PURPOSE: This rule describes the populations served and requirements for services, supports, and staffing in behavioral health community residential programs subject to licensure by the department.

1. (1) Regulations. Licensed behavioral health community residential programs (hereafter referred to as residential programs) shall comply with 9 CSR 40-1 unless specified otherwise in this rule.

2. (2) Fire Safety. Psychiatric Individualized Supported Living (PISL) programs shall comply with 9 CSR 40-1.090 Fire Safety and Emergency Preparedness, with modifications as specified—

   1. (A) Subsection (1)(A), Division of Fire Safety inspection is waived;
   2. (B) Subsection (1)(D), evacuation routes do not need to be posted in the home. Documented training and education on safe exit from the home shall be provided for individuals served. Documentation must include dates of training/education and signature of staff providing the training/education; and
   3. (C) Subsection (1)(M), notification and documentation from the local fire authority is waived.

3. (3) Program Structure. Residential programs provide a high level of services, structure, oversight, and support for adults with serious mental illness who are transitioning from an inpatient psychiatric hospital to the community, or are at risk of returning to inpatient care due to their clinical status or need for increased support. An extensive array of medically necessary services are provided in the individual’s natural home in the community to assist with his or her psychiatric symptoms, functional deficits, and problematic behaviors.

   1. (A) Supports and rehabilitation services related to activities of daily living and crisis prevention and intervention must be provided. Rehabilitation services may be available on-site and in the community to promote psychiatric recovery and a reduction in symptoms in order for each individual to progress toward more independent living.
   2. (B) All individuals receiving services/supports must have an individual treatment plan

4. (ITP) developed by staff of the administrative agent or affiliate involved in their care and shall receive services in accordance with 9 CSR 40-1.075 Person-Centered Services.

   1. 1. A copy of each individual’s current

ITP and crisis prevention plan shall be maintained in a manner so they are readily accessible to staff working in the program. Documentation must indicate program staff are knowledgeable about each individual’s treatment plan and crisis prevention plan.

1. (C) Each residential program shall be structured to ensure safety and prevent the individual’s return to a more restrictive setting. The type of program is based on individual needs for supervision and oversight, tolerance for interactions with other individuals, and the ability to participate in and benefit from other community-based interventions.
2. (D) Psychiatric Individualized Supported Living (PISL) is comprised of services and supports provided in a private home for one

1. (1) to four (4) adults and is most appropriate for individuals who—

   1. 1. Have intermittent difficulty tolerating

other individuals in their immediate living environment; and

1. 2. Require access to an individual bed-

room to promote psychiatric wellness and reduce the potential for aggression or other behaviors associated with a risk of re-hospitalization; and/or

1. 3. Have substantial difficulties with

activities of daily living and require aroundthe-clock observation and oversight; and/or

1. 4. Require daily redirection from staff to

avoid behaviors potentially harmful to themselves or others.

1. A. Each individual served in a PISL

shall have a private, single bedroom unless staff of the administrative agent or affiliate provide adequate justification to the department for shared rooms. Single bedrooms must meet requirements for square footage as specified in 9 CSR 40-1.085(5)(A)1.

1. (E) Intensive Residential Treatment Setting (IRTS) provides service and supports for five

1. (5) to sixteen (16) adults in their natural home and is most appropriate for individuals who—

   1. 1. Can tolerate regular interaction with

their peers, but have significant difficulties with activities of daily living;

1. 2. May require around-the-clock obser-

vation and oversight; and/or

1. 3. Require periodic redirection from

staff to avoid behaviors potentially harmful to themselves or others.

1. A. Each individual served in an IRTS

shall have a private, single bedroom unless staff of the administrative agent or affiliate 9 CSR 40-4

provide adequate justification to the department for shared rooms. Single bedrooms must meet requirements for square footage as specified in 9 CSR 40-1.085 (5)(A)1.

1. (4) Staffing. Each residential program shall have a director who is responsible for making decisions regarding program operations. The director shall delegate a staff person to act on his/her behalf when unavailable.

   1. (A) Staff providing services and supports must be at least eighteen (18) years of age and have a minimum of a high school diploma or equivalent certificate.
   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.
   3. (C) Each staff person must have a training plan that identifies specific topics and frequency of refresher training on each topic, including documentation of course completion.

2. (5) Supervision of Individuals Served. Staff supervision of individuals being served in the program shall be provided in accordance with their assessed needs as documented in the ITP. A system must be in place to ensure each individual is monitored in accordance with his or her ITP. Monitoring shall be documented.

   1. (A) Twenty-four (24) hour protective oversight shall be provided as follows:

      1. 1. PISL programs shall have at least one
3. (1) staff person on duty who is dressed and awake twenty-four (24) hours per day, seven

4. (7) days per week; and

   1. 2. IRTS shall have at least one (1) staff

person on duty during the day and evening shifts for every eight (8) individuals receiving services, and one (1) staff person on duty who is dressed and awake during the night shift for every sixteen (16) individuals served.

1. (B) Procedures shall be in place for staff to rapidly respond to unauthorized absences of individuals being served in the program.
2. (C) Procedures shall be in place to maintain adequate staffing when responding to emergent situations to assure the health and safety of individuals being served.
3. (D) Staff shall be trained on de-escalation and intervention techniques for individuals who may engage in behavior that may be harmful to themselves or others.

1. (6) Program Supervision. A qualified mental health professional (QMHP) as defined in 9 CSR 40-1.015, shall be on site in PISL and IRTS programs a minimum of eight (8) hours per week to provide supervision, program planning, consultation, treatment planning, and support.

   1. (A) A QMHP shall be available twentyfour (24) hours per day, seven (7) days per week, to intervene in crisis situations that may occur in the program.
2. (7) Nursing Services. A licensed RN shall be on-site in PISL and IRTS programs a minimum of four (4) hours per week to provide oversight and coordination of nursing and medical protocols and 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.