Or. Admin. Code § 333-027-0036

Current through Register Vol. 63, No. 10, October 1, 2024

Section 333-027-0036 - Surveys

(1) The Authority shall, in addition to any investigations conducted pursuant to OAR 333-027-0038, conduct at least one in-person inspection of each agency prior to licensure and once every three years thereafter as requirement of licensing and at such other times as the Authority deems necessary.

(2) In lieu of the in-person inspection required by section (1) of this rule, the Authority may accept:

(a) CMS certification by a federal agency or an approved accrediting organization; or

(b) A survey conducted within the previous three years by an accrediting organization approved by the Authority if:

(A) The certification or accreditation is recognized by the Authority as addressing the standards and Condition for Participation requirements of the CMS and other standards set by the Authority;

(B) The agency notifies the Authority to participate in any exit interview conducted by the federal agency or accrediting body; and

(C) The agency provides copies of all documentation concerning the certification or accreditation requested by the Authority including:

(i) Written evidence of all corrective actions underway, or completed, in response to approved accrediting organizations recommendations;

(ii) All progress reports; and

(iii) The letter from CMS indicating the agency's deemed status.

(3) If the deemed status of an agency changes, the agency administrator must notify the Authority within 30 calendar days.

(4) An agency shall permit Authority staff access to any location from which it is operating its agency or providing services during a survey.

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

(a) Interviews of patients, patient family members, agency management and staff;

(b) On-site observations of patients and staff performance;

(c) Review of documents and records; and

(d) Patient audits.

(6) An agency shall make all requested documents and records available to the surveyor for review and copying.

(7) Following a survey, Authority staff may conduct an exit conference with the agency owner or their designee. During the exit conference, Authority staff shall:

(a) Inform the agency representative of the preliminary findings of the inspection; and

(b) Give the person a reasonable opportunity to submit additional facts or other information to the surveyor in response to those findings.

(8) Following the survey, Authority staff shall prepare and provide the agency owner or their designee specific and timely written notice of the findings.

(9) 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.

(10) If no deficiencies are found during a survey, the Authority shall issue written findings to the agency owner indicating that fact.

(11) If deficiencies are found, the Authority shall take informal or formal enforcement action in accordance with OAR 333-027-0180 or 333-027-0185.

Or. Admin. Code § 333-027-0036

PH 7-2012, f. 3-30-12, cert. ef. 4-1-12; PH 3-2022, amend filed 01/11/2022, effective 1/13/2022

Statutory/Other Authority: ORS 443.085

Statutes/Other Implemented: ORS 443.019 & ORS 443.085