Or. Admin. Code § 309-035-0163

Current through Register Vol. 64, No. 1, January 1, 2025

Section 309-035-0163 - [Effective until 6/29/2025] Admission to Program

(1) The provider must ensure the admission process includes the following:

(a) The provider must specify in its admission policy and procedures the program staff responsible for each component of the admission information-gathering and decision-making process. The program must allocate responsibilities to promote effective processing of referrals and admissions.

(b) The provider must develop and implement admission policies and procedures that take into consideration; the placement of prospective residents by a supervisory authority under ORS chapters 161 or 426 or by the informed consent of the prospective resident's legal representative, the ability of the program to meet the service needs of both the prospective resident and current residents of the facility, and the prospective resident's right to select and choose from available service settings when the prospective resident has the capacity to engage in the treatment programs offered by the facility. A prospective resident under civil commitment has the right to appeal the placement by the OHA designee as outlined in OAR 309-033-0290(5).

(c) The provider must support the prospective resident's right to select a program by assisting the person-centered service plan coordinator in identifying and documenting program options in the person-centered service plan, including providing information regarding program services and rates. The prospective resident's right to select a service setting may be limited by a court, OHA, CMHP, or PSRB order under ORS chapters 161 or 426, or by the informed consent of the prospective resident's legal representative.

(2) Unless limited by contractual agreement with the Division or other Division-approved party, the program must accept and process referrals from:

(a) Oregon Health Authority or its designee;

(b) Hospitals;

(c) County Mental Health Programs;

(d) Licensed Residential Facilities and Homes; and

(e) Licensed Adult Foster Homes.

(3) In accordance with ORS 179.505 and the 42 CFR, Part 2, the program shall obtain an authorization for the release of information for disclosure for any confidential information concerning a prospective individual.

(4) The provider must consider a prospective resident for admission and not discriminate based on race, color, sex, gender or sexual orientation, except as may be limited by room arrangement, religion, creed, national origin, age, except under 18 years, familial status, marital status, source of income, cultural identity, socioeconomic status, or disability in addition to the mental health condition or other protected classes.

(5) Prior to accepting a prospective resident for admission to the program, the program administrator must determine the prospective resident meets admission criteria including the following:

(a) The provider must offer each prospective resident referred for placement at the program an opportunity to participate in a screening interview prior to being accepted or denied placement at a program. The screening is intended to provide information about the program and the services available as well as to obtain information from the prospective resident, a relative, and agencies currently providing services to the prospective resident sufficient to determine eligibility for admission and service needs; and

(b) The provider must receive screening packets for each prospective resident referred for placement. At a minimum, screening packets must include:

(A) Written documentation that the prospective resident has or is suspected of having a mental health condition;

(B) Background information including a current mental health assessment, description of previous living arrangements, service history, behavioral support needs, and service needs;

(C) Medical information including a brief history of any health conditions, documentation from a Licensed Medical Professional or other qualified health care professional of the prospective resident's current physical condition, and a written record of any current or recommended medications, treatments, dietary specifications, and aids to physical functioning;

(D) Copies of documentation relating to guardianship, conservatorship, commitment status, advance directives, declaration of mental health treatment, conditions of placement if on a trial visit or outpatient commitment, or any other legal restrictions or jurisdiction;

(E) A copy of the prospective individual's most recent mental health treatment plan or in the case of an emergency or crisis-respite admission a summary of current mental health treatment involvement; and

(F) Documentation of the prospective resident's ability to evacuate a building with or without assistance consistent with OAR 309-035-0145(5)(b) and within three minutes, and other concerns about potential safety risks.

(c) The provider must ensure that screenings be conducted at the prospective program setting unless:

(A) Travel arrangements cannot be made due to inclement weather; or

(B) The prospective resident or their legal representative requests a phone screening or screening at the prospective resident's current location.

(d) The provider must contact the referring agency to schedule a screening appointment within 48 hours of receipt of the referral packet;

(e) The provider must coordinate with the referring agency to schedule a screening appointment to occur within 14 calendar days from the date of receipt of the referral packet;

(f) The provider must provide the following to each prospective referred for placement:

(A) Materials explaining conditions of residency;

(B) Services available to resident residing in the program; and

(C) An opportunity to meet with a prospective roommate if the program uses a shared room model.

(g) The screening meeting must include the program administrator, the prospective resident, and the prospective resident's legal representative, if applicable. With the consent of the prospective resident or the prospective resident's legal representative, the meeting may also include family members, representatives of relevant service-providing agencies, and others with an interest in the prospective resident's admission.

(6) If a prospective resident is referred for emergency admission, an amended or abbreviated screening process may be used to more quickly meet the needs of the prospective resident. Screening and admission information obtained may be less comprehensive than for regular admissions but must be sufficient to determine the prospective resident meets admission criteria and that the setting and program is appropriate considering the prospective resident's needs. The program must document the reasons for incomplete information.

(7) Prior to admission, the provider must evaluate and determine whether a prospective individual is eligible for admission based on the following criteria. The prospective resident must:

(a) Be assessed to have a mental health disorder or a suspected mental health disorder;

(b) Be at least 18 years of age;

(c) Not require continuous nursing care unless a reasonable plan to provide the care exists, the need for residential treatment supersedes the need for nursing care, and the Division approves the placement;

(d) Have evacuation capability consistent with the setting's occupancy classification with or without assistance as described in OAR 309-035-0145(5)(b); and

(e) Meet additional criteria required or approved by the Division through contractual agreement or condition of licensing.

(8) For admission to an SRTF, the provider must also evaluate and determine whether a prospective resident is eligible for admission, based on the prospective resident meeting all criteria in OAR 410-172-0720(7).

(9) The provider may only deny a prospective resident admission to its program for the following reasons:

(a) Failure to meet admission criteria established by these rules;

(b) Inability to pay for services due to lack of presumed Medicaid eligibility or other funds;

(c) Documented instances of behaviors within the last 14 calendar days of receipt of the referral packet that would pose a reasonable and significant risk to the health, safety, and well-being of the prospective resident or another individual, if the prospective resident is admitted;

(d) Lack of availability of necessary medical services required to maintain the health and safety of the prospective resident and those services cannot be reasonably arranged; or

(e) The prospective resident declines the offer for screening, unless the placement of the prospective resident is by a supervisory authority under ORS chapters 161 or 426 or by the informed consent of the prospective resident's legal representative.

(10) The provider may not deny a prospective resident admission to its program as follows:

(a) Prior to offering a face-to-face screening or other screening process as allowed by these rules unless the program waitlist is currently closed as outlined in subsection (15)(g) of this rule; or

(b) Due to county of origin, responsibility, or residency; or

(c) Due to supervisory entity.

(11) The provider's decision must be based on review of screening materials, information gathered during the face-to-face screening meeting, and evaluation of the admission criteria;

(12) The program must inform the prospective resident, and the prospective resident's legal representative, supervisory entity, and referring entity, as applicable, of the admission decisions within 72 hours of the screening meeting.

(13) When the program denies admission, the program shall provide written notification to the prospective resident and the prospective resident's legal representative, supervisory entity, and referring entity, as applicable, of the specific basis for the decision and the prospective resident's right to appeal the decision;

(14) When the program approves admission, the program must inform the prospective resident's and the prospective resident's legal representative, supervisory entity, and referring entity, as applicable, through an acceptance notification that must include:

(a) When not waitlisted or first on the waitlist, an estimated date of admission; and

(b) When waitlisted, the number on the waitlist.

(15) Management of waitlists includes the following:

(a) The program must establish admission waitlists;

(b) The program must document actions taken in the management of the waitlist;

(c) The program must contact a waitlisted prospective resident, the prospective resident's legal representative, and the referring entity, as applicable, monthly to determine if the prospective resident has been placed elsewhere;

(d) The program must prioritize admissions on a waitlist as follows:

(A) The program must give first priority consideration to each of those prospective residents who are seeking to transition from the Oregon State Hospital or other hospital level of care into the community and are:

(i) Under a current civil commitment or extremely dangerous person commitment pursuant to ORS chapter 426; or

(ii) A candidate for court-ordered community restoration as an aid and assist defendant pursuant to ORS chapter 161; or

(iii) Found guilty except for insanity of a criminal offense and is currently under the jurisdiction of the Psychiatric Security Review Board pursuant to ORS 161.327; or

(iv) Found guilty except for insanity of a criminal offense and has been committed to a facility designated by OHA pursuant to ORS 161.328.

(B) The program must give second priority consideration for admission to those prospective residents seeking admission to programs:

(i) As an alternative to or to prevent civil commitment or placement at the Oregon State Hospital; or

(ii) For the purpose of transitioning from a program or a secure residential treatment facility; or

(iii) For the purpose of transitioning from a community hospital for prospective residents who do not meet the criteria established in subsection (14)(d)(A) of this rule.

(C) The program must give third priority consideration to those prospective residents who do not meet the criteria establish in subsection (14)(d)(A) or (B) of this rule.

(e) The program must determine priority for admission based on the priorities described above and on a first-come first-served basis based on the date of receipt of the referral packet. The program may not consider the prospective resident's county of origin, responsibility, or residency; and

(f) Within 72 hours of a provider learning of a pending opening, the program must provide written or electronic notification to the referring entity, the first prospective resident on the established waitlist, as well as their referring entity and their legal representative or supervisory entity, as applicable, of the expected opening. The referring entity is responsible to verify the prospective resident or their representative or supervisory entity, as applicable, received the notification of the opening and respond to the program within three business days of the provider's notification. If any of the following occurs, the program may offer the opening to the next prospective resident on the wait list:

(A) The program receives no response from the prospective resident, the prospective resident's legal representative, supervisory entity or the referring entity, as applicable, within three business days;

(B) The individual will not be ready to transition into the program within one week; or

(C) The individual no longer desires placement at the program.

(g) The program may close their waitlist if there are 10 or more prospective residents on the waitlist. When the waitlist is closed, the provider is not required to accept referrals, conduct screenings, or evaluate additional persons for admissions who are not already on the waitlist.

(h) Waitlists must be opened any time there are less than 10 prospective residents.

(i) The program must verify and update their waitlist by contacting prospective residents or their legal representative monthly to confirm continued need for placement. All verifications must be documented.

(16) The program must obtain informed consent for services from the prospective resident or the prospective resident's legal representative prior to admission to the program. Informed consent is not required for individuals placed at a program pursuant to a court, OHA, CMHP or PSRB order issued under ORS chapter 161 or 426.

(17) The program must obtain copies of legal orders for residents placed at a program pursuant to a court, OHA, CMHP or PSRB order issued under ORS chapter 161 or 426.

(18) Upon admission, the program administrator must provide and document an orientation to each new resident that includes, but is not limited to, the following:

(a) A complete tour of the setting;

(b) Introductions to other residents and program staff;

(c) Explanation of the laundry and food service schedule and policies;

(d) Review of the resident's rights;

(f) Review of grievance procedures;

(g) Review of the residency agreement;

(h) Discussion of the conditions under which residency would be involuntarily transferred or discharged;

(i) General description of available services and activities;

(j) Review and explanation of advance directives. If the resident does not already have any advance directives, the program must provide an opportunity to complete advanced directives;

(k) Emergency procedures in accordance with OAR 309-035-0145(2).

(l) Review of the person-centered planning process; and

(m) Review of the process for imposing individually based limitations on certain program obligations to the individual.

Or. Admin. Code § 309-035-0163

MHS 2-2017(Temp), f. 3-3-17, cert. ef. 3-4-17 thru 8-30-17; MHS 5-2017, f. & cert. ef. 6/8/2017; BHS 10-2018, temporary amend filed 04/24/2018, effective 05/01/2018 through 10/27/2018; BHS 21-2018, temporary amend filed 10/25/2018, effective 10/28/2018 through 04/22/2019; BHS 6-2019, amend filed 03/28/2019, effective 4/1/2019; BHS 41-2023, temporary amend filed 10/12/2023, effective 10/15/2023 through 4/11/2024; BHS 6-2024, amend filed 04/11/2024, effective 4/11/2024; BHS 31-2024, temporary amend filed 12/27/2024, effective 1/1/2025 through 6/29/2025; BHS 35-2024, temporary amend filed 12/31/2024, effective 1/1/2025 through 6/29/2025

Statutory/Other Authority: ORS 413.042 & ORS 443.450

Statutes/Other Implemented: ORS 413.032, ORS 443.400 - 443.465 & ORS 443.991