333-035-0240 Surveys (1) The Authority shall, in addition to any investigations conducted under OAR 333-035-0230, conduct at least one in-person site inspection of each hospice program prior to licensure and once every three years thereafter as a requirement for licensure, and at such other times as the Authority deems necessary. (2) In lieu of a survey required under section (1) of this rule, the Authority may accept deemed status by a CMS-approved accrediting organization following a survey conducted within the previous three years by that accrediting organization if: (a) The certification or accreditation is recognized by the Authority as addressing the standards and Condition for Participation requirements of the CMS and other standards set by the Authority; (b) The hospice program notifies the Authority to participate in any exit interview conducted by the accrediting body; and (c) The hospice program provides copies of all documentation concerning the certification or accreditation requested by the Authority including: (A) Written evidence of all corrective actions underway, or completed, in response to approved accrediting organizations recommendations; (B) All progress reports; and (C) The letter from CMS indicating its deemed status. (3) A hospice program administrator must notify the Authority within seven calendar days if: (a) The deemed status of the hospice program changes; or (b) The hospice program decides not to renew its affiliation with the accrediting organization. (4) A hospice program shall permit Authority staff access to any location from which it is operating its program or providing services during a survey. (5) A survey may include but is not limited to: (a) Interviews of patients, patient family members, hospice program management and staff; (b) On-site observations of patients and staff performance; (c) Review of documents and records; and (d) Patient audits. (6) A hospice program shall timely make all requested documents and records available to the surveyor for review and copying. (7) Following a survey, Authority staff may conduct an exit conference with the hospice program administrator or the administrator's designee. During the exit conference Authority staff may: (a) Inform the hospice program 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. (8) Following the survey, Authority staff shall prepare and provide the hospice program administrator or administrator's designee specific and timely written notice of the findings. (9) 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. (10) If no deficiencies are found during a survey, the Authority shall issue written findings to the hospice program administrator indicating that fact. (11) If deficiencies are found, the Authority shall take informal or formal enforcement action in compliance with OAR 333-035-0260 or 333-035-0270. Statutory/Other Authority: ORS 443.860 Statutes/Other Implemented: ORS 443.860 History: PH 6-2023, amend filed 01/27/2023, effective 01/27/2023 PH 204-2022, renumbered from 333-035-0075, filed 11/18/2022, effective 11/18/2022 PH 19-2010, f. 8-30-10, cert. ef. 9-1-10