Or. Admin. Code § 333-501-0015

Current through Register Vol. 63, No. 11, November 1, 2024

Section 333-501-0015 - Surveys

(1) The Oregon Health Authority (Authority) shall, in addition to any investigations conducted under OAR 333-501-0010, conduct at least one in-person licensing survey of each hospital every three years to determine compliance with health care facility licensing laws and at such other times as the Authority deems necessary.

(2) In lieu of an in-person inspection required under section (1) of this rule, the Authority may accept:

(a) Centers for Medicare and Medicaid Services (CMS) certification by a federal agency or an approved accrediting organization; or

(b) A survey conducted within the previous three years by an accrediting organization approved by the Authority, if:

(A) The certification or accreditation is recognized by the Authority as addressing the standards and condition of participation requirements of the CMS and other standards set by the Authority. Health care facilities must provide the Authority with the letter from CMS indicating its deemed status;

(B) The health care facility notifies the Authority to participate in any exit interview conducted by the federal agency or accrediting body; and

(C) The health care facility provides copies of all documentation concerning the certification or accreditation requested by the Authority.

(3) A hospital shall permit Authority staff access to the facility during a survey.

(4) A survey may include but is not limited to:

(a) Interviews of patients, patient family members, hospital management and staff;

(b) On-site observations of patients, staff performance, and the physical environment of the hospital facility;

(c) Review of documents and records; and

(d) Patient audits.

(5) A hospital shall make all requested documents and records available to the surveyor for review and copying.

(6) Following a survey, Authority staff may conduct an exit conference with the hospital administrator or his or her designee. During the exit conference Authority staff shall:

(a) Inform the hospital representative of the preliminary findings of the inspection; and

(b) Give the person a reasonable opportunity to submit additional facts or other information to the surveyor in response to those findings.

(7) Following the survey, Authority staff shall prepare and provide the hospital administrator or his or her designee specific and timely written notice of the findings.

(8) If the findings result in a referral to another regulatory agency, Authority staff shall submit the applicable information to that referral agency for its review and determination of appropriate action.

(9) If no deficiencies are found during a survey, the Authority shall issue written findings to the hospital administrator indicating that fact.

(10) If deficiencies are found, the Authority shall take informal or formal enforcement action in compliance with OAR 333-501-0025 or 333-501-0030.

Or. Admin. Code § 333-501-0015

PH 11-2009, f. & cert. ef. 10-1-09; PH 26-2010, f. 12-14-10, cert. ef. 12-15-10; PH 2-2024, amend filed 01/29/2024, effective 1/29/2024; PH 27-2024, minor correction filed 04/08/2024, effective 4/8/2024

Statutory/Other Authority: ORS 441.025 & 441.062

Statutes/Other Implemented: ORS 441.060 & 441.062