309-035-0115 Temporary rule language in effect until 06/27/2026. Licensing (1) The Division shall license a program that meets the definition of an RTF or RTH and demonstrates compliance with these and all applicable laws and rules. No person or governmental unit acting individually or jointly with any other person or governmental unit may establish, maintain, manage, or operate a program, including receiving referrals for potential residents, without a license issued by the Division. (2) When a program serves or seeks to serve another category of residents in addition to adults with a mental health condition, the directors of the Authority and the Department will determine the agency responsible for licensure. (3) An initial application for a license must be accompanied by the required fee and submitted to the Division in the form and manner required by the Division. The following information must be included in the application packet: (a) Full and complete information as to the identity and financial interest of each individual, including stockholders, having a direct or indirect ownership interest of five percent or more in the program and all officers and directors in the case of a program operated or owned by a corporation; (b) Name and resume of the program administrator; (c) Name and resume of psychiatric treatment services provider; (d) Physical address of the setting and mailing address; (e) Maximum number of residents to be served at any one time, their age range and evacuation capability; (f) Proposed annual budget identifying sources of revenue and expenses; (g) Signed current approved background check authorizations for all individuals involved in the operation of the program who has contact with the residents, including but not limited to caregivers, administrators, QMHAs, QMHPs, RNs, and LMPs; (h) Written background information pertaining to any current or previous licensure or certification by a state agency, including those licenses or certificates granted to a business or person affiliated with the business, including: (A) Copies of all current licenses or certificates; (B) Documentation showing the final disposition of any suspension, denial, revocation, or other disciplinary actions initiated on any current or previous license or certificate, including settlement agreements, where applicable; and (C) Documentation of any substantiated allegations of abuse or neglect pertaining to the applicant, or anyone employed by or contracted with the applicant. (i) A complete set of policies and procedures specific to the operation of the proposed facility or home; (j) A signed letter of acknowledgement from the Local Mental Health Authority or designee; (k) A written statement describing the type and frequency of clinical services that will be offered to the program residents, including individual and group counseling, skills training, psychiatric treatment, and the contact information of the LMP that provides consultation and oversight of the services offered to the program residents; (l) A copy of all proposed policies and procedures regarding: (A) Personnel practices; (B) Program staff and administrator training; (C) Resident screening, admission, and transfer and discharge; (D) Fire drills and emergency procedures; (E) Resident and program safety; (F) Abuse reporting; (G) Health and sanitation; (H) Records maintenance and confidentiality; (I) Service planning; (J) Behavior management interventions including the use of seclusion or restraints; (K) Food preparation and distribution; (L) Medication administration and storage; (M) Resident belongings, storage and funds; (N) Resident rights, freedoms, and protections; (O) Advanced mental health and medical health directives; (P) Complaints and grievances; (Q) Setting maintenance; (R) Evacuation capability determination; (S) Fees and money management; (T) Cultural competency; (U) Limited English Proficiency (LEP) services; and (V) Facility closure. (m) Strategies to recruit, retain, and promote a diverse staff at all levels; (n) A complete floor plan with all specifications for an existing structure without additions or alterations including the location, size and type of rooms, all exits, all secondary emergency egress, smoke and carbon monoxide alarms, fire extinguishers, planned evacuation routes, point of safety, any designated smoking areas outside the program; and (o) Other information the Division may reasonably require. (4) A complete set of plans and specifications must be submitted to the Division at the time of initial application, whenever a new structure or addition to an existing structure is proposed or when significant physical alterations to an existing program are proposed. Plans must meet the following criteria: (a) Plans must be prepared in accordance with the Building Code and as outlined in OAR 309-035-0140; (b) Plans must be to scale and sufficiently complete to allow full review for compliance with these rules; and (c) Plans must bear the stamp of an Oregon licensed architect or engineer when required by the Building Code. (5) Prior to approval of a license for a new or renovated setting, the applicant must submit the following to the Division: (a) One copy of a written approved certificate of occupancy based on the change of use of the setting, issued by the city or county building codes authority having jurisdiction; (b) One copy of the fire inspection report from the State Fire Marshal or local jurisdiction indicating that the setting complies with the Fire Code; (c) When the setting is not served by an approved municipal water system, one copy of the documentation indicating that the state or county health agency having jurisdiction has tested and certified safe the water supply in accordance with OAR chapter 333, Public Health Division rules to public water systems; (d) When the setting is not connected to an approved municipal sewer system, one copy of the sewer or septic system approval from the Department of Environmental Quality or local jurisdiction. (6) The following fees must be submitted with an initial or renewal application: (a) The RTF license application fee for initial or renewal licensing is $60. No fee is required in the case of a governmentally operated RTF; (b) The RTH license application fee for initial or renewal licensing is $30. No fee is required in the case of a governmentally operated RTH. (7) Incomplete initial applications are void after 60 calendar days from the date the Division receives the application and non-refundable fee, as applicable. The Division will deny the incomplete application if not withdrawn. (8) A license is renewable upon submission of a complete renewal application packet in the form and manner required by the Division and a non-refundable fee as set out in section (6), except that no fee shall be required of a governmentally operated program: (a) Filing of a complete application for renewal 60 days before the date of expiration extends the effective date of the current license until the Division acts upon the renewal application; (b) The Division will deny renewal of a license if the program is not in substantial compliance with these rules or if the State Fire Marshal or authorized representative has given notice of noncompliance; and (c) The Division will deny renewal of a license if the program does not submit a complete renewal application packet prior to the expiration of the license. (9) Upon receipt of an application and fee, the Division shall conduct an application review. Initial action by the Division on the application must begin within 30 days of receipt of all application materials. The review must: (a) Include a complete review of application materials; (b) Determine whether the applicant meets the qualifications outlined in ORS 443.420 including: (A) Demonstrates an understanding and acceptance of these rules; (B) Is mentally and physically capable of providing services for residents; (C) Employs or utilizes only persons whose presence does not jeopardize the health, safety, or welfare of residents; and (D) Provides evidence satisfactory to the Division of financial ability to comply with these rules. (c) Determine that the applicant is not excluded from receiving federal awards or monies including: (A) The U.S. Office of Inspector General’s Exclusion List at www.exclusions.oig.hhs.gov; and (B) The U.S. General Services Administration’s System for Award Management Exclusion List at www.sam.gov. (d) Include a site inspection; and (e) Conclude with a report stating findings and a decision on licensing of the program. (10) The Division may deny an application prior to review when: (a) The applicant has previously had any action taken on a certificate or license; or (b) Action taken on a certificate or license includes denial, suspension, conditions, intent to revoke, or revocation by the Division, the Authority, the Oregon Department of Human Services, or any other state agency. (c) If a license is denied for any reason other than the results of a test or an inspection, the applicant is entitled to a hearing if the applicant requests a hearing in writing within 60 calendar days from the date the notice was mailed. If no written request for a hearing is timely received, the Division shall issue a final order by default. The Division may designate its file as the record for purposes of default. (11) The provider must submit and complete a plan of correction for each finding of noncompliance: (a) If the findings of noncompliance substantially impact the welfare, health, and safety of residents, the provider must submit a plan of correction that must be approved by the Division prior to issuance of a license. In the case of a currently operating program, the findings may result in suspension or revocation of a license; (b) If it is determined that the findings of noncompliance do not threaten the welfare, health, or safety of residents and the program meets other requirements of licensing, the Division may issue or renew a license with the plan of correction submitted and completed as a condition of licensing; (c) The Division must specify required documentation and set the timelines for the submission and completion of plans of correction in accordance with the severity of the findings; (d) The Division must review and evaluate each plan of correction. If the plan of correction does not adequately remedy the findings of noncompliance, the Division must require a revised plan of correction and may apply civil penalties or deny, revoke, or suspend the license; (e) The provider may appeal the finding of noncompliance or the disapproval of a plan of correction within 10 calendar days of receipt of notification by submitting a written request for appeal to the Division. The Division must decide on the appeal within 30 days of receipt of the appeal request. The decision of the Division shall be final. (12) The Division, in its discretion, may grant a variance to these rules based upon a demonstration by the applicant that an alternative method or different approach provides equal or greater program effectiveness and does not adversely impact the welfare, health, or safety of residents: (a) The provider seeking a variance must submit in writing a request to the Division, with CMHP review, that identifies the section of the rules from which the variance is sought, the reason for the proposed variance, and the proposed alternative method or different approach; (b) The director or designee must review and approve or deny the request for a variance; (c) The Division must notify the provider of the decision in writing within 30 days after receipt of the request. A variance may be implemented only after receipt of written approval from the Division; (d) With the exception of facilities operating within the Oregon State Hospital Salem and Junction City campuses, the provider may appeal the denial of a variance request by submitting a request for appeal in writing to the Division's Director or designee. The Director or their designee must decide within 30 days of receipt of the appeal. The decision of the Director or their designee shall be final; (e) Facilities operating within the Oregon State Hospital Salem and Junction City campuses may appeal the denial of a variance request by submitting a request for appeal in writing to the Authority’s Director or designee. The Authority’s Director or their designee must make a decision within 30 days of receipt of the appeal. The decision of the Authority’s Director or their designee shall be final; (f) A variance is not effective until granted in writing by the Division and are only valid for the length of the current issued license or shorter time as specified by the Division. The licensee must re-apply for a variance at the time of license renewal; and (g) In seeking a variance, the burden of proof that the requirements of these rules have been met is upon the applicant or licensee. (13) Upon finding that the applicant is in substantial compliance with these rules, the Division shall issue a license: (a) The license issued must state the name of the provider, the name of the program administrator, the address of the setting to which the license applies, the maximum number of residents to be served at any one time and their evacuation capability, the type of program, and such other information as the Division deems necessary; (b) A license must be effective for two years from the date issued unless sooner revoked or suspended; and (c) A license is not transferable or applicable to any setting, location, or management other than that indicated on the application and license. (14) The license remains valid only under the following conditions: (a) The provider does not operate or maintain the program in combination with a nursing facility, hospital, retirement facility, or other occupancy unless licensed, maintained, and operated as a separate and distinct part. (b) Each program must have sleeping, dining, and living areas for use only by its own residents, caregivers, and invited guests; and (c) The provider must maintain the license posted in a prominent location accessible to the public within the setting. (15) A license becomes void immediately upon suspension or final order of revocation or non-renewal of the license by the Division or if the operation is discontinued by voluntary action of the licensee or if there is a change of ownership. (16) Division staff must conduct an in-person inspection of every program no less than 90 days and not more than 120 days after initial licensure, and at least once every two years to determine whether it is maintained and operated in accordance with ORS 443.416 and these rules. The provider must allow Division staff entry and access to the setting and residents for the purpose of conducting the inspections: (a) Division staff must review methods of resident care and treatment, records, the condition of the setting and equipment, and other areas of operation; (b) All records, unless specifically excluded by law, must be available to the Division for review; and (c) The State Fire Marshal or authorized representatives shall, upon request, be permitted access to the setting, fire safety equipment within the setting, safety policies and procedures, maintenance records of fire protection equipment and systems, and records demonstrating the evacuation capability of setting occupants. (17) Incidents of alleged abuse covered by ORS 430.735 through 430.765 and reported complaints are investigated in accordance with OAR 943-045-0000. The Division may delegate the investigation to a CMHP or other appropriate entity: (a) When abuse is alleged or death of a resident has occurred and a law enforcement agency or the Division, Office of Training, Investigations, and Safety, Oregon Department of Human Services, or their designee has determined to initiate an investigation, the provider may not conduct an internal investigation without prior authorization from the Division. For the purposes of this section, an internal investigation is defined as conducting interviews of the alleged victim, witnesses, the alleged perpetrators, or any other persons who may have knowledge of the facts of the abuse allegation or related circumstances; reviewing evidence relevant to the abuse allegation, other than the initial report; or any other actions beyond the initial actions of determining: (A) If there is reasonable cause to believe that abuse has occurred; or (B) If the alleged victim is in danger or in need of immediate protective services; or (C) If there is reason to believe that a crime has been committed; or (D) What, if any, immediate personnel actions must be taken. (b) When the program has been notified of the completion of the abuse investigation, the program may conduct an internal investigation without Division approval to determine if any other personnel actions are necessary. (18) The provider must report promptly to the Division any significant changes to information supplied in the application or subsequent correspondence. Changes include but are not limited to changes in the setting or program name, provider, program administrator, telephone number, and mailing address. Changes also include but are not limited to changes in the physical nature of the setting, policies and procedures, or staffing pattern when the changes are significant or impact the resident's health, safety, or well-being. (19) In accordance with ORS 443.402, the Division may deny, suspend, revoke or refuse to renew a license of a provider if the Division finds that the provider operates a separate facility that is not currently or has not been in substantial compliance with rules adopted under ORS 443.400 to 443.455 or 443.705 to 443.825. Statutory/Other Authority: ORS 413.042, ORS 443.450 & ORS 443.420 Statutes/Other Implemented: ORS 413.032, ORS 443.400 - 443.465 & ORS 443.991 History: BHS 32-2025, temporary amend filed 12/30/2025, effective 01/01/2026 through 06/27/2026 BHS 4-2025, amend filed 02/28/2025, effective 03/01/2025 BHS 5-2018, amend filed 03/21/2018, effective 03/30/2018 MHS 11-2017, temporary amend filed 10/03/2017, effective 10/03/2017 through 03/30/2018 MHS 5-2017, f. & cert. ef. 6-8-17 MHS 2-2017(Temp), f. 3-3-17, cert. ef. 3-4-17 thru 8-30-17 MHS 13-2016(Temp), f. 9-6-16, cert. ef. 9-7-16 thru 3-3-17 MHD 4-2005, f. & cert. ef. 4-1-05 MHD 4-1998, f. 5-21-98, cert. ef. 6-1-98 MHD 9-1985, f. & cert. ef. 6-7-85 MHD 9-1984 (Temp), f. & cert. ef. 12-10-84