Effective Date: 10-01-2020
Chapter 2.3 – Residential Treatment Services and DMH Placements
This sub-section describes the process of referring a child in out-of-home care to a residential treatment program or a Department of Mental Health (DMH) placement. If residential treatment or a DMH placement is determined to be in the best interest of the child, as discussed below, all treatment planning shall be tied to the child’s permanency plan, and discharge planning shall begin at the time of admission.
Residential treatment may be appropriate for children with significant emotional and/or psychiatric needs, learning difficulties, behavioral disorders, trauma histories, and developmental disabilities or problems. Children suited for this type of placement are often unable to function adequately within the family, the school, or the community and are in need of additional support which cannot be reasonably met in a foster home setting.
Regardless of the reason a child is in need of residential placement, the goal of all levels of treatment must be focused on stabilizing the child’s behaviors so that he/she may be able to return to the community and least restrictive placement.
All children in the custody of the Children’s Division shall be placed in a facility that is licensed and contracted with the Division for residential treatment services, or licensed/certified by the DMH and contracted with on a case-by-case need.
2.3.1 Residential Treatment Referral Process
Residential treatment shall only be considered if it best meets the child’s clinical needs. One of the following events triggers the need for a referral to the Residential Care Screening Team Unit (RCST) for residential treatment:
- A court has ordered residential treatment;
- A Youth with Elevated Needs Staffing Team has recommended residential treatment;
- A Team Decision Making meeting or Placement Stability Family Support Team meeting has recommended residential treatment;
- An emergency exists where the case manager and supervisor have staffed the child’s case, and the child was placed in emergency placement, either a shelter or residential facility; or
- A qualified clinician such as a primary care physician or psychologist has recommended residential treatment, or the youth is being discharged from a hospital setting with a qualified clinician’s recommendation for residential treatment.
When a case manager identifies a possible need for a referral for residential care placement, the following process shall be followed:
- Within three (3) calendar days of the decision to refer the child to a residential setting, the case manager for the child shall complete the Residential Treatment Referral (CS-9) Section A with all attachments and submit it to the RCST Coordinator in their region. Failure to include all documents may cause a delay in the screening process.
- The Childhood Severity of Psychiatric Illness scale (CSPI) is an assessment tool developed to assist in the planning of appropriate services and is required to accompany the CS-9 for children age six (6) years and older.
- The CSPI also serves as the eligibility determination process for youth enrolled in the Medicaid Rehabilitation Option. This program allows Children’s Division to access federal funding to purchase rehabilitative services to meet identified mental health service needs of children.
Note: Emergency residential shelter placement is a short-term resource for children requiring an immediate, temporary living arrangement in an open facility where their safety and supervision is ensured through an organized program of appropriate activities. For children entering residential placement (including emergency), the CS-9 Section A shall be completed and submitted to the RCST within three (3) calendar days of placement.
- If making a referral for Maternity & Parenting Care (Section B), Infant & Toddler Care (Section C), Aftercare (Family Focus Residential Care (Section D), or residential-based Therapeutic Foster Care (TFC), include the respective section of the CS-9 with the submission to the RCST.
- Children authorized for TFC program have special psychological, social and emotional needs, which require more intensive, therapeutic care than can be found in the traditional foster care setting. Please follow the Child Welfare manual Section 4, Chapter 4 (Working with Children), Subsection 7 – Therapeutic Foster Care https://dssmanuals.mo.gov/child-welfare-manual/section-4-chapter-4-working-with-children-subsection-7-theraputic-foster-care/ for further policy information.
- Children are to be accepted into the TFC program when the case manager and RCST Coordinator determined that the current disabling symptoms cannot be or have not been managed in a less intensive treatment program have determined it.
- The RCST Coordinator shall screen the documentation for appropriateness for residential treatment. The RCST Coordinator may reach out to the case manager requesting additional information or for clarification. The RCST Coordinator will follow-up with the case manager within three (3) calendar days with a decision. Factors the RCST Coordinator will consider shall include:
- Severity of behaviors
- Past referrals or treatment in a residential setting
Note: In the event the RCST Coordinator denies a child for residential treatment, the RCST Coordinator will send an email to the case manager, supervisor, and circuit manager/program manager stating the reason(s) for the denial. If the Family Support Team (FST) disagrees with the RCST Coordinator’s decision, the circuit manager/program manager or case manager may contact the RCST Coordinator for further consideration.
- The RCST Coordinator shall determine and secure the most appropriate residential treatment facility and level of care. Meeting the child’s special needs will take priority over the standard of placement in proximity to the parent(s) or guardian(s). The case manager shall be available to answer follow-up questions from the potential facilities. The RCST Coordinator will confirm the child’s admission with the case manager once placement has been identified and secured.
- If Above Level IV services and/or programming are recommended, the residential treatment facility shall send a request and certification for Above Level IV services and programming to the RCST Coordinator. The request shall include supporting documentation of the specific behaviors exhibited by the child and/or the specific treatment needs that require the Above Level IV services and/or programming; to include an explanation of the extra supervision and services that are requested based on the specific needs of the child. If the RCST Coordinator approves the request, the RCST Coordinator will forward the request to the Central Office for final approval. In the event there is a disagreement in the level of care requested by the placement and the Division’s determination, the determination of the Children’s Division shall govern.
- The case manager will proceed with placement by completing the following:
- Complete the residential admission packet and return prior to admission and arrange transportation;
- Prepare the child and parent(s)/guardian(s) for placement, providing information about the facility, location, special programs, and visitation/contact arrangements, etc.;
- If appropriate, invite the parent(s)/guardian(s) to participate in the child’s admission process;
- The case manager should be present to admit the youth into residential treatment and participate in the intake process.
- The case manager shall enter the child’s new placement information into FACES within 24 hours of placement.
- A “Rehabilitation Service Begin Date” shall be added or updated on the Rehabilitation Services Tracking screen in FACES. The Rehabilitation Service Begin Date must be the date the CSPI was completed or the date of placement, but may not be backdated to the date of placement unless the CSPI was completed on or before the placement date.
Note: A copy of any court order identifying a specific facility and payment for these services shall be sent to the RCST Coordinator immediately upon receipt of such an order for possible Division of Legal Servicers (DLS) action.
- When a child moves from a residential placement to another placement (e.g., another residential provider, therapeutic foster home, resource home), a transfer conference shall be held between the current provider and the next placement provider. The purpose of this conference is to share information about the child to aid in his/her transition to the next placement. This conference shall be arranged by the case manager and/or supervisor, with the current and subsequent placement provider, as well as the child (if developmentally appropriate). This can be completed either face-to-face or via conference call within the timeframes specified below:
- For a planned discharge, a transfer conference shall be held prior to a child’s move, but not to exceed the first five (5) working days of a child’s placement move. After an emergency discharge, a transfer conference shall occur during the Placement Stability Family Support Team Meeting (FSTM) within 72 hour hours of placement, or separately from the FSTM within the first five (5) working days of the placement change. Transfer conference notes shall be documented in the contact communication log in FACES.
The RCST Coordinator may also attend the transfer conference, if necessary. Transfer meeting notes shall be documented in the contact communication log in FACES.
2.3.2 Department of Mental Health (DMH) Placement Referral Process
DMH-Department of Developmental Disabilities (DD) placement shall only be considered if it best meets the child’s treatment needs. A DMH placement, such as an Individualized Supported Living (ISL) is appropriate based on the capacity and/or needs of the child.
When a case manager identifies a possible need for a placement with DMH care placement, the following process shall be followed:
- The case manager shall ensure the youth is waiver-eligible by contacting their local Regional Office for the Developmentally Disabled (DD) and making a referral for services.
- The case manager shall ensure that a referral has been made for Supplemental Security Income (SSI) or SSI is currently issued for the youth.
- The case manager shall follow the same referral process listed in 2.3.1 Residential Referral Process (CS-9) including supplying the RCST Coordinator with the information from the Regional Office, stating child meets eligibility for waiver services and child is approved for SSI.
- Case manager shall provide the RCST Coordinator with a detailed explanation of why the placement with DMH is in the best interest of the child, and attach supporting documentation such as the Individualized Supported Plan and/or monthly treatment reports.
- RCST Coordinator if appropriate will request the child to be added to the Children’s Division Medicaid Wavier Wait List.
2.3.3 Residential Care Screening Team Coordinator Responsibilities
A Residential Care Screening Team (RCST) Coordinator is located in each of the regions. His/her role is to screen and prioritize placement requests for the area, secure placements, match a child with a facility which can meet the needs of the child, and monitor the funds available for residential treatment services.
The RCST Coordinator has final approval/authority for all children referred and accepted for residential treatment services, DMH-DD placements and therapeutic foster care (TFC) services. The RCST Coordinator has oversight to ensure FACES is updated with an accurate Rehab Service Begin Date, which is concurrent with the CSPI completion date, and oversees adherence to a child’s residential treatment/service plan.
The RCST Coordinator reviews children’s needs, as identified on the CS-9, to ensure residential treatment or DMH placements will best meet the child’s clinical and developmental needs. If residential treatment is not determined to be appropriate, the RCST Coordinator will notify the case manager, supervisor, and circuit manager/program manager, and the case manager will seek other options for treatment. As stated in other sections of this chapter and in other chapters, treatment for each child shall meet the clinical needs of that child and shall be offered in the least restrictive placement that assures safety for the child and for others.
Activities of the RCST Coordinator include but are not limited to:
- Receive and process referrals for residential treatment (see section 2.3.1 above for the RCST Coordinator’s responsibilities in the referral process);
- Receive and process referrals for potential placement through DMH-DD providers;
- Contact the Regional Office to have the child placed on the DMH database
- Ensure that protocol is followed between CD and DMH with utilization of a DMH placement provider
- Request and review child’s budget that is approved through DMH Regional Office for services and matches the child’s Individual Supported Plan.
- Will complete the Child Specific Contract request packet and submit to Residential Services Manager for a decision of approval.
- Request information required for renewal when the contract prior to expiration of the contract.
- Complete the service authorization in FACES for children approved for residential treatment whose cases are managed by Children’s Division;
- Review and approve/deny requests from the provider or the Children’s Division case manager for extensions of the treatment period. Such decisions will be based on the progress reports received from the provider as well as the recommendations of the FST;
- Monitor the residential facility to confirm the facility is providing treatment services to the child and family, including encouraging visits as a part of the therapeutic process, as appropriate;
- Complete and enter data on the service authorization authorizing residential treatment services as necessary. Update the service authorization to reauthorize or modify services;
- Authorize any special expenses or services not covered by the residential treatment contract. The manager is responsible for authorizing payment for special expenses via a payment request for children receiving residential treatment program services or TFC.
2.3.4 Requirements for Licensed Residential Treatment Facilities
Facilities under contract with the Division for residential treatment services are required to complete treatment plan and progress reports for the child receiving residential treatment. Such reports shall be submitted to the child’s case manager and the RCST Coordinator at the following intervals:
- Residential Treatment (Level II and III): Treatment plans must be developed within fifteen (15) days of placement. Treatment plans must be reviewed quarterly, every ninety (90) days. (See 13 CSR 35-71.060 and 13 CSR 35-71.130)
- Intensive Residential Treatment (Level IV): Treatment plans must be developed within ten (10) days of placement. Treatment plans must be reviewed monthly, every thirty (30) days. (See 13 CSR 35-71.140)
The residential facility shall provide the case manager and the RCST Coordinator a monthly progress report of the child’s treatment within fifteen (15) calendar days of each calendar month following the month of service. The facility shall submit the monthly progress report to the RCST Coordinator at the same time as the invoice for payment for the service month. This report must be submitted using the Department’s online invoicing system as described in the residential treatment service’s contract.
This monthly report shall include, at a minimum:
- An itemized statement describing the actual services provided to each child during the reporting period, including, duration of all individual, family, and group therapies actually provided during the reporting period; notations if the therapies and/or services are part of a specialized program such as chemical dependency/substance use treatments, youth with problem sexual behaviors, etc.;
- A summary of the child’s educational progress during the reporting period; and
- A summary of the child’s health, behavioral health, and mental health care during the reporting period, including compliance with the requirements of the Settlement Agreement in M.B. vs Tidball which can be found at: https://dss.mo.gov/notice-of-proposed-class-action-settlement.htm.
- All treatment sessions which were not provided in accordance with the child’s treatment plan, shall be disclosed to the case manager and RCST Coordinator in writing, by the following reporting month, and documented in the child’s record. A child’s refusal to participate in treatment sessions shall be documented in the treatment record.
Case Managers shall review the child’s progress reports to ensure that the services provided to the child remain consistent with the child’s ongoing treatment needs. The case manager shall address any discrepancies found in the progress reports with the residential provider in a timely manner.
Treatment plans and treatment reviews shall be completed by the facility in accordance with state regulation 13 CSR 35-71 Licensing Rules for Residential Treatment Agencies for Children and Youth. The full regulation can be accessed at: https://www.sos.mo.gov/cmsimages/adrules/csr/current/13csr/13c35-71.pdf
The facility shall complete the Monthly Medical Log utilizing form CD-265 Medical Log which may be found at http://dss.mo.gov/cd/info/forms and the providers Medication Administration Record (MAR) within five (5) calendar days of each calendar month following the month of service to the child’s case manager. The written documentation must contain all medication administered for the month, including the dosage, any adverse reactions, any new medications prescribed, including the dosage, prescriber notes from any medication monitoring appointments, and the dates/times of any upcoming appointments.
Move and Discharge Requirements
The residential facility shall begin planning the child’s discharge immediately upon entry into the residential facility.
The residential facility shall make every effort to reduce or eliminate the number of unplanned discharges, emergency discharges, and moves to more restrictive settings for children who are referred for residential treatment.
If a child is being discharged on an unplanned/emergency basis or as the result of a 30-day notice for removal to another residential facility, the case manager shall follow the CS-9 referral process listed above.
Levels of Care:
- Emergency Shelter: This is a short-term resource (30-day maximum) for children requiring an immediate, temporary living arrangement in an open facility where their safety and supervision is ensured through an organized program of appropriate activities. Emergency placements in excess of thirty (30) days shall transition to residential maintenance only.
- Moderate Need (Level II): This is an extended placement resource for children requiring a planned program affording safety, structure, and supervision. This level is indicated for children who by reason of behavioral disorder, maladaptive behaviors, family situation, relationship problems with family, and level of development are unable to accept traditional family ties and/or successfully participate in traditional family settings. Residential treatment facilities, should provide reunification services, work with the family, community based services, schools, etc. as a part of therapeutic services provided. Moderate
- Severe Need (Level III): This is an extended placement resource for children requiring active, coordinated, and professional intervention on a residential basis. This level is indicated for children who cannot be effectively managed in a less restrictive setting. These children have a significant emotional and/or psychiatric need. These children have continued difficulty adjusting to an open public school setting. Residential Treatment agencies should provide reunification services, work with the family, community based services, schools, etc. as a part of therapeutic services provided.
- Intensive Need (Level IV): This is an extended placement resource for children requiring active, coordinated, and professional intervention in a highly structured and secure environment. Such children will have demonstrated an inability to function in any less restrictive setting. This level is indicated for children who have a significant emotional and/or psychiatric need. These children are unable to function consistently in an open, public school setting, present a chronic runaway risk, and typically present a history of impulsivity, intensify of behavioral problems, significant family issues, self-destructive behaviors, etc. Residential Treatment agencies should provide reunification services, work with the family, community based services, schools, etc. as a part of the therapeutic services provided. These children are unable to function consistently in an open, public school setting. They present a chronic runaway risk. They also typically present a history of showing rage, including physical aggression.
- Maternity and Maternity with Infant Care: At this level, residential care services are provided to serve pregnant and parenting adolescents to help prepare them for parenthood and self-sufficiency.
- Infant/Toddler Care: Residential care services provided to serve children under the age of seven, including those who are medically fragile or drug and alcohol-affected children and severely emotionally disturbed.
2.3.5 Indicators of Treatment Needs in Children Age 0-6
Residential treatment or DMH placements for a child under the age of seven (7) years shall only be considered once other resources have been explored. However, certain behavior and/or physical conditions can exist which would indicate a need for a structured treatment setting for such a child. In most instances, a foster home setting is preferable to another setting. Residential treatment for children under seven (7) years of age shall be indicated as necessary through professional evaluations and recommendations by qualified professionals such as a child psychologist. Residential treatment and/or a DMH placement for a child under the age of seven (7) must be recommended by the Family Support Team (FST) after evaluations and recommendations by qualified professionals are completed and reviewed.
Related Practice Alerts and Memos: