Or. Admin. Code § 309-018-0130 - Documentation, Training, and Supervision

(1) Providers shall maintain personnel records for each program and milieu staff that contain all of the following documentation:

(a) The results of a criminal records check applicable to the current position or title, and:

(A) For personnel who render mental health services or have access to mental health protected health information such as service records or billing information, the program shall use The Oregon Criminal Records Check and those processes and procedures required by OAR 943-007-0001 through 0501; and

(B) For personnel who render only substance use disorder treatment services or have access to only substance use disorder protected health information such as service records or billing information, the program shall use national and state-wide criminal records check processes.

(b) A current job description that includes applicable competencies;

(c) Copies of relevant licensure or certification, diploma, or certified transcripts from an accredited college, indicating that the program staff meets applicable qualifications;

(d) Periodic performance appraisals;

(e) Program orientation documentation;

(f) Disciplinary documentation;

(g) Results of a Tuberculosis screening as per OAR 333-071-0057;

(h) Documentation of trainings required by this or other applicable rules; and

(i) Documentation of clinical and non-clinical supervision. Documentation shall include the date supervision took place, the amount of supervision time, and a brief description of relevant topics discussed.

(2) Program Orientation: Providers shall ensure that each program staff receive training applicable to the specific population for whom services are planned, delivered, or supervised. The provider shall document that the following orientation was completed for each program staff providing or supervising the provision of services or supports within 30 days of the hire date, unless otherwise specified. At a minimum, program orientation training for all program staff shall include but not be limited to:

(a) A review of crisis prevention and response procedures;

(b) A review of emergency evacuation procedures;

(c) A review of program policies and procedures and the procedures for each licensed ASAM Level of Care for each certified ASAM Level of Care for substance use disorder treatment program staff;

(d) A review of rights for individuals receiving services and supports;

(e) A review of mandatory abuse reporting procedures;

(f) A review of confidentiality policies and procedures;

(g) A review of Fraud, Waste and Abuse policies and procedures;

(h) A review of care coordination procedures;

(i) A review of and agreement to abide by the Code of Conduct; and

(j) Substance use disorders treatment staff and substance use disorders clinical supervisors shall complete a training on The ASAM Criteria, Third Edition within the first 3 months of employment or have it documented as completed within the most recent two years.

(3) Milieu Staff Program Orientation: Providers shall ensure that each Milieu staff receive training applicable to the specific population for whom services are planned, delivered, or supervised. The provider shall document that at a minimum, the following orientation training was completed for each staff or person providing or supporting the provision of services or supports within 30 days of the hire date. At a minimum, program orientation training for all program staff shall include but not be limited to:

(a) A review of crisis prevention and response procedures;

(b) A review of emergency evacuation procedures;

(c) A review of program policies and procedures, including medical protocols and the procedures for each licensed ASAM Level of Care;

(d) A review of rights for individuals receiving services and supports;

(e) A review of mandatory abuse reporting procedures;

(f) A review of confidentiality policies and procedures;

(g) A review of an agreement to abide by the Code of Conduct; and

(h) For Milieu Staff, the personnel record shall contain verification of the completion of the following trainings within the first 6 months of employment:

(A) De-escalation;

(B) Overview of substance use disorders;

(C) Overview of mental health symptomology; and

(D) Suicide risk and prevention.

(4) Clinical supervision and non-clinical supervision: program staff including applicable volunteers and interns providing direct services and or supports, and milieu staff, shall receive documented clinical supervision or non-clinicial supervision, and oversight by a qualified clinical supervisor or manager, as applicable and as defined in these rules. Part time program staff shall receive supervision prorated to reflect the average number of hours worked. Half the total supervision hours required may be accomplished through group supervision. Individual face-to face contact may include real time, two-way audio or audio-visual conferencing, and:

(a) Clinical Supervision and non-clinical supervision shall be related to the development of the staff and the services, and the implementation and outcome of the services. Supervision shall be provided to assist staff to:

(b) Increase their skills within their scope of practice;

(c) Improve quality of services or supports to individuals;

(d) Ensure understanding and application of the code of conduct and program policies and procedures; and

(e) Documentation shall include the date, amount of time per session and a brief description of the topics addressed and shall demonstrate the following minimum amounts of clinical supervision:

(A) Non-licensed program staff and volunteers meeting the definition of program staff shall receive at least two hours per month of clinical supervision. The two hours shall include one hour of individual face-to-face supervision;

(B) Program staff holding a license issued by a Division recognized credentialing body shall receive at least two hours of clinical supervision quarterly;

(C) Mental Health Interns, Interns and Student Interns shall receive one-hour of individual clinical supervision per week;

(D) When available, a qualified Peer Delivered Services Supervisor shall provide one of the two hours of required monthly supervision to program staff providing direct Peer Delivered Services. Remaining hours of supervision shall be provided by a qualified clinical supervisor; and

(E) Non-clinical, group supervision shall be provided to milieu staff by the managing staff or clinical supervisor at least one hour per month.

(f) Mental health interns, interns and student interns shall render services and supports under the active supervision of a qualified supervisor, as defined in these rules; and

(g) Individualized, non-clinical supervision shall be utilized as needed and documented.

Notes

Or. Admin. Code § 309-018-0130

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

Statutory/Other Authority: ORS 413.042, 430.640 & 443.450

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