Standards for Children's Intensive Mental Health Treatment Services
Children's Intensive Treatment Rule
DIVISION 032
ALTERNATIVES TO STATE HOSPITALIZATION
Standards for Children's Intensive Mental Health Treatment Services
Purpose and Statutory Authority
309-032-1100 (1) Purpose. These rules prescribe standards and procedures for
intensive mental health treatment services for children within a comprehensive system
of care. The goal of these services is to maintain the child in the community in the least
restrictive treatment setting appropriate to the acuity of the child's disorder. The system
of care shall be child and family-centered and community-based with the needs of the
child and family determining the types and mix of services provided. These services
may be as intensive, frequent and individualized as is medically appropriate to sustain
the child in treatment in the community.
(2) Statutory Authority. These rules are authorized by ORS 430.041, 430.640(1)(h)
and 743.556 to carry out the provisions of ORS 430.630.
Stat. Auth.: ORS 430.041, 430.640(1)(h) and 743.556
Stats. Implemented: ORS 430.630
Hist.: NEW
Definitions
309-032-1110 As used in these rules:
(1) "Accreditation" means official notification given a provider of compliance to
standards established by an accrediting organization approved by the Health Care
Financing Administration to accredit providers of Medicaid reimbursed "inpatient under
21."
(2) "Active treatment" means implementation of a professionally developed and
supervised individual plan of care to improve a child's condition.
(3) "Acute care" means short term psychiatric treatment in a hospital or other
equivalent level of care.
(4) "Admission criteria" means the behavioral and diagnostic requirements to be met
for a child to be admitted to intensive mental health treatment services.
(5) "Assessment and Evaluation Program" means a service designed for children
who need non-hospital level psychiatric assessment, evaluation and brief treatment in a
staff or facility secure program.
(6) "Behavior management policy" means the written policies and procedures
adopted by the provider that describe the behavioral interventions to be used by the
provider to manage maladaptive or problem behavior of an admitted child.
(7) "Case management" means the service provided to children and families to link
and coordinate segments of the service delivery system of a single provider or of
several providers to ensure that the most effective means of meeting the child's needs
for care are used. Case management functions for children with intensive treatment
needs include planning specific treatment goals and services needed to achieve goals;
linking the child to appropriate services delineated in the care plan; monitoring and
ongoing contact with the child to ensure that services are being delivered appropriately;
and advocating for the child's clinical needs.
(8) "Certification" means official approval given by the Division to an appropriately
licensed and/or accredited provider to deliver intensive treatment services.
(9) "Chemical restraint" means the administration of medication for the acute
management of uncontrolled behavior. Chemical restraint is different from the use of
medication for treatment of symptoms of severe emotional disturbances and/or
disorders. Chemical restraint of children is prohibited.
(10) "Child" or "Children" means a person or persons under the age of 18, or for those
with Medicaid eligibility under the age of 21, who receives ITS services.
(11) "CHIP" means the Child Health Insurance Program federal grant-in-aid program
to states under Title XXI of the Social Security Act.
(12) "Client Process Monitoring System" or "CPMS" means the Division's client
information system for community based services.
(13) "Clinical record" means the collection of all documentation regarding a child's
mental health treatment. The record is a legal document. The clinical record provides
the foundation for managing and tracking the provision and quality of services.
(14) "Clinical supervision" means the documented oversight by a Clinical Supervisor of
mental health treatment services provided by Qualified Mental Health Professionals or
Qualified Mental Health Associates.
(15) "Clinical supervisor" means a Qualified Mental Health Professional with two years
post-graduate clinical experience in a mental health treatment setting. The clinical
supervisor, as documented by the provider, operates within the scope of his or her
practice or licensure, and demonstrates the competency to oversee and evaluate the
mental health treatment services provided by other Qualified Mental Health
Professionals or Qualified Mental Health Associates.
(16) "Comprehensive mental health assessment" means the written documentation by a
QMHP of the child's presenting mental health problem(s) and mental status; and
emotional, cognitive, family, substance use, behavioral, social, physical, nutritional,
school or vocational, recreational and cultural functioning; and developmental, medical
and legal history. A comprehensive mental health assessment is collected through
interview with the child, family and other relevant persons; review of previous treatment
records; observation; and psychological and neuropsychological testing when indicated.
The comprehensive mental health assessment concludes with a completed DSM five
axis diagnosis, clinical formulation, prognosis for treatment, and treatment
recommendations. The comprehensive mental health assessment is used to document
the need for mental health services and to develop or update the child's individual plan
of care.
(17) "Consent to treatment" means the informed, voluntary, written agreement as
required in ORS 430.210(d) between the provider and the child's custodial parent or
guardian, or the child if legally emancipated, for the child to receive prescribed
treatment for a specific diagnosis.
(18) "Consultation" means professional advice or explanation given concerning a
specific child to others involved in the treatment process, including family members,
staff members of other human service agencies and care providers.
(19) "Contractor" means a CMHP, MHO or other entity approved by the Division for
contracting or subcontracting to purchase intensive mental health treatment services for
children. A contractor is responsible for assuring that the provider of contracted services
meets the requirements established in this rule including applicable licensing,
certification and accreditation standards and holds a valid Certificate of Approval issued
by the Division.
(20) "Continued stay criteria" means the diagnostic, behavioral and functional indicators
documented in the child's plan of care by the interdisciplinary team to provide the
clinical rationale for a child to remain in an intensive mental health treatment service.
(21) "Crisis" means either an urgent or emergency situation that occurs when a child's
mental status, emotional stability, or functioning evidences a rapid deterioration and
there is an immediate need to address the situation to prevent further deterioration in
the child's condition.
(22) "Custodial parent" means the parent(s) or guardians having legal custody of the
child.
(23) "Custody" means the legal care and supervision of the child by the person, agency
or institution having the authority to authorize ordinary, urgent or emergent medical,
psychiatric, psychological and other remedial care and treatment for the child. The
custodial parent(s) is not required to relinquish custody of the child to receive mental
health treatment services.
(24) "Diagnosis" means the primary mental disorder listed in the most recently
published edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM),
that is the medically appropriate reason for clinical care and the main focus of
treatment. The primary diagnosis is determined through the mental health assessment
and any examinations, tests, procedures or consultations suggested by the
assessment. A DSM "V" code condition, substance use disorder or mental retardation
is not considered the primary diagnosis covered under these rules although these
conditions or disorders may co-occur with the diagnosable mental disorder.
(25) "Direct supervision" means the oversight and coordination by a QMHP of
interventions described in the individual plan of care performed by a Qualified Mental
Health Associate (QMHA) and other direct care staff. Direct supervision also includes
reviewing and evaluating the documentation of interventions directed by the individual
plan of care performed by a QMHA or other direct care staff. Direct supervision is
performed on a regular, routine basis in an individual or group setting.
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(26) "Direction of the psychiatrist" means medical oversight of the clinical aspects of
care required of accredited "inpatient under 21" providers by the Health Care
Financing Administration (HCFA). Medical oversight includes participation on
the interdisciplinary
team, prescribing treatment on individual plans of care by signature, prescribing
and/or
monitoring medications and reviewing special treatment procedures.
(27) "Discharge criteria" means the diagnostic, behavioral and functional indicators
the child and/or family will meet to move to the next level of service.
(28) "Discharge instructions" means a brief document which transmits information about
the child's ongoing care and treatment needs. Discharge instructions include current
medication and medical information, diagnosis and current treatment intervention
strategies to manage the child prior to receiving a discharge summary. Discharge
instructions shall be part of the information given to the parent or guardian upon or prior
to discharge.
(29) "Discharge summary" means written documentation of the last service contact with
the child; the diagnosis at admission; and a summary statement that describes the
effectiveness of treatment modalities and progress, or lack of progress, toward
treatment objectives while in service. The discharge summary also includes the reason
for discharge, changes in diagnosis during treatment, current level of functioning and
prognosis and recommendations for further treatment.
(30) "Division" means the Department of Human Resources Agency responsible for the
administration of mental health and developmental disabilities programs and laws of the
state.
(31) "DSM" means the current edition of the "Diagnostic and Statistical Manual of
Mental Disorders" published by the American Psychiatric Association.
(32) "Enrollment" means the assignment of Oregon Health Plan clients to Mental Health
Organizations (MHOs), Oregon Health Plan Managed Care Enrollment Requirements.
(33) "Family" means the parent(s), legal guardian, siblings, grandparents, spouse
and other primary relations of the child whether by blood, adoption, legal or social
relationship.
(34) "Five-axis diagnosis" means the multiaxial system of evaluation in the DSM
organized to provide a comprehensive approach to psychiatric assessment and to
ascertain that all of the information necessary for planning treatment and predicting
treatment outcomes for children is recorded on each of five axis.
(35) "Formal complaint" means the expression in a manner appropriate to the child
or family/guardian of dissatisfaction or concern about the provision or denial of services
that is the responsibility of the provider under these rules. The formal complaint can be
expressed by a child or by the child's representative.
(36) "Fully Capitated Health Plan" or "FCHP" means a prepaid health plan under
contract with the Office of Medical Assistance Programs to provide capitated physical
health and chemical dependency services under the Oregon Health Plan. Some FCHPs
also serve as Mental Health Organizations.
(37) "Goal" means an expected result or condition to be achieved, which is specified
in a statement of relatively broad scope, provides a guideline for the direction of care
and is related to an identified clinical problem.
(38) "Guardian" means a parent, other person or agency legally in charge of the affairs
of a minor child and having the authority to make decisions of substantial legal
significance concerning the child.
(39) "Indicators of progress" means the diagnostic, behavioral, or functional
measures used by the provider to demonstrate the degree to which a child and family
have made functional or behavioral improvement in the areas being measured.
(40) "Individual plan of care" means the written plan developed by a QMHP for active
treatment for each child admitted to an intensive treatment service program. The
individual plan of care specifies the DSM diagnosis, goals, measurable objectives, and
specific treatment modalities and is based on a completed mental health assessment or
comprehensive mental health assessment of the child's functioning and the acuity and
severity of psychiatric symptoms.
(41) "Individuals with Disabilities Education Act" or "IDEA" means the federal law
requiring that a free and appropriate education be provided to all children with mental
and physical handicapping conditions. The education provided must include all
educational and related services necessary for the child to learn.
(42) "Initial plan of care" means the written plan developed by a QMHP for active
treatment based on the mental health assessment completed at admission. The initial
plan of care specifies assessment and treatment modalities before completing the
individual plan of care.
(43) "Intensive treatment services" or "ITS" means the range of service components in
the system of care inclusive of treatment foster care, therapeutic group homes,
psychiatric day treatment, partial hospitalization, residential psychiatric treatment, sub-acute care or other services as determined by the Division that provides active
psychiatric treatment for children with severe emotional disorders and their families.
(44) "Interdisciplinary team" means a team of qualified treatment and education
professionals including a child and adolescent psychiatrist or LMP and the child's
parent or guardian responsible for assessment and evaluation, the development and
oversight of individual plans of care, and the provision of treatment for children admitted
to an intensive treatment services program.
(45) "Isolation" means the staff-directed placement of a child in a room or other
space in which the child is alone and without ongoing verbal or visual contact with
others. Periodic visual or verbal contact by staff does not prevent the child from being
considered to be in isolation. A child who is placed in his or her bedroom at the child's
normal bedtime or otherwise has a routine separation unrelated to behavior or conduct
is not considered to be isolation.
(46) "Level of care" means the relative amount and intensity of mental health services
provided from the least restrictive and least intensive in a community-based setting to
the most restrictive and most intensive in an inpatient setting. As required in ORS
430.210(a), children are to be served in the most normative, least restrictive, least
intrusive level of care appropriate to their treatment history, degree of impairment,
current symptoms and the extent of family or other supports.
(47) "Level of functioning" means the description and numeric quantification on Axis V
of a DSM diagnosis of the effectiveness of a child's ability to achieve or maintain
developmentally appropriate behavior in one or more of the following areas: role and
task performance, cognition and communication, behavior toward self and others, and
mood and emotions as measured against age appropriate norms.
(48) "Licensed Medical Practitioner" or "LMP" means any person who meets the
following minimum qualifications as documented by the provider:
(a) Holds at least one of the following educational degrees and valid licensure:
(A) Physician licensed to practice in the State of Oregon;
(B) Nurse Practitioner licensed to practice in the State of Oregon;
(C) Physician's Assistant licensed to practice in the State of Oregon; and
(b) A Licensed Medical Practitioner contracting or employed for the first time with a
provider under these rules after July 1, 2000, shall be a board-certified or board-eligible
child and adolescent psychiatrist licensed to practice in the State of Oregon.
(49) "Manual restraint" means the act of involuntarily restricting a child's movement by
holding the whole or a portion of a child's body in order to protect the child or others
from injury. The momentary periods of physical restriction by direct contact with the
child, without the aid of material or mechanical devices, accomplished with limited force,
that prevent the child from completing an act that would result in potential physical harm
to the child or others are not considered to be restraint.
(50) "Mechanical restraint" means the use of any physical device to involuntarily restrain
the movement of all or a portion of a child's body as a means of controlling his or her
physical activities in order to protect the child or other persons from injury. Mechanical
restraint shall only be used by Sub-Acute providers specifically authorized in writing to
use mechanical restraint by the Division. Mechanical restraint does not apply to
movement restrictions stemming from physical medicine, dental, diagnostic or surgical
procedures which are based on widely accepted, clinically appropriate methods of
treatment by qualified professionals operating within the scope of their licensure.
(51) "Medicaid" means the federal grant-in-aid program to state governments to provide
medical assistance to poor and indigent persons under Title XIX of the Social Security
Act.
(52) "Medically appropriate" means services which are required for prevention (including
preventing a relapse), diagnosis or treatment of mental health conditions and which are
appropriate and consistent with the diagnosis; consistent with treating the symptoms of
a mental illness or treatment of a mental condition; appropriate with regard to standards
of good practice and generally recognized by the relevant scientific community as
effective; not solely for the convenience of the provider of the services, child or family;
and the most cost effective of the alternative levels of medically appropriate services
which can be safely and effectively provided to the child and family in the LMP's
judgement.
(53) "Medication service record" means the documentation of written or verbal
orders for medication, laboratory and other medical procedures issued by a Licensed
Medical Practitioner employed by, or under contract with, the provider and acting within
the scope of his or her license. The provision of medication services is documented in
written progress notes and/or medication administration records and placed in the
client's record.
(54) "Mental health assessment" means the written documentation by a QMHP of the
child's presenting mental health problem(s) and relevant child and family history, mental
status examination and DSM 5-axis diagnosis or provisional diagnosis.
(55) "Mental Health Information System" means the information system of the
Division that includes the Client Process Monitoring System for non-hospital services,
the Medicaid Management Information System for the Medicaid eligible population and
billable services delivered, and the Oregon Patient Resident Care System for inpatient
and acute services. It provides a statewide client registry for tracking services utilization
and contractor capacity.
(56) "Mental Health Organization" or "MHO" means a prepaid health plan under
contract with the Division to provide covered services under the Oregon Health Plan.
(57) "Mental status examination" means the face-to-face assessment by a QMHP of a
child's mental functioning within a developmental and cultural context that includes
descriptions of appearance, behavior, speech, language, mood and affect, suicidal or
homicidal ideation, thought processes and content, and perceptual difficulties including
hallucinations and delusions. Cognitive abilities are also assessed and include
orientation, concentration, general knowledge, intellectual ability, abstraction abilities,
judgment, and insight appropriate to the age of the child.
(58) "Milieu" means the daily environment of structure and therapy, education,
recreation and socialization interactions with staff and peers for children in treatment.
(59) "Minor child" means an unmarried person under the age of 18.
(60) "Non-custodial parent" means a parent whose custodial responsibilities have been
removed by the court by divorce decree. Under ORS 107.154, and unless otherwise
ordered by the court, non-custodial parents have the same rights to consult with any
person who may provide care and treatment for the child and to inspect and receive the
child's medical and psychological records to the same extent as the custodial parent.
(61) "Objective" means a quantifiable statement of a desired future state or condition
which is related to the attainment of a goal within a stated deadline for achievement.
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(62) "Oregon Youth Authority (OYA)" means the department of state government
created by the 1995 Legislative Assembly that is charged with the management
and administration of youth correction facilities, state parole and probation
services, and
other functions related to state programs for youth corrections.
(63) "Partial hospitalization program" means a comprehensive interdisciplinary day
treatment program certified under this rule to provide psychiatric services, therapy,
education and therapeutic activities as an alternative to hospitalization which meets
Health Care Financing Administration accreditation standards.
(64) "Plan of correction" means a written document which specifies actions that a
provider will take to come into compliance with these rules.
(65) "Progress note" means the written documentation of the clinical course of
treatment.
(66) "Provider" means an organization or agency certified by the Division to provide
intensive mental health treatment services for children.
(67) "Provisional diagnosis" means a statement on Axis I of a DSM diagnosis when
there is a strong presumption that the full criteria for the diagnosis will ultimately be met.
(68) "Psychiatric Day Treatment" means the comprehensive, interdisciplinary, non-
residential community based program certified under this rule consisting of psychiatric
treatment, family treatment and therapeutic activities integrated with an accredited
education program.
(69) "Psychiatric Residential Treatment Facility" or "PRTF" means the behavioral health
care programs certified under this rule to provide 24-hour, seven days per week active
mental health treatment under the direction of a psychiatrist for children under age 21.
These services are associated with a Residential Psychiatric Treatment Program for
children who can benefit from a less restrictive residential psychiatric environment.
(70) "Psychiatrist" means a Licensed Medical Practitioner who is board-eligible or
board-certified in child and adolescent psychiatry and licensed to practice in the State
of Oregon.
(71) "Qualified Mental Health Associate" or "QMHA" means a person who delivers
services under the direct supervision of a Qualified Mental Health Professional and who
meets the following minimum qualifications as documented by the provider:
(a) Has a bachelor's degree in a behavioral sciences field, or a combination of at
least three years work, education, training or experience; and
(b) Has the competency necessary to:
(A) Communicate effectively;
(B) Understand mental health assessment, treatment and service terminology and to
apply the concepts;
(C) Provide psychosocial skills development; and
(D) Implement interventions as assigned on an individual plan of care.
(72) "Qualified Mental Health Professional" or "QMHP" means a Licensed Medical
Practitioner or any other person who meets the following minimum qualifications as
documented by the provider:
(a) Holds any of the following educational degrees:
(A) Graduate degree in psychology;
(B) Bachelor's degree in nursing and licensed by the State of Oregon;
(C) Graduate degree in social work;
(D) Graduate degree in a behavioral science field;
(E) Graduate degree in recreational, music, or art therapy;
(F) Bachelor's degree in occupational therapy and licensed by the State of Oregon; and
(b) Whose education and experience demonstrate the competency to identify
precipitating events; gather histories of mental and physical disabilities, alcohol and
drug use, past mental health services and criminal justice contacts; assess family,
social and work relationships; conduct a mental status examination; document a
multiaxial DSM diagnosis; write and supervise an individual plan of care; conduct a
Comprehensive Mental Health Assessment and provide individual, family and/or group
therapy within the scope of their training.
(73) "Quality Management" means a continuous process to simultaneously promote
consistency of performance and to promote meaningful change in measurable
objectives. The process is used to improve a provider's performance and adjust
measurable objectives and benchmarks.
(74) "Quality of care" means the degree to which services are consistent with best
practices and produce desired and satisfactory mental health outcomes for the child.
(75) "Reportable incident" means an event in which an admitted child while in the
program is believed to have been abused, endangered or significantly harmed. This
may include, but is not limited to, incidents as a result of staff action or inaction,
incidents between children, incidents that occur on passes, or incidents of self-harm
where medical attention is necessary.
(76) "Residential Psychiatric Treatment Program" means the behavioral health care
programs certified under this rule to provide 24-hour, seven days per week active
mental health treatment under the direction of a psychiatrist for children under age 21.
(77) "Seclusion" means the involuntary confinement of a child alone in a specifically
designed room from which the child is physically prevented from leaving.
(78) "Severe emotional disorder" means an emotional, mental, and/or neurobiological
impairment which is manifested by emotional or behavioral symptoms that are not
solely a result of mental retardation or other developmental disabilities, epilepsy, drug
abuse, or alcoholism and which continue for more than one year, or on the basis of a
specific diagnosis is likely to continue for more than one year.
(79) "Special treatment procedures" means seclusion; manual restraint; staff directed
isolation for more than five hours in five days or a single episode of two hours; and
experimental practices and research projects that involve risk to a child.
(80) "Special Treatment Procedures Committee" means the committee established or
designated by the provider to review special treatment procedures.
(81) "State Office for Services to Children and Families (SOSCF) or (SCF)" means the
Division serving as Oregon's child welfare agency.
(82) "Sub-Acute Psychiatric Care" means mental health treatment under the clinical
direction of a psychiatrist as an alternative to hospitalization certified under this rule for
children who are not in the most acute phase of a mental condition but who require a
level of care higher than that provided in a residential psychiatric treatment setting.
(83) "System of care" means the comprehensive array of mental health and other
necessary services which are organized to meet the multiple and changing needs of
children with severe emotional disorders and their families.
(84) "Therapeutic group home" means mental health treatment settings certified
under this rule for children in group care homes of eight or fewer children in SCF-licensed homes where the home parents are employed or contracted by the supervising
agency to provide in-home psychosocial skills development for each child.
(85) "Treatment foster care" means mental health treatment settings certified under
this rule for children residing in SCF certified homes where the home parents are
employed or contracted by the supervising agency to provide in-home psychosocial
skills development for each child.
Stat. Auth.: ORS 430.041, 430.640(1)(h) and 743.556
Stats. Implemented: ORS 430.630
Hist.: NEW
General Conditions of Participation for Children's Intensive Mental Health
Treatment Services Providers
309-032-1120 Providers delivering children's intensive mental health services shall:
(1) (a) Hold, and/or assure that subcontractors hold, a valid Certificate of Approval
issued by the Division and, if applicable, accreditation approved by the Division and the
Health Care Financing Administration and appropriate license or certification from the
State Office for Services to Children and Families;
(b) Providers that are not required to have accreditation approved by the Health
Care Financing Administration may use alternative standards for the organization of
their services;
(A) Alternative standards include the Day and Residential Treatment Services
(DARTS) Standards or others approved by the Division;
(B) In the event of a conflict between this rule and voluntary standards, the
standards and procedures outlined in this rule will supercede all alternative standards.
(2) Maintain the organizational capacity and interdisciplinary treatment capability to
deliver clinically and developmentally appropriate services in the medically appropriate
amount, intensity and duration for each admitted child specific to the child's diagnosis,
level of functioning and the acuity and severity of the child's psychiatric symptoms;
(3) Maintain 24 hour, seven days per week treatment responsibility for admitted
children. Non-residential programs shall maintain on-call capability at all times to
respond directly or by referral to the treatment needs of admitted children including
crises 24-hours per day, seven days per week;
(4) Deliver active psychiatric treatment in the least restrictive, least intensive setting
appropriate to each admitted child's treatment history, diagnosis, development, level of
functioning and degree of impairment, current symptoms and the extent of family and
other supports;
(5) Use treatment methods appropriate for children with severe emotional disorders that
are based on sound clinical theory and professional standards of care and widely
accepted by qualified professionals in the mental health field;
(6) Demonstrate family involvement and participation in all phases of assessment,
treatment planning and the child's treatment by documentation in the clinical record;
(7) Report suspected child abuse as required in ORS 419B.010;
(8) Maintain reportable incident files including:
(a) Child abuse reports made by the provider to law enforcement or the State Office for
Services to Children and Families child protective services documenting the dates of
the incident the persons involved and, if known, the outcome of such reports; and
(b) Reportable incident information documenting the date of the incident, the persons
involved, the quality and performance actions taken to initiate investigation of the
incident, and correct any identified deficiencies.
(9) Inform the Division and the legal guardian within one working day of reportable
incidents.
(10) Enroll children in the Mental Health Information System when the child's mental
health services are funded all or in part by Division funds, unless the Division contract
does not require enrollment;
(11) Maintain policies and practices prohibiting on- or off-site non-professional
relationships and activities between employees and admitted children and their families
unless the activities are approved by the provider and interdisciplinary team and
identified as clinically appropriate services in the child's individual plan of care;
(12) Provide services for children in a smoke free environment in accordance with
Public Law 103.277, the Pro-Child Act;
(13) Establish systematic and objective methods to accomplish the following:
(a) Periodically monitor and evaluate access to, and provision of, children's intensive
mental health treatment services;
(b) Identify and seek to resolve problems in access to, or provision of, services; and
(c) Improve access and services using reliable and valid performance measures;
and to periodically report pertinent data and information as directed by the Division.
(14) Demonstrate education service integration in all phases of assessment,
treatment planning, active treatment, and discharge planning by documentation in the
clinical record; and
(15) Maintain policies and procedures to ensure the safety and emergency needs of
children, families, staff and visitors including:
(a) First aid and cardiopulmonary resuscitation training for staff who are assigned to
provide direct service to children;
(b) Off campus activities;
(c) Medical and/or dental emergencies; and
(d) Facility and environmental emergencies.
(16) Demonstrate cultural competency, gender responsiveness and language
appropriateness in the delivery of services to clients.
(17) Demonstrate operation by a governing body whose membership reflects
diverse community interests and whose organization and operation shall be set out in
writing.
(18) Develop and publish a comprehensive document which describes the mission
statement, treatment philosophy, programmatic descriptions, admission criteria, and the
policies and procedures for operation of the program.
(19) Develop policies and procedures for orientation of the incoming child and family
that consider pre-admission orientation times convenient for the family and that
facilitate adequate staff program and child and family preparation prior to admission.
(20) Develop policies and procedures prohibiting firearms and outlining the
management of other potentially dangerous objects.
Stat. Auth.: ORS 430.041, 430.640(1)(h) and 743.556
Stats. Implemented: ORS 430.630
Hist.: NEW
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General Treatment Requirements
309-032-1130 (1) Admission. Providers shall plan admissions, help the child and
family understand the reason for admission, give admission consideration to children
that realistically allows the child's family to participate in treatment, and advise the
family on transportation arrangements when needed.
(2) Prior to admission for planned admissions or within 14 days following an emergency
admission, providers shall determine that a child is eligible for intensive treatment
services. Admissions shall be based on the provider's clinical review of the child's
functioning, of the severity and acuity of the child's psychiatric symptoms, and of
documentation of the following:
(a) A completed five-axis diagnosis current within 60 days of the admission date;
(b) Pertinent biological, psychological and sociocultural factors influencing the child's
development and functioning;
(c) The acuity and severity of the child's psychiatric symptoms as scored on measures
established by the Division;
(d) The child's functioning as scored on measures established by the Division; and
(e) Attempts to effectively treat the child in a less restrictive level of care.
(3) Assessment.
(a) On admission the child shall have an initial plan of care based on a mental
health assessment completed by a QMHP.
(b) A comprehensive mental health assessment shall be conducted by the provider's
interdisciplinary team and be completed within 30 treatment days after admission.
(c) The comprehensive assessment shall be revised and updated annually.
(4) Active Treatment and Individual Plans of Care.
(a) Providers shall fully inform the child in developmentally appropriate language
and obtain informed consent from the child's parent(s) or guardian about the proposed
care and shall document in the child's clinical record that the following information has
been reviewed, discussed, and agreed to by the participants:
(A) Active treatment and other interventions to be undertaken;
(B) Alternative treatments or interventions available, if any;
(C) Projected time to complete the treatment process;
(D) Indicators by which progress will be measured;
(E) Benefits which can reasonably be expected;
(F) Risks of treatment, if any;
(G) Prognosis for treatment; and
(H) Discharge plan.
(b) The individual plan of care shall clinically support the level of care to be provided
and shall:
(A) Be developed and implemented no later than 14 treatment days after admission by
an interdisciplinary team in consultation with the child, the parent(s) or guardian and the
provider to which the child will be discharged;
(B) Be based on a mental health assessment of the child's functioning, the acuity
and severity of the child's psychiatric symptoms, diagnosis, and the biological, medical,
psychological and sociocultural factors that influence the child's development and functioning;
(C) State treatment goals and measurable and observable objectives;
(D) Prescribe an integrated program of therapies, activities, interventions and
experiences designed to meet the goals;
(E) Include a discharge plan to ensure continuity of care with the child's family, school,
and community upon discharge; and
(F) Be signed and dated by the psychiatrist and other members of the interdisciplinary
team including the child's guardian, and when appropriate the child.
(5) Individual Plan of Care Review. A written summary of each individual plan of care
review shall be filed in the child's clinical record. Revisions shall be implemented as
necessary based on each child's individualized response to the treatment interventions.
(a) The review in nationally accredited sub-acute, assessment and evaluation programs
and residential psychiatric treatment programs shall be conducted every 30 days by the
interdisciplinary team.
(b) In other programs, the review shall be conducted every 30 days by the child's
interdisciplinary team. The psychiatrist shall participate in the review at least every 90
days.
(6) Discharge Planning and Coordination.
(a) Providers shall establish written policies and practices for identifying, planning and
coordinating discharge to after-care resources. At a minimum, the provider's
interdisciplinary team shall:
(A) Integrate discharge planning into ongoing treatment planning and documentation
from the time of admission, and specify the discharge criteria that will indicate
resolution of the symptoms and behaviors that justified the admission;
(B) Review and, if needed, modify the discharge plan every 30 days;
(C) Include the parent, guardian and provider to which the child will be discharged in
discharge planning and reflect their needs and desires to the extent clinically indicated;
(D) Finalize the discharge plan prior to discharge and identify in the plan the continuum
of services and the type and frequency of follow-up contacts recommended by the
provider to assist in the child's successful transition to the next appropriate level of care;
and
(E) Assure that appropriate medical care and medication management will be provided
to clients who leave through a planned discharge. The discharging provider's
interdisciplinary team shall identify the medical personnel who will provide continuing
care and shall also arrange an initial appointment with that provider.
(b) Providers shall give written discharge instructions to the child's parent(s) or
guardian, or the provider of the next level of care on the date of discharge.
(c) Providers shall notify the child's parent(s) or guardian and the provider to which
the child will be discharged of the anticipated discharge dates at the time of admission
and when the discharge plan is changed.
(d) Providers shall not discharge a child from an intensive treatment service unless
the interdisciplinary team, in consultation with the child's parent(s) or guardian or the
provider of the next level of care, determines that the child requires a more or less,
restrictive level of care. If the determination is to admit the child to acute care, the
provider shall not discharge the child from the program during the acute care stay
unless the interdisciplinary team, in consultation with the child's parent(s) or guardian or
the provider of the next level of care determines that the child requires a more or less
restrictive level of care.
(e) A discharge summary reflecting the active course of treatment shall be
completed and placed in the chart within 15 treatment days following discharge.
Stat. Auth.: ORS 430.041, 430.640(1)(h) and 743.556
Stats. Implemented: ORS 430.630
Hist: NEW
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General Staffing and Personnel Requirements
309-032-1140 (1) Providers of children's intensive mental health treatment services
shall have the clinical leadership and sufficient QMHP, QMHA and other staff to meet
the 24-hour, seven days per week treatment needs of admitted children and shall
establish policies, contracts and practices to assure:
(a) Availability of psychiatric services to meet the following requirements:
(A) Provide medical oversight of the clinical aspects of care in nationally accredited
sub-acute, assessment and evaluation programs and residential psychiatric treatment
programs and provide 24-hour, seven days per week psychiatric on-call coverage; or
consult on clinical care and treatment in psychiatric day treatment, partial
hospitalization, therapeutic group homes and treatment foster care programs;
(B) Assess each child's medication and treatment needs, prescribe medicine or
otherwise assure that case management and consultation services are provided to
obtain prescriptions, and prescribe therapeutic modalities to achieve the child's
individual plan of care goals; and
(C) Participate in the provider's interdisciplinary team and Quality Management
process.
(b) An executive director or clinical director who meets the following minimum
qualifications:
(A) Masters degree in a human service-related field from an accredited school;
(B) Five years experience in a human services program;
(C) Documented professional references, training and academics; and
(D) Subscribes to a professional code of ethics.
(2) Providers of children's intensive mental health services shall have adequate
numbers of QMHP, QMHA and other staff whose care specialization is consistent with
the duties and requirements of the specific level of care. Professional staff shall operate
within the scope of their training and licensure.
(3) Providers shall assure through documentation in personnel files that all
supervisory and clinical staff meet all applicable professional licensing and/or
certification, and QMHP or QMHA competencies.
(4) Providers shall maintain a personnel file for each employee, that contains:
(a) The employment application;
(b) Verification of a criminal history check as required by ORS 181.536 - 181.537;
(c) A written job description;
(d) Documentation and copies of relevant licensure and/or certification that the
employee meets applicable professional standards;
(e) Annual performance appraisals;
(f) Annual staff development and training activities;
(g) Employee incident reports;
(h) Disciplinary actions;
(i) Commendations; and
(j) Reference checks.
Stat. Auth.: ORS 430.041, 430.640(1)(h) and 743.556
Stats. Implemented: ORS 430.630
Hist.: NEW
System of Care
309-032-1150 (1) General Requirements. All ITS providers described in this section
shall meet the following general requirements:
(a) Active psychiatric treatment and education services shall be functionally integrated
in a therapeutic milieu designed to promote achievement of goals and treatment
objectives developed in each child's individual plan of care.
(b) ITS facilities shall meet all applicable licensing, certification and accreditation/or
standards for plant technology, safety management, professional staffing, therapeutic
environment, performance measurement, quality management and utilization review.
(c) ITS providers shall maintain linkages with primary care physicians, CMHPs and
MHOs and the child's parent(s) or guardian to plan for necessary continuing care
resources for the child.
(d) ITS providers shall maintain linkages with the applicable education service
district or school district to coordinate and provide the necessary educational services
for the children.
(e) When treatment services interrupt the child's day to day educational
environment, the program provides or makes arrangements for the continuity of the
child's education.
(f) ITS providers shall ensure that the following services be available and accessible
through direct service, contract or by referral:
(A) Psychiatric and psychological assessment and treatment;
(B) Individual, group and family therapies;
(C) Medication evaluation, management and/or monitoring;
(D) Pre-vocational/vocational rehabilitation;
(E) Therapies supporting speech, language and hearing rehabilitation;
(F) Individual and group psychosocial skills development;
(G) Behavior management;
(H) Activity and recreational therapies;
(I) Nutrition;
(J) Physical health care services or coordination; and
(K) Case management, treatment planning and coordination, and consultation.
(g) Family therapy shall be provided by a Qualified Mental Health Professional. The
family therapist to child ratio shall be at least one family therapist for each 12 children.
(h) There shall be a clinical supervisory ratio of at least one QMHP clinical supervisor
for each nine staff.
(i) Providers of ITS shall measure individual active treatment outcomes for children in
treatment with the provider. Measurement of active treatment outcomes shall include,
but are not limited to:
(A) Stabilization of the acuity and severity of symptoms;
(B) Reduction of danger to self or others;
(C) Improvement in the level of function;
(D) Stabilization of behavior and conduct; and
(E) Development of new adaptive coping skills.
(2) In addition to the general requirements for all ITS providers listed in 309-032-1150(1), the following service specific requirements shall be met.
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(3) Psychiatric Residential Treatment Services. These services are structured
treatment environments with daily 24-hour supervision and active psychiatric treatment.
It includes Sub-Acute Psychiatric Care, Assessment and Evaluation Programs,
Residential Psychiatric Treatment Programs, and Psychiatric Residential Treatment
Facilities. Psychiatric Residential Treatment Services are provided by nationally
accredited providers certified under these rules for children who require active
treatment for a diagnosed mental disorder in a 24-hour residential setting. An education
program provided and admitted children shall have, or have been screened for, an
Individual Education Plan, Personal Education Plan, and/or an Individual Family Service
Plan.
(a) Providers of Psychiatric Residential Treatment Services shall maintain one or more
linkages with acute care hospitals and/or MHOs to coordinate necessary inpatient care.
(b) Psychiatric residential clinical care and treatment shall be under the direction of a
medical director who is a psychiatrist as defined in these rules and delivered by an
interdisciplinary team of board-certified or board-eligible child and adolescent
psychiatrists, registered nurses, psychologists, other qualified mental health
professionals, and other relevant program staff. A psychiatrist shall be available to the
unit 24-hours per day, seven days per week.
(c) Psychiatric Residential Treatment Services shall be staffed to the acuity and severity
of admitted children at a staffing ratio of not less than one staff for three children during
the day and evening shifts. At least one staff for every three staff members during the
day and evening shifts shall be a Qualified Mental Health Professional or Qualified
Mental Health Associate. For overnight staff there shall be a staffing ratio of at least one
staff for six children with one being a Qualified Mental Health Associate. For units that
by this ratio have one overnight staff, there shall be additional staff immediately
available within the facility or on the premises. At least one Qualified Mental Health
Professional shall be on site or on call at all times. At least one staff with designated
clinical leadership responsibilities shall be on site at all times.
(4) Sub-Acute Psychiatric Care. These are services provided by nationally accredited
providers certified under these rules for children who need 24-hour intensive mental
health treatment in a secure setting to assess, evaluate and stabilize or resolve the
symptoms of an acute episode that occurred as the result of the diagnosed mental
disorder. In addition to the requirements provided in 309-032-1150(1)-(3) Sub-Acute
Psychiatric Care providers shall:
(a) Provide psychiatric nursing staffing at least 16 hours per day;
(b) Establish policies and practices to meet the following admission and continued stay
criteria:
(A) Admission:
(i) The child is admitted by physician order for a period up to 14 days to determine
through assessment and evaluation the existence of a primary diagnosis on Axis I of a
completed 5-Axis DSM diagnosis that shall be the basis for the development of a plan
to guide the child's treatment; or
(ii) The child has a primary diagnosis on Axis I of a completed 5-Axis DSM
diagnosis; and
(iii) The child needs treatment 24-hours each day in a secure setting under the
direction of a psychiatrist to stabilize or resolve symptoms or behaviors which were
identified as the reason for admission and which are consistent with the DSM diagnosis;
(iv) The admitting and referring physicians have consulted and agree on the admission;
(v) Proposed treatments for the DSM diagnosis require close nursing supervision and
monitoring and psychiatric supervision at least one to three times per week; and
(vi) Less restrictive or less intensive services cannot be expected to improve the child's
condition or prevent further regression so that Sub-Acute services will no longer be
needed.
(B) Continued Stay:
(i) Children shall remain in Sub-Acute Psychiatric Care only as long as necessary to
provide brief treatment to stabilize the child. Continued stays of more than 30 days shall
be approved at 30-day intervals up to 90 days by the Division or its designated external
review organization.
(ii) Children may continue to receive Sub-Acute Psychiatric Care services for more
than 90 days only by authorization of the attending psychiatrist or the interdisciplinary
team and approval by the Division or its designated external review organization.
(c) Mechanical restraint shall be used only by Sub-Acute providers specifically
authorized by the Division in writing to use mechanical restraint.
(5) Assessment and Evaluation Programs. Assessment and Evaluation Programs shall
provide services for children who need up to 90 days of 24-hour comprehensive mental
health assessment to diagnose a mental disorder and to stabilize assessed symptoms
and behavior that affect the child's functioning. In addition to the requirements provided
in 309-032-1150(1) and (2) providers of assessment and evaluation program services
shall establish policies and practices to meet the following admission and continued
stay criteria:
(a) Admission:
(A) The child is admitted by physician order for a period up to 30 days to assess,
evaluate and make written recommendations for continuing services. If the child is
determined to have a primary diagnosis on Axis I of a completed 5-Axis DSM diagnosis
that shall be the basis to guide the child's treatment; or
(B) The child has a primary diagnosis on Axis I of a completed 5-Axis DSM diagnosis;
and
(C) The child needs additional assessment and brief active treatment 24-hours each
day under the direction of a psychiatrist to stabilize or resolve symptoms or behaviors
which were identified as reason for admission and which are consistent with the DSM
diagnosis; and
(D) Less restrictive or less intensive services cannot be expected to improve the child's
condition or prevent further regression so that residential assessment and evaluation
services will no longer be needed.
(b) Continued Stay:
(A) Children shall remain in an Assessment and Evaluation program only for the period
of time needed to complete the necessary battery of assessments and provide brief
treatment to stabilize the child.
(B) Continued stays of more than 30 days shall be approved at 30-day intervals up to
90 days by the Division or its designated external review organization.
(C) Children may continue to receive Assessment and Evaluation services for more
than 90 days only by authorization of the attending psychiatrist or the interdisciplinary
team and approval by the Division or its designated external review organization.
(c) Assessment and Evaluation programs shall provide the referring source with written
discharge instructions, a comprehensive written assessment and recommendations for
continuing care at the conclusion of the assessment period.
(6) Residential Psychiatric Treatment Program. Services shall include 24-hour
supervision for children who have a serious psychiatric, emotional and/or acute
behavioral health issues which require intensive therapeutic counseling and activity,
intensive staff supervision, support and assistance. In addition to the requirements
provided in 309-032-1150(1)-(3) a Residential Psychiatric Treatment Program shall
establish policies and practices to meet the following admission and continued stay
criteria:
(a) Admission:
(A) A psychiatric or psychological evaluation including a completed 5-axis diagnosis
current within 60 days of the application date. The child shall have a primary diagnosis
on Axis I of a completed 5-Axis DSM diagnosis. The referral information shall have
been reviewed by an independent psychiatric review process established by the
Division to certify the need for services based on the following criteria:
(B) Ambulatory resources available in the community do not meet the child's treatment
needs;
(C) Proper treatment of the child's psychiatric condition requires services on a 24-hour
intensive treatment basis under the direction of a psychiatrist;
(D) The services can reasonably be expected to improve the child's condition or prevent
further regression so that the current level of care is no longer necessary;
(E) Providers shall accept an emergency admission only under unusual and extreme
circumstances. Emergency admissions shall be retrospectively reviewed by the Division
or its designated external review organization.
(b) Continued Stay:
(A) Children shall remain in a 24-hour Residential Psychiatric Treatment Program only
for the period of time determined to be medically appropriate to treat the psychiatric
condition(s) identified on the child's individual plan of care.
(B) Continued stays shall be approved by the Division or its designated external review
organization at 90-day intervals.
(C) Continued stays that exceed one year and at an annual basis thereafter shall be
approved by the Division or a designated external psychiatric review process.
(7) Psychiatric Residential Treatment Facility. Services shall include 24-hour
supervision for children who have a serious psychiatric, emotional and/or behavioral
health issues which require intensive therapeutic counseling and activity, staff
supervision, support and assistance. These services are associated with a Psychiatric
Residential Treatment Program for children who can benefit from a less restrictive
residential environment. In addition to the requirements provided in 309-032-1150(1)-(3)
a Psychiatric Residential Treatment Facility shall:
(a) Be staffed to the acuity and severity of admitted children and have sufficient QMHP
staff to ensure delivery of the appropriate mix and frequency of sound clinical treatment
services. There shall be no less than one QMHP for the first five children enrolled. For
each additional group of five, or any part thereof, a QMHP or QMHA will be added to
the treatment staff ratio. At least one staff per every five staff members shall be a
QMHP. For overnight staff there shall be a staffing ratio of at least one staff for six
children with one being a QMHA. For units that by this ratio have one overnight staff,
there shall be additional staff immediately available within the facility or on the
premises. At least one QMHP shall be on site or on call at all times. At least one staff
with designated clinical leadership responsibilities shall be on site at all times.
(b) Admission criteria:
(A) The admission decision shall be the responsibility of the interdisciplinary team
based on referral information current within the last 60 days;
(B) The referral information shall have been reviewed by an independent psychiatric
review process established by the Division to certify the need for services based on the
following criteria:
(i) Ambulatory resources available in the community do not meet the child's
treatment needs;
(ii) Proper treatment of the child's psychiatric condition requires services on a 24-hour
intensive treatment basis under the direction of a psychiatrist but is less severe than the
need for Residential Psychiatric Treatment Program level of care;
(iii) The services can reasonably be expected to improve the child's condition or prevent
further regression so that the current level of care is no longer necessary.
(c) Continued Stay:
(A) Children shall remain in a 24-hour Psychiatric Residential Treatment Facility only
for the period of time determined to be medically appropriate to treat the psychiatric
condition(s) identified on the child's individual plan of care.
(B) Continued stays shall be approved by the Division or its designated external review
organization at 90-day intervals.
(C) Continued stays that exceed one year and at an annual basis thereafter shall be
approved by the Division or a designated external psychiatric review process.
(8) Partial Hospitalization Programs. Partial Hospitalization services shall be
delivered by nationally accredited providers certified under these rules to provide day
hospital services. Partial Hospitalization services shall be provided to children who can
be maintained at home by a parent, guardian or foster parent by qualified mental health
professionals and qualified mental health associates under the direction of a
psychiatrist.
(a) Partial Hospitalization services providers shall maintain one or more contracts with
acute care hospitals and/or MHOs to coordinate necessary inpatient care with the
MHOs and their contracted hospitals. Partial Hospitalization providers shall maintain
linkages with primary care physicians, CMHPs and MHOs, and the child's parent(s) or
guardian to plan for necessary continuing care resources for the child.
(b) Partial Hospitalization programs shall be staffed to the acuity and severity of
admitted children at a clinical staffing ratio of at least one Qualified Mental Health
Professional or Qualified Mental Health Associate for up to three children. And have the
24-hour on-call availability of at least one Qualified Mental Health Professional during
hours the program is not open.
(c) Providers of Partial Hospitalization services shall establish policies and practices to
meet the following admission, continued stay and discharge criteria:
(A) Admission:
(i) The admission decision shall be the responsibility of the interdisciplinary team. The
admission shall be based on referral information current within the last 60 days.
(ii) The child shall have a primary diagnosis on Axis I of a completed 5-Axis DSM
diagnosis and the referral information shall have been reviewed by a psychiatric review
process established by the Division to certify the need for services based on the
following criteria:
(I) Partial Hospitalization level of care is appropriate to meet the child's treatment
needs;
(II) Proper treatment of the child's psychiatric condition requires intensive treatment
services under the direction of a psychiatrist; and
(III) The services can reasonably be expected to improve the child's condition or
prevent further regression so that the current level of care is no longer necessary.
(B) Continued Stay:
(i) Children shall remain in a Partial Hospitalization program only for the period of time
determined to be medically appropriate to treat the psychiatric conditions identified on
the child's individual plan of care.
(ii) Continued stays shall be reviewed by the interdisciplinary team and approved every
30 days by a Division approved process.
(9) Psychiatric Day Treatment. Psychiatric Day Treatment services are delivered by
providers certified by the Division under these rules to provide Psychiatric Day
Treatment services. Psychiatric Day Treatment services shall be provided to children
who can be maintained at home by a parent, guardian or foster parent by qualified
mental health professionals and qualified mental health associates in consultation with
the psychiatrist. An education program is provided and admitted children shall have, or
have been screened for, an Individual Education Plan, Personal Education Plan or
Individual Family Service Plan.
(a) Psychiatric Day Treatment programs shall be staffed to the acuity and severity of
admitted children at a clinical staffing ratio of at least one Qualified Mental Health
Professional or Qualified Mental Health Associate for three children.
(b) Providers of Psychiatric Day Treatment services shall establish policies and
practices to meet the following admission, and continued stay criteria:
(A) Admission:
(i) The admission decision shall be the responsibility of the interdisciplinary team.
The admission shall be based on referral information current within the last 60 days.
(ii) The child shall have a primary diagnosis on Axis I of a completed 5-Axis DSM
diagnosis and the referral information shall have been reviewed by a review process
approved by the Division to certify the need for services based on the following criteria:
(I) Psychiatric Day Treatment level of care is appropriate to meet the child's treatment
needs;
(II) Proper treatment of the child's psychiatric condition requires intensive treatment
services in consultation with a psychiatrist; and
(III) The services can reasonably be expected to improve the child's condition or
prevent further regression so that the current level of care is no longer necessary.
(B) Continued Stay:
(i) Children shall remain in a psychiatric day treatment program only for the period of
time determined to be medically appropriate to treat the psychiatric conditions identified
on the child's individual plan of care.
(ii) Continued stay shall be reviewed by the interdisciplinary team and approved every
90 days by a review process approved by the Division.
(10) Substitute Care Settings. Providers of community-based intensive mental health
treatment services in substitute care settings shall be certified under these rules. These
services include therapeutic group homes and treatment foster care homes. The
provider delivers active mental health treatment focused on the behavior, feelings and
perceptions the child presents in the treatment/living milieu through regularly scheduled
group and individual skills training. Active treatment is based on a mental health
assessment of the child's developmental level, behavior, functioning and the severity
and acuity of psychiatric symptoms.
(a) Treatment services provided in therapeutic group home and treatment foster
care settings shall be delivered by QMHPs and QMHAs with experience and training in
psychosocial skills development and milieu therapy under the direction of a qualified
mental health professional in consultation with an psychiatrist. The treatment staffing
ratio shall be one staff for every eight children.
(b) Providers of therapeutic group home and treatment foster care services shall
maintain linkages with primary care physicians, applicable education agencies, CMHPs
and MHOs, SCF or OYA representatives, and the child's parent(s) or guardian to
coordinate related services and aftercare resources for the child.
(c) Therapeutic group home and treatment foster care and other individualized intensive
treatment services provided in substitute care settings shall be staffed to the acuity and
severity of admitted children according to the treatment prescribed in each child's
individual plan of care. The provision of these services shall be supervised by a
Qualified Mental Health Professional.
(d) Providers shall establish policies and practices to meet the following admission and
continued stay criteria:
(A) Admission shall be based on referral information current within the last 60 days
and include a written assessment by a Qualified Mental Health Professional of the
child's primary diagnosis on Axis I of a 5-Axis diagnosis supporting the following criteria:
(i) Therapeutic group or treatment foster care home mental health treatment level of
care is appropriate to meet the child's treatment needs; and
(ii) The services can reasonably be expected to improve the child's condition or prevent
further regression so that the current level of care is no longer necessary.
(B) Continued stay in a therapeutic group or treatment foster care home shall be based
upon determination by an LMP of the medical appropriateness of the setting treating
the psychiatric conditions identified in the child's individual plan of care.
Stat. Auth.: ORS 430.041, 430.640(1)(h) and 743.556
Stats. Implemented: ORS 430.630
Hist.: NEW
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Establishing and Maintaining Clinical Records
309-032-1160 (1) Individual record. A single, separate and individualized clinical
record shall be maintained for each child served by the provider.
(2) Terminology. All documentation entries in the clinical record shall be written in
commonly accepted clinical terms in standard, understandable English.
(3) Error corrections. Errors in the clinical record shall be corrected by lining out the
incorrect data with a single line in ink, and then adding the correct information, the date
corrected, and the initials of the person making the correction. Errors may not be
corrected by removal or obliteration.
(4) Signature of authors. All documentation required in this rule must be signed by
the person providing the service and making the entry. Signature must include the
person's academic degree or professional credential and the date signed.
Documentation that is dictated shall also include the date of dictation and date signed.
(5) Organization of clinical records. Each clinical record shall be uniform in organization,
readily identifiable and accessible, and contain all of the content required by these rules
in a current and complete manner within required timelines.
(6) Providers shall insure that each clinical record includes the following documentation:
(a) MHOs, FCHP, or other third party insurance enrollment information;
(b) Identifying data including child's name, date of birth, gender, address, phone
number and name of parent(s) or legal guardian including an address and phone
number if different;
(c) A mental health assessment, comprehensive mental health assessment,
diagnoses and clinical formulation;
(d) An individualized plan of care developed by the interdisciplinary team or
professional;
(e) Written discharge criteria;
(f) Completed medical history including current prescribed medications and allergies;
(g) Emergency medical and dental resources and primary care physician;
(h) A medication service record of all medications administered;
(i) Documentation by the interdisciplinary team that the child's individual plan of care
has been reviewed, the services provided are medically appropriate for the specific
level of care, and changes in the plan recommended by the interdisciplinary team as
indicated by the child's treatment needs have been implemented;
(j) Progress notes documenting specific treatments, interventions, and activities
related to the individual plan of care or have treatment planning implications, and the
child's response to the specific treatment or activities;
(k) Special treatment procedures notations in a separate section or in a separate format
documenting each incident of manual restraint, seclusion, or mechanical, signed and
dated by the staff directing the intervention and if required by the psychiatrist and/or
clinical supervisor authorizing the intervention;
(l) Written discharge instructions and discharge summary; and
(m) The clinical documentation received from the referral source.
(7) The child's parent or guardian, or the child if legally emancipated, must give
informed consent in writing to treatment including specific informed consent to the initial
administration of any medication, or to a subsequent change in the class of the
medication. Each informed consent shall state the information in writing, signed and
dated by the person giving consent, and placed in the child's clinical record.
(8) The child's parent or guardian, or the child if legally emancipated, has the right to
refuse treatment services including those generally accepted such as medication. The
consequences of this service refusal shall be explained verbally and in writing by the
provider to the child and parent or guardian, or the child if legally emancipated. A
refusal of service shall be documented in the child's record.
(9) The child's clinical record shall be secured, safeguarded, stored and retained in
accordance with applicable Oregon Revised Statutes and Oregon Administrative Rules.
(10) The child has the right to confidentiality when referenced in another child's
clinical record.
(11) Providers that use electronic clinical record systems shall establish written policies
and procedures to ensure confidentiality in accordance with ORS 179.505 through
179.507. The policies and procedures shall assure the following:
(a) The capacity to regularly provide printed documentation of all content incorporated
within the clinical record;
(b) The verification of authentication of the individual making an entry including name,
degree and date entered; and
(c) Safeguards to protect access to and the use of information contained in the
electronic system.
Stat. Auth.: ORS 430.041, 430.640(1)(h) and 743.556
Stats. Implemented: ORS 430.630
Hist.: NEW
Child and Family Rights
309-032-1170 Providers shall establish written policies and procedures pertaining to
child and family rights. The written statement of rights shall be posted prominently in
simple, easy to understand language on a form devised by the provider or the Division.
This form shall be given by the provider to the person legally giving consent to
treatment of the child, at the time of admission. In addition, these rights shall be
explained orally at the time of admission to the person giving consent to treatment and
to the child, in a manner appropriate to the child's developmental level. If the child is
initially served in a crisis situation, these rights shall be explained as soon as clinically
practical, but not more than five working days from the initiation of services if the child
who received the crisis service remains in service. Statement of Rights shall include the
following:
(1) Right to provide consent to treatment in accordance with ORS 109.640 and ORS
109.675.
(2) Right to refuse services.
(3) Right to confidentiality in accordance with ORS 179.505, 107.154, and 418.312.
(4) Right to immediate inspection of the clinical record in accordance with ORS
179.505.
(a) The child, if able, and the custodial parent(s) or guardian of a minor child has the
right to immediate inspection of the record.
(b) A copy of the record is to be provided within five working days of a request for it.
The person requesting the record is responsible for payment for the cost of duplication,
after the first copy.
(c) Identifying and clinical information about the child shall be protected in provider
publications such as newsletters and brochures.
(5) Right to humane treatment in the least restrictive environment.
(6) Right to receive services in a humane environment that provides the child with
protection from harm and protects the dignity of the child and his or her family.
(7) Right to participate in treatment planning. The child, to the extent of his or her
capability, and the child's parent or guardian, shall have the right to participate in the
planning of services, including the right to participate in the development and periodic
revision of the child's individual plan of care. The child's attorney or other representative
shall also have the right to participate in the planning process, including attending
individual plan of care development and review meetings, upon the request of the child
or child's parent or guardian.
(8) Right to private and uncensored communications by mail, telephone and visitation.
(a) This right may be restricted only if the treatment provider documents in the child's
record that, in the absence of this restriction, significant physical or clinical harm will
result to the child or others. The nature of the harm shall be specified in reasonable
detail, and any restriction of the right to communicate shall be no broader than
necessary to prevent this harm.
(b) The parent or guardian and the child, in a developmentally appropriate manner,
shall be given specific written notice of each restriction of the child's right to
communicate. The treatment provider shall ensure that correspondence can be
conveniently received and mailed, that telephones are reasonably accessible and allow
for confidential communication, and that space is available for visits. Reasonable times
for the use of telephones and visits may be established in writing by the treatment
provider.
(c) A child shall have the right to uncensored communication with licensed attorneys
at law and the state protection and advocacy agency.
(d) The state protection and advocacy agency shall be permitted access to a child
and the child's records consistent with federal and state statutes and regulations
governing such access. The child's juvenile court attorney and court appointed special
advocate (CASA), if any, shall have access to the child and the child's records in
accordance with applicable statutes and administrative rules.
(9) Right to personal possessions.
(a) A child shall have the right to wear his or her own clothing and to keep personal
possessions. The provider must provide the child with a reasonable amount of storage
space for this purpose.
(b) Possession and use, including reasonable restriction of the time and place of
use, of certain classes of property may be restricted by the treatment provider if
necessary to prevent the child or others from harm, provided that notice of this
restriction is given to all children and their families upon the child's admission.
(c) An individual item not subject to general restriction but substantially likely to cause
significant physical or clinical harm to a particular child or others due to the child's
individual clinical condition may be restricted if the harm that would be likely to result is
specifically documented in the child's record. The parent or guardian and the child, in a
developmentally appropriate manner, shall be given specific written notice of each such
restriction.
(10) Right to receive educational services in the least restrictive environment.
Including, if the child is eligible, a free appropriate public education under the
Individuals with Disabilities Education Act, 20 USC, Secs. 1401 et seq. Section 504 of
the Rehabilitation Act of 1973, 29 USC Sec. 794, and related federal and state statutes
and regulations.
(11) Right to refuse to perform routine labor tasks for the provider and to receive
reasonable compensation for all work performed other than personal housekeeping
duties or chores.
(12) Right to be free from unusual or hazardous treatment procedures and to not
participate in experimental treatment procedures without voluntary informed consent.
(13) Right to be free from seclusion or restraint unless used in compliance with all
applicable statutes and administrative rules.
(14) Right to freely exercise recognized and accepted religious beliefs and other civil
rights.
(15) Right to be thoroughly informed of the provider's rules and regulations.
(16) Right to participate regularly in developmentally appropriate indoor and outdoor
play and recreation.
(17) Right to make informed consent to fees for services. The amount and payment
schedule of any fees to be charged must be disclosed in writing and agreed to by the
person consenting to treatment.
(18) Right to consent to disclosure of clinical records. The person consenting to
treatment, usually the custodial parent or guardian, has the right to authorize disclosure of
the child's clinical record in accordance with ORS 179.505. When a child is admitted for
treatment under a voluntary placement agreement with SCF, the parent(s) or guardian
shall have the right to authorize disclosure.
(19) Right of assertion of rights. The rights contained in this section may be asserted and
exercised by the child (except where the law requires that only the parent or guardian
may exercise a particular right), the child's parent or guardian, or any representative of
the child.
(20) Right of formal complaint. The child, parent or guardian or child's representative shall
have the right to assert formal complaints concerning denial of any rights contained in this
section in a fair, timely and impartial formal complaint procedure. There shall be no
retaliation or punishment for exercise of any rights contained in this section.
Stat. Auth.: ORS 430.041, 430.640(1)(h) and 743.556
Stats. Implemented: ORS 430.630
Hist.: NEW
Behavior Management
309-032-1180 (1) Providers shall have a written behavior management policy
specifying which behavior management practices and restrictions may be used by staff
and the circumstances under which they may be used. The behavior management policy
shall:
(a) Establish a framework, which assures consistent behavior management practices
throughout the program and articulates a rationale consistent with the provider's
philosophy of treatment;
(b) Require the provider to obtain informed consent upon admission from the parent(s)
or guardian in the use of behavior management practices and communicate both verbally
and in writing the information to the parent(s) or guardian and the child in a
developmentally appropriate manner;
(c) Establish thresholds and tracking mechanisms of behavior management interventions
that will activate clinical review and which shall be relevant to the acuity and severity of
symptoms, and developmental functioning of the population served by the provider;
(d) Require that when thresholds established in the policy are exceeded that the
child's individual plan of care be reviewed and revised if necessary within no more than
24 hours and specifies the individual(s) in the program with designated clinical leadership
responsibilities who must participate in the review, and specify that the review be
documented in the child's clinical record;
(e) Describe the manner and regime in which all staff will be trained to manage
aggressive, assaultive, maladaptive, or problem behavior and de-escalate volatile
situations through a Division approved crisis intervention training program, and require
that such training shall occur annually; and
(f) Require that the provider review and update behavior management policies,
procedures, and practices, minimally annually.
(2) Individual behavior management interventions will be developed, implemented, and
reviewed for each child, review shall occur minimally at each individual plan of care
review.
(3) Each staff directed behavior management intervention that isolates a child for more
than 15 minutes shall be noted in the child's clinical record:
(a) The cumulative data shall be reviewed by the child's interdisciplinary team and be
reported in the next required individual plan of care review summary;
(b) The individual plan of care shall outline use of this procedure, therapeutic alternatives,
and methods to reduce its use; and
(c) Assure that when incidents of isolation for more than five hours in five days or a single
episode of two hours the psychiatrist or designee shall within 24 working hours convene
by phone or in person individual(s) in the program with designated clinical leadership
responsibilities to review the child's individual plan of care and behavior management
interventions and make necessary adjustments. This information shall be documented in
the child's clinical record and referred to the Special Treatment Procedures Committee.
Stat. Auth.: ORS 430.041, 430.640(1)(h) and 743.556
Stats. Implemented: ORS 430.630
Hist.: NEW
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Special Treatment Procedures
309-032-1190 (1) Providers shall have policies and procedures and a quality
management system to:
(a) Monitor the use of special treatment procedures to assure that children are
safeguarded and their rights are always protected; and
(b) Review and approve experimental practices other than medications that are outside
usual and customary clinical practices and research projects. Experimental practices and
research require review and approval by the Division Institutional Review Board.
(2) Chemical restraint shall not be used. Medication shall not be used as a restraint, but
shall be prescribed and administered according to acceptable nursing, medical, and
pharmaceutical practices to treat symptoms of serious emotional disorders.
(3) Mechanical restraint shall be used only in a Sub-Acute program specifically authorized
for such use in writing by the Division. Sub-Acute programs that are authorized to use
mechanical restraint shall adhere to the standards for special treatment procedures as
described in this section and other specific conditions as required by the Division.
(4) The provider shall establish a Special Treatment Procedures Committee or designate
this function to an already established Quality Management Committee. Committee
membership shall minimally include a staff person with designated clinical leadership
responsibilities, the person responsible for staff training in crisis intervention procedures,
and other clinical personnel not directly responsible for authorizing the use of special
treatment procedures with individual children. The committee shall:
(a) Meet at least monthly and shall report in writing to the provider's Quality
Management Committee at least quarterly regarding the committee's activities, findings
and recommendations;
(b) Conduct individual and aggregate review of incidents of seclusion and manual
restraint;
(c) Conduct individual and aggregate review of incidents of isolation for more than five
hours in five days or a single episode of two hours;
(d) Analyze special treatment procedures to determine opportunities to reduce their use,
increase the use of alternatives, improve the quality of care of children receiving services,
and recommend whether follow up action is needed; and
(e) Review and update special treatment procedures policies and procedures minimally
annually.
(5) Obtain informed consent upon admission from the parent(s) or guardian in the use
of special treatment procedures. Communicate both verbally and in writing the
information to the parent(s) or guardian and the child in a developmentally appropriate
manner.
(6) General Conditions of Manual Restraint and Seclusion.
(a) There shall be a systematic approach, documented in written policies and
procedures to the treatment of children which employs individualized, preplanned
alternatives to manual restraint and seclusion;
(b) Manual restraint and seclusion shall only be used in an emergency to prevent
immediate injury to a child who is in danger of physically harming him or her self or others
in situations such as the occurrence of, or serious threat of violence, personal injury or
attempted suicide;
(c) Any use of manual restraint and seclusion shall respect the dignity and civil rights of
the child;
(d) A child shall be manually restrained or secluded only when clinically indicated and
alternatives are not sufficient to protect the child or others as determined by the
interdisciplinary team responsible for the child's individual care plan;
(e) The use of manual restraint and seclusion shall be directly related to the child's
individual symptoms and behaviors and the acuity of the symptoms and behaviors.
Manual restraint and seclusion shall not be used as punishment, discipline, or for the
convenience of staff;
(f) Manual restraint and seclusion shall only be used for the length of time necessary for
the child to resume self-control and prevent harm to the child or others;
(g) If manual restraint and seclusion are considered as part of the child's individualized
safety needs, then alternatives to manual restraint and seclusion shall be identified and
made a part of the child's individual plan of care. The individual plan of care shall outline
use of this procedure, and goals addressing therapeutic alternatives and interventions to
reduce its use; and
(h) Each incident of manual restraint and seclusion shall be referred to the Special
Treatment Procedures Committee.
(A) Manual Restraint:
(i) Each incident of manual restraint shall be documented in the clinical record. The
documentation shall specify less restrictive methods attempted prior to the manual
restraint, the required authorization, length of time the manual restraint was used, the
events precipitating the manual restraint, assessment of appropriateness of the manual
restraint based on threat of harm to self or others, assessment of physical injury, and the
child's response to the intervention;
(ii) A minimum of two staff shall implement a manual restraint. If in the event of an
emergency a single staff manual restraint has occurred, the provider's on-call
administrator shall immediately review the intervention;
(iii) A manual restraint intervention that exceeds 30 minutes shall require a documented
review and authorization by a QMHP, interventions which exceed one hour shall require a
documented review and authorization by a psychiatrist or designee; and
(iv) A designated individual with clinical leadership responsibilities shall review the manual
restraint documentation prior to the end of the shift in which the intervention occurred.
(v) If incidents of manual restraint used with an individual child cumulatively exceed five
hours in five days or a single episode of one hour, the psychiatrist or designee shall within
24 hours convene by phone or in person individual(s) in the program with designated
clinical leadership responsibilities to review the child's individual plan of care and/or
behavior management interventions and make necessary adjustments. This information
shall be documented in the child's clinical record and referred to the Special Treatment
Procedures Committee.
(B) Seclusion:
(i) Each episode of seclusion shall be authorized immediately after initiation of the
episode in the child's clinical record by the psychiatrist. A general order for the use of
seclusion is not sufficient. The psychiatrist may delegate the authority to authorize
seclusion to QMHP staff who have satisfactorily completed a Division-approved crisis
intervention training program;
(ii) Written orders for seclusion are limited to two hours for children age nine and older
and one hour for children under age nine. The psychiatrist may extend the original order
for one additional hour for children under age nine to two hours total, and the original
order for two hours for children age nine and older up to six hours total;
(iii) Visual monitoring of a child in seclusion shall occur and be documented at least every
fifteen minutes or more often as clinically indicated;
(iv) The child's right to retain personal possessions and personal articles of clothing may
be suspended during a seclusion only when necessary to ensure the safety of the child or
others. Articles that a child might use to inflict self-injury must be removed;
(v) The child shall have regular meals, bathing, and use of the bathroom during seclusion
and their provision shall be documented in the child's clinical record;
(vi) Each incident of seclusion shall be documented in the child's clinical record. The
documentation shall include the clinical justification for use, the written order by the
authorized individual, the less restrictive methods attempted, length of time the seclusion
was used, the precipitating events, assessment of appropriateness of the intervention
based on threat of harm to self or others, assessment of physical injury, and the child's
response to the intervention; and
(vii) If incidents of seclusion used with an individual child cumulatively exceed five hours
in five days or a single episode of more than two hours for children age nine and older
and more than one hour for children under age nine, the psychiatrist or designee shall
within 24 hours convene by phone or in person individual(s) in the program with
designated clinical leadership responsibilities to review the child's individual plan of care
and/or behavior management interventions and make necessary adjustments. This
information shall be documented in the child's clinical record and referred to the Special
Treatment Procedures Committee.
(7) Application for the use of seclusion. Any facility or program in which the use of
seclusion occurs shall be authorized by the Division for this purpose and shall meet the
following requirements:
(a) A facility or program seeking authorization shall submit a written application to the
Division;
(b) Application shall include a comprehensive plan for the need for and use of seclusion
of admitted children and copies of the facility's policies and procedures for the utilization
and monitoring of seclusion including a statistical analysis of the facility's actual use of
seclusion, physical space, staff training, staff authorization, record keeping and quality
management practices;
(c) The Division shall review the application and, after a determination that the written
application is complete and satisfies all applicable requirements, shall provide for a review
of the facility by authorized Division staff;
(d) The Division shall have access to the records of the facility's clients, the physical plant
of the facility, the employees of the facility, the professional credentials of employees, and
shall have the opportunity to observe fully the treatment and seclusion practices
employed by the facility;
(e) After the review, the Assistant Administrator or designee shall approve or disapprove
the facility's application and if, approved, shall certify the facility based on the
determination of the facility's compliance with all applicable requirements for the
seclusion of children;
(f) If disapproved the facility shall be provided with specific recommendations and have
the right of appeal to the Division; and
(g) Certification of a facility shall be effective for a maximum of three years and may
be renewed thereafter upon approval of a renewal application.
(8) Structural and physical requirements for seclusion. Any facility or program in which
the use of seclusion occurs shall be certified by the Division for this purpose. A provider
seeking this certification under these rules shall have available at least one room that
meets the following specifications and requirements:
(a) The room must be of adequate size to permit three adults to move freely and allows
for one adult to lie down. Any newly constructed room shall be no less than 64 square
feet;
(b) The door must open outward and contain a port of shatterproof glass or plastic
through which the entire room may be viewed from outside;
(c) The room shall contain no protruding, exposed, or sharp objects;
(d) The room shall contain no furniture. A fireproof mattress or mat shall be available for
comfort;
(e) Any windows shall be made of unbreakable or shatterproof glass, or plastic. Non-shatterproof glass shall be protected by adequate climb-proof screening;
(f) There shall be no exposed pipes or electrical wiring in the room. Electrical outlets shall
be permanently capped or covered with a metal shield secured by tamper-proof screws.
Ceiling and wall lights shall be recessed and covered with safety glass or unbreakable
plastic. Any cover, cap or shield shall be secured by tamper-proof screws;
(g) The room shall meet State Fire Marshal fire, safety, and health standards. If sprinklers
are installed, they shall be recessed and covered with fine mesh screening. If pop-down
type, sprinklers must have breakaway strength of under 80 pounds. In lieu of sprinklers,
combined smoke and heat detector shall be used with similar protective design or
installation;
(h) The room shall be ventilated, kept at a temperature no less than 64 F. and no more
than 85 F. Heating and cooling vents shall be secure and out of reach;
(i) The room shall be designed and equipped in a manner that would not allow a child to
climb off the ground;
( j) Walls, floor and ceiling shall be solidly and smoothly constructed, to be cleaned easily,
and have no rough or jagged portions; and
(k) Adequate and safe bathrooms shall be available.
Stat. Auth.: ORS 430.041, 430.640(1)(h) and 743.556
Stats. Implemented: ORS 430.630
Hist.: NEW
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Quality Management
309-032-1200 Providers shall have a planned, systematic and ongoing process for
monitoring, evaluating and improving the quality and appropriateness of services provided
to children and families. The Quality Management system shall include a Quality
Management Committee and a Quality Management Plan which together implement a
continuous cycle of assessment and improvement of clinical outcomes based on
measurement and input from service providers and representatives of the children and
families served.
(1) Providers shall have a continuous quality management process that:
(a) Establishes and reviews expectations about quality and outcomes; and
(b) Seeks to correct any observed deficiencies identified through its quality
management process.
(2) The overall scope of the Quality Management process is described in a written plan
which identifies mechanisms, committees or other means of assigning responsibility for
carrying out and coordinating the Quality Management process activities, and which
includes:
(a) Indicators of quality;
(b) Methods of monitoring;
(c) Reporting of results; and
(d) Follow-up mechanisms.
(3) The written Quality Management Plan shall describe the implementation and
ongoing operation of the functions performed by the Quality Management Committee.
(a) The plan shall be reviewed and revised annually; and
(b) The provider's board shall review the annual Quality Management report and approve
the annual Quality Management plan.
(4) The Quality Management Plan shall include:
(a) A description of the Quality Management Committee's authority to identify and
implement clinical and organizational changes;
(b) The composition and tenure of the Quality Management Committee;
(c) The schedule of Quality Management Committee(s) meetings;
(d) Provisions which require activities to evaluate and recommend improvements as
necessary in the following domains:
(A) Quality of care provided to children and families;
(B) Integration and coordination of services between the provider and other entities
associated with the child and family;
(C) Child and parent and/or guardian satisfaction; and
(D) Clinical outcomes.
(e) The requirements that the following review activities are conducted and integrated into
the overall Quality Management process:
(A) Review of the use of special treatment procedures;
(B) Review of grievances, formal complaints, incidents or accidents; and
(C) Review of problems with the administration or prescription of medications.
(5) The provider shall have a Quality Management Committee that meets at least
quarterly. The Quality Management Committee shall be composed of:
(a) One or more qualified mental health professionals who are representative of the
scope of services delivered;
(b) A representative or representatives of the children and families served;
(c) Other persons who have the ability to identify, design, measure, assess and
implement clinical and organizational changes; and
(d) A representative of external agencies.
(6) Quality Management activities are conducted with representation of those who have
knowledge or ability to effect continuous quality improvement.
(7) The Quality Management process is conducted with input from children, families, and
community stakeholders.
(8) The provider has a participatory process whereby all personnel contribute to and
recommend changes in the Quality Management process.
(9) The provider assures that the psychiatrist participates and is involved in quality
management activities and is recognized within the staff organization as a member of the
quality management committee with responsibilities described in the provider's quality
management plan.
(10) Quality Management activities are conducted in accord with the applicable Oregon
Revised Statutes, Oregon Administrative Rules and the provider's policies and
procedures with regard to confidentiality.
(11) Documentation of the pertinent facts and conclusions of each Quality
Management Committee meeting shall be maintained and be available for review by the
Division.
(12) An annual report of Quality Management activities and data shall be available for
review by the Division.
Stat. Auth.: ORS 430.041, 430.640(1)(h) and 743.556
Stats. Implemented: ORS 430.630
Hist.: NEW
Formal Complaints
309-032-1210 (1) The child, or the person consenting to the child's treatment, has the
right to file an oral or written formal complaint with the entity providing services and
receive a timely response. All providers will:
(a) Have written procedures for accepting, processing and responding to oral or written
formal complaints. The written procedures must include:
(A) The process for registering an oral or written formal complaint;
(B) The time lines for processing an oral or written formal complaint; and
(C) Notification of the appeals process, including time lines for a formal complaint and the
provision of the appropriate appeal forms.
(b) Designate a staff person to coordinate formal complaint information, receive formal
complaint information, assist any person who needs assistance with the process, and
enter the information into a log. The log will identify, at a minimum, the person lodging the
formal complaint, the date of the formal complaint, the nature of the formal complaint, the
resolution and the date of the resolution.
(c) Have written procedures for informing children and their legal guardian orally and in
writing about the provider's formal complaint procedures.
(d) Have written procedures for processing an expedited formal complaint request if it
is believed the child's health is at risk. A request for expedited formal complaint must be
filed by the child or the person consenting to the child's treatment and must include the
following:
(A) A statement requesting an expedited formal complaint;
(B) An explanation of the urgency of resolving the issue; and
(C) A description of the consequences of following the regular formal complaint process.
(2) Service denial. The child, or the person consenting to treatment on behalf of the child,
has the right to appeal when a service has been denied. All providers shall have written
policies and procedures in compliance with applicable Oregon Medical Assistance
Program Administrative Rules for accepting, processing and responding in writing within
five working days to service denial complaints. The written response must include:
(a) The service requested;
(b) A statement of service denial;
(c) The basis for the denial; and
(d) Notification of the appeals process including the required time frame to file an appeal
and provision of the appropriate appeal forms.
(3) Hearing request for Medicaid and CHIP eligible children. In accordance with
applicable Oregon Administrative Rules, providers shall have a written appeals process
whereby a Medicaid or CHIP eligible child, or the person consenting to treatment for the
child, can assert his or her right to file a request for hearing as a result of a denial of
service or an adverse finding against the complainant.
(4) Hearing request for children who are not Medicaid or CHIP eligible. Providers shall
have a written appeals process for non-Medicaid, non-CHIP eligible children with at least
one level of appeal at the provider level. The appeals process must culminate in a
hearing by the Division Administrator or designee if the complaint cannot be satisfactorily
resolved at the provider level.
Stat. Auth.: ORS 430.041, 430.640(1)(h) and 743.556
Stats. Implemented: ORS 430.630
Hist.: NEW
Certificate of Approval
309-032-1220 (1) Providers shall be in compliance with these rules and hold a valid
Certificate of Approval issued by the Division to provide children's intensive mental
health treatment services as described in these rules.
(2) A provider who is determined by the Division to be in substantial compliance with
these rules may receive a Certificate of Approval valid for up to three years.
(3) A provider who is determined by the Division to be not in substantial compliance with
these rules may, at the discretion of the Division, receive a time-limited Certificate of
Approval of less than three years and may have conditions for compliance placed on the
Certificate of Approval.
(4) The Division may require a provider who is not in compliance with these rules to
develop a Plan of Correction within a time period specified by the Division. The Division
may accept, reject, or modify the Plan of Correction or require the provider to comply with
a Plan of Correction directed and approved by the Division.
(5) The Division at its discretion may terminate the provider's Certificate of Approval to
provide children's intensive mental health treatment services, withhold funds, or apply
other applicable sanctions allowable in rule and statute for failure to comply with these
rules.
Stat. Auth.: ORS 430.041, ORS 743.556 and ORS 430.640(1)(h)
Stats. Implemented: ORS 430.630
Hist.: NEW
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Variance
309-032-1230 A variance from portions of these rules that are not derived from federal
regulations or the Office of Medical Assistance Program (OMAP) General Rules may be
granted for a period of up to one year or a time period specified on the provider's
Certificate of Approval in the following manner:
(1) The provider shall submit to the Assistant Administrator of the Division a written
request which includes:
(a) The section of the rule from which the variance is sought;
(b) The reason for the proposed variance;
(c) The alternative practice proposed; and
(d) A plan and timetable for compliance with the section of the rule from which the
variance is sought.
(2) The Assistant Administrator of the Division shall approve or deny the request for
variance in writing.
(3) The Division shall notify the provider of the decision in writing within 30 days of the
receipt of the request.
(4) Appeal of the denial of a variance request shall be to the Administrator of the Division
whose decision shall be final.
(5) All variances must be reapplied for as directed by the Division.
Stat. Auth.: ORS 430.041, ORS 743.556 and ORS 430.640(1)(h)
Stats. Implemented: ORS 430.630
Hist.: NEW
32_1100
02/14/00
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