PURPOSE: This rule defines terms, establishes principles and sets out the process by which Medicaid agencies providing residential habilitation, day habilitation, supported employment or individualized supported living services attain certification.

1. (1) The Division of Mental Retardation and Developmental Disabilities (division) shall establish procedures under which a Medicaid agency (agency) providing residential habilitation, day habilitation, supported employment or individualized supported living services to persons with developmental disabilities attains certification. In establishing those procedures, the division makes the following assumptions:

   1. (A) A person with a developmental disability or the person’s family can best determine the services the person wants and needs;
   2. (B) The division and the agencies shall work cooperatively to provide quality services and supports that effectively and efficiently meet individual needs of persons with developmental disabilities within the contexts of the persons’ preferred lifestyles;
   3. (C) Through ongoing monitoring, persons with developmental disabilities and their families shall determine the quality of the persons’ services and supports and the effectiveness of the services and supports in meeting the persons’ needs;

   4. (D) The certification process shall be flexible and personcentered and shall serve three (3) critical purposes—

      1. 1. To determine how well the division, its regional centers

and the agencies fulfill their responsibilities to persons with developmental disabilities;

1. 2. To determine systems changes and practices needed

so that the agencies will be more responsive to the persons’ needs; and

1. 3. To enhance inclusion of persons with developmental

disabilities as valued members of their communities;

1. (E) Rather than taking the traditional approach of penalizing agencies that fail to meet minimum standards, the division shall direct its resources and support towards assisting agencies that demonstrate innovation and initiative in pursuing best practices and realizing outcomes contained in the principles set out in section (3).
2. (F) The principles in subsections (3)(A) and (B) and paragraphs (3)(C)1. and (3)(D)3. of this rule are intended to enhance the services of agencies. Certification requires agencies’ commitment to continuous improvement toward realization of those principles;
3. (G) Agencies shall subscribe to and meet the principles in paragraphs (3)(C)2. and (3)(D)1. and 2. of this rule. The division shall enforce those principles; and
4. (H) A residential facility or day program that attains certification from the Division of Mental Retardation and Developmental Disabilities to deliver Medicaid Homeand Community-Based Waiver services is deemed licensed by the department under sections 630.705–630.760, RSMo.

1. (2) Terms defined in sections 630.005 and 633.005, RSMo are incorporated by reference for use in this rule. As used in this rule, unless the context clearly indicates otherwise, the following terms also mean:

   1. (A) Consumer and family monitoring—A formalized review of an agency conducted every two (2) years by an organized consumer-parent group;
   2. (B) Consumer and family monitoring team (monitoring team)—An organized group of at least two (2) parents or other consumers that reviews an agency every two (2) years to assess the quality and responsiveness of the agency’s services;
   3. (C) Core issues—Issues identified by a survey team or monitoring team and which threaten the health or safety of people with developmental disabilities or infringe upon the basic rights of those people;
   4. (D) Enforcement plan—A compliance plan under which an agency satisfies core issues identified by a survey team or monitoring team;
   5. (E) Enhancement plan—A plan under which an agency will further enhance its services by building upon strengths and addressing other issues identified by a survey team;
   6. (F) Medicaid agency—An agency serving people with developmental disabilities under the Medicaid Homeand Community-Based or Nursing Home Reform Waiver program;
   7. (G) Survey team—A group of at least two (2) persons, including the team leader, appointed by the division director or designee to conduct surveys of agencies;
   8. (H) Survey team leader—A division employee who heads a survey team and coordinates its work;
   9. (I) Survey team member—A service provider, regional center employee, parent of a person with a developmental disability or other consumer who has completed training and credentialing by the division, qualifying him/her for membership on a survey team; and
   10. (J) Tailored survey—A survey conducted by a survey team or monitoring team to assess the degree to which an agency has satisfied core issues previously identified by the team.

2. (3) This section prescribes four (4) sets of principles for agencies providing residential habilitation, day habilitation, supported employment or individualized supported living services to persons with developmental disabilities under the Medicaid Homeand Community-Based or Nursing Home Reform Waiver program.

   1. (A) Community Membership.

      1. 1. Promoting acceptance through community

involvement—Outcome: Individuals are active participants in the community where they live.

1. A. Individuals’ days are as diverse and enriching as

others in the community.

1. B. Individuals are supported in efforts to actively

participate in community life.

1. C. Individuals receive needed support when using

community resources.

1. D. Individuals who receive specialized supports receive

them in a place or manner typical for all other community members.

1. E. Individuals live, work, and participate in recreational

activities in settings that are physically integrated into the community.

1. F. Individuals spend the majority of their time in

integrated settings.

1. G. Individuals are familiar with their communities.
2. H. Individuals use generic resources.
3. I. Individuals participate in age-appropriate recreational

activities.

1. J. Individuals have the option to participate in the ethnic

life of the community.

1. K. Individuals have the option to participate in cultural

arts activities in the community.

1. L. Individuals receive supports and adaptations with

consideration for acceptance in the community.

1. M. Individuals use methods of transportation that are

typical for others in the community.

1. N. Individuals’ dress and grooming are consistent with

community norms.

1. O. Individuals know or are learning skills which are

critical to their acceptance in the community.

1. P. Individuals receive training in a manner which is

likely to be accepted by the community.

1. Q. Individuals have the option to participate in the

religious life of their choice in the community.

1. R. Individuals have the option to participate in political

activities of their choice in the community.

1. 2. Supporting and promoting relationships—Outcome:

Individuals have positive relationships with people who are not paid providers.

1. A. Individuals are supported in developing friendships.
2. B. Individuals are supported in sustaining friendships.
3. C. Individuals sustain or reestablish relationships with

family members.

1. D. Individuals who choose responsible, consenting,

intimate relationships are supported.

1. E. Individuals’ relationships with others are encouraged

and supported.

1. F. Individuals’ social support networks are expanded

and enhanced.

1. G. Individuals have repeated opportunities for social

contact with the same people or groups of people.

1. H. Individuals are involved in activities at times which

are conducive to building relationships.

1. I. Individuals’ competencies and interests are emphasized

in expanding the scope of relationships.

1. J. Individuals’ environments are conducive to developing

relationships.

1. K. Individuals invite guests to their homes and on social

occasions.

1. L. Individuals have in their possession personal

information concerning significant others.

1. M. Individuals interact with others consistent with the

intensity of the relationship.

1. 3. Supporting and promoting contribution—Outcome:

Individuals experience the rewards and responsibilities of contributing to society.

1. A. Individuals have the option to contribute to and

receive from others.

1. B. Individuals have the option to join and assume roles

in community organizations.

1. C. Individuals have the option to join and assume roles

in religious organizations.

1. D. Individuals have the option to volunteer.
2. E. Individuals have the option to help their neighbors.
3. 4. Facilitating and enhancing communications—Outcome:

Individuals’ communications are recognized, responded to, and supported.

1. A. Individuals have opportunities for communication in

a variety of settings and with a variety of people.

1. B. Individuals receive supports or services, or both, to

enhance functional communication.

1. C. Individuals who need them have alternative or

augmentative communication systems that are functional.

1. D. Individuals who use alternative systems of

communication have those systems or functional alternatives available for use at all times in all environments.

1. E. Individuals’ families and friends have the option to

receive training in the means of communication used by the individual.

1. F. Individuals’ language or communication systems are

understood and used by people when providing supports or services, or both.

1. G. Individuals’ physical environments are arranged to

promote conversation.

1. H. Individuals’ environments contain accessories and

personal possessions which promote conversation.

1. I. Individuals’ lives contain various activities and

experiences about which to communicate.

1. J. Individuals’ suggestions, opinions, and other

communication are recognized and receive a response.

1. 5. Facilitating community involvement through positive

interaction—Outcome: Individuals interact in a manner which promotes inclusion in community life.

1. A. Individuals are in supportive environments where

most individuals engage in positive, acceptable interactions.

1. B. Individuals are assured continued access to the

community even though they may be displaying unacceptable behaviors.

1. C. Individuals’ interactions are understood in terms of

communicative intent and function.

1. D. Individuals’ interactions are understood in terms

of the variables contributing to the behavior as well as the physical characteristics of the behavior.

1. E. Individuals with unacceptable interactions are

directly observed in the environments where the behaviors occur to determine the purpose of the behavior.

1. F. Individuals with unacceptable interactions are

directly observed by persons knowledgeable and experienced in providing behavioral supports.

1. G. Individuals’ behavioral supports reflect an emphasis

on analyzing the possible reasons for unacceptable interactions prior to planning and implementation.

1. H. Individuals’ unacceptable, non-threatening behaviors

are reduced and more functional alternatives acquired.

1. I. Alternatives other than or in addition to behavioral

supports are considered when severe and persistent mental illness is the presumed causal factor.

1. J. Individuals are supported through provision of a

variety of programming strategies for facilitating or teaching appropriate adaptive behaviors.

1. K. Individuals’ plans present a clear, integrated rationale

explaining the importance to the individual for any proposed intervention.

1. L. Individuals are prevented, as much as possible, from

engaging in severe, unexpected and threatening behaviors that endanger themselves, others, or community property.

1. M. Individuals are protected from endangerment

through the supportive, respectful use of behavioral supports.

1. N. Individuals’ rights are actively protected when

behavioral supports are implemented.

1. (B) Self-determination.

   1. 1. Promoting self-esteem through positive self-expression—

Outcome: Individuals have the opportunity to enhance selfesteem through self-expression.

1. A. Interactions with each individual demonstrate

interest, concern, and consistency.

1. B. Individuals routinely receive unconditional positive

feedback.

1. C. Expectations of each individual are positive.
2. D. Individuals have social and interpersonal problem

solving skills.

1. E. Individuals express their own personal style.
2. F. Individuals are aware of and use personal

competencies.

1. G. Individuals express personal opinions and preferences.
2. H. Individuals have options to express their cultural

heritage.

1. I. Individuals have information about their families and

friends.

1. J. Individuals express their personal histories.
2. K. Individuals understand what belongs to them and

what belongs to others.

1. L. Individuals are aware of their own bodies.
2. M. Individuals differentiate between themselves and

others.

1. 2. Maximizing individual choice and decision making—

Outcome: The responsible choices of individuals are respected and supported in all phases of life.

1. A. Individuals establish personal goals.
2. B. Individuals make informed choices and experience

natural consequences.

1. C. Individuals are supported in carrying out choices.
2. D. Individuals make commitments for which they accept

personal responsibility.

1. E. Individuals participate in the decoration of their

personal area.

1. F. Individuals participate in the decoration of common

living areas.

1. G. Individuals make choices regarding health care

providers.

1. H. Individuals have options to choose from a variety of

alternatives in all areas of their lives.

1. I. Individuals have options to retire.
2. J. Individuals receive and spend money in a typical

fashion.

1. K. Individuals plan their own time.
2. L. Individuals choose their personal possessions.
3. 3. Facilitating empowerment—Outcome: Individuals are

in control of their own lives.

1. A. Individuals have options to acquire and use self-

advocacy and assertiveness skills.

1. B. Individuals regularly utilize formal and informal

means to influence decisions and affect changes.

1. C. Individuals are supported in group advocacy efforts.
2. D. Individuals have options to use external advocates of

their own choosing.

1. E. Individuals express satisfaction or dissatisfaction

without fear of recrimination.

1. F. Individuals participate on agency governing boards or

serve as ex officio members.

1. G. Individuals participate in the strategic planning of

agency supports and services.

1. H. Individuals participate in hiring personnel.
2. I. As individuals gain more power over their own lives,

the degree of external control and protection is reduced.

1. 4. Person-centered planning—Outcome: Person-centered

planning facilitates the empowerment of individuals to attain personal goals.

1. A. A profile of personal information about the individual’s

capacities, dreams, interests, and needs is developed.

1. B. A profile of social information about the individual

in the community, his/her family, social support network, and associational life is developed.

1. C. Information used in the development of personal

profiles is obtained in natural settings.

1. D. Information used in the development of personal and

social profiles is obtained from the individual and from others who know the individual well.

1. E. Information is presented in plain language.
2. F. Professionals in specialized disciplines supplement

knowledge about the individual.

1. G. Individuals have options to chair or co-chair their

own person-centered planning sessions.

1. H. Individuals participate in planning the time, place,

approximate length, and agenda for their person-centered planning sessions.

1. I. Person-centered planning sessions are held as

frequently as necessary but at least annually.

1. J. Professionals in specialized disciplines and significant

others invited to the person-centered planning sessions have spent time with the individual prior to the meeting.

1. K. Individuals participate in selecting and inviting the

people who will participate in their own person-centered planning sessions.

1. L. The type of person-centered planning process selected

is based on each individual and his/her life situation.

1. M. Facilitators are trained in the use of various types of

person-centered planning processes.

1. N. Each individual’s personal goals are the focal point

of the person-centered planning session and are actively addressed.

1. O. Outcome statements present a rationale for the

relevance to the person, a statement of what must be accomplished, and criteria for attainment.

1. P. People at the person-centered planning sessions

consider how to use or enhance natural supports before recommending specialized services.

1. Q. Natural supports are enhanced to decrease dependence

on specialized services and to increase interdependence in the community.

1. R. People at the person-centered planning sessions

determine whether support or training strategies, or both, are desirable.

1. S. The amount and duration of supports and services the

person needs are specified.

1. T. People in attendance at the person-centered planning

sessions decide on who will assume responsibility for specific implementation strategies and timelines.

1. U. Supports, adaptations, services or a combination are

located or created to implement the person-centered plan.

1. V. Individuals choose support or service providers.
2. W. Strategies for attaining personal goals are developed

based on the individual’s personal and social profiles and relevant professional disciplinary assessment.

1. X. Strategies used for implementation of the person-

centered plan are functional, effective, and efficient.

1. Y. Training occurs in the community in which the

individual lives, works, engages in recreational activities, and has relationships.

1. Z. Individuals have the option to coordinate their

individual supports and services. AA. Persons responsible for coordinating the personcentered plan review it with the individual as frequently as necessary but at least monthly. BB. Plan review includes specific objective data as well as feedback from the individual.

1. CC. Persons responsible for coordinating the person-

centered plan make revisions based on the findings from the review process.

1. DD. Supports and services are reduced or modified in

amount and intensity whenever indicated.

1. (C) Rights.

   1. 1. Assuring human rights, dignity and respect—Outcome:

Individuals are treated with respect in an environment that promotes dignity.

1. A. The dignity and comfort of individuals are considered

in all aspects of their lives.

1. B. Specialized supports are developed only when

individuals do not have an identifiable natural support network.

1. C. Individuals recognize the rights of others.
2. D. Individuals’ lives are free of arbitrary rules or

unnecessary behavioral consequences.

1. E. Individuals are not unnecessarily separated from staff

by imposed practices.

1. F. Individuals are not discussed while present unless

included in the conversation.

1. G. Individuals’ needs for privacy are accommodated.
2. H. Individuals are addressed using people-first language.
3. I. Individuals are addressed in an age-appropriate

manner.

1. J. Individuals are addressed in a conversational tone.
2. K. Individuals engage in age-appropriate interactions.
3. L. Individuals receive supports and services in age-

appropriate environments.

1. M. Individuals have access to and use of personal

possessions.

1. N. Individuals secure all public and private benefits to

which they are entitled.

1. 2. Assuring legal rights—Outcome: Individuals exercise or

are assisted in exercising all rights under the Constitution of the United States and those stated in statute.

1. A. Individuals have information on the rights and

responsibilities of citizenship.

1. B. Individuals are involved in any process to limit their

rights and are assisted through external advocacy efforts.

1. C. Individuals are entitled to due process when

limitations are imposed.

1. D. Individuals are free to communicate privately.
2. E. Individuals have freedom of movement.
3. F. Staff are trained in preventing, detecting and reporting

abuse and neglect.

1. G. Abuse and neglect are prohibited by policy.
2. H. Research must comply with state and federal

regulations.

1. I. Guardians and advocates, chosen by the individual,

participate in planning and decision making.

1. J. Individuals are informed of, or are assisted in the

process of obtaining a guardian or conservator or are referred to advocacy services, or both.

1. K. Staff maintain all information about individuals in

confidence.

1. L. Individuals have access to their records and staff are

available to answer their questions.

1. M. Individuals do not perform unpaid work for which

others receive pay.

1. N. Individuals’ rights to a free, appropriate public

education are supported.

1. O. Individuals have information on the rights and

responsibilities of living in the community.

1. (D) Meeting Basic Needs.

   1. 1. Assuring and promoting good health—Outcome:

Individuals maintain good health.

1. A. Individuals have a primary health care provider to

meet health care needs.

1. B. Individuals obtain medical care at intervals

recommended for other persons of similar health status.

1. C. Individuals obtain dental examinations at intervals

recommended for other persons of similar health status and receive follow-up dental treatment as needed.

1. D. Individuals requiring specialized medical services

have access to specialists.

1. E. Individuals are offered support in preparation for

medical and dental care.

1. F. Individuals eat well balanced diets appropriate to

nutritional needs.

1. G. Individuals who have special dietary needs have

those needs reviewed by a dietary consultant.

1. H. Individuals have options to participate in fitness

programs.

1. I. Individuals’ health is protected through measures

typically taken to prevent communicable diseases for persons with similar health status.

1. J. Individuals participate in making decisions about

their health care to the maximum extent of their capacities, and their decisions about their health care are recognized and supported.

1. K. Individuals make informed choices about taking

prescribed medications.

1. L. Individuals take medications as prescribed.
2. M. Individuals are supported in safely managing their

medications.

1. N. Individuals’ medications are regularly evaluated to

determine their continued effectiveness.

1. O. Individuals who take medications are supported by

people who have received information about the individuals’ medical conditions, know how the medications should be taken and are aware of possible side effects.

1. 2. Assuring individual safety—Outcome: Individuals’

environments are safe while assuring choices and freedoms.

1. A. Individuals receive the degree of supervision consistent

with personal ability and the nature of the environment.

1. B. Individuals’ homes and other environments are clean,

safe and well maintained.

1. C. Individuals’ homes and other environments have

modifications or adaptations to ensure safety.

1. D. Individuals’ homes and other environments have

passed externally conducted health, safety, and mechanical inspections.

1. E. Individuals’ safety is assured through preventive

maintenance of vehicles, equipment and buildings.

1. F. Individuals are transported safely.
2. G. Individuals have the option to participate in home

repair and maintenance training.

1. H. The temperature of individuals’ homes is within an

accepted comfort range of sixty-eight (68°) to seventy-eight (78°) degrees Fahrenheit.

1. I. Individuals are supported in responding to emergencies

in a safe manner.

1. J. Individuals participate in emergency drills occurring

during daytime, evening and nighttime hours at least four (4) times annually.

1. K. Individuals are supported or served by staff who are

knowledgeable about emergency procedures.

1. L. Individuals have access to adequate evacuation exits.
2. M. Individuals have properly marked and easily

accessible fire fighting equipment in their homes.

1. N. Individuals’ homes have operating smoke detectors.
2. O. Individuals have adaptive emergency alarm systems

based upon need.

1. P. Individuals have options to take first aid, have

access to basic first-aid supplies, or are provided first aid by knowledgeable staff.

1. Q. Individuals are provided cardiopulmonary

resuscitation by knowledgeable staff.

1. R. Individuals incurring injuries or experiencing unusual

incidents have the injuries or incidents documented in their files.

1. S. Individuals are supported or served by staff who have

pertinent information to facilitate ordinary or emergency notification of family, guardians or other interested parties.

1. T. Individuals’ safety is assured by secure storage of

materials and equipment necessary for household maintenance.

1. U. Individuals and staff use safe and sanitary practices in

all phases of food preparation and cleanup.

1. V. Individuals who need assistance to eat in an upright

position are provided needed supports and adaptations.

1. W. Individuals use mechanical supports only as

prescribed.

1. X. Individuals use adaptive, corrective, mobility, orthotic

and prosthetic equipment that is in good repair.

1. 3. Promoting well-being, comfort and security—Outcome:

The physical and emotional well-being of individuals are met at home and promoted in other environments.

1. A. Individuals’ personal preferences are supported to

assure physical comfort.

1. B. Individuals’ environments are secure and stable.
2. C. Individuals express that their home is their own.
3. D. Individuals’ homes are adequate in size and design to

meet the needs of those who live there.

1. E. Individuals are actively involved in the process when

they relocate.

1. F. Individuals have opportunities to learn how to protect

themselves from others.

1. (4) Every two (2) years, all agencies shall seek certification under this section except that agencies accredited by nationally recognized accrediting bodies approved by the division shall not be required to seek certification. For example, agencies accredited by the Accreditation Council on Services for People with Developmental Disabilities or agencies receiving accreditation of appropriate services by the Commission on Accreditation of Rehabilitation Facilities shall not be required to seek certification. The division director shall issue two (2)-year certificates to agencies successfully completing the process and requirements of this section and contingent, upon successful completion, the following year of consumer and family monitoring as set out in section (6).

   1. (A) Presurvey Activities.

      1. 1. The survey team leader shall provide written information

to the agency about the survey process and its purpose and shall provide a list of credentialed, potential survey team members. The survey team leader shall also request information from the agency for his/her use in selecting the sample of persons with developmental disabilities to be surveyed. That information shall include, but not be limited to, the number of persons in each program service and at each service location; number of persons with various support needs, for example, communication, behavioral or medical; and a copy of the agency’s mission statement and organizational chart.

1. 2. The agency shall provide the survey team leader with

the requested information and with preferred survey team members in priority order.

1. 3. The regional center director shall provide information

to the survey team leader about case management for the agency.

1. 4. Based on information provided by the agency, the survey

team leader shall determine the agency’s characteristics in conjunction with the agency and regional center directors. The survey team leader shall also determine the sample size and select the survey team. No survey team member may survey an agency in his/her community or any other agency if s/he or the team leader believes there could be a conflict of interest.

1. 5. The agency and regional center directors shall designate

a liaison person to provide information otherwise assist the survey team.

1. 6. The survey team leader shall inform the team and

the agency director of the survey schedule and shall provide necessary written information to the team.

1. (B) Survey Activities.

   1. 1. The survey team leader shall convene the team to make

assignments and introduce agency and regional center liaison persons.

1. 2. The survey team leader shall convene a meeting at the

agency to introduce team members and liaison persons to the agency director and other staff and to present information about the survey process.

1. 3. The survey team shall gather necessary information

(conduct the survey). The agency director shall make people receiving its services, its staff and relevant records and policies available. The survey team shall cite examples of agency strengths and characteristics on which the agency may build during the enhancement phase of the certification process. Survey activities include but are not limited to—

1. A. A community tour;
2. B. Observation of persons receiving services in their

homes and in the community;

1. C. Discussions with persons receiving services, their

families and agency staff;

1. D. Attendance at individual habilitation plan meetings;
2. E. Record review and
3. F. Informal meetings to share observations, plan, and

identify emerging themes.

1. 4. The survey team shall reach conciliation on each

principle in section (3) through evaluation of trends, not on the agency’s failure to meet the principle.

1. 5. After the survey team has completed the survey, it shall

indicate whether—

1. A. No core issues were identified;
2. B. Core issues were identified, but the issues are not

pervasive; or

1. C. Pervasive core issues were identified.

2. (C) Post-Survey Activities.

   1. 1. If the survey team does not identify core issues—

      1. A. The survey team leader shall conduct an exit meeting

at the agency with the agency and regional center directors, providing them a summary of the team’s findings and its recommendation for certification of the agency;

1. B. The survey team leader shall prepare a survey report,

including the team’s recommendation for certification of the agency;

1. C. The survey team leader shall facilitate a meeting of

the agency and regional center directors, after which those directors shall develop an enhancement plan to focus on themes (issues) identified during the survey. The plan shall include but not be limited to—

1. (I) How the issues will be addressed;
2. (II) Roles of agency and regional center staff in

addressing the issues;

1. (III) Shortand long-range timelines;
2. (IV) Specific methods of agency-regional center

communication about implementation of the plan; and

1. (V) Criteria for measuring success;
2. D. The survey team leader and agency director shall

submit the survey report and enhancement plan to the division director;

1. E. The division director shall issue a two (2)-year

certificate that is contingent upon successful completion the following year of consumer and family monitoring as set out in section (6);

1. F. The agency and regional center directors shall work

together to implement the enhancement plan; and

1. G. The regional center director shall identify common

issues or problems within enhancement plans in his/her region, especially within plans of agencies in particular communities, and shall take steps to resolve the issues or problems.

1. 2. If the survey team identifies core issues, but the issues

are not pervasive—

1. A. The survey team leader and regional center director

shall conduct an exit meeting at the agency with the agency director, providing him/her a summary of the team’s findings and its recommendation on certification of the agency;

1. B. The survey team leader shall prepare a survey report,

including the team’s recommendation on certification of the agency;

1. C. If certification is recommended, the survey team

leader and regional center director shall facilitate a meeting with the agency director, after which the agency and regional center directors shall develop a combination enhancement (for building upon agency strengths)-enforcement (for addressing core issues) plan. The plan shall include but not be limited to requirements set out in items (4)(C)1.C.(I) through (V);

1. D. The survey team leader and agency director shall

submit the survey report and enhancement-enforcement plan to the division director;

1. E. The division director shall issue a two (2)-year certificate

that is contingent upon satisfying core issues identified in the enforcement plan component and successful completion the following year of consumer and family monitoring as set out in section (6);

1. F. The agency and regional center directors shall work

together to implement the enhancement-enforcement plan;

1. G. The regional center director shall identify common

issues or problems within enhancement and enforcement plans in his/her region, especially within plans of agencies in particular communities, and shall take steps to resolve the issues or problems; and

1. H. When the agency director believes his/her agency

has satisfied core issues identified in the enforcement plan component, s/he, the regional center director, and a survey team member appointed by the team leader shall conduct a tailored survey to determine if the core issues have been satisfied.

1. (I) If the core issues have been satisfied, the agency

and regional center directors shall work together to continue implementation of the enhancement plan component.

1. (II) If the agency has not satisfied the core issues but

has made significant progress, the regional center director may extend the timelines in the enforcement plan component so that the agency can satisfy the remaining core issues.

1. (III) If the agency has failed to satisfy the core issues or

even to make significant progress toward satisfying them, the division director shall decertify the agency.

1. 3. If the survey team identifies pervasive core issues—

   1. A. The survey team leader and regional center director

shall conduct an exit meeting at the agency with the agency director, providing him/her a summary of the team’s findings and its recommendation on certification of the agency;

1. B. The survey team leader shall prepare a survey report,

including the team’s recommendation on certification of the agency;

1. C. The survey team leader and regional center director

shall facilitate a meeting with the agency director, after which the agency and regional center directors shall develop an enforcement plan. The plan shall include, but not be limited to, requirements set out in items (4)(C)1.C.(I) through (V);

1. D. The survey team leader and agency director shall

submit the survey report and enforcement plan to the division director;

1. E. The division director shall issue a two (2)-year

certificate that is contingent upon satisfying core issues identified in the enforcement plan and successful completion the following year of consumer and family monitoring as set out in section (6);

1. F. The agency and regional center directors shall work

together to implement the enforcement plan;

1. G. The regional center director shall identify common

issues or problems within enforcement plans in his/her region, especially within plans of agencies in particular communities, and shall take steps to resolve the issues or problems; and

1. H. When the agency director believes his/her agency

has satisfied core issues identified in the enforcement plan, s/he, the regional center director and a survey team member appointed by the team leader shall conduct a tailored survey to determine if the core issues have been satisfied.

1. (I) If the core issues have been satisfied, the agency

and regional center directors shall work together to develop and implement an enhancement plan.

1. (II) If the agency has not satisfied the core issues but

has made significant progress, the regional center director may extend the timelines in the enforcement plan so that the agency can satisfy the remaining core issues.

1. (III) If the agency has failed to satisfy the core issues or

even to make significant progress toward satisfying them, the division director shall decertify the agency.

1. (5) An agency may appeal its decertification to the department’s hearings administrator.

   1. (A) If the agency appeals and the hearings administrator reverses the decertification decision, the agency and regional center directors shall develop an enforcement plan or revise an existing plan, and the agency shall continue through the process set out previously in this rule.
   2. (B) If the agency appeals and the hearings administrator sustains the decertification decision, the division director shall remove the agency from the Medicaid Homeand Community- Based or Nursing Home Reform Waiver Program.
   3. (C) If the agency does not appeal, the division director shall remove the agency from the Medicaid Homeand Community- Based or Nursing Home Reform Waiver Program.

2. (6) Every two (2) years during years when survey teams do not conduct surveys of agencies, consumer and family monitoring teams shall monitor the agencies.

   1. (A) If a monitoring team identifies core issues—

      1. 1. The monitoring team and the regional center director

shall conduct an exit meeting with the agency director at the agency, providing the agency director a summary of the monitoring team’s findings;

1. 2. After the exit meeting, the agency director shall—

   1. A. Develop an enforcement plan with the regional

center director and continue through the process set out previously in this rule; or

1. B. Request that a tailored survey be conducted by the

regional center director, the monitoring team and the agency director; and

1. 3. If a tailored survey is conducted and—

   1. A. The agency has not satisfied the core issues, the agency

and regional center directors shall develop an enforcement plan, and the agency shall continue through the process set out previously in this rule; or

1. B. The agency has satisfied the core issues, the agency

shall continue in its prior status.

AUTHORITY: section 630.655, RSMo 1994.* This rule originally filed as 9 CSR 30-5.050. Original rule filed July 25, 1994, effective March 30, 1995. Amended: Emergency amendment filed July 20, 1995, effective July 30, 1995, expired Nov. 26, 1995. Amended: Filed July 20, 1995, effective Nov. 30, 1995. Amended: Filed May 25, 1995, effective Dec. 30, 1995.

*Original authority: 630.655, RSMo 1980.