OAR 333-035-0075
Surveys
(1)
The Division shall, in addition to any investigations conducted under OAR 333-035-0070 (Investigations), conduct at least one survey of each hospice program every three years and at such other times as the Division deems necessary.(2)
In lieu of a survey required under section (1) of this rule, the Division may:(a)
Accept certification by a federal agency; or(b)
Accept a survey performed by an accrediting organization approved by the Division under OAR 333-035-0100 (Approval of Accrediting Organizations), and conducted within the last three years.(3)
A hospice program shall permit Division staff access to any location from which it is operating its program or providing services during a survey.(4)
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.(5)
A hospice program shall make all requested documents and records available to the surveyor for review and copying.(6)
Following a survey, Division staff may conduct an exit conference with the hospice program administrator or his or her designee. During the exit conference Division staff shall:(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.(7)
Following the survey, Division staff shall prepare and provide the hospice program 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, Division 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 Division shall issue written findings to the hospice program administrator indicating that fact.(10)
If the surveyor’s written notice of findings indicates that the agency was in compliance with hospice program licensing laws and no deficiencies were cited, the agency administrator or administrator’s designee shall sign the written notice and return it to the Division.(11)
If deficiencies are found, the Division shall take informal or formal enforcement action in compliance with OAR 333-035-0085 (Informal Enforcement) or 333-035-0090 (Formal Enforcement).
Source:
Rule 333-035-0075 — Surveys, https://secure.sos.state.or.us/oard/view.action?ruleNumber=333-035-0075.