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Nurse Staffing Ron Prinslow, RN, BS
Manager Health Care Licensing and Certification
971-673-0546
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Nurse Staffing Audits and Complaints
5 Audits (not less than 7% annually)
Current selection process: Large and small hospitals
Union and non-union
Currently limited to hospitals without a
previous audit
Complaint Investigations as received
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Nurse Staffing Complaints 2004 - 5 complaints, 2 substantiated
2005 - 1 complaint, not substantiated 2006 - 2 complaints, both substantiated
2007 - 4 complaints, 1 substantiated
Only 1 Civil penalty for $2500.
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Current Survey Process Two person onsite survey
Includes review of documents and staff
interviews. Survey is focused on the performance of the
Nurse Staffing Committee and the WrittenStaffing plan.
Witness testimony in writing seek out equalrepresentation-management and direct carestaff
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Nursing Services Staffing Nursing Services Staffing 333-510-0045 (1)
The hospital must be responsible for the
implementation of a written hospital-widestaffing plan for nursing services. The
staffing plan shall be developed, monitored,
evaluated and modified by a hospital staffing
plan committee.
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Survey Guide 0045(1) Review of the hospital wide Written
Staffing Plan for nursing services (copy)
Review individual staffing plans for patientcare units (copy)
Question direct care staff as to whether theyhad input into the staffing plan
Review meeting minutes and confirmdiscussion of staffing issues (copy 2meeting notes)
Question clinical staff as to whether they are
satisfied with the staffing process
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Survey Guide 0045(1) Review and confirm that the staffing plan
for each patient unit included the number
and categories of staff needed (copy)
Review job descriptions for each unit to
determine whether each job description
sets forth the required qualifications
(copy)
Review a sample of personnel files - include
individuals from each unit
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Survey Guide 0045(1) Review quality assurance
documentation (copy if allowed)
Review any performance indicators for
staffing effectiveness
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Nurse Staffing Committee 333-510-0045(1)(a) The committee shall
include equal numbers of hospital nurse
managers and direct care nurses; (1)(b) The committee shall include at least
one direct care registered nurse from eachhospital nurse specialty or unit. The hospital
shall define its own specialties or units; (1)(c) Have as its primary consideration the
provision of safe patient care and anadequate nurse staff pursuant to this section.
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Survey Guide 0045 (1)(a) Review the makeup of the hospital
staffing plan committee (copy)
Interview clinical staff regarding their
input into the committee
ommittee shall include equal
numbers of hospital nurse managers
and direct care RNs (copy)
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Nurse Staffing Committee 333-510-0045(2) The written staffing
plan shall be evaluated and monitored
for effectiveness and the staffing plan
shall be revised as necessary as part of
the hospital¶s quality assurance
process. Written documentation of these quality assurance activities shall
be maintained.
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Survey Guide 0045(2) Review quality assurance
documentation for evidence that the
staffing plan has been evaluated,
monitored, and revised as necessary.
(Copy)
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Nurse Staffing 333-510-0045(3)(a)The written staffing
plan shall be based on an accurate
description of individual and aggregatepatient needs and requirements for nursing care and include a periodicquality evaluation process to determine
whether the staffing plan isappropriately and accurately reflectingpatient care needs over time.
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Survey Guide (3)(a) Is the written staffing plan based on
individual and aggregate patient needs
and requirements for nursing care?
Has there been periodic quality
evaluation to determine whether the
staffing plan is appropriate?
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Nurse Staffing Plan 333-510-0045(3)(b) The written staffing
plan shall be based on specialized
qualifications and competencies of the
nursing staff. The skill mix and the
competency of the staff shall ensure
that the nursing care needs of thepatient are met and shall ensure patient
safety.
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Survey Guide 0045(3)(b) Do job descriptions identify specialized
qualifications and competencies required by
nursing staff in the various patient care units? Do personnel files contain documentation of
required licensure and certification for nursing
staff in various patient care units?
Review requirements of individual unit
staffing plans.
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Survey Guide 0045(3)(b) Does the hospital have in place systems
to ensure orientation and competencies
of the nursing staff?
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Nurse Staffing 333-510-0045 (3)(c) The written staffing
plan shall be consistent with nationally
recognized evidence-based standards
and guidelines established by
professional nursing specialty
organizations and recognize differencesin patient acuteness.
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Survey Guide 0045(3)© Review individual unit staffing plans
and staffing schedules. (copy)
Interview administrative, supervisoryand clinical staff regarding thestandards considered in developing thewritten staffing plan.
Were the staffing plans consistent withthe identified standards?
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Nurse Staffing 333-510-0045(3)(d) The hospital shall
maintain and post a list of qualified on-call
nursing staff that may be called to providequalified replacement or additional staff in the
event of emergencies, sickness, vacations,
vacancies and other absences... the provides
a sufficient number of replacement staff for the hospital on a regular basis.
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Survey Guide 0045(3)(d) What are the resources used by the
hospital? (copy)
What is the system for obtainingreplacement staff?
Who is responsible for obtaining
replacement staff? Does the system meet the needs of the
hospital?
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Nurse Staffing 333-510-0045 (4) The written staffing plan for
nursing services shall establish minimum
numbers of nursing staff personnel includinglicensed nurses and certified nursingassistants on specified shifts. The number of nursing staff personnel on duty shall besufficient to assure that the nursing careneeds of each patient are met. In no caseshall fewer than one registered nurse andone other nursing care staff member be onduty in a unit when a patient is present.
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Survey Guide 0045(4) Do the individual unit staffing plans
identify the minimum number of nursing
staff required on all shifts?
Review written documentation including
daily staffing schedules, daily house
supervisor reports that identified unitpatient census and staffing, and
individual payroll records.
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Nurse Staffing 333-510-045 (5) The written staffing
plan shall include a formal process for
evaluating and initiating limitations onadmission or diversion of patients toanother acute care facility when, in thejudgment of the direct care registered
nurse, there is an inability to meetpatient care needs or a risk of harm toexisting and new patients.
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Survey Guide 0045(5) Review process for evaluating and
initiating limitations on admission or
diversion (copy)
Does process include the judgment of
the direct care registered nurse?
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Nurse Staffing 333-510-0045 (7)(a) An employer may not
impose upon unionized nursing staff any
changes in wages, hours or other terms andconditions of employment pursuant to astaffing plan developed or modified under subsection (3) of this rule unless theemployer first provides notice to and, onrequest, bargains with the union as anexclusive collective bargaining representativeof the nursing staff in the bargaining unit.
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Nurse Staffing 333-510-0045 (7)(b)
(b) A staffing plan developed or
modified under subsection (3) of this
rule does not create, preempt or modify
a collective bargaining agreement or
require a union or employer to bargainover the staffing plan while a collective
bargaining agreement is in effect.
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Surveyor Guide 0045(7)(a)(b) This rule is between the hospital and
the Union no survey activity.
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Nurse Staffing 333-510-0045 (8) Upon request of a
hospital, the Department of Human
Services may grant variances in thewritten staffing plan requirements based
on patient care needs or the nursing
practices of the hospital. Such requestfor a variance shall follow the procedure
set forth in OAR 333-515-0060.
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Survey Guide 0045(8) Does the facility have a nurse staffing
waiver?
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333-510-0045 (9) When a hospital learns
about the need for replacement staff, the
hospital shall make every reasonable effort toobtain registered nurses, licensed practical
nurses or certified nursing assistants for
unfilled hours or shifts before requiring a
registered nurse, licensed practical nurse, or certified nursing assistant to work overtime.
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Survey Guide 0045(9) Were efforts to seek replacement staff
documented?
Review staffing documentation for
two one-week periods: Select each
week from a different quarter. (if
complaint select dates identified incomplaint intake or interviews)
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Survey Guide 0045(9) Review documentation for each unit¶s staffing
plan and scope of care, each unit¶s staffing
schedule, daily ³staffing needs´ forms, dailyhouse supervisor shift reports that identifypatient census, unit activity, and staffing oneach unit, and payroll records for all staff oneach unit to identify planned versus actual
staff worked.
Interview administrative staff to determinewho is responsible for filling unexpected staff vacancies that arise on individual shifts.
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Survey Guide 0045(9) Interview direct-care staff (Utilize
witness forms)
Does the hospital have a written
policy that defines the
responsibilities to document all
efforts and results of all efforts toadd or replace staff for identified
staffing needs? (copy)
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Survey Guide 0045(9) Reasonable effort includes the hospital
seeking replacement at the time the
vacancy is known and contacting allavailable resources as described in
(3)(d) of this rule. Such efforts shall be
documented.
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Nurse Staffing 333-510-0045(10) A hospital may not require
a registered nurse, licensed practical nurse,
or certified nursing assistant to work: (a) Beyond the agreed-upon shift;
(b) More than 48 hours in any hospital-defined work week; or
(c) More than 12 consecutive hours in a 24-hour period, except that a hospital mayrequire an additional hour of work beyond the12 hours if:
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Nurse Staffing 0045(10) (A) A staff vacancy for the next shift
becomes known at the end of the
current shift; or
(B) There is a potential harm to an
assigned patient if the registered nurse,
licensed practical nurse or certifiednursing assistant leaves the assignment
or transfers care to another.
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Survey Guide 0045(10) Review payroll records for all staff on
all units for the time periods
referenced (if complaint limit tospecific dates)
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Nurse Staffing 333-510-0045 (11)(a) Time spent in required
meetings or receiving education or training
shall be included as hours worked for purposes of subsection (9) of this rule.
(b) Time spent on call but away from the
premises of the employer may not be
included as hours worked for purposes of subsection (9) of this rule.
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Nurse Staffing (c) Time spent on call or on standby
when the registered nurse, licensed
practical nurse or certified nursingassistant is required to be at the
premises of the employer shall be
included as hours worked for purposesof subsection (9) of this rule.
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Survey Guide 0045(11)(a) Does the on call policy meet these
requirements
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Nurse Staffing 333-510-0045 (12) The provisions of this rule
do not apply to nursing staff needs:
(a) In the event of a national or stateemergency or circumstances requiring theimplementation of a facility disaster plan;
(b) In emergency circumstances. Emergency
circumstances include, but are not limited to: (A) Sudden unforeseen adverse weather
conditions;
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Nurse Staffing 0045(12) (B) Infectious disease epidemic of staff; and
(C) Any unforeseen event preventing
replacement staff from approaching or entering the premises; or
(c) If a hospital has made reasonable efforts
to contact all of the on-call nursing staff or
staffing agencies on the list described in
(3)(d) of this rule and is unable to obtain
replacement staff in a timely manner.
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Survey Guide 0045(12) -Does the hospital¶s written staffing plan
reflect these exceptions?
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Nurse Staffing 333-510-0045 (13) A registered nurse at a
hospital may not place a patient at risk of
harm by leaving a patient care assignmentduring an agreed upon shift or an agreed-
upon extended shift without authorization
from the appropriate supervisory personnel
as required by the Oregon State Board of Nursing Oregon Administrative Rules 851-
045-0015(1)(j) and (5).
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Survey Guide 0045(13) -Does the hospital¶s written staffing plan
acknowledge this responsibility?
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Nurse Staffing 333-510-0045 (14) A hospital may not
take retaliatory action against a nursing
staff because the nursing staff person:
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Nurse Staffing 0045(14) (a) Discloses or intends to disclose to a
manager, a private accreditation organization,
or a public body an activity, policy, or practiceof the hospital or of a hospital that the nursingstaff reasonably believes is in violation of lawor a rule or is a violation of professionalstandards of practice that the nursing staff
person reasonably believes poses a risk tothe health, safety, or welfare of a patient or the public.
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Nurse Staffing 0045(14) (b) Provides information to or testifies before
a private accreditation organization or a
public body conducting an investigation,hearing or inquiry into an alleged violation or law or rule or into an activity, policy or practice that may be in violation of professional standards of practice by a
hospital that the nursing staff reasonablybelieves poses a risk to the health, safety or welfare of a patient or the public;
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Nurse Staffing 0045(14) (c) Objects to or refuses to participate in any
activity, policy or practice of a hospital that
the nursing staff reasonably believes is inviolation of law or rule or is a violation of professional standards of practice that thenursing staff reasonably believes poses a riskto the health, safety or welfare of a patient or
the public; or (d) Participates in a committee or peer review
process or files a report or a complaint thatdiscusses allegations of unsafe, dangerous or
potentially dangerous care.
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Survey Guide 0045(14) Interview administrative staff and clinical
staff to determine awareness of this
restriction (who did youinterview)(attach interview sheets)
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Nurse Staffing 333-510-0045 (15) A hospital shall post
a notice summarizing the provisions of
ORS 441.162, 441.166, 441.168,441.174, 441.176, 441.178, and441.192, in a conspicuous place on thepremises of the hospital. The notice
must be posted where notices toemployees and applicants for employment are customarily displayed.
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Survey Guide 0045(15) Has the hospital posted the required
notice? Where posted?