415-050-0115 Policies, Procedures and Protocols (1) All providers must develop and implement written policies and procedures, compliant with OAR 415-050. (2) Policies must be available upon request. (3) Providers must develop and implement written policies and procedures including, but not limited to: (a) The Program's philosophical approach to withdrawal management; (b) Code of conduct that includes professional boundaries and ethics; (c) Personnel Qualifications, Credentialing and Training; (d) Criminal Records Checks that are conducted using a national and state-wide process for all employees, contracted staff and interns that render medical or behavioral health services and supports or have access to protected health information such as service records or billing information; (e) Fraud, waste and abuse in Federal Medicaid and Medicare programs compliant with OAR 410-120-1380 and 410-120-1510; (f) Fee agreements; (g) Confidentiality and compliance with HIPAA, Federal Confidentiality Regulations (42 CFR, Part 2 and HIPAA), 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) Grievances and Appeals, consistent with these rules; (j) Policy and procedure containing criteria in accordance with ORS 430.397 through 430.401 for the voluntary admission of patient to a withdrawal management program; (k) Care coordination and the transition of care; (l) Patient Rights, consistent with these rules; (m) Crisis prevention and response; (n) Incident and critical incident reporting; (o) Trauma-informed service delivery, consistent with the Division’s Trauma Informed Services Policy; (p) Provision of culturally and linguistically appropriate services; (q) Medical Protocols; (r) Medication Administration, Storage and Disposal; (s) Delivery of services and supports consistent with these rules and The ASAM Criteria for each licensed Level of Care; (t) Facility Standards; and (u) General Safety and Emergency Procedures including providing immediate transportation of a patient to a general hospital in case of a medical emergency. (4) The Program must utilize a written admissions procedure in accordance with these rules, which includes at minimum: (a) Screening for admission, including SUPTR prioritization when applicable; (b) Attempting to gain informed consent and documenting accordingly; (c) Offering a written copy of patient’s rights, grievance and notice of privacy practices; (d) Steps for making referrals for patients not admitted to the Program; (e) Steps for coordinating care with payers and entities responsible for care coordination; (f) A history and physical (H&P) assessment; and (g) A stabilization plan. (5) Additionally, providers must establish and implement written policies that: (a) Prohibit physical or other forms of aversive action to discipline a patient; (b) Prohibit seclusion, personal restraint, mechanical restraint and chemical restraint; (c) Prohibit withholding shelter, regular meals, clothing or aids to physical functioning; (d) Prohibit discipline of one patient receiving services by another; and (e) Prohibit titration of medications prescribed for the treatment of opioid dependence as a condition of receiving, or continuing to receive, treatment. Statutory/Other Authority: ORS 413.042 & ORS 430.256 Statutes/Other Implemented: ORS 430.306 & ORS 430.345-430.375 History: ADS 3-2023, adopt filed 04/07/2023, effective 04/07/2023