OAR 309-019-0140
Service Plan and Service Notes

(1) In addition to any program specific service delivery requirements, the service plan shall be an individualized plan designed to improve the individual’s condition to the point where the individual’s continued participation in the program is no longer necessary. The service plan is included in the individual’s service record and shall:
(a) Be completed prior to the start of services;
(b) Reflect the full assessment and the level of care to be provided;
(c) Include a safety plan when the assessment indicates risk to the health and safety of the individual or to others and be updated as circumstances change. The safety plan may be a separate document from the service plan;
(d) Include the participation of the individual and family members, as applicable;
(e) Be completed and signed by qualified program staff as follows:
(A) A QMHP in mental health programs;
(B) Supervisory or treatment staff in substance use disorders treatment programs; and
(C) Supervisory or treatment staff in problem gambling treatment programs.
(f) For mental health services, a QMHP who is also a licensed health care professional shall recommend the services and supports by signing the service plan within ten business days of the start of services; and
(g) An LMP shall approve the service plan at least annually for each individual receiving mental health services for one or more continuous years. The LMP may designate annual clinical oversight by documenting the designation to a specific licensed health care professional.
(2) At minimum, each service plan shall include:
(a) Treatment objectives that are:
(A) Individualized to meet the assessed needs of the individual;
(B) Measurable for the purpose of evaluating individual progress, including a baseline evaluation.
(b) The specific services and supports indicated by the assessment that shall be used to meet the treatment objectives;
(c) A projected schedule for service and support delivery, including the expected frequency and duration of each type of planned service or support;
(d) The credentials of the personnel providing each service and support; and
(e) A projected schedule for re-evaluating the service plan.
(3) Providers shall document each service and support in a service note to include:
(a) The specific services rendered;
(b) The specific service plan objectives being addressed by the services provided;
(c) The date, time of service, and the actual amount of time the services were rendered;
(d) The relationship of the services provided to the treatment objective described in the service plan;
(e) The personnel rendering the services, including their name, credentials, and signature;
(f) The setting in which the services were rendered; and
(g) Periodic updates describing the individual’s progress.
(4) Decisions to transfer individuals shall be documented including:
(a) The reason for the transfer;
(b) Referrals to follow up services and other behavioral health providers; and
(c) Outreach efforts made, as defined in these rules.

Source: Rule 309-019-0140 — Service Plan and Service Notes, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=309-019-0140.

309–019–0100
Purpose and Scope 309–019–0105
Definitions 309–019–0110
Provider Policies 309–019–0115
Individual Rights 309–019–0125
Specific Staff Qualifications and Competencies 309–019–0130
Personnel Documentation, Training, and Supervision 309–019–0135
Entry and Assessment 309–019–0140
Service Plan and Service Notes 309–019–0145
Co-Occurring Mental Health and Substance Use Disorders (COD) 309–019–0150
Community Mental Health Programs (CMHP) 309–019–0155
Enhanced Care Services (ECS) and Enhanced Care Outreach Services (ECOS) 309–019–0160
Psychiatric Security Review Board and Juvenile Psychiatric Security Review Board 309–019–0165
Intensive Outpatient Services and Supports (IOSS) for Children 309–019–0167
Intensive In-Home Behavioral Health Treatment (IIBHT) for Children 309–019–0170
Outpatient Problem Gambling Treatment and Recovery Services 309–019–0175
Culturally Specific Substance Use Disorders Treatment and Recovery Services 309–019–0185
Outpatient Substance Use Disorders Treatment and Recovery Programs 309–019–0190
Community-Based Substance Use Treatment Programs for Individuals in the Criminal Justice System 309–019–0195
DUII Services Providers 309–019–0200
Medical Protocols in Outpatient Substance Use Disorders Treatment and Recovery Programs 309–019–0205
Building Requirements in Behavioral Health Programs 309–019–0210
Quality Assessment and Performance Improvement 309–019–0215
Grievances and Appeals 309–019–0220
Variances 309–019–0225
Assertive Community Treatment (ACT) Definitions 309–019–0226
Assertive Community Treatment (ACT) Overview 309–019–0230
ACT Provider Qualifications 309–019–0235
ACT Continued Fidelity Requirements 309–019–0240
ACT Failure to Meet Fidelity Standards 309–019–0241
Waiver of Minimum Fidelity Requirements 309–019–0242
ACT Program Operational Standards 309–019–0245
ACT Admission Criteria 309–019–0248
ACT Admission Process 309–019–0250
ACT Transition to Less Intensive Services and Discharge 309–019–0255
ACT Reporting Requirements 309–019–0270
Definitions 309–019–0275
Individual Placement and Support (IPS) Supported Employment Overview 309–019–0280
Supported Employment Providers 309–019–0285
Continued Fidelity Requirements 309–019–0290
Failure to Meet Fidelity Standards 309–019–0295
Reporting Requirements 309–019–0300
Service Requirements 309–019–0305
Provider Standards 309–019–0310
Minimum Staffing Requirements 309–019–0315
Training Requirements 309–019–0320
Documentation Requirements 309–019–0324
Youth Wraparound Definitions 309–019–0326
Youth Wraparound Program Rules
Last Updated

Jun. 8, 2021

Rule 309-019-0140’s source at or​.us