Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 415 - CASE MANAGEMENT SERVICES FOR INDIVIDUALS WITH INTELLECTUAL OR DEVELOPMENTAL DISABILITIES › Section 411-415-0110 - Record Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) In
			 order to meet Department and federal record documentation requirements, a CME
			 through the employees of the CME, must maintain a service record for each
			 individual who receives services from the CME. An individual's service record
			 must include all of the following:
(a)
			 Documentation of the functional needs assessment defining the support needs for
			 ADL, IADL, and other health-related tasks. This may be a current ONA available
			 in the Department's electronic payment and reporting system.
(b) Documentation of choice
			 advising.
(c) Documentation that
			 the individual is eligible for any service authorized in an ISP.
(d) Referral information or documentation of
			 referral materials sent to a provider or another CME.
(e) Progress notes written by a case manager
			 as described in section (2) of this rule.
(f) The findings from service
			 monitoring.
(g) Medical
			 information, as appropriate.
(h)
			 Entry and exit meeting documentation related to residential programs, including
			 plans developed as a result of the meeting.
(i) Current and previous ISP or Annual Plan,
			 including support documents and documentation that the plan is authorized by a
			 case manager.
(j) A Nursing Service
			 Plan must be present when Department funds are used to purchase services
			 requiring the education and training of a licensed professional
			 nurse.
(k) Copies of any incident
			 reports initiated by a CME representative for a serious incident or suspicion
			 of abuse.
(l) Documentation of a
			 review of a serious incident received from a provider. Documentation of the
			 review of a serious incident and abuse allegation must be made in CAM and a
			 progress note and a copy of the incident report must be maintained by the
			 CME.
(m) Documentation of Medicaid
			 eligibility, if applicable.
(n) For
			 an individual whose level of care was determined before July 1, 2018, the
			 initial and, when present, the annual level of care determination on a form
			 prescribed by the Department.
(o) A
			 CDDP must maintain a copy of an initial level of care determination form
			 completed by the CDDP. For an individual whose level of care was determined
			 before July 1, 2018 and is receiving CIIS or services in a 24-hour residential
			 program for children, the CDDP must maintain a copy of annual level of care
			 determinations or maintain documentation of attempts to obtain the annual level
			 of care determinations.
(p) Legal
			 records, such as guardianship, civil commitment, a court order, and probation
			 and parole information (as appropriate).
(q) A case manager must maintain
			 documentation of the referral process of an individual to a provider and if
			 applicable, include the reason the provider preferred by the individual
			 declined to deliver services to the individual.
(r) An information sheet or reasonable
			 alternative must be kept current and reviewed at least annually for each
			 individual receiving case management services. Information must include:
(A) The name of the individual, current
			 address, date of entry into the CME, date of birth, gender, marital status (for
			 individuals 18 or older), religious preference, preferred hospital, medical
			 prime number and private insurance number (where applicable), and guardianship
			 status.
(B) The name, address, and
			 telephone number of:
(i) For an adult, the
			 legal or designated representative, family, and other significant person of the
			 individual (as applicable), and for a child, the parent or guardian and
			 education surrogate (if applicable).
(ii) The primary care provider and clinic
			 preferred by the individual.
(iii)
			 The dentist preferred by the individual.
(iv) The school, day program, or employer of
			 the individual (if applicable).
(v)
			 Other agency representatives providing services to the individual.
(vi) Any court ordered or legal
			 representative authorized contacts or limitations from contact for individuals
			 living in a foster home, supported living program, or 24-hour residential
			 program.