OAR 333-536-0065
Service Plan
(1)
The agency administrator or designee shall conduct an initial evaluation of the client. The evaluation must be documented, dated, and signed by the individual who conducted the evaluation, and maintained in the client’s agency record.(2)
The agency administrator or designee, in conjunction with the client or the client’s representative, shall complete a written service plan within seven days after the initiation of services. The agency administrator or designee shall ensure that the service plan includes a list of individuals participating in development of the plan. The agency administrator or designee shall also sign and date the service plan when it is complete and acceptable to all individuals participating in development of the plan.(3)
The completed service plan shall be client-directed or client representative-directed and include at least the following:(a)
The schedule for the provision of services specifying a range of hours for services per month;(b)
The services to be provided, specifying the tasks to be conducted; and(c)
Pertinent information about the client’s needs in relation to the services to be provided to ensure the provision of safe and appropriate care.(4)
A client or a client’s representative may request changes in the service plan. All changes must be communicated to the caregiver(s) and documented.(5)
An agency shall maintain the original service plan and all updated service plans in each client’s agency record. Complete and legible copies of the service plan shall be given to the client or client’s representative upon request.(6)
The administrator or designee must conduct an initial visit at the client’s residence within 30 days of the initiation of services to evaluate compliance by the caregiver(s) with the service plan and to assess the client’s satisfaction. The initial visit must occur between the 7th and 30th day. An initial visit is not required when:(a)
A client cancels service on or before the 30th day;(b)
A client is residing in a nursing facility or a hospital; or(c)
A client refuses.(7)
The administrator or designee must conduct quarterly monitoring visits after the initial site visit. Quarterly monitoring visits may occur by phone or by other electronic means at the discretion of the administrator or designee under the following circumstances: impending discharge from services; relocation to a facility; when minimal services, such as one shift a month, would cause the client to incur undue financial burden; or, due to other circumstances that are justified in chart note(s). In no case shall the time between the in-person monitoring visits exceed a six-month period.(8)
Each monitoring visit to observe and report on the client’s status must be documented, dated, and signed by the administrator or designee. The caregiver may be present during the monitoring visit.(9)
The administrator or designee must determine and document during a monitoring visit:(a)
Whether appropriate and safe techniques have been used in the provision of care;(b)
Whether the service plan has been followed as written;(c)
Whether the service plan is meeting the client’s needs or needs to be updated;(d)
Whether the caregiver has received sufficient training for the client;(e)
Whether the client is satisfied with his or her relationship with the caregiver(s); and(f)
Whether appropriate follow-up is necessary for any identified issues or problems.(10)
If services are provided in a non-residential setting in accordance with the service plan, monitoring visits shall take place in the same setting that services are provided and must conform to the requirements set forth in this rule.
Source:
Rule 333-536-0065 — Service Plan, https://secure.sos.state.or.us/oard/view.action?ruleNumber=333-536-0065.