PURPOSE: This rule sets forth the requirements for specialized residential treatment, including program director, assessment staff, professional staff, staff/child ratios, training, treatment plan review, and locked isolation.

1. (1) In addition to rules for basic residential treatment for children and youth, an agency seeking to become licensed to provide residential treatment for children and youth, shall meet these additional requirements:

   1. (A) Program Director. The program director must be a fulltime staff dedicated solely to the overall treatment program with at least the following minimum qualifications:

      1. 1. A master’s degree in social work or human service

field from an accredited college or university or licensed as a certified social worker; and

1. 2. Two (2) years’ experience providing treatment services.

One (1) year of this experience must have been in a residential treatment setting; (B) Assessment Staff. Staff responsible for developing initial assessment and treatment plan for each child must have at least the following minimum qualifications:

1. 1. A master’s degree in social work or human service

field from an accredited college or university or licensed as a certified social worker; and

1. 2. One (1) year of experience in a residential treatment

setting;

1. (C) Professional Staff.

   1. 1. The agency must have sufficient, appropriately qualified

professional staff available on a full-time, part-time, or continuing consultative basis, or any combination of these to address the needs of children in care.

1. 2. The professional staffing plan must be in writing and

implemented by the agency.

1. 3. The program director shall document that the number,

qualifications, and responsibilities of professional staff are appropriate to the agency’s size and the scope of its program.

1. (D) Staff/Child Ratios.

   1. 1. At least one (1) direct care staff for every four (4) children,

birth to six (6) years of age, shall be on duty during waking hours.

1. 2. Staff shall be awake during children’s sleeping hours,

and maintain staff/child ratios of one (1) staff for every six (6) children from birth to six (6) years of age.

1. 3. At least one (1) direct care staff for every six (6) children,

age six (6) years and older shall be on duty during waking hours.

1. 4. Staff shall be awake during children’s sleeping hours

and maintain staff/child ratios of one (1) staff for every twelve (12) children age six (6) years and older. Reference Chart

1. 5. An agency licensed, or buildings constructed after

(effective the date of this amendment) shall have no more than two (2) children in a sleeping room.

1. (E) Training. All staff working with children must receive at least forty (40) hours annually of in-service training and meet the training requirements in accordance with 13 CSR 35-71.045. At least ten (10) hours of the training must be related specifically to treatment issues with emotionally disturbed, mentally ill, behaviorally disordered, medically fragile, physically disabled, and/or developmentally delayed children. Professional staff providing sexual abuse treatment are required to have fifteen

1. (15) hours of annual training in investigation, treatment, nature, extent, and causes of sexual abuse pursuant to section 660.526, RSMo;

   1. (F) Treatment Plan Review.

      1. 1. Each child’s treatment plan shall be reviewed and

updated at least every three (3) months.

1. 2. If a child shows no progress toward achieving the

goals and objectives in the treatment plan since the plan was developed or last reviewed, the reasons for continuing the child in the agency’s program must be included in the child’s record.

1. 3. Appropriate information about the updated treatment

plan shall be given to the child and the child’s parent(s), guardian, or legal custodian and documented in the child’s record.

1. 4. A minimum of one (1) hour of individual, group, or

family counseling sessions shall be provided to each child at least one (1) time a week with other sessions available as needed.

1. (G) Locked Isolation.

   1. 1. Prior to the implementation of a locked isolation room,

the agency shall have approval of the State Fire Marshal and the division.

1. 2. Written policies for the use of locked isolation shall be

made available to the child’s parent(s), or guardian or legal custodian, or both, and when appropriate, to the child.

1. 3. Agencies utilizing locked isolation shall submit a plan

for the emergency evacuation of isolated residents to the licensing unit including documentation that staff has included evacuating residents from locked isolation during fire drills.

1. 4. Locked isolation may be used only as a management

method after all other verbal de-escalation measures have been exhausted, and never to replace other more positive measures of control. Documentation of intervention methods used to prevent use of locked isolation must be in the resident’s record.

1. 5. Locked isolation may be used only when a child presents

a danger to him/herself or others.

1. 6. Locked isolation shall be used in the shortest intervals

possible until the child regains reasonable self-control.

1. 7. The maximum time a child may remain in locked

isolation is thirty (30) minutes, unless extensions are approved at the end of every thirty (30) minute period by the program director or a qualified designee. A child shall not remain in locked isolation more than a two (2) hour period. If the child has not regained control after two (2) hours, a medical order shall be obtained.

1. 8. When a child is placed in locked isolation, staff shall

physically monitor the child in at least five (5) minute intervals. Staff shall remain in close proximity to the child in locked isolation with no more than one (1) locked door between the staff and the child. Close proximity means that staff are close enough to the child(ren) to be able to hear any sounds the child(ren) might make that would indicate a need for assistance.

1. 9. Not more than one (1) child shall be in a locked isolation

room. A locked isolation room shall not be utilized for any other purpose.

1. 10. Within twenty-four (24) hours of each locked isolation

incident, treatment staff shall debrief the incident with the resident.

1. 11. The agency shall maintain a record when locked

isolation is used, which shall include:

1. A. The name of the child, the date, and the time the

child was placed in locked isolation;

1. B. The circumstances that led to the placement of the

child in locked isolation and efforts to prevent the use of locked isolation;

1. C. The name of the staff person who requested placement

of the child in locked isolation, the staff person who approved locked isolation, and the name of the staff person who monitored the child while in locked isolation;

1. D. The amount of time the child remained in locked

isolation, the frequency of monitoring and the time of and reasons for release;

1. E. Documented behavioral observations of the child at

each five (5) minute interval;

1. F. Specific notation of any extension of locked isolation

including reasons for the extension and by whom approval for extension was given; and

1. G. Documentation of results of debriefing that includes

recommendations of staff and resident for avoiding similar situations.

1. 12. For agencies permitting the use of locked isolation, the

treatment team shall review its usage at least weekly and sign/ date the isolation report.

1. A. Written policies for the use of locked isolation shall

be distributed to staff, and there shall be documented training

provided to staff in the policies and use of locked isolation, which shall include, but not be limited to:

1. (I) Directions for the removal of all dangerous items

from the child, including but not limited to, belts, shoelaces, jewelry, items in pockets, matches, and any other items which represent a potential hazard during locked isolation; and

1. (II) Proper written documentation of the use of locked

isolation.

1. 13. If the agency does not meet all requirements for the

use of locked isolation, the division shall give written notice of the specific deficiencies and the agency shall not use locked isolation until corrections are made and approved by the division.

1. 14. Locked isolation rooms shall be constructed and

equipped so that control is maximized, but the risk of suicide or injury to children is minimized. The following shall apply:

1. A. An isolation room shall be constructed to allow for

both visual and auditory supervision of a child;

1. B. An isolation room shall have one (1) approved locking-

against-egress device which shall be used only when staff are immediately present, awake, and in possession of a key. There shall be a backup system which does not rely on a key, i.e., an electronic locking-release mechanism, as approved by the State Fire Marshal;

1. C. Potentially dangerous articles shall be removed from

the child prior to placing the child in locked isolation, for example, belts, shoes, matches, and/or contents of pockets;

1. D. An isolation room shall have at least a seven and one-

half foot (7 1/2') ceiling and be of sufficient length and width for the comfort of the child;

1. E. All doors, ceilings, and walls shall be constructed of

such strength and noncombustible material that harm to the child is minimized;

1. F. All switches controlling lights, ventilation, and the

like, shall be on the outside of the room;

1. G. In order to prevent harm to the child, windows

shall be secured and made of tempered material to prevent shattering;

1. H. No functional electrical outlets shall be allowed in

the room;

1. I. Tamper-resistant, recessed ceiling lights shall be

utilized, and steam or hot water radiators shall be enclosed in a tamper-resistant, protective casing;

1. J. The room shall be properly heated, cooled, and

ventilated;

1. K. Normal toileting and bathing facilities shall be

available during isolation; and

1. L. The agency shall have a schedule for monthly routine

maintenance of the locks.

AUTHORITY: sections 210.481, 210.486, and 210.506, RSMo 2000.* This rule originally filed as 13 CSR 40-71.130. Emergency rule filed Nov. 1, 1993, effective Nov. 12, 1993, expired March 11, 1994. Emergency rule filed March 2, 1994, effective March 12, 1994, expired July 9, 1994. Original rule filed Nov. 1, 1993, effective June 6, 1994. Moved to 13 CSR 35-71.130, effective Oct. 30, 2008. Amended: Filed Dec. 16, 2013, effective June 30, 2014. *Original authority: 210.481, RSMo (1982), amended 1985 and 210.486 and 210.506, RSMo (1982), amended 1993.