Eligibility Determination, Assessment, and Treatment Planning in Community Psychiatric Rehabilitation Programs

PURPOSE: This rule specifies the eligibility determination, comprehensive assessment, functional assessment, treatment planning, and documentation requirements for community psychiatric rehabilitation (CPR) programs. (1) Each organization that is certified or deemed certified as a CPR program by the department shall comply with requirements set forth in Department of Mental Health Core Rules for Psychiatric and Substance Use Disorder Treatment Programs, 9 CSR 10-7.030 Service Delivery Process and Documentation. (2) Eligibility Determination. Eligibility determination may be completed to expedite the admission process and requires confirmation of an eligible diagnosis as evidenced by a signature from a licensed diagnostician or a physician/ physician extender. Physician extender includes a licensed assistant physician, physician assistant, psychiatric resident, psychiatric pharmacist, and APRN. The licensed diagnostician or physician/physician extender is accountable for the stated diagnosis. (A) The following mental health professionals are approved to render diagnoses: 1. Physician (includes psychiatrist, psychiatry resident, assistant physician, and physician assistant); 2. Psychologist (licensed or provisionally licensed); 3. Advanced Practice Registered Nurse (APRN); 4. Professional Counselor (licensed or provisionally licensed); 5. Marital and Family Therapist (licensed or provisionally licensed); 6. Licensed Clinical Social Worker (LCSW); and 7. Licensed Master Social Worker (LMSW) under registered supervision with the Missouri Division of Professional Registration for licensure as a Clinical Social Worker. LMSWs not under registered supervision for their LCSW credential cannot render a diagnosis. (B) The professions listed in paragraphs (2)(A)1. to 7. are categorically approved as licensed diagnosticians as long as the diagnostic activities performed fall within the scopes of practice for each. Individuals possessing these credentials should practice in the areas in which they are adequately trained and should not practice beyond their individual levels of competence. (C) The signature/date from a licensed diagnostician or physician/physician extender is required prior to delivery of CPR services. The signature can be obtained as follows: 1. Consultation with the organization’s licensed diagnostician (licensed psychologist, licensed professional counselor, LCSW) or a physician/physician extender; or 2. Consultation with an unlicensed qualified mental health professional (QMHP) with sign-off by the organization’s licensed diagnostician or a physician/physician extender; or 3. Written confirmation of an eligible diagnosis received from a physician for a psychiatric hospitalization within ninety (90) days of discharge. (D) CPR services are billable to the department beginning on the date eligibility determination is completed. (E) Documentation of eligibility determination must include, at a minimum: 1. Presenting problem and referral source; 2. Brief history of previous psychiatric/addiction treatment including type of admission; 3. Current medications; 4. Current mental health symptoms supporting the diagnosis; 5. Current substance use; 6. Current medical conditions; 7. Diagnoses, including mental disorders, medical conditions, and notation for psychosocial and contextual factors; 8. Identification of urgent needs including suicide risk, personal safety, and risk to others; 9. Initial treatment recommendations; 10. Initial treatment goals to meet immediate needs within the first forty-five (45) days of service; and 11. Signature, date, and title of staff completing the eligibility determination, except when the diagnosis is established as specified in paragraph (2)(C)3. of this rule. (3) 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. (4) Initial Comprehensive Assessment. A comprehensive assessment must be completed within thirty (30) days of eligibility determination or date of admission if eligibility determination was not completed. (A) Documentation of the initial comprehensive assessment must include, at a minimum: 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 him/her to seek services; 3. Risk assessment (suicide, safety, risk to others); 4. Trauma history (experienced and/or witnessed abuse, neglect, violence, sexual assault); 5. Mental health treatment history; 6. Mental status; 7. 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; 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. Functional assessment using an instrument approved by the department for individuals whose diagnosis requires a functional score to support admission, and if required by the department as part of the initial comprehensive assessment for all individuals (challenges, problems in daily living, barriers); 11. Risk-taking behaviors including child/youth risk behavior(s); 12. Living situation, including where living 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, 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 problems, hearing and language problems, emotional, behavioral, intellectual functioning, 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/recreational 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, probation/parole; 20. Education, including intellectual functioning, literacy level, learning impairments, attendance, 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, psychological/social adjustment to disabilities and/or disorders; 24. Diagnosis; 25. Individual’s expression of service preferences; 26. Assessed needs/treatment recommendations such as life goals, strengths, preferences, abilities, barriers; and 27. Signature and date of the staff person completing the assessment. (5) Annual Assessment. An annual assessment must be completed for individuals engaged in CPR services. (A) Documentation of the annual assessment must include, at a minimum: 1. Identification of sections of the clinical assessment being updated, such as check boxes; 2. Updated narrative for each section of the previous assessment that has changed; 3. Clinical formulation (interpretive summary); 4. Diagnosis change/update; 5. Individual’s expression of service preferences; 6. Assessed needs/treatment recommendations; and 7. Signature and date of the staff person completing the assessment, community support supervisor (unless they are completing the assessment), and a licensed diagnostician or physician/physician extender. (6) Initial Treatment Plan. An individual treatment plan must be developed within forty-five (45) days of completion of eligibility determination or date of admission to CPR if eligibility determination was not completed. (A) The treatment plan shall be developed collaboratively with the individual or parent/guardian and a QMHP, the individual’s community support supervisor, if different from the QMHP, and a physician/physician extender. (B) Documentation for completion of the initial treatment plan must include, at a minimum: 1. Identifying information; 2. Goals as expressed by the person 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 including action steps, modalities, and services to be used, duration and frequency of interventions, who is responsible for the intervention, and action steps of the individual served and family members/ natural supports; 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 CPR program to be addressed through referral/ services with another organization; 6. Anticipated discharge and continuing recovery planning which includes but is not limited to criteria for service conclusion, how will the individual served and/or parent/guardian and clinician know treatment goals have been accomplished; and 7. Signature and date of the QMHP/community support supervisor. A. Physician/physician extender signature and date must be obtained within ninety (90) days of completion of the eligibility determination after a consultation or case review. The physician/physician extender signature certifies treatment is needed and services are appropriate, as described in the treatment plan, and does not recertify the diagnosis. B. A licensed psychologist may approve (sign and date) the treatment plan when the person served is not currently receiving prescribed medications to treat a mental health condition and the clinical recommendations do not include a need for prescribed medications to treat a mental health condition. (7) Treatment Plan Review. If a functional assessment is not completed, the treatment plan must be reviewed with each individual every ninety (90) days to assess the continued need for services and progress achieved during the past ninety (90) days. (A) The treatment plan shall 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. (B) The treatment plan shall be updated to reflect the current needs and goals of the individual and must be documented in the individual’s record and may be recorded in— 1. A progress note which specifies updates made to the treatment plan; or 2. A treatment plan review conducted quarterly. (C) Treatment plan reviews shall be completed, signed, and dated by a QMHP, community support supervisor, or community support specialist. (8) Annual Treatment Plan. Treatment plans must be updated annually for individuals engaged in CPR services to reflect current goals, needs, and progress in treatment. (A) The plan is updated collaboratively with the individual or parent/guardian, community support supervisor, community support specialist, and physician/physician extender. 1. A licensed psychologist may take the place of the physician/physician extender when the person served is not currently receiving prescribed medications to treat a mental health condition and the clinical recommendations do not include a need for prescribed medications to treat a mental health condition. (B) Documentation for completion of the annual treatment plan must include at a minimum: 1. Updates related to the annual assessment and periodic updates to the functional assessment or treatment plan; 2. Signature and date of community support supervisor; 3. Signature and date of community support specialist; and 4. Signature and date of physician/physician extender or licensed psychologist. (9) Functional Assessment. A department-approved functional assessment must be completed for individuals whose diagnosis requires a functional score to support admission, and if required by the department as part of the initial comprehensive assessment. The functional assessment shall be updated in accordance with the timeframes established by the department to assess current level of functioning, progress toward treatment objectives, and appropriateness of continued services. The treatment plan shall be revised to incorporate the results of the initial functional assessment and subsequent updates. (A) Documentation of the initial functional assessment and regular updates shall include, at a minimum: 1. Barriers, issues, or problems conveyed by the individual, parent/guardian, family members/natural supports, and/or staff indicating the need for focused services; 2. A brief explanation of any changes or progress in the daily living functional abilities in the prior ninety (90) days; and 3. A description of the changes for the treatment plan based on information obtained from the functional assessment. (B) Documentation of the findings from the functional assessment includes any of the following: 1. A narrative section with the treatment plan that includes the functional update content requirements; 2. A narrative section on the functional assessment with the content requirements; or 3. A progress note in the individual record documenting the content requirements. (C) Completed functional assessments must be available to department staff and other authorized representatives for review/audit purposes upon request. (D) For individuals receiving services in a community residential program, the functional assessment must be completed a minimum of every ninety (90) days and documented in the individual record. (10) Crisis Prevention Plan. If a potential risk for suicide, violence, or other at-risk behavior is identified during the assessment process, and any time during the individual’s time in services, a crisis prevention plan shall be developed with the individual. (A) Documentation for completion of the crisis prevention plan shall include, at a minimum, factors that may precipitate a crisis, a hierarchical list of self-care and self-help strategies identified by the individual to regain a sense of control to return to their level of functioning before the crisis or emergency, and a hierarchical list of staff interventions that may be used when a critical situation occurs. (11) Discharge. When individuals are discharged from CPR services, a discharge summary must be prepared and entered in the individual record in accordance with 9 CSR 10-7.030. (12) Data. The CPR 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. (13) Availability of Records. All documentation must be made available to department staff and other authorized representatives for review/audit purposes at the site where the service(s) was rendered. 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: section 630.655, RSMo 2016.* Original rule filed Jan. 19, 1989, effective April 15, 1989. 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. Amended: Filed Feb. 28, 2001, effective Oct. 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 March 15, 2010, effective Sept. 30, 2010. Amended: Filed Dec. 1, 2011, effective June 30, 2012. Amended: Filed April 29, 2019, effective Nov. 30, 2019. ** Amended: Filed March 9, 2022, effective Sept. 30, 2022. *Original authority: 630.655, RSMo 1980. **Pursuant to Executive Order 21-09, 9 CSR 30-4.035, sections (3) and (5) was suspended from April 23, 2020 through December 31, 2021.