413-070-0430 Department Records, Medication Review, and Consent and Authorization Requirements (1) The Department must keep the medical and mental health records of any child or young adult in substitute care. As used in this section, "medical and mental health care records" includes a child or young adult's records of medical and mental health care, including, but not limited to, the names of former and current health providers, medical services and diagnoses, evaluations, immunizations, and prescribed medications. (2) The caseworker must support timely exchange of medical and mental health care information for a child or young adult in substitute care unless: (a) A child or young adult has the authority to consent to his or her own health and mental health care; or (b) The parent or legal guardian of the child or young adult retains authority to consent to health care decisions through a Voluntary Custody Agreement or Voluntary Placement Agreement. (3) The caseworker must: (a) Provide records of previous mental health assessments and assessment updates, including multiaxial DSM diagnosis and treatment recommendations, and progress records from mental health treatment services to the licensed medical professional prior to the medical appointment or no later than the time at which the licensed medical professional examines the child or young adult when a child or young adult may be receiving a prescription for a psychotropic medication. (b) Document and timely inform the substitute caregiver of the child or young adult's known health information, including information regarding any prescribed and administered psychotropic medication: (A) At the time of placement; and (B) When new or updated health information becomes known to the Department. (4) To keep accurate medical records and documentation for a child or young adult's medical and mental health history record, the caseworker must: (a) Retain copies of all medical and mental health records received by the Department in the medical section of the case file of the child or young adult in substitute care. (b) Document and update records of known health conditions, services, and supports of the child or young adult in substitute care when developing the case plan and at each case plan review. (c) Receive and review monthly the medication log of the child or young adult in substitute care and retain a copy in the medical section of the case file of the child or young adult and the Department's electronic information system. (d) Document the medical information of the child or young adult in the Department's electronic information system. (5) The Department must inform the substitute caregiver of the child or young adult that written authorization, as set forth in subsections (a)-(e) of this section, is required prior to filling a prescription for a new psychotropic medication unless there is an urgent medical need, in which case prior written authorization is not required. (a) Unless an exception in subsection (d) of this section applies, the Child Welfare Program Manager or designee must provide written authorization prior to the administration of any new prescription of psychotropic medication to a child or young adult in substitute care when the requirements of at least one of the following paragraphs applies: (A) The Department is the legal guardian of the child or young adult; (B) Parental rights have been terminated and the court has ordered permanent commitment of the child or young adult and placed the child or young adult in the legal custody and guardianship of the Department; or (C) A child or young adult's parents have signed a Release or Surrender Agreement giving the Department guardianship and control over the child or young adult. (b) When the authority to provide authorization for psychotropic medication is not given to the Department in the Voluntary Placement Agreement or Voluntary Custody Agreement, the Department must obtain the written consent of a child or young adult's parent or legal guardian for the administration of psychotropic medication. (c) A child, 15 years of age or older, or a young adult may provide written consent for psychotropic medication under ORS 109.640. (d) Written authorization of the Child Welfare Program Manager or designee is not required prior to the administration of any new prescription of psychotropic medication to a child or young adult in substitute care when the requirements of at least one of the following paragraphs applies: (A) A change in the delivery system of a previously prescribed medication; (B) A change in the dosage of a previously prescribed medication; (C) A change in medication within the same drug classification; (D) A one-time medication given prior to a medical procedure; or (E) An anti-epileptic medication prescribed for a seizure disorder. (6) After the caseworker has obtained the written authorization for psychotropic medication required under section (5) of this rule, the caseworker must do all of the following: (a) Complete the notifications required under OAR 413-070-0480 and 413-070-0490. (b) Ensure a report has been made to the prescribing licensed medical professional when the condition of the child or young adult in substitute care is not improving, is deteriorating, or when the child or young adult, caseworker, substitute caregiver, or other individual has observed suspected side effects of the medication. (c) Request and receive updated health information about the child or young adult in substitute care and the effects of the prescribed psychotropic medication therapy from the substitute caregiver during the monthly contact with the substitute caregiver required under OAR 413-080-0054. (7) Prior to authorization and administration of a new prescription for more than one psychotropic medication or any antipsychotic medication, the Department must ensure a child or young adult in substitute care has received an assessment from a qualified mental health professional or licensed medical professional unless: (a) A medication was prescribed for an urgent medical need; or (b) The prescription is described in paragraphs (5)(d)(A) to (E) of this rule. (8) The assessment required under section (7) of this rule either must: (a) Have been completed within the three months prior to the prescription for psychotropic medication; or (b) Be an update of a prior assessment, which focuses on a new or acute problem, and information from the assessment must be communicated to the licensed medical professional prior to the issuance of a prescription for psychotropic medication. (9) The Department must ensure the requirements of both of the following subsections are met: (a) An annual review of psychotropic medications, by an individual other than the prescriber when: (A) A child or young adult has more than two prescriptions for psychotropic medications; or (B) A child under six years of age has a prescription for psychotropic medication. (b) The annual review required under subsection (a) of this section must be conducted by one of the following: (A) A licensed medical professional; (B) A qualified mental health professional with the authority to prescribe drugs; or (C) A licensed pharmacist with the Drug Use Review Program under the Oregon Health Authority, Division of Medical Assistance Programs OAR 410-121-0100. Statutory/Other Authority: ORS 418.005 & 418.517 Statutes/Other Implemented: ORS 109.640, 109.675, 418.005 & 418.517 History: CWP 12-2015, f. & cert. ef. 7-17-15 CWP 3-2015, f. & cert. ef. 1-1-15 CWP 7-2010, f. & cert. ef. 6-30-10 CWP 8-2007, f. & cert. ef. 5-1-07 SCF 6-1995, f. 12-22-95, cert. ef. 12-29-95 SCF 5-1995, f. & cert. ef. 9-15-95