This Oregon rule establishes minimum service delivery standards for Division-certified outpatient behavioral health providers, covering three service lines: outpatient community mental health services and supports for children and adults, outpatient substance use disorder treatment services (including ASAM Levels 0.5, 1, 2.1, and 2.5), and outpatient problem gambling treatment services. Operators must comply with assessment, service planning, staffing qualification, supervision, incident reporting, and cultural competency requirements as specified. The rule also defines key terms and program types used throughout the certification framework.
View official sourceOregon Health Authority Health Systems Division: Behavioral Health Services - Chapter 309 Division 19 OUTPATIENT BEHAVIORAL HEALTH SERVICES 309-019-0100 Purpose and Scope (1) These rules prescribe minimum service delivery standards for services and supports provided by providers certified by the Health Systems Division (Division) of the Oregon Health Authority (Authority). (2) In addition to applicable requirements in OAR 410-120-0000 through 410-120-1980 and 943-120-0000 through 943-120-1550, these rules specify standards for behavioral health treatment services and supports provided in: (a) Outpatient Community Mental Health Services and Supports for Children and Adults; (b) Outpatient Substance Use Disorders Treatment Services; and (c) Outpatient Problem Gambling Treatment Services. Statutory/Other Authority: ORS 161.390, 413.042, 430.256 & 430.640 Statutes/Other Implemented: ORS 109.675, 161.390 - 161.400, 428.205 - 428.270, 430.010, 430.205 - 430.210, 430.640, 430.850 - 430.955, 461.549 & 743A.168 History: MHS 6-2017, f. & cert. ef. 6-23-17 MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16 MHS 4-2014, f. & cert. ef. 2-3-14 MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14 309-019-0105 Definitions (1) "Abuse of an Adult" means the circumstances defined in ORS 430.735, OAR Chapter 943, Division 45 and OAR Chapter 407, Division 45 for abuse of an adult with mental illness or who is receiving residential substance use disorder treatment or withdrawal management services. (2) “Abuse of a Child” means the circumstances defined in ORS 419B.005 and ORS 418.257. (3) “Active Supervision” means a designated supervisor is physically present who provides direct or indirect observation of the program staff, to determine if the service or task is being completed properly and providing intervention and consultation as needed. (4) “Activities of Daily Living (ADL) or Instrumental Activities of Daily Living (IADL)” means those personal functional activities required by an individual for continued well-being, which are essential for health and safety. Activities include eating, dressing, and grooming, bathing and personal hygiene, mobility, toileting, and cognition. (5) “Acute Care Psychiatric Hospital” means a hospital or facility that provides 24 hours-a-day psychiatric, multi-disciplinary, inpatient, or residential stabilization, care, and treatment. (6) “Adolescent” means an individual from 12 through 21 years of age or those individuals determined to be developmentally appropriate for such services. (7) "Adult" means an individual 18 years of age or older or an emancipated minor. An individual with Medicaid eligibility who needs services specific to children, adolescents, or young adults in transition shall be considered a child until age 21 for the purposes of these rules. Adults who are between the ages of 18 and 21 who are considered children for purposes of these rules shall have all rights afforded to adults as specified in these rules. (8) “ASAM” means The American Society of Addiction Medicine (ASAM). (9) "The ASAM Criteria" means the criteria in the Third Edition of The American Society of Addiction Medicine (ASAM) for the assessment, level of care placement and treatment of addictive, substance-related, and co-occurring conditions. The ASAM Criteria is a clinical guide to developing patient-centered service plans and making objective decisions about admission, continuing care, and transfer or discharge for individuals. The ASAM Criteria is incorporated by reference in these rules. (10) “ASAM Co-Occurring Capable” means an array of psychiatric and mental health services that meet the individuals’ needs are made available to individuals when indicated, by the program or coordinated by the program. (11) “ASAM Co-occurring Enhanced” means mental health services that include psychiatric evaluation, medication management and therapy are made available to the individuals, when indicated, by the program. Program staff are cross trained on substance use disorders and mental health treatment and can document the relationship between the disorders and the individual’s level of functioning. (12) “ASAM Dimensional Criteria” means the documented data demonstrates that the individual meets the criteria per ASAM dimension, as described in The ASAM Criteria, for the ASAM Level of Care assessed. (13) “ASAM Enhanced Service designation(s)” as described in The ASAM Criteria, Third Edition, includes service types per ASAM Level of Care that the program may choose to apply and be approved by the Division to render, to either adults or adolescents, when it corresponds to an ASAM Level of Care that is certified by the Division. (14) “ASAM Level of Care” means one of several discrete intensities of services and supports, as described within The ASAM Criteria, Third Edition, within a substance use disorders program that are delivered in a structured, programmatic fashion, by a Division certified outpatient or licensed residential provider. (a) “Early Intervention ASAM Level of Care 0.5 (ASAM Level 0.5)” means organized services designed to explore and address problems or risk factors that may be related to substance use and assist individuals in recognizing the harmful consequences of high-risk substance use and addictive behavior. ASAM Level 0.5 may be delivered as a Driving Under the Influence of Intoxicants (DUII) service where the length and number of contacts may be mandated, and completion of the program may be a prerequisite to the reinstatement of driving privileges. Individuals eligible for this ASAM level of care do not meet DSM-5-TR diagnostic criteria for a substance use disorder. (b) “Outpatient Substance Use Disorder Services ASAM Level of Care 1” means organized services delivered in a variety of settings and include a vast array of outpatient services and supports, which are tailored to the severity and function of the individual and typically are less than 9 contact hours per week. ASAM Level 1 programs enhance access to care and facilitate earlier engagement into treatment. Services and supports address major lifestyle, attitudinal and behavioral issues related to the substance use that detract from progress towards service plan goals. (c) “Intensive Outpatient Substance Use Disorder Services ASAM Level of Care 2.1” means structured services and supports, mostly comprised of counseling and education. Mental health services are either offered by the program or tightly coordinated with a community provided. When planning a transition to ASAM Level 1 services, a program may provide less than the minimum number of contact hours for up to two weeks: 9 for adults and 6 for children. (d) “Partial Hospitalization Services ASAM Level of Care 2.5” means clinically intensive programming of 20 contact hours or more per week, which is specified by the service plan. Needs identified in Dimensions 1, 2 and 3 warrant daily monitoring or management within an outpatient or combined in a residential setting. Programs staff interdisciplinary teams and offer intensive case management. Psychiatric and medical services are either offered by the program or coordinated. (15) “ASAM Risk Assessment Component” means the portions of a substance use disorders assessment that include an Immediate Need Profile and a rating of severity for each of the ASAM dimensions in a multidimensional assessment, which inform the Level of Care placement decision and the services and supports included in the service plan. (16) “ASAM Service Types” means the ASAM Levels of Care, Co-occurring Capable services, Co-occurring Enhanced services, and any other defined service that is described in The ASAM Criteria and when approved, included within the certificate. (17) “Assertive Community Treatment (ACT)” means an evidence-based practice designed to provide comprehensive treatment and support services to individuals with serious and persistent mental illness. ACT is intended to serve individuals who have severe functional impairments and who have not responded to traditional psychiatric outpatient treatment. ACT services are provided by a single multi-disciplinary team, which typically includes a psychiatrist, a nurse, and at least two case managers and are designed to meet the needs of each individual and to help keep the individual in the community and out of a structured service setting, such as residential or hospital care. ACT is characterized by the following: (a) Low client to staff ratios; (b) Providing services in the community rather than in the office; (c) Shared caseloads among team members; (d) Twenty-four-hour staff availability; (e) Direct provision of all services by the team (rather than referring individuals to other agencies); and (f) Time-unlimited services. (18) “Assessment” means the process of obtaining sufficient information through a face-to-face interview to determine a diagnosis and to plan individualized services and supports. For outpatient substance use disorders services, the assessment is multi-dimensional and consistent with The ASAM Criteria third edition. (19) “Authority” means the Oregon Health Authority. (20) “Baseline evaluation” means an identification of the current status that an individual expresses a desire to change in order to identify the starting point(s) for measuring progress by using pre-determined benchmarks, such as a Likert Scale. Progress can then be determined by using the same benchmarks to obtain additional ratings of the identified status and using the additional ratings to make comparisons between the starting rating and subsequent ratings, from which a measure of change can be assessed. (21) “Behavioral health clinician” means a practitioner of behavioral health services whose authorized scope of practice includes substance use and mental health diagnosis and treatment. (22) “Behavioral Health Treatment” means treatment for mental health, substance use disorders, and problem gambling. (23) "Behavior Support Plan" means the individualized proactive support strategies used to support positive behavior. (24) “Behavior Support Strategies” means proactive supports designed to replace challenging behavior with functional, positive behavior. The strategies address environmental, social, neuro-developmental, and physical factors that affect behavior. (25) “Best Practice Risk Assessment” has the meaning given that term in OAR 309-023-0110. (26) “Board Registered Associate or Board Registered Intern” means a post-graduate who is listed as active on the applicable Oregon Board registry with one of the following qualifications: (a) Psychologist Associate Residents as described in OAR 858-010-0037; (b) Licensed Psychologist Associate under continued supervision as described in OAR 858-010-0038; (c) Licensed Professional Counselor intern or Marriage and Family Therapist intern registered with the Oregon Board of Licensed Professional Counselors and Therapists as described in OAR 833-050-0011; (d) Certificate of Clinical Social Work Associate issued by the Oregon Board of Licensed Social Workers as described in OAR 877-020-0009; or (e) Registered Bachelor of Social Work issued by the Oregon Board of Licensed Social Workers as described in OAR 877-015-0105. (27) “Brief Intervention” means an early intervention for individuals using substances, by utilizing tribal-based, evidence-based, or culturally based practice designed to engage and motivate individuals at risk of substance use disorder and related health problems to seek services and/or support. Brief interventions can also be used to encourage those with more serious dependence or disorders to accept more intensive treatment. Brief interventions are intended to address problematic or risky substance use that presents with or without a previous diagnosis. (28) “Care Coordination” means a process-oriented activity to facilitate ongoing communication and collaboration to meet multiple needs. Care coordination includes facilitating communication between the person or family served, the family, natural supports, community resources, and involved providers and agencies; organizing, facilitating, and participating in team meetings; and providing for continuity of care by creating linkages to and managing transitions between levels of care and transitions for young adults in transition to adult services. (29) "Case Management" or “Targeted Case Management” means the services provided to assist individuals who reside in a community setting or are transitioning to a community setting in gaining access to desired medical, social, educational, entitlement, and other applicable services. (30) “Certificate of Approval” means the document issued by the Authority that identifies and declares certification of a provider pursuant to OAR chapter 309, division 008. (31) “Chief Officer” means the Chief Health Systems Officer of the Division or designee. (32) "Child" means an individual under the age of 18. An individual with Medicaid eligibility who needs services specific to children, adolescents, or young adults in transition shall be considered a child until age 21 for purposes of these rules. (33) "Clinical Supervision" means oversight by a qualified clinical supervisor of the rendering of physical health, substance use, problem gambling, and mental health services and supports, according to these rules, including ongoing evaluation and improvement of the effectiveness of those services and supports. (34) "Clinical Supervisor" means program staff qualified to oversee and evaluate the rendering of physical health, substance use, problem gambling, or mental health services and supports. (35) "Cognition" refers to how the individual is able to use information, make decisions, and ensure their daily needs are met. There are four components to cognition: self-preservation, decision-making, ability to make one’s self understood, and unsafe behaviors. (36) “Cognitive Ability” means a general mental capability involving reasoning, problem solving, planning, abstract thinking, complex idea comprehension and learning from experience. (37) “Cognitive Impairment” means a behavioral health condition or disability which impacts the individual’s cognitive abilities to perform Activities of Daily Living (ADL) or Instrumental Activities of Daily Living (IADL), regardless of whether the individual may be physically capable of performing ADLs or IADLs. For example, a cognitive impairment could prevent an individual from knowing when or how to carry out the task. (38) “Collaborative Educational Agreement” means an individualized written arrangement between an accredited college or university and a Division-certified provider pertaining to a student’s internship or field placement experience. (39) “Co-occurring Capable Substance Use Disorder Programs” means, consistent with The ASAM Criteria, arrangements are in place for coordination and collaboration between addiction and mental health services, internally and with external community partners. Program staff must be trained and qualified to address the interaction between mental health symptoms or conditions and the substance use disorder, and the interactional effect on readiness to change, the severity of risk and the subsequent planning of services and supports. (40) “Co-occurring Enhanced Substance Use Disorder Programs” means, consistent with The ASAM Criteria, Third edition, a setting where integrated services address concurrently unstable mental health and substance use disorder conditions. There is a focus on the integration of mental health and substance use disorders throughout the staffing, services, and program content, as well as the use of Motivational Enhancement therapies throughout services. (41) “Co-occurring Substance Use, Problem Gambling, and Mental Health Disorders (COD)” means the existence of a diagnosis for a substance use disorder, problem gambling disorder, and/or a mental health disorder. (42) “Community Health Worker (CHW)” means a person who meets qualification criteria adopted by the authority under ORS 414.665 and who is certified pursuant to the requirements in OAR 410-180-0310. (43) "Community Mental Health Program (CMHP)" an entity that is responsible for planning and delivery of safety net services for persons with mental or emotional disturbances, drug abuse problems, and alcoholism and alcohol abuse in a specific geographic area of the state under a contract with the Division or a local mental health authority and pursuant to OAR Chapter 309, Division 014. (44) "Conditional Release" means placement by a court or the Psychiatric Security Review Board (PSRB) of an individual found eligible under ORS 161.327 or 161.336 for supervision and treatment in a community setting. (45) “Consistent with ASAM Criteria” means a documented intervention containing information that demonstrates use of and adherence to the description of components contained within The ASAM Criteria, Third Edition. (46) “Coordinated Care Organization (CCO)” means a corporation, governmental agency, public corporation, or other legal entity that is certified as meeting the criteria adopted by the Authority under ORS 414.625 to be accountable for care management and to provide integrated and coordinated health care for each of the organization’s members. (47) "Court" means a criminal court, drug court, circuit court, juvenile court or last convicting or ruling court in this state with jurisdiction over the individual. (48) "Criminal Records Check" means documenting the criminal background check results for all employees, contracted staff, interns and volunteers considered to be program staff that render medical or behavioral health services and supports or have access to protected health information such as service records or billing information. (49) "Crisis" means either an actual or perceived urgent or emergent situation that occurs when an individual’s stability or functioning is disrupted, and there is an immediate need to resolve the situation to prevent a serious deterioration in the individual’s mental or physical health or to prevent referral to a significantly higher level of care or death. (50) “Crisis Intervention” has the meaning given that term in OAR 309-023-0110. (51) “Crisis Line Services” means phone-based services that establish immediate communication links and provide supportive interventions and information for individuals in an urgent or emergent situation. (52) “Crisis Plan” means an individualized document designed in collaboration with the individual served to help anticipate and prevent future crisis episodes and direct interventions in the instance of a crisis. (53) “Crisis Stabilization Services” means providing evaluation and treatment to individuals experiencing a crisis. Crisis Services may be provided prior to completion of an intake. These services are intended to stabilize the individual in crisis, prevent further deterioration, and provide immediate treatment and intervention in a location best suited to meet the needs of the individual and in the least restrictive environment available. (54) "Cultural Competence" means the process by which people and systems respond respectfully and effectively to people of all cultures, languages, classes, races, ethnic backgrounds, disabilities, religions, genders, sexual orientations, and other diversity factors in a manner that recognizes, affirms, and values the worth of individuals, families, and communities and protects and preserves the dignity of each. (55) “Culturally Responsive” means services that are respectful of and relevant to the beliefs, practices, culture and linguistic needs of diverse consumer/client populations and communities whose members identify as having particular cultural or linguistic affiliations. Cultural responsiveness describes the capacity to respond to the issues of diverse communities and requires knowledge and capacity at different levels of intervention: systemic, organizational, professional, and individual. (56) “Culturally Specific Program” means a program designed to meet the unique service needs of a specific culture and that provides services to a majority of individuals representing that culture. (57) "Declaration for Mental Health Treatment" means a written statement of an individual’s preferences concerning their mental health treatment. The declaration is made when the individual is able to understand and legally make decisions related to such treatment. It is honored, as clinically appropriate, in the event the individual becomes unable to make such decisions. (58) "Diagnosis" means the principal mental health, substance use, or problem gambling diagnosis listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5-TR). The diagnosis is determined through the assessment and any examinations, tests, or consultations suggested by the assessment and are medically necessary reason for services. (59) “Division” means the Health Systems Division of the Oregon Health Authority, or its designee. (60) “Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5-TR)” means the textbook used to diagnose and classify mental disorders that is published by the American Psychiatric Association. (61) “Driving Under the Influence of Intoxicants (DUII) Substance Use Disorders Rehabilitation Program” means a program of treatment and therapeutically oriented education services for an individual who is either: (a) A violator of ORS 813.010 (Driving Under the Influence of Intoxicants); or (b) A defendant participating in a diversion agreement under ORS 813.200. (62) “Emergent” means the onset of symptoms requiring attention within 24 hours to prevent serious deterioration in mental or physical health or threat to safety. (63) “Employment Support Services” means services approved by Division, determined to be necessary and provided to an individual to obtain and maintain employment in the community as they are transitioning from an inpatient or residential facility that provides substance use disorder treatment. (64) “Enhanced Care Services (ECS)” and “Enhanced Care Outreach Services (ECOS)” means intensive behavioral and rehabilitative mental health services to eligible individuals who reside in Aging and People with Disabilities (APD) licensed homes or facilities. (65) “Entry” means the act or process of acceptance and enrollment into services regulated by this rule. (66) “Face to Face” means a personal interaction where both words can be heard and facial expressions can be seen in person or through telehealth services where there is a live streaming audio and video, if clinically appropriate. (67) "Family" means the biological or legal parents, siblings, other relatives, foster parents, legal guardians, spouse, domestic partner, caregivers, and other primary relations to the individual whether by blood, adoption, or legal or social relationships. Family also means any natural, formal, or informal support persons identified as important by the individual. (68) "Family Support" means the provision of peer-delivered services to people defined as family to the individual. It includes support to caregivers at community meetings, assistance to families in system navigation and managing multiple appointments, supportive home visits, peer support, parent mentoring and coaching, advocacy, and furthering efforts to develop natural and informal community supports. (69) “Gender Identity” means an individual's self-identification of gender without regard to legal or biological identification including but not limited to individuals identifying themselves as male, female, transgender, gender transitioning and transitioned, non-binary, intersex, and gender diverse. (70) “Gender Expression” means the external characteristics and behaviors that are socially defined as masculine, feminine, or androgynous such as dress, mannerisms, speech patterns, and social interactions. (71) "Geographic Service Area" means the geographic area within the county boundaries in which the CMHP operates. (72) "Grievance" means a formal complaint submitted to a provider verbally or in writing by an individual or the individual’s representative. (73) "Guardian" means an individual appointed by a court of law to act as guardian of a minor or a legally incapacitated individual. Guardian may also mean legal representative. (74) “Health Insurance Portability and Accountability Act (HIPAA)” means the federal Health Insurance Portability and Accountability Act of 1996 and the regulations published in Title 45, parts 160 and 164, of the Code of Federal Regulations (CFR). (75) “Health Systems Services and Supports” means all services and supports including but not limited to Outpatient Community Mental Health Services and Supports for Children and Adults, Intensive Treatment Services for Children, Outpatient and Residential Substance Use Disorders Treatment Services, and Outpatient and Residential Problem Gambling Treatment Services. (76) “Housing Support Services” means services approved by Division, provided to an individual to obtain and reside in an independent community setting and are tailored to the goal of maintaining an individual’s personal health and welfare in a home and community-based setting as they are transitioning from an inpatient or residential facility that provides substance use disorder treatment. (77) “Immediate Need Profile” means the portion of an assessment that includes the identification of the most severe and destabilizing or life-threatening conditions, in order to inform the determination of the level of risk, the level of care placement and need for immediate intervention(s). (78) “Incident” means any event involving an individual or child of an individual receiving services occurring on the premises of the program or involving program staff or any individual occurring on the premises of the program, or during a Service Plan activity and including but not limited to death, injury, major illness, accident, act of physical aggression, medication error, suspected abuse or neglect, or any other type unusual or critical event that presents a risk to health and safety of any persons. Critical incidents are reported to the Division. (79) “Incident Report” means a written description of any incident. (80) “Institutions of Mental Disease (IMD)” means a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, which includes substance use disorders (SUDs). (81) “Individual” means any individual being considered for or receiving services and supports regulated by these rules. (82) "Informed Consent for Services" means that the service options, risks and benefits have been explained to the individual and guardian, if applicable, in a manner that they comprehend, and the individual and guardian, if applicable, have consented to the services on, or prior to, the first date of service. (83) “Institution” means an establishment that furnishes (in single or multiple facilities) food, shelter, and some treatment or services to four or more persons unrelated to the proprietor. (84) “Intensive In-Home Behavioral Health Treatment (IIBHT) for Children” means an intensive, community-based level of care for youth ages 0-20 years with complex mental health needs who are at risk for an out of home placement or who are stepping down from a higher level of care. IIBHT includes access to an array of services including individual and family therapy, case management, psychiatric services, skills training, peer-delivered services, and proactive 24 hours 7 days a week crisis response. A Certificate of Approval from the Oregon Health Authority is required to render IIBHT services to eligible youth and families. For the purposes of IIBHT, “in home” means services delivered in the home, school, or other community setting, as specified by the individual and family. (85) “Intensive Outpatient Services and Supports (IOSS)” means a specialized set of comprehensive in-home and community-based supports and mental health treatment services for children that are developed by the child and family team and delivered in the most integrated setting in the community. (86) “Interdisciplinary Team (IDT)” means a group of program staff that have primary responsibility for the development of a Service Plan for an individual receiving services. (87) “Interim Referral and Information Services” means services provided by a substance use disorders treatment provider to individuals on a waiting list and whose services are funded by the Substance Use, Prevention, Treatment and Recovery (SUPTR) block grant to reduce the adverse health effects of substance use, promote the health of the individual, and reduce the risk of disease transmission. (88) “Juvenile Psychiatric Security Review Board (JPSRB)” means the entity described in ORS 161.385. (89) “Legal Representative” means a person who has been legally designated by court order to make financial or health care decisions for another individual. The legal representative only has authority to act within the scope and limits of the legal representative’s authority as designated by the court or other agreement. Legal representatives acting outside of the legal representative’s authority or scope shall meet the definition of authorized representative. (90) "Level of Care" means the type, frequency, and duration of medically necessary services provided from the most integrated setting to the most restrictive and intensive inpatient setting (91) "Licensed Health Care Professional" means a practitioner of the healing arts acting within the scope of their practice under State law who is licensed by a recognized governing board in Oregon. (92) "Licensed Medical Practitioner (LMP)” means a person who meets the following minimum qualifications as documented by the Local Mental Health Authority (LMHA) or designee: (a) Physician licensed to practice in the State of Oregon; (b) Nurse practitioner licensed to practice in the State of Oregon; or (c) Physician's assistant licensed to practice in the State of Oregon; (d) Whose training, experience, and competence demonstrate the ability to conduct a medical exam, a mental health assessment and provide medication management; and (e) For IOSS and ITS providers, a Board-Certified or Child and Adolescent Psychiatrist licensed to practice in the State of Oregon or a Psychiatric Nurse Practitioner under the consultation of a board-certified or board-eligible child and adolescent psychiatrist licensed to practice in the State of Oregon. (93) “Linkage agreement” has the meaning given that term in OAR 309-032-0860. (94) “Local Mental Health Authority (LMHA)” means one of the following entities: (a) The board of county commissioners of one or more counties that establishes or operates a CMHP; (b) The tribal council in the case of a federally recognized tribe of Native Americans that elects to enter into an agreement to provide mental health services; or (c) A regional local mental health authority composed of two or more boards of county commissioners. (95) "Mandatory Reporter" means anyone required by law, as defined in ORS 419B.005 or 430.735, who is required to report suspected abuse or neglect of a child, elderly person, or other adult as required by law in ORS 430.765, or ORS 419B.010, or ORS 124.060. (96) "Medicaid" means the federal grant-in-aid program to state governments to provide medical assistance to eligible individuals under Title XIX of the Social Security Act. (97) "Medical Director" means a physician licensed to practice medicine in the State of Oregon and is designated by a substance use disorders treatment program to be responsible for the program's medical services, either as an employee or through a contract. (98) “Medical Treatment Staff” means medical personnel directly responsible for the delivery or oversight of client care and treatment, and who are properly trained, educated, and credentialed to deliver withdrawal management and substance use disorders services. (99) “Medically Necessary” means health services and items that are required for an individual to address one or more of the following: (a) The prevention, diagnosis, or treatment of an individual’s condition or disorder that results in behavioral health impairments; or (b) The ability for a client or member to achieve age-appropriate growth and development; and (c) A medically necessary service must also be medically appropriate. (100) “Medication Assisted Treatment (MAT)” means the use of medication in combination with counseling and behavioral therapies for the treatment of substance use disorders. (101) “Mental Health Intern” means program staff who meet qualifications for QMHA and are currently enrolled in a graduate program approved by the Division-approved certification or licensing body but does not have the necessary graduate degree in psychology, social work, or related field of behavioral science, or have an equivalent degree as determined by the Division-approved certification or licensing body. The program staff shall: (a) Be enrolled in a graduate program that will result in a degree in psychology, social work, or related field of behavioral science, or an equivalent degree as evidenced by providing transcripts indicating applicable coursework meeting the required competencies and approved by the OHA-approved certification or licensing body; (b) Have a collaborative educational agreement between the Division-certified provider and the graduate program for the student; and (c) Work under the direct and active supervision of a qualified supervisor employed or contracted by the provider of services, within the scope of practice and competencies identified by the collaborative educational agreement, and within the policies and procedures for the credentialing of program staff as established by the provider. (102) "Mobile Crisis Services" means mental health services for individuals in crisis provided by mental health practitioners who respond to behavioral health crises onsite at the location in the community where the crisis arises and who provide a face-to-face therapeutic response. The goal of mobile crisis services is to help an individual resolve a psychiatric crisis in the most integrated setting possible and to avoid unnecessary hospitalization, inpatient psychiatric treatment, involuntary commitment, and arrest or incarceration. (103) "Mobile Crisis Response Time" means the time from the point when a professional decision is made that a face-to-face intervention is required to the time the actual face-to-face intervention takes place in the community. (104) “Mobility” means assisting the individual with mobility, transfers and repositioning including turning or adjusting padding for physical comfort or pressure relief and encouraging or assisting with range of motion exercises and the use of devises that assist with mobility. (105) “Motivational Enhancement Therapy” (MET) means a person-centered approach to therapy that focuses on improving an individual's motivation to change. (106) “Motivational Therapies” means evidence-based interventions for people experiencing substance use disorder, such as motivational interviewing, cognitive behavioral therapy, and motivational enhancement therapy. (107) “Non-Institutions of Mental Disease (non-IMD)” means a hospital, nursing facility, or other institution with less than 16 beds that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, which includes substance use disorders (SUDs). (108) “Non-Medicaid Service Data” means data collected through the mandated state data system regarding services paid for by any source other than Medicaid and includes, but is not limited to: (a) Diagnosis; (b) Date of service; (c) Place of service; (d) Procedure code; (e) Modifier; (f) Number of service units; and (g) Billed charges. (109) “Nursing Services” means services that are provided by a registered nurse (RN) or a licensed practical nurse (LPN) within the scope of practice as defined in OAR chapter 851 division 045. (110) “Outpatient Problem Gambling Treatment Services” means all outpatient treatment services and supports provided to individuals with gambling related problems and their families. (111) "Outreach" means the delivery of behavioral health services, referral services, and case management services in non-traditional settings including but not limited to the individual's residence, shelters, streets, jails, transitional housing sites, drop-in centers, single room occupancy hotels, child welfare settings, educational settings, or medical settings. It also means attempts made to engage or re-engage an individual in services by such means as letters or telephone calls. (112) “Partial Hospitalization or Day Treatment Substance Use Disorder (SUD) Services ASAM Level 2.5” means a planned, structured array of services and supports, consistent with The ASAM Criteria for Level of Care 2.5, that offer 20 or more therapeutic contact hours of high intensity treatment per week. Contact is in a less restrictive level of care than residential SUD treatment, 24-hour care is not required. (113) “Peer” means program staff supporting an individual or the individual's family member who has similar life experience, either as a current or former recipient of mental health or substance use, problem gambling, or mental health services, or as a family member of an individual who is a current or former recipient of substance use, problem gambling, or mental health services. (114) “Peer-Delivered Services” are community-based services and supports provided by peers, peer support specialists, and peer wellness specialists to individuals or family members with similar lived experience. These services are intended to support individuals and families to engage individuals in ongoing treatment and to live successfully in the community. (115) “Peer-Delivered Services Supervisor" means qualified program staff, with at least one year of experience as a PSS or PWS in behavioral health services, who is responsible for evaluating and guiding PSS and PWS program staff in the delivery of peer-delivered services and supports. (116) “Peer Support Specialist (PSS)” means a qualified program staff providing peer-delivered services to an individual or family member with similar life experience under the supervision of a qualified clinical supervisor and a qualified peer-delivered services supervisor as resources are made available. (117) “Peer Support and Peer Wellness Specialist Supervision" means supervision by a qualified clinical supervisor and a qualified peer-delivered services supervisor as resources are available. The supports provided include guidance in the unique discipline of peer-delivered services and the roles of peer support specialists and peer wellness specialists. (118) “Peer Wellness Specialist (PWS)” means s program staff who supports an individual in identifying behavioral health service and support needs through community outreach, assisting individuals with access to available services and resources, addressing barriers to services, and providing education and information about available resources and behavioral health issues in order to reduce stigma and discrimination toward consumers of behavioral health services and to provide direct services to assist individuals in creating and maintaining recovery, health, and wellness under the supervision of a qualified clinical supervisor and a qualified peer-delivered services supervisor as resources are made available. (119) “Pre-engagement Services” means services delivered prior to completion of an assessment, service plan, and/or commencement of formal treatment in order to engage high risk/high need individuals in ongoing treatment services and to avoid crisis events and higher levels of care. (120) “Problem Gambling Approved Certification Consultant” means individual who is a Certified Gambling Addiction Counselor, level II (CGACII) for a minimum of two years and has a minimum of 12 hours of clinical supervision education. The purpose of the position is to provide consultation for CGAC candidates on 1) Fundamentals of Problem Gambling Treatment case conceptualization 2) the process and requirements of earning certification as a CGAC. This is a Mental Health and Addiction Certification Board of Oregon (MHACBO) distinction. (121) “Problem Gambling Treatment Staff” means program staff certified or licensed by a Division recognized credentialing body to provide problem gambling treatment services that include assessment, development of a Service Plan, group and family counseling. (122) "Program" means an organized system of services and supports delivered by a provider designed to address the treatment needs of individuals and families. (123) "Program Administrator" or "Program Director" means program staff with appropriate professional qualifications and experience who is designated to manage the operation of a program. (124) "Program Staff" means personnel who renders a clinical service or support. Program staff could include, for example, be an employee, contractor, intern, or volunteer who is rendering or assisting with rendering clinical services or supports. (125) “Provider” means an organizational entity or qualified person that is certified or licensed by the Division for the direct delivery of substance use, problem gambling, or mental health services and supports. (126) "Psychiatric Security Review Board (PSRB)" means the entity described in ORS 161.295 through 161.400. (127) Psychiatrist" means a physician licensed by the Oregon Medical Board and who has completed an approved residency training program in psychiatry. (128) "Psychologist" means a person who is currently licensed to practice psychology by the Oregon Board of Psychology. (129) “Publicly Funded” means financial support, in part or in full, with revenue generated by a local, state, or federal government. (130) "Qualified Mental Health Associate (QMHA)” means mental health program staff delivering services under the direct supervision of a QMHP who meets the minimum qualifications as authorized by the LMHA or designee and specified in OAR 309-019-0125. (131) "Qualified Mental Health Professional (QMHP)" means mental health program staff LMP or any other program staff meeting the minimum qualifications as authorized by the LMHA or designee and specified in OAR 309-019-0125. (132) "Qualified Person" means program staff who is a QMHP or a QMHA and is identified by the PSRB and JPSRB in its Conditional Release Order. This individual is designated by the provider to deliver or arrange and monitor the provision of the reports and services required by the Conditional Release Order. (133) "Quality Assessment and Performance Improvement" means the structured, internal monitoring and evaluation of services to improve processes, service delivery, and service outcomes. (134) “Recovery” means a process of healing and transformation for an individual to achieve their full human potential and personhood in leading a meaningful life as they define it in communities of their choice. (135) "Representative" means someone who acts on behalf of an individual at the individual’s request with respect to a grievance including but not limited to a relative, friend, Division employee, attorney, or legal guardian. (136) “Resilience” means the universal capacity that an individual uses to prevent, minimize, or overcome the effects of adversity. Resilience reflects an individual’s strengths as protective factors and assets for positive development. (137) "Respite Care" means planned and emergency supports designed to provide temporary relief from care giving to maintain a stable and safe living environment. Respite care may be provided in or out of the home. Respite care includes supervision and behavior support consistent with the strategies specified in the service plan. (138) "Risk Assessment" means an evaluation of the level or severity of risk the individual is experiencing and how each interact, resulting in an overall risk assessment rating. (139) “Safety Plan” means a best practice, research-based, individualized and directive document developed through a collaborative process in which the provider assists the individual in listing actions to use when self-harm, harm to others or suicide ideation is elevated or following suicidal behavior. (140) "Screening" means the process to determine whether the individual needs further assessment to identify circumstances requiring referrals or additional services and supports. (141) “Screening Specialist” means a person who possesses valid certification issued by the Division to conduct DUII evaluations. (142) "Service Plan" means a comprehensive plan for services and supports provided to or coordinated for an individual and their family, as applicable, that is reflective of the assessment and the intended outcomes of service. (143) “Service Note” means the written record of services and supports provided, including documentation of progress toward intended outcomes consistent with the timelines stated in the service plan. (144) “Service Record” means the written or electronic documentation regarding an individual and resulting from entry into services, assessment, orientation, services and supports planning, services and supports provided, and transfer. (145) "Services" means those activities and treatments described in the service plan and rendered, that are intended to support the individual's transition to recovery from a substance use disorder, problem gambling disorder, or mental health condition and to promote resiliency and rehabilitative and functional individual and family’s desired outcomes. (146) “Signature” means any written or electronic means of entering the name, date of authentication, and credentials of the program staff providing a specific service or the individual authorizing services and supports. Signature also means any written or electronic means of entering the name and date of authentication of the individual, guardian, or any authorized representative of the individual receiving services. (147) "Skills Training" or “Skills Restoration" means providing information and training to individuals and families designed to assist with the development of skills in areas including but not limited to anger management, stress reduction, conflict resolution, self-esteem, parent-child interactions, personal relationships, drug and alcohol awareness, behavior support, symptom management, accessing community services, and daily living. (148) “Stabilization” means the application of medical and psychosocial services and supports and in a manner that results in the reduction of symptomology and increase in skill level to support and redirect patients to the most appropriate and least restrictive setting. Services are directed at restoring patient’s ability to maintain safety while enhancing their recovery, so they can successfully reintegrate into identified community settings. (149) “Status Data” means data collected through the mandated state data system and includes, but is not limited to: (a) Initial admission, diagnostic, and demographics data; (b) Updates and changes as needed through the individual’s enrollment in services; and (c) Discharge or other discontinuation of services. (150) “Student Intern” or “Intern” means a program staff who provides a paid or unpaid program service and does not qualify as a Mental Health Intern. (151) "Substance Use, Prevention, Treatment and Recovery Block Grant” or “SUPTR Block Grant” or “SUPTR” means the federal block grants for prevention and treatment of substance abuse under Public Law 102-321 (31 U.S.C. 7301-7305) and the regulations published in Title 45 Part 96 of the Code of Federal Regulations. (152) "Substance Use Disorders (SUDs)" as defined in DSM-5-TR, means disorders related to the taking of a drug of abuse including alcohol, the side effects of a medication, or a toxin exposure. The disorders include substance use disorders and substance-induced disorders, which include substance intoxication and withdrawal, and substance-related disorders such as delirium, neuro-cognitive disorders, and substance-induced psychotic disorder. (153) “Substance Use Disorders Treatment and Recovery Services” means outpatient, intensive outpatient, and residential services and supports for individuals with substance use disorders. (154) “Substance Use Disorders Treatment Staff” means one type of program staff certified by a Division-approved certification body to render substance use disorders treatment services. (155) “Subsyndromal symptomology” means the individual demonstrates or complains of symptoms, suggesting a particular disorder or condition, that do not meet the threshold of the defined criteria for that disorder or condition, and so a diagnosis of that disorder or condition cannot be assigned. (156) “Successful DUII Completion” means that the DUII program has documented in its records that for the period of service deemed necessary by the program, the individual has: (a) Met the completion criteria approved by the Division; (b) Met the terms of the fee agreement between the provider and the individual; and (c) Demonstrated 90 days of continuous abstinence prior to completion. (157) “Suicide Risk Assessment” means a comprehensive evaluation, usually performed by a clinician, to evaluate suspected suicide risk in an individual, estimate the immediate danger, and decide on a course of treatment. May also be called Risk Assessment. (158) “Suicide Screening” means a procedure in which a validated tool, or protocol is used to identify individuals who may be at risk for suicide. (159) “Supports” means activities, referrals, and supportive relationships designed to enhance the services delivered to individuals and families for the purpose of facilitating progress toward intended outcomes. (160) “Transfer” means the process of assisting an individual to transition from the current services to the next identified setting or ASAM level of care. (161) “Transitioning” means a 90-day period which begins when an individual is discharged from an inpatient or residential stay back to a community setting. (162) “Trauma Informed Services” means services that reflect the consideration and evaluation of the role that trauma plays in the lives of people seeking mental health, substance use, or problem gambling services, including recognition of the traumatic effect of misdiagnosis and coercive treatment. Services are responsive to the vulnerabilities of trauma survivors and are delivered in a way that avoids inadvertent re-traumatization and facilitates individual direction of services. (163) "Treatment" means the planned, individualized program of medical, psychological, and rehabilitative procedures, experiences, and activities designed to remediate symptoms of a DSM-5-TR diagnosis. (164) “Triage” means a classification process to determine priority needs. (165) "Urinalysis Test" means a sensitive, rapid, and inexpensive immunoassay screen that identifies the presence of a specific drug or metabolite in a urine specimen to eliminate "true negative" specimens from further consideration. (166) "Urgent" means the onset of symptoms requiring attention within 24 hours to prevent a serious deterioration in an individual's mental or physical health or threat to safety. (167) "Variance" means an exception from a provision of these rules granted in writing by the Division pursuant to the process regulated by OAR 309-008-1600 upon written application from the provider. Approval and duration of a variance is determined on a case-by-case basis. (168) "Volunteer" means a person who performs a service willingly and without pay. (169) “Warm Handoff” has the meaning given that term in OAR 309-032-0860. (170) “Wellness” means an approach to healthcare that emphasizes good physical and mental health, preventing illness, and prolonging life. (171) “Wraparound” means a high-fidelity model of team-based intensive care coordination for children and their families based on National Wraparound Initiative values and principles. (172) “Young Adult in Transition” means an individual who is developmentally transitioning into independence, sometime between the ages of 14 and 25. Statutory/Other Authority: ORS 161.390, 413.042, 430.256 & 430.640 Statutes/Other Implemented: ORS 161.390 - 161.400, 428.205 - 270, 430.010, 430.205- 430.210, 430.254 - 430.640, 430.850 - 430.955, 743A.168 & 414.665 History: BHS 12-2023, amend filed 05/16/2023, effective 05/16/2023 BHS 11-2023, amend filed 04/07/2023, effective 04/07/2023 BHS 27-2022, amend filed 12/20/2022, effective 12/20/2022 BHS 1-2022, amend filed 01/05/2022, effective 01/05/2022 BHS 11-2021, amend filed 06/16/2021, effective 06/16/2021 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16 MHS 4-2014, f. & cert. ef. 2-3-14 MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14 309-019-0110 Provider Policies (1) All providers shall develop and implement written service delivery policies and specific procedures for office-based, community-based and telehealth services and supports compliant with these rules, to be made available to individuals and family members upon request, and shall include, at a minimum, the following: (a) Personnel qualifications, credentialing, and training; (b) Mandatory abuse reporting compliant with ORS 430.735 - 430.768 and OAR chapter 943, division 45; (c) Criminal Records Checks that address program and volunteer staff, compliant with ORS 181.533 through 181.575 and OAR 943-007-0001 through 0501, where applicable; (d) Fraud, waste, and abuse in federal Medicaid and Medicare programs compliant with OAR 410-120-1380 and 410-120-1510; (e) Alcohol, Drug and Gambling Free Workplace; (f) Fee agreements; (g) Confidentiality and compliance with HIPAA, Federal Confidentiality Regulations (42 CFR, Part 2), and state confidentiality regulations as specified in ORS 179.505 and 192.518 through 192.530; (h) Compliance with Title 2 of the Americans with Disabilities Act of 1990 (ADA); (i) Per ORS 413.046 ; Grievances and appeals, including an example grievance form; (j) Individual rights; (k) Quality assessment and performance improvement; (l) Trauma informed service delivery consistent with the Division Trauma Informed Services Policy; (m) Provision of culturally and linguistically appropriate services; (n) Crisis prevention and response; (o) Incident reporting; (p) Peer delivered services; (q) Prevention of communicable disease transmission; (r) Emergency evacuation; (s) Delivery of substance use disorders treatment services and supports consistent with The ASAM Criteria for each certified level of care; (t) Code of conduct that includes professional boundaries and ethics; (u) Referral, Care Coordination and Transfer of Services (v) Medical Protocols consistent with these rules; and (w) Urinalysis Testing. (x) Opportunity for individuals over the age of 18 to declare advanced directive for their mental health treatment. (y) Opportunity for individuals over the age of 18 to register to vote by making voter registration cards available. (z) Quality Assurance Review process overseen and approved by designated Clinical Supervisor that includes, at minimum, quarterly review of; (A) A pre-determined number of service plans for participants newly admitted to the program; (B) A pre-determined number of service plans for participants engaged in services for more than one year; and (C) A pre-determined number of assessments and other documentation demonstrating a medically necessary reason for services. (2) All written service delivery policies and specific procedures shall prohibit the following: (a) Psychological and physical abuse of an individual; (b) Seclusion, personal restraint, mechanical restraint, and chemical restraint; (c) Withholding shelter, regular meals, medication, clothing, or supports for physical functioning; (d) Discipline of one individual receiving services by another; and (e) Titration of medications prescribed for the treatment of opioid dependence as a condition of receiving or continuing to receive treatment. (3) Providers of Enhanced Care Services (ECS) services shall develop behavior support policies consistent with OAR 309-019-0155(3). (4) Community Mental Health Programs shall develop policies for linkage agreements compliant with OAR 309-032-0870. Statutory/Other Authority: ORS 161.390, 413.042, 430.256 & 430.640 Statutes/Other Implemented: ORS 161.390 - 161.400, 179.505, 413.520 - 413.522, 428.205 - 428.270, 430.010, 430.205 - 430.210, 430.254 - 430.640, 430.850 - 430.955 & 743A.168 History: BHS 24-2024, amend filed 10/25/2024, effective 10/27/2024 BHS 11-2023, amend filed 04/07/2023, effective 04/07/2023 BHS 11-2021, amend filed 06/16/2021, effective 06/16/2021 BHS 8-2020, temporary amend filed 04/30/2020, effective 04/30/2020 through 10/26/2020 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16 MHS 4-2014, f. & cert. ef. 2-3-14 MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14 309-019-0115 Individual Rights (1) In addition to all applicable statutory and constitutional rights, every individual receiving services has the right to: (a) Choose from services and supports that are consistent with the assessment and service plan, culturally competent, provided in the most integrated setting in the community and under conditions that are least restrictive to the individual’s liberty, that are least intrusive to the individual, and that provide for the greatest degree of independence; (b) Be treated with dignity and respect; (c) Participate in the development of a written service plan, receive services consistent with that plan and participate in periodic review and reassessment of service and support needs, assist in the development of the plan, and receive a copy of the written service plan; (d) Have all services explained, including expected outcomes and possible risks; (e) Confidentiality and the right to consent to disclosure in accordance with ORS 107.154, 179.505, 179.507, 192.515, 192.507, 42 CFR Part 2 and 45 CFR Part 205.50; (f) Give informed consent in writing prior to the start of services, except in a medical emergency or as otherwise permitted by law. Minor children may give informed consent to services in the following circumstances: (A) Under age 18 and lawfully married; (B) Age 16 or older and legally emancipated by the court; or (C) Age 14 or older for outpatient services only. For purposes of informed consent, outpatient service does not include service provided in residential programs or in day or partial hospitalization programs. (g) Inspect their service record in accordance with ORS 179.505; (h) Refuse participation in experimentation; (i) Receive medication specific to the individual’s diagnosed clinical needs, including medications used to treat opioid dependence; (j) Receive prior notice of transfer, unless the circumstances necessitating transfer pose a threat to health and safety; (k) Be free from abuse or neglect and to report any incident of abuse or neglect without being subject to retaliation; (L) Have religious freedom; (m) Be free from seclusion and restraint; (n) Be informed at the start of services and periodically thereafter of the rights guaranteed by this rule; (o) Be informed of the policies and procedures, service agreements and fees applicable to the services provided, and to have a custodial parent, guardian, or representative assist with understanding any information presented; (p) Have family and guardian involvement in service planning and delivery; (q) Have an opportunity to make a declaration for mental health treatment, when legally an adult; (r) File grievances, including appealing decisions resulting from the grievance; (s) Exercise all rights set forth in ORS 109.610 through 109.697 if the individual is a child, as defined by these rules; (t) Exercise all rights set forth in ORS 426.385 if the individual is committed to the Authority; and (u) Exercise all rights described in this rule without any form of reprisal or punishment. (2) The provider shall give to the individual and, if appropriate, the guardian a document that describes the applicable individual’s rights as follows: (a) Information given to the individual shall be in written form or, upon request, in an alternative format or language appropriate to the individual’s need; (b) The rights and how to exercise them shall be explained to the individual, and if applicable the guardian; and (c) Individual rights shall be posted in writing in a common area. Statutory/Other Authority: ORS 161.390, 413.042, 430.256, 426.495, 430.640 & 443.450 Statutes/Other Implemented: ORS 109.675, 161.390 - 161.400, 179.505, 413.520 - 413.522, 426.380- 426.395, 426.490 - 426.500, 428.205 - 428.270, 430.010, 430.205 - 430.210, 430.254 - 430.640, 430.850 - 430.955, 443.400 - 443.460 & 743A.168 History: MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 MHS 4-2014, f. & cert. ef. 2-3-14 MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14 309-019-0125 Staff Qualifications Provider must ensure that staff in the following positions meet applicable qualifications, credentialing, and licensing /certification standards and competencies, including those set forth in these rules: (1) Program staff as identified in (21)(a-u) of this rule, providing treatment services and/ or supports in mental health treatment programs, substance use disorders treatment programs , or problem gambling treatment programs must be trained in and familiar with strategies for the delivery of trauma informed and culturally responsive treatment services and supports in compliance with the program’s respective policies . All treatment services and supports must be provided in a trauma informed and culturally responsive manner. All Program staff must meet one of the following: (a) Be licensed in Oregon by a Division recognized Oregon board: (A) Oregon Medical Board ; (B) Oregon Board of Nursing; (C) Oregon Board of Psychology; (D) Oregon Board of Licensed Professional Counselors and Therapists; (E) Oregon Board of Licensed Social Workers; (F) Oregon Occupational Therapy Licensing Board ; (b) Be an Associate registered by a Division recognized Oregon board as identified in (1)(D-E) of this rule and be physically present in Oregon at the time of providing services or supports. (c) Effective July 1, 2027, be under the outpatient (OAR 309, Division 019) certificate of approval (COA) if providing services to individuals under Medicaid; (d) Be credentialed by an OHA approved entity and (e) Be physically present in Oregon at the time of providing services or supports under the outpatient (OAR 309, Division 019) certificate; or. (f) Credentialed as a QMHP or a QMHA as identified in (14) or (15) of this rule, and credentialed by the specific OHA-certified behavioral health program the individual is employed by, consistent with the program’s policy, and be physically present in Oregon. (2) Program administrators and program directors must demonstrate competence in leadership, cultural responsiveness, program planning and budgeting, fiscal management, supervision of program staff, personnel management, program staff performance assessment, use of data, reporting, program evaluation, quality assurance, and developing and coordinating community resources. (3) Medical Directors must be licensed under ORS 677 or 685 and may perform health maintenance and restoration measures consistent with generally recognized and accepted principles of medicine, including but not limited to: (a) Administering, dispensing, or writing prescriptions for medications; (b) Recommending the use of specific and appropriate over-the-counter pharmaceuticals; (c) Ordering diagnostic tests; and (d) Perform tasks required by OAR 309-019-0200. (4) Clinical supervisors in all programs must demonstrate competence in leadership, cultural responsiveness, oversight and evaluation of services, staff development, assessment, person-centered treatment planning, case management and coordination, utilization of community resources; group, family, and individual therapy or counseling; documentation and rationale for services to promote intended outcomes; and implementation of all provider policies. (5) Clinical supervisors in mental health programs must meet , at a minimum, Qualified Mental Health Professional (QMHP) requirements and have completed two years equivalent of post-graduate clinical experience in a mental health treatment setting. All clinical supervisors must: (a) Be licensed in Oregon by a Division recognized Oregon board as identified in (1)( A- F ) of this rule: or (b) Be certified as a Qualified Mental Health Professional (QMHP) by an OHA approved entity, or per policy as described in (1)(d) of this rule, and be physically present in Oregon at the time of providing services or supports under the outpatient (OAR 309, Division 019) certificate. (6) Clinical supervisors in substance use disorders treatment programs must be : (a) Licensed in Oregon by a Division recognized Oregon board as identified in (1)( A- F) of this rule and be physically present in Oregon at the time of providing services, supports, and/or clinical supervision, under the outpatient (OAR 309, Division 019) certificate, or (b) Be certified by a Division approved entity and be physically present in Oregon at the time of providing services, supports, and/or clinical supervision, under the outpatient (OAR 309, Division 019) certificate. (c) For clinical supervisors holding a certification through an OHA approved entity in substance use disorder counseling, qualifications for the certification must have included at least: (A) 4000 hours of supervised experience in substance use counseling; (B) 300 contact hours of education and training in substance use related subjects; and (C) Successful completion of a professional psychometric examination by a an OHA approved entity. A substantively equivalent portfolio evaluation by an OHA approved entity may be accepted in lieu of a professional psychometric examination as approved by the Division. (d) Clinical supervisors not holding a certification in substance use disorder counseling must have a health or allied provider license. The license must have been issued in Oregon by a Division recognized Oregon board as identified in (1)(A-F) of this rule and the supervisor must possess documentation of at least 120 contact hours of academic or continuing professional education in the treatment of substance use disorders. (e) Additionally, clinical supervisors in substance use disorders programs must have one of the following qualifications: (A) Five years of paid full-time experience in the field of substance use disorders counseling; or (B) A Bachelor's degree and four years of paid full-time experience in the social services field with a minimum of two years of direct substance use disorders counseling experience; or (C) A Master's degree and three years of paid full-time experience in the social services field with a minimum of two years of direct substance use or co-occurring disorders counseling experience. (7) Clinical supervisors in problem gambling treatment programs must meet the requirements for clinical supervisors in either mental health or substance use disorders treatment programs and have completed twelve hours of gambling specific training within six months of designation as a problem gambling services supervisor. (8) Peer Delivered Services Supervisors must be a certified Peer Support Specialist (PSS) or Peer Wellness Specialist (PWS) with at least one year experience as a PSS or PWS in behavioral health treatment services and must: (a) Be licensed in Oregon by a Division recognized Oregon board as identified in (1)(A-F) of this rule; or: (b) Be an Associate registered by a Division recognized Oregon board as identified in (1)(D-E) of this rule and be physically present in Oregon at the time of providing services or supports. (c) Be certified by an OHA approved entity and be physically present in Oregon at the time of providing services or supports under the outpatient (OAR 309, Division 019) certificate. (9) Substance use disorders treatment staff must: (a) Be licensed in Oregon by a Division recognized Oregon board as identified in (1)(A-F) of this rule; (b) Be an Associate registered by a Division recognized Oregon board as identified in (1)(D-E) of this rule and be physically present in Oregon at the time of providing services or supports. (c) Effective July 1, 2027, be under the outpatient (OAR 309, Division 019) certificate of approval (COA) if providing services to individuals under Medicaid; (d) Be certified by OHA approved entity and be physically present in Oregon at the time of providing services or supports under the outpatient (OAR 309, Division 019) certificate. (e) Demonstrate competence in the use of The ASAM Criteria, Third Edition, in treatment of substance-use disorders including individual assessment to include identification of health and safety risks to self or others; individual, group, family and other counseling techniques; program policies and procedures for service delivery and documentation and identification; development of a safety plan; implementation and coordination of services identified to facilitate intended outcomes; and (f) Receive clinical supervision that documents progress towards certification and recertification; or (g) At the date of first hire to provide substance use disorder treatment, if the program staff is not certified to provide substance use disorder treatment, they must register with the Division recognized credentialing body within 30 days of hire and obtain professional substance use disorder treatment certification within two years from the date of first hire unless they obtain a variance from the Division before that time has elapsed; (h) For program staff holding certification in substance use disorder counseling, qualifications for certification must have included at least: (A) 1000 hours of supervised experience in substance use counseling; (B) 150 contact hours of education and training in substance use related subjects; and (C) Successful completion of a professional psychometric examination by an OHA approved entity. A substantively equivalent portfolio evaluation by an OHA approved entity may be accepted in lieu of a professional psychometric examination using procedures approved by the Division. (i) Program staff not holding certification/credential from an OHA approved entity in substance use disorder counseling must be licensed in Oregon by an Oregon board as identified in (1)(A-F) and at least 60 contact hours of academic or continuing professional education in the treatment of substance use disorders. (10) Problem Gambling treatment staff must: (A) Be licensed in Oregon by a Division recognized Oregon board as identified in (1)( A- F) of this rule; or (B) Be an Associate registered by a Division recognized Oregon board as identified in (1)(D-E) of this rule and be physically present in Oregon at the time of providing services or supports. (C) Effective July 1, 2027, be under the outpatient (OAR 309, Division 019) certificate of approval (COA) if providing services to individuals under Medicaid; or (D) Be certified by an OHA approved entity and be physically present in Oregon at the time of providing services or supports under the outpatient (OAR 309, Division 019) certificate. (j) Demonstrate competence in the following areas: treatment of problem gambling and gambling disorder including individual assessment to include identification of health and safety risks to self or others; individual, group, family, and other counseling techniques; program policies and procedures for service delivery and documentation, implementation and coordination of services identified to facilitate intended outcomes and cultural responsiveness; (k) Complete a minimum of two hours every two years or three hours every three years of training in suicide risk screening, suicide risk assessment, treatment and management; (l) Receive clinical supervision that documents progress towards certification and recertification; (m) At the date of first hire to provide problem gambling treatment, if the program staff is not certified to provide problem gambling treatment, they must register with the Division recognized credentialing body within 30 days of hire and obtain professional problem gambling treatment certification within two years from the date of first hire unless they obtain a variance from the Division before that time has elapsed; (n) For program staff holding certification in gambling addiction counseling, qualifications for certification must include at least: (A) 500 hours of supervised experience in gambling addiction counselor domains; (B) 30 contact hours of education and training in problem gambling; (C) 24 hours of face-to-face, telephone, or video conferencing communication, of certification consultation from a problem gambling approved certification consultant; and (D) Successful completion of a professional psychometric examination by a Division recognized credentialing body or a substantively equivalent portfolio evaluation by a Division recognized credentialing body may be accepted in lieu of a professional psychometric examination using procedures approved by the Division. (E) Program staff not holding a certification/credential in gambling addiction counseling by an OHA approved entity must have at least 30 contact hours of academic or continuing professional education in the treatment of gambling addiction. The license or registration must be issued in Oregon by a Division approved Oregon board as identified in (1)( A- F) of this rule. (10) Rehabilitative Behavioral Health Service Providers, including medical treatment staff, must demonstrate cultural responsiveness and meet the requirements and qualifications in OAR 410-172-0660. (11) Behavioral health clinicians must have one of the following corresponding license or designation: (a) A licensed psychiatrist; (b) A licensed psychologist; (c) A licensed nurse practitioner with a specialty in psychiatric mental health; (d) A licensed clinical social worker; (e) A licensed professional counselor or licensed marriage and family therapist; (f) A professional counselor associate (g) A marriage and family therapist associate ( h) A certified clinical social work associate (CSWA) ; ( i ) A Mental Health Intern as described in (14)(a-g) of this rule; (j) A psychology resident who is working under a board-approved supervisory contract in a clinical mental health field; ( k ) A Qualified Mental Health Practitioner (QMHP); or (l) Any other clinician whose authorized scope of practice includes mental health diagnosis and treatment. (12) A Board Registered Associate must: (a) Be physically present in Oregon at the time of providing services or supports under the outpatient (OAR 309, Division 019) certificate; (b) Be an Associate registered by a Division recognized Oregon board as identified in (1)(D-E) of this rule and be physically present in Oregon at the time of providing services or supports. (c) Effective July 1, 2027, be under the outpatient (OAR 309, Division 019) certificate of approval (COA) if providing services to individuals under Medicaid ; (d) Provide services consistent with the QMHP scope of work; (e) Demonstrate the following minimum competencies: cultural responsiveness, effective communication, care coordination, inter- and intra-agency collaboration, working alliances with individuals, suicide and other risk assessments and interventions, creating and monitoring safety plans, completion of bio-psycho-social assessments and additional assessments, updating assessments when clinical circumstances change, generating a differential DSM-5-TR diagnosis, prioritizing health, wellness, and recovery needs, writing measurable service objectives, creating, monitoring and revising service plans, delivery of mental health and recovery treatment services in individual, group and family formats within their scope, gathering and recording data that measures progress toward the service objectives and documenting services, supports, and other information supportive of the service plan; (f) Render services and supports within their scope to individuals engaged in a Division approved behavioral health services program if billing or rendering services under Medicaid; and (g) Document a minimum of two hours every two years or three hours every three years of suicide risk screening, suicide risk assessment, treatment and management training . (13) Qualified Mental Health Associates (QMHA) program staff must : (a) Be credentialed by an OHA approved entity and be physically present in Oregon at the time of providing services or supports under the outpatient (OAR 309, Division 019) certificate; or (b) Be credentialed as a QMHA by the specific OHA-certified behavioral health program the individual is employed by, consistent with the program’s policy and be physically present in Oregon at the time of providing services or supports under the outpatient (OAR 309, Division 019) certificate; (c) Demonstrate the following minimum competencies: cultural responsiveness, effective communication, care coordination, inter- and intra-agency collaboration, working alliances with individuals, assist in the gathering and compiling of information to be included in the assessment, screen for suicide and other risks, and implement timely interventions, teach skill development strategies, case management, and transition planning; (d) Render services and supports within their scope to individuals engaged in a Division approved behavioral health services provider; and (e) Must meet the following minimum qualifications: (A) Bachelor's degree in psychology, social work, or behavioral science field and documentation of a minimum of two hours every two years or three hours every three years of suicide risk screening, Intervention, and management training; (B) An equivalent degree as evidenced by providing transcripts indicating applicable coursework meeting the required competencies and approved by a Division certified behavioral health provider and documentation of a minimum of two hours every two years or three hours every three years of suicide risk screening, Intervention and management training; or (C) A combination of at least three years of relevant work, education, training, or experience and documentation of a minimum of two hours every two years or three hours every three years of suicide risk screening, Intervention and management training. (f) Receive clinical supervision that documents progress towards certification and recertification. (14) Qualified Mental Health Professional QMHP program staff must: (a) Be credentialed by an OHA approved entity and be physically present in Oregon at the time of providing services or supports under the outpatient (OAR 309, Division 019) certificate; or (b) Be credentialed as a QMHP by the specific OHA-certified behavioral health program the individual is employed by, consistent with the program’s policy and be physically present in Oregon at the time of providing services or supports under the outpatient (OAR 309, Division 019) certificate; (c) Demonstrate the following minimum competencies: cultural responsiveness, effective communication, care coordination, inter- and intra-agency collaboration, working alliances with individuals, suicide and other risk assessments and interventions, creating and monitoring safety plans, completion of bio-psycho-social assessments and additional assessments, updating assessments when clinical circumstances change, generating a differential DSM-5-TR diagnosis, prioritizing health, wellness and recovery needs, writing measurable service objectives, creating, monitoring and revising service plans, delivery of mental health and recovery treatment services in individual, group and family formats within their scope, gathering and recording data that measures progress toward the service objectives and documenting services, supports and other information supportive of the service plan. (d) Render services and supports within their scope to individuals engaged in a Division approved behavioral health services program; (e) Document a minimum of two hours every two years or three hours every three years of suicide risk screening, suicide risk assessment, treatment and management training; (f) Meet the following minimum qualifications: (A) Bachelor’s degree in nursing and licensed by the State of Oregon. Nurses are accountable to abide by the Oregon Nurse Practice Act to determine if job descriptions are compliant with the competencies listed above; (B) Bachelor’s degree in occupational therapy and licensed by the State of Oregon; (C) Graduate degree in psychology, social work, recreational art or music therapy, or behavioral science field; (D) An equivalent degree as evidenced by providing transcripts indicating applicable coursework meeting the required competencies (g) Receive clinical supervision that documents progress towards certification and recertification. (1 5 ) Mental Health Intern (MHI) program staff must: (a) Be currently enrolled in a graduate program for a master’s degree in psychology, social work, or related field of behavioral science; (b) Have a collaborative educational agreement between the provider and the graduate program for the student; (c) Be physically present in Oregon while providing services or supports; (d) Demonstrate cultural responsiveness, effective communication and competence in care coordination, development of working alliances with individuals, inter- and intra-agency collaboration, and the rendering of services and supports within their scope and in accordance with the service plan, including transition planning; and (e) Work within the scope of practice and competencies identified by collaborative educational agreement and the policies and procedures for the credentialing of clinical staff as established by the provider and the graduate program; (f) Document of a minimum of two hours every two years or three hours every three years of suicide risk screening, suicide risk assessment, treatment and management training. (1 6 ) Student Intern program staff must: (a) Be physically present in Oregon while providing services or supports; (b) Be currently enrolled in an educational program for an undergraduate degree in a behavioral health field; or (c) Demonstrate cultural responsiveness, effective communication and competence in care coordination, development of working alliances with individuals, inter- and intra-agency collaboration, and the rendering of services and supports within their scope and in accordance with the service plan, including transition planning; (d) Have a collaborative education agreement between the Division certified provider and the educational institute for the student; (e) Work within the scope of practice and competencies identified by the collaborative educational agreement and the policies and procedures for the credentialing of clinical staff as established by the provider; and (f) Receive, at a minimum, weekly individual supervision by a qualified clinical supervisor employed by the provider of services. (1 7 ) Intern program staff must: (a) Render services and supports under the direct supervision of a qualified supervisor employed by the provider of services, within the scope of practice and competencies identified by the collaborative educational agreement. (b) Be physically present in Oregon at the time of providing services or supports. ( c ) Be working towards obtaining a behavioral health credential; ( d ) Receive, at a minimum, weekly individual supervision by a qualified clinical supervisor employed by the provider of services; and (e) Demonstrate cultural responsiveness, effective communication and competence in care coordination, development of working alliances with individuals, inter-and intra-agency collaboration, and the rendering of services and supports within their scope and in accordance with the service plan, including transition planning. ( 18 ) Peer Support Specialists, Peer Wellness Specialists, Youth Support Specialists, and Family Support Specialists working or volunteering in health treatment programs must be certified by OHA’s Equity and Inclusion Division and be physically present in Oregon at the time of providing services or supports under the outpatient (OAR 309, Division 019) certificate of approval. (19) Behavioral Health program staff include, but are not limited to: (a) Licensed Medical Professional (LMP); (b) Licensed Practical Nurse (LNP); (c) Registered Nurse (RN); (d) Advanced Practice Nurse including Clinical Nurse Specialist and Certified Nurse Practitioner licensed by the Oregon Board of Nursing; (e) Psychologist licensed by the Oregon Board of Psychology; (f) Professional Counselor (LPC) or Marriage and Family Therapist (LMFT) licensed by the Oregon Board of Licensed Professional Counselors and Therapists; (g) Clinical Social Worker (CSW) licensed by the Oregon Board of Licensed Social Workers; (h) Licensed Master Social Worker (LCSW) licensed by the Oregon Board of Licensed Social Workers as described in OAR 877-015-0105; (i) Licensed Psychologist Associate granted independent status as described in OAR 858-010-0039; (j) Licensed Occupational Therapist licensed by the Oregon Occupational Therapy Licensing Board; (k) Board registered associates , including: (A) Psychologist Associate Residents as described in OAR 858-010-0037; (B) Licensed Psychologist Associate under continued supervision as described in OAR 858-010-0038; (C) Professional Counselor Associate or Marriage and Family Therapist Associate registered with the Oregon Board of Licensed Professional Counselors and Therapists as described in OAR 833-050-0011; (D) Certificate of Clinical Social Work Associate issued by the Oregon Board of Licensed Social Workers as described in OAR 877-020-0009; (E) Registered Bachelor of Social Work issued by the Oregon Board of Licensed Social Workers as described in OAR 877-015-0105. (l) Q ualified M ental H ealth P rofessional (QMHP) as defined in OAR 309-019-0105; (m) Q ualified M ental H ealth A ssociate (QMHA) as defined in OAR 309-019-0105; (n) Mental health intern as defined in OAR 309-019-0105; (o) Student intern as defined in OAR 309-019-0105; ( p ) Problem Gambling treatment staff registered with an OHA approved entity include: (A) Certified Gambling Addiction Counselor-Registered (CGAC-R); (B) Certified Gambling Addiction Counselor-I (CGAC-I); Certified Gambling Addiction Counselor-II (CA G C-II). ( q ) SUD Treatment Staff credentialed/registered by an OHA approved entity include: (A) Certified Alcohol and Drug Counselor-Registered (CADC-R); (B) Certified Alcohol and Drug Counselor-I ( CADC -I); (C) Certified Alcohol and Drug Counselor-II ( CADC -II); (D) Certified Alcohol and Drug Counselor-III ( CADC -III). (r) Behavioral Health treatment Staff credentialed by the OHA Equity and Inclusion Division include: (A) Peer Wellness Specialist (B)Youth Support Specialist (C) Family Support Specialist Statutory/Other Authority: ORS 161.390, 413.042, 430.256 & 430.640 Statutes/Other Implemented: ORS 428.205-428.270, 430.010, 430.254-430.640, 430.850-430.955 & 743A.168 History: BHS 18-2026, amend filed 06/30/2026, effective 07/01/2026 BHS 24-2024, amend filed 10/25/2024, effective 10/27/2024 BHS 12-2023, amend filed 05/16/2023, effective 05/16/2023 BHS 11-2023, amend filed 04/07/2023, effective 04/07/2023 BHS 27-2022, amend filed 12/20/2022, effective 12/20/2022 BHS 1-2022, amend filed 01/05/2022, effective 01/05/2022 BHS 11-2021, amend filed 06/16/2021, effective 06/16/2021 BHS 15-2020, temporary amend filed 12/17/2020, effective 12/18/2020 through 06/15/2021 BHS 14-2020, amend filed 11/12/2020, effective 11/12/2020 BHS 8-2020, temporary amend filed 04/30/2020, effective 04/30/2020 through 10/26/2020 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16 MHS 3-2015, f. & cert. ef. 5-28-15 MHS 1-2015(Temp), f. & cert. ef. 3-25-15 thru 9-20-15 MHS 4-2014, f. & cert. ef. 2-3-14 MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14 309-019-0130 Personnel Documentation, Training, and Supervision (1) All program staff who render services and supports or bill for services and supports and all personnel who have access to protected health information that are associated with the Certificate must be identified on the provider’s organizational chart through a hierarchical chart or through a spreadsheet. If utilizing a spreadsheet, must also indicate reporting structure that demonstrates who is supervising the position. Information must include the individuals: (a) Full legal name ; (b) Licensure and/or credential (based on their certification); (c) Position title; (d) Full-time or part-time status; (e) Remote, Office, or Hybrid (2) Providers must maintain personnel records for each program staff that contains all of the following documentation: (a) The results of a criminal records check applicable to the current position or title, and: (A) For personnel who render mental health services or have access to mental health protected health information such as service records or billing information, the program must use The Oregon Criminal Records Check and those processes and procedures required by OAR 943-007-0001 through 0501; and (B) For personnel who render only substance use disorder treatment services or have access to only substance use disorder protected health information such as service records or billing information, the program must use national and state-wide criminal records check processes. (b) A current job description that includes applicable competencies; (c) Copies of relevant licensure or certification, registration for licensure or certification, diploma, or certified transcripts from an accredited college, indicating that the program staff meets applicable qualifications; (d) Documentation of Employment Eligibility Verification, form I-9; (e) Documentation of a minimum of two hours every two years or three hours every three years of training in suicide risk screening suicide risk assessment, treatment and management; (f) Periodic performance appraisals; (g) Program orientation documentation; (h) Disciplinary documentation; (i) Documentation of trainings required by this or other applicable rules; and (j) Documentation of clinical supervision. (3) Program Orientation: Providers must ensure that program staff receive training applicable to the specific population for whom services are planned, delivered, or supervised. The Provider must document that the following orientation was completed for each program staff providing or supervising services or supports within 30 days of the hire date, unless otherwise specified. At a minimum, program orientation and training for all program staff must include but not be limited to: (a) A review of crisis prevention and response procedures; (b) A review of emergency evacuation procedures; (c) A review of program policies and procedures, including the procedures for each certified ASAM Level of Care for substance use disorder treatment program staff; (d) A review of rights for individuals receiving services and supports; (e) A review of mandatory abuse reporting procedures; (f) A review of confidentiality policies and procedures; (g) A review of Fraud, Waste and Abuse policies and procedures; (h) A review of care coordination policies and procedures; (i) A review of and agreement to abide by the Code of Conduct; (j) Substance use disorders treatment staff and substance use disorders clinical supervisors must complete a training on The ASAM Criteria within the first three months of employment rendering substance use disorder services or supports or have it documented as completed within the most recent two years; and (k) For Enhanced Care Services, positive behavior support training. (4) Clinical Supervision is required for all program staff. providing direct services or supports and must receive documented clinical supervision by a qualified clinical supervisor related to the development, implementation, and outcome of services. Staff licensed by an Oregon Board must be clinically supervised by another individual licensed by an Oregon Board. Unlicensed staff must be clinically supervised by an individual who is licensed by an Oregon Board and who is is physically present in Oregon at the time of clinical supervision, or a QMHP that qualifies as a clinical supervisor and who is physically present in Oregon at the time the services and supports are provided, and while providing clinical supervision. Part time staff must receive supervision no less than, h alf the total supervision hours required for full time staff. Individual face-to face contact may include real time, two-way audio or audio-visual conferencing, and: (a) Documentation must include: (A) The date; (B) Amount of time per session; and (C) A brief description of the topics addressed. (b) Clinical Supervision must be provided to assist staff to: (A) Increase their skills within their scope of practice; (B) Improve quality of services to individuals; and (C) Ensure understanding, application and compliance with the code of conduct and program policies and procedures. (c) Documentation must demonstrate the following minimum hours of clinical supervision for full-time staff per month: (A) Non-licensed program staff , including Board Registered Associates, must receive at least two hours per month of clinical supervision. The two hours must include at minimum one hour of individual face-to-face supervision , and may include one hour of group supervision ; ( B ) Mental Health Interns and Student Interns must receive one-hour of individual clinical supervision per week; and ( C ) When available, a qualified Peer Delivered Services Supervisor must provide one of the two hours of required monthly supervision to program staff providing direct Peer Delivered Services. Remaining hours of supervision must be provided by a qualified clinical supervisor. (d) Mental Health Interns and Student Interns must render services and supports under the active supervision of a qualified supervisor, as defined in these rules; and (e) Individualized non-clinical supervision must be utilized as needed and documented. Statutory/Other Authority: ORS 161.390, 413.042, 430.256 & 430.640 Statutes/Other Implemented: ORS 109.675, 428.205 - 428.270, 430.010, 430.205 - 430.210, 430.254 - 430.640, 430.850 - 430.955 & 743A.168 History: BHS 18-2026, amend filed 06/30/2026, effective 07/01/2026 BHS 12-2023, amend filed 05/16/2023, effective 05/16/2023 BHS 11-2023, amend filed 04/07/2023, effective 04/07/2023 BHS 27-2022, amend filed 12/20/2022, effective 12/20/2022 BHS 11-2021, amend filed 06/16/2021, effective 06/16/2021 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16 MHS 4-2014, f. & cert. ef. 2-3-14 MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14 309-019-0135 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. 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 History: BHS 24-2024, amend filed 10/25/2024, effective 10/27/2024 BHS 11-2024, temporary amend filed 05/21/2024, effective 05/21/2024 through 10/27/2024 BHS 9-2024, temporary amend filed 04/30/2024, effective 05/01/2024 through 10/27/2024 BHS 11-2023, amend filed 04/07/2023, effective 04/07/2023 BHS 11-2021, amend filed 06/16/2021, effective 06/16/2021 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 4-2014, f. & cert. ef. 2-3-14 MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14 309-019-0140 Service Plan and Service Notes (1) The service plan must be a written, individualized plan designed to improve the individual’s condition to the point where the individual’s continued participation in the program or level of care is no longer necessary. (a) Service plans shall be started following the completion of an assessment, or portion thereof, and prior to treatment services being rendered. P rovider must document reason for any delay in the service record. (b) Routine services may be rendered prior to a completion of a service plan or documentation of a medically necessary reason for services. These services can be provided without a service plan or medical necessity, or at any time during a treatment episode: (i) Care Coordination (ii) Case Management (iii) Peer Services (c) Service plans must reflect the assessment in its’ most updated form; (d) Address areas of concern identified in the current assessment that the individual or guardian – if relevant and appropriate -- agrees to address; (e) Include a safety plan when the assessment indicates risk to the health and safety of the individual or to others and be updated as circumstances change. The safety plan may be a separate document from the service plan; (f) Include the participation, and reflect agreement, of the individual and family members, as applicable; (g) Be completed and signed by qualified program staff as follows: (A) A QMHP or appropriately licensed provider in mental health programs; (B) Supervisory or treatment staff in substance use disorders treatment programs; and (C) Supervisory or treatment staff in problem gambling treatment programs. (h) Approval of services and supports shall be demonstrated through operationalization of provider policy described above, in OAR 309-019-0110 (1)(z). (2) At minimum, each service plan must include: (a) Treatment goals that are individualized; (b) Treatment goals that meet the assessed needs of the individual. (c) Measurable for the purpose of evaluating individual progress, including a baseline. (3) Service plans must reflect the most updated assessments on file, and must include: (a) Goals that are measurable for the purpose of evaluating individual progress – including baseline measurement as well as include; (b) The specific services and supports that will be used to meet the treatment goals; (c) Expected frequency, amount, and duration of each type of planned service or support; (d) A schedule for re-evaluating the service plan; and (e) the type of personnel that will be furnishing each of the services. (4) Providers must document the following in a service note for each service and support : (a) The specific service or support rendered; (b) The relationship of the services to the treatment regimen described in the service plan; (c) The date, time of service or support, and the actual amount of time the service or support was rendered; (d) The personnel rendering the services, including their name, credentials, and signature; (e) The setting in which the service or support was rendered; and (f) Periodic updates describing the individual’s progress, or lack thereof (5) Decisions to transfer individuals must be documented including: (a) The date of the transfer; (b) The reason for the transfer; (c) For substance use disorder and co-occurring services, ASAM level of care recommendation and overall determination of the severity of risk the individual is experiencing at the time of transfer; (d) Referrals to follow up services and other behavioral health providers; and (e) Outreach efforts made as applicable and as defined in these rules. 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 History: BHS 24-2024, amend filed 10/25/2024, effective 10/27/2024 BHS 13-2024, temporary amend filed 06/11/2024, effective 06/11/2024 through 10/27/2024 BHS 11-2024, temporary amend filed 05/21/2024, effective 05/21/2024 through 10/27/2024 BHS 9-2024, temporary amend filed 04/30/2024, effective 05/01/2024 through 10/27/2024 BHS 11-2023, amend filed 04/07/2023, effective 04/07/2023 BHS 5-2022, amend filed 03/04/2022, effective 03/18/2022 BHS 19-2021, temporary amend filed 09/14/2021, effective 09/14/2021 through 03/12/2022 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16 MHS 4-2014, f. & cert. ef. 2-3-14 MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14 309-019-0145 Co-Occurring Mental Health and Substance Use Disorders (COD) This rule is effective January 1, 2023. Services shall be integrated and address treatment and recovery for co-occurring Mental Health, Substance Use and/or Gambling Disorders. In addition to requirements in OAR Chapter 309, these rules specify standards and requirements for providers delivering co-occurring mental health, substance use disorder and problem gambling services and supports. (1) Access to services shall: (a) Be trauma informed, culturally relevant, linguistically, and developmentally appropriate, and utilize a harm reduction model where needed; and (b) Be adapted for individuals with intellectual and developmental disabilities. (2) All assessments shall: (a) Be consistent with the most recent version of the ASAM (American Society of Addiction Medicine) criteria and document a level of care determination consistent with ASAM; (b) Provide sufficient information to justify the presence of the Mental Health and Addiction (Substance Use Disorders and/or Gambling Disorder) diagnoses that are the medically appropriate reason for services, using the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM); and (c) Identify any other co-morbid risk factors. (3) Service Plans shall: (a) Accommodate the individual’s holistic needs and preferences; (b) Utilize a harm reduction approach where indicated; (c) Address long term wellness needs; and (d) Be in alignment with participant’s current stage of change in regard to both addiction disorder recovery and mental health disorder recovery. (4) The following services shall be made available: (a) Case Management & Service navigation support; (b) Harm reduction services; (c) Peer Support Services; (d) Family therapy services; and (e) Psychiatric medication and evaluation services, as indicated. (5) Integrated Co-Occurring Disorders Program Staff Qualifications shall align with the provisions described in 309-019-0125 and ensure that: (a) All treatment staff providing Integrated Co-Occurring Disorders treatment services shall hold, at minimum, a qualifying credential to provide treatment services in mental health or substance use disorders treatment. Treatment staff holding one credential shall be limited to providing treatment services in alignment with their credential; (b) Registrants and student interns are permitted to provide services during the duration of their candidacy or internship as described in OAR 309-019-0105; (c) Progression towards additional certifications must be documented on an ongoing basis in the personnel record; (d) The program must retain a credentialed problem gambling treatment provider OR designate a Co-Occurring Problem Gambling Specialist. A Co-Occurring Problem Gambling Specialist must have: (A) Fourteen hours minimum of problem gambling specific training within twelve months of being named as a problem gambling provider, with a minimum of two hours in each of the following seven content areas; Gambling Client Assessment/Intake, Gambling Financial Planning and Budgeting, Gambling Counseling (Individual, Group, Family), Gambling Case Management, Professional Responsibility and Ethics in Gambling Counseling, Crisis Intervention in Gambling Counseling, Co-Occurring Disorders and Problem Gambling; and (B) Documentation of required trainings shall be contained in the personnel file. (e) Peer providers shall be certified as Peer Wellness Specialists (PWS) or Peer Support Specialist (PSS); (f) Supervisors must: (A) Be credentialed in Mental Health and/or Substance Use Disorder treatment provision; (B) Limit their supervision to providers within the scope of their professional credentials. (C) Supervisors must demonstrate completion of 12 CEU’s in approved Problem Gambling training for supervisors within twelve months of beginning to supervise program staff rendering Problem Gambling Treatment Services in Integrated Co-Occurring Disorders Treatment programming; (g) The program must employ or contract with a Licensed Medical Provider (LMP) that shall acquire Division approved Integrated Co-Occurring Disorders training within twelve months of hire or appointment to these services. Approved training will be published by the Division on the OHA Integrated Co-Occurring Disorders website yearly on or before January 1st; (h) All Supervisors, Treatment Service Providers and Peer Services Providers delivering services in Integrated Co-Occurring Disorders Programs shall complete Integrated Co-Occurring Disorders trainings required and provided by OHA and shall ensure certificates of completion are documented in staff personnel files, according to the following conditions: (A) Within twelve months of beginning to render Co-Occurring Disorders services or supports; and (B) On a continuing two-year basis for all Supervisors and Treatment Providers and a continuing three year basis for Peer Staff rendering Co-Occurring Disorders services or supports for more than one year. (i) Continuing Education training required by the Oregon Health Authority (OHA) shall consist of at least two hours but no more than six hours every two years following the initial training year for supervisors and treatment providers, and every three years following the initial training year for peer services providers. (A) Integrated Co-Occurring Disorders trainings required by OHA will be published by the Division yearly on or before January 1st on the OHA Integrated Co-Occurring Disorders website; (B) OHA training will include – but will not be limited to – content relevant to providing integrated treatment, and specialty training on providing treatment services for community members who are marginalized, underserved and oppressed by structural and systemic racism and injustices, Severe Mental Illness and Intellectual and Developmental Disabilities. Statutory/Other Authority: ORS 413.042 & 430.640 Statutes/Other Implemented: ORS 430.010, 430.205 - 430.210, 430.254 - 430.640 & 430.850 - 430.955 History: BHS 1-2023, amend filed 01/11/2023, effective 01/11/2023 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16 MHS 4-2014, f. & cert. ef. 2-3-14 MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14 309-019-0150 Community Mental Health Programs (CMHP) (1) Crisis services must be provided directly or through linkage to a local crisis services provider and must include the following: (a) Twenty-four hours, seven days per week telephone or face-to-face screening within one hour of notification of the crisis event to determine an individual's need for immediate community mental health services; and (b) Twenty-four hours, seven days per week capability to conduct, by or under the supervision of a QMHP, an assessment, resulting in a plan that includes the crisis services necessary to assist the individual and family to stabilize and transition to the appropriate level of care. (2) Case management services must be provided to assist individuals with the following: (a) Gaining access to and maintaining resources such as Social Security benefits, general assistance, food stamps, vocational rehabilitation, and housing; (b) Arrangement of transportation to help them apply for benefits; (c) Referral and coordination to help individuals gain access to services and supports identified in the service plan to include but may not be limited to individuals at risk of suicide; (d) Care coordination and warm handoff processes; and (e) Assist with a follow-up visit within seven days of discharge from an acute care psychiatric hospital. (3) When significant health and safety concerns are identified, program staff must ensure that necessary services or actions occur to address the identified health and safety needs for the individual, including services to individuals at imminent risk of suicide as determined by the assessment. (4) Peer Delivered Services must be made available. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 430.630, 109.675, 161.390 - 161.400, 413.520 - 413.522, 430.010, 430.205 - 430.210, 430.254 - 430.640, 430.850 - 430.955, 461.549 & 743A.168 History: BHS 27-2025, amend filed 12/23/2025, effective 01/01/2026 BHS 20-2025, temporary amend filed 09/15/2025, effective 09/15/2025 through 03/13/2026 BHS 33-2024, temporary amend filed 12/27/2024, effective 01/01/2025 through 06/29/2025 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 1-2017(Temp), f. 1-17-17, cert. ef. 1-18-17 thru 7-16-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 MHS 4-2014, f. & cert. ef. 2-3-14 MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14 309-019-0155 Enhanced Care Services (ECS) and Enhanced Care Outreach Services (ECOS) (1) To be eligible for Enhanced care Services (ECS) an individual shall: (a) Be Medicaid eligible; (b) Meet the diagnostic criteria of severe mental illness with complex behaviors and be approved by the enhanced care services team; (c) Require intensive community mental health services to be in the most integrated setting available; (d) Have a history of unsuccessful placements due to complex behaviors; and (e) be at risk of psychiatric hospitalization; and (f) have a history of or be currently exhibiting two or more of the following: self-endangering behavior, aggressive behavior, intrusive behavior, refractory psychiatric symptoms, complex medication needs, sexually inappropriate behavior, and elopement behavior . (2) ECS providers shall: (a) provide staffing to support the behavioral health needs of the clients within Enhanced Care Unit as outlined in the MOU, with no fewer than four hours a day for programs with 8 or less beds and no fewer than six hours per day for programs with 9-16 beds. ECS mental health staffing shall be available seven days per week provided by or arranged for by the contracted mental health provider; (b) ECS programs who are not able to meet staff hour requirements must submit in writing to the State Enhanced Care Providers a plan of how services are going to delivered and a plan of how they are going to correct the issue. (c) Coordinate weekly interdisciplinary team meetings (IDT) to develop the service plan, and to coordinate care planning with the Department of Human Services (Department) licensed provider staff, APD case manager, QMHP, prescriber, individual consumer, or their representative and related professionals such as the Department licensed facility or program direct care staff, the Department licensed facility RN, and facility administrator. (d) Coordinate quarterly behavioral health trainings as agreed upon in the MOU for Department-licensed providers and related program staff providing services to ECS; and (e) Ensure the availability of consultation and crisis services staffed by a QMHP/QMHA or the local CMHP, with an accessible written plan on how to access these services available to the ECS provider and the Department licensed facility direct care staff 24-hours per day (f) provide reports of critical incidences to the Enhanced Care State Coordinators within 72 business hours. A critical incident can be defined as an actual or alleged event or behavior that can or does result in a negative outcome for a consumer including- Death from unknown causes; Emergency Medical Care; Missing Person; Unplanned Hospitalization; Neglect/Abuse/Exploitation/Mistreatment; Damage or theft of property; medication management issues; criminal justice involvement. ; and (g) submit monthly census reports to the Enhanced Care State Coordinators no later than the 10th day of every calendar month; and (h) submit referral outcome forms within 7 calendar days of date sent referral to the Enhanced Care State Coordinators; and (i) submit Database I forms within 15 calendar days of an individual’s admission to the program; and (j) submit Database II forms within 15 calendar days of an individual’s discharge from the program; and (k) Provide collaboration and support to ODHS Department-licensed providers on their development of behavior support plans. (3) ECS program staffing requirements include: (a) Each ECS program may have services provided by a QMHPs, QMHA’s, CADCs, Peer Delivered Services, and LMP’s. ECS programs staff are responsible for coordinating program entries, transitions, and required IDT’s; assuring the completion of individual assessments and mental health service; ECS programs are responsible for providing supervision of QMHP’s and QMHA’s; and coordinating services and trainings with facility staff; (b) Each CMHP ECS program shall have a QMHA or QMHP available during CMHP ECS provider program hours as outlined in the MOU; (c) Each ECS program shall have LMP consultation available. For ECS programs serving more than ten individuals, the LMP shall participate. (d) ECS programs who are not able to meet staffing requirements must submit in writing to the State Enhanced Care Providers a plan of how services are going to delivered and a plan of how they are going to correct the problem. (4) In ECS programs, the CMHP and the Department licensed provider shall develop a written collaborative agreement that addresses at a minimum: risk management, census management, staff levels, training, treatment and activity programs, entry and transition procedures, a process for reporting and evaluating critical incidents, record keeping, policy and procedure manuals, dispute resolution, and service coordination. This should be reviewed on an annual basis. Statutory/Other Authority: ORS 161.390, 413.042, 430.640 & 443.450 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 History: BHS 23-2024, amend filed 10/14/2024, effective 10/15/2024 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 MHS 4-2014, f. & cert. ef. 2-3-14 MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14 309-019-0157 Enhanced Care Outreach Services (ECOS) (1) To be eligible for Enhanced Care Outreach Services (ECOS), an individual must: (a) Be Medicaid eligible; (b) Meet the diagnostic criteria of severe mental illness with complex behaviors or be approved by the enhanced care services team; (c) Require intensive community mental health services to accomplish or maintain community integration in the least restrictive environment; (d) Be at risk of losing or have a history of failed placement. (e) Have a history of or currently exhibiting two or more of the following: self-endangering behavior, aggressive behavior, intrusive behavior, refractory psychiatric symptoms, complex medication needs, sexually inappropriate behavior, and elopement behavior; (f) Be placed in a community-based residential setting or attempting to gain access to a community-based residential setting that is approved under state or local authorities; (g) Or be at risk of being denied placement due to a history of these factors. (2) ECOS providers must: (a) Provide person-centered, individualized services outlined in the service plan. (b) Provide Care Coordination based on individual needs; (c) Offer resources or trainings specific to the behavioral health needs to in-home or Department licensed facility staff. (d) Ensure the availability of consultation and crisis services staffed by a QMHP /A or the local CMHP available to ECOS provider and the Department licensed facility direct care staff 24-hours per day. (e) Provide services that are in the residence or community based to the fullest extent possible. These services shall be available based off the consumers preference and choice; (f) Provide reports of critical incidences to the Enhanced Care State Coordinators within 72 business hours. A critical incident can be defined as an actual or alleged event or behavior that can or does result in a negative outcome for a consumer including- Death from unknown causes; Emergency Medical Care; Missing Person; Unplanned Hospitalization; Neglect/Abuse/Exploitation/Mistreatment; Damage or theft of property; medication management issues; criminal justice involvement; (g) Submit monthly census reports to Enhanced Care State Coordinators no later than the 10th day of every calendar month. (3) Staffing requirements include: (a) Each ECOS program may have services provided by QMHPs, QMHAs, CADCs, Peer delivered services, and LMPs as indicated in the individual service plan; (b) Each ECOS program must have LMP consultation available; (c) ECOS providers must ensure that CMHP program staff, contractors, volunteers, and interns providing ECOS services are trained and familiar with strategies for delivery of trauma informed and culturally responsive services. Statutory/Other Authority: ORS 161.390, 413.042, 430.640 & 443.450 Statutes/Other Implemented: ORS 161.390 - 161.400, 428.205 - 428.270, 430.010 - 430.210, 430.254 -430.640, 430.850 - 430.955 & 743A.168 History: BHS 23-2024, adopt filed 10/14/2024, effective 10/15/2024 309-019-0160 Psychiatric Security Review Board and Juvenile Psychiatric Security Review Board (1) Services and supports must include all appropriate services, including peer delivered services, determined necessary to assist the Individual in maintaining community placement that are consistent with Conditional Release Orders and the Agreement of Conditional Release. (2) Providers of PSRB services acting through the designated qualified Individual must submit reports to the PSRB as follows: (a) For Individuals under the jurisdiction of the PSRB, providers must take the following action upon receipt of an Order for Evaluation of Conditional Release from the PSRB: (A) Must appoint a Qualified Mental Health Professional (QMHP) to schedule and complete the evaluation interview; (B) Following completion of the evaluation interview, the QMHP must submit the Evaluation Report and, if the Individual is accepted to the placement, the Summary of Conditional Release Plan (SCRP), as follows: (i) The Evaluation Report and the SCRP, when applicable, must be submitted to OHA, the Oregon State Hospital (OSH), or other treatment provider, and the PSRB; (ii) When submitting the Evaluation Report and the SCRP when applicable to OHA, the provider must use the cover sheet provided by OHA and; (iii) The Evaluation Report and the SCRP, when applicable, must be complete and submitted within 30 days of the receipt of the PSRB Order for Evaluation of Conditional Release. (C) If supervision by the provider is recommended, notify the PSRB of the name of the Individual designated to serve as the Individual’s qualified person who will be primarily responsible for delivering or arranging for the delivery of services and the submission of reports under these rules. (b) Monthly reports consistent with PSRB reporting requirements as specified in the Conditional Release Order that summarize the Individual’s adherence to Conditional Release requirements and general progress; and (c) Interim reports including immediate reports by phone, if necessary, to ensure the public or Individual’s safety including: (A) At the time of any significant change in the Individual’s health, legal, employment, or other status that may affect compliance with Conditional Release orders; (B) Upon noting major symptoms requiring psychiatric stabilization or hospitalization; (C) Upon noting any other major change in the Individual’s service plan; (D) Upon learning of any violations of the Conditional Release Order; and (E) At any other time when in the opinion of the qualified person, such an interim report is needed to assist the Individual. (3) An Annual Comprehensive Review must be completed each 364 days to determine if an Individual’s current Conditional Release Order is in alignment with the Individual’s current level of care. If upon completion of the Annual Comprehensive Review it is determined the current Conditional Release Order is not in alignment with the Individuals current level of care, a modification request must be submitted to the PSRB. (4) Providers must submit copies of interim reports to the PSRB. (5) Providers must submit copies of interim reports to the Division upon request. (6) Providers must include the following documents as part of the Individual’s service record: (a) Monthly reports; (b) Interim reports; (c) Serious Incident Reports as described in OAR 859-010-0005(11)(a)(b)(c)(d); (d) The Individual’s most recent Conditional Release Evaluation; and (e) The Individual’s most recent Conditional Release Order. (f) All copies of submissions to the PSRB for modifications of the Conditional Release Order. (g) The electronic submission of the Annual Comprehensive Review that includes an attestation from the provider that verifies the required Collateral Documentation has been reviewed when completing the annual review. The following is the list of Collateral Documentation that must be in the Individual’s service record for each year the Annual Comprehensive Review is completed. (A) Mental Health Treatment Plan that must have not been completed more than 364 days prior to the date of the Annual Comprehensive Review. (B) Conditional Release Order that has been approved by the PSRB. (C) Short-Term Assessment of Risk and Treatability (START) that has been completed no more than 180 days prior to the date of the Annual Comprehensive Review. Statutory/Other Authority: 430.640, 443.450, 426.490 - 426.500, ORS 161.390, 413.042, 430.256, 426.490 - 426.500 & HB 2804 (2024) Statutes/Other Implemented: ORS 161.390 - 161.400, 179.505, 426.380 - 426.395, 426.490 - 426.500, 428.205 - 428.270, 430.010, 430.205 - 430.210, 430.254 - 430.640, 430.850 - 430.955 & 443.400 - 443.460 History: BHS 1-2026, amend filed 03/03/2026, effective 03/03/2026 BHS 16-2025, amend filed 06/25/2025, effective 06/30/2025 BHS 6-2025, temporary amend filed 02/28/2025, effective 03/01/2025 through 08/27/2025 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 MHS 4-2014, f. & cert. ef. 2-3-14 MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14 309-019-0162 Youth Wraparound Definitions (1) "Child and Adolescent Needs and Strengths Assessment or CANS" means a multi-purpose tool developed to support decision making, including level of care and person-centered service planning, to facilitate quality improvement initiatives, and to monitor outcomes of services and supports. It utilizes a communication perspective to facilitate the linkage between the assessment process and the design of individualized Wraparound plans of care, including the application of evidence-based practices. (2) "Child-Serving Systems" means agencies that serve children, youth and families. Agencies include but are not limited to: DHS Child Welfare, Intellectual/Developmental Disabilities, Education, Juvenile Justice, Oregon Youth Authority, Behavioral Health programs, tribal entities, agencies serving homeless youth, and Primary Care. (3) "Crisis and Safety Plan" means a document developed by the youth and family and the Wraparound team to address potential crises that could occur for the youth and their family, and to ensure everyone's safety. It shall include 24-hour, 7-days-a-week response; formal, informal, and natural supports; respite or back-up care; details leading to crises; successful strategies that have worked in the past; and strength-based strategies that prevent escalation and maintain safety. Crisis stabilization occurs during the first phase of Wraparound and crisis and safety planning occurs in phase two. (4) "Family Partner" means an individual certified and listed on the registry as a Family Support Specialist in accordance with ORS 410-180-0305, and who has completed specialized training approved by the Authority, in the Wraparound process. A Family Partner is a formal member of the Wraparound team whose role is to support the family. (5) "Fidelity" means the degree to which the principles, phases, core elements and activities of Wraparound, and supports at the organizational and system level, are implemented as recommended through training, consultation and best practices dissemination. (6) "Formal Supports" means services and supports provided by professionals or individuals who are financially compensated for their time. (7) "Informal Supports" means supports provided by individuals or organizations through citizenship and work on a volunteer basis under a structure of certain qualifications, training and oversight. (8) "Linguistically Responsive" means that individuals are informed of the availability of language assistance services in their preferred language, both verbally and in writing. Individuals are provided with easy to understand print and multi-media materials and signage appears in the languages commonly used by the populations in the service area. (9) "Natural Supports" means individuals or organizations in the youth and family's own community, social, cultural or spiritual networks, such as friends, extended family members, neighbors, and other individuals as identified by the youth and family, providing supports, who are not financially compensated for their time. (10) "Oregon Health Plan or OHP" has the meaning provided for in OAR 410-120-0000(170). (11) "Peer Partner Coach" means an individual with Youth Partner or Family Partner expertis certified and listed on the registry in accordance with OAR 410-180-0300, who has a specific intentional focus in supporting Youth Partners or Family Partners to ensure the meaningful engagement of youth and family voices in the Wraparound plan, to develop their practice skills in Wraparound principles and participation in the Wraparound process and who works in connection with other Peer Support Specialists or peer delivered services. (12) "Phases of Wraparound" means the four distinct phases of Wraparound: Engagement, initial plan development, implementation, and transition. The activities within each phase of Wraparound are part of fidelity practice. (13) "Strength-based" means based on functional assets, skills, capacities, and talents of a person, family or group. (14) "Strengths and Needs Summary" means a comprehensive "strengths and needs assessment” and summary process that begins immediately when a youth and their family are referred into Wraparound. This process is complemented by other Division-approved assessment tools, such as the Child and Adolescent Needs and Strengths Assessment (CANS). (15) "Ten Wraparound Principles" means these principles associated with Wraparound supports: family- driven and youth-guided, collaboration, persistence, culturally and linguistically responsive, community based, team based, natural supports, individualized, strength-based, and outcome-based. (16) "Wraparound" means a voluntary and definable care planning process that results in a unique set of community services and supports individualized for a youth and family to achieve a positive set of outcomes. (17) "Wraparound Care Coordinator or WCC" means a QMHA or QMHP, as defined in OAR 309-019-0125, who is completing or has completed a Division-approved Wraparound foundational training program. The WCC is a member of the Wraparound team specifically trained to coordinate and facilitate the components of a Wraparound team meeting to fidelity, in each phase of the Wraparound process, for an individual family. (18) "Wraparound Coach" means an individual with Wraparound expertise in relation to Wraparound principles and in strategies to facilitate a Wraparound meeting to fidelity. Wraparound Coaches provide clear and constructive feedback regarding fidelity components and facilitation skills to Wraparound Care Coordinators. (19) "Wraparound Flexible Funding" means a financial resource for purchasing one-time or occasional needed goods or services for youth or their families, when the goods and services cannot be provided by another funding source, and the services or goods are directly tied to meeting needs and outcomes in the Wraparound plan of care. (20) "Wraparound Plan of Care" means a dynamic document which describes the youth, the family, the team, and the goals and action plan to be undertaken to meet the youth and family's needs, achieve the team mission and work toward the family's long-term vision. ( 21) “Wraparound Provider” means a certified entity that hires and trains staff to provide coordination and facilitation of Fidelity Wraparound for youth and families. (22) "Wraparound Review Committee" means a local community group representing Child Welfare, Juvenile Justice, Intellectual Developmental Disabilities, Education, Behavioral Health, Federally Recognized Tribes or tribal entities, Youth and Family members or youth and family advocates who convene with the goal of reviewing and determining Wraparound eligibility. (23) "Wraparound Supervisor" means an individual responsible for supervising a Wraparound Care Coordinator, Wraparound Coach, Family Partner, or Youth Partner through their respective agency. (24) "Wraparound Team" means a group of people chosen by the youth and family and connected to them through natural, community, and formal supports. The Wraparound team develops and implements the youth and family's plan, addresses unmet needs, and works toward the family's vision and team mission together with the youth and family. (25) "Wraparound Team Meeting" means a meeting where members of the Wraparound team convene to address the family and youth's mission, vision, strengths and needs identified by the team. (26) "Youth" means a person who participates in Wraparound. Youth is the accepted term in statewide Wraparound to describe children, adolescents, teenagers and young adults. Youth who participate in Wraparound may remain in Wraparound as young adults if they entered/ enrolled prior to age 18. (27) "Youth Partner" means an individual certified and on the registry as a Youth Support Specialist in accordance with OAR 410-180-0305. A Youth Partner is a formal member of the Wraparound team whose role is to support the youth. (28) "Youth Support Specialist" has the meaning defined in OAR 410-180-0305. Youth support specialists provide peer delivered services, as defined in these rules. Statutory/Other Authority: ORS 430.630 & ORS 413.042 Statutes/Other Implemented: ORS 430.630 & ORS 413.042 History: BHS 20-2022, amend filed 11/30/2022, effective 11/30/2022 BHS 20-2021, renumbered from 309-019-0324, filed 10/14/2021, effective 10/14/2021 BHS 3-2020, adopt filed 02/14/2020, effective 02/14/2020 309-019-0163 Youth Wraparound Program Rules (1) Wraparound providers shall: (a) Make eligibility criteria and referral processes available to the public. At a minimum, the following categories of youth shall be eligible: (A) Youth served in two or more child-serving systems and experiencing complex needs; (B) Youth who have been approved by the Wraparound Review Committee. (b) Obtain a mental health assessment within one year of Wraparound referral for youth being served under Medicaid; (c) Provide Wraparound to Medicaid Oregon Health Plan (OHP) members; (d) Implement peer delivered services in accordance with OAR chapter 410, division 180 for youth and families participating in Wraparound; (e) Ensure that youth have access to Wraparound if they are Medicaid-eligible and enrolled in any of the following: Secure Children's Inpatient Program, Secure Adolescent Inpatient Program, Psychiatric Residential Treatment Services, or the Commercial Sexually Exploited Children's residential program funded by the Division; (f) Ensure that program staff, contractors, volunteers, and interns providing Wraparound programs are trained in and familiar with strategies for delivery of trauma informed and culturally responsive treatment services. At a minimum, completion of an online foundational course for trauma informed care approved by the Division shall be required of program staff, contractors, volunteers and interns; (g) Ensure that Youth Partner and Family Partner services have been offered to the youth and family; (h) Ensure team members are selected with the youth and family’s direct involvement and approval; (i) Provide capacity to serve all eligible OHP members into Wraparound. (2) Wraparound providers may not: (a) Require Medicaid-eligible youth to receive services or supports prior to receiving Wraparound; (b) Place any youth on a waitlist. (3) Wraparound team meetings shall: (a) Be facilitated face-to-face or by two-way audio-visual conference or by telephone; (b) Be conducted in the preferred language of the youth and family. Professional interpretation services must be used, if requested by the youth and family; (c) Be scheduled with the youth and family's direct involvement and approval; (d) Ensure decisions are made with the youth and family’s direct involvement and approval. (4) The Wraparound team shall include a Wraparound Care Coordinator (WCC). The WCC shall: (a) Facilitate the Wraparound process to fidelity standards, in accordance with any procedures and standards established by the Authority; (b) Implement the Wraparound process in collaboration with Youth Partners, Family Partners, and other Wraparound team members; (c) Facilitate the Wraparound process for no more than 15 families at any time when in a full-time position; (d) Provide other service or support roles for youth on the Wraparound team they facilitate only when a variance has been approved; (e) Complete a Division-approved Wraparound foundational training within 90 days of the hire date; (f) Receive clinical supervision in accordance with OAR chapter 309, division 019; and (g) Receive orientation and shadowing opportunities, be observed, have documents reviewed, and be coached by a Wraparound Coach as defined in these rules and in accordance with any procedures and standards established by the Authority. (5) Family Partners shall meet the requirements for Family Support Specialists outlined in OAR 410-180-0305. They may receive support or technical assistance from a family organization and shall, at a minimum: (a) Complete a Division-approved Wraparound foundational training within 90 days of the hire date; (b) Receive peer supervision in accordance with OAR 309-019-0130; (c) Provide peer delivered services and supports to no more than 15 families at any time when in a full-time position; (d) Support family members and guardians to: (A) Navigate the child-, youth-, and family-serving systems; (B) Communicate effectively with family members, their support system, and agency representatives; and (C) Make informed decisions to direct the Wraparound process. (e) Provide individual and group support to enable and facilitate meaningful engagement with Wraparound team and service providers; and (f) Assist in connecting the family to resources within the community, support the family through barriers, help family members to acquire tools and strategies for success and advocate for the family's needs, interests, voice, and vision to be heard and thoughtfully considered. (6) Youth Partners shall meet the requirements outlined for Youth Support Specialists in OAR 410-180-0305. They may receive support or technical assistance from a youth organization, and shall, at a minimum: (a) Complete a Division-approved Wraparound foundational training within 90 days of the hire date; (b) Receive peer supervision in accordance with OAR 309-019-0130; (c) Provide peer delivered services and supports to no more than 15 youth at any time when in a full-time position; (d) Have at least one year of relevant lived experience, knowledge of the child- and youth-serving systems, and the ability to navigate the system; (e) Assist the youth to engage in the Wraparound process and support them in expressing themselves to members of their Wraparound team; (f) Assist the youth in identifying community resources, navigating barriers, acquiring tools and strategies for success and bridging the gap between the youth and the adults on the Wraparound team; and (g) Advocate for the youth's needs, interests, voice and vision to be heard. (7) The Wraparound provider shall, gather and compile a strengths and needs summary that is complemented by the Division-approved assessment tools for ages 0-5 and 6-20, as described below as a part of Fidelity Wraparound. Strengths and needs information to gather and compile shall include: (a) Conversations with the youth and family, which shall be conducted at a reasonable time and location chosen by the youth and family; (b) Conversations with team members including formal and natural supports; (c) A review of referral documentation; and (d) Consideration of each one of the following domains: family and relationships, home and a place to live, psychological and emotional, health and medical, crisis and safety, financial, educational and vocational, legal, cultural and spiritual, daily living, substance abuse and addictions, social and recreational. (8) The Wraparound provider shall conduct a strengths and needs assessment tool for each youth enrolled in Wraparound services and supports. The assessment tool shall: (a) Be started within 30 days of enrollment in Wraparound, and updated at least every 90 days thereafter and upon a change in clinical circumstances or other significant event; (b) Be a Division-approved strengths and needs assessment tool for ages 0-5 and 6-20; (c) Be completed by a Wraparound Care Coordinator, Family Partner, or Youth Partner certified in the Division-approved strengths and needs assessment tool; (d) Include strengths and needs of the youth; (e) Incorporate input from the youth, family, and all team members; and (f) Be used to develop a Wraparound plan of care. (9) Wraparound Crisis and Safety Plans shall at a minimum: (a) Be developed and approved by the youth and family in consultation with the Wraparound team; (b) Document the youth and family's definition of crisis; (c) Include within the initial crisis and safety plan at least one strategy to prevent a crisis situation and at least one strategy to use during a crisis situation; (d) Include a list of triggers, warning signs, and recommended de-escalation strategies and supports identified by the youth and family in consultation with the Wraparound Team; (e) Document strategies for risk prevention for existing or anticipated safety concerns; this shall include strategies developed through lethal means counseling to help individuals at risk for suicide and their families to reduce access to lethal means, including but not limited to firearms; (f) Include strength-based strategies for addressing the youth and family's needs when in crisis; (g) Document natural and formal supports approved by the youth and family for crisis response; (h) Be updated at the request of the youth or family, or when clinical circumstances change, including following any placement change, psychiatric crisis, overdose, suicide attempt, police involvement, or other situations identified by the youth or family; (i) Document safety requirements from other child-serving or legal systems; (j) Be culturally and linguistically responsive; (k) Include contact information for resources that the youth and family may use before or during a crisis event; (l) Be provided to the youth and family in a format chosen by the youth and family; and (m) Be available to Wraparound team members. (10) A Wraparound Plan of Care shall: (a) Include a family vision statement developed by the youth and family; (b) Include a team mission statement developed by the Wraparound team; (c) Include strengths and needs derived from the youth, family, the Child and Adolescent Strengths and Needs Assessment, and the strengths and needs summary; (d) Include goals(s) for each prioritized need; (e) Include strategies to achieve the desired outcomes; (f) Include action steps that team members will undertake to meet the needs identified by the youth and family; (g) Documented use of Wraparound flexible funding that supports the mission statement, needs and goals; (h) Be reviewed and updated at each team meeting; (i) Be culturally and linguistically responsive; (j) Be approved by the youth and family; (k) Be made available to the youth and family within five business days of the Wraparound team meeting in the format and language chosen by the youth and family; (l) If desired by the youth or family, include a blend of formal and informal supports; (m) Include a list of team members and contact information; and (n) Be present and discussed at each team meeting. (11) Peer Partner Coaches shall: (a) Be a certified Family Support Specialist or a certified Youth Support Specialist who has, at a minimum, two years of experience as a Traditional Health Worker as defined in OAR 410-180-0305; (b) Demonstrate understanding of the core elements of Fidelity Wraparound such as the ten Wraparound principles and the four phases of Wraparound; (c) Provide peer supervision in accordance with OAR 309-019-0130, including face to face individual and group coaching to Youth or Family Partners a minimum of one time per month; (d) Uphold Wraparound principles as evidenced by coaching notes; (e) Be rater certified in use of the Division-approved assessment tools for ages 0-5 and 6-20; (f) Ensure that Youth and Family Partners are delivering Wraparound to youth and families in a culturally and linguistically responsive manner; (g) Create documentation which demonstrates that coaching is responsive to diverse cultural beliefs, practices, languages, learning styles, and communication as evidenced by written feedback from Youth and Family Partners and Peer Delivered Service Supervisors; (h) be available to provide coaching in the language spoken by the family, when possible, to bilingual Youth and Family Partners and be able to observe meetings and perform document review in the family's primary language without impact on the youth, family or WCC; (i) seek out additional resources when the coach does not have lived experience to provide culturally specific coaching to the Youth or Family Partner; (j) Adapt caseload size to provide adequate time to complete tasks if a WCC is working with a youth or family that requires an interpreter, bilingual services, and other accessibility needs. (12) Wraparound Coaches shall: (a) Have at a minimum two years of experience as a Wraparound Care Coordinator; (b) Demonstrate understanding of the core elements of Fidelity Wraparound such as the ten Wraparound principles, the four phases of Wraparound, and the activities associated with each phase of Wraparound; (c) Complete a Division-approved Wraparound Coaches and Supervisors training within 90 days of the hire date; (d) Meet with the Wraparound Supervisor at least monthly; (e) Provide the following coaching to Wraparound Care Coordinators: (A) For WCCs with less than one year of Wraparound experience: (i) 20 hours of individual coaching, 10 hours of group coaching, and five hours of document review within one year of the WCC's hire date, using the coaching model approved by the Division; (ii) At least 5 of the 20 hours of individual coaching shall occur within the 90-day period before the WCC receives the Division approved foundational training; if the Division approved foundational training is not available or if the WCC is unable to attend during the first 90 days of employment, the WCC must receive biweekly individual coaching until the foundational training takes place; (iii) Within the first twelve months of the WCC beginning to work with youth and families, observe four Wraparound team meetings for each WCC, including one meeting representing each phase of the Wraparound process. (B) For WCCs with at least one year of Wraparound experience, provide 10 hours of individual coaching, 10 hours of group coaching and two to four Wraparound team meeting observations within one calendar year. (f) Utilize the coaching plan created with the Wraparound coach and document to include the names of the Coach and the WCC, the date, and the content of the coaching session; (g) Create documentation which demonstrates that coaching is responsive to diverse cultural beliefs, practices, languages, learning styles, and communication as evidenced by written feedback from WCC and Wraparound Supervisor; (h) Be available to provide coaching to bilingual WCCs inf the language spoken by the family and be able to observe meetings and perform document review in the family's primary language without impact on the youth, family; (i) Seek out additional resources when the Coach does not have shared lived experience to provide culturally responsive coaching to a WCC; and (j) Be rater-certified in the use of the Division-approved assessment tools for ages 0-5 and 6-20. (13) Wraparound Supervisors shall: (a) Demonstrate through experience the ability to understand and articulate core elements of Fidelity practice such as the ten Wraparound principles, the four Wraparound phases, and facilitation components associated with each phase of Wraparound; (b) Be informed of and implement their agency's Wraparound policies and procedures; (c) Complete a Division-approved Wraparound foundational training and Wraparound Coaches and Supervisors training within 90 days of the hire date; (d) Conduct or provide for clinical supervision, in accordance with OAR 309-019-0130, of Wraparound Care Coordinators, Wraparound Coaches, Family Partners, and Youth Partners, and uphold Wraparound principles as evidenced by notes in a supervision log that includes: name, date, and content of supervision; (e) Ensure coaching is provided by the Wraparound Coach and Peer Support Coach; (f) Ensure a coaching plan is written for each WCC, Family Partner, and Youth Partner per the Division-approved Coaches and Supervisor training; (g) Ensure that the provision of Wraparound is culturally and linguistically responsive to the needs of Wraparound Care Coordinators, Youth Partners, Family Partners, youth and families; (h) Adapt caseload size to provide adequate time to complete tasks if a WCC is working with a youth or family that requires an interpreter, bilingual services, or if there are other accessibility needs; (i) Ensure Wraparound Coaches implement coaching plans that are culturally and linguistically responsive; and (j) Be rater-certified in use of the Division-approved assessment tools for ages 0-5 and 6-20. (14) A Fidelity Monitoring Tool (FMT) approved by the Division shall be used to assess fidelity to Wraparound; (a) The FMT shall be offered to youth and caregivers no sooner than six months after a youth has been enrolled in Wraparound; (b) Any youth over the age of eleven may complete the FMT; (c) A parent, guardian, or legal caregiver who knows the youth best and has also participated in Wraparound may complete the FMT; (d) The youth and parent, guardian or legal caregiver shall complete the FMT without the team's Wraparound Care Coordinator present; (e) The FMT shall be offered to wraparound team members when approved of by the youth or family; (f) The FMT shall be administered electronically or in written form, as chosen by the youth and family; and (g) Other approved fidelity tools in addition to the FMT may be administered by the Division. (15) Transitions from Wraparound: (a) Upon completing the Wraparound team's mission statement, the team shall create a transition plan outlining the tasks required for Wraparound to be completed and shall implement the plan; (b) The Wraparound transition plan shall: (A) Outline the mix of formal and natural supports that the youth and family have chosen; and (B) Include a post-transition crisis management plan. (c) The WCC supports the team in creating a transition document that summarizes and highlights the youth and family's functional strengths, lessons learned and successfully used strategies; (d) The team conducts a culturally appropriate activity that acknowledges the end of formal Wraparound; (e) A young adult shall not be made to transition out of Wraparound solely due to attaining the age of 18. Young adults who reach the age of 18 while enrolled in Wraparound shall be offered the option to remain in Wraparound until their mission statement is achieved. Statutory/Other Authority: ORS 413.042 & ORS 430.630 Statutes/Other Implemented: ORS 413.042 & ORS 430.630 History: BHS 20-2022, amend filed 11/30/2022, effective 11/30/2022 BHS 20-2021, renumbered from 309-019-0326, filed 10/14/2021, effective 10/14/2021 BHS 19-2019, adopt filed 12/24/2019, effective 12/27/2019 BHS 7-2019, temporary adopt filed 06/21/2019, effective 07/01/2019 through 12/27/2019 309-019-0170 Outpatient Problem Gambling Treatment and Recovery Services Outpatient problem gambling treatment services include group, individual, and family treatment consistent with the following requirements: (1) Service sessions shall address the challenges of the individual as they relate directly or indirectly to the problem gambling behavior. (2) Providers may provide telephone counseling when face-to-face contact involves an unwise delay, as follows: (a) The individual shall be currently enrolled in the problem gambling treatment program; (b) Phone counseling shall be provided by a qualified program staff within their scope of practice; (c) Service notes for phone counseling shall follow the same criteria as face-to-face counseling and identify the session was conducted by phone and the clinical rationale for the phone session; (d) Telephone counseling shall meet HIPAA and 42 CFR standards for privacy; and (e) There shall be an agreement of informed consent for phone counseling that is discussed with the individual and documented in the individual’s service record. (3) Family counseling includes face-to-face or non-face-to-face service sessions between a program staff member delivering the service and a family member whose life has been negatively impacted by gambling: (a) Service sessions shall address the problems of the family member as they relate directly or indirectly to the problem gambling behavior; and (b) Services to the family shall be offered even if the individual identified as a problem gambler is unwilling or unavailable to accept services. (4) Twenty-four hour crisis response shall be accomplished through agreement with other crisis services, on-call program staff, or other arrangement acceptable to the Division. (5) A financial assessment shall be included in the entry process and documented in the assessment. (6) The service plan shall include a financial component consistent with the financial assessment. (7) A risk assessment for suicide ideation shall be included in the entry process and documented in the assessment as well as appropriate referrals made. (8) The service plan shall address suicidal risks if determined within the assessment process or throughout services. (9) For individuals at risk, the service notes shall contain documented evidence that suicidal risk is continually assessed and that follow-up safety plan activities are being monitored. Statutory/Other Authority: ORS 161.390, 430.640 & 461.549 Statutes/Other Implemented: ORS 161.390 - 161.400, 179.505, 413.520 - 413.522, 426.380- 426.395, 426.490 - 426.500, 428.205 - 428.270, 430.010, 430.205 - 430.210, 430.254 - 430.640, 430.850 - 430.955 & 443.400 - 443.460 History: MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 3-2015, f. & cert. ef. 5-28-15 MHS 1-2015(Temp), f. & cert. ef. 3-25-15 thru 9-20-15 MHS 4-2014, f. & cert. ef. 2-3-14 MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14 309-019-0175 Culturally Specific Substance Use Disorders Treatment and Recovery Services Programs approved and designated as culturally specific programs shall meet the following criteria: (1) Serve a majority of individuals representing culturally specific populations; (2) Maintain a current demographic and cultural profile of the community; (3) Ensure that individuals from the identified cultural group receive effective and respectful care that is provided in a manner compatible with their cultural health beliefs, practices, and preferred language; (4) Implement strategies to recruit, retain, and promote a diverse staff at all levels of the organization that are representative of the population being served; (5) Ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery; (6) Ensure that a majority of the substance use disorders treatment staff be representative of the specific culture being served; (7) Ensure that individuals are offered customer satisfaction surveys that address all areas of service and that the results of the surveys are used for quality improvement; (8) Consider race, ethnicity, and language data in measuring customer satisfaction; (9) Develop and implement cultural awareness policies; (10) Ensure that data on an individual’s race, ethnicity, and spoken and written language are collected in health records, integrated into the organization’s management information systems, and periodically updated; (11) Develop and maintain a governing or advisory board as follows: (a) Have a majority representation of the culturally specific group being served; (b) Receive training concerning the significance of culturally relevant services and supports; (c) Meet at least quarterly; and (d) Monitor agency quality improvement mechanisms and evaluate the ongoing effectiveness and implementation of culturally relevant services (CLAS) and supports within the organization. (12) Maintain accessibility to culturally specific populations including: (a) The physical location of the program shall be within close proximity to the culturally specific populations; (b) Where available, public transportation shall be within close proximity to the program; and (c) Hours of service, telephone contact, and other accessibility issues shall be appropriate for the population. (13) The physical facility where the culturally specific services are delivered shall be psychologically comfortable for the group including: (a) Materials displayed shall be culturally relevant; and (b) Mass media programming shall be sensitive to cultural background. (14) Other cultural differences shall be considered and accommodated when possible, such as the need or desire to bring family members to the facility, play areas for small children, and related accommodations; and (15) Ensure that grievance processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints. Statutory/Other Authority: ORS 413.042, 430.640 & 443.450 Statutes/Other Implemented: ORS 428.205 - 428.270, 430.010, 430.205 - 430.210, 430.254 - 430.640, 430.850 - 430.955 & 443.400 - 443.460 History: MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 4-2014, f. & cert. ef. 2-3-14 MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14 309-019-0181 Early Intervention ASAM Level 0.5 Programs shall be certified by the Division in accordance with OAR 309 Division 008 in order to render outpatient substance use disorder treatment and recovery services. A certificate issued to a program shall be effective for a duration not to exceed three years from the date of issue and may be renewed, conditioned, denied, suspended, or revoked by the Division in the manner set forth in OAR 309-008. Certified programs shall meet the standards set forth in these rules and all applicable statutes. (1) Currently certified providers shall submit complete outpatient substance use disorder treatment and recovery services applications to render each selected ASAM Level(s) of Care no later than October 1, 2023. (2) Division approved ASAM level(s) of Care shall be added to the outpatient substance use disorder treatment and recovery services certificate starting January 1, 2024. (3) Effective April 1, 2024, all outpatient substance use disorder treatment programs must have a valid certificate designating each ASAM Level(s) of Care that they are certified by the Division to provide. (4) Each program shall operate within the scope of the service(s) and ASAM Level of Care types listed on their certificate. (5) In addition to any other requirements described in these rules and applicable statutes, programs certified to render adolescent or adult Early Intervention ASAM Level 0.5 services shall, at a minimum, meet and maintain documentation demonstrating ongoing compliance with each of the following standards; Individuals placed at this ASAM Level of Care shall meet the following ASAM admission criteria: (a) ASAM dimensional admission criteria in at least one of Dimensions 4, 5, or 6; (b) Identifiable concerns in Dimensions 1, 2 and 3 are stable or being addressed through program or other community-based services; (c) Evidence of concern or risk factors that appear to be related to substance use behavior; and (d) R isk factors for developing a substance use disorder when the information is insufficient to diagnose a DSM-5-TR substance use, substance induced or other type of addictive disorder. (6) Programs approved to render ASAM Level 0.5 programs shall meet the following standards: (a) The Medical Director or an LMP shall be available for complex case consultation; (b) Staff in adolescent programs shall be knowledgeable about adolescent development and in engaging adolescents. (c) Program shall offer an array of services and supports, including the following: (A) Individual, group and family counseling; (B) Motivational Interventions; (C) Education; and (D) Referrals, to relevant community social services, healthcare and behavioral healthcare. (d) When it is determined an individual meets criteria for a higher ASAM Level of Care, the program shall provide care coordination to assist the individual in concurrently completing any applicable education requirements at Early Intervention ASAM Level 0.5 and treatment in an Outpatient Level of Care or transitioning to the identified services. 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 History: BHS 11-2023, adopt filed 04/07/2023, effective 04/07/2023 309-019-0182 Outpatient Substance Use Disorder Services ASAM Level 1 Programs shall be certified by the Division in accordance with OAR 309 Division 008 in order to render outpatient substance use disorder treatment and recovery services. A certificate issued to a program shall be effective for a duration not to exceed three years from the date of issue and may be renewed, conditioned, denied, suspended, or revoked by the Division in the manner set forth in OAR 309-008. Certified programs shall meet the standards set forth in these rules and all applicable statutes. (1) Currently certified providers shall submit complete outpatient substance use disorder treatment and recovery services applications to render each selected ASAM Level(s) of Care and any optional Enhanced ASAM Service Designation(s) no later than October 1, 2023. (2) Division approved ASAM level(s) of Care and optional Enhanced ASAM Service designation(s), if any, shall be added to the outpatient substance use disorder treatment and recovery services certificate starting January 1, 2024. (3) Effective April 1, 2024, all outpatient substance use disorder treatment programs must have a valid certificate designating each the following ASAM Level(s) of Care and any optional Enhanced ASAM Service designation(s) that they are certified by the Division to provide. (4) Each program shall operate within the scope of the service and ASAM Level of Care types listed on their certificate. (5) In addition to any other requirements described in these rules and applicable statutes, programs certified to render adolescent or adult residential ASAM Level 1 services shall, at a minimum, meet and maintain documentation demonstrating ongoing compliance with each of the following standards: (a) ASAM Level of Care 1 programs shall ensure the individual meets ASAM dimensional admission criteria: (A) ASAM dimensional admission criteria in each of the Dimensions; (B) Diagnostic criteria for a substance use, substance-induced or other addictive disorder, per DSM-5-TR, or the probability of such a diagnosis is determined through collateral information; and (C) When the ASAM Level of Care placement is not the same as the ASAM Level of Care assessed, the documentation shall include a rationale for this discrepancy. (b) Program staff shall include: (A) Medical Director or LMP who shall be available for complex case consultation; and (B) Adolescent programs shall have program staff knowledgeable about adolescent development and experienced in engaging and working with adolescent. (c) Arrange transfer of individuals to all other ASAM Levels of Care as indicated; and (d) Provide instruction on accessing emergency services by telephone 24 hours per day, 7 days per week. (6) Programs shall provide an array of weekly services and supports that are designed to meet the needs of the individual and their clinical severity through the number of planned hours per week and the type of planned services and supports. Programs shall ensure the following minimum standards: (a) Less than 9 hours of weekly treatment contact for adults; (b) Less than 6 hours of weekly treatment contact for adolescent; (c) Designed to meet the needs of the individual and their clinical severity through the number of planned hours per week and the type of planned services and supports; (d) Address lifestyle, thinking, belief, and behavioral patterns that are identified as barriers to the improvement of functioning; (e) Offer education, monitoring and disease management; (f) Offer or coordinate access to medical, psychiatric, including medication management, psychological services in a timeframe that matches the severity of the need; (g) Offer or coordinate access to urinalysis testing and other toxicology and laboratory testing services; and (h) Have direct affiliation or referral relationship with higher levels of care and medication management. (7) ASAM Enhanced Service designation(s) are service types that the program may choose to apply to render to either adults or adolescents when it corresponds to an ASAM Level of Care that is certified by the Division. Programs certified to render Outpatient Substance Use Disorder Services ASAM Level 1 may choose to also be certified to render any of the following Enhanced Service types: (a) ASAM Level 1 Co-occurring Capable services. Programs certified to render Co-occurring Capable ASAM Level 1 services shall render ASAM Level of Care 1 services as described in this rule and also, at a minimum : (A) Individuals admitted have co-occurring mental disorders that meet the stability criteria for a co-occurring capable program, or experience troublesome but subsyndromal symptomology; and (B) The mental health services are either rendered by community partners and closely coordinated or rendered by program staff who are qualified, credentialed and working within their scope. (b) ASAM Level 1 Co-occurring Enhanced services. Programs certified to render Co-occurring Enhanced ASAM Level 1 services shall render ASAM Level of Care 1 services as described in this rule and also, at a minimum: (A) Be certified to render services in accordance with OAR 309-019-0145 Intensive Co-occurring Disorders Services; (B) Render services as described in ASAM Level 2.5 Co-occurring Capable Program rules; (C) Include individuals whose co-occurring disorders are documented as either: (i) Moderate severity and needing ongoing monitoring; or (ii) High severity and chronic but have stabilized to the extent where these services are potentially beneficial. (D) Offer the following services: (i) Monitor and manage psychotropic medication; (ii) Mental health treatment; and (iii) Services that address the interaction between mental health and substance use disorders. 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 History: BHS 11-2023, adopt filed 04/07/2023, effective 04/07/2023 309-019-0183 Intensive Outpatient Substance Use Disorder Services ASAM Level 2.1 Programs shall be certified by the Division in accordance with OAR 309 Division 008 in order to render outpatient substance use disorder treatment and recovery services. A certificate issued to a program shall be effective for a duration not to exceed three years from the date of issue and may be renewed, conditioned, denied, suspended, or revoked by the Division in the manner set forth in OAR 309-008. Certified programs shall meet the standards set forth in these rules and all applicable statutes. (1) Currently certified providers shall submit complete outpatient substance use disorder treatment and recovery services applications to render each selected ASAM Level(s) of Care and any optional Enhanced ASAM Service Designation(s) no later than October 1, 2023. (2) Division approved ASAM level(s) of Care and optional Enhanced ASAM Service designation(s), if any, shall be added to the outpatient substance use disorder treatment and recovery services certificate starting January 1, 2024. (3) Effective April 1, 2024, all outpatient substance use disorder treatment programs must have a valid certificate designating each the following ASAM Level(s) of Care and any optional Enhanced ASAM Service designation(s) that they are certified by the Division to provide. (4) Each program shall operate within the scope of the service(s) and Level(s) of Care listed on their certificate. ASAM Level 2.1 services and supports may be rendered within an ASAM Level 3.1 service setting that is owned and operated by the same provider. (5) In addition to any other requirements described in these rules and applicable statutes, programs certified to render adolescent or adult residential ASAM Level 2.1 services shall, at a minimum, meet and maintain documentation demonstrating ongoing compliance with each of the following standards: (a) The individual meets ASAM dimensional admission criteria for ASAM Level 2.1 when: (A) Adult ASAM dimensional admission criteria is met in Dimensions 2, 3 and one of 4, 5, or 6; (B) Adolescent ASAM dimensional admission criteria is met in Dimensions 1 and 2, and the severity specifications in at least one of Dimensions 3, 4, 5, or 6; (C) Diagnostic criteria for a substance use or other addictive disorder, per DSM-5-TR, or the probability of such a diagnosis is determined through collateral information; and (D) When the ASAM Level of Care placement is not the same as the ASAM Level of Care assessed, the documentation shall include a rationale for this discrepancy. (b) Program staff include: (A) A Medical Director or LMP with credentialing, training or experience in addiction medicine be available for complex case consultation; and (B) Adolescent programs shall have program staff knowledgeable about adolescent development and experienced in engaging and working with adolescents. (c) Arrange transfer of individuals to all other ASAM Levels of Care as indicated; and (d) Provide instruction on accessing emergency services by telephone 24 hours per day, 7 days per week. (6) Programs shall provide an array of weekly services and supports that are designed to meet the needs of the individual and their clinical severity through the number of planned hours per week and the type of planned services and supports. Programs shall ensure the following minimum standards: (a) 9 to 19 hours of weekly treatment contact for adults; (b) 6 to 19 hours of weekly treatment contact for adolescents; (c) Services rendered by the program: (A) Individual, group and family therapy; and (B) Psychoeducation and motivational strategies. (d) Services rendered by the program or coordinated through consultation and referral: (A) Offer or coordinate access to urinalysis testing and other toxicology and laboratory testing services; (B) Psychiatric and medical services; (C) Medication management; (D) Occupational or recreational; (E) Skill-building; (F) Case management; and (G) Peer delivered services. (e) If an adult individual no longer requires 9 or more hours of structured programming per week or adolescent no longer requires 6 or more hours of structured programming per week and is not yet stable enough to transition to ASAM Level 1, the program may lessen the minimum required hours per week for a maximum of two weeks while focusing on stabilization and transition to Level 1. (7) ASAM Enhanced Service designation(s) are service types that the program may choose to apply to render to either adults or adolescents when it corresponds to an ASAM Level of Care that is certified by the Division. Programs certified to render Outpatient Substance Use Disorder Services ASAM Level 2.1 may choose to also be certified to render any of the following Enhanced Service types: (a) ASAM Level 2.1 Co-occurring Capable services. Programs certified to render Co-occurring Capable ASAM Level 2.1 services shall render ASAM Level of Care 2.1 services as described in this rule and also, at a minimum: (A) Ensure individuals admitted have documented co-occurring mental disorders and are able to tolerate and benefit from a co-occurring capable program, or experience troublesome but subsyndromal symptomology. (B) Be certified to render services in accordance with OAR 309-019-0145 Intensive Co-occurring Disorders Services; (C) Be appropriate for individuals with co-occurring disorders when the services are integrated into the program; and (D) Arrange medical and psychiatric consultation and medication management. (b) ASAM Level 2.1 Co-occurring Enhanced services. Programs certified to render Co-occurring Enhanced ASAM Level 2.1 services shall render ASAM Level of Care 2.1 services as described in this rule and also, at a minimum : (A) Render services as described by ASAM Level of Care 2.1 Co-occurring Capable program rules. (B) Have access to consult with an LMP; and (C) Render a comprehensive assessment with history and examination by an LMP within a reasonable timeframe given the current risk assessment and immediate needs profile. 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 History: BHS 11-2023, adopt filed 04/07/2023, effective 04/07/2023 309-019-0184 Partial Hospitalization Substance Use Disorder Services ASAM Level 2.5 Programs shall be certified by the Division in accordance with OAR 309 Division 008 in order to render outpatient substance use disorder treatment and recovery services. A certificate issued to a program shall be effective for a duration not to exceed three years from the date of issue and may be renewed, conditioned, denied, suspended, or revoked by the Division in the manner set forth in OAR 309-008. Certified programs shall meet the standards set forth in these rules and all applicable statutes. (1) Currently certified providers shall submit complete outpatient substance use disorder treatment and recovery services applications to render each selected ASAM Level(s) of Care and any optional Enhanced ASAM Service Designation(s) no later than October 1, 2023. (2) Division approved ASAM level(s) of Care and optional Enhanced ASAM Service designation(s), if any, shall be added to the outpatient substance use disorder treatment and recovery services certificate starting January 1, 2024. (3) Effective April 1, 2024, all outpatient substance use disorder treatment programs must have a valid certificate designating each the following ASAM Level(s) of Care and any optional Enhanced ASAM Service designation(s) that they are certified by the Division to provide. (4) Each program shall operate within the scope of the service and Level of Care types listed on their certificate. ASAM Level 2.5 services and supports may be rendered within an ASAM Level 3.1 service setting that is owned and operated by the same provider. (5) In addition to any other requirements described in these rules and applicable statutes, programs certified to render adolescent or adult residential ASAM Level 2.1 services shall, at a minimum, meet and maintain documentation demonstrating ongoing compliance with each of the following standards: (a) The individual meets ASAM dimensional admission criteria for ASAM Level 2.5 when: (A) Adult ASAM dimensional admission criteria is met in Dimensions 2, 3 and one of 4, 5, or 6; (B) Adolescent ASAM dimensional admission criteria is met when: (i) Stability specifications are met in Dimensions 1 and 2; and (ii) The severity specifications in at least one of Dimensions 3, 4, 5, or 6. (C) Diagnostic criteria for a substance use or other addictive disorder, per DSM-5-TR, or the probability of such a diagnosis is determined through collateral information; and (D) When the ASAM Level of Care placement is not the same as the ASAM Level of Care assessed, the documentation shall include a rationale for this discrepancy. (b) Program staff include those who are qualified and, when applicable, credentialed according to these rules and working within their scope, and shall include: (A) A Medical Director or LMP with credentialing, training or experience in addiction medicine or addiction psychiatry. The Medical Director or an LMP addiction specialist is available for complex case consultation; and (B) Adolescent programs shall have program staff knowledgeable about adolescent development and experienced in engaging and working with adolescent. (c) Arrange transfer of individuals to all other ASAM Levels of Care as indicated; and (d) Provide instruction on accessing emergency services by telephone 24 hours per day, 7 days per week. (6) Programs shall provide an array of weekly services and supports that are designed to meet the needs of the individual and their clinical severity through the number of planned hours per week and the type of planned services and supports. Programs shall ensure the following minimum standards: (a) 20 or more hours of weekly contact for adults; (b) 20 or more hours of weekly contact hours for adolescents; (c) ASAM Level 2.5 program includes an array of structured service and support treatment contacts per week, offered in a planned format, that are adapted to the individual’s developmental stage and comprehension level. Services and supports offered by the program shall include: (A) Individual, Group and Family therapy; (B) Psychoeducation and Motivational strategies; (C) Skill-building; and (D) Case management. (d) Services either offered by the program or coordinated through consultation and referral, which shall include: (A) Offer or coordinate access to urinalysis testing and other toxicology and laboratory testing services ; (B) Medical consultation and examination, laboratory and toxicology services; (C) Occupational therapy; (D) Recreational therapy; (E) Peer delivered services; and (F) Psychiatric services that are available within a timeframe reflective of the urgency of the symptoms. (7) ASAM Level 2.5 Co-occurring Capable Programs provide an additional and optional version of the services provided in Partial Hospitalization Substance Use Disorder Services ASAM Level of Care 2.5. Programs certified to render Partial Hospitalization Substance Use Disorder Services ASAM Level 2.5 may choose to also be certified to render ASAM Level 2.5 Co-occurring Capable services. All certified service types are listed on one certificate for the program. (8) ASAM Level 2.5 Co-occurring Capable services. Programs certified to render Co-occurring Capable ASAM Level 2.5 services shall render ASAM Level of Care 2.5 services as described in this rule and also, at a minimum: (a) Ensure individuals admitted have documented co-occurring mental disorders who are able to tolerate and benefit from a co-occurring capable program, or experience troublesome but subsyndromal symptomology; (b) Be certified to render services in accordance with OAR 309-019-0145 Intensive Co-occurring Disorders Services; (c) Include program staff working within their scope to document the mental health conditions, the relationship between the mental and substance use disorders, and the individual’s current level of functioning; (d) Offer intensive case management; and (e) Offer medication management and psychotherapy either by the program or through consultation and referral. (9) ASAM Level 2.5 Co-occurring Enhanced Programs provide an additional and optional version of the services provided in Partial Hospitalization Substance Use Disorder Services ASAM Level of Care 2.5. Programs certified to render Partial Hospitalization Substance Use Disorder Services ASAM Level 2.5 may choose to also be certified to render ASAM Level 2.5 Co-occurring Enhanced services. All certified service types are listed on one certificate for the program. (10) ASAM Level 2.5 Co-occurring Enhanced services. Programs certified to render Co-occurring Enhanced Programs ASAM Level 2.5 shall render ASAM Level of Care 2.5 services as described in this rule and also, at a minimum: (a) Render services as described by ASAM Level 2.5 Co-occurring Capable Program rules; (b) Have the capacity to effectively treat individuals who have complex co-occurring conditions. These programs shall provide: (A) Psychiatric services; (B) Medication management; (C) A review of the recent psychiatric history; (D) A mental status examination; and (E) A comprehensive psychiatric history examination and assessment performed within a timeframe determined by the individual’s psychiatric condition. 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 History: BHS 11-2023, adopt filed 04/07/2023, effective 04/07/2023 309-019-0185 Outpatient Substance Use Disorders Treatment and Recovery Programs (1) Programs approved to provide outpatient substance use disorders treatment services shall meet the following standards: (a) Programs shall ensure documentation at the time of entry contains an evaluation that identifies and assesses needs such as social isolation, self-reliance, parenting issues, domestic violence, physical health, housing, and financial considerations; (b) Programs shall ensure the service plan addresses all areas of concern identified in the assessment that the individual agrees to address, and applicable service coordination details to address the identified needs; (c) The program shall provide or coordinate services and supports that meet special access needs such as childcare, mental health services, and transportation; and (d) The program shall provide or coordinate the following services and supports that the individual agrees to address: (A) Gender-specific services and supports; (B) Family services, including therapeutic services for children in the custody of women in treatment; (C) Reintegration with family or community; (D) Peer delivered services; (E) Smoking cessation; (F) Housing; (G) Transportation; and (H) Housing and Employment support services for those who qualify under OAR 309-0190-0105. (2) Services shall include the participation of family and other agencies as appropriate, such as social service, child welfare, or corrections agencies. (3) The program shall coordinate referral services with the following: (a) Agencies providing services to individuals who have experienced physical abuse, sexual abuse, or other types of domestic violence; (b) Parenting training; (c) Continuing care treatment services shall be consistent with The ASAM Criteria and shall include referrals to support groups where available. (4) Programs that receive SUPTR block grant funding shall provide or coordinate the following services for individuals: (a) Primary medical care, including referral for prenatal care if applicable, and childcare and transportation where needed; (b) Primary pediatric care, including immunizations for their children; (c) Gender specific substance use disorders treatment and other therapeutic interventions that may include but are not limited to: (A) Relationship issues; (B) Sexual and physical abuse; (C) Parenting; (D) Access to childcare and transportation while receiving these services; and (E) Therapeutic interventions for children in the custody of women or men in treatment that may include but are not limited to: (i) Their developmental needs; (ii) Any issues concerning sexual and physical abuse and neglect; and (iii) Sufficient case management and transportation to ensure that individuals and their children have access to services. (5) Providers that deliver adolescent substance use disorders treatment services or those with adolescent-designated service funding shall meet the following standards: (a) Development of service plans and case management services shall include participation of parents, other family members, schools, children's services agencies, and juvenile corrections; (b) Services or appropriate referrals shall include: (A) Family counseling; (B) Community and social skills training; and (C) Smoking cessation service. (6) Continuing care services shall be of appropriate duration and designed to maximize recovery opportunities. The services shall include: (a) Reintegration services and coordination with family and schools; (b) Adolescent self-help groups where available; (c) Referral to emancipation services when appropriate; (d) Referral to physical or sexual abuse counseling and support services when appropriate; and (e) Referral for peer delivered services. Statutory/Other Authority: ORS 161.390, 413.042 & 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 History: BHS 11-2023, amend filed 04/07/2023, effective 04/07/2023 BHS 1-2022, amend filed 01/05/2022, effective 01/05/2022 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 MHS 4-2014, f. & cert. ef. 2-3-14 MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14 309-019-0190 Community-Based Substance Use Treatment Programs for Individuals in the Criminal Justice System (1) For individuals in the criminal justice system, community-based substance use treatment services and supports are for individuals who are under the supervision of a probation officer or on parole or post-prison supervision or participating in a drug treatment court program or otherwise under the direct supervision of the court. (2) Services and supports shall incorporate interventions and strategies that target criminogenic risk factors and include: (a) Cognitive behavioral interventions; (b) Motivational interventions; (c) Relapse prevention; and (d) Healthy relationships education. (3) Providers shall demonstrate coordination of services with criminal justice partners through written protocols, program staff activities, and individual record documentation. (4) Program directors or clinical supervisors shall have experience in community-based offender treatment programs and have specific training and experience applying effective, evidence-based clinical strategies and services for individuals receiving community-based substance use disorders treatment services to individuals in the criminal justice system. (5) Within the first six months of hire, program staff shall: (a) Receive training on effective principles of evidenced-based practices for individuals with criminogenic risk factors; and (b) Have documented knowledge, skills, and abilities demonstrating treatment strategies for individuals with criminogenic risk factors. Statutory/Other Authority: ORS 161.390, 413.042 & 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 History: MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 4-2014, f. & cert. ef. 2-3-14 MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14 309-019-0195 DUII Services Providers (1) Outpatient Substance Use Disorders (SUD) Treatment Programs approved by the Division as DUII Services Providers and for ASAM Levels of Care 0.5 and 1.0, , shall provide DUII Education and DUII Rehabilitation as outlined in this rule. (2) A DUII Services Provider may not provide Alcohol and Other Drug Screening Specialist (ADSS) services except as allowed in OAR 415-054-0545 through 415-054-0570. (3) DUII Services Providers shall assess, as outlined in OAR 309-019-0135(3), all individuals seeking DUII services. Level of care, diagnosis, frequency of contact, and duration of treatment services shall be consistent with the current DSM-5-TR diagnostic and The ASAM Criteria . (4) DUII Education shall be provided for individuals who: (a) Do not currently meet DSM-5-TR diagnostic criteria for a SUD; and (b) Meet ASAM Level of Care 0.5; and (c) Have never been diagnosed with a SUD; and (d) Have never been enrolled in a DUII or SUD treatment program. (5) DUII Education shall include a minimum of four sessions over a four-week period and include the provision of a minimum of 12 hours of didactic education. The minimum 12 hours does not include diagnostic assessment, service planning, or transfer planning. DUII Education shall include but is not limited to: (a) Completion of a Division approved DUII Education Pre and Post Test; (b) DUII Laws and Consequences in Oregon; (c) Use of alcohol and other drugs, and their effects on driving; (d) Physical and psychological effects of alcohol and other drugs of abuse; (e) SUD signs and symptoms; (f) SUD recovery support services; and (g) Alternatives to intoxicated driving. (6) No more than four of the 12 minimum hours shall be conducted utilizing educational films or pre-recorded audio-visual presentations. (7) DUII Rehabilitation shall be provided for individuals who: (a) Meet DSM-5-TR diagnostic criteria for a SUD; or (b) Meet ASAM Level of Care 1.0 or higher; or (c) Have been previously diagnosed with a SUD; or (d) Have previously been enrolled in a DUII or SUD treatment program. (8) DUII Rehabilitation shall include: (a) DUII Education as described in section (5) of this rule; and (b) SUD treatment services as outlined in the individual’s service plan. (9) DUII Service Providers shall use urinalysis testing for use of substances of abuse following procedures in OAR 309-019. Urinalysis tests shall be conducted as deemed clinically appropriate, but no less than: (a) At the time of assessment; and (b) Twice per calendar month with no more than 14 calendar days between tests; and (c) Within two weeks prior to completion; and (d) Within 72 hours of receipt of laboratory results indicating that a urinalysis sample was identified as out of range for Creatinine, pH, or Specific Gravity as defined by the urinalysis laboratory results; (10) Urinalysis shall, at a minimum, test for the following substances of abuse: (a) Alcohol; (b) Marijuana; (c) Cocaine; (d) Amphetamines; (e) Opiates; and (f) Benzodiazepines. (11) In addition to the substances of abuse outlined in section (10), an EtG/EtS test for alcohol shall be conducted, at a minimum, at the time of assessment and within two weeks prior to completion. (12) Individuals enrolled in DUII Education are expected to demonstrate abstinence from use of intoxicants as evidenced by negative urinalysis reports, except as allowed in ORS 813.200. Individuals who provide a positive urinalysis test or who self-report use of a substance shall be required to complete DUII Rehabilitation. (13) Individuals enrolled in DUII Rehabilitation are expected to maintain abstinence from use of intoxicants as evidenced by negative urinalysis tests, except as allowed in ORS 813.200, while outside of a controlled environment for no less than the final 90 days of the DUII Rehabilitation program. (14) Notwithstanding sections (9)-(11), DUII Services Providers may issue a DUII Treatment Completion Certificate for individuals convicted of DUII or proof of completion for individuals under a diversion agreement, if the individual has fulfilled all other requirements of this rule except for submission of urinalysis testing as required due to a state of emergency declared by the state or county in which the individual or DUII Services Provider is located. The individual’s service record must clearly document the reason the state of emergency prevented submission of urinalysis as required in sections (9)-(11). (15) Division approved DUII Services Providers shall issue a DUII Treatment Completion Certificate (DTCC) for individuals convicted of a DUII using Division approved forms and procedures after: (a) Receipt of referral from an ADSS; and (b) Completion of DUII Education or DUII Rehabilitation, including applicable abstinence requirements, as outlined in these rules; and (c) Compliance with the terms of the fee agreement between the provider and the individual. (16) The Division shall issue a DTCC for individuals completing an out-of-state intoxicated driving program after: (a) Documentation of the individual’s residency in a state other than Oregon; and (b) Receipt of a copy of the individual’s referral from an ADSS; and (c) Documentation of completion of an intoxicated driving program as allowed for the equivalent conviction in the individual’s state of residence. Residents of states that do not require DUII treatment shall complete a program that is substantially equivalent to Oregon’s standards. (17) Division approved DUII Services Providers must report: (a) To the Division using the mandated state data system; and (b) To the referring ADSS as allowed by HIPPA and 42 CFR Part 2: (A) No later than 30 calendar days from the date of referral; (B) Every 30 calendar days while enrolled in DUII Rehabilitation; (C) No later than 14 calendar days from the date of discharge; (D) No later than seven calendar days from the written request of the ADSS. (18) The individual’s Service Record must include all information necessary to document the individual’s successful or unsuccessful completion of DUII Services. Statutory/Other Authority: ORS 413.042, 430.640, 430.254, 430.256 & 430.357 Statutes/Other Implemented: ORS 430.010, 743A.168, 430.030 & 430.254-430.640 History: BHS 11-2023, amend filed 04/07/2023, effective 04/07/2023 BHS 17-2021, amend filed 08/13/2021, effective 08/13/2021 BHS 7-2021, amend filed 03/18/2021, effective 03/19/2021 BHS 12-2020, temporary amend filed 09/22/2020, effective 09/22/2020 through 03/20/2021 BHS 4-2020, temporary amend filed 03/23/2020, effective 03/23/2020 through 09/18/2020 BHS 8-2018, amend filed 03/22/2018, effective 04/01/2018 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16 MHS 4-2014, f. & cert. ef. 2-3-14 MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14 309-019-0200 Medical Protocols in Outpatient Substance Use Disorders Treatment and Recovery Programs Medical protocols shall be approved by a medical director under contract with a program or written reciprocal agreement with a medical practitioner under coordinated care. The protocols shall: (1) Require a medical history be included in the assessment. (2) Designate those medical symptoms and conditions that, when found, require further investigation, physical examinations, treatment, or laboratory testing. (3) Require that individuals admitted to the program who are currently injecting or intravenously using a drug or have injected or intravenously used a drug within the past 30 days or who are at risk of withdrawal from a drug or who may be pregnant shall be referred for a physical examination and appropriate lab testing within 30 days of entry to the program. This requirement may be waived by the medical director if these services have been received within the past 90 days and documentation is provided. (4) Require pregnant women be referred for prenatal care within two weeks of entry to the program. (5) Require that the program provide HIV and AIDS, TB, sexually transmitted disease, Hepatitis and other infectious disease information and risk assessment, including any needed referral, within 30 days of entry. (6) Specify the steps for follow up and coordination with physical health care providers in the event the individual is found to have an infectious disease or other major medical problem. Statutory/Other Authority: ORS 430.640 & 443.450 Statutes/Other Implemented: ORS 428.205 - 428.270, 430.010, 430.205 - 430.210, 430.254 - 430.640, 430.850 - 430.955 & 443.400 - 443.460 History: MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 4-2014, f. & cert. ef. 2-3-14 MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14 309-019-0205 Building Requirements in Behavioral Health Programs All behavioral health treatment programs must: (1) Comply with all applicable state and local building, electrical, plumbing, fire, safety, and zoning codes. (2) Maintain up-to-date documentation verifying that they meet applicable local business license, zoning, and building codes and federal, state, and local fire and safety regulations. It is the responsibility of the program to check with local government to make sure all applicable local codes have been met. (3) Provide space for services including but not limited to intake, assessment, counseling, and telephone conversations that assure the privacy and confidentiality of individuals and is furnished in an adequate and comfortable fashion including plumbing, sanitation, heating, and cooling. (4) Provide rest rooms for individuals, visitors, and staff that are accessible to individuals with disabilities pursuant to Title II of the Americans with Disabilities Act if the program receives any public funds or Title III of the Act if no public funds are received. (5) Adopt and implement emergency policies and procedures, including an evacuation plan and emergency plan in case of fire, explosion, accident, death, or other emergency. The policies and procedures and emergency plans must be current and posted in a conspicuous area. (6) Outpatient programs may not allow tobacco use in program facilities and on program grounds. Statutory/Other Authority: ORS 413.042, 430.640 & 443.450 Statutes/Other Implemented: ORS 428.205 - 428.270, 430.010, 430.205 - 430.210, 430.524 - 430.640, 430.850 - 430.955 & 443.400 - 443.460 History: MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 Suspended by MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 4-2014, f. & cert. ef. 2-3-14 MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14 309-019-0210 Quality Assessment and Performance Improvement Providers shall develop and implement a structured and ongoing process to assess, monitor, and improve the quality and effectiveness of services provided to individuals and their families. Statutory/Other Authority: ORS 430.640 Statutes/Other Implemented: ORS 430.010, 430.205 - 430.210, 430.254 - 430.640 & 430.850 - 430.955 History: MHS 6-2017, f. & cert. ef. 6-23-17 MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 4-2014, f. & cert. ef. 2-3-14 MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14 309-019-0215 Grievances and Appeals (1) Any individual or parent or guardian receiving services may file a grievance with the provider, the individual’s coordinated care plan, or the Division. (2) The provider’s grievance process shall: (a) Notify each individual or guardian of the grievance procedures by reviewing a written copy of the policy upon entry; (b) Assist individuals and parents or guardians to understand and complete the grievance process and notify them of the results and basis for the decision; (c) Encourage and facilitate resolution of the grievance at the lowest possible level; (d) Complete an investigation of any grievance within 30 calendar days; (e) Implement a procedure for accepting, processing, and responding to grievances including specific timelines for each; (f) Designate a program staff individual to receive and process the grievance; (g) Document any action taken on a substantiated grievance within a timely manner; and (h) Document receipt, investigation, and action taken in response to the grievance. (4) The provider shall post a Grievance Process Notice in a common area stating the telephone numbers of: (a) The Division; (b) Disability Rights Oregon; (c) Any applicable coordinated care organization; and (d) The Governor’s Advocacy Office. (5) In circumstances where the matter of the grievance is likely to cause harm to the individual before the grievance procedures are completed, the individual or guardian of the individual may request an expedited review. The program administrator shall review and respond in writing to the grievance within 48 hours of receipt of the grievance. The written response shall include information about the appeal process. (6) A grievant, witness, or staff member of a provider may not be subject to retaliation by a provider for making a report or being interviewed about a grievance or being a witness. Retaliation may include but is not limited to dismissal or harassment, reduction in services, wages, or benefits, or basing service or a performance review on the action. (7) The grievant is immune from any civil or criminal liability with respect to the making or content of a grievance made in good faith. (8) Individuals and their legal guardians may appeal entry, transfer, and grievance decisions as follows: (a) If the individual or guardian is not satisfied with the decision, the individual or guardian may file an appeal in writing within ten working days of the date of the program administrator's response to the grievance or notification of denial for services. The appeal shall be submitted to the Division; (b) If requested, program staff shall be available to assist the individual; (c) The Division shall provide a written response within ten working days of the receipt of the appeal; and (d) If the individual or guardian is not satisfied with the appeal decision, they may file a second appeal in writing within ten working days of the date of the written response to the Division Director. Statutory/Other Authority: ORS 161.390, 413.042, 430.256 & 430.640 Statutes/Other Implemented: 430.254 - 430.640, 430.850 - 430.955, 743A.168, ORS 161.390 - 161.400, 179.505, 428.205 - 428.270, 430.010 & 430.205 - 430.210 History: MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16 MHS 4-2014, f. & cert. ef. 2-3-14 MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14 309-019-0220 Variances (1) Requirements and standards for requesting and granting variances or exceptions are found in OAR 309-008-1600. (2) The Division’s chief officer or designee shall approve or deny the request for a variance to these rules. The request shall be made in writing using the Division approved variance request form and following the variance request procedure pursuant to OAR 309-008-1600. (3) Granting a variance for one request does not set a precedent that shall be followed by the Division when evaluating subsequent requests for variance. Statutory/Other Authority: ORS 161.390, 413.042, 430.256 & 430.640 Statutes/Other Implemented: ORS 161.390 - 161.400, 179.505, 430.010, 430.205 - 430.210, 430.254 - 430.640, 430.850 - 430.955 & 743A.168 History: MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16 MHS 4-2014, f. & cert. ef. 2-3-14 MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14 309-019-0225 Assertive Community Treatment (ACT) Definitions (1) In addition to the definitions in OAR 309-019-0105, when used and not otherwise defined in OAR 309-019-0225 through OAR 309-019-0255, the following terms shall have the meaning given in this section. (2) 24/7 Crisis Coverage” means the ACT Team will develop internal procedures to ensure ACT participants have access to the on-call ACT staff if they are experiencing a mental health crisis 24 hours a day, 7 days a week, 365 days a year: (a) ACT Teams must be readily available to assist with de-escalation strategies and have direct access to the participants treatment & crisis plans created to ensure full ACT benefit of service. This could include dispatching out to the individual in need; (b) The ACT Team is required to document all received crisis coverage calls and dispatches by the ACT Team as part of this service delivery. (3) “Admission” means for ACT services, when a person is deemed fully eligible by going through the entire Standardized Referral Process for ACT services and is approved for entry. This includes notification of first appointment. (4) “Assertive Community Treatment” or “ACT” means an intensive and highly integrated Community-Based outpatient service. It is expected in Oregon that a certified ACT Program upholds the integrity of the evidence-based practice and recovery-oriented mental health service by being held to a fidelity standard based on the Division approved fidelity scale. This service is a trauma-informed & person-centered approach with a Multidisciplinary Team concept. (5) “Community-Based” means services and supports that must be provided in a setting that is not the ACT Teams office space or building. The term “Community” is intended to be centered on the participant’s dwelling and/or locations the participant deems or approves as having a common characteristic or other form of connection. This includes but not limited to virtual telehealth, or public settings where the participant feels comfortable. (6) “Competitive Integrated Employment” means full-time or part time work with the following criteria: (a) At minimum wage or higher; (b) At a rate that is not less than the customary rate paid by the employer for the same or similar work performed by other employees; (c) With eligibility for the level of benefits provided to other employees; (d) Internships that are open to anyone. This includes work-study opportunities with colleges and or trade schools; (e) Seasonal employment that is consistent with that industry of work; (f) Self-Employment if income is reported to the government and taxes could be filed; (g) Employment gained through temporary agencies that other community members utilize is counted only if that temporary agency and/or the industry of employment typically hires from that temporary services. This avenue does not replace the Employment Specialists roles nor can tasks that are expected to be provided by the Employment Specialist be delegated to that temporary agency. The temporary agency’s tasks or coordination on behalf of the participant will not count nor be taken into consideration during a fidelity review. (h) When the work or employment supports are integrated by way of being added to an existing or become part of a new Mental Health treatment plan. (7) “Comprehensive Evaluation” means the analytic evaluation process that the ACT clinician must do when they are determining if ACT services are the appropriate level of care. This evaluation is evident during the Screening phase within the Standardized Referral Process or if a transfer of care is warranted (either heighten or reduced acuity level). This evaluation may include gathering collateral information in the form of additional documentation or through verbal communication by way of. interviewing key stakeholders consisting of both Informal & Natural Supports. (a) The methods of how this evaluation is conducted is at the discretion of the ACT clinician and or their behavioral health agency policy to allow autonomy in making final determinations on referrals, or closure of services. (b)This evaluation is a key component if any final determinations are also in need of additional level of care recommendation(s). (c) Information to be gained during this evaluation should at minimum include the following: (A) Current and/or past mental health symptom(s) and executive functional status; (B) Effectiveness of past treatment(s); (C) Current treatment, rehabilitation, and/or what support would be needed in order to achieve person-centered and self-directed goals and recovery; and (D) The range of the persons individual strengths (e.g., knowledge gained from dealing with adversity, personal attributes, professional roles, talents, personal traits, etc). (8) “Co-Occurring Disorders (COD) Specialist” means the staff identified within the ACT Team as the core staffing requirement, to conduct integrated assessments and create treatment strategies for ACT Participants who have been identified as having a co-occurring mental health and substance use condition(s). This team member must have proper credentials per Behavioral Health Outpatient OAR’s: Chapter 309, Division 019 Section 0145 in the State of Oregon. (9) Crisis Plan: A document securely stored for proper accessibility by all ACT Team members and/or the identified entity who is delegated for any crisis response for ACT participants which is meant to maintain integrity of the ACT model and treatment service delivery. The document must clearly be identifiable as the Crisis Plan for that individual, however, could be included/identified as a section within the Strength-Based Treatment plan or a completely separate document at minimum, it must include: (a) Identification of known triggers or known risk factors (e.g. history of aggression, self-harm etc.) (b) Intervention tactics or strategies that are recommended to defuse, de-escalate participants to reduce the likelihood of self-inflicted harm or harm to bystanders present during the crisis. (c) Current medications and any known allergies. (d) Key contacts that may be needed during a crisis event such as emergency-medical personnel, relevant staff/person to contact if situation warrants the need for judicial escalation pathway or emergency commitment and Participant’s Guardian, Power of Attorney and/or emergency contact(s). (e) All recommended interventions or strategies need to be precise language and written in a way for quick referencing for adequate implementation to promote safety for participant, bystanders and ACT/crisis staff. (10) “Division” means the Behavioral Health Division within Adult Mental Health of the Oregon Health Authority. (11) “Division Approved Reviewer” means the entity that is selected by the Division to conduct selected ACT functions based on the Divisions discretion to support ACT programs statewide. (12) “Employment Specialist” means for ACT, the staff identified on the ACT Team to provide Employment Support Services per (39) of this ruleset and is considered part of the ACT Multidisciplinary Team based on fidelity. This staff can be a contracted position or employed within the behavioral health agency that offers ACT services. (13) “Face to Face” means fa personal interaction, where communication between at least two-person(s) can be had either physically in-person or virtually through telehealth services per Medicaid OAR 410-120-1990 rule set. Virtual Telehealth meetings for Face-to-Face therapy fidelity measurement purposes will be counted and accepted as face-to-face if documentation supports the meeting followed Medicaid standards including verification of client. If telehealth is used in any manner to deliver quality ACT services, the ACT Team Member is required to have their camera on for the full duration of encounter to promote presence & commitment to rapport building, transparency for HIPAA compliance on participants right to know who they are meeting with and allowing visibility of non-verbal cues. (14) “Fidelity” means the ACT Program is able to reproduce intended outcomes by delivering services that are aligned with the evidence-based model and guidance within the Chapter 309, Division 19 ACT rule set 0225 through 0255. (15) “Fidelity Tool(s)” are any documents used when initiating or conducting a fidelity review for a behavioral health provider who is certified to implement ACT service. They can include, but not limited to approved fidelity scale, team or client survey’s or anything that contributes to gaining information to fully evaluate programs for fidelity based on the Division approved fidelity scale. All tools must be approved through appropriate Division Designee prior to becoming part of the fidelity process. (16) “Fixed Point of Responsibility” means the ACT Team provides essentially all needed mental health treatment services, rather than sending participants to different service deliveries. The term “different” in this context includes other service deliveries even if they are within the same agency of the ACT team. If the ACT Team cannot provide a needed treatment service as a result of lacking the specialty licensure requirement for the treatment, the program will accommodate and delegate this treatment service to appropriate service support, despite any impacts to their fidelity rating to avoid negative impacts to the participant(s) health & wellbeing if that treatment was unavailable. (17) “Frontier ACT Team” for ACT services means the ACT Team capacity or clients served is predominantly in a geographical area with six or fewer people per square mile. (18) “Full-Time Equivalent” or “FTE” means for ACT fidelity purposes, is a way to calculate and measure the client to staff ratio for an ACT Team. Staff members identified to dedicate time to ACT specific duties will be measured based on a 40-hour work week regardless of their job description or agency policies for FTE status. The consistency of using 40 hours ensures equitable evaluation and ratings for all Teams within the State. (19) “Hospital Discharge Planning” means the collaboration between the ACT Team, the Oregon State Hospital (OSH) or any other acute care psychiatric hospital for care coordination, and discharge planning, through a person-centered planning process for active ACT Participant’s or individuals seeking to receive ACT services through the Standardized Referral Process. (20) “Informal Support System” means a person(s) outside of ACT Team that is identified as a key influence or involved person(s) by the participant or ACT staff for the purposes of treatment planning. This person (often another professional) can include a, landlord, shelter staff, or employer (21) “Large ACT Team” means an ACT team that has between 80 to 120 individuals actively enrolled in services. (22) “Life Skills Training” means the modeling & training from the ACT staff to support Participants in developing the necessary and meaningful skills and delivered with the intention to promote independence, self-direction and contribute to enhancement of Participants quality of life within their community and social environments. (23) “Medication Administration” means for ACT services when an ACT team member dispenses and must take several action steps directly with the participant by way of required intended use of the medication in order for the participant to receive and/or ingest the medication. This can include dispensing single or multiple doses, injections or direct application. (a) This can also include if ACT Team need to provide verbal cues or step by step instructions during the active motion of taking the medication because of the Participants limited executive function capabilities or if there are other factors that contribute to the need for a safety protocol. Safety protocols must be documented by an Oregon qualified medical or clinical licensed professional. (b) Administration does not include a hand-to-hand transfer, pass off or drop off to a participant. (24) “Medication Management” means for ACT services can include the prescribing, storing and evaluating and/or monitoring for side effects. In addition, this can also include providing medication education by way of life-skills training tasks that will support a Participant learn to become independent in all medication needs which requires full knowledge of proper management. For the purposes of ACT, Medication Management is a collaborative effort to promote shared decision making between the Participant and the prescribing psychiatrist or psychiatric nurse practitioner. Other staff who contribute to this task: (a) The nurse or staff with proper licensing on the ACT team is recommended to manage & coordinate the overall medication system including ensuring adherence and compliance of storage & accountability tracking if the agency stores medications on site (b) Other staff may contribute to Medicaid Management by way of verifying pill count during home visits, physically brining medications to the participant for hand off or drop off and other minimal avenues based on Oregon standards per their credentials. (25) “Mid-Size Act Team” means an ACT team that has between 41 and 79 individuals actively enrolled. (26) “Natural Supports” means personal associations and relationships typically developed in the community that enhance the quality and security of life for Participants. This includes but not limited to family relationships, friendships reflecting the diversity of the neighborhood and the community, association with fellow students or coworkers in regular classrooms, and associations developed though participation in clubs, organizations, and other civic activities. (27) “Priority Service Population” for ACT services is the criteria for triaging purposes to ensure those individuals with a serious and persistent mental illness are connected to services as quickly as possible and prioritized based on acuity level. ACT services are designed for is adults 18years of age or older who have a primary diagnosis per the current DSM of at least one of the following: (a) Schizophrenia Spectrum Disorders including Schizoaffective; (b) Bipolar (c) Major Depressive Disorder and/or Post-Traumatic Stress Disorder present with psychotic symptomatic features that negatively impact daily living or level of functioning. (d) Obsessive compulsive disorder (OCD) inclusive with persistent & intrusive thoughts contributing to long-term poor insight that negatively impacts daily living activities. (28) “Projection Fidelity” is a mock or unofficial fidelity review with the objective of providing a hypothetical fidelity score. This report is intended to provide a baseline snapshot of that Teams implementation mirroring a rehearsal or preparation training. to create a Technical Assistance plan with identified steps the ACT Team can take to replicate the service delivery model, while also providing highlights of accomplishments. (29) “Psychiatry Services” means the prescribing, administering and reviewing of medications and their side effects, including both pharmacological management as well as supports and training to the individual. Psychiatry services shall be provided by a psychiatrist, or a psychiatric nurse practitioner licensed by the Oregon Medical Board. (30) “Rural ACT Team” means the ACT Team’s capacity or clients served, are predominantly in a geographical area with ten or more miles from a population center of 40,000 people or more. (31) “Screening” for ACT services is the second step of the Standardized Referral Process. It is the comprehensive evaluation per (21) of this rule set. At minimum screenings must include a Face-to-Face interview conducted by an ACT clinician with qualified credentials to evaluate both the diagnostic and level of functioning eligibility criteria. The Screening phase may also include: (a) Obtaining additional information from other sources that are not the referring party; (b) Care Coordination meetings or community networking to identified legal authority (e.g. parole, probation offer, etc.) who could later become Informal Supports if admission is granted. (c) If efforts are made to obtain additional items listed in (a) & (b) of this ruleset, there cannot be any delay in communication or final determination per the Standardized Referral Process’ in 0248. (32) “Single Point of Contact (SPOC)” means the entity that is not directly part of the certified ACT Team and designated to orchestrate the receipt of the Universal Referral Form on behalf of the ACT Team to streamline ease of access for the community. This coordination of supports can be in collaboration with the Coordinated Care Organizations (CCO) or even within the same agency as the ACT Team. Team. (33) “Small ACT Team” means an ACT team that has between 10 to 40 individuals actively enrolled. (34) “Strength-Based treatment Plan” means for ACT a document that has the clinical and health relevant information about the participant and is, stored in a secured, central location so that ACT Team members can gain access as needed to support them in planning interactions with participant. It is an evolving document and be updated as often as necessary to ensure content is current. This includes at minimum, any information deemed relevant during the Comprehensive Evaluation, (7) of this rule set, in addition to the following: (a) Itemized person-centered and/or self-directed goals that clearly identify realistic benchmark(s) for achievement based on participants executive functioning levels and future oriented thinking capacity to ensure their contribution to agreement and to support when/if treatment plan is referenced to participant by any of the ACT Team members. (b) The benchmarks will be focused on participant preferences and cannot be used as a mechanism for enforcing any sort of compliance to receive or maintain ACT services. (c) It must be formatted in a culturally and linguistically specific way as identified by the ACT Participant. (35) “Telehealth” means ACT Team provides Face-to-Face services that are delivered using secure HIPAA compliant audio and video communication. All allowable accommodations will be made for any individuals with any hearing, visual or physical impairments or disabilities who agree to utilize services in this manner per Medicaid compliance within OAR 410-120-1990 rule set. (36) “Time-unlimited Services” means services that are not provided based on predetermined timelines but based on medically appropriateness. (37) “Urban ACT Team” means for ACT services the ACT Team capacity or clients served is predominantly in a geographical area that is less than 10 miles from the center of a population center of 40,000 people or more. (38) “Vocational Services” means the duties performed by the Employment Specialist that leads to Competitive Integrated Employment as defined in this rule set (6). (39) “Waitlisted” means for ACT services when an individual is deemed eligible for ACT services, however, cannot be admitted as a result of the ACT Team having an active enrollment count at the highest capacity per their team size ratio size based on OAR 309-019-0225(21,24,30). Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 430.630 History: BHS 29-2025, amend filed 12/29/2025, effective 01/01/2026 BHS 17-2025, amend filed 06/25/2025, effective 06/29/2025 BHS 32-2024, temporary amend filed 12/27/2024, effective 01/01/2025 through 06/29/2025 BHS 44-2023, amend filed 12/22/2023, effective 01/01/2024 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 1-2017(Temp), f. 1-17-17, cert. ef. 1-18-17 thru 7-16-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16 309-019-0226 Assertive Community Treatment (ACT) Overview (1) The ACT Model is an evidence-based practice with a specified Service Priority Population per 309-019-0225(28) and is implemented as a Community Based service. This service delivery is designed to be a long-term support; therefore, is not intended to be a solution for an immediate or short-term crisis. The clinical evaluation is comprised of specific criteria Oregon’s ACT Teams are expected to: (a) Operate as a Multidisciplinary Team and Fixed-Point of Responsibility per OAR 309-019-0225(16); (b) Operate as close to recommended best practice of at least 10:1 client to staff ratio for Urban teams and 7:1 for Rural and Frontier, to consistently provide necessary staffing diversity and coverage. (c) Provide time-unlimited services; (d) Be flexible with service delivery; (e) 24/7 crisis availability. (2) ACT Programs must adhere to the following: (a) Providing explicit admission criteria that aligns with Oregon Administrative Rules (OAR) with the Service Priority Population as defined in 309-019- 0225 (28) utilizing the Universal Referral Form provided by the Division per 309-019-0248; (b) The admission process and Universal Referral Form must be published for any public person(s) and/or community partners to freely access on program websites to ensure equitable access. This includes promoting the no-wrong-door concept by providing quality customer service for requests of services from non-behavioral health individuals (family members, shelter staff or self-referrals) then routing appropriately to eliminate unintended barriers due to lack of knowledge of the complexities of behavioral health system. (c) Provide a space for group therapy and/or skill building workshops for participants. These spaces can be in agency owned buildings; however, majority of other service delivery of ACT need to take place within a community setting outside of an office-like atmosphere as intended. 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 History: BHS 29-2025, amend filed 12/29/2025, effective 01/01/2026 BHS 17-2025, amend filed 06/25/2025, effective 06/29/2025 BHS 32-2024, temporary amend filed 12/27/2024, effective 01/01/2025 through 06/29/2025 BHS 44-2023, amend filed 12/22/2023, effective 01/01/2024 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 1-2017(Temp), f. 1-17-17, cert. ef. 1-18-17 thru 7-16-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 309-019-0231 ACT Program Operational Standards (1) Operate continuous 24/7 crisis coverage as defined in OAR 309-019-0225. That includes direct after-hours on-call system with staff experienced in skilled crisis intervention procedures. (a) The ACT team will ensure that ACT Participant crisis calls are triaged and if needed, the ACT Team is available to respond accordingly depending on the level of urgency of the crisis. This availability includes de-escalation through telephone or virtual platform or in person dispatch depending on the initial method of communication the participant(s) utilized to reach out for supports and protocol for escalation. This will require staff who are responsible for triaging to have direct access to Crisis Plan per 309-019-0225(9). (b) ACT Participants shall have information provided to them, as often as needed for retention purposes, and a single crisis access pathway for them to seek support if/when needed. If the ACT Team is utilizing a third party to assist in meeting this requirement, ; the ACT Team will need to ensure appropriate HIPAA agreements are in place to release the Crisis Plan to the third party and that the ACT Participants are aware that respondents of this portion of services will not be from the ACT Team. (c) ACT program staff shall document any crisis dispatches or calls the team receives within the participant’s chart as soon as possible. Items to include but not limited to identify location, description of situation & individual, any relevant parties and outcome. If the ACT Team receives care coordination notification that a third party received a crisis call or responded to a crisis call for an ACT Participant, the ACT Team will document in participants chart all forwarding information from third party within 24hrs of receiving information so that proper follow up from ACT Team can occur. (d) If the ACT staff respond to a call and are in need of additional supports, ACT staff may coordinate with other Mental Health community programs and/or Law Enforcement to ensure the crisis is properly handled for safety of the individual and any bystanders. Collaboration and resourcing out to obtain additional supports during a crisis will exempt an ACT Team from adhering to being a Fixed Point of Responsibility per OAR 309-019-0225(16) as long as it is documented why additional supports were needed. (2) Service Intensity: (a) The ACT team shall have the capacity to provide the frequency and duration of staff-to-participant Face to Face contacts as clinically deemed necessary in alignment with evidence-based model which is captured on the fidelity scale. (b) The ACT team shall have the capacity to increase and decrease Face to Face contacts based upon assessment needs as the goal is to maximize independence when possible; (c) The team shall have the capacity to provide multiple contacts to participants in high need and a rapid response to early signs of relapse. (d) Natural supports and Informal Support System contacts as defined in OAR 309-019-0225 will be utilized as part of the treatment goal at the participants discretion of communicating HIPAA protected information. (e) The ACT team Psychiatrist and the Psychiatric Nurse Practitioner (PNP) shall have scheduling flexibility to accommodate individual needs. If the participant approves & is comfortable, the Psychiatrist or PNP can provide services as clinically indicated for through Telehealth. (f) The ACT team shall have the capacity to provide services via group modalities that are at minimum, Face to Face as defined 309-019-0225(13). (3) The ACT Team shall ensure that services are designed to meet participants cultural and linguistic needs and are developmentally appropriate. This includes collaboration and/or MOUs with local Tribal Communities or other diverse community partners within the ACT program’s service area that would benefit participants treatment goals. (4) Core staffing requirements for ACT teams: (a) ACT is a low client/staff ratio that is recommended to not exceed 10:1; if there is a vacancy longer than 30 calendar days that impacts this ratio, the program must communicate this to Division Approved Reviewer to discuss possibility of submitting a Variance to The Division per 309-019-0240 and seek Technical Assistance and support on filling that core position to ensure quality of evidence-based services. (b) A single ACT program will not serve more than 120 participants. (c) ACT Program must hire the appropriate number of staff to meet the minimum 1:10 staff ratio for individuals served. (d) Programs may not create multiple teams unless the program is at or above the 120 individuals served unless: (A) this was permitted by The Division under the previous rules update prior to 2023; (B) The service area spans across large geographical landscape or (C) The program expands services to a specialized targeted population that is person centered, and an additional team is needed to meet that need. (e) A Small ACT Team per OAR 309-019-0225(34) is recommended to have no more than 10 staff (f) A Mid-Size ACT Team per OAR 309-019-0225(26 is recommended to have no more than 12 staff (g) A Large ACT Team per OAR 309-019-0225(22) is recommended to have no more than 14 staff. (5) No individual ACT staff member shall be assigned less than .20 FTE for their role on the team. (6) ACT Team must include at minimum, the following Core team members in order to fully implement ACT services: (a) A primary Team Lead position per team. The team leader is a certified QMHP per OAR 309-019-0125 who is qualified to provide supervision for the clinical ACT staff. (b) A Psychiatric Care Provider (Psychiatrist or PNP) whose FTE is calculated using the client to staff ratio based on geographical area of services and The Division approved fidelity scale. This staff must be licensed by the State of Oregon. (c) A Nurse whose FTE is calculated using the client to staff ratio based on geographical area of services and The Division approved fidelity scale. The nurse must be licensed by the Oregon Board of Nursing. If there are more than two nursing staff for the ACT Team, it is recommended to have at least one Registered Nurse (d) An Integrated Co-Occurring Specialist (ICOD) whose FTE is calculated using the client to staff ratio based on geographical area of services and on The Division approved fidelity scale. The ICOD must maintain compliance with OAR 309-019-0145. (e) An Employment Specialist FTE is calculated using the client to staff ratio based on geographical area of services based on The Division Approved Fidelity Scale. An Employment Specialist competency shall include all Vocational Services for the ACT Participants by; (A) Completing a Career Profile and document any sort of follow-along; (B) Utilizing skillset for job exploration and matching potential Competitive Employment, per OAR 309-019-0225 rule set, opportunities to Participants based on self-directed decisions (C) Maintain data and tracking of job start & end dates for all ACT participants who utilized this service. (D) Support Participants in mitigating employment obstacles by way of transparency and networking to ensure participants have been properly informed of all legal rights as it pertains to earned income and required reporting. (f) Certified Peer Support Specialist or Peer Wellness Specialist as described in OAR 410-180-0300 to 0380 and defined in OAR 309-019-0105(81) and 309-019-0105(84). A registry of certified Peer Support Specialist Specialists and Peer Wellness Specialists may be found at the Office of Equity and Inclusion’s Traditional Health Worker’s website. (g) The ACT Team may identify other mental health Generalists staff as deemed necessary to account for treatment needs and client/staff ratio calculations. These staff will have identified roles per the evidence-based practice to account for being a Fixed-Point of Responsibility. (7) ACT Team Staffing Core Competencies: (a) Upon hiring, all clinical staff on an ACT team shall have experience in providing direct services related to the treatment and recovery of individuals with a serious and persistent mental illness. Clinical staff shall have demonstrated competencies in clinical documentation and engagement interventions; (b) All new staff shall complete ACT 101 within the first three-months of hire from the Division Approved Reviewer. Any staff who are a direct part of the referral & intake process shall complete the Standardize Referral Process training from the Division within two-months of hire. (c) Attend & complete identified trainings within the ACT Programs technical assistance plan. (8) The ACT team shall conduct organizational staff meetings with intention to include as many ACT Team Members as possible. (a) The ACT team will go over the roster of the participants served with triaging highest acuity in the program; and (b) Make necessary updates to document contacts made by multidisciplinary team that have occurred during the last 24 hours and a concise, behavioral description of the individual’s status. (9) The ACT team shall conduct treatment planning meetings under the supervision of the team lead that include the input from the Psychiatrist or PNP. These treatment planning meetings shall maintain compliance with ASAM or Certificate of Approval. If participants need have a significant fluctuation the ACT Team will make appropriate updates. The Division recommends more frequent meetings on new admissions. The ACT Participants presence is needed to ensure the identified treatment plan is an approved pathway for the individual and attainable; (10) A Comprehensive Assessment and Strength-Based Treatment Plan is completed upon each individual’s admission to the ACT program (11) Service note or episode content need to include at minimum: (a) Any relevant intervention tactics used, activity of event, or goal-oriented skill building; (b) Be entered any time the ACT team has contact with participants. Other information that can be included: (A) Type of contact; (B) Place of service; (C) Purpose of the contact or how contact was initiated; (D) Assessment of the effectiveness of the intervention and the individual’s progress towards the individual’s goal. (E) Identify the ACT Team member who provided the service. (12) Medication Management provided by the ACT Program shall include at minimum the following: (a) A written order signed by a prescribing practitioner is required for any medical treatment and medications managed by the Multidisciplinary Team. (b) A logbook that is kept in a secure location that has at minimum: (A) The name of the medication (B) The format of ingestion of the medication; (C) The dosage and quantity of the medication; (D) The frequency of need for the medication; (c) Medications held and/or stored by the ACT Program must all be clearly labeled and properly secured utilizing a locking mechanism with clear protocols to track access. This needs to include at minimum the following: (E) Documentation tracker of access of staff retrieving medications, staff who will be providing the Medication Supports for self-administers and full count of what is taken off site; then compared upon return what medications were accepted by the participant and what medications the participant declined. (F) Written protocols for disposal of medications per all state and federal laws so that disposal of these medications to prevent anyone from retrieving the discarded medications. (G) Medications held and/or stored by the ACT Program may not be withheld or used as reinforcement or punishment or in quantities that are excessive in relation to the amount prescribed to attain the participants best possible functioning. (13) If the participant is able to self-administer but requires verbal interventions such as directions or cueing support for safety in order to self-administer the medication; the ACT Program staff must document information in the participants record what medications were given, any relevant observations and/or any identified risk factors that transpired during medication supports. This will allow for improvement efforts for medication education and proper administrative oversite of task. (a) Any ACT staff who provides Medication Administration per OAR 309-019-0225(25) to ACT Participant must have proper the appropriate medical training, credentials and be licensed in Oregon and comply with all federal and state requirements. (b) Any staff who provides Medication Administration or Medication Management by means of hand-to-hand drop off must have proper first aid and CPR training and ensure all communication, changes or concerns are communicated to ACT Medical team members. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 430.630 History: BHS 29-2025, adopt filed 12/29/2025, effective 01/01/2026 309-019-0233 Initiating ACT Certification (1) In order to be eligible for Medicaid or State General Funds for ACT reimbursement, ACT services shall be provided only by those programs meeting the following minimum qualifications: (2) The provider shall hold and maintain an official Accreditation issued by the Division established in OAR Chapter 309, Division 008 and maintain compliance with Outpatient Certificate of Agreement; and (3) The provider must maintain compliance with OAR’s 309-019-0225 through 309-019-0255 for the purposes of providing ACT services as intended; and (4) A provider certified to provide ACT services must be reviewed for fidelity adherence by the Division Approved Reviewer and may not bill Medicaid nor use General Funds for the provision of ACT services unless they complete the fidelity review process as outlined within OAR 309-019-0235. (5) Re-certification is driven by the program's compliance with the required fidelity review process as outlined in 309-019-0235. Failure to comply with the fidelity review; will result in automatic de-certification and the program will no longer be allowed to promote themselves as an ACT provider within the State of Oregon nor or able to obtain funding that is specified for ACT Services. (6) A program seeking to become a Provisional Provider can do so by following the outlined procedure: (a) A program must already hold a certification of approval under OAR chapter 309, division 008; (b) At minimum, the program must have the Team Lead, ICOD and one of the two core medical specialty staff hired. The hired staff must attend and complete ACT 101 training from the Division or the Division Approved Reviewer prior to letter of request per this OAR set (4). (7) Provisional status must be requested in writing on agency letter head by the intended program leadership and submitted to the Division Designee and at minimum include the following: (a) Geographical location(s) of intended service areas (b) First and last names of hired staff including their credentials, role on ACT Team and full-time equivalent status dedicated to implementing ACT services. (A) If said program only has the minimum required staff at time of provisional letter submission, they must include identifying which core specialized staff positions are vacant and (B) Identify the platform those vacant positions are advertised on to reflect their intent to hire. (c) Intended size of ACT team per OAR 309-019-0225(34,26,22), this is not to be mistaken as the intended capacity. If the team size is not referenced, the letter will be considered incomplete and returned. (d) Any specific/specialized target population demographic’s (i.e. Young Adult, culturally specific, etc.), (e) Letter of support from Division Approved Reviewer that confirms 1(c)(A)(B) and (C) of this rule set. (f) The request must be submitted outlining the anticipated or goal of start that in the future as the Division Designee has 30 days to evaluate status of certificate of agreement and verify staff credentials. (8) If approved, the newly Provisional Provider will have full access to ongoing intensive Technical Support will on a weekly basis There is an expectation to have all core staff hired per OAR 309-019-0230_ within four-months of Provisional Status approval. This will be tracked through TA check-ins. (9) In the sixth month of Provisional status, the ACT Program will receive a condensed Projection Fidelity review per OAR 309-019-0225(27) to properly build a comprehensive technical assistance plan and prepare for the first fidelity review. (10) The Division may extend Provisional status for up to one-year from the projection date if the outcome is reflective of a high-fidelity functioning team. (11) Provisional Providers are allowed to obtain ACT funding if maintaining per requirements. Statutory/Other Authority: ORS 161.390, 413.042, 430.256, ORS 109.675 & 430.640 Statutes/Other Implemented: 161.390 - 161.400, 428.205 - 428.270, 430.010, 430.205 - 430.210, 430.254 - 430.640, 430.850 - 430.955 & 743A.168 History: BHS 29-2025, amend filed 12/29/2025, effective 01/01/2026 BHS 17-2025, amend filed 06/25/2025, effective 06/29/2025 BHS 32-2024, temporary amend filed 12/27/2024, effective 01/01/2025 through 06/29/2025 BHS 44-2023, adopt filed 12/22/2023, effective 01/01/2024 309-019-0235 ACT Fidelity Requirements (1) All programs Certified or granted Provisional Status to provide ACT services shall be reviewed for fidelity adherence by the Division Approved Reviewer and may not bill Medicaid or use General Funds for the provision of ACT services unless they achieve a rating at the minimum benchmark or higher per this rule set based on the Division approved fidelity scale. Extension of a certification period has no bearing on the frequency or scope of fidelity reviews or re-certification reviews required under OAR chapter 309, division 008. (2) All changes to any fidelity or best practice guidance tools or fidelity procedures by the Division Approved Reviewer must be communicated to the Division per contractual agreements prior to being implemented or promoted to ACT Programs. (3) All applicable Fidelity Tools used to create the comprehensive fidelity outcome report shall be provided to an ACT Program at least 45 calendar days prior to scheduled fidelity review. The only exception to this notification will be if a provider has received a Plan of Correction per OAR chapter 309, division 008 that was created outside the scope of an ACT fidelity review and the Division requires ACT fidelity as an addendum with the noted violations or non-compliance items. (4) Every ACT Program will be provided a comprehensive fidelity review report within 30 calendar days of the last day of the onsite fidelity review conducted by the Division Approved Reviewer. (5) If the ACT Program is currently serving participants from a designated CCO, that CCO can request to be included when the report is published to the ACT Program and Division. (6) To comply with Oregon Transparency statutes, any requests made by a public citizen for past fidelity reports shall comply with the Request for Information and Public Records Request per chapter 410, division 120 and will not be granted permission from the Division Approved Reviewer under any circumstances. These requests, if made, will be transferred to the Division Designee for appropriate response and guidance to obtain public records. Any reports provided through the Request for Information and Public Records Request protocols will ensure that proper actions be taken to de-identify data and include redacting Individually Identifying Information per 943-014-0000 prior to releasing. (7) All ACT Programs, whether certified or have Provisional approval, must achieve the following minimum ratings on the Division approved fidelity scale in order to continue being recognized as an ACT Provider: (a) Urban area ACT programs per OAR 309-019-0225(38) rating of no less than 3.4 out of a 5 (b) Rural and Frontier ACT programs per OAR 309-019-0225(17 & 31) _ rating no less than 3.2 out of a 5. (8) If the ACT Program successfully accomplishes a 4.2 out of a 5-fidelity rating, they will be deemed a High Functioning ACT Program and incentivized with a three-year ACT Certification. (a) During this three-year period, the ACT Program will have conditions within their certification to maintain contact with The Division Approved Reviewer, (b) Uphold the integrity of ACT model and (c) Any other items deemed necessary by the Division. Statutory/Other Authority: ORS 161.390, 413.042, 430.256 & 430.640 Statutes/Other Implemented: 430.254 - 430.640, 430.850 - 430.955, 743A.168, ORS 161.390 - 161.400, 428.205 - 428.270, 430.010 & 430.205 - 430.210 History: BHS 29-2025, amend filed 12/29/2025, effective 01/01/2026 BHS 17-2025, amend filed 06/25/2025, effective 06/29/2025 BHS 32-2024, temporary amend filed 12/27/2024, effective 01/01/2025 through 06/29/2025 BHS 44-2023, amend filed 12/22/2023, effective 01/01/2024 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 1-2017(Temp), f. 1-17-17, cert. ef. 1-18-17 thru 7-16-17 MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16 309-019-0240 ACT Failure to Meet Fidelity Standards (1) If a Certified or Provisional Status ACT program does not achieve the minimum fidelity rating per their geographical service area based on OAR 309-019-0235 the following shall occur: (a) Within 14 calendar days, unless otherwise extended by the Division, the Division Approved Reviewer will coordinate & host a meeting with The ACT Program and the Division Designee, to discuss the outcome of the fidelity review and collectively develop a technical assistance plan. (b) If a CCO requests to be involved, the host/scheduler shall forward the invite to the CCO timely. (c) The technical Assistance (TA) plan must include all items within the fidelity comprehensive report that received a rating of a two or below in the following subscale categories: (A) Operations and Structure, (B) Core Practices Subscale, (C) Evidence-Based Practices Subscale and (D) Person-Centered Planning & Practices Subscale. (d) If the Division has identified any non-compliance or other regulatory violations per OAR’s 309-019-0225 through 0255 or any other applicable statutes, administrative rules, or other regulations, these items will be added to the TA plan as addendum items by the Division Designee and/or the Division Licensing and Certification; (2) The Division Approved Reviewer must provide technical assistance for a period of 90 calendar days from the date of the fidelity review publication to address areas identified in the technical assistance plan. (3) The Division will extend certification on a temporary basis for the 90 days period to ensure there are no impacts to billing during the technical assistance period with anticipation that corrections to program operations will be made. (4) At the end of the 90-day technical assistance period, The Division Approved Reviewer shall conduct a follow-up re-review which will include only the identified subscale topics identified within the TA Plan created within this rule set in addition to the Core Team Subscale section to verify integrity and intent to implement the other subscale items on fidelity scale. (5) Within 30 calendar days following the fidelity re-review, the Division Approved Reviewer shall provide a comprehensive amended fidelity report to the Division and the ACT program. (a) If the ACT Program currently serves participants who are members of a CCO, unless otherwise specified in a private contract with that CCO, the ACT Program shall send a copy of the amended fidelity re-review report to the appropriate CCO within 7 calendar days following issuance of that amended fidelity report. (b) If the ACT Program achieves the minimum rating or higher per OAR 309-019-0235 on the fidelity re-review and all other applicable statutes, administrative rules, or other regulations, the Division can approve the program for ACT Accreditation for two-years of original fidelity month. (6) If a Provisional Status Provider per OAR 309-019-0233 does not achieve the minimum fidelity rating on their first fidelity review, the provider has seven calendar days to communicate to the Division one of the following: (a) Accept conclusion and reapply for Provisional Status; (b) Appeal the conclusion in writing on their agency letter head with date stamp to the Division Designee and request a re-assessment. (c) No longer publicize or in any way promote agency as an ACT accredited service provider and agree to follow all necessary steps per OAR 309-019-0250 Transitions to lower level of care or care coordinate transfer of clients to a neighboring accredited ACT Team. (7) Re-Reviews for Provisional Providers must occur within 45 calendar days of appeal receipt by the Division. (8) The Division may deny, revoke, suspend or place conditions on the programs ACT Accreditation if the re-review results in a rating that is below 2.5 out of 5 or the Division has identified a regulatory non-compliance issue per certificate of approval. (9) Congruent with the process outlined in section (1) above, if the Division determines a program is operating outside of compliance with all applicable statutes, administrative rules or other regulations, the Division may require the program to submit a Plan of Correction (POC). The Division shall provide written notice of the requirement to submit a POC and the program shall submit a POC according to the following terms: (a) The program shall submit a POC to the Division and the appropriate CCO within 30 days of receiving a notice of requirement to submit a POC. The Division may issue up to a 90-day extension to the existing certification to allow the program to complete the POC process; and (b) The POC shall address each finding of non-compliance and shall include: (A) The planned action already taken, or to be taken, to correct each finding of non-compliance. (B) The anticipated or requested timeframe for the completion of each corrective action not yet complete at the time of POC submission to the Division; (C) A description of and plan for quality assurance activities intended to ensure ongoing compliance; and (D) The name and role of the individual responsible for ensuring the implementation of each corrective action within the POC. (10) If the Division finds that clarification or supplementation to the POC is required prior to approval, the Division shall contact the program to provide notice of requested clarification or supplementation, and the program shall submit an amended POC within 14 calendar days of receiving notification. (a) The program must submit a sufficient POC approved by the Division prior to receiving a certificate. Upon the Division’s approval of the POC, the Division shall issue the appropriate certification. (b) The Division may deny, revoke, suspend, not renew, or place conditions on the program’s certification and or accreditation if the program fails to submit an adequate POC within the timeframes established in this rule. (11) When the Division determines the need to deny, revoke, not renew, or place conditions on the program’s accreditation issued under these rules, a notice of intent to take action on the accreditation shall be issued to the program. (12) Immediate suspension may occur if the Division finds there is a serious danger to the public health and safety during a specified period of time and/or there is a substantial failure to comply with applicable statutes, administrative rules, or other applicable regulations. (a) The program may request a contested case hearing to contest the immediate suspension order in accordance with ORS Chapter 183. (b) Requests for a hearing must be received by the Division within 90 days from the date the immediate suspension order was served on the program personally, or by certified or registered mail. (13) When the Division issues an Order of Suspension, a notice of intent to revoke, notice of intent to deny an application or notice of refusal to renew the certificate to a program pursuant to these rules, the Division shall offer the program an opportunity for an informal conference. The program shall make its request for an informal conference in writing within 14 calendar days of the issuance of the notice of intent or Order of Suspension. (a) Upon receipt of a timely written request, the Division shall select a location and time for such conference. Following the conference, the Division may: (A) withdraw or amend the notice of intent or suspension order; or (B) not withdraw the notice of intent or suspension order. (b) the Division shall provide written notice of its decision within 14 calendar days following the informal conference. (14) A program who is issued a notice of intent to deny, revoke, refuse to renew, or apply a condition on programs certificate under these rules shall be entitled to request a hearing in accordance with ORS Chapter 183. (15) A Variance per OAR 309-019-0220 and 309-008-1600 is not an allowable avenue in response to an agency’s inability to meet minimum fidelity rating for ACT service accreditation and may only be used for ACT Programs within context of OAR 309-019-0241. Statutory/Other Authority: ORS 413.042, 430.256 & 430.640 Statutes/Other Implemented: ORS 428.205 - 428.270, 430.010, 430.205- 430.210, 430.254 - 430.640, 430.850 - 430.955 & 743A.168 History: BHS 29-2025, amend filed 12/29/2025, effective 01/01/2026 BHS 17-2025, amend filed 06/25/2025, effective 06/29/2025 BHS 32-2024, temporary amend filed 12/27/2024, effective 01/01/2025 through 06/29/2025 BHS 44-2023, amend filed 12/22/2023, effective 01/01/2024 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16 309-019-0241 Modification Requests to Existing Certification& Substitution Alternatives (1) The Division may at its discretion, grant a waiver or variance of minimum ACT fidelity requirements and extend an ACT program’s certification period if the identified substitution or modification or program operations does not diminish the effectiveness of the ACT model, violate the purposes of the program, or adversely affect the program participants’ health and welfare: (2) Waivers and Variances shall not be granted if they are inconsistent with the individual participant’s rights per OAR 309-019-0115 or any federal, state, or local laws and regulations; (3) The Division shall review waivers and variances based on minimum fidelity requirements on a case-by-case basis. (4) Waivers will be requested no later than the date of the fidelity follow up meeting per OAR 309-019-0240. The Division Designee will provide the appropriate form with instructions & deadline to submit Waiver request back to Division Designee. (5) If the Waiver is approved by the Division, the provider will remain eligible to receive Medicaid and State General Fund reimbursement for ACT services as long as the provider engages and makes efforts to comply with technical assistance guidance by both the Division Approved Reviewer and Division Designee (6) If the Waiver is approved, the extension to accreditation may not exceed 180 calendar days. As part of approval, the Division will acknowledge in writing that the 90-day re-review requirement in OAR 309-019-0240 will be suspended. (a) At the end of the 180-day waiver period, the Division Approved Reviewer shall conduct a fidelity re-review of all areas on initial fidelity report that had a two or below rating and any areas that are out of compliance with OAR’s 309-019-0225 through 0255. (b) If the program achieves the minimum rating on this fidelity re-review and meets the requirements of all applicable statutes, administrative rules or other regulations, the Division shall renew ACT Accreditation per OAR 309-019-0240. (7) A waiver of minimum fidelity requirements may only be granted to ACT programs one time during their renewal of accreditation. (8) If a program does not meet fidelity after a Waiver period the Division may immediately suspend or revoke certification. (9) A Variance to communicate a modification or adaption to ACT operations must be done as a proactive step in order for the program to maintain the quality and integrity of ACT model standards as laid out in OAR’s 309-019-0225 through 0255. (10) A Variance can be used to substitute core staffing and/or contract core staffing needs per OAR 309-019-0226 (1) & (2) and If a program does formulate a contract with a separate entity for core staffing positions to fulfill the ACT fidelity standards, a Variance must be submitted to Division within 30 calendar days of known agreement to ensure to identify ACT Multidisciplinary team includes external partners. The Variance submission should not include copies of private contracts or MOUs for ACT substitutions. (11) A Variance submission must be submitted in at least 30 days prior to a scheduled fidelity review. (12) The ACT Provider must be in good standing with Certificate of Approval per chapter 309, division 008 to be approved for a Variance. (13) Variance approval period cannot exceed one calendar year. Statutory/Other Authority: ORS 413.042, 430.256 & 430.640 Statutes/Other Implemented: ORS 430.010, 430.205- 430.210, 430.254 - 430.640, 430.850 - 430.955 & 743A.168 History: BHS 29-2025, amend filed 12/29/2025, effective 01/01/2026 BHS 17-2025, amend filed 06/25/2025, effective 06/29/2025 BHS 32-2024, temporary amend filed 12/27/2024, effective 01/01/2025 through 06/29/2025 BHS 44-2023, amend filed 12/22/2023, effective 01/01/2024 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 309-019-0245 ACT Admission Criteria (1) ACT Programs will triage referrals based on the Service Priority Population per OAR 309-019-0225(28) and medically appropriate standard as designated in OAR 309-019-0105 with the following characteristics: (a) Participants who meet the Service Priority Population per OAR 309-019-0225(28) are the primary target population for ACT services per evidence-based model; however, individuals with serious mental illness’ that are not listed as Service Priority Population should not be ruled out as a possible candidate for admission until properly evaluated. Primary diagnosis outside of the priority population will still need to meet the heightened acuity level of psychosis symptoms ACT model is designed to support. (b) Individuals with a primary diagnosis of a substance use disorder intellectual developmental disabilities, traumatic brain injury, personality disorder, or an autism spectrum disorder are not the intended recipients of ACT. Diagnostic must include a primary within the Service Priority Population. (2) Participants with significant level of executive functioning s as demonstrated by the following circumstances that is either reoccurring or confirmed to not be an isolated brief-episode as the interventions or circumstances would require minimum of 6 service hours a week: (a) Significant difficulty consistently performing on an ongoing daily basis, the range of practical daily living tasks required for basic adult functioning or conflict with basic survival instincts (e.g., caring for personal business affairs; obtaining medical, legal, housing services; recognizing common dangers or hazards meeting nutritional needs; maintaining personal hygiene). (b) Significant negative impacts to living situations pr ability to maintain at a self-sustaining level as a direct result of lack of self-awareness, forward thinking resulting in safety or health risks due to inability to plan or recognize needs (e.g., repeated evictions or loss of housing) that is beyond a poor choice decision. (c) High use of acute care psychiatric hospitals or emergency departments for psychiatric reasons, including psychiatric emergency services as defined in OAR 309-023-0110(18) (e.g., two or more readmissions in a six-month period); (d) Intractable (e.g., persistent or very recurrent) severe major symptoms, affective, psychotic, suicidal; (e) Coexisting Substance Use Disorder of significant duration (e.g., greater than six months); (f) High risk of judicial involvement or history of criminal justice involvement (e.g., arrest, incarceration); with the exception of violence or assault directed at the ACT staff during the screening process only if action results in physical injury of the staff member or significantly impairs the ability to provide treatment services to the individual (g) Residing in an inpatient or supervised community residence in the community, and clinically assessed to be able to live in a more independent living situation if intensive services are provided or requiring a residential or institutional placement if more intensive services are not available; (h) Difficulty effectively utilizing traditional office-based outpatient services. (3) The ACT program shall provide community-based, long-term, and time-unlimited services. (4) If an individual is unable to maintain in community without 1:1 constant care; this is beyond the scope of what ACT could provide. ACT program may deny if the care requires 1:1 intervention on a continuum of care that is beyond the scope of ACT and make proper recommendations for higher level of care. 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 History: BHS 29-2025, amend filed 12/29/2025, effective 01/01/2026 BHS 17-2025, amend filed 06/25/2025, effective 06/29/2025 BHS 32-2024, temporary amend filed 12/27/2024, effective 01/01/2025 through 06/29/2025 BHS 44-2023, amend filed 12/22/2023, effective 01/01/2024 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16 309-019-0248 ACT Admission Process (1) The ACT Program shall complete a Comprehensive Assessment that demonstrates medical appropriateness prior to the provision of this service. If a substantially equivalent assessment is available that reflects current level of functioning and contains standards consistent with OAR 309-019-0135 to include sufficient information and documentation to justify the presence of a diagnosis that is the medically appropriate reason for services, the equivalent assessment may be used to determine admission eligibility for the ACT program. (2) A referral for The ACT Program is managed and coordinated, as defined in these rules and is referred to as the Standardized Referral Process (3) The CCO, Single Point of Contact (SPOC) and or ACT Program shall accept all referrals utilizing the Universal Referral Form provided by the Division and verify the documentation that supports ACT criteria. The referral must include when an approximate, reasonable date of admission and/or Intake for further evaluation for the ACT program is anticipated. (4) Based on the ACT Teams published referral process, the deciding entity shall have 14 calendar days from the date of request to respond to referring party for the purposes of Care Coordination. (a) Care coordination within the Standardized Referral Process consists of notifying participant and referring party if the referral will be moved forward to the second step or if the referral is denied. Once this communication occurs, the care coordination step has been completed. (A) if there is insufficient information within the referral that eliminates ability to properly evaluate for next steps, the SPOC or designated ACT Team staff may send the referring party requesting that information. (B) During Care Coordination step, “ pending ” a referral can only be used if there is a realistic expectation for the referring party to have access to the additional information. (C) If additional information is needed from another source, this request would be made during the Screening Phase, or second step in the Standardized Referral Process. (D) It is recommended to maintain stewardship within the local community and care coordination process by identifying a “date to return by” of no less than 14 calendar days. (E) If the referral is returned, the Standardized Referral Process will begin all over from (4)(a) of this rule with the exception that pending is no longer an option and a decision needs to be made if the referral moves on to second phase or it is denied. If it is denied, the denial procedures in 309-019-0248 (5) (a-c) of this ruleset must be followed. (b) If referral is moving forward within the Standardized Referral Process the Screening phase begins immediately. This process can include several orchestrated arrangements made by the ACT Team-staff and is a designated period to gather information as a hypothetical if the individual would be approved for services and require a Strength-Based Treatment plan, however, must include written notification on the Universal Referral Form to the referring party (if HIPAA allows) & individual. (A) The Screening Phase must at minimum, include a Face-to-Face interview between the designated ACT staff member and the individual applying for services This interview cannot be delegated to a SPOC or third party under any circumstances to ensure ACT Teams maintain as the gatekeeper for all admits. (B) Collateral information may be sought out as needed from other sources if the designated ACT staff member deems relevant. Collateral information can come by way of verbal/interviews, request for documentation from past treatment providers, judicial staff, etc. (c) A referral can be reflected as “pending” if there is more than 60 days until discharge from an acute care setting and the ACT Team requests monitoring for progression. If this option is utilized, the ACT program must document and site this OAR while also continuing to be actively involved in care coordination and will ensure to provide a final determination in good faith prior to discharge or end of jurisdiction date to maintain stewardship and due-diligence that their decision does not negatively interfere or impact discharge progress. (5) The final determination on the referral is communicated per best practice standards within 30 calendar days from the date care coordination communication for Screening Phase was initiated. ACT Clinicians may expedite this process based on severity of needs, symptoms and/or the circumstances of the individual.: (6) Final determination must at minimum be completed by the ACT Team member who completed the face-to-face interview; (a) It shall notify the individual if the final decision is that of admission, waitlist or denial. (b) The final determination must be in written format per the individuals preferred language and capacity of understanding on the agency letterhead; (c) The letter must cite applicable administrative rules and criteria to support conclusion and must be signed by the Decision Maker. (7) If individual is approved for admission; the written response must have an anticipated start date less than seven 7 calendar days of letter or discharge date; whichever comes first. In anticipation of entry to services the ACT Program shall, in good faith, coordinate any additional documentation that can legally be provided proactively that will support in Strength based treatment planning. Items considered is verifying medication and/or possible refill needs as close to discharge or entry to services as possible and verify residency or living situation status prior to first official appointment with an ACT Team Member. (8) Given the severity of mental illness symptoms, executive functioning level that ACT services are intended for, if a referral is denied, the care coordination may rest with the CCO. (9) An individual’s decision not to take psychiatric medication cannot be used for denying admission to an ACT program; (10) ACT Program Capacity in a geographic region or identified service area is not a sufficient reason to deny a referral. The referral must adhere to all required steps within the Standardized Referral Process so that level of care and medical necessity may be established timely. (a) If an individual is deemed ACT eligible but cannot be served or become active in services as a result of an ACT Team being at the max ratio capacity per Team Size in 0225 (22,26,34), the individual will be placed on a Waitlist per OAR 309-019-0225(40). (b) If an individual is waitlisted, the responsible entity who manages or maintains oversite of the waitlist shall provide the individual or legal representative avenues to monitor the status on the waitlist. (11) While an ACT eligible individual is on the waitlist due to Team size capacity, they shall be offered alternative community-based rehabilitative services as described in the Oregon Medicaid State Plan that includes evidence-based practices to the best extent possible per OAR 410-141-3515(21). (12) The Division shall monitor each regional waiting list until sufficient ACT program capacity is developed to meet the needs of the ACT eligible population per OAR 410-141-3515(21) by means of data collection strategies. (13) In addition, if an individual is denied ACT services, they or their guardian may appeal the decision if they do not agree with the denial. The grievance process will follow OAR 309-019-0215 by filing a grievance directly with the behavioral health agency that provides ACT services. Escalated grievances may resort to appeals per Medicaid standards; however, the objective of the grievance process will be to ensure all Individual Rights are intact and honored equitably. 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 History: BHS 29-2025, amend filed 12/29/2025, effective 01/01/2026 BHS 17-2025, amend filed 06/25/2025, effective 06/29/2025 BHS 32-2024, temporary amend filed 12/27/2024, effective 01/01/2025 through 06/29/2025 BHS 44-2023, amend filed 12/22/2023, effective 01/01/2024 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 1-2017(Temp), f. 1-17-17, cert. ef. 1-18-17 thru 7-16-17 MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16 309-019-0250 Closure of ACT Services (1) Planned transitions to less intensive services shall occur if the individual has confirmed they no longer require or want ACT level of care and requests a voluntarily discharge. (2) The ACT Program may transition a participant to lower level of care and graduate when the participant has: (a) Successfully maintained a baseline for the identified self-directed goals within the Strength-based treatment plan in a way that supports improvement of their level of functioning capabilities and enhanced self-awareness that reflect ACT services are no longer needed; (b) Successfully demonstrated an ability to function in all major role areas including but not limited to work, social, and self-care without ongoing intervention assistance from the ACT Program; (c) Moves outside of the geographic area of the ACT program’s responsibility. In such cases, the ACT team shall arrange for transfer of mental health service responsibility to an ACT provider or another provider wherever the individual is moving. The ACT team shall maintain contact with the individual until this service is implemented. (3) If the Individual is incarcerated or institutionalized for more than two months with a date of discharge and/or release longer than three months out, the ACT Team may discharge & close services as this time duration would warrant a closure of Medicaid medical benefits. (4) The ACT Program may discharge and close ACT services if a Participant displays behavior that is abusive to the extent that any continuation efforts would no longer be trauma informed care & impaired to the extent of no longer being effective. This includes but not limited to: (a) The Participant commits or attempts to inflict physical violence & harm directed at ACT staff; (b) The Participant conducts themselves in a way of verbal threats of harm towards ACT staff that could be realistically carried out at any sporadic moment eliminating ACT staff to properly safeguard themselves or bystanders if the threat escalated from verbal to physical action. (c) If an ACT Program discharges a participant for based on this rule, they must provide a copy of the discharge notice per 309-019-0250(4) to The Division Designee, legal guardian and appropriate CCO. (5) Discharge and closure of services can occur if there have been several unsuccessful documented attempts to contact the participant by the ACT program that last up to 90 days. This discharge reason is referred to as whereabouts unknown and must include the following; (a) All attempts must be documented by the ACT Team in good faith, and various different methods of those attempts that could include: (A) Seeking out the individual in-person with identified locations of search, (B) Mail to last known address, (C) Phone calls to participant or relevant Natural and Informal Supports in attempt to locate any new information. (b) If an individual is discharged for whereabouts unknown and they make contact after the discharge date, the program has discretion on readmittance or re-referral. (6) Documentation for discharge including transition to lower levels of care even for graduation purposes shall follow OAR 410-120-1865 and include at minimum the following: (a) The reasons for discharge citing administrative rule or highlighting accomplishments that warranted graduation; (b) The individual’s biopsychosocial status at discharge, transition or last known (if whereabouts unknown applies). (c) The identified new provider if known and effective date. (d) The ACT program, in good faith, must provide a copy of discharge or transition to lower level of care to the participant: (A) Mailed or electronic copy as long as HIPAA approved/permission given to communicate electronically. (B) Mailed or faxed to facility of known incarceration/institutionalization. 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 History: BHS 29-2025, amend filed 12/29/2025, effective 01/01/2026 BHS 17-2025, amend filed 06/25/2025, effective 06/29/2025 BHS 44-2023, amend filed 12/22/2023, effective 01/01/2024 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 1-2017(Temp), f. 1-17-17, cert. ef. 1-18-17 thru 7-16-17 MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16 309-019-0255 ACT Reporting Requirements (1) ACT service data shall be submitted on a quarterly basis for objectives of measuring outcomes per the procedures prescribed by the Division. (2) ACT service delivery data shall be submitted based on the Division mandated state data system per 309-022-0135: Additional fidelity and program specific data outside of state data system will include quantitative data submission of the following: (a) Number of Participants served: (b) Qualitative data those through Medicaid and non- Medicaid. (c) Referral data: (A) Number of total referrals received during each quarter; (B) Number of participants on the waitlist during each quarter and length of duration on the waitlist; (C) Number of participants admitted during each quarter; and (D) Number of participants denied during each quarter and the reason for each denial; (d) Number of participants no longer on services. Two categories will be: (A) Graduated with successful transition to lower level of care (B) Discharged without meeting all goals to graduate. (e) Crisis calls and dispatches by ACT Team for ACT Participants. This does not include any other crisis service delivery that an ACT Team member may be part of. 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 History: BHS 29-2025, amend filed 12/29/2025, effective 01/01/2026 BHS 17-2025, amend filed 06/25/2025, effective 06/29/2025 BHS 32-2024, temporary amend filed 12/27/2024, effective 01/01/2025 through 06/29/2025 BHS 44-2023, amend filed 12/22/2023, effective 01/01/2024 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16 MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16 309-019-0270 IPS Purpose and Definitions (1) Purpose: These rules establish the standards and procedures for an Individual Placement and Support (IPS) Employment Services that will be certified by the Division. The IPS program uses an evidence-based model and integrates employment and Vocational Services with clinical mental health and non-vocational support. (2) “Career Profile” means the approved form(s) completed by program staff during the first weeks of meeting with a participant. Information must include at least; (a) Name of individual (b) Address (c) Contact information; this can include email and cell phone number; (d) Names of treatment team points of contact; if the individual is participating in any outpatient therapy; (e) Preference of type of work (f) Any relevant information about current diagnosis and potential limitations in work environments (g) Strengths and skills (h) Historical work experiences (i) Any career path goals (3) “Competitive Integrated Employment” means full-time or part time work that is: (a) At minimum wage or higher rate that is not less than the customary rate paid by the employer for the same or similar work performed by other employees; (b) With eligibility for level of benefits provided to other employees. (c) Paid Internships open to the public. (d) An unpaid internship that is directly tied to higher education or trade school, including work-study opportunities with colleges. (e) Seasonal Employment that is consistent with that industry of work. (f) Self-Employment if: (A)Income is reported to the government; and (B) Taxes must be filed should income generated meet threshold requirements. (g) Temporary Employment from an Oregon-authorized temporary staffing agency as defined in OAR 331-995-0000. (4) “Division Approved Reviewer” means the Division’s contracted entity responsible for conducting IPS Supported Employment fidelity reviews, training, and technical assistance to support new and existing IPS Supported Employment programs statewide. (5) “Face to Face” means that a personal interaction where communication between at least two-person(s) can be had. This will include any interactions through telehealth services where there is secured Health Insurance Portability and Accountability (HIPAA) approved live streaming audio and video. (6) “Fidelity” for the purposes of the IPS Supported Employment program means the Program is providing services that are faithful to the evidence-based practice model and obtains a satisfactory score from the Division Approved Reviewer for IPS Supported Employment as part of their regular reviews. (7) “Fidelity Tool” means the documents used to score and evaluate a programs fidelity that is based on the Division approved evidence-based fidelity scale. (8) “Full Time Employment” or “FTE” means a way to measure how many full-time employees are required to provide the appropriate level of service to fulfill minimum fidelity requirements per the employer standards. FTE must be reflected in job description (9) “Individual Placement and Support (IPS) Employment Services” means the evidence-based model of Supported Employment Services for people with SPMI per 309-019-0270(12). IPS helps people identify and acquire part-time or full-time employment of their choice in their community. (10) “Person-Centered Planning” means the IPS program services are based on individual preferences and choices for employment. This includes but is not limited to culturally, linguistically, and developmentally appropriate for that participant. (11) “Rapid Job Search” means an approach utilized to help participants obtain jobs directly, training, and or job counseling . (12) Serious Mental Illness (SMI) means for IPS programs, the current Diagnostic and Statistical Manual (DSM) diagnostic criteria as a primary diagnosis for an adult 18 years of age or older: (13) “Systematic Job Development” means the IPS program creates an employer network based on participants’ interests and developing relationships and partnerships with local employers. (14) “Work Incentive Planning” means a document that is personalized to fit the need of a participant to ensure that individuals receive information regarding an array of benefits that may or may not be available to them and how employment could impact those services. This can include but not limited to: SNAP, Medical Benefits, Veteran Affairs benefits, subsidies housing, dependent benefits, transportation assistance etc. This can be also referred to as Personalized Benefit Planning however IPS model reflects as “Work Incentive Planning” (15) “Vocational Services” means employment support that will contribute to gaining competitive integrated employment. This service will include a vocational profile that includes information about the participants preferences, experiences, skills, strengths, person contacts etc. This will include input from participant, treatment team, clinical records, and any others the participant identifies per preference. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 430.630 History: BHS 3-2024, amend filed 01/27/2024, effective 02/01/2024 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 1-2017(Temp), f. 1-17-17, cert. ef. 1-18-17 thru 7-16-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 309-019-0275 Individual Placement and Support (IPS) Supported Employment Overview (1) IPS Supported employment is an evidence-based practice for individuals with SMI per 309-019-0270(12). (2) IPS Supported employment is characterized by: (a) Emphasis on Competitive Integrated Employment; (b) Every individual interested in work is eligible for services regardless of symptoms, substance use disorders, treatment decisions, or any other issue which can also be referred to as “Zero exclusion” in the fidelity tools. (c) Employment services is integrated with mental health treatment (d) Participants have access to Work Incentive Planning by a Certified Benefits Planner (e) Rapid Job search should begin within 30 days of program entry. (f) Client preferences for jobs are honored and included in the Career Profile; (g) Employment Specialists systematically collaborate with employers who are selected based on job seeker preferences to learn about their business needs and hiring preferences; (h) Job supports continue for as long as each participant benefits from the support. (3) IPS Supported Employment services include but are not limited to: (a) Job development; (b)Job training and or Job coaching (c) Consultation with the employer; (d) Employment and/or education Counseling; (e) Skills training; (f) Transportation assistance per certified IPS program’s internal policy. This can include staff transport, gas vouchers, bus passes, planning and/or training or other internal policies the program has identified and (g) Transition planning to less intensive employment supports (h) Follow along supports Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 430.630 History: BHS 3-2024, amend filed 01/27/2024, effective 02/01/2024 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 1-2017(Temp), f. 1-17-17, cert. ef. 1-18-17 thru 7-16-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 309-019-0280 IPS Program Requirements and Operational Standards (1) To be eligible for Medicaid or State General Fund reimbursement, IPS Supported Employment Services shall be provided only by those programs meeting the following minimum qualifications: (a) The program shall hold and maintain a certificate, in good standing and not subject to any adverse action issued by the Division under OAR chapter 309, division 008 for the purpose of providing Outpatient Behavioral Health Services; and (b) The program shall hold and maintain a certificate issued by the Division under OAR 309-019-0270 through 309-019-0295 for the purposes of providing IPS services. (2) The IPS program shall be reviewed annually for fidelity adherence by the Division Approved Reviewer. IPS programs may not bill Medicaid or use general funds for the provision of IPS unless they achieve a minimum score of 100 on the fidelity scale as outlined in OAR 309-019-0285. (3) An IPS program must include, at minimum the following staff: (a) an IPS Supervisor and/or Team Leader, who may carry a case load if needed to ensure case load ratio per(3)(b)(B) of this ruleset. (b) At least one Employment Specialists. (A)The primary focus of this position will be on Vocational Service-related tasks. (B) Case load size should not exceed more than 20:1 ratio. If case load exceeds this amount, it is recommended that the team adapt with additional staffing in attempt to ensure case loads are manageable per evidence-based model. (4) A Peer Support FTE is optional staff as defined in OAR 410-173-0005(27) and/or Peer Wellness Specialist FTE, as described in ORS 414.025(21). A registry of certified Peer Support Specialist Specialists and Peer Wellness Specialists may be found at the Office of Equity and Inclusion’s Traditional Health Worker’s website. (5) Community Collaboration requirements: (a) IPS staff need to attend at least one weekly relevant meeting for treatment planning with any mental health providers identified that participants are working with. These collaborations can be in-house to the IPS program/agency or with community partners as identified. These meetings must be routinely attended and documented. (b) Identify any other employment services and collaborate on behalf of participant. This can include but not limited to Vocational Rehab, State Unemployment Office etc. (6) Progress or chart notes will be updated at least monthly or as needed by IPS staff (7) All IPS Program staff shall attend IPS 101 from the Division Approved Reviewer within four months of hire. Staff’s competency will be evaluated during the annual fidelity review process. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 430.630 History: BHS 3-2024, amend filed 01/27/2024, effective 02/01/2024 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 1-2017(Temp), f. 1-17-17, cert. ef. 1-18-17 thru 7-16-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 309-019-0282 IPS Program Certification (1) Ongoing certification is driven by compliance with annual fidelity review by the Division Approved Reviewer per OAR 309- 019-0285. If a program does not cooperate with annual fidelity review, Division will take necessary actions that could include suspension and/or termination of IPS certification. (2) Programs seeking IPS certification shall submit a letter of request for Provisional Status to the Division with the following information: (a) Statement detailing current certificates in good standing and not subject to any adverse action issued by the Division; (b) Intended service area and or geographical identifiers of services. (c) Intended population if there intends to be any demographical specific services. This can include but not limited to culturally specific, age specific and/or other population identifiers; (d) Intended capacity; (e) Name of program lead. (3) Letters for Provisional Status must be submitted to the Division no later than 60 days prior to projected provisional start date. (4) Included in submission for Provisional Status, the intended program must have a letter of support from the Division Approved Reviewer. (5) All certifications (Provisional and ongoing) shall be effective for one year from the date of approval by the Division. (6) At the end of one year, the program must achieve a passing fidelity score per OAR 309- 019-0285. Statutory/Other Authority: ORS 413.042 History: BHS 3-2024, adopt filed 01/27/2024, effective 02/01/2024 309-019-0285 IPS Fidelity Requirements (1) A certified IPS Program shall be reviewed annually for fidelity adherence by the Division Approved Reviewer and reach a benchmark of at least a score of 100. A program may not bill Medicaid unless certification is current. (2) Fidelity reviews shall be conducted utilizing the Division approved fidelity scale which the Division Approved Reviewer shall make available to programs electronically at least 45 calendar days prior to scheduled fidelity review. (3) Within 30 calendar days following the fidelity review, the Division Approved Reviewer shall provide a comprehensive fidelity review report to the Division and the IPS Program. (4) Within seven calendar days following issuance of the fidelity review report, the IPS Program shall send a copy of the fidelity review report to the appropriate Coordinated Care Organization (CCO) unless otherwise specified in program/CCO contract. (5) Within 14 calendar days of the issuance of fidelity review report, The Division, The Division Approved Reviewer, and program will meet to discuss the outcome of the comprehensive report findings. The CCO can be invited and attend the meeting if the CCO requests. (6) The Division may deny, revoke, suspend, or not renew an IPS Program Certification for failure to participate in an annual fidelity review. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 430.630 History: BHS 3-2024, amend filed 01/27/2024, effective 02/01/2024 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 1-2017(Temp), f. 1-17-17, cert. ef. 1-18-17 thru 7-16-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 309-019-0290 Failure to Meet Fidelity Standards (1) If an IPS program does not achieve minimum score of 100 on a fidelity review, the following shall occur: (a) Once meeting is held per OAR 309-019-0285(5), Technical assistance (TA) shall be made available by the Division Approved Reviewer for a period of 90 days to address areas identified in the fidelity review that require attention and/or improvement. (A)From this meeting a Technical Assistance Plan will be created by the Division Approved Reviewer for the IPS program to follow; (B)The Technical Assistance Plan will consist of recommendations and goals the program can follow to help them achieve the benchmark for fidelity per OAR 309-019-0285(1). (b) At the end of the 90-day period, a follow-up re-review shall be conducted by the Division Approved Reviewer of all areas identified in the Technical Assistance Plan; and (c) The Division approved reviewer shall forward a copy of the fidelity re-review report to the Division and program within 30 calendar days of the re-review. (d)The program shall forward a copy of the amended fidelity review report to the appropriate CCO within seven calendar days of issuance unless otherwise specified in CCO/Program contract. (e)Within 14 business days after issuance of re-review, the Division, The Division Approved Review, the program and CCO if CCO requests, will have a meeting to discuss findings in the comprehensive re-review report. (2) If the Division determines an IPS Program is not operating in substantial compliance with all applicable statutes and administrative rules, the Division may require the IPS Program submit a Plan of Correction (POC). The Division shall provide written notice of the requirement to submit a POC and the IPS Program shall submit a Plant of Correction according to the following requirements: (a) The IPS Program shall submit a Plan of Correction to the Division within 30 calendar days of receiving a notice of requirement to submit a Plan of Correction. The Division may not approve a PLant of Correction that would exceed 90-days. The Division will ensure the extension to the existing certification is completed upon approval of Plant of Correction to allow the program to complete the Plan of Correction process and ensure billing can continue; and (b) The Plan of Correction shall address each finding of non-compliance and shall include: (A) The planned action already taken, or to be taken, to correct each finding of non-compliance; (B) The anticipated or requested timeframe for the completion of each corrective action not yet complete at the time of Plan of Correction submission to the Division; (C) A description of and plan for quality assurance activities intended to ensure ongoing compliance; and (D) The name and title of the individual responsible for ensuring the implementation of each corrective action within the Plan of Correction. (E) Include the appropriate CCO in submission. (c) If the Division finds that clarification or supplementation to the Plan of Correction is required prior to approval, the Division shall contact the IPS Program to provide notice of requested clarification or supplementation, and the IPS Program shall submit an amended Plan of Correction within 14 calendar days of receiving notification; (d) The IPS Program shall submit an adequate Plan of Correction approved by the Division prior to receiving a certificate. Upon the Division’s approval of the Plan of Correction, the Division shall renew the IPS certification. (e) The Division may deny, revoke, suspend, not renew, or place conditions on the program’s certification if the program fails to submit an adequate Plan of Correction within the timeframes established in this rule. (3) When the Division determines the need to deny, revoke, not renew, or place conditions on the program’s certificate issued under these rules, a notice of intent to take action on the certificate shall be issued to the program. (4) Immediate suspension may occur if the Division finds there is a serious danger to the public health and safety during a specified period of time and/or there is a substantial failure to comply with applicable statutes, administrative rules, or other applicable regulations. (a) The program may request a contested case hearing to contest the immediate suspension order in accordance with ORS Chapter 183. (b) Requests for a hearing must be received by the Division within 90 days from the date the immediate suspension order was served on the program personally, or by certified or registered mail. (5) When the Division issues an Order of Suspension, a notice of intent to revoke, notice of intent to deny an application or notice of refusal to renew the certificate to a program pursuant to these rules, the Division shall offer the program an opportunity for an informal conference. The program shall make its request for an informal conference in writing within 14 calendar days of the issuance of the notice of intent or Order of Suspension. (a) Upon receipt of a timely written request, the Division shall select a location and time for such conference. Following the conference, the Division may: (A) withdraw or amend the notice of intent or suspension order; or (B) not withdraw the notice of intent or suspension order. (6) A provider who is issued a notice of intent to apply a condition, revoke, suspend, or refusal to renew its certificate may request a hearing in accordance with ORS Chapter 183 and OAR 309-008-1300. (7) When the Division evaluates the Plan of Correction and determines there is a satisfactory of compliance and improvement by the program to uphold the IPS Model; the Division shall recertify the program from the date of their original annual fidelity review. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 430.630 History: BHS 3-2024, amend filed 01/27/2024, effective 02/01/2024 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 1-2017(Temp), f. 1-17-17, cert. ef. 1-18-17 thru 7-16-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 309-019-0295 IPS Reporting Requirements (1) Providers of IPS Supported Employment Services shall submit quarterly outcome reports using forms and procedures prescribed by the Division within 45 days following the end of each subject quarter to the Division or the Division approved reviewer. (2) Each quarterly report shall provide the following information including but not limited to: (a) All individuals who received IPS services in the reporting quarter; (b) Individuals who received IPS Services who are employed in competitive employment; and (c) Individuals who discontinued receiving IPS services and are employed in competitive employment; and (d) Individuals who received IPS and also were participating in other outpatient treatment models. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 430.630 History: BHS 3-2024, amend filed 01/27/2024, effective 02/01/2024 MHS 6-2017, f. & cert. ef. 6-23-17 MHS 1-2017(Temp), f. 1-17-17, cert. ef. 1-18-17 thru 7-16-17 MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17 309-019-0300 Service Requirements (1) Crisis line services shall be provided directly or through linkages to a crisis line services provider 24/7. (2) Crisis line services shall include but is not limited to: (a) 24/7 accessibility to a QMHP; (b) 24/7 bi-lingual or interpreter availability; (c) 24/7 telephone screening to determine the need for immediate intervention; (d) 24/7 linkage to emergency service providers, including first responders and mobile crisis services; (e) Best practice risk assessment, including suicide risk assessment; (f) Suicide intervention and prevention; (g) Lethal means counseling and safety planning for individuals at risk for suicide; (h) Crisis intervention; (i) Crisis plan development; (j) Triage; (k) Providing information regarding services and resources in the community; and (L) Procedures for de-escalation for calls from suicidal individuals. Statutory/Other Authority: ORS 413.042 & 430.640 Statutes/Other Implemented: ORS 430.630, 430.640 & 430.644 - 430.646 History: MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 309-019-0305 Provider Standards (1) Crisis line services providers shall develop and implement written policies and procedures to address provider standards. (2) Provider standards shall include but is not limited to: (a) Training curriculum and ongoing education programs to meet training requirements; (b) Coordination with other treatment providers including mobile crisis services and other crisis line services providers to support seamless transitions of care; (c) Linkages to emergency services providers including first responders to address imminent risks and to support seamless transitions of care; (d) De-escalation procedures; (e) Follow-up procedures when indicated and appropriate; (f) Documentation; (g) Code of ethics; and (h) Security of information protocols. Statutory/Other Authority: ORS 413.042 & 430.640 Statutes/Other Implemented: ORS 430.630, 430.640 & 430.644 - 430.646 History: MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 309-019-0310 Minimum Staffing Requirements (1) At least one QMHP shall be available by phone or face-to-face 24/7 for consultation. (2) At least one QMHP shall provide regular clinical supervision to staff. Statutory/Other Authority: ORS 413.042 & 430.640 Statutes/Other Implemented: ORS 430.630, 430.640 & 430.644 - 430.646 History: MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 6-2017, f. & cert. ef. 6-23-17 309-019-0315 Training Requirements (1) Staff training curriculum shall include but is not limited to: (a) Triage protocol; (b) Referral resources; (c) Crisis plan development; (d) Screening for a Declaration for Mental Health Treatment. (2) Staff training curriculum shall include best practices for the following: (a) Risk assessment, including suicide risk assessment; (b) Suicide intervention and prevention; (c) Safety planning; (d) Lethal means counseling; (e) De-escalation methods; (f) Crisis intervention; (g) Recovery support, including peer delivered services; (h) Trauma informed care; and (i) Cultural awareness. Statutory/Other Authority: ORS 413.042 & 430.640 Statutes/Other Implemented: ORS 430.630, 430.640 & 430.644 - 430.646 History: MHS 6-2017, f. & cert. ef. 6-23-17 309-019-0320 Documentation Requirements (1) Documentation of calls shall include but is not limited to: (a) Summary of presenting concern, assessment of risk factors, interventions, evaluation of interventions, the plan for the management and resolution of the crisis or emergency situation reported, referrals to other services, and collaboration that occurred with emergency services providers or other treatment providers, when appropriate; (b) If a suicide risk assessment was completed; (c) Summary of safety planning and lethal means counseling, as appropriate. (2) A log or report of all contacts with the provider, including the name of each caller, when available, the crisis line worker, and the time and duration of the call shall be maintained for quality assurance review and ongoing staff supervision. Statutory/Other Authority: ORS 413.042 & 430.640 Statutes/Other Implemented: ORS 430.630, 430.640 & 430.644 - 430.646 History: MHS 6-2017, f. & cert. ef. 6-23-17