Current through Register Vol. 63, No. 9, September 1, 2024
(1) The program shall complete an assessment
for each individual within 14 days after admission to the program unless
admitted for crisis-respite services:
(a) The
assessment shall be based upon an interview with the individual to identify
strengths, preferences, and service needs; observation of the individual's
capabilities within the residential setting; a review of information in the
individual service record; and contact with representatives of other involved
agencies, the supervisory entity, the individual's legal representative, family
members, and others, as appropriate. All contacts with others shall be made
with proper authorization for the release of information or as otherwise
permitted by law;
(b) Assessment
findings shall be summarized in writing and included in the individual service
record. Assessment findings shall include but not be limited to diagnostic and
demographic data; identification of the individual's medical, physical,
emotional, behavioral, and social strengths, preferences, and needs related to
independent living and community functioning; and recommendations for
residential service plan goals; and
(c) The provider shall provide assessment
findings to the person-centered service plan coordinator to assist in the
development of the person-centered service plan.
(2) The person-centered service plan
coordinator under contract with the Division and assigned to the individual or
program site shall schedule and conduct an assessment of the individual for the
purpose of developing a person-centered service plan. The provider shall
support the person-centered service plan coordinator's efforts to develop the
plan and provide information as necessary.
(3) The provider shall develop and implement
an individualized residential service plan for the purpose of implementing and
documenting the provision of services and supports as well as any
individually-based limitations contained within the person-centered service
plan. Provider must also consider the limitations imposed by a court, OHA,
CMHP, or PSRB order, or the individual's legal representative. Identification
of the goals to be accomplished through the services provided shall be prepared
for each individual within 30 days after admission, unless admitted to the
facility for crisis-respite services:
(a) If
the person-centered service plan is unavailable for use in developing the
residential service plan, providers shall still develop an initial residential
service plan based on the information available. Upon the person-centered
service plan becoming available, the providers shall amend the residential
service plan as necessary to comply with this rule;
(b) The residential service plan shall be
based upon the findings of the individual assessment, be developed with
participation of the individual, input from the individual's legal
representative and supervisory entity, as applicable, and be developed through
collaboration with the individual's primary mental health treatment provider.
With consent of the individual or individual's legal representative, family
members, representatives from involved agencies, and others with an interest in
the individual's circumstances shall be invited to participate. All contacts
with others shall be made with proper, prior authorization from the individual
or as otherwise permitted by law;
(c) The residential service plan shall
include the following:
(A) The necessary steps
and actions of the provider for the implementation and provision of services
consistent and as required by the person-centered service plan; and
(B) Identify the individual's service needs,
desired outcomes, and service strategies to address the following: physical and
medical needs, medication regimen, self-care, social-emotional adjustment,
behavioral concerns, independent living capability, and community navigation,
all areas identified in the person-centered service plan and any other
areas.
(d) The
residential service plan shall be signed by the individual or the individual's
legal representative, the program administrator or other designated program
staff person, and others, as appropriate, to indicate mutual agreement with the
course of services outlined in the plan and a copy of the signed plan provided
to the supervisory entity as applicable; and
(e) The provider shall attach the residential
service plan to the person-centered service plan.
(4) For an individual admitted to a program
for 30 days or less for the purpose of receiving crisis-respite services, an
assessment and residential service plan shall be developed within 48 hours of
admission that identifies service needs, desired outcomes, and the service
strategies to be implemented to resolve the crisis or address other needs of
the individual that resulted in the short-term service arrangement.
(5) The provider shall maintain progress
notes within each individual's service record and document significant
information relating to all aspects of the individual's functioning and
progress toward desired outcomes identified in the residential service plan.
The provider shall enter a progress note in the individual's record at least
once each month.
(6) The provider
shall review and update the assessment and residential service plan at least
annually. On an ongoing basis, the provider shall update the residential
service plan as necessary based upon changing circumstances or upon the
individual's request for reconsideration.
Statutory/Other Authority: ORS
413.042 &
443.450
Statutes/Other Implemented: ORS
413.032,
443.400 -
443.465 &
443.991
