PURPOSE: This rule establishes criteria for the screening and follow-up activities of children less than seventy-two (72) months of age for lead poisoning in Missouri.

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. (1) Applicability. This rule applies to health care professionals, local public health agencies (LPHAs), and others who perform blood lead specimen collections and lead case management.

2. (2) Definitions. The following definitions shall apply in the interpretation and application of this rule and shall have the meaning stated below:

   1. (A) “Blood lead testing” shall mean the collection of a capillary or venous blood specimen for analysis of lead in an individual’s bloodstream;
   2. (B) “Capillary blood specimen” shall mean a procedure of lancing the skin and placing an approved lead collection device at the edge of the blood droplet to collect a sample of blood for analysis;
   3. (C) “Chelation” shall mean a treatment in which heavy metals are removed from the bloodstream by means of a medication that binds with metal ions;
   4. (D) “Confirmatory blood lead test” shall mean a blood lead test performed by venous blood specimen;
   5. (E) “Department” shall mean the Missouri Department of Health and Senior Services;
   6. (F) “Elevated blood lead (EBL)” shall mean a blood lead level equal to or greater than three and five-tenths micrograms per deciliter (≥3.5 mcg/dL);

   7. (G) “Follow-up testing” shall mean a blood lead test performed by venous blood specimen to—

      1. 1. Confirm an elevated capillary blood specimen result;

and/or

1. 2. Monitor patient treatment progression;
2. (H) “Health care professional” shall mean medical providers, including but not limited to physicians, nurses, pharmacists, and laboratory technicians;

3. (I) “Lead case manager” shall mean a licensed registered nurse, licensed medical or clinical social worker, or health educator who is supervised by a licensed medical professional and performs services for children with EBLs. The lead case manager is an agent of the—

   1. 1. Health plan for children with an EBL enrolled in MO

HealthNet or Medicaid; or

1. 2. Local Public Health Agency for children with an EBL

enrolled in Fee for Service Medicaid, a private insurance company, or who are uninsured;

1. (J) “Lead poisoning” shall mean a condition resulting from an EBL;
2. (K) “Primary care provider (PCP)” shall mean the health care professional who provides medical care services and/or serves as the contact for coordinating health care services associated with a lead poisoning case;
3. (L) “Treatment” shall mean the medical and/or health actions and intervention procedures to be followed as the result of an identified case of lead poisoning for the purposes of lowering and maintaining the child’s blood lead level below the blood lead reference value; and
4. (M) “Venous blood specimen” shall mean a procedure of puncturing a vein using a needle and an approved lead collection device to collect a sample of blood for analysis.

1. (3) Clinical Lead Education and Assessment.

   1. (A) The primary care provider shall perform a lead risk screening, at least annually for children ages six (6) months up to seventy-two (72) months.

   2. (B) The lead risk screening shall be conducted with the child’s parent/guardian and include—

      1. 1. Educational information regarding potential lead

sources and routes of exposure;

1. 2. Educational information regarding medical and

behavioral effects associated with lead exposure;

1. 3. Completing/updating the Healthy Children and Youth

1. (HCY) Lead Risk Assessment Guide (2023), incorporated by reference as published by the Missouri Department of Health and Senior Services, PO Box 570, Jefferson City, MO 65102-0570, and available by the department at https://health.mo.gov/ living/environment/lead/pdf/HCYLeadRiskAssessmentGuide. pdf. This rule does not incorporate any subsequent amendments or additions;

   1. 4. Assessing the child’s developmental status as it relates

to potential lead exposure;

1. 5. Assessing the child’s nutritional status; and
2. 6. The primary care provider shall offer testing to all

children under age four (4) years annually.

1. (4) A child’s blood lead level shall be tested with the consent of a parent or guardian when—

   1. (A) The child receives Medicaid benefits and—

      1. 1. Is twelve (12) months of age;
      2. 2. Is twenty-four (24) months of age; or
      3. 3. Has not previously tested;
   2. (B) The child has prior blood lead testing results that necessitate follow-up testing as laid out in section 701.342.4, RSMo, and subsection (6)(C) below;
   3. (C) The health care professional determines blood lead testing is warranted;
   4. (D) A “yes” or “unknown” response is documented on the HCY Lead Risk Assessment Guide;
   5. (E) There is a child under seventy-two (72) months of age residing in a household or has recently resided in a household of another lead-poisoned child in which the department is notified of a case of lead poisoning of; or
   6. (F) The child’s parent/guardian requests blood lead testing.

2. (5) Documentation of Blood Lead Testing or Refusal of Blood Lead Testing.

   1. (A) For blood lead testing, the health care professional shall document in the child’s medical record—

      1. 1. The lead risk screening for children ages six (6) months

up to seventy-two (72) months, at least annually;

1. 2. That testing was offered annually for all children under

the age of four (4) years;

1. 3. Indicate capillary and/or venous blood specimen;
2. 4. Collection dates; and
3. 5. Blood lead level results.

4. (B) Refusal of blood lead testing.

   1. 1. Only the parent/guardian of the child may refuse the

blood lead test.

1. 2. The refusal shall be in writing, signed by the parent/

guardian, and documented in the child’s medical record.

1. (6) Capillary Screening and Venous Blood Lead Testing.

   1. (A) An initial capillary or venous blood specimen shall be collected in accordance with section (4) of this rule.
   2. (B) A confirmatory blood lead specimen shall be collected when a capillary blood specimen result indicates an EBL.
   3. (C) Blood lead testing shall be in accordance with the Missouri Guidelines for the Assessment and Management of Childhood Lead Exposure (2024), incorporated by reference as published by the Missouri Department of Health and Senior Services, PO Box 570, Jefferson City, MO 65102-0570, and available at https://health.mo.gov/living/environment/ lead/pdf/recommended-actions-guide.pdf. This rule does not incorporate any subsequent amendments or additions.

2. (7) Blood Lead Specimen Collection and Laboratory Analysis.

   1. (A) Blood lead specimens shall be obtained using federal Clinical Laboratory Improvement Act (CLIA) certified collection devices and protocols unless specifically waived by CLIA.
   2. (B) Laboratories shall be CLIA certified to analyze venous blood specimens.
   3. (C) Health care professionals shall follow the certified laboratory’s criteria and protocols for collecting and submitting blood lead specimens.

3. (8) Reporting of Blood Lead Testing Results.

   1. (A) Health care professionals performing blood lead analysis shall report to the department in accordance with 19 CSR 20- 20.020.

4. (9) Medical Case Management Coordination of Childhood EBL Cases. For a child with an EBL, the—

   1. (A) Primary care provider (PCP) shall—

      1. 1. Refer to Missouri Guidelines for the Assessment and

Management of Childhood Lead Exposure;

1. 2. Provide the parent/guardian with lead poisoning

prevention education;

1. 3. Collaborate with LPHA lead case managers or MO

HealthNet lead case managers, environmental lead risk assessor assigned to the case, and Woman, Infants, and Children (WIC) staff as appropriate;

1. 4. If chelation therapy is initiated, coordinate with the—

   1. A. Lead risk assessor for a lead-safe discharge plan in

accordance with the Missouri Guidelines for the Assessment and Management of Childhood Lead Exposure; and

1. B. LPHA lead case manager or MO HealthNet lead case

manager for a health care discharge plan;

1. 5. Provide the parent/guardian with education regarding

the need for appropriate nutrition, hygiene, specific cleaning techniques, and safe methods for the removal or reduction of lead exposures;

1. 6. Provide clinical evaluation for complications of lead

ingestion/poisoning;

1. 7. Facilitate and coordinate medical treatment services;

and

1. 8. Refer child for specialty services, including but not

limited to WIC, First Steps, Head Start, and Missouri’s Parent Education Program, as appropriate;

1. (B) Lead case managers shall—

   1. 1. Refer to Missouri Guidelines for the Assessment and

Management of Childhood Lead Exposure;

1. 2. Coordinate efforts with the PCP in addressing, scheduling,

and documenting the dates and results of lead interventions as they relate to assessments and results of the child’s iron status, nutrition, development, behavior, cognitive, physical, and social needs; and

1. 3. Provide home or telehealth visits to complete health

questionnaires and provide nutritional and developmental assessments when a child has a blood lead level equal to or greater than ten micrograms per deciliter (≥10 mcg/dL); and

1. (C) Environmental lead risk assessors shall—

   1. 1. Refer to Missouri Guidelines for the Assessment and

Management of Childhood Lead Exposure; and

1. 2. Conduct an environmental risk assessment in accor-

dance with 19 CSR 30-70.620 when a child has a confirmed EBL equal to or greater than ten micrograms per deciliter (≥10 mcg/dL).

1. (10) Reporting Requirements of EBL Case Management Activities.

   1. (A) The PCP providing case management for a child with an EBL shall provide information regarding each case to the department, LPHA, MO HealthNet lead case manager, and the licensed lead risk assessor as appropriate.
   2. (B) The LPHA and/or MO HealthNet lead case manager shall document EBL case management information into the Missouri Department of Health and Senior Services electronic reporting system.

   3. (C) Lead case management information to be reported shall include—

      1. 1. Contact information of lead case manager;
      2. 2. Name of agency performing case management;
      3. 3. Child’s full legal name;
      4. 4. Child’s date of birth;
      5. 5. Child’s residential address including zip code;
      6. 6. Contact information of parent/guardian;
      7. 7. Contact information of health care professional;
      8. 8. Contact information of lead risk assessor;
      9. 9. Description of coordination of services;
      10. 10. Date(s) of blood lead testing;
      11. 11. Laboratory blood lead test results, including initial and

follow-up testing;

1. 12. Date of diagnosis;
2. 13. When chelation therapy is initiated, type of chelation

medication, duration and method of administration, date of hospital admission and discharge information/instructions;

1. 14. Interventions taken, including but not limited to par-

ent/guardian education, nutritional supplementation, iron sufficiency testing and treatment, referrals for specialty services, and other associated testing such as abdominal x-rays and evaluations performed including results;

1. 15. If applicable, date of transition of care due to change of

address or insurance coverage; and

1. 16. Date of and reason for closure of case management.

AUTHORITY: section 701.346, RSMo 2016.* Original rule filed Feb. 3, 2003, effective July 30, 2003. Rescinded and readopted: Filed Sept. 24, 2024, effective April 30, 2025.

*Original authority: 701.346, RSMo 2001.