Or. Admin. Code § 411-360-0200 - [Effective until 7/21/2025] Adjustment, Suspension, or Termination of Payment
(1) The Department
may adjust, suspend, or terminate payment to a provider when any of the
following conditions occur:
(a) The license
for the AFH-DD is revoked, suspended, or terminated.
(b) Upon finding that the provider is failing
to deliver any care or service as agreed to in an ISP or Service
Agreement.
(c) When funding, laws,
regulations, or the priorities of the Department change such that funding is no
longer available, redirected to other purposes, or reduced.
(d) The care and service needs of an
individual change.
(e) An
individual is determined to be ineligible for services.
(f) An individual moves, with or without
notice, from the AFH-DD. The provider is paid only through the last night the
individual slept in the AFH-DD.
(g)
An individual is away from the licensed AFH-DD, accompanied by the provider or
staff paid by the provider, for 30 consecutive days or 45 days in an ISP year.
(A) The provider is not paid for the 31st and
following consecutive days an individual is not at the AFH-DD.
(B) The provider is not paid for the 46th and
following non-consecutive days an individual is not at the AFH-DD.
(C) Days not paid do not count in the 45-day
total.
(2) A
provider may only claim for a day of service when:
(a) An individual sleeps in the AFH-DD
overnight; or
(b) An individual
does not sleep in the AFH-DD overnight, but intends to return to the AFH-DD,
and the provider was responsible for and provided an accumulated period of
eight hours for the primary care, support, safety, and well-being of the
individual, including any of the following:
(A) Providing intermittent physical support
or care.
(B) Providing stand-by
support with the ability to respond in person within the response times as
outlined in the individual's ISP.
(C) Being responsible to communicate
reciprocally within the response times agreed upon by the individual's ISP team
and documented in the individual's ISP, based on the individual's identified
support needs.
(3) A day of service does not apply when an
individual:
(a) Has been admitted to an acute
care hospital unless the individual's ISP authorizes attendant care for the
individual in an acute care hospital and the day of service criteria in section
(2)(b) of this rule is met. An ISP may only authorize attendant care for an
individual who has been admitted to an acute care hospital when the support is
not a duplication of service that the hospital provides and the individual has
one of the following:
(A) Challenging behavior
that interferes with getting medical care. The challenging behavior must
require specific training or experience to support and must be able to be
mitigated by a developmental disability service provider to an extent that
medical care is improved.
(B) An
inability to independently communicate with hospital staff that interferes with
getting medical care. This must not be solely due to limited or emerging
English proficiency.
(C) Support
with one or more activities of daily living that may only be adequately met by
someone familiar with the individual.
(b) Has been admitted to a nursing
facility.
(c) Has been admitted to
a mental health facility.
(d) Is
held in detention or jail.
(4) The Department is under no obligation to
maintain the AFH-DD at its licensed capacity or to provide payments to
potential providers.
Notes
Statutory/Other Authority: ORS 409.050, 427.104, 430.662, 443.001, 443.004, 443.725, 443.730, 443.734, 443.735, 443.738, 443.742, 443.760, 443.765, 443.767, 443.775 & 443.790
Statutes/Other Implemented: ORS 409.010, 427.007, 427.101, 427.104, 430.662, 441.993, 443.001-443.004, 443.705-443.825, 443.875 & 443.991
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