Eligibility Criteria and Admission Criteria for Community Psychiatric Rehabilitation Programs

PURPOSE: This rule establishes criteria and procedures for admission of eligible individuals to a community psychiatric rehabilitation (CPR) program. 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) The department designates the minimum geographic boundaries for CPR service areas throughout the state. Exceptions to the designated service areas may be granted by the department. (A) The CPR program shall operate within its designated service area and provide services to eligible individuals to the extent adequate program capacity allows. (B) Policies and procedures shall ensure eligible individuals have access to CPR services throughout the twelve (12) months of the year and to other services/resources beyond the scope of the program. (C) Community support services shall be available to meet individual needs, which may include evenings and weekends. (D) Community support and crisis intervention services shall be available to eligible individuals in their home and other locations apart from the CPR offices/facilities. (E) Policies and procedures shall ensure eligible individuals are not required to visit a pre-selected site to receive needed services, other than medication, physician consultation, and psychosocial rehabilitation (PSR). Individuals shall have a choice in the location where they receive CPR services, to the extent program capacity and the treatment plan allows. (2) The CPR program shall have written policies and procedures defining its service delivery process, including screening, eligibility determination, admission, assessment, treatment and recovery planning, and discharge for individuals served. (A) Policies and procedures shall ensure admission to services within ten (10) business days of the date of eligibility determination for individuals with serious mental illness or serious emotional disturbance. (B) Individuals shall not be denied admission to a CPR program based on eligibility for Medicaid benefits or other sources of reimbursement for services. (3) Policies and procedures shall ensure all CPR services are provided under the direction of a physician/physician extender and are medically necessary and reasonable for the treatment of the individual’s mental illness or disorder. (A) Emergency and crisis intervention services shall be provided prior to completion of the initial comprehensive assessment for individuals determined to need immediate assistance. (B) A physician/physician extender must be available for emergency and crisis intervention services twenty-four (24) hours per day, seven (7) days per week. (4) The CPR program shall implement written policies and procedures to ensure eligible individuals are admitted to treatment within ten (10) days of the date of eligibility determination. (A) CPR services shall be prioritized for individuals who— 1. Have been discharged from inpatient psychiatric hospitalization programs within the last ninety (90) days; 2. Are residents of supervised or semi-independent apartments, psychiatric group homes, or community residential programs; 3. Have been committed by court order under provisions of section 632.385, RSMo; 4. Have been conditionally released under section 552.040, RSMo; 5. Are homeless or considered homeless in accordance with the following criteria: A. Persons who are sleeping in places not meant for human habitation such as cars, parks, sidewalks, and abandoned buildings; B. Persons who are sleeping in emergency shelters or doubled up (unable to maintain their housing situation and forced to stay with a series of friends and/or extended family members, paying no rent, and uncertain as to how long they will be able to stay); C. Persons who are from transitional or supportive housing for homeless persons who originally came from streets or emergency shelters; D. Persons who are being evicted within the week from a private dwelling unit, no subsequent residence has been identified, and they lack the resources and support networks needed to obtain access to housing; E. Persons who are being discharged within the week from facilities in which they have been a resident for more than ninety (90) consecutive days, no subsequent residence has been identified, and they lack the resources and support networks needed to obtain access to housing; and F. Persons who are fleeing or attempting to flee domestic violence, have no other residence, and lack the resources or support networks to obtain other permanent housing; 6. Are having a current episode of acute crisis or being referred from the crisis system; 7. Have used a hospital emergency room related to a psychiatric illness two (2) or more times during the prior year; 8. Have attempted suicide; 9. Are high utilizers of Medicaid services with co-occurring behavioral health and other chronic health conditions; and 10. Children and adolescents at risk of disruption from a preferred living environment due to symptoms of a serious emotional disturbance. (5) The CPR program may refuse admission when an individual poses an imminent threat of harm to self or others, or the program is operating at full capacity (a level previously determined by organizational leadership). The program shall implement policies and procedures to monitor capacity. (6) Eligibility criteria for admission to a CPR program shall include: (A) Disability—there is clear evidence of serious and/or substantial impairment in the individual’s ability to function at an age or developmentally appropriate level due to serious psychiatric disorder in each of the following two (2) areas of behavioral functioning as indicated by the eligibility determination and comprehensive assessment: 1. Social role functioning/family life—the ability to sustain functionally the role of a worker, student, homemaker, family member, or a combination of these; and 2. Daily living skills/self-care skills—the ability to engage in personal care (such as grooming, personal hygiene) and community living (handling individual finances, using community resources, performing household chores), learning ability/self-direction, and activities appropriate to the individual’s age, developmental level, and social role functioning. (B) Diagnosis—a licensed diagnostician certifies a primary diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) published by and available from the American Psychiatric Association, 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209-3901 or the International Classification of Diseases Tenth Revision (ICD-10) published by and available from the World Health Organization, 525 23rd Street N.W., Washington, DC 20037. The diagnosis may coexist with other psychiatric diagnoses. Specific diagnoses for eligibility can be found in the MO HealthNet CPR Provider Manual published by and available from the Missouri Department of Social Services, 615 Howerton Court, PO Box 6500, Jefferson City, MO 65102-6500. The referenced documents do not include any later revisions or updates. (C) Duration—rehabilitation services shall be provided for individuals whose mental illness is of sufficient duration as evidenced by one (1) or more of the following: 1. Received psychiatric treatment more intensive than outpatient more than once in a lifetime (crisis services, alternative home care, partial hospital, inpatient); 2. Experienced an occurrence of continuous residential care, other than hospitalization, for a period long enough to disrupt the normal living situation; 3. Exhibited the psychiatric disability for one (1) year or more; or 4. Treatment of the psychiatric disorder has been or will be required for longer than six (6) months. (D) For adults and children age six (6) and above a functional assessment may be used to establish eligibility for CPR services, including results from a standardized assessment prescribed by the department. (E) Individuals currently enrolled in a CPR program for youth are automatically eligible for admission to an adult CPR program when the transfer is determined to be clinically appropriate and documented in the record. (7) Children and youth under the age of eighteen (18) may be provisionally admitted to a CPR program based on the following: (A) Disability—there is clear evidence of serious and/or substantial impairment in the child’s ability to function at an age or developmentally appropriate level due to serious psychiatric disorder in each of the following two (2) areas of behavioral functioning as indicated by the eligibility determination and comprehensive assessment: 1. Social role functioning/family life—the child is at risk of out-of-home or out-of-school placement; and 2. Daily living skills/self-care skills—the child is unable to engage in personal care, such as grooming and personal hygiene, and in community living such as performing school work or household chores, learning, self-direction or activities appropriate to the individual’s age, developmental level, and social role functioning. (B) Diagnosis—if a child is exhibiting behaviors or symptoms consistent with a non-established CPR eligible diagnosis, he/ she may be provisionally admitted for further evaluation. There may be insufficient clinical information because of rapidly changing developmental needs to determine if a CPR diagnosis is appropriate without an opportunity to observe and evaluate the child’s behavior, mood, and functional status. In such cases documentation must clearly support the individual’s level of functioning based on disability as defined in subsection (7)(A) of this rule. (C) Duration—there must be documented evidence of the child’s functional disability as defined in subsection (A) of this section for a period of ninety (90) days prior to provisional admission. (D) Provisional admission shall not exceed ninety (90) days. Immediately upon completion of the ninety (90) days, or sooner if the individual has been determined to have an eligible diagnosis as indicated in subsection (A) of this section, the diagnosis must be documented and he/she may continue to receive services in the program. (E) If a child who was provisionally admitted is determined to be ineligible for CPR services, staff shall directly assist the individual and/or family in arranging follow-up services needed. Arrangements for follow-up services must be documented in the discharge summary. (F) All admission documentation is required for those provisionally admitted with the exception of the comprehensive assessment which may be deferred for ninety (90) days. (8) The CPR program shall ensure individuals receive the most appropriate care and treatment available. Transferring an individual to another service, from a community program to a hospital, hospital to a community program, or to another CPR program consistent with individual needs, may be considered to obtain necessary care and treatment. (A) Written procedures shall ensure exchange of information within five (5) days when an individual is referred or transferred to another service component within the organization or to an outside provider for services. Policies and procedures must ensure— 1. Applicable records, portions of records, and other information are readily transferable and handled in compliance with state and federal confidentiality regulations; and 2. Timely follow-up is made with the alternate CPR program or service provider. (B) Policies and procedures stipulate the conditions under which referrals are made, such as the need for special services not provided by the current CPR program or the need for ancillary services which will contribute to the well-being of the individual. (C) Policies and procedures shall assure continuity of care among referring providers including prior inpatient hospitalization, residential support, and outpatient psychiatric and/or substance use disorder treatment. (D) A current resource directory of area community service agencies must be readily available to individuals and family members/natural supports for referral purposes and upon request by the public. (9) The CPR program shall coordinate with providers of inpatient psychiatric care to assure continuity of services for eligible individuals returning to the community. This includes active participation of community support staff in discharge planning for the individual. (A) Policies and procedures shall ensure individuals engaged in CPR have a documented consultation with a community support specialist within five (5) days of discharge from inpatient psychiatric care, including active follow-up within five (5) days for individuals who fail to keep their appointment. (10) The CPR program shall implement written policies and procedures to ensure individuals who miss a scheduled appointment for services or whose absence is unanticipated are contacted by a community support specialist or other staff person providing their services/supports. The procedures shall establish time frames for contacting individuals, consistent with clinical needs and the seriousness of their disability, not to exceed forty-eight (48) hours. (11) The CPR program shall provide equal opportunity to individuals with disabilities in accordance with the Americans with Disabilities Act. (12) The program shall have policies and procedures to ensure individuals determined ineligible for CPR services are referred to other programs and services in the community for which they may be eligible. (13) The CPR program shall only admit individuals who will benefit from services available. Individuals who have not received services for a six- (6-) month period should be discharged from the program. (14) The CPR program shall participate in coordination and liaison activities with the adult and juvenile justice systems to— (A) Promote effective relationships with local law enforcement systems (including courts) through training, education, and consultation; (B) Educate law enforcement and court officials, juvenile officers, and probation/parole personnel about services offered by the CPR program; and (C) Provide CPR services, as capacity allows, to persons with serious mental illness who are on probation/parole or in forensic aftercare by working with probation/parole and juvenile officers and department forensic case monitors within the limits of confidentiality. (15) The CPR program shall participate in coordination and liaison activities with federal, state, and local public assistance agencies, housing agencies, and employment/vocational support agencies to— (A) Promote effective relationships through training, education, and consultation; (B) Educate staff about services offered by the CPR provider; and (C) Assist individuals in seeking public benefits to expedite the application process and maintain/regain their eligibility for assistance within the limits of confidentiality. AUTHORITY: sections 630.050, 630.655, and 632.050, RSMo 2016.* This rule originally filed as 9 CSR 30-4.042. Original rule filed Jan. 19, 1989, effective April 15, 1989. Emergency amendment filed Aug. 27, 1993, effective Sept. 8, 1993, expired Nov. 7, 1993. Emergency amendment filed Oct. 28, 1993, effective Nov. 7, 1993, expired March 6, 1994. Amended: Filed Aug. 27, 1993, effective April 9, 1994. Emergency amendment filed Feb. 15, 1994, effective March 6, 1994, expired April 10, 1994. Emergency amendment filed April 21, 1994, effective May 2, 1994, expired Aug. 29, 1994. Amended: Filed April 21, 1994, effective Oct. 30, 1994. Amended: Filed Dec. 13, 1994, effective July 30, 1995. Emergency amendment filed Aug. 11, 1999, effective Aug. 22, 1999, expired Feb. 17, 2000. Amended: Filed Aug. 11, 1999, effective Feb. 29, 2000. Emergency amendment filed June 30, 2000, effective July 11, 2000, expired Feb. 22, 2001. Amended: Filed June 30, 2000, effective Jan. 30, 2001. Emergency amendment filed Dec. 28, 2001, effective Jan. 13, 2002, expired July 11, 2002. Amended: Filed Dec. 28, 2001, effective July 12, 2002. Amended: Filed July 31, 2002, effective March 30, 2003. Amended: Filed March 15, 2010, effective Sept. 30, 2010. Amended: Filed Dec. 1, 2011, effective June 30, 2012. Moved to 9 CSR 30-4.005 and amended: Filed April 29, 2019, effective Nov. 30, 2019. Amended: Filed March 9, 2022, effective Sept. 30, 2022. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008; 630.655, RSMo 1980; and 632.050, RSMo 1980.