PURPOSE: This rule establishes the basis for administering a personal care program for residents of community residential facilities licensed by the Department of Mental Health. (1) Mental Health Residential Personal Care services are medically oriented activities which assist a resident of a community residential facility licensed by the Department of Mental Health (DMH) with activities of daily living and which serve to maintain the resident’s highest physical and mental functional state in the least restrictive environment.

1. (A) A person eligible for Mental Health Residential Personal Care services includes any person who is determined eligible for Title XIX benefits from the Division of Family Services, assessed to be in need of personal care services as an alternative to institutional care, requires specialized personal care and procedures related to diminished mental or physical capacity and is a resident of an eligible provider facility. The recipient’s need for an institutional level of care shall be redetermined annually by staff and agents of the DMH, who shall also conduct an annual assessment of each recipient’s need for personal care assistance and, from the assessment, develop a plan of care.

2. (B) Mental Health Residential Personal Care services for each individual shall be specified in a plan of care approved by a physician and developed in conjunction with an individualized habilitation plan (IHP) or individualized treatment plan (ITP) developed by the DMH or its administrative agent. All personal care plans developed by the IHP and ITP teams may extend for one (1) year. Mental health residential personal care services include the following:

   1. 1. Basic service tasks include:

      1. A. Preparation of special diet;
      2. B. Assistance or direction with feed-

ing/eating;

1. C. Assistance or direction with dress-

ing/undressing;

1. D. Assistance or direction with hair

care or grooming, or both;

1. E. Assistance or direction with brush-

ing teeth and cleaning dentures;

1. F. Assistance or direction with shav-

ing;

1. G. Assistance or direction with nail-

care for individuals without contraindicating conditions;

1. H. Assistance or direction with

bathing, showering or bed baths;

1. I. Assistance or direction with men-

strual care;

1. J. Assistance or direction with apply-

ing nonprescription topical ointments/lotions to unbroken skin;

1. K. Assistance or direction with toilet-

ing, including assisting with a bedpan;

1. L. Assistance or direction with walk-

ing or using a wheelchair or walker;

1. M. Assistance or direction with ordi-

narily self-administered medication and manual assistance with oral medications in accordance with the provider facility’s license;

1. N. Assistance with passive range of

motion (nonresistive flexion of joint) in accordance with the plan of care, unless contraindicated by underlying joint pathology;

1. O. Assistance or direction with main-

tenance exercise programs post-surgery;

1. P. Assistance or direction with trans-

fers, with or without lift;

1. Q. Assistance or direction with using

adaptive equipment;

1. R. The making of beds/changing of

sheets with resident in or out of the bed;

1. S. Turning and positioning;
2. T. Individual instruction to become

self-sufficient in personal care;

1. U. Nonroutine, medically necessary

housework such as laundry and cleaning of the individual’s personal living space (bedroom and bath) required due to the individual’s inability to manage bodily functions, need for infection control, for example; or

1. V. Performance of essential errands

required for the health and maintenance of the individual, such as shopping for special nutritional supplements and picking up medications;

1. 2. Advanced service tasks include:

   1. A. Perform routine personal care for

persons with ostomies (including tracheostomies, gastrostomies and colostomies with well-healed stoma) and external, indwelling and suprapubic catheters which includes changing bags and soap and water hygiene around ostomy or catheter site;

1. B. Remove external catheters, inspect

skin and reapply same;

1. C. Administer prescribed bowel pro-

gram including use of suppositories and sphincter stimulation, and enemas (prepackaged only) with clients without contraindicating rectal or intestinal conditions;

1. D. Apply medicated (prescription)

lotions or ointments, and dry, nonsterile dressings to unbroken skin;

1. E. Apply nonsterile dressing to super-

ficial skin breaks or abrasions as directed by a registered nurse or licensed practical nurse; or

1. F. Use universal precautions as

defined by the Center for Disease Control;

1. 3. Registered nurse supervision required

for the provision of advanced services. A registered nurse shall—

1. A. Assist the habilitation/treatment

staff with the initial assessment and development of any initial plan of care containing advanced service tasks;

1. B. Evaluate the condition of the indi-

vidual at least monthly, except that this evaluation may be conducted by a licensed practical nurse under the registered nurse’s supervision. However, the registered nurse him/herself must evaluate the adequacy of the authorized services for each advanced personal care recipient at six (6)-month intervals; and

1. C. Train and certify an aide’s profi-

ciency in each advanced personal care task prior to the aide performing it on/for a recipient.

1. (2) Criteria for Providers of Mental Health Residential Personal Care Services.

   1. (A) Providers of Mental Health Residential Personal Care Services shall be regional centers or administrative agents of the DMH or facilities licensed by the DMH under 9 CSR 40-1, 9 CSR 40-2 and one (1) of the following: 9 CSR 40-4; 9 CSR 40-5; 9 CSR 40-6; 9 CSR 40-7; 9 CSR 40-8; 9 CSR 40-11; or 9 CSR 40-12. Providers other than regional centers or administrative agents of the DMH also shall have a community placement agreement or its equivalent in effect with the DMH.
   2. (B) Providers shall conduct or arrange training programs as required for licensure by the DMH and these programs shall include training in techniques and documentation of basic service tasks. In addition, a facility which accepts individuals in need of advanced service tasks, as defined in paragraph (1)(B)2. of this rule, shall provide or arrange for additional training related to those functions and shall employ, contract with or arrange for a registered nurse to assure that staff who perform advanced service tasks are trained and competent to perform them. All non-registered nurse or licensed practical nurse staff administering medication shall successfully complete a course on medication approved by the DMH as required for licensure.
2. (3) Required nurse supervision of Mental Health Residential Personal Care basic services shall consist of at least an annual on-site supervisory review for each client, performed by a registered nurse or by a licensed practical nurse under the registered nurses supervision. Any client for whom advanced service tasks are performed shall be evaluated monthly by either a registered nurse or a nurse under the registered nurses supervision, except that the evaluation must be performed by the registered nurse at least once every six
3. (6) months. Any provider not otherwise required by licensure or DMH community placement contract, or both, to have a regis- 13 CSR 70-91

tered nurse on staff or under contract may arrange with another enrolled provider, including facilities and agents of the DMH, to provide the required nurse supervision.

1. (4) Reimbursement for Mental Health Residential Personal Care services shall exceed neither one hundred percent (100%) of the average cost for care in a nursing facility for the same period of time, as determined by the Division of Medical Services, nor the provider’s usual and customary rate for personal care services as charged to the DMH. Payment shall be made at the lower of the provider’s billed charge or the maximum allowable fee per unit as determined by the Division of Medical Services. The maximum allowable fee per unit shall be an amount per day determined by the Division of Medical Services by dividing the average statewide monthly cost for care in a nursing facility, excluding intermediate care facilities for the mentally retarded, by the average number of days in a month. The provider’s billed charge for each recipient shall be determined as follows:

   1. (A) For each recipient the assessed monthly hours of basic and advanced levels of service required for that individual, plus any nurse visits which the facility will be required to provide for advanced tasks, times the fees per hour or per visit of service for each level and type of service as defined and determined by the Division of Medical Services, shall be summed by the DMH and compared to the average statewide monthly cost for care in a nursing facility determined by the Division of Medical Services and to the facility’s usual and customary monthly rate for personal care services as charged to the DMH. The lowest of these three (3) figures shall be the direct service cost for that recipient;
   2. (B) If no authorized registered nurse visits are needed and will be provided by an enrolled provider other than the facility itself, the direct service cost shall be converted to a charge per day for that recipient. If authorized registered nurse visits are needed, the direct service cost shall be reduced so that the sum of the direct service cost and the registered nurse visit cost exceeds neither the average statewide monthly cost for care in a nursing facility determined by the Division of Medical Services nor the facility’s usual and customary monthly rate for personal care services as charged to the DMH. Then the adjusted direct service cost shall be converted to a charge per day for that recipient; and
   3. (C) The DMH shall collect logs of service and invoices from the provider and pay the provider’s usual and customary rate. From the invoices and logs, the DMH shall determine the days of service delivered to each recipient and bill the Division of Medical Services for each day at the approved charge per day for each recipient. The DMH shall certify its cost to the Division of Medical Services and the Division of Medical Services shall reimburse the DMH only the federal share of the total payment amount.

AUTHORITY: sections 208.152, RSMo Supp. 1993, 208.153, RSMo Supp. 1991 and 208.201, RSMo 1987.* Emergency rule filed March 18, 1993, effective April 1, 1993, expired July 29, 1993. Emergency rule filed July 6, 1993, effective July 30, 1993, expired Nov. 26, 1993. Original rule filed March 16, 1993, effective Oct. 10, 1993.

*Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993; 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991; and 208.201, RSMo 1987.