Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This amendment modifies the requirements for treatment
plan signature, changes the time frame for treatment plan reviews, adds a requirement for obtaining consent
to treatment and related documentation, updates terminology, and adds clarifying language related to
applicability of these regulations and program-specific regulations.
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,
Community Psychiatric Rehabilitation Programs (CPR), and Outpatient Mental Health Treatment
Programs.
(1) Screening. The organization shall implement
written policies and procedures to ensure individuals seeking assistance via telephone, in person, or by
referral have prompt access to 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 in person), 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; and
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 screening agency cannot meet the individual's service needs.
(C) The organization's performance improvement 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 30-3.151 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 the type of admission(s);
5. Family history of
substance use disorders and/or mental illness;
6. Trauma history
(experienced and/or witnessed abuse, neglect, violence, sexual assault) and whether the individual receiving
services has concerns for their safety, such as intimate partner violence;
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 and clinical summary by a licensed mental
health professional, 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;
14. Current housing situation;
and
15. Dated signature, title, and credential(s) of staff
completing the assessment. Signature stamps/typed signatures shall not be used.
(B) The admission assessment shall be completed within seventy-two (72)
hours for individuals in a residential level of care or within the first three (3) outpatient
visits.
(3) Consent to Treatment. Each individual
served or a parent/guardian must provide informed, written consent to treatment.
(A) A copy of the consent form, which must contain the date of consent and
signature of the individual served or a parent/guardian, shall be retained in the individual
record.
(B) Consent to treat shall be updated annually, including
the date of consent and signature of the individual served or a parent/guardian, and be maintained in the
individual record.
(4) Crisis Prevention Plan. If a
potential risk for suicide, violence, or other at-risk behavior (such as increased isolation, increased
substance use, heightened depression or anxiety) is identified during the assessment process and any time
during the individual's time 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, a hierarchical list of self-care and self-help strategies identified
by the individual to regain a sense of control to return to their level of functioning before the crisis or
emergency, and a hierarchical list of staff interventions that may be used when a critical situation
occurs.
(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.
(5)
Individual Treatment Plan. Each individual and/or their parent or guardian shall participate in developing a
treatment plan using information from the assessment process and shall receive a copy of the plan. CSTAR
programs shall comply with treatment plan requirements specified in 9 CSR 30-3.151 and fulfill department
contract requirements. CPR programs shall comply with treatment plan requirements specified in 9 CSR 30-4.035 and fulfill contract requirements.
(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 parents/guardians, family, or
other natural supports;
4. Other community resources and/or peer,
family, and recovery supports necessary; and
5. Dated signature,
title, and credential(s) of staff completing the plan. Signature stamps/typed signatures shall not be used.
The individual shall also sign the plan unless a current signed consent to treatment is included in the
individual record.
(B) A licensed mental health
professional shall approve (sign/date) treatment plans. Signature stamps/typed signatures shall not be
used.
(6) 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 six (6) months to
assess continued need for services, responses to treatment, and progress achieved during the past six (6)
months. The occurrence of a crisis or significant clinical event may require further review and modification
of the treatment plan. Updates must be documented in the individual record.
(B) The dated signature(s), title(s), and credential(s) of staff completing
the review must be included on the treatment plan update. The individual served shall also sign the plan
unless there is a current signed consent to treatment included in the individual record.
(7) Ongoing Service Delivery. The individual treatment plan guides ongoing
service delivery. Services may begin before the admission assessment and treatment plan are 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 multiple
agencies or programs are providing services and supports.
(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.
(8) 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.
(9) Service Transition, Transfer, and Discharge Planning. The
organization shall implement written policies and procedures for developing transfer, transition, and
discharge plans for individuals served.
(A) Transfer, transition, and
discharge planning begins at admission, or as soon as clinically appropriate, to assist the individual in
moving from one level of care to another within the organization or obtain needed services from another
service provider.
1. Individuals are actively involved in developing their
transfer, transition, and/or discharge 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 transition and discharge plan s identify services and supports,
designated provider(s), and other planned activities designed to support the gains achieved by the individual
during participation in services. Plan s shall include but are not limited to-
A. Date of next appointment(s) for follow-up services or other supports, as
applicable;
B. Action steps to access 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 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 admission;
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. Dated signature, title, and
credential(s) of staff completing the discharge summary/discharge plan (not a signature stamp or typed
signature).
(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.
(10) 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 in-person intervention
when clinically indicated.
(B) If the organization utilizes the
services of the designated Access Crisis Intervention (ACI), 988 Call Center, or Mobile Crisis Response
provider for the region, a formal written agreement, memorandum of understanding, or contractual relationship
shall be established and documented to support the 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 (1) staff person designated to ensure coverage during leaves
of absence.
(11) Service Delivery Practices. The
organization shall incorporate evidence-based and emerging best 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.
(12) Utilization Review. Services funded by the department are
subject to utilization 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 utilization review including eligibility, service
definition, authorization, and limitations.
(13) 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.
(14) 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;
5. Any errors are marked through with a single line, initialed, and dated
by the staff person making the correction; and
6. 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, credential(s), and dated
signature of the provider/staff delivering the service (not a signature stamp or typed signature);
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 service(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,
updated annually;
2. Documented acknowledgment of orientation to
the program;
3. Screening, admission assessment, treatment plan,
and related reviews/updates;
4. Service delivery and progress
notes;
5. Transfer, transition, 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;
11. Follow-up for an unplanned discharge, as applicable;
and
12. Proof of purchase for medications, housing,
transportation, or other services/supports utilized by the individual during the episode of care.
(15) 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 within
established program time frames;
(C) The service meets the
service definition;
(D) The amount, duration, and length of
service; and
(E) The services/supports were delivered under the
direction of a current treatment plan, including but not limited to medication(s), transportation, and
housing.
(16) Other Regulations. Core Rules for
Psychiatric and Substance Use Disorder Treatment Programs apply to all organizations that are
certified/deemed certified by the department to provide behavioral health and/or substance use disorder
treatment services.
(A) Organizations that have a contract with the
department shall comply with contractual requirements as well as program-specific regulations, which take
precedence over Core Rules if there is a conflict.
*Original authority: 630.050, RSMo 1980, amended 1993, 1995
and 630.055, RSMo 1980.
