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 full-time 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;

1. (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 resi-

dential 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 con-

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

2. (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 indi-

vidual, 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. 13 CSR 35-71

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 iso-

lation, 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 observa-

tions 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 con-

structed 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 con-

structed to allow for both visual and auditory supervision of a child;

1. B. An isolation room shall have one

1. (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, ven-

tilation, 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 tamperresistant, protective casing;

1. J. The room shall be properly heated,

cooled, and ventilated;

1. K. Normal toileting and bathing facil-

ities 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.