(1) During the
initial 14 calendar days following the resident's admission to the home, the
licensee or administrator must continue to assess and document the resident's
preferences and care needs. The assessment and care plan must be completed by
the licensee or administrator and documented within the initial 14-day period.
The care plan must describe the resident's needs, preferences, capabilities,
what assistance the resident requires for various tasks, and must include:
(a) By whom, when, and how often care and
services shall be provided.
(b) The
resident's ability to perform activities of daily living (ADLs).
(c) Special equipment needs.
(d) Communication needs (examples may
include, but are not limited to, hearing or vision needs, such as eraser boards
or flash cards, or language barriers, such as sign language or non-English
speaking).
(e) Night
needs.
(f) Medical or physical
health problems, including physical disabilities, relevant to care and
services.
(g) Cognitive, emotional,
or other impairments relevant to care and services.
(h) Treatments, procedures, or
therapies.
(i) Registered nurse
consultation, teaching, delegation, or assessment.
(j) Behavioral interventions.
(k) Social, spiritual, and emotional needs,
including lifestyle preferences, name, pronouns, legal name, gender identity,
activities, and significant others involved.
(l) The ability to exit in an emergency,
including assistance and equipment needed.
(m) Any use of physical restraints or
psychotropic medications.
(n)
Dietary needs and preferences.
(o)
Any individually-based limitations according to OAR
411-051-0105(3).
(A) Effective July 1, 2019, and no later than
June 30, 2020, the licensee or administrator must identify any
individually-based limitations to the use of restraints or the HCBS rights as
listed in OAR
411-051-0105(2).
(B) For Medicaid-eligible residents, the
person-centered service plan coordinator must authorize the limitation and the
individual must consent to the limitation. The licensee or administrator must
incorporate and document all applicable elements identified in OAR
411-051-0105(3).
(C) Limitations are not transferable between
care settings. Continued need for any limitation at the new care setting must
comply with the requirements as stated in OAR
411-051-0105.
(2) The licensee or
administrator must:
(a) Review and update each
resident's care plan every six months.
(b) Review and update a resident's care plan
when a resident's condition changes.
(c) Document in the resident's record at the
time of each review and include the date of the review and the licensee or
administrator 's signature. If a care plan contains many changes and becomes
less legible, a new care plan must be written.
(3) The licensee or administrator is
responsible for ensuring implementation of the resident's care plan and, if
applicable, the behavioral support plan with suggested interventions.
Notes
Or. Admin. Code §
411-051-0115
APD
19-2019, adopt filed 06/20/2019, effective 07/01/2019;
APD
25-2019, minor correction filed 07/01/2019, effective
7/1/2019;
APD
25-2019, minor correction filed 07/01/2019, effective
7/1/2019;
APD
15-2024, temporary amend filed 03/28/2024, effective
4/1/2024 through
9/27/2024;
APD
57-2024, amend filed 09/23/2024, effective
9/25/2024
Statutory/Other Authority: ORS
127.520,
409.050,
410.070,
413.085,
441.122,
441.373,
443.001,
443.004,
443.725,
443.730,
443.735,
443.738,
443.742,
443.760,
443.767,
443.775 &
443.790
Statutes/Other Implemented: ORS
409.050,
410.070,
413.085,
441.111,
441.114,
441.373,
443.001 -
443.004,
443.705 -
443.825,
443.875 &
443.991
