OAR 411-300-0150: Scope of CIIS and Limitations

(1) CIIS are intended to support, not supplant, the naturally occurring supports provided by a legally responsible primary caregiver and enable the primary caregiver to meet the needs of caring for a child receiving CIIS. CIIS are not meant to replace other available governmental or community services and supports. All CIIS funded by the Department must be provided according to the Expenditure Guidelines and based on the actual and customary costs related to best practice standards of care for children with similar disabilities. (2) A services coordinator must provide case management and other supports according to OAR chapter 411, division 415 and these rules. (3) To be authorized and eligible for payment by the Department, all CIIS must be: (a) Directly related to the assessed needs of a child or young adult. (b) Required to maintain the health and safety of the child. (c) Cost effective. (d) Considered not typical for a parent or guardian to provide to a child of the same age. (e) Required to help the parent or guardian continue to meet the needs of caring for the child. (f) Included in an approved ISP. (g) Provided according to the Expenditure Guidelines. (4) Department funds may be used to purchase a combination of the following: (a) Ancillary services as described in OAR chapter 411, division 435. (b) Community living supports as described in OAR chapter 411, division 450. (c) Professional behavior services as described in OAR chapter 411, division 304. (d) State plan personal care services as described in OAR chapter 411, division 455. (e) Private duty nursing as described in section (5) of this rule and OAR chapter 410, division 132. (f) Employment services as described in OAR chapter 411, division 345. (5) PRIVATE DUTY NURSING. (a) If the service needs of a child or young adult enrolled in the Medically Fragile Children’s Program require the presence of an RN or LPN on an ongoing basis as determined medically necessary based on their Clinical Criteria, private duty nursing services may be allocated to ensure medically necessary supports are provided. (A) Private duty nursing may be provided on a shift staffing basis as necessary. (B) Private duty nursing must be delivered by a licensed RN or LPN, who does not have limitations of service provision as described in OAR 410-132-0080, as determined by the service needs of the child or young adult and documented in the ISP and Nursing Service Plan. (C) The amount of private duty nursing available to a child or young adult is based on the acuity level of the child or young adult as measured by the Clinical Criteria as follows: (i) Level 1. Score of 75 or above and on a ventilator for 20 hours or more per day = up to a maximum of 554 nursing hours per month. (ii) Level 2. Score of 70 or above = up to a maximum of 462 nursing hours per month. (iii) Level 3. Score of 65 to 69 = up to a maximum of 385 nursing hours per month. (iv) Level 4. Score of 60 to 64 = up to a maximum of 339 nursing hours per month. (v) Level 5. Score of 50 to 59 or if a child requires ventilation for sleeping hours = up to a maximum of 293 nursing hours per month. (vi) Level 6. Score of 45 to 49 = up to a maximum of 140 nursing hours per month. (b) A request for private duty nursing services exceeding limitations in the Expenditure Guidelines must be authorized by the Department. The approval of the Department is limited to 90 calendar days unless re-authorized. A request to exceed private duty nursing limitations in the Expenditure Guidelines is only authorized in the following circumstances: (A) The child is not safely served in the family home without the expenditure. (B) The expenditure provides supports for the emerging or changing service needs or behaviors of the child. (C) A significant medical condition or event, as documented by a primary care provider, prevents or seriously impedes the primary caregiver from delivering services.