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
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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