Citation #1: C0310 - Systems: Medication Administration
Visit History:
t Visit: 9/11/2024 | Not Corrected
1 Visit: 12/4/2024 | Not Corrected
Regulation:
OAR 411-054-0055 (2) Systems: Medication Administration
(2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure residents' MARs included documented reasons for use for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:
1. Resident 1 was admitted to the facility in 07/2024 with diagnoses including cerebrovascular accident and impaired cognition.
The resident's current prescriber orders and 08/01/24 through 09/09/24 MARs were reviewed and the following medications lacked reasons for use:
* Finasteride;
* Tamsulosin;
* Metoprolol succinate;
* Buproprion HCL XL;
* Levetiracetam;
* Atorvastatin;
* Cefdinir;
* Fluoxetine;
* Vazalore;
* Aspirin EC;
* Acetaminophen;
* Senna; and
* Bisacodyl.
During an interview on 09/11/24 at 10:35 am, Staff 2 (Wellness Director) confirmed the above medications lacked reasons for use.
The need to ensure all medications on the MAR included the reason for use was discussed with Staff 1 (ED), Staff 2, and Staff 3 (RN) on 09/11/24 at 1:30 pm. They acknowledged the findings, and no further information was provided.
2. Resident 2 was admitted to the facility on 08/02/2024 with diagnoses including bipolar disorder.
The resident's current prescriber orders and 08/01/24 through 09/09/24 MARs were reviewed and the following medications lacked reasons for use:
*Exemestane;
*Furosemide;
*Labetalol;
*Lamotrigine;
*Miralax;
*Senna;
*Fluticasone;
*Preservision Areds;
*Aspirin;
*Sevelamer Carbonate;
*Tramadol;
*Lamotrigine; and
*Lidoc/Prilocaine.
In an 09/11/24 interview with Staff 2 (Wellness Director), she confirmed the MARs lacked reasons for use for the medications.
The need to ensure MARs were accurate, including reasons for use was discussed with Staff 1 (ED) and Staff 2 on 09/11/24. They acknowledged the findings.
OAR 411-054-0055 (2) Systems: Medication Administration
(2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.
This Rule is not met as evidenced by:
Plan of Correction:
• Community discovered that the 'reason for use' was missing from the printed MAR due to a system setting.
• The setting for 'reason for use' population has now been set to default.
• An initial audit will be performed to ensure all 'reasons for use' are populated in the system.
• Quarterly audits will follow to verify that 'reasons for use' are recorded for each resident.
• The Wellness Director and Resident Care Coordinator will be responsible for completing and monitoring this correction.
Citation #2: C0340 - Restraints and Supportive Devices
Visit History:
t Visit: 9/11/2024 | Not Corrected
1 Visit: 12/4/2024 | Not Corrected
Regulation:
OAR 411-054-0060 Restraints and Supportive Devices
Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07
Inspection Findings:
Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, failed to document other less restrictive alternatives were evaluated prior to the use of the device, and failed to instruct caregivers on the correct use and precautions related to the use of the device for 2 of 2 sampled residents (#s 1 and 3) who used a supportive device with restraining qualities. Findings include, but are not limited to:
1. Resident 1 moved into the facility in 07/2024 with diagnoses including cerebrovascular accident and impaired cognition.
Observations of the resident and interviews with staff indicated the resident had a quarter-length side rail on both sides of his/her bed. On 09/10/24, the side rails were observed to be in the up position, in good repair, and flush with the mattress. The side rails in the up position were identified to be devices with restraining qualities.
The resident's service plan, dated 08/28/24, failed to document other less restrictive alternatives were evaluated prior to the use of the device and to instruct caregivers on the correct use and precautions related to the use of the side rails. Staff reported the resident was primarily wheelchair bound and admitted to the facility with the hospital bed and side rails.
On 09/10/24 at 4:20 pm, Staff 3 (RN) confirmed an assessment of the side rail was not completed prior to survey entry.
The need to ensure supportive devices with restraining qualities were assessed by an RN, PT, or OT and were included in the resident's service plan was discussed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 3 on 09/11/24. They acknowledged the findings, and no further information was provided.
2. Resident 3 was admitted to the facility in 07/2021 with diagnoses including Guillain-Barre syndrome and chronic fatigue.
On 09/11/24 at 11:52 am, Resident 3 was observed transferring to his/her hospital bed using a left side quarter-length siderail in the up position, which was identified as a device with restraining qualities.
Review of Resident 3's record indicated there was no documented evidence of:
* Instruction to caregivers on the correct use and precautions related to use of the device; and
* Documentation of the use of the supportive device in the resident’s service plan.
The need to ensure documentation of the use of the supportive device with restraining qualities was included in Resident 3’s service plan and caregivers were instructed on the correct use and precautions related to the use of the supportive device was discussed with Staff 1 (ED) and Staff 2 (Wellness Director) on 09/11/24. They acknowledged the findings.
OAR 411-054-0060 Restraints and Supportive Devices
Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07
This Rule is not met as evidenced by:
Plan of Correction:
• Resident 1 and 2: Growth and wellness plans have been updated to include instructions for staff on assistive devices with restraining qualities.
• Community will conduct an audit to ensure all residents' assistive devices are documented in their growth and wellness plans.
• Separate evaluations for assistive devices will be included, detailing less restrictive alternatives and staff instructions.
• An in-service will be provided for staff during the 10/30 All Staff meeting, focusing on currently used assistive devices, with a sign-in for attendance.
• The community will follow up with any wellness staff who miss the meeting to ensure they receive the necessary training and sign off on it.
• Assistive device assessments are completed alongside 90-day growth and wellness plans.
• The Community RN and Wellness Director will be responsible for the completion of assessments and ensuring instructional verbiage is included in care plans.
Citation #3: C0370 - Staffing Requirements and Training – Pre-service
Visit History:
t Visit: 9/11/2024 | Not Corrected
1 Visit: 12/4/2024 | Not Corrected
Regulation:
OAR 411-054-0070 (3-4) Staffing Rqmts and Training: Caregiver Rqmts
(3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES.(a) Prior to beginning their job responsibilities, all employees must complete an orientation that includes training regarding:(A) Residents' rights and the values of community-based care.(B) Abuse and reporting requirements.(C) Standard precautions for infection control.(D) Fire safety and emergency procedures.(b) If the staff member's duties include preparing food, they must have a food handler's certificate.(c) All staff must receive a written description of their job responsibilities.(d) PRE-SERVICE INFECTIOUS DISEASE PREVENTION TRAINING. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-monthperiod prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula:(A) Transmission of communicable disease and infections, including:(i) Policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Respiratory hygiene and coughing etiquette.(B) Standard precautions.(C) Hand hygiene.(D) Use of personal protective equipment.(E) Cleaning of physical environment, including, but not limited to:(i) Disinfecting high-touch surfaces and equipment.(ii) Handling, storing, processing and transporting linens to prevent the spread of infection.(F) Isolating and cohorting of residents during a disease outbreak.(G) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (H) Facilities will be required t have all staff trained, as described in this rule, by July 1, 2022.(e) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff.(A) The pre-service training may be provided in person, in writing, by webinar or by other electronic means.(B) Online training will be made available by the Department by January 1, 2022.(C) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval.(D) The Department will review training from facilities or other entities with the goal of making training available to facilities by January 1, 2022.(f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete theDepartment-approved HCBS training, as provided below:(A) Effective March 31, 2024, all staff must have completed the required training.(B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning jobresponsibilities.(4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF.(a) Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training.(b) Pre-service dementia care training requirements for:(A) 2018 - Direct care staff hired on or before December 31, 2018 shall complete pre-service dementia care training outlined in OAR 411-054-0070 by December 31, 2018, regardless of when they first provide direct care to residents.(B) 2019 and beyond - Direct care staff hired on or after January 1, 2019 shall complete required pre-service dementia training prior to providing direct care to residents.(c) Documentation of dementia training:(A) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training.(B) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff.(d) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility ' s pre-service dementia training.(e) A certificate of completion must be made available to the Department upon request.(f) Pre-service dementia care training must include the following subject areas:(A) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms.(B) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses.(C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities.(D) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to:(i) Identify and address pain.(ii) Provide food and fluids.(iii) Prevent wandering and elopement.(iv) Use a person-centered approach.(g) Pre-service orientation to resident:(A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident's service plan.(B) Staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable.
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly-hired direct care staff (#s 6 and 14) completed all required pre-service orientation prior to beginning their job responsibilities. Findings include, but are not limited to:
Training records were reviewed with Staff 4 (Business Office Manager) on 09/11/24.
Staff 6 (MT), hired 06/12/24, and Staff 14 (CG), hired 03/08/24, lacked documented evidence of completing fire safety and emergency procedures orientation prior to beginning job responsibilities.
The need to ensure newly-hired direct care staff completed all required pre-service orientation prior to beginning their job responsibilities was reviewed with Staff 1 (ED) and Staff 2 (Wellness Director) on 09/11/24. They acknowledged the findings.
OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service
(3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding:
(a) A review of their written position description with their job responsibilities.
(b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings.
(A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities.
(B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of
this rule.
(c) Abuse and reporting requirements.
(d) Fire safety and emergency procedures.
(e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease.
(A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula:
(i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease.
(ii) Policy addressing respiratory hygiene and coughing etiquette.
(iii) Standard precautions.
(iv) Hand hygiene.
(v) Use of personal protective equipment.
(vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection.
(vii) Isolating and cohorting of residents during a disease outbreak.
(viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks
under ORS 433.004 and safeguards for employees who report disease outbreaks.
(B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff.
(i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means.
(ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval.
(f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below:
(A) Effective March 31, 2024, all staff must have completed the required training.
(B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities.
(g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate.
(4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF.
(a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training.
(A) Documentation of dementia training:
(i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training.
Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training.
(ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff.
(B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training.
(C) A certificate of completion must be made available to the Department upon request.
(D) Pre-service dementia care training must include the following subject areas:
(i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms.
(ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses.
(iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities.
(iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to:
(I) Identify and address pain.
(II) Provide food and fluids.
(III) Prevent wandering and elopement.
(IV) Use a person-centered approach.
(b) ORIENTATION TO RESIDENT. Pre-service orientation to resident:
(A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan.
(B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable
This Rule is not met as evidenced by:
Plan of Correction:
Staff files will be audited for documentation of fire and life safety training.
• Group training sessions are scheduled for 10/2 and 10/30 during all staff meetings.
• The Maintenance Director will follow up on any outstanding trainings and document completion.
• A checklist will be implemented for each staff member to ensure pre-service requirements are met before they assume full duties.
• The Business Office Manager will ensure all non-wellness staff complete required training.
• The Resident Care Coordinator will ensure all wellness staff complete required training.
• The Administrator and Wellness Director will review records quarterly to ensure compliance.
Citation #4: C0374 - Annual and Biennial Inservice for All Staff
Visit History:
t Visit: 9/11/2024 | Not Corrected
1 Visit: 12/4/2024 | Not Corrected
Regulation:
OAR 411-054-0070 (2-5)(5-8) Annual Training and Other Requirements
(2) An administrator of a facility and the employees of the facility, as specified by the Department of Human Services by rule, must receive training in recognizing disease outbreaks and infection control at the time of hiring, unless the administrator or the employee has received the training at another facility within the 24-month period prior to the time of hiring, and annually as part of, and not in addition to, the administrator or employee's continuing education requirements.(3) The department, in consultation with the Oregon Health Authority, shall prescribe by rule the requirements for the training, which must include at least the following: (a) How to properly prevent and contain disease outbreaks based on the current best evidence in the field of infection and disease outbreak identification, prevention and control;And (b) The responsibility of staff members to report disease outbreaks under ORS 433.004.(4) The training may be provided in person, in writing, by webinar or by other electronic means. The department shall make online trainings available.(5)(a) A facility must establish and maintain infection prevention and control protocols designed to provide a safe, sanitary and comfortable environment and to prevent the development and transmission of communicable diseases.(5) ANNUAL INSERVICE FOR ALL STAFF. Annual infectious disease training requires the following:(a) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training.(b) Annual in-service training must be documented in the employee record.(c) These annual training requirements will be required as of July 1, 2023.(7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF.(a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population and dementia training. Annual in-service training hours are based on the anniversary date of hire.(b) Requirements for annual in-service dementia training:(A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care.(B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter.(C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above.(D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia.(E) The facility shall determine the competency of direct care staff in dementia care in the following ways:(i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19).(ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff.(iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee ' s assessed competency.(8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process.
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long-term direct care staff (#s 7, 8, and 12) completed 12 hours of annual in-service training which included at least 6 hours of dementia care training, and 2 of 2 long-term non-direct care staff (#s 5 and 18) completed annual infectious disease training. Findings include, but are not limited to:
Review of the facility's training records with Staff 4 (Business Office Manager) on 09/11/24 revealed the following:
* Staff 7 (MT), anniversary date of hire 04/14/23, Staff 8 (MT), anniversary date of hire 04/20/23, and Staff 12 (CG), anniversary date of hire 12/27/22, failed to have documented evidence of completing 12 hours of required in-service training, including at least six hours of training on dementia care annually based on date of hire; and
* Staff 5 (Maintenance Director), hired 07/08/22, and Staff 18 (Server), hired 08/01/23, failed to have documented evidence of completing infectious disease prevention training annually.
The need to ensure long-term staff completed and documented the required annual in-service training, which included dementia care and infectious disease prevention, was reviewed with Staff 1 (ED) and Staff 2 (Wellness Director) on 09/11/24. They acknowledged the findings.
OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff
(6) ANNUAL AND BIENNIAL INSERVICE FOR ALL STAFF.
(a) Annual infectious disease training requires the following:
(A) Administrators and employees will be required to complete annual training on infectious disease outbreak and infection control. Such training will be included within the current number of required annual training hours and will not necessitate additional hours of training.
(B) Annual in-service training must be documented in the employee record.
(b) Biennial LGBTQIA2S+ training requires the following:
(A) Administrators and employees shall be required to complete biennial training addressing LGBTQIA2S+ protections, as described in this section. The facility is responsible for the cost of providing this training to all facility staff.
(i) Each facility shall designate two employees, one who represents management and one who represents direct care staff by July 1, 2024. It is acceptable for the designated employee representing management to generally be housed offsite, but the direct care representative must be onsite.
(ii) The designated employees shall serve as points of contact for the facility regarding compliance with the preservice and biennial training requirements. These individuals shall develop a general training plan for the facility.
(B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either:
(i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or
(ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility.
(C) ORS 441.116 requires all LGBTQIA2S+ trainings address:
(i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus.
(ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status.
(iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status.
(iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns.
(v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination.
(vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training.
(vii) The facility, individual or entity providing the training must demonstrate a commitment to advancing quality care for LGBTQIA2S+ residents and residents living with human immunodeficiency virus in this state.
(D) The proposal for training submitted by a facility, entity, or individual shall include:
(i) The regulatory criteria described in paragraph (C) of this section as part of the proposal.
(ii) The following elements must be included in the proposal:
(I) A statement of the qualifications and training experience of the facility, individual or entity providing the training;
(II) The proposed methodology for providing the training either online or in person.
(III) An outline of the training.
(IV) Copies of the materials to be used in the training.
(iii) The Department will review the materials and determine whether to approve or deny the training. No later than 90 days after the request is received, the Department will inform the facility in writing of the Department’s decision.
(c) Annual Home and Community-Based Services (HCBS) training requires the following:
(A) All staff will be required to complete annual training concerning the Home and Community-Based Services regulations.
(B) Annual in-service training must be documented in the employee record.
(C) These annual trainings will be required as of April 1, 2025.
(7) ANNUAL IN-SERVICE TRAINING FOR DIRECT CARE STAFF.
(a) All direct care staff must complete and document a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, LGBTQIA2S+ and dementia training. Annual in-service training hours are based on the anniversary date of hire.
(b) Requirements for annual in-service dementia training:
(A) Except as provided in paragraph (B) of this section, each direct care staff must complete 6 hours of annual in-service training on dementia care.
(B) Exception: Staff hired prior to January 1, 2019 must complete 6 hours of dementia care in-service training by the anniversary of their hire date in 2020 and annually thereafter.
(C) Dementia care training may be included in the required minimum 12 hours of annual in-service training described in subsection (a) above.
(D) Dementia care training must reflect current standards for dementia care and be informed by the best evidence in the care and treatment of dementia.
(E) The facility shall determine the competency of direct care staff in dementia care in the following ways:
(i) Utilize approved dementia care training for its direct care staff, coupled with methods to perform a competency assessment as defined in OAR 411-054-0005(19).
(ii) Ensure direct care staff have demonstrated competency in any duty they are assigned. Facility staff in a supervisory role shall perform assessment of each direct care staff.
(iii) Maintain written documentation of all dementia care training completed by each direct care staff and shall maintain documentation regarding each employee’s assessed competency.
(8) APPROVAL OF DEMENTIA TRAINING CURRICULUM. All dementia care training provided to direct care staff must be approved by a private or non-profit organization that is approved by the Department through a ""Request for Application"" (RFA) process.
This Rule is not met as evidenced by:
Plan of Correction:
• Direct care and non-direct care staff audited by Survey will complete training by the compliance date.
• The remainder of staff files will be audited to track completion of required annual trainings.
• The Business Office Manager will audit Pre-Service Infectious Control training in correlation with staff anniversary dates to ensure annual completion.
• A schedule for monthly trainings, as required by staff to maintain compliance, has been created utilizing oregoncarepartners.com.
• The Business Office Manager will be responsible for tracking training for non-direct care staff.
• The Resident Care Coordinator will be responsible for tracking training for direct care staff.
• The Administrator and Wellness Director will review staff records quarterly to ensure compliance.
Citation #5: C0422 - Fire and Life Safety: Training for Residents
Visit History:
t Visit: 9/11/2024 | Not Corrected
1 Visit: 12/4/2024 | Not Corrected
Regulation:
OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents
(5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed on fire and life safety at least annually, with a written record of the content of the training sessions and the residents attending, per the Oregon Fire Code (OFC). Findings include, but are not limited to:
Fire and life safety records were reviewed on 09/11/24 at 11:54 am.
During an interview on 09/11/24 at 12:00 pm, Staff 5 (Maintenance Director) confirmed there was no written record of the training sessions and residents attending for annual fire and life safety instruction.
The need to re-instruct residents on fire and life safety training per the OFC requirements was discussed with Staff 1 (ED), Staff 2 (Wellness Director), and Staff 3 (RN) on 09/11/24. They acknowledged the findings, and no additional information was provided.
OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents
(5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.
This Rule is not met as evidenced by:
Plan of Correction:
• Mandatory training for residents is scheduled during the week of October 21st to review all fire and life safety protocols.
• A sign-in sheet will be provided for attendance.
• Training documents outlining procedures will be distributed.
• The Maintenance Director and Administrator will conduct the meeting.
• The Maintenance Director will follow up with residents who missed the meeting within two weeks of meeting to review information and document that resident has been re-educated.
Citation #6: C0613 - General Building: Doors-Walls, Cleanable
Visit History:
t Visit: 9/11/2024 | Not Corrected
1 Visit: 12/4/2024 | Not Corrected
Regulation:
OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable
(d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair.
Inspection Findings:
Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:
Observations of the facility interior were made throughout the survey between 09/09/24 and 09/11/24. The following was noted in need of cleaning or repair:
*First and second floor elevator shaft doors, exit door near second floor restrooms, doors and door jambs to rooms 102, 106, 110, 201, 204, 207, 209, 214, and 219 had brown and black scuffs, chipped paint and were damaged on the surfaces; and
*Elevator thresholds and wall vents throughout the first and second floors had brown and black debris on the surface.
The surfaces in need of cleaning and repair were toured with Staff 8 (Maintenance Director) and discussed with Staff 1 (ED) on 09/11/24. They acknowledged the findings.
OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable
(d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. An ALF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair.
This Rule is not met as evidenced by:
Plan of Correction:
Elevator and stairwell doors will be cleaned, painted, and receive necessary touch-ups.
• Apartment doors and doorframes will be painted and receive required touch-ups.
• Vents and elevator thresholds will be cleaned monthly by maintenance and housekeeping staff.
• Apartment doors will be checked monthly for repairs.
• The Maintenance Director is responsible for overseeing these corrections.
• The Administrator will conduct spot checks monthly.