OAR 309-019-0231: ACT Program Operational Standards

(1) Operate continuous 24/7 crisis coverage as defined in OAR 309-019-0225. That includes direct after-hours on-call system with staff experienced in skilled crisis intervention procedures. (a) The ACT team will ensure that ACT Participant crisis calls are triaged and if needed, the ACT Team is available to respond accordingly depending on the level of urgency of the crisis. This availability includes de-escalation through telephone or virtual platform or in person dispatch depending on the initial method of communication the participant(s) utilized to reach out for supports and protocol for escalation. This will require staff who are responsible for triaging to have direct access to Crisis Plan per 309-019-0225(9). (b) ACT Participants shall have information provided to them, as often as needed for retention purposes, and a single crisis access pathway for them to seek support if/when needed. If the ACT Team is utilizing a third party to assist in meeting this requirement, ; the ACT Team will need to ensure appropriate HIPAA agreements are in place to release the Crisis Plan to the third party and that the ACT Participants are aware that respondents of this portion of services will not be from the ACT Team. (c) ACT program staff shall document any crisis dispatches or calls the team receives within the participant’s chart as soon as possible. Items to include but not limited to identify location, description of situation & individual, any relevant parties and outcome. If the ACT Team receives care coordination notification that a third party received a crisis call or responded to a crisis call for an ACT Participant, the ACT Team will document in participants chart all forwarding information from third party within 24hrs of receiving information so that proper follow up from ACT Team can occur. (d) If the ACT staff respond to a call and are in need of additional supports, ACT staff may coordinate with other Mental Health community programs and/or Law Enforcement to ensure the crisis is properly handled for safety of the individual and any bystanders. Collaboration and resourcing out to obtain additional supports during a crisis will exempt an ACT Team from adhering to being a Fixed Point of Responsibility per OAR 309-019-0225(16) as long as it is documented why additional supports were needed. (2) Service Intensity: (a) The ACT team shall have the capacity to provide the frequency and duration of staff-to-participant Face to Face contacts as clinically deemed necessary in alignment with evidence-based model which is captured on the fidelity scale. (b) The ACT team shall have the capacity to increase and decrease Face to Face contacts based upon assessment needs as the goal is to maximize independence when possible; (c) The team shall have the capacity to provide multiple contacts to participants in high need and a rapid response to early signs of relapse. (d) Natural supports and Informal Support System contacts as defined in OAR 309-019-0225 will be utilized as part of the treatment goal at the participants discretion of communicating HIPAA protected information. (e) The ACT team Psychiatrist and the Psychiatric Nurse Practitioner (PNP) shall have scheduling flexibility to accommodate individual needs. If the participant approves & is comfortable, the Psychiatrist or PNP can provide services as clinically indicated for through Telehealth. (f) The ACT team shall have the capacity to provide services via group modalities that are at minimum, Face to Face as defined 309-019-0225(13). (3) The ACT Team shall ensure that services are designed to meet participants cultural and linguistic needs and are developmentally appropriate. This includes collaboration and/or MOUs with local Tribal Communities or other diverse community partners within the ACT program’s service area that would benefit participants treatment goals. (4) Core staffing requirements for ACT teams: (a) ACT is a low client/staff ratio that is recommended to not exceed 10:1; if there is a vacancy longer than 30 calendar days that impacts this ratio, the program must communicate this to Division Approved Reviewer to discuss possibility of submitting a Variance to The Division per 309-019-0240 and seek Technical Assistance and support on filling that core position to ensure quality of evidence-based services. (b) A single ACT program will not serve more than 120 participants. (c) ACT Program must hire the appropriate number of staff to meet the minimum 1:10 staff ratio for individuals served. (d) Programs may not create multiple teams unless the program is at or above the 120 individuals served unless: (A) this was permitted by The Division under the previous rules update prior to 2023; (B) The service area spans across large geographical landscape or (C) The program expands services to a specialized targeted population that is person centered, and an additional team is needed to meet that need. (e) A Small ACT Team per OAR 309-019-0225(34) is recommended to have no more than 10 staff (f) A Mid-Size ACT Team per OAR 309-019-0225(26 is recommended to have no more than 12 staff (g) A Large ACT Team per OAR 309-019-0225(22) is recommended to have no more than 14 staff. (5) No individual ACT staff member shall be assigned less than .20 FTE for their role on the team. (6) ACT Team must include at minimum, the following Core team members in order to fully implement ACT services: (a) A primary Team Lead position per team. The team leader is a certified QMHP per OAR 309-019-0125 who is qualified to provide supervision for the clinical ACT staff. (b) A Psychiatric Care Provider (Psychiatrist or PNP) whose FTE is calculated using the client to staff ratio based on geographical area of services and The Division approved fidelity scale. This staff must be licensed by the State of Oregon. (c) A Nurse whose FTE is calculated using the client to staff ratio based on geographical area of services and The Division approved fidelity scale. The nurse must be licensed by the Oregon Board of Nursing. If there are more than two nursing staff for the ACT Team, it is recommended to have at least one Registered Nurse (d) An Integrated Co-Occurring Specialist (ICOD) whose FTE is calculated using the client to staff ratio based on geographical area of services and on The Division approved fidelity scale. The ICOD must maintain compliance with OAR 309-019-0145. (e) An Employment Specialist FTE is calculated using the client to staff ratio based on geographical area of services based on The Division Approved Fidelity Scale. An Employment Specialist competency shall include all Vocational Services for the ACT Participants by; (A) Completing a Career Profile and document any sort of follow-along; (B) Utilizing skillset for job exploration and matching potential Competitive Employment, per OAR 309-019-0225 rule set, opportunities to Participants based on self-directed decisions (C) Maintain data and tracking of job start & end dates for all ACT participants who utilized this service. (D) Support Participants in mitigating employment obstacles by way of transparency and networking to ensure participants have been properly informed of all legal rights as it pertains to earned income and required reporting. (f) Certified Peer Support Specialist or Peer Wellness Specialist as described in OAR 410-180-0300 to 0380 and defined in OAR 309-019-0105(81) and 309-019-0105(84). A registry of certified Peer Support Specialist Specialists and Peer Wellness Specialists may be found at the Office of Equity and Inclusion’s Traditional Health Worker’s website. (g) The ACT Team may identify other mental health Generalists staff as deemed necessary to account for treatment needs and client/staff ratio calculations. These staff will have identified roles per the evidence-based practice to account for being a Fixed-Point of Responsibility. (7) ACT Team Staffing Core Competencies: (a) Upon hiring, all clinical staff on an ACT team shall have experience in providing direct services related to the treatment and recovery of individuals with a serious and persistent mental illness. Clinical staff shall have demonstrated competencies in clinical documentation and engagement interventions; (b) All new staff shall complete ACT 101 within the first three-months of hire from the Division Approved Reviewer. Any staff who are a direct part of the referral & intake process shall complete the Standardize Referral Process training from the Division within two-months of hire. (c) Attend & complete identified trainings within the ACT Programs technical assistance plan. (8) The ACT team shall conduct organizational staff meetings with intention to include as many ACT Team Members as possible. (a) The ACT team will go over the roster of the participants served with triaging highest acuity in the program; and (b) Make necessary updates to document contacts made by multidisciplinary team that have occurred during the last 24 hours and a concise, behavioral description of the individual’s status. (9) The ACT team shall conduct treatment planning meetings under the supervision of the team lead that include the input from the Psychiatrist or PNP. These treatment planning meetings shall maintain compliance with ASAM or Certificate of Approval. If participants need have a significant fluctuation the ACT Team will make appropriate updates. The Division recommends more frequent meetings on new admissions. The ACT Participants presence is needed to ensure the identified treatment plan is an approved pathway for the individual and attainable; (10) A Comprehensive Assessment and Strength-Based Treatment Plan is completed upon each individual’s admission to the ACT program (11) Service note or episode content need to include at minimum: (a) Any relevant intervention tactics used, activity of event, or goal-oriented skill building; (b) Be entered any time the ACT team has contact with participants. Other information that can be included: (A) Type of contact; (B) Place of service; (C) Purpose of the contact or how contact was initiated; (D) Assessment of the effectiveness of the intervention and the individual’s progress towards the individual’s goal. (E) Identify the ACT Team member who provided the service. (12) Medication Management provided by the ACT Program shall include at minimum the following: (a) A written order signed by a prescribing practitioner is required for any medical treatment and medications managed by the Multidisciplinary Team. (b) A logbook that is kept in a secure location that has at minimum: (A) The name of the medication (B) The format of ingestion of the medication; (C) The dosage and quantity of the medication; (D) The frequency of need for the medication; (c) Medications held and/or stored by the ACT Program must all be clearly labeled and properly secured utilizing a locking mechanism with clear protocols to track access. This needs to include at minimum the following: (E) Documentation tracker of access of staff retrieving medications, staff who will be providing the Medication Supports for self-administers and full count of what is taken off site; then compared upon return what medications were accepted by the participant and what medications the participant declined. (F) Written protocols for disposal of medications per all state and federal laws so that disposal of these medications to prevent anyone from retrieving the discarded medications. (G) Medications held and/or stored by the ACT Program may not be withheld or used as reinforcement or punishment or in quantities that are excessive in relation to the amount prescribed to attain the participants best possible functioning. (13) If the participant is able to self-administer but requires verbal interventions such as directions or cueing support for safety in order to self-administer the medication; the ACT Program staff must document information in the participants record what medications were given, any relevant observations and/or any identified risk factors that transpired during medication supports. This will allow for improvement efforts for medication education and proper administrative oversite of task. (a) Any ACT staff who provides Medication Administration per OAR 309-019-0225(25) to ACT Participant must have proper the appropriate medical training, credentials and be licensed in Oregon and comply with all federal and state requirements. (b) Any staff who provides Medication Administration or Medication Management by means of hand-to-hand drop off must have proper first aid and CPR training and ensure all communication, changes or concerns are communicated to ACT Medical team members.