Or. Admin. R. 309-019-0140

Current through Register Vol. 63, No. 6, June 1, 2024

Section 309-019-0140 - [Effective until 10/27/2024] Service Plan and Service Notes

(1) The service plan must be a written, individualized plan designed to improve the individual's condition to the point where the individual's continued participation in the program or level of care is no longer necessary. The service plan is included in the individual's service record and must:

(a) Be started prior to rendering of treatment services, with a comprehensive service plan completed no later than 90 days from date of initial service contact;

(b) Reflect the assessment in its' most updated form;

(c) Address areas of concern identified in the assessment that the individual agrees to address;

(d) Include a safety plan when the assessment indicates risk to the health and safety of the individual or to others and be updated as circumstances change. The safety plan may be a separate document from the service plan;

(e) Include the participation of the individual and family members, as applicable;

(f) Be completed and signed by qualified program staff as follows:

(A) A QMHP in mental health programs;

(B) Supervisory or treatment staff in substance use disorders treatment programs; and

(C) Supervisory or treatment staff in problem gambling treatment programs.

(g) For mental health services, an appropriately licensed practitioner - program supervisor or Licensed practitioner designated by the program supervisor must recommend the services and supports by signing the service plan within ten business days of the start of services, when service plan objectives are changed or updated. An appropriately Licensed practitioner must approve the service plan at least annually for each individual receiving mental health services for one or more continuous years.

(2) At minimum, each service plan must include:

(a) Treatment objectives that are individualized;

(b) Treatment objectives that meet the assessed needs of the individual.

(3) Comprehensive service plans that must be written within 90 days of initial service contact. Comprehensive service plans will be measurable for the purpose of evaluating individual progress, as well as;

(a) The specific therapeutic and social services and supports that must be used to meet the treatment objectives;

(b) Expected frequency of each type of planned service or support; and

(c) A schedule for re-evaluating the service plan.

(d) the type of personnel that will be furnishing the services.

(4) Providers must document each service and support in a service note to include:

(a) The specific services rendered;

(b) The specific service plan objectives being addressed by the services provided;

(c) The date, time of service, and the actual amount of time the services were rendered;

(d) The personnel rendering the services, including their name, credentials, and signature;

(e) The setting in which the services were rendered; and

(f) Periodic updates describing the individual's progress.

(5) Decisions to transfer individuals must be documented including:

(a) The date of the transfer;

(b) The reason for the transfer;

(c) For substance use disorder and co-occurring services, ASAM level of care recommendation and overall determination of the severity of risk the individual is experiencing at the time of transfer;

(d) Referrals to follow up services and other behavioral health providers; and

(e) Outreach efforts made as applicable and as defined in these rules.

Or. Admin. R. 309-019-0140

MHS 6-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14; MHS 4-2014, f. & cert. ef. 2-3-14; MHS 11-2016(Temp), f. 6-29-16, cert. ef. 7-1-16 thru 12-27-16; MHS 18-2016, f. 11-28-16, cert. ef. 11/30/2016; MHS 26-2016(Temp), f. 12-27-16, cert. ef. 12-28-16 thru 6-23-17; MHS 6-2017, f. & cert. ef. 6/23/2017; MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18; MHS 4-2018, amend filed 02/27/2018, effective 3/1/2018; BHS 19-2021, temporary amend filed 09/14/2021, effective 09/14/2021 through 3/12/2022; BHS 5-2022, amend filed 03/04/2022, effective 3/18/2022; BHS 11-2023, amend filed 04/07/2023, effective 4/7/2023; BHS 9-2024, temporary amend filed 04/30/2024, effective 5/1/2024 through 10/27/2024; BHS 11-2024, temporary amend filed 05/21/2024, effective 5/21/2024 through 10/27/2024

Statutory/Other Authority: ORS 161.390, 413.042, 430.256 & 430.640

Statutes/Other Implemented: ORS 161.390 - 161.400, 428.205 - 428.270, 430.010, 430.205- 430.210, 430.254 - 430.640, 430.850 - 430.955 & 743A.168