Eligibility for In-Home Exceptions to
Maximum Hours of Service.
Department determines the individual's assessed service needs will not be
adequately met within the maximum number of hours for a specific ADL or
specific IADL as set forth in OAR 411-030-0070
, and the Department determines
the individual meets all of the requirements in these rules and in OAR
, then the individual shall receive an exception to the maximum
hours per ADL and IADL.
Department determines the individual's assessed service needs will not be
adequately met within the maximum number of hours to address cognitive
impairments, and the individual meets the requirements in this rule, the
individual shall receive an exception to the maximum hours in cognition and
other affected ADLs as described in OAR 411-015-0006
The Department may deny an exception if
the request is:
(A) Based solely on a desire
for services outside of assessed service needs.
(B) Not medically appropriate.
(F) Based solely on choice of the
Responsibility for Applying for an
(a) An individual, or their
representative, may make an initial exception request either orally or in
writing if the individual believes their service plan is not meeting, or will
not meet, their service needs.
If the individual, or their representative, requests an exception or expresses
concerns that their service needs are not being met, the case manager must help
the individual apply for an exception, including completing required forms and
gathering Department-required documentation.
(c) If the individual's case manager
assesses, or is notified by others with knowledge of the individual's service
needs, that the individual's needs exceed the maximum hours, the case manager
must work with the individual to determine the appropriate number of hours and
submit an exception application;
(d) If the number of hours the case manager
approves or recommends is fewer than the number requested by the individual or
their representative, the individual's requested exception shall be reviewed as
presented by the individual, and a decision will be made on that request per
the process defined in section (3) of this rule.
(e) In-home care providers may not submit
requests for exceptions. They may notify the case manager of concerns and the
case manager shall discuss the concerns with the individual or their
representative and ask if the individual wants to apply for an
An individual may
apply for an exception, described in section (2) of this rule, by:
(A) Completing an exception application form,
available from the case manager, and providing any information that supports
the request for additional hours; or
(B) Requesting that their case manager
complete the SDS 514i on their behalf; or
(C) Expressing to their case manager that the
authorized service hours are not sufficient to meet their needs.
Prior to processing an
application for an exception, the case manager must discuss alternate ways,
resources, and service options, if any, to meet the individual's needs
consistent with the individual's right to independence, choice, and
responsibility to assist in developing the least costly plan as described in
discussing alternative ways to meet the individual's needs described in
subsection (b) of this rule, if the individual continues to desire an
exception, then the exception application shall be processed.
The Exception Application Form,
regardless of who completes the form, must be signed by the individual or their
representative in order for the application to be reviewed unless criteria
described in OAR 411-030-0071
(5)(f) is met.
The CA/PS assessment must have been
completed within three months before the exception request, and it must
represent the individual's current condition and functioning. If the
individual's application for an exception is not within the timeframe noted in
this subsection, a new assessment must be completed to document current needs.
DHS Central Office may waive this requirement when criteria described in OAR
(5)(f) is met.
the wait for a new assessment threatens the health, safety, or welfare of the
individual, as determined by the Department, the Department shall waive the
three-month requirement in subsection (e) of this rule.
The Exception Application Form must
(A) The frequency of the
task that is needed, based on the number of times per day or week that
assistance is needed.
duration of the task, based on the average amount of time a task takes to
complete each time the task is performed or attempted and an explanation of
why, if applicable, the tasks require more time than the maximum allowed hours
described in OAR 411-030-0070
Service needs that occur on a regular but unpredictable schedule.
(D) The number of providers needed for each
task and an explanation of why, if applicable, the tasks require more than one
(E) The reasons why the
current hours do not meet the need, and an explanation of why any less costly
options discussed will not meet the need.
(F) Any other information that explains the
need for the exception.
(h) The Exception Application Form shall
include an attestation that all the information is accurate and
(i) The individual, or
their representative, is responsible for ensuring that sufficient documentation
is provided. A case manager shall assist the individual in collecting the
requested documentation. If the requested documentation is not provided to the
Department, DHS may issue an exception denial.
All Exception applications must include
the Exception Application Form, SDS 514i. The form must be complete, signed by
the individual, or their representative unless criteria described in OAR
(5)(f) is met, and accurate.
To support the application, the
Department may require the individual, or their representative, to provide
further documentation during the Exception decision making process. This
documentation, in addition to the Exception Application Form, may include, but
is not limited to:
(A) An Exception
Calculator, which will be provided by the Department, upon request;
(B) A caregiver time/task log detailing the
performance of the ADL and IADL tasks as defined in OAR chapter 411, division
015 for three (3) consecutive 24-hour periods. The log shall include the name
of the ADL/IADL task, the action performed and the duration that it took the
provider to perform the task. The log must be complete and be acceptable to the
Department to qualify; and
relevant medical and mental health records to support the specific exception
Exception Decision Making Authority.
office management shall make final decisions on the exception application if
the exception application does not exceed the total maximum hours, defined in
(A) The ADL limit is 73
hours per service period; or
The IADL limit is 35 hours per service period.
(b) DHS Central Office shall make final
decisions on exceptions exceeding the maximum hour limits defined in (5)(a)(A)
and (B) of this section.
(c) If the
exception application meets the criteria defined in (5)(a) of this section, the
local office manager must review the exception application, related documents,
and the CA/PS assessment comments for accuracy, completeness, and justification
of the request and either approve, partially approve, or deny the request in
writing no more than 14 calendar days from the date of the exception request.
The individual, or their representative, may appeal any unfavorable
(d) If the exception
application exceeds the authority defined in (5)(a) of this section, the local
office management must submit the exception application to DHS Central Office
within three business days of receipt of the application.
(e) Unless (5)(f) or 5(g) of this rule
applies, DHS Central Office has no more than 30 calendar days from the date the
exception application and any supporting documentation has been received to
complete its review and make a determination.
(f) In emergency situations that threaten the
health, welfare or safety of the individual, DHS Central Office will make a
decision within two business days of receipt of the application. DHS Central
Office may elect to make a decision without all of the required documentation;
however, any approvals will only be made for no longer than the end of next
(g) If DHS Central
Office determines that it needs additional information, DHS Central Office will
notify the case manager or local office manager in writing within three
business days of receipt of the application. The case manager, or local office
manager must notify the individual, or their representative, within two
business days that additional information is needed.
The individual, or their representative,
or case manager must provide the requested information to DHS Central Office
within 14 calendar days of the Department's request. The request for additional
information will specify the due date and explain how to submit the required
(A) DHS Central Office has 14
calendar days from the date of receipt of the additional information to make a
(B) If the
individual fails to timely provide the requested information, DHS Central
Office will complete the review based on the documentation in its possession.
DHS Central Office has 14 calendar days from the date of the individual's
deadline for additional information to complete the review.
(C) If the individual, or their
representative, responds to the request for additional information after the
exception application has been denied due to a failure to provide additional
information, the individual's response will be considered a new request for an
exception, with a new effective date.
(D) If the individual submits the required
documentation after the 14-day timeframe, the individual may request an
extension for good cause and request that the DHS Central Office issue a
individual may request a good cause extension prior to the expiration of 14-day
timeframe by requesting it via their case manager.
(F) Good cause exists when an action, delay,
or failure to act arises from an excusable mistake or from factors beyond an
individual's reasonable control.
For each Exception Application:
(A) If the Department determines that the
documentation supports the requested additional hours over the maximum for the
specific ADLs or IADLs, the exception will be granted.
(B) If the Department determines that the
documentation supports additional hours but not as many hours as requested or
for the timeframe requested, the exception will be granted for only those
additional hours supported by the documentation.
(C) If DHS Central Office determines that the
documentation does not support any additional hours over the maximum, the
exception application will be denied.
(D) If DHS Central Office denies any portion
of an Exception Application, as described in (h)(B) and (h)(C) of this
subsection, the individual, or their representative, may request a
Exception Application Reviews and Decision Making.
All exception applications must be for
hours of services and supports provided by APD. This means that the need must
meet the definitions in each ADL or IADL and match the tasks and assistance
types described in OAR 411-015-0006
and OAR 411-015-0007
(b) Exception approvals are effective no
earlier than the date the Exception Application is requested by the individual
and received by the case manager and the home care provider has been authorized
to work. If these do not occur on the same date, the later date is the
To justify the
need for additional hours, the Department shall review any documentation
(A) Assessment Comments
to ensure that the assessed need meets OAR definitions;
(B) Treatments that may drive care
(C) Diagnosis that may drive
documentation that the way services are being provided is appropriate to the
needs of the individual;
Medical documentation, including those from the Long-Term Care Community Nurse
or Behavior Support Specialists, that shows that the current level of services
is not meeting the individual's needs;
(F) The reasons for increased duration and
information explaining or related to the need for additional hours.
To determine the appropriate
number of exception hours, the Department shall review:
(A) Frequency of the care needs that require
additional time in the relevant ADLs and IADLs.
(B) Duration of the care needs that require
additional time in the relevant ADLs and IADLs.
(C) The reasons for the increased duration
(D) The number of
individuals necessary to perform an assessed task.
(E) The complexity of the individual's care
(F) Whether denying the
exception would put the individual at risk of placement out of home if the
individual prefers to live in their own home.
(G) Whether denying the exception would
result in substantial unmet needs of the individual that may jeopardize the
individual's health and safety.
The Department may reduce the requested
hours if the individual's needs and choices are already met by:
The availability of natural supports as
defined in OAR 411-030-0020
(B) Durable Medical Equipment or assistive
devices or technology;
Emergency Response Systems;
Home and Environmental Modifications;
(E) Home Delivered Meals;
(F) Other supports that replace the need for
human assistance as determined on a case-by-case basis consistent with
The Department may reduce the requested hours if:
(A) Requested hours do not meet ADL and IADL
definitions in 411-015-0006 and 411-015-0007; or
The way tasks are being provided are not
medically appropriate as determined by:
Information from the individual's medical professionals;
(ii) APD's Long Term Care Community Nurses or
other nurses familiar with the care of the individual; or
(iii) Documentation provided from recent
hospitalizations or nursing facility stays.
(a) The Department shall notify the
individual about the outcome of the exception request in the notice of hours
authorization decision, or an amended notice, if appropriate.
Notification shall include:
(A) The name of the person who applied for
exceptional service hours.
date the request was approved or denied.
(C) For each ADL and IADL, the number of
hours requested, compared to maximum hours and total approved hours.
(D) A reference to the attached 514 Exception
(E) A summary of
the reasons why the exceptional hours requested were approved or
(F) The duration of the
(G) Information on
hearing rights and how to request a hearing.
(8) Duration. An exception is valid for the
period defined in the notice, not to exceed the individual's service plan end
(a) If an individual has an existing
exception, the exception application must be resubmitted after the reassessment
and will be reviewed prior to the exception end date. If the individual
requests the same or fewer exception hours, a decision to renew the exception
may be made without the consumer's signature as defined in section (3)(d) of
this rule The case manager may supply the required documentation as outlined in
section (4) of this rule.
Exceptions will be reviewed at reassessments, change of situations, or change