411-323-0060 Agency Policies and Procedures (1) HEALTH. An agency must have and implement policies and procedures that maintain and protect the health of individuals. (2) INDIVIDUAL AND FAMILY INVOLVEMENT. An agency must have and implement a written policy that addresses opportunities for all of the following: (a) Participation of individuals in decisions regarding the agency's operations. (b) Interaction of families, guardians, legal and designated representatives, and significant others with individuals. (c) For individuals, families, guardians, legal and designated representatives, and significant others: (A) Participation on the board of directors or on committees; or (B) Review of the agency's policies directly affecting the individuals receiving services from the agency. (3) CONFIDENTIALITY OF RECORDS. An agency must have and implement written policies and procedures that ensure all records for individuals are kept confidential except as otherwise provided by applicable state and federal rules or laws. (a) For the purpose of disclosure from individual medical records under this rule, an agency is considered a "public provider" as defined in ORS 179.505. (b) Access to records by the Department does not require authorization by an individual or their legal or designated representative or family. (c) For the purpose of disclosure of non-medical individual records, all or portions of the information contained in the non-medical individual records may be exempt from public inspection under the personal privacy information exemption to the public records law set forth in ORS 192.355. (4) PROFESSIONAL BEHAVIOR SERVICES. An agency with an endorsement to deliver professional behavior services must have and implement written policies and procedures to assure professional behavior services are delivered by a qualified behavior professional in accordance with OAR chapter 411, division 304. (5) BEHAVIOR SUPPORTS. An agency must have and implement written policies and procedures for the delivery of behavior supports that prohibits abusive practices and assures behavior supports are consistent with positive behavior theory and practice. (a) The agency must inform each individual, and as applicable their legal or designated representative, of the behavior support policies and procedures at the time of entry and as changes occur. (b) A decision to alter an individual's behavior must be made by the individual or their legal or designated representative. (6) EMERGENCY PHYSICAL RESTRAINT. An agency must have and implement written policies and procedures to assure that the use of any emergency physical restraint is reviewed by an agency's executive director, or as applicable their designee, within two hours of the emergency physical restraint. (7) DIRECT NURSING SERVICES. An agency with an endorsement to deliver direct nursing services must have and implement written policies and procedures to assure direct nursing services are delivered by a qualified registered or licensed professional nurse in accordance with OAR chapter 411, division 380. (8) HANDLING AND MANAGING INDIVIDUALS' MONEY. An agency must have and implement written policies and procedures for the handling and management of money for the individuals. Such policies and procedures must provide for all of the following: (a) Financial planning and management of the funds for an individual. (b) Safeguarding the funds for an individual. (c) Individuals receiving and spending their own money. (d) Taking into account the interests and preferences of the individual. (e) Reimbursement for money or property that is missing due to the theft or mismanagement on the part of any staff or volunteers of the agency, or of any funds within the custody of the agency that are missing due to theft or mismanagement. Reimbursement must be made to the individual within 10 business days from the verification that funds are missing. (9) COMPLAINTS. An agency must have and implement written policies and procedures for individual complaints in accordance with OAR 411-318-0015. (a) Complaints by or on behalf of individuals must be addressed in accordance with OAR 411-318-0015. (b) Upon an individual's entry and request and annually thereafter, the policy and procedures for complaints must be explained and provided to an individual and their legal or designated representative (as applicable). (10) INDIVIDUAL RIGHTS. An agency must have and implement written policies and procedures that individual’s rights described in OAR 411-318-0010 are protected and able to be exercised. (11) AGENCY DOCUMENTATION REQUIREMENTS. An agency must have and implement policies and procedures that address agency documentation requirements. Documentation must be: (a) Prepared at the time or immediately following the event being recorded. (b) Accurate and contain no willful falsifications. (c) Legible, dated, and signed by the person making the entry. (d) Maintained for no less than seven years. (12) An agency must have and implement policies and procedures to describe who, by role, may enter into agreements to deliver program services to an individual as required by OAR 411-323-0065(4). (13) An agency must have and implement policies and procedures to address the temporary unavailability of an executive director. (14) An agency that receives annual payments under the Community First Choice (K Plan) of at least $5,000,000, as a condition of receiving such payments, must: (a) Have written policies for all employees of the agency, including management, and of any contractor or agent of the agency that provide detailed information about: (A) The False Claims Act established under sections 3729 through 3733 of title 31. (B) Administrative remedies for false claims and statements established under chapter 38 of title 31. (C) Any state laws pertaining to civil or criminal penalties for false claims and statements, and whistleblower protections under such laws, with respect to the role of such laws in preventing and detecting fraud, waste, and abuse of Medicaid funds. (b) Have written policies containing detailed provisions regarding the agency’s policies and procedures for detecting and preventing fraud, waste, and abuse. (c) Include in an employee handbook: (A) A specific discussion of the laws described in subsection (a) of this section; (B) The rights of employees to be protected as whistleblowers; and (C) The agency’s policies and procedures for detecting and preventing fraud, waste, and abuse. Statutory/Other Authority: ORS 409.050, 427.024, 427.104 & 430.662 Statutes/Other Implemented: ORS 409.010, 427.007, 427.024, 427.104, 430.215, 430.610 & 430.662 History: APD 1-2026, amend filed 01/12/2026, effective 01/15/2026 APD 50-2024, minor correction filed 07/18/2024, effective 07/18/2024 APD 16-2023, amend filed 09/30/2023, effective 10/01/2023 APD 44-2019, amend filed 10/29/2019, effective 11/01/2019 APD 21-2019, amend filed 06/28/2019, effective 07/01/2019 APD 29-2017, amend filed 11/30/2017, effective 12/01/2017 APD 25-2016, f. & cert. ef. 6-29-16 APD 35-2015(Temp), f. 12-31-15, cert. ef. 1-1-16 thru 6-28-16 APD 42-2014, f. 12-26-14, cert. ef. 12-28-14 APD 24-2014(Temp), f. & cert. ef. 7-1-14 thru 12-28-14 SPD 1-2012, f. & cert. ef. 1-6-12 Reverted to SPD 12-2011, f. & cert. ef. 7-1-11 SPD 12-2011, f. & cert. ef. 7-1-11 SPD 19-2011(Temp), f. & cert. ef. 7-1-11 thru 12-28-11