Oregon Oregon Health Authority, Public Health Division

Rule Rule 333-501-0035
Nurse Staffing Audit Procedure


(1)

The Authority shall conduct an on-site audit of each hospital once every three years to determine compliance with the requirements of ORS 441.152 (Nurse Staffing Advisory Board) to 441.177 (Posting of audit reports and civil penalties) and 441.192 (Notice of employment outside of hospital). The Authority shall notify the hospital and both co-chairs of the hospital nurse staffing committee three business days in advance of the audit.

(2)

During an audit, the Authority shall review any hospital record and conduct any interview or site visit that is necessary to determine that the hospital is in compliance with the requirements of ORS 441.152 (Nurse Staffing Advisory Board) to 441.177 (Posting of audit reports and civil penalties) and 441.192 (Notice of employment outside of hospital).

(3)

In conducting an audit, the Authority shall interview:

(a)

Both co-chairs of the hospital nurse staffing committee; and

(b)

Any additional hospital staff members deemed necessary to determine compliance with applicable nurse staffing laws. Interviews may address, but are not limited to, the following topics:

(A)

Implementation and effectiveness of the hospital-wide staffing plan for nursing services;

(B)

Input, if any, provided to the hospital nurse staffing committee; or

(C)

Any other fact relating to hospital nursing services subject to the Authority’s review.

(4)

In conducting an audit, the Authority may also interview:

(a)

Hospital staff that does not voluntarily come forward for an interview during an audit; and

(b)

Hospital patients or family members. Interviews may address, but are not limited to, any concerns or complaints related to nurse staffing in the hospital.

(5)

Following an audit, the Authority shall issue a written survey report that communicates the results of the audit no more than 30 business days after the survey closes. This survey report:

(a)

Shall be issued to the hospital and both co-chairs of the hospital nurse staffing committee; and

(b)

May include a notice of civil penalties that complies with ORS 441.175 (Civil penalties) and OAR 333-501-0045 (Civil Penalties for Violations of Nurse Staffing Laws).

(6)

If the survey report identifies any area of noncompliance, the hospital shall submit a written plan to correct each identified deficiency. This plan:

(a)

Shall be called the plan of correction;

(b)

Shall be submitted no more than 30 business days after receiving the Authority’s survey report; and

(c)

Shall be evaluated by the Authority for sufficiency.

(7)

No more than 30 business days after receipt of the hospital’s plan of correction, the Authority shall issue a written determination that communicates whether the plan of correction is sufficient. This determination:

(a)

Shall be issued to the hospital and both co-chairs of the hospital nurse staffing committee; and

(b)

Shall require the hospital to either:

(A)

Revise and resubmit the rejected plan of correction no more than 30 business days after receiving the Authority’s determination that the plan is insufficient; or

(B)

Implement the approved plan of correction no more than 45 business days after receiving the Authority’s determination that the plan is sufficient.

(8)

Following the approval of the plan of correction, the Authority shall conduct a second audit of the hospital to verify that the hospital has implemented the approved plan of correction. This audit shall be conducted within 60 business days of the plan of correction approval date.

(9)

The identity of an individual providing evidence during an audit will be kept confidential to the extent permitted by law.
Source

Last accessed
Jun. 8, 2021