1. (1) The licensee must ensure that the program and setting are maintained and operated in compliance with these rules and all other applicable federal, state, and local laws and regulations.

2. (2) The licensee must employ a program administrator who meets the following qualifications and complies with the following standards:

   1. (a) Background including specialized training, experience, and other demonstrated ability in providing care and treatment appropriate to residents with serious mental illness served in the program. Such background must include:

      1. (A) One (1) year or more of clinical experience working in a setting that provides treatment to individuals who are diagnosed with serious mental illness; or
      2. (B) Two (2) years or more of residential experience working in a setting that was licensed to provide care and services to individuals who are diagnosed with serious mental illness;
   2. (b) Documented current approved background checks processed in compliance with the procedures required by OAR 943-007-0001 through 0501;
   3. (c) Ensure the program operates in accordance with the standards outlined in these rules;
   4. (d) Oversee the daily operation and maintenance of the program and must be available to perform administrative duties at the setting for at least 20 hours per week;
   5. (e) Develop and administer written policies and procedures to direct the operation of the program and the provision of services to residents;
   6. (f) Ensure sufficient qualified program staff are available to provide direct services to residents in accordance with the staffing requirements specified in these rules to assure resident safety and resident rights, freedoms, and protections, provision of HCBS services, and that resident’s attain or maintain the highest practical physical, mental and psychosocial well-being as determined by the resident assessments and person-centered service plans, and considering the number, acuity and diagnoses of the program’s resident population;
   7. (g) Supervise or provide for the supervision of program staff and others involved in the operation of the program;
   8. (h) Maintain setting, personnel, and resident service records;
   9. (i) Report regularly to the licensee on the operation of the program; and

   10. (j) Delegate authority and responsibility for the operation and maintenance of the program to a responsible staff person whenever the program administrator is absent from the setting:

       1. (A)  This authority and responsibility may not be delegated to a resident.
       2. (B) If the program administrator is absent from the setting for a period exceeding 60 days, an interim program administrator, who meets all qualification requirements, must be designated. Upon designating an interim program administrator, a notification must be made to the Division.
3. (3) The licensee, administrator and all caregivers must be literate in the English language and can understand and communicate orally and in writing with residents, medical professionals, care coordinators and others involved in the care of residents.

4. (4) The licensee, administrator, and all caregivers must not be listed on the U.S. Office of Inspector General’s or U.S. General Services Administration Exclusion lists:

   1. (a) It is the licensee’s responsibility to ensure the administrator is not listed on either of the Exclusion Lists;
   2. (b) It is the administrator’s responsibility to ensure that all caregivers must not be listed on either of the Exclusion Lists; and
   3. (c) Verification of these requirements must be clearly documented in the program’s personnel records.

5. (5) The licensee must develop and update policies and procedures specific to the licensed setting, maintain a copy in a location easily accessible for staff reference and made available to others upon reasonable request. Policies and procedures must be consistent with requirements of these rules and must address at a minimum the following:

   1. (a) Personnel practices;
   2. (b) Program staff and administrator training;
   3. (c) Resident screening, admission, and transfer and discharge;
   4. (d) Fire drills and emergency procedures;
   5. (e) Resident and program safety;
   6. (f) Abuse reporting;
   7. (g) Health and sanitation;
   8. (h) Records maintenance and confidentiality;
   9. (i) Service planning;
   10. (j) Behavior management interventions including the use of seclusion or restraints;
   11. (k) Food preparation and distribution;
   12. (l) Medication administration and storage;
   13. (m) Weapons and reasonable cause searches;
   14. (n) Resident belongings, storage and funds;
   15. (o) Resident rights, freedoms, and protections;
   16. (p) Advanced mental health and medical health directives;
   17. (q) Complaints and grievances;
   18. (r) Setting maintenance;
   19. (s) Evacuation capability determination;
   20. (t) Fees and money management;
   21. (u) Cultural competency;
   22. (v) Limited English Proficiency (LEP) services;
   23. (w) Facility closure; and
   24. (x) Secure settings must have a policy and procedure regarding resident leave authorization.
6. (6) Any social covenants required by the program must be outlined in the residency agreement and must be posted in a prominent location in the common area.  Social covenants may not conflict with resident rights and freedoms outlined in these rules.
7. (7) The provider must submit critical incident reports to the Division and the CMHP within 48 hours of the incident occurring.
8. (8) The provider must submit all incident reports to the CMHP within 48 hours of the incident occurring.

Statutory/Other Authority

ORS 413.042 & 443.450

Statutes/Other Implemented

ORS 413.032, 443.400 - 443.460 & 443.991

History

BHS 13-2026, temporary amend filed 06/01/2026, effective 06/01/2026 through 11/25/2026
BHS 7-2026, temporary amend filed 05/14/2026, effective 05/15/2026 through 05/31/2026
BHS 6-2026, amend filed 04/30/2026, effective 05/01/2026
BHS 5-2026, amend filed 04/30/2026, effective 06/01/2026
BHS 32-2025, temporary amend filed 12/30/2025, effective 01/01/2026 through 06/27/2026
BHS 4-2025, amend filed 02/28/2025, effective 03/01/2025
MHS 5-2017, f. & cert. ef. 6-8-17
MHS 2-2017(Temp), f. 3-3-17, cert. ef. 3-4-17 thru 8-30-17
MHS 13-2016(Temp), f. 9-6-16, cert. ef. 9-7-16 thru 3-3-17
MHS 4-2008, f. & cert. ef. 6-12-08
MHD 4-2005, f. & cert. ef. 4-1-05
MHD 4-1998, f. 5-21-98, cert. ef. 6-1-98
MHD 9-1985, f. & cert. ef.
MHD 9-1984(Temp), f. & cert. ef. 12-10-84