Sobering Centers

PURPOSE: This rule sets forth requirements for operation of a sobering center. (1) Definitions. Unless the context clearly requires otherwise, the following terms as used in this rule shall mean— (A) Sobering center, short-term care facility designed to allow an individual who is intoxicated and nonviolent to safely recover from the immediately debilitating effects of alcohol and drugs. Sobering centers typically operate twenty-four (24) hours per day, seven (7) days per week and provide supervised care for individuals experiencing acute intoxication for up to twenty-three (23) consecutive hours; and (B) Acute intoxication, a transient condition that follows the ingestion or consumption of alcohol or a psychoactive substance and results in disturbances in the level of consciousness, cognition, perception, judgment, affect or behavior, or other psychophysiological functions and responses. (2) Program Description. Sobering centers are operated by a Certified Community Behavioral Health Organization (CCBHO). (A) Services shall be designed to serve as a community-based alternative to emergency department services, unnecessary hospitalization, and/or jail confinement, offering short-term stabilization for individuals experiencing acute intoxication. (3) Certification. At a minimum, the organization shall comply with 9 CSR 10-7.130 Procedures to Obtain Certification, to apply for certification/deemed status as a sobering center by the department. (4) Program Requirements. Sobering centers shall provide prompt assessment, stabilization (with or without medication), and determination of appropriate monitoring needed for the individual to return to a state of clinical sobriety. (A) Services shall be designed to address acute intoxication with the goal of symptom reduction as evidenced by— 1. Eating, drinking, and/or swallowing without difficulty; 2. Walking without ataxia or unsteady gait; 3. Baseline mental status representing unimpaired cognition; and 4. Cognitive status supporting reasonable decisions. (B) Referrals to community resources and/or treatment and recovery services shall be made, as appropriate. (5) Target Population. The target population includes individuals age eighteen (18) years and older who are experiencing acute intoxication and have a high or imminent risk of law enforcement contact and/or emergency department intervention. (6) Physical Environment and Safety. All sobering centers shall be in compliance with 9 CSR 10-7.120 Physical Environment and Safety, and applicable state and local building codes, fire codes, and ordinances to ensure the health, safety, and security of all individuals. (A) The physical environment shall— 1. Promote a sense of safety and calm for individuals and staff; 2. Have adequate space to ensure the comfort of individuals served; 3. Have adequate space to ensure privacy and confidentiality for individuals served; 4. Have furnishing and fixtures that are constructed of durable materials not capable of breakage into pieces that could be used as a weapon, ligature risk, or for self-harm; and 5. Have interior finishes, lighting, and furnishings that suggest a non-institutional setting that conforms to applicable fire and safety codes. (7) Care Criteria. Each sobering center shall implement written screening and intake criteria for individuals who present for services. (A) All individuals who present for services from a referral source shall be screened as specified in subsection (7)(C) of this rule, including those who are referred/transported by law enforcement. 1. Hours of operation shall be clearly communicated to law enforcement and other referral sources. (B) If in-person screening results in an individual not being offered services, documentation of the rationale for the denial of services and facilitated referral of the individual to other appropriate services must be maintained. (C) Service criteria shall include, but is not limited to— 1. Presence of acute intoxication; and 2. Presence of high or imminent risk of law enforcement contact and/or emergency department intervention. (D) Medical clearance is not required prior to provision of services; however, each individual served must be able to ambulate with minimal assistance, including the use of assistive devices required for existing medical conditions. 1. Individuals referred from a hospital must meet medical stability eligibility criteria. 2. If a physical health issue requiring medical care occurs that cannot be addressed while an individual is receiving services in the sobering center, the treating center shall arrange for the individual to be appropriately transported to a medical facility to address the physical health issue. (E) As appropriate, medications (including medicationassisted treatment for a substance use disorder) shall be prescribed while coordinating ongoing services with the individual. (8) Staff Qualifications. The sobering center shall be adequately staffed to meet the needs of individuals served to ensure their safety and the safety of staff. (A) Each center shall have the staffing capacity to monitor vital signs with established written protocols to transfer an individual to a medical facility, if needed. (B) The center shall be staffed by a multidisciplinary team that is able to respond to the needs of individuals experiencing acute intoxication. Staff shall include, but is not limited to— 1. Medical director, a licensed physician. The medical director for the sobering center can be the same individual who serves as the medical director for the Certified Community Behavioral Health Organization (CCBHO). A. Direct services shall be provided by a licensed physician (includes psychiatrist), resident physician (includes psychiatrist), physician assistant, assistant physician, licensed psychiatric mental health nurse practitioner (PMHNP), and/or advanced practice registered nurse (APRN) who is in a written collaborative practice arrangement with a physician and with experience treating the target population. Services may be provided via telemedicine; 2. Qualified practitioner(s) to treat opioid use disorders with narcotic medications approved by the Food and Drug Administration (methadone must be provided by a certified opioid treatment program); 3. Clinical program director, a qualified mental health professional (QMHP) to oversee program operations and clinical practice, with experience treating the target population; 4. Nurse, paramedic, or emergency medical technician (EMT); and 5. Certified peer specialist(s). (9) Staff Coverage. Staff coverage shall ensure the continuous supervision and safety of individuals served. Staff coverage shall be determined by the sobering center. (A) At a minimum, coverage shall include— 1. Two (2) behavioral health staff who are on-site during receiving hours; 2. One (1) QMHP who is available during receiving hours (may be via telemedicine); 3. One (1) nurse, paramedic, or EMT who is available during receiving hours (may be via telemedicine); and 4. A physician or resident physician (including psychiatrist), assistant physician, physician assistant, PMHNP, and/or APRN, who is available during receiving hours and must immediately respond to calls from staff, delay not to exceed one (1) hour. (B) Qualified staff must be available to administer, screen, inventory, and store prescribed medications within their scope of duties, practice, and/or training. (C) Qualified staff, within their scope of duties, practice, and/or training, shall be available to conduct an initial health assessment and utilize evidence-based tools to determine the individual’s medical stability, intoxication, substance use, and/ or level of withdrawal/impairment. (10) Policies and Procedures. The sobering center shall maintain and implement written policies and procedures including but not limited to— (A) Intake screening, service, and clinical assessment protocols; (B) Community outreach and education strategies for acute intoxication stabilization services including access to and location of service site(s), hours, and days of operation for each site through written material and other means of communication, and how these components will be accomplished on an ongoing basis; (C) Withdrawal management (detoxification) services as defined in 9 CSR 30-3.120. If the sobering center does not provide this service, facilitated referrals to a local hospital or another qualified service provider shall be made for withdrawal management or other medical services, if determined necessary during an individual’s evaluation process; (D) Safety and emergency protocols as specified in 9 CSR 10-7.120 Physical Environment and Safety, as well as specific protocols for the population served; (E) Prescription medication protocols, including storage of medications in accordance with 9 CSR 10-7.070; (F) Screening for and accessing services for emergency medical conditions, including transport by first responders/ emergency medical service; (G) Monitoring the physical and psychological well-being of individuals including but not limited to respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified in the organization’s policies and procedures associated with evaluations; (H) Linking individuals to housing services upon discharge, as needed; (I) Linking individuals to transportation services upon discharge, as needed; (J) Linking individuals to social services or community resources, as needed; (K) Assessment and referral process for individuals with a suspected substance use disorder and/or mental health disorder; (L) Care coordination and continuity of care for individuals served including but not limited to referral process, follow-up, and transfer of records within five (5) days, as applicable; (M) Infection prevention and control; and (N) Exclusion criteria and protocol when the sobering center is not able to provide services to an individual. (11) Referral Sources. At a minimum, the following are required referral sources for consideration for admission: (A) Law enforcement; (B) Emergency medical services; (C) Other first responders; (D) Engaging Patients in Care Coordination (EPICC) Coaches; (E) Community-based organizations participating in department supported outreach services; (F) Local hospitals, primary care clinics, urgent care clinics, and Federally Qualified Health Centers (FQHC); (G) Community Behavioral Health Liaisons; and (H) Mobile Crisis Response. (12) Community Partnerships. At a minimum, sobering centers shall have a referral relationship, collaborative agreement, and/ or memorandum of understanding (MOU) with the following community providers/agencies: (A) Qualified providers of withdrawal management services; (B) Housing supports; (C) Local hospitals, primary care clinics, and FQHCs; (D) Local Continuum(s) of Care; and (E) Recovery support and recovery housing providers. (13) Coordination and Continuity of Care. Service coordination and continuity of care efforts shall include, but are not limited to: (A) Identifying and linking individuals with available community resources necessary to ensure transition to routine care; (B) Referring individuals to behavioral health services, if they are not already receiving those services; (C) Connecting and/or referring individuals to appropriate local resources including emergency room enhancement (ERE) staff, community behavioral health liaisons (CBHL), and/ or certified peer specialists who shall conduct and document timely follow-up to determine the individual’s current status and need for additional assistance or services; (D) Contacting and coordinating care with current service providers when feasible and in accordance with state and federal confidentiality regulations; (E) Connecting individuals to housing, food, or other resources; (F) Connecting individuals with recovery support and/or recovery housing providers; (G) Connecting individuals with community-based behavioral health providers in other geographic regions; and (H) Incorporating intensive support beds into a partner program (within the organization or with another local agency), if available, for individuals who need additional support beyond that of the sobering center. (14) Documentation Requirements. Based on the individual’s ability to cooperate and communicate with staff due to their presenting condition, the following intake documentation shall be obtained: (A) Presenting problem and referral source, if applicable; (B) Rationale for denial of services and referral of the individual to other appropriate services, if necessary; (C) Personal and identifying information; (D) Status as a current or former member of the U.S. Armed Forces; (E) Current mental health and substance use symptoms; (F) Current medications and any medications administered; (G) Screening for suicide risk and completion of a comprehensive, standardized suicide risk assessment and planning, when clinically indicated; (H) Screening for risk of violence and completion of a comprehensive, standardized violence risk assessment and planning, when clinically indicated; (I) Current concerns for personal safety; and (J) Discharge information including services provided, care coordination efforts, follow-up, and referrals. (15) Measuring Program Effectiveness. Sobering centers shall collect, enter, and submit data utilizing all reporting tools as directed by the department. (16) Staff Training and Education. Staff shall comply with the training requirements specified in 9 CSR 10-7.110 Personnel, subsection (2)(F). All staff of the sobering center shall complete minimum training requirements as follows: (A) Screening, assessment, and planning for risk of suicide; (B) Screening, assessment, and planning for risk of violence; (C) Evidence-based and best practice interventions to prevent and address disruptive behaviors and behavioral crises; (D) Basic First Aid; (E) Cardiopulmonary Resuscitation (CPR); (F) Administration of naloxone; and (G) Trauma-informed care. AUTHORITY: section 630.050, RSMo 2016.* Original rule filed March 21, 2023, effective Sept. 30, 2023. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, and 2008.