Or. Admin. Code § 309-019-0135

Current through Register Vol. 63, No. 11, November 1, 2024

Section 309-019-0135 - Entry and Assessment

(1) The provider must utilize and document an entry procedure that at a minimum must ensure 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 will not deny entry to individuals based on their decision to continue currently prescribed or dispensed medications for opioid use disorder (MOUD) while receiving outpatient behavioral health services and supports;

(c) Individuals must receive services in a manner consistent and appropriate with their presenting life circumstances;

(d) 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.

(e) 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 as soon after entry as possible but no later than 90 day from date of entry;

(f) The provider must obtain an authorization for the release of information for the release of any confidential information concerning the individual being considered for or receiving services;

(g) Except as permitted by law in emergencies, the provider must obtain written, voluntary informed consent for services from the individual, or guardian if applicable prior to - or at the start of services.

(h) Prior to or at the start of treatment services, the program must offer to the individual and guardian, if applicable, written description of services provided. The written description must be in the individual's preferred language and must include disclosures regarding risks and benefits to services provided. The written program information shall include:

(A) Disclosure of availability of assistance by program in completing a Declaration for Mental Health Treatment, including information on how to request assistance.

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

(C) Notice of privacy practices;

(D) If written program description information, disclosures, notice of privacy practices, consents and individual rights documents are not provided prior or at the start of treatment services, the reason, and any further attempts to provide written information and consent, 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 counseling 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, counseling 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, an assessment must be initiated by qualified program staff.

(a) An assessment may be completed over more than one session and must be completed within 90 days.

(b) Assessments must record diagnostic information derived from any combination of clinical observation, self-report interview, or collateral information (such as assessments from other programs or previous treatment episodes).

(c) Providers may reduce the number and length of assessments through use of collateral information to inform the current assessment, such as previous assessments on file.

(d) Any changes to the ASAM Level of Care placement decision must be justified within an update to the multidimensional assessment on file, including the ASAM Dimensional Admission Criteria;

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

(f) For mental health treatment services, documentation demonstrating an ongoing medically necessary reason for services and progression in treatment must be completed at least annually by qualified program staff.

(4) When an assessment is completed in more than one encounter, documentation from the first encounter must include, at a minimum :

(a) A medically necessary reason for services, including supporting information. Medical necessity includes a DSM-5-TR diagnosis that is evidenced by diagnostic criteria and the symptoms that support each identified criteria.

(b) If the provider cannot document a DSM-5-TR diagnosis as part of a medically necessary reason for services at entry, the provider must -- at minimum -- document a screening for suicide risk, immediate needs, safety risk and current impacts of trauma on daily functioning..

(c) Appropriateness for treatment by the program;

(d) Suicide and other current safety risk(s);

(e) Immediate need(s);

(f) Identification of current physical and psychological trauma; and

(g) Intoxication and withdrawal symptoms, when applicable;

(h) Referrals to meet risk and immediate needs, including withdrawal management services, when applicable.

(5) Assessments and assessment updates are considered complete when the following information is contained in assessment documentation:

(a) Clinically relevant current and historical biological, psychological, social information;

(b) Documentation of the presence of a DSM-5-TR that is the medically necessary reason for services, including identification of each diagnostic criteria established per diagnosis, and the symptoms supporting each criteria;

(c) Screening for the presence of suicide risk and documented interventions, as indicated;

(d) The identification of psychological and physical trauma and risk to the individual or to others.

(e) Current Substance use, in mental health assessments when an ASAM Dimensional assessment is not needed;

(f) Current Problem Gambling Behavior;

(g) Current Mental Health conditions, including currently prescribed psychiatric medications, as clinically relevant;

(h) Current Medical conditions, including currently prescribed treatments and medications, as clinically relevant;

(i) When indicated, documentation must contain recommendations for each identified need, indicating further assessment, planning, and intervention from an appropriate professional, either with the same provider or with a collaborative community provider.

(j) In addition, for individuals entering substance use disorder services, each complete assessment and update thereof must be a multidimensional assessment that is 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 ASAM Dimension;

(B) An overall ASAM Level of Care determination, with justification for any applicable discrepancies between level of care assessed and level of care placement;

(C) Corresponding ASAM Dimensional Admission Criteria;

(D) Historical and present substance use-related risk(s);

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

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

Or. Admin. Code § 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; BHS 24-2024, amend filed 10/25/2024, effective 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