Rules of Department of Mental Health Division 50–Admission Criteria Chapter 2–Mental Health Services

Title Page

9 CSR 50-2.010 Admissions to Children’s Community Supported Community Living...... 3 9 CSR 50-2.020 Guidelines for Conditional Release...... 8 9 CSR 50-2.510 Admissions to Adult Placement Program...... 8

Rebecca McDowell Cook (2/29/96) CODE OF STATE REGULATIONS 1 Secretary of State Chapter 2—Mental Health Services 9 CSR 50-2

Title 9—DEPARTMENT OF guardian, a court of competent jurisdiction, of the referral, eligibility for services and MENTAL HEALTH or a state or private agency. placement need, if any. The Supported Division 50—Admission Criteria Community Living office may request addi- Chapter 2—Mental Health Services (3) An applicant shall meet all of the follow- tional information as necessary. ing admission criteria to be eligible for 9 CSR 50-2.010 Admissions to Children’s Children’s Supported Community Living ser- (6) If the Supported Community Living Supported Community Living vices from the Division of Comprehensive office makes a preliminary decision to accept Psychiatric Services: a referral, it shall obtain the following refer- PURPOSE: This rule prescribes admis- (A) Be under the age of eighteen (18); ral materials: sions criteria, the application process (B) Have received a DSM IV Axis I prima- (A) A comprehensive multidisciplinary and placement procedures for ry diagnosis of or mental ill- evaluation including a psychosocial history, Children’s Supported Community ness; may have a secondary diagnosis of alco- psychiatric evaluation/diagnosis, psychologi- Living of the Division of Com- hol abuse, substance abuse or mental retarda- cal evaluation/testing, performed within the prehensive Psychiatric Services. tion; and past six (6) months; and information about (C) Have, based upon sufficient documen- the intellectual cognitive functioning of the Editor’s Note: The following material is tation, a mental disorder or mental illness youth; incorporated into this rule by reference: which constitutes substantial impairment in (B) The psychiatric assessment (an evalua- 1) American Psychiatric Association, DSM social role functioning and daily living skills tion which includes diagnosis shall be done IV Diagnostic and Statistical Manual of to the extent that the client cannot function by a or licensed clinical psychol- Mental Disorders (Fourth Edition) successfully outside a mental health facility ogist designated by the department); (Washington, D.C.: American Psychiatric without services. This substantial impairment (C) Current physical examination per- Association, 1994). may include, but not be limited to, the fol- formed within the past ninety (90) days, lab- In accordance with section 536.031(4), lowing behavioral characteristics: oratory tests and X-rays as ordered by physi- RSMo, the full text of material incorporated 1. Substantial impairment in impulse cian; by reference will be made available to any control and judgment in daily living skills; (D) Background information which interested person at the Office of the 2. History of aggressive/assaultive includes the youth’s level of functioning Secretary of State and the headquarters of the behaviors or self-abusive behaviors based on including successes and failures in the adopting state agency. psychological disability; school, home and community as well as in 3. Dysfunctional in school, home, com- other placements; (1) Terms defined in sections 630.005 and munity or a combination of these as a result (E) Any special procedures done in the 632.005, RSMo are incorporated by refer- of a mental disorder or mental illness to the diagnosis process or any special needs of the ence in this rule. Unless the placement con- extent that family and available community client; tract clearly requires otherwise, the following resources are not able to meet needs; and (F) Information on medicines, allergies or other terms, as used in this chapter, shall 4. Evidence of failure in less restrictive other medical conditions; mean: treatment environments. (G) Information on legal status, including (A) Applicant, a minor for whom place- copies of guardianship, circuit or civil deten- ment services have been requested, in writ- (4) Department placement staff shall consid- tion orders, if applicable; ing, including a person seeking readmission er an applicant ineligible for Supported (H) Completed and signed standard means to Supported Community Living; Community Living services from the test, 9 CSR 10-31.011; (B) Client, a minor placed under section Division of Comprehensive Psychiatric (I) Achenbach Child Behavior Checklist; 630.620, RSMo in any residential facility Services if— (J) DMH Form 8311, Application for licensed or certified solely by the department (A) The primary diagnosis is alcohol or Supported Community Living Services for or in conjunction with the Department of substance abuse, or mental retardation; Minors; and Social Services under Chapter 630, RSMo; (B) Medical needs supersede the psychi- (K) Other demographic and pertinent (C) DSM IV, Diagnostic and Statistical atric disability and require considerable information. Manual of Mental Disorders (Fourth Edition) supervision and ongoing medical treatment; of the American Psychiatric Association; (C) Impulses to harm self or others are not (7) Within five (5) working days after receipt (D) Supported Community Living, an under control according to clinical judgment; of the referral information, the Supported office which is responsible for the regional (D) It has been established that appropriate Community Living office shall mail the placement program and services and is the services are otherwise available through applicant a report or overview on the status of entry and exit for regional placement services alternative resources; the application, including a list of the items and funding; (E) The application is submitted solely for missing. Within fourteen (14) working days (E) Minor, any person under the age of the purpose of securing residential placement after receipt of the complete referral informa- eighteen (18) years; and for a school-aged child as defined in Chapter tion, the Supported Community Living office (F) Patient, an individual under observa- 162, RSMo to receive an appropriate educa- shall indicate the disposition of the referral, tion, care, treatment or rehabilitation by any tion; or in writing, by registered/certified mail, hospital or other mental health facility pur- (F) Child’s symptoms meet acute defini- return receipt requested. If the applicant does suant to the provisions of Chapter 632, tion. not meet criteria for acceptance, the depart- RSMo. ment, in the registered/certified letter, shall (5) Supported Community Living offices or notify the agency or person who made appli- (2) Application for placement shall be made designee shall screen applicants for place- cation for the applicant of— by the applicant’s parents, the applicant’s ment services to determine appropriateness (A) The reasons for rejection;

Rebecca McDowell Cook (2/29/96) CODE OF STATE REGULATIONS 3 Secretary of State 9 CSR 50-2—DEPARTMENT OF MENTAL HEALTH Division 50—Admission Criteria

(B) The deadline for appealing the deci- tain relationships and encourage visits benefi- be reviewed weekly by Supported Com- sion; cial to the patient or resident. munity Living office staff. Area directors (C) The name, address and telephone num- will determine priorities for funding alloca- ber of the person to whom the appeal should (11) The Supported Community Living office tions within their regions. be directed; and staff shall notify the agency or person making (D) The name, address and telephone num- application, in writing, to schedule a special AUTHORITY: sections 630.050 and ber of a Department of Mental Health staff staffing with applicant and other 630.705, RSMo (1994).* Original rule person who is qualified to provide informa- interested/responsible persons to determine filed Feb. 29, 1988, effective July 25, tion about the services offered by the all appropriate placement resources and to 1988. Amended: Filed March 30, 1992, Division of Comprehensive Psychiatric designate responsibility for procuring and effective Jan. 15, 1993. Amended: Services. making the placement. Filed July 17, 1995, effective March 30, 1996. (8) Appeals. If the agency or person making (12) Supported Community Living/designee application for the applicant disagrees with staff shall obtain appropriate releases of *Original authority: 630.050, RSMo (1980), referral information signed by parent or amended 1993, 1995 and 630.705, RSMo (1980), the rejection, s/he may appeal, in writing, amended 1982, 1984, 1985, 1990. within thirty (30) days after receipt of the guardian. The referral information shall notice to the children’s area director. Within include appropriate psychiatric, medical and fifteen (15) days of receiving the appeal, the social information. The referral information children’s area director shall review the shall also include: applicant’s referral materials along with a (A) Treatment needs, including strengths copy of the rejection letter and shall notify and weaknesses; and the applicant and the agency or person who (B) Legal status. made application for the applicant, in writ- ing, by registered/certified letter of his/her (13) The proposed Supported Community decision on the appeal. If the agency or per- Living vendor shall indicate acceptance or son making application disagrees with the rejection to the regional placement office, decision of the head of the department’s men- which shall document that response in the tal health facility, s/he may appeal, in writ- client file and inform the agency or person ing, within fifteen (15) days of receipt of the making application of the response. decision to the director of Children and Youth Services. The children and youth director (14) Consent for Placement. shall review the applicant’s referral materials (A) If the applicant is a minor or has a along with a copy of the rejection letter and legal guardian, the department shall obtain notify the applicant and the agency or per- consent of the parent or guardian before son making application, in writing by certi- placement. fied/registered letter, of his/her decision on (B) If the applicant is an involuntary the appeal within fifteen (15) days of its patient/client under Chapter 211 or 632, receipt. The decision of the children and RSMo, the department shall notify the court youth director shall be final. of competent jurisdiction of the proposed placement and allow ten (10) working days (9) If the decision is to accept the applicant for the court to object. into the Supported Community Living (C) For patients committed under Chapter Program, Supported Community Living 552, RSMo, the department shall follow pro- office staff shall follow departmental proce- cedures set out in section 552.040, RSMo for dures for client admission. obtaining conditional release and subsequent placement. (10) Before placing any person in the (D) If a patient in a mental health facility, Supported Community Living Program, the his/her parent, if s/he is a minor, or his/her department shall consider each of the follow- legal guardian refuses to consent to the pro- ing: posed placement, the department shall follow the procedure set out in section 630.635, (A) Best interest of the patient or resident; RSMo. (B) Least restrictive environment for care and treatment consistent with needs and con- (15) Funding will be approved by the area ditions of the patient or resident; director, Children’s Services, or designee for (C) Ability to provide necessary care and an applicant based on the— treatment for the patient or resident which is (A) Applicant’s acceptance by a proposed of comparable quality to existing care and Supported Community Living vendor; and treatment based upon investigation of the (B) Availability of funds. alternative facility and its program of care and treatment; and (16) Applicants for whom placement is being (D) Relationship of the patient or resident sought will have their names placed on a list to family, guardian or friends so as to main- of those eligible for funding. Their status will

4 CODE OF STATE REGULATIONS (2/29/96) Rebecca McDowell Cook Secretary of State

9 CSR 50-2—DEPARTMENT OF MENTAL HEALTH Division 50—Admission Criteria

9 CSR 50-2.020 Guidelines for Conditional with the probate division of the circuit court give written notification to the patient that if Release that committed the patient. Copies of the con- the patient disagrees with the revocation that ditional release shall be given to— the patient may ask the court to hold a hear- PURPOSE: This rule sets guidelines for (A) The patient; ing on the matter. Upon readmission to the implementation of House Bill 971, sec- (B) The facility that conditionally released facility, the patient shall be given notice of tion 632.385, RSMo and applies to all the patient; his/her commitment rights as if s/he were department facilities and private mental (C) The person(s) providing for the condi- detained for the initial ninety-six (96)-hour health facilities certified by the Division tions of release; period and be given the name and phone of Comprehensive Psychiatric Services (D) The mental health coordinator; number of his/her attorney who represented to provide outpatient treatment. (E) The patient’s last attorney of record; and him/her in the last commitment hearing. The (1) The head of a mental health facility or (F) The prosecuting attorney, county coun- attorney who represented the patient on the designee may conditionally release a patient selor or circuit attorney, as appropriate. last commitment hearing shall continue to be who is involuntarily detained pursuant to the attorney of record unless the patient has Chapter 632, RSMo for twenty-one (21) (6) If the patient violates one (1) or more obtained other legal counsel. If the attorney days, ninety (90) days or one (1) year for a conditions of the release, the head of the of record is unable to represent the patient, a period, not to exceed one (1) year, under facility or designee that conditionally new attorney shall be designated by the facil- written conditions provided by the facility. released the patient shall be notified. After ity from the list of attorneys. The mental The facility shall have a continuing responsi- review the head of the facility or designee health coordinator shall be given notice as to bility to assist the client in following the writ- may revoke the patient’s conditional release the patient’s revocation and return to inpa- ten conditions and, as provided in section (6) and return the patient to the hospital if there tient hospitalization. of this rule, may revoke the patient’s condi- is reason to believe that— tional release and return the patient to the (A) The patient has violated one (1) or (10) The period of inpatient hospitalization facility for further inpatient treatment. more of the conditions of release; shall not exceed the period of time left on the (B) The patient requires resumption of full- previous commitment without further hear- (2) The head of the facility or designee shall time hospitalization; or ings for the next appropriate period of com- develop written conditions for the patient’s (C) The safety of the patient or public may mitment. The head of the facility placing the release. These conditions may include, but be in jeopardy if the patient is not hospital- are not limited to, the following: ized. patient on conditional release shall keep ade- (A) Where the patient will reside; quate records to assure that the patient is not (B) What medications the patient must take (7) If a decision to revoke the patient’s con- involuntarily treated as an inpatient for a to treat the mental illness; ditional release is made by the head of the longer period than necessary while on condi- (C) When and where the patient will facility or designee, s/he shall notify and give tional release. receive required , day treat- written notice as to the conditions that were ment, community placement or other violated, how they were violated and reasons AUTHORITY: section 630.050, RSMo required care and treatment necessary to con- for returning the patient to inpatient hospital- (1986).* Original rule filed Aug. 4, tinue the patient on conditional release; ization within ninety-six (96) hours of the 1988, effective Jan. 13, 1989. (D) Which behaviors the patient is expect- patient’s return to the mental health facility to ed to exhibit or avoid; and the following: *Original authority 1980. (E) Any other conditions necessary for the (A) The patient; patient to comply with to reasonably assure (B) The person(s) providing services which 9 CSR 50-2.510 Admissions to Adult success. are called for by the conditions of release; Placement Program (C) The court of jurisdiction; (3) The patient, the head of the facility or (D) The mental health coordinator; PURPOSE: This rule prescribes admis- designee and the persons providing services (E) The patient’s last attorney of record; sions criteria, the application process to the patient while on conditional release and and placement procedures for the adult shall agree to the conditions of the release (F) The prosecuting attorney, county coun- placement program of the Division of agreement. selor or circuit attorney, as appropriate. Comprehensive Psychiatric Services.

(4) The head of the releasing facility or (8) If, after given notice, the patient refuses Editor’s Note: The following material is designee may modify the patient’s conditions to return to the facility, the head of the facil- incorporated into this rule by reference: for release when s/he believes that these ity or designee may take the written notice to 1) American Psychiatric Association, DSM changes are in the best interest of the patient. the probate division of the circuit court where IV Diagnostic and Statistical Manual of Suggested modifications to the conditional the conditional release was filed and request Mental Disorders (Fourth Edition) release agreement may be made to the head of that the probate division of the circuit court (Washington, D.C.: American Psychiatric the releasing facility or designee by the issue a warrant for the patient’s apprehension Association, 1994). patient or the persons providing services. and return to the facility. The court may con- In accordance with section 536.031(4), Any modifications shall be given to the sider the request on an ex parte basis. Any patient in writing and as required in sections court costs related to revocation shall be paid RSMo, the full text of material incorporated (3) and (5) of this rule. as provided in section 632.415, RSMo. by reference will be made available to any interested person at the Office of the (5) The signed conditional release shall be (9) When the patient is returned to the facili- Secretary of State and the headquarters of the filed by the head of the facility or designee ty, the head of the facility or designee shall adopting state agency.

8 CODE OF STATE REGULATIONS (2/29/96) Rebecca McDowell Cook Secretary of State Chapter 2—Mental Health Services 9 CSR 50-2

(1) Terms defined in sections 630.005 and 8. Post-traumatic disorder determine the following: appropriateness of 632.005, RSMo are incorporated by refer- (309.81); the referral, eligibility for services and place- ence in this rule. Unless the residential ser- 9. Borderline ment need, if any. The referring agency or vices contract clearly requires otherwise, the (301.83); person shall provide a preliminary screening following other terms, as used in this chapter, 10. Dissociative identity disorder information summary on a form designated shall mean: (300.14); by the regional placement program. The (A) Applicant, a person for whom place- 11. Generalized regional placement program may request ment services have been requested in writing, (300.02); or additional information as necessary. Regional including a person seeking readmission to the 12. with , placement programs shall conduct screenings community placement program; agoraphobia without history of panic disorder in appropriate settings. (B) Client, a person placed under section and social (300.21, 300.22 or 630.620, RSMo in any residential facility 300.23); and (7) If the regional placement program makes licensed or certified solely by the department (C) Based upon sufficient documentation, a preliminary decision to accept a referral, it or in conjunction with the Department of have a mental disorder which constitutes sub- shall obtain the following materials: Social Services under Chapter 630, RSMo; stantial impairment in social role functioning (A) Psychiatric assessment (an evaluation (C) DSM IV, Diagnostic and Statistical and daily living skills to the extent that, based which includes diagnosis); Manual of Mental Disorders (Fourth Edition) upon the department’s clinical judgment, the (B) Current physical examination, neces- of the American Psychiatric Association; client cannot function successfully outside a sary laboratory tests and X-rays; (D) Forensic client, a person who is a mental health facility without placement ser- (C) Background information and social client of the Division of Comprehensive vices. Substantial impairment may include, history; Psychiatric Services pursuant to Chapter 552, but not be limited to, the following behavioral (D) Any special procedures done in the RSMo; and characteristics: diagnosis process or any special needs of the (E) Regional Placement Program, an area 1. Substantial need for mental health client, such as diet, information on medi- Supported Community Living (SCL) office treatment and social services; cines, allergies or other medical conditions; subject to supervision by the division director 2. History of inability or unwillingness and or any other entity designated by the division to comply with treatment plans, including (E) Copies of guardianship, circuit or civil director with responsibility for the regional taking medications; detention orders, conditional release order, if placement program and services. 3. Inadequate living skills to provide for applicable. basic necessities of food, clothing, shelter, (2) All forensic clients shall be eligible for safety, personal and health care without assis- (8) Within fourteen (14) working days after adult placement services from the Division of tance; receipt of the referral information, the Comprehensive Psychiatric Services. 4. Poor social skills, which may be regional placement program shall indicate the exhibited in aggressive or withdrawn behav- disposition of the referral in writing. If the (3) All adult persons who are inpatients of ior; applicant does not meet criteria for accep- facilities operated by the Division of 5. Frequent personal crises requiring tance, the department shall notify the refer- Comprehensive Psychiatric Services and are emergency treatment or support and assis- ring agency or applicant by registered mail, referred by facility staff receive priority in tance; return receipt requested, of the reasons for admission to the adult placement program of 6. Inability to effectively access com- rejection, including in the notice information the Division of Comprehensive Psychiatric munity services; on the deadline for appealing the decision and Services. 7. Lack of a personal support system to whom the appeal is to be sent. If the appli- (for example, family or friends) to assist in cant disagrees with the rejection, s/he may (4) An applicant who does not meet the cri- accessing services; and appeal in writing within thirty (30) days after teria of section (2) or (3) shall meet all of the 8. Inability to sustain employment. receipt of the notice and may request to meet following admission criteria to be eligible for with the head of the mental health facility to adult placement services from the Division of (5) Department placement staff shall consid- present his/her case in person as well as in Comprehensive Psychiatric Services: er an applicant ineligible for placement ser- writing. If the referring agency disagrees with (A) Be at least seventeen (17) years and vices from the Division of Comprehensive the rejection, it may appeal in writing within nine (9) months of age; Psychiatric Services if— thirty (30) days after receipt of the notice. (B) Have a currently valid DSM-IV Axis I (A) The primary diagnosis is alcohol or Appeals shall be addressed to the head of the diagnosis limited to one (1) of the following substance abuse or mental retardation; department’s mental health facility. Within list of mental disorders: (B) Medical needs supersede the psychi- thirty (30) days of receiving the appeal, the 1. Schizophrenic disorder (295.10, atric disability and require considerable head of the facility shall notify the applicant 295.20, 295.30, 295.60 or 205.90); supervision and ongoing medical treatment; and the referring agency or person in writing 2. Delusional (paranoid) disorder (C) Impulses to harm self or others are not of his/her decision on the appeal. If the refer- (297.1X); under control according to clinical judge- ring agency or applicant disagrees with the 3. (295.70); ment; decision of the head of the department’s men- 4. (296.XX); (D) The diagnosis is ; or tal health facility, s/he may appeal in writing 5. Atypical (298.9X); (E) Appropriate services have been estab- within fifteen (15) days of receipt of the deci- 6. Major , recurrent lished that are otherwise available through sion to the director of the Division of (296.3X); alternative resources. Comprehensive Psychiatric Services. The 7. Obsessive compulsive disorder (6) Regional placement programs shall division director shall notify the applicant (300.30); screen applicants for placement services to and the referring agency or person in writing

Rebecca McDowell Cook (2/29/96) CODE OF STATE REGULATIONS 9 Secretary of State 9 CSR 50-2—DEPARTMENT OF MENTAL HEALTH Division 50—Admission Criteria

of his/her decision on the appeal within thir- (13) The proposed residential facility or pro- ty (30) days of its receipt. The decision of the gram shall indicate acceptance or rejection to division director shall be final. If the appli- the regional placement office which shall cant meets criteria for placement services, document that response in the client file and the department shall notify the referring inform the referring party of the response. If agency or applicant of tentative placement the patient or resident is competent to give plans. informed consent, the department shall allow ten (10) working days to obtain his/her con- (9) If the decision is to accept the applicant sent before making a placement. If the patient into the placement program, placement staff or resident is a minor or has a legal guardian, shall follow department procedures for client the department shall obtain consent of the admission. parent or guardian before placement. If the patient or resident is an involuntary patient or (10) Before placing any person in a residen- resident under Chapter 211 or 632, RSMo, tial facility or program, the department shall the department shall notify the court of com- consider each of the following: petent jurisdiction of the proposed placement (A) The choices and requests of the patient and allow ten (10) working days for the court or resident; to object. For patients or residents committed (B) Least restrictive environment for care under Chapter 552, RSMo, the department and treatment consistent with needs and con- shall follow procedures set out in section ditions of the patient or resident; 552.040, RSMo for obtaining conditional (C) Ability of the facility or program to release and subsequent placement. If a provide necessary care and treatment for the patient in a mental health facility, his/her par- patient or resident; and ent, if s/he is a minor, or his/her legal (D) Relationship of the patient or resident guardian refuses to consent to the proposed to family, guardian or friends so as to main- placement, the department shall follow the tain relationships and encourage visits benefi- procedure set out in section 630.635, RSMo. cial to the patient or resident. (14) At the time of placement, the department (11) Regional placement program staff shall shall include the following information in the consider a variety of placement options con- residential facility placement packet, which sistent with an individual client’s clinical shall accompany the client: needs. When a proposed residential facility (A) Psychiatric evaluation; or program is determined appropriate, the (B) Psychological evaluation, if applicable; regional placement program shall provide to (C) Social history and assessment; the following persons written reasons that the (D) Initial treatment plan; proposed placement is appropriate under sec- (E) A statement of financial resources; tion 630.615, RSMo: (F) Name of guardian, if applicable; (A) The patient or resident; (G) Commitment status; (B) A parent, if the patient or resident is a (H) Medical evaluation, including current minor; physical examination, diet, medication and (C) The legal guardian; special problems or needs; (D) The referring court, state, private (I) Burial plan information; and agency or facility; and (J) Discharge plan, if from an inpatient set- (E) The patient’s or resident’s next of kin. ting.

(12) Regional placement program staff shall (15) The department also shall provide the obtain appropriate releases of referral infor- following items, which shall accompany the mation signed by the patient or resident, client at the time of placement: his/her parent, if a minor, or guardian. The (A) Prescriptions for, or a fourteen (14)- placement staff shall submit the referral day supply of, medication; information to the proposed residential facili- (B) Initial personal spending monies, if available; and ty or program. The referral information shall (C) Sufficient and appropriate clothing and include appropriate psychiatric, medical and personal items. social information. The referral information shall also include: AUTHORITY: section 630.050, RSMo (A) Preliminary screening information (1994).* Original rule filed July 3, summary; 1986, effective Dec. 15, 1986. (B) Level of functioning; Amended: Filed July 17, 1995, effective (C) Treatment needs, including strengths March 30, 1996. and weaknesses; and (D) Legal status. *Original authority 1980, amended 1993, 1995.

10 CODE OF STATE REGULATIONS (2/29/96) Rebecca McDowell Cook Secretary of State