Or. Admin. R. 309-019-0135

Current through Register Vol. 63, No. 5, May 1, 2024

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

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

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

(b) The provider 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 must 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 - or at the time that services begin. Written, voluntary informed consent for services must be obtained from the individual or guardian, if applicable, prior to - or at the time that services begin. If such consent is not obtained, the reason and any further attempts to obtain informed consent must be documented in the service record.

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

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

(g) In accordance with ORS 179.505, HIPAA, and 42 CFR Part 2, an authorization for the release of information must 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, but no later than 30 days from initial service contact, the program must offer to the individual and guardian, if applicable, written program information. The written program information must be in a language understood by the individual and must include:

(A) Program consent, disclosure, and orientation information.

(B) Information on how to complete a Declaration for Mental Health Treatment with the individual's participation and informed consent;

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

(D) Information describing how to file grievance and appeals consistent with these rules, including an example grievance form;

(E) Notice of privacy practices; and

(F) Information on how to register to vote, per the National Voter Registration Act of 1993, Section 7. Provider agency will supply means to register to vote upon request; and

(G) If written information is not provided prior or at the start of treatment services, the reason and any further attempts to provide written information must be documented in the service record.

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

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

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

(B) Individuals who are pregnant;

(C) Individuals who are using substances intravenously; and

(D) Individuals or families with dependent children.

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

(A) An opportunity for the individual to engage in interactive social services through care coordination, peer services or other interactive supports.

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

(C) Educational information and resources about steps that can decrease the likelihood of Hepatitis, HIV, STD, and TB transmission;

(D) For pregnant individuals, interactive social services and educational information addressing the likelihood of blood borne pathogen transmission as well as the effects of alcohol, tobacco, and other drug use on the fetus and referral for prenatal care; and

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

(3) At the time of entry, the assessment process must begin, be updated, or completed and signed by a qualified program staff, provided individual presentation and circumstances allow

(a) Each assessment document must provide clinically relevant information, or documented review of past records that contain, at minimum;

(A) If a DSM-5 TR diagnosis cannot be identified, a Minimally 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) If a DSM-5 TR diagnosis cannot be initially identified, ICD 10 "z", "v" or "r" codes may be utilized to document initial diagnostic impressions for up to 90 days of initial service date.. gnosis when it is determined.

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

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

(B) 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.

(c) 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.

(d) Assessments conducted in less than 90 days are considered complete when the following information has also been documented as part of an assessment within 90 days of the initial 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 must contain recommendations for further assessment, planning, and intervention from an appropriate professional, either with the same provider or with a collaborative community provider.

(e) In addition, for substance use disorder services each assessment and update thereof must 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) 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;

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

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

(C) A comprehensive and complete ASAM assessment will be completed as soon as possible but in no more than 90 days and include full supporting information for purposes of comprehensive service planning, which at minimum will include 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.

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

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

(h) Any individual continuing to receive mental health services for one or more continuous years must 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

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