411-360-0140 AFH-DD Standards and Practices for Health Care (1) INDIVIDUAL HEALTH CARE. An individual must receive care and services that supports and promotes their health and well-being. (a) A provider must ensure each individual has a primary physician or primary licensed health care provider the individual, or as applicable the legal representative of the individual, has chosen from among qualified providers. (b) A provider must ensure each individual receives a medical evaluation by a licensed health care provider no less than every two years or as recommended by the licensed health care provider. (c) A provider must monitor the health status and physical conditions of each individual and take action in a timely manner in response to identified changes or conditions that may lead to deterioration or harm. (d) A written and signed order from a physician or licensed health care provider is required prior to the use or implementation of any of the following: (A) Prescription medications; (B) Non-prescription medications, except over the counter topicals; (C) Treatments other than basic first aid; (D) Modified or special diets; and (E) Adaptive equipment. (e) A provider must implement the order of a physician or licensed health care provider. (f) Injections may be: (A) Self-administered by an individual; or (B) Administered by the following: (i) A relative of the individual; (ii) A currently licensed registered nurse; (iii) A licensed practical nurse under registered nurse supervision; or (iv) A provider, resident manager, or substitute caregiver who has been trained and is monitored by a physician or delegated by a registered nurse in accordance with the rules of the Board of Nursing in OAR chapter 851, divisions 045 and 047. Documentation regarding the physician training or registered nurse delegation must be maintained in the individual's record. (2) REQUIRED DOCUMENTATION. (a) A provider must maintain and keep current records on each individual to aid physicians, licensed health care providers, the CDDP, and the Department in understanding the medical history of the individual. Each individual's record must include the following: (A) A list of known health conditions, medical diagnoses, any known allergies, immunizations, Hepatitis B status, previous TB tests, incidents or injuries affecting the health, safety, or emotional well-being of the individual, and history of emotional or mental health status pertinent to the individual's current care and services. (B) A record of visits and appointments to licensed health care providers, including documentation of the consultation, any treatment provided, and any follow-up reports provided to the provider. (C) A record of known hospitalizations and surgeries. (D) Current signed orders for all medications, treatments, therapies, special diets, and adaptive equipment. (E) Medication administration records (MARs). (F) Documentation of the consent from the individual's legal representative for non-routine medical treatment, including surgery and anesthesia. (G) Copies of previous mental health assessments and assessment updates, including multi-axial DSM diagnosis, treatment recommendations, and progress records for mental health treatment services. (b) When requested, copies of medical records and MARs must be provided to the legal representative, Department case manager, or services coordinator. (3) MEDICATION PROCUREMENT AND STORAGE A provider must ensure prescription drugs dispensed to individuals are packaged in a manner that reduces errors in the tracking and administration of drugs including, but not limited to, the use of unit dose systems or blister packs. All medications must be: (a) Kept in the original containers or unit dosage packs; (b) Labeled by the dispensing pharmacy, product manufacturer, or physician, as specified by the written order of a physician or licensed health care provider; and (c) Kept in a secured, locked container and stored as indicated by the product manufacturer. (4) MEDICATION ADMINISTRATION. (a) All medications and treatments must be recorded on an individualized MAR. The MAR must include the following: (A) The name of the individual. (B) A transcription of the written order of the physician or licensed health care provider, including the brand or generic name of the medication, prescribed dosage, frequency, and method of administration. (C) For an over the counter topical medication without a written order from a physician or licensed health care provider, a transcription of the printed instructions from the topical medication package. (D) The time and date of administration or self-administration of the medication. (E) Signature of the person administering the medication or the person monitoring the self-administration of the medication. (F) Method of administration. (G) An explanation of why a PRN (as needed) medication was administered. (H) Documented effectiveness of any PRN (as needed) medication administration. (I) An explanation of all medication administration or documentation errors, including identifying information for the person making the correction. (J) Documentation of any known allergy or adverse drug reaction. (b) Any errors on a paper MAR must be corrected with a circle of the error and the initials of the person making the correction. (5) SELF-ADMINISTRATION OF MEDICATION. (a) For an individual who independently self-administers medication, the individual's ISP team must determine a plan for the periodic monitoring and review of the self-administration of medications. (b) A provider must ensure individuals able to self-administer medications keep the medications in a place unavailable to other individuals and store the medications as recommended by the product manufacturer. (6) USE OF MEDICAL MARIJUANA. (a) Prior to using medical marijuana in an AFH-DD, an individual must: (A) Possess a valid OMMP registry card. A copy of the current OMMP registry card for the individual must be made available to the provider and maintained in the record for the individual; (B) Provide a copy of the written statement by the physician that indicates medical marijuana may mitigate the symptoms of the qualifying condition of the individual and includes instructions for the use of medical marijuana; (C) Be responsible for obtaining the marijuana from an OMMP approved third party grower who is not the provider, caregiver, resident manager, or any other occupant in or on the premises of the AFH-DD; and (D) Sign an agreement that the individual understands the following: (i) Marijuana is not allowed to be grown by any person in or on the premises of the AFH-DD; (ii) A participant in the OMMP may not possess more than one ounce of marijuana at any one time while in or on the premises of the AFH-DD; (iii) Medical marijuana may only be administered by ingesting it with food and by a vaporizer. If assistance with administration is necessary, the individual must agree to arrange for a "designated primary caregiver". The designated primary caregiver must be authorized by the OMMP and identified on the OMMP registry card for the individual; (iv) A provider, caregiver, resident manager, or any occupants of the AFH-DD cannot be designated as the OMMP-approved designated primary caregiver of the individual and identified on the OMMP registry card for the individual; (v) A provider, caregiver, resident manager, or any occupants of the AFH-DD cannot assist with the preparation, administration, or delivery of medical marijuana; (vi) The individual must maintain any equipment used to administer marijuana; (vii) Marijuana must be kept in locked storage in the bedroom of the individual when not being administered; (viii) The individual must immediately notify the OMMP of any change in status, such as a change in address, designated primary caregiver, or person responsible for the marijuana grow site. A copy of the updated OMMP registry card for the individual must be made available to the provider for the record of the individual; and (ix) Failure to comply with Oregon laws, Oregon rules, or the Residency Agreement of the AFH-DD may result in additional action. (b) An individual must comply with the Oregon Medical Marijuana Act, the rules for the OMMP in OAR chapter 333, division 008, these rules, and any other requirements for the OMMP. (c) An individual must self-administer medical marijuana by ingesting the marijuana or inhaling the marijuana with a vaporizer. Smoking marijuana in or on the premises of the AFH-DD is prohibited. Marijuana must be administered privately in a room that is not shared with another person. The individual may not have visitors, other individuals, or any other person in this private space while self-administering the marijuana. (d) An individual must designate a grower to provide the marijuana as necessary. The grower must not be the provider, resident manager, caregiver, or any occupant in or on the premises of the AFH-DD. The grower designated by the individual must be authorized by OMMP and identified on the OMMP registry card for the individual. (A) The designated grower for individuals being served in the foster care system must accommodate the specific needs related to the dispensation and tracking of the controlled substance. Not more than 28 grams at a time may be stored on the property of the AFH-DD per card holder. The remainder of the OMMP card holder’s marijuana must be stored at the site of the grower. (B) Each 28 grams, as needed, must be packaged in an airtight container clearly dated and labeled as to the total amount in grams with the name of the OMMP card holder. The container must be stored in a locked cabinet as is done with all controlled medications. Each administration must be tracked on the individual's MAR as to dosage in grams as weighed on a scale, date, and time of day. (e) A provider, caregiver, resident manager, or any other occupants in or on the premises of the AFH-DD must not prepare or in any way assist with the administration or procurement of an individual’s marijuana. The provider must monitor the individual’s usage of medical marijuana to ensure safety and to document that the individual's use of medical marijuana is in compliance with the physician’s instructions for using marijuana as documented in the ISP or Service Agreement. (f) If a provider, resident manager, or caregiver also has an OMMP card for medical purposes, a substitute caregiver must be available to support the individuals when the provider, resident manager, or caregiver is under the influence of the medical marijuana. Any OMMP card holder in or on the premises of the AFH-DD must not smoke marijuana in or on the premises of the AFH-DD but may ingest the marijuana or inhale the marijuana with a vaporizer. (7) PSYCHOTROPIC MEDICATIONS. (a) Psychotropic medications and medications for behavior must be: (A) Prescribed by a physician or licensed health care provider through a written order; and (B) Monitored by the prescribing physician or licensed health care provider, ISP team, and provider for desired responses and adverse consequences. (b) A provider, resident manager, or any caregiver may not discontinue, change, or otherwise alter the prescribed administration of a psychotropic medication for an individual without direction from a physician or licensed health care provider. (c) A provider, resident manager, or any caregiver may not use alternative medications intended to alter or affect mood or behavior, such as herbals or homeopathic remedies, without direction and supervision of a physician or licensed health care provider. (d) PRN (as needed) psychotropic medication orders are not allowed. (e) PSYCHOTROPIC MEDICATIONS FOR YOUNG ADULTS. A qualified mental health professional or a licensed health care provider must provide a mental health assessment prior to a young adult individual being prescribed one or more psychotropic medications or an antipsychotic medication. (A) A mental health assessment is not required in the following situations: (i) In case of urgent medical need; (ii) For a change in the delivery system of the same medication; (iii) For a change in medication within the same classification; (iv) A one-time medication order given prior to a medical procedure; or (v) An anti-epileptic medication prescribed for a seizure disorder. (B) When a mental health assessment is required, a provider must notify and inform the following of the need for a mental health assessment: (i) The legal guardian of the young adult, or the case manager of the Department when the Department is the legal guardian of the young adult; and (ii) The services coordinator. (C) The required mental health assessment: (i) Must be completed within three months prior to the prescription of a psychotropic medication; or (ii) May be an update of a prior mental health assessment that focuses on a new or acute problem. (D) Information from the mental health assessment must be provided to a physician or licensed health care provider prior to the issuance of a prescription for a psychotropic medication. (E) Within one business day after receiving a new prescription or knowledge of a new prescription for a psychotropic medication for a young adult, the provider must notify the following: (i) The legal guardian of the young adult, or the case manager of the Department when the Department is the legal guardian of the young adult; and (ii) The services coordinator. (F) The notification described in subsection (E) of this section must contain the following: (i) The name of the prescribing physician or licensed health care provider; (ii) The name of the medication; (iii) The dosage, any change of dosage, or suspension or discontinuation of the current psychotropic medication; (iv) The dosage administration schedule prescribed; and (v) The reason the medication was prescribed. (G) A provider must get a written informed consent from one of the following prior to filling a prescription for any new psychotropic medication, except in case of urgent medical need: (i) The legal guardian of the young adult; or (ii) The Department when the Department is the legal guardian of the young adult. (H) When a young adult has more than two prescriptions for psychotropic medications, an annual review of the psychotropic medications must occur by a physician, licensed health care provider, or a qualified mental health professional who has the authority to prescribe drugs, such as the Oregon Medicaid Drug Use Review Program. (f) BALANCING TEST. When a psychotropic medication is first prescribed and annually thereafter, a provider must obtain a signed balancing test from the prescribing physician or licensed health care provider using the Balancing Test Form (form APD 4110), or by inserting the required form content into a form maintained by the provider. (A) The provider must present the physician or licensed health care provider with a full and clear description of the behavior and symptoms to be addressed, as well as any side effects observed. (B) The provider must keep signed copies of the balancing test in the individual's medical record for seven years. (8) MEDICATION SAFEGUARDS. (a) A provider must use the following safeguards to prevent adverse effects or medication reactions: (A) Whenever possible, obtain all prescription medication for an individual, except samples provided by the physician or licensed health care provider, from a single pharmacy that maintains a medication profile for the individual. (B) Maintain information about each desired effect and side effect of the medication. (C) Ensure medications prescribed for one individual are not administered to, or self-administered by, another individual or caregiver. (b) If all medications for an individual are not provided through a single pharmacy, the provider must document the reason why in the individual's record. (9) MEDICATION DISPOSAL. All unused, discontinued, outdated, recalled, or contaminated medications, including over-the-counter medications, may not be kept in the AFH-DD and must be disposed of within 10 calendar days of expiration, discontinuation, or the provider’s knowledge of a recall or contamination. Prescription medications for an individual that has died must be disposed of within three calendar days. (a) A provider must contact the local Department of Environmental Quality waste management company in the area of the AFH-DD for instructions on proper disposal of medications. (b) Disposal of all controlled medications must be documented and witnessed by at least one other person who is 18 years of age or older. (c) A written record of the disposal of the medication must be maintained and include documentation of the following: (A) Date of disposal; (B) Description of the medication, including dosage, strength, and amount being disposed; (C) Name of the individual for whom the medication was prescribed; (D) Reason for disposal; (E) Method of disposal; (F) Signature of the person disposing of the medication; and (G) For controlled medications, the signature of a witness to the disposal. (10) NURSING SERVICES. (a) When nursing services are provided to an individual a provider must: (A) Coordinate with the registered nurse and the ISP team to ensure the nursing services being provided are sufficient to meet the health needs of the individual; and (B) Implement the Nursing Service Plan, or appropriate portions therein, as agreed upon by the ISP team and registered nurse. (b) COMMUNITY NURSING SERVICES. When community nursing services, as described in OAR chapter 411, division 048, are provided to an individual, a provider must: (A) Coordinate with the registered nurse and the ISP team to ensure the nursing services being provided are sufficient to meet the health needs of the individual; and (B) Implement the Nursing Service Plan, or appropriate portions therein, as agreed upon by the ISP team and registered nurse. (c) PRIVATE DUTY NURSING. Under OAR chapter 410, division 132, young adults aged 18 through 20 who reside in a foster home and who meet the clinical criteria described in OAR 411-300-0120 are eligible for private duty nursing services. (A) A Nursing Service Plan must be present when Department funds are used for private duty nursing services. A services coordinator must authorize the provision of private duty nursing services as identified in an individual's ISP. (B) When private duty nursing services are provided to a young adult, a provider must: (i) Coordinate with the registered nurse and the ISP team to ensure the private duty nursing services being delivered are sufficient to meet the health needs of the young adult; and (ii) Implement the Nursing Service Plan, or appropriate portions therein, as agreed upon by the ISP team and registered nurse. (C) Under OAR 410-132-0080, a provider is not authorized to deliver private duty nursing services. (d) DIRECT NURSING SERVICES. Direct nursing services may be provided to individuals 21 years of age and older as described in OAR chapter 411, division 380. (A) A Nursing Service Plan must be present when Department funds are used for direct nursing services. A services coordinator must authorize the provision of direct nursing services as identified in an ISP. (B) When direct nursing services are provided to an individual a provider must: (i) Coordinate with the registered nurse and the ISP team to ensure the direct nursing services being provided are sufficient to meet the health needs of the individual; (ii) Implement the Nursing Service Plan, or appropriate portions therein, as agreed upon by the ISP team and registered nurse; and (iii) While delivering a direct nursing service exclusively to an eligible individual in the AFH-DD, ensure the needs of other individuals in the home are met, up to and including additional staffing, such as resident managers, substitute caregivers, or additional nurses in the home. Documentation must record staffing coverage. (C) A provider licensed by the Department may provide direct nursing services to an individual in the AFH-DD under the following conditions: (i) The provider must meet the qualifications to provide direct nursing services as described in OAR chapter 411, division 380; (ii) More than one individual resides in the AFH-DD; (iii) The provider is the choice of the individual or the legal representative of the individual and is not for the convenience of the provider; and (iv) The provider meets the requirements as an enrolled Medicaid Provider as described in OAR chapter 411, division 380 and has a separate and distinct Medicaid provider number. (11) DELEGATION AND SUPERVISION OF NURSING TASKS. Nursing tasks must be delegated by a registered nurse to a provider, resident manager, and substitute caregiver in accordance with the rules of the Oregon State Board of Nursing in OAR chapter 851, divisions 045 and 047. (12) COVID-19. A provider must implement all directives related to an AFH-DD to reduce the spread of the Coronavirus (COVID-19) issued by any of the following: (a) Governor’s Executive Order. (b) Written instruction to the provider from the Local Public Health Authority or the Oregon Health Authority Public Health Division. (c) Written guidance directed at the provider through Department policy. Statutory/Other Authority: ORS 409.050, 427.104, 443.001, 443.004, 443.725, 443.730, 443.735, 443.738, 443.742, 443.760, 443.765, 443.767, 443.775 & 443.790 Statutes/Other Implemented: ORS 409.010, 427.104, 443.001-443.004, 443.705-443.825, 443.875 & 443.991 History: APD 55-2020, amend filed 12/30/2020, effective 01/01/2021 APD 31-2020, temporary amend filed 07/22/2020, effective 07/23/2020 through 01/18/2021 APD 30-2018, amend filed 08/09/2018, effective 08/10/2018 APD 34-2017, temporary amend filed 12/29/2017, effective 01/01/2018 through 06/29/2018 APD 14-2017, f. & cert. ef. 6-9-17 APD 1-2017(Temp), f. & cert. ef. 2-15-17 thru 8-13-17 APD 21-2016, f. & cert. ef. 6-29-16 APD 30-2015(Temp), f. 12-31-15, cert. ef. 1-1-16 thru 6-28-16 APD 47-2014, f. 12-26-14, cert. ef. 12-28-14 APD 29-2014(Temp), f. & cert. ef. 7-1-14 thru 12-28-14 SPD 34-2013, f. & cert. ef. 9-27-13 SPD 13-2010, f. 6-30-10, cert. ef. 7-1-10 SPD 3-2005, f. 1-10-05, cert. ef 2-1-05