Or. Admin. Code § 411-054-0025 - Facility Administration
(1)
FACILITY OPERATION.
(a) The licensee is
responsible for the operation of the facility and the quality of services
rendered in the facility.
(b) The
licensee is responsible for the supervision, training, and overall conduct of
staff when staff are acting within the scope of his or her employment
duties.
(c) The licensee is
responsible for ensuring that the facility complies with the tuberculosis
screening recommendations in OAR
333-019-0041.
(d) The licensee is responsible for obtaining
background checks on all subject individuals.
(2) BACKGROUND CHECK REQUIREMENTS.
(a) Background checks must be submitted to
the Department for a criminal fitness determination on all subject individuals
in accordance with OAR chapter
407-007-0200 to
407-007-0370, and
407-007-0600 to 0640, including
before a subject individual's change in position.
(A) On or after July 28, 2009, no individual
may be a licensee, or employed in any capacity in a facility, who has been
convicted of any of the disqualifying crimes listed in OAR
407-007-0275.
(B) Subject individuals who are employees and
hired before July 28, 2009 are exempt from subsection (a) of this section
provided that the employee remains in the same position working for the same
employer after July 28, 2009. This exemption is not applicable to
licensees.
(C) Background checks
are to be completed every two years on all subject individuals.
(b) PORTABILITY OF BACKGROUND
CHECK APPROVAL. A subject individual may be approved to work in multiple
facilities under the same operational entity. The Department's Background Check
Request must be completed by the subject individual to show intent to work at
various facilities.
(3)
EMPLOYMENT APPLICATION. An application for employment in any capacity at a
facility must include a question asking whether the applicant has been found to
have committed abuse. The licensee must check all potential employees against
the Oregon State Board of Nursing (Board) and inquire whether the individual is
licensed or certified by the Board and whether there has been any disciplinary
action by the Board against the individual or any substantiated abuse findings
against a nursing assistant.
(4)
Reasonable precautions must be exercised against any condition that may
threaten the health, safety, or welfare of residents.
(5) REQUIRED POSTINGS. Required postings must
be posted in a routinely accessible and conspicuous location to residents and
visitors and must be available for inspection at all times. The licensee is
responsible for posting the following:
(a)
Facility license.
(b) The name of
the administrator or designee in charge. The designee in charge must be posted
by shift or whenever the administrator is out of the facility.
(c) The current facility staffing plan, with
date(s).
(d) A copy of the most
recent re-licensure survey, including all revisits and plans of correction as
applicable.
(e) The Ombudsman
Notification Poster.
(f) Resident
Rights and Protections, as described in OAR
411-054-0027, including the
LGBTQIA2S+ Rights and Protections.
(g) The LGBTQIA2S+ Nondiscrimination Notice,
as described in paragraph (7)(i) of this section, must be posted in all places
and on all materials where that notice or those written materials are
posted.
(h) Other notices relevant
to residents or visitors required by state or federal law.
(6) NOTIFICATION. The facility must notify
the Department's Central Office immediately by telephone, fax, or email, (if
telephone communication is used the facility must follow-up within 72 hours by
written or electronic confirmation) of the following:
(a) Any change of the administrator of record
through the submission of the Administrator Reference Summary (SDS
0566).
(b) Severe interruption of
physical plant services where the health or safety of residents is endangered,
such as the provision of heat, light, power, water, or food.
(c) Occurrence of epidemic disease in the
facility. The facility must also notify the Local Public Health Authority as
applicable.
(d) Facility fire or
any catastrophic event that requires residents to be evacuated from the
facility.
(e) Unusual resident
death or suicide.
(f) A resident
who has eloped from the facility and has not been found within 24
hours.
(7) POLICIES AND
PROCEDURES. The facility must develop and implement written policies and
procedures that promote high quality services, health and safety for residents,
and incorporate the community-based care principles of individuality,
independence, dignity, privacy, choice, and a homelike environment. The
facility must develop and implement:
(a) A
policy on the possession of firearms and ammunition within the facility. The
policy must be disclosed in writing and by one other means of communication
commonly used by the resident or potential resident in his or her daily
living.
(b) A written policy that
prohibits sexual relations between any facility employee and a resident who did
not have a pre-existing relationship.
(c) Effective methods of responding to and
resolving resident complaints.
(d)
All additional requirements for written policies and procedures as established
in OAR 411-054-0012 (Requirements for
New Construction or Initial Licensure), OAR
411-054-0040 (Change of
Condition and Monitoring), OAR
411-054-0045 (Resident Health
Services), and OAR 411-054-0085 (Refunds and
Financial Management).
(e) A policy
on smoking.
(A) The smoking policy must be in
accordance with:
(i) The Oregon Indoor Clean
Air Act, ORS 433.835 to
433.875;
(ii) The rules in OAR chapter 333, division
015; and
(iii) Any other applicable
state and local laws.
(B) The facility may designate itself as
non-smoking.
(f) A
policy for the referral of residents who may be victims of acute sexual assault
to the nearest trained sexual assault examiner. The policy must include
information regarding the collection of medical and forensic evidence that must
be obtained within 86 hours of the incident.
(g) A policy on facility employees not
receiving gifts or money from residents.
(h) Protocols for preventing and controlling
infection, as described in OAR
411-054-0050.
(i) LGBTQIA2S+ Nondiscrimination Notice:
"(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual's actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual's association with another individual on account of the other individual's actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information)."
(j) ABST
Policy for accurate and consistent implementation of the ABST. The policy must
explain how a facility evaluates and accounts for both scheduled and
unscheduled resident needs.
(8) RECORDS. The facility must ensure the
preparation, completeness, accuracy, and preservation of resident records.
(a) The facility must develop and implement a
written policy that prohibits the falsification of records.
(b) Unless required or allowed by state or
federal law, a facility shall not disclose any personally identifiable
information regarding:
(A) A resident's sexual
orientation;
(B) Whether a resident
is LGBTQIA2S+;
(C) A resident's
gender transition status; or
(D) A
resident's human immunodeficiency virus status.
(c) The facility shall take appropriate steps
to minimize the likelihood of inadvertent or accidental disclosure of
information described in subsection (b) of this section to other residents,
visitors or facility staff, except to the minimum extent necessary for facility
staff to perform their duties. Facilities must notify residents or resident
representatives if the facility inadvertently or accidentally discloses such
information to unauthorized persons.
(d) Resident records must be kept for a
minimum of three years after the resident is no longer in the
facility.
(e) Upon closure of a
facility, the licensee must provide the Department with written notification of
the location of all records.
(9) QUALITY IMPROVEMENT PROGRAM. The facility
must develop and conduct an ongoing quality improvement program that evaluates
services, resident outcomes, and resident satisfaction.
Notes
Statutory/Other Authority: ORS 181.534, 410.070, 441.122, 443.004 & 443.450
Statutes/Other Implemented: ORS 181.534, 441.112, 441.114, 443.004, 443.400 - 443.455 & 443.991
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