Oregon Health Authority
Health Systems Division: Behavioral Health Services - Chapter 309
Division 19
OUTPATIENT BEHAVIORAL HEALTH SERVICES
309-019-0130
Personnel Documentation, Training, and Supervision
(1) All program staff who render services and supports or bill for services and supports and all personnel who have access to protected health information that are associated with the Certificate must be identified on the provider’s organizational chart through a hierarchical chart or through a spreadsheet. If utilizing a spreadsheet, must also indicate reporting structure that demonstrates who is supervising the position. Information must include the individuals:
(a) Full legal name;
(b) Licensure and/or credential (based on their certification);
(c) Position title;
(d) Full-time or part-time status;
(e) Remote, Office, or Hybrid
(2) Providers must maintain personnel records for each program staff that contains all of the following documentation:
(a) The results of a criminal records check applicable to the current position or title, and:
(A) For personnel who render mental health services or have access to mental health protected health information such as service records or billing information, the program must use The Oregon Criminal Records Check and those processes and procedures required by OAR 943-007-0001 through 0501; and
(B) For personnel who render only substance use disorder treatment services or have access to only substance use disorder protected health information such as service records or billing information, the program must use national and state-wide criminal records check processes.
(b) A current job description that includes applicable competencies;
(c) Copies of relevant licensure or certification, registration for licensure or certification, diploma, or certified transcripts from an accredited college, indicating that the program staff meets applicable qualifications;
(d) Documentation of Employment Eligibility Verification, form I-9;
(e) Documentation of a minimum of two hours every two years or three hours every three years of training in suicide risk screening suicide risk assessment, treatment and management;
(f) Periodic performance appraisals;
(g) Program orientation documentation;
(h) Disciplinary documentation;
(i) Documentation of trainings required by this or other applicable rules; and
(j) Documentation of clinical supervision.
(3) Program Orientation: Providers must ensure that program staff receive training applicable to the specific population for whom services are planned, delivered, or supervised. The Provider must document that the following orientation was completed for each program staff providing or supervising services or supports within 30 days of the hire date, unless otherwise specified. At a minimum, program orientation and training for all program staff must include but not be limited to:
(a) A review of crisis prevention and response procedures;
(b) A review of emergency evacuation procedures;
(c) A review of program policies and procedures, including the procedures for each certified ASAM Level of Care for substance use disorder treatment program staff;
(d) A review of rights for individuals receiving services and supports;
(e) A review of mandatory abuse reporting procedures;
(f) A review of confidentiality policies and procedures;
(g) A review of Fraud, Waste and Abuse policies and procedures;
(h) A review of care coordination policies and procedures;
(i) A review of and agreement to abide by the Code of Conduct;
(j) Substance use disorders treatment staff and substance use disorders clinical supervisors must complete a training on The ASAM Criteria within the first three months of employment rendering substance use disorder services or supports or have it documented as completed within the most recent two years; and
(k) For Enhanced Care Services, positive behavior support training.
(4) Clinical Supervision is required for all program staff. providing direct services or supports and must receive documented clinical supervision by a qualified clinical supervisor related to the development, implementation, and outcome of services. Staff licensed by an Oregon Board must be clinically supervised by another individual licensed by an Oregon Board. Unlicensed staff must be clinically supervised by an individual who is licensed by an Oregon Board and who is is physically present in Oregon at the time of clinical supervision, or a QMHP that qualifies as a clinical supervisor and who is physically present in Oregon at the time the services and supports are provided, and while providing clinical supervision. Part time staff must receive supervision no less than, half the total supervision hours required for full time staff. Individual face-to face contact may include real time, two-way audio or audio-visual conferencing, and:
(a) Documentation must include:
(A) The date;
(B) Amount of time per session; and
(C) A brief description of the topics addressed.
(b) Clinical Supervision must be provided to assist staff to:
(A) Increase their skills within their scope of practice;
(B) Improve quality of services to individuals; and
(C) Ensure understanding, application and compliance with the code of conduct and program policies and procedures.
(c) Documentation must demonstrate the following minimum hours of clinical supervision for full-time staff per month:
(A) Non-licensed program staff, including Board Registered Associates, must receive at least two hours per month of clinical supervision. The two hours must include at minimum one hour of individual face-to-face supervision, and may include one hour of group supervision;
(B) Mental Health Interns and Student Interns must receive one-hour of individual clinical supervision per week; and
(C) When available, a qualified Peer Delivered Services Supervisor must provide one of the two hours of required monthly supervision to program staff providing direct Peer Delivered Services. Remaining hours of supervision must be provided by a qualified clinical supervisor.
(d) Mental Health Interns and Student Interns must render services and supports under the active supervision of a qualified supervisor, as defined in these rules; and
(e) Individualized non-clinical supervision must be utilized as needed and documented.
Statutory/Other Authority: ORS 161.390, 413.042, 430.256 & 430.640
Statutes/Other Implemented: ORS 109.675, 428.205 - 428.270, 430.010, 430.205 - 430.210, 430.254 - 430.640, 430.850 - 430.955 & 743A.168
History:
BHS 18-2026, amend filed 06/30/2026, effective 07/01/2026
BHS 12-2023, amend filed 05/16/2023, effective 05/16/2023
BHS 11-2023, amend filed 04/07/2023, effective 04/07/2023
BHS 27-2022, amend filed 12/20/2022, effective 12/20/2022
BHS 11-2021, amend filed 06/16/2021, effective 06/16/2021
MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018
MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18
MHS 6-2017, f. & cert. ef. 6-23-17
MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17
MHS 18-2016, f. 11-28-16, cert. ef. 11-30-16
MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16
MHS 4-2014, f. & cert. ef. 2-3-14
MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14