OAR 411-415-0100: Specialized Services in a Nursing Facility

An individual residing in a nursing facility determined to require specialized services, as described in OAR 411-070-0043, must have an annual plan for specialized services incorporated with a plan of care by the nursing facility. (1) A case manager must coordinate with the individual, the legal representative of the individual, the staff of the nursing facility, and other service providers, as appropriate, to provide or arrange the specialized services. The plan for specialized services must include: (a) The name of the service provider. (b) A description of the specialized services to be provided. (c) The number of hours of service per month. (d) A description of how the services must be tracked. (e) A description of the process of communication between the specialized service provider and the nursing facility in the event of serious incidents, serious illness, absence, and emergencies. (2) A case manager must complete an annual review of the plan for specialized services or when there has been a significant change in the level of functioning of the individual.