Department of Human Services
Aging and People with Disabilities and Developmental Disabilities - Chapter 411
Division 415
CASE MANAGEMENT SERVICES FOR INDIVIDUALS WITH INTELLECTUAL OR DEVELOPMENTAL DISABILITIES
411-415-0070
Service Planning
This rule prescribes standards for the development and implementation of an Individual Support Plan (ISP) or Annual Plan.
(1) An ISP must meet the following requirements:
(a) Be developed using a person-centered planning process consistent with OAR 411-004-0030 and in a manner that addresses issues of independence, integration, and provides opportunities to seek employment and work in competitive integrated employment settings, in order to assist with establishing outcomes, planning for supports, and reviewing and redesigning support strategies.
(b) Be designed to enhance an individual's quality of life.
(c) Be consistent with the following principles:
(A) Adult individuals have the right to make informed choices about the level of family member participation.
(B) The preferences of an individual, and when applicable a child's legal representative or family, must serve to guide the ISP team. A case manager must facilitate active participation of an individual throughout the planning process.
(C) The planning process is designed to identify the types of services and supports necessary to achieve an individual's preferences, and when applicable a child's legal representative or family, identify the barriers to providing those preferred services, and develop strategies for reducing the barriers.
(D) Specify cost-effective arrangements for obtaining the required supports and applying public, private, formal, and alternative resources available to an eligible individual.
(E) When planning for a child in a 24-hour residential program, foster home, or host home, the following must apply:
(i) Unless contraindicated, there must be a goal for family reunification.
(ii) The number of moves or transfers must be kept to a minimum.
(iii) Unless contraindicated, if the placement of a child is distant from their family, the child's case manager must continue to seek a placement that brings the child closer to their family.
(d) Be developed based on assessed need.
(e) For community living supports, the ISP must include an hour allocation that is within the maximum service level for the individual as described in OAR 411-450-0060(7)(f) or (h) or within the amount approved by an exception as described in OAR 411-450-0065.
(2) An individual enrolled in waiver or Community First Choice state plan services must have an ISP, completed on a Department approved document, consistent with the outcome of the person-centered planning process and OAR 411-004-0030.
(a) An initial ISP may begin a transition period as defined in OAR 411-415-0020. During a transition period, the ISP must include the minimum necessary services and supports for an individual upon entry to a new program type, setting, or Case Management Entity (CME). The ISP during a transition period must include, at a minimum, the following:
(A) An authorization of necessary services.
(B) The supports needed to facilitate adjustment to the services offered.
(C) The supports necessary to ensure health and safety.
(D) The assessments and consultations necessary for further ISP development.
(b) An initial ISP has a duration of 12 full months, beginning the month following the authorization of the ISP.
(c) The duration of an annual ISP is 12 months. With an individual's consent, or as applicable the consent of the individual's legal or designated representative, a start date for an initial ISP may be established within the 12 months when the individual enters or exits any of the following:
(A) A 24-hour residential program as described in OAR chapter 411, division 325. A transfer to a new setting within the same 24-hour residential program may not cause a new start date for an ISP.
(B) A host home program as described in OAR chapter 411, division 348. A transfer to a new setting within the same host home program may not cause a new start date for an ISP.
(C) A supported living program as described in OAR chapter 411, division 328. A transfer to a new setting within the same supported living program may not cause a new start date for an ISP.
(D) Foster care as described in OAR chapter 411, division 346 for children or OAR chapter 411, division 360 for adults.
(E) A CIIS program.
(d) All Department-funded developmental disabilities services included in an ISP must be consistent with the ISP manual, Department policy, and the Expenditure Guidelines, when applicable.
(e) For Community First Choice state plan and waiver services, the supports included in an ISP must reflect the services and supports that are important for an individual to meet the needs identified through an assessment of functional need, as well as what is important to the individual with regard to preferences for the delivery of such services and supports.
(3) INDIVIDUALLY-BASED LIMITATIONS.
(a) An initial or annual ISP for an individual receiving services in a residential setting must include any applicable individually-based limitations to the following freedoms:
(A) Support and freedom to access the individual’s personal food at any time.
(B) Visitors of the individual's choosing at any time.
(C) A lock on the individual's bedroom, lockable by the individual.
(D) Choice of a roommate, if sharing a bedroom.
(E) Freedom to furnish and decorate the individual's bedroom as the individual chooses in accordance with a Residency Agreement.
(F) Freedom and support to control the individual's schedule and activities.
(b) An individually-based limitation must be in accordance with OAR 411-004-0040 and be supported by an individual's specific assessed need due to threats to the health and safety of the individual or others.
(c) An initial or annual ISP for an individual receiving services in any setting must include any applicable individually-based limitations to the individual’s freedom from restraint.
(d) An individually-based limitation must only include a safeguarding intervention that:
(A) Meets the definition found in OAR 411-317-0000 and complies with OAR 411-304-0150, OAR 411-304-0160, and applicable program rules.
(B) When used to address a challenging behavior, is directed in a Positive Behavior Support Plan written by a behavior professional qualified to author the safeguarding intervention according to ODDS-approved behavior intervention curriculum and certification as described in OAR 411-304-0150.
(C) When used to address a medical condition or medical support need, is included in a medical order written by an individual's licensed health care provider. The medical order may only indicate the use of a safeguarding intervention to address a medical condition and must include all of the following:
(i) The medical need for the use of the safeguarding intervention.
(ii) Situations for when to use the safeguarding intervention.
(iii) The length of time or situations permitted for the use of the safeguarding intervention.
(e) An individually-based limitation must only include safeguarding equipment that:
(A) Meets the definition found in OAR 411-317-0000 and complies with OAR 411-304-0150 and applicable program rules.
(B) When used to address a challenging behavior, is directed in a Positive Behavior Support Plan written by a behavior professional as described in OAR 411-304-0150.
(C) When used to address a medical condition or medical support need, is included in a medical order written by an individual’s licensed health care provider. The medical order may only indicate the use of safeguarding equipment to address a medical condition and must include all of the following:
(i) The medical condition the safeguarding equipment addresses.
(ii) The type of safeguarding equipment.
(iii) Situations for when to use the safeguarding equipment.
(iv) The length of time or situations permitted for the use of the safeguarding equipment.
(4) TEMPORARY EMERGENCY SAFETY PLAN. A Temporary Emergency Safety Plan described in OAR 411-304-0150 may be in effect for up to 90 calendar days. The date may be extended up to an additional 90 calendar days with approval from an individual and the individual's case manager to allow additional time for the completion of a Functional Behavior Assessment and Positive Behavior Support Plan.
(5) CAREER DEVELOPMENT PLAN.
(a) A Career Development Plan must be completed as part of an ISP:
(A) When an individual is working age; or
(B) Prior to the expected exit from school for students eligible for services under the Individuals with Disabilities Education Act (IDEA). If a student leaves school prior to the expected exit, the student must have the opportunity to have a Career Development Plan within one year of the unexpected exit.
(b) A Career Development Plan must meet the following requirements:
(A) For an individual who uses employment services as described in OAR chapter 411, division 345, include goals and objectives related to obtaining, maintaining, or advancing in competitive integrated employment, or at minimum, exploring competitive integrated employment or developing skills that may be used in competitive integrated employment.
(B) Be developed based on a presumption that, with the right support and job match, an individual may succeed and advance in an integrated employment setting and earn minimum wage or better.
(C) Prioritize competitive integrated employment in the general workforce.
(D) For an individual who has competitive integrated employment, person-centered planning must focus on maintaining employment, maximizing the number of hours the individual works consistent with their preferences and interests, improving wages and benefits, and promoting additional career or advancement opportunities.
(E) For an individual using job coaching or job development services, the Career Development Plan must document either a goal or discussion regarding opportunities for maximizing work hours and other career advancement opportunities. The recommended standard for planning job coaching and job development is the opportunity to work at least 20 hours per week. Individualized planning should ultimately be based on individual choice, preferences, and circumstances, and recognize that an individual may choose to pursue working full-time, part-time, or another goal identified by the individual.
(F) Document all employment service options presented, including the option to use employment services in a non-disability specific setting, meaning a setting that is not owned, operated, or controlled by a provider of home and community-based services.
(G) For an individual who uses employment services in a sheltered workshop setting, the Career Development Plan must document the individual has been encouraged to choose a community-based employment service option and not a sheltered workshop setting option.
(6) ISP REVIEWS.
(a) An ISP must be reviewed, and as needed, revised and re-authorized:
(A) No later than the end of the month following the month in which the Oregon Needs Assessment (ONA) was conducted.
(B) Prior to the expiration of the ISP.
(C) No later than the end of a transition period.
(D) When the circumstances or needs of an individual change significantly.
(E) At the request of an individual or as applicable the individual's legal or designated representative.
(b) For an individual who changes CME, but remains in an in-home setting, the ISP authorized by the previous CME may be used as authorization for available services when the services in the new setting remain appropriate.
(7) TEAM PROCESS IN PERSON-CENTERED PLANNING. This section applies to an ISP developed for an individual receiving services in a residential program.
(a) The ISP is developed by the individual, the individual's legal or designated representative (as applicable), and the services coordinator. Others may be included as a part of the ISP team at the invitation of the individual and as applicable the individual's legal or designated representative. In order to assure adequate planning, provider representatives are necessary informants to the ISP team even when not ISP team members.
(b) In circumstances where an individual is unable to express their opinion or choice using words, behaviors, or other means of communication and the individual does not have a legal or designated representative, the following apply:
(A) On behalf of the individual, the ISP team is empowered to make a decision the ISP team feels best meets the health, safety, and assessed needs of the individual.
(B) Consensus amongst ISP team members is prioritized. When consensus may not be reached, majority agreement is used. For purposes of reaching a majority agreement each interested party, which may be represented by more than one person, is considered as one member of the ISP team. Interested parties may include, but are not limited to, the individual's provider, family, and services coordinator.
(C) No one member of an ISP team has the authority to make decisions for the ISP team.
(c) Any objections to the decisions of an ISP team by a member of the ISP team must be documented in the ISP.
(d) A services coordinator must track the ISP timelines and coordinate the resolution of complaints and conflicts arising from ISP discussions.
(8) ISP AUTHORIZATION.
(a) An initial and annual ISP must be authorized prior to implementation.
(b) Unless noted otherwise in these or program rules, an initial ISP must include the Medicaid funded developmental disabilities services for which an individual is eligible and desires. An initial ISP must be authorized no more than 90 calendar days from the date of the request for the services when the individual making the request is enrolled in a Medicaid Title XIX benefit package or a benefit package through the Healthier Oregon medical program. A completed application, as defined in OAR 411-320-0020 and submitted to the Community Developmental Disabilities Program (CDDP), is a request for services if the individual is enrolled in a Medicaid Title XIX benefit package or a benefit package through the Healthier Oregon medical program at the time the completed application is submitted.
(c) A revision to an initial or annual ISP that begins or ends a developmental disabilities service paid using Department funds must be authorized prior to implementation.
(d) A revision to an initial or annual ISP that does not begin or end a developmental disabilities service paid using Department funds does not require authorization. The CME must provide written notification of the revision to the individual, or as applicable their legal or designated representative, prior to implementation of the revision.
(e) An initial ISP, and a revision to an initial or annual ISP requiring authorization, is authorized on the date:
(A) The signature of the individual, or as applicable the individual's legal or designated representative, is present on the ISP, or documentation is present explaining the reason an individual who does not have a legal or designated representative may be unable to sign the ISP.
(i) Acceptable reasons for an individual without a legal or designated representative not to sign the ISP include physical or behavioral inability to sign the ISP.
(ii) Unavailability is not an acceptable reason for an individual, or as applicable the individual's legal or designated representative, not to sign the ISP.
(iii) Documented oral agreement may substitute for a signature for up to 10 business days when a revision to an initial or annual ISP is in response to an immediate, unexpected change in circumstance, and the revision is necessary to prevent injury or harm to the individual.
(B) The signature of the case manager involved in the development of, or revision to, the ISP is present on the ISP.
(f) A renewing ISP signed as described in this section, is authorized to begin the first calendar day after the previous ISP expired.
(g) All authorized developmental disabilities services funded through the Community First Choice state plan or home and community-based services waivers must occur in a setting consistent with OAR 411-004-0020.
(h) Community First Choice state plan and waiver services are only funded by the Department when the services are authorized in an ISP developed in a manner consistent with this rule.
(i) A legal or designated representative responsible for directing the development of an ISP on behalf of an individual (as applicable) may not be authorized to be a paid provider for the individual.
(j) An ISP may only have services authorized for personal support workers when the services are consistent with the payment limitations described in OAR 411-375-0040.
(k) An hour allocation or staffing ratio that requires approval from the Department may not be included in an authorized ISP prior to the date of the approval unless there is an imminent threat to an individual’s health and safety that may be mitigated by additional supports. A request for the Department to approve additional supports intended to mitigate an imminent threat to an individual’s health and safety must be submitted to the Department by a CME within five calendar days of the authorization of the additional supports.
(l) An ISP for an adult enrolled in a foster home, as described in OAR chapter 411, division 360, must include at least six hours of activities each week that are of interest to the individual that do not include television or movies made available by the provider. Activities are those available in the community and made available or offered by the provider or the Community Developmental Disabilities Program (CDDP).
(A) Activities may include the following:
(i) Recreational and leisure activities.
(ii) Other activities required to meet the needs of an individual as described in the ISP for the individual.
(B) Activities that contribute to the six hours may not include any of the following:
(i) Rehabilitation.
(ii) Educational services.
(iii) Employment services.
(m) Not more than two weeks after authorization, a CME must provide a copy of an individual's most current ISP to the individual, the individual's legal and designated representative (as applicable), and others as identified by the individual. An ISP must be made available using language, format, and presentation methods appropriate for effective communication according to the needs and abilities of an individual receiving services and the people important in supporting the individual. When an authorized ISP must be translated from English, translation must be initiated within two weeks of authorization and the translated document must be provided to the individual by the CME upon receipt.
(n) A case manager may not knowingly authorize a community living supports agency or a standard model agency to utilize an agency employee to deliver community living supports skills training or attendant care services, other than day support activities as defined in OAR 411-450-0020, to an individual that also engages the same person for services as the individual's personal support worker.
(9) DEVELOPMENTAL DISABILITIES SERVICE AUTHORIZATION LIMITS.
(a) Developmental disabilities services may not be authorized or must be terminated in the following circumstances:
(A) An individual does not meet the service eligibility requirements in the program rule corresponding to the service.
(B) A case manager is not permitted to conduct a monitoring visit to an individual's home as required in OAR 411-415-0090 if services can be expected to occur in the home.
(C) An individual fails to participate in, or be available for, the conducting of the components of an ONA within the timeframes identified in OAR 411-415-0060.
(b) A CME may deny, or must terminate, services from a provider, services in a setting, or a combination of services, selected by an eligible individual or the legal or designated representative of the individual in the following circumstances:
(A) The setting has dangerous conditions that jeopardize the health or safety of the individual and necessary safeguards are not available to improve the setting.
(B) Services may not be provided safely or adequately by the provider based on:
(i) The extent of the service needs of the individual; or
(ii) The choices or preferences of the eligible individual or as applicable the individual's legal or designated representative.
(C) Dangerous conditions in the setting jeopardize the health or safety of the provider authorized and paid for by the Department, and necessary safeguards are not available to minimize the dangers.
(D) The individual does not have the ability to express their informed decision, does not have a designated representative to make decisions on their behalf, and the Department or CME are unable to take necessary safeguards to protect the safety, health, and welfare of the individual.
(c) An ISP must not be authorized that includes types or amounts of developmental disabilities services for which the individual is not eligible.
(d) A case manager must present an individual, or as applicable the individual's legal or designated representative, with information on service alternatives and provide assistance to assess other choices when a provider or setting selected by the individual, or as applicable the individual's legal or designated representative, is not authorized.
(e) A services coordinator employed by a CDDP, or a sub-contractor of a CDDP contracted to deliver case management, may authorize an eligible individual to receive the following developmental disabilities services:
(A) Community First Choice 1915(k) state plan services.
(B) Services described in the Adults’ and Children's 1915(c) Home and Community-Based Services waivers.
(C) State Plan Personal Care as described in OAR chapter 411, division 455.
(D) Private duty nursing as described in OAR chapter 410, division 132.
(E) Family support services as described in OAR chapter 411, division 305.
(f) A personal agent may authorize an eligible individual to receive the following developmental disabilities services:
(A) Community First Choice 1915(k) state plan services, except services delivered as part of a residential program.
(B) Services described in the Adults’ 1915(c) Home and Community-Based Services Waiver.
(C) State Plan Personal Care as described in OAR chapter 411, division 455.
(D) Private duty nursing as described in OAR chapter 410, division 132.
(g) A CIIS services coordinator may authorize an eligible individual to receive the following developmental disabilities services:
(A) Community First Choice 1915(k) state plan services.
(B) Services described in the following 1915(c) waivers:
(i) Medically Involved Children's Waiver.
(ii) Medically Fragile (Hospital) Model Waiver.
(iii) Behavioral (Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IDD)) Model Waiver.
(C) State Plan Personal Care as described in OAR chapter 411, division 455.
(D) Private duty nursing as described in OAR chapter 410, division 132 and OAR 411-300-0150.
(h) The Department authorizes entry for children into residential programs, Children's Intensive In-Home Services (CIIS), and the Stabilization and Crisis Unit.
(10) ANNUAL PLANS. An individual enrolled in case management services, but not accessing Community First Choice state plan or waiver services, must have an Annual Plan.
(a) A case manager must develop an Annual Plan within 90 calendar days from the date of the enrollment of an individual into case management services, and annually thereafter if the individual is not enrolled in any Community First Choice state plan or waiver services.
(b) An Annual Plan must be developed as follows:
(A) For an adult, a written Annual Plan must be documented as an Annual Plan or as a comprehensive progress note in the service record for the individual and include all of the following:
(i) A review of the current living situation of the individual.
(ii) A review of the employment status of the individual and a summary of any related support needs.
(iii) A review of any personal health, safety, or behavioral concerns.
(iv) A summary of the support needs of the individual.
(v) Actions to be taken by the case manager and others.
(B) For a child receiving family support services, a services coordinator must coordinate with the child and the child's parent or legal representative in the development of an Annual Plan. The Annual Plan for a child receiving family support services must be in accordance with OAR 411-305-0225.
(c) An Annual Plan must be kept current. A case manager must ensure that a current Annual Plan is maintained for each individual receiving services.
Statutory/Other Authority: ORS 409.050, 427.104, 427.105, 427.115, 427.154, 430.212 & 430.662
Statutes/Other Implemented: 430.212, 430.662, ORS 409.010, 427.005-427.154, 430.215, 430.610, 430.620 & 430.664
History:
APD 23-2023, amend filed 12/21/2023, effective 01/01/2024
APD 5-2023, amend filed 05/01/2023, effective 05/01/2023
APD 45-2019, amend filed 10/29/2019, effective 11/01/2019
APD 46-2018, amend filed 12/28/2018, effective 12/28/2018
APD 23-2018, temporary amend filed 07/02/2018, effective 07/02/2018 through 12/27/2018
APD 29-2017, amend filed 11/30/2017, effective 12/01/2017
APD 2-2017, f. 2-21-17, cert. ef. 2-28-17
APD 35-2016(Temp), f. 8-31-16, cert. ef. 9-1-16 thru 2-27-17
APD 28-2016, f. & cert. ef. 6-29-16