Oregon Bulletin

November 1, 2011


Oregon Health Authority,
Addictions and Mental Health Division:
Mental Health Services
Chapter 309

Rule Caption: Mental Health Services For Homeless Individuals.

Adm. Order No.: MHS 7-2011

Filed with Sec. of State: 9-26-2011

Certified to be Effective: 9-26-11

Notice Publication Date: 7-1-2011

Rules Adopted: 309-032-0301, 309-032-0311, 309-032-0321, 309-032-0331, 309-032-0341, 309-032-0351

Rules Repealed: 309-032-0175, 309-032-0180, 309-032-0185, 309-032-0190, 309-032-0195, 309-032-0200, 309-032-0205, 309-032-0210

Subject: The Addictions and Mental health (AMH) Division is revising these rules in order that they conform with federal requirements and accurately reflect AMH practices.

Rules Coordinator: Nola Russell—(503) 945-7652


Purpose and Scope

These rules prescribe the standards for community-based programs that serve individuals with a serious mental illness experiencing homelessness under the Projects for Assistance in Transition from Homelessness (PATH) program.

Stat. Auth.: ORS 413.042 & 430.640

Stats. Implemented: ORS 430.610 – 430.695

Hist.: MHS 7-2011, f. & cert. ef. 9-26-11



(1) “Co-Occurring Disorders” (COD) means the existence of at least one diagnosis of a substance use disorder and one diagnosis of a serious mental illness.

(2) “Community Mental Health Program” (CMHP) means an entity that is responsible for planning and delivery of services for individuals with substance use or mental illness diagnoses, operated in a specific geographic area of the state under an intergovernmental agreement or a direct contract with the Addictions and Mental Health Division (AMH).

(3) “Division” means the Addictions and Mental Health Division of the Oregon Health Authority (OHA).

(4) “Eligible Individual” means an individual who, as defined in these rules:

(a) Is homeless or at imminent risk of becoming homeless and

(b) Who has, or is reasonably assumed to have, a serious mental illness.

(c) The individual may also have a co-occurring substance use disorder.

(5) “Enrolled” means an eligible individual who:

(a) Receives services supported at least partially with PATH funds and

(b) Has an individual service record that indicates enrollment in the PATH program.

(6) “Homeless Individual” means an individual who:

(a) Lacks housing without regard to whether the individual is a member of a family and whose primary residence during the night is a supervised public or private facility that provides temporary living accommodations; or

(b) Is a resident in transitional housing that carries time limits.

(7) “Individual” means an individual potentially eligible for or who has been enrolled to receive services described in these rules.

(8) “Individual Service and Support Plan” (ISSP) means a comprehensive plan for services and supports provided to or coordinated for an eligible individual that is reflective of the intended outcomes of service.

(9) “Imminent Risk of Homelessness” means that an individual is:

(a) Living in a doubled-up living arrangement where the individual’s name is not on the lease;

(b) Living in a condemned building without a place to move;

(c) In arrears in their rent or utility payments;

(d) Subject to a potential eviction notice without a place to move; or

(e) Being discharged from a health care or criminal justice institution without a place to live.

(10) “Individual Service Record” means the written or electronic documentation regarding an enrolled individual that summarizes the services and supports provided from point of entry to service conclusion.

(11) “Literally Homeless Individual” means an individual who lacks housing without regard to whether the individual is a member of a family, including an individual whose primary residence during the night is a supervised public or private facility that provides temporary living accommodations.

(12) “Local Mental Health Authority” (LMHA) means one of the following entities:

(a) The Board of County Commissioners of one or more counties that establishes or operates a CMHP;

(b) The tribal council of a federally recognized tribe of Native Americans that elects to enter into an agreement to provide mental health services or

(c) A regional LMHA comprised of two or more boards of county commissioners.

(13) “Outreach” means the process of bringing individuals into treatment who do not access traditional services.

(14) “Projects for Assistance in Transition from Homelessness” (PATH) means the Formula Grants, 42 U.S.C. 290cc-21 to 290-cc-35.

(15) “Qualified Mental Health Professional” (QMHP) means any person who meets one of the following minimum qualifications as authorized by the LMHA or designee:

(a) A Licensed Medical Practitioner;

(b) A graduate degree in psychology, social work, or recreational, art or music therapy;

(c) A graduate degree in a behavioral science field;

(d) A bachelor’s degree in occupational therapy and licensed by the State or Oregon; or

(e) A bachelor’s degree in nursing and licensed by the State of Oregon.

(16) “Secretary” means the Secretary of the U.S. Department of Health and Human Services.

(17) “Serious Mental Illness” means a psychiatric condition experienced by an individual who is 18 years of age or older and who is:

(a) Diagnosed by a QMHP as suffering from a serious mental disorder as defined in Oregon Revised Statutes (ORS) 426.495 which includes, but is not limited to conditions such as schizophrenia, affective disorder, paranoid disorder, and other disorders which manifest psychotic symptoms that are not solely a result of a developmental disability, epilepsy, drug abuse or alcoholism; and which continue for more than one year, or

(b) Is impaired to an extent which substantially limits the individual’s consistent ability to function in one or more of the following areas:

(A) Independent attendance to the home environment including shelter needs, personal hygiene, nutritional needs and home maintenance;

(B) Independent and appropriate negotiation within the community such as utilizing community resources for shopping, recreation, transportation and other needs;

(C) Establishment and maintenance of supportive relationships; or

(D) Maintained employment sufficient to meet personal living expenses or engagement in other age appropriate activities.

Stat. Auth.: ORS 413.042 & 430.640

Stats. Implemented: ORS 430.610 – 430.695

Hist.: MHS 7-2011, f. & cert. ef. 9-26-11


Eligible Services

(1) Effective outreach to engage people in the following array of services:

(a) Identification of individuals in need;

(b) Screening for symptoms of serious mental illness;

(c) Development of rapport with the individual;

(d) Offering support while assisting with immediate and basic needs;

(e) Referral to appropriate resources; or

(f) Distribution of information including but not limited to:

(A) Flyers and other written information;

(B) Public service announcements; or

(C) Other indirect methods of contact.

(2) Methods of active outreach including but not limited to face-to-face interaction with literally homeless people in streets, shelters, under bridges and in other non-traditional settings, in order to seek out eligible individuals.

(3) Methods of in-reach, including but not limited to placing outreach staff in a service site frequented by homeless people, such as a shelter or community resource center, where direct, face to face interactions occur, in order to allow homeless individuals to seek out outreach workers.

(4) Screening and diagnosis.

(5) Habilitation and rehabilitation services.

(6) Community mental health services.

(7) Alcohol or drug treatment services.

(8) Staff training, including the training of those who work in shelters, mental health clinics, substance abuse programs, and other sites where homeless individuals require services.

(9) Case management including the following.

(a) Preparing a plan for the provision of community mental health services to the eligible individual and reviewing the plan not less than once every three months;

(b) Assistance in obtaining and coordinating social and maintenance services for the eligible individual, including services related to daily living activities, personal financial planning, transportation, and housing services;

(c) Assistance to the eligible individual in obtaining income support services including housing assistance, food stamps and supplemental security income benefits;

(d) Referring the eligible individual for such other services as may be appropriate and

(e) Providing representative payee services in accordance with section 1631(a)(2) of the Social Security Act [42 U.S.C. 1383(a)(2)] if the eligible individual is receiving aid under title XVI of such act [42 U.S.C. 1381 et seq.] and if the applicant is designated by the Secretary to provide such services;

(10) Supportive and supervisory services in residential settings;

(11) Housing services, which shall not exceed twenty percent of all total PATH expenses and which may include:

(a) Minor renovation, expansion and repair of housing;

(b) Planning of housing;

(c) Technical assistance in applying for housing assistance;

(d) Improving the coordination of housing services; (e) Security deposits;

(f) The costs associated with matching eligible individuals with appropriate housing situations; or

(g) One time rental payments to prevent eviction; and

(12) Referrals to other appropriate services or agencies, for those determined ineligible for other PATH services.

(13) Other appropriate services as determined by the Secretary.

Stat. Auth.: ORS 413.042 & 430.640

Stats. Implemented: ORS 430.610 – 430.695

Hist.: MHS 7-2011, f. & cert. ef. 9-26-11


Staff Qualifications and Training Standards

(1) Staff delivering case management and outreach services to individuals shall have demonstrated ability to:

(a) Identify individuals who appear to be seriously mentally ill;

(b) Identify service goals and objectives and incorporate them into an ISSP; and

(b) Refer the individuals for services offered by other agencies.

(2) All staff delivering PATH services shall have training, knowledge and skills suitable to provide the services described in these rules.

Stat. Auth.: ORS 413.042 & 430.640

Stats. Implemented: ORS 430.610 – 430.695

Hist.: MHS 7-2011, f. & cert. ef. 9-26-11


Rights of Eligible Individuals

(1) In addition to all applicable statutory and constitutional rights, every eligible individual receiving services has the right to:

(a) Choose from available services and supports;

(b) Be treated with dignity and respect;

(c) Have all services explained, including expected outcomes and possible risks;

(d) Confidentiality and the right to consent to disclosure in accordance with ORS 107.154, 179.505, 192.515 and 42 CFR Part 2 and 45 CFR Part 205.50;

(e) Give informed consent to services in writing prior to the start of services, except in a medical emergency or as otherwise permitted by law;

(f) Inspect their Individual Service Record in accordance with ORS 179.505;

(g) Not participate in experimentation;

(h) Receive medications specific to the individual’s diagnosed clinical needs;

(i) Receive prior notice of service conclusion or transfer, unless the circumstances necessitating service conclusion or transfer pose a threat to health or safety;

(j) Be free from abuse or neglect and to report any incident of abuse or neglect without being subject to retaliation;

(k) Have religious freedom;

(l) Be informed at the start of services and periodically thereafter of the rights guaranteed by these rules;

(m) Be informed of the policies and procedures, service agreements and fees applicable to the services provided, and to have a custodial parent, guardian or representative assist with understanding any information presented;

(n) Have family involvement in service planning and delivery;

(o) Make a declaration for mental health treatment, when legally an adult;

(p) File grievances, including appealing decisions resulting from the grievance; and

(q) Exercise all rights described in this rule without any form of reprisal or punishment.

(2) The provider will give to the individual and if applicable, to the guardian, a document that describes the preceding individual rights.

(a) Information given to the individual must be in written form or, upon request, in an alternative format or language appropriate to the individual’s need;

(b) The rights and how to exercise them will be explained and

(c) Individual rights will be posted in writing in a common area.

Stat. Auth.: ORS 413.042 & 430.640

Stats. Implemented: ORS 430.610 – 430.695

Hist.: MHS 7-2011, f. & cert. ef. 9-26-11


Enrollment and Record Requirements

(1) An individual’s eligibility shall be determined and documented at the earliest possible date.

(2) A record shall be maintained for each enrolled individual receiving services under this rule. The record shall contain the following:

(a) An enrollment form which includes:

(A) The individual’s name and PATH enrollment date;

(B) A list or description of the criteria determining the individual’s PATH eligibility; and

(C) The individual’s PATH services discharge date.

(b) A plan defining the enrolled individual’s goals and service objectives including one or more of the following:

(A) Accessing community mental health services for the eligible individual, which includes reviewing the plan not less than once every three months;

(B) Accessing and coordinating needed services for the eligible individual, as detailed in these rules.

(C) Accessing income and income support services, including housing assistance, food stamps, and supplemental security income; and

(D) Referral to other appropriate services.

(c) Progress notes that provide an on-going account of contacts with enrolled individual, a description of services delivered, and progress toward the enrolled individual’s service plan goals; and

(d) A termination summary describing reasons for the enrolled individual no longer being involved in service.

(3) A record shall be maintained for individuals served but not yet enrolled under the provisions of these rules. The record shall contain:

(a) A description of the potentially eligible individual, which may include but not be limited to:

(A) A physical description of the individual;

(B) The location where the individual was served; and

(C) A description of the individual’s personal belongings.

(b) A preliminary assessment of the potentially eligible individual’s needs based on available information; and

(c) A record of where and when contacts with the potentially eligible individual were made and the outcome of those contacts.

(4) Records shall be confidential in accordance with ORS 179.505, 45 CFR Part 2 and OAR 032-1535 pertaining to individuals’ records.

Stat. Auth.: ORS 413.042 & 430.640

Stats. Implemented: ORS 430.610 – 430.695

Hist.: MHS 7-2011, f. & cert. ef. 9-26-11

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