Or. Admin. R. 411-030-0050 - Case Management
(1)
ASSESSMENT. The assessment process identifies an individual's ability to
perform ADLs, IADLs, and determines an individual's ability to address health
and safety concerns.
(a) The case manager
must conduct an assessment in accordance with the standards of practices
established by the Department in OAR 411-015-0008.
(b) The assessment must be conducted by a
case manager or other qualified Department or AAA representative with a
standardized assessment tool approved by the Department in the home of the
eligible individual, no less than annually.
(2) PERSON-CENTERED SERVICE PLAN.
(a) An individual receiving services, or the
individual's representative, and the individual's case manager, must consider
in-home service options as well as assistive devices, architectural
modifications, and other community-based resources to meet the service needs
identified in the assessment process.
(A) The
individual or the individual's representative is responsible for choosing and
assisting in developing less costly service alternatives, including the
Consumer-Employed Provider Program and contracted in-home care agency
services.
(B) The case manager is
responsible for --
(i) Determining
eligibility for specific services;
(ii) Presenting service options, resources,
and alternatives to the individual to assist the individual in making informed
choices and decisions;
(iii)
Identifying risks;
(iv) Assisting
the individual with developing backup plans;
(v) Identifying the individual's goals and
preferences;
(vi) Assessing the
cost effectiveness of the individual's service plan; and
(vii) Developing and coordinating a
person-centered service plan.
(C) The case manager must monitor the service
plan and make adjustments as needed.
(b) The Department takes necessary safeguards
to protect an individual's health, safety, and welfare in implementing an
individual's service plan in accordance with
42 CFR 441.302
and 42 CFR 441.570. When an individual with the ability to make an informed
decision selects a service choice that jeopardizes health and safety, the
Department or AAA staff shall offer or recommend options to the individual in
order to minimize those risks. For the purpose of this rule, an "informed
decision" means the individual understands the benefits, risks, and
consequences of the service choice selected. Options that minimize risks may
include offering or recommending:
(A) Natural
supports to help with safety or health emergencies;
(B) An emergency response system;
(C) A back-up plan for assistance with
service needs;
(D) Resources for
emergency disaster planning;
(E) A
referral for long term care community nursing services;
(F) Resources for provider and consumer
training;
(G) Assistive devices;
or
(H) Architectural
modifications.
(c) The
Department or AAA may not authorize a service provider, service setting, or a
combination of services selected by an eligible individual or the individual's
representative when --
(A) The service setting
has dangerous conditions that jeopardize the health or safety of the individual
and necessary safeguards cannot be taken to improve the setting;
(B) Services cannot be provided safely or
adequately by the service provider based on --
(i) The extent of the individual's service
needs; or
(ii) The choices or
preferences of the eligible individual or the individual's
representative;
(C)
Dangerous conditions in the service setting jeopardize the health or safety of
the service provider that is authorized and paid for by the Department, and
necessary safeguards cannot be taken to minimize the dangers; or
(D) The individual does not have the ability
to make an informed decision, does not have a designated representative to make
decisions on his or her behalf, and the Department or AAA cannot take necessary
safeguards to protect the safety, health, and welfare of the
individual.
(d) The case
manager must present the individual or the individual's representative with
information on service alternatives and provide assistance to assess other
choices when the service provider or service setting selected by the individual
or the individual's representative is not authorized.
(3) PAYMENT.
(a) The service plan payment is considered
full payment for Medicaid home and community-based services rendered. Under no
circumstances is the service provider to demand or receive additional payment
for these services from the consumer or any other source.
(b) Additional payment to homecare workers or
ICP employee providers for the same services covered by Medicaid in-home
services or the Spousal Pay Program is prohibited.
(c) For ICP, the service plan must include
the service budget as described in OAR 411-030-0100.
(d) For service plans in which a consumer
lives in the relative homecare workers home, subsection (a) of this section
does not apply to rent and living expenses.
Notes
Statutory/Other Authority: ORS 409.050, 410.070 & 410.090
Statutes/Other Implemented: ORS 410.010, 410.020 & 410.070
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