Documentation and Records for Professional Behavior Services
(1)A behavior professional must maintain documentation of all delivered professional behavior services and furnish the documentation to the Department, Oregon Health Authority, or case management entity, upon request. A behavior professional employed by a 24-hour residential or supported living agency is exempt from this requirement when providing professional behavior services to an individual within that setting. A behavior professional must document all of the following:
(a)Date of service.
(b)Who provided the service.
(c)Location of where and method of how the service was provided.
(d)Length of time required for the service, including start and end times.
(e)Description of the service delivered.
(f)People present when the service was delivered.
(2)The documents generated by a behavior professional during the delivery of professional behavior services belong to the individual.
(3)Unless stated otherwise, all documentation required by these rules must be:
(a)Prepared at the time of, or immediately following, the event being recorded.
(b)Accurate and contain no willful falsifications.
(c)Legible, dated, and signed by the behavior professional.
(4)A behavior professional must maintain a release of information in accordance with OAR chapter 407 division 014, for each individual receiving professional behavior services from the behavior professional.
(5)A behavior professional must maintain their records for professional behavior services until the behavior professional no longer provides services to the individual, at which time, the behavior professional must provide a copy of any part of the record that was not previously provided to the case management entity. The behavior professional must retain an individual’s service record, following HIPAA practices, for a period of seven years. Financial records, supporting documents, statistical records, and all other records, other than an individual’s service record, must be retained for at least three years after services have ended.
(6)Access to records by the Department and Oregon Health Authority including, but not limited to, medical, nursing, behavior, psychiatric, or financial records, does not require authorization or release by the individual or the individual’s legal representative.
(7)A behavior professional must furnish requested documentation immediately upon the written or electronic request from the Department, Oregon Health Authority, Oregon Department of Justice Medicaid Fraud Unit, Centers for Medicare and Medicaid Services, or their authorized representatives, or within the timeframe specified in the written request. Failure to comply with the request may be considered by the Department as reason to deny or recover payment.
Rule 411-304-0190 — Documentation and Records for Professional Behavior Services,