ADMINISTRATIVE REVIEW TOOL
AGENCY:
REVIEWER:
ADMINISTRATOR:
PARTICIPANTS:
DATE(S) OF REVIEW (mm/dd/yyyy):
-
DATE OF REPORT (mm/dd/yyyy):
Compliant
Criteria for Compliance
I.
Y
N
Comments/Documentation/Explanation/Timelines
ORGANIZATION
A. There is a local public health authority (LPHA). ORS 431.375
B. There is a local board of health (BOH). ORS 431.410
C. There is evidence of communication between the LPHA and BOH.
ORS 431.418(3)(a)(c)
There is a commissioner assigned as liaison to public health. Name:
1. There is an annual public health plan: ORS 431.385 (1-3)
a. The plan was submitted by May 1
b. The plan was approved.
c. The plan addresses all program areas.
2. LPHA maintains an office open to the public during the normal work
week of the local government. OAR 333-014-0070(6)
3. The essential services are provided. ORS 431.416 (2)(a-e)
a. Epidemiology, control of preventable diseases and disorder.
b. Parent and child health services, including family planning clinics
as described in ORS 435.205.
c. Collection and reporting of health statistics.
d. Health information and referral services.
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e. Environmental health services
4. Other programs are provided according to the community's health
needs. OAR 333-014-0050(3)(a-i)
a. Dental health including preventive education, promotion of fluoride
use and procedures for early detection and treatment of dental
problems.
b. Emergency preparedness including participation in the development
of the county's emergency response plans and internal procedures
necessary to carry out the health department's role in the plans.
c. Health education/health promotion including activities and
programs to promote health and assist individuals and groups to
achieve and maintain healthy behaviors.
d. Laboratory services including providing diagnostic and screening
tests to support public health services that are in compliance with
quality assurance guidelines established by the Public Health
Division.
e. Medical examiner services to coordinate the epidemiological
investigation of deaths of public health significance with the county
medical examiner.
f. Nutrition services including identification and intervention with
clients at nutritional risk, and education and consultation for the
promotion of good dietary habits.
g. Older adult health including services to reduce morbidity and
premature death; detect conditions that impair functioning;
strengthen the ability to remain independent; and to promote
physical, social and emotional well-being.
h. Primary health care services including participation in community
efforts to promote necessary services and/or provide health
services.
i. Shellfish sanitation (in coastal counties) to monitor harvesting and
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provide public information to harvesters of shellfish.
II.
STAFFING AND QUALIFICATIONS
If there are staff who do not meet minimum qualifications, this is not a compliance finding, but the issue should be addressed in the annual plan
by providing details of a plan to reach minimum qualifications. CLHO Minimum Standards (CLHO MS), Public Health Personnel
Responsibilities and Qualifications
A. A qualified health administrator has been appointed to supervise activities
of the district in accordance with the law.
ORS 431.418(1); CLHO MS
B. There is a licensed professional nurse who directs nursing practice.
C. The supervising public health nurse meets the minimum qualifications.
CLHO MS.
D. Nursing staff are licensed by the Oregon State Board of Nursing (OSBN).
OAR 333-014-0070(2)
E. A health officer is employed or contracted who is a licensed physician and
is responsible for the medical supervision of the health programs. ORS
431.418(2)
F. The Environmental Health Supervisor meets minimum qualifications.
CLHO MS
G. Environmental Health Specialists (Sanitarians) are registered by the
National Environmental Health Association (Sanitarians Registration
Board).
OAR 333-014-0070(2)
H. Written performance evaluations are conducted annually or according to
county policy. CLHO MS
I. All positions have current written job descriptions, including minimum
qualifications. CLHO MS
III.
MEDICAL RECORDS AND CONFIDENTIALITY
A. Client protected health information (PHI) is safeguarded from unlawful
use or disclosure. ORS 192.553 (a)
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B. HIPAA requirements are met. 45 CFR parts 160 & 164
1. There is a designated privacy official. 45 CFR part 164.530 (a)(1)
2. All members of workforce have been trained in HIPPA.
45 CFR part 164.530 (b)(1)
3. There is a process for new employee training.
45 CFR part 164.530 (b)(2)(B)
C. Written policies and procedures exist to guide staff in maintaining
appropriate confidentiality standards. CLHO MS
1. Clients may access their own records. ORS 192.553 (b)
2. Immunization records ORS 433.092 and ORS 433.280
3. Mandatory reporting:
a. Elder abuse ORS 124.060
b. Child abuse ORS 419B.005 – 419B.050
c. Abuse mentally ill or of those with development disabilities
ORS 430.737 and 430.743
d. Long-term care ORS 441.640 and 441.645
4. Release of protected health information with authorization.
45 CFR part 160.508
5. Release of protected health information without authorization.
45 CFR part 164.512
6. Rights of minors. ORS 109.610, 109.640, 109.650
7. Subpoena. 45 CFR part 164.512 (e)(ii)
D. Records retention policy and practice are compliant with the most current
rules prescribed by the State Archives.
OAR 166-150-0065-0075
E. Records are protected from fire, water, unauthorized access and theft.
OAR 166-020-0015
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IV.
PHARMACY
A. There are written policies and procedures for drug dispensing, storage,
security and accountability, signed by the health officer.
OAR 855-043-0130
B. Drug cabinet or room is locked in the absence of the health officer or
registered nurse. Only these persons shall have a key.
OAR 855-043-0130(1)(a)
C. Drugs which are outdated or damaged shall be quarantined and physically
separated from the other drugs until they are destroyed or returned to
supplier. OAR 855-043-0130(4)(a)
1. Emergency kit is adequately stocked and current.
D. Drug dispensing record is maintained separately from the patient chart and
kept for a minimum of three years. Record shall include the name of
patient, name of drug, date and initials of the person dispensing. OAR
855-043-0130(5)(a)(A-D)
E. Current pharmacy license is posted at all sites. ORS 689.615 (1)
V.
LABORATORY
A. There is a current, valid CLIA certificate. 42 CFR 493.3(a)(1)
VI.
FACILITY
A. LPHA phone numbers and facility addresses are publicized. CLHO MS
B. Written policies and procedures exist to guide staff in responding to an
emergency. 29 CFR § 1910.38
C. Equipment, including scales and fire extinguishers, is maintained and
calibrated regularly. 29 CFR § 1910.157 (e)(3)
D. All indoor areas of health department facilities are smokefree.
ORS 433.835-440
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1. A person may not smoke or carry any lighted instrument within 10 feet
of entrances, exits, windows that open, ventilation intakes that serve an
enclosed area, or accessibility ramps.
OAR 333-015-0035(3)(4)
2. No smoking signs are posted prominently at all entrances and exits.
Signs shall use either the “no smoking” symbol and the words “within
10 feet,” or the words “no smoking within 10 feet,” or both. OAR 333015-0040
3. There are no ashtrays or receptacles used for smoking or depositing
cigarette debris within 10 feet of entrances, exits, accessibility ramps
that extend 10 feet from entrance or exit, windows that open, or
ventilation intakes that serve an enclosed area.
OAR 333-015-0045
E. Entire campus is smokefree.
VII.
CLIENT CARE PROTOCOLS
A. Nurse scope of practice is supported by current, signed policies,
procedures and standing orders.
(Oregon State Board of Nursing, Nurse Practice Act, Division 45)
1. Communicable Disease
2. Immunization
3. STD
4. Reproductive Health
B. There is a nurse delegation policy and procedure in place for:
Certified Nurse Assistant (CNA)
Unlicensed assitive personnel
Medical Assistant (MA)
VIII. CULTURAL & LINGUISTIC COMPETENCY
A. Health promotion interventions are culturally, linguistically and age
appropriate. CLHO MS
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B. Ongoing staff training in cultural competence is documented.
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