Oregon Oregon Health Authority, Public Health Division

Rule Rule 333-027-0036


The Division shall, in addition to any investigations conducted pursuant to OAR 333-027-0038 (Investigations), conduct at least one on-site inspection of each agency prior to licensure and once every three years thereafter as requirement of licensing and at such other times as the Division deems necessary.


In lieu of the on-site inspection required by section (1) of this rule, the Division may accept a certification or accreditation from a federal agency or an accrediting body approved by the Division that the state licensing standards have been met if the agency:


Notifies the Division to participate in any exit interview conducted by the federal agency or accrediting body; and


Provides copies of all documentation concerning the certification or accreditation requested by the Division.


An agency shall permit Division staff access to any location from which it is operating its agency or providing services during a survey.


A survey may include but is not limited to:


Interviews of patients, patient family members, agency management and staff;


On-site observations of patients and staff performance;


Review of documents and records;


Patient audits.


An agency shall make all requested documents and records available to the surveyor for review and copying.


Following a survey, Division staff may conduct an exit conference with the agency owner or his or her designee. During the exit conference, Division staff shall:


Inform the agency representative of the preliminary findings of the inspection; and


Give the person a reasonable opportunity to submit additional facts or other information to the surveyor in response to those findings.


Following the survey, Division staff shall prepare and provide the agency owner or his or her designee specific and timely written notice of the findings.


If the findings result in a referral to another regulator agency, Division staff shall submit the applicable information to that referral agency for its review and determination of appropriate action.


If no deficiencies are found during a survey, the Division shall issue written findings to the agency owner indicating that fact.


If deficiencies are found, the Division shall take informal or formal enforcement action in compliance with OAR 333-027-0180 (Informal Enforcement) or 333-027-0185 (Formal Enforcement).

Last accessed
Jun. 8, 2021