309-033-0540 Administrative Requirements for Hospitals and Nonhospital Facilities Approved to Provide Services to Persons in Custody. (1) Written policies. Each hospital or nonhospital facility shall have written policies concerning the care, custody, and treatment of persons in custody or on diversion. These policies shall be written to provide for the comfort and safety of the person being provided care and for the safety of the facility staff providing care to that person. These policies shall detail staff responsibilities, person’s rights, and emergency procedures. All staff involved in the care of these persons shall be fully familiar with these policies and procedures. These policies shall be reviewed as part of the Division’s approval process. (2) Warning. Each hospital or nonhospital facility shall: (a) Have a Licensed Independent Practitioner (LIP), nurse, or a Qualified Mental Health Professional (QMHP) give the person the following warning: “You are being held in this hospital because someone is concerned that you may hurt yourself or other people. Anything the staff of this hospital observes you do or say while you are in custody here may be used as evidence in a court of law to determine whether you should be under civil commitment as a person with mental illness. You have a right to legal counsel. If you cannot afford an attorney one will be provided for you by the court.” (b) Have the warning given at the time of admission and at times when it is determined that the person will reasonably understand the notice, and as often as it is determined necessary to assure that the person has been given an opportunity to be aware of the notice; (c) Have the warning given to the person in writing, as required by ORS 426.123. An attempt shall be made to have the person sign the written warning. A copy of the signed written warning shall be given to the person and the original shall be kept in the clinical record. The person’s inability to sign the written warning or refusal to sign the written warning shall be documented on the written warning below the place where the person’s signature would be normally found, clearly stating the reasons the signature was not obtained. The written warning shall include a place where the person, by making a mark, may request legal counsel. (3) Notification of next of kin. If the person consents, a LIP or QMHP at a hospital shall make every effort to notify the person’s next of kin of the location and condition of the person as required under ORS 426.234. (4) Notification of the court of hospital hold. The admitting LIP, if the person is at a hospital, shall immediately notify the circuit court in writing. The admitting LIP shall also immediately notify the director in the county where the hospital is located so that an investigation can be conducted. (5) Notification of the court of nonhospital hold. The director, if the person is at a nonhospital facility, shall notify, in writing, the circuit court in the county where the person was taken into custody. (6) Log. Each hospital or nonhospital facility shall maintain a log of persons in custody that includes: name, date of birth, date of admission, type of admission, and a notation of the use of restraints. (7) Posted warning and rights. Each hospital or nonhospital facility shall post a copy of the person’s rights in the holding room behind protective unbreakable plastic or in another location clearly visible from the holding room which, at a minimum, states: (a) The warning described in OAR 309-033-0540; (b) The person’s right to be free from electro-shock therapy or unduly hazardous procedures. (8) Clinical records. Each hospital or nonhospital facility shall maintain a clinical record which accurately documents the care, custody, and treatment of a person in custody. These records shall include: (a) A copy of the hold form which documents the reasons for the hold, including specific behaviors which indicate the person: (A) Is dangerous to self or another person; and (B) Is in need of immediate care, custody or treatment for mental illness. (b) Documentation that the warning described in OAR 309-033-0540 has been given to the person; (c) Documentation of the potential effects and the observed effects of any medication administered which may substantially affect the person to prepare for or function effectively at the commitment hearing, signed by the treating LIP; (d) A report of physical examination and relevant laboratory tests (e) Daily medical progress notes; (f) 24 hour nursing notes; (g) Documentation, signed by the treating LIP, of each use of any mechanical restraints and the specific reasons which justify the use; (h) Documentation of the psychiatric history which, whenever possible, shall include: (A) History of present illness, including specific prodromal symptoms; (B) Medical history; (C) Family history; (D) Past psychiatric history; (E) Substance use and abuse history; (F) History of legal difficulties; and (G) Social history including current support system. (i) A report of mental status; (j) A diagnostic impression; (k) A treatment plan. (9) Access to clothing before release of persons in custody. Each hospital or nonhospital facility shall allow the person in custody to have access to his/her clothing before being released to attend the commitment hearing. Statutory/Other Authority: ORS 413.042, 426.123, 426.232, 426.233, 426.234 & 426.236 Statutes/Other Implemented: ORS 426.005 - 426.395 History: BHS 9-2023, amend filed 04/04/2023, effective 04/07/2023 MHD 8-1998, f. 6-26-98, cert. ef. 7-1-98, Renumbered from 309-210-0050