PURPOSE: This rule prescribes the content requirements of a clinical record maintained by a community psychiatric rehabilitation program.

1. (1) Each agency that is certified shall comply with requirements set forth in Department of Mental Health Core Rules for Psychiatric and Substance Abuse Programs, 9 CSR 10-7.030 Service Delivery Process and Documentation.
2. (2) The CPR provider shall implement policies and procedures to assure routine monitoring of client records for compliance with applicable standards.

3. (3) At intake, each CPR provider shall compile in a format acceptable to the department, and file in the client record an evaluation which shall include:

   1. (A) Presenting problem, request for assistance, symptoms, and functional deficits;
   2. (B) Personal, family, educational, treatment, and community history;
   3. (C) Reported physical and medical complaints and the need for screening for medical, psychiatric, or neurological assessment or other specialized evaluation;
   4. (D) Findings of a brief mental status examination;
   5. (E) Current functional strengths and weaknesses obtained through interview and behavioral observation;
   6. (F) Specific problem indicators for individualized treatment;
   7. (G) Existing personal support systems and current use of community resources;
   8. (H) Diagnostic formulation;
   9. (I) Specific recommendations for further evaluation and treatment;

   10. (J) Consultation between a physician and the psychologist or other mental health professional(s) conducting the psychosocial/clinical evaluation addressing the client’s need and the appropriateness of outpatient rehabilitation. Consultation may be performed by an advanced practice nurse if that individual is providing medication management services to the client; and

       1. (K) The clinical record must support the

level of care.

1. (4) The CPR provider shall develop and maintain for each client an individual treatment plan using a standardized format furnished by the department, at its discretion, which is filed in the master client record. The treatment plans shall record, at a minimum, the following as indicated:

   1. (A) Service Data.

      1. 1. The reason(s) for admission into

rehabilitation services.

1. 2. Criteria or plans, or both for move-

ment.

1. 3. Criteria for discharge.
2. 4. A list of agencies currently providing

program/services; the type(s) of service; date(s) of initiation of program/services.

1. 5. A summary statement of prioritized

problems and assets; and

1. (B) Treatment Goals and Objectives for the Treatment Plan and Any Components.

   1. 1. Specific individualized medication,

psychosocial rehabilitation, behavior management, critical intervention, community support goals and other services and interventions as prescribed by the team.

1. 2. The treatment regimen, including

specific medical and remedial services, therapies and activities that will be used to meet the treatment goals and objectives.

1. 3. A projected schedule for service

delivery, including the expected frequency and duration of each type of planned therapeutic session or encounter.

1. 4. The type of personnel who will fur-

nish the services.

1. 5. A projected schedule for completing

reevaluations of the client’s condition and for updating the treatment plan.

1. 6. Resources required to implement rec-

ommended services.

1. 7. A schedule for the periodic monitor-

ing of the client that reflects factors which may adversely affect client functioning.

1. 8. Level of care.

1. (5) A physician shall approve the treatment plan. A licensed psychologist may approve the treatment plan only in instances when the client is currently receiving no prescribed medications and the clinical recommendations do not include a need for prescribed medications. An advanced practice nurse may approve the treatment plan if that individual is providing medication management services to the client.
2. (6) The CPR provider shall ensure that the client participates in the development of the treatment plan and signs the plan. Client signature is not required if signing would be detrimental to client’s well-being. If the client does not sign the treatment plan, the CPR provider shall insert a progress note in the case record explaining the reason the client did not sign the treatment plan.
3. (7) The treatment plan, goals, and objectives shall be completed within thirty (30) days of the client’s admission to services.

4. (8) Each client’s record shall document services, activities, or sessions that involve the client.

   1. (A) Client records shall be legible and made contemporaneously with the delivery of the service or within three (3) business days of the time the service was provided.
   2. (B) Services shall be documented in the client record prior to submitting for payment.

   3. (C) For psychosocial rehabilitation, the clinical record shall include:

      1. 1. A weekly note that summarizes spe-

cific services rendered, client response to the services, and pertinent information reported by family members or significant others regarding a change in the client’s condition, or an unusual/unexpected occurrence in the client’s life, or both; and

1. 2. Daily attendance records or logs that

include actual attendance times, as well as activity or session attended. These program attendance records/logs must be available for audit and monitoring purposes, however integration into each clinical record is not required.

1. (D) For all other community psychiatric rehabilitation program services, the client record shall include documentation of each session or episode that involves the client.

   1. 1. The specific services rendered.
   2. 2. The date and actual time the service

was rendered.

1. 3. Who rendered the service.
2. 4. The setting in which the services

were rendered.

1. 5. The amount of time it took to deliver

the services.

1. 6. The relationship of the services to the

treatment regimen described in the treatment plan.

1. 7. Updates describing the client’s

response to prescribed care and treatment.

1. (9) In addition to documentation required under section (8), the CPR provider shall 9 CSR 30-4

provide additional documentation for each service episode, unit or as clinically indicated for each service provided to the client as follows:

1. (A) Medication Services.

   1. 1. Description of the client’s presenting

condition.

1. 2. Pertinent medical and psychiatric

findings.

1. 3. Observations and conclusions.
2. 4. Client’s response to medication,

including identifying and tracking over time, one (1) or more target symptoms for each medication prescribed.

1. 5. Actions and recommendations regard-

ing the client’s ongoing medication regimen.

1. 6. Pertinent/significant information

reported by family members or significant others regarding a change in the client’s condition, an unusual or unexpected occurrence in the client’s life, or both;

1. (B) Crisis Intervention and Resolution Services.

   1. 1. Description of the precipitating

event(s)/situation, when known.

1. 2. Description of the client’s mental sta-

tus.

1. 3. Interventions initiated to resolve the

client’s crisis state.

1. 4. Client response to intervention.
2. 5. Disposition.
3. 6. Planned follow-up by staff; and

4. (C) Community Support Services.

   1. 1. Phone contact reports.
   2. 2. Pertinent information reported by

family members or significant others regarding a change in the client’s condition, an unusual or unexpected occurrence in the client’s life, or both.

1. (10) An evaluation team, consisting of at least, a qualified mental health professional and the client’s community support worker, if appropriate, shall review the treatment plan, goals and objectives on a regular basis, as determined by department policy.

   1. (A) The review will determine the client’s progress toward the treatment objectives, the appropriateness of the services being furnished and the need for the client’s continued participation in specific community psychiatric rehabilitation services.
   2. (B) The team shall document the review in detail in the client record.
   3. (C) The CPR provider shall make the review available as requested for state or federal review purposes.
   4. (D) The CPR provider shall ensure the client participates in the treatment plan review.
   5. (E) For clients in the rehabilitation level of care, treatment plans shall be reviewed at a minimum every ninety (90) calendar days and the review documented in the case record.
2. (11) The treatment plan shall be rewritten annually and shall comply with the guidelines set forth in 9 CSR 30-4.035(4), (5), and (6).

3. (12) The CPR program also shall include other information in the client record, if not otherwise addressed in the intake/annual evaluation or treatment plan, including:

   1. (A) The client’s medical history, including:

      1. 1. Medical screening or relevant results

of physical examinations; and

1. 2. Diagnosis, physical disorders, and

therapeutic orders;

1. (B) Evidence of informed consent;
2. (C) Results of prior treatment; and
3. (D) Condition at discharge from prior treatment.

1. (13) Any authorized person making any entry in a client’s record shall sign and date the entry, including corrections to information previously entered in the client record.

2. (14) CPR program staff shall conduct or arrange for periodic evaluations for each client. Clients in the rehabilitation and intensive levels of care shall have annual evaluations completed. The evaluation shall be in a format approved by the department and shall include:

   1. (A) Presenting problem and request for assistance;
   2. (B) Changes in personal, family, educational, treatment, and community history;
   3. (C) Reported physical/medical complaints;
   4. (D) Current functional weaknesses and strengths;
   5. (E) Changes in existing personal support systems and use of community resources;
   6. (F) Description of the client’s apparent change in condition from one (1) year ago;
   7. (G) Specific problem indicators required by the department;
   8. (H) Update of the diagnostic formulation;
   9. (I) Specific recommendations for further evaluation and/or treatment;
   10. (J) Information obtained through interview and behavioral observations that will contribute to the formulation of a new treatment plan; and
   11. (K) Consultation between a physician and/or psychologist and the mental health professional(s) conducting the psychosocial/ clinical evaluation addressing the client’s need and appropriateness for continued outpatient rehabilitation.
3. (15) CPR program staff shall prepare and enter a discharge summary in the client’s record when the client has been discharged from the CPR program. This discharge summary shall meet all requirements in 9 CSR 10-7.030(9).
4. (16) The CPR provider shall establish and implement a procedure that assures the intercenter transfer of referral and treatment information within five (5) working days.
5. (17) The CPR provider shall provide information, as requested, regarding client characteristics, services, and costs to the department in a format established by the department.

6. (18) Each agency that is certified shall be subject to recoupment of all or part of Department of Mental Health payments when:

   1. (A) The client record fails to document the service paid for was actually provided;
   2. (B) The client record fails to document the service paid for was provided by a qualified staff person, as defined in the Department of Mental Health Purchase of Service Catalog;
   3. (C) The client record fails to document the service that was paid meets the service definition, as defined in the Department of Mental Health Purchase of Service Catalog;
   4. (D) The client record fails to document the amount, duration, and length of service paid for by the department; and
   5. (E) The client record fails to document the service paid for was delivered under the direction of a current treatment plan that meets all the requirements for treatment plans set forth in 9 CSR 10-7.030 and 9 CSR 30- 4.035.

AUTHORITY: section 630.655, RSMo 2000.* Original rule filed Jan. 19, 1989, effective April 15, 1989. Amended: Filed Dec. 13, 1994, effective July 30, 1995. Emergency amendment filed Aug. 11, 1999, effective Aug. 22, 1999, expired Feb. 17, 2000. Amended: Filed Aug. 11, 1999, effective Feb. 29, 2000. Amended: Filed Feb. 28, 2001, effective Oct. 30, 2001. Emergency amendment filed Dec. 28, 2001, effective Jan. 13, 2002, expired July 11, 2002. Amended: Filed Dec. 28, 2001, effective July 12, 2002. Amended: Filed March 15, 2010, effective Sept. 30, 2010.

*Original authority; 630.655, RSMo 1980.