OAR 411-360-0170: AFH-DD Documentation and Record Requirements

(1) INDIVIDUAL RECORDS. A record must be developed, kept current, and available on the premises of the AFH-DD for each individual admitted to the AFH-DD. (a) A provider must maintain a summary sheet for each individual in the AFH-DD. The summary sheet must include the following: (A) The name of the individual, current and previous address (when current address is less than six months old), date of entry into the AFH-DD, date of birth, gender, marital status, religious preference, preferred hospital, Medicaid prime and private insurance number (if applicable), and guardianship status. (B) The name, address, and telephone number of the following (as applicable): (i) The individual's legal representative, family, advocate, or other significant person. (ii) The primary physician or licensed health care provider and designated back up physician or licensed health care provider or clinic preferred by the individual. (iii) The dentist preferred by the individual. (iv) The individual's day program or employer. (v) The individual's services coordinator. (vi) Other representatives delivering care and services to the individual. (b) EMERGENCY INFORMATION. A provider must maintain emergency information for each individual receiving care and services in the AFH-DD, in addition to the individual summary sheet identified in subsection (a) of this section. The emergency information must be kept current and must include the following: (A) The individual's name. (B) The provider's name, address, and telephone number. (C) The address and telephone number of the AFH-DD where the individual resides if different from the provider. (D) The individual's physical description, which may include a picture of the individual with the date the picture was taken, and identification of the following: (i) Race, gender, height, weight range, and color of hair and eyes. (ii) Any other identifying characteristics that may assist in identifying the individual, such as marks or scars, tattoos, or body piercings. (E) Information on the individual's abilities and characteristics including, but not limited to, the following: (i) How the individual communicates. (ii) The language the individual uses or understands. (iii) The individual's ability to know how to take care of bodily functions. (iv) Any additional information that may assist a person not familiar with the individual to understand what the individual can do for himself or herself. (F) The individual's health support needs including, but not limited to, the following: (i) Diagnosis. (ii) Allergies or adverse drug reactions. (iii) Health issues a person needs to know when taking care of the individual. (iv) Special dietary or nutritional needs, such as requirements around textures or consistency of foods and fluids. (v) Food or fluid limitations due to allergies, diagnosis, or medications the individual is taking that may be an aspiration risk or other risk. (vi) Additional special requirements the individual has related to eating or drinking, such as special positional needs or a specific way foods or fluids are given to the individual. (vii) Physical limitations that may affect the individual's ability to communicate, respond to instructions, or follow directions. (viii) Specialized equipment needed for mobility, positioning, or other health-related needs. (G) The individual's emotional and behavioral support needs including, but not limited to, the following: (i) Mental health or behavioral diagnosis and the behaviors displayed by the individual. (ii) Approaches to use when supporting the individual to minimize emotional and physical outbursts. (H) Any court ordered or guardian authorized contacts or limitations. (I) The individual's supervision requirements and why. (J) Any additional information the provider has that may assist in the individual's care and support if a natural or man-made disaster occurs. (c) Individual records must be made available to representatives of the Department conducting inspections or investigations as well as to individuals to whom the information pertains, the individual's legal representative, or other legally authorized people. (d) Individual records must be kept by a provider for a period of at least three years. When an individual moves or an AFH-DD closes, copies of the individual's records must be transferred to the individual's new residence. (e) A provider must comply with ORS 179.505 in all other matters pertaining to confidential records and release of information. (2) INDIVIDUAL ACCOUNT RECORDS. For an individual not yet capable of managing money as determined by their ISP team or legal representative, a provider must prepare, maintain, and keep current a separate and accurate written record of all money received or disbursed on behalf of or by the individual. (a) The account record must include the following: (A) Date, amount, and source of income received. (B) Date, amount, and purpose of funds disbursed. (C) Signature of the provider or caregiver making the entry. (b) Purchases of $10.00 or more made on an individual's behalf must be documented by receipts unless an alternate amount is otherwise specified by the individual's ISP team. (c) An individual's Personal Incidental Funds (PIF) are to be used at the discretion of the individual for things such as clothing, video games, and snacks (not part of daily diet) as addressed in their ISP. (d) Each account record must include the disposition of the room and board fee the individual pays to the foster care provider at the beginning of each month. (e) REIMBURSEMENT TO INDIVIDUAL. A provider must reimburse an individual for any missing funds within the custody of the provider or due to theft or mismanagement on the part of the provider, resident manager, or caregiver. Reimbursement must be made within 10 business days from the date of verification the funds are missing. (f) Financial records must be maintained for at least seven years. (3) PERSONAL PROPERTY RECORD. A provider must prepare and maintain an accurate individual written record of personal property that has significant emotional or monetary value to each individual as determined by a documented ISP team or legal representative decision. The personal property record must include the following: (a) A description and identifying number (if any). (b) Date of inclusion in the record. (c) Date and reason for removal from record. (d) Signature of person making the entry. (e) A signed and dated annual review of the personal property record for accuracy. (4) INDIVIDUAL SUPPORT PLAN. (a) A provider must collect and summarize the following information prior to an individual's ISP meeting: (A) One-page profile reflecting, at a minimum, information gathered by the provider; (B) Person-centered information reflecting, at a minimum, information gathered by the provider; and (C) Information about known, identified serious risks. (b) The following information must be developed by a provider and shared with an individual's services coordinator and the individual, or if applicable the individual's legal or designated representative, as directed by the Services 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's risk management strategies in place, including title of document, date, and where the document is located. (D) A Nursing Service Plan, if applicable. (E) Other documents required by the ISP team. (c) When desired by an individual, a provider must participate in the individual's ISP team meetings. (d) A provider must agree in writing to implement the portion of an individual's ISP for which the provider is responsible for implementing. Agreement may be recorded by the provider's signature on the individual's ISP or Service Agreement. (e) A provider must maintain a copy of an individual's ISP or Service Agreement provided by the CDDP. (f) A provider must maintain documentation of implementation of each support and services specified in subsection (b) of this section. The documentation must be kept current and be available for review by the individual, the individual's legal representative, CDDP, and Department representatives. (5) INDIVIDUALLY-BASED LIMITATIONS. (a) A provider may not place any limitations to the following freedoms without an individually-based limitation: (A) Support and freedom to access the individual’s personal food at any time. (B) Visitors of the individual's choosing at any time. (C) A lock on the individual's bedroom, lockable by the individual. (D) Choice of a roommate, if sharing a bedroom. (E) Freedom to furnish and decorate the individual's bedroom as the individual chooses in accordance with their Residency Agreement. (F) Freedom and support to control the individual's schedule and activities. (G) Freedom from restraint, except in accordance with the standards for developmental disabilities services set forth in ORS 443.739, OAR chapter 411, or the relevant Title XIX Medicaid-funding authority. (b) When an individual's freedom in subsection (a) of this section may not be met due to a threat to the health and safety of the individual or others, an individually-based limitation must be authorized and documented in the individual's ISP in accordance with OAR 411-415-0070. (c) A provider is responsible for the following: (A) Maintaining a copy of the completed and signed form documenting an individual's consent to the appropriate individually-based limitation. The form must be signed by the individual or the individual's legal representative, if applicable. (B) Regular collection and review of data to measure the ongoing effectiveness of, and the continued need for, the individually-based limitation. (C) Requesting a review of the individually-based limitation when a new individually-based limitation is indicated, or change or removal of an individually-based limitation is needed. (6) HOUSE RULES. (a) House rules must be submitted to the Department prior to implementation and as changes occur and may be subject to review and approval by the Department. (b) House rules must be posted in a conspicuous location in the AFH-DD accessible to individuals and visitors. (c) House rules may not violate the rights of an individual as stated in ORS 443.739, OAR 411-318-0010, and described in section (11) of this rule. (d) House rules may not be in conflict with these rules or the home and community-based services and settings rules in OAR chapter 411, division 004. (e) A provider must review and provide a copy of the house rules to each individual, and as applicable the individual's legal representative, at the time of entry and annually or as changes occur. The reviews must be documented by having the individual, or as applicable the individual's legal representative, sign and date a copy of the house rules. A copy of the signed and dated house rules must be maintained in the individual's record. (7) RESIDENCY AGREEMENTS. A provider must maintain a Residency Agreement with each individual as described in OAR 411-360-0055, and if applicable, specialized contracts with the Department, and tenancy agreements with room and board tenants. (8) GENERAL INFORMATION. A provider must maintain all other information or correspondence pertaining to an individual. (9) MONTHLY PROGRESS NOTES. A provider must maintain and keep current monthly progress notes for each individual that include, at a minimum, the progress of the supports identified in an individual's ISP or Service Agreement, any medical, behavioral, or safety issues, or any other events significant to the individual. (10) POSITIVE BEHAVIOR SUPPORT PLAN DATA. A provider and caregivers must document, track, and maintain behavioral data specified in an approved Positive Behavior Support Plan for each individual. (11) INDIVIDUAL'S BILL OF RIGHTS. (a) As stated in ORS 443.739, each individual residing in an AFH-DD has the right to the following: (A) Be treated as an adult, with respect and dignity. (B) Be informed of all rights and all house rules. (C) Be encouraged and assisted to exercise legal rights, including the right to vote. (D) Be informed of his or her medical condition and the right to consent to or refuse treatment. (E) Receive appropriate care and services, and prompt medical care as needed. (F) A safe and secure environment. (G) Be free from mental and physical abuse. (H) Be free from restraints, except as described in OAR 411-360-0160. (I) Complete privacy when receiving treatment or personal care. (J) Associate and communicate privately with any person the individual chooses. (K) Send and receive personal mail unopened. (L) Participate in activities of social, religious, and community groups. (M) Have medical and personal information kept confidential. (N) Keep and use a reasonable amount of personal clothing and belongings, and to have a reasonable amount of private, secure storage space. (O) Manage the individual's own money and financial affairs unless legally restricted. (P) Be free from financial exploitation. A provider may not charge or ask for application fees or nonrefundable deposits and may not solicit, accept, or receive money or property from an individual other than the amount agreed to for services. (Q) A written agreement regarding the services to be provided and the rate schedule to be charged. A provider must give written notice 30 calendar days prior to any change in the rates or the ownership of the AFH-DD. (R) Not be transferred or moved out of the AFH-DD without written notice 30 calendar days in advance and an opportunity for a hearing. A provider may transfer or discharge an individual only for medical reasons including a medical emergency described in ORS 443.738(11)(b), or for the welfare of the individual or other individuals residing in the AFH-DD, or for nonpayment. (S) Be free of discrimination on the basis of race, color, religion, sex, sexual orientation, national origin, marital status, age, disability, source of income, duration of Oregon residence, or other protected classes under federal and Oregon Civil Rights laws. (T) Make suggestions and complaints without fear of retaliation. (U) Be encouraged and assisted in exercising all legal, civil, and human rights accorded to other citizens of the same age, except when limited by a court order. (b) A provider must guarantee these rights and help individuals exercise them. (c) A provider must post a copy of the Bill of Rights in the entry or other equally prominent place in the AFH-DD. The Bill of Rights must include the name and phone number of the office to call to report a complaint. (d) A provider must explain and provide a copy of the Bill of Rights along with a description of how to exercise the rights to each individual and the individual's legal representative at the time of entry and document in the individual's file that a copy of the Bill of Rights was provided. (e) A provider must review the Bill of Rights with each individual and the individual's legal representative annually or as changes occur. (f) In addition to the rights described in subsection (11)(a) of this section, individuals receiving home and community-based services in residential and non-residential home and community-based settings have the right to home and community-based settings with the qualities described in OAR 411-004-0020(1). (g) In addition to the rights described in subsections (11)(a) of this section, individuals receiving home and community-based services in provider owned, controlled, or operated residential settings have the right to provider owned, controlled, or operated residential settings with the qualities described in OAR 411-004-0020(2). (12) AFH-DD records must be kept current and maintained by the provider and be available for inspection upon request. (13) EMPLOYMENT RECORDS. AFH-DD records must include proof the provider, resident manager, and any other caregivers have met the minimum qualifications as required by OAR 411-360-0110. The following documentation must be included in the AFH-DD record and made available for review upon request: (a) Completed employment applications including the names, addresses, and telephone numbers of all caregivers employed by the provider. An application for employment in any capacity in an AFH-DD must include a question asking whether the person applying for employment has ever been found to have committed abuse. (b) Proof the provider has an approved background check from the Department in accordance with OAR 411-360-0110, for each subject individual as defined in OAR 411-360-0020. (A) The provider must maintain documentation of preliminary and final fitness determinations in accordance with these rules and the background check rules in OAR chapter 407, division 007. (B) Verification may include printed or electronic documentation. (C) Verification must be readily accessible upon request. (c) Proof of required training according to OAR 411-360-0120. Documentation must include the date of each training, subject matter, name of agency or organization providing the training, and number of training hours. (d) A certificate to document completion of the Department's Basic Training Course for the provider, resident manager, and substitute caregivers, as applicable. (e) Proof of mandatory abuse report training for the provider, resident manager, and substitute caregivers, as applicable. (f) Proof of any additional training required for the specific classification of an AFH-DD or the provider, resident manager, and all caregivers, as applicable. (g) Documentation of caregiver orientation to the AFH-DD, training of emergency procedures, training on the ISPs or Service Agreements for individuals, and training on behavior supports and the Nursing Service Plan (if applicable). (h) For each person implementing the behavior supports identified in an individual's Positive Behavior Support Plan, documentation of training on the individual's Positive Behavior Support Plan and, if applicable, certification in an ODDS-approved behavior intervention curriculum.