Or. Admin. Code § 411-375-0035 - Documentation and Reporting Requirements
(1) SERVICE AGREEMENT.
(a) An independent provider may not provide
services to an individual without a completed and authorized Service Agreement.
For independent providers who are not personal support workers, the signature
of the independent provider on an individual's ISP may serve as the Service
Agreement.
(b) An independent
provider must maintain a copy of the authorized Service Agreement for the
authorized service period.
(2) SAFEGUARDING INTERVENTIONS AND
SAFEGUARDING EQUIPMENT.
(a) An independent
provider must only utilize a safeguarding intervention or safeguarding
equipment when:
(A) BEHAVIOR. Used to address
an individual's challenging behavior, the safeguarding intervention or
safeguarding equipment is included in the individual's Positive Behavior
Support Plan written by a qualified behavior professional as described in OAR
411-304-0150 and implemented
consistent with the individual's Positive Behavior Support Plan.
(B) MEDICAL. Used to address an individual's
medical condition or medical support need, the safeguarding intervention or
safeguarding equipment is included in a medical order written by the
individual's licensed health care provider and implemented consistent with the
medical order.
(b) The
individual, or as applicable their legal representative, must provide consent
for the safeguarding intervention or safeguarding equipment through an
individually-based limitation in accordance with OAR
411-415-0070.
(c) Prior to utilizing a safeguarding
intervention or safeguarding equipment, an independent provider must be
trained.
(A) For a safeguarding intervention,
the independent provider must be trained in intervention techniques using an
ODDS-approved behavior intervention curriculum and trained to the individual's
specific needs. Training must be conducted by a person who is appropriately
certified in an ODDS-approved behavior intervention curriculum.
(B) For safeguarding equipment, the
independent provider must be trained on the use of the identified safeguarding
equipment.
(d) An
independent provider must not utilize any safeguarding intervention or
safeguarding equipment not meeting the standards set forth in this rule even
when the use is directed by the individual or their legal or designated
representative, regardless of the individual's age.
(3) EMERGENCY PHYSICAL RESTRAINTS.
(a) The use of an emergency physical
restraint when not written into a Positive Behavior Support Plan, not
authorized in an individual's ISP, and not consented to by the individual in an
individually-based limitation, must only be employed when all of the following
conditions are met:
(A) In situations when
there is imminent risk of harm to the individual or others or when the
individual's behavior has a probability of leading to engagement with the legal
or justice system;
(B) Only as a
measure of last resort; and
(C)
Only for as long as the situation presents imminent danger to the health or
safety of the individual or others.
(b) The use of an emergency physical
restraint must not include any of the following characteristics:
(A) Abusive.
(B) Aversive.
(C) Coercive.
(D) For convenience.
(E) Disciplinary.
(F) Demeaning.
(G) Mechanical.
(H) Prone or supine restraint.
(I) Pain compliance.
(J) Punishment.
(K) Retaliatory.
(4) PROGRESS NOTES.
(a) An independent provider must maintain
regular progress notes. The progress note must include, at minimum, the
following information regarding the service rendered:
(A) Date and time the service was
delivered.
(B) Information
regarding progress towards achieving the intended ISP goal identified in the
Service Agreement for which the service was delivered.
(C) Documentation of incident reporting made
to a case management entity during the time period covered by the progress
note, including the date the incident was reported and the nature of the
incident.
(b) For a
personal support worker, progress notes must be submitted to the case
management entity with their timesheet as part of their claim for payment, and
additionally upon request from the case management entity. The completed
timesheet fulfills the requirement for date and time the service was
delivered.
(c) For an independent
provider who is not a personal support worker, progress notes must be submitted
as required by applicable program rules.
(5) ABUSE REPORTING.
(a) An independent provider must immediately
notify an individual's case management entity of any reasonable suspicion an
individual is the victim of abuse.
(b) Independent providers who are mandatory
reporters must also make reports of suspected abuse consistent with the
following:
(A) ORS
419B.010 and
419B.015 for abuse of a
child.
(B) ORS
124.060 and
124.065 for abuse of an older
adult 65 years of age or older.
(C)
ORS 430.737 and
430.743 for abuse of an adult
with an intellectual or developmental disability or mental illness.
(D) ORS
441.640 and
441.645 for abuse of a resident
of a long-term care facility as defined in ORS
442.015.
(6) INCIDENT REPORTING.
(a) An independent provider must immediately,
but not later than one business day, notify an individual's case management
entity of the following:
(A) Serious illness,
serious injury, or serious incident involving an individual.
(B) The use of a safeguarding intervention.
Timelines for notification included in a Temporary Emergency Safety Plan
supersede the timeline established by this section.
(b) The report must include all of the
following information:
(A) Name of the
individual who is the subject of the incident.
(B) Date, time, duration, type, and location
of the incident.
(C) Conditions
prior to, or leading to, the incident.
(D) Detailed description of the incident,
including the independent provider's response.
(E) Description of injury, if injury
occurred.
(F) Name of the
independent provider and witnesses to the incident.
(G) Follow-up to be taken to prevent a
recurrence of the incident.
(c) A notification required by section (a) of
this rule must occur by phone, in-person, email, writing, or verbally and
maintain confidentiality.
Notes
Statutory/Other Authority: ORS 409.050
Statutes/Other Implemented: ORS 410.600, 410.606-410.619 & 427.007
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