Missouri Code of State Regulations, Chapter 3, Section 9 CSR 30-3.152 - Comprehensive Substance Treatment and Rehabilitation (CSTAR) Utilizing the American Society of Addiction Medicine (ASAM) Criteria | Missouri Code of State Regulations

(1) This regulation applies to CSTAR programs that have not been granted a temporary waiver as specified in 9 CSR 303.150(4).

(2) Policies and Procedures. In addition to the policies and procedures specified in 9 CSR 10-7.090(4), the organization shall have policies and procedures addressing the following:

(A) Drug screenings in accordance with The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, 2013, 3rd Edition, hereby incorporated by reference and made a part of this rule, developed by and available from the American Society of Addiction Medicine, Inc., 11400 Rockville Pike, Suite 200, Rockville, MD 20852, (301) 656-3920. This rule does not incorporate any subsequent amendments or additions to this publication;

(B) Treatment of co-occurring disorders in accordance with The ASAM Criteria (abbreviated) as referenced above; and

(C) Staff training requirements in accordance with 9 CSR 30-3.155.

(3) Performance Improvement. In addition to the performance improvement requirements specified in 9 CSR 10-7.040, the organization shall have a performance improvement plan that addresses the clinical case review process via internal peer review in accordance with The ASAM Criteria as referenced in subsection (2)(A) of this rule.

(4) Levels of Care. Certification from the department is available for the following ASAM levels of care-

(A) Outpatient-

1. Level 0.5, early intervention;

2. Level 1, outpatient services; and

3. Level 1 OTP, opioid treatment services; and

(B) Intensive outpatient (team-based services)-

1. Level 1-WM, ambulatory withdrawal management without extended on-site monitoring;

2. Level 2-WM, ambulatory withdrawal management without extended on-site monitoring;

3. Level 2-WM-EM, ambulatory withdrawal management with extended on-site monitoring;

4. Level 2.1, intensive outpatient services; and

5. Level 2.5, partial hospitalization services; and

(C) Residential (team-based services)-

1. Level 3.1, clinically managed low intensity residential services;

2. Level 3.2-WM, clinically managed residential withdrawal management;

3. Level 3.3, clinically managed population specific high intensity residential services;

4. Level 3.5, clinically managed high intensity residential services;

5. Level 3.5, clinically managed high intensity residential services (women and children);

6. Level 3.5, clinically managed medium-intensity residential services (adolescents);

7. Level 3.7, medically monitored intensive inpatient services; and

8. Level 3.7-WM, medically monitored inpatient withdrawal management.

(5) Telemedicine. Telemedicine is considered a face-to-face service. Services in all levels of care may be provided via telemedicine, including individual services within residential levels of care such as medication services, individual counseling, and medication services support.

(6) Billing Requirements. No more than one (1) per diem treatment rate may be billed per day for team-based services (intensive outpatient and residential levels of care), with the exception of Level 1-WM and Level 2-WM.

(A) The minimum number of hours of services outlined in this rule for specific levels of care must be provided on a daily basis in order for the service provider to bill for a team-based service as supported by The ASAM Criteria and individual treatment plans. If a program does not provide the minimum number of hours specified, it is at risk of recoupment of funds by the department or other authorized representative(s).

1. Level 1-WM and Level 2-WM may be offered in conjunction with other outpatient levels of care (ASAM Levels 1, 2.1, and 2.5) with the expectation that if additional services are needed, the individual receives them in the appropriate level of care. Providers shall comply with the ASAM Billing Overlap Guidance, 2022, hereby incorporated by reference and made a part of this rule, developed by and available from the Department of Mental Health, 1706 E. Elm St., PO Box 687, Jefferson City MO 65101, (573) 751-4942, https://dmh.mo.gov/media/file/asam-billing-overlap-guidance. This rule does not incorporate any subsequent amendments or additions to this publication.

(7) Minimum Staffing Requirements. Providers shall comply with the The ASAM Minimum Staffing Standards for Department of Mental Health, 2022, hereby incorporated by reference and made a part of this rule, developed by and available from the Department of Mental Health, 1706 E. Elm St., PO Box 687, Jefferson City MO 65101, (573) 751-4942, https://dmh.mo.gov/media/pdf/dbh-asam-minimum-staffing-requirements. This rule does not incorporate any subsequent amendments or additions to this publication.

(8) Multidimensional Assessment. The ASAM multidimensional assessment shall be utilized as specified in 9 CSR 30-3.151 to assist in determining each individual's placement in a level of care that meets individual service needs.

(A) The six (6) dimensions include-

1. Dimension 1, acute intoxication and/or withdrawal potential-exploring an individual's past and current experiences of substance use and withdrawal;

2. Dimension 2, biomedical conditions/complications- exploring an individual's health history and current physical condition;

3. Dimension 3, emotional, behavioral, or cognitive conditions and complications-exploring an individual's thoughts, emotions, and mental health issues;

4. Dimension 4, readiness to change-exploring an individual's readiness and interest in changing;

5. Dimension 5, relapse, continued use, or continued problem potential-exploring an individual's unique relationship with relapse or continued use or problems; and

6. Dimension 6, recovery/living environment-exploring an individual's recovery or living situation, and the surrounding people, places, and things.

(B) All components of The ASAM Criteria, as referenced in subsection (2)(A) of this rule, must be considered when determining level of care placement for individuals served. The levels of care available in the CSTAR program are defined in this rule.

(C) The admission guidelines included in this rule do not constitute a comprehensive list of placement criteria for the levels of care. All dimensional admission criteria specified in The ASAM Criteria must be considered when determining level of care placement for individuals served.

(9) Level 0.5 Early Intervention. Services shall be designed to address problems or risk factors related to substance use and to help individuals recognize the harmful consequences of high-risk substance use.

(A) Level 0.5 services include-

1. Individual counseling;

2. Group counseling;

3. Group rehabilitative support;

4. Family therapy;

5. Community support; and

6. Screening, brief intervention, and referral to treatment (SBIRT).

(B) Individuals meeting diagnostic criteria for a substance use disorder shall be referred to ongoing treatment, as appropriate. Referral may also include medical, psychological, or psychiatric services, including assessment and community social services.

(C) Length of service shall vary based on factors such as the individual's ability to comprehend the information provided and use that information to make behavior changes and avoid problems related to substance use, or the appearance of new problems that require treatment at another level of care.

(D) Admission guidelines for Level 0.5-

1. Acute intoxication and/or withdrawal potential- no signs or symptoms of withdrawal, or the individual's withdrawal can be safely managed in an outpatient setting;

2. Biomedical conditions and complications-none or very stable, any biomedical conditions and problems, if any, are sufficiently stable to permit participation in outpatient treatment;

3. Emotional, behavioral, or cognitive conditions and complications-none or very stable or receiving concurrent mental health monitoring. Adolescents are not at risk of harm and experiencing minimal current difficulties with activities of daily living, but there is significant risk of deterioration;

4. Readiness to change-the individual is open to recovery or willing to explore their substance use disorder and/or mental health condition and is at least contemplating change. The individual may require monitoring and motivating strategies to engage in treatment and to progress through the stages of change;

5. Relapse, continued use, or continued problem potential-the individual is able to achieve or maintain nonuse of alcohol and/or other drugs and pursue related recovery or motivational goals with minimal support; and

6. Recovery environment-family and environment can support recovery with limited assistance, or the individual has the skills to cope. Adolescents' risk of initiation of or progression in substance use and/or high-risk behaviors is increased by substance use or values about use. High-risk behaviors of family, peers, or others in the adolescent's social support system.

(10) Level 1 Outpatient Services. Level 1 outpatient services consist of professionally directed assessment, diagnosis, treatment, and recovery services provided in an organized outpatient treatment setting.

(A) Services shall include, but are not limited to-

1. Individual counseling;

2. Group counseling;

3. Family therapy;

4. Peer and family support;

5. Group rehabilitative support;

6. Medication services;

7. Medication services support;

8. Crisis intervention; and

9. Community support.

(B) For individuals with mental health conditions, issues of psychotropic medications, mental health treatment, and their relationship to substance use shall be addressed, as needed.

(C) Services shall vary in level of intensity based on individual needs and shall be fewer than nine (9) contact hours per week for adults age eighteen (18) and older, and fewer than six (6) contact hours per week for adolescents age nine (9) through eighteen (18).

(D) The duration of treatment shall vary based on the severity of the individual's illness and their response to treatment.

(E) Admission guidelines for Level 1-

1. Acute intoxication and/or withdrawal potential- no signs or symptoms of withdrawal, or the individual's withdrawal can be safely managed in an outpatient setting;

2. Biomedical conditions and complications-any biomedical conditions and problems, if any, are sufficiently stable to permit participation in outpatient treatment;

3. Emotional, behavioral, or cognitive conditions and complications-none or very stable or receiving concurrent mental health monitoring. Adolescents are not at risk of harm and experiencing minimal current difficulties with activities of daily living, but there is significant risk of deterioration;

4. Readiness to change-the individual is open to recovery or willing to explore their substance use disorder and/or mental health condition and is at least contemplating change. The individual may require monitoring and motivating strategies to engage in treatment and to progress through the stages of change;

5. Relapse, continued use, or continued problem potential-the individual is able to achieve or maintain nonuse of alcohol and/or other drugs and pursue related recovery or motivational goals with minimal support; and

6. Recovery environment-family and environment can support recovery with limited assistance, or the individual has the skills to cope.

(11) Level 1 Opioid Treatment Program (OTP). Level 1 OTPs provide community-based outpatient treatment for individuals with a diagnosed opioid use disorder. Medications shall be provided in conjunction with highly structured psychosocial programming that addresses major lifestyle, attitudinal, and behavioral issues that could undermine an individual's recovery-oriented goals.

(A) OTPs shall comply with the federal opioid treatment regulations set forth under 42 CFR 8.12 and 9 CSR 30-3.132.

(B) OTPs shall administer medications approved by the Food and Drug Administration (FDA) to treat opioid use disorder and alleviate the adverse medical, psychological, and physical side effects of opioid dependence.

(C) Interventions shall include, but are not limited to-

1. Nursing assessment at the time of admission which is reviewed by a physician to determine the need for opioid treatment services, eligibility, and appropriate level of care placement for admission and referral;

2. A fully documented physical examination by a program physician or an assistant physician (AP), physician assistant (PA), advanced practice registered nurse (APRN), or resident physician working under the supervision of the program physician. The full medical examination, including the results of serology and other tests, must be completed within fourteen (14) days following admission;

3. A pregnancy test for women, as deemed clinically appropriate; and

4. Referral and assistance, as needed, for the individual to gain access to other needed substance use disorder and/or mental health services.

(D) Admission guidelines for Level 1 OTP-

1. Acute intoxication and/or withdrawal potential-meets diagnostic criteria for an opioid use disorder;

2. Biomedical conditions and complications-meets biomedical criteria for opioid use disorder and may have a concurrent biomedical illness that can be treated on an outpatient basis;

3. Emotional, behavioral, or cognitive conditions and complications-none or stable or receiving concurrent mental health monitoring and/or treatment;

4. Readiness to change-requires a structured therapeutic and pharmacotherapy program to promote treatment progress and recovery;

5. Relapse, continued use, or continued problem potential-high risk of return to use of opioids or continued use without opioid pharmacotherapy, close outpatient monitoring, and structured support; and

6. Recovery environment-sufficiently supportive that outpatient treatment is feasible, or the individual does not have an adequate primary or social support system, but has demonstrated motivation and willingness to obtain such a support system.

(12) Level 1-WM Ambulatory Withdrawal Management Without Extended On-Site Monitoring. Organized outpatient services shall be delivered by trained clinicians who provide medically supervised evaluation, withdrawal management, and referral services according to a predetermined schedule. Services shall be provided in regularly scheduled sessions under a defined set of policies and procedures or medical protocols.

(A) This level of care may be offered in conjunction with ASAM outpatient levels 1, 2.1, and 2.5 with the expectation that if additional services are needed, the individual receives them in the appropriate level of care.

(B) Services shall include, but are not limited to-

1. Assessment;

2. Medication or non-medication methods of withdrawal management;

3. Non-pharmacological clinical support;

4. Involvement of family members/natural supports in the withdrawal management process;

5. Physician and/or nurse monitoring, assessment, and management of signs and symptoms of intoxication and withdrawal; and

6. Referral for counseling and involvement in community recovery support groups and arrangements for counseling, medical, psychiatric, and continuing care.

(C) Individuals shall receive a minimum of thirty (30) minutes of services per day.

(D) Interventions shall include, but are not limited to-

1. A medical history and physical examination by a physician, AP, PA, resident physician, or APRN during the treatment episode or within twenty-four (24) hours of admission, whichever occurs sooner.

A. A physical examination not performed by a physician shall be dated and countersigned by a physician during the treatment episode or within seventy-two (72) hours, whichever occurs sooner, signifying their review of and concurrence with the findings;

2. Daily assessment of progress during withdrawal management and any treatment changes, or less frequent if the severity of withdrawal is sufficiently mild or stable;

3. Transfer, treatment, and discharge planning, beginning at the point of admission; and

4. Referral and assistance for the individual to gain access to other needed substance use disorder and/or mental health services.

(E) Individuals shall meet the diagnostic criteria for a substance withdrawal disorder and the ASAM dimensional criteria for admission to this level of care.

1. For individuals whose presenting alcohol or other substance use history is inadequate to substantiate such a diagnosis, information provided by collateral parties (such as family members/natural supports or a legal guardian) can indicate a high probability of such a diagnosis, subject to confirmation by further evaluation.

(F) Individuals shall remain in this level of care until-

1. Their withdrawal signs and symptoms are sufficiently resolved such that they can participate in self-directed recovery or ongoing treatment without the need for further medical or nursing withdrawal management monitoring; or

2. Their signs and symptoms of withdrawal have failed to respond to treatment and have intensified such that transfer to a more intensive level of withdrawal management service is indicated; or

3. They are unable to complete withdrawal management at Level 1-WM despite an adequate trial, for example, they are experiencing intense craving and evidence insufficient coping skills to prevent continued use concurrent with the withdrawal management medication, indicating a need for more intensive services.

(13) Level 2-WM Ambulatory Withdrawal Management Without Extended On-Site Monitoring. Organized outpatient services shall be provided by trained clinicians to treat the individual's level of clinical severity to achieve safe and comfortable withdrawal from mood-altering chemicals and to effectively facilitate their entry into ongoing treatment and recovery.

(A) This level of care can be offered in conjunction with ASAM outpatient levels 1, 2.1, and 2.5 with the expectation that if additional services are needed, the individual receives them in the appropriate level of care.

(B) Services shall include, but are not limited to-

1. Assessment;

2. Medication or non-medication methods of withdrawal management;

3. Non-pharmacological clinical support;

4. Involvement of family members/natural supports in the withdrawal management process;

5. Physician and/or nurse monitoring, assessment, and management of signs and symptoms of intoxication and withdrawal; and

6. Referral for counseling and involvement in community recovery support groups and arrangements for counseling, medical, psychiatric, and continuing care.

(C) Individuals shall receive a minimum of one hour and fifteen minutes (1.25 hours) of services per day.

(D) Interventions shall include, but are not limited to-

1. A medical history and physical examination by a physician, AP, PA, resident physician, or APRN during the treatment episode or within twenty-four (24) hours of admission, whichever occurs sooner.

A. A physical examination not performed by a physician shall be dated and countersigned by a physician during the treatment episode or within seventy-two (72) hours, whichever occurs sooner, signifying their review of and concurrence with the findings;

2. Daily assessment of progress during withdrawal management and any treatment changes;

3. Transfer, treatment, and discharge planning, beginning at the point of admission; and

4. Referral and assistance for the individual to gain access to other needed substance use disorder and/or mental health services.

(E) Individuals shall meet the diagnostic criteria for substance withdrawal disorder and the ASAM dimensional criteria for admission.

1. For individuals whose presenting alcohol or other substance use history is inadequate to substantiate such a diagnosis, information provided by collateral parties (such as family members/natural supports or a legal guardian) can indicate a high probability of such a diagnosis, subject to confirmation by further evaluation.

(F) Individuals shall remain in this level of care until-

1. Their withdrawal signs and symptoms are sufficiently resolved such that they can be safely managed in a less intensive level of care; or

2. Their signs and symptoms of withdrawal have failed to respond to treatment and have intensified (based on a standardized scoring system) such that transfer to a more intensive level of withdrawal management service is indicated; or

3. They are unable to complete withdrawal management at Level 2-WM despite an adequate trial; for example, they are experiencing intense craving and have insufficient coping skills to prevent continued alcohol or other drug use, indicating a need for more intensive services.

(14) Level 2-WM-EM Ambulatory Withdrawal Management with Extended On-Site Monitoring. Organized outpatient services shall be provided by trained clinicians who provide medically supervised evaluation, withdrawal management, and referral services. Services shall be designed to treat the individual's level of clinical severity to achieve safe and comfortable withdrawal from mood-altering chemicals and to effectively facilitate the individual's entry into ongoing treatment and recovery.

(A) This level of care can be offered in conjunction with ASAM outpatient levels 1, 2.1, and 2.5 with the expectation that if additional services are needed, the individual receives them in the appropriate level of care.

(B) Services shall include, but are not limited to-

1. Assessment;

2. Medication or non-medication methods of withdrawal management;

3. Non-pharmacological clinical support;

4. Involvement of family members/natural supports in the withdrawal management process; and

5. Physician and/or nurse monitoring, assessment, and management of signs and symptoms of intoxication and withdrawal.

(C) Individuals shall receive a minimum of two (2) hours of services per day.

(D) Services shall include up to twenty-three (23) hours of continuous observation, monitoring, and support in a supervised environment for the individual to achieve initial recovery from the effects of alcohol and/or other drugs and to be appropriately transitioned to the most appropriate level of care to continue the recovery process.

(E) Individuals must be discharged within twenty-three (23) hours of admission.

(F) Programs shall operate twenty-four (24) hours per day, seven (7) days per week. Staff shall be dressed and awake. Twenty-four- (24-) hour access to emergency medical consultation services shall be available.

(G) Interventions shall include, but are not limited to-

1. A medical history and physical examination by a physician, AP, PA, resident physician, or APRN during the treatment episode or within twenty-four (24) hours of admission, whichever occurs sooner.

A. A physical examination not performed by a physician shall be dated and countersigned by a physician during the treatment episode or within seventy-two (72) hours, whichever occurs sooner, signifying their review of and concurrence with the findings;

2. Daily assessment of progress during withdrawal management and any treatment changes;

3. Transfer, continuing recovery, and discharge planning beginning at the point of admission;

4. Conduct or arrange for appropriate laboratory and toxicology tests which can be point-of-care testing, as medically necessary; and

5. Referral and assistance for the individual to gain access to other needed substance use disorder and/or mental health services.

(H) Individuals shall meet the diagnostic criteria for substance withdrawal disorder and the ASAM dimensional criteria for admission.

1. For individuals whose presenting alcohol or other substance use history is inadequate to substantiate such a diagnosis, information provided by collateral parties (such as family members/natural supports or a legal guardian) can indicate a high probability of such a diagnosis, subject to confirmation by further evaluation.

(I) Individuals shall remain in this level of care until-

1. Their withdrawal signs and symptoms are sufficiently resolved such that the individual can be safely managed in a less intensive level of care; or

2. Their signs and symptoms of withdrawal have failed to respond to treatment and have intensified (based on a standardized scoring system) such that transfer to a more intensive level of withdrawal management service is indicated; or

3. They are unable to complete withdrawal management at Level 2-WM despite an adequate trial; for example, they are experiencing intense craving and have insufficient coping skills to prevent continued alcohol or other drug use, indicating a need for more intensive services.

(15) Level 2.1 Intensive Outpatient Treatment. This level of care shall include professionally directed assessment, diagnosis, treatment, and recovery services provided in an organized, non-residential treatment setting.

(A) Services shall include, but are not limited to-

1. Psychiatric, medical, and laboratory services, as needed;

2. Comprehensive bio-psychosocial assessments and individualized treatment, allowing for a valid assessment of dependency;

3. Frequent monitoring/management of the individual's medical and emotional concerns in order to avoid hospitalization;

4. Individual counseling, group counseling, family therapy, peer and family support, crisis intervention, and community support; and

5. Monitoring of substance use, medication services, medication services support, medical and psychiatric examinations, crisis intervention, and orientation and referral to community-based support groups.

(B) Timely access to additional support systems and services including medical, psychological, and toxicology shall be available through consultation or referral.

(C) Services shall vary in level of intensity and shall include nine (9) or more contact hours per week for adults, age eighteen (18) years and older, not to exceed nineteen (19) hours per week. Services for adolescents age nine (9) through seventeen (17) shall include six (6) or more contact hours per week, not to exceed nineteen (19) hours per week. The week starts on the individual's date of admission.

1. The duration of treatment shall vary based on the severity of the individual's illness and their response to treatment.

2. Individuals shall receive a minimum of one hour and thirty minutes (1.5) hours of services per day.

(D) Interventions shall include, but are not limited to-

1. Monitoring, including biomarkers and/or toxicology testing, as medically necessary;

2. Random drug screening, as medically necessary, to reinforce treatment gains, as appropriate to the individual treatment plan; and

3. Documented referral to more or less intensive services.

(E) Individuals shall meet diagnostic criteria for a substance use disorder and the ASAM dimensional criteria for admission. If the individual's presenting substance use history is inadequate to substantiate such a diagnosis, the probability of such a diagnosis may be determined from information appropriately submitted or obtained from collateral parties such as family members, legal guardian, or natural supports. Additional admission guidelines include-

1. Acute intoxication and/or withdrawal potential- no signs or symptoms of withdrawal, or the individual's withdrawal needs can be safely managed in an intensive outpatient setting. The adolescent who is appropriately placed in this level of care is likely to attend, engage, and participate in treatment as evidenced by being able to tolerate mild subacute withdrawal symptoms, has made a commitment to sustain treatment and follow treatment recommendations, and has external supports to promote engagement in treatment;

2. Biomedical conditions and complications-none or sufficiently stable to permit participation in outpatient treatment;

3. Emotional, behavioral, or cognitive conditions and complications-none to moderate. If present, the individual must receive appropriate co-occurring disorder services depending on their level of function, stability, and degree of impairment in this dimension;

4. Readiness to change-requires structured therapy and a programmatic milieu to promote treatment progress and recovery because motivational interventions at another level of care were unsuccessful. Adolescents admitted to this level of care may be only passively involved in treatment or demonstrate variable adherence with attendance at outpatient treatment sessions or self-help groups;

5. Relapse, continued use, or continued problem potential-experiencing an intensification of symptoms of the substance-related disorder and level of functioning is deteriorating despite modification of the treatment plan. Alternatively, there is a high likelihood of relapse, continued use, or continued problems without close monitoring and support several times a week as indicated by the individual's lack of awareness of relapse triggers, difficulty in coping or in postponing immediate gratification, or ambivalence toward treatment; and

6. Recovery environment-insufficiently supportive environment and the individual lacks the resources or skills necessary to maintain an adequate level of functioning without services in intensive outpatient treatment. Alternatively, the individual lacks social contacts, has unsupportive social contacts that jeopardize recovery, or has few friends or peers who do not use alcohol or other drugs.

(16) Level 2.5 Partial Hospitalization Services. A planned format of services shall be delivered on an individual and group basis to meet individual needs.

(A) Services shall include, but are not limited to-

1. Psychiatric, medical, and laboratory services, as needed;

2. Comprehensive bio-psychosocial assessments and individualized treatment, allowing for a valid assessment of dependency;

3. Frequent monitoring/management of the individual's medical and emotional concerns in order to avoid hospitalization;

4. Individual counseling, group counseling, family therapy, peer and family support, crisis intervention, and community support; and

5. Monitoring of substance use, medication services, medication services support, medical and psychiatric examinations, crisis intervention, and orientation to community-based support groups.

(B) A minimum of twenty (20) hours of clinically intensive programming shall be provided per week, based on individual treatment plans. The week starts on the individual's date of admission.

1. Individuals shall receive a minimum of two hours and twenty-four minutes (2.4 hours) of services per day.

(C) Interventions shall include, but are not limited to-

1. A physical examination based on the individual's medical condition. Such determinations are made according to established program protocols which include reliance on the individual's personal healthcare provider, when possible. Examinations are based on the staff's capabilities and the severity of the individual's symptoms, and are approved by a physician; and

2. Random drug screening, as medically necessary, to reinforce treatment gains, as appropriate to the individual treatment plan.

(D) Individuals must meet diagnostic criteria for a substance use disorder as well as the ASAM dimensional criteria for admission. If the individual's presenting substance use history is inadequate to substantiate such a diagnosis, the probability of such a diagnosis may be determined from information appropriately submitted or obtained from collateral parties such as family members, legal guardian, or natural supports. Additional admission guidelines include-

1. Acute intoxication and/or withdrawal potential- no signs or symptoms of withdrawal, or the individual's withdrawal needs can be safely managed in a partial hospital setting;

2. Biomedical conditions and complications-none or not sufficient to interfere with treatment but are severe enough to distract from recovery efforts and require medical monitoring and/or medical management;

3. Emotional, behavioral, or cognitive conditions and complications-none to moderate. If present, the individual must receive appropriate co-occurring disorder services depending on the their level of function, stability, and degree of impairment in this dimension;

4. Readiness to change-the individual requires structured therapy and a programmatic milieu to promote treatment progress and recovery because motivational interventions at another level were unsuccessful;

5. Relapse, continued use, or continued problem potential-the individual is experiencing an intensification of symptoms related to their substance use disorder and their level of functioning is deteriorating despite modification of the treatment plan and active participation in a Level 1 or Level 2.1 program; and

6. Recovery environment-insufficiently supportive environment and the individual lacks the resources or skills necessary to maintain an adequate level of functioning without services in a partial hospitalization program. Alternatively, family members and/or other natural supports who live with the individual are not supportive of their recovery goals or are passively opposed to their treatment.

(17) Level 3.1 Clinically Managed Low-Intensity Residential Services. Programs shall provide a structured recovery environment which allows sufficient stability to prevent or minimize relapse or continued use and continued problem potential for individuals served.

(A) Treatment services are focused on improving the individual's readiness to change and/or functioning and coping skills. Services shall include, but are not limited to-

1. Individual counseling;

2. Group counseling;

3. Group rehabilitative support;

4. Family therapy;

5. Medication services;

6. Medication services support; and

7. Community support.

(B) Individuals shall participate in at least five (5) hours of services per week. The week starts on the individual's date of admission. Mutual/self-help meetings shall not be included in the five (5) hours of treatment per week.

1. The target length of stay is one (1) to three (3) months, based on individual needs.

(C) Programs shall be staffed twenty-four (24) hours per day, seven (7) days per week. Staff shall be dressed and awake. Services shall be available seven (7) days per week.

(D) Interventions shall include, but are not limited to-

1. Tuberculosis screening and testing, provided directly or by referral. Pre- and post-test counseling shall be provided, as needed;

2. Random drug screening, as medically necessary, to reinforce treatment gains, as appropriate to the individual treatment plan;

3. Documented physical examination one (1) month prior to admission or a physical examination completed no later than five (5) days after admission. Any individual receiving uninterrupted treatment or care shall require only the documentation of the initial physical examination;

4. Referral and assistance, as needed, for the individual to gain access to other needed substance use disorder or mental health services;

5. Orientation and facilitated connections to recovery resources and community supports, including referrals to selfhelp programs for identified psychiatric, substance use, and cooccurring disorders, as appropriate and for the continuation of appropriate treatment; and

6. Specific and documented plans for community reintegration and transition to less intensive levels of residential and treatment support, including the aftercare to which the individual is being discharged.

(E) Individuals must meet diagnostic criteria for a substance use disorder as well as the ASAM dimensional criteria for admission. If the individual's presenting substance use history is inadequate to substantiate such a diagnosis, the probability of such a diagnosis may be determined from information appropriately submitted or obtained from collateral parties such as family members, legal guardian, or natural supports. Additional admission guidelines include-

1. Acute intoxication and/or withdrawal potential-none, or minimal/stable withdrawal risk and can be safely managed in this level of care. The adolescent's status in this dimension is characterized by problems with intoxication or withdrawal (if any) that are being managed through concurrent placement at another level of care for withdrawal management (typically Level 1, 2.1, or 2.5);

2. Biomedical conditions and complications-biomedical problems, if any, are stable and do not require medical or nurse monitoring and the individual is capable of selfadministering any prescribed medications. The adolescent's status in this dimension is characterized by a biomedical condition that distracts from recovery efforts and requires limited residential supervision to ensure adequate treatment and provide support to overcome the distraction, or continued substance use would place them at risk of serious damage to their physical health;

3. Emotional, behavioral, or cognitive conditions and complications-minimal problems in this area. The individual's mental status is assessed as sufficiently stable to allow them to participate in therapeutic interventions provided at this level of care and to benefit from treatment. The adolescent's status in this dimension is characterized by at least one (1) of the following:

A. Risk of dangerous consequences because of the lack of a stable environment;

B. Emotional, behavioral, or cognitive problems result in moderate impairment in social functioning;

C. Moderate impairment in their ability to manage the activities of daily living;

D. History and present situation suggests an emotional, behavioral, or cognitive condition would become unstable without twenty-four (24) hours supervision; or

E. Emotional, behavioral, or cognitive condition suggests the need for low-intensity and/or longer term reinforcement and practice of recovery skills in a controlled environment;

4. Readiness to change-open to recovery, but in need of a structured, therapeutic environment to promote treatment progress and recovery due to impaired ability to make behavior changes without the support of a structured environment;

5. Relapse, continued use, or continued problem potential-understands the risk of relapse, but lacks relapse prevention skills or requires a structured environment to continue to apply recovery and coping skills. The adolescent is at high risk of substance use or deteriorated mental functioning with dangerous emotional, behavioral, or cognitive consequences in the absence of twenty-four- (24-) hour structured support; and

6. Recovery environment-able to cope for limited periods of time outside of the twenty-four- (24-) hour structure, but the environment jeopardizes recovery. The adolescent's home environment is too chaotic or ineffective to support or sustain treatment goals such that recovery is assessed as unachievable without residential support.

(18) Level 3.2 Clinically Managed Residential Withdrawal Management. Services shall be provided in an organized, residential, non-medical setting and be delivered by appropriately trained staff who provide safe, twenty-four- (24-) hour supervision, observation, and support for individuals who are intoxicated or experiencing withdrawal.

(A) Programs may be staffed to supervise self-administered medications for management of withdrawal symptoms. All programs shall have established clinical protocols to identify individuals in need of medical services beyond the program's capacity and to arrange for transfer to an appropriate healthcare facility.

(B) Services shall include, but are not limited to-

1. Individual counseling;

2. Group counseling;

3. Group rehabilitation support;

4. Peer and family support;

5. Community support; and

6. Medical and medication services support.

(C) Target length of stay is one (1) to three (3) days.

(D) Programs shall be staffed twenty-four (24) hours per day, seven (7) days per week. Staff shall be dressed and awake. Services shall be available seven (7) days per week.

(E) Interventions shall include, but are not limited to-

1. Random drug screening, as medically necessary, to reinforce treatment gains, as appropriate to the individual's treatment plan;

2. A medical history and physical examination by a physician, AP, PA, resident physician, or APRN during the treatment episode or within twenty-four (24) hours of admission, whichever occurs sooner.

A. A physical examination that is not performed by a physician shall be dated and countersigned by a physician during the treatment episode or within seventy-two (72) hours, whichever occurs sooner, signifying their review of and concurrence with the findings;

3. A comprehensive nursing assessment at admission which includes a substance use history and assessment recommendations that are reviewed with a physician; and

4. Documented referral and assistance for the individual to gain access to other needed substance use disorder and/or mental health services.

(F) Individuals admitted to this level of care are experiencing signs and symptoms of withdrawal, or there is evidence (based on history of substance intake, age, gender, previous withdrawal history, present symptoms, physical condition and/or emotional, behavioral, or cognitive conditions) that withdrawal is imminent. The individual is assessed as not being at risk of severe withdrawal and moderate withdrawal is safely manageable at this level of service.

1. In addition, the individual may be assessed as not requiring medication to assist in managing withdrawal symptoms, but requires this level of service to complete withdrawal management and enter into continued treatment or self-help recovery because of inadequate home supervision or support structure, as evidenced by meeting one (1) of the following criteria:

A. The individual's recovery environment is not supportive of withdrawal management and entry into treatment, and they do not have sufficient coping skills to safely manage issues in the recovery environment; or

B. The individual has a recent history of withdrawal management at less intensive levels of service that is marked by inability to complete withdrawal management or to enter into continuing substance use disorder treatment, and continues to have insufficient skills to complete withdrawal management; or

C. The individual recently demonstrated an inability to complete withdrawal management at a less intensive level of service, as evidenced by continued use of non-prescribed drugs or other substances.

(19) Level 3.3 Clinically Managed, Population-Specific High Intensity Residential Services (Adult Criteria). Programs shall provide a structured recovery environment in combination with high-intensity clinical services to meet the individual's functional limitations and to support recovery from substance-related disorders.

(A) Length of stay is based on the individual's severity of illness, level of function, and progress in treatment.

(B) Individuals shall receive a minimum of twenty (20) hours of services per week. The week starts on the individual's date of admission.

1. At least ten (10) of the twenty (20) hours of services shall include a combination of individual counseling, group counseling, group rehabilitative support, family therapy, peer and family support, community support, medication services, and medication services support.

(C) Programs shall be staffed twenty-four (24) hours per day, seven (7) days per week. Staff shall be dressed and awake. Services shall be available seven (7) days per week.

(D) Interventions shall include, but are not limited to-

1. Tuberculosis screening and testing provided directly or by referral. Pre- and post-test counseling shall be provided, as needed;

2. Random drug screening, as medically necessary, to reinforce treatment gains, as appropriate to the individual's treatment plan;

3. Comprehensive nursing assessment completed within seventy-two (72) hours of admission, with consultation with a physician when necessary;

4. A documented physical examination one (1) month prior to admission or a physical examination completed no later than five (5) days after admission. Any individual receiving uninterrupted treatment or care shall require only the documentation of the initial physical examination;

5. Referral and assistance, as needed, for the individual to gain access to other needed substance use disorder and/or mental health services; and

6. Orientation and facilitated connections to recovery resources and community supports, including referrals to selfhelp programs for identified psychiatric, substance use, and co-occurring disorders as appropriate and for the continuation of appropriate treatment.

(E) Individuals admitted to this level of care must meet diagnostic criteria for a moderate or severe substance use disorder as well as the ASAM dimensional criteria for admission. If the individual's presenting history is inadequate to substantiate such a diagnosis, the probability of such a diagnosis may be determined from information submitted by collateral parties such as family members/natural supports and legal guardians. Additional guidelines include-

1. Acute intoxication and/or withdrawal potential-none, or minimal risk of withdrawal, or withdrawal needs can be safely managed at this level;

2. Biomedical conditions and complications-none or stable. Any biomedical problems do not require medical or nurse monitoring and the individual is capable of selfadministering any prescribed medications;

3. Emotional, behavioral, or cognitive conditions and complications-the individual's mental status (including emotional stability and cognitive functioning) is assessed as sufficiently stable to permit them to participate in the therapeutic interventions provided at this level of care and to benefit from treatment;

4. Readiness to change-because of the intensity and chronicity of the substance use disorder or the individual's cognitive limitations, they have little awareness of the need for continuing care or the existence of their substance use or mental health problem and need for treatment and, therefore, has limited readiness to change;

5. Relapse, continued use, or continued problem potential-the individual has limited awareness of relapse triggers and is in imminent danger of relapse or continued substance use. The individual requires relapse prevention activities that are delivered at a slower pace, more concretely, and more repetitively within a twenty-four (24) hour structured environment; and

6. Recovery environment-the environment interferes with recovery and is characterized by moderately high risk of initiation or repetition of physical, sexual, or emotional abuse, or substance use is so prevalent the individual is unable to cope outside of a twenty-four- (24-) hour supervised setting.

(20) Level 3.5 Clinically Managed High-Intensity Residential Services (Adult Criteria). Programs shall be designed to serve individuals who, because of specific functional limitations, need a safe and stable environment in order to develop and/or demonstrate sufficient recovery skills so they do not immediately relapse or continue to use in an imminently dangerous manner upon transfer to a less intensive level of care. Individual needs are of such severity that treatment cannot be safely provided in a less intensive level of care.

(A) Length of stay is based on the individual's severity of illness, level of function, and progress in treatment.

(B) Individuals shall receive at least a twenty- (20-) hour combination of clinical and recovery services per week. The week starts on the individual's date of admission.

1. At least ten (10) of the twenty (20) hours shall include a combination of individual counseling, group counseling and rehabilitative support, family therapy, peer and family support, community support, crisis intervention, medication services, and/or medication services support.

(C) Programs shall be staffed twenty-four (24) hours per day, seven (7) days per week. Staff shall be dressed and awake. Services shall be available seven (7) days per week.

(D) Interventions shall include, but are not limited to-

1. Tuberculosis screening and testing provided directly or by referral. Pre- and post-test counseling are provided as needed;

2. Random drug screening, as medically necessary, to reinforce treatment gains, as appropriate to the individual treatment plan;

3. Comprehensive nursing assessment completed within seventy-two (72) hours of admission, with consultation with a physician when necessary;

4. A documented physical examination one (1) month prior to admission or a physical examination completed no later than five (5) days after admission. Any individual receiving uninterrupted treatment or care shall require only the documentation of the initial physical examination;

5. Modification to the treatment plan based on review of any positive drug screen(s) with the individual served, as applicable;

6. Referral and assistance as needed for the individual to gain access to other needed substance use disorder and/or mental health services;

7. Orientation and facilitated connections to recovery resources and community supports, including referrals to selfhelp programs for identified psychiatric, substance use, and co-occurring disorders as appropriate and for the continuation of appropriate treatment; and

8. Documented plans for community reintegration and transition to less intensive levels of residential and treatment support and services, including the aftercare to which the individual is being discharged.

(E) Individuals admitted to this level of care must meet diagnostic criteria for a substance use disorder of moderate to high severity, as well as the ASAM dimensional criteria for admission. If the individual's presenting history is inadequate to substantiate such a diagnosis, the probability of such a diagnosis may be determined from information submitted by collateral parties such as family members/natural supports, and legal guardians. Other admission guidelines include-

1. Acute intoxication and/or withdrawal potential-none, or withdrawal symptoms can be safely managed at this level;

2. Biomedical conditions and complications-none or stable and the individual can self-administer any prescribed medication or, if their condition is severe enough to distract from treatment and recovery, the individual can receive medical monitoring within the program or through another provider;

3. Emotional, behavioral, or cognitive conditions and complications-the individual's mental status (including emotional stability and cognitive functioning) is assessed as sufficiently stable to permit them to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. Despite the individual's best efforts, they are unable to control their use of alcohol and/or other drugs, and their level of dysfunction is so severe they would not be successful in a less structured level of care;

4. Readiness to change-the individual has marked difficulty with or opposition to treatment, with dangerous consequences, and has limited insight and awareness of the need for continuing care or the existence of their substance use or mental health problem and need for treatment, thereby has limited readiness to change;

5. Relapse, continued use, or continued problem potential-the individual is unable to recognize relapse triggers and has no recognition of the skills needed to prevent continued use, with limited ability to initiate or sustain ongoing recovery in a less structured environment; and

6. Recovery environment-the individual lives in an environment with moderately high risk of neglect, initiation, or repetition of physical, sexual, or emotional abuse, or is in a culture highly invested in substance use. The individual lacks skills to cope with challenges to recovery outside of a highly structured twenty-four- (24-) hour setting.

(21) Level 3.5, Clinically Managed Medium Intensity Residential Services (Adolescent Criteria). This is a residential program offering a twenty-four- (24-) hour supportive treatment environment. Adolescents placed in this level of care typically have impaired functioning across a broad range of psychosocial domains. These impairments may be expressed as disruptive behaviors, delinquency and juvenile justice involvement, educational difficulties, family conflicts and chaotic home situations, developmental immaturity, and psychological problems.

(A) Length of stay shall be based on the individual's severity of illness, level of function, and progress in treatment.

(B) Individuals shall receive at least a twenty- (20-) hour combination of clinical and recovery services per week. The week starts on the individual's date of admission.

1. At least ten (10) of the twenty (20) hours shall include a combination of individual counseling, group counseling and rehabilitative support, family therapy, peer and family support, community support, medication services, and/or medication services support.

(C) Programs shall be staffed twenty-four (24) hours per day, seven (7) days per week. Staff shall be dressed and awake. Services shall be available seven (7) days per week.

(D) Interventions shall include, but are not limited to-

1. Tuberculosis screening and testing provided directly or by referral. Pre- and post-test counseling are provided as needed

2. Random drug screening, as medically necessary, to reinforce treatment gains, as appropriate to the individual treatment plan;

3. Comprehensive nursing assessment completed within seventy-two (72) hours of admission, with consultation with a physician when necessary;

4. A documented physical examination one (1) month prior to admission or a physical examination completed no later than five (5) days after admission. Any individual receiving uninterrupted treatment or care shall require only the documentation of the initial physical examination;

5. Modification to the treatment plan based on review of any positive drug screen(s) with the individual served, as applicable;

6. Referral and assistance, as needed, for the individual to gain access to other needed medical, substance use disorder, and/or mental health services;

7. Orientation and facilitated connections to recovery resources and community supports, including referrals to selfhelp programs for identified psychiatric, substance use, and co-occurring disorders as appropriate and for the continuation of appropriate treatment;

8. Documented plans for community reintegration and transition to less intensive levels of residential and treatment support and services, including the aftercare to which the individual is being discharged; and

9. Educational services provided in accordance with state regulations, including opportunities to address deficits in the education level of adolescents who have fallen behind because of their involvement with alcohol and or other drugs.

(E) Adolescents admitted to this level of care must meet diagnostic criteria for a substance use disorder of moderate to high severity, as well as the ASAM dimensional criteria for admission. If the adolescent's presenting history is inadequate to substantiate such a diagnosis, the probability of such a diagnosis may be determined from information submitted by family members/natural supports and legal guardians. Additional admission guidelines include-

1. Acute intoxication and/or withdrawal potential-at risk of or experiencing acute or subacute intoxication or withdrawal, with mild to moderate symptoms. Needs secure placement and increased treatment intensity to support engagement in treatment, ability to tolerate withdrawal, and prevention of immediate continued use. Alternatively, the adolescent has a history of unsuccessful treatment at the same or a less intensive level of care;

2. Biomedical conditions and complications-biomedical conditions distract from recovery efforts and require residential supervision (that is unavailable in a less intensive level of care) to ensure adequate treatment, or the adolescent requires medium-intensity residential treatment to provide support to overcome the distraction. Continued substance use would place the adolescent at risk of serious damage to their physical health because of a biomedical condition (such as pregnancy or HIV) or an imminently dangerous pattern of high-risk use;

3. Emotional, behavioral, or cognitive conditions and complications-the adolescent is at moderate but stable risk of imminent harm to self or others and needs medium intensity, twenty-four- (24-) hour monitoring and/or treatment for protection and safety, however, does not require access to medical or nursing services. Their recovery efforts are negatively impacted by their emotional, behavioral, or cognitive problems in significant and distracting ways;

4. Readiness to change-because of the intensity and chronicity of their substance use disorder and/or mental health problems, the adolescent has limited insight into and little awareness of the need for continuing care or the existence of their substance use disorder or mental health issues and has limited readiness to change. The individual has marked difficulty in understanding the relationship between their substance use disorder, mental health, or life problems and their impaired coping skills and level of functioning, often blaming others for their problems;

5. Relapse, continued use, or continued problem potential-the adolescent does not recognize relapse triggers and lacks insight into the benefits of continuing care, and is therefore, not committed to treatment. Their continued use of substances poses an imminent danger of harm to self or others in the absence of twenty-four- (24-) hour monitoring and structured support; and

6. Recovery environment-living and social environments have a high risk of neglect or initiation or repetition of physical, sexual, or severe emotional abuse, such that the adolescent is assessed as being unable to achieve or maintain recovery without residential treatment.

(22) Level 3.5 Clinically Managed High-Intensity Residential Services (Women and Children). Programs shall provide a twenty-four- (24-) hour supportive treatment environment specializing in services for women who are pregnant, postpartum, and/or have children. Programs shall arrange for gender-specific substance use disorder treatment and other therapeutic interventions for women and comply with child supervision and other requirements specified in 9 CSR 303.190.

(A) Length of stay shall be based on the individual's severity of illness, level of function, and progress in treatment.

(B) Individuals shall receive at least a twenty- (20-) hour combination of clinical and recovery services per week. The week starts on the individual's date of admission.

1. At least ten (10) of the twenty (20) hours shall include a combination of individual counseling, group counseling and rehabilitative support, family therapy, peer and family support, crisis intervention, community support, medication services, and/or medication services support.

(C) Programs shall be staffed twenty-four (24) hours per day, seven (7) days per week. Staff shall be dressed and awake. Services shall be available seven (7) days per week.

(D) Interventions shall include, but are not limited to-

1. Tuberculosis screening and testing provided directly or by referral. Pre- and post-test counseling shall be provided, as needed;

2. Random drug screening, as medically necessary, to reinforce treatment gains, as appropriate to the individual treatment plan;

3. Comprehensive nursing assessment completed within seventy-two (72) hours of admission, with consultation with a physician when necessary;

4. A documented physical examination one (1) month prior to admission or a physical examination completed no later than five (5) days after admission. Any individual receiving uninterrupted treatment or care shall require only the documentation of the initial physical examination;

5. Children accompanying their mother to services shall receive a screening by a qualified mental health professional (QMHP) or qualified addiction professional (QAP) to determine the appropriateness and need for services.

A. If services are determined to be a need for the child(ren), a licensed diagnostician shall complete an assessment with diagnosis;

6. Modification to the treatment plan based on review of any positive drug screen(s) with the individual served, as applicable;

7. Referral and assistance as needed for the individual to gain access to other needed substance use disorder and/or mental health services;

8. Orientation to and facilitated connections to recovery resources and community supports, including referrals to selfhelp programs for identified psychiatric, substance use and co-occurring disorders as appropriate and for the continuation of appropriate treatment;

9. Documented plans for community reintegration and transition to less intensive levels of residential and treatment support and services, including the aftercare to which the individual is being discharged.

(E) Individuals who are admitted to this level of care must meet diagnostic criteria for a substance use disorder of moderate to high severity, as well as the ASAM dimensional criteria for admission. If the individual's presenting history is inadequate to substantiate such a diagnosis, the probability of such a diagnosis may be determined from information submitted by collateral parties such as family members, legal guardians, and significant others.

(F) Priority shall be given to women who are pregnant, postpartum, or have children in their physical care and custody. Additional admission guidelines include-

1. Acute intoxication and/or withdrawal potential-none, or withdrawal symptoms can be safely managed at this level;

2. Biomedical conditions and complications-none or stable and the individual can self-administer any prescribed medication, or if the condition is severe enough to distract from treatment and recovery, the individual can receive medical monitoring within the program or through another provider;

3. Emotional, behavioral, or cognitive conditions and complications-mental status (including emotional stability and cognitive functioning) is assessed as sufficiently stable to permit them to participate in the therapeutic interventions provided at this level of care and to benefit from treatment;

4. Readiness to change-significant difficulty with treatment, with negative consequences, and may have significant limitations in the areas of readiness to change. Recovery may be perceived as providing a lesser return for the effort;

5. Relapse, continued use, or continued problem potential-needs skills to prevent continued use and may have relapse, continued use, or continued problem potential; and

6. Recovery environment-the individual lives in an environment with moderately high risk of neglect, initiation, or repetition of physical, sexual, or emotional abuse, or is in a culture highly invested in substance use. The individual lacks skills to cope with challenges to recovery outside of a highly structured twenty-four- (24-) hour setting. These social influences may represent a sense of hopelessness or an acceptance of deviance as normative.

(23) Level 3.7 Medically Monitored Intensive Inpatient Services (Adult Criteria). Programs shall provide a planned and structured regimen of twenty-four- (24-) hour professionally directed evaluation, observation, medical monitoring, and substance use disorder treatment in a residential setting. Individuals in this level of care may have co-occurring substance use and mental health disorders that need to be stabilized. The target population includes individuals with a high risk of withdrawal symptoms and moderate co-occurring psychiatric and/or medical problems that are of sufficient severity to require twenty-four- (24-) hour treatment.

(A) Length of stay shall be based on the individual's severity of illness, level of function, and progress in treatment.

(B) Individuals shall receive thirty (30) hours of structured treatment per week. The week starts on the individual's date of admission.

1. At least ten (10) of the thirty (30) hours shall include a combination of individual counseling, group counseling, group rehabilitative support, family therapy, peer and family support, crisis intervention, community support, medication services, and/or medication services support.

(C) Programs shall be staffed twenty-four (24) hours per day, seven (7) days per week. Staff shall be dressed and awake. Services shall be available seven (7) days per week.

(D) Interventions shall include, but are not limited to-

1. Tuberculosis screening and testing provided directly or by referral. Pre- and post-test counseling are provided as needed;

2. Random drug screening, as medically necessary, to reinforce treatment gains, as appropriate to the individual treatment plan;

3. Nursing assessment at time of admission by an RN (or APRN, physician, resident physician, assistant physician, physician assistant in the absence of an RN);

4. A physician or AP, PA, APRN, or resident physician assesses the individual within twenty-four (24) hours of admission or, within twenty-four (24) hours of admission, a physician reviews and updates the record of a physical examination that was conducted no more than seven (7) days prior to admission. A physician must be available to assess the individual thereafter, as medically necessary;

5. Additional medical specialty consultation, psychological, laboratory, and toxicology services are available onsite, through consultation, or referral;

6. Referral and assistance, as needed, for the individual to gain access to other needed substance use disorder and/or mental health services; and

7. Orientation and facilitated connections to recovery resources and community supports, including referrals to selfhelp programs for identified psychiatric, substance use and co-occurring disorders as appropriate and for the continuation of appropriate treatment.

(E) Individuals admitted to this level of care must meet diagnostic criteria for a moderate or severe substance use disorder, as well as the ASAM dimensional criteria for admission. If the individual's presenting history is conflicting or inadequate to substantiate such a diagnosis, the probability of such a diagnosis may be determined from information provided by family members/natural supports and legal guardians. Additional admission criteria includes-

1. Acute intoxication and/or withdrawal potential-high risk of withdrawal symptoms that can be managed in a Level 3.7 program;

2. Biomedical conditions and complications-moderate to severe conditions which require twenty-four- (24-) hour nursing and medical monitoring or active treatment but not the full resources of an acute care hospital;

3. Emotional, behavioral, or cognitive conditions and complications-moderate to severe conditions and complications (such as diagnosable co-morbid mental disorders or symptoms). These symptoms may not be severe enough to meet diagnostic criteria but interfere or distract from recovery efforts (for example, anxiety/hypomanic or depression and/or cognitive symptoms) and may include compulsive behaviors, suicidal or homicidal ideation with a recent history of attempts but no specific plan, or hallucinations and delusions without acute risk to self or others. Psychiatric symptoms are interfering with abstinence, recovery, and stability to such a degree that the individual needs a structured twenty-four-(24-) hour, medically monitored (but not medically managed) environment to address recovery efforts;

4. Readiness to change-the individual is unable to acknowledge the relationship between the substance use disorder and mental health and/or medical issues, or is in need of intensive motivating strategies, activities, and processes available only in a twenty-four- (24-) hour structured medically monitored setting (but not medically managed);

5. Relapse, continued use, or continued problem potential-the individual is experiencing an escalation of relapse behaviors and/or acute psychiatric crisis and/or reemergence of acute symptoms and is in need of twenty-four-(24-) hour monitoring and structured support; and

6. Recovery environment-the environment or current living arrangement is characterized by a high risk of initiation or repetition of physical, sexual, or emotional abuse or substance use so prevalent that the individual is assessed as unable to achieve or maintain recovery at a less intensive level of care.

(24) Level 3.7 Medically Monitored Intensive Inpatient Services (Adolescent Criteria). Programs shall provide a planned and structured regimen of twenty-four- (24-) hour professionally directed evaluation, observation, medical monitoring, and substance use disorder treatment. For adolescents, this level of treatment is often necessary to orient the individual to the structure of daily life. Services must be provided in accordance with 9 CSR 30-3.192.

(A) Length of stay shall be based on the individual's severity of illness, level of function, and progress in treatment.

(B) Individuals shall receive at least thirty (30) hours of structured treatment per week. The week starts on the individual's date of admission.

1. At least ten (10) of the thirty (30) hours shall include a combination of individual counseling, group counseling, group rehabilitative support, family therapy, peer and family support, community support, medication services, and/or medication services support.

(C) Elements of the assessment and treatment plan review in this level of care for adolescents shall include-

1. An initial withdrawal assessment within twenty-four (24) hours of admission, or earlier if clinically warranted;

2. Daily nursing withdrawal monitoring assessments and continuous availability of nursing evaluation; and

3. Daily availability of medical evaluation, with continuous on-call coverage.

(D) Programs shall be staffed twenty-four (24) hours per day, seven (7) days per week. Staff shall be dressed and awake. Services shall be available seven (7) days per week.

(E) Interventions shall include, but are not limited to-

1. Tuberculosis screening and testing provided directly or by referral. Pre- and post-test counseling are provided as needed;

2. Random drug screening, as medically necessary, to reinforce treatment gains, as appropriate to the individual treatment plan;

3. Nursing assessment at the time of admission by an RN (or APRN, physician, resident physician, assistant physician, physician assistant in the absence of an RN);

4. A physician or AP, PA, APRN, or resident physician assesses the individual within twenty-four (24) hours of admission or, within twenty-four (24) hours of admission, a physician reviews and updates the record of a physical examination that was conducted no more than seven (7) days prior to admission. A physician must be available to assess the individual thereafter, as medically necessary;

5. Additional medical specialty consultation, psychological, laboratory, and toxicology services are available onsite, through consultation or referral;

6. Referral and assistance, as needed, for the individual to gain access to other needed substance use disorder and/or mental health services;

7. Orientation and facilitated connections to recovery resources and community supports, including referrals to selfhelp programs for identified psychiatric, substance use and cooccurring disorders, as appropriate, and for the continuation of appropriate treatment; and

8. Educational services provided in accordance with state regulations, including opportunities to address deficits in the educational level of adolescents who have fallen behind because of their involvement with alcohol and/or other drugs.

(F) Adolescents admitted to this level of care must meet diagnostic criteria for a moderate or severe substance use disorder, as well as ASAM dimensional criteria for admission. If the adolescent's presenting history is conflicting or inadequate to substantiate such a diagnosis, the probability of such a diagnosis may be determined from information provided by collateral parties such as parent/guardian, family members, or other natural supports. Additional admission guidelines include-

1. Acute Intoxication and/or withdrawal potential- experiencing or at risk of acute or subacute intoxication or withdrawal with moderate to severe signs and symptoms. The individual needs twenty-four- (24-) hour treatment services including the availability of active medical and nurse monitoring to manage withdrawal, support engagement in treatment, and prevent immediate continued use;

2. Biomedical conditions and complications-significant risk of serious damage to physical health or concomitant biomedical conditions, or a biomedical condition requires twenty-four- (24-) hour nursing and medical monitoring or active treatment, but not the full resources of an acute care hospital;

3. Emotional, behavioral, or cognitive conditions and complications-moderate and possibly unpredictable risk of imminent harm to self or others and needs twenty-four-(24-) hour monitoring and/or treatment in a high-intensity programmatic environment for safety;

4. Readiness to change-despite experiencing serious consequences or effects of the substance use disorder and/ or behavioral health problem, does not accept or relate the disorder to the severity of the presenting problem. The individual is in need of intensive monitoring strategies, activities, and processes available in a twenty-four- (24-) hour setting;

5. Relapse, continued use, or continued problem potential-experiencing an acute psychiatric or substance use crisis, marked by intensification of symptoms of the substance use or mental disorder such as poor impulse control or drugseeking behavior; and

6. Recovery environment-has been living in an environment in which supports that might otherwise have enabled treatment at a less intensive level of care are unavailable, or the family is unable to sustain treatment attendance at a less intensive level of care.

(25) Level 3.7 Medically Monitored Inpatient Withdrawal Management (Adult Criteria). Services shall be provided by medical and nursing professionals who provide medically supervised evaluation under a defined set of physician-approved policies and physician-monitored procedures or clinical protocols.

(A) Twenty-four- (24-) hour observation, monitoring, and treatment shall be provided by an interdisciplinary team of trained staff.

(B) Individuals remain in this level of care until withdrawal signs and symptoms are sufficiently resolved such that they can be safely managed at a less intensive level of care, or their signs and symptoms of withdrawal have failed to respond to treatment and have intensified (as confirmed by higher scores on a standardized scoring system).

(C) Services shall include assessment, individual and group counseling, group rehabilitative support, peer/family support, community support, medication services, crisis intervention, and medication services support.

(D) Admissions shall be accepted twenty-four (24) hours per day, seven (7) days per week. Staff shall be dressed and awake.

Services shall be available seven (7) days per week. The week starts on the individual's date of admission.

(E) Interventions shall include, but are not limited to-

1. Random drug screening, as medically necessary, to reinforce treatment gains, as appropriate to the individual treatment plan;

2. A nursing assessment by an RN at admission (or APRN, resident physician, assistant physician, physician assistant in the absence of an RN) that is reviewed with a physician;

3. A physician or AP, PA, APRN, or resident physician assessment within twenty-four (24) hours of admission or, within twenty-four (24) hours of admission, a physician reviews and updates the record of a physical examination that was conducted no more than seven (7) days prior to admission. A physician must be available to assess the individual thereafter, as medically necessary;

4. Daily assessment of the individual's progress through withdrawal management and any treatment changes;

5. For individuals new to the program, it is recommended that an assessment be completed within twenty-four (24) hours of admission which substantiates appropriate level of care placement; and

6. Referral and assistance for the individual to gain access to other needed substance use disorder and/or mental health services.