Or. Admin. R. 309-019-0140 - Service Plan and Service Notes
(1) In addition to any program specific service delivery requirements, the service plan shall be an individualized plan designed to improve the individual's condition to the point where the individual's continued participation in the program is no longer necessary. The service plan is included in the individual's service record and shall:
(a) Be completed prior to the start of services;
(b) Reflect the full assessment and the level of care to be provided;
(c) Include a safety plan when the assessment indicates risk to the health and safety of the individual or to others and be updated as circumstances change. The safety plan may be a separate document from the service plan;
(d) Include the participation of the individual and family members, as applicable;
(e) Be completed and signed by qualified program staff as follows:
(A) A QMHP in mental health programs;
(B) Supervisory or treatment staff in substance use disorders treatment programs; and
(C) Supervisory or treatment staff in problem gambling treatment programs.
(f) For mental health services, a QMHP who meets the qualifications of a Clinical Supervisor shall recommend the services and supports by signing the service plan within ten business days of the start of services; and
(g) A QMHP who meets the qualifications of a Clinical Supervisor shall approve the service plan at least annually for each individual receiving mental health services for one or more continuous years.
(2) At minimum, each service plan shall include:
(a) Treatment objectives that are:
(A) Individualized to meet the assessed needs of the individual;
(B) Measurable for the purpose of evaluating individual progress, including a baseline evaluation.
(b) The specific services and supports indicated by the assessment that shall be used to meet the treatment objectives;
(c) A projected schedule for service and support delivery, including the expected frequency and duration of each type of planned service or support;
(d) The credentials of the personnel providing each service and support; and
(e) A projected schedule for re-evaluating the service plan.
(3) Providers shall document each service and support in a service note to include:
(a) The specific services rendered;
(b) The specific service plan objectives being addressed by the services provided;
(c) The date, time of service, and the actual amount of time the services were rendered;
(d) The relationship of the services provided to the treatment objective described in the service plan;
(e) The personnel rendering the services, including their name, credentials, and signature;
(f) The setting in which the services were rendered; and
(g) Periodic updates describing the individual's progress.
(4) Decisions to transfer individuals shall be documented including:
(a) The reason for the transfer;
(b) Referrals to follow up services and other behavioral health providers; and
(c) Outreach efforts made, as defined in these rules.
Statutory/Other Authority: ORS 161.390, 413.042, 430.256 & 430.640
Statutes/Other Implemented: ORS 161.390 - 161.400, 428.205 - 428.270, 430.010, 430.205- 430.210, 430.254 - 430.640, 430.850 - 430.955 & 743A.168
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