Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This amendment changes the chapter title and
purpose, updates terminology, and revises the service delivery process and
documentation requirements for certified and deemed programs.
PURPOSE: This rule describes requirements for the
delivery and documentation of services in Opioid Treatment Programs, Substance
Use Disorder Treatment Programs, Comprehensive Substance Treatment and
Rehabilitation Programs (CSTAR), Gambling Disorder Treatment Programs,
Institutional Treatment Centers, Community Psychiatric Rehabilitation Programs
(CPRP), and Outpatient Mental Health Treatment Programs.
(1) Screening. The organization shall
implement written policies and procedures to ensure individuals seeking
assistance via telephone, face-to-face contact, or by refererral have prompt
access to a screening to determine the need for further clinical assessment.
The screening process is welcoming, conducted in a safe, culturally, and
linguistically appropriate manner, and conveys a hopeful message to individuals
and their families/natural supports.
(A) At
the individual's first contact with the organization (whether by telephone or
face-to-face) emergency, urgent, or routine service needs shall be identified
and addressed as follows:
1. Emergency service
needs are indicated when a person presents a likelihood of immediate harm to
self or others. Qualified staff must address emergency needs
immediately.
2. An urgent need is
one that, if not addressed immediately, could result in the individual becoming
a danger to self or others, or could cause a health risk. Appropriately
qualified staff shall address urgent service needs within one (1) business day
of the time the request was made.
3. Routine service needs are indicated when a
person requests services or follow-up, but otherwise presents no significant
impairment in the ability to care for self and no apparent harm to self or
others. Routine service needs shall be addressed within ten (10)
days.
(B) Documentation
of the screening shall include, but is not limited to-
1. A brief interview with the individual or
referral source to obtain basic information and presenting situation and
symptoms;
2. Collection of basic
demographic information;
3.
Identification of requested service needs;
4. Determination of the organization's
ability to provide the requested services; and
5. Referral and coordination with alternate
resources when the individual's service needs cannot be met by the screening
agency.
(C) The
organization's quality assurance processes shall ensure trained staff uniformly
administer its designated screening instrument(s). Each screening shall be
signed and documented by staff.
(2) Admission Assessment. The organization
shall implement written policies and procedures to ensure all individuals
participate in an admission assessment to determine service needs. Programs
should only admit individuals who will benefit from available services.
Comprehensive Substance Treatment and Rehabilitation (CSTAR) programs must
comply with assessment requirements specified in
9 CSR
30-3.100 and fulfill department contract requirements.
Community Psychiatric Rehabilitation (CPR) programs must comply with assessment
requirements specified in
9 CSR
30-4.035 and fulfill contract requirements.
(A) Documentation of the admission assessment
shall include, but is not limited to-
1.
Personal and identifying information;
2. Presenting problem and referral
source;
3. Status as a current or
former member of the U.S. Armed Forces;
4. Brief history of previous substance use
and/or psychiatric treatment including type of admission(s);
5. Family history of substance use disorders
and/or mental illness;
6. History
of trauma, current trauma-related symptoms, and/or concerns for personal
safety;
7. Current medications and
any known allergies or allergic reactions;
8. Current substance use including
utilization of a standardized and validated alcohol and substance-use screening
instrument;
9. Current mental
health symptoms including utilization of standardized and validated depression
and suicide screening instruments;
10. Physical health concerns including a
health screening, previously identified medical diagnoses, and identification
of unmet needs with specific recommendations for further evaluation, treatment,
and referral;
11. Diagnosis by a
licensed diagnostician, including substance use and mental health;
12. Family, social, legal, and
vocational/educational status and functioning;
13. Statement of needs, goals, preferences,
and treatment expectations; and
14.
Signature, title, and credential(s) of staff completing the
assessment.
(B) The
admission assessment shall be completed within seventy-two (72) hours for
individuals receiving residential support or within the first three (3)
outpatient visits.
(3)
Crisis Prevention Plan. If 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, a crisis prevention plan shall be
developed with the individual as soon as possible.
(A) At a minimum, the crisis prevention plan
shall include factors that may precipitate a crisis, and skills and strengths
identified by the individual to regain a sense of control and return to his/her
level of functioning before the crisis or emergency.
(B) Staff shall conduct a monthly case review
of all critical interventions that occurred during the previous month and
incorporate the results into the organization's performance improvement
processes.
(4)
Individual Treatment Plan. Each individual and/or their parent or guardian
shall participate in the development of a treatment plan using information from
the assessment process. The individual and/or parent/guardian shall receive a
copy of the plan.
(A) The treatment plan shall
include, but is not limited to-
1. Identifying
information;
2. Objectives that-
A. Are reflective of the individual's culture
and ethnicity;
B. Are linked to the
individual's assessed needs and goals;
C. Are achievable, measurable, time specific,
strengths-and skills-based;
D.
Identify supports and resources needed to meet objectives; and
E. Are understandable, developmentally
appropriate, and responsive to the disability/disorder or concerns of the
individual.
3. Duration
and frequency of interventions, staff responsible for intervention, and action
steps of the individual and his/her parents/guardians, family or other natural
supports;
4. Other community
resources and/or peer and recovery supports necessary; and
5. Signature, title, and credential(s) of the
service provider(s) completing the plan and signature of the individual and/or
parents/legal guardians, as applicable. For situations when the individual does
not sign the treatment plan, such as refusal, a brief explanation must be
documented.
(B)
Treatment plans shall be approved by a licensed mental health
professional.
(5)
Treatment Plan Updates. Progress toward treatment goals and objectives shall be
reviewed and updated on a periodic basis with active involvement of the
individual served, parent/guardian, and family members/natural supports as
applicable and appropriate.
(A) At a minimum,
treatment plans shall be reviewed every ninety (90) days. The occurrence of a
crisis or significant clinical event may require further review and
modification of the treatment plan.
(6) Ongoing Service Delivery. The individual
treatment plan guides ongoing service delivery. Services may begin before the
assessment is completed and the treatment plan is fully developed.
(A) Staff with appropriate training,
licenses, and credentials shall provide identified services and
supports.
(B) Services shall be
provided in accordance with applicable eligibility criteria. Decisions
regarding the treatment setting, intensity, and duration of services are based
on the needs of the individual including, but not limited to:
1. Need for personal safety and protection
from harm;
2. Severity of the
behavioral health disorder;
3.
Emotional and behavioral functioning and need for structure;
4. Social, family, and community
functioning;
5. Readiness to
change;
6. Availability of peer and
social supports for recovery/resiliency;
7. Ability to avoid high risk behaviors;
and
8. Ability to cooperate with
and benefit from the services offered.
(C) Services shall be developmentally
appropriate and responsive to the individual's social/cultural situation and
any linguistic/communication needs.
(D) Coordination of care is demonstrated when
services and supports are being provided by multiple agencies or
programs.
(E) To the fullest extent
possible, individuals are responsible for action steps to achieve their goals.
Services and supports provided by staff should be readily available to help
individuals achieve their goals and objectives.
(7) Missed Appointments. Organizations shall
implement written policies and procedures to contact individuals who miss a
scheduled program activity or appointment consistent with their service needs.
(A) Such efforts shall be initiated within
forty-eight (48) hours unless circumstances indicate an immediate contact
should be made due to the individual's symptoms and functioning or the nature
of the scheduled service.
(B)
Efforts to contact the individual shall be documented.
(8) Continuing Recovery Plan. The
organization shall implement written policies and procedures for developing
continuing recovery plans and discharge plans for individuals served.
(A) Continuing recovery planning begins at
admission or as soon as clinically appropriate.
1. Individuals are actively involved in the
development of their continuing recovery plan. Family members/natural supports,
program staff, referral source(s), and staff or peers involved in follow-up
services and supports in the community are included when applicable and
permitted.
2. The plan shall be
signed by the staff person who completes it. The individual served and/or
parents/legal guardians, family members, or other natural supports shall
receive a copy of the plan as appropriate.
3. The plan identifies services and supports,
designated provider(s), and other planned activities designed to promote
further recovery/resiliency. The plan shall include, but is not limited to-
A. Date of next appointment(s) for follow-up
services or other supports;
B.
Action steps to access personal support system(s) or other resources to assist
in community integration and obtain help if symptoms recur and additional
services/supports are needed;
C.
Safe use of medication(s) as prescribed;
D. Referral information such as contact name,
telephone number, locations, hours, and days of services, when applicable;
and
E. Action steps for maintaining
a healthy lifestyle such as exercising, volunteering, participating in
spiritual support groups, and managing personal finances.
(B) A written discharge summary
shall be completed to ensure the individual record includes documented
treatment episode(s) and the outcome of each episode, including but not limited
to:
1. Date of admission and
discharge;
2. Identified needs at
intake;
3. Referral source as
applicable;
4. Services provided
and the extent to which established goals and objectives were
achieved;
5. Reason(s) for or type
of discharge;
6. Diagnosis or
diagnostic impression at last contact;
7. Recommendations for continued services and
supports;
8. Information on
medication(s) prescribed or administered, as applicable; and
9. Signature of staff completing the
plan.
(C) Follow-up with
individuals who have an unplanned discharge shall be conducted in accordance
with the organization's written policies and procedures which include, but are
not limited to:
1. Clarifying the reason for
the unplanned discharge;
2.
Determining if further services are needed; and
3. Referring the individual to other
necessary services, if applicable.
(D) The organization shall implement written
policies and procedures to ensure a seamless transition for individuals who
transfer to more or less intensive services, to another component of care, or
are being discharged from the program.
(9) Crisis Assistance and Intervention. Ready
access to crisis assistance and intervention shall be available to all
individuals served, when needed.
(A) The
organization shall directly provide or arrange for crisis assistance to be
available twenty-four (24) hours per day, seven (7) days per week. Services
shall be provided by qualified staff in accordance with applicable program
rules, and include face-to-face intervention when clinically
indicated.
(B) If the organization
utilizes the services of the designated Access Crisis Intervention (ACI)
provider for the region, a formal written agreement, memorandum of
understanding, or contractual relationship shall be established and documented
to support coordination of services and sharing of information to meet
individual needs.
(C) If crisis
services are provided within the organization, there shall be more than one
staff person designated to ensure coverage during leaves of absence.
(10) Effective Practices. The
organization shall incorporate evidence-based and promising practices into its
service array that are designed to-
(A)
Support the recovery, resiliency, health, and wellness of the individuals and
families/natural supports served;
(B) Enhance the quality of life for
individuals and families/natural supports served;
(C) Reduce symptoms or needs and build
resilience;
(D) Restore and/or
improve functioning; and
(E)
Support the integration of individuals into the community.
(11) Clinical Review. Services funded by the
department are subject to clinical review by department staff to ensure they
are necessary, appropriate, likely to benefit the individual, and provided in
accordance with admission criteria and service definitions. The department has
authority in all matters subject to clinical review including eligibility,
service definition, authorization, and limitations.
(12) Designated or Required Instruments. In
order to promote consistency in clinical practice, eligibility determination,
service documentation, and outcome measurement, the department may require the
use of designated instruments in the screening, assessment, and treatment
process. The required use of particular instruments is applicable to services
funded by the department.
(13)
Organized Record System and Documentation Requirements. The organization must
maintain an organized clinical record system that ensures easily retrievable,
complete, and usable records stored in a secure and confidential manner.
(A) The organization shall implement written
policies and procedures to ensure-
1. All
local, state, and federal laws and regulations related to the confidentiality
of records and release of information are followed;
2. Electronic health record systems conform
to federal and state regulations;
3. Individual records are retained for at
least six (6) years or until all litigation, adverse audit findings, or both,
are resolved;
4. Ready access to
paper or electronic records requested by authorized staff and/or other
authorized parties, including department staff; and
5. All services provided are adequately
documented in the individual record to ensure the type(s) of services rendered
and the amount of reimbursement received by the organization can be readily
discerned and verified with reasonable certainty.
A. Adequate individual records are of the
type and in a form such that symptoms, conditions, diagnoses, treatments,
prognosis, and the identity of the individual to which these things relate can
be readily discerned and verified with reasonable certainty. All documentation
must be available at the site where the service was rendered. The record must
be legible and made contemporaneously with the delivery of the service (at the
time the service was performed or within five (5) business days of the time it
was provided), address the individual's specifics including, at a minimum,
individualized statements that support the assessment or treatment
encounter.
(B) Unless specified otherwise by another
payer source(s), all treatment sessions must have accompanying documentation
that includes the following:
1. First name,
last name, and middle initial or date of birth of the individual and any other
identifying information required by a payer source, such as a Document Control
Number (DCN);
2. Accurate,
complete, and legible description of each service provided;
3. Name, title, and signature of the
provider/staff delivering the service;
4. Name of referring entity, when
applicable;
5. Date of service
(month/day/year);
6. Actual begin
and end time taken to deliver a service;
7. Setting in which the service was
provided;
8. Plan of treatment,
evaluation(s), test(s), findings, results, and prescription(s), as
necessary;
9. Need for the
services(s) in relationship to the individual treatment plan;
10. Individual's progress toward the goals
stated in the individual treatment plan; and
11. For applicable programs, adequate
invoices, trip tickets/reports, activity log sheets.
(C) The content of the individual record must
include, but is not limited to-
1. Signed
consent to treatment;
2.
Acknowledgement of orientation to the program;
3. Screening, assessment, treatment plan, and
related reviews/updates;
4. Service
delivery and progress notes;
5.
Continuing recovery and discharge plan(s), as applicable.
6. Documentation of any referral(s) to other
services or community resources and outcome of those referrals;
7. Signed authorization(s) to release
confidential information, as applicable;
8. Missed appointments and efforts to
reengage the individual, as applicable;
9. Urine drug screening(s) or other lab
reports, as applicable;
10. Crisis
or other significant clinical events; and
11. Follow up for an unplanned discharge, as
applicable.
(14) The organization is subject to
recoupment of all or part of reimbursement from the department if individual
records do not document-
(A) The service was
actually provided;
(B) The service
was delivered by a qualified staff person;
(C) The service meets the service
definition;
(D) The amount,
duration, and length of service; and
(E) The service was delivered under the
direction of a current treatment plan.
*Original authority: 630.050, RSMo 1980, amended 1993, 1995
and 630.055, RSMo 1980.
