Or. Admin. Code § 411-304-0190 - Documentation and Records for Professional Behavior Services
(1) A behavior
professional must maintain documentation of all delivered professional behavior
services and furnish the documentation to the Department, Oregon Health
Authority, or case management entity, upon request. A behavior professional
must document all of the following:
(a) Date
of service.
(b) Who provided the
service.
(c) Location of where and
method of how the service was provided.
(d) Length of time required for the service,
including start and end times.
(e)
Description of the service delivered.
(f) People present when the service was
delivered.
(2) The
documents generated by a behavior professional during the delivery of
professional behavior services belong to the individual.
(3) Unless stated otherwise, all
documentation required by these rules must be:
(a) Prepared at the time of, or immediately
following, the event being recorded.
(b) Accurate and contain no willful
falsifications.
(c) Legible, dated,
and signed by the behavior professional.
(4) A behavior professional must maintain a
release of information according to OAR chapter 407 division 014, for each
individual receiving professional behavior services from the behavior
professional.
(5) A behavior
professional must maintain their records for professional behavior services
until the behavior professional no longer provides services to the individual,
at which time, the behavior professional must provide a copy of any part of the
record that was not previously provided to the case management entity. The
behavior professional must retain an individual's service record for a period
of seven years. Financial records, supporting documents, statistical records,
and all other records, other than an individual's service record, must be
retained for at least three years after services have ended.
(6) Access to records by the Department and
Oregon Health Authority including, but not limited to, medical, nursing,
behavior, psychiatric, or financial records, does not require authorization or
release by the individual or the individual's legal representative.
(7) A behavior professional must furnish
requested documentation immediately upon the written or electronic request from
the Department, Oregon Health Authority, Oregon Department of Justice Medicaid
Fraud Unit, Centers for Medicare and Medicaid Services, or their authorized
representatives, or within the timeframe specified in the written request.
Failure to comply with the request may be considered by the Department as
reason to deny or recover payment.
Notes
Statutory/Other Authority: ORS 409.050, 427.104 & 430.662
Statutes/Other Implemented: ORS 409.010, 427.007, 427.104, 430.610 & 430.662
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