Or. Admin. Code § 309-018-0140

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

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

(1) At the time of entry, the assessment process must begin, be updated or completed and signed by a qualified program staff. Each assessment document shall provide record, or documented review of past record, at minimum;

(a) Sufficient information and documentation to justify the presence of a DSM-5-TR or ICD-10 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;

(A) Screening for the presence of suicide risk and interventions based on the information gathered; and

(B) A determination of the need for follow-up actions, additional services and supports, and the level of risk to the individual or to others.

(C) For updated assessments or assessments for participants returning to services in less than one calendar year, collateral information such as previous assessments can be used to inform the current assessment. Information supporting medical necessity, immediate risk screenings must be verified in initial assessment interviews.

(b) Should medical necessity not be possible to document at entry, the following services may be rendered prior to an assessment being completed or at any appropriate time during a treatment episode:

(A) Care coordination;

(B) Peer mentoring;

(C) Screening; and

(D) Crisis intervention.

(c) Assessments conducted over no more than ten business days are complete when the following information has also been documented within ten business days of the first assessment service date;

(A) Symptoms related to psychological and physical trauma;

(B) Current suicide risk;

(C) Current Substance use;

(D) Current Problem Gambling Behavior;

(E) Current Mental Health conditions;

(F) Current Medical conditions;

(G) Additional and sufficient Historical, Biological, Psychological and Social information relevant to planning services; and

(H) When indicated, 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) When the assessment and screening processes determine 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 recommendations for further assessment, planning, and intervention from an appropriate professional, either with the same provider or with a collaborative community provider.

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

(b) An initial ASAM assessment can record information derived from observation, self-report interview, collateral information or any combination of these. An initial ASAM assessment will also cover, at minimum;

(A) Diagnostic criteria for Substance Use Disorders endorsed by individual in interest of supporting medical necessity for Substance Use Disorder diagnosis.

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

(C) An identification of immediate need(s) and risks;

(D) A severity of risk for each dimension;

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

(c) A comprehensive and complete ASAM assessment will be completed as soon as possible but in no more than 10 business days and include full supporting historical, biological, social and psychological information for purposes of comprehensive service planning.

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

(e) 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