Or. Admin. R. 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.
Notes
Statutory/Other Authority: ORS 441.025 & 441.062
Statutes/Other Implemented: ORS 441.060 & 441.062
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(1) The Public Health Division (Division) 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 Division deems necessary.
(2) In lieu of an in-person inspection required under section (1) of this rule, the Division 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 Division, if:
(A) The certification or accreditation is recognized by the Division as addressing the standards and condition of participation requirements of the CMS and other standards set by the Division. Health care facilities must provide the Division with the letter from CMS indicating its deemed status;
(B) The health care facility notifies the Division 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 Division.
(3) A hospital shall permit Division 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, Division staff may conduct an exit conference with the hospital administrator or his or her designee. During the exit conference Division 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, Division 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, Division 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 Division shall issue written findings to the hospital administrator indicating that fact.
(10) If deficiencies are found, the Division shall take informal or formal enforcement action in compliance with OAR 333-501-0025 or 333-501-0030.
Notes
Statutory/Other Authority: ORS 441.025 & 441.062
Statutes/Other Implemented: ORS 441.060 & 441.062