Individual Support Plan
(1)A provider must collect and summarize the following information prior to an ISP meeting:
(a)One page profile reflecting, at a minimum, information gathered by the provider at the setting where the individual receives services.
(b)Person-centered Information reflecting, at a minimum, information gathered by the provider at the setting where the individual receives services.
(c)Information about known, identified serious risks.
(2)A provider must develop and share the following information with an individual’s case manager and the individual, or if applicable the individual’s legal or designated representative, as directed by the individual’s ISP or Service Agreement.
(a)Implementation strategies, such as action plans, for desired outcomes or goals.
(b)Necessary protocols or plans that address health, behavioral, safety, and financial supports.
(c)A summary of the provider risk management strategies in place, including title of document, date, and where the document is located.
(d)A Nursing Service Plan, if applicable.
(e)Other documents required by the ISP team.
(3)When desired by an individual, their provider must participate in the individual’s ISP team meetings.
(4)A provider must agree in writing to implement the portion of the ISP for which the provider is responsible for implementing. Agreement may be recorded by a signature on the ISP or a Service Agreement.
(5)A provider must maintain a copy of the ISP or Service Agreement provided by the case management entity.
(6)A provider must maintain documentation of implementation of each support and services specified in sections (2)(a) to (2)(e) of this rule in an individual’s ISP. The documentation must be kept current and be available for review by the individual, the individual’s legal representative, case management entity, and Department representatives.
(a)A provider may not place any limitations to the following freedoms without an individually-based limitation:
(A)Support and freedom to access the individual’s personal food at any time.
(B)Visitors of the individual’s choosing at any time.
(C)A lock on the individual’s bedroom, lockable by the individual.
(D)Choice of a roommate, if sharing a bedroom.
(E)Freedom to furnish and decorate the individual’s bedroom as the individual chooses in accordance with their Residency Agreement.
(F)Freedom and support to control the individual’s schedule and activities.
(G)Freedom from restraint, except in accordance with the standards for developmental disabilities services set forth in ORS 443.739 (Rights of residents), OAR chapter 411, or the relevant Title XIX Medicaid-funding authority.
(b)When an individual’s freedom in subsection (a) of this section may not be met due to a threat to the health and safety of the individual or others, an individually-based limitation must be authorized and documented in the individual’s ISP in accordance with OAR 411-415-0070 (Service Planning).
(c)A provider is responsible for all of the following:
(A)Maintaining a copy of the completed and signed form documenting an individual’s consent to the appropriate individually-based limitation. The form must be signed by the individual or the individual’s legal representative, if applicable.
(B)Regular collection and review of data to measure the ongoing effectiveness of, and the continued need for, the individually-based limitation.
(C)Requesting a review of the individually-based limitation when a new individually-based limitation is indicated, or change or removal of an individually-based limitation is needed.
Rule 411-325-0430 — Individual Support Plan,