PURPOSE: This rule describes the certification requirements, service delivery process, and staff qualifications for substance use disorder treatment programs within Department of Corrections’ (DOC) institutions, referred to in this rule as Institutional Treatment Centers (ITCs).

1. (1) Definitions. The following definitions apply to terms used in this rule.

   1. (A) Behavior contract—therapeutic intervention consisting of a written, time limited specific plan of behavior to be followed by the offender that is designed to assist him/her in modifying inappropriate behavior.
   2. (B) Cardinal Rules—prohibitions that maintain the integrity of the treatment community or unit, protect against dangers to the community or unit, and ensure physical and psychological safety for all offenders and staff. Cardinal Rules include: all DOC major conduct rules 1-9 and minor assault; possession/use of an intoxicating substance; threats; sexual misconduct; theft; fighting; gambling; destroying property; and any written or verbal acts of discrimination to include race, creed, or gender.
   3. (C) Clinical Director—staff member responsible for supervising the clinical services and/or programs of a DOC substance use disorders treatment center or ITC.
   4. (D) Counseling services—address offender needs in an individual or group setting, provided by staff employed as treatment professionals who are supervised by experienced and/or credentialed supervisors. Counseling services involve processing of information in a collaborative fashion.
   5. (E) Group counseling—face-to-face, goaloriented therapeutic interaction between a treatment professional and no fewer than three (3), and no more than fifteen (15) offenders.
   6. (F) Individual counseling—structured, goal-oriented therapeutic process in which the offender interacts on a face-to-face basis with a treatment professional to address problems identified on their individual treatment plan.
   7. (G) Individual treatment plan—structured and individualized plan that directs an offender’s treatment. The plan includes assessment information and the offender’s needs, problem areas, and concerns to develop goals, objectives, and interventions to address the areas identified.
   8. (H) Lack of therapeutic gain—an offender’s consistent or serious failure to apply reasonable effort and attainment of therapeutic goals as documented by the substance use disorders treatment team. An offender must show a continued pattern of negative behavior in areas such as therapeutic programming engagement, program expectations, and/or institutional rule violations. All levels of therapeutic intervention are utilized prior to an unsuccessful exit for lack of therapeutic gain.
   9. (I) Offender Management Team (OMT)— therapeutic in nature and utilized to address an offender’s problematic actions in an attempt to re-direct the offender towards appropriate behavior so he/she can be successful in treatment. The team consists of at least two (2) staff members, one (1) of which is a treatment staff member, and one (1) from classification, probation and parole, or custody.
   10. (J) Program Review Committee (PRC)— committee that evaluates an offender’s progress in treatment and recommends continuation or exit from the program. The committee consists of at least three (3) staff members from the following areas: treatment, classification, custody, and/or probation and parole, as available. At least one (1) treatment staff member must be present. The chairperson is a substance use disorders unit supervisor, a functional unit manager, or a DOC (non-contracted) clinical director. A PRC is therapeutic in nature and addresses an offender’s behavior and progress in the program. The PRC can be utilized to reengage an offender in the program, or to remove an offender via a no-fault or unsuccessful exit, if reengagement is determined not to be an option.
   11. (K) Progress notes—entries by appropriate treatment staff documenting the offender’s activities, progress toward achievement of the substance use disorders treatment plan goals, treatment contacts, significant events, services delivered, and future follow up.
   12. (L) Recovery-oriented therapeutic class— didactic presentation of general information regarding substance use disorders, criminality and related topics, and the practical application of the information through group discussion, and as directed by the offender’s treatment plan. The number of participants shall not exceed the comfort and safety level of the room utilized.
   13. (M) Recovery support groups—voluntary associations of people who share a common desire to overcome a substance use disorder. Different groups use different methods, and the approaches range from completely secular to explicitly spiritual. In an ITC, abstinence from substance use is a requirement and expectation. Programs that provide spiritually-based groups such as Alcoholics Anonymous and Narcotics Anonymous must provide secular options as well.
   14. (N) Structured recreational activity— scheduled and organized recreational activities that do not include a classroom/process component.
   15. (O) Substance use disorders education—a therapeutic service designed to provide information on topics regarding substance use, addictions, and recovery. The information is provided to offenders through didactic and interactive educational methods and may be reinforced through homework assignments.
   16. (P) Substance use disorders treatment file—the record of information established by assigned treatment staff pertaining to an offender’s progress during participation in a substance use disorders treatment program.
   17. (Q) Substance use disorders treatment plan—document recording each offender’s individualized treatment goals and objectives, interventions to address the objectives, and his/her progress in the ITC.
   18. (R) Substance use disorders treatment team—a group of professionals comprised of contracted treatment staff, DOC treatment staff, and other DOC staff who work collaboratively to guide the offender’s progress on his/her substance use disorders treatment plan and within the ITC.
   19. (S) Therapeutic community—residential substance use disorders treatment model in which participants are designated as families and/or communities. Staff members are considered rational authorities and the community itself is considered the primary agent of change.
   20. (T) Therapeutic family—the institutional therapeutic community participants.
   21. (U) Therapeutic gain—achievement of therapeutic goals and objectives established by the treatment plan, and growth toward responsible behavior as indicated by active participation, following rules, and personal application of ITC principles and concepts.
   22. (V) Therapeutic interventions—tools for bringing negative or positive behaviors and attitudes to the awareness of an offender’s therapeutic family to assist him/her in achieving and/or reinforcing therapeutic goals and growth toward responsible behaviors.
   23. (W) Therapeutic services—have defined therapeutic benefit, are led or facilitated primarily by treatment staff, and may be provided in collaboration with other DOC or contracted staff.
   24. (X) Treatment plan review—documented discussion between a treatment professional and the offender regarding specific treatment plan goals and objectives and progress made toward the goals and objectives. Written changes to the treatment plan are considered treatment plan updates. This is a component of each one-on-one (individual) counseling contact.
   25. (Y) Treatment plan update—occurs in the course of a treatment plan review with the offender when a change to the plan is appropriate, such as the addition of new goals or objectives and closing of completed goals and objectives.

2. (2) Program Certification and Applicable Regulations. Institutional Treatment Centers (ITCs) applying for program certification from the Department of Mental Health (department) shall comply with requirements set forth in 9 CSR 10-7.130. Other department regulations applicable to certified ITCs, in full or in part, are specified in this rule.

   1. (A) ITCs shall comply with the following department regulations without modification:

      1. 1. 9 CSR 10-7.030; and
      2. 2. 9 CSR 10-7.140.

   2. (B) ITCs shall comply with the following department regulations as specified:

      1. 1. 9 CSR 10-7.010, with the exception

of subsection (6)(B);

1. 2. 9 CSR 10-7.020, with the exception

of paragraphs (3)(A)10., (3)(B)5., and (4)(C)1.;

1. 3. 9 CSR 10-7.040, with the exception

of subsection (2)(A);

1. 4. 9 CSR 10-7.110, with the exception

of subsection (2)(C), paragraph (2)(F)1., and section (4); and

1. 5. 9 CSR 30-3.032, subject to the mod-

ifications specified in this rule.

1. (C) The following department regulations are waived for ITCs unless it is determined a specific requirement is applicable due to the unique circumstances and service delivery methods of a particular ITC:

   1. 1. 9 CSR 10-5.190;
   2. 2. 9 CSR 10-5.200;
   3. 3. 9 CSR 10-7.035;
   4. 4. 9 CSR 10-7.050;
   5. 5. 9 CSR 10-7.060;
   6. 6. 9 CSR 10-7.070;
   7. 7. 9 CSR 10-7.080, the application for

program certification must include documentation verifying the ITC’s dietary staff, services, and facility comply with applicable DOC dietary requirements;

1. 8. 9 CSR 10-7.090;
2. 9. 9 CSR 10-7.100;
3. 10. 9 CSR 10-7.120, the application for

program certification must include documentation verifying the ITC complies with DOC safety requirements including fire, emergency preparedness, security, cleanliness, and comfort; and

1. 11. 9 CSR 30-3.100.

1. (3) ITC Services. Services delivered within an ITC shall provide a structured array of therapeutic processes and interventions to affect cognitive and behavioral changes for individuals who are incarcerated. Services shall address the individual’s substance use disorder(s) and/or addiction and criminality.

   1. (A) A treatment week for each individual in the program consists of a minimum of twenty-five (25) hours of treatment services, regardless of program length, and includes, at a minimum:

      1. 1. Two (2) hours of group counseling

provided to groups of offenders, in addition to the individual counseling contact specified in paragraph (3)(B)5. of this rule;

1. 2. Eighteen (18) hours of therapeutic

services; and

1. 3. Five (5) hours of adjunctive services.

2. (B) Counseling services identify individual needs and group needs of offenders. Services are provided by staff employed as treatment professionals who are supervised by experienced and/or credentialed supervisors as specified in section (8) of this rule. Regardless of program length, counseling services for each offender shall include:

   1. 1. An initial individual counseling con-

tact within seven (7) calendar days of program admission;

1. 2. An assessment and assessment inter-

view within ten (10) calendar days of program admission;

1. 3. Treatment planning and treatment

planning follow-up sessions. The initial treatment plan must be completed within ten (10) calendar days of program admission, and treatment plan reviews shall occur at fortyfive (45) day intervals at a minimum;

1. 4. A minimum of two (2) hours of group

counseling per week, and the maximum group size is fifteen (15) individuals;

1. 5. A minimum of one (1) contact hour

of individual counseling per month; and

1. 6. Mental health counseling and group

counseling, as applicable.

1. (4) Therapeutic Services. Therapeutic services have defined therapeutic benefit and are led or facilitated primarily by treatment professionals. Services may be provided in collaboration with other DOC staff or contracted staff.

   1. (A) Therapeutic services include—

      1. 1. Recovery-oriented therapeutic class-

es, a minimum of four (4) hours per week, to be counted toward the therapeutic activities allowance;

1. 2. Education classes or classroom

videos related to substance use disorders with clarifying discussions and/or assignments, with no more than eight (8) hours per week to be counted toward the therapeutic activities allowance;

1. 3. Therapeutic community groups with

treatment staff physically present;

1. 4. Impact of Crime on Victims Classes

(IC/VC) with interdisciplinary facilitation;

1. 5. Anger management with interdiscipli-

nary facilitation;

1. 6. DOC-approved cognitive skills pro-

gram with interdisciplinary facilitation;

1. 7. Employment skills and/or life-skills

classes;

1. 8. Waysafe and/or other health-related

HIV/hepatitis classes;

1. 9. Recovery support groups facilitated

by staff or an approved DOC volunteer;

1. 10. Case management for release plan-

ning;

1. 11. Reentry services and groups;
2. 12. Work release hours, if accompanied

by journaling and/or homework assignments;

1. 13. Institutional jobs, if accompanied by

journaling and/or homework assignments;

1. 14. Therapeutic community job assign-

ment at or above coordinator level;

1. 15. High School Equivalency (HSE),

Adult Education Literacy (AEL), and/or vocational classes, if accompanied by journaling and/or homework assignments;

1. 16. Structured recreational activities

with staff supervision; and

1. 17. Graduation/program completion

ceremony.

1. (5) Adjunctive Services. Adjunctive services provide potential benefit for the individual, but have no treatment or case management staff supervision or involvement.

   1. (A) Adjunctive services shall include:

      1. 1. Mentoring (receiving or providing);
      2. 2. Tutoring (receiving or providing);
      3. 3. Films with therapeutic benefit with-

out follow-up discussion or assignment;

1. 4. Recovery support groups facilitated

exclusively by offenders;

1. 5. Restorative justice activities;
2. 6. Temporary work assignments; and
3. 7. Study hall, with no more than one (1)

hour per week to be counted toward the adjunctive activities allowance.

1. (6) Admission and Exit Criteria. This section provides guidance related to admission and exit criteria for ITC programs. Placement, admission, and program exit for offenders is determined by policy and standard protocol for Missouri correctional facilities and substance use disorder services. The Assistant Division Director, Division of Offender Rehabilitative Services, Substance Use and Recovery Services, has final approval and 9 CSR 30-3

authority on all matters related to program admission, placement, and exit. (A) Admission to an ITC program is based on— 1. A court order for institutional sub- stance use disorders treatment; 2. A probation and parole referral for institutional substance use disorders treatment; or 3. The results of a professional sub- stance use disorders assessment and classification instrument indicating the need for treatment. (B) Exit from an ITC program may occur based on the following: 1. Successful program exit—indicated when an offender has met program expectations by remaining in the treatment program for the duration of the assigned treatment episode as defined by governing laws and policies, and has successfully completed the objectives on their individualized treatment plan. The quality of the completion is to be described in the offender’s exit/discharge summary and in any report initiated by the treatment provider to probation and parole and/or to the court; 2. No fault program exit/transfer—indi- cated when an offender’s continued participation in the program is no longer feasible due to factors out of his/her control. Examples of no fault program exit/transfer include protective custody needs, increases in classification scores, or a need for federally-mandated services such as medical, mental health, and special education that exceed the capability of institutional staff to provide; and 3. Unsuccessful program exit—indicated when an offender poses a true threat to other offenders and/or staff, endangers the security of the treatment unit, causes significant and repeated disruptions, and/or endangers the program success of other offenders. Due to the important role of treatment in recovery from substance use disorders and criminal behavior, unsuccessful program exits should be held to a minimum. A. Due to the significant conse- quences that may follow an offender’s unsuccessful exit from an ITC, the minimal efforts, guidelines, and protocols explained in section (14) of this rule shall be followed and documented. B. When determined necessary, offenders enrolled in an ITC may receive an unsuccessful program exit in accordance with DOC policies and procedures. (7) Service Delivery and Documentation Requirements. All services provided for offenders shall be delivered and documented as specified in this rule. (A) An assessment must be completed within ten (10) calendar days of the offender’s admission to the ITC. If an assessment was completed within the twelve (12) months prior to the individual’s admittance to the ITC and it is obtained for the treatment file, a new assessment may not be necessary. Documentation of the assessment must be included in the treatment and classification file (record) of each offender and include verification that the assessment report was reviewed with the individual. Documentation remains the same regardless of when the assessment was completed or obtained. The assessment shall include, but is not limited to: 1. Demographic and identifying infor- mation for the offender; 2. Statement of needs, goals, and treat- ment expectations from the offender; 3. Presenting situation/problem and referral source; 4. History of previous psychiatric and/or substance use disorders treatment, including number and type of admissions; 5. Alcohol and drug use for the thirty (30) days prior to current incarceration, during incarceration, and substance use history including duration, patterns, and consequences of use; 6. Current psychiatric symptoms; 7. Family, social, legal, vocational/edu- cational status, and functioning, including history, if appropriate; 8. Personal and social resources and strengths, including the availability and use of family, social, peer, and other natural supports; 9. Stage of motivation; and 10. Screening using a DOC-approved instrument. (B) An individualized treatment plan shall be developed based on the results of the offender’s assessment. The plan is developed in collaboration with the offender within ten (10) working days of his/her admission to treatment. The treatment plan must reflect the offender’s unique needs and goals. Documentation of the treatment plan interview shall be made in each offender’s treatment record and include his/her involvement in the treatment planning process. The treatment plan shall be signed by the staff person and the offender and shall include, but is not limited to: 1. Goals and measurable objectives; 2. Interventions to accomplish each objective—documentation includes specific supports, actions, and services, and identifies the staff member responsible for providing the services/supports and action steps of the offender and members of his/her support system (such as family, social, peer, and other natural supports); 3. Involvement of family, when possible; 4. Service needs beyond the scope of ITC staff that are provided or assisted by other disciplines within the institution or through referral to other community resources and organizations, as applicable; 5. Projected time frame for the comple- tion of each objective; and 6. Estimated program completion/exit date. (C) Review of the treatment plan, objectives, and program progress shall be conducted and documented in the offender’s treatment file a minimum of every forty-five (45) days. Each offender shall actively participate in the review of his/her treatment plan. The plan and objectives shall be updated, as appropriate, to reflect individual needs, accomplishments, and progress. (D) A discharge summary shall be completed and entered in the treatment file within three (3) working days of an offender’s transfer or exit from the ITC. The discharge summary shall include, but is not limited to: 1. ITC admission and exit dates; 2. Reason for admission and referral source; 3. Assessment summary; 4. Statement of the problem; 5. Description of treatment services pro- vided and progress achieved; 6. Continuing care recommendations; 7. Reason and type of treatment pro- gram exit; 8. Known medical and/or mental health needs that may require ongoing support services, if available; and 9. Other service needs, if applicable. (E) A relapse prevention/continuing care plan shall be completed with the offender and specific resources provided to him/her prior to exit from the ITC. The plan shall identify services, designated provider(s) of support services, and other planned activities designed to promote continuing recovery. (F) Individual counseling contacts shall be documented in progress notes and include, at a minimum: 1. Description of the specific service provided; 2. The date and actual time (beginning and ending times) the contact was rendered; 3. Name and title of the treatment pro- fessional who rendered the service; 4. Reference to specific objectives addressed within the individualized treatment plan; 5. Description of the individual’s response to services provided; and 6. Planned follow-up by the treatment professional and the offender. (G) Individual treatment records shall be maintained by staff of the ITC and delivery of services must be recorded in a timely manner, as follows: 1. All entries are legible, clear, com- plete, and accurate; 2. All entries are dated and authenticat- ed by the treatment professional providing the service, including name, title, and credential(s), as applicable; 3. Errors are indicated in the paper copy by the staff member marking through the error with a single line, initialing, and dating the correction; 4. Language is clear and concise, so it is readily understood by anyone reading the document, even if they are not familiar with the environment, profession, or discipline of substance use disorders or corrections; and 5. Acronyms, abbreviations, profession- al slang, or jargon is not used. (H) All required documentation and forms shall be signed and dated by staff and the offender, as indicated. Documentation in the offender’s record shall include, but is not limited to, the following: 1. Forms related to program orientation, with signed acknowledgement of receipt by the offender, including: A. Consent to treatment; B. Rights and responsibilities; C. Institutional treatment contract; D. Authorization for disclosure of medical/health information; E. Grievance process; F. Handbook; G. Receipt of orientation; and H. Verification of program options for self-help groups and information about the availability of self-help groups and related materials; 2. Assessment summary, with offend- er’s signature; 3. Individualized treatment plan, with offender’s signature; 4. Treatment plan reviews, with offend- er’s signature; 5. Services delivered; 6. Treatment progress and any develop- ment, crisis, or significant incident occurring during the treatment episode; 7. Referrals, if made while the offender is in the ITC, including applicable release of information, as needed, and any known outcomes; 8. Missed appointments and efforts to reengage; 9. Behavior contract, effort, and out- comes; 10. Conduct violation reports and applied sanctions; 11. Offender Management Team (OMT), Program Review Committee (PRC), and all significant therapeutic staffing; and 12. Discharge summary, with plan for continuing recovery to address ongoing needs, as identified. (I) A schedule of program services, groups, and other structured activities shall be maintained by the ITC and be readily available to offenders on site. 1. A program log shall be maintained to record any cancelled sessions, including the name, time, date, and reason for the cancellation. 2. A supervisor or program manager shall review the program log on a monthly basis, at a minimum. 3. A record of small process groups shall be maintained indicating beginning and ending times, individuals in attendance, and the name of the staff member providing the service. This record may be retained electronically. (8) Staff Requirements. This section identifies the qualifications, ratios, and training requirements for staff employed as treatment professionals in an ITC. (A) All staff who have direct contact with offenders must be at least eighteen (18) years of age and, at the time of their application for employment with DOC, verify and document they meet the qualifications of their respective profession and the specific requirements of DOC. 1. Interns and volunteers must be approved in accordance with DOC policies and procedures. (B) At a minimum, staff must meet Missouri Office of Administration (OA) requirements for a position specified in subsection (C) of this section or as designated by contract. OA requirements are available online at: http://oa.mo.gov/personnel/classificationspecifications. (C) ITC staff positions are designated as follows: 1. Addiction Counselor I (AC I); 2. Addiction Counselor II (AC II); 3. Addiction Counselor III (AC III); 4. Treatment Unit Supervisor (TUS); 5. Corrections Manager Band I; 6. Corrections Manager Band II; and 7. Interns and volunteers, as defined in DOC policy. (D) Organizations that are contracted by DOC to provide services in an ITC shall ensure staff are qualified in accordance with the positions identified in subsection (C) of this section. (E) Group counseling shall be provided by treatment professionals trained in substance use disorders treatment. Newly employed treatment staff shall be observed by and receive instructive feedback from an experienced facilitator for no less than eight (8) hours prior to facilitating group sessions. (F) Substance use disorders education and recovery-oriented therapeutic classes shall be provided by staff who possess the education, background, or experience to deliver the information, demonstrate competency and skill in educational techniques, are knowledgeable about the topic being presented, and are present with offenders throughout the education process. (G) Staff providing direct clinical services for offenders shall have a staff-to-offender ratio not to exceed one (1) staff person per twenty-five (25) offenders, or as specified by contract. Interns and volunteers may be used to provide rehabilitation services, but cannot be included in the required staff-to-offender ratio. (H) All staff providing services in an ITC must receive training to ensure services are provided ethically and effectively in a competent, safe, and secure manner. 1. At a minimum, newly hired staff must receive a program orientation specific to the job function(s) for which he/she was hired. When possible, a staff mentor shall be provided to new staff for guidance and to answer job-related questions. 2. A clinical training plan shall be devel- oped for each ITC staff position. The plan shall be maintained in the staff person’s training file and be updated yearly to reflect completion of the ITC training requirements. 3. All staff having direct contact with offenders shall complete a minimum of twenty (20) hours of in-service training per year. At least ten (10) of those hours must relate to substance use disorders treatment services and skills. Required annual training shall include: A. Ethics and professional bound- aries; and B. Documentation. 4. Training related to substance use dis- orders treatment or job-related skills may include, but is not limited to: A. Non-adversarial confrontation; B. Group counseling; C. Individual counseling; D. Motivational interviewing; E. Co-occurring substance use and mental health disorders; F. Avoiding job burnout, re-energiz- ing, and self-wellness; G. The four (4) domains—screening, assessment, and engagement; treatment planning, collaboration, and referral; counseling; and professional and ethical responsibility; H. Therapeutic continuum of inter- vention; and I. Medication. (I) All staff must attend Basic Training at the DOC Training Academy as required by DOC policy. Staff must also attend any required introductory level counseling skills training within the first six (6) months of employment, or otherwise specified in contract, or as directed by training plans recom- 9 CSR 30-3 mended by the Assistant Division Director, Division of Offender Rehabilitation Services, Substance Use and Recovery Services or his/her designee. (J) A training record that is separate from the personnel file must be maintained for all staff who deliver substance use disorders treatment services in an ITC. The training record must contain a complete record of all training completed and the employee’s credentials. At a minimum, the record shall include documentation of the employee’s— 1. Education, current and valid creden- tials/licensure, as applicable; 2. Completion of DOC Basic Training; 3. Completion of facility and program orientation; 4. Training and development plan (non- certified or non-licensed counselors); 5. In-service and outside training; 6. Completion of cognitive skills facili- tation training, as required by DOC; 7. Completion of Prison Rape Elimina- tion Act training; 8. Completion of cyber-security train- ing; 9. Completion of annual discrimination, harassment, and retaliation training; and 10. Completion of any other training required by DOC. (9) Staff Supervision Requirements. This section includes the staff supervision requirements for ITCs. (A) Treatment professionals providing any ITC service must receive continuous supervision from a trained treatment professional supervisor(s), preferably an individual who is a credentialed or licensed professional. (B) All treatment professional functions shall be performed with the knowledge, oversight, guidance, and full professional responsibility of the supervisor(s). The treatment supervisor shall maintain a record of their supervision activities. Supervisors, or a credentialed designee, must countersign specified documentation in the offender treatment file when it is entered by a non-credentialed addiction counselor, including, but not limited to: 1. Assessments; 2. Treatment plans and treatment plan updates; 3. Discharge summaries; 4. Behavioral contracts; and 5. Case evaluations/short-term treatment center reviews. (C) Treatment supervisors shall maintain the appropriate credential(s) and/or license(s) for their respective position. Supervisors shall conduct and document regularly scheduled supervision sessions and ongoing direct observation of treatment professionals delivering services in the ITC. (D) Supervision of staff who are seeking credentials must follow the supervision guidelines established by the specific credentialing body. Supervision must be tailored to the knowledge base, skills, and experience of each staff member in order to promote professional development and proficiency in substance use disorders counseling competencies. (E) Non-credentialed and unlicensed staff of the ITC shall have access to their supervisor as frequently as possible to address immediate, brief questions. The supervisor shall meet with non-credentialed and unlicensed staff on a weekly basis and provide assistance with setting clear goals. All supervisory sessions with staff shall be recorded, including the date and time, personal goals, and notation of progress being made toward goals. (10) Quality Assurance and Program Evaluation. This section includes the quality assurance and program evaluation requirements for ITCs. (A) Each ITC must submit a quality assurance plan to the DOC Office of Substance Use and Recovery Services in accordance with established timelines. Plans must include the intended process by which internal measurement and/or program auditing will occur to ensure compliance with the quality assurance plan. Plans must be updated as specified by DOC. (B) Plans will be returned to the ITC by the designated DOC staff person in accordance with established timelines indicating: approved as submitted; approved with modifications needed; or not approved. Plans needing revisions must be resubmitted by the ITC to designated DOC staff in accordance with established timelines. (C) ITCs shall implement the quality assurance plan in accordance with timelines established by DOC. (D) Quality assurance measures shall be reviewed and updated on a quarterly basis by staff of the ITC and submitted in the form of a written report to the DOC designee. (E) Each ITC shall establish specific compliance indicators consisting of process quality assurance measures and outcome quality assurance measures. (F) Process quality assurance measures must include, but are not limited to: 1. Review of clinical records of offend- ers in the ITC; and 2. A monthly, in-depth review of a ran- dom sample of one (1) clinical record maintained by each primary treatment professional of the ITC using a pre-defined criteria checklist. The review shall be conducted by a designated treatment professional supervisor(s), the clinical director, program manager, or other clinical administrative staff of the ITC. Results of the review determine whether the program is meeting ninety percent (90%) or more of the criteria pertaining to satisfactory quality in-chart documentation. (G) Each non-licensed or non-credentialed treatment professional’s group performance shall be observed directly by a treatment professional supervisor at least one (1) time per month. Feedback shall be provided orally by the treatment professional supervisor to the non-licensed or non-credential treatment professional and documented in the performance log. If the ratio of direct treatment professional supervisors to treatment professionals does not allow monthly review by the direct treatment professional supervisor(s), another member of the clinical management team shall assist in this review. Credentialed and/or licensed treatment professionals shall be reviewed on a quarterly basis, at a minimum. (H) Ongoing reviews of fidelity to the practices and curricula being utilized in the ITC shall be conducted and documented by ITC staff. (I) Each ITC shall establish and monitor multidisciplinary indicators to measure maintenance of a therapeutic environment. The indicators will be reviewed quarterly by DOC custody, classification, and treatment supervisors. Reviews shall include, but are not limited to: 1. OMTs and PRCs; 2. Conduct violations; 3. Informal resolution requests; 4. Grievances; 5. Unsuccessful program exits; 6. Offender satisfaction surveys; 7. Number of in-service trainings; 8. Sentinel events; 9. Temporary administrative segregation confinement or disciplinary segregation; 10. Staff turnover; 11. Other program exits; and 12. ITC Exit Evaluations. (11) Maintenance of Records. Each ITC shall maintain an organized record system as specified in this rule. (A) All records shall be maintained in accordance with all state and federal laws and regulations related to the confidentiality of records and release of information. (B) Electronic records must conform to federal and state regulations, and 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. (C) Individual records shall be retained for at least six (6) years, or until all litigation, adverse audit findings, or both, are resolved. (D) The ITC shall assure timely access to records by authorized staff and other authorized parties, including DOC staff. (12) Interdisciplinary Services and Referrals. ITCs shall advocate for and pursue interdisciplinary collaboration and provide adequate services and/or make referrals to meet the diverse treatment needs of individuals served. (A) ITCs shall actively seek to promote interdisciplinary involvement in assessment, treatment planning, service delivery, and evaluation of progress with all agencies represented at the program site, as appropriate, based on individual needs. (B) ITCs shall refer or provide needed services for offenders, as appropriate under the scope of practice by contract or DOC guidelines, related to: 1. Psychological, mental health, or emo- tional needs, in cooperation with the designated mental health service provider of the institution; 2. Physical well-being or medical needs, in cooperation with the designated medical services provider of the institution; 3. Educational needs, in cooperation with the designated educational services provider of the institution; 4. Spiritual needs, in cooperation with the on-site chaplain; 5. Institutional adjustment and function- ing, in cooperation with the designated DOC classification staff at each location; 6. Behaviors, safety, and security of offenders, in cooperation with the appropriate DOC custody staff; and 7. Criminal cases, sentencing, and release, in cooperation with the designated institutional probation and parole staff. (C) Documentation of referrals related to the needs of offenders and/or collaboration with other agencies shall be maintained in the individual’s treatment record. (D) ITCs shall hold regularly scheduled quality assurance meetings with collaborative service providers. Documentation of quality assurance meetings must be maintained in the form of minutes, identifying all individuals in attendance. Representation at these meetings shall include, but is not limited to, the following agencies and/or disciplines: 1. DOC custody; 2. DOC classification; 3. DOC administration; 4. Mental health; 5. Medical; 6. Education; 7. Probation and parole; 8. Chaplain; 9. Recreation officers; and 10. ITC staff. (13) Exceptions Process. The primary treatment supervisor of the ITC may request the department to waive any of the requirements in these rules by submitting a request in accordance with 9 CSR 10-5.210, Exceptions Committee Procedures. (14) Disciplinary Guidance. This section provides guidance to staff of the ITC for taking disciplinary or corrective action with offenders who fail to comply with program expectations or rules and directives. (A) Offenders admitted to an ITC are referred as the result of self-defeating thinking patterns and problematic, anti-social behaviors that lead to commission of crimes. Program staff must focus on facilitating necessary changes in thinking and behavior over the course of treatment. Every offender is expected to diligently strive for change in their thinking and behavior, and be receptive to the guidance and redirection provided by ITC staff. (B) Behaviors that represent a certain and severe threat to offenders, staff, or the good order of the correctional institution shall not be tolerated. 1. Such behaviors are identified under Cardinal Rules in DOC Policies. Violation of Cardinal Rules must result in referral for review by the PRC. The PRC determines the appropriate action to be taken. 2. Action may include unsuccessful exit from the ITC, if such action is deemed appropriate by the PRC. A. Unsuccessful exit for a Cardinal Rule violation should never be the only option for consideration. Many program rules do not meet the criteria of Cardinal Rules, but may create a security risk. (C) Offenders adapt over time to increasingly higher levels of behavioral compliance. It is reasonable to expect such adaptation to take longer for some offenders than for others. It is part of the mission of ITCs to continue to work with the offenders as they navigate the stages of change in relation to their self-defeating thinking patterns and non-compliant behaviors. (D) Compliance with program rules and directives are important, but it is vital that offenders be allowed time to learn the skills required to move forward in their recovery, and for staff to resist the temptation to prematurely execute the unsuccessful program exit of an offender. (E) DOC classification and DOC administrative staff are primarily responsible for responding to an offender’s behavior that results in writing a conduct violation report. ITC treatment staff may write conduct violation reports, but they shall not interfere with the due process involved in the hearing of such reports and in the adjudication of those reports. (F) An offender’s behavior that results in a conduct violation report, or otherwise has been documented as negative behavior or behavior that is inconsistent with the rules and regulations of the ITC, shall be addressed through the therapeutic intervention continuum. 1. Depending on the seriousness or con- sistency of the offender’s non-compliant behavior, stages of the continuum may be superseded. Every effort shall be made to intervene at the least intensive level of intervention possible, and to proceed forward over time in intensified interventions. The continuum of therapeutic intervention shall include, but is not limited to: A. Non-adversarial confrontation; B. Non-adversarial confrontation with therapeutic assignments; C. Treatment plan modifications; D. Behavioral contracts; E. Referral to the OMT; and F. Referral to the PRC. 2. Depending on the offender’s recep- tiveness to a given intervention, some interventions may be repeated. Interventions repeated for different types of behavior shall be considered distinct and separate. 3. Successful interventions shall be acknowledged as such, with documentation in the offender’s record. A successful intervention is an indication of progress, even if the intervention may need to be repeated later in the offender’s treatment. (G) Consistent non-compliance with program rules by an offender, despite documented and intensified interventions, may result in referral to the PRC due to lack of therapeutic gain. 1. Such referral must indicate docu- mented attempts to assist the offender in understanding the need to change their behavior and challenging thinking patterns that have resulted in the non-compliance. The integrity of the therapeutic process shall be emphasized. Substantial documentation of all interventions is required to substantiate a termination based on lack of therapeutic gain. AUTHORITY: sections 313.842, 630.050, and 630.655, RSMo 2016.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed March 20, 2019, effective Oct. 30, 2019.

*Original authority: 313.842, RSMo 1991, amended 1996, 2000; 630.050, RSMo 1980, amended 1993, 1995, 2008; and 630.655, RSMo 1980.