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. 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 History: APD 69-2024, amend filed 12/20/2024, effective 12/24/2024 APD 33-2024, temporary amend filed 06/24/2024, effective 07/01/2024 through 12/27/2024 APD 20-2021, amend filed 06/08/2021, effective 06/09/2021 APD 51-2020, temporary amend filed 12/18/2020, effective 01/01/2021 through 06/29/2021 APD 23-2020, amend filed 06/20/2020, effective 06/24/2020 APD 55-2019, temporary amend filed 12/23/2019, effective 01/01/2020 through 06/28/2020 APD 10-2016, f. 6-27-16, cert. ef. 6-28-16 APD 26-2015(Temp), f. 12-29-15, cert. ef. 1-1-16 thru 6-28-16 SPD 11-2012, f. 8-31-12, cert. ef. 9-1-12 SPD 10-2010, f. 6-30-10, cert. ef. 7-1-10 SPD 1-2010(Temp), f. & cert. ef. 3-11-10 thru 6-30-10 SPD 23-2009(Temp), f. 12-31-09, cert. ef. 1-1-10 thru 6-30-10 SPD 13-2009, f. 9-30-09, cert. ef. 10-1-09 SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07