OAR 309-033-0540
Administrative Requirements for Hospitals and Nonhospital Facilities Approved to Provide Services to Persons In Custody

(1)

Written policies. Each hospital or nonhospital facility shall have written policies concerning the care, custody, and treatment of persons in custody or on diversion. These policies shall be written to provide for the comfort and safety of the person being provided care and for the safety of the facility staff providing care to that person. These policies shall detail staff responsibilities, person’s rights, and emergency procedures. All staff involved in the care of these persons shall be fully familiar with these policies and procedures. These policies shall be reviewed as part of the Division’s approval process.

(2)

Warning. Each hospital or nonhospital facility shall:

(a)

Have a physician, nurse or QMHP give the person the following warning:
“You are being held in this hospital because someone is concerned that you may hurt yourself or other people. Anything the staff of this hospital observes you do or say while you are in custody here may be used as evidence in a court of law to determine whether you should be committed as a mentally ill person. You have a right to legal counsel. If you cannot afford an attorney one will be provided for you by the court.”

(b)

Have the warning given at the time of admission and at times when it is determined that the person will reasonably understand the notice, and as often as it is determined necessary to assure that the person has been given an opportunity to be aware of the notice.

(c)

Have the warning given to the person in writing, as required by ORS 426.123 (Observation of person in custody). An attempt shall be made to have the person sign the written warning. A copy of the signed written warning shall be given to the person and the original shall be kept in the clinical record. The person’s inability to sign the written warning or refusal to sign the written warning shall be documented on the written warning below the place where the person’s signature would be normally found, clearly stating the reasons the signature was not obtained. The written warning shall include a place where the person, by making a mark, may request legal counsel.

(3)

Notification of next of kin. If the person consents, a physician, nurse or QMHP at a hospital shall make every effort to notify the person’s next of kin of the location and condition of the person as required under ORS 426.234 (Duties of professionals at facility where person admitted).

(4)

Notification of the court of hospital hold. The admitting physician, if the person is at a hospital, shall immediately notify the circuit court in writing. The admitting physician shall also immediately notify the director in the county where the hospital is located so that an investigation can be conducted.

(5)

Notification of the court of nonhospital hold. The director, if the person is at a nonhospital facility, shall notify, in writing, the circuit court in the county where the person was taken into custody.

(6)

Log. Each hospital or nonhospital facility shall maintain a log of persons in custody that includes: name, date of birth, date of admission, type of admission and a notation of the use of restraints.

(7)

Posted warning and rights. Each hospital or nonhospital facility shall post a copy of the person’s rights in the holding room behind protective unbreakable plastic or in another location clearly visible from the holding room which, at a minimum, states:

(a)

The warning described in OAR 309-033-0540 (Administrative Requirements for Hospitals and Nonhospital Facilities Approved to Provide Services to Persons In Custody);

(b)

The person’s right to be free from electro-shock therapy or unduly hazardous procedures.

(8)

Clinical records. Each hospital or nonhospital facility shall maintain a clinical record which accurately documents the care, custody and treatment of a person in custody. These records shall include:

(a)

A copy of the hold form which documents the reasons for the hold, including specific behaviors which indicate the person:

(A)

Is dangerous to self or another person; and

(B)

Is in need of immediate care, custody or treatment for mental illness.

(b)

Documentation that the warning described in OAR 309-033-0540 (Administrative Requirements for Hospitals and Nonhospital Facilities Approved to Provide Services to Persons In Custody) has been given to the person.

(c)

Documentation of the potential effects and the observed effects of any medication administered which may substantially affect the person to prepare for or function effectively at the commitment hearing, signed by the treating physician.

(d)

A report of physical examination and relevant laboratory tests.

(e)

Daily medical progress notes.

(f)

Twenty-four hour nursing notes.

(g)

Documentation, signed by the treating physician, of each use of any mechanical restraints and the specific reasons which justify the use.

(h)

Documentation of the psychiatric history which, whenever possible, shall include:

(A)

History of present illness, including specific prodromal symptoms;

(B)

Medical history;

(C)

Family history;

(D)

Past psychiatric history;

(E)

Substance use and abuse history;

(F)

History of legal difficulties; and

(G)

Social history including current support system.
(i)
A report of mental status.

(j)

A diagnostic impression.

(k)

A treatment plan.

(9)

Access to clothing before release of persons in custody. Each hospital or nonhospital facility shall allow the person in custody to have access to his/her clothing before being released to attend the commitment hearing.

Source: Rule 309-033-0540 — Administrative Requirements for Hospitals and Nonhospital Facilities Approved to Provide Services to Persons In Custody, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=309-033-0540.

309‑033‑0200
Statement of Purpose and Statutory Authority 309‑033‑0210
Definitions 309‑033‑0220
General Standards 309‑033‑0230
Custody of Persons Alleged to Be Mentally Ill Prior to Filing a Notification of Mental Illness 309‑033‑0240
Initiation of the Civil Commitment Process 309‑033‑0250
Standards for Custody, Hospital and Nonhospital Holds, Emergency Commitment and Emergency Hospitalization of Persons Under Warrant of Detention 309‑033‑0260
Diversion from Commitment Hearing 309‑033‑0270
Provision of Care, Custody and Treatment of Persons Committed to the Division 309‑033‑0280
Procedures for Committed Persons on Outpatient Commitment or Trial Visit 309‑033‑0290
Assignment and Placement of Persons Committed to the Division 309‑033‑0300
Transfers Between Classes of Facilities 309‑033‑0310
Recertification for Continued Commitment 309‑033‑0320
Revocation of Conditional Release, Outpatient Commitment or Trial Visit 309‑033‑0330
Discharge of Committed Persons, Who Are Placed in the Community, from Commitment Status 309‑033‑0340
Variances 309‑033‑0400
Statement of Purpose and Statutory Authority 309‑033‑0410
Definitions 309‑033‑0420
Transportation and Transfer of Persons in Custody or On Diversion 309‑033‑0430
Transportation of a Committed Person to a State Hospital, Community Hospital or Nonhospital Facility 309‑033‑0432
Standards for the Approval of a Secure Transport Provider to Transport a Person in Custody or On Diversion to an Approved Holding Hospital or Nonhospital Facility 309‑033‑0435
Client Rights with Regards to a Secure Transport Provider 309‑033‑0437
Mechanical Restraint by a Secure Transport Provider 309‑033‑0440
Variance 309‑033‑0500
Statement of Purpose and Statutory Authority 309‑033‑0510
Definitions 309‑033‑0520
Classes of Facility that Provide Care, Custody or Treatment to Committed Persons or to Persons In Custody or On Diversion 309‑033‑0530
Approval of Hospitals and Nonhospital Facilities to Provide Services to Committed Persons and to Persons In Custody and On Diversion 309‑033‑0540
Administrative Requirements for Hospitals and Nonhospital Facilities Approved to Provide Services to Persons In Custody 309‑033‑0550
Standards for the Approval of Hospitals Detaining Persons In Custody Pending Transport to an Approved Holding Hospital or Nonhospital Facility 309‑033‑0560
Variances 309‑033‑0600
Statement of Purpose and Statutory Authority 309‑033‑0610
Definitions 309‑033‑0620
Obtaining Informed Consent to Treatment From a Person and the Administration of Significant Procedures Without the Informed Consent of a Committed Person 309‑033‑0625
Administration of Medication and Treatment without the Informed Consent of a Person in Custody 309‑033‑0630
Administration of Significant Procedures in Emergencies Without the Informed Consent of a Committed Person 309‑033‑0640
Involuntary Administration of Significant Procedures to a Committed Person With Good Cause 309‑033‑0650
Variances 309‑033‑0700
Purpose and Scope 309‑033‑0710
Definitions 309‑033‑0720
Application, Training and Minimum Staffing Requirements 309‑033‑0725
Medical Services 309‑033‑0727
Structural and Physical Requirements 309‑033‑0730
Seclusion and Restraint Procedures 309‑033‑0732
Time Limits 309‑033‑0733
Documentation 309‑033‑0735
Quarterly Reports 309‑033‑0740
Variances 309‑033‑0800
Statement of Purpose and Statutory Authority 309‑033‑0810
Definitions 309‑033‑0820
Denial of Payment for Services to Persons In Custody or On Diversion 309‑033‑0830
Variances 309‑033‑0900
Statement of Purpose and Statutory Authority 309‑033‑0910
Definitions 309‑033‑0920
Certification of Mental Health Investigators 309‑033‑0930
Investigation of Person Alleged to Be a Mentally Ill Person 309‑033‑0940
The Investigation Report 309‑033‑0950
Certification of Mental Health Examiners 309‑033‑0960
Mental Health Examiner’s Report to the Court 309‑033‑0970
Variances
Last Updated

Jun. 8, 2021

Rule 309-033-0540’s source at or​.us