OAR 411-020-0120
Facility Investigation, Documentation, and Notification


Facility investigations shall be objective, professional, and complete.


A facility investigation shall be conducted and documented when a resident of a facility licensed by APD is reported to have been abused by a licensee, staff member, contractor or volunteer of the facility.


Facility investigations may also occur when a facility resident is reported to have been abused by an alleged perpetrator not employed, contracted or supervised by the facility, to determine whether the licensee or facility staff failed to protect the resident.


In completing a facility investigation, the APS worker must:


Identify the alleged victim, the alleged perpetrators, and any parties reported to have information relevant to proving or disproving the allegation.


Conduct interviews with the parties described in section (a) above to gather all relevant available evidence. Interviews shall be in person and unannounced whenever possible. All interviews must be private unless the individual being interviewed requests the presence of someone else. Any individuals listening to the interview must be advised of the confidential nature of the investigation.


Obtain and review any available and relevant documentary or physical evidence.


Gather and include evidence relevant to determining the conduct of the alleged perpetrators and severity of the risk or outcome to the alleged victim.


The Department may photograph, or cause to have photographed, any alleged victim for the purposes of preserving evidence of the alleged victim’s condition observed at the time of the investigation. The photographs shall be considered records and subject to confidentiality rules.


Create additional investigatory aids, such as maps or drawings, that may aid in proving or disproving the allegations.


Maintain a record of interviews and evidentiary review, in notes, recordings, photographs, scanned documents, or other appropriate means.


Determine the facts of the case based on a fair and objective review of the available relevant evidence; and


Conclude whether the preponderance (majority) of the evidence indicates that abuse was substantiated or unsubstantiated, that the evidence is inconclusive, or that the investigation should be closed administratively without a determination.


In conducting facility abuse investigations, the Department protocols governing activities of investigations further include:


Notifying the Department’s Office of Safety, Oversight and Quality (SOQ) if a situation exists in a licensed care facility that may cause SOQ to conduct a survey or provide an immediate regulatory response. This includes reports of facility-wide issues.


Providing an opportunity for the reporter, a designee of the reporter, or both, to accompany the investigator to the site of the reported violation for the sole purpose of identifying individuals or objects relevant to the investigation.


Conducting an unannounced site visit to the facility.


Confirming that immediate protection for facility residents is in place. The worker must obtain and document a safety plan from the provider to correct any problem immediately, and communicate with SOQ as needed.


Investigations must be documented and closed in the Centralized Abuse Management (CAM) system.


The local office must complete the facility investigation within the timelines determined by the Department and relevant statute (unless delayed by a concurrent criminal investigation or otherwise by policy) and prepare a preliminary report that includes, but is not limited to, the following information:


The dates, locations, and a description of the initial reported abuse.


The date that the investigation was commenced and completed, and by whom.


Characteristics of the alleged victim including identified language, race, and ethnicity.


Relationship of the alleged victim to the reporter, witnesses, and alleged perpetrators.


A statement of the specific allegations investigated.


The statements of all parties interviewed regarding the allegation.


A description of documents and records reviewed during the investigation, summarizing their content to the extent necessary to explain their relevance to the investigation, and support the findings of fact.


A summary of any direct observations by the investigator that are relevant to the investigation and its findings.


A statement of the factual basis for any findings and a summary of the findings made as a result of the investigation, including attributions to witness statements, documents, or observations that support each finding of fact.


A conclusion.


A summary of actions taken by the licensee or provider to ensure the safety of the victim and other residents of the facility.


A summary of protective services offered to the alleged victim, with outcomes, if known.


A summary of referrals to other agencies or authorities resulting from the investigation, with outcomes, if known.


Reasons for any deviations from required timelines or standard practices.


When the preliminary facility investigation is closed, the local office shall distribute a copy of substantiated reports to the facility for their information and safety planning. The local office must retain facility investigation records for a period of 15 years after last activity.


Upon receipt of the preliminary report from the local office, SOQ will review and finalize the report. Final facility reports are maintained and distributed by APD central office. When abuse is substantiated, findings may be used to support civil or criminal sanctions against the perpetrators or the care facility.


The Department must collect statewide data on all aspects of Adult Protective Services as specified by Department policy and procedure. As reasonably requested, the local offices shall provide data not otherwise available through centralized Department data systems.

Source: Rule 411-020-0120 — Facility Investigation, Documentation, and Notification, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=411-020-0120.

Last Updated

Jun. 8, 2021

Rule 411-020-0120’s source at or​.us