OAR 411-034-0070
State Plan Personal Care Service Assessment, Authorization, and Monitoring
(1)
CASE MANAGER RESPONSIBILITIES.(a)
ASSESSMENT AND REASSESSMENT.(A)
A case manager must meet in person with an individual to assess the individual’s ability to perform the personal care tasks listed in OAR 411-034-0020 (State Plan Personal Care Services).(B)
An individual’s natural supports may participate in the assessment if requested by the individual.(C)
A case manager must assess an individual’s service needs, identify the resources meeting any, some, or all of the individual’s needs, and determine if the individual is eligible for State Plan personal care services or other services.(D)
A case manager must meet with an individual in person at least once every 365 days to review the individual’s service needs.(b)
SERVICE PLANNING.(A)
A case manager must prepare a service plan identifying the tasks for which an individual requires assistance and the number of authorized service hours per service period. The case manager must document an individual’s natural supports that currently meet some or all of the individual’s assistance needs.(B)
The service plan must describe the tasks to be performed by a qualified provider and must authorize the maximum hours per service period that may be reimbursed for those services.(C)
When developing service plans, a case manager must consider the cost effectiveness of services that adequately meet the individual’s service needs.(D)
Payment for State Plan personal care services must be prior authorized by a case manager and based on the service needs of an individual as documented in the individual’s written service plan.(c)
ONGOING MONITORING AND AUTHORIZATION.(A)
When there is an indication that an individual’s personal care needs have changed, a case manager must conduct an in person re-assessment with the individual (and any of the individual’s natural supports if requested by the individual).(B)
Following annual re-assessments and those conducted after a change in an individual’s personal care needs, a case manager must review service eligibility, the cost effectiveness of the individual’s service plan, and whether the services provided are meeting the identified service needs of the individual. The case manager may adjust the hours or services in the individual’s service plan and must authorize a new service plan, if appropriate, based on the individual’s current service needs.(d)
ONGOING CASE MANAGEMENT. A case manager must provide ongoing coordination of State Plan personal care services, including authorizing changes in providers and service hours, addressing risks, and monitoring and providing information and referral to an individual when indicated.(2)
LONG TERM CARE (LTC) COMMUNITY NURSING SERVICES. A LTC community nurse is a licensed, registered nurse (RN) who has been approved under a contract or provider agreement with the Department, Division, or Designee to provide nursing assessment for indicators identified in subsection (a) of this section and may provide on-going nursing services as identified in subsection (b) of this section to certain individuals served by the Department, Division, or Designee. Individuals receiving LTC community nursing services are primarily older adults and adults with disabilities.(a)
A case manager may refer a LTC community nurse where available, for nursing assessment and monitoring when it appears an individual needs assistance to manage health support needs and may need delegated nursing tasks, nurse assessment and consultation, teaching, or services requiring RN monitoring. Indicators of the need for LTC community nurse assessment and monitoring include:(A)
Complex health problem or multiple diagnoses resulting in the need for assistance with health care coordination;(B)
Medical instability, as demonstrated by frequent emergency care, physician visits, or hospitalizations;(C)
Behavioral symptoms or changes in behavior or cognition;(D)
Nutrition, weight, or dehydration issues;(E)
Skin breakdown or risk for skin breakdown;(F)
Pain issues;(G)
Medication safety issues or concerns;(H)
A history of recent, frequent falls; or(I)
A provider may benefit from teaching or training about the health support needs of an eligible individual.(b)
Following the completion of an initial nursing assessment in an individual’s home by a LTC community nurse, the provision of ongoing LTC community nursing services must be prior-authorized by a case manager and may include:(A)
Ongoing health monitoring and teaching for an eligible individual specific to the individual’s identified needs;(B)
Medication education for an eligible individual and the individual’s provider;(C)
Instructing or training a provider or natural support to address an individual’s health needs;(D)
Consultation with other health care professionals serving an individual and advocating for the individual’s medical and restorative needs in a non-facility setting; or(E)
Delegation of nursing tasks defined in OAR 411-034-0010 (Definitions) to a non-family provider.(c)
LTC Community nursing services must be provided as described in OAR chapter 411, division 048.(3)
UNAUTHORIZED SERVICE SETTINGS AND PROVIDERS.(a)
The Department, Division, or Designee may not authorize services within an eligible individual’s home when --(A)
The individual’s home has dangerous conditions that jeopardize the health or safety of the individual and necessary safeguards cannot be taken to improve the setting;(B)
The services cannot be provided safely or adequately by a provider;(C)
The individual’s home has dangerous conditions that jeopardize the health or safety of the provider and necessary safeguards cannot be taken to minimize the dangers; or(D)
The eligible individual does not have the ability to make an informed decision, does not have a designated representative to make decisions on his or her behalf, and necessary safeguards cannot be provided to protect the safety, health, and welfare of the individual.(b)
A case manager must present an individual or the individual’s representative with information on service alternatives and provide assistance to assess other choices when a provider or service setting selected by the individual or the individual’s representative is not authorized.
Source:
Rule 411-034-0070 — State Plan Personal Care Service Assessment, Authorization, and Monitoring, https://secure.sos.state.or.us/oard/view.action?ruleNumber=411-034-0070.