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In 2001 the Oregon Legislature enacted into law the provisions of House Bill (HB) 2800. The law can be found in the Oregon Revised Statutes (ORS) 441.160 through 441.192. The law sets forth requirements for hospital nursing services staffing. These include:
- Specific requirements and limitations with respect to hospital nursing services staffing;
- A requirement that hospitals post a notice of the ORS affecting nurses;
- A mandate to the Oregon Department of Human Services to conduct a random audit of not less than seven percent of all hospitals in the state solely to verify compliance with the requirements of ORS 441.162, written staffing plan for nursing services; ORS 441.166, need for replacement of staff; and ORS 441.192, notice of employment outside of hospital;
- A mandate to the Oregon Department of Human Services to prepare an annual report summarizing the audit findings;
- Provisions for assessment of civil penalties, when applicable; and
- Whistle-blower protection.
The Health Care Regulation and Quality Improvement (HCRQI) section of the Department of Human Services is the agency responsible for the licensure of hospitals in the State of Oregon. HCRQI was charged with drafting the Oregon Administrative Rules (OARs) for Hospitals that were required to implement the statutes.
As part of the rule-making process, HCRQI convened a work group with broad representation of all interested parties to draft rule language. The work group met a number of times and rules were drafted. Two public hearings were held on the proposed rule language, and the rules were filed on December 10, 2002.
The rule-making process resulted in the adoption of two new sections and significant revisions to the OARs for Hospitals for nurse staffing. The rules can be found in the OARs for Hospitals at the following sites:
HCRQI staff developed a standardized audit process intended to evaluate a hospital's compliance with all of the rules related to nurse staffing. Hospitals will be randomly selected from the list of hospitals licensed in the State of Oregon. The audits will be unannounced - surveyors will not notify the hospital of the audit prior to their arrival at the hospital.
The audit process will include the following tasks:
- A tour will be conducted of one or more hospital units. Clinical staff assigned to the unit are interviewed with respect to the nursing process and staffing.
- Documentation is reviewed including, but not limited to, the following: the hospital's written staffing plan for nursing services; individual unit staffing plans; staffing guidelines or matrices for each unit; the daily staffing or payroll reports for each unit to verify actual staff who worked and the number of hours staff worked; nurse staffing policies; nurse staffing committee meeting minutes; quality assurance data; reports of inadequate staffing filed by clinical staff; nurse sensitive outcome data related to infection control, decubitus ulcers, medication errors, and patient satisfaction surveys; job descriptions; and personnel files for evaluation of current licensure/certification, qualifications, in-service training, and performance evaluations.
- Interviews are conducted with nursing administrative, management, and clinical staff.
- The hospital environment is observed for posting of the required notice.
The findings are reviewed against the requirements set forth in the OARs for Hospitals. A narrative report is documented for each hospital audit. A copy of the report is sent to the hospital along with a standard form entitled a Statement of Deficiencies. A copy of both is retained in the hospital's permanent facility file in the HCRQI office located in the Portland State Office Building, 800 NE Oregon Street, Portland, OR 97232. The telephone number is 971-673-0540.