medical records for individuals must be kept confidential as described in OAR
(2) The provider
must provide sufficient oversight and guidance to ensure that the health and
medical needs of the individuals are adequately addressed.
(3) Written health and medical supports must
be developed as required for an individual and integrated into a Transition
Plan or ISP. The plan must be based on a functional needs assessment of the
health and medically related support needs and preferences of the individual
and updated annually or as significant changes occur.
The provider must have and implement
written policies and procedures that maintain and protect the physical health
of individuals. The policies and procedures must address the following:
(a) Early detection and prevention of
Treatment and documentation of illness and health care concerns; and
(d) Obtaining, administering, storing, and
disposing of prescription and non-prescription drugs, including
self-administration of medication.
(5) The provider must ensure an individual
has a primary physician or health care provider whom the individual has chosen
from among qualified providers.
(6) Provisions must be made for a secondary
physician, health care provider, or clinic in the event of an emergency.
The provider must ensure that
an individual receives a medical evaluation by a qualified health care provider
no fewer than every two years or as recommended by a health care provider.
Evidence of the medical evaluation must be placed in the record for the
individual and must address:
(b) Changes in
Recommendations, if any, for further medical intervention;
(d) Any remedial and corrective action
required and the date of action;
(e) Restrictions on activities due to medical
medications, treatments, special diets, and therapies.
(8) The provider must monitor the health
status and physical conditions of the individual and take action in a timely
manner in response to identified changes or conditions that may lead to
deterioration or harm.
the entry of an individual, the provider must obtain the most complete medical
profile available for the individual, including:
(a) The results of most recent physical exam;
(b) Results of any dental
(c) A record of
(d) A record of
known communicable diseases and allergies; and
(e) A summary of the medical history of the
individual, including chronic health concerns.
The provider must ensure that all
medications, treatments, and therapies:
Have a written order or a copy of a written order signed by a physician or
qualified health care provider before any medication, prescription, or
non-prescription is administered to, or self-administered by, an individual
unless otherwise indicated by an ISP team in the written health and medical
support section of the ISP or Transition Plan for the individual; and
(b) Be followed per written
(11) PRN (as
needed) orders are not allowed for psychotropic medication.
(12) The drug regimen of an individual on
prescription medication must be reviewed and evaluated by a physician or
physician designee no less often than every 180 days unless otherwise indicated
by an ISP team in the written health and medical support section of the ISP or
Transition Plan for the individual.
All prescribed medications and
treatments must be self-administered unless contraindicated by an ISP team or
physician. For an individual who requires assistance in the administration of
his or her own medication, the following must be met:
(a) The ISP team must recommend that the
individual receive assistance with taking his or her own medication;
(b) There must be a written training program
for the self-administration of medication unless contraindicated by the ISP
(c) There must be a
written record of medications and treatments that documents that the orders of
a physician are being followed.
(14) The ISP for an individual who
independently self-administers medication must include a plan for the periodic
monitoring or review of the self-administration of medication.
(15) The provider must assist an individual
with the use of a prosthetic device as ordered.