PURPOSE: This rule prescribes the contents to be found in client’s records. (1) Each agency that is certified shall comply with all requirements set forth in Department of Mental Health Core Rules for Psychiatric and Substance Abuse Programs, 9 CSR 10- 7.030 Service Delivery Process and Documentation.

1. (2) Treatment plans shall be reviewed and updated as necessary to reflect client progress and changes in treatment goals and services.
2. (3) Treatment plans shall be revised and rewritten at least annually.
3. (4) Treatment plans shall be developed by and approved by an individual who meets the minimum requirements for a qualified mental health professional as defined in 9 CSR 30- 4.010.

4. (5) The provider shall ensure that the client participates in the development of the treatment plan and signs the plan. Client signature is not required if signing would be detrimental to the client’s well-being. If the client does not sign the treatment plan, the provider shall insert a progress note in the case record explaining the reason why the client did not sign the plan.

   1. (A) For children and youth, the parent or guardian shall participate in the development of the treatment plan and sign the plan. If the parent or guardian does not sign the treatment plan, the provider shall insert a progress note in the case record explaining why they did not sign the plan.
   2. (B) The child or youth is not required to sign the treatment plan. However, the child or youth shall participate in the development of the treatment plan as appropriate.
5. (6) Each agency shall have a written method and procedure to assure quality client records which includes routine review of client records.

6. (7) Each agency that is certified shall be subject to recoupment of all or part of Department of Mental Health payments when:

   1. (A) The client record fails to document the service paid for was actually provided;
   2. (B) The client record fails to document a qualified staff person as defined in the Department of Mental Health Purchase of Service Catalog, provided the service;
   3. (C) The client record fails to document the service that was paid meets the service definition as defined in the Department of Mental Health Purchase of Service Catalog;
   4. (D) The client record fails to document the amount, duration, and length of the service paid for by the department; and 9 CSR 30-4
   5. (E) The client record fails to document the service paid for was delivered under the direction of a current treatment plan that meets all the requirements for treatment plans set forth in 9 CSR 10-7.030 and 9 CSR 30- 4.160.

AUTHORITY: sections 630.050 and 630.655, RSMo 2000.* Original rule filed June 14, 1985, effective Dec. 1, 1985. Amended: Filed Feb. 28, 2001, effective Oct. 30, 2001.

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