Assertive Community Treatment (ACT) in Community Psychiatric Rehabilitation Programs

9 CSR 30-4.0432 Assertive Community Treatment (ACT) in Community Psychiatric Rehabilitation Programs PURPOSE: This rule sets forth standards and regulations for the provision of ACT services in community psychiatric rehabilitation programs for adults. PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Assertive Community Treatment (ACT) is a transdisciplinary team model used to deliver comprehensive and flexible treatment, support, and services to adults or transition-age youth who have the most severe symptoms of a serious mental illness or severe emotional disturbance and who have the greatest difficulty with basic daily activities. (A) These regulations apply to all ACT teams including specialized teams for women and children, transition-age youth, transition-age youth with behavioral health and developmental disabilities, transition-age youth with co-occurring disorders, and forensic assertive community treatment. (2) Organizations certified or deemed certified as Community Psychiatric Rehabilitation (CPR) providers by the department may offer ACT services and shall use the Assertive Community Treatment: How to Use the Evidence-Based Practice KIT published in 2008 by the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services, Publication No. SMA-08-4344, Rockville, MD 20008. This publication may be downloaded at https://store.samhsa. gov/product/Assertive-Community-Treatment-ACT-Evidence- Based-Practices-EBP-KIT/sma08-4345. Agencies shall also use A Manual for ACT Start-Up by Deborah J. Allness, M.S.S.W., and William H. Knoedler, M.D., published in 2003 by National Alliance for the Mentally Ill (NAMI), 3803 N. Fairfax Drive, Suite 100, Arlington, VA 22203, (703) 524-7600. The documents incorporated by reference with this rule do not include any later amendments or additions. (3) Agencies providing ACT services shall comply with requirements set forth in Department of Mental Health Core Rules for Psychiatric and Substance Use Disorder Treatment Programs, 9 CSR 10-7.010 through -7.140. (4) The agencies providing ACT services shall have policies approved by the governing body as defined in -7.090 that are consistent with the provision of effective evidencebased interventions to guide the ACT services and be consistent with the ACT model of treatment. (5) Personnel and Staff Development. ACT shall be delivered by a transdisciplinary team (team) responsible for coordinating a comprehensive array of services. The team shall include, but is not limited to, the following disciplines: (A) The team shall have adequate prescribing capacity by meeting one (1) of the following: 1. A physician/physician extender who shall be available a minimum of sixteen (16) hours per week to no more than fifty (50) individuals to assure adequate direct psychiatric treatment; 2. A combination of a physician/physician extender equaling sixteen (16) hours per week shall be available to no more than fifty (50) individuals (physician extender includes licensed assistant physician, physician assistant, psychiatric resident, psychiatric pharmacist, and advanced practice registered nurse (APRN ; or 3. In a service area designated as a Mental Health Professional Shortage Area, the psychiatrist, physician assistant, psychiatric pharmacist, assistant physician, or psychiatric resident shall be available ten (10) hours per week to no more than fifty (50) individuals; or an advanced practice registered nurse shall be available sixteen (16) hours per week to no more than fifty (50) individuals; two (2) prescribers working on the same team must include each prescriber working a minimum of eight (8) hours per week; (B) The ACT team prescriber shall attend at least two (2) team meetings per week either face-to-face or by teleconference; (C) A registered nurse with six (6) months of psychiatric nursing experience who shall work with no more than fifty (50) individuals on a full-time basis; (D) A team leader who is a qualified mental health professional (QMHP) as defined in -7.140 that is full time on the team with one (1) year of supervisory experience and a minimum of two (2) years experience working with adults and/ or transition-age youth with a serious mental illness or severe emotional disturbance in community settings; (E) A qualified co-occurring disorders specialist by being one (1) of the following: 1. A physician or QMHP in Missouri or an individual who meets the applicable training and credentialing required by the Missouri Credentialing Board for any of the following accreditations (QAP): A. Certified Alcohol and Drug Counselor (CADC); B. Certified Reciprocal Alcohol and Drug Counselor (CRADC); C. Certified Reciprocal Advanced Alcohol and Drug Counselor (CRAADC); D. Certified Criminal Justice Addictions Professional (CCJP); E. Registered Alcohol Drug Counselor-Provisional (RADC-P); F. Registered Alcohol Drug Counselor (RADC); G. Co-Occurring Disorders Professional (CCDP); and H. Co-Occurring Disorders Professional-Diplomat (CCDP-D); and 2. The QMHP or QAP shall also have one (1) year of training or supervised experience in substance use disorder treatment. If they have less than one (1) year of experience in providing cooccurring disorder treatment, they shall be actively acquiring twenty-four (24) hours of training in co-occurring disorders content and receive supervision from experienced co-occurring disorders staff as approved by the department; (F) The team shall have adequate employment and education specialization capacity by meeting one (1) of the following: 1. An employment and education specialist who qualifies as a community support specialist as defined in -7.140 with one (1) year of experience and training in supported employment shall be available to no more than fifty (50) individuals; or 2. If the employment and education specialist is not assigned to a team full-time or is assigned to a team with less than fifty (50) individuals, the employment and education specialist shall attend at least two (2) team meetings per week; (G) The team shall include a peer specialist who is selfidentified as currently or formerly receiving mental health services; is assigned full-time to a team and participates in the clinical responsibilities and functions of the team in providing direct services; and serves as a model, a support, and a resource for the team members and individuals being served. Peer specialists, at a minimum, shall meet the qualifications of a Certified Peer Specialist as defined in -7.140; (H) The team shall include a program assistant. The program assistant shall have education and experience in human services or office management. The program assistant shall organize, coordinate, and monitor all non-clinical operations of the team including, but not limited to, the following: 1. Managing medical records; 2. Operating and coordinating the management information system; and 3. Triaging telephone calls and coordinating communication between the team and individuals receiving ACT services; (I) Other team members may be assigned to work exclusively with the team and must qualify as a community support specialist or a qualified mental health professional as defined in -7.140; and (J) In addition to training required in -4.034, team members shall receive ongoing training relevant to ACT services. (6) Team Operations. (A) The team shall function as the primary provider of services for the purpose of recovery from serious mental illness or severe emotional disturbance and/or substance use disorders and shall have responsibility to help adults or transition-age youth meet their needs in all aspects of living in the community. (B) The team shall meet face-to-face at least five (5) times per week to review the status of each individual via the daily communication log, staff report, services, and contacts scheduled per treatment plans and triage. (C) The team members shall be available to one another throughout the day to provide consultation or assistance. (D) The ACT specialists shall cross-train their teammates to help each member develop knowledge and skills for each specialty area. (7) Eligibility Criteria. Adults or transition-age youth who receive ACT services typically have needs that have not been effectively addressed by traditional, less intensive behavioral health services. Individuals shall have at least one (1) of the diagnoses as specified by the department, meet one (1) or more of the conditions specified in this rule, and meet all other CPR admission criteria as defined in -4.005. (A) The diagnosis may coexist with other psychiatric diagnoses. (B) For adults or transition-age youth exhibiting extraordinary clinical needs, the team may apply to the department to approve admission to ACT services. (C) Individuals must meet one (1) or more of the following conditions to receive ACT services: 1. Recent discharge from an extended stay of three (3) months or more in a state hospital for an adult or an extended stay in a residential facility for transition-age youth (ages 16- 25); 2. High utilization of two (2) admissions or more per year in an acute psychiatric hospital and/or six (6) or more per year for psychiatric emergency services; 3. Have a co-occurring substance use disorder greater than six (6) months duration; 4. Exhibit socially disruptive behavior with high risk of involvement in the justice system including arrest and incarceration; 5. Reside in substandard housing, is homeless, or at imminent risk of becoming homeless; 6. Experience the symptoms of an initial episode of psychosis within the past two (2) years (hallucinations, delusions or false beliefs, confused thinking, or other cognitive difficulties) leading to a significant decrease in overall functioning; or 7. Other indications demonstrating that the adult or transition-age youth has difficulty thriving in the community. (8) Admission Process. (A) The team shall develop a process for identifying adults or transition-age youth who are appropriate for ACT services. (B) When the team receives a referral for ACT services, the team leader shall confirm the individual meets the ACT eligibility criteria. (C) The team leader shall arrange an admission meeting that includes current providers of services, the team leader, and the individual. The meeting may also include, but is not limited to, the following: 1. Family members, significant others, natural supports or guardians, if the individual grants permission; 2. Team members who will be working with the newly enrolled individual; and/or 3. The team psychiatrist. (D) At the admission meeting, team members shall introduce themselves and explain the ACT program. (E) When the individual decides he or she accepts ACT services, the team shall immediately open a record and schedule initial service contacts with the individual for the next few days. (F) An initial assessment shall be completed on the day of admission. The initial assessment shall be based on information obtained from the individual, referring treatment provider, and family/natural supports or other supporters who participate in the admission process and shall include, but not be limited to, the following: 1. The individual’s mental and functional status; 2. The effectiveness of past treatment; and 3. The current treatment, rehabilitation, and support service needs. (G) The initial treatment plan shall be completed on the day of admission, include initial needs and interventions, be used to support recovery, and be used by the team as a guide until the comprehensive assessment and treatment plans are completed. (H) The team shall ensure the individual receiving services participates in the development of the treatment plan. (I) The team’s physician/physician extender shall approve the treatment plan. A licensed psychologist, as a team member, may approve the treatment plan only when the individual is currently receiving no prescribed medications to treat a mental health condition and the clinical recommendations do not include a need for prescribed medications for a mental health condition. (9) Comprehensive Assessment and Treatment Planning. (A) To be in compliance with this standard, the team shall follow a systematic process including admission, comprehensive and ongoing assessment, and continuous treatment planning utilizing the assessment and treatment planning protocol and components included in the publication A Manual for ACT Start-Up and in the fidelity protocol specified by the department. (B) The team shall conduct the comprehensive ACT assessment as they are working with the individual in the community delivering services outlined in the initial treatment plan. (C) The comprehensive ACT assessment provides a guide for the team to collect information including the individual’s history, including trauma history, past treatment, and to become acquainted with the individual and their family members. This assessment enables the team to individualize and tailor ACT services to ensure courteous, helpful, and respectful treatment. The comprehensive assessment includes, but is not limited to: 1. Psychiatric history, mental status, and diagnosis; 2. Physical health; 3. Use of drugs and/or alcohol; 4. Education and employment; 5. Social development and functioning; 6. Activities of daily living; 7. Family structure and relationships; and 8. Functional assessment approved by the department for individuals whose diagnosis requires a functional score to support admission and if required by the department as part of the comprehensive assessment. (D) Team members, with supervision from the team leader, shall complete their respective sections of the comprehensive assessment within thirty (30) days of admission. (E) The assessment is ongoing throughout the course of ACT treatment and consists of information and understanding obtained through day-to-day interactions with the individual, the team, and others, such as landlords, employers, family, friends, and others in the community. (F) The comprehensive assessment is a daily and ongoing process that is continuously updated and documented as information changes or is received. (G) Treatment plans shall be developed utilizing information obtained from the comprehensive assessment. (H) Treatment plans shall contain objective goals based on the individual’s preferences and shall be person-specific. (I) Treatment plans shall contain specific interventions and services that will be provided, by whom, for what duration, and location of the service. (J) The comprehensive treatment plan shall be developed within forty-five (45) days of admission. (K) The treatment plan shall be revised or re-written every six (6) months. (10) Service Provision. (A) ACT services shall be delivered seven (7) days per week, including evenings and holidays based upon individual needs. (B) At least two (2) hours of direct ACT services shall be available on each day of the weekend and on holidays. (C) A team member shall be on call twenty-four (24) hours per day, seven (7) days per week. (D) The team shall be available to individuals on an ACT team who are in crisis twenty-four (24) hours a day, seven (7) days a week. The team is the first-line crisis evaluator and responder. If another crisis responder screens calls, there is minimal triage. When the team is contacted, the team shall determine the need for team intervention and whether that be by telephone or face-to-face, with back-up by the team leader and ACT team prescriber. (E) Individualized, practical crisis prevention plans shall be available to staff who are on call. (F) Individuals shall be offered services on a time unlimited basis, with less than ten percent (10%) dropping out annually, excluding those who graduate from services. (G) The team shall provide goal driven services for all individuals enrolled in ACT including, but not limited to: 1. Psychopharmacologic treatment; 2. Nursing; 3. Integrated treatment for co-occurring disorders; 4. Supported employment and education; 5. Peer support; 6. Crisis intervention; 7. Psychiatric rehabilitation and skills training to improve functioning; 8. Wellness management and recovery; 9. Empirically supported psychotherapy; and 10. Supportive housing. (H) The team shall have a process to manage emergency funds for individuals served. (I) The ratio for clinical staff to individuals served, excluding the psychiatrist, shall be no more than one to ten (1:10). (J) The ratio for clinical staff to individuals served shall be no more than one to thirteen (1:13) if the team continues to demonstrate outcomes in areas such as employment, housing, and hospitalizations comparable to teams with lower caseloads. (K) The clinical team shall be of sufficient, absolute size to consistently provide necessary staffing diversity and coverage, based on team caseload size. (L) At a minimum, individuals shall be contacted face-to-face by the team an average of two (2) hours per week. (M) For individuals who refuse services, the team shall attempt to engage individuals with at least two (2) face-to-face contacts per month for a minimum of six (6) months. (N) Individuals who are experiencing severe, emergent, or acute symptoms shall be contacted multiple times daily by the team. (O) At a minimum, seventy-five percent (75%) of team contacts shall occur out of the office. (P) Individuals shall have direct contact with more than two (2) team members per month. (Q) Individuals with co-occurring disorders shall be provided integrated mental health and substance use disorder treatment. (R) The team shall monitor and, when needed, provide supervision, education, and support in the administration of psychiatric medications for all individuals. (S) The team shall monitor symptom response and medication side-effects. (T) The team shall educate individuals and families about symptom management and early identification of symptoms. (U) The team shall have an average of one (1) or more contacts per month with family and support systems in the community, including landlords and employers, after obtaining the individual’s permission. (V) The team shall actively and assertively engage and reach out to family members, natural supports, and significant others to include, but not be limited to, the following: 1. Establishing ongoing communication and collaboration between the team, family members/natural supports, and others; 2. Educating the family/natural supports about mental illness or severe emotional disturbance and/or substance use disorder and the family’s role in treatment; 3. Educating the family/natural supports about symptoms management and early identification of symptoms indicating onset of illness; and 4. Providing interventions to promote positive interpersonal relationships. (W) At a minimum, the team supports, facilitates, or ensures the individual’s access to the following services: 1. Medical and dental services; 2. Social services; 3. Transportation; and 4. Legal advocacy. (X) Inpatient admissions shall be jointly planned with the team and the team, at a minimum, shall make weekly contact with individuals while hospitalized. (Y) The team shall coordinate discharge planning in cooperation with hospital staff. (11) Transition to Less Intensive Services. (A) The team shall conduct regular assessment of the need for ACT services. (B) The team shall use explicit criteria or markers for the need to transfer to a less intensive service option. (C) Transition shall be gradual and individualized, with assured continuity of care. (D) The team shall monitor the individual’s status following transition based on individual need. (E) There shall be an option to return to the team, as needed. (F) A transition plan shall be developed incorporating graduated step down in intensity and including overlapping team meetings as needed to facilitate the transition of the individual. (G) The individual shall be engaged in the next step of treatment and rehabilitation. (H) Documentation of transition to less intensive services shall include a systematic plan to maintain continuity of treatment at appropriate levels of intensity to support the individual’s continued recovery and have easy access to return to the ACT team if needed. (I) A discharge summary shall include, but is not limited to, the following: 1. Dates of admission and transition to less intensive services; 2. Reason for admission and referral source; 3. Diagnosis or diagnostic impression; 4. Description of services provided and outcomes achieved, including any prescribed medication, dosage, and response; 5. Reason for or type of transition or discharge from the team; and 6. Medical status and needs that may require ongoing monitoring and support. (J) An aftercare plan shall be completed prior to transition to less intensive services or discharge from the team. The plan shall identify services, designated provider(s), or other planned activities designed to promote further recovery. (12) Records. (A) The ACT provider shall implement policies and procedures to assure routine monitoring of individual records for compliance with applicable standards. (B) All staff contacts with individuals shall be documented and easily accessible to team members. (C) Each individual’s record shall document services, activities, or sessions that involve the individual including— 1. The specific services rendered; 2. The date and actual time the service was rendered; 3. The name of the team member who rendered the service; 4. The setting in which the services were rendered; 5. The amount of time it took to deliver the services; 6. The relationship of the services to the treatment regimen described in the treatment plan; and 7. Updates describing the individual’s response to prescribed care and treatment. (D) In addition to documentation required under subsection (12)(C), for medication services, the ACT provider shall provide additional documentation for each service episode, unit, or as clinically indicated, for each service provided to the individual as follows: 1. Description of the individual’s presenting condition; 2. Pertinent medical and psychiatric findings; 3. Observations and conclusions; 4. Individual’s response to medication, including identifying and tracking over time one (1) or more target symptoms for each medication prescribed; 5. Actions and recommendations regarding the individual’s ongoing medication regimen; and 6. Pertinent/significant information reported by family members, natural supports, or significant others regarding a change in the individual’s condition, an unusual or unexpected occurrence in the individual’s life, or both. (E) The ACT team shall update the treatment plan or department-approved functional assessment every ninety (90) days to assess individual functioning, progress toward treatment objectives, and appropriateness of continued services. The treatment plan shall be revised and updated based on the findings from the functional assessment. Documentation in the individual record shall include but is not limited to: 1. Barriers, issues, or problems identified by the individual, family, guardian, and/or team that identify the need for focused services; 2. A brief explanation of any change or progress in the daily living functional abilities in the prior ninety (90) days; and 3. A description of the changes for the plan of treatment based on information obtained from the functional assessment. (F) The ACT program also shall include other information in the individual record, if not otherwise addressed in the intake/ annual evaluation or treatment plan, including— 1. The individual’s medical history, including— A. Medical screening or relevant results of physical examinations; and B. Diagnosis, physical disorders, and therapeutic orders; 2. Evidence of informed consent; 3. Results of prior treatment; and 4. Condition at discharge from prior treatment. (G) Any authorized person making any entry in an individual’s record shall sign and date the entry, including corrections to information previously entered in the individual’s record. (H) The ACT program shall implement written procedures to ensure exchange of information within five (5) working days when an individual is referred or transfers to another service component within the organization or to an outside entity for services. (I) The ACT provider shall provide information, as requested, regarding individual characteristics, services, and costs to the department in a format established by the department. (13) Performance Improvement. The agency’s performance improvement plan shall include monitoring compliance with the ACT standards. (A) Records shall show evidence that the team monitors hospitalization, housing, employment/education, substance use, and contact with the justice system for all individuals using a tracking form approved by the department and submitted to the department on a quarterly basis. (B) The agency shall include fidelity improvement as part of its overall performance improvement efforts. (C) The team shall participate in fidelity reviews and fidelity improvement activities conducted by the department. (D) Team members or a designee(s) shall meet with the department and stakeholder groups and collaborate as needed. AUTHORITY: sections 630.050, 630.655, and 632.050, RSMo 2016.* Original rule filed Aug. 14, 2009, effective March 30, 2010. Amended: Filed April 29, 2019, effective Nov. 30, 2019. Amended: Filed March 9, 2022, effective Nov. 30, 2022. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008; 630.655, RSMo 1980; and 632.050, RSMo 1980. -4.044 Behavior Management (Rescinded October 30, 2001) AUTHORITY: section 630.655, RSMo 1994. Original rule filed Jan. 19, 1989, effective April 15, 1989. Amended: Filed Dec. 13, 1994, effective July 30, 1995. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001. -4.045 Intensive Community Psychiatric Rehabilitation (ICPR) PURPOSE: This rule sets forth standards and regulations for the provision of ICPR services. PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Intensive Community Psychiatric Rehabilitation (ICPR). ICPR is separate and distinct from other community psychiatric rehabilitation (CPR) services. The individual treatment plan shall specify interventions and supports to be provided by ICPR staff that are separate from other CPR services (such as community support) to prevent duplication of services. (A) Services are designed to help individuals who are experiencing a severe psychiatric condition, alleviating or eliminating the need to admit them into a psychiatric inpatient setting or a restrictive living setting. ICPR is a comprehensive, time-limited, community-based service for individuals who are exhibiting symptoms that interfere with individual/family life in a highly disabling manner. (B) ICPR in all settings (children/youth and adult) must be approved by the department prior to implementation. Written proposals shall be submitted to the department and must include the following: 1. The proposed service, setting, and timeline for implementation; 2. Method for determining eligibility for the service; 3. Staffing patterns/staff qualifications, including identification of the qualified mental health professional (QMHP) who supervises the ICPR setting; 4. Evidence that the site(s) is safe; 5. Process for obtaining multidisciplinary input into treatment plans; 6. Type of documentation to be used; 7. Strategy for preventing the duplication of services and supports delivered by residential and community-based CPR staff; 8. Plan for financial separation of room and board from services; and 9. Plan for providing personal spending funds to individuals served. (C) ICPR is intended for— 1. Persons who would be hospitalized without the provision of intensive community-based intervention; 2. Persons who have extended or repeated hospitalizations; 3. Persons who have psychiatric crisis episodes; 4. Persons who are at risk of being removed from their home or school to a more restrictive environment; and 5. Persons who require assistance in transitioning from a highly restrictive setting to a community-based alternative, including specifically persons being discharged from inpatient psychiatric settings who need intensive CPR services and may require assertive outreach and engagement. (D) Treatment teams deliver services that will maintain the individual within the family and significant support systems and assist them in meeting basic living needs and age appropriate developmental needs. (2) Admission Criteria. To be eligible for ICPR, the individual must meet admission criteria as defined in -4.005 and at least one (1) of the following criteria: (A) Is being discharged from a department facility or bed funded by the department; (B) Has had extended or repeated psychiatric inpatient hospitalizations or crisis episodes within the past six (6) months; (C) Has received services in multiple out-of-home residential settings due to their mental disorder; or (D) Is at risk of being removed from their home, school, or other community living situation. (3) Staff Requirements. Staff requirements for ICPR in residential settings are as follows: (A) Intensive Residential Treatment Settings (IRTS) and Psychiatric Individualized Supported Living (PISL), in accordance with 9 CSR 40-1 and -4.001; (B) Clustered apartments (CA). Staff shall be available on a full- or part-time basis in accordance with the agency’s written proposal approved by the department; 1. Clustered apartment services are provided on-site at the individual’s place of residence. Staff providing services shall be located on site, within a five (5) mile radius of the CA, or within a ten (10) minute drive of the CA. (C) Treatment Family Home-Based Services and Professional Parent Home-Based Services, as specified in section (7) of this rule and -6.001. (4) Treatment for Children/Youth and Adults. All treatment teams shall be supervised by a qualified mental health professional (QMHP). The team coordinates a comprehensive array of services available to the individual through the CPR program as specified in -4.043. Other services shall be provided as clinically appropriate to meet individual needs, however, shall not duplicate services being provided on site. Each team shall include: (A) Staff required to provide specific services identified on the individualized treatment plan; (B) The individual receiving services and family members or other natural supports, if developmentally appropriate; (C) ICPR shall include: 1. Multiple face-to-face contacts with the individual on a weekly basis, and may require contact on a daily basis, as required for each service type; 2. Services that are available twenty-four (24) hours per day, seven (7) days per week for programs that require daily services; and 3. Crisis response services that may be coordinated with an existing crisis system; (D) The amount and frequency of services is based upon the individual’s assessed acuity and need; (E) A crisis prevention plan shall be developed for each individual, including clinical issues that may impact transition to less intensive services; (F) At a minimum, quarterly treatment plan reviews shall occur to ensure individuals are receiving the appropriate level of services to meet needs and goals; and (G) Individuals no longer need ICPR when— 1. There is a reduction of severe symptoms; and 2. They are able to function without intensive services; or 3. They choose to no longer receive intensive services. (5) Documentation Requirements. ICPR services must be documented in accordance with -7.030(13), and as specified in this rule. (A) For individuals currently enrolled in the CPR program, the following documentation is required upon admission to ICPR: 1. Verification they meet admission criteria; 2. Acuity level; and 3. Treatment plan update indicating the higher level of service the individual will be receiving. (B) For individuals newly admitted directly from the community into ICPR, an intake evaluation must be completed to substantiate acuity and criteria for admission. 1. Each individual shall have a psychiatric evaluation at admission. For individuals discharged from inpatient hospitalization into ICPR, a psychiatric evaluation completed at the facility/hospital may be initially accepted. 2. The comprehensive assessment must be completed within thirty (30) days of admission except for individuals admitted provisionally. 3. Treatment plans shall be developed upon admission and be updated at least quarterly, or more frequently if clinically indicated. (C) Treatment plans shall be reviewed as required for each service type and documented in the individual record with a summary progress note, including updates to the treatment plan as appropriate. (D) Upon change from ICPR services, a transition summary must be completed by a QMHP and included in an updated treatment plan. (6) ICPR for Children and Youth. Services are medically necessary to maintain a child with a Serious Emotional Disturbance (SED) in their natural home, or maintain a child with a serious mental illness or SED in a community setting who has a history of failure in multiple community settings, and/or the presence of ongoing risk of harm to self or others, which would otherwise require long-term psychiatric hospitalization. Clinical interventions are provided by a multidisciplinary treatment team on a daily basis, and the interventions must be available twenty-four (24) hours per day, seven (7) days per week for stabilization purposes. The child’s family and other natural supports may receive services when they are for the direct benefit of the child in accordance with their individual treatment plan. (A) When a child/youth is receiving this service, it is vital that the parent/guardian be actively involved in the program if the individual is to receive the full benefit of the program. Services shall be provided to the child/youth’s family and other natural supports when such services are for the direct benefit of the individual, in accordance with their needs and treatment goals identified in the treatment plan, and for assisting in their recovery. (B) Services shall include, but are not limited to: 1. Medication administration/management of medication; 2. Ongoing behavioral health assessment and diagnosis; 3. Monitoring to assure individual safety; 4. Individual and group counseling; and 5. Community support. (C) The ICPR multidisciplinary team shall include the following staff, based on the needs of the individual served: 1. Physician, psychiatrist, child psychiatrist, psychiatric resident, assistant physician, physician assistant, or Advanced Practice Registered Nurse (APRN); 2. QMHP; 3. RN; 4. LPN; 5. Community Support Specialist; and 6. Individuals with a high school diploma, or equivalent certificate, under the direction and supervision of a QMHP. (D) Services are limited to ninety (90) days. Exceptions may be granted by the department and must be documented in the individual record. (7) ICPR for Children/Youth in Residential Settings (Treatment Family Home-Based Services and Professional Parent Home- Based Services). Intensive therapeutic interventions are provided to improve the child’s functioning and prevent them from being removed from their natural home and placed into a more restrictive residential treatment setting due to a SED. (A) Services are for children whose therapeutic needs cannot be met in their natural home or an alternative therapeutic environment is required for transition back to their home or least restrictive setting. (B) Providers must complete extensive, specialized training required by the department and meet department licensure requirements as specified in -6. (C) The provider shall participate in pre-placement and ongoing meetings with the child’s CPR treatment team and assist in development of the treatment plan. The provider is responsible for implementing the treatment plan and maintaining contact with the child’s natural parent/guardian and completing documentation as required by the department. (D) Services and supports are individualized and strengthbased to meet the needs of the child and family across life domains to promote success, safety, and permanence in the home, school, and community. Therapeutic interventions target the child’s serious mental health issues and promote positive development and healthy family functioning. (E) Children must meet CPR admission criteria and their behavior must be sufficiently under control to live safely in a community setting with appropriate support. (F) Staff of the CPR program who supervise the child’s services must be available twenty-four (24) hours a day, seven (7) days per week to assist the provider if a crisis situation occurs. (G) Placement, duration, and intensity of services is based on the specific needs of each child as specified in the MO HealthNet CPR Provider Manual, hereby incorporated by reference and made a part of this rule and available from the Department of Social Services, 615 Howerton Court, PO Box 6500, Jefferson City, MO 65102-6500, and as specified in the department contract, September 2019. This rule does not incorporate any subsequent amendments or additions to this publication. (H) A maximum of three (3) children may receive services in a Treatment Family Home (TFH), subject to licensed capacity. One (1) child may be served in a Professional Parent Home (PPH). (8) Evidence-Based Practices (EBP) for Youth. Services involve proven treatment supports for children and youth to address specific behavioral health needs. The selected EBP is based on individual needs and desired outcomes as identified in the treatment plan. (A) The EBP must be approved by the department. (B) Activities associated with the service must include, but are not limited to: 1. Extensive monitoring and data collection; 2. Specific skills-training in a prescribed or natural environment; and 3. Prescriptive responses to a psychiatric crisis and/or frequent contact with the individual and/or family, in addition to the arranged therapy sessions. (9) ICPR for Adults in Non-Residential Settings. Services are delivered by teams using one (1) of the following methods: (A) Linking and transitioning individuals from acute or longterm services to less intensive treatment. The time frame for services is approximately ninety (90) days or less, but varies according to individual needs; (B) Modified Assertive Community Treatment (ACT), as approved by the department. The time frame varies based on individual needs; or (C) Intensive wrap-around stabilization services for individuals with substantial mental health needs who may otherwise require inpatient hospitalization. The expected period of engagement is approximately ninety (90) days or less, but varies according to individual needs. (D) Teams may be designated exclusively for individuals in ICPR or be mixed teams serving individuals in ICPR and rehabilitation services. (E) A department-approved functional assessment must be completed monthly and documented in the individual record. (F) Community support services shall not be provided while an individual is receiving ICPR non-residential services. (10) ICPR for Transition Age Youth in Non-Residential Settings. Services are delivered by transdisciplinary specialty teams using intensive wrap-around stabilization for individuals with substantial mental health and/or co-occurring needs, with the primary diagnosis being a mental disorder. (A) Services are for individuals who may otherwise require inpatient hospitalization. The period of engagement varies based upon individual needs as specified in the treatment plan. (B) An initial comprehensive assessment must be completed within thirty (30) days of admission. (C) An individual treatment plan shall be developed within forty-five (45) days of admission and shall be updated as required by the department. (11) ICPR for Adults in Residential Settings (IRTS, PISL, Clustered Apartments). Medically necessary services/supports are provided to adults who have a serious mental illness and are transitioning from an inpatient psychiatric hospital to the community, or who are at risk of returning to inpatient care due to their clinical status or need for increased support. Services and supports are provided on site where the individual lives under the supervision of a QMHP. Residential settings are structured to meet individual needs to ensure safety and prevent the individual’s return to a more restrictive setting for services. (A) Staff providing services/supports must be at least eighteen (18) years of age and have a minimum of a high school diploma or equivalent certificate. Two (2) years of direct heath care experience, or a bachelor’s degree in behavioral sciences, is preferred. (B) Staff must be systematically trained to provide intensive interventions and supports to reduce the symptoms of mental illness, and provide de-escalation and intervention techniques to individuals in a psychiatric crisis who are exhibiting behaviors potentially dangerous to themselves or others. A training plan must be in place for each staff person identifying specific topics and frequency of refresher training on each topic, including documentation of course completion. (C) Support and rehabilitation services related to activities of daily living and crisis prevention and intervention must be provided. (D) Documentation must reflect delivery of direct (face-toface) services and supports such as, daily summary progress notes, group notes, individualized progress notes documenting interventions including crisis assistance, conflict management, behavior redirection, and prompting or reminders. (12) Children’s Inpatient Diversion. A full array of intensive clinical services are provided to children/youth in a highly structured therapeutic setting. Services are designed to restore the child to a prior level of functioning, decrease risk of harm, and prevent transition to a more restrictive setting. (A) Emergency medical services must be available on site or in close proximity. (B) A psychiatrist must supervise services which are delivered by a multi-disciplinary treatment team. (C) Licensed nursing staff must be available on a daily basis. (D) Licensed occupational and recreational therapists must be available based on individual needs. (E) The provision of services is limited to certified or deemedcertified CPR programs for children and youth. The service must be accredited by a national accrediting body approved by the department. (F) There shall be one (1) staff person for every two (2) individuals served during waking hours. The ratio for staff to individuals served may decrease to one (1) staff to six (6) individuals during sleeping hours. (13) Adult Inpatient Diversion. A full array of intensive clinical services are provided to adults in a highly supervised twentyfour (24) hour, structured therapeutic setting. Services are designed to restore the individual to a prior level of functioning, decrease risk of harm, and prepare for transition to a less restrictive setting. (A) Emergency medical services must be available on site or in close proximity. (B) Intensive therapeutic services must be provided in a coordinated effort under the direction of a psychiatrist. Other staff on the treatment team includes licensed nurses, licensed psychologists, social workers, counselors, psychosocial rehabilitation specialists, and other trained supportive staff. (C) Services shall include, but are not limited to: 1. Nursing; 2. Community support; 3. Psychosocial rehabilitation; and 4. Treatment for co-occurring disorders and other evidencebased services. (D) The provision of services is limited to CPR programs for adults. The service must be accredited by a national accrediting body approved by the department. (E) The staffing ratio for daytime and evening hours shall be one staff to six individuals served (1:6), and one staff to eight individuals served (1:8) during nighttime hours. AUTHORITY: sections 630.050, 630.655, and 632.050, RSMo 2016.* Emergency rule filed Dec. 28, 2001, effective Jan. 13, 2002, expired July 11, 2002. Original rule filed Dec. 28, 2001, effective July 12, 2002. Emergency amendment filed June 14, 2010, effective July 1, 2010, expired Feb. 24, 2011. Amended: Filed June 14, 2010, effective Feb. 24, 2011. Amended: Filed April 29, 2019, effective Nov. 30, 2019. Amended: Filed March 9, 2022, effective Sept. 30, 2022. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008; 630.655, RSMo 1980; and 632.050, RSMo 1980. -4.046 Psychosocial Rehabilitation (PSR) in Community Psychiatric Rehabilitation Programs PURPOSE: This rule provides standards for PSR programs operated as part of a community psychiatric rehabilitation (CPR) program. (1) The Psychosocial Rehabilitation (PSR) program must be accredited by CARF International, The Joint Commission, Council on Accreditation, or other accrediting body recognized by the department. If the PSR program is not accredited, department licensure rules as specified in -1 and 9 CSR 40-9 shall apply, as applicable, until accreditation is obtained. (2) The community psychiatric rehabilitation (CPR) program shall provide or arrange transportation to and from the PSR site, and to/from various locations in the community, to provide individuals with opportunities for off-site training and rehabilitation in realistic settings. (3) Policies and procedures shall be implemented for intake screening, referral, and assignment of individuals eligible for services. (A) Intake policies and procedures shall define referral procedures to be followed for persons determined ineligible for PSR services. (B) The maximum wait time from an individual’s initial faceto-face contact with the PSR program to intake screening shall be ten (10) working days, or sooner, if clinically indicated. (C) The intake screening shall determine the individual’s need for PSR, functional strengths and weaknesses, and transportation needs. (D) PSR services shall be incorporated into the individual’s treatment plan within forty-five (45) days of admission to the program. (4) Policies and procedures shall ensure program staff document measurable progress for individuals engaged in key services. (A) Key services shall include, but are not limited to— 1. Training/rehabilitation in community living skills; 2. Development of personal support systems through a group modality; and 3. Prevocational training/rehabilitation provided directly by the program or through subcontract, including at a minimum— A. Interview and job application skills; B. Therapeutic work opportunities; and C. Temporary employment opportunities. (B) Documentation of key services must include— 1. A weekly note summarizing specific services rendered, the individual’s involvement in and response to the services, and relationship of the services to the treatment plan; 2. Pertinent information reported by family members or other natural supports regarding a change in the individual’s condition and/or an unusual or unexpected occurrence in his or her life; and 3. Daily attendance records, including each individual’s actual attendance time and the activity or session attended (this information does not need to be integrated into the individual record). Attendance records must be available to department staff and other authorized representatives for audit and monitoring purposes, upon request. (5) PSR services shall be structured and may occur during the day, evening, weekend, or a combination of these, to effectively address the rehabilitation needs of individuals served. Services and activities are not limited to the program location/site. (A) The program shall directly provide or ensure the following services available for individuals served: 1. Opportunities for training and rehabilitation in daily living skills, including activities associated with meal preparation and laundry, at a minimum; 2. Off-site training/rehabilitation in community living skills; and 3. Opportunities for family members/natural supports and advocates to participate in the planning, development, and evaluation of the PSR program. (6) PSR for Adults. Services are for adults who need ageappropriate, developmentally focused rehabilitation. A combination of goal-oriented and rehabilitative services shall be provided in a group setting to assist individuals in developing personal support systems, social skills, community living skills, and pre-vocational skills that promote community inclusion, integration, and independence. (A) Key service functions shall include, but are not limited to— 1. Screening to evaluate the appropriateness of the individual’s participation in PSR; 2. Addressing individualized program goals and objectives; 3. Enhancing independent living skills; 4. Addressing basic self-care skills; and 5. Enhancing use of personal support systems. (B) The director of the program must be a Qualified Mental Health Professional (QMHP) with two (2) years of relevant work experience. (C) All direct care staff must have a high school diploma or equivalent certificate. (D) Each day program shall have, as a minimum, a daily direct care staff ratio of one (1) staff person for each sixteen (16) individuals served (1:16) unless program needs or the needs of individuals being served require otherwise. (E) At least one (1) staff person must be on duty at all times when individuals enrolled in PSR are present at the program. (7) PSR for Children and Youth. A combination of goal-oriented and rehabilitative services shall be provided in a group setting to improve or maintain the child’s ability to function as independently as possible within their family and/or in the community. Services are provided according to the individual treatment plan, with an emphasis on community integration, independence, and resiliency. Hours of operation are determined by the program based on capacity, staffing availability, geography, and space requirements, but shall be no more than six (6) hours daily, per child. (A) The director must be a qualified mental health professional (QMHP) with two (2) years of experience working with children and youth. One (1) full-time mental health professional must be available during the provision of services. (B) Staffing ratios shall be based on the ages and needs of the children being served. For individuals aged eleven (11) and younger, the staffing ratio shall be one (1) staff to eight (8) participants (1:8). For individuals aged twelve (12) to seventeen (17), the staffing ratio shall be one (1) staff to ten (10) participants (1:10). (C) Other staff of the PSR team shall include the following, based on the needs of individuals served: 1. Registered nurse; 2. Occupational therapist; 3. Recreational therapist; 4. Rehabilitation therapist; 5. Community support specialist; 6. Certified family support provider; and 7. Certified peer specialist. (D) Key service functions shall include but are not limited to— 1. Assisting the child in gaining or regaining skills for community/family living such as personal hygiene, completing age-appropriate household chores, and family, peer, and school activities; 2. Developing interpersonal skills which provide a sense of participation and personal satisfaction (opportunities should be age and culturally appropriate daytime and evening activities which offer the chance for companionship, socialization, and skill building); and 3. Assisting the child and family in developing normative behaviors and expectations of relationships and providing the opportunity to practice affiliated skills which can be valuable to an individual reestablishing family and personal support relationships. (E) Group sessions may be provided for parents/guardians to develop and enhance parenting skills. In these situations, the PSR services and expected goals and outcomes must be documented in the child/youth’s treatment plan and clearly relate to the treatment and rehabilitation goals of the child or youth. (8) Psychosocial Rehabilitation Illness Management and Recovery (PSR-IMR). Services promote physical and mental wellness, well-being, self-direction, personal empowerment, respect, and responsibility. Services shall be provided in individual and group settings using curriculum approved by the department. Services must be delivered by staff who have completed required training. (A) The maximum group size shall not exceed eight (8) individuals; however, if there are other curriculum-based approaches that suggest different group size guidelines, larger groups may be approved by the department. (B) Services shall be person-centered and strength-based including, but not limited to— 1. Psychoeducation; 2. Relapse prevention; and 3. Coping skills training. (C) CPR programs must be approved by the department to provide this service. (D) If a program is accredited by Clubhouse International and submits its accreditation report to the department, it may be deemed as a PSR-IMR program by the department. (E) Required documentation includes a weekly note summarizing the services rendered and the individual’s response to the services, and pertinent information reported by family members or other natural supports regarding a change in the individual’s condition, or an unusual/unexpected occurrence in their life, or both. 1. If an individual is participating in PSR-IMR and PSR, a single, weekly summary progress note must clearly address the PSR-IMR and PSR sessions and activities during the week, or two (2) separate summary progress notes must address each type of PSR service provided during the week. 2. Daily attendance records or logs clearly identifying and distinguishing PSR-IMR as the specific type of session/activity, with actual attendance times and description of service, must also be maintained. The attendance records/logs must be available for audit and monitoring purposes, but do not need to be integrated into each clinical record. AUTHORITY: section 630.655, RSMo 2016.* Original rule filed Jan. 19, 1989, effective April 15, 1989. Amended: Filed Dec. 13, 1994, effective July 30, 1995. Amended: Filed Dec. 1, 2011, effective June 30, 2012. Amended: Filed April 29, 2019, effective Nov. 30, 2019. Amended: Filed March 9, 2022, effective Sept. 30, 2022. Amended: Filed Oct. 18, 2023, effective May 30, 2024. *Original authority: 630.655, RSMo 1980. -4.047 Community Support in Community Psychiatric Rehabilitation Programs PURPOSE: This rule sets out requirements for community support services provided by a community psychiatric rehabilitation program. (1) Service Delivery. The community psychiatric rehabilitation (CPR) program shall establish an identifiable unit which coordinates and provides community support services for children, youth, families, and/or adults. The unit shall be organized to perform functions within the scope of community support services, including critical interventions. (2) Policies and Procedures. The CPR program shall implement policies and procedures to provide adequate, appropriate, and effective community support services to individuals. Policies and procedures shall include: (A) A mechanism to assure the provision of all needed CPR services, as indicated in the individual’s current treatment plan; (B) A mechanism to assure the provision of all needed services in addition to those provided by the CPR program, as indicated in the individual’s current treatment plan; (C) A method for assigning individuals to a community support specialist or team, including: 1. Procedures to assure each individual is afforded an opportunity to express preferences in the selection of a community support specialist; and 2. A mechanism to assure all individuals admitted who need community support are assigned to an active caseload of a community support specialist; (D) A process to assure an effective transfer and follow-up of an individual between or among community support specialists or community support teams. Staff shall document the rationale for the transfer, the individual’s acceptance, and follow-up by the community support specialist in the clinical record; (E) A process for determining overall increase or decrease in the level of functioning for individuals served through ongoing performance improvement activities; (F) A method to assure staff providing community support services in the CPR program have the opportunity to participate and contribute to the agency’s performance improvement process; (G) Development of suitable revisions to treatment goal(s) as indicated by growth or deterioration of individual functioning and/or condition; and (H) Program and aggregate evaluation activities to determine effectiveness of services delivered. (3) Staff Requirements. The CPR program shall ensure an adequate number of appropriately qualified staff are available to provide community support services and functions. (A) Qualified staff includes: 1. A qualified addiction professional (QAP) as defined in 9 CSR 10-7.140; 2. A qualified mental health professional (QMHP) as defined in -7.140; 3. An individual with a bachelor’s degree in a human services field which includes social work, psychology, nursing, education, criminal justice, recreational therapy, human development and family studies, counseling, child development, gerontology, sociology, human services, behavioral science, and rehabilitation counseling; 4. An individual with any four- (4-) year combination of higher education and qualifying experience; 5. An individual with any four- (4-) year degree and two (2) years of qualifying experience; 6. An individual with an Associate of Applied Science in Behavioral Health Support degree from an approved institution; or 7. An individual with four (4) years of qualifying experience. (B) Qualifying experience must include delivery of services to individuals with mental illness, substance use disorders, or developmental disabilities. Experience must include some combination of the following: 1. Providing one-on-one or group services with a rehabilitation/habilitation and recovery/resiliency focus; 2. Teaching and modeling for individuals how to cope and manage psychiatric, developmental, or substance use disorder issues while encouraging the use of natural resources; 3. Supporting individuals in their efforts to find and maintain employment and/or to function appropriately in family, school, and community settings; and 4. Assisting individuals to achieve the goals and objectives in their individual treatment plan. (C) It is the responsibility of the CPR program to document how staff meet the qualifications based on the criteria in subsections (3)(A) and (3)(B) of this rule. (D) Community support specialists must also complete orientation and training required by the department. (E) Community support specialists must be supervised by— 1. A qualified addiction professional (QAP); 2. A qualified mental health professional (QMHP); 3. Staff possessing a Master’s degree in a behavioral health or related field who has completed a practicum or has one (1) year of experience in a behavioral health field; or 4. Staff who meet the qualifications of a community support specialist with at least three (3) years of populationspecific experience providing community support services in accordance with the key service functions specified in paragraphs (5)(B)1. to 8. of this rule. (F) Community support supervisors who are not a QAP or QMHP must be supervised by a QAP or QMHP. (4) Monitoring. To the extent the individual is able to participate, periodic observation and monitoring shall take place in his/ her home or other community location as stipulated in the individual treatment plan. (A) Observation and monitoring shall be documented including, but not limited to: 1. Assessment of the individual’s mental health status and/ or substance use; 2. Safety and home care; and 3. Functional abilities and skill transference related to activities of daily living including educating, demonstrating, observing, and practicing skills in his/her natural environment. (5) Service Delivery. Community support is a comprehensive service designed to reduce the individual’s disability resulting from a mental illness, emotional disorder, and/or substance use disorder and restore functional skills of daily living, principally by developing natural supports and solutionoriented interventions intended to achieve recovery/resiliency as identified in the goals and/or objectives in the individual treatment plan. (A) This service may be provided to the individual’s family/ natural supports when such services are for the direct benefit of the individual served, in accordance with needs and goals identified in the treatment plan, to assist in the individual’s recovery/resiliency. Most contact occurs in community locations where the individual lives, works, attends school, and/or socializes. (B) Key service functions of community support shall include, but are not limited to: 1. Developing recovery goals and identifying needs, strengths, skills, resources, and supports and teaching individuals how to use them to support recovery, identifying barriers to recovery, and assisting individuals in the development and implementation of plans to overcome them; 2. Helping individuals restore skills and resources negatively impacted by their substance use disorder and/or co-occurring mental illness or emotional disorder including, but not limited to: A. Seeking or successfully maintaining employment or volunteering including, but not limited to, communication, personal hygiene and dress, time management, capacity to follow directions, planning transportation, managing symptoms/cravings, learning appropriate work habits, and identifying behaviors that interfere with work performance; B. Maintaining success in school including, but not limited to, communication with teachers, personal hygiene and dress, age appropriate time management, capacity to follow directions and carry out school assignments, appropriate study habits, and identifying and addressing behaviors that interfere with school performance; and C. Obtaining and maintaining housing in the least restrictive setting including, but not limited to, issues related to nutrition, meal preparation, and personal responsibility; 3. Supporting and assisting individuals in a crisis to access needed treatment services to resolve the crisis; 4. Continuing recovery planning and discharge planning with individuals who are hospitalized for a medical or behavioral health condition; 5. Assisting individuals, other natural supports, and referral sources in identifying risk factors related to relapse in mental illness and/or substance use disorders, developing strategies to prevent relapse, and advising and otherwise assisting individuals in implementing those strategies; 6. Promoting the development of positive support systems by providing information to family members/natural supports, as appropriate, regarding mental illness, emotional disorders, and/or substance use disorders and ways they can be of support to their family member’s recovery. Such activities must be directed toward the primary well-being and benefit of the individual served; 7. Developing and advising individuals on implementing lifestyle changes needed to cope with the side effects of psychotropic medications and/or to promote recovery/ resiliency from the disabilities, negative symptoms, and/or functional deficits associated with a mental illness, emotional disorder, and/or substance use disorder; and 8. Advising individuals on maintaining a healthy lifestyle including, but not limited to, recognizing the physical and psychological signs of stress, creating a self-defined daily routine that includes adequate sleep and rest, walking or exercise and appropriate levels of activity and productivity, involvement in creative or structured activities that counteract negative stress responses, learning to assume personal responsibility and care for minor illnesses and knowing when professional medical attention is needed. (6) Documentation. Documentation must be maintained in the individual record for each community support session, service, or activity in accordance with -7.030(13). The following must also be documented: (A) Phone contacts; and/or (B) Pertinent/significant information reported by family members/natural supports regarding a change in the individual’s condition and/or an unusual or unexpected occurrence in his/her life. AUTHORITY: section 630.655, RSMo 2016.* Original rule filed Jan. 19, 1989, effective April 15, 1989. Amended: Filed Dec. 13, 1994, effective July 30, 1995. Amended: Filed Nov. 10, 2020, effective May 30, 2021. *Original authority: 630.655, RSMo 1980. -4.100 Governing Authority (Rescinded October 30, 2001) AUTHORITY: sections 630.050, RSMo Supp. 1993 and 630.655, RSMo 1986. Original rule filed June 14, 1985, effective Dec. 1, 1985. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001. -4.110 Client Rights (Rescinded October 30, 2001) AUTHORITY: sections 630.050, RSMo Supp. 1993 and 630.655, RSMo 1986. Original rule filed June 14, 1985, effective Dec. 1, 1985. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001. -4.120 Environment (Rescinded October 30, 2001) AUTHORITY: sections 630.050, RSMo Supp. 1993 and 630.655, RSMo 1986. Original rule filed June 14, 1985, effective Dec. 1, 1985. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001. -4.130 Fiscal Management (Rescinded October 30, 2001) AUTHORITY: sections 630.050, RSMo Supp. 1993 and 630.655, RSMo 1986. Original rule filed June 14, 1985, effective Dec. 1, 1985. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001. -4.140 Personnel (Rescinded October 30, 2001) AUTHORITY: sections 630.050, RSMo Supp. 1993 and 630.655, RSMo 1986. Original rule filed June 14, 1985, effective Dec. 1, 1985. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001. -4.150 Research (Rescinded October 30, 2001) AUTHORITY: sections 630.050 and 630.655, RSMo 1986. Original rule filed June 14, 1985, effective Dec. 1, 1985. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001. -4.160 Client Records (Rescinded November 30, 2019) AUTHORITY: sections 630.050 and 630.655, RSMo 2000. Original rule filed June 14, 1985, effective Dec. 1, 1985. Amended: Filed Feb. 28, 2001, effective Oct. 30, 2001. Rescinded: Filed April 29, 2019, effective Nov. 30, 2019. -4.170 Referral Procedures (Rescinded October 30, 2001) AUTHORITY: sections 630.050 and 630.655, RSMo 1986. Original rule filed June 14, 1985, effective Dec. 1, 1985. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001. -4.180 Medication (Rescinded October 30, 2001) AUTHORITY: sections 630.050, RSMo Supp. 1993 and 630.655, RSMo 1986. Original rule filed June 14, 1985, effective Dec. 1, 1985. Rescinded: Filed Feb. 28, 2001, effective Oct. 30, 2001. -4.190 Outpatient Mental Health Treatment Programs PURPOSE: This rule prescribes policies and procedures for outpatient mental health treatment programs. (1) Each agency that is certified by the department as an outpatient mental health treatment program shall comply with all requirements set forth in Department of Mental Health Core Rules for Psychiatric and Substance Use Disorder Treatment Programs, -7.010 through -7.140. (A) The agency shall have written policies and procedures defining eligibility for services, screening, admission, and clinical assessment to assist in the support of each individual. (B) The program shall maintain reasonable hours to assure accessibility. (2) The program shall ensure an intake screening and admission assessment is conducted in accordance with -7.030 (1) and (2). (A) The following services shall be provided on an outpatient basis, in accordance with individual needs: 1. Crisis prevention and intervention; 2. Treatment planning; 3. Individual and group counseling; 4. Continuing recovery planning; and 5. Information and education. (3) Consent to Treatment. Each individual served or a parent/ guardian must provide informed, written consent to treatment. (A) A copy of the consent form, which must include the date of consent and signature of the individual served or a parent/ guardian, shall be retained in the individual record. (B) Consent to treat shall be updated annually, including the date of consent and signature of the individual served or a parent/guardian, and be maintained in the individual record. (4) Services shall be provided under the direction of an individual treatment plan as specified in -7.030(4). (A) An initial treatment goal shall be developed at intake to address immediate needs during the admission process to the outpatient treatment program. (B) The admission assessment and treatment plan shall be completed within the first three (3) outpatient visits. 1. Each individual shall participate in the development of their treatment plan. 2. For children and youth, the parent or guardian must participate in the development of the treatment plan and the child/youth shall participate, as appropriate. (C) Treatment plans shall be reviewed and updated every ninety (90) days to reflect the individual’s progress and changes in treatment goals and services. (D) Treatment plans must be revised and rewritten at least annually to align with the annual assessment to reflect current needs and goals. (E) Treatment plans shall be approved by a licensed mental health professional as defined in -4.035(2)(A). (5) Individual and group counseling must be delivered by a licensed mental health professional. (6) Each agency shall maintain an organized clinical record system in accordance with -7.030(13) which ensures easily retrievable, complete, and usable records stored in a secure and confidential manner. (A) Each agency shall implement written procedures to assure quality of individual records, including a routine review to ensure documentation requirements are being met. AUTHORITY: sections 630.050 and 630.655, RSMo 2016.* Original rule filed June 14, 1985, effective Dec. 1, 1985. Amended: Filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed April 29, 2019, effective Nov. 30, 2019. Amended: Filed March 9, 2022, effective Sept. 30, 2022. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008, and 630.655, RSMo 1980. -4.195 Access Crisis Intervention (ACI) Programs PURPOSE: This rule sets forth standards and regulations for ACI Programs. (1) The ACI program is provided or arranged by administrative agents. (2) The terms defined in section 630.005, RSMo are used in this rule. (3) Unless the context clearly requires otherwise, the following terms as used in this rule shall mean— (A) Access Crisis Intervention (ACI)—crisis intervention/ referral services provided twenty-four (24) hours per day, seven (7) days per week by telephone hotline or face-to-face mobile response at the location of the crisis or at another location in the community; (B) Administrative agent—an agency and its approved designee(s) authorized by the Division of Behavioral Health (DBH) as an entry and exit point into the state mental health service delivery system for a geographic service area defined by the department; (C) Advocate—individual who assists those receiving department-funded services with treatment planning, care issues, and the complaint/grievance and resolution process; (D) Community outreach/education plan—a plan outlining how individuals receiving services and their family members/ natural supports, advocates, state agencies, law enforcement and others in the community will become familiar with the local Access Crisis Intervention System; (E) Community Psychiatric Rehabilitation Program—a specialized program that provides or arranges for, at a minimum, the following core services: eligibility determination, initial comprehensive assessment, annual assessment, treatment planning, crisis intervention and resolution, medication services, physician/professional consultation services, medication administration, community support, metabolic syndrome screening (for individuals receiving antipsychotic medication), and psychosocial rehabilitation in a nonresidential setting for individuals with serious mental illness or serious emotional disturbances; (F) Community support—as defined in -4.047; (G) Crisis Intervention Team (CIT)—law enforcement officers with specialized training for response to behavioral health crisis; (H) Individual served—anyone receiving department-funded services directly from an organization/agency; (I) Internal agency protocol—a specific method indicating how the agency plans to respond to guidelines set forth by the department; (J) Mobile crisis response—specialized staff available twentyfour (24) hours per day, seven (7) days per week to assess and intervene face-to-face with individuals where the crisis is occurring or another secure location in the community; (K) Qualified Mental Health Professional (QMHP)—as defined in -7.140; (L) Risk assessment—the process of assessing dangerousness to self or others; (M) Residential crisis services—a service used for persons who are at high risk for hospitalization or who are being diverted from hospitalization and can include specific crisis stabilization units, group homes, residential, apartments, motels/hotels, and foster home type settings; (N) Specialized program—programs operated by an agency that provide specific services to designated eligible individuals enrolled in that program; (O) Telephone hotline services—a published, centralized, twenty-four (24) hours per day, seven (7) days per week staffed toll-free telephone number to provide direct means of crisis assessment and triage for individuals in crisis, their families/ natural supports, and agencies needing assistance; and (P) Withdrawal management/detoxification—support provided to persons served during withdrawal from alcohol and/or other drugs. (4) Records and Documentation Requirements. (A) A treatment plan is not required for individuals receiving only telephone hotline or mobile outreach through the ACI program. Evidence of coordination between the ACI staff and the treating staff for individuals currently receiving department-funded services, or those who are in the process of being admitted to a CPR program, must be documented in the individual record. (B) At a minimum, programs funded for ACI must keep the following records for telephone hotline services when possible to obtain from caller: 1. Date and time of telephone call; 2. Identity of caller, including but not limited to, parent, individual receiving services, law enforcement, judge, hospital, emergency room, mental health professional; 3. Name, address, telephone number, and date of birth; 4. Presenting problem; and 5. Disposition and follow-up. (C) ACI programs must have a method for retaining hotline data in compliance with -7.030. (D) When a call is received on behalf of another individual who is in crisis, the caller and the individual in crisis must both be identified as recipients of the crisis intervention services provided by the ACI program. For data collection purposes, the identified service recipient is the individual in crisis. (E) At a minimum, agencies providing ACI services must keep the following records for mobile outreach services when the individual agrees to provide identifying information: 1. Date and time of referral; 2. Date, time and place of face-to-face contact; 3. Person accompanying mobile worker; 4. Person in attendance at face-to-face contact; 5. Name, address, telephone number, date of birth; 6. Presenting problem; and 7. Disposition and follow-up. (F) The agency must document when the individual does not provide identifying information. (G) Agencies providing ACI services must submit data reports and documentation to the department in accordance with the department’s standardized form and protocol. (H) Agencies providing ACI services must meet the documentation and confidentiality requirements as defined in -7.030. (5) Treatment. (A) Each administrative agent must provide or arrange for the delivery of ACI services. (B) ACI programs must operate or arrange for a twenty-four- (24-) hour per day, seven (7) day per week telephone hotline. Each program shall have a written description of the telephone hotline system including the following: 1. Name of the agency or contractor that operates the hotline; 2. Numbers and qualifications of hotline staff; 3. Written documentation that clinical supervision is provided including, but not limited to: meeting minutes, supervision logs, or peer review processes; 4. Written description of how the telephone hotline is staffed; 5. Written documentation of case reviews and quality assurance activities relating to hotline services; 6. Written documentation of how telephone hotline services are provided to individuals who are deaf, have limited English proficiency, or are from cultural minority groups; 7. Written description of ongoing hotline outreach activities; and 8. Written description of a process for identifying and utilizing community resources in the delivery of telephone hotline service. (C) Each administrative agent must have a designated agency staff person or persons on call to the ACI system twenty-four (24) hours per day, seven (7) days per week. (D) If the individual served, advocate, family member/ natural support requests to speak with a staff member from a specialized program including, but not limited to, the CPR program’s community support specialist and the ACI clinical staff have determined this action is clinically necessary, the ACI hotline staff shall contact the appropriate designated agency staff person. (E) The ACI hotline staff shall remain in contact with the caller until a successful hand-off contact between caller and designated agency staff person has occurred. (F) Once contact between the caller and agency staff has occurred, the designated agency staff person shall respond to the caller and/or secure the appropriate requested specialized program personnel involved. (G) The designated agency staff person shall remain in contact with the caller until a successful hand-off or contact between specialized program personnel and caller has occurred. (H) Each administrative agent must have a written internal agency protocol in place for how the designated agency staff person will be able to contact staff from specialized programs that require twenty-four (24) hour, seven (7) day per week crisis intervention as a component of their service menu. (I) If ACI staff does not follow the procedure listed in subsection (H) of this rule, there must be a written protocol for contacting the ACI supervisor and the specialized program supervisor within twenty-four (24) hours to review the immediate action taken and then reviewed for a performance improvement process within forty-eight (48) hours. (J) ACI programs must have a written description for resource and referral to the following services: 1. Acute hospitalization; 2. Medical services; 3. Withdrawal management/detoxification services; 4. Priority outpatient scheduling within twenty-four (24) hours or the next working day; 5. Children and youth services; and 6. Psychiatric availability. (K) ACI programs must operate a twenty-four- (24-) hour per day, seven (7) day per week mobile response system. Each program shall have a written description of the mobile response system including the following: 1. Name of the agency or contractor that operates the mobile response system; 2. Written description of how mobile crisis response teams are staffed twenty-four (24) hours per day, seven (7) days per week; 3. Numbers and qualifications of staff; 4. Written documentation that clinical supervision is provided including, but not limited to: meeting minutes, supervision logs, or peer review processes; 5. Written documentation of case reviews and quality assurance activities relating to mobile response services; and 6. Written documentation of how mobile response services respond to individuals who are deaf, have limited English proficiency, or are from cultural minority groups. (L) ACI programs shall provide mobile response to known and unknown individuals twenty-four (24) hours per day, seven (7) days per week at the location of the crisis or another secure community location. (M) Mobile response shall not be provided exclusively in emergency rooms, jails, or mental health facilities. (N) When a call is referred to mobile response, a phone-only response is appropriate if the clinical needs of the person who is in crisis can be addressed over the phone and/or the crisis has been deescalated. (O) Each agency providing ACI services must have safety mechanisms in place for mobile response. These may include, but are not limited to: 1. Mobile phones; 2. Risk assessments for phone and continually during contact; 3. Availability of multiple staff to respond for face-to-face contact; 4. Backup availability; and 5. Written protocols for mobile response to be delivered in safe locations when necessary. (P) In crisis situations in which law enforcement need to be contacted by the ACI staff, the ACI staff must make the initial contact and remain involved until the crisis is resolved, by phone or with the mobile response team. 1. ACI staff shall first contact law enforcement officers trained in crisis intervention, if they are available in the city/ county where the crisis situation is taking place and ACI staff have established arrangements to make direct contact with them. (Q) If the caller is not satisfied, the grievance procedure must be followed as defined in -7.020(7). (6) Performance Improvement. (A) Each administrative agent must develop a community outreach/education plan that includes details of how the following groups will become familiar with the ACI system: 1. Families/natural supports; 2. Individuals receiving services; 3. Advocates of individuals receiving services; 4. State agencies including, but not limited to, the Department of Social Services, Family Support Division, Children’s Division, and Division of Youth Services; the Department of Health and Senior Services, Division of Senior and Disability Services; and the Department of Corrections, Division of Probation and Parole; 5. Emergency responders (law enforcement agencies, 911, paramedics); 6. Primary and secondary schools; 7. Court system including, but not limited to, juvenile, family, mental health, and drug courts; 8. Residential care programs, homeless shelters, public housing; 9. Public health agencies; 10. Community health centers; 11. Primary care medical offices; and 12. General public. (B) The community outreach/education plan must include the various action steps that will be taken in educating the community as to how to access the ACI system through written material and other means of communication. (C) The community outreach/education plan must indicate how the components will be accomplished on an ongoing basis. (D) Agencies providing ACI services must be able to demonstrate their community awareness and education activities, at least annually, in a report or other format specified by the department which may include, but is not limited to, number of hotline calls, walk-ins, media outreach, and outreach/educational efforts with schools, law enforcement, or other entities in the community. (E) The telephone number for ACI must be published in local telephone books distributed in each service area and be prominently displayed on agency websites and social media pages. (F) If the level of crisis services provided by an agency is significantly below the state average or other established benchmarks, this circumstance must be addressed in the performance improvement plan. (G) Agencies providing ACI services must promptly respond to requests from local institutions of higher education to assist in developing appropriate crisis response systems on college campuses. (7) Personnel and Staff Development. (A) Staff providing telephone hotline services must have a bachelor’s degree with three (3) years of behavioral health and crisis intervention experience or a master’s degree with one (1) year of behavioral health and crisis intervention experience. 1. Staff providing telephone hotline services must be supervised by a QMHP. 2. Staff providing telephone hotline services must have immediate access to a QMHP. (B) For mobile response, the mobile crisis team shall have at least one (1) QMHP to provide face-to-face crisis intervention for each mobile response. (C) Each administrative agent shall designate a coordinator for ACI services who must be a QMHP. (D) The agency shall have written documentation that clinical supervision is provided on a scheduled basis including, but not limited to: meeting minutes, supervision logs, or peer review processes. (E) For administrative agents that subcontract for hotline services this standard applies. Administrative agents shall have designated staff on call to the ACI system twenty-four (24) hours per day, seven (7) days per week for specialized programs. This designated staff person or persons shall have received crisis intervention training and have experience in responding to crisis situations with individuals and families. (F) Each agency shall have an ACI Training Plan. The training plan shall include individuals served, families/natural supports, and advocates in the development and implementation of the plan. (G) Staff providing ACI services shall complete the designated ACI training required by the department at least annually that includes, but is not limited to, the following core competencies as defined by the department: 1. Crisis intervention strategies and techniques; 2. ACI and legal issues; 3. Safety; 4. ACI responsiveness to individuals and families served; and 5. Available resources and services in the community. (H) ACI staff shall have a working familiarity with the core competencies prior to providing crisis intervention services. (I) New ACI staff shall be trained and document the demonstration of the core competencies within the first six (6) months of employment. (J) The administrative agent shall describe how the core competencies will be incorporated into the ACI staff training program on an ongoing basis. (K) Each agency shall provide a written plan of how it will measure the competencies of the ACI staff. The plan must include at least two (2) measurable outcomes including, but not limited to: 1. Review of case documentation; 2. Review of assessment forms for appropriate interventions; and 3. Question, answer, observation, and feedback by supervisory staff and peers. (L) New ACI staff must receive clinical supervision and jobshadow the supervisor or experienced crisis workers for a minimum of forty (40) hours prior to providing crisis services. AUTHORITY: sections 630.050 and 630.655, RSMo 2016.* Original rule filed Aug. 28, 2002, effective April 30, 2003. Amended: Filed Dec. 29, 2003, effective July 30, 2004. Amended: Filed April 29, 2019, effective Nov. 30, 2019. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.055, RSMo 1980.