Missouri Code of State Regulations › Title 9 - DEPARTMENT OF MENTAL HEALTH › Division 40 - Licensing Rules › Chapter 1 - Definitions, Licensing Procedures, and General Requirements for Community Residential Programs and Day Program › Section 9 CSR 40-1.015 - Definition

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment updates terms and definitions
				  used in licensing rules. Outdated terms have been removed.
PURPOSE: This rule defines terms used in licensing
				  procedures and rules developed under sections 630.705-630.760, RSMo, for all
				  community residential programs and day programs subject to licensure by the
				  department, including Residential Care Facilities and Assisted Living
				  Facilities dually licensed by the Department of Health and Senior
				  Services.
(1) Unless the
				context clearly indicates otherwise, the terms defined in sections
				630.005,
				632.005 and
				633.005, RSMo and as
				used in 9 CSR 40 are incorporated by reference as if set out in this
				rule.
(2) The following additional
				words and terms, as used in 9 CSR 40, mean:
(A) Administrative agent, an organization and
				its approved designee(s) authorized by the department as an entry and exit
				point into the state mental health service delivery system for a geographic
				service area defined by the department. Administrative agents provide statewide
				access crisis intervention services, including a twenty-four (24) hour crisis
				mobile response by qualified mental health professionals;
(B) Access Crisis Intervention (ACI), as
				defined in 9 CSR 30-4.195 Access Crisis
				Intervention (ACI) Programs;
(C)
				Affiliate, an organization that is contracted with the department to provide
				specific community psychiatric rehabilitation (CPR) services for adults in a
				specific designated geographic region;
(D) Applicant, an individual, partnership,
				association, corporation, or governmental entity which has applied to the
				department for a license or program license;
(E) Assisted living facility (ALF), any
				residence, intermediate care facility, or skilled nursing facility licensed
				under Chapter 198, RSMo, that provides twenty-four (24) hour care and services
				and protective oversight to three (3) or more adults who need assistance with
				activities of daily living and instrumental activities of daily living;
				storage, distribution, or administration of medications; and/or supervision of
				health care under the direction of a licensed physician;
(F) Behavioral health, the promotion of
				mental health, resilience, and well-being, the treatment of mental health and
				substance use disorders, and the support of individuals who experience and/or
				are in recovery from these conditions, along with their families/natural
				supports and communities;
(G)
				Behavioral crisis/mental health crisis, any situation in which a person's
				behavior puts him/her at risk of hurting him/herself or others and/or prevents
				him/her from being able to care for him/herself or function effectively in the
				community;
(H) Behavioral health
				services, mental health services, substance use disorder treatment services, or
				a combination of both, for youth, children, and adults. Services may be
				provided in a residential program, on an outpatient basis, or in a home or
				community program;
(I) Care plan,
				document developed by staff of a community residential program or day program
				in collaboration with the individual served and family members/natural
				supports, as appropriate, which includes measurable goals and objectives
				important to the individual to assist him or her in achieving personally
				defined outcomes, ensures delivery of services and supports in a manner that
				reflect personal preferences and choices, and contributes to the assurance of
				health and wellness of the individual served;
(J) Community Psychiatric Rehabilitation
				(CPR), an array of community-based outpatient mental health services for
				children, youth, and adults who have been diagnosed with a severe, disabling
				mental illness or serious emotional disturbance. Administrative agents or their
				affiliates are responsible for providing these services to eligible individuals
				in designated service area(s);
(K)
				Community residential program, any premises where services, structure,
				oversight, and supports are provided on a residential basis for adults with
				mental illness who otherwise would not be able to function outside of
				psychiatric inpatient care due to the severity and chronicity of their mental
				illness. This includes, but is not limited to, Intensive Residential Treatment
				Settings (IRTS), Psychiatric Individualized Supported Living (PISL),
				Residential Care Facilities (RCF), Intermediate Care Facilities (ICF), and
				Assisted Living Facilities (ALF);
(L) Competency-based training, the provision
				of knowledge and skills sufficient to enable the trained staff person to meet
				specified standards of performance consistent with generally accepted
				professional standards or specified in law, regulation, or policy, as validated
				by the person's demonstration that he/she can use such knowledge or skills
				effectively;
(M) Compliance, a
				program may be found in compliance with these licensing rules when deficiencies
				do not involve-
1. Abuse or neglect-any
				instance of abuse/neglect in which corrective action has not been
				taken;
2. Life endangering
				conditions-any single life-endangering event or combination of minor
				deficiencies which collectively are life endangering or which become perilous
				contingent upon an event such as the outbreak of fire;
3. Legal requirements-deficiencies related to
				statutory requirements for programs licensed by the department, such as
				individual rights and licensing procedures;
4. Repeated deficiencies-issues which may or
				may not be serious in and of themselves, but which become significant when left
				uncorrected according to agreed upon schedules over a period of time;
5. Numerous deficiencies-deficiencies which
				may or may not be serious themselves, but become significant collectively
				because they indicate an ineffective maintenance plan, deficient environmental
				standards, inadequate orientation or training of staff, poor nursing care
				practice, inadequate diet, lack of treatment or rehabilitation, ineffective
				policies and procedures, inadequate staffing, improper recordkeeping, or other
				issues which may affect the well being of individuals served; or
6. Minimum environmental
				requirements-quantitative requirements under environment and fire
				safety/emergency preparedness relating to minimum dimensions for hallways,
				doors, ceiling heights, window space, floor space, number of bathrooms, and
				individuals per bedroom;
(N) Consent agreement, an agreement with the
				department that is entered into by the director of a community residential
				program or day program to obtain a probationary license. Such a consent
				agreement will include a provision that the director of the program will
				voluntarily surrender the license if compliance with licensing requirements is
				not reached in accordance with the terms and deadlines established under the
				agreement. The agreement specifies the stages, actions, and time span to
				achieve compliance;
(O) Continuing
				care, the provision of a treatment plan and program structure that will ensure
				an individual receives the type of care he/she needs at the time, particularly
				at the point of discharge or transfer from the current program. Programs are
				flexible and tailored to the changing needs of individuals served;
(P) Crisis, an event or time period for an
				individual characterized by a substantial increase in symptoms, legal or
				medical problems, and/or loss of housing, employment, or personal
				supports;
(Q) Crisis prevention
				plan, developed with individuals who have a mental illness when a potential
				risk for suicide, violence, or other at-risk behavior is identified during the
				assessment process or any time during the individual's engagement in services.
				At a minimum, the crisis prevention plan includes factors that may precipitate
				a crisis, a hierarchical list of skills/strengths identified by the individual
				to regain a sense of control to return to his/her level of functioning before
				the crisis or emergency, and a hierarchical list of staff interventions that
				may be used when a critical situation occurs;
(R) Deemed license, acknowledges that an
				organization/program is monitored and held accountable by a recognized national
				accrediting body and the department accepts the organization's verification of
				good standing with the accrediting body as sufficient to meet the department's
				standards of care;
(S) Deficiency,
				a condition, event, or omission that does not comply with a department
				licensing rule;
(T) Discharge, the
				point at which an individual's active involvement with a treatment or
				rehabilitation program concludes in accordance with the goals in his or her
				individual support plan (ISP), individual treatment plan (ITP), or care plan,
				applicable utilization criteria, and/or program rules;
(U) Electronic health record (EHR), digital
				version of individual records;
(V)
				Family living arrangement (FLA) for adults, a program in the owned or leased
				permanent residence of the licensee, serving no more than three (3) adults who
				have a developmental disability who are integrated into the licensee's family
				unit. The licensee of the home provides care and support as directed in the
				individual support plan (ISP);
(W)
				Family living arrangement (FLA) for children/youth, a program in the owned or
				leased permanent residence of the licensee in which mental health interventions
				are provided for children and youth placed in the home, allowing the child to
				remain in his/her community until returning to his/her natural home or
				alternative community placement to avoid being removed from a community
				setting;
(X) Individual, a
				person/consumer/client receiving services from a program licensed under 9 CSR
				40;
(Y) Individualized education
				plan (IEP), a plan developed by trained school staff for children who have a
				disability and a need for specialized instruction;
(Z) Individual support plan (ISP), a document
				resulting from a person-centered planning process with an individual with
				intellectual or developmental disabilities, with assistance as needed by a
				representative, in collaboration with an interdisciplinary team. The plan is
				intended to identify the strengths, capacities, preferences, needs, and desired
				outcomes of the person served. The process may include other people freely
				chosen by the individual who are able to contribute to the process. The
				person-centered planning process enables and assists the individual in
				accessing a personalized mix of paid and non-paid services and supports that
				will assist him/her in achieving personally defined outcomes and the training,
				supports, therapies, treatments, and/or other services that become part of the
				ISP;
(AA) Individual Treatment Plan
				(ITP), written document developed in collaboration with the individual seeking
				assistance for a behavioral health condition (or his or her parent/legal
				guardian) that identifies the individual's strengths, goals, preferences,
				abilities, physical and behavioral health needs, and desired outcomes for a
				healthy lifestyle in the community. Treatment staff, treatment team members,
				and family members/natural supports (if acceptable to the individual being
				served) participate in the development of the plan and assist the individual in
				identifying and accessing a mix of services and supports to meet his/her needs
				and achieve desired goals for recovery and resiliency;
(BB) Intensive Residential Treatment Setting
				(IRTS), living environment where medically necessary services/supports are
				provided for five (5) to sixteen (16) 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. This environment is most appropriate for individuals who
				can tolerate regular interaction with their peers, but have significant
				difficulties with activities of daily living and may require round-the-clock
				observation and oversight and/or periodic redirection from staff to avoid
				behaviors potentially harmful to them-self or others;
(CC) Isolation, removing an individual from a
				social setting to prevent spread of contagious disease;
(DD) License, written notification that a
				community residential program or day program complies with department licensing
				requirements to serve individuals with mental illness, intellectual
				disabilities, and developmental disabilities;
(EE) Licensee, an individual, partnership,
				association, corporation, or governmental entity which has received a license
				or program license from the department to operate a community residential
				program or day program to provide services and supports for individuals with
				mental illness, intellectual disabilities, and developmental
				disabilities;
(FF) Mechanical
				supports, supportive devices used in normative situations to achieve proper
				body position and balance; these are not restraints;
(GG) Medication administration, qualified
				staff preparing and/or giving a legally prescribed individual dose of
				medication to an individual served, including observation and monitoring the
				individual's response to the medication;
(HH) Medication control, the process of
				physically controlling, transporting, storing, and disposing of medications,
				including medications self-administered by individuals served;
(II) Medication use, the practice of
				handling, prescribing, and dispensing medication (including administering and
				observing self-administration) to persons served in response to specific
				symptoms, behaviors, and conditions for which the use of medication is
				indicated and deemed effective. This includes prescribed and sample medications
				and may, when required as part of the treatment regimen, include
				over-the-counter or alternative medication provided to persons
				served;
(JJ) Misuse of
				funds/property, as defined in
				9 CSR
				10-5.200, Report of Complaints of Abuse, Neglect, and
				Misuse of Funds/Property;
(KK)
				Natural supports, provided by a person of the individual's choice to assist him
				or her in achieving personal goals and facilitating integration into their
				community. Natural supports are provided by persons who are not paid staff of
				an agency but may be initiated, planned, and facilitated in partnership with an
				agency;
(LL) Neglect, as defined in
				9 CSR
				10-5.200, Report of Complaints of Abuse, Neglect, and
				Misuse of Funds/Property;
(MM)
				Outcome, a specific measurable result of services/supports provided to an
				individual or identified target population;
(NN) Person-centered, services and supports
				developed in collaboration with the individual served that are respectful of
				informed consent and the preferences of the individual, resulting in a
				therapeutic alliance which contributes significantly to
				treatment/rehabilitation outcomes;
(OO) Physical abuse, as defined in
				9 CSR
				10-5.200, Report of Complaints of Abuse, Neglect, and
				Misuse of Funds/Property;
(PP)
				Probationary license, written authorization to continue service delivery for a
				specified period of time to enable a licensee to achieve compliance with the
				department's licensing requirements as set forth in a consent agreement between
				the department and the licensee;
(QQ) Program license, written notification
				that a community residential program with a current license, temporary
				operating permit, or probationary license from the Department of Health and
				Senior Services (DHSS) under sections 198.006-198.096, RSMo, also meets the
				department's licensing requirements relative to admission criteria, care,
				treatment, and habilitation or rehabilitation needs of individuals
				served;
(RR) Psychiatric crisis, an
				individual is exhibiting a substantial increase in symptoms related to a severe
				emotional disturbance or mental illness based upon his or her baseline
				functioning. The reason(s) why the crisis occurred and how it is expressed
				varies by individual and may include harm to self or others, disorientation,
				being out of touch with reality, compromised ability to function, or other
				expression of emotional distress not characteristic to the individual.
				Immediate clinical assessment and intervention is necessary to ensure the
				safety of the individual and others;
(SS) Psychiatric Individualized Supported
				Living (PISL), living environment where medically necessary services/supports
				are provided for one (1) to four (4) 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. This environment is most appropriate for individuals who-
1. Have intermittent difficulty tolerating
				other individuals in their immediate living area;
2. Require access to an individual bedroom to
				avoid psychiatric relapse, aggression, or other behaviors associated with a
				risk of re-hospitalization; and/or
3. Have substantial difficulties with
				activities of daily living and require round-the-clock observation and
				oversight; and/or
4. Require daily
				redirection from staff to avoid behaviors potentially harmful to themselves or
				others;
(TT) Qualified
				mental health professional (QMHP), any of the following:
1. A physician licensed under Missouri law to
				practice medicine or osteopathy and with training in mental health services or
				one (1) year of experience, under supervision, in treating problems related to
				mental illness or specialized training;
2. A psychiatrist licensed under Missouri law
				as a physician and who has successfully completed a training program in
				psychiatry approved by the American Medical Association, the American
				Osteopathic Association, or other training program identified as equivalent by
				DMH;
3. A psychologist licensed
				under Missouri law to practice psychology with specialized training in mental
				health services;
4. A professional
				counselor licensed under Missouri law to practice counseling with specialized
				training in mental health services;
5. A clinical social worker licensed under
				Missouri law with a master's degree in social work from an accredited program
				and with specialized training in mental health services;
6. A psychiatric nurse licensed under Chapter
				335, RSMo, as a registered professional nurse with at least two (2) years of
				experience in a psychiatric or substance use disorder treatment setting or a
				master's degree in psychiatric nursing;
7. An individual possessing a master's or
				doctorate degree in counseling and guidance, rehabilitation counseling and
				guidance, vocational counseling, psychology, pastoral counseling, family
				therapy, or related field who has successfully completed a practicum or has one
				(1) year of experience under the supervision of a QMHP;
8. An occupational therapist certified by the
				National Board for Certification in Occupational Therapy, registered in
				Missouri, who has a bachelor's degree and has completed a practicum in a
				psychiatric setting or has one (1) year of experience in a psychiatric setting,
				or has a master's degree and has completed either a practicum in a psychiatric
				setting or has one (1) year of experience in a psychiatric setting;
9. An advanced practice registered nurse
				(APRN) under section
				335.016, RSMo, who
				has had education beyond the basic nursing education and is certified by a
				nationally recognized professional organization as having a nursing specialty,
				or who meets criteria for APRNs established by the board of nursing;
				or
10. A psychiatric pharmacist,
				registered pharmacist in good standing with the Missouri Board of Pharmacy who
				is a board-certified psychiatric pharmacist through the Board of Pharmaceutical
				Specialties, or a registered pharmacist currently in a psychopharmacology
				residency where the service has been supervised by a board-certified
				psychiatric pharmacist;
(UU) Reciprocal license, issued by the
				department to a residential program that has a current valid license as a
				Residential Treatment Agency for Children and Youth from the Department of
				Social Services under 13 CSR 35-71, if the applicant has applied for a license
				from the department and paid the application fee;
(VV) Research, as defined in
				9 CSR
				60-1.010;
(WW) Residential care facility (RCF), as
				defined in section
				198.006,
				RSMo;
(XX) Residential program,
				program in the community serving ten (10) or more individuals with intellectual
				or developmental disabilities by providing social support, health supervision,
				and habilitation training in skills of daily living;
(YY) Restraint, as defined in
				9 CSR
				10-7.140;
(ZZ) Safety crisis plan, as defined in
				9 CSR
				45-3.090 Behavior Supports;
(AAA) Scheduled (controlled) medication,
				categories or schedules assigned to medication by the Drug Enforcement
				Administration based on a drug's acceptable medical use and the drug's abuse or
				dependency potential;
(BBB)
				Seclusion, involuntary confinement of an individual alone in a room or an area
				from which he/she is physically prevented from leaving or having contact with
				others;
(CCC) Self-administration
				of medication (adults), the application of a medication, (whether by injection,
				inhalation, oral ingestion, or any other means) by the individual served to his
				or her body, and may include the program storing the medication and staff
				handing the medication container to the individual at the time designated to
				take the medication;
(DDD) Sexual
				abuse, as defined in 9 CSR 10-5.200, Report of
				Complaints of Abuse, Neglect, and Misuse of Funds/Property;
(EEE) Staff (staff member, employee,
				personnel), paid employee or contractor providing services and/or supports on
				behalf of a licensed or deemed licensed program, on a full- or part-time basis,
				and has contact with individuals served by the program;
(FFF) Stock supply/stock pharmaceutical,
				prescription and non-prescription medication stored on-site for the provision
				of medication services by a program. Stock supplies are checked by qualified
				staff on a routine basis for expiration dates and reviewed annually by a
				pharmacy consultant and approved by the medical director or pharmacy
				technician;
(GGG) Substance use
				disorder, diagnostic term in the fifth edition of the Diagnostic and
				Statistical Manual of Mental Disorders (DSM-5) referring to recurrent use of
				alcohol or other drugs that causes clinically and functionally significant
				impairment such as health problems, disability, and failure to meet major
				responsibilities at work, school, or home. Depending on the level of severity,
				this disorder is classified as mild, moderate, or severe. The document
				incorporated by reference does not include any later revisions or updates and
				is available from the American Psychiatric Association, 1000 Wilson Boulevard,
				Suite 1825, Arlington, VA 22209-3901;
(HHH) Supports, array of activities,
				resources, relationships, and services designed to assist an individual's
				integration into the community, participation in services/supports, improve
				functioning, and/or recovery and resiliency;
(III) Targeted case management, Medicaid
				program that assists individuals served by the Division of Developmental
				Disabilities (DD) to gain access to needed medical, social, educational, and
				other services;
(JJJ) Temporary
				operating permit, written authorization from the department permitting a
				licensee seeking license renewal or a new owner applying for an initial license
				to continue service delivery pending completion of the licensing survey process
				and the applicant is not at fault for any delay in the process;
(KKK) Time-out, temporarily separating a
				person from an environment where he or she has exhibited unacceptable
				behavior;
(LLL) Trauma, experiences
				that cause intense physical and psychological stress reactions. May refer to a
				single event, multiple events, or a set of circumstances experienced by an
				individual as physically and emotionally harmful or threatening and has lasting
				adverse effects on the individual's physical, social, emotional, or spiritual
				well-being;
(MMM) Treatment, a
				professionally recognized approach that applies accepted theories, principles,
				and techniques designed to achieve rehabilitative outcomes for individuals
				served;
(NNN) Verbal abuse, as
				defined in 9 CSR 10-5.200, Report of
				Complaints of Abuse, Neglect, and Misuse of Funds/Property; and
(OOO) Volunteer, an unpaid person formally
				recognized by a program to provide direct services or supports to individuals
				it serves.