Or. Admin. Code § 411-415-0090 - Case Management Contact and Monitoring of Services
(1) CASE MANAGEMENT
CONTACT.
(a) Every individual who has an ISP
must have a case management contact no less than once every three months.
(A) The purpose of a case management contact
must be to assure one of the following:
(i)
Known health and safety risks are adequately addressed.
(ii) An individual's support needs have not
significantly changed.
(iii) An
individual and the individual's legal or designated representative are
satisfied with the current services and supports.
(B) Over the course of an ISP year, a case
manager must assure subsections (i) through (iii) of section (A) are
met.
(b) Monthly case
management contact must be provided:
(A) To an
individual with three or more significant health and safety risks as identified
in a Risk Management Plan;
(B) If
determined to be necessary by a case manager; or
(C) To a child enrolled in the Children's
Extraordinary Needs Program.
(c) For a child, reciprocal contact with the
child's parent or legal representative may substitute for contact with the
child, except as specified in subsection (d) and if the parent or legal
representative is not being paid to deliver attendant care to the
child.
(d) At least one case
management contact per year must be in person with an individual, including
when an individual is a child. If an individual or the individual's legal
representative agrees, other case management contact may be made by telephone
or by other interactive methods. A child enrolled in the Children's
Extraordinary Needs Program must have a minimum of two in-person case
management contacts per year.
(e)
The outcome of all case management contact must be recorded in an individual's
progress notes.
(2)
MONITORING OF SERVICES: A case manager must conduct monitoring activities using
the framework described in this section.
(a) A
case manager is required to provide assistance to an individual or the
individual's legal or designated representative with monitoring and improving
the quality of supports.
(b) For an
individual with an ISP that authorizes waiver or Community First Choice (K
Plan) services, monitoring must include an assessment of all of the following:
(A) Are services being provided as described
in the ISP and do the services result in the achievement of the identified
action plans?
(B) Are the
individual's personal, civil, and legal rights protected in accordance with OAR
chapter 411, division 318?
(C) Are
the individual's personal desires, and as applicable the legal or designated
representative or family of the individual, addressed?
(D) Do the services authorized in the ISP
continue to meet the individual's assessed needs and what is important to, and
for, the individual?
(E) Do
identified desired outcomes and associated goals and action plans remain
relevant and are the goals supported and being met?
(F) Are technological and adaptive equipment
and environmental modifications being maintained and used as
intended?
(G) Have changing needs
or availability of other resources altered the need for continued use of
Department funds to purchase supports?
(H) Are the services delivered in a setting
that is in compliance with OAR
411-004-0020(1)?
(I) Are all the necessary protocols or
mitigation strategies present that are needed to keep the individual healthy
and safe?
(c) For an
individual receiving employment services, a case manager must:
(A) Assess the progress of the individual
toward competitive integrated employment; and
(B) When an individual is receiving
facility-based employment path services, visit each setting at least twice per
plan year, while the individual is present, to verify and document the progress
being made to support the individual to achieve employment goals documented in
the Career Development Plan. Visits must be at least three months
apart.
(d) When a case
manager receives an incident report documenting the use of an emergency
physical restraint, the case manager must review the use for potential
abuse.
(e) When a case manager
becomes aware of the wrongful use of a physical or chemical restraint, as
described in ORS 430.735, the case manager must
document the following efforts:
(A) Direction
to the provider, and as applicable the common law employer, that the use of
such restraint must immediately cease.
(B) Notification to the individual and the
individual's legal representative of the individual's right to be free from
unauthorized restraint.
(C) Report
of potential abuse by the wrongful use of a physical or chemical
restraint.
(f) When a
case manager receives three incident reports in a six-month period documenting
the use of an emergency physical restraint, the case manager must assess the
effectiveness of existing services authorized in an individual's ISP and take
appropriate action.
(g) When an
individual or the individual's legal representative has consented to an
individually-based limitation, service monitoring must include an evaluation of
the ongoing need for the limitation.
(h) Unless specified in these rules, the
minimum frequency of service monitoring must be determined by a case manager,
based on an individual's needs, and not less than once per plan year.
(i) For an individual receiving only case
management services and not enrolled in any other funded developmental
disabilities services, a case manager must make contact with the individual at
least once annually.
(A) Whenever possible,
annual contact must be made in person. If annual contact is not made in person,
a progress note in the service record must document how contact was
achieved.
(B) If the individual has
any identified high-risk medical issue including, but not limited to, risk of
death due to aspiration, seizures, constipation, dehydration, diabetes, or
significant behavioral issues, the case manager must maintain contact in
accordance with planned actions as described in the Annual Plan.
(j) For an individual who is
enrolled in a residential program, the monitoring of services may be combined
with the site visits described in section (3) of this rule. In addition:
(A) During the ISP year, a services
coordinator must review, at least once, services specific to health, safety,
and behavior, using questions established by the Department.
(B) A semi-annual review of the process by
which an individual accesses and utilizes their own funds must occur, using
questions established by the Department. A services coordinator must determine
whether financial records, bank statements, and personal spending funds are
correctly reconciled and accounted for.
(i)
The financial review standards for 24-hour residential programs are described
in OAR 411-325-0380.
(ii) The financial review standards for adult
foster homes are described in OAR
411-360-0170.
(iii) Any misuse of funds must be reported to
the CDDP and the Department. The Department determines whether a referral to
the Medicaid Fraud Control Unit is warranted.
(C) A services coordinator must monitor
reports of serious incidents.
(k) If State Plan Personal Care services are
authorized in an Annual Plan, the services must be monitored as described in
OAR 411-455-0030.
(3) SITE VISITS.
(a) A CDDP must ensure that a quarterly site
visit is conducted at each child or adult foster home, each host home, and each
24-hour residential program setting licensed by the Department to serve
individuals with intellectual or developmental disabilities. A person
conducting a site visit must meet the qualifications of a case manager
described in OAR 411-415-0040. An assessor may
not fulfill the site visit requirement.
(b) A CDDP must establish an annual schedule
for site visits to each site that is owned, operated, or controlled by:
(A) An employment program certified and
endorsed according to OAR chapter 411, division 345.
(B) A provider agency delivering community
living supports certified and endorsed according to OAR chapter 411, division
450.
(c) A CDDP must
conduct at least one visit annually to the home of an individual receiving
services in a supported living setting.
(d) When services are anticipated to be
delivered in an individual's home, a case management entity must conduct at
least one visit annually to the individual's home.
(e) Site visits may be increased for any of
the following reasons including, but not limited to:
(A) Increased certified and licensed
capacity.
(B) New individuals
receiving services.
(C) Newly
licensed or certified and endorsed provider.
(D) An abuse investigation.
(E) A serious incident.
(F) A change in the management or staff of
the licensed site or certified and endorsed program operator.
(G) An ISP team request.
(H) Significant change in the functioning of
an individual who receives services at the site.
(f) A case management entity must develop a
procedure for the conduct of a site visit.
(g) A case management entity must document a
site visit and provide information concerning the site visit to the Department
upon request.
(h) If there are no
Department-funded individuals at a site, a visit by a case management entity is
not required.
(i) When a provider
is a Department-contracted and licensed, certified, and endorsed 24-hour
residential program for children and a children's residential services
coordinator for the Department is assigned to monitor services, the children's
residential services coordinator and the CDDP shall coordinate the site visit.
If the site visit is made by Department staff, Department staff shall provide
the results of the site visit to the local services coordinator.
(j) The Department may conduct site visits on
a more frequent basis than described in this section based on program
needs.
(4) MONITORING
FOLLOW-UP. A case manager and a case management entity are responsible for
ensuring the appropriate follow-up to monitoring of services, except in the
instance of children in 24-hour residential programs directly contracted with
the Department when the Department conducts the follow-up.
(a) If a case manager determines
developmental disabilities services are not being delivered as agreed in an
individual's ISP, or that an individual's service needs have changed since the
last review, the case manager must initiate at least one of the following
actions:
(A) Update the individual's
ISP.
(B) To remediate service
delivery shortcomings, provide or refer technical assistance to an agency
provider or common law employer for a personal support worker.
(b) If there are concerns
regarding the ability of a provider to deliver services, a case management
entity must determine the need for technical assistance or other follow-up
activities, such as:
(A) Coordination or
provision of technical assistance.
(B) Referral to a CDDP manager or brokerage
director for consultation or corrective action.
(C) Requesting assistance from the Department
for licensing or other administrative support.
(D) Meeting with a provider's executive
director or board of directors.
(c) A case management entity must ensure that
there is monitoring and follow-up on serious incidents.
(5) DEPARTMENT NOTIFICATION. A case
management entity must notify the Department when:
(a) A provider demonstrates substantial
failure to comply with any applicable licensing, certification, or endorsement
rules for Department-funded programs.
(b) A personal support worker may have met
any of the conditions identified in OAR
411-375-0070 that would cause
the Department to inactivate or terminate the personal support worker's
provider enrollment.
(c) The case
management entity finds a serious and current threat endangering the health,
safety, or welfare of an individual in a program.
Notes
Statutory/Other Authority: ORS 409.050, 427.104, 427.105, 427.115, 427.154, 427.191, 430.212, 430.662 & 430.731
Statutes/Other Implemented: ORS 409.010, 427.005-427.154, 427.191, 430.212, 430.215, 430.610, 430.620, 430.662, 430.664 & 430.731-430.768
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