Oregon Regulatory Compliance Resources for Residential Care Facilities

The sources outline several conditions and actions that are prohibited within these facilities:

• Abuse: Facilities, their employees, agents, and licensees are prohibited from permitting, aiding, or engaging in abuse of residents under their care. Abuse includes sexual, physical, mental, verbal, and financial exploitation.
• Discrimination: Facilities must not discriminate or permit discrimination, including 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 association with another individual on these grounds. This prohibition extends to:
  • Denying admission, transfer, or refusing to transfer or evict a resident based on discriminatory criteria.
  • Denying a request to choose a roommate when sharing a room.
  • Refusing to assign a room to a transgender or LGBTQIA2S+ resident other than in accordance with the resident’s gender identity, unless requested by the resident or required by federal law.
  • Prohibiting a resident from using, or harassing a resident who seeks to use or does use, a restroom available to other individuals of the same gender identity, regardless of transition status, hormones, surgery, or presentation. Harassment includes requiring documentation of gender identity for restroom access.
  • Repeatedly and willfully refusing to use a resident’s name or pronouns after being reasonably informed.
  • Denying a resident the right to wear clothing, accessories, or cosmetics, or engage in grooming practices permitted to other residents.
  • Restricting a resident’s right to associate with others, including consensual sexual relations or physical affection, unless the restriction is uniformly applied in a nondiscriminatory manner.
  • Denying or restricting appropriate medical or nonmedical care, or providing care that unduly demeans dignity or causes avoidable discomfort.
  • Failing to accept a resident’s verbal or written attestation of gender identity or requiring proof.
  • Failing to take reasonable actions to prevent discrimination or harassment when the facility knows or should have known.
  • Refusing or willfully failing to provide any service, care, or reasonable accommodation to a resident or potential resident.
• Interference and Retaliation: Facilities shall not interfere with an employee or volunteer making a good faith disclosure about abuse or actions affecting a resident’s safety or welfare. This includes asking staff to sign non-disclosure agreements, training them not to disclose information, or communicating that they may not disclose information. Facilities must not retaliate in any way against anyone who participates in an abuse complaint, such as restricting access to the facility or residents, or dismissing or harassing an employee.
• Inappropriate Financial Practices: Resident personal incidental fund accounts may not be co-mingled with facility funds. Using resident funds for items or services that are not for the exclusive benefit of the resident is prohibited if the resident lacks capacity and has no legal representative. Facilities or businesses with incident of ownership history that failed to reimburse states for Medicaid overpayments or civil penalties or failed to compensate employees/pay operational costs during the past five years are prohibited from obtaining a license.
• Record Falsification and Improper Disclosure: A written policy must prohibit the falsification of records. Unless required by law, facilities shall not disclose personally identifiable information about a resident’s sexual orientation, LGBTQIA2S+ status, gender transition status, or HIV status. Appropriate steps must be taken to minimize inadvertent disclosure, and residents/representatives must be notified if it occurs.
• Conflicting Agreements: Facilities may not include any provision in the residency agreement, summary statement, or disclosure information that conflicts with these rules or requires a resident to waive their rights or the facility’s liability for negligence.
• Medication/Treatment Issues: Only a physician or legally recognized prescribing practitioner can change a medication or treatment order. Direct care staff administering psychotropic medications for behavior must know specific reasons, common side effects, and when to contact a health professional. Psychotropic medication administered p.r.n. for behavior must have written, resident-specific parameters.
• Restraint Use: Supportive devices with restraining qualities are permitted only under specific documented circumstances. Anything meeting the definition of restraint, including supportive devices with restraining qualities, must follow the Individually-Based Limitation process as of July 1, 2018. A risk agreement shall not be entered into or continued with a resident unable to recognize the consequences of their behavior or choices.
• Staffing Restrictions: Staff under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under 18 must be directly supervised when providing bathing, toileting, incontinence care, or transferring services.
• Facility Structure/Safety: Stairways, halls, doorways, passageways, and exits must be unobstructed. Exit doors may not include locks that delay or prevent evacuation, except as specified by building codes and with written Department approval. The use of extension cords and other special taps is not allowed in wiring systems.

Facilities are required to prepare, maintain, and provide various documents:

• Licensing Application: Applicants for initial licensure or renewal must complete the Department’s application form, signed and dated by the legally authorized representative, including all requested information and the licensing fee.
• Ownership Information: Applications must include identification of financial interest for individuals with 10% or more incident of ownership (5% or more for Medicaid population), and for facilities serving Medicaid populations managed by a Board of Directors, the social security number and date of birth for each board member.
• Background Checks: A completed background check request form is required for the applicant and individuals with significant ownership interest (10%+ or 5%+ for Medicaid) with initial applications and for renewal when required. Background checks must be submitted for all subject individuals for a criminal fitness determination, including before a change in position.
• ABST Information: Facilities must identify the Department-approved Acuity-Based Staffing Tool (ABST) they will implement. For proprietary ABSTs, facilities must submit a review request form and sample reports. An ABST Summary Statement for approved proprietary ABSTs must be developed and maintained, available upon request. An annual statement attesting to no substantive changes in proprietary ABST design is required. ABST reports must be produced for all residents, identifying care elements and staff time. The date of the last ABST evaluation for each resident must be available.
• Fiscal Responsibility: Applicants must submit proof of fiscal responsibility, including verifiable evidence of fiscal solvency sufficient to operate for 60 days, with liquid assets for 45 days (Anticipated Medicaid income is not liquid assets). A pro forma for the first 12 months of operation is also required.
• Market Analysis: For new construction or licensing of existing buildings not currently licensed, an independent market analysis completed by a third-party professional is required before applying for a building permit. This is not required for Conversion Facilities or change of owner applicants of existing licensed buildings.
• Letter of Intent: Prospective applicants for new construction or licensing of an existing building not currently licensed must submit a letter of intent to the Department before applying for a building permit. Conversion Facility licensees must submit a Letter of Intent at least 90 days before planned closure.
• Building Drawings: After submitting the letter of intent, one set of building drawings and specifications must be submitted to FPS. Drawings for assisted living or residential facilities must be prepared by and bear the stamp of an Oregon licensed architect or engineer.
• Project Completion Checklist: At least two working days before the scheduled onsite licensing inspection, a completed and signed Project Completion/Inspection Checklist must be submitted to the Department and FPS.
• Certificate of Occupancy: A copy of the Certificate of Occupancy must be submitted to the Department and FPS before admitting any resident.
• Confirmation of Licensure: The applicant must receive written confirmation of licensure from the Department before admitting any resident.
• Policies and Procedures: Facilities must develop and implement written policies and procedures covering areas such as firearms, sexual relations between staff and residents, resident complaints, change of condition monitoring, health services, refunds, financial management, smoking, referral for acute sexual assault, not receiving gifts, infection prevention/control, and ABST implementation. An LGBTQIA2S+ Nondiscrimination Notice must be included and posted.
• Disclosure Documents: Facilities must provide the Uniform Disclosure Statement (Department form APD 9098A), Residency Agreement, and Consumer Summary Statement to potential residents before move-in. Disclosure information must be written in compliance with rules. A revised Consumer Summary Statement must be sent to the Department before a change of ownership or management.
• Residency Agreement: A written, legally enforceable agreement between the facility and the resident or legal representative must be provided before move-in. It must be reviewed by the Department before distribution and include specific terms regarding occupancy, payment, service evaluation/costs, rate changes, refunds, scope of services, service planning, available services, health care philosophy, resident rights/responsibilities, medication packaging, and move-out criteria. Facilities must retain copies and provide them to the resident/representative. Changes require 30 days’ notice to residents and submission to the Department.
• Resident Evaluations: Evaluations must be performed before move-in (with updates within 30 days), at least quarterly (corresponding with service plan updates), and reviewed/updated upon a significant change of condition. Evaluations must be done in person, documented, dated, and indicate who was involved. The evaluation must address specific elements including name, pronouns, gender identity, routines/preferences, and physical health status. 24 months of past evaluations must be kept on-site. The ABST evaluation must be updated based on changes to the service plan, quarterly updates, or significant change of condition. Each resident’s ABST evaluation must individually address and document all ABST care elements.
• Service Plans: A service plan must be completed before resident move-in (with updates within 30 days) and following quarterly evaluations. It must be readily available to staff and provide clear direction. The plan must describe who, what, when, how, and how often services are provided. Changes must be dated and initialed. The service plan must be reviewed and updated for a significant change of condition. A copy of the plan and updates must be offered to the resident/legal representative.
• Training Documentation: Facilities must maintain written documentation of all trainings completed by each employee. This includes documentation of direct care staff competency. Certificates of completion for pre-service infectious disease training and dementia care training (if applicable) must be available upon request. Appropriate staff must document observation and evaluation of staff’s ability to perform medication/treatment administration unsupervised.
• Medication and Treatment Records: An accurate Medication Administration Record (MAR) must be kept for all medications and treatments administered by the facility. It must include specific details like resident name, medication/treatment name, dose, route, frequency, date/time administered, allergies, parameters for p.r.n., initials of person administering, and documentation of deviations or refusals. Legible signatures of staff administering medications/treatments must be maintained. Documentation related to recommendations from the 90-day review of medications/treatments by a pharmacist or RN must be provided.
• Documentation for Supportive Devices: Documentation of circumstances allowing supportive devices with restraining qualities (resident request/approval, assessment, less restrictive alternatives, staff instruction) is required. Documentation of supportive device use must be included in the service plan and evaluated quarterly.
• Documentation for Individually-Based Limitations: Use of an individually-based limitation must be documented in the person-centered service plan using a program-approved form, documenting the specific assessed need, positive interventions used, less intrusive methods tried, clear description of the limitation, data collection plan, time limits for review (at least annually), informed consent (including any discrepancy with legal representative), and assurance of no harm. Providers must maintain a copy of the signed consent form. Regular data collection and review are required.
• Change of Condition Documentation: Documentation of staff instructions or interventions for a change in condition must be resident-specific and part of the resident record, with weekly progress noted until the condition resolves.
• Monitoring Policies: Written policies are required for a 24-hour resident monitoring and reporting system, specifying staff responsibilities and criteria for notifying the administrator, RN, or healthcare provider.
• Nursing Documentation: Documentation of RN delegation and teaching must be in accordance with Oregon State Board of Nursing rules. If a licensed nurse participates in a Service Planning Team meeting due to a significant change of condition, or reviews the updated service plan, it must be documented with date and signature within 48 hours.
• Staffing Plan: A posted staffing plan must be developed using ABST results, outlining required staffing numbers per shift. Historical posted staffing plans must be maintained for a minimum of three years. Staffing documentation must be maintained to show consistent staffing meeting or exceeding the posted plan 24/7.
• Involuntary Move-out Documentation: When proposing an involuntary move-out, facilities must submit documentation to the Department, which may include attempts to resolve the issue, progress notes, MARs, evaluations, clinical assessments, physician notes, consistency with facility disclosures/agreements, and witness information. Upon Department approval, the facility must submit the final version of forms APD 0568 and MSC 0443 to specified parties.
• Resident Account Records: Facilities must maintain a record showing all monies received and disposition of funds on behalf of the resident, with supporting documentation. A copy must be provided to the resident quarterly. Lists and receipts are required for items purchased for residents.
• Fire Drill Records: Records of fire drills must be maintained, including date, time, shift, person conducting, escape route, problems, evacuation time, staff participating, and number of occupants evacuated.
• Emergency Preparedness Plan: A written emergency preparedness plan must be prepared and maintained, analyzing potential hazards and addressing resident medical needs and supplies for shelter in place. The plan must be reviewed/updated annually and available on-site. Written notification to the Department of facility status is required during emergencies requiring evacuation or when requested.
• Administrator Documentation: Newly hired administrators must complete and submit the Administrator Reference Summary (SDS 0566) to the Department upon hire. Documentation of background and qualifications for a proposed interim administrator is required.
• Closure Notification: Upon facility closure, the licensee must provide written notification to the Department of the location of all resident records. For permanent closure, a written proposal must be submitted 60 days prior, specifying the plan for safe resident transfer.

Facilities must ensure adequate and qualified staffing to meet resident needs and regulatory requirements:

• Sufficient Staffing: Facilities must consistently have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Staffing levels are the number of staff required to meet these needs, established using an acuity-based staffing tool. The licensee is responsible for assuring staffing is increased for resident move-in needs and changing physical or mental needs. Facilities must consistently meet the scheduled and unscheduled needs of all residents, 24 hours a day, seven days a week.
• Acuity-Based Staffing Tool (ABST): Facilities must select and implement a Department-approved ABST for determining appropriate staffing levels. The ABST must accurately capture care time and elements provided to each resident based on their individual service plan, with care time being resident-specific. It must include care elements and staff time needed for each, presenting total time in minutes per shift, per day (or daily minutes for proprietary ABSTs). ABST evaluations must be completed, updated, reviewed, and documented before move-in, whenever there is a significant change of condition, and at least quarterly corresponding with service plan updates.
• Staffing Plan: Facilities must develop a staffing plan for each shift, which outlines the staffing numbers required to meet the scheduled and unscheduled needs of all residents. Staffing plans must incorporate and be consistent with the facility’s ABST data. Posted staffing plans must reflect distinct and segregated areas within the facility. Staffing plans must incorporate ABST total time, unscheduled needs, minimum staffing requirements per OAR 411-054-0070(1), and other applicable factors. Paid or unpaid staff meal breaks should not be included in the total scheduled staff time. Facilities must maintain documentation to show consistent staffing meets or exceeds the posted staffing plan 24 hours a day, seven days a week.
• Minimum Staffing: A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs. In facilities with residents in two or more detached buildings or distinct/segregated areas, a designated caregiver must be awake and available in each building/area at all times.
• Specific Needs/Exceptional Payments: Staffing required by Specific Needs Contracts or exceptional payments must be included in the ABST. Facilities must staff to the greater of the numbers indicated by the contract/exception or the ABST.
• Universal Workers: If universal workers perform duties in addition to direct care, staffing must be increased to maintain adequate resident care.
• Nursing Staff: Adequate nursing hours relevant to the census and acuity of the resident population must be assured. IICs must meet contract requirements for nursing hours. Licensed nurses must deliver specific nursing services. A licensed nurse must participate in the Service Planning Team or review/sign the updated service plan within 48 hours if a resident experiences a significant change of condition.
• Fire Safety Staffing: There must be adequate direct care staff present at all times to meet fire safety evacuation standards based on resident acuity and facility structural design. If a facility fails to meet the applicable evacuation level during a drill, they must make immediate efforts to make changes, including potentially increasing staff levels.
• Administrator: Each facility must employ a full-time administrator who is scheduled to be on-site at least 40 hours per week. Administrators must be licensed by January 1, 2022.
• Training Requirements: Direct care staff must be trained prior to providing care. Required training includes resident care assistance, Department-approved LGBTQIA2S+ training, abuse reporting, fire safety, emergency procedures, and infectious disease prevention. Facilities with memory care endorsements/contracts must ensure staff complete pre-service dementia care training. Direct care staff must receive pre-service orientation to the resident and their service plan. Staff must be directly supervised until competency is demonstrated.
• Department Assessment: The Department is required to assess facility staffing levels during surveys or investigations into complaints regarding abuse, injury, safety, or staffing levels. The Department confirms the use of an approved ABST and verifies consistent staffing to meet needs, consistent staffing level updates, and consistent staffing to the posted plan. Regulatory action may be taken if the facility is not consistently staffing to ABST levels, updating plans, updating ABSTs, accurately capturing care element time, accurately capturing care provided, or using an approved ABST.