Oregon Department of Human Services, Aging and People with Disabilities and Developmental Disabilities

Rule Rule 411-054-0320
Quality Measurement Program and Council

(1) The purpose of the Quality Measurement Program is to allow facilities and the public to compare residential care and assisted living facility performance on each quality metric. The Department shall provide and maintain a web-based report based on metrics defined in Or Laws 2017, ch 679, § 15(1) and any other metrics determined by the Quality Measurement Council. The first report from this program will be published July 1, 2021.
(2) Quality Measurement Council. The Quality Measurement Council is appointed by the Governor, and consists of the following members:
(a) One individual representing the Oregon Patient Safety Commission.
(b) One individual representing residential care facilities or assisted living facilities.
(c) One consumer representative from an Alzheimer’s advocacy organization.
(d) One licensed health care practitioner with experience in geriatrics.
(e) Two individuals associated with academic institutions who have expertise in research data and analytics and community-based care and quality reporting.
(f) The Long-Term Care Ombudsman or a designee of the Long-Term Care Ombudsman.
(g) One individual representing the Department.
(3) A staff coordinator shall be assigned by the Department to support the council. The staff coordinator will assist the council as needed and ensure the annual report required by Or Laws 2017, ch 679, § 15(3) and (4) are implemented.
(4) The council shall determine the form and manner for facilities to report metrics for the prior calendar year. Data that identifies a resident is excluded from this requirement.
(a) In developing quality metrics, the council shall consider whether:
(A) Reported data reflects and promotes quality care; and
(B) Reporting the data is unnecessarily burdensome on residential care and assisted living facilities.
(b) On or after January 1, 2022, the council may update, by rule, the quality metrics to be reported by residential care and assisted living.
(5) Annual facility reports.
(a) All residential care and assisted living facilities shall report required metrics to the Department no later than January 31 of each year. The first reports are due January 31, 2021.
(b) Each facility shall report the following quality metrics for the prior calendar year:
(A) Retention of direct care staff.
(B) Falls resulting in physical injury.
(C) Use of antipsychotic medication for nonstandard purposes.
(D) Facility compliance with staff training requirements.
(E) Results of an annual resident satisfaction survey conducted by an independent entity.
(F) A metric that measures the quality of the resident experience.
(G) Any other metrics determined by the council.
(6) Annual report from the Department.
(a) The Department shall develop an annual report by July 1st that is based on the information provided by all reporting residential care and assisted living facilities. This report shall be made available online to each facility. The first report is due July 1, 2021.
(b) The report shall be in a standard format and written in plain language.
(c) The report must include data compilation, illustration, and narratives. The report also must:
(A) Describe statewide patterns and trends that emerge from the collected data.
(B) Describe compliance data maintained by the Department.
(C) Identify facilities that substantially fail to report data as required.
(D) Allow facilities and the public to compare a facility’s performance on each quality metric, by demographics, geographic region, facility type, and other categories the Department believes may be useful to consumers and facilities.
(E) Show trends in performance for each quality metric.
(F) Identify patterns of performance by geographic regions, and other categories the Department believes will be useful to consumers.
(G) Identify the number, severity, and scope of regulatory violations by each geographic region.
(H) Show average timelines for surveys and investigations of abuse or regulatory noncompliance.
(d) Quality metric data reported to the Department under this section may not be used against the facility, as required under Or Laws 2017, ch 679, § 15(7). This section does not exempt a facility from complying with state law. Also, the Department may use quality metric data obtained during the normal course of business or compliance activity, as required by Or Laws 2017, ch 679, § 15(8).
(7) Online Training. The Department shall develop online training modules for facilities and the public.
(a) Training modules shall address the top two statewide issues identified by surveys or reviews of facilities during the prior year.
(b) Training modules shall be available and accessible by January 1, 2019.
(c) The Department shall post and regularly update the data used to prepare the report.

Last accessed
Jun. 8, 2021