Or. Admin. Code § 333-076-0117

Current through Register Vol. 63, No. 12, December 1, 2024

Section 333-076-0117 - ASC Surveys

(1) The Authority shall, in addition to any investigations conducted under OAR 333-076-0116, conduct at least one on-site licensing survey of each ASC 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 onsite inspection required under section (1) of this rule, the Authority may accept:

(a) 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 for Coverage requirements of the CMS and other standards set by the Authority;

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

(C) The ASC provides copies of all documentation concerning the certification or accreditation requested by the Authority including:

(i) Written evidence of all corrective actions underway, or completed, in response to approved accrediting organizations recommendations;

(ii) All progress reports; and

(iii) The letter from CMS indicating its deemed status.

(3) If the deemed status of an ASC changes, the ASC administrator must notify the Authority.

(4) An ASC shall permit Authority staff access to the facility during a survey.

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

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

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

(c) Review of documents and records; and

(d) Patient audits.

(6) An ASC shall make all requested documents and records available to the surveyor for review and copying.

(7) Following a survey, Authority staff may conduct an exit conference with the ASC administrator or the administrator's designee. During the exit conference Authority staff shall:

(a) Inform the ASC 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.

(8) Following the survey, Authority staff shall prepare and provide the ASC administrator or the administrator's designee specific and timely written notice of the findings.

(9) 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.

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

(11) If deficiencies are found, the Authority shall take informal or formal enforcement action in accordance with OAR 333-076-0255 or OAR 333-076-0260.

Or. Admin. Code § 333-076-0117

PH 1-2019, adopt filed 01/07/2019, effective 1/7/2019

Statutory/Other Authority: ORS 441.025 & 441.062

Statutes/Other Implemented: ORS 441.025, 441.062 & 441.060