Or. Admin. Code § 309-018-0145 - Service Plan and Service Notes

(1) The Service Plan shall be a written, individualized plan to improve the individual's condition to the point where the individual's continued participation in the program or level of care is no longer necessary.

(2) Routine services may be provided prior to completion of a Service Plan. Per Services not documented in a Service Plan may be provided with documented explanation. The Service Plan is included in the individual's service record and shall:

(a) Be started prior to the rendering of treatment services, and provider must document reason for any delay in the service record ;

(b) Reflect the assessment in its' most updated form;

(c) Address areas of concern identified in the assessment that the individual agrees to address;

(d) Include a safety plan when the assessment indicates risk to the health and safety of the individual or to others and be updated as circumstances change. The safety plan may be a separate document from the Service Plan;

(e) Include the participation, and reflect agreement, of the individual and family members as applicable; and

(f) Be completed and signed by qualified program staff as follows:

(A) Supervisory or treatment staff in substance use disorders treatment and recovery programs; and

(B) Supervisory or treatment staff in problem gambling treatment and recovery programs.

(3) At minimum, each service plan, in addition to requirements in 309-018-0145 (2) above, each service plan shall include:

(a) Treatment goals that are:

(A) Individualized to meet the assessed needs of the individual.

(B) Completed within ten business days from entry.

(C) Measurable, with inclusion of baseline measurements, for the purpose of evaluating individual progress, as well as include;

(b) The specific services and supports that shall be used to meet the treatment objectives;

(c) The expected frequency, and duration of each type of planned service or support; and

(d) A schedule for re-evaluating the service plan.

(3) Providers shall document in a service note each service and support that includes the following:

(a) The specific services rendered;

(b) The specific service plan objectives being addressed by the services provided;

(c) The date, time of service, and the actual amount of time the services were rendered;

(d) The personnel rendering the services, including the name, credentials and signature;

(e) The setting in which the services were rendered; and

(f) Periodic updates describing the individual's progress.

Notes

Or. Admin. Code § 309-018-0145

MHS 10-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14; MHS 3-2014, f. & cert. ef. 2-3-14; MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18; MHS 4-2018, amend filed 02/27/2018, effective 3/1/2018; BHS 10-2023, amend filed 04/07/2023, effective 4/7/2023; BHS 8-2024, temporary amend filed 04/30/2024, effective 5/1/2024 through 10/27/2024; BHS 10-2024, temporary amend filed 05/21/2024, effective 5/21/2024 through 10/27/2024; BHS 25-2024, amend filed 10/25/2024, effective 10/27/2024

Statutory/Other Authority: ORS 413.042, 428.205 - 428.270, 430.640 & 443.450

Statutes/Other Implemented: ORS 430.010, 430.205 - 430.210, 430.254 - 430.640, 430.850 - 430.955, 443.400 - 443.460, 443.991, 461.549 & 743A.168