PURPOSE: This rule establishes requirements for CSTAR programs serving women and children.

PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

1. (1) Treatment Philosophy and Guiding Principles. Women and children’s CSTAR programs shall demonstrate through policy and practice that women’s substance use disorders differ from men’s, both in their etiology and the services and supports needed for recovery.

   1. (A) Women and children’s CSTAR programs shall ensure—

      1. 1. Emotional and physical safety of the women and

children served takes precedence over other considerations in the delivery of services;

1. 2. Women-only therapeutic environments are available;
2. 3. Trauma-sensitive services and supports to increase

women’s access to care, engagement, and retention in treatment are provided or arranged, such as community support, transportation, and child care;

1. 4. Women-specific service needs and topic areas are

addressed in treatment and through support services; and

1. 5. Multiple modalities are offered to meet the needs of

women such as group and individual counseling, community support, peer support, and opportunities for women to be in treatment with their children.

1. (B) Staff shall possess the knowledge and expertise to engage women with histories of trauma, recognize the presence of trauma symptoms, understand the role of trauma in the lives of women seeking services, and conduct themselves in ways that are not retraumatizing to those being served. The following trauma-informed principles shall be integrated into the program’s service delivery practices:

   1. 1. Safety—ensuring physical and emotional safety for

individuals and staff;

1. 2. Trustworthiness—maximizing trustworthiness through

task clarity, consistency, and maintaining appropriate interpersonal boundaries;

1. 3. Choice—maximizing the experience of developmentally

appropriate choice and control;

1. 4. Collaboration—maximizing collaboration and sharing

of power between individuals and staff; and

1. 5. Empowerment—building on individuals’ capacities,

encouraging them to have a voice and mastery of life, and prioritizing power and growth.

1. (C) All women shall receive or have trauma-informed, evidence-based services available and shall not be required to disclose their trauma history in order to receive those services. Women’s treatment shall incorporate universal, traumainformed principles into every service, regardless of whether trauma is disclosed.
2. (D) The Substance Abuse and Mental Health Services Administration (SAMHSA), Treatment Improvement Protocol 51, Substance Abuse Treatment: Addressing the Specific Needs of Women, 2015, hereby incorporated by reference and made a part of this rule, shall serve as a guide for the program’s service delivery practices. This document is published by and available from SAMHSA, 1 Choke Cherry Road, Rockville, Maryland 20857,

1. (877) 726-4727, www.samhsa.gov. This rule does not incorporate any subsequent amendments or additions to this publication.

2. (2) Eligibility Criteria and Program Structure. The program shall provide treatment services and other supports solely to women and their children. Services shall be based on individual and family needs, in accordance with admission and eligibility criteria for CSTAR.

   1. (A) Priority admission shall be for women who are—

      1. 1. Pregnant and inject drugs;
      2. 2. Pregnant;
      3. 3. Postpartum (up to one (1) year after delivery);
      4. 4. Have children in their care and custody, including those

at risk of losing custody or attempting to regain custody of their children;

1. 5. Applicants or recipients of Temporary Assistance for

Needy Families referred by the Department of Social Services, Family Support Division; and

1. 6. Other populations specified by the department.

2. (B) Women who meet priority criteria shall be immediately admitted to the CSTAR program and receive appropriate services.

   1. 1. If the program is unable to provide immediate admission,

staff shall facilitate referral to another women and children’s CSTAR program that can provide immediate admission.

1. 2. If immediate admission with an alternative women and

children’s CSTAR program is not available for a woman who is pregnant, program staff shall contact designated department staff to obtain assistance in facilitating arrangements for immediate admission with another program.

1. 3. Women shall not be denied admission based solely on

medication prescribed and monitored by a licensed physician, physician assistant, assistant physician, or advanced practice registered nurse (APRN) for an opioid disorder or other physical or behavioral health disorder.

1. (C) Adolescents who meet priority criteria shall be admitted if, in the staff’s clinical judgment, the adolescent can appropriately participate in and benefit from the services and milieu offered. Programs shall have policies and procedures for serving adults and adolescents in the same environment.

2. (D) Culturally competent services shall be provided in the context of a family-centered and family-focused treatment model. Members of the treatment team shall be responsible for adapting to the needs of the mother and her family. An array of services shall be available to—

   1. 1. Assist families in functioning as a unit by establishing

and maintaining a schedule, structure, regular habits, and healthy routines;

1. 2. Allow for an integrated family plan that builds coherence

and prioritizes the needs of individual family members;

1. 3. Accommodate children who accompany their mother,

in accordance with the mother’s wishes;

1. 4. Address substance use, mental, physical and emotional

health, developmental, social, economic, and environmental needs of women and their families;

1. 5. Allow women to define their families and focus on

healthy relationships between parents, children, and others identified by the mother;

1. 6. Address evolving and changing family engagement,

recognizing everyone may not participate at the same time, stay the same length of time, or have the same motivations; and

1. 7. Assist women and their families in accessing other

services and supports in the community.

1. (E) Family oriented living arrangements, indoor recreational space for children and families, and safe, protected outdoor recreational and leisure space shall be available.
2. (F) Women and their children shall have access to ageappropriate physical healthcare, including obstetric and pediatric care.

1. (3) Gender-Responsive Services. The program shall address therapeutic issues relevant to women and their specific needs, as identified in individual treatment plans.

   1. (A) Staff shall understand and recognize the distinctive characteristics and biopsychosocial issues associated with women in general, and specifically women who have substance use disorders, to provide effective treatment.
   2. (B) Services shall be culturally sensitive and recognize the unique characteristics of women’s initiation of substance use, effects of use, histories of trauma, co-occurring mental, developmental, and physical health disorders, and other treatment issues specific to women.

   3. (C) Services shall be designed to assist women in maintaining their recovery and resiliency, such as—

      1. 1. Parenting and child development;
      2. 2. Life skills;
      3. 3. Family programs;
      4. 4. Facilitation of supervised parent-child bonding;
      5. 5. Educational remediation and support;
      6. 6. Employment readiness services;
      7. 7. Linkages with legal and child welfare systems, including

reunification with children if applicable;

1. 8. Housing support efforts and referrals;
2. 9. Co-occurring disorder services, including access to

psychological and pharmacological treatments for mental health disorders;

1. 10. Education and linkage to eating disorder and nutrition

services;

1. 11. Medication services, including access to approved

medication to treat substance use disorders for women who are pregnant; and

1. 12. Recovery support and community support services that

address long-term recovery needs such as domestic violence services, career counseling, legal services, and transportation services.

1. (4) Child Care. The program shall ensure child care is not a barrier to engagement in services or retention in treatment by ensuring coordination or facilitation of child care when the mother is participating in services.

   1. (A) Programs offering on-site child care shall obtain licensure as a child care center as specified in 5 CSR 25-500.

   2. (B) On-site child care shall—

      1. 1. Be designed to meet the developmental needs of the

various age groups served and address cultural and other identified needs;

1. 2. Provide each child with a variety of easily accessible,

developmentally appropriate learning and play materials;

1. 3. Provide for a balance between free play and organized

activities, between individual play and sharing experiences among children, and promote individual contact between staff and each child;

1. 4. Provide reasonable regularity of age-appropriate

activities with allowance for a variety of special events and time for children to be outdoors daily, weather permitting;

1. 5. Be culturally responsive, nonjudgmental, trauma

sensitive, and respectful;

1. 6. Take responsible precautions to ensure a safe, welcoming,

and sanitary environment appropriate for children;

1. 7. Ensure no weapons are brought on to the premises;
2. 8. Provide privacy (such as use of bathroom, sleeping

arrangements) for opposite sex children transitioning into school and for any children demonstrating a need for privacy; and

1. 9. Accommodate the needs of children with disabilities

in accordance with the Americans with Disabilities Act as amended (ADAAA) or refer to another provider if the child’s needs are identified to be beyond the scope of the program. The ADAAA, effective January 1, 2009, is hereby incorporated by reference and made a part of this rule and is available from the U.S. Department of Justice, 950 Pennsylvania Avenue NW, Civil Rights Division, Disability Rights Section-NYA, Washington, DC 20530, (800) 514-0301 voice, (800) 514-0383 TTY. This rule does not incorporate any subsequent amendments or additions to this publication.

1. (C) Child care may be arranged through a contractual agreement with a local, licensed child care center. Contracts shall comply with 9 CSR 10-7.090(6).
2. (D) Child care will not be funded by the department for children who are over fourteen (14) years of age, unless specific authorization has been granted by department staff.

1. (5) Supervision of Children. The program shall ensure children in child care are supervised in accordance with Department of Elementary and Secondary Education staff/child ratios as specified in 5 CSR 25-500.

   1. (A) The parent/guardian shall be responsible for providing supervision when the child is not attending child care or participating in other scheduled program activities.
   2. (B) Program staff shall assist the parent in providing ageappropriate activities, training, and guidance.
2. (6) Education for Children. The program shall assist the parent/ guardian as necessary to ensure educational opportunities for school-age children in accordance with the requirements of the Department of Elementary and Secondary Education.

3. (7) Assessing Children’s Needs and Documenting Services. Program staff shall inform women of the services available for children and educate them about involving their children in treatment while respecting the mother’s wishes.

   1. (A) When the mother chooses to involve her children in treatment, a trained staff member shall complete an initial screening utilizing an age-appropriate, validated instrument to determine specific service needs beyond child care and community support. The screening shall include an interview with at least one (1) parent and the child, whenever appropriate.
   2. (B) If the need for a clinical assessment is indicated by the screening, a qualified staff member shall complete an assessment utilizing an age-appropriate, validated instrument. The assessment must be completed prior to delivery of services beyond child care and community support.
   3. (C) An individual plan shall be developed based on the needs of the mother and child, with the results of the assessment serving as a guide. The child’s consent for treatment must be signed by the legal guardian.
   4. (D) Services provided for children, including child care and community support, shall be documented in a separate clinical record for the child. The record shall include the child’s developmental, physical, emotional, social, educational, and family background and current status.

4. (8) Services for Children. The program shall ensure traumainformed services are available to address therapeutic issues relevant to children, based on the needs of individuals being served at those locations.

   1. (A) Developmentally appropriate activities and services shall be offered to meet the social, emotional, and behavioral needs of children to—

      1. 1. Build self-esteem and self-awareness;
      2. 2. Learn to identify and express feelings;
      3. 3. Build positive family relationships;
      4. 4. Learn healthy social engagement, peer relationships,

social pressure skills, and teamwork;

1. 5. Develop decision-making skills;
2. 6. Learn self-management (impulse control, stress

management, and goal-setting);

1. 7. Understand substance use disorders and its effects on

the family;

1. 8. Learn and practice nonviolent ways to resolve conflict;
2. 9. Learn safety practices such as personal space,

boundaries, and personal safety;

1. 10. Address developmental needs; and
2. 11. Provide education on preventing alcohol, tobacco, and

other drug use.

1. (B) Services for children shall address the issues and needs identified by the mother and her children, as documented in the individual plan, utilizing structured and unstructured therapeutic activity.
2. (C) Specialized services shall be provided including, but not limited to, children with high risk of sexual abuse, sexual acting-out behaviors, suicide risk, and the service needs of infants, toddlers, and preschoolers.
3. (D) Services for children from birth to three (3) years of age shall include, at a minimum, developmentally appropriate parent-child interactive bonding activities and developmentally appropriate structured activities that promote and nurture the growth and well-being of the infant.

1. (9) Qualified and Competent Staff. The program shall maintain a core workforce (employed or contracted) that is appropriately qualified and determined to be competent to adequately address the needs of women and children and deliver the behavioral health services the program is certified to provide.

   1. (A) The program shall document that staff providing services for women and/or children have training in the following areas:

      1. 1. Trauma knowledge, trauma-informed treatment,

identification of signs and symptoms of domestic violence, spousal or partner abuse, and child abuse and neglect, with special emphasis on failure to thrive and sexual abuse of children;

1. 2. Child development and age-appropriate behaviors;
2. 3. Parenting attachment styles and skills appropriate to

infants, toddlers, preschool, and school-age children; and

1. 4. The impact of substance use and substance use disorders

on parenting and family units.

1. (B) The program shall document that staff working with children have ongoing training and demonstrate jobappropriate functional comprehension in the following areas:

   1. 1. The impact of prenatal drug and alcohol exposure on

child development;

1. 2. The effect of substance use disorders on parenting

children and families;

1. 3. Trauma knowledge, trauma’s impact on child brain

development, and long-term impact of adverse childhood experiences;

1. 4. Parenting attachment styles and skills appropriate to

infants, toddlers, preschool, and school-age children;

1. 5. Appropriate play activities according to developmental

stage;

1. 6. Common children’s behavioral and developmental

problems;

1. 7. Recognition of sexual acting-out behavior; and
2. 8. The substance use disorder recovery process, especially

as it relates to family units.

1. (10) Health Promotion. The program shall maintain a safe, healthy environment that is responsive to the physical, behavioral, and emotional health needs of women and children.

   1. (A) A full-time licensed nurse shall be accessible to women and children to provide trauma-informed medical and other consultative services necessary to monitor and manage health issues.

      1. 1. Services performed by a licensed practical nurse (LPN)

must fall within their scope of practice and shall be supervised by a licensed physician (including psychiatrist), licensed physician assistant, licensed assistant physician, APRN, or registered nurse (RN).

1. (B) Key service functions of the nurse(s) shall include, but are not limited to—

   1. 1. Obtaining initial medical histories and vital signs of

individuals admitted to the program;

1. 2. Monitoring general health needs and meeting with

individuals about medical concerns;

1. 3. Providing disease prevention, risk reduction, and

reproductive health education;

1. 4. Reviewing medication requirements and educating

individuals about the benefits of taking medications as prescribed and monitoring medication compliance; and

1. 5. Monitoring lab levels, including consultation with the

individual served, her physician, and the treatment team.

1. (C) The program shall employ staff in sufficient numbers and with appropriate training to respond to emergency situations and provide cardiopulmonary resuscitation (CPR) when necessary.

   1. 1. At least one (1) staff member who has current training in

First Aid and CPR for infants, children, and adults shall be on duty seven (7) days per week, twenty-four (24) hours per day.

1. 2. Staff must maintain current First Aid and CPR

certification for healthcare providers through training that includes hands-on practice and in-person skills assessment. Online-only training is not acceptable.

1. (D) The program shall demonstrate effective working relationship(s) with a licensed physician, hospital, and/or clinic to provide access to emergency services and/or ongoing medical care for women, including pregnant and postpartum women, and their children.

2. (E) The program shall ensure an evaluation of medical need for each woman and child and shall ensure that each woman and child is medically stable to safely and adequately participate in services. For women, the evaluation of medical need shall include:

   1. 1. Current physical status, including vital signs; and
   2. 2. Symptoms of intoxication, impairment, or withdrawal.
3. (F) The program shall ensure that recommendations related to an individual’s behavioral or physical health from a licensed physician (including psychiatrist), licensed physician assistant, licensed assistant physician, or APRN are encouraged and coordinated regularly by their primary health care provider.

4. (G) Health-related services may include but are not limited to—

   1. 1. Nutritional counseling;
   2. 2. Education about reproductive health;
   3. 3. Wellness programs;
   4. 4. Education on sleep and dental hygiene;
   5. 5. Education about trauma and long-term physical health

risks and conditions;

1. 6. Education about sexually transmitted infections and

infectious diseases, such as viral hepatitis and HIV/AIDS; and

1. 7. Preventive healthcare education.
2. (H) If a specialized program for women and children provides withdrawal management/detoxification services, the program shall comply with applicable standards under 9 CSR 30-3.120. A specialized program for women and children shall not be required to accept applications for ninety-six- (96-) hour civil detention of intoxicated persons due to the presence of children within the program.

AUTHORITY: sections 630.050, 630.655, and 631.010, RSMo 2016.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Rescinded and readopted: Filed Aug. 17, 2022, effective March 30, 2023. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008; 630.655, RSMo 1980; and 631.010, RSMo 1980.