Mo. Code Regs. tit. 9 § 40-4.001

Current through Register Vol. 50, No. 1, January 2, 2025

Section 9 CSR 40-4.001 - Program and Staffing Requirements

PURPOSE: This amendment updates terminology, clarifies staff supervision requirements, and adds a provision to allow a licensed practical nurse (LPN) to provide nursing oversight and coordination under specific circumstances as specified in the regulation.

(1) Regulations. Licensed behavioral health community residential programs (hereafter referred to as residential programs) shall comply with 9 CSR 40-1 unless specified otherwise in this rule.

(2) Fire Safety. Psychiatric Individualized Supported Living (PISL) programs shall comply with 9 CSR 40-1.090 Fire Safety and Emergency Preparedness, with modifications as specified-

(A) Subsection (1)(A), Division of Fire Safety inspection is waived;

(B) Subsection (1)(D), evacuation routes do not need to be posted in the home. Documented training and education on safe exit from the home shall be provided for individuals served. Documentation must include dates of training/education and signature of staff providing the training/education; and

(C) Subsection (1)(M), notification and documentation from the local fire authority is waived.

(3) Program Structure. Community residential programs provide a high level of services, structure, oversight, and support for 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. An extensive array of medically necessary services are provided to assist the individual in managing their psychiatric symptoms, co-occurring disorders, functional deficits, and problematic behaviors.

(A) Supports and rehabilitation services related to an individual's needs for activities of daily living and crisis prevention and intervention must be provided. Rehabilitation services may be available on-site and in the community to promote recovery and a reduction in symptoms in order for each individual to progress toward more independent living.

1. Service supports for community activities shall be made available which are separate and distinct from intensive residential treatment settings (IRTS) and psychiatric individualized supported living (PISL) services provided on-site. When individuals participate in community services and activities away from the residential site, staffing requirements shall be maintained on-site in accordance with paragraph (5)(A)1.-2. of this rule.

(B) All individuals receiving services/supports must have an individual treatment plan (ITP) developed by staff of the administrative agent or affiliate involved in their care and shall receive services in accordance with 9 CSR 40-1.075 Person-Centered Services.

1. A copy of each individual's current ITP and crisis prevention plan shall be maintained in a manner so they are readily accessible to staff working in the program. Documentation must indicate program staff are knowledgeable about each individual's treatment plan and crisis prevention plan.

(C) Each residential program shall be structured to ensure safety and prevent the individual's need for a more restrictive setting. The type of program is based on individual needs for supervision and oversight, tolerance for interactions with other individuals, and the ability to participate in and benefit from other community-based interventions.

(D) Psychiatric Individualized Supported Living (PISL) is comprised of services and supports provided in a private home for one (1) to four (4) adults and is most appropriate for individuals who-

1. Have intermittent difficulty tolerating other individuals in their immediate living environment; and

2. Require access to an individual bedroom to promote psychiatric wellness and reduce the potential for aggression or other behaviors associated with a risk of re-hospitalization; and/or

3. Have substantial difficulties with activities of daily living and require around-the-clock observation and oversight; and/or

4. Require daily redirection from staff to avoid behaviors potentially harmful to themselves or others.

A. Each individual served in a PISL shall have a private, single bedroom unless staff of the administrative agent or affiliate provide adequate justification to the department for shared rooms. Single bedrooms must meet requirements for square footage as specified in 9 CSR 40-1.085(5)(A) 1.

(E) Intensive residential treatment setting (IRTS) provides service and supports for five (5) to sixteen (16) adults and is most appropriate for individuals who-

1. Can tolerate regular interaction with their peers, but have significant difficulties with activities of daily living;

2. May require around-the-clock observation and oversight; and/or

3. Require periodic redirection from staff to avoid behaviors potentially harmful to themselves or others.

A. Each individual served in an IRTS shall have a private, single bedroom unless staff of the administrative agent or affiliate provide adequate justification to the department for shared rooms. Single bedrooms must meet requirements for square footage as specified in 9 CSR 40-1.085(5)(A) 1.

(4) Staffing. Each residential program shall have a director who is responsible for making decisions regarding program operations. The director shall delegate a staff person to act on his/her behalf when unavailable. Oversight of the program must be provided by a qualified mental health professional (QMHP) as defined in 9 CSR 40-1.015(2)(TT).

(A) Staff providing services and supports must be at least eighteen (18) years of age and have a minimum of a high school diploma or equivalent certificate.

(B) Staff must be systematically trained to provide intensive interventions and supports to reduce the symptoms of mental illness and co-occurring disorders. Training shall include interventions to redirect individuals in a psychiatric crisis who are exhibiting behaviors potentially dangerous to themselves or others.

(C) Each staff person must have a training plan that identifies specific topics and frequency of refresher training on each topic, including documentation of course completion.

(5) Supervision of Individuals Served. Staff supervision of individuals being served in the program shall be provided in accordance with their assessed needs as documented in the ITP. A system must be in place to ensure each individual is monitored in accordance with his or her ITP. Services and monitoring shall be documented.

(A) Twenty-four (24) hour protective oversight shall be provided as follows:

1. PISL programs shall have at least one (1) staff person on duty at the residential setting who is dressed and awake twenty-four (24) hours per day, seven (7) days per week; and

2. IRTS shall have at least one (1) staff person on duty at the residential setting during the day and evening shifts for every eight (8) individuals receiving services, and one (1) staff person on duty at the residential setting who is dressed and awake during the night shift for every sixteen (16) individuals served.

(B) Procedures shall be in place for staff to rapidly respond to unauthorized absences of individuals being served in the program.

(C) Procedures shall be in place to maintain adequate staffing when responding to emergent situations to assure the health and safety of individuals being served.

(D) Staff shall be trained on de-escalation and intervention techniques for individuals who may engage in behavior that may be harmful to themselves or others.

(E) Staffing requirements shall be maintained at all times at the residential site.

(6) Program Supervision. A qualified mental health professional (QMHP) as defined in 9 CSR 40-1.015, shall be on site in PISL and IRTS programs a minimum of eight (8) hours per week to provide supervision, program planning, consultation, treatment planning, and support.

(A) A QMHP shall be available twenty-four (24) hours per day, seven (7) days per week, to intervene in crisis situations that may occur in the program.

(7) Nursing Services. A licensed registered nurse (RN) shall be on-site in PISL and IRTS programs a minimum of four (4) hours per week to provide oversight and coordination of nursing and medical protocols and individual needs.

(A) On-site nursing oversight and coordination may be performed by a licensed practical nurse (LPN) for a minimum of eight (8) hours per week in lieu of the on-site RN under the following circumstances:

1. An RN is available to the LPN and other program staff for consultation and is able to respond on-site, if needed, in the event an individual experiences a change of condition. The staffing plan shall reflect availability of the RN, including location and proximity to the program; and

2. The LPN consults with an RN on a monthly basis, at a minimum, regarding observations and findings regarding physicians' orders, medication administration trends and patterns, health conditions, and care processes for individuals served. Observations and findings reviewed must be documented in each individual's records and include the dated signature and credentials of the RN providing the consultation or dated signature of the LPN indicating the name of the consulting RN.

9 CSR 40-4.001

Adopted by Missouri Register November 2, 2020/Volume 45, Number 21, effective 12/31/2020

Amended by Missouri Register February 1, 2024/volume 49, Number 03, effective 3/31/2024.