Service Definitions, Staff Qualifications, and Documentation Requirements for Substance Use Disorder Treatment Programs

PURPOSE: This rule defines and describes services, staff qualifications, and documentation requirements for certified/ deemed certified substance use disorder treatment programs. (1) Service Definitions and Staff Qualifications. Services shall be provided as defined in this rule, in accordance with the organization’s certification and contractual status with the department. (A) Case management—links the individual and family members with needed services and supports. Key service functions include, but are not limited to: 1. Arranging for or referring individuals/family members to appropriate services/supports and resources; 2. Communicating with referral sources and coordinating services with other entities including, but not limited to, physical and behavioral healthcare providers, the criminal justice system, and social service agencies; and 3. Assisting individuals in resolving a crisis situation. 4. Services shall be provided by— A. A qualified addiction professional (QAP); B. An associate addiction counselor (AAC); or C. A staff person with a bachelor’s degree in social work, psychology, nursing, or a closely related field from an accredited college or university. Equivalent experience may be substituted on the basis of one (1) year for each year of required educational training. (B) Collateral dependent counseling (individual and group)— face-to-face, goal-oriented therapeutic interaction with an individual, or a group of individuals, to address dysfunctional behaviors and life patterns associated with being a family member of an individual who has a substance use disorder and is currently participating in treatment. Group sessions shall not exceed twelve (12) family members, which may involve multiple individuals engaged in treatment. 1. This service shall only be provided to family members of the individual in treatment when the services are for the direct benefit of the individual in accordance with his/her needs and goals identified in the treatment plan, and for assisting in the individual’s recovery. 2. The individual being served in treatment shall not participate in collateral dependent counseling sessions. 3. Key service functions include, but are not limited to: A. Exploration of substance use disorders and its impact on the family member’s functioning; B. Development of coping skills and personal responsibility for changing one’s own dysfunctional patterns in relationships; C. Examination of attitudes, feelings, and long-term consequences of living with a person with a substance use disorder; D. Identification and consideration of alternatives and structured problem-solving; E. Productive and functional decision-making; and F. Development of motivation and action by group members through peer support, structured confrontation, and constructive feedback. 4. Counseling for family members age five (5) and younger shall only be provided when the child is shown to have the requisite social and verbal skills to participate in and benefit from the service. 5. This service shall be provided by a Marital and Family Therapist or QAP practicing within his/her current competence. 6. Group services for children under age twelve (12) shall be provided by a graduate of an accredited college or university with a bachelor’s degree in counseling, psychology, social work, or closely related field. (C) Communicable disease counseling—assists individuals in understanding how to reduce the behaviors that interfere with their ability to lead healthy, safe lives and help them achieve optimal functioning and desired personal potential. Topics may include, but are not limited to, disclosing human immunodeficiency virus (HIV), sexually transmitted infections (STI), tuberculosis (TB) status, and/or substance use to family members/natural supports, addressing stigma in accessing services, maximizing healthcare service interactions, reducing substance use and avoiding overdose, and addressing anxiety, anger, and depressive episodes. 1. The program shall have a working relationship with the local health department, a physician, or other qualified healthcare practitioner to provide individuals with necessary testing for HIV, TB, STIs, and hepatitis. 2. Prior to an individual being tested for HIV, counseling shall be provided by a staff person who is knowledgeable about communicable diseases including HIV, STIs, and TB through training and/or previous employment experience. 3. The program shall make referrals and cooperate with appropriate entities to ensure coordinated treatment is provided for individuals with positive test results. 4. Post-test counseling may be provided for individuals who test positive for HIV or TB. Program staff providing post-test counseling must be knowledgeable about additional services and care coordination available through the Department of Health and Senior Services. 5. Program staff shall arrange and coordinate post-test follow-up for individuals who test positive for a STI or hepatitis. 6. This service shall be provided by a licensed mental health professional, QAP, or AAC who is knowledgeable about communicable diseases including HIV, STIs, and TB through training and/or previous employment experience. Knowledge shall include, but is not limited to, awareness of risks, disease management/treatment and resources for care, confidentiality requirements, and therapeutically assisting individuals in understanding and appropriately responding to test results. (D) Community support—as specified in 9 CSR 30-3.157; (E) Crisis prevention and intervention—face-to-face emergency or telephone intervention available twenty-four (24) hours per day, on an unscheduled basis, to assist individuals in resolving a crisis and providing support and assistance to promote a return to routine, adaptive functioning. 1. Minimum service functions shall include, but are not limited to: A. Interacting with the identified individual and his or her family members/natural supports, legal guardian, or a combination of these; B. Specifying factors that led to the individual’s crisis state, when known; C. Identifying maladaptive reactions exhibited by the individual; D. Evaluating potential for rapid regression; E. Attempting to resolve the crisis; and F. Referring the individual for treatment in an alternative setting when indicated. 2. Documentation must include— A. A description of the precipitating event(s)/situation when known; B. A description of the individual’s mental status; C. The intervention(s) initiated to resolve the individual’s crisis state; D. The individual’s response to the intervention(s); E. The individual’s disposition; and F. Planned follow-up by staff. 3. Services must be provided by a qualified mental health professional (QMHP) or QAP. Non-licensed or non-credentialed staff providing this service must have immediate, twenty-four (24) hour telephone access to consultation with a licensed physician/psychiatrist, licensed physician assistant, licensed assistant physician, or advanced practice registered nurse (APRN). (F) Day treatment—combines group rehabilitative support with medically necessary services that are structured and therapeutic and focus on providing opportunities for individuals to apply and practice healthy skills, decisionmaking, and appropriate expression of thoughts and feelings. 1. Day treatment shall be provided in a group setting. 2. Services shall be designed to assist individuals with compensating for or eliminating functional deficits and interpersonal and/or environmental barriers associated with a substance use disorder. Services are intended to restore individuals to being active and productive members of their family, community, and/or culture to the fullest extent possible. 3. Key service functions include, but are not limited to: A. Promoting an understanding of the relevance of the nature, course, and treatment of substance use disorders to assist individuals in understanding their individual recovery needs and how they can restore functionality; B. Assisting in the development and implementation of lifestyle changes needed to cope with the side effects of addiction, use of prescribed psychotropic medications, and/ or promote recovery from the disabilities, negative symptoms, and/or functional delays associated with a substance use disorder; and C. Assisting with the restoration of skills and use of resources to address symptoms that interfere with activities of daily living and community integration. 4. Services shall be provided by a team consisting of Group Rehabilitation Support Specialists and Day Treatment Technicians. (G) Drug testing—conducted to determine and detect an individual’s use of alcohol or other drugs and/or monitor compliance with a prescribed medication regimen as a necessary support and adjunct to treatment. 1. Drug testing may be of greater importance for individuals— A. With known or suspected diversion of medication for substance use disorders; B. Who present in person to the program with symptoms and signs of intoxication or withdrawal; C. With a self-reported or otherwise identified overdose; and D. With significantly unstable opioid and/or other substance use disorders. 2. Test results shall be discussed with persons served in order to intervene with substance use behavior, including updates to the treatment plan based on test results. 3. Test results and actions taken shall be documented in the individual record, including the category or type of test (on-site or laboratory), the number of panels, types of drugs tested for, and the test results. 4. Drug testing may be performed on-site or sent to a laboratory. A laboratory which analyzes specimens must meet all applicable state and federal laws and regulations. 5. Written policies and procedures regarding the collection and handling of specimens shall be implemented. Urine or other specimens shall be collected in a manner that communicates respect for persons served, while taking reasonable steps to prevent falsification of samples. 6. The program shall implement written policies and procedures outlining the interpretation of results and actions to be taken when the presence of alcohol or other drugs has been determined. (H) Family conference—intervention that enlists the assistance of the individual’s support system through meeting with family members, referral sources, and other natural supports about the individual’s treatment plan, continuing recovery plan, and discharge plan. The service must include the individual served and be for his/her direct benefit in accordance with needs and goals identified in the treatment plan and to assist in his/her recovery. 1. Key service functions include, but are not limited to: A. Communicating about issues in the individual’s home that are barriers to achieving his/her treatment goals; B. Identifying relapse triggers and establishing a continuing recovery plan; C. Assessing the need for family therapy or other referrals to support the family system; and D. Participating in continuing recovery and discharge planning conferences. 2. Services shall be provided by a QAP or AAC. 3. Documentation must indicate the relationship of the family members and/or other participants to the individual in treatment. (I) Family therapy—face-to-face counseling or family-based therapeutic interventions (such as role playing or educational discussions) for the individual served and/or one (1) or more of his/her family members/natural supports. Services must be for the direct benefit of the individual served in accordance with his/her treatment needs and goals and to assist in their recovery. 1. Services shall address and resolve patterns of dysfunctional communication and interactions that have become persistent over time, particularly as they relate to alcohol and/or other drug use. 2. Services may be offered to members of a single family or members of multiple families dealing with similar issues. 3. Services may be provided in an office setting or the individual’s home, depending on those involved. 4. Key service functions include, but are not limited to: A. Utilizing generally accepted principles of family therapy to influence family interaction patterns; B. Examining family interaction styles, confronting patterns of dysfunctional behavior, and strengthening communication patterns that promote healthy family function; C. Facilitating family participation in family self-help recovery groups; D. Developing and applying skills and strategies for improving family functioning; and E. Promoting healthy family interactions independent of formal helping systems. 5. Documentation must indicate the relationship of the family members/natural supports to the individual engaged in treatment. 6. In any calendar month, for fifty percent (50%) of family therapy sessions, the individual engaged in treatment must be present, in addition to one (1) or more of his/her family members/natural supports. Family members younger than age twelve (12) can be counted as one (1) of the required family members when the child is shown to have the requisite social and verbal skills to participate in and benefit from the service. 7. Services shall be provided by a professional who— A. Is licensed or provisionally licensed in Missouri as a marital and family therapist; or B. Has a degree in marriage and family therapy, psychology, social work, or counseling and— (I) Has at least one (1) year of supervised experience in family therapy and has specialized training in family therapy; or (II) Receives close supervision from a professional who meets the requirements of subparagraph (1)(I)7.A. and B. of this rule; or C. A QAP who receives close supervision from an individual who meets the requirements of subparagraphs (1) (I)7.A. and B. of this rule. (J) Group counseling—face-to-face, goal-oriented therapeutic interaction between a counselor and two (2) or more individuals based on needs and goals specified in their treatment plans. Services shall be designed to promote individual functioning and recovery through personal disclosure and interpersonal interaction among group members. 1. This service can include trauma-related symptoms and co-occurring behavioral health and substance use disorders. 2. Evidence-based practices, such as motivational interviewing and cognitive behavioral therapy, shall be utilized by appropriately trained staff. 3. Some scheduled group sessions may not be applicable to or appropriate for all individuals, therefore, participation shall be on a designated or selective basis. Examples of designated or selective groups include, but are not limited to, parenting skills, budgeting, anger management, domestic violence, cooccurring disorders, life skills, and trauma. 4. Key service functions include, but are not limited to: A. Facilitating individual disclosure of addiction-related issues which permits generalization of the issues to the larger group; B. Promoting recognition of addictive thinking and behaviors and teaching strategies that support non-use of alcohol and/or other drugs that interfere with the individual’s functioning; C. Preparing individuals to cope with physical, cognitive, and emotional symptoms of craving alcohol and/or other drugs; D. Encouraging and modeling productive and positive interpersonal communication; and E. Developing motivation and action by group members through peer influence, structured confrontation, and constructive feedback. 5. Services shall be provided by a QAP, QMHP, AAC, or an intern/practicum student as specified in 9 CSR 10-7.110(5). 6. The usual and customary group size is twelve (12) individuals. The size of group counseling sessions shall not exceed an average of twelve (12) individuals during a calendar month, per facilitator, per group. 7. A group log or documentation in the individual record (paper or electronic format) shall be maintained for each session documenting the type of service, summary of the service, date, actual beginning and ending time of the group, each individual’s in and out time, and the signature and title of the staff member providing the service. Signature stamps shall not be used. (K) Group rehabilitative support—facilitated group discussions based on individual needs and treatment plan goals to promote an understanding of the relevance of the nature, course, and treatment of substance use disorders to assist individuals in understanding their recovery needs and how they can restore functionality. 1. Key service functions include, but are not limited to: A. Classroom style didactic lecture to present information about a topic and its relationship to substance use; B. Presentation of audio-visual materials that are educational in nature with required follow-up discussion. Instructional aids shall be incorporated into education sessions to enhance understanding and promote discussion and interaction among individuals. Aids may include, but are not limited to, DVDs or other electronic media, worksheets, and informational handouts and shall not comprise more than twenty percent (20%) of group rehabilitative support sessions; C. Promotion of discussion and questions about the topic presented to the individuals in attendance; and D. Generalization of the information and demonstration of its relevance to recovery and enhanced functioning. 2. The program shall develop a schedule and curriculum for delivery of group rehabilitative support that addresses topics and issues relevant to the individuals served. Individuals shall attend group sessions that are relevant to their needs and goals based on the assessment and interventions recommended in their individual treatment plan. 3. Services shall be provided by a group rehabilitation support specialist who is present throughout the session and— A. Is suited by education, background, or experience to present the information being discussed; B. Demonstrates competency and skill in facilitating group discussions; and C. Has knowledge of the topic(s) being taught. 4. Group size shall not exceed an average of thirty (30) individuals during a calendar month, per facilitator, per group session. 5. A group log or documentation in the individual record (paper or electronic format) shall be maintained for each session documenting the type of service, summary of the service, date, actual beginning and ending time of the group, each individual’s in and out time, and the signature and title of the staff member providing the service. Signature stamps shall not be used. (L) Individual counseling—face-to-face, structured, and goaloriented therapeutic counseling designed to resolve issues related to the use of alcohol and/or other drugs that interfere with the individual’s functioning. 1. Evidence-based interventions including, but not limited to, motivational interviewing, cognitive behavioral therapy, and trauma-informed care shall be utilized, when appropriate. 2. Key service functions shall include, but are not limited to: A. Exploration of an identified problem and its impact on the individual’s functioning; B. Examination of attitudes, feelings, and behaviors that promote recovery and improved functioning; C. Identification and consideration of alternatives and structured problem-solving; D. Discussion of skills to aid in making positive decisions; and E. Application of information presented in the program to the individual’s life situation to promote recovery and improved functioning. 3. Services shall be provided by a QAP, QMHP, AAC, or an intern/practicum student as specified in 9 CSR 10-7.110(5). (M) Individual counseling, co-occurring disorders— individual, face-to-face, structured and goal-oriented therapeutic interaction between an individual and a counselor designed to identify and resolve issues related to substance use and co-occurring mental illness functioning. 1. This service must be provided by— A. A licensed or provisionally licensed qualified mental health professional (QMHP); B. An individual holding the Co-Occurring Disorders Professional or Co-Occurring Disorders Professional/Diplomate credential from the Missouri Credentialing Board; C. A non-licensed QMHP who meets the co-occurring counselor competency requirements established by the department; or D. A QAP who meets the co-occurring counselor competency requirements established by the department. (N) Individual counseling, trauma—individual, face-to-face counseling provided to the individual in accordance with his/ her treatment plan to resolve issues related to psychological trauma in the context of a substance use disorder. Personal safety and empowerment of the individual must be addressed. 1. This service must be provided by a— A. Licensed or provisionally licensed mental health professional; or B. Professional licensed by the Missouri Division of Professional Registration who is practicing within their current competence. 2. Qualified staff must have specialized training on trauma and trauma-informed care and/or equivalent work experience and shall utilize an evidence-based treatment model for the delivery of this service. (O) Medication services—goal-oriented interaction to assess the appropriateness of medications in an individual’s treatment, periodic evaluation/reevaluation of the efficacy of prescribed medications, and ongoing management of a medication regimen within the context of the individual’s treatment plan. 1. Key service functions include, but are not limited to: A. Assessment of the individual’s presenting condition; B. Mental status exam; C. Review of symptoms and screening for medication side effects; D. Review of functioning; E. Assessment of the individual’s ability to self-administer medications; F. Education regarding the effects of medication and its relationship to the individual’s substance use disorder and/or mental illness; and G. Prescription of medication(s), when indicated. 2. Services shall be provided by a licensed physician, or licensed psychiatrist, or licensed physician assistant, licensed assistant physician, or APRN who is in a collaborating practice agreement with a licensed physician. (P) Medication services support—medical and other consultative services for the purpose of monitoring and managing an individual’s health needs while taking medications. 1. Services must be provided by a registered nurse (RN) or licensed practical nurse (LPN). (Q) Peer and family support—coordinated services within the context of a comprehensive, individualized treatment plan that includes specific individualized goals. Services are person-centered and promote the individual’s ownership of his/her treatment plan. 1. Services may be provided to the individual’s family/ natural supports when the services are for the direct benefit of the individual served in accordance with his/her needs and goals identified in the treatment plan and to assist in the individual’s recovery. 2. Key service functions include, but are not limited to: A. Planning in a person-centered manner to promote the development of self-advocacy skills; B. Empowering the individual to take a proactive role in developing, updating, and implementing his/her personcentered treatment plan; C. Providing crisis support; D. Assisting the individual and his/her family and other natural supports in the use of positive self-management techniques, problem-solving skills, coping mechanisms, symptom management, and communication strategies identified in the treatment plan, so the individual remains in the least restrictive setting, achieves recovery and resiliency goals, self-advocates for quality physical and behavioral health services, and has access to strength-based behavioral health and physical health services in the community; E. Assisting individuals and their family members/ natural supports in identifying strengths and personal/family resources to aid recovery, promote resilience, and recognize their capacity for recovery/resilience; F. Serving as an advocate, mentor, or facilitator for resolution of issues and skills necessary to enhance and improve the health of a child/youth with a substance use and/ or co-occurring disorder; and G. Providing information and support to the parent(s)/ caregiver(s) of a child who has a serious emotional disorder so they have a better understanding of the child’s needs, the importance of his/her voice in the development and implementation of the individual treatment plan, the roles of the various service/support providers and the importance of the team approach, and assisting in the exploration of options to be considered as part of treatment. 3. Services shall be provided by a certified peer specialist or family support provider. (R) Withdrawal management/detoxification, as defined in 9 CSR 30-3.120. (2) Ratio of Qualified Addiction Professionals. A majority of the program’s staff who provide individual and group counseling shall be Qualified Addiction Professionals (QAP). (3) Supervision of Associate Counselors. If an AAC provides individual or group counseling, he/she shall meet the requirements of the Missouri Credentialing Board or the appropriate board of professional registration within the Department of Commerce and Insurance. All counselor functions performed by an AAC shall be performed pursuant to the supervisor’s authority, oversight, guidance, and full professional responsibility. (A) The supervisor shall review and countersign documentation in individual records made by the AAC. (B) Documentation which must be countersigned includes the initial treatment plan, treatment plan updates, and discharge summaries. (C) A training plan must be in place for each AAC and be available for review by department staff or other authorized representatives. (4) Credentials for Supervisor of Counselors. Unless otherwise required by these rules, supervision of counselors must be provided by a QAP who has— (A) A degree from an accredited college in an approved field of study; or (B) Four (4) or more years of employment experience in the treatment and rehabilitation of persons with substance use disorders. AUTHORITY: sections 630.050, 630.655, and 631.010, RSMo 2016.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed Sept. 25, 2002, effective May 30, 2003. Rescinded and readopted: Filed May 28, 2021, effective Dec. 30, 2021. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008; 630.655, RSMo 1980; and 631.010, RSMo 1980.