Oregon Administrative Code

309-114-0010 General Policy on Obtaining Informed Consent to Treatment and Training (1)(a) Basic Rule. Patients, guardians, or healthcare representatives may refuse any significant procedure and may withdraw at any time consent previously given to a significant procedure. Any ref…

309-114-0015 Administration of Significant Procedures Without Informed Consent in Emergencies (1) An emergency exists if in the opinion of the chief medical officer or designee: (a) Immediate action is required to preserve the life or physical health of the patient and it is impr…

309-114-0020 Involuntary Administration of Significant Procedures to Persons Committed to the Division with Good Cause (1) Good cause: Good cause exists to administer a significant procedure to an individual committed to the Division without informed consent if in the opinion of …

309-114-0025 Contested Case Hearing (1) Patient’s Rights: A patient has the right to contest the hospital’s determination that it has good cause to involuntarily administer a significant procedure without informed consent pursuant to OAR 309-114-0020(5)(c). If the patient is lega…

309-116-0200 Oregon State Hospital Patients Privacy Rights Patients of the Oregon State Hospital have the right to a humane physical environment that provides adequate privacy for each patient. Each patient shall be provided living quarters that afford reasonable privacy and secu…

309-118-0000 Purpose and Scope These rules prescribe a process to address the informal complaints and grievances that an Oregon State Hospital patient, or a representative on the patient's behalf, might have in regards to the hospital or its staff. These rules also establish a re…

309-118-0005 Definitions As used in these rules: (1) “Abuse” means any act or absence of action toward a patient by staff that falls within the definition of abuse found in ORS 430.735. (2) “Allegation of Abuse” means a grievance by a patient or their representative alleging that…

309-118-0010 Policy Statement (1) It is the policy of OSH that the care and treatment of its patients be administered in a manner that preserves their civil and legal rights. OSH will maintain a process for patients and their representatives to resolve informal complaints or grie…

309-118-0015 Issues Ineligible for Grievance or Review Process Notwithstanding the definition of a grievance in OAR 309-118-0005, a patient’s or their representative’s compliant shall not be processed through the grievance or review procedures set forth in these rules if: (1) The…

309-118-0020 Grievance Process (1) Informal Complaint: Whenever possible, a patient or patient’s representative should attempt to present and resolve complaints informally with the individual(s) involved in the complaint. (a) An informal complaint may be made verbally or in writi…

309-118-0023 OSH and OHA Review Processes for Resolved Grievances (1) OSH and OHA recognize that a patient or their representative may not be satisfied with the resolution of their grievance(s) as provided in OAR 309-118-0020 and therefore provide an optional two-tiered review pr…

309-118-0030 Representatives (1) A patient has the right to have a representative, as defined in OAR 309-118-0005, to assist them in the grievance and review process. A patient shall not act as a representative for another patient in the grievance process. (2) If the patient and …

309-118-0035 Responsibilities of OSH Staff in Grievance and Review Process (1) Treatment staff and Ombuds shall be notified in writing of the rules and policies related to the grievance and review process. (2) Treatment staff shall assist the patient or their representative with …

309-118-0046 Grievance Committee (1) If any member of the Grievance Committee is the subject of the patient’s or their representative’s grievance, then that member shall recuse themselves from the decision-making process on that grievance. If recusal will lead to fewer than two m…

309-118-0050 Posting of Grievance and Review Process Upon admission, OSH shall inform patients both orally and in writing, of the rights, policies, and processes set forth in these rules. A clear and simple statement of the grievance and review processes shall be prominently post…

309-120-0070 Purpose These rules prescribe procedures by which offenders in Oregon Youth Authority (OYA) close custody facilities may be transferred to a state mental hospital or a facility designated by the Addictions and Mental Health Division for evaluation and treatment. Stat…

309-120-0075 Definitions As used in these rules: (1) “Close custody facility” means any of the secure facilities operated by the OYA, including, but not limited to, youth correctional facilities, work/study camps, and transition camps. (2) “Facility designated by the Oregon Healt…

309-120-0080 Procedures for Transfer (l) The OYA close custody facility Superintendent, the Director of the OYA, or the Director’s designee may request that the Superintendent of a state mental hospital or a facility designated by the Authority for evaluation and treatment accept…

309-120-0200 Purpose Purpose. These rules prescribe procedures by which adults in custody of Department of Corrections facilities may be transferred to a state mental hospital listed in ORS 426.010. Statutory/Other Authority: ORS 179.040, 179.473, 179.479 & 413.042 Statutes/Other…

309-120-0205 Definitions As used in these rules: (1) "Department of Corrections Facility" means any institution, facility or staff office, including the grounds, operated by the Department of Corrections. (2) "Adult in custody" means any person under the supervision of the Depart…

309-120-0210 Administrative Transfers (Mentally Ill Adults in Custody) (1) The Administrator of the Department of Corrections Counseling and Treatment Services Unit/designee may request the Superintendent/designee of a state mental hospital listed in ORS 426.010 to accept a trans…

309-120-0215 Hearings Process (1) The Oregon Health Authority shall provide for an administrative commitment hearing conducted by a hearings officer employed or under contract with the Department of Corrections for administrative commitment or extension of the transfer of the adu…

309-120-0220 Representation (1) In all cases, the adult in custody is entitled to: (a) Speak in his or her own behalf; and (b) Be present at all stages of the hearings process, except when the hearings officer finds that to have the adult in custody present would present an immed…

309-120-0225 Notice of Hearing (1) The adult in custody shall be given written notice that an administrative commitment to a state mental hospital listed in ORS 426.010, a hospital or facility designated by the Oregon Health Authority, or an extension of the transfer is being con…

309-120-0230 Investigation (1) The adult in custody may request that an investigation be conducted. If an investigation is ordered, a designee of the hearings officer shall conduct the investigation. No person shall serve as an investigator who has participated in any previous wa…

309-120-0235 Documents/Reports (1) An adult in custody may present documents or reports during the hearing, subject to the exclusion and restrictions provided in these rules. (2) The reporting employee or other agents of the Department of Corrections or Oregon Health Authority wh…

309-120-0240 Witnesses (1) The hearings officer shall direct the scheduling and taking of testimony of witnesses at the hearing. Witnesses may include adults in custody, employees, or other persons. Testimony may be taken in person, by telephone, or by written report or statement…

309-120-0245 Postponement (1) A hearing may be postponed by the hearings officer for good cause and for reasonable periods of time. (2) Good cause includes, but is not limited to: (a) Illness or unavailability of the adult in custody; (b) Gathering of additional evidence; or (c) …

309-120-0250 Findings (1) No Justification: The hearings officer may find that the evidence does not support placement in a state mental hospital listed in ORS 426.010 or a hospital or facility designated by the Oregon Health Authority, in which case the hearings officer will rec…

309-120-0255 Hearing Record (1) Upon completion of a hearing, the hearings officer shall prepare and cause to be delivered to the Superintendent/designee of the Oregon State Hospital a hearing record within three (3) days from the date of the hearing. (2) The record of the formal…

309-120-0260 Superintendent’s Review (1) The results of any hearing held to place an adult in custody in a state mental hospital for administrative commitment will be reviewed and approved by the Superintendent/designee of the Oregon State Hospital. (2) The Superintendent/designe…

309-120-0265 Extension of Transfer (1) If the Oregon Health Authority determines that the administrative commitment must exceed 180 days in order to stabilize the adult in custody, the administrative commitment must be renewed in a subsequent administrative commitment hearing hel…

309-120-0270 Handling of Adult in custody Money and Personal Property (1) When an adult in custody is transferred to a state mental hospital, the Department of Corrections shall send a check for the balance of the adult in custody's account to the business office of the state men…

309-120-0275 Visiting Privileges (1) When an adult in custody is transferred to a state mental hospital, the Department of Corrections facility shall provide a copy of the adult in custody's approved list of visitors. (2) All visitors shall be approved according to the state ment…

309-120-0280 Short-Term Transitional Leaves, Emergency Leaves and Supervised Trips When an adult in custody is administratively transferred to a state mental hospital, no short-term transitional leaves, emergency leaves, or supervised trips shall be approved by the state mental h…

309-120-0285 Releases from a State Mental Hospital An adult in custody who is transferred to a state mental hospital may be discharged and transferred back to a Department of Corrections facility for one of the following reasons: (1) Completion of treatment; (2) He/she could rece…

309-120-0290 Reporting of Unusual Incidents Reporting of unusual incidents involving adults in custody administratively transferred to a state mental hospital shall be handled in accordance with the Department of Corrections policy on Unusual Incident Reporting Process. Statutory…

309-120-0295 Confidentiality and Sharing of Information (1) Department of Corrections records and other adult in custody information shall not be available to adults in custody or persons not employed by, nor under contract to, the Oregon Health Authority. (2) Authority records a…

325-001-0001 Notice To Interested Persons Before adopting, amending, or repealing any permanent rule, the Patient Safety Commission will give notice of its intended action: (1) In the Secretary of State’s Bulletin referred to in ORS 183.360 at least 21 days before the effective d…

325-001-0005 Model Rules of Procedure The Patient Safety Commission adopts, in their entirety, the current Attorney General's Uniform and Model Rules of Procedure under the Administrative Procedures Act. Statutory/Other Authority: ORS 442.820 & 442.831 Statutes/Other Implemented:…

325-005-0015 Biennial Budget The Oregon Patient Safety Commission (OPSC) hereby establishes the OPSC 2025-2027 biennial budget of $4,347,510 covering the period July 1, 2025, through June 30, 2027. The OPSC Executive Director will amend budgeted accounts as necessary within the a…

325-011-0001 Definitions As used in OAR 325-011-0001 to 325-011-0055: (1) “Adverse event” means an objective and definable negative consequence of patient care, or the risk of an objective and definable negative consequence of patient care, that: (a) Is unanticipated and usually …

325-011-0002 Participation in the Oregon Patient Safety Reporting Program (1) Participation in the Oregon Patient Safety Reporting Program is voluntary. (2) The following entities are eligible to participate: (a) Hospitals as defined in ORS 442.015; (b) Long term care facilities …

325-011-0005 Reporting Patient Safety Data (1) The Oregon Patient Safety Commission (OPSC) will provide Participants with the means to submit Patient Safety Reports. (2) Participants must use the format specified by OPSC when reporting Patient Safety Data. (3) If a Participant su…

325-011-0010 Reporting of Less Serious Adverse Events or Close Calls In addition to Serious Adverse Events, Participants are also encouraged to report less serious adverse events and close calls. Participants should do so when they believe other organizations will benefit from th…

325-011-0015 Auditing and oversight of the Oregon Patient Safety Reporting Program The Oregon Patient Safety Commission (OPSC) Board of Directors will establish auditing and oversight procedures for the Oregon Patient Safety Reporting Program, including a process to: (1) Evaluate…

325-011-0020 Public Health Officer Certification (1) At least annually, the Oregon Patient Safety Commission (OPSC) will request that the Public Health Officer certify that OPSC is administering the patient safety reporting program consistent with the mission described in ORS 442…

325-011-0025 Patient Notification of Serious Adverse Events (1) After a Serious Adverse Event occurs, a Participant must notify each affected patient or the patient's personal representative. Notification must be timely and should be consistent with the Participant's internal com…

325-011-0030 Waivers The Oregon Patient Safety Commission (OPSC) may waive any provision of these rules if the waiver will not adversely affect OPSC’s mission described in ORS 442.820. Statutory/Other Authority: ORS 442.820 & 442.831 Statutes/Other Implemented: ORS 442.819-442.85…

325-011-0035 Protection of Patient Safety Data (1) The Oregon Patient Safety Commission (OPSC) is subject to all the confidentiality provisions set forth in ORS 442.820, 442.831, 442.837, and 442.846. (2) OPSC will maintain the confidentiality of all Patient Safety Data that iden…