Comprehensive Substance Treatment and Rehabilitation (CSTAR) Program for Adolescents

PURPOSE: This rule establishes requirements for certified/deemed certified CSTAR programs for adolescents. 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. Adolescent CSTAR programs shall comply with 9 CSR 10-7 Core Rules for Psychiatric and Substance Use Disorder Treatment Programs, 9 CSR 10-5 General Program Procedures, and 9 CSR 30-3 Substance Use Disorder Prevention and Treatment Programs, as applicable. (2) Age Criteria. The program shall provide treatment, rehabilitation, and other services solely to individuals age nine through seventeen (9-17) and their family members/natural supports, as appropriate. Services in a residential setting shall be available for individuals age twelve through seventeen (1217). (A) Exceptions to the age requirements may be authorized through the department’s clinical review process. (3) Registered Sex Offenders and Youth Identified on the Juvenile County Registry. Prior to admission, program staff shall verify whether the individual is registered as a juvenile sex offender in the county in which they reside pursuant to section 211.425, RSMo, or is identified as an offender on the Missouri State Highway Patrol (MSHP) sex offender registry pursuant to sections 589.400-589.425, RSMo. (A) If the individual is an identified juvenile sex offender on the juvenile county sex offender registry, admission to the CSTAR program can be considered. (B) If the individual is an identified offender on the MSHP sex offender registry, admission to the CSTAR program shall not be made. (C) All results of verification with the county juvenile sex offender registry or MSHP sex offender registry, as well as decisions related to program admission, shall be documented and a record of communication to the individual’s parent/ guardian and referral source(s), as applicable, shall be maintained by the program. 1. If the parent/guardian disagrees with a decision of ineligibility for admission, they shall be informed of the grievance process of the CSTAR program. (D) If the individual is not admitted to the program within sixty (60) days after program staff have conducted verification of the county juvenile sex offender registry, staff are responsible for rechecking the registry prior to admission. Rechecking the registry is always an option and should be completed any time there is a concern, even when the sixty (60) days have not yet passed. (E) The MSHP registry is updated in real time and should be checked any time the sixty (60) days has passed. (4) Eligibility Criteria and Level of Care. The program shall comply with 9 CSR 30-3.151 Eligibility Determination, Assessment, and Treatment Planning in CSTAR Programs, to ensure individuals are placed in the appropriate level of care and receive individualized services. (5) Treatment Principles and Therapeutic Issues Relevant to Adolescents. The program shall address therapeutic issues relevant to adolescents and shall address their specific needs. The following principles and methods shall be reflected in services delivered to adolescents: (A) Adolescents are effectively treated in therapeutic environments that are programmatically and physically separate from treatment services for adults; (B) Services shall maintain individuals in the family and community setting, as clinically appropriate; (C) Services shall involve parents/guardian and other family members/natural supports in the treatment and recovery process, when clinically appropriate. If the caregivers are not available, program staff shall assist in developing alternate social and family/natural support systems for the adolescent; (D) Services to family members/natural supports shall be directed to understanding and supporting the adolescent’s recovery and resiliency, identifying and intervening with any behavioral health needs of their caregiver(s), improving parenting skills and communication skills within the family or with other caregivers/natural supports, and facilitating improved family function; (E) A cooperative team approach shall be utilized in order to provide a consistent therapeutic environment; (F) Effectively treating substance use disorders in adolescents requires identifying and treating other co-occurring conditions they may have; (G) Services shall be coordinated with the juvenile justice system, children’s services, and other community agencies to ensure the needs of individuals are met; (H) Staff shall possess the knowledge and expertise to engage adolescents with histories of trauma, recognize the presence of trauma symptoms, understand the role of trauma in the lives of adolescents, and conduct themselves in ways that are not retraumatizing to those being served; (I) Issues such as violence, child abuse, and risk of suicide shall be identified and addressed; (J) Communicable disease counseling and testing for sexually transmitted infections, such as HIV and hepatitis B and C, are important aspects of adolescent treatment (refer to 9 CSR 30-3.110(C) for service delivery requirements). Testing may be waived if parent/guardian consent is not obtained and is documented, as applicable to the individual served; and (K) Service delivery shall address recovery/resiliency skill development including, but not limited to— 1. Substance use prevention and education; 2. Assertiveness training; 3. Conflict resolution skills; 4. Emotional regulation; 5. Social network development; 6. Leisure time management; 7. Problem-solving skills; 8. Adolescent development; 9. Sexual health; and 10. Trauma. (6) Treatment Setting. Adolescents may receive substance use disorder treatment services in a variety of settings including but not limited to the following: (A) Home of the parent/guardian; (B) Foster home; (C) Residential settings operated by the CSTAR program; (D) Juvenile detention (services are not reimbursable by Medicaid); (E) Other supervised living arrangements; (F) Independent living; and (G) School. (7) Family Involvement. Each adolescent’s living arrangement and family situation shall be reviewed by program staff in order to identify needs and to develop treatment goals and recovery supports for the adolescent and their family members and/or other natural supports. (A) This review shall be conducted by a licensed mental health professional (LMHP) or a qualified addiction professional (QAP) or qualified mental health professional (QMHP) who is under the supervision of an LMHP. (B) Refusal by the caregiver for an in-home visit shall not constitute automatic denial of treatment services for the individual. (C) The program shall actively involve family members/natural supports in the treatment process including educational and counseling sessions and transfer and discharge planning, unless contraindicated for legal or clinical reasons which are documented in the individual record. Efforts to involve family members/natural supports, and any reasons for lack of participation, shall be included in documentation. (D) Staff shall orient the parent or legal guardian regarding— 1. Treatment philosophy and design; 2. Discipline and any emergency safety interventions used by the program; 3. Availability of staff to conduct home-based treatment and community support services; 4. Emergency medical procedures; and 5. Expectations about ongoing participation by family members/natural supports. (8) Educational and Vocational Opportunities. The program shall have established partnerships with local school district(s) to ensure individuals’ academic and vocational needs are met in accordance with their Individual Education Program (IEP) and/or 504 Plan. (A) For youth enrolled in American Society of Addiction Medicine (ASAM) Level 1, Level 2.1, or Level 2.5, certain CSTAR services may be provided within the school setting. An agreement for the provision of such services must be arranged by the CSTAR provider and their local school district(s). The ASAM Criteria: Treatment Criteria for Addictive, SubstanceRelated, and Co-Occurring Conditions, 3rd Edition, 2013, is hereby incorporated by reference and made a part of this rule as published by and available from The American Society of Addiction Medicine, 11400 Rockville Pike, Suite 200, Rockville, MD 20852, (301) 656-3920. This rule does not incorporate any subsequent amendments or additions to this publication. (B) CSTAR services delivered in the school setting are limited to three (3) hours, twelve (12) units per week total. (C) CSTAR services that may be delivered in school settings are limited to the following: 1. Comprehensive assessment; 2. Community support; 3. Individual counseling; 4. Group counseling; 5. Group rehabilitative support; 6. HIV pre-testing and post-testing counseling; 7. Medication services support; 8. Family therapy/conference; and 9. Peer support. (9) Privilege System. Any system used by the program that encourages/rewards appropriate behaviors or restricts privileges in response to an individual exhibiting impermissible behaviors must be trauma sensitive, defined in writing, stated in behavioral terms to the extent possible, and applied consistently to all individuals. (10) Safety and Health. The program shall maintain a safe, healthy environment which is responsive to the behavioral and physical health needs of adolescents. (A) Adolescents shall be prohibited from using tobacco or products containing nicotine on the premises, grounds, and any off-site program functions with the exception of prescribed nicotine replacement therapies with parent/guardian consent. (B) Physical examinations shall be completed as specified in (C) The program shall demonstrate effective collaborative working relationship(s) with local healthcare providers, hospital(s), urgent care clinic(s), and other community resources to provide physical health care for adolescents, as needed. (11) Staff Training and Supervision. The program shall comply with The ASAM Minimum Staffing Standards for Department of Mental Health, September 2022, hereby incorporated by reference and made a part of this rule, developed by and available from the Department of Mental Health, 1706 E. Elm St., PO Box 687, Jefferson City MO 65101, (573) 751-4942, https://dmh.mo.gov/media/pdf/dbh-asam-minimum-staffingrequirements. This rule does not incorporate any subsequent amendments or additions to this publication. (12) Structured Activities. In addition to treatment services, individuals receiving services in a residential level of care shall participate in structured activities during daytime and evening hours such as academic education, completing assignments, self-help groups, family visits, and positive leisure activities. (13) Staffing Patterns in Residential Levels of Care. Programs shall comply with The ASAM Minimum Staffing Standards for Department of Mental Health, September 2022, hereby incorporated by reference and made a part of this rule, developed by and available from the Department of Mental Health, 1706 E. Elm St., PO Box 687, Jefferson City MO 65101, (573) 751-4942, https://dmh.mo.gov/media/pdf/dbh-asam-minimumstaffing-requirements. This rule does not incorporate any subsequent amendments or additions to this publication. (A) If the program serves a mixed-gender population in residential levels of care, the staffing pattern shall include at least one (1) female and at least one (1) male staff member any time individuals are present. (B) If a residential level of care is provided only for individuals of the female gender, a female staff member must be present twenty-four (24) hours per day, seven (7) days per week. (C) If a residential level of care is provided only for individuals of the male gender, a male staff member must be present twenty-four (24) hours per day, seven (7) days per week. 1. Refer to 9 CSR 10-7.010(4)(A)7. and 9 CSR 10-7.020(3)(A)4., related to service delivery practices that are responsive to individual needs. AUTHORITY: sections 630.050, 630.655, and 631.010, RSMo 2016.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed April 15, 2002, effective Nov. 30, 2002. Amended: Filed July 29, 2002, effective March 30, 2003. Amended: Filed Sept. 14, 2023, effective March 30, 2024. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008; 630.655, RSMo 1980; and 631.010, RSMo 1980.