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The Oregon Administrative Rules contain OARs filed through April 15, 2013

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DEPARTMENT OF HUMAN SERVICES,
AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES

DIVISION 325

24 HOUR RESIDENTIAL SERVICES FOR CHILDREN AND ADULTS WITH DEVELOPMENTAL DISABILITIES

411-325-0010

Statement of Purpose

These rules prescribe standards, responsibilities, and procedures for 24-Hour Residential Programs providing services to individuals with developmental disabilities. These rules also prescribe the standards and procedures by which the Department of Human Services licenses programs to provide residential care and training to individuals with developmental disabilities.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04

411-325-0020

Definitions

(1) "24-Hour Residential Program" means a comprehensive residential home or facility licensed by the Department under ORS 443.410 to provide residential care and training to individuals with developmental disabilities.

(2) "Abuse" means:

(a) Abuse of a child as defined in ORS 419B.005 and for the purpose of these rules, abuse of a child also means abuse as defined in OAR 407-045-0260.

(b) Abuse of an adult as defined in OAR 407-045-0260.

(3) "Abuse Investigation and Protective Services" means reporting and investigation activities as required by OAR 407-045-0300 and any subsequent services or supports necessary to prevent further abuse as required in OAR 407-045-0310.

(4) "Administration of Medication" means the act of placing a medication in or on an individual's body by a staff member who is responsible for the individual's care.

(5) "Adult" means an individual 18 years or older with developmental disabilities.

(6) "Advocate" means a person other than paid staff who has been selected by the individual or by the individual's legal representative to help the individual understand and make choices in matters relating to identification of needs and choices of services, especially when rights are at risk or have been violated.

(7) "Aid to Physical Functioning" means any special equipment prescribed for an individual by a physician, therapist, or dietician that maintains or enhances the individual's physical functioning.

(8) "Appeal" means the process under ORS Chapter 183 that the service provider may use to petition conditions or the suspension, denial, or revocation of their application, certificate, endorsement, or license.

(9) "Applicant" means a person, agency, corporation, or governmental unit, who applies for a license to operate a residential home or facility providing 24-hour comprehensive services to individuals with developmental disabilities.

(10) "Assessment" means an evaluation of an individual's needs.

(11) "Baseline Level of Behavior" means the frequency, duration, or intensity of a behavior, objectively measured, described, and documented prior to the implementation of an initial or revised Behavior Support Plan. This baseline measure serves as the reference point by which the ongoing efficacy of the Individual Support Plan (ISP) is to be assessed. A baseline level of behavior is reviewed and reestablished at minimum yearly, at the time of the ISP team meeting.

(12) "Behavior Data Collection System" means the methodology specified within the individual's Behavior Support Plan that directs the process for recording observations, interventions, and other support provision information critical to the analysis of the efficacy of the Behavior Support Plan.

(13) "Behavior Data Summary" means a document composed by the service provider to summarize episodes of physical intervention. The behavior data summary serves as a substitution for the requirement of individual incident reports for each episode of physical intervention.

(14) "Board of Directors" means a group of persons formed to set policy and give directions to a service provider that provides residential services to individuals with developmental disabilities. A board of directors includes local advisory boards used by multi-state organizations.

(15) “Certificate" means a document issued by the Department to a service provider that certifies the service provider is eligible under the rules in OAR chapter 411, division 323 to receive state funds for the provision of endorsed 24-hour residential services.

(16) "Chemical Restraint" means the use of a psychotropic drug or other drugs for punishment or to modify behavior in place of a meaningful behavior or treatment plan.

(17) "Child" means an individual under the age of 18 that has a provisional determination of developmental disability.

(18) "Choice" means the individual's expression of preference, opportunity for, and active role in decision-making related to the selection of assessments, services, service providers, goals and activities, and verification of satisfaction with these services. Choice may be communicated verbally, through sign language, or by other communication methods.

(19) "Community Developmental Disability Program (CDDP)" means an entity that is responsible for planning and delivery of services for individuals with developmental disabilities according to OAR chapter 411, division 320. A CDDP operates in a specific geographic service area of the state under a contract with the Department, local mental health authority, or other entity as contracted by the Department.

(20) "Competency Based Training Plan" means a written description of a service provider's process for providing training to newly hired staff. At a minimum, the Competency Based Training Plan:

(a) Addresses health, safety, rights, values and personal regard, and the service provider's mission; and

(b) Describes competencies, training methods, timelines, how competencies of staff are determined and documented including steps for remediation, and when a competency may be waived by a service provider to accommodate a staff member's specific circumstances.

(21) "Complaint Investigation" means an investigation of any complaint that has been made to a proper authority that is not covered by an abuse investigation.

(22) "Condition" means a provision attached to a new or existing certificate, endorsement, or license that limits or restricts the scope of the certificate, endorsement, or license or imposes additional requirements on the service provider.

(23) "Crisis" means:

(a) A situation as determined by a qualified services coordinator that may result in civil court commitment under ORS 427.215 to 427.306 and for which no appropriate alternative resources are available; or

(b) Risk factors described in OAR 411-320-0160(2) are present for which no appropriate alternative resources are available.

(24) "Denial" means the refusal of the Department to issue a certificate, endorsement, or license to operate a 24-hour residential home or facility for children or adults because the Department has determined that the service provider or the home or facility is not in compliance with these rules or the rules in OAR chapter 411, division 323.

(25) "Department" means the Department of Human Services (DHS). The term "Department" is synonymous with "Division (SPD)".

(26) "Developmental Disability" means a neurological condition that originates in the developmental years, that is likely to continue, and significantly impacts adaptive behavior as diagnosed and measured by a qualified professional as described in OAR 411-320-0080.

(27) "Direct Nursing Service" means the provision of individual-specific advice, plans, or interventions, based on nursing process as outlined by the Oregon State Board of Nursing, by a nurse at the home or facility. Direct nursing service differs from administrative nursing services. Administrative nursing services include non-individual-specific services, such as quality assurance reviews, authoring health related agency policies and procedures, or providing general training for staff.

(28) "Director" means the Director of the Department's Office of Developmental Disability Services, or that person's designee. The term "Director" is synonymous with "Assistant Director".

(29) "Domestic Animals" mean any various animals domesticated so as to live and breed in a tame condition. Examples of domestic animals are dogs, cats, and domesticated farm stock.

(30) "Educational Surrogate" means a person who acts in place of a parent in safeguarding a child's rights in the special education decision-making process:

(a) When the parent cannot be identified or located after reasonable efforts;

(b) When there is reasonable cause to believe that the child has a disability and is a ward of the state; or

(31) "Endorsement" means authorization to provide 24-hour residential services issued by the Department to a certified service provider that has met the qualification criteria outlined in these rules and the rules in OAR chapter 411, division 323.

(32) "Entry" means admission to a Department-funded developmental disability service. For the purpose of these rules, "entry" means admission to a licensed 24-hour home or facility.

(33) "Executive Director" means the person designated by a board of directors or corporate owner that is responsible for the administration of 24-hour residential services.

(34) "Exit" means either termination from a Department-funded developmental disability service provider or transfer from one Department-funded service provider to another.

(35) "Founded Reports" means the Department's or Law Enforcement Authority's (LEA) determination, based on the evidence, that there is reasonable cause to believe that conduct in violation of the child abuse statutes or rules has occurred and such conduct is attributable to the person alleged to have engaged in the conduct.

(36) "Guardian" means a parent for individuals under 18 years of age or a person or agency appointed and authorized by the courts to make decisions about services for an individual.

(37) "Health Care Provider" means a person or health care facility licensed, certified, or otherwise authorized or permitted by Oregon law to administer health care in the ordinary course of business or practice of a profession.

(38) "Health Care Representative" means:

(a) A health care representative as defined in ORS 127.505; or

(b) A person who has authority to make health care decisions for an individual under the provisions of OAR chapter 411, division 365.

(39) "Incident Report" means a written report of any injury, accident, acts of physical aggression, or unusual incident involving an individual.

(40) "Independence" means the extent to which individuals with developmental disabilities exert control and choice over their own lives.

(41) "Individual" means an adult or a child with developmental disabilities for whom services are planned and provided.

(42) "Individualized Education Plan (IEP)" means a written plan of instructional goals and objectives in conference with the teacher, parent or guardian, student, and a representative of the school district.

(43) "Individual Support Plan (ISP)" means the written details of the supports, activities, and resources required for an individual to achieve personal goals. The type of service supports needed, how supports are delivered, and the frequency of provided supports are included in the ISP. The ISP is developed at minimum annually to reflect decisions and agreements made during a person-centered process of planning and information gathering. The ISP is the individual's Plan of Care for Medicaid purposes.

(44) "Individual Support Plan (ISP) Team" means a team composed of the individual served, representatives who provide service to the individual (if appropriate for in-home supports), the guardian (if any), the services coordinator, and family or other persons requested to develop the ISP.

(45) "Integration" as defined in ORS 427.005 means:

(a) The use by individuals with developmental disabilities of the same community resources used by and available to other persons;

(b) Participation by individuals with developmental disabilities in the same community activities in which persons without a developmental disability participate, together with regular contact with persons without a developmental disability; and

(c) Individuals with developmental disabilities reside in homes or home-like settings that are in proximity to community resources and foster contact with persons in their community.

(46) "Legal Representative" means the parent, if the individual is under age 18, unless the court appoints another person or agency to act as guardian. For those individuals over the age of 18, a legal representative means an attorney at law who has been retained by or for the individual or a person or agency authorized by the court to make decisions about services for the individual.

(47) "Licensee" means a person or organization to whom a certificate, endorsement, and license is granted.

(48) "Majority Agreement" means for purposes of entry, exit, transfer, and annual Individual Support Plan (ISP) team meetings, that no one member of the ISP team has the authority to make decisions for the team unless so authorized by the team process. Service providers, families, community developmental disability programs, advocacy agencies, or individuals are considered as one member of the ISP team for the purpose of reaching majority agreement.

(49) "Mandatory Reporter" means any public or private official as defined in OAR 407-045-0260 who:

(a) For the purpose of these rules, is a staff or volunteer working with individuals birth to 17 years of age who, comes in contact with and has reasonable cause to believe a child has suffered abuse, or comes in contact with any person whom the official has reasonable cause to believe abused a child, regardless of whether or not the knowledge of the abuse was gained in the reporter’s official capacity. Nothing contained in ORS 40.225 to 40.295 shall affect the duty to report imposed by this section of this rule, OAR 411-325-0020, except that a psychiatrist, psychologist, clergy, attorney, or guardian ad litem appointed under ORS 419B.231 is not required to report if the communication is privileged under ORS 40.225 to 40.295.

(b) For the purpose of these rules, is a staff or volunteer working with adults 18 years and older who, while acting in an official capacity, comes in contact with and has reasonable cause to believe an adult with developmental disabilities has suffered abuse, or comes in contact with any person whom the official has reasonable cause to believe abused an adult with developmental disabilities. Nothing contained in ORS 40.225 to 40.295 shall affect the duty to report imposed by this section of this rule, OAR 411-325-0020, except that a psychiatrist, psychologist, clergy, or attorney is not required to report if the communication is privileged under ORS 40.225 to 40.295.

(50) "Mechanical Restraint" means any mechanical device, material, object, or equipment that is attached or adjacent to an individual's body that the individual cannot easily remove or easily negotiate around, and that restricts freedom of movement or access to the individual's body.

(51) "Medicaid Agency Identification Number" means the numeric identifier assigned by the Department to a service provider following the service provider's enrollment as described in OAR chapter 411, division 370.

(52) "Medicaid Performing Provider Number" means the numeric identifier assigned to an entity or person by the Department, following enrollment to deliver Medicaid funded services as described in OAR chapter 411, division 370. The Medicaid Performing Provider Number is used by the rendering service provider for identification and billing purposes associated with service authorizations and payments.

(53) "Medication" means any drug, chemical, compound, suspension, or preparation in suitable form for use as a curative or remedial substance taken either internally or externally by any person.

(54) "Modified Diet" means the texture or consistency of food or drink is altered or limited. Examples include but are not limited to no nuts or raw vegetables, thickened fluids, mechanical soft, finely chopped, pureed, or bread only soaked in milk.

(55) "Nurse" means a person who holds a current license from the Oregon Board of Nursing as a registered nurse or licensed practical nurse pursuant to ORS chapter 678.

(56) "Nursing Care Plan" means a plan of care developed by a registered nurse that describes the medical, nursing, psychosocial, and other needs of the individual and how those needs shall be met. The Nursing Care Plan includes which tasks shall be taught or delegated to the provider and staff.

(57) "Oregon Core Competencies" means:

(a) A list of skills and knowledge for newly hired staff in the areas of health, safety, rights, values and personal regard, and the service provider's mission; and

(b) The associated timelines in which newly hired staff must demonstrate competencies.

(58) "Oregon Intervention System (OIS)" means a system of providing training to people who work with designated individuals to provide elements of positive behavior support and non-aversive behavior intervention. OIS uses principles of pro-active support and describes approved protective physical intervention techniques that are used to maintain health and safety.

(59) "Person-Centered Planning" means:

(a) A process, either formal or informal, for gathering and organizing information that helps an individual:

(A) Determine and describe choices about personal goals, activities, and lifestyle preferences;

(B) Design strategies and networks of support to achieve goals and a preferred lifestyle using individual strengths, relationships, and resources; and

(b) The methods for gathering information vary, but all are consistent with individual needs and preferences.

(60) "Prescription Medication" means any medication that requires a physician prescription before it may be obtained from a pharmacist.

(61) "Productivity" as defined in ORS 427.005 means:

(a) Engagement in income-producing work by an individual with developmental disabilities that is measured through improvements in income level, employment status, or job advancement; or

(b) Engagement by an individual with developmental disabilities in work contributing to a household or community.

(62) "Protection" and "Protective Services" means necessary actions taken as soon as possible to prevent subsequent abuse or exploitation of the individual, to prevent self-destructive acts, and to safeguard an individual's person, property, and funds.

(63) "Protective Physical Intervention (PPI)" means any manual physical holding of, or contact with, an individual that restricts the individual's freedom of movement. The term "protective physical intervention" is synonymous with "physical restraint".

(64) "Psychotropic Medication" means medication the prescribed intent of which is to affect or alter thought processes, mood, or behavior including but not limited to anti-psychotic, antidepressant, anxiolytic (anti-anxiety), and behavior medications. The classification of a medication depends upon its stated, intended effect when prescribed.

(65) "Respite" means intermittent services provided on a periodic basis, but not more than 14 consecutive days, for the relief of, or due to the temporary absence of, persons normally providing the supports to individuals unable to care for themselves.

(66) "Revocation" means the action taken by the Department to rescind a certificate, endorsement, or 24-hour home or facility license after the Department has determined that the service provider is not in compliance with these rules or the rules in OAR chapter 411, division 323.

(67) "Self-Administration of Medication" means the individual manages and takes his or her own medication, identifies his or her own medication and the times and methods of administration, places the medication internally in or externally on his or her own body without staff assistance upon written order of a physician, and safely maintains the medication without supervision.

(68) "Service Provider" means a public or private community agency or organization that provides recognized developmental disability services and is certified and endorsed by the Department to provide these services under these rules and the rules in OAR chapter 411, division 323. For the purpose of these rules, "agency", "provider", "program", "applicant", or "licensee" is synonymous with "service provider."

(69) "Services" mean supportive services, including but not limited to supervision, protection, and assistance in bathing, dressing, grooming, eating, management of money, transportation, or recreation. Services also include being aware of the individual's general whereabouts at all times and monitoring the activities of the individual to ensure the individual's health, safety, and welfare. The term "services" is synonymous with "care".

(70) "Services Coordinator" means an employee of the community developmental disability program or other agency that contracts with the county or Department, who is selected to plan, procure, coordinate, and monitor Individual Support Plan services, and to act as a proponent for individuals with developmental disabilities.

(71) "Significant Other" means a person selected by the individual to be the individual's friend.

(72) "Specialized Diet" means that the amount, type of ingredients, or selection of food or drink items is limited, restricted, or otherwise regulated under a physician's order. Examples include but are not limited to low calorie, high fiber, diabetic, low salt, lactose free, or low fat diets. A specialized diet does not include a diet where extra or additional food is offered without physician's orders but may not be eaten, for example, offer prunes each morning at breakfast or include fresh fruit with each meal.

(73) "Staff" means paid employees responsible for providing services to individuals whose wages are paid in part or in full with funds sub-contracted with the community developmental disability program or contracted directly through the Department.

(74) "Substantiated" means an abuse investigation has been completed by the Department or the Department's designee and the preponderance of the evidence establishes the abuse occurred.

(75) "Support" means assistance that individuals require, solely because of the affects of developmental disability, to maintain or increase independence, achieve community presence and participation, and improve productivity. Support is subject to change with time and circumstances.

(76) "Suspension" means an immediate temporary withdrawal of the approval to operate 24-hour residential services after the Department determines that the service provider or 24-hour home or facility is not in compliance with one or more of these rules or the rules in OAR chapter 411, division 323.

(77) "These Rules" mean the rules in OAR chapter 411, division 325.

(78) "Transfer" means movement of an individual from one home or facility to another home or facility within the same county, administered by the same service provider.

(79) "Transition Plan" means a written plan for the period of time between an individual's entry into a particular service and when the individual's Individual Support Plan (ISP) is developed and approved by the ISP team. The Transition Plan includes a summary of the services necessary to facilitate adjustment to the services offered, the supports necessary to ensure health and safety, and the assessments and consultations necessary for ISP development.

(80) "Unusual Incident" means incidents involving serious illness or accidents, death of an individual, injury or illness of an individual requiring inpatient or emergency hospitalization, suicide attempts, a fire requiring the services of a fire department, or any incident requiring an abuse investigation.

(81) "Variance" means a temporary exception from a regulation or provision of these rules that may be granted by the Department upon written application by the service provider.

(82) "Volunteer" means any person assisting a service provider without pay to support the services provided to an individual.

Stat. Auth.: ORS 409.050, 410.070, 443.450, & 443.455
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04; SPD 25-2009(Temp), f. 12-31-09, cert. ef. 1-1-10 thru 6-30-10; SPD 5-2010, f. 6-29-10, cert. ef. 7-1-10; SPD 19-2011(Temp), f. & cert. ef. 7-1-11 thru 12-28-11; SPD 1-2012, f. & cert. ef. 1-6-12

411-325-0025

Program Management

(1) CERTIFICATION, ENDORSEMENT, AND ENROLLMENT. To provide 24-hour residential services, a service provider must have:

(a) A certificate and an endorsement to provide 24-hour residential services as set forth in OAR chapter 411, division 323;

(b) A Medicaid Agency Identification Number assigned by the Department as described in OAR chapter 411, division 370; and

(c) For each specific geographic service area where 24-hour residential services shall be delivered, a Medicaid Performing Provider Number assigned by the Department as described in OAR chapter 411, division 370.

(2) INSPECTIONS AND INVESTIGATIONS. The service provider must allow inspections and investigations as described in OAR 411-323-0040.

(3) MANAGEMENT AND PERSONNEL PRACTICES. The service provider must comply with the management and personnel practices as described in OAR 411-323-0050.

(4) COMPETENCY BASED TRAINING PLAN. The service provider must have and implement a Competency Based Training Plan that meets, at a minimum, the competencies and timelines set forth in the Department's Oregon Core Competencies.

(5) GENERAL STAFF QUALIFICATIONS. Any staff member providing direct assistance to individuals must:

(a) Have knowledge of individuals' ISP's and all medical, behavioral, and additional supports required for the individuals; and

(b) Have met the basic qualifications in the service provider's Competency Based Training Plan. The service provider must maintain written documentation kept current that the staff member has demonstrated competency in areas identified by the service provider's Competency Based Training Plan as required by OAR 411-325-0025(4) of this rule, and that is appropriate to their job description.

(6) CONFIDENTIALITY OF RECORDS. The service provider must ensure all individuals' records are confidential as described in OAR 411-323-0060.

(7) DOCUMENTATION REQUIREMENTS. All entries required by these rules, unless stated otherwise must:

(a) Be prepared at the time, or immediately following the event being recorded;

(b) Be accurate and contain no willful falsifications;

(d) Be maintained for no less than three years.

Stat. Auth. ORS 409.050, 410.070, 443.450, & 443.455
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 19-2011(Temp), f. & cert. ef. 7-1-11 thru 12-28-11; SPD 1-2012, f. & cert. ef. 1-6-12

411-325-0030

Issuance of License

(1) License required. No person, agency or governmental unit acting individually or jointly with any other person, agency or governmental unit will establish, conduct, maintain, manage or operate a residential home or facility providing 24-hour support services without being licensed for each home or facility.

(2) Not transferable. No license is transferable or applicable to any location, home or facility, agency, management agent or ownership other than that indicated on the application and license.

(3) Terms of license. The Department will issue a license to an applicant found to be in compliance with these rules. The license will be in effect for two years from the date issued unless revoked or suspended.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04

411-325-0040

Application for Initial License

(1) Application. At least 30 days prior to anticipated licensure the applicant must submit an application and required non-refundable fee. The application will be provided by the Department and must include all information requested by the Department.

(2) Number of beds. The application must identify the number of beds the residential home or facility is presently capable of operating at the time of application, considering existing equipment, ancillary service capability and the physical requirements as specified by these rules. For purposes of license renewal, the number of beds to be licensed must not exceed the number identified on the license to be renewed unless approved by the Department.

(3) Contracts. The initial application must include a copy of any lease agreements or contracts, management agreements or contracts, and sales agreements or contracts, relative to the operation and ownership of the home or facility.

(4) Floor Plan. The initial application must include a floor plan of the home or facility showing the location and size of rooms, exits, smoke alarms and extinguishers.

(5) Scheduled onsite-licensing inspection. Should the scheduled, onsite licensing inspection reveal that the applicant is not in compliance with these rules, as attested to on the Licensing Onsite Inspection Checklist, the onsite licensing inspection may be rescheduled at the Department's convenience.

(6) License required prior to providing services. Applicants must not admit any individual to the home or facility prior to receiving a written confirmation of licensure from the Department.

(7) Demonstrated Capability and Performance History.

(a) If an applicant fails to provide complete, accurate, and truthful information during the application and licensing process, the Department may cause initial licensure to be delayed, or may deny or revoke the license.

(b) Any applicant or person with a controlling interest in an agency will be considered responsible for acts occurring during, and relating to, the operation of such home/facility or agency for purpose of licensing.

(c) The Department may consider the background and operating history of the applicant(s) and each person with a controlling ownership interest when determining whether to issue a license.

(d) When an application for initial licensure is made by an applicant(s) who owns or operates other licensed homes or facilities in Oregon, the Department may deny the license if the applicant's existing home(s) or facility(ies) are not, or have not been, in substantial compliance with the Oregon Administrative Rules.

(8) Separate buildings. Separate licenses are not required for separate buildings located contiguously and operated as an integrated unit by the same management.

(9) Admittance of individuals. No residential home or facility will admit individuals whose care needs exceed the classification on its license without prior written consent of the Department.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04

411-325-0050

License Expiration, Termination of Operations, License Return

(1) Expiration. Unless revoked, suspended or terminated earlier, each license to operate a residential home or facility will expire two years following the date of issuance.

(2) Termination of operation.

(a) If the home or facility operation is discontinued for any reason, the license will be considered to have been terminated.

(b) Each license will be considered void immediately if the operation is discontinued by voluntary action of the licensee or if there is a change in ownership.

(3) Return of license. The license must be returned to the Department immediately upon suspension or revocation of the license or when the operation is discontinued.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04

411-325-0060

Conditions on License

The Department may attach conditions to the license that limit, restrict, or specify other criteria for operation of the home or facility. The type of condition attached to a license shall directly relate to a risk of harm or potential risk of harm to individuals.

(1) The Department may attach a condition to a license upon a finding that:

(a) Information on the application or initial inspection requires a condition to protect the health, safety, or welfare of individuals;

(b) A threat to the health, safety, or welfare of an individual exists;

(d) The home or facility is not being operated in compliance with these rules; or

(e) The service provider is licensed to provide services for a specific person only and further placements may not be made into that home or facility.

(2) Conditions that the Department may impose on a license include but are not limited to:

(a) Restricting the total number of individuals that may be served;

(b) Restricting the number of individuals allowed within a licensed classification level based upon the capacity of the service provider and staff to meet the health and safety needs of all individuals;

(c) Restricting the support level of individuals allowed within a licensed classification level based upon the capacity of the service provider and staff to meet the health and safety needs of all individuals;

(d) Requiring additional staff or staff qualifications;

(e) Requiring additional training;

(f) Restricting the service provider from allowing persons on the premises who may be a threat to an individual's health, safety, or welfare;

(g) Requiring additional documentation; or

(h) Restriction of admissions.

(3) The Department shall notify the service provider in writing of any conditions imposed, the reason for the conditions, and the opportunity to request a hearing under ORS chapter 183. Conditions take effect immediately upon issuance of the notice, or at such later date as indicated on the notice, and shall continue until removed by the Department.

(4) The service provider may request a contested case hearing in accordance with ORS chapter 183 and this rule upon written notice from the Department of the imposition of conditions.

(a) The service provider must request a hearing within 21 days of receipt of the Department's written notice of conditions.

(b) In addition to, or in lieu of a hearing, a service provider may request an administrative review as described in OAR 411-325-0060(5) of this rule. The administrative review does not diminish the service provider's right to a hearing.

(5) ADMINISTRATIVE REVIEW.

(a) A service provider, in addition to the right to a contested case hearing, may request an administrative review by the Department’s Director or designee for imposition of conditions.

(b) The request for administrative review must be received by the Department within 10 days from the date of the Department’s notice of imposition of conditions. The service provider may submit, along with the request for administrative review, any additional written materials the service provider wishes to have considered during the administrative review.

(c) The Department shall conduct the administrative review and issue a decision within 10 days from the date of receipt of the request for administrative review, or by a later date as agreed to by the service provider.

(d) If the decision of the Department is to affirm the condition, the service provider may appeal the decision to a contested case hearing as long as the request for a contested case hearing was received by the Department within 21 days of the original written notice of imposition of conditions.

(6) The service provider may send a written request to the Department to remove a condition if the service provider believes the situation that warranted the condition has been remedied.

Stat. Auth.: ORS 409.050, 410.070, 443.450, & 443.455
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04; SPD 19-2011(Temp), f. & cert. ef. 7-1-11 thru 12-28-11; SPD 1-2012, f. & cert. ef. 1-6-12

411-325-0070

Renewal of License

(1) Renewal application required. A license is renewable upon submission of an application to the Department and the payment of the required non-refundable fee, except that no fee will be required of a governmental owned home or facility.

(2) Filing of application extends date of expiration. Filing of an application and required fee for renewal before the date of expiration extends the effective date of expiration until the Department takes action upon such application. If the renewal application and fee are not submitted prior to the expiration date, the home or facility will be treated as an unlicensed home or facility subject to Civil Penalties (OAR 411-325-0460).

(3) Licensing review. The Department will conduct a licensing review of the service prior to the renewal of the license. The review will be unannounced, be conducted 30 - 120 days prior to expiration of the license, and will review compliance with OAR 411-325-0010 through 411-325-0480.

(4) Refusal to renew a license. The Department will not renew a license if the home or facility is not in substantial compliance with these rules, or if the State Fire Marshal or the authorized representative has given notice of noncompliance pursuant to ORS 479.220.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04

411-325-0090

Change of Ownership, Legal Entity, Legal Status, Management Corporation

(1) Notice of pending change in ownership, legal entity, legal status, or management corporation. The home or facility must notify the Department in writing of any pending change in the program's ownership or legal entity, legal status, or management corporation.

(2) New license required. A new license will be required upon change in a program's ownership, legal entity or legal status. The program must submit a license application and required fee at least 30 days prior to change in ownership, legal entity or legal status.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04

411-325-0110

Variances

(1) The Department may grant a variance to these rules based upon a demonstration by the service provider that an alternative method or different approach provides equal or greater program effectiveness and does not adversely impact the welfare, health, safety, or rights of individuals.

(2) The service provider requesting a variance must submit, in writing, an application to the CDDP that contains the following:

(a) The section of the rule from which the variance is sought;

(b) The reason for the proposed variance;

(d) If the variance applies to an individual's services, evidence that the variance is consistent with an individual's currently authorized ISP.

(3) The CDDP must forward the signed variance request form to the Department within 30 days of receipt of the request indicating its position on the proposed variance.

(4) The Department shall approve or deny the request for a variance.

(5) The Department's decision shall be sent to the service provider, the CDDP, and to all relevant Department programs or offices within 30 calendar days of the receipt of the variance request.

(6) The service provider may appeal the denial of a variance request within 10 working days of the denial, by sending a written request for review to the Director and a copy of the request to the CDDP. The Director's decision is final.

(7) The Department shall determine the duration of the variance.

(8) The service provider may implement a variance only after written approval from the Department.

Stat. Auth.: ORS 409.050, 410.070, 443.450, & 443.455
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 1-2012, f. & cert. ef. 1-6-12

411-325-0120

Health: Medical

(1) Written policies and procedures. The program must have and implement policies and procedures that maintain and protect the physical health of individuals. Policies and procedures must address the following:

(a) Individual health care;

(b) Medication administration;

(d) Response to emergency medical situations;

(e) Nursing service provision, if provided ;

(f) Disposal of medications; and

(g) Early detection and prevention of infectious disease.

(2) Individual health care. The individual must receive care that promotes their health and well being as follows:

(a) The program must ensure each individual has a primary physician or primary health care provider whom he or she, the parent, guardian or legal representative has chosen from among qualified providers;

(b) The program must ensure each individual receives a medical evaluation by a qualified health care provider no less than every two years or as recommended by a physician;

(c) The program must monitor the health status and physical conditions of each individual and take action in a timely manner in response to identified changes or conditions that could lead to deterioration or harm;

(d) A physician's or qualified health care provider's written, signed order is required prior to the usage or implementation of all of the following:

(A) Prescription medications;

(B) Non prescription medications except over the counter topical;

(D) Modified or special diets;

(E) Adaptive equipment; and

(F) Aids to physical functioning.

(e) The program must implement a physician's or qualified health care provider's order.

(3) Required documentation. The program must maintain records on each individual to aid physicians, licensed health professionals and the program in understanding the individual's medical history. Such documentation must include:

(a) A list of known health conditions, medical diagnoses; known allergies and immunizations;

(b) A record of visits to licensed health professionals that include documentation of the consultation and any therapy provided; and

(4) Medication procurement and storage. All medications must be:

(a) Kept in their original containers;

(b) Labeled by the dispensing pharmacy, product manufacturer or physician, as specified per the physician's or licensed health care practitioner's written order; and

(5) Medication administration. All medications and treatments must be recorded on an individualized medication administration record (MAR). The MAR must include:

(a) The name of the individual;

(b) A transcription of the written physician's or licensed health practitioner's order, including the brand or generic name of the medication, prescribed dosage, frequency and method of administration;

(c) For topical medications and treatments without a physician's order, a transcription of the printed instructions from the package;

(d) Times and dates of administration or self administration of the medication;

(e) Signature of the person administering the medication or the person monitoring the self administration of the medication;

(f) Method of administration;

(g) An explanation of why a PRN (i.e., as needed) medication was administered;

(h) Documented effectiveness of any PRN (i.e., as needed) medication administration;

(i) An explanation of any medication administration irregularity; and

(j) Documentation of any known allergy or adverse drug reaction.

(6) Self-administration of medication. For individuals who independently self-administer medications, there must be a plan as determined by the ISP team for the periodic monitoring and review of the self-administration of medications.

(7) Self-administration medications unavailable to other individuals. The program must ensure that individuals able to self-administer medications keep them in a secure locked container unavailable to other individuals residing in the same residence and store them as recommended by the product manufacturer.

(8) PRN/Psychotropic medication prohibited. PRN (i.e., as needed), orders will not be allowed for psychotropic medication.

(9) Adverse medication effects safe guards. Safeguards to prevent adverse effects or medication reactions must be utilized and include:

(a) Obtaining, whenever possible, all prescription medication except samples provided by the health care provider, for an individual from a single pharmacy which maintains a medication profile for him or her;

(b) Maintaining information about each medication's desired effects and side effects;

(c) Ensuring that medications prescribed for one individual are not administered to, or self-administered by, another individual or staff member; and

(d) Documentation in the individual's record of reason why all medications should not be provided through a single pharmacy.

(10) Unused, discontinued, outdated, recalled and contaminated medications. All unused, discontinued, outdated, recalled and contaminated medications must be disposed of in a manner designed to prevent the illegal diversion of these substances. A written record of their disposal must be maintained that includes documentation of:

(a) Date of disposal;

(b) Description of the medication, including dosage strength and amount being disposed;

(d) Reason for disposal;

(e) Method of disposal;

(f) Signature of the person disposing of the medication; and

(g) For controlled medications, the signature of a witness to the disposal.

(11) Direct nursing services. When direct nursing services are provided to an individual the program must:

(a) Coordinate with the nurse or nursing service and the ISP team to ensure that the services being provided are sufficient to meet the individual's health needs; and

(b) Implement the Nursing Care Plan, or appropriate portions therein, as agreed upon by the ISP team and the registered nurse.

(12) Notification. When the individual's medical, behavioral or physical needs change to a point that they cannot be met by the program, the Services Coordinator must be notified immediately and that notification documented.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04

411-325-0130

Health: Food and Nutrition

(1) Well balanced diet. The provider must provide access to a well balanced diet in accordance with the U.S. Department of Agriculture.

(2) Modified or special diets. For individuals with physician or health care provider ordered modified or special diets the program must:

(a) Have menus for the current week that provide food and beverages which consider the individual's preferences and are appropriate to the modified or special diet; and

(b) Maintain documentation that identifies how modified texture or special diets are prepared and served for individuals.

(3) Number of meals. At least three meals must be made available or arranged for daily.

(4) Need and preference of individual. Foods must be served in a form consistent with the individual's need and provide opportunities for choice in food selection.

(5) Prohibited food items. Unpasteurized milk and juice or home canned meats and fish must not be served or stored in the residence.

(6) Supply of food. Adequate supplies of staple foods for a minimum of one week and perishable foods for a minimum of two days must be maintained on the premises.

(7) Sanitation. Food must be stored, prepared and served in a sanitary manner.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04

411-325-0140

Health: Physical Environment

(1) Clean and in good repair. All floors, walls, ceilings, windows, furniture and fixtures must be kept in good repair, clean and free from odors. Walls, ceilings, and floors must be of such character to permit frequent washing, cleaning, or painting.

(2) Water and sewage. The water supply and sewage disposal must meet the requirements of the current rules of the Oregon Health Authority governing domestic water supply.

(3) Public water supply. A public water supply must be utilized if available. If a non-municipal water source is used, a sample must be collected yearly by the provider, sanitarian, or a technician from a certified water-testing laboratory. The water sample must be tested for coliform bacteria and action taken to ensure potability. Test records must be retained for three years.

(4) Septic tanks or other non-municipal sewage disposal systems. Septic tanks or other non-municipal sewage disposal systems must be in good working order. Incontinence garments must be disposed of in closed containers.

(5) Room temperature. The temperature within the residence must be maintained within a normal comfort range. During times of extreme summer heat, the provider must make reasonable effort to keep individuals comfortable using ventilation, fans, or air conditioning.

(6) Heat source screens. Screening for workable fireplaces and open-faced heaters must be provided.

(7) Heating and cooling devices. All heating and cooling devices must be installed in accordance with current Building Codes and maintained in good working order.

(8) Handrails. Handrails must be provided on all stairways.

(9) Swimming pools, hot tubs, saunas or spas. Swimming pools, hot tubs, saunas, or spas must be equipped with safety barriers and devices designed to prevent injury and unsupervised access.

(10) Sanitation for household pets and other domestic animals. Sanitation for household pets and other domestic animals must be adequate to prevent health hazards. Proof of current rabies vaccinations and any other vaccinations that are required for the pet by a licensed veterinarian must be maintained on the premises. Pets not confined in enclosures must be under control and must not present a danger or health risk to individuals residing at the residence or their guests.

(11) Insects and rodents. All measures necessary must be taken to prevent the entry of rodents, flies, mosquito's and other insects.

(12) Garbage. The interior and exterior of the residence must be kept free of litter, garbage and refuse.

(13) State and local codes. Any work undertaken at a residence, including but not limited to, demolition, construction, remodeling, maintenance, repair, or replacement must comply with all applicable State and local building, electrical, plumbing and zoning codes appropriate to the individuals served.

(14) Zoning. Programs must comply with all applicable, legal zoning ordinances pertaining to the number of individuals receiving services at the residence.

Stat. Auth. ORS 409.050, 443.450 & 443.455
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04

411-325-0150

Safety: General

(1) TOXIC MATERIALS. All toxic materials including, but not limited to, poisons, chemicals, rodenticides and insecticides must be:

(a) Properly labeled;

(b) Stored in original container separate from all foods, food preparation utensils, linens, and medications; and

(c) Stored in a locked area unless the Risk Tracking records for all individuals residing in the home document that there is no risk present.

(2) FLAMMABLE AND COMBUSTIBLE MATERIALS. All flammable and combustible materials must be properly labeled, stored, and locked in accordance with State Fire Code.

(3) KNIVES AND SHARP OBJECTS. For children, knives and sharp kitchen utensils must be locked unless otherwise determined by a documented ISP team decision.

(4) WINDOW COVERINGS. Window shades, curtains, or other covering devices must be provided for all bedroom and bathroom windows to assure privacy.

(5) HOT WATER TEMPERATURE. Hot water in bathtubs and showers may not exceed 120 degrees Fahrenheit. Other water sources, except the dishwasher, may not exceed 140 degrees Fahrenheit.

(6) WINDOW OPENINGS. Sleeping rooms on ground level must have at least one window readily openable from the inside without special tools that provides a clear opening of not less than 821 square inches, with the least dimension not less than 22 inches in height or 20 inches in width. Sill height may not be more than 44 inches from the floor level. Exterior sill heights may not be greater than 72 inches from the ground, platform, deck, or landing. There must be stairs or a ramp to ground level. Those homes or facilities previously licensed having a minimum window opening of not less than 720 square inches are acceptable unless through inspection it is deemed that the window opening dimensions present a life safety hazard.

(7) SQUARE FOOTAGE REQUIREMENTS FOR SLEEPING ROOMS. Sleeping rooms must have 60 square feet per individual with beds located at least three feet apart.

(8) FLASHLIGHTS. Operative flashlights, at least one per floor, must be readily available to staff in case of emergency.

(9) FIRST-AID KIT AND MANUAL. First-aid kits and first-aid manuals must be available to staff within each residence in a designated location. First aid kits must be locked if, after evaluating any associated risk, items contained in the first aid kit present a hazard to individuals living in the house. First aid kits containing any medication including topical must be locked.

411-325-0170

Safety: Staffing Requirements

(1) General staffing requirements. Each residence must provide staff appropriate to the number of individuals served as follows:

(a) Each home or facility serving five or fewer individuals must provide at a minimum one staff on the premises when individuals are present; and

(b) Each program serving five or fewer individuals in apartments must provide at a minimum one staff on the premises of the apartment complex when individuals are present; and

(c) Each home or facility serving six or more individuals must provide a minimum of one staff on the premises for every 15 individuals during awake hours and one staff on the premises for every 15 individuals during sleeping hours, except residences licensed prior to January 1, 1990; and

(d) Each home or facility serving children, for any number of individuals, must provide at a minimum one awake night staff on the premises when individuals are present.

(2) Exceptions to minimum staffing requirements in OAR 411-325-0170(1)(a), (b) and (c) for homes or facilities serving adults. A home or facility is granted an exception to staffing requirements in OAR 411-325-0170(1)(a), (b) and (c) for adults to be home alone when the following conditions have been met:

(a) No more than two adults will be left alone in the home at any time without on staff supervision;

(b) The amount of time any adult can be left alone will not exceed five hours within a twenty-four hour period and no adult will be responsible for any other adult or child in the home or community;

(d) The adult has a documented history of being able to do the following safety measures or there is a documented ISP team decision agreeing to an equivalent alternative practice:

(A) Independently call 911 in an emergency and give relevant information after calling 911;

(B) Evacuate the premises during emergencies or fire drills without assistance in three minutes or less;

(D) Before opening door, checks who is there;

(E) Does not invite strangers to the home/facility;

(F) Answers door appropriately;

(G) Use small appliances, sharp knives, kitchen stove and microwave safely;

(H) Self-administers medications, if applicable;

(I) Safely adjusts water temperature at all faucets; and

(J) Safely takes shower/bathes without falling.

(e) There is a documented ISP team decision annually noting team agreement that the adult meets the requirements of OAR 411-325-0170(2)(d)(A)-(J).

(3) Changes in an adult's ability to remain home alone without supervision. If at any time the adult is unable to meet the requirements in OAR 411-325-0170(2)(d)(A)-(J), the provider must not leave the adult alone without supervision. In addition, the provider must notify the adult's Services Coordinator within one working day and request that the ISP team meet to address the adult's ability to be left alone without supervision.

(4) Contract requirements for staff ratios. Each residence must meet all requirements for staff ratios as specified by contract requirements.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04

411-325-0180

Safety: Individual Summary Sheets

Current one to two page summary sheet. A current one to two page summary sheet must be maintained for each individual receiving services from the program. The record must include:

(1) The individual's name, current and previous address, date of entry into the program, date of birth, sex, marital status (for individuals 18 or older), religious preference, preferred hospital, medical prime number and private insurance number where applicable, guardianship status; and

(2) The name, address and telephone number of:

(a) The individual's legal representative, family, advocate or other significant person, and for children, the child's parent or guardian, education surrogate, if applicable;

(b) The individual's preferred physician, secondary physician or clinic;

(d) The individual's identified pharmacy;

(e) The individual's school, day program, or employer, if applicable;

(f) The individual's Services Coordinator, and for Department direct contracts, Department representative; and

(g) Other agency representatives providing services to the individual.

(3) For children under the age 18, any court ordered or guardian authorized contacts or limitations must also be included on the individual summary sheet.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04

411-325-0185

Safety: Emergency Information

(1) Effective September 1, 2009, a program must maintain emergency information for each individual receiving services from the program in addition to an individual summary sheet identified in OAR 411-325-0180.

(2) The emergency information must be kept current and must include:

(a) The individual's name;

(b) The provider's name, address and telephone number;

(d) The individual's physical description, which could include a picture and the date it was taken, and identification of:

(A) The individual's race, sex, height, weight range, hair and eye color; and

(B) Any other identifying characteristics that could assist in identifying the individual should the need arise, such as marks or scars, tattoos, or body piercings.

(e) Information on the individual's abilities and characteristics including:

(A) How the individual communicates;

(B) The language the individual uses or understands;

(D) Any additional information that could assist a person not familiar with the individual to understand what the individual can do for him or herself.

(f) The individual's health support needs including:

(A) Diagnosis;

(B) Allergies or adverse drug reactions;

(D) Special dietary or nutritional needs such as requirements around the textures or consistency of foods and fluids;

(E) Food or fluid limitations, due to allergies, diagnosis or medications the individual is taking, that may be an aspiration risk or other risk for the individual;

(F) 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;

(G) Physical limitations that may affect the individual’s ability to communicate, respond to instructions or follow directions; and

(H) Specialized equipment needed for mobility, positioning or other health related needs.

(g) The individual's emotional and behavioral support needs including:

(A) Mental health or behavioral diagnosis and the behaviors displayed by the individual; and

(B) Approaches to use when dealing with 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; and

(j) Any additional pertinent information the provider has that could assist in the care and support of the individual should a natural or man-made disaster occur.

Stat. Auth. ORS 409.050, 410.070 & 443.450
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 11-2008, f. & cert. ef. 9-11-08

411-325-0190

Safety: Incident Reports and Emergency Notifications

(1) INCIDENT REPORTS. A written report that describes any incident as defined in OAR 411-325-0020 involving an individual must be placed in the individual's record. Such description must include:

(a) Conditions prior to or leading to the incident;

(b) A description of the incident;

(d) Administrative review to include the follow-up to be taken to prevent a recurrence of the incident.

(2) SENT TO GUARDIAN AND SERVICES COORDINATOR. Copies of all unusual incident reports must be sent to the individual's services coordinator within five working days of the incident. Upon request of the guardian, copies of unusual incident reports shall be sent to the guardian within five working days of the incident. Such copies must have any confidential information about other individuals removed or redacted as required by federal and state privacy laws. Copies of unusual incident reports may not be provided to a guardian when the report is part of an abuse or neglect investigation.

(3) NOTIFICATION OF ALLEGATIONS OF ABUSE AND ABUSE INVESTIGATIONS. The program must notify the CDDP immediately of an incident or allegation of abuse falling within the scope of OAR chapter 407, division 045.

(a) When an abuse investigation has been initiated, the Department or the Department's designee must provide notice to the program according to OAR chapter 407, division 045.

(b) When an abuse investigation has been completed, the Department or the Department's designee must provide notice of the outcome of the investigation according to OAR chapter 407, division 045.

(c) When a program receives notification of a substantiated allegation of abuse of an adult as defined in OAR 407-045-0260, the program must provide written notification immediately to:

(A) The person found to have committed abuse;

(B) Residents of the program;

(D) Residents’ guardians.

(d) The program’s written notification must include:

(A) The type of abuse as defined in OAR 407-045-0260;

(B) When the allegation was substantiated; and

(e) The program must have policies and procedures to describe how the program implements notification of substantiated abuse as listed in sections (3)(c) and (d) of this rule.

(4) IMMEDIATE NOTIFICATION FOR SERIOUS ILLNESS, INJURY, OR DEATH. In the case of a serious illness, injury, or death of an individual, the program must immediately notify:

(a) The individual's guardian or conservator, parent, next of kin, or other significant person;

(b) The CDDP; and

(5) EMERGENCY NOTIFICATION. In the case of an individual who is away from the residence, without support beyond the time frames established by the ISP team, the program must immediately notify:

(a) The individual's guardian, if any, or nearest responsible relative;

(b) The individual's designated contact person;

(d) The CDDP.

Stat. Auth.: ORS 410.070 & 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04; SPD 25-2009(Temp), f. 12-31-09, cert. ef. 1-1-10 thru 6-30-10; SPD 5-2010, f. 6-29-10, cert. ef. 7-1-10

411-325-0200

Safety: Transportation

(1) Vehicles operated to transport individuals. Providers, including employees and volunteers who own or operate vehicles that transport individuals, must:

(a) Maintain the vehicles in safe operating condition;

(b) Comply with Department of Motor Vehicles laws;

(d) Carry in vehicles a first aid kit.

(2) Seat belts and appropriate safety devices. When transporting, the driver must ensure that all individuals use seat belts. Individual car or booster seats will be used for transporting all children as required by law. When transporting individuals in wheel chairs, the driver must ensure that wheel chairs are secured with tie downs and that individuals wear seat belts.

(3) Drivers. Drivers operating vehicles that transport individuals must meet applicable Department of Motor Vehicles requirements as evidenced by a driver's license.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04

411-325-0220

Individual Furnishings

(1) Bedroom furniture. Bedroom furniture must be provided or arranged for each individual and include:

(a) A bed, including a frame unless otherwise documented by an ISP team decision, a clean comfortable mattress, a waterproof mattress cover, if the individual is incontinent, and a pillow;

(b) A private dresser or similar storage area for personal

belongings which is readily accessible to the individual; and

(2) Linens. Two sets of linens must be provided, or arranged for each individual and include:

(a) Sheets and pillowcases;

(b) Blankets, appropriate in number and type for the season and the individual's comfort; and

(3) Personal hygiene items. Each person must be assisted in obtaining personal hygiene items in accordance with individual needs and items must be stored in a sanitary and safe manner.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04

411-325-0230

Emergency Plan and Safety Review

(1) EFFECTIVE DATE. This rule shall become effective on September 1, 2009.

(2) EMERGENCY PLANNING.

(a) Providers must post the following emergency telephone numbers in close proximity to all phones used by staff.

(A) The telephone numbers of the local fire, police department, and ambulance service, if not served by a 911 emergency services; and

(B) The telephone number of the program's executive director, emergency physician and additional persons to be contacted in the case of an emergency.

(b) If an individual regularly accesses the community independently, the provider must provide the individual information about appropriate steps to take in an emergency, such as emergency contact telephone numbers, contacting police or fire personnel, or other strategies to obtain assistance.

(3) WRITTEN EMERGENCY PLAN. Providers must develop, maintain, update and implement a written emergency plan for the protection of all individuals in the event of an emergency or disaster.

(a) The emergency plan must:

(A) Be practiced at least annually. The emergency plan practice may consist of a walk-through of the duties or a discussion exercise dealing with a hypothetical event, commonly known as a tabletop exercise.

(B) Consider the needs of the individuals being served and address all natural and human-caused events identified as a significant risk for the home such as a pandemic or an earthquake.

(C) Include provisions and sufficient supplies, such as sanitation supplies, to shelter in place, when unable to relocate, for a minimum of three days under the following conditions:

(i) Extended utility outage;

(ii) No running water;

(iii) Inability to replace food or supplies; and

(iv) Staff unable to report as scheduled.

(D) Include provisions for evacuation and relocation that identifies:

(i) The duties of staff during evacuation, transporting, and housing of individuals including instructions to staff to notify the Seniors and People with Disabilities Division, local office, or designee of the plan to evacuate or the evacuation of the home as soon as the emergency or disaster reasonably allows;

(ii) The method and source of transportation;

(iii) Planned relocation sites that are reasonably anticipated to meet the needs of the individuals in the home;

(iv) A method that provides persons unknown to the individual the ability to identify each individual by the individual's name and to identify the name of the individual's supporting provider; and

(v) A method for tracking and reporting to the Seniors and People with Disabilities Division, local office, or designee, the physical location of each individual until a different entity resumes responsibility for the individual,

(E) Address the needs of the individuals, including provisions to provide:

(i) Immediate and continued access to medical treatment with the evacuation of the individual summary sheet identified in OAR 411-325-0180 and the individual's emergency information identified in OAR 411-325-0185 and other information necessary to obtain care, treatment, food, and fluids for individuals.

(ii) Continued access to life-sustaining pharmaceuticals, medical supplies and equipment during and after an evacuation and relocation;

(iii) Behavior support needs anticipated during an emergency; and

(iv) Adequate staffing to meet the life-sustaining and safety needs of the individuals.

(b) Providers must instruct and provide training to all staff about the staffs' duties and responsibilities for implementing the emergency plan.

(c) The provider must re-evaluate and revise the emergency plan at least annually or when there is a significant change in the home.

(d) The emergency plan summary, on the form supplied by the Seniors and People with Disabilities Division, must be sent to the Seniors and People with Disabilities Division annually and upon change of ownership.

(e) Applicable parts of the emergency plan must coordinate with each applicable employment and alternative-to-employment provider to address the possibility of an emergency or disaster during work hours.

(4) QUARTERLY SAFETY REVIEW. A documented safety review must be conducted quarterly to ensure that each residence is free of hazards. The provider must keep the quarterly safety review reports for three years and must make them available upon request by the CDDP or the Seniors and People with Disabilities Division.

Stat. Auth. ORS 409.050, 410.070 & 443.450
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 11-2008, f. & cert. ef. 9-11-08

411-325-0240

Safety: Assessment of Fire Evacuation Assistance Required

(1) Assessment of level of evacuation assistance required. The program must assess within 24 hours of entry to the residence the individual's ability to evacuate the residence in response to an alarm or simulated emergency.

(2) Documentation of level of assistance required. The program must document the level of assistance needed by each individual to safely evacuate the residence and such documentation must be maintained in the individual's entry records.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04

411-325-0250

Safety: Fire Drill Requirements and Fire Safety

(1) General fire drill requirements. The program must conduct unannounced evacuation drills when individuals are present, one per quarter each year with at least one drill per year occurring during the hours of sleep. Drills must occur at different times of the day, evening and night shifts with exit routes being varied based on the location of a simulated fire.

(2) Written fire drill documentation required. Written documentation must be made at the time of the fire drill and kept by the program for at least two years following the drill. Fire drill documentation must include:

(a) The date and time of the drill or simulated drill;

(b) The location of the simulated fire and exit route;

(d) The type of evacuation assistance provided by staff to individuals' as specified in each individual's safety plan;

(e) The amount of time required by each individual to evacuate or staff simulating the evacuation; and

(f) The signature of the staff conducting the drill.

(3) Smoke alarms or detectors and protection equipment. Smoke alarms or detectors and protection equipment must be inspected and documentation of inspections maintained as recommended by the local fire authority or State Fire Marshal.

(4) Adaptations required for sensory or physically impaired. The program must provide necessary adaptations to ensure fire safety for sensory and physically impaired individuals.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04

411-325-0260

Safety: Individual Fire Evacuation Safety Plans

(1) Written fire safety evacuation plan for five or fewer individuals residing in homes, duplexes, or apartments who are unable to evacuate residence in three minutes or less, or who request not to participate in fire drills. For individuals who are unable to evacuate the residence within the required evacuation time, or who, with concurrence of the ISP team, request not to participate in fire drills, the program must develop a written fire safety and evacuation plan that includes the following:

(a) Documentation of the risk to the individual's medical, physical condition and behavioral status;

(b) Identification of how the individual will evacuate his/her residence including level of support needed;

(d) Identification of assistive devices required for evacuation;

(e) The frequency the plan will be practiced and reviewed by the individual and staff;

(f) The alternative practices;

(g) Approval of the plan by the individual's guardian, case manager and the program director; and

(h) A plan to encourage future participation.

(2) Required documentation of practice and review of fire safety and evacuation plans. The program must maintain documentation of the practice and review of the safety plan by the individual and the staff.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04

411-325-0270

Specific Standards: Safety- Fire Safety Requirements for Homes(s) on a Single Property or on Contiguous Property Serving Six or More Individuals

(1) State of Oregon Building Codes and Fire Code. The home must provide safety equipment appropriate to the number and level of individuals served and meet the requirements of the State of Oregon Structural Specialty and the Fire Code as adopted by the State:

(a) Each residence housing six or more, but fewer than 11 individuals, or each residence that houses five or fewer individuals, but is licensed as single facility due to the total number of individuals served per the license or meets the contiguous property provision, must meet the requirements of a SR 3.3 occupancy and must:

(A) Provide and maintain permanent wired smoke alarms from a commercial source with battery back-up in each bedroom and at a point centrally located in the corridor or area giving access to each separate sleeping area and on each floor;

(B) Provide and maintain a 13D residential sprinkler system as defined in the most recent edition of the National Fire Protection Association standard; and

(C) Have simple hardware for all exit doors and interior doors that cannot be locked against exit that has an obvious method of operation. Hasps, sliding bolts, hooks and eyes, double key deadbolts, and childproof doorknobs are not permitted. Any other deadbolts must be single action release so as to allow the door to open in a single operation.

(b) Each residence housing 11 or more but fewer than 17 individuals must meet the requirements of a SR-3.2 occupancy.

(2) Licensed capacity plus respite bed for homes on a single property or on a contiguous property serving six or more individuals. At no time will the number of individuals served exceed the licensed capacity, except that one additional individual may receive respite care services not to exceed two weeks. Respite supports must not violate the safety and health sections of this rule.

(3) No admittance of person unable to appropriately respond. The program must not admit individuals functioning below the level indicated on the license for the residence.

Stat. Auth. ORS 409.050, 410.070 & 443.450
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04; SPD 11-2008, f. & cert. ef. 9-11-08

411-325-0280

Specific Standards: Safety-Fire Safety Requirements for Homes or Duplexes Serving Five or Fewer Individuals

(1) Fire safety requirements. The home or duplex must be made fire safe.

(a) A second means of egress must be provided.

(b) A class 2A10BC fire extinguisher easily accessible on each floor in the home or duplex must be provided.

(c) Permanent wired smoke alarms from a commercial source with battery back up in each bedroom and at a point centrally located in the corridor or area giving access to each separate sleeping area and on each floor must be provided and maintained.

(d) A 13D residential sprinkler system in accordance with the most recent edition of the National Fire Protection Association Code must be provided and maintained. Homes or duplexes rated as "Prompt" facilities per Chapter 3 of the 2000 edition NFPA 101 Life Safety Code are granted an exception from the residential sprinkler system requirement.

(e) Hardware for all exit doors and interior doors must be simple hardware that cannot be locked against exit and must have an obvious method of operation. Hasp, sliding bolts, hooks and eyes, double key deadbolts, and childproof doorknobs are not permitted. Any other deadbolts must be single action release so as to allow the door to open in a single operation.

(2) Exception for permanent wired smoke alarms and 13D residential sprinkler systems. A home or duplex is granted an exception to requirements in OAR 411-325-0280(1)(c) and (d) under the following circumstances:

(a) All individuals residing in the home or duplex have demonstrated the ability to respond to an emergency alarm with or without physical assistance from staff, to the exterior and away from the home, in three minutes or less, as evidenced by three or more consecutive documented fire drills;

(b) Battery operated smoke alarms with a 10 year battery life and hush feature have been installed in accordance with the manufacturer's listing, in each bedroom, adjacent hallways, common living areas, basements, and in two-story homes, at the top of each stairway. Ceiling placement of smoke alarms is recommended. If wall mounted, smoke alarms must be between 6" and 12" from the ceiling and not within 12" of a corner. Alarms must be equipped with a device that warns of low battery condition when battery operated. All smoke alarms are to be maintained in functional condition; and

(c) A written fire safety evacuation plan is implemented that assures that staff assist all individuals in evacuating the premises safely during an emergency or fire as documented by fire drill records.

(3) Respite care. At no time will the number of individuals served at the residence exceed the maximum capacity of five including respite services. An individual may receive respite services not to exceed two weeks. Respite services must not violate the safety and health sections of this rule.

Stat. Auth.: ORS 410.070 & 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 11-2008, f. & cert. ef. 9-11-08

411-325-0290

Specific Standards: Safety-Fire Safety Requirements for Apartments Serving Five or Fewer Individuals

(1) Fire safety requirements. The apartment must be made fire safe by:

(a) Providing and maintaining in each apartment battery-operated smoke alarms with a 10-year life in each bedroom and in a central location on each floor;

(b) Providing first floor occupancy apartments. Individuals who can exit in three minutes or less without assistance may be granted a variance from the first floor occupancy requirement;

(d) Providing access to telephone equipment or intercom in each apartment, usable by the individual served; and

(e) Providing constantly usable unblocked exits from the apartment and apartment building.

(2) Respite care. At no time will the number of individuals served at the residence exceed the maximum capacity of five including respite services. An individual may receive respite services not to exceed two weeks. Respite services must not violate the safety and health sections of this rule.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04

411-325-0300

Rights: General

(1) Abuse prohibited for adults and children. Adults as defined at 411-325-0020 must not be abused nor will abuse be tolerated by any employee, staff or volunteer of the program. Children as defined at 411-325-0020 or as defined in these rules must not be abused nor will abuse be tolerated by any employee, staff or volunteer of the program.

(2) Protection and wellbeing. The program must ensure the health and safety of individuals from abuse including the protection of individual rights, as well as, encourage and assist individuals through the ISP process to understand and exercise these rights. Except for children under the age of 18, where reasonable limitations have been placed by a parent or guardian, these rights must at a minimum provide for:

(a) Assurance that each individual has the same civil and human rights accorded to other citizens of the same age except when limited by a court order:

(b) Adequate food, housing, clothing, medical and health care, supportive services and training;

(c) Visits with family members, guardians, friends, advocates and others of the individual's choosing, and legal and medical professionals;

(d) Confidential communication including personal mail and telephone;

(e) Personal property and fostering of personal control and freedom regarding that property;

(f) Privacy in all matters that do not constitute a documented health and safety risk to the individual;

(g) Protection from abuse and neglect, including freedom from unauthorized training, treatment and chemical/mechanical/ physical restraints;

(h) Freedom to choose whether or not to participate in religious activity;

(i) The opportunity to vote for individuals over the age of 18 and training in the voting process;

(j) Expression of sexuality within the framework of State and Federal Laws, and for adults over the age of 18, freedom to marry and to have children;

(k) Access to community resources, including recreation, agency services, employment and community inclusion services, school, educational opportunities and health care resources;

(l) Individual choice for children and adults that allows for decision making and control of personal affairs appropriate to age;

(m) Services which promote independence, dignity and self-esteem and reflect the age and preferences of the individual child or adult;

(n) Individual choice for adults to consent to or refuse treatment, unless incapable, and then an alternative decision maker is allowed to consent or refuse. For children consent to or refusal of treatment by the child's parent or guardian except as defined in statute (ORS 109.610) or limited by court order;

(o) Individual choice to participate in community activities;

(p) Access to a free and appropriate education for children and individuals under the age of 21 including a procedure for school attendance or refusal to attend.

(3) Policies and procedures. The program must have and implement written policies and procedures that protect an individual's rights as listed in OAR 411-325-0300(2)(a - p).

(4) Notification of policies and procedures. The program must inform each individual and parent or guardian orally and in writing of their rights and a description of how to exercise those rights. This must be completed at entry to the program and in a timely manner, thereafter, as changes occur. Information must be presented using language, format, and methods of communication appropriate to the individual's needs and abilities.

Stat. Auth. ORS 409.050, 443.450 & 443.455
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04

411-325-0320

Rights: Informal Complaints and Formal Grievances

(1) The service provider must implement written policies and procedures for individuals' grievances as required by OAR 411-323-0060.

(2) The service provider must send copies of the documentation on all grievances to the services coordinator within 15 working days of initial receipt of the grievance.

(3) At entry to service and as changes occur, the service provider must inform each individual and parent, guardian, or advocate orally and in writing of the service provider's grievance policy and procedures and a description of how to utilize them.

Stat. Auth.: ORS 409.050, 410.070, 443.450 & 443.455
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04; SPD 19-2011(Temp), f. & cert. ef. 7-1-11 thru 12-28-11; SPD 1-2012, f. & cert. ef. 1-6-12

411-325-0330

Rights: Medicaid Fair Hearings

Medicaid service recipients policy and procedure. The program must have a policy and procedure that provides for immediate referral to the CDDP when a Medicaid recipient, parent or guardian requests a fair hearing. The policy and procedure must include immediate notice to the individual, parent or guardian of the right to a Medicaid fair hearing each time a program takes action to deny, terminate, suspend or reduce an individual's access to services covered under Medicaid.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04

411-325-0340

Rights: Behavior Support

(1) Written policy required. The program must have and implement a written policy for behavior support that utilizes individualized positive behavior support techniques and prohibits abusive practices.

(2) Development of an individualized plan to alter a person's behavior. A decision to develop a plan to alter a person's behavior must be made by the ISP team. Documentation of the ISP team decision must be maintained by the program.

(3) Functional behavioral assessment required. The program must conduct a functional behavioral assessment of the behavior, which must be based upon information provided by one or more persons who know the individual. The functional behavioral assessment must include:

(a) A clear, measurable description of the behavior which includes (as applicable) frequency, duration and intensity of the behavior;

(b) A clear description and justification of the need to alter the behavior;

(c) An assessment of the meaning of the behavior, which includes the possibility that the behavior is one or more of the following:

(A) An effort to communicate;

(B) The result of medical conditions;

(D) The result of environmental causes or other factors.

(d) A description of the context in which the behavior occurs; and

(e) A description of what currently maintains the behavior.

(4) Behavior support plan requirements. The behavior support plan must include:

(a) An individualized summary of the person's needs, preferences and relationships;

(b) A summary of the function(s) of the behavior, (as derived from the functional behavioral assessment);

(c) Strategies that are related to the function(s) of the behavior and are expected to be effective in reducing problem behaviors;

(d) Prevention strategies including environmental modifications and arrangement(s);

(e) Early warning signals or predictors that may indicate a potential behavioral episode and a clearly defined plan of response;

(f) A general crisis response plan that is consistent with the Oregon Intervention System (OIS);

(g) A plan to address post crisis issues;

(h) A procedure for evaluating the effectiveness of the plan which includes a method of collecting and reviewing data on frequency, duration and intensity of the behavior;

(i) Specific instructions for staff who provide support to follow regarding the implementation of the plan; and

(j) Positive behavior supports that includes the least intrusive intervention possible.

(5) Additional documentation requirements for implementation of behavioral support plans. Providers must maintain the following additional documentation for implementation of behavioral support plans:

(a) Written evidence that the individual, parent(s) (if applicable), guardian or legal representative (if applicable) and the ISP team are aware of the development of the plan and any objections or concerns have been documented;

(b) Written evidence of the ISP team decision for approval of the implementation of the behavior support plan; and

(6) Notification of policies and procedures. The program must inform each individual and the parent(s), guardian, legal representative of the behavior support policy and procedures at the time of entry to the program and as changes occur.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04

411-325-0350

Rights: Physical Intervention

(1) Circumstances allowing the use of physical intervention. The program must only employ physical intervention techniques that are included in the current approved OIS curriculum or as approved by the OIS Steering Committee. Physical intervention techniques must only be applied:

(a) When the health and safety of the individual and others are at risk, and the ISP team has authorized the procedures in a documented ISP team decision that is included in the ISP and uses procedures that are intended to lead to less restrictive intervention strategies; or

(b) As an emergency measure, if absolutely necessary to protect the individual or others from immediate injury; or

(c) As a health related protection ordered by a physician, if absolutely necessary during the conduct of a specific medical or surgical procedure, or for the individual's protection during the time that a medical condition exists.

(2) Staff training. Staff supporting an individual must be trained by an instructor certified in the Oregon Intervention System (OIS) when the individual has a history of behavior requiring physical intervention and the ISP team has determined there is probable cause for future application of physical intervention. Documentation verifying such training must be maintained in the staff's personnel file.

(3) Modification of OIS physical intervention procedures. The program must obtain the approval of the OIS Steering Committee for any modification of standard OIS physical intervention technique(s). The request for modification of physical intervention technique(s) must be submitted to the OIS Steering Committee and must be approved in writing by the OIS Steering Committee prior to the implementation of the modification. Documentation of the approval must be maintained in the individual's record.

(4) Physical intervention techniques in emergency situations. Use of physical intervention techniques that are not part of an approved plan of behavior support in emergency situations must:

(a) Be reviewed by the program's executive director or designee within one hour of application;

(b) Be used only until the individual is no longer an immediate threat to self or others;

(c) Submit an incident report to the CDDP Services Coordinator, or other Department designee (if applicable), personal agent (if applicable), and the person's legal guardian (if applicable), no later than one working day after the incident has occurred; and

(d) Prompt an ISP team meeting if an emergency intervention is used more than three times in a six-month period.

(5) Incident report. Any use of physical intervention(s) must be documented in an incident report excluding circumstances defined in OAR 411-325-0350(7)(a-h). The report must include:

(a) The name of the individual to whom the physical intervention was applied;

(b) The date, type, and length of time the physical intervention was applied;

(d) Documentation of any injury;

(e) The name and position of the staff member(s) applying the physical intervention;

(f) The name(s) and position(s) of the staff witnessing the physical intervention;

(g) The name and position of the person providing the initial review of the use of the physical intervention; and

(h) Documentation of an administrative review that includes the follow-up to be taken to prevent a recurrence of the incident by the director or his/her designee who is knowledgeable in OIS, as evident by a job description that reflects this responsibility.

(6) Copies submitted. A copy of the incident report must be forwarded within five working days of the incident, to the CDDP Services Coordinator and when applicable to the legal guardian and the personal agent.

(a) The Services Coordinator or when applicable the Department designee will receive complete copies of incident reports.

(b) Copies of incident reports will not be provided to a legal guardian, personal agent or other service providers, when the report is part of an abuse or neglect investigation.

(c) Copies provided to a legal guardian, personal agent, or other service provider must have confidential information about other individuals removed or redacted as required by federal and state privacy laws.

(d) All interventions resulting in injuries must be documented in an incident report and forwarded to the CDDP Services Coordinator or other Department designee (if applicable) within one working day of the incident.

(7) Behavior data summary. The program may substitute a behavior data summary in lieu of individual incident reports when:

(a) There is no injury to the individual or others;

(b) The intervention utilized is not a physical restraint;

(d) The individual's behavior support plan defines and documents the parameters of the baseline level of behavior;

(e) The physical intervention technique(s), and the behavior(s) for which they are applied remain within the parameters outlined in the individual's behavior support plan and the OIS curriculum;

(f) The behavior data collection system for recording observation, intervention and other support information critical to the analysis of the efficacy of the behavior support plan, is also designed to record items as required in support in OAR 411-325-0350(5)(a)-(c) and (e)-(h); and

(g) There is written documentation of an ISP team decision that a behavior data summary had been authorized for substitution in lieu of incident reports.

(8) Copy to CDDP. A copy of the behavior data summary must be forwarded every thirty days to the CDDP Services Coordinator or other Department designee (if applicable), or personal agent (if applicable) and the person's legal guardian (if applicable).

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04

411-325-0360

Rights: Psychotropic Medications and Medications for Behavior

(1) Requirements. Psychotropic medications and medications for behavior must be:

(a) Prescribed by physician or health care provider through a written order; and

(b) Monitored by the prescribing physician, ISP team and program for desired responses and adverse consequences.

(2) Balancing test. When medication is first prescribed and annually thereafter, the provider must obtain a signed balancing test from the prescribing health care provider using the DHS Balancing Test Form or by inserting the required form content into the provider's agency forms. Providers must present the physician or health care provider with a full and clear description of the behavior and symptoms to be addressed, as well as any side effects observed.

(3) Documentation requirements. The provider must keep signed copies of these forms in the individual's medical record for seven years.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04

411-325-0370

Rights: Individuals' Personal Property

(1) Record of personal property. The program must prepare and maintain an accurate individual written record of personal property that has significant or monetary value to each individual as determined by a documented ISP team or guardian decision. The record must include:

(a) The description and identifying number, if any;

(b) Date of inclusion in the record;

(d) Signature of staff making each entry; and

(e) A signed and dated annual review of the record for accuracy.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04

411-325-0380

Rights: Handling and Managing Individuals' Money

(1) Policies and procedures. The program must have and implement written policies and procedures for the handling and management of individuals' money. Such policies and procedures must provide for:

(a) The individual to manage his/her own funds unless the ISP documents and justifies limitations to self-management;

(b) Safeguarding of an individual's funds;

(d) Taking into account the individual's interests and preferences.

(2) Individual written record. For those individuals not yet capable of managing their own money, as determined by the ISP Risk Tracking Record or guardian, the program must prepare and maintain an accurate written record for each individual of all money received or disbursed on behalf of or by the individual. The record must include:

(a) The date, amount and source of income received;

(b) The date, amount and purpose of funds disbursed; and

(3) Reimbursement to individual. The program must reimburse the individual any funds that are missing due to theft, or mismanagement on the part of any staff member of the program or for any funds within the custody of the program that are missing. Such reimbursement must be made within 10 working days of the verification that funds are missing.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04

411-325-0390

Entry, Exit and Transfer: General

(1) Qualifications for Department funding. All individuals considered for Department funded services must:

(a) Be referred by the Community Developmental Disability Program;

(b) Be determined to have a developmental disability by the Department or its designee; and

(c) Not be discriminated against because of race, color, creed, age, disability, national origin, duration of Oregon residence, method of payment, or other forms of discrimination under applicable state or federal law.

(2) Authorization of entry into 24-Hour Residential Programs. The CDDP Services Coordinator, except in the cases of children's residential services and state operated community programs, must make authorization of entry into 24-Hour residential program. The Department must authorize admission into children's residential services and state operated community programs.

(3) Information required for entry meeting. The program must acquire the following information prior to or upon an entry ISP team meeting:

(a) A copy of the individual's eligibility determination document;

(b) A statement indicating the individual's safety skills including ability to evacuate from a building when warned by a signal device, and adjusting water temperature for bathing and washing;

(d) A medical history and information on health care supports that includes, where available:

(A) The results of a physical exam made within 90 days prior to entry;

(B) Results of any dental evaluation;

(D) A record of known communicable diseases and allergies; and

(E) A record of major illnesses and hospitalizations.

(e) A written record of any current or recommended medications, treatments, diets and aids to physical functioning;

(f) Copies of documents relating to guardianship or conservatorship or health care representative or any other legal restrictions on the rights of the individual, if applicable;

(g) Written documentation that the individual is participating in out of residence activities including school enrollment for individuals under the age of 21; and

(h) A copy of the most recent Functional Behavioral Assessment, Behavior Support Plan, Individual Support Plan, and Individual Education Plan if applicable.

(4) Crisis entries from family homes. If the individual is being admitted from his or her family home and the information required in OAR 411-325-0390(3)(a)-(h) is not available, the program will ensure that they assess the individual upon entry for issues of immediate health or safety and document a plan to secure the remaining information no later than thirty days after entry. This must include a written justification as to why the information is not available.

(5) Entry meeting. An entry ISP team meeting must be conducted prior to the onset of services to the individual. The findings of the meeting must be recorded in the individual's file and include, at a minimum:

(a) The name of the individual proposed for services;

(b) The date of the meeting and the date determined to be the date of entry;

(d) Documentation of the pre-entry information required by OAR 411-325-0390(3)(a)-(h);

(e) Documentation of the decision to serve or not serve the individual requesting service, with reasons; and

(f) A written transition plan to include all medical, behavior and safety supports needed by the individual, to be provided to the individual for no longer than 60 days, if the decision was made to serve.

(6) Exit meeting. Each individual considered for exit must have a meeting by the ISP team before any decision to exit is made. Findings of such a meeting must be recorded in the individual's file and include, at a minimum:

(a) The name of the individual considered for exit;

(b) The date of the meeting;

(d) Documentation of the circumstances leading to the proposed exit;

(e) Documentation of the discussion of strategies to prevent an exit from service (unless the individual, individual's guardian, or for a child the parent or guardian is requesting exit);

(f) Documentation of the decision regarding exit including verification of a majority agreement of the meeting participants regarding the decision; and

(g) Documentation of the proposed plan for services to the individual after the exit.

(7) Requirements for waiver of exit meeting. Requirements for an exit meeting may be waived if an individual is immediately removed from the home under the following conditions:

(a) The individual and his/her guardian or legal representative requests an immediate move from the home; or

(b) The individual is removed by a legal authority acting pursuant to civil or criminal proceedings other than detention for a child.

(8) Transfer meeting. A meeting of the ISP Team to discuss any proposed transfer of an individual must precede the decision to transfer. Findings of such a meeting must be recorded in the individual's file and include, at a minimum:

(a) The name of the individual considered for transfer;

(b) The date of the meeting or telephone call(s);

(c) Documentation of the participants included in the meeting or telephone call(s) including for a child, a parent or guardian who is participating to sign documents;

(d) Documentation of the circumstances leading to the proposed transfer;

(e) Documentation of the alternatives considered instead of transfer;

(f) Documentation of the reasons any preferences of the individual, guardian, legal representative, parent or family members cannot be honored;

(g) Documentation of a majority agreement of the participants with the decision; and

(h) The written plan for services to the individual after transfer.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04

411-325-0400

Grievance of Entry, Exit and Transfer

(1) Grievances. In cases where the individual, parent or guardian objects to, or the ISP team cannot reach majority agreement regarding an entry refusal, a request to exit the program or a transfer within a program, a grievance may be filed by any member of the ISP team.

(a) In the case of a refusal to serve, the program vacancy may not be permanently filled until the grievance is resolved.

(b) In the case of a request to exit or transfer, the individual must continue to receive the same services until the grievance is resolved.

(2) Grievance to the CDDP. All grievances must be made to the CDDP Director or designee in writing, in accordance with the CDDP's dispute resolution policy. The CDDP will provide written response to the individual making the appeal within the timelines specified in the CDDP's dispute resolution policy.

(3) Grievance to the Department. In cases where the CDDP's decision is in dispute a written grievance must be made to the Department within ten days of receipt of the CDDP's decision.

(4) Department Grievance process. The Administrator or designee will review all unresolved appeals. Such review will be completed and a written response provided within 45 days of receipt of written request for Department review. The decision of the Administrator or designee will be final.

(5) Documentation required. Documentation of each grievance and its resolution must be filed or noted in the individual's record.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04

411-325-0410

Respite Care Services

(1) Qualifications for respite care services. All individuals considered for respite care services funded through 24-hour residential services must:

(a) Be referred by the Community Developmental Disability Program or Department;

(b) Be determined to have a developmental disability by the Department or its designee; and

(2) Respite care plan. The individual, provider, and the guardian, legal representative, advocate, parent and family or other ISP team members (as available) must participate in an entry meeting prior to the initiation of respite care services. This meeting may occur by phone and the CDDP or Department will ensure that any critical information relevant to the individual's health and safety, including physicians' orders, will be made immediately available. The outcome of this meeting will be a written respite care plan that must take effect upon entry and be available on site, and must:

(a) Address the individual's health, safety and behavioral support needs;

(b) Indicate who is responsible for providing the supports described in the plan; and

(3) Waiver of exit meeting requirement. Exit meetings are waived for individuals receiving respite care services.

(4) Waiver of appeal rights for entry, exit and transfer. Individuals receiving respite care services do not have appeal rights regarding entry, exit or transfer.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04

411-325-0420

Crisis Services

(1) Qualifications for crisis services. All individuals considered for crisis services funded through 24-hour residential services must:

(a) Be referred by the Community Developmental Disability Program or Department;

(b) Be determined to have a developmental disability by the Department or its designee;

(d) Not be discriminated against because of race, color, creed, age, disability, national origin, duration of Oregon residence, method of payment, or other forms of discrimination under applicable state or federal law.

(2) Support Services Plan of Care and Crisis Addendum required. Persons receiving support services under chapter 411 division 340, and receiving crisis services must have a Support Services Plan of Care and a Crisis Addendum upon entry to the program.

(3) Plan of Care required for persons not enrolled in support services. Persons, not enrolled in support services, receiving crisis services for less than 90 consecutive days must have a plan of care on entry that addresses any critical information relevant to the individual's health and safety including current physicians' orders.

(4) Risk Tracking Record required. Persons not enrolled in support services, receiving crisis services for 90 days or more must have a completed Risk Tracking Record and a Plan of Care that addresses all identified health and safety supports as noted in the Risk Tracking Record.

(5) Entry meeting required. Entry meetings are required for individuals receiving crisis services.

(6) Exit meeting required. Exit meetings are required for individuals receiving crisis services.

(7) Waiver of appeal rights for entry, exit and transfers. Individuals receiving crisis services do not have appeal rights regarding entry, exit or transfers.

Stat. Auth. ORS 409.050, 443.450 & 443.455
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04

411-325-0430

Individual Support Plan

(1) A copy of each individual's ISP and supporting documentation on the required Department forms must be available at the residence within 60 days of entry and annually thereafter.

(2) The following information must be collected and summarized prior to the ISP meeting:

(a) Personal Focus Worksheet;

(b) Risk Tracking Record;

(c) Necessary protocols or plans that address health, behavioral, safety, and financial supports as identified on the Risk Tracking Record;

(d) A Nursing Care Plan, if applicable, including but not limited to those tasks required by the Risk Tracking Record; and

(e) Other documents required by the ISP team.

(3) A completed ISP must be documented on the Department required form and include the following:

(a) What's most important to the individual;

(b) Risk summary;

(d) Action plan;

(e) Discussion record;

(f) Service supports; and

(g) Signature sheet.

(4) The provider must maintain documentation of implementation of each support and services specified in OAR 411-325-0430(2)(c) to (2)(e) of this rule in the individual's ISP. This documentation must be kept current and be available for review by the individual, guardian, CDDP, and Department representatives.

411-325-0440

Children's Direct Contracted Services

For purposes of this rule chapter 411 division 325, any documentation or information required to be submitted to the CDDP Services Coordinator must also be submitted to the Department Residential Services Coordinator assigned to the home or facility.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04

411-325-0460

Civil Penalties

(1) For purposes of imposing civil penalties, 24-hour residential homes and facilities licensed under ORS 443.400 to 443.455 and 443.991(2) are considered to be long-term care facilities subject to 441.705 to 441.745.

(2) The Department issues the following schedule of penalties applicable to 24-hour residential homes and facilities as provided for under ORS 441.705 to 441.745:

(a) Violations of any requirement within any part of the following rules may result in a civil penalty up to $500 per day for each violation not to exceed $6,000 for all violations for any licensed 24-hour residential home or facility within a 90-day period:

(A) 411-325-0025(3), (4), (5), (6), and (7);

(B) 411-325-0120(2), and (11);

(D) 411-325-0140;

(E) 411-325-0150;

(F) 411-325-0170;

(G) 411-325-0190;

(H) 411-325-0200;

(I) 411-325-0220(1), and (2);

(J) 411-325-0230;

(K) 411-325-0240, 0250, 0260, 0270, 0280, and 0290;

(L) 411-325-0300, 0320, 0330, 0340, and 0350;

(M) 411-325-0360;

(N) 411-325-0380;

(O) 411-325-0430(3) and (4); and

(P) 411-325-0440.

(b) Civil penalties of up to $300 per day per violation may be imposed for violations of any section of these rules not listed in OAR 411-325-0460(2)(a)(A) to (2)(a)(N) of this section if a violation has been cited on two consecutive inspections or surveys of a 24-hour residential home or facility where such surveys are conducted by an employee of the Department. Penalties assessed under this section of this rule, OAR 411-325-0460(2), may not exceed $6,000 within a 90-day period.

(3) For the purpose of this rule, OAR 411-325-0460, monitoring occurs when a 24-hour residential home or facility is surveyed, inspected, or investigated by an employee or designee of the Department or an employee or designee of the Office of State Fire Marshal.

(4) In imposing a civil penalty pursuant to the schedule published in OAR 411-325-0460(2) of this rule, the Department shall consider the following factors:

(a) The past history of the service provider incurring a penalty in taking all feasible steps or procedures necessary or appropriate to correct any violation;

(b) Any prior violations of statutes or rules pertaining to 24-hour residential homes or facilities;

(d) The immediacy and extent to which the violation threatens or threatened the health, safety, or well-being of individuals.

(5) Any civil penalty imposed under ORS 443.455 and 441.710 shall become due and payable when the service provider incurring the penalty receives a notice in writing from the Department's Director. The notice referred to in this section of this rule, OAR 411-325-0460(5), shall be sent by registered or certified mail and shall include:

(a) A reference to the particular sections of the statute, rule, standard, or order involved;

(b) A short and plain statement of the matters asserted or charged;

(d) A statement of the service provider's right to request a hearing.

(6) The person representing the service provider, to whom the notice is addressed, shall have 20 days from the date of mailing of the notice in which to make a written application for a hearing before the Department.

(7) All hearings shall be conducted pursuant to the applicable provisions of ORS chapter 183.

(8) If the service provider notified fails to request a hearing within 20 days, an order may be entered by the Department assessing a civil penalty.

(9) If, after a hearing, the service provider is found to be in violation of a license, rule, or order listed in ORS 441.710(1), an order may be entered by the Department assessing a civil penalty.

(10) A civil penalty imposed under ORS 443.455 or 441.710 may be remitted or reduced upon such terms and conditions as the Director considers proper and consistent with individual health and safety.

(11) If the order is not appealed, the amount of the penalty is payable within 10 days after the order is entered. If the order is appealed and is sustained, the amount of the penalty is payable within 10 days after the court decision. The order, if not appealed or sustained on appeal, shall constitute a judgment and may be filed in accordance with the provisions of ORS 183.745. Execution may be issued upon the order in the same manner as execution upon a judgment of a court of record.

(12) A violation of any general order or final order pertaining to a 24-hour residential home or facility issued by the Department shall be subject to a civil penalty in the amount of not less than $5 and not more than $500 for each and every violation.

(13) Judicial review of civil penalties imposed under ORS 441.710 shall be provided under ORS 183.480, except that the court may, in its discretion, reduce the amount of the penalty.

(14) All penalties recovered under ORS 443.455 and 441.710 to 441.740 shall be paid into the State Treasury and credited to the General Fund.

Stat. Auth. ORS 409.050, 443.450 & 443.455
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04; SPD 19-2011(Temp), f. & cert. ef. 7-1-11 thru 12-28-11; SPD 1-2012, f. & cert. ef. 1-6-12; SPD 1-2012, f. & cert. ef. 1-6-12

411-325-0470

License Denial, Suspension, Revocation, Refusal to Renew

(1) Substantial failure to comply with rules. The Department will deny, suspend, revoke or refuse to renew a license where it finds there has been substantial failure to comply with these rules; or where the State Fire Marshal or his or her representative certifies there is failure to comply with all applicable ordinances and rules relating to safety from fire.

(2) Imminent danger to individuals. The Department will suspend the home or facility license where imminent danger to health or safety of individuals exists.

(3) Provider agency on list for Centers for Medicare and Medicaid Services excluded or debarred providers. The Department will deny, suspend, revoke or refuse to renew a license where it finds that a provider is on the current Centers for Medicare and Medicaid Services list of excluded or debarred providers.

(4) Revocation, suspension or denial done in accordance with ORS Chapter 183. Such revocation, suspension or denial will be done in accordance with rules of the Department and ORS Chapter 183.

(5) Failure to disclose requested information. Failure to disclose requested information on the application or provision of incomplete or incorrect information on the application will constitute grounds for denial or revocation of the license.

(6) Failure to implement a plan of correction or comply with a final order. The Department will deny, suspend, revoke or refuse to renew a license if the licensee fails to implement a plan of correction or comply with a final order of the Department imposing an administrative sanction, including the imposition of a civil penalty.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04; SPD 25-2004, f. 7-30-04, cert. ef. 8-1-04

411-325-0480

Criminal Penalties

(1) Violation of ORS 443.400 to 443.455. Violation of any provision of 443.400 to 443.455 is a Class B misdemeanor.

(2) Violation of ORS 443.881. Violation of any provision of 443.881 is a Class C misdemeanor.

Stat. Auth. ORS 410.070, 409.050
Stats. Implemented: ORS 443.400 - 443.455
Hist.: SPD 25-2003, f. 12-29-03, cert. ef. 1-1-04

The official copy of an Oregon Administrative Rule is contained in the Administrative Order filed at the Archives Division, 800 Summer St. NE, Salem, Oregon 97310. Any discrepancies with the published version are satisfied in favor of the Administrative Order. The Oregon Administrative Rules and the Oregon Bulletin are copyrighted by the Oregon Secretary of State. Terms and Conditions of Use

Oregon State Archives

DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES

DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES

DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES

DEPARTMENT OF HUMAN SERVICES,
AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES

DEPARTMENT OF HUMAN SERVICES,
AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES

DEPARTMENT OF HUMAN SERVICES,
AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES