9 CSR 30-4.045 - Intensive Community Psychiatric Rehabilitation (ICPR)

PURPOSE: This amendment clarifies the intent of ICPR services as well as the related staffing requirements for this service.

PUBLISHER'S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

(1) Intensive Community Psychiatric Rehabilitation (ICPR). ICPR is separate and distinct from other community psychiatric rehabilitation (CPR) services. The individual treatment plan shall specify interventions and supports to be provided by ICPR staff that are separate from other CPR services (such as community support) to prevent duplication of services.

(A) Services are designed to help individuals who are experiencing a severe psychiatric condition, alleviating or eliminating the need to admit them into a psychiatric inpatient setting or a restrictive living setting. ICPR is a comprehensive, time-limited, community-based service for individuals who are exhibiting symptoms that interfere with individual/family life in a highly disabling manner.

(B) ICPR in all settings (children/youth and adult) must be approved by the department prior to implementation. Written proposals shall be submitted to the department and must include the following:

1. The proposed service, setting, and timeline for implementation;

2. Method for determining eligibility for the service;

3. Staffing patterns/staff qualifications, including identification of the qualified mental health professional (QMHP) who supervises the ICPR setting;

4. Evidence that the site(s) is safe;

5. Process for obtaining multidisciplinary input into treatment plans;

6. Type of documentation to be used;

7. Strategy for preventing the duplication of services and supports delivered by residential and community-based CPR staff;

8. Plan for financial separation of room and board from services; and

9. Plan for providing personal spending funds to individuals served.

(C) ICPR is intended for-

1. Persons who would be hospitalized without the provision of intensive community-based intervention;

2. Persons who have extended or repeated hospitalizations;

3. Persons who have psychiatric crisis episodes;

4. Persons who are at risk of being removed from their home or school to a more restrictive environment; and

5. Persons who require assistance in transitioning from a highly restrictive setting to a community-based alternative, including specifically persons being discharged from inpatient psychiatric settings who need intensive CPR services and may require assertive outreach and engagement.

(D) Treatment teams deliver services that will maintain the individual within the family and significant support systems and assist them in meeting basic living needs and age appropriate developmental needs.

(2) Admission Criteria. To be eligible for ICPR, the individual must meet admission criteria as defined in 9 CSR 30-4.005 and at least one (1) of the following criteria:

(A) Is being discharged from a department facility or bed funded by the department;

(B) Has had extended or repeated psychiatric inpatient hospitalizations or crisis episodes within the past six (6) months;

(C) Has received services in multiple out-of-home residential settings due to their mental disorder; or

(D) Is at risk of being removed from their home, school, or other community living situation.

(3) Staff Requirements. Staff requirements for ICPR in residential settings are as follows: Staff requirements for ICPR in residential settings are as follows:

(A) Intensive Residential Treatment Settings (IRTS) and Psychiatric Individualized Supported Living (PISL), in accordance with 9 CSR 40-1 and 9 CSR 40-4.001;

(B) Clustered apartments (CA). Staff shall be available on a full- or part-time basis in accordance with the agency's written proposal approved by the department;

1. Clustered apartment services are provided on-site at the individual's place of residence. Staff providing services shall be located on site, within a five (5) mile radius of the CA, or within a ten (10) minute drive of the CA.

(C) Treatment Family Home-Based Services and Professional Parent Home-Based Services, as specified in section (7) of this rule and 9 CSR 40-6.001.

(4) Treatment for Children/Youth and Adults. All treatment teams shall be supervised by a qualified mental health professional (QMHP). The team coordinates a comprehensive array of services available to the individual through the CPR program as specified in 9 CSR 30-4.043. Other services shall be provided as clinically appropriate to meet individual needs, however, shall not duplicate services being provided on site. Each team shall include:

(A) Staff required to provide specific services identified on the individualized treatment plan;

(B) The individual receiving services and family members or other natural supports, if developmentally appropriate;

(C) ICPR shall include:

1. Multiple face-to-face contacts with the individual on a weekly basis, and may require contact on a daily basis, as required for each service type;

2. Services that are available twenty-four (24) hours per day, seven (7) days per week for programs that require daily services; and

3. Crisis response services that may be coordinated with an existing crisis system;

(D) The amount and frequency of services is based upon the individual's assessed acuity and need;

(E) A crisis prevention plan shall be developed for each individual, including clinical issues that may impact transition to less intensive services;

(F) At a minimum, quarterly treatment plan reviews shall occur to ensure individuals are receiving the appropriate level of services to meet needs and goals; and

(G) Individuals no longer need ICPR when-

1. There is a reduction of severe symptoms; and

2. They are able to function without intensive services; or

3. They choose to no longer receive intensive services.

(5) Documentation Requirements. ICPR services must be documented in accordance with 9 CSR 10-7.030(13), and as specified in this rule.

(A) For individuals currently enrolled in the CPR program, the following documentation is required upon admission to ICPR:

1. Verification they meet admission criteria;

2. Acuity level; and

3. Treatment plan update indicating the higher level of service the individual will be receiving.

(B) For individuals newly admitted directly from the community into ICPR, an intake evaluation must be completed to substantiate acuity and criteria for admission.

1. Each individual shall have a psychiatric evaluation at admission. For individuals discharged from inpatient hospitalization into ICPR, a psychiatric evaluation completed at the facility/hospital may be initially accepted.

2. The comprehensive assessment must be completed within thirty (30) days of admission except for individuals admitted provisionally.

3. Treatment plans shall be developed upon admission and be updated at least quarterly, or more frequently if clinically indicated.

(C) Treatment plans shall be reviewed as required for each service type and documented in the individual record with a summary progress note, including updates to the treatment plan as appropriate.

(D) Upon change from ICPR services, a transition summary must be documented in a level of care transition summary and reflected in an updated treatment plan. must be completed by a QMHP and included in an updated treatment plan.

(6) ICPR for Children and Youth. Services are medically necessary to maintain a child with a Serious Emotional Disturbance (SED) in their natural home, or maintain a child with a serious mental illness or SED in a community setting who has a history of failure in multiple community settings, and/or the presence of ongoing risk of harm to self or others, which would otherwise require long-term psychiatric hospitalization. Clinical interventions are provided by a multidisciplinary treatment team on a daily basis, and the interventions must be available twenty-four (24) hours per day, seven (7) days per week for stabilization purposes. The child's family and other natural supports may receive services when they are for the direct benefit of the child in accordance with their individual treatment plan.

(A) When a child/youth is receiving this service, it is vital that the parent/guardian be actively involved in the program if the individual is to receive the full benefit of the program. Services shall be provided to the child/youth's family and other natural supports when such services are for the direct benefit of the individual, in accordance with their needs and treatment goals identified in the treatment plan, and for assisting in their recovery.

(B) Services shall include, but are not limited to:

1. Medication administration/management of medication;

2. Ongoing behavioral health assessment and diagnosis;

3. Monitoring to assure individual safety;

4. Individual and group counseling; and

5. Community support.

(C) The ICPR multidisciplinary team shall include the following staff, based on the needs of the individual served:

1. Physician, psychiatrist, child psychiatrist, psychiatric resident, assistant physician, physician assistant, or Advanced Practice Registered Nurse (APRN);

2. QMHP;

3. RN;

4. LPN;

5. Community Support Specialist; and

6. Individuals with a high school diploma, or equivalent certificate, under the direction and supervision of a QMHP.

(D) Services are limited to ninety (90) days. Exceptions may be granted by the department and must be documented in the individual record.

(7) ICPR for Children/Youth in Residential Settings (Treatment Family Home-Based Services and Professional Parent Home Based Services). Intensive therapeutic interventions are provided to improve the child's functioning and prevent them from being removed from their natural home and placed into a more restrictive residential treatment setting due to a SED.

(A) Services are for children whose therapeutic needs cannot be met in their natural home or an alternative therapeutic environment is required for transition back to their home or least restrictive setting.

(B) Providers must complete extensive, specialized training required by the department and meet department licensure requirements as specified in 9 CSR 40-6.

(C) The provider shall participate in pre-placement and ongoing meetings with the child's CPR treatment team and assist in development of the treatment plan. The provider is responsible for implementing the treatment plan and maintaining contact with the child's natural parent/guardian and completing documentation as required by the department.

(D) Services and supports are individualized and strength-based to meet the needs of the child and family across life domains to promote success, safety, and permanence in the home, school, and community. Therapeutic interventions target the child's serious mental health issues and promote positive development and healthy family functioning.

(E) Children must meet CPR admission criteria and their behavior must be sufficiently under control to live safely in a community setting with appropriate support.

(F) Staff of the CPR program who supervise the child's services must be available twenty-four (24) hours per day, seven (7) days per week to assist the provider if a crisis situation occurs.

(G) Placement, duration, and intensity of services is based on the specific needs of each child as specified in the MO HealthNet CPR Provider Manual, hereby incorporated reference and made a part of this rule and available from the Department of Social Services, 615 Howerton Court, PO Box 6500, Jefferson City, MO 651026500, and as specified in the department contract, September 2019. This rule does not incorporate any subsequent amendments or additions to this publication.

(H) A maximum of three (3) children may receive services in a Treatment Family Home (TFH), subject to licensed capacity. One (1) child may be served in a Professional Parent Home (PPH).

(8) Evidence-Based Practices (EBP) for Youth. Services involve proven treatment supports for children and youth to address specific behavioral health needs. The selected EBP is based on individual needs and desired outcomes as identified in the treatment plan.

(A) The EBP must be approved by the department.

(B) Activities associated with the service must include, but are not limited to:

1. Extensive monitoring and data collection;

2. Specific skills-training in a prescribed or natural environment; and

3. Prescriptive responses to a psychiatric crisis and/or frequent contact with the individual and/or family, in addition to the arranged therapy sessions.

(9) ICPR for Adults in Non-Residential Settings. Services are delivered by teams using one (1) of the following methods:

(A) Linking and transitioning individuals from acute or long-term services to less intensive treatment. The time frame for services is approximately ninety (90) days or less, but varies according to individual needs;

(B) Modified Assertive Community Treatment (ACT), as approved by the department. The time frame varies based on individual needs; or

(C) Intensive wrap-around stabilization services for individuals with substantial mental health needs who may otherwise require inpatient hospitalization. The expected period of engagement is approximately ninety (90) days or less, but varies according to individual needs.

(D) Teams may be designated exclusively for individuals in ICPR or be mixed teams serving individuals in ICPR and rehabilitation services.

(E) A department-approved functional assessment must be completed monthly and documented in the individual record.

(F) Community support services shall not be provided while an individual is receiving ICPR non-residential services.

(10) ICPR for Transition Age Youth in Non-Residential Settings. Services are delivered by transdisciplinary specialty teams using intensive wrap-around stabilization for individuals with substantial mental health and/or co-occurring needs, with the primary diagnosis being a mental disorder.

(A) Services are for individuals who may otherwise require inpatient hospitalization. The period of engagement varies based upon individual needs as specified in the treatment plan.

(B) An initial comprehensive assessment must be completed within thirty (30) days of admission.

(C) An individual treatment plan shall be developed within forty-five (45) days of admission and shall be updated as required by the department.

(11) ICPR for Adults in Residential Settings (IRTS, PISL, Clustered Apartments). Medically necessary services/supports are provided to adults who have a serious mental illness and are transitioning from an inpatient psychiatric hospital to the community, or who are at risk of returning to inpatient care due to their clinical status or need for increased support. Services and supports are provided on site where the individual lives under the supervision of a QMHP. Residential settings are structured to meet individual needs to ensure safety and prevent the individual's return to a more restrictive setting for services.

(A) Staff providing services/supports must be at least eighteen (18) years of age and have a minimum of a high school diploma or equivalent certificate. Two (2) years of direct heath care experience, or a bachelor's degree in behavioral sciences, is preferred.

(B) Staff must be systematically trained to provide intensive interventions and supports to reduce the symptoms of mental illness, and provide de-escalation and intervention techniques to individuals in a psychiatric crisis who are exhibiting behaviors potentially dangerous to themselves or others. A training plan must be in place for each staff person identifying specific topics and frequency of refresher training on each topic, including documentation of course completion.

(C) Support and rehabilitation services related to activities of daily living and crisis prevention and intervention must be provided.

(D) Documentation must reflect delivery of direct (face-to-face) services and supports such as, daily summary progress notes, group notes, individualized progress notes documenting interventions including crisis assistance, conflict management, behavior redirection, and prompting or reminders.

(12) Children's Inpatient Diversion. A full array of intensive clinical services are provided to children/youth in a highly structured therapeutic setting. Services are designed to restore the child to a prior level of functioning, decrease risk of harm, and prevent transition to a more restrictive setting.

(A) Emergency medical services must be available on site or in close proximity.

(B) A psychiatrist must supervise services which are delivered by a multi-disciplinary treatment team.

(C) Licensed nursing staff must be available on a daily basis.

(D) Licensed occupational and recreational therapists must be available based on individual needs.

(E) The provision of services is limited to certified or deemed-certified CPR programs for children and youth. The service must be accredited by a national accrediting body approved by the department.

(F) There shall be one (1) staff person for every two (2) individuals served during waking hours. The ratio for staff to individuals served may decrease to one (1) staff to six (6) individuals during sleeping hours.

(13) Adult Inpatient Diversion. A full array of intensive clinical services are provided to adults in a highly supervised twenty-four (24) hour, structured therapeutic setting. Services are designed to restore the individual to a prior level of functioning, decrease risk of harm, and prepare for transition to a less restrictive setting.

(A) Emergency medical services must be available on site or in close proximity.

(B) Intensive therapeutic services must be provided in a coordinated effort under the direction of a psychiatrist. Other staff on the treatment team includes licensed nurses, licensed psychologists, social workers, counselors, psychosocial rehabilitation specialists, and other trained supportive staff.

(C) Services shall include, but are not limited to:

1. Nursing;

2. Community support;

3. Psychosocial rehabilitation; and

4. Treatment for co-occurring disorders and other evidence-based services.

(D) The provision of services is limited to CPR programs for adults. The service must be accredited by a national accrediting body approved by the department.

(E) The staffing ratio for daytime and evening hours shall be one staff to six individuals served (1:6), and one staff to eight individuals served (1:8) during nighttime hours.

Notes

9 CSR 30-4.045

AUTHORITY: section 630.050, RSMo Supp. 2010 and sections 630.655 and 632.050, RSMo 2000.* Emergency rule filed Dec. 28, 2001, effective Jan. 13, 2002, expired July 11, 2002. Original rule filed Dec. 28, 2001, effective July 12, 2002. Emergency amendment filed June 14, 2010 , effective July 1, 2010, expired Feb. 24, 2011 . Amended: Filed June 14, 2010, effective Feb. 24, 2011 . Amended by Missouri Register October 15, 2019/Volume 44, Number 19, effective 11/30/2019 Amended by Missouri Register August 15, 2022/Volume 47, Number 16, effective 9/30/2022

*Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008; 630.655, RSMo 1980; and 632.050, RSMo 1980.