PURPOSE: This rule sets out requirements for quality assurance activities and functions for community psychiatric rehabilitation programs.

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 10-7.040 Quality Improvement.
2. (2) The community psychiatric rehabilitation

3. (CPR) provider shall establish a quality assurance process that includes, but is not limited to, the following functions:

   1. (A) Evaluating the competencies of clinical staff as set out in 9 CSR 40-4.034(6);
   2. (B) Supervising of all staff as set out in 9 CSR 30-4.034(2);
   3. (C) Monitoring of clinical records as set out in 9 CSR 30-4.035(2);
   4. (D) Monitoring of identified process and outcomes of the CPR provider’s community psychiatric rehabilitation program as set out in sections (3)–(6); and
   5. (E) Monitoring compliance of affiliate programs and subcontractors with applicable program standards.

4. (3) The CPR provider shall establish, support and maintain the quality assurance process through the CPR provider’s professional and administrative staff by—

   1. (A) Delegating the administration and coordination of the quality assurance process to a quality assurance committee, group or individual; and
   2. (B) Actively involving the CPR program’s medical staff in the activities of the quality assurance process including, but not limited to, clinical care issues and practices related to the use of medications.

5. (4) The CPR provider shall develop and implement a quality assurance plan that integrates the functions of the quality assurance process into the CPR program’s psychiatric services.

   1. (A) The CPR provider shall describe the quality assurance process in a written quality assurance plan, approved by the governing body.
   2. (B) The quality assurance plan shall identify the persons or positions responsible for the implementation of the quality assurance program.
   3. (C) The CPR provider and its governing body shall review the plan annually and revise it as appropriate.

6. (5) The CPR provider shall monitor key programmatic indicators jointly identified by the CPR provider and the Division of Comprehensive Psychiatric Services.

   1. (A) The CPR provider shall collect data for each indicator on an ongoing basis, using a standardized format, which the department, at its discretion, may require.
   2. (B) When a significant problem or quality of care issue is identified, the CPR provider shall act to correct the problem or improve the effectiveness of care, or both. The CPR provider shall assess corrective or supportive actions through continued monitoring.

7. (6) The CPR provider shall maintain a quality assurance record system.

   1. (A) The record system shall contain documentation, including monitoring reviews, reports, recommendations, corrective actions and the status of previously identified problems or outcomes related to certification standards, or both.
   2. (B) The CPR provider shall centrally maintain the record system and make it available for review.
   3. (C) The record system shall include minutes of all quality assurance meetings with attendance, time, place, date, actions or recommendations for action noted.

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. Amended: Filed Feb. 28, 2001, effective Oct. 30, 2001.

*Original authority: 630.655, RSMo 1980.