OAR 333-071-0400
Organization Policies

(1) An SICF’s internal organization shall be structured to include appropriate departments and services consistent with the needs of its defined community.
(2) An SICF shall adopt and maintain clearly written definitions of its organization, authority, responsibility, relationships and scope of services offered.
(3) An SICF shall adopt, maintain and follow written patient care policies that include but are not limited to:
(a) Admission and transfer policies that address:
(A) Types of clinical conditions not acceptable for admission;
(B) Constraints imposed by limitations of services, staff coverage or physical facilities. No patient shall be admitted to a bed in any room, other than one regularly designated as a bedroom or ward;
(C) Emergency admissions;
(D) Requirements for informed consent signed by the patient or legal representative of the patient for diagnostic and treatment procedures; such policies and procedures shall address informed consent of minors in accordance with provisions in ORS 109.610 (Right to care for certain sexually transmitted infections without parental consent), 109.640 (Right to medical or dental treatment without parental consent), 109.670 (Right to donate blood), and 109.675 (Right to diagnosis or treatment for mental or emotional disorder or chemical dependency without parental consent);
(E) Requirements for identifying persons responsible for obtaining informed consent and other appropriate disclosures and ensuring that the information provided is accurate and documented appropriately in accordance with these rules and ORS 441.098 (Health practitioner referral of patient to treatment or diagnostic testing facility); and
(F) A process for the internal transfer of patients from one level or type of care to another, if applicable;
(b) Discharge planning and termination of services in accordance with OAR 333-505-0055 (Discharge Planning Requirements);
(c) Patient rights;
(d) Housekeeping;
(e) All patient care services provided by the facility;
(f) Preventive maintenance program for all aspects of the facility’s physical plant, operations, and equipment used in patient care and patient environment;
(g) Treatment or referral of acute sexual assault patients in accordance with ORS 147.403 (Policies, guidelines and training requirements for providers of medical care to sexual assault patients); and
(h) Identification of patients who could benefit from palliative care in order to provide information and facilitate access to appropriate palliative care in accordance with ORS 413.273 (Palliative care for patients and residents of hospitals, long term care facilities and residential care facilities).
(4) In addition to the policies described in section (3) of this rule, an SICF shall, in accordance with the Patient Self-Determination Act, 42 CFR 489.102, adopt policies and procedures that require (applicable to all capable individuals 18 years of age or older who are receiving health care in the facility):
(a) Providing to each adult patient, including emancipated minors, not later than five days after an individual is admitted as an inpatient, but in any event before discharge, the following in written form, without recommendation:
(A) Information on the rights of the individual under Oregon law to make health care decisions, including the right to accept or refuse medical treatment and the right to execute directives and powers of attorney for health care;
(B) Information on the policies of the facility with respect to the implementation of the rights of the individual under Oregon law to make health care decisions;
(C) A copy of the advance directive form set forth in 2018 Oregon Laws, chapter 36; and
(D) The name of a person who can provide additional information concerning the forms for directives.
(b) Documenting in a prominent place in the individual’s medical record whether the individual has executed a directive.
(c) Compliance with ORS chapter 127 relating to directives for health care.
(d) Educating the staff and the community on issues relating to directives.
(5) An SICF’s transfer agreements or contracts shall clearly delineate the responsibilities of parties involved.
(6) Patient care policies shall be evaluated triennially and rewritten as needed, and presented to the governing body or a designated administrative body for approval triennially. Documentation of the evaluation is required.
(7) An SICF shall have a system, described in writing, for the periodic evaluation of programs and services, including contracted services.

Source: Rule 333-071-0400 — Organization Policies, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=333-071-0400.

333‑071‑0200
Purpose and Applicability 333‑071‑0205
Definitions 333‑071‑0210
License Application and Fees 333‑071‑0215
Application Review 333‑071‑0220
Approval of License Application 333‑071‑0225
Fees for Complaint Investigations and Compliance Surveys 333‑071‑0230
Expiration and Renewal of License 333‑071‑0235
Denial of License Application 333‑071‑0240
Return of SICF License and SICF Closure 333‑071‑0245
Discontinuance and Recommencement of Operations 333‑071‑0250
Classification 333‑071‑0260
Waivers 333‑071‑0270
Complaints 333‑071‑0280
Investigations 333‑071‑0290
Surveys 333‑071‑0300
Nurse Staffing Audit and Complaint Investigation Procedures 333‑071‑0310
Violations 333‑071‑0315
Informal Enforcement 333‑071‑0320
Formal Enforcement 333‑071‑0330
Approval of Accrediting Organization 333‑071‑0340
Civil Penalties for Violations of Nurse Staffing Laws 333‑071‑0345
Civil Penalties for Violation of Smoking Prohibition 333‑071‑0350
Civil Penalties, Generally 333‑071‑0360
Governing Body Responsibility 333‑071‑0370
Health Care Practitioner Credentialing 333‑071‑0380
Administrator 333‑071‑0390
Medical Staff 333‑071‑0400
Organization Policies 333‑071‑0410
Patient Rights 333‑071‑0420
Personnel 333‑071‑0430
Medical Records 333‑071‑0440
Quality Assessment and Performance Improvement 333‑071‑0450
Infection Control 333‑071‑0470
Patient Admission and Treatment Orders 333‑071‑0480
Nursing Care Management 333‑071‑0485
Nursing Services 333‑071‑0490
Nurse Executive 333‑071‑0510
Dietary Services 333‑071‑0520
Laboratory Services 333‑071‑0530
Pharmacy Services 333‑071‑0535
Radiology Services 333‑071‑0550
Sanitary Precautions 333‑071‑0560
Safety and Emergency Preparedness 333‑071‑0570
Smoking Prohibition 333‑071‑0580
Physical Environment Requirements
Last Updated

Jun. 8, 2021

Rule 333-071-0400’s source at or​.us