Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This amendment clarifies the intent of ICPR
services as well as the related staffing requirements for this
service.
PUBLISHER'S NOTE: The secretary of state has
determined that the publication of the entire text of the material which 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) Intensive Community Psychiatric
Rehabilitation (ICPR). ICPR is separate and distinct from other community
psychiatric rehabilitation (CPR) services. The individual treatment plan shall
specify interventions and supports to be provided by ICPR staff that are
separate from other CPR services (such as community support) to prevent
duplication of services.
(A) Services are
designed to help individuals who are experiencing a severe psychiatric
condition, alleviating or eliminating the need to admit them into a psychiatric
inpatient setting or a restrictive living setting. ICPR is a comprehensive,
time-limited, community-based service for individuals who are exhibiting
symptoms that interfere with individual/family life in a highly disabling
manner.
(B) ICPR in all settings
(children/youth and adult) must be approved by the department prior to
implementation. Written proposals shall be submitted to the department and must
include the following:
1. The proposed
service, setting, and timeline for implementation;
2. Method for determining eligibility for the
service;
3. Staffing patterns/staff
qualifications, including identification of the qualified mental health
professional (QMHP) who supervises the ICPR setting;
4. Evidence that the site(s) is safe;
5. Process for obtaining
multidisciplinary input into treatment plans;
6. Type of documentation to be used;
7. Strategy for preventing the
duplication of services and supports delivered by residential and
community-based CPR staff;
8. Plan
for financial separation of room and board from services; and
9. Plan for providing personal spending funds
to individuals served.
(C) ICPR is intended for-
1. Persons who would be hospitalized without
the provision of intensive community-based intervention;
2. Persons who have extended or repeated
hospitalizations;
3. Persons who
have psychiatric crisis episodes;
4. Persons who are at risk of being removed
from their home or school to a more restrictive environment; and
5. Persons who require assistance in
transitioning from a highly restrictive setting to a community-based
alternative, including specifically persons being discharged from inpatient
psychiatric settings who need intensive CPR services and may require assertive
outreach and engagement.
(D) Treatment teams deliver services that will
maintain the individual within the family and significant support systems and
assist them in meeting basic living needs and age appropriate developmental
needs.
(2) Admission
Criteria. To be eligible for ICPR, the individual must meet admission criteria
as defined in 9 CSR 30-4.005 and at least one
(1) of the following criteria:
(A) Is being
discharged from a department facility or bed funded by the
department;
(B) Has had extended or
repeated psychiatric inpatient hospitalizations or crisis episodes within the
past six (6) months;
(C) Has
received services in multiple out-of-home residential settings due to their
mental disorder; or
(D) Is at risk
of being removed from their home, school, or other community living
situation.
(3) Staff
Requirements. Staff requirements for ICPR in residential settings are as
follows: Staff requirements for ICPR in residential settings are as follows:
(A) Intensive Residential Treatment Settings
(IRTS) and Psychiatric Individualized Supported Living (PISL), in accordance
with 9 CSR 40-1 and 9 CSR 40-4.001;
(B) Clustered apartments (CA). Staff shall be
available on a full- or part-time basis in accordance with the agency's written
proposal approved by the department;
1.
Clustered apartment services are provided on-site at the individual's place of
residence. Staff providing services shall be located on site, within a five (5)
mile radius of the CA, or within a ten (10) minute drive of the CA.
(C) Treatment Family Home-Based
Services and Professional Parent Home-Based Services, as specified in section
(7) of this rule and 9 CSR 40-6.001.
(4) Treatment for Children/Youth
and Adults. All treatment teams shall be supervised by a qualified mental
health professional (QMHP). The team coordinates a comprehensive array of
services available to the individual through the CPR program as specified in
9 CSR
30-4.043. Other services shall be provided as
clinically appropriate to meet individual needs, however, shall not duplicate
services being provided on site. Each team shall include:
(A) Staff required to provide specific
services identified on the individualized treatment plan;
(B) The individual receiving services and
family members or other natural supports, if developmentally
appropriate;
(C) ICPR shall
include:
1. Multiple face-to-face contacts
with the individual on a weekly basis, and may require contact on a daily
basis, as required for each service type;
2. Services that are available twenty-four
(24) hours per day, seven (7) days per week for programs that require daily
services; and
3. Crisis response
services that may be coordinated with an existing crisis system;
(D) The amount and frequency of
services is based upon the individual's assessed acuity and need;
(E) A crisis prevention plan shall be
developed for each individual, including clinical issues that may impact
transition to less intensive services;
(F) At a minimum, quarterly treatment plan
reviews shall occur to ensure individuals are receiving the appropriate level
of services to meet needs and goals; and
(G) Individuals no longer need ICPR when-
1. There is a reduction of severe symptoms;
and
2. They are able to function
without intensive services; or
3.
They choose to no longer receive intensive services.
(5) Documentation Requirements.
ICPR services must be documented in accordance with
9 CSR
10-7.030(13), and as specified in
this rule.
(A) For individuals currently
enrolled in the CPR program, the following documentation is required upon
admission to ICPR:
1. Verification they meet
admission criteria;
2. Acuity
level; and
3. Treatment plan update
indicating the higher level of service the individual will be
receiving.
(B) For
individuals newly admitted directly from the community into ICPR, an intake
evaluation must be completed to substantiate acuity and criteria for admission.
1. Each individual shall have a psychiatric
evaluation at admission. For individuals discharged from inpatient
hospitalization into ICPR, a psychiatric evaluation completed at the
facility/hospital may be initially accepted.
2. The comprehensive assessment must be
completed within thirty (30) days of admission except for individuals admitted
provisionally.
3. Treatment plans
shall be developed upon admission and be updated at least quarterly, or more
frequently if clinically indicated.
(C) Treatment plans shall be reviewed as
required for each service type and documented in the individual record with a
summary progress note, including updates to the treatment plan as
appropriate.
(D) Upon change from
ICPR services, a transition summary must be documented in a level of care
transition summary and reflected in an updated treatment plan. must be
completed by a QMHP and included in an updated treatment
plan.
(6) ICPR for
Children and Youth. Services are medically necessary to maintain a child with a
Serious Emotional Disturbance (SED) in their natural home, or maintain a child
with a serious mental illness or SED in a community setting who has a history
of failure in multiple community settings, and/or the presence of ongoing risk
of harm to self or others, which would otherwise require long-term psychiatric
hospitalization. Clinical interventions are provided by a multidisciplinary
treatment team on a daily basis, and the interventions must be available
twenty-four (24) hours per day, seven (7) days per week for stabilization
purposes. The child's family and other natural supports may receive services
when they are for the direct benefit of the child in accordance with their
individual treatment plan.
(A) When a
child/youth is receiving this service, it is vital that the parent/guardian be
actively involved in the program if the individual is to receive the full
benefit of the program. Services shall be provided to the child/youth's family
and other natural supports when such services are for the direct benefit of the
individual, in accordance with their needs and treatment goals identified in
the treatment plan, and for assisting in their recovery.
(B) Services shall include, but are not limited to:
1. Medication administration/management of
medication;
2. Ongoing behavioral
health assessment and diagnosis;
3.
Monitoring to assure individual safety;
4. Individual and group counseling;
and
5. Community support.
(C) The ICPR multidisciplinary
team shall include the following staff, based on the needs of the individual
served:
1. Physician, psychiatrist, child
psychiatrist, psychiatric resident, assistant physician, physician assistant,
or Advanced Practice Registered Nurse (APRN);
2. QMHP;
3. RN;
4. LPN;
5. Community Support Specialist;
and
6. Individuals with a high
school diploma, or equivalent certificate, under the direction and supervision
of a QMHP.
(D) Services
are limited to ninety (90) days. Exceptions may be granted by the department
and must be documented in the individual record.
(7) ICPR for Children/Youth in Residential
Settings (Treatment Family Home-Based Services and Professional Parent Home
Based Services). Intensive therapeutic interventions are provided to improve
the child's functioning and prevent them from being removed from their natural
home and placed into a more restrictive residential treatment setting due to a
SED.
(A) Services are for children whose
therapeutic needs cannot be met in their natural home or an alternative
therapeutic environment is required for transition back to their home or least
restrictive setting.
(B) Providers
must complete extensive, specialized training required by the department and
meet department licensure requirements as specified in 9 CSR 40-6.
(C) The provider shall participate in
pre-placement and ongoing meetings with the child's CPR treatment team and
assist in development of the treatment plan. The provider is responsible for
implementing the treatment plan and maintaining contact with the child's
natural parent/guardian and completing documentation as required by the
department.
(D) Services and
supports are individualized and strength-based to meet the needs of the child
and family across life domains to promote success, safety, and permanence in
the home, school, and community. Therapeutic interventions target the child's
serious mental health issues and promote positive development and healthy
family functioning.
(E) Children
must meet CPR admission criteria and their behavior must be sufficiently under
control to live safely in a community setting with appropriate
support.
(F) Staff of the CPR
program who supervise the child's services must be available twenty-four (24)
hours per day, seven (7) days per week to assist the provider if a crisis
situation occurs.
(G) Placement,
duration, and intensity of services is based on the specific needs of each
child as specified in the MO HealthNet CPR Provider Manual, hereby incorporated
reference and made a part of this rule and available from the Department of
Social Services, 615 Howerton Court, PO Box 6500, Jefferson City, MO 651026500,
and as specified in the department contract, September 2019. This rule does not
incorporate any subsequent amendments or additions to this
publication.
(H) A maximum of three
(3) children may receive services in a Treatment Family Home (TFH), subject to
licensed capacity. One (1) child may be served in a Professional Parent Home
(PPH).
(8)
Evidence-Based Practices (EBP) for Youth. Services involve proven treatment
supports for children and youth to address specific behavioral health needs.
The selected EBP is based on individual needs and desired outcomes as
identified in the treatment plan.
(A) The EBP
must be approved by the department.
(B) Activities associated with the service
must include, but are not limited to:
1.
Extensive monitoring and data collection;
2. Specific skills-training in a prescribed
or natural environment; and
3.
Prescriptive responses to a psychiatric crisis and/or frequent contact with the
individual and/or family, in addition to the arranged therapy
sessions.
(9)
ICPR for Adults in Non-Residential Settings. Services are delivered by teams
using one (1) of the following methods:
(A)
Linking and transitioning individuals from acute or long-term services to less
intensive treatment. The time frame for services is approximately ninety (90)
days or less, but varies according to individual needs;
(B) Modified Assertive Community Treatment
(ACT), as approved by the department. The time frame varies based on individual
needs; or
(C) Intensive wrap-around
stabilization services for individuals with substantial mental health needs who
may otherwise require inpatient hospitalization. The expected period of
engagement is approximately ninety (90) days or less, but varies according to
individual needs.
(D) Teams may be
designated exclusively for individuals in ICPR or be mixed teams serving
individuals in ICPR and rehabilitation services.
(E) A department-approved functional
assessment must be completed monthly and documented in the individual
record.
(F) Community support
services shall not be provided while an individual is receiving ICPR
non-residential services.
(10) ICPR for Transition Age Youth in
Non-Residential Settings. Services are delivered by transdisciplinary specialty
teams using intensive wrap-around stabilization for individuals with
substantial mental health and/or co-occurring needs, with the primary diagnosis
being a mental disorder.
(A) Services are for
individuals who may otherwise require inpatient hospitalization. The period of
engagement varies based upon individual needs as specified in the treatment
plan.
(B) An initial comprehensive
assessment must be completed within thirty (30) days of admission.
(C) An individual treatment plan shall be
developed within forty-five (45) days of admission and shall be updated as
required by the department.
(11) ICPR for Adults in Residential Settings (IRTS,
PISL, Clustered Apartments). Medically necessary services/supports are provided
to adults who have a serious mental illness and are transitioning from an
inpatient psychiatric hospital to the community, or who are at risk of
returning to inpatient care due to their clinical status or need for increased
support. Services and supports are provided on site where the individual lives
under the supervision of a QMHP. Residential settings are structured to meet
individual needs to ensure safety and prevent the individual's return to a more
restrictive setting for services.
(A) Staff
providing services/supports must be at least eighteen (18) years of age and
have a minimum of a high school diploma or equivalent certificate. Two (2)
years of direct heath care experience, or a bachelor's degree in behavioral
sciences, is preferred.
(B) Staff
must be systematically trained to provide intensive interventions and supports
to reduce the symptoms of mental illness, and provide de-escalation and
intervention techniques to individuals in a psychiatric crisis who are
exhibiting behaviors potentially dangerous to themselves or others. A training
plan must be in place for each staff person identifying specific topics and
frequency of refresher training on each topic, including documentation of
course completion.
(C) Support and
rehabilitation services related to activities of daily living and crisis
prevention and intervention must be provided.
(D) Documentation must reflect delivery of direct
(face-to-face) services and supports such as, daily summary progress notes,
group notes, individualized progress notes documenting interventions including
crisis assistance, conflict management, behavior redirection, and prompting or
reminders.
(12)
Children's Inpatient Diversion. A full array of intensive clinical services are
provided to children/youth in a highly structured therapeutic setting. Services
are designed to restore the child to a prior level of functioning, decrease
risk of harm, and prevent transition to a more restrictive setting.
(A) Emergency medical services must be
available on site or in close proximity.
(B) A psychiatrist must supervise services
which are delivered by a multi-disciplinary treatment team.
(C) Licensed nursing staff must be available
on a daily basis.
(D) Licensed
occupational and recreational therapists must be available based on individual
needs.
(E) The provision of
services is limited to certified or deemed-certified CPR programs for children
and youth. The service must be accredited by a national accrediting body
approved by the department.
(F)
There shall be one (1) staff person for every two (2) individuals served during
waking hours. The ratio for staff to individuals served may decrease to one (1)
staff to six (6) individuals during sleeping hours.
(13) Adult Inpatient Diversion. A full array
of intensive clinical services are provided to adults in a highly supervised
twenty-four (24) hour, structured therapeutic setting. Services are designed to
restore the individual to a prior level of functioning, decrease risk of harm,
and prepare for transition to a less restrictive setting.
(A) Emergency medical services must be
available on site or in close proximity.
(B) Intensive therapeutic services must be
provided in a coordinated effort under the direction of a psychiatrist. Other
staff on the treatment team includes licensed nurses, licensed psychologists,
social workers, counselors, psychosocial rehabilitation specialists, and other
trained supportive staff.
(C)
Services shall include, but are not limited to:
1. Nursing;
2. Community support;
3. Psychosocial rehabilitation; and
4. Treatment for co-occurring disorders and
other evidence-based services.
(D) The provision of services is limited to
CPR programs for adults. The service must be accredited by a national
accrediting body approved by the department.
(E) The staffing ratio for daytime and
evening hours shall be one staff to six individuals served (1:6), and one staff
to eight individuals served (1:8) during nighttime hours.
*Original authority: 630.050, RSMo 1980, amended 1993,
1995, 2008; 630.655, RSMo 1980; and 632.050, RSMo
1980.
