Or. Admin. Code § 309-035-0190

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

Section 309-035-0190 - Person-Centered Service Plan

This rule becomes effective July 1, 2016, and enforceable as described in OAR 309-035-0115(17).

(1) When developed as described in sections (2) and (3), a person-centered service plan shall be developed through a person-centered service planning process. The person-centered service planning process:

(a) Is driven by the individual;

(b) Includes people chosen by the individual;

(c) Provides necessary information and supports to ensure the individual directs the process to the maximum extent possible and is enabled to make informed choices and decisions, except as limited or required by a court order, an administrative order, the supervisory entity or the individual's legal representative;

(d) Is timely, responsive to changing needs, occurs at times and locations convenient to the individual, and is reviewed at least annually;

(e) Reflects the cultural considerations of the individual;

(f) Uses language, format, and presentation methods appropriate for effective communication according to the needs and abilities of the individual and the individual's legal representative;

(g) Includes strategies for resolving disagreement within the process including clear conflict of interest guidelines for all planning participants such as:

(A) Discussing the concerns of the individual 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) Referring concerns to the Office of the Long-Term Care Ombudsman; or

(E) For Medicaid recipients, following existing, program-specific grievance processes.

(h) Offers choices to the individual regarding the services and supports the individual receives and from whom and records the alternative HCB settings considered by the individual, except as limited by a court, OHA, CMHP, or PSRB order;

(i) Provides a method for the individual, or the individual's legal representative to request updates to the person-centered service plan;

(j) Is 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;

(k) Identifies the strengths and preferences, service and support needs, goals, and desired outcomes of the individual;

(l) Includes any services that are self-directed, if applicable;

(m) Includes but is not limited to individually identified goals and preferences related to relationships, greater community participation, employment, income and savings, healthcare and wellness, and education;

(n) Includes risk factors and plans to minimize any identified risk factors; and

(o) Results in a person-centered service plan documented by the person-centered services plan coordinator, signed by the individual or the individual's legal representative, the individual's case manager, and all persons responsible for the implementation of the person-centered service plan. The person-centered service plan is distributed to the individual, the individual's legal representative, the supervisory entity if applicable, and other people involved in the person-centered service plan.

(2) Person-Centered Service Plans:

(a) To avoid conflict of interest, the person-centered service plan may not be developed by the provider for individuals receiving Medicaid. The Division may grant an exception when it has determined that the provider is the only willing and qualified entity to provide case management and develop the person-centered service plan;

(b) When the provider is responsible for developing the person-centered service plan, the provider shall ensure that the plan includes the following:

(A) HCBS and setting options based on the individual's needs and preferences, and for residential settings, the individual's available resources 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 greater 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 supports provided voluntarily;

(I) Risk factors and measures in place to minimize risk;

(J) Individualized backup plans and strategies, when needed;

(K) People who are important in supporting the individual;

(L) The person responsible for monitoring the person-centered service plan;

(M) Language, format, and presentation methods appropriate for effective communication according to the needs and abilities of the individual receiving services and the individual's legal representative;

(N) The written informed consent of the individual or the individual's legal representative, unless the individual is placed with the provider by a court, OHA, CMHP, or PSRB order under ORS chapters 161 or 426;

(O) Signatures of the individual or the individual's legal representative, or documentation of the individual's verbal consent of services, participants in the person-centered service planning process, and all persons and entities responsible for the implementation of the person-centered service plan unless the individual is placed with the provider by a court, OHA, CMHP, or PSRB order under ORS chapters 161 or 426;

(P) Self-directed supports; and

(Q) Provisions to prevent unnecessary or inappropriate services and supports.

(c) When the provider is not responsible for developing the person-centered service plan but provides or shall provide services to the individual, the provider shall provide relevant information and provide necessary support for the person-centered service plan coordinator or other individuals developing the plan to fulfill the characteristics described in subsection (b) of this section;

(d) The individual or the individual's legal representative 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;

(e) The person-centered service plan shall be distributed to the individual and the individual's legal representative and supervisory entity, as applicable, and others involved in the person-centered service plan;

(f) The person-centered service plan shall justify and document any individually-based limitation to be applied as outlined in OAR 309-035-0195 when the qualities under 309-035-0195(1) create a threat to the health and safety of the individual or others; and

(g) The person-centered service plan shall be reviewed and revised:

(A) At the request of the individual or the individual's legal representative;

(B) When the circumstances or needs of the individual change; and

(C) Upon reassessment of functional needs as required every 12 months.

(3) Because it may not be possible to assemble complete records and develop a comprehensive person-centered service plan during the crisis-respite individual's short stay, the provider is not required to develop a person-centered service plan. At a minimum, the provider must develop an assessment and residential service plan as deemed appropriate to identify service needs, desired outcomes, and service strategies to resolve the crisis or address the individual's other needs that caused the need for crisis-respite services. In addition, the provider shall provide relevant information and provide necessary support for the person-centered service plan coordinator as described in this rule.

Or. Admin. Code § 309-035-0190

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. 6-1-9; MHD 4-2005, f. & cert. ef. 4-1-05 8; 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 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