Or. Admin. Code § 847-010-0073 - Reporting Requirements
(1) Board
licensees and health care facilities must report to the Board as required by
ORS 676.150,
677.092,
677.190, and
677.415. These reports include,
but are not limited to, the following:
(a) A
licensee must self-report to the Board:
(A)
Any conviction of a misdemeanor or felony or any arrest for a felony crime to
the Board within 10 days after the conviction or arrest;
(B) Any adverse action taken by another
licensing jurisdiction or any peer review body, health care institution,
professional or medical society or association, governmental agency, law
enforcement agency or court for acts or conduct similar to acts or conduct that
would constitute grounds for disciplinary action as described in ORS chapter
677;
(C) Any official action taken
against the licensee within 10 business days of the official action;
or
(D) A voluntary withdrawal from
practice, voluntary resignation from the staff of a health care facility or
voluntary limitation of the licensee's staff privileges at a health care
facility if the licensee's voluntary action occurs while the licensee is under
investigation by the health care facility or its committee for any reason
related to possible medical incompetence, unprofessional conduct or physical
incapacity or impairment within 30 calendar days.
(b) A licensee who has reasonable cause to
believe that another state licensed health care professional has engaged in
prohibited or unprofessional conduct must report the conduct within 10 working
days to the board responsible for the other professional unless disclosure is
prohibited by state or federal laws relating to confidentiality or protection
of health information.
(c) A
licensee must report within 10 business days to the Board any information that
appears to show that a licensee is or may be medically incompetent or is or may
be guilty of unprofessional or dishonorable conduct or is or may be a licensee
with a physical incapacity.
(d) A
health care facility must report to the Board:
(A) Any official action taken against a
licensee within 10 business days of the date of the official action;
or
(B) A licensee's voluntary
withdrawal from practice, voluntary resignation from the staff of a health care
facility or voluntary limitation of the licensee's staff privileges at a health
care facility if the licensee's voluntary action occurs while the licensee is
under investigation by the health care facility or its committee for any reason
related to possible medical incompetence, unprofessional conduct or physical
incapacity or impairment within 30 calendar days.
(2) For purposes of the statutes, reporting
to the Board means making a report to the Board's Investigation Unit or the
Board's Executive Director or the Board's Medical Director. Making a report to
the Board's Health Professionals' Services Program (HPSP) or HPSP's Medical
Director does not satisfy the duty to report to the Board.
(3) For the purposes of ORS chapters 676 and
677, the terms medical incompetence, unprofessional conduct, and impaired
licensee have the following meanings:
(a)
Medical Incompetence: A licensee who is medically incompetent is one who is
unable to practice medicine with reasonable skill or safety due to lack of
knowledge, lack of ability, or impairment. Evidence of medical incompetence
shall include:
(A) Gross or repeated acts of
negligence involving patient care.
(B) Failure to achieve a passing score or
satisfactory rating on a competency examination or program of evaluation when
the examination or evaluation is ordered or directed by the Board or a health
care facility.
(C) Failure to
complete a course or program of remedial education when ordered or directed to
do so by the Board or a health care facility, or a medical education or
training program.
(b)
Unprofessional conduct: Unprofessional conduct includes the behavior described
in ORS 677.188(4),
defined as conduct which is unbecoming to a person licensed by the Board or
detrimental to the best interest of the public, and which includes:
(A)
(i) Any
conduct or practice contrary to recognized standards of ethics of the medical,
podiatric, or acupuncture professions, or
(ii) Any conduct which does or might
constitute a danger to the health or safety of a patient or the public, to
include a violation of patient boundaries, or
(iii) Any conduct or practice which does or
might adversely affect a provider's ability to safely and skillfully practice
medicine, podiatry, or acupuncture; or
(iv) Practicing with a condition that is
adversely affecting a provider's ability to safely and skillfully practice
medicine, podiatry, or acupuncture.
(B) Willful performance of any surgical or
medical treatment which is contrary to acceptable medical standards.
(C)
(i)
Willful and repeated ordering or performance of unnecessary laboratory tests or
radiologic studies; or
(ii)
Administration of unnecessary treatment; or
(iii) Employment of outmoded, unproved, or
unscientific treatments, except as allowed in ORS
677.190 (1)(b);
or
(iv) Failing to obtain
consultations when failing to do so is not consistent with the standard of
care; or
(v) Otherwise utilizing
medical service for diagnosis or treatment which is or may be considered
inappropriate or unnecessary.
(D) Fraud in the performance of, or the
billing for, medical procedures.
(E) Repeated instances of disruptive behavior
in the health care setting that could adversely affect the delivery of health
care to patients.
(F) Sexual
misconduct: Licensee sexual misconduct is behavior that exploits the
licensee-patient relationship in a sexual way. The behavior is non-diagnostic
and non-therapeutic, may be verbal, physical or other behavior, and may include
expressions of thoughts and feelings or gestures that are sexual or that
reasonably may be construed by a patient as sexual. Sexual misconduct includes
but is not limited to:
(i) Sexual violation:
Licensee-patient sex, whether or not initiated by the patient, and engaging in
any conduct with a patient or the patient's immediate family that is sexual or
may be reasonably interpreted as sexual, including but not limited to:
(I) Sexual intercourse;
(II) Genital to genital contact;
(III) Oral to genital contact;
(IV) Oral to anal contact;
(V) Genital to anal contact;
(VI) Kissing in a romantic or sexual
manner;
(VII) Touching breasts,
genitals, or any sexualized body part for any purpose other than appropriate
examination or treatment, or where the patient has refused or has withdrawn
consent;
(VIII) Encouraging the
patient to masturbate in the presence of the licensee or masturbation by the
licensee while the patient is present; or
(IX) Offering to provide practice-related
services, such as medications, in exchange for sexual
favors.
(ii) Sexual
impropriety: Behavior, gestures, or expressions that are seductive, sexually
suggestive, or sexually demeaning to a patient or the patient's immediate
family, to include:
(I) Sexually exploitative
behavior, to include taking, transmitting, viewing, or in any way using photos
or any other image of a patient, their family or associates for the prurient
interest of others.
(II)
Intentional viewing in the health care setting of any sexually explicit conduct
for prurient interests.
(III)
Having any involvement with child pornography, which is defined as any visual
depiction of a minor (a child younger than 18) engaged in sexually explicit
conduct.
(IV) Sexually explicit
communication in person, by mail, by telephone, or by other electronic means,
including but not limited to text message, e-mail, video or social
media.
(G)
Conduct not otherwise allowed by Oregon law which is contrary to or
inconsistent with recognized standards of ethics of the medical, podiatric, or
acupuncture professions, specifically conduct that is contrary to or
inconsistent with:
(i) Any principle, opinion,
or provision of the American Medical Association's 2016 Code of
Ethics.
(ii) Ethical standards
established by a specialty board as defined in OAR
847-020-0100:
(I) In which the licensee is certified,
and
(II) Which were in place at the
time the conduct occurred.
(iii) Ethical standards established by the
medical college or specialty society:
(I) In
which the licensee practices or practiced at the time of the conduct,
and
(II) Which were in effect as of
April 7, 2022.
(iv) Any
provision of the American Osteopathic Association's 2016 Code of
Ethics.
(v) Any provision of the
American Podiatric Medical Association's 2017 Code of Ethics.
(vi) Any provision of the 2008 (reaffirmed in
2013) American Association of Physician Assistants' Guidelines for Ethical
Conduct for the Physician Assistant Profession.
(vii) Any provision of the Oregon Association
of Acupuncture and Oriental Medicine's 2008 Code of Ethics.
(viii) Any provision of the National
Certification Commission for Acupuncture and Oriental Medicine's 2023 Code of
Ethics.
(H) Intentionally
contacting the known complainant or allowing any person authorized to act on
behalf of the licensee to contact the known complainant in regard to the
complaint or investigation unless and until the licensee has requested a
contested case hearing and the Board has authorized the taking of the
complainant's deposition pursuant to ORS
183.425.
(I) In the practice of acupuncture, the
failure to meet the standard of care of a reasonably prudent, careful, and
skillful practitioner of acupuncture under the same circumstances, in the same
or similar community. In the practice of acupuncture, errors of such repetition
or magnitude that a willful disregard of practice standards or patient safety
may be inferred.
(J) Discrimination
in the practice of medicine, podiatry, or acupuncture resulting in differences
in the quality of healthcare delivered that is not due to access-related
factors or clinical needs, preferences, and appropriateness of
intervention.
(c)
Licensee Impairment: A licensee who is impaired is a licensee who is unable to
practice medicine with reasonable skill or safety due to factors which include,
but are not limited to:
(A) The use of
alcohol, drugs, prescribed medication, or other substances while on or off duty
which causes impairment when on duty, including taking call or supervising
other healthcare professionals, regardless of practice setting.
(B) Mental or emotional illness.
(C) Physical deterioration or long term
illness or injury which adversely affects cognition, motor, or perceptive
skills.
(4) For
the purposes of the reporting requirements of this rule and ORS
677.415, licensees shall be
considered to be impaired if they refuse to undergo an evaluation for mental or
physical competence or chemical impairment, or if they resign their privileges
to avoid such an evaluation, when the evaluation is ordered or directed by a
health care facility or by this Board.
(5) For the purposes of the reporting
requirements of this rule and ORS
677.415, official action does
not include administrative suspensions of seven or fewer calendar days for
failure to maintain or complete records. Administrative suspensions described
in this section must be reported as an official action when the suspensions
occur more than three times in any 12-month period.
(6) A report made by a board licensee or the
Oregon Medical Association or other health professional association, to include
the Osteopathic Physicians and Surgeons of Oregon, Inc, or the Oregon Podiatric
Medical Association to the Board under ORS
677.415 shall include the
following information:
(a) The name, title,
address and telephone number of the person making the report;
(b) The information that appears to show that
a licensee is or may be medically incompetent, is or may be guilty of
unprofessional or dishonorable conduct or is or may be a licensee with an
impairment.
(7) A report
made by a health care facility to the Board under ORS
677.415 (5) and
(6) shall include:
(a) The name, title, address and telephone
number of the health care facility making the report;
(b) The date of an official action taken
against the licensee or the licensee's voluntary action withdrawing from
practice, voluntary resignation or voluntary limitation of licensee staff
privileges; and
(c) A description
of the official action or the licensee's voluntary action, as appropriate to
the report, including:
(A) The specific
restriction, limitation, suspension, loss or denial of the licensee's medical
staff privileges and the effective date or term of the restriction, limitation,
suspension, loss or denial; or
(B)
The fact that the licensee has voluntarily withdrawn from the practice of
medicine or podiatry, voluntarily resigned from the staff of a health care
facility or voluntarily limited the licensee's privileges at a health care
facility and the effective date of the withdrawal, resignation or
limitation.
(8)
A report made under ORS
677.415 Section 2 may not
include any information that is privileged peer review data, see ORS
41.675.
(9) All required reports shall be made in
writing.
(10) Any person who
reports or provides information in good faith as required by the statutes is
immune from civil liability for making the report.
Notes
Statutory/Other Authority: ORS 677.265 & 677.417
Statutes/Other Implemented: ORS 676.150, 677.092, 677.190, 677.205, 677.265 & 677.415
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