Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This rule establishes requirements for CSTAR
programs serving women and children.
PUBLISHER'S NOTE: The secretary of state has
determined that publication of the entire text of the material that is
incorporated by reference as a portion of this rule would be unduly cumbersome
or expensive. This material as incorporated by reference in this rule shall be
maintained by the agency at its headquarters and shall be made available to the
public for inspection and copying at no more than the actual cost of
reproduction. This note applies only to the reference material. The entire text
of the rule is printed here.
(1) Treatment Philosophy and Guiding
Principles. Women and children's CSTAR programs shall demonstrate through
policy and practice that women's substance use disorders differ from men's,
both in their etiology and the services and supports needed for recovery.
(A) Women and children's CSTAR programs shall
ensure-
1. Emotional and physical safety of
the women and children served takes precedence over other considerations in the
delivery of services;
2. Women-only
therapeutic environments are available;
3. Trauma-sensitive services and supports to
increase women's access to care, engagement, and retention in treatment are
provided or arranged, such as community support, transportation, and child
care;
4. Women-specific service
needs and topic areas are addressed in treatment and through support services;
and
5. Multiple modalities are
offered to meet the needs of women such as group and individual counseling,
community support, peer support, and opportunities for women to be in treatment
with their children.
(B)
Staff shall possess the knowledge and expertise to engage women with histories
of trauma, recognize the presence of trauma symptoms, understand the role of
trauma in the lives of women seeking services, and conduct themselves in ways
that are not retraumatizing to those being served. The following
trauma-informed principles shall be integrated into the program's service
delivery practices:
1. Safety-ensuring
physical and emotional safety for individuals and staff;
2. Trustworthiness-maximizing trustworthiness
through task clarity, consistency, and maintaining appropriate interpersonal
boundaries;
3. Choice-maximizing
the experience of developmentally appropriate choice and control;
4. Collaboration-maximizing collaboration and
sharing of power between individuals and staff; and
5. Empowerment-building on individuals'
capacities, encouraging them to have a voice and mastery of life, and
prioritizing power and growth.
(C) All women shall receive or have
trauma-informed, evidence-based services available and shall not be required to
disclose their trauma history in order to receive those services. Women's
treatment shall incorporate universal, trauma-informed principles into every
service, regardless of whether trauma is disclosed.
(D) The Substance Abuse and Mental Health
Services Administration (SAMHSA), Treatment Improvement Protocol 51, Substance
Abuse Treatment: Addressing the Specific Needs of Women, 2015, hereby
incorporated by reference and made a part of this rule, shall serve as a guide
for the program's service delivery practices. This document is published by and
available from SAMHSA, 1 Choke Cherry Road, Rockville, Maryland 20857, (877)
726-4727,
www.samhsa.gov. This rule does
not incorporate any subsequent amendments or additions to this
publication.
(2)
Eligibility Criteria and Program Structure. The program shall provide treatment
services and other supports solely to women and their children. Services shall
be based on individual and family needs, in accordance with admission and
eligibility criteria for CSTAR.
(A) Priority
admission shall be for women who are-
1.
Pregnant and inject drugs;
2.
Pregnant;
3. Postpartum (up to one
(1) year after delivery);
4. Have
children in their care and custody, including those at risk of losing custody
or attempting to regain custody of their children;
5. Applicants or recipients of Temporary
Assistance for Needy Families referred by the Department of Social Services,
Family Support Division; and
6.
Other populations specified by the department.
(B) Women who meet priority criteria shall be
immediately admitted to the CSTAR program and receive appropriate services.
1. If the program is unable to provide
immediate admission, staff shall facilitate referral to another women and
children's CSTAR program that can provide immediate admission.
2. If immediate admission with an alternative
women and children's CSTAR program is not available for a woman who is
pregnant, program staff shall contact designated department staff to obtain
assistance in facilitating arrangements for immediate admission with another
program.
3. Women shall not be
denied admission based solely on medication prescribed and monitored by a
licensed physician, physician assistant, assistant physician, or advanced
practice registered nurse (APRN) for an opioid disorder or other physical or
behavioral health disorder.
(C) Adolescents who meet priority criteria
shall be admitted if, in the staff's clinical judgment, the adolescent can
appropriately participate in and benefit from the services and milieu offered.
Programs shall have policies and procedures for serving adults and adolescents
in the same environment.
(D)
Culturally competent services shall be provided in the context of a
family-centered and family-focused treatment model. Members of the treatment
team shall be responsible for adapting to the needs of the mother and her
family. An array of services shall be available to-
1. Assist families in functioning as a unit
by establishing and maintaining a schedule, structure, regular habits, and
healthy routines;
2. Allow for an
integrated family plan that builds coherence and prioritizes the needs of
individual family members;
3.
Accommodate children who accompany their mother, in accordance with the
mother's wishes;
4. Address
substance use, mental, physical and emotional health, developmental, social,
economic, and environmental needs of women and their families;
5. Allow women to define their families and
focus on healthy relationships between parents, children, and others identified
by the mother;
6. Address evolving
and changing family engagement, recognizing everyone may not participate at the
same time, stay the same length of time, or have the same motivations;
and
7. Assist women and their
families in accessing other services and supports in the community.
(E) Family oriented living
arrangements, indoor recreational space for children and families, and safe,
protected outdoor recreational and leisure space shall be available.
(F) Women and their children shall have
access to age-appropriate physical healthcare, including obstetric and
pediatric care.
(3)
Gender-Responsive Services. The program shall address therapeutic issues
relevant to women and their specific needs, as identified in individual
treatment plans.
(A) Staff shall understand
and recognize the distinctive characteristics and biopsychosocial issues
associated with women in general, and specifically women who have substance use
disorders, to provide effective treatment.
(B) Services shall be culturally sensitive
and recognize the unique characteristics of women's initiation of substance
use, effects of use, histories of trauma, co-occurring mental, developmental,
and physical health disorders, and other treatment issues specific to
women.
(C) Services shall be
designed to assist women in maintaining their recovery and resiliency, such as-
1. Parenting and child development;
2. Life skills;
3. Family programs;
4. Facilitation of supervised parent-child
bonding;
5. Educational remediation
and support;
6. Employment
readiness services;
7. Linkages
with legal and child welfare systems, including reunification with children if
applicable;
8. Housing support
efforts and referrals;
9.
Co-occurring disorder services, including access to psychological and
pharmacological treatments for mental health disorders;
10. Education and linkage to eating disorder
and nutrition services;
11.
Medication services, including access to approved medication to treat substance
use disorders for women who are pregnant; and
12. Recovery support and community support
services that address long-term recovery needs such as domestic violence
services, career counseling, legal services, and transportation
services.
(4)
Child Care. The program shall ensure child care is not a barrier to engagement
in services or retention in treatment by ensuring coordination or facilitation
of child care when the mother is participating in services.
(A) Programs offering on-site child care
shall obtain licensure as a child care center as specified in 5 CSR
25-500.
(B) On-site child care
shall -
1. Be designed to meet the
developmental needs of the various age groups served and address cultural and
other identified needs;
2. Provide
each child with a variety of easily accessible, developmentally appropriate
learning and play materials;
3.
Provide for a balance between free play and organized activities, between
individual play and sharing experiences among children, and promote individual
contact between staff and each child;
4. Provide reasonable regularity of
age-appropriate activities with allowance for a variety of special events and
time for children to be outdoors daily, weather permitting;
5. Be culturally responsive, nonjudgmental,
trauma sensitive, and respectful;
6. Take responsible precautions to ensure a
safe, welcoming, and sanitary environment appropriate for children;
7. Ensure no weapons are brought on to the
premises;
8. Provide privacy (such
as use of bathroom, sleeping arrangements) for opposite sex children
transitioning into school and for any children demonstrating a need for
privacy; and
9. Accommodate the
needs of children with disabilities in accordance with the Americans with
Disabilities Act as amended (ADAAA) or refer to another provider if the child's
needs are identified to be beyond the scope of the program. The ADAAA,
effective January 1, 2009, is hereby incorporated by reference and made a part
of this rule and is available from the U.S. Department of Justice, 950
Pennsylvania Avenue NW, Civil Rights Division, Disability Rights Section-NYA,
Washington, DC 20530, (800) 514-0301 voice, (800) 5140383 TTY. This rule does
not incorporate any subsequent amendments or additions to this
publication.
(C) Child
care may be arranged through a contractual agreement with a local, licensed
child care center. Contracts shall comply with
9 CSR
10-7.090(6).
(D) Child care will not be funded by the
department for children who are over fourteen (14) years of age, unless
specific authorization has been granted by department staff.
(5) Supervision of Children. The
program shall ensure children in child care are supervised in accordance with
Department of Elementary and Secondary Education staff/child ratios as
specified in 5 CSR 25-500.
(A) The
parent/guardian shall be responsible for providing supervision when the child
is not attending child care or participating in other scheduled program
activities.
(B) Program staff shall
assist the parent in providing age-appropriate activities, training, and
guidance.
(6) Education
for Children. The program shall assist the parent/ guardian as necessary to
ensure educational opportunities for school-age children in accordance with the
requirements of the Department of Elementary and Secondary Education.
(7) Assessing Children's Needs and
Documenting Services. Program staff shall inform women of the services
available for children and educate them about involving their children in
treatment while respecting the mother's wishes.
(A) When the mother chooses to involve her
children in treatment, a trained staff member shall complete an initial
screening utilizing an age-appropriate, validated instrument to determine
specific service needs beyond child care and community support. The screening
shall include an interview with at least one (1) parent and the child, whenever
appropriate.
(B) If the need for a
clinical assessment is indicated by the screening, a qualified staff member
shall complete an assessment utilizing an age-appropriate, validated
instrument. The assessment must be completed prior to delivery of services
beyond child care and community support.
(C) An individual plan shall be developed
based on the needs of the mother and child, with the results of the assessment
serving as a guide. The child's consent for treatment must be signed by the
legal guardian.
(D) Services
provided for children, including child care and community support, shall be
documented in a separate clinical record for the child. The record shall
include the child's developmental, physical, emotional, social, educational,
and family background and current status.
(8) Services for Children. The program shall
ensure trauma-informed services are available to address therapeutic issues
relevant to children, based on the needs of individuals being served at those
locations.
(A) Developmentally-appropriate
activities and services shall be offered to meet the social, emotional, and
behavioral needs of children to-
1. Build
self-esteem and self-awareness;
2.
Learn to identify and express feelings;
3. Build positive family
relationships;
4. Learn healthy
social engagement, peer relationships, social pressure skills, and
teamwork;
5. Develop
decision-making skills;
6. Learn
self-management (impulse control, stress management, and
goal-setting);
7. Understand
substance use disorders and its effects on the family;
8. Learn and practice nonviolent ways to
resolve conflict;
9. Learn safety
practices such as personal space, boundaries, and personal safety;
10. Address developmental needs;
and
11. Provide education on
preventing alcohol, tobacco, and other drug use.
(B) Services for children shall address the
issues and needs identified by the mother and her children, as documented in
the individual plan, utilizing structured and unstructured therapeutic
activity.
(C) Specialized services
shall be provided including, but not limited to, children with high risk of
sexual abuse, sexual acting-out behaviors, suicide risk, and the service needs
of infants, toddlers, and preschoolers.
(D) Services for children from birth to three
(3) years of age shall include, at a minimum, developmentally appropriate
parent-child interactive bonding activities and developmentally appropriate
structured activities that promote and nurture the growth and well-being of the
infant.
(9) Qualified and
Competent Staff. The program shall maintain a core workforce (employed or
contracted) that is appropriately qualified and determined to be competent to
adequately address the needs of women and children and deliver the behavioral
health services the program is certified to provide.
(A) The program shall document that staff
providing services for women and/or children have training in the following
areas:
1. Trauma knowledge, trauma-informed
treatment, identification of signs and symptoms of domestic violence, spousal
or partner abuse, and child abuse and neglect, with special emphasis on failure
to thrive and sexual abuse of children;
2. Child development and age-appropriate
behaviors;
3. Parenting attachment
styles and skills appropriate to infants, toddlers, preschool, and school-age
children; and
4. The impact of
substance use and substance use disorders on parenting and family
units.
(B) The program
shall document that staff working with children have ongoing training and
demonstrate job-appropriate functional comprehension in the following areas:
1. The impact of prenatal drug and alcohol
exposure on child development;
2.
The effect of substance use disorders on parenting children and
families;
3. Trauma knowledge,
trauma's impact on child brain development, and long-term impact of adverse
childhood experiences;
4. Parenting
attachment styles and skills appropriate to infants, toddlers, preschool, and
school-age children;
5. Appropriate
play activities according to developmental stage;
6. Common children's behavioral and
developmental problems;
7.
Recognition of sexual acting-out behavior; and
8. The substance use disorder recovery
process, especially as it relates to family units.
(10) Health Promotion. The program
shall maintain a safe, healthy environment that is responsive to the physical,
behavioral, and emotional health needs of women and children.
(A) A full-time licensed nurse shall be
accessible to women and children to provide trauma-informed medical and other
consultative services necessary to monitor and manage health issues.
1. Services performed by a licensed practical
nurse (LPN) must fall within their scope of practice and shall be supervised by
a licensed physician (including psychiatrist), licensed physician assistant,
licensed assistant physician, APRN, or registered nurse (RN).
(B) Key service functions of the
nurse(s) shall include, but are not limited to-
1. Obtaining initial medical histories and
vital signs of individuals admitted to the program;
2. Monitoring general health needs and
meeting with individuals about medical concerns;
3. Providing disease prevention, risk
reduction, and reproductive health education;
4. Reviewing medication requirements and
educating individuals about the benefits of taking medications as prescribed
and monitoring medication compliance; and
5. Monitoring lab levels, including
consultation with the individual served, her physician, and the treatment
team.
(C) The program
shall employ staff in sufficient numbers and with appropriate training to
respond to emergency situations and provide cardiopulmonary resuscitation (CPR)
when necessary.
1. At least one (1) staff
member who has current training in First Aid and CPR for infants, children, and
adults shall be on duty seven (7) days per week, twenty-four (24) hours per
day.
2. Staff must maintain current
First Aid and CPR certification for healthcare providers through training that
includes hands-on practice and in-person skills assessment. Online-only
training is not acceptable.
(D) The program shall demonstrate effective
working relationship(s) with a licensed physician, hospital, and/or clinic to
provide access to emergency services and/or ongoing medical care for women,
including pregnant and postpartum women, and their children.
(E) The program shall ensure an evaluation of
medical need for each woman and child and shall ensure that each woman and
child is medically stable to safely and adequately participate in services. For
women, the evaluation of medical need shall include:
1. Current physical status, including vital
signs; and
2. Symptoms of
intoxication, impairment, or withdrawal.
(F) The program shall ensure that
recommendations related to an individual's behavioral or physical health from a
licensed physician (including psychiatrist), licensed physician assistant,
licensed assistant physician, or APRN are encouraged and coordinated regularly
by their primary health care provider.
(G) Health-related services may include but
are not limited to-
1. Nutritional
counseling;
2. Education about
reproductive health;
3. Wellness
programs;
4. Education on sleep and
dental hygiene;
5. Education about
trauma and long-term physical health risks and conditions;
6. Education about sexually transmitted
infections and infectious diseases, such as viral hepatitis and HIV/AIDS;
and
7. Preventive healthcare
education.
(H) If a
specialized program for women and children provides withdrawal
management/detoxification services, the program shall comply with applicable
standards under 9 CSR 30-3.120. A specialized
program for women and children shall not be required to accept applications for
ninety-six- (96-) hour civil detention of intoxicated persons due to the
presence of children within the program.
*Original authority: 630.050, RSMo 1980, amended 1993,
1995; 630.655, RSMo 1980; and 631.010, RSMo
1980.