Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 4 - HOME AND COMMUNITY-BASED SERVICES AND SETTINGS AND PERSON-CENTERED SERVICE PLANNING › Section 411-004-0030 - Person-Centered Service Plans

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 PERSON-CENTERED SERVICE PLANNING PROCESS. A person-centered service plan must
			 be developed through a person-centered service planning process. The
			 person-centered service planning process:
(a)
			 Is driven by the individual;
(b)
			 Includes people chosen by the individual;
(c) Provides necessary information and
			 supports to ensure the individual directs the process to the maximum extent
			 possible and is enabled to make informed choices and decisions;
(d) Is timely, responsive to changing needs,
			 occurs at times and locations convenient to the individual, and is reviewed at
			 least annually;
(e) Reflects the
			 cultural considerations of the individual;
(f) Uses language, format, and presentation
			 methods appropriate for effective communication according to the needs and
			 abilities of the individual and, as applicable, the legal or designated
			 representative of the individual;
(g) Includes strategies for resolving
			 disagreement within the process, including clear conflict of interest
			 guidelines for all planning participants, such as:
(A) Discussing the concerns of the individual
			 and determining acceptable solutions;
(B) Supporting the individual in arranging
			 and conducting a person-centered service planning meeting;
(C) Utilizing any available greater community
			 conflict resolution resources;
(D)
			 Referring concerns to the Office of the Long-Term Care Ombudsman; or
(E) For Medicaid recipients, following
			 existing, program-specific grievance processes.
(h) Offers choices to the individual
			 regarding the services and supports the individual receives, and from whom, and
			 records the alternative HCB settings that were considered by the individual;
(i) Provides a method for the
			 individual or, as applicable, the legal or designated representative of the
			 individual, to request updates to the person-centered service plan for the
			 individual, as needed;
(j) Is
			 conducted to reflect what is important to the individual to ensure delivery of
			 services in a manner reflecting personal preferences and ensuring health and
			 welfare;
(k) Identifies the
			 strengths and preferences, service and support needs, goals, and desired
			 outcomes of the individual;
(l)
			 Includes any services that are self-directed, if applicable;
(m) Includes, but is not limited to,
			 individually identified goals and preferences related to relationships, greater
			 community participation, employment, income and savings, healthcare and
			 wellness, and education;
(n)
			 Includes risk factors and plans to minimize any identified risk factors; and
(o) Results in a person-centered
			 service plan documented by the person-centered services plan coordinator,
			 signed by the individual or, as applicable, the legal or designated
			 representative of the individual, participants in the person-centered service
			 planning process, and all people and providers responsible for the
			 implementation of the person-centered service plan as described below in
			 section (2)(d) of this rule. The person-centered service plan is distributed to
			 the individual, and, as applicable, the legal or designated representative of
			 the individual, and other people involved in the person-centered service plan
			 as described below in section (2)(d) of this rule.