PURPOSE: This rule specifies the service delivery 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).

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) Person-Centered Planning. Each individual being served in a residential program or day program who has a diagnosed mental illness and/or Intellectual or Developmental Disabilities (IDD) must have a plan to guide service delivery and coordinate resources and supports in accordance with his or her needs, expressed preferences, and decisions concerning his/her life in the community.

   1. (A) Types of plans—

      1. 1. Individual Support Plan (ISP)—devel-

oped as defined in 9 CSR 45-3.010; a copy is provided to the residential program or day program by staff of the Developmental Disabilities (DD) targeted case management team;

1. 2. Individual Treatment Plan (ITP)—

developed by the individual served and/or his or her parents/guardian, with assistance from staff of the administrative agent or affiliate involved in his or her care and treatment; a copy is provided to the residential program or day program by staff of the administrative agent or affiliate; and

1. 3. Care Plan—for individuals who do

not have an ISP or ITP, developed by the individual served and/or his or her parents/guardian with assistance from staff of the residential program or day program, family members, and other natural supports of his/her choice.

1. A. Care plans shall be developed

within thirty (30) days of an individual’s admission to a residential program or day program. If the individual already has a care plan, the plan shall be updated within thirty (30) days of admission to create action steps to support implementation of the plan and add any new services or supports needed.

1. B. The care plan shall include mea-

surable goals and objectives important to the individual such as, self-sufficiency, community membership and involvement, education and employment, leisure time and activities, health and wellness, and personal relationships. The plan assists the individual in achieving personally defined outcomes, ensures delivery of services and supports in a manner that reflect personal preferences and choices, and contributes to the assurance of health and wellness.

1. (B) Residential services and supports consistent with the individual’s needs and goals must be addressed in his/her plan. If the ISP, ITP, or care plan does not include services/supports specific to the residential program or day program, staff shall incorporate appropriate services/supports into the plan with input from the individual served and/or family members and other natural supports, as appropriate.
2. (C) Plan reviews and updates shall be com- 9 CSR 40-1

pleted as follows:

1. 1. Staff of the residential program or day

program enter monthly documentation into each individual’s ISP, ITP, or care plan including, at a minimum, progress toward personal goals, modifications to necessary services and supports, and significant changes in the person’s life, as applicable;

1. 2. Quarterly and annual reviews and

updates to the ISP or ITP are completed by staff of the DD case management team or administrative agent or affiliate respectively. A copy is maintained on file at the residential program or day program; and

1. 3. Care plans are updated at least annu-

ally by staff of the residential program or day program in collaboration with the individual served and/or his or her parents/guardian, family members, and other natural supports of his/her choice.

1. (D) Individuals shall be supported in their efforts to obtain and maintain competitive employment of their choice, participate in job-training programs, educational opportunities, self-help skills, leisure time activities, and other programs of their choice.
2. (E) Opportunities for a variety of activities inside and outside the program shall be available, consistent with the interests of individuals served.

1. (2) Health Screen and Risk Assessment. Within thirty (30) days of transition into a residential program or day program, each individual served shall have verification in his/her record of having a health screening and risk assessment within the past year from their primary healthcare provider. The primary healthcare provider may be a physician, assistant physician, advanced practice registered nurse (APRN), or physician assistant.

   1. (A) The health screening and any additional screenings or tests shall be directed by the individual’s primary healthcare provider.
   2. (B) Individuals shall receive vision, hearing, and dental examinations as recommended by their primary healthcare provider.
   3. (C) Individuals shall receive psychiatric evaluations and continuing care and treatment by a physician or physician’s designee of their choice, as needed.
   4. (D) Immunizations shall be current as recommended by DHSS 2020 immunization schedules incorporated by reference and available at: https://health.mo.gov/living/wellness/immunizations/schedules.php., MO Department of Health and Senior Services, 912 Wildwood, PO Box 570, Jefferson City, Missouri 65102, Phone: 573-751-6400. This rule does not incorporate any subsequent amendments or additions to the schedules listed above. This rule does not prohibit programs from complying with schedules set forth in newer versions of the incorporated by reference material listed in this subsection of this rule.
   5. (E) Individuals shall receive an annual health screening unless specified otherwise by their primary healthcare provider.

   6. (F) A risk assessment shall be completed for each individual at the time of admission to the residential program or day program to identify factors that may influence his or her behavior. The assessment shall include, but is not limited to:

      1. 1. Suicide risk;
      2. 2. Risk of self-harm;
      3. 3. Risk of harm to others;
      4. 4. Physical, sexual, and/or emotional

abuse experienced or witnessed;

1. 5. History and presence of trauma symp-

toms; and

1. 6. Aggressive or disruptive behavior.

2. (G) A safety crisis plan or crisis prevention plan shall be developed with individuals identified as having risk factors for harm to self or others. The plans must be readily accessible to all staff involved in the individual’s support.

   1. 1. Individuals with pro re nata (PRN)

orders for antipsychotic medication(s) must have parameters for use in their safety crisis plan or crisis prevention plan, including nonpharmacological interventions.

1. 2. PRN use of antipsychotic medication

for individuals with a safety crisis plan or crisis prevention plan shall be reviewed quarterly by the individual’s primary healthcare provider.

1. (H) If an individual needs support with personal hygiene, grooming, telephone use, or other aspect of daily living, appropriate assistance shall be provided by staff and must be specified in his or her ISP, ITP, or care plan.
2. (I) Prompt healthcare, including dental treatment, shall be arranged for individuals receiving services in a residential program, as needed.

1. (3) General Healthcare and Medications. Medications for individuals served shall be properly stored and administered by staff.

   1. (A) An order from a licensed physician (including psychiatrist) or an assistant physician, physician assistant, or APRN who is in a collaborating practice arrangement with a licensed physician is required for all medication and treatment being administered to individuals in the program except nonprescription topical medications. Orders must include diagnosis and indications for use.
   2. (B) Each individual’s record shall include current orders from all healthcare providers and all orders shall be followed by staff.
   3. (C) Medication and treatment orders shall be reviewed as directed by the individual’s primary healthcare provider, and all reviews must be documented at least annually in the individual record. Orders do not need to be rewritten if there are no changes; the healthcare provider’s signature and date are sufficient.
   4. (D) PRN orders for antipsychotic medication(s) must be documented in the individual’s record with parameters for use, including non-pharmacological interventions.
   5. (E) Standing PRN orders for the entire residential program or day program are not permitted.
   6. (F) PRN orders for nonprescription medication and treatment may be utilized if the individual’s primary healthcare provider’s order specifies the dosage and/or treatment for specific indications.
   7. (G) In an emergency, a healthcare provider may give or change an order by telephone. In such cases, the order must be signed by the healthcare provider within forty-eight (48) hours of the order being issued by telephone.
   8. (H) For individuals under the care of multiple healthcare providers, all medical orders shall be maintained together in the individual record.
   9. (I) Individuals shall be provided with a comprehensive list of their medications to take to healthcare and dental appointments.
   10. (J) Any special dietary needs must be included in the individual’s orders from their primary healthcare provider.

2. (4) Administration of Medication. A safe and effective process for medication control and use shall be implemented and maintained by staff.

   1. (A) All medication administered to individuals served must be in accordance with their primary healthcare provider’s orders using acceptable nursing practices.
   2. (B) Staff who administer medication must be at least eighteen (18) years of age.
   3. (C) The staff person who prepares a medication(s) must administer and chart it at the time of administration.

   4. (D) All staff who administer and/or observe self-administration of medication by individuals served, with the exception of licensed physicians, nurses, pharmacists, assistant physicians, and physician assistants, must comply with one (1) of the following prior to the provision of services:

      1. 1. Complete training and remain in

good standing as a Level I Medication Aide or Certified Medication Technician with DHSS as specified at: https://health.mo.gov/safety/cnaregistry/lima .php; or

1. 2. Complete Medication Aide training

in accordance with curriculum established by the Division of Developmental Disabilities as specified in 9 CSR 45-3.070, available at: https://www.sos.mo.gov/cmsimages/adrules/csr/current/9csr/9c45-3.pdf.

1. A. Medication Aides must update and

document their training every two (2) years.

1. (E) At least one (1) staff person trained in medication administration must be on duty in the residential program or day program twenty-four (24) hours per day, seven (7) days per week.

2. (F) Self-administration of medication is allowed and must be supervised by staff trained in medication administration.

   1. 1. If an individual self-administers med-

ication, it must be included in his or her primary healthcare provider’s orders and his/her ITP, ISP, or care plan, including the level of supervision and documentation required. Self-administration of medication should be encouraged, and individuals should be assisted in learning how to safely manage their medications.

1. (G) Errors in administration of medication must be reported immediately to the individual’s primary healthcare provider, parent/guardian, if applicable, and to the department as specified in 9 CSR 10-5.206.

1. (5) Storage and Disposal of Medication. All medications, including over-the-counter medications, must be packaged and labeled in accordance with applicable professional pharmacy standards and state and federal drug laws.

   1. (A) All prescription medications shall be supplied as individual prescriptions except when an emergency medication supply is allowed.

   2. (B) Labeling of medications must include accessory and cautionary instructions, expiration date, when applicable, and the name of the medication as specified in the primary healthcare provider’s order. Over-the-counter medications must be labeled with at least the individual’s name. Medications shall not be repackaged or altered by staff except as allowed when an individual temporarily leaves the program premises.

      1. 1. The program shall have policies and

procedures for family members and other natural supports and/or legal representative to provide adequate advance notice so prescription medication can be provided in a separate container by the pharmacy when an individual will be leaving the program for an extended period.

1. (C) All medications must be stored in a locked container or storage area as follows:

   1. 1. Schedule II-V medications must be

stored separately from other medications under double lock;

1. 2. Internal and external medications

must be stored separately; and

1. 3. Medications requiring refrigeration

must be stored in a locked container separated from food. for Community Residential Programs and Day Programs

1. (D) Controlled medications must be documented on a medication administration record and controlled substance count sheet in accordance with state and federal regulations.
2. (E) Stock supplies of nonprescription medication may be kept in the program when specific medications are approved in writing by a consulting physician, registered nurse, or pharmacist.

3. (F) Unused, discontinued, outdated, or deteriorated prescription and over-thecounter medications must be properly disposed of in accordance with DHSS regulation 19 CSR 30-86.042(60), available at: h ttps://www.sos.mo.gov/cmsimages/adru les/csr/previous/19csr/19csr1012/19c30- 86.pdf.

   1. 1. Medications shall be destroyed within

the program by a pharmacist and a licensed nurse or by two (2) licensed nurses. When two (2) licensed nurses are not available, medications must be destroyed by two (2) staff who have authority to administer medications, one (1) of whom is a licensed nurse or a pharmacist.

1. 2. A record of all destroyed medications

must be maintained at the program and include the individual’s name, date, medication name and strength, quantity, prescription number, and signatures of staff destroying the medication.

1. 3. A record of medications released or

returned to a pharmacy must be maintained by the program and include the individual’s name, date, medication name and strength, quantity, prescription number, and signature(s) of the staff who received and released the medications. (6) Equipment. Medical equipment and firstaid supplies needed to treat simple emergencies must be maintained in operable condition and be available at the program at all times. If the program has medical and nursing equipment, it must be maintained in operable condition and stored so it is reasonably accessible and used only for the purpose intended. (7) Isolation. If a healthcare provider recommends an individual with a contagious or infectious disease be placed in isolation, staff of the program shall ensure the recommendation is implemented immediately. (8) Personal Supports. Staff of the program shall ensure individuals have access to clean clothing and personal care items, as needed.

1. (A) Each individual shall have an adequate supply of properly-fitting, age-appropriate clothing that is neat, clean, seasonable, and suitable to the occasion. Identification on clothing should be discreet.
2. (B) Each individual shall have his/her own toothbrush, toothpaste, washcloth, towel, comb or hairbrush, or both.
3. (C) Shaving equipment shall be provided, as needed, in accordance with the ISP, ITP, or care plan of the individual served.
4. (D) Personal hygiene items shall be stored to maintain sanitary conditions and prevent the transmission of communicable disease.
5. (E) Individuals shall be trained and supported in developmental and self-help skills to include dressing, grooming, toileting, bathing/showering, and hygiene, as needed.
6. (F) Individuals shall be trained and supported in eating skills and the use of adaptive equipment in accordance with their individual needs. 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.