Or. Admin. Code § 410-173-0005

Current through Register Vol. 64, No. 1, January 1, 2025

Section 410-173-0005 - Definitions

(1) "Activities of Daily Living (ADL)," means functional activities required by an Individual for continued well-being that are essential for health and safety. ADL's include eating, dressing/grooming, bathing/personal hygiene, mobility (ambulation and transferring), and elimination toileting bowel, and maintaining continence

(2) "Adult Foster Home (AFH)" means any home licensed by the Division in which residential care is provided to five (5) or fewer Individuals who are not related to the provider by blood or marriage as described in ORS 443.705 through 443.825. If an adult family member of the provider receives care, they shall be included as one of the Individuals within the total license capacity of the AFH. An AFH or Individual that advertises, including word-of-mouth advertising, to provide room, board, and care and services for adults is considered an AFH.

(3) "Aging and People with Disabilities (APD)" means the division in the Oregon Department of Human Services (ODHS or Department) that administers programs for older adults and people with disabilities.

(4) "Alternative Service Resources" means other resources for the provision of services to meet an Individual's needs. Alternative service resources include but are not limited to natural supports or other community supports. Alternative service resources are not paid by Medicaid and shall be identified through the person-centered planning process. When possible, alternative service resources shall be used in lieu of Medicaid paid supports.

(5) "Assistance" means the help needed by an Individual to complete Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL). For 1915(i) HCBS, assistance includes only the following activities:

(a) "Cueing" means giving verbal or visual clues during an activity to help an Individual complete the activity without hands-on assistance;

(b) "Hands-on" means a provider physically performs all or parts of an activity because an Individual is unable to do so; and

(c) "Supervision" means, along with cueing, helping the Individual know when or how to carry out the task. Supervision may be in the form of monitoring, set-up, reassurance, or stand-by to ensure the Individual completes the task. Need for assistance may not be based on possible or preventative measures:

(A) "Monitoring" means a provider observes an Individual to determine if assistance is needed;

(B) "Set-up" means the preparation, cleaning, and maintenance of personal effects, supplies, assistive devices, or equipment so an Individual may perform an activity;

(C) "Reassurance" means to offer an Individual encouragement and support;

(D) "Stand-by" means a provider is at the side of an Individual ready to step in and take over the task if the Individual is unable to complete the task independently.

(6) "Assisted Living Facility" or "ALF" means a building, complex, or distinct part thereof, consisting of fully, self-contained, individual living units where six (6) or more seniors and adult Individuals with disabilities may reside in homelike surroundings. The assisted living facility offers and coordinates a range of supportive services available on a 24-hour basis to meet the activities of daily living, health, and social needs of the residents as described in these rules. A program approach is used to promote resident self-direction and participation in decisions that emphasize choice, dignity, privacy, individuality, and independence.

(7) "Authority" means the Oregon Health Authority, the agency established in ORS 413 that administers the funds for Titles XIX and XXI of the Social Security Act. It is the single state agency for the administration of the medical assistance program under ORS 414. For purposes of these rules, the agencies under the authority of the Oregon Health Authority are the Public Health Division, Health Systems Division, External Relations, Health Policy and Analytics, Fiscal and Operations, Office of Equity and Inclusion, and the Oregon State Hospital.

(8) "Authorized Representative" means any adult with longstanding involvement in assuring the Individual's health and safety, appointed to participate in service planning process, and is:

(a) Chosen and appointed by the individual or their legal representative, if applicable

(b) Not a paid provider of Home and Community Based Services (HCBS), and supports;

(c) Authorized, in writing or other method that clearly indicates consenting choice, by the Individual or legal representative, if applicable, to serve as the Individual's representative in connection with the provision of funded supports; and

(d) Responsible to act as the authorized representative until the Individual, or legal representative, if applicable, modifies the authorization or notifies the authority or authority's contractor that the authorized representative is no longer authorized to act on their behalf.

(9) "Behavioral Health licensed facility" (BH Licensed) means a community-based treatment facility that meets the licensing requirements set forth by the Authority as described in Chapter 309, Division 35 and Chapter 309, Division 40. BH licensed facilities for these rules includes, Residential Treatment Facilities (RTH), Residential Treatment Home (RTH), and Adult Foster Homes (AFH).

(10) "Chronic Mental Health Illness" means an Individual who is diagnosed by a psychiatrist, a licensed clinical psychologist, a licensed independent practitioner as defined in ORS 426.005 or a non-medical examiner certified by OHA or ODHS as havening chronic schizophrenia, a chronic major affective disorder, a chronic paranoid disorder, or another chronic psychotic mental disorder other than those caused by substance abuse.

(11) "Cognitive impairment" means an Individual may be physically capable of performing ADL's or IADL's but may have limitations in performing these tasks due to remembering, learning new things, concentrating, or making decisions that affect their everyday life. Personal care services may be required because a cognitive impairment prevents an Individual from knowing when or how to carry out the task. Assistance may include cueing or supervision to support the Individual while performing the task. This does not include or replace community-based integrated support services that support the Individual to develop the skills needed to complete the task independently.

(12) "Community-Based Integrated Supports (CBIS)" means services and supports offered to Individuals who require assistance in the acquisition, retention, or improvement with life management, socialization skills and community engagement and community integration and engagement to maintain their maximum level of functioning and integration within the broader community.

(13) "Court-imposed restrictions for individuals under the jurisdiction of a civil or criminal court, or under the jurisdiction of the Oregon Psychiatric Security Review Board" (PRSB) means a court order imposing requirements or restrictions on adult offenders placed on supervision, either in lieu of incarceration or as a condition of release from prison. Individuals who received court-imposed restrictions while on probation or parole accept the court order or the court ordered entity or program as their decision-making authority for the purposes of the rules described in 410-173-0000 through 410-173-00075.

(14) "Cultural Competence" means the provider of 1915(i) HCBS shall participate in the state's efforts to promote the delivery of services in a culturally competent manner to all enrollees, including those with limited English proficiency, diverse cultural and ethnic backgrounds, carceral histories, disabilities, and regardless of gender, sexual orientation, or gender identity.

(15) "Cultural Consideration" means to promote the delivery of services in a culturally competent manner to all enrollees, including those with limited English proficiency and diverse cultural and ethnic backgrounds, carceral histories, disabilities, and regardless of gender, sexual orientation, or gender identity.

(16) "Delegated Nursing Task" means a registered nurse (RN) authorizes a person as described in OAR 851-047-0000 who is not licensed to provide or perform a nursing task. In accordance with OAR chapter 851 division 047, the RN shall, prior to issuing written authorization of a delegated nursing task, assess a specific eligible Individual's care needs, evaluate the person's ability to perform the specific nursing task, provide the person with education and training to perform the nursing task, and supervise and re-evaluate the Individual and the person performing the task.

(17) "Face-to-Face" means a personal interaction where both words can be heard and facial expressions can be seen, either in person or through telehealth services where there is a live streaming audio and video, if medically appropriate and necessary. Face-to-face could include communication methods such as telehealth/telemedicine, in lieu of in-person visits, in accordance with HIPAA, as directed by OHA and as chosen by the Individual. Medically appropriate and necessary accommodations shall be made for Individuals with disabilities including those with hearing or sight impairments. For telehealth the following conditions must be met:

(a) The agent performing the assessment is independent and qualified as defined in 42 CFR § 441.730 and meets the provider qualifications defined by the State, including any additional qualifications or training requirements for the operation of required information technology.

(b) The Individual receives appropriate support during the assessment, including the use of any necessary on-site support-staff.

(c) The Individual provides informed consent for this type of assessment.

(18) "Fiduciary" means a guardian or conservator appointed under the provisions of ORS 125 or any other person appointed by a court to assume duties with respect to a protected person under the provisions of ORS 125.

(19) "Functional Needs Assessment" means the comprehensive assessment or reassessment conducted by the Independent Qualified Agent (IQA), that documents an Individual's physical, mental, and social functioning that impacts an Individual's ability to perform everyday tasks, and the Individual's need for 1915(i) Home and Community-Based Services using Authority-approved assessment tools.

(20) "Group Home" has the same meaning as Oregon's Department of Human Services (ODHS) 24-hour residential setting and means a residential home, apartment, or duplex, licensed by the Department under ORS 443.410, where home and community-based services are provided to individuals with intellectual or developmental disabilities. A 24-hour residential setting is considered a provider owned, controlled, or operated residential setting.

(21) "Habilitation" means services that support an Individual to develop, maintain, or improve skills and competencies necessary to function as independently as possible to the extent as they would if they did not have a disability or chronic condition.

(22) "Home and Community Based Services (HCBS)" means services and supports that assist eligible Individuals to remain in their home and community in accordance with the Code of Federal Regulations, approved Medicaid State Plan authorities, and Oregon Administrative Rules.

(23) "Home and Community-Based Settings" or "HCB Settings" means a physical location meeting the qualities of 42 CFR § 441.710(a)(1) and (2), OAR 410-173-0035, and OAR 411-004-0020 where an Individual receives HCBS.

(24) "Home Delivered Meals" means services provided to Individuals who live in their own homes, are home bound, are unable to do meal preparation, and do not have another person available for meal preparation. Provision of the home delivered meal reduces the need for reliance on paid staff during some mealtimes by providing meals in a cost-effective manner. It is an Individuals choice whether they want to receive home delivered meals, nor not.

(25) "Housing Support Services" means the services determined necessary in the Person-Centered Service plan (PCSP) for an Individual to obtain and reside in an independent community setting that is tailored to the goal of maintaining an Individual's personal health and welcome in a HCBS where the person ins directly responsible for their own living expenses.

(26) "Individually Based Limitation (IBL)" means any limitation outlined in OAR 410-173-0040 due to health and safety risks. An IBL is based on specific assessed needs and only implemented with informed consent from the Individual or, as applicable, the legal representative or authorized representative of the individual, as described in these rules.

(27) "Instrumental Activities of Daily Living (IADL)" means those self-management activities performed by an individual on a day-to-day basis that are not essential to basic self-care and independent living. IADLs individual include but are not limited to housekeeping, including laundry, shopping, transportation, medication management, and meal preparation.

(28) "Independent and Qualified Agent (IQA)" means an entity meeting the provider qualification requirements identified in 42 CFR § 441.730 and under contract with the Division who:

(a) Determines 1915(i) program eligibility initially, annually, when an individual's circumstances or needs change significantly, or upon individual request;

(b) Provides education and technical assistance regarding HCBS and settings;

(c) Coordinates and assists the individual in directing the person-centered planning process;

(d) Drafts, documents, regularly reviews and updates person-centered service plans;

(e) Prior authorizes HCBS Residential Services as described in these rules;

(f) Conducts quality assurance and quality improvement activities;

(g) Completes the face-to-face needs-based assessment in person; and

(h) Performs transition management.

(29) "Individual" means the Medicaid-eligible person applying for or receiving 1915(i) program services.

(30) "Informed consent" means the service options, risks, and benefits have been explained to the Individual, legal representative, or authorized representative, in a manner that they understand, and the Individual legal representative or authorized representative have agreed to the services on or prior to the first date of service.

(31) "Legal Representative" means a person who has been legally designated by court order to make financial or health care decisions for another Individual. The legal representative only has authority to act within the scope and limits of their authority as designated by the court or other agreement. Legal representatives acting outside of their authority or scope shall meet the definition of authorized representative.

(32) "Legally Responsible Relative" means an unpaid relative of the Individual receiving 1915(i) services who by law is responsible for the support and care of another person.

(33) "Level of Care Utilization System (LOCUS)" means a single assessment instrument that uses quantifiable measures to guide assessment, level of care placement decisions, continued stay criteria for applicable settings, and clinical outcomes in a variety of settings for both mental health and addiction purposes.

(34) "Level of Service Inquiry (LSI)" means a person-centered assessment used to determine residential service and support needs of an individual experiencing functional deficits resulting from the symptoms of a diagnosed mental health condition and the existence of other physical, oral, and behavioral health conditions.

(35) "Local Mental Health Authority (LMHA)" has the same meaning as Community Mental Health Program (CMHP) as described in OAR Chapter 309, Division 014.

(36) "Medically Appropriate" has the meaning as defined in OAR 410-120-0000 and 410-172-0630.

(37) "Medically Necessary" has the meaning as defined in OAR 410-120-0000.

(38) "Natural Support" means resources and supports (e.g., relatives, friends, significant others, neighbors, roommates, or the community associates) who voluntarily provide services and supports to an Individual without the expectation of compensation. Natural supports are identified in collaboration with the Individual and the potential "natural support." The natural support is required to have the skills, knowledge, and ability to provide the needed services and supports and shall be identified within the Person-Centered Service Plan (PCSP).

(39) "Notice of Planned Action" means a written notice mailed to the Individual as described in OAR 410-120-1865 in the event an Individual's course of treatment or covered services shall be denied, terminated, suspended, or reduced.

(40) "ODDS" means the Oregon Department of Human Services, Office of Developmental Disabilities Services.

(41) "OHP" means the Oregon Health Plan.

(42) "Oregon Department of Human Services (Department)" or "ODHS" means the agency established in ORS Chapter 409, including such divisions, programs and offices as may be established therein.

(43) "Peer Support Specialist" means a certified person as defined in ORS 414.025 providing peer delivered services to an Individual or family member with similar life experience.

(44) "Person-Centered Service Plan (PCSP)" means the written document prepared by the IQA or the person-centered service plan coordinator that details the supports, desired outcomes, activities, and resources required for an Individual to achieve and maintain personal goals, health, and safety as described in OAR 410-173-0025. The PCSP shall be completed and signed prior to the Individual receiving HCBS. The PCSP is not satisfied by a document primarily prepared by a provider.

(a) The PCSP authorizes the Medicaid services that may be rendered and claimed;

(b) The effective date of the PCSP is upon signature by the Individual, or authorized representative, the providers of services, and the IQA PCSP coordinator;

(c) Billing for services is not authorized prior to the PSCP effective date or for any services not included in the PCSP.

(45) "Person-Centered Service Plan Coordinator (PCSP Coordinator)" means the Qualified Mental Health Professional (QMHP) or licensed professional operating within the scope of their license and employed by the Division's contracted IQA who is designated to provide service coordination and person-centered service planning with Individuals, their person-centered services planning team, and legal or authorized representative if applicable.

(46) "Person-Centered Planning Process" means the process required by 42 CFR § 441.720 and used by the IQA to develop and approve a written PCSP jointly with the Individual, their identified person-centered service planning team, and legal or authorized representative if applicable. The person-centered planning process is directed by the Individual to the maximum extent possible. The process and service plan shall meet the requirements of OAR 410-173-0025 and are based on the independent assessment of the Individual's assessed, approved and agreed upon needs

(47) "Provider Owned, Controlled, or Operated Residential Setting" means:

(a) The residential provider is responsible for delivering HCBS to Individuals in the setting and the provider:

(A) Owns the setting;

(B) Leases or co-leases the residential setting; or

(C) If the provider has a direct or indirect financial relationship with the property owner, the setting is presumed to be provider controlled or operated.

(b) A setting is not provider-owned, controlled, or operated if the Individual leases directly from a third party that has no direct or indirect financial relationship with the provider;

(c) When an Individual receives services in the home of a family member, the home is not considered provider-owned, controlled, or operated.

(48) "Psychosocial Rehabilitation Services (PSR)" means services that are medical or remedial and recommended by a licensed physician or other licensed practitioner to reduce impairment to an Individual's functioning associated with the symptoms of a mental disorder or to restore functioning to the highest degree possible. PSR helps Individuals compensate for or eliminate functional deficits, environmental and interpersonal barriers, and helps Individuals integrate as an active and productive member of their family and community with the least possible professional intervention.

(49) "Qualified Mental Health Associate (QMHA)" means an individual delivering services under the direct supervision of a QMHP who meets the minimum qualifications as authorized by the Local Mental Health Authority (LMHA) or designee and specified in OAR 309-019-0125.

(50) "Qualified Mental Health Professional (QMHP)" means a Licensed Medical Practitioner (LMP) or any other individual meeting the minimum qualifications as authorized by the LMHA or designee and outlined in OAR 309-019-0125.

(51) "Recovery Assistant" means a provider who provides a flexible range of services. Recovery assistants provide face-to-face services in accordance with a service plan that enables a participant to maintain a home or apartment, encourages the use of existing natural supports, and fosters involvement in treatment, social, and community activities. A recovery assistant shall:

(a) Be at least 18 years of age;

(b) Meet the background check requirements described in OAR 950-060-0060;

(c) Conform to the standards of conduct as described in OAR 950-060-0080.

(52) "Representative Payee" or "Payee" means an individual designated by the Social Security Administration to receive money payments of aid.

(53) "Residential Treatment Facility (RTF)" means a program licensed by the Division to provide services on a 24-hour basis for six (6) to sixteen (16) Individuals as described in ORS 443.400(11).

(54) "Residential Treatment Home (RTH)" means a program that is licensed by the Division and operated to provide services on a 24-hour basis for up to five (5) Individuals as defined in ORS 443.400(12).

(55) "Service Need" means the cueing, hands-on assistance, and supervision an individual requires from another person or equipment to complete functions or activities as independently as possible. Service need is based on the independent assessment of the Individual's needs.

(56) "Skilled Services means services delegated by a Registered Nurse (RN) under Oregon's Nurse Practice Act maybe considered personal care services when the RN provides appropriate training and delegation of the listed nursing tasks in accordance with the Oregon Nurse Practice Act. (OAR Chapter 851 Division 047).

(57) "Therapeutic Activities" means group and generalized activity therapy as determined in the person-centered service plan, related to the care and treatment of the Individual and administered by a qualified provider to Individuals diagnosed with a behavioral health condition that result in the improvement or reduction of symptoms and are not for recreation. (58) "Serious and Persistent Mental Illness (SPMI)" means the current DSM diagnostic criteria for at least one (1) of the following conditions, as a primary diagnosis for an adult 18 years of age or older:

(a) Schizophrenia spectrum and other psychotic disorders;

(b) Depressive disorders;

(c) Bipolar and related disorders;

(d) Obsessive Compulsive Disorder (OCD);

(e) Post Traumatic Stress Disorder (PTSD) and Other Specified Trauma- and Stressor-Related Disorder due to cultural syndromes; or

(f) Borderline personality disorder.

(58) "These Rules" means the rules in OAR 410, division 173.

(59) "Transition Management" means the services and supports offered to an Individual to assist them transition from a residential setting to an independent living setting of their choice.

Or. Admin. Code § 410-173-0005

DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019; DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019; DMAP 42-2024, amend filed 02/14/2024, effective 2/29/2024

Statutory/Other Authority: ORS 409.050, 412.001, 413.042, 413.085, 414.025, 443.738, 427.104 & 430.662

Statutes/Other Implemented: ORS 409.050, 413.042, 413.085, 414.025, ORS 410.600, 427.007, 430.610, 430.620 & 430.662 - 430.670