OAR 411-071-0020: Assessment Process

(1) The Department must develop and provide to certified programs an assessment instrument to be used for all admission assessments. (2) The admission assessment must consist of: (a) Information necessary to comply with federal pre-admission screening requirements as established by the Centers for Medicare Services; (b) Recommendations regarding appropriate care settings and services based on the individual's personal, family, and community support system, discussion of the individual's lifestyle preferences and goals, and other information. An individual or the individual's representative must indicate on the assessment form provided by the Department whether the individual has received information about care options or does not want the information. An individual may not be required to receive this information. Documentation by non-hospital based programs must be on the form designated by the Department. Hospital based programs must document information regarding appropriate care settings and services in their own discharge planning documents for all individuals assessed. (3) Appropriate information about care settings and services may be made available to individuals choosing to receive such information, including information on community-based care services, nursing facility options, and additional information as may be appropriate to a particular geographic area. (4) The recommendations of the admission assessment are not binding; an individual has the right to choose any or none of the available options. An individual may designate someone to participate in the assessment process. (5) As part of the admission assessment process, the individual or the individual's representative, as specified in section (6) of this rule, must be requested to certify on the assessment instrument whether the individual has received information about care options or does not want the information. (6) The following descending hierarchy is to be observed when certifying the information required in sections (5) and (6) of this rule and signing the assessment form: (a) The individual, if the individual is capable at the time the assessment is performed; (b) The individual's legally designated representative (as defined in OAR 411-071-0005) if the individual is not capable at the time the admission assessment is performed; (c) The individual's next of kin or, if appropriate, a knowledgeable friend if the individual has no legally designated representative and is not capable at the time the admission assessment is performed; (d) The person performing the assessment if a good faith effort fails to locate the individual's next of kin or appropriate friend, the individual has no legally designated representative, and is not capable at the time the admission assessment is performed; (e) The person performing the assessment if the individual is capable at the time the assessment is performed but refuses to sign.