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