2023 Oregon Revised Statutes › Volume : 12 - Public Health › Chapter 441 - Health Care Facilities › Section 441.791 - Process for investigating and resolving complaints.

(1) As used in this section, "valid complaint" means a complaint containing an allegation that, if assumed to be true, is a violation listed in ORS 441.792.
(2) To ensure compliance with ORS 441.761 to 441.795, the Oregon Health Authority shall:
(a) Establish a method by which a hospital staff person or an exclusive representative of a hospital staff person may submit a complaint through the authority’s website regarding any violation listed in ORS 441.792;
(b) No later than 14 days after receiving a complaint, send a copy of the complaint to the exclusive representative, if any, of the staff person or staff persons who filed the complaint;
(c) No later than 30 days after receiving a valid complaint of a violation listed in ORS 441.792, open an investigation of the hospital and provide a notice of the investigation to the hospital and the cochairs of the relevant staffing committee established pursuant to ORS 441.762, 441.775 or 441.776, and to the exclusive representative, if any, of the staff person or staff persons filing the complaint. The notice must include a summary of the complaint that does not include the complainant’s name or the specific date, shift or unit but does include the calendar week in which the complaint arose;
(d) Not later than 80 days after opening the investigation, conclude the investigation and provide a written report on the complaint to the hospital, the cochairs of the hospital staffing committee and the exclusive representative, if any, of the staff person or staff persons filing the complaint. The report:
(A) Shall include a summary of the complaint;
(B) Shall include the nature of the alleged violation or violations;
(C) Shall include the authority’s findings and factual bases for the findings;
(D) Shall include other information the authority determines is appropriate to include in the report; and
(E) May not include the name of any complainant, the name of any patient or the names of any individuals that the authority interviewed in investigating the complaint;
(e) If the authority issues a warning or imposes one or more civil penalties based on the report described in paragraph (d) of this subsection, provide a notice of the civil penalty that complies with ORS 183.415, 183.745 and 441.793 to the hospital, the cochairs of the applicable hospital staffing committee and the exclusive representative, if any, of the staff person or staff persons who filed the complaint; and
(f) In determining whether to impose a civil penalty, consider all relevant evidence, including but not limited to witness testimony, written documents and the observations of the investigator.
(3) A hospital subject to a valid complaint shall provide to the authority, no later than 20 days after receiving the notice under subsection (1)(c) of this section:
(a) The staffing plan that is the subject of the complaint;
(b) If relevant to the complaint, documents that show the scheduled staffing and the actual staffing on the unit that is the subject of the complaint during the period of time specified in the complaint; and
(c) Documents that show the actions described in ORS 441.793 (4), if any, that the hospital took to comply with the staffing plan or to address the issue raised by the complaint.
(4) In conducting an investigation, the authority shall review any document:
(a) Related to the complaint that is provided by the exclusive representative that filed the complaint or by the hospital staff person who filed the complaint and the person’s exclusive representative, if any; and
(b) Provided by the hospital in response to the complaint.
(5) In conducting an investigation, the authority may:
(a) Make an on-site inspection of the unit that is the subject of the complaint;
(b) Interview a manager for the unit and any other staff persons with information relevant to the complaint;
(c) Interview the cochairs of the relevant staffing committee;
(d) Interview the staff person or staff persons who filed the complaint unless the individual declines to be interviewed; and
(e) Compel the production of books, papers, accounts, documents and testimony pertaining to the complaint, other than documents that are privileged or not otherwise subject to disclosure.
(6) A complaint by a hospital staff person or the staff person’s exclusive representative must be filed no later than 60 days after the date of the violation alleged in the complaint. The authority may not investigate a complaint or take any enforcement action with respect to a complaint that has not been filed timely. [Formerly 441.171]
Note:
See note under 441.761.