Service Planning Team. Contractor shall designate an administrative employee whose position description includes scheduling, facilitating, coordinating, overseeing and documenting monthly Service Planning Team meetings. Health care providers shall be invited to participate in the SPT meetings as needed. The Service Planning Team shall:
a. Review each Individual’s Service Plan and attached component plans monthly, or more frequently if the Individual’s physical or behavioral health deteriorates, with subsequent updates to the Service Plan and all attached component plans as needed;
b. Document participation and attendance in the Service Plan meetings. Virtual participation is acceptable but must be documented. Team members who are unable to attend the meeting must receive copies of the updated Service Plans;
c. Oversee communication and implementation of any changes to the Service Plan and all attached component plans to Contractor’s direct care staff in a timely manner;
d. Designate a SPT member to review the Service Plan with the Individual in a manner which encourages the Individual’s fullest participation possible in the planning process, assures the Individual’s preferences, goals and ability to self- direct are maximized and that the Individual is given opportunity to choose IADL, ADL and activities on a daily basis. The Individual’s response to this review must be documented;
e. Review changes in behavioral status and critical incidents, and modify Behavior Plans as necessary, to promote Individual safety and stability; and
f. Engage Contract Administrator and ODHS Designee within 72 hours of a change of condition which results in a Less-Than-30-Day Move-Out notice.
Service Planning Team. Contractor shall designate an administrative employee whose position description includes scheduling, facilitating, coordinating, overseeing, and documenting quarterly Service Planning Team (SPT) meetings. Health care providers shall be invited to participate in the SPT meeting as needed. The Service Planning Team shall:
a. Review each Individual’s Service Plan and attached component plans on a quarterly basis, or more frequently if the Individual’s physical or behavioral health deteriorates, with subsequent updates to the Service Plan and all attached component plans as needed.
b. Document participation and attendance in the Service Plan meetings. Virtual participation is acceptable but must be documented. Team members who are unable to attend the meeting must receive copies of the updated Service Plans.
c. Oversee communication and implementation of any changes to the Service Plan and all attached component plans to Contractor’s direct care staff in a timely manner.
d. Designate a SPT member to review the Service Plan with the Individual in a manner which encourages the Individual’s fullest participation possible in the planning process, assures the Individual’s preferences, goals and ability to self- direct are maximized and that the Individual is given opportunity to choose IADL, ADL and activities on a daily basis. The Individual’s response to this review must be documented.
e. Review changes in behavioral status and critical incidents, and modify Behavior Plans as necessary, to promote resident safety and stability.
f. Engage Contract Administrator and ODHS Designee within 72 hours of a change of condition which results in an immediate revision to the Service Plan or a Less- Than-30-Day notice.
Service Planning Team. Contractor shall designate an administrative employee, whose position description includes scheduling, facilitating, coordinating, overseeing, and documenting quarterly Service Planning Team meetings. Health care providers shall be invited to participate in the SPT meeting as needed. The Service Planning Team shall:
a. Review each Individual’s Service Plan and attached component plans on a quarterly basis, or more frequently if the Individual’s physical or behavioral health deteriorates, with subsequent updates to the Service Plan and all attached component plans as needed;
b. Document participation and attendance in the Service Plan meetings. Virtual participation is acceptable but must be documented. Team members who are unable to attend the meeting must receive copies of the updated Service Plans;
c. Oversee communication and implementation of any changes to the Service Plan and all attached component plans to Contractor’s direct care staff in a timely manner;
d. Designate a SPT member to review the Service Plan with the Individual in a manner which encourages the Individual’s fullest participation possible in the planning process, assures the Individual’s preferences, goals, and ability to self- direct are maximized, and that the Individual is given opportunity to choose IADL, ADL and activities on a daily basis. The Individual’s response to this review must be documented; and
e. Engage Contract Administrator and ODHS Designee within 72 hours of a change of condition which results in an immediate revision to the Service Plan or a Less- Than-30-Day notice.
Service Planning Team. (SPT).
a. Contractor shall ensure the Service Planning Team:
(1) Develops an initial Service plan based on the Individual’s assessment, in accordance with the facility’s licensure.
(2) Develop and oversee implementation of the Activity Plan within 15 calendar days of admission that identities activities the Individual finds meaningful and which can be provided onsite as well as in the community. The Activity Plan must be pursuant to the Service Plan and may be attached or a separate document;
(3) Develop and oversee implementation of a Nursing Service Plan within 15 calendar days of admission addressing any health conditions, delegated or non-delegated nursing tasks, medical treatments, PRN medications, and ADL needs which require caregiver teaching. The Nursing Service Plan must also identify all coordination necessary with the Individual's health providers. The Nursing Service Plan must be pursuant to the Service Plan and may be attached or a separate document;
(4) Designation of an Administrative staff who are responsible for scheduling, facilitating, coordinating, overseeing and documenting monthly Service Planning Team (SPT) meetings;
(5) DHS Designee and health care providers are invited to participate in the SPT meeting as needed. Those team members who are unable to attend the meeting must receive copies of the updated Service Plans for review;
(6) All changes to the Service Plan are documented and a system for communicating the changes to direct care staff are identified and documented;
(7) Designate a SPT member to review the Service Plan and treatment goals with the Individual in a manner that allows the Individual to maximize the services provided by the SPT. The Individual’s response to the Service Plan must be documented;
(8) Development of a Risk Management Plan and/or 1-1 staffing for up to 48 hours is attempted in cases where the person is engaged in self-harm or aggression to other persons that could result in hospitalization or ER visit; and
(9) If an Individual is being considered for eviction, a crisis plan is needed or has been activated, or the Individual has experienced an ER visit or hospitalization, the Service Plans are reviewed by the Service Planning Team at least weekly.
Service Planning Team. Contractor shall designate an administrative employee whose position description includes scheduling, facilitating, coordinating, overseeing and documenting monthly Service Planning Team meetings. Health care providers shall be invited to participate in the SPT meetings as needed. The Service Planning Team shall:
a. Review and attached component plans monthly, or subsequent updates to the Service Plan and all attached component plans as needed;
b. Document participation and attendance in the Service Plan meetings. Virtual participation is acceptable but must be documented. Team members who are unable to attend the meeting must receive copies of the updated Service Plans;
c. Oversee communication and implementation of any changes to the Service Plan manner;
d. Designate a SPT member to review the Service Plan with the Individual in a - direct are maximized and that the Individual is given opportunity to choose IADL, be documented;
e. Review changes in behavioral status and critical incidents, and modify Behavior Plans as necessary, to promote Individual safety and stability;
f. Engage Contract Administrator and ODHS Designee within 72 hours of a change of condition which results in a Less-Than-30-Day Move-Out notice; and
g. Follow Home and Community-Based Services and Setting and Person-Centered Service Planning as outlined in OAR 000-000-0000 through 411-004-0040 and from the Individual or their representative and approved by the ODHS Designee.
Service Planning Team a. Contractor shall designate an administrative employee whose position description includes scheduling, facilitating, coordinating, overseeing, and documenting monthly SPT meetings. Health care providers shall be invited to participate in the SPT meetings as needed.
