Oregon Department of Human Services, Aging and People with Disabilities and Developmental Disabilities

Rule Rule 411-004-0030
Person-Centered Service Plans


(1)

PERSON-CENTERED SERVICE PLANNING PROCESS. A person-centered service plan must be developed through a person-centered service planning process. The person-centered service planning process:

(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 legal or designated representative of the individual;

(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;

(C)

Utilizing any available greater community conflict resolution resources;

(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 or, as applicable, the legal or designated representative of the individual, to request updates to the person-centered service plan for the individual, as needed;

(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 or, as applicable, the legal or designated representative 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 section (2)(d) of this rule. The person-centered service plan is distributed to the individual, and, as applicable, the legal or designated representative of the individual, and other people involved in the person-centered service plan as described below in section (2)(d) of this rule.

(2)

PERSON-CENTERED SERVICE PLANS.

(a)

For individuals receiving Medicaid:

(A)

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.

(B)

The person-centered service plan must 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 legal or designated representative.

(C)

To avoid conflict of interest, the person-centered service plan may not be developed by the provider of HCBS for individuals receiving Medicaid. Exceptions may be granted when DHS or OHA has determined that the only willing and qualified entity to provide case management and develop the person-centered service plan in a specific geographic area also provides HCBS.

(b)

For private pay individuals, a person-centered service plan will be developed by the individual, or, as applicable, the legal or designated representative of the individual, and others chosen by the individual. Providers may 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.

(c)

For individuals receiving Medicaid services the written person-centered service plan reflects:

(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 must 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 and, as applicable, the legal or designated representative of the individual.

(N)

The written informed consent of the individual or, as applicable, the legal or designated representative of the individual.

(O)

Signatures of the individual or, as applicable, the legal or designated representative 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 (d) of this section.

(P)

Self-directed supports.

(Q)

Provisions to prevent unnecessary or inappropriate services and supports.

(d)

The individual or, as applicable, the legal or designated representative of the individual, decides on the level of information in the person-centered service plan that is shared with providers. To effectively provide services, providers must have access to the portion of the person-centered service plan that the provider is responsible for implementing.

(e)

The person-centered service plan is distributed to the individual and, as applicable, the legal or designated representative of the individual, and other people involved in the person-centered service plan as described above in subsection (d) of this section.

(f)

The person-centered service plan must justify and document an individually-based limitation as described in OAR 411-004-0040 (Individually-Based Limitations) when conditions under OAR 411-004-0020 (Home and Community-Based Services and Settings)(1)(d) and (2)(d) to (2)(j) may not be met due to threats to the health and safety of the individual or others.

(g)

The person-centered service plan must be reviewed and revised:

(A)

At the request of the individual or, as applicable, the legal or designated representative of the individual;

(B)

When the circumstances or needs of the individual change; or

(C)

Upon reassessment of functional needs as required every 12 months.
Source

Last accessed
Jun. 8, 2021