1. (1) The Authority shall, in addition to any investigations conducted under OAR 333-076-0880, conduct at least one on-site licensing survey of each ESC every three years to determine compliance with health care facility licensing laws and at such other times as the Authority deems necessary.
2. (2) An ESC shall permit Authority staff access to the facility during a survey.

3. (3) A survey may include but is not limited to:

   1. (a) Interviews of patients, patient family members, ESC management and staff;
   2. (b) On-site observations of patients, staff performance, and the physical environment of the facility;
   3. (c) Review of documents and records, including documents and records of the affiliated ASC if necessary; and
   4. (d) Patient audits.
4. (4) An ESC shall make all requested documents and records available to the surveyor for review and copying.

5. (5) Following a survey, Authority staff may conduct an exit conference with the ESC administrator or the administrator's designee. During the exit conference Authority staff shall:

   1. (a) Inform the ESC representative of the preliminary findings of the inspection; and
   2. (b) Give the person a reasonable opportunity to submit additional facts or other information to the surveyor in response to those findings.
6. (6) Following the survey, Authority staff shall prepare and provide the ESC administrator or the administrator's designee specific and timely written notice of the findings.
7. (7) If the findings result in a referral to another regulatory agency, Authority staff shall submit the applicable information to that referral agency for its review and determination of appropriate action.
8. (8) If no deficiencies are found during a survey, the Authority shall issue written findings to the ESC administrator indicating that fact.
9. (9) If deficiencies are found, the Authority shall take informal or formal enforcement action in compliance with OAR 333-076-1080 or OAR 333-076-1090.

Statutory/Other Authority

ORS 441.025 & OL 2018 Chapter 50

Statutes/Other Implemented

ORS 441.025, 441.060 & OL 2018 Chapter 50

History

PH 1-2019, adopt filed 01/07/2019, effective 01/07/2019