Oregon Oregon Health Authority, Public Health Division

Rule Rule 333-501-0015


The Division shall, in addition to any investigations conducted under OAR 333-501-0010 (Investigations), conduct at least one on-site licensing survey of each hospital every three years to determine compliance with health care facility licensing laws and at such other times as the Division deems necessary.


In lieu of an onsite inspection required under section (1) of this rule, the Division may accept:


CMS certification by a federal agency or an approved accrediting organization; or


A survey conducted within the previous three years by an accrediting organization approved by the Division, if:


The certification or accreditation is recognized by the Division as addressing the standards and condition of participation requirements of the CMS and other standards set by the Division. Health care facilities must provide the Division with the letter from CMS indicating its deemed status;


The health care facility notifies the Division to participate in any exit interview conducted by the federal agency or accrediting body; and


The health care facility provides copies of all documentation concerning the certification or accreditation requested by the Division.


A hospital shall permit Division staff access to the facility during a survey.


A survey may include but is not limited to:


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


On-site observations of patients, staff performance, and the physical environment of the hospital facility;


Review of documents and records; and


Patient audits.


A hospital 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 hospital administrator or his or her designee. During the exit conference Division staff shall:


Inform the hospital 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 hospital administrator or his or her designee specific and timely written notice of the findings.


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.


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


If deficiencies are found, the Division shall take informal or formal enforcement action in compliance with OAR 333-501-0025 (Informal Enforcement) or 333-501-0030 (Formal Enforcement).

Last accessed
Jun. 8, 2021