Or. Admin. Code § 309-018-0140 - Assessment

(1) Prior to, or at the time of entry, an assessment must be initiated and by a qualified program staff.

(a) Assessments must record diagnostic information derived from any combination of clinical observation, self-report interview, or collateral information (such as assessments from other programs or previous treatment episodes).

(b) Providers may minimize the number and length of assessments through use of collateral information to inform the current assessment, such as previous assessments on file.

(c) Any changes to the ASAM Level of Care placement decision must be justified within an update to the multidimensional assessment on file;

(d) Providers must update assessments within the scope of their practice when there are changes in clinical circumstances;

(e) At a minimum, each of following must be documented during initial assessment interview(s):

(A) A medically necessary reason for services, including supporting information;

(B) Appropriateness for treatment by the program;

(C) Current risk(s), including suicide risk;

(D) Immediate risk(s);

(E) Identification of current physical and psychological trauma; and

(2) In addition, for individuals entering residential substance use disorder services, each assessment and update thereof must be a multidimensional assessment that is consistent with The ASAM Criteria, Third Edition, and include, at a minimum, the following components, each consistent with The ASAM Criteria, Third Edition:

(a) The Level of Care recommendation for each ASAM dimension based on current and available information;

(b) A consideration of the history of each substance use-related risk as well as the present substance use related risk concern(s);

(c) A severity of risk for each dimension;

(d) An overall determination of the severity of risk the individual currently is experiencing.

(3) Assessments and assessment updates are considered complete when the following information has also been added to assessment documentation as soon as possible, but within a timeline that prioritizes the individual's immediate needs:

(a) Clinically relevant current and historical biological, psychological, social information;

(b) Documentation of the presence of a DSM-5-TR diagnosis that is the medically necessary reason for services, including identification of each DSM-5-TR criteria established per diagnosis, and the symptoms supporting each criteria;

(c) Screening for the presence of suicide risk and documented interventions, as indicated;

(d) A determination of immediate need for follow-up actions, additional services and supports; and

(e) The identification of psychological and physical trauma and risk to the individual or to others.

(f) Current Substance use;

(g) Current Problem Gambling Behavior;

(h) Current Mental Health conditions, including currently prescribed psychiatric medications, as clinically relevant;

(i) Current Medical conditions, including currently prescribed treatments and medications, as clinically relevant;

(j) When indicated, documentation must contain recommendations for each identified need, indicating further assessment, planning, and intervention from an appropriate professional, either with the same provider or with a collaborative community provider.

(k) ASAM Level of Care determination per dimension, overall, and noting any applicable discrepancies.

(l) If the provider cannot document a medically necessary reason for services that includes a DSM-5-TR diagnosis at entry, the provider must at minimum, document a screening for suicide risk, immediate needs, safety risk and current impact of trauma on daily functioning. The provider can render the following routine services for up to 3 business days without a documented medically necessary reason for services, or at any appropriate time during a treatment episode:

(A) Care co-ordination;

(B) Case Management; and

(C) Peer Mentoring.

Notes

Or. Admin. Code § 309-018-0140

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 8-2024, temporary amend filed 04/30/2024, effective 5/1/2024 through 10/27/2024; BHS 10-2024, temporary amend filed 05/21/2024, effective 5/21/2024 through 10/27/2024; 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 430.010, 430.205 - 430.210, 430.254 - 430.640, 430.850 - 430.955, 443.400 - 443.460, 443.991, 461.549 & 743A.168