justicedao/ipfs_state_laws huggingface dataset:
333-501-0010 Investigations (1) As soon as practicable after receiving a complaint, taking into consideration the nature of the complaint, Oregon Health Authority (Authority) staff will begin an investigation. (2) A hospital shall permit Authority staff access to the facility during an investigation. (3) An investigation may include but is not limited to: (a) Interviews of the complainant, patients of the hospital, patient family members, witnesses, hospital management and staff; (b) On-site observations of patients, staff performance, and the physical environment of the hospital; and (c) Review of documents and records. (4) In determining whether a violation has occurred under OAR 333-501-0020(8), the Authority will consider the facility name, advertising used, and related content. (5) Except as otherwise specified in 42 CFR § 401, Subpart B, information obtained by the Authority during an intake, triage, or investigation of a complaint or reported violation under this section is confidential and not subject to public disclosure under ORS 192.311 to 192.431. Upon the conclusion of the investigation, the Authority may publicly release a report of its findings but may not include information in the report that could be used to identify the complainant or any patient at the health care facility. The Authority may use any information obtained during an investigation in an administrative or judicial proceeding concerning the licensing of a health care facility, and may report information obtained during an investigation to a health professional regulatory board as defined in ORS 676.160 as that information pertains to a licensee of the board. Statutory/Other Authority: ORS 441.025 Statutes/Other Implemented: ORS 441.044 History: PH 24-2025, amend filed 12/18/2025, effective 12/23/2025 PH 25-2024, minor correction filed 04/04/2024, effective 04/04/2024 PH 9-2023, minor correction filed 02/07/2023, effective 02/07/2023 PH 97-2018, minor correction filed 03/20/2018, effective 03/20/2018 PH 31-2016, f. 11-14-16, cert. ef. 11-15-16 PH 26-2010, f. 12-14-10, cert. ef. 12-15-10 PH 11-2009, f. & cert. ef. 10-1-09
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. Statutory/Other Authority: ORS 441.025 & 441.062 Statutes/Other Implemented: ORS 441.060 & 441.062 History: PH 27-2024, minor correction filed 04/08/2024, effective 04/08/2024 PH 2-2024, amend filed 01/29/2024, effective 01/29/2024 PH 26-2010, f. 12-14-10, cert. ef. 12-15-10 PH 11-2009, f. & cert. ef. 10-1-09
333-501-0020 Violations In addition to non-compliance with any health care facility licensing law or condition of participation, it is a violation to: (1) Refuse to cooperate with an investigation or survey, including but not limited to failure to permit Oregon Health Authority (Authority) staff access to the hospital, its documents or records; (2) Fail to implement an approved plan of correction; (3) Fail to comply with all applicable laws, lawful ordinances and rules relating to safety from fire; (4) Refuse or fail to comply with an order issued by the Authority; (5) Refuse or fail to pay a civil penalty; (6) Fail to comply with rules governing the storage of medical records following the closure of a hospital; (7) Establish, conduct, maintain, manage or operate a health care facility or health maintenance organization, without a license; or (8) Use the terms "emergency," "emergency department (ED)," "emergency room (ER)," "emergency-," "emergent-," or "emergi- care center" or any derivative term in a posted name or advertising that would give the impression that emergency medical services as that is defined in OAR 333-500-0010 is provided by the person at a particular facility unless that facility is a hospital licensed under ORS 441.025 with an emergency department. Use of the words "urgent" or "immediate" shall not be considered derivative terms. (9) A person not licensed as a hospital under ORS 441.025 with an emergency department using the terms prescribed in section (8) of this rule has 90 days from November 15, 2016 to come into compliance. Statutory/Other Authority: ORS 441.025 Statutes/Other Implemented: ORS 441.015, 441.025, 441.030 & 441.055 History: PH 28-2024, minor correction filed 04/08/2024, effective 04/08/2024 PH 31-2016, f. 11-14-16, cert. ef. 11-15-16 PH 11-2009, f. & cert. ef. 10-1-09
333-501-0025 Informal Enforcement (1) If, during an investigation or survey Oregon Health Authority (Authority) staff document violations of health care facility licensing laws or conditions of participation, the Authority may issue a statement of deficiencies that cites the law alleged to have been violated and the facts supporting the allegation. (2) A signed plan of correction must be received by the Authority within 10 business days from the date the statement of deficiencies was mailed to the hospital. A signed plan of correction will not be used by the Authority as an admission of the violations alleged in the statement of deficiencies. (3) A hospital shall correct all deficiencies within 60 days from the date of the exit conference, unless an extension of time is requested from the Authority. A request for such an extension shall be submitted in writing and must accompany the plan of correction. (4) The Authority shall determine if a written plan of correction is acceptable. If the plan of correction is not acceptable to the Authority, the Authority shall notify the hospital administrator in writing and request that the plan of correction be modified and resubmitted no later than 10 working days from the date the letter of non-acceptance was mailed to the administrator. (5) If the hospital does not come into compliance by the date of correction reflected on the plan of correction or 60 days from date of the exit conference, whichever is sooner, the Authority may propose to deny, suspend, or revoke the hospital license, or impose civil penalties. Statutory/Other Authority: ORS 441.025 Statutes/Other Implemented: ORS 441.015 & 441.025 History: PH 29-2024, minor correction filed 04/08/2024, effective 04/08/2024 PH 11-2009, f. & cert. ef. 10-1-09
333-501-0030 Formal Enforcement (1) If, during an investigation or survey Oregon Health Authority (Authority) staff document substantial failure to comply with health care facility licensing laws, conditions of participation or if a hospital fails to pay a civil penalty imposed under ORS 441.793, the Authority may issue a Notice of Proposed Suspension or Notice of Proposed Revocation in accordance with ORS 183.411 through 183.470. (2) The Authority may issue a Notice of Imposition of Civil Penalty for violations of health care facility licensing laws. (3) At any time the Authority may issue a Notice of Emergency License Suspension under ORS 183.430(2). (4) If the Authority revokes a hospital license, the order shall specify when, if ever, the hospital may reapply for a license. Statutory/Other Authority: ORS 441.025 Statutes/Other Implemented: ORS 441.015, 441.025, 441.030 & 441.037 History: PH 30-2024, minor correction filed 04/08/2024, effective 04/08/2024 PH 98-2018, minor correction filed 03/20/2018, effective 03/20/2018 PH 11-2009, f. & cert. ef. 10-1-09
333-501-0050 Civil Penalties for Violation of Smoking Prohibition (1) If the Oregon Health Authority (Authority) determines that an administrator or person in charge of a hospital permits a person to smoke tobacco in a hospital or within 10 feet of a doorway, open window or ventilation intake of a hospital, the Authority may assess a civil penalty of not more than $500 per day against the administrator or the person in charge of a hospital. (2) In determining whether an administrator or person in charge of a hospital has permitted a person to smoke tobacco in violation of ORS 441.815, the Authority shall consider whether: (a) A hospital administrator or person in charge of a hospital has taken steps to enforce the smoking prohibitions, including calling law enforcement to report a violation; (b) The hospital administrator or person in charge of a hospital took affirmative action to address any complaints about smoking in a hospital or within 10 feet of a doorway, open window or ventilation intake of a hospital; and (c) A hospital administrator or person in charge of a hospital has taken steps to educate the public and staff about the smoking ban. (3) A civil penalty issued under this rule shall not exceed $2,000 in any 30-day period. (4) A civil penalty imposed under this rule shall comply with ORS 183.745. Statutory/Other Authority: ORS 441.815 Statutes/Other Implemented: ORS 441.815 History: PH 31-2024, minor correction filed 04/08/2024, effective 04/08/2024 PH 11-2009, f. & cert. ef. 10-1-09
333-501-0055 Civil Penalties, Generally (1) This rule does not apply to civil penalties for violations of ORS 441.763, 441.770, 441.815, or 435.254 or rules adopted to implement these statutes. (2) A person that violates a health care facility licensing law, including OAR 333-501-0020 (violations), is subject to the imposition of a civil penalty not to exceed $500 per day per violation. (3) In addition to the penalties under section (2) of this rule, civil penalties may be imposed for violations of ORS 441.030, 441.015(1), 441.048, and 441.049. (4) In determining the amount of a civil penalty, the Oregon Health Authority (Authority) shall consider whether: (a) The Authority made repeated attempts to obtain compliance; (b) The licensee has a history of noncompliance with health care facility licensing laws; (c) The violation poses a serious risk to the public's health; (d) The licensee gained financially from the noncompliance; and (e) There are mitigating factors, such as a licensee's cooperation with an investigation or actions to come into compliance. (5) The Authority shall document its consideration of the factors in section (4) of this rule. (6) Each day a violation continues is an additional violation. (7) A civil penalty imposed under this rule shall comply with ORS 183.745. Statutory/Other Authority: ORS 441.025 Statutes/Other Implemented: ORS 441.990, ORS 441.048, ORS 441.049 & ORS 441.992 History: PH 32-2024, minor correction filed 04/08/2024, effective 04/08/2024 PH 6-2021, amend filed 01/22/2021, effective 01/24/2021 PH 59-2020, temporary amend filed 07/29/2020, effective 08/01/2020 through 01/24/2021 PH 31-2016, f. 11-14-16, cert. ef. 11-15-16 PH 26-2010, f. 12-14-10, cert. ef. 12-15-10 PH 11-2009, f. & cert. ef. 10-1-09
333-501-0060 Approval of Accrediting Organizations (1) An accrediting organization may request approval by the Oregon Health Authority (Authority) to ensure that hospitals meet state licensing standards. (2) An accrediting organization shall request approval in writing and shall provide, at a minimum: (a) Evidence that it is recognized as a deemed organization by CMS; or (b) If the accrediting organization is not a deemed organization under CMS, provide: (A) Documentation of program policies and procedures that its accreditation process meets state licensing standards; (B) Accreditation history; and (C) References from a minimum of two facilities currently receiving services from the organization. (3) If the Authority finds that an accrediting organization has the necessary qualifications to certify that state licensing standards have been met, the Authority will enter into an agreement with the accrediting organization. Statutory/Other Authority: ORS 441.062 Statutes/Other Implemented: ORS 441.062 History: PH 33-2024, minor correction filed 04/08/2024, effective 04/08/2024 PH 26-2010, f. 12-14-10, cert. ef. 12-15-10
333-503-0002 Applicability These rules apply to hospital staffing pursuant to ORS 441. 760 to 441. 795 . Statutory/Other Authority: ORS 413.042 & ORS 441.760 - 441.795 Statutes/Other Implemented: ORS 441.760 - 441.795 History: PH 46-2024, adopt filed 05/15/2024, effective 05/15/2024 PH 59-2023, temporary adopt filed 12/21/2023, effective 01/01/2024 through 06/28/2024
333-503-0010 Filing Hospital Staffing Complaints (1) Only a hospital staff person or an exclusive representative of a hospital staff person may submit a complaint. (2) Complaints must be submitted through the Oregon Health Authority (Authority)’s website, on a form prescribed by the Authority. Individuals that need an accommodation for filing a complaint can contact the Authority . (3) Once a complaint has been filed, the Authority will process complaints in the manner described in ORS 441. 791 and OAR 333-503-0020. Statutory/Other Authority: ORS 413.042 & ORS 441.760 - 441.795 Statutes/Other Implemented: ORS 441.151 - 441.177 History: PH 46-2024, adopt filed 05/15/2024, effective 05/15/2024 PH 59-2023, temporary adopt filed 12/21/2023, effective 01/01/2024 through 06/28/2024
333-503-0020 Processing Complaints (1) The Oregon Health Authority (Authority) will only investigate complaints that are: (a) Valid complaints; and (b) Submitted within 60 calendar days of the violation alleged in the complaint. (2) Once the Authority has determined that a complaint is a timely valid complaint, the Authority will begin its investigation in accordance with ORS 441. 791 and these rules. (3) To establish it is not subject to civil penalty for a violation of a staffing plan pursuant to ORS 441.793(4), the hospital must submit, no later than 20 days after receiving notice of an investigation under ORS 441.791(2 )(c), documentation to the Authority demonstrating the actions it took, if any, described in ORS 441.793(4). The Authority will consider the documentation timely submitted by a hospital to determine whether the hospital is subject to civil penalty under ORS 441.793(4) for a violation of a nurse staffing plan, a professional or technical staffing plan, or a service staffing plan. (4) To establish that a hospital is not in violation of a staffing plan under ORS 441.765(6), 441.775(12), or 441.776(12), the hospital must submit no later than 20 days after receiving notice of an investigation under ORS 441.791(2)(c), documentation of all allowed deviations, including documentation that the deviation was reported to the applicable staffing committee within 10 days of the deviation, occurring on the day of the alleged violations and the 29 days prior to the alleged violation. The Authority will consider documentation timely submitted by a hospital to determine the number of allowed deviations accrued in a rolling 30-day period under ORS 441.765(6), 441.775(12), and 441.776(12), including whether the alleged violation is an allowed deviation. Statutory/Other Authority: ORS 413.042 & ORS 441.760 - 441.795 Statutes/Other Implemented: ORS 441.760 - 441.795 History: PH 46-2024, adopt filed 05/15/2024, effective 05/15/2024 PH 59-2023, temporary adopt filed 12/21/2023, effective 01/01/2024 through 06/28/2024
333-503-0050 Hospital Staffing Plan Waiver (1) A hospital may request a waiver under ORS 441. 778 to the written hospital-wide staffing plan requirements in ORS 441. 760 to 441. 795 , if the waiver is necessary to ensure that the hospital is staffed to meet the health care needs of its patients. (2) All requests for a waiver must: (a) Be submitted to the Oregon Health Authority (Authority) in writing; (b) Identify the specific requirement requested to be waived; (c) State the reason or reasons for which the hospital is seeking the waiver; (d) Identify alternatives considered, if any, and why alternatives (including compliance) were not selected; (e) Demonstrate that the waiver is necessary for the hospital to ensure the hospital is staffed to meet patient health care needs; and (f) Explain whether the hospital notified the applicable staffing committee of the request for a waiver prior to its submission. (3) Upon finding that the hospital has satisfied the conditions of this rule, the Authority may grant a waiver. (4) A hospital may not implement a waiver under ORS 441. 778 until it has received written approval from the Authority. (5) This rule does not apply to variances under ORS 441.763(6). Statutory/Other Authority: ORS 413.042 & ORS 441.778 Statutes/Other Implemented: ORS 441.760 - 441.795 History: PH 46-2024, adopt filed 05/15/2024, effective 05/15/2024 PH 59-2023, temporary adopt filed 12/21/2023, effective 01/01/2024 through 06/28/2024
333-503-0060 Nursing Staff Member Overtime For purposes of determining hospital compliance with ORS 441. 770 , and whether a hospital has a violation under ORS 441.792 (2)(h): (1) “Emergency circumstances” includes: (a) Sudden and unforeseen adverse weather conditions; (b) An infectious disease outbreak suffered by hospital staff; (c) Any unforeseen event preventing replacement staff from approaching or entering the premises; or (d) Unplanned direct care staff vacancies of 20 percent or more of the nursing staff for the next shift hospital-wide at the Oregon State Hospital if, based on the patient census, the Oregon State Hospital determines the number of direct care staff available hospital-wide cannot ensure patient safety. (2) "Infectious disease outbreak " means a significant or notable increase in the number of cases in hospital staff of a disease or other condition of public health importance. (3) “Nursing staff” means only registered nurses, licensed practical nurses, and certified nursing assistants. (4) "Require" means to make compulsory as a condition of employment, whether as a result of a previously scheduled shift or hours actually worked during time spent on call or on standby. Statutory/Other Authority: ORS 413.042 & ORS 441.770 Statutes/Other Implemented: ORS 441.760 - 441.795 History: PH 1-2026, minor correction filed 01/06/2026, effective 01/06/2026 PH 46-2024, adopt filed 05/15/2024, effective 05/15/2024 PH 59-2023, temporary adopt filed 12/21/2023, effective 01/01/2024 through 06/28/2024
333-505-0001 Applicability These rules apply to all hospitals, regardless of classification. Statutory/Other Authority: ORS 441.025 Statutes/Other Implemented: 441.025 History: PH 17-2012, f. 12-20-12, cert. ef. 1-1-13 PH 11-2009, f. & cert. ef. 10-1-09 HD 21-1993, f. & cert. ef. 10-28-93
333-505-0005 Governing Body Responsibility (1) In a multi-hospital system, one governing body may oversee multiple hospitals. (2) The governing body of a hospital shall be responsible for the operation of the hospital, the selection of the medical staff and the quality of care rendered in the hospital. The governing body shall ensure that: (a) All health care personnel for whom a state license or registration is required are currently licensed or registered; (b) Qualified individuals allowed to practice in the hospital are credentialed and granted privileges consistent with their individual training, experience and other qualifications; (c) Procedures for granting, restricting and terminating privileges exist and that such procedures are regularly reviewed to assure their conformity to applicable law; (d) It has an organized medical staff responsible for reviewing the professional practices of the hospital for the purpose of reducing morbidity and mortality and for the improvement of patient care; (e) A physician is not denied medical staff privileges at the facility solely on the basis that the physician holds medical staff membership or privileges at another health care facility; (f) Licensed podiatric physicians and surgeons are permitted to use the hospital in accordance with ORS 441.063; and (g) All hospital employees and health care practitioners granted hospital privileges have been tested for tuberculosis in compliance with OAR 333-505-0070. (3) A hospital may grant privileges to nurse practitioners or physician associates in accordance with ORS 441.064 and subject to hospital rules governing credentialing and staff privileges. Privileges granted to certified nurse midwives, if any, must be consistent with privileges granted to other medical staff and include: (a) Admitting privileges that do not require a certified nurse midwife to co-admit a patient with a physician who is a member of the medical staff; and (b) Voting rights; (4) A hospital shall require that every patient admitted shall be and remain under the care of a member of the medical staff as specified under the medical staff by-laws. Statutory/Other Authority: ORS 441.025 Statutes/Other Implemented: ORS 441.055 & 441.064 History: PH 57-2024, minor correction filed 06/06/2024, effective 06/06/2024 PH 2-2024, amend filed 01/29/2024, effective 01/29/2024 PH 14-2020, amend filed 03/24/2020, effective 03/24/2020 PH 210-2018, amend filed 05/17/2018, effective 05/17/2018 PH 7-2016, f. & cert. ef. 2-24-16 PH 17-2012, f. 12-20-12, cert. ef. 1-1-13 PH 26-2010, f. 12-14-10, cert. ef. 12-15-10 PH 11-2009, f. & cert. ef. 10-1-09 OHD 20-2002, f. & cert. ef. 12-10-02 HD 2-2000, f. & cert. ef. 2-15-00 HD 21-1993, f. & cert. ef. 10-28-93, Renumbered from 333-505-0000 HD 29-1988, f. 12-29-88, cert. ef. 1-1-89, Renumbered from 333-070-0050 HD 11-1980, f. & cert. ef. 9-10-80, Renumbered from 333-023-0125
333-505-0007 Health Care Practitioner Credentialing Each hospital shall comply with the health care practitioner and telemedicine provider credentialing requirements in accordance with OAR chapter 409, division 045. Statutory/Other Authority: ORS 441.056 Statutes/Other Implemented: ORS 441.056 & ORS 441.222 History: PH 7-2016, f. & cert. ef. 2-24-16 PH 17-2012, f. 12-20-12, cert. ef. 1-1-13 PH 11-2009, f. & cert. ef. 10-1-09 PH 3-2005, f. & cert. ef. 2-4-05 PH 4-2004, f. & cert. ef. 2-6-04 OHD 5-2002, f. & cert. ef. 3-4-02