Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This amendment updates terminology and event
reporting requirements for community-based agencies providing department-funded
services for individuals with intellectual disabilities, developmental
disabilities, and/or behavioral health disorders.
PURPOSE: This rule prescribes procedures for
documenting, reporting, analyzing, and addressing certain events that affect
individuals who reside in a community residential program or are receiving day
program or specialized services from an agency that is licensed, certified,
accredited, in possession of deemed status, is funded by, and/or has a
contractual relationship with the Department of Mental Health for the provision
of services as required by sections
630.005,
630.020,
630.163,
630.165, 630.167 and 630.655, RSMo.
(1) Definitions. The following words and
terms, as used in this rule, 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;
(B) Affiliate, an
organization that is contracted with the department to provide specific
community psychiatric rehabilitation (CPR) services in a designated geographic
region;
(C) Agency, a community
residential program/center, day program, group home, outpatient program, and/or
specialized services licensed, certified, deemed certified, or deemed licensed
by the department, and/or funded by, and/or has a contractual relationship with
the department for the provision of services. This does not include entities
licensed by the Department of Health and Senior Services under Chapter 198,
RSMo, unless the entity is also licensed by the department to serve individuals
that have a primary diagnosis of mental illness and/or developmental disability
and their services and supports are funded by the department;
(D) Customer Information Management,
Outcomes, and Reporting, Event Management and Tracking (CIMOR-EMT), system used
by the department to collect and analyze relevant data on events that have
actual or potential adverse outcomes for individuals served. Data is entered
into the system by agency staff or department staff in accordance with
established policies and procedures;
(E) Deemed status, acknowledges that an
agency is monitored and held accountable by a recognized national accrediting
body and the department accepts the agency's verification of good standing with
the accrediting body as sufficient to meet the department's standards of
care;
(F) Department, the
Department of Mental Health, executive agency of Missouri state government
comprised of the Division of Behavioral Health (DBH) and Division of
Developmental Disabilities (DD) and its regional and district
offices;
(G) Division of Behavioral
Health (DBH), operating division of the department responsible for ensuring
prevention, evaluation, treatment, recovery supports, and rehabilitation
services are available for individuals and family members experiencing a
substance use disorder and/or mental illness;
(H) Division of Developmental Disabilities
(DD), operating division of the department responsible for supporting the needs
of individuals, family members, and caregivers who experience a developmental
disability;
(I) EMT Community Event
Report, form used by community providers for reporting events to the department
in accordance with DBH and DD protocol;
(J) Guardian, individual who is court
appointed to be legally responsible for the care and custody of the individual
being served;
(K) Individual, a
person/consumer/client receiving department-funded services directly from an
agency or self-directed services;
(L) Reportable events/categories, events
affecting individuals residing in or receiving services from an agency, as
defined in subsection (1)(C) of this rule, that meet reporting requirements
applicable to DBH or DD;
(M)
On-call system, procedure in which identified staff in DD are available to
receive notification of reportable events requiring immediate notification
during non-business hours, a weekend, or holiday;
(N) Plan of Action (POA), documents the
action to be taken by agency staff to reduce the likelihood an event will recur
or to remediate an area found out of compliance. Such action may include, but
is not limited to, staff training, improvements to the physical plant, and/or
revision of operating procedures;
(2) Reporting Requirements. This rule applies
to any employee of an agency as defined in subsection (1)(C) of this rule.
(A) Agency designee(s) shall ensure events
are reported in accordance with protocol established by DD or DBH, as
applicable to the individual being served.
1.
Event reports involving individuals served by DD shall be submitted via the
CIMOR-EMT system in accordance with established protocols.
2. Event reports involving individuals served
by DBH shall be submitted to designated DBH staff via the EMT Community Event
Report form MO 650-9475, included herein, in accordance with established
protocols.
A. Administrative agents/affiliates
shall be notified of events involving individuals receiving DBH-funded
services. The administrative agent/affiliate shall submit event reports to the
appropriate DBH regional office staff via the EMT Community Event Report form
MO 650-9475, included herein, in accordance with established
protocols.
(B) Any allegation or suspicion of abuse,
neglect, or misuse of funds/property, as defined in
9 CSR
10-5.200, which is reported to or suspected by agency
staff must be immediately reported to the applicable division in accordance
with procedures described in
9 CSR
10-5.200.
(C) Events requiring immediate notification
which occur after 5:00 p.m. on a weekday, weekend, or holiday shall be reported
as follows:
1. To DBH staff no later than the
next business day in a written report utilizing the EMT Community Event Report
form MO 650-9475.
2. To DD staff
verbally in accordance with the on-call protocol, followed by entry into
CIMOR-EMT on the next business day.
(D) The parent(s) of a minor or the legal
guardian of an individual who is involved in a report of abuse, neglect, and/or
misuse of funds/property shall receive verbal notification from agency staff
regarding the details of the event, except the names of any employees or other
individuals shall not be revealed. This notification shall occur as soon as
possible, but no later than twenty-four (24) hours following the agency's
notification of the alleged event.
1. Email
or text communication may be substituted for the verbal notification if the
parent/guardian has indicated that is the preferred means of
communication.
2. The date and time
of parent/guardian notification shall be documented on the event
report.
3. Agency staff shall
communicate to the parent/guardian that the applicable division (DBH or DD) has
been notified of the event.
4. If
the parent/guardian is suspected to be involved in the event, notification to
the parent/guardian shall be waived.
5. If agency staff are unable to contact the
parent/guardian regarding such an event, efforts to comply must be documented
and included in the agency's event report to the applicable division.
(3) Policies and
Procedures. Agencies shall maintain and implement written policies and
procedures to ensure the event notification, reporting requirements, and
division-specific protocol outlined in this rule are followed.
(A) The policies and procedures shall clearly
indicate the action to be taken by the agency if staff fail to report an event
in accordance with the event notification, reporting requirements, and
division-specific protocol outlined in this rule.
(B) The agency shall ensure all employees,
contracted staff, students/interns, and volunteers receive training on the
event notification and reporting requirements applicable to their agency,
including the agency's internal policies and procedures.
1. This training shall be included as part of
the agency's orientation process and take place within the first thirty (30)
days of employment and annually thereafter.
2. Employees, contracted staff,
students/interns, and volunteers who will have direct contact with individuals
served must be trained on the event notification, reporting requirements, and
division-specific protocol prior to interacting alone with
individuals.
3. This training shall
include review of the definitions included in
9 CSR
10-5.200 for abuse, neglect, and misuse of
funds/property.
(4) Plan of Action (POA) and Follow-up. The
DBH or DD may request a POA from an agency based on the facts surrounding the
event. This POA is subject to approval by the DBH or DD designee, must be
carried out as specified, and shall be implemented by the agency in accordance
with the approval criteria issued by the applicable division.
(A) Corrective measures and action steps to
resolve the issue must be documented and maintained by the agency and be
available for review by DBH or DD staff or other authorized representatives
upon request.
(5)
Failure to follow these regulations may result in administrative sanctions up
to and including contract cancellation or revocation of licensure,
certification, or deemed status.
Click to
view image
Click to
view image
Click to
view image
*Original authority: 630.005, RSMo 1980, amended 1981,
1982, 1990, 1993, 1995, 1996; 630.020, RSMo 1980; 630.165, RSMo 1980, amended
1996, 2003; 630.167, RSMo 1980, amended 1985, 1990, 1993, 1996, 1998, 2003; and
630.655, RSMo 1980.
