Oregon Administrative Rules
Chapter 415 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: ADDICTION SERVICES
Division 12 - LICENSURE OF SUBSTANCE USE DISORDERS AND PROBLEM GAMBLING RESIDENTIAL TREATMENT AND RECOVERY SERVICES
Section 415-012-0032 - Application Information

(1) Name and address of the applicant;

(2) Name, address, and qualifications of the executive director or administrator;

(3) Outline of the staff organization with names and qualifications;

(4) Articles of incorporation and bylaws;

(5) Names and addresses of the board of directors, sponsors, or advisory boards of the program;

(6) Names and addresses of physicians, other professionally trained personnel, medical facilities, and other individuals or organizations with whom the program has a direct referral agreement or is otherwise affiliated;

(7) Description of the treatment services provided by the program setting forth program philosophy, goals, objectives, and a description of the treatment methodology for each service element;

(8) Materials demonstrating compliance with the administrative rules governing the specific service provided;

(9) Materials showing compliance with all related federal, state and local acts, ordinances, rules and amendments such as State Fire Marshal rules, board of health and building zoning codes, and the American Disabilities Act;

(10) Materials substantiating compliance with distance requirements subject to ORS 430.590 for programs using methadone to treat opioid addiction. These application procedures apply to new programs and existing programs moving to a new location after 1-14-2013;

(11) Materials substantiating compliance with other licensing authorities such as the Child Welfare Division for residential adolescent services or the Drug Enforcement Administration and a federally approved accreditation agency for methadone treatment services;

(12) For residential treatment and detoxification facilities, the maximum individual capacity requested;

(13) Source of funds used to finance the program such as an annual budget of the organization or a copy of the most current fiscal audit or review;

(14) Written evidence of applicable insurance such as liability insurance;

(15) Floor plan for the proposed facility;

(16) Representative sample individual file;

(17) Written nondiscrimination policy including:

(18) Identification of any individual, including stockholders or other legal entities, who have an ownership interest of any person, property or structure representing five percent or more. For purposes of these rules, an individual with a five percent or more ownership interest is presumed to have an effect on the operation of the provider, unless the individual establishes that the individual has no involvement in the operation of the provider;

(19) Background information on all licenses, certifications and letters of approval held or previously held by the applicant, or by any owner disclosed under subsection (e) of this rule, to provide care or treatment, or engage in a profession or trade. The list shall include every license, certification and letter of approval, regardless of whether it was issued by the Authority or another regulatory body:

(20) Disclosure of any substantiated findings of abuse, neglect, or mistreatment by the applicant, owner, or program staff.