PURPOSE: This rule sets policies and procedure requirements relating to psychiatric treatment services provided by community psychiatric rehabilitation programs.

1. (1) The community psychiatric rehabilitation

2. (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 (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;
3. (E) Medication Administration Support. The 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; monitoring medication compliance; and monitoring vital signs;
4. (F) Community support, activities designed to ease an individual’s immediate and continued adjustment to community living by coordinating delivery of mental health ser- 9 CSR 30-4

vices 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/self-care 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) Community support assistants, as defined in 9 CSR 30-4.030 and 9 CSR 30- 4.034, may provide the following community support services:

   1. 1. Providing individual assistance to

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

1. 2. Providing individual assistance to

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

1. 3. Assisting clients to access and utilize

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

1. 4. 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. 5. Accompanying clients to activities in

the community if appropriate;

1. 6. Following up with clients regarding

appointments, completion of forms, returning forms or receipts and other similar activities;

1. (H) Intensive Community Psychiatric Rehabilitation (CPR) as defined in 9 CSR 30- 4.045;

2. (I) 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; and

1. (J) Psychosocial Rehabilitation-Recovery Support. A program certified by the department. Key service functions include, but are not limited to, the following services as indicated by individual client need:

   1. 1. A supervised, low demand environ-

ment that permits clients to practice skills and behaviors that will generalize to assist with personal relationships and supports, community integration and other life activities;

1. 2. Support of informal, low demand

group activities to engage the client to promote receptiveness to service delivery, cooperation with clinical interventions and medication as well as building trust to promote self-disclosure about symptoms, medication effects and other pertinent information;

1. 3. Participation in support and self-help

activities and groups that promote recovery;

1. 4. Participation in informal and orga-

nized group activities to help reduce stress and improve coping that are normative to the community such as exercise, self-education, sports, hobbies, supportive social networks, etc.;

1. 5. Provision of a safe environment for

adaptive skills development and practice for individuals vulnerable to victimization due to the severity of their symptomatology and for those experiencing acute distress due to their psychiatric illness;

1. 6. Ongoing informal assessment regard-

ing participant mental status and communication of relevant information and behavioral descriptions to the team for follow-up as necessary; and

1. 7. Participation may be scheduled or

unscheduled.

AUTHORITY: sections 630.050, 630.655 and 632.050, RSMo 2000.* 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.

*Original authority: 630.050, RSMo 1980, amended 1993, 1995; 630.655, RSMo 1980; and 632.050, RSMo 1980.