309-022-0140 Service Planning and Coordination (1) The provider shall deliver or coordinate for each individual appropriate services and supports to collaboratively facilitate intended service outcomes as identified by the individual and family: (a) Qualified program staff shall facilitate a planning process, resulting in a service plan that reflects the assessment; (b) A service plan shall be completed prior to the start of services; (c) A licensed health care professional shall recommend the services and supports by signing the service plan; (d) Individuals and family members shall be invited to participate in the development of the service plan; (e) Providers shall fully inform the individual and guardian when applicable of the proposed services and supports in developmentally and culturally appropriate language, obtain informed consent for all proposed services, offer peer delivered services, and give the individual and guardian a written copy of the service plan; (f) Providers shall collaborate with community partners to coordinate or deliver services and supports identified in the service plan; (g) Providers shall collaborate to exchange information with any applicable physical health care providers for the individual to promote regular and adequate health care. (2) The service plan shall be a written, individualized plan to improve the individual’s condition to the point where the individual’s continued participation in the program is no longer necessary. The service plan is included in the individual’s service records and shall: (a) Be completed prior to the start of services; (b) Reflect the full assessment and the level of care to be provided; (c) Include the participation of the individual and family members; (d) Be completed by a QMHP; (e) A QMHP who is also a licensed health care professional shall recommend the services and supports by signing the service plan within ten business days of the start of services; and (f) An LMP shall approve the service plan at least annually for everyone receiving mental health services for one or more continuous years. The LMP may designate annual clinical oversight by documenting the designation to a specific licensed health care professional. (3) At a minimum, each service plan shall include: (a) Treatment objectives that are: (A) Individualized to meet the assessed needs of the individual; and (B) Measurable for evaluating individual progress, including a baseline evaluation. (b) The specific services and supports indicated by the assessment that shall be used to meet the treatment objectives; (c) A projected schedule for service and support delivery, including the expected frequency and duration of each type of planned service or support; (d) The credentials of the personnel providing each service and support; and (e) A projected schedule for re-evaluating the service plan; (f) Proactive safety and crisis planning; and (g) A behavior support plan. (4) The interdisciplinary team shall conduct a review of progress and transfer criteria at least every 30 days from the date of entry and shall document the member’s present, progress, and changes made. For Psychiatric Day Treatment Services, the review shall be conducted every 30 days, and the LMP shall participate in the review at least every 90 days. (5) Providers shall document each service and support in a service note. A service note, at minimum, shall include: (a) The specific services rendered; (b) The specific service plan objectives being addressed by the services provided; (c) The relationship of the services provided to the treatment objective described in the service plan; (d) The date, time of service, and the actual amount of time the services were rendered; (e) The personnel rendering the services, including the name, credential, and signature; (f) The setting in which the services were rendered; and (g) Periodic updates describing the individual’s progress. (6) Decisions to transfer individuals shall be documented and include: (a) The reason for the transfer; (b) Referrals to follow up services and other behavioral health providers; and (c) Outreach efforts made. Statutory/Other Authority: ORS 161.390, 413.042, 430.256, 426.490 - 426.500, 428.205 - 428.270, 430.640 & 443.450 Statutes/Other Implemented: ORS 109.675, 161.390 - 161.400, 179.505, 413.520 - 413.522, 426.380 - 426.395, 426.490 - 426.500, 430.010, 430.205 - 430.210, 430.240 - 430.640, 430.850 - 430.955, 443.400 - 443.460, 443.991 & 743A.168 History: BHS 24-2018, amend filed 12/27/2018, effective 01/25/2019 BHS 16-2018, temporary amend filed 07/17/2018, effective 08/01/2018 through 01/27/2019 MHS 7-2017, f. & cert. ef. 6-23-17 MHS 27-2016(Temp), f. & cert. ef. 12-29-16 thru 6-26-17 MHS 5-2014, f. & cert. ef. 2-3-14 MHS 8-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14