Or. Admin. Code § 309-018-0140

Current through Register Vol. 63, No. 10, October 1, 2024

Section 309-018-0140 - [Effective 10/27/2024] Assessment

(1) At the time of entry, an assessment shall be completed, or updated and signed by a qualified program staff.

(2) Each assessment shall include:

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

(b) Screening for the presence of:

(A) Substance use;

(B) Problem gambling;

(C) Mental health conditions;

(D) Chronic medical conditions;

(E) Presence of symptoms related to psychological and physical trauma; and

(F) Suicide risk.

(c) When the screening process determines the presence of any of the above conditions or any risk to health and safety to the individual or others:

(A) Further assessment shall be completed to determine the need for follow-up actions, additional services and supports and the level of risk to the individual or to others; and

(B) Documentation shall contain referral for further assessment, planning, and intervention from an appropriate professional, either with the same provider or with a collaborative community provider.

(d) In addition, for substance use disorder services each assessment and update thereof shall be a multidimensional assessment, consistent with The ASAM Criteria, Third Edition, and include, at a minimum the following components, each consistent with The ASAM Criteria, Third Edition:

(A) An ASAM Level of Care determination per dimension, overall, and noting any applicable discrepancies; and

(B) A Risk Assessment that is comprised of:

(i) A consideration of the history of each risk as well as the present concern(s);

(ii) An identification of immediate need(s);

(iii) A severity of risk for each dimension; and

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

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

(f) Providers shall update assessments within the scope of their practice when there are changes in clinical circumstances.

Or. Admin. Code § 309-018-0140

MHS 10-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14; MHS 3-2014, f. & cert. ef. 2-3-14; MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18; MHS 4-2018, amend filed 02/27/2018, effective 3/1/2018; BHS 10-2023, amend filed 04/07/2023, effective 4/7/2023; BHS 8-2024, temporary amend filed 04/30/2024, effective 5/1/2024 through 10/27/2024; BHS 10-2024, temporary amend filed 05/21/2024, effective 5/21/2024 through 10/27/2024

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

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