PURPOSE: This rule specifies the administrative requirements for all community residential programs and day programs subject to licensure by the department in accordance with 9 CSR 40-1.055, including Residential Care Facilities (RCF) and Assisted Living Facilities (ALF) dually licensed by the Department of Health and Senior Services (DHSS).

1. (1) Director. Each community residential program and day program shall have a chief administrative officer/program director who shall—

   1. (A) Be empowered to make decisions regarding the operation of the program;
   2. (B) Delegate a staff person who is empowered to act for him/her when absent from the program; and
   3. (C) Report any change in the ownership, management, or administration to the department within five (5) days.
2. (2) Licensing. The director shall ensure the program maintains a license in good standing with the Department of Health and Senior Services (DHSS) as specified in 9 CSR 40- 1.055, subsection (2)(C), if applicable.

3. (3) Policies and Procedures. A policy and procedure manual shall be maintained on-site which promotes compliance with these licensing regulations and other federal, state, and/or local regulations applicable to the program.

   1. (A) The director shall ensure the policies and procedures are followed by staff and are readily available for review by all employees, department staff, and other authorized representatives. The policy and procedure manual shall include, but is not limited to:

      1. 1. A description of program goals, mis-

sion, purpose, services, and costs;

1. 2. The number, characteristics, and

needs of individuals served, including how the program is specifically designed to support those needs;

1. 3. Admission, discharge, and transfer of

individuals served which ensures—

1. A. The program does not admit, nor

keep in residence, any person whose needs exceed its provisions for care, support, and program functions;

1. B. Each individual admitted is able to

function safely within the physical environment of the program;

1. C. Individuals admitted to an adult

residential program or day program are at least eighteen (18) years of age; and

1. D. The program does not admit more

individuals than its licensed capacity;

1. 4. Rights, responsibilities, and grievance

procedures in accordance with 9 CSR 40- 1.065;

1. 5. Provisions for an organized record

system in accordance with 9 CSR 40-1.070;

1. 6. Delivery of person-centered services

in accordance with 9 CSR 40-1.075;

1. 7. Dietary services in accordance with 9

CSR 40-1.080;

1. 8. Use and storage of firearms and

ammunition in accordance with 9 CSR 40- 1.085 subsection (12)(A);

1. 9. Environmental safety and mainte-

nance in accordance with 9 CSR 40-1.085;

1. 10. Fire safety and emergency prepared-

ness in accordance with 9 CSR 40-1.090;

1. 11. Background screening process in

accordance with 9 CSR 10-5.190;

1. 12. Reporting of complaints of abuse,

neglect, and misuse of funds/property in accordance with 9 CSR 10-5.200 and 9 CSR 10-5.206;

1. 13. Research in accordance with 9 CSR

60-1.010;

1. 14. The care and maintenance of pets,

including documentation of all applicable vaccinations and health statements in accordance with local and state regulations; and

1. 15. Employee policies and procedures

including, but not limited to:

1. A. Orientation process;
2. B. Health and safety practices, use of

tobacco products, illegal and legal substances brought into the program, prescription medication brought into the program, and weapons brought into the program; and

1. C. Confidentiality of individual

records and information.

1. (B) Policies and procedures shall clearly state that an individual receiving services cannot supervise or discipline another individual who is receiving services.
2. (C) Business activities shall not be allowed on the premises of the program other than those authorized by the department as consistent with the health, welfare, and safety of individuals served and as compatible with the integrity of the program.

1. (4) Staffing and Training. Staff shall be available in sufficient numbers to provide necessary and beneficial services/supports and possess the training, experience, and credentials to effectively perform their assigned duties.

   1. (A) All employees shall complete orientation and training within the first thirty (30) days of employment in order to be knowledgeable of their job duties including, but not limited to:

      1. 1. An overview of the population

served, program goals, mission, policies, and procedures;

1. 2. Respective job assignment(s) and

related duties;

1. 3. Regulations regarding individual

rights, confidentiality, duty to warn, and reporting alleged abuse, neglect, and misuse of funds/property of individuals served in accordance with 9 CSR 10-5.200, 9 CSR 10- 5.206, and 19 CSR 30-88.010; and

1. 4. Emergency and evacuation policies

and procedures, including protocol to be followed when accompanying individuals in the community.

1. (B) Staff who are promoted or transferred to a new job assignment(s) shall receive training and orientation on their new responsibilities within thirty (30) days of actual transfer to the new assignment.
2. (C) A new employee shall not be assigned sole responsibility for implementation of an individual support plan (ISP), individual treatment plan (ITP), or care plan until his or her training and orientation have been completed.

3. (D) Each employee providing direct services and/or supports shall participate in annual in-service training including, but not limited to:

   1. 1. Emergency and evacuation policies

and procedures;

1. 2. Individual rights;
2. 3. Infection control procedures;
3. 4. Reporting of abuse, neglect, and mis-

use of funds/property in accordance with 9 CSR 10-5.200, 9 CSR 10-5.206, and 19 CSR 30-88.010; and

1. 5. Specialized training to meet the needs

of individuals served.

1. (E) Records of attendance and documentation of successful completion of all training for Community Residential Programs and Day Programs

and orientation must be documented in a centralized location and/or each employee’s personnel record, including the trainee’s name, topic, date(s), length of time or training, and instructor(s) name, title, credentials, and signature.

1. (5) Volunteers. If the program uses volunteers to provide services and/or supports, written policies and procedures shall be implemented to guide the roles and activities of volunteers in an organized and productive manner. Volunteers shall be qualified to deliver the services and/or supports provided, have a background screening in accordance with 9 CSR 10-5.190, and receive orientation, training, and adequate supervision.

   1. (A) Orientation shall occur within thirty

2. (30) days of the individual’s volunteer work with the program including, but not limited to:

   1. 1. An overview of the population

served, program goals, mission, policies, and procedures;

1. 2. Regulations regarding individual

rights, confidentiality, duty to warn, and reporting alleged abuse, neglect, and misuse of funds/property of individuals served in accordance with 9 CSR 10-5.200, 9 CSR 10- 5.206, and 19 CSR 30-88.010;

1. 3. Emergency and evacuation policies

and procedures, including protocol to be followed when accompanying individuals in the community; and

1. 4. Other topics relevant to their assign-

ment(s).

1. (6) Emergency Planning. The policies and procedures for emergency situations shall include instructions for staff and individuals served including, but not limited to:

   1. (A) Medical emergencies, including response to an incapacitated person, protocol for initiating a 911 emergency call, and use of cardiopulmonary resuscitation (CPR) and First Aid.

      1. 1. Drills shall be conducted at least

quarterly for staff involved in the 911 protocol and administration of CPR and first aid.

1. 2. Trained staff shall be available in suf-

ficient numbers to respond to emergency situations and provide first aid and CPR, when necessary. At least one (1) trained staff person shall be on duty in the program twentyfour (24) hours per day, seven (7) days per week. Depending on the configuration of the building and number of individuals being served, more than one (1) trained staff person per shift may be required.

1. A. Staff must maintain current First

Aid and CPR certification for healthcare providers through training that includes hands-on practice and in-person skills. Training provided solely online is not acceptable;

1. (B) Natural disasters, such as a fire or tornado;
2. (C) Bomb threats;
3. (D) Utility failure;
4. (E) Violent or threatening situations;
5. (F) Elopements;
6. (G) Behavioral crisis;
7. (H) Psychiatric crisis;
8. (I) Death of an individual served;
9. (J) Arrest or detention of an individual served;
10. (K) Use of cellular phones during an emergency; and

11. (L) Infectious or contagious disease.

    1. 1. Policies and procedures for the pre-

vention, containment, and reporting of infectious and contagious diseases shall be established in accordance with DHSS communicable disease regulations as specified in 19 CSR 20-20, available at: https://s1.sos.mo.gov/cmsimages/adrules/csr /current/19csr/19c20-20.pdf.

1. 2. Any employee or volunteer diagnosed

or suspected of having a contagious or infectious disease shall not work with individuals served or in dietary service until a written statement is obtained from a healthcare provider indicating the disease is no longer contagious or is found to be noninfectious.

1. (7) Emergency Safety Interventions. Written policies and procedures shall be implemented to prevent and respond to disruptive behavior, a behavioral crisis, or a psychiatric crisis that may occur with individuals served, staff, visitors, and others. All efforts shall be made to minimize re-traumatization of persons served or others involved in a disruptive situation, including consideration as to whether the program is suitable to meet the individual’s needs.

   1. (A) Policies and procedures shall indicate whether time-out, seclusion, and restraint are used in the program. If such interventions are used, policies and procedures shall include, but are not limited to:

      1. 1. Staff authorized to order, apply, and

monitor their use;

1. 2. Protocol for their use with individuals

served;

1. 3. Time limits for such orders;
2. 4. Duration of such orders;
3. 5. Incorporation of such orders in the

ISP, ITP, or care plan of the individual served; and

1. 6. Documentation of such orders in the

individual record.

1. (B) Programs may prohibit by policy and practice the use of time-out, seclusion, and restraint and must implement policies and 9 CSR 40-1

procedures to address disruptive behaviors and behavioral and psychiatric crises.

1. (C) All policies and procedures must be—

   1. 1. Approved by the board of directors,

as applicable;

1. 2. Available to all program staff and ser-

vice providers;

1. 3. Available to individuals served and

parents/guardians, family members, and other natural supports, as appropriate;

1. 4. Developed with input from individu-

als served and, whenever possible, parents/guardians, family members, and other natural supports; and

1. 5. Consistent with department regula-

tions regarding individual rights.

1. (D) All staff and volunteers having direct contact with individuals served shall receive documented initial and ongoing competencybased training on evidence-based and best practice interventions for preventing disruptive behaviors, behavioral crises, and psychiatric crises and addressing them in the least restrictive manner if they occur.

2. (E) All programs shall prohibit by policy and practice—

   1. 1. Aversive conditioning of any kind—

the application of startling, unpleasant, or painful stimulus or stimuli that have a potentially harmful effect on an individual in an effort to decrease maladaptive behavior;

1. 2. Withholding of food, water, or bath-

room privileges;

1. 3. Painful stimuli;
2. 4. Corporal punishment (such as use of

pepper spray, mace, Taser, stun gun);

1. 5. Techniques that obstruct an individ-

ual’s airway or impairs breathing;

1. 6. Techniques that restrict an individ-

ual’s ability to communicate;

1. 7. Use of time-out or other disciplinary

action for staff convenience; and

1. 8. Chemical restraints—use of a medica-

tion to sedate or limit an individual’s ability to participate in services/supports rather than treat the symptoms of his or her behavioral health disorder or IDD as prescribed and specified in the ISP, ITP, or care plan. Medication used as prescribed and as indicated in the individual’s plan to treat symptoms of a behavioral health disorder or IDD, including aggressive behavior, is not considered a chemical restraint.

1. (F) Preventive strategies including, but not limited to, de-escalation, changes to the physical environment (time-away), redirection, and active listening shall be employed to moderate potentially aggressive behavior.
2. (G) Seclusion and restraint shall only be used when an individual’s behavior presents an immediate risk of danger to themselves or others and no other safe or effective treatment intervention is possible. These measures shall only be implemented when alternative, less restrictive interventions have failed or cannot be safely implemented. Seclusion and restraint are never used as treatment interventions. They are emergency/security measures to maintain safety when all other less restrictive interventions are inadequate.
3. (H) The use of seclusion or restraint shall be in accordance with the order of the program’s attending physician or clinical director. Staff shall notify the attending physician or clinical director at the earliest possible time when a situation has a significant likelihood of leading to seclusion or restraint. If seclusion or restraint is initiated prior to obtaining an order, staff must obtain an order immediately.
4. (I) Standing or pro re nata (PRN) orders for seclusion or restraint are not allowed.
5. (J) Orders for seclusion or restraint shall be individualized to each event, define specific time limits, and be ended at the earliest possible time. Orders shall not exceed four

1. (4) hours for adults, two (2) hours for children/youth age nine (9) to seventeen (17), and one (1) hour for children under age nine (9). If there is a need for continuing seclusion or restraint beyond the time limits specified herein, the attending physician or clinical director must write a new order for seclusion or restraint.

   1. (K) Seclusion and restraint shall only be implemented by staff who are trained and competent in the proper techniques for administering/applying the form of seclusion or restraint ordered, and for providing ongoing monitoring and assessment of individuals for their safety and well-being. At a minimum, documented initial and ongoing training shall include:

      1. 1. Techniques to identify individual

behaviors, events, and environmental factors that may trigger circumstances requiring the use of seclusion or restraint;

1. 2. The use of nonphysical intervention

skills;

1. 3. Choosing the least restrictive inter-

vention based on an individualized assessment of the individual’s medical and/or behavioral status or condition;

1. 4. The safe application and use of all

types of seclusion or restraint used by the program, including how to recognize and respond to signs of physical and psychological distress;

1. 5. Clinical identification of specific

behavioral changes that indicate restraint or seclusion is no longer necessary;

1. 6. Monitoring the physical and psycho-

logical well-being of the individual who is secluded or restrained, including, but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified in the program’s policies and procedures associated with face-toface evaluations; and

1. 7. The use of first aid techniques and

certification in CPR, including required periodic recertification.

1. A. Staff administering seclusion or

restraint shall receive annual training and demonstrate competence on the particular intervention(s) ordered and used in the program.

1. (L) Mechanical supports are not considered restraints.

2. (M) While an individual is being secluded or restrained, trained staff shall continually observe and assess him or her to assure appropriate care and treatment including, but not limited to:

   1. 1. Attention to vital signs;
   2. 2. Need for meals and liquids;
   3. 3. Bathing and use of the restroom; and
   4. 4. Need for seclusion or restraint to con-

tinue.

1. (N) Documentation of an order for seclusion, restraint, or time-out shall be placed in the individual record as soon as possible after the occurrence and include, but not be limited to:

   1. 1. Reason for the intervention;
   2. 2. Staff who ordered the intervention;
   3. 3. Type of intervention used;
   4. 4. Starting and ending time;
   5. 5. Regular observations of the individual

including any resulting injuries or other issues as a result of the intervention;

1. 6. Notification of parent/guardian, as

applicable;

1. 7. Notification of healthcare provider, as

applicable; and

1. 8. Modifications to the ISP, ITP, or care

plan as a result of the intervention.

1. (O) The program’s clinical director and/or performance improvement coordinator shall review every episode of seclusion, restraint, or time-out to ensure policies and procedures were followed and to identify any areas needing improvement. A written report on the program’s overall use of these interventions, including progress made in reduction of their use, shall be prepared at least annually and reviewed by administrative leadership of the organization/program.

1. (8) Behavior Support Plans. Behavior support plans shall be developed as specified in 9 CSR 10-7.060 and 9 CSR 45-3.090. AUTHORITY: sections 630.050 and 630.705, RSMo 2016.* Original rule filed May 14, 2020, effective Dec. 30, 2020. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.705, RSMo 1980, amended 1982, 1984, 1985, 1990, 2000, 2011, 2014.