Or. Admin. Code § 309-018-0110 - Provider Policies

(1) All providers shall develop and implement written policies and procedures compliant with these rules.

(2) Policies shall be available to individuals, guardians, and family members upon request.

(3) Providers shall develop and implement written policies and procedures including but not limited to:

(a) Personnel qualifications, credentialing and training;

(b) Criminal Records Checks that address program and milieu staff, compliant with ORS 181.533 through 181.575 and OAR 943-007-0001 through 0501, where applicable;

(c) Fraud, waste and abuse in Federal Medicaid and Medicare programs compliant with OAR 410-120-1380 and 410-120-1510;

(d) Alcohol, Drug and Gambling free workplace;

(e) Fee agreements;

(f) Confidentiality and compliance with, Federal Confidentiality Regulations (42 CFR, Part 2), and state confidentiality regulations as specified in ORS 179.505 and 192.518 through 192.530;

(g) Compliance with Title 2 of the Americans with Disabilities Act of 1990 (ADA);

(h) Per ORS 413.046; Grievances and appeals, including an example grievance form;

(i) Individual rights;

(j) Quality assessment and performance improvement;

(k) Crisis prevention and response;

(l) Incident and critical incident reporting;

(m) Family involvement;

(n) Trauma-informed service delivery, consistent with the Division's Trauma Informed Services Policy;

(o) Provision of culturally and linguistically appropriate services;

(p) Medical protocols;

(q) Medication administration, storage, and disposal;

(r) Facility standards;

(s) General safety and emergency procedures to include an evacuation plan and emergency plan in case of fire, explosion, accident, death, or other emergencies. The evacuation and emergency procedures and plans shall be current and posted in a common area;

(t) Delivery of services and supports consistent with The ASAM Criteria, Third Edition for each licensed level of care;

(u) Code of conduct that includes professional boundaries and ethics; and

(v) Referral, Care Coordination and Transfer of Services.

(4) Additionally, providers shall establish written policies that:

(a) Prohibit psychological and physical discipline of an individual;

(b) Prohibit seclusion, personal restraint, mechanical restraint, and chemical restraint;

(c) Prohibit withholding shelter, regular meals, medication, clothing, or supports for physical functioning;

(d) Prohibit discipline of one individual receiving services by another; and

(e) Prohibit titration of medications prescribed for the treatment of opioid dependence as a condition of receiving or continuing to receive treatment.

(f) Opportunity for individuals over 18 years of age to declare advanced directive for their mental health treatment per ORS 127.700 to 127.736

(g) Opportunity for individuals over 18 years of age to register to vote by making voter registration cards available.

Notes

Or. Admin. Code § 309-018-0110

MHS 10-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14; MHS 3-2014, f. & cert. ef. 2-3-14; MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18; MHS 4-2018, amend filed 02/27/2018, effective 3/1/2018; BHS 10-2023, amend filed 04/07/2023, effective 4/7/2023; BHS 25-2024, amend filed 10/25/2024, effective 10/27/2024

Statutory/Other Authority: ORS 413.042, 428.205 - 428.270, 430.640 & 443.450

Statutes/Other Implemented: ORS 109.675, 161.390 - 161.400, 179.505, 430.010, 430.205 - 430.210, 430.254 - 430.640, 430.850 - 430.955, 443.400 - 443.460, 443.991, 461.549 & 743A.168