Or. Admin. Code § 309-019-0135 - Entry and Assessment
(1) The
provider must utilize and document an entry procedure that at a minimum must
ensure the following:
(a) Individuals must be
considered for entry without regard to race, ethnicity, gender, gender
identity, gender expression, sexual orientation, religion, creed, national
origin, age (except when program eligibility is restricted to children, adults,
or older adults), familial status, marital status, source of income, and
disability;
(b) The provider will
not deny entry to individuals based on their decision to continue currently
prescribed or dispensed medications for opioid use disorder (MOUD) while
receiving outpatient behavioral health services and supports;
(c) Individuals must receive services in a
manner consistent and appropriate with their presenting life
circumstances;
(d) The provider
must develop and maintain service records and other documentation that
demonstrates the amount, duration and scope of each specific services and
supports provided for each individual.
(e) The provider must submit the identified
status and service data, including Non-Medicaid Service Data where required, in
the mandated state data system according to the timelines required by the
Division for each individual whose services are paid for in-full or in-part by
public funds and for individuals enrolled in DUII services as soon after entry
as possible but no later than 90 day from date of entry;
(f) The provider must obtain an authorization
for the release of information for the release of any confidential information
concerning the individual being considered for or receiving services;
(g) Except as permitted by law in
emergencies, the provider must obtain written, voluntary informed consent for
services from the individual, or guardian if applicable prior to - or at the
start of services.
(h) Prior to or
at the start of treatment services, the program must offer to the individual
and guardian, if applicable, written description of services provided. The
written description must be in the individual's preferred language and must
include disclosures regarding risks and benefits to services provided. The
written program information shall include:
(A)
Disclosure of availability of assistance by program in completing a Declaration
for Mental Health Treatment, including information on how to request
assistance.
(B) A description of
individual rights consistent with these rules, and;
(C) Notice of privacy practices;
(D) If written program description
information, disclosures, notice of privacy practices, consents and individual
rights documents are not provided prior or at the start of treatment services,
the reason, and any further attempts to provide written information and
consent, must be documented in the service record.
(2) Entry requirements for
providers that receive the Substance Use Prevention, Treatment and Recovery
(SUPTR) Block Grant:
(a) Document that
individuals are prioritized for entry in the following order:
(A) Individuals who are pregnant and using
substances intravenously;
(B)
Individuals who are pregnant;
(C)
Individuals who are using substances intravenously; and
(D) Individuals or families with dependent
children.
(b)
Individuals using substances intravenously must receive interim resource
recommendations and information prior to entry to reduce the adverse health
effects of substance use, promote the health of the individual, and reduce the
risk of transmission of disease. At a minimum, interim resource recommendations
and informational services must include:
(A)
An opportunity for the individual to engage in counseling through care
coordination, peer services or other interactive supports.
(B) Educational material about blood borne
pathogens including Hepatitis, HIV, STDs, and Tuberculosis (TB); the risks of
needle and paraphernalia sharing; and the likelihood of transmission to sexual
partners and infants;
(C)
Educational information and resources about steps that can decrease the
likelihood of Hepatitis, HIV, STD, and TB transmission;
(D) For pregnant individuals, counseling and
educational information addressing the likelihood of blood borne pathogen
transmission as well as the effects of alcohol, tobacco, and other drug use on
the fetus and referral for prenatal care; and
(E) Peer Delivered Services that address
parenting and youth in transition support, as indicated
(3) At the time of entry, an
assessment must be initiated by qualified program staff.
(a) An assessment may be completed over more
than one session and must be completed within 90 days.
(b) 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).
(c) Providers may reduce the number and
length of assessments through use of collateral information to inform the
current assessment, such as previous assessments on file.
(d) Any changes to the ASAM Level of Care
placement decision must be justified within an update to the multidimensional
assessment on file, including the ASAM Dimensional Admission
Criteria;
(e) Providers must update
assessments within the scope of their practice when there are changes in
clinical circumstances;
(f) For
mental health treatment services, documentation demonstrating an ongoing
medically necessary reason for services and progression in treatment must be
completed at least annually by qualified program staff.
(4) When an assessment is completed in more
than one encounter, documentation from the first encounter must include, at a
minimum :
(a) A medically necessary reason for
services, including supporting information. Medical necessity includes a
DSM-5-TR diagnosis that is evidenced by diagnostic criteria and the symptoms
that support each identified criteria.
(b) If the provider cannot document a
DSM-5-TR diagnosis as part of a medically necessary reason for services at
entry, the provider must -- at minimum -- document a screening for suicide
risk, immediate needs, safety risk and current impacts of trauma on daily
functioning..
(c) Appropriateness
for treatment by the program;
(d)
Suicide and other current safety risk(s);
(e) Immediate need(s);
(f) Identification of current physical and
psychological trauma; and
(g)
Intoxication and withdrawal symptoms, when applicable;
(h) Referrals to meet risk and immediate
needs, including withdrawal management services, when applicable.
(5) Assessments and assessment
updates are considered complete when the following information is contained in
assessment documentation:
(a) Clinically
relevant current and historical biological, psychological, social
information;
(b) Documentation of
the presence of a DSM-5-TR that is the medically necessary reason for services,
including identification of each diagnostic criteria established per diagnosis,
and the symptoms supporting each criteria;
(c) Screening for the presence of suicide
risk and documented interventions, as indicated;
(d) The identification of psychological and
physical trauma and risk to the individual or to others.
(e) Current Substance use, in mental health
assessments when an ASAM Dimensional assessment is not needed;
(f) Current Problem Gambling
Behavior;
(g) Current Mental Health
conditions, including currently prescribed psychiatric medications, as
clinically relevant;
(h) Current
Medical conditions, including currently prescribed treatments and medications,
as clinically relevant;
(i) 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.
(j) In addition, for
individuals entering substance use disorder services, each complete 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) ASAM
Level of Care determination per ASAM Dimension;
(B) An overall ASAM Level of Care
determination, with justification for any applicable discrepancies between
level of care assessed and level of care placement;
(C) Corresponding ASAM Dimensional Admission
Criteria;
(D) Historical and
present substance use-related risk(s);
(E) A severity of risk for each dimension;
and
(F) An overall determination of
the severity of risk the individual currently is experiencing.
Notes
Statutory/Other Authority: ORS 161.390, 413.042, 430.256 & 430.640
Statutes/Other Implemented: ORS 161.390 - 161.400, 428.205 - 428.270, 430.010, 430.205- 430.210, 430.254 - 430.640, 430.850 - 430.955 & 743A.168
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