Eligibility Determination, Assessment, and Treatment Planning in Comprehensive Substance Treatment and Rehabilitation (CSTAR) Programs

PURPOSE: This rule specifies the eligibility determination, assessment, treatment planning, and documentation requirements for Comprehensive Substance Treatment and Rehabilitation (CSTAR) programs. 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) 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. (2) Eligibility Determination. Eligibility determination may be completed to expedite the admission process for individuals seeking services. Eligibility determination requires a diagnosis and placement in a level of care. (A) A diagnosis shall be rendered in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR), 2022, hereby incorporated by reference and made a part of this rule, published by and available from the American Psychiatric Association, 800 Maine Avenue SW, Suite 900, Washington, DC 20024, (202) 559-3900. This rule does not incorporate any subsequent amendments or additions to this publication. (B) The following licensed or provisionally licensed mental health professionals (LMHP) are approved to render diagnoses. Professionals possessing the credentials listed below are expected to provide services within their scope of practice in the area(s) in which they are adequately trained and should not practice beyond their individual level of competence: 1. Physician (including psychiatrist); 2. Physician assistant; 3. Assistant physician; 4. Resident physician (including psychiatrist); 5. Advanced practice registered nurse (APRN); 6. Psychologist; 7. Professional counselor; 8. Marital and family therapist; and 9. Licensed clinical social worker. (C) Individuals shall be placed in a level of care utilizing The ASAM Criteria: Treatment Criteria for Addictive, SubstanceRelated, and Co-Occurring Conditions, 2013, hereby incorporated by reference and made a part of this rule, developed by and available from the American Society of Addiction Medicine, Inc., 11400 Rockville Pike, Suite 200, Rockville, MD 20852, (301) 656-3920. This rule does not incorporate any subsequent amendments or additions to this publication. (D) Eligibility determination shall be completed by qualified staff as follows: 1. An LMHP conducts a diagnostic assessment, including dated signature; or 2. A qualified addiction professional (QAP) or qualified mental health professional (QMHP) assists in obtaining information from the individual to complete the eligibility determination with finalization by an LMHP for completion of the diagnosis and clinical summary, including dated signature. (E) Documentation of eligibility determination, with inclusion of The ASAM Criteria (abbreviated) as referenced in subsection (2)(C) of this rule, must include the following: 1. Presenting problem and referral source; 2. Brief history of previous substance use disorder/ psychiatric treatment, including type of admission; 3. Current medications; 4. Current substance use supporting the diagnosis; 5. Current mental health symptoms; 6. Current medical conditions; 7. Diagnoses, including substance use, mental disorders, medical conditions, and notation for psychosocial and contextual factors; 8. Functional assessment using a department-approved instrument, if required; 9. Identification of urgent needs including suicide risk, personal safety, and risk to others; 10. Initial treatment recommendations; 11. Initial treatment goals to meet immediate needs within the first forty-five (45) days of service; and 12. Dated signature(s), title(s), and credential(s) of staff determining eligibility. (3) Comprehensive Assessment. A comprehensive assessment shall be completed for each individual as follows: (A) On the date of admission or within seven (7) days of the date of CSTAR eligibility determination, if completed, for individuals admitted to a residential level of care; or (B) On the date of admission or within thirty (30) days of the date of CSTAR eligibility determination, if completed, for individuals admitted to an outpatient level of care; (C) If a diagnosis was rendered through eligibility determination, other trained staff may assist in collecting assessment information from the individual with finalization by a QAP or QMHP, including development of treatment recommendations; (D) If a diagnosis is rendered during the assessment process, finalization by an LMHP is required for completion of the diagnosis and clinical summary; (E) The ASAM Criteria as referenced in subsection (2)(C) of this rule shall be utilized in completing the comprehensive assessment. Documentation of the comprehensive assessment shall include but is not limited to the following: 1. Basic information (demographics, age, language spoken); 2. Presenting concerns from the perspective of the individual, including reason for referral/referral source, what occurred to cause them to seek services; 3. Risk assessment for determining emergency, urgent, or routine need for services (suicide, safety, risk to others); 4. Trauma history (experienced and/or witnessed abuse, neglect, violence, sexual assault); 5. Substance use treatment history and current use including alcohol, tobacco, and/or other drugs. For children/ youth, prenatal exposure to alcohol, tobacco, or other substances; 6. Mental status; 7. Mental health treatment history; 8. Medication information including current medications, medication allergies/adverse reactions, efficacy of current or previously used medications; 9. Physical health summary (health screen, current primary care, vision and dental, date of last examinations, current medical concerns, body mass index, tobacco use status, and exercise level. Immunizations for children/youth and medical concerns expressed by family members that may impact the child/youth; 10. Assessed needs based on functioning (challenges, problems in daily living, barriers, and obstacles); 11. Risk-taking behaviors, including child/youth risk behavior(s); 12. Living situation including living accommodations (where and with whom), financial situation, guardianship, need for assistive technology, and parental/guardian custodial status for children/youth; 13. Family, including cultural identity, current and past family life experiences. For family functioning/dynamics, relationships, current issues/concerns impacting children/ youth; 14. Developmental information, including an evaluation of current areas of functioning such as motor development, sensory, speech, hearing and language, emotional, behavioral, intellectual functioning, and self-care abilities; 15. Spiritual beliefs/religious orientation; 16. Sexuality, including current sexual activity, safe sex practices, and sexual orientation; 17. Need for and availability of social, community, and natural supports/resources such as friends, pets, meaningful activities, leisure/recreation interests, self-help groups, resources from other agencies, interactions with peers including child/youth and family; 18. Legal involvement history; 19. Legal status such as guardianship, representative payee, conservatorship, and probation/parole; 20. Education, including intellectual functioning, literacy level, learning impairments, attendance, and achievement; 21. Employment, including current work status, work history, interest in working, and work skills; 22. Status as a current or former member of the U.S. Armed Forces; 23. Clinical formulation, an interpretive summary including identification of co-occurring or co-morbid disorders and psychological/social adjustment to disabilities and/or disorders; 24. Diagnosis(es); 25. Individual’s expression of service preferences; 26. Assessed needs/treatment recommendations such as life goals, strengths, preferences, abilities, and barriers; and 27. Dated signature(s), title(s), and credential(s) of staff completing the comprehensive assessment; and (F) The date of the LMHP’s signature on the eligibility determination or assessment, if eligibility determination is not completed, is the effective date of program eligibility, and is the date on which billing for CSTAR services may begin. (4) Assessment Updates. Assessment updates shall be completed as clinically indicated by the treatment team and as specified in The ASAM Criteria, as referenced in subsection (2)(C) of this rule, to facilitate transition between levels and placement in the appropriate level of care. (A) At a minimum, reassessment in outpatient levels of care shall take place every twelve (12) months. (B) Documentation for assessment updates shall include— 1. A narrative summary of the individual’s risk ratings in each of the six (6) ASAM dimensions; 2. The recommended level of care; and 3. Any recommended changes to the treatment plan based on the reassessment. (C) Reassessment should not be conducted when an individual is intoxicated or experiencing withdrawal symptoms. (5) Initial Treatment Plan. A treatment plan shall be developed for each individual admitted to CSTAR within forty-five (45) days of the date of admission with completion of a comprehensive assessment or eligibility determination with requirements met. (A) The treatment plan shall be developed collaboratively with the individual and/or parent/guardian and members of the treatment team with input from family members/natural supports, as appropriate. (B) Documentation for completion of the initial treatment plan must include, at a minimum— 1. Identifying information; 2. Goals as expressed by the individual served and family members/natural supports, as appropriate, that are measurable, achievable, time-specific with start date, strength/ skill based, and include supports/resources needed to meet goals and potential barriers to achieving goals; 3. Specific treatment objectives, including a start date, that are understandable to the individual served, sufficiently specific to assess progress, responsive to the disability or concern, and reflective of age, development, culture, and ethnicity; 4. Specific interventions and services including action steps, modalities, and services to be utilized, duration and frequency of interventions, who is responsible for the intervention, and action steps of the individual served and family members/natural supports, as appropriate; 5. Identification of other agency/community resources and supports including others providing services, plans for coordinating with other agencies, services needed beyond the scope of the CSTAR program to be addressed through referral/ services with another organization; 6. Transfer, treatment, and discharge planning beginning at the point of admission and includes but is not limited to criteria for service conclusion, how the individual served and/ or parent/guardian and treatment team will know treatment goals have been accomplished; and 7. Dated signature of the QAP or QMHP completing the plan with finalization by an LMHP. The LMHP’s dated signature certifies that treatment is needed and services are appropriate as described in the treatment plan and does not recertify the diagnosis. The individual must also sign the plan unless there is a current signed consent to treatment included in the individual record. (6) Treatment Plan Updates. Treatment plans shall be updated each time an individual is reassessed as specified in section (4) of this rule. A functional assessment may be utilized as the treatment plan update. (A) At a minimum, treatment plans shall be reviewed and updated every ninety (90) days to determine the individual’s continued need for services and progress achieved during the past ninety (90) days. The occurrence of a crisis or significant clinical event may require a further review and modification of the treatment plan. (B) The plan shall be updated collaboratively with the individual and/or parent/guardian and reflect the individual’s current strengths, needs, abilities, and preferences in the goals and objectives that have been established or continued based on the review. Updates must be documented in the individual record with one (1) of the following: 1. A progress note which specifies updates made to the treatment plan; or 2. A treatment plan review conducted quarterly; or 3. An updated functional assessment score with a brief narrative. (C) 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) Crisis Prevention Plan. If a potential risk for suicide, violence, risk of relapse, overdose, or other at-risk behavior is identified during the assessment process, or any time during the individual’s engagement in services, a crisis prevention plan shall be developed as specified in 9 CSR 10-7.030(3). (A) Documentation for completion of the crisis prevention plan shall include, at a minimum— 1. Factors that may precipitate a crisis; 2. A hierarchical list of skills/strengths identified by the individual to regain a sense of control to return to their level of functioning before the crisis or emergency; and 3. A hierarchical list of staff interventions that may be used when a critical situation occurs. (8) Service Transition, Transfer, and Discharge Planning. Transfer, transition, and discharge planning begins at admission. Decisions concerning continued service, transfer, or discharge involve review of the treatment plan and assessment of the individual’s progress, with clearly defined and agreed-upon goals and outcomes, rather than the result of a preset program structure. (9) Data. The CSTAR program shall provide data to the department, upon request, regarding characteristics of individuals served, services, costs, or other information in a format specified by the department. (10) Availability of Records. All documentation must be made available to department staff and other authorized representatives for review/audit purposes. Documentation must be legible and made contemporaneously with the delivery of the service (at the time the service was provided or within five (5) business days of the time it was provided), and address individual specifics including, at a minimum, individualized statements that support the assessment or treatment encounter. AUTHORITY: sections 630.050, 630.655, and 631.010, RSMo 2016.* Original rule filed Aug. 7, 2023, effective Feb. 29, 2024. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008; 630.655, RSMo 1980; and 631.010, RSMo 1980.