PURPOSE: This rule specifies the core and optional psychiatric treatment services, staffing requirements, and documentation requirements for community psychiatric rehabilitation (CPR) programs.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

1. (1) CPR programs shall comply with requirements set forth in department Core Rules for Psychiatric and Substance Use Disorder Treatment Programs, 9 CSR 10-7.030 Service Delivery Process and Documentation.

   1. (A) Service delivery and documentation requirements specific to the CPR program are included in this rule.

2. (2) Core Services. At a minimum, CPR programs shall directly provide the following core services, or ensure the services are available through a subcontract as specified in 9 CSR 10-7.090(6):

   1. (A) Eligibility determination, in accordance with 9 CSR 30-4.005;
   2. (B) Initial comprehensive assessment, in accordance with 9 CSR 30-4.035;
   3. (C) Annual assessment, in accordance with 9 CSR 30-4.035;
   4. (D) Treatment planning, in accordance with 9 CSR 30-4.035;
   5. (E) Community support, in accordance with 9 CSR 30-4.047;

   6. (F) Crisis Intervention and Resolution— face-to-face emergency or telephone intervention available twenty-four (24) hours a day, on an unscheduled basis, to assist individuals in resolving a crisis and providing support and assistance to promote a return to routine, adaptive functioning. Services must be provided by a qualified mental health professional (QMHP). Nonmedical staff providing crisis intervention and resolution must have immediate, twenty-four (24) hour telephone access to consultation with a physician/physician extender. Minimum service functions shall include, but are not limited to—

      1. 1. Interacting with the identified indi-

vidual and their family members/natural supports, legal guardian, or a combination of these;

1. 2. Specifying factors that led to the indi-

vidual’s crisis state, when known;

1. 3. Identifying maladaptive reactions

exhibited by the individual;

1. 4. Evaluating potential for rapid regres-

sion;

1. 5. Attempting to resolve the crisis; and
2. 6. Referring the individual for treatment

in an alternative setting when indicated.

1. 7. Documentation must include—

   1. A. A description of the precipitating

event(s)/situation when known;

1. B. A description of the individual’s

mental status;

1. C. The intervention(s) initiated to

resolve the individual’s crisis state;

1. D. The individual’s response to the

intervention(s);

1. E. The individual’s disposition; and
2. F. Planned follow-up by staff.

3. (G) Medication Administration—assures the appropriate administration and continuing effectiveness of medication(s) being prescribed for the individual served. Services must be provided by a physician, assistant physician, physician assistant, registered professional nurse (RN), licensed practical nurse (LPN), advanced practice nurse (APRN), psychiatric resident, or psychiatric pharmacist. Key service functions shall include—

   1. 1. Administering therapeutic injections

of medication (subcutaneous or intramuscular);

1. 2. Monitoring lab tests/levels including

consultation with the physician(s), individual served, and community support specialist;

1. 3. Coordinating medication needs with

the individual served and his or her family members/natural supports, as appropriate, and pharmacy staff, including the use of indigent drug programs (does not include routine placing of prescription orders and refills with pharmacies);

1. 4. Setting up medication boxes;
2. 5. Delivering medication to the individ-

ual’s home;

1. 6. Educating the individual about med-

ications;

1. 7. Recording the individual’s initial his-

tories and vital signs;

1. 8. Ensuring medication is taken as pre-

scribed;

1. 9. Monitoring side effects of medication

including the use of standardized evaluations; and

1. 10. Monitoring prescriber’s orders for

treatment modifications and educating the individual served.

1. (H) Medication Services—goal-oriented interaction with the individual served regarding the need for medication and management of a medication regimen. A physician assistant, assistant physician, psychiatric resident, APRN, or psychiatric pharmacist may provide this service, subject to the guidelines and limitations promulgated for each specialty in statutes and administrative rules.

   1. 1. Individuals requiring or requesting

medication shall be seen by a qualified staff person within fifteen (15) days, or sooner, if clinically indicated. All efforts shall be made to ensure established psychotropic medications are continued without interruption. Medication services must occur at least every six (6) months for individuals taking psychiatric medications. Key service functions shall include, but are not limited to—

1. A. Review of the individual’s present-

ing condition;

1. B. Mental status exam;
2. C. Review of symptoms and medica-

tion side effects;

1. D. Review of the individual’s func-

tioning;

1. E. Review of the individual’s ability

to self-administer medication;

1. F. Education on the effects of medica-

tion and its relationship to the individual’s mental illness and his/her choice of medication; and

1. G. Prescription of medications when

indicated.

1. 2. Documentation for medication ser-

vices must include, at a minimum:

1. A. A description of the individual’s

presenting condition;

1. B. Pertinent medical and psychiatric

findings;

1. C. Observations and conclusions;
2. D. Any side effects of medication as

reported by the individual;

1. E. Actions and recommendations

regarding the individual’s ongoing medication regimen; and

1. F. Pertinent information reported by

family members/natural supports regarding a change in the individual’s condition or an unusual or unexpected occurrence in his or her life, or both.

1. (I) Metabolic Syndrome Screening—identifies risk factors for obesity, hypertension, hyperlipidemia, and diabetes. The screening is required annually for adults and children/youth who are receiving antipsychotic medication.

   1. 1. Services must be provided by an RN

or LPN. Key service functions shall include, but are not limited to—

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

levels and blood glucose levels and/or HgbA1c, or arranging and coordinating lab tests to assess lipid levels and blood glucose levels and/or HgbA1c;

1. C. Obtaining results of recently com-

pleted lab tests from other health care providers to assess lipid levels and blood glucose levels and/or HgbA1c; and

1. D. Recording the results of the meta-

bolic screening on a form/tool approved by the department.

1. 2. Metabolic syndrome screening is lim-

ited to no more than one (1) screening every ninety (90) days, per individual. If the lab tests are conducted by a nurse, an analyzer approved by the department must be used.

1. 3. Documentation must reflect comple-

tion of the Metabolic Syndrome Screening and Monitoring Tool and a summary progress note.

1. (J) Physician Consultation/Professional Consultation—medical services provided by a physician, assistant physician, physician assistant, APRN, psychiatric resident, or a psychiatric pharmacist. The service is intended to provide direction to treatment and consists of a review of an individual’s current medical situation either through consultation with one (1) staff person, or a team discussion(s) related to a specific individual. This service cannot be substituted for supervision or face-to-face intervention with the individual. Key service functions shall include, but are not limited to:

   1. 1. An assessment of the individual’s pre-

senting condition as reported by staff;

1. 2. Review of the treatment plan through

consultation;

1. 3. Participant-specific consultation with

staff especially in situations which pose a high risk of psychiatric decompensation, hospitalization, or safety issues; and

1. 4. Participant-specific recommendations

regarding high risk issues and, when needed, to promote early intervention.

1. (K) Psychosocial Rehabilitation for Adults, in accordance with 9 CSR 30-4.046.

1. (3) Optional Services. In addition to the core services defined in subsection (2) of this rule, the following optional services may be provided directly by the CPR program, or through a subcontract as specified in 9 CSR 10-7.090(6):

   1. (A) Adult Inpatient Diversion, in accordance with 9 CSR 30-4.045;
   2. (B) Assertive Community Treatment (ACT), in accordance with 9 CSR 30-4.032;
   3. (C) Children’s Inpatient Diversion, in accordance with 9 CSR 30-4.045;

   4. (D) Day Treatment for Children/Youth—an intensive array of services provided to children/youth in a highly structured and supervised environment designed to reduce symptoms of a psychiatric disorder and maximize the child’s functioning so they can attend school and interact in their community and family setting. Services are individualized based on the child’s needs and include a multidisciplinary approach to care under the direction of a physician. The provision of educational services must comply with the Individuals with Disabilities Education Act and section 167.126, RSMo.

      1. 1. Hours of operation are based on pro-

gram capacity, staffing availability, space requirements, and as specified by the department.

1. 2. Eligibility criteria includes—

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

and older, he or she must be at risk of inpatient or residential placement as a result of a serious emotional disturbance (SED);

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

younger, he or she must exhibit 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 SED or diagnosis based on the 2016 edition of the Diagnostic Classification of Mental Health and Development Disorders of Infancy and Early Childhood (DC:0-5TM), published by and available from ZERO TO THREE, 1255 23rd St. NW, Suite 350, Washington, DC 20037, telephone (202) 638- 1144 or (800) 899-4301. The document incorporated by reference does not include any later amendments or additions;

1. (II) Is at risk for placement in an

acute psychiatric hospital or residential treatment center as a result of a SED; or

1. (III) Has a score in the seriously

impaired functioning level on the standardized functional tools approved by the depart- 9 CSR 30-4

ment for this age range.

1. 3. Key service functions shall include,

but are not limited to:

1. A. Providing integrated treatment

combining education, counseling, and family interventions;

1. B. Promoting active involvement of

the parent/guardian in the program;

1. C. Consulting and coordinating with

the child’s/family’s private service providers, as applicable, to establish and maintain continuity of care;

1. D. Coordinating and sharing informa-

tion with the child’s school, including discharge planning, consistent with the Family Educational Rights and Privacy Act and Health Insurance Portability and Accountability Act (HIPAA);

1. E. Requesting screening and assess-

ment reports from the child’s school to determine any special education needs;

1. F. Planning the individualized educa-

tional needs of the child with his or her school; and

1. G. Providing other core services as

prescribed by the department.

1. 4. For programs serving children three

1. (3) to five (5) years of age, services must be provided by a team of at least one (1) QMHP and one (1) appropriately certified, licensed, or credentialed ancillary staff. For programs serving school-age children, services must be provided by a team consisting of at least one

2. (1) QMHP and two (2) appropriately certified, licensed, or credentialed ancillary staff. Ancillary staff include—

   1. A. Occupational therapists;
   2. B. Physical therapists;
   3. C. Assistant behavior analysts;
   4. D. Individuals with a bachelor’s

degree in child development, psychology, social work, or education; and

1. E. Individuals with an associate’s

degree, or two (2) years of college, and two (2) years of experience in a mental health or child-related field.

1. 5. Documentation must include relevant

information reported by family members/natural supports regarding a change in the child’s condition or an unusual or unexpected occurrence in his/her life.

1. (E) Evidence-Based Practices for Children and Youth, in accordance with 9 CSR 30- 4.045;

2. (F) Family Assistance—services focus on development of home and community living skills and communication and socialization skills for children and youth, including coordination of community-based services. Staff must have a high school diploma or equivalent and two (2) years of experience working with children who have a SED or have experienced abuse and neglect. Staff must also complete training approved by/provided by the department and be supervised by a QMHP. Key service functions shall include, but are not limited to:

   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 for 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 resolving conflict with peers.

1. (G) Family Support—provides a support system for parents/caregivers of a child or youth seventeen (17) years of age and younger who has a SED. Activities are directed and authorized by the individualized treatment plan. Services must be provided by a family member of a child who has or had a behavioral or emotional disorder. The family member must have a high school diploma or equivalent certificate, complete training required by the department, and be supervised by a QMHP. Key service functions shall include, but are not limited to:

   1. 1. Providing information and support to

the parents/caregivers so they have a better understanding of the child’s needs and options to be considered as part of treatment;

1. 2. Assisting the parents/caregivers in

understanding the planning process and importance of their voice in the development and implementation of the individualized treatment plan;

1. 3. Providing support to empower the

parents/caregivers to be a voice for the child and family in the planning meeting;

1. 4. Working with the family to highlight

the importance of individualized planning and the strengths-based approach;

1. 5. Assisting the family in understanding

the roles of various providers and the importance of the team approach;

1. 6. Discussing the benefits of natural

supports within the family and community;

1. 7. Introducing methods for problem-

solving and developing strategies to address issues needing attention;

1. 8. Providing support and information to

parents and caregivers to shift from being the decision maker to the support person as the child/youth becomes more independent;

1. 9. Connecting families to community

resources;

1. 10. Empowering parents and caregivers

and children/youth to become involved in activities related to planning, developing, implementing, and evaluating programs and services; and

1. 11. Connecting parents, caregivers, chil-

dren/youth to others with similar lived experiences to increase their support system.

1. (H) Individual Professional PSR and Group Professional PSR—mental health interventions provided on an individual or group basis. A skills-based approach is utilized to address identified behavioral problems and functional deficits related to a mental disorder that interfere with an individual’s personal, family, or community adjustment. Maximum group size is one (1) professional to eight (8) individuals. This service cannot be provided to individuals under the age of five (5). Services must be provided by the following staff who complete training required by the department:

   1. 1. A professional counselor licensed or

provisionally licensed under Missouri law with specialized training in mental health services;

1. 2. A licensed clinical social worker or

master social worker licensed under Missouri law with specialized training in mental health services;

1. 3. A licensed, provisionally licensed, or

temporarily licensed psychologist under Missouri law with specialized training in mental health services; or

1. 4. A marital and family therapist

licensed or provisionally licensed under Missouri law with specialized training in mental health services.

1. (I) Integrated Treatment for Co-Occurring Disorders (ITCD), in accordance with 9 CSR 30-4.0431;
2. (J) Intensive CPR, in accordance with 9 CSR 30-4.045;
3. (K) Metabolic Syndrome Screening— optional service for individuals not receiving antipsychotic medications and, if provided, must be in accordance with paragraph (2)(I) of this rule;

4. (L) Peer Support—assists individuals in their recovery from a behavioral health disorder in a person-centered, recovery-focused manner. Individuals direct their own recovery and advocacy processes to develop skills for coping with and managing their symptoms, and identify and utilize natural support systems to maintain and enhance community living skills. Services are directed toward achievement of specific goals defined by the person served and specified in the individual treatment plan.

   1. 1. Services are provided by Certified

Peer Specialists who have at least a high school diploma or equivalent certificate, complete applicable training and testing required by the department, and are supervised by a QMHP. Certified Peer Specialists are part of the individual’s treatment team and participate in staff meetings/discussions related to services, but they cannot be assigned an independent caseload. The Certified Peer Specialist Code of Ethics must be followed. Job duties include, but are not limited to:

1. A. Starting and sustaining mutual

support groups;

1. B. Promoting dialogues on recovery

and resilience;

1. C. Teaching and modeling skills to

manage symptoms;

1. D. Teaching and modeling skills to

assist in solving problems;

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. 2. Certified Peer Specialists use the

power of peers to support, encourage, and model recovery and resilience from behavioral health disorders in ways that are specific to the needs of each individual. Services may be provided on an individual or group basis and are designed to assist individuals in achieving the goals and objectives on their individual treatment plan or recovery plan. Activities emphasize the opportunity for individuals to support each other as they move forward in their recovery. Interventions may include, but are not limited to—

1. A. Sharing lived experiences of

recovery, 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 peers and their community at large;

1. D. Helping individuals who have

behavioral health disorders develop a network for information and support;

1. E. Assisting individuals in making

indepen dent choices and taking a proactive role in their treatment;

1. F. Assisting individuals in identifying

strengths and personal resources to aid in their recovery; and

1. G. Helping individuals set and

achieve recovery goals.

1. (M) Professional Parent Home-Based Services, in accordance with 9 CSR 30-4.045;
2. (N) Psychosocial Rehabilitation Illness Management and Recovery (PSR-IMR), in accordance with 9 CSR 30-4.046;
3. (O) Psychosocial Rehabilitation for Youth, in accordance with CSR 30-4.046; and
4. (P) Intensive Home-Based Services for Children and Youth, in accordance with 9 CSR 30-4.045. AUTHORITY: sections 630.050, 630.655, and 632.050, RSMo 2016.* 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. Amended: Filed April 29, 2019, effective Nov. 30, 2019.

*Original authority: 630.050, RSMo 1980, amended 1993, 995, 2008; 630.655, RSMo 1980; and 632.050, RSMo 1980.