Or. Admin. Code § 410-173-0025

Current through Register Vol. 63, No. 10, October 1, 2024

Section 410-173-0025 - Person-Centered Service Planning Process

(1) A person-centered service plan shall be developed through a person-centered service planning process that includes the following:

(a) Be completed face-to-face with the Individual to ensure the individual's involvement and direction in the development of their PCSP;

(b) Be directed by the Individual accessing 1915(i) services and supports;

(c) Include the Individual and those people chosen by the Individual to participate in the planning process;

(d) Reflect the services, supports, and delivery of those services and supports in a way that is important to the Individual;

(e) Provide necessary information and support to ensure the Individual directs their PCSP process to the maximum extent possible and is enabled to make informed choices and decisions. This information and support shall include:

(A) Notification to the individual accessing 1915(i) HCBS services informing them of their right to invite others they want to attend their PCSP meeting;

(B) Notification to the Individual's legal representative and/or authorized representative, if applicable, informing them of the right to be included in the person-centered service planning process; and

(f) Processes that are timely, responsive to changing needs, occurs at times and locations chosen by and convenient to the Individual;

(g) A review of the PCSP with the individual, and legal or authorized representative, every ninety (90) days or more often as determined by the Individual;

(h) Practices must reflect cultural considerations and values of the Individual;

(i) Use language, format, and presentation methods appropriate for effective communication according to the needs and abilities of the Individual and, as applicable, the legal representative or authorized representative of the Individual;

(j) Include strategies for resolving disagreement within the process, including clear conflict of interest guidelines for all planning participants that include:

(A) Discussing concerns of each person-centered service planning team member 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) For Individuals living in a residential facility refer concerns to the Oregon Residential Facilities ,Ombudsperson; and

(E) For those living independently refer concerns to the Oregon Health Plan Ombuds person; and

(F) Following existing, program-specific grievance or complaint processes;

(k) Offer choices to the Individual regarding the services and supports the Individual receives and from whom and record the alternative HCBS settings that were considered by the Individual;

(l) Provide a method for the Individual or, as applicable, the legal representative or authorized representative of the Individual to request updates to the person-centered service plan for the Individual;

(m) Be 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;

(n) Identify the strengths and preferences, service and support needs, goals, and desired outcomes of the Individual;

(o) Include individually identified goals and preferences related to relationships, greater community participation, employment, income and savings, healthcare and wellness, and education;

(p) Include risk factors and plans to minimize any identified risk factors, including:

(A) Identification of back-up plans, as needed; and

(B) Identification of procedures to follow when the primary provider is unable to deliver approved services.

(q) Results in a person-centered service plan conducted by the IQA and implemented by the provider of HCBS in the home and community settings.

(2) Person-Centered Service Plans (PCSP):

(a) The IQA documents the person-centered service plan on behalf of the Individual and provides the necessary information and supports to ensure the Individual directs the person-centered service planning process to the maximum extent possible;

(b) The person-centered service plan shall be developed and signed at least every 365 calendar days, by the Individual, the legal representative or authorized representative of the Individual, if applicable, and the IQA. Others may be included at the invitation of the Individual and, as applicable, the legal representative or authorized representative;

(c) Authorizes Medicaid services and is effective upon the date the PSCP is signed by all parties listed above and services cannot be claimed prior to the service plan effective date;

(d) To avoid conflict of interest, the PCSP may not be developed by the provider of HCBS;

(e) The written PCSP reflects:

(A) HCBS and setting options based on the needs, preferences, strengths, and desired outcomes of the Individual, and for residential settings, the available resources of the Individual 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 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 natural supports provided voluntarily and other alternative resources;

(I) The amount, duration, and scope of services to be provided to include:

(i) Requested dates of service;

(ii) The amount of service or units requested; and

(iii) Procedure codes for each type of service;

(iv) The name and contact information of the provider or community-based organization providing HCBS to the Individual

(J) Risk factors identified through the person-centered services planning process and measures in place to mitigate each identified risk;

(K) Individually based limitations as identified through person-centered planning that limit or restrict HCBS settings to keep the Individual and others safe from harm;

(L) Individualized backup plans and strategies;

(M) People who are important in supporting the Individual;

(N) The person responsible for monitoring the person-centered service plan including the Individual, legal representative, or authorized representative;

(O) Language, format, and presentation methods appropriate for plain and effective communication according to the needs and abilities of the Individual receiving services and, as applicable, the legal representative or authorized representative of the Individual;

(P) The written informed consent of the Individual or, as applicable, the legal representative or authorized representative of the Individual, indicating agreement with the information, supports and services identified within the PCSP;

(Q) Signatures of the Individual or, as applicable, the legal representative or authorized representative of the Individual, participants in the person-centered service planning process, providers responsible for the implementation of the PCSP, and people identified as providing natural supports within the PCSP;

(R) Provisions to prevent unnecessary or inappropriate services and supports;

(f) The Individual or, as applicable, the legal representative or authorized representative of the Individual, 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;

(g) The PCSP is distributed to the Individual and, as applicable, the legal representative or authorized representative of the Individual, and other people involved in the person-centered service plan as described above in subsection (e) of this section;

(h) The PCSP shall justify and document any individually-based limitation as described in OAR 410-173-0040 when conditions under OAR 410-173-0035(1)(d) and (2) (d-j) may not be met due to threats to the health and safety of the individual or others

(3) The person-centered service plan shall be reviewed and revised as directed by the Individual, their legal representative or authorized representative

(a) At least annually and upon reassessment of functional needs;

(b) At the request of the Individual or, as applicable, the legal representative or authorized representative of the Individual; or

(c) When documentation supports the circumstances or needs of the Individual have changed significantly.

(4) The PCSP shall be signed by the Individual, and legal or authorized representative any time a revision occurs.

Or. Admin. Code § 410-173-0025

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, 413.042, 413.085, 414.025, 443.738 & 427.104

Statutes/Other Implemented: ORS 409.050, 413.042, 413.085, 414.025, 443.738, 410.020, 427.007, 430.610, 430.620 & 430.662 - 430.670