1. (1) The program must complete an assessment for each resident within 14 days after admission to the program:

   1. (a) The assessment must be based upon:

      1. (A) An interview with the resident to identify strengths, preferences, and service needs;
      2. (B) Observation of the resident's capabilities within the residential setting;
      3. (C) A review of information in the resident service record; and
      4. (D) Contact with representatives of other involved agencies, the supervisory entity or the resident’s legal representative if applicable, family members, and others, as appropriate. All contacts with others must be made with proper authorization for the release of information or as otherwise permitted by law.

   2. (b) Assessment findings must be summarized in writing and included in the resident service record. Assessment findings must include but not be limited to:

      1. (A) Diagnostic and demographic data;
      2. (B) Identification of the resident's medical, physical, emotional, behavioral, and social strengths, preferences, and needs related to independent living and community functioning; and
      3. (C) Recommendations for residential service plan goals; and
   3. (c) The provider must provide assessment findings to the person-centered service plan coordinator to assist in the development of the person-centered service plan.
2. (2) The person-centered service plan coordinator under contract with the Division and assigned to the resident or program site must schedule and conduct an assessment of the resident for the purpose of developing a person-centered service plan. The provider must support the person-centered service plan coordinator’s efforts to develop the plan and provide information as necessary.
3. (3) The provider must develop and implement an individualized residential service plan for the purpose of implementing and documenting the provision of services and supports as well as any individually-based limitations contained within the person-centered service plan. The provider must also include the limitations imposed by a court, OHA, CMHP, or PSRB order, or the resident’s legal representative, and identification of the goals to be accomplished through the services provided. The provider must complete and implement an individualized residential service plan for each resident within 30 days of admission.
4. (4) Upon receipt of the person-centered service plan, the providers must amend the residential service plan as necessary to comply with this rule;
5. (5) The residential service plan must be based upon the findings of the resident assessment, be developed with participation of the resident, input from the resident’s legal representative or supervisory entity, as applicable, and be developed through collaboration with the resident's primary mental health treatment provider. With consent of the resident, resident’s legal representative if applicable, family members, representatives from involved agencies, and others with an interest in the resident's circumstances must be invited to participate. All contact with other persons must be made with proper, prior authorization from the resident or as otherwise permitted by law;

6. (6) The residential service plan must include:

   1. (a) The necessary steps and actions of the provider for the implementation and provision of services consistent with and as required by the person-centered service plan;
   2. (b) Identification of the resident’s service needs, desired outcomes, and service strategies to address transition planning, physical and medical needs, medication regimen, self-care, social-emotional adjustment, behavioral concerns, independent living capability, community navigation, and all areas identified in the person-centered service plan.
   3. (c) Signatures of the resident or the resident’s legal representative if applicable, the program administrator or other designated program staff person, and others, as appropriate, to indicate mutual agreement with the course of services outlined in the plan.
7. (7) A copy of the signed plan must be provided to the legal representative or supervisory entity, if applicable.
8. (8) The provider must attach the residential service plan to the person-centered service plan within the resident record.
9. (9) The provider must maintain detailed progress notes within each resident's service record and document significant information relating to all aspects of the resident's functioning and progress toward desired outcomes identified in the residential service plan as described in OAR 410-120-1360, 410-172-0620 and 410-173-0045.
10. (10) The provider must enter a progress note in the resident's record at least once each month summarizing progress made relevant to the goals outlined in the residential service plan.
11. (11) The provider must review and update the assessment and residential service plan at least annually and as described in OAR chapter 410, Division 173. On an ongoing basis, the provider must update the residential service plan as necessary based upon changing circumstances or upon the resident’s request for reconsideration. The new plan must be signed by the resident or the resident’s legal representative, if applicable, the program administrator or other designated program staff person, and others, as appropriate, to indicate mutual agreement with the course of service outlined in the plan.

Statutory/Other Authority

ORS 413.042 & 443.450

Statutes/Other Implemented

ORS 413.032, 443.400 - 443.465 & 443.991

History

BHS 6-2026, amend filed 04/30/2026, effective 05/01/2026
BHS 5-2026, amend filed 04/30/2026, effective 06/01/2026
BHS 32-2025, temporary amend filed 12/30/2025, effective 01/01/2026 through 06/27/2026
BHS 4-2025, amend filed 02/28/2025, effective 03/01/2025
BHS 6-2024, amend filed 04/11/2024, effective 04/11/2024
BHS 41-2023, temporary amend filed 10/12/2023, effective 10/15/2023 through 04/11/2024
BHS 6-2020, temporary amend filed 04/21/2020, effective 04/21/2020 through 10/09/2020
BHS 5-2018, amend filed 03/21/2018, effective 03/30/2018
MHS 5-2017, f. & cert. ef. 6-8-17
MHS 2-2017(Temp), f. 3-3-17, cert. ef. 3-4-17 thru 8-30-17
MHS 13-2016(Temp), f. 9-6-16, cert. ef. 9-7-16 thru 3-3-17
MHS 4-2008, f. & cert. ef. 6-12-08
MHD 4-2005, f. & cert. ef. 4-1-05
MHD 4-1998, f. 5-21-98, cert. ef. 6-1-98
MHD 9-1985, f. & ef. 6-7-85
MHD 9-1984(Temp), f. & ef. 12-10-84