OAR 411-415-0050: Standards for Case Management Services

(1) A Case Management Entity (CME) must apply the principles of self-determination, person-centered practices, diversity, equity, and inclusion to the provision of case management services. (2) A CME must ensure that a case manager is available to provide case management services and other supports to an individual. (a) Case management services include the activities related to: (A) Assessment and periodic reassessment of an eligible individual to determine service needs, including activities that focus on needs identification, to determine the need for any medical, educational, social, or other services including those assessments described in OAR 411-415-0060. (B) Development and periodic revision of an ISP or Annual Plan based on the information collected through an assessment or reassessment that specifies the desired outcomes, goals, and actions to address the medical, employment, social, educational, and other services needed by an eligible individual as described in OAR 411-415-0070. (C) Support to access available services, including referral and related activities to help an individual obtain needed services as described in OAR 411-415-0080. (D) Monitoring and follow-up activities, including activities and contacts that are necessary to ensure an ISP or Annual Plan is effectively implemented and adequately addresses the needs of an eligible individual as described in OAR 411-415-0090. (b) Other supports provided by a CME may include, but are not limited to: (A) Authorizing services in the Department’s electronic payment and reporting system. (B) Arranging employer-related supports that may include, but are not limited to: (i) Education about employer responsibilities. (ii) Orientation to basic wage and hour issues. (iii) Use of common employer-related tools, such as service agreements. (C) Assisting the Department with establishing provider credentials. (D) Assistance with understanding and accessing financial, medical, and other benefits. (3) Prior to an initial ISP, at least annually, and at the request of an individual, or as applicable the individual’s legal representative, a CME must provide all of the following to the individual, and if applicable, the individual’s legal representative: (a) A Notification of Rights (form 0948); (b) An explanation of the individual rights described in OAR 411-318-0010; (c) An explanation of the complaint process described in OAR 411-318-0015; (d) A reminder of the freedom to engage in advocacy along with any known opportunities for advocacy, including but not limited to the presence of, and contact information for, the Oregon Self Advocacy Coalition; and (e) For an individual receiving or considering hourly attendant care, the ability to request an exception to their service level or staffing ratio and the process for making an exception request. (4) A CME may not authorize services that are delivered by an affiliated entity. (5) Developmental disabilities services must be authorized in accordance with OAR 411-415-0070. A case manager must authorize any developmental disabilities services and delivery of those services by an available, qualified provider chosen by an individual, or as applicable the legal or designated representative of the individual, for which the individual is eligible as described in the relevant program rules. A provider is considered available when the provider has the capacity and willingness to deliver services chosen by an individual. (a) NOTIFICATION OF PLANNED ACTION. In the event that a developmental disabilities service is denied, reduced, suspended, or terminated, or a chosen qualified provider is not authorized to deliver a chosen service to an individual, a written advance Notification of Planned Action (form 0947) must be provided as described in OAR 411-318-0020. (b) HEARINGS. (A) An individual may request a hearing as provided in ORS chapter 183 and OAR 411-318-0025. (B) Hearings are addressed in accordance with ORS chapter 183 and OAR 411-318-0025. (c) Upon entry into case management, upon request, and annually thereafter, a notice of hearing rights and the policy and procedures for hearings as described in OAR chapter 411, division 318 must be explained and provided to an individual, and as applicable the legal or designated representative of the individual. (6) Services authorized in an Individual Support Plan (ISP) must be entered into the Department’s electronic payment and reporting system prior to the authorized start date of the services being delivered by a provider. (7) If an individual loses eligibility for a medical assistance program delivered by the Oregon Health Authority, a case manager must assist the individual to identify why the eligibility was lost. Whenever possible, the case manager must assist the individual in reestablishing the eligibility. The case manager must document the assistance given in the service record for the individual. (8) A CME must complete the steps required for an individual to access an authorized service in a timely manner, including but not limited to, as needed: (a) Service planning and authorization according to OAR 411-415-0070. (b) Payment authorization. (c) Assistance with identifying and referring the individual to service providers. (9) CHOICE ADVISING. Through choice advising, a CME must assure that case management and other developmental disabilities service options, provider options, and setting options, including non-disability specific settings and an option for a private or shared unit in a residential program, are described to an individual receiving case management services from the CME, or to the individual’s legal representative. (a) Within 10 business days of an individual being found eligible for developmental disabilities services, the individual must receive choice advising, including all of the following: (A) The choice of institutional or home and community-based services. (B) Options for developmental disabilities services available to the individual. (C) For an adult, information about all CMEs operating in the county of origin, using materials provided by each CME when the materials are made available. (b) Choice advising occurs as part of the person-centered planning process and must be conducted prior to an initial ISP and prior to a review of the ISP when required according to OAR 411-415-0070. (c) Prior to an individual's 18th birthday, the individual must be offered the choice of institutional or home and community-based services. (d) Prior to an individual's 17th birthday, the individual must be informed about all CMEs operating in the county of origin that will be available to the individual as an adult, using materials provided by each CME when the materials are made available. (e) Prior to entry into a 1915(c) Home and Community-Based Services waiver, an individual, or as applicable the individual's legal representative, must be informed of the individual's choice to receive home and community-based or institutional services and verify the individual's choice using the Freedom of Choice form (ODHS 2808). (f) A CME must present to an adult at least three types of community living settings as defined in ORS 427.101, including an option for services in the adult’s own or family home, annually and when an adult is moving from one community living setting to another community living setting unless: (A) The adult is at imminent risk to health or safety in the adult’s current placement setting; or (B) The adult is moving from one non-residential program setting to another non-residential program setting. (g) If a CME is affiliated with an agency provider of developmental disabilities services in addition to case management services, the CME must disclose the relationship and inform the individual, or as applicable the individual’s legal or designated representative, that the CME cannot authorize the affiliated provider. The CME must discuss other case management provider options when the individual, or as applicable the individual’s legal or designated representative, expresses interest in receiving services from the affiliated provider. (10) A case manager must coordinate services with the Child Welfare caseworker assigned to a child to ensure the provision of required supports from the Department, CDDP, and Child Welfare. (11) A case manager must participate in transition planning by attending Individualized Education Program (IEP) meetings or other transition planning meetings for a student 16 years of age or older to discuss the student’s transition to adult living and work situations, unless the case manager’s attendance is refused by the student’s parent or guardian or the student if the student is 18 years of age or older. A case manager must participate in transition planning for a student as young as 14 years of age if transition planning is deemed appropriate by the student’s IEP team, unless the case manager’s attendance is refused by the student’s parent or guardian. (12) When appropriate, a case manager must coordinate with Vocational Rehabilitation regarding employment services. When appropriate, a case manager must facilitate referrals to Vocational Rehabilitation. (13) HEALTH CARE ADVOCATES. (a) For an individual determined to be incapable as defined in OAR 411-390-0120, and who does not have a guardian with medical decision-making authority or a health care representative, a case manager must have a documented discussion with the individual's ISP team regarding the appointment of a health care advocate as described in OAR chapter 411, division 390 when a significant medical procedure or treatment is being considered. The case manager must assure the individual is informed of all of the following: (A) The ISP team’s decision to seek a health care advocate, prior to the appointment of the health care advocate. (B) The name of the appointed health care advocate. (C) The proposed decision about any significant medical procedure or treatment. (b) A case manager must give an individual's health care advocate appointed according to OAR chapter 411, division 390 a copy of OAR chapter 411, division 390 and document this in the individual's service record. (c) A case management entity must provide health care advocate training materials to a potential health care advocate prior to appointment and any health care decision-making. (14) A case manager who becomes aware that a health care representative is considering withholding or withdrawing life-sustaining procedures for an individual, must provide the health care representative with any information in the case manager’s possession that is related to the individual’s values, beliefs, and preferences with respect to the withholding or withdrawing of life-sustaining procedures. (15) EXCEPTIONS. (a) If an individual eligible for community living supports as described in OAR chapter 411, division 450, or the individual's legal or designated representative, requests an exception to the service level, for a staff ratio greater than 1:1, or expresses concerns that the individual's service needs are not being met after exhausting available resources, the case manager must help the individual apply for an exception as described in OAR 411-450-0065, including completing a funding review and exception request, and gathering documentation required by the Department. (b) If the individual’s case manager assesses that the individual’s needs exceed the available resources or require a staffing ratio greater than 1:1, the case manager must work with the individual to determine the appropriate hour allocation and staffing ratio and submit a Funding Review and Exception Request Form, or other form designated by the Department to request an exception, if necessary. The form is submitted to the Department or the Department’s designee. (c) When required by the Department, an individual’s case manager must complete a Funding Review and Exception Request Form, or other form designated by the Department to request an exception, to inform an exception request. (d) A CME has 14 calendar days, or a later time determined by the Department, from the Department’s date of a request for information related to an exception request, to provide the information or inform the Department the information is not available. (16) A CME must implement procedures to address individual, designated representative, or family complaints regarding service delivery that have not been resolved using the complaint procedures of a provider agency. The complaint procedures must be consistent with the requirements in OAR 411-318-0015. (17) A case manager must coordinate with other state, public, and private agencies regarding services to individuals. (18) When appropriate, a case manager must facilitate referrals to nursing facilities as described in OAR 411-070-0043. (19) A case manager must coordinate and monitor the services provided to an eligible individual living in a nursing facility. (20) A Department case manager must make referrals for entry and participate in all entry meetings for children in residential programs, CIIS, and the Stabilization and Crisis Unit. (21) A CME must provide case management services to individuals who are eligible for and desire them. If an individual receiving case management services from a CDDP is receiving other developmental disabilities services in more than one county, the county of origin must be responsible for case management services unless otherwise negotiated and documented in writing with the mutually agreed upon conditions. (22) CHANGE OF CASE MANAGER. (a) If a CME changes the assignment of an individual's case manager for any reason, the CME must notify the individual, the individual’s legal and designated representative (as applicable), and all providers within 10 business days of the change. The notification must be in writing and include the name, telephone number, email address, and mailing address of the new case manager. (b) An individual receiving services, or as applicable the individual’s legal or designated representative, may request a new case manager within the same CME or request a change of CME. (23) FAMILY RECONNECTION. A CME and a case manager must provide assistance to the Department when a family member is attempting to reconnect with an individual who was previously discharged from Fairview Training Center or Eastern Oregon Training Center or an individual who is currently receiving developmental disabilities services. (a) If a family member contacts a CME for assistance in locating an individual, the CME must refer the family member to the Department. A family member may contact the Department directly. (b) The Department shall send the family member a Department form requesting further information to be used in providing notification to the individual. The form shall include the following information: (A) Name of requestor. (B) Address of requestor and other contact information. (C) Relationship to individual. (D) Reason for wanting to reconnect. (E) Last time the family had contact. (c) The Department shall determine: (A) If the individual was previously a resident of Fairview Training Center or Eastern Oregon Training Center. (B) If the individual is deceased or living. (C) Whether the individual is currently or previously enrolled in Department services. (D) The county in which services are being provided, if applicable. (d) With permission from the individual, the Department shall notify the family member if the individual is enrolled or no longer enrolled in Department services within 10 business days from the receipt of the request. (e) If the individual is enrolled in Department services, the Department shall send the completed family information form to the individual and the case manager. (f) If the individual is deceased, the Department shall follow the process for identifying the individual’s personal representative in accordance with ORS 192.573. (A) If the personal representative and the requesting family member are the same, the Department shall inform the personal representative that the individual is deceased. (B) If the personal representative is different from the requesting family member, the Department shall contact the personal representative for permission before sharing information about the individual with the requesting family member. The Department must make a good faith effort to find the personal representative and obtain a decision concerning the sharing of information as soon as practicable. (g) When an individual is located, the CME must facilitate a meeting with the individual to discuss and determine if the individual wishes to have contact with the family member. (A) The case manager must assist the individual in evaluating the information to make a decision regarding initiating contact, including providing the information from the form and any relevant history with the family member that may support contact or present a risk to the individual. (B) If the individual does not have a legal representative or is unable to express their wishes, the individual’s ISP team must be convened to review factors and choose the best response for the individual after evaluating the situation. (h) If the individual wishes to have contact, the individual or ISP team designee may directly contact the family member to make arrangements for the contact. (i) If the individual does not wish to have contact, the CME must notify the Department. The Department shall inform the family member in writing that no contact is requested. (j) The notification to the family member regarding the decision of the individual must be within 60 business days from the receipt of the information form from the family member. (k) The decision by the individual is not appealable.