PURPOSE: This rule establishes requirements relative to specialized substance abuse programs for adolescents.

1. (1) Age Criteria for Adolescents. The program shall provide treatment, rehabilitation, and other services solely to clients between the ages of twelve through seventeen (12–17) years inclusive and their families. Exceptions to these age requirements may be authorized through clinical utilization review for those individuals in which there is justification and documentation of behavior and experience appropriate for the services available.

2. (2) Other Eligibility Criteria. The level of care and treatment setting for adolescent services shall be based on problem severity ratings in the following domains:

   1. (A) Substance Abuse Patterns/Withdrawal Risk. This includes factors such as recent use patterns (substances used, frequency, amount, method of administration), consequences of use, progression, tolerance, and withdrawal risk;
   2. (B) Physical Health. This includes physical health conditions that require ongoing care and that may be a factor in treatment planning;
   3. (C) Emotional/Behavioral Functioning. This includes factors such as suicidal ideation or plans, aggressiveness, severe conflict with others, recent running away from home; cooccurring psychiatric disorders, and need for continuous supervision;
   4. (D) Acceptance/Resistance. This includes factors such as blaming others, willingness to acknowledge problems, and attempts to stop or cut back substance use;
   5. (E) Abstinence Potential. This includes factors such as substance use in the past thirty (30) days, longest period of abstinence in the past six (6) months, impulsiveness, general ability to follow through with appointments and responsibilities;
   6. (F) Recovery Environment. This includes factors such as non-using friends, involvement in non-using activities, school attendance and performance, geographic access to treatment services, and involvement of other persons or agencies to support recovery; and
   7. (G) Family/Caregiver Functioning. This includes factors such as appropriateness of rules and consequences, availability of supervision, presence of others in the household with active substance abuse, emotional and psychiatric functioning of caregivers, ability and willingness to participate in the treatment and recovery process.

3. (3) Treatment Principles and Therapeutic Issues Relevant to Adolescents. The program shall address therapeutic issues relevant to adolescents and shall address their specific needs. The following principles and methods shall be reflected in services delivered to adolescents:

   1. (A) Adolescents are best treated in settings that are programmatically and physically separate from treatment services for adults;
   2. (B) Services shall maintain youth in the family and community setting, whenever clinically feasible;
   3. (C) Services shall support the family and engage the family in a recovery and change process, whenever appropriate. If the parent(s) are not an available and appropriate resource, program staff shall assist in developing alternate social and family support systems for the adolescent;
   4. (D) Services to the family shall be directed to understanding and supporting the youth’s recovery process, identifying and intervening with parental substance abuse 9 CSR 30-3

problems, improving parenting skills and communication skills within the family, and assisting the family in improving its level of functioning;

1. (E) A cooperative team approach shall be utilized in order to provide a consistent environment and therapeutic milieu;
2. (F) Cooperation with other youth-serving agencies shall be demonstrated in order to ensure that needs of youth in treatment are met and that services are coordinated. Coordination of service needs are critical with youth due to their involvement with other community agencies and reliance on the family, as well as the fact that substance abuse affects multiple life areas; and

3. (G) Service delivery shall address—

   1. 1. Recovery issues such as peer relation-

ships, use of leisure time, and abuse and neglect;

1. 2. Skill development such as decision-

making and study skills; and

1. 3. Information and education regarding

adolescent developmental issues and sexuality.

1. (4) Living Arrangements. Adolescents may be served from a variety of living arrangements including, but not limited to, the following:

   1. (A) Home of the parent/guardian;
   2. (B) Foster home;
   3. (C) Residential settings operated by the program;
   4. (D) Juvenile detention;
   5. (E) Other supervised living arrangements; or
   6. (F) Independent living.

2. (5) Family Involvement. Each adolescent’s living arrangement and family situation shall be reviewed by program staff in order to identify needs and to develop treatment goals and recovery supports for the adolescent and the family.

   1. (A) This review shall be done by a family therapist.
   2. (B) Refusal by the family for an in-home assessment shall not constitute automatic denial of treatment services for adolescents.
   3. (C) The program shall actively involve family members in the treatment process, unless contraindicated for legal or clinical reasons which are documented in the client record.

   4. (D) Staff shall orient the parent or legal guardian regarding—

      1. 1. Treatment philosophy and design;
      2. 2. Discipline and any behavioral man-

agement techniques used by the program;

1. 3. Availability of staff to conduct home-

based treatment and community support services;

1. 4. Emergency medical procedures; and
2. 5. Expectations about ongoing family

participation.

1. (E) Staff shall seek family participation in treatment planning, service delivery and continuing recovery planning.

   1. 1. Services may include family partici-

pation in educational and counseling sessions.

1. 2. Family participation in treatment

planning shall be documented in the client record. In the event that the family does not participate, then staff shall document efforts to involve the family and reasons why the family did not participate.

1. (6) Educational and Vocational Opportunities. The program shall assist the adolescent and parent/guardian as necessary to ensure educational and/or vocational opportunities during treatment.
2. (7) Privilege System. Any system used by the program to modify behavior by requiring certain behaviors to earn privileges or restricting privileges (that is, step-down program) for failure to comply with requirements shall be defined in writing, stated in behavioral terms to the extent possible, and applied consistently to all clients.

3. (8) Safety and Health. The program shall maintain a safe, healthy environment which is responsive to the physical and medical needs of adolescents.

   1. (A) Adolescents shall be prohibited from smoking on the premises, grounds and any off-site program functions.
   2. (B) For adolescents receiving residential support, the program must provide or arrange for a history and physical examination performed by a physician licensed in Missouri or a nurse practitioner licensed and authorized to title and practice as an advanced practice nurse pursuant to 335.016, RSMo and who is engaged in a written collaborative practice arrangement as defined by law. Registered nurses may still conduct initial health screenings upon admission to a residential support setting, but this screening does not satisfy the requirement for a history and physical examination as defined above.
   3. (C) The program shall demonstrate effective working relationship(s) with a physician, hospital, and/or clinic to provide medical care for adolescents.

4. (9) Staff Training and Supervision. Service delivery staff shall—

   1. (A) Have training and demonstrate expertise regarding the treatment of both substance abuse and other disorders related to adolescents; and
   2. (B) Receive clinical supervision by an appropriately licensed, certified, or otherwise credentialed person with experience in the treatment of adolescents.
5. (10) Structured Activities Available to Adolescents Living in a Residential Setting. In addition to treatment services, adolescents living in a residential setting operated by the program shall have their awake time structured in activities, such as academic education, completing assignments, attendance at self-help groups, family visits and positive leisure.

6. (11) Staffing Patterns in a Residential Facility. The following minimum client to staff ratios shall be maintained at all times adolescents are present in a residential facility—

   1. (A) At a facility with six (6) residents or less, one (1) staff member must be providing supervision of clients during program hours and also during designated client sleeping hours;
   2. (B) At a facility with seven through twelve (7–12) residents, two (2) staff members must be providing supervision of clients during program hours and also during designated client sleeping hours;
   3. (C) At a facility with thirteen through sixteen (13–16) residents, three (3) staff members must be providing supervision of clients during program hours, with a required ratio of two (2) staff during designated client sleeping hours; and
   4. (D) At a foster home funded by the department, a foster parent must provide or arrange for appropriate supervision of the adolescent(s) at all times.
7. (12) If the adolescent residential support facility serves a coed population, the staffing pattern shall include at least one (1) female and at least one (1) male staff member any time residents are present. If residential support is provided for girls only, a female staff member must be present at all times. If residential support is provided for boys only, a male staff member must be present at all times.

AUTHORITY: sections 630.050, 630.655 and 631.010, RSMo 2000.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed April 15, 2002, effective Nov. 30, 2002. Amended: Filed July 29, 2002, effective March 30, 2003. *Original authority: 630.050, RSMo 1980, amended 1993, 1995; 630.655, RSMo 1980; and 631.010, RSMo 1980.