Service Provision, Staff Qualifications, and Documentation Requirements for Community Psychiatric Rehabilitation Programs

PURPOSE: This rule specifies the core and optional psychiatric treatment services, staffing requirements, and documentation requirements for community psychiatric rehabilitation (CPR) 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) CPR programs shall comply with requirements set forth in department Core Rules for Psychiatric and Substance Use Disorder Treatment Programs, 9 CSR 10-7.030 Service Delivery Process and Documentation. (A) Service delivery and documentation requirements specific to the CPR program are included in this rule. (2) Core Services. At a minimum, CPR programs shall directly provide the following core services, or ensure the services are available through a subcontract as specified in 9 CSR 107.090(6): (A) Eligibility determination (to expedite the admission process, if necessary), in accordance with 9 CSR 30-4.005; (B) Initial comprehensive assessment, in accordance with 9 CSR 30-4.035; (C) Annual assessment, in accordance with 9 CSR 30-4.035; (D) Treatment planning, in accordance with 9 CSR 30-4.035; (E) Community support, in accordance with 9 CSR 30-4.047; (F) Crisis Prevention and Intervention—face-to-face emergency or telephone intervention available twenty-four (24) hours a day, on an unscheduled basis, to assist individuals in resolving a crisis and providing support and assistance to promote a return to routine, adaptive functioning. Services must be provided by a qualified mental health professional (QMHP), licensed mental health professional (LMHP), qualified addiction professional (QAP), or community support specialist with population-specific experience providing community support services in accordance with the key service functions specified in 9 CSR 30-4.047(5)(B). Nonmedical staff providing crisis prevention and intervention must have immediate, twenty-four (24) hour telephone access to consultation with a physician/physician extender. Minimum service functions shall include, but are not limited to— 1. Interacting with the identified individual and their family members/natural supports, legal guardian, or a combination of these; 2. Specifying factors that led to the individual’s crisis state, when known; 3. Identifying maladaptive reactions exhibited by the individual; 4. Evaluating potential for rapid regression; 5. Attempting to resolve the crisis; and 6. Referring the individual for treatment in an alternative setting when indicated; 7. Documentation must include— A. A description of the precipitating event(s)/situation when known; B. A description of the individual’s mental status; C. The intervention(s) initiated to resolve the individual’s crisis state; D. The individual’s response to the intervention(s); E. The individual’s disposition; and F. Planned follow-up by staff; (G) Integrated Treatment for Co-Occurring Disorders (ITCD), in accordance with 9 CSR 30-4.0431; (H) Medication Administration—assures the appropriate administration and continuing effectiveness of medication(s) being prescribed for the individual served. Services must be provided by a physician, assistant physician, physician assistant, registered professional nurse (RN), licensed practical nurse (LPN), advanced practice registered nurse (APRN), psychiatric resident, or psychiatric pharmacist. Key service functions shall include— 1. Administering therapeutic injections of medication (subcutaneous or intramuscular); 2. Monitoring lab tests/levels including consultation with the physician(s), individual served, and community support specialist; 3. Coordinating medication needs with the individual served and his or her family members/natural supports, as appropriate, and pharmacy staff, including the use of indigent drug programs (does not include routine placing of prescription orders and refills with pharmacies); 4. Setting up medication boxes; 5. Delivering medication to the individual’s home; 6. Educating the individual about medications; 7. Recording the individual’s initial histories and vital signs; 8. Ensuring medication is taken as prescribed; 9. Monitoring side effects of medication including the use of standardized evaluations; and 10. Monitoring prescriber’s orders for treatment modifications and educating the individual served; (I) Medication Services—goal-oriented interaction with the individual served regarding the need for medication and management of a medication regimen. A physician/physician extender shall provide this service, subject to the guidelines and limitations promulgated for each specialty in statutes and administrative rules. 1. Individuals requiring or requesting medication shall be seen by a qualified staff person within fifteen (15) days, or sooner if clinically indicated. All efforts shall be made to ensure established psychotropic medications are continued without interruption. Medication services must occur at least every six (6) months for individuals taking psychiatric medications. Key service functions shall include, but are not limited to— A. Review of the individual’s presenting condition; B. Mental status exam; C. Review of symptoms and medication side effects; D. Review of the individual’s functioning; E. Review of the individual’s ability to self-administer medication; F. Education on the effects of medication and its relationship to the individual’s mental illness and choice of medication; and G. Prescription of medications when indicated. 2. Documentation for medication services must include, at a minimum: A. A description of the individual’s presenting condition; B. Pertinent medical and psychiatric findings; C. Observations and conclusions; D. Any side effects of medication as reported by the individual; E. Actions and recommendations regarding the individual’s ongoing medication regimen; and F. Pertinent information reported by family members/ natural supports regarding a change in the individual’s condition or an unusual or unexpected occurrence in his or her life, or both; (J) Metabolic Syndrome Screening—identifies risk factors for obesity, hypertension, hyperlipidemia, and diabetes. The screening is required annually for adults and children/youth who are receiving antipsychotic medication. 1. Services must be provided by an RN or LPN. Key service functions shall include, but are not limited to: A. Taking and recording vital signs; B. Conducting lab tests to assess lipid levels and blood glucose levels and/or HgbA1c, or arranging and coordinating lab tests to assess lipid levels and blood glucose levels and/or HgbA1c; C. Obtaining results of recently completed lab tests from other health care providers to assess lipid levels and blood glucose levels and/or HgbA1c; and D. Recording the results of the metabolic screening on a form/tool approved by the department. 2. Metabolic syndrome screening is limited to no more than one (1) screening every ninety (90) days, per individual. If the lab tests are conducted by a nurse, an analyzer approved by the department must be used. 3. Documentation must reflect completion of the Metabolic Syndrome Screening and Monitoring Tool and a summary progress note; (K) Physician Consultation/Professional Consultation— medical services provided by a physician, assistant physician, physician assistant, APRN, psychiatric resident, or a psychiatric pharmacist. The service is intended to provide direction to treatment and consists of a review of an individual’s current medical situation either through consultation with one (1) staff person, or a team discussion(s) related to a specific individual. This service cannot be substituted for supervision or face-toface intervention with the individual. Key service functions shall include, but are not limited to: 1. An assessment of the individual’s presenting condition as reported by staff; 2. Review of the treatment plan through consultation; 3. Participant-specific consultation with staff especially in situations which pose a high risk of psychiatric decompensation, hospitalization, or safety issues; and 4. Participant-specific recommendations regarding high risk issues and, when needed, to promote early intervention; and (L) Psychosocial Rehabilitation for Adults, in accordance with (3) Optional Services. In addition to the core services defined in section (2) of this rule, the following optional services may be provided directly by the CPR program, or through a subcontract as specified in 9 CSR 10-7.090(6): (A) Adult Inpatient Diversion, in accordance with 9 CSR 304.045; (B) Assertive Community Treatment (ACT), in accordance with 9 CSR 30-4.032; (C) Children’s Inpatient Diversion, in accordance with 9 CSR 30-4.045; (D) Co-Occurring Individual Counseling, a structured, goaloriented therapeutic process in which an individual interacts with a qualified provider in accordance with their treatment plan to resolve problems related to their documented mental illness and substance use disorder that interferes with functioning. 1. Services involve the use of evidence-based practices such as motivational interviewing, cognitive behavior therapy, and relapse prevention. 2. Counseling provided to the individual’s family is for the direct benefit of the individual served in accordance with their needs and treatment goals, and for the purpose of assisting in the individual’s recovery. 3. Services must be provided by a QMHP or QAP; (E) Co-Occurring Group Counseling—goal-oriented therapeutic interaction between a counselor and two (2) or more individuals as specified in individual treatment plans to promote self-understanding, self-esteem, and resolution of personal problems related to the individual’s documented mental disorders and substance use disorders through personal disclosure and interpersonal interaction among group members. This service utilizes evidence-based practices. 1. Services must be provided by a QMHP or QAP; 2. Group size shall not exceed ten (10) individuals; (F) Co-Occurring Group Rehabilitative Support—informational and experiential services to assist individuals, family members, and others identified by the individual as a primary natural support, in the management of substance use and mental health disorders. 1. Services are delivered through systematic, structured, didactic methods to increase knowledge of mental illnesses and substance use disorders. This includes integrating affective and cognitive aspects in order to enable the individuals served, as well as family members/natural supports, to cope with the illness and understand the importance of their individual plan of care. 2. The primary goal is to restore lost functioning and promote reintegration and recovery through knowledge of one’s disease, symptoms, and precursors to crisis, crisis planning, community resources, recovery management, and medication action, interaction, and side effects. 3. The service includes use of evidence-based practices such as promotion of participation in peer self-help, brain chemistry and functioning, the latest research on illness causes and treatments, medication education and management, symptom management, behavior management, stress management, improving daily living skills, and independent living skills. 4. Group size is limited to twenty (20) individuals. 5. Services must be provided by staff who have documented education and experience related to the topic presented and either be or be supervised by a QMHP or a QAP; (G) Day Treatment for Children/Youth—an intensive array of services provided to children/youth in a highly structured and supervised environment designed to reduce symptoms of a psychiatric disorder and maximize the individual’s functioning so they can attend school and interact in their community and family setting. Services are individualized based on individual needs and include a multidisciplinary approach to care under the direction of a physician. The provision of educational services must comply with the Individuals with Disabilities Education Act and section 167.126, RSMo. 1. Hours of operation are based on program capacity, staffing availability, space requirements, and as specified by the department. 2. Eligibility criteria includes— A. For children six (6) years of age and older, the individual must be at risk of inpatient or residential placement as a result of a serious emotional disturbance (SED); B. For children five (5) years of age or younger, the individual must exhibit one (1) or more of the following: (I) Has been expelled from multiple day care/early learning programs due to emotional or behavioral dysregulation in relation to SED or diagnosis based on the 2021 edition of the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-5TM, Version 2.0), published by and available from ZERO TO THREE, 2445 M Street NW, Suite 600, Washington, DC 20037, telephone (202) 638-1144 or (800) 899-4301. The document incorporated by reference does not include any later amendments or additions; (II) Is at risk for placement in an acute psychiatric hospital or residential treatment center as a result of a SED; or (III) Has a score in the seriously impaired functioning level on the standardized functional tools approved by the department for this age range. 3. Key service functions shall include, but are not limited to: A. Providing integrated treatment combining education, counseling, and family interventions; B. Promoting active involvement of the parent/guardian in the program; C. Consulting and coordinating with the individual’s/ family’s private service providers, as applicable, to establish and maintain continuity of care; D. Coordinating and sharing information with the individual’s school, including discharge planning, consistent with the Family Educational Rights and Privacy Act and Health Insurance Portability and Accountability Act (HIPAA); E. Requesting screening and assessment reports from the individual’s school to determine any special education needs; F. Planning the individualized educational needs with the individual’s school; and G. Providing other core services as prescribed by the department. 4. For programs serving children three (3) to five (5) years of age, services must be provided by a team of at least one (1) QMHP and one (1) appropriately certified, licensed, or credentialed ancillary staff. For programs serving school-age children, services must be provided by a team consisting of at least one (1) QMHP and two (2) appropriately certified, licensed, or credentialed ancillary staff. Ancillary staff include— A. Occupational therapists; B. Physical therapists; C. Assistant behavior analysts; D. Individuals with a bachelor’s degree in child development, psychology, social work, or education; E. Individuals with an associate’s degree, or two (2) years of college, and two (2) years of experience in a mental health or child-related field; and F. Individuals meeting the qualifications of a community support specialist with at least three (3) years of populationspecific experience providing community support services in accordance with the key service functions for community support services as specified in 9 CSR 30-4.047. 5. Documentation must include relevant information reported by family members/natural supports regarding a change in the individual’s condition or an unusual or unexpected occurrence in their life; (H) Evidence-Based Practices for Children and Youth, in accordance with 9 CSR 30-4.045; (I) Family Assistance—services focus on development of home and community living skills and communication and socialization skills for children and youth, including coordination of community-based services. Staff must have a high school diploma or equivalent and two (2) years of experience working with children who have a SED or have experienced abuse and neglect. Staff must also complete training approved by/provided by the department and be supervised by a QMHP. Key service functions shall include, but are not limited to: 1. Modeling appropriate behaviors and coping skills for the child; 2. Exposing the child to activities that encourage positive choices, promote self-esteem, support academic achievement, and develop problem-solving skills for home and school; 3. Teaching appropriate social skills through hands-on experiences; and 4. Mentoring appropriate social interactions with the child or resolving conflict with peers; (J) Family Support—provides a support system for parents/ caregivers of an individual twenty-five (25) years of age and younger who has a SED. Activities are directed and authorized by the individualized treatment plan. Services must be provided by a family member of an individual twenty-five (25) years of age and younger who has or had a behavioral or emotional disorder. The family member must have a high school diploma or equivalent certificate, complete training required by the department, and be supervised by a QMHP. Key service functions shall include, but are not limited to: 1. Providing information and support to the parents/ caregivers so they have a better understanding of the individual’s needs and options to be considered as part of treatment; 2. Assisting the parents/caregivers in understanding the planning process and importance of their voice in the development and implementation of the individualized treatment plan; 3. Providing support to empower the parents/caregivers to be a voice for the individual and family in the planning meeting; 4. Working with the family to highlight the importance of individualized planning and the strengths-based approach; 5. Assisting the family in understanding the roles of various providers and the importance of the team approach; 6. Discussing the benefits of natural supports within the family and community; 7. Introducing methods for problem-solving and developing strategies to address issues needing attention; 8. Providing support and information to parents and caregivers to shift from being the decision maker to the support person as the individual becomes more independent; 9. Connecting families to community resources; 10. Empowering parents, caregivers, and individuals served to become involved in activities related to planning, developing, implementing, and evaluating programs and services; and 11. Connecting parents, caregivers, and individuals served to others with similar lived experiences to increase their support system; (K) Individual Professional PSR and Group Professional PSR— mental health interventions provided on an individual or group basis. A skills-based approach is utilized to address identified behavioral problems and functional deficits related to a mental disorder that interfere with an individual’s personal, family, or community adjustment. Maximum group size is one (1) professional to eight (8) individuals. This service cannot be provided to individuals under the age of five (5). Services must be provided by the following staff who complete training required by the department: 1. A professional counselor licensed or provisionally licensed under Missouri law with specialized training in mental health services; 2. A licensed clinical social worker or master social worker licensed under Missouri law with specialized training in mental health services; 3. A licensed, provisionally licensed, or temporarily licensed psychologist under Missouri law with specialized training in mental health services; or 4. A marital and family therapist licensed or provisionally licensed under Missouri law with specialized training in mental health services. (L) Intensive CPR, in accordance with 9 CSR 30-4.045; (M) Metabolic Syndrome Screening—optional service for individuals not receiving antipsychotic medications and, if provided, must be in accordance with subsection (2)(J) of this rule; (N) Peer Support—assists individuals in their recovery from a behavioral health disorder in a person-centered, recoveryfocused manner. Individuals direct their own recovery and advocacy processes to develop skills for coping with and managing their symptoms, and identify and utilize natural support systems to maintain and enhance community living skills. Services are directed toward achievement of specific goals defined by the person served and specified in the individual treatment plan. 1. Peer support services shall be provided in a manner that reflect the core competencies, principles, and values identified in the publication, Core Competencies for Peer Workers in Behavioral Health Services, 2018, developed by and available from the Substance Abuse and Mental Health Services Administration (SAMHSA), 5600 Fishers Lane, Rockville, MD 20857, (877) 726- 4727, hereby incorporated by reference and made a part of this rule. This rule does not incorporate any subsequent amendments or additions to this publication. 2. Services are provided by Certified Peer Specialists who have at least a high school diploma or equivalent certificate, complete applicable training and testing required by the department, and are supervised by a QMHP. Certified Peer Specialists are part of the individual’s treatment team and participate in staff meetings/discussions related to services, but they cannot be assigned an independent caseload. The Certified Peer Specialist Code of Ethics must be followed. Job duties include, but are not limited to: A. Starting and sustaining mutual support groups; B. Promoting dialogues on recovery and resilience; C. Teaching and modeling skills to manage symptoms; D. Teaching and modeling skills to assist in solving problems; E. Supporting efforts to find and maintain paid employment; F. Using the stages in recovery concept to promote selfdetermination; and G. Assisting peers in setting goals and following through on wellness and health activities. 3. Certified Peer Specialists use the power of peers to support, encourage, and model recovery and resilience from behavioral health disorders in ways that are specific to the needs of each individual. Services may be provided on an individual or group basis and are designed to assist individuals in achieving the goals and objectives on their individual treatment plan or recovery plan. Activities emphasize the opportunity for individuals to support each other as they move forward in their recovery. Interventions may include, but are not limited to: A. Sharing lived experiences of recovery, sharing and supporting the use of recovery tools, and modeling successful recovery behaviors; B. Helping individuals recognize their capacity for resilience; C. Helping individuals connect with other peers and their community at large; D. Helping individuals who have behavioral health disorders develop a network for information and support; E. Assisting individuals in making independent choices and taking a proactive role in their treatment; F. Assisting individuals in identifying strengths and personal resources to aid in their recovery; and G. Helping individuals set and achieve recovery goals; (O) Psychosocial Rehabilitation Illness Management and Recovery (PSR-IMR), in accordance with 9 CSR 30-4.046; (P) Psychosocial Rehabilitation for Youth, in accordance with 9 CSR 30-4.046; and (Q) Professional Parent Home-Based Services and Treatment Family Home-Based Services (ICPR for Children/Youth in Residential Settings), in accordance with 9 CSR 30-4.045. AUTHORITY: sections 630.050, 630.655, and 632.050, RSMo 2016.* 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. Emergency amendment filed Feb. 15, 1994, effective March 6, 1994, expired April 10, 1994. Amended: Filed Aug. 27, 1993, effective April 9, 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. 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 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: 630.050, RSMo 1980, amended 1993, 995, 2008; 630.655, RSMo 1980; and 632.050, RSMo 1980.