Certification of Home and CommunityBased Providers Serving Persons with Intellectual and

Developmental Disabilities PURPOSE: This rule defines terms, establishes principles, and sets out the process by which agencies providing individualized supported living (ISL), group home, shared living, day habilitation, individualized skills development, community networking, out- of-home respite, intensive therapeutic residential habilitation, and employment services to individuals with intellectual and developmental disabilities through the Medicaid Home and Community-Based Waiver (HCBS) attain certification. 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 Division of Developmental Disabilities (division) establishes procedures under which a provider of Medicaid home and community-based waiver services to individuals with intellectual or developmental disabilities attains certification. In establishing those procedures, the division makes the following assumptions: (A) An individual with an intellectual or developmental disability and the individual’s family can best determine the services the individual wants and needs; (B) The division and the provider collaborate to provide quality services and supports that effectively and efficiently meet needs of individuals with intellectual or developmental disabilities within the contexts of the individual’s expressed needs; (C) Through ongoing monitoring, individuals with intellectual or developmental disabilities and their families are best positioned to determine the quality of the individual’s services and supports and the effectiveness of the services and supports in meeting their needs; (D) The certification process is flexible and person-centered and serves three (3) critical purposes— 1. To determine how well providers fulfill their responsibilities to individuals with intellectual or developmental disabilities; 2. To determine systems changes and practices needed so that the provider will be more responsive to the individual’s needs; and 3. To enhance inclusion and self-determination of individuals with intellectual or developmental disabilities as valued members of their communities; (E) Providers shall subscribe to and meet all principles in this rule. The division shall enforce those principles; and (F) A residential or day program that attains certification from the division to deliver Medicaid Home and CommunityBased Waiver services is not subject to the requirements of 9 CSR 40-1 Licensing Rules. (2) Terms defined in sections 630.005 and 633.005, RSMo, are incorporated by reference for use in this rule. As used in this rule, unless the context clearly indicates otherwise, the following terms also mean— (A) Department—unless otherwise specified, the Department of Mental Health (DMH); (B) Individual—a person who has been found eligible for services with the Division of Developmental Disabilities; and (C) Provider—any entity or person under contract or applying for a contract with the Department of Mental Health (DMH) to serve individuals with intellectual or developmental disabilities funded by general revenue or through home and community-based waivers administered by DMH. (3) Providers certified under this rule shall comply with 42 CFR 441.301, January 2014, hereby incorporated by reference and made a part of this rule as published by and available in the Code of Federal Regulations, Office of Federal Register, National Archives and Records Administration, 7 G Street NW, Suite A-734, Washington, DC 20401, (201) 741-6000. 42 CFR 441. 301 ensures individuals served have full access to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community to the same degree of access as individuals not receiving Medicaid HCBS. This rule does not incorporate any subsequent amendments or additions to this publication. (4) This section prescribes eight (8) sets of principles for providers serving participants of any HCBS waiver operated by DMH. (A) Individuals are integrated in and have access to the greater community. 1. Individual’s decisions are respected. 2. Individuals are supported in being active participants in the community. 3. Individuals have knowledge of or access to information regarding age-appropriate activities reflective of their interests, needs, and preferences. 4. Individuals are supported in participating in nondisability-specific activities/functions that are not limited to individuals with disabilities. 5. Individuals are supported in participating in cultural and ethnic activities that reflect their interests and preferences. 6. Individuals are supported in learning to use and have ready access to public transportation, if available in their community. 7. Individuals are supported in attending religious services and worshiping as they choose. 8. Individuals are supported in regularly receiving and visiting family, friends, or other community members. 9. Individuals are supported by persons who are knowledgeable and respectful of their wants, needs, and preferences. 10. Individuals are able to come and go in the community in accordance with their wants, needs, and preferences. 11. Individuals are supported in their efforts to further their education and skill development, in the area and manner of their choice. (B) Individuals are provided with opportunities to seek employment and work in competitive integrated settings, engage in community life, and control personal resources. 1. Individuals are supported in participating in competitive integrated employment opportunities of their choice within the community. 2. Individuals are assisted in obtaining employment in a setting that is non-disability-specific and fully integrated into the community. 3. Individuals are supported in obtaining employment in a setting that is located among other private businesses and facilitates integration with the greater community. 4. Individuals are supported in obtaining employment in a setting which encourages interaction with the public. 5. Individuals who work in provider owned and controlled employment settings have knowledge of or access to information regarding competitive work outside of the setting. 6. Individuals are supported in obtaining employment in settings physically accessible and which do not limit individuals’ mobility or freedom of movement in the workplace, including access to bathrooms and break rooms. 7. Individuals are supported in self-advocacy activities in the workplace. 8. Individuals are supported in making decisions and exercising autonomy to the greatest extent possible. Individual’s decisions are respected. 9. Individuals are supported in obtaining employment with wages and benefits, including but not limited to medical benefits, annual leave, sick leave, and retirement programs, to the same extent as individuals not receiving Medicaid-funded HCBS. 10. Individuals seeking employment services are given informed choice of available providers and setting options from which to choose. 11. Employment services are provided in a manner and setting that reflects the individual’s wants, assessed needs, and preferences, taking into account the individual’s skills, capabilities, and aptitudes. 12. Individuals are supported in developing and maintaining relationships with coworkers. 13. Individuals are supported by staff who are knowledgeable about the individual’s capabilities, interests, preferences, and needs related to employment. 14. Individuals are supported in making a budget, which takes into account the individual’s financial goals. 15. Individuals are supported in making informed choices related to working, earning, spending, and saving. 16. Individuals are supported in controlling their personal finances/resources. 17. Individuals are supported in becoming financially independent. (C) Individuals receive services in the community to the same degree of access as individuals not receiving Medicaidfunded HCBS. 1. Individuals who receive specialized supports receive them in a place or manner typical for all other community members. 2. Individuals are supported in living, working, and participating in activities located in settings that are integrated into the community and consistent with their interests. 3. Individuals are provided community options in order to make informed choices of how and where they receive their services and their choices are honored. 4. Individuals are supported in finding living arrangements that are non-disability-specific and fully integrated into the community, which they can afford with their own income. 5. Individuals are supported in learning transportation skills and are transported safely. 6. Individuals’ environments are secure, stable, and physically accessible to the individual. (D) The residence is selected by the individual from among setting options including non-disability-specific settings. 1. Individuals are supported and given informed choice in selecting settings to receive Medicaid waiver services that are reflective of the individual’s wants, needs, and preferences. 2. Individuals are given the opportunity and choice to reside in community settings with individuals not receiving Medicaid Home and Community-Based Services. 3. The setting is physically accessible without obstructions that limit individual mobility in the setting. 4. Individuals own, rent, or occupy, under a legally enforceable agreement, their own specific unit/dwelling. A copy of the lease, residency agreement, or other written agreement is maintained. 5. Individuals’ residences are located among other residences that facilitate integration with the greater community. 6. Individuals’ residences are indistinguishable from other residences; for example, the use of yard signs or other advertisement should not be used which distinguish the setting as disability specific. 7. Individuals are supported in opening their homes to interact with community members of their choice. 8. Individuals have freedom to move about inside and outside of their residence and are not restricted to or from any areas or rooms within their residence. 9. Individuals have full access to the typical facilities in a home such as a kitchen, dining area, laundry, bathroom, and living room. 10. Individuals have choice with whom they live and how to furnish and decorate their home. (E) Individuals are assured the right of privacy, respect, and freedom from coercion and restraint. 1. Individuals’ right to personal privacy, dignity, and respect is ensured and supported. 2. Provider policy, procedure, and practices shall protect and promote the rights of each individual. 3. Each individual’s privacy is respected in their sleeping or living unit, as determined by the individual. 4. In provider owned and/or controlled residential settings, the following applies: A. Units have entrance doors lockable by the individual, with only appropriate staff having keys to doors; and B. Individuals sharing units have a choice of housemates in that setting. 5. Individuals are informed both orally and in writing, in a manner that the individual understands, of their rights in accordance with sections 630.110 and 630.115, RSMo, and 9 CSR 45-3.030, and responsibilities and advocacy resources, documented in writing and signed by the individual or guardian, as applicable. Notification is made prior to or upon receiving services and annually thereafter. Receipt is acknowledged in writing. 6. Individuals are supported by staff who are knowledgeable and trained annually, with documentation of the training, on individual rights in accordance with sections 630.110 and 630.115, RSMo, and 9 CSR 45-3.030. 7. Annually, individuals shall be given information written or communicated in a format understood by the individual on how to file a grievance with the provider or complaint with the department. 8. Individuals are supported by not having limitations imposed on their rights without due process, as required by 9 CSR 45-3.030. 9. Individuals are supported in an environment where they are free to communicate privately with whom they choose. 10. Individuals have access to telephones appropriate to their needs and accessible at all times. Individuals are able to make and receive calls privately. 11. Individuals who are unable to open or read their own mail are supported by staff to whom they have given consent. 12. Individuals are supported by staff who are trained annually in identifying, preventing, detecting, and reporting abuse and neglect. 13. Abuse and neglect are prohibited by provider policy and procedures. Providers follow their policies and procedures and ensure action is taken to protect individuals who report abuse or neglect. 14. Individuals are supported in planning and participating in discussions regarding their lives. 15. Individuals are supported by staff who are knowledgeable of the provider policies on confidentiality and the Privacy Rule of Health Insurance Portability and Accountability Act of 1996 (HIPAA) Health Information Protection. Staff shall maintain all information about individuals in confidence and shall not share information about individuals without consent. 16. Individuals have access to their records and are supported in maintaining their records where they choose. Staff shall assist them as needed in reviewing records and answering questions. 17. Individuals are supported in environments that support their dignity. Signs shall not be posted in easily visible areas describing information about the individual that is private or confidential. 18. Individuals are supported in their activities of daily living in a manner that is dignified and respectful. 19. Individuals are supported in making decisions and not persuaded through the use of intimidation, force, or threats. 20. Individuals are not treated differently or retaliated against for exercising his/her rights. 21. Individuals are free from mechanical, physical, and chemical restraints. (F) Individual initiative, autonomy, and independence are optimized in making life choices. 1. Individuals’ needs and preferences are honored. Individuals’ right to choice and self-determination are respected. 2. Individuals are supported in a manner that meets the individual’s expressed wants, needs, and preferences. 3. Individuals determine the quality and the effectiveness of the services and supports in meeting their needs. 4. Individuals are supported in their efforts to be active members of the community. 5. Individuals are encouraged to interact with members of the community both inside and outside their home. 6. Individuals are supported in dressing and grooming consistent with personal preferences. 7. Individuals are supported in carrying out activities of daily living, including dressing, eating, and grooming, in a manner that enhances their self-esteem and self-worth. 8. Individuals receive supports in a manner that promotes positive involvement in the community. 9. Individuals have the option to participate in political activities of their choice in the community. 10. Individuals have the freedom and support to control their own schedules and activities and have access to food at any time. 11. Individuals are supported, and assistance provided as needed, to furnish and decorate their sleeping and living units as they choose. 12. Individuals are encouraged and supported in developing and sustaining friendships and family relationships. 13. Individuals are supported in developing intimate relationships of their choice. 14. Individuals are supported in their efforts to have social contact with the same people and have repeated opportunities for social contact with the same people or groups of people. 15. Individuals are supported in their efforts to be involved in activities at times which take into consideration their wants, needs, and preferences. 16. Individuals are supported by staff who emphasize to others their abilities and interests. 17. Individuals are able to have visitors of their choosing at any time. 18. Individuals have the option to join and be supported in assuming roles in community organizations. 19. Individuals have the option to join and be supported in assuming roles in religious organizations. 20. Individuals have the option to and are supported in volunteering and helping in the community. 21. Individuals are informed and assisted in determining how they would like to make decisions about their health care, and whether or not they would like anyone else to be involved in those decisions. 22. Individuals with limited ability to communicate are supported by persons knowledgeable of how they communicate physical needs, how they communicate emotional and psychological needs. 23. Individuals are supported in an environment where individuals engage in positive, acceptable interactions. 24. Individuals are self-aware and use personal competencies. 25. Individuals are offered training and ongoing support in developing their self-advocacy skills. (G) Individuals are supported in making choices regarding services and supports and who provides them. 1. Individuals choose the services and supports they want and need. 2. Individuals are provided options in a manner that allows informed choice in selecting who their provider of services will be and their choices are honored. 3. Individuals are provided options in manner that allows informed choice in selecting settings to receive Medicaid waiver services that are reflective of the individual’s wants, needs, and preferences, and their choices are honored. 4. Individuals have choice in selecting their own health care providers to meet their needs. 5. Individuals participate in making decisions about their health care and their decisions are recognized and supported. 6. Individuals’ personal preferences are supported. (H) Individuals are assured their basic needs will be met. 1. Individuals are supported by staff who are knowledgeable of, have access to, and who provide services in accordance with their current Individualized Support Plan (ISP). 2. Individuals have the right to receive physical, emotional, and mental health care from the practitioner of their choice. 3. Individuals obtain routine medical and preventative medical care at intervals typical for the individual’s gender, age, and condition. 4. Individuals obtain dental, hearing, and vision exams, and follow-up treatment as recommended by their practitioner. 5. Individuals requiring specialized medical services have access to specialists. 6. Individuals are supported in accessing their physician or medical care consistent with their wants, needs, and preferences. 7. Individuals are supported in eating a diet which honors individual choice and meets nutritional needs. 8. Individuals who have a specialized diet, prescribed to meet identified healthcare needs of the individual, are informed of the reason for the diet and consent to the diet. Orders for specialized diets are reviewed at least annually by a registered dietician, the individual’s physician, physician assistant, or advanced practical nurse (APN). Direct care staff shall be trained by either a dietician or registered nurse in the preparation and implementation of the diet prior to providing independent direct care services. Individual choice shall be honored. Providers may elect to have management staff trained as a trainer for non-nurse delegated diets. 9. Individuals are educated about and supported in choosing to participate in wellness activities and fitness programs, both in their home and in their community. 10. Individuals’ health is protected through measures typically taken to prevent communicable diseases for persons with similar health status. Individuals shall be supported by persons who are knowledgeable of infection control practices through annual training. 11. Individuals are educated about the purpose, benefits, risks, and side effects of all prescribed medications and treatments, to assist them in making informed choices about their health care. Individuals are respected in their decision to refuse medication and treatment. 12. Individuals are supported in taking medications, receiving treatments, and utilizing adaptive equipment as prescribed. 13. Individuals are encouraged and supported in learning to safely manage and self-administer their medications as reflected in their ISP. 14. Individuals’ medications are reviewed annually by their physician to determine their continued effectiveness. The provider shall develop an effective system of medication administration, including monthly review of the medication system by a registered nurse. 15. Staff who assist in the system of medication administration shall be certified as a DD Medication Aide or be a licensed nurse or pharmacist. Individuals and staff shall be knowledgeable of the individuals’ medical conditions and possible side effects of medication. 16. Individuals receive the necessary services, supports, and degree of supervision consistent with the personal abilities of the individual and in accordance with their ISP. 17. Individuals’ homes and other environments are clean, safe, and well maintained. 18. Individuals are supported in obtaining living arrangements that are safe and take into account their physical abilities. 19. Individuals’ homes and environments are modified and/or adapted to meet identified needs as described in ISPs and are based upon assessments to ensure safety and mobility. 20. Individuals’ homes and other environments comply with federal, state, and local building and environmental codes. 21. Individuals’ safety is assured through preventive maintenance of vehicles, equipment, and buildings. 22. Individuals have the opportunity to assist in maintaining their home. 23. The temperature of individuals’ homes is determined by the individuals who live there. Homes shall have heating and air conditioning equipment capable of maintaining temperatures within a comfortable range for the individual. 24. In situations in which individuals do not have the ability to regulate water temperatures or have a physical or health condition that makes self-regulation unsafe, water temperatures are not to exceed 120 degrees Fahrenheit at the point of use. 25. Individuals are supported in responding to emergencies in a safe manner. 26. Individuals are supported by staff knowledgeable about emergency procedures, as included in the provider’s written procedures and any additional expectations as indicated in the individual’s ISP. 27. Individuals participate in emergency drills (tornado, earthquake, intruder) occurring during daytime, evening, and sleep hours at least four (4) times annually. Individuals participate in fire drills at least four (4) times annually, including one (1) during sleep hours. Documentation of drills shall be maintained. 28. Individuals shall have access to adequate evacuation exits which are appropriate to their abilities and an unobstructed path of egress to safety. 29. Individuals shall have access to at least one (1) fire extinguisher on each floor of the home. At least one (1) fire extinguisher shall be accessible in or near the kitchen area. All fire extinguishers shall have an expiration date or maintenance tag/documentation and indicator of charge. The fire extinguisher shall have directions for use on the equipment and shall be within the expiration date. 30. Individuals’ homes shall have operable smoke detectors on each level of the home, including basements. Detectors shall be located in or near each bedroom and in proximity to the area where an individual or staff sleep. Smoke detectors shall be placed in the home according to manufacturer’s recommendations. 31. Individuals have adaptive emergency alarm systems based upon need. 32. Individuals’ homes which utilize gas appliances and/or have an attached garage shall have operable carbon monoxide detectors on each level of the home, including basements. 33. Individuals have the option to take first aid and cardiopulmonary resuscitation training and have access to basic first aid supplies. 34. Staff shall maintain current first aid and cardiopulmonary resuscitation (CPR) certification for healthcare providers through training using curricula that is comparable to National Safety Council, American Red Cross, or American Heart Association. Training shall include hands-on practice and in-person skills assessment. Online-only certification is not acceptable. Individuals are provided first aid and cardiopulmonary resuscitation by knowledgeable staff, in accordance with their written advance directive. 35. Each provider shall have written policies and procedures approved by the department regarding medical emergencies. Such policies and procedures shall include— A. Protocol for initiating 911 emergency call; B. Protocol for use of CPR and first aid; C. Instructions for staff and individuals on how to respond to an incapacitated person; and D. A system for ensuring emergency response drills on the emergency protocol are conducted at least every six (6) months for all staff. 36. Individuals experiencing events that meet reportable event criteria shall have those events reported to the department, per 9 CSR 10-5.206. 37. Individuals and staff who support them have access to current contact information for family, guardians, or other interested parties identified by the individual. 38. Storage of materials necessary for household maintenance should be stored according to safety standards for the item itself as well as according to supports specified in the ISP. If there are restrictions, the individual shall be given due process. 39. Staff use and individuals are supported to use safe and sanitary practices in food storage, preparation, and cleanup. 40. Individuals who need assistance to eat are provided needed supports and adaptations, as identified in the ISP. 41. Individuals use mechanical supports only as prescribed. Individuals are supported by staff who are knowledgeable of use of the supports as addressed in the ISP. 42. Individuals are supported in the use and maintenance of adaptive, corrective, mobility, orthotic, and prosthetic equipment, as addressed in the ISP. Individuals and staff are trained in purpose, use, and maintenance of the equipment. (5) Every two (2) years, all agencies shall seek certification under this section except that agencies accredited by nationally recognized accrediting bodies approved by the division shall not be required to seek certification. The division director shall issue two- (2-) year certificates to agencies successfully completing the process and requirements. AUTHORITY: section 630.655, RSMo 2016.* This rule originally filed as 9 CSR 30-5.050. Original rule filed July 25, 1994, effective March 30, 1995. Emergency amendment filed July 20, 1995, effective July 30, 1995, expired Nov. 26, 1995. Amended: Filed July 20, 1995, effective Nov. 30, 1995. Amended: Filed May 25, 1995, effective Dec. 30, 1995. Rescinded and readopted: Filed Aug. 2, 2023, effective Feb. 29, 2024. *Original authority: 630.655, RSMo 1980.