The findings of the re-licensure survey, conducted 03/27/23 through 03/28/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation was completed prior to providing services to residents, and staff received a copy of their job description for 2 of 2 newly hired staff (#s 4 and 5) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were requested on 03/27/23.

Staff 5 (Universal Worker/MT), hired 12/22/22, lacked documented evidence of completing the required pre-service orientation, prior to providing service to residents, including:

* Resident rights and values of CBC care;

* Abuse reporting requirements; and

* Fire safety and emergency procedures.

Staff 4 (Universal Worker/MT), hired 11/15/22, lacked evidence of receiving a written job description.

The need for staff to complete required pre-service orientation before working with residents and be provided a written job description was reviewed with Staff 1 (Administrator) on 03/27/23 and 03/28/23. She acknowledged the findings.

OAR 411-054-0070 (3-4) Staffing Rqmts

and Training: Caregiver Rqmts

1.a) Staff hired on 12/22/22 has been removed from the schedule and will complete the required

pre-service orientation prior to being scheduled for resident care; including residents rights and value's of CBC care, abuse reporting requirements and fire safety and emergency procedures.

1.b) Staff hired on 11/15/22 signed her job description during her onboarding, 11/08/22. This was printed out and placed in her file on 4/03/23.  

2)Each new staff members pre-service orientation will be reviewed to ensure completed, before providing service to residents.

3.)Staff training records will be reviewed with every new hire and audited monthly using the Monthly Administrator Quality Assurance Audit Tool.

4.)The Administrator or designee will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly hired staff (# 4) had documented demonstration of competency in all required areas within 30 days of hire, including competency prior to performing medication and treatment administration. Findings include, but are not limited to:

Review of the facility's training records on 03/27/23 indicated the following:

*Staff 4 (Universal Worker/MT), hired 12/22/23, lacked documented evidence an observation and evaluation had been completed which determined Staff 4's abilities to perform safe medication and treatment administration unsupervised and lacked documented evidence of 30-day competency in the following areas:

* Role of service plans in providing individualized care;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of  condition;

* Conditions that require assessment, treatment, observation and reporting; and

* First Aid/Abdominal Thrust.

Staff 4 had been observed passing medication, but there was no evidence appropriate facility staff had evaluated Staff 4's ability to perform safe medication and treatment administration unsupervised.

Staff 1 (Administrator) agreed Staff 4 would have documented evidence of competence in medication administration before completing the task independently.

The need to ensure staff demonstrated competency in their job duties within 30-days of hire, or prior to independently performing the duties as a MT was discussed with Staff 1 (Administrator) on 03/27/23 and 03/28/23. She acknowledged the findings.

OAR 411-054-0070 (6)(9) Training within

30 days: Direct Care Staff

1a.) Staff hired on 12/22/22 has been removed from performing medication and treatment administration until documented re-training can be completed.  

1.(b) An audit of staff training records will be completed and any staff without the required demonstrated competencies within 30 days of hire including: Role of service plans in providing individualized care; changes associated with normal aging; identification, documentation and reporting of changes of condition; conditions that require assessment, treatment and observation and reporting, as well as abdominal thrust,  will be provided the training.  

2.) An audit will be completed at initial, 30 day, 60 day, and 90 days to ensure all required demonstrated compentencies and trainings are complete and done in a timely manner.

3.)Staff training records will be reviewed with every new hire and audited monthly using the Monthly Administrator Quality Assurance Audit Tool.

4.)The Administrator or designee will be responsible to see that the corrections are completed and monitored.