The Oregon Administrative Rules contain OARs filed through November 15, 2015
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OREGON HEALTH AUTHORITY,
ADDICTIONS AND MENTAL HEALTH DIVISION: ADDICTION SERVICES
DIVISION 12
STANDARDS FOR APPROVAL/LICENSURE OF ALCOHOL AND OTHER DRUG ABUSE PROGRAMS
415-012-0000
Purpose and Scope
Purpose. These rules establish procedures
for approval of the following:
(1) Any substance use disorder
service provider which is, or seeks to be, contractually affiliated with the Addictions
and Mental Health Division (AMH), a Coordinated Care Organization, or local mental
health authority for the purpose of providing alcohol and other drug abuse treatment
and prevention services;
(2) Any service provider
using public funds in the provision of substance use disorder prevention, intervention,
or treatment services in Oregon;
(3) Performing providers
under AMH rules under OAR 309-016-0000 through 309-016-0120;
(4) Organizations seeking
approval from the Division for provision of residential services as provided in
ORS 430.010 and 443.400 or detoxification services under ORS 430.306; or
(5) Alcohol and drug evaluation
specialists designated to do Driving Under the Influence of Intoxicants (DUII) diagnostic
screenings and assessments under ORS 813.020 and 813.260.
(6) Scope. These rules do
not establish procedures for regulating behavioral health care practitioners that
are otherwise licensed to render behavioral healthcare services in accordance with
applicable statutes. These rules do not establish procedures for regulating practices
exclusively comprised of behavioral healthcare practitioners that are otherwise
licensed to render behavioral healthcare services in accordance with applicable
statutes.
Stat. Auth.: ORS 413.042 & 430.256
Stats. Implemented: ORS 430.010,
430.306, 430.397, 430.405, 430.450, 430.590, 430.630, 430.850, 443.400, 813.020,
813.260 & 813.500
Hist.: ADAP 2-1993, f. &
cert. ef. 11-5-93; ADS 2-2008, f. & cert. ef. 11-13-08; ADS 2-2013(Temp), f.
& cert. ef. 1-14-13 thru 7-12-13; ADS 4-2013, f. & cert. ef. 5-3-13; ADS
1-2014(Temp), f. & cert. ef. 1-28-14 thru 7-21-14; ADS 3-2014, f. 6-10-14, cert.
ef. 6-19-14
415-012-0010
Definitions
(1) "Applicant"
means any person or entity who has requested, in writing, a letter of approval or
license.
(2) "Director"
means the Director of the AMH.
(3) "Community
Mental Health Program (CMHP)" means the organization of all services for individuals
with mental or emotional disturbances, drug use problems, mental retardation or
other developmental disabilities, and alcoholism and alcohol use problems, operated
by, or contractually affiliated with, a local mental health authority, operated
in a specific geographic area of the state under an intergovernmental agreement
or direct contract with the Division.
(4) “Coordinated
Care Organization (CCO)” means a corporation, governmental agency, public
corporation or other legal entity that is certified as meeting the criteria adopted
by the Oregon Health Authority under ORS 414.625 to be accountable for care management
and to provide integrated and coordinated health care for each of the organization’s
members.
(5) "Contract"
is the document describing and limiting the relationship and respective obligations
between an organization other than a county and the Division for the purposes of
operating the alcohol and drug use disorder service within a county's boundaries,
or operating a statewide, regional, or specialized service.
(6) “Division”
means the Addictions and Mental Health Division of the Oregon Health Authority.
(7) “Individual”
means the person requesting or receiving services addressed in these rules.
(8) "Intergovernmental
Agreement" or "Agreement" is the document describing and limiting the contractual
relationship and respective obligations between a county or other government organization
and the Division for the purpose of operating an alcohol and drug use disorder service.
(9) "Letter
of Approval (LOA)" means a certificate issued by the Assistant Director to applicants
who are in substantial compliance with applicable administrative rules for alcohol
and drug use disorder treatment in an outpatient setting, Driving Under the Influence
of Intoxicants (DUII) diagnostic assessment, or prevention services, and which is
renewable every three years.
(10) "License"
means a certificate issued by the Assistant Director to applicants who are in substantial
compliance with applicable administrative rules for alcohol and drug use treatment
in a residential setting and which is renewable every two years.
(11) “Licensed
Child Care Facility” means a facility licensed under ORS 657A.280.
(12) "Non-Funded
Provider" means an organization not contractually affiliated with the Division,
a CMHP, or other contractor of the Division.
(13) "Provider"
means an organization providing substance abuse prevention, intervention, or treatment
services under contract with the Division or under subcontract with a local entity
or public body or otherwise receiving public funds for these services.
(14) "Provisional"
means a LOA or license issued for one year or less pending completion of specified
requirements because of substantial failure to comply with applicable administrative
rules.
(15) "Quality
Assurance" means the process of objectively and systematically monitoring and evaluating
the quality and appropriateness of care to identify and resolve identified problems.
(16) "Restriction"
means any limitations placed on a LOA or license such as age of individuals to be
served or number of individuals to be served.
(17 "Revocation"
means the removal of authority for a provider to provide certain services under
a LOA or license.
(18) “School
Attended Primarily By Minors” means an existing public or private elementary,
secondary or career school attended primarily by individuals under age eighteen.
(19) "Service
Element" means a distinct service or group of services for persons with alcohol
or other drug use disorders defined in administrative rule and included in a contract
or agreement issued by the Division.
(20) "Subcontract"
means the document describing and limiting the relationship and respective obligations
between a government and other entity having an agreement or contract with the Division
and a third organization (subcontractor) for the purpose of delivering some or all
of the services specified in the agreement or contract with the Division.
(21) "Substantial
Compliance" means a level of adherence to applicable administrative rules which,
while not meeting one or more of the requirements, does not, in the determination
of the Division:
(a) Constitute
a danger to the health or safety of any individual;
(b) Constitute
a willful or ongoing violation of the rights of service recipients as set forth
in administrative rules; or
(c) Prevent
the accomplishment of the state's purposes in approving or supporting the subject
service.
(22) "Substantial
Failure to Comply" is used in this rule to mean the opposite of "substantial compliance."
(23) "Suspension"
means a temporary removal of authority for a provider to conduct a service for a
stated period of time or until the occurrence of a specified event under a LOA or
license.
(24) "Temporary"
means a LOA license issued for 185 days to a program approved for the first time.
A temporary LOA license cannot be extended.
(25) "Variance
or Exception" means a waiver of a regulation or provision of these rules granted
by the Division upon written application.
Stat. Auth.: ORS
413.042 & 430.256
Stats. Implemented:
ORS 430.010 - 430.030, 430.306, 430.397, 430.405, 430.450, 430.630, 430.850, 443.400,
813.020, 813.260 & 813.500
Hist.: ADAP
2-1993, f. & cert. ef. 11-5-93; ADAP 1-2001, f. 3-29-01, cert. ef. 4-1-01; ADS
2-2008, f. & cert. ef. 11-13-08; ADS 2-2013(Temp), f. & cert. ef. 1-14-13
thru 7-12-13; ADS 4-2013, f. & cert. ef. 5-3-13
415-012-0020
General Requirements
(1) Providers That
Must Have LOA or License: Every provider that operates a service element by contract
with the Division or subcontracts with a local entity or public body or otherwise
receives public funds for providing substance abuse prevention, intervention, or
treatment services must have an LOA or license:
(a) No provider
shall represent themselves as conducting any service described in this rule without
first obtaining an LOA or license;
(b) A provider
that does not have an LOA or license for conducting a service described in this
rule may not admit a person needing that service; and
(c) The LOA
or license shall be posted in the facility and available for inspection at all times.
(2) Discretionary
LOA: The Division may also issue an LOA to organizations seeking approval for insurance
reimbursement as provided in ORS 430.065 or to other non-funded providers.
(3) Facilities
Requiring License: Any facility which meets the definition of a residential treatment
facility for substance-dependent persons under ORS 443.400 or a detoxification center
as defined in ORS 430.306 must be licensed by the Division:
(a) No individual
or entity shall represent themselves as a residential treatment facility for substance-dependent
persons or as a detoxification center without first being licensed;
(b) A residential
treatment facility or a detoxification center that is not licensed may not admit
individuals needing residential or detoxification care or treatment; and
(c) A license
shall be posted in the facility and available for inspection at all times.
(4) LOA or
License is not a Contract: Approval or licensure of a service element pursuant to
this rule does not create an express or implied contract in the absence of a fully
executed written contract.
(5) Distance
Requirements for Methadone Treatment Programs: Programs using methadone to treat
opioid addiction may not operate within 1,000 linear feet of a licensed child care
facility or school primarily attended by minors pursuant to ORS 430.590. The Division
will not issue a variance to programs unable to meet this requirement.
(5) Services
eligible for an LOA include but are not limited to:
(a) Outpatient
alcohol or other drug treatment;
(b) Outpatient
methadone maintenance and outpatient methadone detoxification;
(c) Outpatient
DUII alcohol and other drug information and rehabilitation services and marijuana
education and treatment services;
(d) Outpatient
occupational drivers license services;
(e) Title
XIX service;
(f) Prevention
services;
(g) Alcohol
and drug evaluation specialists; and
(h) Marijuana
evaluation specialists.
Stat. Auth.: ORS
430.256
Stats. Implemented:
ORS 430.010 - 430.030, 430.306, 430.397, 430.405, 430.450, 430.630, 430.850,
443.400, 813.020, 813.260 & 813.500
Hist.: ADAP
2-1993, f. & cert. ef. 11-5-93; ADS 2-2008, f. & cert. ef. 11-13-08; ADS
2-2013(Temp), f. & cert. ef. 1-14-13 thru 7-12-13; ADS 4-2013, f. & cert.
ef. 5-3-13
415-012-0030
Initial Application
Procedures
(1) Application
Packet: The Division shall mail an application packet to all applicants, except
those who wish to become Alcohol and Drug Evaluation Specialists (ADES), who should
refer to OAR 415-054-0045 to 415-054-0100.
(2) Initial
Meeting: All programs applying for the first time for a LOA or license to operate
a treatment or prevention program shall schedule a meeting with Division staff for
the purpose of receiving needed technical assistance regarding the approval and
licensure criteria and procedures.
(3) Multiple
Locations: A separate application is required for each location where the provider
intends to operate.
(4) Copy
of Application: A copy of the application shall be provided by the applicant to
the local mental health authority (CMHP) and to the Local Alcohol Planning Committee
(LAPC) for review and comment. A program seeking to provide services on a statewide
or regional basis must provide application material to the CMHP and the LAPC in
the county where the program resides.
(5) Withdrawal
of Application: The applicant may withdraw the application at any time during the
application process by notifying the Division in writing. At such time, all materials
shall be returned to the applicant.
Stat. Auth.: ORS
430.256
Stats. Implemented:
ORS 430.010 - 430.030, 430.306, 430.397, 430.405, 430.450, 430.630, 430.850,
443.400, 813.020, 813.260 & 813.500
Hist.: ADAP
2-1993, f. & cert. ef. 11-5-93; ADS 2-2008, f. & cert. ef. 11-13-08; ADS
2-2013(Temp), f. & cert. ef. 1-14-13 thru 7-12-13; ADS 4-2013, f. & cert.
ef. 5-3-13
415-012-0032
Initial Application
Information
Initial Application
Information: An applicant for a LOA or license shall submit the information listed
below on forms provided by the Division:
(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 Children,
Adults and Families (CAF) 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:
(a) Explanation
of methods used to disseminate the policy;
(b) Description
of procedures used to communicate with sensory impaired person or persons of limited
English proficiency;
(c) Written
statement about the accessibility of the facility and services for disabled persons;
and
(d) Written
grievance procedure for handling discrimination complaints.
Stat. Auth.: ORS
413.042 & 430.256
Stats. Implemented:
ORS 430.010-30, 430.306, 430.397, 430.405, 430.450, 430.630, 430.850, 443.400, 813.020,
813.260 & 813.500
Hist.: ADS
4-2013, f. & cert. ef. 5-3-13
415-012-0035
Responses
To Application
(1) Application
Satisfactory: If the application is found to be complete and if the material documents
compliance with applicable administrative rules, the Division shall issue a temporary
LOA or license no later than 30 days after final approval of the application.
(2) Unsatisfactory
Application: If the application is not complete or if the application does not document
compliance:
(a) The applicant
shall be provided with written notification that identifies needed information or
areas of non-compliance within 60 days of receipt of the application; and
(b) The original
application shall be kept on file for 60 days after written notice has been given,
at which time, if no further material is submitted to correct the deficiencies noted,
the application shall be denied and all material shall be returned to the applicant.
(3) Application
Denied: If an initial LOA or license is denied:
(a) The applicant
shall be entitled to a hearing with the Assistant Director if the applicant requests
a hearing in writing within 60 days of the receipt of the notice;
(b) The Assistant
Director, whose decision is final, shall hold a hearing within 60 days of receipt
of the written request; and
(c) If no
written request for a hearing is received within the 60-day timeline, the notice
of denial shall become the final order by default and the Assistant Director may
designate its file as the record for purposes of order by default.
Stat. Auth.: ORS
413.042 & 430.256
Stats. Implemented:
ORS 430.010-30, 430.306, 430.397, 430.405, 430.450, 430.630, 430.850, 443.400, 813.020,
813.260 & 813.500
Hist.: ADS
4-2013, f. & cert. ef. 5-3-13
415-012-0040
Letters of
Approval and Licenses
(1) Types of Certification:
The Division may issue the following types of certificates:
(a) Temporary
LOA or temporary license for 185 days;
(b) Provisional
LOA or license for one year or less;
(c) A license
for two years; or
(d) An LOA
for three years.
(2) Renewal:
Renewal of three-year letters of approval and two-year licenses shall be contingent
upon demonstration of compliance with appropriate administrative rules:
(a) A program
may continue to operate until final determination of its approval or licensure status
is made by the Division;
(b) Failure
to demonstrate compliance may result in the issuance of a provisional LOA, license,
suspension, or revocation.
(3) Provisional
Certification: Programs with provisional letters of approval or licenses upon demonstrating
substantial compliance with appropriate administrative rules may be eligible for
a three-year LOA or a two-year license. However, the provider's failure to demonstrate
substantial compliance may result in an extension, suspension, or revocation of
the provisional LOA or license.
(4) Nondiscrimination;
Special Populations: The Division shall not discriminate in its review procedures
or services on the basis of race, color, national origin, age, or disability. The
Division may issue LOA or licenses to specialized programs to assure maximum benefit
for special populations, in which case, the Division may identify that special population
in the LOA or license and impose applicable program criteria.
(5) Restrictions:
Restrictions which may be attached to a LOA or license include:
(a) Limiting
the total number of individuals (in residential or detoxification treatment);
(b) Defining
the age level of individuals (i.e., youth or adult) to be admitted into the facility;
(c) Defining
the gender of individuals, if the provider is identified as serving only males or
females;
(d) Assuring
compliance with other licensing entities such as the CAF Division, the State Public
Health Division, or the Food and Drug Administration; or
(e) Other
restrictions as required by the Division.
(6) Time
Limits on Restrictions: Restrictions may be imposed for the extent of the approval
period or limited to some other shorter period of time. If the restriction corresponds
to the licensing period, the reasons for the restriction shall be considered at
the time of renewal to determine if the restrictions are still appropriate.
(7) Restriction
to Appear on LOA or License: The effective date and expiration date of the restriction
shall be indicated on the certificate.
(8) Non-Transferability:
An LOA or license issued by the Division for the operation of a substance use disorder
program applies both to the applicant program and the premises upon which the program
is to be operated. A LOA or license is not transferable to another person, entity,
or to any other location:
(a) Any person
or other legal entity acquiring an approved licensed facility for the purpose of
operating a substance use disorder program shall make an application as provided
herein for a new LOA or license;
(b) Any person
or legal entity having been issued a license and desiring to fundamentally alter
the treatment philosophy or transfer to different premises must notify the Division
30 days prior to doing so in order for the Division to review the program or site
change and to determine further necessary action.
(9) Change
of Administrator: If the administrator of the program changes during the period
covered by the letter of approval or license:
(a) A request
for a change must be submitted to the Division within 15 days, along with the qualifications
of the proposed new administrator;
(b) Upon
a determination that the administrator meets the requirements of applicable administrative
rules, a revised LOA or license shall be issued with the name of the new administrator.
(10) Discontinued
Program: When a program is discontinued, its current LOA or license is void immediately
and the certificate shall be returned to the Division. A discontinued program is
one which has terminated its services for which it has been approved or licensed.
A program planning to discontinue services must:
(a) Notify
the Division 60 days prior to a voluntary closure of a facility with written notice
of how the provider will comply with OAR 309-014-0035(4) and 42 CFR Part 2, Federal
Confidentiality Regulations, regarding the preservation of all individual records;
and
(b) Provide
individuals 30 days written notice and shall be responsible for making reasonable
efforts to obtain treatment placement of individuals as appropriate.
Stat. Auth.: ORS
430.256
Stats. Implemented:
ORS 430.397, 430.010-030, 430.306, 430.405, 430.450, 430.630, 430.850,
443.400, 813.020, 813.260 & 813.500
Hist.: ADAP
2-1993, f. & cert. ef. 11-5-93; ADAP 1-2001, f. 3-29-01, cert. ef. 4-1-01; ADS
2-2008, f. & cert. ef. 11-13-08; ADS 4-2013, f. & cert. ef. 5-3-13
415-012-0050
Onsite Reviews
and Access Requirements
(1) Scheduled Inspections:
The Division shall inspect the facilities and must review procedures utilized:
(a) Before
issuing a LOA or license to an applicant; and
(b) Before
renewal of an existing LOA or license.
(2) Discretionary
Onsite Inspections: The Division may conduct onsite inspections:
(a) Upon
receipt of verbal or written complaints of violations that allege conditions that
may threaten the health, safety, or welfare of individuals or for any other reason
to be concerned for individual welfare; or
(b) Any time
the Division has reason to believe it is necessary to assure if a provider is in
compliance with the administrative rules or with conditions placed upon the LOA
or license.
(3) Substance
of Reviews: The review may include but is not limited to case record audits and
interviews with staff and individuals, consistent with the confidentiality safeguards
of state and federal laws.
(4) Access
to Facilities and Records: Each applicant or provider agrees, as a condition of
LOA or license approval:
(a) To permit
designated representatives of the Division to inspect premises of programs to verify
information contained in the application or to assure compliance with all laws,
rules, and regulations during all hours of operation of the facility and at any
other reasonable hour;
(b) To permit
properly designated representatives of the department to audit and collect statistical
data from all records maintained by the approved or licensed program; and
(c) That
such right of immediate entry and inspection shall, under due process of law, extend
to any premises on which the Division has reasons to believe a program is being
operated by the provider in violation of these rules.
(5) Access
if Requirement for LOA or License: An applicant or provider shall not be granted
approval or licensing which does not permit inspection by the Division or examination
of all records, including financial records as appropriate, methods of administration,
the disbursement of drugs and method of supply, and any other records the Division
considers to be relevant to the establishment of such a program.
(6) Inspection
by Other Agencies: Each applicant or provider agrees, as a condition of LOA or license
approval that:
(a) State
or local fire inspectors shall be permitted access to enter and inspect the facility
regarding fire safety upon the request of the Division; and
(b) State
or local health inspectors shall be permitted access to enter and inspect the facility
regarding health safety upon the request of the Division.
(7) Notice:
The Division has authority to conduct inspections with or without advance notice
to the administrator, staff, or individuals:
(a) The Division
is not required to give advance notice of any onsite inspection if the Division
reasonably believes that notice might obstruct or seriously diminish the effectiveness
of the inspection or enforcement of these administrative rules; and
(b) If Division
staff are not permitted access for inspection, a search warrant may be sought.
Stat. Auth.: ORS
409.410
Stats. Implemented:
ORS 430.397, 430.010-030, 430.306, 430.405, 430.450, 430.630, 430.850,
443.400, 813.020, 813.260 & 813.500
Hist.: ADAP
2-1993, f. & cert. ef. 11-5-93; ADS 2-2007, f. & cert. ef. 5-25-07; ADS
2-2008, f. & cert. ef. 11-13-08; ADS 4-2013, f. & cert. ef. 5-3-13
415-012-0055
Review Process
and Review Reports
(1) For renewal
of a LOA or license: The Division shall designate a lead specialist and other onsite
review members as appropriate, such as a peer reviewer or the designee of the CMHP,
to perform a formal onsite review of the service element or elements;
(2) Access
to Reports: Public access to final reports of onsite inspections, except for confidential
information, shall be available upon written request from the Division during business
hours in accordance with OAR chapter 407, division 003.
(3) Corrective
Action Plan. Programs issued a provisional LOA or license must submit an action
plan to the Assistant Director or his or her designee for approval no later than
30 days following receipt of the final onsite report. The corrective action plan
shall include, but not be limited to:
(a) Specific
problem areas cited as out of compliance;
(b) A delineation
of corrective measures to be taken by the program to bring the program into compliance;
and
(c) A delineation
of target dates for completion of corrective measures for each problem area.
(4) Failure
to Take Corrective Action: Failure to demonstrate compliance with the corrective
action plan may result in an extension, suspension or revocation of the provisional
LOA or license.
Stat. Auth.: ORS
413.042 & 430.256
Stats. Implemented:
ORS 430.01030, 430.306, 430.397, 430.405, 430.450, 430.630, 430.850, 443.400, 813.020,
813.260 & 813.500
Hist.: ADS
4-2013, f. & cert. ef. 5-3-13
415-012-0057
Organizational Provider Assessment
Information
In addition to the review procedures
outlined in Section 415-012-0055, the Division will ensure that the following minimum
information will be obtained during the site reviews;
(1) A current program description
that reflects the type and scope of behavioral health services provided by the applicant;
(2) Provider policies regarding
credentialing practices of individual practitioners. The policies must reflect
current credentialing standards as defined by nationally accepted accrediting bodies
such as The Joint Commission, the National Committee for Quality Assurance, and/or
URAC;
(3) Copies of the provider’s
liability insurance coverage;
(4) Copies of the provider’s
policies and procedures regarding seclusion and restraint practices; and
(5) Copies of the provider’s
Code of Conduct.
Stat. Auth.: ORS 413.042 & 430.256
Stats. Implemented: ORS 430.01030,
430.306, 430.397, 430.405, 430.450, 430.630, 430.850, 443.400, 813.020, 813.260
& 813.500
Hist.: ADS 8-2013(Temp),
f. & cert. ef. 12-20-13 thru 6-18-14; ADS 3-2014, f. 6-10-14, cert. ef. 6-19-14
415-012-0058
Availability of Information to Coordinated
Care Organizations and Other Health Plans
Upon completion of the site review process
and the issuance of a Certificate of Approval for Mental Health Services, the Division
shall make copies of the following information available to Coordinated Care Organizations
and other health plans for the purpose of credentialing a provider:
(1) A current program description
that reflects the type and scope of behavioral health services provided by the applicant;
(2) Provider policies and
procedures regarding the provider’s credentialing practices of individual
clinicians;
(3) Statements of provider’s
liability insurance coverage;
(4) An attestation from the
Authority verifying that the provider has passed a screening and meets the minimum
requirements to Medicaid provider;
(5) Reports detailing the
findings of the Division’s site review of the provider;
(6) The provider’s
Medicaid Vendor Identification Number issued by the Authority;
(7) Copies of the provider’s
policies and procedures regarding seclusion and restraint practices; and
(8) Copies of the provider’s
Code of Conduct.
Stat. Auth.: ORS 413.042 & 430.256
Stats. Implemented: ORS 430.01030,
430.306, 430.397, 430.405, 430.450, 430.630, 430.850, 443.400, 813.020, 813.260
& 813.500
Hist.: ADS 8-2013(Temp),
f. & cert. ef. 12-20-13 thru 6-18-14; ADS 3-2014, f. 6-10-14, cert. ef. 6-19-14
415-012-0060
Denial, Revocation,
or Non-renewal
(1) Denial of Application
or Request for Renewal: The Division shall deny an application or request for renewal,
or revoke an LOA or license where it finds any of the following:
(a) The provider
has substantially failed to comply with applicable administrative rules or with
local codes and ordinances or any other applicable state or federal law or rule;
(b) The applicant
or provider has had a prior LOA or license to operate an alcohol and drug use disorder
treatment program denied, revoked, or refused to be renewed in any county in Oregon
within three years preceding the present application for reason of abuse or neglect
of individuals or the administrator's failure to possess adequate physical health,
mental health, or good personal character;
(c) If such
prior denial, revocation, or refusal to renew occurred more than three years from
the present action, the provider is required to establish to the Division by clear
and convincing evidence his or her ability and fitness to operate a treatment program.
If the applicant or provider does not provide such evidence, the Division shall
deny the application;
(d) The applicant
or provider submits fraudulent or untrue information to the Division;
(e) The applicant
or provider has a history of, or currently demonstrates, financial insolvency such
as filing for bankruptcy, foreclosures, eviction due to failure to a pay rent, termination
of utility services due to failure to pay bills, failure to pay taxes such as employment
or social security in a timely manner;
(f) The applicant
or provider refuses to allow immediate access and onsite inspection by the Division;
or
(g) The applicant
or provider fails to maintain sufficient staffing or fails to comply with staff
qualifications requirements.
(2) Notification
of Denial: When the Division determines that an applicant's request for an LOA or
license should be denied, the Assistant Director or designee shall notify the applicant,
by certified mail, return receipt requested, of the Division's decision to deny
the approval or licensure and the reasons for the denial.
Stat. Auth.: ORS
430.256
Stats. Implemented:
ORS 430.397, 430.010-030, 430.306, 430.405, 430.450, 430.630, 430.850,
443.400, 813.020, 813.260 & 813.500
Hist.: ADAP
2-1993, f. & cert. ef. 11-5-93; ADAP 1-1997, f. & cert. ef. 12-18-97; ADS
2-2008, f. & cert. ef. 11-13-08; ADS 4-2013, f. & cert. ef. 5-3-13
415-012-0065
Suspension
of LOA
If the Division
finds that the health, safety, or welfare of the public are seriously endangered
by continued operation of a treatment or prevention program and sets forth specific
reasons for its findings, summary suspension of an LOA or license may be ordered.
The Division may suspend an LOA or license for any of the following reasons:
(1) Violation
by the program, its director or staff, of any rule promulgated by this Division
pertaining to treatment or prevention services;
(2) Permitting,
aiding or abetting the commitment of an unlawful act within the facilities maintained
by the program, or permitting, aiding or abetting the commitment of an unlawful
act involving chemical substances within the program;
(3) Conduct
or practices found by the Division to be detrimental to the general health or welfare
of an individual in the program; or
(4) Deviation
by the program from the plan of operation originally approved or licensed which,
in the judgment of the Division, adversely affects the character, quality or scope
of services intended to be provided to individuals within the program.
Stat. Auth.: ORS
413.042 & 430.256
Stats. Implemented:
ORS 430.010-30, 430.306, 430.397, 430.405, 430.450, 430.630, 430.850, 443.400, 813.020,
813.260 & 813.500
Hist.: ADS
4-2013, f. & cert. ef. 5-3-13
415-012-0067
Response
to Criminal Records
(1) The Division
may deny, refuse to renew, suspend, or revoke an LOA or license if:
(a) Any of
the program's staff, within the previous three years, has been convicted of:
(A) Any crime
or violation under ORS chapter 475, including but not limited to the Uniform Controlled
Substances Act, or under ORS 813.010, driving under the influence of intoxicants;
(B) A substantially
similar crime or violation in any other state; or
(C) Any felony.
(b) Any of
the program's staff has entered into, within the past three years, a diversion agreement
under ORS 813.010 or 135.907 through 135.921, or a diversion agreement under a substantially
similar law in any other state;
(2) Criminal
Record Checks: The Assistant Director or designee may make criminal record inquiries
necessary to ensure implementation of these rules.
Stat. Auth.: ORS
413.042 & 430.256
Stats. Implemented:
ORS 430.010-30, 430.306, 430.397, 430.405, 430.450, 430.630, 430.850, 443.400, 813.020,
813.260 & 813.500
Hist.: ADS
4-2013, f. & cert. ef. 5-3-13
415-012-0070
Hearings
(1) Requesting Hearings:
If a license or letter of approval is suspended, not renewed, or revoked: The provider
shall be entitled to a hearing preceding the effective date of the denial, suspension,
non-renewal, or revocation if requested in writing within 21 days after receipt
of notice. (b) If no timely written request is received, the notice shall become
the final order by default and the Assistant Director may designate the Division
file as the record for purposes of order by default.
(2) Contested
Case Hearings: Programs that wish to contest the suspension, non-renewal, or revocation
of their LOA or license shall have an opportunity for a hearing by the Division
according to the Attorney General's Model Rules of Procedure.
Stat. Auth.: ORS
430.256
Stats. Implemented:
ORS 430.397, 430.010-030, 430.306, 430.405, 430.450, 430.630, 430.850,
443.400, 813.020, 813.260 & 813.500
Hist.: ADAP
2-1993, f. & cert. ef. 11-5-93; ADS 2-2008, f. & cert. ef. 11-13-08; ADS
4-2013, f. & cert. ef. 5-3-13
415-012-0080
Complaints
(1) Investigation
of Complaints: Any person who believes that administrative rules have been violated
may file a complaint with the Division:
(a) The Division
may require that complainant exhaust grievance procedures available to them through
the provider prior to initiation of an investigation;
(b) The Division
shall investigate complaints and notify the provider of the results of the investigation
and any proposed action.
(2) Records
of Complaints: A record shall be maintained by the Division of all complaints and
any action taken on the complaint and shall:
(a) Be placed
into the public file. Any information regarding the investigation of the complaint
shall not be filed in the public file until the investigation has been completed;
(b) Protect
the identification of the complainant; and
(c) Treat
the identities of the witnesses and individuals as confidential information.
(3) Inspection
of Records: Any person may inspect and receive a photocopy of the public complaint
files maintained by the Division upon requesting an appointment to do so. A fee
shall be charged in accordance with OAR chapter 407, division 003.
(4) Substantiated
Complaint Grounds for Action: Providers who acquire substantiated complaints pertaining
to the health, safety, or welfare of individuals may have their LOA or licenses
suspended, revoked, or not renewed and arrangements made to move the individuals.
(5) Retaliation
Toward An Individual Forbidden: The provider shall not retaliate against any individual
for filing a complaint with the Division by:
(a) Increasing
charges; decreasing services; rights or privileges;
(b) Threatening
to increase charges or decrease services, rights, or privileges;
(c) Taking
or threatening to take any action to coerce or compel the individual to leave the
facility; or
(d) Abusing
or threatening to harass or abuse an individual in any manner.
(6) Retaliation
Toward Employee or Witness: The provider shall not retaliate against any complainant,
witness, or employee of a facility for making a report to or being interviewed by
the Division about a complaint including restriction to access to the service or
to an individual or, if an employee, to dismissal or harassment.
Stat. Auth.: ORS
430.256
Stats. Implemented:
ORS 430.397, 430.010-030, 430.306, 430.405, 430.450, 430.630, 430.850,
443.400, 813.020, 813.260 & 813.500
Hist.: ADAP
2-1993, f. & cert. ef. 11-5-93; ADS 2-2007, f. & cert. ef. 5-25-07; ADS
2-2008, f. & cert. ef. 11-13-08; ADS 4-2013, f. & cert. ef. 5-3-13
415-012-0090
Variance
or Exception
(1) Procedure for
Submission of Request. Request must be made in writing:
(a) For an
initial application it should be included with the application documents submitted
to the Division, local mental health authority, and the Local Alcohol Planning Committee;
(b) If the
provider is an agency under contract with the local mental health authority, it
must submit the request through the local mental health authority to the Assistant
Director; and
(b) If the
provider is not under contract to the local mental health authority, the request
should be submitted directly to the Assistant Director.
(2) Substance
of Request: The request should include the following:
(a) The reason
for the proposed variance or exception;
(b) The alternative
practice proposed; and
(c) For an
exception, a plan and timetable for compliance with the section of the rule from
which the exception is sought.
(3) Approval
or Denial: The Assistant Director, whose decision shall be final, shall approve
or deny the request for variance or exception.
(4) Notification:
The Division shall notify the provider requesting the variance or exception and
the community mental health program of the decision.
(5) Variance
Part of LOA or License: A variance granted by the Division shall be attached to,
and become part of, the LOA or license. Continuance of the variance shall be reviewed
at the time the LOA or license is considered for renewal.
Stat. Auth.: ORS
430.256
Stats. Implemented:
ORS 430.010-030, 430.306, 430.397, 430.405, 430.450, 430.630, 430.850,
443.400, 813.020, 813.260 & 813.500
Hist.: ADAP
2-1993, f. & cert. ef. 11-5-93; ADS 2-2008, f. & cert. ef. 11-13-08; ADS
4-2013, f. & cert. ef. 5-3-13
The official copy of an Oregon Administrative Rule is
contained in the Administrative Order filed at the Archives Division,
800 Summer St. NE, Salem, Oregon 97310. Any discrepancies with the
published version are satisfied in favor of the Administrative Order.
The Oregon Administrative Rules and the Oregon Bulletin are
copyrighted by the Oregon Secretary of State. Terms
and Conditions of Use
