OAR 411-051-0120. Person-Centered Service Plan

(1) A Medicaid-eligible resident's case manager shall complete a person-centered service plan, pursuant to OAR 411-004-0030. The licensee or administrator must incorporate all applicable elements identified in the person-centered service plan that the licensee or administrator is responsible for implementing. The licensee or administrator must notify the resident's case manager in the event a review and change or removal of an existing limitation is warranted, and when a new limitation is supported by a specific assessed need. (a) All attempts to notify the resident's case manager about a review to change, remove, or add a limitation must be documented, and available in the resident's record. (b) The licensee or administrator may not be held responsible for any failure on the case manager's part to conduct a review of current limitations or to complete the person-centered service plan if there have been multiple documented attempts to contact the resident’s case manager and the resident has been reasonably protected from harm. (2) Licensees or administrators may assist non-Medicaid residents in developing a person-centered service plan when no alternative resources are available.