OAR 411-328-0630. Medical Supports for Supported Living

(1) A provider must have and implement policies and procedures that maintain and protect an individual’s physical health. The policies and procedures must address all of the following: (a) Early detection and prevention of infectious disease. (b) Emergency medical intervention. (c) Treatment and documentation of illness and health care concerns. (d) Obtaining, administering, storing, and disposing of prescription and non-prescription drugs, including self-administration of medication. (e) Emergency medical procedures, including the handling of bodily fluids. (f) Confidentiality of medical records. (2) INDIVIDUAL HEALTH CARE. (a) A provider must maintain a current health care record for each individual. The record must be available to staff and include all of the following: (A) Health status as known. (B) Observed changes in health status. (C) Any remedial and corrective action required and when such actions were taken. (D) A description of any known restrictions on activities due to medical limitations. (E) Any health and medical support documents required to support an individual’s medical needs and risks. These documents must be provided to an individual’s case manager and updated at least annually or as changes occur. The supports must be developed consistent with the individual’s: (i) Functional needs assessment; (ii) ISP; (iii) Known medical orders; and (iv) Preferences. (F) Current medical information, including all of the following: (i) Primary and secondary health care providers. (ii) Other known health care or behavioral health providers. (iii) Prescribed medications, treatments, special diets, and therapies. (iv) Evidence of the most recent medical evaluation, if required by subsection (b)(C) of this section. (b) Unless otherwise directed by an ISP, a provider must ensure an individual has all of the following: (A) Current primary health care provider whom the individual has chosen from among qualified providers. (B) A secondary health care provider or clinic in the event of an emergency. (C) Evidence of a medical evaluation by a qualified health care provider no fewer than every two years or as recommended by the health care provider. (c) A provider must provide sufficient oversight and guidance to monitor an individual’s health status and physical conditions and take action in a timely manner in response to identified changes or conditions that may lead to deterioration or harm. (3) MEDICATION MANAGEMENT. (a) The support document for an individual who independently self-administers medication must include a plan for the provider’s periodic monitoring or review of the self-administration of medication. (b) If providing support with medication management when an individual is unable to self-administer medications, a provider must: (A) Have an individualized support document describing the supports with medication management to be delivered by the provider, including a record of staff trained on the support document. (B) Have a medical order or copy of the medical order, prepared by a physician or qualified health care provider, before providing any support with prescription medication. (C) Provide medication support consistent with the medical order. (D) Distribute medications from containers labeled as specified per the medical orders. (E) Store medications as prescribed. (F) Secure medications consistent with an individual’s needs and support documents. (G) Record medication administration on an individualized Medication Administration Record (MAR), including treatments and PRN, or "as needed", orders. (H) Not distribute unused, discontinued, outdated, or recalled medication. (I) Not provide support for PRN psychotropic medication, except: (i) While an individual is receiving hospice care; or (ii) When an individual self-administers the PRN medication without support or direction from the provider. (J) Follow labeling instructions and record the purpose of use for any non-prescription medications. (K) Not recommend or direct the use of any non-prescription medication. (L) Record support provided for medications consistent with an individual’s ISP and support documents. (c) When medication is administered by a provider, the provider must maintain a MAR. The MAR must include all of the following: (A) The name of the individual. (B) The brand name or generic name of the medication, including the prescribed dosage and frequency of administration as contained on the medical order and medication. (C) The time and date of the administration of medication. (D) The signature of the staff administering the medication. (E) Method of administration of medication. (F) Documentation of any known allergies or adverse reactions to a medication. (G) Documentation and an explanation of why a PRN, or "as needed", medication was administered and the results of such administration. (H) An explanation of any medication administration irregularity with documentation of a review by the provider’s executive director, or their designee. (d) Provide safeguards to prevent adverse medication reactions including, but not limited to, all of the following: (A) Maintaining information about the effects and side-effects of medications the provider has agreed to support. (B) Communicating any concerns regarding any medication usage, effectiveness, or effects, to an individual or the individual's legal or designated representative (as applicable). (C) Prohibiting the use of one individual's prescription medications by another individual or person. (4) MEDICAL SUPPORTS (a) Unless otherwise directed by an ISP, a provider must support medical treatments, health-related tasks, prosthetic devices, assistive devices, and special diets. When providing these supports, the provider must: (A) Have an individualized support document describing the supports to be delivered by the provider, including a record of staff trained on the support document. (B) Have a medical order or copy of the medical order prepared by a licensed health care provider. (C) Maintain documentation of support as required by the support document. (b) HEALTH-RELATED TASKS. Unless otherwise directed by an ISP, a provider must support all health-related tasks. If providing support for a health-related task, the provider must maintain evidence of training or delegation from a health care provider at least annually.