Or. Admin. R. 411-323-0060 - Policies and Procedures

(1) HEALTH. An agency must have and implement policies and procedures that maintain and protect the health of individuals.
(2) INDIVIDUAL AND FAMILY INVOLVEMENT. An agency must have and implement a written policy that addresses opportunities for all of the following:
(a) Participation of individuals in decisions regarding the agency's operations.
(b) Interaction of families, guardians, legal and designated representatives, and significant others.
(c) For individuals, families, guardians, legal and designated representatives, and significant others:
(A) Participation on the Board of Directors or on committees; or
(B) Review of the agency's policies directly affecting the individuals receiving services from the agency.
(3) CONFIDENTIALITY OF RECORDS. An agency must have and implement written policies and procedures that ensure all records for individuals are kept confidential except as otherwise provided by applicable state and federal rule or laws.
(a) For the purpose of disclosure from individual medical records under this rule, an agency is considered a "public provider" as defined in ORS 179.505.
(b) Access to records by the Department does not require authorization by an individual or their legal or designated representative or family.
(c) For the purpose of disclosure of non-medical individual records, all or portions of the information contained in the non-medical individual records may be exempt from public inspection under the personal privacy information exemption to the public records law set forth in ORS 192.502.
(4) BEHAVIOR POLICIES.
(a) PROFESSIONAL BEHAVIOR SERVICES. An agency must have and implement written policies and procedures to assure professional behavior services are delivered by a qualified behavior professional in accordance with OAR chapter 411, division 304.
(b) BEHAVIOR SUPPORTS. An agency must have and implement written policies and procedures for the delivery of behavior supports that prohibits abusive practices and assures behavior supports are included in a Positive Behavior Support Plan.
(A) The agency must inform each individual, and as applicable their legal or designated representative, of the behavior support policies and procedures at the time of entry and as changes occur.
(B) A decision to alter an individual's behavior must be made by the individual or their legal or designated representative.
(5) EMERGENCY PHYSICAL RESTRAINT. An agency must have and implement written policies and procedures to assure that the use of any emergency physical restraint is reviewed by an agency's Executive Director, or as applicable their designee, within two hours of the emergency physical restraint.
(6) DIRECT NURSING SERVICES. An agency must have and implement written policies and procedures to assure direct nursing services are delivered by a qualified registered or licensed professional nurse in accordance with OAR chapter 411, division 380.
(7) HANDLING AND MANAGING INDIVIDUALS' MONEY. An agency must have and implement written policies and procedures for the handling and management of money for the individuals. Such policies and procedures must provide for all of the following:
(a) Financial planning and management of the funds for an individual.
(b) Safeguarding the funds for an individual.
(c) Individuals receiving and spending their own money.
(d) Taking into account the interests and preferences of the individual.
(8) COMPLAINTS. An agency must have and implement written policies and procedures for individual complaints in accordance with OAR 411-318-0015.
(a) Complaints by or on behalf of individuals must be addressed in accordance with OAR 411-318-0015.
(b) Upon an individual's entry and request and annually thereafter, the policy and procedures for complaints must be explained and provided to an individual and their legal or designated representative (as applicable).
(9) AGENCY DOCUMENTATION REQUIREMENTS. An agency must have and implement policies and procedures that address agency documentation requirements. Documentation must be:
(a) Prepared at the time or immediately following the event being recorded.
(b) Accurate and contain no willful falsifications.
(c) Legible, dated, and signed by the person making the entry.
(d) Maintained for no less than five years.

Notes

Or. Admin. R. 411-323-0060
SPD 12-2011, f. & cert. ef. 7-1-11; SPD 19-2011(Temp), f. & cert. ef. 7-1-11 thru 12-28-11; SPD 1-2012, f. & cert. ef. 1-6-12; APD 42-2014, f. 12-26-14, cert. ef. 12/28/2014; APD 25-2016, f. & cert. ef. 6/29/2016; APD 29-2017, amend filed 11/30/2017, effective 12/1/2017; APD 21-2019, amend filed 06/28/2019, effective 7/1/2019; APD 44-2019, amend filed 10/29/2019, effective 11/1/2019

Statutory/Other Authority: ORS 409.050

Statutes/Other Implemented: ORS 427.007 & 430.215

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