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The Oregon Administrative Rules contain OARs filed through August 15, 2014
 
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OREGON HEALTH AUTHORITY,
PUBLIC HEALTH DIVISION

 

DIVISION 71

SPECIAL INPATIENT CARE FACILITIES

333-071-0000

Licensing Procedures and Definitions

As used in OAR chapter 333, division 71, unless the context requires otherwise, the following definitions apply:

(1) "Health Care Facility" (HCF) has the meaning given the term in ORS 442.015, and includes but is not limited to the following classifications:

(a) "Hospital" means an establishment with an organized medical staff with permanent facilities that include inpatient beds, and with medical services, including physician services and continuous nursing services under the supervision of registered nurses, to provide diagnosis and medical or surgical treatment primarily for, but not limited to, acutely ill patients and accident victims, or to provide treatment for the mentally ill or to provide treatment in special inpatient care facilities. "Special inpatient care facilities" are facilities with inpatient beds and other facilities designed and utilized for special health care purposes, to include but not be limited to: Rehabilitation center, college infirmary, chiropractic facility, facility for the treatment of alcoholism or drug abuse, freestanding hospice facility, infirmary for the homeless, critical access hospital, or inpatient care facility meeting the requirements of ORS 441.065, and any other establishment falling within a classification established by the Division, after determination of the need for such classification and the level and kind of health care appropriate for such classification.

(b) An "ambulatory surgical center" or ambulatory surgical facility means a health care facility without patient beds, not sponsored by a hospital which performs outpatient surgery not routinely or customarily performed in a physician's or dentist's office, and is able to meet health facility licensure requirements. In the case of outpatient surgery involving termination of pregnancy, procedures routinely and customarily done in physicians' offices are the following:

(A) Dilation and curettage;

(B) Suction curettage;

(C) Sharp curettage;

(D) Dilation and evacuation.

(c) A "hospital associated ambulatory surgery center" means an ambulatory surgical service that is separately identifiable; physically, administratively and financially independent, distinct from other operations of the hospital, and is not located proximate to or adjoining the hospital's campus. The hospital associated ambulatory surgery center performs surgery not routinely or customarily performed in the physician's or dentist's office, and is able to meet health facility licensure requirements. In the case of outpatient surgery involving termination of pregnancy, procedures routinely and customarily done in physicians' offices are the following:

(A) Dilation and curettage;

(B) Suction curettage;

(C) Sharp curettage;

(D) Dilation and evacuation.

(d) "Freestanding birth center" means a health care facility licensed for the primary purpose of performing low risk deliveries.

(2) "Authentication" means verification that an entry in the patient medical record is genuine.

(3) "Certified Nursing Assistant" (CNA) means a person who holds a current, valid Oregon CNA certificate by meeting the requirements specified by the Oregon State Board of Nursing; and who assists licensed nursing personnel in the provision of nursing care.

(4) "Certified Registered Nurse Anesthetist" (CRNA) means a registered nurse licensed by the Oregon State Board of Nursing as a certified registered nurse anesthetist.

(5) "Certified Nurse Midwife" (CNMW) means a registered nurse certified by the Oregon State Board of Nursing (OSBN) as a nurse practitioner midwife.

(6) "Chiropractor" means a person licensed under ORS Chapter 684 to practice chiropractic.

(7) "Critical Access Hospital" means an acute care inpatient facility located in an eligible rural area and which meets those requirements as delineated by the Office of Rural Health and approved by the Health Care Financing Administration (HCFA).

(8) "Division" means the Public Health Division of the Oregon Health Authority.

(9) "Freestanding Hospice Facility" (FSHF) means a health care facility which:

(a) Only admits patients who have been certified by the attending physician to be terminally ill, to have a life expectancy not to exceed 12 months, and have given up active treatment aimed at cure; and

(b) Complies with ORS Sections 443.850 and 443.860.

(10) "Governing Body" means the body or person legally responsible for the direction and control of the operation of the facility.

(11) "Governmental Unit" means the state, or any county, municipality, or other political subdivision, or any related department, division, board or other agency.

(12) "Health Care Facility Licensing Law" means ORS 441.005 to 441.990 and rules thereunder.

(13) " Infirmary for the Homeless" means a facility designed to provide inpatient medical care to indigent, homeless members of the community.

(14) "Inpatient Beds" means a bed in a facility available for occupancy by a patient who will or may be cared for and treated on an overnight basis.

(15) "Licensed" means that the person or facility to whom the term applies is currently licensed, certified or registered by the proper authority to follow his or her profession or vocation within the State of Oregon, and when applied to a health care facility means that the facility is currently and has been duly and regularly licensed by the state Public Health Division.

(16) "Licensed Nurse" means a Registered Nurse (RN) or a Licensed Practical Nurse (LPN).

(17) "Licensed Practical Nurse" (LPN) means a person licensed under ORS Chapter 678 to practice practical nursing.

(18) "Major Alteration" means changes other than repair or replacement of building materials and equipment with materials and equipment of a similar type.

(19) "Naturopath" means a person licensed under ORS Chapter 685 to practice naturopathy.

(20) "New Construction" means a new building or an addition to an existing building.

(21) "NFPA" means National Fire Protection Association.

(22) "Nurse Practitioner" (NP) means a registered nurse who has been certified by the Oregon State Board of Nursing (OSBN) as qualified to practice in an expanded specialty role within the practice of nursing.

(23) "Nursing Assistant" means a person who assists licensed nursing personnel in the provision of nursing care.

(24) "Oregon Sanitary Code" means the Food Sanitation Rules, OAR 333-150-0000 through 333-168-0020 except 333-157-0000 through 333-158-0030.

(25) "Patient audit" means review of the medical record and/or physical inspection of a patient.

(26) "Person" means an individual, a trust or estate, a partnership, corporation, (including associations, joint stock, companies and insurance companies, a state or a political subdivision or instrumentality including a municipal corporation) of a state.

(27) "Physician" means a person licensed under ORS Chapter 677 to practice medicine.

(28) "Physician's Assistant" means a person who is registered as a physician's assistant in accordance with ORS Chapter 677.

(29) "Podiatrist" means a person licensed under ORS Chapter 677 to practice podiatry.

(30) "Podiatry" means the diagnosis or the medical, physical or surgical treatment of ailments of the human foot, except treatment involving the use of a general or spinal anesthetic unless the treatment is performed in a hospital certified in the manner described in subsection (2) of ORS 441.055 and is under the supervision of or in collaboration with a physician licensed to practice medicine by the Board of Medical Examiners for the State of Oregon. "Podiatry" does not include the administration of general or spinal anesthetics or the amputation of the foot.

(31) "Registered Nurse" (RN) means a person licensed under ORS Chapter 678.

Stat. Auth.: ORS 441 .055
Stats. Implemented: ORS 441 .015 - 441.087
Hist.: HD 13-1987, f. 9-1-87, ef. 9-15-87; HD 11-1988, f. & cert. ef. 5-27-88; HD 5-1989, f. 7-14-89, cert. ef. 8-1-89; OHD 6-1999, f. & cert. ef. 10-22-99

333-071-0005

Issuance of License

(1) Application for a license to operate a health care facility shall be in writing on a form provided by the Division including demographic, ownership and administrative information. The form shall specify such information required by the Division.

(2) No person or health care facility licensed pursuant to the provisions of ORS Chapter 441, shall in any manner or by any means assert, represent, offer, provide or imply that such person or facility is or may render care or services other than that which is permitted by or which is within the scope of the license issued to such person or facility by the Division nor shall any service be offered or provided which is not authorized within the scope of the licensed issued to such person or facility.

(3) Each application for license renewal shall accurately reflect only the number of beds the facility is then presently capable of operating considering existing equipment, and ancillary service capability of the facility and the physical requirements as specified within these rules and regulations. The number of beds to be licensed shall not exceed the number of beds reflected in the license to be renewed unless approved by the Division.

(4) Separate licenses are not required for separate buildings operated as an integrated unit by the same management. Special inpatient care beds and other services approved by the Division may be included within the scope of the license of the hospital and do not require a separate license.

(5) The license shall be conspicuously posted in the area where patients are admitted.

(6) No license shall be issued or renewed for any Health Care Facility that offers or proposes to develop a new health service subject to ORS 442.320, unless a certificate of need has first been issued therefore pursuant to 442.340.

(7) A facility license that has been suspended or revoked may be reissued after the Division determines that compliance with HCF laws has been achieved satisfactorily.

(8) Submission of Plans, OAR 333-071-0140, shall also apply.

Stat. Auth.: ORS 441 .055
Stats. Implemented: ORS 441.020 - 441.025
Hist.: HD 17-1987(Temp), f. 10-13-87, ef. 10-15-87 thru 4-15-88; HD 11-1988, f. & cert. ef. 5-27-88; HD 5-1989, f. 7-14-89, cert. ef. 8-1-89; OHD 6-1999, f. & cert. ef. 10-22-99

333-071-0010

Annual License Fee

The following license fee applies to special inpatient facilities, (alcohol and drug abuse treatment facilities, college infirmaries, christian science facility, chiropractic facilities, freestanding hospice facilities, infirmaries for the homeless, critical access hospitals):

(1) Less than twenty-six beds, the annual license fee will be $750.

(2) Twenty-six beds or more beds and fewer than 50 beds, the annual license fee will be $1,000.

(3) Fifty or more beds and fewer than 100 beds, the annual license fee will be $1,900.

(4) One hundred or more beds and fewer than 200 beds, the annual license fee will be $2,900.

(5) More than two hundred beds, the annual license fees will be $3,400.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.020
Hist.: HD 11-1988, f. & cert. ef. 5-27-88; HD 5-1989, f. 7-14-89, cert. ef. 8-1-89; OHD 6-1999, f. & cert. ef. 10-22-99

333-071-0015

Expiration and Renewal of License

Each license to operate a health care facility shall expire on December 31 following the date of issue, and if a renewal is desired, the licensee shall make application at least 30 days prior to the expiration date upon a form prescribed by the Division.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.025
Hist.: HD 11-1988, f. & cert. ef. 5-27-88; HD 5-1989, f. 7-14-89, cert. ef. 8-1-89

333-071-0020

Denial or Revocation of License

(1) A license for any health care facility may be denied, suspended or revoked by the Division when the Division finds that there has been a substantial failure to comply with the provisions of Health Care Facility licensing law.

(2) A person or persons in charge of a health care facility shall not permit, aid or abet any illegal act affecting the welfare of the patient.

(3) A license shall be denied, suspended or revoked in any case where the State Fire Marshal or representative of the State Fire Marshal, certified that there is a failure to comply with all applicable laws, lawful ordinances, and rules relating to safety from fire.

(4) A license may be suspended or revoked for failure to comply with a Division order arising from a health care facility's substantial lack of compliance with the rules or statutes.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.030
Hist.: HD 11-1988, f. & cert. ef. 5-27-88; HD 5-1989, f. 7-14-89, cert. ef. 8-1-89

333-071-0025

Return of Facility License

Each license certificate in the licensee's possession shall be returned to the Division immediately on the suspension or revocation of the license, failure to renew the license by December 31, or if operation is discontinued by the voluntary action of the licensee.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 11-1988, f. & cert. ef. 5-27-88

333-071-0030

Classification

(1) The various types of health care facilities within the provisions of ORS Chapter 441 are classified as follows:

(a) Hospital Classifications:

(A) General Hospital;

(B) Mental Hospital or Psychiatric Hospital;

(C) Orthopedic Hospital;

(D) Special Inpatient Care Facility:

(i) Chiropractic Facility;

(ii) Alcohol and/or Drug Abuse Treatment Facility;

(iii) Infirmary: College Infirmary or Student Health Center;

(iv) Rehabilitation Center;

(v) Christian Science Facility;

(vi) Infirmary for the Homeless;

(vii) Freestanding Hospice Facility;

(viii) Critical Access Hospital.

(b) Ambulatory Surgical Center;

(c) Hospital Associated Ambulatory Surgical Center;

(d) Freestanding Birthing Center.

(2) The classification of each health care facility shall be so designated on the license.

(3) Health care facilities licensed by the Division shall neither assume a descriptive title or be held out under any descriptive title other than the classification title established by the Division and under which the facility is licensed. This not only applies to the name on the facility but where stationery, advertising and other representations are involved: General Hospitals may be described as hospitals without modifications by the term "general".

(4) No change in the licensed classification of any health care facility, as set out in this rule, shall be allowed by the Division unless such facility shall file a new application, accompanied by the required license fee, with the Division, if the Division finds that the applicant and facility comply with HCF laws and the regulations of the Division relating to the new classification for which application for licensure is made, the Division shall issue a license for such classification.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.085
Hist.: HD 13-1987, f. 9-1-87, ef. 9-15-87; HD 11-1988, f. & cert. ef. 5-27-88; HD 5-1989, f. 7-14-89, cert. ef. 8-1-89; OHD 6-1999, f. & cert. ef. 10-22-99

333-071-0035

Hearings

Upon written notification by the division of revocation, suspension or denial to issue or renew a license, a written request by the facility for a hearing in accordance with ORS 183.310 to ORS 183.500 shall be granted by the Division.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.037
Hist.: HD 11-1988, f. & cert. ef. 5-27-88

333-071-0040

Adoption by Reference

All rules, standards and publications referred to in Oregon Administrative Rules, Chapter 333 Division 71 are made a part thereof. Copies are available for inspection in the Division during office hours. Where publications are in conflict with the rules, the rules shall govern.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 11-1988, f. & cert. ef. 5-27-88; HD 5-1989, f. 7-14-89, cert. ef. 8-1-89

333-071-0045

Division Procedures

Inspections and investigations:

(1) Complaints:

(a) Any person may make a complaint to the Public Health Division regarding violations of health care facility, laws or regulations. A complaint investigation will be carried out as soon as practicable and may include but not be limited to, as applicable to facts alleged: Interview of the complainant, patient(s), witnesses, and HCF management and staff; observations of the patient(s), staff performance, patient environment and physical environment; and review of documents and records.

(b) Copies of all complaint investigations, which are not exempt from disclosure, will be available from the Division provided that the identity of any patient referred to in an investigation will not be disclosed without legal authorization.

(2) Inspections:

(a) The Division may, in addition to any inspections conducted pursuant to complaint investigations, conduct at least one general inspection of each HCF to determine compliance with HCF laws during each calendar year and at such other times as the Division deems necessary.

(b) Inspections may include but not be limited to those procedures stated in subsection (1)(a) of this rule.

(c) The inspection may include a patient audit, the results of which shall be summarized on the licensing survey form.

(d) When documents and records are requested under section (1) or (2) of this rule, the HCF shall make the requested materials available to the investigator for review and copying.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.057 & 441.060
Hist.: HD 29-1988, f. & cert. ef. 5-27-88; HD 5-1989, f. 7-14-89, cert. ef. 8-1-89

333-071-0050

Governing Body Responsibility

The governing body of each health care facility shall be responsible for the operation of the facility, the selection of the medical staff and the quality of care rendered in the facility. The governing body shall:

(1) Ensure that all health care personnel for whom state licenses or registration are required are currently licensed or registered;

(2) Ensure that physicians, nurse practitioners, and physicians' assistants admitted to practice in the facility are granted privileges consistent with their individual training, experience and other qualifications;

(3) Ensure that procedures for granting, restricting and terminating privileges exist and that such procedures are regularly reviewed to assure their conformity to applicable law; and

(4) Ensure that physicians, nurse practitioners, and physicians' assistants admitted to practice in the facility are organized into a medical staff insofar as applicable in such a manner as to effectively review the professional practices of the facility for the purposes of reducing morbidity and mortality and for the improvement of patient care.

(5) In a Critical Access Hospital, the governing body shall be responsible for the development of a plan by which a person, presenting for services when no patients and staff members are in the facility, is able to contact a health care practitioner who is either a doctor of medicine or osteopathy, a physician assistant, or a nurse practitioner. The governing body shall ensure that a practitioner with training or experience in emergency care is on call and immediately available by telephone or radio contact, and available on site within 30 minutes, on a 24-hours a day basis.

(6) This section is not applicable to facilities meeting the requirements of ORS 441.065.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 17-1987(Temp), f. 10-13-87, ef. 10-15-87 thru 4-15-88; HD 11-1988, f. & cert. ef. 5-27-88; HD 5-1989, f. 7-14-89, cert. ef. 8-1-89; OHD 6-1999, f. & cert. ef. 10-22-99

333-071-0055

Medical Staff

(1) The physicians, nurse practitioners and physician assistants organized into a medical staff pursuant to OAR 333-071-0050 shall propose medical staff by-laws to govern the medical staff. The bylaws shall include, but not be limited to the following:

(a) Procedures for physicians, nurse practitioners and physician assistants admitted to practice in the facility to organize into a medical staff;

(b) Procedures for insuring that physicians, nurse practitioners and physician assistants admitted to practice in the facility are granted privileges consistent with their individual training, experience and other qualifications;

(c) Provisions establishing a frame work for the medical staff to nominate, elect, appoint or remove officers and other persons to carry out medical staff activities with accountability to the governing body;

(d) Procedures for insuring that physicians, nurse practitioners and physician assistants admitted to practice in the facility are currently licensed by the Oregon Medical Board for the State of Oregon or the Oregon State Board of Nursing;

(e) Procedures for insuring that the facility's procedures for granting, restricting and terminating privileges are followed and that such procedures are regularly reviewed to assure their conformity to applicable law; and

(f) Procedures for insuring that physicians, nurse practitioners and physician assistants provide services within the scope of the privileges granted by the governing body.

(2) Amendments to medical staff bylaws shall be accomplished through a cooperative process involving both the medical staff and the governing body. Medical staff bylaws shall be adopted, repealed or amended when approved by the medical staff and the governing body. Approval shall not be unreasonably withheld by either. Neither the medical staff nor the governing body shall withhold approval if such repeal, amendment, or adoption is mandated by law, statute or regulation or is necessary to obtain or maintain accreditation or to comply with fiduciary responsibilities or if the failure to approve would subvert the state moral or ethical purposes of this institution.

(3) Physicians and all other health care practitioners with individual admitting privileges are subject to applicable provisions of the medical staff bylaws and rules governing admission and staff privileges.

(4) This section is not applicable to facilities meeting the requirements of ORS 441.065.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 17-1987(Temp), f. 10-13-87, ef. 10-15-87 thru 4-15-88; HD 11-1988, f. & cert. ef. 5-27-88; HD 5-1989, f. 7-14-89, cert. ef. 8-1-89; OHD 6-1999, f. & cert. ef. 10-22-99

333-071-0057

Personnel

(1) Health care facility shall maintain a sufficient number of qualified personnel to provide effective patient care and all other related services.

(2) There shall be written personnel policies and procedures which shall be made available to personnel.

(3) Provisions shall be made for orientation.

(4) Provisions shall be made for an annual continuing education plan.

(5) There shall be a job description for each position which delineates the qualifications, duties, authority and responsibilities inherent in each position.

(6) There shall be an annual work performance evaluation for each employee with appropriate records maintained.

(7) There shall be an employee health program for the protection of patients.

(a) Pursuant to OAR 333-019-0205:

(A) A person who is diagnosed to have a health care facility restrictable disease shall not engage, as long as she/he is communicable, in any occupation in which he/she provides personal care to or has direct contact with patients in a health care facility. This restriction is removed by the written certification of the local health officer (or designee or) a licensed medical doctor (in concurrence with the local health officer) that the person is no longer communicable.

(B) Examples of health care facility restrictable diseases include but are not restricted to:

(i) Amebiasis;

(ii) Chickenpox;

(iii) Cholera;

(iv) Diphtheria;

(v) Hepatitis A;

(vi) Measles;

(vii) Meningococcal Disease;

(viii) Mumps;

(ix) Pediculosis;

(x) Pertussis;

(xi) Plague;

(xii) Rubella;

(xiii) Salmonellosis;

(xiv) Scabies;

(xv) Shigellosis;

(xvi) Staphylococcal Infections;

(xvii) Streptococcal Infections;

(xviii) Tuberculosis, active pulmonary.

(C) The infection control committee of the health care facility shall adopt policies to restrict the working of employees with health care facility restrictable diseases. When measures have been taken to prevent the transmission of disease and these measures are in accordance with written procedures approved by the infection control committee of the facility after consultation with the local health officer, infectious employees may work in a health care facility. Nothing in these rules prohibits health care facilities and local health departments from adopting additional or more stringent rules for exclusion from these facilities.

(b) Pursuant to OAR 333-019-0405:

(A) Any employee working in a health care facility who does not have a documented history of a positive tuberculin test shall have a Mantoux method tuberculin test applied and interpreted within two weeks of first employment.

(B) If the tuberculin test is negative, the employee does not need to have further routine tuberculin skin tests, except as outlined in paragraph (7)(b)(F) of this rule.

(C) If the tuberculin test is positive or if the employee has a previously documented positive tuberculin skin test, and if the employee has not had adequate chemotherapy, the employee shall have a chest X-ray and medical evaluation to identify communicable tuberculosis within two weeks of first employment.

(D) Tuberculin positive employees who do not have communicable tuberculosis and who complete one year of isoniazid preventive therapy tuberculosis and who complete one year of isoniazid preventive therapy (or adequate anti-tuberculosis chemotherapy) shall be released from further routine tuberculosis screening activities.

(E) Tuberculin positive employees who do not have communicable tuberculosis shall have a medical evaluation for the presence of any of the following risk factors: evidence of inadequately treated past tuberculosis disease, history of close exposure to a case of communicable pulmonary tuberculosis within the previous two years, acquired immunodeficiency syndrome, history of a negative tuberculin test within the previous two years, diabetes mellitus (severe or poorly controlled), diseases associated with severe immunologic deficiencies, immuno-suppressive therapy, silicosis, gastrectomy, or excessive alcohol intake. Tuberculin positive employees with any of these risk factors who have not completed one year of isoniazid preventive therapy shall have annual chest X-rays for the duration of their employment. Tuberculin positive employees who have not completed one year of isoniazid preventive therapy and who do not have any of the risk factors shall be released from further tuberculosis surveillance. The facility shall have a policy to assure that a change in risk status of such an individual will be identified.

(F) Tuberculin negative employees of health care facilities whose work has the potential for frequent or periodic close exposure to persons with communicable tuberculosis or laboratory specimens of M. tuberculosis shall have periodic tuberculin tests at intervals to be specified by the facility's infection control committee, or by the facility's administrative policy when there is no infection control committee.

(G) An employee whose employment never requires him/her to be in a room where patients or residents might enter, and who does not handle clinical specimens or other material from patients or their rooms, may be exempted from the requirements of paragraph (b)(A)-(F) of this section. An example of such an employee would be an administrative person or research worker whose place of work is remote from patient or residential care areas and who does not come in contact with clinical specimens.

(H) In the event that a case of communicable tuberculosis is diagnosed in an employee or patient of a health care facility, the facility shall conduct an investigation to identify contacts. The local health department shall assist in the investigation and shall assure that the investigation follows the guidelines of the American Thoracic Society referred to in OAR 333-017-0005(3).

(I) The actions taken under paragraphs (b)(A) through (H) of this section and all results thereof shall be fully documented for each employee. Such documentation is subject to review by authorized representatives of the Division.

(8)(a) Any person admitted to a facility for treatment of alcoholism, or rehabilitation center, who does not have a documented history of a positive tuberculin test shall have a Mantoux method tuberculin test within two weeks of first admission. If the admission tuberculin test is negative, the patient is not required to have periodic tuberculin tests.

(b) If an admission tuberculin skin test is positive, or if the patient has had a previously documented positive tuberculin test, and the patient has not had adequate chemotherapy, the patient shall have a chest X-ray and medical evaluation to identify communicable tuberculosis unless such an X-ray and evaluation has been performed within the preceding three months. If communicable tuberculosis is suspected or diagnosed, the patient shall be cared for in general accordance with AFB isolation as follows: In health care facilities, cases of current pulmonary tuberculosis shall be placed in AFB isolation or the appropriate disease-specific precautions until they have been determined to be non-infectious by the infection control committee of the facility or the local health officer (or designee). In health care facilities, suspected cases of pulmonary tuberculosis shall be placed in AFB isolation until the diagnosis of infectious pulmonary tuberculosis has been excluded by the attending licensed medical doctor.

(c) The admission skin test and chest x-ray requirements in subsections (8)(a) and (b) do not apply to persons readmitted to the same facility after having been directly discharged to a hospital and readmitted directly from the hospital.

(d) The tuberculin positive patient who does not have tuberculosis disease shall be offered isoniazid preventive therapy according to the American Thoracic Society guidelines. Tuberculin positive patients who have not completed one year of isoniazid preventive therapy shall have annual chest X-rays while at the facility. Such patients who are under age 65, and do not have any of the risk factors described in subsection (7)(a)(C) of this rule shall be released from further routine tuberculosis surveillance following three negative yearly chest x-rays.

(e) The actions taken under subsections (8)(a) through (d) of this rule and all results thereof shall be fully documented for each patient. Such documentation is subject to review by authorized representatives of the Division.

(9) Only subsections (1) - (6) of this rule apply to facilities meeting the requirements of ORS 441.065.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 5-1989, f. 7-14-89, cert. ef. 8-1-89 ; OHD 6-1999, f. & cert. ef. 10-22-99

333-071-0060

Medical Records

(1) A medical record shall be maintained for every patient admitted for care in all Health Care Facilities.

(2) A legible reproducible medical record in ink or typescript shall include at least the following (if applicable):

(a) Admitting identification data including date of admission.

(b) Chief compliant.

(c) Pertinent family and personal history.

(d) Medical history, physical examination report and provisional diagnosis:

(A) If a patient is readmitted within a month's time for the same condition, the previous medical history and physical examination report, with an interval note, will suffice.

(B) If a medical history and physical examination report which complies with the above requirements has been completed within 7 days prior to admission, it may be used as the admission history and physical as provided in the medical staff rules and regulations.

(e) Clinical laboratory reports as well as reports on any special examinations. (The original report shall be authenticated and recorded in the patient's medical record.)

(f) X-ray reports shall be recorded in the medical record and shall bear the identification (authentication) of the originator of the interpretation.

(g) Signed or authenticated report of consultant when such services have been obtained.

(h)(A) All entries in a patient's medical record must be dated, timed and authenticated. Verification of an entry requires use of a unique identifier, i.e., signature, code, thumb print, voice print, or other means, which allows identification of the individual responsible for the entry.

(B) Verbal orders may be accepted by those individuals authorized by law and/or scope of practice and by medical staff rules and regulations and shall be countersigned or authenticated by the prescriber within 24 hours, except in the case of Freestanding Hospice Facilities, in which verbal orders must be countersigned by the house physician in 72 hours and by the attending physician within seven days.

(C) A single signature or authentication of the physician, dentist, podiatrist or other individual authorized within the scope of his or her professional license on the medical record does not suffice to cover the entire content of the record.

(i) Records of assessment and intervention, including graphic charts and medication records and appropriate personnel notes.

(j) Summary including final diagnosis.

(k) Date of discharge and discharge note.

(l) Autopsy report if applicable.

(m) Such signed documents as may be required by law.

(3) The completion of the medical record shall be the responsibility of the attending practitioner. The dentist, podiatrist or other individual authorized within the scope of his or her professional license shall complete those portions of the record which pertain to his/her portion of the patient's care. The appropriate individual shall separately sign or authenticate the history and physical examination, operative report, progress notes, orders and the summary. In a facility using unlicensed house officers, the attending physician shall countersign, without 24 hours, all entries written by such house officers. Externs working in a program may be considered house officers. The physician, dentist, podiatrist or other individual authorized within the scope of his or her professional license shall also authenticate any clinical entries which he/she makes himself/herself. A single signature or authentication of the physician, dentist, podiatrist or other individual authorized within the scope of his or her professional license on the face sheet of the medical record does not suffice to cover the entire content of the record:

(a) Medical records shall be completed by the physician, dentist, podiatrist or other individual authorized within the scope of his or her professional license within four weeks following the patient's discharge.

(b) If a patient is transferred to another health care facility, transfer information shall accompany the patient. Transfer information shall include but not be limited to facility from which transferred, name of physician to assume care, date and time of discharge, current medical findings, current nursing assessment, current history and physical, diagnosis, orders from a physician for immediate care of the patient, operative report, if applicable; TB test, if applicable; other information germane to patient's condition. If discharge summary is not available at time of transfer, it shall be transmitted as soon as available.

(4) Diagnoses and operations shall be expressed in standard terminology.

(5) The medical records shall be filed in a manner which renders them easily retrievable. Medical records shall be protected against unauthorized access, fire, water and theft.

(6) Medical records are the property of the health care facility. The medical record, either in original, electronic or microfilm form, shall not be removed from the institution except where necessary for a judicial or administrative proceeding. Authorized personnel of the Division shall be permitted to review medical records. When a health care facility uses off-site storage for medical records, arrangements must be made for delivery of these records to the health care facility when needed for patient care or other health care facility activities. Precautions must be taken to protect patient confidentiality.

(7) All medical records shall be kept for a period of at least ten years after the date of last discharge. Original medical records may be retained on paper, microfilm, electronic or other media.

(8) If a health care facility changes ownership all medical records in original, electronic or microfilm form shall remain in the facility or related institution, and it shall be the responsibility of the new owner to protect and maintain these records.

(9) If any facility shall be finally closed, its medical records may be delivered and turned over to any other facility or facilities in the vicinity willing to accept and retain the same as provided in section (7) of this rule.

(10) All original clinical records or photographic or electronic facsimile thereof, not otherwise incorporated in the medical record, such as X-rays, electrocardiograms, electroencephalograms, and radiological isotope scans shall be retained for seven years after patient's last discharge if professional interpretations of such graphics are included in the medical records.

(11) If a qualified medical record practitioner, RRA (Registered Record Administrator) or ART (Accredited Record Technician) is not the Director of the Medical Records Department, periodic and at least annual consultation must be provided by a qualified medical records consultant, RRA/ART. The visits of the medical records consultant shall be of sufficient duration and frequency to review medical record systems and assure quality records of the patients. Contract for such services shall be available to the Division.

(12) A current written policy on the release of medical record information including patient access to his/her medical record shall be maintained in the medical records department.

(13) This section is not applicable to facilities meeting the requirements of ORS 441.065.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 17-1987(Temp), f. 10-13-87, ef. 10-15-87 thru 4-15-88; HD 11-1988, f. & cert. ef. 5-27-88; HD 5-1989, f. 7-14-89, cert. ef. 8-1-89; OHD 6-1999, f. & cert. ef. 10-22-99

333-071-0065

Quality Assurance

The governing body must ensure that there is an effective, written, facility-wide quality assurance program to evaluate and monitor the quality and appropriateness of patient care, including contracted services. Written documentation of quality assurance activities shall be recorded at least quarterly. This section does not apply to those facilities meeting the requirements of ORS 441.065.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 17-1987(Temp), f. 10-13-87, ef. 10-15-87 thru 4-15-88; HD 11-1988, f. & cert. ef. 5-27-88; HD 5-1989, f. 7-14-89, cert. ef. 8-1-89

333-071-0070

Medically Related Patient Care Services

(1) Medically-related patient care services: The facility must have an ongoing plan consistent with available community and facility resources, to provide or make available social work, psychological, and educational services to meet the medically-related needs of its patients. The facility also must have an effective, ongoing discharge planning program that facilitates the provision of follow-up care.

(a) Discharge planning must be initiated in a timely manner.

(b) Patients, along with necessary medical information, must be transferred or referred to appropriate facilities, agencies, or outpatient services, as needed, for follow-up or ancillary care.

(2) This section does not apply to facilities meeting the requirements of ORS 441.065.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 11-1988, f. & cert. ef. 5-27-88; OHD 6-1999, f. & cert. ef. 10-22-99

333-071-0073

Physician Services

(1) No patient shall be admitted to the facility except on the order of a physician or a nurse practitioner. The admitting medical staff member for the facility shall provide sufficient information at the time of admission to establish that care can be provided to meet the needs of the patient. Admission medical information shall include a statement concerning the admitting diagnosis and general condition of the patient. Other pertinent medical information, orders for medication, diet and treatments shall also be provided, and a medical history and a physical.

(2) Orders pertinent to the care of the patient shall be initiated, dated, timed and signed by the practitioner ordering the care. The disposition of these orders shall be documented in the patient's medical record.

(3) Visits from practitioners shall be according to patient's needs. Initial and ongoing assessments shall be performed for each patient and the results and observations recorded in the medical record.

(4) A M.D. or D.O. physician or nurse practitioner to whom admitting privileges have been granted shall be responsible, as permitted by the individual's scope of practice, for the care of any medical problem that may be present on admission or that may arise during an inpatient stay for dental, podiatric or other purpose. Patients in a Critical Access Hospital will have care provided by a member of the medical staff under the individual's scope of practice.

(5) No medication or treatment shall be given except on the order of one duly authorized to give such orders within the State of Oregon.

(6) Each facility shall provide for one or more appropriate practitioners on the medical staff to be called in the event of an emergency.

(7) This section does not apply to facilities meeting the requirements of ORS 441.065.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 5-1989, f. 7-14-89, cert. ef. 8-1-89; OHD 6-1999, f. & cert. ef. 10-22-99

333-071-0075

Nursing Care Management

(1) The nursing care of each patient in a health care facility shall be the responsibility of a registered nurse (R.N.).

(2) The nurse will only provide services to the clients for which she/he is educationally and/or experientially prepared and for which competency has been maintained.

(3) The R.N. shall be responsible and accountable for managing the nursing care of her/his assigned patients. She/he shall coordinate the nursing functions and tasks for those patients with the functions and tasks of physicians and other health care providers. The responsible R.N. shall ensure that the following activities are completed:

(a) Summarize the admission status of the patient within 4 hours;

(b) Develop and document, within 8 hours, a plan of care for nursing services for the patient, based on the patient assessment and realistic, understandable, achievable patient goals consistent with ORS 851-045-0010, Standards of R.N. Scope of Practice.

(c)(A) Observe and report to the nurse manager and the patient's practitioner when appropriate, any significant changes in the patient's condition that warrant interventions that have not been previously prescribed or planned for;

(B) When the R.N. questions the efficacy, need or safety of continuation of medications being administered by that R.N. to a patient therein, the R.N. shall report that question to the practitioner authorizing the medication and shall seek further instructions concerning the continuation of the medication.

(4)(a) The Health Care Facility shall maintain documentation of certification of CNA's, which shall be available on request to Division personnel.

(b) CNAs must be certified by the Oregon State Board of Nursing prior to assuming nursing assistant duties.

(c) The Health Care Facility shall maintain documentation that Certified Medication Aides (CMAs) hold current certification with the Oregon State Board of Nursing. This documentation shall be available on request to Division personnel.

(5) This section does not apply to facilities meeting the requirements of ORS 441.065.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 11-1988, f. & cert. ef. 5-27-88; HD 5-1989, f. 7-14-89, cert. ef. 8-1-89; OHD 6-1999, f. & cert. ef. 10-22-99

333-071-0077

Nurse Executive

(1) In a freestanding Hospice Facility, the nurse executive position shall be full-time (40 hours per week). Time spent in professional association workshops, seminars and continuing education may be counted as his/her duties in considering whether or not he/she is full-time.

(2) In all Special Inpatient Care Facilities, the nurse executive shall have had progressive responsibility in managing in a health care setting. The nurse executive shall be a registered nurse licensed in Oregon with a baccalaureate degree or other advanced degree or appropriate equivalent experience, with emphasis in management preferred.

(3) In all Special Inpatient Care Facilities, the nurse executive shall have written administrative authority, responsibility and accountability for assuring functions and activities of the nursing services department and shall participate in the development of any policies that affect the nursing services department. This includes budget formation, implementation and evaluation. The nurse executive shall ensure the:

(a) Development and maintenance of a nursing service philosophy, objective, standards of practice, policy and procedure manuals and job descriptions for each level of nursing service personnel;

(b) Development and maintenance of personnel policies of recruitment, orientation, in-service education, supervision, evaluation and termination of nursing service staff or ensure it is done by another department;

(c) Development and maintenance of policies and procedures for determination of nursing staff's capacity for providing nursing care for any patient seeking admission to the facility;

(d) Development and maintenance of a quality assurance program for nursing service;

(e) Coordination of nursing service departmental function and activities with the function and activities of other departments;

(f) Ensure participation with the administrator and other department directors in development and maintenance of practices and procedures that promote infection control, fire safety and hazard reduction.

(4) In all Special Inpatient Care Facilities, whenever the nurse executive is not available in person or by phone, she/he shall designate in writing a specific registered nurse or nurses, licensed to practice in Oregon, to be available in person or by phone to direct the functions and activities of the nursing services department.

(5) This section does not apply to facilities meeting the requirements of ORS 441.065.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 5-1989, f. 7-14-89, cert. ef. 8-1-89; OHD 6-1999, f. & cert. ef. 10-22-99

333-071-0080

Nursing Services

(1) The facility shall provide a nursing service department which provides 24-hours, 7 days per week, nursing care, except in the case of College Infirmary which must provide 24 hour nursing only during periods of operation and except in the case of a Critical Access Hospital which must provide 24-hour nursing only when inpatients are present in the facility.

(2) The nursing services department shall be under the direction of a Nurse Executive who is a registered nurse, licensed to practice in Oregon.

(3) The facility shall be responsible for developing, and implementing under the direction of the Nurse Executive, a written staffing plan consistent with the scope of practice for R.N.'s and L.P.N.'s:

(a) Each staffing plan shall make allowances for sickness, vacations, vacancies and other absences and shall list the service(s) or persons to be called for replacement of nursing personnel. Nursing care required by different types of patients shall be the major consideration in determining number, quality and categories of nursing personnel needed.

(b) Each staffing plan shall establish minimum numbers of nursing staff personnel (licensed nurses and nursing assistants) on specified shifts. In no case shall fewer than one registered nurse and one other nursing care staff member be on duty when a patient is present.

(4) This section does not apply to facilities meeting the requirements of ORS 441.065.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 17-1987(Temp), f. 10-13-87, ef. 10-15-87 thru 4-15-88; HD 11-1988, f. & cert. ef. 5-27-88; HD 5-1989, f. 7-14-89, cert. ef. 8-1-89; OHD 6-1999, f. & cert. ef. 10-22-99

333-071-0082

Surgical Services in Critical Access Hospitals (CAH)

Surgical services, if provided, must be performed in a safe manner by qualified practitioners who have been granted clinical privileges by the governing body of the Critical Access Hospital in accordance with the designation requirements under paragraph (1) of this section.

(1) Designation of qualified practitioners. The CAH designates the practitioners who are allowed to perform surgery for CAH patients, in accordance with its approved policies and procedures, and with State scope of practice laws. Surgery is performed only by:

(a) A doctor of medicine or osteopathy, including an osteopathic practitioner;

(b) A doctor of dental surgery or dental medicine; or

(c) A doctor of podiatric medicine.

(2) Anesthetic risk and evaluation. A qualified practitioner must examine the patient immediately before surgery to evaluate the risk of anesthesia and of the procedure to be performed. Before discharge from the CAH, each patient must be evaluated for proper anesthesia recovery by a qualified practitioner.

(3) Administration of anesthesia. The CAH designates the person who is allowed to administer anesthesia to CAH patients in accordance with its approved policies and procedures and with State scope of practice laws. Anesthetics must be administered by:

(a) A qualified anesthesiologist;

(b) A doctor of medicine or osteopathy other than an anesthesiologist;

(c) A doctor of dental surgery or dental medicine;

(d) A doctor of podiatric medicine;

(e) A certified registered nurse anesthetist;

(f) A supervised trainee in an approved anesthesia educational program.

(4) Discharge. All patients are discharged in the company of a responsible adult, except those exempted by the practitioner who performed the surgical procedure.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: OHD 6-1999, f. & cert. ef. 10-22-99

333-071-0084

Blood and Blood Products in Critical Access Hospitals

The facility provides, either directly or under arrangements, the following:

(1) Services for the procurement, safekeeping, and transfusion of blood, including the availability of blood products needed for emergencies on a 24-hours a day basis.

(2) If blood banking services are provided under an arrangement, the arrangement is approved by the facility's medical staff and by the persons directly responsible for the operation of the facility.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: OHD 6-1999, f. & cert. ef. 10-22-99

333-071-0085

Dietary

An organized dietary department shall be directed by qualified personnel and shall conform to the requirements in the Oregon Food Sanitation Rules, OAR 333-150-0000 and 333-160-0000 and shall meet the following criteria:

(1) The facility shall employ supportive personnel competent to carry out the functions of the dietary service;

(2) The quality and appropriateness of nutritional care provided by the dietetic service shall be regularly reviewed and evaluated;

(3) Services of a consulting dietician shall be obtained;

(4) Arrangements may be made for outside services. All food services shall meet the requirements of the Oregon Food Sanitation Rules.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 17-1987(Temp), f. 10-13-87, ef. 10-15-87 thru 4-15-88; HD 11-1988, f. & cert. ef. 5-27-88

333-071-0090

Laboratory

The facility shall provide, or shall have a written contract with a licensed clinical laboratory under ORS Chapter 438 and OAR chapter 333, division 24, or its equivalent. A list of available tests and procedures shall be maintained. This section does not apply to facilities meeting the requirements of ORS 441.065.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 17-1987(Temp), f. 10-13-87, ef. 10-15-87 thru 4-15-88; HD 11-1988, f. & cert. ef. 5-27-88

333-071-0095

Transfer

(1) The facility shall have a procedure which provides for transfer of patients to an acute care setting as appropriate.

(2) Transfer information shall include but not be limited to facility from which transferred, name of physician to assume care, current medical findings, current nursing assessment, diagnosis and other information germane to patient's condition.

(3) This section does not apply to facilities meeting the requirements of ORS 441.065.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 17-1987(Temp), f. 10-13-87, ef. 10-15-87 thru 4-15-88; HD 11-1988, f. & cert. ef. 5-27-88

333-071-0100

Accommodations for Patients

(1) There shall be provided for each patient a good bed: mattress and pillow with a protective cover and necessary bed coverings; and other appropriate furniture.

(2) Freestanding Hospice Facilities shall also provide the following:

(a) Bedside table and chair;

(b) A reading light;

(c) An electrically operated call system which registers at the nurses' station. The call system cord shall be secured in a manner which will prevent the patient from injuring him/herself with it.

(3) According to his/her needs, each patient shall be provided with individual equipment, such as bedpans, bedpan covers, urinals, washbasins, emesis basins, mouthwash cups, soap, washcloths, towels and drinking glasses. Single patient use items must be identified with patient name and/or room number and disposed of upon patient discharge.

(4) Equipment such as wheelchairs, walkers, geri chairs, and crutches shall be readily available for patients needing this equipment.

(5) Separate storage space for clothing, toilet articles, and other personal belongings of patients shall be provided.

(6) In multiple-bed rooms, opportunity for patient privacy shall be provided by flame retardant curtains or screen. Cubicle curtains or screens are not required for beds assigned to pediatric patients.

(7) The use of torn or unclean bed linen is prohibited.

(8) After the discharge of any patient, the bed, bed furnishing, bedside furniture and equipment shall be thoroughly cleansed and disinfected prior to re-use. Mattresses shall be professionally renovated when necessary.

(9) Hot water bags and electric heating pads or blankets may be used only on the written order of the physician.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 17-1987(Temp), f. 10-13-87, ef. 10-15-87 thru 4-15-88; HD 11-1988, f. & cert. ef. 5-27-88; HD 5-1989, f. 7-14-89, cert. ef. 8-1-89

333-071-0105

Building Requirements

(1) Patient Care Units:

(a) In the care of rehabilitation centers, a minimum of 80 square feet of floor space per bed is required in semi-private rooms and wards.

(b) In all other Special Inpatient Care Facilities, a minimum of 70 square feet of floor space per bed is required in semi-private rooms and wards.

(c) 100 square feet of floor space shall be provided in private rooms.

(d) No more than four beds shall be placed in each patient room.

(e) All rooms shall be entered from an exit corridor.

(f) All patient rooms shall have one or more windows, the overall size shall be not less than one-tenth the room floor area. The windows shall be fitted so as to provide natural ventilation, or a mechanical ventilation system shall be provided including a system for exhausting smoke directly to the exterior in accordance with the provisions of NFPA 90A, 1985 edition.

(g) Storage space for clothing, toilet articles, and other personal belongings of the patient shall be provided.

(2) If social space and space for patient dining is necessary to support the program needs, a minimum of 30 square feet per patient is required.

(3) A room or space for group therapy activities is required, if applicable.

(4) A room shall be available for examination and treatment of patients. (May be omitted if the unit is connected to or a part of a general hospital).

(5) Separate consultation room(s) as necessary to support the program needs of the facility shall be provided. (Consultation may be performed in the examination/treatment room when the number of alcohol treatment beds is less than 16).

(6) If Physical Therapy Services are provided by the facility, the following elements shall be present:

(a) Treatment Area(s). It shall have space and equipment for thermotherapy, diathermy, ultrasonics and hydrotherapy. Provisions shall be made for a cubicle curtain around each individual treatment area. Provisions shall include handwashing facilities, (one lavatory or sink may serve more than one cubicle);

(b) Exercise area;

(c) Storage for clean linen, supplies, and equipment;

(d) Storage for soiled linen and equipment;

(e) Service sink;

(f) Wheelchair and stretcher storage.

(7) If Occupational Therapy Services are provided by the facility, the following elements shall be present:

(a) Therapy area shall include sink;

(b) Storage for supplies and equipment;

(c) Treatment area.

(8) In facilities for the treatment of alcoholism and drug abuse, a minimum of one patient room for detoxification, located to allow direct observation by nursing staff, shall be provided. Windows in detoxification rooms shall be of a security type that can only be opened by keys or tools that are under the control of the staff. An adjoining or closely available toilet room and handwashing lavatory is also required serving detoxification patients only. The detoxication area must comply with the Group I, Division 3 of the State Structural Specialty Code.

(9) Degree of security required shall be as determined by the program, but operation of such shall be restricted to inhibit possible tendency for escape, suicide, and to limit potential for self-inflicted injury.

(10) Where glass fragments may create a hazard, safety glazing and/or other appropriate security measures are recommended.

(11) Additional Requirements:

(a) An Administrative center or nurses station;

(b) Storage for administrative supplies;

(c) Charting facilities for nurses and doctors;

(d) Toilet room for staff;

(e) Janitor closet;

(f) Clean storage room or enclosed cabinet spaces for clean supplies and linen storage;

(g) Separate enclosed soiled utility or holding room for soiled linens and refuse;

(h) Equipment storage room; (May be combined with clean supply room if space allows for both functions.);

(i) Linen Services:

(A) On-Site Processing. If linen is to be processed on the site, the following shall be provided:

(i) Laundry processing room with commercial-type equipment which can process seven days' needs within a regularly scheduled work week. Handwashing facilities shall be provided. Soiled linen receiving, holding and sorting area;

(ii) Storage for laundry supplies;

(iii) Clean linen inspection and mending room or area;

(iv) Clean linen storage, issuing, and holding room or area;

(v) Cart sanitizing facilities and cart storage area. The sanitizing facilities may be combined with those required for dietary facilities.

(B) If linen is processed off-site, following shall be provided:

(i) Soiled linen holding room;

(ii) Clean linen receiving, holding, inspection, and storage room(s);

(iii) Cart sanitizing facilities and cart storage area. The sanitizing facilities may be combined with those required for dietary facilities.

(12) The building shall be kept clean and in good repair.

(13) Rehabilitation centers must provide handicap accessibility for the patient's activities of daily living.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 17-1987(Temp), f. 10-13-87, ef. 10-15-87 thru 4-15-88; HD 11-1988, f. & cert. ef. 5-27-88; HD 5-1989, f. 7-14-89, cert. ef. 8-1-89

333-071-0110

Pharmacy

(1) Special Inpatient Care Facilities are subject to ORS Chapter 689 and all the rules thereunder as applicable.

(2) Pharmacy services shall be in accordance with ORS Chapter 689 and OAR 855-041-0105 through 855-041-0140.

(3) Provision shall be made for convenient and prompt 24-hour distribution of drugs to patients. This may be from a medicine preparation room or unit, a self-contained medicine dispensing unit, or by another approved system meeting the rules of the Board of Pharmacy. If used, a medicine preparation room or unit shall be under the nursing staff's visual control and contain a work counter, refrigerator and locked storage for biologicals and drugs. A medicine dispensing unit may be located at the nurses' station, in the clean workroom, or in an alcove or other space under direct control of nursing or pharmacy staff.

(4) Storage and disposal of drugs: Old medications, including special prescriptions for patients who have left the facility, shall be disposed of by incineration or other equally effective method, except narcotics and other drugs under the drug abuse law, which shall be handled in the manner prescribed by the Drug Enforcement Administration of the United State Department of Justice.

(5) Dispensing of drugs: Drugs shall not be supplied or given to either inpatients or outpatients, unless ordered by a physician or individual authorized within the scope of his or her professional license to prescribe drugs; and such order shall be in writing over the physician's or other authorized individual's signature or authentication.

(6) In a Special Inpatient Care Facility having a drug room and no pharmacy, the drug room must be supervised by a licensed pharmacist who provides his or her services with sufficient professionalism, quality and availability to adequately protect the safety of the patients and to properly serve the needs of the facility, pursuant to OAR 855-041-0135.

(7) This section does not apply to facilities meeting the requirements of ORS 441.065.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 17-1987(Temp), f. 10-13-87, ef. 10-15-87 thru 4-15-88; HD 11-1988, f. & cert. ef. 5-27-88

333-071-0115

Infection Control

(1) Each Health Care Facility shall establish an active facility-wide infection control program. In the hospital the program shall be under the direction of a multi-disciplinary committee which shall be responsible for investigating, controlling and preventing infections in the facilities. This committee shall include representation from major departments and services and shall provide for consultation from other departments and services. Each Health Care Facility shall be responsible for developing written policies and for annual review of such policies, relating to at least the following:

(a) Identification of existing or potential infections in patients and employes.

(b) Control of factors affecting the transmission of infections.

(c) Provisions for orienting and educating all employes and volunteers on the cause, transmission, and prevention of infections.

(d) Collection, analysis, and use of data relating to infections in the hospital.

(2) Each Health Care Facility shall be responsible for the implementation of policies under section (1) of this rule.

(3) All Health Care Facilities shall maintain compliance with the current publication of the rules of the Division for the control of communicable diseases.

(4) Written isolation procedures in accordance with Center for Communicable Disease Control Guidelines universal precautions shall be established and followed by all Health Care Facility personnel for control and prevention of cross-infection between patients, departments and services. Guidelines can be obtained from U.S. Department of Health and Human Services, Public Health Center for Disease Control, Atlanta, GA 30333. Any guidelines published and distributed by the Division shall also be taken into consideration.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 17-1987(Temp), f. 10-13-87, ef. 10-15-87 thru 4-15-88; HD 11-1988, f. & cert. ef. 5-27-88; HD 5-1989, f. 7-14-89, cert. ef. 8-1-89

333-071-0120

Sanitary Precautions

(1) Provisions shall be made for the proper cleaning of linen and other washable goods and proper disposal of all refuse.

(2) All garbage and refuse shall be stored and disposed of in a manner that will not create a nuisance or a public health hazard and by a method approved by the Local Health Officer.

(3) Measures shall be taken to prevent the entry of rodents, flies, mosquitoes, and other insects. Adequate measures shall include but are not limited to preventing their entry through doors, windows, or other outside opening.

(4) The walls and floors shall be of a durable and cleanable composition necessary to maintain a sanitary environment appropriate to the use of the area. The building shall be kept clean and in good repair.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 17-1987(Temp), f. 10-13-87, ef. 10-15-87 thru 4-15-88; HD 11-1988, f. & cert. ef. 5-27-88

333-071-0125

Safety and Emergency Precautions

(1) Telephone communication to summon help in case of fire or other emergency shall be available.

(2) In accordance with ORS chapter 479 and the rules thereunder all requirements of the State Fire Marshal shall be met.

(3) When required, emergency power facilities shall be tested monthly and shall be in readiness at all times for use in all areas required in NFPA 99 and the National Electrical Code.

(4) Emergency preparedness:

(a) The health care facility shall develop, maintain, update, train, and exercise an emergency plan for the protection of all individuals in the event of an emergency, in accordance with the regulations as specified in Oregon Fire Code (Oregon Administrative Rules chapter 837, division 40).

(A) The health care facility shall conduct at least two drills every year that document and demonstrate that employees have practiced their specific duties and assignments, as outlined in the emergency preparedness plan.

(b) The emergency plan shall include the contact information for local emergency management.

(c) The summary of the emergency plan shall be sent to the Oregon Health Authority (Authority) within one year of the filing of this rule. New facilities that have submitted licensing documents to the state before this provision goes into effect will have one year from the date of license application to submit their plan. All other new facilities shall have a plan prior to licensing. The Authority shall request updated plans as needed.

(d) The emergency plan shall address all applicable hazards that may include, but is not limited to, the following:

(A) Chemical emergencies;

(B) Dam failure;

(C) Earthquake;

(D) Fire;

(E) Flood;

(F) Hazardous material;

(G) Heat;

(H) Hurricane;

(I) Landslide;

(J) Nuclear power plant emergency;

(K) Pandemic;

(L) Terrorism; or

(M) Thunderstorms.

(e) The emergency plan shall address the provision of sufficient supplies for patients and staff to shelter in place for a minimum of four days under the following conditions:

(A) Extended power outage;

(B) No running water;

(C) Replacement of food or supplies is unavailable; and

(D) Staff members do not report to work as scheduled.

(f) The emergency plan shall address evacuation, including:

(A) Identification of individual positions’ duties while vacating the building, transporting, and housing residents;

(B) Method and source of transportation;

(C) Planned relocation sites;

(D) Method by which each patient will be identified by name and facility of origin by people unknown to them;

(E) Method for tracking and reporting the physical location of specific patients until a different entity resumes responsibility for the resident; and

(F) Notification to the Authority about the status of the evacuation.

(g) The emergency plan shall address the clinical and medical needs of the patients, including provisions to provide:

(A) Storage of and continued access to medical records necessary to obtain care and treatment of patients, and the use of paper forms to be used for the transfer of care or to maintain care on-site when electronic systems are not available;

(B) Continued access to pharmaceuticals, medical supplies and equipment, even during and after an evacuation; and

(C) Alternative staffing plans to meet the needs of the patients when scheduled staff members are unavailable. Alternative staffing plans may include, but is not limited to, on-call staff, the use of travelers, the use of management staff, or the use of other emergency personnel.

(h) The emergency plan shall be made available as requested by the Authority and during licensing and certification surveys. Each plan will be re-evaluated and revised as necessary or when there is a significant change in the facility or population of the health care facility.

(i) A checklist for inpatient health care facilities has been developed in conjunction with the Office of the State Fire Marshal to assist facilities in developing emergency plans and ensuring compliance with the State Fire Marshal’s administrative rules.

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 441.020, 442.015
Stats. Implemented: ORS 441.020, 442.015
Hist.: HD 17-1987(Temp), f. 10-13-87, ef. 10-15-87 thru 4-15-88; HD 11-1988, f. & cert. ef. 5-27-88; HD 5-1989, f. 7-14-89, cert. ef. 8-1-89; PH 13-2008, f. & cert. ef. 8-15-08

333-071-0130

Plumbing and Sanitation Requirements

(1)(a) Separate men's and women's toilet facilities shall be provided at a rate of one per eight patient beds conveniently located to serve patients and provide for individual privacy, except in the case of Freestanding Hospice Facilities, which shall provide the following:

(b) Each patient shall have access to a toilet room without entering the general corridor area. One toilet room shall serve no more than four beds and no more than two patient rooms. The toilet room shall contain a toilet and a lavatory. The lavatory may be omitted from a toilet room which serves a single-bed room if the patient room contains a lavatory.

(2) Adequate handwashing facilities, including hot and cold running water, soap and single use sanitary towels shall be provided for the total facility population. A handwashing facility shall be available in or in a reasonable proximity to each toilet room and in close proximity to the administrative center or nurses' station.

(3) Bathing facilities for patients shall be provided to include at least one shower or tub for each 12 beds, serving patient rooms not containing bathing facilities directly adjoining the room. Rehabilitation Centers shall make available special bathing facilities for the physically disabled.

(4) Partitions between fixtures shall be provided when there are multiple toilet and/or bathing facilities. These partitions shall be at least six feet in height and provide for privacy closure.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 17-1987(Temp), f. 10-13-87, ef. 10-15-87 thru 4-15-88; HD 11-1988, f. & cert. ef. 5-27-88; HD 5-1989, f. 7-14-89, cert. ef. 8-1-89

333-071-0135

Construction Requirements

Special Inpatient Care Facilities shall comply with all requirements of the State Structural, Plumbing, Mechanical and Electrical Specialty Codes in effect at the time of initial licensure and current code for construction or additions to existing facilities as enforced by the Oregon Building Codes Division and local jurisdictions having authority.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 17-1987(Temp), f. 10-13-87, ef. 10-15-87 thru 4-15-88; HD 11-1988, f. & cert. ef. 5-27-88

333-071-0140

Submission of Plans

Any party proposing to make certain alterations or additions to an existing health care facility or to construct new facilities shall, before commencing such alteration, addition or new construction, submit plans and specifications to the Licensing Plan Review Program, Oregon Public Health Division, Oregon Health Authority for preliminary inspection and approval or recommendations with respect to compliance with Health Division rules for compliance to National Fire Protection Association standards when the facility is also to be Medicare or Medicaid certified. Submissions shall be in accord with rules of the Licensing Plan Review Program, OAR 333, Division 675. Plans should also be submitted to the local building division having authority for review and approval in accordance with state building codes.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 11-1988, f. & cert. ef. 5-27-88; OHD 6-1999, f. & cert. ef. 10-22-99

333-071-0145

Exceptions to Rules (All HCFs)

(1) While all Health Care Facilities are required to maintain continuous compliance with the Division's rules, these requirements do not prohibit the use of alternative concepts, methods, procedures, techniques, equipment, facilities, personnel qualifications or the conducting of pilot projects or research. Requests for exceptions to the rules must be:

(a) Submitted to the Division in writing; and

(b) Identify the specific rule for which an exception is requested; and

(c) The special circumstances relied upon to justify the exception; and

(d) What alternatives were considered, if any, and why alternatives (including compliance) were not selected; and

(e) Demonstrate that the proposed exception is desirable to maintain or improve the health safety of the patients, and will not jeopardize patient health and safety; and

(f) The proposed duration of the exception.

(2) Upon finding that the facility has satisfied the conditions of this rule, the Division may grant an exception.

(3) The facility may implement an exception only after written approval from the Public Health Division.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055
Hist.: HD 11-1988, f. & cert. ef. 5-27-88

The official copy of an Oregon Administrative Rule is contained in the Administrative Order filed at the Archives Division, 800 Summer St. NE, Salem, Oregon 97310. Any discrepancies with the published version are satisfied in favor of the Administrative Order. The Oregon Administrative Rules and the Oregon Bulletin are copyrighted by the Oregon Secretary of State. Terms and Conditions of Use

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