Or. Admin. Code § 309-019-0140 - Service Plan and Service Notes
(1) The service plan must be a written,
individualized plan designed 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.
(a) Service plans
shall be started following the completion of an assessment, or portion thereof,
and prior to treatment services being rendered. Provider must document reason
for any delay in the service record.
(b) Routine services may be rendered prior to
a completion of a service plan or documentation of a medically necessary reason
for services. These services can be provided without a service plan or medical
necessity, or at any time during a treatment episode:
(i) Care Coordination
(ii) Case Management
(iii) Peer Services
(c) Service plans must reflect the assessment
in its' most updated form;
(d)
Address areas of concern identified in the current assessment that the
individual or guardian - if relevant and appropriate -- agrees to
address;
(e) 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;
(f) Include the participation, and reflect
agreement, of the individual and family members, as applicable;
(g) Be completed and signed by qualified
program staff as follows:
(A) A QMHP or
appropriately licensed provider in mental health programs;
(B) Supervisory or treatment staff in
substance use disorders treatment programs; and
(C) Supervisory or treatment staff in problem
gambling treatment programs.
(h) Approval of services and supports shall
be demonstrated through operationalization of provider policy described above,
in OAR 309-019-0110
(1)(z).
(2) At minimum, each service plan must
include:
(a) Treatment goals that are
individualized;
(b) Treatment goals
that meet the assessed needs of the individual.
(c) Measurable for the purpose of evaluating
individual progress, including a baseline.
(3) Service plans must reflect the most
updated assessments on file, and must include:
(a) Goals that are measurable for the purpose
of evaluating individual progress - including baseline measurement as well as
include;
(b) The specific services
and supports that will be used to meet the treatment goals;
(c) Expected frequency, amount, and duration
of each type of planned service or support;
(d) A schedule for re-evaluating the service
plan; and
(e) the type of personnel
that will be furnishing each of the services.
(4) Providers must document the following in
a service note for each service and support :
(a) The specific service or support
rendered;
(b) The relationship of
the services to the treatment regimen described in the service plan;
(c) The date, time of service or support, and
the actual amount of time the service or support was rendered;
(d) The personnel rendering the services,
including their name, credentials, and signature;
(e) The setting in which the service or
support was rendered; and
(f)
Periodic updates describing the individual's progress, or lack
thereof
(5) Decisions to
transfer individuals must be documented including:
(a) The date of the transfer;
(b) The reason for the transfer;
(c) For substance use disorder and
co-occurring services, ASAM level of care recommendation and overall
determination of the severity of risk the individual is experiencing at the
time of transfer;
(d) Referrals to
follow up services and other behavioral health providers; and
(e) Outreach efforts made as applicable and
as defined in these rules.
Notes
Statutory/Other Authority: ORS 161.390, 413.042, 430.256 & 430.640
Statutes/Other Implemented: ORS 161.390 - 161.400, 428.205 - 428.270, 430.010, 430.205- 430.210, 430.254 - 430.640, 430.850 - 430.955 & 743A.168
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