Current through Register Vol. 63, No. 12, December 1, 2024
(1) The provider shall deliver or coordinate
for each individual appropriate services and supports to collaboratively
facilitate intended service outcomes as identified by the individual and
family:
(a) Qualified program staff shall
facilitate a planning process, resulting in a service plan that reflects the
assessment;
(b) A service plan
shall be completed prior to the start of services;
(c) A licensed health care professional shall
recommend the services and supports by signing the service plan;
(d) Individuals and family members shall be
invited to participate in the development of the service plan;
(e) Providers shall fully inform the
individual and guardian when applicable of the proposed services and supports
in developmentally and culturally appropriate language, obtain informed consent
for all proposed services, offer peer delivered services, and give the
individual and guardian a written copy of the service plan;
(f) Providers shall collaborate with
community partners to coordinate or deliver services and supports identified in
the service plan;
(g) Providers
shall collaborate to exchange information with any applicable physical health
care providers for the individual to promote regular and adequate health
care.
(2) The service
plan shall be a written, individualized plan to improve the individual's
condition to the point where the individual's continued participation in the
program is no longer necessary. The service plan is included in the
individual's service records and shall:
(a)
Be completed prior to the start of services;
(b) Reflect the full assessment and the level
of care to be provided;
(c) Include
the participation of the individual and family members;
(d) Be completed by a QMHP;
(e) A QMHP who is also a licensed health care
professional shall recommend the services and supports by signing the service
plan within ten business days of the start of services; and
(f) An LMP shall approve the service plan at
least annually for everyone receiving mental health services for one or more
continuous years. The LMP may designate annual clinical oversight by
documenting the designation to a specific licensed health care
professional.
(3) At a
minimum, each service plan shall include:
(a)
Treatment objectives that are:
(A)
Individualized to meet the assessed needs of the individual; and
(B) Measurable for evaluating individual
progress, including a baseline evaluation.
(b) The specific services and supports
indicated by the assessment that shall be used to meet the treatment
objectives;
(c) A projected
schedule for service and support delivery, including the expected frequency and
duration of each type of planned service or support;
(d) The credentials of the personnel
providing each service and support; and
(e) A projected schedule for re-evaluating
the service plan;
(f) Proactive
safety and crisis planning; and
(g)
A behavior support plan.
(4) The interdisciplinary team shall conduct
a review of progress and transfer criteria at least every 30 days from the date
of entry and shall document the member's present, progress, and changes made.
For Psychiatric Day Treatment Services, the review shall be conducted every 30
days, and the LMP shall participate in the review at least every 90
days.
(5) Providers shall document
each service and support in a service note. A service note, at minimum, shall
include:
(a) The specific services
rendered;
(b) The specific service
plan objectives being addressed by the services provided;
(c) The relationship of the services provided
to the treatment objective described in the service plan;
(d) The date, time of service, and the actual
amount of time the services were rendered;
(e) The personnel rendering the services,
including the name, credential, and signature;
(f) The setting in which the services were
rendered; and
(g) Periodic updates
describing the individual's progress.
(6) Decisions to transfer individuals shall
be documented and include:
(a) The reason for
the transfer;
(b) Referrals to
follow up services and other behavioral health providers; and
(c) Outreach efforts made.
Statutory/Other Authority: ORS
161.390,
413.042,
430.256,
426.490 -
426.500,
428.205 -
428.270,
430.640 &
443.450
Statutes/Other Implemented: ORS
109.675,
161.390 -
161.400,
179.505,
413.520 -
413.522,
426.380 -
426.395,
426.490 -
426.500,
430.010,
430.205 -
430.210,
430.240 -
430.640,
430.850 -
430.955,
443.400 -
443.460,
443.991 &
743A.168
