PURPOSE: This rule specifies the eligibility determination, comprehensive assessment, functional assessment, treatment planning, and documentation requirements for commu- 9 CSR 30-4

nity psychiatric rehabilitation (CPR) programs.

1. (1) Each organization that is certified or deemed certified as a CPR program by the department shall comply with requirements set forth in Department of Mental Health Core Rules for Psychiatric and Substance Use Disorder Treatment Programs, 9 CSR 10- 7.030 Service Delivery Process and Documentation.

2. (2) Eligibility Determination. Eligibility determination requires confirmation of an eligible diagnosis as evidenced by a signature from a licensed diagnostician or a physician/physician extender. The licensed diagnostician or physician/physician extender is accountable for the stated diagnosis.

   1. (A) The following mental health professionals are approved to render diagnoses:

      1. 1. Physician (includes psychiatrist, psy-

chiatry resident, assistant physician, and physician assistant);

1. 2. Psychologist (licensed or provisional-

ly licensed);

1. 3. Advanced Practice Nurse (APRN);
2. 4. Professional Counselor (licensed or

provisionally licensed);

1. 5. Marital and Family Therapist

(licensed or provisionally licensed);

1. 6. Licensed Clinical Social Worker

(LCSW); and

1. 7. Licensed Master Social Worker

(LMSW) under registered supervision with the Missouri Division of Professional Registration for licensure as a Clinical Social Worker. LMSWs not under registered supervision for their LCSW credential cannot render a diagnosis.

1. A. These professions are categorical-

ly approved as licensed diagnosticians as long as the diagnostic activities performed fall within the scopes of practice for each. Individuals possessing these credentials should practice in the areas in which they are adequately trained and should not practice beyond their individual levels of competence.

1. (B) The signature from a licensed diagnostician or physician/physician extender is required prior to delivery of CPR services. The signature can be obtained as follows:

   1. 1. A face-to-face meeting with the orga-

nization’s licensed diagnostician (licensed psychologist, licensed professional counselor, LCSW) or a physician/physician extender; or

1. 2. A face-to-face meeting with an unli-

censed qualified mental health professional (QMHP) with sign-off by the organization’s licensed diagnostician or a physician/physician extender; or

1. 3. Written confirmation of an eligible

diagnosis received from a physician for a psychiatric hospitalization within ninety (90) days of discharge.

1. (C) CPR services are billable to the department beginning on the date eligibility determination is completed.

2. (D) Documentation of eligibility determination must include, at a minimum:

   1. 1. Presenting problem and referral

source;

1. 2. Brief history of previous psychi-

atric/addiction treatment including type of admission;

1. 3. Current medications;
2. 4. Current mental health symptoms sup-

porting the diagnosis;

1. 5. Current substance use;
2. 6. Current medical conditions;
3. 7. Diagnoses, including mental disor-

ders, medical conditions, and notation for psychosocial and contextual factors;

1. 8. Identification of urgent needs includ-

ing suicide risk, personal safety, and risk to others;

1. 9. Initial treatment recommendations;
2. 10. Initial treatment goals to meet

immediate needs within the first forty-five (45) days of service; and

1. 11. Signature and title of staff complet-

ing the eligibility determination, except when the diagnosis is established as specified in subsection (2)(B)3. of this rule.

1. (3) Initial Comprehensive Assessment. A comprehensive assessment must be completed within thirty (30) days of eligibility determination.

   1. (A) Documentation of the initial comprehensive assessment must include, at a minimum:

      1. 1. Basic information (demographics,

age, language spoken);

1. 2. Presenting concerns from the per-

spective of the individual, including reason for referral/referral source, what occurred to cause him/her to seek services;

1. 3. Risk assessment (suicide, safety, risk

to others);

1. 4. Trauma history (experienced and/or

witnessed abuse, neglect, violence, sexual assault);

1. 5. Mental health treatment history;
2. 6. Mental status;
3. 7. Substance use treatment history and

current use including alcohol, tobacco, and/or other drugs; for children/youth prenatal exposure to alcohol, tobacco, or other substances;

1. 8. Medication information, including

current medications, medication allergies/adverse reactions, efficacy of current or previously used medications;

1. 9. Physical health summary (health

screen, current primary care, vision and dental, date of last examinations, current medical concerns, body mass index, tobacco use status, and exercise level; immunizations for children/youth and medical concerns expressed by family members that may impact the child/youth);

1. 10. Functional assessment using an

instrument approved by the department (challenges, problems in daily living, barriers);

1. 11. Risk-taking behaviors including

child/youth risk behavior(s);

1. 12. Living situation, including where

living and with whom, financial situation, guardianship, need for assistive technology, and parental/guardian custodial status for children/youth;

1. 13. Family, including cultural identity,

current and past family life experiences, family functioning/dynamics, relationships, current issues/concerns impacting children/youth;

1. 14. Developmental information, includ-

ing an evaluation of current areas of functioning such as motor development, sensory, speech problems, hearing and language problems, emotional, behavioral, intellectual functioning, self-care abilities;

1. 15. Spiritual beliefs/religious orienta-

tion;

1. 16. Sexuality, including current sexual

activity, safe sex practices, and sexual orientation;

1. 17. Need for and availability of social,

community, and natural supports/resources such as friends, pets, meaningful activities, leisure/recreational interests, self-help groups, resources from other agencies, interactions with peers including child/youth and family;

1. 18. Legal involvement history;
2. 19. Legal status such as guardianship,

representative payee, conservatorship, probation/parole;

1. 20. Education, including intellectual

functioning, literacy level, learning impairments, attendance, achievement;

1. 21. Employment, including current

work status, work history, interest in working, and work skills;

1. 22. Status as a current or former mem-

ber of the U.S. Armed Forces;

1. 23. Clinical formulation, an interpretive

summary including identification of cooccurring or co-morbid disorders, psychological/social adjustment to disabilities and/or disorders;

1. 24. Diagnosis;
2. 25. Individual’s expression of service

preferences;

1. 26. Assessed needs/treatment recom-

mendations such as life goals, strengths, preferences, abilities, barriers; and

1. 27. Signature of the staff person com-

pleting the assessment.

1. (4) Annual Assessment. An annual assessment must be completed for individuals engaged in CPR services.

   1. (A) Documentation of the annual assessment must include, at a minimum:

      1. 1. Identification of sections of the clini-

cal assessment being updated, such as check boxes;

1. 2. Updated narrative for each section of

the previous assessment that has changed;

1. 3. Clinical formulation (interpretive

summary);

1. 4. Diagnosis change/update;
2. 5. Individual’s expression of service

preferences;

1. 6. Assessed needs/treatment recommen-

dations; and

1. 7. Signature of the staff person complet-

ing the assessment, Community Support Supervisor (unless they are completing the assessment), and a licensed diagnostician or physician/physician extender.

1. (5) Initial Treatment Plan. An individual treatment plan must be developed within forty-five (45) days of completion of eligibility determination for CPR services.

   1. (A) The treatment plan is developed collaboratively with the individual or parent/guardian and a QMHP, the individual’s community support supervisor, if different from the QMHP, and a physician/physician extender.

   2. (B) Documentation for completion of the initial treatment plan must include, at a minimum:

      1. 1. Identifying information;
      2. 2. Goals as expressed by the person

served and family members/natural supports, as appropriate, that are measurable, achievable, time-specific with start date, strength/skill based and include supports/resources needed to meet goals and potential barriers to achieving goals;

1. 3. Specific treatment objectives, includ-

ing a start date, that are understandable to the individual served, sufficiently specific to assess progress, responsive to the disability or concern, and reflective of age, development, culture, and ethnicity;

1. 4. Specific interventions including

action steps, modalities, and services to be used, duration and frequency of interventions, who is responsible for the intervention, and action steps of the individual served and his/her family/natural supports;

1. 5. Identification of other agency/com-

munity resources and supports including others providing services, plans for coordinating with other agencies, services needed beyond the scope of the CPR program to be addressed through referral/services with another organization;

1. 6. Anticipated discharge and continuing

recovery planning which includes, but is not limited to, criteria for service conclusion, how will the individual served and/or parent/guardian and clinician know treatment goals have been accomplished; and

1. 7. Signature of the individual or par-

ent/guardian and the QMHP/community support supervisor.

1. A. Physician/physician extender sig-

nature must be obtained within ninety (90) days of completion of the eligibility determination after a face-to-face meeting, consultation, or case review. The physician/physician extender signature certifies treatment is needed and services are appropriate, as described in the treatment plan, and does not recertify the diagnosis.

1. B. A licensed psychologist may

approve the treatment plan when the person served is not currently receiving prescribed medications and the clinical recommendations do not include a need for prescribed medications.

1. (C) If obtaining the individual’s signature on the treatment plan is determined to be detrimental to their well-being and he/she does not sign the plan, a progress note must justify the lack of signature.

   1. 1. For persons eighteen (18) years of age

and younger, the parent/guardian must sign the treatment plan. Lack of parent/guardian signature must be justified in a progress note.

1. 2. For adults with a legal guardian, the

guardian’s signature must be obtained. Lack of the guardian’s signature must be justified in a progress note and include two (2) reasonable attempts to obtain the signature. Reasonable attempts include home visits, phone calls, mailed letters, and faxes to the guardian.

1. (6) Crisis Prevention Plan. If a potential risk for suicide, violence, or other at-risk behavior is identified during the assessment process, or any time during the individual’s engagement in services, a crisis prevention plan shall be developed with the individual as soon as possible.

   1. (A) Documentation for completion of the crisis prevention plan shall include, at a minimum, factors that may precipitate a crisis, a hierarchical list of skills/strengths identified by the individual to regain a sense of control to return to his or her level of functioning before the crisis or emergency, and a hierarchical list of staff interventions that may be used when a critical situation occurs.

2. (7) Annual Treatment Plan. Treatment plans must be updated annually for individuals engaged in CPR services to reflect current goals, needs, and progress in treatment.

   1. (A) The plan is updated collaboratively with the individual or parent/guardian, community support supervisor, community support specialist, and physician/physician extender.

      1. 1. A licensed psychologist may take the

place of the physician/physician extender if medications are not currently prescribed and the clinical recommendations do not include a need for prescribed medications.

1. (B) Documentation for completion of the annual treatment plan must include, at a minimum:

   1. 1. Updates related to the annual assess-

ment and periodic updates to the functional assessment;

1. 2. Signature of community support

supervisor;

1. 3. Signature of community support spe-

cialist;

1. 4. Signature of individual or

parent/guardian; and

1. 5. Signature of physician/physician

extender or licensed psychologist.

1. (C) If obtaining the individual’s signature on the annual treatment plan is determined to be detrimental to his or her well-being and he/she does not sign the plan, a progress note must justify the lack of signature.

1. (8) Functional Assessment. A departmentapproved functional assessment must be completed with each individual as part of the initial comprehensive assessment. The functional assessment shall be updated in accordance with the timeframes established by the department to assess current level of functioning, progress toward treatment objectives, and appropriateness of continued services. The treatment plan shall be revised to incorporate the results of the initial functional assessment and subsequent updates.

   1. (A) Documentation of the initial functional assessment and regular updates shall include, at a minimum:

      1. 1. Barriers, issues, or problems con-

veyed by the individual, parent/guardian, family/natural supports, and/or staff indicating the need for focused services;

1. 2. A brief explanation of any changes or

progress in the daily living functional abilities in the prior ninety (90) days; and

1. 3. A description of the changes for the

treatment plan based on information obtained from the functional assessment.

1. (B) Documentation of the findings from the 9 CSR 30-4

functional assessment includes any of the following:

1. 1. A narrative section with the treatment

plan that includes the functional update content requirements;

1. 2. A narrative section on the functional

assessment with the content requirements; or

1. 3. A progress note in the individual

record documenting the content requirements.

1. (C) Completed functional assessments must be available to department staff and other authorized representatives for review/audit purposes upon request.
2. (D) For individuals receiving services in a community residential program, the functional assessment must be completed a minimum of every ninety (90) days and documented in the individual record.

1. (9) Discharge. When individuals are discharged from CPR services, a discharge summary must be prepared and entered in the individual record in accordance with 9 CSR 10-7.030.
2. (10) Data. The CPR program shall provide data to the department, upon request, regarding characteristics of individuals served, services, costs, or other information in a format specified by the department.
3. (11) Availability of Records. All documentation must be made available to department staff and other authorized representatives for review/audit purposes at the site where the service(s) was rendered. Documentation must be legible and made contemporaneously with the delivery of the service (at the time the service was provided or within five (5) business days of the time it was provided), and address individual specifics including, at a minimum, individualized statements that support the assessment or treatment encounter.

AUTHORITY: section 630.655, RSMo 2016.* 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. Amended: Filed Dec. 1, 2011, effective June 30, 2012. Amended: Filed April 29, 2019, effective Nov. 30, 2019. ** *Original authority; 630.655, RSMo 1980. **Pursuant to Executive Orders 20-04, 20-10, and 20-12, 9 CSR 30- 4.035, sections (3) and (5) was suspended from April 23, 2020 through December 30, 2020.