Oregon Department of Human Services, Aging and People with Disabilities and Developmental Disabilities
Service Plan — General
If the resident has a Person-Centered Service Plan pursuant to 411-004-0030 (Person-Centered Service Plans), the facility must incorporate all elements identified in the person-centered service plan into the resident’s service plan.
SERVICE PLAN. The service plan must reflect the resident’s needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
The service plan must be completed:
Before resident move-in, with updates and changes as appropriate within the first 30-days; and
Following quarterly evaluations.
The service plan must be readily available to staff and provide clear direction regarding the delivery of services.
The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
Changes and entries made to the service plan must be dated and initialed.
When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.
A copy of the service plan, including each update, must be offered to the resident or to the resident’s legal representative.
The facility administrator is responsible for ensuring the implementation of services.
SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.
Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.
The initial service plan must be reviewed within 30-days of move- in to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident’s needs and preferences.
Staff must document and date adjustments or changes as applicable.
QUARTERLY SERVICE PLAN REQUIREMENTS.
Service plans must be completed quarterly after the resident moves into the facility.
The quarterly evaluation is the basis of the resident’s quarterly service plan.
If the resident’s service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.
SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident’s legal representative, if applicable, any person of the resident’s choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.
As applicable, the Service Planning Team must also include:
Local APD or AAA case managers and family invited by the resident, as available.
A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045 (Resident Health Services)(1)(f)(D) (Resident Health Services).
The resident’s physician or other health practitioner.
Each resident must actively participate in the development of the service plan to the extent of the resident’s ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility’s attempts to determine the resident’s preferences.
RISK AGREEMENT. When a resident’s actions or choices pose a potential risk to that resident’s health or well-being, the facility may utilize a risk agreement to explore alternatives and potential consequences with the resident.
The facility must identify the need for and develop a written risk agreement following the facility’s established guidelines and procedures. A risk agreement must include:
An explanation of the cause of concern;
The possible negative consequences to the resident or others;
A description of the resident’s preference;
Possible alternatives or interventions to minimize the potential risks associated with the resident’s current preferences and actions;
A description of the services the facility shall provide to accommodate the residents’ choice or minimize the potential risk; and
The final agreement, if any, reached by all involved parties, must be included in the service plan.
The licensing policy analyst must be consulted and alternatives reviewed before the resident signs the agreement.
The facility must involve the resident, the resident’s designated representative, and others as indicated, to develop, implement, and review the risk agreement. The resident’s preferences shall take precedence over those of a family member.
A risk agreement shall not be entered into or continued with, or on behalf of, a resident who is unable to recognize the consequences of their behavior or choices.
The risk agreement must be reviewed at least quarterly.