Or. Admin. R. 411-415-0090 - Case Management Contact and Monitoring of Services

(1) CASE MANAGEMENT CONTACT.
(a) Every individual who has an ISP must have a case management contact no less than once every three months.
(A) The purpose of a case management contact must be to assure one of the following:
(i) Known health and safety risks are adequately addressed.
(ii) The support needs of an individual have not significantly changed.
(iii) An individual and their designated representative are satisfied with the current services and supports.
(B) Over the course of an ISP year, the case manager must assure subsections (i) through (iii) of section (A) are met.
(b) Individuals with three or more significant health and safety risks as identified in the Risk Management Plan, or if determined to be necessary by the case manager, must have monthly case management contact.
(c) For a child, reciprocal contact with the child's parent or legal representative may substitute for contact with the child, except as specified in sub-section (d).
(d) At least one case management contact per year must be face to face with the individual, including when the individual is a child. If an individual or their legal representative agrees, other case management contact may be made by telephone or by other interactive methods.
(e) The outcome of all case management contact must be recorded in the individual's progress notes.
(2) MONITORING OF SERVICES: A case manager must conduct monitoring activities using the framework described in this section.
(a) A case manager is required to provide assistance to the individual or the legal or designated representative with monitoring and improving the quality of supports.
(b) For all individuals with an ISP that authorizes waiver or Community First Choice state plan services, monitoring must include an assessment of the following:
(A) Are services being provided as described in the ISP and do the services result in the achievement of the identified action plans?
(B) Are the personal, civil, and legal rights of the individual protected in accordance with OAR chapter 411, division 318?
(C) Are the personal desires of the individual, and as applicable the legal or designated representative or family of the individual, addressed?
(D) Do the services authorized in the ISP continue to meet the assessed needs of the individual and what is important to, and for, the individual?
(E) Do identified desired outcomes and associated goals and action plans remain relevant and are the goals supported and being met?
(F) Are technological and adaptive equipment and environmental modifications being maintained and used as intended?
(G) Have changing needs or availability of other resources altered the need for continued use of Department funds to purchase supports?
(H) Are the services delivered in a setting that is in compliance with OAR 411-004-0020(1)?
(I) Are all the necessary protocols or mitigation strategies present that are needed to keep the individual healthy and safe?
(c) For an individual receiving employment services, the case manager must:
(A) Assess the progress of the individual toward competitive integrated employment; and
(B) When an individual is receiving facility based employment path services, visit each setting at least twice per plan year, while the individual is present, to verify and document the progress being made to support the individual to achieve employment goals documented in the Career Development Plan. Visits must be at least three months apart.
(d) When a case manager receives an incident report documenting the use of an emergency physical restraint, the case manager must review the use for potential abuse.
(e) When a case manager becomes aware that a wrongful use of a physical or chemical restraint, as described in ORS 430.735, may have been employed, the case manager must document the following efforts:
(A) Direction to the provider, and as applicable the common law employer, that the use of such restraint must immediately cease.
(B) Notification to the individual and the individual's legal representative of their right to be free from unauthorized restraint.
(C) Report of potential abuse by the wrongful use of a physical or chemical restraint.
(f) When a case manager receives three incident reports in a six-month period documenting the use of an emergency physical restraint, the case manager must assess the effectiveness of existing services authorized in the individual's ISP and take appropriate action.
(g) When an individual or legal representative has consented to an individually-based limitation, service monitoring must include an evaluation of the ongoing need for the limitation.
(h) Unless specified in these rules, the minimum frequency of service monitoring must be determined by the case manager, based on the needs of an individual, not less than once per plan year.
(i) For an individual receiving only case management services and not enrolled in any other funded developmental disabilities services, the case manager must make contact with the individual at least once annually.
(A) Whenever possible, annual contact must be made in person. If annual contact is not made in person, a progress note in the service record must document how contact was achieved.
(B) If the individual has any identified high-risk medical issue including, but not limited to, risk of death due to aspiration, seizures, constipation, dehydration, diabetes, or significant behavioral issues, the case manager must maintain contact in accordance with planned actions as described in the Annual Plan.
(j) For an individual who is enrolled in a residential program the monitoring of services may be combined with the site visits described in section (3) of this rule. In addition:
(A) During the ISP year, the services coordinator must review, at least once, services specific to health, safety, and behavior, using questions established by the Department.
(B) A semi-annual review of the process by which an individual accesses and utilizes their own funds must occur, using questions established by the Department. The services coordinator must determine whether financial records, bank statements, and personal spending funds are correctly reconciled and accounted for.
(i) The financial review standards for 24-hour residential programs are described in OAR 411-325-0380.
(ii) The financial review standards for adult foster homes are described in OAR 411-360-0170.
(iii) Any misuse of funds must be reported to the CDDP and the Department. The Department determines whether a referral to the Medicaid Fraud Control Unit is warranted.
(C) The services coordinator must monitor reports of serious incidents.
(k) If State Plan Personal Care services are authorized in an Annual Plan, the services must be monitored as described in OAR chapter 411, division 455.
(3) SITE VISITS.
(a) The CDDP must ensure that quarterly site visits are conducted at each child or adult foster home, each host home, and each 24-hour residential program setting licensed by the Department to serve individuals with intellectual or developmental disabilities.
(b) The CDDP must establish an annual schedule for site visits to each site that is owned, operated, or controlled by:
(A) An employment program certified and endorsed under OAR chapter 411, division 345; and
(B) A community living supports program certified and endorsed under OAR chapter 411, division 450.
(c) The CDDP must conduct at least one visit annually to the home of an individual receiving services in a supported living setting.
(d) When services are anticipated to be delivered in an individual's home, the CME must conduct at least one visit annually to the individual's home.
(e) Site visits may be increased for any of the following reasons including, but not limited to the following:
(A) Increased certified and licensed capacity.
(B) New individuals receiving services.
(C) Newly licensed or certified and endorsed provider.
(D) An abuse investigation.
(E) A serious incident.
(F) A change in the management or staff of the licensed site or certified and endorsed program operator.
(G) An ISP team request.
(H) Significant change in the functioning of an individual who receives services at the site.
(f) The CME must develop a procedure for the conduct of the site visits.
(g) The CME must document site visits and provide information concerning the site visits to the Department upon request.
(h) If there are no Department-funded individuals at the site, a visit by the CME is not required.
(i) When a provider is a Department-contracted and licensed, certified, and endorsed 24-hour residential program for children and the children's residential services coordinator for the Department is assigned to monitor services, the children's residential services coordinator and the CDDP shall coordinate the site visit. If the site visit is made by Department staff, Department staff shall provide the results of the site visit to the local services coordinator.
(j) The Department may conduct site visits on a more frequent basis than described in this section based on program needs.
(4) MONITORING FOLLOW-UP. A case manager and the CME are responsible for ensuring the appropriate follow-up to monitoring of services, except in the instance of children in 24-hour residential programs directly contracted with the Department when the Department conducts the follow-up.
(a) If the case manager determines that developmental disabilities services are not being delivered as agreed in the ISP for an individual, or that the service needs of an individual have changed since the last review, the case manager must initiate at least one of the following actions:
(A) Update the ISP of the individual.
(B) To remediate service delivery shortcomings, provide or refer technical assistance to an agency provider or common law employer for a personal support worker.
(b) If there are concerns regarding the ability of a provider to provide services, the CME must determine the need for technical assistance or other follow-up activities, such as coordination or provision of technical assistance, referral to the CDDP manager or brokerage director for consultation or corrective action, requesting assistance from the Department for licensing or other administrative support, or meeting with the executive director or board of directors of the provider.
(c) The CME must ensure that there is monitoring and follow-up on serious incidents.
(5) DEPARTMENT NOTIFICATION. The CME must notify the Department when:
(a) A provider demonstrates substantial failure to comply with any applicable licensing, certification, or endorsement rules for Department-funded programs.
(b) A personal support worker may have met any of the conditions identified in OAR 411-375-0070 that would cause the Department to inactivate or terminate the provider enrollment of the worker.
(c) The CME finds a serious and current threat endangering the health, safety, or welfare of individuals in a program.

Notes

Or. Admin. R. 411-415-0090
APD 28-2016, f. & cert. ef. 6/29/2016; APD 29-2017, amend filed 11/30/2017, effective 12/1/2017; APD 29-2017, amend filed 11/30/2017, effective 12/01/2017; APD 46-2018, amend filed 12/28/2018, effective 12/28/2018; APD 45-2019, amend filed 10/29/2019, effective 11/1/2019

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

Statutes/Other Implemented: ORS 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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