Service Delivery Process and Documentation

PURPOSE: This rule describes requirements for the delivery and documentation of services in Opioid Treatment Programs, Substance Use Disorder Treatment Programs, Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), Gambling Disorder Treatment Programs, Community Psychiatric Rehabilitation Programs (CPR), and Outpatient Mental Health Treatment Programs. (1) Screening. The organization shall implement written policies and procedures to ensure individuals seeking assistance via telephone, in person, or by referral have prompt access to screening to determine the need for further clinical assessment. The screening process is welcoming, conducted in a safe, culturally and linguistically appropriate manner, and conveys a hopeful message to individuals and their families/ natural supports. (A) At the individual’s first contact with the organization (whether by telephone or in person), emergency, urgent, or routine service needs shall be identified and addressed as follows: 1. Emergency service needs are indicated when a person presents a likelihood of immediate harm to self or others Qualified staff must address emergency needs immediately; 2. An urgent need is one that, if not addressed immediately, could result in the individual becoming a danger to self or others or could cause a health risk. Appropriately qualified staff shall address urgent service needs within one (1) business day of the time the request was made; and 3. Routine service needs are indicated when a person requests services or follow-up but otherwise presents no significant impairment in the ability to care for self and no apparent harm to self or others. Routine service needs shall be addressed within ten (10) days. (B) Documentation of the screening shall include but is not limited to— 1. A brief interview with the individual or referral source to obtain basic information and presenting situation and symptoms; 2. Collection of basic demographic information; 3. Identification of requested service needs; 4. Determination of the organization’s ability to provide the requested services; and 5. Referral and coordination with alternate resources when the screening agency cannot meet the individual’s service needs. (C) The organization’s performance improvement processes shall ensure trained staff uniformly administer its designated screening instrument(s). Each screening shall be signed and documented by staff. (2) Admission Assessment. The organization shall implement written policies and procedures to ensure all individuals participate in an admission assessment to determine service needs. Programs should only admit individuals who will benefit from available services. Comprehensive Substance Treatment and Rehabilitation (CSTAR) programs must comply with assessment requirements specified in 9 CSR 30-3.151 and fulfill department contract requirements. Community Psychiatric Rehabilitation (CPR) programs must comply with assessment requirements specified in 9 CSR 30- 4.035 and fulfill contract requirements. (A) Documentation of the admission assessment shall include but is not limited to— 1. Personal and identifying information; 2. Presenting problem and referral source; 3. Status as a current or former member of the U.S. Armed Forces; 4. Brief history of previous substance use and/or psychiatric treatment, including the type of admission(s); 5. Family history of substance use disorders and/or mental illness; 6. Trauma history (experienced and/or witnessed abuse, neglect, violence, sexual assault) and whether the individual receiving services has concerns for their safety, such as intimate partner violence; 7. Current medications and any known allergies or allergic reactions; 8. Current substance use, including utilization of a standardized and validated alcohol and substance-use MENTAL HEALTH screening instrument; 9. Current mental health symptoms, including utilization of standardized and validated depression and suicide screening instruments; 10. Physical health concerns, including a health screening, previously identified medical diagnoses, and identification of unmet needs with specific recommendations for further evaluation, treatment, and referral; 11. Diagnosis and clinical summary by a licensed mental health professional, including substance use and mental health; 12. Family, social, legal, and vocational/educational status and functioning; 13. Statement of needs, goals, preferences, and treatment expectations; 14. Current housing situation; and 15. Dated signature, title, and credential(s) of staff completing the assessment. Signature stamps/typed signatures shall not be used. (B) The admission assessment shall be completed within seventy-two (72) hours for individuals in a residential level of care or within the first three (3) outpatient visits. (3) Consent to Treatment. Each individual served or a parent/ guardian must provide informed, written consent to treatment. (A) A copy of the consent form, which must contain the date of consent and signature of the individual served or a parent/ guardian, shall be retained in the individual record. (B) Consent to treat shall be updated annually, including the date of consent and signature of the individual served or a parent/guardian, and be maintained in the individual record. (4) Crisis Prevention Plan. If a potential risk for suicide, violence, or other at-risk behavior (such as increased isolation, increased substance use, heightened depression or anxiety) is identified during the assessment process and any time during the individual’s time in services, a crisis prevention plan shall be developed with the individual as soon as possible. (A) At a minimum, the crisis prevention plan shall include factors that may precipitate a crisis, a hierarchical list of selfcare and self-help strategies identified by the individual to regain a sense of control to return to their level of functioning before the crisis or emergency, and a hierarchical list of staff interventions that may be used when a critical situation occurs. (B) Staff shall conduct a monthly case review of all critical interventions that occurred during the previous month and incorporate the results into the organization’s performance improvement processes. (5) Individual Treatment Plan. Each individual and/or their parent or guardian shall participate in developing a treatment plan using information from the assessment process and shall receive a copy of the plan. CSTAR programs shall comply with treatment plan requirements specified in 9 CSR 30-3.151 and fulfill department contract requirements. CPR programs shall comply with treatment plan requirements specified in 9 CSR 30-4.035 and fulfill contract requirements. (A) The treatment plan shall include but is not limited to— 1. Identifying information; 2. Objectives that— A. Are reflective of the individual’s culture and ethnicity; B. Are linked to the individual’s assessed needs and goals; C. Are achievable, measurable, time specific, strengths- and skills-based; D. Identify supports and resources needed to meet objectives; and E. Are understandable, developmentally appropriate, and responsive to the disability/disorder or concerns of the individual; 3. Duration and frequency of interventions, staff responsible for intervention, and action steps of the individual and parents/guardians, family, or other natural supports; 4. Other community resources and/or peer, family, and recovery supports necessary; and 5. Dated signature, title, and credential(s) of staff completing the plan. Signature stamps/typed signatures shall not be used. The individual shall also sign the plan unless a current signed consent to treatment is included in the individual record. (B) A licensed mental health professional shall approve (sign/ date) treatment plans. Signature stamps/typed signatures shall not be used. (6) Treatment Plan Updates. Progress toward treatment goals and objectives shall be reviewed and updated on a periodic basis with active involvement of the individual served, parent/ guardian, and family members/natural supports as applicable and appropriate. (A) At a minimum, treatment plans shall be reviewed every six (6) months to assess continued need for services, responses to treatment, and progress achieved during the past six (6) months. The occurrence of a crisis or significant clinical event may require further review and modification of the treatment plan. Updates must be documented in the individual record. (B) The dated signature(s), title(s), and credential(s) of staff completing the review must be included on the treatment plan update. The individual served shall also sign the plan unless there is a current signed consent to treatment included in the individual record. (7) Ongoing Service Delivery. The individual treatment plan guides ongoing service delivery. Services may begin before the admission assessment and treatment plan are fully developed. (A) Staff with appropriate training, licenses, and credentials shall provide identified services and supports. (B) Services shall be provided in accordance with applicable eligibility criteria. Decisions regarding the treatment setting, intensity, and duration of services are based on the needs of the individual, including but not limited to— 1. Need for personal safety and protection from harm; 2. Severity of the behavioral health disorder; 3. Emotional and behavioral functioning and need for structure; 4. Social, family, and community functioning; 5. Readiness to change; 6. Availability of peer and social supports for recovery/ resiliency; 7. Ability to avoid high-risk behaviors; and 8. Ability to cooperate with and benefit from the services offered. (C) Services shall be developmentally appropriate and responsive to the individual’s social/cultural situation and any linguistic/communication needs. (D) Coordination of care is demonstrated when multiple agencies or programs are providing services and supports. (E) To the fullest extent possible, individuals are responsible for action steps to achieve their goals. Services and supports provided by staff should be readily available to help individuals achieve their goals and objectives. (8) Missed Appointments. Organizations shall implement written policies and procedures to contact individuals who miss a scheduled program activity or appointment consistent with their service needs. (A) Such efforts shall be initiated within forty-eight (48) hours unless circumstances indicate an immediate contact should be made due to the individual’s symptoms and functioning or the nature of the scheduled service. (B) Efforts to contact the individual shall be documented. (9) Service Transition, Transfer, and Discharge Planning. The organization shall implement written policies and procedures for developing transfer, transition, and discharge plans for individuals served. (A) Transfer, transition, and discharge planning begins at admission, or as soon as clinically appropriate, to assist the individual in moving from one level of care to another within the organization or obtain needed services from another service provider. 1. Individuals are actively involved in developing their transfer, transition, and/or discharge plan. Family members/ natural supports, program staff, referral source(s), and staff or peers involved in follow-up services and supports in the community are included when applicable and permitted. 2. The plan shall be signed by the staff person who completes it. The individual served and/or parents/legal guardians, family members, or other natural supports shall receive a copy of the plan, as appropriate. 3. The transition and discharge plans identify services and supports, designated provider(s), and other planned activities designed to support the gains achieved by the individual during participation in services. Plans shall include but are not limited to— A. Date of next appointment(s) for follow-up services or other supports, as applicable; B. Action steps to access support system(s) or other resources to assist in community integration and obtain help if symptoms recur and additional services/supports are needed; C. Safe use of medication(s) as prescribed; D. Referral information such as contact name, telephone number, locations, hours, and days of services, when applicable; and E. Action steps for maintaining a healthy lifestyle such as exercising, volunteering, participating in support groups, and managing personal finances. (B) A written discharge summary shall be completed to ensure the individual record includes documented treatment episode(s) and the outcome of each episode, including but not limited to— 1. Date of admission and discharge; 2. Identified needs at admission; 3. Referral source, as applicable; 4. Services provided and the extent to which established goals and objectives were achieved; 5. Reason(s) for or type of discharge; 6. Diagnosis or diagnostic impression at last contact; 7. Recommendations for continued services and supports; 8. Information on medication(s) prescribed or administered, as applicable; and 9. Dated signature, title, and credential(s) of staff completing the discharge summary/discharge plan (not a signature stamp or typed signature). (C) Follow-up with individuals who have an unplanned discharge shall be conducted in accordance with the organization’s written policies and procedures which include but are not limited to— 1. Clarifying the reason for the unplanned discharge; 2. Determining if further services are needed; and 3. Referring the individual to other necessary services, if applicable. (D) The organization shall implement written policies and procedures to ensure a seamless transition for individuals who transfer to more or less intensive services, to another component of care, or are being discharged from the program. (10) Crisis Assistance and Intervention. Ready access to crisis assistance and intervention shall be available to all individuals served, when needed. (A) The organization shall directly provide or arrange for crisis assistance to be available twenty-four (24) hours per day, seven (7) days per week. Services shall be provided by qualified staff in accordance with applicable program rules and include in-person intervention when clinically indicated. (B) If the organization utilizes the services of the designated Access Crisis Intervention (ACI), 988 Call Center, or Mobile Crisis Response provider for the region, a formal written agreement, memorandum of understanding, or contractual relationship shall be established and documented to support the coordination of services and sharing of information to meet individual needs. (C) If crisis services are provided within the organization, there shall be more than one (1) staff person designated to ensure coverage during leaves of absence. (11) Service Delivery Practices. The organization shall incorporate evidence-based and emerging best practices into its service array that are designed to— (A) Support the recovery, resiliency, health, and wellness of the individuals and families/natural supports served; (B) Enhance the quality of life for individuals and families/ natural supports served; (C) Reduce symptoms or needs and build resilience; (D) Restore and/or improve functioning; and (E) Support the integration of individuals into the community. (12) Utilization Review. Services funded by the department are subject to utilization review by department staff to ensure they are necessary, appropriate, likely to benefit the individual, and provided in accordance with admission criteria and service definitions. The department has authority in all matters subject to utilization review including eligibility, service definition, authorization, and limitations. (13) Designated or Required Instruments. In order to promote consistency in clinical practice, eligibility determination, service documentation, and outcome measurement, the department may require the use of designated instruments in the screening, assessment, and treatment process. The required use of particular instruments is applicable to services funded by the department. (14) Organized Record System and Documentation Requirements. The organization must maintain an organized clinical record system that ensures easily retrievable, complete, and usable records stored in a secure and confidential manner. (A) The organization shall implement written policies and procedures to ensure— 1. All local, state, and federal laws and regulations related to the confidentiality of records and release of information are followed; MENTAL HEALTH 2. Electronic health record systems conform to federal and state regulations; 3. Individual records are retained for at least six (6) years or until all litigation, adverse audit findings, or both, are resolved; 4. Ready access to paper or electronic records requested by authorized staff and/or other authorized parties, including department staff; 5. Any errors are marked through with a single line, initialed, and dated by the staff person making the correction; and 6. All services provided are adequately documented in the individual record to ensure the type(s) of services rendered and the amount of reimbursement received by the organization can be readily discerned and verified with reasonable certainty. A. Adequate individual records are of the type and in a form such that symptoms, conditions, diagnoses, treatments, prognosis, and the identity of the individual to which these things relate can be readily discerned and verified with reasonable certainty. All documentation must be available at the site where the service was rendered. The record must be legible and made contemporaneously with the delivery of the service (at the time the service was performed or within five (5) business days of the time it was provided), address the individual’s specifics including, at a minimum, individualized statements that support the assessment or treatment encounter. (B) Unless specified otherwise by another payer source(s), all treatment sessions must have accompanying documentation that includes the following: 1. First name, last name, and middle initial or date of birth of the individual and any other identifying information required by a payer source, such as a Document Control Number (DCN); 2. Accurate, complete, and legible description of each service provided; 3. Name, title, credential(s), and dated signature of the provider/staff delivering the service (not a signature stamp or typed signature); 4. Name of referring entity, when applicable; 5. Date of service (month/day/year); 6. Actual begin and end time taken to deliver a service; 7. Setting in which the service was provided; 8. Plan of treatment, evaluation(s), test(s), findings, results, and prescription(s), as necessary; 9. Need for the service(s) in relationship to the individual treatment plan; 10. Individual’s progress toward the goals stated in the individual treatment plan; and 11. For applicable programs, adequate invoices, trip tickets/ reports, activity log sheets. (C) The content of the individual record must include but is not limited to— 1. Signed consent to treatment, updated annually; 2. Documented acknowledgment of orientation to the program; 3. Screening, admission assessment, treatment plan, and related reviews/updates; 4. Service delivery and progress notes; 5. Transfer, transition, and discharge plan(s), as applicable. 6. Documentation of any referral(s) to other services or community resources and outcome of those referrals; 7. Signed authorization(s) to release confidential information, as applicable; 8. Missed appointments and efforts to reengage the individual, as applicable; 9. Urine drug screening(s) or other lab reports, as applicable; 10. Crisis or other significant clinical events; 11. Follow-up for an unplanned discharge, as applicable; and 12. Proof of purchase for medications, housing, transportation, or other services/supports utilized by the individual during the episode of care. (15) The organization is subject to recoupment of all or part of reimbursement from the department if individual records do not document— (A) The service was actually provided; (B) The service was delivered by a qualified staff person within established program time frames; (C) The service meets the service definition; (D) The amount, duration, and length of service; and (E) The services/supports were delivered under the direction of a current treatment plan, including but not limited to medication(s), transportation, and housing. (16) Other Regulations. Core Rules for Psychiatric and Substance Use Disorder Treatment Programs apply to all organizations that are certified/deemed certified by the department to provide behavioral health and/or substance use disorder treatment services. (A) Organizations that have a contract with the department shall comply with contractual requirements as well as program-specific regulations, which take precedence over Core Rules if there is a conflict. AUTHORITY: sections 630.050 and 630.055, RSMo 2016.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed Dec. 12, 2001, effective June 30, 2002. Amended: Filed Nov. 5, 2018, effective June 30, 2019. ** Amended: Filed March 5, 2024, effective Oct. 30, 2024. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008, and 630.055, RSMo 1980. **Pursuant to Executive Order 21-09, 9 CSR 10-7.030, subsection (2)(B) and paragraph (4)(A)5. was suspended from April 23, 2020 through December 31, 2021.