Definitions

PURPOSE: This rule defines terms used in licensing procedures and rules developed under sections 630.705–630.760, RSMo, for all community residential programs and day programs subject to licensure by the department, including Residential Care Facilities and Assisted Living Facilities dually licensed by the Department of Health and Senior Services. PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which 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) Unless the context clearly indicates otherwise, the terms defined in sections 630.005, 632.005 and 633.005, RSMo and as used in 9 CSR 40 are incorporated by reference as if set out in this rule. (2) The following additional words and terms, as used in 9 CSR 40, mean: (A) Administrative agent, an organization and its approved designee(s) authorized by the department as an entry and exit point into the state mental health service delivery system for a geographic service area defined by the department. Administrative agents provide statewide access crisis intervention services, including a twenty-four (24) hour crisis mobile response by qualified mental health professionals; (B) Access Crisis Intervention (ACI), as defined in 9 CSR 30-4.195 Access Crisis Intervention (ACI) Programs; (C) Affiliate, an organization that is contracted with the department to provide specific community psychiatric rehabilitation (CPR) services for adults in a specific designated geographic region; (D) Applicant, an individual, partnership, association, corporation, or governmental entity which has applied to the department for a license or program license; (E) Assisted living facility (ALF), any residence, intermediate care facility, or skilled nursing facility licensed under Chapter 198, RSMo, that provides twenty-four (24) hour care and services and protective oversight to three (3) or more adults who need assistance with activities of daily living and instrumental activities of daily living; storage, distribution, or administration of medications; and/or supervision of health care under the direction of a licensed physician; (F) Behavioral health, the promotion of mental health, resilience, and well-being, the treatment of mental health and substance use disorders, and the support of individuals who experience and/or are in recovery from these conditions, along with their families/natural supports and communities; (G) Behavioral crisis/mental health crisis, any situation in which a person’s behavior puts him/her at risk of hurting him/herself or others and/or prevents him/her from being able to care for him/herself or function effectively in the community; (H) Behavioral health services, mental health services, substance use disorder treatment services, or a combination of both, for youth, children, and adults. Services may be provided in a residential program, on an outpatient basis, or in a home or community program; (I) Care plan, document developed by staff of a community residential program or day program in collaboration with the individual served and family members/natural supports, as appropriate, which includes measurable goals and objectives important to the individual to assist him or her in achieving personally defined outcomes, ensures delivery of services and supports in a manner that reflect personal preferences and choices, and contributes to the assurance of health and wellness of the individual served; (J) Community Psychiatric Rehabilitation (CPR), an array of community-based outpatient mental health services for children, youth, and adults who have been diagnosed with a severe, disabling mental illness or serious emotional disturbance. Administrative agents or their affiliates are responsible for providing these services to eligible individuals in designated service area(s); (K) Community residential program, any premises where services, structure, oversight, and supports are provided on a residential basis for adults with mental illness who otherwise would not be able to function outside of psychiatric inpatient care due to the severity and chronicity of their mental illness. This includes, but is not limited to, Intensive Residential Treatment Settings (IRTS), Psychiatric Individualized Supported Living (PISL), Residential Care Facilities (RCF), Intermediate Care Facilities (ICF), and Assisted Living Facilities (ALF); (L) Competency-based training, the provision of knowledge and skills sufficient to enable the trained staff person to meet specified standards of performance consistent with generally accepted professional standards or specified in law, regulation, or policy, as validated by the person’s demonstration that he/she can use such knowledge or skills effectively; (M) Compliance, a program may be found in compliance with these licensing rules when deficiencies do not involve— 1. Abuse or neglect—any instance of abuse/neglect in which corrective action has not been taken; 2. Life endangering conditions—any single life-endangering event or combination of minor deficiencies which collectively are life endangering or which become perilous contingent upon an event such as the outbreak of fire; 3. Legal requirements-deficiencies related to statutory requirements for programs licensed by the department, such as individual rights and licensing procedures; 4. Repeated deficiencies—issues which may or may not be serious in and of themselves, but which become significant when left uncorrected according to agreed upon schedules over a period of time; 5. Numerous deficiencies—deficiencies which may or may not be serious themselves, but become significant collectively because they indicate an ineffective maintenance plan, deficient environmental standards, inadequate orientation or training of staff, poor nursing care practice, inadequate diet, lack of treatment or rehabilitation, ineffective policies and procedures, inadequate staffing, improper recordkeeping, or other issues which may affect the well being of individuals served; or 6. Minimum environmental requirements—quantitative requirements under environment and fire safety/emergency preparedness relating to minimum dimensions for hallways, doors, ceiling heights, window space, floor space, number of bathrooms, and individuals per bedroom; (N) Consent agreement, an agreement with the department that is entered into by the director of a community residential program or day program to obtain a probationary license. Such a consent agreement will include a provision that the director of the program will voluntarily surrender the license if compliance with licensing requirements is not reached in accordance with the terms and deadlines established under the agreement. The agreement specifies the stages, actions, and time span to achieve compliance; (O) Continuing care, the provision of a treatment plan and program structure that will ensure an individual receives the type of care he/she needs at the time, particularly at the point of discharge or transfer from the current program. Programs are flexible and tailored to the changing needs of individuals served; (P) Crisis, an event or time period for an individual characterized by a substantial increase in symptoms, legal or medical problems, and/or loss of housing, employment, or personal supports; (Q) Crisis prevention plan, developed with individuals who have a mental illness when a potential risk for suicide, violence, or other at-risk behavior is identified during the assessment process or any time during the individual’s engagement in services. At a minimum, the crisis prevention plan includes factors that may precipitate a crisis, a hierarchical list of skills/strengths identified by the individual to regain a sense of control to return to his/her level of functioning before the crisis or emergency, and a hierarchical list of staff interventions that may be used when a critical situation occurs; (R) Deemed license, acknowledges that an organization/program is monitored and held accountable by a recognized national accrediting body and the department accepts the organization’s verification of good standing with the accrediting body as sufficient to meet the department’s standards of care; (S) Deficiency, a condition, event, or omission that does not comply with a department licensing rule; (T) Discharge, the point at which an individual’s active involvement with a treatment or rehabilitation program concludes in accordance with the goals in his or her individual support plan (ISP), individual treatment plan (ITP), or care plan, applicable utilization criteria, and/or program rules; (U) Electronic health record (EHR), digital version of individual records; (V) Family living arrangement (FLA) for adults, a program in the owned or leased permanent residence of the licensee, serving no more than three (3) adults who have a developmental disability who are integrated into the licensee’s family unit. The licensee of the home provides care and support as directed in the individual support plan (ISP); (W) Family living arrangement (FLA) for children/youth, a program in the owned or leased permanent residence of the licensee in which mental health interventions are provided for children and youth placed in the home, allowing the child to remain in his/her community until returning to his/her natural home or alternative community placement to avoid being removed from a community setting; (X) Individual, a person/consumer/client receiving services from a program licensed under 9 CSR 40; (Y) Individualized education plan (IEP), a plan developed by trained school staff for children who have a disability and a need for specialized instruction; (Z) Individual support plan (ISP), a document resulting from a person-centered planning process with an individual with intellectual or developmental disabilities, with assistance as needed by a representative, in collaboration with an interdisciplinary team. The plan is intended to identify the strengths, capacities, preferences, needs, and desired outcomes of the person served. The process may include other people freely chosen by the individual who are able to contribute to the process. The person-centered planning process enables and assists the individual in accessing a personalized mix of paid and nonpaid services and supports that will assist him/her in achieving personally defined outcomes and the training, supports, therapies, treatments, and/or other services that become part of the ISP; (AA) Individual Treatment Plan (ITP), written document developed in collaboration with the individual seeking assistance for a behavioral health condition (or his or her parent/legal guardian) that identifies the individual’s strengths, goals, preferences, abilities, physical and behavioral health needs, and desired outcomes for a healthy lifestyle in the community. Treatment staff, treatment team members, and family members/natural supports (if acceptable to the individual being served) participate in the development of the plan and assist the individual in identifying and accessing a mix of services and supports to meet his/her needs and achieve desired goals for recovery and resiliency; (BB) Intensive Residential Treatment Setting (IRTS), living environment where medically necessary services/supports are provided for five (5) to sixteen (16) adults with serious mental illness who are transitioning from an inpatient psychiatric hospital to the community, or are at risk of returning to inpatient care due to their clinical status or need for increased support. This environment is most appropriate for individuals who can tolerate regular interaction with their peers, but have significant difficulties with activities of daily living and may require round-the-clock observation and oversight and/or periodic redirection from staff to avoid behaviors potentially harmful to themself or others; (CC) Isolation, removing an individual from a social setting to prevent spread of contagious disease; (DD) License, written notification that a community residential program or day program complies with department licensing requirements to serve individuals with mental illness, intellectual disabilities, and developmental disabilities; (EE) Licensee, an individual, partnership, association, corporation, or governmental entity which has received a license or program license from the department to operate a community residential program or day program to provide services and supports for individuals with mental illness, intellectual disabilities, and developmental disabilities; (FF) Mechanical supports, supportive devices used in normative situations to achieve proper body position and balance; these are not restraints; (GG) Medication administration, qualified staff preparing and/or giving a legally prescribed individual dose of medication to an individual served, including observation and monitoring the individual’s response to the medication; (HH) Medication control, the process of physically controlling, transporting, storing, and disposing of medications, including medications self-administered by individuals served; (II) Medication use, the practice of handling, prescribing, and dispensing medication (including administering and observing selfadministration) to persons served in response to specific symptoms, behaviors, and conditions for which the use of medication is indicated and deemed effective. This includes prescribed and sample medications and may, when required as part of the treatment regimen, include over-the-counter or alternative medication provided to persons served; (JJ) Misuse of funds/property, as defined in 9 CSR 10-5.200, Report of Complaints of Abuse, Neglect, and Misuse of Funds/Property; (KK) Natural supports, provided by a person of the individual’s choice to assist him or her in achieving personal goals and facilitating integration into their community. Natural supports are provided by persons who are not paid staff of an agency but may be initiated, planned, and facilitated in partnership with an agency; (LL) Neglect, as defined in 9 CSR 105.200, Report of Complaints of Abuse, Neglect, and Misuse of Funds/Property; for Community Residential Programs and Day Programs (MM) Outcome, a specific measurable result of services/supports provided to an individual or identified target population; (NN) Person-centered, services and supports developed in collaboration with the individual served that are respectful of informed consent and the preferences of the individual, resulting in a therapeutic alliance which contributes significantly to treatment/rehabilitation outcomes; (OO) Physical abuse, as defined in 9 CSR 10-5.200, Report of Complaints of Abuse, Neglect, and Misuse of Funds/Property; (PP) Probationary license, written authorization to continue service delivery for a specified period of time to enable a licensee to achieve compliance with the department’s licensing requirements as set forth in a consent agreement between the department and the licensee; (QQ) Program license, written notification that a community residential program with a current license, temporary operating permit, or probationary license from the Department of Health and Senior Services (DHSS) under sections 198.006—198.096, RSMo, also meets the department’s licensing requirements relative to admission criteria, care, treatment, and habilitation or rehabilitation needs of individuals served; (RR) Psychiatric crisis, an individual is exhibiting a substantial increase in symptoms related to a severe emotional disturbance or mental illness based upon his or her baseline functioning. The reason(s) why the crisis occurred and how it is expressed varies by individual and may include harm to self or others, disorientation, being out of touch with reality, compromised ability to function, or other expression of emotional distress not characteristic to the individual. Immediate clinical assessment and intervention is necessary to ensure the safety of the individual and others; (SS) Psychiatric Individualized Supported Living (PISL), living environment where medically necessary services/supports are provided for one (1) to four (4) adults with serious mental illness who are transitioning from an inpatient psychiatric hospital to the community, or are at risk of returning to inpatient care due to their clinical status or need for increased support. This environment is most appropriate for individuals who— 1. Have intermittent difficulty tolerating other individuals in their immediate living area; 2. Require access to an individual bedroom to avoid psychiatric relapse, aggression, or other behaviors associated with a risk of re-hospitalization; and/or 3. Have substantial difficulties with activities of daily living and require roundthe-clock observation and oversight; and/or 4. Require daily redirection from staff to avoid behaviors potentially harmful to themselves or others; (TT) Qualified mental health professional (QMHP), any of the following: 1. A physician licensed under Missouri law to practice medicine or osteopathy and with training in mental health services or one (1) year of experience, under supervision, in treating problems related to mental illness or specialized training; 2. A psychiatrist licensed under Missouri law as a physician and who has successfully completed a training program in psychiatry approved by the American Medical Association, the American Osteopathic Association, or other training program identified as equivalent by DMH; 3. A psychologist licensed under Missouri law to practice psychology with specialized training in mental health services; 4. A professional counselor licensed under Missouri law to practice counseling with specialized training in mental health services; 5. A clinical social worker licensed under Missouri law with a master’s degree in social work from an accredited program and with specialized training in mental health services; 6. A psychiatric nurse licensed under Chapter 335, RSMo, as a registered professional nurse with at least two (2) years of experience in a psychiatric or substance use disorder treatment setting or a master's degree in psychiatric nursing; 7. An individual possessing a master's or doctorate degree in counseling and guidance, rehabilitation counseling and guidance, vocational counseling, psychology, pastoral counseling, family therapy, or related field who has successfully completed a practicum or has one (1) year of experience under the supervision of a QMHP; 8. An occupational therapist certified by the National Board for Certification in Occupational Therapy, registered in Missouri, who has a bachelor's degree and has completed a practicum in a psychiatric setting or has one (1) year of experience in a psychiatric setting, or has a master's degree and has completed either a practicum in a psychiatric setting or has one (1) year of experience in a psychiatric setting; 9. An advanced practice registered nurse (APRN) under section 335.016, RSMo, who has had education beyond the basic nursing education and is certified by a nationally recognized professional organization as having a nursing specialty, or who meets criteria for APRNs established by the board of nursing; or 10. A psychiatric pharmacist, registered pharmacist in good standing with the Missouri Board of Pharmacy who is a board-certified psychiatric pharmacist through the Board of Pharmaceutical Specialties, or a registered pharmacist currently in a psychopharmacology residency where the service has been supervised by a board-certified psychiatric pharmacist; (UU) Reciprocal license, issued by the department to a residential program that has a current valid license as a Residential Treatment Agency for Children and Youth from the Department of Social Services under 13 CSR 35-71, if the applicant has applied for a license from the department and paid the application fee; (VV) Research, as defined in 9 CSR 601.010; (WW) Residential care facility (RCF), as defined in section 198.006, RSMo; (XX) Residential program, program in the community serving ten (10) or more individuals with intellectual or developmental disabilities by providing social support, health supervision, and habilitation training in skills of daily living; (YY) Restraint, as defined in 9 CSR 107.140; (ZZ) Safety crisis plan, as defined in 9 CSR 45-3.090 Behavior Supports; (AAA) Scheduled (controlled) medication, categories or schedules assigned to medication by the Drug Enforcement Administration based on a drug’s acceptable medical use and the drug’s abuse or dependency potential; (BBB) Seclusion, involuntary confinement of an individual alone in a room or an area from which he/she is physically prevented from leaving or having contact with others; (CCC) Self-administration of medication (adults), the application of a medication, (whether by injection, inhalation, oral ingestion, or any other means) by the individual served to his or her body, and may include the program storing the medication and staff handing the medication container to the individual at the time designated to take the medication; (DDD) Sexual abuse, as defined in 9 CSR 10-5.200, Report of Complaints of Abuse, Neglect, and Misuse of Funds/Property; (EEE) Staff (staff member, employee, personnel), paid employee or contractor providing services and/or supports on behalf of a licensed or deemed licensed program, on a full- or part-time basis, and has contact with individuals served by the program; (FFF) Stock supply/stock pharmaceutical, prescription and non-prescription medication stored on-site for the provision of medication services by a program. Stock supplies are checked by qualified staff on a routine basis for expiration dates and reviewed annually by a pharmacy consultant and approved by the medical director or pharmacy technician; (GGG) Substance use disorder, diagnostic term in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) referring to recurrent use of alcohol or other drugs that causes clinically and functionally significant impairment such as health problems, disability, and failure to meet major responsibilities at work, school, or home. Depending on the level of severity, this disorder is classified as mild, moderate, or severe. The document incorporated by reference does not include any later revisions or updates and is available from the American Psychiatric Association, 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209-3901; (HHH) Supports, array of activities, resources, relationships, and services designed to assist an individual’s integration into the community, participation in services/supports, improve functioning, and/or recovery and resiliency; (III) Targeted case management, Medicaid program that assists individuals served by the Division of Developmental Disabilities (DD) to gain access to needed medical, social, educational, and other services; (JJJ) Temporary operating permit, written authorization from the department permitting a licensee seeking license renewal or a new owner applying for an initial license to continue service delivery pending completion of the licensing survey process and the applicant is not at fault for any delay in the process; (KKK) Time-out, temporarily separating a person from an environment where he or she has exhibited unacceptable behavior; (LLL) Trauma, experiences that cause intense physical and psychological stress reactions. May refer to a single event, multiple events, or a set of circumstances experienced by an individual as physically and emotionally harmful or threatening and has lasting adverse effects on the individual’s physical, social, emotional, or spiritual wellbeing; (MMM) Treatment, a professionally recognized approach that applies accepted theories, principles, and techniques designed to achieve rehabilitative outcomes for individuals served; (NNN) Verbal abuse, as defined in 9 CSR 10-5.200, Report of Complaints of Abuse, Neglect, and Misuse of Funds/Property; and (OOO) Volunteer, an unpaid person formally recognized by a program to provide direct services or supports to individuals it serves. (3) Unless the context clearly indicates otherwise, certain terms shall be used in 9 CSR 40 as follows: (A) Parent, the parent of a minor child unless his/her parental rights have been terminated, or the parent of an adult who consents to having the parent have access to or participate in the record or activity subject of a particular rule. The term shall be disregarded if the individual’s parents are deceased or have had their parental rights terminated; and (B) Guardian, the person appointed by a Missouri court of competent jurisdiction to have the care, custody, and control of the individual. The term shall be disregarded if the individual has not had a guardian appointed. AUTHORITY: sections 630.050 and 630.705, RSMo 2016.* Original rule filed Oct. 13, 1983, effective Jan. 15, 1984. Amended: Filed March 14, 1984, effective Aug. 15, 1984. Amended: Filed July 15, 1985, effective Feb. 1, 1986. Amended: Filed Jan. 2, 1990, effective June 11, 1990. Amended: Filed Jan. 31, 1991, effective July 8, 1991. Amended: Filed July 17, 1995, effective March 30, 1996. Amended: Filed May 14, 2020, effective Dec. 30, 2020. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.705, RSMo 1980, amended 1982, 1984, 1985, 1990, 2000, 2011, 2014.