OAR 411-328-0750: Personalized Plans

(1) The following information must be collected and summarized by the provider prior to any ISP meeting: (a) One page profile reflecting, at a minimum, information gathered by the site where the individual receives services; (b) Person-centered information reflecting, at a minimum, information gathered by the site where the individual receives services; and (c) Information about known, identified serious risks. (2) The following information must be developed by the provider and shared with the case manager and the individual, or if applicable the legal or designated representative of the individual, as directed by the ISP or Service Agreement. (a) Implementation strategies, such as action plans, for desired outcomes or goals. (b) Necessary protocols or plans that address health, behavioral, safety, and financial supports. (c) A summary of the provider risk management strategies in place, including title of document, date, and where it is kept. (d) A Nursing Service Plan, if applicable. (e) Other documents required by the ISP team. (3) The provider must maintain a copy of the ISP or Service Agreement provided the case management entity and signed by the provider. (4) The provider must participate in ISP team meetings as requested by the individual or the legal or designated representative of the individual (if applicable). (5) The provider must maintain documentation of implementation of each support and services specified in sections (2)(a) to (2)(e) of this rule in the ISP or Service Agreement for the individual. This documentation must be kept current and be available for review by the individual, the legal representative of the individual, the case management entity, and Department representatives. (6) INDIVIDUAL PROFILE. (a) The provider must develop a written profile within 90 days of entry. The profile is used to train new staff. The profile must include information related to the history or personal highlights, lifestyle and activity choices and preferences, social network and significant relationships, and other information that helps describe an individual. (b) The profile must be composed of written information generated by the provider. The profile may include: (A) Reports of assessments or consultations; (B) Historical or current materials developed by the case management entity or nursing facility; (C) Material and pictures from the family and friends of the individual; (D) Newspaper articles; and (E) Other relevant information. (c) The profile must be maintained at the service site and updated as significant changes occur.