Or. Admin. Code § 309-035-0185

Current through Register Vol. 63, No. 12, December 1, 2024

Section 309-035-0185 - Individual Assessment and Residential Service Plan

(1) The program shall complete an assessment for each individual within 14 days after admission to the program unless admitted for crisis-respite services:

(a) The assessment shall be based upon an interview with the individual to identify strengths, preferences, and service needs; observation of the individual's capabilities within the residential setting; a review of information in the individual service record; and contact with representatives of other involved agencies, the supervisory entity, the individual's legal representative, family members, and others, as appropriate. All contacts with others shall be made with proper authorization for the release of information or as otherwise permitted by law;

(b) Assessment findings shall be summarized in writing and included in the individual service record. Assessment findings shall include but not be limited to diagnostic and demographic data; identification of the individual's medical, physical, emotional, behavioral, and social strengths, preferences, and needs related to independent living and community functioning; and recommendations for residential service plan goals; and

(c) The provider shall provide assessment findings to the person-centered service plan coordinator to assist in the development of the person-centered service plan.

(2) The person-centered service plan coordinator under contract with the Division and assigned to the individual or program site shall schedule and conduct an assessment of the individual for the purpose of developing a person-centered service plan. The provider shall support the person-centered service plan coordinator's efforts to develop the plan and provide information as necessary.

(3) The provider shall develop and implement an individualized residential service plan for the purpose of implementing and documenting the provision of services and supports as well as any individually-based limitations contained within the person-centered service plan. Provider must also consider the limitations imposed by a court, OHA, CMHP, or PSRB order, or the individual's legal representative. Identification of the goals to be accomplished through the services provided shall be prepared for each individual within 30 days after admission, unless admitted to the facility for crisis-respite services:

(a) If the person-centered service plan is unavailable for use in developing the residential service plan, providers shall still develop an initial residential service plan based on the information available. Upon the person-centered service plan becoming available, the providers shall amend the residential service plan as necessary to comply with this rule;

(b) The residential service plan shall be based upon the findings of the individual assessment, be developed with participation of the individual, input from the individual's legal representative and supervisory entity, as applicable, and be developed through collaboration with the individual's primary mental health treatment provider. With consent of the individual or individual's legal representative, family members, representatives from involved agencies, and others with an interest in the individual's circumstances shall be invited to participate. All contacts with others shall be made with proper, prior authorization from the individual or as otherwise permitted by law;

(c) The residential service plan shall include the following:

(A) The necessary steps and actions of the provider for the implementation and provision of services consistent and as required by the person-centered service plan; and

(B) Identify the individual's service needs, desired outcomes, and service strategies to address the following: physical and medical needs, medication regimen, self-care, social-emotional adjustment, behavioral concerns, independent living capability, and community navigation, all areas identified in the person-centered service plan and any other areas.

(d) The residential service plan shall be signed by the individual or the individual's legal representative, the program administrator or other designated program staff person, and others, as appropriate, to indicate mutual agreement with the course of services outlined in the plan and a copy of the signed plan provided to the supervisory entity as applicable; and

(e) The provider shall attach the residential service plan to the person-centered service plan.

(4) For an individual admitted to a program for 30 days or less for the purpose of receiving crisis-respite services, an assessment and residential service plan shall be developed within 48 hours of admission that identifies service needs, desired outcomes, and the service strategies to be implemented to resolve the crisis or address other needs of the individual that resulted in the short-term service arrangement.

(5) The provider shall maintain progress notes within each individual's service record and document significant information relating to all aspects of the individual's functioning and progress toward desired outcomes identified in the residential service plan. The provider shall enter a progress note in the individual's record at least once each month.

(6) The provider shall review and update the assessment and residential service plan at least annually. On an ongoing basis, the provider shall update the residential service plan as necessary based upon changing circumstances or upon the individual's request for reconsideration.

Or. Admin. Code § 309-035-0185

MHD 9-1984(Temp), f. & ef. 12-10-84; MHD 9-1985, f. & ef. 6-7-85; MHD 4-1998, f. 5-21-98, cert. ef. 6-1-98; MHD 4-2005, f. & cert. ef. 4-1-05; MHS 4-2008, f. & cert. ef. 6-12-08; MHS 13-2016(Temp), f. 9-6-16, cert. ef. 9-7-16 thru 3-3-17; MHS 2-2017(Temp), f. 3-3-17, cert. ef. 3-4-17 thru 8-30-17; MHS 5-2017, f. & cert. ef. 6-8-17; BHS 5-2018, amend filed 03/21/2018, effective 03/30/2018; BHS 6-2020, temporary amend filed 04/21/2020, effective 04/21/2020 through 10/09/2020; BHS 41-2023, temporary amend filed 10/12/2023, effective 10/15/2023 through 4/11/2024; BHS 6-2024, amend filed 04/11/2024, effective 4/11/2024

Statutory/Other Authority: ORS 413.042 & 443.450

Statutes/Other Implemented: ORS 413.032, 443.400 - 443.465 & 443.991