1. (1) The provider must maintain a written job description for each staff position that specifies the position’s qualifications and job duties:

   1. (a) A direct care staff person must be:

      1. (A) At least 18 years of age;
      2. (B) Be capable of implementing the setting’s emergency procedures and disaster plan; and
      3. (C) Be capable of performing other duties of the job as described in the job description;
   2. (b) All program staff having contact with a resident must have a documented current approved background check in accordance with OAR 943-007-0001 through 943-007-0501 prior to working alone with residents. All program staff must have a preliminary background check prior to working with residents under supervision of qualified staff. The provider must maintain documentation of current approved or preliminary background checks for each applicable staff person.

   3. (c) A new background check must be completed:

      1. (A) Every three years;
      2. (B) Prior to any subject individual’s change in employment position; and
      3. (C) If the Division has reason to believe a new background check is needed.
   4. (d) All program staff must meet other qualifications when required by a contract or financing arrangement approved by the Division.
2. (2) Personnel policies must be made available to all program staff and must describe hiring, leave, promotion, and disciplinary practices.

3. (3) The program administrator must provide or arrange a minimum of 16 hours pre-service orientation for each program staff within 60 days of hire and prior to working alone with residents. Pre-service orientation training for direct care staff must include, but is not limited to:

   1. (a) A comprehensive tour of the setting;
   2. (b) A review of emergency procedures developed in accordance with OAR 309-035-0145;
   3. (c) A review of setting policies and procedures;
   4. (d) Background on mental, emotional, or behavioral disorders and conditions;
   5. (e) Behavior management including interventions and de-escalation techniques;
   6. (f) An overview of resident rights;
   7. (g)  Medication management procedures;
   8. (h) Food service arrangements;
   9. (i) Grievances, complaints and an overview of the Oregon Residential Facilities Ombudsperson program;
   10. (j) A summary of each resident's assessment and residential service plan;
   11. (k) Culturally responsive care;
   12. (l) Completion of the approved course Mandatory Reporting for Individuals Working in Community Mental Health Programs;
   13. (m) Completion of an approved HCBS training course; and
   14. (n) Other information relevant to the job description and scheduled shifts.

4. (4) The program administrator must provide or arrange a minimum of 8 hours annual in-service training for each program staff: Annual in-service training topics for direct care staff must include but are not limited to:

   1. (a) Culturally responsive care;
   2. (b) Implementing residential service plans;
   3. (c) Behavior management including interventions and de-escalation techniques;
   4. (d) Daily living skills development;
   5. (e) Nutrition;
   6. (f) Opioid overdose kits and administration of an FDA-approved short-acting, non-injectable, opioid antagonist medication;
   7. (g) Understanding mental illness;
   8. (h) Sanitary food handling;
   9. (i) Resident rights, freedoms, and protections;
   10. (j) Identifying health care needs;
   11. (k) Complaints, grievances, incidents and abuse reporting; and
   12. (l) Psychotropic medications.

5. (5) The licensee must ensure that all direct care staff have and maintain current Cardiopulmonary Resuscitation (CPR) and First Aid certifications from a Division-approved entity within 60 days of hire and prior to working alone with residents:

   1. (a) Accepted CPR and First Aid courses must be provided by or meet the standards of the American Heart Association or the American Red Cross.
   2. (b) CPR or First Aid courses conducted online are only accepted by the Division when an in-person skills competency check is conducted by a qualified instructor meeting the standards of the American Heart Association or the American Red Cross.

6. (6) The licensee must ensure that all program staff and entities contracting with the program to provide direct care must complete a general worker safety training within 90 days of hire and at least two years thereafter:

   1. (a) This training must focus on providing program staff and contracted entities with skills and knowledge regarding:

      1. (A) The potential risks that program staff may face in the work environment of a particular behavioral health setting, including but not limited to behavioral health settings involving mobile crisis intervention teams, as defined in ORS 430.626;
      2. (B) Protocols for using safety equipment, emergency communication devices and alert systems in emergency or crisis situations; and
      3. (C) The available options for reporting alleged workplace safety violations and allegations of discrimination, retaliation or harassment to the Occupational Safety and Health Division of the Department of Consumer and Business Services, the Bureau of Labor and Industries and other relevant state agencies, including the rights and protections afforded to workers who engage in such reporting.
   2. (b) The training must incorporate simulated scenarios and roleplaying to ensure program staff and contracted entities have an opportunity to apply the training principles in real-world scenarios.
   3. (c) The program must retain records documenting the completion of the training required under this section. At a minimum, the records must include the date of training, topics covered and the names of the program staff and contracted entities who attended the training. The records shall be made available, upon request, to the Division.

7. (7) All program staff and entities contracting with the program to provide direct care must complete a Division-approved LGBTQIA2S+ training within 60 days of hire and prior to working alone with residents and every two years thereafter. This training must include the following elements:

   1. (a) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus;
   2. (b) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression, or human immunodeficiency virus status;
   3. (c) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status;
   4. (d) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns;
   5. (e) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination; and
   6. (f) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to policies and procedures, forms, signage, communication between residents and their families, activities, in-house services, and staff training.
   7. (g) Proof of all training completion must be documented in the program staff member’s individual personnel file as outlined in OAR 309-035-0125. Proof of training completion for entities contracting with the program must be maintained in the program files.

8. (8) The provider must ensure that an adequate number of trained and qualified program and direct care staff are available at all times to meet the treatment, health, and safety needs of all residents. Program staff must be scheduled to meet the changing needs and ensure safety of residents. Minimum staffing requirements are as follows:

   1. (a) There must be at least one direct care staff on duty at all times;
   2. (b) In the case of a specialized program, staffing requirements outlined in the contractual agreement for specialized services must be implemented and maintained at all times;
   3. (c) Class I and Class II SRTFs must ensure staffing levels meet the requirements set forth in chapter 309, divisions 32 and 33 as applicable; and
   4. (d) Program and direct care staff on night duty must be awake, dressed, observant of program operations, and accessible to residents at all times.

Statutory/Other Authority

ORS 413.042 & 443.450

Statutes/Other Implemented

ORS 413.032, 443.400 - 443.465 & 443.991

History

BHS 13-2026, temporary amend filed 06/01/2026, effective 06/01/2026 through 11/25/2026
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
BHS 15-2024, amend filed 06/25/2024, effective 07/01/2024
BHS 1-2024, temporary amend filed 01/09/2024, effective 01/10/2024 through 04/11/2024
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
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. & ef. 6-7-85
MHD 9-1984(Temp), f. & ef. 12-10-84