333-200-0295 Enforcement (1) Following a survey, a member of the survey team may conduct an exit conference with the applicant or his or her designee. During the exit conference, a survey team member shall: (a) Inform the applicant or designee of the preliminary findings of the survey; and (b) Give the person a reasonable opportunity to submit additional facts or other information to the surveyor in response to those findings. (2) Following the survey, a determination shall be made and Oregon Health Authority (Authority) staff shall prepare and provide the applicant or his or her designee specific and timely written notice of the findings. An applicant shall have 30 days from receipt of the survey report to request a reconsideration of the categorization. (3) If during a survey, the survey team documents non-compliance with trauma rules or laws, the deficiencies will be identified in the survey report and the laws alleged to have been violated and the facts supporting the allegation. (a) A corrective action plan must be mailed to the Authority within 45 to 60 calendar days from the date the survey report was received by the applicant. (b) The Authority shall prescribe the time frame an applicant has to correct all deficiencies. The time frame shall be based on the seriousness of the deficiencies and whether any deficiencies affect patient safety. (c) The Authority may determine that a focused review is necessary within one year of the date of the survey in order to determine that the deficiencies identified in the survey report have been corrected. (4) Upon receipt of the Authority’s written survey report, an applicant shall be provided an opportunity to dispute any findings including identified deficiencies. If an applicant desires an informal conference to dispute the survey findings, the applicant shall notify the Authority in writing within 10 calendar days after receipt of the written survey report. The written request must include a detailed explanation of why the applicant believes the findings are inaccurate. (5) The Authority shall determine if a corrective action plan is acceptable. If the plan of correction is not acceptable to the Authority, the Authority shall notify the applicant in writing or by telephone: (a) Identifying which provisions in the plan the Authority finds unacceptable; (b) Citing the reasons the Authority finds them unacceptable; and (c) Requesting that the plan of correction be modified and resubmitted no later than 30 calendar days from the date the letter of non-acceptance was received by the applicant. (6) The Authority may re-survey a trauma system hospital, immediately suspend or revoke a trauma system hospital categorization or place a hospital on probation under any of the following circumstances: (a) Substantial failure, for any reason, of a hospital to comply with these rules, all current state and area trauma system standards, and all policies, protocols and procedures as set forth in the approved area trauma system plan; or (b) Submission of reports to the Authority that are incorrect or incomplete in any material aspect. (7) Except as set forth in OAR 333-200-0285(3), occasional failure of a trauma system hospital to meet its obligations will not be grounds for probation, suspension or revocation by the Authority if the circumstances under which the failure occurred: (a) Do not reflect an overall deterioration in quality of and commitment to trauma care; and (b) Are corrected immediately by the hospital. (8) Failure of a trauma system hospital to comply with the data reporting requirements under OAR 333-200-0265(8) after the Authority has utilized an independent data collection and abstraction service pursuant to OAR 333-200-0285(3) is grounds for suspension or revocation as a trauma hospital. (9) A hospital which is dissatisfied with the decision of the Authority regarding revocation, suspension, or probation in section (6) or (8) of this rule may request a contested case hearing pursuant to ORS chapter 183. Statutory/Other Authority: ORS 431A.065 Statutes/Other Implemented: ORS 431A.060, ORS 431A.065 & ORS 431A.090 History: PH 76-2024, amend filed 10/29/2024, effective 11/01/2024 PH 2-2021, amend filed 01/05/2021, effective 01/06/2021 PH 246-2018, minor correction filed 08/09/2018, effective 08/09/2018 PH 27-2015, f. 12-8-15, cert. ef. 1-1-16