309-022-0135 Entry and Assessment (1) The program shall utilize a written entry procedure to ensure the following: (a) Individuals shall be considered for entry without regard to race, ethnicity, gender, gender identity, gender presentation, 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) Individuals shall receive services in the timeliest manner feasible consistent with the presenting circumstances; (c) Written informed consent for services shall be obtained from the individual or guardian, if applicable, prior to the start of services. If such consent is not obtained, the reason shall be documented and further attempts to obtain informed consent shall be made as appropriate; (d) The provider shall develop and maintain service records and other documentation for each individual that demonstrates the specific services and supports and the applicable date; (e) The provider shall report the entry of all individuals on the mandated state data system; (f) In accordance with ORS 179.505 and HIPAA, an authorization for the release of information shall be obtained for any confidential information concerning the individual being considered for or receiving services. (2) At the time of entry, the program shall offer to the individual and guardian, if applicable, written program orientation information. The written information shall be in a language understood by the individual and shall include: (a) A description of individual rights consistent with these rules; and (b) Policies concerning grievances and appeals, including an example grievance form: and (c) Policies concerning confidentiality. (3) Entry of children in community-based mental health services shall be prioritized in the following order: (a) Children who are at immediate risk of psychiatric hospitalization or removal from home due to emotional and mental health conditions; (b) Children who have severe mental health conditions; (c) Children who exhibit behavior that indicates high risk of developing conditions of a severe or persistent nature; and (d) Any other child who is experiencing mental health conditions that significantly affect the child’s ability to function in everyday life but not requiring hospitalization or removal from home in the near future. (4) Assessment: (a) At the time of entry, an assessment shall be completed prior to development of the service plan; (b) The assessment shall be completed by a QMHP. A QMHA may assist in the gathering and compiling of information to be included in the assessment; (c) Each assessment shall include: (A) Sufficient information and documentation to justify the presence of a DSM diagnosis that is the medically appropriate reason for services; (B) Suicide potential shall be assessed and service records shall contain follow-up actions and referrals when an individual reports symptoms indicating risk of suicide; (C) Screening for the presence of co-occurring disorders and chronic medical conditions; and (D) Screening for the presence of symptoms related to physical or psychological trauma. (d) When the assessment process determines the presence of co-occurring substance use and mental health disorders or any significant risk to health and safety: (A) Additional assessments shall be used to determine the need for additional services and supports and the level of risk to the individual or to others; and (B) All providers shall document referral for further assessment, planning, and intervention from an appropriate professional, either with the same provider or with a collaborative community provider. (e) In addition to periodic assessment updates based on changes in the clinical circumstance, any individual continuing to receive mental health services for one or more continuous years shall receive an annual assessment by an LMP. (f) Integrated/IPSR providers shall also meet the requirements specified in OAR 309-018-0140 for conducting assessments. Statutory/Other Authority: ORS 161.390, 413.042, 430.256, 426.490 - 426.500, 428.205 - 428.270, 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, 430.010, 430.205 - 430.210, 430.240 - 430.640, 430.850 - 430.955, 443.400 - 443.460, 443.991 & 743A.168 History: BHS 24-2018, amend filed 12/27/2018, effective 01/25/2019 BHS 16-2018, temporary amend filed 07/17/2018, effective 08/01/2018 through 01/27/2019 MHS 21-2016, f. & cert. ef. 12-1-16 MHS 9-2016(Temp), f. 6-28-16, cert. ef. 7-1-16 thru 12-27-16 MHS 5-2014, f. & cert. ef. 2-3-14 MHS 8-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14