department of Mental Health as a Community Psychiatric Rehabili- tation (CPR) program and as an outpatient program; (B) Operate or arrange for availability of a twenty-four (24)-hour crisis response system for psychiatric clients; and (C) Have a current purchase of service contract with the Division of Comprehensive Psychiatric Services. (4) CPR or outpatient program providers with provisional or probationary certification sta- tus shall not be recognized by the department and are not eligible to admit persons who are detained for outpatient mental health treat- ment by the court pursuant to Chapter 632, RSMo. (5) Only recognized programs can admit per- sons who have a mental illness and are detained for outpatient mental health treat- ment by the court pursuant to Chapter 632, RSMo. (6) Eligible programs shall make a written application for recognition to the Division of Comprehensive Psychiatric Services. (A) The written application shall specify the name of the agency, the name of the exec- utive director of the agency, the name of the CPR program it operates and the program director name(s), the geographic area served, the judicial districts included in the service area, the average number of clients enrolled in outpatient and CPR at any given time, the client capacity for each of its programs, copies of required certificates for CPR and outpatient programs, the name of the contact person for department or court communica- tions, an affidavit attesting to compliance with 9 CSR 80-1.005(1) through (35) and any other information deemed necessary by the department. (B) For programs requesting renewal of their recognition status, the written request shall be submitted to the department at least sixty (60) days prior to expiration of recogni- tion. CODE OF STATE REGULATIONS 3Rebecca McDowell Cook (3/31/98) Secretary of State Chapter 1—Standards and and Procedures for Program Recognition, Client Admissions and Performance 9 CSR 80-1 (C) The department reserves the right to request additional information prior to recog- nizing the program or at any time while the program is recognized by the department. (D) The department reserves the right to conduct unannounced, on-site review activi- ties of applicants or recognized programs. (7) Upon receipt of the written request for recognition, the department shall review the request and issue its written decision regard- ing the request within thirty (30) working days. (A) The department may recognize a pro- gram for a time period not to exceed one (1) year. The written notice to the applicant/pro- gram shall specify the expiration date of the recognition. (B) The department may deny recognition to a program if 1. The program does not meet the crite- ria established in sections (3) and (4) above; 2. The application includes information that is false; 3. The program is found to have com- mitted fraud or illegal activities or had reason to know its staff were engaged in fraud or illegal activities; 4. The program employs any individual to provide services for which the individual is not licensed as required by law; 5. The program employs any individual who is statutorily excluded from service as a result of convictions under sections 630.170 and 660.317, RSMo, specifically A. A person who has been convicted of, found guilty to, pled guilty to or nolo con- tendere to any of the following crimes shall be disqualified from holding any position in the agency: (I) Physical abuse or Class I Neglect of a patient, resident or client; (II) Furnishing unfit food to patients, residents or clients; and (III) Failure of a specified profes- sional to report suspected abuse or neglect of a patient; B. A person who has been convicted of, found guilty to, pled guilty to or nolo con- tendere to any of the following felonies shall be disqualified from holding any direct-care position in the agency: (I) First or second degree murder; second degree murder; (II) V oluntary manslaughter (includes assistance in self-murder); (III) Involuntary manslaughter; (IV) First or second degree assault; (V) Assault while on school prop- erty; (VI) Unlawful endangerment of another; (VII) First or second degree assault of a law enforcement officer; (VIII) Tampering with a judicial officer; (IX) Kidnapping; (X) Felonious restraint; (XI) False imprisonment; (XII) Interference with custody; (XIII) Parental kidnapping; (XIV) Child abduction; (XV) Elder abuse in the first degree or the second degree; (XVI) Harassment; (XVII) Stalking; (XVIII) Forcible rape; (XIX) First or second degree statu- tory rape; (XX) Sexual assault; (XXI) Forcible sodomy; (XXII) First or second degree statutory sodomy; (XXIII) First or second degree child molestation; (XXIV) Deviate sexual assault; (XXV) First degree sexual miscon- duct; (XXVI) Sexual abuse; (XXVII) Endangering the welfare of a child; (XXVIII) Abuse of a child; (XXIX) Robbery in the first degree or second degree; (XXX) Arson in the first or second degree; (XXXI) First or second degree pharmacy robbery; (XXXII) Incest; (XXXIII) Causing catastrophe; (XXXIV) First degree burglary; or (XXXV) Any equivalent felony offense; or 6. The program interferes with or refus- es access by authorized agents of the Depart- ment of Mental Health to the programs sites of operation, to client or other records required in this rule, or to staff. (C) The department shall include the rea- son for denial of recognition in its written notification to the agency. (8) The department may suspend or revoke recognition of a program at any time that (A) The program does not meet the crite- ria established in sections (3) and (4) above; (B) The program is not in substantial com- pliance with the requirements codified in 9 CSR 80-1.005(1) through (35); (C) The application includes information that is false; (D) The program is found to have commit- ted fraud or illegal activities or had reason to know its staff were engaged in fraud or ille- gal activities; (E) The program employs any individual to provide services for which the individual is not licensed as required by law or is disqual- ified from employment as specified in para- graph (7)(B)5. above; or (F) The program interferes with or refuses access by authorized agents of the Depart- ment of Mental Health to the programs sites of operation, to client or other records required in this rule, or to staff. (9) When recognition has been denied, sus- pended, or revoked, a program may appeal to the director of the department within thirty (30) days of receiving notice of the denial or revocation. The director of the department shall conduct a hearing under procedures set out in Chapter 536, RSMo and shall issue findings of fact, conclusions of law and a decision that shall be the final decision of the department. (10) A recognized program shall be responsi- ble for notifying the department of material changes in status that occur during their recognition period such as, but not limited to, change in location, change in ownership, change in corporate status, legal proceedings initiated against the agency, change in regula- tory status, accreditation or certification sta- tus, or other substantive changes in the pro- grams status or ability to perform its duties related to outpatient detention and treatment. (11) The department shall maintain a listing of programs recognized to admit and serve persons who have been detained for outpa- tient mental health treatment. (12) At a minimum the program shall have the capability to conduct clinical screenings on a twenty-four (24)-hour-per-day basis, seven (7) days per week to allow for next day admissions for persons detained by the court for outpatient mental health treatment. (A) The method to contact the program to arrange for admissions shall be specified in written form to the access/crisis intervention system (ACI) hotline and all mental health coordinators in the programs service area. (B) An individual who has been detained by the court for outpatient treatment shall not be placed on a waiting list for admission or services. (13) For each person admitted for outpatient mental health treatment by the court pursuant to Chapter 632, RSMo, the program must have made a determination that the program 4 CODE OF STATE REGULATIONS (3/31/98) Rebecca McDowell Cook Secretary of State 9 CSR 80-1—MENTAL HEALTH Division 80—Division of Comprehensive Psychiatric Services can and will provide necessary and appropri- ate care, treatment and services to the indi- vidual in the least restrictive environment that will reasonably assure the individuals safety and the safety of the public. (A) The program shall promptly provide this information for inclusion in the petition to the court. (B) If a clinical screening is required to make a determination of appropriateness for admission, the screening shall be conducted within twenty-four (24) hours of the request. (C) Screening and evaluation activities shall be adequate to address a broad range of clinical, social, and environmental factors that have relevance to the decision to accept or deny admission including, but not limited to: 1. Determination that the person has a mental illness; 2. Interventions and adaptations neces- sary to reasonably assure client and public safety including the frequency and nature of monitoring efforts designed for the individu- al; 3. Amount and nature of available sup- port of family, friends and other social sup- ports; 4. History of response to treatment and willingness to comply with medication and other necessary treatments; 5. Persons motivation and available resources for living in the community; 6. Assessment of the persons need for guardianship and the programs obligation to petition for guardianship, if needed; and 7. Adequacy of the recommended ser- vices to provide needed support to the person to live safely in the community. (D) When a program has made a determi- nation to accept a person for admission, the program shall also specify, in writing, specif- ic conditions of participation individualized to address the persons situation. These con- ditions of commitment shall be included in the petition to the court and the program shall review the conditions with the person to be admitted as well as care providers and other caregivers, as appropriate and consistent with statutes and regulations governing client con- fidentiality. (14) A person shall not be considered eligible for admission to a recognized agency for involuntary outpatient detention and mental health treatment if the person (A) Has been committed to the Department of Mental Health for treatment pursuant to Chapter 552, RSMo and such commitment remains in force; (B) Is under the age of eighteen (18) and has a parent or legal guardian responsible for making treatment decisions; or (C) Has been determined to be incapacitat- ed and a guardian has been appointed by the probate court pursuant to Chapter 475, RSMo. (15) When a person is determined to be eli- gible for admission to the program for outpa- tient mental health treatment, the program shall specify in writing the range of care, treatment and services that shall be provided to the person, the source of funding for the specified interventions, the individualized conditions of commitment for the person, and the name of the inpatient mental health facil- ity that has agreed to accept the person for admission and treatment at the direction of the program. This information shall be promptly furnished to the court in written form. (16) Within seven (7) days of admission or sooner if clinically indicated, a treatment plan shall be completed that encompasses the requirements set forth in section (15) above. (A) Services shall be designed to educate and assist the individual to comply with treat- ment that results in return to voluntary status as soon as possible. (B) To the extent possible and consistent with client confidentiality, the treatment plan- ning process should include family members, care providers, caregivers and other members of the clients support system. (C) In addition to meeting the requirements of the appropriate CPR certification stan- dards, the treatment plan for each person detained for outpatient mental health treat- ment shall also address conditions of com- mitment and the following issues, at a mini- mum: 1. Monitoring and limitations of client residence, movement and travel; 2. Communication protocols and coordi- nation with other health care providers during the period of involuntary commitment to rea- sonably assure client and public safety; 3. Consequences of noncompliance related to criteria for referral to inpatient treatment; 4. Medication compliance and monitor- ing; and 5. Conditions of release from involun- tary outpatient commitment. (D) The treatment plan shall be reviewed on a periodic basis but no less frequently than monthly, and more often if clinically indicat- ed. (E) The program shall notify the court when a client detained for outpatient treat- ment fails to comply with conditions of com- mitment and the program is no longer able to reasonably assure client and/or public safety. (F) A copy of the clients ITP shall be sent to the inpatient facility that has agreed to accept the client when directed by the pro- gram. (17) The program shall maintain a client list- ing of persons currently being served by the program who have been involuntarily detained for outpatient mental health treat- ment. To assure continuity of care, the list shall be updated on a daily basis and shall be provided, with a current treatment plan and additional clinical information as indicated, to the hotline staff of the appropriate ACI sys- tem and to the mental health coordinator for the area in which the client lives. (18) When a client has been detained for out- patient mental health treatment and the pro- gram has good cause to believe that immedi- ate detention to an inpatient setting is required because the client presents a likeli- hood of serious harm as defined in subsection (2)(C) due to mental illness, the program (A) Shall confirm and document in the client record, based on an evaluation by a qualified mental health professional, that the client requires immediate detention to an inpatient setting; (B) Shall involve the responsible physician, if appropriate, in the decision to arrange inpatient admission; (C) Shall initiate the admission process with appropriate staff of the inpatient facility specified in the petition or court order that agreed to accept the client; (D) Shall direct that the client be detained for up to ninety-six (96) hours at an appro- priate inpatient facility that has agreed to accept the client; (E) May authorize the sheriff to detain and transport the client to the inpatient facility; (F) Shall promptly provide a letter or oth- er written documentation to the inpatient facility directing the inpatient facility to admit the client and detailing the clinical reasons for the inpatient admission, including specif- ic violations of conditions of commitment, as appropriate, and other relevant clinical infor- mation; (G) Shall provide written notice to the client of the clinical reasons for the inpatient admission, including violation of conditions of commitment; (H) Shall immediately provide written notification to the committing court including copies of correspondence and notice described in (18)(G) and (H) above; and CODE OF STATE REGULATIONS 5Rebecca McDowell Cook (3/31/98) Secretary of State Chapter 1—Standards and Procedures for Program Recognition, Client Admissions and Performance 9 CSR 80-1 (I) Shall provide copies of documents ref- erenced in (18)(G) and (H) above to counsel for the client and counsel for the petitioner. (19) The program director shall release any person who is involuntarily detained for out- patient treatment when, in his/her opinion and based on a determination by a qualified mental health professional, the person is no longer mentally ill or, although mentally ill, does not present a likelihood of serious harm as defined in subsection 2(C), even though the detention period has not expired. (A) The release decision shall be based on information gathered in observation of the client including but not limited to response to treatment, and mental status as well as infor- mation gathered from family and others who interact with the client. (B) The program shall document in the client record their clinical rationale for the release decision. (C) When the program releases a person prior to expiration of the detention order, the program shall send written notification to the court and the mental health coordinator. (20) Whenever a client who has been detained for outpatient treatment requests to be voluntarily admitted to the program and the program agrees and accepts the person for voluntary admission, the involuntary deten- tion shall end and the program shall send written notice to the court and the mental health coordinator. (A) Upon request by a client for voluntary admission, the program shall evaluate the request to include considerations such as, but not limited to, clients mental status and competency to make decisions, the genuine- ness of the request, whether the client still meets commitment criteria of likelihood of serious harm, and the clients understanding of the proposed course of outpatient treat- ment. The program shall utilize information gained through observation of the client and information gathered from family, care providers and others. (B) If, as a result of the review of the request, it is determined that the client is capable of making decisions, has made the request in good faith, and consents to volun- tarily participate in outpatient treatment to reasonably assure client and public safety, the program shall grant the request in a timely manner. (C) Changing a clients status from invol- untary to voluntary shall not be used solely to avoid civil detention proceedings or for staff convenience. (D) The program shall document their activities and clinical judgments related to acceptance or denial of changes in client admission status in response to client requests. (21) Any person who has been committed to the program on an outpatient basis shall be entitled to a reexamination of the court order on his/her own motion, or that of his/her par- ent, spouse, relative, friend or attorney to the court. Upon receipt of the motion, the court shall conduct proceedings in accordance with 632.340, RSMo. (22) At any time that a client who is detained for outpatient treatment fails to comply with the conditions of the court order or condi- tions of commitment, the program shall request a hearing pursuant to 632.340, RSMo. (23) At the end of any detention period ordered by the court, the client shall be dis- charged unless (A) A petition for further detention is filed and heard for successive outpatient detention periods; or (B) The client consents to continuing treat- ment. (24) As required by section 632.392, RSMo, for all clients released or discharged from outpatient commitment for any reason (A) The program shall provide to the client and the care provider a written packet of edu- cational information developed and supplied by the department describing symptoms of common mental illnesses, early warning signs of decompensation, and availability of other education, community and statewide services; (B) The program may disclose confidential treatment information to the primary care provider or care providers, when such infor- mation is medically necessary for the provi- sion of appropriate health care treatment by the care provider or is reasonably related to the safety of the client or care provider; (C) Prior to the disclosure of the informa- tion specified in subsection (24)(B) above, the mental health program shall 1. Provide written notice to the client; 2. Request in writing the consent of the client; 3. Work with the client and care provider to encourage and secure appropriate client authorization; 4. Function as a mediator, negotiating the boundaries of confidentiality to meet the needs of the client and care provider; and 5. Work with the client to stress the importance of keeping the care provider informed and involved with his/her treatment process; (D) If the client refuses to consent and the treating physician deems the information is medically necessary for the appropriate pro- vision of health care or treatment by the care provider or is related to the safety of the client or care provider, the information may still be released to the appropriate care provider; (E) The reason for the intended disclosure, the specific information to be released and the persons to whom the disclosure is to be made, even if consent has not been obtained, will be provided to the client and care provider; and (F) All these procedures shall be docu- mented by the treating physician in the client record, including a specific notation as to whether client consent was given. (25) Whenever possible, the program shall plan for orderly discharge and referral of dis- charged clients to appropriate services and support systems. (26) The program shall maintain information to document its participation as a recognized program to accept outpatient commitments in a format approved by the department. (A) The program shall document referrals from the court, admissions, denials, client grievances and their resolution, and dis- charges. (B) The program shall submit information in aggregate form to the department on a periodic basis or upon request. (C) The department reserves the right to develop a format for submission of such information. (D) The department reserves the right to review and verify such information on-site. (27) The program shall be responsible for maintaining clinical records for persons receiving services consistent with these stan- dards 9 CSR 80-1.005(1) through (35) and other applicable standards. (28) The program shall maintain clinical records for persons who have been committed to their program on an outpatient basis for at least five (5) years following the last clinical contact with the person. (29) For those persons who have been detained for involuntary outpatient treatment and are enrolled in CPR services, the pro- gram shall submit CPR outcome information required by the department on a periodic basis and shall appropriately identify individ- uals on outpatient commitment status. The program will maintain the ability to track persons on outpatient commitment separately from other CPR clients. 6 CODE OF STATE REGULATIONS (3/31/98) Rebecca McDowell Cook Secretary of State 9 CSR 80-1—MENTAL HEALTH Division 80—Division of Comprehensive Psychiatric Services (30) The department shall have the authority to access program records and client records for purposes of monitoring the performance of any recognized program. (31) The program shall cooperate fully with any investigations of client abuse, neglect, exploitation or violation of client rights. (32) The program shall cooperate fully with on-site program reviews by authorized agents of the department related to complaints received about the agency, its staff or opera- tions. (33) When these standards are more stringent than those in other certification or licensure regulations, these standards shall supersede for persons who are involuntarily committed on an outpatient basis. (34) Agency quality assurance and quality improvement mechanisms and plans at the program should incorporate specific indica- tors for monitoring the performance and out- comes for outpatient commitment clients. (35) The agency shall assure that its staff are appropriately trained for provision of outpa- tient commitment to its clients ordered for such treatment by the court. (A) The agency shall send appropriate staff to training required by the department. (B) The agency shall implement orientation and training to assure that staff have adequate information to effectively perform their staff functions in the provision of outpatient com- mitment to detained persons including, but not limited to, training regarding methods to work with families and promote their involve- ment in treatment. (C) The department may require the agen- cy, at its own expense, to provide additional training to its staff if the agencys perfor- mance is not in substantial compliance with the requirements codified in 9 CSR 80- 1.005(1) through (35). AUTHORITY: sections 630.655, RSMo (1994) and 632.005(13) and 632.330, RSMo (Cum. Supp. 1997).* Original rule filed Oct. 10, 1997, effective April 30, 1998. *Original authority: 650.655, RSMo (1980); 632.005, RSMo (1980), amended 1985, 1988, 1996; and 632.330, RSMo (1980), amended 1996. CODE OF STATE REGULATIONS 7Rebecca McDowell Cook (3/31/98) Secretary of State Chapter 1—Standards and Procedures for Program Recognition, Client Admissions and Performance 9 CSR 80-1