OAR 411-320-0070: Service Records

(1) CONFIDENTIALITY. The service record for an individual must be kept confidential in accordance with ORS 179.505, 192.515, 192.517, 192.553, and any Department rules or policies pertaining to individual service records. (2) INFORMATION SHARING. Pertinent clinical, financial eligibility, and legal status information concerning an individual supported by the CDDP must be made available to other CDDPs responsible for the services of the individual, consistent with state statutes and federal laws and regulations concerning confidentiality and privacy. (3) RECORD REQUIREMENTS. In order to meet Department and federal record documentation requirements, the CDDP, through the employees of the CDDP, must maintain a service record for each individual who receives services from the CDDP. Information contained in the service record must include: (a) Documentation of any initial referral to the CDDP for services; (b) The application for developmental disabilities services. The application for developmental disabilities services must be completed prior to an eligibility determination and must be on the application form required by the Department or transferred onto CDDP letterhead; (c) Sufficient documentation to conform to Department eligibility requirements, including notices of eligibility determination; (d) Documentation of the initial intake interview or home assessment, as well as any subsequent social service summaries; (e) Documentation of the request for support services and the selection of an available Brokerage within the geographic service area of the CDDP; (f) For individuals receiving case management services from the CDDP, the service record must contain the records requirements identified in OAR 411-415-0110. (4) RETENTION OF RECORDS. The CDDP must have a record retention plan for all records relating to the provision of, and contracts for, CDDP services that is consistent with this rule and OAR 166-150-0055. The record retention plan must be made available to the public or the Department upon request. (a) Financial records, supporting documents, and statistical records must be retained for at least three years after the close of the contract period or until the conclusion of the financial settlement process with the Department, whichever is longer. (b) Individual service records must be kept for seven years after the date of the death of an individual, if known. If the case is closed, inactive, or the date of death is unknown, the individual service record must be kept for 70 years. (c) Copies of annual ISPs must be kept for 10 years. (5) TRANSFER OF RECORDS. In the event an individual moves from one county to another county in Oregon, the complete service record for an individual as described in section (3) of this rule must be transferred to the receiving CDDP within 30 days of transfer. The sending CDDP must ensure that the service record required by this rule is maintained in permanent record and transferred to the CDDP having jurisdiction for the services for the individual. The sending CDDP must retain the following information to document that services were provided to the individual while enrolled in CDDP services: (a) Documentation of eligibility for developmental disabilities services received while enrolled in services through the CDDP, including waiver or state plan eligibility; (b) Service enrollment and termination forms; (c) CDDP progress notes; (d) Documentation of services provided to the individual by the CDDP; and (e) Any required documentation necessary to complete the financial settlement with the Department. [Publications: Publications referenced are available from the agency.]