OAR 411-375-0035: Documentation and Reporting Requirements

(1) SERVICE AGREEMENT. (a) An independent provider may not provide services to an individual without a completed and authorized Service Agreement. For independent providers who are not personal support workers, the signature of the independent provider on an individual's ISP may serve as the Service Agreement. (b) An independent provider must maintain a copy of the authorized Service Agreement for the authorized service period. (2) SAFEGUARDING INTERVENTIONS AND SAFEGUARDING EQUIPMENT. (a) An independent provider must only utilize a safeguarding intervention or safeguarding equipment when: (A) BEHAVIOR. Used to address an individual's challenging behavior, the safeguarding intervention or safeguarding equipment is included in the individual's Positive Behavior Support Plan written by a qualified behavior professional as described in OAR 411-304-0150 and implemented consistent with the individual's Positive Behavior Support Plan. (B) MEDICAL. Used to address an individual's medical condition or medical support need, the safeguarding intervention or safeguarding equipment is included in a medical order written by the individual's licensed health care provider and implemented consistent with the medical order. (b) The individual, or as applicable their legal representative, must provide consent for the safeguarding intervention or safeguarding equipment through an individually-based limitation in accordance with OAR 411-415-0070. (c) Prior to utilizing a safeguarding intervention or safeguarding equipment, an independent provider must be trained. (A) For a safeguarding intervention, the independent provider must be trained in intervention techniques using an ODDS-approved behavior intervention curriculum and trained to the individual's specific needs. Training must be conducted by a person who is appropriately certified in an ODDS-approved behavior intervention curriculum. (B) For safeguarding equipment, the independent provider must be trained on the use of the identified safeguarding equipment. (d) An independent provider must not utilize any safeguarding intervention or safeguarding equipment not meeting the standards set forth in this rule even when the use is directed by the individual or their legal or designated representative, regardless of the individual's age. (3) EMERGENCY PHYSICAL RESTRAINTS. (a) The use of an emergency physical restraint when not written into a Positive Behavior Support Plan, not authorized in an individual’s ISP, and not consented to by the individual in an individually-based limitation, must only be employed when all of the following conditions are met: (A) In situations when there is imminent risk of harm to the individual or others or when the individual’s behavior has a probability of leading to engagement with the legal or justice system; (B) Only as a measure of last resort; and (C) Only for as long as the situation presents imminent danger to the health or safety of the individual or others. (b) The use of an emergency physical restraint must not include any of the following characteristics: (A) Abusive. (B) Aversive. (C) Coercive. (D) For convenience. (E) Disciplinary. (F) Demeaning. (G) Mechanical. (H) Prone or supine restraint. (I) Pain compliance. (J) Punishment. (K) Retaliatory. (4) PROGRESS NOTES. (a) An independent provider must maintain regular progress notes. The progress note must include, at minimum, the following information regarding the service rendered: (A) Date and time the service was delivered. (B) Information regarding progress towards achieving the intended ISP goal identified in the Service Agreement for which the service was delivered. (C) Documentation of incident reporting made to a case management entity during the time period covered by the progress note, including the date the incident was reported and the nature of the incident. (b) For a personal support worker, progress notes must be submitted to the case management entity with their timesheet as part of their claim for payment, and additionally upon request from the case management entity. The completed timesheet fulfills the requirement for date and time the service was delivered. (c) For an independent provider who is not a personal support worker, progress notes must be submitted as required by applicable program rules. (5) ABUSE REPORTING. (a) An independent provider must immediately notify an individual's case management entity of any reasonable suspicion an individual is the victim of abuse. (b) Independent providers who are mandatory reporters must also make reports of suspected abuse consistent with the following: (A) ORS 419B.010 and 419B.015 for abuse of a child. (B) ORS 124.060 and 124.065 for abuse of an older adult 65 years of age or older. (C) ORS 430.737 and 430.743 for abuse of an adult with an intellectual or developmental disability or mental illness. (D) ORS 441.640 and 441.645 for abuse of a resident of a long-term care facility as defined in ORS 442.015. (6) INCIDENT REPORTING. (a) An independent provider must immediately, but not later than one business day, notify an individual's case management entity of the following: (A) Serious illness, serious injury, or serious incident involving an individual. (B) The use of a safeguarding intervention. Timelines for notification included in a Temporary Emergency Safety Plan supersede the timeline established by this section. (b) The report must include all of the following information: (A) Name of the individual who is the subject of the incident. (B) Date, time, duration, type, and location of the incident. (C) Conditions prior to, or leading to, the incident. (D) Detailed description of the incident, including the independent provider's response. (E) Description of injury, if injury occurred. (F) Name of the independent provider and witnesses to the incident. (G) Follow-up to be taken to prevent a recurrence of the incident. (c) A notification required by section (a) of this rule must occur by phone, in-person, email, writing, or verbally and maintain confidentiality.