OAR 411-085-0210: Facility Policies

(1) A Quality Assessment and Assurance Committee must develop and adopt facility policies. The policies must be followed by the facility staff and evaluated annually by the Quality Assessment and Assurance Committee and rewritten as needed. Policies must be adopted regarding: (a) Admission, fees, and services; (b) Transfer and discharge, including discharge planning; (c) Physician services; (d) Nursing services; (e) Dietary services; (f) Rehabilitative services and restorative services; (g) Pharmaceutical services, including self administration; (h) Care of residents in an emergency; (i) 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; (j) Activities; (k) Social services; (l) Clinical records; (m) Infection control; (n) Diagnostic services; (o) Oral care and dental services; (p) Accident prevention and reporting of incidents; (q) Housekeeping services and preventive maintenance; (r) Employee orientation and in-service; (s) Laundry services; (t) Possession of firearms and ammunition; (u) Consultant services; (v) Resident grievances; (w) LGBTQIA2S+ Protections policy that includes adding the following statement in its written materials, and in all places and on all materials where that policy or other written materials are posted: “(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).”; and (x) Facility closure. The policy must identify an administrator’s responsibility to assure compliance with OAR 411-085-0025, OAR 411-088-0020(1)(f), and OAR 411-088-0070(1)(g), (3)(d), and (4). (2) Each policy must be in writing and must specify the date the policy was last reviewed by the Quality Assessment and Assurance Committee.