Current through Register Vol. 63, No. 12, December 1, 2024
This rule becomes effective July 1, 2016, and enforceable as
described in OAR 309-035-0115(17).
(1) When developed as described in sections
(2) and (3), a person-centered service plan shall be developed through a
person-centered service planning process. The person-centered service planning
process:
(a) Is driven by the
individual;
(b) Includes people
chosen by the individual;
(c)
Provides necessary information and supports to ensure the individual directs
the process to the maximum extent possible and is enabled to make informed
choices and decisions, except as limited or required by a court order, an
administrative order, the supervisory entity or the individual's legal
representative;
(d) Is timely,
responsive to changing needs, occurs at times and locations convenient to the
individual, and is reviewed at least annually;
(e) Reflects the cultural considerations of
the individual;
(f) Uses language,
format, and presentation methods appropriate for effective communication
according to the needs and abilities of the individual and the individual's
legal representative;
(g) Includes
strategies for resolving disagreement within the process including clear
conflict of interest guidelines for all planning participants such as:
(A) Discussing the concerns of the individual
and determining acceptable solutions;
(B) Supporting the individual in arranging
and conducting a person-centered service planning meeting;
(C) Utilizing any available greater community
conflict resolution resources;
(D)
Referring concerns to the Office of the Long-Term Care Ombudsman; or
(E) For Medicaid recipients, following
existing, program-specific grievance processes.
(h) Offers choices to the individual
regarding the services and supports the individual receives and from whom and
records the alternative HCB settings considered by the individual, except as
limited by a court, OHA, CMHP, or PSRB order;
(i) Provides a method for the individual, or
the individual's legal representative to request updates to the person-centered
service plan;
(j) Is conducted to
reflect what is important to the individual to ensure delivery of services in a
manner reflecting personal preferences and ensuring health and
welfare;
(k) Identifies the
strengths and preferences, service and support needs, goals, and desired
outcomes of the individual;
(l)
Includes any services that are self-directed, if applicable;
(m) Includes but is not limited to
individually identified goals and preferences related to relationships, greater
community participation, employment, income and savings, healthcare and
wellness, and education;
(n)
Includes risk factors and plans to minimize any identified risk factors;
and
(o) Results in a
person-centered service plan documented by the person-centered services plan
coordinator, signed by the individual or the individual's legal representative,
the individual's case manager, and all persons responsible for the
implementation of the person-centered service plan. The person-centered service
plan is distributed to the individual, the individual's legal representative,
the supervisory entity if applicable, and other people involved in the
person-centered service plan.
(2) Person-Centered Service Plans:
(a) To avoid conflict of interest, the
person-centered service plan may not be developed by the provider for
individuals receiving Medicaid. The Division may grant an exception when it has
determined that the provider is the only willing and qualified entity to
provide case management and develop the person-centered service plan;
(b) When the provider is responsible for
developing the person-centered service plan, the provider shall ensure that the
plan includes the following:
(A) HCBS and
setting options based on the individual's needs and preferences, and for
residential settings, the individual's available resources for room and
board;
(B) The HCBS and settings
are chosen by the individual and are integrated in and support full access to
the greater community;
(C)
Opportunities to seek employment and work in competitive integrated employment
settings for those individuals who desire to work. If the individual wishes to
pursue employment, a non-disability specific setting option shall be presented
and documented in the person-centered service plan;
(D) Opportunities to engage in greater
community life, control personal resources, and receive services in the greater
community to the same degree of access as people not receiving HCBS;
(E) The strengths and preferences of the
individual;
(F) The service and
support needs of the individual;
(G) The goals and desired outcomes of the
individual;
(H) The providers of
services and supports including unpaid supports provided voluntarily;
(I) Risk factors and measures in place to
minimize risk;
(J) Individualized
backup plans and strategies, when needed;
(K) People who are important in supporting
the individual;
(L) The person
responsible for monitoring the person-centered service plan;
(M) Language, format, and presentation
methods appropriate for effective communication according to the needs and
abilities of the individual receiving services and the individual's legal
representative;
(N) The written
informed consent of the individual or the individual's legal representative,
unless the individual is placed with the provider by a court, OHA, CMHP, or
PSRB order under ORS chapters 161 or 426;
(O) Signatures of the individual or the
individual's legal representative, or documentation of the individual's verbal
consent of services, participants in the person-centered service planning
process, and all persons and entities responsible for the implementation of the
person-centered service plan unless the individual is placed with the provider
by a court, OHA, CMHP, or PSRB order under ORS chapters 161 or 426;
(P) Self-directed supports; and
(Q) Provisions to prevent unnecessary or
inappropriate services and supports.
(c) When the provider is not responsible for
developing the person-centered service plan but provides or shall provide
services to the individual, the provider shall provide relevant information and
provide necessary support for the person-centered service plan coordinator or
other individuals developing the plan to fulfill the characteristics described
in subsection (b) of this section;
(d) The individual or the individual's legal
representative decides on the level of information in the person-centered
service plan that is shared with providers. To effectively provide services,
providers shall have access to the portion of the person-centered service plan
that the provider is responsible for implementing;
(e) The person-centered service plan shall be
distributed to the individual and the individual's legal representative and
supervisory entity, as applicable, and others involved in the person-centered
service plan;
(f) The
person-centered service plan shall justify and document any individually-based
limitation to be applied as outlined in OAR
309-035-0195 when the qualities
under 309-035-0195(1)
create a threat to the health and safety of the individual or others;
and
(g) The person-centered service
plan shall be reviewed and revised:
(A) At
the request of the individual or the individual's legal
representative;
(B) When the
circumstances or needs of the individual change; and
(C) Upon reassessment of functional needs as
required every 12 months.
(3) Because it may not be possible to
assemble complete records and develop a comprehensive person-centered service
plan during the crisis-respite individual's short stay, the provider is not
required to develop a person-centered service plan. At a minimum, the provider
must develop an assessment and residential service plan as deemed appropriate
to identify service needs, desired outcomes, and service strategies to resolve
the crisis or address the individual's other needs that caused the need for
crisis-respite services. In addition, the provider shall provide relevant
information and provide necessary support for the person-centered service plan
coordinator as described in this rule.
Statutes/Other Implemented: ORS
413.032,
443.400 -
443.465 &
443.991