Or. Admin. Code § 411-015-0005

Current through Register Vol. 63, No. 11, November 1, 2024

Section 411-015-0005 - Definitions

Unless the context indicates otherwise, the following definitions apply to the rules in OAR chapter 411, division 015:

(1) "AAA" means "Area Agency on Aging" as defined in this rule.

(2) "Activities of Daily Living (ADL)" mean those personal functional activities required by an individual for continued well-being, which are essential for health and safety. Activities include eating, dressing and grooming, bathing and personal hygiene, mobility, elimination, and cognition.

(3) "Adult" means any person at least 18 years of age.

(4) "Alternative Service Resources" means other possible resources for the provision of services to meet an individual's needs. Alternative service resources include, but are not limited to, natural supports, risk intervention services, Older Americans Act programs, or other community supports. Alternative service resources are not paid by Medicaid.

(5) "Architectural Modifications" means any service leading to the alteration of the structure of a dwelling to meet the specific service needs of an eligible individual.

(6) "Area Agency on Aging (AAA)" means the Department designated agency charged with the responsibility to provide a comprehensive and coordinated system of services to older adults and adults with disabilities in a planning and service area. The term Area Agency on Aging (AAA) is inclusive of both Type A and Type B AAAs as defined in ORS 410.040 to 410.300.

(7) "Assistance Types" needed for activities of daily living and instrumental activities of daily living include the following:

(a) "Cueing" means giving verbal or visual clues during an activity to help an individual complete the activity without hands-on assistance.

(b) "Hands-on" means a provider physically performs all or parts of an activity because an individual is unable to do so.

(c) "Monitoring" means a provider must observe an individual to determine if intervention is needed.

(d) "Reassurance" means to offer an individual encouragement and support.

(e) "Redirection" means to divert an individual to another more appropriate activity.

(f) "Set-up" means getting personal effects, supplies, or equipment ready so that an individual may perform an activity.

(g) "Stand-by" means a provider is at the side of an individual ready to step in and take over the task if the individual is unable to complete the task independently.

(h) "Support" means to enhance the environment to enable an individual to be as independent as possible.

(8) "Assistive Devices" means any category of durable medical equipment, mechanical apparatus, electrical appliance, instrument of technology, service animal, general household items, or furniture used to assist and enhance an individual's independence in performing any activity of daily living.

(9) "Behavioral Care Plan" means a documented set of procedures, reviewed by the Department or AAA representative, which describes interventions for use by a provider to prevent, mitigate, or respond to behavioral symptoms that negatively impact the health and safety of an individual or others in a home or community-based services setting. The preferences of an individual are included in developing a Behavioral Care Plan.

(10) "Business Days and Hours" means Monday through Friday and excludes Saturdays, Sundays, and state or federal holidays. Hours are from 8:00 AM to 5:00 PM.

(11) "CA/PS" means "Client Assessment and Planning System" as defined in this rule.

(12) "Care Setting" means a Department contracted facility where an eligible individual resides and receives services. Care settings include adult foster homes, residential care facilities, assisted living facilities, specialized living contracted residences, and nursing facilities.

(13) "Case Manager" means an employee of the Department or AAA who assesses the service needs of individuals, determines eligibility, and offers service choices to eligible individuals. The case manager authorizes and implements an individual's service plan and monitors the services delivered as described in OAR chapter 411, division 028.

(14) "Client Assessment and Planning System (CA/PS)" means:

(a) The single entry data system used for -

(A) Completing a comprehensive and holistic assessment;

(B) Surveying an individual's physical, mental, and social functioning; and

(C) Identifying risk factors, individual choices and preferences, and the status of service needs.

(b) The CA/PS documents the level of need and calculates the individual's service priority level in accordance with these rules, calculates the service payment rates, and accommodates individual participation in service planning.

(15) "Cognition" means the individual's mental functional ability to ensure their health, safety and basic needs are met. It includes the individual's understanding of the need to perform and manage ADLs and IADLS. It does not refer to choices an individual may make that others may deem to be unsafe. Nor does it refer to an individual's knowledge and skills, rather their cognitive ability to use and process information.

(16) "Component" means distinct parts of an ADL or IADL that are defined within each ADL or IADL.

(17) "Cost Effective" means being responsible and accountable with Department resources. This is accomplished by offering less costly alternatives when providing choices that adequately meet an individual's service needs. Those choices consist of all available services under the home and community-based service options, the utilization of assistive devices, natural supports, architectural modifications, and alternative service resources not paid for by the Department.

(18) "Department" means the Oregon Department of Human Services (ODHS).

(19) "Disability" means a physical, cognitive, or emotional impairment which, for an individual, constitutes or results in a functional limitation in one or more of the activities of daily living defined in OAR 411-015-0006.

(20) "Event Specific" means situations that are not part of the individual's daily or weekly routine, such as doctor visits or other outings.

(21) "Extraordinary Circumstances" means:

(a) An individual being assessed is working full time during business hours; or

(b) A family member, whose presence is requested by an individual being assessed, is traveling from outside the area, and is available for only a limited period of time that does not include business days and hours.

(22) "Extended Waiver Eligibility (EWE)" means the criteria that allows individuals assessed at Service Priority Level 14-17, who are determined to have a high risk for hospitalization or institutionalization within 30 days of Long Term Services and Supports ending to continue receiving Long Term Services and Supports until the risks can be mitigated.

(23) "Functional Impairment" means an individual's pattern of mental and physical limitations that restricts the individual's ability to perform activities of daily living and instrumental activities of daily living without the assistance of another person.

(24) "Health and Safety" means the essential actions necessary to meet an individual's health care, food, shelter, clothing, personal hygiene and other care needs without which serious physical injury or illness is likely to occur that would result in hospitalization, death or permanent disability.

(25) "Healthier Oregon" means an OHP Plus equivalent benefit (410-120-1210(4)(h)) for individuals described in 461-135-1080.

(26) "Home" means a setting that exhibits the characteristics described in OAR 411-030-0033(2)(a) - (d) and is not a care setting as defined in this rule.

(27) " Home and Community-Based Services" means the non-institutional services and settings approved and funded by the Centers for Medicare and Medicaid Services (CMS) for eligible individuals in accordance with Title XIX of the Social Security Act or funded through Healthier Oregon.

(28) "Independent" means an individual does not meet the definition of "assist" or "full assist" when assessing an activity of daily living as described in OAR 411-015-0006 or when assessing an instrumental activity of daily living as described in OAR 411-015-0007.

(29) "Individual" means an older adult or an adult with a disability applying for or eligible for services. The term "individual" is synonymous with "consumer" or "client".

(30) "Medicaid" means a joint federal and state funded program for medical assistance established by Title XIX of the Social Security Act as amended and administered in Oregon by the Authority.

(31) "Medicaid OHP Plus Benefit Package" means the Medicaid benefit packages provided under OAR 410-120-1210(4)(a) and (b) and those receiving Healthier Oregon benefits under OAR 461-135-1080. This excludes individuals receiving Title XXI benefits.

(32) "Mental or Emotional Disorder" means:

(a) A schizophrenic, mood, paranoid, panic, or other anxiety disorder;

(b) A somatoform, personality, dissociative, factitious, eating, sleeping, impulse control, or adjustment disorder; or

(c) Other psychotic disorders as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual.

(33) "Natural Support" means resources and supports (e.g. relatives, friends, significant others, neighbors, roommates, or the community) who are willing to voluntarily provide services to an individual without the expectation of compensation. Natural supports are identified in collaboration with the individual and the potential "natural support". The natural support is required to have the skills, knowledge, and ability to provide the needed services and supports.

(34) "Older Adult" means any person at least 65 years of age.

(35) "OSIPM" means Oregon Supplemental Income ProgramMedical as defined in OAR 461-101-0010. OSIPM is Oregon Medicaid insurance coverage for individuals who meet eligibility criteria as described in OAR chapter 461.

(36) "Physically Aggressive" means an individual has used physical force that resulted in bodily injury, physical pain, or impairment to another individual. This may include hitting, shoving, scratching, striking out (with or without an object), pushing, shoving, or sexually assaulting others. As used in these rules, an individual who is physically abusive does not have the cognitive ability to regulate their behaviors.

(37) "Service Priority Level (SPL)" means the order in which the Department and AAA staff identify individuals eligible for a nursing facility level of care, Oregon Project Independence, or home and community-based services. A lower SPL number indicates greater or more severe functional impairment. The number is synonymous with the SPL.

(38) "Significant Health Outcome" means the individual would require immediate assistance from a physician, nurse practitioner or physician assistant to safely address the outcome. This means incidents such as a broken bone or a wound that requires stiches rather than bruising or scrapes.

(39) "Socially Inappropriate" means the individual conducts self-abusive acts, exhibits sexual aggression towards others, or displays a loss of inhibitions resulting in inappropriate behaviors, such as disrobing in public, smearing feces, throwing food or eliminating in inappropriate places. As used in these rules, the individual who is socially inappropriate does not have the cognitive ability to regulate their behaviors.

(40) "Soiled" means the individual has urinated or defecated in their incontinence supplies or clothing to the degree that the individual would face a significant health outcome.

(41) "Substance Abuse Related Disorders" means disorders related to the taking of a drug or toxin, including alcohol.

(a) Substance abuse related disorders include:

(A) Substance dependency and substance abuse;

(B) Alcohol dependency and alcohol abuse; and

(C) Substance induced disorders and alcohol induced disorders as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders.

(b) Substance abuse related disorders are not considered physical disabilities. Dementia or other long term physical or health impairments resulting from substance abuse may be considered physical disabilities.

(42) "Tasks" means distinct parts of an activity of daily living.

(43) "These Rules" means the rules in OAR chapter 411, division 015.

(44) "Verbally Aggressive" means an individual has threatened or screamed at others to the level that it became disruptive to having their own daily needs met. This does not include verbal altercations or reactions to pain. As used in these rules, an individual who is verbally aggressive does not have the cognitive ability to regulate their behaviors.

(45) "Without Supports" means an individual lacks the assistance of another person, a care setting and staff, or an alternative service resource as defined in this rule.

Or. Admin. Code § 411-015-0005

SSD 3-1985, f. & ef. 4-1-85; SSD 5-1986, f. & ef. 4-14-86; SSD 9-1986, f. & ef. 7-1-86; SSD 12-1987, f. 12-31-87, cert. ef. 1-1-88; SSD 12-1991(Temp), f. 6-28-91, cert. ef. 7-1-91; SSD 21-1991, f. 12-31-91, cert. ef. 1-1-92, Renumbered from former 411-015-0000(2)(a) - (l); SDSD 11-2002(Temp), f. 12-5-02, cert. ef. 12-6-02 thru 6-3-03; SPD 12-2003, f. 5-30-03, cert. ef. 6-4-03; SPD 16-2003(Temp), f. & cert. ef. 10-27-03 thru 4-23-04; SPD 8-2004, f. & cert. ef. 4-27-04; SPD 19-2005, f. & cert. ef. 12-29-05; SPD 19-2006, f. 5-26-06, cert. ef. 6-1-06; SPD 14-2013(Temp), f. & cert. ef. 7-1-13 thru 12-28-13; SPD 45-2013, f. 12-13-13, cert. ef. 12-15-13; APD 9-2014(Temp), f. 4-17-14, cert. ef. 4-21-14 thru 10-18-14; APD 35-2014, f. & cert. ef. 10-1-14; APD 19-2017, temporary amend filed 09/29/2017, effective 10/01/2017 through 03/29/2018; APD 10-2018, amend filed 03/28/2018, effective 3/29/2018; APD 25-2022, temporary amend filed 06/14/2022, effective 7/1/2022 through 12/27/2022; APD 58-2022, amend filed 12/22/2022, effective 12/23/2022

Statutory/Other Authority: ORS 410.070

Statutes/Other Implemented: ORS 410.060, 410.070 & 414.065