Or. Admin. R. 333-505-0030 - Organization, Hospital Policies
(1) A hospital 's internal organization shall
be structured to include appropriate departments and services consistent with
the needs of its defined community.
(2) A hospital shall adopt and maintain
clearly written definitions of its organization, authority, responsibility and
relationships.
(3) A hospital shall
adopt, maintain and follow written patient care policies that include but are
not limited to:
(a) Admission and transfer
policies that address:
(A) Types of clinical
conditions not acceptable for admission;
(B) Constraints imposed by limitations of
services, physical facilities or staff coverage;
(C) Emergency admissions;
(D) Requirements for informed consent signed
by the patient or legal representative of the patient for diagnostic and
treatment procedures; such policies and procedures shall address informed
consent of minors in accordance with provisions in ORS
109.640,
109.670, and
109.675;
(E) Requirements for identifying persons
responsible for obtaining informed consent and other appropriate disclosures
and ensuring that the information provided is accurate and documented
appropriately in accordance with these rules and ORS
441.098; and
(F) A process for the internal transfer of
patients from one level or type of care to another;
(b) Discharge , termination of services, and
release from emergency department policies in accordance with OAR 333-505-0055
and OAR 333-520-0070;
(c) Patient
rights, including but not limited to compliance with OAR
333-505-0033;
(d)
Housekeeping;
(e) All patient care
services provided by the hospital ;
(f) Maintenance of the hospital 's physical
plant, equipment used in patient care and patient environment;
(g) Treatment or referral of acute sexual
assault patients in accordance with ORS
147.403; and
(h) Identification of patients who could
benefit from palliative care in order to provide information and facilitate
access to appropriate palliative care in accordance with ORS
413.273.
(4) In addition to the policies described in
section (3) of this rule, a hospital shall, in accordance with
42 CFR
489.102, ORS
127.649, and ORS
127.652, adopt and maintain
written policies and procedures concerning a patient's right to accept or
refuse medical or surgical treatment and the right to formulate an advance
directive or appoint a health care representative.
(5) A hospital may not condition the
provision of treatment on a patient having a POLST as that term is defined in
ORS 127.663, an advance directive as
defined in ORS 127.505, a form appointing a
health care representative under ORS
127.510, or any instruction
relating to the administration, withholding or withdrawing of life-sustaining
procedures or artificially administered nutrition and hydration.
(6) A hospital 's transfer agreements or
contracts shall clearly delineate the responsibilities of parties
involved.
(7) Patient care policies
shall be evaluated triennially and rewritten as needed and presented to the
governing body or a designated administrative body for approval triennially.
Documentation of the evaluation is required.
(8) A hospital shall have a system, described
in writing, for the periodic evaluation of programs and services, including
contracted services.
Notes
Statutory/Other
Statutes/Other Implemented: ORS 413.273, 441.025, 441.051, 441.054 & 441.048
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