justicedao/ipfs_state_laws huggingface dataset:
411-380-0040 Complaints, Notifications of Planned Actions, and Hearings (1) INDIVIDUAL COMPLAINTS. Complaints by or on behalf of individuals must be addressed in accordance with OAR 411-318-0015. (2) NOTIFICATION OF PLANNED ACTION. In the event that direct nursing services are denied, reduced, suspended, or terminated or voluntarily reduced, suspended, or terminated, a written advance Notification of Planned Action (form 0947) must be provided as described in OAR 411-318-0020. (3) HEARINGS. (a) Hearings must be addressed in accordance with ORS chapter 183 and OAR 411-318-0025. (b) An individual may request a hearing as provided in ORS chapter 183 and OAR 411-318-0025 for a denial, reduction, suspension, or termination of direct nursing services. Statutory/Other Authority: ORS 409.050, 413.085 & 427.104 Statutes/Other Implemented: ORS 409.010, 413.085, 427.007 & 427.104 History: APD 16-2021, amend filed 05/26/2021, effective 06/01/2021 APD 14-2016, f. 6-28-16, cert. ef. 6-29-16 APD 28-2015(Temp), f. 12-31-15, cert. ef. 1-1-16 thru 6-28-16
411-380-0060 Qualifications for Providers of Direct Nursing Services (1) Direct nursing services may be delivered by the following enrolled Medicaid providers: (a) A self-employed LPN or RN licensed under ORS 678.021 that may also be an adult foster home provider or family member. (A) An adult foster home provider must also be licensed under OAR 411-360-0040. (B) The decision to have an adult foster home provider or family member deliver direct nursing services must: (i) Be made by the individual and the ISP team; (ii) Be documented; and (iii) Not be for the convenience of the adult foster home provider or family member. (b) Home health agency licensed under ORS 443.015 and meeting the requirements in OAR chapter 333, division 027. (c) In-home care agency licensed under ORS 443.315 and meeting the requirements in OAR chapter 333, division 536. (d) A direct nursing services agency meeting the requirements in OAR 411-380-0065. (2) The legal representative of an individual is prohibited from providing direct nursing services. (3) A provider of direct nursing services must: (a) Be a licensed RN or LPN with a current and unencumbered license; and (b) Meet and maintain the provider enrollment requirements under OAR 407-120-0320 and section (5) of this rule. . (4) At least one year of experience working with individuals with intellectual or developmental disabilities is recommended, but not required. (5) PROVIDER ENROLLMENT. (a) Providers must enroll through the MMIS system by: (A) Completing and submitting the Medicaid Provider Enrollment Application that includes the Provider Enrollment Agreement; (B) Completing a Background Check as described in OAR 407-007-0200 through 407-007-0370. Background check approval is effective for two years from the initial fitness determination; and (C) Enrolling, receiving, and submitting a National Provider Index Number. (b) An applicant listed in the exclusions database of the Office of the Inspector General is not eligible to become an enrolled Medicaid provider according to OAR 410-120-1400(3)(b). (6) All enrolled Medicaid providers must comply with federal, state, and Department conflict of interest regulations or policy. Statutory/Other Authority: ORS 409.050, 413.085 & 427.104 Statutes/Other Implemented: ORS 409.010, 413.085, 427.007 & 427.104 History: APD 16-2021, amend filed 05/26/2021, effective 06/01/2021 APD 1-2020, minor correction filed 02/07/2020, effective 02/07/2020 APD 21-2019, amend filed 06/28/2019, effective 07/01/2019 APD 3-2017, f. 2-21-17, cert. ef. 2-28-17 APD 34-2016(Temp), f. 8-30-16, cert. ef. 9-1-16 thru 2-27-17 APD 14-2016, f. 6-28-16, cert. ef. 6-29-16 APD 28-2015(Temp), f. 12-31-15, cert. ef. 1-1-16 thru 6-28-16
411-380-0065 Standards for Direct Nursing Services Agencies (1) CERTIFICATION, ENDORSEMENT, AND ENROLLMENT. In addition to completing the provider enrollment requirements in OAR 411-380-0060, a direct nursing services agency must also have the following: (a) A certificate and endorsement to deliver direct nursing services according to OAR chapter 411, division 323. (b) A Medicaid Agency Identification Number assigned by the Department as described in OAR chapter 411, division 370. (2) POLICIES AND PROCEDURES. A direct nursing services agency must develop and implement written policies and procedures required for administration and operation in compliance with these rules including, but not limited to, all of the following: (a) Assuring each RN and LPN employed by the agency has a current and unencumbered license from the Oregon State Board of Nursing. (b) Protecting individual rights according to OAR 411-318-0010. (c) Addressing individual complaints according to OAR 411-380-0040. (d) Complying with all of the following: (A) Management and personnel practices described in OAR 411-323-0050. (B) Confidentiality of records according to OAR 411-323-0060. (C) Inspections and investigations according to OAR 411-323-0040. (D) Complaints of abuse and serious incidents must be treated as described in OAR 411-323-0063. Statutory/Other Authority: ORS 409.050, 413.085 & 427.104 Statutes/Other Implemented: ORS 409.010, 413.085, 427.007 & 427.104 History: APD 16-2021, adopt filed 05/26/2021, effective 06/01/2021
411-380-0070 Provider Disenrollment and Termination (1) Enrolled Medicaid providers may be denied enrollment, terminated, or prohibited from providing direct nursing services for any of the following: (a) Violation of any part of these rules. (b) A founded report of child abuse or substantiation of a violation of the protective service and abuse rules in OAR chapter 411, division 020 or OAR chapter 419, division 100. (c) Any sanction or action as a result of an investigation of the Oregon State Board of Nursing. (d) Failure to keep required licensure or certifications current. (e) Failure to provide copies of the records described in these rules to OHA, the Department, or case management entity. (f) Failure to participate in the review of the Nursing Service Plan or care coordination meetings when requested by the case management entity. (g) Failure to provide services. (h) Fraud or misrepresentation in the provision of direct nursing services. (i) Evidence of conduct derogatory to the standards of nursing as described in OAR 851-045-0070 that results in referral to the Oregon State Board of Nursing. (j) A demonstrated pattern of repeated unsubstantiated complaints of neglect or abuse per OAR chapter 411, division 020 or OAR chapter 419, division 100. (k) The provider is listed in the exclusions database of the Office of the Inspector General. (2) Enrolled Medicaid providers may appeal a termination of their Medicaid provider number based on OAR 407-120-0360(8)(g) and OAR chapter 410, division 120, as applicable. (3) An enrolled Medicaid provider of direct nursing services must provide advance written notice to the Department and any individuals the provider is delivering direct nursing services to at least 30 days prior to no longer providing direct nursing services. Statutory/Other Authority: ORS 409.050, 413.085 & 427.104 Statutes/Other Implemented: ORS 409.010, 413.085, 427.007 & 427.104 History: APD 51-2024, minor correction filed 07/18/2024, effective 07/18/2024 APD 16-2021, amend filed 05/26/2021, effective 06/01/2021 APD 14-2016, f. 6-28-16, cert. ef. 6-29-16 APD 28-2015(Temp), f. 12-31-15, cert. ef. 1-1-16 thru 6-28-16
411-380-0080 Provider Documentation and Records (1) Documentation of direct nursing services must be written in an accurate, timely, thorough, and clear manner. (2) Documentation must comply with OAR chapter 851 and must include all of the following: (a) The name of the individual on each page of documentation. (b) The date of service. (c) Time of start and end of service delivery by each provider. (d) Anything unusual from the standard plan of care expanded in the narrative. (e) Interventions. (f) Outcomes, including the response of the individual to services delivered. (g) Nursing assessment of the status of the individual and any changes in that status per each working shift. (h) Full signature of the provider. (3) Documentation of provided direct nursing services must be sent to the case management entity upon request or as outlined in the ISP and maintained in the home, foster home, 24-hour residential setting, or the place of business of the provider of services. (4) Providers must furnish requested documentation immediately upon the written request from the Department, the Oregon Department of Justice Medicaid Fraud Unit, OHA, 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 payments. (5) Access to records by the Department including, but not limited to, medical, nursing, behavior, psychiatric, or financial records, to include providers and vendors providing goods and services, does not require authorization or release by the individual or the legal representative of the individual. (6) Per OAR 410-120-1360(2)(e), providers must: (a) Retain billing forms, timesheets, and financial records for at least five years from the date of service; and (b) Retain clinical record documentation of provided services for at least seven years from the date of service. Statutory/Other Authority: ORS 409.050, 413.085 & 427.104 Statutes/Other Implemented: ORS 409.010, 413.085, 427.007 & 427.104 History: APD 16-2021, amend filed 05/26/2021, effective 06/01/2021 APD 14-2016, f. 6-28-16, cert. ef. 6-29-16 APD 28-2015(Temp), f. 12-31-15, cert. ef. 1-1-16 thru 6-28-16
411-390-0100 Statement of Purpose (1) The rules in OAR chapter 411, division 390 prescribe standards by which a health care advocate may be appointed for an adult with an intellectual or developmental disability. (2) The Department recognizes the individual rights described in OAR 411-318-0010 and supports the rights of adult individuals to make informed choices including refusal of, and consent to, health care. The intent of these rules is to maximize access to health care by prescribing standards for the appointment of a health care advocate when an adult individual is incapable of making a health care decision. (3) These rules encourage and provide for the appointment of a health care advocate in situations not covered by ORS 127.505 through 127.660 and when there is no legally appointed guardian with authority over health care decisions. ORS 127.635 provides for appointment of a health care representative to decide whether life-sustaining procedures may be withheld or withdrawn for an incapable individual. Statutory/Other Authority: ORS 127.765 & 409.050 Statutes/Other Implemented: ORS 127.765 History: APD 5-2020, adopt filed 02/25/2020, effective 03/01/2020
411-390-0140 Limits on Rule (1) These rules do not impair or supersede Oregon's existing laws relating to any of the following: (a) Any requirement of notice to others of proposed health care. (b) The standard of care required of a health care provider in the administration of health care. (c) Whether consent is required for health care. (d) The elements of informed consent for health care according to ORS 677.097 or other law. (e) The provision of health care in an emergency. (f) Any right a capable person may have to consent or withhold consent to health care administered in good faith pursuant to religious tenets of the person requiring health care. (g) Delegation of health care decision-making to, or by, a health care representative. (h) Any legal right or responsibility any person may have to affect the providing, withholding, or withdrawal of life-sustaining procedures including artificially administered nutrition and hydration in any lawful manner. (i) Guardianship or conservatorship proceedings or appointments. (j) Any right a person may otherwise have to make their own health care decisions, or to make a health care decision for another. (2) In following the decision of a health care advocate, a health care provider shall exercise the same independent medical judgment that the health care provider may exercise in following the decisions of an individual if the individual were capable. Statutory/Other Authority: ORS 127.765 & 409.050 Statutes/Other Implemented: ORS 127.765 History: APD 5-2020, adopt filed 02/25/2020, effective 03/01/2020
411-390-0180 Authority and Responsibility of a Health Care Advocate (1) When making a health care decision for an individual, a health care advocate must first consider any preference indicated by the individual by any means of communication (verbal or nonverbal) and attempt to make the decision that the individual may have made if capable. If this is not possible, the health care decision must be made in what the health care advocate believes to be in the individual's best interest. (2) A health care advocate must inform an individual and the individual’s case manager of all health care decisions made, or considered by, the health care advocate. (3) A health care advocate must consult with any other available surrogate decision-maker and an individual's attending physician to provide information with regards to the health care decision being made. (4) A health care advocate shall have all the authority over an individual's health care that the individual may have if not incapable, subject to the limitations of the health care advocate's appointment, these rules, and ORS 127.765. (5) A health care advocate is authorized to access the medical records necessary to make a health care decision. (6) A health care advocate may not disclose the contents of, and must maintain the confidentiality of, an individual’s health information, as required by state and federal laws. Statutory/Other Authority: ORS 127.765 & 409.050 Statutes/Other Implemented: ORS 127.765 & 409.010 History: APD 19-2021, amend filed 06/07/2021, effective 06/10/2021 APD 52-2020, temporary amend filed 12/21/2020, effective 12/21/2020 through 06/18/2021 APD 5-2020, adopt filed 02/25/2020, effective 03/01/2020
411-390-0220 Safeguards (1) When an individualized written service plan team is discussing the appointment of a health care advocate for an individual, or discussing an individual's significant medical treatment or procedure, the individual and any advocate named to the individualized written service plan team by the individual must be included in the individualized written service plan team and may not be excluded. (a) The individualized written service plan team must be composed of at least three members other than the individual. (b) The individualized written service plan team may include, but is not limited to, family, advocates, and staff with a vested interest in the individual. (c) An individual is not required to participate in the discussion if the individual declines to participate or is unable to participate due to the individual’s medical condition. (2) The composition of the individualized written service plan team may not be changed, except by the individual, to override the objection of any member of the individualized written service plan team. The case manager and any authorized representative of the individual must be allowed to continue to be members of the individualized written service plan team. (3) A case manager and at least one other person from the individualized written service plan team must receive approved training from the Department before using these rules to designate a health care advocate. (4) When these rules are used to appoint a health care advocate, information and data specified by the Department must be submitted to the case management entity and the Department. Statutory/Other Authority: ORS 127.765 & 409.050 Statutes/Other Implemented: ORS 127.765 & 409.010 History: APD 19-2021, amend filed 06/07/2021, effective 06/10/2021 APD 52-2020, temporary amend filed 12/21/2020, effective 12/21/2020 through 06/18/2021 APD 5-2020, adopt filed 02/25/2020, effective 03/01/2020
411-415-0010 Statement of Purpose (1) The rules in OAR chapter 411, division 415 prescribe standards, responsibilities, and procedures for the delivery of case management services to individuals with intellectual or developmental disabilities. (2) Providers of case management services are limited to employees of: (a) A Community Developmental Disabilities Program (CDDP); (b) A Support Services Brokerage (Brokerage); (c) Other public or private agencies contracted by a local community mental health authority; or (d) The Department of Human Services, Office of Developmental Disabilities Services. (3) Case management services are delivered using person-centered practices to assist individuals in accessing needed medical, employment, social, educational, and other services. Case management services include, but are not limited to: (a) Assessment and periodic reassessment of individual needs and preferences; (b) Development and periodic revision of the Individual Support Plan; (c) Referral and related activities; (d) Monitoring; and (e) Follow-up activities. (4) Services provided under these rules are intended to identify, strengthen, expand, and where required, supplement private, public, formal, and informal support available to individuals with intellectual or developmental disabilities. The case management services described in these rules encourage the exercising of self-determination in the design and direction of the individual receiving services. Statutory/Other Authority: ORS 409.050, 427.104, 427.154 & 430.662 Statutes/Other Implemented: ORS 427.005, 427.007, 427.101, 427.154-427.163, 430.212, 430.610, 430.620 & 430.662-430.695 History: APD 28-2016, f. & cert. ef. 6-29-16
411-415-0100 Specialized Services in a Nursing Facility An individual residing in a nursing facility determined to require specialized services, as described in OAR 411-070-0043, must have an annual plan for specialized services incorporated with a plan of care by the nursing facility. (1) A case manager must coordinate with the individual, the legal representative of the individual, the staff of the nursing facility, and other service providers, as appropriate, to provide or arrange the specialized services. The plan for specialized services must include: (a) The name of the service provider. (b) A description of the specialized services to be provided. (c) The number of hours of service per month. (d) A description of how the services must be tracked. (e) A description of the process of communication between the specialized service provider and the nursing facility in the event of serious incidents, serious illness, absence, and emergencies. (2) A case manager must complete an annual review of the plan for specialized services or when there has been a significant change in the level of functioning of the individual. Statutory/Other Authority: ORS 409.050, 427.104, 427.105, 427.115, 427.154, 430.662 & 430.731 Statutes/Other Implemented: ORS 427.007, 427.104, 427.105, 427.115, 427.121, 427.154, 427.160, 430.212, 430.215, 430.610, 430.620, 430.662, 430.664 & 430.731-430.768 History: APD 45-2019, amend filed 10/29/2019, effective 11/01/2019 APD 28-2016, f. & cert. ef. 6-29-16
411-415-0120 Reimbursement for Case Management Services A CME is reimbursed for case management activities. Reimbursement may only be made when: (1) The claim for reimbursement is for a service provided to an individual determined eligible for case management services. (2) The person providing the service is a qualified case manager as described in OAR 411-415-0040 or an assessor as defined in OAR 411-317-0000. (3) An individual is properly enrolled into the Department’s electronic payment and reporting system. (4) A claim has been made in the Department’s electronic payment and reporting system. (5) Case management has been authorized in an ISP or as part of an Annual Plan. (6) The claim is for a qualifying case management service. (7) A progress note is in the individual file supporting the delivery of a case management service. Statutory/Other Authority: ORS 409.050, 427.104, 427.105, 427.115, 427.154 & 430.662 Statutes/Other Implemented: ORS 427.007, 427.104, 427.105, 427.115, 427.121, 427.154, 427.160, 430.212, 430.215, 430.610, 430.620, 430.662 & 430.664 History: APD 46-2018, amend filed 12/28/2018, effective 12/28/2018 APD 23-2018, temporary amend filed 07/02/2018, effective 07/02/2018 through 12/27/2018 APD 28-2016, f. & cert. ef. 6-29-16
411-425-0005 Statement of Purpose (1) The rules in OAR chapter 411, division 425 prescribe standards, responsibilities, and procedures for conducting an Oregon Needs Assessment (ONA). (2) The purpose of conducting an ONA is to assist the Department in addressing the following: (a) Assuring an individual's strengths, preferences, risks, and support needs are identified to inform the development of an ISP. (b) Providing access to services paid by the Department to eligible individuals who have an assessed need. (c) Providing services to eligible individuals at an appropriate service level based on the Department's assessment of the individual's functional support needs. (3) The rules in OAR chapter 411, division 425 are effective as of July 1, 2018. Statutory/Other Authority: ORS 409.050, 427.104, 427.105, 427.115 & 430.662 Statutes/Other Implemented: ORS 427.104, 427.105, 427.115 & 430.662 History: APD 17-2019, adopt filed 04/23/2019, effective 05/01/2019 APD 2-2019, temporary adopt filed 01/07/2019, effective 01/09/2019 through 07/03/2019
411-425-0015 Definitions and Acronyms In addition to the following definitions, OAR 411-317-0000 includes general definitions for words and terms frequently used in OAR chapter 411, division 425. If a word or term is defined differently in OAR 411-317-0000, the definition in this rule applies. (1) "ADL" means "Activities of Daily Living". (2) "CME" means "Case Management Entity". (3) "IADL" means "Instrumental Activities of Daily Living". (4) "ONA" means "Oregon Needs Assessment". (5) "Submission date" means the date an ONA is uploaded to the Department's electronic payment and reporting system, indicating a completed ONA. (6) "Supervisor" means an employee of a CME who provides management level oversight of an assessor and is trained and qualified to conduct an ONA according to these rules. (7) "These Rules" mean the rules in OAR chapter 411, division 425. Statutory/Other Authority: ORS 409.050, 427.104, 427.105, 427.115 & 430.662 Statutes/Other Implemented: ORS 427.104, 427.105, 427.115 & 430.662 History: APD 17-2019, adopt filed 04/23/2019, effective 05/01/2019 APD 2-2019, temporary adopt filed 01/07/2019, effective 01/09/2019 through 07/03/2019
411-425-0025 Policies and Procedures (1) Each CME must have adequate policies and procedures to assure adherence to these rules no later than June 30, 2019. (2) CONFLICTS OF INTEREST. A CME must assure that an ONA is free from conflicts of interest to the greatest extent possible. (a) ASSESSOR. (A) At a minimum, an assessor may not conduct an assessment for an individual for whom the assessor: (i) Acted in the role of the individual's case manager within the previous six months prior to the start of the assessment. (ii) Is related by blood or marriage to the individual, or to any paid provider of the individual. (iii) Is financially responsible for the individual. (iv) Is empowered to make financial or health-related decisions on behalf of the individual. (B) After June 30, 2019, the only case management service an assessor may deliver is the completion of an ONA. (b) SUPERVISOR. A supervisor who conducts an assessment for an individual may not contribute to the development of the ISP for the individual. A supervisor may not conduct an assessment for an individual for whom the supervisor: (A) Is related by blood or marriage to the individual, or to any paid provider of the individual. (B) Is financially responsible for the individual. (C) Is empowered to make financial or health-related decisions on behalf of the individual. Statutory/Other Authority: ORS 409.050, 427.104, 427.105, 427.115 & 430.662 Statutes/Other Implemented: ORS 427.104, 427.105, 427.115 & 430.662 History: APD 17-2019, adopt filed 04/23/2019, effective 05/01/2019 APD 2-2019, temporary adopt filed 01/07/2019, effective 01/09/2019 through 07/03/2019