1. (1) An agency shall clearly set forth in writing the organization, services provided, administrative control, and lines of authority for the delegation of responsibility to the patient care level. An agency shall not delegate administrative and supervisory functions to another agency, individual, or organization.

2. (2) An agency shall ensure that:

   1. (a) A clinical manager is employed who is responsible for the oversight of all patient care services and personnel and that the clinical manager is available during all operating hours;
   2. (b) A professional policy-making committee is established in accordance with ORS 443.065; and
   3. (c) All patient complaints are reviewed including documentation and resolution.

3. (3) If an agency chooses to provide professional students with a practicum in home health, the agency must ensure that:

   1. (a) A contract between the agency and the accredited educational institution is in effect and includes at a minimum, a description of:

      1. (A) Program objectives;
      2. (B) Program coordination;
      3. (C) Student supervision;
      4. (D) Adherence to agency policy; and
      5. (E) Conformance with applicable professional practice laws, rules, and regulations.
   2. (b) The governing body shall be informed about the contract specified in subsection (3)(a) prior to its implementation.
   3. (c) The agency maintains documentation of each practicum and the student's activities, supervision, and the evaluation of these activities.
   4. (d) The agency maintains documentation of patient care services provided by the student.
4. (4) An agency's governing body shall assume full legal and fiscal responsibility for the agency's operation. The agency's governing body shall provide for effective communication with administration of the agency and the owner of the agency.

5. (5) An agency's governing body shall:

   1. (a) Employ a qualified administrator, unless exempted under ORS 443.025;
   2. (b) Regularly monitor the performance of the administrator; and
   3. (c) Ensure there is a quality assessment and performance improvement program established and maintained in accordance with OAR 333-027-0160.
6. (6) The administrator shall identify a qualified alternate, designated in writing by the administrator and the governing body to assume responsibilities and obligations of the agency during the administrator's absence. The clinical manager may be designated to serve in this role.

7. (7)

   1. (a) The agency shall develop personnel policies which must be appropriate to the agency, be documented, and include:

      1. (A) Hours of work;
      2. (B) Orientation that is appropriate to the classification of the employee;
      3. (C) An inservice program that provides ongoing education to ensure that skills of personnel are maintained for the responsibilities assigned and ensures that personnel are educated in their responsibility in infection control;
      4. (D) Employee notification about the availability of personnel safety training provided in accordance with OAR 333-027-0115;
      5. (E) Work performance evaluations;
      6. (F) Employee health program;
      7. (G) A tuberculosis infection control plan that includes provisions for employee assessment and screening for protecting patient and employees from tuberculosis in accordance with OAR 333-019-0041; and
      8. (H) Provisions for the completion of criminal records checks in accordance with ORS 443.004 and OAR 333-027-0064.
   2. (b) Personnel records shall include job descriptions, personnel qualifications, evidence of any required licensure or certification, evidence of orientation and performance evaluations, evidence of a completed criminal records check and fitness determination, and evidence of personnel safety training notification.
8. (8) An agency shall provide health care interpreter services to a patient who prefers to communicate in a language other than English in accordance with ORS 413.559 and OAR 950-050-0160.

9. (9) An agency contracting with individual personnel or public or private entities for home health care services shall maintain written contracts and shall clearly designate:

   1. (a) That patients are accepted for care only by the primary agency;
   2. (b) The services to be provided;
   3. (c) The rights and responsibilities of the contracting individual or entity in the coordination, supervision, and evaluation of the care or service provided;
   4. (d) The obligation to comply with all applicable agency policies;
   5. (e) The party with responsibility for development and revisions of the plan of care, patient assessment, progress reports, and patient care conferences, scheduling of visits or hours, and discharge planning;
   6. (f) Appropriate documentation of services provided on record forms provided by the agency; and
   7. (g) The terms of the agreement and basis for renewal or termination.

10. (10) The professional policy-making committee appointed by the agency shall:

    1. (a) Be composed of personnel associated with the agency and that meet the requirements in ORS 443.065.
    2. (b) Establish in writing and review annually, the agency's policies governing scope of services, admission and discharge policies, personnel safety program requirements in accordance with OAR 333-027-0115, potential threat or disruptive behavior flagging systems in accordance with OAR 333-027-0125, medical supervision, plans of treatment, emergency care, clinical records, personnel qualifications, and quality assessment and performance improvement.
    3. (c) Meet as needed to advise the agency on other professional issues.
    4. (d) Participate with personnel in the annual evaluation of the agency's program.
11. (11) The agency shall document the professional-policy making committee's systematic involvement and effective communication with the governing body and the management of the agency.

Statutory/Other Authority

ORS 443.085

Statutes/Other Implemented

ORS 443.014, ORS 443.055, ORS 443.065, ORS 43.085, ORS 413.559, ORS 413.561, ORS 441.201, ORS 443.190 & ORS 443.195

History

PH 16-2026, amend filed 01/29/2026, effective 02/01/2026
PH 18-2023, minor correction filed 04/18/2023, effective 04/18/2023
PH 197-2022, amend filed 09/07/2022, effective 09/21/2022
PH 3-2022, amend filed 01/11/2022, effective 01/13/2022
PH 14-2020, amend filed 03/24/2020, effective 03/24/2020
PH 7-2012, f. 3-30-12, cert. ef. 4-1-12
OHD 13-1998, f. & cert. ef. 11-6-98
HD 20-1993, f. & cert. ef. 10-28-93
HD 22-1988, f. & cert. ef. 9-16-88
HD 19-1987, f. 11-10-87, ef. 12-1-87
HD 151, f. & ef. 12-30-77