justicedao/ipfs_state_laws huggingface dataset:
411-044-0030 Application Review (1) The Department shall review all applications and may request any additional information needed to assure applications are complete. (2) After an application is determined to be complete and concordant with the intended goals and outcomes of the program, it shall be forwarded to the Lifespan Advisory Review Committee, a sub-committee of the Oregon Family Support Council, for review and possible recommendation for selection approval. (3) In reviewing applications, the Committee shall consider the following elements: (a) The amount of available funds for the Oregon Lifespan Respite Care Program; (b) The existence of a strong community coalition representing children, adults and seniors with special needs and situations. The coalition should include, but not be limited to, members from the following areas: (A) Families and/or consumers; (B) Respite providers; (C) Medical and/or health related fields; (D) State, federal and/or county agencies; (E) Private businesses; (F) Civic, social and community organizations; (G) Faith communities; and (H) Community volunteers. (c) The willingness and ability to contract with the Department and participate in all required Oregon Lifespan Respite Care Program activities; (d) The ability to articulate program outcomes and strategies, which include Family Support principles, as described in ORS 417.342; (e) The amount of in-kind services; (f) The stability of other funding sources; and (g) Additional departmental administrative costs or responsibilities associated with the individual application. Statutory/Other Authority: ORS 409.050 & 409.474 Statutes/Other Implemented: ORS 409.450 – 409.478 History: Renumbered from 410-015-0030 by SPD 25-2006, f. 7-12-06 cert. ef. 7-14-06 Suspended by OMAP 4-1999, f. & cert. ef. 2-23-99 OMAP 42-1998(Temp), f. & cert. ef. 11-9-98 thru 5-8-99 OMAP 19-1998, f. & cert. ef. 5-4-98
411-044-0040 Selection (1) The Director of the Department of Human Services or his/her designee shall make the final decision regarding selection of community-based lifespan respite programs. (2) The Department shall notify applicants in writing of the approval or rejection of the applications. (3) Selected applicants shall: (a) Develop and maintain a point of contact for access to lifespan respite care services within a designated geographical area; (b) Develop and maintain a mechanism to recruit and screen potential respite providers and volunteers; (c) Identify local training resources and coordinate respite training opportunities for caregivers, respite providers, and families; (d) Publicize the lifespan respite care program phone number and address; and (e) Comply with all program policies and guidelines established by the Oregon Lifespan Respite Care Program. (4) Selected applicants shall make available to the Department records and materials necessary to provide funding and to monitor the program, including projected and actual budgets, performance criteria and reports. (5) If the term and conditions are not met, the Department may, upon written notice, take one or more of the following actions: (a) Immediately revoke approval of funding; (b) Require repayment of all or a portion of any funds advanced; or (c) Take any other appropriate legal action necessary. Statutory/Other Authority: ORS 409.050 & 409.474 Statutes/Other Implemented: ORS 409.450 – 409.478 History: Renumbered from 410-015-0040 by SPD 25-2006, f. 7-12-06 cert. ef. 7-14-06 Suspended by OMAP 4-1999, f. & cert. ef. 2-23-99 OMAP 42-1998(Temp), f. & cert. ef. 11-9-98 thru 5-8-99 OMAP 19-1998, f. & cert. ef. 5-4-98
411-045-0000 Purpose (1) The Program of All-inclusive Care for the Elderly (PACE) is a permanent provider type under Medicare that allows states the option to pay for PACE services under Medicaid. The PACE program is capitated by both Medicare and Medicaid to provide all medical and long-term care services. (2) The intent of these rules is to implement the PACE program as administered by the Department of Human Services and to address the responsibilities of the Department as the state administering agency under 42 CFR 460, that includes additional obligations of coordination with CMS in the administration of the Medicare aspects of the PACE program. The Department will regularly consult with CMS in conducting related responsibilities and in the implementation of the PACE program through the submission of appropriate state plan amendments and the PACE program agreement. Statutory/Other Authority: ORS 410.090 Statutes/Other Implemented: ORS 410.070 History: SPD 2-2005, f. & cert. ef. 1-4-05 SDSD 5-2000, f. 12-29-00 cert. ef. 1-1-01
411-045-0030 Financial (1) PACE programs will assume the risk for providing capitated services under their contracts with the Department. PACE programs must maintain sound financial management procedures, maintain protections against insolvency, and generate periodic financial reports for submission to the Department as applicable: (2) PACE programs must comply with solvency requirements specified in contracts with the Department, as applicable. Solvency requirements of PACE programs must include the following components: (a) Maintenance of restricted reserve funds with balances equal to amounts specified in contracts with the Department; (b) Protection against catastrophic and unexpected expenses related to capitated services for PACE programs. The method of protection may include the purchase of stop loss coverage, reinsurance, self-insurance or any other alternative determined acceptable by the Department, as applicable. Self-insurance must be determined appropriate by the Department; and (c) Maintenance of professional liability coverage of not less than $1,000,000 per person per incident and not less than $1,000,000 in the aggregate either through binder issued by an insurance carrier or by self-insurance with proof of same, except to the extent that the Oregon Tort Claims Act, ORS 30.260 to 30.300 is applicable. (3) The PACE program must be able to satisfy the fiscal soundness requirements in 42 CFR Sec. 460.80. If the amount required in the federal PACE regulations exceeds the sum of the restricted reserve and net worth requirement, the difference may be a combination of insolvency insurance, reinsurance, letters of credit, or excess net worth. Statutory/Other Authority: ORS 410.090 Statutes/Other Implemented: ORS 410.070 History: SPD 2-2005, f. & cert. ef. 1-4-05 SDSD 5-2000, f. 12-29-00 cert. ef. 1-1-01
411-045-0070 Access to Care (1) PACE programs will develop written policies and procedures for communicating with, and providing care to PACE participants who have difficulty communicating due to a medical condition or who are living in a household where there is no adult available to communicate in English or where there is no telephone. Such policies and procedures will address the provision of qualified interpreter services by phone or in person in the PACE Center, PACE administrative offices, and participant's residence. (2) PACE programs will provide or ensure the provision of qualified interpreter services for covered medical, mental health or dental care visits, including home health visits and after hours emergency calls, to interpret for persons with hearing impairment or in the primary language of non-English speaking PACE participants. (a) Interpreters must be linguistically appropriate and be capable of communicating in English and the primary language of the PACE participant and be able to translate clinical information effectively. Interpreter services must be sufficient for the provider to be able to understand the PACE participant's grievance; to make a diagnosis; respond to a participant's questions and concerns; and to communicate instructions to the PACE participant; and (b) Interpreters must be culturally appropriate, i.e., demonstrating both awareness for and sensitivity to cultural differences and similarities and the effect of those on the medical care of the PACE participant. (3) PACE programs must have written policies and procedures that ensure compliance with requirements of the Americans with Disabilities Act (ADA) of 1990 in providing access to covered services for all PACE participants and must arrange for services to be provided by non-participating referral providers when necessary: (a) The policies and procedures must include the assurance of appropriate physical access to obtain covered services for all PACE participants including, but not limited to the following: (A) Street level access or accessible ramp into facility; (B) Wheelchair access to lavatory; (C) Wheelchair access to examination room; and (D) Doors with levered hardware or other special adaptations for wheelchair access. (b) PACE programs must ensure that providers, their facilities and personnel are prepared to meet the special needs of PACE participants who require accommodations because of a disability. PACE programs must monitor providers for compliance with ADA and take corrective action, when necessary. Statutory/Other Authority: ORS 410.090 Statutes/Other Implemented: ORS 410.070 History: SPD 2-2005, f. & cert. ef. 1-4-05 SDSD 5-2000, f. 12-29-00 cert. ef. 1-1-01
411-045-0090 Quality Improvement System (1) A PACE program must have a planned, systematic and ongoing process for monitoring, collecting data and evaluating data and using that process for improving the quality and appropriateness of services provided to PACE participants. This process must include an internal Quality Improvement Program based on written policies, standards and procedures that are in accordance with relevant law, accepted medical practice and with accepted professional standards. (2) A PACE program must designate a Quality Improvement Coordinator who will develop and coordinate systems to facilitate the work of the Quality Improvement Committee. The Quality Improvement Coordinator is generally responsible for the operations of the Quality Improvement Program and must have the management authority to implement changes to the Quality Improvement Program within the parameters of the PACE program. The Quality Improvement Coordinator must be qualified to assess the care of people who are aged, blind, or disabled or must retain consultation from individuals who are so qualified. (3) The PACE program must have a written quality assessment and performance improvement plan. The plan must include all items included in the PACE program's contract with the Department. Statutory/Other Authority: ORS 410.090 Statutes/Other Implemented: ORS 410.070 History: SPD 2-2005, f. & cert. ef. 1-4-05 SDSD 5-2000, f. 12-29-00 cert. ef. 1-1-01
411-046-0100 Purpose (1) The rules in OAR chapter 411, division 46 establish standards and procedures for Medicaid Behavior Support Services. Behavior Support Services are provided to support a wide range of individuals who receive Medicaid funded home and community-based care services. The scope of these rules cover: (a) Department contractors of Behavior Support Services; (b) Licensed assisted living, residential, and adult foster home providers who provide Behavior Support interventions Services to eligible individuals who receive Behavior Support Services; (c) In-home agencies, specialized living, or homecare workers who provide Behavior Support interventions to eligible individuals who receive Behavior Support Services. (2) Behavior Support Services are provided by a behavior consultant who provides eligible individuals and their caregivers with: (a) A Behavior Support Plan; (b) Ideas and strategies to support an individualized Activity Plan; and (c) Coaching for designated caregivers on behavior and activity strategies. (3) The goals of Behavior Support Services are to: (a) Ensure all individuals eligible for State Plan K Community First Choice or Independent Choices receive behavior interventions in a person-centered manner that follows the behavior support standards described in these rules. (b) Ensure individuals who have diagnoses that place them ‘at risk’ of negative behaviors receive proactive environmental strategies and activities which promote: (A) Placement stability; (B) Quality of life; and (C) Autonomy and satisfaction with the individuals' caregivers. (c) Provide caregivers with the environmental strategies and communication skills to revise and implement a Behavior Support Plan. Statutory/Other Authority: ORS 410.070 Statutes/Other Implemented: ORS 410.070 History: APD 17-2014, f. & cert. ef. 6-23-14
411-046-0120 Eligibility (1) Individuals must meet the following requirements to receive Behavior Support Services: (a) Be eligible for home and community-based care services provided through APD; and (b) Be receiving services through either State Plan K Community First Choice or Independent Choices. (2) Behavior Support Services may be provided to eligible individuals noted in (1) above who may benefit from the service or have caregivers who may benefit from the service based on the individual's functional needs assessment that is performed by the case manager. An eligible individual includes, but is not limited to: (a) An individual at risk of requiring behavior interventions; (b) An individual whose caregiver requests assistance in developing person-centered interventions; (c) An individual with a placement failure related to their behavior; (d) An individual at risk of involuntary move out or who has received an eviction notice; (e) An individual receiving Medicaid service payments to support behavior interventions, such as a behavior add-on or an exception; or (f) An individual whose provider receives a payment for costs associated with interventions needed to address the individual’s challenging behaviors. (3) All Behavior Support Services must be pre-authorized by: (a) The eligible individual’s case manager; or (b) A Department authorized placement in a home or community-based care setting where the Medicaid service payment includes Behavior Support Services. (4) Eligible individuals, or their designated representative, may request or refuse to participate in Behavior Support Services. Consultation may still be provided to the care provider. Statutory/Other Authority: ORS 410.070 Statutes/Other Implemented: ORS 410.070 History: APD 17-2014, f. & cert. ef. 6-23-14
411-046-0130 Limitations (1) Behavior Support Services, defined in this rule, may not be provided to: (a) Individuals who are receiving: (A) Specific needs setting contracted rate for "enhanced care services"; or (B) Services through Developmental Disabilities per OAR chapter 411, division 308, OAR chapter 411, division 330, or OAR chapter 411, division 325. (b) Individuals receiving services in a nursing facility or hospital; (2) Behavior consultation services may not be provided solely to: (a) Assist in protective service investigations or licensing inspections; (b) Assist in administrative functions such as, pre-admission screenings, eligibility determinations, or case manager assessments; or (c) Replace or support interventions for adult protective services, crisis management, law enforcement, or 911 emergency services that are required when the behavior of concern is causing an immediate danger to the client, other residents, or caregivers. (3) Behavior Support Services are separate from interventions addressing behavior symptoms as part of: (a) Mental health therapy or counseling; (b) Health or mental health plan coverage; or (c) Vocational or educational services. Statutory/Other Authority: ORS 410.070 Statutes/Other Implemented: ORS 410.070 History: APD 17-2014, f. & cert. ef. 6-23-14
411-046-0150 Authorizations (1) Behavior Support Services must be prior-authorized by the eligible individual’s case manager using the referral process noted in OAR 411-046-0140(4)(a). The Case manager is responsible for ensuring the individual is eligible for an initial referral and ongoing Behavior Support Services. (2) Service hours for person-centered evaluation and development of the Behavior Support Plan are authorized by the individual’s case manager effective on the date the behavior consultant accepts and signs the Department approved referral form. (3) Case managers can authorize up to 40 hours for the initial assessment, service planning, and follow up. An additional 40 hours may be approved by the local office management for ongoing service delivery. The Department may approve additional hours as defined in OAR 411-046-0220 if the individual’s functional needs assessment indicates the need for additional hours. (4) For services noted in OAR 411-046-0140(4)(a) to (4)(f), the provider should make every effort to complete them within 120 days from the service activation date. However, prior authorizations are effective for a full 12 month period from the initial service activation date. After 12 months, a new authorization must be requested and approved. (5) Authorizations for service hours must be completed by the local office within 5 business days of receiving notification of referral acceptance. (6) Prior authorizations are in effect for a 12 month period from the initial service activation date. After 12 months, a new authorization must be requested and approved. (7) Requests for more than 80 hours of service must be reviewed and approved by the Department. Statutory/Other Authority: ORS 410.070 Statutes/Other Implemented: ORS 410.070 History: APD 17-2014, f. & cert. ef. 6-23-14
411-046-0160 Communication (1) Required Reporting. Behavior consultants must report suspected or known neglect or abuse of all adults and elderly individuals as required by ORS 124.050 to 095, 430.735 to 765 and 419B to 419B.045. (2) Confidentiality. (a) Behavior consultants must adhere to the confidentiality standards as described in the Department contract as well as the Federal HIPAA privacy rules. (b) Any written, verbal, digital, video, and electronic information regarding an individual must adhere to the Department's confidentiality standards as described in OAR chapter 407, division 14 and Federal HIPAA standards. (3) Notification. (a) Behavior consultants must notify the home and community-based care contractor of the following: (A) Life threatening health and safety concerns must be reported immediately. This communication may occur in person or by phone. (B) Concerns regarding a caregiver's response to coaching activity must be reported as soon as possible. This communication may occur in person, by phone, or by email. (C) Any permanent reassignment of a behavior consultant must be reported within 5 business days or prior to onsite service delivery. This communication may occur in person, by phone, or by email. (b) Behavior consultants must notify the case manager or local office designee of the following: (A) Life threatening health and safety concerns of an individual must be reported immediately, by phone or in person. (B) Concerns regarding the individual’s placement must be reported within one business day. This communication may occur by email or phone. (C) Any permanent reassignment of a behavior consultant, must be reported within 5 business days or prior to onsite service delivery. This communication may occur by email or phone. (D) An administrator, licensee, or designated caregiver who is unwilling or unable to implement the Behavior Support Plan, after completion of coaching plans and service coordination activities. This communication may occur by email or phone. (c) Case managers and behavior consultants are required to exchange information regarding changes in the individual’s eligibility status, service location, or service needs during the duration of the Behavior Support Service. (d) Behavior consultants must report suspected abuse immediately to the local Departmental office, designee office, or by calling the Department’s toll-free abuse reporting hotline. Statutory/Other Authority: ORS 410.070 Statutes/Other Implemented: ORS 410.070 History: APD 17-2014, f. & cert. ef. 6-23-14
411-046-0170 Documentation (1) Compliance with documentation standards in this rule and completion of mandatory Department forms is intended to ensure communication between case managers and home and community-based care providers. (2) The documentation requirements in this rule do not replace or substitute for the documentation requirements in the: (a) Medicaid Provider Rules governing provider requirements as described in OAR chapter 407, division 120, Provider Rules, MMIS Provider Enrollment and Claiming; Contractor Audits, Appeals and Post Payment Recoveries; (b) Medicaid General Rules under OAR chapter 410, division 120 as applicable; and (c) Licensing or Medicaid Program rules governing the home and community-based care provider, as applicable. (3) Behavior consultants are expected to complete mandatory Department forms for support services provided under 411-046-0140. (4) Use of alternative, but equivalent forms, may be approved by the Department using the exceptions process under 411-046-0220 or as defined in supplemental or specific needs setting contracts or individuals who receive Behavior Support Services as part of their monthly service rate. (5) Mandatory forms must be sent to the case manager before or at the time of submission of invoices or before receipt of the monthly Medicaid service rate. (a) Documentation must support the services billed and adhere to the timeframes noted in this rule and on the mandatory forms. (b) Claims will not be paid until the mandatory forms are submitted to the individual’s case manager and the documentation noted in 411-046-0170(2) is completed. (6) Behavior Support Service providers are expected to maintain a written record of all services provided to, and for, an individual and an individual's caregiver. (a) The record must include copies of all documentation provided to the: (A) Case manager; (B) Home and community-based care contractor; and (C) Behavior consultant or provider maintained to meet 411-046-0170(2)(a)–(c). (b) The record must be retained until the behavior consultant no longer provides services to the individual, at which time, the behavior consultant or the agency must provide a copy of any part of the record that was not previously provided to the case manager. (c) The behavior consultant or agency must retain the original record, following HIPAA practices, for a period of seven years. (d) All documentation must be provided in HIPAA secure format. Statutory/Other Authority: ORS 410.070 Statutes/Other Implemented: ORS 410.070 History: APD 17-2014, f. & cert. ef. 6-23-14
411-046-0180 Qualifications for Providers and Behavior Consultants (1) The Department shall select qualified providers according to standards: (a) In these rules; (b) In OAR 407-120-0320; and (c) In OAR chapter 410, division 120, as applicable. (2) Providers must be enrolled as a Medicaid provider. (3) Behavior consultants must complete the background check process described in OAR 407-007-0200 to 407-007-0370 with an outcome of approved or approved with restrictions. (4) Behavior Support Service Medicaid providers must have a Department contract to provide: (a) Home or community-based care services defined under a specific needs setting, and which includes Behavior Support Services as part of the contracted rate; or (b) Behavior Support Services with qualified employees or subcontractors who provide time limited consultation, at a range of settings, where the referred individual lives. (5) A Behavior Support Service Medicaid provider must employ or subcontract with behavior consultants who meet all of the following requirements: (a) Pass the Department required criminal record check processes per OAR 407-007-0200 to 407-007-0370 and meet one of the following: (A) Pass the Behavior Consultant Competency Evaluation administered by a Department approved contractor; (B) Possess and maintain certification from a Department approved program noted on the Department website; or (C) Have written approval to perform behavior consultant work from the Department based upon review of resume, certification, or education. Requests for this approval must follow 411-046-0220, exceptions to rules. (b) Maintain compliance with continuing education requirements under 411-046-0210. Statutory/Other Authority: ORS 410.070 Statutes/Other Implemented: ORS 410.070 History: APD 17-2014, f. & cert. ef. 6-23-14