OAR 333-505-0030
Organization, Hospital Policies

(1) A hospital’s internal organization shall be structured to include appropriate departments and services consistent with the needs of its defined community.
(2) A hospital shall adopt and maintain clearly written definitions of its organization, authority, responsibility and relationships.
(3) A hospital 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, physical facilities or staff coverage;
(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;
(b) Discharge, termination of services, and release from emergency department policies in accordance with OAR 333-505-0055 (Discharge Planning Requirements) and OAR 333-520-0070 (Emergency Department and Emergency Services);
(c) Patient rights, including but not limited to compliance with OAR 333-505-0033 (Patient Rights);
(d) Housekeeping;
(e) All patient care services provided by the hospital;
(f) Maintenance of the hospital’s physical plant, 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, a hospital shall, in accordance with 42 CFR 489.102, ORS 127.649 (Health care organizations required to have written policies and procedures on providing information on patient’s right to make health care decisions), and ORS 127.652 (Time of providing information), adopt and maintain written policies and procedures concerning a patient’s right to accept or refuse medical or surgical treatment and the right to formulate an advance directive or appoint a health care representative.
(5) A hospital may not condition the provision of treatment on a patient having a POLST as that term is defined in ORS 127.663 (Definitions for ORS 127.663 to 127.684), an advance directive as defined in ORS 127.505 (Definitions for ORS 127.505 to 127.660), a form appointing a health care representative under ORS 127.510 (Appointment of health care representative and alternate health care representative), or any instruction relating to the administration, withholding or withdrawing of life-sustaining procedures or artificially administered nutrition and hydration.
(6) A hospital’s transfer agreements or contracts shall clearly delineate the responsibilities of parties involved.
(7) 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.
(8) A hospital shall have a system, described in writing, for the periodic evaluation of programs and services, including contracted services.

Source: Rule 333-505-0030 — Organization, Hospital Policies, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=333-505-0030 (accessed May 26, 2025).

May 26, 2025

Rule 333-505-0030's source at or​.us