PURPOSE: This rule describes the rights of individuals being served and grievance procedures in Alcohol and Drug Abuse Treatment Programs, Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), Compulsive Gambling Treatment Programs, Substance Abuse Traffic Offender Programs (SATOP), Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric Rehabilitation Programs (CPRP), and Psychiatric Outpatient Programs.

1. (1) General Policy and Practice. The organization shall demonstrate through its policies, procedures and practices an ongoing commitment to the rights, dignity, and respect of the individuals it serves. In addition to the requirements of this rule, the organization must also comply with 9 CSR 10-5.200 regarding protection from abuse and neglect and investigations of any such allegations.

2. (2) Information and Orientation. Immediately upon admission, each individual shall be informed and oriented as to what will happen as care and treatment are provided.

   1. (A) An individual who is admitted on a voluntary basis shall be expected to give written, informed consent to care and treatment.

   2. (B) The orientation given to each individual shall address service costs, availability of crisis assistance, rights, responsibilities, and grievance procedures.

      1. 1. Information regarding responsibilities

shall include applicable program rules, participation requirements or other expectations.

1. 2. Information regarding grievance pro-

cedures shall include how to file a grievance, time frames, rights of appeal, and notification of outcome.

1. 3. Each client shall be given the name,

address and phone number of the department’s client rights monitor and informed that the monitor may be contacted regarding a complaint of abuse, neglect or violation of rights.

1. (C) The orientation information shall be provided in written form using simple, straightforward language understandable to the individual and explained by staff as necessary.
2. (D) When appropriate, families receive information to promote their participation in or decisions about care and treatment.

1. (3) Rights Which Cannot Be Limited. Each individual has basic rights to humane care and treatment that cannot be limited under any circumstances.

   1. (A) The following rights apply to all settings:

      1. 1. To receive prompt evaluation, care

and treatment;

1. 2. To receive these services in the least

restrictive environment;

1. 3. To receive these services in a clean

and safe setting;

1. 4. To not be denied admission or ser-

vices because of race, gender, sexual preference, creed, marital status, national origin, disability or age;

1. 5. To confidentiality of information and

records in accordance with federal and state law and regulation;

1. 6. To be treated with dignity and

addressed in a respectful, age appropriate manner;

1. 7. To be free from abuse, neglect, cor-

poral punishment and other mistreatment such as humiliation, threats or exploitation;

1. 8. To be the subject of an experiment or

research only with one’s informed, written consent, or the consent of an individual legally authorized to act;

1. 9. To medical care and treatment in

accordance with accepted standards of medical practice, if the certified substance abuse or psychiatric program offers medical care and treatment; and

1. 10. To consult with a private, licensed

practitioner at one’s own expense.

1. (B) The following additional rights apply to residential settings, and where otherwise applicable, and shall not be limited under any circumstances:

   1. 1. To a nourishing, well-balanced, var-

ied diet;

1. 2. To attend or not attend religious ser-

vices;

1. 3. To communicate by sealed mail with

the department and, if applicable, legal counsel and court of jurisdiction; 9 CSR 10-7

1. 4. To receive visits from one’s attorney,

physician or clergy in private at reasonable times; and

1. 5. To be paid for work unrelated to treat-

ment, except that an individual may be expected to perform limited tasks and chores within the program that are designed to promote personal involvement and responsibility, skill building or peer support. Any tasks and chores beyond routine care and cleaning of activity or bedroom areas within the program must be directly related to recovery and treatment plan goals developed with the individual.

1. (4) Rights Subject to Limitation. Each individual shall have further rights and privileges, which can be limited only to ensure personal safety or the safety of others.

   1. (A) Any limitation due to safety considerations shall occur only if it is—

      1. 1. Applied on an individual basis;
      2. 2. Authorized by the organization’s

director or designee;

1. 3. Documented in the individual’s

record;

1. 4. Justified by sufficient documentation;
2. 5. Reviewed on a regular basis at the

time of each individualized treatment plan review; and

1. 6. Rescinded at the earliest clinically

appropriate moment.

1. (B) In all care and treatment settings, each individual shall have the right to see and review one’s own record, except that specific information or records provided by other individuals or agencies may be excluded from such review. The organization may require a staff member to be present whenever an individual accesses the record.

2. (C) The following additional rights and privileges apply to individuals in residential settings, and where otherwise applicable:

   1. 1. To wear one’s own clothes and keep

and use one’s own personal possessions;

1. 2. To keep and be allowed to spend a

reasonable amount of one’s own funds;

1. 3. To have reasonable access to a tele-

phone to make and to receive confidential calls;

1. 4. To have reasonable access to current

newspapers, magazines and radio and television programming;

1. 5. To be free from seclusion and

restraint;

1. 6. To have opportunities for physical

exercise and outdoor recreation;

1. 7. To receive visitors of one’s choosing

at reasonable hours; and

1. 8. To communicate by sealed mail with

individuals outside the facility. (5) Other Legal Rights. The organization shall ensure that all individuals have the same legal rights and responsibilities as any other citizen, unless otherwise limited by law.

1. (6) Access to Services. An individual shall not be denied admission or services solely on the grounds of prior treatment, withdrawal from treatment against advice, or continuation or return of symptoms after prior treatment.

2. (7) Grievances. The organization shall establish policies, procedures and practices to ensure a prompt, responsive, impartial review of any grievance or alleged violation of rights.

   1. (A) Reasonable assistance shall be given to an individual wishing to file a grievance.
   2. (B) The review shall be consistent with principles of due process.
   3. (C) The organization shall cooperate with the department in any review or investigation conducted by the department or its authorized representative.
3. (8) Surrogate Decision Maker. The organization’s policies, procedures and practices shall ensure an opportunity for the individual to designate or establish a surrogate decision maker, in the event the individual may become incapable of understanding or unable to communicate his or her wishes regarding the treatment plan or a proposed service.

4. (9) Practices to Promote Safety and Well- Being. The organization shall demonstrate a commitment to the safety and well-being of the individuals it serves. The organization’s policies, procedures and practices shall—

   1. (A) Promote therapeutic progress by addressing matters such as medication compliance, missed appointments, use of alcohol and drugs, and other program expectations or rules;
   2. (B) Encourage appropriate behavior by providing positive instruction and guidance; and
   3. (C) Ensure safety by effectively responding to any threats of suicide, violence or harm. Any use of seclusion or restraint shall be in accordance with 9 CSR 10-7.060 Behavior Management.

AUTHORITY: sections 630.050 and 630.055, RSMo 2000.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. *Original authority: 630.050, RSMo 1980, amended 1993, 1995 and 630.055, RSMo 1980. 9 CSR 10–7.030 Service Delivery Process and Documentation PURPOSE: This rule describes requirements for the delivery and documentation of services in Alcohol and Drug Abuse Treatment Programs, Comprehensive Substance Treatment and Rehabilitation (CSTAR), Compulsive Gambling Treatment Programs, Community Psychiatric Rehabilitation Programs (CPRP), and Psychiatric Outpatient Programs. (1) Screening. Each individual requesting services shall have prompt access to a screening in order to determine eligibility and to plan an initial course of action, including referral to other services and resources, as needed. (A) At the individual’s first contact with the organization (whether by telephone or face-to-face contact), any emergency or urgent service needs shall be identified and addressed. 1. Emergency service needs are indicat- ed when a person presents a likelihood of immediate harm to self or others. A person who presents at the program site with emergency service needs shall be seen by a qualified staff member within fifteen (15) minutes of presentation. If emergency service needs are reported by telephone, the program shall initiate face-to-face contact within one (1) hour of telephone contact or shall immediately notify local emergency personnel capable of promptly responding to the report. 2. Urgent service needs are indicated when a person presents a significant impairment in the ability to care for self but does not pose a likelihood of immediate harm to self or others. A person with urgent service needs shall be seen within forty-eight (48) hours, or the program shall make appropriate arrangements to provide for necessary supports until the person can be seen for screening. 3. Routine service needs are indicated when a person requests services or follow-up but otherwise presents no significant impairment in the ability to care for self and no apparent harm to self or others. A person with routine service needs should be seen as soon as possible to the extent that resources are available. (B) The screening shall include basic information about the individual’s presenting situation and symptoms, presence of factors related to harm or safety, and demographic and other identifying data. (C) The screening— 1. Shall be conducted by trained staff; 2. Shall be responsive to the individual’s request and needs; and 3. Shall include notice to the individual regarding service eligibility and an initial course of action. If indicated, the individual shall be linked to other appropriate services and resources in the community. (2) Assessment and Individualized Treatment Plan. Each individual shall participate in an assessment that more fully identifies their needs and goals and develops an individualized plan. The participation of family and other collateral parties (e.g., referral source, employer, school, other community agencies) in assessment and individualized plan development shall be encouraged, as appropriate to the age, guardianship, services provided or wishes of the individual. (A) The assessment shall assist in ensuring an appropriate level of care, identifying necessary services, and developing an individualized treatment plan. The assessment data shall subsequently be used in determining progress and outcomes. Documentation of the screening and assessment must include, but is not limited to, the following: 1. Demographic and identifying infor- mation; 2. Statement of needs, goals and treat- ment expectations from the individual requesting services. The family’s perceptions are also obtained, when appropriate and available; 3. Presenting situation/problem and re- ferral source; 4. History of previous psychiatric and/or substance abuse treatment including number and type of admissions; 5. Health screening; 6. Current medications and identifica- tion of any medication allergies and adverse reactions; 7. Recent alcohol and drug use for at least the past thirty (30) days and, when indicated, a substance use history that includes duration, patterns, and consequences of use; 8. Current psychiatric symptoms; 9. Family, social, legal, and vocation- al/educational status and functioning. The collection and assessment of historical data is also required, unless short-term crisis intervention or detoxification are the only services being provided; 10. Current use of resources and ser- vices from other community agencies; 11. Personal and social resources and strengths, including the availability and use of family, social, peer and other natural supports; and 12. Multi-axis diagnosis or diagnostic impression in accordance with the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. (B) Recommendations for specialized services may require more extensive diagnostic testing. (C) Each person shall directly participate in developing his/her individualized treatment plan including, but not limited to, signing the treatment plan. (D) The individualized treatment plan shall reflect the person’s unique needs and goals. The plan shall include, but is not limited to, the following: 1. Measurable goals and outcomes; 2. Services, supports and actions to accomplish each goal/outcome. This includes services and supports and the staff member responsible, as well as action steps of the individual and other supports (family, social, peer, and other natural supports); 3. Involvement of family, when indicat- ed; 4. Service needs beyond the scope of the organization or program that are being addressed by referral or services at another community organization, where applicable; 5. Projected time frame for the comple- tion of each goal/outcome; and 6. Estimated completion/discharge date for the level of care. (3) Ongoing Service Delivery. The individualized treatment plan shall guide ongoing service delivery. However, services may begin before the assessment is completed and the plan is fully developed. (A) Services shall be provided in accordance with applicable eligibility and utilization criteria. Criteria specified in program rules shall be incorporated into the treatment process, applied to each individual, and used to guide the intensity, duration, and type of services provided. Decisions regarding the level of care and the treatment setting shall be based on— 1. Personal safety and protection from harm; 2. Severity of the psychiatric or sub- stance abuse problem; 3. Emotional and behavioral functioning and need for structure; 4. Social, family and community func- tioning; 5. Readiness and social supports for recovery; 6. Ability to avoid high risk behaviors; and 7. Ability to cooperate with and benefit from the services offered. (B) Services shall be appropriate to the individual’s age and development and shall be responsive to the individual’s social/cultural situation and any linguistic/communication needs. (C) There is a designated staff member who coordinates services and ensures implementation of the plan. Coordination of care shall also be demonstrated when services and supports are being provided by multiple agencies or programs. (D) To the fullest extent possible, individuals shall be responsible for action steps to achieve their goals. Services and supports provided by staff shall be readily available to encourage and assist the individuals in their recovery. (E) Services and supports shall be provided by staff with appropriate licenses or credentials. (4) Crisis Assistance and Intervention. During the course of service delivery, ready access to crisis assistance and intervention is available, when needed. The organization shall provide or arrange crisis assistance twenty-four (24) hours per day, seven (7) days per week which is provided by qualified staff in accordance with any applicable program rules and includes face-to-face intervention, when clinically indicated. (5) Missed Appointments. Agencies shall establish policies and procedures, consistent with needs and requirements of clients, to contact persons who fail to appear at a scheduled program activity. (A) Such efforts should be initiated within forty-eight (48) hours, unless circumstances indicate a more immediate contact should be made due to the person’s symptoms and functioning or the nature of the scheduled service. (B) Efforts to contact the person shall be documented in the individual’s record. (6) Reviewing Treatment Goals and Outcomes. Progress toward treatment goals and outcomes shall be reviewed on a periodic basis. (A) Each person shall directly participate in the review of their individualized treatment plan. (B) The frequency of treatment plan reviews shall be based on the individual’s level of care or other applicable program rules. The occurrence of a crisis or significant clinical event may require a further review and modification of the treatment plan. (C) The individualized treatment plan shall be updated and changed as indicated. (7) Effective Practices. Service delivery shall be consistent with the current state of knowl- 9 CSR 10-7 edge and generally accepted practices in the following areas: (A) Support of personal recovery process which addresses clinical issues such as overcoming denial, recognizing feelings and behavior, encouraging personal responsibility, and constructively using leisure time; (B) Provision of information and education about the person’s disorder(s), principles and availability of self-help groups, and health and nutrition; (C) Skill development which addresses clinical issues such as communication, stress reduction and management, conflict resolution, decision making, assertiveness and parenting; (D) Promotion of positive family relationships; and (E) Relapse prevention. (8) Clinical Utilization Review. Services may be subject to clinical utilization review when funded by the department or provided through a service network authorized by the department. Clinical utilization review shall promote the delivery of services that are necessary, appropriate, likely to benefit the individual and provided in accordance with admission criteria and service definitions. (A) The department shall have authority in all matters subject to clinical utilization review including client eligibility and service definition, authorization and limitations. (B) Clinical utilization review may be required of any individual’s situation and needs prior to initial or continued service authorization. (C) Clinical utilization review shall include, but is not limited to, unusual patterns of service or utilization for individual clients based on periodic data analysis and norms compiled by the department. (D) Clinical utilization review may include, but is not limited to, the following situations regarding a program: 1. Unusual patterns of service or utiliza- tion, based on periodic data analysis and norms compiled by the department regarding the use of particular services and total service cost; and 2. Compliance issues related to certifi- cation standards or contract requirements that can reasonably be monitored through clinical utilization review. (E) Staff who conduct clinical utilization review shall be credentialed with relevant professional experience. (9) Discharge Summary and Aftercare Plan. Each individual shall be actively involved in planning for discharge and aftercare. The participation of family and other collateral parties (e.g., referral source, employer, school, other community agencies) in such planning shall be encouraged, as appropriate to the age, guardianship, service provided or wishes of the individual. (A) A written discharge summary and, where applicable, an aftercare plan shall be prepared upon— 1. Transferring to a different provider; 2. Successfully completing treatment; or 3. Discontinuing further participation in services. (B) A discharge summary shall include, but is not limited to, the following: 1. Dates of admission and discharge; 2. Reason for admission and referral source; 3. Diagnosis or diagnostic impression; 4. Description of services provided and outcomes achieved, including any prescribed medication, dosage, and response; 5. Reason for or type of discharge; 6. Medical status and needs that may require ongoing monitoring and support; and (C) An aftercare plan shall be completed prior to discharge. The plan shall identify services, designated provider(s), or other planned activities designed to promote further recovery. (D) The organization shall consistently implement criteria regarding discharge or successful completion; termination or removal from the program; and readmission following discharge or termination. (10) Designated or Required Instruments. In order to promote consistency in clinical practice, eligibility determination, service documentation, and outcome measurement, the department may require the use of designated instruments in the screening, assessment and treatment process. The required use of particular instruments shall be applicable only to those services funded by the department or provided through a service network authorized by the department. (11) Organized Record System. The organization has an organized record system for each individual. (A) Records shall be maintained in a manner which ensures confidentiality and security. 1. The organization shall abide by all local, state and federal laws and regulations concerning the confidentiality of records. 2. If records are maintained on comput- er systems, there must be a backup system to safeguard records in the event of operator or equipment failure and to ensure security from inadvertent or unauthorized access. 3. The organization shall retain individ- ual records for at least five (5) years or until all litigation, adverse audit findings, or both, are resolved. 4. The organization shall assure ready access to the record by authorized staff and other authorized parties including department staff. (B) All entries in the individual record shall be legible, clear, complete, accurate and recorded in a timely fashion. Entries shall be dated and authenticated by the staff member providing the service, including name and title. Any errors shall be marked through with a single line, initialed and dated. (C) There shall be documentation of services provided and results accomplished. Documentation shall be made with indelible ink or print. (D) The documentation of services funded by the department or provided through a service network authorized by the department shall include the following: 1. Description of the specific service provided; 2. The date and actual time (beginning and ending times) the service was rendered; 3. Name and title of the person who ren- dered the service; 4. The setting in which the service was rendered; 5. The relationship of the services to the individual treatment plan; and 6. Description of the individual’s response to services provided. (E) The record of each person served shall include documentation of screening, consent to treatment, orientation, assessment, diagnostic interview, individualized treatment plan and reviews, service delivery and progress reports, and discharge summary with plans for continuing recovery. Where applicable, the record shall also include documentation of referrals to other services or community resources and the outcome of these referrals, signed authorization to release confidential information, missed appointments and efforts to reengage the individual, urine drug screening or other toxicology reports, and crisis or other significant clinical events. (12) Service System Reporting. For those services funded by the department or provided through a service network authorized by the department, the organization shall provide information to the department which includes, but is not limited to, admission and demographic data, services provided, costs, outcomes, and discharge or transfer information. (A) The organization shall maintain equipment and capabilities necessary for this purpose. (B) The organization shall submit information in a timely manner. Information regarding discharge or transfer shall be submitted within the following time frames: 1. Within fifteen (15) days of discharge or transfer from residential or inpatient status; 2. Within thirty (30) days of completing outpatient treatment in a planned manner; and 3. Within one hundred eighty (180) days of the date of last outpatient service delivery if the individual discontinues services in an unplanned manner. AUTHORITY: sections 630.050 and 630.055, RSMo 2000.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. *Original authority: 630.050, RSMo 1980, amended 1993, 1995 and 630.055, RSMo 1980. 9 CSR 10–7.040 Quality Improvement PURPOSE: This rule describes requirements for quality improvement activities in Alcohol and Drug Abuse Programs, Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), Compulsive Gambling Treatment Programs, Substance Abuse Traffic Offender Programs (SATOP), Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric Rehabilitation Programs (CPRP), and Psychiatric Outpatient Programs. (1) The organization develops and implements a written plan for a systematic quality assessment and improvement process that is accountable to the governing body and addresses those programs and services certified by the department. (A) An individual or committee is designated as responsible for coordinating and implementing the quality improvement plan. (B) Direct service staff and consumers are involved in the planning, design, implementation and review of the organization’s quality improvement activities. (C) Records and reports of quality improvement activities are maintained. (D) The organization updates its plan for quality assessment and improvement at least annually. (2) Data are collected to assess quality, monitor service delivery processes and outcomes, identify opportunities for improvement, and monitor improvement efforts. (A) Data collection shall reflect priority areas identified in the plan. (B) Consumer satisfaction data shall be included as part of the organization’s quality assessment and improvement process. Such data must be collected in a manner that promotes participation by all consumers. (C) Data are systematically aggregated and analyzed on an ongoing basis. (D) Data collection analyses are performed using valid, reliable processes. (E) The organization compares its performance over time and with other sources of information. (F) Undesirable patterns in performance and sentinel events are intensively analyzed. (3) The organization develops and implements strategies for service improvement, based on the data analysis. (A) The organization evaluates the effectiveness of those strategies in achieving improved services delivery and outcomes. (B) If improved service delivery and outcomes have not been achieved, the organization revises and implements new strategies. (4) The department may require, at its option, the use of designated measures or instruments in the quality assessment and improvement process, in order to promote consistency in data collection, analysis, and applicability. The required use of particular measures or instruments shall be applicable only to those programs or services funded by the department or provided through a service network authorized by the department. AUTHORITY: sections 630.050 and 630.055, RSMo 2000.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. *Original authority: 630.050, RSMo 1980, amended 1993, 1995 and 630.055, RSMo 1980. 9 CSR 10–7.050 Research PURPOSE: This rule establishes standards and procedures for conducting research in Alcohol and Drug Abuse Programs, Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), Compulsive Gambling Treatment Programs, Substance Abuse Traffic Offender Programs (SATOP), Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric Rehabilitation Programs (CPRP), and Psychiatric Outpatient Programs. (1) General Policy. The organization shall have a written policy regarding research activities involving individuals served. The organization may prohibit research activities. (2) Policies and Practices in Conducting Research. If research is conducted, the organization shall assure that— (A) Compliance is maintained with all federal, state and local laws and regulations concerning the conduct of research including, but not limited to, sections 630.192, 630.199, 630.194, and 630.115, RSMo, 9 CSR 60-1.010 and 9 CSR 60-1.015; (B) Participating individuals are not the subject of experimental research without their prior written and informed consent or that of their parents or guardian, if minors; (C) Participating individuals understand that they may decide not to participate or may withdraw from any research at any time for any reason. (3) Notice to the Department. If any participating individual is receiving services funded by the department or provided through a service network authorized by the department, the organization shall assure that the research has the prior approval of the department. The organization shall immediately inform the department of any adverse outcome experienced by an individual served due to participation in a research project. AUTHORITY: sections 630.050 and 630.055, RSMo 2000.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. *Original authority: 630.050, RSMo 1980, amended 1993, 1995 and 630.055, RSMo 1980. 9 CSR 10–7.060 Behavior Management PURPOSE: This rule establishes requirements for the use of restraint, seclusion and time out in Alcohol and Drug Abuse Treatment Programs, Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), Compulsive Gambling Treatment Programs, Substance Abuse Traffic Offender Programs (SATOP), Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric Rehabilitation Programs (CPRP), and Psychiatric Outpatient Programs. (1) General Policy. Any behavior management methods used by an organization shall promote the rights, dignity and safety of individuals being served. An organization may prohibit by policy and practice the use of behavior management, including physical, mechanical and chemical restraint; seclusion; time out; and the use of behavior management plans for selected individuals. If any of these methods of behavior management are to be used within the organization, it shall 9 CSR 10-7 develop policies and procedures which define, describe and limit the conditions and circumstances of their use. (A) Organizations utilizing seclusion and restraint must obtain a separate written authorization from the appropriate division of the Department of Mental Health, in addition to other requirements of this rule. The department may issue such authorization on a timelimited basis subject to renewal. (B) The organization must prohibit by policy and practice: 1. Aversive conditioning of any kind. Aversive conditioning is defined as the application of startling, unpleasant or painful stimulus or stimuli that have a potentially noxious effect on an individual in an effort to decrease maladaptive behavior; 2. Withholding of food, water or bath- room privileges; 3. Painful stimuli; 4. Corporal punishment; and 5. Use of seclusion, restraint, time out, discipline or coercion for staff convenience. (C) Behavior management policies and procedures shall be: 1. Approved by the organization’s board of directors; 2. Made available to all program employees and providers; 3. Made available to the individuals served, their families and others upon request; 4. Developed with the participation of the individuals and, whenever possible, their family members or advocates, or both; and 5. Consistent with department rules regarding individual rights. (2) Seclusion and Restraint. (A) The organization shall assure that seclusion and restraint are only used when an individual’s behavior presents an immediate risk of danger to themselves or others and no other safe or effective treatment intervention is possible. It shall only be implemented when alternative, less restrictive interventions have failed. Seclusion and restraint is never a treatment intervention. It is an emergency/security measure to maintain safety when all other less restrictive interventions are inadequate. (B) Seclusion and restraint shall only be implemented by competent, trained staff. (C) The organization shall assure that seclusion and restraint is used only when ordered by a licensed, independent practitioner. Orders for seclusion and restraint must define specific time limits. Seclusion and restraint shall be ended at the earliest possible time. 1. Standing or pro re nata (PRN) orders for seclusion and restraint are not allowed. 2. An order cannot exceed four (4) hours for adults, two (2) hours for children and adolescents ages nine to seventeen (9–17), or one (1) hour for children under age nine (9). If nonindependent licensed staff initiates seclusion and restraint, an order must be obtained from a licensed, independent practitioner within one (1) hour. 3. Individuals in restraint shall be mon- itored continuously. Monitoring may be faceto-face by assigned staff or by audiovisual equipment. 4. Individuals in seclusion shall be visu- ally monitored at least every fifteen (15) minutes. 5. Individuals in seclusion and restraint are offered regular food, fluid and an opportunity to meet their personal hygiene needs no less than every two (2) hours. 6. The need for continuing seclusion and restraint shall be evaluated by and, where necessary, must be further ordered by a licensed, independent practitioner at least every four (4) hours for adults, two (2) hours for children and adolescents ages nine through seventeen inclusively (9–17), or one (1) hour for children under age nine (9). The evaluation shall be based on face-to-face observation and/or interview with the individual. 7. The organization’s clinical director or quality improvement coordinator shall review every episode of seclusion and restraint within seventy-two (72) hours. 8. Any incident of restraint shall be promptly reported to the person’s parent or legal guardian, when applicable. (3) Individualized Behavioral Management Plan. (A) Definitions. The following terms shall mean: 1. Behavioral management plan, array of positive and negative reinforcement to reduce unacceptable or maladaptive interactions and behaviors; 2. Time out, an individual’s voluntary compliance with the request to remove himself or herself from a service area to a separate location. (B) The need for a behavioral management plan shall be evaluated upon— 1. Any incident of seclusion or restraint; 2. The use of time-out two (2) or more times per day; or 3. The use of time-out three (3) or more times per week. (C) Behavioral plan shall include the input of the individual being served and family, if appropriate. (D) The plan shall identify what the individual is attempting to communicate or achieve through the maladaptive behavior before identifying interventions to change it. (E) The plan shall be reevaluated within the first seven (7) calendar days and every seven (7) days thereafter to determine whether maladaptive and unacceptable behaviors are being reduced and more functional alternatives acquired. AUTHORITY: sections 630.050 and 630.055, RSMo 2000.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. *Original authority: 630.050, RSMo 1980, amended 1993, 1995 and 630.055, RSMo 1980. 9 CSR 10–7.070 Medications PURPOSE: This rule describes training and procedures for the proper storage, use and administration of medications in Alcohol and Drug Abuse Treatment Programs, Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), Compulsive Gambling Treatment Programs, Substance Abuse Traffic Offender Programs (SATOP), Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric Rehabilitation Programs (CPRP), and Psychiatric Outpatient Programs. (1) General Guidelines, Policies and Practices. The following requirements apply to all programs, where applicable. (A) The organization shall assure that staff authorized by the organization and by law to conduct medical, nursing and pharmaceutical services do so using sound clinical practices and following all applicable state and federal laws and regulations. (B) The organization shall have written policies and procedures on how medications are prescribed, obtained, stored, administered and disposed. (C) The organization shall implement policies that prevent the use of medications as punishment, for the convenience of staff, as a substitute for services or other treatment, or in quantities that interfere with the individual’s participation in treatment and rehabilitation services. (D) The organization shall allow individuals to take prescribed medication as directed. 1. Individuals cannot be denied service due to taking prescribed medication as directed. If the organization believes that a prescribed medication is subject to abuse or could be an obstacle to other treatment goals, then the organization’s treatment staff shall attempt to engage the prescribing physician in a collaborative discussion and treatment planning process. If the prescribing physician is nonresponsive, a second opinion by another physician may be used. 2. Individuals shall not be denied ser- vice solely due to not taking prescribed medication as directed. However, a person may be denied service if he or she is unable to adequately participate in and benefit from the service offered due to not taking medication as directed. (2) Medication Profile. Where applicable, the individual’s record shall include a medication profile that includes name, age, weight, current diagnosis, current medication and dosage, prescribing physician, allergies to medication, non-prescription medication and supplements, medication compliance; and other pertinent information related to the individual’s medication regimen. (3) Prescription of Medication. If a program prescribes medications, there shall be documentation of each medication service episode including description of the individual’s presenting condition and symptoms, pertinent medical and psychiatric findings, other observations, response to medication, and action taken. (4) Medication Administration and Related Requirements. The following requirements apply to programs that prescribe or administer medication and to those programs where individuals self-administer medication under staff observation. (A) Staff Training and Competence. The organization shall ensure the training and competence of staff in the administration of medication and observation for adverse drug reactions and medication errors, consistent with each staff individual’s job duties. 1. Staff whose duties include the admin- istration of medication shall complete Level I medication aide training in accordance with 13 CSR 15-13.030. This requirement shall not apply to those staff who— A. Have prior education and training which meets or exceeds the Level I medication aide training hours and skill objectives; or B. Work in settings where clients self- administer their own medication under staff observation. 2. In residential programs, staff whose duties are limited to observing clients selfadminister their own medication or to documenting that medication is taken as prescribed shall consult a physician, pharmacist, registered nurse or reference material regarding the action and possible side effects or adverse reactions of each medication under their supervision. This consultation shall be documented. (B) Education. If medication is part of the treatment plan, the organization shall document that the individual and family member, if appropriate, understands the purpose and side effects of the medication. (C) Compliance. The program shall take steps to ensure that each individual takes medication as prescribed and the program shall document any refusal of medications. A licensed physician shall be informed of any ongoing refusal of medication. (D) Medication Errors. The program shall establish and implement policies defining the types of medication errors that must be reported to a licensed physician. (E) Adverse Drug Reactions. A licensed physician shall be immediately notified of any adverse reaction. The type of reaction, physician recommendation and subsequent action taken by the program shall be documented in the individual’s record. (F) Records and Documentation. The organization shall maintain records to track and account for all prescribed medications in residential programs and, where applicable, in nonresidential programs. 1. Each individual receiving medication shall have a medication intake sheet which includes the individual’s name, known allergies, type and amount of medication, dose and frequency of administration, date and time of intake, and name of staff who administered or observed the medication intake. If medication is self-administered, the individual shall sign or initial the medication intake sheet. 2. The amount of medication originally present and the amount remaining can be validated by the medication intake sheet. 3. Documentation of medication intake shall include over-the-counter products. 4. Medication shall be administered in single doses to the extent possible. 5. The organization shall establish a mechanism for the positive identification of individuals at the time medication is dispensed, administered or self-administered under staff observation. (G) Emergency Situations. The organization’s policies shall address the administration of medication in emergency situations. 1. Medical/nursing staff shall accept telephone medication orders only from physicians who are included in the organization’s list of authorized physicians and who are known to the staff receiving the orders. A physician’s signature shall authenticate verbal orders within five (5) working days of the receipt of the initial telephone order. 2. The organization may prohibit tele- phone medication orders, if warranted by staffing patterns and staff credentials. (H) Periodic Review. The organization shall document that individuals’ medications are evaluated by qualified staff at least every six (6) months to determine their continued effectiveness. (I) Individuals Bringing Their Own Medication. Any medication brought to the program by an individual served is allowed to be administered or self-administered only when the medication is appropriately labeled. (J) Labeling. All medication shall be properly labeled. Labeling for each medication shall include drug name, strength, dispense date, amount dispensed, directions for administration, expiration date, name of individual being served, and name of the prescribing physician. (K) Storage. The organization shall implement written policies and procedures on how medications are to be stored. 1. The organization shall establish a locked storage area for all medications that provides suitable conditions regarding sanitation, ventilation, lighting and moisture. 2. The organization shall store ingestible medications separately from noningestible medications and other substances. 3. The organization shall maintain a list of personnel who have been authorized access to the locked medication area and who are qualified to administer medications. (L) Inventory. Where applicable, the organization shall implement written policies and procedures for: 1. Receipt and disposition of stock phar- maceuticals must be accurately documented; 2. A log shall be maintained for each stock pharmaceutical that documents receipts and disposition; 3. At least quarterly, each stock phar- maceutical shall be reconciled as to the amount received and the amount dispensed; and 4. A stock supply of a controlled sub- stance must be registered with the Drug Enforcement Administration and the Missouri Department of Health, Bureau of Narcotics and Dangerous Drugs. (M) Disposal. The organization shall implement written procedures and policies for the disposal of medication. 1. Medication must be removed on or before the expiration date and destroyed. 2. Any medication left by an individual at discharge shall be destroyed within thirty (30) days. 3. The disposal of all medications shall be witnessed and documented by two (2) staff members. 9 CSR 10-7 AUTHORITY: sections 630.050 and 630.055, RSMo 2000.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. *Original authority: 630.050, RSMo 1980, amended 1993, 1995 and 630.055, RSMo 1980. 9 CSR 10–7.080 Dietary Service PURPOSE: This rule establishes dietary and food service requirements in Alcohol and Drug Abuse Treatment Programs, Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), Compulsive Gambling Treatment Programs, Substance Abuse Traffic Offender Programs (SATOP), Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric Rehabilitation Programs (CPRP), and Psychiatric Outpatient Programs. (1) Dietary Standards for Programs with an Incidental Dietary Component. (A) Programs defined as having only an incidental dietary component shall include: 1. A permanent residence serving no more than four (4) individuals; or 2. Programs and service sites that do not provide for the preparation, storage or provision of food including food brought by the individuals being served. (B) Programs and service sites defined as having only an incidental dietary component shall address diet and food preparation on a person’s individualized treatment plan, if it is identified as an area in need of intervention based on the assessment. (C) Where the program does not provide meals, but individuals are allowed to bring their own food, the following standards apply: 1. All appliances must be clean and in safe and proper operating condition; and 2. Hand washing facilities including hot and cold water, soap and hand drying means shall be readily accessible. (2) Dietary Standards for Programs and Treatment Sites with Minimal Dietary Component. (A) A program or service site shall be defined as having a minimal dietary component if one of the following criteria apply and it does not meet the definition of incidental dietary component: 1. It provides for the preparation, stor- age or consumption of no more than one (1) meal a day; or 2. The program or service site has an average length of stay of less than five (5) days. (B) The following standards apply for programs with a minimal dietary component: 1. Meals shall be nutritious, balanced and varied based on the latest edition of the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences. The practical application of these recommendations can be met by following the Dietary Guidelines for Americans and the Food Guide Pyramid of U.S. Department of Agriculture and the U.S. Department of Health and Human Services; 2. Special diets for medical reasons must be provided; 3. Menus shall be responsive to the cul- tural and religious beliefs of individuals; 4. Food will be served at realistic meal times in a pleasant, relaxed dining area; 5. Food will be stored safely, appropri- ately and sanitarily; 6. Food shall be in sound condition, free from spoilage, filth or other contamination and safe for human consumption; 7. All appliances shall be in safe and proper operating condition; 8. Food preparation areas will be cleaned regularly and kept in good repair. Utensils shall be sanitized according to Missouri Department of Health standards; 9. Hand washing facilities that include hot and cold water, soap and a means of hand drying shall be readily available; and 10. Paragraphs 5.–9. of this subsection shall be met if the site has a current inspection in compliance with 19 CSR 20-1.010. (3) Dietary Standards for Programs and Treatment Sites with a Substantial Dietary Component. (A) Programs with a substantial dietary component shall be defined as meeting one of the following criteria and are not the permanent residence of more than four (4) individuals: 1. Programs or treatment sites that serve more than one (1) meal per day; and 2. Programs or treatment sites with an average length of stay of over five (5) days. (B) Programs with a substantial dietary component shall have the following: 1. An annual inspection finding them in compliance with the provisions of 19 CSR 20-1.010. Inspections should be conducted by the local health department or by the Department of Health; 2. Those organizations arranging for provision of food services by agreement or contract with the second party shall assure that the provider has demonstrated compliance with this rule; 3. Programs providing meals shall implement a written plan to meet the dietary needs of the individuals being served, including: A. Written menus developed and annually reviewed by a registered dietitian or qualified nutritionist who has at least a bachelor’s degree from an accredited college with emphasis on foods and nutrition. The organization must maintain a copy of the dietitian’s current registration or the qualified nutritionist’s academic record. B. Any changes or substitution in menus must be noted; C. Menus for at least the past three (3) months shall be maintained; D. The written dietary plan shall insure that special diets for medical reasons are provided. Menu samples shall be maintained showing how special diets are developed or obtained; E. Menus shall be responsive to cul- tural and religious beliefs of individuals; 4. Meals shall be served in a pleasant, relaxed dining area; and 5. Hand washing facilities including hot and cold water, soap and hand drying means shall be readily accessible. AUTHORITY: sections 630.050 and 630.055, RSMo 2000.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. *Original authority: 630.050, RSMo 1980, amended 1993, 1995 and 630.055, RSMo 1980.