Or. Admin. R. 309-019-0135

Current through Register Vol. 63, No. 6, June 1, 2024

Section 309-019-0135 - [Effective 10/27/2024] Entry and Assessment

(1) The program shall utilize an entry procedure that at a minimum shall ensure the provision and documentation of the following:

(a) Individuals shall be considered for entry without regard to race, ethnicity, gender, gender identity, gender expression, sexual orientation, religion, creed, national origin, age (except when program eligibility is restricted to children, adults, or older adults), familial status, marital status, source of income, and disability;

(b) The provider may not deny entry to individuals based on their decision to continue their currently prescribed or dispensed medication to treat opioid dependence while receiving outpatient behavioral health services and supports;

(c) Individuals shall receive services in the timeliest manner feasible consistent with the presenting circumstances;

(d) Except as permitted by law in emergencies, informed consent for services must be obtained prior to services. Written, voluntary informed consent for services shall be obtained from the individual or guardian, if applicable, prior to the start of services. If such consent is not obtained, the reason and any further attempts to obtain informed consent shall be documented in the service record.

(e) Per CFR 440.230, the provider shall develop and maintain service records and other documentation that demonstrates the amount, duration and scope of each specific services and supports provided for each individual;

(f) The provider shall submit the identified status and service data, including Non-Medicaid Service Data where required, in the mandated state data system according to the timelines required by the Division for each individual whose services are paid for in-full or in-part by public funds and for individuals enrolled in DUII services;

(g) In accordance with ORS 179.505, HIPAA, and 42 CFR Part 2, an authorization for the release of information shall be obtained and contained in the service record for the release of any confidential information concerning the individual being considered for or receiving services;

(h) Prior to or at the start of treatment services, the program shall offer to the individual and guardian, if applicable, written program orientation information. The written information shall be in a language understood by the individual and shall include:

(A) An opportunity to complete a Declaration for Mental Health Treatment with the individual's participation and informed consent;

(B) A description of individual rights consistent with these rules;

(C) Policy concerning grievances and appeals consistent with these rules, including an example grievance form;

(D) Notice of privacy practices; and

(E) An opportunity to register to vote, per the National Voter Registration Act of 1993, Section 7.

(2) Entry requirements for providers that receive the Substance Use Prevention, Treatment and Recovery (SUPTR) Block Grant:

(a) Document that individuals are prioritized for entry in the following order:

(A) Individuals who are pregnant and using substances intravenously;

(B) Individuals who are pregnant;

(C) Individuals who are using substances intravenously; and

(D) Individuals or families with dependent children.

(b) Individuals using substances intravenously shall receive interim referrals and information prior to entry to reduce the adverse health effects of substance use, promote the health of the individual, and reduce the risk of transmission of disease. At a minimum, interim referral and informational services shall include:

(A) Counseling and education about blood borne pathogens including Hepatitis, HIV, STDs, and Tuberculosis (TB); the risks of needle and paraphernalia sharing; and the likelihood of transmission to sexual partners and infants;

(B) Counseling and education about steps that can decrease the likelihood of Hepatitis, HIV, STD, and TB transmission; caal

(C) For pregnant individuals, counseling on the likelihood of blood borne pathogen transmission as well as the effects of alcohol, tobacco, and other drug use on the fetus and referral for prenatal care; and

(D) Peer Delivered Services that address parenting and youth in transition support, as indicated.

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

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

(B) 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;

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

(g) Any individual continuing to receive mental health services for one or more continuous years shall receive an annual assessment by a QMHP.

Or. Admin. R. 309-019-0135

MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14; MHS 4-2014, f. & cert. ef. 2-3-14; MHS 18-2016, f. 11-28-16, cert. ef. 11/30/2016; MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17; MHS 6-2017, f. & cert. ef. 6/23/2017; 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 11-2021, amend filed 06/16/2021, effective 6/16/2021; BHS 11-2023, amend filed 04/07/2023, effective 4/7/2023; BHS 9-2024, temporary amend filed 04/30/2024, effective 5/1/2024 through 10/27/2024; BHS 11-2024, temporary amend filed 05/21/2024, effective 5/21/2024 through 10/27/2024

Statutory/Other Authority: ORS 161.390, 413.042, 430.256 & 430.640

Statutes/Other Implemented: ORS 161.390 - 161.400, 428.205 - 428.270, 430.010, 430.205- 430.210, 430.254 - 430.640, 430.850 - 430.955 & 743A.168