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. (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.

   1. (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. 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.

1. 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 provide information about treatment alternatives or community supports where available.

1. 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.

1. (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.

2. (C) The screening—

   1. 1. Shall be conducted by trained staff;
   2. 2. Shall be responsive to the individual’s

request and needs; and

1. 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.

1. (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.

   1. (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. 1. Demographic and identifying infor-

mation;

1. 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;

1. 3. Presenting situation/problem and re-

ferral source;

1. 4. History of previous psychiatric and/or

substance abuse treatment including number and type of admissions;

1. 5. Health screening;
2. 6. Current medications and identifica-

tion of any medication allergies and adverse reactions;

1. 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;

1. 8. Current psychiatric symptoms;
2. 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;

1. 10. Current use of resources and ser-

vices from other community agencies;

1. 11. Personal and social resources and

strengths, including the availability and use of family, social, peer and other natural supports; and

1. 12. Multi-axis diagnosis or diagnostic

impression in accordance with the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association.

1. (B) Recommendations for specialized services may require more extensive diagnostic testing.
2. (C) Each person shall directly participate in developing his/her individualized treatment plan including, but not limited to, signing the treatment plan.

3. (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. 1. Measurable goals and outcomes;
   2. 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);

1. 3. Involvement of family, when indicat-

ed;

1. 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;

1. 5. Projected time frame for the comple-

tion of each goal/outcome; and

1. 6. Estimated completion/discharge date

for the level of care.

1. (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.

   1. (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. 1. Personal safety and protection from

harm;

1. 2. Severity of the psychiatric or sub-

stance abuse problem;

1. 3. Emotional and behavioral functioning

and need for structure;

1. 4. Social, family and community func-

tioning;

1. 5. Readiness and social supports for

recovery;

1. 6. Ability to avoid high risk behaviors;

and

1. 7. Ability to cooperate with and benefit

from the services offered.

1. (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.
2. (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.
3. (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.
4. (E) Services and supports shall be provided by staff with appropriate licenses or credentials.

1. (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.

2. (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.

   1. (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.
   2. (B) Efforts to contact the person shall be documented in the individual’s record.

3. (6) Reviewing Treatment Goals and Outcomes. Progress toward treatment goals and outcomes shall be reviewed on a periodic basis.

   1. (A) Each person shall directly participate in the review of their individualized treatment plan.
   2. (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.
   3. (C) The individualized treatment plan shall be updated and changed as indicated.

4. (7) Effective Practices. Service delivery shall be consistent with the current state of knowledge and generally accepted practices in the following areas:

   1. (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;
   2. (B) Provision of information and education about the person’s disorder(s), principles and 9 CSR 10-7

availability of self-help groups, and health and nutrition;

1. (C) Skill development which addresses clinical issues such as communication, stress reduction and management, conflict resolution, decision making, assertiveness and parenting;
2. (D) Promotion of positive family relationships; and
3. (E) Relapse prevention.

1. (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.

   1. (A) The department shall have authority in all matters subject to clinical utilization review including client eligibility and service definition, authorization and limitations.
   2. (B) Clinical utilization review may be required of any individual’s situation and needs prior to initial or continued service authorization.
   3. (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.

   4. (D) Clinical utilization review may include, but is not limited to, the following situations regarding a program:

      1. 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

1. 2. Compliance issues related to certifi-

cation standards or contract requirements that can reasonably be monitored through clinical utilization review.

1. (E) Staff who conduct clinical utilization review shall be credentialed with relevant professional experience.

1. (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.

   1. (A) A written discharge summary and, where applicable, an aftercare plan shall be prepared upon—

      1. 1. Transferring to a different provider;
      2. 2. Successfully completing treatment; or
      3. 3. Discontinuing further participation in

services.

1. (B) A discharge summary shall include, but is not limited to, the following:

   1. 1. Dates of admission and discharge;
   2. 2. Reason for admission and referral

source;

1. 3. Diagnosis or diagnostic impression;
2. 4. Description of services provided and

outcomes achieved, including any prescribed medication, dosage, and response;

1. 5. Reason for or type of discharge;
2. 6. Medical status and needs that may

require ongoing monitoring and support; and

1. (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.
2. (D) The organization shall consistently implement criteria regarding discharge or successful completion; termination or removal from the program; and readmission following discharge or termination.

1. (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.

2. (11) Organized Record System. The organization has an organized record system for each individual.

   1. (A) Records shall be maintained in a manner which ensures confidentiality and security.

      1. 1. The organization shall abide by all

local, state and federal laws and regulations concerning the confidentiality of records.

1. 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.

1. 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.

1. 4. The organization shall assure ready

access to the record by authorized staff and other authorized parties including department staff.

1. (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.
2. (C) There shall be documentation of services provided and results accomplished. Documentation shall be made with indelible ink or print.

3. (D) The documentation of services funded by the department or provided through a service network authorized by the department shall include the following:

   1. 1. Description of the specific service

provided;

1. 2. The date and actual time (beginning

and ending times) the service was rendered;

1. 3. Name and title of the person who ren-

dered the service;

1. 4. The setting in which the service was

rendered;

1. 5. The relationship of the services to the

individual treatment plan; and

1. 6. Description of the individual’s

response to services provided.

1. (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.

1. (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.

   1. (A) The organization shall maintain equipment and capabilities necessary for this purpose.

   2. (B) The organization shall submit information in a timely manner. Information regarding discharge or transfer shall be submitted within the following time frames:

      1. 1. Within fifteen (15) days of discharge

or transfer from residential or inpatient status;

1. 2. Within thirty (30) days of completing

outpatient treatment in a planned manner; and

1. 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. Amended: Filed Dec. 12, 2001, effective June 30, 2002. *Original authority: 630.050, RSMo 1980, amended 1993, 1995 and 630.055, RSMo 1980.