PURPOSE: This rule sets forth standards and regulations for the provision of ICPR services. (1) Intensive Community Psychiatric Rehabilitation (ICPR). Services are designed to help individuals who are experiencing a severe psychiatric condition, alleviating or eliminating the need to admit them into a psychiatric inpatient setting or a restrictive living setting. ICPR is a comprehensive, time-limited community-based service for individuals who are exhibiting symptoms that interfere with individual/family life in a highly disabling manner.

1. (A) ICPR is intended for—

   1. 1. Persons who would be hospitalized

without the provision of intensive community-based intervention;

1. 2. Persons who have extended or repeat-

ed hospitalizations;

1. 3. Persons who have crisis episodes;
2. 4. Persons who are at risk of being

removed from their home or school to a more restrictive environment; and

1. 5. Persons who require assistance in

transitioning from a highly restrictive setting to a community-based alternative, including specifically persons being discharged from inpatient psychiatric settings who require assertive outreach and engagement.

1. (B) Treatment teams deliver services that will maintain the individual within the family and significant support systems and assist them in meeting basic living needs and age appropriate developmental needs.

1. (2) Admission Criteria. To be eligible for ICPR, the individual must meet admission criteria as defined in 9 CSR 30-4.005 and at least one (1) of the following criteria:

   1. (A) Is being discharged from a department facility or bed funded by the department;
   2. (B) Has had extended or repeated psychiatric inpatient hospitalizations or crisis episodes within the past six (6) months;
   3. (C) Has had multiple out-of-home placements due to his/her mental disorder; or
   4. (D) Is at risk of being removed from his/her home, school, or current natural living situation.

2. (3) Staff Requirements. A treatment team coordinates a comprehensive array of services available to the individual through the CPR program.

   1. (A) The treatment team is supervised by a qualified mental health professional (QMHP) and includes the following:

      1. 1. Staff required to provide specific ser-

vices identified on the individualized treatment plan; and

1. 2. The individual receiving services and

family members or other natural supports if developmentally appropriate.

1. (4) Treatment.

   1. (A) ICPR shall include—

      1. 1. Multiple face-to-face contacts with

the individual on a weekly basis, and may require contact on a daily basis, as required for each service type;

1. 2. Services that are available twenty-four

1. (24) hours per day, seven (7) days per week; and

   1. 3. Crisis response services that may be

coordinated with an existing crisis system.

1. (B) A full array of CPR services, as defined in 9 CSR 30-4.043, shall be available to each individual based upon identified needs.
2. (C) The amount and frequency of services is based upon the individual’s assessed acuity and need.
3. (D) A crisis prevention plan shall be developed for each individual, including clinical issues that may impact his/her transition to less intensive services.

4. (E) Individuals no longer need ICPR when—

   1. 1. There is a reduction of severe symp-

toms; and

1. 2. They are able to function without

intensive services; or

1. 3. They choose to no longer receive

intensive services.

1. (5) Documentation Requirements. ICPR services must be documented in accordance with 9 CSR 10-7.030(13), and as specified in this rule.

   1. (A) For individuals currently enrolled in the CPR program, the following documentation is required upon admission to ICPR:

      1. 1. Verification they meet admission cri-

teria;

1. 2. Acuity level; and
2. 3. Treatment plan update indicating the

higher level of service he/she will be receiving.

1. (B) For individuals newly admitted directly from the community into ICPR, a comprehensive behavioral health assessment must be completed to substantiate acuity and criteria for admission.

   1. 1. Each individual shall have a psychi-

atric evaluation at admission. For individuals discharged from inpatient hospitalization into ICPR, a psychiatric evaluation completed at the facility/hospital will initially be accepted.

1. 2. The comprehensive assessment must

be completed within thirty (30) days of admission except for individuals admitted provisionally.

1. 3. Treatment plans shall be developed

upon admission and updated as necessary.

1. (C) Treatment plans shall be reviewed as required for each service type and documented in the individual record with a summary progress note, including updates to the treatment plan as appropriate.
2. (D) Upon change from ICPR services, a transition summary must be completed by a QMHP and included in an updated treatment plan.

1. (6) ICPR for Children and Youth. Services are medically necessary to maintain a child with a Serious Emotional Disturbance (SED) in their natural home, or maintain a child with a serious mental illness or SED in a community setting who has a history of failure in multiple community settings, and/or the presence of ongoing risk of harm to self or others, which would otherwise require long-term psychiatric hospitalization. Clinical interventions are provided by a multidisciplinary treatment team on a daily basis, and the interventions must be available twenty-four

2. (24) hours per day, seven (7) days per week for stabilization purposes. The child’s family and other natural supports may receive services when they are for the direct benefit of the child in accordance with their individual treatment plan.

   1. (A) Services shall include, but are not limited to—

      1. 1. Medication administration/manage-

ment of medication;

1. 2. Ongoing behavioral health assessment

and diagnosis;

1. 3. Monitoring to assure individual safe-

ty;

1. 4. Individual and group counseling; and
2. 5. Community support.

3. (B) The ICPR multidisciplinary team shall include the following staff, based on the needs of the individual served:

   1. 1. Physician, psychiatrist, child psychia-

trist, psychiatric resident, or Advanced Practice Nurse (APRN);

1. 2. QMHP;
2. 3. RN;
3. 4. LPN;
4. 5. Community Support Specialist; and
5. 6. Individuals with a high school diplo-

ma, or equivalent certificate, under the direction and supervision of a QMHP.

1. (C) Services are limited to ninety (90) days. Exceptions may be granted by the department and must be documented in the individual record.

1. (7) Intensive Home-Based Services for Children and Youth. Intensive therapeutic interventions are provided to improve the child’s functioning and prevent them from being removed from their natural home and placed into a more restrictive residential treatment setting due to a SED.

   1. (A) Services are for children whose therapeutic needs cannot be met in their natural home or an alternative therapeutic environment is required for transition back to their home or least restrictive setting.
   2. (B) Providers must complete extensive, specialized training required by the department and meet department licensure requirements as specified in 9 CSR 40-6.
   3. (C) The provider shall participate in preplacement and ongoing meetings with the child’s CPR treatment team and assist in development of the treatment plan. The provider is responsible for implementing the treatment plan and maintaining contact with the child’s natural parent/guardian and completing documentation as required by the department.
   4. (D) Services and supports are individualized and strength-based to meet the needs of the child and family across life domains to promote success, safety, and permanence in the home, school, and community. Therapeutic interventions target the child’s serious mental health issues and promote positive development and healthy family functioning.
   5. (E) Children must meet CPR admission criteria and their behavior must be sufficiently under control to live safely in a community setting with appropriate support.
   6. (F) Staff of the CPR program who supervise the child’s services must be available twenty-four (24) hours a day, seven (7) days per week to assist the provider if a crisis situation occurs.
   7. (G) Placement, duration, and intensity of services is based on the specific needs of each child as specified in the MO HealthNet CPR Provider Manual, available from the Department of Social Services, 615 Howerton Court, PO Box 6500, Jefferson City, MO 65102-6500, and as specified in the department contract. The referenced document does not include any later revisions or updates.

2. (8) Evidence-Based Practices (EBP) for Youth. Services involve proven treatment supports for children and youth to address specific behavioral health needs. The selected EBP is based on individual needs and desired outcomes as identified in the treatment plan.

   1. (A) The EBP must be approved by the department. 9 CSR 30-4

   2. (B) Activities associated with the service must include, but are not limited to:

      1. 1. Extensive monitoring and data collec-

tion;

1. 2. Specific skills-training in a prescribed

or natural environment; and

1. 3. Prescriptive responses to a psychiatric

crisis and/or frequent contact with the individual and/or family, in addition to the arranged therapy sessions.

1. (9) ICPR for Adults and Transition-Age Youth. Services are delivered by teams using one (1) of the following methods:

   1. (A) Linking and transitioning individuals from acute or long-term services to less intensive treatment. The time frame for services is approximately ninety (90) days or less, but varies according to individual needs;
   2. (B) Modified Assertive Community Treatment (ACT), as approved by the department. The time frame varies based on individual needs; or
   3. (C) Intensive wrap-around stabilization services for individuals with substantial mental health needs who may otherwise require inpatient hospitalization. The expected period of engagement is approximately ninety (90) days or less, but varies according to individual needs.
   4. (D) Teams may be designated exclusively for individuals in ICPR or be mixed teams serving individuals in ICPR and rehabilitation services.
   5. (E) A department-approved functional assessment must be completed monthly and documented in the individual record.

2. (10) Intensive Home-Based Services for Adults. Medically necessary services/supports are provided to adults who have a serious mental illness and are transitioning from an inpatient psychiatric hospital to the community, or who are at risk of returning to inpatient care due to their clinical status or need for increased support. Services and supports are provided in the individual’s natural home, under the supervision of a QMHP. The home/program is structured to meet individual needs to ensure safety and prevent the individual’s return to a more restrictive setting for services.

   1. (A) Staff providing services/supports must be at least eighteen (18) years of age and have a minimum of a high school diploma or equivalent certificate. Two (2) years of direct heath care experience, or a bachelor’s degree in behavioral sciences, is preferred.
   2. (B) Staff must be systematically trained to provide intensive interventions and supports to reduce the symptoms of mental illness, and intervene and redirect individuals in a psychiatric crisis who are exhibiting behaviors potentially dangerous to themselves or others. A training plan must be in place for each staff person identifying specific topics and frequency of refresher training on each topic, including documentation of course completion.
   3. (C) Support and rehabilitation services related to activities of daily living and crisis prevention and intervention must be provided.
   4. (D) CPR programs that provide services for adults must be approved by the department to provide intensive home-based services.
   5. (E) Documentation must reflect delivery of direct (face-to-face) services and supports such as, daily summary progress notes, group notes, individualized progress notes documenting interventions including crisis assistance, conflict management, behavior redirection, and prompting or reminders.

3. (11) Children’s Inpatient Diversion. A full array of intensive clinical services are provided to children/youth in a highly structured therapeutic setting. Services are designed to restore the child to a prior level of functioning, decrease risk of harm, and prevent transition to a more restrictive setting.

   1. (A) Emergency medical services must be available on site or in close proximity.
   2. (B) A psychiatrist must supervise services which are delivered by a multi-disciplinary treatment team.
   3. (C) Licensed nursing staff must be available on a daily basis.
   4. (D) Licensed occupational and recreational therapists must be available based on individual needs.
   5. (E) The provision of services is limited to certified or deemed-certified CPR programs for children and youth. The service must be accredited by a national accrediting body approved by the department.

4. (12) Adult Inpatient Diversion. A full array of intensive clinical services are provided to adults in a highly supervised and structured therapeutic setting. Services are designed to restore the individual to a prior level of functioning, decrease risk of harm, and prevent transition to a more restrictive setting.

   1. (A) Emergency medical services must be available on site or in close proximity.
   2. (B) Services must be provided in a coordinated effort under the direction of a psychiatrist. Other staff on the treatment team includes licensed nurses, licensed psychologists, social workers, counselors, psychosocial rehabilitation specialists, and other trained supportive staff.

   3. (C) Services shall include, but are not limited to—

      1. 1. Nursing;
      2. 2. Community support;
      3. 3. Psychosocial rehabilitation; and
      4. 4. Co-occurring disorder counseling

and other evidence-based services.

1. (D) The provision of services is limited to CPR programs for adults. The service must be accredited by a national accrediting body approved by the department.

AUTHORITY: sections 630.050, 630.655, and 632.050, RSMo 2016.* Emergency rule filed Dec. 28, 2001, effective Jan. 13, 2002, expired July 11, 2002. Original rule filed Dec. 28, 2001, effective July 12, 2002. Emergency amendment filed June 14, 2010, effective July 1, 2010, expired Feb. 24, 2011. Amended: Filed June 14, 2010, effective Feb. 24, 2011. Amended: Filed April 29, 2019, effective Nov. 30, 2019. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008; 630.655, RSMo 1980; and 632.050, RSMo 1980.