Mo. Code Regs. tit. 9 § 30-4.042
Current through Register Vol. 49, No.12, June 17, 2024
Section 9 CSR 30-4.042 - Admission CriteriaPURPOSE: This rule establishes criteria and procedures for admission of eligible individuals to a community psychiatric rehabilitation program.
(1) Prior to admitting any individual, community psychiatric rehabilitation (CPR) providers that have been awarded provisional certification may be required to submit documentation for clinical review. (A) The clinical review unit, within seven (7) working days, either shall 1. Determine that the individual is eligible for admission and authorize the appropriate services;2. Suspend eligibility determination and prior authorization of services pending the receipt of requested additional information; or3. Determine that the individual is not eligible for admission.(B) No provisionally-certified CPR provider shall admit any individual before approval is given by the clinical review unit.(2) Prior to admitting or reauthorizing any individual for CPR services, all certified CPR providers and affiliates shall submit to the appropriate administrative agent or designee, the name of the person seeking services with basic demographic information, background, and historical information, if available and shall provide support to the person by arranging an appointment for an evaluation. The administrative agent or designee shall conduct an evaluation to determine that the individual is eligible for admission to the CPR provider and to determine whether the individual is among the priority populations of the division as specified in 9 CSR 30-4.039(1)(A) and further defined in the Administrative Agent's Service Area Agreements and Plans available from the Division of Comprehensive Psychiatric Services. (A) The administrative agent or designee within thirty (30) working days, shall 1. Conduct a complete intake or annual evaluation as set out in 9 CSR 30-4.035(7) and (18);2. For persons seeking admission to the CPR services, provide or authorize emergency services and crisis intervention during the period prior to completion of the intake evaluation; and3. Forward to the referring agency and the client A. Confirmation that the individual is eligible to be admitted to the CPR program, and determine that the individual is among the priority populations of the division;B. A determination that the individual is not eligible for admission to the CPR program and a statement of the client's rights of appeal; orC. Confirmation that the individual is eligible to be admitted to the CPR program, but has been determined not to be among the priority populations of the division and, therefore, is eligible for admission only after eligible priority clients have been admitted to the CPR program. A statement of the client's right of appeal with regard to any finding that the individual is not in the priority population shall also be provided.(B) If the administrative agent or designee confirms that the individual is eligible to be admitted to the CPR program and determines that the individual is among the priority populations of the division, then the individual shall be given an opportunity to select a CPR provider from among the CPR programs available in the service area. All eligible priority clients shall be provided the list of providers as set out in Appendix A. 1. The CPR provider selected by the individual shall work with the individual to develop the individual treatment/rehabilitation plan.2. If an individual does not express a CPR provider preference, then the individual will be admitted to the administrative agent's, or the designee's, program.(C) If the administrative agent or designee determines that the individual is not eligible to be admitted to the CPR program, then the individual shall be referred to other programs and services for which s/he may be eligible. The referral to other programs and services shall accompany the notice of appeal rights furnished the client as set out in 9 CSR 30-4.042(2)(A) 3.C.(D) If the administrative agent or designee confirms that the individual is eligible to be admitted to the CPR program, but determines that the individual is not among the priority populations of the division, the administrative agent or designee may provide services as appropriate.(E) An individual denied services because of the intake process shall have the right to appeal the decision to deny services to the division director or his/her designee. This appeal shall be sent in written form to the division director within sixty (60) days following notice of denial by the administrative agent.(3) The CPR provider shall not admit any person who would not benefit from the services of a CPR provider.(4) The criteria for admission to community psychiatric rehabilitation program services shall include: (A) Disability. There shall be clear evidence of serious and/or substantial impairment in the ability to function at an age or developmentally-appropriate level due to serious psychiatric disorder in each of the following two (2) areas of behavioral functioning, as indicated by intake evaluation and assessment: 1. Social role functioning/family life the ability to sustain functionally the role of worker, student, homemaker, family member, or a combination of these; and2. Daily living skills/self-care skills the ability to engage in personal care (such as grooming, personal hygiene) and community living (handling individual finances, using community resources, performing household chores), learning ability/self-direction, and activities appropriate to the individual's age, developmental level, and social role functioning;(B) Diagnosis. A physician or licensed psychologist shall certify a primary Diagnostic and Statistical Manual (DSM) diagnosis as defined in 9 CSR 10-7.140(2)(OO) or International Classification of Diseases, Ninth Revision with Clinical Modification (ICD-9-CM), using the current edition of the manual. This diagnosis may coexist with other psychiatric diagnoses in Axis I or other areas. 1. Schizophrenia. A. Disorganized. (II) ICD-9-CM code: 295.1XB. Catatonic. (II) ICD-9-CM code: 295.2XC. Paranoid. (II) ICD-9-CM code: 295.3XD. Schizophreniform. (II) ICD-9-CM code: 295.4XE. Residual. (II) ICD-9-CM code: 295.6XF. Schizoaffective. (II) ICD-9-CM code: 295.7XG. Undifferentiated. (II) ICD-9-CM code: 295.9X3. Bipolar I disorders. A. Single manic episode. (II) ICD-9-CM code: 296.0XB. Most recent episode manic. (II) ICD-9-CM code: 296.4XC. Most recent episode depressed. (II) ICD-9-CM code: 296.5XD. Most recent episode mixed. (II) ICD-9-CM code: 296.6X5. Psychotic disorders NOS. 6. Major depressive disorder-recur. 7. Obsessive-Compulsive Disorder. 8. Post Traumatic Stress Disorder. 9. Borderline Personality Disorder. 10. Anxiety Disorders. A. Generalized Anxiety Disorder. (II) ICD-9-CM code: 300.02B. Panic Disorder with Agoraphobia. (II) ICD-9-CM code: 300.21C. Panic Disorder without Agoraphobia. (II) ICD-9-CM code: 300.01D. Agoraphobia without Panic Disorder. (II) ICD-9-CM code: 300.22E. Social Phobia. (II) ICD-9-CM code: 300.2311. For children and youth only. A. Major depressive disorder, single episode. (II) ICD-9-DM code: 296.2B. Bipolar disorder, not otherwise specified. (II) ICD-9-CM code: 296.7C. Reactive attachment disorder of infancy or early childhood. (II) ICD-9-CM code: 313.8912. For adults aged sixty (60) years and over. A. Major depressive disorder, single episode. (II) ICD-9-DM code: 296.2(C) Duration. Rehabilitation services shall be provided to those individuals whose mental illness is of sufficient duration as evidenced by one (1) or more of the following occurrences: 1. Persons who have undergone psychiatric treatment more intensive than outpatient more than once in a lifetime (crisis services, alternative home care, partial hospital, in patient);2. Persons who have experienced an episode of continuous residential care other than hospitalization, for a period long enough to disrupt the normal living situation;3. Persons who have exhibited the psychiatric disability for one (1) year or more; or4. Persons whose treatment of psychiatric disorders has been or will be required for longer than six (6) months;(D) A functional assessment may be used to establish eligibility and the need for and amount of services, including results from a standardized assessment prescribed by the department; and(E) Whenever discrepancies occur regarding the appropriateness of an ICD-9-CM versus a DSM diagnosis, the DSM diagnosis shall prevail.(5) Under the following circumstances, children and adolescents under the age of eighteen (18) years of age may be provisionally admitted to community psychiatric rehabilitation program services: (A) Disability: There shall be clear evidence of serious and/or substantial impairment in the ability to function at an age or developmentally appropriate level due to serious psychiatric disorder in each of the following two (2) areas of behavioral functioning as indicated by intake evaluation and assessment: 1. Social role functioning/family life the individual is at risk of out-of-home or out-of-school placement; and2. Daily living skills/self-care skills the individual is unable to engage in personal care (such as grooming, personal hygiene) and community living (performing school work or household chores), learning, selfdirection, or activities appropriate to the individual's age, developmental level, and social role functioning;(B) Diagnosis: If a person is exhibiting behaviors or symptoms that are consistent with an unestablished CPRP eligible diagnosis, they may be provisionally admitted to CPRP for further evaluation. There may be insufficient clinical information because of rapidly changing developmental needs to determine if a CPR eligible diagnosis is appropriate without an opportunity to observe and evaluate the person's behavior, mood, and functional status. In such cases, there must be documentation that clearly supports the individual's level of functioning as defined in subsection (5)(A);(C) Duration: There must be documented evidence of an individual's functional disability as defined in subsection (5)(A) for a period of ninety (90) days prior to provisional admission;(D) Provisional admissions shall not exceed ninety (90) days. Immediately upon completion of the ninety (90) days or sooner, if the individual has been determined to have an eligible diagnosis as listed in 9 CSR 30-4.042(4)(B) of the rule, the diagnosis must be documented and the individual may continue in the CPR program;(E) If an individual who has been provisionally admitted is determined to be ineligible for CPR services, staff shall directly assist the individual and/or family in arranging appropriate follow-up services. Follow-up services shall be documented in the discharge summary of the clinical record; and(F) All admission documentation is required for those provisionally admitted, with the exception of the comprehensive evaluation, which may be deferred for ninety (90) days. AUTHORITY: sections 630.655 and 632.050, RSMo 2000, and section 630.050, RSMo Supp. 2011.* Original rule filed Jan. 19, 1989, effective April 15, 1989. Emergency amendment filed Aug. 27, 1993, effective Sept. 8, 1993, expired Nov. 7, 1993. Emergency amendment filed Oct. 28, 1993, effective Nov. 7, 1993, expired March 6, 1994. Amended: Filed Aug. 27, 1993, effective April 9, 1994. Emergency amendment filed Feb. 15, 1994, effective March 6, 1994, expired April 10, 1994. Emergency amendment filed April 21, 1994, effective May 2, 1994, expired Aug. 29, 1994. Amended: Filed April 21, 1994, effective Oct. 30, 1994. Amended: Filed Dec. 13, 1994, effective July 30, 1995. Emergency amendment filed Aug. 11 , 1999, effective Aug. 22, 1999, expired Feb. 17, 2000. Amended: Filed Aug. 11 , 1999, effective Feb. 29, 2000. Emergency amendment filed June 30, 2000, effective July 11 , 2000, expired Feb. 22, 2001. Amended: Filed June 30, 2000, effective Jan. 30, 2001. Emergency amendment filed Dec. 28, 2001, effective Jan. 13, 2002, expired July 11 , 2002. Amended: Filed Dec. 28, 2001, effective July 12, 2002. Amended: Filed July 31, 2002, effective March 30, 2003. Amended: Filed March 15, 2010 , effective Sept. 30, 2010. Amended: Filed Dec. 1, 2011 , effective June 30, 2012. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008; 630.655, RSMo 1980; and 632.050, RSMo 1980.