ODHS expands safety action plan with consultant’s early report on oversight of long-term care

Today, the Oregon Department of Human Services (ODHS) released details of its safety action plan for oversight of providers who serve older adults and people with disabilities who live in facilities and adult foster homes.

The plan follows the preliminary report from a third-party consultant hired to conduct an external assessment of state oversight of licensed long-term care providers.

“Safety is essential to the well-being of the people we serve and is our program’s number one priority,” said Nakeshia Knight-Coyle, Ph.D., director of the ODHS Office of Aging and People with Disabilities (APD). “A&M’s independent perspective is valuable as we work to better meet people’s needs and prepare to keep pace with demand in coming decades.”

Consultant Alvarez and Marsal (A&M) issued a preliminary report on its findings and recommendations as part of a contract with ODHS to conduct an external assessment of state oversight of licensed long-term care providers. The external consultant began its work at Governor Tina Kotek’s direction following a report released in April 2024 by the Oregon Long-Term Care Ombudsman’s office.

This is all part of the agency’s proactive work to reform the licensing and oversight unit to better align resources with state and federal requirements and strengthen operations.

In 2024, ODHS developed a short- and long-term safety action plan. ODHS added to that plan with additional 30-, 60- and 90-day goals that build upon this work and align with specific A&M recommendations. Some of these improvements are:

Improve protocol for responding to serious safety violations

• Action plan: In 30 days update the protocol for an Immediate Jeopardy finding in facilities and adult foster homes with serious safety breaches.
• Already underway: Twice-a-week huddles added in 2024 to give staff additional guidance in responding to serious safety incidents.

Clarify Letters of Agreement policy

• Action plan: Update the policy in 30 days for agreements that address provider performance issues that could result in regulatory action. In 60 days, provide training and update the Compliance Framework Guide. In 90 days, convene a Rules Advisory Committee to update Oregon Administrative Rules.
• Already underway: In 2024, APD developed more detailed manager guidance on when a Letter of Agreement would be allowed.

Add workshops on statutory requirements

• Action plan: Compile in 30 days a list of statutes by license type to serve as a training tool. In 60 days, managers will complete a refresher review. In 90 days, staff will renew training.
• Already underway: APD leadership identified areas of statute in 2024 to provide additional guidance for managers.
  

Improve morale and add support for managers

• Action plan: Identify resources within 30 days to develop an employee engagement program. In 60 days, finalize the plan.
• Already underway: Managers in February 2025 began developing staff support strategies in response to an employee survey and feedback.
  

Address resource shortages in the unit

• Action plan: In 60 days, use results of a second A&M analysis underway to evaluate distribution of resources.
• Already underway: APD’s budget request included in the Governor's Recommended Budget​ calls for 19​ ​new positions. In 2024, APD issued a Request for Application for contractors to provide temporary staffing.

When complete by June 2025, A&M’s full assessment will include an evaluation of resources needed to meet current and future demand. ODHS hired A&M through a competitive Request for Proposal process.

Updates on APD’s safety initiatives are provided on the ODHS website.