Or. Admin. Code § 411-360-0200

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

Section 411-360-0200 - Adjustment, Suspension, or Termination of Payment

(1) The Department may adjust, suspend, or terminate payment to a provider when any of the following conditions occur:

(a) The license for the AFH-DD is revoked, suspended, or terminated.

(b) Upon finding that the provider is failing to deliver any care or service as agreed to in an ISP or Service Agreement.

(c) When funding, laws, regulations, or the priorities of the Department change such that funding is no longer available, redirected to other purposes, or reduced.

(d) The care and service needs of an individual change.

(e) An individual is determined to be ineligible for services.

(f) An individual moves, with or without notice, from the AFH-DD. The provider is paid only through the last night the individual slept in the AFH-DD.

(g) An individual is away from the licensed AFH-DD, accompanied by the provider or staff paid by the provider, for 30 consecutive days or 45 days in an ISP year.

(A) The provider is not paid for the 31st and following consecutive days an individual is not at the AFH-DD.

(B) The provider is not paid for the 46th and following non-consecutive days an individual is not at the AFH-DD.

(C) Days not paid do not count in the 45-day total.

(2) A provider may only claim for a day of service when:

(a) An individual sleeps in the AFH-DD overnight; or

(b) An individual does not sleep in the AFH-DD overnight, but intends to return to the AFH-DD, and the provider was responsible for and provided an accumulated period of eight hours for the primary care, support, safety, and well-being of the individual, including any of the following:

(A) Providing intermittent physical support or care.

(B) Providing stand-by support with the ability to respond in person within the response times as outlined in the individual's ISP.

(C) Being responsible to communicate reciprocally within the response times agreed upon by the individual's ISP team and documented in the individual's ISP, based on the individual's identified support needs.

(3) A day of service does not apply when an individual:

(a) Has been admitted to an acute care hospital unless the individual's ISP authorizes attendant care for the individual in an acute care hospital and the day of service criteria in section (2)(b) of this rule is met. An ISP may only authorize attendant care for an individual who has been admitted to an acute care hospital when the support is not a duplication of service that the hospital provides and the individual has one of the following:

(A) Challenging behavior that interferes with getting medical care. The challenging behavior must require specific training or experience to support and must be able to be mitigated by a developmental disability service provider to an extent that medical care is improved.

(B) An inability to independently communicate with hospital staff that interferes with getting medical care. This must not be solely due to limited or emerging English proficiency.

(C) Support with one or more activities of daily living that may only be adequately met by someone familiar with the individual.

(b) Has been admitted to a nursing facility;

(c) Has been admitted to a mental health facility;

(d) Is held in detention or jail; or

(e) Is outside the United States.

(4) The Department is under no obligation to maintain the AFH-DD at its licensed capacity or to provide payments to potential providers.

Or. Admin. Code § 411-360-0200

SPD 3-2005, f. 1-10-05, cert. ef 2-1-05; SPD 13-2010, f. 6-30-10, cert. ef. 7-1-10; SPD 34-2013, f. & cert. ef. 9-27-13; APD 21-2016, f. & cert. ef. 6/29/2016; APD 32-2018, temporary amend filed 08/23/2018, effective 08/23/2018 through 02/15/2019; APD 11-2019, amend filed 02/14/2019, effective 2/15/2019; APD 39-2019, amend filed 10/29/2019, effective 11/1/2019; APD 38-2020, temporary amend filed 09/08/2020, effective 9/8/2020 through 3/6/2021; APD 8-2021, amend filed 02/11/2021, effective 3/1/2021

Statutory/Other Authority: ORS 409.050, 427.104, 443.001, 443.004, 443.725, 443.730, 443.735, 443.738, 443.742, 443.760, 443.765, 443.767, 443.775 & 443.790

Statutes/Other Implemented: ORS 409.010, 427.104, 443.001-443.004, 443.705-443.825, 443.875 & 443.991