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

Rule Rule 411-051-0115
Care Plan


(1) During the initial 14 calendar days following the resident’s admission to the home, the licensee or administrator must continue to assess and document the resident’s preferences and care needs. The assessment and care plan must be completed by the licensee or administrator and documented within the initial 14-day period. The care plan must describe the resident’s needs, preferences, capabilities, what assistance the resident requires for various tasks, and must include:
(a) By whom, when, and how often care and services shall be provided.
(b) The resident’s ability to perform activities of daily living (ADLs).
(c) Special equipment needs.
(d) Communication needs (examples may include, but are not limited to, hearing or vision needs, such as eraser boards or flash cards, or language barriers, such as sign language or non-English speaking).
(e) Night needs.
(f) Medical or physical health problems, including physical disabilities, relevant to care and services.
(g) Cognitive, emotional, or other impairments relevant to care and services.
(h) Treatments, procedures, or therapies.
(i) Registered nurse consultation, teaching, delegation, or assessment.
(j) Behavioral interventions.
(k) Social, spiritual, and emotional needs, including lifestyle preferences, activities, and significant others involved.
(l) The ability to exit in an emergency, including assistance and equipment needed.
(m) Any use of physical restraints or psychotropic medications.
(n) Dietary needs and preferences.
(o) Any individually-based limitations according to OAR 411-051-0105 (Resident’s Rights) (3).
(A) Effective July 1, 2019 and no later than June 30, 2020, the licensee or administrator must identify any individually-based limitations to the use of restraints or the HCBS rights as listed in OAR 411-051-0105 (Resident’s Rights)(2).
(B) For Medicaid-eligible residents, the person-centered service plan coordinator must authorize the limitation and the individual must consent to the limitation. The licensee or administrator must incorporate and document all applicable elements identified in OAR 411-051-0105 (Resident’s Rights)(3).
(C) Limitations are not transferable between care settings. Continued need for any limitation at the new care setting must comply with the requirements as stated in OAR 411-051-0105 (Resident’s Rights).
(2) The licensee or administrator must:
(a) Review and update each resident’s care plan every six months.
(b) Review and update a resident’s care plan when a resident’s condition changes.
(c) Document in the resident’s record at the time of each review and include the date of the review and the licensee or administrator ’s signature. If a care plan contains many changes and becomes less legible, a new care plan must be written.
(3) The licensee or administrator is responsible for ensuring implementation of the resident’s care plan and, if applicable, the behavioral support plan with suggested interventions.
Source

Last accessed
Jun. 8, 2021