PURPOSE: This rule sets policies and procedure requirements relating to psychiatric treatment services provided by community psychiatric rehabilitation programs. (1) The community psychiatric rehabilitation (CPR) provider shall establish and implement written policies and procedures regarding the evaluation of the medical need of clients in consultation with a physician.

1. (A) The evaluation team shall determine a person’s need for a physical examination.

   1. 1. The procedure shall include health

questions, date of last physical examination, awareness of any medical problems, and current medications prescribed and taken.

1. 2. The CPR provider shall file results of

the physical examination in the person’s clinical record.

1. (2) The CPR provider shall provide the following community psychiatric rehabilitation services to eligible clients, as prescribed by individualized treatment plans:

   1. (A) Crisis intervention and resolution, face-to-face emergency or telephone intervention services, available twenty-four (24) hours a day on an unscheduled basis to the client, designed to resolve crisis, provide support and assistance, and to promote a return to routine adaptive functioning. Key service functions shall include, at a minimum, but are not limited to:

      1. 1. Interacting with an identified client,

family members, legal guardian, significant others, or a combination of these;

1. 2. Specifying factors that led to the

client’s crisis state, when known;

1. 3. Identifying the maladaptive reactions

exhibited by the client;

1. 4. Evaluating the potential for rapid

regression;

1. 5. Attempting to resolve the crisis; and
2. 6. When indicated, referring the client

for treatment in an alternative setting. Nonmedical staff providing crisis intervention and resolution shall have immediate twentyfour- (24-) hour telephone access to physician consultation;

1. (B) Medication services, goal-oriented interaction regarding the need for psychoactive medications and the management of a medication regimen. Advanced practice nurses and psychiatric pharmacists may provide this service, subject to the guidelines and limitations promulgated for each specialty in statutes and administrative rules. Psychiatric pharmacists are allowed to provide all key service functions with the exception of prescribing medications under paragraph (2)(B)7. Key service functions shall include, but are not limited to:

   1. 1. An assessment of the client’s present-

ing condition;

1. 2. A mental status exam;
2. 3. A review of symptoms and medica-

tion side effects;

1. 4. A review of client functioning;
2. 5. An assessment of the client’s ability

to self-administer medication;

1. 6. Client education regarding the effects

of medication and its relationship to the client’s mental illness; and

1. 7. When indicated, the prescription of

medications;

1. (C) Consultation services, a service provided by a physician, an advanced practice nurse, or a psychiatric pharmacist and consisting of a review of a client’s current medical situation either through consultation with one (1) staff person or in team discussions related to the specific client. The intent is to provide direction to treatment. This is an optional service which may not substitute for supervision nor for face-to-face intervention with clients;
2. (D) Medication Administration. Key service functions include: any therapeutic injection of medication (subcutaneous or intramuscular); monitoring lab levels including consultation with physicians, consumers, and caseworkers; coordination of medication needs with pharmacies, clients, and families, including the use of indigent drug programs (excluding the routine placing of prescription orders and refills with pharmacies); setting up medication boxes; medication drops to consumer residences; patient education regarding medications; recording initial patient histories and vital signs; monitoring medication compliance; monitoring medication side-effects including the use of standardized evaluations; and monitoring physician orders for treatment modifications requiring patient education; 9 CSR 30-4

3. (E) Metabolic Syndrome Screening. Clients who are receiving antipsychotic medications shall be screened annually for the following risk factors: obesity, hypertension, hyperlipidemia, and diabetes.

   1. 1. Services shall be provided by a regis-

tered nurse or a licensed practical nurse. Key service functions include:

1. A. Taking and recording of vital signs;
2. B. Conducting lab tests to assess lipid

levels and blood glucose levels and/or HgbA1c;

1. C. Arranging for and coordinating lab

tests to assess lipid levels and blood glucose levels and or HgbA1c;

1. D. Obtaining results of lab tests to

assess lipid levels and blood glucose levels and/or HgbA1c; and

1. E. Recording the results of all

required vital signs and lab tests on a form approved by the department.

1. 2. If the lab tests are conducted by a reg-

istered nurse or a licensed practical nurse onsite, the provider shall use the Cholestech LDX analyzer or other machine approved by the department. Recently completed lipid panel and blood glucose levels and/or HgbA1c from other health care providers may be obtained. When a client is being regularly followed by a health care provider, the results of the most recently completed lipid panel and blood glucose levels and/or HgbA1c may be obtained and used to complete the metabolic syndrome screening process. Metabolic syndrome screening shall be limited to no more than one (1) time every ninety (90) days per individual;

1. (F) Community support, activities designed to ease an individual’s immediate and continued adjustment to community living by coordinating delivery of mental health services with services provided by other practitioners and agencies, monitoring client progress in organized treatment programs, among other strategies. Key service functions include, but are not limited to:

   1. 1. Assessing and monitoring a client’s

adjustment to community living;

1. 2. Monitoring client participation and

progress in organized treatment programs to assure the planned provision of service according to the client’s individual treatment plan;

1. 3. Participating in the development or

revision of a specific individualized treatment plan;

1. 4. Providing individual assistance to

clients in accessing needed mental health services including accompanying clients to appointments to address medical or other health needs;

1. 5. Providing individual assistance to

clients in accessing a variety of public services including financial and medical assistance and housing, including assistance on an emergency basis, and directly helping to meet needs for food, shelter, and clothing;

1. 6. Assisting the client to access and uti-

lize a variety of community agencies and resources to provide ongoing social, educational, vocational and recreational supports and activities;

1. 7. Interceding on behalf of individual

clients within the community-at-large to assist the client in achieving and maintaining their community adjustment;

1. 8. Maintaining contact with clients who

are hospitalized and participating in and facilitating discharge planning;

1. 9. Training, coaching, and supporting in

daily living skills, including housekeeping, cooking, personal grooming, accessing transportation, keeping a budget, paying bills, and maintaining an independent residence;

1. 10. Assisting in creating personal sup-

port systems that include work with family members, legal guardians, or significant others regarding the needs and abilities of an identified client;

1. 11. Encouraging and promoting recov-

ery efforts, consumer independence/selfcare, and responsibility; and

1. 12. Providing support to families in

areas such as treatment planning, dissemination of information, linking to services, and parent guidance;

1. (G) Certified Missouri Peer Specialists, as defined in 9 CSR 30-4.030 and 9 CSR 30- 4.034, may provide the following peer support services:

   1. 1. Assisting an individual to recover

by—

1. A. Helping an individual recognize

what he or she thinks would improve the quality of his or her life such as setting a recovery goal; and

1. B. Helping an individual identify and

remove the barriers to achieving that life;

1. 2. Certified Missouri Peer Specialists

use the power of peers to support, encourage, and model recovery and resilience from mental illness in ways that are specific to the needs of each individual including the following:

1. A. Peer support services are individ-

ual or group services with a rehabilitation and recovery focus;

1. B. Peer support services promote

skills for coping with and managing psychiatric symptoms while encouraging the use of natural supports and enhancing community living;

1. C. Peer support activities assist in

achieving goals and objectives set forth by the individual in their individualized treatment or recovery plan; and

1. D. Peer support activities emphasize

the opportunity for individuals to support each other as they move forward in their recovery;

1. 3. Certified Missouri Peer Specialists

interventions may include, but are not limited to, the following:

1. A. Sharing lived experiences of

recovery and sharing and supporting the use of recovery tools and modeling successful recovery behaviors;

1. B. Helping individuals recognize their

capacity for resilience;

1. C. Helping individuals connect with

other consumers and their communities at large;

1. D. Helping individuals who have

mental illness develop a network for information and support;

1. E. Assisting individuals who have

mental illness to make independent choices and to take a proactive role in their treatment;

1. F. Assisting individuals with identify-

ing strengths and personal resources to aid in their recovery; and

1. G. Helping individuals set and

achieve recovery goals;

1. 4. The job description for a Certified

Missouri Peer Specialist shall include supportive activities including, but not limited to, the following:

1. A. Starting and sustaining mutual

support groups;

1. B. Promoting dialogues on recovery

and resilience;

1. C. Teaching and modeling symptom

management skills;

1. D. Teaching and modeling problem-

solving skills;

1. E. Supporting efforts to find and

maintain paid employment;

1. F. Using the stages in recovery con-

cept to promote self-determination; and

1. G. Assisting peers in setting goals and

following through on wellness and health activities;

1. 5. Certified Missouri Peer Specialists

shall follow a code of ethics determined by the department;

1. (H) Family Support. Services designed to provide a support system for parents of children up to age twenty-one (21) with serious emotional disorders. Activities are directed and authorized by the child’s individualized treatment plan. Key service functions include, but are not limited to the following:

   1. 1. Determining level of understanding of

the child’s diagnosis and special needs;

1. 2. Engaging the parents or guardians to

actively participate in the child and family team meetings by helping them predetermine their roles and the roles of natural supports;

1. 3. Assisting the parents or guardians in

identifying their natural supports or surrogate supports;

1. 4. Helping the parents or guardians

identify the child’s strengths and strengths of the family;

1. 5. Supporting the parents or guardians at

child and family team meetings and modeling good advocacy skills;

1. 6. Assisting in trouble shooting and

problem solving with strategies that are not working;

1. 7. Connecting families to community

resources; and

1. 8. Helping the parents or guardians find

and empower their own voice to become part of the system of care for their child;

1. (I) Child and Adolescent Family Assistance. Services designed to focus on the child or adolescent and the development of home and community living skills, communication, socialization, and identifying and arranging for appropriate community services. Key service functions include, but are not limited to, the following:

   1. 1. Modeling appropriate behaviors and

coping skills for the child;

1. 2. Exposing the child to activities that

encourage positive choices, promote selfesteem, support academic achievement, and develop problem solving skills regarding home and school;

1. 3. Teaching appropriate social skills

through hands on experiences; and

1. 4. Mentoring appropriate social interac-

tions with the child or adolescent or resolving conflict with peers;

1. (J) Day Treatment for Youth. An intensive array of services provided in a structured, supervised environment designed to reduce symptoms of a psychiatric disorder and maximize functioning. Services are individualized based on the child’s needs and include a multidisciplinary approach of care under the direction of a physician. The provision of educational services shall be in compliance with Individuals with Disabilities Education Act 2004 and section 167.126, RSMo. Services shall be provided in the following manner:

   1. 1. Hours of operation shall be deter-

mined by the individual providers based on capacity, staffing availability, and space requirements. The child shall be in attendance for a minimum of three (3) hours per day, four (4) days per week, and no more than seven (7) hours per day;

1. 2. Eligibility criteria shall include the

following:

1. A. For children six (6) years of age

and older, the client must be at risk of inpatient or residential placement as a result of their serious emotional disturbance; and

1. B. For children five (5) years of age or

younger, the child must have one (1) or more of the following:

1. (I) Has been expelled from multiple

day care/early learning programs due to emotional or behavioral dysregulation in relation to serious emotional disturbance or Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood Zero to Three, Revised (DC03R) diagnosis and previous services provided in an early childhood program were unsuccessful;

1. (II) At risk for an acute psychiatric

hospital or residential treatment center placement as a result of their serious emotional disturbance; and/or

1. (III) Score in the seriously impaired

functioning level on the standardized functional tools approved by DMH for this age range; and

1. 3. Key service functions include, but are

not limited to the following:

1. A. Providing integrated treatment

combining education, counseling, and family interventions;

1. B. Promoting active involvement of

parents or guardians in the program;

1. C. Providing consultation and coordi-

nation to establish and maintain continuity of care with the child’s/family’s private service providers;

1. D. Coordinating and information

sharing, consistent with Family Educational Rights and Privacy Act and Health Insurance Portability and Accountability Act, and discharge planning with the school;

1. E. Requesting screening and assess-

ment reports for special education from the school;

1. F. Planning with the school how the

individualized education needs of each child will be addressed; and

1. G. Additional core services as pre-

scribed by the department;

1. (K) Psychosocial Rehabilitation for Youth. A combination of goal-oriented and rehabilitative services provided in a group setting to improve or maintain the youth’s ability to function as independently as possible within the family or community. Services shall be provided according to the individual treatment plan with an emphasis on community integration, independence, and resiliency;
2. (L) Intensive Community Psychiatric Rehabilitation (CPR) as defined in 9 CSR 30- 4.045;

3. (M) Psychosocial Rehabilitation. Key service functions include, but are not limited to, the following services which must be available within the community psychiatric rehabilitation program as indicated by individual client need:

   1. 1. Initial screening to evaluate the

appropriateness of the client’s participation in the program;

1. 2. Development of individualized pro-

gram goals and objectives;

1. 3. The provision of rehabilitative ser-

vices which may occur during the day, evenings, weekends, or a combination of these. Services should be structured, but are not limited to a program site;

1. 4. Services that enhance independent

living skills;

1. 5. Services that address basic self-care

needs;

1. 6. Services that enhance the use of per-

sonal support systems;

1. 7. Transportation to and from communi-

ty facilities and resources as a part of program strategies;

1. 8. Services shall be provided according

to individual need toward goals of community inclusion, integration, and independence; and

1. 9. Services should be available to adults

as well as children and youth who need ageappropriate developmental focused rehabilitation;

1. (N) Psychosocial Rehabilitation Illness Management and Recovery (PSR-IMR). A Psychosocial Rehabilitation program may offer department-approved psychosocial services provided individually or in a small group setting with a focus on recovery and the management of mental illness. Key service functions include, but are not limited to, the following services:

   1. 1. Psychoeducation;
   2. 2. Relapse prevention; and
   3. 3. Coping skills training;
2. (O) Individualized Professional Psychosocial Rehabilitation. Individualized mental health interventions may be offered using a skills based approach to address identified behavioral problems and functional deficits relating to a mental disorder that interferes with an individual’s personal, family, or community adjustment. Services must be documented according to the requirements set forth in 9 CSR 30-4.035(8)(E); and
3. (P) Group Professional Psychosocial Rehabilitation. Group mental health interventions may be offered using a skills-based approach to address identified behavioral problems and functional deficits relating to a mental disorder that interferes with an individual’s per- 9 CSR 30-4

sonal, family, or community adjustment. Maximum group size is one (1) professional to eight (8) individuals. Services must be documented according to the requirements set forth in 9 CSR 30-4.035(8)(E).

AUTHORITY: sections 630.655 and 632.050, RSMo 2000, and section 630.050, RSMo Supp. 2011.* Original rule filed Jan. 19, 1989, effective April 15, 1989. Emergency amendment filed Aug. 27, 1993, effective Sept. 8, 1993, expired Nov. 7, 1993. Emergency amendment filed Oct. 28, 1993, effective Nov. 7, 1993, expired March 6, 1994. Emergency amendment filed Feb. 15, 1994, effective March 6, 1994, expired April 10, 1994. Amended: Filed Aug. 27, 1993, effective April 9, 1994. 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 Dec. 1, 2011, effective June 30, 2012. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008; 630.655, RSMo 1980; and 632.050, RSMo 1980.