1. (1) A hospital's internal organization shall be structured to include appropriate departments and services consistent with the needs of its defined community.
2. (2) A hospital shall adopt and maintain clearly written definitions of its organization, authority, responsibility and relationships.

3. (3) A hospital shall adopt, maintain and follow written patient care policies that include but are not limited to:

   1. (a) Admission and transfer policies that address:

      1. (A) Types of clinical conditions not acceptable for admission;
      2. (B) Constraints imposed by limitations of services, physical facilities or staff coverage;
      3. (C) Emergency admissions;
      4. (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 109.640, 109.670, and 109.675;
      5. (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;
      6. (F) A process for the internal transfer of patients from one level or type of care to another; and
      7. (G) A plan to share with home health or hospice agencies any known patient history of violence within the last 12 months, when a patient is referred to receive home health or hospice services;
   2. (b) Discharge, termination of services, and release from emergency department policies in accordance with OAR 333-505-0055 and OAR 333-520-0070;
   3. (c) Patient rights, including but not limited to compliance with OAR 333-505-0033;
   4. (d) Housekeeping;
   5. (e) Mandatory use of identification badges for health care practitioners providing direct patient care which must include the practitioner’s name and professional title in accordance with ORS 441.096. The policy must also identify the size of badges to be used;
   6. (f) All patient care services provided by the hospital;
   7. (g) Maintenance of the hospital's physical plant, equipment used in patient care and patient environment;
   8. (h) Treatment or referral of acute sexual assault patients in accordance with ORS 147.403; and
   9. (i) 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.

4. (4) In addition to the policies described in section (3) of this rule, a hospital shall:

   1. (a) In accordance with 42 CFR 489.102, ORS 127.649, and ORS 127.652, 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; and
   2. (b) In accordance with OAR 333-505-0045, adopt and maintain protocols and procedures for implementing and using potential threat or disruptive flagging systems. These protocols and procedures must be reviewed on an annual basis.
5. (5) A hospital may not condition the provision of treatment on a patient having a physician order or portable order for life-sustaining treatment (POLST) as that term is defined in OAR chapter 333, division 270 and ORS 127.663, an advance directive as defined in ORS 127.505, a form appointing a health care representative under ORS 127.510, or any instruction relating to the administration, withholding or withdrawing of life-sustaining procedures or artificially administered nutrition and hydration.
6. (6) A hospital's transfer agreements or contracts shall clearly delineate the responsibilities of parties involved.
7. (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. (8) A hospital shall have a system, described in writing, for the periodic evaluation of programs and services, including contracted services.

Statutory/Other Authority

ORS 441.025 & ORS 413.042

Statutes/Other Implemented

ORS 413.273, ORS 441.025, ORS 441.051, ORS 441.054, ORS 441.048, ORS 441.096 & ORS 441.201

History

PH 16-2026, amend filed 01/29/2026, effective 02/01/2026
PH 2-2024, amend filed 01/29/2024, effective 01/29/2024
PH 40-2023, minor correction filed 09/08/2023, effective 09/08/2023
PH 6-2021, amend filed 01/22/2021, effective 01/24/2021
PH 59-2020, temporary amend filed 07/29/2020, effective 08/01/2020 through 01/24/2021
PH 233-2018, amend filed 08/02/2018, effective 08/02/2018
PH 7-2016, f. & cert. ef. 2-24-16
PH 17-2012, f. 12-20-12, cert. ef. 1-1-13
PH 26-2010, f. 12-14-10, cert. ef. 12-15-10
PH 11-2009, f. & cert. ef. 10-1-09
HD 29-1988, f. 12-29-88, cert. ef. 1-1-89