415-050-0135 Quality Assurance and Performance Improvement Providers must develop and implement a structured and ongoing process to assess, monitor, and improve the quality and effectiveness of services provided to patients, including: (1) The program must document a quality assurance and performance improvement process that occurs at least quarterly and, at a minimum, addresses: (a) Process improvement projects; (b) Incident reports; and (c) Grievances. (2) Critical Incidents must be reported to the Division through submission of an incident report and as applicable, to the Office of Training Investigation and Safety (OTIS), and other authorities: (a) Including, but not limited to the following circumstances: (A) Death, including by suicide or overdose; (B) Severe injury, including injury leading to hospitalization, injury resulting in medical attention needed or no medical attention needed, overdose resulting in hospitalization or needing medical attention, and emergency services needed; (C) Ongoing risk to health, (for example: environmental risks such as black mold); (D) Police involvement; (E) Extensive damage to the facility or other substantial change in living conditions; and (F) Where abuse or neglect is suspected, including unethical client and staff relationships; and (G) Relationships between individuals that result in harm to at least one individual or that are sexual in nature. (b) Within 24 hours of the event; (c) On the original, unredacted incident report; (d) All incident reports must be maintained in the corresponding service record and in a common, secure file for quality improvement purposes and review by the Division; and (e) In accordance with privacy rules and regulations, incident reports filed in service records must not contain protected health information belonging to any other individual. (3) Incident reports must contain, at a minimum, the following information: (a) The time and date of the event; (b) The time and date of when the incident report form was completed; (c) Name and title of staff who filled out the report; (d) Identification of all staff involved in the incident and the response to the incident, and their titles; (e) Identification of each individual involved; (f) Description of event; (g) Description of program response; (h) Description of which policies and procedures were followed and when appliable, any that were not followed; (i) Identification of staff who were notified, and their titles; (j) Identification of which authorities the event was reported to; and (k) Description of administrative response and follow-up. (4) The program must document the Medical Director’s involvement in the development and review of medical standing orders, medical and medication protocols and operating procedures within the first three months of hire for a new Medical Director and annually thereafter. (5) The provider must develop and maintain service records for each patient that demonstrates the specific services and supports, including: (a) Identifying information or documentation of attempts to obtain the information ; (b) Informed Consent for Services including medications or documentation specifying why the provider could not obtain consent by the patient or guardian as applicable; (c) Written refusal of any services and supports offered, including medications; (d) A signed fee agreement, when applicable; (e) A personal belongings inventory created upon entry and updated whenever an item of significant value is added or removed or on the date of transfer; (f) Copies of documents relating to guardianship or any other legal considerations, as applicable; (g) Documentation of the patient’s ability to evacuate the home consistent with the program’s evacuation plan developed in accordance with the Oregon Structural Specialty Code and Oregon Fire Code; (h) Documentation of any safety risks; (i) Documentation of follow-up actions and referrals when patient reports symptoms indicating risk of suicide; (j) Incident reports involving the patient; and (k) Report the status date for the entry of all patients on the mandated state data system. (6) When medical services are provided, the following documents must be part of the service record as applicable: (a) Medication administration records as per these rules; (b) Laboratory reports; (c) LMP orders for medication, protocols or procedures; (d) Documentation of medical screenings, assessments, consultations, interventions and procedures; (e) The administration of nursing and withdrawal assessments as indicated throughout the episode to safely complete acute withdrawal from each substance of concern; (f) The administration or dispensing of medication in accordance with current orders; (g) All changes to protocol, including medical rationale must be noted by the LMP or their designee; (h) Any deviation from protocol, including circumstance or rationale must be noted in the service record by the responsible program staff; (i) The medical stabilization plan; (j) Motivational Enhancement services; (k) Care coordination, case management, and referral activities and plans; and (l) The patient's involvement in stabilization activities and progress toward achieving objectives contained in the patient's stabilization plan. Statutory/Other Authority: ORS 413.042, 428.205 - 428.270, 430.640 & 443.450 Statutes/Other Implemented: ORS 430.010, 430.205- 430.410, 430.254-430.640, 430.850 - 430.955, 443.400-443.460, 443.991, 461.549 & 743A.168 History: ADS 3-2023, adopt filed 04/07/2023, effective 04/07/2023