ODDS In-Home Services Exception Request for Hour Allocations and Staffing Ratio Exceptions

ODDS In-Home Services Exception Request for Hour Allocations and Staffing Ratio Exceptions

ODDS In-Home Staffing Ratio and Hours Exceptions

Please review the In-Home Staffing Ratio and Hours Exceptions Workers Guide to assist with completion of this form. www.oregon.gov/odhs/providers-partners/idd/workerguides/in-home-hours-exceptions.pdf

ODDS has posted blank copes of the PDF version of the Hour Allocation and Staffing Ratio PDF form, as well as a copy of all the Smartsheet Exception Request questions with the form skip logic on the Resources for Case Management Entities Webpage https://www.oregon.gov/odhs/providers-partners/idd/Pages/cme.aspx.

The PDF version of the form, is for gathering information during the exceptions process. It is not a substitute for the In-Home Smartsheet Exception Request Form.

Language Access

You can get this document in other languages, large print, braille or a format you prefer free of charge. Contact Office of Developmental Disabilities Services at DD.DirectorsOffice@odhsoha.oregon.gov or 503-945-5811 (voice/text). We accept all relay calls.

This form is only to be used for ODDS In-Home Services Hour Allocation and Staffing ratio exceptions. All other exception requests must be made using the ODDS 0514 form.

Individuals Name*

Individual's Prime Number*

Date of Birth*

Individual's Mailing Address*

Does the Individual have a Legal Guardian?

Yes

Legal Guardian Name*

Legal Guardian Email Address*

Legal Guardian Street Address*

Case Management Entity*

Select or enter value

SC/PA Name:*

SC/PA Email Address*

SC/PA Phone Number*

Phone

SC/PA Supervisor Name*

SC/PA Supervisor Email Address*

Does the final determination need to be translated?*

Does ODDS need to include a translated copy of the final determination?

Yes

What language does the final determination need to be translated to?*

Individuals ONA Age*

Infant/Toddler (ages 0-3)

Child (ages 4-11)

Adolescent (ages 12-17)

Adult (ages 18+)

Children's Support Needs*

Describe how the exceptional support need requested is a support that exceeds what is commonly provided to a minor child that would be commonly provided by a parent or other guardian. Describe how the support is related to the child's developmental disability

Does the ONA reflect the individuals current support needs and support the exception being requested?*

Yes

Why doesn't the ONA reflect the individual's current support needs?*

There is an acute change in need, the increased support needs are expected to last fewer than 90 days

This is an urgent change in need, there is a plan for a change in need ONA within the next 45 days

The ONA is accurate, however, the reason for this exception is not covered by the ONA questions

Is this an urgent request?*

Yes

Identify the reason(s) this request is urgent

If the request doesn't meet the following criteria, it is not considered urgent and will be reviewed in the order it was received.

The individual is in crisis and the request could help stabilize services

The individual requires immediate additional support due to an unforeseen injury or illness

The individual is at risk of losing a provider or placement

Provide a brief explanation of why an exception is needed.*

Briefly describe why this exception is needed

Exception Service Type*

If this request is not for In-Home Hour Allocation or Staffing Ratios, the 0514DD form must be completed and sent to the ODDS.FundingReview@odhsoha.oregon.gov

Hour Allocation

Staffing Ratio

Hour Allocation Exception

Hour Allocation Exception Request Type*

New Request- On-Going Need

Renewal Request- On-Going Need

Increase in previously Approved Exception

Limited Duration Increased Support Need

Exception Request Start Date*

Requested Exception End Date*

ONA Service Group Hours*

How many hours does the individual have in the ONA Service Group?

Additional Requested Hour Allocation Hours per Month*

Select the number of additional hours being requested per month. The total requested hours and the current approved hours in the ISP should not exceed 744 hours/month (approvals will not exceed 744 hours). Hour amounts are in increments of 30.

Select

Total Monthly Hours of Support Needed*

Identify the total monthly hours needed per month. This should include the hours included in the individuals ONA Service Group + the additional hours requested per month (in increments of 30).

Hour Allocation Exception Criteria*

Identify reason(s) for the need for an Increase in Monthly Hour Allocation

Intermittent support needs that cannot be scheduled

ADL or health related task takes substantially more time to complete than others with similar assessed needs.

Risk of Isolation

Intermittent Supports: Which of the following needs that cannot be scheduled, arises regularly, and would likely result in physical harm to the person or others if unmet in one of the following areas:*

Please identify all intermittent needs that cannot be scheduled.

Intermittent Support Needs: Other*

Please identify the intermittent support needs that are not already identified above.

Identify the intermittent recurring challenging behaviors that require additional support*

Intermittent Supports: Describe the intermittent support needs that requires additional support*

Describe the supports that are needed to support the intermittent needs

How often in occurrences per week does this need arise?*

How much time does it take to meet this need in hours per week?*

What are the consequences that are reasonably expected if the need is unmet?*

ADL/Health Related Tasks: Select the ADL/Health-Related tasks that take substantially more time to complete than others with similar assessed needs.*

Identify the other ADL or health related support need*

ADL/Health-Related Support Needs:*

Describe the task or need that requires additional support, specifically include details about the reasons this need takes substantially more time than others with similar assessed needs.

ADL/Health Related Tasks: How often in occurrences per day does this need arise?*

ADL Health Related Task: How much time does it take to meet this need in hours per week?*

ADL/Health Related Task: What are the consequences that are reasonably expected if the need is unmet?*

Risk of Isolation: Is the person unable to access the community for at least 20 hours a week due to needing support while in the community and having to utilize all available support hours to meet other ADL, IADL and health related tasks?*

Yes

Risk of Isolation: Number of hours the person can currently access the community per week:*

Include time spent doing the following: IADLs that occur away from home, travel time, entertainment out, dining out, attending religious services, errands, and day support activities.

Risk of Isolation: Number of hours desired to access the community per week, up to 20 hours per week:*

Risk of Isolation: Explain how the current hour allocation is used to meet other ADL, IADL, and health related tasks resulting in inadequate hours for community inclusion*

Staffing Ratio Exception

Staffing Ratio Exception Request Type*

New Request- On-Going Need

Renewal Request- On-Going Need

Increase in previously Approved Exception

Limited Duration Increased Support Need

Staffing Ratio Exception Start Date*

Staffing Ratio Exception End Date*

Current Approved Staffing Ratio*

2:1

3:1

4:1

No Staffing Ratio hours currently

Approved 2:1 Hours*

Approved 3:1 Hours*

Approved 4:1 Hours*

Staffing Ratio(s) Requested*

Enter the total Staffing Allocation Hours being requested

2:1

3:1

4:1

Total 2:1 Monthly Hours Requested: *

Total 3:1 Monthly Hours Requested: *

Total 4:1 Monthly Hours Requested: *

Does the person meet the criteria to approve an increased staffing ratio at the CME?*

Yes, but the person requires a staffing ratio above 2:1

Yes, but the person requires more hours of increased staffing than is able to be approved by the CME

Yes, but the person requires a staffing ratio above 2:1 and more hours of increased staffing than is able to be approved by the CME

Staffing Ratio Exception Criteria*

Behavior Support Needs: The person has a challenging behavior that requires more than one supporter to provide support to either respond to the challenging behavior as it occurs, or to provide proactive supports to prevent the challenging behavior.

Intensive Focus: Individual requires intensive focus from a paid provider to assure the individual’s health and safety and it is necessary for a different provider to complete an IADL that would otherwise detract from the intensive focus.

Medical needs: The person has medical needs that require more than one person to provide supports.

ADL needs: The person has ADL needs that require more than one person to provide supports.

Does the person have a positive behavior support plan that is currently implemented?*

Yes

Does the positive behavior support plan include safe guarding interventions?*

Yes

If no, why doesn't the person have a positive behavior support plan?*

Identify the challenging behavior, that has been present in the last year, that leads to a need for increased staffing*

Self-injurious behavior that may lead to serious injury

Aggressive or combative

Injurious to animals

Sexual aggression or assault

Property destruction

Leaving supervised area

A diagnosis of PICA

OTHER challenging behavior that requires more than one supporter at a time to provide supports

Describe the OTHER challenging behavior that requires more than one supporter at a time to provide supports*

Describe how the need for increased staffing to support the identified above behavior(s) presents for this person:*

How often in occurrences per week does the need for additional staffing arise?*

Describe how long, in hours per day, the amount of time it takes to support this need*

Behavior Staffing Ratio Being Requested*

2:1

3:1

4:1

Behavior Support Need: How many 2:1 hours are needed per week to support this need?*

Number of times per week times the amount of time per day

Behavior Support Need: How many 3:1 hours are needed per week to support this need?*

Behavior Support Need: How many 4:1 hours are needed per week to support this need?*

Does this person have a current Nursing Care Plan?*

Yes

Why don't they have a Nursing Care Plan?*

Treatments and Therapies*

Identify all of the treatments and therapies that the individual is receiving support for at least 5 times per day

Select or enter value

Identify the "Other" Treatments and Therapies that the individual is receiving support for at least 5 times a day that is not identified above*

Describe the medical need, treatment/monitoring/therapy, that requires increased staffing?*

Medical Support Need: How often in occurrences per week does the need for additional staffing arise?*

Medical Support Need: Describe how long, in hours per day, the amount of time it takes to support this need*

Medical Support Need: Staffing Ratio Being Requested*

2:1

3:1

4:1

Medical Support Needs: How many 2:1 staffing ratio hours are needed per week?*

Medical Support Needs: How many 3:1 staffing ratio hours are needed per week?*

Medical Support Needs: How many 4:1 staffing ratio hours are needed per week?*

Identify the Other ADL Support needs not identified above.*

Describe how the need for increased staffing to support the identified ADL support needs presents for this person*

Describe how the additional staffing supports each ADL that requires a staffing ratio exception support.

ADL Support Need: How often in occurrences per week does the need for additional staffing arise?*

How many staffing ratio hours are needed per day for ADL support needs?*

ADL Support Need: Staffing Ratio*

2:1

3:1

4:1

ADL Support Needs: How many 2:1 hours are needed per week?*

ADL Support Needs: How many 3:1 hours are needed per week?*

ADL Support Needs: How many 4:1 hours are needed per week?*

Intensive Focus: Is the need for intensive focus related to challenging behavior?*

Yes

Identify the challenging behavior, that has been present in the last year, that leads to a need for increased staffing*

Self-injurious behavior that may lead to serious injury

Leaving supervised area

A diagnosis of PICA

OTHER challenging behavior that requires more than one supporter at a time to provide supports

Describe the OTHER challenging behavior that requires more than one supporter at a time to provide supports*

Describe the health and safety need that requires intensive focus supports and if it is necessary for a different provider to complete an IADL that would otherwise detract from the intensive focus.*

Intensive Focus Supports*

Describe the person's support that requires the caregiver to *continuously attend the individual and another caregiver is required to complete necessary IADLs. Describe What would happen if the individual was left unattended while the primary caregiver completes necessary IADL tasks?

*Continuously attend means the caregiver cannot do anything else other then focus on the person and if the caregiver needs a break from any amount of time, the caregiver must be relieved by another caregiver who will focus on the person

Intensive Focus: How often in occurrences per week does the need for additional staffing arise?*

Intensive Focus: How many staffing ratio hours are needed per day for intensive focus supports?*

Intensive Focus Staffing Ratio Requested*

2:1

3:1

4:1

Intensive Focus Support Needs: How many 2:1 hours are needed per week?*

Intensive Focus Support Needs: How many 3:1 hours are needed per week?*

Intensive Focus Support Needs: How many 4:1 hours are needed per week?*

Exception Submission

What other documents are being attached?*

File Upload

Drag and drop files here or

Case Management Entity Recommendation*

Explain or summarize the case management entity's recommendation for approval or denial. Include any concerns or issues related to the request.

Person Submitting Request*

Relationship to the Individual*

Personal Agent

Services Coordinator

SC/PA Supervisor

Person Submitting Request Email Address

In-Home Exceptions Request Feedback

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