Current through Register Vol. 63, No. 9, September 1, 2024
(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.
Stat. Auth.: ORS
413.042,
409.410 &
409.420
Stats. Implemented: ORS
430.240 -
430.640,
430.850 -
430.955,
813.010 -
813.052 &
813.200 -
813.270
