Staff Requirements for Comprehensive Substance Treatment and Rehabilitation (CSTAR) Programs

PURPOSE: This rule describes requirements for caseload size, clinical privileging, training, and core competencies for staff working in 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) Other Regulations. Each organization that is certified/ deemed certified by the department as a CSTAR program shall comply with requirements set forth in Department of Mental Health Core Rules for Psychiatric and Substance Use Disorder Treatment Programs, 9 CSR 10-7.110 Personnel. (2) Qualified Staff. The program director shall ensure an adequate number of qualified professionals are available to provide CSTAR services. (A) Caseload size may vary according to the acuity, symptom complexity, and needs of individuals served. An individual being served or his or her parent/guardian has the right to request an independent review by the CSTAR director if they believe individual needs are not being met. If the CSTAR director deems it necessary, caseload size or other changes may be implemented. (B) The supervisory-to-staff ratio shall be based on the needs of individuals being served, focusing on successful outcomes and satisfaction with services and supports as expressed by persons served. (C) The organization shall have policies and procedures for monitoring and adjusting caseload size and ensure there is documented, ongoing supervision of clinical and direct service staff. (3) Clinical Privileging. The program shall have and implement a process for granting clinical privileges to practitioners to deliver CSTAR services. (A) Each treatment discipline shall define clinical privileges based upon identified and accepted criteria approved by the governing body. (B) The process shall include periodic review of each practitioner’s credentials, performance, education, and the like, and the renewal or revision of clinical privileges at least every two (2) years. (C) Initial granting and renewal of clinical privileges shall be based on— 1. Well-defined written criteria for qualifications, clinical performance, and ethical practice related to the goals and objectives of the program; 2. Verified licensure, certification, or registration, if applicable; 3. Verified training and experience; 4. Recommendations from the agency’s program, department service, or all of these, in which the practitioner will be or has been providing service; 5. Evidence of current competence; 6. Evidence of health status related to the practitioner’s ability to discharge his/her responsibility, if indicated; and 7. A statement signed by the practitioner that he/she has read and agrees to be bound by the policies and procedures established by the provider and governing body. (D) Renewal or revision of clinical privileges shall also be based on— 1. Relevant findings from the CSTAR program’s quality assurance activities; and 2. The practitioner’s adherence to the policies and procedures established by the CSTAR program and its governing body. (E) As part of the privileging process, the CSTAR program shall establish procedures to— 1. Afford a practitioner an opportunity to be heard, upon request, when denial, curtailment, or revocation of clinical privileges is planned; 2. Grant temporary privileges on a time-limited basis; and 3. Ensure that non-privileged staff receive close and documented supervision from privileged practitioners until training and experience are adequate to meet privilege requirements. (4) Training and Staff Competencies. Direct care staff and staff providing supervision to direct care staff shall complete training in the service competency areas listed below. (A) Competent staff shall— 1. Operate from person-centered, person-driven, recoveryoriented, and stage-wise service delivery approaches that promote health and wellness; 2. Develop cultural competence that results in the ability to understand, communicate with, and effectively interact with people across cultures; 3. Deliver services according to key service functions that are evidence-based and best practices; 4. Practice in a manner that demonstrates respect and understanding of the unique needs of persons served; 5. Use effective strategies for engagement, re-engagement, relationship-building, and communication; and 6. Be knowledgeable of mandated reporting requirements for abuse and neglect of children and reporting requirements related to abuse, neglect, or financial exploitation of senior citizens and individuals who are disabled. (B) Staff providing supervision to community support specialists must have additional training or experience in order to be knowledgeable in the supervision competency areas listed below. Competent supervisors— 1. Practice in a manner that demonstrates use of management strategies that focus on individual outcomes, care coordination, collaboration, and communication with other service providers both within and external to the organization; 2. Ensure new and existing staff are competent by providing training/supervision, guidance and feedback, field mentoring, and oversight of services to individuals served by the team; 3. Ensure processes exist for tracking and review of data such as missed appointments, hospitalization and follow-up care, crisis responsiveness and follow-up, timeliness and quality of documentation, and need for outreach and engagement; and 4. Monitor and review services, interventions, and contacts with individuals served to ensure services are implemented according to individualized treatment plans or crisis prevention plans, evaluate the effectiveness and appropriateness of services in achieving recovery/resiliency outcomes in areas such as housing, employment, education, leisure activities, and family, peer, and social relationships. (C) New staff shall job shadow their supervisor and/or experienced staff in a position equivalent to their qualifications and skill level. (D) Staff shall receive ongoing and regular clinical supervision. (E) A written plan shall be developed indicating how competencies will be measured and ensured for all staff providing direct services and staff providing supervision including, but not limited to, some combination of the following: 1. Testing; 2. Observation/field supervision; 3. Clinical supervision/case discussion; 4. Quality review of case documentation; 5. Use of relevant findings from quality assurance activities; 6. Satisfaction with services as conveyed by individuals served and family members/natural supports; 7. Stakeholder/interagency satisfaction with services; and 8. Treatment outcomes for individuals and family members/natural supports. (F) Demonstrated competency must be documented within the first six (6) months of employment with the CSTAR program. (G) Staff shall participate in at least thirty-six (36) clock hours of relevant training during any two (2) year period. A minimum of twelve (12) clock hours of training must be completed annually. (H) CSTAR programs providing services in accordance with The ASAM Criteria shall ensure the following training requirements are met: 1. All direct care staff are trained on utilization of The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, 2013, 3rd edition, hereby incorporated by reference and made a part of this rule, developed by and available from the American Society of Addiction Medicine (ASAM), 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. Training must be provided by an entity with permission from ASAM to deliver the training; 2. All direct care staff participate in fifty (50) hours of annual training including, but not limited to— A. Treatment of co-occurring disorders; B. Suicide prevention (best-practice or evidence-based), as specified in the organization’s Zero Suicide Plan; C. Trauma-informed care, must align with the agency’s trauma-informed assessment and implementation plan; 3. Annual training applies to the requirement specified in subsection (4)(G) of this rule; and 4. Ongoing training based on staff roles and responsibilities including, but not limited to— A. Peer support, provided by the Missouri Credentialing Board; B. Family support, provided by the Missouri Credentialing Board; C. Smoking cessation, approved by the department; and D. The ASAM Criteria advanced training (must be provided by an entity with permission from ASAM to deliver the training). (I) Documentation of all orientation, training, job shadowing, and supervision activities must be maintained and available for review by department staff or other authorized representatives. (J) Documentation of training must include the topic, date(s) and length, skills targeted/objective of skill, certification/ continuing education units (as applicable), location, and name, title, and credentials of instructor(s). AUTHORITY: sections 630.050, 630.655, and 631.010, RSMo 2016.* Original rule filed May 28, 2021, effective Dec. 30, 2021. Amended: 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.