reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 45 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 411-045-0030 - Financial

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 45 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 411-045-0050 - Enrollment

Current through Register Vol. 63, No. 7, July 1, 2024
(1) ELIGIBILITY: To
			 be eligible to enroll in a PACE program a person must:
(a) Reside in the PACE program's approved
			 service area upon enrollment;
(b)
			 Be 55 years of age or older;
(c)
			 Be able to be maintained in a community-based setting at the time of enrollment
			 without jeopardizing his or her health or safety or the health and safety of
			 others;
(d) Be determined by the
			 local Department/AAA agency to need the level of care required under Oregon's
			 State Medicaid Plan for coverage of nursing facility services in accordance
			 with the rules in OAR chapter 411, division 15 (Long-Term Care Service
			 Priorities for Individuals Served);
(e) Be Medicaid eligible or be willing to pay
			 private fees; and
(f) Be willing
			 to abide by the provision that requires enrollees to receive all health and
			 long term care services exclusively from the PACE program and its contracted or
			 referred providers.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 45 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 411-045-0060 - Disenrollment

Current through Register Vol. 63, No. 7, July 1, 2024
(1) PACE
			 Participant Requests for Disenrollment:
(a)
			 All PACE participant initiated requests for disenrollment from PACE programs
			 must be initiated by the PACE participant or his or her
			 representative;
(b) An applicant
			 may request disenrollment if he or she has surgery scheduled at the time the
			 PACE enrollment is effective and the provider is not on the PACE program's
			 provider panel and the participant wishes to have the services performed by
			 that provider; and
(c) PACE
			 participant or representative requests for disenrollment will be effective at
			 the end of the month following the date of request for disenrollment except in
			 the case of (b) above.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 45 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 411-045-0070 - Access to Care

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 45 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 411-045-0080 - Provision of Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) PACE
			 Services:
(a) PACE covered services for all
			 participants must be the same regardless of the source of payment. They must
			 include all OHP covered services specified in OAR
			 410-141-0480 and Medicare
			 covered services. In addition the covered services must include the following:
(A) Interdisciplinary assessment and
			 treatment planning;
(B) Case
			 management and social work services;
(C) Personal care and supportive
			 services;
(D) Nutritional
			 counseling;
(E) Recreational
			 therapy;
(F) Meals and nutritional
			 supplement as appropriate;
(G)
			 Community based long term care including nursing facility care as appropriate;
			 and
(H) Other services determined
			 necessary by the Interdisciplinary Team to improve or maintain the PACE
			 participants overall health and functioning or to provide pain management and
			 comfort care.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 45 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 411-045-0090 - Quality Improvement System

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Stat. Auth.: ORS
				  410.090
Stats. Implemented: ORS
				  410.070
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 45 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 411-045-0100 - Confidentiality and Reporting

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 PACE program must have policies and procedures that ensure maintenance of a
			 clinical record keeping system that is consistent with state and federal
			 regulations to which the PACE program is subject.
(2) Access to clinical records:
(a) Provider Access to clinical records:
(A) PACE programs will release health service
			 information requested by a provider involved in the care of a PACE participant
			 within ten working days of receiving a signed release;
(B) PACE programs will assure that health
			 service providers have access to the applicable contents of a PACE
			 participant's mental health records when necessary for use in the diagnosis or
			 treatment of the participant. Such access is permitted under ORS
			 179.505;
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 45 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 411-045-0120 - Grievance Process

Current through Register Vol. 63, No. 7, July 1, 2024
(1) PACE
			 programs must have written policies and procedures for the receipt, disposition
			 and documentation of all grievances from PACE participants and their
			 representatives. The PACE program's written procedures for handling grievances,
			 must, at a minimum:
(a) Address how the PACE
			 program will accept, process and respond to all grievances from PACE
			 participants or their representatives, including expedited and additional
			 reviews; and the continuation of care during the appeal process;
(b) Address the resolution of all grievances
			 that PACE participants identify as needing resolution and must describe how
			 grievances will be resolved or reviewed should the PACE participant or his or
			 her representative decline to provide a release of information;
(c) Address how information concerning an
			 PACE participant's grievance is kept confidential, with the exception that the
			 Department and the local SPD/AAA office have the right to this information
			 without a signed release from the PACE participant;
(d) Describe how the PACE program informs
			 PACE participants, both orally and in writing, about the PACE program's
			 grievance procedures. Information provided to the participant must include at
			 least:
(A) Written material describing the
			 grievance process;
(B) Assurance in
			 all written, oral, and posted material of PACE participant confidentiality in
			 the grievance process; and
(C)
			 Information on alternatives to the PACE programs grievance and appeals process,
			 including but not limited to, the Medicare appeals process, and the state's
			 administrative hearing process.
(e) Include a requirement for a Department
			 approved grievance and appeals log to be maintained by the PACE program;
			 and
(f) Addresses how the PACE
			 program will ensure the availability of a supply of blank complaint forms (OHP
			 3001) in all PACE sites and in the administrative offices.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 45 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 411-045-0130 - Appeal Process

Current through Register Vol. 63, No. 7, July 1, 2024
(1) All denials,
			 reductions, or terminations of services or service coverage by the PACE program
			 must be in writing in accordance with Section (3) of this rule. PACE programs
			 must make available to all PACE staff and contracted providers information
			 concerning client notices, appeals and hearings processes.
(2) When the PACE program authorizes a course
			 of treatment or covered service, but subsequently acts (as defined in
			 42
			 CFR 431.201) to terminate, discontinue, or
			 reduce the course of treatment or a covered service, the PACE program must mail
			 a written notice to the participant at least ten (10) working days before the
			 date of the termination or reduction of the covered service unless there is
			 documentation that the participant had previously agreed to the change as part
			 of the course of treatment.
(3) The
			 written client notice must be a Department approved format and is to be used
			 for all denials, reductions, or terminations of services and denials of claims
			 payment. The notice must inform the PACE participant of the following:
(a) Relevant information to include but is
			 not limited to the following:
(A) Date of
			 notice;
(B) Program name;
(C) Primary Care Provider's name;
(D) Participant's name and ID
			 number;
(E) Date of
			 Request/Service;
(F) Service or
			 Item Requested or provided;
(G) Who
			 Requested or Provided the item or service;
(H) Effective Date of Action;
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 45 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 411-045-0140 - Administrative Hearings

Current through Register Vol. 63, No. 7, July 1, 2024
(1) PACE
			 participants are entitled to an administrative hearing by the Department
			 regarding the action by the PACE program to deny services, payment of a claim,
			 or to terminate, discontinue or reduce a course of treatment. PACE participants
			 are also entitled to an administrative hearing for issues related to their
			 eligibility for PACE benefits, or issues related to enrollment in a PACE
			 program. Administrative hearings are governed by the following:
(a) A written hearing request must be
			 received by the SPD/AAA PACE Liaison Case Manager no later than the 45th day
			 following the date of the Notice of Action or written decision regarding an
			 appeal;
(b) If the action involves
			 a Notice of Action or decision concerning an appeal that involves continuation
			 of services, and the PACE participant or PACE participant's representative
			 wishes to have services continued while the hearing issue is being resolved,
			 the PACE participant or PACE participant's representative must request a
			 hearing before the effective date of the intended action or within 10 calendar
			 days after the notice of action or written grievance decision was mailed or
			 given to the PACE participant or PACE participant's representative.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 46 - BEHAVIOR SUPPORT SERVICES › Section 411-046-0100 - Purpose

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 46 - BEHAVIOR SUPPORT SERVICES › Section 411-046-0110 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
Unless the context indicates otherwise, the following
				definitions apply to the rules in OAR chapter 411, division 046:
(1) "Abuse" means Abuse of an adult or
			 elderly person as defined in ORS
			 124.050-095 and
			 430.735-430.765; and as defined in OAR
			 411-020-0002 for older adults
			 and individuals with a physical disability who are 18 years of age or older.
(2) "Acquired brain injury or
			 traumatic brain injury" means individuals who have or who are at risk of
			 developing challenging behaviors as a result of a recent or longstanding brain
			 injury diagnosis and who can benefit from Behavior Support Services. Acquired
			 brain injury may include individuals with cognitive and behavioral disorders
			 related to stroke, spinal cord injuries, or other neurological diseases that
			 may benefit from Behavior Support Services.
(3) "Activation date" means service
			 activation date as defined in these rules.
(4) "Activity evaluation" is part of the
			 person-centered evaluation to determine what activities an individual enjoys
			 doing.
(5) "Activity Plan" is part
			 of the Behavior Support Plan and includes an activity list of the specific,
			 private, group and community person-centered activities the individual finds
			 meaningful or enjoys. The plan includes strategies to help caregivers ensure
			 these activities become part of the individual's daily routine.
(6) "Adult foster home" means a licensed home
			 providing services to a person who is eligible for or is receiving Behavior
			 Support Services per OAR chapter 411, division 50.
(7) "Behavior consultants" are Medicaid
			 providers who have a contract with the Department to provide Behavior Support
			 Services. When Behavior Support Services are provided as part of a supplemental
			 or specific needs contract, per OAR chapter 411, division 027, the behavior
			 consultant is a designated employee, who meets the qualifications of a behavior
			 consultant, and has a job description to provide Behavior Support Services.
(8) "Behavior interventions" mean
			 any planned or repeated pattern of interventions or social interactions
			 intended to modify an individual's environment or behavior.
(9) "Behavioral support" means the theories
			 and evidenced-based practices supporting a proactive approach to behavioral
			 intervention and that:
(a) Emphasize the
			 development of functional alternative behavior;
(b) Prevent the need for, or minimize the use
			 of, intrusive or restrictive interventions;
(c) Ensure abusive or demeaning interventions
			 are never used; and
(d) Evaluate
			 the effectiveness of behavior interventions based on objective data.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 46 - BEHAVIOR SUPPORT SERVICES › Section 411-046-0120 - Eligibility

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 46 - BEHAVIOR SUPPORT SERVICES › Section 411-046-0130 - Limitations

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 46 - BEHAVIOR SUPPORT SERVICES › Section 411-046-0140 - Behavior Support Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Behavior Support Services assist individuals with behavioral challenges, due to
			 their disability, in accomplishing activities of daily living, instrumental
			 activities of daily living, and health-related tasks.
(2) Behavior Support Services include
			 consultation to the caregiver on mitigating behavior that may place the
			 individual's health and safety at risk and to prevent institutionalization.
(3) All referrals must be made by
			 the individual's case manager, on the Department's mandatory form, which is
			 sent to the Behavior Support Service provider.
(4) Behavior Support Service providers, their
			 employees, or subcontractors acting as behavior consultants, must provide the
			 following services to individuals they accept for services:
(a) Review of Referral.
(A) The Behavior Support Service consultant
			 or provider must provide a documented decision regarding denial or acceptance
			 of the referral within 2 business days.
(B) Service activation dates that are more
			 than 7 days past the referral acceptance date must be approved by the referring
			 Case Manager.
(C) Providers must
			 ensure adequate numbers of behavior consultants are available to meet the
			 service needs of all individuals accepted for service.
(D) The following entities must be informed
			 of accepted referrals by the case manager:
(i) The individual or their legal
			 representative; and
(ii) The
			 person in charge of the individual's Medicaid residential or home-based service
			 plan.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 46 - BEHAVIOR SUPPORT SERVICES › Section 411-046-0150 - Authorizations

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Stat. Auth.: ORS
				  410.070
Stats. Implemented: ORS
				  410.070
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 46 - BEHAVIOR SUPPORT SERVICES › Section 411-046-0160 - Communication

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 46 - BEHAVIOR SUPPORT SERVICES › Section 411-046-0170 - Documentation

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 46 - BEHAVIOR SUPPORT SERVICES › Section 411-046-0180 - Qualifications for Providers and Behavior Consultants

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 46 - BEHAVIOR SUPPORT SERVICES › Section 411-046-0190 - Disenrollment or Termination

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Medicaid providers of Behavior Support Services, their behavior consultant
			 employees, or subcontractors may be terminated or prohibited from providing
			 services for any of the following:
(a)
			 Violation of any part of these rules;
(b) Violation of the protective service and
			 abuse rules in OAR chapter 411, division 20 and OAR chapter 407, division 45;
(c) A demonstrated pattern of
			 repeated unsubstantiated complaints of neglect and abuse per OAR chapter 411,
			 division 020 and OAR chapter 407, division 045;
(d) Failure to meet behavior consultant
			 qualifications or continuing education requirements;
(e) Failure to provide copies of records to
			 designated Department or Oregon Health Authority entities;
(f) Repeated failure to participate in
			 Behavior Support Plan review or service planning meetings when requested by an
			 individual's case manager;
(g)
			 Failure to provide the services noted in these rules; or
(h) Fraud or misrepresentation in the
			 provision of services under these rules.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 46 - BEHAVIOR SUPPORT SERVICES › Section 411-046-0200 - Compensation and Billing

Current through Register Vol. 63, No. 7, July 1, 2024
(1) All
			 billing and claims must comply with OAR
			 407-120-0330; OAR
			 407-120-0340; and OAR chapter
			 410, division 120, as applicable.
(2) Compensation for Behavior Support
			 Services in supplemental or specific needs setting contracts shall be defined
			 through the Department contract.
(3) The Department may adjust rates in
			 underserved areas to ensure individuals have access to services.
(4) Failure to comply with standards in this
			 rule may result in determination of overpayment for which restitution may be
			 sought.
Stat. Auth.: ORS
				  410.070
Stats. Implemented: ORS
				  410.070
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 46 - BEHAVIOR SUPPORT SERVICES › Section 411-046-0210 - Continuing Education Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Behavior consultants must maintain a
			 record verifying completion of at least 12 hours of continuing education per
			 year in person-centered care or behavior support training that is provided by a
			 Department approved trainer or training organization noted on the Department
			 website.
(2) Requests for
			 documentation verifying compliance with this requirement must be provided upon
			 request to the Department.
Stat. Auth.: ORS
				  410.070
Stats. Implemented: ORS
				  410.070
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 46 - BEHAVIOR SUPPORT SERVICES › Section 411-046-0220 - Exceptions to Rules

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Exceptions
			 to these rules may be made by the Department central office and must be granted
			 by the Department in writing. Implementation of an exception may not occur
			 without written approval.
(2) On a
			 case specific basis, the following exceptions may be granted by local office
			 managers:
(a) Changing the timeframes for
			 service activation,
(b) Initiating
			 the person-centered evaluation,
(c) Completing the Behavior Plan; or
(d) Initiating coaching.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 48 - LONG TERM CARE COMMUNITY NURSING › Section 411-048-0150 - Purpose

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The rules in
			 OAR chapter 411, division 048 establish standards and procedures for Medicaid
			 enrolled providers who provide long term care community nursing services. Long
			 term care community nursing services provide ongoing registered nurse (RN)
			 services to eligible individuals who are receiving services in a
			 Medicaid-funded home and community-based setting.
(2) Long term care community nursing services
			 provide the following:
(a) Evaluation and
			 identification of supports that help an individual maintain maximum functioning
			 and minimize health risks, while promoting the individual's autonomy and
			 self-management of healthcare.
(b)
			 Teaching an individual, or the individual's caregiver or family, what is
			 necessary to assure the individual's health and safety in a Medicaid-funded
			 home and community-based setting as described in OAR
			 411-048-0180.
(c) Delegation of nursing tasks to an
			 individual's caregiver as described in OAR
			 411-048-0180.
(d) Providing case managers and healthcare
			 providers with the information needed to maintain an individual's health,
			 safety, and community living situation while honoring the individual's autonomy
			 and choices.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 48 - LONG TERM CARE COMMUNITY NURSING › Section 411-048-0160 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
Unless the context indicates otherwise, the following
				definitions apply to the rules in OAR chapter 411, division 048:
(1) "AAA" means the Area Agency on Aging
			 designated by the Department that is responsible for providing a comprehensive
			 and coordinated system of services to older adults and adults with disabilities
			 in a designated planning and service area.
(2) "Abuse" means:
(a) "Abuse" as it applies to a "child" as
			 those terms are defined in ORS
			 419B.005.
(b) "Abuse" as it applies to a "child in
			 care" as those terms are defined in ORS
			 418.257.
(c) "Abuse" as it applies to an "adult" as
			 those terms are defined in ORS
			 430.735.
(d) "Abuse" as defined in ORS
			 124.005 and OAR
			 411-020-0002 for older adults
			 and adults with a physical disability who are 18 years of age or
			 older.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 48 - LONG TERM CARE COMMUNITY NURSING › Section 411-048-0170 - Eligibility and Limitations

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 ELIGIBILITY. Long term care community nursing services may be provided by an RN
			 to an individual if the individual meets the following requirements:
(a) The individual must be determined
			 eligible for Medicaid-funded home and community-based services provided through
			 the Department.
(b) The individual
			 must be receiving services through one of the following:
(A) A child who lives in the family home and
			 receives children's intensive in-home services as described in OAR chapter 411,
			 division 300.
(B) An adult foster
			 home for:
(i) Individuals with intellectual or
			 developmental disabilities as described in OAR chapter 411, division 360;
			 or
(ii) Individuals found eligible
			 for service in OAR chapter 411, division 015 residing in a Medicaid enrolled
			 adult foster home as described in OAR chapter 411, divisions 049 through
			 052.
(C) A foster home
			 for children with intellectual or developmental disabilities as described in
			 OAR chapter 411, division 346.
(D)
			 An adult or child who live in their own or family home as described in OAR
			 chapter 411, division 030 or division 450.
(E) Independent Choices Program participants
			 as described in OAR chapter 411, division 030.
(F) State Plan personal care participants as
			 described in OAR chapter 411, division 034 or division 455.
(G) An adult who is eligible to receive day
			 support activities as described in OAR chapter 411, division 450 or eligible to
			 receive employment services as described in OAR chapter 411, division
			 345.
(H) Long term care community
			 nursing services may be provided for individuals while receiving services in
			 settings for employment services or day support activities regardless of their
			 residential home and community-based setting.
(c) The individual must be referred by their
			 case manager for long term care community nursing services. Individuals may
			 request long term care community nursing services through their case
			 manager.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 48 - LONG TERM CARE COMMUNITY NURSING › Section 411-048-0180 - Long Term Care Community Nursing Services

Current through Register Vol. 63, No. 7, July 1, 2024
When authorized by an individual's case manager, the following
				long term care community nursing services must be provided by an RN in
				accordance with these rules and the scope of practice as stated in the OSBN
				rules in OAR chapter 851.
(1) REVIEW
			 OF REFERRAL. An RN must screen a referral and notify the individual's case
			 manager of their decision to accept or refuse the referral within two business
			 days of receiving the referral on the Department approved form. The RN may
			 refuse any referral.
(2) INITIAL
			 ASSESSMENT. The RN must perform a face-to-face nursing assessment within 10
			 business days following the acceptance of a referral. The assessment is defined
			 in OAR chapter 851, division 006 and regulated by OAR chapter 851, division
			 045.
(a) The RN must document the nursing
			 assessment pursuant to OAR chapter 851, divisions 006 and 045.
(b) The RN must send copies of the nursing
			 assessment to the individual's case manager. If the RN recommends ongoing long
			 term care community nursing services, the RN must also send a copy of the
			 Nursing Service Plan as described in section (4) of this rule..
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 48 - LONG TERM CARE COMMUNITY NURSING › Section 411-048-0190 - Communication and Notification Practices

Current through Register Vol. 63, No. 7, July 1, 2024
(1) MANDATORY REPORTING. The RN must report
			 suspected or known neglect or abuse of all older adults, adults, and children
			 as required by ORS 124.050 to
			 095, ORS 418, ORS
			 430.735 to
			 765, ORS 441, ORS
			 419B.005 to
			 045, ORS
			 676.150 and OSBN's ORS
			 678.135.
(2) The RN or agency must notify the
			 Department in writing of material changes in any status or condition that
			 relates to their qualifications or eligibility to provide medical assistance
			 services.
(3) CONFIDENTIALITY.
(a) The RN must protect client confidential
			 information in a manner consistent with current laws, standards as described in
			 OAR chapter 851 as well as the federal regulations adopted to implement the
			 Health Insurance Portability and Accountability Act.
(b) The RN must provide all written, verbal,
			 digital, video, and electronic information regarding an individual in
			 accordance with the Department's confidentiality parameters as described in OAR
			 chapter 407, division 014 and the federal regulations adopted to implement the
			 Health Insurance Portability and Accountability Act.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 48 - LONG TERM CARE COMMUNITY NURSING › Section 411-048-0200 - Additional Documentation Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The RN must meet the documentation,
			 record keeping, and communication standards as required by the Department. The
			 RN who meets the Department's standards remains responsible to also document in
			 accordance with the Nurse Practice Act. This documentation shall include a
			 record of all RN delegation as described in OAR
			 411-048-0180 and the RN's
			 initial and assessment of the nursing procedures delegated to the individual's
			 unregulated assistive person.
(2)
			 The documentation standards in this rule and on the Department approved forms
			 provided by the Department do not replace or substitute for the documentation
			 requirements in the:
(a) Rules for
			 professional nursing standards as prescribed by the OSBN in OAR chapter 851,
			 divisions 006, 045, and 047;
(b)
			 Medicaid provider rules governing provider requirements in OAR chapter 407,
			 division 120; and
(c) As
			 applicable, the Medicaid General Rules in OAR chapter 410, division
			 120.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 48 - LONG TERM CARE COMMUNITY NURSING › Section 411-048-0210 - Qualifications for Enrolled Medicaid Providers

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Department may determine the number
			 and type of enrolled Medicaid providers in a geographic area to assure that
			 there is an appropriate number of qualified enrolled Medicaid providers to meet
			 the needs of individuals eligible for long term care community nursing
			 services.
(2) The Department shall
			 select qualified enrolled Medicaid providers for long term care community
			 nursing services according to the standards in these rules, OAR
			 407-120-0320, and OAR chapter
			 410, division 120 as applicable.
(3) The long term care community nursing
			 services provided under these rules may be delivered by the following enrolled
			 Medicaid providers:
(a) An RN who is a
			 self-employed provider.
(b) Home
			 health agencies meeting the requirements in OAR chapter 333, division
			 027.
(c) In-home care agencies
			 meeting the requirements in OAR chapter 333, division 536.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 48 - LONG TERM CARE COMMUNITY NURSING › Section 411-048-0220 - Medicaid Provider Disenrollment / Termination

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Enrolled Medicaid providers of long term
			 care community nursing services, or RN employees of an agency enrolled as a
			 Medicaid provider delivering long term care community nursing services may be
			 denied enrollment, terminated, or prohibited from providing long term care
			 community nursing services for, but not limited to, any of the following:
(a) Violation of any part of these rules at
			 any time.
(b) Violation of the
			 protective service and abuse rules in OAR chapter 411, division 020 and OAR
			 chapter 407, division 045.
(c)
			 Violation of the applicable service rules in OAR chapter 410, division 120 or
			 173, or the provider rules in OAR chapter 333, division 027 or 536.
(d) Any sanction or action as a result of an
			 OSBN investigation.
(e) Failure to
			 keep required licensure or certifications current.
(f) Failure to provide copies of the records
			 described in these rules to designated Department or Oregon Health Authority
			 entities.
(g) Failure to
			 participate in Nursing Service Plan review or care coordination meetings when
			 requested by an individual's case manager.
(h) Failure to obtain a pass score on the
			 Department's test on OSBN's OAR division 006, 045, and 047 as requested by the
			 Department.
(i) Failure to provide
			 services.
(j) Fraud or
			 misrepresentation in the application for enrollment or for the provision of
			 long-term care community nursing services.
(k) Evidence of conduct derogatory to the
			 standards of nursing as described in OAR
			 851-045-0070 that results in
			 referral to OSBN.
(l) A
			 demonstrated pattern of repeated unsubstantiated complaints of neglect or abuse
			 per OAR chapter 411, division 020 or OAR chapter 407, division 045.
(m) Exclusion by the Office of Inspector
			 General from participating in publicly funded programs. Agencies listed in
			 section (3)(b) and (c) of this rule are prohibited from employing or paying any
			 excluded person or entity and must promptly notify the Authority Health Systems
			 Division's Provider Enrollment Unit or the Office of Inspector General in
			 writing of any violation.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 48 - LONG TERM CARE COMMUNITY NURSING › Section 411-048-0230 - Compensation and Billing

Current through Register Vol. 63, No. 7, July 1, 2024
(1) All
			 long term care community nursing services must be authorized by an individual's
			 case manager using Department approved forms provided by the Department prior
			 to the delivery of long term care community nursing services.
(2) All billing and claims must comply with:
(a) OAR
			 407-120-0330 and
			 407-120-0340;
(b) OAR chapter 410, divisions 120 and 173 as
			 applicable; and
(c) The Long Term
			 Care Nursing Procedure Codes and Payment Authorization Guidelines posted at
https://www.oregon.gov/odhs/providers-partners/ltccn/Pages/resources.aspx#billing
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 48 - LONG TERM CARE COMMUNITY NURSING › Section 411-048-0240 - Orientation Requirements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A
			 self-employed RN or agency administrator as described in OAR
			 411-048-0210 must complete an
			 orientation with the Local Office for the area they intend to provide services.
			 The orientation must be completed prior to accepting Referrals as described
			 under OAR 411-048-0180.
(2) Local office management and RN or agency
			 administrator shall review at a minimum the following:
(a) Local area practices that the RN should
			 be aware of, schedules or best access times for case managers.
(b) Local CCO resources and practices that
			 the RN or agency may need to know about.
(c) Communication, documentation and
			 problem-solving activities that occur between the RN or agency and case
			 managers.
(d) Develop expectation
			 regarding when the RN or agency should contact management for concerns
			 regarding the program, a client, a case manager or other providers.
(e) Review any questions the RN or agency may
			 have from the program material and connect with LTCCN Contract Administrator
			 for any additional guidance.
(f)
			 Other procedures as required by ODHS offices or designee.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 48 - LONG TERM CARE COMMUNITY NURSING › Section 411-048-0250 - Variances

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Department
			 may grant a variance to these rules. Implementation of a variance may not occur
			 without the Department's written approval.
(2) A request for a variance to these rules
			 must include but not be limited to the following standards:
(a) A written request must be provided to
			 central office Department management for prior approval. The variance request
			 must include;
(A) Local office management
			 support for the variance request;
(B) A description of the benefit to the
			 individual served by the Department that may occur as result of the variance;
			 and
(C) Details regarding the
			 specific rule for which the variance may be granted, the rationale for why the
			 variance is needed, the proposed duration of the variance, identification of
			 alternatives (including rule compliance), and costs of the variance if
			 any.
Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 49 - ADULT FOSTER HOMES FOR OLDER ADULTS OR ADULTS WITH PHYSICAL DISABILITIES - PURPOSE, DEFINITIONS, AND LICENSURE › Section 411-049-0100 - Purpose

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The purpose of
			 the rules in OAR chapter 411, division 049, 050, 051, and 052 is to establish
			 the minimum standards and procedures for Adult Foster Homes (AFH) that provide
			 care and services for adults who are older or adults with physical disabilities
			 in a homelike environment that is safe and secure.
(2) Adult foster homes:
(a) Provide necessary care and services that
			 emphasize the resident's independence through a cooperative relationship
			 between the resident (or court-appointed guardian) and the resident's care
			 providers.
(b) Care and services
			 are provided in a setting that protects and encourages resident dignity,
			 choice, and decision-making while addressing the needs of the resident in a
			 manner that supports and enables the residents to maximize their ability to
			 function at the highest level of independence possible.