OAR 411-328-0630
Medical Services
(1)
The medical records for individuals must be kept confidential as described in OAR 411-323-0060 (Policies and Procedures).(2)
The provider must provide sufficient oversight and guidance to ensure that the health and medical needs of the individuals are adequately addressed.(3)
Written health and medical supports must be developed as required for an individual and integrated into a Transition Plan or ISP. The plan must be based on a functional needs assessment of the health and medically related support needs and preferences of the individual and updated annually or as significant changes occur.(4)
The provider must have and implement written policies and procedures that maintain and protect the physical health of individuals. The policies and procedures must address the following:(a)
Early detection and prevention of infectious disease;(b)
Emergency medical intervention;(c)
Treatment and documentation of illness and health care concerns; and(d)
Obtaining, administering, storing, and disposing of prescription and non-prescription drugs, including self-administration of medication.(5)
The provider must ensure an individual has a primary physician or health care provider whom the individual has chosen from among qualified providers.(6)
Provisions must be made for a secondary physician, health care provider, or clinic in the event of an emergency.(7)
The provider must ensure that an individual receives a medical evaluation by a qualified health care provider no fewer than every two years or as recommended by a health care provider. Evidence of the medical evaluation must be placed in the record for the individual and must address:(a)
Current health status;(b)
Changes in health status;(c)
Recommendations, if any, for further medical intervention;(d)
Any remedial and corrective action required and the date of action;(e)
Restrictions on activities due to medical limitations; and(f)
Prescribed medications, treatments, special diets, and therapies.(8)
The provider must monitor the health status and physical conditions of the individual and take action in a timely manner in response to identified changes or conditions that may lead to deterioration or harm.(9)
Before the entry of an individual, the provider must obtain the most complete medical profile available for the individual, including:(a)
The results of most recent physical exam;(b)
Results of any dental evaluation;(c)
A record of immunizations;(d)
A record of known communicable diseases and allergies; and(e)
A summary of the medical history of the individual, including chronic health concerns.(10)
The provider must ensure that all medications, treatments, and therapies:(a)
Have a written order or a copy of a written order signed by a physician or qualified health care provider before any medication, prescription, or non-prescription is administered to, or self-administered by, an individual unless otherwise indicated by an ISP team in the written health and medical support section of the ISP or Transition Plan for the individual; and(b)
Be followed per written orders.(11)
PRN (as needed) orders are not allowed for psychotropic medication.(12)
The drug regimen of an individual on prescription medication must be reviewed and evaluated by a physician or physician designee no less often than every 180 days unless otherwise indicated by an ISP team in the written health and medical support section of the ISP or Transition Plan for the individual.(13)
All prescribed medications and treatments must be self-administered unless contraindicated by an ISP team or physician. For an individual who requires assistance in the administration of his or her own medication, the following must be met:(a)
The ISP team must recommend that the individual receive assistance with taking his or her own medication;(b)
There must be a written training program for the self-administration of medication unless contraindicated by the ISP team; and(c)
There must be a written record of medications and treatments that documents that the orders of a physician are being followed.(14)
The ISP for an individual who independently self-administers medication must include a plan for the periodic monitoring or review of the self-administration of medication.(15)
The provider must assist an individual with the use of a prosthetic device as ordered.
Source:
Rule 411-328-0630 — Medical Services, https://secure.sos.state.or.us/oard/view.action?ruleNumber=411-328-0630.