Or. Admin. R. 411-415-0050 - Standards for Case Management Services

(1) The CME must apply the principles of self-determination and person-centered practices to provision of case management services.
(2) The CME must ensure that a case manager is available to provide case management services and other supports to the individual.
(a) Case management services include the activities related to:
(A) Assessment and periodic reassessment of an eligible individual to determine service needs, including activities that focus on needs identification, to determine the need for any medical, educational, social, or other services including those assessments described in OAR 411-415-0060.
(B) Development and periodic revision of an ISP or Annual Plan based on the information collected through an assessment or reassessment that specifies the desired outcomes, goals, and actions to address the medical, employment, social, educational, and other services needed by the eligible individual as described in OAR 411-415-0070.
(C) Support to access available services, including referral and related activities to help an individual obtain needed services as described in OAR 411-415-0080.
(D) Monitoring and follow-up activities, including activities and contacts that are necessary to ensure that the ISP or Annual Plan is effectively implemented and adequately addresses the needs of the eligible individual as described in OAR 411-415-0090.
(b) Other supports provided by a CME may include, but are not limited to:
(A) Authorizing services in the Department's electronic payment and reporting system;
(B) Arranging employer-related supports that may include, but are not limited to:
(i) Education about employer responsibilities;
(ii) Orientation to basic wage and hour issues; and
(iii) Use of common employer-related tools, such as service agreements.
(C) Assisting the Department with establishing provider credentials; and
(D) Assistance with understanding and accessing financial, medical, and other benefits.
(3) Prior to an initial ISP, at least annually, and at the request of an individual, or as applicable the legal representative of the individual, a CME must provide a Notification of Rights (form 0948) and an explanation of the individual rights described in OAR 411-318-0010 to the individual and if applicable the legal representative of the individual.
(4) A CME may not authorize services that are delivered by an affiliated entity.
(5) Developmental disabilities services must be authorized in accordance with OAR 411-415-0070. A case manager must authorize any developmental disabilities services and delivery of those services by a qualified provider chosen by the individual, or as applicable the legal or designated representative of the individual, for which the individual is eligible as described in the relevant program rules.
(a) NOTIFICATION OF PLANNED ACTION. In the event that a developmental disabilities service is denied, reduced, suspended, or terminated, or a chosen qualified provider is not authorized to deliver a chosen service to an individual, a written advance Notification of Planned Action (form 0947) must be provided as described in OAR 411-318-0020.
(b) HEARINGS.
(A) Hearings must be addressed in accordance with ORS chapter 183 and OAR 411-318-0025.
(B) An individual may request a hearing as provided in ORS chapter 183 and OAR 411-318-0025.
(c) Upon entry into case management, upon request, and annually thereafter, a notice of hearing rights and the policy and procedures for hearings as described in OAR chapter 411, division 318 must be explained and provided to an individual, and as applicable the legal or designated representative of the individual.
(6) Services authorized in an ISP must be entered into the Department's electronic payment and reporting system within 30 calendar days of the start of the services being delivered by any individual provider.
(7) If an individual loses eligibility for a Medicaid Title XIX (OHP) Benefit Package, a case manager must assist the individual to identify why the eligibility was lost. Whenever possible, the case manager must assist the individual in reestablishing the eligibility. The case manager must document the assistance given in the service record for the individual.
(8) CHOICE ADVISING. Through choice advising, the CME must assure that case management and other developmental disabilities service options, provider options, and setting options, including non-disability specific settings and an option for a private or shared unit in a residential program, are described to all individuals receiving case management services from the CME, or to the legal representative of the individual.
(a) An individual newly determined eligible for developmental disabilities services must receive choice advising, including the choice of institutional or home and community-based services, prior to the authorization of the initial ISP.
(b) Choice advising occurs as part of the person-centered planning process and must be conducted prior to an initial ISP and prior to a review of the ISP when required according to OAR 411-415-0070.
(c) Choice advising, including the choice of institutional or home and community-based services, must occur at least six months before the18th birthday of a child.
(d) Prior to entry into a 1915(c) Home and Community-Based Services waiver, an individual, or as applicable their legal representative, must be informed of their choice to receive home and community-based or institutional services and verify their choice using the Freedom of Choice form (DHS 2808).
(e) If a CME is affiliated with an agency provider of developmental disabilities services in addition to case management services, the CME must disclose the relationship and inform the individual, or as applicable the legal or designated representative of the individual, that the CME cannot authorize the affiliated provider. The CME must discuss other case management provider options when the individual, or as applicable the legal or designated representative of the individual, expresses interest in receiving services from the affiliated provider.
(9) A case manager must coordinate services with the child welfare caseworker assigned to a child to ensure the provision of required supports from the Department, CDDP, and child welfare.
(10) The case manager must participate in transition planning by attending IEP meetings or other transition planning meetings for students 16 years of age or older to discuss the transition of the student to adult living and work situations, unless the attendance of the case manager is refused by the parent or guardian of the student or the student if the student is 18 years or older. The case manager must participate in transition planning as young as age 14, if transition planning deemed appropriate by the student's IEP team, unless the attendance of the case manager is refused by the parent or guardian of the student or the student if the student is 18 years or older.
(11) When appropriate, a case manager must coordinate with vocational rehabilitation regarding employment services. When appropriate, a case manager must facilitate referrals to vocational rehabilitation.
(12) Until a CME is certified as a CAM user by the Department, a services coordinator at a CDDP must ensure that all serious events related to an individual are reported to the Department using the SERT system. The CDDP must ensure that there is monitoring and follow-up on both individual events and system trends.
(13) HEALTH CARE ADVOCATES.
(a) For an individual determined to be incapable as defined in OAR 411-390-0120, and who does not have a guardian with medical decision-making authority or a health care representative, a case manager must have a documented discussion with the individual's ISP team regarding the appointment of a health care advocate as described in OAR chapter 411, division 390 when a significant medical procedure or treatment is being considered. The case manager must assure the individual is informed of all of the following:
(A) The ISP team's decision to seek a health care advocate, prior to the appointment of the health care advocate.
(B) The name of the appointed health care advocate.
(C) The proposed decision about any significant medical procedure or treatment.
(b) A case manager must give an individual's health care advocate appointed according to OAR chapter 411, division 390 a copy of OAR chapter 411, division 390 and document this in the individual's service record.
(c) A case management entity must provide health care advocate training materials to a potential health care advocate prior to appointment and any health care decision-making.
(14) A case manager who becomes aware that a health care representative is considering withholding or withdrawing life-sustaining procedures for an individual, must provide the health care representative with any information in the case manager's possession that is related to the individual's values, beliefs, and preferences with respect to the withholding or withdrawing of life-sustaining procedures.
(15) The CME must implement procedures to address individual, designated representative, or family complaints regarding service delivery that have not been resolved using the complaint procedures of a provider agency. The complaint procedures must be consistent with the requirements in OAR 411-318-0015.
(16) A case manager must coordinate with other state, public, and private agencies regarding services to individuals.
(17) When appropriate, a case manager must facilitate referrals to nursing facilities as described in OAR 411-070-0043.
(18) A case manager must coordinate and monitor the services provided to an eligible individual living in a nursing facility.
(19) A Department case manager must make referrals for entry and participate in all entry meetings for children in residential programs, CIIS, and the Stabilization and Crisis Unit.
(20) The CME must provide case management services to individuals who are eligible for and desire them. If an individual receiving case management services from a CDDP is receiving other developmental disabilities services in more than one county, the county of origin must be responsible for case management services unless otherwise negotiated and documented in writing with the mutually agreed upon conditions.
(21) CHANGE OF CASE MANAGER.
(a) If the CME changes the assignment of a case manager for any reason, the CME must notify the individual, the legal and designated representative of the individual (as applicable), and all providers within 10 business days of the change. The notification must be in writing and include the name, telephone number, email address, and mailing address of the new case manager.
(b) The individual receiving services, or as applicable the legal or designated representative of the individual, may request a new case manager within the same CME or request a change of case management entity.
(22) FAMILY RECONNECTION. The CME and a case manager must provide assistance to the Department when a family member is attempting to reconnect with an individual who was previously discharged from Fairview Training Center or Eastern Oregon Training Center or an individual who is currently receiving developmental disabilities services.
(a) If a family member contacts the CME for assistance in locating an individual, the CME must refer the family member to the Department. A family member may contact the Department directly.
(b) The Department shall send the family member a Department form requesting further information to be used in providing notification to the individual. The form shall include the following information:
(A) Name of requestor;
(B) Address of requestor and other contact information;
(C) Relationship to individual;
(D) Reason for wanting to reconnect; and
(E) Last time the family had contact.
(c) The Department shall determine:
(A) If the individual was previously a resident of Fairview Training Center or Eastern Oregon Training Center;
(B) If the individual is deceased or living;
(C) Whether the individual is currently or previously enrolled in Department services; and
(D) The county in which services are being provided, if applicable.
(d) With permission from the individual, the Department shall notify the family member if the individual is enrolled or no longer enrolled in Department services within 10 business days from the receipt of the request.
(e) If the individual is enrolled in Department services, the Department shall send the completed family information form to the individual and the case manager.
(f) If the individual is deceased, the Department shall follow the process for identifying the personal representative of the individual as provided for in ORS 192.573.
(A) If the personal representative and the requesting family member are the same, the Department shall inform the personal representative that the individual is deceased.
(B) If the personal representative is different from the requesting family member, the Department shall contact the personal representative for permission before sharing information about the individual with the requesting family member. The Department must make a good faith effort to find the personal representative and obtain a decision concerning the sharing of information as soon as practicable.
(g) When an individual is located, the CME must facilitate a meeting with the individual to discuss and determine if the individual wishes to have contact with the family member.
(A) The case manager must assist the individual in evaluating the information to make a decision regarding initiating contact, including providing the information from the form and any relevant history with the family member that may support contact or present a risk to the individual.
(B) If the individual does not have a legal representative or is unable to express his or her wishes, the ISP team of the individual must be convened to review factors and choose the best response for the individual after evaluating the situation.
(h) If the individual wishes to have contact, the individual or ISP team designee may directly contact the family member to make arrangements for the contact.
(i) If the individual does not wish to have contact, the CME must notify the Department. The Department shall inform the family member in writing that no contact is requested.
(j) The notification to the family member regarding the decision of the individual must be within 60 business days from the receipt of the information form from the family member.
(k) The decision by the individual is not appealable.

Notes

Or. Admin. R. 411-415-0050
APD 28-2016, f. & cert. ef. 6/29/2016; APD 23-2018, temporary amend filed 07/02/2018, effective 07/02/2018 through 12/27/2018; APD 46-2018, amend filed 12/28/2018, effective 12/28/2018; APD 45-2019, amend filed 10/29/2019, effective 11/1/2019; APD 5-2020, amend filed 02/25/2020, effective 3/1/2020

Statutory/Other Authority: ORS 127.765, 409.050, 427.104, 427.105, 427.115, 427.154, 430.662 & 430.731

Statutes/Other Implemented: ORS 127.765, 427.007, 427.104, 427.105, 427.115, 427.121, 427.154, 427.160, 430.212, 430.215, 430.610, 430.620, 430.662, 430.664 & 430.731-430.768

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