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 person-centered and shall serve three

2. (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. (2) persons, including the team leader, appointed by the division director or designee to conduct surveys of agencies;

   1. (H) Survey team leader—A division employee who heads a survey team and coordinates its work;
   2. (I) Survey team member—A service provider, regional center employee, parent of 9 CSR 45-5

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

1. (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.

1. (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 com-

munity 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 special-

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

1. E. Individuals live, work, and partic-

ipate 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.

1. H. Individuals use generic resources.
2. I. Individuals participate in age-

appropriate recreational activities.

1. J. Individuals have the option to par-

ticipate in the ethnic life of the community.

1. K. Individuals have the option to par-

ticipate 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 trans-

portation 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 par-

ticipate in the religious life of their choice in the community.

1. R. Individuals have the option to par-

ticipate in political activities of their choice in the community.

1. 2. Supporting and promoting relation-

ships—Outcome: Individuals have positive relationships with people who are not paid providers.

1. A. Individuals are supported in devel-

oping friendships.

1. B. Individuals are supported in sus-

taining friendships.

1. C. Individuals sustain or reestablish

relationships with family members.

1. D. Individuals who choose responsi-

ble, consenting, intimate relationships are supported.

1. E. Individuals’ relationships with oth-

ers are encouraged and supported.

1. F. Individuals’ social support net-

works are expanded and enhanced.

1. G. Individuals have repeated opportu-

nities for social contact with the same people or groups of people.

1. H. Individuals are involved in activi-

ties 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 con-

ducive to developing relationships.

1. K. Individuals invite guests to their

homes and on social occasions.

1. L. Individuals have in their posses-

sion personal information concerning significant others.

1. M. Individuals interact with others

consistent with the intensity of the relationship.

1. 3. Supporting and promoting contribu-

tion—Outcome: Individuals experience the rewards and responsibilities of contributing to society.

1. A. Individuals have the option to con-

tribute 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 vol-

unteer.

1. E. Individuals have the option to help

their neighbors.

1. 4. Facilitating and enhancing communi-

cations—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 ser-

vices, 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 communi-

cation 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 envi-

ronments 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 addi-

tion 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 posi-

tive self-expression—Outcome: Individuals have the opportunity to enhance self-esteem 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.

1. D. Individuals have social and inter-

personal problem solving skills.

1. E. Individuals express their own per-

sonal style.

1. F. Individuals are aware of and use

personal competencies.

1. G. Individuals express personal opin-

ions and preferences.

1. 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.

1. K. Individuals understand what

belongs to them and what belongs to others.

1. L. Individuals are aware of their own

bodies.

1. 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.

1. B. Individuals make informed choices

and experience natural consequences.

1. C. Individuals are supported in carry-

ing out choices.

1. D. Individuals make commitments for

which they accept personal responsibility.

1. E. Individuals participate in the deco-

ration of their personal area.

1. F. Individuals participate in the deco-

ration of common living areas.

1. G. Individuals make choices regard-

ing 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.

1. 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.

1. 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.

1. 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 develop-

ment of personal profiles is obtained in natural settings.

1. D. Information used in the develop-

ment 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.

1. F. Professionals in specialized disci-

plines 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 disci-

plines 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 plan-

ning 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 plan-

ning 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 plan-

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

1. S. The amount and duration of sup-

ports 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. 9 CSR 45-5

1. V. Individuals choose support or ser-

vice providers.

1. 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 person-centered 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 coordi-

nating 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 indi-

viduals 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.

1. D. Individuals’ lives are free of arbi-

trary 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.

1. H. Individuals are addressed using

people-first language.

1. I. Individuals are addressed in an age-

appropriate manner.

1. J. Individuals are addressed in a con-

versational tone.

1. K. Individuals engage in age-appro-

priate interactions.

1. 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 pro-

cess when limitations are imposed.

1. D. Individuals are free to communi-

cate privately.

1. E. Individuals have freedom of move-

ment.

1. F. Staff are trained in preventing,

detecting and reporting abuse and neglect.

1. G. Abuse and neglect are prohibited

by policy.

1. 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 examina-

tions 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 partic-

ipate 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.

1. M. Individuals are supported in safe-

ly managing their medications.

1. N. Individuals’ medications are regu-

larly 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 envi-

ronments are clean, safe and well maintained.

1. C. Individuals’ homes and other envi-

ronments have modifications or adaptations to ensure safety.

1. D. Individuals’ homes and other envi-

ronments 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 par-

ticipate 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 emergen-

cy 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.

1. M. Individuals have properly marked

and easily accessible fire fighting equipment in their homes.

1. N. Individuals’ homes have operating

smoke detectors.

1. O. Individuals have adaptive emergen-

cy 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 car-

diopulmonary 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 sup-

ports only as prescribed.

1. X. Individuals use adaptive, correc-

tive, 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.

1. C. Individuals express that their home

is their own.

1. 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. (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 direc-

tors 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 neces-

sary 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 habilita-

tion plan meetings;

1. E. Record review and
2. F. Informal meetings to share obser-

vations, plan, and identify emerging themes.

1. 4. The survey team shall reach concilia-

tion 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 identi-

fied.

1. (C) Post-Survey Activities.

   1. 1. If the survey team does not identify

core issues—

1. A. The survey team leader shall con-

duct 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 pre-

pare a survey report, including the team’s recommendation for certification of the agency;

1. C. The survey team leader shall facil-

itate 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; 9 CSR 45-5
2. (II) Roles of agency and regional cen-

ter 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 agen-

cy 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 pre-

pare 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 agen-

cy 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 sat-

isfied, 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 sat-

isfy 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 pre-

pare 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 agen-

cy 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 sat-

isfied, 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 sat-

isfy 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 region-

al 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.