OAR 415-050-0165: Medically Monitored Inpatient Withdrawal Management, ASAM Level of Care 3.7-WM

In addition to any other requirements described in these rules and applicable statutes, programs approved to render Medically Monitored Inpatient Withdrawal Management Services, ASAM Level of Care 3.7-WM to adolescents or adults must, at a minimum, meet and maintain documentation demonstrating ongoing compliance with each of the following requirements: (1) Render a planned and structured regimen of 24-hour professionally directed services delivered by medical treatment staff that include evaluation, observation, medical monitoring, and withdrawal management in an inpatient setting, under a defined set of physician approved and monitored medical procedures and protocols. (2) Patients must meet the following ASAM dimensional assessment criteria required for placement in ASAM Level of Care 3.7-WM: (a) The patient is experiencing signs and symptoms of severe withdrawal or there is evidence, based on history or other relevant factors, that severe withdrawal syndrome is imminent; (b) The severe withdrawal syndrome is assessed as manageable at this level of care; and (c) The patient scores within a defined range on CIWA-Ar, COWs or other assessment metric for the drug(s) identified for withdrawal management services and meets physician-defined protocol for admission at this Level of Care. (3) Medical services must include: (a) A LMP onsite daily to render medical assessments, provide monitoring of care and further evaluation; (b) A Medical treatment staff onsite and readily available 24 hours a day, 7 days per week, to oversee the monitoring of the patient’s progress and medication administration on an hourly basis, or as needed; and (c) Medical staff must have access to specialized clinical consultation and supervision for biomedical, emotional, or behavioral issues related to intoxication and withdrawal management. (4) Starting April 1, 2024 the following standards are in effect: ASAM Level 3.7-WM Programs must maintain a 24-hour, daily minimum of on-site medical staffing as follows: (a) Minimum licensed nurse staffing: (A) A medical treatment staff must be on each shift 24 hours per day; (B) An LNP must serve as the licensed charge nurse for no less than eight consecutive hours between the start of day shift and the end of evening shift, seven days a week; and (C) Section (4)(e) of this rule may be variance by the Division. The request for variance must comply with OAR 415-012-0090 and must be reviewed annually. The variance shall be considered by the Division if the program attests that: (i) The program has been unable to recruit appropriate personnel despite diligent efforts, including offering wages at the community prevailing rate for withdrawal management facilities; (ii) The variance does not endanger the health or safety of patients; and (iii) An RN or physician is available and obligated to immediately respond to telephone calls from the program and respond on-site when medically necessary. (b) Minimum Certified Nursing Assistant (nursing assistant) staffing ratios: (A) Day shift: 1 nursing assistant per 8 patients; (B) Evening shift: 1 nursing assistant per 10 patients; and (C) Night shift: 1 nursing assistant per 16 patients. (c) At a minimum, one additional medical treatment staff must be onsite and readily available 24 hours per day: (A) When the census is between 9-20; and (B) For each additional 10 patients or part thereof when the census is 21 or higher. (d) Providers are responsible for assuring appropriate staffing and must increase the number of medical treatment staff present beyond the minimum levels set forth above, as necessary to safely monitor and treat patients. Providers must consider patient acuity and medical treatment staff responsibilities when determining the appropriate levels of additional staffing. (5) The following staffing standards are in effect until March 31, 2024: (a) ASAM Level 3.7-WM Programs must be staffed by: (A) LMPs who are available 24 hours a day by telephone, available to assess the patient within 24 hours of admission, or earlier, (if medically necessary), and available to provide on –site monitoring of care and further evaluation on a daily basis; (B) A licensed and credentialed nurse must be available to conduct a nursing assessment upon admission and to oversee the monitoring of the patient’s progress and medication administration on an hourly basis, if needed; (C) Appropriately licensed and credentialed staff must be available to administer medications in accordance with physician orders; and (D) The level of nursing care must be appropriate to the severity of patient needs. (b) The Program must maintain a minimum ratio of paid full-time staff to bed capacity as follows: (A) 1 through 8 beds — 1 staff person on duty; (B) 9 through 18 beds — 2 staff persons on duty; (C) 19 through 30 beds — 3 staff persons on duty; (D) 31 beds and above — One additional staff person beyond the three staff required above for each additional 15 beds or part thereof. (c) The Program’s written staffing plan must address the provision of appropriate and adequate staff coverage during emergency and high demand situations. (d) The Program must provide a minimum of one hour per month of personal clinical supervision and consultation for each staff person and volunteer who is responsible for the delivery of treatment services. The clinical supervision must relate to the individual's skill level with the objective of assisting staff and volunteers to increase their treatment skills and quality of services to individuals. (6) Adolescent ASAM Level of Care 3.7-WM Withdrawal Management Services are a version of Medically Monitored Inpatient Withdrawal Management, ASAM Level of Care 3.7-WM services, designed specifically for adolescents. When licensed as such, in addition to all requirements for Medically Monitored Inpatient Withdrawal Management, ASAM Level of Care 3.7-WM, programs must, at a minimum, meet and maintain documentation demonstrating ongoing compliance with each of the following requirements: (a) Medical protocols developed by a physician knowledgeable in withdrawal management and preferably knowledgeable about adolescent development and medicine; (b) LMPs monitor the delivery of procedures and protocols; (c) Adolescents placed at this level of care must be experiencing withdrawal signs and symptoms that are moderate to severe and thus require 24-hour medical inpatient care; (d) Identification of when an adolescent requires a higher level of care and facilitation of the transfer to that level of care; and (e) Medical services must include: (A) Provision of 24-hour per day, 7-days per week access to LMP consultation; (B) Availability for 24-hour per day, 7-days per week LMP evaluation of adolescents; and (C) 24-hour per day, 7-days per week medical monitoring of the safety and outcome of the withdrawal management services; and (D) Medical treatment staff provide 24-hour per day, 7-days per week organized, on-site services that include medical supervision, observation and treatment.