PURPOSE: This rule prescribes requirements for services and supports in all community residential facilities and Psychiatric Group Homes II as required by section 630.710, RSMo.

1. (1) Every resident of a licensed community residential facility and Psychiatric Group Home II shall have an individualized treatment plan (ITP) or individualized habilitation plan (IHP). The plan shall be reviewed at least quarterly and updated annually. The annual update of the plan shall be implemented within three hundred sixty-five (365) days after the implementation of the previous plan.
2. (2) The IHP or ITP shall be person-centered and shall address community membership and involvement, resident choice and positive relationships with people who are not paid staff.

3. (3) The responsibility for the development, monthly or quarterly review and annual update of the ITP or IHP shall be as follows:

   1. (A) The head of the facility is responsible for the plan with respect to residents who are not clients of the department; and 9 CSR 40-4
   2. (B) The regional center, department facility, or administrative agent or designee shall be responsible for the plan with respect to residents who are clients of the department but the head of the facility shall participate in the development of the plan, the monthly or quarterly reviews and annual updates.
4. (4) The head of the facility shall assure that the resident participates in the development of the individualized habilitation or treatment plan.
5. (5) The IHP for each resident of a semi-independent living arrangement shall include affirmative evidence that the resident had been assessed for skills relating to hot water and toxic chemicals. If a resident cannot safely use hot water and toxic chemicals, it shall be so documented in the record.
6. (6) The person responsible for implementation of individual objectives of the ITP or IHP shall collect data on their implementation and shall prepare a monthly summary.
7. (7) The head of the facility shall schedule social and recreational activities both in the facility and in the community.
8. (8) School-age residents shall be enrolled in the local public school, state school for the severely handicapped or private school approved by the Department of Elementary and Secondary Education, except as provided for in section (8).
9. (9) If a school-age resident is not enrolled in school, the head of the facility shall document in the resident’s record efforts that have been taken to involve the resident and why these efforts have failed.
10. (10) The facility shall assure every resident an adequate supply of neat, clean, suitable and seasonable clothing. Clothing shall be appropriate to the resident’s age and to the occasion. Identification marks on clothing shall be unobtrusive.
11. (11) The facility shall provide each resident his/her own toothbrush, washcloth, towel, and comb, hairbrush, or both. Personal hygiene items shall be stored in such a way so as to maintain sanitary conditions and prevent transmission of communicable diseases. Adult residents shall have individual shaving equipment as appropriate.
12. (12) The facility shall train residents in activities of daily living skills.
13. (13) Except in semi-independent living arrangements, every resident shall have a tub bath or shower daily.
14. (14) The facility shall provide training in eating skills and in the use of adaptive equipment where it serves the eating-skill development process.
15. (15) If a facility does not have trained staff or otherwise is incapable of meeting sections (16)—(26) regarding seclusion, restraints or time-outs, the head of the facility shall arrange for the transfer of the resident requiring restraints to a state-operated facility or other appropriate facility.
16. (16) The facility shall not use seclusion or aversive stimuli.

17. (17) The facility shall not use physical restraint, mechanical restraint or chemical restraint for—

    1. (A) The convenience of staff;
    2. (B) Punishment;
    3. (C) A substitute for activities or programs; and
    4. (D) A degree or in a quantity that interferes with a resident’s habilitation or treatment plan.
    5. (18) The facility shall not use physical restraint, mechanical restraint, chemical restraint or protective devices unless—
    6. (A) It is necessary to protect the resident or others from serious physical injury;
    7. (B) Less restrictive alternatives have failed;
    8. (C) Authorization is obtained in accordance with section (20);
    9. (D) It is applied by staff trained in the use of restraints; and
    10. (E) It is applied in a way that will not cause physical injury, bodily discomfort or psychological trauma to the resident.

18. (19) If a facility has a policy prohibiting the use of physical restraint, that policy shall be in writing and stipulate the following:

    1. (A) The facility specifically states in writing that it will never use physical restraint under any circumstances;
    2. (B) The policy prohibiting use of physical restraint is appropriate and realistic for residents being served;
    3. (C) The admission criteria would prohibit admitting any resident who would likely need to be physically restrained; and
    4. (D) The facility describes how explosive behavior will be managed without the use of physical restraint.

19. (20) The facility shall not use restraint or protective devices unless it has been authorized as follows:

    1. (A) In emergency situations, physical restraint may be applied without prior authorization;
    2. (B) Chemical restraint and mechanical restraint shall require a prior written order from the attending physician and the approval of the head of the facility. An authorization, including pro re nata (PRN) orders shall be for a single application only. In an emergency, a physician may give or change an order by telephone but the order shall be signed by the physician within forty-eight

20. (48) hours; and

    1. (C) Protective devices shall require a prior order from the attending physician, the approval of the head of the facility and except in emergencies, the approval of the interdisciplinary team. PRN orders shall be allowed if renewed every ninety (90) days and are in compliance with section (20).

21. (21) The facility shall require orders for mechanical restraint, chemical restraints and protective devices to include:

    1. (A) The name of the resident;
    2. (B) The name and signature of the person(s) ordering the restraint or protective device;
    3. (C) The reason for ordering the restraint or protective device including specific behavior and the frequency of behaviors that led to the order and what less restrictive alternatives had been attempted; and
    4. (D) The type and duration of the restraint or protective device.

22. (22) The facility shall limit the duration of restraint as follows:

    1. (A) An application of physical restraint shall end as soon as the precipitating causes have ended;
    2. (B) An application of mechanical restraint shall end as soon as the precipitating causes have ended or be evaluated after two (2) hours and continued by order of the physician; and
    3. (C) An application of a protective device shall end as specified by a physician in a current order.

23. (23) The facility shall have residents checked periodically as follows:

    1. (A) Residents under chemical restraint shall be checked as specified by the attending physician, but not to exceed two (2) hours, in terms of the effect of the medication. Checks shall be made by staff trained in the administration of medications; and
    2. (B) Residents under mechanical restraints shall be checked every fifteen (15) minutes in terms of the resident’s comfort, body adjustment and circulation. After one (1) hour, a resident in mechanical restraint shall be given an opportunity for motion and exercise.

24. (24) When behavior necessitating restraint recurs beyond the initial twenty-four (24)- hour period more than once (1) within a week or twice (2) within a month, the head of the facility and the interdisciplinary team shall immediately develop a plan to respond to the behavior in a systematic manner in order to reduce the likelihood of its recurrence. This plan shall be incorporated in the resident’s individualized habilitation or treatment plan and shall include:

    1. (A) Behavior to be eliminated;
    2. (B) Less restrictive methods and medications used;
    3. (C) Current method and medications to be used;
    4. (D) Schedule for use of the method;
    5. (E) Person responsible for the program; and
    6. (F) Data to be collected to assess progress toward the objective.

25. (25) The facility shall use time-out only as follows:

    1. (A) A resident is placed in time-out only under conditions set out in a written behavior modification program incorporated in his/her individualized habilitation or treatment plan;
    2. (B) The resident’s IHP or ITP identifies the precise behavior which may precipitate time-out and identifies staff persons authorized to implement time-out procedures;
    3. (C) A single time-out period does not exceed fifteen (15) minutes;
    4. (D) The date, time and duration of each time-out period shall be documented in the resident’s file; and
    5. (E) THe client is not placed alone in a locked room.
26. (26) Temporary exclusion or removal of a resident as a behavior control method but not as a formal behavior modification procedure shall be governed by written policies regarding control and discipline, as required by 9 CSR 40-2.075(2)(A)3.E.
27. (27) Mechanical supports are not considered restraints.
28. (28) Mechanical supports shall be prescribed by a licensed physician, designed and applied under the supervision of a registered occupational therapist, physical therapist, registered nurse or physician, who shall issue an order indicating how often residents shall be checked for proper body alignment, circulation, position change and other bodily functions which might be affected by use of mechanical supports. The orders shall be Licensed by the Division of Aging and Psychiatric Group Homes II

reviewed at least quarterly by the physician, occupational therapist, physical therapist or registered nurse. Residents in mechanical supports shall be checked at a minimum of twice daily, upon application of the supports and upon their removal unless more frequent checks are required by the order.

1. (29) A notation of all observations and checks of the person placed under restraint, in timeout or in mechanical supports shall be entered in the resident’s record.
2. (30) Physical and mechanical restraints shall only be applied by staff who have completed a department-approved training program on the application and use of restraints.

AUTHORITY: sections 630.050 and 630.705, RSMo (1994).* Original rule filed Oct. 13, 1983, effective Jan. 15, 1984. Amended: Filed March 14, 1984, effective Aug. 15, 1984. Amended: Filed July 15, 1985, effective Feb. 1, 1986. Amended: Filed Jan. 2, 1990, effective June 11, 1990. Amended: Filed April 1, 1993, effective Dec. 9, 1993. Amended: Filed July 17, 1995, effective March 30, 1996. *Original authority: 630.050, RSMo (1980), amended 1993, 1995 and 630.705, RSMo (1980), amended 1982, 1984, 1985, 1990.