333-525-0000
Mental or Psychiatric Hospital

A hospital classified as mental or psychiatric shall:

(1) Be devoted primarily to the diagnosis and treatment of mentally ill persons.

(2) Have adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures, and engage in discharge planning, including:

(a) A clinical director, service chief, or equivalent who:

(A) Is qualified to provide the leadership required for an intensive treatment program;

(B) Meets the training and experience requirements for examination by the American Board of Psychiatry and Neurology or the American Osteopathic Board of Neurology and Psychiatry;

(C) Monitors and evaluates the quality and appropriateness of services and treatment provided by the medical staff; and

(D) Supervises inpatient psychiatric services.

(b) Doctors of medicine or osteopathy and other appropriate professional personnel available to provide necessary medical and surgical diagnostic and treatment services. If medical and surgical diagnostic and treatment services are not available within the hospital, the hospital must have an agreement with an outside source of these services to ensure that they are immediately available or a satisfactory agreement must be established for transferring patients to a licensed hospital.

(c) A director of psychiatric nursing services who:

(A) Is a registered nurse with a master's degree in psychiatric or mental health nursing, or its equivalent from a school of nursing accredited by the National League for Nursing Accrediting Commission, or the Commission on Collegiate Nursing Education, or is qualified by education and experience in the care of the mentally ill; and

(B) Demonstrates competence to participate in interdisciplinary formulation of individual treatment plans; to give skilled nursing care and therapy; and to direct, monitor, and evaluate the nursing care furnished.

(d) Registered nurses, licensed practical nurses, and mental health workers to provide nursing care necessary under each patient's active treatment program and to maintain progress notes on each patient.

(e) The availability of a registered professional nurse 24 hours each day.

(f) The availability of staff to provide other psychological services to meet the needs of the patients.

(g) A director of social services who:

(A) Has a master's degree from an accredited school of social work or is qualified by education and experience in the social services needs of the mentally ill; and

(B) Monitors and evaluates the quality and appropriateness of social services furnished.

(h) At least one staff member with a master’s degree in social work if the director of social services does not have such a degree.

(i) Social service staff with responsibilities that include, but are not limited to, participating in discharge planning, arranging for follow-up care, and developing mechanisms for exchange of appropriate information with sources outside the hospital.

(j) Qualified therapists, support personnel, and consultants adequate to provide comprehensive therapeutic activities consistent with each patient's active treatment program.

(k) In a satellite as defined in OAR 333-500-0010(46)(b), the prompt availability of at least one psychiatrist to provide emergency psychiatric services or other psychiatric services to meet the needs of the patients 24 hours each day in person or using telemedicine technology.

(3) Have a therapeutic activities program that is appropriate to the needs and interests of patients and directed toward restoring and maintaining optimal levels of physical and psychosocial functioning.

(4) Maintain medical records in a manner that permits determination of the degree and intensity of the treatment provided to individuals who are furnished services in the institution. Medical records shall stress the psychiatric components of the record, including history of findings and treatment provided for the psychiatric condition for which the patient is hospitalized. A patient's medical record shall include:

(a) The patient's legal status;

(b) The provisional or admitting diagnosis, including the diagnoses of intercurrent diseases as well as the psychiatric diagnoses;

(c) The reasons for admission as stated by the patient or others significantly involved;

(d) The social service records, including reports of interviews with patients, family members, and others, including an assessment of home plans and family attitudes, and community resource contacts as well as a social history;

(e) When indicated, a complete neurological examination recorded at the time of the admission physical examination;

(f) Documentation of all active therapeutic efforts; and

(g) A discharge summary that includes a recapitulation of the patient's hospitalization and recommendations from appropriate services concerning follow-up or aftercare, as well as a brief summary of the patient's condition on discharge.

(5) Have a psychiatrist perform a psychiatric evaluation of each patient that:

(a) Is completed within 60 hours of admission;

(b) Includes a medical history;

(c) Contains a record of mental status;

(d) Notes the onset of illness and the circumstances leading to admission;

(e) Describes attitudes and behavior;

(f) Estimates intellectual functioning, memory functioning, and orientation; and

(g) Includes an inventory of the patient's assets in descriptive, not interpretative, fashion.

(6) Develop a written individual comprehensive treatment plan that is based on an inventory of the patient's strengths and disabilities that includes:

(a) A substantiated diagnosis;

(b) Short-term and long-range goals;

(c) The specific treatment modalities utilized;

(d) The responsibilities of each member of the treatment team; and

(e) Adequate documentation to justify the diagnosis and the treatment and rehabilitation activities carried out.

(7) Ensure that progress notes are recorded by:

(a) The doctor of medicine or osteopathy responsible for the care of the patient; and

(b) Nurses, social workers and, when appropriate, others significantly involved in active treatment modalities.

(8) The frequency of progress notes is determined by the condition of the patient but must be recorded at least weekly for the first two months and at least once a month thereafter and must contain recommendations for revisions in the treatment plan as indicated as well as precise assessment of the patient's progress in accordance with the original or revised treatment plan.

(9) Provide discharge planning in accordance with OAR 333-505-0055.

(10) Comply with the applicable rules of the Oregon Health Authority's Behavioral Health Division, OAR chapter 309, divisions 31 and 33.

Statutory/Other Authority: ORS 441.025
Statutes/Other Implemented: ORS 441.025
History:
PH 44-2024, minor correction filed 04/08/2024, effective 04/08/2024
PH 233-2018, amend filed 08/02/2018, effective 08/02/2018
PH 7-2016, f. & cert. ef. 2-24-16
PH 5-2015, f. & cert. ef. 2-6-15
PH 11-2009, f. & cert. ef. 10-1-09
HD 21-1993, f. & cert. ef. 10-28-93
HD 29-1988, f. 12-29-88, cert. ef. 1-1-89, Renumbered from 333-073-0000
HD 11-1980, f. & cert. ef. 9-10-80, Renumbered from 333-023-0138
HD 18, f. 7-31-72, cert. ef. 8-15-72
HD 17(Temp), f. & cert. ef. 6-19-72
HB 209, f. & cert. ef. 12-18-68
HB 183, f. & cert. ef. 5-26-66