The Oregon Administrative Rules contain OARs filed through November 15, 2015

 

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DEPARTMENT OF HUMAN SERVICES,

AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES




 

DIVISION 15
LONG-TERM CARE SERVICE PRIORITIES FOR INDIVIDUALS SERVED

411-015-0000
Purpose
The purpose of establishing priorities for persons to be served is to assist the Department in addressing the following goals:
(1) To enable persons eligible for and receiving services to remain in the least restrictive and least costly setting consistent with their service needs; and
(2) To serve those persons who are the most functionally impaired and who have no or inadequate alternative service resources; and
(3) To assure access to services paid by the Department to eligible persons; and
(4) To assure that services paid by the Department, and the setting in which they are provided are safe and adequate; and
(5) To manage limited resources to enable the greatest possible number of persons to receive needed services through a priority system based on the Department's assessment of the individual's functional impairment and alternative service resources.
Stat. Auth.: ORS 410.070

Stats. Implemented: ORS 410.070

Hist.: SSD 3-1985, f. & ef. 4-1-85; SSD 5-1986, f. & ef. 4-14-86; SSD 9-1986, f. & ef. 7-1-86; SSD 12-1987, f. 12-31-87, cert. ef. 1-1-88; SSD 12-1991(Temp), f. 6-28-91, cert. ef. 7-1-91; SSD 21-1991, f. 12-31-91, cert. ef. 1-1-92, Former (2)(a) - (l) Renumbered to 411-015-0005; Former (3) renumbered to 411-015-0010; Former (4) Renumbered to 411-015-0015; SDSD 11-2002(Temp), f. 12-5-02, cert. ef. 12-6-02 thru 6-3-03; SPD 12-2003, f. 5-30-03, cert. ef. 6-4-03; SPD 19-2006, f. 5-26-06, cert. ef. 6-1-06
411-015-0005
Definitions
Unless the context indicates otherwise,
the following definitions apply to the rules in OAR chapter 411, division 015:
(1) "AAA" means "Area Agency
on Aging" as defined in this rule.
(2) "Adult" means any person
at least 18 years of age.
(3) "All Phases" means each
part of an activity.
(4) "Alternative Service
Resources" means other possible resources for the provision of services to meet
an individual's needs. Alternative service resources includes, but is not limited
to, natural supports, risk intervention services, Older Americans Act programs,
or other community supports. Alternative service resources are not paid by Medicaid.
(5) "Architectural Modifications"
means any service leading to the alteration of the structure of a dwelling to meet
the specific service needs of an eligible individual.
(6) "Area Agency on Aging
(AAA)" means the Department designated agency charged with the responsibility to
provide a comprehensive and coordinated system of services to older adults and adults
with disabilities in a planning and service area. The term Area Agency on Aging
(AAA) is inclusive of both Type A and Type B Area Agencies on Aging as defined in
ORS 410.040 to 410.300.
(7) "Assistance Types" needed
for activities of daily living and instrumental activities of daily living include
but are not limited to the following terms:
(a) "Cueing" means giving
verbal or visual clues during an activity to help an individual complete the activity
without hands-on assistance.
(b) "Hands-on" means a provider
physically performs all or parts of an activity because an individual is unable
to do so.
(c) "Monitoring" means a
provider must observe an individual to determine if intervention is needed.
(d) "Reassurance" means to
offer an individual encouragement and support.
(e) "Redirection" means to
divert an individual to another more appropriate activity.
(f) "Set-up" means getting
personal effects, supplies, or equipment ready so that an individual may perform
an activity.
(g) "Stand-by" means a provider
is at the side of an individual ready to step in and take over the task if the individual
is unable to complete the task independently.
(h) "Support" means to enhance
the environment to enable an individual to be as independent as possible.
(8) "Assistive Devices" means
any category of durable medical equipment, mechanical apparatus, electrical appliance,
instrument of technology, service animals, general household items, or furniture
used to assist and enhance an individual's independence in performing any activity
of daily living.
(9) "Behavioral Care Plan"
means a documented set of procedures, reviewed by the Department or AAA representative,
which describes interventions for use by a provider to prevent, mitigate, or respond
to behavioral symptoms that negatively impact the health and safety of an individual
or others in a home or community-based services setting. The preferences of an individual
are included in developing a Behavioral Care Plan.
(10) "Business Days and Hours"
means Monday through Friday and excludes Saturdays, Sundays, and state or federal
holidays. Hours are from 8:00 AM to 5:00 PM.
(11) "CA/PS" means "Client
Assessment and Planning System" as defined in this rule.
(12) "Care Setting" means
a Medicaid contracted facility at which a Medicaid eligible individual resides and
receives services. Care settings include adult foster homes, residential care facilities,
assisted living facilities, specialized living contracted residences, and nursing
facilities.
(13) "Case Manager" means
an employee of the Department or Area Agency on Aging who assesses the service needs
of individuals, determines eligibility, and offers service choices to eligible individuals.
The case manager authorizes and implements an individual's service plan and monitors
the services delivered as described in OAR chapter 411, division 028.
(14) "Client" means "individual"
as defined in this rule.
(15) "Client Assessment and
Planning System (CA/PS)":
(a) Is the single entry data
system used for:
(A) Completing a comprehensive
and holistic assessment;
(B) Surveying an individual's
physical, mental, and social functioning; and
(C) Identifying risk factors,
individual choices and preferences, and the status of service needs.
(b) The CA/PS documents the
level of need and calculates the individual's service priority level in accordance
with these rules, calculates the service payment rates, and accommodates individual
participation in service planning.
(16) "Cost Effective" means
being responsible and accountable with Department resources. This is accomplished
by offering less costly alternatives when providing choices that adequately meet
an individual's service needs. Those choices consist of all available services under
the Medicaid home and community-based service options, the utilization of assistive
devices, natural supports, architectural modifications, and alternative service
resources not paid for by the Department.
(17) "Department" means the
Department of Human Services (DHS).
(18) "Disability" means a
physical, cognitive, or emotional impairment which, for an individual, constitutes
or results in a functional limitation in one or more of the activities of daily
living defined in OAR 411-015-0006.
(19) "Extraordinary Circumstances"
means:
(a) An individual being assessed
is working full time during business hours; or
(b) A family member, whose
presence is requested by an individual being assessed, is traveling from outside
the area, and is available for only a limited period of time that does not include
business days and hours.
(20) "Functional Impairment"
means an individual's pattern of mental and physical limitations that restricts
the individual's ability to perform activities of daily living and instrumental
activities of daily living without the assistance of another person.
(21) "Independent" means
an individual does not meet the definition of "assist" or "full assist" when assessing
an activity of daily living as described in OAR 411-015-0006 or when assessing an
instrumental activity of daily living as described in 411-015-0007.
(22) "Individual" means an
older adult or an adult with a disability applying for or eligible for services.
The term “individual” is synonymous with “client”.
(23) "Medicaid Home and Community-Based
Services" means the services approved and funded by the Centers for Medicare and
Medicaid Services for eligible individuals in accordance with Title XIX of the Social
Security Act.
(24) “Medicaid OHP
Plus Benefit Package” means only the Medicaid benefit packages provided under
OAR 410-120-1210(4)(a) and (b). This excludes individuals receiving Title XXI benefits.
(25) "Mental or Emotional
Disorder" means:
(a) A schizophrenic, mood,
paranoid, panic, or other anxiety disorder;
(b) Somatoform, personality,
dissociative, factitious, eating, sleeping, impulse control, or adjustment disorder;
or
(c) Other psychotic disorder
as defined by the American Psychiatric Association in the Diagnostic and Statistical
Manual.
(26) "Natural Support" means
resources and supports (e.g. relatives, friends, significant others, neighbors,
roommates, or the community) who are willing to voluntarily provide services to
an individual without the expectation of compensation. Natural supports are identified
in collaboration with the individual and the potential "natural support". The natural
support is required to have the skills, knowledge, and ability to provide the needed
services and supports.
(27) "Older Adult" means
any person at least 65 years of age.
(28) "OSIPM" means Oregon
Supplemental Income Program-Medical as defined in OAR 461-101-0010. OSIPM is Oregon
Medicaid insurance coverage for individuals who meet eligibility criteria as described
in OAR chapter 461.
(29) "Service Priority Level
(SPL)" means the order in which Department and Area Agency on Aging staff identify
individuals eligible for a nursing facility level of care, Oregon Project Independence,
or Medicaid home and community-based services. A lower service priority level number
indicates greater or more severe functional impairment. The number is synonymous
with the service priority level.
(30) "SPL" means "service
priority level" as defined in this rule.
(31) "Substance Abuse Related
Disorders" means disorders related to the taking of a drug or toxin of abuse (including
alcohol).
(a) Substance abuse related
disorders include:
(A) Substance dependency
and substance abuse;
(B) Alcohol dependency and
alcohol abuse; and
(C) Substance induced disorders
and alcohol induced disorders as defined by the American Psychiatric Association
in the Diagnostic and Statistical Manual.
(b) Substance abuse related
disorders are not considered physical disabilities. Dementia or other long term
physical or health impairments resulting from substance abuse may be considered
physical disabilities.
(32) "These Rules" means
the rules in OAR chapter 411, division 015.
(33) "Without Supports" means
an individual lacks the assistance of another person, a care setting and staff,
or an alternative service resource as defined in this rule.
Stat. Auth.: ORS 410.070
Stats. Implemented: ORS 410.060,
410.070 & 414.065
Hist.: SSD 3-1985, f. &
ef. 4-1-85; SSD 5-1986, f. & ef. 4-14-86; SSD 9-1986, f. & ef. 7-1-86; SSD
12-1987, f. 12-31-87, cert. ef. 1-1-88; SSD 12-1991(Temp), f. 6-28-91, cert. ef.
7-1-91; SSD 21-1991, f. 12-31-91, cert. ef. 1-1-92, Renumbered from former 411-015-0000(2)(a)
- (l); SDSD 11-2002(Temp), f. 12-5-02, cert. ef. 12-6-02 thru 6-3-03; SPD 12-2003,
f. 5-30-03, cert. ef. 6-4-03; SPD 16-2003(Temp), f. & cert. ef. 10-27-03 thru
4-23-04; SPD 8-2004, f. & cert. ef. 4-27-04; SPD 19-2005, f. & cert. ef.
12-29-05; SPD 19-2006, f. 5-26-06, cert. ef. 6-1-06; SPD 14-2013(Temp), f. &
cert. ef. 7-1-13 thru 12-28-13; SPD 45-2013, f. 12-13-13, cert. ef. 12-15-13; APD
9-2014(Temp), f. 4-17-14, cert. ef. 4-21-14 thru 10-18-14; APD 35-2014, f. &
cert. ef. 10-1-14
411-015-0006
Activities of Daily Living (ADL)
(1) "Activities of Daily Living (ADL)"
mean those personal functional activities required by an individual for continued
well-being which are essential for health and safety. Activities include eating,
dressing, grooming, bathing, personal hygiene, mobility (ambulation and transfer),
elimination (toileting, bowel and bladder management), and cognition, and behavior.
(2) Evaluation of the individual's
need for assistance in Activities of Daily Living is based on:
(a) The individual's abilities
rather than the services provided;
(b) How the individual functioned
during the 30 days prior to the assessment date, with consideration of how the person
is likely to function in the 30 days following the assessment date; and
(c) Evidence of the actual
or predicted need for assistance of another person within the assessment time frame
and it must not be based on possible or preventative needs.
(3) "Independent" means the
individual does not meet the definition of "Assist" or "Full Assist" for each Activity
of Daily Living as defined in this rule.
(4) Bathing and personal
hygiene. Bathing and personal hygiene are comprised of two components. To be considered
Assist, the individual must require assistance in bathing or full assistance in
hygiene. To be considered Full Assist, the individual must require full assistance
in bathing.
(a) Bathing means the activities
of bathing and washing hair and using assistive devices if needed. Bathing includes
the act of getting in and out of the bathtub or shower.
(A) Assist: Even with assistive
devices, the individual is unable to accomplish some tasks of bathing without the
assistance of another person. This means hands-on assistance for part of the task,
cueing during the activity, or stand-by presence during the activity.
(B) Full Assist: Even with
assistive devices, the individual is unable to accomplish any task of bathing without
the assistance of another person. This means the individual needs hands-on assistance
of another person through all phases of the activity, every time the activity is
attempted.
(b) Personal hygiene means
the activities of shaving, caring for the mouth, or assistance with the tasks of
menstruation care.
(A) Assist: Even with assistive
devices, the individual is unable to accomplish at least one task of personal hygiene
without the assistance of another person. This means hands-on assistance for part
of the task, cueing during the activity, or stand-by presence during the activity.
(B) Full Assist: Even with
assistive devices, the individual is unable to accomplish at least two personal
hygiene tasks, without the assistance of another person. This means the individual
needs hands-on assistance of another person through all phases of the activity,
every time the activity is attempted.
(5) Cognition and behavior
refers to how the brain functions in the areas of adaptation, awareness, judgment,
memory, and orientation. Cognition includes three components of behavioral symptoms
which are demands on others, danger to self or others, and wandering.
(a) The individual's ability
to manage each component of cognition and behavior is assessed by how the person
functions without supports, meaning the assistance of another person, a care setting,
or an alternative service resource as defined in OAR 411-015-0005. Lack of medication
or lack of medication management is not considered when evaluating cognition or
behavior.
(b) The assessment time frame
in OAR 411-015-0008 of 30 days prior to the date of the assessment may be expanded
when assessing cognition and behavior without supports. History or incidents in
the past, more than 30 days prior to the assessment date, may be considered if they
negatively impacted health and safety and are currently a concern that needs to
be addressed.
(c) An individual under age
65, with cognition or behavior assistance or full assistance needs based on a mental
or emotional disorder, does not meet the criteria for service eligibility per OAR
411-015-0015.
(d) An individual must require
assistance in at least three of the eight components of cognition and behaviors
to meet the criteria for assist in cognition and behaviors. An individual must require
full assistance in three of the eight components to meet the criteria for full assistance
in cognition and behaviors.
(A) Adaptation is the ability
to respond, cope, and adjust to major life changes such as a change in living situation
or a loss (such as health, close relationship, pet, divorce, or a death).
(i) Assist: The individual
requires reassurance from another person to cope with or adjust to change. Assistance
involves multiple occurrences, less than daily.
(ii) Full Assist: The individual
requires constant emotional support and reassurance or is unable to adapt to change.
These are daily, ongoing occurrences.
(B) Awareness means the ability
to understand basic health and safety needs (such as the need for food, shelter,
and clothing).
(i) Assist: The individual
requires assistance of another person to understand basic health and safety needs.
(ii) Full Assist: The individual
does not have the ability to understand basic health and safety needs and requires
daily, ongoing intervention by another person.
(C) Judgment means decision-making.
It is the ability to identify choices and understand the benefits, risks, and consequences
of those choices. Individuals who lack the ability to understand choices, or the
potential risks and consequences of choices, need assistance in decision-making.
Judgment does not include what others might deem a poor choice.
(i) Assist: At least weekly,
the individual needs protection, monitoring, and guidance from another person to
make decisions.
(ii) Full Assist: The individual's
decisions require daily intervention by another person.
(D) Memory means the ability
to remember and appropriately use current information impacting the health and safety
of the individual.
(i) Assist: The individual
has difficulty remembering and using current information and requires reminding
from another person.
(ii) Full Assist: The individual
is unable to remember or use information and requires assistance beyond reminding.
(E) Orientation means the
ability to accurately understand or recognize person, place, or time in order to
maintain health and safety.
(i) Assist: The individual
is disoriented to person, place, or time and requires the assistance of another
person. These occurrences are episodic during the week, but less than daily.
(ii) Full Assist: The individual
is disoriented daily to person, place, or time and requires the assistance of another
person.
(F) Danger to self or others
means behavioral symptoms, other than wandering, that are hazardous to the individual
(including self-injury), or harmful or disruptive to those around the individual.
(i) Assist: At least monthly,
the individual is disruptive or aggressive in a non-physical way, agitated, or sexually
inappropriate and needs the assistance of another person. These behavioral symptoms
are challenging, but the individual can be verbally redirected.
(ii) Full Assist: The individual
has had more than one episode of aggressive, disruptive, agitated, dangerous, or
physically abusive or sexually aggressive behavioral symptoms directed at self or
others. These behavioral symptoms are extreme, may be unpredictable, and necessitate
intervention beyond verbal redirection, requiring an individualized behavioral care
plan (as defined in OAR 411-015-0005) that all staff are trained to deliver.
(G) Demands on others means
behavioral symptoms, other than wandering, that negatively impact and affect living
arrangements, providers, or other residents.
(i) Assist: The individual's
habits and emotional states limit the types of living arrangements and companions,
but can be modified with individualized routines, changes to the environment (such
as roommates or noise reduction), or general training for the provider that is not
specific to the individual.
(ii) Full Assist: The individual's
habits and emotional states can be modified only with a 24-hour specialized care
setting or an individualized behavioral care plan (as defined in OAR 411-015-0005)
that all staff are trained to deliver.
(H) Wandering means moving
about aimlessly, or elopement, without relationship to needs or safety.
(i) Assist: The individual
wanders within the home or facility, but does not jeopardize safety.
(ii) Full Assist: The individual
wanders inside or outside and jeopardizes safety.
(6) Dressing and Grooming
is comprised of two elements. To be considered Assist, the individual must require
assistance in dressing or full assistance in grooming. To be considered Full Assist
the individual must require full assistance in dressing:
(a) Dressing means the activities
of dressing and undressing.
(A) Assist: Even with assistive
devices, the individual is unable to accomplish some tasks of dressing without the
assistance of another person. This means hands-on assistance for part of the task,
cueing during the activity, or stand-by presence during the activity.
(B) Full Assist: Even with
assistive devices, the individual is unable to accomplish any tasks of dressing
without the assistance of another person. This means the individual needs hands-on
assistance through all phases of the activity, every time the activity is attempted.
(b) Grooming means nail and
hair care.
(A) Assist: Even with assistive
devices, the individual is unable to accomplish tasks of grooming, without the assistance
of another person. This means hands-on assistance for part of the task, cueing during
the activity, or stand-by presence during the activity.
(B) Full Assist: Even with
assistive devices, the individual is unable to perform any tasks of grooming without
the assistance of another person. This means the individual needs hands-on assistance
of another person through all phases of the activity, every time the activity is
attempted.
(7) Eating means the activity
of feeding and eating and may include using assistive devices.
(a) Assist: When eating,
the individual requires another person to be within sight and immediately available.
Assistance requires hands-on feeding, hands-on assistance with special utensils,
cueing during the act of eating, or monitoring to prevent choking or aspiration.
Assistance with eating is a daily need or may vary if an individual's medical condition
fluctuates significantly during a one-month period.
(b) Full Assist: When eating,
the individual always requires one-on-one assistance for direct feeding, constant
cueing, or to prevent choking or aspiration. This includes nutritional IV or feeding
tube set-up by another person. This means the individual needs the assistance of
another person through all phases of the activity, every time the activity is attempted.
(8) Elimination is comprised
of three components. To be considered Assist, the individual must require assistance
in at least one of the three components. To be considered Full Assist the individual
must require full assistance in any of the three components. Dialysis care needs
are not assessed as part of elimination.
(a) Bladder means managing
bladder care. This includes tasks such as catheter care, toileting schedule, monitoring
for infection, ostomy care, and changing incontinence supplies.
(A) Assist: Even with assistive
devices or supplies, the individual is unable to accomplish some of the tasks of
bladder care without at least monthly assistance from another person.
(B) Full Assist: The individual
is unable to manage any part of bladder or catheter care without the assistance
of another person. This means the individual needs the assistance of another person
through all phases of the activity, every time the activity is attempted.
(b) Bowel means managing
bowel care. This includes tasks such as digital stimulation, toileting schedule,
suppository insertion, ostomy care, enemas, and changing incontinence supplies.
(A) Assist: Even with assistive
devices the individual is unable to accomplish some tasks of bowel care without
at least monthly assistance of another person.
(B) Full Assist: The individual
is unable to accomplish any part of bowel care without the assistance of another
person. This means the individual needs the assistance of another person through
all phases of the activity, every time the activity is attempted.
(c) Toileting means the activity
of getting to and from, and on and off the toilet (including bedpan, commode, or
urinal), cleansing after elimination or adjusting clothing, cleaning and maintaining
assistive devices, or cleaning the toileting area after elimination because of unsanitary
conditions that pose a health risk. This does not include routine bathroom cleaning.
(A) Assist: Even with assistive
devices, the individual is unable to accomplish some tasks of toileting without
hands-on assistance of another person at least monthly. Hands-on assistance is required
for all tasks, except tasks associated with cleaning devices or the toileting area.
(B) Full Assist: The individual
is unable to accomplish any part of toileting without the assistance of another
person. This means the individual needs hands-on assistance of another person through
all phases of the activity, every time the activity is attempted. Hands-on assistance
is required for all tasks, except tasks associated with cleaning devices or the
toileting area.
(9) Mobility is comprised
of two components, which are ambulation and transfer. In the mobility cluster only,
assistance is categorized into three levels. To be considered Minimal Assist, the
individual must require minimal assistance in ambulation. To be considered Substantial
Assist, the individual must require substantial assistance with ambulation or an
assist with transfer. To be considered Full Assist, the individual must require
full assistance with ambulation or transfer.
(a) Mobility does not include
getting in and out of a motor vehicle, getting in or out of a bathtub or shower,
moving on or off the toilet, or moving to and from the toilet.
(b) Mobility, for the purposes
of this rule, inside the home or care setting, means inside the entrance to the
client's home or apartment unit or inside the care setting (as defined in OAR 411-015-0005).
Courtyards, balconies, stairs or hallways exterior to the doorway of the home or
apartment unit are not considered inside.
(c) A history of falls with
an inability to rise without the assistance of another person, or with negative
physical health consequences, may be considered in assessing ambulation or transfer
if they occur within the assessment time frame. Falls prior to the assessment time
frame, or the need for prevention of falls alone, even if recommended by medical
personnel, is not sufficient to qualify for assistance in ambulation or transfer.
(d) Ambulation means the
activity of moving around both inside and outside the home or care setting, during
the assessment time frame, while using assistive devices, if needed. Ambulation
does not include exercise or physical therapy.
(A) Minimal Assist: Even
with assistive devices, if needed, the individual can get around inside his or her
home or care setting without the assistance of another person. Outside of the individual's
home or care setting, the individual requires hands-on assistance of another person.
(B) Substantial Assist: Even
with assistive devices, the individual is unable to ambulate during the assessment
time frame without hands-on assistance of another person inside his or her home
or care setting. Even with assistive devices, this assistance may also be needed
outside.
(C) Full Assist: Even with
assistive devices, the individual is unable to ambulate without assistance from
another person. This means the individual needs the hands-on assistance of another
person through all phases of the activity, every time the activity is attempted.
(e) Transfer means the activity
of moving to or from a chair, bed, or wheelchair using assistive devices, if needed.
This assistance must be needed inside the individual's home or care setting.
(A) Assist: Even with assistive
devices, the individual is unable to accomplish a transfer without hands-on assistance
of another person at least four days during a month.
(B) Full Assist: Even with
assistive devices, the individual is unable to transfer and is dependent on at least
one other person to perform the transfer. This means the individual needs hands-on
assistance of another person through all phases of the activity, every time the
activity is attempted.
Stat. Auth.: ORS 410.070
Stats. Implemented: ORS 410.070
Hist.: SPD 19-2006, f. 5-26-06,
cert. ef. 6-1-06; APD 9-2014(Temp), f. 4-17-14, cert. ef. 4-21-14 thru 10-18-14;
APD 35-2014, f. & cert. ef. 10-1-14
411-015-0007
Instrumental Activities of Daily Living
(1) "Instrumental Activities of Daily Living (IADL)" or "Self-Management tasks" consists of housekeeping including laundry, shopping, transportation, medication management and meal preparation.
(2) Evaluation of the individual's needs for assistance in Instrumental Activities of Daily Living is based on:
(a) The individual's abilities rather than the services provided; and
(b) How the individual functioned during the thirty days prior to the assessment date, with consideration of how the person is likely to function in the thirty days following the assessment date; and
(c) Evidence of the actual or predicted need for assistance of another person within the assessment time frame and can not be based on potential or preventative needs.
(3) "Independent" means the individual does not meet the definition of "Assist" or "Full Assist" for IADLs as defined in this rule.
(4) "Housekeeping" means the ability to maintain the interior of the individual's residence for the purpose of health and safety. Housekeeping includes activities such as wiping surfaces, cleaning floors, making the individual's bed, cleaning dishes, taking out the garbage and dusting. Housekeeping does not include pet care or home repair. Only the housekeeping activities related to the eligible individual's needs may be considered in housekeeping. Housekeeping needs of roommates, guests, family members or other residents of the household can not be considered.
(a) Assist: Even with assistive devices, the individual is unable to accomplish some tasks of housekeeping without the assistance of another person.
(b) Full Assist: Full assist means the individual needs assistance of another person through all phases of the activity, every time the activity is attempted.
(5) "Laundry" means the ability to gather and wash soiled clothing and linens, use washing machines and dryers, hang clothes, fold and put away clean clothing and linens. For service planning, laundry needs are included in Housekeeping.
(a) Assist: Even with assistive devices, the individual is unable to accomplish some tasks of laundry without the assistance of another person.
(b) Full Assist: Full assist means the individual needs assistance of another person through all phases of the activity, every time the activity is attempted.
(6) "Meal Preparation" means the ability to safely prepare food to meet the basic nutritional requirements of the individual. It includes cutting food and placing food, dishes and utensils within reach for eating.
(a) Meal Preparation for breakfast, lunch and dinner/supper is assessed for each meal.
(b) When assessing and developing service plans, dinner/supper is considered as the individual's main meal of the day, regardless of the time the meal is served or eaten.
(c) An individual who needs assistance with meal preparation and who meets the criteria established in OAR 411-040-0000 may receive home delivered meals, if available in the individual's local area. Even with home delivered meal service, an individual may still meet the assistance or full assistance meal preparation criteria in this rule if the individual is unable to accomplish some or all of the meal preparation tasks.
(d) Set-up for tube feeding is assessed in Eating per OAR 411-015-0005.
(e) Assist: Even with assistive devices, the individual is unable to accomplish some tasks of meal preparation without the assistance of another person.
(f) Full Assist: Full assist means the individual needs assistance of another person through all phases of the activity, every time the activity is attempted.
(7) "Medication Management" means the ability to order, organize and administer prescribed medications. Administering prescribed medications includes pills, drops, ointments, creams, injections, inhalers and suppositories unrelated to bowel care. Administering as a paid service means set-up, reminding, cueing, checking for effect and monitoring for choking while taking medications. Oxygen management is included in medication management. Oxygen management means assisting with the administration of oxygen, monitoring the equipment and assuring adequate oxygen supply.
(a) Assist: Even with assistive devices, the individual is unable to accomplish some tasks of medication management without the assistance of another person.
(b) Full Assist: Full assist means the individual needs assistance of another person through all phases of the activity, every time the activity is attempted.
(8) "Shopping" means the ability to purchase goods that are necessary for the health and safety of the individual being assessed and are related to the individual's service plan. Goods that are related to the service plan include items such as food (meal preparation), clothing (dressing), and medicine (medication management).
(a) Assist: Even with assistive devices, the individual is unable to accomplish some tasks of shopping without the assistance of another person.
(b) Full Assist: Full assist means the individual needs assistance of another person through all phases of the activity, every time the activity is attempted.
(9) "Transportation" means, assuming transportation is available, the ability to arrange rides, the ability to get in or out of a vehicle, and the need for assistance during a ride. The need for assistance during a ride means assistance for a physical or cognitive need such as spasticity, memory impairment, aspiration, choking or seizure. Transportation as a paid service means in accordance with a plan of care, assisting an individual during a ride, assisting an individual to get in or out of a vehicle, or arranging a ride for an individual. Transportation does not include mileage reimbursement.
(a) Assist: Even with assistive devices, the individual is unable to accomplish some of the tasks of transportation without the assistance of another person.
(b) Full Assist: Full assist means the individual needs assistance of another person through all phases of the activity, every time the activity is attempted.
Stat. Auth.: ORS 410.070

Stats. Implemented: ORS 410.070

Hist.: SPD 16-2006, f. 4-27-06, cert. ef. 5-1-06
411-015-0008
Assessments
(1) ASSESSMENT.
(a) The assessment process:
(A) Identifies an individual's
ability to perform activities of daily living and instrumental activities of daily
living (self-management tasks);
(B) Determines an individual's
ability to address health and safety concerns; and
(C) Includes an individual's
preferences to meet service needs.
(b) A case manager must conduct
an assessment in accordance with the standards of practice established by the Department.
(c) A case manager must assess
an individual's abilities, regardless of, architectural modifications, assistive
devices, or services provided in a care setting, alternative service resources,
or other community providers.
(d) The time frame of reference
for evaluation is 30 days prior to the assessment date, with consideration of how
the individual is likely to function in the 30 days following the assessment date.
(A) In order to be eligible,
an individual must demonstrate the need for assistance of another person within
the assessment time frame and expect the need to be on-going beyond the assessment
time frame.
(B) The time frame for assessing
the cognition and behavior activity of daily living may be extended as described
in OAR 411-015-0006.
(e) The assessment must be
conducted at least annually, or when requested by an individual, with a standardized
assessment tool, approved by a Department case manager, or other qualified Department
or AAA representative.
(f) The initial assessment
must be conducted face to face, in an individual's home or care setting.
(g) All re-assessments must
be conducted face to face in an individual's home or care setting, unless there
is a compelling reason to meet elsewhere and the individual requests an alternative
location. Case managers must visit an individual's home or care setting to complete
the re-assessment and identify service plan needs, as well as safety and risk concerns.
(A) Individuals must be sent
a notice of the need for re-assessment a minimum of 14 days in advance.
(B) Consumer requested re-assessments
based on a change in the consumer's condition or service needs are exempt from the
14-day advance notice requirement.
(h) An individual may request
the presence of natural supports at any assessment.
(i) Assessment times must
be scheduled within business days and hours unless extraordinary circumstances necessitate
an alternate time. If an alternate time is necessary, an individual must request
the after-hours appointment, and coordinate a mutually acceptable appointment time
with the local Department or AAA office.
(j) An individual, or the
individual's representative, has the responsibility to participate, in and provide
information necessary to, complete assessments and re-assessments within the time
frame requested by the Department.
(A) Failure to participate
in or provide requested assessment or re-assessment information within the application
time frame, results in a denial of service eligibility.
(B) The Department may allow
additional time if circumstances beyond the control of the individual or the individual's
representative prevent timely participation or submission of information.
(2) SERVICE PLAN.
(a) An individual being assessed,
others identified by the individual, and a case manager must consider the service
options as well as assistive devices, architectural modifications, and other alternative
service resources as defined in OAR 411-015-0005 to meet an individual's service
needs identified in the assessment process.
(b) A case manager is responsible
for:
(A) Determining eligibility
for specific services;
(B) Presenting service options,
resources, and alternatives to an individual to assist the individual in making
informed choices and decisions;
(C) Identifying goals, preferences,
and risks; and
(D) Assessing the cost effectiveness
of an individual's service plan.
(c) A case manager must monitor
the service plan and make adjustments as needed.
(d) An eligible individual,
or the individual's representative, is responsible for choosing and assisting in
developing less costly service alternatives.
(e) The service plan payment
must be considered full payment for the Medicaid home and community-based services
rendered. Under no circumstances, may any provider demand or receive additional
payment for Medicaid home and community-based services from an eligible individual
or any other source.
Stat. Auth.: ORS 410.070
Stats. Implemented: ORS 410.070
Hist.: SPD 19-2006, f. 5-26-06,
cert. ef. 6-1-06; SPD 14-2013(Temp), f. & cert. ef. 7-1-13 thru 12-28-13; SPD
45-2013, f. 12-13-13, cert. ef. 12-15-13; APD 35-2014, f. & cert. ef. 10-1-14
411-015-0010
Priority of Paid Services
To determine the service priority level, an individual must be found eligible, using the Department's standardized assessment tool, as meeting at least the requirements for Assist or Full Assist in activities of daily living as defined in OAR 411-015-0006, in the following order and as designated in 411-015-0015.
(1) Requires Full Assistance in Mobility, Eating, Elimination, and Cognition.
(2) Requires Full Assistance in Mobility, Eating, and Cognition.
(3) Requires Full Assistance in Mobility, or Cognition, or Eating.
(4) Requires Full Assistance in Elimination.
(5) Requires Substantial Assistance with Mobility, Assistance with Elimination and Assistance with Eating.
(6) Requires Substantial Assistance with Mobility and Assistance with Eating.
(7) Requires Substantial Assistance with Mobility and Assistance with Elimination.
(8) Requires Minimal Assistance with Mobility and Assistance with Eating and Elimination.
(9) Requires Assistance with Eating and Elimination.
(10) Requires Substantial Assistance with Mobility.
(11) Requires Minimal Assistance with Mobility and Assistance with Elimination.
(12) Requires Minimal Assistance with Mobility and Assistance with Eating.
(13) Requires Assistance with Elimination.
(14) Requires Assistance with Eating.
(15) Requires Minimal Assistance with Mobility.
(16) Requires Full Assistance in Bathing or Dressing.
(17) Requires Assistance in Bathing or Dressing.
(18) Independent in the above levels but requires structured living for supervision for complex medical problems or a complex medication regimen.
Stat. Auth.: ORS 410.070

Stats. Implemented: ORS 410.070

Hist.: SSD 3-1985, f. & ef. 4-1-85; SSD 5-1986, f. & ef. 4-14-86; SSD 9-1986, f. & ef. 7-1-86; SSD 12-1987, f. 12-31-87, cert. ef. 1-1-88; SSD 12-1991(Temp), f. 6-28-91, cert. ef. 7-1-91; SSD 21-1991, f. 12-31-91, cert. ef. 1-1-92, Renumbered from former 411-015-0000(3); SDSD 11-2002(Temp), f. 12-5-02, cert. ef. 12-6-02 thru 6-3-03; SPD 12-2003, f. 5-30-03, cert. ef. 6-4-03; SPD 16-2003(Temp), f. & cert. ef. 10-27-03 thru 4-23-04; SPD 8-2004, f. & cert. ef. 4-27-04; SPD 19-2006, f. 5-26-06, cert. ef. 6-1-06
411-015-0015
Current Limitations
(1) The Department has the authority
to establish, by administrative rule, service eligibility within which to manage
the Department's limited resources. The Department is currently able to serve:
(a) Individuals determined
eligible for the Medicaid OHP Plus benefit package who are assessed as meeting at
least one of the service priority levels (1) through (13) as described in OAR 411-015-0010.
(b) Individuals eligible
for Oregon Project Independence funded services, if the individual meets at least
one of the service priority levels (1) through (18) of OAR 411-015-0010.
(c) Individuals needing risk
intervention services in areas designated to provide such services. Individuals
with the lowest service priority level number under OAR 411-015-0010 are served
first.
(2) Individuals 65 years
of age or older, determined eligible for developmental disability services, or having
a primary diagnosis of a mental or emotional disorder, are eligible for nursing
facility or Medicaid home and community-based services if:
(a) The individual meets
section (1) of this rule; and
(b) The individual is not
in need of specialized mental health treatment services or other specialized Department
residential program interventions as identified through the mental health assessment
process or PASRR process described in OAR 411-070-0043.
(3) Individuals under 65
years of age, determined eligible for developmental disability services, or having
a primary diagnosis of a mental or emotional disorder, are not eligible for Department
nursing facility services unless determined appropriate through the PASRR process
described in OAR 411-070-0043.
(4) Individuals under 65
years of age determined to be eligible for developmental disability services are
not eligible for Medicaid home and community-based services administered by the
Department's Aging and People with Disabilities. Eligibility for Medicaid home and
community-based services for individuals with intellectual or developmental disabilities
is determined by the Department's Office of Developmental Disability Services or
designee.
(5) Individuals under 65
years of age who have a diagnosis of mental or emotional disorder or substance abuse
related disorder are not eligible for Medicaid home and community-based services
administered by the Department's Aging and People with Disabilities unless:
(a) The individual has a
medical non-psychiatric diagnosis or physical disability;
(b) The individual's need
for services is based on his or her medical, non-psychiatric diagnosis, or physical
disability; and
(c) The individual provides
supporting documentation demonstrating that his or her need for services is based
on the medical, non-psychiatric diagnosis, or physical disability. The Department
authorizes documentation sources through approved and published policy transmittals.
(6) Medicaid home and community-based
services are not intended to replace a natural support system as defined by OAR
411-015-0005. Paid support is provided if a natural support is unwilling or unable
to provide identified services.
(7) Individuals with excess
income must contribute to the cost of service pursuant to OAR 461-160-0610 and 461-160-0620.
Stat. Auth.: ORS 410.070 & 411.070
Stats. Implemented: ORS 410.070
Hist.: SSD 3-1985, f. &
ef. 4-1-85; SSD 5-1986, f. & ef. 4-14-86; SSD 9-1986, f. & ef. 7-1-86; SSD
12-1987, f. 12-31-87, cert. ef. 1-1-88; SSD 12-1991(Temp), f. 6-28-91, cert. ef.
7-1-91; SSD 21-1991, f. 12-31-91, cert. ef. 1-1-92, Renumbered from former 411-015-0000(4);
SSD 1-1993, f. 3-19-93, cert. ef. 4-1-93; SDSD 11-2002(Temp), f. 12-5-02, cert.
ef. 12-6-02 thru 6-3-03; SPD 1-2003(Temp), f. 1-7-03, cert. ef. 2-1-03 thru 6-3-03;
SDP 3-2003(Temp), f. 2-14-03, cert. ef. 2-18-03 thru 6-3-03; SPD 5-2003(Temp), f.
& cert. ef. 3-12-03 thru 6-3-03; SPD 6-2003(Temp), f. & cert. ef. 3-20-03
thru 6-3-03; SPD 12-2003, f. 5-30-03, cert. ef. 6-4-03; SPD 16-2003(Temp), f. &
cert. ef. 10-27-03 thru 4-23-04; SPD 5-2004(Temp), f. & cert. ef. 3-23-04 thru
4-27-04; SPD 8-2004, f. & cert. ef. 4-27-04; SPD 20-2004(Temp), f. & cert.
ef. 7-7-04; SPD 29-2004(Temp), f. & cert. ef. 8-6-04 thru 1-3-05; SPD 1-2005,
f. & cert. ef. 1-4-05; SPD 8-2006, f. 1-26-06, cert. ef. 2-1-06; SPD 19-2006,
f. 5-26-06, cert. ef. 6-1-06; SPD 14-2013(Temp), f. & cert. ef. 7-1-13 thru
12-28-13; SPD 45-2013, f. 12-13-13, cert. ef. 12-15-13; APD 9-2014(Temp), f. 4-17-14,
cert. ef. 4-21-14 thru 10-18-14; APD 35-2014, f. & cert. ef. 10-1-14
411-015-0100
Eligibility for Nursing Facility or Medicaid
Home and Community-Based Services
(1) To be eligible for nursing facility
services or Medicaid home and community-based services, a person must:
(a) Be age 18 or older.
(b) Be eligible for the Medicaid
OHP Plus benefit package.
(A) Individuals receiving
Medicaid OHP Plus under OAR 410-200 coverage for services in a nonstandard living
arrangement as defined in 461-001-0000 are subject to the requirements in the same
manner as if they were requesting these services under OSIPM, including the rules
regarding:
(i) The transfer of assets
as set forth in OAR 461-140-0210 to 461-140-0300; and
(ii) The equity value of
a home which exceeds the limits as set forth in OAR 461-145-0220.
(B) When an individual is
disqualified for a transfer of assets, a notice for transfer of assets is required
in accordance with OAR 461-175-0310.
(C) When an individual is
determined ineligible for the equity value of a home, a notice for being over resources
is required in accordance with 461-175-0200.
(c) Meet the functional impairment
level within the service priority levels currently served by the Department as outlined
in OAR 411-015-0010 and the requirements in 411-015-0015.
(2) To be eligible for services
paid through the Spousal Pay Program, an individual must meet the requirements listed
above in section (1) of this rule in addition to the requirements in OAR 411-030-0080.
(3) Individuals who are age
17 or younger and reside in a nursing facility, are eligible for nursing facility
services only and are not eligible to receive Medicaid home and community-based
services administered by the Department's Aging and People with Disabilities.
Stat. Auth.: ORS 410.070
Stats. Implemented: ORS 410.060,
410.070 & 414.065
Hist.: SSD 7-1991(Temp),
f. & cert. ef. 4-1-91; SSD 13-1991, f. 6-28-91, cert. ef. 7-1-91; SDSD 11-2002(Temp),
f. 12-5-02, cert. ef. 12-6-02 thru 6-3-03; SPD 1-2003(Temp), f. 1-7-03, cert. ef.
2-1-03 thru 6-3-03; SPD 12-2003, f. 5-30-03, cert. ef. 6-4-03; SPD 17-2003(Temp),
f. 10-31-03, cert. ef. 11-1-03 thru 4-28-04; SPD 8-2004, f. & cert. ef. 4-27-04;
SPD 29-2004(Temp), f. & cert. ef. 8-6-04 thru 1-3-05; SPD 1-2005, f. & cert.
ef. 1-4-05; SPD 19-2005, f. & cert. ef. 12-29-05; SPD 19-2006, f. 5-26-06, cert.
ef. 6-1-06; SPD 14-2013(Temp), f. & cert. ef. 7-1-13 thru 12-28-13; SPD 45-2013,
f. 12-13-13, cert. ef. 12-15-13; APD 9-2014(Temp), f. 4-17-14, cert. ef. 4-21-14
thru 10-18-14; APD 35-2014, f. & cert. ef. 10-1-14; APD 49-2014(Temp), f. 12-30-14,
cert. ef. 1-1-15 thru 6-29-15; APD 9-2015, f. 3-30-15, cert. ef. 4-3-15

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