OAR 333-076-0930
ESC Policies and Procedures

(1) The governing body of an ESC shall have a formal organizational plan with written policies, procedures and by-laws that are enforced and that clearly set forth the organizational plan with written responsibilities, accountability and relationships of professional and other personnel including volunteers that are separate and distinct from the affiliated ASC.
(2) The clinical services of each ESC shall be under the supervision of a manager who shall be an RN or a physician.
(3) An ESC shall develop and implement written policies and procedures including but not limited to:
(a) Admission and discharge criteria. Such policies shall be evaluated annually and rewritten as needed. Documentation of the policy evaluation is required;
(b) Patient care;
(c) Transfer criteria that meets the requirements in OAR 333-076-0950 (ESC Patient Transfer);
(d) Patient notification requirements including but not limited to:
(A) Oral and written notification about financial interest as required by ORS 441.098 (Health practitioner referral of patient to treatment or diagnostic testing facility);
(B) Oral and written notification that services are not covered by Medicare;
(C) The manner in which care will be provided in the event that complications occur beyond what the ESC has the capability to provide; and
(D) The manner in which patients may express concerns regarding the ESC and the services provided. The information must include contact information for the Authority;
(e) Nursing service activities;
(f) Infection control;
(g) Visitor’s conduct and control;
(h) Criteria and procedures for credentialing of physicians, dentists, or other individuals within the scope of his or her license, to the staff;
(i) Content and form of medical records that includes the requirements in OAR 333-076-1010 (ESC Medical Records);
(j) Release of medical record information including patient access to his or her medical record;
(k) Storage and dispensing of clean and sterile supplies and equipment and the processing and sterilizing of all supplies, instruments and equipment used in procedures unless disposable sterile packs are used;
(L) Disposal of pathological and other potentially infectious waste and contaminated supplies that meets the requirements in OAR chapter 333, division 56;
(m) Procurement, storage and dispensing of drugs;
(n) Provision of dietary services that conforms to Food Sanitation Rules, OAR chapter 333, division 150 and OAR 333-076-1000 (ESC Dietary Services).
(o) Cleaning, storage and handling of soiled linen and the storage and handling of clean linen;
(p) Routine laboratory testing;
(q) Annual training, at a minimum, in emergency procedures, including, but not limited to:
(A) Procedures for fire and other disasters;
(B) Infection control measures; and
(C) For staff involved in direct patient care, procedures for life threatening situations including, but not limited to, cardiopulmonary resuscitation and the life saving techniques for choking;
(r) 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); and
(s) Requirements for identifying persons responsible for obtaining informed consent and other appropriate disclosures and ensuring that the information provided is accurate.

Source: Rule 333-076-0930 — ESC Policies and Procedures, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=333-076-0930.

333‑076‑0001
Applicability 333‑076‑0095
Purpose 333‑076‑0101
Definitions 333‑076‑0102
Application for ASC License and Fees 333‑076‑0103
ASC Application Review 333‑076‑0104
Approval of ASC License Application 333‑076‑0107
Denial of ASC License Application 333‑076‑0108
Expiration and Renewal of ASC License 333‑076‑0110
Return of ASC License and ASC Closure 333‑076‑0111
ASC Classification 333‑076‑0114
ASC Complaints 333‑076‑0116
ASC Investigations 333‑076‑0117
ASC Surveys 333‑076‑0118
ASC Health Care Practitioner Credentialing 333‑076‑0119
ASC Governing Body Responsibility 333‑076‑0120
ASC Medical Staff 333‑076‑0125
ASC Personnel 333‑076‑0130
ASC Policies and Procedures 333‑076‑0135
ASC Nursing Services 333‑076‑0137
ASC Surgery Services 333‑076‑0140
ASC Anesthesia Services (If Provided) 333‑076‑0145
ASC Storage, Disposal and Dispensing of Drugs 333‑076‑0150
ASC Emergency Services 333‑076‑0155
ASC Laboratory Services 333‑076‑0160
Care of ASC Patients 333‑076‑0165
ASC Medical Records 333‑076‑0170
ASC Quality Assessment and Performance Improvement 333‑076‑0175
ASC Infection Control 333‑076‑0180
In-service Training for ASC Nurses 333‑076‑0185
ASC Physical Environment 333‑076‑0190
ASC Emergency Preparedness 333‑076‑0246
Waivers 333‑076‑0250
ASC Violations 333‑076‑0255
ASC Informal Enforcement 333‑076‑0260
ASC Formal Enforcement 333‑076‑0265
Civil Penalties, Generally 333‑076‑0270
Approval of ASC Accrediting Organizations 333‑076‑0450
Birthing Centers: Definitions 333‑076‑0470
Birthing Centers: Licensing 333‑076‑0490
Birthing Centers: Submission of Plans 333‑076‑0510
Birthing Centers: Expiration and Renewal of License 333‑076‑0530
Birthing Centers: Denial or Revocation of a License 333‑076‑0550
Birthing Centers: Return of Facility License 333‑076‑0560
Birthing Centers: Classification 333‑076‑0570
Birthing Centers: Hearings 333‑076‑0590
Birthing Centers: Adoption by Reference 333‑076‑0610
Birthing Centers: Division Procedures 333‑076‑0630
Birthing Centers: Administration 333‑076‑0650
Birthing Centers: Service Restrictions 333‑076‑0670
Birthing Centers: Policies and Procedures 333‑076‑0690
Birthing Centers: Health and Medical Records 333‑076‑0710
Birthing Centers: Physical Facility 333‑076‑0800
Extended Stay Center (ESC) Applicability 333‑076‑0805
Application for ESC License and Fees 333‑076‑0810
ESC Application Review 333‑076‑0820
Approval of ESC License Application 333‑076‑0830
Denial of ESC License Application 333‑076‑0840
Expiration and Renewal of ESC License 333‑076‑0850
Return of ESC License and ESC Closure 333‑076‑0860
ESC Surveys 333‑076‑0870
ESC Complaints 333‑076‑0880
ESC Investigations 333‑076‑0890
ESC Health Care Practitioner Credentialing 333‑076‑0900
ESC Governing Body 333‑076‑0910
ESC Medical Staff 333‑076‑0920
ESC Personnel 333‑076‑0930
ESC Policies and Procedures 333‑076‑0940
ESC Admission Criteria, Patient Care and Discharge 333‑076‑0950
ESC Patient Transfer 333‑076‑0960
ESC Nursing Services 333‑076‑0970
ESC Pharmacy Services 333‑076‑0980
ESC Laboratory Services 333‑076‑0990
ESC Radiologic Services 333‑076‑1000
ESC Dietary Services 333‑076‑1010
ESC Medical Records 333‑076‑1020
ESC Quality Assessment and Performance Improvement 333‑076‑1030
ESC Infection Control 333‑076‑1040
ESC Data Collection and Reporting 333‑076‑1050
ESC Physical Environment 333‑076‑1065
ESC Waivers 333‑076‑1070
ESC Violations 333‑076‑1080
ESC Informal Enforcement 333‑076‑1090
ESC Formal Enforcement 333‑076‑1100
ESC Civil Penalties
Last Updated

Jun. 8, 2021

Rule 333-076-0930’s source at or​.us