415-057-0030 Administrative Requirements for Treatment Programs (1) The program will implement written policies and procedures to ensure compliance with these administrative rules, including program operations, quality assurance and reporting procedures. The policies and procedures will describe how the program will deliver treatment that ensures desired outcomes. The Quality Assurance Plan must: (a) Include a measurement of the proportion of full-time equivalent program staff who are licensed and or certified as defined in this rule; (b) Have and follow a supervision plan for program staff; and (c) Have an audit process that includes: (A) Monitoring treatment groups and program activities to evaluate fidelity and effectiveness; (B) Reviewing clinical charts to ensure permanent records are accurate, legible and meet documentation requirements set forth in these rules; (C) Providing a formal mechanism for clients to give input into the delivery of treatment services and program structure that at a minimum includes client satisfaction surveys; and (D) Providing a written policy and procedure for reporting unusual incidents to the designated DOC administrator and AMH that includes a detailed description of the event, the persons involved and the final resolution of the incident. (2) The program will have and implement the following written personnel policies and procedures, which are applicable to all program staff, volunteers, and interns or students: (a) Rules of conduct and standards for ethical practices of program staff, including written procedures to report misconduct to the appropriate authority; (b) Managing incidents of alcohol and drug use by program staff that, at a minimum, comply with Drug Free Workplace Standards; and (c) Compliance with the federal and state personnel regulations including the Civil Rights Act of 1964 as amended in 1972, Equal Pay Act of 1963, the Age Discrimination in Employment Act of 1967, Title I of the Americans with Disabilities Act, Oregon civil rights laws related to employment practices, and any subsequent amendments to these laws effective on or before the effective date of these rules. The program will give individualized consideration to all applicants who, with or without reasonable accommodation, can perform the essential functions of the job position. (3) The program will maintain a personnel record for each program staff documenting applicable qualification standards as described in OAR 415-057-0110 to 0130 and 415-057-0150. The program will maintain the record for a period of three years following the departure of a program staff. (4) The program receiving public funds must comply with Title 2 of the Americans with Disabilities Act of 1990, 42 USC § 1231 et seq. after July 26, 1992. (5) The program will maintain malpractice and liability insurance and be able to demonstrate evidence of current compliance with this requirement. Programs operated by a public body will demonstrate evidence of insurance or a self-insurance fund pursuant to ORS 30.282. (6) The program will: (a) Comply with federal regulations (42 CFR § 2 and 45 CFR § 205.50) and state statutes including ORS 179.505 and 430.399 pertaining to confidentiality of permanent client records; (b) Accurately record all information about the client as required by these rules in the permanent client record and unless specified otherwise, within seven days of delivering the service or obtaining the information; (c) Maintain each permanent client record to assure identification, permanency, accessibility, uniform organization, and completeness of all components required by these rules and in a manner to protect against damage or separation from the permanent client or program record; (d) Keep all documentation legible and current; (e) Include the date that the service was provided; (f) Include the signature and credentials of the person providing the service and include the date of the signature; (g) Not falsify, alter, or destroy any client information required by these rules to be maintained in the permanent client record or program records; (h) Require that errors in the permanent client record be corrected by lining out the incorrect information with a single line in ink, adding the correct information, dating, and initialing the correction. Errors may not be corrected by removal or obliteration through the use of correction fluid or tape; (i) Provide written description in the permanent client record of any injury, accident or unusual incident involving any client occurring during program services or on program grounds; and (j) Permit inspection of permanent client records upon request by the Division to determine compliance with these rules. (7) Permanent client records will be kept for a minimum of seven years. If a program is acquired by another program, the original program is responsible for assuring compliance with the requirements of 42 CFR § 2.19(a)(1) or (b), whichever is applicable. (8) If a program discontinues operations, the program is responsible for: Transferring permanent client records to the DOC records administrator; and (9) When a program discontinues operations, the identified DOC records administrator is responsible for: (a) Assuring compliance with the requirement of 42 CFR §2.19(a)(1) or (b), whichever is applicable for transferred permanent client records; (b) Keeping all transferred permanent client records for a minimum of seven years; or (c) With client consent, transferring permanent client records to another program. Statutory/Other Authority: ORS 413.042, 409.410 & 409.420 Statutes/Other Implemented: ORS 430.240 - 430.640, 430.850 - 430.955, 813.010 - 813.052 & 813.200 - 813.270 History: ADS 2-2010, f. & cert. ef. 5-6-10