Or. Admin. Code § 411-016-0030

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

Section 411-016-0030 - Person-Centered Service Planning

(1) Services Case Managers (SCMs) must use a person-centered service planning process to develop person-centered service plans. The process must:

(a) Be directed by the individual and include people chosen by the individual;

(b) Occur at times and locations of convenience to the individual;

(c) Provide necessary information and supports so that the individual can make informed choices and decisions;

(d) Offer all available service options including assistive devices, home modifications and other alternative service resources as defined in OAR 411-014-0005 to meet the identified needs;

(e) Include assessing the cost effectiveness and sustainability of the plan;

(f) Result in authorization of the minimum level of services that the individual chooses and is eligible for, that are required to adequately meet the individual's assessed needs or support the unpaid caregiver and caregiving relationship;

(g) Be documented in Oregon Access, CA/PS and other approved forms and systems.

(h) Local offices should work with participants to resolve service disagreements through local processes and the OPI-M grievance process. In the event there is no local level resolution, OPI-M participants have contested case hearing rights as described in OAR chapter 461, division 025.

(i) The SCM must contact the eligible individual within 14 days of the eligibility determination and complete the service plan within 30 days.

(2) The individual or individual's representative is responsible for choosing and assisting in developing a cost-effective person-centered service plan.

(a) The case manager must ensure the individual's preferences are represented in the plan and other involved parties do not exert undue influence.

(b) There must be no conflicts of interest between the individual and others involved in the service planning process.

(3) In developing the service plan, SCMs must address the:

(a) Personal preferences and cultural considerations of the individual; and

(b) Health and welfare of the individual.

(4) The process must use the language, format, and presentation methods appropriate for effective communication according to the needs, preferences, and abilities of the individual, and if applicable, representative of the individual.

(5) Eligible OPI-M consumers may choose one or more of the following services for their OPI-M service plan, if the requirements of the service are met, available and the services are authorized by the SCM:

(a) Adult day services;

(b) Assisted and community transportation;

(c) Assistive technology;

(d) Caregiver education and training;

(e) Case management and service coordination;

(f) Chore services;

(g) Community Caregiver Supportive Services;

(h) Emergency response systems;

(i) Evidence-based health promotion services;

(j) Home delivered meals;

(k) Home modifications;

(l) In-Home services from either:

(A) A Homecare worker employed in the Consumer-Employed Provider Program in OAR 411-016-0075; or

(B) In-Home Care Agency;

(m) Long term care community nursing;

(n) Supports for Consumer Direction; and

(o) Special Medical Equipment.

(6) All services in the plan must be prior authorized by the Department or the Services Case Manager.

(7) The plan must include and document in CA/PS or Department approved forms the following:

(a) The goals, strengths and preferences of the individual, including but not limited to relationships, greater community participation, employment, healthcare and wellness, and education;

(b) The selected services and supports;

(c) Providers of services and supports, including natural supports;

(d) Agreed upon contact frequency with the individual or representative, no less than quarterly;

(e) Risk assessment, factors and measures agreed upon to minimize risk;

(f) The assignment of the fiscal intermediary, if available; and

(g) For individuals, receiving Community Caregiver Supportive Services and Caregiver Education and Training, the Unpaid Caregiver assessment.

(8) The individual or their representative must sign the plan or may give verbal consent. Verbal consent must be documented in the case narrative.

(9) The SCM must monitor and may adjust the person- centered service plan:

(a) At the request of the individual or representative of the individual;

(b) When the circumstances or needs of the individual change;

(c) After any service eligibility determination; or

(d) When other circumstances warrant change, including but not limited to provider availability or inability to meet client-employed provider requirements; or

(e) At least every 12 months.

Or. Admin. Code § 411-016-0030

APD 22-2024, temporary adopt filed 05/20/2024, effective 5/31/2024 through 11/26/2024; APD 64-2024, adopt filed 11/20/2024, effective 11/22/2024

Statutory/Other Authority: ORS 410.070

Statutes/Other Implemented: ORS 410.060, 410.070 & 414.065