Current through Register Vol. 63, No. 9, September 1, 2024
Providers must develop and implement a structured and ongoing
process to assess, monitor, and improve the quality and effectiveness of
services provided to patients, including:
(1) The program must document a quality
assurance and performance improvement process that occurs at least quarterly
and, at a minimum, addresses:
(a) Process
improvement projects;
(b) Incident
reports; and
(c)
Grievances.
(2) Critical
Incidents must be reported to the Division through submission of an incident
report and as applicable, to the Office of Training Investigation and Safety
(OTIS), and other authorities:
(a) Including,
but not limited to the following circumstances:
(A) Death, including by suicide or
overdose;
(B) Severe injury,
including injury leading to hospitalization, injury resulting in medical
attention needed or no medical attention needed, overdose resulting in
hospitalization or needing medical attention, and emergency services
needed;
(C) Ongoing risk to health,
(for example: environmental risks such as black mold);
(D) Police involvement;
(E) Extensive damage to the facility or other
substantial change in living conditions; and
(F) Where abuse or neglect is suspected,
including unethical client and staff relationships; and
(G) Relationships between individuals that
result in harm to at least one individual or that are sexual in
nature.
(b) Within 24
hours of the event;
(c) On the
original, unredacted incident report;
(d) All incident reports must be maintained
in the corresponding service record and in a common, secure file for quality
improvement purposes and review by the Division; and
(e) In accordance with privacy rules and
regulations, incident reports filed in service records must not contain
protected health information belonging to any other individual.
(3) Incident reports must contain,
at a minimum, the following information:
(a)
The time and date of the event;
(b)
The time and date of when the incident report form was completed;
(c) Name and title of staff who filled out
the report;
(d) Identification of
all staff involved in the incident and the response to the incident, and their
titles;
(e) Identification of each
individual involved;
(f)
Description of event;
(g)
Description of program response;
(h) Description of which policies and
procedures were followed and when appliable, any that were not
followed;
(i) Identification of
staff who were notified, and their titles;
(j) Identification of which authorities the
event was reported to; and
(k)
Description of administrative response and follow-up.
(4) The program must document the Medical
Director's involvement in the development and review of medical standing
orders, medical and medication protocols and operating procedures within the
first three months of hire for a new Medical Director and annually
thereafter.
(5) The provider must
develop and maintain service records for each patient that demonstrates the
specific services and supports, including:
(a)
Identifying information or documentation of attempts to obtain the
information;
(b) Informed Consent
for Services including medications or documentation specifying why the provider
could not obtain consent by the patient or guardian as applicable;
(c) Written refusal of any services and
supports offered, including medications;
(d) A signed fee agreement, when
applicable;
(e) A personal
belongings inventory created upon entry and updated whenever an item of
significant value is added or removed or on the date of transfer;
(f) Copies of documents relating to
guardianship or any other legal considerations, as applicable;
(g) Documentation of the patient's ability to
evacuate the home consistent with the program's evacuation plan developed in
accordance with the Oregon Structural Specialty Code and Oregon Fire
Code;
(h) Documentation of any
safety risks;
(i) Documentation of
follow-up actions and referrals when patient reports symptoms indicating risk
of suicide;
(j) Incident reports
involving the patient; and
(k)
Report the status date for the entry of all patients on the mandated state data
system.
(6) When medical
services are provided, the following documents must be part of the service
record as applicable:
(a) Medication
administration records as per these rules;
(b) Laboratory reports;
(c) LMP orders for medication, protocols or
procedures;
(d) Documentation of
medical screenings, assessments, consultations, interventions and
procedures;
(e) The administration
of nursing and withdrawal assessments as indicated throughout the episode to
safely complete acute withdrawal from each substance of concern;
(f) The administration or dispensing of
medication in accordance with current orders;
(g) All changes to protocol, including
medical rationale must be noted by the LMP or their designee;
(h) Any deviation from protocol, including
circumstance or rationale must be noted in the service record by the
responsible program staff;
(i) The
medical stabilization plan;
(j)
Motivational Enhancement services;
(k) Care coordination, case management, and
referral activities and plans; and
(l) The patient's involvement in
stabilization activities and progress toward achieving objectives contained in
the patient's stabilization plan.
Statutory/Other Authority: ORS
413.042,
428.205 - 428.270, 430.640 &
443.450
Statutes/Other Implemented: ORS
430.010,
430.205- 430.410,
430.254-430.640, 430.850 - 430.955, 443.400-443.460, 443.991, 461.549 &
743A.168
