OAR 309-019-0140: Service Plan and Service Notes

(1) The service plan must be a written, individualized plan designed to improve the individual’s condition to the point where the individual’s continued participation in the program or level of care is no longer necessary. (a) Service plans shall be started following the completion of an assessment, or portion thereof, and prior to treatment services being rendered. P rovider must document reason for any delay in the service record. (b) Routine services may be rendered prior to a completion of a service plan or documentation of a medically necessary reason for services. These services can be provided without a service plan or medical necessity, or at any time during a treatment episode: (i) Care Coordination (ii) Case Management (iii) Peer Services (c) Service plans must reflect the assessment in its’ most updated form; (d) Address areas of concern identified in the current assessment that the individual or guardian – if relevant and appropriate -- agrees to address; (e) Include a safety plan when the assessment indicates risk to the health and safety of the individual or to others and be updated as circumstances change. The safety plan may be a separate document from the service plan; (f) Include the participation, and reflect agreement, of the individual and family members, as applicable; (g) Be completed and signed by qualified program staff as follows: (A) A QMHP or appropriately licensed provider in mental health programs; (B) Supervisory or treatment staff in substance use disorders treatment programs; and (C) Supervisory or treatment staff in problem gambling treatment programs. (h) Approval of services and supports shall be demonstrated through operationalization of provider policy described above, in OAR 309-019-0110 (1)(z). (2) At minimum, each service plan must include: (a) Treatment goals that are individualized; (b) Treatment goals that meet the assessed needs of the individual. (c) Measurable for the purpose of evaluating individual progress, including a baseline. (3) Service plans must reflect the most updated assessments on file, and must include: (a) Goals that are measurable for the purpose of evaluating individual progress – including baseline measurement as well as include; (b) The specific services and supports that will be used to meet the treatment goals; (c) Expected frequency, amount, and duration of each type of planned service or support; (d) A schedule for re-evaluating the service plan; and (e) the type of personnel that will be furnishing each of the services. (4) Providers must document the following in a service note for each service and support : (a) The specific service or support rendered; (b) The relationship of the services to the treatment regimen described in the service plan; (c) The date, time of service or support, and the actual amount of time the service or support was rendered; (d) The personnel rendering the services, including their name, credentials, and signature; (e) The setting in which the service or support was rendered; and (f) Periodic updates describing the individual’s progress, or lack thereof (5) Decisions to transfer individuals must be documented including: (a) The date of the transfer; (b) The reason for the transfer; (c) For substance use disorder and co-occurring services, ASAM level of care recommendation and overall determination of the severity of risk the individual is experiencing at the time of transfer; (d) Referrals to follow up services and other behavioral health providers; and (e) Outreach efforts made as applicable and as defined in these rules.