OAR 411-345-0085: Reports and Recordkeeping

(1) A provider must maintain progress notes regarding the employment service provided. (a) A progress note must include, at minimum, all of the following information regarding the service rendered: (A) Date and time the service was delivered. (B) Information regarding progress towards achieving the intended employment goal for which the employment service was utilized, including progress towards outcomes and milestones outlined in the Career Development Plan and the implementation strategies or plan. (C) At least every six months, documentation of the number of hours the supported individual works, the wages and level of benefits, as well as any opportunities presented to the individual for increased work hours. (D) Any discussion about work hours and related goals. (b) Progress notes must be made available upon request. (2) JOB DEVELOPMENT. A provider being paid for job development must report activity for each individual supported, at least monthly, to the individual's case management entity. (3) DISCOVERY PROFILE. A provider being paid for discovery must complete a Discovery Profile for each individual supported and submit the Discovery Profile to the individual's case management entity. (4) BENEFITS COUNSELING. A benefits counselor must document the outcome of benefits counseling, including the advisement provided to an individual regarding benefits and work incentives and whether a referral for additional benefits counseling was made. (5) Unless stated otherwise, all entries required by these rules must: (a) Be prepared at the time, or immediately following, the event being recorded; (b) Be accurate and contain no willful falsifications; (c) Be legible, dated, and signed by the person making the entry; and (d) Be maintained for no less than five years. (6) Failure to furnish written documentation upon the written request from the Department, the Oregon Health Authority, the Oregon Department of Justice Medicaid Fraud Unit, Centers for Medicare and Medicaid Services, or their authorized representatives, immediately or within timeframes specified in the written request, may be deemed reason to recover payment. (7) Records must be retained in accordance with OAR chapter 166, division 150, Secretary of State, Archives Division. (a) Financial records, supporting documents, statistical records, and all other records (except individual records) must be retained for at least three years after the close of a contract period. (b) Individual records must be kept for at least seven years.