1. (1) When the program qualities described below create a threat to the health and safety of a resident or others, a provider may seek to apply an individually-based limitation through the process described in this rule. The program qualities subject to a potential individually-based limitation include the resident’s right to:

   1. (a) The freedom and support to access food at any time;
   2. (b) Have visitors of the resident’s choosing at any time;
   3. (c) Have a unit entrance door that is lockable by the resident with only appropriate staff having access;
   4. (d) Choose a roommate when sharing a unit;
   5. (e) Furnish and decorate the resident’s unit as agreed to in the Residency Agreement;
   6. (f) The freedom and support to control the resident’s schedule and activities; and
   7. (g) Privacy in the resident’s unit.

2. (2) A provider may apply an individually-based limitation only if:

   1. (a) The program quality threatens the health or safety of the resident or others;
   2. (b) The individually-based limitation is supported by a specific assessed need;
   3. (c) The resident or the resident’s legal representative consents, or the limitation is mandated by the resident’s supervisory entity;
   4. (d) The limitation is directly proportionate to the specific assessed need; and
   5. (e) The individually-based limitation will not cause harm to the resident.

3. (3) The provider must demonstrate and document that the individually-based limitation meets the requirements of section (2) of this rule and the measures described below in the person-centered service plan. The provider must sign and submit a Division-approved form that includes the following:

   1. (a) The specific and individualized assessed need justifying the individually-based limitation;
   2. (b) The positive interventions and supports used prior to consideration of any individually-based limitation;
   3. (c) Records that document the provider or other entities have tried other less intrusive methods, but those methods did not work;
   4. (d) A clear description of the limitation that is directly proportionate to the specific assessed need;
   5. (e) Regular collection and review of documentation and data to measure the ongoing effectiveness of the individually-based limitation;
   6. (f) Established time limits for periodic reviews of the individually-based limitation to determine if the limitation should be terminated or remains necessary;
   7. (g) The informed consent of the resident or the resident’s legal representative, or the authorization of the resident’s supervisory entity, including any discrepancy between the wishes of the resident and the consent of the resident’s legal representative or the supervisory entity, if applicable; and
   8. (h) An assurance that the interventions and support do not cause harm to the resident.

4. (4) The provider must:

   1. (a) Not implement an incomplete individually-based limitation.
   2. (b) Maintain a copy of the completed and signed form documenting the consent to the individually-based limitation described in section (4) of this rule. The form must be signed by the resident, the resident’s legal representative, or supervisory entity;
   3. (c) Regularly collect and review the ongoing effectiveness of and the continued need for the individually-based limitation; and
   4. (d) Request review of the individually-based limitation by the person-centered service plan coordinator when a new individually-based limitation is indicated, or an existing individually-based limitation is changed. The review of an individually-based limitation is as needed but not less than annually.
5. (5) The qualities described in section (1) (b), (c), (d), (f) and (g) do not apply to residents receiving services at a SRTF. A SRTF provider does not need to seek an individually-based limitation to comply with these rules.
6. (6) The qualities described in section (1) of this rule also apply to a residents receiving services under a court, OHA, CMHP, or PSRB order under ORS chapters 161 or 426 in an RTF or RTH, which may be modified or restricted by a supervisory entity. A provider is not required to seek an individually-based limitation for rights modified or restricted by the supervisory entity, which may be implemented without the authorization of the resident. When applicable, these modifications or restrictions must be documented in the person-centered service plan.

Statutory/Other Authority

ORS 413.042 & 443.450

Statutes/Other Implemented

ORS 413.032, 443.400 - 443.465 & 443.991

History

BHS 4-2025, amend filed 02/28/2025, effective 03/01/2025
BHS 6-2024, amend filed 04/11/2024, effective 04/11/2024
BHS 41-2023, temporary amend filed 10/12/2023, effective 10/15/2023 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