OAR 410-172-0835: Temporary rule language in effect until 02/15/2027. Person-centered Service Planning, Coordinating and Monitoring

(1) When the needs-based assessment demonstrates that personal care services are medically necessary and appropriate, the service coordinator will develop a person-centered service plan (PCSP). The individual has the right, but is not required to, participate in the development of the PCSP. (2) A completed PCSP must identify the tasks for which an individual requires assistance and the number of authorized service hours, and individual’s natural supports who currently meet some or all the individual’s service needs. (a) The PCSP must describe: (A) The tasks the personal care attendant (PCA) or the Agency with Choice (AWC), including the direct support worker (DSW), will perform; (B) The maximum authorized hours that the individual may receive personal care services during each 14-day pay period; and (C) The individual’s monitoring preferences as described in section (4) below of this rule. (b) The service coordinator must consider the cost effectiveness of medically necessary and appropriate services when developing the individual’s PCSP. (3) The service coordinator will provide ongoing coordination of services, including: (a) Authorizing changes in PCAs, DSWs, and other providers and service hours; (b) Addressing risks; (c) Monitoring services; (d) Providing information to the individual; and (e) Making referrals to other providers for the individual when indicated. (4) The service coordinator will monitor the personal care services provided to the individual to ensure the PCSP is effectively implemented and continues to meet the needs of the individual. Monitoring will occur at least every quarter of the service plan year and more frequently if requested by the individual, the individual’s authorized representative or legal representative (or both if different), or if determined necessary by the service coordinator. (a) Monitoring requires: (A) The individual and the service coordinator to meet in-person, face-to-face using telehealth, or telephone interviews. The meeting may include the individual’s authorized representative or legal representative (of both if different); (B) Monitoring preferences shall be determined by the individual or their authorized representative; and (C) The service coordinator must meet with the individual for in-person or face-to-face telehealth monitoring at least once annually, or more often, as determined by the individual or their authorized representative or legal representative (or both if different), or the service coordinator. (b) The service coordinator must document all monitoring activities in the individual’s record, which must identify, at minimum, the following: (A) Identification of the personal care services delivered in accordance with the individual’s PCSP and applicable Oregon Administrative Rules; (B) Whether and how the PCSP adequately meets the individual’s assessed needs and goals; (C) Any changes in the needs or status of the individual; (D) Any follow-up actions needed to be performed and by whom to ensure the PCSP is adjusted to meet the individual’s needs. (5) The Authority may not authorize the delivery of personal care services in an individual’s home or family home when: (a) The individual’s home or family home presents conditions that jeopardize the health or safety of the individual, their PCA, or their DSW and cannot be mitigated through reasonable safeguards; (b) The services cannot be provided safely by the PCA or DSW in the individual’s home or family home; (c) The individual is unable to make informed decisions, and, as applicable, does not have an authorized representative to make decisions on their behalf, and necessary safeguards cannot be implemented to protect the individual’s safety, health, and welfare; or (d) The individual is unable to fulfill employer or co-employer responsibilities, as applicable, and does not have an authorized representative to perform those responsibilities. (6) The service coordinator shall provide the individual or the individual’s representative with information on service alternatives and assist with exploring other options when a PCA or a DSW employed by an AWC is not authorized. Eligible individuals have free choice of qualified providers of in-home care services.