OAR 309-040-0390
Standards and Practices for Care and Services

(1) There shall be a provider, resident manager, or substitute caregiver on duty 24 hours per day in an AFH in accordance with ORS 443.725 (License required)(3).

(2) Medications and Prescriber’s Orders:

(a) There shall be a copy of a medication, treatment, or therapy order signed by a physician, nurse practitioner, or other licensed prescriber in the individual’s file for the use of any medications, including over the counter medications, treatments, and other therapies;

(b) A provider, resident manager, or substitute caregiver shall dispense medications, treatments, and therapies as prescribed by a physician, nurse practitioner, or other licensed prescriber. Changes to orders for the dispensing and administration of medication or treatment may not be made without a written order from a physician, nurse practitioner, or other licensed prescriber. A copy of the medication, treatment, or therapy order shall be maintained in the individual’s record. The provider, resident manager, or substitute caregiver shall promptly notify the individual’s case manager of any request for a change in the individual’s orders for medications, treatments, or therapies;

(c) Each individual’s medications shall be clearly labeled with the pharmacist’s label or the manufacturer’s originally labeled container and kept in a locked location. The provider or provider’s family medication shall be stored in a separate locked location. All medication for pets or other animals shall be stored in a separate locked location. Unused, outdated, or recalled medications may not be kept in the AFH and shall be disposed in a manner to prevent diversion into the possession of people other than for whom it was prescribed. The provider shall document disposal of all unused, outdated, and recalled medication on individuals’ drug disposal forms;

(d) Medications may not be mixed together in another container prior to administration except as packaged by the pharmacy or by physician order;

(e) A written medication administration record (MAR) for each individual shall be kept of all medications administered by the program staff to that individual, including over the counter medications. The MAR shall indicate name of medication, dosage and frequency of administration, route or method, dates and times given, and be immediately initialed by the caregiver dispensing using only blue or black indelible ink. Treatments, therapies, and special diets shall be immediately documented on the medication administration record including times given, type of treatment or therapy, and initials of the caregiver giving it using only blue or black indelible ink. The medication administration record shall have a legible signature for each set of initials using only blue or black indelible ink;

(f) The MAR shall include documentation of any known allergy or adverse reactions to a medication and documentation and an explanation of why a PRN medication was administered and the results of such administration;

(g) For any individual who is self-administering medication, the individual’s record shall include the following documentation:

(A) That the individual has been trained for self-administering of prescribed medication or treatment or that the prescriber has provided documentation that training for the individual is unnecessary;

(B) That the individual is able to manage his or her own medication regimen, and the provider shall keep medications stored in an area that is inaccessible to others and locked;

(D) Of review of self-administration of medication as part of the residential care plan process; and

(E) Of a current prescriber order for self-administration of medication.

(h) Injections may be self-administered by the individual or administered by a relative of the individual, a currently licensed registered nurse, a licensed practical nurse under registered nurse supervision, or providers who have been trained and are monitored by a physician or delegated by a registered nurse in accordance with administrative rules of the Board of Nursing chapter 851, division 047. Documentation regarding the training or delegation shall be maintained in the individual’s record;

(3) Nursing tasks may be delegated by a registered nurse to providers and other caregivers only in accordance with administrative rules of the Board of Nursing chapter 851, division 47. This includes but is not limited to the following conditions:

(a) The registered nurse has assessed the individual’s condition to determine there is not a significant risk to the individual if the provider or other caregiver performs the task;

(b) The registered nurse has determined the provider or other caregiver is capable of performing the task;

(d) The provider or caregiver has satisfactorily demonstrated to the registered nurse the ability to perform the task safely and accurately;

(e) The registered nurse provides written instructions for the provider or caregiver to use as a reference;

(f) The provider or caregiver has been instructed that the task is delegated for this specific person only and is not transferable to other individuals or taught to other care providers;

(g) The registered nurse has determined the frequency for monitoring the provider or caregiver’s delivery of the delegated task; and

(h) The registered nurse has documented a residential care plan for the individual including delegated procedures, frequency of registered nurse follow-up visits, and signature and license number of the registered nurse doing the delegating.

(4) The initial residential care plan shall be developed within 24 hours of admission to the AFH.

(5) This section and its subsections are effective July 1, 2016, and enforceable as described in OAR 309-040-0315 (License Application and Fees)(7):

(a) During the initial 30 calendar days following the individual’s admission to the AFH, the provider shall continue to assess and document the individual’s preferences and care needs. The provider shall complete and document the assessment in an RCP within 30 days after admission, unless the individual is admitted to the AFH for crisis-respite services;

(b) An RCP is an individualized plan intended to implement and document the provider’s delivery of services and identifies the goals to be accomplished through those services. The RCP shall describe the individual’s needs, preferences, capabilities, and what assistance the individual requires for various tasks;

(c) The provider shall develop the RCP based upon the findings of the individual assessment and the person-centered service plan with participation of the individual and through collaboration with the individual’s primary mental health treatment provider. With consent of the individual, family members, representatives from involved agencies, and others with an interest in the individual’s circumstances may be invited to participate in the development of the RCP. The provider shall have proper, prior authorization from the individual or the individual’s representative prior to such contact;

(d) The RCP shall adequately consider and facilitate the implementation of the individual’s person-centered service plan by addressing the following:

(A) Address the implementation and provision of services by the provider consistent with the obligations imposed by the person-centered service plan;

(B) Identify the individual’s service needs, desired outcomes, and service strategies to advance all areas identified in the person-centered service plan, the individual’s physical and medical needs, medication regimen, self-care, social-emotional adjustment, behavioral concerns, independent living capability and community navigation, as well as any other area of concern or the other goals set by the individual;

(C) If the person-centered service plan is unavailable for use in developing the RCP, providers shall still develop an RCP based on the information available. Upon the person-centered service plan becoming available, the providers shall amend the RCP as necessary to comply with this rule; and

(D) The provider shall attach the person-centered service plan to the RCP.

(e) The RCP shall be signed by the individual, the provider, or the provider’s designee, and others, as appropriate, to indicate mutual agreement with the course of services outlined in the plan;

(f) The provider shall review and update each individual’s RCP every six months and when an individual’s condition changes. The review shall be documented in the individual’s record at the time of the review and include the date of the review and the provider’s signature. If an RCP contains many changes and becomes less legible, the provider shall write a new care plan.

(6) A person-centered service plan shall be completed in the following circumstances:

(a) A person-centered service plan coordinator under contract with the Division shall complete a person-centered service plan with each individual pursuant to OAR 411-004-0030 (Person-Centered Service Plans). The provider shall make a good faith effort to implement and complete all elements the provider is responsible for implementing as identified in the person-centered service plan;

(b) The person-centered service plan coordinator documents the person-centered service plan on behalf of the individual and provides the necessary information and supports to ensure the individual directs the person-centered service planning process to the maximum extent possible;

(c) The person-centered service plan shall be developed by the individual, and as applicable, the legal or designated representative of the individual, and the person-centered service plan coordinator. Others may be included only at the invitation of the individual and, as applicable, the individual’s representative;

(d) To avoid conflict of interest, the person-centered service plan may not be developed by the provider for individuals receiving Medicaid. The Division may grant exceptions when it determines that the provider is the only willing and qualified entity to provide case management and develop the person-centered service plan in a specific geographic area;

(e) For private pay individuals, a person-centered service plan may be developed by the individual, or as applicable, the legal or designated representative of the individual, and others chosen by the individual. Providers shall assist private pay individuals in developing person-centered service plans when no alternative resources are available. Private pay individuals are not required to have a written person-centered service plan.

(7) A person-centered service plan shall be developed through a person-centered service planning process. The person-centered service planning process includes the following:

(a) Is driven by the individual;

(b) Includes people chosen by the individual;

(c) Provides necessary information and supports to ensure the individual directs the process to the maximum extent possible and is enabled to make informed choices and decisions;

(d) Is timely, responsive to changing needs, occurs at times and locations convenient to the individual, and is reviewed at least annually;

(e) Reflects the cultural considerations of the individual;

(f) Uses language, format, and presentation methods appropriate for effective communication according to the needs and abilities of the individual and, as applicable, the individual’s representative;

(g) Includes strategies for resolving disagreement within the process, including clear conflict of interest guidelines for all planning participants, such as:

(A) Discussing the concerns of the individual and determining acceptable solutions;

(B) Supporting the individual in arranging and conducting a person-centered service planning meeting;

(D) Referring concerns to the Office of the Long-Term Care Ombudsman; or

(E) For Medicaid recipients, following existing, program-specific grievance processes.

(h) Offers choices to the individual regarding the services and supports the individual receives and from whom, and records the alternative HCB settings that were considered by the individual;

(i) Provides a method for the individual to request updates to the person-centered service plan for the individual;

(j) Is conducted to reflect what is important to the individual to ensure delivery of services in a manner reflecting personal preferences and ensuring health and welfare;

(k) Identifies the strengths and preferences, service and support needs, goals, and desired outcomes of the individual;

(L) Includes any services that are self-directed, if applicable;

(m) Includes but is not limited to individually identified goals and preferences related to relationships, greater community participation, employment, income and savings, healthcare and wellness, and education;

(n) Includes risk factors and plans to minimize any identified risk factors; and

(o) Results in a person-centered service plan documented by the person-centered services plan coordinator, signed by the individual, participants in the person-centered service planning process, and all individuals responsible for the implementation of the person-centered service plan, including the provider, as described in these rules. The person-centered service plan is distributed to the individual and other people involved in the person-centered service plan as described in these rules.

(8) Required contents of the person-centered service plan:

(a) When the provider is required to develop the person-centered service plan, the provider shall ensure that the plan includes the following:

(A) HCBS and setting options based on the needs and preferences of the individual and for residential settings, the available resources of the individual for room and board;

(B) The HCBS and settings are chosen by the individual and are integrated in and support full access to the greater community;

(C) Opportunities to seek employment and work in competitive integrated employment settings for those individuals who desire to work. If the individual wishes to pursue employment, a non-disability specific setting option shall be presented and documented in the person-centered service plan;

(D) Opportunities to engage in greater community life, control personal resources, and receive services in the greater community to the same degree of access as people not receiving HCBS;

(E) The strengths and preferences of the individual;

(F) The service and support needs of the individual;

(G) The goals and desired outcomes of the individual;

(H) The providers of services and supports, including unpaid supports provided voluntarily;

(I) Risk factors and measures in place to minimize risk;

(J) Individualized backup plans and strategies, when needed;

(K) People who are important in supporting the individual;

(L) The person responsible for monitoring the person-centered service plan;

(M) Language, format, and presentation methods appropriate for effective communication according to the needs and abilities of the individual receiving services;

(N) The written informed consent of the individual;

(O) Signatures of the individual, participants in the person-centered service planning process, and all people and providers responsible for the implementation of the person-centered service plan as described below in subsection (c) of this section;

(P) Self-directed supports; and

(Q) Provisions to prevent unnecessary or inappropriate services and supports.

(b) When the provider is not required to develop the person-centered service plan but provides services to the individual, the provider shall provide relevant information and provide necessary support for the person-centered service plan coordinator or other persons developing the plan to fulfill the characteristics described in these rules;

(c) The individual decides on the level of information in the person-centered service plan that is shared with providers. To effectively provide services, providers shall have access to the portion of the person-centered service plan that the provider is responsible for implementing;

(d) The person-centered service plan is distributed to the individual and other people involved in the person-centered service plan as described in these rules;

(e) The person-centered service plan shall justify and document any individually-based limitation to be applied as outlined in OAR 309-040-0393 (Individually-Based Limitations) when an individual’s rights under OAR 309-040-0410 (Residents’ Bill of Rights, Complaints, and Grievances)(2)(b) through (i) may not be met due to threats to the health and safety of the individual or others;

(f) The person-centered service plan shall be reviewed and revised:

(A) At the request of the individual:

(B) When the circumstances or needs of the individual change; or

(9) Because it may not be possible to assemble complete records and develop a person-centered service plan during the crisis-respite individual’s short stay, the provider is not required to develop a person-centered service plan under these rules, but shall, at a minimum, develop an initial care plan as required by section (7) of these rules to identify service needs, desired outcomes, and service strategies to resolve the crisis or address the individual’s other needs that caused the need for crisis-respite services. In addition, the provider shall provide relevant information and provide necessary support for the person-centered service plan coordinator as described in section (11)(b) of this rule.

(10) The provider shall develop an individual record for each individual. The provider shall keep the individual record current and available on the premises for each individual admitted to the AFH. The provider shall maintain an individual record consistent with the following requirements:

(a) The record shall include:

(A) The individual’s name, previous address, date of entry into AFH, date of birth, sex, marital status, religious preference, preferred hospital, Medicaid or Medicare numbers where applicable, guardianship status, and;

(B) The name, address, and telephone number of:

(i) The individual’s legal representative, designated representative, family, advocate, or other significant person;

(ii) The individual’s preferred primary health provider, designated back up health care provider or clinic;

(iii) The individual’s preferred dentist;

(iv) The individual’s day program or employer, if any;

(v) The individual’s case manager; and

(vi) Other agency representatives providing services to the individual.

(C) Individual records shall be available to the Authority conducting inspections or investigations as well as to the individual or the individual’s representative;

(D) Original individual records shall be kept for a period of three years after discharge when an individual no longer resides in the AFH;

(E) In all other matters pertaining to confidential records and release of information, providers shall comply with ORS 179.505 (Disclosure of written accounts by health care services provider).

(b) Medical Information:

(A) History of physical, emotional, and medical problems, accidents, illnesses or mental status that may be pertinent to current care;

(B) Current orders for medications, treatments, therapies, use of restraints, special diets, and any known food or medication allergies;

(D) Name and claim number of medical insurance and any pertinent medical information such as hospitalizations, accidents, immunization records including previous TB tests, incidents or injuries affecting the health, safety, or emotional well-being of any individual.

(A) Individual’s Income Sources;

(B) Refer to the individual’s residential care plan with supporting documentation from the income sources to be maintained in the individual’s individual record;

(C) The individual or the individual’s representative shall agree to specific costs for room and board and services within the pre-set limits of the state contract. A copy shall be given to the individual, the individual’s representative, and the original in the individual’s individual record;

(D) Individual’s record of discretionary funds.

(d) If an individual maintains custody and control of his or her discretionary funds, then no accounting record is required;

(e) If a designee of the AFH maintains custody and control of an individual’s discretionary fund, a signed and dated account and balance sheet shall be maintained with supporting documentation for expenditures $10 and greater. The AFH designee shall have specific written permission to manage an individual’s discretionary fund;

(f) The provider shall maintain a copy of the written house rules with documentation that the provider discussed the house rules with the individual;

(g) A written incident report of any unusual incidents relating to the AFH including but not limited to individual care. The incident report shall include how and when the incident occurred, who was involved, what action was taken by staff, and the outcome to the individual. In compliance with HIPAA rules, only the individual’s name may be used in the incident report. Separate reports shall be written for each individual involved in an incident. A copy of the incident report shall be submitted to the CMHP within five working days of the incident. The original shall be placed in the individual’s individual record;

(h) Any other information or correspondence pertaining to the individual;

(i) Progress notes shall be maintained within each individual’s record and document significant information relating to all aspects of the individual’s functioning and progress toward desired outcomes as identified in the individual’s personal care plan. A progress note shall be entered in the individual’s record at least once each month.

(11) Residents’ Bill of Rights:

(a) The provider shall guarantee the Residents’ Bill of Rights as described in ORS 443.739 (Rights of residents). The provider shall post a copy of the Residents’ Bill of Rights in a location that is accessible to individuals, individuals’ representatives, parents, guardians, and advocates. The provider shall give a copy of the Residents’ Bill of Rights to each individual, individuals’ representative, parent, guardian, and advocate along with a description of how to exercise these rights;

(b) The provider shall explain and document in the individual’s file that a copy of the Residents’ Bill of Rights was given to each individual at admission and is posted in a conspicuous place including the name and phone number of the office to call to report complaints.

(12) Providers, resident managers, or substitute caregivers may not use physical restraints for individuals receiving personal care services authorized or funded through the Division.

(13) The provider shall:

(a) Conspicuously post the State license and Abuse and Complaint poster where it can be seen by individuals;

(b) Cooperate with Division personnel or designee in complaint investigation procedures, abuse investigations, and protective services, planning for individual care, application procedures, and other necessary activities, and allow access of Division personnel to the AFH, its individuals, and all records;

(c) Give care and services, as appropriate to the age and condition of the individual and as identified on the RCP. The provider shall ensure that physicians’ orders and those of other medical professionals are followed and that the individual’s physicians and other medical professionals are informed of changes in health status or if the individual refuses care;

(d) House Rules:

(A) The provider shall develop reasonable written house rules regarding hours, visitors, use of tobacco and alcohol, meal times, use of telephones and kitchen, monthly charges and services to be provided and policies on refunds in case of departure, hospitalization, or death;

(B) The provider shall discuss house rules with the individual and families at the time of arrival and be posted in a conspicuous place in the facility. The provider shall maintain written documentation in the individual record that the provider discussed the house rules with the individual along with a copy of the house rules;

(C) House rules are subject to review and approval by the Division and may not violate individual’s rights as stated in ORS 430.210 (Rights of persons receiving mental health services);

(D) House rules may not restrict or limit the individual rights under OAR 309-040-0410 (Residents’ Bill of Rights, Complaints, and Grievances)(2). This subsection is effective July 1, 2016, and enforceable according to 309-040-0315 (License Application and Fees)(7).

(e) In the provider’s absence, the provider shall have a resident manager or substitute caregiver on the premises to provide care and services to individuals. For absences greater than 72 consecutive hours, the CMHP shall be notified of the name of the substitute caregiver for the provider or resident manager;

(f) A provider, resident manager, or substitute caregiver shall be present in the home at all times;

(g) Allow and encourage individuals to exercise all civil and human rights accorded to other citizens;

(h) Not allow or tolerate physical, sexual, or emotional abuse or punishment, or exploitation, or neglect of individuals;

(i) Provide care and services as agreed to in the RCP;

(j) Keep information related to individuals confidential as required under ORS 179.050 (Authority to hold property);

(k) Ensure that the number of individuals requiring nursing care does not exceed the provider’s capability as determined by the Division or CMHP;

(L) Not admit individuals who are clients of Aging and People with Disabilities without the express permission of the Division;

(m) Notify the Division prior to a closure and give individuals, the individuals’ representative, families, and CMHP staff 30 days written notice of the planned change except in circumstances where undue delay might jeopardize the health, safety, or well-being of individuals, providers, or caregivers. If a provider has more than one AFH, an individual may not be shifted from one AFH to another without the same period of notice unless prior approval is given and agreement obtained from individuals, family members, and CMHP;

(n) Exercise reasonable precautions against any conditions that threatens the health, safety, or welfare of individuals;

(o) Immediately notify the appropriate RCP Team members (in particular the CMHP representative and family or guardian) if: The individual has a significant change in medical status; the individual has an unexplained or unanticipated absence from the AFH; the provider becomes aware of alleged or actual abuse of the individual; the individual has a major behavioral incident, accident, illness, hospitalization; the individual contacts or is contacted by the police; or the individual dies, and follow-up with an incident report.

(14) The provider shall write an incident report for any unusual incident and forward a copy of the incident report to the CMHP within five working days of the incident. Any incident that is the result of or suspected of being abuse shall be reported to the Office of Investigations and Training within 24 hours of occurrence.

Source: Rule 309-040-0390 — Standards and Practices for Care and Services, https://secure.sos.state.or.us/oard/view.action?ruleNumber=309-040-0390.

California:	Codes
Colorado:	C.R.S.
Nevada:	NRS
New York:	Laws
Oregon:	OAR, ORS
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OAR 309-040-0390 Standards and Practices for Care and Services

OAR 309-040-0390
Standards and Practices for Care and Services